TEST 5: Comprehensive

Question 1

1. A nurse has been working with a battered woman who is being discharged and returning home
   with her husband. The nurse says, “All this work with her has been useless. She’s just going back to
   him as usual.” Which of the following statements by a nursing colleague would be most helpful to this
   nurse?
2. “Her reasons for staying are complex. She can leave only when she is ready and can be safe.”
3. “I know it is frustrating to work with clients who don’t follow our advice.”
4. “You did your best. You will see her again and have another chance.”
5. “These women almost never leave for good because of their emotional and financial
   dependency.”
   The nurse is to administer ergonovine maleate (Ergotrate) 200 mcg IM. The ampule label reads 0.2
   mg/mL. The nurse should administer how many milliliters?
   _______________ mL.
6. An infant is being admitted to the hospital with dehydration secondary to viral gastroenteritis.
   Which of the following room assignments is the most appropriate for this infant?
7. A semiprivate room with an 8-year-old child who has had an appendectomy.
8. A semiprivate room with a 10-year-old child with a closed head injury.
9. A private room.
10. A semiprivate room with a 4-year-old child with leukemia.
11. For which of the following should the nurse be especially alert when caring for a term neonate,
    who weighed 10 lb (4,536 g) at birth, 1 hour after a vaginal birth?
12. Hypoglycemia.
13. Hypercalcemia.
14. Hypermagnesemia.
15. Hyperbilirubinemia.
16. A female client with infertility related to anovulatory cycles is prescribed menotropins. Which
    of the following, if stated by the client as a possible adverse effect of this medication, indicates
    successful teaching?
17. Pulmonary edema.
18. Ovarian enlargement.
19. Visual disturbances.
20. Breast tenderness.

Answer 1

1. 1. The colleague needs to provide the nurse with information about spouse abuse. Giving
      information about reasons for staying is useful for decreasing the nurse’s frustration. Although
      expressing empathy is appropriate, it does not help the nurse understand the client’s needs and
      behaviors. Telling the nurse that there will be another chance is not helpful and fails to educate the
      other nurse about the dynamics of abuse. Although dependence is a problem, women who are abused
      can overcome this and leave if they have support, not criticism. Saying that abused women almost
      never leave does not help the nurse understand the client’s needs and behavior.
      CN: Psychosocial integrity; CL: Synthesize
2. 1 mL
   First, convert micrograms to milligrams:
   CN: Pharmacological and parenteral therapies; CL: Apply
3. 3. Viral gastroenteritis may be communicable, and all of the other children are already at risk
      for infection. The infant should be placed in a private room.
      CN: Safety and infection control; CL: Synthesize
4. 1. The neonate would be considered large for gestational age (LGA) because the neonate
      weighs more than 4,000 g (90th percentile). Therefore, the nurse needs to assess for the possibility of
      complications. Hypoglycemia is a problem for the LGA neonate because glycogen stores are quickly
      used to maintain the weight. Other common complications for an LGA neonate include
      hyperbilirubinemia from the bruising and polycythemia, cephalhematoma, caput succedaneum,
      molding, phrenic nerve paralysis, and a fractured clavicle. However, hyperbilirubinemia would not
      be evident 1 hour after birth. Hypercalcemia is not usually found in the LGA neonate. Hypocalcemia
      is common in infants of diabetic mothers. Hypermagnesemia may occur in neonates whose mothers
      received large doses of magnesium sulfate to treat severe preeclampsia.
      CN: Reduction of risk potential; CL: Analyze
5. 2. Ovarian enlargement, hyperstimulation syndrome, febrile reaction, and multiple pregnanciesare considered adverse effects of menotropins. If ovarian enlargement occurs, the drug should be
      discontinued to prevent damage to the ovary. Pulmonary edema is not associated with menotropin use.
      Visual disturbances and breast tenderness are associated with the use of clomiphene citrate, another
      drug prescribed for infertility.
      CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 2

6. A healthy client mentions hearing that many people die each year awaiting transplants, and
   asks how to become an organ donor. Which response from the nurse is most appropriate?
7. “I can get you information about how to register.”
8. “Would you like to discuss your wishes with our social worker?”
9. “If that time comes, your physician will make the decision.”
10. “Which organs would you like to donate?”7. The nurse is involved in preoperative teaching with a client who will be undergoing a lung
    resection. The client is told that two chest tubes will be placed during surgery. The nurse explains that
    the purpose of the lower chest tube is to:
11. Prevent clots.
12. Remove air.
13. Remove fluid.
14. Facilitate “milking” of the tubes.
15. A nurse is assessing an 82-year-old for depression. Because of the client’s age, the nurse’s
    assessment should be guided by the fact that:
16. Sadness of mood is usually present but it is masked by other symptoms.
17. Impairment of cognition usually is not present.
18. Psychosomatic tendencies do not tend to dominate.
19. Antidepressant therapies are less effective in older adults.
20. A primary concern of the hospitalized adolescent is:
21. Respect for the need for privacy.
22. Allowing parents to visit after hours.
23. Wearing a hospital gown.
24. The fear of loss of control when in pain.
25. A 20-year-old single parent brings her 3-year-old son into the emergency department because
    he “fell.” The child has bruises on his face, arms, and legs; his mother says that she did not witness
    the fall. The nurse suspects child abuse. While examining the child, the mother says, “Sometimes I
    guess I’m pretty rough with him. I’m alone, and I just don’t know how to manage him.” The nurse
    should ask the mother if she would find it helpful to have a referral to:
26. A program for single parents.
27. A parenting education program.
28. A women’s support group.
29. A support group for abusive parents.

Answer 2

6. 1. Nurses should encourage interested clients to sign up through an organ donor registry. To
      ensure that their wishes are met, clients should create advanced directives and tell their wishes to
      their families and healthcare providers. Registering as an organ donor does not require collaboration
      with a social worker. A physician may determine viability of organs but cannot make the decision to
      donate a client’s organs. The nurse would not need to record the specific organs at this time.
      CN: Management of care; CL: Apply
7. 3. Fluid accumulates in the base of the pleura postoperatively. The lower chest tube, called the
      posterior or lower tube, will drain serous and serosanguineous fluid that accumulates as a result of
      the surgical procedure. A larger-diameter tube is usually used for the lower tube to ensure drainage of
      clots. Air rises, and the anterior or upper tube is used to remove air from the pleural space. The
      practice of “milking” the tubes to prevent clots is becoming less common; the surgeon’s prescriptions
      must be followed regarding this procedure.
      CN: Physiological adaptation; CL: Apply
8. 1. Elderly clients are a high-risk group for depression. The classic symptoms of depression
      frequently are masked, and depression presents differently in the aging population. Depression in late
      life is underdiagnosed because the symptoms are incorrectly attributed to aging or medical problems.
      Impairment of cognition in a previously healthy elderly client or psychosomatic problems may be the
      presenting symptom of depression. Antidepressant therapy is usually effective.
      CN: Psychosocial adaptation; CL: Analyze
9. 4. Fears of the adolescent include body changes and loss of control. The young adolescent is
      typically concerned about the inability to control body changes and feelings and about embarrassment.
      The typical adolescent is more concerned about being separated from the peer group than from the
      family and schoolwork and is realistically worried about experiencing pain and loss of control. The
      adolescent may prefer to wear her own clothes, but this is not a primary concern. The nurse should
      respect the client’s privacy, but this is not a primary concern for this client.
      CN: Health promotion and maintenance; CL: Apply
10. 2. The mother’s statements reveal that she is having problems with parenting. Therefore, a
       referral to a parenting education program is the most appropriate measure at this time.
       CN: Management of care; CL: Synthesize

Question 3

11. The nurse is planning to complete the following assessments during the last half hour of the
    shift. Which of the following assessments has the highest priority and should be accomplished first?
12. A postpartum couplet with the infant who has had transient tachypnea of the newborn (TTN) at
    birth and now has a respiratory rate of 60 breaths/min.
13. A newly admitted postpartum client who is receiving magnesium sulfate at 3 g an hour initiated
    10 hours ago for preeclampsia; her infant ate poorly previously and has not eaten for 4 hours.
14. A mother who had a cesarean section and is 6 hours after birth with the baby in special care
    nursery; the mother has not yet seen her baby.
15. A couplet with baby born at 36 weeks’ gestation; the 5-lb (2,268-g) infant had initial blood
    glucose of 35 mg/dL (1.9 mmol/L) and when taken to the room had a glucose of 46 mg/dL (2.6
    mmol/L).
16. A nurse who fails to check a client’s armband before administering medications is:
17. Res judicata.
18. Negligent.
19. Stare decisis.4. Vicariously liable.
20. Before administering morphine to a client, the nurse should assess the client’s:
21. Blood pressure.
22. Respiration rate.
23. Pulse.
24. Temperature.
    A client is to receive 1 unit of packed red blood cells over 2 hours. There are 250 mL in the infusion
    bag. The IV administration infusion set delivers 10 gtt/mL. At what flow rate (in drops per minute)
    should the nurse run the infusion?
    _______________ gtt/min.
25. A mother states that she is very angry with the primary care provider who diagnosed her
    child with leukemia. Which statement helps the nurse understand this mother’s reaction?
26. Anger is a natural result of a sense of loss and helplessness.
27. Parents of sick children are usually unable to control their anger.
28. Anger is rarely demonstrated by parents when coping with a sick child.
29. The mother cannot overcome her anger in an acceptable manner.

Answer 3

11. 2. The infant who has not eaten in 4 hours is the highest priority of this group of couplets. The
       last feeding was 4 hours ago and the prior poor feeding puts this infant at risk. An assessment of this
       infant is needed from a safety perspective since the mother had magnesium sulfate. The nurse should
       question whether the poor feeding may be a result of magnesium sulfate in the newborn’s system by
       evaluating respiratory rate, tone, and current ability to feed. The couplet with an infant with TTN and
       a respiratory rate of 60 is within normal limits but should have the respiratory rate reevaluated to
       assure normalcy. The mother who had a Cesarean section should be evaluated to determine when shewill be able to go to SCN to see her infant. Urgency concerning taking her to the nursery will also
       depend on the condition of the newborn. The newborn of 36 weeks’ gestation is currently within
       normal blood glucose range, but would need to be monitored frequently because of the small infant
       size and prior low blood glucose.
       CN: Management of care; CL: Synthesize
12. 2. The nurse acts in a reasonable and prudent manner to correctly identify a client by checking
       the client’s armband and asking the client’s name. Omitting to do so is an act of negligence. Res
       judicata and stare decisis are legal doctrines used to guide the courts in making decisions. Vicarious
       liability is a concept in which the employer is held liable for the nurse’s act. It was established after
       precedent-setting cases in the 1960s.
       CN: Management of care; CL: Apply
13. 2. Morphine can cause respiratory depression, leading to respiratory arrest. The nurse should
       assess the client’s respiratory rate before administration and throughout the course of analgesic
       treatment. Morphine does not affect blood pressure, pulse rate, or temperature.
       CN: Pharmacological and parenteral therapies; CL: Analyze
14. 21 gtt/min
    There are 250 mL of fluid in this unit of packed blood red cells, which are to infuse over 2 hours
    (120 minutes). First, determine the number of mL/min by dividing 250 mL by 120 minutes:
    Then multiply by the drop factor of 10 gtt/mL:
    CN: Pharmacological and parenteral therapies; CL: Apply
15. 1. Anger is a natural result of feelings of loss and helplessness in normal, healthy people. It is
       a natural response to coping with a sick child. Nurses should recognize anger in clients and families.
       Parents are usually able to control their anger in a socially acceptable manner. Nurses can assist
       clients and families to overcome helplessness and anger in an acceptable manner.
       CN: Psychosocial adaptation; CL: Synthesize

Question 4

16. Which of the following nursing strategies would be effective in managing a client who has
    Alzheimer’s disease and wanders?
17. Encourage participation in activities such as board games.
18. Discourage wandering by allowing the behavior at selected intervals.
19. Involve the client in activities that promote walking.
20. Promote safety by restraining the client in a geriatric chair.
21. A child who had a cast applied to his arm earlier this morning tells the nurse that his fingers
    are numb. The nurse should:
22. Notify the primary care provider who applied the cast.
23. Cut the cast to loosen it.
24. Assess the circulation to the fingers.
25. Ensure that the arm is positioned correctly.
26. A client is admitted with low back pain (LBP). The nurse should further assess the client for:
27. Osteoporosis.
28. Herniated disk.
29. Muscle strain.
30. Spondylosis.
31. While helping clients brought to a crisis center during a severe flood, the nurse interviews a
    client whose pregnant wife is missing and whose home has been destroyed. The client keeps talking
    rapidly about his experience and says, “I can’t see how I can ever rebuild my life.” Which of the
    following responses by the nurse would be most appropriate?
32. “If you start organizing your life now, I’m sure all will be fine.”
33. “This has been a terrible experience. Tell me more about how you feel.”
34. “Let me note a few of the things you said before you continue with your story.”
35. “Tonight, think some more of what happened, so that we can continue with this tomorrow.”20. A client with asthma has been prescribed beclomethasone via metered-dose inhaler. To
    determine if the client has been rinsing the mouth after each use of the inhaler, the nurse should inspect
    the client’s mouth for:
36. Gingival hyperplasia.
37. Oral candidiasis.
38. Ulceration.
39. Dental caries.

Answer 4

16. 3. Supervised activities that promote walking are behavioral management strategies that help
       a client such as this. The client’s cognitive and memory impairment would not be conducive to
       playing board games. Allowing the behavior at selected intervals would further encourage the client
       to wander. The client should not be restrained in a chair.
       CN: Psychosocial adaptation; CL: Synthesize
17. 3. With a new problem of numbness in the fingers, the nurse needs to first assess the
       circulation to evaluate color, evidence of swelling, and presence of pulses to determine whether there
       is any circulatory compromise. Once the nurse has evaluated the child’s circulatory status, the next
       action would be to verify the arm’s position above the level of the heart. Notifying the primary care
       provider would not be done until the child’s neurovascular status and position are checked. Cutting
       the cast would be done only with a primary care provider’s prescription.
       CN: Physiological adaptation; CL: Synthesize
18. 3. LBP is commonly associated with overuse or an injury to the soft-tissue structures. It is
       estimated that 50% to 70% of people will experience musculoskeletal back pain at some time.Although the other causes of pain must be excluded, the initial treatment of LBP is usually aimed at
       decreasing the inflammatory response to the tissue injury.
       CN: Physiological adaptation; CL: Analyze
19. 2. At the time of a major crisis, the client suffering a great loss is best helped by being
       encouraged to talk about his experience and describe his feelings. Crisis interventions focus on
       reestablishing emotional equilibrium and preventing decompensation. Telling the client that
       everything will be fine is a cliché and inappropriate. Asking the client to stop talking so that the nurse
       can write notes places more emphasis on the nurse’s needs than on the client’s needs. Telling the client
       to think more about what happened for further discussion the next day is not helping him with the
       crisis.
       CN: Psychosocial adaptation; CL: Synthesize
20. 2. Beclomethasone is an inhaled steroid used for the maintenance treatment of asthma. The
       steroid can precipitate overgrowth of fungus, such as oral Candida albicans. Rinsing the mouth well
       after each use decreases the incidence of oral fungal infections. Beclomethasone does not cause
       gingival hyperplasia, ulceration, or caries.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 5

21. The nurse finds a client lying on the floor next to the bed. After returning the client to bed,
    assessing for injury, and notifying the primary care provider, the nurse fills out an incident report.
    Which of the following is the nurse’s next action?
22. Give the incident report to the nurse-manager.
23. Place the incident report on the chart.
24. Call the family to inform them.
25. Omit mentioning the fall in the chart documentation.
26. The charge nurse on an antepartal unit is making staffing assignments for the day. There is a
    registered nurse (RN), licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP)
    to care for 15 clients. The nurse should assign which of the following clients to the LPN?
27. A newly admitted G5 P2 Ab 2 with second trimester bleeding, reportedly currently saturating
    one to two pads in 12 hours.
28. A 22-year-old G2 P1 with urinary retention who is being catheterized with an intermittent in
    and out every 4 to 6 hours PRN while awaiting urine cultures to be returned.
29. A G4 P2 with a twin pregnancy who was admitted in preterm labor and is now able to
    ambulate two to three times daily and having no contractions.
30. A 30-year-old G4 P0 who was admitted with sickle cell crisis currently receiving blood and
    pain medication.
31. The mother of a 2-year-old who has been bitten by the family dog asks the nurse what to do
    about the bite. What should the nurse tell the mother?
32. “You need to take the child to the local urgent-care center immediately.”
33. “Wash the bite area with lots of running water, and then check the injury.”
34. “Determine when the child’s latest tetanus vaccine was administered.”
35. “Make an appointment to see the child’s primary care provider now to start rabies shots.”
36. The nurse is discharging a client who has been hospitalized for preterm labor. The client
    needs further instruction when she says:
37. “If I think I have a bladder infection, I need to see my obstetrician.”
38. “If I have contractions, I should contact my health care provider.”
39. “Drinking water may help prevent early labor for me.”
40. “If I travel on long trips, I need to get out of the car every 4 hours.”
41. A 7-year-old has been diagnosed with bacterial meningitis. Which of the following should
    receive chemoprophylaxis?
42. All children at the school.
43. All household contacts and close contacts.
44. The entire community.4. Household contacts only

