TEST 4: Comprehensive

Question 1

1. A primigravid client at 26 weeks’ gestation asks the nurse what causes heartburn during
   pregnancy. The nurse should explain to the client that heartburn during pregnancy is usually caused by which of the following?
2. Increased peristaltic action during pregnancy.
3. Displacement of the stomach by the diaphragm.
4. Decreased secretion of hydrochloric acid.
5. Backflow of stomach contents into the esophagus.
6. A client at a follow-up appointment after having a miscarriage 2 weeks previously yells at the
   nurse, “How could God do this to me? I’ve never done anything wrong.” Which of the following
   responses by the nurse would be most appropriate at this time?
7. “God can handle your anger. It’s okay.”
8. “I know you are angry. It’s so hard to lose your baby.”
9. “It isn’t God’s fault. It was an accident.”
10. “You’re a strong person. You will get through this.”
11. A client who has been prescribed chemotherapy is worried and wants to take herbal treatments
    instead. The nurse’s best response to the client is which of the following?
12. “You are making a mistake and placing your life in jeopardy.”
13. “Herbal treatments are not approved by the government’s regulatory agency.”
14. “Herbal treatments have not been researched with cancer.”
15. “Tell me about your concerns with chemotherapy.”
16. A 4-year-old child is admitted for a cardiac catheterization. Which of the following is most
    important to include as the nurse teaches this child about the cardiac catheterization?
17. A plastic model of the heart.
18. A catheter that will be inserted into the artery.
19. The parents.
20. Other children undergoing a catheterization.
21. A client has a reddened area over a bony prominence. The nurse finds a nursing assistant
    massaging this area. The nurse should:
22. Reinforce the nursing assistant’s use of this intervention over the bony prominence.
23. Explain to the nursing assistant that massage is effective because it improves blood flow to the
    area.
24. Inform the nursing assistant that massage is even more effective when combined with the use of
    lotion.
25. Instruct the nursing assistant that massage is contraindicated because it decreases blood flow
    to the area.

Answer 1

1. 4. Heartburn is caused when stomach contents enter the distal end of the esophagus, producing a burning sensation. To avoid heartburn during pregnancy, the client should avoid spicy foods; eat smaller, more frequent meals; and avoid lying down after eating. Peristalsis usually decreases during the latter half of pregnancy. Displacement of the stomach by the uterus, not the diaphragm, may contribute to heartburn. Increased, not decreased, secretion of hydrochloric acid also contributes to heartburn during pregnancy.
      CN: Basic care and comfort; CL: Apply
2. 2. Acknowledging the anger and its source encourages communication about the client’s feelings. Although anger at God is common after a loss, the client is displacing the anger that she needs to deal with more directly. Telling the client that the miscarriage was an accident or that she is a strong person and will get through this ignores the client’s feelings of anger and loss, thereby cutting off communication.
      CN: Psychosocial integrity; CL: Synthesize
3. 4. Asking the client to speak about his concerns encourages open discussion. Telling the client that he is making a mistake is judgmental of the client’s wishes and eliminates opportunities for the client to explore the situation and discuss various treatment options. Saying that herbal treatments have not been approved by regulatory agencies or that they have not been researched is irrelevant, places a value judgment on the client’s wishes, and provides no opportunity for discussion.
      CN: Management of care; CL: Synthesize
4. 3. The most important aspect of teaching a preschooler is to have the family members there for
      support. Preschoolers are able to understand information that is individualized to their level. Including a plastic model of the heart and a catheter as part of the preoperative preparation may be helpful. The other family members will understand the heart model and catheter better than the preschooler will.
      CN: Reduction of risk potential; CL: Synthesize
5. 4. Massaging an area that is reddened due to pressure is contraindicated because it further reduces blood flow to the area. In the past, massaging reddened areas was thought to improve blood flow to the area, and some nursing personnel may still believe that massaging the area is effective in preventing pressure ulcer formation.
      CN: Management of care; CL: Synthesize

Question 2

6. A worried mother confides in the nurse that she wants to change primary care providers
   because her infant is not getting better. The best response by the nurse is which of the following?
7. “This doctor has been on our staff for 20 years.
   ”2. “I know you are worried, but the doctor has an excellent reputation.”
8. “You always have an option to change. Tell me about your concerns.”
9. “I take my own children to this doctor.”
10. A mother who is breast-feeding and has known food sensitivities is asking the nurse what foods she should avoid in her diet. The nurse should advise her to avoid which foods? Select all that apply.
11. Shellfish.
12. Eggs.
13. Peanuts.
14. Beef.
15. Lamb.
16. A widowed client who is receiving chemotherapy tells the nurse that he does not like to cook for himself. A community resource for this client is:
17. Hospice/palliative care association.
18. Home care/visiting nurses group.
19. Meals on Wheels.
20. Association for Retirees.

9. After the client has a temporary pacemaker inserted, the nurse should verify that which of the
following has been documented?
1. The client's cardiovascular status.
2. The client's emotional state.
3. The type of sedation used.
4. Pacemaker rate, type, and settings.

10. The nurse judges that the parent of a 9-month-old infant in a hip spica cast understands how to feed the child when the parent states which of the following?
11. “I can lay my child flat and feed that way.”
12. “I’ll raise my child’s head up and leave the hips and legs on a pillow.”
13. “I can borrow a special feeding table to use.”
14. “It will take two of us, one to hold and one to feed.”

Answer 2

6. 3. Asking the mother to talk about her concerns acknowledges the mother’s rights and encourages open discussion. The other responses negate the parent’s concerns.
      CN: Management of care; CL: Synthesize
7. 1, 2, 3. Some providers recommend that breast-feeding mothers avoid consuming potentially allergic foods.The top 6 foods known to cause allergies in children are shellfish, peanuts, eggs, milk, soy and treenuts.
   CN: Health promotion and maintenance; CL: Apply
8. 3. The Meals on Wheels program delivers meals to clients once a day in their homes. In addition to the improved nutrition, it is commonly valued as a means to check on elderly persons who live alone. Hospice care involves daily needs for the terminally ill at home. Visiting and home care provide skilled nursing care to clients at home. Organizations for retired people are not health care organizations.
      CN: Management of care; CL: Apply
9. 1. The cardiovascular status of the client is the first information documented, and will validate the effective-ness of the temporary pacemaker. The client’s emotional state and the type of sedation are important but not a high priority. The nurse will need to document the pacemaker information (settings of the pacemaker); this will be considered part of the cardiovascular information.
      CN: Management of care; CL: Apply
10. 3. Using a special feeding table or modified high chair is the best method for an infant who is used to sitting up for feedings. The child should not be flat because of the danger of aspiration. Raising the child’s head will not work as well as using a feeding table because the child is not used to lying down to eat. Two people are not necessary.
       CN: Health promotion and maintenance; CL: Evaluate

Question 3

11. The nurse is assessing home care needs for a group of clients. Which clients qualify for home care services? The client who: (Select all that apply.)
12. Requires monitoring of prothrombin time due to Coumadin (warfarin) therapy.
13. Needs additional instruction regarding preparation of food on a low-sodium diet.
14. Has episodes of vertigo that result in falls.
15. Has multiple sclerosis with an open, draining lesion on a foot.
16. Needs stronger lenses for glasses.
17. Forty-eight hours after a ventriculoperitoneal shunt placement, an infant is irritable and vomits a large amount. The assessment reveals a bulging fontanel. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the primary health care provider with the recommendation for:
18. A dose of morphine (Astramorph).
19. A fluid bolus of normal saline.3. A computerized tomography scan.
20. A dose of furosemide (Lasix).
21. The nursing staff has finished restraining a client. In addition to determining whether anyone
    was injured, the staff is mandated to evaluate the incident to obtain which of the following ultimate
    outcomes?
22. Coordinate documentation of the incident.
23. Resolve negative feelings and attitudes.
24. Improve the use of restraint procedures.
25. Calm down before returning to the other clients.
26. The nurse is caring for a client who has experienced severe multiple trauma. The client’s
    arterial blood gases reveal low arterial oxygen levels that are not responsive to high concentrations
    of oxygen. This finding is an indicator of the development of which of the following conditions?
27. Hospital-acquired pneumonia.
28. Hypovolemic shock.
29. Acute respiratory distress syndrome (ARDS).
30. Asthma
31. A client asks the nurse why it is necessary to complete an advance directive on admission to
    the hospital. The nurse’s best response is which of the following?
32. “This will provide a substitute for informed discussion with your primary care provider.”
33. “It is your chance to make your wishes known if you ever become incapable of making your
    own decisions.”
34. “Your primary care provider will make the best decisions for you in an emergency.”
35. “Are you worried that extraordinary means will be taken if you are dying?”

Answer 3

11. 3, 4. Home care may be services for people who are recovering, disabled, or chronically ill and who are in need of treatment or support to function effectively in the home environment. The client with multiple sclerosis and an open lesion is at risk for infection and will require assistance with managing the lesion. Prothrombin monitoring is usually done at the clinic or health care provider office. Diet instruction can be accomplished at a health care facility or dietitian office. The client with vertigo should be monitored for safety in the home. Clients receiving home care services are usually under the care of a physician with the focus of care being treatment or rehabilitation. Lenses for glasses can be evaluated at an eye clinic or an ophthalmologist’s office; a prescription for stronger lenses could be written.
    CN: Management of care; CL: Evaluate
12. 3. The infant is exhibiting signs and symptoms of increased intracranial pressure (ICP) caused by a shunt malfunction. A CT scan, shunt series x-ray, and tapping the shunt are performed to diagnose a shunt malfunction. The irritability is caused by the increased ICP, not postoperative pain. The infant has increased intracranial pressure: a fluid bolus will further increase her ICP. The increased ICP is caused by a shunt malfunction and will not be relieved by Lasix. Surgical intervention is necessary to correct a shunt malfunction.
       CN: Physiological adaptation; CL: Apply
13. 3. Although coordinating documentation, resolving negative feelings, and calming down are
       goals of debriefing after a restraint, the ultimate outcome is to improve restraint procedures.
       CN: Safety and infection control; CL: Synthesize
14. 3. ARDS frequently develops after a major insult to the body. The major diagnostic indicator is low arterial oxygen levels that are not responsive to the administration of high concentrations of oxygen. Early recognition of ARDS is important to increase the client’s chances of recovery. The oxygen levels of clients with hospital-acquired pneumonia, hypovolemic shock, or asthma would be expected to improve with oxygen administration.
       CN: Physiological adaptation; CL: Analyze
15. 2. Clients are offered the chance to make an advance directive, so that their wishes will be
       followed if they become incapable of decision-making. By U.S. law, all clients are asked about
       advanced directives on entering a hospital. In Canada, rules vary by province. The directive is not a substitute for informed discussion with the physician. Worry about extraordinary means can be discussed later, but the client needs to be informed that the directive is a requirement to protect the client’s autonomy.
       CN: Management of care; CL: Synthesize

Question 4

16. When witnessing an adult client’s signature on a consent for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. The nurse should verify which of the following? Select all that apply.
17. That there was adequate disclosure of information.
18. That the client understood the information.
19. That there was voluntary consent on the client’s part.
20. That the client has full awareness of the potential complications.
21. That the client’s relative, spouse, or legal guardian was present.
22. A pregnant woman at 22 weeks’ gestation is diagnosed with gonorrhea. The physician
    prescriptions doxycycline (Vibramycin). The nurse should first:
23. Instruct the client about the effects of the drug.
24. Make sure the record notes that the baby must receive eyedrops when born.
25. Have the physician add a single dose of ceftriaxone (Rocephin).
26. Discuss with the physician the need to change the prescription.
27. After a client undergoes a contraction stress test that is negative, which of the following should the nurse assess next?
28. Evidence of ruptured membranes.
29. Viability status of the fetus.
30. Indications that contractions have ceased.4. Fetal heart rate variability.
31. A 2-month-old infant is at risk for an ileus after surgery to correct intussusception. Which of the following should be included in a focused assessment for this complication? Select all that apply.
32. Measurement of urine specific gravity.
33. Assessment of bowel sounds.
34. Characteristics of the first stool.
35. Measurement of gastric output.
36. Bilirubin levels.
37. A client with asthma asks the nurse if she should use her salmeterol inhaler when she exercises and experiences wheezing and shortness of breath. The nurse’s best response is which of the following?
38. “Yes, use the inhaler immediately for these symptoms.”
39. “No, this drug is a maintenance drug, not a rescue inhaler.”
40. “Use the inhaler 5 minutes before you exercise to prevent the wheezing.”
41. “This inhaler is for allergic rhinitis, not asthma.”

Answer 4

16. 1, 2, 3, 4. The role of the nurse in witnessing the signing of the consent is to witness that the client is informed of the procedure, understands the information, is aware of potential complications, and is signing of his or her own free will. It is not necessary for a spouse, relative, or guardian to be present.
    CN: Management of care; CL: Apply
17. 4. Doxycycline is contraindicated in pregnancy because it can stain the teeth of the developing
       fetus when given during the last half of pregnancy. The nurse should withhold the drug and notify the
       physician to change the prescription. All neonates are given prophylactic ophthalmic ointment for the
       prevention of ophthalmic neonatorum, conjunctivitis caused by gonorrhea. Naprosyn and aspirin may
       be used to treat headaches. Imuran is used to prevent rejection of transplanted organs.
       CN: Pharmacological and parenteral therapies; CL: Synthesize
18. 3. The contraction stress test simulates labor and determines the fetal response to the labor process and the mother’s contractions. Therefore, determining that contractions have ceased after the
       test is important. Although spontaneous rupture of membranes is a possibility after a contraction stress test, it is not a typical occurrence. The test should not affect the viability of the fetus. Fetal viability is related to gestational age. A fetus of at least 23 weeks’ gestation is considered viable, or capable of extrauterine life. A negative contraction stress test should not affect or alter fetal heart rate variability.
       CN: Reduction of risk potential; CL: Synthesize
19. 2, 3, 4. A postoperative ileus is a functional obstruction of the bowel. Assessment of bowel
    sounds, the first stool, and the amount of gastric output provide information about the return of gastric function. Measurement of urine specific gravity provides information about fluid and electrolyte status; bilirubin levels provide information about liver function, and neither of these tests need to be included in a focused assessment for ileus.
    CN: Reduction of risk potential; CL: Analyze
20. 2. Salmeterol is a beta 2 -agonist, a maintenance drug that the asthmatic client uses twice daily, every 12 hours. Albuterol is used as the “rescue inhaler” for bronchospasms. Salmeterol can be used to prevent exercise-induced bronchospasms, but it should be taken 30 to 60 minutes before exercise. If the client is taking salmeterol twice daily, it should not be used in additional doses before exercise; twice daily is the maximum dosage. Indications for salmeterol include only asthma and bronchospasm induced by chronic obstructive pulmonary disease.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 5

21. The nurse should assess the child with nephrotic syndrome for which of the following? Select all that apply.
22. Normal blood pressure.
23. Generalized edema.
24. Normal serum lipid levels.
25. No red blood cells in the urine.
26. Elevated streptococcal antibody titers.
27. A client is receiving spironolactone (Aldactone) for treatment of bilateral lower extremity edema. The nurse should instruct the client to make which of the following nutritional modifications to prevent an electrolyte imbalance?
28. Increase intake of milk and milk products.
29. Restrict fluid intake to 1,000 mL/day.
30. Decrease foods high in potassium.
31. Decrease foods high in sodium.

23. A nurse is assessing a client who is receiving clozapine. The nurse reviews the chart below.
What should the nurse do next?
VITAL SIGNS
06/12/14  - 8 AM
TEMPERATURE -  98 F (36.7 C)
PR - 140
RR - 22
BP - 120/80

06/12/14 -  12 NOON
TEMPERATURE - 98 F (36.7 C)
PR - 148
RR - 24
BP - 122/84

1. Give the clozapine, and tell the client to lie down.
2. Withhold the clozapine, and tell the client to go to an exercise group.
3. Administer the clozapine, and notify the physician.
4. Withhold the clozapine, and notify the primary care provider.
5. A nurse is assessing a client with a history of myocardial infarction who is in the surgical unit
   following a gastric resection. The client has chest pains. The nurse obtains the electrocardiogram
   (ECG) shown (see figure). What should the nurse do first?
6. Administer oxygen.
7. Inspect the client’s incision.
8. Call the rapid response team.
9. Reposition the ECG electrodes.
10. The nurse is watching two siblings, ages 7 and 9 years, verbally arguing over a toy. The nurse
    has counseled the parent before about how to handle this situation. The nurse should judge that the teaching has been effective when the parent does which of the following?
11. Tells the siblings to stop arguing and shake hands.
12. Ignores the arguing and continues what she is doing.
13. Tells the children they will be punished when they go home.
14. Says they will not go out to lunch now since they have argued.

