2021 NCLEX Readiness corrected

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2021 NCLEX READINESS STUDY GUIDE What intervention is essential prior to starting a client on atorvastatin therapy? 1. Assessing for muscle strength 2. Assessing the client's dietary intake ... 3. Determining if the client is on digoxin therapy 4. Monitoring liver function tests Correct Answer: 4 Rationale Prior to starting therapy with statin medications (eg, rosuvastatin, simvastatin, pravastatin, atorvastatin), the client's liver function tests should be assessed. The drug is metabolized by the hepatic enzyme system and could cause drug-induced hepatitis and increased liver enzymes. Liver function tests should be assessed prior to the start of therapy. Question: 2 The nurse provides discharge instructions to a client at 14 weeks gestation who has received a prophylactic cervical cerclage. Which client statement indicates an understanding of the teaching? 1. "I need to be on bedrest for the duration of my pregnancy." 2. "I will notify my health care provider if I start having low backaches." 3. "Pelvic pressure is to be expected after cerclage placement." 4. "The cerclage will be removed once my baby is at 28 weeks." Correct Answer: 2 Rationale Cervical cerclage is placed to prevent preterm delivery, usually in clients with histories of second-trimester loss or premature birth. A heavy suture is placed transvaginal or trans-abdominally to keep the internal cervical closed. Placement occurs at 12–14 weeks gestation for clients with a history of cervical insufficiency (ie, painless, premature cervical dilation and miscarriage or preterm delivery) or up to 23 weeks gestation if signs of cervical insufficiency (eg, short cervix) are noted. Discharge instructions include activity restriction and recognition of signs of preterm labor (eg, low back aches, contractions, pelvic pressure) and rupture of membranes (Option2). (Option 1) Bed rest is usually recommended for a few days after the procedure. Long-term bed rest is individualized but uncommon and increases the risk for complications (eg, deep vein thrombosis). Pelvic rest (eg, avoiding sexual intercourse) is determined by the health care Provider. (Option 3) Mild abdominal cramping following cerclage placement is common; however, regular contractions, pelvic pressure, and low back aches may indicate preterm labor. (Option 4) The cerclage remains in place until 36–37 weeks gestation. Early removal is indicated by rupture of membranes (to prevent infection) or preterm labor (to prevent damage to the cervix as it dilates). Educational objective: Following cerclage placement, discharge teaching includes recognizing and reporting signs of preterm labor (eg, low back aches, contractions, pelvic pressure) or rupture of membranes and understanding activity restrictions (eg, bed rest for a short time after placement) Question: 3 During the first prenatal assessment, the client reports the last normal menstrual period starting on March 1 and ending on March 5, but also slight spotting on March 23. The client had unprotected intercourse on March 15. Using Naegele's rule, what is the estimated date of birth? 1. December 8 2. December 12 3. December 22 4. December 30 Correct Answer: 1 Rationale Various methods to determine the estimated date of birth (EDB) include the use of Naegele's rule, ultrasound, uterine height measurement (McDonald's measurement), and auscultation of fetal heart rate with a Doppler device. The most accurate dating of pregnancy involves the use of ultrasound around the 16th-18th week of pregnancy. However, Naegele's rule can be used to quickly determine an EDB early in the pregnancy. This calculation uses the date of the first day of the last normal menstrual period (LMP) for the determination of EDB. • EDB = (LMP minus 3 months) + 7 days This client's LMP is March 1, minus 3 months = December 1. Add 7 days to obtain EDB =December 8. Clients who conceive in January, February and most of March will deliver in the current year. Those who conceive after March will deliver in the following year; as a result, a third step is adding 1 to the current year to determine the estimated date of birth. For example, LMP of May 10, 2014 would have an EDB of February 17, 2015. It is important to note that Naegele's rule is based on a client having a menstrual cycle of 28 days. It therefore may not be as accurate if the client has a shorter or longer menstrual cycle. (Option 2) Using the last day of the LMP to calculate EDB provides an inaccurate due date as clients may have varying lengths of menstrual bleeding. (Option 3) Conception occurs around the time of ovulation and is about 14 days from the beginning of the LMP. Eggs are fertile for about 12-24 hours after ovulation with sperm able to remain fertile for 24-72 hours. Implantation of the trophoblast occurs about 7-10 days after fertilization. Using the conception date calculates the gestational age of the embryo approximately 2 weeks later than the true gestational age. (Option 4) Spotting around the time the next menstrual period is due may be considered normal and is probably caused by implantation of the trophoblast into the uterine endometrial lining. This is not considered a problem but using this occurrence to date the pregnancy erroneously delays the EDB by 4 weeks. It is important to calculate EDB from the beginning of the last normal menstrual period. Educational objective: Naegele's rule provides a quick determination of the estimated date of birth (EDB). EDB = (LMP minus 3 months) + 7 days. If the LMP occurs in January, February, or March, the EDB will be in the current year. If the LMP occurs after March, the EDB will be in the next year. Question: 4 A client is prescribed long-term pharmacologic therapy with hydroxychloroquine to treat systemic lupus erythematosus. Which intervention related to the drug's adverse effects should the nurse include in the teaching plan? 1. Have an ophthalmologic examination every 6 months 2. Take the medication on an empty stomach 3. Take vitamin D and calcium supplements 4. Wear a Medic Alert bracelet Correct Answer: 1 Rationale Hydroxychloroquine (Plaquenil) is an antimalarial drug, but it is more commonly prescribed to Reduce fatigue and treat the skin and arthritic (eg, joint inflammation, pain) manifestations of Systemic lupus erythematosus (SLE). Hydroxychloroquine can also help to reduce lupus exacerbations in clients with inactive to mild disease, but several months can pass before its therapeutic effects become apparent. Although rare, serious adverse drug reactions such as retinal toxicity and visual Disturbances can occur with hydroxychloroquine. Therefore, clients are instructed to undergo Regular ophthalmologic examination every 6-12 months (Option 1). (Option 2) Hydroxychloroquine should be taken with food to decrease gastrointestinal upset (A common side effect). (Option 3) Some clients with severe SLE are prescribed long-term corticosteroid (prednisone) Therapy to prevent organ damage and are at risk for adverse reactions, such as accelerated osteoporosis. Osteoporosis is not an adverse reaction of hydroxychloroquine, and vitamin D and calcium supplementation are not required. (Option 4) There are no effects of hydroxychloroquine that would require wearing a Medic Alert bracelet. Educational objective: Hydroxychloroquine (Plaquenil) is used to treat the skin and arthritic manifestations of SLE. Taking the medication with food can help alleviate gastrointestinal upset. Serious adverse drug reactions include retinopathy and visual disturbances; therefore, regular ophthalmologic examination every 6-12 months is required. Question: 5 The nurse is caring for a client diagnosed with Guillain-Barre syndrome (GBS) after a recent gastrointestinal (GI) illness. Monitoring for which of the following is a nursing care priority for this client? 1. Diaphoresis with facial flushing 2. Hypoactive or absent bowel sounds 3. Inability to cough or lift the head 4. Warm, tender, and swollen leg Correct Answer: 3 Rationale GBS is an acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle weakness and absent deep tendon reflexes. Many clients have a history of antecedent respiratory tract or GI infection. Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves. However, neuromuscular respiratory failure is the most life-threatening complication. Early signs indicating impending respiratory failure include: • Inability to cough • Shallow respirations • Dyspnea and hypoxia • Inability to lift the head or eyebrows Assessing the client's pulmonary function by serial spirometry is also recommended. Measurement of forced vital capacity (FVC) is the gold standard for assessing ventilation; a decline in FVC indicates impending respiratory arrest requiring endotracheal intubation. (Option 1) Severe autonomic dysfunction can present as diaphoresis and facial flushing. (Option 2) The client with GBS is also at risk for paralytic ileus, which is related to either immobility or nerve damage. As a result, the nurse should monitor for the presence of hypoactive/absent bowel sounds. (Option 4) Clients with GBS are at risk of developing deep venous thrombosis due to lack of ambulation and should receive pharmacologic prophylaxis (heparin) and support stockings. Although symptoms in options 1, 2, and 4 represent a progressive illness and are important to communicate to the health care provider promptly, they are not the highest priority compared to impending respiratory failure. Educational objective: Respiratory distress is a potential complication of progressing paralysis in clients with Guillain-Barre syndrome. The nurse should prioritize and monitor for the presence of this complication. Measurement of serial spirometry (FVC) is the gold standard for assessing ventilation. Question: 6 The nurse notes muffled heart tones in a client with a pericardial effusion. How would the nurse assess for a pulses paradoxus? 1. Check for variation in amplitude of QRS complexes on the electrocardiogram strip 2. Compare apical and radial pulses for any deficit 3. Measure the difference between Korotkoff sounds auscultated during expiration and throughout the respiratory cycle. 4. Multiply diastolic blood pressure (DBP) by 2, add systolic blood pressure (SBP), and divide the result by 3; [(DBP x 2) + (SBP)]/3 Correct Answer: 3 Rationale Muffled heart tones in a client with pericardial effusion can indicate the development of cardiac tamponade. This results in the build-up of fluid in the pericardial sac, which leads to compression of the heart. The cardiac output begins to fall as cardiac compression increases, resulting in hypotension. Additional signs and symptoms of tamponade include tachypnea, tachycardia, jugular venous distension, narrowed pulse pressure, and the presence of a pulsus paradoxus. Pulsus paradoxus is defined as an exaggerated fall in systemic BP >10 mm Hg during inspiration. The procedure for measurement of pulsus paradoxus is as follows: 1. Place client in semi-recumbent position 2. Have client breathe normally 3. Determine the SBP using a manual BP cuff 4. Inflate the BP cuff to at least 20 mm Hg above the previously measured SBP 5. Deflate the cuff slowly, noting the first Korotkoff sound during expiration along with the pressure 6. Continue to slowly deflate the cuff until you hear sounds throughout inspiration and expiration; also note the pressure. 7. Determine the difference between the 2 measurements in steps 5 and 6; this equals the amount of paradox. 8. The difference is normally <10 mm Hg, but a difference >10 mm Hg may indicate the presence of cardiac tamponade. (Option 1) Variation in QRS amplitude is termed electrical alternans. It could be present in cardiac tamponade, but it is not how pulsus paradoxus is determined. Electrical alternans is due to the swinging motion of the heart in a fluid-filled pericardial sac. (Option 2) An apical/radial pulse deficit may be present during certain dysrhythmias, but this is not the procedure for measuring pulsus paradoxus. (Option 4) This is the formula for calculating mean arterial pressure. Educational objective: The nurse should assess the client for pulsus paradoxus when cardiac tamponade is suspected. The amount of paradox is the difference between the pressures heard at the first Korotkoff sound during expiration and the Korotkoff sounds heard throughout inspiration and expiration. A difference of <10 mm Hg is normal, but if it is >10 mm Hg, this may indicate cardiac tamponade. Question: 7 The nurse is developing a nutritional plan for a 6-month-old who has recently been started on solid foods. Which of the following recommendations has the highest priority in the plan? 1. Canned baby food is more expensive than food prepared at home 2. Finger foods can be introduced before the child has teeth 3. New foods should be introduced at least 5-7 days apart 4. Rice cereal can be mixed with cow's milk to increase nutritional intake Correct Answer: 3 Rationale The introduction of solid foods generally occurs at 4-6 months. The process usually starts with a form of iron-fortified infant cereal, such as rice or oatmeal. Cereal can be mixed with breast milk, formula, or water. When introducing new foods, it is important to allow 5-7 days between foods to observe for any allergies to a particular food. Allergic responses often worsen with subsequent exposure, so it is a priority to identify food triggers as soon as possible (Option 3). (Option 1) A mashed portion of soft fruits or fully cooked vegetables made at home is less expensive than commercially prepared baby food. Carrots, peas, and bananas are examples of early foods that are simple to prepare. However, this is not the highest priority. (Option 2) When an infant reaches age 6-8 months, pureed fruits and vegetables are introduced to provide needed vitamins. After introducing purees, it is also appropriate to begin offering simple finger foods, such as teething crackers and small pieces of fruit, soft vegetables, or cheese. These foods help children develop motor skills and learn to chew, even before they have teeth. (Option 4) Cow's milk is not introduced until after the first year because it lacks crucial vitamins and minerals for appropriate growth and is also more difficult for an infant to digest. Educational objective: Solid foods are introduced at age 4-6 months, beginning with iron- fortified cereal and progressing to soft fruits and vegetables. Five to 7 days should elapse before a new food is introduced to observe for allergies. Simple finger foods may be introduced at age 6-9 months. Cow's milk should not be introduced until after age 1 year. Question: 8 A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis. The client is receiving a heparin infusion and suddenly develops epistaxis. Which laboratory value would indicate that the heparin infusion needs to be turned off? 1. Hematocrit of 30% (0.30) 2. Partial thromboplastin time of 110 seconds 3. Platelet count of 80,000/mm3 (80 x 109/L) 4. Prothrombin time of 11 seconds Correct Answer: 2 Rationale Heparin is an anticoagulant that helps prevent further clot formation. It is titrated based on a partial thromboplastin time (PTT). The therapeutic PTT target is 1.5-2.0 times the normal reference range of 25-35 seconds. A PTT value >100 seconds would be considered critical and could result in life-threatening side effects. Common sentinel events that result from heparin drips include epistaxis, hematuria, and gastrointestinal bleeds. (Option 1) A normal hematocrit for a female is 35%-47% (0.35-0.47). In a client with a history of chronic anemia, a hematocrit of 30% (0.30) may be an expected finding. (Option 3) A normal platelet count is 150,000-400,000/mm3 (150-400 x 109/L). In a client with a history of liver cirrhosis, a platelet count of 80,000/mm3 (80 x 109/L) would be anticipated. An episode of bleeding rarely occurs with a platelet count >50,000 mm3 (50 x 109/L). (Option 4) A normal prothrombin time is 11-16 seconds, and so a level of 11 seconds would not be concerning. Educational objective: Heparin infusions require close monitoring by the nurse. The partial thromboplastin time is the laboratory value required to accurately monitor the therapeutic effects of heparin Question: 9 An 84-year-old client with oxygen-dependent chronic obstructive pulmonary disease is admitted with an exacerbation and steady weight loss. The client has been in the hospital 4 times over the last several months and is "tired of being poked and prodded." Which topic would be most important for the nurse to discuss with this client's health care team? 1. Need for discharge to a skilled nursing facility 2. Nutritional consult with instructions on a high-calorie diet 3. Option of palliative care 4. Physical therapy prescription to promote activity Correct Answer: 3 Rationale This client with advanced chronic obstructive pulmonary disease is approaching the end of life. The client has expressed the desire to avoid further tests, treatments, and hospitalizations. The goals of care should be consistent with the client's wishes and emphasize comfort and quality of life. Palliative care is appropriate for clients who wish to focus on quality of life and symptom management rather than life-prolonging treatments (Option 3). Palliative care may eventually include hospice care, after it is determined that the client has a life expectancy of less than 6 months. The nurse should advocate for the client and collaborate with members of the health care team to explore care options based on the client's wishes. (Option 1) This client has not clearly demonstrated a need for skilled nursing; additional assessment is needed to determine the most appropriate discharge setting. (Option 2) A high-calorie diet is appropriate for a client with weight loss, but many clients may have difficulty maintaining weight due to factors such as advanced disease and poor appetite. It is not the highest priority in this client, who is nearing the end of life and has expressed an interest in avoiding further testing and hospitalization. (Option 4) Physical therapy may be appropriate to help this client maintain current abilities. However, a client with disease this advanced is not likely to tolerate more activity or gain much additional functional capacity. Therefore, physical therapy is not the highest priority at this point. Educational objective: The client with an advanced, terminal disease (eg, chronic obstructive pulmonary disease) is often an appropriate candidate for palliative care. Palliative care emphasizes quality of life and symptom control and may eventually include hospice care based on the client's life expectancy. Question: 10 The nurse working on the inpatient psychiatric unit is preparing to administer 9:00 AM medications to a client. The medication administration record is shown in the exhibit. On assessment, the client is tremulous, exhibits muscle rigidity, and has a temperature of 101.1 F (38.4 C). Which action should the nurse take? 1. Give all medications, including acetaminophen, and reassess in 30 minutes 2. Hold the haloperidol, give acetaminophen, and reassess in 30 minutes 3. Hold the haloperidol and notify the health care provider (HCP) immediately 4. Hold the hydrochlorothiazide and notify the HCP immediately Correct Answer: 3 Rationale This client is exhibiting signs and symptoms of neuroleptic malignant syndrome (NMS), a rare but potentially life-threatening reaction. NMS is most often seen with the "typical" antipsychotics (eg, haloperidol, fluphenazine). However, even the newer "atypical" antipsychotic drugs (eg, clozapine, risperidone, olanzapine) can cause the syndrome. NMS is characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction (e.g., sweating, hypertension, and tachycardia). Treatment is supportive and is directed at reducing fever and muscle rigidity and preventing complications. Treatment in an intensive care unit (ICU) may be required. The most important intervention is to immediately discontinue the antipsychotic medication and notify the HCP for further assessment. (Option 1) Administering acetaminophen may be appropriate, but it is more important to discontinue the haloperidol and notify the HCP immediately. (Option 2) Due to the life-threatening nature of NMS, the HCP should be informed immediately. The HCP may order muscle enzymes, administer IV fluids/medications, and move the client for close monitoring (eg, to the ICU). (Option 4) Hydrochlorothiazide is a diuretic commonly used for hypertension. It does not cause NMS symptoms. Educational objective: NMS is characterized by fever, muscle rigidity, altered mental status, and autonomic dysfunction. The most important intervention is to discontinue the antipsychotic medication Question: 11 A client, who has been hospitalized for 3 days with major depressive disorder, has stayed in the room and not gotten out of bed except for toileting. The nurse enters the room to remind the client that breakfast will be served in the dining room in 20 minutes. The client says, "I'm not hungry and I don't feel like doing anything." What is the best response by the nurse? 1. "I will help you get ready; then we can walk to the dining room together." 2. "I'll have breakfast brought to your room." 3. "It's okay. You can join us when you are ready." 4. "You'll feel better when you get up." Correct Answer: 1 Rationale Reduced appetite and low energy level are common clinical findings in major depressive disorder. The lethargy accompanying the depressed mood makes it difficult for a client with this diagnosis to even get up and out of bed. Personal hygiene and grooming are neglected, and there is no desire to interact with others. The client needs direction and structure in performing activities of daily living (ADLs); waiting for the client to feel more energetic and initiate activity and interaction on one's own is not helpful. Assisting the client with ADLs helps convey a sense of caring, provides an opportunity for interaction with the nurse, and helps raise the client's self-esteem. (Option 2) This action reinforces the client's desire to stay in the room and is not therapeutic. (Option 3) This response is non-therapeutic; the client needs assistance with ADLs. (Option 4) Clients with depression often do feel better after even minimal exercise and activity. However, this response does not give the client direction or structure. Educational objective: Clients with low energy, lethargy, or fatigue associated with major depressive disorder need structure and direction in performing basic ADLs, including personal hygiene and grooming. The nurse needs to provide assistance to the client in completing ADLs and in initiating social interaction with others. Question: 12 The public health nurse conducts a program at the community senior citizen center about preventing falls at home. Which statement made by a participant indicates that further education is needed? 1. "I bought a new nightlight for the hallway to the bathroom." 2. "I feel so much more secure wearing my electronic fall alert device." 3. "I walk in my stockings at home because it helps to relieve my bunion pain." 4. "My daughter helped me secure the small, thin rug in my kitchen with strong tape." Correct Answer: 3 Rationale According to the Centers for Disease Control and Prevention, 1 out of 3 adults aged >65 experience a fall every year. Walking barefoot or while wearing stockings increases the risk of slipping on slick surfaces. Shoes or slippers with non-skid soles should be worn inside and outside of the home. There are multiple simple strategies that can help reduce falls in the home environment and these include: • Exercising regularly for 30 minutes 3 times/week increases strength, balance, coordination, and flexibility; therefore, decreasing fall risk. • Maintaining a well-lit, clutter-free environment (eg, adding nightlights and removing or securing area rugs to the floor with double- sided tape) (Options 1 and 4). • Using grab bars and non-skid bath mats in the bathroom. • Wearing shoes or slippers with non-skid soles, both inside and outside of the home. • Periodically reviewing medications and side effects (eg, orthostatic hypotension) with a pharmacist and/or health care provider (HCP). • Getting regular vision exams. • Wearing an electronic fall alert device. The fear of falling increases fall risk and these devices provide the security of knowing help is available immediately if a fall occurs (Option 2). Educational objective: Many falls in the home can be prevented by exercising regularly, getting regular vision exams, maintaining a well-lit, clutter-free environment, using grab bars in the bathroom, periodically reviewing medications and side effects with a pharmacist and/or HCP, and wearing an electronic fall alert device. Question: 13 A 15-year-old parent brings a 4-month-old infant for a well-baby checkup. The parent tells the nurse that the baby cries all the time; the parent has tried everything to keep the infant quiet but nothing works. What is the priority nursing action? 1. Advise the parent to give a pacifier whenever the infant cries 2. Ask the parent to describe what is done to "keep the baby quiet" 3. Assess the infant's pattern and frequency of crying 4. Explore the parent's support system Correct Answer: 3 Rationale During the first 3-4 months of life, it is not unusual for an infant to cry 1-3 hours a day in response to being hungry, thirsty, tired, in pain, bored, or lonely. A very young, first-time parent may not have an appreciable understanding of normal infant behavior and may perceive normal crying as excessive. It is most important for the nurse to assess the infant's pattern and quality of crying to better understand whether it is normal behavior or a sign of something more serious that requires further evaluation and treatment. The nurse needs to determine: • What "all the time" means • When the "all the time" crying started • What makes the crying worse and what makes it better? • The quality of the crying (tone, pitch, loudness) • Length and quality of periods of silence (Option 1) A pacifier would be appropriate to calm and soothe this infant. However, the nurse needs to first assess the pattern and quality of the crying along with the methods the parent is already using. (Option 2) Finding out what the parent is already doing to comfort the child is part of the nursing assessment. In this case, however, it is more important to determine if the crying is normal or abnormal. (Option 4) Exploring the parent's support system is an appropriate nursing action to determine if the parent has anyone to turn to when frustrated in caring for the infant. However, it is not the most important assessment. Educational objective: When a parent tells the nurse that an infant cries "all the time," the priority nursing action is to assess the pattern, quality, and frequency of the child's crying. This will help the nurse determine if the crying is normal infant behavior or a sign of a more serious condition that requires further evaluation and treatment. Question: 14 A major earthquake has occurred. Local gas lines and water pipes are breaking with resulting fires and flooding in collapsed buildings. Multiple victims arrive at the triage area. Which client should the nurse care for first? 1. Client with charred, leathery skin over entire back, chest, and legs 2. Client with cool skin, shivering from sitting in water until rescued 3. Client with diabetes who was unable to take prescribed insulin today 4. Client with high-pitched, crowing inspiratory respirations Correct Answer: 4 Rationale Disaster triage is based on the principle of providing the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system to categorize them from highest medical priority (emergent) to lowest (expectant). The client with stridor (eg, high pitched, crowing inspiratory respirations), which typically occurs from constricted or blocked upper airways, is at risk for impending respiratory failure due to a compromised airway. This client should be classified as emergent, requiring immediate treatment and possibly prophylactic intubation (Option 4). (Option 1) Using the rule of nines, clients with full-thickness burns to the chest, back, and legs are suspected to have at least 72% total body surface area burns and should be classified as expectant (black tag). (Option 2) Clients with wet clothing or cold water immersion are at risk for hypothermia but can be easily self-managed by provision of warm, dry blankets; this client should be classified as Non-urgent (green tag). Untreated hypothermia may lead to decreased cerebral metabolism, dysrhythmias, and coagulopathies. (Option 3) Clients with diabetes mellitus who are unable to receive insulin may develop hyperglycemia, which is unlikely to cause rapid deterioration. This client can perform self-care and should be classified as nonurgent (green tag). Educational objective: During mass casualty events, the goal is the greatest good for the greatest number of people. Clients are triaged rapidly using a color- coded system that categorizes them from highest medical priority to lowest: red (emergent), yellow (urgent), green (nonurgent), and black (Expectant). Question: 15 The charge nurse in the cardiac intensive care unit responds to a client room where a resuscitation effort is in progress. The client's immediate family member refuses to leave the room. How should the charge nurse handle this situation? 1. Call security to escort the family member to the waiting room 2. Have the family member stand or sit in an area that is not in the staff's way 3. Inform the family member that relatives are not allowed in rooms during emergency situations 4. Let the family member stay and assign a staff person to explain what is happening Correct Answer: 4 Rationale If family members are not causing a disruption in care of the client, they should be allowed to stay in the room with a staff member assigned to explain the interventions being implemented. The nurse should always try to be an advocate for the client and family. Witnessing the efforts of the resuscitation team can be reassuring even when the outcome is negative. The charge nurse should be prepared to escort family members from the room if they become disruptive. (Option 1) Calling security is appropriate only if the family member is disruptive or abusive to the staff. (Option 2) This could increase the family member's anxiety and result in a traumatizing experience if this person does not understand what is occurring during the resuscitation effort. (Option 3) Many professional organizations support allowing a family member to stay during emergency situations, in accordance with specific hospital policy. Educational objective: The nurse should support a family member who wants to be present during the resuscitation of a client. The family member should be allowed to sit or stand in an area that is out of the way of the resuscitation team. A staff member should be assigned to stay with the family member to explain the interventions taking place. Question: 16 The nurse prepares to administer clozapine to a client with schizophrenia. Which client statement would require priority investigation before administering the medication? 1. "I have gained a few pounds since I started this medication." 2. "I have had a sore throat for 3 days and feel feverish today." 3. "I have noticed increased salivation and drooling." 4. "I often feel sleepy when I take this medication." Correct Answer: 2 Rationale Clozapine (Clozaril) is an atypical antipsychotic medication used to manage schizophrenia in clients who have not improved with other antipsychotic medications. Clozapine is highly effective at controlling schizophrenia; however, it has many severe, life-threatening adverse effects, including agranulocytosis, cardiac disease (myocarditis), and seizures. Agranulocytosis (decreased neutrophils) increases the risk for infection. Clients require serial monitoring of white blood cell counts and frequent assessment for signs of infection (e.g., sore throat, fever, flulike symptoms), which should be reported immediately to the health care provider (Option 2). (Option 1) Weight gain is a common side effect. Clients should be educated about weight management. (Option 3) Hypersalivation and drooling are common side effects. When excessive, they can occasionally pose risk for aspiration, especially while the client is sleeping. This is important but not an immediate priority. The side effect can be reduced by lowering the dose. The client should chew sugarless gum to promote swallowing and reduce drooling. (Option 4) Many clients experience significant sedation when the medication is started. Most will develop tolerance to this and eventually improve. Educational objective: Clozapine, an atypical antipsychotic, is used to manage schizophrenia in clients who have not improved with other medications. Clozapine may cause agranulocytosis, which increases the risk of life-threatening infection. Clients receiving clozapine should be monitored for signs of infection (eg, fever, flulike symptoms). Question: 17 The nurse admits a postoperative client following weight loss surgery. Which prescription should the nurse question? 