Theory 2

Question 1

You have a patient who has acute angina.
Which of the following medications would be appropriate for this condition?

Digoxin

Nitroglycerin

Atropine

Propranolol

Answer 1

Nitroglycerin

Nitroglycerin causes dilatation of the coronary arteries which allows more O2 to get to the heart muscle. Digoxin is not appropriate because it increases the strength and contractility of the heart muscle; it will not help the heart muscle to receive more O2. Atropine increases the heart rate by blocking vagal stimulation thus suppressing the heart rate; it will not help the heart muscle to receive more O2. propranolol is appropriate only for long-term management of stable angina because it acts as a beta-blocker to control vasoconstriction.

Question 2

A client who was trapped inside a car for hours after a head on collision is rushed to the emergency department with multiple injuries.
During the neurologic examination, the client responds to painful stimuli with decerebrate posturing.
This finding indicates damage to which part of the brain?

Diencephalon

Medulla

Midbrain

Cortex

Answer 2

MIDBRAIN

Decerebrate posturing, characterized by abnormal extension in response to painful stimuli, indicates damage to the midbrain. With damage to the diencephalon or cortex, abnormal flexion occurs when a painful stimulus is applied. Damage to the medulla results in flaccidity.

Question 3

A 20-year-old male tells the nurse, “I have this stabbing pain in my right tonsil.”
When completing the review of systems, the client’s description of the pain indicates which of the following?

Timing

Location

Intensity

Character

Answer 3

Character

During the review of systems, the character is the feature of the problem, feeling or sensation the client is having. For instance, the stabbing pain tells the character of the feeling or sensation the client is having.

Question 4

Lithium carbonate is ordered for a client with overactive behavior. The nurse should observe the client for which of these side effects?

Diarrhea

Glycosuria

Rash

Rhinitis

Answer 4

Diarrhea

Diarrhea is a common side effect of lithium carbonate and may indicate toxicity.

Rhinitis, glycosuria and rash are not side effects of lithium.

Question 5

A 44-year-old patient is in the hospital oncology unit for a round of chemotherapy.
The nurse in charge has the option of having an LPN help her.
Which of the following activities is appropriate to assign to the LPN?

Checking the patient’s blood pressure

Administering follow-up doses of the chemotherapy after the nurse administers the first dose

Flushing the medication lines

Educating the patient about the side effects of the chemotherapy

Answer 5

checking the patient’s blood pressure

Of all of the choices only the task of checking the patient’s blood pressure should be delegated to an LPN. The other tasks are ones that should be taken care of by the nurse in charge. They are not activities that are appropriate for an LPN.

Question 6

Part of your patient’s treatment for atrial flutter is the use of antidysrhythmic drugs.
Quinidine has been prescribed.
You recognize that this is which of the following types of antidysrhythmic drug?

Class I

Class II

Class III

vasopressor

Answer 6

Class I

Quinidine is a Class I antidysrhythmic drug. It is the type of drug often used to treat atrial fibrillation. It is also used to treat ventricular dysrhythmias.

Question 7

The nurse is assessing the labor pains of a 23 year old female.
Which of the following is an assessment element for labor pains that the nurse should evaluate?

transition and presentation

uterine inversion and uterine bleeding

nausea and vomiting

frequency, duration, and intensity

Answer 7

frequency, duration, and intensity

When assessing and documenting contractions that happens during labor, the nurse should evaluate the frequency, duration and intensity of the contractions. The frequency is the time that has elapsed between the start of a contraction and the start of the next contraction. Then, the duration is the length of time that has elapsed from the start of the contraction to the end of that contraction. Also, with intensity, the strength of the contraction is measured with a process known as acme.

Question 8

The nurse is caring for a busy woman with four children who reports not having slept through an entire night for more than a week because several of the children were ill. The nurse attributes which of the following behaviors to the woman’s lack of sleep?

sitting quietly in the waiting room reading a book

pacing in the waiting room

acting irritable with the receptionist

talking on the phone with the babysitter

Answer 8

acting irritable with the receptionist

Acting irritable with the receptionist. Common results of sleep deprivation include depression and emotional instability, which could explain why the client is irritable with the receptionist. Sitting quietly reading, pacing in the waiting room, or talking on the phone would not be associated with sleep deprivation.

Question 9

The nurse is caring for a client who has Bell’s Palsy.
Which of the following would be an appropriate nursing care for this client?

Teach the client injury prevention and proper nutrition.

Perform range of motion exercises.

Administer an analgesic for headaches.

Teach the client to identify muscle spasm.

Answer 9

Teach the client injury prevention and proper nutrition

Much of the care for clients with Bell’s Palsy is client self-care. However, nurses do have a role in the care of the client with Bell’s Palsy which includes teaching the client injury prevention, education on proper nutrition, and assisting the client to develop an understanding of Bell’s Palsy.

Question 10

The nurse is caring for a newborn with a large neural tube defect, and herniation of the meninges through the defect. The nurse documents this as what?

spina bifida

a meningocele

a meningomyelocele

gastroschisis

Answer 10

meningocele

Spina bifida is a general term reflecting a neural tube defect, but the more specific term, and the best response to the question for the defect described, is a meningocele. A meningomyelocele is herniation of the meninges and the spinal nerves through the defect. A gastroschisis is herniation of the abdominal contents through the umbilicus.

Question 11

Which client is at the greatest risk for vascular dementia?

A 45-year-old who smokes two packs of cigarettes a week.

A 30-year-old female who has a history of chronic pain and myeloma.

A 62-year-old male smoker with hypertension.

A 76 year old with irritable bowel syndrome and a history of a stroke

Answer 11

A 62-year-old male smoker with hypertension

62-year-old smoker with hypertension. Risk factors for vascular dementia are increased age, current smoker or history of smoking, atrial fibrillation, diabetes mellitus, hypertension or coronary artery disease. The 62 year old who smokes and has hypertension has a higher risk for vascular dementia because of his age, his smoking habit and condition, which is hypertension.

Question 12

A 50-year-old woman comes to the doctor’s office complaining of profuse menstrual bleeding.
After examination, the doctor determines that she has a uterine fibroid.
Which of the following would NOT be considered a treatment for this woman?

myomectomy

hysterectomy

Kegel exercises

hormonal regimen

Answer 12

Kegel exercises

Kegel exercises will not help with uterine fibroids. Treatment for this woman might be any of the other choices along with uterine artery embolization of the blood vessels supplying the fibroid tumor and cryosurgery.

Question 13

Mr. Clarkson visits the doctor’s office to receive a yearly physical.
The client is a 66-year-old African-American male who is 6 feet tall and weighs 220 lbs.
While completing the assessment, the nurse learns that the client smokes two packs of cigarettes per day and has a history of alcohol use.
Further, the client states he rides his bicycle every day to his job at a grocery store, where he works as a cashier.
What part of the client’s assessment does not present a risk factor for hypertension?