Answer 5

21. 1, 2, 4. Nephrotic syndrome is characterized by massive proteinuria, hypoalbuminemia, edema, and hyperlipidemia and normal or lower than normal blood pressure. Elevated streptococcal antibody titers are associated with poststreptococcal glomerulonephritis, an immune complex disease.
    CN: Physiological adaptation; CL: Analyze
22. 3. Aldactone is a potassium-sparing diuretic often used to counteract potassium loss caused by other diuretics. If foods or fluids are ingested that are high in potassium, hyperkalemia may result and lead to cardiac arrhythmias. Increasing the intake of milk or milk products does not affect the potassium level. Restricting fluid may elevate all electrolytes due to extracellular fluid volume depletion. By increasing foods high in sodium, water would tend to be retained and so would dilute all electrolytes in the extracellular fluid compartment.
       CN: Health promotion and maintenance; CL: Synthesize
23. 4. Because clozapine can cause tachycardia, the nurse should withhold the medication if the
       pulse rate is greater than 140 bpm and notify the physician. Giving the drug or telling the client to
       exercise could be detrimental to the client.
       CN: Pharmacological and parenteral therapies; CL: Synthesize
24. 3. The client has ventricular fibrillation, an arrhythmia that can lead to cardiac arrest. Given the client’s history, the nurse should call the rapid response team to initiate interventions to avoid cardiac arrest. After calling the team, the nurse can administer oxygen. Taking time to inspect the incision delays the necessary intervention. This ECG strip does not show loose electrodes.
       CN: Management of care; CL: Synthesize
25. 2. The best approach by the mother is not to interfere. The children need to learn how to solve
       disagreements on their own. If the parent always intervenes, then the children do not learn how to do
       this. Siblings will disagree and argue as part of normal development. Punishment, including telling the children that they will not go out to lunch, is not warranted.
       CN: Health promotion and maintenance; CL: Evaluate

Question 6

26. A client is diagnosed with genital herpes, (herpes simplex virus type 2, or HSV-2). The nurse should instruct the client that:
27. Using occlusive ointments may decrease the pain from the lesions.
28. Reducing stressful life events may decrease the incidence of herpetic outbreaks.
29. There are no effective drug therapies to manage herpes symptoms.
30. Herpes is transmitted to partners only when lesions are weeping.
31. The client is having ototoxic effects of the vestibular branch of the acoustic nerve. The nurse should assess the client for which of the following? Select all that apply.
32. Vertigo.
33. Tinnitus.
34. Nausea.
35. Ataxia.5. Hearing loss.
36. A young adult has been bitten by a human, and the skin on the forearm is broken. The client’s last tetanus shot was about 8 years ago. The nurse should prepare the client for:
37. An injection of tetanus toxoid.
38. An application of a corticosteroid cream.
39. Closure of the wound with sutures.
40. Testing for tuberculosis.
41. A client 6 weeks postpartum is asking the nurse about taking progesterone (Depo-Provera) for birth control. Prior to discussing options, what should the nurse determine? Select all that apply.
42. If the client has a sexually transmitted disease.
43. How willing her husband is to have her take the drug.
44. If the woman is experiencing postpartum depression.
45. That the woman is not currently pregnant.
46. If the woman is breast-feeding.
47. A mother who is visibly upset tells the nurse she wants to take her child home because the child is dying. Which of the following would be the nurse’s best response?
48. “I know how you feel, but the medication will make your child feel better.”
49. “I can’t let you do this without calling your physician first.”
50. “Can you tell me why you want to take your child home now?”
51. “I can imagine how hard this is for you, but it’s not what’s best for the child.”

Answer 6

26. 2. Managing stressful life events can decrease the incidence of outbreaks of HSV-2. Occlusive
       ointments should not be applied. Antiviral therapies will not cure herpes, but they can manage symptoms and decrease the incidence of outbreaks. Clients with HSV-2 should use condoms to prevent HSV transmission. Cells can be shed at other times, not only when the vesicles are weeping.
       CN: Physiological adaptation; CL: Synthesize
27. 1, 3, 4. The nurse should assess the client for adverse effects affecting the vestibular branch of
    the acoustic nerve, such as vertigo, nausea and vomiting with motion, and ataxia. Tinnitus, or a ringingin the ears, is a clinical manifestation of altered function of the auditory branch of the eighth cranial nerve, not the vestibular branch. The client will not have hearing loss.
    CN: Physiological adaptation; CL: Analyze
28. 1. Tetanus toxoid is indicated, since there has been no booster in the last 5 years. With a
       human bite there is a risk of severe infection; application of a steroid cream does not prevent
       infection. The closure of the wound should be delayed until it is determined that there is no infection, in approximately 24 to 48 hours. Tuberculosis is not transmitted through human bites.
       CN: Reduction of risk potential; CL: Apply
29. 3, 4, 5. Before discussing the use of Depo-Provera as a birth control option, the nurse should
    determine if the woman is or has been depressed because Depo-Provera can increase depression in a
    client with depression. The drug can be transmitted in breast milk, and the long-term effects on the
    baby are not known. Women who are pregnant should not take Depo-Provera. Depo-Provera does not treat or prevent sexually transmitted diseases, so this information is not essential when considering its
    use. Although the husband should be a part of birth control decisions, the final decision is made by the
    client.
    CN: Pharmacological and parenteral therapies; CL: Analyze
30. 3. With a parent who is visibly upset, it is best to try to determine the cause. Therefore, asking the mother about why she wants to take the child home can provide insight into the problem. The nurse cannot stop the mother from taking her child home. However, the physician should be notified about the mother’s decision and efforts are needed to explain the ramifications of taking the child home. It is inappropriate for the nurse to say “I know how you feel” or “I can imagine how hard this is” unless the nurse has had the same experience.
       CN: Psychosocial integrity; CL: Synthesize

Question 7

31. A client with chronic obstructive pulmonary disease is bedridden at home and gets little exercise. The nurse should assess the client for which of the following?
32. Increased sodium retention.
33. Increased calcium excretion.
34. Increased insulin use.
35. Increased red blood cell production.
36. Which of the following indicates that a 5-month-old weighing 15 lb (6.8 kg) and being treated for dehydration has a normal urine output? The urine output is:
37. 1 to 2 mL/kg/h.
38. 3 to 5 mL/kg/h.
39. 6 to 8 mL/kg/h.
40. 10 to 12 mL/kg/h.
41. The nurses in the neonatal intensive care unit are not identifying important clinical changes in
    the clients that need to be documented. The unit director should initiate which of the following
    actions? Select all that apply.
42. Identify the problem at a staff meeting without placing blame on any individual or group.
43. Ask the unit staff to develop a plan that they think will work for the unit members.
44. Ask an experienced nurse to spend time reorienting newer staff members.
45. Collaborate with the staff development educator to develop a plan.
46. Ask the neonatologist to give a presentation about assessing newborns.
47. A 24-year-old client, diagnosed with acute osteomyelitis in the left leg, has acute pain in the
    leg that intensifies on movement. The client has a temperature of 101°F (38.3°C) and a reddened,warm area in the midcalf region over the shaft of the tibia. Based on this information, the nurse should
    do which of the following first?
48. Prepare the client for possible left lower leg amputation.
49. Instruct the client to keep the leg immobile.
50. Develop a plan for pain management.
51. Obtain a prescription for fluid replacement.
52. A client has undergone a vasectomy. The nurse instructs the client that he can begin having
    unprotected intercourse:
53. When desired because sterilization is immediate.
54. As soon as scrotal edema and tenderness resolve.
55. When the sperm count reflects sterilization.
56. After 6 to 10 ejaculations.

Answer 7

31. 2. Prolonged inactivity causes the body to excrete excessive calcium. This leads to breakdown of bone tissue; as a result, the bones become brittle and fracture easily, a condition known as osteoporosis. The excessive calcium excretion that occurs during bed rest also predisposes the client to formation of renal calculi. Prolonged bed rest does not increase sodium retention, insulin use, or red blood cell production.
       CN: Physiological adaptation; CL: Analyze
32. 1. Normal urine output for an infant is 1 to 2 mL/kg/h.
       CN: Physiological adaptation; CL: Evaluate
33. 1, 2, 4. All areas concerned with the safety and quality of care need to participate in the decision-making process and arrive at a plan that will meet the needs of the clients on the neonatal care unit. Identifying the problem at a staff meeting is an ideal forum to bring up the need for improvement and education. The staff is an integral part of the development team. The staff educator is an important member of the team and is responsible for orienting new nurses to the unit. Asking an experienced staff member to spend time in reorienting staff members is difficult to do as the nurses have their own clients to care for. Although the unit director can obtain additional information from the physicians about the problem, the nursing staff has responsibility for assuring that they are
    providing safe and high quality care.
    CN: Safety and infection control; CL: Synthesize
34. 3. Based on the data given, the nurse should develop a plan with the client to manage the pain.
       It is not necessary for the client to be completely immobile. There is no clinical indication that the leg
       will need to be amputated. A temperature of 101°F (38.3°C) would be unlikely to produce a fluid volume deficit in this client.
       CN: Physiological adaptation; CL: Analyze
35. 3. After vasectomy, a sperm analysis will be performed every 4 to 6 weeks. A sperm-free analysis is necessary before the man can be considered sterile. Sperms gradually disappear from the ejaculate. Clients must be informed that conception is possible in the immediate postvasectomy period.
       CN: Physiological adaptation; CL: Apply

Question 8

36. Long-term administration of gentamicin sulfate (Garamycin) to a client has been discontinued.
    The nurse should assess which of the following?
37. Hemoglobin level in 2 weeks.
38. White blood cell count in 2 weeks.
39. Vestibular check in 3 to 4 weeks.
40. Serum potassium level in 1 week.
41. The nurse is assessing an infant diagnosed with bacterial meningitis. The nurse should ask the
    parent if the infant has which of the following? Select all that apply.
42. Fever.
43. Vomiting.
44. Diarrhea.
45. Poor feeding.
46. Abdominal pain.
47. Which of the following nursing interventions would best accomplish the goal of preventing
    atelectasis and pneumonia in a postoperative client?
48. Administering oxygen therapy as needed to maintain adequate oxygenation.
49. Offering pain medication before having the client deep-breathe and use incentive spirometry.
50. Encouraging the client to cough, deep-breathe, and turn in bed once every 4 hours.
51. Forcing fluids to 2,000 mL every 24 hours.
52. A 7-year-old child is admitted to the hospital with acute rheumatic fever. When discussing long-term care for the child with the parents, the nurse should teach them that a necessary part of this care is:
53. Physical therapy.
54. Antibiotic therapy.
55. Psychological therapy.
56. Anti-inflammatory therapy.
57. The nurse is assessing the perineal changes of a woman in the second stage of labor. The
    figure below represents which of the following perineal changes?
58. Anterior-posterior slit.
59. Oval opening.
60. Circular shape.
61. Crowning.

Answer 8

36. 3. Gentamicin (Garamycin) is ototoxic; therefore, the client should have a vestibular and auditory check 3 to 4 weeks after discontinuing the drug. This is the most likely time for deafness to occur. It is not necessary to check the client’s hemoglobin level, white blood cell count, or serum potassium level solely on the basis of having taken gentamicin. The blood urea nitrogen level and the creatinine level will be checked to assess renal function, if necessary.
       CN: Pharmacological and parenteral therapies; CL: Analyze
37. 1, 2, 4. Classic signs of meningitis in an infant include fever, poor feeding, vomiting, and irritability. Abdominal pain and diarrhea are not usual signs of meningitis; they are more commonly associated with gastroenteritis.
    CN: Physiological adaptation; CL: Analyze
38. 2. Deep-breathing exercises and use of incentive spirometry are more effective when pain is minimal. A client in severe pain tends to limit movement and to breathe shallowly to decrease the pain. Enough pain medication should be given to decrease pain without depressing respirations. Administration of oxygen or forcing fluids will not prevent atelectasis or pneumonia. Deep-breathing exercises and use of incentive spirometry should be done 10 times every hour while awake. The client’s position should be changed every 1 to 2 hours to allow for full chest expansion. Ambulation,
       not just sitting in the chair, should be implemented as soon as physician approval is obtained.
       CN: Reduction of risk potential; CL: Synthesize
39. 2. A child who has had rheumatic fever is likely to develop the illness again after a future streptococcal infection. Therefore, it is advised that the child receive antibiotic prophylaxis for at least 5 years and sometimes even longer after the acute attack to prevent recurrence.
       CN: Physiological adaptation; CL: Synthesize
40. 4. Crowning occurs when the fetal head is visible. Anterior-posterior slit occurs as the perineum flattens and is followed by an oval opening. As labor progresses, the perineum takes on a circular shape, followed by crowning.
       CN: Physiological adaptation; CL: Apply

Question 9

41. A client is admitted to the hospital with a diagnosis of suspected pulmonary embolism.
    Physician prescriptions include the following: oxygen 2 to 4 L/min per nasal cannula, oximetry at all
    times, and IV administration of 5% dextrose in water at 100 mL/h. The client has increasing dyspnea
    and has a respiratory rate of 32 breaths/min. The nurse should first:
42. Increase the oxygen flow rate from 2 to 4 L/min.
43. Call the physician immediately.
44. Provide reassurance to the client.
45. Obtain a sample for arterial blood gas analysis.
46. A 10-month-old child has cold symptoms. The mother asks how she can clear the infant’s nose. Which of the following would be the nurse’s best recommendation?
47. Use a cool air vaporizer with plain water.
48. Use saline nose drops and then a bulb syringe.
49. Blow into the child’s mouth to clear the infant’s nose.
50. Administer a nonprescription vasoconstrictive nose spray.

43. A nurse is assessing a client with metastatic lung cancer. The nurse should assess the client
specifically for:
1. Diarrhea.
2. Constipation.
3. Hoarseness.
4. Weight gain.

44. A primary care provider is calling the pediatric unit and asking the nurse to go into the electronic medical record (EMR) for test results of a fellow pediatrician. How should the nurse respond to this request?
45. Identify if the caller is the primary care provider of record or has a need to know.
46. Access the EMR and give the primary care provider the test results.
47. Decline to give the primary care provider the information requested.4. Determine whether the nurse can access the EMR.
48. A client is at risk for development of metabolic alkalosis because of persistent vomiting. The
    nurse should assess the client specifically for:
49. Irritability.
50. Hyperventilation.
51. Diarrhea.
52. Edema

Answer 9

41. 1. The first action is to increase the oxygen flow rate from 2 to 4 L/min to help ensure adequate oxygenation for the client. Although it is important to notify the physician for additional prescriptions and to obtain further assessment data, such as arterial blood gas measurements, it is a priority to support the client’s cardiopulmonary system. It would be appropriate to reassure the clientwhile these other interventions are occurring.
       CN: Reduction of risk potential; CL: Synthesize
42. 2. Although a cool air vaporizer may be recommended to humidify the environment, using
       saline nose drops and then a bulb syringe before meals and at nap and bed times will allow the child to breathe more easily. Saline helps to loosen secretions and keep the mucous membranes moist. The bulb syringe then gently aids in removing the loosened secretions. Blowing into the child’s mouth to clear the nose introduces more organisms to the child. A nonprescription vasoconstrictive nasal spray is not recommended for infants because if the spray is used for longer than 3 days a rebound effect with increased inflammation occurs.
       CN: Reduction of risk potential; CL: Synthesize
43. 3. Hoarseness may indicate metastatic disease to the recurrent laryngeal nerve and is commonly noted with left upper lobe lung tumors. Diarrhea and constipation are not associated with lung cancer. Weight loss, not weight gain, can be a symptom of extensive disease.
       CN: Physiological adaptation; CL: Analyze
44. 1. The nurse should determine if the physician is the physician of record and should have access to the information in the record. The EMR is not for public access. The nurse would not give client information to any physician or refuse to give information without first determining the physician of record and/or a legitimate need to know. As an employee, the nurse should have access to EMRs, but it is not acceptable to enter a medical record without justification.
       CN: Management of care; CL: Synthesize
45. 1. A client with metabolic alkalosis may exhibit irritability or nervousness. Hyperventilation is a clinical manifestation of respiratory alkalosis. Diarrhea is a possible clinical finding in metabolic acidosis. Edema is not specifically associated with an acid-base imbalance.
       CN: Physiological adaptation; CL: Analyze

Question 10

46. Which of the following should first alert the nurse that a child is hemorrhaging after a tonsillectomy?
47. Mouth breathing.
48. Frequent swallowing.
49. Requests for a drink.
50. Increased pulse rate.
51. A nurse is caring for a client who is having an allergic reaction to a blood transfusion. In what order should the nurse provide care for this client?
52. Stop the transfusion.
53. Send the blood bag and blood slip to the blood bank.
54. Keep the vein open with normal saline solution.
55. Administer an antihistamine as directed.
56. The nurse is to administer chloramphenicol (Chloromycetin) 50 mg IV in 100 mL of dextrose 5% in
    water over 30 minutes. The infusion set administers 10 gtt/mL. At what flow rate (in drops per minute) should the nurse set the infusion?
    _______________ gtt/min.
57. A client claims to have a “special mission from God.” The nurse incorporates this religious
    delusion of grandeur into the client’s plan of care based on the understanding that the primary purpose
    of such a delusion is to provide which of the following?
58. Sexual outlet.
59. Comfort.
60. Safety.
61. Self-esteem.
62. A client who has been vomiting for 2 days has a nasogastric tube inserted. The nurse notes that over the past 10 hours the tube has drained 2 L of fluid. The nurse should further assess the client for:
63. Hypermagnesemia.
64. Hypernatremia.
65. Hypokalemia.
66. Hypocalcemia.