1. Begin a sugar-free, clear liquid diet 2. Insert nasogastric tube for uncontrolled nausea 3. Place client in low Fowler position during mealtimes 4. Start morphine via patient-controlled analgesia Correct Answer: 2 Rationale Bariatric surgery for weight loss involves a surgical modification of the client's stomach and/or small intestine to restrict the client's intake. Postoperative nursing care focuses on managing pain and nausea and monitoring for complications (eg, infection, fluid and electrolyte imbalance, dumping syndrome, anastomotic leak). Nasogastric tubes are contraindicated after gastric surgery due to potential disruption of the surgical site, which can cause hemorrhage and anastomotic leak (Option 2). Postoperative nausea would be controlled using IV antiemetics. (Option 1) Clients are placed on a clear liquid diet for the first 48-72 hours after bariatric surgery to promote healing. The diet is restricted to low-carbohydrate (eg, sugar-free) liquids to decrease the risk of dumping syndrome, rapid emptying into the small intestines that causes unpleasant vasomotor symptoms (eg, sweating, dizziness, cramping, diarrhea). (Option 3) After bariatric surgery, low Fowler position is preferred during mealtimes as it slows gastric emptying, reducing the risk of dumping syndrome. (Option 4) Morphine and patient-controlled analgesia pumps are commonly used to manage pain after bariatric surgery. Educational objective: Nasogastric tube placement is contraindicated after gastric surgery due to the potential for disturbing the surgical site, which can result in hemorrhage and anastomotic leak. Question: 18 The registered nurse (RN) is supervising a graduate nurse (GN) providing postoperative teaching for a male client after an inguinal hernia repair. Which statement by the GN would cause the RN to intervene? 1. "Elevate your scrotum and apply an ice bag to reduce swelling." 2. "Practice coughing to clear secretions and prevent pneumonia." 3. "Stand up to use the urinal if you have difficulty voiding." 4. "Turn in bed and perform deep breathing every 2 hours." Correct Answer: 2 Rationale An inguinal hernia is the protrusion of abdominal contents through the inguinal canal, which appears as a bulge in the lateral groin. Herniation occurs spontaneously or results from increased intraabdominal pressure (eg, heavy lifting). Inguinal hernias occur most commonly in male clients and are usually repaired with minimally invasive surgery. If intestinal strangulation develops, the client requires emergency treatment to prevent bowel ischemia or perforation. Strangulation symptoms include abdominal distension, severe pain, nausea, and vomiting. To prevent hernia reoccurrence after surgical repair, the client is taught to avoid activities that increase intraabdominal pressure (eg, coughing, heavy lifting) for 6-8 weeks (Option 2). If sneezing or coughing are unavoidable, the client should splint incisions and keep the mouth open while sneezing. (Option 1) Scrotal support garments and ice packs help decrease postoperative pain and scrotal swelling. The scrotum should be elevated with a pillow while the client is in bed. (Option 3) The nurse monitors urine output to assess for difficulty voiding after inguinal hernia repair. Male clients are encouraged to stand when voiding to improve bladder emptying. (Option 4) To prevent postoperative complications (eg, pneumonia, constipation) following inguinal hernia repair, the client should reposition frequently, ambulate as soon as possible, and practice deep breathing every 2 hours. Educational objective: After inguinal hernia repair surgery, clients should avoid coughing and heavy lifting, ambulate early, turn and deep breathe every 2 hours, and stand when voiding. Scrotal elevation and ice packs help decrease pain and swelling. Question: 19 A graduate student, who has been studying for final exams and using energy drinks to stay awake, comes to the clinic reporting a fluttering feeling in the chest. The student is connected to the cardiac monitor that displays the rhythm in the exhibit. The nurse recognizes this as which rhythm? 1. Atrial flutter 2. Sinus rhythm with premature atrial contractions (PACs) 3. Sinus rhythm with premature ventricular contractions (PVCs) 4. Ventricular tachycardia Correct Answer: 3 Rationale A PVC is a contraction coming from an ectopic focus in the ventricles. It is a premature (early) conduction of a QRS complex. PVCs are wide and distorted in shape compared to a QRS conducted through the normal conduction pathway. PVCs can be associated with stimulants (eg, caffeine), medications (eg, digoxin), heart diseases, electrolyte imbalances, hypoxia, and emotional stress. PVCs are usually not harmful in the client with a healthy heart. In the client with myocardial ischemia/infarction, PVCs indicate ventricular irritability and increase the risk for the rhythm to deteriorate into a life-threatening dysrhythmia (eg, ventricular tachycardia, ventricular fibrillation). The nurse should assess the client's physiological response, including apical-radial pulse. Treatment is based on the underlying cause of the PVCs (eg, oxygen for hypoxia, reduction of caffeine intake, electrolyte replacement). (Option 1) Atrial flutter is an atrial dysrhythmia identified by recurring, regular, sawtooth shaped flutter waves that originate from a single ectopic focus in the atria. (Option 2) A PAC is a contraction starting from an ectopic focus in the atrium (other than the sinus node) and coming sooner than the next sinus beat. The P wave has a different shape than the P wave that originated in the sinus node. (Option 4) Ventricular tachycardia has a ventricular rate of 150-250/min and originates from foci firing repeatedly in the ventricle. Educational objective: PVCs are wide and distorted and occur early in the underlying rhythm. They are usually not harmful in the client with a healthy heart. PVCs in the client with myocardial infarction indicate ventricular irritability and should be assessed immediately. Question: 20 An experienced nurse precepts a graduate nurse caring for a hospitalized client who has a prescription for a transfusion of packed red blood cells (RBCs) to be hung over 3 hours. Which statement by the graduate nurse indicates the correct rationale for asking the client to void prior to starting the transfusion? 1. "A drop in blood pressure is expected during the transfusion and getting up to void may cause a fall." 2. "Bedrest is required; therefore, voiding will prevent intermittent catheterization during the procedure." 3. "If a transfusion reaction occurs, it will be important to collect a fresh urine specimen to check for hemolyzed RBCs." 4. "The urine is collected and analyzed prior to starting the transfusion to assess the client's baseline results." Correct Answer: 3 Rationale The nurse should ask the client to void or empty the urinary catheter and discard urine prior to starting a blood transfusion. In the event of an acute hemolytic transfusion reaction, a fresh urine specimen should be collected and sent to the laboratory to analyze for hemolyzed RBCs. An acute hemolytic transfusion reaction is a life-threatening reaction in which the host's antibodies rapidly destroy the transfused RBCs and is generally related to incompatibility. Early signs of a hemolytic reaction include red urine, fever, and hypotension; late signs include disseminated intravascular coagulation and hypovolemic shock. The transfusion should be stopped immediately if any sign of transfusion reaction occurs. Starting the transfusion with an empty bladder will help ensure that any urine specimen collected after a reaction is reflective of the body's physiological processes after the blood transfusion has started (Option 4). (Options 1 and 2) Hypotension is a sign of a transfusion reaction and is not expected. Bedrest is not required, but the client should be assisted if out of bed during a transfusion to prevent falls. Educational objective: An acute hemolytic transfusion reaction is a life-threatening reaction caused primarily by blood incompatibility. If it occurs, the transfusion should be stopped and a fresh urine specimen should be collected and sent to the laboratory to analyze for hemolyzed RBCs. Asking the client to void prior to starting the transfusion helps ensure that any urine specimen collected after a reaction is reflective of the body's physiological processes after the blood transfusion. Question: 21 The emergency department nurse is triaging clients. Which neurologic presentation is most concerning for a serious etiology and should be given priority for definitive treatment? 1. History of Bell's palsy with unilateral facial droop and drooling 2. History of multiple sclerosis and reporting recent blurred vision 3. Reports unilateral facial pain when consuming hot foods 4. Temple region hit by ball, loss of consciousness, but Glasgow Coma Scale score is now 14 Correct Answer: 4 Rationale Epidural hematoma is an accumulation of blood between the skull bone and dura mater. The majority of epidural hematomas are associated with fracture of the temporal bone and subsequent rupture or tear of the middle meningeal artery. The bleed is arterial in origin, and so, hematoma develops quickly. The clinical presentation of epidural hematoma is characteristic. The client may lose consciousness at the time of impact. The client then regains consciousness quickly and feels well for some time after the injury. This transient period of well-being is called a lucid interval. It is followed by a quick decline in mental function that can progress into coma and death. (Option 1) Bell's palsy (peripheral facial paralysis) is an inflammation of the facial nerve (CN VII) in the absence of other disease etiologies, such as stroke. There is flaccidity of the affected side with drooling. This differs from the concerning drooling with epiglottis in which the client's throat is too sore and/or swollen to swallow saliva. Treatment includes steroids, measures to relieve symptoms, and protection of the eye (which may not close tightly), but the condition is not emergent. (Option 2) Multiple sclerosis is a chronic, relapsing, and remitting degenerative disorder involving the brain, optic nerve, and spinal cord. Optic neuritis is a common presentation but is not life-threatening. (Option 3) Trigeminal neuralgia (tic douloureux) presents with paroxysms of unilateral excruciating facial pain along the distribution of the trigeminal nerve (CN V) that are often triggered by touch, talking, or hot/cold air or intake. Carbamazepine (Tegretol) is the drug of choice; the condition is not life-threatening. Educational objective: The classic presentation of intracranial epidural bleed is loss of consciousness to a period of lucidity and then gradual loss of consciousness. The bleed is arterial in origin, and so hematoma develops quickly. Emergent diagnosis and treatment are needed to prevent brain stem herniation. Question: 22 A nurse in the emergency department cares for 4 clients with orthopedic injuries. Which client should the nurse assess first? 1. Client who sustained a closed, incomplete ulnar fracture while playing sports 2. Client with bilateral metacarpal fractures after falling out of bed 3. Client with multiple myeloma who has a vertebral fracture and aching back pain 4. Client with pain and obvious shoulder deformity reporting a "pins- and-needles" sensation Correct Answer: 4 Rationale Joint dislocations may become orthopedic emergencies because articular bone may compress surrounding vasculature, causing limb- threatening distal ischemia (Option 4). When a joint is dislocated, the articular tissues, blood vessels, and nerves are often traumatized by stretching. Signs of joint dislocation include pain, deformity, decreased range of motion, and extremity paresthesia. The nurse should frequently assess the neurovascular status and provide analgesics until the dislocation can be reduced and immobilized. (Option 1) In incomplete greenstick fractures, the bone bends and cracks but remains in one piece. These fractures are most common in children, as their bones are soft and flexible. The nurse should provide analgesics and offer reassurance; however, the client with neurovascular impairment should be assessed first. (Option 2) Fractures of the bones of the hand (ie, metacarpals) are common in fall injuries, when the brunt of the fall is borne against the hands and fingers, resulting in hyperflexion or hyperextension. The nurse should provide analgesics; however, the client with neurovascular impairment should be assessed first. (Option 3) Pathologic vertebral compression fractures and pain are expected in clients with multiple myeloma. These clients commonly experience fractures of the vertebral column and spinal processes as cancer weakens and decalcifies the vertebrae. This client should be evaluated next to rule out spinal cord involvement. Educational objective: Joint dislocations may constitute an orthopedic emergency. Because articular tissues, blood vessels, and nerves are stretched and compressed, neurovascular compromise may occur. Prolonged disruption of the vasculature and nerves may cause permanent injury and even loss of the distal extremity. Question: 23 The post-anesthesia care unit nurse receives a report on a client after abdominal surgery. What sounds would the nurse expect to hear when auscultating the bowel? 1. Absent bowel sounds 2. Borborygmi sounds 3. High-pitched and gurgling sounds 4. Swishing or buzzing sounds Correct Answer: 1 Rationale Auscultation of abdominal sounds during physical assessment includes bowel and cardiovascular components. Bowel sounds are normally intermittent (every 5-15 seconds), high-pitched, gurgling sounds that can be auscultated with the diaphragm of the stethoscope in all 4 quadrants. Cardiovascular bruits (swishing, humming, buzzing) are rarely benign and usually indicate arterial narrowing or dilation. Procedures that require bowel manipulation cause a temporary halting of peristalsis (paralytic ileus) for the first 24-48 hours, resulting in absent bowel sounds (Option 1). For bowel sounds to be considered absent, the nurse must auscultate for 2-5 minutes in each quadrant. Peristalsis will usually return in the small intestine in 24 hours, but the large intestine may be delayed 3-5 days. Other procedures requiring general anesthesia, late stages of mechanical obstruction, and peritonitis may cause absent bowel sounds. (Option 2) Borborygmi sounds are loud, gurgling sounds suggesting increased peristalsis. Potential disease processes resulting in borborygmi include gastroenteritis, diarrhea, and the early phases of mechanical obstruction. (Option 3) High-pitched, gurgling sounds signify normal bowel sounds and are unlikely to be heard immediately following abdominal surgery. (Option 4) A swishing, humming, or buzzing sound (bruit) may be cardiovascular in origin; a bruit indicates turbulent blood flow as with artery dilation (aneurysm) or narrowing (obstruction). A bruit can best be auscultated with the bell of the stethoscope. Educational objective: Bowel sounds following abdominal manipulation may be absent for 24- 48 hours. Any disease process that causes an increase in peristalsis may cause borborygmi (loud, gurgling sounds). Swishing and humming sounds heard best with the bell of the stethoscope may be indicative of turbulent blood flow. Question: 24 The nurse is teaching self-care management to a client experiencing an outbreak of genital herpes. Which statement by the client indicates a need for further teaching? 1. "I will be sure we use condoms during intercourse as long as I have lesions." 2. "I will not touch the lesions to prevent spreading the virus to other parts of my body." 3. "I will use a hair dryer on a cool setting to dry the lesions after taking a shower." 4. "I will use warm running water and mild soap without perfumes to wash the area." Correct Answer: 1 Rationale Herpes simplex virus type 2 (HSV-2) is usually associated with genital herpes. Lesions are painful and appear as multiple small, vesicular lesions. Management strategies focus on disease spread, including autoinoculation (eg, fingers) and pain relief, and include: • Avoid sexual activity when lesions are present as the virus spreads through contact with the lesion; barrier contraception is not sufficient during an outbreak (Option 1). After the outbreak has resolved, condoms should be used in future sexual encounters as the transmission is possible even in the absence of active lesions. • Keep the area with lesions clean and dry. • Avoid the use of perfumed soaps and bubble baths. • Maintain proper hand hygiene and avoid touching the lesions to prevent spreading. • Use sitz baths and oatmeal baths to provide comfort and relief of itching and burning. (Option 2) Vesicles contain numerous virus particles, leading to the possibility of self-inoculation. This can be prevented by avoidance of hand contact with lesions during an outbreak. (Option 3)The use of a hairdryer in a cool setting is an effective means of drying the lesions and promoting client comfort. (Option 4) Warm water provides symptomatic relief. Mild soap containing no perfumes reduces the risk of irritation to the area. Educational objective: Clients experiencing an outbreak of genital herpes should abstain from sexual activity when lesions are present and use condoms in future sexual encounters as the transmission is possible even in the absence of active lesions. Question: 25 The nurse is reviewing new prescriptions from the health care provider. Which prescription would require further clarification? 1. Atorvastatin for hyperlipidemia in a client with angina pectoris 2. Bupropion for smoking cessation in a client with emphysema 3. Cyclobenzaprine for muscle spasms in a client with hepatitis 4. Metronidazole for trichomoniasis in a client with Crohn’s disease Correct Answer: 3 Rationale Cyclobenzaprine (Flexeril) is a common, centrally acting skeletal muscle relaxant prescribed for muscle spasticity, muscle rigidity, and acute or chronic muscle pain/injury. Centrally acting muscle relaxants interfere with reflexes within the central nervous system (CNS) to decrease muscle spasm and rigidity. Like many medications, muscle relaxants are metabolized by the liver. The presence of liver disease (eg, hepatitis) decreases hepatic metabolism and can cause a buildup of medication, leading to medication toxicity and increased CNS depression (eg, weakness, confusion, drowsiness, lethargy). The prescription for a muscle relaxant would need to be clarified in a client with liver disease (Option 3). (Option 1) Atorvastatin (Lipitor) is a statin prescribed for hyperlipidemia. It is used for primary and secondary prevention of cardiovascular disease and would not warrant further clarification when used in a client with angina pectoris. (Option 2) Bupropion (Wellbutrin, Zyban) and varenicline (Chantix, Champix) are commonly prescribed for smoking cessation. Both bupropion and varenicline can cause serious neuropsychiatric effects (eg, depression, suicide); however, there is no contraindication for clients with emphysema. (Option 4) Metronidazole (Flagyl) is an antibiotic that can be used to treat a Trichomonas infection. There is no contraindication for its use in clients with Crohn’s disease. Educational objective: Like many medications, skeletal muscle relaxants (eg, cyclobenzaprine) are metabolized hepatically. In the presence of hepatic impairment (eg, hepatitis), drug metabolism is reduced and results in the accumulation of medication in the body, which leads to toxicity and serious adverse effects. Question: 26 The nurse receives reports on 4 clients. Which client should the nurse assess first? 1. Client 1-day postoperative receiving patient-controlled analgesia with morphine who reports itching and nausea 2. Client receiving maintenance IV normal saline solution with labeled tubing indicating that tubing was changed 48 hours ago 3. Client with a pulmonary embolus receiving continuous IV heparin infusion and warfarin who has an International Normalized Ratio of 1.9 4. Client with a resistant bacterial infection receiving IV vancomycin who reports discomfort at the peripheral IV site Correct Answer: 4 Rationale Phlebitis is an inflammation of a vein. Common manifestations include pain, swelling, warmth at the site, and redness extending along the vein. Causes include irritating drugs (eg, vancomycin), catheter movement within the vein (eg, inadequate stabilization), or bacteria (eg, poor aseptic technique). If signs of phlebitis are present, immediate removal of the catheter is necessary as phlebitis can lead to thrombophlebitis and emboli or a bloodstream infection. (Option 1) Itching (pruritus) and nausea are common and expected adverse effects associated with the administration of opioids. Histamine blockers, such as diphenhydramine (Benadryl) or hydroxyzine (Atarax), and an antiemetic, such as ondansetron (Zofran), can provide relief. (Option 2) Evidence-based practice guidelines recommend changing a continuous IV peripheral tubing administration set no earlier than every 72 hours unless it becomes contaminated (institutional policies and procedures vary). Intermittent infusions and hypertonic solutions (eg, total parenteral nutrition, propofol, blood) require more frequent changes (eg, 4-24 hours) due to increased risk for infection. (Option 3) Parenteral and oral anticoagulant medications are administered concurrently until the International Normalized Ratio reaches a therapeutic range of 2-3, at which time the heparin infusion can be discontinued and the warfarin continued. This therapy is expected. Educational objective: Manifestations of phlebitis associated with a peripheral IV catheter include pain, swelling, warmth at the site, and redness extending along the vein. If phlebitis is present, immediate removal of the catheter is necessary as the condition can lead to a serious bloodstream infection or thrombophlebitis. Question: 27 The nurse administers lactulose to a client diagnosed with cirrhosis and hepatic encephalopathy. Which nursing action is inappropriate when administering this medication? 1. Assess mental status and orientation 2. Give on an empty stomach for rapid effect 3. Hold if 3 soft stools occur in a day 4. Mix with fruit juice to improve the flavor Correct Answer: 3 Rationale Hepatic encephalopathy is a reversible neurological complication of cirrhosis caused primarily by increased ammonia levels in the blood. Normally, ammonia created in the intestines is converted to urea in the liver and excreted in the kidneys. However, in the presence of liver damage, blood is shunted around the liver portal system and ammonia is able to cross the blood brain barrier, leading to neurological dysfunction (Option 1). Lactulose is the most common treatment for hepatic encephalopathy. Lactulose is not digested or absorbed until it reaches the large intestines where it is metabolized, producing an acidic environment and a hyperosmotic effect (laxative). In this acidic environment, ammonia (NH3) is converted to ammonium (NH4+) and excreted rapidly. Lactulose can be given orally with water, juice, or milk (to improve flavor) or it can be administered via enema (Option 4). For faster results, it can be administered on an empty stomach (Option 2). The desired therapeutic effect of lactulose is the production of 2-3 soft bowel movements each day; therefore, the dose is titrated until the therapeutic effect is achieved. This therapeutic dose should not be held but instead should be maintained until the desired outcomes are reached (improved mental status, decreased ammonia levels) (Option 3). The client's electrolyte levels should be closely monitored during therapy as lactulose is a laxative that can cause dehydration, hypernatremia, and hypokalemia. Educational objective: Increased ammonia levels in the blood can lead to hepatic encephalopathy, a complication of liver disease. Lactulose, a laxative, removes ammonia and is given orally with juice, milk, or water or rectally via enema to produce 2-3 soft bowel movements a day. Therapeutic effects are evident via laboratory results and improving mental status. Question: 28 The nurse assistant reports vital signs on 4 clients. Which client should be a priority for the nurse to assess? 1. 28-year-old with infective endocarditis and heart rate of 105/min 2. 45-year-old with acute pancreatitis and sinus tachycardia of 120/min 3. 65-year-old with tachycardia of 110/min after liver biopsy 4. 74-year-old on diltiazem drip with atrial fibrillation and heart rate of 115/min Correct Answer: 3 Rationale The liver is a highly vascular organ and bleeding is a major complication. Tachycardia is an early sign of internal hemorrhage. The 65-year-old client should be assessed first. (Option 1) Tachycardia can be caused by underlying infection and can resolve with treatment of the infection. Valve infections can require several weeks of antibiotics. This client is not the priority. (Option 2) Pancreatitis is a very painful condition and sinus tachycardia is expected. These clients are also at risk of developing complications such as third spacing of volume and require large quantities of IV fluids. This client is the second priority. (Option 4) Atrial fibrillation is commonly treated with calcium channel blockers such as diltiazem. The dosage needs to be adjusted to achieve a goal heart rate of <100/min. Atrial fibrillation is usually not immediately life-threatening. Educational objective: Liver biopsy can cause internal bleeding. Clients with internal bleeding require priority assessment. Question: 1 The nurse assesses 4 clients in the emergency department. Which client should the nurse prioritize first? 1. 12-year-old with right lower quadrant abdominal pain that started in the periumbilical region 2. 14-year-old with severe scrotal pain; right testis is tender, swollen, and more elevated than the left 3. 16-year-old with sickle cell disease who has excruciating generalized body pain 4. 34-year-old with sudden-onset, right-sided flank pain radiating to the right groin Correct Answer: 2 Rationale Testicular torsion is an emergency condition in which blood flow to the testis (scrotum) has stopped. The testicle rotates and twists the spermatic cord, initially causing venous drainage obstruction that leads to swelling and severe pain. Arterial blood supply is subsequently interrupted, resulting in testicular ischemia and necrosis, which require surgical removal of the testis. The condition can be diagnosed with ultrasound. There is a short time frame in which testicular torsion can be treated (to untwist the rotation), generally 4-6 hours, making this condition a priority. (Option 1) Right lower quadrant pain referred from the periumbilical area is a classic sign of appendicitis. If left untreated, the appendix could perforate and release bacteria into the abdomen, causing peritonitis, a more serious condition. Surgery is usually required within 24 hours. This client should receive prompt attention but is not a priority over the client with testicular torsion. (Option 3) Clients with sickle cell disease have episodes of sickle cell crisis, in which the sickle-shaped cells occlude the blood vessels. This decreased blood flow is responsible for the generalized body pain. This client should be treated emergently with pain medications and IV fluids but is not a priority over the client with testicular torsion. (Option 4) Sudden-onset, right-sided flank pain radiating to the groin is classic for renal stones. Kidney stones are very painful but in most cases cause no permanent damage unless a stone completely blocks kidney flow. This client is not a priority over the client with testicular torsion. Educational objective: Testicular torsion can result in testicular ischemia and necrosis from inadequate blood supply. There is a short time frame (4-6 hours) in which testicular torsion can be treated to prevent death of the testicle, and the client will most likely require emergency surgery. Question: 2 A client with dilated cardiomyopathy has the rhythm shown in the exhibit. Which action should the nurse take first? 1. Assess the client for a pulse 2. Assess the oxygen saturation 3. Initiate cardiopulmonary resuscitation (CPR) 4. Prepare to defibrillate the client Correct Answer: 1 Rationale Clients in ventricular tachycardia (VT) can be pulseless or have a pulse. Treatment is based on this important initial assessment. VT with a pulse should be further assessed for clinical stability or instability. Signs of instability include hypotension, altered mental status, signs of shock, Chest pain, and acute heart failure. The unstable client in VT with a pulse is treated with synchronized cardioversion. The stable client in VT with a pulse is treated with antiarrhythmic medications (eg, amiodarone, procainamide, sotalol). (Option 2) Oxygen saturation should be assessed after the presence of a pulse has been established. (Options 3 and 4) CPR and defibrillation should be initiated only in a client who is pulseless. Educational objective: The client in VT must be assessed for the presence or absence of a pulse before further assessment or treatment is initiated. The unstable (hypotensive) client in VT with a pulse is treated with synchronized cardioversion. Question: 3 Which statement by a client with a diagnosis of dependent personality disorder would the nurse? recognize as progress toward a positive therapeutic outcome? 1. "I really appreciate all the time you have spent trying to help me." 2. "I think I really messed up at work today." 3. "My mother could not drive me here today, so I took the bus." 4. "When my parents go away on vacation, I'm planning to stay with my cousin." Correct Answer: 3 Rationale Individuals with dependent personality disorder have a persistent and extreme need to be taken care of that manifests as submissive and clinging behaviors and fear of separation. Additional characteristics of dependent personality disorder may include: • Difficulty in making day-to-day decisions • An excessive need for advice, reassurance, and nurturance from others • Lack of self-confidence - afraid to do things on one's own • Afraid of confrontation or expressing disagreement with others • Feelings of helplessness and anxiety when alone; fear of being unable to take care of oneself. A client making a decision about and carrying out a daily activity on his/her own would be indicative of progress toward a therapeutic outcome. (Option 1) Clients with dependent personality disorder will often express appreciation or make flattering comments to the nurse/therapist to gain approval. (Option 2) Clients with dependent personality disorder lack confidence in their own abilities; this client is expressing self-doubt and is not showing evidence of improvement. (Option 4) The need to stay with someone while the client's parents are away is not evidence of progress toward a therapeutic outcome; the client cannot tolerate being alone. Educational objective: Clients with dependent personality disorder have an extreme need to be taken care of by another person, cannot make decisions on their own, and have intense fear of separation and being left alone. The ability to make a decision and act on one's own would indicate progress toward a therapeutic outcome. Question: 4 A nurse performs the initial assessments for 4 assigned clients. The nurse identifies which client as being at greatest risk for the development of delirium? 1. 32-year-old client with gastroenteritis 2. 55-year-old client with coronary artery disease, 4 days post coronary bypass surgery 3. 60-year-old client with type II diabetes, 2 months post bilateral above- knee amputations 4. 80-year-old client with chronic obstructive pulmonary disease, chronic respiratory failure, and urosepsis Correct Answer: 4 Rationale Major predisposing factors for the development of delirium in hospitalized clients include: 1. Advanced age 2. Underlying neurodegenerative disease (stroke, dementia) 3. Polypharmacy 4. Coexisting medical conditions (eg, infection) 5. Acid-base/arterial blood gas imbalances (eg, acidosis, hypercarbia, hypoxemia) 6. Metabolic and electrolyte disturbances 7. Impaired mobility - early ambulation prevents delirium 8. Surgery (postoperative setting) 9. Untreated pain and inadequate analgesia Client 4 has 4 predisposing risk factors: advanced age, acidosis and hypoxemia associated with chronic respiratory failure, and sepsis. This client is at greatest risk for developing delirium. (Option 1) Although gastroenteritis with possible dehydration and electrolyte imbalances predisposes to delirium, this client is not at greatest risk. (Option 2) Although surgery, especially that requiring cardiac bypass, predisposes to delirium, this client is not at greatest risk. Early ambulation and adequate pain control prevent the development of delirium in the postoperative setting. (Option 3) Although coexisting medical conditions, such as diabetes mellitus and impaired mobility, predispose to delirium, this client is not at greatest risk. Educational objective: Risk factors for hospital-induced delirium include advanced age, underlying neurodegenerative disease, infections, medical illness, surgery, impaired mobility, and inadequate pain control. Question: 5 The nurse is assessing a client with hypertension and essential tremor 2 hours after receiving a first dose of propranolol. Which assessment is most concerning to the nurse? 1. Client reports a headache 2. Current blood pressure is 160/88 mm Hg 3. Heart rate has dropped from 70/min to 60/min 4. Slight wheezes auscultated during inspiration Correct Answer: 4 Rationale Propranolol is a nonselective beta-blocker that inhibits beta1 (heart) and beta2 (bronchial) receptors. It is used for many indications (eg, essential tremor) in addition to blood pressure control. Blood pressure decreases secondary to a decrease in heart rate. Bronchoconstriction may occur due to the effect on the beta2 receptors. The presence of wheezing in a client taking propranolol may indicate that bronchoconstriction or bronchospasm is occurring. The nurse should assess for any history of asthma or respiratory problems with this client and notify the health care provider (HCP). (Option 1) A headache is a common occurrence with hypertension. The nurse may administer an analgesic as needed. (Option 2) This is the first dose of propranolol that the client has received. It may take several days of treatment for the blood pressure to reduce to a more normal reading. (Option 3) A reduction in heart rate is expected with a beta-blocker. The nurse should continue to monitor it for further reduction. Educational objective: The nurse should be concerned about the presence of wheezing in a client taking a nonselective beta-blocker like propranolol. Wheezing may indicate bronchoconstriction or bronchospasm. The nurse should assess for any history of asthma or other respiratory problems and report to the HCP. Question: 6 When triaging 4 pregnant clients in the obstetric clinic, the nurse should alert the health care provider to see which client first? 