TEST 1: COMPREHENSIVE Flashcards

Question 1

Q

A client with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome
confides that he is homosexual and his employer does not know his HIV status. Which response by the
nurse is best?
“Would you like me to help you tell them?”
“The information you confide in me is confidential.”
“I must share this information with your family.”
“I must share this information with your employer.”

2. The mother of a child with bronchial asthma tells the nurse that the child wants a pet. Which of
the following pets is most appropriate?
1. Cat.
2. Fish.
3. Gerbil.
4. Canary.

An elderly client is being admitted to same-day surgery for cataract extraction. The client has
several diamond rings. The nurse should explain to the client that:
The rings will be taped before the surgery.
The rings will be placed in an envelope, the client will sign the envelope, and the envelope
will be placed in a safe.
The rings will be locked in the narcotics box.
The nursing supervisor will hold onto the rings during the surgery.
When an infant resumes taking oral feedings after surgery to correct intussusception, the
parents comment that the child seems to suck on the pacifier more since the surgery. The nurse
explains that sucking on a pacifier:
Provides an outlet for emotional tension.
Indicates readiness to take solid foods.
Indicates intestinal motility.
Is an attempt to get attention from the parents.
Under which circumstance may a nurse communicate medical information without the client’s
consent?
When certifying the client’s absence from work.
When requested by the client’s family.
When treating the client with a sexually transmitted disease.
When prescribed by another physician.
A 22-year-old client is brought to the emergency department with his fiancée after being
involved in a serious motor vehicle accident. His Glasgow Coma Scale score is 7, and he
demonstrates evidence of decorticate posturing. Which of the following is appropriate for obtaining
permission to place a catheter for intracranial pressure (ICP) monitoring?
The nurse will obtain a signed consent from the client’s fiancée because he is of legal age andthey are engaged to be married.
The physician will get a consultation from another physician and proceed with placement of
the ICP catheter until the family arrives to sign the consent.
Two nurses will receive a verbal consent by telephone from the client’s next of kin before
inserting the catheter.
The physician will document the emergency nature of the client’s condition and that an ICP
catheter for monitoring was placed without a consent.
A 68-year-old client’s daughter is asking about the follow-up evaluation for her father after his
pneumonectomy for primary lung cancer. The nurse’s best response is which of the following?
“The usual follow-up is chest x-ray and liver function tests every 3 months.”
“The follow-up for your father will be a chest x-ray and a computed tomography scan of the
abdomen every year.”
“No follow-up is needed at this time.”
“The follow-up for your father will be a chest x-ray every 6 months.”
The nurse is preparing to administer blood to a client who requires postoperative blood
replacement. The nurse should use a blood administration set that has a:
Micron mesh filter.
Nonfiltered blood administration set.
Special leukocyte-poor filter.
Microdrip administration set.
During the health history interview, which of the following strategies is the most effective for
the nurse to use to help clients take an active role in their health care?
Ask clients to complete a questionnaire.
Provide clients with written instructions.
Ask clients for their views of their health and health care.
Ask clients if they have any questions about their health.
The nurse is planning care for a client who chews the fingers constantly. Before applying
mitten restraints, the nurse could try which of the following interventions? Select all that apply.
Ask the client to rub lotion over the hands every day after bathing.
Encourage physical activity, such as ambulation.
Provide frequent contacts for communication and socialization.
Provide family education.
Encourage involvement of family and friends.

Answer

A

1. The nurse is responsible for maintaining confidentiality of this disclosure by the client.
  CN: Psychosocial integrity; CL: Synthesize
1. Pets are discouraged when parents are trying to allergy-proof a home for a child with
  bronchial asthma, unless the pets are kept outside. Pets with hair or feathers are especially likely to
  trigger asthma attacks. A fish is a satisfactory pet for this child, but the parents should be taught to
  keep the fish tank clean to prevent it from harboring mold.
  CN: Health promotion and maintenance; CL: Synthesize
1. Under the policy for valuables, the nurse documents the description on an envelope with the
  client, the client and nurse sign the envelope, and the valuables envelope is locked in the safe. The
  other options increase the risk of loss or damage to the client’s valuables.
  CN: Management of care; CL: Synthesize
1. Sucking provides the infant with a sense of security and comfort. It also is an outlet for
  releasing tension. The infant should not be discouraged from sucking on the pacifier. Fussiness after
  feeding may indicate that the infant’s appetite is not satisfied. Sucking is not manipulative in the sense
  of seeking parental attention.
  CN: Health promotion and maintenance; CL: Analyze
1. Sexually transmitted diseases are communicable diseases that must be reported. The nurse is
  responsible for reporting these diseases to the appropriate public health agency and to otherwise
  maintain the client’s confidentiality. The client’s family cannot request release of medical information
  without the client’s consent. A physician’s prescription is not a substitute for a client’s consent to
  release medical information in the absence of a communicable disease.
  CN: Management of care; CL: Synthesize
1. In a life-threatening emergency where time is of the essence in saving life or limb, consent is
  not required. This client has a Glasgow Coma Scale score of 7, which indicates a comatose state. The
  client cannot be aroused, withdraws in a purposeless manner from painful stimuli, exhibits
  decorticate posturing, and may or may not have brain stem reflexes intact. The placement of the ICP
  monitor is crucial to determine cerebral blood flow and prevent herniation. The client’s fiancée
  cannot sign the consent because, until she is his wife or has designated power of attorney, she is not
  considered his next of kin. The physician should insert the catheter in this emergency. He does not
  need to get a consultation from another physician. When consent is needed for a situation that is not atrue emergency, two nurses can receive a verbal consent by telephone from the client’s next of kin.
  CN: Management of care; CL: Apply
1. Follow-up generally involves semiannual chest radiographs. Recurrence usually occurs
  locally in the lungs and may be identified on chest radiographs. Follow-up after cancer treatment is an
  important component of the treatment plan. Serum markers (liver function tests) have not been shown
  to detect recurrence of lung cancer. There are no data to support the need for an abdominal computed
  tomography scan.
  CN: Reduction of risk potential; CL: Synthesize
1. All blood products should be administered through a micron mesh filter. Blood is never
  administered without a filter. Leukocytes can be removed by using leukocyte-poor filters, and this is
  recommended to decrease reactions in clients, such as hemophiliacs, who require frequent
  transfusions. Blood is too concentrated to administer through a microdrip set.
  CN: Pharmacological and parenteral therapies; CL: Apply
1. One of the best strategies to help clients feel in control is to ask them their view of situations
  and to respond to what they say. This technique acknowledges that clients’ opinions have value and
  relevance to the interview. It also promotes an active role for clients in the process. Use of a
  questionnaire or written instructions is a means of obtaining information but promotes a passive client
  role. Asking whether clients have questions encourages participation, but alone it does not acknowledge their views.
  CN: Management of care; CL: Synthesize
2, 3, 4, 5. Socialization and communication, in addition to increased activity, are all means to
aid in prevention of self-injury. Education of family members may foster development of strategies to
prevent self-injury; hence, mitten restraints could be avoided. Applying lotion after bathing may not
be appropriate when the skin is broken and not intact.
CN: Management of care; CL: Synthesize

Question 2

Q

A client with severe depression states, “My heart has stopped and my blood is black ash.”
The nurse interprets this statement to be evidence of which of the following?
Hallucination.
Illusion.
Delusion.
Paranoia.
When a client wants to read the chart, the nurse should:
Call the health care provider to obtain permission.
Give the client the chart and answer the client’s questions.3. Tell the client to read the chart when the doctor makes rounds.
Answer any questions the client has without giving the client the chart.
A client with a fractured leg has been instructed to ambulate without weight bearing on the
affected leg. The nurse evaluates that the client is ambulating correctly if the client uses which of the
following crutch-walking gaits?
Two-point gait.
Four-point gait.
Three-point gait.
Swing-to gait.
A client with major depression states, “Life isn’t worth living anymore. Nothing matters.”
Which of the following responses by the nurse is best?
“Are you thinking about killing yourself?”
“Things will get better, you know.”
“Why do you think that way?”
“You shouldn’t feel that way.”
A client with bipolar 1 disorder has been prescribed olanzapine (Zyprexa) 5 mg two times a
day and lamotrigine (Lamictal) 25 mg two times a day. Which of the following adverse effects should
the nurse report to the physician immediately? Select all that apply.
Rash.
Nausea.
Sedation.
Hyperthermia.
Muscle rigidity.
A client is prescribed atropine 0.4 mg intramuscularly. The atropine vial is labeled 0.5 mg/mL. How
many milliliters should the nurse plan to administer?
_______________ mL.
A multiparous client tells the nurse that she is using medroxyprogesterone (Depo-Provera) for
contraception. The nurse should instruct the client to increase her intake of which of the following?
Folic acid.
Vitamin C.
Magnesium.
Calcium.
Which of the following statements made by a pregnant woman in the first trimester are
consistent with this stage of pregnancy? Select all that apply.
“My husband told his friends we will have to give up the Mustang for a minivan.”
“Oh my, how did this happen? I don’t need this now.”
“I can’t wait to see my baby. Do you think it will have my blond hair and blue eyes?”
“I used a Disney theme for decorating the room.”
“I wonder how it will feel to buy maternity clothes and be fat.”
“We went to the mall yesterday to buy a crib and dressing table.”
The nurse is teaching a client about using topical gentamicin sulfate (Garamycin). Which ofthe following comments by the client indicates the need for additional teaching?
“I will avoid being out in the sun for long periods.”
“I should stop applying it once the infected area heals.”
“I’ll call the physician if the condition worsens.”
“I should apply it to large open areas.”

20. A client takes hydrochlorothiazide (HCTZ) for treatment of hypertension. The nurse should
instruct the client to report which of the following? Select all that apply.
1. Muscle twitching.
2. Abdominal cramping.
3. Diarrhea.
4. Confusion.
5. Lethargy.
6. Muscle weakness

Answer

A

1. A client with severe depression may experience symptoms of psychosis such as
  hallucinations and delusions that are typically mood congruent. The statement, “My heart has stopped
  and my blood is black ash,” is a mood-congruent somatic delusion. A delusion is a firm, false, fixed
  belief that is resistant to reason or fact. A hallucination is a false sensory perception unrelated to
  external stimuli. An illusion is a misinterpretation of a real sensory stimulus. Paranoia refers to
  suspiciousness of others and their actions.
  CN: Psychosocial integrity; CL: Analyze
1. The client should be allowed to see the chart. As a client advocate, the nurse should answer
  questions for the client. The nurse helps the client become a primary partner in the health team. The
  Bill of Rights for Patients has existed since the 1960s, and every client should be aware of this
  document. The doctor should not need to give permission for the client to see the chart. As a client
  advocate, the nurse should not make excuses to put the client off in regard to seeing the chart.
  CN: Management of care; CL: Apply
1. The three-point gait, in which the client advances the crutches and the affected leg at the
  same time while weight is supported on the unaffected extremity, is the appropriate gait of choice.This allows for non–weight bearing on the affected extremity. The two-point, four-point, and swing-to
  gaits require some weight bearing on both legs, which is contraindicated for this client.
  CN: Reduction of risk potential; CL: Evaluate
1. When the client verbalizes that life isn’t worth living anymore, the nurse needs to ask the
  client directly about suicide by saying, “Are you thinking about killing yourself?” Asking directly
  does not provoke suicide but conveys concern, understanding, and the worth of the client. Commonly,
  the client experiences a sense of relief that someone finally hears him. It also helps the nurse plan
  responsible care by identifying the client who is at risk for suicide. The nurse should then evaluate the
  seriousness of the suicidal ideation by inquiring about the intent and plan. Stating, “Things will get
  better,” offers hope too soon without first evaluating the intent of the suicidal ideation. Asking, “Why
  do you think that way?” implies a lack of understanding and knowledge on the part of the nurse. Major
  depression usually is endogenous and biochemically based. Therefore, the client may not know why
  he doesn’t want to live. Saying, “You shouldn’t feel that way,” admonishes the client, decreases self-
  worth, and conveys a lack of understanding.
  CN: Psychosocial integrity; CL: Synthesize
1, 4, 5. Lamotrigine, an antiepileptic, is used as a mood stabilizer for clients with bipolar
disorder and has been found to be effective for the depressive phase of bipolar disorder. Common
adverse effects are dizziness, headache, sedation, tremors, nausea, vomiting, and ataxia. The
development of a rash needs to be reported and evaluated by the physician because it could indicate
the start of a severe systemic rash known as Stevens-Johnson syndrome, a toxic epidermal necrolysis,
which would necessitate the discontinuation of lamotrigine. Hyperthermia in conjunction with muscle
rigidity suggests the development of neuroleptic malignant syndrome, a life-threatening complication
associated with olanzapine.
CN: Pharmacological and parenteral therapies; CL: Analyze
0.8 mL
CN: Pharmacological and parenteral therapies; CL: Apply
1. The nurse should instruct the client to increase her intake of calcium because there is a
  slight increase in the risk of osteoporosis with this medication. Weight-bearing exercises are also
  advised. The drug may also impair glucose tolerance in women who are at risk for diabetes.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1, 2, 5. The first trimester is when the couple works through the psychological task of
accepting the pregnancy. These statements describe the client and her partner coping with the
pregnancy, how it feels, and how it will impact their lives. The feelings include pleasure, excitement,
and ambivalence. Wondering what the baby will look like and planning for the baby’s room occur
later in the pregnancy.CN: Health promotion and maintenance; CL: Analyze
1. The aminoglycoside antibiotic gentamicin sulfate should not be applied to large denuded
  areas because toxicity and systemic absorption are possible. The nurse should instruct the client to
  avoid excessive sun exposure because gentamicin sulfate can cause photosensitivity. The client
  should be instructed to apply the cream or ointment for only the length of time prescribed because a
  superinfection can occur from overuse. The client should contact the physician if the condition
  worsens after use.
  CN: Pharmacological and parenteral therapies; CL: Evaluate
2, 5, 6. HCTZ is a thiazide diuretic used in the management of mild to moderate hypertension
and in the treatment of edema associated with heart failure, renal dysfunction, cirrhosis,
corticosteroid therapy, and estrogen therapy. It increases the excretion of sodium and water by
inhibiting sodium reabsorption in the distal tubule of the kidneys. It promotes the excretion of
chloride, potassium, magnesium, and bicarbonate. Side effects include drowsiness, lethargy, and
muscle weakness but not muscle twitching. Although there may be abdominal cramping, there is no
diarrhea. The client does not become confused as a result of taking this drug.
CN: Health promotion and maintenance; CL: Analyze

Question 3

Q

A client has been taking imipramine (Tofranil) for depression for 2 days. His sister asks the
nurse, “Why is he still so depressed?” Which of the following responses by the nurse is most
appropriate?
“Your brother is experiencing a very serious depression.”
“I’ll be sure to convey your concern to his physician.”
“It takes 2 to 4 weeks for the drug to reach its full effect.”
“Perhaps we need to change his medication.”
Which interventions should the nurse use to assist the client with grandiose delusions? Select
all that apply.
Accepting the client while not arguing with the delusion.
Focusing on the feelings or meaning of the delusion.
Focusing on events and topics based in reality.
Confronting the client’s beliefs.
Interacting with the client only when the client is based in reality.
Which of the following responses is most helpful for a client who is euphoric, intrusive, and
interrupts other clients engaged in conversations to the point where they get up and leave or walk
away?
“When you interrupt others, they leave the area.”
“You are being rude and uncaring.”
“You should remember to use your manners.”
“You know better than to interrupt someone.”

24. At what time should the blood be drawn in relation to the administration of the IV dose of
gentamicin sulfate (Garamycin)?
1. 2 hours before the administration of the next IV dose.
2. 3 hours before the administration of the next IV dose.
3. 4 hours before the administration of the next IV dose.
4. Just before the administration of the next IV dose.

25. Which finding requires immediate intervention when planning care for an adolescent with
cystic fibrosis (CF)?1. Delayed puberty.
2. Chest pain with dyspnea.
3. Poor weight gain.
4. Large foul-smelling bulky stools.

A 4-year-old is brought to the emergency department with sudden onset of a temperature of
103°F (39.5°C), sore throat, and refusal to drink. The child will not lie down and prefers to lean
forward while sitting up. Which of the following should the nurse do next?
Give 600 mg of acetaminophen (Tylenol) rectally, as prescribed.
Inspect the child’s throat for redness and swelling.
Have an appropriate-sized tracheostomy tube readily available.
Obtain a specimen for a throat culture.
Assessment of a client taking lithium reveals dry mouth, nausea, thirst, and mild hand tremor.
Based on an analysis of these findings, which of the following should the nurse do next?
Withhold the lithium and obtain a lithium level to determine therapeutic effectiveness.
Continue the lithium and immediately notify the physician about the assessment findings.
Continue the lithium and reassure the client that these temporary side effects will subside.
Withhold the lithium and monitor the client for signs and symptoms of increasing toxicity.
A client asks the nurse how long will it be necessary to take the medicine for hypothyroidism.
The nurse’s response is based on the knowledge that:
Lifelong daily medicine is necessary.
The medication is expensive, and the dose can be reduced in a few months.
The medication can be gradually withdrawn in 1 to 2 years.
The medication can be discontinued after the client’s thyroid-stimulating hormone (TSH) level
is normal.
The nurse should advise which of the following clients who is taking lithium to consult with
the physician regarding a potential adjustment in lithium dosage?
A client who continues work as a computer programmer.
A client who attends college classes.
A client who can now care for her children.
A client who is beginning training for a tennis team.
The nurse is discharging a client who has been hospitalized for preterm labor. The client
needs further instruction when she says:
“If I think I have a bladder infection, I need to see my obstetrician.”
“If I have contractions, I should contact my health care provider.”
“Drinking water may help prevent early labor for me.”
“If I travel on long trips, I need to get out of the car every 4 hours.”