Answer 10

46. 2. An initial sign of hemorrhaging after a tonsillectomy is swallowing frequently as mucus and
       blood combine to increase secretions. Mouth breathing is expected after surgery because the child’s mouth is very dry and the throat is sore. Because the child has been without fluids for some time, the child usually is thirsty and asks for a drink. Increased pulse rate is a later sign of hemorrhage.
       CN: Reduction of risk potential; CL: Analyze

47.
1. Stop the transfusion.
3. Keep the vein open with normal saline solution.
4. Administer an antihistamine as directed.
2. Send the blood bag and blood slip to the blood bank.The nurse should first stop the transfusion. The nurse should next keep the IV open at the original
blood transfusion site with normal saline at a keep-vein-open rate. Then, the nurse should administer
an antihistamine. Last, the nurse should return the blood bag and blood slip to the blood bank for
testing.
CN: Pharmacological and parenteral therapies; CL: Synthesize

48. 33 gtt/min
    The flow rate is determined by the rate of infusion and the number of drops per milliliter of the fluid being administered: gtt/mL × mL/min = IV flow rate (gtt/min).Therefore:
    CN: Pharmacological and parenteral therapies; CL: Apply
49. 4. Delusions of grandeur provide the client with an exaggerated sense of self-esteem that is
       unrelated to the client’s actual achievements. Other, less grandiose, religious delusions may provide
       comfort or meaning for the client. Delusions of persecution are frequently related to safety issues.
       Delusions may also be related to sexual issues.
       CN: Psychosocial integrity; CL: Analyze
50. 3. Loss of electrolytes from the gastrointestinal tract through vomiting, diarrhea, or nasogastric suction is a common cause of potassium loss, resulting in hypokalemia. Hypermagnesemia
       does not result from excessive loss of gastrointestinal fluids. Common causes of hypernatremia are water loss (as in diabetes insipidus or osmotic diuresis) and excessive sodium intake. Common causes of hypocalcemia include chronic renal failure, elevated phosphorus concentration, and primary hypoparathyroidism.
       CN: Physiological adaptation; CL: Analyze

Question 11

51. During the clinical breast examination, which of the following is a normal finding?
52. Pronounced unilateral venous pattern.
53. Peau d’orange breast tissue.
54. Long-term, bilateral nipple inversion.
55. Breast tissue that is darker than the areolae.
56. A child with sickle cell crisis is being discharged. As part of discharge teaching to prevent further crisis, the nurse advises the parent to do which of the following?
57. Encourage the child to drink lots of liquids.
58. Take the child’s temperature every morning.
59. Weigh the child every day.
60. Offer the child a high-protein diet.
61. While assessing a neonate 30 minutes after birth, the nurse observes that the child has a short neck covered with webbing. The nurse should further assess the client for:
62. Genetic deviations.
63. Cleft palate.
64. Potter’s syndrome.
65. Neural tube defects.
66. A client has severe diarrhea that has lasted for 2 days. The nurse should now assess the client for:
67. Muscle spasms.
68. Thirst.
69. Arrhythmia.
70. Confusion.
71. The nursing staff on the antepartal unit has Depo Lupron and Depo Provera in the pharmacy for their clients. The nursing staff observed that the vials are similar in size and shape and could be confused. In order to promote client safety, the nursing staff should take which of the following actions? Select all that apply.
72. Petition the pharmacy to relocate one drug away from the other product.
73. Move the drugs to a new position within the medication administration system during the night
    shift.
74. Communicate concerns, measures to remedy, and final decisions to all staff.
75. Leave repositioning of drugs to pharmacy staff to resolve.
76. Collaborate with pharmacy staff to develop a location that works well for both groups

Answer 11

51. 3. It is a normal variation for women to have long-term, bilateral nipple inversion. A woman who has a unilateral nipple inversion that is a new change is at risk for a tumor; the weight of the tumor causes pulling on the nipple. A pronounced unilateral venous pattern, peau d’orange breast tissue, and breast tissue darker than the areolae are definite warning signals for breast cancer that must be reported to the physician immediately.
       CN: Health promotion and maintenance; CL: Analyze
52. 1. It is important for children with sickle cell disease to drink lots of fluids to help prevent a
       crisis. Dehydration precipitates sickling and a crisis. Although taking the child’s temperature may provide information about the child’s status, it will do nothing to prevent a crisis, nor will weighing the child daily. Offering the child a high-protein diet will not prevent a crisis, nor is it recommended.
       CN: Reduction of risk potential; CL: Synthesize
53. 1. The nurse notifies the pediatrician because a short, webbed neck is associated with genetic
       deviations or chromosomal disorders such as Turner’s syndrome. Cleft palate is associated with
       embryonic developmental failures and an abnormal opening in the palate. Potter’s syndrome (renal
       agenesis) is characterized by an atypical facial appearance consisting of a flat nose, recessed chin,
       epicanthal folds, low-set abnormal ears, limb abnormalities, and pulmonary hypoplasia. Neural tube defects are associated with spina bifida or myelomeningocele.
       CN: Physiological adaptation; CL: Analyze
54. 3. Clinical manifestations of hypokalemia include an irregular pulse, fatigue, muscle weakness, flabby muscles, decreased reflexes, nausea, vomiting, and ileus. Muscle spasms are not seen in hypokalemia. Thirst is a symptom of hypernatremia. Confusion can be seen in hyponatremia and hypocalcemia.
       CN: Physiological adaptation; CL: Analyze
55. 1, 3, 5. Notifying the pharmacy of the nursing concerns is an appropriate first action. The nursing staff should work cooperatively with the pharmacy to develop a system that works well for both nursing and pharmacy. Constant communication with all nursing staff during the quality improvement process is integral to the final approval process of both groups. Moving the drugs to a new position within the medication system during an off shift may create errors, as medications are inserted into the system in a certain position. Leaving the decisions to the pharmacy staff eliminates the input provided by nursing, a vital link between medication and the client.
    CN: Management of care; CL: Synthesize

Question 12

56. Which of the following is the most reliable indicator of the existence and intensity of acute pain?
57. The client’s vital signs.
58. The client’s self-report of pain.
59. The nurse’s assessment of the client.
60. The severity of the condition causing the pain.
61. The nurse advises a mother with a 2-year-old child to avoid encouraging excessive milk consumption (more than 3.5 cups per day) by the infant because excess milk consumption can lead to:
62. Vitamin C deficiency.
63. Iron deficiency.
64. Biotin deficiency.
65. Folate deficiency.
66. The nurse is caring for a client with a fracture of a long bone. Which of the following assessments would be the earliest symptom of a fat embolism?
67. Respiratory distress.
68. Confusion.
69. Petechiae.
70. Fever.
71. A client tells the nurse, “Everybody smiles at me because they know that I was chosen by God for this mission.” The nurse interprets this statement as which of the following?
72. Idea of reference.
73. Thought insertion.
74. Visual hallucination.
75. Neologism.
76. The mother of a newborn is voicing concerns about her baby’s ability to hear. The nurse should tell the mother:
77. Newborns cannot hear well until they are at least 6 weeks old.
78. Her concern is unfounded because hearing problems are rare in newborns.
79. Most American states and Canadian jurisdictions now mandate hearing tests for infants.
80. She can test the baby’s hearing by clapping her hands 24 inches (60 cm) from the infant’s head.

Answer 12

56. 2. The client’s self-report of pain is the most reliable indicator of the existence and intensity of the pain. Client response to pain is highly individualized and subjective. The nurse must respect the client’s self-report.
       CN: Basic care and comfort; CL: Evaluate
57. 2. Excessive milk consumption can lead to the displacement of iron-rich foods in the diet. This can result in iron deficiency anemia. Drinking excess milk will not cause vitamin C, biotin, or folate deficiencies.
       CN: Health promotion and maintenance; CL: Apply
58. 2. Although all the symptoms listed can occur in cases of fat embolism syndrome, confusion is the earliest symptom noted. The confusion is caused by a low arterial oxygen level.
       CN: Physiological adaptation; CL: Analyze
59. 1. An idea of reference is a person’s view that other people recognize that she has an important characteristic or power. Thought insertion refers to a person’s belief that others, or a specific other, can put thoughts into her mind. Visual hallucinations involve seeing objects or persons not based on reality. A neologism is a word or phrase that has meaning only to the person using it.
       CN: Psychosocial integrity; CL: Analyze
60. 3. The American Academy of Pediatrics and the American College of Obstetrics and Gynecology recommend hearing screening for all newborns. Currently more than 30 American states mandate screening, as do most Canadian provinces. Newborns can hear as soon as the amniotic fluid drains from the ear canal. Even though hearing problems are not common in newborns, the mother’s concerns should be addressed. Clapping to elicit a response is crude and unreliable. If done for minimal screening, the distance should be no more than 12 inches (30 cm).
       CN: Health promotion and maintenance; CL: Apply

Question 13

61. The physician decides to change a client’s current dose of IM meperidine hydrochloride (Demerol) to an oral dosage. The current IM dosage is 75 mg every 4 hours as needed. What dosage of oral meperidine will be required to provide an equivalent analgesic dose?
62. 25 to 50 mg every 4 hours.
63. 75 to 100 mg every 4 hours.
64. 125 to 140 mg every 4 hours.
65. 150 to 300 mg every 4 hours.
66. The parent asks the nurse about causes of brain injury in children. Which of the following should the nurse expect to include in the response as the major causes? Select all that apply.
67. Falls.
68. Motor vehicle accidents.
69. Bicycle accidents.
70. Child abuse.
71. Tumors.
72. Which of the following nursing measures is most useful in preventing the development of osteoporosis in a client who is immobilized?
73. Beginning weight-bearing activities as soon as possible.
74. Increasing the client’s calcium intake in the diet.
75. Performing passive range-of-motion (ROM) exercises four times a day.
76. Teaching the client to perform isometric exercises.
77. The mother of a toddler asks the nurse what she should do with her toddler when he has a temper tantrum. Which of the following suggestions would be most appropriate?
78. Move the toddler to a time-out chair.
79. Try to talk the toddler out of the tantrum.
80. Leave the toddler alone during the tantrum as long as he is safe.
81. Punish the toddler for having a temper tantrum.
82. A 6-month-old has had a pyloromyotomy to correct a pyloric stenosis. Three days after surgery, the parents have placed their infant in his own infant seat (see figure). The nurse should do which of the following?
83. Reposition the infant to the left side.
84. Ask the parents to put the infant back in his crib.
85. Remind the parents that the infant cannot use a pacifier now.
86. Tell the parents they have positioned their infant correctly.

Answer 13

61. 4. The equianalgesic dose of oral meperidine hydrochloride is up to four times the IM dose.
       Meperidine hydrochloride (Demerol) can be given orally, but it is much more effective when given
       IM.
       CN: Pharmacological and parenteral therapies; CL: Apply62. 1, 2, 3. Children tend to be impulsive, which contributes to head injuries. Also, the larger size
       of the heads of infants and toddlers causes them to fall more easily than older children. Falls account
       for one-third of all head injuries. Motor vehicle accidents account for about 80% of all severe head
       injuries in children. Children aged 5 to 15 are most likely to be involved in bicycle accidents as a
       result of only about 50% wearing helmets. Child abuse and tumors involve a much smaller number of children.
       CN: Health promotion and maintenance; CL: Apply
62. 1. In order to prevent disuse osteoporosis, it is important to implement weight-bearing activities as soon as medically allowed. Increasing the client’s calcium intake will not prevent the development of osteoporosis without the inclusion of weight-bearing activity. Passive ROM exercises and isometric exercises do not provide the bone stress necessary to reduce the risk of
       osteoporosis.
       CN: Reduction of risk potential; CL: Synthesize
63. 3. Toddlers have temper tantrums in their attempt to develop autonomy. Toddlers should be left alone as long as they are safe during a tantrum. Moving the child to a time-out chair or punishing the child reinforces the behavior and is to be avoided. Attempting to talk to the toddler also reinforces the behavior. Additionally, at this cognitive level, toddlers do not understand as well as
       older children do.
       CN: Health promotion and maintenance; CL: Synthesize
64. 4. Following pyloromyotomy, the infant should be positioned with the head elevated and slightly on the right side to promote gastric emptying; the parents have positioned their infant correctly. The infant should be positioned on the right side, not the left side. When the child is in a crib, the head can be elevated and the infant can be propped on the right side. The infant can use a
       pacifier if needed.
       CN: Physiological adaptation; CL: Synthesize

Question 14

66. The nurse on the orthopedic unit is receiving a client from the Post Anesthesia Care Unit (PACU). Which of the following must occur to ensure a safe “hand-off”?
67. An e-mail on the intranet from the nurse in the PACU to the receiving nurse on the orthopedic unit.
68. A page from a transporter who is bringing the client to the receiving nurse.
69. Interactive communication between the nurse from the PACU and the nurse from the orthopedic unit.
70. Delegation of registered nurse (RN) responsibility and accountability to a non-RN on the receiving unit.
71. Which of the following nursing interventions is appropriate for preventing pressure ulcers in an older adult?
72. Cleaning the skin daily using mild soap and hot water.
73. Performing a systematic skin assessment at least once a day.
74. Massaging bony prominences gently every shift.
75. Encouraging the client to sit in a chair as much as possible.
76. The nurse is evaluating the pin insertion site of a client’s skeletal traction. Which of the following indicate a complication?
77. Presence of crusts around the pin insertion site.
78. Serous drainage on the dressing.
79. Slight movement of pin at insertion site.
80. No pain felt by the client at insertion site.
81. On the night before a 58-year-old wife and mother is to have a lobectomy for lung cancer, she
    remarks to the nurse, “I am so scared of this cancer. I should have quit smoking years ago. Now I’ve
    brought all this fear and sadness on myself and now my family.” The nurse should tell the client:
82. “It’s normal to be scared. I would be, too. We’ll help you through it.”
83. “Do you feel guilty because you smoked?”
84. “Don’t be so hard on yourself. You don’t know if your smoking caused the cancer.”
85. “It’s okay to be scared. What is it about cancer that you’re afraid of?”
86. The nurse is caring for an elderly client who has hip pain related to rheumatoid arthritis. The client is practicing appropriate self-care activities when the client chooses to sit in which of the following chairs?
87. Recliner chair with arms to support wrists and hands.
88. Couch with soft cushions to support thighs.
89. Straight-back chair with elevated seat.
90. Curved-back rocking chair.

Answer 14

66. 3. Interactive communication allowing the opportunity for questioning between the giver and
       receiver of client information, including up-to-date information regarding the client’s care, treatment
       and services, current condition, and any recent or anticipated changes is hand-off communication as
       mandated by The Joint Commission and Health Council of Canada. RNs bear primary responsibility and accountability for utilization of all nursing care provided to clients. The RN retains the right and has the responsibility to refrain from delegating specific activities based on individual client care needs, caregiver expertise, and/or client care program requirements.
       CN: Management of care; CL: Apply
67. 2. Daily skin inspection is essential in preventing pressure ulcers. Hot water is irritating to skin and should be avoided. Massaging bony prominences is contraindicated and may actually promote skin breakdown. Prolonged, uninterrupted chair sitting should be avoided; the client’s position should be adjusted at least every hour.
       CN: Reduction of risk potential; CL: Synthesize
68. 3. Skeletal pins should not be loose and able to move. Any pin loosening should be reported
       immediately. Slight serous drainage is normal and may crust around the insertion site or be present on
       the dressing. The pin insertion site should be cleaned with aseptic technique according to facilitypolicy. Pin insertion sites are typically not painful; pain may be indicative of an infection and should be reported.
       CN: Physiological adaptation; CL: Analyze
69. 4. Acknowledging the basic feeling that the client expressed and asking an open-ended
       question allows the client to explain her fears. Saying, “It’s normal to be scared. We’ll help you
       through it,” does not focus on the client’s feelings; rather, it gives reassurance. Asking if the client
       feels guilty for having smoked assumes guilt, which might be present, but additional information is
       needed to confirm. Telling the client not to be so hard on herself does not acknowledge the client’s
       feelings at all.
       CN: Psychosocial integrity; CL: Synthesize
70. 3. It is important that clients with rheumatoid arthritis maintain proper posture and body alignment to support joints and decrease pain and stiffness. Clients with hip pain will be most comfortable when sitting in a straight-back chair with an elevated seat. Elevated seats avoid excessive hip flexion and place less stress on the hip joints.
       CN: Basic care and comfort; CL: Evaluate

Question 15

71. The nurse is planning discharge care with the parents of a 16-year-old boy who recently attempted suicide. The nurse should advise the parents to tell the nurse if their son:
72. Expresses a desire to date.
73. Decides to try out for an extracurricular activity.
74. Gives away valued personal items.
75. Desires to spend more time with his friends.
76. Which of the following responses would be most appropriate for the nurse when comforting a primiparous client whose critically ill neonate delivered at 25 weeks dies while the mother is
    present?
77. “This is probably for the best because his organs were so immature.”
78. “You should try to get pregnant again soon to get over this loss.”
79. “You can stay with your baby as long as you want and say anything you want.”
80. “If you want me to, I can call the chaplain to stay with you.”

73. A nurse is caring for a toddler who is assessed as having hypertonicity, delayed fine motor skills, and poor control of coordinated motion. This is indicative of what cerebral palsy (CP)
classification? Select all that apply.
1. Abnormal involuntary movements.
2. Worm-like writhing movements.
3. Poor coordination.
4. Gross motor skills impairment.
5. Hypertonicity.

74. A 32-year-old woman recently diagnosed with Hodgkin’s disease is admitted for staging by
    undergoing a bone marrow aspiration and biopsy. To obtain more information about the client’s
    nutrition status, the nurse should review the results of which of the following tests?
75. Red blood cell count.
76. Direct and indirect bilirubin levels.
77. Reticulocyte count.
78. Albumin level.
79. The nurse teaches a client taking desmopressin (DDAVP) nasal spray about how to manage
    treatment. The nurse determines that the client needs additional instruction when the client says which of the following?
80. “I should check for sores in my nose while taking this medication.”
81. “I should use the same nostril each time I take the medicine.”
82. “I should report nasal congestion.”
83. “I should report any signs of respiratory infection.”

