TEST 3: Comprehensive

Question 1

1. A primigravid client at 10 weeks’ gestation tells the nurse that she eats fruits and vegetables
   but doesn’t like them. After teaching the client about accurate serving sizes, the nurse determines that
   the teaching has been successful when the client states that one serving of fruit is equivalent to which
   of the following?
2. One-fourth of a cantaloupe.
3. 3 oz (90 mL) of vegetable juice cocktail.
4. Three tomatoes.
5. One raw apricot.
6. A nurse performs care on the client’s Hickman catheter according to hospital policy. The client
   develops an infection and is considering litigation. The nurse’s practice is:
7. Malpractice.
8. Respondeat superior.
9. Negligent.
10. Tort.
11. When conducting the preoperative preparations, the nurse determines that the client with a
    primary language of Spanish has difficulty understanding English. The surgeon needs to obtain the
    client’s informed consent. The best course for obtaining the client’s informed consent is to:
12. Have the client call a family member to act as interpreter.
13. Have the client sign the Spanish surgical consent form.
14. Call the Spanish interpreter to translate the surgeon’s explanation of the procedure, risks, and
    alternatives to obtain the client’s consent and to answer the client’s questions.
15. Notify the surgical charge nurse of the situation.
16. A client who has glaucoma has been prescribed timolol (Timoptic) eyedrops. Which of the
    following instructions should the nurse give the client about the administration of the eyedrops?
17. Instill the eyedrops whenever the eyes feel irritated.
18. The medication may cause some transient eye discomfort.
19. Keep the medication refrigerated between doses.
20. The need to use the eyedrops will be reevaluated after 1 month.
21. A 6-year-old will have a cardiac catheterization. The child asks if the procedure will hurt.
    Which of the following statements offers the nurse the best guide for responding to the child’s
    question?
22. The medication used to numb the insertion site will sting.
23. Momentary sharp pain usually occurs when the catheter enters the heart.
24. It is usual for a 6-year-old to feel discomfort during the procedure.
25. It is a painless procedure, although a tingling sensation may be felt in the extremities.

Answer 1

1. 1. One serving of fruit is equivalent to one-fourth of a cantaloupe. The client needs 6 oz (60
      mL) of a vegetable juice cocktail, two tomatoes, or two raw apricots to meet one fruit serving.
      CN: Basic care and comfort; CL: Evaluate
2. 2. Respondeat superior is Latin for “The master is responsible for the acts of his servants.”
      The nurse, as an employee of the hospital, acted according to the established policy of the hospital.
      Because the nurse followed hospital policy, it is unlikely that this incident involved malpractice,
      negligence, or tort law.
      CN: Management of care; CL: Evaluate
3. 3. The surgeon is required to give the client explanations and have questions answered. The
      nurse has no way of assessing the client’s understanding without the interpreter. The client should sign the Spanish consent form only after receiving an explanation of the procedure, its risks, and
      alternatives. A family member cannot be relied on to translate the surgeon’s instructions. The nurse is commonly asked to witness the explanation and to obtain the client’s signature on the informed
      consent form. Informed consent is the provision of information concerning the procedure and its risks,
      not obtaining the client’s signature on the form. The surgical charge nurse does not need to be notified.
      CN: Management of care; CL: Synthesize
4. 2. Timolol can cause some eye discomfort when administered. It is important for the client tomcontinue to take the drug. Glaucoma eyedrops should be administered as prescribed, not whenever the client desires. The client with glaucoma needs to take eye medication on an ongoing basis to control
      the disorder and prevent vision damage. There is no need to refrigerate the drug.
      CN: Pharmacological and parenteral therapies; CL: Synthesize
5. 1. The nurse’s best response when a child asks if cardiac catheterization is painful is to explain that the child will feel a little stinging when the numbing medicine is inserted into the area around the intro-duction site of the catheter. There may also be a feeling of pressure when the catheter is introduced. The child’s trust in the nurse will be quickly lost if the nurse is untruthful. The child is
      usually sedated and feels little during the procedure.
      CN: Reduction of risk potential; CL: Synthesize

Question 2

6. The nurse is assessing a client with chronic obstructive pulmonary disease. The client weighs
   200 lb (90.7 kg) and is 6 feet (182.9 cm) tall. Using the diagram shown here, the nurse should record
   in the health history that the client’s chest is:
7. Barrel-shaped.
8. Muscular.
9. Normal for the client’s age, height, and weight.
10. Showing the effects of long-term use of bronchodilators.
11. A diabetic primigravid client at 38 weeks’ gestation asks the nurse why she had a fetal acoustic stimulation during her last nonstress test. Which of the following should the nurse include as the rationale for this test?
12. To listen to the fetal heart rate.
13. To startle and awaken the fetus.
14. To stimulate mild contractions.
15. To confirm amniotic fluid amount.
16. The mother of an older infant reports stopping the prescribed iron supplements after 2 weeks of treatment. Which of the following responses by the nurse is most appropriate?
17. “Bring the child in so that we can retest him.”
18. “You need to continue the iron for several more weeks.”
19. “Let’s start a diet that is high in iron.”
20. “No more medication is needed at this time.”

9. A Jewish client requests an orthodox diet while hospitalized. The nurse should refer this
request to the:
1. Dietitian.
2. Physician.
3. Unit case manager.
4. Rabbi in pastoral care.

10. A mother reports she cannot afford the antibiotic azithromycin (Zithromax), which was prescribed by the physician for her toddler’s otitis media. The nurse’s best response is to:
11. Instruct the mother on the importance of the medication.
12. Ask the mother if she knows anyone who could loan her the money.
13. Confer with the physician about whether a less expensive drug could be prescribed.
14. Consult with the social worker.

Answer 2

6. 1. This client has a barrel chest. The anterior-posterior diameter of the chest is larger than the
      transverse diameter, as is characteristic of the client with chronic obstructive pulmonary disease.
      Although the client may be muscular, the barrel chest is not associated with the client’s age, height, orweight. Use of bronchodilators will not change the shape of the client’s chest.
      CN: Physiological adaptation; CL: Analyze
7. 2. Fetal acoustic stimulation involves the use of an instrument that emits sound levels of
      approximately 80 dB at a frequency of 80 Hz. The sharp sound startles and awakens the fetus and is
      used with nonstress testing as a method to evaluate fetal well-being. A fetoscope or Doppler
      stethoscope is used to listen to the fetal heart rate. Nipple stimulation or intravenous oxytocin is used
      to stimulate contractions. Ultrasound testing is used to determine amniotic fluid volume.
      CN: Reduction of risk potential; CL: Apply
8. 2. Typically, iron supplements are needed for at least 1 month. By the end of this time, there
      should be a significant rise in the hemoglobin and hematocrit. Therefore, the mother needs to continue
      the iron supplements for several more weeks. Testing the child after only 2 weeks of treatment may
      not be beneficial. A significant rise in hemoglobin and hematocrit usually requires approximately 1
      month of therapy. An iron-rich diet should have been started when the diagnosis was made and
      continued for at least the duration of iron supplement therapy.
      CN: Pharmacological and parenteral therapies; CL: Synthesize
9. 1. The dietary department should meet with the client to ensure that the foods are available and prepared according to religious beliefs. On admission, the client should be asked whether there are special dietary needs. The dietary department should be notified of these special needs, and a dietary representative should meet with the client and family when possible. The physician should be consulted if a requested food is con-trary to a prescribed diet restriction. The unit case manager does not need to be contacted regarding a dietary request. The rabbi is not involved in dietary requests.
      CN: Management of care; CL: Apply
10. 3. The nurse must act as an advocate for the client when the client cannot afford treatment. It is possible to substitute a less expensive antibiotic. Correct procedure includes contacting the physician
       to explain the mother’s economic situation and request a substitution. For example, amoxicillin
       (Amoxil) is more economical than azithromycin.
       CN: Management of care; CL: Synthesize

Question 3

11. The nurse is transferring a client who is G4 P3 at 25 weeks’ gestation with preeclampsia from the obstetrical intensive care unit to the antenatal unit. To safely manage this pre-eclamptic client, what
    should be included in the transfer report about this client? Select all that apply.
12. Record of blood pressure trends.
13. Record of urine protein.
14. Edema observed by health care provider.
15. Client use of dietary sodium.
16. Fetal position.
17. Fetal heart rate pattern.
18. Medical and nursing interventions utilized.
19. The physician has prescribed nitroglycerin to a client with angina. The client also has closed-angle glaucoma. The nurse contacts the physician to discuss the potential for:
20. Decreased intraocular pressure.
21. Increased intraocular pressure.
22. Hypotension.
23. Hypertension.
24. A client believes she is experiencing premenstrual syndrome (PMS). The nurse should next
    ask the client about which of the following?
25. Menstrual cycle irregularity with increased menstrual flow.
26. Mood swings immediately after menses.
27. Tension and fatigue before menses and through the 2nd day of the menstrual cycle.
28. Midcycle spotting and abdominal pain at the time of ovulation.
29. Which of the following should the nurse closely assess in a client who is reversing from
    halothane general anesthesia and receiving clindamycin?
30. Tachycardia.
31. Respiratory depression.
32. Hypotension.
33. Renal failure.
34. A hospitalized adolescent with type 1 diabetes mellitus is weak and nauseated with poor skin turgor. The nurse notes a fruity odor to the client’s breath. The client uses Lispro insulin. The last
    meal was lunch, 2 hours ago. Place the following nursing actions in the order in which the nurse should perform them.
35. Obtain a fingerstick test for blood glucose.
36. Start an IV infusion with normal saline solution.
37. Administer Lispro.4. Notify the physician.

Answer 3

11. 1, 2, 3, 6, 7. The important information to be given with a pre-eclamptic client should include blood pressure trends while being monitored and the protein that is and has been present in the urine
    as these are indicators of increasing eclampsia. Edema of the face, a history of headache, blurred vision, and epigastric pain are important as these also indicate worsening preeclampsia. The fetal
    position at 25 weeks is of minor importance as the fetus is constantly changing positions at this point in the pregnancy. The medical and nursing interventions utilized to treat preeclampsia will provide the nurse on the antenatal unit with information about what has been utilized and their effect. The use of dietary sodium does not have an impact on preeclampsia. Glycosuria is an important consideration if this client has gestational diabetes but is not significant for the client with pre-eclampsia.
    CN: Safety and infection control; CL: Synthesize
12. 2. Nitroglycerin causes vasodilation, which results in increased intraocular pressure. The vaso-dilatory effects of the medication can trigger an attack, causing pain and loss of vision. Hypotension is a common side effect of nitro-glycerin, which dilates the blood vessels but is not a
       concern in the client with glaucoma.
       CN: Pharmacological and parenteral therapies; CL: Synthesize
13. 3. The timing of symptoms is important to the diagnosis of PMS. The client should keep a 3-
       month log of symptoms and menses. With PMS, the symptoms begin 3 to 7 days before menses and resolve 1 to 2 days after the menstrual cycle has started. Menstrual cycle irregularity and mood swings after menses are not related to PMS, and other causes should be investigated. Midcycle spotting and pain are related to ovulation.
       CN: Health promotion and maintenance; CL: Analyze
14. 2. The client who has received general anesthesia with halothane or other neuromuscular
       blocking agents must be carefully monitored when given clindamycin. A serious interaction is
       enhanced neuromuscular blockage, skeletal muscle weakness, or respiratory depression if this
       combination is used during or immediately after surgery. Concurrent use should be avoided. The combined effect of the medications places the client at increased risk, and the nurse should assess the client closely for respiratory depression or paralysis. The nurse will be monitoring the client’s heart rate, blood pressure, and urinary output but not specifically because of potential drug interactions and adverse effects of clindamycin.
       CN: Pharmacological and parenteral therapies; CL: Analyze
16. Start an IV infusion with normal saline solution.
17. Obtain a fingerstick test for blood glucose.
18. Notify the physician.
19. Administer Lispro.
    The client is experiencing ketoacidosis. The first action is to initiate IV fluids to prevent further
    dehydration. Next, the nurse should obtain serum glucose values to report to the physician, who will then prescribe the appropriate dose of insulin.
    CN: Physiological adaptation; CL: Synthesize

Question 4

16. The nurse observes an 18-month-old who has been admitted with a respiratory tract infection
    (see figure). The nurse should first:
17. Position the child supine.
18. Call the rapid response team.
19. Offer the child a carbonated drink.
20. Place the child in a croup tent.
21. A nulliparous client visiting the clinic tells the nurse that she stopped taking oral
    contraceptives 6 months ago but doesn’t think she is ovulating. Which of the following should the
    nurse anticipate that the physician would prescribe if the client is anovulatory?
22. Dienestrol.
23. Clomiphene citrate.
24. Medroxyprogesterone.
25. Norgestrel.
26. A client who has been recently diagnosed with acquired immunodeficiency syndrome (AIDS)
    inquires about hospice services. The nurse explains that hospice care is appropriate:
27. For clients with an inevitable death within weeks to months.
28. For all clients with AIDS at any stage.
29. Only for clients with cancer.
30. When the client is ready to discuss his prognosis.19. While assessing a neonate at age 24 hours, the nurse observes several irregularly shaped,
    red, flat patches on the back of the neonate’s neck. The nurse interprets this finding as which of the
    following?
31. Stork bite.
32. Port-wine stain.
33. Newborn rash.
34. Café au lait spot.
35. A mother who is Mexican brings her 2-month-old son to the emergency department with a
    high fever and possible sepsis. A lumbar puncture is prescribed, but the mother will not sign the
    consent until the father arrives to give permission. The nurse should:
36. Report this to the social worker.
37. Call Child Protective Services (Ministry of Children).
38. Wait until the father arrives.
39. Inform the physician that the mother has refused to have the procedure.

Answer 4

16. 4. The child is in respiratory distress and is sitting in a position to relieve the airway
       obstruction; the nurse should provide a humidified environment with a croup tent with cool mist to facilitate breathing and liquefy secretions. The child should remain sitting to facilitate breathing; the
       nurse should allow the child to determine the most comfortable position. After the child is breathing normally, the nurse can offer fluids; the physician also may prescribe intravenous fluids. The nurse
       can call the rapid response team if the respiratory distress is not relieved by using a croup tent or other vital sign changes indicate further distress.
       CN: Reduction of risk potential; CL: Synthesize
17. 2. When ovulation is suppressed for 6 to 8 months after oral contraceptive use, the physicianmay prescribe clomiphene citrate to stimulate ovulation. Clomiphene acts to give the hypothalamus the signal to increase secretion of follicle-stimulating hormone and luteinizing hormone, thereby stimulating ovulation. Dienestrol is an estrogen applied topically to treat atrophic vaginitis and kraurosis vulvae in postmenopausal women. Medroxyprogesterone is a progesterone derivative that prevents maturation of the follicle and ovulation. Norgestrel is a progesterone-only contraceptive that
       is believed to alter the cervical mucus, possibly suppress ovulation, and interfere with implantation in the uterus.
       CN: Pharmacological and parenteral therapies; CL: Apply
18. 1. Hospice programs are appropriate programs for clients with any type of terminal illness when death is imminent within weeks up to 6 months. Clients may discuss their prognosis of a terminal illness before it progresses to the terminal stage when a referral to hospice care is indicated.
       CN: Management of care; CL: Apply
19. 1. Several irregularly shaped red patches, common skin variations in neonates, are termed
       stork bites. They eventually fade away as the neonate grows older. Port-wine stains are disfiguring darkish red or purplish skin discolo-rations on the scalp and face that may need laser therapy for removal. Newborn rash is typically generalized over the body, not localized to one body area, and is
       commonly raised. Café au lait spots are brown and typically found anywhere on the body. More than six spots or spots larger than 1.5 cm are associated with neurofibromatosis, a genetic condition of
       neural tissue.
       CN: Health promotion and maintenance; CL: Analyze
20. 3. In the traditional Mexican household, the man is the head of the family and makes the major decisions. Efforts should be made to reach the father as soon as possible to acquire his permission. It is not necessary to contact the social worker at this point. The client has not refused the procedure, so it is premature to contact the physician. This is not a situation of suspected child abuse.
       CN: Management of care; CL: Synthesize

Question 5

21. A client with Alzheimer’s disease is started on a low dose of lorazepam (Ativan) because of
    agitation and a sleep disturbance. The nurse should assess the client for which of the following?
22. Nighttime agitation.
23. Extrapyramidal side effects.
24. Vomiting.
25. Anticholinergic side effects.
26. A client who is postmenopausal with an intact uterus asks the nurse why her hormone
    medicine has two drugs, estrogen and progesterone. Which of the following statements by the nurse
    provides the client with accurate information?
27. “The progesterone will help prevent cervical cancer.”
28. “The progesterone will help prevent breast cancer.”
29. “The progesterone will help prevent liver disease.”
30. “The progesterone will help prevent endometrial cancer.”
31. The nurse on the antenatal unit is planning care for four clients. The nurse should assess
    which of the following clients first?
32. A 29-year-old G3 P2 carrying twins, being treated for preterm labor at 29 weeks’ gestation.
    She is receiving magnesium sulfate at 2 g/h. She has had no contractions for the past 2 hours
    and both twins appear stable, according to the nurse’s shift report.
33. A 19-year-old 18 weeks’ intrauterine pregnancy (IUP) who is now 12 hours post motor vehicle
    accident with bright red vaginal bleeding.
34. A G8 P4 Ab3 at 38 weeks’ gestation hospitalized frequently during this pregnancy for placenta
    previa. Two days ago, she was admitted with severe bright red vaginal bleeding that has
    tapered off now.
35. A 9-week IUP hospitalized for hyperemesis gravidarum who has not vomited for the last 12
    hours.
36. The nurse should turn the client on bed rest every 2 hours to prevent the development of
    pressure ulcers. In addition, the nurse should:
37. Have the client walk at least twice a day.
38. Insert an indwelling urinary catheter.3. Monitor serum albumin.
39. Monitor the white blood cell count.
40. A client, hospitalized with heart failure, is receiving digoxin (Lanoxin) and furosemide
    (Lasix) intravenously and now has continuous ringing in the ears. What is the appropriate action for
    the nurse to take at this time?
41. Obtain a digoxin level to check for toxicity.
42. Note the observation in the chart and plan to reassess in 2 hours.
43. Ask the client about taking aspirin in addition to other medications.
44. Discontinue the furosemide and notify the physician.