66-year-old African-American.

History of alcohol use.

Smokes two packs of cigarettes per day

Rides his bicycle every day to work.

Answer 13

Rides his bicycle every day to work

Because a sedentary lifestyle is a risk factor for hypertension, riding his bicycle every day helps to keep the client active, thus reducing the risk for hypertension. On the other hand, being an older African-American is a risk factor, as well as his history of cigarette and alcohol use.

Question 14

Elderly clients who fall are most at risk for which injuries?

wrist fractures

pelvic fractures

humerus fractures

cervical spine fractures

Answer 14

pelvic fractures

Elderly clients how fall often sustain pelvic and lower extremity fractures. These injuries are devastating because they can seriously alter an elderly client’s lifestyle and reduce function independence. Wrist fractures usually occur with falls on an outstretched hand or from a direct blow. They are commonly found in young men. Humerus fractures and cervical spine fractures are not age specific.

Question 15

When teaching a client with peripheral vascular disease about foot care, the nurse should include which instruction?

avoid using cornstarch on the feet

avoid using a nail clipper to cut toenails

avoid wearing canvas shoes

avoid wearing cotton socks

Answer 15

avoid wearing canvas shoes

The client should be instructed to avoid wearing canvas shoes. Canvas shoes cause the feet to perspire, which may, in turn, cause skin irritation and breakdown. Both cotton and cornstarch absorb perspiration. The client should be instructed to cut toenails straight across with nail clippers.

Question 16

Which of the following comments indicates that an 11-year-old child does NOT understand the concept of death?

“Death is irreversible and final.”

“Maybe I will see grandma again when she visits at Christmas.”

“My grandma died because she was sick and nothing could be done to make her better.”

“My grandma’s death has been hard to understand.”

Answer 16

Maybe I will see grandma again when she visits at Christmas”

Children this age do not yet understand that death is universal. They do not understand specific details of death.

Question 17

A postpartum client tells the nurse she is having trouble moving her bowels.
The nurse should recommend that she do which of the following to combat constipation?

eat more cheese

add high-fiber foods to her diet

maintain bed rest and avoid exercise

limit fluid intake to 32 oz daily

Answer 17

add high-fiber foods to her diet

If a postpartum client has trouble moving her bowels, the nurse should recommend that she eat more high-fiber foods (such as fresh fruits and vegetables, bran, and prunes) and drink plenty of fluids (1 to 2 qt daily to replace fluids lost during labor and delivery) to promote peristalsis. Activity and exercise also aid peristalsis. Cheese is not known to promote bowel movements.

Question 18

Which of the following is defined as “textbook” practices used by medical personnel to help prevent the spread of infectious microorganisms?

Surgical asepsis

Standard precautions

Susceptible host

Vehicle transmission

Answer 18

Standard precautions

Surgical asepsis is a way of doing away with disease-causing microorganisms before they infiltrate the body.

A susceptible host is an individual who lacks the strength of an immune system required to fight off the effects of invading microorganisms.

Vehicle transmission refers to microorganisms that are spread via items that are contaminated.

Question 19

In a client who is close to death, the nurse can assess which of the following manifestations?

decreased blood pressure

slow, shallow breathing

increased sensation

breathing through the nose

Answer 19

decreased blood pressure

The clinical manifestations that are associated with someone who is approaching death are decreased blood pressure, cyanosis of the extremities, cold skin unless the client has a fever, noisy breathing, blurred vision, relaxed muscles, trouble talking, difficulty swallowing, urinary incontinence and limited body movement. Also, the client will have diminished sensation and not increased sensation, which makes increased sensation an incorrect answer choice. Then, slow, shallow breathing and breathing through the nose are not the best answer choices as individuals who are approaching death have rapid, shallow breathing and mouth breathing associated with the dryness in the nasal passages.

Question 20

A nurse is caring for a patient who has just been given the news that she has gastric cancer.
Which of the following actions would be inappropriate for the nurse to take immediately after the news has been given?

Allow family members to gather with the client to absorb the implications of the diagnosis

Allow the patient to express her feelings

Educate the patient about what the diagnosis means to her now and in the future

Avoid a definite time frame in talking to the patient

Answer 20

Educate the client about what the diagnosis means to her now and in the future

After a patient has received a diagnosis of cancer, it is recommended that the patient be allowed to express her feelings, have private time with family members and that any definite time frame should be avoided. Educating the patient at this time would be not only inappropriate but more than likely ineffective.

Question 21

Which of the following procedures requires sedation?

pulse oximetry

bronchoscopy

chest x-ray

polysomnography

Answer 21

bronchoscopy

bronchoscopy. A bronchoscopy is performed under sedation as a bronchoscope, a flexible tube, is inserted into the client’s nose or mouth. The remaining answer choices are incorrect as they do not require sedation.

Question 22

Which of the following arteries primarily feeds the anterior wall of the heart?

Circumflex artery

Internal mammary artery

Left anterior descending artery

Right coronary artery

Answer 22

Left anterior descending artery

The left anterior descending artery is the primary source of blood for the anterior wall of the heart.

The circumflex artery supplies the lateral wall, the

internal mammary artery supplies the mammary,

right coronary artery supplies the inferior wall of the heart.

Question 23

You are assessing a child who has been diagnosed with Duchenne muscular dystrophy.
Which of the following would NOT be an indicator of this disease?

Gowers sign

vomiting (usually in the morning)

increasing clumsiness

waddling gait

Answer 23

vomiting (usually in the morning)

There are a number of assessments that you might make in a patient with Duchenne muscular dystrophy. Vomiting is not one of them. The child may have a waddling gait, increasing clumsiness and muscle weakness, Gower sign (difficulty rising to standing position), delayed cognitive development, elevated CPK and SGOT/AST among other signs.

Question 24

The nurse is about to administer the client’s morning digoxin, but decided it is appropriate to hold his dosage. Which of the following findings caused the nurse to make this decision?

Apical pulse of 51

Heartbeat is regular

Serum digoxin level of 1.3

Serum potassium of 4.8 mEq/L

Answer 24

Apical pulse of 51

A dose of digoxin should be withheld for an apical pulse below 60 beats per minute, unless otherwise directed by a physician. Dosing is acceptable for any regular heartbeat above 60 beats per minute. The dose would not be withheld for the digoxin and potassium blood serum levels, as these are within normal limits, with the therapeutic range of digoxin serum level being 0.9 to 2.0 mg/mL and normal serum potassium levels being 3.7 to 5.0 mEq/L.

