NURSING MISC Module 10 Questions and Answers,100% CORRECT

NURSING MISC Module 10 Questions and Answers 1. 1.ID: 18630147534 A nurse is assigned to care four clients on the medical-surgical unit. Which client should the nurse see first on the shift assessment? A. A client ...

NURSING MISC Module 10 Questions and Answers 1. 1.ID: 18630147534 A nurse is assigned to care four clients on the medical-surgical unit. Which client should the nurse see first on the shift assessment? A. A client admitted with pneumonia with a fever of 100°F and some diaphoresis B. A client with congestive heart failure with clear lung sounds on the previous shift C. A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema Correct Rationale: The client who should be seen first is the one with SOB and a history of pulmonary edema. In light of such a history, SOB could indicate that fluid- volume overload has once again developed. The client with a fever and who is diaphoretic is at risk for insufficient fluid volume as a result of loss of fluid through the skin, but this client is not the priority. Test-Taking Strategy: Use the process of elimination and focus on the subject of the question, the client who should be seen first. Recall the rule of assessment of the ABCs—airway, breathing, and circulation—which means that the client experiencing shortness of breath should take precedence over the other clients on the unit. This client’s condition could progress to respiratory arrest if the client were not assessed immediately on the basis of the signs and symptoms. Read each option and think about the client in most critical condition and review the disorders to determine which clients have the most critical needs. If you had difficulty with this question, review the various disease processes presented in this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Delegating/Prioritizing D. A client undergoing long-term corticosteroid therapy with mild bruising on the anterior surfaces of the arms Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 18630146839 A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the hospital with a diagnosis of dehydration. For which clinical manifestations that correlate with this fluid imbalance would the nurse assess the client? Select all that apply. A. Decreased pulse B. Decreased urine output Correct C. Increased blood pressure D. Increased respiratory rate Correct E. Decreased respiratory depth Rationale: A client with dehydration has an increased depth and rate of respirations. The diminished fluid volume is perceived by the body as a decreased oxygen level (hypoxia), and increased respiration is an attempt to maintain oxygen delivery. Other assessment findings in insufficient fluid volume are decreased urine volume, increased pulse, weight loss, poor skin turgor, dry mucous membranes, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness. Increased blood pressure, decreased pulse, and increased urine output occur with fluid-volume overload. Test-Taking Strategy: Use the process of elimination and focus on the subject, dehydration (deficient fluid volume). Think about the pathophysiology of deficient fluid volume. Remember that the body will increase the respiratory rate in an attempt to maintain the oxygen level. If you had difficulty with this question, review the signs of insufficient fluid volume. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fluid and Electrolytes Awarded 2.0 points out of 2.0 possible points. 3. 3.ID: 18630147505 A nurse is reviewing the medical records of the clients for the assigned 7 a.m.–7 p.m. shift. Which client will the nurse monitor most closely for excessive fluid volume? A. A 48-year-old client receiving diuretics to treat hypertension B. A 35-year old client who is vomiting undigested food after eating C. An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hrCorrect Rationale: The older adult client receiving IV therapy at 100 mL/hr is at the greatest risk for excessive fluid volume because of the diminished cardiovascular and renal function that occur with aging. Other causes of excessive fluid volume include renal failure, heart failure, liver disorders, excessive use of hypotonic IV fluids to replace isotonic losses, excessive irrigation of body fluids, and excessive ingestion of table salt. A client who is receiving diuretics, vomiting, or has a nasogastric tube attached to suction is at risk for deficient fluid volume. Test-Taking Strategy: Read the question carefully, noting that it asks for the client at risk for excessive fluid volume. Look for comparable or alike options that indicate fluid volume deficits. Read each option and think about the fluid imbalance that could occur in each situation; in the case of the incorrect options, it is fluid-volume deficiency; the only option reflecting conditions that could result in an excess is the correct option. If you had difficulty with this question, review the causes of excessive fluid volume. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fluid and Electrolytes D. A 65-year-old client with a nasogastric tube attached to low suction following partial gastrectomy Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 18630146876 A nurse is caring for a client who is being treated for congestive heart failure and has been assigned a nursing diagnosis of excessive fluid volume. Which finding causes the nurse to determine that the client’s condition has improved? A. Dyspnea B. 1+ edema in the legs C. Moist crackles in the lower lobes of the lungs D. Weight loss of 4 lb in 24 hours Correct Rationale: One sign that excessive fluid volume is resolving is loss of body weight. It is important to recall that 1 L of fluid weighs 1 kg, which equals 2.2 lb (1 liter = 2.2 lb = 1 kg). The other options listed indicate that the client is retaining fluid. Assessment findings associated with excessive fluid volume include cough, dyspnea, rales or crackles, tachypnea, tachycardia, increased blood pressure and bounding pulse, increased central venous pressure, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. These symptoms must be reversed if the fluid- volume excess is to be resolved. Test-Taking Strategy: Use the process of elimination and focus on the subject, a sign that the client’s condition is improving. The only such finding is decreasing body weight. If you had difficulty with this question, review the assessment findings noted in excessive fluid volume and the signs that the condition is resolving. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fluid and Electrolytes Awarded 1.0 points out of 1.0 possible points. 5. 5.ID: 18630146862 A nurse notes that a client has ST-segment depression on the electrocardiogram (ECG) monitor. With which potassium reading does the nurse associate this finding? A. 3.1 mEq/L Correct Rationale: A serum potassium level below 3.5 mEq/L is indicative of hypokalemia, the most common electrolyte imbalance, which is potentially life- threatening. ECG changes in hypokalemia include peaked P waves, flat T waves, a depressed ST segment, and prominent U waves. Readings of 4.5 mEq/L and 4.2 mEq/L are normal potassium levels; 5.4 mEq/L indicates hyperkalemia. Test-Taking Strategy: Begin to answer this question by recalling the normal range of values for serum potassium. Next it is necessary to know that ST- segment depression occurs in hypokalemia. Look for comparable or alike options that indicate a normal potassium reading. If you had difficulty with this question, review the ECG changes that occur in hypokalemia. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Fluid and Electrolytes B. 4.2 mEq/L C. 4.5 mEq/L D. 5.4 mEq/L Awarded 1.0 points out of 1.0 possible points. 6. 6.ID: 18630146885 A health care provider writes a prescription for the administration of intravenous (IV) potassium chloride to a client with hypokalemia. The nurse should reinforce which client instructions? A. A catheter will be inserted to drain your bladder. B. A large intravenous line will be inserted into your chest vein. C. This infusion requires use of a large caliber IV tubing. D. This medication is diluted in a large bag of IV fluid and infused slowly into your vein. Correct Rationale: Potassium chloride administered IV must always be diluted in IV fluid. Undiluted potassium chloride given IV can cause cardiac arrest. Potassium chloride is never administered as a bolus (IV push) injection; an IV push would result in sudden severe hyperkalemia, which could precipitate cardiac arrest. Although urine output is monitored carefully during administration, it is not necessary to insert a Foley catheter unless this is specifically prescribed. Potassium chloride should be administered with the use of a controlled IV infusion device to avoid bolus infusion and increased risk of cardiac arrest. A central IV line is not necessary; potassium chloride may be administered through a peripheral IV line. Test-Taking Strategy: Use the process of elimination and note the strategic words “intravenous potassium chloride.” Recalling that the medication must be diluted will direct you to the correct option. If you had difficulty with this question, review the guidelines for the administration of potassium chloride. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology Awarded 1.0 points out of 1.0 possible points. 7. 7.ID: 18630146897 A nurse notes that a client’s serum potassium level is 5.8 mEq/L. The nurse interprets this as an expected finding in the client with? A. Diarrhea B. Wound drainage C. Addison disease Correct Rationale: A serum potassium level greater than 5.1 mEq/L indicates hyperkalemia, and the nurse would report the finding to the health care provider. Adrenal insufficiency (Addison disease) is a cause of hyperkalemia. Other common causes of hyperkalemia include tissue damage, such as that in burn injuries, renal failure, and the use of potassium-sparing diuretics. The client with diarrhea or wound drainage or the client being treated with diuretics is at risk for hypokalemia. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that the client is experiencing body fluid losses and therefore a loss of potassium. If you had difficulty with this question, review the risk factors associated with hyperkalemia. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Fluid and Electrolytes D. Heart failure being treated with loop diuretics Awarded 1.0 points out of 1.0 possible points. 8. 8.ID: 18630146883 A nurse is caring for a client experiencing hyponatremia who was admitted to the medical-surgical unit with fluid-volume overload. For which clinical manifestations of this electrolyte imbalance does the nurse monitor this client? Select all that apply. A. Slow pulse B. Decreased urine output C. Skeletal muscle weakness Correct D. Hyperactive bowel sounds Correct E. Hyperactive deep tendon reflexes Rationale: Signs of hyponatremia include a rapid, thready pulse; skeletal muscle weakness; diminished deep tendon reflexes; abdominal cramping and hyperactive bowel sounds; increased urine output; headache; and personality changes. The nurse must assess these changes from baseline. If muscle weakness is detected, the nurse should immediately check respiratory effectiveness because ventilation depends on strength of the respiratory muscles. Test-Taking Strategy: Specific knowledge of the subject, the manifestations of hyponatremia, is needed to answer this question. Remember that muscle weakness and hyperactive bowel sounds are characteristics of hyponatremia. If you had difficulty with this question, review the clinical manifestations of hyponatremia. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fluid and Electrolytes Awarded 2.0 points out of 2.0 possible points. 9. 9.ID: 18630148316 A nurse is monitoring a client with hyperparathyroidism for signs of hypercalcemia. For which of the following clinical manifestations, associated with this electrolyte imbalance, does the nurse assess the client? Select all that apply. A. Paresthesias B. Muscle weakness Correct C. Increased urine output Correct D. Chvostek sign E. Hyperactive deep tendon reflexes Rationale: Signs of hypercalcemia include muscle weakness, diminished deep tendon reflexes or an absence thereof, increased urine output, decreased gastrointestinal motility, and increased heart rate and blood pressure. Hyperactive deep tendon reflexes, the presence of the Chvostek sign, and paresthesias are signs of hypocalcemia. Test-Taking Strategy: Use the process of elimination, focusing on the subject, signs of hypercalcemia. Note that all of the incorrect options are comparable or alike options in that they reflect hyperactivity of the neuromuscular system. Review the clinical signs noted in hypercalcemia if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fluid and Electrolytes Awarded 2.0 points out of 2.0 possible points. 10. 10.ID: 18630146837 A nurse is caring for a client with Crohn disease whose magnesium level is 1.0 mg/dL. Which assessment findings does the nurse expect to note? Select all that apply. A. Hypotension B. Abdominal distention Correct C. Trousseau sign Correct D. Skeletal muscle weakness E. Decreased deep tendon reflexes Rationale: The normal magnesium level is 1.6 to 2.6 mg/dL. A magnesium level of 1.0 mg/dL reflects hypomagnesemia. Assessment signs include hypertension; gastrointestinal manifestations such as anorexia, nausea, abdominal distention, and decreased bowel sounds; shallow respirations; neuromuscular manifestations such as twitches, paresthesias, hyperreflexia, and the Trousseau and Chvostek signs; and irritability and confusion. Test-Taking Strategy: Use the process of elimination, noting the options that are comparable or alike options because they reflect neurological, musculoskeletal, and cardiovascular depression. If you had difficulty with this question, review the clinical signs found in magnesium imbalances. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fluid and Electrolytes Awarded 2.0 points out of 2.0 possible points. 11. 11.ID: 18630146847 A nurse enters a client’s room and finds the client unconscious. The nurse quickly determines that the client is not breathing. Which action does the nurse take first? A. Beginning chest compressions Correct Rationale: According to the American Heart Association, detecting a pulse may be difficult. The health care provider should take not more than 10 seconds to check for a pulse; if the rescuer does not definitely feel a pulse within that period, he or she should start chest compressions. The acronym CAB (circulation, airway, and breathing) is used to prioritize the steps of cardiopulmonary resuscitation (CPR). Effective chest compressions are essential for providing blood flow during CPR. To provide effective chest compressions, the provider must push hard and fast. Current guidelines for CPR call for the initiation of compressions before ventilations. Oxygen may be helpful at some point, but the airway is opened before the administration of oxygen. Checking the client’s pulse oximetry reading delays implementation of lifesaving measures. Test-Taking Strategy: Visualize the steps of CPR to answer the question. Recall the subject, the guidelines of life support: C (circulation), A (airway), B (breathing). This will direct you to the correct option. Review the steps of basic life support if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care B. Checking the client’s pulse oximetry reading C. Placing an oxygen mask on the client D. Counting the client’s carotid pulse for 15 seconds Awarded 1.0 points out of 1.0 possible points. 12. 12.ID: 18630146870 A nurse arrives at the scene of a client experiencing a cardiac/respiratory arrest and begins to assist with cardiopulmonary resuscitation (CPR) of an adult. The nurse delivers compressions by pushing down on the chest to which depth? A. 1 inch B. 1½ inches C. 2 inches Correct Rationale: When CPR is being performed on an adult, the sternum should be depressed at least 2 inches (5 cm). The other options are incorrect because they are too shallow to be effective or are too deep, which can cause damage to internal organs. The rescuer should allow complete recoil of the chest after each compression to allow the heart to fill completely before the next compression. Test-Taking Strategy: Knowledge regarding the subject, the procedure for performing chest compressions on an adult, is necessary to answer the question. Consider the normal body structure of an adult to answer the question correctly. If you had difficulty with this question, review the procedure for CPR for an adult. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care D. 4 inches Awarded 1.0 points out of 1.0 possible points. 13. 