TEST 2: Comprehensive Flashcards

Question 1

Q

The unit secretary who transcribes the physicians’ prescriptions asks the nurse to interpret an
illegible prescription. The nurse should:
Interpret the prescription according to the client’s previous medication record.
Clarify the prescription with the pharmacist.
Clarify the prescription by calling the physician.
Clarify the client’s medications with the client’s family.

2. A client with cholecystitis is taking propantheline bromide (Pro-Banthine). The expected
outcome of this drug is:
1. Increased bile production.
2. Decreased biliary spasm.
3. Absence of infection.
4. Relief from nausea.

The nurse refers the parents of a child with cystic fibrosis to an organization that helps
families with children who have this disease. Such organizations are especially beneficial for parents
by helping them:
Find tutors to educate their children at home.
Obtain genetic counseling.
Meet with other parents of children with cystic fibrosis for mutual support.
Obtain financial assistance to purchase medications for their children.
After a bronchoscopy with biopsy, the nurse assesses the client. Which of the following signs
should be reported immediately to the physician?
Green sputum.
Dry cough.
Hemoptysis.
Laryngeal stridor.
A client tells the nurse that “the hospital food is horrible.” Which of the following is the most
appropriate response by the nurse?
“The staff is doing the best they can to cook in such large quantities.”
“I’ll report this to the physician.”
“Would you like to speak with the dietitian about the food and meal selection?”
“I don’t like the hospital cafeteria food either.”
The nurse must be aware that adverse drug reactions in the elderly client may be
underestimated because:
Adverse reactions rarely have an atypical presentation.
Cognitive impairment is an expected finding in the elderly client.
Physical or psychological symptoms are attributed to the effects of aging.
Excess sedation is difficult to assess in the elderly client.
An elderly man experiences a thrombotic cerebrovascular accident and subsequent flaccid
hemiplegia of the right side. When planning care for this client, rehabilitation begins:
As soon as anticoagulant therapy is started.
When the client is admitted to the hospital.
When the client can first work cooperatively with health care personnel.
As directed by the physical therapist.
An unmarried pregnant teenager tells the nurse that she is undecided about having an abortion
or giving the baby up for adoption. The best response for the nurse to offer is which of the following?
“You should give the baby up so that it can have a better home and opportunities.”
“Research studies show that babies do better with their natural mothers.”
“It must be a difficult decision. What have you thought about so far?”
“Why don’t you try keeping the baby. You can always give it up for adoption later.”
When administering blood, the nurse must check the name on the label of the blood with the
name on the client’s:
Wristband with a family member present.
Wristband in the presence of another nurse.
Medical chart with the unit clerk.
Medication administration record with the pharmacist.
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The
nurse should assess the client for which alteration in fluid and electrolyte balance?
Increased osmolality of the plasma.
Decreased serum sodium level.
Increased urine output.
Decreased blood pressure.
A client is admitted to the emergency department with crushing chest injuries sustained in a
car accident. Which of the following signs indicates a possible pneumothorax?
Cheyne-Stokes respirations.
Increased fremitus.
Diminished or absent breath sounds on the affected side.
Decreased sensation on the affected side.
Which of the following statements by a client taking valproic acid for bipolar disorder
indicates that further teaching about this medication is necessary?
“I need to take the pills at the same time each day.”
“I can chew the pills if necessary.”
“I can take the pills with food.”
“I need to call my doctor if I start bruising easily.”
A nurse is obtaining the history of an infant with suspected acute otitis media. What should
the nurse ask the parent about?
Position of the infant when taking a bottle.
Covering of the infant’s ears when out in the cold.
Thorough drying of the infant’s ears after a bath.
Immunization status of the infant.

14. A client is having elective surgery under general anesthesia. Who is responsible for obtaining
the informed consent?
1. The nurse.
2. The surgeon.
3. The anesthesiologist.
4. The nurse anesthetist.

The family of an elderly client with terminal cancer inquires about hospice services. The
nurse explains that hospice care:
Focuses only on the needs of the client.
Can only be provided in the inpatient setting.
Is staffed exclusively by professional health care workers.
Focuses on supportive care for the client and family.
A primigravid client at 8 weeks’ gestation tells the nurse that she doesn’t like milk. To ensure
that the client consumes an adequate intake of milk products, the nurse should instruct the client that an
8-oz (250-mL) glass of milk is equal to which of the following?
2 tablespoons (30 mL) of Parmesan cheese.
11⁄2 cup (375 mL) of a milkshake.
11⁄2 to 2 slices of presliced cheddar cheese.
1⁄2 cup (125 mL) of cottage cheese.
A primigravid client at 35 weeks’ gestation is scheduled for a biophysical profile. After
instructing the client about the test, which of the following, if stated by the client as one of the
parameters of this test, indicates effective teaching?
Amniotic fluid volume.
Placement of the placenta.
Amniotic fluid color.
Fetal gestational age.

18. When caring for a child who has been receiving long-term steroid therapy, the nurse should
assess the child for:
1. Usual behavior and temperament.
2. Loss of weight from baseline.
3. Development of truncal obesity.
4. Demonstration of a growth spurt.

The nurse manager has assigned a nurse as the circulating nurse for a surgical abortion. The
nurse is Roman Catholic and wishes to refuse to participate in an abortion. The nurse manager of the
operating room should:
Require the nurse to do this assignment.
Change the assignment, and record the behavior on the nurse’s evaluation.
Change the assignment without comment.
Change the assignment to circulate, but have the nurse prepare the equipment.
An 86-year-old has few health problems, performs self-care, plays cards, and talks about
“the good old days.” The client wants to make “final” arrangements, such as completing an advance
directive and planning and paying for a funeral and burial. The nurse determines that the client:1. Is depressed and should be watched for further signs of depression.
Is responding in an age-appropriate manner.
Is potentially suicidal and should be placed on suicide precautions and seen by a psychiatrist.
Has a premonition about dying soon.

Answer

A

1. Illegible writing is one of the most common reasons for medication errors. The physician
  should be called to clarify the prescription. The previous medication record should not be used as a
  substitute for the exact prescription written by the physician. The pharmacist or the client’s family
  cannot interpret a prescription written by a physician.
  CN: Management of care; CL: Synthesize
1. Propantheline bromide is an anticholinergic used to decrease biliary spasm. Decreasing
  biliary spasm helps to reduce pain in cholecystitis. Propantheline does not increase bile production
  or have an antiemetic effect, and it is not effective in treating infection.
  CN: Pharmacological and parenteral therapies; CL: Apply
1. An important function of support organizations for any health problem is to put parents of
  children with the condition in touch with each other. Other parents can commonly offer support and
  help. In some instances, organizations can offer assistance, such as providing equipment required for
  home care of their child with cystic fibrosis. These organizations do not obtain tutors for children, nor
  do they provide medications, financial assistance, or genetic counseling for parents.
  CN: Management of care; CL: Apply
1. Laryngeal stridor is characteristic of respiratory distress from inflammation and swelling
  after bronchoscopy. It must be reported immediately. Green sputum indicates infection and would
  occur 3 to 5 days after bronchoscopy. A mild cough or hemoptysis is typical after bronchoscopy. If a
  tissue biopsy specimen was obtained, sputum may be blood-streaked for several days.
  CN: Reduction of risk potential; CL: Analyze
1. Strategies for meeting client satisfaction include involving hospital department personnel to
  improve service. Saying, “The staff is doing the best they can,” or, “I will report this to the
  physician,” does not offer a practical resolution to the client’s problem. Expressing a personal dislike
  for the food negates the client’s problem and does not offer a solution.
  CN: Management of care; CL: Synthesize
1. The elderly client commonly has vague or atypical responses to medications and diseases
  that are erroneously attributed to aging. A new cognitive change needs to be investigated and is not an
  expected change with aging. Changes in a client’s behavior should be investigated to see whether
  there is a relation to excessive sedation. The nurse can interview the family members to obtain
  information.CN: Health promotion and maintenance; CL: Apply
1. Rehabilitation for a client who has sustained a cerebrovascular accident begins at the time
  he is admitted to the hospital. The first goal of rehabilitation should be to help prevent deformities.
  This goal is achieved through such techniques as positioning the client properly in bed, changing his
  position frequently, and supporting all parts of his body in proper alignment. Passive range-of-motion
  exercises may also be started, unless contraindicated.
  CN: Management of care; CL: Synthesize
1. The nurse’s response should suggest exploration of the difficult decision-making process the
  client must go through. The client should be encouraged to verbalize the various options in order to
  make the choice that is right for her. Telling the client that she should give the baby up so it can have a
  better home or that research shows babies do better with their birth mothers is judgmental and does
  not place the control of the decision with the client. Suggesting that the client try keeping the baby at
  first minimizes the situation and also does not put the control of the decision with the client.
  CN: Psychosocial adaptation; CL: Synthesize
1. Two nurses must verify the name and label of the blood with the client’s wristband.
  CN: Pharmacological and parenteral therapies; CL: Apply
1. SIADH is characterized by excess antidiuretic hormone (ADH, vasopressin) secretion,
  despite low plasma osmolality. Excess ADH causes water to be retained. As blood volume expands,
  plasma becomes diluted resulting in dilutional hyponatremia. Aldosterone is suppressed, resulting in
  increased renal sodium excretion. Water moves from the hypotonic plasma and the interstitial spaces
  into the cells.
  CN: Physiological adaptation; CL: Analyze
1. Accumulation of air in the pleural cavity after a crushing chest injury may be assessed by
  unilateral diminished or absent breath sounds. Cheyne-Stokes respirations with periods of apnea
  commonly precede death. They indicate heart failure or brain death. Fremitus is increased with lung
  consolidation and decreased with pleural effusion or pneumothorax. Pain occurs at the injury site and
  increases with inspiration.
  CN: Physiological adaptation; CL: Analyze
1. Chewing the pill or capsule form of valproic acid can cause mouth and throat irritation and
  is contraindicated. Taking the pills at the same time each day is important to maintain therapeutic
  effectiveness of the drug. Taking the pills with food is appropriate if the client is experiencing
  gastrointestinal upset. Valproic acid may cause clotting problems; therefore, bruising should be
  reported.
  CN: Pharmacological and parenteral therapies; CL: Evaluate
1. A significant association between feeding position and otitis media exists. Children fed in a
  supine position have a high incidence of otitis media because of the reflux of milk into the eustachian
  tubes during feedings. Keeping the infant’s ears covered when out in the cold or thoroughly drying the
  ears after a bath has not been identified as a contributing factor to an infant’s development of ear
  infections. Although the infant’s immunization status is always important to ascertain, other factors,
  such as the position of the infant when taking a bottle, have more impact.CN: Reduction of risk potential; CL: Analyze
1. It is the role of the surgeon or the person performing the procedure to obtain the informed
  consent. This consists of informing the client about the procedure, the risks of treatment, the side
  effects, other types of treatments available, and the effects without the procedure.
  CN: Management of care; CL: Apply
1. Hospice care focuses on supportive care for the client and family. Care for the family may
  continue throughout the bereavement period. Hospice care involves care of the client at home as well
  as in an inpatient setting. Although professional care is provided in hospice, family members,
  volunteers, and unlicensed nursing personnel also participate in the care of the client.
  CN: Basic care and comfort; CL: Apply
1. An 8-oz (250-mL) glass of milk is equivalent to 11⁄2 to 2 slices of presliced cheddar cheese.
  The listed amount of Parmesan cheese or milkshake is equivalent to 4 oz (125 mL) of milk, and 1⁄2 cup
  (125 mL) of cottage cheese is equivalent to 2 oz (30 mL) of milk.
  CN: Health promotion and maintenance; CL: Apply
1. The biophysical profile typically measures five parameters to assess the fetus: fetal
  breathing, movement, and tone; amniotic fluid volume; and fetal heart reactivity. The test uses a scale
  of 0 to 2 for each parameter with a maximum score of 10.
  CN: Physiological adaptation; CL: Evaluate
1. One of the side effects of steroid therapy is fat deposition on the trunk and face, producing
  classic Cushingoid signs. Therefore, the nurse should expect to find truncal obesity. Steroids also can
  cause altered moods or mood swings. Typically, long-term steroid use results in weight gain. Steroids
  may inhibit the action of growth hormone. Therefore, a growth spurt is not likely.
  CN: Pharmacological and parenteral therapies; CL: Analyze
1. The nurse should not be required to participate in an abortion if it contradicts the nurse’s
  religious beliefs. The behavior should not be reflected negatively on the nurses’ evaluation. Preparing
  equipment and supplies for the case may be viewed as the same as circulating for the case. The nurse
  has a right not to participate in an abortion unless it is an absolute emergency and no one else is
  available to care for the client.
  CN: Management of care; CL: Synthesize
1. Given the client’s age, making final plans is age appropriate. The absence of any signs of ill
  health, depression, or suicidal ideation makes the other options inappropriate.
  CN: Psychosocial adaptation; CL: Analyze

Question 2

Q

21. A client is taking phenytoin (Dilantin) as an antiepileptic medication. The nurse should
instruct the client to obtain:
1. Increased iron.
2. Increased calcium.
3. Frequent dental examinations.
4. Frequent eye examinations.

The nurse should establish baseline data on a client who is starting on long-term gentamicin
sulfate (Garamycin) therapy. Which of the following is least important for assessment screening in
this client?
Visual acuity.
Vestibular function.
Renal function.
Auditory function.
A hospitalized 5-year-old is pulseless, and after verifying the child is not breathing, the nurse
begins chest compressions. The nurse should apply pressure:
On the lower sternum with the heel of one hand.
Midway on the sternum with the tips of two fingers.
Over the apex of the heart with the heel of one hand.
On the upper sternum with the heels of both hands.
When developing a nutritional plan for a child who needs to increase protein intake, the nurse
should suggest which of the following foods? Select all that apply.
Bacon.
Cooked dry beans.
Peanut butter.
Yogurt.
Apple.
The nurse is auscultating S 1 and S 2 in a client. Identify the area where the nurse should hear
S 1 the loudest.26. The nurse instructs a client with coronary artery disease in the proper use of nitroglycerin
(Nitrostat). At the onset of chest pain, the client should:
Call 911 when three nitroglycerin tablets taken every 5 minutes are ineffective.
Call 911 when five nitroglycerin tablets taken every 5 minutes are ineffective.
Take three nitroglycerin tablets, 10 minutes apart, and call 911.
Go to the emergency department if three nitroglycerin tablets are ineffective.

27. A diet high in which of the following food substances contributes to increases in serum
cholesterol?
1. Polyunsaturated fat.
2. Saturated fat.
3. Monounsaturated fat.
4. Phospholipids.

During the health history, a client bluntly states, “I think I’m better off dead.” The best
response by the nurse is which of the following?
“Has a family member ever committed suicide?”
“When did these feelings begin?”
“Do you have someone at home to help you?”
“Are you thinking about suicide?”
A client is taking methotrexate for severe rheumatoid arthritis. The nurse instructs the client
that it will be necessary to monitor:
Serum glucose.
Serum electrolytes.
Complete blood count (CBC) with differential and platelet count.
Sedimentation rate.
Which of the following meals would be appropriate for the child with osteomyelitis to
choose?
Beef and bean burrito with cheese, carrot and celery sticks, and an orange.
Buttered wheat bread, cream of broccoli soup, lettuce salad with ranch dressing, and an apple.
Potato soup; bacon, lettuce, and tomato sandwich; and a peach.
Tomato soup, grilled cheese sandwich, and banana.
An elderly client is constipated and tells the nurse that this has not happened before. The best
response for the nurse to make is which of the following?
“Constipation is an expected problem at your age.”
“You need to eat more fiber.”
“You need to drink more water.”
“The new onset of constipation may be a sign of a more serious problem.”
A nurse is interviewing a client who will begin rehabilitation for alcohol dependency. Which
approach by the nurse is most helpful to the client before starting the program?
“You need to be very serious about this program.”
“You need to want to be alcohol-free before we can help you.”
“This program requires you to do a lot of hard work.”
“We’ll help you be successful so that you can stay alcohol-free.”
A client who has been newly diagnosed with type 1 diabetes asks the nurse, “Why do I have
to take two shots of insulin? Shouldn’t one shot be enough?” The best response for the nurse to make
is which of the following?
“A single shot of long-acting insulin would be preferable.”
“You might be able to change to oral medications soon.”
“Two shots will give you better control and decrease complications.”
“I’ll ask the physician to change your insulin schedule.”
The nurse reviews the peak and trough serum levels from a client who is receiving
gentamicin sulfate (Garamycin) in order to:
Adjust the dosage to the therapeutic range.
Avoid allergic reactions.
Prevent side effects.
Reach therapeutic levels more quickly.
A client with a history of type 1 diabetes mellitus and chronic obstructive pulmonary disease
should have which of the following immunizations?
Influenza.
Hepatitis A.
Measles-mumps-rubella.
Varicella.
A parent tells the nurse that their 8-month-old infant is anxious. Which of the following
suggestions by the nurse is most appropriate to help the parent lessen anxiety about the infant?
Limit holding the infant to feeding times.
Talk quietly to the infant while awake.
Play music in his room for most of the day and night.
Have a close friend keep the infant for a few days.
The parent of a 2-week-old infant brings the child to the clinic for a checkup. The parent
expresses concern about the baby’s breathing because the infant breathes quickly for a while and then
breathes slowly. The nurse interprets this finding as an indication of which of the following?
A normal pattern in infants of this age.
The need for an apnea monitor.3. A need for close monitoring for the parent.
The need for a chest radiograph.
Which of the following complications is associated with a tracheostomy?
Decreased cardiac output.
Damage to the laryngeal nerve.
Pneumothorax.
Acute respiratory distress syndrome.
The nurse who is caring for a client with type 1 diabetes mellitus should use which of the
following to determine how well the insulin, diet, and exercise are balanced?
Fasting serum glucose level.
1-week dietary recall.
Home log of blood glucose levels.
Glycosylated hemoglobin level.
The nurses have instituted a falls prevention program. Which of the following strategies will
have the highest likelihood of preventing falls?
Putting a falls risk sign on the clients’ doors.
Having the client wear a color-coded armband.
Making rounds of the unit and clients’ rooms.
Keeping all beds in low position.