Question 25

The physician prescribes lithium to a client with bipolar disorder.
The client is in the manic phase and has just begun medication.
Which of the following best identifies the number of times the client will need to have blood levels drawn for monitoring the therapeutic level of this medication?

1 time per week

2-3 times per week

Once a month

Once every 6 months

Answer 25

2-3 times per week

When the client first starts taking lithium, the client should have their blood draw between 2-3 times a week to monitor the therapeutic levels of the medication. Once the client reaches therapeutic range, the client should have blood drawn to monitor therapeutic levels of Lithium once a month.

Question 26

You are educating a group of student nurses about eating disorders.
In speaking about anorexia nervosa which of the following statement is correct?

15 – 20% of patients diagnosed with anorexia nervosa die from it.

The disorder is characterized by eating excessive amounts of food and then purging by vomiting.

This disorder is indicated by a weight loss of at least 10%.

Patients with this disorder tend also to be narcissistic.

Answer 26

15 – 20% of patients diagnosed with anorexia nervosa die from it.

Anorexia nervosa occurs primarily in adolescents and young adults. They have a distorted body image that keeps them from eating and from maintaining their ideal weight. There is a 15 – 20% patient fatality rate from this disorder.

Binging and purging are signs of bulimia nervosa not anorexia nervosa.

A weight loss of at least 15% of original body weight is an indication of the disorder.

Question 27

A nurse is reviewing a physician’s progress notes and reads where it is documented that the client has “insensible fluid loss of approximately 800 mL daily.”
The professional nurse has knowledge that this type of loss can occur through:

wound drainage

the gastrointestinal tract

the skin

urinary output

Answer 27

skin

Losses that are sensible are those of which the person is aware of, such as through wound drainage, gastrointestinal tract, and urination. Insensible losses occur daily through the skin and lungs and without the person’s awareness.

Question 28

The nurse understands a complication of Esophagectomy is which of the following?

Elevated temperature

Anastomosis leak

Increased sweating

Decreased pulse rate

Answer 28

Anastomosis leak

An esophagectomy is the resection of the esophagus that is affected by the cancer. Complications of this procedure are anastomosis leak, pneumonia, acute respiratory distress syndrome, gastric bleeding, dysrhythmias and sepsis.

Question 29

Your patient has had a uterine artery embolization to treat a fibroid tumor.
She is being discharged and you will be giving her instructions for home care.
Which of the following would NOT be a part of your instructions?

alter diet to eliminate fiber

call the health care provider if you run a fever of 101.1 degrees F or more

do not use tampons for at least four weeks

avoid straining during bowel movements

Answer 29

alter diet to eliminate fiber

This patient would be told to eat a normal diet including fiber and fluids. All of the other choices are appropriate instructions. Other instructions may include: take prescribed medications as ordered; call the physician if she has bleeding, pain, swelling, hematoma at the puncture site, urinary retention or abnormal vaginal drainage; and refrain from using douches or having vaginal intercourse for at least four weeks.

Question 30

The nurse has administered the varicella vaccine to a 5-year-old client who is entering kindergarten.
The nurse instructs the mother and the child to take a seat in the waiting room for 30 minutes after the varicella vaccine was injected.
Which of the following best explains why the client has to wait 30 minutes after receiving the vaccine?

To receive a follow up visit from the office manager.

To observe for potential adverse reactions.

To allow the nurse time to document the vaccine administration in the client’s medical record.

To provide client teaching on the drug administered.

Answer 30

To observe for potential adverse reactions

After the administration of a vaccine, the nurse should observe the client for approximately 30 minutes. This will allow sufficient time to monitor the client for potential adverse reactions that may occur.

Question 31

Which outcome indicates effective client teaching to prevent constipation?

The client verbalizes consumption of low fiber foods.

The client maintains a sedentary life style.

The client limits water intake to three glasses per day.

The client reports engaging in a regular exercise regimen.

Answer 31

The client reports engaging in a regular exercise regimen

A regular exercise regimen promotes peristalsis and contributes to regular bowel elimination patterns. A low fiber diet, a sedentary lifestyle, and limited water intake would predispose the client to constipation.

Question 32

Which of the following medications is most appropriate for a client with deep vein thrombosis who is breastfeeding?

Prevacid

Coumadin

Revlimid

Lovenox

Answer 32

Lovenox

Lovenox is safe to take during pregnancy because it is not passed to the baby through the breast milk.

Coumadin and Revlimid should not be taken while breastfeeding as these medications are passed through the breast milk to the infant and can harm the infant.

Prevacid is not the best answer choice as this medication is not used for the treatment of deep vein thrombosis but for conditions such as gastric reflux disease.

Question 33

All of the following are common adverse effects of chemotherapy except:

Sleeping

Anemia

Weakening of teeth

Vomiting

Answer 33

Weakening of teeth

Other adverse effects are alopecia, pain, reddened skin, and an increased susceptibility to infection. Weakening of the teeth is not indicated.

Question 34

Which of the following is the location where the small intestine starts?

ileocecal sphincter

pyloric sphincter

hepatic sphincter

duodenal sphincter

Answer 34

pyloric sphincter

The small intestines is a structure found inside of the body that soaks up the nutrients and vitamins from what we eat and digest. Also, the small intestines play a role in the elimination of waste products from the foods we eat. The small intestine starts at the pyloric sphincter and stops at the ileocecal junction that is located at the beginning of the large intestines.

Question 35

You are teaching a class of student nurses about dementia in older adults. All of the following may be included in your discussion EXCEPT:

The two most common types of dementia are infarct dementia and Alzheimer disease.

The incidence of dementia in the United States in people over the age of 65 is 1.2 million.

Nearly 90% of institutionalized older adults have some form of cognitive impairment.

Approximately 20% of those diagnosed with dementia actually have pseudodementia which is reversible.

Answer 35

Nearly 90% of institutionalized older adults have some form of cognitive impairment.

Question 36

Your patient has been prescribed morphine for pain relief. You know that you must monitor him for respiratory depression.
If your patient experiences narcotic-induced respiratory depression, which of the following drugs is the most likely to be prescribed to address this?

codeine

naloxone

butorphanol

dilaudid

Answer 36

naloxone

Narcotic analgesics are preferred for pain relief because they bind to the various opiate receptor sites in the CNS. However, they may also cause respiratory depression. For narcotic-induced respiratory depression, naloxone (Narcan) may be administered as prescribed by the patient’s physician.

Question 37

A nurse is to instruct a client on the medication levothyroxine (Synthroid).
Appropriate advise would be to tell this client to take the medication:

At bedtime with a snack

At lunchtime

On an empty stomach

With food

Answer 37

On an empty stomach.

An oral dose of levothyroxine (Synthroid) should be taken on an empty stomach to enhance absorption. Dosing should be done in the morning before breakfast.

Question 38

Which of the following is NOT an accurate statement regarding advocacy?