Answer 5

21. 1. In the cognitively impaired client, benzo-diazepines, such as lorazepam, can increase
       confusion and nighttime agitation. Extrapyramidal side effects are more common with antipsy-chotics. Vomiting and sweating are signs of benzodiazepine with-drawal. Anticholinergic side effects are more
       likely with antipsychotics and tricyclic antidepressants.
       CN: Pharmacological and parenteral therapies; CL: Analyze
22. 4. A woman with a uterus who takes unopposed estrogen has an increased risk of endometrial cancer. The addition of progesterone prevents the formation of endometrial hyperplasia.
       CN: Pharmacological and parenteral therapies; CL: Apply
23. 2. The client who is 18 weeks with an intrauterine pregnancy (IUP) is not stable with bright red vaginal bleeding. Even with a nonviable fetus, the mother is in jeopardy with continued bleeding.
       The client who is 9 weeks’ IUP and has not vomited for 12 hours appears stable at this point with a
       nonviable fetus. The G8 also appears stable as her bleeding has tapered off since admission. The 29-
       week gestation client carrying twins has no information indicating that she is in jeopardy, with no
       contractions in the past 2 hours, and is becoming more stable.
       CN: Health promotion and maintenance; CL: Synthesize
24. 3. The nurse should monitor the client’s serum albumin. A decreased serum albumin indicates
       malnutrition and is considered a risk factor in the development of pressure ulcers. Other risk factors include immobility, incontinence, and decreased sensation. Having the client walk and inserting an indwelling catheter require a physician’s prescription. The white blood cell count is monitored if an infection is present.
       CN: Physiological adaptation; CL: Synthesize
25. 4. The nurse should recognize the ringing in the ears, or tinnitus, as a sign of ototoxicity probably caused by the furosemide. The appropriate action is for the nurse to stop the furosemide and notify the physician. If the drug is stopped soon enough, permanent hearing loss can be avoided, and the tinnitus should subside. The nurse should note the observation in the chart but should not delay action. Tinnitus is not a symptom of digoxin (Lanoxin) toxicity. Aspirin can cause tinnitus, but the nurse should first investigate the obvious cause of tinnitus, which in this case is the furosemide.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 6

26. Which of the following discharge instructions about thermal injury should be given to a client
    with peripheral vascular disease? Select all that apply.
27. “Warm the fingers or toes by using an electric heating pad.”
28. “Avoid sunburn during the summer.”
29. “Wear extra socks in the winter.”
30. “Choose loose, soft, cotton socks.”
31. “Use an electric blanket when you are sleeping.”
32. A client receives an IV dose of gentamicin sulfate (Garamycin). How long after the
    completion of the dose should the peak serum concentration level be measured?
33. 10 minutes.
34. 20 minutes.
35. 30 minutes.
36. 40 minutes.
37. A client with hydrocephalus reports having had a headache in the morning on arising for the
    last 3 days, but it disappears later in the day. The nurse should:
38. Notify the physician.
39. Tell the client that this is normal because intracranial pressure (ICP) fluctuates throughout the
    day.
40. Instruct the client to increase fluid intake prior to going to bed to prevent headache in the
    morning.
41. Advise the client to request pain medication from the physician.
42. A primigravid client visits the clinic for a routine examination at 35 weeks’ gestation. The
    client’s blood pressure is near the baseline of 120/74 mm Hg with no proteinuria or evidence of
    facial edema. The client asks the nurse, “What should I take if I get an occasional headache after
    looking at my computer at work all day?” The nurse instructs the client that she can occasionally take
    which of the following?
43. Acetaminophen (Tylenol).
44. Aspirin.
45. Ibuprofen (Advil).
46. Naproxen (Aleve).
47. A 19-year-old client has undergone an examination and had evidence collected after being
    raped. Her father is overheard yelling at his daughter, “You’re going to tell me who did this to you.
    What’s his name?” Which of the following is the nurse’s most immediate action?1. “Please come with me, sir. I need some important information.”
48. “Stop yelling. You’re being inappropriate.”
49. “Please be quiet. You’re not helping your daughter this way.”
50. “If you don’t stop yelling, I’ll have to call Security.”

Answer 6

26. 2, 3, 4. The client should recognize the signs of potential thermal dangers to prevent skin
    breakdown and wear clean, loose, soft cotton socks so that the feet are comfortable, air can circulate, and moisture is absorbed. In the winter or if the client has cold feet, the client should be encouraged to wear an extra pair of socks and a larger shoe size. Getting a sunburn during the summer puts the client at risk for tissue injury and skin breakdown. Using a heating pad to warm the feet or using an electric blanket places the client at risk for injury and should be avoided.
    CN: Reduction of risk potential; CL: Create
27. 3. The peak serum dose of an antibiotic is drawn 30 minutes after the completion of the IV dose of the antibiotic.
       CN: Pharmacological and parenteral therapies; CL: Apply
28. 1. ICP is highest in the early morning, and the client with hydrocephalus may be experiencing
       signs of increased ICP that need to be treated. The increased ICP is not related to fluid levels, and the nurse should not advise the client to increase fluid intake. While ICP does fluctuate during the day, it
       is highest in the morning, and the nurse should notify the physician. Pain medication will not treat the potentially increasing ICP and may mask important signs of increasing ICP.
       CN: Physiological adaptation; CL: Synthesize
29. 1. The nurse should instruct the client that symptoms from an occasional headache due to eye strain or continuous work at a computer can be relieved by acetaminophen. Although this drug causes prostaglandin inhibition, this effect is rapidly reversed and cleared with no apparent harmful effects in pregnancy. If the headaches become more frequent or severe, the client should be instructed to contact her health care provider immediately. Aspirin should be avoided during pregnancy because it
       inhibits prostaglandin synthesis. It also decreases uterine contractility and may delay the onset of
       labor or prolong pregnancy and labor. Aspirin decreases platelet aggregation, possibly increasing the risk of bleeding. Ibuprofen and naproxen can lead to premature closure of the fetal ductus arteriosus and decreased amniotic fluid with prolonged use. They may also prolong pregnancy or labor because of their antiprostaglandin effects.
       CN: Pharmacological and parenteral therapies; CL: Synthesize
30. 1. With this level of anger in a crisis, the father needs simple but firm directions to leave theroom, calm down, and then to talk. Doing so relieves the daughter of any pressure from her father. Telling the father to stop yelling or be quiet provides no concrete directions to the father and may embarrass him in front of his daughter. Telling the father that if he doesn’t stop yelling, the nurse will call Security is a threat, possibly leading to an escalation of the situation.
       CN: Psychosocial adaptation; CL: Synthesize

Question 7

31. Which of the following groups is more likely to develop severe hypertension?
32. Asian.
33. African.
34. European.
35. Native American/First Nations.
36. During a neonate’s assessment shortly after birth, the nurse observes a large pad of fat at the
    back of the neck, widely set eyes, simian hand creases, and epicanthal folds. Which of the following
    actions is most appropriate?
37. Notify the physician immediately.
38. Ask the mother to consent to genetic studies.
39. Explain these deviations to the newborn’s mother.
40. Document these findings as minor deviations.
41. A client with severe arthritis has been receiving maintenance therapy of prednisone 10
    mg/day for the past 6 weeks. The nurse should instruct the client to immediately report symptoms of:
42. Respiratory infection.
43. Joint pain.
44. Constipation.
45. Joint swelling.
46. A 90-year-old client discloses that he has two guns at home. The nurse asks him whether he
    has any grandchildren who come to visit or other school-aged visitors because a common risk factor
    for school-aged children associated with injury or death from firearms is:
47. An argument with a stranger.
48. Firearm access.
49. Substance use.
50. Peer pressure.
51. A 7-year-old child is admitted to the hospital with acute rheumatic fever. During the acute
    phase of the illness, it is least desirable to interest the child in which of the following diversional
    activities?
52. Reading a book with the father.
53. Playing with a doll with the nurse.
54. Watching the television with a sibling.
55. Playing checkers with a roommate.

Answer 7

31. 2. Epidemiologic and experimental research studies indicate that people of African descent
       are more likely to develop severe hypertension.
       CN: Health promotion and maintenance; CL: Analyze
32. 1. A large pad of fat at the back of the neck, widely set eyes, a simian crease in the hands, and epicanthal folds are typically associated with Down syndrome. The nurse should notify the physician immediately. The physician should obtain consent for genetic studies and is responsible for explaining these deviations to the parents. However, the nurse may need to provide additional teaching to the mother and to answer any questions that may arise.
       CN: Health promotion and maintenance; CL: Synthesize
33. 1. Clients receiving chronic steroid therapy can become immuno-suppressed and are prone to infections. Signs of infection can also be masked with prednisone. Signs and symptoms of infection should be reported immediately. Joint pain, constipation, and joint swelling are not related to the adverse effects of steroid therapy.
       CN: Pharmacological and parenteral therapies; CL: Synthesize
34. 2. Injury and death from firearms is a major public health problem. One reason is that children, granchildren, and neighbor’s children may have easy access to firearms and accidentally use them. The nurse should assess the family situation for presence of firearms.
       CN: Safety and infection control; CL: Analyze
35. 4. School-aged children enjoy board games and are commonly intense about following rules. Their play can become emotional. Adequate rest is of utmost importance during the acute stage of rheumatic fever. Therefore, playing a game with another child probably would be too strenuous. Such diversional activities as reading a book, playing with a doll, and watching television would be moremsatisfactory.
       CN: Health promotion and maintenance; CL: Synthesize

Question 8

36. A woman is taking oral contraceptives. The nurse teaches the client to report which of the
    following danger signs?
37. Breakthrough bleeding.
38. Severe calf pain.
39. Mild headache.
40. Weight gain of 3 lb (1.4 kg).37. Which nursing action is essential for the hospitalized client with a new tracheostomy?
41. Decrease secretions.
42. Provide client teaching regarding tracheostomy care.
43. Relieve anxiety related to the tracheostomy.
44. Maintain a patent airway.
45. Immediately after receiving an injection of bupivacaine, the client becomes restless and
    nervous and reports a feeling of impending doom. Which of the following actions by the nurse is
    appropriate?-
46. Ask the client to explain these feelings.
47. Reassure the client that it is normal to feel restless before a procedure.
48. Assess the client’s vital signs.
49. Administer epinephrine.
50. A menopausal woman is taking hormone replacement therapy. The nurse teaches the client
    that a warning sign for endometrial cancer that needs to be reported is:
51. Hot flashes.
52. Irregular vaginal bleeding.
53. Urinary urgency.
54. Dyspareunia.
55. When explaining the risk for having a child with cystic fibrosis to a husband and wife, the
    nurse should tell them:
56. The risk is greatest when both clients have the recessive gene.
57. The gene is carried on the X chromosome and there is little risk.
58. The disease will only occur if the child is a male.
59. The disease does not have a genetic basis.

Answer 8

36. 2. Women who take oral contraceptives are at increased risk for thromboembolic conditions.
       Severe calf pain needs to be investigated as a potential sign of deep vein thrombosis. Breakthrough bleeding, mild headache, or weight gain may be common benign side effects that accompany oral contraceptive use. Clients may be monitored for these side effects without a change in treatment.
       CN: Pharmacological and parenteral therapies; CL: Synthesize
37. 4. The priority for a client with a new trache-ostomy is to maintain a patent airway. A new
       tracheostomy commonly causes bleeding and excess secretions, and the client may require frequent suctioning to maintain a patent airway.
       CN: Reduction of risk potential; CL: Synthesize
38. 3. The nurse should assess the client’s vital signs because there is a likelihood of having a reaction to the bupivacaine. If the client’s vital signs are ab- normal, immediate intervention may be necessary. Although the nurse may ask the client to continue to describe feelings, this is not likely to be a psycho- social reaction. Simple reassurance is inappropriate in most clinical situations and can be dangerous if physiologic causes of restlessness are overlooked. The nurse should not administer epinephrine until vital signs have been assessed.
       CN: Pharmacological and parenteral therapies; CL: Synthesize
39. 2. Endometrial cancer has very few warning signals; irregular bleeding may be the only sign.
       Any irregular bleeding in a menopausal woman should be investigated, and an endometrial biopsy may be prescribed. Hot flashes result from the decreased estrogen levels that accompany menopause. Urinary urgency should be monitored and treated as a separate problem. Dyspareunia is the occurrence of pain in the labial, vaginal, or pelvic areas during or after sexual intercourse. It may be caused by inadequate vaginal lubrication in the menopausal woman.
       CN: Pharmacological and parenteral therapies; CL: Analyze
40. 1. Cystic fibrosis is an autosomal recessive genetic disorder. This means that both parents
       have the gene. There is a one in four chance with each pregnancy from such parents that the child will have cystic fibrosis.
       CN: Physiological adaptation; CL: Synthesize

Question 9

41. The client has severe vulvar pruritus and a yellow-green, malodorous vaginal discharge. The
    nurse recognizes that the symptoms suggest:
42. Gonorrhea.
43. Syphilis.
44. Chlamydia.
45. Trichomoniasis.
46. Following surgery, to evaluate the effectiveness of the client’s use of an incentive spirometer,
    the nurse should determine if the client:
47. Has increased circulation in the extremities.
48. Is ready to ambulate without pain.
49. Has stronger abdominal muscles.
50. Can breathe easier.
51. A client was talking with her husband by telephone, and then she began swearing at him. The nurse interrupts the call and offers to talk with the client. She says, “I can’t talk about that bastard right now. I just need to destroy something.” Which of the following should the nurse do next?
52. Tell her to write her feelings in her journal.
53. Urge her to talk with the nurse now.
54. Ask her to calm down or she will be restrained.4. Offer her a phone book to “destroy” while staying with her.
55. The nurse is caring for a multigravid client in active labor when the nurse detects variable
    fetal heart rate decelerations on the electronic monitor. The nurse interprets this as the compression of which of the following structures?
56. Head.
57. Chest.
58. Umbilical cord.
59. Placenta.
60. Which of the following findings should lead the nurse to suspect that a client who had a cesarean birth 8 hours earlier is developing disseminated intravascular coagulation (DIC) and report to the health care provider? Select all that apply.
61. Petechiae on the arm where the blood pressure was taken.
62. Heart rate of 126 bpm.
63. Abdominal incision dressing with bright red drainage.
64. Platelet count of 80,000/mm 3 (80 × 10 9 /L).
65. Urine output of 350 mL in the past 8 hours.
66. Temperature of 98.4°F (36.9°C).

Answer 9

41. 4. Trichomoniasis is caused by a protozoan. Although the client may not have symptoms, the classic symptom of trichomoniasis is a malodorous, yellow-green discharge. Gonorrhea, syphilis, and chlamydia do not commonly manifest as a vaginal discharge.
       CN: Physiological adaptation; CL: Analyze
42. 4. Incentive spirometry promotes lung expansion and increases respiratory function. When used properly, an incentive spirometer causes sustained maximal inspiration and increased cardiac output.
       CN: Reduction of risk potential; CL: Evaluate
43. 4. At this level of aggression, the client needs an appropriate physical outlet for the anger. She is beyond writing in a journal. Urging the client to talk to the nurse now or making threats, such as telling her that she will be restrained, is inappro-priate and could lead to an escalation of her anger.
       CN: Psychosocial adaptation; CL: Synthesize
44. 3. Variable decelerations are associated with compression of the umbilical cord. The nurse
       should alter the client’s position and increase the IV fluid rate. Fetal head compression is associated with early decelerations. Severe compression of the fetal chest, such as during the process of vaginal
       birth, may result in transient bradycardia. compression or damage to the placenta, typically from abruptio placentae, results in severe, late decelerations.
       CN: Reduction of risk potential; CL: Analyze
45. 1, 2, 3, 4. DIC is diagnosed based on clinical symptoms and laboratory findings. Findings such as excessive and unusual bruising or bleeding over areas of tissue trauma, such as IV insertion
    or incision sites or application of a blood pressure cuff should be reported to the health care provider. Tachycardia and diaphoresis also may be noted. Laboratory results reveal low platelet, fibrinogen, proaccelerin, antihemophiliac factor, and pro-thrombin levels. Bleeding time is normal and partial thromboplastin time is increased. A urine output of 350 mL in 8 hours indicates adequate renal function. Temperature is not an indication of DIC.
    CN: Physiological adaptation; CL: Analyze

Question 10

46. Two days after placement of a pleural chest tube, the tube is accidentally pulled out of the chest wall. The nurse should first:
47. Immerse the tube in sterile water.
48. Apply an occlusive dressing such as petroleum jelly gauze.
49. Instruct the client to cough to expand the lung.
50. Auscultate the lung to determine whether it collapsed.
51. A client is admitted to the hospital with a diagnosis of a pulmonary embolism. Which of the
    following problems should the nurse address first?
52. Nonproductive cough.
53. Activity intolerance.
54. Difficulty breathing.
55. Impaired gas exchange.
56. Which of the following is characteristic of cardio-genic shock?
57. Hypovolemia.
58. Increased cardiac output.
59. Decreased myocardial contractility.
60. Infarction.
61. The nurse is reviewing the laboratory results of a client with hypothyroidism. An expected finding is:
62. Decreased thyroxine (T 4 ) and increased thyroid-stimulating hormone (TSH) levels.
63. Decreased TSH and increased T 4 levels.
64. Decreased creatine phosphokinase levels.
65. Absence of antithyroid antibodies.
66. The mother of a 7-month-old child born 6 weeks early asks the nurse what play activities andtoys is appropriate for her child. Which of the following should the nurse suggest?
67. Picture books.
68. Peek-a-boo.
69. Rattle.
70. Colored blocks.