1. First-trimester client reporting frequent nausea and vomiting 2. Second-trimester client with dysuria and urinary frequency 3. Second-trimester client with obesity reporting decrease in fetal movement 4. Third-trimester client with right upper quadrant pain and nausea Correct Answer: 4 Rationale Right upper quadrant (RUQ) or epigastric pain can be an indicator of HELLP syndrome, a severe form of preeclampsia. HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) is often mistaken for viral gastroenteritis due to its variable and nonspecific presentation. Misdiagnosis may lead to severe complications (eg, placental abruption, liver failure, and stroke) and/or maternal/fetal death. Clients may have RUQ pain, nausea, vomiting, and malaise. Headache, visual changes, proteinuria, and hypertension may or may not be present. (Option 1) Nausea and vomiting during the first trimester are normal, expected findings. Vomiting that continues past the first trimester or that is accompanied by fever, pain, or weight loss is considered abnormal and requires intervention. (Option 2) Although urinary frequency is common in pregnancy, dysuria could indicate a urinary tract infection. This client should be evaluated but does not take priority over a client with symptoms of HELLP. (Option 3) Maternal perception of fetal movement can be altered by obesity, maternal position, fetal sleep cycle, fetal position, anterior placenta, and amniotic fluid volume (increased or decreased). This client should be evaluated to determine the cause of decreased fetal movement; however, this is not the priority. Educational objective: HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) is a severe form of preeclampsia. Its clinical presentation can be quite variable and may include nonspecific symptoms such as right upper quadrant/epigastric pain, nausea, vomiting, and malaise. Complications including placental abruption, stroke, and death may occur if HELLP syndrome is not treated immediately. Question: 7 A client at 20 weeks gestation states that she started consuming an increased amount of cornstarch about 3 weeks ago. Based on this assessment, the nurse should anticipate that the health care provider will order which laboratory test(s)? 1. Hemoglobin and hematocrit levels 2. Human chorionic gonadotropin level 3. Serum folate level 4. White blood cell count Correct Answer: 1 Rationale Pica is the abnormal, compulsive craving for and consumption of substances normally not considered nutritionally valuable or edible. Common substances include ice, cornstarch, chalk, clay, dirt, and paper. Although the condition is not exclusive to pregnancy, many women only have pica when they are pregnant. Pica is often accompanied by iron deficiency anemia due to insufficient nutritional intake or impaired iron absorption. However, the exact relationship between pica and anemia is not fully understood. The health care provider would likely order hemoglobin and hematocrit levels to screen for the presence of anemia. (Option 2) Human chorionic gonadotropin is the hormone detected in a urine or serum pregnancy test to determine if a client is pregnant. It is not affected by iron deficiency anemia or pica. (Option 3) Increased folic acid consumption is necessary during pregnancy to reduce the risk for neural tube defects in the developing fetus. However, folate levels are not related to pica. (Option 4) A white blood cell count should be assessed when a client is suspected of having an infection. There is no indication that this client has an infection. Educational objective: Pica is the constant craving for and consumption of nonfood and/or nonnutritive food substances that may occur in pregnancy. It may be accompanied by iron deficiency anemia. Hemoglobin and hematocrit levels are useful in these clients to screen for anemia. Question: 8 A child on the playground is experiencing an anaphylactic reaction. The school nurse arrives with an EpiPen. The weather is cold and the child is wearing several layers of clothing. How should the nurse proceed with the EpiPen? 1. Inject into the upper arm where the sleeve can be pulled up 2. Inject into the most accessible vein 3. Inject through the clothing into thigh and hold in place for 10 seconds 4. Take the child inside, remove excess clothing, and inject into the thigh Correct Answer: 3 Rationale The EpiPen is designed to be administered through clothing with a swing and firm push against the mid-outer thigh until the injector clicks. The position should be held for 10 seconds to allow the entire contents to be injected (Option 3). The site should be massaged for an additional 10 seconds. Timing is essential in the delivery of epinephrine during an anaphylactic reaction. The nurse should administer the medication immediately on the playground without removing the child's clothing. Any delays can cause client deterioration and make maintenance of a patent airway difficult (Option 4). (Option 1) The EpiPen should be injected into the mid-outer thigh, not the upper arm. (Option 2) IV epinephrine is not administered outside the hospital setting. It requires cardiac monitoring and is indicated in clients with profound hypotension (shock) or those who do not respond to intramuscular epinephrine and fluid resuscitation. Educational objective: The EpiPen is designed to be delivered through clothing in the mid-outer thigh area. The nurse should not delay anaphylaxis treatment by attempting to remove the client's clothing Question: 9 A nurse receives information in a change of shift report. Which client is the priority? 1. Client prescribed levothyroxine to treat hypothyroidism who reports nervousness, sweating, and insomnia 2. Client receiving intravenous antibiotics for bacterial pneumonia who reports cough with blood-tinged sputum 3. Client with a femoral external fixator who has a temperature of 100.9 F (38.3 C) and redness and pain around the pin sites 4. Client with chronic pancreatitis who reports upper abdominal pain and voluminous, foulsmelling, fatty stools Correct Answer: 3 Rationale External fixation stabilizes bone by inserting metal pins through skin into the bone and attaching them to a metal rod outside the skin. The nurse should assess this client first as any signs and symptoms of an infection (eg, low-grade fever, drainage, pain, redness, swelling) warrant immediate evaluation and treatment. Localized pin tract infection can progress to osteomyelitis, a serious bone infection that requires long- term treatment with antibiotics. (Option 1) The dose of levothyroxine, a thyroid replacement drug that raises the metabolic rate, may need to be adjusted as the client is now exhibiting manifestations of hyperthyroidism (eg, nervousness, sweating, and insomnia). (Option 2) Hemoptysis can sometimes be seen with pneumonia, lung abscess, tuberculosis, and lung cancer, as well as in bronchiectasis. Unless there is a significant amount of blood, this is not a concerning finding. (Option 4) Epigastric abdominal pain and steatorrhea (voluminous, foul- smelling, fatty stools) due to fat malabsorption are expected findings in chronic pancreatitis. Appropriate pain medication and pancreatic enzyme supplements (prior to each meal) are administered for prevention. Educational objective: An external fixator stabilizes bone by inserting metal pins through skin into the bone and attaching them to a metal rod outside the skin. Signs and symptoms of infection (eg, fever, drainage, pain, redness, swelling) warrant immediate evaluation and treatment with antibiotics as these can progress to osteomyelitis, a serious bone infection. Question: 10 The nurse is teaching the parents of a 4-month-old who has developed positional plagiocephaly (flat head syndrome). Which statement by the parents indicates a need for further teaching? 1. "I should alternate head positions when the infant is supine." 2. "I should place the infant in the prone position during naps." 3. "I will minimize the amount of time the infant is in a car seat." 4. "I will place interesting toys opposite the affected side." Correct Answer: 2 Rationale Positional plagiocephaly (flat head syndrome) occurs when an infant's soft, pliable skull is placed in the same position for an extended time. Positional plagiocephaly has become common due to the Safe to Sleep (formerly Back to Sleep) campaign, which advocates for infants to sleep in the supine position to prevent sudden infant death syndrome (SIDS). The risk of SIDS utweighs the benefit of a shapely head; the infant should not be placed in the prone position to sleep, even for a daytime nap (Option 2). Plagiocephaly can usually be prevented or corrected by: • Frequently alternating the supine infant's head position from side to side (Option 1) • Minimizing the amount of time an infant's head rests against a firm surface (eg, car seat) (Option 3) • Placing pictures and toys opposite the favored (affected) side to encourage turning the head (Option 4) • Placing the infant in the prone position for 30-60 min/day ("tummy time") Educational objective: Positional plagiocephaly, or flattening of the skull, can develop when infants spend a lot of time in the same position. Positioning techniques (eg, "tummy time," alternating the head position) can prevent or correct plagiocephaly. Infants should always be placed in the supine position to sleep. Question: 11 A nurse is assisting a new mother as she is breastfeeding her infant. The infant has been diagnosed with tetralogy of Fallot. During feeding, the infant becomes cyanotic and is having difficulty breathing. What should be the nurse's first action? 1. Administer morphine to the infant 2. Administer oxygen via mask 3. Assess infant's vital signs and pulse oximetry 4. Place the infant in the knee-chest position Correct Answer: 4 Rationale Tetralogy of Fallot is a congenital cardiac defect that typically has 4 characteristics: pulmonary stenosis, right ventricular hypertrophy, overriding aorta, and ventricular septal defect. This infant is experiencing a hypercyanotic episode, or "tet spell," which is an exacerbation of tetralogy of Fallot that can happen when a child cries, becomes upset, or is feeding. The child should first be placed in a knee-to-chest position. Flexion of the legs provides relief of dyspnea as this angle improves oxygenation by reducing the volume of blood that is shunted through the overriding aorta and the ventricular septal defect. (Option 1) Morphine may be considered if the dyspnea is not relieved by the knee-to-chest position. (Option 2) If oxygen saturation remains low, oxygen may need to be administered. (Option 3) Vital signs and pulse oximetry may be checked after the infant has been placed in the knee-chest position. Educational objective: To relieve a hypercyanotic episode, or "tet spell," the nurse should place the infant or child in the knee-chest position. Question: 12 The nurse administers 8 units of regular insulin subcutaneously at 11:30 AM to a client with type 1 diabetes mellitus and serves the client lunch 30 minutes later. The client eats a few bites, becomes nauseated, and is unable to finish the meal. When is the client at highest risk for experiencing an insulin-related hypoglycemic reaction? 1. 12:30 PM 2. 2:00 PM 3. 5:00 PM 4. 6:00 PM Correct Answer: 2 Rationale The client is at highest risk for experiencing an insulin-related hypoglycemic reaction when the drug peaks. The peak indicates the time during which insulin works at its maximum strength to lower the blood glucose. Regular insulin is short-acting and peaks 2-5 hours after administration. The onset of regular insulin is 30 minutes-1 hour with duration of 5-8 hours. (Option 1) 12:30 PM is 1 hour after insulin administration. Rapid-acting insulins (lispro, aspart, glulisine) reach peak effect in 30 minutes-3 hours. (Option 3) 5:00 PM is 5.5 hours after insulin administration. Neutral protamine Hagedorn (NPH) is an intermediate-acting insulin that reaches peak effect in 4 hours. (Option 4) 6:00 PM is 6.5 hours after insulin administration. Detemir reaches peak around this time (varies from 4-9 hours). Educational objective: The client is at highest risk for experiencing an insulin-related hypoglycemic reaction when the drug peaks. Regular insulin is short- acting and peaks 2-5 hours after administration. Question: 13 An elderly client with type 2 diabetes is admitted to the medical unit due to urosepsis. The client is wearing an insulin pump for continuous subcutaneous insulin infusion therapy. The client's significant other reports that the client self-manages the insulin pump extremely well and keeps blood glucose in the specified target range. What is the admitting nurse's priority action? 1. Assess the client's level of orientation 2. Assess the insulin pump infusion site 3. Check the prescribed insulin pump settings 4. Consult the diabetic resource nurse or educator Correct Answer: 1 Rationale Change in mental status and confusion is a common presenting symptom of sepsis in the elderly. The nurse should assess the client's cognitive status and level of orientation and consciousness. Diminished mental acuity, side effects of medication, and impairment related to a medical condition during hospitalization affect the client's ability to manage the insulin pump safely. Mental status is the key to safe insulin pump use, so if the client is not competent to operate the pump, the nurse should notify the health care provider (HCP) and document the findings in the client's electronic medical record. The HCP will determine if continuing the use of the pump during hospitalization is appropriate. (Option 2) Assessing the infusion pump site for signs of infection and intactness of the infusion set is important, but it is not the priority action. (Option 3) The HCP prescribes the basal insulin along with the parameters for bolus and correction doses while the client is hospitalized. The nurse should check and document the make and model, pump settings, type of insulin, and the date that the infusion site and set were changed. However, this is not the priority action. (Option 4) Consulting with the diabetic resource nurse or educator to determine the client's competency and ability to manage a specific type of pump and provide ongoing client education is an appropriate action. However, this is not the priority. Educational objective: When caring for a hospitalized client wearing an insulin pump, the priority nursing action is to assess the client's mental capacity to determine the ability to self-manage the pump safely. Question: 14 The nurse cares for a child with bed bug bites. Which parent statement indicates that further teaching is required? 1. "I need to have the entire house treated by pest control to ensure the bed bugs are gone." 2. "I should concentrate on alleviating scratching as it can cause further complications." 3. "My other family members and pets are at risk of bed bug bites." 4. "This must have happened because I did not wash the bed sheets this week." Correct Answer: 4 Rationale It is a common misconception that bed bugs are drawn only to dirty environments. They can inhabit any environment and can travel and spread easily in clothing, bags, furniture, and bedding. Although they do not pose significant harm, bed bugs can cause an itchy red rash that can be uncomfortable and affect sleep. Bed bugs should be exterminated, especially in a home with children. (Option 1) It is important to treat the entire house for bed bugs. Washing a single pillowcase or blanket will not stop the infestation. Bed bugs multiply quickly and can hide in any crevice. Once pest control is complete, the home will need to be monitored for signs of lingering bugs. (Option 2) Bed bug bites can cause a rash that clients, especially children, will be inclined to scratch. Precautions should be taken to help alleviate the rash as itching can cause complications such as secondary skin infections. (Option 3) Once a home is infested, the bugs can travel quickly and occupy spaces and crevices. All household members and pets will be afflicted. Educational objective: Bed bugs spread quickly and travel in bedding, clothing, and furniture. It is important to recognize bed bug bites and eliminate this pest from the home. Client treatment aims to minimize itching until the rash is gone. Question: 15 An African American client comes to the clinic for a follow-up visit 2 months after starting enalapril for hypertension. Which client statement should be reported to the health care provider immediately? 1. "Is there anything I can take for my dry, hacking cough?" 2. "My blood pressure this morning was 158/84 mm Hg." 3. "Sometimes I feel somewhat dizzy when I stand up." 4. "Will you look at my tongue? It feels thicker than normal." Correct Answer: 4 Rationale Angioedema is swelling that usually affects areas of the face (lips, tongue), larynx, extremities, gastrointestinal tract, and genitalia. The swelling often starts in the face and can quickly become life threatening as it progresses to the airways. Angioedema is an adverse effect of ACE inhibitors (eg, enalapril, lisinopril, and captopril) and occurs more commonly in African American clients. Unlike other typical drug allergies, this side effect can occur any time after starting the medication. The nurse should immediately report angioedema to the health care provider and carefully monitor the client (Option 4). (Option 1) A persistent, dry, hacking cough is a common side effect of ACE inhibitors. It is not life-threatening, but the medication should be discontinued or changed to resolve the cough. (Option 2) The nurse should review the client's blood pressure readings over the past month since starting enalapril. The client may need a dosage change or an additional medication. This should be reported but is not the priority in this situation. (Option 3) Occasional dizziness upon rising (ie, orthostatic hypotension) is a common side effect of most antihypertensives. The client should be taught to rise slowly and sit on the side of the bed for a few minutes before standing up. Educational objective: Swelling of the tongue can be a sign of angioedema in clients taking ACE inhibitors; this can be potentially life-threatening if the airway becomes compromised. The nurse should report this immediately to the health care provider. Angioedema occurs more commonly in African American clients Question: 16 The nurse reviews the laboratory results of several clients. Which finding should the nurse report to the health care provider immediately? 1. Client who is receiving tube feedings and has a phenytoin level of 8 mcg/mL (32 mcmol/L) 2. Client with a heart rate of 62/min who has a digoxin level of 1.3 ng/mL (1.7 nmol/L) 3. Client with a new prosthetic aortic valve who has an INR of 3.0 4. Client with a poor appetite and a lithium level of 0.8 mEq/L (0.8 mmol/L) Correct Answer: 1 Rationale Narrow therapeutic index medications have a higher chance of producing adverse effects due to a very small difference between therapeutic and toxic levels. These medications require close monitoring of serum drug levels for adequate, but not toxic, dosing. Clients should also be monitored for signs of toxicity, which are specific to each medication. Phenytoin (Dilantin) is an antiseizure medication with a therapeutic index of 10-20 mcg/mL (40-79 mcmol/L) (Option 1). Tube feedings decrease phenytoin absorption, which reduces serum drug concentrations and may precipitate seizures. The nurse should pause tube feedings for 1-2 hours before and after phenytoin administration to ensure adequate absorption. Phenytoin toxicity produces nystagmus, dysarthria, ataxia, and encephalopathy. (Option 2) A heart rate of 62/min is expected in a client taking digoxin (therapeutic index 0.5- 2.0 ng/mL [0.6-2.6 nmol/L]). Digoxin toxicity produces gastrointestinal symptoms (nausea, vomiting, and diarrhea), bradycardia, and visual disturbances (blurred vision, yellow-green halos). (Option 3) The therapeutic INR for a client with a mechanical heart valve is 2.5-3.5. (Option 4) Anorexia is a common side effect of lithium (therapeutic index 0.6-1.2 mEq/L [0.6-1.2 mmol/L]). Lithium toxicity produces nausea, vomiting, ataxia, and tremors. Educational objective: Tube feedings decrease phenytoin (Dilantin) absorption, which reduces serum drug concentrations (therapeutic index 10-20 mcg/mL [40-79 mcmol/L]) and may precipitate seizures. The nurse should pause tube feedings for 1-2 hours before and after phenytoin administration to ensure adequate absorption. Question: 17 A client with active pulmonary tuberculosis is prescribed 4-drug therapy with ethambutol. The community health nurse instructs the client to notify the health care provider immediately if which adverse effect associated with ethambutol occurs? 1. Blurred vision 2. Dark-colored urine 3. Difficulty hearing 4. Yellow skin Correct Answer: 1 Rationale Ethambutol (Myambutol) is used in combination with other antitubercular drugs (eg, isoniazid, rifampin, pyrazinamide) to treat active tuberculosis. The client must have baseline and periodic eye examinations during therapy as optic neuritis is a potentially reversible adverse effect. The client is instructed to report signs of decreased visual acuity and loss of color (redgreen) discrimination. (Options 2 and 4) Dark-colored urine and yellow skin can indicate the presence of hepatotoxicity, which is associated with many drugs used to treat tuberculosis (eg, isoniazid, pyrazinamide, and rifampin). However, hepatotoxicity is not common with ethambutol. (Option 3) Difficulty hearing (tinnitus, subjective hearing loss) is an adverse reaction to streptomycin. Streptomycin, an aminoglycoside antibiotic, is a second-line drug sometimes used to treat multi-drug- resistant tuberculosis, with ototoxic and nephrotoxic adverse effects. Educational objective: Clients taking ethambutol must have baseline and periodic eye examinations during therapy as optic neuritis is a potentially reversible adverse effect. Question: 18 A client with unstable angina and chronic kidney disease is receiving a continuous infusion of unfractionated heparin. Which value for activated partial thromboplastin time (aPTT) would indicate to the nurse that the heparin therapy is at an optimal therapeutic level? 1. 30 seconds 2. 35 seconds 3. 60 seconds 4. 85 seconds Correct Answer: 3 Rationale Unfractionated heparin is used as an anticoagulant in unstable angina. It prevents the conversion of fibrinogen to fibrin and prothrombin to thrombin, both components of clot formation. The aPTT is a laboratory test that characterizes blood coagulation. It is used to monitor treatment effects of clients receiving heparin. The normal aPTT is 25–35 seconds. Heparin infusions are titrated to obtain a therapeutic value of aPTT, typically 1.5–2 times the normal value. Therapeutic value for aPTT is 46–70 seconds. The nurse would evaluate the aPTT for a therapeutic value and make adjustments in the rate of infusion of the heparin as needed. (Options 1 and 2) These are normal aPTT levels for clients not being anticoagulated. (Option 4) This aPTT is too high. This client is at risk for bleeding. The heparin should be titrated down based on the heparin drip protocol. Educational objective: The nurse caring for a client receiving a heparin infusion should monitor the aPTT and follow the heparin infusion protocol for titration. A therapeutic level is 1.5–2 times normal, or an aPTT of 46–70 seconds. Question: 19 The nurse is preparing medications for the following 4 clients. Which prescription should the nurse clarify with the health care provider before administration? 1. Acetaminophen for a client with a temperature of 102.2 F (39 C) with productive cough 2. Azathioprine for a client with Crohn disease with leukopenia who is reporting malaise 3. Baclofen for a client with multiple sclerosis who reports dizziness when changing positions 4. Colchicine for a client with an acute gout attack who reports intense, burning left toe pain Correct Answer: 2 Rationale Azathioprine is an immunosuppressant drug that can cause bone marrow depression and increase the risk for infection. It is prescribed to treat autoimmune conditions such as inflammatory bowel diseases (eg, Crohn disease) and to prevent organ transplant rejection. Fatigue and nausea can be expected as minor adverse effects or may be associated with the disease. However, leukopenia (white blood cell count <4,000/mm3 [4 × 109/L]) can be a severe adverse effect of the drug and should be reported to the health care provider before administering the medication due to high risk for infection (Option 2). (Option 1) Acetaminophen is a nonopioid analgesic with antipyretic properties. The client with a productive cough and fever should be assessed further for infection. This prescription would be appropriate. (Option 3) Baclofen is an antispasmodic drug commonly prescribed to clients with multiple sclerosis to relieve uncomfortable spasms and muscular pain. Dizziness when attempting to stand or changing positions (ie, orthostatic hypotension) is a common adverse effect but is not a contraindication. (Option 4) Colchicine is prescribed for clients with an acute attack of gout because it decreases the inflammation and pain associated with deposition of uric acid crystals in the joints. This is an appropriate prescription. Educational objective: Azathioprine is an immunosuppressant drug that can cause bone marrow suppression and increase the risk for infection. Leukopenia, a severe adverse effect of azathioprine, should be reported to the health care provider before the medication is administered. Question: 20 The charge nurse on a medical-surgical step-down unit is responsible for making assignments. Which client is most appropriate to assign to a new graduate nurse who is still in orientation? 1. 65-year-old client 1 day postoperative left femoral-popliteal bypass graft surgery with a diminished pedal pulse 2. 66-year-old client admitted for hypertensive crisis 2 days ago; blood pressure currently 180/102 mm Hg; reports headache and blurred vision 3. 75-year-old client with an ischemic stroke transferred from the intensive care unit 1 hour ago; unresponsive with right-sided paralysis 4. 78-year-old client with diabetes and cellulitis of the left foot; requires frequent dressing changes due to excessive drainage Correct Answer: 4 Rationale The new nurse has the basic skills to provide insulin coverage if necessary, perform wound care (eg, assessment, sterile dressing changes, documentation), and provide diabetic teaching for this client. (Option 1) A more experienced nurse should care for this client as frequent assessments are needed to determine artery patency and changes in circulatory status distal to the graft, especially in the presence of a diminished pedal pulse. (Option 2) A more experienced nurse should care for this client due to frequent assessments and neurologic checks to determine the possible development of target organ disease (eg, brain, heart, lungs, kidneys), especially in the presence of headache and visual disturbances. (Option 3) A more experienced nurse should care for this client due to airway management, aspiration precautions, blood pressure control, and frequent assessments to determine changes in neurologic status. Educational objective: The registered nurse makes assignments according to staff members' experience, knowledge, and skill level. The more experienced nurse is assigned to clients who are less stable and require more in-depth analysis of assessment data to implement and plan care. The less experienced graduate nurse is assigned to more stable clients who require basic nursing care. Question: 21 Which client does the nurse assess first after receiving morning report? 1. Client 1 day postoperative with intravenous (IV) patient-controlled analgesia (PCA) who reports burning at the IV site 2. Client with a bowel obstruction prescribed continuous nasogastric suction who was admitted yesterday 3. Client with atrial fibrillation and an irregular heart rate of 94/min 4. Client with dementia and Clostridium difficile (C difficile) who was incontinent of liquid stool Correct Answer: 1 Rationale The nurse assesses the client who reports burning at the PCA IV site first. The analgesia runs through a special PCA administration set that is attached to the PCA pump. It is attached to a running IV line, which is on its own infusion pump, to flush the PCA drug through the IV line each time a dose is administered. If the IV line infiltrates the subcutaneous tissue or the catheter becomes occluded, the PCA drug can back up into the primary tubing each time a dose is administered, resulting in inadequate pain control. In addition, burning can indicate phlebitis, which causes vessel wall injury and can lead to thrombophlebitis (Option 1). (Option 2) The nurse will perform abdominal and pain assessments and will check the function and patency of the suction. However, this client was admitted yesterday, is stable, and does not need to be assessed first. (Option 3) An irregular heart rhythm is to be expected in a client with atrial fibrillation, and a heart rate of 94/min is within the normal range (eg, 60-100/min). This client is stable and does not need to be assessed first. (Option 4) Incontinence of stool in a client with dementia and C difficile is not uncommon. To provide for immediate client comfort, the nurse can delegate the task of bathing the client to the unlicensed assistive personnel. This client does not need to be assessed first. Educational objective: To prioritize care, the nurse first identifies the type of problem, associated complications, and desired outcomes. The nurse then decides which client problems and needs are most urgent and require immediate action and which can be delayed. Question: 22 The nurse caring for a client with tuberculosis (TB) transports the client to the radiology department for a chest x-ray. The nurse ensures that the client uses which personal protective equipment when out of the negative-pressure room? 1. Isolation gown, surgical mask, goggles, and gloves 2. Isolation gown and surgical mask 3. N95 respirator mask 4. Surgical mask Correct Answer: 4 Rationale Clients with airborne infections such as TB, measles, or chickenpox (varicella) are confined to a negative-pressure room except when traveling to various departments for essential diagnostic procedures or surgery. While being transported through the health care facility, the client on airborne transmission-based precautions wears a surgical mask to protect health care workers (HCWs) and other clients from respiratory secretions. (Options 1 and 2) The client on airborne transmission-based precautions must wear a surgical mask to contain exhaled respiratory secretions. The other personal protective equipment is not necessary. (Option 3) The Centers for Disease Control and Prevention recommends that HCWs who transport clients wear N95 respirator masks as protection against exposure to airborne droplets. N95 respirator masks protect HCWs by removing particles from inhaled air. The client is already infectious and does not require protection from inhaled air. Educational objective: While away from the negative-pressure isolation room, all clients on airborne transmission-based precautions must wear a surgical mask to contain exhaled respiratory secretions. Question: 23 The parent of a 6-year-old calls the nurse and reports that the child was playing outside in the snow and the child's feet now appear red and swollen. What is the best response by the nurse? 1. "Bring the child to the health care provider's (HCP) office immediately." 2. "Give your child something warm to drink." 3. "Massage the child's feet gently until they warm up." 4. "Place the child's feet in warm water immediately." Correct Answer: 4 Rationale The clinical indications of a cold injury include redness and swelling of the skin (chilblains or pernio) and blanched skin with hardness of the affected area (frostbite). For any cold injury, it is important to re-warm the area as soon as possible to restore blood flow and reduce the risk of permanent tissue damage. The recommendation for re-warming is immersion of the affected area in warm water (104 F[40 C]) for about 30 minutes or until the area turns pink in cases of frostbite. The face and ears can be re-warmed with the application of warm facecloths (Option 4). Once re-warming has been effective, the child should be seen by an HCP as soon as possible (Option 1). (Option 2) Giving the child something warm to drink is an appropriate intervention; however, re-warming the child's feet in warm water is the priority action. (Option 3) Massaging a body part that has sustained a cold injury is contraindicated due to the risk of tissue injury. Educational objective: The most important treatment for suspected chilblains/pernio or frostbite is re-warming of the affected area by immersion in warm (104 F [40 C]) water. The individual can also be given a warm liquid to drink and should be seen by an HCP as soon as possible. Question: 24 A major disaster involving hundreds of victims has occurred, and an emergency nurse is sent to assist with field triage. Which client should the nurse prioritize for transport to the hospital? 