13.ID: 18630146889 The nurse is administering cardiopulmonary resuscitation (CPR) to an adult client. Which compression/ventilation ratio is correct? A. 15:1 B. 15:2 C. 20:2 D. 30:2 Correct Rationale: A 30:2 ratio of compressions to ventilations is recommended for CPR in adults. The other options are incorrect. Test-Taking Strategy: Knowledge regarding the subject, the procedure for performing CPR on an adult client, is needed to answer this question. Remember that the 30:2 ratio of compressions to ventilations is recommended for CPR in adults. Review CPR procedure if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care Awarded 1.0 points out of 1.0 possible points. 14. 14.ID: 18630147576 A nurse finds a hospitalized child unresponsive. A quick assessment reveals that the child is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR). How many chest compressions per minute does the nurse deliver? A. 15 B. 30 C. 50 D. 100 Correct Rationale: In an infant or child, the rate of chest compressions is at least 100/min. Test-Taking Strategy: Knowledge regarding the subject, the procedure for performing CPR on a child, is needed to answer this question. Remember that the rate of chest compressions is at least 100/min. Review CPR procedure for a child if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care Awarded 1.0 points out of 1.0 possible points. 15 15.ID: 18630146817 A nurse attending a recertification course in basic life support (BLS) for health care professionals is practicing BLS on an infant mannequin. Where does the nurse place the fingers to assess the infant’s pulse? A. Neck B. Wrist C. Behind the knee D. Antecubital fossa of the arm Correct Rationale: An infant’s pulse should be checked at the brachial artery. The relatively short, fat neck of an infant makes palpation of the carotid artery (neck) difficult. Palpation of the pulse in the radial (wrist) and popliteal (behind the knee) area would also be difficult. Test-Taking Strategy: Use data in the question, the age of the child, and visualize each location identified in the options. This will direct you to the correct option. Review the procedure for performing BLS on an infant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Basic Life Support Awarded 1.0 points out of 1.0 possible points. 16. 16.ID: 18630146831 A nurse is working in the emergency department. Which client should be assessed first A. A client with new-onset dizziness B. A client admitted with a recent ear injury C. A client who has been experiencing nausea and vomiting for 12 hours D. A client with new-onset atrial fibrillation with a rate of 118 beats/min Correct Rationale: The client with new-onset atrial fibrillation is at risk for complications associated with the tachydysrhythmia. This dysrhythmia may result in decreased cardiac output because of ineffective atrial contractions. Thrombi form in the atria as a result of the pooling of blood. All of the other clients will require the nurse’s attention, but the client who requires immediate attention and is the most hemodynamically unstable is the one with atrial fibrillation. Test-Taking Strategy: Use the process of elimination and use the ABCs—airway, breathing, and circulation—to find the correct option. The client experiencing atrial fibrillation is the least stable of the clients identified in the other options. Review the principles of prioritization if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Awarded 1.0 points out of 1.0 possible points. 17. 17.ID: 18630146849 A nurse is having dinner at a restaurant when a man sitting at the next table collapses and falls to the floor. The nurse yells for help and quickly notes that the client is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR) immediately, and the restaurant manager rushes to the scene with an automatic external defibrillator (AED). What should the nurse do next? A. Use the AED Correct Rationale: Basic components of CPR include immediate recognition of the sudden cardiac arrest (unresponsiveness and absence of normal breathing) and activation of the emergency response system, early CPR, and rapid defibrillation with the use of an AED. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that the resuscitation efforts should be terminated. To select from the remaining options it is necessary to know the components of CPR. Review the components of CPR and the procedure for using an AED if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Basic Life Support B. Stop the resuscitation efforts C. Perform CPR until emergency medical services arrives D. Check for a pulse for 30 seconds before continuing CPR Awarded 1.0 points out of 1.0 possible points. 18. 18.ID: 18630147574 A client with cancer of the larynx is receiving external radiation therapy of the neck. Which side effect related specifically to the site of irradiation does the nurse tell the client to expect? A. Diarrhea B. Dyspnea C. Headache D. Dysphagia Correct Rationale: In general, skin reactions and fatigue may occur with radiation therapy of any site, whereas other side effects occur only when a specific area lies in the treatment field. A client undergoing radiation therapy of the larynx is most likely to experience dysphagia. Diarrhea may occur with irradiation of the gastrointestinal tract. Dyspnea may occur with lung irradiation. Headache may occur with irradiation of the head. Test-Taking Strategy: Use the process of elimination and note the strategic words “related specifically to the site.” Focus on the anatomic location of the radiation therapy to identify the correct option. Review the effects of radiation therapy if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Oncology Awarded 1.0 points out of 1.0 possible points. 19. 19.ID: 18630146893 The nurse has instructed a client who is about to begin external radiation therapy in how to maintain optimal skin integrity during therapy. Which statement by the client indicates a need for further instruction? A. “I need to keep the sun off the radiation site.” B. “I can use over-the-counter cortisone cream on the radiation site if it gets red.”Correct Rationale: The client should use no powders, ointments, lotions, or creams on the skin at the radiation site unless they have been prescribed by the health care provider. Avoiding sun exposure of the radiation site, not removing marks made on the skin by the radiologist, and washing the skin with mild soap and water and patting it dry are all correct measures. The client should also be instructed to avoid using harsh detergents to wash clothing. Test-Taking Strategy: Note the strategic words “need for further instruction” in the query of the question, which indicate a negative event query and the need to select the incorrect client statement. Noting the words “over-the-counter” will direct you to the correct option. Review client teaching points for skin care during radiation therapy if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Oncology C. “I need to be careful not to wash off the marks that the radiologist made on my skin.” D. “I need to wash the skin at the radiation site with a mild soap and water and pat it dry.” Awarded 1.0 points out of 1.0 possible points. 20. 20.ID: 18630146887 A nurse is participating in a care planning session for a client with a sealed radiation implant. Which stipulation does the nurse expect to see included in the plan? A. Visitors must be limited to one half-hour per day. Correct Rationale: The nurse would limit each visitor to a half-hour per day and be sure that visitors remain at least 6 feet from the radiation source. The nurse would wear the dosimeter badge when caring for the client. The dosimeter badge measures an individual’s exposure to radiation and should be used by only one individual. The dosimeter badge is not left in the client’s room. The client is assigned to a private room with a private bath to keep other clients from being exposed to radiation. Test-Taking Strategy: Use the process of elimination. Thinking about the subject, the measures that will prevent exposure to radiation, will direct you to the correct option. Review care of the client with a radiation implant if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Safety B. Visitors must remain at least 2 feet from the client. C. A dosimeter badge must be placed on the client’s bedside stand. D. The client may be maintained in a semiprivate room as long as the client uses a commode. Awarded 1.0 points out of 1.0 possible points. 21. 21.ID: 18630147585 A female client who has undergone placement of a sealed radiation implant asks the nurse whether she can take a walk around the nursing unit. How should the nurse respond to the client’s request? A. “Short walks are OK.” B. “You need to stay in your room for now.” Correct Rationale: The client with a sealed radiation implant must remain in a private room to keep others from being exposed to radiation. The other options are all incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that the client is permitted to leave the room for ambulation. Review care of the client with a radiation implant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety C. “Yes, it’s fine to take a walk around the nursing unit.” D. “Do you think that a walk around the unit will tire you out?” Awarded 1.0 points out of 1.0 possible points. 22. 22.ID: 18630147523 A nurse answers the call bell of a client who has been fitted with an internal cervical radiation implant, and the client states that she thinks that the implant has fallen out. The nurse checks the client and sees the implant lying in the bed. Which action should the nurse take first? A. Calling the health care provider B. Reinserting the implant into the client’s vagina C. Picking up the implant with gloved hands and placing it in sterile water D. Using long-handled forceps to place the implant in a lead container Correct Rationale: A lead container and long-handled forceps should be kept in the client’s room at all times during internal radiation therapy. If the implant is dislodged, the nurse should pick it up with long-handled forceps and place it in the lead container. Reinserting the implant into the vagina and picking up the implant with gloved hands and placing it in sterile water are both incorrect nursing actions. The health care provider is called after action is taken to maintain the safety of the client. Test-Taking Strategy: Use the process of elimination and note the strategic word “first” in the query of the question. Recalling that the nurse needs to protect himself or herself from exposure to the radiation will direct you to the correct option. Review the measures for dealing with a dislodged implant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Awarded 1.0 points out of 1.0 possible points. 23. 23.ID: 18630146827 A client who experienced a brain attack (stroke) exhibits right-sided unilateral neglect. The nurse caring for this client plans to place the client’s personal care items in which manner? A. Within the client’s reach on the left side B. Within the client’s reach on the right side Correct Rationale: Unilateral neglect is unawareness of one side of the body. The client behaves as if that part is not there. It is possible for the client to relearn to look for and to move the affected limb(s). Therefore in this condition the client’s personal care items are placed within the client’s reach on the right side. The client with one-sided hemiparesis benefits from having objects placed on the unaffected side and within reach. This reduces client frustration and aids in ensuring client safety because the client does not have to strain and reach for needed items. The nurse adapts the client’s environment to the deficit by focusing on the client’s unaffected side and by placing the client’s personal care items on the affected side within reach. Test-Taking Strategy: Use the process of elimination. Eliminate the options first that are potentially hazardous to the client. To select from the remaining options, focus on the subject, unilateral neglect. With unilateral neglect, objects are placed on the affected side to train the client to attend to that part of the environment. Review care of the client with unilateral neglect if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Neurological C. Just out of the client’s reach on the left side D. Just out of the client’s reach on the right side Awarded 1.0 points out of 1.0 possible points. 24. 24.ID: 18630147568 A client who is recovering from a brain attack (stroke) has residual dysphagia. Which measure does the nurse plan to implement at mealtimes? A. Giving the client thin liquids B. Thickening all liquids served Correct Rationale: The client with dysphagia may be started on a diet once the gag and swallow reflexes have returned. Liquids should be thickened to help prevent aspiration. Food is placed on the unaffected side of the mouth. The client is assisted with meals as needed and is given ample time to chew and swallow. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that involve giving thin liquids or primarily liquids. To select from the remaining options, visualize each. Recalling that placing food on the affected side of the mouth will put the client at risk for aspiration will assist you in eliminating this option. Review care of the client with residual dysphagia if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological C. Giving foods that are primarily liquid D. Placing food in the affected side of the client’s mouth Awarded 1.0 points out of 1.0 possible points. 25. 25.ID: 18630148308 A nurse is teaching a client who is experiencing homonymous hemianopsia after a brain attack (stroke) about measures to overcome the deficit. The nurse reinforces which client instruction? A. Wear eyeglasses 24 hours a day. B. Wear a patch on the affected eye. C. Turn the head to scan the lost visual field. Correct Rationale: Homonymous hemianopsia is loss of half of the visual field. The nurse instructs the client to scan the environment to overcome the visual deficit. The nurse encourages the use of personal eyeglasses to improve overall vision, but it is not necessary to wear the glasses 24 hours a day. The client should keep objects in the intact field of vision whenever possible. An eye patch is of no use because the client does not have double vision. Test-Taking Strategy: Use knowledge of the subject, homonymous hemianopsia. Recalling that homonymous hemianopsia is loss of half of the visual field will direct you to the correct option. Review care of the client with homonymous hemianopsia if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Neurological D. Keep all objects in the impaired field of vision. Awarded 1.0 points out of 1.0 possible points. 26. 26.ID: 18630146821 A nurse is reviewing home care instructions to a client with Parkinson disease about measures to avoid rigidity and to overcome tremor and bradykinesia. The nurse reinforces which information? A. Sit in soft, deep chairs. B. Rock back and forth to start movement. Correct Rationale: The client with Parkinson disease should rock back and forth to initiate movement with bradykinesia (slowed movement). The client should avoid sitting in soft, deep chairs to prevent rigidity and because they are difficult to get up from. The client should exercise in the morning, when the energy level is at its highest. The client with a tremor is instructed to use both hands to accomplish a task. Test-Taking Strategy: Use the process of elimination. Eliminate the option that uses the closed-ended word “only” first. To select correctly from the remaining options, recall that bradykinesia means slowed movement to identify the correct option. Review client teaching points for Parkinson’s disease if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Neurological C. Exercise in the evening to combat fatigue. D. Perform tasks with only the hand that has the tremor. Awarded 1.0 points out of 1.0 possible points. 27. 27.ID: 18630147580 A client with a spinal cord injury suddenly complains of a pounding headache. The nurse quickly arrives at the bedside and notes that the client is diaphoretic, his blood pressure has increased, and his heart rate has slowed. Suspecting that the client is experiencing autonomic dysreflexia, the nurse elevates the head of the client’s bed and takes which immediate action? A. Documents the event B. Notifies the health care provider C. Checks the client’s bladder for distention Correct Rationale: Autonomic dysreflexia is an emergency that occurs as a result of exaggerated autonomic responses to stimuli that are innocuous in normal individuals. It occurs only after spinal shock has resolved. A variety of stimuli may trigger this response, including a distended bladder (the most common cause); distention or contraction of the visceral organs, especially the bowel (as a result of constipation or impaction); or stimulation of the skin. When autonomic dysreflexia occurs, the client is immediately placed in a sitting position to lower the blood pressure. The nurse then performs a rapid assessment to identify and alleviate the cause. The client’s bladder is emptied immediately by way of a urinary catheter, the rectum is checked for the presence of a fecal mass, and the skin is examined for areas of pressure, irritation, or compromise. The health care provider is notified, and then the nurse documents the occurrence and the actions taken. Test-Taking Strategy: Focus on the data in the question and note that the nurse has already elevated the head of the client’s bed. Next, recall that autonomic dysreflexia occurs as a result of exaggerated autonomic responses to stimuli, which will direct you to the correct option. Review immediate interventions for autonomic dysreflexia if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological D. Checks to see whether the client has a prescription for an antihypertensive Awarded 1.0 points out of 1.0 possible points. 