Answer 5

21. 1. The incident report should be given to the nurse-manager. Incident reports are processed
       independently of the client’s chart and do not become part of the health record. It is appropriate,
       ethical, and legally required that the fall be documented in the chart. Unless there is a change in the
       client’s condition reflecting an injury from the fall, there is no need to notify the family. If the family
       does need to be notified, the nurse-manager or the primary care provider should place the call.
       CN: Management of care; CL: Synthesize
22. 2. The 22-year-old G2 with urinary retention and needing to be I & O catheterized by a health
       care provider can be cared for by the LPN. There is nothing else indicating a need for a higher level
       of care. The newly admitted G5 client is in need of an admission assessment and assessment of fetal
       well-being and bleeding that will need to be done by an RN. The G4 P2 with a twin pregnancy who
       has been in preterm labor can be cared for by a UAP since there is no active labor and no indication
       of distress in the fetuses. The client in sickle cell crisis requires a high level of care to be provided
       by an RN.
       CN: Management of care; CL: Synthesize
23. 2. General wound care is appropriate initially. This includes washing the bite area with lots
       of water because infections occur frequently with animal bites, especially those on the arms or hands.
       Next, the mother should be advised to determine the extent of the injury and then to follow up with the
       child’s primary care provider if needed. A trip to the local care center would be warranted if the bite
       injury was extensive or there was severe bleeding. Although knowledge of when the child last had a
       tetanus vaccination is important, the child’s wound takes priority. For rabies injections, there needs to
       be a history of rabies or unusual behavior in the pet.
       CN: Physiological adaptation; CL: Synthesize
24. 4. Traveling is usually discouraged if preterm labor has been a problem as it restricts normal
       movement. A client should be able to walk around frequently to prevent blood clots and to empty her
       bladder at least every 1 to 2 hours. Bladder infections often stimulate preterm labor and to preventthem is of great importance to this client. Contractions that recur indicate the return of preterm labor
       and the health care provider needs to be notified. Dehydration is known to stimulate preterm labor
       and encouraging the client to drink adequate amounts of water helps to prevent this problem.
       CN: Reduction of risk potential; CL: Evaluate
25. 2. Chemoprophylaxis should be given to household contacts and close contacts only. To
       prevent community outbreaks, chemoprophylaxis with rifampin 600 mg twice a day for 2 days or a
       single dose of Cipro 500 mg is indicated.
       CN: Reduction of risk potential; CL: Synthesize

Question 6

26. The mother of a newborn is concerned about the number of persons with heart disease in her
    family. She asks the nurse when she should start her baby on a low-fat, low-cholesterol diet to lower
    the risk of heart disease. The nurse should tell her to start diet modifications:
27. At birth.
28. At age 2.
29. At age 5.
30. At age 10.
31. A client is being treated for severe pediculosis. The nurse should instruct the client to treat
    the problem in the eyebrows and eyelashes by:
32. Applying petroleum jelly to lashes and brows three to four times a day.
33. Applying a pediculicide with a cotton-tipped swab three to four times a day.
34. Applying lindane ointment to the lashes and eyebrows three times a day.
35. Applying bacitracin ointment to the lashes and brows three times a day.
36. The nurse is discussing safety and accident prevention with the mother of a 9-month-old. The
    teaching has been effective when the mother states which of the following?
37. “I make sure that I keep my cleaning supplies locked up.”
38. “Sometimes she plays in the bathroom when I’m cleaning in there.”
39. “Occasionally she gets under the chair and plays with the telephone cord.”
40. “I’ve found that those child-protective cabinet locks don’t work very well.”
41. When assessing a child receiving tobramycin sulfate, which findings would indicate that the
    child is experiencing adverse effects? Select all that apply.
42. Increased blood pressure.
43. Weight gain.
44. Rash.
45. Fever.
46. Ringing in the ears.
47. Decreased heart rate.
48. The nurse instructs the client who is taking gentamicin to monitor renal function. The nurse
    determines that the client needs additional instruction when he makes which of the following
    statements?
49. “I should call you if I notice that I’m not urinating as much.”
50. “I should call you if my urine looks dark or unusual.”
51. “I should call you if my legs swell or I notice my skin looks puffy around my eyes.”
52. “I should call you if I have a fever.

Answer 6

26. 2. Infants and toddlers younger than age 2 should not be placed on a fat-restricted diet because
       cholesterol and other fatty acids are required for continued neural growth. After age 2 it is believed
       that no harm is done by encouraging a child to eat a variety of foods, maintain a desirable body
       weight, limit saturated fat and cholesterol, and increase fiber.
       CN: Health promotion and maintenance; CL: Apply
27. 1. Petroleum jelly is thought to smother the lice. A pediculicide should not be applied to the
       face or close to the eyes. Bacitracin ointment will not kill the lice.
       CN: Pharmacological and parenteral therapies; CL: Apply
28. 1. A major goal of safety and accident prevention focuses on having all cleaning supplies and
       medications locked up. Toddlers are great climbers and can very quickly get into what they should
       not. The child should not play in the bathroom even if the parent is present because the child will
       think that it is okay to play with these items when the parent is not present. Playing with cords could
       lead to possible strangulation. The child-protective cabinet locks should work unless they were
       installed incorrectly or are defective.
       CN: Safety and infection control; CL: Evaluate
29. 3, 4, 5. Common adverse effects of tobramycin include nephrotoxicity, ototoxicity, fever, and
    rash. Hypertension, weight gain, and decreased heart rate are not associated with this drug.
    CN: Pharmacological and parenteral therapies; CL: Analyze
30. 4. Fever is generally not thought to be a sign of impaired renal function related to long-term
       use of gentamicin. The client should report signs of decreasing urinary function, such as decreased
       output, unusual appearance of the urine, or edema.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 7

31. A child with the diagnosis of pneumonia is placed in a mist tent. Which of the following toys
    would be appropriate for this child?
32. A pull toy.
33. Storybooks.
34. Crayons and paper.
35. Plastic blocks.
36. When teaching a group of parents about the potential for febrile seizures in children, which ofthe following facts should the nurse include?
37. The exact cause is known.
38. The seizures occur as the fever rises.
39. Children older than age 3 are most at risk.
40. These seizures commonly occur after immunization administration.
41. A 19-year-old G1 P0 is being discharged home after hospitalization for hyperemesis
    gravidarum and is being referred to home health care. The nurse should develop a discharge plan that
    includes which of the following? Select all that apply.
42. Refer client to a nutritionist for the following day.
43. Ensure that the client has a prescription for an antiemetic.
44. Ask the health care provider for an anxiolytic prescription.
45. Encourage return to normal routine when client feels ready.
46. Coordinate follow-up appointment with provider in 6 weeks.
47. Discuss plan of care and discharge instructions with client.
48. The nurse should instruct a woman taking folic acid supplements for folic acid deficiency
    anemia that:
49. It will take several months to notice an improvement.
50. Folic acid should be taken on an empty stomach.
51. Iron supplements are contraindicated with folic acid supplementation.
52. Oral contraceptive use, pregnancy, and lactation increase daily requirements.
53. The nurse makes a home visit to a primiparous client and her neonate at 1 week after a
    vaginal birth. Which of the following findings should be reported to the primary care provider?
54. A scant amount of maternal lochia serosa.
55. The presence of a neonatal tonic neck reflex.
56. A nonpalpable maternal fundus.
57. Neonatal central cyanosis

Answer 7

31. 4. Plastic blocks are the most appropriate toy for a toddler in a mist tent. Because the blocks
       are plastic, they can be washed. For the pull toy to be used, the child would need to leave the mist
       tent, which is not advisable at this time. Although crayons may be appropriate for a mist tent, any
       paper, including storybooks, would become damp, crumble, and provide an environment for the
       growth of microorganisms.
       CN: Health promotion and maintenance; CL: Synthesize
32. 2. Febrile seizures commonly occur as the fever rises. The exact cause of febrile convulsions
       is not known. Infants and young toddlers are the age-groups primarily affected. Febrile seizures
       typically do not follow immunization administration.
       CN: Health promotion and maintenance; CL: Apply33. 1, 2, 4, 6. The nurse case manager should refer the client to a nutritionist so the client is aware
       of and can be monitored regarding her food intake to assure transition to a normal pregnancy diet with
       intake of adequate nutrients to support growth and development of the fetus. A PRN (as needed)
       prescription for an antiemetic is useful to overcome occasional episodes of nausea and vomiting.
       Encouraging a return to normal activities when the client feels ready gives the client a goal to look
       forward to and activity is not contraindicated in hyperemesis when the client feels ready to initiate
       activity. Discussion of the plan of care and discharge instructions is a standard of care when
       discharging a client from a health care facility. There is no indication for an anxiolytic and
       hyperemesis gravidarum typically is not associated with anxiety. Six weeks is too long to wait for a
       follow-up appointment post hospitalization.
       CN: Management of care; CL: Create
33. 4. Oral contraceptive use, pregnancy, and lactation are situations that increase demand for
       folic acid. With supplementation, a response should cause the reticulocyte count to increase within 2
       to 3 days after therapy has begun. It is not necessary to take folic acid on an empty stomach. A client
       may safely take both iron and folic acid supplementation.
       CN: Pharmacological and parenteral therapies; CL: Synthesize
34. 4. Although acrocyanosis may be present for 24 to 48 hours after birth, central cyanosis of the
       trunk indicates decreased oxygenation from respiratory distress or another disease state (eg, cardiac
       anomalies). This should be reported to the primary care provider and evaluated further. Maternal
       lochia serosa in scant amount is a normal finding 1 week postpartum, as is a nonpalpable maternal
       fundus. Presence of a neonatal tonic neck reflex is a normal finding in a 1-week-old neonate.
       CN: Physiological adaptation; CL: Analyze

Question 8

36. The nurse is obtaining a health history for a client with osteoporosis. The nurse should
    specifically ask the client about which of the following? Select all that apply.
37. Amount of alcohol consumed daily.
38. Use of antacids.
39. Dietary intake of fiber.
40. Use of vitamin K supplements.
41. Intake of fruit juices.
42. The nurse tells a rape victim that even if she was protected against pregnancy by a
    contraceptive and has no intention of taking any legal action against her assailant, she should still be
    checked by a primary care provider for early detection of which of the following?
43. Sexually transmitted disease.
44. Anxiety reaction.
45. Periurethral tears.
46. Menstrual difficulties.
47. A hospitalized client fell on the floor and sustained a small laceration on the hand that
    required stitches. The intern will suture the client’s hand at the client’s bedside and asks forbupivacaine with epinephrine and a suture kit in order to suture the laceration. The nurse should
    question which of the following?
48. The intern’s ability to suture.
49. The client’s room as an aseptic environment.
50. Bupivacaine with epinephrine as the local anesthetic.
51. The cosmetic effect from not having a plastic surgeon do the suturing.
52. A 5-lb 8-oz (2.5 kg) baby was born 1 hour ago by a 19-year-old primigravida. The priority
    nursing assessments include monitoring the infant for:
53. Jaundice and physical assessment.
54. Vital signs and gestational age assessments.
55. Feedings and vital signs.
56. APGAR and gestational age assessments.
57. When assessing a dark-skinned client for cyanosis, the nurse should examine which of the
    following?
58. The client’s retinas.
59. The client’s nail beds.
60. The client’s oral mucous membranes.
61. The inner aspects of the client’s wrists.

Answer 8

36. 1, 2, 3, 4. The nurse should ask the client about alcohol use, because heavy alcohol use causes
    fluid excretion resulting in heavy losses of calcium in urine. If the client uses antacids containing
    aluminum or magnesium, a net loss of calcium can occur. If the client has a high-fiber diet, the fiber
    can bind up some of the dietary calcium. People with hip fractures have been found to have low
    vitamin K intakes; vitamin K plays an important role in production of at least one bone protein. Fruit
    juices do not affect calcium absorption.
    CN: Health promotion and maintenance; CL: Analyze
37. 1. The postrape examination is important for detecting the possibility of sexually transmitted
       disease, which can be spread through rape. Additionally, if the victim or the rapist was not using a
       contraceptive, postcoital contraceptive methods should be discussed. The information provided does
       not indicate anxiety or physical injury, such as periurethral tears, and these are not the primary reason
       for the examination. Menstrual difficulties are not a common result of rape.
       CN: Safety and infection control; CL: Synthesize
38. 3. The nurse should question the use of a local anesthetic agent with epinephrine on the hands
       or feet because the epinephrine is a vasoconstrictor and can cause ischemia and gangrene of
       extremities. The nurse should suggest that the intern use bupivacaine without epinephrine as the local
       anesthetic agent. An intern should be trained in suturing small superficial incisions, and the cosmetic
       effect should be acceptable. The client’s room should be a sufficiently aseptic environment because
       there is no other client in the room.CN: Management of care; CL: Synthesize
39. 3. Infants should be monitored for hypoglycemia, temperature stability, and respiratory
       distress. The answer that best includes these components is monitoring the infant feedings and vital
       signs. APGAR assessments are done at 1 and 5 minutes of age, not at 1 hour of age. The gestational
       age assessment is important for this infant, but after completion, does not require additional
       monitoring. The infant should be regularly assessed for jaundice as part of their physical assessment,
       but this is not the priority assessment at this time.
       CN: Basic care and comfort; CL: Analyze
40. 3. In dark-skinned clients, cyanosis can best be detected by examining the conjunctiva, lips,
       and oral mucous membranes. Examining the retinas, nail beds, or inner aspects of the wrists is not an
       appropriate assessment for determining cyanosis in any client.
       CN: Health promotion and maintenance; CL: Analyze

Question 9

41. Betamethasone (Celestone) syrup 0.9 mg has been prescribed. It is available in a 0.6 mg/5 mL
    solution. How many milliliters should the nurse administer?
    _______________ mL.
42. A client at 37 weeks’ gestation is scheduled for a biophysical profile. Which of the following
    should the nurse instruct the client to do before the test?
43. Drink 1 to 2 L of fluid.
44. Take nothing by mouth after midnight before the test.
45. Plan to remain in the clinic for 4 hours after the test.
46. Eat a high-fiber meal after the test.
47. A 12-year-old boy has depression and posttrauma response. The boy’s father is now in jail
    for molesting him from ages 6 to 9. Given the typical reactions of incest victims, the nurse should
    assess the child for which behavior? Select all that apply.
48. Sexualized play.
49. Aggression.
50. Isolation at home.
51. Running away.
52. Truancy.
53. Which of the following is true with regard to delegation of client care responsibilities?
    Select all that apply.
54. The nurse must know the nursing model that underlies care at the institution.
55. The nurse delegates in accordance with demands on his/her time.
56. The nurse validates with the nonregistered nurse (non-RN) caregiver that he/she has performed
    the same activity before.
57. The nurse retains the right to determine which tasks are delegated.5. The nurse must document that the task has been delegated and to whom.
58. A mother is concerned about the amount of snacking her teenage boy is doing. She is
    concerned that this behavior could lead to obesity. Which of the following is an appropriate
    percentage of the daily diet to be obtained from snacks?
59. 10%.
60. 25%.
61. 40%.
62. 50%.

Answer 9

41. 7.5 mL
    CN: Pharmacological and parenteral therapies; CL: Apply
42. 1. A biophysical profile includes a nonstress test; evaluation of fetal breathing movements,
       gross body movements, and fetal tone; and amniotic fluid volume measurement. Because an
       ultrasound analysis is used during the test, the client should plan to drink 1 to 2 L of fluid before the
       test to ensure a full bladder, which provides better visualization of the fetus. The client does not need
       to be on nothing-by-mouth status before the test. The client does not need to remain in the clinic for 4
       hours after the test. However, if the client were scheduled for a contraction stress test, she would be
       observed as an outpatient for 1 to 4 hours after the test to make certain that the contractions had
       stopped. The client does not need to eat a high-fiber meal after the test. A high-fiber meal typically is
       indicated after certain radiographic procedures, such as an upper gastrointestinal series.
       CN: Reduction of risk potential; CL: Apply
43. 1, 2, 4, 5. Children typically act out their feelings (such as depression and anger) in response
    to incest. Sexualized play, aggression, running away, and truancy are typical acting-out behaviors.
    Isolation at home is not common for incest victims who are preadolescents.
    CN: Psychosocial adaptation; CL: Analyze
44. 1, 3, 4. Delegation involves the reassignment or transfer of selected aspects of a job to
    selected persons in selected situations. Although responsibility for completion of a task or activity
    can be delegated, accountability for that task remains with the RN. In delegating nursing acts,
    functions, or tasks, the RN must consider the nursing model to determine the appropriate delegation of
    assignment. Prior to delegation, the RN validates that the non-RN caregiver has orientation and
    experience in completion of the activity. The amount of time the nurse has does not direct the
    delegation procedure; the focus is on the task and capability of the staff to whom the task is delegated.
    It is not necessary to document that the task has been delegated and to whom; however, the outcome of
    the task should be documented by the nurse.
    CN: Management of care; CL: Apply45. 2. About 25% of the teenager’s diet can come from snacks. This is a way for teenagers to
    obtain protein, thiamine, riboflavin, vitamin B 6 , magnesium, and zinc. Although not all snacks are low
    in fat or contain these nutrients, the nurse should encourage the mother to provide snacks with these
    nutrients.
    CN: Health promotion and maintenance; CL: Apply

Question 10

46. The client has sore nares while a nasogastric (NG) tube is in place. Which of the following
    nursing measures would be most appropriate to help alleviate the client’s discomfort?
47. Reposition the tube in the nares.
48. Irrigate the tube with a cool solution.
49. Apply a water-soluble lubricant to the nares.
50. Have the client change position more frequently.
51. The nurse is instructing a Hindu client to increase protein in the diet. Which of the following
    foods are appropriate to include in this client’s diet? Select all that apply.
52. Lentil soup.
53. Hamburger.
54. Steak.
55. Veal cutlet.
56. Broiled fish sandwich.
57. A child with partial- and full-thickness burns is admitted to the pediatric unit. Which of the
    following should be the priority at this time?
58. Preventing wound infection.
59. Evaluating vital signs frequently.
60. Maintaining fluid and electrolyte balance.
61. Managing the child’s pain.
62. A normal, healthy infant is brought to the clinic for the first immunization against polio.
    Which of the following is the appropriate route to administer this vaccine?
63. Oral.
64. Intramuscular
65. Subcutaneous.
66. Intradermal.
67. A child has been prescribed diphenhydramine hydrochloride (Benadryl) to help control the
    itching from atopic dermatitis. The nurse should instruct the parents to report which of the following
    conditions? Select all that apply.
68. Weight loss.
69. Drowsiness.
70. Thickened bronchial secretions.
71. Upset stomach.
72. Bradycardia.