Answer

A

1. The nurse needs to inform the sister that it takes 2 to 4 weeks before a full clinical effect
  occurs with the drug. The nurse should let her know that her brother will gradually get better and
  symptoms of depression will improve. Telling the sister that her brother is experiencing a very
  serious depression does not give the sister important information about the medication. Additionally,
  this statement may cause alarm and anxiety. Conveying the sister’s concern to the physician does not
  provide her with the necessary information about the client’s medication. Telling the sister that the
  client’s medication may need to be changed is inappropriate because a full clinical effect occurs after
  2 to 4 weeks.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1, 2, 3. For the client with grandiose delusions, the nurse should accept the client but not argue
with the delusion to build trust and the client’s self-esteem. Focusing on the underlying feeling or
meaning of the delusion helps to meet the client’s needs. Focusing on events and topics based in
reality distracts the client from the delusional thinking. Confronting the client’s delusions or beliefs
can lead to agitation in the client and the need to cling to the grandiose delusion to preserve self-
esteem. Interacting with the client only when based in reality ignores the client’s needs and
therapeutic nursing intervention.
CN: Psychosocial integrity; CL: Synthesize
1. Saying, “When you interrupt others, they leave the area,” is most helpful because it serves
  to increase the client’s awareness of others’ perceptions of the behavior by giving specific feedback
  about the behavior. The other statements are punitive and authoritative, possibly threatening to the
  client, and likely to increase defensiveness, decrease self-worth, and increase feelings of guilt.
  CN: Psychosocial integrity; CL: Synthesize
1. To determine how low the gentamicin serum level drops between doses, the trough serum
  level should be drawn just before the administration of the next IV dose of gentamicin sulfate.
  CN: Pharmacological and parenteral therapies; CL: Apply25. 2. Chest pain and dyspnea are signs of a pneumothorax and should be treated immediately.
  Delayed puberty is common in adolescents with CF and is caused by poor nutrition. Poor weight gain
  is common in children with CF because so little is absorbed in the small intestine. Large, foul-
  smelling stools indicate noncompliance with taking enzymes and should be addressed, but respiratory
  complications are the greatest concern.
  CN: Physiological adaptation; CL: Analyze
1. The child is exhibiting signs and symptoms of possible epiglottiditis. As a result, the child
  is at high risk for laryngospasm and airway occlusion. Therefore, the nurse should have a
  tracheostomy tube and setup readily available should the child experience an airway occlusion.
  Although acetaminophen is an antipyretic, the dosage of 600 mg to be administered rectally is too
  high. A typical 4-year-old weighs approximately 40 lb (18.1 kg). The recommended dose is 125 mg.
  When any type of respiratory illness, and especially epiglottiditis, is suspected, putting any object,
  including a tongue depressor for inspection or a cotton-tipped applicator to obtain a throat culture, in
  the back of the mouth or throat or having the child open the mouth is inappropriate because doing so
  may predispose the child to laryngospasm or occlusion of the airway by a swollen epiglottis.
  CN: Reduction of risk potential; CL: Synthesize
1. The client is exhibiting temporary side effects associated with lithium therapy. Therefore,
  the nurse should continue the lithium and explain to the client that the temporary side effects of lithium
  that will subside. Common side effects of lithium are nausea, dry mouth, diarrhea, thirst, mild hand
  tremor, weight gain, bloating, insomnia, and light-headedness. Immediately notifying the physician
  about these common side effects is not necessary.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. Thyroid replacement is a lifelong maintenance therapy. The medication is usually given as
  one dose in the morning. It cannot be tapered or discontinued because the client needs thyroid
  supplementation to maintain health. The medication cannot be discontinued after the TSH level is
  normal; the dose will be maintained at the level that normalizes the TSH concentration.
  CN: Pharmacological and parenteral therapies; CL: Apply
1. A client who is beginning training for a tennis team would most likely require an adjustment
  in lithium dosage because excessive sweating can increase the serum lithium level, possibly leading
  to toxicity. Adjustments in lithium dosage would also be necessary when other medications have been
  added, when an illness with high fever occurs, and when a new diet begins.
  CN: Pharmacological and parenteral therapies; CL: Analyze
1. Traveling is usually discouraged if preterm labor has been a problem, as it restricts normal
  movement. A client should be able to walk around frequently to prevent blood clots and to empty her
  bladder at least every 1 to 2 hours. Bladder infections often stimulate preterm labor and preventing
  them is of great importance to this client. Contractions that recur indicate the return of preterm labor,
  and the health care provider needs to be notified. Dehydration is known to stimulate preterm labor
  and encouraging the client to drink adequate amounts of water helps to prevent this problem.
  CN: Reduction of risk potential; CL: Evaluate

Question 4

Q

A client admitted with a gastric ulcer has been vomiting bright red blood. The hemoglobin level is 5.11 g/dL (51 g/L), and blood pressure is 100/50 mm Hg. The client and family state that their
religious beliefs do not support the use of blood products and refuse blood transfusions as a treatment
for the bleeding. The nurse should collaborate with the physician and family to next:
Discontinue all measures.
Notify the hospital attorney.
Attempt to stabilize the client through the use of fluid replacement.
Give enough blood to keep the client from dying.
The parents of a child with cystic fibrosis express concern about how the disease was
transmitted to their child. The nurse should explain that:
A disease carrier also has the disease.
Two parents who are carriers may produce a child who has the disease.
A disease carrier and an affected person will never have children with the disease.
A disease carrier and an affected person will have a child with the disease.
A client with angina shows the nurse the nitroglycerin (Nitrostat) that the client carries in a
plastic bag in a pocket. The nurse instructs the client that nitroglycerin should be kept in:
The refrigerator.
A cool, moist place.
A dark container to shield from light.
A plastic pill container where it is readily available.
When teaching a client with bipolar disorder who has started to take valproic acid about
possible side effects of this medication, the nurse should instruct the client to report:
Increased urination.
Slowed thinking.
Sedation.
Weight loss.
An infant is born with facial abnormalities, growth retardation, mental retardation, and vision
abnormalities. These abnormalities are likely caused by maternal:
Alcohol consumption.
Vitamin B 6 deficiency.
Vitamin A deficiency.
Folic acid deficiency.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used in the treatment of
musculoskeletal conditions. It is important for the nurse to remind the client to:
Take NSAIDs at least three times per day.
Exercise the joints at least 1 hour after taking the medication.
Take antacids 1 hour after taking NSAIDs.
Take NSAIDs with food.
The nurse should suspect that the client taking disulfiram (Antabuse) has ingested alcohol
when the client exhibits which of the following symptoms?
Sore throat and muscle aches.
Nausea and flushing of the face and neck.
Fever and muscle soreness.
Bradycardia and vertigo.
The nurse holds the gauze pledget against an IM injection site while removing the needle
from the muscle. This technique helps to:
Seal off the track left by the needle in the tissue.
Speed the spread of the medication in the tissue.3. Avoid the discomfort of the needle pulling on the skin.
Prevent organisms from entering the body through the skin puncture.
A client whose condition remains stable after a myocardial infarction gradually increases
activity. Which the following conditions should the nurse assess to determine whether the activity is
appropriate for the client?
Edema.
Cyanosis.
Dyspnea.
Weight loss.
The nurse is conducting a counseling session with a client experiencing posttraumatic stress
disorder (PSTD) using a 2-way video telehealth system from the hospital to the client’s home, which
is 2 hours away from the nearest mental health facility. Which of the following are expected outcomes
of using telehealth as a venue to provide health care to this client? Select all that apply. The client
will:
Save travel time from the house to the health care facility.
Avoid reliving a traumatic event that might be precipitated by visiting a health care facility.
Experience a shorter recovery time than being treated on-site at a health care facility.
Receive health care for this mental health problem.
Obtain group support from others with a similar health problem.

Answer

A

1. The most appropriate response is to continue all treatments and attempt to stabilize the
  client using fluid replacement without administering blood or blood products. It is imperative that thehealth care team respect the client’s religious beliefs and wishes, even if they are not those of the
  health care team. Discontinuing all measures is not an option. The health care team should continue to
  provide the best care possible and does not need to notify the attorney.
  CN: Management of care; CL: Synthesize
1. Cystic fibrosis is the most common inherited disease in children. It is inherited as an
  autosomal recessive trait, meaning that the child inherits the defective gene from both parents. The
  chances are one in four for each of this couple’s pregnancies.
  CN: Reduction of risk potential; CL: Apply
1. Nitroglycerin in all dosage forms (sublingual, transdermal, or intravenous) should be
  shielded from light to prevent deterioration. The client should be instructed to keep the nitroglycerin
  in the dark container that is supplied by the pharmacy, and it should not be removed or placed in
  another container.
  CN: Pharmacological and parenteral therapies; CL: Apply
1. Valproic acid causes sedation as well as nausea, vomiting, and indigestion. Sedation is
  important because the client needs to be cautioned about driving or operating machinery that could be
  dangerous while feeling sedated from the medication. Valproic acid does not cause increased
  urination, slowed thinking, or weight loss. However, some clients may experience weight gain.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. These effects and others when seen after birth are known as a cluster of symptoms called
  fetal alcohol syndrome. Vitamin B 6 and vitamin A deficiency can affect growth and development but
  not with these specific effects. Folic acid deficiency contributes to neural tube defects.
  CN: Reduction of risk potential; CL: Analyze
1. NSAIDs irritate the gastric mucosa and should be taken with food. NSAIDs are usually
  taken once or twice daily. Joint exercise is not related to the drug administration. Antacids may
  interfere with the absorption of NSAIDs.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. The client who drinks alcohol while taking disulfiram experiences sweating, flushing of the
  neck and face, tachycardia, hypotension, a throbbing headache, nausea and vomiting, palpitations,
  dyspnea, tremor, and weakness.
  CN: Pharmacological and parenteral therapies; CL: Analyze
1. Holding the gauze pledget against an IM injection site while removing the needle from the
  muscle avoids the discomfort of the needle pulling on the skin.
  CN: Pharmacological and parenteral therapies; CL: Apply
1. Physical activity is gradually increased after a myocardial infarction while the client is still
  hospitalized and through a period of rehabilitation. The client is progressing too rapidly if activity
  significantly changes respirations, causing dyspnea, chest pain, a rapid heartbeat, or fatigue. When
  any of these symptoms appears, the client should reduce activity and progress more slowly. Edema
  suggests a circulatory problem that must be addressed but doesn’t necessarily indicate overexertion.
  Cyanosis indicates reduced oxygen-carrying capacity of red blood cells and indicates a severe
  pathology. It is not appropriate to use cyanosis as an indicator for overexertion. Weight loss indicatesseveral factors but not overexertion.
  CN: Reduction of risk potential; CL: Analyze
1, 2, 4. Telehealth is becoming an increasingly available way for nurses to conduct counseling
sessions with clients who are at a distance from a health care provider or health care facility. The
client saves travel time and can avoid precipitating symptoms associated with the stress disorder that
might occur as a result of a visit to a health care facility. The client also can access care that might not
otherwise be easily available. Treatment for PSTD is long-term, and there is no evidence to suggest
that telehealth versus face-to-face counseling shortens recovery time. Counseling sessions using
telehealth technology are conducted on an individual basis between one client and a health care
provider, but group support may be available if required as a part of a treatment plan.
CN: Management of care; CL: Evaluate

Question 5

Q

When a client with alcohol dependency begins to talk about not having a problem with
alcohol, the nurse should use which of the following approaches?
Questioning the client about how much alcohol the client consumes each day.
Confronting the client about being intoxicated 2 days ago.
Pointing out how alcohol has gotten the client into trouble.
Listening to what the client states and then asking the client about plans for staying sober.
The nurse is caring for a toddler in contact isolation for respiratory syncytial virus (RSV). In
what order should the nurse remove personal protective equipment (PPE)?
Gloves.
Goggles.
Gown.
Mask.
The nurse is preparing a teaching plan for a 45-year-old client recently diagnosed with type 2
diabetes mellitus. What is the first step in this process?
Establish goals.
Choose video materials and brochures.
Assess the client’s learning needs.
Set priorities of learning needs.
A loading dose of digoxin (Lanoxin) is given to a client newly diagnosed with atrial
fibrillation. The nurse instructs the client about the medication and the importance of monitoring his
heart rate. An expected outcome of this instruction is:
A return demonstration of palpating the radial pulse.
A return demonstration of how to take the medication.
Verbalization of why the client has atrial fibrillation.
Verbalization of the need for the medication.
A multigravid client is scheduled for a percutaneous umbilical blood sampling procedure.
The nurse instructs the client that this procedure is useful for diagnosing which of the following?
Twin pregnancies.
Fetal lung maturation.
Rh disease.
Alpha fetoprotein level.

46. Which of the following is an adverse effect of vancomycin (Vancocin) and needs to be
reported promptly?
1. Vertigo.
2. Tinnitus.
3. Muscle stiffness.
4. Ataxia.

Which of the following statements indicates that the client with a peptic ulcer understands the
dietary modifications to follow at home?
“I should eat a bland, soft diet.”
“It is important to eat six small meals a day.”
“I should drink several glasses of milk a day.”
“I should avoid alcohol and caffeine.”
The client with a nasogastric (NG) tube has abdominal distention. Which of the following
measures should the nurse do first?
Call the physician.
Irrigate the NG tube.
Check the function of the suction equipment.
Reposition the NG tube.
A male client has been diagnosed as having a low sperm count during infertility studies. After
instructions by the nurse about some causes of low sperm counts, the nurse determines that the client
needs further instructions when he says low sperm counts may be caused by which of the following?
Varicocele.2. Frequent use of saunas.
Endocrine imbalances.
Decreased body temperature.
A nurse is relieving the triage nurse in the labor and birth unit who is going to lunch. The
report indicates that there are three clients having their vital signs assessed and a fourth client is on
her way to the unit from the emergency department. In which order of priority should the nurse
manage these clients?
The client with clear vesicles and brown vaginal discharge at 16 weeks’ gestation.
The client with right lower quadrant pain at 10 weeks’ gestation.
The client who is at term and has had no fetal movement for 2 days.
The client from the emergency department at term and screaming loudly because of labor
contractions.

Answer

A

1. When a client talks about not having a problem with alcohol, the nurse needs to point out
  how alcohol has gotten the client into trouble. Concrete facts are helpful in decreasing the client’s
  denial that alcohol is a problem. The other approaches allow the client to use defense mechanisms,
  such as rationalization, projection, and minimization, to explain her actions. Therefore, these
  approaches are not helpful.
  CN: Psychosocial integrity; CL: Synthesize

42.
1. Gloves
3. Gown
2. Goggles
4. Mask
The nurse should remove the dirtiest items first. This typically is the gloves followed by the
gown. It is then recommend that the nurse perform hand hygiene and remove the goggles, which may
fit over the mask. Finally, the mask is removed from behind. The nurse should then again perform
hand hygiene when all PPE has been removed.
CN: Safety and infection control; CL: Apply

1. Before development and implementation of the teaching plan, it is vital to determine what
  the client currently knows regarding diabetes and what the client needs to know.
  CN: Management of care; CL: Create
1. The goal of the education program is to instruct the client to take the pulse; therefore, the
  expected outcome would be the ability to give a return demonstration of how to palpate the heart rate.
  CN: Reduction of risk potential; CL: Evaluate
1. Percutaneous umbilical blood sampling is a useful procedure for diagnosing Rh disease,
  obtaining fetal complete blood count, and karyotyping chromosomes to evaluate for genetic disorders.
  Ultrasound commonly is used to detect twins. A lecithin-sphingomyelin ratio is the procedure of
  choice to diagnose fetal lung maturation. A maternal blood test is used to determine the alpha
  fetoprotein level.
  CN: Reduction of risk potential; CL: Apply
1. The client should report tinnitus because vancomycin can affect the acoustic branch of the
  eighth cranial nerve. Vancomycin does not affect the vestibular branch of the acoustic nerve; vertigo
  and ataxia would occur if the vestibular branch were involved. Muscle stiffness is not associated
  with vancomycin.
  CN: Pharmacological and parenteral therapies; CL: Analyze
1. Caffeinated beverages and alcohol should be avoided because they stimulate gastric acid
  production and irritate gastric mucosa. The client should avoid foods that cause discomfort; however,
  there is no need to follow a soft, bland diet. Eating six small meals daily is no longer a common
  treatment for peptic ulcer disease. Milk in large quantities is not recommended because it actually
  stimulates further production of gastric acid.
  CN: Reduction of risk potential; CL: Evaluate
1. When a client with a NG tube exhibits abdominal distention, the nurse should first check the
  suction machine. If the suction equipment is functioning properly, then the nurse should take other
  steps, such as repositioning the tube or checking tube patency by irrigating it. If these steps are not
  effective, then the physician should be called.
  CN: Reduction of risk potential; CL: Synthesize
1. Increased, not decreased, body temperature resulting from occupations or infections can
  contribute to low sperm counts caused by decreased sperm production. Heat can destroy sperm.
  Varicocele, an abnormal dilation of the veins in the spermatic cord, is an associated cause of a low
  sperm count. The varicosity increases the temperature within the testes, inhibiting sperm production.
  Frequent use of saunas or hot tubs may lead to a low sperm count. The temperature of the scrotum
  becomes elevated, possibly inhibiting sperm production. Endocrine imbalances (thyroid problems)
  are associated with low sperm counts in men because of possible interference with spermatogenesis.
  CN: Reduction of risk potential; CL: Evaluate
1. The client from the emergency department at term and screaming loudly because of labor
  contractions.
The client with right lower quadrant pain at 10 weeks’ gestation.
The client with clear vesicles and brown vaginal discharge at 16 weeks’ gestation.3. The client who is at term and has had no fetal movement for 2 days.
First, the nurse should assess the client from the emergency department who is screaming because
she may be anywhere along the labor continuum and her status will be unknown until she has a
vaginal exam to determine cervical effacement and dilation. The nurse should next assess the client
with right lower quadrant pain as she may be experiencing an ectopic pregnancy or appendicitis and
may need further evaluation by the health care provider. The client with clear vesicles and brown
vaginal discharge is experiencing a molar pregnancy and will need to have a D&C to evacuate the
vesicles; this condition will not jeopardize the life of the mother if no intervention occurs within an
hour. The client who is at term without fetal movement is a priority from an emotional standpoint if
there is no heart beat when she is evaluated, but the physical status of the fetus with no fetal
movement for 2 days will not change if not seen within the next 1/2 hour and the nurse can see this
client last. The emotional care for this client will be extensive if there is a diagnosis of fetal demise,
and the nurse should plan the time to be available to support this client as needed.
CN: Management of care; CL: Synthesize