Answer 15

71. 3. Giving away personal items has consistently been shown to be an indicator of suicidal plans in the depressed and suicidal individual. The other behaviors indicate a return of interest in normal adolescent activities.
       CN: Psychosocial integrity; CL: Synthesize
72. 3. When a neonate dies, the mother should be allowed to stay with the baby as long as she wants and say anything she wants. She is grieving and needs time with the neonate. A photograph should be taken in case the mother wants a photograph at a later time. Telling the mother that this is for the best is inappropriate because such a statement discounts the mother’s feelings. Advising the mother to get pregnant again to get over the loss is not helpful because the mother needs time to grieve and be with the neonate. The nurse should remain near the mother and not delegate this responsibility to the hospital’s chaplain. A chaplain or other religious member can be contacted if the mother
       desires.
       CN: Psychosocial integrity; CL: Synthesize
73. 3, 4, 5. Spastic CP is the most common type, characterized by poor coordination and balance,
    gross motor skills impairment, and hypertonicity. CP is nonprogressive and is caused by a variety of prenatal, perinatal, and postnatal factors. Dyskinetic or athetoid CP is the next most common type and is characterized by abnormal involuntary movements and worm-like writhing movements.
    CN: Physiological adaptation; CL: Analyze
74. 4. Serum albumin levels help determine whether protein intake is sufficient. Proteins are broken down into amino acids during digestion. Amino acids are absorbed in the small intestine, and albumin is built from amino acids. The red blood cell count, bilirubin levels, and reticulocyte count do not indicate protein intake.
       CN: Physiological adaptation; CL: Analyze
75. 2. The client who is taking desmopressin (DDAVP) nasal spray should not use the same nares for administration each time. The client should alternate nares every dose. The client should observefor and report promptly signs and symptoms of nasal ulceration, congestion, or respiratory infection.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 16

76. The nurse has a prescription to administer ampicillin 250 mg IM. After reconstituting the ampicillin with sterile water for injection, the solution available is 500 mg/mL. How many milliliters should the nurse administer?
    _______________ mL.
77. A client is a 43-year-old G2 P1 at 16 weeks’ gestation that has completed prenatal testing for
    chromosomal abnormalities. The results reveal the infant is a female with Down syndrome. The
    parents are seeking information about this syndrome. The nurse should tell the parents which of the following? Check all that apply.
78. Down syndrome can occur in mothers of any age.
79. Down syndrome is correlated with autosomal dominant traits carried by the parents.
80. Down syndrome is a result of autosomal recessive traits carried by the parents.
81. Down syndrome depends upon maternal prenatal care since pregnancy began.
82. Down syndrome occurs more frequently with advanced maternal age.
83. Down syndrome results from a trisomy of chromosome 21.
84. The nurse assesses a client and notes a weak, irregular pulse, as well as soft, flabby muscles.
    The nurse should assess the client further for:
85. Hypercalcemia.
86. Hypernatremia.
87. Hypokalemia.
88. Hypomagnesemia.
89. A primiparous client at 48 hours postpartum is to be given medroxyprogesterone acetate (Depo-Provera) before discharge. Which of the following should the nurse include in the teaching plan before administering this medication?
90. There is an increased risk of ovarian cancer with use of this drug.
91. Amenorrhea is common during the first 6 months.
92. Heavy menstrual bleeding may occur.
93. The client may experience periods of increased energy.
94. The nurse establishes the goal of preventing the development of a stress ulcer in a burn client.
    Which of the following interventions would most likely contribute to the achievement of this goal?
95. Implementing relaxation exercises.
96. Administering a sedative as needed.
97. Providing a soft, bland diet.
98. Administering famotidine (Pepcid) as prescribed.

Answer 16

76. 0.5 mL
    CN: Pharmacological and parenteral therapies; CL: Apply
77. 1, 5, 6. Down syndrome is the most common trisomal abnormality. It can occur at any maternal age with the average being 27 years. The risk of bearing a Down syndrome infant increases with advanced maternal age. The syndrome is caused by nondisjunction during the first meiotic cell division, rather than autosomal dominant or recessive traits. There is no association with timing or quality of prenatal care.
    CN: Health promotion and maintenance; CL: Apply
78. 3. Common clinical manifestations of hypokalemia include ventricular arrhythmias, weak and irregular pulse, soft and flabby muscles, and decreased deep tendon reflexes. Hypercalcemia causes confusion and decreased memory, bone pain, polyuria, and nausea, vomiting, and constipation. Hypernatremia causes signs of fluid volume deficit. Hypomagnesemia is manifested by tremors, confusion, hyperactive deep tendon reflexes, and seizures.
       CN: Physiological adaptation; CL: Analyze
79. 3. As with other contraceptives that are progestin based, heavy menstrual bleeding may occur. Other adverse effects include rash, acne, alopecia, fluid retention, edema, and sudden loss of vision. Depression and weight gain have been reported. For clients taking this drug, the risk of endometrial or ovarian cancer is decreased. Amenorrhea has been reported in clients after receiving four injections 3 months apart for 1 year. Depression and loss of energy have been reported.
       CN: Pharmacological and parenteral therapies; CL: Create
80. 4. Clients with burns are susceptible to the development of Curling’s ulcer, a gastroduodenal
       ulcer that is caused by a generalized stress response. The stress response results in increased gastric acid secretion and a decreased production of mucus. Prevention is the best treatment, and clients are
       frequently treated prophylactically with antacids and H 2 histamine blockers such as famotidine
       (Pepcid).
       CN: Reduction of risk potential; CL: Synthesize

Question 17

81. The nurse is instructing the parents of a child with acquired immunodeficiency syndrome (AIDS) how to look for signs and symptoms of infection when the child has a cut or open wound. The nurse should tell the parents to report:
82. Erythema around the area.
83. Rectal temperature higher than 100.5°F (38°C).
84. Tenderness around the area.
85. Increased warmth of the skin in the involved area

.

82. The nurse is teaching a group of unlicensed assistive personnel (UAP) about providing care to clients with depression. Which approach by one of the UAPs indicates an understanding of the most effective approach to a depressed client?
83. Cheerful.
84. Empathetic.
85. Serious.
86. Humorous.
87. When fluids by mouth are appropriate for the infant after surgery to correct intussusception, the nurse most likely would initiate feeding with:
88. Cereal-thickened formula.
89. Full-strength formula.
90. Half-strength formula.
91. Oral electrolyte solution.
92. A client is taking paroxetine (Paxil) 20 mg PO every morning. The nurse should monitor the client for which of the following adverse effects?
93. Hypertensive crisis.
94. Sexual problems.
95. Sleep disturbance.
96. Orthostatic hypotension.
97. Which of the following neurologic changes indicates that the client is in the progressive stage of shock?
98. Restlessness.
99. Confusion.
100. Incoherent speech.
101. Unconsciousness.

Answer 17

81. 2. Fever is a cardinal manifestation of infection in people with AIDS. Because the major physiologic alteration in AIDS is generalized immune system dysfunction, typical indicators of the body’s response to infection (eg, erythema, warmth, tenderness) may be absent.
       CN: Physiological adaptation; CL: Synthesize
82. 2. To care effectively for clients with depression, the nurse should teach the importance of demonstrating empathetic concern. Caregivers must accept clients as they are even though many will
       be angry and negative, acknowledge their emotional pain, and offer to help them work through their
       pain. For the client who is depressed, using a cheerful demeanor or a humorous, light-hearted
       approach may be overwhelming because the client will be unable to meet the caregiver’s expectations, subsequently leading to decreased self-worth. A serious, business-like affect may threaten the client and inhibit the development of trust.CN: Management of care; CL: Evaluate
83. 4. When a child is ready to take fluids by mouth postoperatively, clear liquids are given initially. If clear liquids are tolerated, the concentration and amount of oral feedings are gradually increased. This means advancing to half-strength and then to full-strength formula while increasing the amount given with each feeding.
       CN: Basic care and comfort; CL: Synthesize
84. 2. The nurse should monitor the client taking paroxetine, a selective serotonin reuptake inhibitor, for sexual problems, such as decreased libido, impotence, and ejaculatory disturbances, because these adverse effects can occur frequently and lead to medication noncompliance. Sleep disturbances can occur with an SSRI such as paroxetine. However, this client is taking the drug every morning, which would not affect nighttime sleep. Hypertensive crisis is associated with the ingestion of foods rich in tyramine when a client is taking a monoamine oxidase inhibitor. Orthostatic hypotension is a potential adverse effect of tricyclic antidepressants.
       CN: Pharmacological and parenteral therapies; CL: Analyze
85. 2. In the progressive stage of shock, the client can display listlessness or agitation, confusion,
       and slowed speech. Restlessness occurs in the compensatory stage. Incoherent speech and
       unconsciousness are clinical manifestations of the irreversible stage.
       CN: Physiological adaptation; CL: Analyze

Question 18

86. A child diagnosed with osteomyelitis will be discharged on IV nafcillin (Unipen). After teaching the parents about adverse effects that are important to report, which effects as stated by the parents indicate that they understand the teaching? Select all that apply.
87. Sore mouth.
88. Pain with urination.
89. Headache.
90. Stomach upset.
91. Fever.
92. The rapid response team arrives in the room of a client who has had a cardiac arrest. The nurse should first apply which piece of monitoring equipment?
93. Electrocardiogram (ECG) electrodes.
94. Pulse oximeter.
95. Blood pressure cuff.
96. Doppler for pulse check.
97. A nurse is counseling a client who is depressed. What nursing action promotes trust between the client and the nurse? Select all that apply.
98. Indicating an understanding for the client’s feelings as well as for their cause.
99. Listening and encouraging the client to say more.
100. Acknowledging that the nurse heard what the client said.
101. Maintaining eye contact with the client at all times.
102. Standing very close to the client.

89. The nurse is assessing a client for heroin addiction. Which of the following indicate the client
has used heroin?
1. Whites red and bloodshot.
2. Pupils small and constricted.
3. Pupils large and dilated.
4. Drooping eyelids.

90. When performing routine health evaluations in school-age children, which of the following would alert the school nurse to pediculosis capitis (head lice)?
91. Spotty baldness.
92. Wheals with scalp blistering.
93. Frequent scalp scratching.
94. Dry, scaly patches on the skin.

Answer 18

86. 1, 4, 5. Common adverse effects of nafcillin include vomiting, diarrhea, sore mouth, fever, and gastritis. Pain with urination and headache are not associated with this drug. CN: Pharmacological and parenteral therapies; CL: Evaluate
87. 1. The nurse should first apply the ECG electrodes to the client’s chest. If the client is found to be in ventricular fibrillation, the immediate priority is to defibrillate the client. Pulse oximetry is not an immediate priority. The client’s oxygenation is evaluated in a code situation using arterial blood gas analysis. The client’s blood pressure is evaluated after the ECG rhythm has been established. A portable Doppler ultrasound unit may be needed to check for the presence of a pulse or to check the blood pressure in a code situation.
       CN: Safety and infection control; CL: Synthesize
88. 1, 2, 3. Active listening facilitates trust. It means that the nurse acknowledges that she has heard the client and indicates in her own words an understanding of what the client says and the emotions underlying what is said. It also involves encouraging the client to say more. Constant eye contact and standing very close to a client can be unnerving and can hamper trust building.
    CN: Psychosocial integrity; CL: Synthesize
89. 2. Heroin causes pinpoint pupils. Marijuana causes the eyes to appear red and bloodshot. Cocaine use causes pupils to dilate. Drooping of the eyelids is not typically associated with the use of any substance.
       CN: Pharmacological and parenteral therapies; CL: Analyze
90. 3. A typical sign of pediculosis capitis (head lice) is frequent scratching of the scalp because the condition causes severe itching. Scratch marks are usually easily visible. Because head lice are easily transmitted to others, the child’s family members and peers also should be examined forinfestation. Spotty baldness, wheals, and scaly lesions are often allergic in nature.
       CN: Physiological adaptation; CL: Analyze

Question 19

91. Which of the following best indicates that a client’s peristaltic activity is returning to normal after surgery?
92. The client passes flatus.
93. The client says that she is hungry.
94. Bowel sounds are hypoactive on auscultation.
95. Peristalsis can be felt on abdominal palpation.
96. A client appears flushed and has shallow respirations. The arterial blood gas report shows
    the following: pH, 7.24; partial pressure of arterial carbon dioxide (Pa CO2 ), 49 mm Hg (6.5 kPa);
    bicarbonate (HCO 3 ), 24 mEq/L (24 mmol/L). These findings are indicative of which of the followingacid-base imbalances?
97. Metabolic acidosis.
98. Metabolic alkalosis.
99. Respiratory acidosis.
100. Respiratory alkalosis.
101. Which of the following measures is most important for pain management for a client after a
     lobectomy for lung cancer?
102. Repositioning the client immediately after administering pain medication.
103. Reassessing the client after administering pain medication.
104. Reassuring the client after administering pain medication.
105. Readjusting the pain medication dosage as needed.
106. The nurse is evaluating a female client’s understanding of how to prevent sexually transmitted diseases (STDs). Which of the following statements indicates that the client understands how to protect herself?
107. “I will be sure my partner uses a condom.”
108. “I need to be sure to take my birth control pills.”
109. “I will always douche after sexual intercourse.”
110. “I will be sure to take antibiotics to prevent an STD.”
111. While assessing a multigravid client at 10 weeks’ gestation, the nurse notes a purplish color to the vagina and cervix. The nurse documents this finding as which of the following?
112. Goodell’s sign.
113. Chadwick’s sign.
114. Hegar’s sign.
115. Melasma.

Answer 19

91. 1. Passing flatus indicates the return of peristalsis, as does active bowel sounds. Hunger is not the best indicator of peristaltic return. Hypoactive bowel sounds indicate that there is some peristaltic activity but it is limited and not yet normal. Palpation is not an appropriate method of assessing bowel activity.
       CN: Physiological adaptation; CL: Evaluate
92. 3. The pH of 7.24 indicates that the client is acidotic. The Pa CO2 value of 49 mm Hg (6.5 kPa) is elevated. The HCO 3 value of 24 mEq/L (24 mmol/L) is normal. The client is in uncompensated respiratory acidosis. Hypoventilation and a flushed appearance are additional clinical manifestations of respiratory acidosis.
       CN: Physiological adaptation; CL: Analyze
93. 2. It is essential for the nurse to evaluate the effects of pain medication after it has had time to act. Although other interventions may be appropriate, continual reassessment is most important to determine the effectiveness and need for additional intervention, if any. Repositioning could provide some comfort, but assessment of the client’s pain level is essential. Reassuring the client is important, but it will be of no value unless the nurse evaluates the client’s pain level. To readjust the pain dosage is appropriate only if titration is prescribed by the physician.
       CN: Basic care of comfort; CL: Synthesize
94. 1. Barrier contraceptives must be used to protect against STDs. Birth control pills and douching are not effective for prevention of STDs. Prophylactic antibiotics are not used to prevent the acquisition of STDs.
       CN: Safety and infection control; CL: Evaluate
95. 2. A purplish blue discoloration of the vagina and cervix is termed Chadwick’s sign; it is caused by increased vascularity of the vagina during pregnancy and is considered a probable sign of pregnancy. Goodell’s sign, also considered a probable sign of pregnancy, refers to a softening of the cervix during pregnancy. Hegar’s sign, also a probable sign of pregnancy, refers to a softening of the lower uterine segment. Melasma, the mask of pregnancy, refers to the pigmentation of the skin on the face during pregnancy. Melasma is considered a presumptive sign of pregnancy.
       CN: Health promotion and maintenance; CL: Apply

Question 20

96. A client with bipolar disorder, mania, has flight of ideas and grandiosity and becomes easily agitated. To prevent harmful behaviors, which of the following should the nurse do initially?
97. Encourage the client to stay in his room.
98. Seclude the client at the first sign of agitation.
99. Tell the client to seek out staff when feeling agitated.
100. Instruct the client to ask for medication when agitated.
101. The nurse is preparing written information for an older adult who is to manage intermittent self-catheterization. Which of the following will be most effective?
102. Use charts to help convey information.
103. Prepare information at a tenth-grade reading level.
104. Use short words.
105. Print the material in a condensed font.
106. The nurse should assess which of the following in a child newly diagnosed with hyperthyroidism? Select all that apply.
107. Weight gain.
108. Dry skin.
109. Constipation.
110. Rapid pulse.
111. Heat intolerance.
112. The nurse is planning care for four mothers and their newborns. After reviewing the clients’ charts, the nurse should make rounds on which of the following clients first?
113. An 18-year-old G2 P2 with an uncomplicated spontaneous vaginal birth 12 hours ago who has
     abdominal cramps.
114. A 35-year-old G4 P4 with an uncomplicated vaginal birth 4 hours ago. The nurse’s notes indicated she soaked two peripads over the last 2 hours; fundus is firm.
115. A 16-year-old G1 P1 with a caesarean section 4 hours ago, diagnosed with preeclampsia and receiving magnesium sulfate at 2 g/h. Reflexes are 2+, and the nurse’s notes indicate she has a headache. Vital signs are T 99.4 ̊F (37.4 ̊C), P 88, R 20, BP 128/86.
116. An 18-year-old G2 P2 who had a caesarian birth 2 days ago and now has severe breast pain. Vital signs are T 99.8 ̊F (37.7 ̊C), P 96, R 22.
117. A nurse is evaluating the proper use of crutches by a client who has fractured the right leg. Which statement indicates the client is using the correct technique?
118. “I move my left leg forward first as I swing forward on my crutches.”
119. “I need to increase my arm strength because my arms tingle after I use my crutches.”
120. “I padded the tops of my crutches so that I can lean more comfortably on my crutches.”
121. “I feel pressure on the palms of my hands when I am walking with my crutches.”