Answer 10

46. 3. Applying a water-soluble lubricant to the nares helps alleviate sore nares when an NG tube
       is in place. Repositioning the tube does not eliminate the possibility of irritating the nares. Irrigating
       the tube with a cool solution or changing positions will not relieve the local irritation from the NG
       tube.
       CN: Basic care and comfort; CL: Synthesize
47. 1, 5. Hindus do not eat beef. Sufficient protein can be obtained from lentils and fish.
    CN: Health promotion and maintenance; CL: Synthesize
48. 3. Although monitoring vital signs frequently is important, for the first few days the primary
       concern in burn care is fluid and electrolyte balance, with the goal being to replace fluid and
       electrolytes lost. With burns, fluid and electrolytes move from the interstitial spaces to the burn injury
       and are lost. These must be replaced. Once the child’s fluid and electrolyte status has been addressed
       and fluid resuscitation has begun, preventing wound infection is a priority and efforts to control the
       child’s pain can be initiated.
       CN: Reduction of risk potential; CL: Synthesize
49. 2. Inactivated polio vaccine is given intramuscularly, usually with other vaccines. As a killed
       virus it can be given to immunocompromised children.
       CN: Pharmacological and parenteral therapies; CL: Apply
50. 2, 3, 4. Diphenhydramine hydrochloride is an antihistamine that blocks the effects of histamine
    at receptor sites and has atropine-like effects, such as dry mouth, nausea, drowsiness, tachycardia,
    and thickened bronchial secretions. Weight loss and bradycardia are not adverse effects of this
    medication.
    CN: Pharmacological and parenteral therapies; CL: Apply

Question 11

51. The nurse observes that a client who has received midazolam for conscious sedation ishaving shallow respirations. The nurse should do all but:
52. Encourage the client to deep-breathe.
53. Have respiratory resuscitation equipment in the room.
54. Administer oxygen as prescribed.
55. Administer naloxone.
56. The nurse is planning to assist the primary care provider with a thoracentesis for a client who
    has a pleural effusion. Which of the following positions would be appropriate for the client to
    assume?
57. Lying supine with the arms extended.
58. Lying prone with the head supported by the arms.
59. Sitting upright and leaning on an overbed table.
60. Side-lying with the knees drawn up to the abdomen.
61. The nurse is preparing a presentation on nutrition to a group of pregnant adolescents. Which
    of the following would be important for the nurse to include in the teaching plan?
62. Spinach is an excellent source of calcium in the diet.
63. Two to four servings of whole-grain products are recommended.
64. Three or more servings of dairy products meet the calcium requirement.
65. Vitamin A supplements may be necessary for clients who are vegetarian.
66. A client has a coxackie B (viral) or trypanosomal (parasite) infection. The nurse should
    further assess the client for:
67. Myocarditis.
68. Myocardial infarction.
69. Renal failure.
70. Liver failure.
71. Which of the following would be true regarding medication reconciliation? Select all that
    apply.
72. Medication reconciliation is an important patient safety goal.
73. Medication reconciliation is designed to obtain and communicate an accurate list of a client’s
    home medications across the continuum of care.
74. Only nurses or health care providers can be involved in medication reconciliation.
75. Medications are considered reconciled if a medication prescription exists that is
    therapeutically equivalent to the one prior to admission.
76. A medication is considered to be any medication prescribed by a primary care provider.

Answer 11

51. 4. The nurse does not administer naloxone because naloxone is the antidote for morphine, not
       midazolam. The benzodiazepine-receptor antagonist for midazolam is flumazenil. The nurse can
       promote oxygenation by encouraging deep breathing and administering oxygen. Resuscitation
       equipment should be accessible if needed.
       CN: Reduction of risk; CL: Synthesize
52. 3. The client should be seated upright with the arms raised and crossed in front and supported
       by the overbed table. The client’s head should rest on the arms. This position allows for outward
       expansion of the chest wall and promotes collection of the pleural fluid at the base of the thorax.
       CN: Reduction of risk potential; CL: Synthesize
53. 3. Three or more servings of dairy products meet the calcium requirement. These can be
       obtained through milk, cheese, yogurt, and foods such as tofu. Spinach contains oxalates, which
       decrease the availability of calcium. Six to eleven servings of whole grains are recommended.Vitamin A supplements are not necessary in vegetarian diets because most vegetarian diets are rich in
       vitamin A. Vitamin A supplements can lead to anorexia, irritability, hair loss, and damage to the fetus.
       CN: Basic care and comfort; CL: Synthesize
54. 1. Intracellular microorganisms, such as viruses and parasites, invade the myocardium to
       survive. These microorganisms damage the vital organelles and cause cell death in the myocardium.
       The myocardium becomes weak, leading to heart failure; then T lymphocytes invade the myocardium
       in response to the viral infection. The T lymphocytes respond to the viral infection by secreting
       cytokines to kill the virus, but they also kill the virus-infected myocardium. Myocardial infarction,
       renal failure, and liver failure are not direct consequences of a viral or parasitic infection.
       CN: Safety and infection control; CL: Analyze
55. 1, 2, 4. An important patient safety goal is to accurately and completely reconcile medications
    across the continuum of care. The requirement is that there is a process for comparing the client’s
    current medications with those prescribed for the client while under the care of the health care
    organization. Clients are most at risk during transitions in care (hand-offs) across settings, services,
    providers, or levels of care. The development, reconciliation, and communication of an accurate
    medication list throughout the continuum of care are essential in the reduction of transition-related
    adverse drug events. The client or client’s family is an integral component of medication
    reconciliation, particularly at the point of admission to, and discharge from a health care facility. Any
    medications that the client uses, for example, over-the-counter medications, must be included in the
    reconciliation process.
    CN: Safety and infection control; CL: Apply

Question 12

56. Which of the following compensatory actions by the body would occur if a client were in
    respiratory acidosis?
57. Excretion of bicarbonate (HCO 3− ) by the kidneys.
58. Retention of HCO 3− by the kidneys.
59. Increase in respiratory rate by the lungs.
60. Decrease in respiratory rate by the lungs.
61. A client has started taking amiodarone (Cordarone). The nurse should inform the client that
    periodic laboratory tests will be done to monitor the client’s:
62. Hemoglobin.2. Liver enzymes.
63. Creatine kinase (CK) concentration.
64. Renal function.
65. A 9-month-old child has been diagnosed with an ear infection. The father asks what else to
    do to help his child. The nurse can tell the father:
66. “Your child should also take an antihistamine.”
67. “The antibiotic is the only medicine necessary.”
68. “Cotton in the ears helps the discomfort.”
69. “Over-the-counter eardrops often are helpful.”
70. A child’s plan of care lists increasing protein intake as a goal. Which of the following foods
    that the child likes should the nurse encourage the child to eat?
71. A bacon, lettuce, and tomato sandwich.
72. Fruit-flavored yogurt.
73. Nacho chips and salsa.
74. Crackers with butter and jelly.
75. Thirty minutes after a Sengstaken-Blakemore tube is inserted, the nurse observes that the
    client appears to be having difficulty breathing. The nurse’s first action should be to:
76. Remove the tube.
77. Deflate the esophageal portion of the tube.
78. Determine whether the tube is obstructing the airway.
79. Increase the oxygen flow rate.

Answer 12

56. 2. The compensatory mechanism for respiratory acidosis is the renal system. In respiratory
       acidosis, the kidneys will conserve HCO 3− in an attempt to correct the acidosis. Excretion of HCO 3−
       would exacerbate the body’s acidosis. The lungs cannot compensate for a problem that arises in the
       respiratory system.
       CN: Physiological adaptation; CL: Analyze
57. 2. Amiodarone is metabolized in the liver and excreted in the bile and feces. Liver toxicity
       has been reported with the use of this drug, so the nurse will want to monitor the client’s liver
       enzymes. Amiodarone does not affect hemoglobin, CK, or renal function.
       CN: Pharmacological and parenteral therapies; CL: Apply
58. 2. Antibiotics are the drug of choice in treating otitis media. Antihistamines, eardrops, and
       cotton in the ears are not helpful and are not recommended.
       CN: Health promotion and maintenance; CL: Synthesize
59. 2. Yogurt is high in protein because it is made from milk. The other choices are much higher in
       carbohydrates than protein except for bacon, which is higher in fat.
       CN: Reduction of risk potential; CL: Apply
60. 3. If the gastric balloon should rupture or deflate, the esophageal balloon can move and
       partially or totally obstruct the airway, causing respiratory distress. The client must be observed
       closely. No direct action should be taken until the condition is accurately diagnosed.
       CN: Reduction of risk potential; CL: Synthesize

Question 13

61. A client is taking ciprofloxacin (Cipro). Which of the following laboratory studies will not
    be affected by ciprofloxacin?
62. Theophylline level.
63. Prothrombin time (PT).
64. Partial thromboplastin time (PTT).
65. Total iron-binding capacity.
66. A 10-year-old child is diagnosed with pediculosis. The mother is concerned about the spread
    of the lice to children who have been in contact with her child. The nurse should instruct the mother to
    have her child avoid:
67. Sharing craft supplies.
68. Having contact during a swimming class.
69. Sharing batting helmets.
70. Showering after football practice.
71. A 24-year-old nulligravid client with a history of irregular menstrual cycles visits the clinic
    because she suspects that she is “about 6 weeks pregnant.” An ultrasound is scheduled in 2 weeks.
    The nurse should instruct the client that this test will be done to:
72. Assess gestational age.
73. Determine a multifetal pregnancy.
74. Identify the gender of the fetus.
75. Assess of maternal pelvic adequacy.
76. A client with a history of peptic ulcer disease is admitted to the hospital. Initial assessmentreveals that his blood pressure is 96/60 mm Hg, his pulse rate is 120 bpm, and he has vomited coffee-
    ground material. Based on this assessment, what is the nurse’s priority action?
77. Administer an antiemetic.
78. Prepare to insert a nasogastric (NG) tube.
79. Collect data regarding recent client stressors.
80. Place the client in a modified Trendelenburg position.
81. In the early postoperative period, the nurse notes a bright red, 3′′ × 5′′ (7.6 × 12.7 cm) area of
    drainage on the client’s abdominal laparotomy dressing. What should be the nurse’s first action in
    response to this observation?
82. Ignore it because drainage is normal.
83. Increase the IV flow rate.
84. Take the client’s vital signs.
85. Change the dressing

Answer 13

61. 3. Ciprofloxacin (Cipro) does not affect the PTT. It increases the theophylline level by 15% to
       30% and may increase the PT. Iron decreases the absorption of ciprofloxacin.
       CN: Pharmacological and parenteral therapies; CL: Apply
62. 3. Pediculosis capitis, or head lice, can be spread by close contact or sharing of head gear or
       combs and brushes with other children. Sharing craft supplies, swimming, or showering usually do
       not provide close enough contact to permit transmission.
       CN: Safety and infection control; CL: Synthesize
63. 1. In the first trimester, ultrasound scanning typically is prescribed to determine the gestational
       age. This is especially important for a client with a history of irregular menstrual cycles to establish
       an estimated accurate date of birth. There is no reason at this point in pregnancy to determine whether
       twins are present. This might be indicated if the fundal height were larger than the gestational age may
       indicate. Identifying the gender of the fetus is not a reason for an ultrasound examination unless there
       is a history of sex-linked genetic disorders. Pelvic adequacy can be determined by physical
       examination. If the client has a borderline pelvis, an ultrasound scan cannot confirm this. Pelvimetry
       can be done, but it is not performed as frequently as it once was.
       CN: Health promotion and maintenance; CL: Apply
64. 2. The nurse should prepare to insert an NG tube. The data collected provide evidence that the
       client is experiencing an upper gastrointestinal bleed secondary to a peptic ulcer. The client will be
       placed on nothing-by-mouth status and an NG tube will be inserted to provide gastric decompression
       and alleviate vomiting. Administering antiemetics is not a priority action for a client who is
       hypotensive and vomiting coffee-ground emesis. Assessment of client stressors is appropriate after
       emergency care has been provided and the client stabilized. A modified Trendelenburg position is
       inappropriate for clients who are vomiting.
       CN: Reduction of risk potential; CL: Synthesize
65. 3. The sudden onset of bright red drainage of this magnitude needs to be further assessed.
       Assessing vital signs is an important nursing action to determine whether there have been any changes
       in the client’s status. Additional steps would include reinforcing the dressing and notifying the
       primary care provider. Increasing the IV flow rate does not address the bleeding. Changing the
       dressing would be done only if the primary care provider prescribed it.
       CN: Reduction of risk potential; CL: Synthesize

Question 14

66. A 6-year-old client is diagnosed with attention deficit hyperactivity disorder (ADHD). When
    asking this client to complete a task, what techniques should the nurse use to communicate most
    effectively with him?
67. Obtain eye contact before speaking, use simple language, and have him repeat what was said.
    Praise him if he completes the task.
68. Fully explain to the client the actions required of him, offer verbal praise and a food reward
    for task completion.
69. Explain to the client what he is to do, the consequences if he does not comply, and follow
    through with praise or consequences as appropriate.
70. Demonstrate to the client what he is to do, have him imitate the nurse’s actions, and give a food
    reward if he completes the task.
71. A 10-year-old child has the following blood glucose readings during a 24-hour period.
    Which reading requires the most immediate intervention?
72. 50 mg/dL (2.8 mmol/L).
73. 100 mg/dL (5.6 mmol/L).
74. 150 mg/dL (8.4 mmol/L).
75. 200 mg/dL (11.2 mmol/L).
76. A client has massive bleeding from esophageal varices. In what order should the nurse and
    care team provide care for this client?
77. Control hemorrhaging.
78. Replace fluids.
79. Relieve the client’s anxiety.
80. Maintain a patent airway.69. Which of the following would be most important for the nurse to include in the teaching plan
    for a client who is taking phenelzine (Nardil)?
81. Eating a normal amount of salt in the diet.
82. Drinking 10 to 12 glasses of water each day.
83. Allowing 10 days to achieve therapeutic effects.
84. Avoiding foods high in tyramine.
85. The nurse should closely monitor the client with an open fracture for which of the following
    complications?
86. Avascular necrosis.
87. Compartment syndrome.
88. Osteomyelitis.
89. Fat embolism syndrome.

Answer 14

66. 1. Because the client with ADHD is easily distractible, it is important to obtain eye contact
       before explaining the task. Simple language and having him repeat what he is told are necessary
       because of his age. Praise encourages the client to repeat the task in the future as well as building the
       client’s self-esteem. A full explanation with verbal praise and a food reward is inappropriate because
       a food reward increases the chance that he will expect a physical reward for completing tasks. In
       addition, a full explanation might be too confusing for someone his age. Explaining consequences
       focuses on punishment, rather than praise. Although demonstration and imitation is an effective
       teaching method, rewarding with food fosters dependence on food reward for task completion.
       CN: Psychosocial adaptation; CL: Synthesize
67. 1. Normal blood sugar is 70 to 110 mg/dL (3.9 to 6.2 mmol/L). Hypoglycemia causes the most
       immediate concern. When the brain does not have enough glucose, the client will become rapidlyunconscious and, if uncorrected, seizures and death can result. A reading of 100 mg/dL (5.6 mmol/L)
       is normal. Readings of 150 to 200 mg/dL (8.4 to 11.2 mmol/L) are elevated and could cause
       complications, but complications from the elevation would not occur as rapidly.
       CN: Reduction of risk potential; CL: Analyze
       68.
68. Maintain a patent airway.
69. Control hemorrhaging.
70. Replace fluids.
71. Relieve the client’s anxiety.
    The goal that has the highest priority when a client has a massive bleed from esophageal varices
    is to maintain a patent airway. The nurse should position the client to prevent aspiration and assess
    respirations and oxygen saturation. The nurse should then assist the health care provider in controlling
    the hemorrhage by using esophageal balloon tamponade. Octreotide (Sandostatin) may be
    administered to reduce portal pressure. The third priority is to restore circulating blood volume with
    blood and IV fluids. Esophageal bleeding is an anxiety-provoking event for the client and, although
    life-saving measures are the priority, the nurse and health care team should explain procedures to the
    client and provide reassurance as needed.
    CN: Physiological adaptation; CL: Synthesize
72. 4. A client who is taking phenelzine (Nardil), a monoamine oxidase inhibitor, needs to avoid
       foods that are rich in tyramine because this food-drug combination can cause hypertensive crisis. The
       client should be given a list of foods to avoid and should report headaches, palpitations, and a stiff
       neck to the primary care provider immediately. The client does not need to restrict or add salt to the
       diet. Drinking 10 to 12 glasses of water each day is important to teach the client who is receiving
       lithium therapy. Antidepressant drugs take 2 to 4 weeks to achieve therapeutic effects.
       CN: Pharmacological and parenteral therapies; CL: Synthesize
73. 3. Clients with open fractures are particularly susceptible to infections. If not treated
       promptly, these infections can lead to the development of osteomyelitis. Localized symptoms of
       osteomyelitis include tenderness, swelling, and warmth at the site of infection, as well as unrelieved
       severe bone pain. Systemic symptoms include fever, chills, night sweats, and malaise. Avascular
       necrosis occurs when the blood supply to a bone is interrupted, most commonly in intracapsular hip
       fractures. Compartment syndrome is most commonly associated with fractures of the distal humerus
       and proximal tibia; it results from an increase in pressure on the nerves and blood supply within a
       closed tissue compartment. Fat embolism syndrome is associated most frequently with fractures of the
       long bones, ribs, and pelvis, which may or may not be open fractures.
       CN: Reduction of risk potential; CL: Analyze

Question 15

71. An adult client who has been treated with antidepressants for a year has had antianxiety
    medication added to the treatment regimen. The client says to the nurse, “I have reached the bottom of
    the barrel now. I have to take both Prozac (fluoxetine) and Klonopin (clonazepam) to control my
    symptoms.” What would be the best nurse reply to the client?
72. “If the medications work, why worry? Just take them, and be happy they are effective.”
73. “I can understand your concern. Those psychiatric medications are pretty potent.”
74. “It seems you are concerned your illness may be worsening. Tell me more about that.”
75. “You seem to feel guilty about taking psychiatric medication for your illness. There is nothing
    to feel guilty about.”
76. The nurse is assessing a client who has a long history of uncontrolled hypertension. The nurse
    should assess the client for damage in which area of the eye?
77. Iris.
78. Cornea.
79. Retina.
80. Sclera.
81. While preparing to provide neonatal care instructions to a primiparous client who gave birth
    to a term neonate 24 hours ago, which of the following should the nurse include in the client’s teaching
    plan?
82. Term neonates generally have few creases on the soles of their feet.
83. Strawberry hemangiomas—deep, dark red discolorations—require laser therapy for removal.
84. Milia are white papules from plugged sebaceous ducts that disappear by age 2 to 4 weeks.
85. If erythema toxicum is present, it will be treated with antibiotic therapy.
86. Two days after being placed in a cast for a fractured femur, the client suddenly has chest pain
    and dyspnea. The client is confused and has an elevated temperature. The nurse should assess theclient for:
87. Osteomyelitis.
88. Compartment syndrome.
89. Venous thrombosis.
90. Fat embolism syndrome.
91. A client has received an overdose of sympathomimetic agents. The nurse should assess the
    client for which of the following late signs of an overdose? Select all that apply.
92. Hypotension.
93. Bradycardia.
94. Seizures.
95. Profound pyrexia.
96. Hypertension.