An advocate avoids letting personal values influence their advocacy for the client and supports the client’s decision

An advocate inhibits the client from making his or her own decision.

An advocate represents the client’s viewpoint to others.

An advocate speaks up for or acts on behalf of the client.

Answer 38

An advocate inhibits the client from making his or her own decision.

An advocate protects the client’s right to make his or her own decisions and upholds the principle of fidelity. The other answers (a, c, and d) are all accurate statements regarding advocacy.

Question 39

How does Vitamin C assist in wound healing?

It increases blood flow to the wound.

It is essential for the repair of tissue.

It aids in the absorption of calcium

It improves overall respiration.

Answer 39

It is essential for the repair of tissue

Vitamin C is essential for the repair of tissue. This is because it enhances the synthesis of protein.

Question 40

The nurse knows that in the past, inadequate community and occupational skills often limited clients who had severe mental illness.
Today, though, some teaching is best done in the client’s own setting.
What would be the priority of this community-based teaching?

Conflict management skills

Job training

ADL skills

Social skills training

Answer 40

Social skills training

Individuals with severe mental illness often benefit from social skills training, focusing primarily on the teaching of basic coping skills necessary to live as autonomously as possible in the community.

Job training will come after the client is able to interact well with others.

ADL skills are beneficial, but clients will be taught these skills in their own setting.

Conflict management skills will be taught after the social skills training.

Question 41

A 63 year old client’s wound has purulent exudate.
Which of the following would the nurse identify as the bacteria responsible for making pus?

hematoma bacteria

keloid bacteria

subdural bacteria

pyogenic bacteria

Answer 41

pyogenic bacteria

Purulent exudate is material that has leukocytes, dead tissue and bacteria. The bacterial that makes pus is known as pyogenic bacteria.

Question 42

An infant has active acquired immunity.
Which of the following statements best explains this type of immunity?

The infant has received immunizations

The mother transferred the immunity to the infant

This is a childhood disease that the infant is recovering from that conferred immunity

After exposure to hepatitis, the infant has received gamma globulin.

Answer 42

The infant has received immunizations

Active acquired immunity occurs when an infant, child or adult receives an immunization against a specific disease.

Natural active immunity occurs when the child, infant or adult has had the disease.

Natural passive immunity occurs with transfer of antibodies from the mother to the infant at birth or through breast milk.

Passive artificial immunity occurs with injection of gamma globulins; the response is immediate but short term.

Question 43

A client is diagnosed with rheumatoid arthritis.
What should the nurse teach the client in order to prevent further deteriorating with this disease?

Maintain a slightly erect posture when walking.

At night, sleep on the back using a soft mattress.

Sit in chairs with a low arm rest.

Wear shoes that have adequate support.

Answer 43

Wear shoes that have adequate support

Rheumatoid arthritis is a chronic disease. To help a client reduce the progression of this disorder and to move more comfortably, the nurse can teach the client strategies such as wearing shoes with proper support when walking. Other strategies include using a fully erect posture when walking, standing and sitting; sleep on a firm mattress without pillows; sitting in chairs that have high arm rests and high seats; getting adequate sleep; and avoid putting a lot of stress on the joints by using assistive aids.

Question 44

A client is having problems with voiding and emptying her bladder.
Which of the following helps with bladder emptying?

Canalith repositioning maneuver

Crede maneuver

Epley maneuver

Semont maneuver

Answer 44

Crede maneuver.

The Crede maneuver is pressing down onto a client’s abdomen manually while the client is holding her breath. The Crede maneuver helps with bladder emptying because the pressure that is applied to the abdomen causes a release of the urine.

Question 45

Which of the following nursing actions would be considered negligence if a pediatric RN performed them?

Instructing a 6-year-old asthmatic to blow on a pinwheel.

Playing kickball with a 12-year-old boy with juvenile arthritis.

Obtaining a Guthrie blood test on a 5-day-old infant.

Massaging lotion on the abdomen of a 4-year-old diagnosed with Wilm’s tumor.

Answer 45

massaging lotion on the abdomen of a 4 year old diagnosed with Wilm’s tumor

Negligence is the unintentional failure of a nurse to perform an act that a reasonable person would or would not perform in similar circumstances. Massaging lotion could manipulate the mass and may cause dissemination of cancer cells. Teaching use of the pinwheel (answer a) provides an exercise that will extend expiratory time and increase expiratory pressure. Answer b shows an excellent moving and stretching exercise for the client. The Guthrie test should be done no later than 7 days post delivery and is appropriate.

Question 46

A young child is brought into the emergency room. Her parents have told the medical personnel that she has been vomiting a lot and has had severe diarrhea for two days.

The child was suffering hypovolemic shock and was put on mechanical ventilation (which has been effective) to treat oxygenation problems. Which of the following should the nurse consider a priority at this time?

getting a complete medical history

explaining what is happening to the child and the parents

risk for infection

reassessing the child’s vital signs

Answer 46

risk for infection

None of the choices are unimportant. But the priority (as the question asks) is assessing the risk for infection. The child has had inadequate tissue perfusion already so the priority is to prevent infection that would further complicate the child’s condition.

Question 47

A 24 year old pregnant client presents for her initial antepartum visit.
She has a 1-year-old son born at 39 weeks and a 4-year-old son born at 37 weeks.
The client had a spontaneous abortion 7 years ago at 8 weeks.
By using the GTPAL format, the nurse can determine the client’s pregnancy history as:

G3 T2 A1 L2

G4 T2 A0 L2

G4 T2 A1 L2

G3 T2 A0 L2

Answer 47

G4 T2 A1 L2

Question 48

To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), the nurse should palpate which pulse site?

Radial

Apical

Carotid

Brachial

Answer 48

Carotid

During CPR, the carotid artery pulse is the most accessible and may persist when the peripheral pulses no longer are palpable because of decreases in cardiac output and peripheral perfusion. Chest compressions performed during CPR preclude accurate assessment of the apical pulse.

Question 49

An infant received the wrong medication dosage.
What is the charge nurse’s role in following up on the incident?

suggest that the nurse who administered the medication speak to the hospital lawyer

make sure the nurse has liability insurance

objectively assess the circumstances surrounding the error

send the nurse to a medication administration course

Answer 49

objectively assess the circumstances surrounding the error.

The charge nurse should objectively assess the circumstances surrounding the medication administration error. After completing her assessment, the charge nurse should develop a plan with the nurse to prevent future errors. The charge nurse does not need to make sure the nurse has liability insurance or suggest that the nurse speak with the hospital lawyer until the circumstances surrounding the error are investigated. Nothing suggests that the nurse needs to attend a medication administration course.

Question 50

What does psychosocial mean?

Inability to establish strong relationships.