28. 28.ID: 18630146851 A nurse is monitoring a client who has just undergone radical neck dissection. The nurse notes that the client’s blood pressure has dropped from 132/84 to 90/50 mm Hg and that the pulse has increased from 78 to 96 beats/min. On the basis of these findings, the nurse takes which immediate action? A. Suctions the client B. Contacts the health care provider Correct Rationale: In the immediate postoperative period, the nurse assesses the client for signs of bleeding. A drop in blood pressure and an increase in pulse are indicators of bleeding. The health care provider is notified immediately if either of these events occurs. Suctioning is performed to remove secretions that cannot be expectorated by the client. Increasing the rate of the client’s IV solution is not done without a health care provider’s prescription. A pulse oximeter may be needed, but this is not the action to be taken immediately. Test-Taking Strategy: Use the process of elimination. Focus on the data in the question and note that the nurse’s findings indicate bleeding. This will direct you to the correct option. Review the nursing actions to be taken immediately if bleeding occurs if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Perioperative Care C. Obtains a pulse oximeter D. Increases the rate of the client’s intravenous (IV) solution Awarded 1.0 points out of 1.0 possible points. 29. 29.ID: 18630146835 An emergency department (ED) nurse receives a telephone call from emergency medical services and is told that a client who has sustained severe burns of the face and upper arms is being transported to the ED. Which action does the nurse, preparing for the arrival of the client, plan to implement first? A. Inserting a Foley catheter B. Initiating an intravenous (IV) line C. Cleansing the burn wound D. Administering 100% humidified oxygen Correct Rationale: When a victim who sustains a burn injury arrives at the ED, breathing is assessed, a patent airway is established, and the client is given 100% humidified oxygen. Inserting a Foley catheter, initiating an IV line, and cleansing the burn wound are also components of the plan of care for a burned client, but these are not the immediate actions. Test-Taking Strategy: Use the ABCs (airway, breathing, and circulation) to answer the question. The correct option is the only one related to the airway. Review care of the burned client if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Integumentary Awarded 1.0 points out of 1.0 possible points. 30. 30.ID: 18630146878 A nurse is assessing a client with a diagnosis of acquired immunodeficiency syndrome (AIDS) for signs of Pneumocystis jiroveci infection. Which sign of the infection is the earliest manifestation? A. Fever B. Dyspnea at rest C. Dyspnea on exertion D. Nonproductive cough Correct Rationale: The client with P. jiroveci infection usually has a cough as the first symptom, which begins as nonproductive then progresses to productive. Later signs include fever, dyspnea on exertion, and finally dyspnea at rest. Test-Taking Strategy: Note the strategic word “earliest.” Eliminate the comparable or alike options that involve dyspnea. To select from the remaining options, focus on the anatomic location of the infection, which will direct you to the correct option. Review the early manifestations of P. jiroveci infection if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Immune Awarded 1.0 points out of 1.0 possible points. 31. 31.ID: 18630147521 A client arrives at the emergency department with complaints of a headache, hives, itching, and difficulty swallowing. The client states that he took ibuprofen (Motrin) 1 hour earlier and believes that he is experiencing an allergic reaction to this medication. After ensuring that the client has a patent airway, which intervention does the nurse prepare the client for first? A. Administration of normal saline solution B. Administration of an intravenous (IV) glucocorticoid C. Administration of pain medication to relieve the client’s headache D. Administration of a subcutaneous injection of epinephrine (Adrenalin) Correct Rationale: Once airway has been established, the client would be given subcutaneous epinephrine. IV corticosteroids and IV fluids may also be prescribed. Pain medication may or may not be prescribed. Test-Taking Strategy: Note the strategic word “first” in the query of the question. All of the interventions in the options may be prescribed for the client experiencing a hypersensitivity reaction. Remember that once airway is established, the client will receive epinephrine. Review care of the client who experiences an allergic reaction if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Critical Care Awarded 1.0 points out of 1.0 possible points. 32. 32.ID: 18630147503 The nurse is participating in a care planning conference for a patient with acquired immunodeficiency syndrome (AIDS). What is the nurse’s highest priority in providing care to this client? A. Providing emotional support to the client B. Discussing the cause of AIDS with the client C. Instituting measures to prevent infection in the client Correct Rationale: The client with AIDS has inadequate immune bodies and is at risk for infection. The priority nursing intervention is protecting the client from infection. The nurse would also provide emotional support to the client. Discussing the cause of AIDS and the ways in which AIDS is contracted are not priority interventions. Test-Taking Strategy: Note the strategic words “highest priority.” Use Maslow’s Hierarchy of Needs theory to answer the question. Remember that physiological needs are the priority. This will direct you to the correct option. Review the priority needs of a client with AIDS if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Immune D. Identifying risk factors related to contracting AIDS with the client Awarded 1.0 points out of 1.0 possible points. 33. 33.ID: 18630147556 A client who sustained a fracture of the left arm requires the application of a plaster cast. The nurse tells the client that the procedure for applying the cast involves which step? A. Administering a local anesthetic to the fractured arm B. Soaking the left arm in a warm-water bath for 2 hours before cast application C. Debriding any open wounds and applying antibiotic ointment before the cast material is applied D. Applying soft padding and stockinette over the fractured arm, followed by the application of the cast material Correct Rationale: To apply a cast, the skin is washed and dried well, but it is not soaked in a warm-water bath. Padding is applied and a stockinette is placed smoothly and evenly over the area to be casted. The plaster is then rolled onto the padding and the edges are trimmed or smoothed as needed. Local anesthesia of the fractured extremity is not necessary, although an analgesic may be administered to alleviate pain. A local anesthetic will block nerve sensation, and it is important for the client to be able to report any changes in sensations after the cast is applied. If the client has open wounds on the fractured extremity, a window will be cut in the cast to allow visualization and treatment of the wound. A wound would not be covered with cast material. Test-Taking Strategy: Use knowledge of the subject, cast application. Eliminate the option containing the words “2 hours.” Next eliminate the option that involves administration of a local anesthetic, recalling that a local anesthetic will block nerve sensation. Recognizing that covering an open wound with a cast material would not permit assessment of the wound will allow you to eliminate this option. Review client instructions regarding the application of a plaster cast if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Awarded 1.0 points out of 1.0 possible points. 34. 34.ID: 18630148310 A client has just had a plaster leg cast applied, and the nurse has given the client instructions on cast care. Which statement by the client indicates the need for further instruction? A. “I may feel cool while the cast is drying.” B. “I shouldn’t use anything to scratch underneath the cast.” C. “If I smell any odor from the cast, I should call the doctor.” D. “I can dry the cast faster if I use a hairdryer on the hot setting.” Correct Rationale: Using a blow dryer on the hot setting to dry the cast is not advised because it may burn the client’s skin under the cast and crack the cast. While the cast is still damp, the client may feel cold and may experience a decrease in body temperature. The client should never insert any item under the cast because of the risk skin compromise. An odor coming from the cast could indicate the presence of infection, warranting health care provider notification. Test-Taking Strategy: Use the process of elimination and note the strategic words “need for further instruction,” which indicate a negative event query and the need to select the incorrect client statement. Recalling that the use of a hot blow dryer can cause burns will direct you to this option. Review client teaching points in regard to cast care if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Musculoskeletal Awarded 1.0 points out of 1.0 possible points. 35. 35.ID: 18630148306 A client with a leg fracture who has been placed in skeletal traction is transported to the orthopedic unit after surgery. Which finding would indicate the need to take action? A. The traction knots are intact. B. The traction weights are hanging freely. C. The clamps on the traction frame are tight. D. The traction ropes are unable to move over the pulleys. Correct Rationale: After skeletal traction pins are inserted and traction is applied, all ropes, knots, and pulleys are inspected to ensure that they are positioned properly. Traction knots and ropes must be intact and secure. Ropes should move easily over pulleys and weights, and the weights should hang freely at all times. The clamps on the traction frame should be tight. Test-Taking Strategy: Use the process of elimination and note the strategic words “need to take action,” which indicate the need to select the option that constitutes an unsafe or incorrect observation. Noting the words “unable to move over the pulleys” will help you identify to the correct option. Review care of the client in skeletal traction if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Musculoskeletal Awarded 1.0 points out of 1.0 possible points. 36. 36.ID: 18630147599 Buck extension traction is applied to the right leg of a client who sustained a right hip fracture. Which intervention should the nurse expect to see included in the plan of care? A. Assessing the pin sites at least every 8 hours B. Removing the traction weights to provide skin care C. Applying lanolin to the skin of the right leg once per shift D. Checking the skin integrity of the right leg at least every 8 hours Correct Rationale: Buck extension traction is a type of skin traction. It is important with skin traction to inspect the skin underneath at least once every 8 hours for irritation or inflammation. The nurse never releases the weights of traction unless specifically asked to do so by the health care provider. Applying lanolin to the skin could leave the skin slippery, making it difficult to maintain the belt or boot used for the skin traction. There are no pins to care for with skin traction. Test-Taking Strategy: Use knowledge of the subject, Buck traction. Recalling that Buck extension traction is a type of skin traction will assist you in eliminating the option of assessing the pin sites. Next eliminate the option that indicates the nurse may remove traction weights without a specific prescription to do so. To select from the remaining options, use the steps of the nursing process. The correct option addresses assessment. Review care of the client in Buck traction if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Musculoskeletal Awarded 1.0 points out of 1.0 possible points. 37. 37.ID: 18630146829 A nurse provides home care instructions to a client with a below-the-knee amputation (BKA) about residual limb and prosthesis care. Which statement by the client indicates a need for further instruction? A. “I should wear a sock over my stump.” B. “I can wash my leg with a mild soap.” C. “I need to check my leg for irritation every day.” D. “I’ll put lotion on my stump a few times a day.” Correct Rationale: The client should be instructed to don the prosthesis immediately on arising and to keep it on all day (once the incision has healed completely) to reduce residual limb swelling. “I can wash my leg with a mild soap,” “I need to check my leg for irritation every day,” and “I should wear a sock over my stump” are correct statements regarding residual limb and prosthesis care. The client should not use any lotions, alcohol-containing powders, or oils on the residual limb unless told to do so by the health care provider. The client should also perform range-of-motion exercises of the joints, as well as strengthening exercises, including the upper extremities, every day. Test-Taking Strategy: Use the process of elimination and note the strategic words “need for further instruction,” which indicate a negative event query and the need to select the incorrect client statement. Recalling that the prosthesis is used to reduce residual limb edema will direct you to the correct option. Review client instructions regarding prosthesis and residual limb care if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Musculoskeletal Awarded 1.0 points out of 1.0 possible points. 38. 38.ID: 18630146891 A nurse provides instructions to a client with rheumatoid arthritis about joint exercises that are important to prevent deformity and reduce pain. Which statement by the client indicates the need for further instruction? A. “I should always maintain good posture.” B. “I should stop my exercises if I get tired.” C. “I should avoid all exercise when my joints are inflamed.” Correct Rationale: The client should avoid activities (other than gentle range of motion) when the joints are inflamed. Isometric exercises are also helpful when the joints are inflamed. Daily range-of-motion exercises are an important component of the program and will help relieve pain, but the client should exercise only to the point of fatigue or discomfort. All clients are taught to maintain good posture. Test-Taking Strategy: Use the process of elimination and note the strategic words “need for further instruction,” which indicate a negative event query and the need to select the incorrect client statement. Noting the closed-ended word “all” will direct you to the correct option. Review exercise instructions for the client with rheumatoid arthritis if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Musculoskeletal D. “Doing range-of-motion exercises every day will ease the pain.” Awarded 1.0 points out of 1.0 possible points. 39. 39.ID: 18630146825 A nurse provides instructions to a client about measures to prevent an acute attack of gout. The nurse determines that the client needs additional instructions if the client makes which statement? A. “It’s important for me to drink a lot of fluids.” B. “A fad diet or starvation diet can cause an acute attack.” C. “I don’t need medication unless I’m having a severe attack.” Correct Rationale: Treatment of gout includes both nutrition and medication therapy. The client should be encouraged to limit the use of alcohol and reduce the consumption of foods high in purines. Such foods include sardines, herring, mussels, liver, kidney, goose, venison, and sweetbreads. Medication therapy is a primary component of management for clients with gout, and the health care provider normally prescribes a medication that will promote uric acid excretion or reduce its production. Fluid intake is important in preventing the development of uric acid stones. Fad or starvation diets can precipitate an acute attack because of the rapid breakdown of cells they induce. Excessive physical and emotional stress can exacerbate the disease. Test-Taking Strategy: Use the process of elimination and your knowledge of the treatment for gout. Also note the strategic words “needs additional instruction,” which indicate a negative event query and the need to select the incorrect client statement. Recall that in this disorder the client experiences an increased uric acid level and that medications are needed to promote the acid’s excretion. Review the management of gout if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Musculoskeletal D. “Physical and emotional stress can cause an attack.” Awarded 1.0 points out of 1.0 possible points. 