Question 6

Q

During the process of restraining a client, a staff member is injured. The nurse manager
would conclude that a peer support program has been helpful for the injured staff member if which of
the following outcomes had been achieved? Select all that apply.
The injured staff member has debriefed with the other staff involved in the restraint.
Legal action has been taken against the client.
The injured staff member had the opportunity to express his or her feeling with a support
group.
The injured staff member has decided whether or not to talk to the assaultive client.
A plan has been arranged to facilitate the return of the injured staff member to work.
A client with severe osteoarthritis and decreased mobility is transferred to an assisted living
facility. The nurse notices that the client smells of alcohol, exhibits an unsteady gait, and has six wine
bottles in the trash. The client tells the nurse, “Those are my other pain medicines.” Which of the
following statements by the nurse are most appropriate? Select all that apply.
“I didn’t realize that your pain was not being managed with your current medications.”
“It is important for me to know how many bottles of wine you drank this week.”
“I’m worried about the amount of wine you are drinking and its effects on your balance.”
“How are you getting all this wine?”
“I am calling your doctor to have all of us to talk about better pain control without the wine.”
When teaching unlicensed assistive personnel (UAP) about the importance of handwashing in
preventing disease, the nurse should instruct the UAP that:
“It is not necessary to wash your hands as long as you use gloves.”
“Hand washing is the best method for preventing cross-contamination.”
“Waterless commercial products are not effective for killing organisms.”
“The hands do not serve as a source of infection.”
The nurse is performing Leopold’s maneuvers on a woman who is in her eighth month of
pregnancy. The nurse is palpating the uterus as shown below. Which of the following maneuvers is the
nurse performing?
First maneuver.
Second maneuver.
Third maneuver.
Fourth maneuver.
A client in cardiac rehabilitation would like to eat the right foods to ensure adequate
endurance on the treadmill. Which of the following nutrients is most helpful for promoting endurance
during sustained activity?
Protein.
Carbohydrate.
Fat.
Water.
A client’s chest tube is connected to a drainage system with a water seal. The nurse notes that
the fluid in the water-seal column is fluctuating with each breath that the client takes. The fluctuation
means that:
There is an obstruction in the chest tube.
The client is developing subcutaneous emphysema.3. The chest tube system is functioning properly.
There is a leak in the chest tube system.
A client with diabetes is explaining to the nurse how to care for the feet at home. Which
statement indicates that the client understands proper foot care?
“When I injure my toe, I will plan to put iodine on it.”
“I should inspect my feet at least once a week.”
“It is okay to go barefoot in the house.”
“It is important to dry my feet carefully after my bath.”

58. The nurse assesses a client with diverticulitis. The nurse should report which of the
following to the health care provider?
1. Hyperactive bowel sounds.
2. Rigid abdominal wall.
3. Explosive diarrhea.
4. Excessive flatulence.

A nurse is assessing a client who has a potential diagnosis of pancreatitis. Which risk factors
predispose the client to pancreatitis? Select all that apply.
Excessive alcohol use.
Gallstones.
Abdominal trauma.
Hypertension.
Hyperlipidemia with excessive triglycerides.
Hypothyroidism.
The nurse is beginning the shift and is planning care for 6 clients on the postpartum unit.
Three of the clients have immediate needs and three of the clients are listed as “stable.” For the best
utilization of time and client safety, the nurse should make rounds on which of the following clients
first?
The three clients who are reported to be stable.
The mother with a 4-hour-old infant with initial blood glucose of 33 mg/dL (1.8 mmol/L) and
now at 45 mg/dL (2.5 mmol/L) breast-feeding her infant.
A mother who had a spontaneous vaginal birth (SVB) and received carboprost 1 hour ago for
increased bleeding.
A mother with a 3-day-old who had a bilirubin level of 13 mg/dL (1149.2 μmol/L) 30 minutes
ago and is now in a “biliblanket” at the mother’s bedside.

Answer

A

1, 3, 4, 5. Talking with other staff and his personal support system help diminish fears and
anger about being injured. It is appropriate to facilitate the injured staff member’s return to work to
decrease the chance of resignation or difficulties in performing duties. Talking with the assaultive
client can be helpful if the client is apologetic but is not required. Legal action against a client is
controversial and not always appropriate depending on the client’s illness.
CN: Management of Care; CL: Evaluate
1, 2, 3, 5. Acknowledging the client’s concern about pain and expressing the nurse’s concern
about the client’s condition are important to help the client open up and gain further assessment of
pain in this client. Awareness of the amount of wine consumption in a week will be helpful to-guide
which kind of detoxification will be needed. Notifying the primary care provider about the situation
and arranging for a joint conference are important for the client’s safety and recovery. How the client
is getting the wine is least important because there are so many possibilities such a weekly shopping
trips in the facility van or having friends or family bring it in.
CN: Safety and infection control; CL: Apply
1. Hand washing with the correct technique is the best method for preventing cross-
  contamination. The hands serve as a source of infection. Waterless commercial products containing at
  least 60% alcohol are as effective at killing organisms as handwashing.
  CN: Management of care; CL: Synthesize
1. The third maneuver is used to identify the presenting part. This maneuver is used to identify
  the part of the fetus that lies over the inlet to the pelvis. While facing the client, the nurse places the
  tips of the first three fingers on the side of the woman’s abdomen above the symphysis pubis and
  palpates deeply around the presenting part to identify its contour and size. The first maneuver
  involves using the tips of the fingers of both hands to palpate the uterine fundus. The second maneuver
  identifies the back of the fetus, and the fourth maneuver identifies the cephalic prominence.
  CN: Reduction of risk potential; CL: Apply
1. The stored glucose of muscle glycogen is the major fuel during sustained activity. Glucoseproduction slows as the body begins to depend on fat stores for glucose and fatty acids. Protein is not
  the body’s preferred energy source. Fat is a secondary source of energy. Water is not an energy
  source, although sufficient water is required to engage in aerobic activity without causing dehydration.
  CN: Health promotion and maintenance; CL: Apply
1. Fluctuation of fluid with respirations in the water seal column indicates that the system is
  functioning properly. If an obstruction were present in the chest tube, fluid fluctuation would be
  absent. Subcutaneous emphysema occurs when air pockets can be palpated beneath the client’s skin
  around the chest tube insertion site. A leak in the system is indicated when bubbling occurs in the
  water seal column.
  CN: Reduction of risk potential; CL: Apply
1. It is important to dry the feet carefully after a bath to prevent a fungal infection. Clients with
  diabetes should seek medical attention when they injure their toes or feet to prevent complications.
  Iodine is highly toxic to the tissues. Clients with diabetes should inspect their feet daily and should
  wear shoes that support their feet while in the house.
  CN: Reduction of risk potential; CL: Evaluate
1. Diverticular rupture causes peritonitis from the release of intestinal contents (chemicals
  and bacteria) into the peritoneal cavity. A rigid abdominal wall results from a diverticular cavity, and
  the nurse should report this to the health care provider. The inflammatory response of the peritoneal
  tissue produces severe abdominal rigidity and pain, diminished intestinal motility, and retention of
  intestinal contents (air, fluid, and stool). Hyperactive bowel sounds, explosive diarrhea, and
  excessive flatulence do not indicate peritonitis.
  CN: Reduction of risk potential; CL: Analyze
1, 2, 3, 5. Pancreatitis, a chronic or acute inflammation of the pancreas, is a potentially life-
threatening condition. Excessive alcohol intake and gallstones are the greatest risk factors.
Abdominal trauma can potentiate inflammation. Hyperlipidemia is a risk factor for recurrent
pancreatitis. Hypertension and hypothyroidism are not associated with pancreatitis.
CN: Reduction of risk potential; CL: Analyze
1. The client most in need of validating safety is the mother who has received carboprost 1
  hour ago for increased bleeding. Her bleeding level needs to be documented as having been evaluated
  at the beginning of the shift and to determine if it has decreased to within normal limits (ie, saturating
  <1 pad/h). The three stable clients will need to have an initial assessment by the oncoming nurse but
  can wait until the nurse can first assess the mother who is receiving carboprost. The mother with the
  4-hour-old infant is able to breast-feed to maintain the blood glucose level, and the mother with the 3-
  day-old infant in the “biliblanket” is stable at this point.
  CN: Management of care; CL: Synthesize

Question 7

Q

When performing chest percussion on a child, which of the following techniques should the
nurse use?
Firmly but gently striking the chest wall to make a popping sound.
Gently striking the chest wall to make a slapping sound.
Percussing over an area from the umbilicus to the clavicle.
Placing a blanket between the nurse’s hand and the child’s chest.
The nurse walks into the room of a client who has a “do not resuscitate” prescription and
finds the client without a pulse, respirations, or blood pressure. The nurse should first?
Stay in the room and call the nursing team for assistance.2. Push the emergency alarm to call a code.
Page the client’s physician.
Pull the curtain and leave the room.

63.
A client is trying to lose weight at a moderate pace. If the client eliminates 1,000 cal/day from his
normal intake, how many pounds (or kilograms) would the client lose in 1 week?
_______________ lbs/kgs.

A nulligravid client calls the clinic and tells the nurse that she forgot to take her oral
contraceptive this morning. Which of the following should the nurse instruct the client to do?
Take the medication immediately.
Restart the medication in the morning.
Use another form of contraception for 2 weeks.
Take two pills tonight before bedtime.
The nurse recognizes that a client with pain disorder is improving when the client says which
of the following?
“I need to have a good cry about all the pain I’ve been in and then not dwell on it.”
“I need to find another physician who can accurately diagnose my condition.”
“The pain medicine that you gave me helps me to relax.”
“I’m angry with all of the doctors I’ve seen who don’t know what they’re doing.”
A client admitted in an acute psychotic state hears terrible voices in the head and thinks a
neighbor is upset with the client. Which of the following is the nurse’s best response?
“What has your neighbor been doing that bothers you?”
“How long have you been hearing these terrible voices?”
“We won’t let your neighbor visit, so you’ll be safe.”
“What exactly are these terrible voices saying to you?”
The nurse should assess the client with severe diarrhea for which acid-base imbalance?
Respiratory acidosis.
Respiratory alkalosis.
Metabolic acidosis.
Metabolic alkalosis.
A nurse is planning care for a client who has heart failure. Which goal is appropriate for a
client with excess fluid volume?
A weight reduction of 10% will occur.
Pain will be controlled effectively.
Arterial blood gas values will be within normal limits.
Serum osmolality will be within normal limits.
A 7-year-old child is admitted to the hospital with the diagnosis of acute rheumatic fever.
Which of the following laboratory blood findings confirms that the child has had a streptococcal
infection?
High leukocyte count.
Low hemoglobin count.
Elevated antibody concentration.4. Low erythrocyte sedimentation rate.
The nurse on the postpartum unit is caring for four couplets. There will be a new admission
in 30 minutes. The new client is a G4 P4, Spanish-speaking only client with an infant who is in the
special care nursery (SCN) for fetal distress. The nurse should place the new client in a room with
which of the following clients?
A G4 P4 who is 2 days postpartum with infant, Spanish speaking only.
A G1 P1 who is 1 day postpartum with an infant in the SCN.
A G6 P6 who gave birth 4 hours ago by C/S for fetal distress, infant at bedside.
A G1 P1 who is a non–English-speaking client with infant in SCN for fetal distress.

Answer

A

1. The nurse should firmly yet gently strike the chest wall with the hand cupped to make a
  hollow popping sound. A slapping sound indicates that an incorrect technique is being used. The area
  over the rib cage is percussed to loosen mucus from the underlying lung passages. The child should
  wear a thin piece of clothing (T-shirt) over the chest area to protect the skin without diminishing the
  effect of the percussion.CN: Reduction of risk potential; CL: Analyze
1. The nurse should call to the nursing station to ask the nursing team for assistance. It is not
  necessary to page the physician because this is not an emergency, but the nurse will need to notify the
  physician of the client’s death, and then also notify the family. A “code” should not be called because
  the client and family have designated a “do not resuscitate” status. Nursing personnel should begin
  postmortem care so that the family does not walk in unannounced to find their loved one deceased and
  looking disarrayed.
  CN: Management of care; CL: Synthesize
2 lb or 0.9 kg. One pound or 0.45 kilograms of weight is approximately equivalent to 3,500
cal. Removing 1,000 cal/day results in a 2-lb (0.9-kg) weight loss per week (7,000 cal divided by 7
days). A client who wanted to lose 1 lb (0.45 kg) in a 7-day period would need to cut out 500 cal/day
(3,500 cal divided by 7 days). It is unsafe to try to lose more than 2 lb (0.9 kg)/wk.
CN: Health promotion and maintenance; CL: Apply
1. The nurse should instruct the client to take the medication immediately or as soon as she
  remembers that she missed the medication. There is only a slight risk that the client will become
  pregnant when only one pill has been missed, so there is no need to use another form of contraception.
  However, if the client wishes to increase the chances of not getting pregnant, a condom can be used
  by the male partner. The client should not omit the missed pill and then restart the medication in the
  morning because there is a possibility that ovulation can occur, after which intercourse could result in
  pregnancy. Taking two pills is not necessary and also will result in putting the client off her schedule.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. Pain disorder is a somatoform disorder involving severe pain in one or more anatomic sites
  causing severe distress or impaired function. The statement, “I need to have a good cry about all the
  pain I’ve been in and then not dwell on it,” indicates improvement because the client has a realistic
  view of the physical symptoms and pain and is willing to let them go and move on. The other
  statements indicate the continued presence of denial, lack of insight, and the need for symptoms to
  manage anxiety.
  CN: Psychosocial integrity; CL: Evaluate
1. The nurse needs to collect additional information about the client’s report about hearing
  voices. Assessing the content of hallucinations is essential to determine whether they are command
  hallucinations that the client might act on. Asking about what the neighbor has been doing or telling
  the client that the neighbor won’t visit indirectly reinforces the delusion about the neighbor. Although
  determining the onset and duration of the voices is important, the nurse needs to assess the content of
  the hallucinations first.
  CN: Psychosocial integrity; CL: Synthesize
1. A client with severe diarrhea loses large amounts of bicarbonate, resulting in metabolic
  acidosis. Metabolic alkalosis does not result in this situation. Diarrhea does not affect the respiratory
  system.
  CN: Reduction of risk potential; CL: Analyze
1. Serum osmolality indicates the water balance of the body. A normal plasma osmolalitybetween 275 and 295 mOsm/kg (mmol/kg) indicates that the fluid volume excess has been resolved.
  A weight reduction of 10% may not necessarily return the client to a state of normal serum osmolality.
  Clients with excess fluid volume do not necessarily have pain or abnormal arterial blood gas values.
  CN: Reduction of risk potential; CL: Synthesize
1. Exactly why rheumatic fever follows a streptococcal infection is not known, but it is
  theorized that an antigen-antibody response occurs to an M protein present in certain strains of
  streptococci. The antibodies developed by the body attack certain tissues such as in the heart and
  joints. Antistreptolysin O titer findings show elevated or rising antibody levels. This blood finding is
  the most reliable evidence of a streptococcal infection.
  CN: Reduction of risk potential; CL: Analyze
1. The ability to communicate with a person of the same language would be an advantage, an
  opportunity for socialization and support for the new mother who speaks Spanish. If a Spanish-
  speaking mother were placed with the client who also had a baby in SCN, she would have no
  communication opportunity, and the same would apply for rooming with the mother who has had a
  cesarean section. The client who is non–English speaking does not identify the language spoken, and
  the nurse cannot assume that it is Spanish.
  CN: Management of care; CL: Synthesize

Question 8

Q

A client scheduled for hip replacement surgery wishes to receive his own blood for the
upcoming surgery. The nurse should:
Document the client’s request on the chart.
Notify the hematology laboratory.
Notify the surgeon’s office.
Call the blood bank.
A client is scheduled to have surgery to relieve an intestinal obstruction. Prior to surgery the
nurse should verify that the client has:
Discontinued use of blood thinners.
Followed a low-residue diet.
Performed abdominal tightening exercises.
Signed a last will and testament.
After teaching a client about collecting a stool sample for occult testing, which client
statement indicates effective teaching? Select all that apply.
“I will avoid eating meat for 1 to 3 days before getting a stool sample.”
“I need to eat foods low in fiber a few days before collecting the sample.”
“I’ll take the sample from different areas of the stool that I have passed.”
“I need to send the stool sample to the lab in a covered container right away.”
“I can continue to take all of my regular medications at home.”
A client who is on nothing-by-mouth (NPO) status is constantly asking for a drink of water.
Which of the following is the most appropriate nursing intervention?
Reexplain why it is not possible to have a drink of water.
Offer ice chips every hour to decrease thirst.
Offer the client frequent oral hygiene care.
Divert the client’s attention by turning on the television.
A female client is admitted with fatigue, cold intolerance, weight gain, and muscle weakness.
The initial nursing assessment reveals brittle nails, dry hair, constipation, and possible goiter. The
nurse should conduct a focused assessment for further signs of:
Cushing’s disease.
Hypothyroidism.
Hyperthyroidism.
A pituitary tumor.
A mother tells the nurse that her 10-year-old daughter has an increase in hair growth andbreast enlargement. The nurse explains to the mother and daughter that after the symptoms of puberty
are noticed, menstruation typically occurs within which of the following time frames?
6 months.
12 months.
30 months.
36 months.
While a mother is feeding her full-term neonate 1 hour after birth, she asks the nurse, “What
are these white dots in my baby’s mouth? I tried to wash them out, but they’re still there.” After
assessing the neonate’s mouth, the nurse explains that these spots are which of the following?
Koplik’s spots.
Epstein’s pearls.
Precocious teeth.
Thrush curds.
The nurse should assess a newborn with esophageal atresia and tracheoesophageal fistula
(TEF) for which of the following? Select all that apply.
Copious frothy mucus.
Episodes of cyanosis.
Several loose stools.
Initial weight loss.
Poor gag reflex.
Which of the following factors is most important for healing an infected decubitus ulcer?
Adequate circulatory status.
Scheduled periods of rest.
Balanced nutritional diet.
Fluid intake of 1,500 mL/day.
A client is receiving digoxin (Lanoxin) and the pulse range is normally 70 to 76 bpm. After
assessing the apical pulse for 1 minute and finding it to be 60 bpm, the nurse should first:
Notify the physician.
Withhold the digoxin.
Administer the digoxin.
Notify the charge nurse.