Involving both psychological and social aspects.

An introvert

An extrovert.

Answer 50

Involving both psychological and social aspects

“Psychosocial is the study of both mental and social health. It studies mental and emotional disorders or maladaptive behaviors, or mental phenomena such as dreams, hypnosis, and altered states or levels of consciousness”.

Question 51

A client is admitted to the psychiatric hospital with a diagnosis of catatonic schizophrenia.
During the physical examination, the client’s arm remains outstretched after the nurse obtains the pulse and blood pressure, and the nurse must reposition the arm.
This client is exhibiting what?

Suggestibility

Negativity

Waxy flexibility

Retardation

Answer 51

Waxy flexibility

Waxy flexibility, the ability to assume and maintain awkward or uncomfortable positions for long periods is characteristic of catatonic schizophrenia. Clients commonly remain in these awkward positions until someone repositions them.

Clients with dependency problems may demonstrate suggestibility a response pattern in which one easily agrees to the ideas and suggestions of others rather than making independent judgments.

Negativity and retardation also occur in catatonic clients.

Question 52

A 12-year-old boy comes into your office to be assessed for asthma. If this child does indeed suffer from asthma which of the following assessments would you not expect to make?

expiratory wheezing

signs of altered blood gases

tight cough

sub-normal body temperature

Answer 52

sub-normal body temperature

A person with asthma will likely have expiratory wheezing, a tight cough and signs of altered blood gases. High or low body temperatures have nothing to do with a diagnosis of asthma.

Question 53

Many times before administering medication, a nurse must convert the dosage amount for the appropriate weight. Which of the following metric conversions is correct for 1,000 micrograms?

1 milligram

1 gram

1 kilogram

1 pound

Answer 53

1 milligram

One milligram is equal to 1,000 micrograms. One gram is the correct weight conversion for 1,000 milligrams. One kilogram is the weight conversion for 1,000 grams.

Question 54

Patients are coming into the emergency room as a result of an apartment house fire.
You are examining a patient who is in distress but has no visible burn marks.
You suspect that she is suffering from inhalation burns. Which of the following signs would NOT be associated with inhalation burns?

singed nasal hairs

conjunctivitis

hoarseness

clear sputum

Answer 54

clear sputum

The signs of inhalation burn would not include clear sputum; the sputum would appear sooty or bloody. The other signs of inhalation burn would include: singed nasal hairs, circumoral burns, conjunctivitis, hoarseness, asymmetry of chest movements with respirations, and wheezing.

Question 55

A nurse is teaching a class of students about respiratory failure.
She describes a patient who was admitted to the hospital with hypoxemia that persisted even when 100% oxygen was given, decreased pulmonary compliance, dyspnea and non-cardiac-associated bilateral pulmonary edema. Radiography showed dense pulmonary infiltrates.
This patient had no previous pulmonary problems.
Which of the following is the most likely diagnosis for this patient?

pneumonia

COPD

ARDS

emphysema

Answer 55

ARDS

All of the information about this patient points to an unexpected, catastrophic pulmonary complication – ARDS (acute respiratory distress syndrome). The mortality rate for ARDS is 50%. ARDS patients often require intubation and mechanical ventilation with positive end-expiratory pressure (PEEP).

Question 56

It is your job at the health department you work at to provide instructions on self-care and prevention of chlamydial infection to clients.
The nurse would determine that further instructional teaching is necessary if the client makes which statement?

“I should reduce the chance of reinfection by limiting the number of sexual partners I have.”

“I should return to the health department for a follow-up culture in one week.”

„I should use the doxycycline prophylactically to prevent chlamydia.”

“I should use condoms to prevent disease transmission.”

Answer 56

“I should use the doxycycline prophylactically to prevent chlamydia.”

Antibiotics are not taken prophylactically for infections, they are taken to treat infections. Antiviral medications (such as zovirax and famvir) are taken prophylactically to prevent herpes breakouts in the client who has the disease. The risk of reinfection can be reduced by limiting the number of sex partners and by the use of condoms. Follow-up cultures are necessary for the client and should be obtained 4 to 7 days after treatment is initiated.

Question 57

The nurse writes the following note in the client’s chart: “The physician is incompetent because he ordered the wrong drug dosage.” This statement may lead to a charge of what?

Assault

Slander

Battery

Libel

Answer 57

Libel

Libel refers to written communication that injures a person’s reputation.

Assault is an unjustifiable attempt or threat to touch or injure another person.

Slander is oral communication that injures a person’s reputation.

Battery refers to touching another person unlawfully or carrying out threatened physical harm.

Question 58

A local school has had a small outbreak of rubeola (measles) and the school nurse is conducting a teaching session for the mothers of the school children. Which statement made by a mother indicates a need for further instructions regarding this disease?

“The rash usually begins on the face and spreads down toward the feet.”

“Respiratory symptoms such as profuse runny nose, cough, and fever occur before the development of a rash.”

“The communicable period ranges from 10 days before the onset of symptoms to 15 days after the rash appears.”

“Small blue-white spots with a red base may appear in the mouth.”

Answer 58

The communicable period ranges from 10 days before the onset of symptoms to 15 days after the rash appears.”

This period for rubeola ranges from 4 days before to 5 days after the rash appears, mainly during the prodromal stage. The other answers (a, b, and d) are accurate statements concerning rubeola.

Question 59

A client with a myocardial infarction (MI) develops pulmonary crackles and dyspnea. A chest X-ray shows evidence of pulmonary edema.
The specific type of MI the client had is MOST LIKELY what?

Anterior

Posterior

Lateral

Inferior

Answer 59

Anterior

An anterior MI causes left ventricular dysfunction and can lead to manifestations of heart failure, which include pulmonary crackles and dyspnea. The other types of MI are not usually associated with heart failure.

Question 60

A client is diagnosed with Tay Sach’s disease. The nurse understands what about this condition?

Hereditary

An autoimmune disorder

Contagious

A cognitive disorder

Answer 60

Hereditary

Tay Sach’s disease, a rare disorder, causes the inability to create enzymes that are vital for the metabolism of fat. This disease occurs in the Jewish descent. Further, the remaining answer choices are not considered genetic disorders.

Question 61

The best place to assess for dehydration by checking skin turgor in older adults is which of the following?

Back of the wrist

At the base of the neck

Anterior chest, below the clavicle

On the interior of the knee or elbow

Answer 61

Anterior chest, below the clavicle

This is the commonly accepted place to check for skin turgor in older adults. The neck and extremities are not reliable test points to check for dehydration.

Question 62

Which of the following is the second step to utilizing any fire extinguisher?

“Pull the pin.”

„Aim at the base of the fire.”

“Squeeze the handles.”

“Sweep the fire from side to side.”