Answer 15

71. 3. The nurse should confirm the client’s concern about taking psychiatric medications.
       Suggesting that he feels guilty is probably too direct, may not be accurate, and may cut off further
       discussion. Expressing concern is likely to promote further discussion about the reasons for his
       concern. Telling the client he is correct feeds any fear or guilt he may feel and telling him not to worry
       demeans his concerns.
       CN: Psychosocial integrity; CL: Apply
72. 3. The retina is especially susceptible to damage in a client with chronic hypertension. The
       arterioles supplying the retina are damaged. Such damage can lead to vision loss. The iris, cornea,
       and sclera are not affected by hypertension.
       CN: Physiological adaptation; CL: Analyze
73. 3. Milia are white papules resulting from plugged sebaceous ducts that disappear by age 2 to
       4 weeks. Parents should be instructed to avoid scratching them to prevent secondary infection. Term
       neonates generally have many creases on the soles of their feet. Preterm neonates may have only a
       few creases due to their immaturity. Strawberry hemangiomas are elevated areas formed by immature
       capillaries that will disappear over time. Port wine stains are deep, dark red discolorations that
       require laser therapy for removal. Erythema toxicum is a newborn rash or “flea bite” rash that
       requires no treatment and disappears over time.
       CN: Health promotion and maintenance; CL: Synthesize
74. 4. Clients with fractures of the long bones such as the femur are particularly susceptible to fat
       embolism syndrome (FES). Signs and symptoms include chest pain, dyspnea, tachycardia, and
       cyanosis. Changes in mental status are caused by hypoxemia and can be the first symptoms noted in
       FES. The client can also be restless and febrile and can develop petechiae. Osteomyelitis is infection
       of the bone; signs and symptoms of osteomyelitis do not include respiratory symptoms. Compartment
       syndrome causes signs of localized neurovascular impairment, not systemic symptoms. Venous
       thrombosis occurs in the lower extremities and is caused by venous stasis.
       CN: Reduction of risk potential; CL: Analyze
75. 1, 3, 4. As the homeostatic responses begin to decompensate, late clinical manifestations from
    a large overdose of sympathomimetic agents include loss of function of the hypothalamus such as
    temperature regulation, leading to profound pyrexia, and ectopic brain activity leading to seizures.
    Hypotension is a late sign that occurs as the vascular system collapses. Hypertension, an earlier sign,
    precedes hypotension. Tachycardia occurs as a reflex to hypotension, a late sign.
    CN: Pharmacological and parenteral therapies; CL: Analyze

Question 16

76. While assessing a neonate at 4 hours after birth, the nurse observes an indentation with a
    small tuft of hair at the base of the neonate’s spine. The nurse should document this finding as which
    of the following?
77. Spina bifida cystica.
78. Spina bifida occulta.
79. Meningocele.
80. Myelomeningocele.
81. A nurse is administering indomethacin to a neonate. To ensure that the nurse has identified the
    neonate correctly, the nurse should do which of the following? Select all that apply.
82. Ask the parents to confirm that this is their baby.
83. Ask another nurse to confirm that this is the neonate for whom the medication has been
    prescribed.
84. Check the neonate’s identification band against the medical record number.
85. Verify the date of birth from the medical record with the date of birth on the client’s
    identification band.
86. Compare the number on the crib with the number on the client’s identification band.
87. The nurse instills 5 mL of normal saline before suctioning a client’s tracheostomy tube. The
    instillation is effective when:
88. The secretions are thinned.
89. The client coughs.
90. There is minimal friction when the catheter is passed into the tracheostomy tube.
91. There is humidification for the respiratory tract.
92. A client with emphysema is receiving continuous oxygen therapy. Depressed ventilation is
    likely to occur unless the nurse ensures that the oxygen is administered in which of the following
    ways?
93. Cooled.
94. Humidified.
95. At a low flow rate.
96. Through nasal cannula.
97. A client at 12 weeks’ gestation tells the nurse that she is a vegan and eats “lots of rice.” Tohelp meet the client’s need for protein during pregnancy, the nurse suggests that the client combine the
    rice with which of the following?
98. Beans.
99. Soy milk.
100. Yogurt.
101. Corn.

Answer 16

76. 2. A small tuft of hair and an indentation at the base of the neonate’s spine is termed spina
       bifida occulta. This condition usually occurs between the L5 and S1 vertebrae with failure of the
       vertebrae to completely fuse. There are usually no sensory or motor deficits with this condition.
       Spina bifida cystica includes meningocele, myelomeningocele, and lipomeningocele. Meningocele is
       characterized by a saclike protrusion filled with spinal fluid and meninges. Usually, this condition is
       associated with sensory and motor deficits. Myelomeningocele is characterized by a saclike
       protrusion filled with spinal fluid, meninges, nerve roots, and spinal cord. With myelomeningocele,
       there are usually sensory and motor deficits.
       CN: Health promotion and maintenance; CL: Analyze77. 3, 4. The nurse should use at least two sources of identification prior to administering
       medication to any client, such as the medical record number and the client’s date of birth. It is not safe
       practice to ask the parent or a nurse to verify the correct client. It is also not safe to use the room
       number or crib number as a source of identification because clients’ locations in the hospital change
       frequently.
       CN: Safety and infection control; CL: Apply
77. 1. The primary purpose of instilling 5 mL of normal saline solution before suctioning a
       tracheostomy tube is to thin the secretions to be suctioned. The saline may stimulate a cough;
       however, this is not the reason for using saline. The tracheostomy tube is larger than the catheter and
       will easily pass into the tube. Humidification is provided by a nebulizer if needed.
       CN: Reduction of risk potential; CL: Evaluate
78. 3. The client with emphysema has a chronically elevated carbon dioxide level. As a result, the
       normal stimulus for breathing in the medulla becomes ineffective. Instead, peripheral pressoreceptors
       in the aortic arch and carotid arteries, which are sensitive to oxygen blood levels, stimulate
       respirations. This is in response to low oxygen levels that have developed over time. If the client
       receives high concentrations of oxygen, the blood level of oxygen will rise excessively, the stimulus
       for respiration will decrease, and respiratory failure may result. Oxygen is not cooled.
       Humidification or administration of the oxygen through nasal cannula will not prevent depressed
       ventilation if the flow rate of the oxygen is too high.
       CN: Physiological adaptation; CL: Apply
79. 1. Protein intake is a concern in all vegetarian diets. Combining two incomplete proteins to
       make a complete protein (with all of the essential amino acids) can improve the client’s protein
       intake. Rice with beans or tofu provides a complete protein. Soy milk would provide vitamin D and
       calcium, not protein. Yogurt contains protein, but vegans do not eat dairy products. Corn and rice do
       not make up a complete protein. However, corn and beans would be a complete protein.
       CN: Basic care and comfort; CL: Apply

Question 17

81. A client with rheumatoid arthritis tells the nurse that she feels “quite alone” in adjusting to
    changes in her lifestyle. Which of the following nursing actions is most appropriate in response to
    this statement?
82. Refer the client and her husband for counseling to decrease her sense of isolation.
83. Suggest that the client develop a hobby to occupy her time.
84. Tell the client about her community’s arthritis support group.
85. Suggest that the client discuss her feelings with her minister.
86. Which of the following should the nurse include in the plan of care to ensure adequate
    nutrition for a very active, talkative, and easily distractible client who is unable to sit through meals?
87. Direct the client to the room to eat.
88. Offer the client nutritious finger foods.
89. Ask the client’s family to bring the client’s favorite foods from home.
90. Ask the client about food preferences.
91. A client in a group home is very dependent on the staff but is able to make simple decisions.
    The client asks, “Would you do my laundry? I don’t know how the machine works.” Which of the
    following responses would be best?
92. “Sure, I have time; I can do it for you.”
93. “You’ll have to wait; I don’t have time now.”
94. “Can your family do it for you?”
95. “Get your laundry; I’ll show you how the machine works.”
96. The nurse is caring for a client with chronic renal failure. For which of the following signs
    and symptoms of hypermagnesemia should the nurse closely monitor the client?
97. Flushed skin.
98. Lethargy.
99. Severe thirst.
100. Tremors.
101. When determining the parents’ compliance with treatment for their infant who has otitis
     media, the nurse should ask the parents if they are:
102. Cleaning the child’s ear canals with hydrogen peroxide.
103. Administering continuous, low-dose antibiotic therapy.
104. Instilling ear drops regularly to prevent cerumen accumulation.
105. Holding the child upright when feeding with a bottle.

Answer 17

81. 3. The client should be encouraged to join the community arthritis support group so that she
       can share her feelings with others who are facing similar experiences with this chronic illness and
       can identify with her concerns. A hobby will not help her resolve her feelings of being alone. Seeking
       counseling or discussing her feelings with a minister may be helpful, but these activities will not
       necessarily help the client to understand that there are many individuals who must adjust their
       lifestyles because of arthritis and that she is not alone.
       CN: Health promotion and maintenance; CL: Synthesize
82. 2. For the client who is unable to sit through meals to maintain adequate nutrition, the nurse
       should offer the client nutritious finger foods and fluids that he can consume while “on the run.”
       Foods high in protein and carbohydrates, such as half of a peanut butter sandwich, will help to
       maintain nutritional needs. Adequate fluid intake is necessary, especially if the client has been started
       on lithium therapy. Directing the client to his room to eat is not helpful because the client will not stay
       in his room long enough to eat. Asking the client’s family to bring his favorite foods or asking the
       client about his food preferences is not helpful in ensuring adequate nutrition for the hyperactive
       client who is unable to sit and eat.CN: Basic care and comfort; CL: Synthesize
83. 4. Telling the client to get her laundry and then showing her how to use the machine helps keep
       the client from becoming overly dependent on the nurse, establishes boundaries between the client
       and the nurse, and promotes positive self-worth. The statement, “Sure, I have time; I’ll do it for you,”
       is not therapeutic because it increases the client’s dependency. Telling the client that she will have to
       wait because the nurse doesn’t have time dismisses the client and insinuates that the nurse will do the
       laundry later, thus fostering dependency. Asking, “Can your family do it for you?” is not appropriate
       because the client is capable of doing her own laundry. This statement places responsibility on the
       family instead of the client.
       CN: Psychosocial adaptation; CL: Synthesize
84. 2. Early signs and symptoms of hypermagnesemia include drowsiness, lethargy, nausea, and
       vomiting. Flushed skin is a sign of hypernatremia. Severe thirst is associated with hyperglycemia.
       Tremors are associated with hypomagnesemia.
       CN: Reduction of risk potential; CL: Analyze
85. 4. Sitting or holding a child upright for formula feedings helps prevent pooling of formula in
       the pharyngeal area. When the vacuum in the middle ear opens into the pharyngeal cavity, formula
       (along with bacteria) is drawn into the middle ear. Cleaning the ear canals does not reduce the
       incidence of otitis media because the pathogenic bacteria are in the nasopharynx, not the external area
       of the ears. Continuous low-dose antibiotic therapy is used only in cases of recurrent otitis media,
       when the child finishes a course of antibiotics but then develops another ear infection a few days
       later. Although accumulation of cerumen makes it difficult to visualize the tympanic membrane, it
       does not promote inner ear infections.
       CN: Health promotion and maintenance; CL: Evaluate

Question 18

86. When giving a change-of-shift report, which of the following statements by the nurse is not
    appropriate?
87. “Randi Smith is a 38-year-old female client of Dr. Born with cholecystitis and cholelithiasis.”
88. “Mrs. Jones’ pain is best relieved in the left lateral Sims’ position.”3. “Mr. Levi is just contrary today, and nothing is going to please him.”
89. “Mr. Emmert was able to walk around the unit twice today with no dizziness.”
90. The nurse is teaching unlicensed assistive personnel (UAP) about caring for a client who is
    withdrawing from alcohol and street drugs. Which of the following communication techniques when
    observed by the nurse indicate the UAP has understood the instructions? The UAP talks to the client
    using:
91. Matter-of-fact manner and short sentences.
92. Cheerful tone of voice, using humor when appropriate.
93. Loud voice and giving general comments.
94. Clear explanations in a quiet voice.
95. A couple has completed testing and is a candidate for in vitro fertilization. The nurse is
    reviewing the procedure with them and realizes that further instruction is needed when the woman
    states:
96. “One of the greatest risks is multiple pregnancies.”
97. “I will need to redefine how I view my job if I do become pregnant.”
98. “The fertilization procedure can be done anytime during my cycle.”
99. “We can use our own eggs and sperm or someone else’s.”
100. When obtaining the diet history from a client with anemia, the nurse should include questions
     specifically about which of the following vitamins or minerals that are most likely missing in this
     client’s diet? Select all that apply.
101. Vitamin B 6 .
102. Vitamin K.
103. Vitamin B 12 .
104. Iron.
105. Vitamin C.
106. What is the primary goal of nursing care during the emergent phase after a burn injury?
107. Replace lost fluids.
108. Prevent infection.
109. Control pain.
110. Promote wound healing.

Answer 18

86. 3. Calling a client “contrary” is critical in nature and judgmental on the nurse’s part. It is
       inappropriate for the nurse to make a comment like this at shift report or at any time. The other
       statements provide important and appropriate information (diagnosis, primary care provider’s name,
       pain relief strategies, and evaluation of ambulation).
       CN: Management of care; CL: Apply
87. 1. The nurse should teach personnel to communicate with clients who are withdrawing from
       alcohol and street drugs in a calm, matter-of-fact manner, using short sentences and a moderate tone of
       voice. This approach promotes orientation, reinforces cognitive-perceptual functions, and decreases
       anxiety. A cheerful tone and humor are inappropriate, possibly leading to misperceptions by the client
       with cognitive-perceptual impairment. Using general and abstract terms and a loud tone of voice
       increases anxiety and may lead to misunderstanding. Lengthy explanations delivered with a quiet
       voice will lead to frustration and increased anxiety.
       CN: Psychosocial adaptation; CL: Evaluate
88. 3. The best opportunity for a successful pregnancy is when the normal menstrual cycle is
       created either naturally or through hormonal augmentation. Implantation can occur only when the
       levels of estrogen and progesterone are at particular levels. For many women, more than one
       fertilized egg is placed into the uterus. This increases the risk that more than one embryo will implant
       and reach maturity. Couples can choose to utilize their own eggs and sperm if they have beendetermined to be healthy or they can choose to use donor oocytes and sperm. For many women who
       utilize in vitro fertilization, a career has taken precedence over having a family and these women will
       need to rebalance a career with the demands of pregnancy and parenting.
       CN: Physiological adaptation; CL: Evaluate
89. 1, 3, 4, 5. Vitamins B 6 , B 12 , and iron are important in the production of red blood cells.
    Therefore, the nurse should question the client specifically about food intake that contains these
    vitamins and minerals. Vitamin C helps iron absorption and plays a small role in red blood cell
    production. Vitamin K has little role in the production of red blood cells.
    CN: Health promotion and maintenance; CL: Analyze
90. 1. During the emergent phase of burn care, one of the most significant problems is
       hypovolemic shock. The development of hypovolemic shock can lead to impaired blood flow through
       the heart and kidneys, resulting in decreased cardiac output and renal ischemia. Efforts are directed
       toward replacing lost fluids and preventing hypovolemic shock. Preventing infection and controlling
       pain are important goals, but preventing circulatory collapse is a higher priority. It is too early in the
       stage of burn injury to promote wound healing.
       CN: Physiological adaptation; CL: Synthesize

Question 19

91. The nurse assesses for euphoria in a client with multiple sclerosis, looking for which of the
    following characteristic clinical manifestations?
92. Inappropriate laughter.
93. An exaggerated sense of well-being.
94. Slurring of words when excited.
95. Visual hallucinations.
96. The client with a burn injury is assessed using the “rule of nines” to determine which of the
    following?
97. Amount of body surface area burned.
98. Rehabilitation needs.
99. Respiratory needs.
100. Type of intravenous fluids required.93. When assessing a 2-month-old infant, the nurse feels a “click” when abducting the infant’s left
     hip. Which of the following should the nurse do next?
101. Document the finding as normal for a 2-month-old.
102. Check the lengths of the femurs to determine if they are equal.
103. Instruct the mother to keep the leg in an adducted position.
104. Reschedule the child for a follow-up assessment in 3 weeks.
105. Which of the following laboratory tests should the nurse monitor when the client is receiving
     warfarin sodium (Coumadin) therapy?
106. Partial thromboplastin time (PTT).
107. Serum potassium.
108. Arterial blood gas (ABG) values.
109. Prothrombin time (PT).
110. A client who had transurethral resection of the prostate (TURP) 2 days earlier has lower
     abdominal pain. The nurse should:
111. Auscultate the abdomen for bowel sounds.
112. Administer an oral analgesic.
113. Have the client use a sitz bath for 15 minutes.
114. Assess the patency of the urethral catheter.