Answer

A

1. The nurse should call the surgeon’s office so that arrangements can be made for the client to
  donate a unit of his blood for possible future autotransfusion. This must be done in sufficient time
  before surgery so that the client is not at risk for being anemic at the time of the scheduled procedure.
  The client’s request must be scheduled through the surgeon’s office because the surgeon has ultimate
  responsibility for the client. The nurse can document that the surgeon’s office was notified of the
  client’s request. Notifying the hematology laboratory or blood bank is not an appropriate response.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. Nurses should verify that clients having surgery discontinued use of any blood thinners to
  prevent postoperative bleeding. Prior to bowel resection the client should follow a high-residue diet
  with increased fluids. Abdominal tightening exercises are not necessary before this surgery. Clients
  may write a will before surgery, but the nurse does not have to inquire about it.
  CN: Reduction of risk potential; CL: Synthesize
1, 3. When a client collects stool for occult blood, the nurse should instruct the client to avoid
eating meat, especially red meat, for 1 to 3 days before the sample collection because meat
eliminated in the stool can lead to false-positive results. Eating foods high in fiber a few days before
sample collection may be recommended because doing so improves the chances of finding occult
blood if a lesion is present. The client should take stool samples from different sites of the stool for a
better sample. The stool sample should be covered to protect everyone from body secretions. The
specimen does not have to be sent to the laboratory immediately. Some medications, herbs, foods, and
activities can lead to false results of the occult testing. For example, iron pills, turnips, and
horseradish lead to false-positive results. Vitamin C leads to false-negative results. Some anti-
inflammatory drugs and aspirin should be avoided due to antiplatelet properties that increase the risk
of gastrointestinal bleeding.
CN: Reduction of risk potential; CL: Evaluate
1. The most appropriate intervention is to offer the client frequent mouth care to moisten the
  dry oral mucosa. Reexplaining why the client cannot drink may be helpful but will not relieve the
  thirst. Ice chips cannot be given to a client who is on NPO status. Diverting the client’s attention does
  not help manage the thirst.
  CN: Basic care and comfort; CL: Synthesize
1. This client is demonstrating classic symptoms of hypothyroidism. Primary hypothyroidism
  results from pathologic changes in the thyroid gland. In this case, the thyroid gland cannot secrete
  sufficient amounts of thyroid hormone, leading to a decrease in cellular metabolic activity, decreased
  oxygen consumption, and decreased heat production. Cushing’s disease is manifested by a buffalo
  hump, moonface, hypertension, fatigability, and weakness, resulting from the inappropriate release of
  cortisol. Hyperthyroidism, or Graves’ disease, is manifested by increased appetite with weight loss,
  increased anxiety, hand tremors, palpitations, heat intolerance, and insomnia. A pituitary tumor can
  have many symptoms, depending on the location.
  CN: Reduction of risk potential; CL: Analyze
1. After the symptoms of puberty, such as increased hair growth and enlargement of the
  breasts, are noticed, menstruation typically begins within 30 months.
  CN: Health promotion and maintenance; CL: Apply
1. Epstein’s pearls are tiny, hard, white nodules found in the mouth of some neonates. They are
  considered normal and usually disappear without treatment. Koplik’s spots, associated with measles
  in children, are patchy and bright red with a bluish-white speck in the middle. Precocious teeth are
  actual teeth that some neonates have at birth. Usually, only one or two teeth are present. Candida
  albicans, or thrush, is not apparent in the mouth immediately after birth but may appear a day or 2
  later. This infection is manifested by yellowish-white spots or lesions that resemble milk curds and
  bleed when attempts are made to wipe them away.
  CN: Health promotion and maintenance; CL: Analyze
1, 2. The initial signs of esophageal atresia and TEF include lots of frothy mucus and
unexplained episodes of cyanosis usually caused by overflow of mucus from the esophagus. Loose
stools and poor gag reflex are not signs of TEF. Initial weight loss is common in newborns and not
related to TEF.
CN: Reduction of risk potential; CL: Analyze
1. Adequate circulatory status is the most important factor in the healing process of an infected
  decubitus ulcer. Blood flow to the area must be present to bring nutrients and prescribed antibiotics to
  the tissues. Rest and a balanced diet are essential to health maintenance but are not the priority for
  healing an infected decubitus ulcer. A fluid intake of 2,000 to 3,000 mL/day, if not contraindicated, is
  recommended to provide hydration to the client’s tissues.
  CN: Reduction of risk potential; CL: Synthesize
1. The nurse’s initial response should be to withhold the digoxin. The nurse should then notify
  the physician if the apical pulse is 60 bpm or lower because of the risk of digoxin toxicity. The charge
  nurse does not need to be notified, but the nurse needs to document the notification and follow-up in
  the chart.
  CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 9

Q

The nurse hears a pregnant client yell, “Oh my! The baby’s coming!” After placing the client
in a supine position and trying to maintain some privacy, the nurse sees that the neonate’s head is
being born. Which of the following should the nurse do first?
Suction the mouth with two fingertips.
Check for presence of a cord around the neck.
Tell the client to bear down with force.
Advise the mother that help is on the way.
The nurse is preparing a discharge plan for a 16-year-old who has fractured the femur and
ulna. The client asks the nurse how quickly the fractures will heal. Which of the following responses
is most appropriate for the nurse to make?
“The healing of your leg will be delayed because you have had skeletal traction.”2. “It will take your arm about 12 weeks to heal completely, but it will take your leg about 24
weeks.”
“Because you are young and healthy, your bones should heal in less than 12 weeks.”
“You will require long-term rehabilitation and should expect it to take at least 8 months for
your bones to heal.”
A client with delirium becomes very anxious and says, “I can’t stop what is happening to me.
Make it stop, please!” Which of the following is the nurse’s most appropriate response?
“I’ll get you some medicine to help you relax. The more you worry, the worse it will get.”
“As soon as we know what’s causing this, we can try to stop it. I’ll get you some medicine to
help you relax.”
“I wish I could do something to make it stop, but unfortunately I can’t.”
“I’ll sit with you until you calm down a little.”
After teaching a primigravid client at 10 weeks’ gestation about the recommendations for
exercise during pregnancy, which of the following client statements indicates successful teaching?
“While pregnant, I should avoid contact sports.”
“Even though I’m pregnant, I can learn to ski next month.”
“While we are on vacation next month, I can continue to scuba dive.”
“Sitting in a hot tub after exercise will help me to relax.”
The nurse is assessing a client who has had a myocardial infarction. The nurse notes the
cardiac rhythm shown below. The nurse identifies that this rhythm is:
Atrial fibrillation.
Ventricular tachycardia.
Premature ventricular contractions.
Third-degree heart block.
The physician has prescribed a chemotherapy drug to be administered to a client every day
for the next week. The client is on an adult medical-surgical floor, but the nurse assigned to the client
has not been trained to handle chemotherapy agents. What is the nurse’s most appropriate response?
Send the client to the oncology floor for administration of the medication.
Ask a nurse from the oncology floor to come to the client and administer the medication.
Ask another nurse to help mix the chemotherapy agent.
Ask the pharmacy to mix the chemotherapy agent and administer it.
Which of the following is a priority goal after surgical repair of a cleft lip?
Managing pain.
Preventing infection.3. Increasing mobility.
Developing parenting skills.
Which of the following is an appropriate outcome for a client with rheumatoid arthritis?
The client will manage joint pain and fatigue to perform activities of daily living.
The client will maintain full range of motion in joints.
The client will prevent the development of further pain and joint deformity.
The client will take anti-inflammatory medications as indicated by the presence of disease
symptoms.
A client’s burn wounds are being cleaned twice a day in a hydrotherapy tub. Which of the
following interventions should be included in the plan of care before a hydrotherapy treatment is
initiated?
Limit food and fluids 45 minutes before therapy to prevent nausea and vomiting.
Increase the IV flow rate to offset fluids lost through the therapy.
Apply a topical antibiotic cream to burns to prevent infection.
Administer pain medication 30 minutes before therapy to help manage pain.
A health care provider has been exposed to hepatitis B through a needlestick. Which of the
following drugs should the nurse anticipate administering as postexposure prophylaxis?
Hepatitis B immune globulin.
Interferon.
Hepatitis B surface antigen.
Amphotericin B.

Answer

A

1. In an emergency in which the neonate’s head is already being born, the first action by the
  nurse should be to check for the presence of a cord around the neonate’s neck. If the cord is present,
  the nurse should gently remove it from around the neck. The mother should be told to breathe gently
  and avoid forceful bearing-down efforts, which could lead to lacerations. Although blood and bodily
  fluid precautions are always present in client care, this is an emergency. If possible, the nurse should
  put on gloves. Suctioning the mouth can be done after the nurse has checked that the cord is not around
  the neonate’s neck. Telling the mother that help is on the way is not reassuring because emergency
  medical technicians may take some time to arrive. Birth is imminent because the neonate’s head is
  emerging.
  CN: Reduction of risk potential; CL: Synthesize
1. The ulna heals in approximately 12 weeks. The femur takes approximately 24 weeks to heal
  because of the size of the bone and the muscle forces exerted on the femur. Skeletal traction does not
  delay healing but can actually promote healing by properly aligning the fracture.
  CN: Reduction of risk potential; CL: Synthesize
1. The client needs to know that there is a cause for the delirium, that there is hope for
  treatment, and that medications can help decrease anxiety. Giving medications can help the anxiety,
  but the client also needs an explanation about the condition. Saying that the more the client worries,
  the worse the delirium will get is inappropriate and most likely would add to the client’s anxiety.
  CN: Psychosocial integrity; CL: Synthesize
1. The client understands the instructions when she says she should avoid contact sports
  because they may result in injury to the client and the fetus. Learning to ski while pregnant is not
  recommended because injury may occur. Scuba diving should be avoided because depth pressures
  could cause fetal damage. Hot tubs should be avoided during the first trimester because sitting in them
  can result in fetal hyperthermia and fetal hypoxia. Mild exercises, such as walking, can help
  strengthen the muscles and prevent some discomforts such as backache.
  CN: Health promotion and maintenance; CL: Evaluate
1. Third-degree heart block occurs when atrial stimuli are blocked at the atrioventricular
  junction. Impulses from the atria and ventricles are conducted independently of each other. The atrial
  rate is 60 to 100 bpm; the ventricular rate is usually 10 to 60 bpm.
  CN: Reduction of risk potential; CL: Analyze
1. The nurse should call the oncology unit to institute a transfer. The nurse handling
  chemotherapy agents should be specially trained. It is an unwise use of nursing resources to send a
  nurse from one unit to administer medications to a client on another unit. It is better to centralize and
  send the client who needs chemotherapy to one unit. Even if the pharmacy mixes the agent, the drug
  must be administered by a specially trained nurse.
  CN: Management of care; CL: Synthesize
1. After surgery, the most important nursing goal is to prevent infection. Surgery involves an
  incision, which places the infant at risk for infection. The infant with this type of procedure does have
  discomfort, which can be relieved with acetaminophen (Tylenol), and managing pain is important but
  not the priority. The infant may be in arm restraints or have the cuff of the sleeve pinned to the diaper
  or pants. It is important that the infant not touch the incision line or disrupt the sutures, but the infant isnot at risk for problems related to immobility. There is no indication that the parents need to improve their skills, but the nurse can support the family as they would be reacting normally with a first
  reaction of shock.
  CN: Reduction of risk potential; CL: Analyze
1. An appropriate outcome for the client with rheumatoid arthritis is that he will adopt self-
  care behaviors to manage joint pain, stiffness, and fatigue and be able to perform activities of daily
  living. Range-of-motion (ROM) exercises can help maintain mobility, but it may not be realistic to expect the client to maintain full ROM. Depending on the disease progression, there may be further development of pain and joint deformity, even with appropriate therapy. It is important for the client
  to understand the importance of taking the prescribed drug therapy even if symptoms have abated.
  CN: Reduction of risk potential; CL: Synthesize
1. Hydrotherapy wound cleaning is very painful for the client. The client should be medicated
  for pain about 30 minutes before the treatment in anticipation of the increased pain the client will
  experience. Wounds are debrided but excessive fluids are not lost during the hydrotherapy session.
  However, electrolyte loss can occur from open wounds during immersion, so the sessions should be
  limited to 20 to 30 minutes. There is no need to limit food or fluids 45 minutes before hydrotherapy
  unless it is an individualized need for a given client. Topical antibiotics are applied after
  hydrotherapy.
  CN: Reduction of risk potential; CL: Create
1. Hepatitis B immune globulin is given as prophylactic therapy to individuals who have been
  exposed to hepatitis B. Interferon has been approved to treat hepatitis B. Hepatitis B surface antigen
  is a diagnostic test used to detect current infection. Amphotericin B is an antifungal.
  CN: Pharmacological and parenteral therapies; CL: Apply

Question 10

Q

When performing an otoscopic examination of the tympanic membrane of a 2-year-old child,
the nurse should pull the pinna in which of the following directions?
Down and back.
Down and slightly forward.
Up and back.
Up and forward.

92. Which of the following findings should the nurse note in the client who is in the compensatory
stage of shock?
1. Decreased urinary output.
2. Significant hypotension.
3. Tachycardia.
4. Mental confusion.

A client has been prescribed hydrochlorothiazide (HydroDIURIL) to treat heart failure. For
which of the following symptoms should the nurse monitor the client?
Urinary retention.
Muscle weakness.
Confusion.
Diaphoresis.
The son of a client with Alzheimer’s disease excitedly tells the nurse, “Mom was singing one
of her favorite old songs. I think she’s getting her memory back!” Which of the following responses by
the nurse is most appropriate?1. “She still has long-term memory, but her short-term memory will not return.”
“I’m so happy to hear that. Maybe she is getting better.”
“Don’t get your hopes up. This is only a temporary improvement.”
“I’m glad she can sing even if she can’t talk to you.”
The nurse collects a urine specimen from a client for a culture and sensitivity analysis. Which
of the following is the correct care of the specimen?
Promptly send the specimen to the laboratory.
Send the specimen with the next pickup.
Send the specimen the next time a nursing assistant is available.
Store the specimen in the refrigerator until it can be sent to the laboratory.
A 16-year-old client is in the emergency department for treatment of minor injuries from a car
accident. A crisis nurse is with the client because the client became hysterical and was saying, “It’s
my fault. My Mom is going to kill me. I don’t even have a way home.” Which of the following should
be the nurse’s initial intervention?
Hold her hands and say, “Slow down. Take a deep breath.”
Say, “Calm down. The police can take you home.”
Put a hand on her shoulder and say, “It wasn’t your fault.”
Say, “Your mother is not going to kill you. Stop worrying.”
The nurse is developing a community health education program about sexually transmitted
diseases. Which information about women who acquire gonorrhea should be included?
Women are more reluctant than men to seek medical treatment.
Gonorrhea is not easily transmitted to women who are menopausal.
Women with gonorrhea are usually asymptomatic.
Gonorrhea is usually a mild disease for women.
A client has the leg immobilized in a long leg cast. Which of the following assessments
indicates the early beginning of circulatory impairment?
Inability to move toes.
Cyanosis of toes.
Sensation of cast tightness.
Tingling of toes.
A client tells the nurse that she has had sexual contact with someone whom she suspects has
genital herpes. Which of the following instructions should the nurse give the client in response to this
information?
Anticipate lesions within 25 to 30 days.
Continue sexual activity unless lesions are present.
Report any difficulty urinating.
Drink extra fluids to prevent lesions from forming.
A multigravid client at 34 weeks’ gestation who is leaking amniotic fluid has just been
hospitalized with a diagnosis of preterm premature rupture of membranes and preterm labor. The
client’s contractions are 20 minutes apart, lasting 20 to 30 seconds. Her cervix is dilated to 2 cm. The
nurse reviews the physician prescriptions (see chart). Which of the following prescriptions should the
nurse initiate first?1. Initiate fetal and contraction monitoring.
Start the intravenous infusion.
Obtain the urine specimen.
Administer betamethasone

PHYSICIAN PRESCRIPTION

COntinuous external fetal and contraction monitoring IV of D5LR @ 125 ml / h
i&O catheterization for urinalysis and culture and sensitivity
Bethamethasone 12 mg IM daily x 2 days