Answer 10

46. 2. If the chest tube is accidentally pulled out (a rare occurrence), a petroleum jelly gauze and sterile 4×4 inch dressing should be applied over the chest wall insertion site immediately. The dressing should be covered with adhesive tape and be occlusive, and the surgeon should be notified. The lungs can be auscultated and vital signs can be taken after the dressing is in place and the surgeon has been called.
       CN: Reduction of risk potential; CL: Synthesize
47. 4. Emboli obstruct blood flow, leading to a decreased perfusion of the lung tissue. Because of the decreased perfusion, a ventilation-perfusion mismatch occurs, causing hypoxemia to develop.
       Arterial blood gas analysis typically will indicate hypoxemia and hypocapnia. A priority objective in the treatment of pulmonary emboli is maintaining adequate oxygenation. A nonproductive cough and
       activity intolerance do not indicate impaired gas exchange. The client does not demonstrate an
       ineffective breathing pattern; rather, the problem of impaired gas exchange is caused by the inability of blood to flow through the lung tissue.
       CN: Physiological adaptation; CL: Synthesize
48. 3. Cardiogenic shock occurs when myocardial contractility decreases and cardiac output
       greatly decreases. The circulating blood volume is within normal limits or increased. Infarction is not always the cause of cardiogenic shock.
       CN: Physiological adaptation; CL: Analyze
49. 1. The nurse should expect to find decreased levels of thyroxine and triiodothyronine and
       increased TSH. Other indicators of hypothyroidism are the presence of antithyroid antibodies and
       elevation of the creatine phosphokinase (CPK-MM) level. Hypothyroidism has a metabolic effect on
       skeletal muscle. Muscle injury results, causing the CPK-MM to spill out of the damaged cells and into
       the bloodstream.
       CN: Physiological adaptation; CL: Analyze
50. 3. Although chronologically the infant is 7 months old, because of being born 6 weeks early, the child is only 51⁄2 months old developmentally. Appropriate activities for a 5- to 51⁄2-month-old
       infant include placing a rattle or ball in the infant’s hand. Picture books are an appropriate choice for
       an infant older than 9 months. Playing peek-a-boo is appropriate for a 9- to 12-month-old infant.
       Colored blocks are appropriate for a toddler approximately age 15 to 18 months.
       CN: Health promotion and maintenance; CL: Synthesize

Question 11

51. Which of the following is the most accurate method of determining the extent of a client’s fluid loss?
52. Measuring intake and output.
53. Assessing vital signs.
54. Weighing the client.
55. Assessing skin turgor.
56. The nurse is counseling a client regarding treatment of the client’s newly diagnosed
    depression. The nurse emphasizes that full benefit from antidepressant therapy usually takes how
    long?
57. 1 week.
58. 2 to 4 weeks.
59. 5 to 7 weeks.
60. 8 weeks.
61. A 70-year-old, previously well client asks the nurse, “I notice I have tremors. Is this just normal for my age?” The best response for the nurse to make is which of the following?
62. “I wouldn’t be worried because this is common with aging.”
63. “You should report this to the physician because it may indicate a problem.”
64. “You should drink orange juice when this occurs.”
65. “You should have your blood pressure checked when this occurs.”
66. A school-aged child diagnosed with attention deficit hyperactivity disorder is prescribed
    methylphenidate (Ritalin). Which of the following should alert the school nurse to the possibility that
    the child is experiencing a common side effect of the drug?
67. Loss of appetite.
68. Vomiting.
69. Photosensitivity.
70. Weight gain.
71. A client has a dull headache, is dizzy, and has an increased pulse rate. The results of arterial blood gas analysis are as follows: pH 7.26; partial pressure of carbon dioxide, 50 mm Hg (6.7 kPa); and bicarbonate, 24 mEq/L (24 mmol/L). These findings indicate which of the following acid-base imbalances?
72. Respiratory alkalosis.
73. Respiratory acidosis.
74. Metabolic acidosis.
75. Metabolic alkalosis.

Answer 11

51. 3. Accurate daily weight measurement provides the best measure of a client’s fluid status: 1 kg (2.2 lb) is equal to 1,000 mL of fluid. To be accurate, weight should be obtained at the same time every day, with the same scale, and with minimal clothing on.
       CN: Physiological adaptation; CL: Analyze
52. 2. Full benefit from an antidepressant medication usually takes about 2 to 4 weeks on an adequate dose.
       CN: Pharmacological and parenteral therapies; CL: Apply
53. 2. Fine tremors are the first symptom reported in 70% of clients with Parkinson’s disease. Anew onset of tremors needs to be investigated by the physician. Tremors are not an expected change with aging.
       CN: Reduction of risk potential; CL: Synthesize
54. 1. Loss of appetite is one of the more common adverse effects associated with methylphenidate. Although nausea is associated with this drug, vomiting is not. Photosensitivity is not associated with this drug. Because of decreased appetite, the client will not gain more weight.
       CN: Pharmacological and parenteral therapies; CL: Evaluate
55. 2. The pH of 7.26 indicates that the body is in a state of acidosis. The elevated partial pressure of carbon dioxide value accompanied by a normal bicarbonate value indicates that the acid-base imbalance is respiratory acidosis. The additional clinical findings of headache, dizziness, and increased pulse rate, resulting from the elevated partial pressure of carbon dioxide, further support this diagnosis.
       CN: Physiological adaptation; CL: Analyze

Question 12

56. The nurse is planning a continuous quality improvement (CQI) process to decrease the infection rate on the nursing unit. The nurse should consider which of the following when planning the process? Select all that apply.
57. CQI processes are required by accrediting agencies.
58. The approach to CQI can be retrospective or concurrent.
59. Institutional Review Board (IRB) approval is required.
60. CQI is conducted by people who are not part of the process.
61. The CQI process has a fixed endpoint.
62. Which of the following is appropriate for a client with metabolic alkalosis?
63. Monitor serum potassium levels.
64. Maintain the client on bed rest.
65. Have the client inhale carbon dioxide using a paper bag.
66. Administer sodium bicarbonate as prescribed.
67. Which of the following demonstrates that the client needs further instruction after being taught
    about ciprofloxacin (Cipro)?
68. “I must drink 500 to 1,500 mL of water a day.”
69. “I shouldn’t take an antacid before taking the Cipro.”
70. “I should let the doctor know if I start vomiting from the Cipro.”
71. “I may get light-headed from the Cipro.”
72. When developing the plan of care for a client with Alzheimer’s disease, which of the
    following activities is least beneficial to the client?
73. Reminiscence group.
74. Walking.
75. Pet therapy.
76. Stress management.
77. The nurse should instruct the parents of a school-aged child with hemophilia to implement which of the following when the child develops bleeding into a joint? Select all that apply.
78. Having the child rest.
79. Applying heat to the joint area.
80. Beginning factor VIII therapy.
81. Starting physical therapy.
82. Applying a topical antifibrinolytic.

Answer 12

56. 1, 2. The purpose of CQI is to improve a local process to benefit clients and providers; it is
    required by the institution, regulatory, or accrediting agencies. The approach to the problem can be
    retrospective or concurrent; institutional review board (IRB approval is not required unless the
    results will be made available to external parties and specific clients could be identified. CQI is
    performed by clinicians and managers who are part of the process being studied; the timeframe is
    continuous or cyclical.
    CN: Management of care; CL: Synthesize
57. 1. With a client in metabolic alkalosis, the nurse should monitor for hypokalemia. Metabolic
       alkalosis can cause potassium to shift into the cells, resulting in a decrease of serum potassium. In
       metabolic alkalosis, the body tries to compensate by conserving carbon dioxide, so there is no need
       to have the client inhale carbon dioxide, as would be the case if hyperventilation were occurring.
       There is already a base bicarbonate excess with this condition, so the nurse should not administer
       sodium bicarbonate. Unless symptoms dictate, the client does not need to be placed on bed rest.
       CN: Physiological adaptation; CL: Synthesize
58. 1. To reduce the risk of crystalluria, the client should drink 2,000 to 3,000 mL of water a day,
       not 1,000 to 1,500 mL. The client should not take an antacid before taking Cipro. An antacid
       decreases the absorption of the Cipro. The client should let the doctor know if vomiting occurs from the medication. The client may get light-headed from the Cipro. If so, the client should not drive a motor vehicle and should contact the physician.
       CN: Pharmacological and parenteral therapies; CL: Evaluate
59. 4. Stress management is not beneficial to the client with Alzheimer’s disease because of
       cognitive impairment, confusion, and short-term memory loss. Reminiscence group, walking, and pet
       therapy are beneficial.
       CN: Psychosocial adaptation; CL: Synthesize
60. 1, 3. When a child with hemophilia develops bleeding into a joint, the parents should have the
    child rest and begin factor VIII therapy. If therapy is started immediately, usually other interventions
    such as ice are not necessary. Heat causes vasodilation and promotes bleeding. Starting factor VIIIimmediately helps prevent chronic joint disease. Starting physical therapy further traumatizes the
    joint, possibly increasing the bleeding. Applying a topical agent does not control internal bleeding.
    CN: Reduction of risk potential; CL: Create

Question 13

61. Which of the following goals is most important when developing a long-term care plan for a child with hemophilia?
62. Increase the parent’s and child’s knowledge about hemophilia.
63. Prevent injury during each stage of development.
64. Improve the child’s self-esteem during bleeding episodes.
65. Manage acute pain when there is bleeding into joints.
66. When preparing a 3-year-old child to have blood specimens drawn for laboratory testing, the nurse should:
67. Explain the procedure in advance.
68. Explain why the blood needs to be drawn.
69. Use distraction techniques during the procedure.
70. Provide verbal explanations about what will occur.
71. The client has been prescribed lisinopril (Prinivil) to treat hypertension. The nurse shouldassess the client for which of the following electrolyte imbalances?
72. Hyponatremia.
73. Hypocalcemia.
74. Hyperkalemia.
75. Hypermagnesemia.
76. A client with a chronic mental illness who does not always take her medications is separated
    from her husband and receives public assistance funds. She lives with her mother and older sister and
    manages her own medication. The client’s mother is in poor health and also receives public assistance benefits. The client’s sister works outside the home, and the client’s father is dead. Which of the following issues should the nurse need to address first?
77. Family.
78. Marital.
79. Financial.
80. Medication.
81. A client is receiving total parenteral nutrition (TPN). The nurse notices that the bag of TPN
    solution has been infusing for 24 hours but has 300 mL of solution left. The nurse should:
82. Continue the infusion until the remaining 300 mL is infused.
83. Change the filter on the tubing and continue with the infusion.
84. Notify the physician and obtain prescriptions to alter the flow rate of the solution.
85. Discontinue the current solution, change the tubing, and hang a new bag of TPN solution.

Answer 13

61. 2. The priority for ongoing care for this child is to prevent injury while maintaining normal growth and interests. As with all chronic illnesses, there is a potential for self-esteem problems, but no data are presented to support this as a priority for care planning. The parents should have a good under- standing of the disease process and realize the importance of obtaining regular health care for their child. The client may have episodes of acute pain, for the child who has bleeding into a joint, but
       this is a transient situation.
       CN: Reduction of risk potential; CL: Synthesize
62. 3. A 3-year-old child responds best to distraction during a procedure because of the typical level of cognitive development of a 3-year-old and the fear of painful events. Preparation for the procedure should be done immediately beforehand, so that the child will not become too frightened. Am3-year-old is not concerned about the why of the procedure but about whether the procedure will hurt. This child is too young for verbal explanations alone because of the limited verbal abilities at this age and the fear of a painful event.
       CN: Health promotion and maintenance; CL: Synthesize
63. 3. Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor. Hyperkalemia can be a side effect of ACE inhibitors. Because of this side effect, ACE inhibitors should not be administered with potassium-sparing diuretics.
       CN: Pharmacological and parenteral therapies; CL: Analyze
64. 4. Medication noncompliance is a primary cause of exacerbation in chronic mental illnesses. Of the issues listed, medications should be addressed first. Other issues, such as family, marriage, and finances, can be addressed as client stabilization is maintained.
       CN: Psychosocial adaptation; CL: Synthesize
65. 4. IV fluids should not be infused for longer than 24 hours because of the risk of bacterial growth in the solution. The appropriate action for the nurse to take is to discontinue the current TPN solution, change the tubing, and hang a new bag of solution. Changing the filter does not decrease the risk of
       contamination. Notifying the physician for a change in flow rate is not an acceptable solution.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 14

66. A client with a history of cardiac problems is having severe chest pain. What should be nurse’s first response?
67. Notify the physician.
68. Administer an analgesic to control the pain.
69. Assess the client’s pain.
70. Start oxygen at 2 L/min via nasal cannula.
71. Which of the following characteristics should the nurse include in the teaching plan for a multiparous client after giving birth to a neonate diagnosed with trisomy 13?
72. Webbed neck.
73. Small testes.
74. Congenital heart defects.
75. Polydactyly.
76. A client is being treated for acute low back pain. The nurse should report which of these clinical manifestations to the physician immediately?
77. Diffuse, aching sensation in the L4 to L5 area.
78. New onset of footdrop.
79. Pain in the lower back when the leg is lifted.
80. Pain in the lower back that radiates to the hip.
81. A client with type 1 diabetes mellitus asks the nurse about taking ginseng at home. The nurse
    should tell the client:
82. “No, there are no therapeutic benefits of ginseng.”
83. “Taking ginseng will increase the risk of hypoglycemia.”3. “You can take the ginseng to help improve your memory.”
84. “You can take ginseng if you take it with a carbohydrate.”
85. The nurse teaches the client with cirrhosis that the expected outcome of taking lactulose is:
86. One regular bowel movement a day.
87. Two to three soft stools per day.
88. Four to five loose stools per day.
89. Five to six loose stools per day.

Answer 14

66. 3. The nurse’s first response is to further assess the client’s pain. After a thorough assessment, additional appropriate actions may be to notify the physician, administer an analgesic, and administer oxygen.
       CN: Basic care and comfort; CL: Synthesize
67. 4. Trisomy 13 (Patau’s syndrome) is an autosomal disorder. Characteristics include cleft lip and palate, polydactyly, malformed ears, and mental retardation. These neonates typically die during infancy. A webbed neck is associated with Turner’s syndrome (45 total chromosomes). Small testes and absence of sperm are associated with Klinefelter’s syndrome (47 chromosomes). Congenital heart defects are associated with trisomy 21 (Down syndrome) and trisomy 18 (Edwards’ syndrome).
       CN: Physiological adaptation; CL: Synthesize
68. 2. Neurologic symptoms, such as footdrop, or bowel or bladder changes, should be reported
       to the physician immediately. When musculoskeletal strain causes back pain, these symptoms may
       take 4 to 6 weeks to resolve. As an accompanying symptom of acute low back pain, the client may
       have a diffuse, aching sensation in the L4 to L5 area, pain in the lower back when the leg is lifted, or pain that radiates to the hip.
       CN: Reduction of risk potential; CL: Analyze
69. 2. Taking ginseng when on insulin is not encouraged because ginseng increases the risk of hypoglycemia. Ginseng can be therapeutic in certain situations but is potentially harmful for clients taking insulin. Taking ginseng with a carbohydrate will not offset the effect of the ginseng.
       CN: Pharmacological and parenteral therapies; CL: Synthesize
70. 2. The expected effect of lactulose is for the client to have two to three soft stools a day to
       help reduce the pH and serum ammonia levels, which will prevent hepatic encephalopathy.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 15

71. The nurse is evaluating the laboratory results of a client who was recently admitted to the
    hospital. Which one of the following results indicates the presence of inflammation?
72. Decreased sedimentation rate.
73. Thrombocytopenia.
74. Leukocytosis.
75. Erythrocytosis.
76. The nurse is assessing a teenage girl (see figure). The nurse should describe the girl shown in
    the figure as having:
77. Normal posture.
78. Kyphosis.
79. Scoliosis.
80. Lordosis.
81. A client reports having pain in the casted left arm that is unrelieved by pain medication. The
    nurse assesses the arm and notes that the fingers are swollen and difficult to separate. Which action is
    most appropriate for the nurse to take at this time?
82. Administer morphine 2 mg intravenously.2. Apply an ice bag to the fingers to relieve pain.
83. Elevate the arm on two pillows and reassess in 30 minutes.
84. Call the physician to report swelling and pain.
85. A primiparous client develops uterine atony and postpartum hemorrhage 1 hour after a
    vaginal birth. The physician has prescribed IM prostaglandin-F 2a . After administration of the
    medication, the nurse should observe the client for which of the following?
86. Tachycardia.
87. Hypotension.
88. Constipation.
89. Abdominal distention.
90. While caring for a mother and her 1-day-old neonate born vaginally at 30 weeks’ gestation,
    the nurse explains about the neonate’s need for gavage feeding at this time instead of the mother’s plan
    for bottle feeding. Which of the following should the nurse include as the rationale for this feeding
    plan?
91. The neonate has difficulty coordinating sucking, swallowing, and breathing.
92. A high-calorie formula, presently needed at this time, is more easily delivered via gavage.
93. Gavage feedings can minimize the neonate’s increased risk of developing hypoglycemia.
94. This type of feeding, easily given in the isolette, decreases the neonate’s risk of cold stress.