40. 40.ID: 18630146899 A nurse is providing instructions to a nursing assistant about effective measures for communicating with a hearing-impaired client. The nurse instructs the nursing assistant communicate with the client in which way? A. Raise his voice when talking to the client B. Talk directly into the client’s impaired ear C. Be cordial and smile when talking to the client D. Face the client when talking, keeping the hands away from the mouth Correct Rationale: To facilitate communication with a client who is hearing impaired, the nurse should speak in a normal tone, not shout or raise the voice. The nurse should speak clearly and directly while facing the client and keep the hands away from the mouth so that the client can read the nurse’s lips. It may be helpful for the nurse to move closer to the client and toward the better ear to facilitate communication, but it is not helpful to talk directly into the client’s impaired ear. Smiling while talking will make it difficult for the client to lip-read. Test-Taking Strategy: Use the process of elimination and focus on the subject, communicating with a hearing-impaired client. Visualizing each of the options will direct you to the correct one. Review these communication techniques with a hearing impaired client f you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Ear Awarded 1.0 points out of 1.0 possible points. 41. 41.ID: 18630147517 A stapedectomy is performed on a client with otosclerosis. During the preparations for discharge, which home care instruction does the nurse reinforce for the client? A. Expect excessive ear drainage for about 2 weeks. B. Avoid rapidly moving the head and bending over for at least 3 weeks. Correct Rationale: The client must avoid rapidly moving the head, bouncing, and bending over for at least 3 weeks to prevent disruption of the surgical site. The client should keep the affected ear dry at all times and should avoid getting the head wet, washing the hair, or showering for 1 week. The client should not rinse out the ear. The client also needs to avoid drinking through a straw for 2 to 3 weeks because the sucking action necessary to use the straw could cause disruption of the surgical site. The client should notify the health care provider if excessive ear drainage is noted. Test-Taking Strategy: Use knowledge of the subject, care of the client after a stapedectomy, to answer this question. Eliminate first the option containing the word “excessive.” Recalling that the ear needs to remain dry will assist you in eliminating the option that involves showering. To select from the remaining options, think about each action and its effect on the ear. This will direct you to the correct option. Review care after stapedectomy if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Ear C. Rinse the ear canal at least twice a day to clear out any excess drainage. D. It is all right to shower as long as the ear dressing is changed immediately after the shower. Awarded 1.0 points out of 1.0 possible points. 42. 42.ID: 18630148318 A nurse provides home care instructions to a client with Ménière disease about measures to control and treat vertigo. The nurse provides which explanation? A. Limit sodium in the diet. Correct Rationale: Limiting and fluids in the diet will help reduce the amount of endolymphatic fluid, which is excessive in Ménière disease. The client’s room should be darkened to reduce the acute symptoms of vertigo. The client should limit head movement to prevent worsening of the symptoms of vertigo. Test-Taking Strategy: Use knowledge of the subject, Ménière disease, to help you answer the question. Recalling the pathophysiology of Ménière disease and remembering that the disease is caused by excess endolymph will direct you to the correct option. Review the measures that will reduce vertigo in the client with Ménière disease if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Ear B. Increase fluid intake to at least 3000 mL/day. C. Lie down when vertigo occurs and keep a light on in the room. D. Move the head from the right to the left when vertigo occurs to determine the extent of its effects. Awarded 1.0 points out of 1.0 possible points. 43. 43.ID: 18630147544 A client is transported to the recovery area of the ambulatory care unit after cataract surgery. In which position does the nurse place the client? A. Supine B. Semi-Fowler Correct Rationale: After cataract extraction surgery, the client should be placed in the semi-Fowler position or on the unaffected side to prevent edema at the surgical site. Supine, on the affected side, and prone are all incorrect because they will result in increased edema at the site. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate flat positions. To select from the remaining options, remember that local edema may occur after the trauma of surgery. Use the principles of gravity and measures to prevent accumulation of fluid around the surgical site to direct you to the correct option. If you had difficulty with this question, review care of the client immediately after cataract surgery. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Eye C. On the side that has undergone surgery D. Prone on the side that has undergone surgery Awarded 1.0 points out of 1.0 possible points. 44. 44.ID: 18630147591 A nurse is providing discharge instructions to a client after outpatient surgery for cataract removal. The nurse determines that the client needs additional instructions if the client indicates that he will take which measure? A. Limit activity for 24 hours. B. Take acetaminophen (Tylenol) for discomfort. C. Leave the eye patch in place until he has been seen by the health care provider. D. Expect to experience pain, nausea, and vomiting after the procedure. Correct Rationale: If the client experiences any pain that is unrelieved, redness around the eye, or nausea or vomiting, the health care provider must be notified because such findings could be an indication of increased intraocular pressure. Usually the client is given a follow-up appointment on the day after the surgery, and the health care provider removes the eye patch at this time. The client is instructed to limit activity to sitting in a chair, resting, and walking to the bathroom for 24 hours. Aspirin or medications containing aspirin should not be taken by the client; rather, acetaminophen (Tylenol) should be used to alleviate discomfort. Test-Taking Strategy: Use the process of elimination and note the strategic words “needs additional instruction,” which indicate a negative event query and the need to select the incorrect client statement. Recalling the signs of increased intraocular pressure will direct you to the correct option. If you had difficulty with this question, review the discharge instructions for the client after cataract extraction. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Eye Awarded 1.0 points out of 1.0 possible points. 45. 45.ID: 18630146868 During a client’s yearly eye examination, the nurse checks the intraocular pressure. The nurse notes that the pressure in the right eye is 12 mm Hg and 19 mm Hg in the left. The nurse explains the results in which manner? A. That he has glaucoma in the left eye B. That he has glaucoma in the right eye C. That the intraocular pressure in both eyes is normal Correct Rationale: Normal intraocular pressure ranges from 10 to 21 mm Hg. Therefore this client’s intraocular pressure is normal. Increased intake of fluids is unrelated to increasing intraocular pressure. Test-Taking Strategy: Knowledge that normal intraocular pressure ranges from 10 to 21 mm Hg will help you identify the correct option. Note there are several comparable or alike options that involve the nurse telling the patient a diagnosis. Review this normal intraocular pressure finding and the findings in glaucoma if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Eye D. That he needs to increase his fluid intake because the pressure in the right eye is low Awarded 1.0 points out of 1.0 possible points. 46. 46.ID: 18630147532 A nurse provides home care instructions to a client after a scleral buckling procedure. The nurse should reinforce which client teaching point? A. To maintain strict bedrest for 48 hours B. To expect bloody drainage on the eye dressing C. That vision will be perfectly clear immediately after surgery D. That redness and swelling of the eyelids and conjunctiva are expected Correct Rationale: The scleral buckling procedure is performed to treat retinal detachment. In the preoperative period the nurse places an eye patch over the client’s affected eye to reduce eye movement. Some clients may require bilateral patching. Redness and swelling of the eyelids and conjunctiva, the result of surgical manipulation, are expected. Blood loss in retinal detachment surgery is minimal, and only serous drainage is expected on the postoperative dressing. The client should not expect immediate return of vision. Postoperative inflammation and eye drops interfere with vision. Because healing takes place over weeks to months, vision will improve gradually. Strict bedrest for 48 hours is not required; however, depending on the location and size of the retinal break, activity restrictions may be needed to prevent further tearing or detachment and to promote drainage of any subretinal fluid. Test-Taking Strategy: Use the process of elimination. Eliminate first the options containing the strategic words “strict” and “perfectly clear.” To select from the remaining options, recall that redness and swelling of the eye occur as a result of surgical manipulation. Review client instructions after scleral buckling if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Eye Awarded 1.0 points out of 1.0 possible points. 47. 47.ID: 18630147587 A nurse receives a telephone call from a neighbor, who says that her child was just hit in the eye with a swing. The nurse rushes to the neighbor’s house and notes that the child has sustained a contusion of the eye. The nurse advises the child’s mother to immediately perform which action? A. Call an ambulance. B. Call an optometrist. C. Apply ice to the affected eye. Correct Rationale: Treatment for a contusion ideally begins at the time of injury and includes the application of ice to the site. Although the child should also undergo a thorough eye examination to rule out other injuries, calling an optometrist is not the first action to be taken. Irrigating the eye with cool water may be implemented for injuries that involve a splash of an irritant into the eye. It is not necessary to call an ambulance. Test-Taking Strategy: Use the process of elimination and note the strategic word “immediately.” Eliminate the comparable or alike options, (i.e., calling an ambulance or an optometrist). To select from the remaining options, focus on the type of injury that has been sustained, which will direct you to the correct option. Review initial treatment after an eye contusion if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health – Eye D. Irrigate the eye with cool water. Awarded 1.0 points out of 1.0 possible points. 48. 48.ID: 18630147564 A client arrives in the emergency department for treatment of a surface injury sustained when sand blew into the eye. Which action does the nurse take first? A. Assessing the client’s vision Correct Rationale: When a client has sustained a surface injury of the eye as a result of the introduction of a foreign body, the nurse must first assess visual acuity. The eye is then assessed for corneal abrasions; this is followed by irrigation with sterile normal saline solution to gently remove the particles. Ice would be placed on the eye if the client had sustained an eye contusion. Test-Taking Strategy: Use the steps of the nursing process to answer the question. The correct option is the only one that involves assessment. Eliminate the options that reflect implementation. Review content related to initial treatment of various eye injuries if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Eye B. Placing ice on the eye C. Removing the sand particles D. Irrigating the eye with sterile saline solution Awarded 1.0 points out of 1.0 possible points. 49. 49.ID: 18630147540 A client with chronic renal failure is undergoing his first hemodialysis treatment, and the nurse is monitoring the client for signs of disequilibrium syndrome. For which signs of this syndrome does the nurse monitor the client? A. Fever and tachycardia B. Headache and confusion Correct Rationale: Disequilibrium syndrome most often occurs in clients who are new to hemodialysis. It is characterized by headache, confusion, decreasing level of consciousness, nausea, vomiting, twitching, and, in some cases, seizure activity. It results from rapid removal of solutes from the body during hemodialysis and a higher residual concentration gradient in the brain, caused by the blood-brain barrier. Water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. It is prevented with the use of shorter dialysis times or dialysis at a reduced blood flow rate. Irritability and generalized weakness, fever and tachycardia, and bradycardia and hypothermia are not associated with disequilibrium syndrome. Test-Taking Strategy: Use the process of elimination. Focusing on the data in the question, including the name of the syndrome will direct you to the correct option. This is the only option that completely addresses neurological signs. Review the signs of disequilibrium syndrome if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal C. Bradycardia and hypothermia D. Irritability and generalized weakness Awarded 1.0 points out of 1.0 possible points. 50. 50.ID: 18630147501 A hospitalized client with chronic renal failure has returned to the nursing unit after a hemodialysis treatment. Which parameters contained in the predialysis and postdialysis documentation does the nurse utilize to determine whether the procedure was effective? A. Blood urea nitrogen (BUN) and creatinine levels B. Blood pressure and weight Correct Rationale: After hemodialysis, the client’s vital signs are monitored to determine whether the client is remaining hemodynamically stable and for comparison with predialysis measurements. The client’s blood pressure and weight are expected to be reduced as a result of fluid removal. Laboratory studies are performed as per protocol but are not necessarily done after the hemodialysis treatment has ended. Test-Taking Strategy: Use the process of elimination and focus on the subject, determination of the effectiveness of hemodialysis. Think about the purpose and effects of hemodialysis to answer correctly. Recalling that vital signs reflect hemodynamic stability will also direct you to the correct option. Review the parameters that reflect the effectiveness of hemodialysis if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Renal C. Potassium and creatinine levels D. Weight and BUN Awarded 1.0 points out of 1.0 possible points. 51. 51.ID: 18630146874 A nurse is caring for a hospitalized client who is undergoing peritoneal dialysis. The nurse notes that the outflow is less than the inflow on the first exchange. What should the nurse do first? A. Irrigate the catheter. B. Reposition the client. C. Check the system for kinks. Correct Rationale: If outflow drainage is inadequate, the nurse must first check the system for kinks. If there are no kinks in the system, the nurse should change the client’s position to shift abdominal fluid. The catheter should not be irrigated. Hanging the next exchange and continuing to monitor outflow will not alleviate the problem. Test-Taking Strategy: Use the process of elimination and note the strategic word “first.” Also note that the subject of the question is related to inadequate outflow. Use the steps of the nursing process to answer correctly. The correct option addresses assessment. Review nursing interventions related to administering peritoneal dialysis if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Renal D. Hang the second exchange and continue to monitor the outflow. Awarded 1.0 points out of 1.0 possible points. 52. 