Answer

A

1. Phenytoin causes hyperplasia of the gums, and the client needs frequent dental examinations
  and meticulous oral hygiene. Phenytoin therapy may contribute to a folic acid deficiency, but it is not
  related to iron or calcium metabolism. A need for frequent eye examinations is not related to the side
  effects of phenytoin.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. Visual acuity is not affected by long-term gentamicin sulfate therapy. The nurse should
  establish baseline data for vestibular, renal, and auditory function because gentamicin sulfate isototoxic and causes renal toxicity.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. The chest is compressed with the heel of one hand positioned on the lower sternum, two
  fingerbreadths above the sternal notch (at the nipple line). Fingertips are used to compress the
  sternum in infants, and the heels of both hands are used in adult cardiopulmonary resuscitation.
  CN: Safety and infection control; CL: Apply
2, 3, 4. Yogurt, dry beans, and peanut butter all contain protein in amounts that make them
good sources of protein for the child. Bacon is high in fat; an apple is a carbohydrate.
CN: Basic care and comfort; CL: Apply
S 1 is loudest at the mitral area.
CN: Health promotion and maintenance; CL: Apply
1. Nitroglycerin (Nitrostat) tablets should be taken 5 minutes apart for three doses; if this is
  ineffective, 911 should be called to obtain an ambulance to take the client to the emergency
  department. The client should not drive or have a family member drive the client to the hospital.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. Saturated fats raise blood cholesterol. Polyunsaturated fats maintain blood cholesterol.
  Monounsaturated fats may help to maintain or lower blood cholesterol. Phospholipids do not have an
  effect on cholesterol but act as emulsifiers, keeping fats dispersed in water.
  CN: Health promotion and maintenance; CL: Apply
1. The client who voices death wishes must be asked directly about thoughts of suicide and
  specific suicide plans. The other questions are important history questions but are not crucial to
  address the follow-up needed when the client verbalizes a death wish.
  CN: Psychosocial adaptation; CL: Synthesize
1. This client should be monitored for blood dyscrasias, evidenced by decreased platelet
  count and white blood cell count with changes in the CBC differential.
  CN: Pharmacological and parenteral therapies; CL: Apply
1. Children with osteomyelitis need a diet that is high in protein and calories. Milk, eggs,
  cheese, meat, fish, and beans are the best sources of these nutrients.
  CN: Physiological adaptation; CL: Synthesize
1. The new onset of constipation may be a sign of a tumor from colon cancer. Constipation is
  not an expected change of aging. Increased fiber and fluid intake is helpful with constipation, but in
  this case, the client needs to be seen by a health care provider to rule out colon cancer.
  CN: Reduction of risk potential; CL: Synthesize
1. Saying, “We’ll help you be successful so that you can stay alcohol-free,” conveys interest in
  the client as a worthwhile individual who needs help and treatment. This statement also helps to build
  trust and enhances self-esteem. The other statements confront the client and may result in the client’s
  feeling belittled, judged, and rejected.
  CN: Psychosocial adaptation; CL: Synthesize
1. Research has shown that at least two injections daily provide improved blood glucose
  control and decreased incidence of target end-organ damage. Type 1 diabetes requires insulin
  replacement and cannot be managed with oral medications alone. It would be inappropriate to ask the
  physician to change the insulin schedule.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. Peak and trough serum levels are used to adjust the dosage within a therapeutic range.
  CN: Pharmacological and parenteral therapies; CL: Apply
1. The client with diabetes and a chronic respiratory condition is most at risk for influenza
  and should receive the vaccine yearly. Diabetes and chronic respiratory conditions do not increase
  the risk of hepatitis A. An adult client is not as likely to need the measles-mumps-rubella or varicella
  immunizations, but titers can be checked if the client has not had childhood immunizations or the
  disease.
  CN: Reduction of risk potential; CL: Apply
1. Infants are sensitive to stress in their caretakers. The best way to handle an anxious infant is
  to talk quietly, thereby soothing the infant. Limiting holding of the infant to feeding periods interferes
  with meeting the infant’s needs for close contact, possibly compromising his ability to develop trust.
  Playing music in the room for most of the day and night will make it difficult for the infant to
  differentiate days from nights. Having a friend take the infant for several days will not necessarily
  take care of the problem because when the infant returns to the parents, the same behaviors will recur
  unless the parents makes some changes.
  CN: Psychosocial adaptation; CL: Synthesize
1. The infant is exhibiting periodic breathing, which is normal in infants of this age. The infant
  typically alternates short periods of rapid, louder respirations with periods of slower, quieter
  respirations.
  CN: Health promotion and maintenance; CL: Analyze
1. Tracheostomy tubes are associated with several potential complications, including
  laryngeal nerve damage, bleeding, and infection. Tracheostomy tubes do not cause decreased cardiac
  output, pneumothorax, or acute respiratory distress syndrome.CN: Physiological adaptation; CL: Analyze
1. A glycosylated hemoglobin level gives the nurse data about the average blood glucose
  concentration over 2 to 3 months, providing a picture of the client’s overall glucose control. A fasting
  serum glucose level gives a picture of the child’s recent glucose level, not the overall effectiveness of
  the child’s therapeutic regimen. A 1-week diet recall is not always accurate. Although a home log
  would provide some information about the child’s overall control and compliance, the log may not
  have all of the glucose levels recorded.
  CN: Reduction of risk potential; CL: Evaluate
1. When making rounds, nurses can note a variety of risks in the clients’ rooms, in the
  hallways, and other areas where clients might be at risk. Using signs, color-coded armbands, and
  keeping the bed in a low position are also useful, but making rounds offers the opportunity for nurses
  to intervene immediately and teach the client, family, and staff when risks are noted.
  CN: Safety and infection control; CL: Synthesize

Question 3

Q

A client is receiving a unit of packed red blood cells. Before the transfusion started, the
client’s blood pressure was 90/50 mm Hg, pulse rate 100 bpm, respirations 20 breaths/min, and
temperature 98°F (36.7°C). Fifteen minutes after the transfusion starts, the client’s blood pressure is
92/54 mm Hg, pulse 100 bpm, respirations 18 breaths/min, and temperature is 101.4°F (38.6°C). The
nurse should first:
Stop the transfusion.
Raise the head of the bed.
Obtain a prescription for antibiotics.
Offer the client a cool washcloth.
For which of the following findings in a client receiving opioid epidural analgesia should the
nurse notify the physician? Select all that apply.
Blood pressure of 80/40 mm Hg, baseline blood pressure of 110/60 mm Hg.
Respiratory rate of 14 breaths/min, baseline respiratory rate of 18 breaths/min.
Report of crushing headache.
1.5 mL of blood aspirated from the catheter before the bolus injection.
Pain rating of 3 on a scale of 1 to 10.
Which of the following dietary strategies best meets the nutritional needs of a client with
acquired immunodeficiency syndrome (AIDS)?
Tell the client to eat large meals frequently.
Encourage megadoses of nutritional supplements.
Instruct the client to cook foods thoroughly and adhere to safe food-handling practices.
Tell the client to prepare food in advance and leave it out to eat small amounts throughout the
day.
Before an incisional cholecystectomy is performed, the nurse instructs the client in the correct use of an incentive spirometer. Why is incentive spirometry essential after surgery in the upper abdominal area?
The client will be maintained on bed rest for several days.
Ambulation is restricted by the presence of drainage tubes.
The operative incision is near the diaphragm.
The presence of a nasogastric tube inhibits deep breathing.
The nurse is examining a 6-week-old dark-skinned infant. There are large spots of deep blue
pigmentation across the infant’s buttocks. The nurse should identify this sign as characteristic of:
Vascular disease.
Telangiectatic nevi.
Infant milia.
Mongolian spots.
A nulliparous client has been given a prescription for oral contraceptives. Which of the
following should the nurse instruct the client to report to the health care provider immediately?
Blurred vision.
Nausea.
Weight gain.
Mild headache.
A client experienced a pneumothorax after the placement of a central venous pressure line.
Which of the following supports a diagnosis of pneumothorax?
Sudden, sharp pain on the affected side.
Tracheal deviation toward the affected side.
Bradypnea and elevated blood pressure.
Presence of crackles and wheezes.
A client is experiencing a flashback from the use of lysergic acid diethylamide. The nurse
should:
Confront the client’s misperceptions.
Reassure the client while presenting reality.
Seclude the client until the flashback ends.
Challenge the client’s unrealistic statements.
The nurse should dispose of a used needle and syringe by:
Cutting the needle at the hilt in a needle cutter before disposing of it in the universal precaution
container in the client’s room.
Placing uncapped, used needles and syringes immediately in the universal precaution container
in the client’s room.
Recapping the needle and placing the needle and syringe in the universal precaution container
in the client’s room.
Separating the needle and syringe and placing both in the universal precaution container in the
client’s room.
The nurse is planning a health promotion education session for a community health fair. The
nurse reviews health data for the community (see below) prior to planning the session. To develop aprogram which is appropriate for the residents of this community and is cost-effective, the nurse
should plan to do which of the following? Select all that apply.
Focus on information about preventing heart disease.
Appeal to college graduates.
Present the program in Spanish and English.
Develop content that is culturally appropriate for members of all ethnic/racial groups in the
community.
Provide printed materials for each participant.

DEATHS BY CAUSE
ACCIDENT 28 
HOMICIDE 2
HEART DISEASE 238
SUICIDE 12
CANCER 203
MVA 10

EDUCATIONAL ATTAINMENT
HIGHSCHOOL DROPOUTS 6,604
NO HIGHSCHOOL DIPLOMA 11,596
HIGHSCHOOL DIPLOMA ONLY 163,995
HIGHSCHOOL DIPLOMA OR MORE 451,863
SOME COLLEGE  147,330
ASSOCIATE DEGREE OR MORE 171,410
BACHELOR DEGREE OR MORE 1440,550

RACE/ETHNICITY
BLACK 54,083
NATIVE AMERICAN / FIRST NATIONS 294
ASIAN 2,047
CAUCASIAN 78,122
MEXICAN 459
MULTIRACIAL 7,073

An 80-year-old client is admitted with nausea and vomiting. The client has a history of heart
failure and is being treated with digoxin (Lanoxin). The client has been nauseated for a week and
began vomiting 2 days ago. Laboratory values indicate hypokalemia. Because of these clinical
findings, the nurse should assess the client carefully for signs of which of the following conditions?
Chronic renal failure.
Exacerbation of heart failure.
Digoxin toxicity.
Metabolic acidosis.
The nurse instructs the client with osteoporosis that food products high in calcium include:
Rice.
Broccoli.
Apples.
Meat.
A woman is using progestin injections (Depo-Provera) for contraception. The nurse instructs
the client to return for an appointment in:
1 month.
3 months.
4 months.
6 months.
A client exhibits increased restlessness. Arterial blood gas results are pH, 7.52; partial
pressure of carbon dioxide, 38 mm Hg (5.1 kPa); bicarbonate, 34 mg/L (34 mmol/L). The nurse
should plan care based on the fact that these findings indicate which of the following acid-base
imbalances?
Respiratory alkalosis.
Respiratory acidosis.
Metabolic acidosis.
Metabolic alkalosis.
While the nurse is caring for a multigravid client at 39 weeks’ gestation in active labor whose
cervix is dilated to 7 cm and completely effaced at +1 station, the client says, “I need to push!” Which
of the following should the nurse do next?
Turn the client to her left side.
Tell her to push when she has the urge.
Have her pant quickly during the contraction.
Tell her to focus on an object in the room to relax.
When teaching a client with chronic renal failure who is taking antibiotics about signs and
symptoms of potential nephrotoxicity to report, the nurse should encourage the client to promptly
report which of the following changes in the color of the urine? Select all that apply.
Straw-colored.
Cloudy.
Smoky.
Pink.
The nurse is assessing a child with suspected juvenile hypothyroidism. Which of the
following should the nurse expect this child to manifest?
Short attention span and weight loss.
Weight loss and flushed skin.
Rapid pulse and heat intolerance.
Dry skin and constipation.
A 10-year-old diagnosed with attention deficit hyperactivity disorder (ADHD) has been
switched from a stimulant to atomoxetine (Strattera) 40 mg two times a day. The nurse is instructing
the client and the mother about the change in medication. Which statement indicates that the client’s
mother needs further education about the medication? Select all that apply.
“I have to give her both doses before lunch.”
“I’ll have to make sure she’s gaining weight appropriately.”
“She may have nausea or dizziness for 1 or 2 months.”4. “If she has mood swings, I should call her psychiatrist.”
“She can’t take monoamine oxidase inhibitors while on Strattera.”
“If her ADHD symptoms don’t improve in 2 to 3 weeks, I should stop the Strattera.”
Which of the following will be most effective in reducing a client’s fluid volume excess?
Low-sodium diet.
Monitoring serum electrolytes daily.
Restricting fluid intake.
Elevation of the client’s feet.
The nurse observes a darkish blue pigment on the buttocks and back of an infant of African
descent. Which of the following actions is most appropriate?
Ask the obstetrician to assess the child.
Assess the child for other areas of cyanosis.
Document this observation in the child’s record.
Advise the mother that laser therapy is needed.