Answer 15

71. 3. Leukocytosis, an increased white blood cell count, indicates the presence of inflammation,
       infection, or a leukemia process. In inflammation and infection, the client’s sedimentation rate is
       increased. Thrombocytopenia, a platelet deficiency, occurs in the client with leukemia, immuno- compromised client, client with aplastic anemia, or client with other conditions. Erythrocytosis, an elevation of the red blood cell count, occurs in polycythemia vera.
       CN: Physiological adaptation; CL: Analyze
72. 4. This girl has an exaggeration of the lumbar spine, swayback, or lordosis. Kyphosis is an increased convexity or roundness of the curve of the thoracic spine. Scoliosis is a lateral curvature of the spine.
       CN: Health promotion and maintenance; CL: Analyze
73. 4. The most appropriate action is to report the swelling, loss of mobility, and unrelieved pain to the physician. These symptoms are indicators of neurovascular impairment. Administering opioids
       will not eliminate the cause of the problem, which is unrelieved pressure on nerves and blood supply.
       If prompt action (cutting the cast) is not taken to relieve the pressure, permanent muscular and
       neurologic injury may result. Applying the ice bag would have been appropriate earlier to decrease or prevent swelling, but applying it at this time could actually lead to further decreased circulation. The arm should be elevated, but the nurse cannot wait 30 minutes to reassess the client without risking permanent damage.
       CN: Reduction of risk potential; CL: Synthesize
74. 1. Prostaglandin F 2a promotes uterine con- tractions, thereby minimizing uterine atony and subsequent hemorrhage. Possible side effects include nausea, tachycardia, hypertension, and diarrhea. Abdominal distention is not associated with the use of prostaglandin F 2a .
       CN: Pharmacological and parenteral therapies; CL: Analyze
75. 1. Before 32 weeks’ gestation, most neonates have difficulty coordinating sucking and swallowing reflexes along with breathing. Increased respiratory distress may occur with bottle feeding. Bottle feedings can be given after the neonate shows sucking and swallowing behaviors. High-calorie formulas can be given by bottle or by gavage feeding. Although frequent feedingprevents hypoglycemia, the feeding does not have to be given via a gavage tube. Although these neonates can be stressed by cold, they can be kept warm with blankets while being bottle-fed or fed while in the warm isolette environment.
       CN: Health promotion and maintenance; CL: Apply

Question 16

76. The nurse is teaching a client with rheumatoid arthritis about how to manage the fatigue
    associated with this disease. Which statement indicates the client understands how to manage the
    fatigue?
77. “I sleep for 8 to 10 hours every night so that I’ll have the energy to care for my children during
    the day.”
78. “I schedule afternoon rest periods for myself in addition to sleeping 10 hours every night.”
79. “I spend one weekend day a week resting in bed while my husband cares for the children.”
80. “I get up early in the morning and get all my household chores completed before my children
    wake up.”
81. The nurse is caring for a child with hemophilia who is actively bleeding from the leg. The nurse should apply:
82. Direct pressure, checking every few minutes to see if the bleeding has stopped.
83. Ice to the injured leg area several times a day.
84. Direct pressure to the injured area continuously for 10 minutes.
85. Ice bag with elevation of the leg twice a day.
86. Which of the following is least likely a danger associated with pancytopenia?
87. Anemia.
88. Bleeding.
89. Infection.
90. Hypothyroidism.
91. A client suspected of being a victim of abuse returns to the emergency department and, sobbing, tells the nurse, “I guess you really know that my husband beats me and that’s why I have bruises all over my body. I don’t know what to do. I’m afraid he’ll kill me one of these times.” Which of the following responses best demonstrates that the nurse recognizes the client’s needs at this time?
92. “The fear that your husband will kill you is unfounded.”
93. “We can begin by discussing various options open to you.”
94. “You can legally leave your husband because he has no right to hurt you.”
95. “We can begin by listing ways to avoid making your husband angry with you.”

80. A client has just returned from surgery for a gastrectomy. The nurse should position the client
in which position?
1. Prone.
2. Supine.
3. Low Fowler's.
4. Right or left Sims'.

Answer 16

76. 2. Regularly scheduled rest periods during the day along with 8 to 10 hours of sleep at night helps relieve the fatigue, pain, and stiffness associated with rheumatoid arthritis. Even with mild rheumatoid arthritis, the client may find it difficult to perform activities of daily living without some rest periods. Spending 1 day a week in bed to relieve fatigue does not adequately manage the disease. The client must recognize the need for rest before feeling exhausted because overexertion can cause exacerbations. In addition, prolonged periods of inactivity can increase joint stiffness and pain.
       Getting up early to do household chores before the children are awake does not allow for adequate
       rest.
       CN: Basic care and comfort; CL: Evaluate
77. 3. For the child with hemophilia who is actively bleeding, the nurse should apply direct pressure to the injured area for 10 minutes continuously along with elevating the leg. The continuous application of direct pressure aids in stopping the bleeding. Elevating the leg reduces blood flow to the area, thereby minimizing the extent of blood loss. Although ice will cause local vasoconstriction and slow the bleeding, applying continuous direct pressure is essential.
       CN: Physiological adaptation; CL: Synthesize
78. 4. Hypothyroidism is not associated with pancy- topenia. Various anemias are associated with pancy- topenia owing to the reduction in all cellular ele- ments of the blood. Bleeding and clotting diffi- culties can be associated with pancytopenia. Infection is a common danger associated with
       pancytopenia.
       CN: Physiological adaptation; CL: Analyze
79. 2. The client’s return to the emergency depart- ment and her statement about not knowing what
       to do about being abused by her husband indicate that the client is asking for help. The nurse’s best course of action is to explain the various options available to her. This helps the client make decisions based on appropriate knowledge. Research reveals that women are more likely to be killed by partners than by strangers. Although the client can legally leave her husband, this answer provides the client with no safety options. Listing ways to avoid making the husband angry ignores the dynamics of abuse and blames the victim.
       CN: Psychosocial adaptation; CL: Synthesize
80. 3. The nurse places a postoperative client who has had abdominal surgery in low Fowler’s
       position. This position relaxes abdominal muscles and promotes maximum respiratory and cardio- vascular function.
       CN: Reduction of risk potential; CL: Synthesize

Question 17

81. A child with heart disease starts on oral digoxin (Lanoxin). When preparing to administer the medication, which of the following should the nurse do first?
82. Check the last serum electrolyte results for the child.
83. Verify the dosage with a licensed practical nurse who is working that day.
84. Ask the mother if she is willing to administer the medication.
85. Teach the mother how to measure the child’s heart rate.
86. The nurse is caring for a client who has deep partial-thickness and full-thickness burns. During the emergent (resuscitative) phase of burn management, the nurse should assess the client for a fluid shift from the:
87. Intracellular to extracellular compartment.
88. Extracellular to intravascular compartment.
89. Interstitial to the intracellular compartment.
90. Intravascular to the interstitial compartment.
91. The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period of burn management. Which of the following indicates that adequate fluid replacement has been achieved in the client?
92. An increase in body weight.
93. Fluid intake less than urinary output.
94. Urine output greater than 35 mL/h.
95. Blood pressure of 90/60 mm Hg.
96. A client who comes to the emergency department with multiple bruises on her face and arms, a black eye, and a broken nose says that these injuries occurred when she fell down the stairs. The nurse suspects that the client may have been physically assaulted. Which of the following should the nurse do next?
97. Ask the client specifically about the possibility of physical abuse.
98. Tell the client that it is difficult to believe that such injuries resulted from a fall.
99. Ask the client what she did to make someone beat her so badly.
100. Discuss with the client what she can do to de-escalate the situation next time.
101. What is the primary goal for the care of a client who is in shock?
102. Achieve adequate tissue perfusion.
103. Preserve renal function.
104. Prevent hypostatic pneumonia.4. Maintain adequate vascular tone.

Answer 17

81. 1. It is most important to know the child’s serum potassium level when administering digoxin.
       Digoxin increases contractility of the heart and increases renal perfusion, resulting in a diuretic effect with increased loss of potassium and sodium. Hypokalemia increases the risk of digoxin toxicity.
       Verifying the dosage is specified by facility policy and varies among facilities. Although the child may take the medication better from the mother than from the nurse, asking the mother to give the medication is not necessary. In addition, this would be done after the nurse has checked the electro lyte levels. Teaching the parent how to measure the child’s heart rate can be done at any time, not necessarily when preparing to give digoxin.
       CN: Pharmacological and parenteral therapies; CL: Synthesize
82. 4. During the emergent phase of burn manage- ment, there is a massive shift of fluid from the blood vessels (intravascular compartment) into the tissues (interstitial compartment). The result of [this shift is hypovolemic shock and edema formation. The fluid shift, which occurs between the intravascular and interstitial extracellular compartments, is caused by increased capillary permeability that allows water, sodium, and protein to shift to the tissues. As the emergent period ends and capillary permeability returns to normal, the fluid in the interstitial compart- ment will return to the intravascular compartment.
       CN: Physiological adaptation; CL: Analyze
83. 3. A urine output of 30 to 50 mL/h indicates adequate fluid replacement in the client with burns. An increase in body weight may indicate fluid reten- tion. A urine output greater than fluid intake does not represent a fluid balance. Depending on the client, blood pressure of 90/60 mm Hg could indicate the presence of a hypovolemic state; by itself, it does not indicate adequate fluid replacement.
       CN: Physiological adaptation; CL: Evaluate
84. 1. Many clients who experience abuse are hesitant to talk about it and need help to do so. The nurse should ask the client directly about abuse when it is suspected, using a sensitive, empathetic,
       and compassionate approach. In this way, the client can feel comfortable revealing information about
       the abuse. Telling the client that it’s difficult to believe her injuries resulted from a fall is not helpful
       because it is blameful and puts the client on the defensive. Asking the client what she did to make someone hit her or discussing what she can do the next time blames and alienates the client.
       CN: Psychosocial adaptation; CL: Synthesize
85. 1. A primary outcome for the care of the client in shock is to achieve adequate tissue perfusion, thus avoiding multiple organ dysfunction. The lungs are susceptible to injury, especially acute respiratory distress syndrome. vasoconstriction occurs as a compensatory mechanism until the client enters the irreversible stage of shock.
       CN: Reduction of risk potential; CL: Evaluate

Question 18

86. The parent of a young child diagnosed with low-dose lead exposure asks about long-term effects. Which of the following should the nurse mention as possible long-term effects to this mother? Select all that apply.
87. Seizures.
88. Depression.
89. Hyperactivity.
90. Aggression.
91. Impulsiveness.
92. Which of the following is appropriate to include in an incident report?
93. An interpretation of the likely cause of the incident.
94. What the nurse saw and did.
95. The client’s statement about the incident that occurred.
96. The extenuating circumstances involved in the situation.
97. To reduce urethral irritation, where should the nurse tape the female client’s Foley catheter?
98. Inner thigh.
99. Groin area.
100. Lower abdomen.
101. Lower thigh.
102. The nurse is reconciling the medications with a client who is being discharged. Which of the
     following indicates there is a “discrepancy”?
103. There is agreement between the client’s home medication list and current medication prescriptions.
104. There is justification for a difference in the medication prescriptions.
105. There is lack of congruence between a client’s home medication list and current medication prescriptions.
106. Sample medications have been included in the medication list.
107. The physician has determined that a primigravid client in active labor requires a cesarean
     birth because of cephalopelvic disproportion. After the birth of a healthy neonate, the nurse should
     assess the neonate for which of the following first?
108. Nasopharyngeal secretions.
109. High-pitched cry.
110. Skull fracture.
111. Decreased muscle tone

Answer 18

86. 3, 4, 5. The neurologic system can be affected and cause long-term consequences in a young
    child exposed to lead. Common behavioral effects include hyperactivity, impulsivity, and aggression.
    Seizures may occur in a child with high-dose lead exposure. Depression is not usually associated
    with lead exposure.
    CN: Physiological adaptation; CL: Apply
87. 2. The incident report includes only what the nurse saw and did—the objective data. The
       nurse does not try to interpret the likely cause of the incident, include statements from the client about the incident, or comment on extenuating circumstances.
       CN: Management of care; CL: Apply
88. 1. To reduce urethral irritation and allow drainage, the nurse should tape the Foley catheter toa female client’s inner thigh. Taping the catheter also prevents excessive traction against the bladder neck. Taping the catheter to the groin or lower abdomen would not allow for proper drainage and would cause urethral discomfort. Taping the catheter to the lower thigh would pull on the catheter and cause urethral irritation.
       CN: Reduction of risk potential; CL: Apply
89. 3. The medications prescribed for, administered to, or dispensed to the client while under the
       care of a health care organization are compared to those on the list, and any discrepancies (eg,
       omissions, duplications, potential interactions) are resolved. A complete list of the client’s
       medications is communicated to the next provider of service when a client is referred or transferred
       to another setting, service, practitioner, or level of care within or outside the organization. The complete, accurate list of medications is also provided to the client on discharge from the
       organization. The next provider of service checks the Medication Reconciliation List again to make sure it is accurate and in concert with any new medications to be prescribed.
       CN: Safety and infection control; CL: Analyze
90. 1. A neonate born by cesarean section has not had the benefit of the chest-squeezing action of a vaginal birth, which helps remove some of the nasopharyngeal secretions. The nurse should place the neonate under the radiant warmer and suction the mouth and nares with a bulb syringe to remove
       nasopharyngeal secretions. A high-pitched cry is associated with neurologic involvement or neonatal
       drug withdrawal and is unrelated to cesarean birth. Skull fractures may occur with difficult vaginal births and are not typically seen with cesarean births. Decreased muscle tone is associated with
       oversedation, neurologic impairment, or use of general anesthesia.

Question 19

91. A parent of a toddler brings the child to the emergency room because the child has accidentally been scalded by hot water spilling from the stove. In order to differentiate the burn from potential abuse, the nurse should assess the child:
92. On the back of the body.
93. On the front of the body.
94. For a circular or glove pattern.
95. On the buttocks.
96. A 17-year-old client visits the clinic at 36 weeks’ gestation. The client’s blood pressure is130/90 mm Hg. On previous visits, her blood pressure ranged from 100 to 110 mm Hg systolic and 70 to 80 mm Hg diastolic. Further assessment reveals slight edema of her hands and 1+ proteinuria. The nurse anticipates that the physician will most likely prescribe which of the following?
97. IV magnesium sulfate.
98. Labetalol.
99. Bed rest with bathroom privileges.
100. Hourly blood pressure checks.
101. The nurse observes that an area in the mouth of a child with leukemia is bleeding. Which of the following items should the nurse use to promote homeostasis over the lesion?
102. Karaya gum.
103. A cotton ball imbedded with petroleum jelly.
104. A nonsticking gauze sponge.
105. A dry tea bag.
106. Which of the following is appropriate for the nurse to include in a plan for the prevention of pressure ulcers?
107. Daily skin cleaning with soap and hot water.
108. Gentle massage of bony prominences every shift.
109. Encouraging the client to sit up as much as possible.
110. Systematic skin assessment at least once per shift.
111. A client at 36 weeks’ gestation tells the nurse, “I’ve been having a lot of backaches lately.” After giving instructions about how to decrease the backaches, the nurse determines that the client
     needs further instruction when she says which of the following?
112. “I should walk with my pelvis tilted backward.”
113. “I may need to put a board under my mattress.”
114. “I should squat and not bend to pick up objects.”
115. “I should wear flat or low-heeled shoes.”