1. Client at 8 weeks gestation with spotting and pulse of 90/min 2. Client with a compound femoral fracture and an oozing laceration 3. Client with fixed and dilated pupils and no spontaneous respirations 4. Client with paradoxical chest movement throughout respirations Correct Answer: 4 Rationale Disaster triage is based on the principle of providing the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system to categorize them from highest medical priority (emergent) to lowest (expectant). The client with flail chest (ie, paradoxical chest movement during respiration) from multiple fractured ribs is at risk for respiratory failure from impaired ventilation. In addition, mobile fractured ribs may puncture the pleura or vessels, causing hemothorax and/or pneumothorax at any time. Therefore, this client would be classified as emergent due to airway compromise, which requires immediate treatment (Option 4). (Option 1) Spotting at 8 weeks gestation may indicate complications of pregnancy (eg, miscarriage, ectopic pregnancy, hydatidiform mole). With stable vital signs, this client would be classified as nonurgent as the fetus is not at the age of viability and there is no evidence of risk to the mother's life. (Option 2) The client with a compound fracture and oozing laceration would be classified as urgent and require care within 2 hours to prevent life-threatening complications (eg, hemorrhagic shock). (Option 3) Absent respirations and fixed pupils indicate severe neurologic damage or death. Therefore, this client would be classified as expectant. Educational objective: During mass casualty events, the goal is the greatest good for the greatest number of people. Clients are triaged rapidly using a color- coded system that categorizes them from highest medical priority to lowest: red (emergent), yellow (urgent), green (nonurgent), and black (expectant). Question: 25 The nurse is caring for an adolescent client diagnosed with type 1 diabetes. The client exhibits hot, dry skin and a glucose level of 350 mg/dL (19.4 mmol/L). Arterial blood gases show a pH of 7.27. STAT serum chemistry labs have been drawn. Cardiac monitoring shows a sinus rhythm with peaked T waves, and the client has minimal urine output. What is the nurse's next priority action? 1. Administer IV regular insulin 2. Administer normal saline infusion 3. Obtain urine for urinalysis 4. Request prescription for potassium infusion Correct Answer: 2 Rationale This client has diabetic ketoacidosis (DKA). All clients with DKA experience dehydration due to osmotic diuresis. Prompt and adequate fluid therapy restores tissue perfusion and suppresses the elevated levels of stress hormones. The initial hydrating solution is 0.9% saline infusion. (Option 1) Insulin therapy should be started after the initial rehydration bolus as serum glucose levels fall rapidly after volume expansion. (Option 3) Urinalysis is important but not a priority. (Option 4) Potassium should never be given until the serum potassium level is known to be normal or low and urinary voiding is observed. Peaked T waves indicate hyperkalemia in this client. Clients with insulin deficiency frequently have increased serum potassium levels due to the extracellular shift despite having total body potassium deficit from urinary losses. Once insulin is given, serum potassium levels drop rapidly, often requiring potassium replacement. Potassium is never given as a rapid IV bolus, as cardiac arrest may result. Educational objective: Clients with diabetic ketoacidosis and hyperosmolar hyperglycemic state require IV normal saline as a priority due to severe dehydration. Once fluids are given as a bolus, insulin is initiated. The serum potassium levels can be elevated in the initial stages despite a low total body potassium. Potassium repletion is started once the serum potassium levels are normalized or trending low (from elevated levels). Question: 26 The home care nurse is making an initial visit to a client just discharged after admission for severe exacerbation of chronic obstructive pulmonary disease (COPD). The nurse observes wall-to-wall stacks of old newspapers and magazines in every room, with pathways that just allow passage from one room to another. What is the priority nursing action? 1. Call the mobile community mental health crisis unit 2. Contact a service to remove the newspapers and magazines 3. Reconcile the client's discharge medications 4. Teach the safe use of oxygen Correct Answer: 4 Rationale This client exhibits signs of hoarding disorder, an anxiety disorder defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (American Psychiatric Association) as persistent difficulty with discarding or parting with possessions, even those of little value. Clients with hoarding disorder will typically accumulate items such as clothing, food, boxes, bags, newspapers, and magazines. These items commonly fill up and clutter their living areas and can create environmental and fire hazards. The client will most likely experience severe anxiety if the items are removed. Clients with hoarding disorder may never seek mental health services or come to the attention of a mental health professional. Their own behavior usually does not concern them, although it may cause great distress in family members or friends. The treatment for the client with severe COPD will include home oxygen therapy. The priority nursing action is to ensure the safety of the client when using oxygen in an environment that is already at high risk for a hazardous event. (Option 1) Referral to mental health services is an appropriate intervention but is not the priority nursing action. (Option 2) The nurse cannot intervene in this manner without the consent of the client. Removing the newspapers and magazines could cause the client to experience severe anxiety. (Option 3) Reconciling the client's discharge medications is appropriate but is not the priority nursing action. Educational objective: Teaching the safe use of home oxygen is the priority nursing intervention for a client with hoarding disorder who lives in an environment at high risk for fire due to the accumulation of newspapers and magazines. Hoarding disorder is the persistent difficulty with discarding possessions, no matter their value. Removal of the items will cause the client to experience severe anxiety. Question: 27 A nurse in the intensive care unit is caring for a client in the immediate postoperative period following abdominal surgery. The nurse receives several prescriptions. Which prescription should the nurse initiate first? 1. Acetaminophen 1000 mg IVPB every 8 hours 2. Cefazolin 2 g IVPB once, now 3. Norepinephrine 0.02-2.0 mcg/kg/min titrated IV 4. Normal saline 2 L via rapid IV bolus Correct Answer: 4 Rationale Hypotension, tachycardia, and low central venous pressure (normal: 2- 8 mm Hg) may indicate hypovolemic shock. Central venous pressure is a measurement of right ventricular preload (volume within the ventricle at the end of diastole) and reflects the client's fluid volume status. This client is recovering from major abdominal surgery and has a low- grade fever, placing the client at risk for fluid volume losses (eg, blood loss during surgery, insensible losses [sweating]). This client should be treated with isotonic fluids (eg, normal saline, lactated Ringer solution) to restore adequate fluid volume status. IV boluses of isotonic fluids (ie, fluid resuscitation) increase intravascular volume, which increases blood pressure and end-organ perfusion (Option 4). (Option 1) Acetaminophen is an analgesic and antipyretic that reduces fever and pain; however, the client's hemodynamic stability should be addressed first. (Option 2) Cefazolin, a cephalosporin antibiotic, may be prescribed prophylactically to prevent intra-abdominal infection after major abdominal surgery. Medications timed "now" should be administered within 90 minutes. This intervention should be performed after stabilizing the client's hemodynamic status. (Option 3) If the client remains hypotensive following a fluid bolus, vasopressor or inotropic medications (eg, norepinephrine, dopamine) should be initiated. However, vasopressor medications are not effective without first restoring circulatory fluid volume as there is insufficient volume to compress within the vascular space. Educational objective: Hypotension, tachycardia, and decreased central venous pressure (normal: 2-8 mm Hg) may indicate hypovolemic shock. IV boluses of isotonic fluids (ie, fluid resuscitation) increase intravascular volume, which increases blood pressure and perfusion. Question: 28 After making initial rounds on all the assigned clients by 8:00 AM, which client should the nurse care for first? 1. Client 1-day postoperative who was medicated with tramadol 50 mg orally 1.5 hours ago 2. Client 1-day postoperative with pink colored urine after transurethral resection of the prostate (TURP) 3. Client scheduled for discharge today who needs instruction on how to change a sterile dressing 4. Client with adenocarcinoma scheduled for a lobectomy at 9:00 AM who was restless and awake all night Correct Answer: 4 Rationale The nurse should care for the client with adenocarcinoma scheduled for a lobectomy at 9:00 AM first. Not being able to sleep the night before surgery is a common manifestation of anxiety and fear; these emotions can negatively affect recovery. For this reason, it is important to identify and listen to the client's concerns (eg, diagnosis of cancer, fear of death, pain, anesthesia), teach the client about what to expect following surgery (eg, pain control, tubes, intensive care environment), and provide emotional support to help alleviate the fear and anxiety. The nurse can provide for the physical preparation of the client and complete the preoperative checklist as well. (Option 1) Tramadol (Ultram) 50-100 mg orally every 4-6 hours is prescribed for moderate-tosevere postoperative pain. The client was medicated 1.5 hours ago. The drug onset is 1 hour, the peak is 2-3 hours, and the duration is 4-6 hours. Therefore, this client is most likely stable at this time. The nurse does not need to care for this client first. (Option 2) Moderate-to-mild bleeding 1-2 days after undergoing TURP is expected. Pink urine is a normal assessment finding. The nurse does not need to care for this client first. (Option 3) The client who is scheduled for discharge is stable and needs teaching about how to change the surgical dressing. The nurse does not need to care for this client first. Educational objective: To prioritize client care, the nurse first identifies the type of problem the client has, expected findings, associated complications, and desired outcomes. The nurse then uses clinical judgment to decide which client has the most urgent need, and then cares for that client first. Question: 29 The partner of a client with borderline personality disorder calls the clinic and reports coming home from work to find the client with self- inflicted superficial cuts to the arm. The partner tells the nurse, "My partner does something like this every time I have to go away on business. My partner is not serious about doing something really harmful, just trying to stop me from going away." What is the best response by the nurse? 1. "Are you still going to take your business trip?" 2. "It sounds like you are having a difficult time coping with your partner's behavior." 3. "Your partner is most likely doing it for attention, so it's best to just ignore it." 4. "Your partner needs to be seen in the clinic today." Correct Answer: 4 Rationale Clients diagnosed with borderline personality disorder (BPD) often make suicidal threats, gestures, and attempts. They may use these behaviors to bring about a response when there is a real or perceived risk of abandonment from a significant other. All suicidal behavior should be taken seriously; the client's current self-injurious action needs to be evaluated to assess whether it involved suicidal intent. Clients with BPD have been known to demonstrate years of benign suicide threats and gestures before completing a suicide. Predicting a client's risk for completing a suicide is difficult due to the impulsive nature of the behavior. (Options 1 and 3) The priority is for the client to be evaluated at the clinic due to the diagnosis and risk for suicide. The partner's response to the client's behavior can be discussed later. (Option 2) This is not the priority response; it focuses on the partner's needs rather than the client's. Educational objective: Clients with borderline personality disorder are at very high risk for suicide. Suicidal gestures and attempts must be taken seriously and evaluated for suicidal intent. Question: 30 The nurse has just admitted a client with a history of aortic abdominal aneurysm who is experiencing back pain. The nurse needs to assess for a bruit. Where would the nurse place the stethoscope to auscultate for a bruit? Correct Answer: Rationale An aneurysm is an outpouching or dilation of a vessel wall. An abdominal aneurysm occurs on the aorta. A bruit, a swishing or buzzing sound that indicates turbulent blood flow in the aneurysm, is best heard with the bell of the stethoscope. It may be auscultated over the aortic aneurysm in the periumbilical or epigastric area slightly left of the midline. Educational objective: The nurse should listen for a bruit with the bell of the stethoscope over the periumbilical or epigastric area. Question: 31 The nurse cares for an 11-lb (5-kg) infant admitted with dehydration and prepares to calculate intake and output over an 8-hour shift. Using the data in the exhibit, calculate the total output in milliliters for the 8-hour shift. Record your answer as a whole number. Correct Answer: 178mL Rationale To measure the urinary output of an infant in diapers, subtract the weight of the diaper when dry from its weight when wet. One (1) gram of weight is equal to one (1) milliliter of fluid. Adequate urinary output for an infant is 2 mL/kg/hr. Calculation: Urine output in diapers: Diaper 1: 50 − 30 = 20 g Diaper 2: 52 − 30 = 22 g Diaper 3: 46 − 30 = 16 g Total mg of urine: 58 g = 58 mL Total output: (Emesis) + (Urine) = 120 mL + 58 mL = 178 mL Educational objective: Urinary output for a child in diapers is calculated by subtracting the dry weight of the diaper from its weight when wet. One (1) gram of weight is equal to one (1) milliliter of fluid Question: 32 The nurse is assessing a client in the outpatient clinic who has a cast on for a distal humerus fracture. Which statements made by the client would be the priority to assess further? 1. "I am having problems extending my fingers since this morning." 2. "I can't take any of the pain medicine because it makes me feel sick." 3. "I have to scratch under the cast with a nail file because of the itching." 4. "I noticed a warm spot on my cast, and a bad smell is coming from it." Correct Answer: 1 Rationale Volkmann contracture occurs as a result of compartment syndrome associated with distal humerus fractures. Swelling of antecubital tissue causes pressure within the muscle compartment, restricting arterial blood flow (brachial artery). The resulting ischemia leads to tissue damage, wrist contractures, and an inability to extend the fingers. A Volkmann contracture is a medical emergency that can cause permanent damage to the extremity if left untreated. Any restrictive dressing should be removed immediately, and the health care provider (HCP) must be notified for possible surgical intervention (eg, fasciotomy). (Option 2) The nurse should educate the client about ways to prevent medication-related nausea, or the HCP may consider switching pain medications. This would be addressed last. (Option 3) The client must be instructed to never stick anything inside the cast; this can lead to altered skin integrity and infection. This would be addressed third. (Option 4) A warm spot on the cast with a foul odor can indicate infection under the cast, especially if the client has been sticking objects inside to scratch the skin. This would be addressed second. Educational objective: Volkmann contracture (wrist contracture, inability to extend the fingers) occurs as a result of ischemia from compartment syndrome after a distal humerus fracture. It is a medical emergency that requires immediate intervention. Question: 33 The nurse is caring for an 83-year-old bedridden client experiencing fecal incontinence. Which nursing intervention is the highest priority for this client? 1. Consult with the wound care nurse specialist 2. Insert a rectal tube to contain the feces 3. Provide perianal skin care with barrier cream 4. Use incontinence briefs to protect the skin Correct Answer: 3 Rationale Disruptions of motor function (anal sphincter and rectal floor muscle dysfunction) and/or sensory function (lack of urge to defecate or inability to sense stool) can result in fecal incontinence. The presence of stool can lead to skin breakdown, urinary tract infections, spread of infection (eg, Clostridium difficile), and contamination of wounds. Therefore, maintenance of perineal and perianal skin integrity is the highest priority. Stool should be removed promptly from the skin by gently cleansing the perineum and perianal area with mild soap. Dry the soiled area and apply a thick moisture barrier product to the skin (Option 3). Clean, dry linens and clothing should be provided. (Option 1) Wound care and incontinence specialists are useful resources in developing a bowel and/or incontinence management plan; however, the highest priority is promotion of skin integrity. (Option 2) Rectal tubes and other indwelling containment devices can cause skin/mucosal breakdown, decreased response of the anal sphincter, and infection. Skin integrity may be maintained without the risks associated with these devices; however, if other measures fail, these devices may be used. (Option 4) Absorptive incontinence products (eg, pads, undergarments) can be used after interventions to prevent incontinence and maintain perineal hygiene have failed. Incontinence products such as adult briefs may cause chemical irritation of the skin, further exacerbating skin breakdown. These products should wick moisture away from the client's skin. Educational objective: Interventions to prevent and handle fecal incontinence should be implemented from least to most invasive. Maintenance of skin integrity through perineal and perianal hygiene is the highest priority. Implementation of containment products (eg, absorbent pads, adult briefs, and rectal tubes) can be considered after hygiene practices fail. Question: 34 The nurse is assessing a client at 36 weeks gestation during a routine prenatal visit. Which statement by the client should the nurse investigate first? 1. "I am not sleeping as well due to cramps in my calves at night." 2. "I have noticed less kicking movements as the baby grows bigger." 3. "Over the last few weeks, I have not been able to wear any of my shoes." 4. "Sometimes I feel short of breath after walking up a flight of stairs." Correct Answer: 2 Rationale Fetal movement is a sign of fetal health and indicates an intact fetal central nervous system. Fetal movement may occur numerous times per hour during the last trimester of pregnancy, although the client may not perceive every movement. Multiple factors (eg, maternal substance abuse, medications, fasting, and fetal sleep) can affect fetal movement. However, fetal movements should not decrease as the fetus increases in size. Decreased fetal movement is a potential warning sign of fetal compromise (ie, impaired oxygenation), which may precede fetal death (Option 2). The nurse prioritizes assessment of client reports of decreased fetal movement to evaluate fetal well-being (eg, nonstress test). (Option 1) Leg cramps commonly occur in the third trimester, especially at night, due to the weight of the gravid uterus applying pressure to nerves affecting calf muscles. Home interventions include stretching legs, massaging calves, and increasing fluid intake. (Option 3) Dependent edema in the lower extremities is common in the third trimester due to decreased venous return (gravid uterus pressure on vena cava), especially with prolonged sitting/standing. This is not a priority over decreased fetal movement. (Option 4) As the uterus rises in the third trimester, the diaphragm is prevented from allowing full lung expansion, causing dyspnea, especially with exertion. Educational objective: Fetal movement is a sign of fetal health and represents an intact fetal central nervous system. The nurse should educate clients that fetal movements do not decrease in the late third trimester and prioritize assessment of clients reporting decreased fetal movement. Question: 35 The nurse teaches a client with osteopenia, who is lactose intolerant, how to increase dietary calcium and vitamin D intake. Which lunch food is the best choice? 1. Broiled chicken breast 2. Canned sardines 3. Egg white omelet 4. Peanut butter Correct Answer: 2 Rationale Osteopenia is more than normal bone loss for the client's age and sex. Adequate dietary intake of calcium and vitamin D is necessary to promote bone growth, prevent resorption (bone loss), and prevent progression to osteoporosis. Milk and milk productsare the best sources of calcium. However, other food sources are available for individuals who are lactose intolerant. They include some fish (eg, sardines, salmon, trout), tofu, some green vegetables (eg, spinach, kale, broccoli), and almonds. Good food sources of vitamin D include egg yolks and oily fish (eg, salmon, sardines, tuna). Canned sardines are the best choice as sardines are an excellent source of calcium and vitamin D (Option 2). (Options 1, 3, and 4) These foods have only small amounts of calcium per serving and no vitamin D. Educational objective: Sardines are a good alternate dietary source of both calcium and vitamin D for individuals who are lactose intolerant. Question: 36 The office nurse for an orthopedic health care provider receives 4 telephone messages. Which client does the nurse call back first? 1. Client who had a left total knee replacement 7 days ago and reports cramping pain in the left calf 2. Client with a fractured wrist who reports severe itching under a cast that was applied 3 days ago 3. Client with an ankle sprain who is using crutches and reports tingling in the forearm and fingers 4. Client with an intact anterior cruciate ligament injury who reports tightness in the knee unrelieved with ice Correct Answer: 1 Rationale The nurse should call the client with the knee replacement first. Cramping calf pain can indicate the presence of a deep vein thrombosis (DVT), which can occur following joint replacement surgery despite prophylactic anticoagulation. This symptom needs immediate intervention with diagnostic testing (eg, venous Doppler study) as a venous embolus can lead to a pulmonary embolus, which is potentially life-threatening. (Option 2) Itching is to be expected due to drying of the skin under the cast. The nurse can suggest directing the air from a hair dryer on a cool setting under the cast to help relieve itching. This is not a potentially life-threatening event. (Option 3) This client is most likely using the crutches incorrectly or they are not fitted correctly. Pressure on the ulna or radial nerves can lead to numbness and tingling of the fingers and hand weakness. This symptom needs intervention, but it is not potentially life-threatening. (Option 4) Pain and swelling are to be expected with an anterior cruciate ligament injury and are treated with RICE (rest, ice, compression, elevation) for 24-48 hours. Pain and a feeling of tightness can indicate an effusion that may require aspiration, but the condition is not potentially life-threatening. Educational objective: Cramping calf pain following joint replacement surgery can indicate the presence of a venous thrombosis and needs immediate intervention with diagnostic testing as the condition is potentially life-threatening. Question: 37 The parent of a 1-year-old says to the nurse, "I would like to start toilet training my child as soon as possible." What information does the nurse provide to the parent that correctly describes a child's readiness for toilet training? 1. "A good time to start toilet training is when your child can dress and undress autonomously." 2. "When your child can sit on the toilet until urination occurs, you can start toilet training." 3. "Your child may be ready to start toilet training when able to communicate and follow directions." 4. "Your child will be ready to start toilet training at about age 15 months." Correct Answer: 3 Rationale Toilet training is a major developmental achievement for the toddler. The degree of readiness progresses relative to development of neuromuscular maturity with voluntary control of the anal and urethral sphincters occurring at age 18-24 months. Bowel training is less complex than Bladder training; bladder training requires more self-awareness and self- discipline from the child and is usually achieved at age 2.-3. years. In addition to physiological factors, developmental milestones rather than the child's chronological age signal a child's readiness for toilet training. These include the ability to: • Ambulate to and sit on the toilet • Remain dry for several hours or through a nap • Pull clothes up and down • Understand a two-step command • Express the need to use the toilet (urge to defecate or urinate) • Imitate the toilet habits of adults or older siblings • Express an interest in toilet training (Option 1) In order to achieve toilet training, the child will need to be able to pull clothing up and down but not necessarily dress and undress autonomously. (Option 2) Having the child sit on the toilet until urination occurs is not appropriate and will not facilitate bladder control; any urination that occurs is accidental and not due to sphincter control. However, the child should have the ability to remain on the toilet for about 5 – 8 minutes without getting off or crying. (Option 4) Age 15 months is too early to begin toilet training; voluntary control of the anal and urethral sphincters does not occur until age 18-24 months. Educational objective: Readiness for toilet training is dependent on the child's ability to voluntarily control the anal and urethral sphincters, which usually occurs at age 18-24 months. Other developmental and behavioral indicators of toilet training readiness include the child's ability to express the urge to defecate or urinate, understand simple commands, pull clothing up and down, and walk to and sit on the toilet. Question: 38 The nurse cares for an elderly client with type II diabetes who was diagnosed with diabetic retinopathy. Which statement by the client requires the most immediate action by the nurse? 1. "Half of my vision looks like its being blocked by a curtain." 2. "I have to use reading glasses to see small print." 3. "My vision seems cloudy and I notice a lot of glare." 4. "The colors don’t seem as bright as they used to." Correct Answer: 1 Rationale Chronic hyperglycemia can cause microvascular damage in the retina, leading to diabetic retinopathy, the most common cause of new blindness in adults. Option 1 indicates a retinal detachment requiring emergency management. A partial retinal detachment may be painless and cause symptoms such as a curtain blocking part of the visual field, floaters or lines, and sudden flashes of light. An unrepaired complete retinal detachment can cause blindness. (Option 2) The need for reading glasses is associated with presbyopia and is a common, nonemergency, age-related visual disorder. (Option 3) Cloudy vision with a glare is associated with a cataract, a nonemergency, age-related visual disorder. (Option 4) Although decreased vibrancy of colors is a sign of diabetic retinopathy and requires intervention, it is not indicative of a partial or complete retinal detachment; therefore, it is not an emergency. Educational objective: Chronic hyperglycemia can cause microvascular damage in the retina, leading to diabetic retinopathy, the most common cause of new blindness in adults. A partial retinal detachment may be painless and cause symptoms such as a curtain blocking part of the visual field, floaters or lines, and sudden flashes of light. Question: 39 A client with a blood pressure (BP) of 250/145 mm Hg is admitted for hypertensive crisis. The health care provider prescribes a continuous IV infusion of nitroprusside sodium. Which of these is the priority goal in initial management of hypertensive crisis? 1. Decrease mean arterial pressure (MAP) by no more than 25% 2. Keep blood pressure at or below 120/80 mm Hg 3. Maintain heart rate (HR) of 60-100/min 4. Maintain urine output of at least 30 mL/hr Correct Answer: 1 Rationale Hypertensive crisis is a life-threatening emergency due to the possibility of severe organ damage. If not treated promptly, complications such as intracranial hemorrhage, heart failure, myocardial infarction (MI), renal failure, aortic dissection, or retinopathy may occur. Emergency treatment includes IV vasodilators such as nitroprusside sodium. It is important to lower the blood pressure slowly, as too rapid a drop may cause decreased perfusion to the brain, heart, and kidneys. This may result in stroke, renal failure, or MI. The initial goal is usually to decrease the MAP by no more than 25% or to maintain MAP at 110-115 mm Hg. The pressure can then be lowered further over a period of 24 hours. MAP is calculated by adding the systolic blood pressure (SBP) and double the diastolic blood pressure (DBP), and then dividing the resulting value by 3. MAP = (2 x DBP + SBP) / 3 (Option 2) A blood pressure of 120/80 mm Hg (MAP 93 mm Hg) is too low for an initial goal. This rapid drop from the client's initial pressure of 250/145 mm Hg (MAP 180 mm Hg) is a decrease of greater than 25% and could cause organ damage. However, it may be necessary to lower the SBP below 120 mm Hg if the client is experiencing an aortic dissection, as a higher BP can cause rupture. (Option 3) The nurse should monitor HR and rhythm for signs of MI or heart failure. However, the priority goal for this client is to achieve a therapeutic blood pressure, not HR. (Option 4) The nurse should carefully monitor urine output as an indicator of renal function. Output should be greater than 30 mL/hr, but this is not the priority goal in management of hypertensive crisis. Educational objective: Hypertensive crisis may require continuous infusion of an IV vasodilator. BP should be lowered slowly to prevent organ damage. The initial goal is to lower MAP by 25% or less or to maintain MAP of 110- 115 mm Hg. Question: 40 A client is receiving normal saline 75 mL/hr and morphine sulfate via patient-controlled analgesia (PCA) bolus doses. The PCA and normal saline tubing are connected at the "Y" site. The nurse reviews a prescription from the health care provider to discontinue the normal saline. What is the most appropriate nursing action? 1. Change the rate of the normal saline to 10 mL/hr 2. Clarify the prescription with the health care provider 3. Flush the IV with normal saline and then convert it to a saline lock 4. Turn off the normal saline and disconnect it from the "Y" site Correct Answer: 2 Rationale Patient-controlled analgesia (PCA) delivers a set amount of IV analgesic each time the client presses the administration button. With many PCA pumps, a continuous IV solution (eg, normal saline) is required to keep the vein open and flush the PCA medicationthrough the line so that the boluses reach the client. Many facilities have a policy regarding IV fluid for use with PCA; however, a prescription may be required. To ensure uninterrupted delivery of this client's PCA, the nurse should contact the health care provider to clarify the prescription to discontinue the normal saline. (Option 1) A "keep-vein-open" rate (eg, 5-20 mL/hr) may be appropriate; however, a prescription is necessary before the nurse can implement this. (Option 3) This client is still receiving PCA, so it is inappropriate to convert the IV to a saline lock. In addition, this does not address the need to flush the PCA medication through the line. (Option 4) Continuous IV fluids may be required to deliver the PCA boluses; before discontinuing the normal saline, the nurse should receive clarification from the health care provider. Educational objective: Continuous IV fluids are often necessary with use of a patient-controlled analgesia (PCA) pump; the fluids maintain an open vein and provide a vehicle for PCA delivery. Question: 41 A graduate nurse (GN) is caring for a client with acute appendicitis who is awaiting surgery. Which action by the GN would require the precepting nurse to intervene? 1. Administers morphine IV PRN for pain 2. Initiates continuous normal saline IV 3. Provides a heating pad for abdominal discomfort 4. Teaches client about prescribed strict NPO status Correct Answer: 3 Rationale Appendicitis is inflammation of the appendix often resulting from obstruction by fecal matter. Appendiceal obstruction traps fluid and mucus typically secreted into the colon, causing increased intraluminal pressure and inflammation. As appendiceal intraluminal pressure and Inflammation increase, blood circulation to the appendix is impaired, resulting in swelling and ischemia. These factors increase the risk for appendiceal perforation, a medical emergency, which may lead to peritonitis and sepsis. Appendicitis is often treated surgically via removal of the appendix (ie, appendectomy). Nurses caring for clients with appendicitis should avoid interventions that increase intestinal blood circulation, gut motility, or appendiceal intraluminal pressure. The application of heat to the abdomen (eg, heating pad, warm blanket) increases intestinal circulation and the risk for appendiceal perforation (Option 3). (Option 1) Pain and nausea may be managed with prescribed IV analgesics (eg, morphine) and antiemetics. (Option 2) NPO status and vomiting contribute to dehydration, which frequently requires continuous IV fluids (eg, normal saline) to maintain fluid and electrolyte balance. (Option 4) Food and drink increase gastric motility, thereby increasing circulation to the appendix and risk of perforation. The nurse should teach the client about remaining NPO before surgery. Educational objective: Appendicitis is an inflammation of the appendix that often requires surgical treatment. Nurses caring for clients with appendicitis should avoid applying heat to the abdomen as this increases appendiceal swelling and the risk of appendix perforation, which is a medical emergency. Question: 42 While delegating to the unlicensed assistive personnel (UAP), the registered nurse (RN) should utilize the 5 rights of delegation. The "right direction and communication" related to the task is one of those rights. Which statement best meets that standard? 