52.ID: 18630147593 A client has an arteriovenous fistula in place for hemodialysis. What should the nurse do to assess the patency of the fistula? A. Irrigate the fistula with 3 mL of normal saline solution. B. Infuse 50 mL of normal saline once per 24 hours. C. Palpate for a vibrating sensation at the fistula site. Correct Rationale: An arteriovenous fistula is created in a surgical procedure in which an anastomosis is created between an artery and a vein in the arm in an end- to-side, side-to-side, side-to-end, or end-to-end fashion. In a patent fistula (or graft), a “thrill,” or vibrating sensation, should be palpable and a bruit should be audible with a stethoscope. An arteriovenous fistula is the client’s lifeline, and the nurse does not irrigate or infuse solutions into it. It is used only for hemodialysis. Test-Taking Strategy: Use the process of elimination and focus on the subject, the patency of an arteriovenous fistula. Eliminate the comparable or alike options that involve infusing a solution into the fistula. Review care of the client with an arteriovenous fistula if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Renal D. Flush the fistula with 1 mL of heparin solution once per shift. Awarded 1.0 points out of 1.0 possible points. 53. 53.ID: 18630146880 A nurse is administering care to a client with angina pectoris who is attached to a cardiac monitor. The monitor alarm sounds, and the nurse notes the rhythm shown here. How does the nurse interpret the rhythm? A. Atrial fibrillation B. Sinus tachycardia C. Sinus bradycardia D. Ventricular tachycardia Correct Rationale: Ventricular tachycardia is characterized by a ventricular rate of 100 to 250 times/min. There is a wide QRS complex and an absence of P waves. The rhythm is usually fairly regular. In atrial fibrillation, multiple rapid impulses from many foci depolarize in the atria in a totally disorganized manner at a rate of 350 to 600 times/min. The atria quiver, which can lead to the formation of thrombi. No definitive P wave is observed, only fibrillatory waves before each QRS. Sinus tachycardia is characterized by a normal sinus rhythm that is rapid (faster than normal) in rate. Sinus bradycardia is characterized by a rhythm that is slower than normal. Test-Taking Strategy: Knowledge regarding the subject, the characteristics of ventricular tachycardia, is needed to answer this question. Focus on the characteristics noted in the rhythm to identify the correct option. Review the characteristics of ventricular tachycardia if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Awarded 1.0 points out of 1.0 possible points. 54. 54.ID: 18630146856 A nurse is monitoring a client after transurethral resection of the prostate for benign prostatic hypertrophy. The client has a bladder irrigation infusing, and the urine output is a light cherry color. An hour later the nurse notes that the urine output is now bright red in color with clots and that the client’s blood pressure has dropped. Which action by the nurse is appropriate? A. Contacting the health care provider Correct Rationale: Some hematuria is normal for several days after transurethral resection of the prostate. If bright-red bleeding occurs, the health care provider needs to be notified, particularly if the client exhibits a change in vital signs. These findings are a potential sign of excessive blood loss and the need for emergency surgical intervention. Continuing to monitor the client delays necessary interventions. The nurse would not increase the rate of flow of an IV without a health care provider’s order. Placing pressure on the bladder to aid expulsion of any additional clots is an inappropriate and unsafe action that could worsen the bleeding. Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Recalling the normal postoperative findings after a transurethral resection and using your knowledge of concepts related to hypovolemic shock will direct you to the correct option. Noting the strategic word “bright-red” will also help you answer correctly. Review the signs of complications after transurethral resection of the prostate if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Renal B. Continuing to monitor the client C. Increasing the flow rate of the intravenous (IV) solution D. Placing pressure on the bladder to aid expulsion of any additional clots Awarded 1.0 points out of 1.0 possible points. 55. 55.ID: 18630147527 A nurse is monitoring a client with deep vein thrombosis (DVT) for signs of pulmonary embolism. For which common sign of pulmonary embolism does the nurse assess the client? A. Fatigue B. Yellowish sputum C. Tenderness in the calf D. Sudden onset of dyspnea Correct Rationale: Pulmonary embolism is a life-threatening complication of thrombophlebitis or DVT. Dyspnea is a common clinical manifestation and occurs suddenly. Fatigue and yellowish sputum are characteristic of pneumonia, not pulmonary embolism. Tenderness in the calf is characteristic of the DVT but not pulmonary embolism. Test-Taking Strategy: Knowledge regarding the subject, the signs of pulmonary embolism, is needed to answer this question. A pulmonary embolism causes sudden symptoms of breathing difficulty. Look for comparable or alike options that indicate later signs of a disease process. Fatigue, yellowish sputum, and calf tenderness usually occur later in a disease process. Review the complications of DVT and the signs of pulmonary embolism if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Awarded 1.0 points out of 1.0 possible points. 56. 56.ID: 18630147538 A nurse is caring for a client who has undergone resection of an abdominal aortic aneurysm (AAA). Which action should the nurse implement to prevent graft occlusion? A. Monitoring urine output B. Monitoring bowel sounds C. Checking pedal pulses distal to the graft site D. Limiting elevation of the head of the bed to 45 degrees Correct Rationale: To prevent graft occlusion, the nurse limits elevation of the head of the bed to 45 degrees. The nurse does assess the client for signs of graft occlusion, but assessment will not prevent occlusion. The signs of graft occlusion include changes in peripheral pulses, cool-to-cold extremities distal to the graft, white or blue extremities or flanks, severe pain, and abdominal distention. Bowel sounds and urine output are also assessed, but these parameters are unrelated to graft occlusion. Test-Taking Strategy: Use the process of elimination and note the strategic word “prevent.” The question is asking for a nursing intervention. This will direct you to the correct option because this is the only option that identifies a preventive action. Review nursing interventions to prevent graft occlusion after AAA resection if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Awarded 1.0 points out of 1.0 possible points. 57. 57.ID: 18630147507 A client who experiences frequent episodes of chest pain is admitted to the hospital for cardiac monitoring. The client suddenly complains of chest pain, and the nurse obtains a 12-lead electrocardiogram (ECG). Which finding would the nurse expect to note in the event of an ischemic episode? A. Peaked T waves B. ST-segment depression Correct Rationale: An ECG taken in the presence of pain may reveal ischemic changes with ST-segment elevation or depression. Peaked T waves may indicate hyperkalemia. PVCs are caused by the firing of an irritable pacemaker in the ventricle. A widened QRS complex indicates a delay in intraventricular conduction, such as bundle branch block. Test-Taking Strategy: Knowledge regarding the subject, the effects of ischemia on myocardial tissue and how it is reflected on an ECG, is needed to answer this question. Remember that ST-segment elevation or depression indicates myocardial ischemia. Review the effects of myocardial ischemia if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular C. Widened QRS complex D. An isolated premature ventricular contraction (PVC) Awarded 1.0 points out of 1.0 possible points. 58. 58.ID: 18630147525 The wife of a client with angina pectoris calls the health care provider’s office and reports to the nurse that her husband is experiencing chest pain and has taken 2 sublingual nitroglycerin tablets 5 minutes apart, with no relief. The nurse tells the client’s wife to: A. Take her husband to the emergency department (ED) immediately. B. Have her husband rest and, if no relief is obtained, call back. C. Discuss the situation with the health care provider, who will call her as soon as he gets into the office. D. Give her husband a third tablet and, if no relief is obtained, call an ambulance to have him transported to the ED. Correct Rationale: Chest pain that is unrelieved by rest and three doses of nitroglycerin taken 5 minutes apart may be not typical anginal pain but instead a sign of myocardial infarction (MI). Because the risk of sudden cardiac death is greatest in the 24 hours after MI, it is imperative that the client receive emergency cardiac care. If the client needs to go to the ED, the nurse must instruct the client’s wife to call an ambulance to transport her husband. The client’s wife must not drive the client because the client should not exert energy and place an increased workload on the heart and the client’s wife would not be able to provide care if an emergency arose during transport to the hospital. Telling the wife that she will have to discuss the situation with the health care provider, who will call her as soon as he gets to his office, delays necessary interventions. Having her husband rest delays necessary interventions; also, the usual procedure is to have the client take three nitroglycerin tablets before seeking medical attention. Test-Taking Strategy: Use the process of elimination. Eliminate first the comparable or alike options that would delay necessary intervention. To select from the remaining options, recall that three nitroglycerin tablets should be taken 5 minutes apart and that in such an emergency an ambulance is called for transport to the hospital. Review the interventions when an MI is suspected if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Awarded 1.0 points out of 1.0 possible points. 59. 59.ID: 18630147570 A cardiac monitor alarm sounds, and a nurse notes a straight line on the monitor screen. Which action should the nurse take immediately? A. Call a code. B. Assess the client. Correct Rationale: If a monitor alarm sounds, the nurse should first assess the clinical status of the client to see whether the problem is an actual dysrhythmia or a malfunction of the monitoring system. Asystole should not be mistaken for an unattached electrocardiogram wire. If the client is alert and the client’s status is stable, the problem is likely an unattached cardiac lead or wire. Calling a code and obtaining a rhythm strip from the monitor device are unnecessary if the client’s condition is stable. Test-Taking Strategy: Note the strategic word “immediately.” Use the steps of the nursing process, remembering that assessment is the first step. This will direct you to the correct option, the one that is client focused. Review care of the client undergoing cardiac monitoring if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular C. Check the cardiac leads and wires. D. Obtain a rhythm strip from the monitor device. Awarded 1.0 points out of 1.0 possible points. 60. 60.ID: 18630147550 The nurse assists with data collection on a client who has a diagnosis of left-sided heart failure. Which findings does the nurse expect to note? Select all that apply. A. Dyspnea Correct B. Dependent edema C. Neck vein distention D. Abdominal distention E. Crackles on auscultation of the lungs Correct Rationale: Signs of left-sided heart failure result from decreased cardiac output and increased pulmonary venous congestion, and the nurse would note signs related to the respiratory system, such as cough, dyspnea, and crackles and wheezes on auscultation of the lungs. Right-sided heart failure is associated with increased systemic venous pressure and congestion, and the nurse would note signs such as neck vein distention, dependent edema, abdominal distention, and weight gain. Test-Taking Strategy: Use the process of elimination and note the subject, left-sided heart failure. Remember “left and lungs” to remind yourself that the signs would be respiratory in nature. Review the signs of left- and right-sided heart failure if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Awarded 2.0 points out of 2.0 possible points. 61. 61.ID: 18630147509 A nurse provides instructions to a client with chronic obstructive pulmonary disease (COPD) about the positions that are most effective in alleviating dyspnea. Which statement by the client indicates a need for further instruction? A. “I should sit up in my recliner.” B. “I should lie on my right side in bed.” Correct Rationale: Positions that will help the client with COPD breathe more freely include sitting up and leaning on an overbed table, sitting up and resting with the elbows on the knees, sitting up in a chair, and standing and leaning against the wall. These positions allow for the greatest expansion of the lungs and respiratory cage in all directions. Lying on the side is not effective. Test-Taking Strategy: Use the process of elimination and note the strategic words “need for further instruction,” which indicate a negative event query and the need to select the incorrect client statement. Also eliminate the comparable or alike options that are all upright positions. Review the positions that will alleviate dyspnea in the client with COPD if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Respiratory C. “I should sit on the side of my bed and lean on the overbed table.” D. “I should stand with my back and hips against the wall and my shoulders bent slightly forward.” A nurse has admitted a client with a diagnosis of tuberculosis (TB) to the nursing unit. Which finding that confirms the diagnosis does the nurse expect to see documented in the client’s record? A. Night sweats and a low-grade fever B. Positive result on an acid-fast bacillus smear Correct Rationale: A definitive diagnosis of TB is confirmed through culture and isolation of Mycobacterium tuberculosis (acid-fast bacillus), which is the organism responsible for the disease. The initial testing involves microscopic examination of stained sputum smears for acid-fast bacilli (aka the ABF test). In the tuberculin skin test, or Mantoux test, 0.1 mL of purified protein derivative (PPD) is injected intradermally on the dorsal surface of the forearm. The injection site is then assessed in 48 to 72 hours for the presence of an induration. In low-risk individuals (e.g., those who are not immunocompromised), an area of induration (not redness) measuring 10 mm or more in diameter 48 to 72 hours after injection indicates exposure to and infection with TB. Night sweats, a low-grade fever, cough, and mucopurulent sputum are clinical manifestations of TB but do not confirm the diagnosis. Test-Taking Strategy: Use the process of elimination. Note the strategic word “confirms” in the query of the question. Remember that for an infectious disease to be confirmed, the causative organism must be identified. The correct option is the only one that involves a test to isolate the organism. If you had difficulty with this question, review the diagnostic tests related to TB. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Respiratory C. Cough and expectoration of mucopurulent sputum D. A Mantoux skin testing result that indicates 5 mm of redness Awarded 1.0 points out of 1.0 possible points. 63. 63.ID: 18630148304 A visitor to the long-term care center runs out of the dining room and yells, “My mom is choking on her peanut butter sandwich!” What is the nurse’s first action? A. Ask if she has nut allergies. B. Ask the client if she can speak. Correct Rationale: In the event of choking, the nurse’s first action should be to determine if the client can speak. The inability to speak indicates respiratory obstruction. Asking about nut allergies would delay care. Calling for the rapid response team and assessing for the presence of a carotid pulse would also delay care. Test-Taking Strategy: Use the ABCs (airway, breathing, circulation) to answer this question. Note the comparable or alike options that would delay establishing an airway rapidly. Review the steps for the Heimlich maneuver if you had difficulty answering this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care C. Call for the rapid response team. D. Assess for the presence of a carotid pulse. Incorrect Awarded 0.0 points out of 1.0 possible points. 64. 64.ID: 18630146843 A client who has a tracheostomy has wet, noisy respirations, and sputum can be seen at the top of the tracheostomy. The nurse will take which action first when suctioning this client’s tracheostomy? A. Preoxygenate the client. Correct Rationale: The nurse should preoxygenate the client before suctioning to prevent hypoxia from occuring during the suctioning process. Moistening the suction tip and inserting the suction tube until resistance is felt are both important steps when suctioning a client’s tracheostomy, but they are not the first steps. The nurse should not use the oropharyngeal suction catheter at the tracheostomy site because the oropharyngeal suction catheter is not sterile. Test-Taking Strategy: Use the ABCs (airway, breathing, circulation) to assist you in answering this question. Focus on the client’s need for an adequate airway. If you had difficulty with this question, review the steps to perform tracheostomy suctioning. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care B. Insert the suction tubing until resistance is felt. C. Dip the suction tip into the sterile water to moisten the catheter. D. Use the tip of the oropharyngeal suction catheter to remove the sputum. Awarded 1.0 points out of 1.0 possible points. 65. 65.ID: 18630146853 The nurse teaches a client with gastroesophageal reflux disease (GERD) about measures to prevent reflux during sleep. The nurse determines that the client needs additional instructions if the client makes which statement? A. “I should take an antacid at bedtime.” B. “I should sleep flat on my right side.” Correct Rationale: A side-lying position with head of the bed elevated is most likely to prevent reflux while sleeping. A flat position will increase reflux. The client is instructed to avoid eating in the 3 hours before bedtime because a full stomach may also cause reflux. Antacids and histamine antagonists may be prescribed for the client. Test-Taking Strategy: Use the process of elimination and note the strategic words “needs additional instruction,” which indicate a negative event query and the need to select the incorrect option. Recalling that a backward flow of gastric contents occurs in this disorder will direct you to the correct option. Review client teaching points for GERD if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Gastrointestinal C. “The histamine antagonist will help me.” D. “I should avoid eating in the 3 hours before bedtime.” Awarded 1.0 points out of 1.0 possible points. 66. 66.ID: 18630146833 A client is found to have viral hepatitis, and the nurse provides home care instructions to the client. The nurse should reinforce which instruction? A. Maintain strict bed rest. B. Limit the intake of alcohol. C. Take acetaminophen (Tylenol) for discomfort. D. Eat small, frequent meals that are low in fat and protein and high in carbohydrates. Correct Rationale: Fatigue is a normal response to hepatic cellular damage. During the acute stage, rest is an essential intervention to reduce metabolic demand on the liver and increase its blood supply, but strict bed rest is unnecessary. The client should avoid taking medications, including acetaminophen (which is hepatotoxic), unless they are prescribed by the health care provider. The client must avoid all alcohol consumption. The client should consume small frequent meals that are low in fat and protein and high in carbohydrates to reduce the workload of the liver. Test-Taking Strategy: Use knowledge of the subject, care of the client with viral hepatitis. Eliminate first the option of advising the client to limit alcohol intake, recalling that the nurse should advise the client to avoid alcohol intake altogether. Next eliminate the option of advising the client to maintain strict bed rest because of the strategic word “strict.” To select from the remaining options, recall that acetaminophen is hepatotoxic, which will assist you in eliminating this option. Review client instructions for the client with viral hepatitis if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Gastrointestinal Awarded 1.0 points out of 1.0 possible points. 67. 67.ID: 18630147542 A nurse is caring for a client with acute pancreatitis who will be admitted to the hospital. Into which position that will ease the abdominal pain does the nurse assist the client? A. Prone B. Supine with the legs straight C. With the knees drawn up to the chest Correct Rationale: Helping the client assume the fetal position (legs drawn up to the chest) will ease the abdominal pain of pancreatitis. Other helpful positions include sitting up, leaning forward, and flexing the legs (especially the left leg). Prone, supine with the legs straight, and side-lying with the head of the bed flat are incorrect. Test-Taking Strategy: Use the process of elimination. Focus on the subject, acute pancreatitis, and evaluate each of the options in terms of the amount of stretching or flexing of the abdominal wall that the position will cause. Also note the options that are comparable or alike in that they are flat positions. Review the positions that will ease pain in the client with acute pancreatitis if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Gastrointestinal D. Side-lying with the head of the bed flat Awarded 1.0 points out of 1.0 possible points. 68. 68.ID: 18630147511 A nurse is participating in a care planning conference regarding the care for a client with a new diagnosis of Graves disease. Which intervention does the nurse expect to see included in the plan? A. Placing extra blankets on the client B. Keeping the room warm C. Providing a high-calorie, high-protein diet Correct Rationale: Graves disease is characterized by a hypermetabolic state, and the client benefits most from an environment that is restful both physically and mentally. Therefore the client is encouraged to rest. As compensation for the hypermetabolic state, the client needs a diet that is high in calories and high in protein. Individuals with Graves disease experience heat intolerance and diaphoresis and require a cool environment. Test-Taking Strategy: Use the process of elimination. Eliminate first the comparable or alike options (i.e., extra blankets and a warm room). To select from the remaining options, recall that Graves disease is characterized by a hypermetabolic state, which will direct you to the correct option. Review care of the client with Graves disease if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine D. Encouraging frequent ambulation and activities Awarded 1.0 points out of 1.0 possible points. 69. 69.ID: 18630147589 A nurse is teaching a client with diabetes mellitus who requires insulin about methods of preventing diabetic ketoacidosis (DKA) when the client is ill. The nurse reinforces which client instruction? A. Refrain from eating or drinking during periods of vomiting. B. Take the prescribed insulin dose even if he is unable to eat. Correct Rationale: Insulin should never be independently stopped or decreased, and the client is instructed to take prescribed insulin even if he or she is vomiting or unable to eat. Acute illness may cause a counterregulatory hormone response, resulting in hyperglycemia. During times of illness, the client should monitor the blood glucose level and notify the health care provider if it exceeds 250 mg/dL. Adequate fluids and carbohydrates are essential during illness. The client should eat 10 to 15 g of carbohydrate every 1 to 2 hours and drink a small quantity of fluid every 15 to 30 minutes to help prevent dehydration and ketoacidosis. The client should notify the health care provider of a fever over 100°F. Test-Taking Strategy: Thinking about the subject, the pathophysiology of DKA, and recalling that the client should not stop or adjust the insulin dose will direct you to the correct option. Review diabetic management during times of illness if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Endocrine C. Contact the health care provider if a fever over 102°F occurs. D. Contact the health care provider when the premeal blood glucose value is greater than 350 mg/dL. Awarded 1.0 points out of 1.0 possible points. 70. 70.ID: 18630148312 A home care nurse visits a pregnant client with a diagnosis of mild preeclampsia. During the assessment, the client tells the nurse that she has had an upset stomach and pain in the epigastric area. The nurse should perform which action? A. Contact the client’s health care provider. Correct Rationale: Preeclampsia is dangerous to the woman and fetus because it can progress rapidly, and the earliest manifestations may go unnoticed by the woman. Some symptoms, such as epigastric pain and upset stomach, are particularly ominous because they indicate distention of the hepatic capsule and often mean that a seizure is imminent. Therefore telling the client to avoid lying flat, instructing the client to eat a small portion of food every 2 to 3 hours, and administering an antacid and telling the client to take a dose every 6 hours are all incorrect. Additionally, the nurse would not administer an antacid to the pregnant client without a prescription to do so. Test-Taking Strategy: Use the process of elimination. Recalling that the nurse would not administer medication to the pregnant client without a prescription to do so will assist you in eliminating the option of administering an antacid first. Although the other options may be generally helpful interventions, focus on the data in the question, the client’s diagnosis and recall that epigastric pain is a sign of impending seizures. Review the signs that indicate a worsening of preeclampsia if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Antepartum B. Tell the client to avoid lying flat. C. Instruct the client to eat a small portion of food every 2 to 3 hours. D. Administer an antacid to the client and tell her to take a dose every 6 hours. Awarded 1.0 points out of 1.0 possible points. 71. 71.ID: 18630147548 A nurse is assisting with data collection of a client with mild preeclampsia. Which sign indicates improvement in the client’s condition? A. Trace protein in the urine Correct Rationale: Preeclampsia is considered mild when the systolic blood pressure is 140 mm Hg or greater but less than 160 mm Hg and the diastolic blood pressure is 90 mm Hg or greater but less than 110 mm Hg, proteinuria is 1+ on a random dipstick, and symptoms such as headache, visual disturbances, and abdominal pain are absent. In addition, signs of kidney or liver involvement are absent. An increased BUN level indicates kidney damage, a result of the preeclampsia. Test-Taking Strategy: Use the process of elimination, noting the strategic words “improvement in the client’s condition.” Think about the manifestations of mild preeclampsia; the only option that is indicative of improvement is trace protein in the urine. Review the signs of mild and severe preeclampsia and the signs that indicate improvement if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Intrapartum B. Blood urea nitrogen (BUN) of 40 mg/dL C. Blood pressure 148/94 mm Hg D. Complaint of headache Awarded 1.0 points out of 1.0 possible points. 72. 72.ID: 18630146860 A nurse is monitoring a client who is in the active phase of labor and has been experiencing contractions that are coordinated but weak. Which finding indicates to the nurse that the client may be experiencing hypotonic contractions? A. Fetal hypoxia B. Discomfort with each contraction C. Increased frequency and longer duration of contractions D. Contractions that can be indented easily with fingertip pressure at their peakCorrect Rationale: Hypotonic contractions, coordinated but too weak to be effective, usually occur during the active phase of labor, when progress normally quickens. Contractions are infrequent and brief and can easily be indented on the abdomen with fingertip pressure at their peak. These contractions cause minimal discomfort because the contractions are weak. Fetal hypoxia is not usually seen with hypotonic contractions. Test-Taking Strategy: Use the data in the question to assist you with finding the correct option. Note the relationship between the subject, hypotonic contractions, and the correct option. Review the characteristics of hypotonic contractions if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Awarded 1.0 points out of 1.0 possible points. 73. 73.ID: 18630146841 A client in active labor says “something is sticking out of me.” The nurse notes that the umbilical cord is protruding from the vagina. The nurse summons the registered nurse while taking which immediate action? A. Push the cord gently back into the vagina. B. Prepare the client for cesarean delivery. C. Place the client in the knee-chest position. Correct Rationale: When cord prolapse occurs, prompt action is taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. Such positions include knee-chest, Trendelenburg, and the hips elevated on pillows with the client in a side-lying position. The nurse should push the call light to summon help, and other staff members should call the health care provider and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because to do so could traumatize it and further reduce blood flow. Oxygen at 8 to 10 L/min by way of facemask is administered to the mother to increase fetal oxygenation. A tocolytic medication is administered to inhibit contractions on the order of the health care provider, and the client is quickly prepared for delivery, but these are not the actions that would be taken immediately. Test-Taking Strategy: Use the process of elimination, noting the words “umbilical cord is protruding from the vagina.” Eliminate first the comparable or alike options describing actions that delay necessary and immediate treatment. To select from the remaining options, recall that the cord should not be pushed back into the vagina; this will direct you to the correct option. Review priority nursing interventions for a prolapsed cord if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care D. Prepare to administer a tocolytic medication. Awarded 1.0 points out of 1.0 possible points. 74. 74.ID: 18630147562 A woman in labor suddenly complains of abdominal tenderness and pain and states that she felt as though “something ripped.” Which manifestations does the nurse suspect are caused by uterine rupture? Select all that apply. A. Bradypnea B. Severe abdominal pain Correct C. Absence of fetal heart tones Correct D. Increased blood pressure E. Increased frequency of uterine contractions Rationale: Signs of uterine rupture vary with the degree of rupture. Signs and symptoms include abdominal pain and tenderness, chest pain, hypovolemic shock, signs associated with impaired fetal oxygenation, an absence of fetal heart tones, cessation of uterine contractions, and palpation of the fetus outside the uterus if the rupture is complete. Signs of hypovolemic shock include tachycardia; tachypnea; pallor; cool, clammy skin; and anxiety. Test-Taking Strategy: Use the process of elimination, thinking about the subject, the manifestations that would be present in the event of uterine rupture. Knowing that bleeding would occur and recalling the signs of shock will assist you in answering correctly. Also, recalling that contractions would cease if rupture occurred will assist you in eliminating the option of increased frequency of uterine contractions. Review the manifestations associated with uterine rupture if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Awarded 2.0 points out of 2.0 possible points. 75. 75.ID: 18630147552 A client in the third trimester of pregnancy is experiencing painless vaginal bleeding, and placenta previa is suspected. For which of the following interventions does the nurse prepare the client? A. An ultrasound examination Correct Rationale: A manual pelvic examination or any action that would stimulate uterine activity is contraindicated when vaginal bleeding is apparent in the third trimester until a diagnosis is made and placenta previa is ruled out. Digital examination of the cervix can lead to maternal and fetal hemorrhage. A diagnosis of placenta previa is made with the use of ultrasound. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus that is at risk for severe hypoxia, but internal fetal monitoring is contraindicated. Oxytocin would stimulate uterine contractions and is therefore contraindicated. Test-Taking Strategy: Think about the pathophysiology of placenta previa, noting the comparable or alike options that would stimulate uterine activity and would endanger the safety of the client and fetus. Review care of the client with placenta previa if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Antepartum B. Internal fetal monitoring C. Administration of oxytocin (Pitocin) D. A manual (digital) pelvic examination Awarded 1.0 points out of 1.0 possible points. 76. 76.ID: 18630147558 A nurse is reading the medical record of a pregnant client in the second trimester with a diagnosis of abruptio placentae. Which clinical manifestation of the disorder does the nurse expect to see documented? A. Uterine tenderness Correct Rationale: In abruptio placentae, abdominal pain and uterine tenderness are present. Uterine tenderness accompanies placental abruption, especially with a central abruption in which blood becomes trapped behind the placenta. The abdomen will feel hard and boardlike on palpation because the blood penetrates the myometrium, resulting in uterine irritability. Excessive uterine activity with poor relaxation between contractions is present. Fetal monitoring often reveals increased uterine resting tone, caused by failure of the uterus to relax in an attempt to constrict blood vessels and control bleeding. Painless bright-red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. Constipation is not associated with this disorder. Test-Taking Strategy: Use the process of elimination, focusing on the subject, abruptio placentae. Think about the pathophysiology of this disorder. Recalling that abdominal pain and uterine tenderness accompany abruptio placentae will direct you to the correct option. Review the signs of abruptio placentae if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum B. Lack of uterine activity C. Painless vaginal bleeding D. Constipation Awarded 1.0 points out of 1.0 possible points. 