Answer 19

91. 2. A client with multiple sclerosis may have a sense of optimism and euphoria, particularly
       during remissions. Euphoria is characterized by mood elevation with an exaggerated sense of well-
       being. Inappropriate laughter, slurring of words, and visual hallucinations are uncharacteristic of
       euphoria.
       CN: Psychosocial adaptation; CL: Analyze
92. 1. The “rule of nines” is used to determine the percentage of the client’s body surface area that
       was burned. Medical treatment, including fluid volume replacement therapy, is based on the
       percentage of body surface area burned.
       CN: Reduction of risk potential; CL: Analyze
93. 2. The “click” the nurse feels when abducting the femur is made by the head of the femur as it
       slips into the acetabulum. This is Ortolani’s sign and indicates a dislocated hip. This is not a normal
       finding for a 2-month-old. The nurse needs to gather additional information by checking for unequal
       leg lengths and asymmetry of the gluteal and thigh folds. Once the nurse has obtained additional
       assessment information, the nurse would notify the primary care provider. Usual medical treatment
       involves keeping the hip joint in an abducted position through triple diapering or a Pavlik harness.
       The goal of treatment is to keep the head of the femur centered in the acetabulum. Treatment needs to
       begin as soon as possible. Usually, the earlier treatment is started, the better the outcome.
       CN: Health promotion and maintenance; CL: Synthesize
94. 4. Warfarin sodium (Coumadin) interferes with clotting. The nurse should monitor the PT and
       evaluate for the therapeutic effects of Coumadin. A therapeutic PT is between 1.5 and 2.5 times the
       control value; the PT should be established by the health care provider. It may also be reported as an
       International Normalized Ratio, a standardized system that provides a common basis for
       communicating and interpreting PT results. The PTT is monitored in clients who are receiving
       heparin therapy. Serum potassium levels and ABG values are not affected by Coumadin.
       CN: Pharmacological and parenteral therapies; CL: Analyze95. 4. The lower abdominal pain is most likely caused by bladder spasms. A common cause of
       bladder spasms after TURP is blood clots obstructing the catheter; therefore, the nurse’s first action
       should be to assess the patency of the catheter. Auscultating the abdomen for bowel sounds would be
       appropriate after patency of the catheter has been established. The nurse should assess for bladder
       spasms before administering an analgesic. A sitz bath would not relieve bladder spasms that are
       caused by an obstructed catheter.
       CN: Physiological adaptation; CL: Synthesize

Question 20

96. The nurse is ready to administer a partial fill of imipenem-cilastatin (Primaxin) in the IV
    pump when a full partial fill bag of imipenem-cilastatin is found hanging at the client’s bedside. The
    nurse should do which of the following first?
97. Discard the full partial fill of imipenem-cilastatin found hanging at the client’s bedside.
98. Check the identifying information of the full partial fill of imipenem-cilastatin found hanging at
    the client’s bedside.
99. Determine when the client received the last dose of the imipenem-cilastatin.
100. Administer the new partial fill of imipenem-cilastatin.
101. A client with a moderate level of anxiety is pacing quickly in the hall and tells the nurse,
     “Help me. I can’t take it anymore.” Which of the following would be the best response initially?
102. “It would be best if you would lie down until you’re calmer.”
103. “Let’s go to a quieter area where we can talk if you want.”
104. “Try doing your relaxation exercises to calm down.”
105. “I’ll get some medicine to help you relax.”
106. The nurse should plan to teach a client who is taking warfarin sodium (Coumadin) to do
     which of the following?
107. Consult the primary care provider before undergoing dental work.
108. Avoid the use of a toothbrush during oral hygiene.
109. Use rectal suppositories to treat constipation.
110. Eat green leafy vegetables.
111. A 30-year-old client hospitalized with a fractured femur, which is being treated with skeletal
     traction, has not had a bowel movement for 2 days. Which of the following interventions is most
     appropriate at this time?
112. Administer a tap water enema.2. Place the client on the bedpan every 2 to 3 hours.
113. Increase the client’s fluid intake to 3,000 mL/day.
114. Perform range-of-motion movements to all extremities.
115. A client is receiving a tube feeding and has developed diarrhea, cramps, and abdominal
     distention. Which of the following interventions would be most appropriate? Select all that apply.
116. Change the feeding apparatus every 24 hours.
117. Use a higher volume of formula because the formula may be too hypotonic.
118. Slow the administration rate.
119. Use a diluted formula, gradually increasing the volume and concentration.
120. Anticipate changing to a lactose-free formula.

Answer 20

96. 3. The nurse should first determine whether the client received the last dose of imipenem-
       cilastatin. If the client did not receive the last dose, the nurse should notify the primary care provider
       that the client did not receive the dose, receive prescriptions, document, implement the prescriptions,
       and complete an incident report. The nurse should not automatically discard the partial fill of
       imipenem-cilastatin (Primaxin) found at the client’s bedside until further investigation is done. The
       nurse should recognize the cost of medications such as imipenem-cilastatin and consult the pharmacist
       after identifying information on the partial fill bag that was found. After verifying all information, the
       nurse can administer the new partial fill of imipenem-cilastatin so that the client can receive the
       antibiotic on time.
       CN: Safety and infection control; CL: Synthesize
97. 2. For a client with moderate anxiety, the nurse should initially lead the client to a less
       stimulating environment and help him discuss his feelings. Doing so helps the client to gain control
       over anxiety that could be overwhelming. Telling the client that it would be best to lie down until he
       is calmer is not appropriate because the client is too anxious to benefit from this intervention.
       Suggesting that the client try relaxation exercises could be helpful after the nurse takes the client to a
       less stimulating environment and allows the client to vent and discuss his feelings. Getting some
       medication to help the client relax is an intervention that the nurse would carry out later after trying to
       help the client decrease anxiety through ventilation and relaxation exercises.
       CN: Psychosocial adaptation; CL: Synthesize
98. 1. Clients who are receiving anticoagulant therapy should consult the primary care provider
       before undergoing any dental work. The dentist should also be aware that the client is taking
       anticoagulants. A soft toothbrush is desirable for oral hygiene if the client is receiving anticoagulant
       therapy; it helps prevent the gums from bleeding. Rectal suppositories are contraindicated during
       anticoagulant therapy because their insertion may cause bleeding. Stool softeners may be used instead
       to prevent straining, which also may promote bleeding. Green leafy vegetables should not be eaten in
       excess because of their vitamin K content, which may alter the effectiveness of the anticoagulant
       therapy.
       CN: Pharmacological and parenteral therapies; CL: Synthesize
99. 3. Increasing the client’s fluid intake to 3,000 mL/day, unless contraindicated, is the most
       appropriate action. Typically, clients who are immobilized by skeletal traction are given stool
       softeners. Treating constipation with diet, increased fluids, and stool softeners is preferred to the
       administration of an enema. Placing the client on the bedpan will not encourage a bowel movement.
       Range-of-motion movements maintain joint mobility but do not stimulate peristalsis.
       CN: Reduction of risk potential; CL: Synthesize
100. 1, 3, 4, 5. Although about 50% of diarrhea in clients receiving tube feedings is caused bysorbitol-containing medications, the nurse should assess for other possible causes. Diarrhea can
     occur as a result of bacterial contamination if fresh formula is not used or stored in a refrigerator, or
     if the feeding apparatus is not changed at least every 24 hours. Lactose intolerance, rapid formula
     administration, low serum albumin level, and hypertonic solutions may also cause diarrhea.
     Hypotonic solutions would not be a likely cause of diarrhea, abdominal distention, or cramping.
     CN: Basic care and comfort; CL: Synthesize

Question 21

101. A 62-year-old client with a 29-pack-per-year history is admitted with a diagnosis of lung
     cancer. She reports having “no appetite” and exhibits symptoms of anorexia. The client is 5 feet, 8
     inches (172.7 cm) tall and weighs 112 lb (50.8 kg). The client is now scheduled for a left lung
     lobectomy. Which of the following increases the client’s risk of developing postoperative pulmonary
     complications?
102. The client tends to keep her real feelings to herself.
103. The client ambulates and can climb one flight of stairs without dyspnea.
104. The client is aged 62.
105. The client is 5 feet, 8 inches (172.7 cm) tall and weighs 112 lb (50.8 kg).
106. When developing the plan of care for a 12-year-old child who is to receive chemotherapy
     that is associated with nausea and vomiting, the nurse should plan to administer an antiemetic at
     which of the following times?
107. Thirty minutes after the chemotherapy has started, then every 4 to 6 hours.
108. Thirty minutes before the chemotherapy starts, then every 4 to 6 hours.
109. When the 12-year-old requests medication for nausea, then every 4 hours as needed.
110. On starting the chemotherapy infusion, and then routinely every 8 hours.
111. The membranes of a multigravid client in active labor rupture spontaneously, revealing
     greenish colored amniotic fluid. The nurse interprets this finding as related to which of the following?
112. Passage of meconium by the fetus.
113. Maternal intrauterine infection.
114. Rh incompatibility between mother and fetus.
115. Maternal sexually transmitted disease.
116. A client’s arterial blood gas values are as follows:

LABORATORY RESULTS
PH - 7.24
PACO2 - 35 mmHg
HCO3 - 15 mEq/L

These findings indicate which of the following acid-base imbalances?
1. Metabolic acidosis.
2. Metabolic alkalosis.
3. Respiratory acidosis.
4. Respiratory alkalosis.
105. A client is suspected of having a slow gastrointestinal bleed. The nurse should evaluate the
client for which of the following?
1. Increased pulse.
2. Nausea.
3. Tarry stools.
4. Abdominal cramps.

Answer 21

101. 4. Risk factors for postoperative pulmonary complications include malnourishment, which is
        indicated by the client’s height and weight. Although keeping feelings inside can be problematic, it
        would not be considered a postoperative risk for pulmonary complications. The absence of dyspnea
        on exertion is not indicative of postoperative complications. The client’s age does not necessarily
        place her at increased risk.
        CN: Health promotion and maintenance; CL: Analyze
102. 2. Administering an antiemetic before beginning chemotherapy and then routinely around the
        clock helps prevent nausea and vomiting. Waiting until the client requests it may be too late because
        nausea is already present.
        CN: Pharmacological and parenteral therapies; CL: Synthesize
103. 1. Greenish colored amniotic fluid is caused by the passage of meconium, usually secondary
        to a fetal insult during labor. Meconium passage also may be related to an intact gastrointestinal
        system of the neonate, especially those neonates who are full term or of postdate gestational age.
        Amnioinfusion may be used to treat the condition and dilute the fluid. Cloudy amniotic fluid is
        associated with an infection caused by bacteria or a sexually transmitted disease. Severe yellow-
        colored fluid is associated with Rh incompatibility or erythroblastosis fetalis.
        CN: Health promotion and maintenance; CL: Analyze
104. 1. The pH of 7.24 indicates that the client is acidotic. The carbon dioxide level is normal,
        but the HCO 3− level is decreased. These findings indicate that the client is in metabolic acidosis.
        CN: Reduction of risk potential; CL: Analyze
105. 3. Black, tarry stools indicate the presence of a slow upper gastrointestinal bleed. The
        longer the blood is in the system, the darker it becomes as the hemoglobin is broken down and iron is
        released. Vital sign changes, such as an increased pulse, are not evident with slow gastrointestinal
        bleeds. Nausea and abdominal cramps can occur but are not definitive signs of gastrointestinal
        bleeding.
        CN: Physiological adaptation; CL: Analyze

Question 22

106. Which of the following suggestions should the nurse give to an adolescent football player
     with Osgood-Schlatter disease of the left knee?
107. Apply ice on the knee after playing.
108. Use crutches until healing has occurred.
109. Stop playing until healing has occurred.
110. Make an appointment with a physical therapist.
111. The nurse instructs a client who is taking iron supplements that:
112. Iron supplements should be taken on an empty stomach.
113. A daily bulk laxative such as psyllium hydrophilic mucilloid (Metamucil) should be avoided.
114. The stools will become darker.
115. Liquid iron supplements will not discolor teeth.
116. Which of the following should the nurse teach a client with generalized anxiety disorder to
     help the client cope with anxiety?
117. Cognitive and behavioral strategies.
118. Issue avoidance and denial of problems.
119. Rest and sleep.
120. Withdrawal from role expectations and role relationships.
121. After a lobectomy for lung cancer, the nurse instructs the client to perform deep-breathing
     exercises to:
122. Decrease blood flow to the lungs for rest and increased surface alveoli ventilation.
123. Elevate the diaphragm to enlarge the thorax so that the lung surface area available for gas
     exchange is increased.
124. Control the rate of air flow to the remaining lobe to decrease the risk of hyperinflation.
125. Expand the alveoli and increase lung surface available for ventilation.
126. Which of the following is the correct technique for applying an elastic bandage to a leg?
127. Increase tension with each successive turn of the bandage.
128. Start at the distal end of the extremity and move toward the trunk.
129. Secure the bandage with clips over the area of the inner thigh.
130. Overlap each layer twice when wrapping.

Answer 22

106. 1. Most adolescents with Osgood-Schlatter disease are able to continue to exercise and use
        ice afterward. Ibuprofen also may be prescribed. Because Osgood-Schlatter disease is self-limited,
        crutches or physical therapy is usually unnecessary, and the adolescent usually does not need to stop
        playing sports. Only in severe cases would the adolescent have to stop playing sports.
        CN: Physiological adaptation; CL: Synthesize
107. 3. Iron supplements will darken the stools. Iron supplements should not be taken on an empty
        stomach because they can cause gastric irritation. Iron is constipating, and a daily bulk-forming
        laxative should be started prophylactically. A straw should be used when taking liquid iron to avoiddiscoloring the teeth.
        CN: Pharmacological and parenteral therapies; CL: Apply
108. 1. A client with generalized anxiety disorder needs to learn cognitive and behavioral
        strategies to cope with anxiety appropriately. In doing so, the client’s anxiety decreases and becomes
        more manageable. The client may need assertiveness training, reframing, and relaxation exercises to
        adaptively deal with anxiety.
        CN: Psychosocial adaptation; CL: Synthesize
109. 4. Deep breathing helps prevent microatelectasis and pneumonitis and also helps force air
        and fluid out of the pleural space into the chest tubes. It does not decrease blood flow to the lungs or
        control the rate of air flow. The diaphragm is the major muscle of respiration; deep breathing causes
        it to descend, thereby increasing the ventilating surface.
        CN: Reduction of risk potential; CL: Apply
110. 2. When applying an elastic bandage to a leg, start at the distal end and move toward the
        trunk in order to support venous return. Tension should be kept even and not increased with each turn
        to prevent circulatory impairment. Overlapping each layer twice when wrapping can also impair
        circulation. The clips securing the bandage should be placed on the outer aspect of the leg to avoid
        creating a pressure point on the other leg.
        CN: Reduction of risk potential; CL: Evaluate

Question 23

111. A nulliparous client says that she and her husband plan to use a diaphragm with spermicide
     to prevent conception. Which of the following should the nurse include as the action of spermicideswhen teaching the client?
112. Destruction of spermatozoa before they enter the cervix.
113. Prevention of spermatozoa from entering the uterus.
114. A change in vaginal pH from acidic to alkaline.
115. Slowing of the movement of the migrating spermatozoa.
116. A client with acquired immunodeficiency syndrome (AIDS) is admitted because of paranoia
     and visual hallucinations probably related to progressive dementia. The client continues to be restless
     and have hallucinations. The nurse calls the primary care provider, and after explaining the situation,
     background, and assessment recommends that the primary care provider consider writing a
     prescription for the client to have:
117. Methylphenidate.
118. Lorazepam.
119. Trazodone.
120. Sertraline.
121. Which of the following assessment finding is expected in a client with bacterial pneumonia?
122. Increased fremitus.
123. Bilateral expiratory wheezing.
124. Resonance on percussion.
125. Vesicular breath sounds.
126. A client is admitted with severe abdominal pains and the diagnosis of acute pancreatitis.
     The nurse should develop a plan of care during the acute phase of pancreatitis that will involve
     interventions to manage which of the following problems?
127. Drug and alcohol abuse.
128. Risk for injury.
129. Severe pain.
130. Ineffective airway clearance.
131. A client with diabetes who takes insulin is being seen by the nurse for a low blood glucose
     level. Which of the following would be the appropriate choices to begin to raise the blood glucose
     level? Select all that apply.
132. One-half cup of orange juice.
133. One cup of milk.
134. One quarter cup of tuna.
135. One tablespoon of peanut butter.
136. One piece of bread.
137. One-half cup of regular soda.

Answer 23

111. 1. Spermicidal agents work by destroying the spermatozoa before they enter the cervix. In
        addition, some spermicides alter the vaginal pH to a strong acidic environment, which is not
        conducive to survival of spermatozoa. Spermicides do not prevent the spermatozoa from entering the
        uterus, but the diaphragm or condom is a barrier.
        CN: Pharmacological and parenteral therapies; CL: Apply
112. 4. A low dosage of sertraline is helpful in controlling dementia-induced paranoia and
        hallucinations. Methylphenidate would be indicated for attention deficit hyperactivity disorder.
        Lorazepam would be prescribed if the client were anxious and agitated. Trazodone would be used if
        depression were prominent.
        CN: Pharmacological and parenteral therapies; CL: Synthesize
113. 1. Increased fremitus can be present in bacterial pneumonia, indicating the presence of
        pulmonary consolidation. Additional findings would include crackles, bronchial breath sounds, and
        dullness on percussion. Bilateral expiratory wheezing and resonance on percussion are not present in
        bacterial pneumonia. Vesicular breath sounds are normal and would not be an expected finding in
        bacterial pneumonia.
        CN: Physiological adaptation; CL: Analyze
114. 3. Acute pancreatitis is very painful; management involves interventions for pain. Although
        alcohol abuse is often implicated in pancreatitis, drug and alcohol counseling will be an individual
        consideration. Risk for injury and ineffective airway clearance are not typically associated with acute
        pancreatitis.
        CN: Basic care and comfort; CL: Synthesize
115. 1, 2, 5, 6. To treat a low blood glucose level, the nurse should provide the client withapproximately 15 g of carbohydrate and monitor the blood glucose level within 15 minutes. The
     orange juice, milk, bread, and soda would provide approximately 15 g of carbohydrate. Meat or fish,
     such as tuna, does not contain carbohydrate, although some of it can be converted to carbohydrate if
     sufficient carbohydrate from other sources is not provided. Processed peanut butter may contain small
     amounts of carbohydrate, but it is also high in fat and protein. To raise a blood glucose level in a
     timely manner, peanut butter is not a good option.
     CN: Reduction of risk potential; CL: Synthesize

Question 24

116. An infant with increased intracranial pressure (ICP) on a regular diet vomits while eating
     dinner. Which of the following should the nurse do next?
117. Put the child on nothing-by-mouth (NPO) status for 4 hours.
118. Call to report this event to the primary care provider.
119. Wait a few minutes, then refeed the child.
120. Administer the prescribed antiemetic.
121. When preparing to draw up 8 units of a short-acting insulin and 20 units of a long-actinginsulin in the same syringe, the nurse should:
122. Inject air in the vial with the long-acting insulin first.
123. Draw up the long-acting insulin first.
124. Draw up either insulin first.
125. Use a high-dose insulin syringe.
126. The mother of an infant with iron deficiency anemia asks the nurse what she could have done
     to prevent the anemia. The nurse should teach the mother that it is helpful to introduce solid foods into
     the infant’s diet at age:
127. 1 to 2 months.
128. 5 to 6 months.
129. 8 to 10 months.
130. 10 to 12 months.
131. The nurse is caring for a client who is having an acute asthma attack. The nurse should notify
     the primary care provider of which of the following?
132. Loud wheezing.
133. Tenacious, thick sputum.
134. Decreased breath sounds.
135. Persistent cough.
136. Which of the following skin care instructions would be appropriate for a client receiving
     radiation therapy?
137. Avoid shaving with straight-edge razors.
138. Clean the skin daily with antibacterial soap.
139. Apply moisturizing lotion before and after each treatment.
140. Keep the radiated area covered with a sterile gauze dressing.