Answer

A

1. When examining the tympanic membrane of a child younger than age 3 years, the nurse
  should pull the pinna down and back. For an older child, the nurse should pull the pinna up and back
  to view the tympanic membrane.
  CN: Reduction of risk potential; CL: Apply
1. In the compensatory stage of shock, the client exhibits moderate tachycardia. If the shock
  continues to the progressive stage, decreased urinary output, hypotension, and mental confusion
  develop as a result of failure to perfuse and ineffective compensatory mechanisms. These findings are
  indications that the body’s compensatory mechanisms are failing.
  CN: Reduction of risk potential; CL: Analyze
1. Hydrochlorothiazide is a thiazide diuretic. Muscle weakness can be an indication of
  hypokalemia. Polyuria is associated with this diuretic, not urinary retention. Confusion and
  diaphoresis are not side effects of hydrochlorothiazide.
  CN: Pharmacological and parenteral therapies; CL: Analyze
1. The ability to remember an old song is related to long-term memory, which persists after
  short-term memory is lost. Therefore, the nurse should respond by providing the son with this
  information. Stating that the nurse is happy to hear about the change and that the client is getting better
  is inappropriate and inaccurate. This statement ignores the issue of long-term versus short-termmemory. Telling the client not to get his hopes up because the improvement is only temporary is
  inappropriate. The information provided does not indicate that the client has expressive aphasia,
  which would be suggested by the statement that the client can’t talk to the son.
  CN: Psychosocial integrity; CL: Analyze
1. A specimen for culture and sensitivity should be sent to the laboratory promptly so that a
  smear can be taken before organisms start to grow in the specimen.
  CN: Reduction of risk potential; CL: Apply
1. The client is in a crisis and has a high anxiety level. Holding the client’s hands and
  encouraging the client to slow down and take a deep breath convey caring and helps decrease anxiety.
  Telling the client to calm down or stop worrying offers no concrete directions for accomplishing this
  task. It is unknown from the data who was at fault in the accident. Therefore, it is inappropriate for
  the nurse to state that it wasn’t the client’s fault.
  CN: Psychosocial integrity; CL: Synthesize
1. Many women who acquire gonorrhea are asymptomatic or experience mild symptoms that
  are easily ignored. They are not necessarily more reluctant than men to seek medical treatment, but
  they are more likely not to realize they have been affected. Gonorrhea is easily transmitted to all
  women and can result in serious consequences, such as pelvic inflammatory disease and infertility.
  CN: Management of care; CL: Create
1. Tingling and numbness of the toes would be the earliest indication of circulatory
  impairment. Inability to move the toes and cyanosis are later indicators. Cast tightness should be
  investigated because cast tightness can lead to circulatory impairment; it is not, however, an indicator
  of impairment.
  CN: Reduction of risk potential; CL: Analyze
1. The client should be encouraged to report painful urination or urinary retention. Lesions
  may appear 2 to 12 days after exposure. The client is capable of transmitting the infection even when
  asymptomatic, so a barrier contraceptive should be used. Drinking extra fluids will not stop the
  lesions from forming.
  CN: Management of care; CL: Synthesize
1. The nurse should initiate fetal and contraction monitoring for this client upon arrival to the
  unit. This gives the nurse data regarding changes in fetal and maternal contraction status before
  completing the other prescriptions. Next, the betamethasone would be given to begin the maturation
  process for the fetal lungs. Next, the nurse should start an intravenous infusion to provide a line for
  immediate intravenous access, if needed, and provide hydration for the client. The nurse should
  obtain the urine specimen prior to administering any antibiotic therapy, if prescribed.
  CN: Management of care; CL: Synthesize

Question 11

Q

101. The nurse is assessing a client with irreversible shock. The nurse should document which of
the following?
1. Increased alertness.
2. Circulatory collapse.
3. Hypertension.
4. Diuresis.

The nurse is caring for a client who has been diagnosed with deep vein thrombosis. When
assessing the client’s vital signs, the nurse notes an apical pulse of 150 bpm, a respiratory rate of 46
breaths/min, and blood pressure of 100/60 mm Hg. The client appears anxious and restless. What
should be the nurse’s first course of action?
Notify the physician.
Administer a sedative.
Try to elicit a positive Homans’ sign.
Increase the flow rate of intravenous fluids.
A client who has Ménière’s disease is trying to cope with chronic tinnitus. Which of the
following interventions is most appropriate for the nurse to suggest for coping with the tinnitus?
Maintain a quiet environment.
Play background music.
Avoid caffeine and nicotine.
Take a mild sedative.
A 4-year-old child who has been ill for 4 hours is admitted to the hospital with difficulty
swallowing, a sore throat, and severe substernal retractions. The child’s temperature is 104°F (40°C),
and the apical pulse is 140 bpm. The white blood cell count is 16,000/mm 3 (16 × 10 9 /L). Which of
the following is the priority for nursing intervention?
Anxiety.
Airway obstruction.
Difficulty breathing.
Potential for aspiration.
The nurse is conducting walking rounds and observes the client (see figure). The nurse
should do which of the following?
Loosen the bed restraints so the client can sit up.
Raise the side rails to full upright position.
Assess the client to determine why she wants to sit up.
Elevate the head of the bed.
The nurse caring for a client with diabetes realizes that the client has a higher risk of
developing cataracts and should also assess the client for indications of:
Background retinopathy.
Proliferative retinopathy.
Neuropathy.
Diabetic retinopathy.
Of the following clients, which client is at greatest risk for falling?
A 22-year-old man with three fractured ribs and a fractured left arm.
A 70-year-old woman with episodes of syncope.
A 50-year-old man with angina.
A 30-year-old woman with a fractured ankle.
Which of the following baseline laboratory data should be established before a client is
started on tissue plasminogen activator or alteplase recombinant (Activase)?
Potassium level.
Lee-White clotting time.
Hemoglobin level, hematocrit, and platelet count.
Blood glucose level.
The nurse is developing an education plan for clients with hypertension. Which of the
following long-term goals is most appropriate for the nurse to emphasize?
Develop a plan to limit stress.
Participate in a weight reduction program.
Commit to lifelong therapy.
Monitor blood pressure regularly.
The nurse should consider which of the following principles when developing a plan of care
to manage a client’s pain from cancer?
Individualize the pain medication regimen for the client.
Select medications that are least likely to lead to addiction.
Administer pain medication as soon as the client requests it.
Change pain medications periodically to avoid drug tolerance.

Answer

A

1. Severe hypoperfusion to all vital organs results in failure of the vital functions and then
  circulatory collapse. Hypotension, anuria, respiratory distress, and acidosis are other symptoms
  associated with irreversible shock. The client in irreversible shock will not be alert.
  CN: Reduction of risk potential; CL: Analyze
1. Pulmonary embolism is a potentially life-threatening complication of deep veinthrombosis. The client’s change in mental status, tachypnea, and tachycardia indicates a possible
  pulmonary embolism. The nurse should promptly notify the doctor of the client’s condition.
  Administering a sedative without further evaluation of the client’s condition is not appropriate. There
  is no need to elicit a positive Homans’ sign; the client is already diagnosed with deep vein
  thrombosis. Increasing the IV flow rate may be an appropriate action but not without first notifying the
  physician.
  CN: Reduction of risk potential; CL: Synthesize
1. Coping with the chronic tinnitus of Ménière’s disease can be very frustrating. Providing
  background sound, such as music, can help camouflage the low-pitched, roaring sound of tinnitus.
  Maintaining a quiet environment can make the sounds of tinnitus more pronounced. Avoiding caffeine
  and nicotine is recommended because this can decrease the occurrence of the tinnitus. However,
  avoiding these substances does not help the client with coping with tinnitus when it occurs. Taking a
  sedative does not affect tinnitus.
  CN: Reduction of risk potential; CL: Synthesize
1. The child’s signs and symptoms in conjunction with the acute onset suggest possible croup
  or epiglottiditis. The priority diagnosis at this time is airway obstruction. The airway may become
  completely occluded by the epiglottis at any time. Although the child is probably experiencing fear
  and anxiety, and the client has respiratory distress, the immediate priority is to establish and maintain
  a patent airway. No evidence is provided to support the potential for aspiration.
  CN: Reduction of risk potential; CL: analyze
1. The nurse should first determine why the client wants to sit up and then, if needed delegate
  someone to assist the client. Loosening the restraints will not keep the client safe in bed. Raising the
  side rails and elevating the head of the bed do not address the client’s needs.
  CN: Management of care; CL: Synthesize
1. Diabetic retinopathy involves background and proliferative retinopathy. Both forms are
  associated with vascular changes in the basement membrane of the arterioles and capillaries of the
  choroid and retina. Neuropathy is usually associated with the lower extremities.
  CN: Reduction of risk potential; CL: Analyze
1. The 70-year-old woman with syncopal episodes is at greatest risk for falling. The nurse
  should assess the client’s gait and balance and the syncopal episodes. The 22-year-old man with
  upper body fractures and the 50-year-old man with angina are not at risk for falling. The 30-year-old
  woman could be at risk for falling, but she is at less risk than the 70-year-old client with syncope.
  CN: Management of care; CL: Analyze
1. The baseline laboratory data that are established before a client is started on tissue
  plasminogen activator or alteplase recombinant include hematocrit, hemoglobin level, and platelet
  count.
  CN: Reduction of risk potential; CL: Apply
1. The most appropriate long-term goal for the client with hypertension is to commit to
  lifelong therapy. A significant problem in the long-term management of hypertension is compliance
  with the treatment plan. It is essential that the client understand the reasons for modifying lifestyle,taking prescribed medications, and obtaining regular health care. Limiting stress, losing weight, and
  monitoring blood pressure are important aspects of care for the client with hypertension; however, the
  treatment plan must be individualized to include aspects of care that are appropriate for each client.
  CN: Health promotion and maintenance; CL: Synthesize
1. The nurse should work with the client to individualize the plan of care for managing pain.
  Cancer pain is best managed with a combination of medications, and each client needs to be worked
  with individually to find the treatment regimen that works best. Cancer pain is commonly undertreated
  because of fear of addiction. The client who is in pain needs the appropriate level of analgesic and
  needs to be reassured that addiction is unlikey. Cancer pain is best treated with regularly scheduled
  doses of medication. Administering the medication only when the client asks for it will not lead to
  adequate pain control. As drug tolerance develops, the dosage of the medication can be increased.
  CN: Basic care and comfort; CL: Synthesize

Question 12

Q

After explaining to a multigravid client at 36 weeks’ gestation who is diagnosed with severe
hydramnios about the possible complications of this condition, which of the following statements
indicates that the client needs further instruction?
“Because I have hydramnios, I may gain weight.”
“Hydramnios has been associated with gastrointestinal disorders in the fetus.”
“I should continue to eat high-fiber foods and avoid constipation.”
“I can continue to work at my job at the automobile factory until labor starts.”
An obese diabetic client has bilateral leg aching and is to start a cardiac rehabilitation to
start an exercise program. Which of the following activities is most helpful for the client?
Interval training on the stationary bicycle.
Interval training on the treadmill.
Interval training on a commercial ski machine.
Interval training on the stair climber.
The nurse is assigned to a client with jaundice and collects the following data: poor
appetite, nausea, and two episodes of emesis in the past 2 hours. The client reports having spasms in
the stomach area. The nurse should develop a care plan for which of the following health problems
first?
Nausea.
Poor appetite.
Jaundice.
Abdominal spasms.
Which of the following is recommended protocol for all clients who are at risk for pressure
sore development?
Identify at-risk clients on admission to the health care facility.
Place at-risk clients on an every-2-hour turning schedule.
Automatically place clients in specialty beds.
Provide at-risk clients with a high-protein, high-carbohydrate diet.
A client has been prescribed digoxin (Lanoxin). Which of the following symptoms should
the nurse tell the client to report as a potential indication of digoxin toxicity?
Urticaria.
Shortness of breath.
Visual disturbances.
Hypertension.
The nurse is instructing a client on how to care for skin that has become dry after radiation
therapy. Which of the following statements by the client indicates that the client understands the
teaching?1. “I should take antihistamines to decrease the itching I am experiencing.”
“It is safe to apply a nonperfumed lotion to my skin.”
“A heating pad, set on the lowest setting, will help decrease my discomfort.”
“I can apply an over-the-counter cortisone ointment to relieve the dryness.”
A neonate is experiencing respiratory distress and is using a neonatal oxygen mask. An
unlicensed assistive personnel has positioned the oxygen mask as shown below. The nurse is
assessing the neonate and determines that the mask:
Is appropriate for the neonate.
Is too large because it covers the neonate’s eyes.
Is too small because it is obstructing the nose.
Should be covered with a soft cloth before being placed against the skin.
The nurse is preparing a client for a thoracentesis. How should the nurse position the client
for the procedure?
Supine with the arms over the head.
Sims’ position.
Prone position without a pillow.
Sitting forward with the arms supported on the bedside table.
The antidote for heparin is:
Vitamin K.
Warfarin (Coumadin).
Thrombin.
Protamine sulfate.
Which of the following actions is most appropriate when dealing with a client who is
expressing anger verbally, is pacing, and is irritable?
Conveying empathy and encouraging ventilation.
Using calm, firm directions to get the client to a quiet room.
Putting the client in restraints.
Discussing alternative strategies for when the client is angry in the future.

Answer

A

1. The client needs further instructions when she says, “I can continue to work at my job at
  the automobile factory until labor starts.” The goal is to avoid preterm labor. Because the client is
  experiencing severe hydramnios, she will most likely be maintained on bed rest to increase
  uteroplacental circulation and reduce pressure on the cervix. Hydramnios has been associated with
  increased weight gain caused by increased amniotic fluid volume. Hydramnios has been associated
  with gastrointestinal disorders in the fetus, such as tracheoesophageal fistula with stenosis or
  intestinal obstruction. The client should continue to eat high-fiber foods and should avoid straining,
  which could lead to ruptured membranes. Stool softeners may also be prescribed. The client should
  report any symptoms of fluid rupture or labor.
  CN: Reduction of risk potential; CL: Evaluate
1. The stationary bicycle is the most appropriate training modality because it is a non–
  weight-bearing exercise. Interval training involves rest and exercise. The time that the individual
  exercises on the stationary bicycle is increased with improved functional capacity, and the rest time is
  decreased.
  CN: Health promotion and maintenance; CL: Synthesize
1. The nurse should first plan to relieve the nausea and vomiting; if these continue, the client
  is at risk for dehydration and electrolyte imbalance. The client’s poor appetite is likely related to the
  underlying health problem and is not the priority; the nausea does not improve the appetite, and
  relieving the nausea may allow the client an opportunity to eat and drink. The client has jaundice but
  does not report uncomfortable symptoms such as pruritus. The abdominal spasms may be related to
  nausea and vomiting and can be assessed again when the nausea and vomiting have stopped.
  CN: Reduction of risk potential; CL: Analyze
1. All clients who are at risk for pressure ulcer development should be identified on
  admission to health care facilities so that preventive actions can be implemented by the nursing staff.
  These preventive actions need to be individualized to the client, so automatic placement of all at-risk
  clients on an every-2-hour turning schedule, a specialty bed, or a high-protein, high-carbohydrate diet
  is not appropriate.
  CN: Reduction of risk potential; CL: Apply
1. Visual disturbances are a symptom of digoxin (Lanoxin) toxicity. These disturbances caninclude double, blurred, or yellow vision. Cardiovascular manifestations of digoxin toxicity include
  bradycardia, other dysrhythmias, and pulse deficit. Gastrointestinal symptoms include anorexia,
  nausea, and vomiting.
  CN: Pharmacological and parenteral therapies; CL: Analyze
1. Irradiated skin can become dry and irritated, resulting in itching and discomfort. The client
  should be instructed to clean the skin gently and apply nonperfumed, nonirritating lotions to help
  relieve dryness. Taking an antihistamine does not relieve the skin dryness that is causing the itching.
  Heat should not be applied to the area because it can cause further irritation. Medicated ointments,
  especially corticosteroids, which are controversial, should not be applied to the skin without the
  prescription of the radiation therapist.
  CN: Reduction of risk potential; CL: Evaluate
1. The mask is appropriate because it covers the nose and mouth and fits snugly against the
  cheeks and chin. Masks that are too large may cover the eyes. Masks that are too small obstruct the
  nose. The mask does not need to be covered with a cloth.
  CN: Management of care; CL: Evaluate
1. In preparation for a thoracentesis, the client should be asked to sit forward and place his
  arms on the bedside table for support. This position provides access to the chest wall and intercostal
  spaces for insertion of the needle. The supine, Sims’, or prone position would not provide adequate
  access to the chest wall or separate the intercostal spaces sufficiently for needle insertion.
  CN: Reduction of risk potential; CL: Apply
1. The antidote for heparin is 1% protamine sulfate. Vitamin K is the antidote for warfarin,
  an oral anticoagulant. Thrombin is a topical anticoagulant.
  CN: Pharmacological and parenteral therapies; CL: apply
1. At this time, the client’s anger is not out of control, so empathy and talking are appropriate
  to diffuse the anger. Using time-out is appropriate when the client’s anger is escalating and the client
  can no longer talk about the anger rationally. Restraints are appropriate only when there is imminent
  risk of harm to the client or others. Future strategies are discussed after the initial incident is
  resolved.
  CN: Psychosocial integrity; CL: Synthesize

Question 13

Q

Which of the following measures should be implemented promptly after a client’snasogastric (NG) tube has been removed?
Provide the client with oral hygiene.
Offer the client liquids to drink.
Encourage the client to cough and deep breathe.
Auscultate the client’s bowel sounds.
The nurse applies warm compresses to a client’s leg. To determine effectiveness of the
compresses, the nurse should determine if there is:
Less scaling on the skin.
Decreased bruising.
Improved circulation to the area.
Decreased swelling in the area.
While assisting the physician with an amniocentesis on a multigravid client at 38 weeks’
gestation, the nurse observes that the fluid is very cloudy and thick. The nurse interprets this finding
as indicating which of the following?
Intrauterine infection.
Fetal meconium staining.
Erythroblastosis fetalis.
Normal amniotic fluid.
The nurse instructs the unlicensed assistive personnel on how to collect a 24-hour urine
specimen. Which of the following instructions is correct for a collection that is scheduled to start at 7
AM Monday and end at 7 AM Tuesday?
Collect and save the urine voided at 7 AM on Monday.
Send the first voided urine specimen on Monday to the laboratory for culture.
Collect and save the urine voided at 7 AM on Tuesday.
Keep each day’s urine collection in separate containers.
Which of the following laboratory values for a client with cirrhosis who has developed
ascites should the nurse report to the health care provider?
Decreased aspartate aminotransferase.
Hypoalbuminemia.
Hyperkalemia.
Decreased alanine aminotransferase.
An infant is to receive the diphtheria, tetanus, and acellular pertussis (DTaP) and inactivated
polio vaccine (IPV) immunizations. The child is recovering from a cold and is afebrile. The child’s
sibling has cancer and is receiving chemotherapy. Which of the following actions is most
appropriate?
Giving the DTaP and withholding the IPV.
Administering the DTaP and IPV immunizations.
Postponing both immunizations until the sibling is in remission.
Withholding both immunizations until the infant is well.
When creating a program to decrease the primary cause of disability and death in children,
which of the following is most effective for the community health nurse to do?
Encourage legislators to draft legislation to promote prenatal care.2. Require all children to be immunized.
Teach accident prevention and safety practices to children and their parents.
Hire a nurse practitioner for each of the schools in the community.
A client has had an incisional cholecystectomy. Which of the following nursing interventions
has the highest priority in postoperative care for this client?
Using incentive spirometry every 2 hours while awake.
Performing leg exercises every shift.
Maintaining a weight reduction diet.
Promoting incisional healing.
The nurse is evaluating an infant for auditory ability. Which of the following is the expected
response in an infant with normal hearing?
Blinking and stopping body movements when sound is introduced.
Evidence of shy and withdrawn behaviors.
Saying “da-da” by age 5 months.
Absence of squealing by age 4 months.
A client who had a transurethral resection of the prostate (TURP) 1 day earlier has a three-
way Foley catheter inserted for continuous bladder irrigation. Which of the following statements best
explains why continuous irrigation is used after TURP?
To control bleeding in the bladder.
To instill antibiotics into the bladder.
To keep the catheter free from clot obstruction.
To prevent bladder distention.