Answer

A

1. The nurse’s first action should be to clamp off the transfusion because the client is having a
  transfusion reaction. It is most important that the client not receive any more blood. Other measures
  may be appropriate after the blood has been stopped. The nurse should raise the head of the bed if the
  client becomes short of breath. There is no need for antibiotic therapy for a blood transfusion related
  to a temperature spike. The nurse can provide a cool washcloth for a headache or fever; however, this
  is not a priority.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1, 3, 4. A drop in blood pressure to 80/40 mm Hg is significant and should be reported to the
physician. Hypotension and vasodilation may occur as a result of sympathetic nerve blockage along
with the pain nerve blockage. A report of a crushing headache suggests that the epidural catheter may
be dislodged and in the subarachnoid space rather than the epidural space. The physician also should
be notified anytime more than 1 mL of fluid or blood is aspirated from the catheter before a bolus
injection. A respiratory rate of 14 breaths/min, although somewhat decreased from baseline, is within
acceptable parameters. However, if the rate drops to 10 breaths/min or less, the physician should be
notified. A pain rating of 3 out of 10 suggests that pain is being relieved with the epidural analgesia.
CN: Pharmacological and parenteral therapies; CL: Synthesize
1. A client with AIDS is immunocompromised, and food safety is an important concern. Food-
  borne illnesses and infections can be devastating to the client with AIDS. Large, frequent meals are
  not necessary. Megadoses of vitamins can result in toxicities that may aggravate the client’s clinical
  condition. Leaving food out encourages growth of microorganisms.
  CN: Safety and infection control; CL: Synthesize
1. The incisions made for upper abdominal surgeries, such as cholecystectomies, are near the
  diaphragm and make deep breathing painful. Incentive spirometry, which encourages deep breathing,
  is essential to prevent atelectasis after surgery. The client is not maintained on bed rest for several
  days. The client is encouraged to ambulate by the first postoperative day, even with drainage tubes in
  place. Nasogastric tubes do not inhibit deep breathing and coughing.
  CN: Physiological adaptation; CL: Apply
1. This finding describes Mongolian spots, which are common in newborns of African, Asian,
  or Latin descent. Telangiectatic nevi, or “stork bites,” are pink lesions commonly found on the back of
  the neck. Milia are small white papules over the nose and cheek that indicate blocked sebaceous
  glands.
  CN: Health promotion and maintenance; CL: Analyze
1. Blurred vision is a serious adverse effect of oral contraceptives, possibly because of
  severe hypertension as a result of the medication. If the client experiences blurred vision, she needs
  to contact her health care provider immediately. Nausea, weight gain, and mild headache are common
  and possibly bothersome side effects and should be noted. However, they do not need to be reported
  immediately unless they are severe, prolonged, or accompanied by other symptoms.
  CN: Pharmacological and parenteral therapies; CL: Analyze
1. Signs and symptoms of a pneumothorax include sudden, sharp pain with breathing or
  coughing on the affected side, tachypnea, dyspnea, diminished or absent breath sounds on the affected
  side, tachycardia, anxiety, and restlessness. Tracheal deviation away from the affected side indicates
  a tension pneumothorax, which is a medical emergency.
  CN: Physiological adaptation; CL: Analyze
1. When a client is experiencing a flashback, the nurse should stay with the client, offer
  reassurance, and present reality in a nonthreatening manner to minimize the client’s anxiety and
  agitation. The client needs to be told that he or she is experiencing an effect from lysergic acid
  diethylamide and that he or she is safe and the flashback will end. Confronting the client’s
  misperceptions or challenging unrealistic statements could increase anxiety and agitation, possibly
  leading to aggressive behavior. Secluding the client until the flashback ends usually is not necessary
  or appropriate unless the client threatens or demonstrates aggression toward self or others.
  CN: Psychosocial adaptation; CL: Apply
1. The nurse should dispose of any used needle and syringe by immediately placing uncapped,
  used needles and syringes in the universal precaution container.
  CN: Pharmacological and parenteral therapies; CL: Apply
1, 4. The greatest cause of death in this community is from heart disease, and therefore, the
education session should focus on heart health and prevention of heart disease. This community has a
diverse racial/ethnic mix, and the session should be planned to be culturally appropriate for all
members of the community. The majority of this community does not have a college education; the
session should be planned for those with an education level of high school or less. There is not a
sufficient number of people of Mexican ethnicity in this community to justify having the session
presented in Spanish. While printed materials enhance educational sessions, particularly for visual
learners, there is no indication that this is necessary or would be cost-effective.
CN: Management of care; CL: Synthesize
1. Nausea and vomiting, along with hypokalemia, are likely indicators of digoxin toxicity.
  Hypokalemia is a common cause of digoxin toxicity; therefore, serum potassium levels should be
  carefully monitored if the client is taking digoxin. The earliest clinical signs of digoxin toxicity are
  anorexia, nausea, and vomiting. Bradycardia, other dysrhythmias, and visual disturbances are also
  common signs. Chronic renal failure usually causes hyperkalemia. With persistent vomiting, the clientis more likely to develop metabolic alkalosis than metabolic acidosis.
  CN: Pharmacological and parenteral therapies; CL: Analyze
1. Food sources high in calcium include steamed broccoli, dairy products, and fortified
  cereals. Rice, apples, and meat are not calcium-rich sources. Menopausal women need 1,500 mg of
  calcium daily.
  CN: Reduction of risk potential; CL: Apply
1. At the time a client receives a Depo-Provera injection, a follow-up appointment should be
  made for 3 months later. The nurse should emphasize the need to adhere to the medication schedule to
  prevent an unplanned pregnancy. One of the most common reasons for failure of this contraceptive is
  lack of adherence to the appointment schedule for injections every 3 months.
  CN: Pharmacological and parenteral therapies; CL: Apply
1. The pH of 7.52 indicates that the body is in a state of alkalosis. The partial pressure of
  carbon dioxide value is normal, and the bicarbonate value is elevated. The increased bicarbonate
  value indicates that the acid-base imbalance is metabolic alkalosis. Restlessness can be a clinical
  finding in metabolic alkalosis.
  CN: Physiological adaptation; CL: Analyze
1. Panting will alleviate the client’s urge to push. The client risks edema or tearing of the
  cervix if pushing begins before complete cervical dilation (10 cm) is achieved. Although turning the
  client to her left side improves uteroplacental blood flow, it will have no effect on diminishing the
  client’s urge to push. Although focusing on an object in the room may help the client to relax, it will
  have no effect on diminishing the client’s urge to push due to the pressure of a fetus at +1 station.
  CN: Health promotion and maintenance; CL: Synthesize
2, 3, 4. The client who is taking potentially nephrotoxic antibiotics should notify the health
care provider if the urine is cloudy, smoky, or pink; early signs of nephrotoxicity are manifested by
changes in urine color. Straw-colored urine is normal.
CN: Pharmacological and parenteral therapies; CL: Analyze
1. Clinical manifestations of juvenile hypothyroidism include dry skin, constipation, sparse
  hair, and sleepiness. Short attention span, weight loss, moist flushed skin, rapid pulse, and heat
  intolerance suggest hyperthyroidism.
  CN: Physiological adaptation; CL: Analyze
1, 6. Atomoxetine is a selective norepinephrine reuptake inhibitor antidepressant, not a
stimulant. Therefore, a two-times-a-day dosing schedule is appropriate, with a dose given in the
morning and late afternoon. It may take more than 2 to 3 weeks to see the full effects of this
medication. Nausea and dizziness are transient side effects. Monoamine oxidase inhibitors are
contraindicated with atomoxetine.
CN: Pharmacological and parenteral therapies; CL: Evaluate
1. In clients with excess fluid volume, sodium restriction may be necessary to promote fluid
  loss. Monitoring electrolytes daily may be appropriate but will not reduce the excess fluid.
  Restricting fluid intake will not reduce retained fluids; increased fluids will increase urine output and
  promote improved fluid balance. Elevating the client’s feet helps promote venous return and fluidreabsorption but in itself will not reduce the volume of excess fluid.
  CN: Reduction of risk potential; CL: Synthesize
1. The bluish pigment on the buttocks and back of an infant of African descent is a common
  finding and should be documented as Mongolian spots in the child’s record. These spots typically
  fade by the time the child is 5 or 6 years. Additional assessment by the physician is not indicated.
  Laser therapy is not used. Rather, laser therapy is useful for port wine stains, which are dark purple
  and disfiguring.
  CN: Health promotion and maintenance; CL: Synthesize

Question 4

Q

During a physical examination, the nurse observes a copper bracelet on a client’s wrist. The
client states that she is wearing it to treat her arthritis. The nurse should:
Recognize that the client is wearing a protective object she believes wards off illness.
Inform the client that this is a not a helpful practice and ask her to remove the bracelet.
Tell the client that wearing the bracelet is a form of quackery and not to use the bracelet as a
treatment.
Continue to wear the copper bracelet because this is a medically supported treatment for arthritis.
The heart rate of a newly born term neonate is regular at 142 bpm. Which of the following
should the nurse do next?
Notify the neonate’s pediatrician.
Check for the presence of cyanosis.
Assess the heart rate again in 3 hours.
Document this as a normal neonatal finding.
The fetus of a multigravid client at 38 weeks’ gestation is determined to be in a frank breech
presentation. The nurse describes this presentation to the client as which of the following fetal parts
coming in contact with the cervix?
Buttocks.
Head.
Both feet.
Shoulder.
The therapeutic effects of desmopressin nasal spray (DDAVP) are obtained when the client
no longer has:
Polydipsia.
Nasal congestion.
Headache.
Blurred vision.
The nurse advises a 42-year-old client to have a screening mammogram. The client asks whythis is necessary since she performs a breast self-examination (BSE) monthly. The nurse’s best
response is:
“All women over 35 should have an annual mammogram.”
“A mammogram can identify breast cancer before it’s detectable by BSE.”
“Most women don’t perform BSE thoroughly enough to detect cancer.”
“A mammogram can detect other endocrine abnormalities as well.”
A client is recovering from an infected abdominal wound. Which of the following foods
should the nurse encourage the client to eat to support wound healing and recovery from the infection?
Chicken and orange slices.
Cheeseburger and french fries.
Cheese omelet and bacon.
Gelatin salad and tea.

67. The nurse teaches the client with iron deficiency anemia that food sources with high iron
content include:
1. Cheese.
2. Squash.
3. Eggs.
4. Beef.

The mother of a toddler diagnosed with iron deficiency anemia asks what foods she should
give her child. The nurse should evaluate the teaching as successful when the mother later reports that
she feeds the toddler which of the following?
Milk, carrots, and beef.
Raisins, chicken, and spinach.
Beef, lettuce, and juice.
Eggs, cheese, and milk.
A toddler admitted in respiratory distress keeps pulling at the oxygen mask, trying to remove
it. The nurse should do which of the following? Select all that apply.
Restrain the child.
Have the parent read to the child.
Administer a sedative.
Encourage the parent to hold the child.
Tell the child the mask will help him breathe better.
Ask the parent to leave the child’s bedside.
Four hours after a cast has been applied for a fractured ulna, the nurse assesses that the
client’s fingers are pale and cool and capillary refill is delayed for 4 seconds. How should the nurse
interpret these findings?
Nerve impairment is developing in the fingers.
Arterial blood supply to the fingers is decreased.
Venous stasis is occurring in the fingers.
The finding is normal for this recovery period.
The nurse is developing a plan of care for a client who has joint stiffness due to rheumatoid
arthritis. Which of the following interventions is most effective in relieving stiffness?1. A warm shower before performing activities of daily living.
Aspirin after activity to decrease inflammation.
A 10-lb (4.5-kg) weight loss to limit stress on joints.
Cold compresses to joints for 30 minutes to relieve stiffness.
The nurse walks into the room and finds that a client who has just had surgery is diaphoretic,
appears to have no respirations, and has a barely palpable pulse. The nurse should first:
Call a code.
Open the airway.
Start rescue breathing.
Start cardiac compressions.
A client with obsessive-compulsive disorder washes the hands multiple times daily and is
late for meals and milieu activities. Which of the following is most appropriate for the nurse to do
initially?
Totally eliminate the client’s ritual.
Allow the client to decide whether to attend meals and activities.
Inform the client that absence from meals and activities is not permitted.
Remind the client about meal and activity times so that the ritual can be completed on time.
After discussing preconception needs with a nulliparous client of Asian descent, which of the
following client statements indicates the need for further instruction?
“I should take folic acid supplements before I get pregnant.”
“If I become pregnant, I can continue to eat sushi twice a week.”
“I should continue to steam my vegetables rather than cooking them for a long time.”
“Eating soy products can increase my protein levels once I’m pregnant.”
A client with osteoarthritis purchased a copper bracelet to wear and tells the nurse that there
is less pain now. Which response by the nurse is most appropriate?
Tell the client to remove the bracelet because it does not have any therapeutic value.
Warn the client not to spend any more money on quackery such as bracelets.
Instruct the client to remove the bracelet because the copper in it can interfere with salicylate
metabolism.
Acknowledge that the client feels better, but encourage the client to continue with the
prescribed therapy.
The client is started on simvastatin (Zocor) as a component of cholesterol management.
Which of the following laboratory tests needs to be monitored while on this therapy?
Complete blood count.
Serum glucose.
Total protein.
Liver function tests.
A man of Chinese descent is admitted to the hospital with multiple injuries after a motor
vehicle accident. His pain is not under control. The client states, “If I could be with my people, I
could receive acupuncture for this pain.” The nurse should understand that acupuncture in the Asian
culture is based on the theory that it:
Purges evil spirits.2. Promotes tranquility.
Restores the balance of energy.
Blocks nerve pathways to the brain.
A client is taking large doses of aspirin daily to treat rheumatoid arthritis. Which of the
following side effects should the nurse instruct the client to report?
Abdominal cramps.
Tinnitus.
Rash.
Hypotension.
A client is transferred from the coronary care unit to the step-down unit. Which of the
following should be included in the transfer report? Select all that apply.
The client needs oxygen at 2 L/min.
The client has a “do not resuscitate” prescription.
The client uses the bedpan.
The client has four grandchildren.
The client has been in normal sinus rhythm for 6 hours.
The nurse is assessing fetal presentation in a multiparous client. The figure below indicates
which of the following types of presentations?
Frank breech.
Complete breech.
Footling breech.
Vertex.

Answer

A

1. The client might wear objects as a protection against specific medical disorders. Typically,
  these practices bring no harm to the client and should not be discouraged. The client should continue
  to be encouraged to follow the medical guidance of her health care provider. If the practice is not
  harming the client, it is inappropriate to label it quackery and demand that the client discontinue it.
  There is no medical evidence to support the wearing of a copper bracelet.
  CN: Health promotion and maintenance; CL: Synthesize
1. Normally, a neonate’s heart rate should be between 120 and 160 bpm shortly after birth.
  The nurse should document this as a normal neonatal finding. The physician does not need to be
  notified. Assessing for cyanosis is a routine assessment at birth, but with the neonate’s heart rate at
  142 bpm, cyanosis should be minimal and typically located in the hands and feet. Heart rate
  assessments are performed routinely according to facility protocol. For example, the heart rate is
  assessed soon after birth, every 15 minutes for 1 hour, every 30 minutes for 1 hour, and then every 4
  hours.
  CN: Health promotion and maintenance; CL: Synthesize
1. In a frank breech, the buttocks alone are at the cervix, while the knees are extended to rest
  on the chest. In a cephalic presentation, the head is the fetal body part first coming in contact with the
  cervix. Both feet at the cervix is termed double footling breech. In a shoulder presentation, one of the
  shoulders (actually the acromion process) presents to the cervix. Typically, the fetus is lying
  horizontally (transverse lie).
  CN: Health promotion and maintenance; CL: Apply
1. The therapeutic effects of desmopressin nasal spray are relief from polydipsia and control
  of polyuria and nocturia in the client with diabetes insipidus. Side effects include nasal congestion
  and headache. Blurred vision is not related to desmopressin.
  CN: Pharmacological and parenteral therapies; CL: Evaluate
1. A mammogram can detect a lesion the size of a pinhead, and a lump is about 2 cm before it
  can be detected by a BSE. The American and Canadian Cancer Societies recommend a mammogram
  yearly after age 40. A mammogram will not detect other endocrine abnormalities.
  CN: Health promotion and maintenance; CL: Synthesize
1. Protein and vitamin C are particularly important in promoting wound healing and recovery
  from infection. A diet high in carbohydrates is also essential. Because the client with an infection
  commonly does not feel like eating, it is important that what he is encouraged to eat should be
  nutritious. Chicken and orange slices would help meet the client’s protein and vitamin needs. A mealof cheeseburger and fries or cheese omelet and bacon is high in fat and low in vitamins. Gelatin salad
  and tea contain minimal nutrients.
  CN: Basic care and comfort; CL: Apply
1. Beef, liver, iron-fortified cereals, and spinach are iron-rich foods. Cheese, squash, and
  eggs are not significant sources of iron.
  CN: Reduction of risk potential; CL: Apply
1. Good sources of dietary iron include red meats, poultry, green leafy vegetables, and dried
  fruits such as raisins. Milk products are poor sources of iron. Carrots are high in vitamin A.
  CN: Reduction of risk potential; CL: Evaluate
2, 4. Children in respiratory distress need to be kept as quiet as possible to decrease
respiratory and heart rates. Toddlers need a parent with them for security. The best way to quiet
toddlers is to read to or hold them. Restraints increase heart and respiratory rates. A sedative will
mask the signs of further respiratory distress. Although you could tell toddlers that a mask will help
with breathing, they cannot understand the rationale and thus fully comprehend its importance. Asking
the parents to leave the bedside will most likely result in greater upset, further contributing to
respiratory distress.
CN: Basic care and comfort; CL: Synthesize
1. The pallor and cool temperature of the fingers and the decreased return time for capillary
  refill indicate decreased arterial blood supply to the fingers. These findings are not normal for any
  time in the recovery process. Nerve impairment includes numbness, tingling, and impaired movement
  of the fingers. Signs of venous stasis include edema and reddening of the fingers, not pallor and cool
  temperature.
  CN: Physiological adaptation; CL: Analyze
1. Warm showers, baths, or hand soaks can help relieve joint stiffness and allow the client to
  more comfortably perform activities of daily living. Aspirin or other anti-inflammatory drugs should
  be taken before activity to help decrease inflammation and reduce joint pain and inflammation.
  Although weight loss may decrease stress on joints, pain and stiffness will continue to be a problem.
  Cold compresses are most effective for relieving joint pain, whereas moist heat is useful for
  decreasing pain and stiffness. When cold compresses are applied, their use should be limited to 10 to 15 minutes at a time to decrease the risk of tissue damage.
  CN: Basic care and comfort; CL: Synthesize
1. The most appropriate immediate response is to open the airway. The nurse then should
  look, listen, and feel for respirations. Noting none, the nurse calls a code and attempts ventilations
  with a bag mask or mask with a one-way valve until the full code team responds. Using standard
  precautions with the mask protects the nurse from exposure to possible client microorganisms.
  CN: Physiological adaptation; CL: Synthesize
1. The nurse should remind the client about meal and activity times so that the ritual can be
  completed beforehand and not interfere with meals and activities. The client must be allowed to
  complete the ritual because it keeps anxiety in check. Totally eliminating the client’s ritual will
  increase anxiety and the need for the hand washing. Allowing the client to decide to attend meals andactivities is not appropriate or in the client’s best interest because the client must perform the ritual to
  assuage anxiety. Informing the client that absence from meals and activities is not permitted scolds the
  client, increasing anxiety and the need for the ritual.
  CN: Psychosocial adaptation; CL: Synthesize
1. The client needs further instructions when she says, “If I become pregnant, I can continue to
  eat sushi twice a week.” Raw fish, including tuna, should be avoided while the client is pregnant
  because of the risk of contamination with mercury and other potential teratogens. Folic acid
  supplements taken before the client gets pregnant and during pregnancy can help reduce the risk of
  neural tube defects. Steaming vegetables reduces the risk that vitamins will be lost in the cooking
  water. Soy products can increase the client’s protein levels.
  CN: Health promotion and maintenance; CL: Evaluate
1. The nurse should acknowledge that the client feels better but should also remind the client
  to continue his drug therapy and other self-care activities of rest, exercise, joint protection, and
  adequate nutrition. Wearing the bracelet is not harmful, and the nurse should not instruct the client to remove it or label it quackery. Copper bracelets do not interfere with salicylate metabolism.
  CN: Psychosocial adaptation; CL: Synthesize
1. Liver function tests, including aspartate transaminase (AST), should be monitored before
  therapy, 6 to 12 weeks after initiation of therapy or after dose elevation, and then every 6 months. If
  AST levels increase to three times normal, therapy should be discontinued. Simvastatin does not
  influence serum glucose, complete blood count, or total protein. Serum cholesterol and triglyceride
  levels should be evaluated before initiating therapy, after 4 to 6 weeks of therapy, and periodically
  thereafter.
  CN: Health promotion and maintenance; CL: Analyze
1. Acupuncture, like acumassage and acupressure, is performed in certain Asian cultures to restore the energy balance within the body. Pressure, massage, and fine needles are applied to energy pathways to help restore the body’s balance. Acupuncture is not based on a belief in purging evil
  spirits. Although pain relief through acupuncture can promote tranquility, acupuncture is performed to
  restore energy balance. In the Western world, many researchers think that the gate-control theory of
  pain may explain the success of acupuncture, acumassage, and acupressure.
  CN: Basic care and comfort; CL: Apply
1. Tinnitus or ringing in the ears is a sign of aspirin toxicity and should be reported. Clients
  should be instructed to take aspirin as prescribed and to avoid overdosage. Gastrointestinal
  symptoms associated with aspirin include nausea, heartburn, and epigastric discomfort caused by
  gastric irritation. Abdominal cramps, rash, and hypotension are not related to aspirin therapy.
  CN: Pharmacological and parenteral therapies; CL: Analyze
1, 2, 3, 5. The nurse should report that the client is using oxygen, has a “do not resuscitate”
prescription, can use the bedpan, and is in normal sinus rhythm. Information about having four
grandchildren is not needed to help with the client’s continuity of care.
CN: Management of care; CL: Apply
1. Although breech presentations are rare, footling breech occurs when there is an extensionof the fetal knees and one or both feet protrude through the pelvis. In frank breech, there is flexion of
  the fetal thighs and extension of the knees. The feet rest at the sides of the fetal head. In complete
  breech, there is flexion of the fetal thighs and knees; the fetus appears to be squatting. Vertex position
  occurs in 95% of births; in such cases, the head is engaged in the pelvis.
  CN: Health promotion and maintenance; CL: Apply