Answer 19

91. 2. Accidental scaldings are usually splash-related and occur on the front of the body. Any burns on the back of the body or in a well-defined circular or glove pattern may indicate physical abuse. Immersion burns on the buttocks are also suspicious injuries.
       CN: Health promotion and maintenance; CL: Analyze
92. 3. A client exhibiting mild preeclampsia is initially treated with activity restriction. Bed rest, or lying on the left side, decreases pressure on the vena cava and improves circulatory blood flow. Restriction of visitors and a quiet environment are also necessary. IV magnesium sulfate, a central
       nervous system depressant, is usually prescribed for the client with severe pre-eclampsia. Labetalol is
       used for the client with severe preeclampsia. Frequent monitoring of the client’s blood pressure is important. However, hourly blood pressure checks are more routinely prescribed for the client with severe preeclampsia. Additionally, the client needs to rest, and checking her blood pressure hourly
       could interfere with her ability to rest.
       CN: Reduction of risk potential; CL: Synthesize
93. 4. A dry tea bag placed on the bleeding area can be effective to control bleeding from lesions on the oral mucosa. The tannic acid in the tea apparently helps control bleeding.
       CN: Reduction of risk potential; CL: Synthesize
94. 4. The best treatment for a pressure ulcer is prevention. If a client has been determined to be
       at risk for developing a pressure ulcer, a systematic skin assessment should be conducted at least
       once per shift. Other preventive measures include daily gentle cleaning of the skin and avoiding harshsoaps and hot water, which are damaging to the skin. Massage of bony prominences is not done
       because it can increase damage to the underlying tissue. The client should be encouraged to change position at least every 2 hours to avoid pressure on any one area for a prolonged period.
       CN: Reduction of risk potential; CL: Synthesize
95. 1. The client needs further instructions when she says, “I should walk with my pelvis tilted
       backward.” Walking in this position puts greater strain on the back. The client should walk with her pelvis tilted forward. Pelvic tilt exercises can also help the client with backaches. Putting a board under the mattress makes the mattress firmer and provides more support. Squatting and not bending to
       pick up objects helps decrease back strain. Squatting involves the use of the large thigh muscles rather than those of the back. Flat or low-heeled shoes provide better balance and greater support and
       can help decrease backaches.
       CN: Reduction of risk potential; CL: Evaluate

Question 20

96. Which of the following is an initial clinical manifestation of gonorrhea in men?
97. Impotence.
98. Scrotal pain.
99. Penile lesion.
100. Urethral discharge.
101. A client’s blood pressure is elevated at 160/90 mm Hg. The physician prescribed “clonidine (Catapres) 1 mg by mouth now.” The nurse sent the prescription to pharmacy at 7:10 AM , but the medication still has not arrived at 8:00 AM . The nurse should do all except which of the following?
102. Check all appropriate places on the unit to which the drug could have been delivered.
103. Check the client’s blood pressure.
104. Call the pharmacy.
105. Go to the pharmacy to obtain the drug.
106. The client with major depression states, “I’m too tired to get out of bed to go to group therapy. I just want to rest.” The nurse should tell the client:
107. “Perhaps you’ll feel better later on.”
108. “I’ll let you rest for as long as you need.”
109. “Attending group therapy is an important part of your treatment plan.”
110. “You’ve been in bed long enough and need to get up.”
111. After teaching the mother of a 7-month-old diagnosed with bronchiolitis, the nurse determines that the teaching has been effective when the mother states which of the following as a sign to report immediately?
112. Seven wet diapers a day.
113. Temperature of 100°F (37.8°C) for 2 days.
114. Clear nasal discharge for longer than 2 days.
115. Longer periods of sleep than usual.
116. Which of the following clients would benefit from the application of warm moist heat?
117. A client with appendicitis.
118. A client with a recently sprained joint.
119. A client with a suspected malignancy.
120. A client with low back pain.

Answer 20

96. 4. Urethritis is usually the initial clinical manifestation of gonorrhea in men. The symptoms include a profuse, purulent discharge and dysuria. Complications are uncommon, but they include prostatitis and sterility. Impotence, scrotal pain, and penile lesions are not associated with gonorrhea.
       CN: Safety and infection control; CL: Analyze
97. 4. Although the nurse needs to obtain and administer the medication as soon as possible, it is
       inappropriate for the nurse to go to the pharmacy and request the drug without first calling the pharmacy and checking to see whether the medication was delivered. The drug may have been
       delivered to several appropriate spots on the unit, such as the client’s drug bin, the transport system, or the delivery box. The nurse should assess the client’s blood pressure to determine the immediacy of the condition for which the medication was prescribed.
       CN: Safety and infection control; CL: Synthesize
98. 3. The client with major depression suffers from lack of energy and withdrawal. The nurse
       should emphasize the importance of group involvement for the client to gain support from others and to see that others have similar problems and concerns. Attendance at group sessions and activities
       decreases social isolation and destructive rumination. The other statements are not therapeutic and
       interfere with increasing the client’s involvement with others.
       CN: Psychosocial adaptation; CL: Synthesize
99. 4. An infant’s sleeping longer than usual can indicate that the child is expending too much
       energy to breathe and is tiring, suggesting that the child’s condition is getting worse. This should be reported to the physician. Fewer than seven wet diapers a day indicates that the child is not drinking enough. A temperature of 100°F (37.8°C) for longer than 2 days should be reported. Clear nasal drainage is normal. However, yellow nasal drainage lasting longer than 24 hours should be reported.
       CN: Reduction of risk potential; CL: Evaluate
100. 4. Direct application of warm moist heat would benefit a client with low back pain because
        the heat relaxes muscle spasms. Heat should not be applied to a client who has appendicitis because
        it can lead to rupture of the appendix and peritonitis. Ice is applied to recently sprained joints to help
        decrease edema. Applying heat to the area of a suspected malignancy can increase blood flow to the
        tumor and promote nourishment of the cancer cells.
        CN: Basic care and comfort; CL: Analyze

Question 21

101. A client is newly diagnosed with pernicious anemia. The nurse empha-sizes to the client the need to increase vitamin B 12 intake by:
102. Increasing dietary intake of vitamin B 12 .
103. Taking an oral vitamin B 12 replacement.
104. Taking vitamin B 12 injections or nasal spray replacement.
105. Chelation therapy.
106. The nurse is caring for a client with an acute exacerbation of Crohn’s disease. The nurse has received a prescription to add 20 mEq of potassium chloride to a 1,000-mL bottle of IV fluid. The nurse has a 30-mL, multiple-dose vial of potassium chloride. The label reads 2 mEq/mL. How many milliliters should the nurse add to the IV fluid?
     _______________ mL.
107. A client with major depression and suicidal ideation is suddenly calmer and more energetic. Which of the following conclusions should the nurse reach?
108. The client is improving.
109. The client’s medication dosage is too high.
110. The client is overstimulated.
111. The client is suicidal.
112. A multigravid client at 38 weeks’ gestation is scheduled to undergo a contraction stress test. Which of the following should the nurse include in the explanation as the purpose of this test?
113. Evaluation of fetal lung maturity.
114. Determination of the fetal biophysical profile.
115. Assessment of fetal ability to tolerate labor.
116. Determination of fetal response during move-ments.

105. The nurse is caring for a client who has been diagnosed with atypical pneumonia. The nurse
should assess this client carefully for:
1. High fever.
2. Tachypnea.
3. Dry cough.
4. Severe chills.

Answer 21

101. 3. The client with pernicious anemia will require lifelong supplementation of vitamin B 12 ,
        available through injection or nasal spray administration. It must be given in these forms to ensure absorption. Oral vitamin B 12 would not be absorbed because the client lacks the intrinsic factor in the
        stomach necessary for absorption. Chelation therapy is used to extract metals at toxic levels such as
        in lead poisoning.
        CN: Pharmacological and parenteral therapies; CL: Apply
102. 10 mL. To administer 20 mEq of potassium chloride, the nurse needs to administer 10 mL. The following formula is used to calculate the correct dosage:
     CN: Pharmacological and parenteral therapies; CL: Apply
103. 4. When a client with major depression and suicidal ideation displays a sudden elevation in mood, seems calmer, has more energy, and is more peaceful, the nurse should judge these behaviors as an indication that a suicide attempt is imminent. These symptoms may indicate relief from
        ambivalent thoughts about suicide and that the client has an immediate plan for killing himself.
        CN: Psychosocial adaptation; CL: Analyze
104. 3. The purpose of a contraction stress test is to determine fetal response during labor. If late decelerations are noted with the contractions, the test is considered positive or abnormal. Fetal lung
        maturity is evaluated through amniocentesis to obtain the lecithin-sphingomyelin ratio. The nonstress test is part of the biophysical profile. Determining fetal response during movements is evaluated as part of the nonstress test.
        CN: Reduction of risk potential; CL: Apply
105. 3. Atypical pneumonia is characterized by a gradual onset of symptoms, such as dry cough, headache, sore throat, fatigue, nausea, and vomiting. Typical pneumonia is characterized by
        tachypnea, fever, chills, and productive cough with purulent sputum.
        CN: Physiological adaptation; CL: Analyze

Question 22

106. The nurse is teaching a client with emphysema how to do pursed-lip breathing. What is the
     expected outcome of using pursed-lip breathing?
107. Increased oxygenation.
108. Prolonged exhalation.
109. Absence of respiratory infection.
110. Relief from shortness of breath.
111. The advantage of using automated medication dispensing equipment includes which of the following?
112. It facilitates the change-of-shift count of narcotics.
113. It keeps a record of narcotic usage.
114. It allows nurses unmonitored access to narcotics.
115. It cancels the charges for narcotics.
116. Immediately following an automobile accident, a 21-year-old client has severe pain in the right chest from hitting the steering wheel and a compound fracture of the right tibia and fibula and
     multiple lacerations and contusions. The priority for care is to first:
117. Reduce the client’s anxiety.
118. Maintain adequate oxygenation.
119. Decrease chest pain.
120. Maintain adequate circulating volume.
121. While assessing a primiparous client 8 hours after childbirth, the nurse inspects the episiotomy site, finding it edematous and slightly reddened. Which of the following interpretations by the nurse is most appropriate?
122. The client needs application of an ice pack.
123. The episiotomy site is infected.
124. A hematoma will likely develop.
125. The client has had a repair of a vaginal laceration.

110. When administering an IM injection, the nurse should use the Z-track technique when the
medication:
1. Takes a long time to absorb.
2. Takes effect very quickly.
3. Is irritating to tissues.
4. Is viscous in consistency.

Answer 22

106. 2. The primary reason for instructing the client with emphysema about how to pursed-lip
        breathe is to prolong exhalation. Prolonging exhalation helps to prevent bronchiolar collapse and the
        trapping of air. It does not directly prevent respiratory infection. Because pursed-lip breathing affects
        the expiratory phase of the respiratory cycle, it does not affect oxygenation. It may decrease shortness
        of breath, but this is not the primary reason for the technique.
        CN: Reduction of risk potential; CL: Apply
107. 2. The primary purpose of the automated dispensing machine for nurses is to keep an up-to-date record of the narcotic usage and count. The automated dispensing machine has eliminated the need for change-of-shift counts for narcotics. It does not include unmonitored access by nurses to narcotics, which would not be considered an advantage. The pharmacy has direct information about
        the narcotics being used on the client at what intervals and by whom, and it automatically records the charges of narcotics used. Not recording the charges would not be an advantage.
        CN: Management of care; CL: Apply
108. 2. Blunt chesttrauma can lead to respiratory failure. Maintenance of adequate oxygenation isthe priority for the client. Decreasing the client’s anxiety is related to maintaining effective
        respirations and oxygenation. Although pain is distressing to the client and can increase anxiety and decrease respiratory effectiveness, pain control is secondary to maintaining oxygenation, as is
        maintaining adequate circulatory volume.
        CN: Physiological adaptation; CL: Synthesize
109. 1. An episiotomy that is edematous and slightly reddened 8 hours after childbirth is normal.
        Therefore, the nurse should offer the client an ice pack to provide some relief from the perineal pain for the first 24 hours. An infection is present if greenish, purulent drainage is observed from the site. The edema and discoloration of the episiotomy at this time after childbirth are normal and do not
        indicate that a hematoma is likely to develop. A laceration when repaired should appear intact with
        edges well-approximated, clean, and dry.
        CN: Health promotion and maintenance; CL: Analyze
110. 3. The Z-track technique is used with medications that are irritating to tissues. It allows the medication to be trapped in the muscle and prevents it from leaking back through the tissues.
        CN: Basic care and comfort; CL: Apply

Question 23

111. A client with an Axis I diagnosis of bipolar disorder, mania, is mono- polizing the use of the
     telephone by making several calls each day, interfering with the ability of other clients to use the
     telephone. The nurse should:
112. Instruct the other clients to be patient.
113. Limit the amount of calls the client can make each day.
114. Remind the client that others need to use the telephone.
115. Take away the client’s telephone privileges.
116. When preparing a 20-month-old with a foreign body in the nasal passage for removal of theforeign body by the health care provider, the nurse should use which of the following methods of restraint?
117. Jacket restraint.
118. Elbow restraint.
119. Use of father to hold.
120. Papoose board.
121. The nurse auscultates the lungs of a client who has been diagnosed with lung cancer and notes wheezing over one lung. The nurse should assess the client further for:
122. The presence of exudate in the airways.
123. The client’s history of smoking.
124. An indication of pleural effusion.
125. Obstruction of the airway by a tumor.

114. The nurse is teaching a client who is taking insulin about the signs of diabetic ketoacidosis,
which include:
1. Kussmaul's respirations.
2. Excessive hunger.
3. Dry, flaky skin.
4. High blood pressure.

115. A nurse receives a lithium level report of 1.0 mEq/L (1.0 mmol/L) for a client who has been
     taking lithium for 2 months. The nurse should interpret this level to indicate which of the following?
116. An error in reporting.
117. Too low to be thera- peutic.
118. Too high, indicating toxicity.
119. Within the therapeutic range.

Answer 23

111. 2. The nurse should limit the amount of telephone calls the client can make. Setting limits for a client with bipolar disorder, mania, helps to control the hyperactive client who has excessive goal-directed activity, especially when it interferes with the rights of other clients. Instructing the other clients to be patient is neither fair to them nor helpful to the hyperactive client in managing behavior.
        Reminding the client that others need to use the telephone will probably be futile because the client with mania is experiencing cognitive impairment and needs to be active. Taking away the client’s telephone privileges is not the best action because the client has a right to use the telephone. The
        nurse is responsible for helping the client manage behavior by setting constructive limits.
        CN: Psychosocial adaptation; CL: Synthesize
112. 4. Because a toddler is strong and moves frequently, the child needs to be restrained during the removal procedure by a total body restraint. To protect the child, the papoose board is best because the arms, legs, chest, and head can be fully restrained. A jacket restraint would immobilize only the child’s upper body. Elbow restraints would immobilize only the child’s arms. The father
        should be available to provide comfort before and after the procedure but not to hold the child down during the procedure.
        CN: Safety and infection control; CL: Synthesize
113. 4. Wheezing over one lung in the presence of lung cancer is most likely caused by obstruction of the airway by a tumor. Exudate would be more likely to cause crackles. The client’s history of smoking would not cause unilateral wheezing. Pleural effusion would produce diminished
        or absent breath sounds.
        CN: Physiological adaptation; CL: Apply
114. 1. The client with diabetic ketoacidosis exhibits Kussmaul’s respiration, as well as flushed skin, dry mouth, urinary frequency, hyperglycemia, and ketonuria. Excessive hunger and high blood
        pressure are not associated with diabetic ketoacidosis.
        CN: Reduction of risk potential; CL: Apply
115. 4. For the client who has been receiving lithium therapy for the past 2 months, a maintenance
        serum lithium level of 0.6 to 1.2 mEq/L (0.6 to 1.2 mmol/L) is considered therapeutic. A lithium level greater than 1.2 mEq/L (1.2 mmol/L) suggests toxicity.
        CN: Pharmacological and parenteral therapies; CL: Analyze

Question 24

116. A 16-year-old at 10 weeks’ gestation has been diagnosed with mild iron deficiency anemia. The client tells the nurse that she doesn’t like to eat much meat. Which of the following foods should
     the nurse suggest to provide the client with the greatest amount of iron in her diet?
117. 1 cup of lentils.
     2.1 cup of sunflower seeds.
118. 11⁄2 oz (50 mg) of hard cheese.
119. 2 poached eggs.
120. A client has been receiving radiation therapy for 3 weeks to treat cancer and has fatigue. Which of the following should be considered while the nurse plans interventions to help the client cope with the fatigue?
121. Fatigue is a temporary problem that requires no active intervention.
122. The cause of the fatigue should be determined.
123. Fatigue indicates that the client’s cancer is not under control.
124. A balance of activity and rest will help manage the fatigue.
125. When educating unlicensed assistants about how to prevent the development of pressure
     ulcers, the nurse should emphasize that most tissue injuries related to shearing can be prevented by
     implementing which of the following activities?
126. Close adherence to a turning schedule.
127. Keeping the skin clean and dry.
128. Proper positioning and moving of the client.
129. Use of skin lubricants.
130. When using crutches, the nurse should instruct the client to bear weight primarily on the:
131. Axillae.
132. Elbows.
133. Upper arms.
134. Hands.
135. Which of the following goals is most important for the family whose child is dying of leukemia?
136. Help the family cope.
137. Improve parenting skills.
138. Overcome fear.
139. Facilitate grieving