Answer 62

Aim at the base of the fire

1. Pull the pin
2. Aim at the base of the fire
3. Squeeze the handles
4. Sweep the fire from side to side

Question 63

Paralytic ileus is a possible complication of which of the following body systems?

Cardiovascular

Gentourinary

Respiratory

Gastrointestinal

Answer 63

Gastrointestinal

Question 64

Which of the following defense mechanisms is defined as exhibiting positive behavior to make up for negative behavior?

Reaction formation

Repression

Resistance

Sublimation

Answer 64

Sublimation

Reaction formation is when an individual acts in manner opposite of the way he or she feels.

Repression is when an individual removes negative thoughts from the conscious mind.

Resistance is when an individual is opposed to recalling anxiety-causing situations.

Question 65

When a woman who has been raped is admitted to the emergency room, which nursing intervention has priority?

Explain exactly what will need to be done to preserve legal evidence.

Assure the woman that everything will be all right.

Create a safe, secure atmosphere for her.

Contact family members.

Answer 65

Create a safe, secure atmosphere for her

create a safe, secure atmosphere for her. The first priority in caring for a survivor of a sexual assault is to create a safe, secure atmosphere. The other interventions are not the highest priority.

Question 66

A client is scheduled to undergo vascular surgery.
Which of the following interventions is most important for the nurse to implement in the postoperative period?

Conduct circulation checks proximally to the graft every hour for 48 hours.

Conduct circulation checks distal to the graft every hour for 24 hours.

Conduct circulation checks proximally to the graft every 15 minutes.

Conduct circulation checks distal to the graft every 15 minutes

Answer 66

Conduct circulation checks distal to the graft every 15 minutes

During the postoperative period following vascular surgery, the nurse will assess the client’s circulation and the patency of the graft. The nurse does this through circulation checks that are distal to the graft every 15 minutes, afterwards hourly for 24 hours.

Question 67

When caring for a child with spina bifida, the nurse should?

position the child in the supine position

ausculate the lungs for ticking breath sounds

avoid latex gloves

monitor the client for shock

Answer 67

avoid latex gloves

Avoid latex gloves. Children with spina bifida can develop an allergic reaction to latex. Therefore, the nurse should avoid latex gloves when caring for a child with spina bifida. Spina bifida is a disorder that affects the spine and is congenital, which means it exists at birth.

Question 68

In order to prevent infections, nurses are required to wash their hands continuously. Which of the following methods is the most effective for the prevention of infections?

washing hands before and after client procedures

washing hands before and after entering a patient’s room

washing hands between visits to different patients

washing hands after removing gloves

Answer 68

washing hands before and after entering a patient’s room

All of the choices are appropriate; however the most effective method is to wash hands before and after entering a patient’s room. Washing hands after patient contact is good but not enough. Washing hands between patients is also appropriate but not enough.

Question 69

A teenage girl from a local high school has been in a serious automobile accident.
The teachers at the school have asked if they can donate blood for her.
Her blood type is B negative.
You tell them that PRBCs for this girl could be used from anyone with a blood type of

type B negative

type O positive

type AB negative

type AB positive

Answer 69

type B negative

The ABO system identifies the type of antigen present on the person’s erythrocyte membrane. This teenager has B antigen on the erythrocyte and does not have an Rh antigen on the cell. She can receive the same blood type to prevent a significant PRBC reaction or O negative.

Question 70

A nurse is caring for an elderly client with dementia.
The client asks the nurse the same question repeatedly because she can not remember if she had asked the nurse the question previously.
The nurse becomes angry with the client, tells the client “shut up already. You have asked me that question. I am tired of telling you the same answer over and over.”
The client asks the nurse the same question 10 minutes later.
The nurse slaps the client and says, “maybe this will help you remember the answer.” The nurse could be charge with a…

misdemeanor

malpractice

inquest

euthanasia

Answer 70

misdemeanor

A misdemeanor is a type of crime. A crime is an act that is performed that violates the law. A crime can either be a misdemeanor or a felony. A misdemeanor is a less serious crime because it does not involve murder. However, the nurse can be charged with a misdemeanor for physically harming the client by slapping her. Most states have laws that addressing physical violence.

Question 71

The nurse is teaching a group of women to perform a breast self-examination.
The nurse should explain that the purpose of performing the examination is to discover what?

Cancerous lumps.

Changes from previous self-examinations.

Areas of thickness or fullness.

Fibrocystic masses.

Answer 71

Changes from previous self-examinations

Women are instructed to examine themselves to discover changes that have occurred in the breast. Only a physician can diagnose lumps that are cancerous, areas of thickness or fullness that signal the presence of a malignancy, or masses that are fibrocystic as opposed to malignant.

Question 72

Which of the following is the nurse’s role in group therapy?

require that each member contribute to group therapy

select clients suitable for group therapy

conduct group therapy sessions

counsel each group member in individual psychotherapy sessions

Answer 72

select client’s suitable for group therapy

The nurse’s role in group therapy is varied. The nurse can select the clients who would be suitable for group therapy. Also, the nurse orients the clients to the processes for group therapy along with ensuring the psychological and physical safety of each member. The nurse does not conduct group therapy sessions or counsel each group member in individual sessions, as this is the role of a licensed therapist. Further, the nurse should encourage group members to participate and not require them to participate in group discussions.

Question 73

When assessing the chest of a 4-month-old infant, the nurse identifies which ratio of the anteroposterior-to-lateral diameter as normal?

1:1

1:3

2:1

3:1

Answer 73

1:1

In an infant, the anteroposterior diameter normally equals the lateral diameter. In a toddler, the anteroposterior diameter should be less than the lateral diameter.

Question 74

A severely depressed patient rarely moves from the sofa. To prevent complications associated with psychomotor retardation, what action should be taken?

The bladder should be emptied on a schedule

The sofa should be moved so it is not as comfortable for the patient

The client should watch television to stabilize his mood

The client should continue the use of prescribed anti-depressants

Answer 74

The bladder should be emptied on a schedule

Complications with psychomotor retardation include bladder infections. When the bladder is emptied regularly, this will assist in the prevention of urinary infections.

Question 75

Which of the following should the nurse include in the client teaching plan for the medication Gemfibrozil (Lopid)?

teach the client that this medication may cause a flushing feeling in the face

report muscle weakness to the physician as muscle weakness is associated with taking this medication

expect to experience gastric distress while taking this medication

teach the client that it will take up to 2 months before effects of the medication is achieved.

Answer 75

teach the client that it will take up to 2 months before effects of the medication is achieved

Gemfibrozil (Lopid) is an fibric acid derivative that is prescribed to help lower triglycerides, which are fatty molecules used in the body for energy, in clients who have high levels of triglycerides. With these fibric acid derivatives, it can take up to 2 months for a client to experience therapeutic effects.