Question 5

Q

A multigravid client at 26 weeks’ gestation with a history of pregnancy-induced hypertension
(PIH) asks the nurse about traveling from North America to a village in India by airplane to visit her
father, who wishes to see her before she gives birth. Which of the following responses by the nurse is
most appropriate?1. “Air travel at this point in your pregnancy can lead to preterm labor.”
“You can travel by airplane as long as you take frequent walks during the trip.”
“You need to avoid traveling because of your history of PIH.”
“You’d be placing yourself and your fetus at risk for communicable diseases common in India.”
A pregnant woman does not have funds to purchase adequate, nutritious food. She works part
time at a low-wage job and has two other children. The nurse can refer the client to which of the
following?
Home-delivered meals.
Neighbors who can provide food.
The pregnant woman’s employer.
Food bank.
The nurse is caring for a client who has severe burns on the head, neck, trunk, and groin
areas. Which position would be most appropriate for preventing contractures?
High Fowler’s.
Semi-Fowler’s.
Prone.
Supine.
The client sustained an open fracture of the femur from an automobile accident. For which of
the following types of shock should the client be assessed?
Cardiogenic.
Hypovolemic.
Neurogenic.
Anaphylactic.
The client has various sensory impairments associated with type 1 diabetes. The nurse
determines that the client needs further instruction when the client says:
“I’ll carefully test the temperature of my bathwater.”
“I’ll avoid kitchen activities.”
“I’ll avoid hot water bottles or heating pads.”
“I’ll inspect my skin daily for pressure points and injury.”
The nurse is providing discharge instructions to the client with peripheral vascular disease.
Which of the following instructions should be included in the discussion with this client? Select all
that apply.
Avoiding prolonged standing and sitting.
Limiting walking so as not to activate the “muscle pump.”
Keeping extremities elevated on pillows.
Keeping the legs in a dependent position.
Using a heating pad to promote vasodilation.
A father tells the nurse that his adolescent son spends lots of time in his room, his grades are
falling, and he has given away a few of his most favorite compact disks. Which of the following is the
most appropriate action for the nurse?
Give the father the telephone number for the local crisis hotline.
Have the father take the adolescent to the nearest mental health outpatient facility now.3. Make a same-day appointment for the adolescent with his usual health care provider.
Obtain more history information from the distraught father before making a decision.
A 7-year-old child is admitted to the hospital with acute rheumatic fever with chorea-like
movements. Which of the following eating utensils should the nurse remove from the meal tray?
Fork.
Spoon.
Plastic cup.
Drinking straw.
The nurse should prepare the client for which of the following during the immediate
postoperative care after reversal of a colostomy? Select all that apply.
Nasogastric (NG) tube attached to low intermittent suction.
Administration of IV fluids.
Daily measurement of abdominal girth.
Calculation of intake and output every 8 hours.
Assessment of vital signs every 6 hours.
A client’s catheter is removed 4 days after a transurethral resection of the prostate (TURP).
He is experiencing urinary dribbling. The nurse should do which of the following?
Teach the client Kegel exercises.
Obtain a urine culture and sensitivity analysis to screen for a urinary infection.
Encourage voiding every hour to prevent dribbling.
Inform him that the dribbling will stop after a few days.
An adolescent primigravid client at 26 weeks’ gestation has gained 25 lb since becoming
pregnant. Which of the following is the recommended amount of weight gain during the third
trimester?
1 lb (0.45 kg) per week.
2 lbs (0.9 kg) per week.
7 lbs (3.2 kg per week).
5 to 6 lbs (2.3 to 2.7 kg) for the trimester.

92.The nurse is preparing to administer 0.1 mg of digoxin (Lanoxin) intravenously. Digoxin comes in a
concentration of 0.5 mg/2 mL. How many milliliters should the nurse administer?
_______________ mL.

The mother of a 2-month-old infant with colic states, “I don’t know what to do anymore. She’s
up in the middle of the night crying all the time.” The nurse should tell the mother to:
Walk the floor with the baby at night.
Take the infant for a short drive in the car.
Allow the infant to cry it out in her crib.
Offer cereal to fill the baby’s stomach.
After the application of an arm cast, the client has pain on passive stretching of the fingers,
finger swelling and tightness, and loss of function. Based on these data, the nurse anticipates that the
client may be developing which of the following?
Delayed bone union.2. Compartment syndrome.
Fat embolism.
Osteomyelitis.
Which of the following is a priority for a client who has just had a myocardial infarction?
Low-back training program.
Risk modification education.
Strength training program.
Jogging exercise program.
While assessing a 4-day-old neonate born at 28 weeks’ gestation, the nurse cannot elicit the
neonate’s Moro reflex, which was present 1 hour after birth. The nurse notifies the physician because
this may indicate which of the following?
Postnatal asphyxia.
Skull fracture.
Intracranial hemorrhage.
Facial nerve paralysis.
After transurethral resection of the prostate, the nurse notices that the client’s urine is bright
red, has numerous clots, and is viscous. Which nursing action is most appropriate?
Irrigate the catheter to remove clots.
Milk the catheter tube vigorously.
Increase the client’s fluid intake.
Assess vital signs and notify the surgeon.
The nurse is teaching the client about the appropriate use of lorazepam (Ativan) to manage
anxiety. Which of the following statements indicates that the client understands the nurse’s teaching?
“I can take my medicine whenever I feel anxious.”
“It’s okay to double my dose if I need to.”
“My medicine isn’t for the everyday stress of life.”
“It’s safe to have a glass of wine while taking this medicine.”
The physician prescribes a maternal blood test for alpha fetoprotein for a nulligravid client at
16 weeks’ gestation. When developing the teaching plan, the nurse bases the explanations on the
understanding that this test is used to detect which of the following?
Neural tube defects.
Chromosomal anomalies.
Inborn errors of metabolism.
Lecithin-sphingomyelin ratio.
A client with end-stage cancer who is receiving chemotherapy tells her husband that she
feels useless now and wants to die. Prioritize, starting with first priority, the following statements the
nurse should make to the husband.
“I will assess your wife to determine if she is suicidal.”
“She may feel differently when her chemotherapy is completed.”
“Thanks for telling me this; it must be scary to have her tell you this.”
“Let’s discuss what you can say to her that may help.”

Answer

A

1. Traveling is not advised because of the client’s history of PIH. The client may be in
  jeopardy if complications occur and medical care is not available. In some cases, insurance
  companies will not cover costs of medical care in foreign countries. Air travel is not associated with
  preterm labor, although some airlines advise clients who are at 28 weeks’ gestation or beyond not to
  travel by air. Any travel that causes fatigue should be avoided. Additionally, any pregnant client
  should get frequent exercise while traveling to avoid venous stasis from prolonged sitting. The client
  is not at greater risk for communicable diseases. The priority is the client’s history of PIH, which, if it
  occurs, could lead to complications.
  CN: Reduction of risk potential; CL: Synthesize
1. The best option is a food bank; the nurse can guide the client to choose optimally nutritious
  foods. Home-delivered meals are expensive. Neighbors are unlikely to sustain providing sufficient
  food. The employer is not responsible for providing food.
  CN: Management of care; CL: Apply
1. Supine in extension is the position most likely to prevent contractures. Clients who have
  experienced burns will find a flexed position most comfortable. However, flexion promotes the
  development of contractures. The high Fowler’s and semi-Fowler’s positions create hip flexion. The
  prone position is contraindicated because of head and neck burns. In clients with head and neck
  burns, pillows should not be used under the head or neck to prevent neck flexion contractures.
  CN: Reduction of risk potential; CL: Synthesize
1. A fractured femur, especially an open fracture, can cause much soft tissue damage and lead
  to significant blood loss. Hypovolemic shock can develop. Cardiogenic shock occurs when cardiac
  output is decreased as a result of ineffective pumping. Neurogenic shock occurs as a result of an
  impaired autonomic nervous system function. Anaphylactic shock is the result of an allergic reaction.
  CN: Physiological adaptation; CL: Analyze
1. Safety concerns are essential for a client with sensory impairment. Water temperature
  should be tested carefully, hot water bottles should be avoided, and the skin should be inspected
  regularly. Independence and self-care are also important; the client should not be instructed to avoid
  kitchen activities out of fear of injury.
  CN: Safety and infection control; CL: Evaluate
1, 3. Elevating the extremities counteracts the forces of gravity and promotes venous return
and reduces venous stasis. Walking is encouraged to activate the muscle pump and promote collateral
circulation. Prolonged sitting and standing lead to venous stasis and should be avoided. Although heat
promotes vasodilation, use of a heating pad is to be avoided to reduce the risk of thermal injury
secondary to diminished sensation.
CN: Reduction of risk potential; CL: Create
1. These behaviors suggest that the adolescent is thinking of suicide. Because of these
  behaviors, it is imperative for the adolescent to see his health care professional as soon as possible
  to determine whether he has suicidal thoughts. After the nurse makes the appointment, then obtaining
  more information would be appropriate. Giving the father the telephone number for the local crisis
  hotline is appropriate after the appointment is made, to ensure that the father has additional support
  should the adolescent’s behavior escalate and an emergency arises. Taking the adolescent to the
  nearest mental health outpatient facility now is not warranted unless the adolescent’s behavior
  escalates.
  CN: Psychosocial adaptation; CL: Synthesize
1. For a child with chorea-like movements, safety is of prime importance. Feeding the child
  may be difficult. Forks should be avoided because of the danger of injury to the mouth and face with
  the tines.
  CN: Safety and infection control; CL: Synthesize
1, 2, 4. After bowel surgery, an NG tube attached to low intermittent suction is used to remove
gastric fluids. The amount of fluid from the NG tube suction is important because it contributes to the
client’s overall fluid and electrolyte balance. IV fluids are used to maintain hydration, and intake and
output is measured to determine hydration status. Postoperative vital signs are assessed more
frequently than every 6 hours. Bowel sounds will be auscultated to determine when they return.
Measuring abdominal girth is not necessary following colostomy reversal.
CN: Physiological adaptation; CL: Synthesize
1. After TURP, sphincter tone is poor, resulting in dribbling or incontinence. Kegel exercises
  can increase sphincter tone and decrease dribbling. Voiding every hour will not prevent dribbling or
  improve sphincter tone. It may take up to 12 months for urinary continence to be regained.
  CN: Reduction of risk potential; CL: Synthesize
1. The pattern of weight gain is commonly more important than the amount. Clients should be
  advised to gain a total of 25 to 35 lb (11.3 to 15.9 kg) if they are of average weight when becoming
  pregnant. The recommended pattern is 1 lb (0.45 kg)/mo in the first trimester, then 1 lb (0.45 kg)/wk
  in the second and third trimesters. A sudden increase in weight gain is associated with pregnancy-
  induced hypertension, whereas a sudden weight loss may indicate an illness.
  CN: Health promotion and maintenance; CL: Evaluate
0.4 mL. The nurse should administer 0.4 mL to administer 0.1 mg of digoxin IV if it comes in
a concentration of 0.5 mg/2 mL, or 0.25 mg/mL.
CN: Pharmacological and parenteral therapies; CL: Apply
1. Numerous things have been tried by mothers with babies crying with colic. However,
  research has identified that the motion of a car is soothing to a baby with colic, commonly quieting the
  infant. The more the infant cries, the more air is swallowed, adding to the colic pain. Cereal should
  not be offered until the infant is age 4 to 6 months because of the increased risk of food allergies.
  Additionally, cereal has not been found to help with colic.
  CN: Health promotion and maintenance; CL: Synthesize
1. Compartment syndrome, caused by compression of blood vessels and nerves, can lead toirreversible muscle and nerve damage if not detected early. Common signs of compartment syndrome
  in the arm include pain unrelieved by analgesics, pain on passive extension of fingers, loss of
  function, numbness and tingling, pallor, coolness of the extremity, and decreased or absent peripheral
  pulse. Delayed bone union does not cause symptoms of neurovascular impairment. Fat embolism is
  characterized primarily by confusion and respiratory symptoms. Osteomyelitis is a bone infection and
  is manifested by signs and symptoms of inflammation and infection.
  CN: Reduction of risk potential; CL: Analyze
1. Cardiac rehabilitation includes client and family education and individualized activity
  counseling. Generally, the educational programs focus on presenting all of the risk factors associated
  with coronary artery disease. Low-back training is associated with a back injury recovery program. A
  strength training or jogging exercise program is not appropriate immediately after a cardiac event.
  CN: Basic care and comfort; CL: Synthesize
1. When the nurse cannot elicit the Moro reflex of a 4-day-old preterm infant and the Moro
  reflex was present at birth, intracranial hemorrhage or cerebral edema should be suspected. Other
  symptoms include lethargy, bulging fontanels, and seizure activity. Confirmation can be made by
  ultrasound. Postnatal asphyxia is suggested by respiratory distress, grunting, nasal flaring, and
  cyanosis. A skull fracture can be confirmed by radiography. However, it is unlikely to occur in a
  preterm neonate. Rather, it is more common in the large-for-gestational-age neonate. Facial nerve
  paralysis is indicated when there is no movement on one side of the face. This condition is more
  common in the large-for-gestational-age neonate.
  CN: Reduction of risk potential; CL: Analyze
1. Blood clots are normal after transurethral resection of the prostate, but bright red urine can
  indicate a hemorrhage. The nurse should assess the client’s vital signs and notify the surgeon.
  Irrigation of the catheter may help remove clots, but it does not decrease bleeding. Milking a urinary
  catheter or increasing fluid intake is not effective for controlling bleeding or decreasing clots.
  CN: Reduction of risk potential; CL: Synthesize
1. The statement, “My medicine is not for the everyday stress of life,” indicates an accurate
  understanding of the nurse’s teaching about the use of lorazepam. Antianxiety agents like the
  benzodiazepines are used to treat anxiety that is unmanageable by other means and beyond the client’s ability to cope. For the drug to be effective, it must be taken as prescribed. Lorazepam can cause
  physical and psychological dependence. Tolerance can occur, and doubling the dose of lorazepam
  may increase the risk of tolerance. Lorazepam is a central nervous system depressant. When it is
  taken in combination with alcohol, the depressant effect increases, posing a danger to the client.
  CN: Pharmacological and parenteral therapies; CL: Evaluate
1. A blood test for alpha fetoprotein is recommended at 15 to 20 weeks’ gestation to screen for neural tube defects such as spina bifida. Chorionic villi sampling is used to detect chromosomal anomalies. Amniotic fluid amino acid determination is used to detect inborn errors of metabolism
  such as phenylketonuria. An amniocentesis is used to determine the lecithin-sphingomyelin ratio for
  fetal lung maturity, indicated by a ratio of 2:1, or chromosomal abnormalities.
  CN: Reduction of risk potential; CL: Apply
1. “Thanks for telling me this; it must be scary to have her tell you this.”4. “Let’s discuss what you can say to her that may help.”
“I will assess your wife to determine if she is suicidal.”
“She may feel differently when her chemotherapy is completed.”
The nurse should first acknowledge the husband’s feelings as the first step to developing trust. The
nurse can then help the husband learn how to talk to his wife. Assuring the husband that the nurse will
assess the client’s potential to commit suicide may help the husband believe positive action is being
taken. Acknowledging that the client’s desperation is likely related to her physical condition and may
improve as her condition improves can give the husband hope for improvement in her mood.
CN: Psychosocial adaptation; CL: Synthesize

Question 6

Q

A nursing assistant recorded a client’s 6:00 AM blood glucose level as 126 (7 mmol/L)instead of 216 (12 mmol/L). The nursing assistant did not recognize the error until 9:00 AM but
reported it to the nurse right away. The nurse should next:
Reassign the nursing assistant to another client.
Wait and observe the client for symptoms of hyperglycemia.
Reprimand the nursing assistant for the error.
Call the physician and complete an incident report.
A client recovering from an abdominal hysterectomy has pain in her right calf. The nurse
should:
Palpate the calf to note pain.
Measure the circumference of both calves and note the difference.
Have the client flex and extend her leg and note the presence of pain.
Raise the right leg and lower it to detect changes in skin color.
The nurse is caring for an elderly client who has experienced a sensorineural hearing loss.
The nurse anticipates that the client will exhibit which one of the following symptoms?
Difficulty hearing high-pitched sounds.
Problems with speaking clearly.
Inability to assign meaning to sound.
Vertigo when changing positions.
A client recently diagnosed with lung cancer tells the nurse that she has been having
difficulty sleeping and is often preoccupied with thoughts about how her life has changed. She says, “I
wish my life could just go on the way it was.” Which of the following should the nurse discuss with
the client first?
Preparing a will.
Managing insomnia.
Understanding grief.
Relieving anxiety.
The physician prescribes IV nalbuphine (Nubain) for a primigravid client in early active
labor. After administering the drug, which of the following should the nurse do first?
Elevate the head of the bed.
Cover the client with a blanket.
Pull the side rails up.
Dim the lights in the room.