Answer 24

116. 2. One cup of sunflower seeds contains 15 mg of iron. During pregnancy, 30 mg of iron is recommended daily. One cup of lentils provides the equivalent of 6.9 mg of iron. One and one-half ounces (50 mg) of hard cheese provides the equivalent of the amount of calcium in one cup of milk.
        Two poached eggs provide only 2 mg of iron.
        CN: Health promotion and maintenance; CL: Synthesize
117. 4. The plan of care to treat fatigue associated with radiation therapy should include
        encouraging the client to remain active and to plan scheduled rest periods as necessary before
        activity. Engaging in activities, such as walking, has been shown to decrease the cycle of fatigue, anxiety, and depression that can occur during treatment. Fatigue is a very common side effect of
        radiation therapy that typically begins during the 3rd or 4th week of treatment and persists until after treatment ends. The presence of fatigue does not mean that the cancer is not responding to treatment or that the client has developed another health problem.
        CN: Reduction of risk potential; CL: Synthesize
118. 3. Shearing forces occur because of improper movement and positioning, which causes the underlying tissues and capillary blood supply to be pulled and disrupted. This leads to tissue trauma and the potential beginning of skin breakdown. To prevent shearing, clients should be moved with the
        use of lift sheets and other devices, thus preventing dragging of the skin across the mattress and linens. Clients should also be positioned and supported to prevent pulling or tension of the skin
        across bony prominences. Turning clients, if not done properly, can cause shearing injuries. Keeping
        the skin clean, dry, and lubricated is an important aspect of care, but care must be used to decrease the amount of pulling forces exerted on the tissues.
        CN: Reduction of risk potential; CL: Apply
119. 4. The proper use of crutches requires supporting the body weight primarily on the hands. Improper use of crutches can cause nerve damage from excess pressure on the axillary nerve.
        CN: Reduction of risk potential; CL: Apply
120. 4. Because this family is waiting for the child to die, the most important goal is to help the client through the grieving process. Families grieve at the time of diagnosis as well as during the illness, as the child is dying, and after death has occurred. This is a normal process. There is no evidence that the family is having difficulty coping or is fearing the child’s death. There are no data to
        suggest the parents do not have effective parenting skills.
        CN: Psychosocial adaptation; CL: Analyze

Question 25

121. Which of the following should the nurse do first for a toddler just admitted with croup?
122. Monitor vital signs.
123. Assess respiratory status.
124. Ensure adequate fluid intake.
125. Place a tracheostomy set at the bedside.
126. Before the nurse administers IV replacement of 5% dextrose in water with potassium chloride, what nursing intervention must be completed first?
127. Adding potassium chloride to the bag at the bedside.
128. Evaluating laboratory results for electrolytes.
129. Priming tubing using sterile technique.
130. Checking the rate for IV push administration.
131. A 45-year-old client diagnosed with colon cancer states, “I don’t want any treatment. I
     haven’t seen any family members in 25 years. I’m a loner. Besides, I’ll decide when and how I want to
     die.” In which order of priority from first to last should the nurse do the following?
132. Ask the client what methods for suicide are available.
133. Tell the client that primary care provider will ask for a psychiatric consult.
134. Ask the client about thoughts of suicide.
135. Express concern for the client’s feelings and safety.
136. Which of the following is an early indication that a client has developed hypocalcemia?
137. Tingling in the fingers.
138. Depressed reflexes.
139. Ventricular dysrhythmias.
140. Memory changes.
141. The nurse is auscultating the lung sounds of a client with long-standing emphysema. The nurse should determine if the client has:
142. Fine crackles.
143. Diminished breath sounds.
144. Stridor.
145. Pleural friction rub.

Answer 25

121. 2. For the child with croup, assessing the child’s respiratory status is the priority. It is
        especially important to assess airway patency because laryngeal spasms can occur suddenly. After the
        nurse has assessed the toddler’s respiratory status, having a tracheostomy set at the bedside would be
        the next priority. Monitoring vital signs is important, as is ensuring adequate fluid intake to keep secretions loose, but assessing respiratory status is key.
        CN: Physiological adaptation; CL: Synthesize
122. 2. IV solutions are prescribed based upon the fluid and electrolyte status of the client, so
        laboratory results should be monitored first. Safety recommendations are for standard premixed
        solutions. If solutions are not premixed, additives are completed by the pharmacy, not at the bedside. Potassium chloride is never given by IV push because this could be fatal. Administration guidelines
        require no more than 10 mEq (10 mmol/L) of potassium chloride be infused per hour on a general medical-surgical unit. An infusion device or pump is required for safe administration.
        CN: Pharmacological and parenteral therapies; CL: Synthesize
124. Ask the client about thoughts of suicide.
125. Ask the client what methods for suicide are available.
126. Express concern for the client’s feelings and safety.
127. Tell the client that primary care provider will ask for a psychiatric consult.

Even with such a blatant suicide clue, it is still important to confirm that he is truly suicidal. Then,
it is crucial to know what methods of suicide are available to him. Before asking for a psychiatric
consult, the client needs to understand that the nurse cares, is empathetic, and will take actions to protect him from harm.
CN: Safety and infection control; CL: Analyze
124. 1. Neuromuscular irritability is usually the first indication that a client has developed a low
serum calcium level. Numbness and tingling around the mouth as well as in the extremities is an early sign of neuro-muscular irritability. Depressed reflexes, decreased memory, and ventricular dysrhythmias are indications of hypercalcemia.
CN: Physiological adaptation; CL: Analyze

125. 2. In emphysema, the anteroposterior diameter of the chest wall is increased. As a result, the
        client’s breath sounds may be diminished. Fine crackles are present when there is fluid in the lungs.
        Stridor occurs as a result of a partially obstructed larynx or trachea; stridor can be heard without
        auscultation. A pleural friction rub is present when pleural surfaces are inflamed and rub together.
        CN: Physiological adaptation; CL: Analyze

Question 26

126. A client with a paranoid personality disorder sees some clients laughing during a group activity and asks the nurse, “Why are they laughing at me? I bet they’re making fun of me.” Which of
     the following responses by the nurse is most appro-priate?
127. “You shouldn’t let your-self get so upset.”
128. “Don’t worry about them. They don’t mean any harm.”
129. “Look. They seem to be having fun.”
130. “They’re laughing at a joke John told. They aren’t laughing at you.”
131. Mebendazole (Vermox) is prescribed for an 8-year-old child with pinworms. The child has
     an 18-month-old brother and a 4-year-old sister. The nurse should be sure that the parents are also
     treating which of the following family members with this drug?
132. Both of the siblings.
133. The parents and brother.
134. Everyone who lives in the household.
135. The parents and sister.
136. When planning a presentation on the topic of osteoporosis to a group of middle-aged women, which of the following should the nurse plan to include in the presen-tation?
137. An early symptom of osteoporosis is the dowager’s hump.
138. Women of African and Latin descent are at greater risk.
139. Loss of height is an early symptom of the disease.
140. Conventional radiographs are usually used to confirm the disease.
141. Which of the following statements best explains why the nurse should evaluate gastric residual before administering the client’s next enteral feeding?
142. To determine how well nutrients are being absorbed.
143. To determine if the client is receiving enough feeding.
144. To prevent overdis-tention of the stomach.
145. To prevent mixing undigested formula with partially digested formula.
146. The results of which of the following serologic tests should the nurse have on the chart before a client is started on tissue plasminogen activator or alteplase recombinant (Activase)?
147. Partial thromboplastin time.
148. Potassium level.
149. Lee-White clotting time.
150. Fibrin split product.

Answer 26

126. 4. The client with paranoid personality disorder interprets the actions of others as personal threats, feels vulnerable, and is overly sensitive to others’ motives. Saying, “They’re laughing at a joke John told. They aren’t laughing at you,” is a simple explanation of others’ behavior, which helps
        to decrease the client’s suspiciousness and promote trust. The other statements do not help the client to realistically interpret situations and the behavior of others, and are not helpful in reducing the client’s suspicions or mistrust.
        CN: Psychosocial adaptation; CL: Synthesize
127. 4. Mebendazole is prescribed for household members older than 2 years. Although the
        child’s 18-month-old brother would not receive the drug, the 4-year-old sister and parents would.
        CN: Pharmacological and parenteral therapies; CL: Synthesize
128. 3. Loss of height and back pain are early indications of the disease that are caused by
        collapse of the vertebrae. Later signs include the dowager’s hump and loss of the waistline. The
        dowager’s hump is a later sign of osteoporosis that occurs when the vertebrae can no longer support the upper body in an upright position. Fair-skinned, small-boned, white and Asian women are at greater risk for osteoporosis. Conventional radiographs are little help because more than 30% of the
        bone mass must be lost before the disease is detected. High-density bone scans can detect the disease earlier.
        CN: Reduction of risk potential; CL: Synthesize
129. 3. The primary reason for evaluating gastric residual is to determine whether gastric emptying has been delayed and the stomach is becoming overdistended from the feeding. With delayed gastric emptying, the possibility of aspiration of the feeding into the lungs is increased. It is
        not possible to determine how well the client’s body is absorbing nutrients or whether the client is
        receiving enough feeding by checking the gastric residual. It is not necessary to keep partially digested formula separate from undigested formula.
        CN: Reduction of risk potential; CL: Apply
130. 1. The baseline values of the client’s partial thromboplastin time, bleeding time, and
        prothrombin time should be obtained. Potassium levels do not indicate a client’s coagulation time.
        The Lee-White clotting time or baseline fibrin split product does not need to be established before starting tissue plasminogen activator or alteplase.
        CN: Reduction of risk potential; CL: Apply

Question 27

131. When planning the care for a client diagnosed with hepatitis A, which of the following nursing interventions should the nurse include? Select all that apply.
132. Implementing an exercise program.
133. Providing relief from nausea and vomiting.
134. Administering pain medication.
135. Encouraging multiple small meals daily.
136. Planning frequent rest periods.
137. Following cardiac bypass surgery, the client has been referred to a cardiac rehabilitation
     exercise program. The client has type 1 diabetes and has bilateral leg discomfort with walking. The nurse should advise the client to exercise using a stationary bicycle and intermittent training because of the client’s:
138. Diabetic neuropathy.
139. Muscle atrophy.
140. Raynaud’s disease.
141. Transient ischemic attacks.
142. The client with border- line personality disorder spends much time around the nurse’s station, making numerous minor requests. The nurse interprets these behaviors as indicating which of the following?
143. Fears of abandonment and attention seeking.
144. Enjoyment of bothering the staff.
145. Boredom suggesting the need for something to do.
146. Lack of desire for involvement in milieu activities.
147. A client has soft wrist restraints to prevent the client from pulling out the nasogastric tube. Which of the following nursing interventions should be implemented while the restraints are on the
     client?
148. Instruct the client not to move while the restraints are in place.
149. Remove the restraints every 4 hours to provide skin care.
150. Secure the restraints to side rails of the bed.
151. Check on the client every 30 minutes while the restraints are on.
152. A client with alcohol dependence states, “I feel so bad because of what I’ve done to my wife
     and kids. I’m just no good.” Which of the following responses by the nurse is most appropriate?
153. “You’ll need to make up for a lot of things.”
154. “They will need to forgive your shortcomings.”
155. “Alcohol dependence is a disease that can be treated.”
156. “Alcoholism is painful for everyone involved.”

Answer 27

131. 2, 4, 5. Clients with hepatitis A commonly experience fatigue and altered nutrition due to
     anorexia and nausea. Because of the severe fatigue associated with hepatitis, clients are encouraged to rest and restrict activity during the active phase of the disease. It is important that frequent rest
     periods be planned throughout the day. Clients may experience nausea and vomiting; thus, providing
     relief is important. Small, frequent meals help clients manage the anorexia associated with hepatitis. An exercise program is not appropriate due to the need for rest. Clients with hepatitis do not
     experience pain. All medications administered to clients with hepatitis need to be evaluated for their potential for hepatotoxicity.
     CN: Physiological adaptation; CL: Synthesize
132. 1. A common complication of diabetes is diabetic neuropathy. Diabetic neuropathy results from the metabolic and vascular factors related to hyperglycemia. Damage leads to sensory deficits
        and peripheral pain. Muscle atrophy can result from disuse, but it is not a direct consequence of
        diabetes. Raynaud’s disease is associated with vasospasms in the hands and feet. Transient ischemic attacks involve the cerebrum.
        CN: Reduction of risk potential; CL: Analyze
133. 1. Clients with borderline personality disorder have fears of abandonment and seek
        attention. Clients are dependent and fear being alone; this stems from disapproval, feelings of being abandoned, and not having needs met earlier in their life. The nurse intervenes by reducing attention-seeking behaviors and abandonment fears to help with intense feelings and emotions.
        CN: Psychosocial adaptation; CL: Analyze
134. 4. The application of restraints places the client in a vulnerable, confined position. The nurse should check on the client every 30 minutes while restrained to make sure that the client is safe. The
        client should be able to move while the restraints are in place. The restraints should be removed every 2 hours to provide skin care and exercise the extremities. Restraints should not be secured to the side rails; they should be secured to the movable bed frame so that when the bed is adjusted the
        restraints will not be pulled too tightly.
        CN: Safety and infection control; CL: Synthesize
135. 3. The most appropriate response is, “Alcohol dependence is a disease that can be treated” because it conveys hope. It also emphasizes that the client has a treatable illness, which is helpful in
        reducing denial and guilt and encouraging the client to seek and comply with treatment. The other
        statements are judgmental and guilt-producing, possibly leading to denial and furthering the need for
        alcohol.
        CN: Psychosocial adaptation; CL: Synthesize

Question 28

136. After teaching the parent of a toddler about appropriate snack foods for their child, the nurse
     judges that the instructions about not giving the child raisins for snacks are effective when the parent states which of following?
137. “Raisins are low in nutritional value.”
138. “Raisins can increase tooth decay.”
139. “Raisins are easy to choke on.”
140. “Raisins are hard to digest entirely.”
141. A client has been diagnosed with atrial fibrillation. The physician prescribed warfarin
     (Coumadin) to be taken on a daily basis. The nurse instructs the client to avoid using which of the following over-the-counter medications while taking warfarin?
142. Aspirin.
143. Diphenhydramine (Benadryl).
144. Digoxin (Lanoxin).
145. Pseudoephedrine (Sudafed).
146. The nurse should inform a client taking carbamazepine that it can affect other medica-tions in which of the following ways?
147. It decreases the effects of oral anticoagulants.
148. It decreases the serum concentration of verapamil.
149. It increases the serum concentration of other anticonvulsants.
150. It increases the effects of oral contraceptives.
151. A client has been diagnosed with viral hepatitis. Which of the following goals is most
     appropriate for the client?
152. Achieve control of abdominal pains.
153. Increase activity levels gradually.
154. Be able to breathe without difficulty.
155. Experience relief from edema.
156. Which of the following activities by the mother offers the most support to the child during the first few days after surgery to repair a cleft lip?
157. Holding and cuddling the child.
158. Helping the child play with some toys.
159. Reading some of the child’s favorite stories.
160. Staying at the bedside and holding the child’s hand.

Answer 28

136. 2. Raisins are high in nutritional value but are sticky and have a high sugar content. The
        raisin can stick to the teeth and act like high-sugar foods in promoting tooth decay. Although anything
        can be aspirated, round, hard, smooth foods are more easily aspirated than raisins, which are soft and
        chewy. Raisins need to be chewed thoroughly for maximum nutritional value.
        CN: Health promotion and maintenance; CL: Evaluate
137. 1. Aspirin is an antiplatelet medication. The use of aspirin is contraindicated while taking warfarin because it will potentiate the drug’s effects. Diphenhydramine and pseudoephedrine do not affect blood coagulation. Digoxin is not an over-the-counter medication; it requires a physician’s prescription.
        CN: Pharmacological and parenteral therapies; CL: Synthesize
138. 1. The nurse should inform the client that carbamazepine can decrease the effects of oral
        anticoagulants. Tegretol can increase the serum concentration of verapamil and can decrease the
        serum concentration of other anticonvulsants and the effects of oral contraceptives.
        CN: Pharmacological and parenteral therapies; CL: Apply
139. 2. Viral hepatitis causes fatigue. It is important for the client to rest to allow the liver to
        recover. Activity levels are resumed gradually as the client begins to recover. Abdominal pain is not
        a common manifestation of hepatitis. The client typically does not have difficulty breathing or
        experience edema.
        CN: Physiological adaptation; CL: Synthesize
140. 1. The mother should be encouraged to hold and cuddle her child to provide needed
        emotional support. Such activities as helping the child play with toys, reading stories, and staying with the child would not be contraindicated but do not offer as much emotional support as holding and
        cuddling.
        CN: Psychosocial adaptation; CL: Synthesize

Question 29

141. Which of the following is the most effective strategy for a nurse to use to reduce the number of children involved in automobile accidents who were not wearing seat belts?
142. Contact the local government represen-tative to discuss new legislation about child seat belts.
143. Attend a school board meeting to advocate for classes teaching children seat belt safety.
144. Call the town mayor’s office with this infor-mation so that the mayor can discuss it with the
     media.
145. Start a letter-writing campaign to the school superintendent about seat belt importance.
146. The nurse is deve-loping a discharge plan for a client who has had a myocardial infarction.
     Planning for discharge for this client should begin:
147. On discharge from the hospital.
148. On discharge from the cardiac care unit.
149. On admission to the hospital.
150. 4 weeks after the onset of illness.
151. A child is admitted to the emergency depart-ment with dyspnea related to bronchospasms. The nurse should place the client in which of the following positions?
152. High Fowler’s.
153. Side-lying.
154. Prone.
155. Supine.
156. The nurse is preparing to administer IM morphine sulfate to a client who is in pain. On checking the physician’s prescription, the nurse notes that the prescription states, “morphine sulfate 60
     mg IM every 4 hours as needed for pain.” The usual dose of morphine is 10 to 15 mg. What is the
     most appropriate action for the nurse to take?
157. Administer the medica-tion as prescribed.
158. Administer 15 mg of the drug.
159. Contact the physician to verify the prescription.
160. Ask another nurse to review the prescription.
161. Following surgery for removal of a brain tumor, a client is coughing, short of breath, and has a “bad” feeling. The nurse obtains the following vital signs: blood pressure of 80/60 mm Hg, pulse rate of 120 bpm, and respiratory rate of 30 shallow breaths/min. What should the nurse do first?
162. Call the neurosurgeon.
163. Place the client in the Trendelenburg position.
164. Consult the neurologic Clinical Nurse Specialist (CNS).
165. Activate the rapid response team (RRT)