Answer

A

1. The nurse’s first action after the removal of a NG tube is to provide the client with oral hygiene. Then it is appropriate to give the client liquids to drink if the client is no longer on nothing-
  by-mouth status. There is no association between removal of an NG tube and having the client cough
  and deep breathe. Auscultating the client’s bowel sounds should be done before removal of the NG
  tube.
  CN: Basic care and comfort; CL: Synthesize
1. Heat applications cause vasodilation, which promotes circulation to the area, and increase
  tissue metabolism and leukocyte mobility. Heat applications do not prevent swelling; applications of
  cold are used to prevent swelling by causing vasoconstriction. Moist heat applications do not reduce
  bruising or scaling on the skin.
  CN: Reduction of risk potential; CL: Evaluate
1. Thick, cloudy amniotic fluid indicates an intrauterine infection. Typically, the client has a
  fever, lethargy, and malaise. Greenish-colored amniotic fluid is associated with meconium staining. A
  strong yellowish color is associated with erythroblastosis fetalis because of the presence of bilirubin
  and hemolyzed red blood cells. The normal color of amniotic fluid is clear or with a very slight
  yellow tint later in pregnancy.
  CN: Reduction of risk potential; CL: Analyze
1. When finishing a 24-hour urine collection, the final voided urine is saved and added to the
  collection container. The first urine specimen, voided at 7 AM Monday, is discarded. The urine is not
  sent for a urine culture. It is not necessary to separate each day’s collection of urine.
  CN: Reduction of risk potential; CL: Apply
1. Hypoalbuminemia occurs in cirrhosis because the liver cannot synthesize albumin. This
  causes a decrease in colloidal osmotic pressure, resulting in ascites. Hyperkalemia is not an expected
  electrolyte imbalance of cirrhosis. The aspartate aminotransferase and alanine aminotransferase
  values are increased in liver disease.
  CN: Reduction of risk potential; CL: Analyze
1. At this time, the infant can be given the vaccines. The fact that the child’s sibling is
  immunosuppressed because of chemotherapy is not a reason to withhold the vaccines. The fact that
  the child has a cold is not grounds for delaying the immunizations. However, if the child had a high
  fever, the immunizations would be delayed.
  CN: Health promotion and maintenance; CL: Synthesize
1. The primary cause of disability and death in children is injury from accidents. Teaching
  safety measures to children and their parents is the best way to decrease injury and accidents.
  CN: Management of care; CL: Synthesize
1. A major goal of postoperative care for the client who has had an incisional
  cholecystectomy is the prevention of respiratory complications. Because of the location of the
  incision, the client has a difficult time breathing deeply. Use of incentive spirometry promotes chest
  expansion and decreases atelectasis. Performing leg exercises each shift is not frequent enough; they
  should be performed hourly. Maintaining a weight reduction diet may be appropriate for the client,
  but it is not the highest priority in the immediate postoperative phase. Promoting wound healing is
  important, but respiratory complications are most common after a cholecystectomy.
  CN: Reduction of risk potential; CL: Synthesize
1. In response to hearing a noise, normally hearing infants blink or startle and stop body
  movements. Shy and withdrawn behaviors are characteristic of older children with hearing
  impairment. Squealing occurs in 90% of infants by age 4 months. Most infants can say “da-da” by age
  9 months.
  CN: Health promotion and maintenance; CL: Evaluate
1. Continuous irrigation, usually consisting of sterile normal saline, is used after TURP to
  keep blood clots from obstructing the catheter and impeding urine flow. Antibiotics may be instilled
  in the bladder with the use of an irrigating solution, but this is not the primary reason for using
  continuous irrigation in TURP. The irrigating solution may secondarily help prevent bladderdistention because it keeps the catheter from becoming obstructed.
  CN: Reduction of risk potential; CL: Apply

Question 14

Q

131. Which of the following sounds should the nurse expect to hear when percussing a distended
bladder?
1. Hyperresonance.
2. Tympany.
3. Dullness.
4. Flatness.

A tour bus has overturned on an exit ramp. Many passengers are injured, but there are no
fatalities. While the emergency department nurse prepares for treating the injured, the nurse also calls
the crisis nurse based on the understanding about which of the following?
The accident victims will be experiencing grief and mourning.
Many of the passengers may be experiencing feelings of victimization.
There is a need for someone to coordinate calls from relatives about the passengers.
Some of the passengers will need psychiatric hospitalization.
A postoperative nursing goal for the infant who has had surgery to correct imperforate anus
is to prevent tension on the perineum. To achieve this goal, the nurse should not place the neonate on
the:
Abdomen, with legs pulled up under the body.
Back, with legs suspended at a 90-degree angle.
Left side, with hips elevated.
Right side, with hips elevated.
A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation
for the child’s arrival, the nurse should first:
Institute droplet precautions.
Obtain the child’s vital signs.
Ask the parent about medication allergies.
Inquire about the health of siblings at home.
When developing the plan of care for a 14-year-old boy who is bored due to being
immobilized in a cast, which of the following activities is most appropriate?
Playing a card game with a boy the same age.
Putting together a puzzle with his mother.
Playing video games with a 9-year-old.
Watching a movie with his younger brother.
An adolescent is being prepared for an emergency appendectomy. What should the nurse tell
the client? Select all that apply.
Friends can visit whenever they want.
The scar will be small.
The teen will be back in school in 1 week.
Antibiotics will be given to prevent an infection.
A dressing will stay in place for 1 week.
A client receives morphine for postoperative pain. Which of the following assessments
should the nurse include in the client’s plan of care?
Take apical heart rate after each dose of morphine.
Assess urinary output every 8 hours.
Assess mental status every shift.
Check for pedal edema every 4 hours.

138. When infusing total parenteral nutrition (TPN), the nurse should assess the client for which
of the following complications?
1. Essential amino acid deficiency.
2. Essential fatty acid deficiency.
3. Hyperglycemia.
4. Infection.

When assessing for signs of a blood transfusion reaction in a client with dark skin, the nurse
should assess for which of the following?
Hypertension.
Diaphoresis.
Polyuria.
Warm skin.
The nurse is caring for a child with a head injury. Place the following assessments in order
of priority, starting with the nursing assessment the nurse should perform first.
Vital signs.
Decreased urine output.
Level of consciousness.
Motor strength.

Answer

A

1. A distended bladder produces dullness when percussed because of the presence of urine.
  Hyperresonance is a percussion sound that is present in hyperinflated lungs. Tympany, a loud
  drumlike sound, occurs over gas-filled areas such as the intestines. Flat sounds occur over very dense
  tissue that has no air present.
  CN: Reduction of risk potential; CL: Analyze
1. Major accidents can induce feelings similar to those of victims of other kinds of disasters
  and crime. Therefore, the nurse calls the crisis nurse to assist the passengers with their feelings of
  victimization. Passengers may mourn the loss of a vacation, but with no fatalities, major grief
  reactions are not expected. Other personnel can take calls from relatives, while the crisis nurse helps
  the passengers. Psychiatric hospitalization is a premature assumption.
  CN: Psychosocial integrity; CL: Analyze
1. When placed on the abdomen, a neonate pulls the legs up under the body, which puts
  tension on the perineum. Therefore, after surgery, the neonate should be positioned either supine with
  the legs suspended at a 90-degree angle or on either side with the hips elevated.
  CN: Reduction of risk potential; CL: Apply
1. The child with meningococcal meningitis requires droplet precautions for at least the first
  24 hours after effective therapy is initiated to reduce the risk of transmission to others on the unit.
  After the child has been placed on droplet precautions, other actions, such as taking the child’s vital
  signs, asking about medication allergies, and inquiring about the health of siblings at home, can be
  performed.
  CN: Management of care; CL: Synthesize
1. Teenagers usually enjoy activities with peers in preference to socializing with their
  parents or siblings. Peer relationships help the adolescent develop self-identity.
  CN: Health promotion and maintenance; CL: Synthesize
2, 3. Teens are very concerned about their body image and knowing about the size of the scar
is important to them. Typically, teens return to school in 1 week. While hospitalized, friends can visit
during visiting hours. Clients are usually hospitalized for an uncomplicated appendectomy for about
24 hours. Antibiotics are not routinely given to prevent an infection. The dressing is removed within a
few days.
CN: Reduction of risk potential; CL: Synthesize
1. Morphine can cause urinary retention. The nurse should assess the client for urinary
  hesitancy or retention and note the urinary output. It is not necessary to take the apical heart rate after
  each dose of morphine. Mental status should be assessed after each dose because morphine can cause
  such effects as sedation, delirium, and disorientation. Assessing for pedal edema is not necessary.
  CN: Pharmacological and parenteral therapies; CL: Analyze
1. Infection is the greatest concern to the nurse. Infection occurs more frequently because of
  the number of procedures performed on clients that require this therapy and people they come in
  contact with in the hospital. Infection can be reduced if proper infection control techniques are usedand human contact is reduced. Deficiencies and toxicities of nutrients are rare because of the use of
  standard protocols and prescriptions for TPN formulas. Hyperglycemia can occur with TPN
  administration; however, all clients receiving TPN have their serum glucose concentration monitored
  frequently, and the hyperglycemia can easily be managed by adding insulin to the TPN solution. An
  infection is a much more serious complication.
  CN: Pharmacological and parenteral therapies; CL: Analyze
1. The nurse should assess for signs of impending shock such as diaphoresis. The client
  would have hypotension, dysuria, and cool skin.
  CN: Pharmacological and parenteral therapies; CL: Analyze

140.
3. Level of consciousness.
4. Motor strength.
1. Vital signs.
2. Decreased urine output.
In order of priority, the nurse would assess level of consciousness, motor strength, vital signs, and
then decreased urine output. Level of consciousness is the best indication of brain function. If the
child’s condition deteriorates, the nurse would observe changes in level of consciousness before any
other changes. Motor strength is primarily assessed as a voluntary action. With a change in level of
consciousness, there may be changes in motor function. If the client’s fluids are restricted, then the
urine output would decrease. In children, the usual urine output is 1 mL/kg/h.
CN: Reduction of risk potential; CL: Synthesize

Question 15

Q

After surgery to create a urinary diversion, the client is at risk for a urinary tract infection.
The nurse should plan to incorporate which of the following interventions into the client’s care?
Clamp the urinary appliance at night.
Empty the urinary appliance when one-third full.
Administer prophylactic antibiotics.
Change the urinary appliance daily.
When suctioning a client’s tracheostomy tube, the nurse should do which of the following?
Oxygenate the client before suctioning.
Insert the suction catheter about 2 inches (5.1 cm) into the cannula.
Use a bolus of sterile water to stimulate cough.
Use clean gloves during the procedure.

143. A 14-month-old child has a severe diaper rash. Which of the following recommendations
should the nurse provide to the parents?
1. Continue to use the baby wipes.
2. Change the diaper every 4 to 6 hours.
3. Wash the buttocks using mild soap.
4. Apply powder to the diaper area.

On entering a toddler’s room, the nurse finds the mother sitting about 8 feet (240 cm) from
the child and watching television while the toddler is screaming. Which of the following is the most
appropriate response by the nurse?
“What happened between you and your child?”
“Why is your child screaming?”
“Did something cause your child to be upset?”
“Have you tried to calm down your child?”
A client has a total hip replacement. Which of the following client statements indicates a
need for further teaching before discharge?
“I will implement my exercise program as soon as I get home.”
“I will be careful not to cross my legs.”
“I will need an elevated toilet seat.”4. “I can’t wait to take a tub bath when I get home.”

146. An adolescent thinks she has infectious mononucleosis. The nurse should next assess the
client for: Select all that apply.
1. Sore throat.
2. Malaise.
3. Weight loss.
4. Rash.
5. Swollen lymph glands.

While assessing the fundus of a multiparous client on the first postpartum day, the nurse
performs hand washing and puts on clean gloves. Which of the following should the nurse do next?
Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus.
Ask the client to assume a side-lying position with the knees flexed.
Perform massage vigorously at the level of the umbilicus if the fundus feels boggy.
Place the client on a bedpan in case the uterine palpation stimulates the client to void.
A nulligravid client with gestational diabetes tells the nurse that she had a reactive nonstress
test 3 days ago and asks, “What does that mean?” The nurse explains that a reactive nonstress test
indicates which of the following about the fetus?
Evidence of some compromise that will require childbirth soon.
Fetal well-being at this point in the pregnancy.
Evidence of late decelerations occurring during the test.
No accelerations demonstrated within a 20-minute period.

149. A client has been diagnosed with right-sided heart failure. The nurse should assess the client
further for:
1. Intermittent claudication.
2. Dyspnea.
3. Dependent edema.
4. Crackles.

To help prevent hip flexion deformities associated with rheumatoid arthritis, the nurse
should help the client assume which of the following positions in bed several times a day?
Prone.
Very low Fowler’s.
Modified Trendelenburg.
Side-lying.

Answer

A

1. The urinary appliance should be emptied before the pouch is one-third full to prevent
  urinary reflux. The appliance should be attached to a leg bag at night to allow for adequate drainage.
  It is not appropriate to administer prophylactic antibiotics when incorporating positive self-care
  activities into the client’s routine can prevent most urinary tract infections. The urinary appliance is
  not changed daily. If no leakage occurs and the client’s skin remains free from irritation, the appliance
  can be left in place for 1 week or more.
  CN: Basic care and comfort; CL: Synthesize
1. Preoxygenating the client before suctioning helps prevent the development of hypoxia
  during the procedure. The suction catheter is inserted about 5 to 6 inches (12.7 to 15.2 cm) into the
  cannula. A bolus of 3 to 5 mL of sterile normal saline solution may be inserted into the cannula before
  suctioning to stimulate coughing and loosen secretions. The nurse uses sterile technique when
  suctioning a client.
  CN: Reduction of risk potential; CL: Apply
1. Because the toddler has a severe diaper rash, it may be best to change all that the parents
  are doing. The buttocks need to be washed thoroughly with mild soap and dried well. In fact, it is
  helpful to leave the diaper off and expose the buttocks to the air. Baby wipes commonly contain
  additives and perfumes that may be irritating to the baby’s sensitive skin. The diaper needs to be
  changed more often than every 4 to 6 hours. Otherwise, the moist diaper environment will continue to
  irritate the skin, causing the rash to worsen. Powder has limited absorbing ability and will most likely
  irritate the area more. In addition, some powders contain perfumes or are scented and can irritate the
  skin.
  CN: Basic care and comfort; CL: Synthesize
1. The toddler is screaming for a reason, so it is most therapeutic to ask the mother why the
  child is screaming. This type of question is nonaccusatory, just seeking information. Asking the
  mother what happened between her and the child makes the assumption that something did happen and
  limits the amount of information to be gained from the question. Asking whether something caused the
  child to be upset makes an assumption that something happened and limits the answer to a yes or no
  response, cutting off communication. Asking whether the mother has tried to calm the child is
  accusatory and also limits the response to yes or no, thus cutting off communication.
  CN: Health promotion and maintenance; CL: Synthesize
1. The client will need to avoid extremes of motion in the hip to avoid dislocation. The hip
  should not be flexed more than 90 degrees, internally rotated, or legs crossed. It is not possible to
  safely sit in the bathtub without flexing the hip beyond the recommended 90 degrees. The client can
  implement the prescribed exercise program at the time of discharge home. The client should take care
  not to stress the hip for 3 to 6 months after surgery. An elevated toilet seat will be necessary during
  the recovery from surgery.
  CN: Reduction of risk potential; CL: Evaluate
1, 2, 5. The common presenting symptoms of infectious mononucleosis vary greatly but
commonly include fever, malaise, sore throat, and lymphadenopathy. Skin rash, cold symptoms,
abdominal pain, and weight loss are rarely presenting symptoms.
CN: Reduction of risk potential; CL: Analyze
1. The nurse should place the nondominant hand above the symphysis pubis and the dominant
  hand at the umbilicus to palpate the fundus. This prevents uterine inversion and trauma, which can be
  very painful to the client. The nurse should ask the client to assume a supine, not side-lying, position
  with the knees flexed. The fundus can be palpated in this position, and the perineal pads can be
  evaluated for lochia amounts. The fundus should be massaged gently if the fundus feels boggy.
  Vigorous massaging may fatigue the uterus and cause it to become firm and then boggy again. The
  nurse should ask the client to void before fundal evaluation. A full bladder can cause discomfort to
  the client, the uterus to be deviated to one side, and postpartum hemorrhage.
  CN: Health promotion and maintenance; CL: Apply
1. A reactive nonstress test is a positive sign indicating that the fetus is doing well at this
  point in the pregnancy. For a nonstress test to be a reactive test, at least two accelerations (15 beats
  or more) of the fetal heart rate lasting at least 15 seconds must occur after movement. If the fetus were
  compromised, the nonstress test would demonstrate no accelerations in fetal heart rate; a contraction
  stress test would show fetal heart rate decelerations during simulated labor. Late decelerations areassociated with a positive or abnormal contraction stress test. No accelerations in a 20-minute period
  during a nonstress test may mean that the fetus is sleeping; however, this is interpreted as a
  nonreactive nonstress test.
  CN: Reduction of risk potential; CL: Apply
1. Right-sided heart failure causes venous congestion resulting in such symptoms as
  peripheral (dependent) edema, splenomegaly, hepatomegaly, and neck vein distention. Intermittent
  claudication is associated with arterial occlusion. Dyspnea and crackles are associated with
  pulmonary edema, which occurs in left-sided heart failure.
  CN: Reduction of risk potential; CL: Analyze
1. To help prevent flexion deformities, a client with rheumatoid arthritis should lie in a prone
  position in bed for about 1⁄2 hour several times a day. This positioning helps keep the hips and knees
  in an extended position and prevents joint flexion. Low Fowler’s, modified Trendelenburg, and side-
  lying positions do not prevent hip flexion.
  CN: Basic care and comfort; CL: Synthesize