106. A client with emphysema has been admitted to the hospital. The nurse should assess the
client further for:
1. Frequent coughing.
2. Bronchospasms.
3. Underweight appearance.
4. Copious sputum.

A 12-year-old has a fractured femur and is immobilized in traction as shown in the figure.
The nurse should:
Add additional weight until the foot is only 2 inches (5.1 cm) from the bed.
Offer foods that are easy to eat.
Place a pillow under the fractured leg to provide support.
Provide opportunities for age-appropriate activities.
The nurse is participating in a blood pressure screening event. After three separate readings
taken at least 2 minutes apart, the nurse determines that a client has a blood pressure of 160/90 mm
Hg. The nurse should advise the client to:
Have blood pressure evaluated within 1 month.
Begin an exercise program.
Examine lifestyle to decrease stress.
Schedule a complete physical immediately.
Which of the following activities is least effective in preventing sensory deprivation during
a client’s stay in the cardiac care unit?
Watching television.
Visiting with family.
Reading the newspaper.
Keeping the door closed to provide privacy.
The nurse is teaching a client who is taking dexamethasone (Decadron) for cerebral edema
about early symptoms of Cushing’s disease. The nurse should advise the client to report which of the
following is a symptom of hyperadrenocorticism?
Hypotension.
Increased urinary frequency.
Increased muscle mass.
Easy bruising.
A client’s wife arrives on the nursing unit 6 hours after her husband’s car accident,
explaining that she has been out of town. She is distraught because she was not with her husband
when he was admitted. The nurse should first:
Allow her to verbalize her feelings and concerns.
Describe her husband’s medical treatment since admission.
Explain the nature of the injury and reassure her that her husband’s condition is stable.
Reassure her that the important fact is that she is here now.
A client is scheduled to have a graded exercise test. The nurse explains to the client that the
test will determine how:
Well he thinks under pressure.
Well his body reacts to controlled exercise stress.
Far he can walk.
Long he can walk.

113. A client who has asthma is taking albuterol to treat bronchospasms. The nurse should assess
the client for which of the following adverse effects that can occur as a result of taking this drug?
Select all that apply.
1. Lethargy.
2. Nausea.
3. Headache.
4. Nervousness.
5. Constipation.

A client fears chemotherapy because of the side effects. What is the nurse’s best response to
the client’s concerns?
“Your health has been excellent. It’s unlikely that you’ll experience serious side effects.”
“We’ll give you medications to prevent the side effects, so you shouldn’t be too concerned.”
“Each person responds differently to chemotherapy treatments. We’ll monitor your responses
closely.”
“It’s important for you to accept this treatment. If you refuse your chemotherapy treatments,
you’ll die.”
The mother of an infant with hemophilia tells the nurse that she is planning to do home
schooling when the child reaches school age. She does not want her child in school because the
teacher will not watch the child as well as she would. The mother’s comments represent what
common parental reaction to a child’s chronic illness?
Overprotection.
Devotion.
Mistrust.
Insecurity.
A mother tells a nurse that her child has been exposed to roseola. After teaching the mother
about the illness, which of the following, if stated by the mother as the most characteristic sign of
roseola, indicates successful teaching?
Fever and sore throat.
Normal temperature followed by a low-grade fever.
High fever followed by a drop and then a rash.
Coldlike signs and symptoms and a rash.
A client with acute psychosis has been taking haloperidol (Haldol) for 3 days. When
evaluating the client’s response to the medication, which of the following comments reflects the
greatest improvement?
“I know these voices aren’t really real, but I’m still scared of them.”
“I’m feeling so restless, and I can’t sit still.”3. “Boy, do I need a shower. I think it has been days since I’ve had one.”
“I’ll be fine if you just let me out of here today.”
A 58-year-old homeless person is brought to the emergency department by the police after
being found unconscious on the street. Following examination and evaluation of laboratory test
results, a diagnosis of diabetic ketoacidosis is confirmed. Which of the following information is most
crucial to document on the client’s chart? Select all that apply.
Size of pupils and reaction of pupils to light.
Response to verbal and painful stimuli.
Skin condition and presence of any rashes, lesions, or ulcers.
Blood pressure.
Length of time the client has had diabetes.
Hourly urine output.
An older adult who experienced a brief period of delirium realizes that the condition was
caused by prescription medication intoxication. Which of the following statements indicates the need
for further education?
“I never realized that taking a little extra medication now and then could cause such a
problem.”
“I get medicines from three different doctors, and they don’t all know what I’m taking.”
“I thought that the herbal medicines would help me. I never realized they would make me
sick.”
“I didn’t know that cold and flu medicines might not mix with my regular medicines.”
During an emergency, a physician has asked for IV calcium to treat a client with
hypocalcemia. The nurse should:
Hand the physician calcium chloride for IV use.
Check with the physician for the complete prescription.
Hand the physician calcium gluconate for IV use.
Hand the physician the kind of calcium available on the unit

Answer

A

1. The error should be reported to the physician promptly and the physician may write
  additional prescriptions. The nurse should complete an incident report because an unusual occurrence
  happened during the client’s care. The nurse should observe the client for symptoms of hyperglycemia
  but first must call the physician and complete an incident report. The nursing assistant does not need
  to be reassigned for this error. The nurse does not need to reprimand the nursing assistant for the error
  because the nursing assistant already knows an error was made.
  CN: Management of care; CL: Synthesize
1. After abdominal pelvic surgery, the client is especially prone to thrombophlebitis.
  Measuring calf circumference can help detect edema in the affected leg. The calf should not be
  rubbed or palpated because a clot could be loosened and travel to the lungs as a pulmonary
  embolism. Homans’ sign, which is calf pain on dorsiflexion of the foot when the leg is raised, is
  sometimes associated with thrombophlebitis. Having the client flex and extend the leg does not
  provide useful assessment data; the leg will not change color when raised and lowered.
  CN: Reduction of risk potential; CL: Analyze
1. The client with sensorineural hearing loss has difficulty hearing high-pitched sounds.
  Aging and ototoxicity are two causes of sensorineural hearing loss. The client’s ability to speak is not
  affected. The client who cannot assign meaning to sound has central hearing loss. Vertigo is
  commonly an indication of an inner ear problem.
  CN: Physiological adaptation; CL: Analyze
1. The client is grieving and is telling the nurse that she grieves for the changes occurring in
  her life since her cancer diagnosis. The nurse can discuss the grief process with the client and offer
  support at this time. While the client does have insomnia and is anxious, the priority is to help the
  client manage her grieving. It is premature to discuss preparing a will.
  CN: Psychosocial adaptation; CL: Analyze
1. Nalbuphine is an analgesic that is used for clients in labor. It has a sedative effect and can
  slow the respiratory rate. After administering the drug, the nurse should first put the side rails up to
  prevent injury to the client and then assess her vital signs. Then the nurse can lower the head of the
  bed slightly to allow the client to sleep, cover the client with a blanket, and dim the lights.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. The client with emphysema is commonly underweight in appearance. It is theorized that
  weight loss is caused by the increased energy required to support the work of breathing. Frequent
  coughing, bronchospasms, and copious sputum are clinical manifestations of chronic bronchitis.CN: Physiological adaptation; CL: Analyze
1. The traction is set up correctly. Additional weights are not needed. A well-balanced diet
  with fiber should be offered. A pillow under the leg would negate the effects of the traction. Because
  the adolescent is positioned this way for an extended period, the nurse can help by finding activities
  that interest the client.
  CN: Basic care and comfort; CL: Synthesize
1. The client with a systolic blood pressure of 160 to 179 mm Hg should be evaluated by a
  health care professional within 1 month of the screening. The client with a diastolic blood pressure of
  90 to 99 mm Hg should be rechecked within 2 months. Exercise and stress reduction may be desirable
  activities, but it is first necessary to evaluate the cause of elevated blood pressure. In the absence of
  other symptoms, it is not necessary to have the client evaluated immediately.
  CN: Health promotion and maintenance; CL: Synthesize
1. Keeping the client’s door closed is likely to contribute to feelings of isolation and sensory
  deprivation. Such activities as watching television, visiting with a relative, and reading a newspaper
  help prevent sensory deprivation and yet do not require physical effort.
  CN: Psychosocial adaptation; CL: Synthesize
1. The client taking dexamethasone needs to know the early signs of Cushing’s disease, which
  include easy bruising, moonface, buffalo hump, and osteoporosis. Loss of collagen makes the skin
  weaker and thinner; therefore, the client bruises more easily. The nurse should instruct the client to
  report any of these signs to the physician. Hypertension is a symptom of Cushing’s disease, and
  muscle mass is decreased. Increased urinary frequency is not a symptom of Cushing’s disease.
  CN: Pharmacological and parenteral therapies; CL: Analyze
1. Verbalizing feelings and concerns helps decrease anxiety and allows the family member to
  move on to understanding the current situation. Describing events or explaining equipment is
  appropriate when the person is not distraught and is ready to learn. Reassuring the family member
  does not allow verbalization of feelings and discounts the person’s feelings.
  CN: Psychosocial adaptation; CL: Synthesize
1. Graded exercise testing is a diagnostic and prognostic tool used to determine the
  physiologic responses to controlled exercise stress. Information gained from a graded exercise test
  can achieve diagnostic, functional, and therapeutic objectives for the client. Graded exercise tests
  involve the use of a treadmill, stationary bicycle, or arm ergometry. Thinking under pressure, distance
  walked, and duration of walking are not the purpose of a graded exercise test.
  CN: Reduction of risk potential; CL: Apply
2, 3, 4. Albuterol is a beta-adrenergic agonist. Possible adverse effects include nausea,
headache, and nervousness, as well as insomnia and vomiting. Constipation is not associated with
this drug. The client will not become lethargic; instead, he may experience restlessness.
CN: Pharmacological and parenteral therapies; CL: Analyze
1. It is normal for the client who is beginning chemotherapy to be anxious and fearful about
  possible side effects. It is important that the nurse listen to the client’s concerns, correct any
  misconceptions, and explain the supportive care that will be provided during the chemotherapytreatments. The client needs to understand that individuals do respond differently to the treatments,
  and the experience may be very different from those of other people. A previously excellent health
  record does not necessarily ensure that the client will not experience side effects. Medications may
  lessen but not prevent the side effects, so client concerns should not be dismissed. Telling the client
  that he or she will die if treatment is refused does nothing to allay fears and concerns.
  CN: Psychosocial adaptation; CL: Synthesize
1. Overprotection is a typical parental reaction to chronic illness in a child. Characteristics
  include sacrifice of self and family for the child, failure to recognize the child’s capabilities and sense
  of responsibility, placement of overly stringent restrictions on play and peer friendship, and a lack of
  confidence in other peoples’ capabilities.
  CN: Psychosocial adaptation; CL: Analyze
1. Children with roseola have a high fever for 3 days, which drops suddenly. Then a
  nonpruritic rash appears, typically lasting for 1 to 2 days. High fever followed by a rash is a
  characteristic sign. Associated symptoms include cold symptoms, cough, and lymphadenopathy.
  CN: Physiological adaptation; CL: Evaluate
1. Knowing that the voices are not real is a reflection that the haloperidol is effective in
  decreasing psychosis. Restlessness may be a side effect of haloperidol, not an indication of
  improvement. Awareness of need for activities of daily living is an indicator of improvement.
  However, recognizing that the voices are not real demonstrates a greater awareness of the client’s
  disorder than the need for hygiene does. Wanting discharge reflects denial of illness.
  CN: Pharmacological and parenteral therapies; CL: Evaluate

118. 1, 2, 3, 4, 6. Diabetic ketoacidosis is a potentially life-threatening problem. The state of
unconsciousness requires very astute monitoring of the neurologic condition. Frequent assessments of
neurologic status (including the client's ability to respond to stimuli), blood pressure, and urinary
output need to be documented. Assessment of skin condition for the presence of lesions, bruises,
ulcers, or bumps is documented to assess for possible injuries, such as falls associated with head
injury or internal injuries. Although it would be helpful to know how long the client has had diabetes,
this information is not essential to document.
CN: Physiological adaptation; CL: Analyze

1. The elderly client commonly has multiple physicians. The client needs to inform every
  doctor about all the medications being prescribed by all of them.
  CN: Pharmacological and parenteral therapies; CL: Evaluate
1. The nurse should first check with the physician for the complete prescription of calcium
  because calcium chloride has a concentration of 13.6 mEq (3.4 mmol/L) of calcium per gram and
  calcium gluconate has 4.65 mEq (1.2 mmol/L) of calcium per gram. The nurse can always offer the
  doctor the type of calcium available after the conversion in calcium has been made; otherwise, the
  error could be fatal.
  CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 7

Q

The nurse is administering an IV potassium chloride supplement to a client who has heart
failure. When developing a plan of care for this client, which of the following should the nurse
incorporate?
Hyperkalemia will intensify the action of the client’s digoxin (Lanoxin) preparation.
The client’s potassium levels will be unaffected by a potassium-sparing diuretic.
The administration of the IV potassium chloride should not exceed 10 or a concentration of 40.
Metabolic alkalosis will increase the client’s serum potassium levels.
A client is receiving morphine sulfate by a patient-controlled analgesia (PCA) system after
a left lower lobectomy 4 hours ago. The client reports moderately severe pain in the left thorax that
worsens when coughing. The nurse’s first course of action is to:
Reassure the client that the PCA system is working and will relieve pain.
Encourage the client to rest; no further assessment is needed.
Assess the pain systematically with the hospital-approved pain scale.
Encourage the client to ignore the pain and sleep because pain is expected after this type of
surgery

.123. Which of the following factors can most alter tissue tolerance and lead to the development
of a pressure ulcer?
1. The client's age.
2. Exposure to moisture.
3. Presence of hypertension.
4. Smoking.