Answer 24

116. 3. Increased ICP can cause vomiting, particularly in children whose fontanels are closed. An
        infant with an open anterior fontanelle may have less vomiting because the cranium can respond,
        expanding with increased ICP. The best course of action is to wait a few minutes and then refeed the
        child. Putting the child on NPO status may not be helpful because this is not a gastrointestinal
        problem. Because this is an expected event, notifying the primary care provider is not necessary.
        Antiemetics frequently make a client sleepy, making neurologic checks difficult to interpret.
        CN: Physiological adaptation; CL: Synthesize
117. 1. The air is injected into the long-acting insulin first. Air is then injected into the short-
        acting insulin and the short-acting insulin is withdrawn. Then the long-acting insulin is withdrawn. It
        does matter which insulin is drawn up first because the nurse does not want to contaminate the short-
        acting insulin with the long-acting insulin. It is not necessary to use a high-dose insulin syringe to
        prepare 28 units of insulin.
        CN: Pharmacological and parenteral therapies; CL: Apply
118. 2. Solids should be introduced at about age 5 to 6 months. Full-term infants use up their
        prenatal iron stores within 4 to 6 months after birth. Cow’s milk contains insufficient iron.
        CN: Health promotion and maintenance; CL: Apply
119. 3. Diminished breath sounds during an acute asthma attack are a serious sign of airway
        obstruction, fatigue, and impending respiratory failure. Wheezing, coughing, and the production of
        sputum indicate the presence of airflow through the lungs and are less ominous symptoms.
        CN: Physiological adaptation; CL: Analyze
120. 1. Clients should use an electric razor, instead of a straight-edge razor, on any skin areas that
        are receiving radiation. The skin should be cleaned daily with a mild soap, not harsh antibacterials.
        Lotion should be removed from the skin before any treatment and then reapplied after the treatment.
        The radiated skin area needs to be kept clean, dry, and open to air.
        CN: Basic care and comfort; CL: Synthesize

Question 25

121. A client has had a cardiac catheterization. The left femoral dressing has a moderate amount
     of bloody drainage, and the client has severe pain in that area. The nurse should first:
122. Assess the airway.
123. Administer oxygen.
124. Apply pressure to the site.
125. Assess the pulse in the left extremity.
126. The nurse should instruct the parent of a child who is taking valproic acid (Depakene) that
     the child will need to have routine blood analyses consisting of which of the following?
127. Complete blood count (CBC) and alkaline phosphate level.
128. Cholesterol and platelet levels.
129. Electrolytes and CBC.
130. Platelet and fibrinogen levels.
131. Bacterial conjunctivitis has affected several children at a local day care center. A nurse
     should advise which measure to minimize the risk of infection?
132. Close the day care center for 1 week to control the outbreak.
133. Restrict the infected children from returning for 48 hours after treatment.
134. Perform thorough hand washing before and after touching any child in the day care center.
135. Set up a conference with the parents of each child to explain the situation carefully.124. The nurse is evaluating the client’s risk for having a pressure sore. Which of the following is
     the best indicator of risk for the client’s developing a pressure sore?
136. Nutritional status.
137. Circulatory status.
138. Mobility status.
139. Orientation status.
140. A client with acute pancreatitis is put on nothing-by-mouth status, with the intent of not
     stimulating the pancreas. The client is prescribed an IV infusion of dextrose 5% in half-normal saline
     solution at 120 mL/h. After 3 days of this regimen, the nurse should observe the client for which of the
     following metabolic conditions?
141. Ketosis.
142. Hyperglycemia.
143. Metabolic syndrome.
144. Lactic acidosis.

Answer 25

121. 3. A moderate amount of bloody drainage could indicate active bleeding. The priority action
        is to apply pressure to the area and call for help. Assessing the airway or pulse or administering
        oxygen does not address the bleeding.
        CN: Reduction of risk potential; CL: Synthesize
122. 4. Because valproic acid is associated with thrombocytopenia and hypofibrinogenemia,
        routine follow-up blood work would consist of monitoring platelet and fibrinogen levels for
        decreases. A CBC count and serum electrolyte level are not necessary. Aspartate transaminase, not
        alkaline phosphatase, is routinely monitored to evaluate for hepatic toxicity, a possible but rare effectof valproic acid. Valproic acid has no effect on cholesterol levels.
        CN: Pharmacological and parenteral therapies; CL: Apply
123. 3. Bacterial conjunctivitis is very contagious. Attention should be paid to thorough
        handwashing, a major means of stopping the transmission of the disease. Closing the day care center
        for 1 week is not necessary because thorough handwashing will stop the spread of the infection.
        Keeping the children out for 48 hours is not necessary. A child may return to day care after being
        treated for 24 hours. Although the parents of each child should be told about the outbreak, doing so
        will not help to curtail or prevent the spread of the infection.
        CN: Safety and infection control; CL: Synthesize
124. 3. The client’s mobility status is the best indicator of risk for development of a pressure sore.
        Nutritional and circulatory status are other factors that can contribute to pressure sore development,
        but immobility, even in the presence of adequate nutrition and circulation, is the leading cause of
        pressure sores. Disorientation can cause a client to neglect making needed position changes, but the
        underlying factor will be immobility.
        CN: Reduction of risk potential; CL: Analyze
125. 1. Ketosis is an adaptation to prolonged fasting or carbohydrate deprivation. The body takes
        partially broken-down fat fragments and combines them into ketone bodies, which the brain can then
        use for energy. Hypoglycemia is more likely to occur than hyperglycemia, although glucagon assists in
        preventing this. Metabolic syndrome refers to syndrome X, which includes an abnormal lipid profile
        and a tendency to gain weight in the abdomen. Lactic acidosis is a metabolic reaction that occurs
        when oxygen is reduced or not present.
        CN: Physiological adaptation; CL: Analyze

Question 26

126. While the nurse is assisting a client to ambulate as part of a cardiac rehabilitation program,
     the client has midsternal burning. The nurse should next:
127. Stop and assess the client further.
128. Measure the client’s blood pressure and heart rate.
129. Call for help and place the client in a wheelchair.
130. Administer nitroglycerin.
131. The nurse is counseling a client about the prevention of coronary heart disease. Which of the
     following vitamins should the nurse recommend the client include in his diet to reduce homocysteine
     levels? Select all that apply.
132. Vitamin K.
133. Vitamin B 6 .
134. Folate.
135. Vitamin B 12 .
136. Vitamin D.
137. The nurse evaluates a client’s knowledge as deficient when the client makes which of the
     following statements about the drug dexamethasone (Decadron)?
138. “I cannot stop the Decadron all at one time.”
139. “If I forget a dose, it’s no big deal; I’ll just take it when I remember it.”
140. “When I get a cold, I need to let my doctor know.”
141. “I need to watch for an allergic reaction when I first start taking Decadron.”
142. A 3-month-old has moderate dehydration. The nurse should assess the client for:
143. Oliguria.
144. Bulging eyes.
145. Sunken posterior fontanelle.
146. Pale skin color.
147. The nurse is assessing a client who is suspected of being in the early symptomatic stages of
     human immunodeficiency virus (HIV) infection. Which of the following signs and symptoms of
     infection should the nurse detect during this stage?1. Whitish yellow patches in the mouth.
148. Dyspnea.
149. Bloody diarrhea.
150. Raised, hyperpigmented lesions on the legs

Answer 26

126. 1. The nurse should stop and assess the client further. A chair should be available for the
        client to sit down. Obtaining the client’s blood pressure and heart rate are important when exercising.
        These values can be used to predict when the oxygen demand becomes greater than the oxygen supply.
        Calling for help is not necessary for the midsternal burning. If the primary care provider has
        prescribed nitroglycerin, the nurse can administer it; however, stopping the activity may restore the
        oxygen balance.
        CN: Physiological adaptation; CL: Synthesize
127. 2, 3, 4. Vitamin B 6 , folate, and vitamin B 12 have been shown to reduce homocysteine levels.
     The effects of vitamins K and D have not been established with regard to homocysteine.
     CN: Health promotion and maintenance; CL: Synthesize
128. 2. The statement, “If I forget a dose, it’s no big deal, I’ll just take it when I remember it,”
        indicates a knowledge deficit. The nurse should reinforce that the client should take dexamethasone as
        prescribed and at the same time each day. The drug has to be tapered off and cannot be stopped
        abruptly. The primary care provider should be notified when the client is under additional stress (eg,
        infection, surgery, illness). The client can have an allergic reaction to inactive ingredients contained
        in dexamethasone.
        CN: Pharmacological and parenteral therapies; CL: Evaluate
129. 1. A child with moderate dehydration, described as a loss of 50 to 90 mL/kg of body fluid,would have oliguria, gray skin color, increased pulse rate, and poor skin elasticity. Sunken eyes not
        bulging are a sign of dehydration. The anterior fontanelle may be sunken, but the posterior fontanelle
        is normally closed by 6 to 8 weeks of age. A child with mild dehydration, described as a loss of less
        than 50 mL/kg of body fluid, would have pale skin color, decreased skin elasticity, decreased urine
        output, and normal or increased pulse rate.
        CN: Physiological adaptation; CL: Analyze
130. 1. Oropharyngeal candidiasis, or thrush, is the most common infection associated with the
        early symptomatic stages of HIV infection. Thrush is characterized by whitish yellow patches in the
        mouth. Various other opportunistic diseases can occur in clients with HIV infection, but they tend to
        occur later, after the diagnosis of acquired immunodeficiency syndrome has been made. Dyspnea can
        be indicative of pneumonia, which is caused by a variety of infective organisms. Bloody diarrhea is
        indicative of cytomegalovirus infection. Hyperpigmented lesions are indicators of Kaposi’s sarcoma.
        CN: Physiological adaptation; CL: Analyze

Question 27

131. A primiparous client who is breast-feeding develops endometritis on the third postpartum
     day. Which of the following instructions should the nurse give to the mother?
132. The neonate will need to be bottle-fed for the next few days.
133. The condition typically is treated with IV antibiotic therapy.
134. The client’s uterus may become “boggy,” requiring frequent massage and oxytocics.
135. The client needs to remain in bed in a side-lying position as much as possible.
136. After instructing a primiparous client who is breast-feeding on how to prevent nipple
     soreness during feedings, the nurse determines that the client needs further instruction when she states
     which of the following?
137. “I should position the baby the same way for each feeding.”
138. “I should make sure the baby grasps the entire areola and nipple.”
139. “I should air dry my breasts and nipples for 10 to 15 minutes after the feeding.”
140. “I shouldn’t use a hand breast pump if my nipples get sore.”
141. A client who has Ménière’s disease is experiencing an acute attack of vertigo. Which of the
     following interventions should the nurse include in the plan of care?
142. Darken the client’s room and provide a quiet environment.
143. Provide a low-sodium, bland diet.
144. Administer an opioid to relieve headache.
145. Encourage fluid intake to prevent dehydration.
146. During a home visit to a primiparous client 1 week postpartum who is bottle-feeding her
     neonate, the client tells the nurse that her mother has suggested that she feed the neonate cereal so he
     will sleep through the night. Which of the following would be the nurse’s best response?
147. “It is permissible to give the baby cereal if it is thinned with formula.”
148. “The time for starting cereal varies, so check with your pediatrician.”
149. “Formula is the food best digested by the baby until about 4 to 6 months of age.”
150. “If cereal is given too early in life, the undigested food can lead to a need for surgery.”
151. When a client reports being allergic to amoxicillin even though the medication
     administration record and armband do not indicate medication allergies, the nurse should:
152. Administer the prescribed medication.
153. Withhold the amoxicillin.
154. Administer another, similarly acting antibiotic.
155. Call the family to verify the client’s statement.

Answer 27

131. 2. Postpartum infection is a leading cause of maternal mortality in the United States and
        Canada. Typical treatment for the condition is IV antibiotic therapy with drugs such as clindamycin,
        gentamicin, or both. Cultures of the lochia will also be obtained. The neonate can continue to breast-
        feed as long as the mother desires. A switch to bottle-feeding is not necessary. The uterus tends to be
        firm, with increased cramping to rid the uterus of the infection. The client should be encouraged to
        remain in Fowler’s position when in bed to allow for drainage of the lochia.
        CN: Physiological adaptation; CL: Synthesize
132. 1. The mother needs further instruction when she says, “I should position the baby the same
        way for each feeding.” This can contribute to sore nipples. The position should vary for each feeding
        to prevent repeated pressure on the same area each time. Grasping the entire areola and nipple will
        help to decrease nipple soreness. Air drying the breasts and not using a hand pump will help to
        decrease nipple soreness.
        CN: Health promotion and maintenance; CL: Evaluate
133. 1. During an acute attack of vertigo, it is best for the client to lie down in a darkened, quiet
        room and to avoid sudden position changes. A low-sodium diet may be helpful in decreasing the
        number of attacks, but it is not recommended during the attack. Headaches are not a component of the
        vertigo attack. Because vertigo is frequently accompanied by nausea and vomiting, the client will not
        want to eat or drink. Fluids are usually administered parenterally to maintain hydration and
        administer medications.
        CN: Basic care and comfort; CL: Synthesize
134. 3. The American Academy of Pediatrics and Canadian Pediatric Society recommend that all
        neonates should receive only formula or breast milk for the first 4 to 6 months of life. Cereal will not
        help the neonate sleep through the night and may result in allergies and other digestive disorders.
        CN: Health promotion and maintenance; CL: Synthesize
135. 2. Once the client has stated that he is allergic to a substance, the nurse would be negligent to
        ignore the client’s statement and administer the substance. The nurse should check the chart for
        allergies and call the primary care provider for an alternative antibiotic prescription.
        CN: Management of care; CL: Synthesize

Question 28

136. While assessing a term neonate on a home visit to a primiparous client 2 weeks after a
     vaginal birth, the nurse observes that the neonate is slightly jaundiced and the stool is a pale, light
     color. The nurse notifies the primary care provider because these findings indicate which of the
     following?
137. Biliary atresia.
138. Rh isoimmunization.3. ABO incompatibility.
139. Esophageal varices.
140. A 6-year-old child has had heart surgery to repair tetralogy of Fallot. When developing the
     discharge plan, the nurse should include information about:
141. Allowing the child to lead a normal, active life.
142. Persuading the child to get enough rest.
143. Having the child develop postoperative complications.
144. Having the child out of school for a month.
145. A client is recovering from abdominal surgery and has a nasogastric (NG) tube inserted.
     The expected outcome of using the NG tube is gastrointestinal tract:
146. Compression.
147. Lavage.
148. Decompression.
149. Gavage.
150. The nurse teaches the mother of a toddler who has had a cleft palate repair that her child is
     at risk for developing which of the following in the future?
151. Hearing problems.
152. Poor self-concept.
153. A speech defect.
154. Chronic sinus infections.
155. The nurse assesses a client who is receiving a tube feeding. Which of the following
     situations would require prompt intervention from the nurse?
156. The client is sitting upright in bed while the feeding is infusing.
157. The feeding that is infusing has been hanging for 8 hours.
158. The client has a gastric residual of 25 mL.
159. The feeding solution is at room temperature

Answer 28

136. 1. Jaundice that persists past the third or 4th day of life and pale, light stools are associated
        with biliary atresia. Alkaline phosphatase levels will also be elevated. Surgical intervention is
        necessary to remove the blockage. Rh isoimmunization and ABO incompatibility are associated with
        neonatal anemia as the red blood cells are hemolyzed by the antibodies. Esophageal varices are
        associated with cirrhosis of the liver and large amounts of bleeding when the vessels rupture. The
        child with esophageal varices will exhibit manifestations of anemia such as pallor, and may
        experience hemorrhage and shock.
        CN: Physiological adaptation; CL: Analyze
137. 1. Most parents find it especially difficult to allow a child who was unable to be normally
        active before corrective heart surgery to lead a normal and active life after surgery. These parents are
        less likely to be apprehensive about persuading the child of the need for rest, about postoperative
        complications, or having the child out of school for a month.
        CN: Physiological adaptation; CL: Synthesize
138. 3. After abdominal surgery, the reason for inserting a NG tube is to decompress the
        gastrointestinal tract until peristaltic action returns. Compression may be used to control bleeding
        esophageal varices. Lavage is used to remove substances from the stomach or control bleeding.
        Gavage is used to provide enteral feedings.
        CN: Physiological adaptation; CL: Evaluate
139. 3. The most common long-term problem experienced by children with cleft palate repair is
        speech problems. These children frequently need speech therapy for a period of time. Hearing
        problems may occur as a result of chronic ear infections and the placement of myringotomy tubes. A
        poor self-concept may develop in any child. However, if a child with a cleft palate receives adequate
        parenting and support, this should not occur. Chronic sinus infections are more commonly associated
        with asthma, not with this defect.
        CN: Physiological adaptation; CL: Apply
140. 2. Feeding solutions that have not been infused after hanging for 8 hours should be discarded
        because of the increased risk of bacterial growth. Sitting the client upright during the feeding helps
        prevent aspiration of the feeding. A gastric residual of 25 mL is considered acceptable. A gastric
        residual of 100 to 150 mL, or a residual greater than 100% of the previous hour’s intake, indicates
        delayed emptying. The feeding solution should be at room or body temperature.
        CN: Pharmacological and parenteral therapies; CL: Analyze

Question 29

141. A client has been taking furosemide (Lasix) for 2 days. The nurse should assess the client
     for:
142. An elevated blood urea nitrogen (BUN) level.
143. An elevated potassium level.
144. A decreased potassium level.
145. An elevated sodium level.
146. When suctioning the respiratory tract of a client, it is recommended that the suctioning
     period not exceed how many seconds?
147. 5 seconds.
148. 10 seconds.
149. 15 seconds.
150. 20 seconds.
151. An 80-year-old client with severe kidney damage is placed on life support and dialysis.
     Care decisions are being made by his wife, who is showing signs of early Alzheimer’s disease. The
     client’s daughter arrives from out of town with a copy of the client’s living will, which states that the
     client did not want to be on life support. The nurse should:1. Immediately inform the primary care provider about the living will.
152. Suggest to the daughter that she discuss her father’s wishes with her mother.
153. Prepare to remove the client from life support.
154. Make a copy of the living will and give it to the client’s wife.
155. Prior to administering plasminogen activator (t-PA) to a client admitted with a stroke, the
     nurse should verify that the client (select all that apply):
156. Is older than 65 years.
157. Has had symptoms of the stroke less than 3 hours.
158. Has a blood pressure within normal limits.
159. Does not have active internal bleeding.
160. Has not had an alcoholic beverage within the last 8 hours.
161. When caring for a client with myasthenia gravis who is receiving anticholinesterase drug
     therapy, the nurse must be able to distinguish cholinergic crisis from myasthenic crisis. Which of the
     following symptoms is not present in cholinergic crisis?
162. Improved muscle strength after IV administration of edrophonium chloride (Tensilon).
163. Increased weakness.
164. Diaphoresis.
165. Increased salivation.