Question 16

Q

Which of the following should be the nurse’s priority assessment after an epidural anesthetic
has been given to a nulligravid client in active labor?
Level of consciousness.
Blood pressure.
Cognitive function.
Contraction pattern.
Assessment of a nulligravid client in active labor reveals the following: moderate
discomfort; cervix dilated 3 cm, 0 station, and completely effaced; and fetal heart rate of 136 bpm.
Which of the following should the nurse plan to do next?1. Assist the client with comfort measures and breathing techniques.
Turn the client from the left side-lying position to the right side-lying position.
Prepare the client for epidural anesthesia to relieve pain.
Instruct the client that internal fetal monitoring is necessary.
The nurse monitors the serum electrolyte levels of a client who is taking digoxin (Lanoxin).
Which of the following electrolyte imbalances is a common cause of digoxin toxicity?
Hyponatremia.
Hypomagnesemia.
Hypocalcemia.
Hypokalemia.
After abdominal surgery, a client has a prescription for meperidine (Demerol) IM 100 mg
every 3 to 4 hours and acetaminophen (Tylenol) with codeine 30 mg. The client has been taking
meperidine every 4 hours for the past 48 hours but tells the nurse that the meperidine is no longer
lasting 4 hours and that the client needs to have it every 3 hours. Which of the following nursing
actions is most appropriate?
Realizing that the client is developing tolerance to the meperidine, the nurse administers the
meperidine every 3 hours.
The nurse urges the client to take the acetaminophen with codeine to prevent addiction to the
meperidine.
The nurse requests a prescription from the physician to change the dose to an equianalgesic
dose of morphine.
The nurse encourages the client to do relaxation exercises to provide distraction from the pain.
The nurse assesses a 7-month-old infant’s growth and development. Which behavior should
the nurse consider unusual?
Drinking from a cup and spilling little of the liquid.
Raising the chest and upper abdomen off the bed with the hands.
Imitating sounds that the nurse makes.
Crying loudly in protest when the mother leaves the room.
A 13-year-old client is dying of cancer. When providing care for this client, the nurse should
incorporate the developmental tasks for this age. According to Erikson’s developmental model, the
child normally is expected to be working on which of the following psychosocial issues?
Lifetime vocation.
Social conscience.
Personal values.
Sense of competence.
The physician has prescribed amiodarone (Cordarone) for a client with cardiomyopathy.
The nurse should monitor the client’s electrocardiogram to determine the effectiveness of the
medication in controlling:
Sinus node dysfunction.
Heart block.
Severe bradycardia.
Life-threatening ventricular dysrhythmias.
An 18-year-old female client who is sexually active with her boyfriend has a purulent
vaginal discharge that is sometimes frothy. The nurse interprets this as suggesting which of the
following?
Sexually transmitted disease.
Normal variations in vaginal discharge.
Need for vaginal douching.
Change in birth control method.
An elderly client has been bedridden since a cerebrovascular accident that resulted in total
right-sided paralysis. The client has become increasingly confused, is occasionally incontinent of
urine, and is refusing to eat. In planning the client’s care, which of the following factors should the
nurse consider as most critical in contributing to skin breakdown in this client?
Nutritional status.
Urinary incontinence.
Episodes of confusion.
Right-sided paralysis.
Assessment of a client who has just been admitted to the inpatient psychiatric unit reveals an
unshaven face, noticeable body odor, visible spots on the shirt and pants, slow movements, gazing at
the floor, and a flat affect. Which of the following should the nurse interpret as indicating
psychomotor retardation?
Slow movements.
Flat affect.
Unkempt appearance.
Avoidance of eye contact.

Answer

A

1. Administration of an epidural anesthetic can result in a hypotensive effect on maternal
  blood pressure. Therefore, the priority assessment is the mother’s blood pressure. Ephedrine or
  wedging the client to a position to keep pressure off the vena cava, such as on the left side, can be
  used to elevate maternal blood pressure should it drop too low. Epidural anesthesia has no effect on
  the level of consciousness or the client’s cognitive function. Although the client’s contraction pattern
  may decrease in frequency after administration of the anesthesia, the priority assessment is the client’s
  blood pressure. After blood pressure is maintained, contractions can be assessed.
  CN: Pharmacological and parenteral therapies; CL: Analyze
1. The client’s assessment findings indicate that the client is in the latent phase of the first
  stage of labor. Therefore, the nurse should plan to assist the client with comfort measures and
  breathing techniques to relieve discomfort. The client can move around, walk, or ambulate at this
  phase of labor. If the client chooses to remain in bed, a left side-lying position provides the greatest
  perfusion. It is too early for the client to have an epidural anesthetic. Epidural anesthesia is usually
  administered when the cervix is dilated 4 to 5 cm. The fetal heart rate is normal, so internal fetal
  monitoring is not warranted at this time.
  CN: Health promotion and maintenance; CL: Synthesize
1. Hypokalemia is one of the most common causes of digoxin (Lanoxin) toxicity. It is
  essential that the nurse carefully monitor the potassium levels of clients taking digoxin to avoid
  toxicity. Low serum potassium levels can cause cardiac dysrhythmias.
  CN: Pharmacological and parenteral therapies; CL: Apply
1. Current pain guidelines recommend the removal of meperidine from formularies and the
  substitution of morphine commonly administered by patient-controlled analgesia. Meperidine can be
  prescribed for severe pain, but its use is limited by the high incidence of neurotoxicity (seizures)
  associated with the accumulation of its metabolite, normeperidine. It is contraindicated in clients with
  acute pain lasting more than 2 days and in those for whom large daily doses (more than 600 mg) are
  needed. It would be inappropriate to urge the client to take the acetaminophen and codeine to prevent
  addiction. Addiction is a psychological condition in which a client is driven to take drugs for reasonsthat are not therapeutic. The client is in pain and her need for the morphine is therapeutic. Although
  the client may obtain some relief from relaxation exercises, this alone is not sufficient to provide pain
  relief.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. 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 the hands, enjoy imitating sounds, and are developing
  separation anxiety.
  CN: Health promotion and maintenance; CL: Analyze
1. According to Erikson, a child of 13 years is normally seeking to meet the need to develop
  personal identity. Personal values are a component of this identity. Developing a conscience is a
  component of achieving initiative during the preschool years. Developing a sense of competence is a
  component of achieving industry in the school-age years. Developing a lifetime vocation is a
  component of achieving generativity in adulthood.
  CN: Psychosocial integrity; CL: Analyze
1. Cardiomyopathy means that the myocardium is weak and irritable. Amiodarone is an
  antiarrhythmic and acts directly on the cardiac cell membrane. In this situation, amiodarone is used to
  increase the ventricular fibrillation threshold. Amiodarone is contraindicated in sinus node
  dysfunction, heart block, and severe bradycardia.
  CN: Reduction of risk potential; CL: Evaluate
1. A frothy, purulent vaginal discharge in a sexually active female client is typically caused
  by a sexually transmitted disease such as trichomonas. Other diseases, such as chlamydia, may also
  be present. Both the client and the boyfriend need treatment after the disease is determined. Normal
  variations in female vaginal discharge should be clear to white, not frothy or purulent. The client
  should be instructed to wear cotton underwear and avoid pantyhose, wet gym clothes, and tight-fitting
  garments, such as jeans, so that air can circulate.
  CN: Management of care; CL: Analyze
1. The most common factor in skin breakdown is immobility. Right-sided paralysis, in which
  the client cannot perceive the need to change position and lacks control over movement of the
  extremities, is the condition most likely to lead to skin breakdown. It is essential that the nurse plan to
  change the client’s position at least every 2 hours. Nutritional status and urinary incontinence can
  contribute to skin breakdown but neither is the most critical factor. Confusion does not directly
  influence skin breakdown.
  CN: Reduction of risk potential; CL: Analyze
1. Psychomotor retardation refers to a general slowdown of motor activity commonly seen in
  a client with depression. Movements appear lethargic, energy is absent or lacking, and performance
  of activity is slow and difficult. A flat affect reflects a lack of emotion. An unkempt appearance
  reflects lack of self-care. Avoiding eye contact reflects low self-esteem or suspiciousness.
  CN: Psychosocial integrity; CL: Analyze

Question 17

Q

A nurse notices that a newborn has a swelling in the scrotal area. The nurse interprets this
swelling as indicative of hydrocele if which of the following occurs?
The swollen bulge can be reduced.
The increase in scrotal size is bilateral.
The scrotal sac can be transilluminated.
The bulge appears during crying.
When cleaning the skin around an incision and drain site, which of the following procedures
should the nurse follow?
Clean the incision and drain site separately.
Clean from the incision to the drain site.
Clean from the drain site to the incision.
Clean the incision and drain site simultaneously.
A woman who speaks Spanish only and is very upset brings her child to the clinic with
bleeding from the mouth. Which of the following is the most appropriate action by the nurse who
does not speak Spanish?
Call for the Spanish interpreter.
Grab the child and take the child to the treatment room.
Immediately apply ice to the child’s mouth.
Give the ice to the mother and demonstrate what to do.
The nurse is instructing a nursing assistant on the prevention of postoperative pulmonary
complications. Which of the following statements indicates that the assistant has understood the
nurse’s instructions?
“I will turn the client every 4 hours.”
“I will keep the client’s head elevated.”
“I should suction the client every 2 hours.”
“I will have the client take 5 to 10 deep breaths every hour.”
Which of the following outcomes is desired when a client with arterial insufficiency has
poor tissue perfusion in the extremities? Select all that apply.
Extremities warm to touch.
Improved respiratory status.
Decreased muscle pain with activity.
Participation in self-care measures.
Lungs clear to auscultation.
The infusion rate of total parenteral nutrition (TPN) is tapered before being discontinued.
This is done to prevent which of the following complications?
Essential fatty acid deficiency.
Dehydration.
Rebound hypoglycemia.
Malnutrition.
While assessing the psychosocial aspects of a primigravid client at 30 weeks’ gestation,
which of the following feelings are expected?
Vulnerability.
Confirmation.
Ambivalence.
Body image disturbance.
The nurse teaches a client scheduled for an IV pyelogram what to expect when the dye is
injected. The client has correctly understood what was taught when the client states that there may be
which of the following sensations when the dye is injected?
A metallic taste.
Flushing of the face.
Cold chills.
Chest pain.
To prevent development of peripheral neuropathies associated with isoniazid
administration, the nurse should teach the client to:
Avoid excessive sun exposure.
Follow a low-cholesterol diet.
Obtain extra rest.
Supplement the diet with pyridoxine (vitamin B 6 ).
A usually reliable interpreter called by the nurse to help communicate with a mother of a
child who does not speak English and has brought her child in for a routine visit has yet to arrive in
the clinic. The nurse has paged the interpreter several times. Which of the following should the nursedo next?
Continue with the examination.
Reschedule the infant’s appointment for later in the week.
Ask the mother to stay longer in the hope that the interpreter arrives.
Page the interpreter one more time.

Answer

A

1. A hydrocele, defined as fluid in the processus vaginalis, is determined when the scrotal
  sac can be transilluminated. A swelling in the scrotal area that can be reduced indicates an inguinalhernia. Both hydroceles and hernias can enlarge the scrotal sac, and both can be either unilateral or
  bilateral. A hernia typically is more obvious during crying.
  CN: Reduction of risk potential; CL: Analyze
1. When cleaning the skin around an incision and drain, the nurse should clean the incision
  and drain separately to avoid contaminating either wound. This is applying the principle of working
  from the least contaminated area to the most contaminated area. In this case, both areas are fresh
  wounds and should be kept separate.
  CN: Management of care; CL: Apply
1. Any injury to the mouth results in copious amounts of blood because the mouth is a highly
  vascular area. Because the nurse does not know the mother and does not speak Spanish, the most
  appropriate action is to give the mother the ice and demonstrate what she is to do. The child will be
  less fearful if the ice is applied by the mother. Calling for an interpreter is appropriate after caring for
  the immediate need of the child. Grabbing the child away will probably upset the mother more,
  further adding to the stress experienced by the child.
  CN: Psychosocial integrity; CL: Synthesize
1. Having the client deep breathe hourly is the most appropriate action for the assistant to
  take to help prevent pulmonary complications. The client should be turned at least every 2 hours.
  Keeping the client’s head elevated will not prevent pulmonary complications. Suctioning the client is
  not an assistant’s responsibility, nor does it prevent pulmonary complications.
  CN: Management of care; CL: Evaluate
1, 3. The desired outcome for the client with poor circulation to the extremities is evidence
of adequate blood flow to the area. The temperature of the involved extremity is an important
indicator for a client with peripheral vascular disease. The temperature will indicate the degree to
which the blood supply is getting to the extremity. Warmth indicates adequate blood flow. Pain is also
an indicator of blood flow. Pain, such as muscle pain, suggests ischemia and lack of oxygen that
results when the oxygen demand becomes greater than the supply. Thus, a decrease in muscle pain
with activity would suggest improvement in blood flow to the area. Improved respiratory status and
clear lungs are unrelated to the poor tissue perfusion. Although participation in self-care measures is
always helpful, this outcome not a result of establishing circulation to the extremities.
CN: Reduction of risk potential; CL: Evaluate
1. When dextrose is abruptly discontinued, rebound hypoglycemia can occur. The nurse
  should assess the client for symptoms of hypoglycemia. Essential fatty acid deficiency is very
  unlikely to occur because some of these fatty acids are stored. Preventing dehydration or malnutrition
  is not the reason for tapering the infusion rate; the client’s hydration and nutritional status and ability
  to maintain adequate intake must be established before TPN is discontinued.
  CN: Pharmacological and parenteral therapies; CL: Apply
1. During the third trimester, particularly in the seventh month of pregnancy, the client
  typically exhibits feelings of vulnerability and fear that the baby will be lost. Confirmation that the
  fetus is real occurs during the second trimester. Ambivalence is typically seen and resolved during
  the first trimester. Body image disturbance commonly occurs during the second trimester because of
  the profound changes that occur to the body during this time.CN: Health promotion and maintenance; CL: Analyze
1. As the dye is injected, the client may experience a feeling of warmth, flushing of the face,
  and a salty taste in the mouth. The client should not experience chest pain or cold chills; these would
  be adverse reactions warranting close monitoring of the client.
  CN: Reduction of risk potential; CL: Evaluate
1. Isoniazid competes for the available vitamin B 6 in the body and leaves the client at risk
  for developing neuropathies related to vitamin deficiency. Supplemental vitamin B 6 is routinely
  prescribed to address this issue. Avoiding sun exposure is a preventive measure to lower the risk of
  skin cancer. Following a low-cholesterol diet lowers the individual’s risk of developing
  atherosclerotic plaque. Rest is important in maintaining homeostasis but has no real impact on
  neuropathies.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. The interpreter may have been delayed. Therefore, the nurse’s best action would be to
  reschedule the child’s appointment when the interpreter can be scheduled as well. Because the mother
  does not speak English, there is no point in examining the infant because history information is needed
  and most likely would be too difficult to obtain. Asking the mother to stay longer is rude to her. Also,
  doing so would probably be difficult because of the communication gap. If the interpreter is delayed,
  paging one more time will not help.
  CN: Management of care; CL: Synthesize