Question 76

A nurse places a client in full leather restraints. How often must the nurse check the client’s circulation?

once per hour

every 10 to 15 minutes

once per shift

every 2 hours

Answer 76

every 10 to 15 minutes

Every 10 to 15 minutes. Circulatory as well as skin and nerve damage can occur within 15 minutes. Checking every hour, 2 hours, or 8 hours is not often enough and could result in permanent damage to the client’s extremities. Restraints should be removed every 2 hours, and range-of-motion exercises should be performed.

Question 77

You are assisting with a blood transfusion for a patient who has had a great deal of bleeding caused by deficiency in clotting factors.
Which of the following blood products are you most likely going to be administering?

Fresh-frozen plasma (FFP)

Albumin

Frozen red blood cells (RBC)

Platelets

Answer 77

Fresh-frozen plasma (FFP)

Fresh-frozen plasma in which the liquid portion of whole blood is separated from cells and frozen is the most likely blood product to be used for bleeding caused by a deficiency in clotting factors. It is interesting to note, however, that the use of FFP is being replaced by albumin plasma expanders.

Question 78

Which of the following is a characteristic of a manic state?

Playing solitaire for three hours.

Watching television or movies for ten hours.

Non-stop pacing for three days.

Taking ten showers in a period of five hours.

Answer 78

Non-stop pacing for three days

Quiet activities would be related to a depressed state. Manic activities refer to an excited or hyper active state. Option D would be more characteristic of an obsessive-compulsive disorder.

Question 79

Many times before administering medication, a nurse must convert the dosage amount for the appropriate volume. Which of the following metric conversions is correct for 1,000 milliliters?

1 grain

1 liter

2.2 pounds

8 ounces

Answer 79

1 liter

Question 80

The nurse is caring for a client who is on naloxone (Narcan). Which of the following should the nurse monitor when caring for the client?

Bleeding

Urinary frequency

Elevated blood pressure

Muscle spasms

Answer 80

Bleeding

Naloxone (Narcan) is given to counteract the withdrawal symptoms of opioids. This medication can increase anticoagulant laboratory tests results, such as prothrombin time tests. A prothrombin time test identifies abnormal bleeding or blood clotting. When caring for clients on naloxone, the nurse should monitor the client for bleeding. Elevated blood pressure, muscle spasms and urinary frequency are not associated with this medication.

Question 81

Which finding is a risk factor for testicular cancer?

Age

Cryptorchidism

A weight gain of more than 10 pounds

A history of cocaine abuse

Answer 81

Cryptorchidism

Cryptorchidism, or an undescended testicle, is a risk factor for testicular cancer. The other factors have no bearing in this case.

Question 82

The nurse is caring for a client who had a stroke.
Which nursing intervention promotes urinary continence?

Encouraging intake of at least 2 L of fluid daily.

Giving the client a glass of soda before bedtime

Taking the client to the bathroom twice per day

Consulting with a dietitian.

Answer 82

Encouraging intake of at least 2 L of fluid daily

By encouraging a daily fluid intake of at least 2 L, the nurse helps fill the client’s bladder, thereby promoting bladder retraining by stimulating the urge to void. The nurse should not give the client soda before bedtime; soda acts as a diuretic and may make the client incontinent. The nurse should take the client to the bathroom or offer the bedpan at least every 2 hours throughout the day; twice per day is insufficient. Consultation with a dietitian won’t address the problem of urinary incontinence.

Question 83

You have observed a nurse doing an endotracheal suctioning.
You see that she has prevented hypoxia during the suctioning by doing which of the following?

delivering 100% O2 before and after the suctioning

delivering 100% O2 before the suctioning and 80% O2 after the suctioning

delivering 100% O2 only before the suctioning

delivering 100% O2 only after the suctioning

Answer 83

delivering 100% O2 before and after the suctioning

When a nurse is doing an endotracheal suctioning he or she must take caution to prevent hypoxia. Hypoxia is the deficiency of oxygen for the body. The way to do this is to deliver 100% O2 both before and after the suctioning.

Question 84

A client with quadriplegia is in spinal shock. What should the nurse expect?

Absence of reflexes along with flaccid extremities.

Positive Babinski’s reflex along with spastic extremities.

Hyperreflexia along with spastic extremities.

Spasticity of all four extremities.

Answer 84

Absence of reflexes along with flaccid extremities

During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate positive Babinski’s reflex, hyperreflexia, and spasticity of all four extremities.

Question 85

A 30-month-old child is diagnosed with intussusception and scheduled for a barium enema.
How can the nurse best demonstrate the procedure to the patient?

Show the child the actual barium enema equipment to be used.

Explain the procedure to the child in words they understand.

Blow through a straw and encourage the child to mimic the action.

Ask the child to imagine a water fountain spraying the sidewalk.

Answer 85

Blow through a straw and encourage the child to mimic the action.

The child cannot conceptualize either B or D. Showing the child the equipment will not help either. However, the child will be able to relate the blowing of the straw to the enema.

Question 86

It is very important that water and air quality are monitored for safe consumption.
This is an example of which of the following?

Information dissemination

Lifestyle and behavior change

Health risk appraisal and wellness assessment

Environmental control program

Answer 86

Environmental control program

Many assume that the air and water quality just happens. This is far from true. Controlling and making the necessary adjustments to air and water quality affects how we essentially live and breathe.

Question 87

In a client who has burns on the legs, which nursing intervention helps prevent contractures?

Applying knee splints.

Hyperextending the client’s palms.

Elevating the foot of the bed.

Performing shoulder range of motion exercises

Answer 87

Applying knee splints

Applying knee splints prevents leg contractures by holding the joints in a position of function.

Elevating the foot of the bed cannot prevent contractures because this action does not hold the joints in a position of function.

Hyperextending a body part for an extended time is inappropriate because it can cause contractures.

Performing shoulder range of motion exercises can prevent contractures in the shoulders, but not in the legs.

Question 88

You are administering a blood transfusion to a 55-year-old patient with a bleeding ulcer.
When you check on this patient you find that he is experiencing abdominal pain, chills and diarrhea?
Which of the following actions should be your priority?

Notify the HCP about what the patient is experiencing.

Help the patient to the bathroom for relief.

Increase the patient’s pain medication.

Discontinue the transfusion.

Answer 88

Discontinue the transfusion

Knowing that chills, abdominal pain and diarrhea are signs of a reaction to the transfusion, your priority should be to stop the transfusion. Signs and symptoms of a transfusion reaction also include hives, pruritus, flushing and back pain.

Question 89

You are caring for a postpartum patient.
You have assessed that she has a slight fever, a positive Homan sign, pain in her right calf with swelling below this pain.
Which of the following puerperal infections would you diagnose?

perineal infection

thrombophlebitis

parametritus

peritonitis

Answer 89

thrombophlebitis

Everything that the nurse has assessed points to thrombophlebitis. All of the other infections pertain to pelvic or uterine infections.