The nurse is screening clients for cancer prevention. Which of the following is the
recommended screening protocol for colon cancer in asymptomatic clients who have a low-risk
profile?
Fecal occult blood testing should be performed annually after age 50 years and up to age 75.
Digital rectal examinations are recommended every 5 years after age 40 years.
Sigmoidoscopy is recommended if symptoms of colon problems are present.
A low-fat diet should be implemented after age 50 years.
The nurse is evaluating the effectiveness of antipsychotic medications in a client with severe
Alzheimer’s disease. Which of the following changes indicates improvement resulting from
medications?
Adjustment to the structured daily routine.
Return of the client’s short-term memory.
Decrease in verbal and physical aggression.
Diminished resistance with activities of daily living done one step at a time.
After vaginal birth of a term neonate, the nurse determines that the placenta is about to
separate when which of the following occurs?
The uterus becomes oval shaped.
The uterus enlarges.
A sudden gush of dark blood occurs.
The client expends efforts pushing.
The nurse should complete which of the following assessments on a client who has received
tissue plasminogen activator or alteplase recombinant (Activase) therapy?
Neurologic signs frequently throughout the course of therapy.
Excessive bleeding every hour for the first 8 hours.
Blood glucose level.
Arterial blood gas values.
During the emergent stage of burn management for a client with burns of 30% of the body,
the nurse should assess the client for which of the following? Select all that apply.
Hyponatremia.
Hyperkalemia.
Hypoglycemia.
Increased hematocrit.
“Fever spikes.”
A 6-year-old child is to have a cardiac catheterization and asks the nurse if it will hurt.
Which of the following statements provides the nurse with the best guide for responding to the child’s
question?1. “The medication used to numb the insertion site will sting.”
“A momentary sharp pain usually occurs when the catheter enters the heart.”
“Most 6-year-olds feel some discomfort during the procedure.”
“It’s a painless procedure, although a tingling sensation may be felt in the extremities.”
A 10-year-old with a history of recent respiratory infection has swelling around the eyes in
the morning and dark urine. Which of the following should the nurse ask first?
“Has the child had a rash and fever?”
“Has the child had a sore throat?”
“Does the child have any allergies?”
“Does the child drink lots of liquids?”
After a nasogastric (NG) tube has been inserted, the nurse can most accurately determine
that the tube is in the proper place if which of the following can be demonstrated?
The client is no longer gagging or coughing.
The pH of the aspirated fluid is measured.
Thirty milliliters of normal saline can be injected without difficulty.
A whooshing sound is auscultated when 10 mL of air is inserted.
A client at 40+ weeks’ gestation visits the emergency department because she thinks she is in
labor. Which of the following is the best indication that the client is in true labor?
Fetal descent into the pelvic inlet.
Cervical dilation and effacement.
Painful contractions every 3 to 5 minutes.
Leaking amniotic fluid clear in color.
Which of the following should be considered the highest priority during the first 24 hours
postoperatively for the client who had a total laryngectomy due to cancer of the larynx?
Provide adequate nourishment.
Prevent skin breakdown.
Maintain proper bowel elimination.
Maintain a patent airway.
It has been 5 months since a client lost his wife and child in a car-train accident. The nurse
should determine that the client needs continuing counseling if he makes which of the following
statements?
“I’m sleeping, eating, and working pretty well, but I still get so sad at times.”
“I miss them so much, but I can tell I’m getting better day by day.”
“I wish I didn’t have to sleep. I hate the nightmares about what the car looked like.”
“I never thought I’d get over this, but I’m working with my legislator for train crossing safety.”
A client is hearing voices that are telling her to kill herself. She is demanding a knife to use
on her wrists. Which of the following is most appropriate at this time?
Put the client in restraints after giving an IM dose of PRN medication.
Ask the client to talk about her anger and what is causing it.
Give oral PRN doses of haloperidol (Haldol) and lorazepam (Ativan) as prescribed.
Search the client’s room for potential weapons after locking the unit kitchen.
The nurse should adjust a client’s heparin dose according to a prescribed anticoagulationprescription based on maintaining which laboratory value at what therapeutic level for anticoagulant
therapy?
Partial thromboplastin time, 1.5 to 2.5 times the normal control.
Prothrombin time, 1.5 to 2.5 times the normal control.
International Normalized Ratio, 2 to 3 seconds.
Thrombin clotting time, 10 to 15 seconds.
Which of the following measures is contraindicated when the nurse assists a child who has
leukemia with oral hygiene?
Applying petroleum jelly to the lips.
Cleaning the teeth with a toothbrush.
Swabbing the mouth with moistened cotton swabs.
Rinsing the mouth with a nonirritating mouthwash.
The nurse realizes that a medication error has been made and a client has received the
wrong medication. What should be the nurse’s first action when realizing an error has been made?
Assess the client’s condition.
Notify the physician of the error.
Complete an incident report.
Report the error to the unit manager.
The nurse has been assigned to a client who has had diabetes for 10 years. The nurse gives
the client’s usual dose of Humulin Regular insulin at 7:00 AM . At 10:30 AM , the client has light-
headedness and sweating. The nurse should contact the physician; report the situation, background,
and assessment; and recommend intervention for:
Metabolic acidosis.
Hyperglycemia.
Hypoglycemia.
Ketoacidosis.
A 6-year-old boy is being treated in the emergency department for injuries inflicted by his
stepfather. The client’s mother says, “This never happened before. Jim got fired today. He got drunk
and came home in a tirade. I’m so sorry that Jason got hurt, but I don’t think it will ever happen again.”
Which of the following responses is most appropriate initially?
“I’m sorry too, but I agree it probably won’t happen again.”
“I’m not as forgiving as you are. I think you need to file charges on Jim.”
“This is child abuse, and I have to file a report with the authorities.”
“I want to know more about your situation. Let’s sit and talk.”

Answer

A

1. When administering IV potassium chloride, the administration should not exceed 10 or a
  concentration of 40 via a peripheral line. These limits are extremely important to prevent thedevelopment of hyperkalemia and the possibility of cardiac dysrhythmias. In some situations, with
  dangerously low serum potassium levels, the client may need cardiac monitoring and more than 10
  mEq (mmol/L) of potassium per hour. Potassium-sparing diuretics may lead to hyperkalemia because
  they affect the kidney’s ability to excrete excess potassium. Metabolic alkalosis can cause potassium
  to shift into the cells, thus decreasing the client’s serum potassium levels. Hypokalemia can lead to
  digoxin toxicity.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. Systematic pain assessment is necessary for adequate pain management in the
  postoperative client. Even though the client is receiving morphine sulfate by PCA, assessment is
  needed if the client is experiencing pain. Encouraging the client to rest or to ignore pain without
  further assessment is not a sufficient intervention.
  CN: Basic care and comfort; CL: Synthesize
1. Exposure to moisture can lead to maceration and the development of pressure ulcers. It is
  important for the client’s skin to be kept clean and dry with prompt attention to cleanliness after
  incidents of incontinence. The client’s age and the presence of hypertension are not factors leading to
  pressure ulcers. Smoking affects the oxygen status of the client but does not directly lead to the
  development of pressure ulcers.
  CN: Reduction of risk potential; CL: Apply
1. The screening protocol recommended by the American and Canadian Cancer Societies for
  early detection of cancer in asymptomatic people includes the following: Beginning at age 50, men
  and women should have fecal occult blood testing, flexible sigmoidoscopy, or colonoscopy every
  year until age 75 unless determined otherwise by a health care provider. A diet low in fat and high in
  fruit and fiber is not a screening protocol but is good dietary advice for all clients.
  CN: Health promotion and maintenance; CL: Apply
1. A low dose of an antipsychotic can decrease aggression. Adjustment to the structured
  daily routine and diminished resistance with activities of daily living are improvements related to the
  nursing care given, not the medications. No medications currently given to treat Alzheimer’s disease
  return short-term memory.
  CN: Pharmacological and parenteral therapies; CL: Evaluate
1. A sudden gush of dark blood, a lengthening of the umbilical cord, a smaller uterus, and
  changing of the uterus to a round or spherical shape are impending signs of placental separation.
  Pushing effort from the client is not a reliable indicator for impending placental separation, nor is it
  necessary for placental expulsion.
  CN: Health promotion and maintenance; CL: Analyze
1. The nurse needs to assess neurologic status throughout the therapy. Altered sensorium or
  neurologic changes may indicate intracranial bleeding for the client who has received tissue
  plasminogen activator or alteplase. The nurse should carefully check for bleeding every 15 minutes
  during the first hour of therapy, every 15 to 30 minutes during the next 9 hours, and at least every 4
  hours during the duration of therapy. Bleeding may occur from sites of invasive procedures or from
  body orifices. The blood glucose level does not need to be evaluated. Arterial blood gas values
  relate to acid-base status and oxygenation and are avoided due to the invasiveness of arterial punctureat this time.
  CN: Pharmacological and parenteral therapies; CL: Analyze
2, 4, 5. In the emergent phase of burn management, hyperkalemia develops as a result of the
destruction of red blood cells. The hematocrit is increased in response to the plasma loss that has
occurred and the resulting hemoconcentration. Initially, hyponatremia may occur as sodium shifts into
the interstitial spaces. “Fever spikes” to 102 to 103°F (38.9 to 39.4°C) are common during this stage.
The client will have hyperglycemia due to decreased levels of insulin production.
CN: Physiological adaptation; CL: Analyze
1. The nurse should explain that the child will feel a stinging when the numbing medicine is
  inserted into the area around the introduction site of the catheter. There may also be a feeling of
  pressure when the catheter is introduced. Because the child will be sedated and will feel little during
  the procedure, telling the child that a momentary sharp pain is felt on entering the heart is
  inappropriate. A tingling sensation in the extremities is not felt.
  CN: Reduction of risk potential; CL: Synthesize
1. In conjunction with the child’s history of recent respiratory infection and report of dark
  urine, swelling around the eyes should lead the nurse to suspect acute glomerulonephritis. Therefore,
  the nurse should ask about a recent sore throat because a child with glomerulonephritis typically
  would have had a sore throat in the past 10 days. Drinking lots of liquids is unrelated to the
  periorbital edema.
  CN: Physiological adaptation; CL: Analyze
1. Measuring the pH of the aspirated gastric fluid is the most accurate determination of the
  placement of the NG tube. A pH lower than 4 indicates that the tube is in the stomach. Whether or not
  the client is gagging or coughing is not an accurate way to determine if the tube is placed correctly.
  No fluids should be inserted into the tube until the placement has been determined. Inserting air into
  the tube and listening for the resulting whoosh can be used, but this is not as accurate as pH
  measurement.
  CN: Reduction of risk potential; CL: Evaluate
1. True labor is present when cervical dilation and effacement occur. Fetal descent into the
  pelvic inlet is an indication that labor will begin soon. However, for a nulligravid client, this may
  take 1 to 2 weeks. Painful contractions every 3 to 5 minutes may be Braxton Hicks contractions.
  Contractions that disappear when the client lies down are a sign of false labor. Although leaking
  amniotic fluid should be reported, it is not a sign of true labor.
  CN: Health promotion and maintenance; CL: Analyze
1. During the first 24 hours after a total laryngectomy, maintaining a patent airway is a
  priority goal. After a total laryngectomy, the client will have a tracheostomy with increased
  secretions and will require suctioning and tracheostomy care. Providing adequate nutrition,
  preventing skin breakdown, and maintaining proper bowel elimination will be appropriate as the
  client recovers, but maintaining a patent airway is the initial priority goal.
  CN: Reduction of risk potential; CL: Synthesize
1. Not sleeping to avoid nightmares reflects inadequate grief resolution. The client is notletting go or resolving the vivid memories of the trauma as expected. Statements that the client gets
  sad at times but can function in daily activities or that the client still misses his family but
  acknowledges improvement indicate that the client is recovering and continued counseling is not
  necessary. Working for train crossing safety indicates motivation to help others escape what he has
  experienced. This action also denotes a goal for the future, indicating recovery.
  CN: Psychosocial adaptation; CL: Evaluate
1. Haloperidol and lorazepam together decrease hallucinations and agitation, thus decreasing
  the risk of self-harm. Putting the client in restraints is premature because danger is not imminent.
  Asking the client to talk about her anger is inappropriate because the client is beyond rational
  conversation. A room search is appropriate only after the crisis with the client is handled.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. The nurse should adjust the heparin dose to maintain the client’s partial thromboplastin
  time between 1.5 and 2.5 times the normal control. The prothrombin time and International
  Normalized Ratio are used to maintain therapeutic levels of warfarin (Coumadin), oral
  anticoagulation therapy. The thrombin clotting time is used to confirm disseminated intravascular
  coagulation.
  CN: Pharmacological and parenteral therapies; CL: Apply
1. The oral mucous membranes are easily damaged and are commonly ulcerated in the client
  with leukemia. It is better to provide oral hygiene without using a toothbrush, which can easily
  damage sensitive oral mucosa. Applying petroleum jelly to the lips, swabbing the mouth with
  moistened cotton swabs, and rinsing the mouth with a nonirritating mouthwash are appropriate oral
  care measures for a child with leukemia.
  CN: Basic care and comfort; CL: Synthesize
1. The nurse’s first response to the error is to assess the client for any untoward reactions as
  a result of the error. Notifying the physician and unit manager of the error as well as completing an
  incident report are all appropriate later actions, but the first action is to assess the client.
  CN: Management of care; CL: Synthesize
1. The peak action of regular insulin is approximately 2 to 3 hours after administration. The
  client is having typical hypoglycemic symptoms. Acidosis results from uncontrolled diabetes
  mellitus, with hyperpnea (Kussmaul respirations) as the outstanding symptom. The hallmark
  symptoms of hyperglycemia are increased thirst, fruity breath, and glycosuria. The signs and
  symptoms of diabetic ketoacidosis include Kussmaul respirations, fruity breath, tachycardia,
  abdominal pain, nausea, vomiting, headache, thirst, dry skin, and dehydration.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. The nurse needs to obtain more information before plans are developed. Therefore, asking
  to know more about the situation is most appropriate. The nurse has no way of predicting whether abuse will occur again. Therefore, it is inappropriate for the nurse to agree with the mother, stating that the abuse probably will not happen again. Filing charges and a formal report may be needed, but more information is needed first. These actions would not be done without the mother’s understanding why.
  CN: Psychosocial adaptation; CL: Synthesize

Question 8

Q

The nurse administers a tap water enema to a client. While the solution is being infused, the
client has abdominal cramping. What should be the nurse’s first response?
Clamp the tubing and carefully withdraw the tube.
Temporarily stop the infusion and have the client take deep breaths.
Raise the height of the enema container.
Rub the client’s abdomen gently until the cramps subside.
In preparing for insertion of a peripheral IV catheter, the nurse must select an appropriate
site. Which of the following areas should the nurse try first if an appropriate vein is found?1. Back of the hand.
Inner aspect of the elbow.
Inner aspect of the forearm.
Outer aspect of the forearm.
The nurse administers lactulose to a client with cirrhosis. What is the expected outcome
from the administration of the lactulose?
Stimulation of peristalsis of the bowel.
Reduced peripheral edema and ascites.
Reduced serum ammonia levels.
Prevention of hemorrhage.
A 12-month-old child is seen in the neighborhood clinic for a regular checkup. Which
statement by the child’s mother about the influenza vaccine reflects the need for more teaching?
“Yearly influenza vaccinations are recommended to begin as early as 6 months of age.”
“The Haemophilus influenzae vaccine my child has already received helps protect against
some forms of influenza.”
“My child is too young to receive the live attenuated intranasal vaccine.”
“The first time a child receives the influenza vaccine, a second dose is recommended in 1
month.”
When planning a health promotion class with a group of women, the nurse should include
which of the following strategies to help reduce the risk of developing osteoarthritis?
Follow a high-protein diet.
Exercise at least three times per week.
Prevent obesity.
Take a multivitamin supplement daily.
A deficiency of which of the following vitamins is thought to be the first step in the
formation of plaque and oxidative changes in the arteries?
Vitamin C.
Vitamin A.
Vitamin E.
Vitamin B 6 .
A neonate circumcised with a Plastibell 1 hour ago is brought to his mother for feeding. The
nurse should instruct the mother to do which of the following?
Read a pamphlet about circumcision care.
Remove the petroleum jelly gauze in 24 hours.
Tell the nurse when the neonate voids.
Place petroleum jelly over the site every 2 hours.
A client has been diagnosed with early alcoholic cirrhosis. The client should be taught that
changing which of the following behaviors could potentially reverse the pathologic changes occurring
in the liver?
Do not become fatigued.
Avoid drinking alcohol.
Eliminate smoking.
Eat a high-carbohydrate, low-fat diet.
A child is to receive dexamethasone (Decadron) intravenously at the prescribed dosage of 7.6 mg.
The drug concentration in the vial is 4 mg/mL. The nurse should administer?
_______________ mL.
A 40-year-old primigravid client with AB-positive blood visits the outpatient clinic for an
amniocentesis at 16 weeks’ gestation. The nurse determines that the most likely reason for the client’s
amniocentesis is to determine if the fetus has which of the following?
Cri-du-chat syndrome.
ABO incompatibility.
Erythroblastosis fetalis.
Down syndrome.
The nurse is assessing a client who has benign prostatic hypertrophy (BPH). The nurse
should ask the client if he has:
Impotence.
Flank pain.
Difficulty starting the urinary stream.
Hematuria.
Which of the following is the most helpful strategy to use for anger management when
dealing with a verbally aggressive client?
Role-playing assertive statements with the nurse.
Watching a videotape about assertiveness.
Describing feelings that occur after aggressive outbursts.
Discussing situations that appear to be threatening.
Which of the following actions should the nurse anticipate using when caring for a term
neonate diagnosed with transient tachypnea at 2 hours after birth?
Monitoring the neonate’s color and cry every 4 hours.
Feeding the neonate with a bottle every 3 hours.
Obtaining extracorporeal membrane oxygenation equipment.
Providing warm, humidified oxygen in a warm environment.

154. The skin tone of a client of Vietnamese descent with dark skin who has early signs of iron
deficiency anemia appears:
1. Reddish-brown.
2. Yellowish-brown.
3. Black-brown.
4. Whitish-brown.