1. "I need for you to take vital signs on all clients in rooms 1-10 this morning." 2. "Mr. Wu's blood pressure has been low. Please take his vital signs first and let me know if his systolic blood pressure is <100." 3. "Mrs. Jones fell out of bed during the night. Be sure you keep a close eye on her this shift." 4. "Would you please make sure Mr. Garcia in bed 8 ambulates several times?" Correct Answer: 2 Rationale Five rights of delegation Right task • Within delegatee's scope of practice • Routine, frequently recurring task; minimal potential risk • Established sequence of steps; requires little to no modification for individual clients • Predictable outcome Right circumstances • Relatively stable client; noncomplex task • Adequate staffing, resources & supervision available Right person • Delegator should assess competency prior to delegating • Delegatee must have the appropriate knowledge, skills & abilities Right direction/ communication • Delegator needs to provide clear instructions; must include specific client concerns & observations to be reported back or recorded • Delegatee should verbalize understanding & have the opportunity to ask questions Right supervision/ evaluation • Monitor, evaluate & intervene as needed • Delegator retains ultimate accountability for task In the Joint Statement on Delegation (2007), the American Nurses Association and the National Council of State Boards of Nursing outline the 5 Rights of Delegation as seen in the table above. The RN needs to direct the UAP's actions and communicate clearly about the assigned tasks including any specific information necessary for completion (eg, methods for collection, time frame, when to report back to the RN). Option 2 gives the UAP directions with prioritization and specific instructions for reporting back findings. (Option 1) The time frame in this option should be more specific. In addition, there is no communication about what the RN expects as follow-up. (Option 3) The instruction to "keep a close eye" on the client leaves the UAP too much room for interpretation. The expectation from the RN is not clear and the UAP needs more direction. (Option 4) The instructions are too broad and don't give a specific time frame. This delegation also needs to communicate the method needed to accomplish the task. Educational objective: The RN should communicate directions to the delegate that include any unique client requirements and characteristics as well as clear expectations on what to do, what to report, and when to ask for assistance. Question: 43 The nurse cares for a group of clients in a medical surgical unit. The client with which diagnosis and condition requires the most immediate assistance by the nurse? 1. Post cholecystectomy, reporting incision pain of a 5 on a scale of 1-10 2. Post open reduction of the right femur, reporting nausea 3. Type 1 diabetes mellitus with a blood glucose of 55 mg/dL (3.1 mmol/L) 4. Type 2 diabetes mellitus with a blood glucose of 250 mg/dL (13.9 mmol/L) Correct Answer: 3 Rationale Hypoglycemia (blood glucose <70 mg/dL [3.9 mmol/L]) is the most life-threatening condition listed. It occurs when the proportion of insulin exceeds the glucose in the blood. Counterregulatory hormones (eg, epinephrine) are then released and the autonomic nervous system is activated, causing multiple hypoglycemia-associated symptoms, including increased heart rate, shakiness, sweating, hunger, anxiety, and pallor. The lack of glucose in the brain is also responsible for other symptoms, including disorientation, impaired vision and speech, seizures, and coma. However, most clients respond rapidly to the correction of hypoglycemia. (Options 1 and 2) The client post cholecystectomy with incisional pain and the client reporting nausea after open reduction of the right femur are in need of nursing attention. However, these are not life-threatening problems. (Option 4) The client with type 2 diabetes mellitus has a blood glucose level of 250 mg/dL (13.9 mmol/L), but this is not immediately life- threatening compared to the client with hypoglycemia. Educational objective: Hypoglycemia (blood glucose <70 mg/dL [3.9 mmol/L]) is a serious condition that occurs when the proportion of insulin exceeds the glucose in the blood. Clients respond rapidly to nursing intervention (eg, sugar tablets, orange juice). Question: 44 The nurse provides instruction to a community group about lung cancer prevention, health promotion, and smoking cessation. Which statement made by a member of the group indicates the need for further instruction? 1. "Even though I am getting nicotine in my patches, I am not being exposed to all of the other toxic stuff in cigarettes." 2. "I can't get lung cancer because I don't smoke." 3. "My husband needs to take smoking cessation classes." 4. "We installed a radon detector in our home." Correct Answer: 2 Rationale Smoking is responsible for 80%-90% of all lung cancers. Although the risk is greater among smokers, former smokers and nonsmokers can develop lung cancer as well. Risk factors include secondhand smoke, air pollution, genetic predisposition, and exposure to radon, asbestos, and chemicals in the workplace. (Option 1) Smoking cessation is the best way to prevent lung cancer. Nicotine replacement therapy (eg, patches, gum, inhalers, lozenges) is effective in helping smokers quit by reducingcravings. Although users receive a low dose of nicotine, they do not receive the other toxins that cigarettes include. (Option 3) The best way to reduce the risk of lung cancer is to avoid both firsthand and secondhand smoke. Smoke from someone else's burning cigarette contains the same carcinogens as those found in mainstream smoke and creates a health risk to those inhaling it. (Option 4) Exposure to high levels of radon can cause lung cancer. Radon levels must be tested before a home can be sold. Educational objective: Although the risk is greater among smokers, former smokers and nonsmokers can develop lung cancer. Risk factors include secondhand smoke, air pollution, genetic predisposition, and exposure to radon, asbestos, and chemicals in the workplace Question: 45 A nursing unit implements a quality improvement process of written reminders to ameliorate incentive spirometer (IS) use in postoperative clients. What is the best indicator that the client goal for this process has been met? 1. Chart audits indicate that client incidence of nosocomial pneumonia decreased by 20% 2. Documentation shows that 100% of nurses attended an inservice seminar on the topic 3. Nurses report an increased number of written reminders given to appropriate clients 4. Surgeons who admit to the unit report increased satisfaction with current client IS used Correct Answer: 1 Rationale The best indicators of a successful intervention (desired effect achieved) are objective criteria. This is an objective measurable result that can be correlated with the intervention. (Option 2) Attending an inservice seminar for staff education is an important and necessary step for intervention implementation. However, the intervention will be successful only if the information is applied and the desired outcome is achieved. (Option 3) Reporting the number of written reminders given to respective clients is necessary. However, this reporting of intervention achievement is subjective as recall can be inaccurate. Even if it were an accurate recounting, it does not prove that the intervention succeeded. The appropriate focus should be on client outcomes, not nursing staff behaviors. (Option 4) Although approval from surgeons provides helpful support for the intervention, an objective evaluation beyond personal opinions is required. Educational objective: The effectiveness of an intervention should be determined by objective measurable outcomes that can be correlated with the intervention. It should not be based only on opinion or staff activities. Question: 46 Several children are brought to the emergency room after a boating accident in which they were thrown into the water. The children are now 6 hours post-admission to the clinical observation unit. Which client should the nurse evaluate first? 1. Client who did not require CPR but now has a new oxygen requirement of 2 L via nasal cannula to maintain a saturation of 95% 2. Client who did not require CPR but was coughing on arrival to the hospital and is now crying inconsolably and asking for the mother 3. Client who received CPR for 2 minutes on the scene and whose respiratory rate has now dropped from 61/min to 18/min 4. Client who was briefly submerged in water and received rescue breaths on the scene and is now irritable and refusing food and drink Correct Answer: 3 Rationale Clients with morbidity related to immersion in water are described as having submersion injury. Even if an individual was submerged for a very brief time, it is possible that water may have been aspirated, which can lead to respiratory compromise. Observation for at least 6 hours is recommended as the majority of significant respiratory problems will manifest in this time period. A marked decrease in respiratory rate or increased work of breathing may indicate respiratort fatigue, and immediate intervention is needed (Option 3). Impending respiratory failure is the immediate priority. (Option 1) A new oxygen requirement is an important symptom; however, this child has good oxygen saturation with the nasal cannula and is therefore not the immediate priority. (Option 2) This child who is coughing and emotionally distressed should be seen and comforted by the nurse but is not the priority. (Option 4) Irritability can be an early sign of hypoxia in a toddler. This child should be assessed promptly but is not the immediate priority. Educational objective: Clients who have sustained submersion injury should be evaluated immediately and observed for at least 6 hours for new or worsening respiratory failure. Changes in respiratory pattern or rate, oxygen saturation, and level of consciousness can signal impending respiratory failure, which can be life-threatening. Question: 47 The nurse prepares a client for discharge following a vasectomy. The client asks, "When can I have sexual intercourse with my wife without using a condom?" What is the best response by the nurse? 1. "Discontinue alternative birth control after at least 5 ejaculations." 2. "There is no need to use alternative birth control following today's procedure." 3. "Use alternative birth control for 6 months following today's procedure." 4. "Use alternative birth control until cleared by the health care provider." Correct Answer: 4 Rationale A vasectomy is a surgical procedure performed for permanent male sterilization. During the procedure, the vasa deferentia (ie, ducts that carry sperm from the testicles to the urethra) are cut and sealed, preventing sperm from entering the ejaculate. The vasa deferentia are severed in the scrotum at the site before the seminal vesicles and prostate. As a result, the procedure should not affect the ability to ejaculate, amount and consistency of ejaculatory fluid, or other physiological mechanisms (eg, hormone production, erection, orgasm). Following a vasectomy, sperm continue to be produced but are absorbed by the body. Following the procedure, it can take several months for the remaining sperm to be ejaculated or absorbed. Alternative birth control should be used until the health care provider confirms that semen samples taken at a follow-up appointment are free of sperm; otherwise, pregnancy can occur (Option 4). (Options 1, 2, and 3) The length of time and number of ejaculations necessary to evacuate remaining sperm will vary. The only way to ascertain that the ejaculate no longer contains sperm is to test a client's semen samples. Educational objective: To prevent an unwanted pregnancy following a vasectomy, alternative methods of birth control should be used until semen samples are found to be free of sperm Question: 48 A client is being discharged home after open radical prostatectomy. Which statement indicates a need for further teaching? 1. "I will try to drink lots of water." 2. "I will try to walk in my driveway twice a day." 3. "I will wash around my catheter twice a day." 4. "If I get constipated, I will use a suppository." Correct Answer: 4 Rationale Following open radical prostatectomy, any rectal interventions such as suppositories or enemas must be avoided to prevent stress on the suture lines and problems with healing in the surgical area. The client should not strain when having a bowel movement for these reasons. Therefore, interventions to prevent constipation are an important part of postoperative care and discharge teaching. Prevention of constipation is particularly important while the client remains on opioid analgesics, which can cause constipation (Option 4). (Option 1) Fluid intake should be encouraged in this client. (Option 2) The client is at risk for postoperative deep vein thrombosis and pulmonary embolism. Ambulation is an important part of preventing these serious surgical complications. Ambulation will also help reduce constipation. (Option 3) The client who goes home with an indwelling catheter should learn how to clean around the catheter at the urinary meatus with warm water and soap to prevent infection. Educational objective: Clients who have had an open radical prostatectomy for prostate cancer should avoid anything that could cause strain on the rectal area. Straining, suppositories, and enemas are contraindicated in these clients, and interventions should be implemented to prevent constipation. Question: 49 A graduate nurse (GN) is inserting an oropharyngeal airway in a client emerging from general anesthesia. The nurse preceptor intervenes when the GN performs which action? 1. Inserts oropharyngeal airway (OPA) into mouth with curved end pointing upward 2. Measures OPA against the cheek and jaw angle before insertion 3. Rotates OPA tip downward once it reaches the soft palate 4. Tapes OPA to ensure it is secure and to prevent dislodgement Correct Answer: 4 Rationale An oropharyngeal airway (OPA) is a temporary, artificial airway device used to prevent tongue displacement and tracheal obstruction in clients who are sedated or unconscious. As consciousness and the ability to protect the airway return, the client will often cough or gag, indicating a need to remove the OPA; clients may also independently remove or expel the OPA. Nurses caring for a client with an OPA must ensure that the device is easily removable from the client's mouth, as an obstructed (eg, taped) OPA may cause choking and aspiration (Option 4). (Options 1 and 3) The OPA should be inserted with the distal end pointing upward toward the roof of the mouth to prevent displacement of the tongue and obstruction of the trachea. Once the OPA reaches the soft palate (eg, back of the mouth), the nurse rotates the OPA tip downward toward the esophagus, which pushes the tongue forward and maintains airway patency. (Option 2) Appropriate OPA size should be measured prior to insertion, as inappropriate size could push the tongue back and cause airway obstruction. The OPA should be measured with the flange next to the client's cheek. With correct sizing, the OPA curve will reach the jaw angle. Educational objective: An oropharyngeal airway (OPA) is a temporary artificial airway used to prevent tongue displacement and tracheal obstruction in clients who are sedated or unconscious. An OPA should never be taped in place, due to the risk of choking and aspiration when the client awakens. Question: 50 The emergency department nurse performs an admission assessment for a client with priapism of about 3 hours duration who also has sickle cell anemia. What assessment finding is of most concern and warrants immediate notification of the health care provider? 1. Bluish discoloration of the erect penis 2. Drank a 6-pack of beer 8 hours ago 3. Extreme penile pain rated as 9 on 0-10 scale 4. Has not voided for at least 6 hours Correct Answer: 1 Rationale Priapism is a sustained, painful erection often associated with sickle cell anemia, as the sickling (crescent shaping) of red blood cells can lead to penile vascular occlusion, erectile tissue hypoxia, and tissue necrosis. Bluish discoloration is of most concern as it can be a sign of ischemia to the penis. (Option 2) Some factors, such as alcohol intake; spinal cord injury; and phosphodiesterase-5 enzyme inhibitor (ie, sildenafil), psychotropic (ie, trazodone), and illegal (ie, cocaine) drugs can contribute to the development of priapism. Possible penile ischemia is a more urgent concern than alcohol intake. (Option 3) Extreme pain related to tissue hypoxia is an expected, characteristic manifestation of priapism and requires analgesia, but it is not as urgent a concern as possible penile ischemia. (Option 4) Difficulty voiding and urinary retention are complications associated with priapism. It is important to monitor urine output as catheterization may be necessary, but this is not as urgent a concern as possible penile ischemia. Educational objective: Priapism is a sustained, painful erection that lasts for more than 2 hours. Common associated clinical manifestations include discoloration of the penis, intense pain, rigid penis, difficulty voiding, and anxiety and embarrassment. Question: 1 The nurse is admitting a client with a possible diagnosis of Guillain- Barre syndrome. When collecting data to develop a plan of care for the client, the nurse should give priority to which of the following items? 1. Orthostatic blood pressure changes 2. Presence or absence of knee reflexes 3. Pupil size and reaction to light 4. Rate and depth of respirations Correct Answer: 4 Rationale Guillain-Barré syndrome (GBS) is an acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle paralysis and absence of reflexes. Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves (CNs). Neuromuscular respiratory failure is the most life-threatening complication. The rate and depth of the respirations should be monitored (Option 4). Measurement of serial bedside forced vital capacity (spirometry) is the gold standard for assessing early ventilation failure. (Option 1) Autonomic dysfunction is common in GBS and usually results in orthostatic hypotension, paralytic ileus, urinary retention, and diaphoresis. These complications need to be assessed but are not a priority. (Option 2) Absence of knee reflexes is expected early in the course of GBS due to the ascending nature of the disease. Absence of gag reflex indicates GBS progression. (Option 3) PERRLA (pupils equal, round, reactive to light, accommodation) evaluation assesses CNs II, III, IV, and VI. CN abnormalities are expected after the thoracic muscles (respiratory) are involved due to the ascending nature of GBS. Educational objective: The most serious complication to monitor for in new-onset Guillain- Barre syndrome is respiratory compromise from the paralysis ascending into the thoracic region. Monitoring for rate/depth of respirations and measuring serial bedside vital capacity (spirometry) help to detect this early in the disease course. Question: 2 A 55-year-old client on a medical-surgical unit has just received a diagnosis of pancreatic cancer. The client says to the nurse, "Is this disease going to kill me?" What is the best response by the nurse? 1. "Hearing this diagnosis must have been difficult for you. What are your thoughts?" 2. "We will do everything possible to prevent that from happening." 3. "Well, we're all going to die sometime." 4. "You should concentrate on getting better rather than thinking about death." Correct Answer: 1 Rationale The stress of receiving a life-threatening diagnosis often causes clients to feel very vulnerable. There is a tendency to keep feelings and concerns closed off; clients may not be able to express how distressed they feel or find the right words to express feelings and concerns. In asking, "Is this disease going to kill me?" the client is most likely not looking for a direct "yes" or "no" answer. This would immediately close off the conversation and create a missed opportunity for a meaningful engagement and communication with the nurse. It is more likely that this question is being asked to provide an opening for further discussion about the meaning of this devastating diagnosis as well as the client's thoughts and feelings. The nurse can facilitate a sense of trust, connection, and collaboration by the following: • Providing empathy - acknowledging the distressing nature of the diagnosis • Providing situations (eg, broad opening for discussion) in which the client can share thoughts and feelings in a safe environment • Active listening - being very attentive to what the client is saying and trying to understand what the client is thinking and feeling • Focusing - going beyond words and explanations to attain new awareness of a client's concerns • Communicating effectively will assist the client in coping with difficult situations, reducing stress, and developing approaches for making necessary life changes (Option 2) This response attempts to give reassurance but does not address the client's thoughts and concerns. (Option 3) This is a very trite response and will close down any opportunity for further discussion. (Option 4) This response gives advice to the client and is non- therapeutic; it does not acknowledge the client's current concerns. Educational objective: Clients with devastating conditions or situations may have difficulty expressing their concerns, thoughts, and feelings. A nurse who is skilled in using effective communication techniques such as active listening, providing broad openings for discussion, and focusing can help clients cope with and reduce the stress of difficult situations. Question: 3 The nurse is calculating IV fluid resuscitation for a client weighing 85 kg with visible partialthickness burns covering 40% of the body. Using the Parkland formula, how many liters of IV fluid resuscitation are needed during the first 8 hours? Record your answer using one decimal place. Correct Answer: 6.8L Rationale Burn injuries are caused by direct tissue damage from exposure to caustic (eg, thermal, chemical, electrical) sources. This initial tissue injury, combined with the systemic inflammatory response, causes increased capillary permeability, fluid and electrolyte shifts, and decreased intravascular volume. This intravascular loss often leads to hypovolemic shock in clients with extensive burns and requires emergency fluid resuscitation for client survival. The Parkland formula is an IV fluid resuscitation protocol used to calculate the fluid replacement needed in the first 24 hours after a burn injury. Half of the calculated fluid volume is administered during the first 8 hours after injury, when the greatest amount of intravascular volume loss occurs. The following steps should be used to calculate the volume needed for infusion during the first 8 hours. 1. Calculate the total volume needed for infusion for 24 hours Educational objective: The Parkland formula (4 mL × weight [kg] × body surface area burned [%]) is used to calculate the amount of IV fluid required for a burn victim during the initial 24 hours after injury. Half of the calculated volume is administered within the first 8 hours. Question: 4 The registered nurse (RN) on an orthopedic unit is orienting a new graduate nurse (GN) assigned to a client with a fractured hip and in Buck's traction. The RN intervenes when the GN performs which action? 1. Elevates the head of the bed 45 degrees 2. Holds the weight while the client is repositioned up in bed 3. Loosens the Velcro straps when the client reports that the boot is too tight 4. Provides the client with a fracture pan for elimination needs Correct Answer: 1 Rationale Buck's skin traction maintains proper alignment of an injured body part by using weights to apply a continuous pulling force. Appropriate actions for a client in Buck's skin traction include: • The client should be supine or in semi-Fowler's position (maximum of 20-30 degrees). Elevating the head of the bed more than 30 degrees would promote sliding (Option 1). • Regularly assess the neurovascular status and skin integrity of the limb in traction. Loosen Velcro straps if the boot is too tight as they can impair neurovascular status and skin integrity; tighten the straps if the boot is too loose as this can decrease the effectiveness of the traction. When a change is made in the application of the boot or traction pulley system, the nurse should reassess neurovascular status in 30 minutes (Option 3). • Provide a fracture pan, which is smaller than a bedpan, for elimination needs to minimize client movement and provide comfort (Option 4). • Weights should be always free hanging and should never be placed onto the bed or touch the floor. A staff member should support the weight while the client is repositioned up in bed to prevent excessive pull on the extremity (Option 2). Skeletal traction is applied directly to the bone with a metal wire or pin and is used to immobilize, position, or align a fracture when continuous traction is needed, and skin traction is not possible. Removing the weights can cause injury to the client and should never be removed unless there is a life-threatening situation. Educational objective: To maintain effective pull and avoid interrupting traction, weights should be free hanging at all times. Proper body alignment should be maintained with the client supine or in semi-Fowler's position (maximum 30 degrees). The nurse should monitor the neurovascular status and skin integrity of the limb in traction Question: 5 The health care provider (HCP) orders a small bowel follow-through (SBFT) for a client. Which instructions should the nurse include when teaching the client about this test? 1. "After the test, you may notice your stools are tarry black for a few days." 2. "During the test, a series of x-rays will be taken to assess the function of the small bowel." 3. "The HCP will use an endoscope to visualize your small bowel." 4. "Your examination is scheduled for 8:00 AM. Please drink all of the polyethylene glycols by midnight." Correct Answer: 2 Rationale An SBFT examines the anatomy and function of the small intestine using x-ray images taken in succession. Barium is ingested, and x-ray images are taken every 15-60 minutes to visualize the barium as it passes through the small intestine (Option 2). Using this technique, decreased motility (eg, ileus), increased motility (eg, malabsorption syndromes), fistulas, or obstructions are identified. Clients should be instructed as follows: • Fast 8 hours prior to the examination. • The test usually takes 60-120 minutes, but if obstruction or decreased motility is present, it can take longer. • Drink plenty of fluids after the examination to facilitate barium removal. Chalky stools may be present 24-72 hours after the examination. If brown stools do not return after 72 hours or abdominal pain or fullness is present, contact the HCP. (Option 1) Black, tarry stools (melena) is not an expected symptom of an SBFT; melena is indicative of gastrointestinal bleeding and should be reported immediately to an HCP. (Option 3) An endoscope is not used to complete an SBFT. (Option 4) Clients should refrain from eating 8 hours prior to the examination. Polyethylene glycol (Nu-LYTELY) is prescribed as a bowel preparation for a colonoscopy, not an SBFT. Educational objective: An SBFT uses sequential x-ray images to visualize the structure and function of the small intestine. The client should fast for 8 hours prior to the examination. Stools may be chalky for up to 72 hours. Black, tarry stools indicate a potential gastrointestinal bleed and should be reported immediately. Question: 6 The nurse is caring for a 72-year-old client 1-day postoperative colectomy. The nurse assesses an increased work of breathing, diminished breath sounds at the bases with fine inspiratory crackles, respirations 12/min and shallow, and pulse oximetry 96% on 2 L oxygen. There is no jugular venous distension or peripheral edema. Pain is regulated with client-controlled morphine. Which prescription does the nurse anticipate? 1. Bolus dose of IV morphine 2. Incentive spirometer 3. IV furosemide 4. Non-rebreather mask Correct Answer: 2 Rationale During the initial postoperative period, a client needs respiratory interventions to keep the lungs expanded and prevent atelectasis and postoperative pneumonia. Atelectasis is maximal during the second postoperative night. Clients can be asymptomatic or have increased work of breathing, hypoxia, and basal crackles. Postoperative pain, opioid respiratory depression, limited mobility, and reluctance to take a deep breath due to anticipated pain contribute to postoperative atelectasis. The elderly and postoperative abdominal and thoracic surgery clients are at increased risk for atelectasis. The incentive spirometer encourages the client to breathe deeply with maximum inspiration. This action improves ventilation and oxygenation by expanding the lungs, encourages coughing, and prevents or improves atelectasis. It is the most appropriate prescription for this client. (Option 1) In a client whose pain is regulated with client-controlled analgesia (eg, morphine), administration of a bolus dose is not indicated and may increase the risk for respiratory depression. (Option 3) Fine crackles in the lungs usually indicate atelectasis. The presence of coarse crackles, elevated jugular venous distension, and peripheral edema usually indicates volume overload (fluid in the alveoli). In addition, clients with fluid overload breathe at a rapid rate (tachypnea) rather than take slow, shallow breaths. IV furosemide (Lasix) is an appropriate intervention for volume overload but not for atelectasis. (Option 4) As-needed oxygen may be prescribed postoperatively, especially with blood loss. A non-rebreather mask, which has 100% oxygen, is not indicated in this client as the pulse oximeter shows 96% saturation, indicating adequate oxygenation. Educational objective: The incentive spirometer is a handheld, inexpensive breathing device. It encourages the client to breathe deeply with maximum inspiration, which improves ventilation and oxygenation and encourages coughing. The incentive spirometer is used to prevent or improve atelectasis in clients who are postoperative, have respiratory problems (eg, pneumonia), or have experienced trauma. Question: 7 The registered nurse is developing a nursing care plan for a client who has just undergone surgery for treatment of ulcerative colitis with the creation of a permanent ileostomy. What is the priority outcome for this client? 1. The client will contact the United Ostomy Association of America 2. The client will look at and touch the stoma 3. The client will read the materials provided on ostomy care 4. The client will verbalize methods to control gas and odor Correct Answer: 2 Rationale A client who has undergone ostomy surgery must become independent in self-care. This requires adaptation to a significant alteration in body image and dealing with a number of psychosocial issues that are associated with a change in appearance and the loss of bowel control. It is not uncommon for a client to cope with this loss by refusing to look at or participate in the care of the stoma. Nursing interventions for this client will include: • Supportive counseling and assistance in psychosocial adjustment • Teaching and facilitating self-care • Providing information about the reason for the surgery, prognosis, potential complications, and community resources The priority outcome of nursing care is that the client will look at and touch the stoma; this is an indication that the client has accepted or begun to accept the change in body image and functioning and can begin participating in self-care. (Option 1) This is an appropriate outcome; community organizations can offer support and educational materials to the client; however, it is not the priority. (Option 3) This is an appropriate outcome, but as a passive activity, it is not a strong indicator that the client is ready for self-care. (Option 4) This is an appropriate outcome as it indicates effective ostomy teaching; however, it is not the priority. Teaching will be more effective once the client has accepted the ostomy. Educational objective: A client with a change in body image and functioning, such as the creation of an ostomy, will need to adapt to and cope with the significant changes. Support and teaching will assist the client in overcoming psychosocial barriers to self-care; performance of a desired action is the strongest indicator of learning and acceptance. Question: 8 The clinic nurse is asked by the mother of a 15-month-old, "I am worried about my child's thumb sucking and its effects on tooth alignment. What should I do?" What is the nurse's best response? 