Answer 20

96. 3. Initially, the nurse would tell the client to seek out staff when feeling agitated or upset to
       prevent violent episodes. Doing so helps the client to redirect negative feelings in an appropriate
       manner (eg, talking). Encouraging the client to stay in his room is inappropriate because it does not
       help the client to deal with his feelings. Secluding the client at the first sign of agitation is not indicated and may be perceived by the client as punishment. Instructing the client to ask for medication when agitated would not be the initial course of action. The nurse would interact with the client and direct the client to an activity to decrease his anxiety before intervening with any required medication.
       CN: Psychosocial integrity; CL: Synthesize
97. 3. The nurse should use short words, sentences, and paragraphs and avoid medical jargon.Correct terminology should be used when appropriate (eg, type 1 diabetes, not “sugar diabetes”). The format should be as simple as possible; charts are not necessary and may be confusing to some clients. Information should be prepared at a fifth-grade reading level. The information should be presented in large-sized type.
       CN: Psychosocial integrity; CL: Synthesize
98. 4, 5. Rapid pulse, heat intolerance, diarrhea, exophthalmos, and accelerated linear growth are
    more characteristic of hyperthyroidism, which is caused by an autoimmune response to thyroid-
    stimulating hormone receptors. Weight gain, dry skin, and constipation are characteristic of
    hypothyroidism, which results from a deficiency in secretion of thyroid hormone.
    CN: Physiological adaptation; CL: Analyze
99. 2. The criteria for hemorrhage is saturating one pad per hour. The 35-year-old who gave birth
       4 hours ago had saturated a peripad per hour. Even though her fundus is firm, she may have experienced a cervical laceration which would be the source of the bleeding. She needs to be
       evaluated first, based on the bleeding. The 18-year-old who has abdominal cramps is within normal
       limits for a G2 P2 and is experiencing afterbirth pains normally seen in a multiparous client; she will
       need pain medication. The 16-year-old status post cesarean section on magnesium sulfate is stable
       with adequate urinary output and normal reflexes. Her vital signs are within normal limits for a post- partum client. The headache is the one area of concern for this client. The 18-year-old who is 2
       days postpartum with breast pain may be experiencing her milk coming in, although it does not indicate whether she is breast- or bottle-feeding; either situation may find a mother with milk
       developing within her system. The vital signs for this client are slightly elevated, but this may be from
       the milk coming in and would require nursing evaluation but is not emergent.
       CN: Management of care; CL: Synthesize
100. 4. It is normal for the client to feel pressure on the palms of the hands when walking with crutches. The client should move her affected (right) leg forward first as she swings forward with the
        crutches. Leaning on the crutches can apply pressure to the axillae, leading to neurovascular
        impairment. If the client’s arms are tingling after she uses her crutches, she is probably applying
        pressure on her axillae when walking.
        CN: Reduction of risk potential; CL: Evaluate

Question 21

101. Which of the following factors is a priority when evaluating discharge plans for an older adult after a lower left lobectomy for lung cancer?
102. The distance the client lives from the hospital.
103. Support available for assisting the client at home.
104. The client’s ability to do home blood pressure monitoring.
105. The client’s knowledge of the causes of lung cancer.
106. A primiparous client planning to breast-feed her term neonate born vaginally asks, “When will my ‘real’ milk come in?” The nurse explains to the client that after childbirth, breasts begin to fill with milk within which of the following periods?
107. 12 hours.
108. 24 hours.
109. 2 to 4 days.
110. 7 days.
111. The nurse is caring for an elderly, debilitated client who has been bedridden for an extended period. Which of the following indicates that the client has hypoxia?
112. Chills.
113. Productive cough.
114. Confusion.
115. Pleuritic chest pain.
116. A child with rheumatic fever has polyarthritis and chorea. An echocardiogram shows swelling of the cardiac tissue. Which of the following should the nurse include in the child’s plan of care?
117. Explaining that the chorea will disappear over time.
118. Performing neurologic checks every 4 hours until the chorea subsides.
119. Promoting ambulation by administering aspirin every 4 hours.
120. Keeping the child in a slightly cool environment.
121. A 19-year-old unmarried college student who is approximately 8 weeks pregnant asks the nurse, “If I have an abortion in the next 2 or 3 weeks, how will it be done?” The nurse instructs the client that at this gestational age, an abortion is usually performed by which of the following techniques?
122. Dilatation and curettage.
123. Menstrual extraction.
124. Dilatation and vacuum extraction.
125. Saline induction.

Answer 21

101. 2. Because clients are discharged as soon as possible from the hospital, it is essential to
        evaluate the support for assistance and self-care at home. If the client has support at home, the
        distance from the hospital may be irrelevant. The client or support team will monitor vital signs as
        needed, but blood pressure monitoring is not specifically indicated. It is more important at this point for the client to understand how to manage his care at home, rather than knowing the causes of lung cancer.
        CN: Management of care; CL: Analyze
102. 3. If the client begins breast-feeding early and often after childbirth, the breasts begin to fill with milk within 48 to 96 hours, or 2 to 4 days. The breasts secrete colostrum for the first 24 to 48
        hours, which is beneficial to the neonate because of the immunoglobulins contained in colostrum.
        CN: Health promotion and maintenance; CL: Apply
103. 3. The predominant clinical finding in elderly or debilitated clients indicating that they havehypoxia is confusion. Fever and chills, productive cough, and pleuritic chest pain could be indicative of a respiratory track infection.
        CN: Physiological adaptation; CL: Analyze
104. 1. It is important for the child and family to understand that chorea associated with rheumatic
        fever is not permanent. Therefore, the nurse should explain that the chorea will disappear over time.
        It is not necessary to assess the child’s neurologic status because the chorea is self-limited and
        nonprogressive. Because the child has cardiac involvement, ambulation is contraindicated. Aspirin is used primarily as an anti-inflammatory drug and secondarily for pain relief. A slightly cool environment is unnecessary. Environmental temperature does not affect the child’s polyarthritis and chorea.
        CN: Physiological adaptation; CL: Synthesize
105. 1. When the gestation is less than 13 weeks, an elective abortion is usually performed by the
        dilatation and curettage method. Menstrual extraction, or suction evacuation, is the easiest method, but it is used only when the client is between 5 and 7 weeks’ gestation. Dilatation and vacuum extraction is used when clients are between 12 and 16 weeks’ gestation. Saline induction, used for clients between 16 and 24 weeks’ gestation, involves instillation of a hypertonic saline solution into the amniotic sac to initiate expulsion. Oxytocin infusion may also be used with saline induction.
        CN: Health promotion and maintenance; CL: Apply

Question 22

106. The nurse is performing a respiratory assessment on a client who has a pleural effusion. The nurse should determine if the client has:
107. Decreased chest movement on the affected side.
108. Normal bronchial breath sounds.
109. Hyperresonance on percussion.
110. Fever.
111. A nurse is caring for a child with intussusception. Which of the following is an expected outcome for a goal to relieve acute pain from abdominal cramping?
112. The child exhibits no manifestations of discomfort.
113. The child is very still.
114. The child has a normal bowel movement.
115. The child has not vomited in 3 hours.
116. Gentamicin sulfate (Garamycin) 25 mg IM has been prescribed every 6 hours. Garamycin 40 mg/mL is available. The nurse should administer how many milliliters? _______________ mL.
117. Assessment of a 36-year-old woman who has malaise and dysuria reveals a temperature of
     100°F (37.4°C) and painful blisters on the outside of her vagina. The client tells the nurse she had
     intercourse with a new partner 5 days ago. The nurse should:
118. Advise the client to ask her partner to use a condom.
119. Encourage the client to increase fluid to 3,000 mL/day.
120. Tell the client to use a lubricant jelly on the blisters.
121. Refer the client to a health care provider.
122. A child with leukemia fails to respond to therapy. Which of the following statements offers the nurse the best guide in making plans to assist the parents in dealing with their child’s imminent death?
123. Knowing that the prognosis is poor helps prepare relatives for the death of children.
124. Relatives are especially grieved when a child does well at first but then declines rapidly.
125. Trust in health personnel is most often destroyed by a death that is considered untimely.
126. It is more difficult for relatives to accept the death of a 10-year-old than the death of a younger
     child whose family membership has been short.

Answer 22

106. 1. A pleural effusion is a collection of fluid between the pleural layers of the lung. The effusion decreases chest wall movement on the affected side. The nurse should expect the breath sounds to be decreased or diminished over the affected area. Because of the presence of fluid, percussion would elicit dullness, not hyperresonance. Fever may be present if empyema (purulent pleural fluid with bacterial infection) has developed, but not in the case of a nonpurulent pleural
        effusion.
        CN: Basic care and comfort; CL: Analyze
107. 1. An expected client outcome for a goal to reduce acute pain related to cramping is that the client exhibits no manifestations of discomfort, such as crying or drawing the legs to the abdomen. Being very still may indicate either a pain state or a state of relaxation, and the nurse would need to assess the client further. Having normal bowel movements and not vomiting are desired outcomes, but the goal here is to relieve the pain.
        CN: Physiological adaptation; CL: Synthesize
108. 0.6 mL
     CN: Pharmacological and parenteral therapies; CL: Apply
109. 4. The client is likely exhibiting symptoms of herpes genitalis, which include painful blisters
        or vesicles that appear 2 to 20 days after transmission of the disease. The client was most likely exposed from her new partner. The client should be referred to a health care provider for treatment. Having her partner wear a condom, increasing fluids, or using lubricant jelly will not treat the infection.
        CN: Management of care; CL: Synthesize
110. 2. It has been found that parents are more aggrieved when optimism is followed by defeat.
        The nurse should recognize this when planning various ways to help the parents of a dying child. It is not necessarily true that knowing about a poor prognosis for years helps prepare parents for a child’s death, that trust in health personnel is destroyed when a death is untimely, or that it is
        more difficult for parents to accept the death of an older child than that of a younger child.
        CN: Psychosocial integrity; CL: Synthesize

Question 23

111. The nurse is caring for a child receiving a blood transfusion. The child becomes flushed andis wheezing. What should the nurse do first?
112. Notify the physician.
113. Administer oxygen.
114. Switch the transfusion to normal saline solution.
115. Take the child’s vital signs.
116. A client who is allergic to penicillin has a prescription to receive cefazolin (Ancef). The nurse’s initial response is to:
117. Ask if the client has taken cefazolin before.
118. Consult with the physician or a clinical pharmacist.
119. Administer cefazolin immediately.
120. Observe the client closely for urticaria.
121. Which of the following nursing interventions will promote successful achievement of Erickson’s stage of development for the 3-year-old toddler?
122. Allowing the toddler to choose what time to take her antibiotic.
123. Encouraging the toddler to assist in removing the dressing on her leg.
124. Allowing the toddler to work on an art project that she can complete.
125. Encouraging friends to visit the toddler in the hospital.
126. When preparing the teaching plan for a client about lithium therapy, the nurse should teach the client about:
127. Maintaining an adequate sodium intake.
128. Discontinuing sodium in the diet.
129. Buying foods labeled “low in sodium.”
130. Increasing sodium in the diet.
131. A client who is undergoing radiation therapy develops mucositis. Which of the following interventions should be included in the client’s plan of care?
132. Increasing mouth care to twice per shift.
133. Providing the client with hot tea to drink.
134. Promoting regular flossing of teeth.
135. Using half-strength hydrogen peroxide on mouth ulcers.

Answer 23

111. 3. The child is having a reaction to the blood transfusion. The priority is to stop the blood
        transfusion but maintain an open venous access for medication or high fluid volume delivery. Thus,
        switching the transfusion to normal saline solution would be done first. Since the child is having
        difficulty breathing, applying oxygen would be the next action. Additionally, vital signs are taken to
        determine the extent of circulatory involvement. Then the physician would be notified and, if
        necessary, the crash cart would be obtained.
        CN: Pharmacological and parenteral therapies; CL: Synthesize
112. 1. A client who has an allergy to penicillin may have a cross-sensitivity to cefazolin (Ancef), a first-generation cephalosporin, and the drug should be given with caution. The nurse should ask the client whether he has taken cefazolin before. The nurse should inform the pharmacy of the client’s allergy after asking the client about prior use of cefazolin. The medication should not be administered until the nurse first inquires about the client’s exposure to cefazolin and then consults the pharmacist or physician. Observing the client for urticaria is appropriate but is not an initial response.
        CN: Safety and infection control; CL: Synthesize
113. 2. Toddlers are in Erikson’s stage of autonomy versus shame and doubt. They want to do things on their own and experience despair when they are not allowed to be independent in areas which they are capable. Allowing the toddler to participate in the dressing change promotes their independence. Medications must be administered on a schedule to maintain therapeutic levels. Toddlers have short attention spans and would not likely complete an art project. Toddlers commonly engage in parallel play. Having another toddler visit will not aid in the achievement of Erikson’s stage of development.
        CN: Psychosocial integrity; CL: Analyze
114. 1. The nurse would teach the client taking lithium and his family about the importance of maintaining adequate sodium intake to prevent lithium toxicity. Because lithium is a salt, reduced sodium intake could result in lithium retention with subsequent toxicity. Increasing sodium in the diet is not recommended and may be harmful. Increased sodium levels result in lower lithium levels.
        Therefore, the drug may not reach therapeutic effectiveness.
        CN: Pharmacological and parenteral therapies; CL: Synthesize
115. 3. Mucositis is an inflammation of the oral mucosa caused by radiation therapy. It is important that the client with mucositis receive meticulous mouth care, including flossing, to prevent the development of an infection. Mouth care should be provided before and after each meal, at bedtime, and more frequently as needed. Extremes of temperature should be avoided in food and
        drink. Half-strength hydrogen peroxide is too harsh to use on irritated tissues.
        CN: Reduction of risk potential; CL: Synthesize

Question 24

116. A parent calls the Poison Control Center because her 3-year-old has eaten 10 to 12 chewable acetamino-phen tablets. What should the nurse instruct the parent to do?
117. Give the child a large glass of milk.
118. Induce vomiting.
119. Take the child to the emergency department.
120. Monitor the child’s respirations for 24 hours.
121. The parent of a preschool-aged child tells the nurse that the child is hyperactive and something needs to be done. Which of the following responses by the nurse would be most appropriate initially?
122. “What makes you think your child is hyperactive?”
123. “What do you think needs to be done?”
124. “How does your child behave normally?”
125. “Why not wait and see what the doctor says?”
126. When preparing for the discharge of a newborn after surgery to correct tracheoesophageal fistula (TEF), the nurse teaches the parents about the need for long-term health care because their child has a high probability of developing which of the following?
127. Recurrent mild diarrhea with dehydration.
128. Esophageal stricture.
129. Speech problems.
130. Ulcers.
131. A young man with Hodgkin’s disease has been readmitted to the hospital because of aggressive disease that is unresponsive to multiple therapies. Death appears imminent. A priority goal for this client is to:
132. Reduce feelings of isolation.
133. Reduce fear of pain.
134. Reduce fear of more aggressive therapies.
135. Reduce feelings of social inadequacy.
136. A client is admitted in early active labor at 39 weeks’ gestation with intact membranes. When assessing the fetal heart rate, the nurse locates the heart sounds above the client’s umbilicus at midline. The nurse should further confirm that the fetus is lying in which of the following positions?
137. Cephalic.
138. Frank breech.
139. Face.
140. Transverse.

Answer 24

116. 3. Acetaminophen ingestion can cause severe liver disease. The child should be evaluated inthe emergency department. The child should not be offered any fluids, and the parents should not
        attempt to induce vomiting. Assessing the child’s respirations for 24 hours will delay needed
        emergency treatment.
        CN: Management of care; CL: Synthesize
117. 1. The best approach by the nurse is to determine why the parent thinks the child is
        hyperactive. Some children are very active but do not have the necessary defining characteristics of
        hyperactivity. Asking what the parent thinks needs to be done or how the child behaves normally
        would be an appropriate follow-up question once more information is gathered from the parent to
        determine whether the child indeed is hyperactive. Telling the parent to wait for the physician ignores
        the parent’s concern and does not deal with the parent’s issue.
        CN: Physiological adaptation; CL: Synthesize
118. 2. Dilatation at the anastomosis site is needed during the first years of childhood in about 50% of children who have had corrective surgery for TEF. Recurrent mild diarrhea with dehydration is not likely to develop with this surgery. Speech problems can occur if other abnormalities are present to produce them; the larynx and structures of speech are not affected by TEF. Dysphagia and strictures may decrease food intake, and poor weight gain may be noted, but gastric ulcers should not develop from surgery to repair TEF.
        CN: Reduction of risk potential; CL: Analyze
119. 1. Terminally ill clients most often describe feelings of isolation because they feel ignored.
        The terminally ill client may sense any discomfort that family and friends feel in the client’s presence.
        Nursing interventions include spending time with the client, encouraging discussion about feelings,
        and answering questions openly and honestly. Reducing fear of pain or fear of more aggressive
        therapies is secondary to lessening the client’s feelings of isolation. Reducing feelings of social
        inadequacy is not relevant to the terminally ill client.
        CN: Psychosocial integrity; CL: Synthesize
120. 2. When the fetus is in a breech position, the fetal heart rate most often is located above the
        umbilicus because the fetal heart is near the top of the mother’s uterus. The heart of a fetus in the
        cephalic position is typically located on either the left or the right side of the client’s uterus. Also,
        because the fetal heart typically is located in the lower portion of the mother’s uterus, the sounds
        would be heard below the umbilicus. With a face presentation, fetal heart sounds are typically located
        on either the left or the right side of the client’s uterus; in addition, because the fetal heart typically is located in the lower portion of the mother’s uterus, the sounds would be heard below the umbilicus.
        When the fetus is in a transverse position, the fetal heart sounds typically would be located below the
        umbilicus and in the midline.
        CN: Health promotion and maintenance; CL: Analyze

Question 25

121. The nurse is caring for a client who has been diagnosed with pernicious anemia. Which of the following statements by the client indicates an understanding of the treatment of pernicious
     anemia?
122. “I will need to increase my dietary intake of foods that are high in vitamin B 12 .”
123. “I will receive my first injection of vitamin B 12 tomorrow, and I will return for a follow-up injection in 1 month.”
124. “I understand that the oral form of vitamin B 12 is preferred because it is safer and less expensive than the injection form.”
125. “I will need to take vitamin B 12 replacements for the rest of my life.”
126. A client’s 12:00 noon blood glucose was inaccurately documented as 310 (17.2 mmol/L)
     instead of 130 (7.2 mmol/L). This error was not noticed until 1:00 PM . The nurse administered the
     sliding scale insulin for a blood glucose of 310 (17.2 mmol/L). What should the nurse do first?
127. Notify the physician.
128. Assess for hypoglycemia.
129. Consult with the clinical pharmacist.
130. Call the charge nurse.
131. An older infant who has been injured in an automobile accident is to wear a splint on the
     injured leg. The mother reports that the infant has become mobile even while wearing the splint. The
     nurse should advise the mother to do which of the following?
132. Notify the physician immediately to adjust the treatment plan.
133. Confine the infant to one room in the apartment.3. Keep the infant in the splint at night, removing it during the day.
134. Remove any unsafe items from the area in which the infant is mobile.
135. While preparing a client for surgery, the nurse assesses for psychosocial problems that may cause preoperative anxiety. Which of the following is believed to be the most distressing fear a
     preoperative client is likely to experience?
136. Fear of the unknown.
137. Fear of changes in body image.
138. Fear of the effects of anesthesia.
139. Fear of being in pain.
140. A 56-year-old woman is admitted for a modified radical mastectomy. The client appears anxious and asks many questions. The nurse’s best course of action is to:
141. Tell the client as much as she wants to know and is able to understand.
142. Delay discussing the client’s questions with her until the convalescent phase of her care.
143. Delay discussing the client’s questions with her until her apprehension subsides.
144. Explain to the client that she should discuss her questions with her physician.