Question 18

Q

Before discharge from the hospital after a myocardial infarction, a client is taught to
exercise by gradually increasing the distance walked. Which vital sign should the nurse teach the
client to monitor to determine whether to increase or decrease the exercise level?
Pulse rate.
Blood pressure.
Body temperature.
Respiratory rate.
During an appointment with the nurse, a client says, “I could hate God for that flood.” The
nurse responds, “Oh, don’t feel that way. We’re making progress in these sessions.” The nurse’s
statement demonstrates a failure to do which of the following?
Look for meaning in what the client says.
Explain to the client why he may think as he does.
Add to the strength of the client’s support system.
Give the client credit for solving his own problems.
The nurse has just received the change of shift report on the following clients on the labor,
birth, recovery, and postpartum unit. Which of these clients should the nurse assess first?
An 18-year-old single primigravid client, in labor for 9 hours, with cervical dilation at 6 cm, 0
station, contractions occurring every 5 minutes, and receiving epidural anesthesia.
A 24-year-old primiparous client who gave vaginal birth to a 7-lb, 3-oz (3,260-g) boy 1 hour
ago, has a firm fundus and scant lochia rubra, and is attempting to breast-feed.
A 26-year-old multigravid client, in labor for 8 hours, with cervical dilation at 8 cm, 1+
station, contractions every 3 to 4 minutes, and receiving no anesthesia.
A 30-year-old multipara who gave birth to a 6-lb, 5-oz (2,863-g) girl by cesarean owing to
fetal distress 3 hours ago, has a firm fundus and scant lochia rubra, and is receiving morphine
by patient-controlled analgesia.
A client with type 1 diabetes mellitus is scheduled to have surgery. The client has been
nothing-by-mouth (NPO) since midnight. In the morning, the nurse notices that the client’s daily insulin
has not been prescribed. Which action should the nurse do first?
Obtain the client’s blood glucose level at the bedside.
Contact the physician for further prescriptions regarding insulin dosage.
Give the client’s usual morning dose of insulin.
Inform the Post Anesthesia Care Unit (PACU) staff to obtain the insulin prescription.
A client’s chest tube is to be removed by the physician. Which of the following items should
the nurse have ready to be placed directly over the wound when the chest tube is removed?
Butterfly dressing.
Montgomery strap.
Fine mesh gauze dressing.4. Petrolatum gauze dressing.
The nurse observes that the client with multiple sclerosis looks untidy and sad. The client
suddenly says, “I can’t even find the strength to comb my hair,” and bursts into tears. Which of the
following responses by the nurse is best?
“It must be frustrating not to be able to care for yourself.”
“How many days have you been unable to comb your hair?”
“Why hasn’t your husband been helping you?”
“Tell me more about how you’re feeling.”
A client newly diagnosed with bulimia is attending a nurse-led group at the mental health
center. She tells the group that she only came because her husband said he would divorce her if she
didn’t get help. Which of the following responses by the nurse is most appropriate?
“You sound angry with your husband. Is that correct?”
“You will find that you like coming to group. These people are a lot of fun.”
“Tell me more about why you are here and how you feel about that.”
“Tell me something about what has caused you to be bulimic.”
A diabetic client has been diagnosed with hypertension, and the physician has prescribed
atenolol (Tenormin), a beta-blocker. When performing discharge teaching, it is important for the client
to recognize that the addition of Tenormin can cause:
A decrease in the hypoglycemic effects of insulin.
An increase in the hypoglycemic effects of insulin.
An increase in the incidence of ketoacidosis.
A decrease in the incidence of ketoacidosis.
The parent of a child who is taking an antibiotic for bilateral otitis media tells the nurse that
they have stopped the medicine since the child is better and are saving the rest of the medication to
use the next time the child gets sick. Which of the following is the nurse’s best response?
“It is important to give the medicine as prescribed.”
“How do you know your child’s ears are cured?”
“Your child needs all of the medicine so that the infection clears.”
“Stopping the medicine is not what’s best for your child!”
The nurse is making rounds and observes a client who is unconscious (see figure). The
nursing assistant has just turned the client from lying on her back. Before raising the side rail, the
nurse should:
Elevate the head of the bed to 30 degrees.
Ask the nursing assistant to add a pillow under the right arm.
Inspect the skin at pressure points from the back-lying position.
Help the nursing assistant move the client closer to the head of the bed.

Answer

A

1. The client who is on a progressive exercise program at home after a myocardial infarction
  should be taught to monitor the pulse rate. The pulse rate can be expected to increase with exercise,
  but exercise should not be increased if the pulse rate increases more than about 25 bpm from baseline
  or exceeds 100 to 125 bpm. The client should also be taught to decrease exercise if chest pain or
  dyspnea occur.
  CN: Basic care and comfort; CL: Analyze
1. The nurse’s response fails to identify the meaning in what the client has said. The nurse
  needs to explore the client’s statement about hating God for that flood because the meaning of the
  client’s statement is unclear. Also, clichés such as, “Don’t feel that way,” are not helpful because they
  ignore the client’s feelings and his interpretation of the situation in which he finds himself. Explaining
  to the client why he may think as he does (offering a rationale) is inappropriate. The nurse’s response
  fails to identify the meaning in what the client has said and is not supportive. There is no evidence
  that the client is solving his problems.
  CN: Psychosocial integrity; CL: Analyze
1. The client who should be assessed first is the multigravid client who has been in labor for
  8 hours and whose cervix is 8 cm dilated at 1+ station with contractions every 3 to 4 minutes. A
  multigravid client typically has a shorter labor than a primigravid, and this client’s station is 1+,
  which means that birth of the fetus is imminent.
  CN: Management of care; CL: Synthesize
1. The nurse should first obtain the blood glucose level and then contact the physician and
  clarify whether the client’s usual insulin dose should be given before surgery; having the bloodglucose level is objective information that the physician may need to know before making a final
  decision as to the insulin dosage. The nurse should not assume that the usual insulin dose is to be
  given. It is not appropriate for the nurse to defer decision-making on this issue until after the surgery.
  CN: Reduction of risk potential; CL: Synthesize
1. Immediately after chest tube removal, a petrolatum gauze is placed over the wound and
  covered with a dry sterile dressing. This serves as an airtight seal to prevent air leakage or air
  movement in either direction. Bandages or straps are not applied directly over wounds. Mesh gauze
  allows air movement.
  CN: Management of care; CL: Apply
1. By asking the client to tell more about how she is feeling, the nurse is not making any
  assumptions about what is troubling the client. The nurse should acknowledge the client’s feelings and
  encourage her to discuss them. Saying that this situation must be frustrating involves assumptions by
  the nurse about why the client is crying and is not a therapeutic response. Asking how long the client
  has been unable to comb her hair takes the focus off her feelings and inhibits therapeutic
  communication. Inquiring why the client’s husband hasn’t helped insinuates that the husband is not
  helping enough, which is inappropriate, takes the focus off the client’s feelings, and inhibits
  therapeutic communication.
  CN: Psychosocial integrity; CL: Synthesize
1. Encouraging the client to talk about why she is here and about her feelings may reveal
  more information about what led her to come to the group and what led to her diagnosis. It also
  provides the nurse with valuable information needed to develop an appropriate plan of care. The
  comment that the client sounds angry presumes what the client is feeling and asks her to talk about her
  husband. The focus here should be on the client, not the husband. Telling the client that she will like
  coming to group imposes the nurse’s view onto the client. The statement stresses that the group is fun
  instead of giving its therapeutic value. Having the client tell the nurse something about the cause of
  her bulimia ignores the client’s original statement. Additionally, this statement requires the client to
  have insight into the cause of her disease, which may not be possible at this time. Also, it may be too
  early in the relationship to discuss the disorder.
  CN: Psychosocial integrity; CL: Synthesize
1. There is a direct interaction between the effects of insulin and those of beta blockers. The
  nurse must be aware that there is a potential for increased hypoglycemic effects of insulin when a beta
  blocker is added to the client’s medication regimen. The client’s blood sugar should be monitored.
  Ketoacidosis occurs in hyperglycemia. Although a decrease in the incidence of ketoacidosis could
  occur when a beta blocker is added, the direct result is an increase in the hypoglycemic effect of
  insulin.
  CN: Pharmacological and parenteral therapies; CL: Apply
1. Commonly, when a child appears better, the parents stop the medication. Unfortunately, the
  infection remains. Therefore, the nurse needs to explain that all of the medication must be
  administered to clear up the infection. Explaining why the medicine should be continued is more
  helpful to parents than saying it needs to be given.. Telling the parent that stopping the medication is
  not what is best for the child implies blame and is condescending.CN: Pharmacological and parenteral therapies; CL: Synthesize
1. The client is positioned correctly in the side-lying position. The pillows support the
  client’s joints and do not cause unnecessary pressure on the joints or skin. It is not necessary to add
  another pillow under the arm or to elevate the head of the bed. The nurse should assess the client’s
  skin for signs of breakdown, particularly at the elbows, back, hips, and heels where there were
  pressure points from the position in which the client was previously lying.
  CN: Reduction of risk potential; CL: Evaluate

Question 19

Q

The nurse is preparing a teaching plan for a client who is being discharged after being
admitted for chest pain. The client has had one previous myocardial infarction 2 years ago and has
been taking simvastatin 40 mg for the last 2 years. After reviewing the lab results for the client’s
cholesterol levels (see chart below), the nurse should:
Ask if the client is taking the simvastatin regularly.
Tell the client that the cholesterol levels are within normal limits.
Instruct the client to lower the saturated fat in the diet.
Review the chart for lab reports of hemoglobin and hematocrit.
Sodium polystyrene sulfonate (Kayexalate) is prescribed for a client following crush injury.
The drug is effective if:
The pulse is weak and irregular.
The serum potassium is 4.0 mEq/L (4.0 mmol/L).
The ECG is showing tall, peaked T waves.
There is muscle weakness on physical examination.
The nurse is teaching a young female about using oxcarbazepine (Trileptal) to control
seizures. The nurse determines teaching is effective when the client states:
“I will use one of the barrier methods of contraception.”
“I will need a higher dose of oral contraceptive when on this drug.”
“Since I am 28 years old, I should not delay starting a family.”4. “I must weigh myself weekly to check for sudden gain in weight.”
A client diagnosed with chronic renal failure is undergoing hemodialysis. Postdialysis, the
client weighs 59 kg. The nurse should teach the client to:
Increase the amount of sodium in the diet to 4 g/day.
Limit the total amount of calories consumed each day to 1,000.
Increase fluid intake to 3,000 mL each day.
Control the amount of protein intake to 59 to 70 g/day.
An elderly client admitted with new-onset confusion, headache, and bounding pulse has
been drinking copious amounts of water and voiding frequently. The nurse reviews the lab results (see chart).

LAB VALUES 
Serum Osmolality 325 mmol/kg H2O
Platelet Count 122
Serum Sodium 122
Urine Specific Gravity 1.041

Which of the abnormal lab values is consistent with the client’s symptoms?

Serum osmolality.
Platelet count.
Serum sodium.
Urine specific gravity.
A term primigravida was involved in a car accident 3 hours ago. She is having labor
contractions every 4 minutes and her cervix is 3/100/-1. She is crying uncontrollably and states her
pain is constant and severe rating it at 10/10. The priority action by the nurse is to:
Reassure the woman and assist with nonpharmacologic pain interventions.
Assess intensity of contractions and determine if she would like an epidural.
Notify the provider of the pain and request an assessment for potential abruption.
Perform a vaginal exam and coach the woman with breathing exercise for pain control.
A school nurse interviews the parent of a middle school student, who is exhibiting
behavioral problems, including substance abuse, following a sibling’s suicide. The parent says, “I am
a single parent who has to work hard to support my family and now, I’ve lost my only son and my
daughter is acting out and making me crazy! I just can’t take all this stress!” Which of the following
issues is the priority?
Parent’s ability to emotionally support the adolescent in this crisis.
Potential suicidal thoughts/plans of both family members.
The adolescent’s anger.4. The parent’s frustration.
When creating an educational program about safety, what information should the nurse
include about sexual predators? Select all that apply.
Child molesters pick children or teens over which they have some authority, making it easier
for them to manipulate the child with special favors or attention.
Child molesters resort to molestation because they have bad childhoods, so understanding that
can help them decrease their molesting.
Child molesters gain the child’s trust before making sexual advances so the child feels
obligated to comply with sex.
Child molesters often choose children whose parents must work long hours, making the extra
attention initially welcomed by the child.
Child molesters maintain the secrecy of their actions by making threats if offering attention and
favors fail or if the child is close to revealing the secret.
Sequential compression therapy is to be used postoperatively on the client’s legs. The nurse
must take which of the following actions first when the client returns to the room?
Confirm the client’s identity using two client identifiers.
Wash hands.
Explain the sequential compression therapy to the client.
Determine the size of sleeve that is needed.
The nurse is caring for a previously healthy, independent 28-year-old client who is alert and oriented and is being admitted to the hospital for unexplained vomiting and abdominal pain. The client has intravenous fluids infusing through a saline lock and has been ambulating in the hallway with a steady gait. Using the Morse Fall Risk Scale (see chart), what is this client’s total score and risk level?Score __________ Risk __________.
The nurse is planning care for an 80-year-old client with a pressure ulcer (see figure). The
nurse should do which of the following? Select all that apply.
Elevate the head of the bed to 50 degrees.
Obtain daily cultures.
Cover with protective dressing.
Reposition the client every 2 hours.
Request an alternating-pressure mattress.

Answer

A

1. The serum cholesterol is within normal range for this client indicating the medication is
  effective. Since the cholesterol levels are within normal limits, it is likely that the client is taking the
  medication and asking may indicate the nurse has doubts or mistrusts that the client is taking the
  medication. The client does not need to change the diet at this point. Hemoglobin and hematocrit are
  not affected by simvastatin; since liver damage is a side effect of simvastatin, the nurse could review
  the liver function studies.
  CN: Pharmacologic and parenteral therapies; CL: Synthesize
1. Following crush injury, serum potassium rises to high levels. Sodium polystyrene
  sulfonate (Kayexalate) is a potassium binding resin. The resin combines with potassium in the colon
  and is then eliminated, and serum potassium levels should come back to normal. Normal serum
  potassium is 3.5 to 5.3. Weak, irregular pulse and tall peaked T waves on ECG are signs of
  hyperkalemia, and muscle weakness is a sign of hypokalemia.
  CN: Pharmacological and Parenteral Therapies; CL: Evaluate
1. An alternative or additional method of birth control must be used since oxcarbazepine
  (Trileptal) reduces the effectiveness of oral contraceptives. Higher doses of oral contraceptives will
  not help in achieving this purpose, but the client needs additional or alternative method of birth
  control. The client does not need advice about when to start her family. A side effect of
  Oxcarbazepine (Trileptal) may be weight gain, but it is typically gradual.
  CN: Pharmacological and Parenteral Therapies; CL: Apply
1. Hemodialysis clients have their protein requirements individually tailored according to
  their postdialysis weight. The protein requirement is 1.0 to 1.2 g/kg body weight per day. Hence, for a
  59-kg weight, the amount of protein will be 59 to 70 g/day. Sodium should be restricted to 3 g/day.
  The client should obtain sufficient calories; if calories are not supplied in adequate amount, the body
  will use tissue protein for energy, which will lead to a negative nitrogen balance and malnutrition.
  Fluid intake needs to be restricted. The fluid amount is restricted to 500 to 700 mL plus the urine
  output.
  CN: Pharmacological and parenteral therapies; CL: Synthesize.
1. This client is exhibiting behaviors and symptoms associated with hyponatremia caused by
  water intoxication; the nurse would expect to find confirmation of a low serum sodium level by
  checking the electrolyte levels. The nurse would expect this client’s serum osmolality and urine
  specific gravity to be low, not high. The platelet count is not relevant as there is no correlation
  between sodium levels and platelet counts.
  CN: Physiological adaptation; CL: Analyze
1. The woman is at risk for placental abruption due to her recent car accident. Symptoms of a
  placental abruption include unrelenting pain and a rigid boardlike abdomen. She may or may not have
  vaginal bleeding. In contrast, labor contractions are intermittent. The priority action by the nurse
  should be to ensure this client is further evaluated by her health care provider. Subsequent actions
  could include assisting with pain control measures, assessing contractions, and checking cervical
  dilation.
  CN: Management of care; CL: Analyze
1. The parent’s lament of stress and grief and the adolescent’s behavior and drug use could be
  preludes to suicide, especially since another member of the family succeeded in suicide. Suicide
  attempts are more likely in families in which there has been a previous suicide attempt or suicide
  death, especially for young people. Though the family’s emotional states are important, one is not
  more important than the other. Obviously, the parent’s ability to emotionally support the adolescent in
  this crisis has been comprised, but the safety of both supersedes this concern.
  CN: Safety and infection control; CL: Analyze
1, 3, 4, 5. Child molesters prey on lonely children or those who spend a lot of time at home
alone due to a working parent. They initially show interest and assist the child and family such as
providing rides, money, and homework help. Once trust is established, molesters push for a more
sexual relationship, which they justify by pointing out what they have done to help the child. If the
child tries to stop the sexual interaction or appears ready to tell someone, molesters will use threats
to maintain the secret. Though some child molesters have had difficult childhoods in which they may
have been molested, having them recognize that is not enough to keep them from offending again.
CN: Safety or psychosocial integrity; CL: Apply
1. The nurse must use at least two ways to identify clients. This is done to make sure that
  each client gets the correct medication/s and/or treatment/s. Although all of the remaining actions
  need to be done, none of the others would be the first action.
  CN: Physiological adaptation; CL: Apply
20, Low Risk: This client’s only risk factor is IV access, making this client low risk for a
fall. The nurse must remember to revaluate a client’s risk for fall after any change in condition, upon
transfer to another unit within the hospital or after a fall. In most acute care facilities, a fall risk is
completed at least every 24 hours if not every shift.
CN: Safety and infection control; CL: Evaluate
3, 4, 5. The client has a Stage II pressure ulcer. The nurse should take measures to relieve the
pressure, treat the local infection, and protect the wound. The nurse should keep the ulcer covered
with a protective dressing. The client should turn every 2 hours and use an alternating-pressure
mattress to relieve pressure on the buttocks. The head of the bed should be elevated no more than 30
degrees. All wounds have bacteria, and obtaining frequent cultures (unless prescribed otherwise) is
not necessary.
CN: Safety and infection control; CL: Synthesize

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