1. "As long as your child's thumb sucking stops by age 2-3 years when all of the primary teeth have erupted, there is little concern." 2. "Because your child already has teeth, it is important to implement a plan to stop the thumb sucking as soon as possible." 3. "Newer research shows that thumb sucking has little effect on a child's teeth." 4. "The risk for misaligned teeth occurs when thumb sucking persists after eruption of permanent teeth." Correct Answer: 4 Rationale Rooting and sucking are a part of an infant's natural reflexes. Nonnutritive sucking assists in helping the infant to feel secure. Some parents become very concerned about their infants sucking fingers, thumbs, or a pacifier and try to stop the behavior. As a rule, if thumb sucking stops before the permanent teeth begin to erupt, misalignment of the teeth and malocclusion can be avoided. Parents should be taught that teasing and punishing a child for using a pacifier or sucking the thumb is not an effective method for getting the child to stop. This can increase the child's anxiety and cause the child to increase the behavior. (Options 1, 2, and 3) These options are incorrect. Use of a pacifier or thumb sucking prior to eruption of the permanent teeth does not tend to cause dental issues such as teeth misalignment or malocclusion. Educational objective: The risk of teeth misalignment and malocclusion occurs when a child uses a pacifier or sucks the thumb after the eruption of the permanent teeth. Question: 9 The nurse prepares to administer an IV infusion of potassium chloride through a peripheral vein to a client with hypokalemia. The health care provider's prescription states: IV potassium chloride 10 mEq (10 mmol)/100 mL 5% dextrose in water now, infuse over 30 minutes. What is the nurse's priority action? 1. Assess the patency of the peripheral IV site 2. Check the most current serum potassium level 3. Contact the health care provider to verify the prescription 4. Set the electronic IV pump to 100 mL/hr Correct Answer: 3 Rationale The recommended rates for an intermittent IV infusion of potassium chloride (KCl) are no greater than 10 mEq (10 mmol) over 1 hour when infused through a peripheral line and no greater than 40 mEq/hr (40 mmol/hr) when infused through a central line (follow facility guidelines and policy). If the nurse were to administer the medication as prescribed, the rate would exceed the recommended rate of 10 mEq/hr (10 mmol/hr) (ie, 10 mEq [10 mmol] over 30 minutes = 20 mEq/hr [20 mmol/hr]). A too rapid infusion can lead to pain and irritation of the vein and postinfusion phlebitis. Contacting the health care provider to verify this prescription is the priority action. (Option 1) The nurse would assess the IV site for swelling, tenderness, and redness just before initiating the KCl infusion and every 30 minutes during administration. However, this is not the priority action. (Option 2) The nurse would check the most current serum potassium level just before administering the KCl and may obtain another level following the infusion, if prescribed. This is not the priority action. (Option 4) An electronic IV pump should always be used to administer KCl. To administer the infusion at the recommended rate of 10 mEq/hr (10 mmol/hr), the nurse would set the pump at 100 mL/hr, but this is not the priority action. Educational objective: The maximum rate for infusion of IV potassium chloride through a peripheral vein is 10 mEq/hr, and the maximum rate through a central vein is 40 mEq/hr. Question: 10 A child received the varicella immunization. The day after the injection, the parent calls the nurse to say that the child has discomfort, slight redness, and 2 vesicles at the injection site. What instruction would be appropriate for the nurse to provide to this parent? 1. Administer aspirin to decrease discomfort 2. Cover the vesicles with a small bandage until they are dry 3. Isolate the child from other children for 21 days to avoid exposure 4. Make an appointment with the health care provider (HCP) as soon as possible Correct Answer: 2 Rationale The varicella immunization is administered to prevent infection of varicella zoster, commonly known as chickenpox. Side effects of the immunization include discomfort, redness, and a few vesicles at the injection site. Covering the vesicles with clothing or a small bandage will reduce the risk of transmission from any exudate. Once the vesicles have dried, or crusted, a dressing is no longer necessary. (Option 1) Acetaminophen is the appropriate medication to reduce the discomfort of the injection. Aspirin should be avoided in children due to the risk of Reye syndrome. (Option 3) Unless the rash becomes widespread, isolation of the child is unnecessary. It is unlikely that the infection will be transmitted by the 2 vesicles, but covering them with clothing or a small bandage will decrease the risk of transmission. (Option 4) Discomfort, redness, and a few vesicles at the injection site are common side effects of the varicella immunization and do not require the attention of an HCP. Educational objective: Discomfort, redness, and vesicles at the injection site are common side effects of the varicella immunization. Covering the vesicles with clothing or a small bandage will reduce the risk of transmission from any exudate. Question: 11 The nurse cares for a client with type 1 diabetes mellitus who is obtunded and responding to only painful stimuli. A STAT blood sample reveals a blood glucose level of 38 mg/dL (2.11 mmol/L). Which initial action by the nurse is best? 1. Administer 50% dextrose in water IV push 2. Assist the client to drink 4 oz (120 mL) of orange juice 3. Measure the client's heart rate and blood pressure 4. Observe for sweating, shakiness, and pallor Correct Answer: 1 Rationale Hypoglycemia, a potentially life-threatening complication of diabetes mellitus, is identified by blood glucose <70 mg/dL (<3.9 mmol/L) and often occurs as a result of illness or inappropriate use of antidiabetic medications. When blood glucose levels (BGLs) are low, the body activates the autonomic nervous system, causing shakiness, palpitations, and sweating. Without intervention, hypoglycemia may cause altered mental status (eg, difficulty speaking, confusion), which may progress to seizures, coma, and death. Nurses caring for clients with hypoglycemia and altered mental status or dysphagia should immediately administer IV glucose replacement (eg, 50% dextrose in water) to quickly restore BGLs and prevent potentially lethal neurological changes (Option 1). Afterward, the nurse should retest the BGL every 15 minutes, repeating treatment if it remains low. (Option 2) Clients with altered mental status (eg, obtunded, responsive only to painful stimuli) are at high risk for aspiration and are not appropriate candidates for oral glucose replacement. (Options 3 and 4) Obtundation, a sign of severe hypoglycemia, and a confirmed BGL of 38 mg/dL (2.11 mmol/L) are sufficient indicators for implementing emergency intervention. Assessment of additional signs of hypoglycemia, heart rate, and blood pressure should not delay implementation of lifesaving treatment. Educational objective: Hypoglycemia is a complication of diabetes mellitus that can lead to coma, seizures, and death without prompt intervention. Nurses caring for clients with hypoglycemia and altered mental status should administer IV glucose to quickly restore blood glucose levels. Lifesaving treatment should not be delayed performing further assessments. Question: 12 The nurse is caring for a 50-year-old client in the clinic. The client's annual physical examination revealed a hemoglobin value of 10 g/dL (100 g/L) compared to 13 g/dL (130 g/L) a year ago. What should be the nurse's initial action? 1. Encourage intake of over-the-counter iron pills 2. Encourage intake of red meat and egg yolks 3. Facilitate a screening colonoscopy 4. Facilitate another blood test in 6 months Correct Answer: 3 Rationale Early signs of colorectal cancer are usually nonspecific and include fatigue, weight loss, anemia, and occult gastrointestinal bleeding. Clients should have regular screening colonoscopy for colon cancer starting at age 50 if their risk is average or earlier if their risk is high. Colorectal screening can also include fecal occult blood test or fecal immunochemical test annually. Newonset anemia should be taken seriously at this client's age, and colon cancer must be ruled out. The etiology of anemia must be determined prior to recommending treatment. (Options 1 and 2) The cause of anemia must be determined before recommendations can be provided for iron deficiency. There are many causes of anemia (including pernicious anemia) in older adults that involve deficiencies in vitamin B12, not iron. (Option 4) Waiting for 6 months will delay care. Educational objective: The etiology of new-onset anemia in an adult should be determined prior to treatment. Clients age ≥50 should be screened for colorectal cancer. Early signs include anemia Question: 13 A 37-weeks-pregnant woman comes to the emergency department with a fractured ankle. Which assessment finding is most concerning and requires the nurse to follow up? 1. Fetal heart rate remains 206/min 2. Fetus kicked 4 times in the past hour 3. Mother reports feeling 2 contractions every hour 4. Mother's hemoglobin is 11 g/dL (110 g/L) Correct Answer: 1 Rationale Fetal tachycardia is a baseline of >160 beats/min for >10 minutes. Tachycardia needs evaluation and continued surveillance. The most sensitive indicators of fetus health are fetal movement and fetal heart rate. (Option 2) This is an expected finding. Monitoring fetal movement/kick counts is a primary method of fetal surveillance. The reassuring finding is when the movement equals or exceeds the established baseline. In general, 4 movements/hour or 10 distinct fetal movements within 2 hours is a reassuring finding. (Option 3) Braxton-Hicks contractions are felt mid-pregnancy onward. These painless, occasional physiological contractions are normal. The contractions are a concern if they become regular and persist. (Option 4) During pregnancy, hemoglobin can drop to 11 g/dL (110 g/L), a condition known as physiological anemia of pregnancy. Due to the increased oxygen requirements of pregnancy, the red blood cell count increases 30%. However, anemia can result from an increase in the plasma volume that is relatively larger than the increase in red blood cells. This lowered maternal hemoglobin is within the expected range. Educational objective: Sustained fetal tachycardia (>160/min for >10 minutes) is a concerning finding that requires further follow-up. Question: 14 The nurse provides teaching about methotrexate to a client with rheumatoid arthritis. It is most important to address which topic regarding this drug? 1. Need for an eye examination 2. Need for sunblock 3. Risk for infection 4. Risk for kidney injury Correct Answer: 3 Rationale Methotrexate (Rheumatrex) is classified as a folate antimetabolite, antineoplastic, immunosuppressant drug used to treat various malignancies and as a nonbiologic diseasemodifying antirheumatic drug (DMARD) used to treat rheumatoid arthritis and psoriasis. Methotrexate can cause bone marrow suppression resulting in anemia, leukopenia, and thrombocytopenia. Leukopenia and its immunosuppressant effects can increase susceptibility to infection. Clients should be educated about obtaining routine killed (inactivated) vaccines (eg, influenza, pneumococcal) and avoiding crowds and persons with known infections. Live vaccines (eg, herpes zoster) are contraindicated in clients receiving immunosuppressants, such as methotrexate. Alcohol should be avoided in clients taking methotrexate as it is hepatotoxic and drinking alcohol increases the client's risk for hepatotoxicity. (Option 1) Regular eye examinations every 6 months are indicated for clients prescribed the nonbiological DMARD antimalarial hydroxychloroquine (Plaquenil) as it can cause retinal damage. Ethambutol, used to treat tuberculosis, also requires frequent eye examinations. (Options 2 and 4) Photosensitivity (common with tetracycline, thiazide diuretics, and sulfonamides) and nephrotoxicity (common with aminoglycosides, vancomycin, and nonsteroidal anti-inflammatory drugs) can occur, but immunosuppression is more likely and potentially fatal. Educational objective: Methotrexate is a nonbiologic disease-modifying antirheumatic drug used to treat rheumatoid arthritis. The major adverse effects associated with its use include bone marrow suppression, hepatotoxicity, and gastrointestinal irritation. Question: 15 A 24-year-old female client has been prescribed isotretinoin for severe nodulocystic acne that has been resistant to other therapies. Which instruction is most important for the nurse to reinforce with this client? 1. "Apply lubricating eye drops when wearing contacts." 2. "Swallow capsules whole." 3. "Use sunscreen routinely." 4. "Use 2 forms of contraception." Correct Answer: 4 Rationale Isotretinoin (Accutane) decreases sebum secretion and is prescribed for severe, disfiguring nodular acne that has been unresponsive to other therapies, including antibiotics. It is a pregnancy category X drug and is known to cause serious birth defects if taken during pregnancy. Females prescribed isotretinoin must have 2 negative pregnancy tests before taking the medication. Also, 2 forms of contraception must have been in place for at least 1 month prior to starting isotretinoin, and these must be continued both during treatment and for 1 month after the medication is discontinued. Before refills can be obtained, enrollment in a risk management program is required to verify that pregnancy tests are negative and 2 forms of contraception are being used. Blood donation is also discouraged while on therapy and for 1 month afterward to ensure that pregnant women do not receive any donated blood. (Option 1) Dryness of the eyes, mouth, and skin are common side effects. Lubricating eye drops may be needed to wear contacts. Some clients are unable to wear contacts while taking this medication. Good oral hygiene and skin care are needed. (Option 2) Capsules should be swallowed whole with at least 8 oz of water or other fluid. Capsules should not be broken, crushed, or chewed as contents of opened capsules could irritate esophagus. (Option 3) This medication causes photosensitivity. The nurse should teach the client to use sunscreen routinely. Educational objective: Isotretinoin is a pregnancy category X drug and will cause birth defects if taken during pregnancy. The client must use 2 forms of birth control for 1 month prior to taking the medication as well as during treatment and 1 month afterward. The client must also be enrolled in a risk management program prior to receiving refills. Question: 16 The nurse is caring for a client who is taking riluzole for amyotrophic lateral sclerosis (ALS). The client asks, "There's no cure for ALS, so why should I keep taking this expensive drug?" What is the nurse's best response? 1. "It may be able to slow the progression of ALS." 2. "It reduces the amount of glutamate in your brain." 3. "The case manager may be able to find a program to assist with cost." 4. "You have the right to refuse the medication." Correct Answer: 1 Rationale Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig disease, is a debilitating, progressive neurodegenerative disease with no cure. Clients develop fatigue and muscle weakness that progresses to paralysis, dysphagia, difficulty speaking, and respiratory failure. Most clients diagnosed with ALS survive only 3-5 years. Riluzole (Rilutek) is the only medication approved for ALS treatment. Riluzole, a glutamate antagonist, is thought to slow neuron degeneration by decreasing the production and activity of the neurotransmitter glutamate in the brain and spinal cord. In some clients, riluzole may slow disease progression and prolong survival by 3-6 months. The nurse should provide teaching about the purpose of the medication so that the client can make an informed decision about taking it (Option 1). (Option 2) Explaining the pharmacology of riluzole is not the best response for helping the client understand the purpose of taking the medication. (Option 3) It would be appropriate to consult the case manager if the client expresses concern about not having the appropriate resources to acquire a costly medication, but the nurse should first ensure that the client understands the medication's purpose. (Option 4) The client has the right to refuse any medication, but the nurse should first ensure that the client is informed and understands the purpose of the medication. Educational objective: Although there is no cure for amyotrophic lateral sclerosis, the medication riluzole may slow disease progression and prolong survival. Question: 17 The nurse administers 15 units of aspart insulin subcutaneously to a hospitalized client with type 1 diabetes mellitus at 7:00 AM for a fasting blood glucose of 180 mg/dL (10 mmol/L). Which nursing action is a priority? 1. Ensure that the client continues to fast for at least 30 more minutes 2. Give the client breakfast within 15 minutes 3. Recheck the blood glucose in 1 hour 4. Teach the client about the signs and symptoms of hyperglycemia Correct Answer: 2 Rationale Aspart (NovoLOG) is a rapid-acting insulin with an onset of 10-15 minutes. Onset is the time it takes for the insulin to enter the circulation and begin to lower blood glucose. The peak effect takes 30 minutes-3 hours and the duration of action is 3-5 hours. It is important for the nurse to ensure that the client eats within 15 minutes of administration of aspart/lispro/glulisine to prevent an insulin-related hypoglycemic reaction (Option 2). (Option 1) The client is at risk for a hypoglycemic reaction if breakfast is delayed for 30 minutes. (Option 3) Rechecking the blood glucose in 1 hour is not indicated unless hypoglycemia is suspected. (Option 4) Teaching is vital, but it is most important to ensure that the client eats breakfast to prevent a hypoglycemic reaction at drug onset. Educational objective: It is important for the nurse to ensure that the client eats within 15 minutes of administration of rapid-acting insulins such as aspart (NovoLOG), lispro (HumaLOG), and glulisine (Apidra) to prevent an insulin-related hypoglycemic reaction. Question: 18 The nurse assesses 4 clients. Which assessment finding requires the nurse's priority action? 1. 26-year-old with splenectomy reports a headache and chills 2. 40-year-old with immune thrombocytopenic purpura has petechiae on the arms 3. 60-year-old with marked anemia reports shortness of breath when ambulating 4. 68-year-old with polycythemia vera has a hematocrit of 66% (0.66) Correct Answer: 1 Rationale The spleen is part of the immune system and functions as a filter to purify the blood and remove specific microorganisms that cause infections (eg, pneumococcal pneumonia, meningococcal meningitis). Overwhelming postsplenectomy bacterial infection or rapid-onset sepsis are major lifelong complications in a client without a functioning spleen. A minor infection can quickly become life-threatening, and so any indicator of infection such as a low-grade fever, chills, or headache needs immediate intervention (eg, cultures, imaging, antibiotic therapy). Therefore, the client with the splenectomy who is reporting headache and chills requires immediate action. (Option 2) Immune thrombocytopenic purpura (ITP) is an autoimmune condition in which clients have abnormal platelet destruction with a count <150,000/mm3 (150 x 109/L). ITP is associated with an increased risk of bleeding. A common manifestation of ITP includes petechiae, which are pinpoint flat, red or brown microhemorrhages under the skin caused by leakage of red blood cells. Petechiae are an expected finding. (Option 3) A client with marked anemia can develop exertional dyspnea due to the body's inability to meet the metabolic demands (oxygen supply) associated with activity. This is an expected finding. (Option 4) Polycythemia vera (true primary polycythemia) is a chronic myeloproliferative disease characterized by bone marrow overproduction of red blood cells, white blood cells, and platelets. This leads to increased hematocrit (>53% [0.53]) and blood volume, enhanced blood viscosity, and abnormal clotting. A hematocrit of 66% (0.66) is an expected finding. Educational objective: Overwhelming postsplenectomy bacterial infection is a major lifelong complication in clients without a functioning spleen. A minor infection can quickly become life- threatening and septic; therefore, any indicator of infection requires immediate attention and treatment intervention. Question: 19 The nurse evaluates the effectiveness of desmopressin use for diabetes insipidus in a client with a pituitary tumor. Which client assessment finding indicates that the medication is having the desired effect? 1. Appetite has improved 2. Blood glucose is 110 mg/dL (6.1 mmol/L) 3. Urine output has decreased 4. Urine specific gravity is lower Correct Answer: 3 Rationale Diabetes insipidus (DI) results in low levels of antidiuretic hormone (ADH), which is produced by the hypothalamus and stored in the pituitary gland. The function of ADH is to concentrate urine by signaling the kidneys to retain water in the setting of thirst. When ADH levels are insufficient, the kidneys excrete large quantities of very dilute urine (polyuria). This causes hypernatremia (elevated serum sodium due to deficit of free water) and increased serum osmolality, which lead to excessive thirst (polydipsia). Desmopressin acetate (DDAVP) is a synthetic form of ADH, which can be administered intravenously, orally, or via nasal spray. Effectiveness of therapy with desmopressin would be manifested by decreased urinary output and increased urine specific gravity as the urine becomes less dilute (Option 3). (Option 1) A client's thirst, not appetite, is affected by DI. (Option 2) DI is related to water balance, but not to diabetes mellitus, a disorder of glucose metabolism. (Option 4) If desmopressin therapy is effective, the client's urine specific gravity will be higher due to the urine output decreasing and becoming less dilute. Educational objective: Use of desmopressin acetate (DDAVP) in clients with diabetes insipidus will lower urinary output and cause the urine specific gravity to increase. Question: 20 The unlicensed assistive personnel on the cardiac floor reports to the registered nurse that during the first vital sign measurement on the shift, a client's blood pressure measured 198/102 mm Hg on the automated blood pressure machine. What action should the nurse take first? 1. Have the unlicensed assistive personnel recheck the client's blood pressure 2. Immediately notify the health care provider 3. Obtain the client's PRN labetalol from the medication dispensing machine 4. Recheck the client's blood pressure with a manual cuff Correct Answer: 4 Rationale This client's abnormally high blood pressure increases the risk for complications such as stroke. The nurse should assess this client and recheck the blood pressure with a manual cuff to verify the accuracy of the previous measurement taken by the unlicensed assistive personnel (UAP). The nurse will need to assess the client further before making additional nursing judgments and taking action. (Option 1) The nurse should not instruct the UAP to perform additional blood pressure measurements as this client could have severe hypertension; delegation of such a task is inappropriate (does not fit the "right circumstances" for delegation). If the client's reading is not as high as previously thought after blood pressure measurement with a manual cuff, the nurse can then instruct the UAP to take subsequent measurements with a different automatic blood pressure machine. (Option 2) The nurse may need to notify the health care provider but only after the client has been assessed further by the nurse. (Option 3) The client's blood pressure must be verified for accuracy before administering a PRN antihypertensive. Educational objective: When the unlicensed assistive personnel (UAP) reports an abnormal vital sign to the nurse, the nurse should assess the client further. It is inappropriate delegation to have the UAP recheck the client. Question: 21 A client who was discharged 3 days ago following prostatectomy calls the clinic and tells the nurse of passing some small blood clots and experiencing a decreased urinary stream. What is the nurse's best response? 1. "I'll consult the health care provider (HCP) and then give you further instructions." 2. "Those symptoms are normal the first week following surgery." 3. "Try to bear down as if having a bowel movement." 4. "You should increase your daily fluid intake." Correct Answer: 1 Rationale Signs of complications after a prostatectomy, such as bleeding, passage of blood clots, a decrease in the urinary stream, urinary retention, or symptoms of a urinary tract infection, should be reported to the HCP for further evaluation. (Option 2) The passage of blood clots may indicate bleeding from the prostatic fossa. The client requires further evaluation. (Option 3) While the prostatic tissue is healing, the Valsalva maneuver should be avoided as it may increase venous pressure and produce hematuria. (Option 4) Maintaining adequate fluid intake to prevent dehydration, which increases the tendency for a blood clot to form, is important. However, this client is currently reporting blood clots and needs further evaluation. Educational objective: Following a prostatectomy, bleeding is a potential complication that requires a thorough assessment. Any bleeding, passage of clots, decrease in urinary stream, urinary retention, or symptoms of urinary tract infection should be reported to the HCP. Question: 22 The emergency department nurse receives report on 4 clients. Which client should the nurse assess first? 1. Client with acute cholecystitis who reports right shoulder pain 2. Client with gastroparesis who reports persistent nausea and vomiting 3. Client with intractable lower back pain who reports new urinary incontinence 4. Client with Meniere disease who reports increasing tinnitus Correct Answer: 3 Rationale Cauda equina syndrome is a disorder that results from injury to the lumbosacral nerve roots (L4-L5) causing motor and sensory deficits. The main symptoms are severe lower back pain, inability to walk, saddle anesthesia (ie, motor weakness/loss of sensation to inner thighs and buttocks), and bowel and bladder incontinence (late sign). Cauda equina syndrome is a medical emergency. Treatment requires urgent reduction of pressure on the spinal nerves to prevent permanent damage. This client displays characteristic late signs of cauda equine syndrome (ie, incontinence); therefore, the nurse should assess this client first. (Option 1) Clients with acute cholecystitis may experience referred pain to the right shoulder due to irritation of the diaphragm from the inflamed gallbladder. Although the client's pain should be addressed, this client is not the priority. (Option 2) Clients with gastroparesis have delayed gastric emptying and often report persistent nausea and vomiting. Treatment includes antiemetics, but this client is not the priority. (Option 4) Meniere disease is an inner ear disorder. Expected symptoms include episodic vertigo, tinnitus, and muffled hearing. Treatment during an acute attack includes antihistamines, anticholinergics, and benzodiazepines. As long as the client is safe from falling, treatment is not emergent. Educational objective: Signs and symptoms of cauda equina syndrome (eg, acute spinal/back pain, inability to walk, saddle anesthesia, bowel/bladder incontinence) require emergency attention to prevent permanent damage. Question: 23 The charge nurse must assign a semi-private room to a client with diabetes mellitus admitted for IV antibiotic therapy to treat leg cellulitis. Which of the 4 room assignments is the best option for this client? 1. Room 1: Client 1 day postoperative laparoscopic cholecystectomy who is awaiting discharge 2. Room 2: Client with dementia and urinary incontinence wearing an external urine collection device 3. Room 3: Client with history of splenectomy 15 years ago, now admitted for pulmonary embolism 4. Room 4: Client with lupus nephritis who is prescribed treatment with azathioprine Correct Answer: 2 Rationale Cellulitis is a common skin bacterial infection that is usually treated with IV antibiotics in clients with diabetes mellitus. Room 2 is the best assignment option for this client with cellulitis. The client with dementia and urinary incontinence who has an external urinary condom catheter is the least susceptible to infection compared to those in rooms 1, 3, and 4. (Option 1) The client who is 1 day postoperative laparoscopic cholecystectomy (surgical procedure with small incisions) is at increased risk for infection. The client with cellulitis should not be placed in room 1. (Option 3) Although this client has pulmonary embolism, the history of prior splenectomy leads to a very high lifelong risk of rapid sepsis. Splenectomy clients need vaccination against encapsulated organisms (eg, pneumococcus, meningococcus, and Haemophilus influenzae type B). Even a low-grade fever should be taken seriously in these clients. The client with cellulitis should not be placed in room 3. (Option 4) Lupus nephritis is a serious renal complication of systemic lupus erythematosus (SLE), an inflammatory autoimmune disease that can lead to end-stage kidney disease. The systemic disease and the immunosuppressant (azathioprine [Imuran]) prescribed to slow its progression increase infection risk. The client with cellulitis should not be placed in room 4. Educational objective: A client with an infection should not be assigned to a semi-private room with a client who had surgery or is immunocompromised and receiving immunosuppressants as these clients are highly susceptible to infection. Post-splenectomy clients are also at lifelong risk for rapid sepsis. Question: 24 The nurse is triaging clients in the emergency department. Which client needs to be seen first? 1. 18-year-old female with fever, suprapubic pain, and dysuria 2. 21-year-old male with diffuse abdominal pain 3. 64-year-old male with a pulsatile mass in the periumbilical area and back pain 4. 75-year-old with nausea, fever, and left lower quadrant pain Correct Answer: 3 Rationale Abdominal aneurysms may present with a pulsatile mass in the periumbilical area slightly to the left of the midline. A bruit may be auscultated over the site. Back/abdominal pain can be present due to compression of nearby anatomical sites or nerve compression from an expanding/rupturing abdominal aortic aneurysm (AAA). Rupture of an abdominal aneurysm can quickly cause exsanguination and death. This client may need emergency surgery to repair the aneurysm. (Option 1) Fever, suprapubic pain, and dysuria in a young female client indicate urinary tract infection, a much lower priority than AAA. (Option 2) Diffuse pain and a rigid abdomen indicate peritonitis (eg, from ruptured appendicitis or perforated bowel). Peritonitis is also an emergency but not immediately life-threatening like AAA rupture. This client should be seen next after the client with AAA. (Option 4) Fever and left lower quadrant pain in an elderly client are usually due to acute diverticulitis. The client needs bowel rest, antibiotics, and IV fluids. This is a lower priority than AAA and peritonitis. Educational objective: Clients with an impending aortic aneurysm rupture present with abdominal/back pain, and a pulsatile abdominal mass. They may also have a bruit. Rupture of an abdominal aneurysm can lead to exsanguination and death in minutes. Question: 25 A client is admitted to the postpartum floor after a vaginal birth. Which finding indicates the need for immediate intervention? 1. Lochia that soaks a perineal pad every 2 hours 2. Persistent headache with blurred vision 3. Red, painful nipple on one breast 4. Strong-smelling vaginal discharge Correct Answer: 2 Rationale Persistent headache and blurred vision could indicate postpartum preeclampsia. The majority of clients with preeclampsia develop symptoms before birth; however, a small percentage do not develop the complication until several days after birth. This potentially serious condition can rapidly worsen, leading to seizures and death if left untreated. Additional signs and symptoms may include high blood pressure, proteinuria, and edema (Option 2). (Option 1) In the immediate postpartum period, lochia should be assessed frequently to monitor for postpartum hemorrhage. Soaking a perineal pad in ≤1 hour would indicate excessive bleeding that requires urgent intervention. (Option 3) Red or painful nipples in a breastfeeding client may be the result of incorrect latch and/or improper breastfeeding technique. The nurse should observe the client while breastfeeding, identify any problems with the newborn's latch, and obtain additional assessment from a lactation consultant, if appropriate. (Option 4) Strong- or foul-smelling vaginal discharge may represent an infection (eg, endometritis). This assessment finding indicates the need for further evaluation but is not immediately life-threatening. Educational objective: Preeclampsia can develop in the postpartum period several days after birth. Clients in the postpartum period with signs and symptoms of preeclampsia (eg, edema, persistent headache, vision changes, elevated blood pressure) should be evaluated and treated immediately. Question: 26 The nurse working on an orthopedic unit is receiving report on 4 clients with recent fractures. Which client should the nurse assess first? 