Answer 29

141. 3. Furosemide is a loop diuretic and inhibits the reabsorption of sodium and chloride from
        the proximal and distal renal tubules and the loop of Henle. Furosemide promotes sodium diuresis,
        resulting in a loss of potassium and serious electrolyte imbalances. Furosemide does not affect the
        BUN level.
        CN: Pharmacological and parenteral therapies; CL: Analyze
142. 3. Suctioning the respiratory tract for prolonged periods depletes the client’s oxygen supply
        and causes hypoxia. It is recommended that each suctioning period not exceed 15 seconds.
        CN: Reduction of risk potential; CL: Apply
143. 2. The most appropriate action is to encourage the daughter to talk to her mother about theend-of-life issues first to reach a consensus or agreement. This is a family decision. Immediately
        informing the primary care provider or preparing to remove the client from life support would be
        premature if the family is not in agreement. Although a copy of the living will should be on the client’s
        chart, it is up to the daughter to show it to her mother.
        CN: Management of care; CL: Synthesize
144. 2, 3, 4. Contraindications for t-PA or alteplase recombinant therapy include current active
     internal bleeding, 3 hours or longer since the onset of symptoms of a stroke, and severe hypertension.
     Age greater than 65 years or having had an alcoholic beverage are not contraindications for the
     therapy.
     CN: Pharmacological and parenteral therapies; CL: Analyze
145. 1. Extreme muscle weakness is present in both cholinergic crisis and myasthenic crisis. In
        cholinergic crisis, IV edrophonium chloride (Tensilon), a cholinergic agent, does not improve muscle
        weakness; in myasthenic crisis, it does. Diaphoresis and increased salivation are not present in
        cholinergic crises.
        CN: Physiological adaptation; CL: Analyze

Question 30

146. The nurse identifies the type of presentation shown in the figure as which of the following?
147. Frank breech.
148. Compound breech.
149. Complete breech.
150. Incomplete breech.
151. Which of the following client statements indicates that the client with hepatitis B
     understands discharge teaching?
152. “I will not drink alcohol for at least 1 year.”
153. “I must avoid sexual intercourse.”3. “I should be able to resume normal activity in a week or two.”
154. “Because hepatitis B is a chronic disease, I know I will always be jaundiced.”
155. Which of the following examples should the nurse use to describe bulimia to a group of
     parents at a local community center?
156. An adolescent male who uses calorie-counting to maintain his weight in the desirable range for
     his height.
157. A college-age male who uses regular exercise to be able to eat and drink what he wants
     without gaining weight.
158. A middle-aged female who uses diet pills occasionally to help her lose small amounts of
     weight.
159. A college-age female who binges and then purges to prevent weight gain.
160. A client who has been taking diazepam (Valium) for 3 months for skeletal muscle spasms
     and lower back pain states that he stopped taking the medication 2 days ago because it was no longer
     helping him, but now he feels terrible. The nurse should assess the client for which of the following?
     Select all that apply.
161. Insomnia.
162. Euphoria.
163. Bradycardia.
164. Diaphoresis.
165. Tremor.
166. Vomiting.
167. An IV infusion is to be administered through a scalp vein on an infant’s head. What should
     the nurse tell the parents to prepare them for the procedure?
168. It may be necessary to remove a small amount of hair from the infant’s scalp.
169. A sedative will be given to help keep the infant quiet.
170. Visiting the infant will be delayed until the infusion has been completed.
171. Holding the infant will be contraindicated while the infusion is being administered

Answer 30

146. 3. For a complete breech, the buttocks present, the feet and legs are flexed on the thighs, and
        the thighs are flexed on the abdomen. For a frank breech, the buttocks present with the hips flexed and
        the legs extended against the abdomen and chest. This is the most common type of breech
        presentation. For a compound breech, the buttocks present together with another part, such as a hand.
        This is a rare occurrence. For an incomplete breech, one or both feet or the knees extend below the
        buttocks. This can also be termed a single footling or double footling breech.
        CN: Health promotion and maintenance; CL: Analyze
147. 1. It is important that the client understand that alcohol should be avoided for at least 1 year
        after an episode of hepatitis. Sexual intercourse does not need to be avoided, but the client should be
        instructed to use condoms until the hepatitis B surface antigen measurement is negative. The client
        will need to restrict activity until liver function test results are normal; this will not occur within 1 to
        2 weeks. Jaundice will subside as the client recovers; it is not a permanent condition.
        CN: Reduction of risk potential; CL: Evaluate
148. 4. The individual who is bulimic is most commonly female and age 15 to 24. She binges and
        purges to control her weight and to prevent weight gain. Sometimes excessive exercise is also used.
        Use of regular exercise and calorie counting and occasional use of diet medication to maintain normal
        weight are not considered dysfunctional in our society.
        CN: Psychosocial adaptation; CL: Synthesize
149. 1, 4, 5, 6. Diazepam (Valium) is a benzodiazepine that causes symptoms of withdrawal when
     stopped abruptly. The nurse should assess the client for tremors, agitation, irritability, insomnia,
     vomiting, sweating, tachycardia, headache, anxiety, and confusion. Euphoria or elevated mood is not
     a symptom of benzodiazepine withdrawal.
     CN: Pharmacological and parenteral therapies; CL: Analyze
150. 1. Parents are typically quick to notice changes in their infant’s physical appearance. The
        removal of the infant’s hair may be upsetting to them if they have not been told why it is being done.Hair may be removed on the scalp at the site of needle insertion for IV therapy to provide better
        visualization and a smooth surface on which to attach tape to secure the needle. Sedatives are not
        ordinarily prescribed before IV fluid administration. In most instances, it is acceptable for parents to
        visit their infant while the IV solution is infusing. Holding the infant is encouraged to provide
        comfort.
        CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 31

151. Which of the following goals is most important for a client with acute pancreatitis?
152. The client reports minimal abdominal pain.
153. The client regains a normal pattern for bowel movements.
154. The client limits alcohol intake to two to three drinks per week.
155. The client maintains normal liver function.
156. A nurse is caring for a child with type 1 diabetes mellitus at camp. The child is irritable and
     has a headache. Which of the following should the nurse do first?
157. Administer 2 oz (60 mL) of orange juice.
158. Notify the primary care provider about the child’s status.
159. Check the child’s blood glucose level.
160. Send the child back to the planned activities.
161. A client tells the nurse that her bra fits more snugly at certain times of the month and she is
     concerned this may be a sign of breast cancer. The best response for the nurse is to explain that:
162. A change in breast size should be checked by her primary care provider.
163. Benign cysts tend to cause the breast to vary in size.3. It is normal for the breast to increase in size before menstruation begins.
164. A difference in the size of her breasts is related to normal growth and development.
165. Which of the following is an example of beliefs of traditional Chinese medicine found in
     Asian culture?
166. Health is described as harmony between family members.
167. Illness is caused by an imbalance of the yin and yang.
168. Exercise to the point of overexertion can improve health.
169. Illness is caused by a change in eating habits.
170. A client is scheduled for an intravenous pyelogram (IVP). Which of the following questions
     would be most important for the nurse to ask the client in preparation for the procedure?
171. “Have you ever had an IVP before?”
172. “Do you have any allergies to shellfish?”
173. “When was your last bowel movement?”
174. “Have you ever experienced urinary incontinence?”

Answer 31

151. 1. Abdominal pain can be a significant problem in acute pancreatitis. An expected outcome
        is to decrease or eliminate the pain the client is experiencing. Patterns of bowel elimination and liver
        function are not typically affected by pancreatitis. The client should avoid alcohol.
        CN: Physiological adaptation; CL: Synthesize
152. 3. The most appropriate initial response by the nurse would be to test the child’s blood
        glucose level. The child’s symptoms are consistent with hypoglycemia but could also be used by the
        child to avoid participation in planned activities. Administering milk or fruit juice during a mild
        reaction may also be appropriate if testing cannot be done. Notifying the primary care provider may
        be appropriate after the child’s glucose level has been obtained and emergency treatment has been
        initiated if the child is experiencing hypoglycemia. Returning the child to previous activities is not
        appropriate until either testing or administering treatment has been done.
        CN: Physiological adaptation; CL: Synthesize
153. 3. Normally, breasts are about the same size. They can vary in size before menstruation due
        to breast engorgement caused by hormonal changes. It is not necessary for a primary care provider to
        check this slight change in breast size. The changes in breast size this client described are most likely
        caused by hormonal changes, not a benign cyst or normal growth and development.
        CN: Health promotion and maintenance; CL: Synthesize
154. 2. Traditional Chinese medicine describes health as the balance of yin and yang. It describes
        health as harmony between the mind, body, and soul.
        CN: Health promotion and maintenance; CL: Apply
155. 2. Before an IVP, the client should be assessed for allergies to iodine. Shellfish is a source
        of iodine, so people who are allergic to shellfish should not receive an IVP. Asking the client whether
        he or she has ever had an IVP before can help determine the degree of teaching needed before the
        procedure, but that is not the most important question. Neither the client’s last bowel movement nor
        urinary incontinence has any relationship to an IVP.
        CN: Reduction of risk potential; CL: Analyze

Question 32

156. Which oral contraceptive is considered safe for use while breast-feeding because it will not
     affect the breast milk or breast-feeding?
157. Estrogen.
158. Estrogen and progestin.
159. Progestin.
160. Testosterone.
161. A multigravid client at 36 weeks’ gestation who is visiting the clinic for a routine visit
     begins to sob and tells the nurse, “My boyfriend has been beating me up once in a while since I
     became pregnant, but I can’t bring myself to leave him because I don’t have a job and I don’t know
     how I would take care of my other children.” Which of the following actions should be the priority by
     the nurse at this time?
162. Contact a social worker for assistance and family counseling.
163. Help the client make concrete plans for the safety of herself and her children.
164. Tell the client that she shouldn’t allow anyone to hit her or her children.
165. Provide the client with brochures on the statistics about violence against women.
166. Sulfamethoxazole/trimethoprim has been prescribed for a client who has a urinary tract
     infection. Which of the following nursing interventions is most appropriate for administering
     sulfonamides?
167. Encourage the client to take the medication with meals.
168. Instruct the client to drink at least eight glasses of water a day.
169. Measure the client’s urine output.
170. Instruct the client that the urine may turn reddish orange.
171. A client with chronic undifferentiated schizophrenia is having an acute exacerbation of
     symptoms. The client states, “Black cats and black hats. Where does the time go?” Which of the
     following would be most important for the nurse to say?
172. “Halloween is getting close, isn’t it.”
173. “Do you have a black cat?”
174. “What’s the connection between cats, hats, and time?”4. “Time certainly does go faster these days.”
175. A client has been diagnosed with multi-infarct (or vascular) dementia (MID). When
     preparing a teaching plan for the client and family, which of the following should the nurse indicate as
     the most critical factor for slowing MID?
176. Administering anticoagulants such as warfarin (Coumadin).
177. Administering benzodiazepines such as lorazepam (Ativan) to decrease choreiform
     movements.
178. Managing related symptoms such as depression.
179. Managing the symptoms by increasing dopamine availability.

Answer 32

156. 3. Progestin alone has no effect on breast milk or breast-feeding once the milk supply is well
        established. Estrogen suppresses milk output. Testosterone is not given as an oral contraceptive.
        CN: Pharmacological and parenteral therapies; CL: Apply
157. 2. In this situation, the client has indicated that she is not willing to leave the abusive
        boyfriend because of potential economic concerns and other children in the household. The nurse
        should explain the cycle of abuse (eg, tension-building phase, battering incident, and honeymoon
        phase). The priority intervention is to assist the client to make concrete plans for the safety of herself
        and her children. The client should identify the safest, quickest routes out of the house and be able toidentify where she will go once the cycle of violence escalates. Contacting a social worker at this
        time is not appropriate because the client is not ready to leave the abusive situation. The nurse can
        tell the client that these services are available, but it is up to the client to determine whether a referral
        is necessary. Telling the client that she shouldn’t allow anyone to hit her or her children does not
        assist the client to make plans for her safety and the children’s safety should the violence escalate.
        The client may have a flat affect or feel extreme humiliation from the abuse. The client may also be
        feeling that the abuse is her fault. When the client is ready to leave the abusive situation and receive
        continuous counseling, efforts can be made to increase her self-esteem and prevent additional
        violence. The client should be made aware of the available services in the community for women
        who are involved in abusive relationships. The location and phone numbers for available shelters
        should be provided to the client. Giving her a brochure related to the statistics about violence against
        women is not helpful and, if found by the abuser, may lead to further violence.
        CN: Safety and infection control; CL: Synthesize
158. 2. The client who is taking sulfamethoxazole/trimethoprim should be instructed to drink at
        least eight glasses of water a day to prevent crystalluria. This medication does not need to be taken
        with food. It does not require that the client’s urine output be measured and does not affect the color of
        the urine.
        CN: Pharmacological and parenteral therapies; CL: Synthesize
159. 3. The client is demonstrating loose associations. Therefore, the nurse needs to clarify the
        meaning of and the connection between ideas. The nurse’s statement about Halloween makes the
        assumption that the client is talking about Halloween from the mention of black cats and black hats.
        Asking if the client has a black cat is not helpful. The statement about time going faster ignores the
        client’s statement entirely.
        CN: Psychosocial adaptation; CL: Synthesize
160. 1. MID results from multiple small blood clots in the brain. Therefore, the most critical
        factor is using anticoagulants to reduce the risk of more infarcts. Administering benzodiazepines such
        as lorazepam to decrease choreiform movements is associated with Huntington’s disease. Although
        depression is common with MID, managing depression-related symptoms will not slow the
        progression of MID. Managing symptoms by increasing dopamine availability is appropriate for
        clients with Parkinson’s disease.
        CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 33

161. While performing cardiopulmonary resuscitation (CPR) on a 5-year-old child, the nurse
     palpates for a pulse. Which of the following sites is best for checking the pulse during CPR in a 5-
     year-old child?
162. Femoral artery.
163. Carotid artery.
164. Radial artery.
165. Brachial artery.
166. A nurse is assessing a client with nephrotic syndrome. The nurse should assess the client for
     which condition?
167. Hematuria.
168. Massive proteinuria.
169. Increased serum albumin level.
170. Weight loss.
171. A child with tetralogy of Fallot and a history of severe hypoxic episodes is to be admitted to
     the pediatric unit. Which of the following would be most important for the nurse to have at the
     bedside?
172. Morphine sulfate in a syringe ready to administer.
173. Oxygen tubing and gauge plugged in.
174. Blood pressure cuff and stethoscope.
175. Suction tubing and equipment.
176. Which statement would most likely be made by a Mexican client with pain?
177. “Enduring pain is a part of God’s will.”
178. “This pain is killing me.”
179. “I’ve got to see a doctor right away.”
180. “I can’t go on in pain like this any longer.”
181. A client is voiding small amounts of urine every 30 to 60 minutes. Which of the following
     actions is the nurse’s first priority?
182. Palpate for a distended bladder.
183. Catheterize the client for residual urine.
184. Request a urine specimen for culture.
185. Encourage an increased fluid intake.

Answer 33

161. 2. Checking the carotid artery pulse in a child during CPR provides information about
        perfusion of the brain. The brachial pulse is checked in an infant because the infant’s short and
        typically fat neck makes it difficult to palpate the carotid pulse. The femoral and radial arteries might
        indicate perfusion to the peripheral body sites, but the critical need is for adequate circulation to the
        brain.
        CN: Physiological adaptation; CL: Apply
162. 2. Nephrotic syndrome is characterized by massive proteinuria caused by increased
        glomerular membrane permeability. Other symptoms include peripheral edema, hyperlipidemia, and
        hypoalbuminemia. Because of the edema, clients retain fluid and may gain weight. Hematuria is not a
        symptom related to nephrotic syndrome.CN: Physiological adaptation; CL: Analyze
163. 2. Because the child has a history of severe hypoxic episodes, having oxygen readily
        available at the bedside is most important. Should the child experience another hypoxic episode,
        oxygen could be administered easily and quickly. Although morphine causes peripheral dilation,
        which causes the blood to remain in the periphery, decreasing system volume, oxygen administration
        is the priority. Typically a child with tetralogy of Fallot with episodes of hypoxia does not require
        suctioning.
        CN: Physiological adaptation; CL: Synthesize
164. 1. Although individuals differ, the most likely attitude of a Mexican client is to bear pain
        stoically, to endure pain as a part of God’s will, and to delay seeking treatment.
        CN: Basic care and comfort; CL: Apply
165. 1. When a client voids frequent, small amounts, the nurse should suspect that the client is
        retaining urine. Palpating for a distended bladder is the first assessment that the nurse should perform
        to verify this suspicion. Obtaining a prescription to catheterize for residual urine may be appropriate
        as a follow-up activity. Obtaining a urine specimen for culture is not a first priority. The nurse would
        not encourage an increased fluid intake until further assessment of the situation is completed.
        CN: Physiological adaptation; CL: Synthesize

Question 34

166. Which of the following has the highest priority in the care of a client with chronic renal
     failure?1. Apply corticosteroid creams to relieve itching.
167. Achieve pain control with analgesics.
168. Maintain a low-sodium diet.
169. Measure abdominal girth daily.
170. The father of an 18-month-old with no previous illness, who has been admitted to a surgery
     center for repair of an inguinal hernia, tells the nurse that his child is having trouble breathing. The
     father does not think the child choked. After telling the clerk to call the rapid response team, the nurse
     should do which of the following? Place in order from first to last.
171. Notify the surgeon.
172. Start an intravenous infusion.
173. Assess the effectiveness of the abdominal thrusts.
174. Perform the abdominal thrust maneuver.
175. Listen for breath sounds.
176. The nurse is assessing a child’s skeletal traction and notices that the weights are on the floor.
     Which of the following should the nurse do next?
177. Raise the weights so that the child can move up in bed.
178. Notify the primary care provider immediately.
179. Put the foot of the bed on blocks.
180. Move the child up in bed.
181. Compared to the food requirements of preschoolers and adolescents, the food requirements
     of school-age children are not as great because these children have a lower:
182. Growth rate.
183. Metabolic rate.
184. Level of activity.
185. Hormonal secretion rate.
186. When assessing a 17-year-old client with depression for suicide risk, which of the
     following questions would be best?
187. “What movies about death have you watched lately?”2. “Can you tell me what you think about suicide?”
188. “Has anyone in your family ever committed suicide?”
189. “Are you thinking about killing yourself?”