77. 77.ID: 18630147560 A nurse assessing a client in the fourth stage of labor notes that the uterine fundus is firmly contracted and is midline at the level of the umbilicus. On the basis of this finding, the nurse most appropriately performs which action? A. Records the findings Correct Rationale: In the postpartum period, the nurse assesses for uterine atony and checks the consistency and location of the uterine fundus. The uterine fundus should be firmly contracted, at or near the level of the umbilicus, and midline. Therefore the nurse would record the findings. Because the finding is normal, massaging the fundus, contacting the health care provider, and assisting the mother to void are not necessary. The nurse would massage the uterine fundus if it were soft and boggy. The health care provider would be contacted if the client were to experience excessive bleeding. A full bladder could cause a displaced fundus and one that is above the level of the umbilicus. Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Recalling the normal location and consistency of the fundus will direct you to the correct option. Review expected postpartum findings if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum B. Massages the fundus C. Contacts the health care provider D. Helps the mother void Awarded 1.0 points out of 1.0 possible points. 78. 78.ID: 18630146858 Mastitis is diagnosed in a client who recently gave birth. The nurse should provide which client teaching? A. Wearing a bra will increase the discomfort. B. Antibiotics are not usually used to treat this disorder. C. Breastfeeding must be discontinued until the condition resolves. D. Moist heat will increase circulation and may be used before the breasts are emptied. Correct Rationale: Antibiotic therapy and continued decompression of the breasts, by means of breastfeeding or with a breast pump, is prescribed for the client with mastitis. In most cases the mother may continue to feed with both breasts. If the affected breast is too sore, the mother may pump the breast gently. Regular emptying of the breast is important in preventing abscess formation. Antibiotic therapy helps resolve mastitis within 24 to 48 hours. Additional supportive measures include moist heat or ice packs, breast support, and analgesics. Moist heat promotes comfort and increases circulation. A shower or hot packs should be used before the breasts are emptied or before feeding. Test-Taking Strategy: Use data in the question to assist you with this question. Recalling that mastitis is an infection of the breasts and remembering that breast support will alleviate discomfort will assist you in answering correctly. Also, recalling the effects of heat will direct you to the correct option. Review measures for the client with mastitis if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Maternity/Postpartum Awarded 1.0 points out of 1.0 possible points. 79. 79.ID: 18630147515 A mother calls the clinic and tells the nurse that her newborn’s umbilical cord site looks red and swollen. The nurse should give the mother which instruction? A. That this is a normal occurrence B. To bring the newborn to the clinic Correct Rationale: Symptoms of cord infection include moistness, oozing, discharge, swelling, and a reddened base. If symptoms of infection occur, the newborn must be seen by the health care provider. Telling the mother to increase the number of times that the cord is cleansed each day or to place an ice pack on the umbilical cord site and stating that this is a normal occurrence are inappropriate nursing interventions. Test-Taking Strategy: Use the process of elimination, focusing on the clinical manifestations provided in the question. Noting the strategic words “red and swollen” should direct you to the option of having the newborn be seen by the health care provider. Review cord care interventions if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Newborn C. To increase the number of cord site cleanings each day D. To place an ice pack on the cord for 10 minutes three times a day Awarded 1.0 points out of 1.0 possible points. 80. 80.ID: 18630147529 A nurse provides instructions to the mother of a newborn with hyperbilirubinemia who is being breastfed. The nurse determines that the mother understands the instructions if the mother says that she will perform which action? A. Bottle feed only B. Breastfeed the newborn every 2 to 3 hours Correct Rationale: Breastfeeding should be initiated within 2 hours of birth and performed every 2 to 3 hours thereafter. Supplementation with water should be avoided because the newborn may take less milk, which is more effective than water in removing bilirubin from the intestines. The infant should not be fed less frequently. It is not necessary to stop breastfeeding and to bottle feed only. Test-Taking Strategy: Use the process of elimination. Eliminate the option that includes the closed-ended word “only.” Because the newborn requires nutrition and feeding to speed the elimination of bilirubin, you should eliminate the option of feeding the newborn less frequently. To select from the remaining options, choose the option that indicates frequent feedings. Review home care instructions in regard to hyperbilirubinemia in the newborn if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Newborn C. Provide water feedings between breast feedings D. Feed her newborn less frequently until the bilirubin level drops Awarded 1.0 points out of 1.0 possible points. 81. 81.ID: 18630148314 A nurse in the newborn nursery is monitoring a neonate born to a mother with diabetes mellitus. For which of the following findings does the nurse monitor the neonate most closely? A. Hypercalcemia B. Hyperglycemia C. Hypobilirubinemia D. Respiratory distress syndrome Correct Rationale: The major neonatal complications of preexisting diabetes mellitus in the mother are hypoglycemia, hypocalcemia, hyperbilirubinemia, and respiratory distress syndrome. The infant of a diabetic mother is more likely to have delayed production of pulmonary surfactant, which is needed to keep the alveoli open after birth. Test-Taking Strategy: Use the process of elimination. Focusing on the subject, the mother’s diagnosis of diabetes mellitus, will assist you in eliminating the incorrect options. Also, thinking about the pathophysiology of diabetes mellitus and recalling that the infant is likely to have delayed production of pulmonary surfactant will direct you to the correct option. Review the effects of maternal diabetes mellitus on the fetus if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Newborn Awarded 1.0 points out of 1.0 possible points. 82. 82.ID: 18630146895 A nurse is assessing a newborn for fetal alcohol syndrome (FAS). Which finding would the nurse expect to note in the newborn? A. Greater-than-average length B. Higher-than-normal birth weight C. Short palpebral fissures and a flat midface Correct Rationale: Fetal alcohol syndrome (FAS) is characterized by recognizable facial anomalies, prenatal and postnatal growth restriction, and central nervous system impairment. The common facial anomalies include short palpebral fissures (the openings between the eyelids), a flat midface, an indistinct philtrum (median groove on the external surface of the upper lip), and a thin upper lip. Test-Taking Strategy: Use the process of elimination. Eliminate comparable or alike options that are related to the size of the newborn. If you had difficulty with this question, review the characteristics of the newborn with FAS. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Newborn D. Greater-than-average head circumference Awarded 1.0 points out of 1.0 possible points. 83. 83.ID: 18630147597 A nurse is preparing a teaching plan for the parents of an infant with a ventricular peritoneal shunt. Which of the following questions does the nurse plan to include? A. Call the health care provider if the infant is lethargic. Correct Rationale: If the shunt is broken or malfunctioning, the fluid from the ventricle part of the brain will not be diverted to the peritoneal cavity, cerebrospinal fluid will build up in the cranial area. The result is intracranial pressure, which causes the infant to make a high-pitched cry or induces changes in level of consciousness, such as lethargy. The infant should not be positioned on the side of the shunt, because this will cause pressure on the shunt and skin breakdown. This type of shunt affects the gastrointestinal system, not the genitourinary system, and an increased urine output is not expected. The anterior fontanel normally bulges when the infant cries. Test-Taking Strategy: Use knowledge of the subject, ventricular-peritoneal shunt placement. Remember that a change in the level of consciousness indicates increased intracranial pressure, which occurs with shunt malfunction. If you had difficulty with this question, review assessment findings and home care instructions for the parents of an infant with a ventricular peritoneal shunt. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Child Health—Neurological B. Expect increased urine output with the shunt. C. Call the health care provider if the anterior fontanel bulges when the infant cries. D. Position the infant on the side of the shunt for sleep. Awarded 1.0 points out of 1.0 possible points. 84. 84.ID: 18630147572 A nurse in a newborn nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (meningomyelocele type) will be transported to the nursery. Which item does the nurse, preparing for the arrival of the newborn, make a priority of placing at the newborn’s bedside? A. Flashlight B. Sterile dressing Correct Rationale: The newborn with spina bifida is at risk for infection before the closure of the gibbus. A sterile normal saline dressing is placed over the gibbus to maintain moisture of the gibbus and its contents. This prevents tearing or breakdown of the skin at the site. A flashlight may be needed to closely assess the status of the gibbus, but is not a priority item. A cardiac monitor is not necessary. Blood pressure is difficult to assess during the newborn period and is not the best indicator of infection. The blood pressure cuff would not be a priority item. Test-Taking Strategy: Knowledge of the subject, characteristics of spina bifida, the care involved, and the potential complications is needed to answer this question. Recalling that this newborn will have a gibbus requiring covering with sterile normal saline dressings will direct you to the correct option. Review care of the newborn with spina bifida if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Newborn C. Cardiac monitor D. Blood pressure cuff Awarded 1.0 points out of 1.0 possible points. 85. 85.ID: 18630147583 A nurse is assessing a child with increased intracranial pressure who has been exhibiting decorticate posturing. The nurse notes extension of the upper and lower extremities, with internal rotation of the upper arms and wrists and the knees and feet. The nurse makes which determination about the child’s condition? A. Indicates improved neurological status B. Indicates decreased intracranial pressure C. Indicates deterioration in neurological function Correct Rationale: In decorticate posturing, the upper extremities are flexed and the lower extremities are extended. In decerebrate posturing, the upper and lower extremities are extended and the upper arms and wrists and the knees and feet are internally rotated. The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants health care provider notification. The remaining options are inaccurate interpretations. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate improvement in the child’s condition. Also, recalling the significance of decerebrate posturing will direct you to the correct option. If you are unfamiliar with the significance of assessment findings in the child with increased intracranial pressure, review this content. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Child Health—Neurological D. Is unchanged from the previous neurological assessment Awarded 1.0 points out of 1.0 possible points. 86. 86.ID: 18630146815 An ambulatory care nurse is providing home care instructions to the mother of a child who had a tonsillectomy. The nurse determines that the mother needs further instruction if she indicates that she will take which action? A. Avoid giving citrus juices to her child. B. Have her child use a straw to make drinking easier. Correct Rationale: Introduction of a straw, fork, or any other pointed object into the mouth could result in accidental contact with the surgical site and disrupt its integrity. Citrus fruits are avoided because they could irritate the throat. Acetaminophen is used for pain relief. A foul mouth odor is normal and can be relieved by drinking fluids. Test-Taking Strategy: Use the process of elimination, noting the strategic words “needs further instruction,” which indicate a negative event query and the need to select the incorrect statement. Considering the anatomic location of the surgery will direct you to the correct option. Remember, introducing a straw, fork, or any other pointed object into the mouth could result in accidental contact with the surgical site and disrupt its integrity. Review postoperative care after tonsillectomy if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Child Health—Throat and Respiratory C. Give acetaminophen (Tylenol) to her child for discomfort. D. Give her child extra fluids to relieve a foul odor from the mouth. Awarded 1.0 points out of 1.0 possible points. 87. 87.ID: 18630147595 A home care nurse has provided instructions to the father of a child with croup regarding treatment measures. Which statement by the father indicates a need for further instruction? A. “I should put a steam vaporizer in her room.” Correct Rationale: Steam from running water in a closed bathroom and cool mist from a bedside humidifier or a freezer are effective in reducing mucosal edema. A cool mist humidifier is recommended over a steam vaporizer, which presents a danger of scald burns. Taking the child out into the cool humid night air may also relieve mucosal swelling. Test-Taking Strategy: Note the strategic words “need for further instruction,” which indicate a negative event query and the need to select the incorrect statement. Use the process of elimination, keeping in mind that the goal is to reduce mucosal edema and to provide a safe environment. Also note that the correct option presents an unsafe situation for the child. Review home care instructions for the child with croup if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Child Health—Throat and Respiratory B. “I’ll take her out into the cool, humid night air.” C. “I can open the freezer door and encourage her to breathe in the cool air.” D. “I can run the hot water in my bathroom and cuddle her in the steamy room.” Awarded 1.0 points out of 1.0 possible points. 88. 88.ID: 18630146864 A nurse is caring for a hospitalized child with a diagnosis of Kawasaki disease. During the subacute phase, the nurse monitors the child closely for which manifestation? A. Bleeding B. A high fever C. Failure to thrive D. Signs of congestive heart failure (CHF) Correct Rationale: Kawasaki disease is an acute systemic vasculitis that primarily affects the cardiovascular system. The subacute phase is characterized by continued irritability, anorexia, desquamation of the fingers and toes, arthritis and arthralgia, and cardiovascular manifestations, including CHF. Nursing care is focused on observation of the child for signs of CHF. The nurse is alert for an increased respiratory rate, increased heart rate, dyspnea, congestion and crackles, and abdominal distention. Bleeding, a high fever, and failure to thrive are not directly associated with this disorder. In the subacute phase, the fever subsides. Test-Taking Strategy: Use data in the question and recall the pathophysiology of Kawasaki disease. Recalling that Kawasaki disease primarily affects the cardiovascular system will direct you to the correct option. If you are unfamiliar with Kawasaki disease, review this content. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health—Cardiovascular Awarded 1.0 points out of 1.0 possible points. 89. 