Answer 25

121. 4. Clients who have been diagnosed with pernicious anemia are lacking adequate amounts of the intrinsic factor (IF) that is secreted by the gastric mucosa. IF is necessary for the absorption of cobalamin (vitamin B 12 ) in the distal ileum. Without the presence of IF, dietary intake of vitamin B 12 is useless because it cannot be absorbed. Treatment of pernicious anemia includes IM injections of cobalamin, at first daily for 2 weeks, then weekly until the anemia is corrected. A maintenance
        schedule of monthly injections is then implemented. The injections will need to be continued for therest of the client’s life. CN: Physiological adaptation; CL: Evaluate
122. 2. The nurse should first assess the client because a hypoglycemic reaction is likely to occur. The nurse should provide a fast-acting simple carbohydrate. The nurse (charge nurse or otherwise) should notify the physician for prescriptions to prevent or treat severe hypoglycemia. The nurse could consult the clinical pharmacist until able to contact the physician. The nurse should ask for assistance so that the client can be monitored by a nurse while someone prepares a longer-acting carbohydrate or protein.
        CN: Reduction of risk potential; CL: Synthesize
123. 4. Safety is the priority in caring for this infant. Infants adapt easily, increasing mobility even with a splint in place. Therefore, the mother needs to ensure that the area in which the infant is mobile is safe. There is no need to contact the physician to alter the treatment plan. Confining the infant to one room may not allow the child to achieve normal development. The child needs different environments for maximum development. The infant needs to wear the splint as prescribed by the physician to ensure optimal healing.
        CN: Safety and infection control; CL: Synthesize
124. 1. Anxiety in a preoperative client may be caused by many different fears, such as fear of the effects of anesthesia, the effects of surgery on body image, separation from family and friends, job loss, disability, pain, or death. However, fear of the unknown is most likely to be the greatest fear because the client feels helpless. Therefore, an important part of preoperative nursing care is to assess the client for anxieties and explore possible causes. Emotional support can then be offered, so that the client is in the best possible psychological condition for surgery.
        CN: Psychosocial integrity; CL: Analyze
125. 1. An important nursing responsibility is preoperative teaching. The recommended guide for
        teaching is to tell the client as much as she wants to know and is able to understand. Delaying discussion of issues or concerns will most likely increase the client’s anxiety. Telling the client to discuss questions with the physician avoids acknowledging the client’s concerns.
        CN: Psychosocial integrity; CL: Synthesize

Question 26

126. The nurse asks the client to sign a consent form before undergoing surgery. The client cannot state the risks of the surgical procedure. Which of the following statements by the nurse is most appropriate?
127. “What are your concerns? I can answer any questions that you have.”
128. “You can go ahead and sign the form. I will be sure to tell the surgeon you have questions.”
129. “It is important that your questions are answered and you understand the risks before you consent to the procedure. I will contact the surgeon.”
130. “Actually, the risks associated with this procedure are minimal. The surgeon has performed this surgery many times.”
131. The nurse is assessing fetal position in a 32-year-old woman in her 8th month of pregnancy. From the figure below, the fetal position can be described as:
132. Left occipital transverse.
133. Left occipital anterior.
134. Right occipital transverse.
135. Right occipital anterior.
136. A child has a urinary tract infection and is being treated with antibiotics. The nurse should instruct the parents to report which of the following?
137. Increased urine output.
138. Loss of appetite.
139. Jaundice.
140. Fever.
141. After teaching a mother about the neonate’s positive Babinski’s reflex, the nurse determines that the mother understands the instructions when she says that a positive Babinski’s reflex indicates:
142. Possible partial paralysis.
143. Possible lower limb defect.
144. Immature central nervous system.
145. Possible injury to nerves that innervate the legs.

130. The nurse should instruct a client who is taking dexamethasone (Decadron) and furosemide
(Lasix) to report:
1. Excitability.
2. Muscle weakness.
3. Diarrhea.
4. Increased thirst.

Answer 26

126. 3. The client must have adequate disclosure of the risks associated with the surgery before signing the consent form. It is the physician’s responsibility to explain the risks of any procedures and to obtain the client’s informed consent. If the nurse suspects that the client has not been truly informed, it is the responsibility of the nurse to act as a client advocate and contact the surgeon to provide additional information to the client. It is not appropriate to have the client sign the consent form if the client has questions. The nurse should not minimize the procedure or dismiss the client’s concerns.
        CN: Management of care; CL: Synthesize
127. 4. In right occipital anterior lie, the occiput faces the right anterior segment of the woman’s pelvis. In left occipital transverse lie, the occiput faces the woman’s left hip. In left occipital anterior lie, the occiput faces the left anterior segment of the woman’s pelvis. In right occipital transverse lie,
        the occiput faces the woman’s right hip.
        CN: Physiological adaptation; CL: Analyze
128. 4. The nurse should advise the parents to report an increasing fever which would indicate the infection is not resolving. Increased urine output may occur, but it would be very difficult for the parent to actually determine this and it is not a cardinal sign of increasing infection. The child may have a loss of appetite related to the infection or the medication, but is not indicative of an infection that is becoming worse. The child should not have jaundice from a urinary tract infection that is being treated.
        CN: Physiological adaptation; CL: Synthesize
129. 3. A positive Babinski’s reflex in a neonate is a normal finding demonstrating the immaturity of the central nervous system in corticospinal pathways. A neonate’s muscle coordination is immature, but the Babinski’s reflex does not help determine this immaturity. A positive Babinski’s reflex does not indicate a defect in the spinal cord or an injury to nerves that innervate the legs. There is no evidence to suggest partial paralysis. A positive Babinski’s reflex in an adult indicates disease.
        CN: Health promotion and maintenance; CL: Evaluate
130. 2. The nurse should instruct the client who is taking dexamethasone (Decadron) and furosemide (Lasix) to observe for signs and symptoms of hypokalemia, such as malaise, muscle weakness, vomiting, and a paralytic ileus, because both dexamethasone and furosemide deplete serum
        potassium. This combination of drugs does not cause the client to become excitable or have diarrhea or thirst.
        CN: Pharmacological and parenteral therapies; CL: Analyze

Question 27

131. A client with a suspected diagnosis of lung cancer has a bronchoscopy with biopsy. Following the procedure the nurse should:
132. Encourage the client to gargle with oral lidocaine to decrease throat irritation.
133. Monitor the client for signs of pneumothorax.
134. Administer pain medication as needed to relieve mediastinal discomfort.
135. Advise the client not to talk until the gag reflex returns.
136. A nurse is preparing to administer 500 mL of an IV solution to a child over 12 hours via tubing thatdelivers microdrips at 60 gtt/mL. At what rate should the nurse infuse the solution?
     _______________ gtt/min.
137. Which of the following techniques is correct when administering a subcutaneous injection?
138. Using a 1-inch (2.5-cm) needle for injection.
139. Inserting the needle at a 45-degree angle to the skin.
140. Spreading the skin tightly at the injection site.
141. Drawing 0.2 mL of air into the syringe before administration.
142. An elderly client hospitalized 4 days for treatment of acute respiratory distress has become
     confused and disoriented. The client has been picking invisible items off blankets and has been
     yelling at the daughter who is not in the room. The family tells the nurse that the client has been
     treated for anxiety with Xanax (alprazolam) for years, but Xanax is not on the current medication list.
     Which of the following safety measures should be implemented? Select all that apply.
143. The client should be placed on withdrawal precautions and treatment started immediately.
144. The client should be placed in soft restraints.
145. The medications should be available to help with the hallucinations.
146. The daughter should not visit until the client is better.
147. The client’s medical and mental status should be evaluated frequently and treated as needed.
148. The mother of a 3-year-old child tells the nurse her child is “fussy” and not as “easygoing” as her other children. She is having difficulty feeding the child because he fusses and cries when she serves a meal. The nurse should instruct the mother to:
149. Allow the child to determine when feeding should occur.
150. Not feed the child if he cries.
151. Provide structured feeding times and routines.
152. Give the child finger foods and let him eat when he wants.

Answer 27

131. 2. After a bronchoscopy with a biopsy, the nurse should monitor the client for signs of pneumothorax as well as hemorrhage. The client should not gargle with oral lidocaine; this will not allow the gag reflex to return. The client should not have any mediastinal discomfort after a bronchoscopy; if pain does occur, it should be reported promptly to the physician. It is not necessary
        to tell the client not to talk until the gag reflex returns.
        CN: Reduction of risk potential; CL: Synthesize
132. 42 gtt/min
     The number of drops the client should receive each minute is determined as follows:
     CN: Pharmacological and parenteral therapies; CL: Apply
133. 2. Subcutaneous injections are administered at an angle of 45 to 90 degrees, depending on the size of the client. Subcutaneous needles are typically 3⁄8 to 5⁄8 inches in length. The skin should be pinched up at the injection site to elevate the subcutaneous tissue. Air is not drawn into the syringe for a subcutaneous injection.
        CN: Pharmacological and parenteral therapies; CL: Apply
134. 1, 3, 5. Especially in the elderly, Xanax withdrawal requires immediate and aggressive treatment. Hallucinations are frightening for the client and family. Changes in medical and mentalstatus can occur quickly in the elderly and the client must be monitored closely. Restraints are not indicated for the client and would likely aggravate the confusion and agitation. There is no need to restrict the daughter from visiting at this point.
     CN: Pharmacological and parenteral therapies; CL: Create
135. 3. Each child has unique temperaments and energy levels, and parents must adapt parenting strategies for each child. Children who are easily upset do better in structured environments where they can learn what to expect. Easy-going children can manage flexible feeding times. Not feeding the child when he cries will not promote nutrition and does not provide the structure that will help the child learn appropriate eating behaviors. Children who are very active and always “on the go” respond well to eating food that can be carried in their hand, and eating more frequently.
        CN: Health promotion and maintenance; CL: Synthesize

Question 28

136. When giving a client a tube feeding, the nurse should:
137. Warm the feeding solution before administration.
138. Place the client in a left side-lying position.
139. Aspirate residual gastric contents before the feeding and discard.
140. Verify position of the tube before beginning feeding.
141. A multiparous client 48 hours postpartum who is breast-feeding tells the nurse, “I’m having a lot of cramping. This didn’t happen when I nursed my first baby.” Which of the following would be the nurse’s best response?
142. “I will notify your doctor. It’s possible there are some placental fragments remaining.”
143. “I need to check your lochial flow. You may have a clot that is being dislodged.”
144. “You must have gotten a heavy dose of oxytocin. It should wear off soon.”
145. “The cramping is normal and is caused by your baby’s sucking, which stimulates the release of
     oxytocin. ”
146. The mother of a child with moderate diarrhea asks how to manage her child’s illness. Which of the following should the nurse suggest?
147. Begin clear liquids for 24 hours.
148. Feed the child bananas, rice, applesauce, and toast.
149. Offer foods that are low in fat.
150. Continue the child’s regular diet.
151. The nurse is performing routine tracheostomy care. Which of the following steps would be appropriate for the nurse to include in the performance of the procedure?
152. Remove the inner cannula every 2 hours for cleaning.
153. Secure the tracheostomy ties with a square knot.
154. Use cut gauze under the neck plate to protect the skin.
155. Suction the inner cannula on completion of the procedure.
156. The nurse finds a sealed container of IV 50% dextrose in a catch all bin on the nursing unit. The nurse should:
157. Leave it where found and notify risk management.
158. Send it to the pharmacy.
159. File an incident report.
160. Discard it in a sharps container.

Answer 28

136. 4. The position of the tube should be verified before the feeding is implemented. Warming the solution is not necessary or desirable because it can encourage bacterial growth. The client should be lying down with the head elevated or sitting upright during administration of the feeding. Gastric residual should be aspirated and then reinstilled to prevent electrolyte losses.
        CN: Reduction of risk potential; CL: Apply
137. 4. The cramping is caused by the baby’s sucking and subsequent stimulation for the release of
        oxytocin. This cramping is normal. With each subsequent pregnancy, the uterus becomes “stretched” and the release of oxytocin causes the uterus to contract, resulting in the feeling of cramping. Continued moderate to large amounts of lochia rubra are indicative of retained placental fragments. Cramping indicates that the uterus is contracting and most likely firm. A boggy uterus, continued moderate to heavy lochia, mild vasoconstriction, and restlessness and anxiety suggest delayed postpartum hemorrhage due to subinvolution of the placental site, retained placental tissue, or infection. Most clients receive a standard dose of oxytocin after childbirth. Oxytocin has a duration of action of 60 minutes. Therefore, the effects of the drug would have worn off by 24 hours postpartum.
        CN: Health promotion and maintenance; CL: Synthesize
138. 4. The current recommendations for children experiencing mild to moderate diarrhea are to
        continue the child’s regular diet. With this diet plan, children seem to get well faster. Clear liquids, such as juices, colas, and gelatin, are high in carbohydrates but low in electrolytes, as are foods such as bananas, rice, applesauce, and toast. Foods low in fat also typically lack the electrolytes that the child needs.
        CN: Physiological adaptation; CL: Synthesize
139. 2. When performing tracheostomy care, it is important that the tracheostomy ties be securely
        tied to prevent dislodgment of the tube. It is not necessary to remove the inner cannula every 2 hours
        for cleaning. Routine cleaning is usually performed every 8 hours. The nurse should use precut tracheostomy dressings under the neck plate to protect the skin surrounding the stoma. Cutting and
        using a gauze dressing can cause loose gauze fibers to enter the airway. The inner cannula should be
        suctioned before cleaning, not afterward.
        CN: Reduction of risk potential; CL: Apply
140. 2. The nurse should send the sealed container of IV 50% dextrose found in the catch-all bin to the pharmacy. A concentrated medication such as 50% dextrose could be lethal if inadvertentlyadministered and should not be stored outside the pharmacy. An incident report is not necessary in this situation. The sharps container is not the appropriate method for disposal of this medication.
        CN: Safety and infection control; CL: Synthesize

Question 29

141. To reduce the risk of pressure ulcer formation, which of the following activities should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury?
142. Bathe daily.
143. Eat a high-carbohydrate diet.
144. Shift your weight every 15 minutes.
145. Move from the bed to the wheelchair every 2 hours.
146. A client in the second stage of labor has had no anesthesia or analgesia. The nurse should assist the client into which of the following positions so the client can begin pushing?
147. Squatting with the body curved in a C shape.
148. Side-lying while keeping the head elevated.
149. In the knee-chest position while keeping the head down.
150. Squatting with the back arched.
151. A client with antisocial personality disorder tells the nurse, “I punched the guy out because he deserved it and then the cops arrested me.” Which of the following responses would be most helpful to the client?
152. “It’s wrong to punch others.”
153. “If you punch people out, you’ll get into trouble.”
154. “I wouldn’t do that again if I were you.”
155. “Don’t ever do that again; you’re an adult.”
156. The nurse is teaching an unlicensed assistive personnel about the care of clients with self-mutilation. Which of the following, if stated by the unlicensed personnel about self-mutilation, demonstrates that the teaching has been effective?
157. “It is a means of getting what the person wants.”
158. “It is a nonserious event that can be ignored.”
159. “It is a way to express anger and rage.”
160. “It is a form of manipulation.”
161. The nurse is obtaining a nursing history of a client suspected of having hepatitis C. The nurse should ask the client if he has:
162. Drunk contaminated water.
163. Traveled to India.
164. Had a tattoo.
165. Eaten shellfish.