Question 90

A woman is being treated for severe depression. During the acute phase of her illness, which of these measures should have priority in the client’s care?

Keeping her in seclusion

Repeating unit routines

Providing her with physical care

Encouraging social interaction with other clients

Answer 90

providing her with physical care

During the acute phase of depression, the client is not meeting her physical needs. Therefore, the nurse must institute strategies to help the client meet physical needs such as hygiene, proper eating habits and taking medication as prescribed.

Question 91

Which of the following factors affects blood pressure by lowering it?

stress

severe pain

exercise

fatigue

Answer 91

severe pain

Pain that is very severe can lower blood pressure because pain causes the dilation of the arterioles. Other factors that can play a role with changes in blood pressure are physical activity, age, stress, gender, race, medications, obesity and certain conditions. For example, stress and exercise can cause the blood pressure to rise.

Question 92

You are preparing to care for a child with a diagnosis of intussusception.
Upon review of the child’s record, you expect to note which symptom of this disorder documented?

Ribbon-like stools.

Profuse projectile vomiting.

Bright red blood and mucus in the stools.

Watery diarrhea.

Answer 92

Bright red blood and mucus in the stools

Intussusception is a telescoping of one portion of the bowel into another. This condition results in an obstruction to the passage of intestinal contents. A child with this condition will have severe abdominal pain. Ribbon-like stools and watery diarrhea are not manifestations of this condition and vomiting may be present, but not projectile type.

Question 93

You are caring for a newborn with hyperbilirubinemia. His bilirubin levels are rising 5 mg/day, he is jaundiced, has dark urine and dark stools.
You recognize that it is likely that the newborn may have had any of the following risk factors except

gestation of over 40 weeks

Rh incompatibility

sepsis

perinatal asphyxia

Answer 93

gestation of over 40 weeks

Prematurity is a risk factor for the newborn, not gestation of over 40 weeks. Other risk factors are Rh incompatibility, sepsis, perinatal asphyxia and ABO incompatibility.

Question 94

A nurse on the first shift, Janice, fails to document in the client’s medication administration record administering the client 50 mg of hydrocodone for pain.
The second shift nurse, Paula, sees the doctor’s order the administration of 50 mg of hydrocodone every four hours for pain but she does not see where the first shift nurse, Janice, gave the client the medication.
Also, Paula notices that Janice signed out the medication to administer to the client but it is not documented in the client’s chart. The nurse should suspect…

possible impairment

assault

battery

invasion of privacy

Answer 94

possible impairment

Nurses who are impaired are unable to perform their jobs effectively. Impairment is due to drug or alcohol abuse, or a mental illness. In the case of the second shift nurse, Paula, she should suspect impairment of the first shift nurse, Janice as the nurse did not document giving the client the medication but the medication was signed out to give to the client. Additional warning signs of an impaired nurse are mood changes, frequent bathroom breaks or absences from the unit, signing out more than what is ordered for controlled drugs or not documenting the administration of a controlled drug to a client.

Question 95

In a client with acute hepatitis, the nurse assesses the client’s aspartate aminotransferase (AST) range on the laboratory test at 520 units.
What should the nurse understand about this test value?

The AST is normal.

The AST is decreased.

The AST is elevated.

The AST is stable.

Answer 95

The AST is elevated

In clients with acute hepatitis, liver disease and myocardial infarction, the aspartate aminotransferase (AST) is elevated. The normal range for this enzyme in the blood is 10 to 26 units per liter. In clients with acute hepatitis, the enzyme may be elevated four times above the normal range.

Question 96

A client with chronic obstructive pulmonary disease (COPD) is admitted to an acute care facility because of an acute respiratory infection.
When assessing the client’s respiratory rate, the nurse notes an abnormal inspiratory-expiratory ratio of 1:4.
What is the normal I:E ratio?

2:2

1:2

1:1

2:1

Answer 96

1:2

The normal I:E ratio is 1:2, meaning that expiration takes twice as long as inspiration. Because inspiration is shorter than expiration, the other choices reflect abnormal physiology.

Question 97

Which of the following tasks can a registered nurse delegate to a nursing assistant in an acute mental health setting?

Assessing mental status on admission.

Administering medication.

Checking for sharp objects.

Discussing the treatment plan.

Answer 97

Checking for sharp objects

A nursing assistant may be assigned to search a client’s luggage or room for potentially harmful objects, such as glass or sharp metal. A mental status assessment should be conducted by the nurse on admission. Administering medication cannot be delegated to an unlicensed person. A nurse or physician must discuss the treatment plan with the client.

Question 98

In order to determine a patient’s coping mechanisms, support system, and other mental health factors to maintain a healthy lifestyle, what type of assessment should be conducted?

Biological assessment.

Psychological assessment.

Social assessment.

Physical assessment

Answer 98

Psychological assessment

A psychological assessment should be used to determine a patient’s coping style, support system, and other mental health issues that may affect their health. This information is important during the treatment and healing process in order to provide the best patient-centered care.

Question 99

The RN will be administering intravenous (IV) solutions often during her career.
Which of the following is NOT correct concerning IV solutions administration.

Use sterile technique when inserting an IV line and when changing the dressing over the IV site.

Change the venipuncture site every 48 to 72 hours depending on the agency policy.

IV tubing should be changed every two weeks.

Do not let an IV bag or bottle of solution hang for more than 24 hours because of the potential for bacterial contamination.

Answer 99

IV tubing should be change every two weeks

IV tubing is changed every 72 hours, depending on agency policy. The other answers (a, b, and d) are correct. Other important issues with IV administration include check the IV solution against the physician’s orders for the type, amount, percentage of solution, and rate of flow. Assess the health status of the client. Wash hands before handling IV solutions or supplies. Prime the IV tubing to remove air from the system. Change the venipuncture site every 48 to 72 hours.

Question 100

A client, 38 weeks pregnant, arrives in the emergency department complaining of contractions.
To help confirm that she is in true labor, the nurse should assess for which of the following?

Irregular contractions.

Increased fetal movement.

Changes in cervical effacement and dilation after 1 to 2 hours.

Contractions that feel like pressure in the abdomen and groin.

Answer 100

Changes in cervical effacement and dilation after 1 to 2 hours

True labor is characterized by progressive cervical effacement and dilation after 1 to 2 hours, regular contractions, discomfort that moves from the back to the front of the abdomen and, possibly bloody show. False labor causes irregular contractions that are felt primarily in the abdomen and groin and commonly decrease with walking, increased fetal movement, and lack of change in cervical effacement or dilation even after 1 or 2 hours.