Which of the following laboratory findings is present in nephrotic syndrome?
Decreased total serum protein.
Hypercalcemia.
Hyperglycemia.
Decreased hematocrit.
While caring for several preterm infants in the special care nursery, which of the followingactions is most important for preventing nosocomial infections in these neonates?
Using sterile supplies for all treatments.
Performing thorough hand washing before giving infant care.
Donning cover gowns for nurses and visitors to the unit.
Wearing a mask, and changing it frequently when giving care.
Which of the following types of restraints is best for the nurse to use for a child in the
immediate postoperative period after cleft palate repair?
Safety jacket.
Elbow restraints.
Wrist restraints.
Body restraints.
When preparing to present a community program about women who are victims of physical
abuse, which of the following should the nurse stress about the incidence of battering?
Death from battering is rare.
Battering is a major cause of injury to women.
Lower socioeconomic groups are primarily affected.
Battering rarely involves pregnant women.
A client undergoes a nephrectomy. In the immediate postoperative period, which nursing
intervention has the highest priority?
Monitoring blood pressure.
Encouraging the use of the incentive spirometer.
Assessing urine output hourly.
Checking the flank dressing for urine drainage.
A nulliparous client tells the nurse that during her last pelvic examination, the physician said
that her uterus was in a severe retroverted position. The nurse determines that the client may
experience which of the following?
Frequent vaginal infections.
Pain from endometriosis.
Severe menstrual cramping.
Difficulty conceiving a child.

Answer

A

1. If the client begins to experience abdominal cramping during administration of the enema
  fluid, the nurse’s first action is to temporarily stop the infusion and have the client take a few deep
  breaths. After the cramping subsides, the nurse can continue with the enema solution. If the cramping
  does not subside, the nurse should clamp the tubing and remove it. Raising the height of the container
  will increase the flow of fluid and cause the cramping to increase. Rubbing the abdomen while
  infusing the enema fluid will not stop the cramping.
  CN: Basic care and comfort; CL: Synthesize
1. When inserting an IV catheter needle, the nurse initially uses veins low on the hand or arm
  if available, unless contraindicated. Should the IV fluid infiltrate or vein become irritated at this
  insertion site, veins higher on the arm are still available. After a vein higher up on the arm has been
  damaged, veins below it cannot be used.
  CN: Pharmacological and parenteral therapies; CL: Apply
1. Haemophilus influenzae is a bacteria that can cause severe disease in children younger
  than 5 years, but it does not cause influenza. Yearly vaccination for influenza is recommended to
  begin at 6 months. The live vaccine is not recommended for children younger than 2 years or with respiratory disease. A second vaccine 4 weeks after the first is recommended the first time a child
  younger than 9 years receives the flu vaccine.
  CN: Pharmacological and parenteral therapies; CL: Evaluate
1. Haemophilus influenzae is a bacteria that can cause severe disease in children younger
  than 5 years, but it does not cause influenza. Yearly vaccination for influenza is recommended to
  begin at 6 months. The live vaccine is not recommended for children younger than 2 years or with respiratory disease. A second vaccine 4 weeks after the first is recommended the first time a child
  younger than 9 years receives the flu vaccine.
  CN: Health promotion and maintenance; CL: Apply
1. Obesity is a risk factor for osteoarthritis because it places increased stress on the joints. A
  high-protein diet, regular exercise, and vitamin supplements do not reduce a client’s risk of
  developing osteoarthritis.
  CN: Health promotion and maintenance; CL: Create
1. Vitamin E is a powerful antioxidant that helps to prevent oxidation of the cell membrane.
  Vitamins C, A, and B 6 are helpful in the prevention of heart disease, but vitamin E plays a more
  important role.
  CN: Health promotion and maintenance; CL: Analyze
1. The nurse should instruct the mother to report the first voiding after the circumcision
  because edema could cause a urinary obstruction. Although reading a pamphlet about circumcision
  care may be helpful, it may not be appropriate for all mothers. Some mothers could have difficulty
  reading or understanding the information. Petroleum jelly gauze is used with Gomco clamp
  circumcisions, not Plastibell. Petroleum jelly should not be used with Plastibell circumcision
  methods because the bell prevents further bleeding.
  CN: Health promotion and maintenance; CL: Synthesize
1. Alcoholic cirrhosis is associated with excessive alcohol intake. In the early stages, theliver develops fatty changes. If alcohol intake stops, the fatty changes can be reversed. Avoiding
  overexertion is important in the client with cirrhosis, but it does not reverse the disease. Stopping
  smoking is a positive, healthy lifestyle change, but it does not have an impact on cirrhosis. A diet high
  in carbohydrates and low in fat is also recommended for the client with cirrhosis, but the diet does
  not reverse the pathologic changes that have occurred in the liver.
  CN: Reduction of risk potential; CL: Synthesize
1.9 mL. Using the ratio-proportion method, the equations are as follows:
CN: Pharmacological and parenteral therapies; CL: Apply
1. Because of the client’s age, the amniocentesis is most likely being done to evaluate for Down syndrome (trisomy 21). Women older than 35 years are at higher risk for having a child with
  Down syndrome. Cri-du-chat syndrome is a genetic disorder involving a short arm on chromosome 5.
  This disorder is not associated with mothers who are older than 35 years. The client is AB-positive,
  so the amniocentesis is not being done for ABO incompatibility, in which the mother is type O and the
  fetus is type A, B, or AB. The amniocentesis is not being done to detect erythroblastosis fetalis
  because the mother is Rh-positive.
  CN: Reduction of risk potential; CL: Analyze
1. The symptoms of BPH are related to obstruction as a result of an enlarged prostate.
  Difficulty in starting the urinary stream is a common symptom, along with dribbling, hesitancy, and
  urinary retention. Impotence does not result from BPH. Flank pain is most commonly related to
  pyelonephritis. Hematuria occurs in urinary tract infections, renal calculi, and bladder cancer, to
  name some of the most common causes.
  CN: Physiological adaptation; CL: Analyze
1. Having the client role-play assertive statements assists the client in learning how to use
  assertiveness and practicing appropriate behaviors in a safe environment. Watching a videotape on
  assertiveness or discussing situations that appear threatening is a step toward actually using assertive
  techniques. Describing feelings that occur after an angry outburst motivates the client to make changes
  in behavior.
  CN: Psychosocial adaptation; CL: Synthesize
1. Symptoms of transient tachypnea include respirations as high as 150 breaths/min,
  retractions, flaring, and cyanosis. Treatment is supportive and includes provision of warm,
  humidified oxygen in a warm environment. The nurse should continuously monitor the neonate’s
  respirations, color, and behaviors to allow for early detection and prompt intervention should
  problems arise. Feedings are given by gavage rather than bottle to decrease respiratory stress.
  Obtaining extracorporeal membrane oxygenation equipment is not necessary but may be used for the
  neonate diagnosed with meconium aspiration syndrome.
  CN: Physiological adaptation; CL: Synthesize
1. One of the early signs of iron deficiency anemia in a client of Vietnamese descent with
  dark skin is yellowish-brown skin tones. The nurse can assess for petechiae or jaundice, which maybe observed in the conjunctiva or buccal mucosa.
  CN: Physiological adaptation; CL: Analyze
1. A decreased total serum protein occurs as extensive amounts of protein are excreted from
  the body through the urine. Clients may develop hypocalcemia. Hyperglycemia is not a finding related
  to nephrotic syndrome. A decreased hematocrit is not a finding related to nephrotic syndrome.
  CN: Physiological adaptation; CL: Analyze
1. The number one cause of nosocomial infections in hospital units is not washing the hands.
  Nosocomial infections can be significantly reduced by thorough handwashing before caring for each
  infant. Sterile supplies are not necessary for all treatments. Cover gowns and masks, although helpful
  in reducing the risk of exposure to blood and body fluids, do not decrease the risk of nosocomial
  infection.
  CN: Safety and infection control; CL: Synthesize
1. Recommended restraints for a child who has had palate surgery are elbow restraints. They
  minimize the limitation placed on the child but still prevent the child from injuring the repair with
  fingers and hands. A safety jacket or wrist or body restraints restrict the child unnecessarily.
  CN: Safety and infection control; CL: Synthesize
1. Battering is a major cause of injury to women. Although battering occurs in all
  socioeconomic groups, it may appear to be more common in members of lower socioeconomic
  groups because they are more likely to use emergency department services. Pregnant women are
  frequent victims of battering. Death from battering is not rare.
  CN: Psychosocial adaptation; CL: Create
1. After a nephrectomy, a specific aspect of immediate postoperative management includes
  monitoring urine output at least hourly. Monitoring blood pressure and encouraging the use of
  incentive spirometry are other important considerations, but because of the surgical disruption of the
  urinary system, urine output is a priority. Measurement of urine output should also include an
  estimation of the amount of urine drainage on the flank dressing.
  CN: Reduction of risk potential; CL: Synthesize
1. Severe retroversion or anteversion may lead to infertility or difficulty conceiving a child
  because these positions can block the deposition or migration of sperm. The normal position of the
  uterus is tipped slightly forward. Frequent vaginal infections commonly are associated with diabetes
  or human immunodeficiency virus infection, not abnormal uterine positions. Pain from endometriosis
  (abnormal myometrial growth outside the uterus) is not associated with abnormal uterine positions.
  Severe menstrual cramping or dysmenorrhea (primary) is caused by increased prostaglandin
  production, not abnormal uterine positions. Secondary dysmenorrhea is associated with pelvic
  inflammatory disease or endometriosis.
  CN: Health promotion and maintenance; CL: Analyze

Question 9

Q

A mother tells the nurse that she wants her 4-year-old to stop sucking her thumb. When
developing the teaching plan, which of the following should the nurse suggest?
Apply a special medicine that tastes terrible on the thumb.
Get the child to agree to stop the thumb sucking.
Remind the child every time the mother sees the thumb in her mouth.
Put the child in time-out every time the mother observes thumb sucking.
A client in severe respiratory distress is admitted to the hospital. When assessing the client,
the nurse should:
Conduct a complete health history.
Complete a comprehensive physical examination.
Delay assessment until client’s respiratory distress is resolved.
Focus assessment on the respiratory system and distress
A client has had a total hip replacement. Which of the following signs most likely indicates
that the hip has dislocated?
Abduction of the affected leg.
Loosening of the prosthesis.
External rotation of the affected leg.
Shortening of the affected leg.
A client with paranoid schizophrenia is withdrawn, suspicious of others and projects blame.
The client’s behavior reflects problems in which of the following stages of development as identified
by Erikson?
Trust versus mistrust.
Autonomy versus shame and doubt.
Initiative versus guilt.
Intimacy versus isolation.
During the initial interview, a client with a compulsive eating disorder remarks, “I can’t
stand myself and the way I look.” Which of the following statements by the nurse is most therapeutic?
“Everyone who has the same problem feels like you do.”
“I don’t think you look bad at all.”
“Don’t worry. You’ll soon be back in shape.”
“Tell me more about your feelings.”
A client with a new ileal conduit asks the nurse when to wear his appliance. Which of the
following responses by the nurse is best?
“You need to wear your appliance all the time.”
“You need to wear your appliance after you irrigate.”
“It is only necessary to wear your appliance at night.”
“The appliance must be worn after your meals.”

167. A child has been exposed to varicella. Which of the following should the nurse institute for
infection control?
1. Airborne precautions.
2. Droplet precautions.
3. Contact precautions.
4. Indirect contact precautions.

Which of the following goals is appropriate for a client with multiple myeloma?
Achieve effective management of bone pain.
Recover from the disease with minimal disabilities.
Decrease episodes of nausea and vomiting.
Avoid hyperkalemia.
A client with major depression is completing his morning care independently. When the
nurse approaches the client with his medication, he tells the nurse that he is a failure as a husband and
a father and is worthless. His wife told the nurse previously that the client is a good provider and a
wonderful father and husband. Which of the following responses by the nurse is most appropriate?
“You were able to shower and dress without help this morning.”
“Your wife told me that you are a good husband and father.”3. “You don’t have any reason why you should feel that way.”
“This medication will help your thinking.”
The nurse uses Montgomery straps primarily to achieve which of the following outcomes?
The client is free from falls.
The client is free from bruises.
The client is free from skin breakdown.
The client is free from wandering.
After an episode of severe pain, a client says to the nurse, “The pain really frightened me. I
thought I was going to die.” Which statement is the most appropriate response from the nurse?
“I understand that pain can be a frightening experience.”
“Why were you frightened? You have had pain before.”
“There’s no need to be frightened of pain.”
“Pain can’t cause you to die. Try to relax.”
A child returns to the pediatric unit after a bowel resection. Which of the following actions
has the highest priority?
Administer IV fluids.
Keep the child on nothing-by-mouth status.
Monitor vital signs frequently.
Assess the child’s pain level.
During a health history, a client is being evaluated for possible type 2 diabetes mellitus.
Which of the following client statements indicates the need for further follow-up?
“I have some shortness of breath when I exercise.”
“No matter how much I drink, I’m still thirsty all the time.”
“I wake up early in the morning and can’t return to sleep.”
“In the past couple of weeks, I’ve been having a lot of trouble urinating.”

174. A 25-year-old has been diagnosed with hypertrophic cardiomyopathy. The nurse should
assess the client for:
1. Angina.
2. Fatigue and shortness of breath.
3. Abdominal pain.
4. Hypertension.

The nurse should advise the mother of a toddler suspected of having pinworms to do the
cellophane tape test at which of the following times?
Before bathing.
After a bowel movement.
While the child is asleep.
After a meal.
Which of the following conditions occurring in a mother’s pregnancy provides a clue that the
newborn might have a gastrointestinal tract anomaly?
Meconium in the amniotic fluid.
Low implantation of the placenta.
Increased amount of amniotic fluid.4. Toxemia in the last trimester.

177. A client is taking steroids to treat ulcerative colitis. The nurse should assess the client for
which of the following?
1. Peptic ulcer.
2. Hypoglycemia.
3. Tachycardia.
4. Renal failure.

A client’s abdominal incision eviscerates. The nurse should first:
Take the client’s vital signs and call the physician.
Lower the client’s head and elevate the feet.
Cover the incision with a dressing moistened with sterile normal saline solution.
Start an emergency infusion of IV fluids.
What is the priority nursing intervention for a client who is admitted to the emergency
department with burns over an estimated 27% of the upper body surface area?
Insert a large-caliber IV line.
Administer morphine intramuscularly.
Establish an airway.
Administer tetanus toxoid.
The client is to have a gastrectomy. The surgeon will use a transverse incision. Prior to
surgery, the nurse is checking to be sure the client has marked the correct site. Identify the site the
client should have marked.