89.ID: 18630148302 A nurse has been assigned to care for an infant with tetralogy of Fallot. The infant suddenly exhibits rapid, deep respirations; irritability; and cyanosis. The nurse determines that the infant is experiencing a hypercyanotic episode and immediately performs which action? A. Calls a code B. Holds the infant in an upright position C. Places the infant in the knee-chest position Rationale: If a hypercyanotic episode occurs, the infant is calmed and placed in the knee-chest position, and the health care provider is notified. The knee- chest position is thought to increase pulmonary blood flow by increasing systemic vascular resistance. This position also improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to achieve this position and relieve chronic hypoxia. Oxygen is also administered to the infant. Test-Taking Strategy: Use the process of elimination and note the strategic word “immediately” in the query of the question. Because there is no information in the question to indicate that calling a code is necessary, you may eliminate this option. To select from the remaining options, remember that a toddler or child would squat to achieve the position of relief; this will assist in directing you to the correct option. Review nursing measures for the infant experiencing a hypercyanotic episode if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Cardiovascular D. Contacts the respiratory therapy department Awarded 1.0 points out of 1.0 possible points. 90. 90.ID: 18630146866 A nurse is assisting with data collection for a child with rheumatic fever. Which question does the nurse ask the parents to elicit information specific to the development of the disease? A. “Has he had any loss of appetite?” B. “Has he complained of a backache recently?” C. “Has he been excessively tired or lethargic?” D. “Has he had a sore throat in the last few months?” Rationale: Rheumatic fever characteristically presents 2 to 6 weeks after an untreated or partially treated group A beta-hemolytic streptococcal infection of the upper respiratory tract. The nurse first determines whether the child had a sore throat or an unexplained fever within the past 2 months. Asking the parents whether the child has had any loss of appetite, complained of backache recently, or been excessively tired or lethargic will elicit information unrelated to rheumatic fever. Test-Taking Strategy: Use knowledge of the subject, rheumatic fever. It is necessary to know that a streptococcal infection of the upper respiratory tract is associated with rheumatic fever. This will direct you to the correct option. Review the origin of rheumatic fever if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health—Cardiovascular Awarded 1.0 points out of 1.0 possible points. 91. 91.ID: 18630147578 A nurse is obtaining subjective data from the mother of a child admitted to the hospital with a diagnosis of intussusception. Which occurrences does the nurse expect the mother to report? A. Scleral jaundice B. Projectile vomiting C. Hard, pale stools D. Bloody mucus stools and diarrhea Correct Rationale: In the child with intussusception, bloody mucus stools, commonly described as “currant jelly” stools, and diarrhea may occur. The child classically presents with severe abdominal pain that is crampy and intermittent, causing the child to draw the knees to the chest. This pain progresses to a more severe constant pain. Vomiting may be present, but it is not projectile in nature. Pale, hard stools and scleral jaundice are not manifestations of this disorder. Test-Taking Strategy: Focus on the subject, the child’s diagnosis of intussusception. Recalling that a classic manifestation of this disorder is currant jelly stools will direct you to the correct option. Review the clinical manifestations of intussusception if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health—Gastrointestinal Awarded 1.0 points out of 1.0 possible points. 92. 92.ID: 18630146823 A nurse provides dietary instructions to the mother of a child with celiac disease. Which of the following foods does the nurse tell the mother to include in the child’s diet? A. Rice Correct Rationale: Dietary management is the mainstay of treatment in celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements, especially fat-soluble vitamins and folate, may be needed in the early period of treatment to correct deficiencies. Dietary restrictions are likely to be lifelong, although small amounts of grains may be tolerated after the ulcerations have healed. Test-Taking Strategy: Use the process of elimination and knowledge regarding the subject, dietary management of celiac disease, to answer this question. Recalling that corn and rice are substitutes for gluten-containing foods in this disease will direct you to the correct option. Review dietary management of celiac disease if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Child Health—Gastrointestinal B. Wheat cereal C. Rye crackers D. Oatmeal biscuits Awarded 1.0 points out of 1.0 possible points. 93. 93.ID: 18630146819 A child with a diagnosis of pertussis (whooping cough) is being admitted to the pediatric unit. As soon as the child arrives to the unit, the nurse takes which action first? A. Weighs the child B. Takes the child’s temperature C. Attaches the child to a pulse oximeter Correct Rationale: To adequately determine whether the child is getting enough oxygen, the nurse attaches the child to a pulse oximeter. The pulse oximeter will then provide ongoing information on the child’s oxygen level. The child is also immediately attached to a cardiorespiratory monitor to provide early identification of periods of apnea and bradycardia. Next the nurse performs an assessment, including the child’s temperature and weight, and asks the parents about the child. An antibiotic may be prescribed, but the child’s airway status must be assessed first. Test-Taking Strategy: Note the strategic word “first.” Focus on the child’s diagnosis and use the ABCs (airway, breathing, and circulation). This will direct you to the correct option. Review the priority interventions in the care of a child with pertussis if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Throat and Respiratory D. Administers the prescribed antibiotic Awarded 1.0 points out of 1.0 possible points. 94. 94.ID: 18630147554 A nurse is assisting with data collection on a 12-month-old child with iron-deficiency anemia. Which finding does the nurse expect to note in this child? A. Lethargy Correct Rationale: Clinical manifestations of iron-deficiency anemia vary with the degree of anemia but usually include extreme pallor with porcelainlike skin, tachycardia, lethargy, and irritability. Test-Taking Strategy: Use the process of elimination and think about the subject, the manifestations that would be noted in anemia. Recalling that pallor, rather than reddened skin, would most likely be noted will assist you in eliminating this option. Eliminate the option of hyperactivity because when iron deficiency occurs the child is lethargic and irritable rather than hyperactive. Next eliminate the option of bradycardia because tachycardia would occur as the body attempted to compensate for the low hemoglobin and hematocrit levels. Review the clinical manifestations of iron-deficiency anemia if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health—Hematological B. Bradycardia C. Hyperactivity D. Reddened cheeks Awarded 1.0 points out of 1.0 possible points. 95. 95.ID: 18630147519 A nurse is caring for a child with newly diagnosed type 1 diabetes mellitus who is receiving insulin. The child suddenly exhibits tachycardia and beings to sweat and tremble, and the nurse determines that the child is experiencing a hypoglycemic reaction. The nurse would immediately give the child which item? A. A sugar cube B. A teaspoon of sugar C. ½ cup of diet cola D. ½ cup of fruit juice Correct Rationale: Hypoglycemia is immediately treated with 15 g of carbohydrate. Glucose tablets or glucose gel may be administered. Other items used to treat hypoglycemia include ½ cup of fruit juice, ½ cup of a regular (nondiet) soft drink, 8 oz of skim milk, 6 to 10 hard candies, 4 cubes of sugar or 4 tsp of sugar, 6 saltines, 3 graham crackers, and 1 tablespoon of honey or syrup. One sugar cube, a teaspoon of sugar, or ½ cup of diet cola would not be adequately treatment for hypoglycemia. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options (i.e., they contain sugar). To select from the remaining options, recall that a diet cola does not contain an adequate amount of carbohydrate to treat hypoglycemia. Review the treatment for hypoglycemia if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Endocrine Awarded 1.0 points out of 1.0 possible points. 96. 96.ID: 18630147546 A nurse is reviewing the assessment findings and laboratory results of a child with a diagnosis of new-onset glomerulonephritis. Which finding would the nurse expect to note? A. Hypertension Correct Rationale: Hypertension is a common finding in glomerulonephritis. Gross hematuria resulting in dark-brown or smoky tea-colored urine is also a classic symptom of glomerulonephritis. The blood urea nitrogen and creatinine levels are increased only when there is an 80% decrease in glomerular filtration rate and renal insufficiency is severe. A high potassium level results from inadequate glomerular filtration. Test-Taking Strategy: Use the process of elimination and your knowledge of the subject, the assessment findings associated with glomerulonephritis, to answer this question. Recalling that the creatinine level is increased only with an 80% decrease in glomerular filtration rate will assist you in eliminating this option. Eliminate cloudy yellow urine next, knowing that this assessment finding is not normally noted in glomerulonephritis. To select from the remaining options, it is necessary to know that hypertension and a high potassium level are most likely in this kidney disorder. If you had difficulty with this question, review the clinical manifestations of glomerulonephritis. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health—Renal B. Low serum potassium C. Increased creatinine level D. Cloudy yellow urine Awarded 1.0 points out of 1.0 possible points. 97. 97.ID: 18630147536 A home care nurse is providing instructions to the mother of a 3-year-old with hemophilia regarding care of the child. Which of these statements by the mother indicate a need for further instructions? Select all that apply. A. “I will be so glad when my baby outgrows all of this bleeding.” Correct B. “I need to cancel all of the dental appointments that I’ve made for him.” Correct C. “If he gets a cut, I should hold pressure on it until the bleeding stops.” D. “I should check the house for any household items that could fall over easily.” E. “I should move furniture with sharp corners out of the way and pad the corners of the furniture.” Rationale: Hemophilia is the term given to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Identifying the specific coagulation deficiency is important because it allows definitive treatment with the specific replacement agent to be implemented; aggressive replacement therapy is initiated to prevent the chronic crippling effects of joint bleeding. The child does not outgrow the disorder, and lifetime management is needed. The nurse must stress the importance of immunizations, dental hygiene, and routine well-child care for the child with hemophilia. The remaining statements represent appropriate care measures. Test-Taking Strategy: Note the strategic words “need for further instruction” in the query of the question, which indicate a negative event query and the need to select the incorrect statement. Recalling that bleeding is a concern in this disorder and remembering that the disorder is lifelong will assist you in answering correctly. If you had difficulty with this question, review care of the child with hemophilia. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Child Health—Hematological Awarded 2.0 points out of 2.0 possible points. 98. 98.ID: 18630147513 A client has undergone creation of an Indiana pouch for urine diversion after cystectomy, and the nurse provides instructions about reservoir catheterization. The nurse provides which client teaching? A. To plan to drain the reservoir every 2 to 3 hours initially Correct Rationale: An Indiana pouch is a continent internal ileal reservoir, and the nurse instructs the client in the technique of catheterization. Initially the client drains the reservoir every 2 to 3 hours. Each week thereafter, the interval is increased by 1 hour until finally catheterization is completed every 4 to 6 hours during the day. The catheter is never forced into the reservoir. If resistance is met, the client is instructed to pause and apply only gentle pressure while slightly rotating the catheter. A 16F to 20F catheter is used; 26F is too large and could damage the reservoir. Mucus is expected, and the client is instructed to irrigate the reservoir with 50 to 60 mL of normal saline solution to prevent excessive mucus buildup. Test-Taking Strategy: Use the process of elimination. Use knowledge of the subject to answer this question. Eliminate first the option that includes the word “force.” Next, visualize a 26F catheter; this will assist you in eliminating this option. To select from the remaining options it is necessary to recall that mucus is an expected occurrence. Review client teaching points for catheterization of an Indiana pouch if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Renal B. That if mucus drains from the reservoir, the health care provider should be contacted C. That sometimes force is needed to insert the catheter into the reservoir D. To obtain 26F catheters from the medical supply store for the irrigations Awarded 1.0 points out of 1.0 possible points. 99. 99.ID: 18630146872 A nurse is reviewing this rhythm strip from a cardiac monitor. Which type of abnormal beats does the nurse recognize? A. Sinus bradycardia B. Ventricular fibrillation C. Ventricular tachycardia D. Premature ventricular contractions (PVCs) Correct Rationale: PVCs are labeled as premature because they occur early in relation to the timing of previous normal beats. They have no visible P wave and have a characteristically wide and bizarre QRS complex. There is a compensatory pause. These ectopic beats are generally easy to recognize on the electrocardiogram (ECG). When every other beat is a PVC, the rhythm is called ventricular bigeminy. When every third beat is a PVC, it is called trigeminy. Sinus bradycardia is characterized by a normal sinus rhythm, but the rate is slower than normal. Ventricular fibrillation is the result of chaos in the ventricles. Impulses from many irritable foci fire in a totally disorganized manner, preventing ventricular contraction. There are no recognizable deflections. Ventricular tachycardia occurs because of a repetitive firing of an irritable ventricular ectopic focus at a rate of 140 to 250 tines/min or more; it may present as a paroxysm of three self-limiting beats or more or may be a sustained rhythm. Test-Taking Strategy: Knowledge of the subject, the characteristics of PVCs, is needed to answer this question. Use the process of elimination and think about the characteristics of each rhythm identified in the options. Review the characteristics of PVCs if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Awarded 1.0 points out of 1.0 possible points. 100. 100.ID: 18630147566 The alarm on a client’s cardiac monitor goes off, and the nurse rushes to the client’s bedside and finds the client unconscious. After noting the following rhythm on the monitor, the nurse immediately takes which action? A. Checks for a radial pulse B. Assesses the client’s neurological status C. Increases the flow rate of the client’s intravenous infusion D. Begins cardiopulmonary resuscitation (CPR) Correct Rationale: Ventricular fibrillation is the result of chaos in the ventricles. Impulses from many irritable foci fire in a totally disorganized manner, preventing ventricular contraction. There are no recognizable deflections. The goals of treatment are to terminate the ventricular fibrillation promptly and to convert it to an organized rhythm by means of defibrillation. The nurse would immediately begin CPR and continue it until a defibrillator arrived. Because the nurse has already noted that the client is unconscious, assessing the client’s neurological status is incorrect. Increasing the flow rate of the oxygen and increasing the flow rate of the client’s IV infusion will not provide the support needed in this emergency. CPR guidelines recommend CAB—circulation, airway, and breathing. If the nurse checks for a pulse, it should be a carotid pulse, not a radial pulse. Test-Taking Strategy: Use knowledge of the subject, measures to be taken with ventricular fibrillation. Note that the nurse has already determined that the client is unconscious to eliminate the option in which the nurse assesses the client’s neurological status. To select from the remaining options, note that the rhythm is ventricular fibrillation; this should direct you to the correct option. Review the characteristics of ventricular fibrillation and the interventions to be taken immediately if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care Awarded 1.0 points out of 1.0 possible points.