Answer 29

141. 3. The client who is wheelchair-bound with a spinal cord injury should be taught to make small weight shifts, lifting off the sacral area every 15 minutes. This decreases the risk of pressure ulcer formation. Bathing daily promotes skin cleanliness, but by itself will not prevent pressure ulcer formation. Eating a well-balanced diet that includes proteins and carbohydrates promotes good skin integrity. Moving from the bed to the wheelchair every 2 hours is not desirable because the client should not spend excessive amounts of time in bed. Pressure sores can develop in less than 2 hours.
        CN: Reduction of risk potential; CL: Synthesize
142. 1. Anatomically, the squatting position enlarges the pelvic outlet and uses the force of gravity during pushing. The mother should curve her body into a C shape for the greatest effectiveness.
        CN: Health promotion and maintenance; CL: Synthesize
143. 2. Saying, “If you punch people out, you’ll get into trouble,” helps the client by pointing out the negative consequences of his behavior. Clients with antisocial personality disorder are aggressive, impulsive, and reckless; engage in illegal activities; and lack guilt or remorse. The nurse teaches the client that there are consequences to his irresponsible behavior and that the way to stay
        out of trouble is to change his behavior. Saying, “It’s wrong to punch others,” is not helpful since the
        client does not feel guilt or remorse. Saying, “I wouldn’t do that again if I were you” or “Don’t ever
        do that again,” is authoritative and scolds the client without helping him.
        CN: Psychosocial integrity; CL: Synthesize
144. 3. Self-mutilation is a way to express anger and rage, commonly seen in clients with borderline personality disorder. It typically is a cry for help, an expression of intense anger, helplessness, or guilt. When a client is experiencing numbness or feelings of unreality, self-mutilation induces physical pain which validates the person’s being alive because of the ability to feel the physical pain. Self-mutilation is not a means of getting what the person wants. It is not used as a form of manipulation, although it is often misinterpreted as such. Self-mutilation is a serious behavior that is harmful to the self and cannot be ignored.
        CN: Management of care; CL: Evaluate
145. 3. Hepatitis C is transferred by percutaneous exposure, such as tattooing. Hepatitis A is acquired through contaminated water, exposure in under-developed countries, or shellfish in contaminated waters.
        CN: Physiological adaptation; CL: Analyze

Question 30

146. A client is experiencing symptoms of early alcohol withdrawal. The client’s blood pressure is 150/85 mm Hg and the pulse is 98 bpm. The nurse should:
147. Administer lorazepam (Ativan).
148. Apply arm and leg restraints.
149. Assign an unlicensed assistive personnel to sit with the client.
150. Notify the primary care provider.
151. Which of the following diet instructions are appropriate when teaching a client in the early stages of cirrhosis about nutritional needs? Select all that apply.
152. “Limit your caloric intake so that you don’t become overweight.”
153. “An adequate intake of protein is important to your health.”
154. “I encourage you to eat small, frequent meals.”
155. “Restrict your fluid intake to 1,000 mL/day.”
156. “Limit your alcohol intake to one glass of wine daily.”
157. After a child returns from the postanesthesia care unit after surgery, which of the following should the nurse assess first?
158. The IV fluid access site.
159. The child’s level of pain.
160. The surgical site dressing.
161. The functioning of the nasogastric tube.
162. To protect a client who has received tissue plasminogen activator (t-PA) or alteplase recombinant (Activase) therapy, the nurse should:
163. Use the radial artery to obtain blood gas samples.
164. Maintain arterial pressure for 10 seconds.
165. Administer IM injections.
166. Encourage physical activity.
167. A client is admitted with acute pancreatitis. The nurse should monitor which of the following laboratory values?
168. Decreased urine amylase level.
169. Increased calcium level.
170. Decreased glucose level.
171. Increased serum amylase and lipase levels.

Answer 30

146. 1. Lorazepam (Ativan), a benzodiazepine, is commonly used to decrease the symptoms of
        central nervous system irritability in the client who is experiencing early symptoms of alcohol withdrawal. There is no indication that restraints are needed at this time. If the lorazepam is effective, it will not be necessary to have someone sit with the client. At this point, it is not necessary to notify the physician.
        CN: Management of care; CL: Synthesize
147. 2, 3. Appropriate diet instructions for the client in the early stages of cirrhosis includeensuring an adequate intake of protein and eating small, frequent meals. There is no need to limit protein intake unless the client has evidence of hepatic encephalopathy. Additionally, fluid intake is not restricted unless the client has significant ascites or edema (these typically occur later in the disease). Because of gastrointestinal dysfunction, small, frequent meals are frequently better tolerated
     than three regular meals. Clients with cirrhosis should be encouraged to increase their caloric intake instead of restricting it. Alcohol intake in any amount is discouraged.
     CN: Physiological adaptation; CL: Synthesize
148. 3. After surgery, the nurse’s initial assessment is the surgical site dressing to determine whether there is any bleeding or drainage. Once this assessment is completed, then the nurse would
        assess the other areas such as the IV access site, pain, and nasogastric tube function.
        CN: Physiological adaptation; CL: Analyze
149. 1. The nurse should use the radial artery to obtain blood gas samples because it is easier to
        maintain firm pressure there than on the femoral artery. Nursing interventions to protect the client who has received t-PA or alteplase recombinant (Activase) therapy include maintaining arterial pressure for 30 seconds because it takes longer for coagulation to occur with the thrombolytic agent on board. IM injections are contraindicated during thrombolytic therapy. The nurse should prevent physical manipulation of the client, which can cause bruising.
        CN: Reduction of risk potential; CL: Synthesize
150. 4. Serum amylase and lipase are increased in pancreatitis, as is urine amylase. Other abnormal laboratory values include decreased calcium level and increased glucose and lipid levels.
        CN: Reduction of risk potential; CL: Analyze

Question 31

151. For the client with a substance abuse problem, which of the following would be most helpful to aid the client in dealing with feelings and concerns related to alcohol and drugs?
152. Individual therapy.
153. Group sessions.
154. Solitary activities.
155. Recreation.
156. A client has cystitis. The nurse should further assess the client for:
157. Flank pain.
158. Oliguria.
159. Nausea and vomiting.
160. Foul-smelling urine.
161. A client with acute stress disorder is telling the nurse about the tornado that leveled his house and killed his wife and baby while he was out of town on business. He states, “If only I’d been at home, I could have saved them.” Which of the following responses would be most appropriate?
162. “Don’t blame yourself; you’ll only feel worse.”
163. “It’s not your fault; so stop feeling so guilty.”
164. “You might not have been at home.”
165. “You couldn’t have prevented the tornado; it just happened.”
166. On the first postpartum day, the nurse is caring for a primiparous client who has recently emigrated from Japan to North America and speaks only a little English. The nurse observes that the client has been bottle-feeding her neonate on occasion, but most of the neonatal care is being performed by the client’s mother-in-law. Which of the following actions would be most appropriate?
167. Notify the social worker because bonding may be affected.
168. Document the unusual maternal behavior in the client’s chart.
169. Determine whether this is a cultural practice for the client and her family.
170. Obtain a prescription to make a home visit after the client’s discharge.
171. A client is scheduled for a creatinine clearance test. Which one of the following
     preparations is appropriate for the nurse to make?
172. Instruct the client about the need to collect urine for 24 hours.
173. Prepare to insert an indwelling urethral catheter.
174. Provide the client with a sterile urine collection container.
175. Instruct the client to force fluids to 3,000 mL/day.

Answer 31

151. 2. For the client with an alcohol or drug problem, group sessions are helpful in dealing with emotions and concerns about alcohol and drugs. Clients with substance abuse problems identify with each other’s similar experiences and can best help each other deal with these feelings and emotions. Additionally, the members of the group are able to support and confront each other. Individual therapy is not as helpful as group sessions because group members offer peer support and confrontation when needed. Solitary activities and recreation lead to increased avoidance of the issues that must be faced and dealt with by the client. These are often areas that the client must learn to develop and manage while in recovery.
        CN: Psychosocial integrity; CL: Synthesize
152. 4. Foul-smelling urine is indicative of cystitis. Other symptoms include dysuria and urinary frequency and urgency. Flank pain, nausea, and vomiting indicate pyelonephritis.
        CN: Physiological adaptation; CL: Analyze
153. 4. By saying, “You couldn’t have prevented the tornado; it just happened,” the nurse helps the
        client to develop an objective perspective and promotes a better understanding of the event. The other statements tell the client how to feel, possibly causing resistance and thus delay therapeutic healing. Guilt and self-blame will not be decreased.
        CN: Psychosocial integrity; CL: Synthesize
154. 3. In many Asian cultures, the 30 days after the birth of the neonate is a time for the mother to heal from the birth. The appropriate action by the nurse is to determine whether this is a culturalpractice for this client and her family. If so, the client is behaving within her cultural practices. Teaching should be provided to both the mother and her mother-in-law. There is no indication that bonding is not taking place. Lack of bonding might be indicated if the client did not show any interest in the neonate. Documenting the client’s maternal behavior in her chart is a routine task. However, the nurse should not assume that this behavior is unusual because it may be reflective of the client’s cultural framework. A home visit is not warranted unless there is evidence of infant neglect or the family needs additional follow-up or teaching.
        CN: Health promotion and maintenance; CL: Synthesize
155. 1. A creatinine clearance test is a 24-hour urine test that measures the degree of protein breakdown in the body. The collection is not maintained in a sterile container. There is no need to insert an indwelling urinary catheter as long as the client is able to control urination. It is not necessary to force fluids.
        CN: Reduction of risk potential; CL: Synthesize

Question 32

156. When the nurse is assessing a client’s cultural adaptation, which of the following statements
     is least sensitive to the client’s needs?
157. “What are some of your favorite foods?”
158. “Describe any health problems in your past.”
159. “Please tell me how you would like to be addressed.”
160. “Your eyes look dark; is this normal for you?”
161. After several months of taking olanzapine (Zyprexa), the client reports that he is no longer hearing voices of any kind. Which of the following would confirm that the client is developing insight into his illness?
162. “That Zyprexa is the best medicine I have ever had.”
163. “I didn’t realize how sick I could get from a chemical brain imbalance.”
164. “My mom is proud of me for staying on my medicines.”
165. “I think I may be able to get a little part-time job soon.”
166. A client who is a computer operator has developed carpal tunnel syndrome. The nurse can instruct the client to relieve the pain by managing:
167. Decreased circulation to the brachial nerve.
168. Muscle atrophy resulting from disuse.
169. Median nerve compression.
170. Progressive flexion contracture of the wrist.
171. A client with type I diabetes mellitus is scheduled to have surgery. The client has been nothing-by-mouth (NPO) since midnight. In the morning, the nurse notices the client’s daily insulin has not been prescribed. Which action should the nurse do first?
172. Obtain the client’s blood glucose at the bedside.
173. Contact the primary care provider for further prescription regarding insulin dosage.
174. Give the client’s usual morning dose of insulin.
175. Inform the Post Anesthesia Care Unit (PACU) staff to obtain the insulin prescription.
176. A client who is recovering from transurethral resection of the prostate (TURP) experiences urinary incontinence and has decreased the fluid intake because of the incontinence. What would be the nurse’s best response to the client?
177. “Yes, limiting your fluids can decrease your incontinence.”
178. “Limiting your fluids will cause kidney stones.”
179. “Drink eight glasses of water a day and urinate every 2 hours.”
180. “If your incontinence continues, we will reinsert your catheter.”

Answer 32

156. 4. The statement, “Your eyes look dark,” is the least sensitive statement because it points out
        an obvious difference for no real purpose. The nurse has a reason to ask the client about favorite
        foods and needs to know about past health problems. Also, it is appropriate for the nurse to ask the client how she wishes to be addressed.
        CN: Psychosocial integrity; CL: Analyze
157. 2. Insight into the illness is demonstrated when the client recognizes the relationship between
        the chemical imbalance and his illness and symptoms. Stating that the olanzapine is the best medicine or that the client’s mother is proud of him for staying on his medicines reflects awareness about the effect of medications and the need for compliance. Stating that he may be able to get a part-time job indicates an awareness of his increased capacity for work.
        CN: Psychosocial integrity; CL: Evaluate
158. 3. Carpal tunnel syndrome is a condition in which the median nerve becomes compressed in
        the wrist. The brachial nerve is not affected. Carpal tunnel syndrome may be the result of a systemic
        disease, such as rheumatoid arthritis or diabetes mellitus, or it may be an occupational hazard for
        people whose jobs require repetitive hand movements. It is not a condition resulting from disuse. The wrists do not develop flexion contractures with carpal tunnel syndrome.
        CN: Physiological adaptation; CL: Synthesize
159. 1. The nurse should contact the physician and clarify whether the client’s usual insulin dose
        should be given before surgery; having the blood glucose level is objective information that the
        physician may need to know before making a final decision as to the insulin dosage. The nurse should
        not assume that the usual insulin dose is to be given. It is not appropriate for the nurse to defer
        decision making on this issue until after surgery.
        CN: Reduction of risk potential; CL: Synthesize
160. 3. Clients who have undergone TURP need to be instructed to maintain an adequate fluid intake despite urinary dribbling or incontinence. The client should be advised to drink at least eight glasses of water a day to dilute the urine and help prevent urinary tract infections. Maintaining a voiding schedule of every 2 hours can help decrease incidents of incontinence. Teaching the client
        Kegel exercises is also beneficial for strengthening sphincter tone. The nurse should not encouragethe client to decrease fluids. It is not necessarily true that a decreased intake will cause renal calculi.
        Threatening the client with a catheter is not beneficial, and it is not the treatment of choice for a client who is experiencing incontinence from TURP.
        CN: Reduction of risk potential; CL: Synthesize

Question 33

161. Which of the following is a risk factor for toxic shock syndrome (TSS)?
162. Changing tampons every 3 hours.
163. Avoiding use of deodorized tampons.
164. Alternating tampons with sanitary pads.
165. Using only tampons at night.
166. A client with a history of cystitis is admitted to the hospital with a diagnosis of pyelonephritis. The nurse should assess the client for which of the following?
167. Suprapubic pain.
168. Dysuria.
169. Urine retention.
170. Costovertebral tenderness.
171. A woman is taking oral contraceptives. The nurse teaches the client that medications that
     may interfere with oral contraceptive efficacy include:
172. Antihypertensives.
173. Antibiotics.
174. Diuretics.
175. Antihistamines.

164. A 28-year-old female client is prescribed danazol for endometriosis. The nurse should
instruct the client to report:
1. Headaches.
2. Weight loss.
3. Increased libido.
4. Hair loss.

165. To which of the following unlicensed assistive personnel should the nurse assign a male Muslim client who needs complete morning care?
166. Mary, who has two other clients requiring complete morning care.
167. Joe, who has one client requiring complete morning care.3. Jill, who has four clients requiring partial morning care.
168. Jim, who has five clients requiring partial morning care.

Answer 33

161. 4. Risk factors for TSS include the use of tampons at night, when the tampon would be in place for 7 to 9 hours. TSS can occur in other situations, but it is commonly associated with women during menses, particularly women who use tampons. The longer the tampon is left in place, the greater the risk for TSS. Changing tampons every 3 hours or more frequently, avoiding use of deodorized tampons, and alternating tampons with sanitary pads are actions that decrease the risk of TSS.
        CN: Reduction of risk potential; CL: Analyze
162. 4. Costovertebral tenderness occurs on the side of the affected kidney in pyelonephritis. Dysuria, suprapubic pain, and urine retention may occur in pyelonephritis but do not specifically support a diagnosis of pyelonephritis. Dysuria, suprapubic pain, and urine retention are symptoms of cystitis, which can lead to pyelonephritis if not treated.
        CN: Physiological adaptation; CL: Analyze
163. 2. Broad-spectrum antibiotics can cause decreased efficacy of oral contraceptives, placing the client at risk for an unplanned pregnancy. When a client is prescribed a course of antibiotics, a back-up method of contraception should be used. Antihypertensives, diuretics, and antihistamines do not interfere with oral contraceptive efficacy.
        CN: Pharmacological and parenteral therapies; CL: Apply
164. 1. Adverse effects of danazol include headaches, dizziness, irritability, and decreased
        libido. Masculinization effects, such as deepened voice, facial hair, and weight gain, also may occur.
        CN: Pharmacological and parenteral therapies; CL: Synthesize
165. 2. The nurse should assign the Muslim male client who needs complete morning care to Joe.
        Muslim men cannot be cared for by female nurses. The nurse must also consider work load, and Joe
        has the lightest assignment.
        CN: Management of care; CL: Synthesize

Question 34

166. A client with chronic renal failure is experiencing central nervous system changes caused by uremic toxins. Which nursing intervention would be most appropriate for addressing the changes?
167. Allow the client to grieve for body image changes.
168. Restrict foods that are high in potassium.
169. Restrict fluid intake to 1,000 mL/day.
170. Assess the client’s mental status regularly.
171. The nurse is preparing to give a subcutaneous injection to an elderly, emaciated client.
     Which needle length and angle should the nurse plan to use to administer the injection safely?
172. A 3⁄8-inch (0.95-cm) needle at a 90-degree angle.
173. A 5⁄8-inch (1.6-cm) needle at a 45-degree angle.
174. A 1⁄2-inch (1.3-cm) needle at a 15-degree angle.
175. A 5⁄8-inch (1.6-cm) needle at a 90-degree angle.
176. A female client is treated for trichomoniasis with metronidazole (Flagyl). The nurse instructs the client that:
177. The medication should not alter the color of the urine.
178. She should discontinue oral contraceptive use during this treatment.
179. She should avoid alcohol during treatment and for 24 hours after completion of the drug.
180. Her partner does not need treatment.
181. A client is in the advanced stages of osteoarthritis. Which of the following best describes
     the pain that occurs in the advanced stage of the disease?
182. Pain occurs with minimal activity.
183. Crepitation develops and intensifies pain.
184. Joints are symmetrically affected by pain.
185. Fatigue accompanies pain.
186. A family may request to have a client who is Vietnamese transferred to die at home because
     it is traditionally believed that:
187. It is disloyal to leave their loved one in the hospital.
188. The hospital cannot be trusted.
189. The family can provide more comfort at home.
190. Reincarnation will not occur in the hospital.