Answer

A

1. A 4-year-old is old enough to be able to cooperate and stop the behavior. Therefore, the
  first step is to obtain the child’s cooperation. When this has occurred, then the mother makes sure it is
  okay to remind the child when the behavior is viewed. Using a substance that does not taste good is
  not effective as the child may suck it off and does not promote health behavior. The mother alsoshould be encouraged to praise the child when she sees her not engaging in the behavior; “time-out” is
  considered a punishment and does not promote the desired behavior
  CN: Health promotion and maintenance; CL: Create
1. During an episode of acute respiratory distress, it is important that the nurse focus the
  assessment on the client’s respiratory system and distress to quickly address the client’s problem.
  Conducting a complete health history and a comprehensive physical examination can be deferred until
  the client’s condition is stabilized. It is not appropriate to delay all assessments until the respiratory
  distress is resolved because the nurse must have data to guide treatment.
  CN: Physiological adaptation; CL: Analyze
1. The most likely indication of a dislocated hip is a shortening of the affected leg. Other
  indications of dislocation include increasing pain, loss of function to the extremity, and deformity.
  Abduction of the leg after total hip replacement is a desirable position to prevent dislocation.
  Loosening of the prosthesis does not necessarily indicate that the hip has dislocated. External rotation
  of the hip can occur without the hip’s being dislocated. However, a neutral position of rotation is the
  desired position.
  CN: Physiological adaptation; CL: Analyze
1. The client who is withdrawn, is suspicious, and projects blame is exhibiting problems in
  trust versus mistrust. Shame and doubt would be reflected as low self-esteem and suspiciousness.
  Guilt would be reflected in self-blame for all problems. Isolation would be reflected in a lack of
  long-term relationships.
  CN: Psychosocial adaptation; CL: Analyze
1. The nurse needs to explore more about the client’s feelings to assess what underlies the
  eating disorder. The nurse also needs to evaluate the client’s suicide risk. The other statements are not
  therapeutic because they minimize the client’s feelings.
  CN: Psychosocial adaptation; CL: Synthesize
1. An ileal conduit is a urinary diversion that requires the client to wear an appliance, or
  pouch, at all times because urine drains continuously. Ileal conduits are not irrigated. The urinary drainage is affected by fluid intake, not meals.
  CN: Physiological adaptation; CL: Apply
1. Children with varicella or suspected varicella should be treated under airborne
  precautions in addition to standard precautions. Varicella is transmitted by airborne nuclei. Droplet
  precautions are indicated for conditions such as pertussis, meningococcal pneumonia, and rubella.
  Contact precautions are indicated for conditions such as draining major abscesses, acute viral
  conjunctivitis, and Clostridium difficile gastroenteritis. Indirect contact is not a method of controlling
  infection. Rather, it is a mode of transmission involving contamination via some intermediate object, such as an instrument, needle, or dressing, or by hands that are not washed or gloves that are not
  changed between clients.
  CN: Safety and infection control; CL: Synthesize
1. In multiple myeloma, neoplastic plasma cells invade the bone marrow and begin to
  destroy the bone. As a result of this skeletal destruction, pain can be significant. There is no cure formultiple myeloma. Nausea and vomiting are not characteristics of the disease, although the client may experience anorexia. The client should be monitored for signs of hypercalcemia resulting from bone destruction, not for hyperkalemia.
  CN: Physiological adaptation; CL: Synthesize
1. Stating, “You were able to shower and dress without any help this morning,” points out a
  visible, realistic accomplishment and strength to the client with self-deprecatory statements, thereby
  helping to increase the client’s self-worth. The statements, “Your wife told me that you are a good
  husband and father,” and, “You don’t have any reason why you should feel this way,” are not helpful
  because logical statements are ineffective in changing the thinking of a client who is depressed. The client may agree with what the nurse states but be just as depressed because intellectual
  understanding does not help the severely depressed client. The statement, “This medication will help
  your thinking,” although true, does not recognize the client’s accomplishment and will have no
  positive effect on his self-esteem.
  CN: Psychosocial adaptation; CL: Synthesize
1. The nurse uses Montgomery straps primarily to avoid the removal of long-term abdominal
  dressing tape and ultimate skin breakdown.
  CN: Basic care and comfort; CL: Apply
1. The nurse’s most appropriate response is to acknowledge and validate the client’s
  concerns. Questioning the client’s fears is not a therapeutic response and can make the client feel
  defensive. False reassurance that the client should not be afraid disregards the client’s fears and does
  not promote further communication between the client and nurse. Dismissing the client’s feelings and
  telling the client to relax do not encourage sharing of feelings.
  CN: Psychosocial adaptation; CL: Synthesize
1. In a child with abdominal surgery, it is important to check vital signs frequently to assess
  for internal bleeding. Administering IV fluids, assessing pain, and keeping the child on nothing-by-
  mouth status are all important, but monitoring vital signs frequently is the priority.
  CN: Reduction of risk potential; CL: Synthesize
1. Polydipsia, or increased thirst, is a classic clinical manifestation of diabetes. The
  excessive loss of fluids is the result of the osmotic diuresis that occurs with glycosuria. It is unlikely
  that shortness of breath, early awakening, or trouble urinating are related to diabetes mellitus.
  CN: Physiological adaptation; CL: Analyze
1. Cardiomyopathy is a broad term that includes three major forms: dilated, hypertrophic,
  and restrictive cardiomyopathies. The underlying etiology of hypertrophic cardiomyopathy is
  unknown; it is typically observed in young men but is not limited to them. Common symptoms are
  fatigue, low tolerance to activity related to the low ejection fraction, and shortness of breath. Angina
  may be observed if coronary artery disease is present. Abdominal pain and hypertension are not
  common. CN: Physiological adaptation; CL: Analyze
1. Pinworms come out of the rectum during the nighttime and early morning hours. Therefore,
  the best time to apply the tape to get results is while the child is asleep.CN: Physiological adaptation; CL: Apply
1. Maternal hydramnios occurs when the fetus has a congenital obstruction of the
  gastrointestinal tract, such as in the presence of a tracheoesophageal fistula. The fetus normally
  swallows amniotic fluid and absorbs the fluid from the gastrointestinal tract. Excretion then occurs
  through the kidneys and placenta. Most fluid absorption occurs in the colon. Absorption cannot occur when the fetus has a gastrointestinal obstruction. Meconium in the amniotic fluid, low implantation of
  the placenta, and toxemia could occur but are more specifically associated with fetal hypoxia.
  CN: Health promotion and maintenance; CL: Analyze
1. A common complication of steroid therapy is gastric irritation and peptic ulcers.
  Hyperglycemia is a potential complication. Tachycardia and renal failure are not associated with
  steroid therapy.
  CN: Pharmacological and parenteral therapies; CL: Analyze
1. When an incision eviscerates, it is a medical emergency. The nurse’s first response is to
  apply a sterile dressing that has been moistened with sterile normal saline solution. The client should
  also be placed in semi-Fowler’s position to release any tension on the abdominal area. Vital signs
  should be taken, and an IV line may be started for emergency treatment; however, the first action is to
  protect the wound and abdominal contents.
  CN: Reduction of risk potential; CL: Synthesize
1. Establishing a patent airway is the priority intervention. Prophylactic intubation is
  initiated if heat has been inhaled or if the neck, head, or face is involved. Swelling of the upper
  airways can progress to obstruction. Fluid replacement can best be achieved using a large-caliber peripheral IV catheter, and morphine sulfate is appropriate for analgesia in a burn client. Although
  these are priorities, they are secondary to establishing a patent airway. Administering tetanus toxoid is a secondary priority.
  CN: Reduction of risk potential; CL: Synthesize
1. The client should mark the area on the abdomen where the transverse incision will be
  made.
  CN: Reduction of risk potential; CL: Evaluate

Question 10

Q

A client is taking Gelusil tablets along with sucralfate daily 1 hour before meals. The nurse
should instruct the client to do which of the following?
Sucralfate should be taken every 4 hours to be effective.
Gelusil and sucralfate are ineffective when used in combination.
Sucralfate should be taken on an empty stomach 1 hour before meals.
Sucralfate and Gelusil should be taken early in the morning.
A client takes Metamucil (psyllium) granules one rounded teaspoon mixed in fruit juice
three times daily for constipation. Which of the following statements by the client indicates that
further teaching is required?
“I will mix this medication with at least 8 oz (240 mL) of water or juice immediately before
taking it.”
“I will check for soft to semiliquid stools being passed within 1 to 3 days of taking this
medication.”
“I will drink at least 6 to 10 glasses of water or juice when taking this laxative.”
“I will need to take the medication for 4 weeks.”
When administering metoclopramide for vomiting due to migraine headaches, the nurse
notices that the client has continuous movements of tongue and lip smacking after taking this
medication. The nurse should:
Administer the medication to the client with food.
Instruct the client to take the medication early in the morning before breakfast.
Withhold the medication until the unusual movements come to a stop.
Stop the medication and notify the health care provider.
Using the Morse Fall Risk scale (see exhibit), the nurse should initiate highest fall risk
precautions for which of the following clients?
84-year-old client with diabetes admitted with new-onset confusion. The client reportedly fell
at home last week, is currently on bed rest, and has normal saline infusing per saline lock.
48-year-old alert and oriented client with quadriplegia admitted for wound care of a stage IV
pressure ulcer, receiving IV antibiotics per a peripherally inserted central catheter.
62-year-old client with a history of Parkinson’s disease, admitted for pneumonia and receiving
IV antibiotics. The client has fallen at home but is able to ambulate with a cane. During his
hospitalization, he has gotten out of bed without calling for assistance.
27-year-old client with acute pancreatitis receiving morphine sulfate IV every 2 hours as
needed for pain; no significant medical history, smokes two packs of cigarettes per day; may
be up independently; and has steady gait.

MORSE FAL RISK/SCALE
1. HISTORY OF FALLING, IMMEDITE OR WITHIN 3 MOS
NO - 0
YES - 25

SECONDARY OF DIAGNOSIS
NO - 0
YES - 15
AMBULATORY AID
BED REST/NURSE ASSIST - 0
CRUTCHES / CANE /WALKER - 15
FURNITURE - 30
IV/HEPARIN LOCK
NO - 0
YES - 20
GAIT/TRANSFERRING
NORMAL/BED REST/IMMOBILE - 0
WEAK - 10
IMPAIRED - 20
MENTAL STATUS
ORIENTED TO OWN ABILITY - 0
FORGETS LIMITATIONS - 15
The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client’s vital
signs have been stable for the last 24 hours, but the client now has a temperature of 38.4°C (101.1°F),
a heart rate of 116, and a respiratory rate of 26 breaths/min. The client has an IV infusion running at a
keep open rate. The nurse contacts the physician and receives the following prescriptions (see chart
below).
CONTINUE TO CHECK VITAL SIGNS EVERY 2 HOURS
DRAW STAT BLOOD CULTURES X 2
CT OF ABDOMEN
START BROAD-SPECTRUM IV ANTIBIOTIC 4 HOURS AFTER BLOOD CULTURES ARE DRAWN
DRAW CBC, CRP, ESR, ADN UA WITH CULTURE AND SENSITIVITY IF INDICATED.
ENSURE PATEN IV ACCESS FOR FLUID BOLUS

Which of the following prescriptions should the nurse implement first?

Obtain blood cultures.
Increase the rate of the intravenous infusion.
Obtain CT of abdomen.
Chart vital signs.
A 17-year-old gang member, who is living on the streets, is hospitalized after an overdose.
When medically stable, the teen is admitted to the adolescent psychiatric unit of the same hospital. In
what order of priority from first to last should the nurse explore the following issues?
The reason the teen is not living with parents.
The desire to leave or remain in the gang.
The current level of suicidal risk.
The desire to return home or go elsewhere after discharge.
On the obstetrics unit, the nurse assures client safety by doing which of the following?
Select all that apply.
Reconciliation of medication prescriptions.
Communication among staff.
Placing culturally similar clients together.
Use of two unique identifiers.
Staff training.
The nurse has completed breast-feeding discharge instructions and determines the mother
understands when she states which of the following? Select all that apply.
“My calorie intake will need to increase by 1,000 calories per day.”
“Any drugs that I take may pass through to my breast milk.”
“Babies should have six to eight wet diapers per day after the first 3 days of life.”
“I have the phone number for the lactation consultant if I have questions.”
“Babies should be satisfied from the feeding for 5 to 6 hours after daytime feedings.”
A nurse is planning care with a family of a 4-year-old in preschool who is often disruptive
in class, is difficult to engage, and rarely speaks. The child flaps his arms and screeches when he is
upset. Which of the following questions and comments would be appropriate for the nurse to make to
the parents? Select all that apply.
“Has your child received all his childhood immunizations? You know there is evidence that
childhood immunizations play a role in the development of autism.”
“Has your child been evaluated by a pediatrician? He seems to have some behaviors that are
abnormal for a child of his age.”
“How does your child behave at home? If you do not see acting out behavior at home, part of
his problem may be dealing with new situations such as school.”
“How do you respond if he disobeys or acts out at home? If your techniques help stop or
prevent negative behavior, perhaps the teachers can try similar measures at school.”
“Have you considered private school? This environment does not seem right for your child.”
A client is anxious following a robbery. The client is worried about identity theft and states,
“I could lose everything. I can’t stand the fears I have. I reported everything, but I still can’t eat or
sleep.” Which of the following interventions should the nurse implement first?
Request a prescription for an antianxiety medication.
Provide a list of free legal resources.
Refer the client to a support group.
Listen empathetically while the client discusses the fears.

Answer

A

1. Sucralfate is taken on an empty stomach at least 1 hour before meals and at bedtime to
  allow a protective coating over the ulcer before high levels of gastric acidity occur. It is not to be
  taken every 4 hours. Gelusil and sucralfate are effective when prescribed together. Gelusil should be
  taken for 2 hours before or after taking sucralfate, not at the same time
  CN: Pharmacological and parenteral therapies; CL: Apply
1. Metamucil (psyllium) is a bulk-forming laxative, used to treat constipation. It absorbs
  liquid in the intestines, swells, and forms a bulky stool, which is easy to pass. It comes as a powder,
  granules, capsule, liquid, and wafer to take by mouth. It is usually taken one to three times daily. It
  should not be taken for more than 1 week unless advised. Client cannot continue this drug for 4
  weeks. Regular use may prevent normal bowel function, cause adverse drug reactions, and delay
  treatment for conditions that cause constipation. The powder or granules must be mixed with 8 oz
  (240 mL) of pleasant-tasting liquid such as fruit juice right before use. Therapeutic effects (soft to
  semiliquid stools) occur in approximately 1 to 3 days with bulk-forming laxatives like Metamucil and
  stool softeners while effects (liquid to semiliquid stools) occur in 1 to 3 hours with saline cathartics
  and castor oil. These granules absorb water rapidly in the intestines and solidify into a gelatinous
  mass, and so, the client should drink 6 to 10 glasses of water or juice daily.
  CN: Pharmacological and parenteral therapies; CL: Apply.
1. Metoclopramide is a prokinetic agent used as an antiemetic. It has central antiemetic
  effects and antagonizes the action of dopamine, a catecholamine neurotransmitter. It can cause serious
  muscle problems called tardive dyskinesia (extrapyramidal effect) in which the client’s muscles
  especially of the face move in unusual ways. It may not be reversible. This medication must be
  stopped, and the nurse should notify the health care provider immediately. Administering the
  medication with food, withholding the medication until movements come to a stop, or taking the
  medication early in the morning will not stop the extrapyramidal side effects of the medication.
  CN: Pharmacological and parenteral therapies; CL: Synthesize.
1. Using the Morse fall scale, risk factors for this client include history of falling, secondary
  diagnosis, ambulatory aid, IV/heparin lock, weak gait/transfer, and forgetting limitations (100 points).
  Client no. 1 is also high risk with a secondary diagnosis, history of falling, IV access, and confusionbut is on bed rest (75 points). Client no. 2 risks include IV access and secondary diagnosis (35
  points). Client no. 4 is at risk due to his IV access only (20 points).
  CN: Safety and infection control; CL: Analyze
1. The nurse should first obtain the blood culture because subsequent treatment will be
  dependent on the results. The client has an intravenous infusion; the physician did not write a
  prescription to increase the infusion rate. Unless indicated otherwise, the nurse can take the client’s
  vital signs after completing scheduling the CT scan and other laboratory work.
  CN: Reduction of risk potential; CL: Synthesize
1. The current level of suicidal risk.
The desire to leave or remain in the gang.
The desire to return home or go elsewhere after discharge.
The reason the teen is not living with parents.
Safety is the first priority, followed by the client’s feelings about leaving the gang. If the client
chooses to remain in the gang, the other issues are moot. If the client wishes to leave the gang, the
issue of living arrangements becomes significant. If the wish is to return home, it would be important
to discover the reasons why the teen left the home and to explore if relationships can be repaired. If
the client desires to live elsewhere, it would need to be a place safe from the gang. Foster or
adoptive care is unlikely because the client is near 18 years of age.
CN: Safety and infection control; CL: Create
1, 2, 4, 5. Client care safety is enhanced by the process of reconciling all medication
prescriptions at least one time each 24 hours of hospitalization. This can rule out duplication of
prescriptions, missing medication prescriptions, or alerting the staff to medications that should have
been terminated. Communication among all staff members enhances client safety and prevents errors
in written or in verbal format. Culturally similar clients are appreciative of being with someone who
can speak their language or share thoughts and ideas, but this does not increase the safety of the
clients. The use of two identifiers should be consistently used to prevent wrong client and procedure
errors. Staff training is an extremely valuable tool to educate and increase communication among staff
members concerning existing or potential safety situations.
CN: Safety and infection control; CL: Create
2, 3, 4. Maternal intake will need to increase approximately 500 cal/day while breast-
feeding. It is true that many drugs taken by the mother cross through breast milk. When any medication
is taken by the breast-feeding mom, the medication should be determined to be safe with the OB or
pediatricians office. Infants who have six to eight wet diapers per day have had an adequate intake of
breast milk. If there are fewer, the mother should try to increase the frequency of the infant’s feedings.
Within the first 24 to 72 hours of life, there will be fewer wet diapers as the mother’s milk has not
come in yet. Prior to discharge, clients should know how to access community resources to support
breast-feeding. After a mother’s breast milk is in at about the 3rd day after birth, the infant should be
satisfied for approximately 1 1⁄2 to 3 hours after feeding. There is a need for more frequent feedings
with breast-fed infants than bottle-fed as the fat content in the breast milk is lower.
CN: Health promotion and maintenance; CL: Evaluate
2, 3, 4. The child’s behavior appears to fit the criteria for autism, but suggesting the child’s
immunizations are causative is inaccurate according to recent research and dangerous regardingpossibly convincing the mother to forego future immunizations. A better approach would be to suggest
a full evaluation by a primary care provider, especially since symptoms could result from other
illnesses or conditions. Inquiring about the child’s behavior at home and the mother’s discipline
techniques would give the nurse a better idea of the home environment and could help determine
whether this is a problem confined to the school setting or one that also occurs at home. Asking for
the mother’s input regarding discipline demonstrates a desire to involve her in problem solving.
Suggesting a different school without a full evaluation does not address the problem.
CN: Psychosocial integrity; CL: Apply
1. Receiving empathy and talking about fears and feelings validates that the client is having
  typical reactions to a crime. A support group may help, but its effects will not be immediate. Legal
  resources may prove helpful, but the nurse does not yet have a clear picture if more legal resources
  are needed. Short-term medications for anxiety may be appropriate if other strategies are not quickly
  effective.
  CN: Psychosocial integrity; CL: Analyze

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