1. Client who has a femur fracture with a rash of pin-sized red spots on the chest and increased restlessness 2. Client who has purulent drainage oozing from a skeletal traction pin insertion site and a temperature of 100.8 F (38.2 C) 3. Client with a hip fracture receiving continuous IV saline with bilateral 2+ pitting leg edema and a blood pressure of 176/89 mm Hg 4. Client with a rib fracture who is breathing at a rate of 23/min and is reporting 8/10 pain that is worse with inspiration Correct Answer: 1 Rationale Clients with orthopedic injuries, particularly pelvic and long bone injuries (eg, femoral fracture), may develop a fat embolus. Fat emboli are thought to occur from the release of fat globules (lipids) from bone marrow or the systemic release of triglycerides into the bloodstream following a mechanical insult. The circulating lipids can occlude small vessels in the lungs (similar to pulmonary embolism), brain, and skin, which impair circulation and oxygenation, leading to: • Respiratory distress syndrome (eg, dyspnea, tachycardia, sudden and worsening chest pain, hypoxemia, restlessness, anxiety) • Altered mental status (eg, confusion, memory loss) • Petechial hemorrhages in the arms, chest, and/or neck (Option 1) (Option 2) Purulent (eg, yellow, foul-smelling) drainage from skeletal pins and fever may indicate infection that could progress to osteomyelitis. Treatment with antibiotics is required, but this infection is not emergently life threatening. (Option 3) Pitting edema may occur in clients with impaired mobility (eg, hip fracture) and often relates to fluid volume excess. Hypertension may also be related to fluid volume excess in clients receiving IV fluids. This client should be assessed next. (Option 4) Clients with rib fractures often take frequent, shallow breaths as they experience intense pain with inspiration. Adequate pain control allows for deep breathing, which prevents buildup of secretions, atelectasis, and pneumonia. Educational objective: Clients with pelvic and long bone injuries are at risk for fat emboli, which can occlude small vessels in the lungs, brain, and skin. Sign and symptoms include altered mental status (eg, restlessness), chest pain, respiratory distress, and petechial hemorrhage. Question: 27 The nurse plans discharge teaching for a client with active herpes lesions who has a new prescription for oral acyclovir and topical lidocaine. What information will the nurse include in the teaching plan? 1. Adhesive bandaging should remain on the lesions to prevent virus shedding 2. Blood tests will be drawn to ensure the virus is eradicated 3. Condoms should be used during intercourse until the lesions are healed 4. Gloves should be used to apply the medication to the lesions Correct Answer: 4 Rationale Acyclovir (Zovirax), famciclovir, and valacyclovir are commonly used to treat herpes infection as they shorten the duration and severity of active lesions. Genital herpes is a sexually transmitted infection caused by a herpes simplex virus and is highly contagious, especially when lesions are active. It remains dormant in the body even when active lesions are healed. There is no cure for genital herpes; treatment is aimed at relieving symptoms and preventing the spread of infection. Touching the lesions and then rubbing or scratching another part of the body can spread the infection. Therefore, gloves should be used when applying topical antiviral or analgesic (eg, lidocaine) medications. (Option 1) Herpetic lesions should be kept clean and dry. They can be cleansed with warm water and soap or other solutions. Bandages are not applied to the lesions. (Option 2) There is no cure for herpes infection. Genital herpes often leads to local recurrence. Some clients may need long-term suppressive therapy. (Option 3) During periods of active lesions, abstinence from sexual intercourse is indicated. Condoms should be used during periods of dormancy due to viral shedding. Educational objective: Clients should be taught to use gloves when applying topical medication to herpes lesions to avoid the spread of infection. There is no cure for genital herpes infection; recurrences are common. Complete abstinence from sexual intercourse is recommended when active lesions are present as barrier contraception alone is insufficient to prevent the spread of infection. Question: 28 A client comes to the emergency department with severe dyspnea and a cough. Vital signs are temperature 99.2 F (37.3 C), blood pressure 108/70 mm Hg, heart rate 88/min, and respirations 24/min. The client has a history of chronic obstructive pulmonary disease (COPD) and chronic heart failure. Which diagnostic test will be most useful to the nurse in determining if this is an exacerbation of heart failure? 1. Arterial blood gases (ABGs) 2. B-type natriuretic peptide (BNP) 3. Cardiac enzymes (CK-MB) 4. Chest x-ray Correct Answer: 2 Rationale BNP is a peptide that causes natriuresis. B-type natriuretic peptides are made, stored, and released primarily by the ventricles. They are produced in response to stretching of the ventricles due to the increased blood volume and higher levels of extracellular fluid (fluid overload) that accompany heart failure. Elevation of BNP >100 pg/mL helps to distinguish cardiac from respiratory causes of dyspnea. (Option 1) ABGs will be helpful in determining the client's oxygenation status and acid-base balance but will not determine whether the cause of the dyspnea is cardiac or respiratory. (Option 3) CK-MB is a cardiospecific isozyme that is released in the presence of myocardial tissue injury. Elevations are highly indicative of a myocardial infarction but not specific for heart failure. (Option 4) A chest x-ray can show heart enlargement in the case of heart failure and may show infiltrations in the lungs. Pneumonia can also exacerbate COPD and can be confused with heart failure infiltrates. Chest x-ray is not as specific to heart failure as the BNP lab test. Educational objective: Elevation of BNP to >100 pg/mL is seen in heart failure. It aids in the assessment of the severity of heart failure and helps distinguish cardiac from respiratory causes of dyspnea. Question: 29 The health care provider prescribes a continuous IV infusion of regular insulin at 5 units/hr. The infusion bag contains 50 units of regular insulin in 100 mL of normal saline solution. At what rate in milliliters per hour (mL/hr) does the nurse set the IV pump? Record your answer using a whole number. Correct Answer: 10 mL/hr Rationale Using dimensional analysis, use the following steps to calculate the infusion rate of regular insulin: 1. Identify the prescribed, available, and required medication information Educational objective: To calculate the infusion rate of IV regular insulin, the nurse should first identify the prescribed dose (eg, 5 units/hr) and available dose (eg, 50 units/100 mL) and then convert to milliliters per hour (eg, 10 mL/hr). Question: 30 A critical care nurse is caring for a newly admitted client with acute aortic dissection. Which prescription should the nurse prioritize while awaiting surgical revision of the client's aortic dissection? 1. Administer IV labetalol to maintain blood pressure within prescribed parameters 2. Initiate and maintain strict bed rest and a low-stimulation environment 3. Monitor bilateral lower extremity peripheral pulse strength 4. Prepare the client's consent form for surgical repair of the aorta Correct Answer: 1 Rationale Aortic dissection is a tear in the inner lining of the aorta that allows blood to surge between the layers of the arterial wall, separating and weakening the aortic wall. Perfusion to vital organs may become impaired, and the dissection can rapidly progress to life- threatening cardiac tamponade or aortic rupture. Aortic dissection is characterized by acute onset of excruciating, sharp or "ripping" chest pain that radiates to the back. Emergency surgical repair is usually required. Before surgical repair, the priority is decreasing the risk of aortic rupture by maintaining normal pressure in the aorta. Administering IV beta blocker medication (eg, labetalol, metoprolol, propranolol) helps achieve this by lowering the heart rate and blood pressure, which are often elevated with aortic dissection (Option 1). (Option 2) Bed rest and a low-stimulation environment help lower heart rate and blood pressure, but antihypertensive medication is more effective and rapid- acting, making it the highest priority. (Option 3) Assessing peripheral pulses helps monitor for complications of aortic dissection but is not a priority over interventions that reduce the risk of aortic rupture. (Option 4) Informed consent is required before all surgical interventions; however, consent forms can be completed any time prior to surgery and are not a priority over reducing the risk of aortic rupture. Educational objective: Before emergency surgical repair of aortic dissection, the priority is decreasing the risk of aortic rupture by maintaining normal pressure in the aorta. Administering an IV beta blocker helps achieve this by rapidly lowering elevated heart rate and blood pressure Question: 31 The graduate nurse (GN) is reinforcing education on sitting on and standing up from a chair to a client with crutches. Which instruction by the GN would cause the supervising nurse to intervene? 1. "Hold a crutch in each hand on both sides when standing up from a chair." 2. "Move to the edge of the chair before standing and use your unaffected leg to rise." 3. "Touch the back of your unaffected leg to the chair before preparing to sit." 4. "Use an armrest or seat for assistance when lowering your body into a chair." Correct Answer: 1 Rationale Clients prescribed crutches after a musculoskeletal injury must understand appropriate device use to facilitate independent ambulation, promote wound healing, and prevent reinjury. When educating a client to rise from sitting, the nurse instructs the client to hold the hand grips of both crutches in the hand on the affected side, move to the chair's edge, and hold the armrest with the hand on the unaffected side (Option 1). The client then uses the crutches, armrest, and unaffected leg for support when rising. To sit, the client backs up to the chair and moves both crutches into the hand on the affected side. The client holds the armrest with the other hand and lowers the body. (Option 2) To rise from a chair, the client should move to the edge of the chair and flex the unaffected leg for support. (Option 3) Before sitting, the client should back up to the chair until the unaffected leg touches the chair seat. (Option 4) When standing or sitting, clients should place the hand opposite the injury on the armrest or chair seat for support. Educational objective: When standing or sitting in a chair, clients with crutches should hold both crutches in the hand on the affected side and hold the armrest with the other hand for support. Clients should touch the back of the unaffected leg to the chair before sitting, and should move to the chair edge and rise with the unaffected leg to stand Question: 32 Which client needs follow-up education by the nurse? 1. Client with peripheral arterial disease (PAD) who insists on dangling leg over the side of the bed when sleeping 2. Client with Raynaud's phenomenon who routinely soaks hands in warm water before going out 3. Client with venous leg ulcer who refuses to wear elastic compression stockings during the day 4. Postsurgical client who points and flexes feet when lying in bed Correct Answer: 3 Rationale The nurse needs to provide education to the client with a venous leg ulcer who refuses to wear compression stockings. Compression is essential for the treatment of chronic venous insufficiency, venous ulcer healing, and prevention of ulcer recurrence. The client will need individual evaluation to determine what level of compression is needed. Assessment of the ankle-brachial index (ABI) should be performed as well. An ABI of <0.9 suggests concurrent PAD and the need for lower levels of compression therapy. There are several options that the nurse can explore with the client to decide which compression device will work best in the situation (custom-fitted elastic compression stockings, elastic tubular support bandages, Velcro wrap, paste bandage with elastic wrap, or a multilayer bandage system). (Option 1) Dangling a limb over the side of the bed is a common practice among PAD clients to relieve pain. There is no need for this client to discontinue this practice as it allows gravity to maximize blood flow. (Option 2) Immersing hands in warm water can decrease vasospasm in this client with Raynaud's phenomenon. (Option 4) This practice should be encouraged by the nurse. It can help prevent venous thromboembolism following surgery. Educational objective: The nurse needs to educate the client with a venous leg ulcer that wearing some kind of compression stockings is essential for healing and prevention of ulcer recurrence. Question: 33 The parents of a hospitalized preschooler are concerned because their toilet-trained child has started wetting the bed. Which response by the nurse is most helpful? 1. "Discipline your child by taking away playroom privileges." 2. "It is normal for your child to regress while hospitalized." 3. "Restricting fluids at nighttime will solve this problem." 4. "Your child is acting out due to the hospitalization." Correct Answer: 2 Rationale Regression during hospitalization is a normal response to the stress of an unfamiliar environment, the fear and pain of invasive procedures, and the change in a child's normal routine. Toilet-trained children may start bed-wetting, and children who gave up the bottle or pacifier may ask for it. It is important for the nurse to explain that this behavior is completely normal and that the child will gain back previous milestones after discharge. (Option 1) Firm discipline would be counterproductive at this time. Punishment by restricting playtime would create more stress for the child. (Option 3) Limiting fluids at nighttime, voiding before bedtime, and involving the child in planning (eg, changing wet linens) are all appropriate interventions for enuresis. However, the first step is to reassure the parents and then teach them therapeutic interventions. (Option 4) Misbehaving is not an unusual behavior for a preschooler. Acting out would not be due exclusively to the hospitalization. Educational objective: Hospitalization can be very stressful for a child. Regressive behaviors during hospitalization are a normal response to changes in routine. The nurse should inform the caregivers that this behavior is temporary and that the child will regain lost milestones rapidly after discharge. Question: 34 A client with Alzheimer disease is admitted to the hospital for a urinary tract infection. The daughter says to the nurse, "I really want to take my mother home and continue care there. However, lately, my mother has become agitated and restless at night. I'm awake most of the night, feel exhausted, and do not know what to do." What is the best response by the nurse? 1. "Do not let your mother take naps in the afternoon." 2. "Our social worker can discuss long-term care options with you." 3. "We can ask the health care provider for medication that will help your mother sleep." 4. "Your mother can be cared for in a nursing home." Correct Answer: 2 Rationale This caregiver is experiencing high levels of stress and exhaustion related to caring for the client; without help, the caregiver could easily experience burnout. A social worker can provide information on resources and services for assistance and support; these include adult day programs, in-home assistance, visiting nurse services, and home delivered meals. The social worker can also provide the names of agencies that seek the support of others in similar situations (eg, local chapter of the Alzheimer's Association). (Option 1) Keeping a client with Alzheimer disease awake during the day is a behavioral strategy that may reduce the risk of sundowning (increased confusion and agitation in the evenings). However, this response does not address the caregiver's stress and exhaustion. (Option 3) Antipsychotic medications are used cautiously in elderly clients with dementia due to the high risk of a cardiovascular event. This response does not provide an effective approach to the caregiver's increasing levels of stress. (Option 4) Institutional care may be the best option for this client. However, giving an opinion or telling the caregiver what the appropriate action "should" be is a non- therapeutic response. Educational objective: Caregivers of clients with Alzheimer disease and other types of dementia often experience burnout due to stress and exhaustion. They need information on community resources that can provide assistance with client care. Question: 35 The nurse receives an obese client in the postanesthesia care unit who underwent a procedure under general anesthesia. The nurse notes an oxygen saturation of 88%. Which is the most appropriate initial intervention? 1. Assess pupillary response 2. Auscultate lung sounds 3. Inform anesthesia professional 4. Perform head tilt and chin lift Correct Answer: 4 Rationale Head tilt and chin lift is a maneuver used to open the airway. The tongue may fall back and occlude the airway due to muscular flaccidity after general anesthesia. Manifestations associated with airway obstruction include snoring, use of accessory muscles, decreased oxygen saturations, and cyanosis. (Option 1) Constricted pupils can help identify opioid overdose. However, this should not be assessed before opening the airway. (Option 2) Auscultation of lung sounds should be done for every client as part of the postoperative assessment. However, the initial goal is to return the oxygen saturation level to normal (95%-100%). Hypoxia in an obese postoperative client who received general anesthesia is most likely due to airway obstruction. (Option 3) The anesthesia professional may need to be informed, but methods to restore the oxygen saturation level should be tried first. The anesthesia professional may then want to assess the sedation level of the client and prescribe a reversal agent. Educational objective: Postoperative client care after general anesthesia requires careful monitoring for hypoxia. One of the first nursing interventions is the head tilt and chin lift to open an occluded airway. Question: 36 The nurse is caring for a client involved in a motor vehicle collision who had a chest tube inserted to evacuate a pneumothorax caused by fractured ribs. Where would the nurse observe an air leak? 1. Section A 2. Section B 3. Section C 4. Section D Correct Answer: 3 Rationale The presence of an air leak is indicated by continuous bubbling of fluid at the base of the water seal chamber. If the client has a known pneumothorax, intermittent bubbling would be expected. Once the lung has re-expanded and the air leak is sealed, the bubbling will cease. The nurse is expected to assess for the presence or absence of an air leak and to determine whether it originates from the client or the chest tube system. (Option 1) Section A is the suction control chamber. Gentle, continuous bubbling indicates that suction is present. (Option 2) Section B is part of the water seal chamber, but an air leak will not be evident in this upper portion. Tidaling of fluid is expected in this portion of the chamber and indicates patency of the tube. (Option 4) Section D is the collection chamber, where drainage from the client will accumulate. The nurse will assess amount and color of the fluid and record these as output. Educational objective: An air leak is indicated by bubbling of fluid in the base of the water seal chamber of a chest tube drainage unit. The client with a known pneumothorax is expected to have an intermittent air leak, with bubbling in the water seal chamber. Continuous bubbling indicates an air leak somewhere in the chest tube system. Question: 37 An adult diagnosed with celiac disease 3 weeks ago was placed on a gluten-free diet. The client returns for ambulatory care follow-up, reports continuation of symptoms, and does not seem to be responding to therapy. Which is the best response by the nurse? 1. "I will refer you to the dietitian." 2. "It should take about 6-8 weeks before you see improvement in your symptoms." 3. "Tell me what you had to eat yesterday." 4. "You must not be following your diet." Correct Answer: 3 Rationale This client with celiac disease continues to have symptoms. An assessment of the client's food intake must be obtained to determine if it includes foods that contain gluten, a protein in barley, rye, oats, and wheat (mnemonic: BROW). The most common reason for nonresponsiveness to a gluten-free diet in clients with celiac disease is that gluten has not been entirely eliminated from their food intake. (Option 1) Referral to a dietitian is an appropriate intervention. However, the nurse must first explore why the client is not responding to therapy. This is not the first or best response by the nurse. (Option 2) Most people experience dramatic relief of gastrointestinal symptoms within a few days of eliminating gluten from their diet. (Option 4) This is a non-therapeutic response that "blames" the client for symptoms. In addition, this conclusion cannot be made without an assessment of the client's intake. Educational objective: When a client with celiac disease does not experience symptom relief after being on a gluten-free diet, it is most important for the nurse to assess the underlying cause. The most common reason for refractory symptoms is failure to follow the strict gluten-free diet Question: 38 A legally blind client is being prepared to ambulate 1 day after an appendectomy. What is the most appropriate action by the nurse? 1. Arrange for the client's service dog to come to the health care facility as soon as possible 2. Describe the environment in detail so the client can ambulate safely with a cane 3. Instruct the unlicensed assistive personnel to walk beside the client and lead by the hand 4. Walk slightly ahead of the client with the client's hand resting on the nurse's elbow Correct Answer: 4 Rationale On the first postoperative day, the nurse assists the client with ambulation to evaluate alertness, pain level, signs of orthostatic hypotension, problems with gait or mobility, and ability to ambulate safely. The nurse also considers pre-existing limitations to ambulation such as the use of assistive aids (eg, sighted guides, canes, guide dogs). Clients who used any ambulatory assistive aids before surgery require postoperative evaluation prior to ambulatory independence. When walking with a client who is legally blind, the nurse uses the sightedguide technique by walking slightly ahead of the client with the client holding the nurse's elbow. The nurse should describe the environment while ambulating the client. (Option 1) The service dog may be brought to the hospital to assist in ambulation once the nurse has determined the client can ambulate safely. (Option 2) After evaluation by the nurse, the client may be allowed to use a cane to ambulate around the nursing unit. (Option 3) Instructing the unlicensed assistive personnel to ambulate the client is an inappropriate assignment for a client who is 1 day postoperative and legally blind. Nursing assessment is required to determine if the client is able to ambulate safely. Educational objective: When ambulating a client who is legally blind, the nurse uses the sighted-guide technique by walking slightly ahead with the client holding the nurse's elbow. Question: 39 The nurse is caring for a client who has undergone a colonoscopy. Which client assessment finding should most concern the nurse? 1. Abdominal cramping 2. Frequent, watery stools 3. Positive rebound tenderness 4. Recurring flatus Correct Answer: 3 Rationale A risk of a colonoscopy (or any procedure in which a firm scope is inserted into a "hollow tube" organ) is perforation. Signs of perforation include abdominal pain (with shoulder tip pain), positive rebound tenderness, guarding, abdominal distension, tenesmus, and/or boardlike (rigid) abdomen. Another potential complication is rectal bleeding. (Option 1) Abdominal cramping post procedure is an expected finding. It is caused by the stimulation of peristalsis as the bowel is constantly inflated with air during the procedure. (Option 2) The preparation for the procedure, emptying the colon of stool, includes clear liquids, cathartics, and/or enemas. The stool is watery and copious and may continue for a short time after the procedure. It is not a concerning finding. (Option 4) During the procedure, air is inflated into the colon. The client needs to expel this "gas" afterward. It is an expected finding. Educational objective: The complication risks of a colonoscopy are perforation and rectal bleeding. Abdominal cramping, flatus, and watery stool are expected findings. Perforation can lead to peritonitis, with positive rebound tenderness, guarding, abdominal distension, tenesmus, and/or boardlike (rigid) abdomen. Question: 40 Correct Answer: 1 The nurse caring for multiple clients who underwent renal system diagnostic testing should report which post-procedure finding to the health care provider? 1. 150 mL residual urine on bladder scan 2. Burning sensation when voiding after cystoscopy 3. Increased urinary output after arteriogram 4. Less than 10,000 organisms/mL on urine culture Rationale Various diagnostic tests, including bladder scans, urine cultures, cystoscopy, renal arteriograms, and renal scans, assess the renal system. It is necessary to understand the purpose and procedures for each examination when evaluating complications arising from these assessments. Portable ultrasonic bladder scanners are used at the bedside to determine the amount of residual urine in the bladder. Amounts >100 mL should be reported as the client may be experiencing urinary retention (Option 1). (Option 2) A cystoscope is inserted through the urethra to directly visualize the bladder wall and urethra. Irritation of the urethral and bladder lining from the insertion and manipulation of the cystoscope may cause a slight burning sensation with voiding for a day or two. (Option 3) Renal arteriogram is a radiologic test performed to visualize renal blood vessels to detect abnormalities (renal artery stenosis or aneurysm). A contrast medium is injected into the femoral artery; therefore, the client should be taught to increase fluid intake after the procedure to flush the dye from the body. Increased output is an expected finding. (Option 4) Urine is sterile, but the urethra contains bacteria and a few white blood cells. Less than 10,000 organisms/mL is a normal value for urine culture. Values >10,000 organisms/mL indicate urinary tract infection (UTI). Educational objective: Residual urine volume of >100 mL on bladder scan may indicate urinary retention. Urine culture showing values >10,000 organisms/mL can suggest UTI. Burning sensation is common after cystoscopy. Renal arteriogram is performed with a contrast agent; excretion of the dye with oral and intravenous hydration is recommended to prevent kidney injury. Question: 41 Correct Answer: 1 The client with malignant left pleural effusion undergoes a thoracentesis and 900 mL of excess pleural fluid is removed. Which of these manifestations, if noted on the post-procedure assessment, should the nurse report to the health care provider immediately? 1. Asymmetrical chest expansion and decreased breath sounds on the left 2. Blood pressure 100/65 mm Hg (mean arterial pressure 77 mm Hg) 3. Client complains of 6/10 pain at the needle insertion site 4. Respiratory rate 24/min, pulse oximetry 94% on oxygen 2 L/min Rationale A thoracentesis involves the insertion of a large-bore needle through an intercostal space to remove excess fluid. The procedure has the following advantages: 1. Diagnostic - analysis of fluid to diagnose the underlying cause of the pleural effusion (eg, infection, malignancy, heart failure), including cytology, bacterial culture, and related testing 2. Therapeutic - removal of excess fluid (>1 L) improves dyspnea and client comfort Complications from insertion of the needle and removal of large amounts of fluid include iatrogenic pneumothorax, hemothorax, pulmonary edema, and infection. After the procedure, the nurse assesses for pain and difficulty breathing; monitors vital signs and oxygen saturation; and observes for changes in respiratory rate and depth, symmetry of chest expansion, and breath sounds. If any abnormalities are noted, a post- procedure chest x-ray is obtained. Decreased chest expansion with inspiration and breath sounds on the affected side, tachypnea, tracheal deviation to the opposite side, and hyperresonance (air) on the affected side are manifestations of a pneumothorax. These should be reported immediately. (Option 2) Hypotension, pulmonary edema, and tachycardia can occur as the result of removal of large amounts of pleural fluid (>1.5 L). This client's blood pressure is adequate (mean arterial pressure 77 mm Hg), and the nurse should continue to monitor. However, this blood pressure does not need to be reported immediately. (Option 3) Mild to moderate pain is common after the procedure. It does not need to be reported immediately. (Option 4) Difficulty breathing, tachypnea, and hypoxemia are pulmonary complications that can occur after thoracentesis. Saturation (94%) and respiratory rate (24/min) are adequate and do not need to be reported immediately. Educational objective: Complications of thoracentesis include iatrogenic pneumothorax, hemothorax, and infection. Post-procedure, the nurse assesses for pain and difficulty breathing; monitors vital signs and oxygen saturation; and observes for changes in respiratory rate and depth, symmetry of chest expansion, and breath sounds. Question: 42 Correct Answer: 1 A newly reassigned nurse enters a hospital room at the beginning of the shift and finds the client unconscious and unresponsive. Resuscitation is initiated and then continued by the rapid response team. The nurse realizes that there is a do not resuscitate (DNR) prescription posted in the client's chart. Which action is correct? 1. Stop all resuscitation activity immediately 2. Continue resuscitation until DNR status is verified with health care provider 3. If client shows any signs of life, follow advanced cardiovascular support protocol until stable 4. Once resuscitation has begun, complete it regardless of client code status Rationale Many health care professionals react to an emergency situation automatically. However, some states and provinces will further penalize health care workers with loss of their professional license if they fail to render cardiopulmonary resuscitation in an emergency situation. Health care professionals will not be penalized for an honest mistake. However, resuscitation must end immediately after they are notified of the error (Option 1). (Option 2) Continuing treatment until the code status is verified with the health care provider (HCP) constitutes malpractice. Before a do not resuscitate prescription can be posted in a client's medical record/chart, the HCP must provide documentation that the client's code status has been established through consultation with the client or family. (Options 3 and 4) Gross negligence of a client's advance directive can result in legal action. Educational objective: Failure to stop an erroneous code on a client with an advance directive in a timely fashion may result in legal action. Question: 43 Correct Answer: 1 The nurse reinforces teaching to a client with HIV during a follow-up clinic visit after being on antiretroviral drugs for the past 2 months. Which statement by the client indicates a need for further instruction? 1. "I can stop taking these HIV drugs once my viral levels are undetectable." 2. "I need to get tested regularly for sexually transmitted infections because I'm sexually active." 3. "I should use latex condoms and barriers when having anal, vaginal, or oral sex." 4. "I won't stop injecting drugs, but I will use a needle exchange program." Rationale Antiretroviral therapy (ART) is a medication regimen consisting of multiple drugs for managing and preventing progression of HIV infections. ART impairs viral replication at multiple points, which leads to decreased viral loads and increased CD4+ (ie, helper T) cell counts. When educating clients about ART, it is critical to explain that treatment is lifelong and requires strict adherence (Option 1). Even clients with undetectable viral loads remain infected with HIV. The discontinuation of, or poor adherence to, ART results in the progression of HIV (which may lead to AIDS) and promotes viral drug resistance. (Option 2) Clients with HIV who are sexually active are at increased risk for sexually transmitted infections (STIs). Regular testing (≥1 time annually) and treatment for STIs are recommended. (Option 3) Latex or polyurethane barriers should be used during sex to prevent STI transmission, as nonbarrier contraception and natural skin condoms (eg, lambskin) offer poor protection against HIV and STI transmission. (Option 4) IV drug use is a common source of HIV infection. Although abstinence from IV drugs is preferred, clients who continue to use them should be instructed to avoid sharing needles and receive information about needle and syringe exchange programs. Educational objective: Clients with HIV must be educated to strictly adhere to prescribed antiretroviral therapy to prevent disease progression. Clients with HIV who are sexually active should seek testing for sexually transmitted infections and use latex condoms/barriers during sex. Clients with HIV should use a needle exchange program if using IV drugs. Question: 44 Correct Answer: 4 A client recently diagnosed with a major depressive disorder reports use of herbal supplements. It is most important for the nurse to provide education about which supplement reported by the client? 