Answer 29

141. 2. The best strategy to affect child seat belt safety is to attend the school board meeting andadvocate for educational programming. The programming could be simple and done quickly. This action also targets the best audience.
        CN: Health promotion and maintenance; CL: Synthesize
142. 3. A basic principle of rehabilitation, including cardiac rehabilitation, is that rehabilitation
        begins on hospital admission. Early rehabilitation is essential to promote maximum functional ability
        as the client recovers from an illness. Delaying rehabilitation activities is associated with poorer
        client outcomes.
        CN: Basic care and comfort; CL: Apply
143. 1. The goal of the intervention is to decrease the child’s work of breathing by decreasing
        pressure on the diaphragm and increase chest expansion by increasing the pull of gravity on the
        diaphragm. Placing the client in high Fowler’s position accomplishes this. Side-lying positions make it more difficult to expand the side of the lung closest to the bed. The prone or supine position does
        not decrease the work of breathing unless the head of the bed is raised.
        CN: Physiological adaptation; CL: Synthesize
144. 3. The most appropriate action is to contact the physician to verify that the prescription is
        correct. Although 60 mg of morphine is a significant dose, the amount of morphine administered to a
        client can vary widely, especially if a client has been taking morphine for an extended period and has developed a tolerance to the medication. The safest approach is for the nurse to verify prescriptions
        that do not appear to fall within the norm. Administering the medication without verification is unsafe.
        The nurse cannot decide to reduce the amount of a prescribed medication without a prescription.
        Asking another nurse to review the prescription is not inappropriate; however, checking with the physician to verify the prescription should be done.
        CN: Pharmacological and parenteral therapies; CL: Synthesize
145. 4. RRTs, or medical emergency teams, provide a team approach to evaluate and treat
        immediately clients with alterations in vital signs or neurological deterioration. Calling the
        neurosurgeon or consulting the CNS may not result in a rapid response. The Trendelenburg position is
        usually used in treating shock, but because the client has had brain surgery, the head should not be lower than the trunk.
        CN: Physiological adaptation; CL: Synthesiz

Question 30

146. The nurse is preparing a client for paracentesis. Which of the following activities should the nurse complete in preparation for this test?
147. Have the client void before the procedure.
148. Scrub the client’s abdomen with Betadine solution.
149. Position the client supine.
150. Put the client on nothing-by-mouth (NPO) status 4 hours before the procedure.
151. A nurse suspects that a 20-month-old is being abused. Which of the following behaviors
     should lead the nurse to suspect this?
152. Absence of crying during the examination.
153. Clinging to the parent during the examination.
154. Playing with toys on the examination room floor.
155. Talking easily with the nurse.
156. Which of the following should the nurse plan to include when teaching the client and family about a subs-tance abuse problem?
157. The role of the family in perpetuating the problem.
158. The family’s responsibility for the client.
159. The physical, physiologic, and psychological effects of substances.
160. The reasons that could have led the client to use the substance.
161. A client who has had a laparoscopic chole-cystectomy receives discharge instructions from [the nurse. Which statement indicates that the client has understood the instructions?
162. “I need to maintain a low-fat diet for the next 6 months.”3. “I can remove the dressing from my incision tomorrow and take a shower.”
163. “I can anticipate some nausea for several days after surgery.”
164. “I can return to work in 4 to 6 weeks.”
165. The nurse is obtaining a health history from a Mexican adult. The nurse should interpret the findings by understanding that in this client’s culture, which of the following are highly valued?
166. Children.
167. Materialism.
168. Firstborn sons.
169. The elderly.

Answer 30

146. 1. Before paracentesis, the client is asked to void. This is done to collapse the bladder and decrease the risk of accidental bladder perforation. The abdomen is not prepared with Betadine. The client is placed in a Fowler’s position. The client does not need to be put on NPO status before the
        procedure.
        CN: Reduction of risk potential; CL: Apply
147. 1. Children who are being abused may demonstrate behaviors such as withdrawal, apparent fear of parents, and lack of an appropriate reaction, such as crying and attempting to get away when faced with a frightening event (an examination or procedure).
        CN: Psychosocial adaptation; CL: Analyze
148. 3. The nurse should include teaching the client and family about the physical, physiologic,
        and psychological effects of substances to educate them about the potential injury, illness, and disability that can result from substance use. Teaching about the role of the family in perpetuating the
        problem, the family’s responsibility for the client, or the reasons that could have led the client to use the substance is inappropriate and based on an erroneous assumption. Including these topics blames
        the family for the problem and attempts to rationalize the use of the substance.
        CN: Psychosocial adaptation; CL: Synthesize
149. 2. Postoperative care after a laparoscopic cholecystectomy includes removal of the dressing
        from the incisional site the day after surgery and allowing the client to bathe or shower. The client can resume a normal diet but may wish to follow a low-fat diet for a few weeks after surgery. Nausea is
        not expected to last for several days after surgery. The client usually can return to work within 1
        week.
        CN: Reduction of risk potential; CL: Evaluate
150. 1. Children are highly valued and are closely protected by godparents. The tradition of the
        family is all-encompassing, and the health care provider gains trust and improved compliance rates
        by including the family in teaching and health care matters.
        CN: Psychosocial adaptation; CL: Apply

Question 31

151. A client has extreme fatigue, is malnourished and laboratory tests reveal a hemoglobin level of 8.5 g/dL (85 g/L). The nurse should specifically ask the client about the intake of food high in which of the following nutrients?
152. Vitamins A, E, and C.
153. Vitamins B 6 and B 12 , folate, iron, and copper.
154. Thiamine, riboflavin, and niacin.
155. Vitamins A and B.

152. The nurse is assess-ing a neonate born to a mother with type 1 dia- betes. Which of the
following findings are expected?
1. Hypertonia.
2. Hyperactivity.
3. Large size.
4. Scaly skin.

153. A client who had transurethral resection of the prostate has dribbling urine after his Foley cathe- ter is removed on the 2nd postoperative day. The nurse notes that the client had 200 mL of urine output in the last 8 hours with a 1,000 mL intake. Which of the following interventions is a priority for the nurse at this time?
154. Apply a condom catheter.
155. Assess for bladder distention.
156. Obtain a urine specimen for culture.
157. Teach the client Kegel exercises.
158. A client has atrial fibrillation. The nurse should monitor the client for:
159. Cardiac arrest.
160. Cerebrovascular accident.
161. Heart block.
162. Ventricular fibrillation.
163. A child diagnosed with tinea is being treated with griseofulvin (Grifulvin V). Which of the following instructions should the nurse give to the parents?
164. Give the medication before a meal.
165. Have the child avoid intense sunlight.
166. Give the medication for 10 days.
167. Encourage increased fluid intake.

Answer 31

151. 2. Many vitamin and mineral deficiencies can result in anemia. All of these vitamins and
        minerals need to be assessed, preferably through a nutrition assessment. Deficiencies of vitamins A,
        B 6 , and C result in a small cell, microcytic anemia. Folate and vitamin B 12 deficiencies result in a
        large cell, macrocytic anemia. Iron, copper, and vitamin E deficiencies can also result in anemia.
        CN: Physiological adaptation; CL: Analyze
152. 3. Women with diabetes mellitus generally have neonates who are large but physically immature. Other common findings in these infants are hypoglycemia, hypocalcemia,
        hyperbilirubinemia, polycythemia, renal thrombosis, and congestive anomalies. The neonates do not
        exhibit hypertonia, hyperactivity, or scaly skin.
        CN: Health promotion and maintenance; CL: Analyze
153. 2. The imbalance between the client’s intake and output indicates that the client may be retaining urine since the removal of his Foley catheter. The nurse’s first action is to validate this assumption by assessing for bladder distention. Applying a condom catheter will not relieve urinary
        retention; condom catheters are meant to be used for incontinence. A urine specimen for a culture is obtained if a urinary infection is suspected, but this is not a priority at this point. Kegel exercises are
        helpful in controlling urinary dribbling but do not treat retention.
        CN: Reduction of risk potential; CL: Synthesize
154. 2. Because of the poor emptying of blood from the atrial chambers, there is an increased risk
        for clot formation around the valves. The clots become dislodged and travel through the circulatory system. As a result, cerebrovascular accident is a common complication of atrial fibrillation.
        CN: Physiological adaptation; CL: Analyze
155. 2. Griseofulvin is associated with photosensitivity reactions. Therefore, the nurse should instruct the parents to have the child avoid intense sunlight. Griseofulvin is best absorbed when
        administered after a high-fat meal. Treatment with griseofulvin typically lasts for at least 1 month.
        There are no indications that increased fluid intake affects absorption.CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 32

156. After going through the necessary procedures for collecting physical evidence after a rape, aclient is crying and talking about what happened to her. The nurse should:
157. Advise the client to try to forget about what happened.
158. Recommend that the client be thankful for the fact that she’s alive.
159. Question the client about what she could have done to deter the attack.
160. Listen to the client’s descriptions about what occurred.
161. A client undergoes cystoscopy with bladder biopsy. After the proce-dure, which assessment
     is most appropriate for the nurse to make?
162. Assess the patency of the Foley catheter.
163. Assess urine for excessive bleeding.
164. Percuss the bladder for distention.
165. Obtain a urine specimen for culture.
166. When a client of Mexican descent tells the nurse that she treated her infection by drinking milk, the nurse interprets the client’s remark as:
167. Confusion from fever.
168. Use of the hot disease concept.
169. Use of milk as a laxa-tive.
170. The need for a dietitian to assist her with meal planning.
171. A female client with paranoid schizophrenia has been hearing negative voices and “getting special messages from various sources.” Which of the following interventions is most appropriate for
     the client’s symptoms?
172. Asking her to make simple decisions.
173. Being matter-of-fact with her.
174. Monitoring her reactions to television programs.
175. Reinforcing appropriate dress and hygiene.
176. The nurse is talking with a client who was diagnosed with bulimia 3 months ago. The client
     needs more education about the illness if she makes which of the following comments? Select all that apply.
177. “I know that this illness is chronic and intermittent. I’ll always have to control it.”
178. “If I start severely restricting my eating, I may be building up to a bingeing episode.”
179. “When I’m not bingeing and purging, I can skip that eating disorder support group.”
180. “I’ve made a real effort to be more social and involved in activities.”
181. “My depression is gone so I don’t need my antidepressant any longer.”

Answer 32

156. 4. The nurse should actively listen to the client’s descriptions and details about being raped
        and allow her to talk about the trauma. This allows the client to vent, decreases feelings of isolation, and guides the nurse to potential areas that could be problematic for the client. The nurse is a safe person to confide in, thus helping to decrease the client’s apprehension about disclosing intimate
        details and feelings. Advising the client to try to forget about what happened, recommending that she
        be thankful for being alive, or questioning her about what she could have done to deter the attack is contraindicated for the victim of violence. These responses blame the victim and tend to increase her guilt, as if somehow she is to blame or would have been capable of preventing the rape.
        CN: Psychosocial adaptation; CL: Synthesize
157. 2. After cystoscopy with biopsy, the nurse would assess for excessive hematuria, which might indicate hemorrhage caused by the biopsy. Catheters are not routinely inserted after cystoscopy.
        The nurse would not assess for bladder distention unless the client was having difficulty voiding.
        Urine cultures are not routinely prescribed after cystoscopy.
        CN: Reduction of risk potential; CL: Analyze
158. 2. The nurse interprets the client’s statement as use of the hot disease concept in the Mexican culture, where the belief of a hot and cold balance of the body exists. A hot disease such as an
        infection is treated with the opposite, a cold food such as milk. The nurse should focus on the cultural differences and be sensitive to the cultural diversity.
        CN: Health promotion and maintenance; CL: Analyze
159. 3. A client who is “getting special messages” (ideas of reference) commonly misinterprets content presented on television as containing messages for the client. Therefore, it is important for the
        nurse to monitor the client’s reactions to television programs.
        CN: Psychosocial adaptation; CL: Synthesize
160. 3, 5. Not attending the support group consistently and not taking the antidepressant may lead to a relapse and the client needs this information. Bulimia is chronic and intermittent and involves cycles of bingeing, purging, and restrictive eating. Increased socialization and activities promote
     healthy relationships.
     CN: Psychosocial adaptation; CL: Evaluate

Question 33

161. The nurse judges that the parents of a newborn with imperforate anus know what a low defect is when they say that the rectum:
162. Is below the abdominal rectus muscle.
163. Is above the abdominal rectus muscle.
164. Has descended through the puborectalis muscle.
165. Has ascended through the puborectalis muscle.
166. An elderly client is receiving meperidine (Demerol) after abdominal surgery. For which of
     the following side effects of meperidine should the nurse carefully evaluate the client?
167. Respiratory depression.
168. Dysrhythmias.
169. Constipation.
170. Seizures.
171. A client with iron deficiency anemia is taking iron supplements. The nurse emphasizes to the client that the drug will have increased absorption if taken with:
172. Milk.
173. Orange juice.
174. Food.
175. Beta-carotene.
176. When obtaining the nursing history of a client who has type 1 diabetes mellitus, the nurse should assess the client for which early symptom of renal insufficiency?
177. Polyuria.
178. Dysuria.
179. Hematuria.
180. Oliguria.
181. A client is planning to be treated for infertility with the zygote intra-fallopian transfer (ZIFT)
     method. Which of the following should the nurse include when teaching the client about this type of
     treatment method?
182. Fertilization takes place outside of the body.
183. ZIFT is helpful for clients with bilateral blocked fallopian tubes.
184. Ova and sperm are needed for instillation into the fallopian tube.
185. Fertilized ova are instilled into the vagina to enter the uterus.

Answer 33

161. 3. In a low anorectal anomaly, the rectum has descended normally through the puborectalis
        muscle. In an intermediate anomaly, the rectum is at or below the level of the puborectalis muscle; in a high anomaly, the rectum ends above the puborectalis muscle.
        CN: Physiological adaptation; CL: Evaluate
162. 1. It is especially important for the nurse to carefully assess the elderly client for respiratory depression after administering a dose of meperidine. It may be necessary to reduce the dosage to prevent respiratory depression. Dysrhythmias, constipation, and seizures are all potential adverse
        effects of meperidine, but respiratory depression is most significant in the elderly.
        CN: Pharmacological and parenteral therapies; CL: Analyze
163. 2. Ascorbic acid (vitamin C) increases iron absorption. Taking iron with a food rich in
        ascorbic acid, such as orange juice, increases absorption. Milk delays iron absorption. It is best togive iron on an empty stomach to increase absorption. Beta-carotene does not affect iron absorption.
        CN: Pharmacological and parenteral therapies; CL: Apply
164. 1. In early renal insufficiency, the kidneys lose the ability to concentrate urine, resulting in polyuria. Oliguria occurs later. Dysuria and hematuria are not associated with renal insufficiency.
        CN: Physiological adaptation; CL: Analyze
165. 1. The ZIFT method requires that fertilization take place outside the body. After fertilization
        has occurred, the fertilized eggs are transferred by laparoscopy to the open end of the fallopian tube.
        At least one tube must be patent for this procedure to succeed, so it is not beneficial if the client has
        bilateral blocked fallopian tubes. Ova and sperm are instilled in the fallopian tube for fertilization
        when the gamete intrafallopian transfer method is used. With in vitro fertilization, a fertilized ovum is
        instilled into the vagina to enter the uterus for implantation.
        CN: Health promotion and maintenance; CL: Synthesize

Question 34

166. When assessing for oxygenation in a client with dark skin, the nurse should examine the client’s:
167. Skin.
168. Buccal mucosa.
169. Nape of the neck.
170. Forehead.
171. Which of the following rehabilitative measures should the nurse teach the client to perform after chest surgery to prevent shoulder ankylosis?
172. Turn from side to side.
173. Raise and lower the head.
174. Raise the arm on the affected side over the head.
175. Flex and extend the elbow on the affected side.
176. A client with a trache- ostomy tube coughs and dislodges the trache- ostomy tube. The nurse’s
     first action should be to:
177. Call for emergency assistance.
178. Attempt reinsertion of tracheostomy tube.
179. Position the client in semi-Fowler’s position with the neck hyperextended.
180. Insert the obturator into the stoma to reestablish the airway.
181. An infant is to return to the clinic for a regular check-up and receive immunizations. In prepa- ration for this next visit, which of the following should the nurse suggest to the parents?
182. “Be prepared for the infant to be very fussy.”2. “Give the infant acetaminophen (Tylenol) before coming to the clinic.”
183. “Plan to keep the infant out of day care for that day.”
184. “Bring someone else to the appointment to help you.”
185. A first-time mother is concerned that her 6-month-old infant is not gaining enough weight.
     The best response for the nurse to make is which of the following?
186. “Birth weight doubles by 6 months of age.”
187. “Birth weight doubles by 3 months of age.”
188. “The baby will eat what he needs.”
189. “You need to make sure the baby finishes each bottle.”