Answer 34

166. 3. It is appropriate for the client to be on a low-sodium diet to help decrease fluid retention.
        Dry skin and pruritus are common in renal failure. Lotions are used to relieve the dry skin, and
        antihistamines may be used to control itching; corticosteroids are not used. Pain is not a major
        problem in chronic renal failure, but analgesics that are excreted by the kidneys must be avoided. It is
        not necessary to measure abdominal girth daily because ascites is not a clinical problem in renal
        failure.
        CN: Reduction of risk potential; CL: Synthesize
        167.
167. Listen for breath sounds.
168. Perform the abdominal thrust maneuver.
169. Assess the effectiveness of the abdominal thrusts.
170. Start an intravenous infusion.
171. Notify the surgeon.
     The most frequent cause of respiratory distress in a toddler with no previous illness is foreign
     body aspiration. After having the clerk call for the rapid response team, the nurse should assess thechild for breaths, and then begin abdominal thrusts. Next, the nurse (or rapid response team if present)
     should assess the effectiveness of the abdominal thrusts, and then start an intravenous infusion.
     Finally, the nurse can notify the surgeon.
     CN: Reduction of risk potential; CL: Synthesize
172. 4. The traction weights should be hanging freely to maintain pull. The child needs to be
        moved up in bed with the weights left untouched to continue countertraction. Then the nurse can
        determine whether blocks are necessary to maintain the child in the correct position. Raising the
        weights is inappropriate because doing so interferes with countertraction. The primary care provider
        does not need to be notified. The nurse can easily correct the problem by moving the child up in bed.
        CN: Safety and infection control; CL: Synthesize
173. 1. Children ages 6 to 12 have a slower growth rate than do younger children and
        adolescents. As a result, their food requirements are comparatively less.
        CN: Health promotion and maintenance; CL: Apply
174. 4. Asking whether the client is thinking about killing herself is the most direct and therefore
        the best way to assess suicide risk. Knowing whether the client has recently watched movies on
        suicide and death, what the client thinks about suicide, or about previous suicides of family members
        will not tell the nurse whether the client herself is thinking about committing suicide right now.
        CN: Psychosocial adaptation; CL: Synthesize

Question 35

171. Which of the following is a major risk factor for having a low-birth-weight baby?
172. Heredity.
173. Age.
174. Drug use during pregnancy.
175. Poor nutrition.
176. Which of the following techniques is best for the nurse to use in evaluating the parents’
     ability to administer eardrops correctly?
177. Observe the parents instilling the drops in the child’s ear.
178. Listen to the parents as they describe the procedure.
179. Ask the parents to list the steps in the procedure.
180. Ask the parents whether they have read the handout on the procedure.
181. Ibuprofen (Motrin) is prescribed for a client with osteoarthritis. Which of the following
     instructions about ibuprofen should the nurse include in the client’s teaching plan?
182. Report the development of tinnitus.
183. Increase vitamin B 12 intake.
184. Take with food or antacids.
185. Have the complete blood count (CBC) monitored monthly.
186. A staff member states, “I don’t know why Mary is so depressed. She lives in an exclusive
     part of town and has gorgeous clothes. Her husband seems to care about her very much. She really has
     it all.” Which of the following should the nurse conclude from the staff member’s statement?
187. An accurate assessment of the client has been made.
188. The staff member is jealous of the client.
189. There is no reason for the client to be depressed.
190. The staff member needs teaching about major depression.
191. The nurse is instructing the mother of a child with asthma about noting food triggers for
     asthma attacks. Which of the following foods would most likely be responsible for causing an
     allergic reaction?
192. Whitefish.
193. Tossed salad.
194. Hamburger.
195. Fudge brownies.

Answer 35

171. 4. Proper nutrition before and during pregnancy helps to ensure that the uterus will be able to
        support the growth of a healthy placenta. If the placenta never develops properly, the fetus will fail to
        thrive and the infant may have a low birth weight.
        CN: Health promotion and maintenance; CL: Analyze
172. 1. Return demonstrations are the best way to evaluate a person’s ability to perform a skill.
        This technique enables the teacher to observe not only the learner’s sequencing of steps of the
        procedure but also the learner’s ability to perform the skill.
        CN: Health promotion and maintenance; CL: Evaluate
173. 3. Ibuprofen (Motrin) should be taken with food or antacids to avoid the development of
        gastrointestinal distress. Tinnitus is not an adverse effect of ibuprofen; it is a sign of salicylate
        toxicity. There is no need to increase vitamin B 12 intake. The CBC is not typically monitored monthly,
        although clients should be told to report signs of unusual bleeding because ibuprofen can prolong
        bleeding time.
        CN: Pharmacological and parenteral therapies; CL: Synthesize
174. 4. The nurse concludes that the staff member needs teaching about depression, specifically
        the biological basis of major depression, when the staff member states the client has no reason to be
        depressed because “she really has it all.” Major depression, or endogenous depression, is caused by
        alterations of neurotransmitters, primarily serotonin and norepinephrine. Genetics and hereditary also
        predispose an individual to develop depression. Therefore, there may not be an external cause or a
        reason for depression to develop. Depression that occurs from an external cause is known as reactive
        depression and it could be caused by a loss or a life stress.
        CN: Management of care; CL: Analyze175. 4. In asthma, the airways react to certain external and internal stimuli, including allergens,
        infections, exercise, and emotions. Food allergens commonly associated with asthma include wheat,
        egg white, dairy products, citrus fruits, corn, and chocolate.
        CN: Physiological adaptation; CL: Analyze

Question 36

176. When preparing to administer a tap water enema, in which position should the nurse place
     the client?
177. Supine.
178. Semi-Fowler’s.
179. Right lateral.
180. Left Sims’.
181. Which of the following is a risk factor for the development of pressure ulcers?
182. Ambulating less than twice a day.2. An indwelling urinary catheter.
183. Decreased serum albumin level.
184. Elevated white blood cell count.
185. An adult admitted to the hospital with a hemoglobin of 6.5 g/dL (65 g/L) is experiencing
     signs and symptoms of cerebral tissue hypoxia. The nurse should:
186. Plan frequent rest periods throughout the day.
187. Assist the client in ambulating to the bathroom.
188. Check the temperature of the water before the client showers.
189. Refer the client to occupational therapy for energy conservation interventions.
190. A nurse is assessing an older adult with pneumonia. Where should the nurse place the
     stethoscope to listen for breath sounds that will indicate the client is fully oxygenating the lung on the
     right side?
191. The nurse is giving care to an infant in an oxygen hood (see figure). The nurse should do
     which of the following? Select all that apply.
192. Assure that the oxygen is not blowing directly on the infant’s face.
193. Place the butterfly mobile on the outside of the hood.
194. Immobilize the infant with restraints.
195. Remove the hood for 10 minutes every hour.
196. Encourage the parents to visit the child.

Answer 36

176. 4. When administering an enema, the nurse should position the client in a left Sims position.
        Placing the client in this position facilitates the flow of fluid into the rectum and colon. It also allows
        the client to flex the right leg forward, adequately exposing the rectal area.
        CN: Basic care and comfort; CL: Apply
177. 3. Risk factors for the development of pressure ulcers include poor nutrition, indicated by a
        decreased serum albumin level. Other risk factors include immobility, incontinence, and decreased
        sensation. A client who does not ambulate often can be repositioned frequently to prevent pressure
        ulcers. Having an indwelling urinary catheter does not normally increase the risk of developing a
        pressure ulcer unless pressure from the tubing impinges on urethral or other tissue. An elevated white
        blood cell count does not place a client at risk for pressure ulcers.
        CN: Reduction of risk potential; CL: Analyze
178. 2. Cerebral hypoxia is commonly associated with dizziness. The greatest risk of injury to a
        client with dizziness is a fall. Frequent rests and energy conservation measures should be included in
        the client’s plan of care, but safety from falls is the greatest need. Checking the shower water
        temperature is not critical for this client, who will not be showering because of her fall risk.
        CN: Reduction of risk potential; CL: Synthesize
179. The nurse should auscultate the right lower lobe and listen as the client inhales and exhales.
     The nurse should be able to hear vesicular breath sounds.
     CN: Physiological adaptation; CL: Apply
180. 1, 2, 5. When an oxygen hood is used, the nurse should be sure the oxygen source is notdirected on the infant’s face to avoid skin irritation. Mobiles can be used to provide visual
     stimulation, but they should not be placed inside of the hood where they are a potential choking
     hazard. It is not necessary to restrain the infant unless there is an indication to do so, and the primary
     care provider has written the prescription. There should be as little movement in and out of the hood
     as possible in order to maintain the warm and humid oxygen levels. The nurse should encourage the
     parents to visit the child and provide verbal and tactile stimulation.
     CN: Physiological adaptation; CL: Synthesize

Question 37

181. During care, the client suddenly blurts out “my doctor just told me that I am going to have to
     have chemotherapy after all; I was hoping to avoid it.” Which of the following is the nurse’s most
     therapeutic response?
182. “Well, he is our best oncologist; I am certain he knows what is best.”
183. “What concerns you most about possible chemotherapy?”
184. “You know, you can get a second opinion before you agree to any of that.”
185. “I understand how you feel. I would feel the same way.”
186. A hospitalized client is experiencing “fight versus flight,” a stress-mediated physiologic
     response. As a result, the nurse should assess the client for which of the following?
187. Increased urinary output.
188. Decreased arterial blood pressure.
189. Increased blood glucose.
190. Decreased mental acuity.
191. The nurse observes a nursing assistant sharing extensive stories of her own mother’s death
     with a dying client’s husband. Which of the following is appropriate feedback for the nurse to offer to
     the nursing assistant?
192. “I thought that was really great how you talked with him; he seemed really scared.”
193. “You provided excellent client education by sharing your stories.”
194. “I think it helps clients to see us as real people, and friends too, when you share your own
     stories.”
195. “It is probably best to avoid talking about your personal experience very much; keep
     communication client-centered.”
196. Which of the following clients is at greatest risk for obtaining adequate nutrition?
197. The client with diabetic peripheral neuropathy.
198. The client recovering from a femur fracture.
199. The client who is breast-feeding.
200. The client with burns to 45% of the body.
201. The use of a patient-controlled analgesia (PCA) pump is effective in which of the following
     situations?
202. The client achieves a therapeutic level of analgesia.
203. The client does not become dependent on opioids postoperatively.
204. There is decreased cost by decreasing use of intramuscular (IM) injections.4. The family can assist the client in managing the pain.

Answer 37

181. 2. The most therapeutic nursing response is client-centered and goal-directed, and provides
        an opportunity for the client to say more, for example, to express additional emotions, needs, or
        issues. Option 1 is nontherapeutic; it is a false reassurance. Option 3 is also nontherapeutic; the nurse
        offers a personal opinion of the client’s situation. Option 4 is also nontherapeutic; the nurse changes
        the subject, and appears to be uncomfortable discussing the client’s concerns.
        CN: Basic care and comfort; CL: Synthesize
182. 3. Responses to physiologic stress, such as hospitalization, surgery, or pain, are a result of
        catecholamine release, and specifically include increased heart rate and blood pressure, increased
        bronchiolar dilation, water retention and decreased urinary output, increased blood glucose, and
        increased mental acuity.
        CN: Basic care and comfort; CL: Apply
183. 4. Therapeutic communication is always purposeful, goal-directed, and client-centered. If
        self-disclosure is used by the nurse, it should be very focused and limited to just enough to support
        further communication with the client. It is not always helpful (or educational) and often
        inappropriate for the nurse to self-disclose while establishing a therapeutic relationship that is client
        centered.
        CN: Management of care; CL: Synthesize
184. 4. With illness or injury, there is a need to heal or recover. To accomplish this, the client
        must consistently consume adequate nutrition (and protein) to maintain a positive nitrogen balance,
        and to experience necessary growth and/or healing. The client with burns has the greatest nutritional
        needs, due to the extent of the injury. Clients with diabetic neuropathy can be encouraged to follow
        the diabetic diet plan and manage pharmacological therapy to prevent further neuropathy. The client
        with a fractured femur is not at risk for inadequate nutrition unless there is also a reason the client is
        not eating. The client who is breast-feeding needs additional calories, but if the client is eating a
        well-balanced diet with additional calories, the client is not at risk for obtaining inadequate nutrition.
        CN: Physiologic adaptation; CL: Analyze
185. 1. PCA is used to manage postoperative or persistent pain. Clients can control the
        administration of their own medication within predetermined safety limits; there is not a risk of
        dependence on opioids when using PCAs is not a concern. Family members who are not authorized
        agents are cautioned not to push the button for the client because this overrides some of the safety
        features of the PCA system. The nurse retains the responsibility for monitoring the client. Cost is not
        the primary factor in pain management.
        CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 38

186. A client is taking metformin (Glucophage). To prevent lactic acidosis when taking this drug,
     the nurse should instruct the client to report which of the following? Select all that apply.
187. Hyperventilation.
188. Muscle discomfort.
189. Dizziness.
190. Headache.
191. Increased hunger.
192. Tingling in the fingertips.
193. The nurse is serving on a task force to update the medical record. The task force should
     ensure that the revisions of the medical record will do which of the following? Select all that apply.
194. Aid in client care.
195. Serve as a legal document.
196. Have sufficient room for charting nurses’ notes.
197. Facilitate data collection for clinical research.
198. Guide performance improvement.
199. Be written so the client can understand what is written.
200. The nurse discovers that a hospitalized client with stage 4 esophageal cancer and major
     depression has a gun in the home. What is the best nurse intervention to help the client remain safe
     after discharge?
201. Give the client the number of a 24-hour crisis phone line for use, if needed.
202. Tell the primary care provider the client is too high risk for discharge at this time.
203. Have the client promise to use the gun only for home protection.
204. Talk with the primary care provider about requiring gun removal as a condition of discharge.
205. Which child most needs a referral for developmental language delay?
206. The 1-year-old who does not have three words.
207. The 18-month-old who only points to one body part.
208. The 2-year-old who only combines two words.
209. The 4-year-old who is difficult to understand.
210. A client is being admitted with a nursing home–acquired pneumonia. The unit has four empty
     beds in semiprivate rooms. The room that would be most suitable for this client is the one with a:
211. 60-year-old client admitted for investigation of transient ischemic attacks.
212. 45-year-old client with an abdominal hysterectomy.
213. 24-year-old client with non-Hodgkin’s lymphoma.
214. 55-year-old client with alcoholic cirrhosis

Answer 38

186. 1, 2, 3. There is a high risk of lactic acidosis when using metformin (Glucophage); 50% ofthe cases may be fatal. A Black Box Warning for metformin (Glucophage) is to instruct the client to
     stop the drug and immediately notify prescriber about unexplained hyperventilation, muscle pain,
     malaise, dizziness, light-headedness, unusual sleepiness, unexplained stomach pain, feelings of
     coldness, slow or irregular heart rate, or other nonspecific symptoms of early lactic acidosis.
     Headache, hunger, and tingling in the fingertips are not signs of lactic acidosis.
     CN: Pharmacological and parenteral therapies; CL: Synthesize
187. 1, 2, 4, 5. The Medical Record should contain sufficient information to identify the client,
     support the diagnosis, justify treatment, document the client’s course and results, and facilitate
     continuity of care among health care providers. The Medical Record will: facilitate client care; serve
     as a financial and legal record; aid in clinical research; support decision analysis; and guide
     professional and organizational performance improvement. The Medical Record should be compiled
     concurrently and be completed at the time of discharge. Many disciplines may be authorized to make
     entries in the Medical Record. All health care personnel will document care on this record. The
     medical record is not written for clients; if clients need information, the nurse or appropriate health
     care professional can explain the information to them.
     CN: Management of care; CL: Synthesize
188. 4. The only action that keeps the client safe is removal of the gun. If the primary care
        provider is considering discharge, the client is medically stable and will not be able to remain in the
        medical hospital any longer. The client’s lack of current suicidal ideation means he cannot be
        hospitalized for psychiatric reasons. While helpful, the crisis phone line number and the client’s
        promise do not ensure safety.
        CN: Safety and infection control; CL: Analyze
189. 4. More than 90% of children have speech that is totally intelligible at 4 years of age.
        Having one word at 1 year is the expectation. Having three words is a 15-month milestone. Pointing
        to one body part at 18 months and combining two words at 2 years would be a normal finding.
        CN: Health Promotion and maintenance; CL: Analyze
190. 1. The client with a possible transient ischemic attack is the only client who has not had
        surgery and is not immunocompromised. The client with a recent surgery and incision should not be
        exposed to a client with infection. Clients with cancer or alcoholic cirrhosis are very susceptible to
        infection, and it would not be safe to expose them to a client with a respiratory infection.
        CN: Management of care; CL: Synthesize