Answer 34

166. 4. Central nervous system changes include such symptoms as apathy, lethargy, and decreased
        concentration. Seizures and coma can also occur. The nurse should assess the client’s level of consciousness at regular intervals and maintain client safety. Allowing the client to express feelings related to body image changes and restricting foods high in potassium and fluid intake are all appropriate activities, but they are not related to the central nervous system changes.
        CN: Physiological adaptation; CL: Synthesize
167. 3. Elderly individuals have less subcutaneous tissue. An elderly, emaciated client will require a short needle and a shallow angle to avoid hitting an underlying bone. The nurse should choose the shortest subcutaneous needle available, and use the least angle.
        CN: Pharmacological and parenteral therapies; CL: Apply
168. 3. Metronidazole (Flagyl) can cause a disulfiram (Antabuse)-like reaction if it is taken with alcohol. Tachycardia, nausea, vomiting, and other serious interaction effects can occur. Flagyl willmake the urine a darker color. Oral contraceptives should never be discontinued with trichomoniasis. The partner also requires treatment to prevent retransmission of infection.
        CN: Pharmacological and parenteral therapies; CL: Synthesize
169. 1. In the advanced stages of osteoarthritis, pain can occur with minimal activity or even when the client is at rest. Crepitation can be present at any stage of the disease and does not exacerbate pain. Joints are not symmetrically affected by the disease. Symmetric joint involvement and fatigue are characteristics of rheumatoid arthritis.
        CN: Physiological adaptation; CL: Analyze
170. 3. A traditional Vietnamese belief is that the family can provide more comfort for their loved
        one at home. It is not seen as being disloyal if their loved one dies in the hospital. The request is not
        based on a feeling that the hospital cannot be trusted. People of Vietnamese descent accept death as a part of life and do not think that reincarnation is prevented in the hospital.
        CN: Psychosocial integrity; CL: Apply

Question 35

171. A client has just been admitted with acute delirium of unknown etiology. The client’s daughter states that she is worried about her mom because she has never been this sick before. Which of the following should be the most helpful statement to make to the daughter?
172. “Please don’t worry. We will take good care of your mother.”
173. “The doctor will prescribe tests to find out what is causing her condition.”
174. “We can help you learn how to take care of her after she is discharged.”
175. “It helps if you avoid arguing when she talks about seeing people who aren’t there.”
176. A client with Alzheimer’s disease is going to live with his daughter who does not work outside of the home. The nurse determines that the daughter needs further education when she makes which of the following statements?
177. “I’ve put special locks on all the doors that Dad won’t be able to unlock.”
178. “Dad said that what he missed most while he was here was using his aftershave.”
179. “Dad will be in a bedroom that has nothing for him to trip over getting to the bathroom.”
180. “I’ve taken the knobs off of the stove so he won’t be able to turn it on.”
181. Allopurinol (Zyloprim) is prescribed for a client who has chronic gout. Which of the following comments indicates that the client understands how to take the allopurinol?
182. “I will take the medication whenever my joints hurt.”
183. “I must take this drug on an empty stomach.”
184. “I should drink plenty of fluids when taking allopurinol.”
185. “I should not take aspirin when taking allopurinol.”
186. The mother calls the nurse to report that her toddler has just been burned on the arm. The nurse should advise the mother to first:
187. Pack the arm in ice, then take the child to the closest emergency department.
188. Rub the burned area with an antibacterial ointment, then call the doctor.
189. Run cool water over the burned area, then wrap it in a clean cloth.
190. Call the child’s health care provider immediately, then wrap the arm in a clean cloth.
191. The nursing assessment of a client with osteo-myelitis of the left great toe reveals pain with
     partial weight-bearing, unsteady gait, and general weakness. Based on these data, the nurse should
     institute which of the following?
192. Bed rest.
193. Airborne precautions.
194. Referral to physical therapy.
195. Falls precautions

Answer 35

171. 2. It is important for the daughter to know that there is an underlying cause for what her mother is experiencing and that it is treatable. Telling her not to worry is a useless cliché and does nothing to inform the daughter. Talking about care after discharge implies that the delirium is irreversible. Delirium is a reversible condition. Although not arguing with hallucinations is valid, this response ignores the daughter’s concern.
        CN: Psychosocial integrity; CL: Synthesize
172. 2. The client with Alzheimer’s dementia should not have access to toiletries that could be swallowed (such as aftershave) unless closely supervised. Putting special locks on all the doors is appropriate to prevent wandering, thus maintaining the client’s safety. Placing the client in a room that has nothing to trip over is appropriate to reduce the client’s risk of falling. Taking the knobs off of the stove is appropriate to prevent possible burns. CN: Safety and infection control; CL: Evaluate
173. 3. It is important that the client force fluids to 3,000 mL/day to avoid the development of renal calculi when taking allopurinol. Allopurinol must be taken consistently to be effective in the treatment of gout. The drug should be taken after meals to avoid gastrointestinal distress. Although the client can take aspirin when taking allopurinol, both drugs can cause gastrointestinal irritation and the practice is not recommended if the client is sensitive to the medications.
        CN: Pharmacological and parenteral therapies; CL: Evaluate
174. 3. The best advice for the nurse to give the child’s mother is to run cool water over the burned area to stop the burning process. Then the area should be wrapped in a clean cloth. Once these initial actions are completed, the mother can call the child’s primary care provider. Packing the arm in ice may cause more damage to the burned area because cold can cause burns just as heat can. For most burns, it is not advised to apply ointment until the area has been evaluated.
        CN: Reduction of risk potential; CL: Synthesize
175. 4. The client is at risk for falling, and the nurse should initiate falls precaution. The client does not require airborne precautions. There is no indication the client needs a referral to physical therapy. The client should be encouraged to maintain mobility.CN: Reduction of risk potential; CL: Analyze

Question 36

176. A client receiving a blood transfusion begins to have chills and headache within the first 15 minutes of the transfusion. The nurse should first:
177. Administer acetaminophen.
178. Take the client’s blood pressure.
179. Discontinue the transfusion.
180. Check the infusion rate of the blood.
181. The family of an older adult wants their mother to have counseling for depression. During the initial nursing assessment, the client denies the need for counseling. Which of the following comments by the client supports the fact that the client may not need counseling?
182. “My doctor just put me on an antidepressant, and I’ll be fine in a week or so.”
183. “My daughter sent me here. She’s mad because I don’t have the energy to take care of my grandkids.”
184. “Since I’ve gotten over the death of my husband, I’ve had more energy and been more active
     than before he died.”
185. “My son got worried because I made this silly comment about wanting to be with my husband
     in heaven.”
186. A client takes isosorbide dinitrate (Isordil) as an antianginal medication. Which of the following statements indicates that the client understands the adverse effects of the drug?
187. “I should take my pulse before taking the medication.”
188. “I should take Isordil with food.”
189. “I will need to change positions slowly so I won’t get dizzy.”
190. “It is important that I report any swelling in my ankles.”
191. The nurse is working on discharge plans with a client who is diagnosed with intermittent explosive disorder, characterized by sudden angry outbursts. The nurse determines that the client is ready for discharge when the client makes which of the following comments?
192. “I’m just not going to let myself get angry anymore.”
193. “Drinking doesn’t help, but I like being with my buddies at the bar.”
194. “I’ll be taking valproic acid and propranolol to help stay in control.”
195. “It would help if my mom would stop getting on my case all the time.”
196. The nurse walks into a client’s room to administer the 9:00 AM medications and notices that the client is in an awkward position in bed. What is the nurse’s first action?
197. Ask the client his name.
198. Check the client’s name band.
199. Straighten the client’s pillow behind his back.
200. Give the client his medications.

Answer 36

176. 3. Chills and headache are signs of a febrile, nonhemolytic blood transfusion reaction, and the nurse’s first action should be to discontinue the transfusion as soon as possible and then notify the physician. Antipyretics and antihistamines may be prescribed. The nurse would not administer acetaminophen without a prescription from the physician. The client’s blood pressure should be taken after the transfusion is stopped. Checking the infusion rate of the blood is not a pertinent action; the infusion needs to be stopped regardless of the rate. CN: Pharmacological and parenteral therapies; CL: Synthesize
177. 3. Resolving grief and having increased energy and activity convey good mental health, indicating that counseling is not necessary at this time. Taking an antidepressant or having less energy and involvement with grandchildren reflects possible depression and the need for counseling. Wanting to be with her dead husband suggests possible suicidal ideation that warrants serious further assessment and counseling.
        CN: Psychosocial integrity; CL: Evaluate
178. 3. Common adverse effects of isosorbide are light-headedness, dizziness, and orthostatic hypotension. Clients should be instructed to change positions slowly to prevent these adverse effects and to avoid fainting. Ankle swelling is not related to isosorbide administration. The client does not need to take his pulse before taking the medication. The client does not need to take the medication with food.
        CN: Pharmacological and parenteral therapies; CL: Evaluate
179. 3. Valproic acid and propranolol are often prescribed to help manage explosive anger.
        Recognizing the need for medications indicates readiness for discharge. Not ever getting angry is
        difficult, impractical, and unrealistic without specific anger management strategies. Drinking does not
        address anger control and suggests a risk of continued drinking. Blaming others, such as the client’s
        mother, does not address anger control and indicates a lack of responsibility for the client’s own behavior.
        CN: Pharmacological and parenteral therapies; CL: Evaluate
180. 3. The nurse should first help the client into a position of comfort even though the primary
        purpose for entering the room was to administer medication. After attending to the client’s basic care
        needs, the nurse can proceed with the proper identification of the client, such as asking the client his
        name and checking his armband, so that the medication can be administered.
        CN: Basic care and comfort; CL: Synthesize

Question 37

181. The nurse is performing the initial assessment on a middle age woman recently diagnosed with Cushing’s syndrome. The nurse reviews the history and physical (See chart). The nurse should develop a plan with the client to manage which of the following? Select all that apply.

HISTORY AND PHYSICAL
A recent ground-level fall resulting in multiple bruises on both arms and left shoulder

A low-healing laceration on the right hand from a fall 2 weeks prior.

Muscle weakness

Unable to sleep more than 2 to 3 hours at a time

Moon-faced appearance
Oily skin
Recent 20-lb (9.1kg) weight gain

VITAL SIGNS
BP - 148/94
HR - 96/strong/ regular
RR - 20 / REGULAR / UNLABORED
PAIN -  DENIES

1. Low blood volume.2. Risk for injury.
2. Slow healing.
3. Changes in physical appearance.
4. Risk for infection.
5. A “read-back” procedure has been implemented on a nursing unit to prevent discrepancies in telephone prescriptions and reports. This procedure should be implemented when the:
6. Float nurse gives a written report to the oncoming nurse.
7. Nurse receives a critical lab value via phone or in person from the lab.
8. Lab report shows up on the computerized health record.
9. Unit clerk takes a telephone prescription for a stat lab test.
10. Four patients in a critical care unit have been diagnosed with Pseudomonas aeruginosa. The Infection Prevention and Control Department has determined that this is probably a nosocomial
    infection. Select the most appropriate intervention by the nurse. The nurse should:
11. Wear an N-95 mask when caring for these clients.
12. Initiate transmission-based precautions.
13. Initiate contact precautions.
14. Ensure that staff does not have artificial fingernails.
15. The nurse is instructing the spouse of a client who had an incision and drainage procedure for an abscess how to care for the wound at home. The nurse should instruct the spouse to:
16. Clean the incision and drainage sites simultaneously.
17. Clean from the incision site to the drainage site.
18. Clean from the drainage site to the incision site.
19. Clean both sites independently.
20. After completing initial assessment rounds, which of the following should the nurse discuss
    with the primary care provider first?
21. A client who was admitted from the emergency department last evening after a blow to the head who is now vomiting and confused as to time and place.
22. A client who returned from abdominal surgery last evening and now has a dime-sized bright red spot on the dressing.
23. A client who had a right total knee replacement 2 days ago and now is reporting constipation and abdominal discomfort.
24. A client admitted for lower extremity vasculitis and wound care who is requesting more pain medication before the next dressing change in 2 hours.

Answer 37

181. 2, 3, 4, 5. Cushing’s syndrome results from excessive levels of cortisol. Some effects of excessive adrenocortical activity include musculoskeletal changes, and the client may be at risk for injury and falls. There is excessive protein catabolism causing muscle wasting, decreased inflammatory response, and potential for delayed healing and infection. The increased cortisol levels cause a moon-faced appearance to which clients must adjust. The skin becomes thin and fragile and
     the client is also at risk for infection. Increased cortisol levels do not cause deficient fluid volume.
     CN: Management of care; CL: Analyze
182. 2. For any verbal or telephone prescription or result, it is important to read back theinformation to ensure its accuracy. It is also important to document that it was read back according to facility policy. It is not necessary to use “read-back” procedures when data are entered on the computerized health record. The Unit clerk is not a licensed health care worker and should not take
        telephone prescriptions. When giving a written report, it is not necessary to “read back,” but the nurse
        should always clarify if there is any question.
        CN: Safety and Infection Control; CL: Apply
183. 4. It is well documented that the subungal areas of the hand harbor bacteria that can be transmitted to others despite aggressive hand-washing procedures, and therefore it is important that the staff on this unit do not have artificial fingernails that could be the source of the infection on this unit. The Joint Commission and Health Canada follow the hand cleaning guidelines from the Centers for Disease Control and Prevention, World Health Organization, and Public Health Agency of Canada to prevent infection. There is no need to institute transmission-based or contact precautions. It is not necessary to wear a mask when caring for these clients.
        CN: Safety and infection control; CL: Synthesize
184. 4. The sites should be treated as separate sites to avoid cross contamination. This adheres to the principle of cleaning from the least contaminated area to the most contaminated area. Each site is considered a separate area for wound care.
        CN: Safety and infection control; CL: Apply
185. 1. Any change in level of consciousness (vomiting, severe headache that is not improving or is getting worse, memory changes, confusion, irritability, change in pupils) should be immediately reported to the physician and further evaluated, especially in a client with head trauma. The nurse should mark a circle around the amount of drainage on a dressing after surgery so it can be monitored and reported to the physician if it grows in size, but a dime-sized spot is not an immediate priority.
        Constipation and abdominal discomfort after surgery require attention but are not priority. Obtaining proper pain medication in order to promote wound care and healing must be addressed with the physician but it is not the first priority.
        CN: Reduction of risk potential; CL: Synthesize

Question 38

186. Which is the correct knot used to secure a restraint correctly to the bed frame?
1.
2.
3.
4.

187. The obstetrical triage nurse is assessing a client with a term pregnancy. There has not been any change in the cervix for the past 2 hours despite irregular contractions. When discharging the client to her home, the nurse should tell the client to return to the hospital when which of the following occur? Select all that apply.
188. She feels more than three contractions an hour.
189. Contractions become more intense and closer together.
190. She notices vaginal bleeding.
191. She thinks the membranes have ruptured.
192. She notices an absence of fetal movement.
193. She feels the urge to push.
194. The parents of a newborn with Down syndrome are tearful when they tell the nurse that the diagnosis was a surprise to them. Which statement by the parents indicates that they have some
     understanding of Down syndrome?
195. “Children with Down syndrome are often fearful of strangers and have difficulty making friends.”
196. “At some point during their lifespan, children with Down syndrome will need to be institutionalized.”
197. “Children with Down syndrome often become violent when they experience hormonal changes
     during puberty.”
198. “There is a broad spectrum of mental capabilities and physical characteristics of children with Down syndrome.”
199. A 2-year-old is brought to the emergency room after experiencing a seizure. The child currently has the flu and has had fevers for the last 3 days. The father asks what caused the seizure to occur. The nurse’s best response is:
200. “Your child’s seizure was likely caused by the rapid elevation of her temperature.”
201. “The seizure likely occurred because your child’s temperature rose beyond a personal threshold.”
202. “Your child’s seizure was likely caused by the prolonged duration of her fevers.”
203. “The seizure likely occurred because your child’s immune system is not developed.”
204. Thirty minutes ago, a term multigravida was 5 cm dilated, 100% effaced, and –1 station. She is now visibly uncomfortable and states that she needs to get up for a bowel movement. The best nursing intervention is:
205. Assist the patient up to the bathroom.
206. Reassure the patient that the sensation she is feeling is due to pressure from the fetal head.
207. Perform another sterile vaginal exam on the client.
208. Notify the primary health care provider of the client’s pain.

Answer 38

186. 2. In order to prevent injury to a client, restraints must be secured to the bed frame using a slip knot in order to ensure quick release if necessary. A square knot would be secure but would not be easily released in an emergency. A restraint tied in a bow at the client’s side would not be easily released in an emergency. A hitch, although secure, is not easily released in an emergency.
        CN: Safety and infection control; CL: Evaluate.
187. 2, 3, 4, 5, 6. Because there have been no cervical changes, the client is not in labor. The client should understand to return to the hospital if the contractions become more intense and regular, if she has vaginal bleeding, if she thinks her membranes rupture, if the baby is not moving, or if she has an urge to push. Three contractions an hour would be too infrequent to indicate active labor.
     CN: Management of care; CL: Apply
188. 4. The mental abilities of Down syndrome children range from severe intellectual disabilities to low average intelligence. They also exhibit a wide range of physical features including almond-shaped eyes, a small, flat nose, a small mouth with a protruding tongue, and small ears. Many also have a single crease across the palms of their hands, short stubby fingers, and straight hair that isfine and thin. Children with Down syndrome are socially 2 to 3 years behind their peers. Many children with Down syndrome will be capable of living in group homes. They may also continue living with their parents or other family members. Children with Down syndrome are well tempered and very friendly.
        CN: Psychosocial integrity; CL: Evaluate
189. 2. Febrile seizures usually occur during the rise in temperature and are related to the peak of the temperature rather than the rapidity or duration of elevation. When children experience febrile seizures, fevers usually exceed 38.8°C (100.4°F). Febrile seizures are not related to the rapidity or duration of elevation. Febrile seizures are most common among children 18 months to 3 years but are not related to the maturity of their immune system.
        CN: Physiological adaptation; CL: Analyze
190. 3. This client could have progressed rapidly and is now ready to give birth to her infant. A sterile vaginal exam is indicated prior to getting her up to the bathroom to determine if she is fully dilated. If she is ready to give birth, she could be reassured that the sensation she is feeling is due to pressure from the fetal head. If her cervix exam is unchanged, she may need pain control interventions. The nurses’ assessment findings then should be discussed with the patient and the primary health care provider.
        CN: Reduction of risk potential; CL: Apply