Answer 34

166. 2. The nurse should examine the buccal mucosa, along with the conjunctiva and sclera, nail beds, palms, soles, lips, and tongue to assess for oxygenation in a client with dark skin.
        CN: Reduction of risk potential; CL: Apply
167. 3. A client who has undergone chest surgery should be taught to raise the arm on the affected
        side over the head to help prevent shoulder ankylosis. This exercise helps restore normal shoulder movement, prevents stiffening of the shoulder joint, and improves muscle tone and power.
        CN: Reduction of risk potential; CL: Synthesize
168. 2. The nurse’s first action should be to attempt to replace the tracheostomy tube immediately so that the client’s airway is reestablished. Although the nurse may also call for assistance, there
        should be no delay before attempting reinsertion of the tube. The client is placed in a supine position with the neck hyperextended to facilitate reentry of the tube. The obturator is inserted into the
        replacement tracheostomy tube to guide insertion and is then removed to allow passage of air through
        the tube.
        CN: Reduction of risk potential; CL: Synthesize
169. 2. Many parents are advised to administer acetaminophen before the child receives
        immunizations to minimize local and systemic reactions. Typically, infants should not be very fussy
        after receiving immunizations. There is no reason to keep the infant out of day care that day; the child is not contagious. Although it may be helpful to the parents to have someone with them at the
        appointment, advising them to give the infant acetaminophen is more important.
        CN: Health promotion and maintenance; CL: Synthesize
170. 1. A general growth parameter is that the birth weight doubles in 6 months and triples in a
        year. Telling the mother that the baby will eat what he needs is not appropriate. The nurse needs to investigate whether the baby’s weight is within the normal parameters of infant weight gain. A bottle-fed baby should not be forced to complete the bottle because this may contribute to obesity.
        CN: Health promotion and maintenance; CL: Synthesize

Question 35

171. When assessing a client who reports a back injury, it is critical for the nurse to question the
client about which of the following?
1. Family history of back problems.
2. Previous hospitalizations.
3. Personal history of illness.
4. Mechanism of injury.

172. A client is taking metoprolol and hydro- chlorothiazide. The medication are effective if it:
173. Lowers the blood pressure.
174. Increases the heart rate.
175. Improves circulation in the extremities.
176. Decreases dyspnea.
177. The nurse is examining a client with possible rheumatoid arthritis. Which of the following symptoms should the nurse assess at this time?
178. Nausea.
179. Joint swelling.
180. Fatigue.
181. Limitation of movement.
182. The nurse instructs the client in mixing and administering regular and NPH insulin. Which of
     the following statements indicates that the client needs additional instruction?
183. “I draw up the regular insulin first.”
184. “I shake the bottle of NPH insulin before drawing it up.”
185. “I store the insulin in a cool place.”
186. “I insert the needle at a 90-degree angle.”
187. The mother of a child with newly diagnosed Duchenne’s muscular dystrophy asks how her
     child developed the disease. The nurse gives a response incorporating which of the following
     statements about its transmission?
188. It is an autosomal recessive genetic disorder.
189. It is a genetic disorder carried by males and transmitted to male children.
190. It is a disorder primarily transmitted by males in the family.
191. It is a disorder usually carried by females and transmitted to male children.

Answer 35

171. 4. The mechanism of injury is always the most critical information to obtain from a client
        with a musculoskeletal injury. In the event of a back injury, the mechanism of injury provides the greatest clue as to the extent of injury and the proper treatment plan. The other questions are importantbut will not give the critical information needed related to this specific problem and injury.
        CN: Physiological adaptation; CL: Analyze
172. 1. Antihypertensive medications such as metoprolol and hydrochlorothiazide work to lower the blood pressure by reducing peripheral resistance or decreasing cardiac output; the effectiveness
        of these drugs is noted by a lowering of the blood pressure. Vasodilators are used to improve
        peripheral circulation. Cardiac stimulants and antiarrythmia drugs are used to increase heart rate. Although cardiac problems can cause dyspnea, the use of drugs to manage dyspnea depends on the
        underlying cause.
        CN: Pharmacological and parenteral therapies; CL: Evaluate
173. 3. Typical early signs of rheumatoid arthritis are nonspecific and not necessarily related to
        specific joint pain. Common early symptoms include fatigue, anorexia, weight loss, and generalized feelings of stiffness. Joint swelling and limitation of movement usually occur as joint involvement
        becomes more specific. Nausea is not typically associated with the disease process but can be related to medications prescribed to treat rheumatoid arthritis.
        CN: Physiological adaptation; CL: Analyze
174. 2. NPH insulin should be rolled between the palms to mix it before drawing it up; shaking it
        will introduce air bubbles into the solution, which can cause inaccurate dosing. The client should
        draw up the insulin first, store the insulin in a cool place, and inject the insulin at a 90-degree angle.
        CN: Pharmacological and parenteral therapies; CL: Evaluate
175. 4. The gene for Duchenne’s muscular dystrophy is carried by women and transmitted to their male children. It involves an X-linked inheritance pattern. About one-third of new cases involve mutations.
        CN: Physiological adaptation; CL: Apply

Question 36

176. Which of the following is a priority nursing goal for an infant with intussusception?
177. Restore fluids.
178. Control diarrhea.
179. Protect the skin.
180. Manage acute pain.
181. The physician prescribes IV cefazolin (Kefzol) 1 g for a client. In preparing to administer
     the Kefzol, the nurse notes that the client is allergic to penicillin. Based on this information, what is
     an appropriate action for the nurse to take?
182. Continue to prepare to administer the Kefzol as prescribed.
183. Notify the physician of the client’s allergy to penicillin.
184. Administer the Kefzol, staying at the client’s bedside during the infusion.
185. Call the pharmacist to verify that the Kefzol should be administered as prescribed.
186. A client is prescribed buspirone (Buspar) 5 mg two times a day. Which of the following statements indicates that the client has understood the nurse’s teaching about this drug? Select all that
     apply.
187. “This medicine will make me sleepy.”
188. “Buspar will relax my muscles.”
189. “My anxiety will be completely gone by tomorrow.”
190. “Buspar will help me not to worry so much.”
191. “I’ll be able to focus better.”
192. When a client has a tearing of tissue with irregular wound edges, the nurse should docu- ment this as:
193. Contusion.
194. Abrasion.
195. Laceration.
196. Colonization.
197. A client with schizo- phrenia is responding well to risperidone (Risperdal) and is no longer psychotic. After teaching the client about managing the illness, which of the following statements reflects a need for further education?
198. “I just don’t know if I can afford to keep taking medicines every day.”
199. “When my thoughts start racing, I know I need to relax more.”
200. “I can name the side effects of Risperdal, but I’m not having any.”
201. “I don’t listen to my mom’s religious beliefs about not using medicines.”

Answer 36

176. 4. Infants with intussusception have colic-like abdominal pain caused by the telescoping of
        the bowel. The nursing priority is to relieve this pain. There are no data to indicate a skin problem or
        dehydration. Diarrhea or constipation may precede the appearance of currant jelly stools.
        CN: Physiological adaptation; CL: Analyze
177. 2. The nurse should notify the physician that the client is allergic to penicillin before giving the Kefzol. Cephalosporins are contraindicated in clients who are allergic to penicillin. Clients who
        are allergic to penicillin may have a cross-allergy to cephalosporins.
        CN: Pharmacological and parenteral therapies; CL: Synthesize
178. 4, 5. Buspirone is not a benzodiazepine but acts as a serotonin agonist. Serotonin is the
     neurotransmitter implicated in depression. Buspar reduces symptoms of worry, apprehension,
     difficulty with concentration, and irritability. It is not sedating, does not cause a high, takes 1 to 6 weeks to be effective, does not cause muscle relaxation, and does not produce dependence, withdrawal, or tolerance. Full therapeutic benefit takes 3 to 6 weeks.
     CN: Pharmacological and parenteral therapies; CL: Evaluate
179. 3. The nurse should document a tearing of tissue with irregular wound edges as a laceration. A contusion or a bruise is a closed wound caused by a blunt object resulting in bleeding in underlying
        tissue. An abrasion is a superficial wound from a rubbing or a scraping of the surface of the skin suchas from a fall. Colonization is a wound containing microorganisms.
        CN: Safety and infection control; CL: Apply
180. 1. The major cause of relapse is noncompliance. If the client cannot afford to keep taking the
        medicines, it is a warning sign to the nurse that the client may be at risk for noncompliance.
        Therefore, the nurse needs to stress the need for compliance to prevent relapse. If money is a
        problem, a referral to a social worker may be necessary.
        CN: Psychosocial adaptation; CL: Evaluate

Question 37

181. A nurse is assessing a client with viral hepatitis. The client reports that the appetite is poor and the presence of food causes nausea. The nurse should encourage the client to eat:
182. High-fat foods at each meal.
183. Foods high in protein.
184. The majority of the calories in the morning during small frequent snacks.
185. A low-calorie diet with numerous snacks.
186. A client had a cast applied to the left femur to stabilize a fracture. To promote early rehabilitation, the nurse should first:
187. Call physical therapy to provide passive exercise of the affected limb.
188. Teach the client how to do isometric exercises of the quadriceps.
189. Show the family how to do active range of motion exercises of the unaffected limb.
190. Obtain weights so the client can exercise the upper extremities.
191. The client arrives in the emergency room following a bicycle accident in which the client’s forehead hit the pavement. The client is diagnosed as having a hyphema. The nurse should place the client in which position?
192. Supine.
193. Semi-Fowler’s.
194. Side-lying on the affected side.
195. Side-lying on the unaffected side.
196. The nurse has just received change-of-shift report for four clients. Based on this report, the nurse should assess which of the following clients first?
197. A 38-year-old who is 2 days postmastectomy due to breast cancer, having difficulty coping with the diagnosis.
198. A 52-year-old with pneumonia and chronic back pain who is requesting pain medication.
199. A 35-year-old admitted after motor vehicle accident whose urine output has totaled 30 mL
     over the last 2 hours.
200. An 84-year-old with resolving left-sided weakness who is slightly confused and has been
     awake most of the night.
201. The nurse has received change-of-shift report. The nurse should assess which of the following clients first?
202. A 72-year-old admitted 2 days ago with a blood alcohol level of 0.08.
203. A 36-year-old with chest tube due to spontaneous pneumothorax with current respiratory rate 18 breaths/min, oxygen saturation 95% on oxygen at 2 L per nasal cannula.
204. A 28-year-old who is 2 days postappendectomy with discharge prescriptions written and whose husband is waiting to take her home.
205. A 62-year-old admitted with a recent gastro-intestinal (GI) bleeding whose hemoglobin is 13.8 g/dL (138 g/L).

Answer 37

181. 3. It is important to explain to the client who is having nausea that the majority of calories should be eaten in the morning because nausea most often occurs in the afternoon and evening. Small, frequent portions are best. Clients with viral hepatitis should select a diet high in calories because energy is required for healing. An intake of adequate carbohydrates can spare the protein because protein places an increased workload on the liver. Changes in bilirubin interfere with fat absorption, so low-fat diets are better tolerated.
        CN: Health promotion; CL: Synthesize
182. 2. The nurse should teach the client how to do isometric exercise, contraction of the quadri ceps muscle without movement of joint, to maintain muscle strength. Physical therapy may assist the client later, and will then teach the client how to do active exercises and crutch walking if
        prescribed. The client will be able to move the unaffected limb; the family will not need to assist. If the client will be using crutches, building upper extremity strength will be helpful, but the immediate
        need is to maintain and develop strength in the quadriceps.
        CN: Health promotion; CL: Synthesize
183. 2. A hyphema is the presence of blood in the anterior chamber of the brain. Hyphema is
        produced when a force is sufficient to break the integrity of the blood vessels in the eye and can be caused by direct injury, such as pene- trating injury from a small bullet or pellet, or indirectly, such as from striking the forehead on the pavement during an accident. The client is treated by bed rest in a
        semi-Fowler’s position to assist gravity in keeping the hyphema away from the optical center of the cornea.
        CN: Physiological integrity; CL: Apply
184. 3. Urine output should be at least 500 mL in 24 hours (20 mL/h); this client’s output has been just 15 mL/h for the past 2 hours requiring further assessment by the nurse. The nurse should first assess all clients and address physio-logical needs including pain control and safety measures; the nurse should then take time with the client having difficulty coping in order to listen and further
        determine her needs.
        CN: Reduction of risk potential; CL: Synthesize
185. 1. The nurse should closely monitor the client admitted with an elevated blood alcohol level for several hours for signs and symptoms of withdrawal, adminis-tering sedation as needed; delirium tremens, the most severe form of with-drawal, usually peaks at 48 to 72 hours following the last drink. The client with the chest tube is not in any distress and has no pressing needs. For an older client who
        has had GI bleeding, a hemoglobin of 13.8 g/dL (138 g/L) is within normal limits. After assessing all
        clients’ needs, the nurse will prepare the client who had an appendectomy for discharge as soon as
        possible.CN: Reduction of risk potential; CL: Synthesize

Question 38

186. The adolescent with cystic fibrosis has been placed on ciprofloxacin (Cipro) for a lung infection. Which statement from the client indicates the need for more teaching?
187. “Cipro should not be taken with dairy products.”
188. “I will need to have drug levels drawn while I am on this medication.”
189. “I should immediately report any muscle or joint pain.”
190. “If I miss a dose, I should take it as soon as I remember.”
191. The parents of a 7-year-old child with glomerulonephritis ask what they can do to ensure that their other children do not develop the disease. The nurse should respond with which of the following?
192. “If you suspect your child has a urinary tract infection, see your primary health care provider right away.”
193. “I am afraid there is nothing you can do; glomerulonephritis is a genetic disorder.”
194. “Glomerulonephritis is not contagious, so your other children will not get the disease.”
195. “If your child has a streptococcal infection, complete the course of prescribed antibiotics.”
196. A depressed client attempted suicide after being out of work for 9 months. After 4 days in
     the psychiatric unit, which of the following state-ments to the nurse would indicate that the client was significantly better?
197. “I had no idea that so many people are willing to help me with finances and my job search.”2. “I don’t think that suicide is the answer, and it would hurt so many people.”
198. “I guess I was being selfish to think about abandoning my family that way.”
199. “My wife is afraid to have me come home and maybe try suicide again.”
200. When admitting a neonate whose mother received magnesium sulfate, the nurse should
     assess the baby for which of the following? Select all that apply.
201. Increased Moro reflex.
202. Decreased muscle tone.
203. Increased respirations.
204. Decreased respirations.
205. Increased temperature.
206. The neonate has a prescribed IV rate of 8 mL/h. Fluid totals are recorded every 2 hours on the even hours. There is a new prescription written at 10:30 to decrease the IV rate to 6 mL/h. What is the
     fluid total to be infused and recorded at 12:00?
     _______________ mL

Answer 38

186. 2. Therapeutic serum drug monitoring is not routinely done with ciprofloxacin. This
        medicine should not be taken with dairy products or calcium-fortified juice. While this side effect is more common in older adults, ciprofloxacin may cause tendon damage including a ruptured Achilles tendon. Clients may take a missed dose as soon as they remem-ber. If it is very close to the time of the next dose, the missed dose should be omitted. The client should not take a double dose.
        CN: Pharmacology and parental therapies; CL: Evaluate
187. 4. The most common noninfectious renal disease in children is acute poststreptococcal
        glomerulonephritis. Ensuring that children diagnosed with strepto-coccal infections omplete a full course of antibiotics will decrease their risk of developing acute glomerulone-phritis. Parents should contact the primary health care provider if they suspect a UTI; however, glomerulo-nephritis is not caused by a UTI. Glomerulo-nephritis is not a genetic disease and is not contagious, which makes answers 2 and 3 incorrect information.
        CN: Reduction of risk potential; CL: Apply
188. 1. Recognizing that people care and are willing to help conveys a decrease in hopelessness and despair, as well as a decrease in suicide risk. Stating that he knows suicide is not the answer and seeing himself as selfish does not show that he has more positive plans. His wife’s fears about his trying to kill himself again are not a statement that he won’t attempt suicide again.
        CN: Psychosocial integrity; CL: Evaluate
189. 2, 4. Magnesium sulfate decreases muscle contractility and crosses the placenta. Because of
     this, a neonate that has been exposed to this drug may have decreased muscle tone and decreased
     respirations. The Moro reflex will be decreased because of the decreased muscle tone. There are no
     findings that show magnesium sulfate has a direct effect on temperature.
     CN: Pharmacological and parenteral therapies; CL: Analyze
190. 13 mL. 10:00 to 10:30 = 4 mL (hourly rate 8), 10:30 to 11:00 = 3 mL (hourly rate 6 mL),
     11:00 to 12:00 = 6 mL (hourly rate 6 mL). 4 + 3 + 6 = 13.
     CN: Pharmacological and parenteral therapies; CL: Apply