1. Echinacea 2. Garlic 3. Glucosamine 4. St John's wort Rationale Herbal supplement Uses Side effects Ginkgo biloba • Memory enhancement • Increased bleeding risk Ginseng • Improved mental performance • Increased bleeding risk Saw palmetto • Benign prostatic hyperplasia • Mild stomach discomfort • Increased bleeding risk Black cohosh • Postmenopausal symptoms (hot flashes & vaginal dryness) • Hepatic injury St John's wort • Depression • Insomnia • Drug interactions: Antidepressants (serotonin syndrome), OCs, anticoagulants (↓ INR), digoxin • Hypertensive crisis Kava • Anxiety • Insomnia • Severe liver damage Licorice • Stomach ulcers • Bronchitis/viral infections • Hypertension • Hypokalemia Echinacea • Treatment & prevention of cold & flu • Anaphylaxis (more likely in asthmatics) Ephedra • Treatment of cold & flu • Weight loss & improved athletic performance • Hypertension • Arrhythmia/MI/sudden death • Stroke • Seizure MI = myocardial infarction; OCs = oral contraceptives. St John's wort is an herbal supplement commonly used to treat depression and anxiety. Some clients with mild or moderate depression claim that its antidepressant effect is comparable to that of prescription medications. The herbal supplement mimics the action of selective serotonin reuptake inhibitors (SSRIs) by increasing available serotonin in the brain. Taken in combination with an SSRI (eg, sertraline, fluoxetine, citalopram, paroxetine), St John's wort may cause an excess of serotonin, resulting in serotonin syndrome, which is characterized by mental status changes, autonomic dysregulation, and neuromuscular hyperactivity. The client with a newly diagnosed depressive disorder will likely be prescribed an antidepressant. The nurse should teach the client not to take St John's wort concurrently with SSRIs to prevent serotonin syndrome (Option 4). (Option 1) Echinacea is commonly used to prevent or treat the common cold/flu, although there is no evidence of its efficacy. It is thought to work by stimulating the immune system. Worsening asthma and anaphylaxis have been reported. (Option 2) Garlic is used to improve cholesterol and lower blood pressure. Ginkgo, garlic, and ginseng (the 3 Gs) increase bleeding risk when taken with anticoagulants or thrombolytics. (Option 3) Glucosamine is used to improve joint function. Hypoglycemia may result when it is taken with antidiabetic drugs. Educational objective: Selective serotonin reuptake inhibitors and St John's wort increase serotonin levels in the brain. Clients taking both products concurrently are at risk for potentially life-threatening serotonin syndrome (agitation, confusion, tachycardia, diaphoresis, tremors, hyperreflexia). Question: 45 Correct Answer: 3 The nurse reviews the assigned clients' laboratory results and medication administration records. Which finding is the highest priority for the nurse to follow-up with the health care provider? 1. Gram-negative infection and positive blood cultures in a client prescribed tobramycin 2. Serum B-type natriuretic peptide (BNP) 650 pg/mL (650 ng/L) in a client prescribed furosemide 3. Serum potassium 5.7 mEq/L (5.7 mmol/L) in a client prescribed spironolactone 4. Serum sodium 132 mEq/L (132 mmol/L) in a client prescribed IV normal saline solution at 175 mL/hr Rationale This client who was prescribed spironolactone (Aldactone), a potassium-sparing diuretic that counteracts the potassium loss caused by other diuretics, has high serum potassium (normal 3.5- 5.0 mEq/L [3.5-5.0 mmol/L]). The continuation of this medication puts this client at risk for lifethreatening hyperkalemia-induced cardiac dysrhythmias. This finding is of highest priority for the nurse to follow-up with the health care provider (HCP). (Option 1) This client has positive gram-negative blood cultures. Tobramycin, an aminoglycoside antibiotic drug, is used to treat serious gram-negative bacterial infections. There is no indication to follow-up with the HCP. (Option 2) BNP is a hormone released by heart muscle in response to mechanical stress (stretching). BNP levels are usually elevated (normal <100 pg/mL [100 ng/L]) in clients with heart failure, and the prescription for furosemide (Lasix), a loop diuretic, is expected. (Option 4) This client has hyponatremia (normal 135-145 mEq/L [135- 145 mmol/L]) and is receiving isotonic normal saline solution; there is no indication to follow-up with the HCP. Educational objective: A nurse should monitor clients receiving spironolactone, a potassium- sparing diuretic, for hyperkalemia. The continuation of this medication in the presence of an elevated serum potassium level puts a client at risk for life-threatening cardiac dysrhythmias. Question: 46 Correct Answer: 3 A nurse is caring for a college athlete who was recently diagnosed with moderate persistent asthma. Which common asthma trigger should the nurse teach this client to avoid? 1. Latex-containing products 2. Penicillin antibiotics 3. Secondhand cigarette smoke 4. Strenuous physical activity Rationale In clients with asthma, the airways are chronically inflamed with varying degrees of airway obstruction that can be exacerbated by exposure to triggering agents. Common asthma triggers include: • Allergens: Dander (eg, cat, dog), dust mites, pollen • Drugs: Beta blockers; nonsteroidal anti-inflammatory agents, including aspirin • Environmental: Chemicals, sawdust, soaps/detergents • Infectious: Upper respiratory infections • Intrinsic: Emotional stress, gastrointestinal reflux disease • Irritants: Aerosols/perfumes, cigarette smoke (including secondhand smoke), dry/polluted air (Option 3) Clients must be able to identify their individual triggers and avoid or learn to manage them. (Options 1 and 2) Penicillin antibiotics and latex-containing products may commonly trigger allergic reactions in many clients but do not commonly trigger asthma exacerbations in clients without these allergies. (Option 4) Although physical activity is an asthma trigger, athletes with asthma do not need to avoid activity altogether. Rather, they may take an inhaled bronchodilator 20 minutes before activity to help prevent exercise-induced asthma attacks. In addition, this client may be prone to minor musculoskeletal injuries (eg, sprains, strains) due to an active lifestyle; the nurse should teach about alternatives to common over-the-counter nonsteroidal anti- inflammatory medications that may be used for analgesia (eg, acetaminophen [Tylenol]). Educational objective: The nurse should teach an active young adult with asthma to identify and manage common triggers of asthma attacks, including cigarette smoke and nonsteroidal anti-inflammatory medications. Clients with asthma should take an inhaled bronchodilator 20 minutes before athletic activity to prevent exercise-induced asthma attacks. Question: 47 Correct Answer: 1.2 mL A laboring client weighing 187 lb is 5 cm dilated and having contractions every 2-3 minutes. The client rates the pain at 7 out of 10. Nalbuphine hydrochloride 10 mg/70 kg IV push × 1 is prescribed by the health care provider. Nalbuphine hydrochloride 10 mg/1 mL is available. How many milliliters does the nurse administer? Record your answer using one decimal place. Rationale The client is in active labor with an established contraction pattern and pain in the severe range. This is considered a safe time in labor to administer pain medication. The usual dose of nalbuphine hydrochloride is 10-20 mg, and the dose prescribed is within the normal dose range for labor. The nurse must convert the client's weight to kilograms (1 kg = 2.2 lb) and then determine the desired dose in milligrams. Finally, the nurse must calculate the dose to be administered in milliliters. Educational objective: The usual and safe dose of nalbuphine hydrochloride is 10–20 mg/70 kg of body weight given intramuscularly or by IV push. The nurse should convert weight to kilograms and then calculate the dose in milliliters based on the client's body weight and using the 2 formulas: Question: 48 Correct Answer: 1 A client in the mental health unit picks up a fire extinguisher and throws it at a nurse standing by the nurses' station. What is the most important intervention by the nurse? 1. Facilitate immediate removal of people from the area 2. Inform the client that the client cannot act that way 3. Pull the fire alarm to get additional immediate help 4. State that the nurse can see the client is upset Rationale When a situation is out of control, safety is the primary concern. The nurse and everyone else should leave the area, and security should be called immediately. (Option 2) The situation is no longer diffusible. Quoting authoritative rules will not likely have the desired effect as the client has lost control (and may not be in touch with reality). The nurse's priority is to move out of harm's way. (Option 3) Staff members should call security immediately and/or institute a back-up staff/takedown protocol. The fire alarm will activate a call to a fire department, which is not the type of help needed. However, when security arrives, the "best-trained brain" remains in control and the nurse should direct the actions of the team. (Option 4) When violence (eg, throwing a fire extinguisher) occurs, trying to defuse the situation verbally is no longer the priority. Educational objective: Safety is the priority when violence occurs. People should leave the area and call security immediately. Question: 49 Correct Answer: 3 A client with a diagnosis of schizophrenia with catatonia has recently been admitted to the psychiatric unit. Which of the following is the priority nursing diagnosis? 1. Impaired social interaction 2. Impaired verbal communication 3. Risk for deficient fluid volume 4. Risk for impaired skin integrity Rationale A diagnosis of schizophrenia with catatonia can be made if the clinical features meet the criteria for a diagnosis of schizophrenia and include at least 2 of the following additional features: • Immobility—the client remains in a fixed stupor or position for long periods o Refuses to move about or engage in activities of daily living o May have brief spurts of excitement or hyperactivity • Remaining mute • Bizarre postures—the client holds the body rigidly in one position • Extreme negativism—the client resists instructions or attempts to be moved • Waxy flexibility—the client's limbs stay in the same position in which they are placed by another person • Staring • Stereotyped movements, prominent mannerisms, or grimacing Clients with catatonic schizophrenia are unable to meet their basic needs for adequate fluid and food intake and are at high risk for dehydration and malnutrition. The priority nursing action is to anticipate the client's needs, and to ensure that the client is well hydrated and has adequate nourishment. Some clients will need total care. (Option 1) Impaired social interaction is also an appropriate nursing diagnosis in a client with catatonic schizophrenia. However, it is not a priority, especially during the early phases of the disease. (Option 2) The client's mutism makes the diagnosis of impaired verbal communication appropriate, and the nurse should gently encourage this client to talk without undue expectations or pressure. This is not the priority nursing diagnosis. (Option 4) If this client is in a bizarre or fixed posture, there may be a risk for decreased circulation and pressure ulcers. The nurse needs to encourage ambulation and/or provide rangeof- motion exercises. Educational objective: Clients with catatonic schizophrenia are unable to meet their own needs for fluids, food, movement, and elimination and need assistance in performing basic activities of daily living. However, a priority diagnosis is deficient fluid volume. Question: 50 Correct Answer: 4 A client comes to the emergency department after being assaulted. Imaging studies show a simple fracture of the mandible. The nurse assesses edema of the face and jaw, drooling, and bleeding in the mouth; the client rates pain as a 9 out of 10. What is the priority nursing intervention? 1. Administer nasal oxygen at 3 L/min 2. Administer opioids for pain 3. Apply ice pack to face for 20 minutes each hour 4. Suction the mouth and oropharynx Rationale A direct blow to the face or a motor vehicle collision is usually the cause of mandibular fracture. The client drools due to inability to close the mouth from edema and misalignment of the jaw. Structural damage, excessive saliva, and bleeding with pooled blood in the mouth can compromise the airway. Therefore, the priority nursing intervention is to suction the mouth and oropharynx to maintain airway patency. (Options 1, 2, and 3) Administration of nasal oxygen to facilitate breathing, administration of opioids to control pain, and application of ice to reduce edema and help reduce pain are all appropriate interventions for this client. However, these are not the priority interventions as the greatest threat to the client's survival is airway occlusion. Educational objective: Common clinical manifestations in a client with a fractured mandible are pain, edema of the face and jaw, difficulty speaking, drooling, and bleeding. Appropriate nursing interventions include oral suction to maintain airway patency, administration of oxygen and analgesia, and application of ice to the face. Question: 51 Correct Answer: 4 What is the priority when caring for a 6-month-old diagnosed with atopic dermatitis? 1. Encouraging use of humidifier 2. Exploration of family feelings 3. Instruction regarding hypoallergenic diet 4. Prevention of scratching Rationale Atopic dermatitis, also known as eczema, is a chronic skin disorder characterized by pruritus, erythema, and dry skin. In infants, red, crusted, scaly lesions may also be present. It is commonly first diagnosed before age 1 year. The exact cause is unknown, although it is associated with an impaired skin barrier that allows penetration of allergens, leading to an immune response. The primary goals of management are to alleviate pruritus and keep the skin hydrated to prevent scratching. Scratching leads to the formation of new lesions and predisposes to secondary infections. Important measures to prevent scratching include cutting and filing nails short, placing gloves or cotton stockings over the hands, not wearing rough fabrics or woolen clothing, and applying moisturizer. These measures would have an immediate effect in preventing scratching. (Option 1) A room humidifier may improve skin hydration and comfort in clients with excessively dry skin. However, comfort measures are not as crucial as immediate prevention of scratching (eg, gloves or cotton stockings placed over the hands). (Option 2) Having an infant with severe atopic dermatitis may be a source of anxiety or stress for parents. Although it may be beneficial to explore the psychosocial effects on the family, prevention of scratching is a higher priority as it can lead to secondary infection. (Option 3) Many clients with atopic dermatitis are also diagnosed with food sensitivities that aggravate the condition and require a hypoallergenic diet. However, nutritional education is a lower priority than infection prevention. Educational objective: Atopic dermatitis (eczema) is a chronic skin disorder manifested in infants by pruritus, dry skin, and red, crusted, scaly lesions. The priority management is to prevent scratching as this would promote formation of new lesions and predispose to secondary infections. Question: 52 Correct Answer: 2 The hospitalized client with anorexia nervosa is started on nutrition via enteral and parenteral routes. Which client assessment is the most important for the nurse to check during the first 24- 48 hours of administration? 1. Serum albumin level and body weight 2. Serum potassium and phosphate 3. Symptoms of dumping syndrome 4. White blood cell count and neutrophils Rationale Refeeding syndrome is a potentially fatal complication of nutritional rehabilitation in chronically malnourished clients (eg, anorexia nervosa, chronic alcoholism). The client's lack of oral intake results in the pancreas making less insulin. After the client receives food or IV fluids with glucose, insulin secretion is increased, leading to phosphorous, potassium, and magnesium shifting intracellularly. Phosphorus is the primary deficient electrolyte as it is required for energy (adenosine triphosphate). Hypophosphatemia causes muscle weakness and respiratory failure. Deficiencies in potassium and magnesium potentiate cardiac arrhythmias. Therefore, aggressive initiation of nutrition without adequate electrolyte repletion can quickly precipitate cardiopulmonary failure. (Option 1) Daily weights and periodic serum albumin level are indicated to evaluate the efficacy of nutritional replenishment but are not the most important assessment as failure to monitor these does not result in death. (Option 3) Dumping syndrome is seen after surgery for stomach cancer or bariatric surgery, which results in decreased storage area in the stomach. Eating concentrated carbohydrates or excess fluids causes the food to be "dumped"/emptied rapidly into the small intestine. Symptoms include diaphoresis, cramping, weakness, and diarrhea within 30 minutes of eating. Dumping syndrome is not seen with anorexia nervosa. (Option 4) The central lines carry a risk of infection. The signs of infection include leukocytosis and left shift. However, risk of infection is not greatest in the first few days of parenteral nutrition. Educational objective: Refeeding syndrome is a potentially fatal complication of nutritional rehabilitation in chronically malnourished clients. Electrolytes, especially phosphorous, potassium, and magnesium, must be monitored frequently during the first few days of nutritional replenishment. Question: 53 Correct Answer: 4 The nurse is caring for 4 clients. Based on the assessment data, which client does the nurse anticipate the health care provider transferring to the intensive care unit? 1. 36-year-old with alcohol abuse who is prescribed IV lorazepam every 3 hours for agitation and has a blood pressure of 190/98 mm Hg and serum magnesium level of 1.5 mEq/L (0.75 mmol/L) 2. 56-year-old with stable angina who has chest and jaw pain relieved with nitroglycerin, blood pressure of 98/70 mm Hg, and dizziness when getting up 3. 60-year-old with chronic kidney disease who has a blood pressure of 168/88 mm Hg, serum creatinine level of 5.0 mg/dL (442 μmol/L), and reports nausea and itching 4. 82-year-old with pressure injury who has a change in mental status, temperature of 96.4 F (35.8 C), pulse of 110/min, and blood pressure of 96/72 mm Hg Rationale Sepsis is a potentially life-threatening condition. Physiologic changes related to the aging process, including decreased immune function and inflammatory response (immunosenescence) and altered febrile response to pyrogens, increase the risk for sepsis. Although evidence indicates that early recognition of sepsis is critical to survival, atypical presentation associated with immunosenescence and absence of fever can delay diagnosis and treatment. Hypothermia in the presence of altered mental status, tachycardia, and borderline low blood pressure should alert the nurse to the possibility of early sepsis. Transfer to the intensive care unit for evaluation, continual monitoring, and evidenced- based treatment measures (ie, sepsis bundles) should be anticipated. Pressure injury could be the likely source of bacteremia in this client. (Option 1) Hypertension, agitation, and anxiety associated with catecholamine release are expected. The serum magnesium level is normal (1.5-2.5 mEq/L [0.75- 1.25 mmol/L]). (Option 2) Chest and jaw pain relieved with sublingual nitroglycerin and orthostatic hypotension (an adverse effect of nitrate drugs) are expected. (Option 3) Hypertension, elevated serum creatinine level (normal: 0.6- 1.3 mg/dL [53-115 μmol/L]), nausea associated with azotemia, and pruritus associated with dry skin are expected for chronic kidney disease clients. Educational objective: Hypothermia can be the presenting feature of sepsis in elderly clients. Question: 54 Correct Answer: 4 The charge registered nurse (RN) on a medical-surgical unit is responsible for making assignments. Which assignment made by the RN is most appropriate? 1. A licensed practical nurse (LPN) assigned to a client receiving blood transfusions 2. A student nurse assigned to a client who requires frequent intravenous pain medication 3. An LPN assigned to a client 2 days postoperative appendectomy scheduled to be discharged today 4. An RN assigned to a client 1 day postoperative repair of a compound fracture Rationale An RN is appropriately assigned to the client who is most unstable. Following this client's orthopedic surgery, the nurse must perform frequent neurovascular, pain, drain, wound, and respiratory assessments; assess for potential risk factors (eg, pulmonary embolus); and provide emotional support as well. Good critical thinking skills are needed to develop, implement, and evaluate an appropriate plan of care for this client. (Option 1) Administration of blood is not within the scope of the LPN's practice. (Option 2) A student nurse may not be able to administer medications independently and/or would require close supervision by either nursing faculty or an RN preceptor. The student nurse may not be able to provide adequate pain relief in a timely manner. The nurse who assesses the pain should administer the medication and evaluate the response. (Option 3) A postoperative client requires thorough education and evaluation prior to discharge. This level of client education should be performed by an RN; an LPN may reinforce prior teaching completed by an RN but is not able to provide initial teaching or evaluate learning outcomes. Educational objective: An RN is appropriately assigned to the client who is most unstable. The LPN's scope of practice does not include new discharge teaching or the administration of blood. Question: 55 Correct Answer: 3 The nurse reviews and reinforces an asthma action plan with a client who has moderate persistent asthma. Which statement by the client indicates an understanding of how to follow a plan appropriately when peak expiratory flow (PEF) readings are in the green, yellow, or red zones? 1. "If I am in the green zone (PEF 80%-100% of personal best) but am coughing, wheezing, and having more trouble breathing, I will not make any changes in my medications." 2. "If I am in the yellow zone (50%-80%) and I return to the green zone after taking my rescue medication, I will not make any changes in my daily medications." 3. "If I am in the yellow zone (50%-80%), I will take my rescue medication every 4 hours for 1-2 days and call my health care provider (HCP) for follow-up care." 4. "If I remain in the red zone, my lips are blue, and my PEF is still <50% of my personal best reading after taking my rescue medication, I will wait 15 minutes before calling an ambulance." Rationale An asthma action plan is an individualized management plan developed collaboratively between the client and the HCP to facilitate self-management of asthma. It includes information on daily and long-term treatment, prescribed medicines and when to take them according to a zone system, how to manage worsening symptoms or attacks, and when to call the HCP or go to the emergency department. The action plan uses traffic signal colors to categorize into zones degrees of asthma symptom severity and airway obstruction (peak flow meter readings): • Green zone indicates asthma is under control and PEF is 80%-100% of personal best. When in this zone, there is no worsening of cough, wheezing, or trouble breathing (Option 1). • Yellow zone means caution; even on a return to the green zone after use of rescue medication, further medication or a change in treatment is needed (Option 2). • Red zone indicates a medical alert and signals the need for immediate medical treatment if the level does not return to yellow immediately after taking rescue medications (Option 4). Educational objective: A peak flow meter uses traffic signal colors to categorize degrees of asthma symptoms. Green zone indicates asthma is under control. Yellow zone indicates caution, symptoms are getting worse, PEF is 50%-80% of personal best, and there is a need for further medication. Red zone indicates the need for emergency treatment if the level does not immediately return to yellow after taking rescue medications. Question: 56 Correct Answer: 4 A client is receiving chemotherapy for acute myeloid leukemia. The health care provider prescribes allopurinol to prevent tumor lysis syndrome (TLS). Which laboratory value indicates a therapeutic response to the medication? 1. Serum calcium 9.5 mg/dL (2.38 mmol/L) 2. Serum phosphate 4.0 mg/dL (1.29 mmol/L) 3. Serum potassium 4.5 mEq/L (4.5 mmol/L) 4. Serum uric acid level 6.0 mg/dL (357 μmol/L) Rationale A potential complication of chemotherapy is acute tumor lysis syndrome (TLS), a rapid release of intracellular components into the bloodstream. Massive cell lysis releases intracellular ions (potassium and phosphorus) and nucleic acids into the bloodstream. Catabolism of the nucleic acids produces uric acid, resulting in severe hyperuricemia. Released phosphorus binds calcium, producing calcium phosphate mixture but lowering serum calcium levels. Both calcium phosphate and uric acid are deposited into the kidneys, causing renal injury. Allopurinol (Zyloprim) blocks the nucleic acid catabolism and prevents hyperuricemia but would not affect potassium, phosphate, and calcium levels. Chronic gout and uric acid calculi also require the administration of allopurinol to decrease uric acid accumulation. A normal blood uric acid level for an adult male is 4.4–7.6 mg/dL (262–452 μmol/L) and female is 2.3-6.6 mg/dL (137-393 μmol/L). (Option 1) The normal calcium level for adults is 8.6–10.2 mg/dL (2.15–2.55 mmol/L). The client with this complication would experience hypocalcemia. (Option 2) The normal phosphate level for adults is 2.4–4.4 mg/dL (0.78–1.42 mmol/L). In this condition, the phosphate level would show hyperphosphatemia. (Option 3) The normal potassium level for adults is 3.5–5.0 mEq/L (3.5–5.0 mmol/L). Hyperkalemia is usually present in a client with this chemotherapy-induced complication. Educational objective: The therapeutic effect of allopurinol (Zyloprim) is to decrease hyperuricemia caused by TLS. Laboratory values of significance in TLS include rising blood uric acid, potassium, and phosphate levels, with decreasing calcium levels. Question: 57 Correct Answer: 2 The nurse is conducting a follow-up interview with a client who is being treated for depression and suicidal ideation. Which factor bestindicates the client is not currently at risk for suicide? 1. Client claims to have more energy and vigor since starting therapy 2. Client has clear future plans involving personal goals and family milestones 3. Client has signed a contract promising not to commit suicide 4. Client reports losing amitriptyline and requests a refill Rationale Clients receiving treatment for depression and suicidal ideation must be carefully monitored for indications of increasing intent. During the client interview, the nurse should assess: • Access to psychiatric medications • Availability of help during a crisis (eg, counselor, family) • Future goals and plans • Home and work environment risks • Overall affect and level of energy • Possible access to weapons Clients who articulate long-term personal goals and family milestones are less likely to commit suicide (Option 2). (Option 1) Clients often feel more energetic after beginning treatment, yet thoughts of suicide may not have fully resolved and the client may now have the energy to follow through with suicide plans. (Option 3) "No-harm/no-suicide" contracts are widely used in clinical practice to support a client's ability to avoid acting on suicidal thoughts. This practice is controversial as there is no evidence that contracts reduce suicide rates. These agreements do not guarantee safety and have no legal credibility. (Option 4) Amitriptyline is a tricyclic antidepressant, an overdose of which is extremely dangerous and likely fatal. Although the nurse may interpret the client's report of having lost the prescription as an attempt to be compliant, the nurse must also be aware that the client may be "stockpiling" medication for a suicide attempt. Educational objective: Nursing care for clients with suicidal ideation includes assessment of home and work environments, access to psychiatric medications, overall affect, and energy level. Clients who articulate long-term personal goals are less likely to commit suicide. Question: 1 Correct Answer: After listening to the parents' reports and seeing the following pediatric clients, the nurse knows that which client demonstrates signs of abuse that may necessitate mandatory reporting? 1. 1-year-old with dyspnea, drooling, and a swollen tongue after eating part of a houseplant 2. 2-year-old who is crying and has a large forehead hematoma after falling out of a chair 3. 3-year-old with second-degree burns on the face after pulling a cup of hot tea off the table 4. 5-year-old whose x-ray reveals 1 new and 2 healed humerus fractures after falling from a tree Rationale Question: 2 Correct Answer: The charge nurse is responsible for making room assignments for multiple clients. Which pair of client assignments to a shared room is appropriate? 1. Client with blood loss anemia and client with intractable diarrhea 2. Client with gastroenteritis and client with chemotherapy-induced nausea and vomiting 3. Client who had a bowel resection 1 day ago and client with asthma exacerbation 4. Client who had a total hip arthroplasty 2 days ago and client with influenza Rationale Question: 3 Correct Answer: The nurse cares for a client with a terminal disease who has an advance directive supporting a do not resuscitate (DNR) code status. The client stops breathing and loses a pulse. The client's adult child states, "I changed my mind. Do whatever you can to save him!" Which intervention is most appropriate at this time? 1. Call for help to initiate cardiopulmonary resuscitation 2. Call the health care provider to confirm the DNR status 3. Explain the client's wishes to the client's child 4. Offer to call the hospital chaplain to provide support Rationale Question: 4 Correct Answer: The clinic nurse is assessing a client who is being treated for depression and suicidal ideation. Which client statement best indicates that the client is not currently at risk for suicide? 1. "I lost my imipramine prescription. Could I have a refill?" 2. "I plan to attend my granddaughter's graduation next month." 3. "I seem to have a lot more energy since I started therapy." 4. "I will sign a 'no-suicide' contract at today's appointment." Rationale Question: 5 Correct Answer: The nurse is reviewing the medical history of a client who has sustained a right tibia/fibula fracture from a fall. The nurse identifies which finding as most likely to hinder healing? 1. BMI of 29.5 kg/m 2 2. Family history of osteoporosis 3. History of a daily glass of wine 4. Peripheral arterial disease Rationale Question: 6 Correct Answer: Based on the nursing assessment progress notes, what is the correct staging of the client's pressure injury? 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4 Rationale Question: 7 Correct Answer: A client with type 1 diabetes has prescriptions for NPH insulin and regular insulin. At 7:30 AM, the client's blood glucose level is 322 mg/dL (17.9 mmol/L), and the client's breakfast tray has arrived. What action should the nurse take? Rationale Question: 8 Correct Answer: The pediatric nurse plans a home visit for a 2-year-old who will soon be discharged with home health care. Which condition presents the most concern as a safety hazard in the child's home environment? 1. Family lives in a rural area 2. House is heated by a wood-burning stove 3. House was built in 1983 4. Parents are unemployed with limited financial resources Rationale Question: 9 Correct Answer: While the nurse is transporting a client to a new unit, the client's chest tube drainage system falls off the bed and the tube becomes dislodged from the chest wall. What is the nurse's priority action? 1. Activate the hospital emergency response system 2. Apply supplemental oxygen and quickly transport to the new unit 3. Check the client's respiratory pattern and effort and oxygen saturation 4. Firmly cover the insertion site with the palm of a clean, gloved hand Rationale Question: 10 Correct Answer: The nurse is caring for a client who had an anterior wall myocardial infarction 2 days ago. The telemetry technician notifies the nurse at 8:30 AM that the client is in ventricular trigeminy. What is the nurse's priority intervention? 1. Administer potassium replacement 2. Administer the dose of amiodarone 3. Attach cardiac defibrillator pads 4. Notify the health care provider Rationale Question: 11 Correct Answer: A nurse in the cardiac intensive care unit receives report on 4 clients. Which client should the nurse assess first? Rationale Question: 12 Correct Answer: There has been a major disaster involving a manufacturing plant explosion. The emergency department nurse is sent to triage victims. Which client should the nurse send to the hospital first? 1. Client who has partial-thickness burns on both hands 2. Client who is screaming and has a left lower arm laceration 3. Client with a broken, protruding right tibia and gray, pulseless foot 4. Client with a gaping head wound and Glasgow Coma Scale score of 3 Rationale Question: 13 Correct Answer: A client with sickle cell crisis reports severe generalized pain. Which intervention is a priority for correcting vasoocclusion? 1. Administering high-flow IV fluids 2. Applying oxygen via nasal cannula 3. Maintaining strict bed rest 4. Transfusing packed red blood cells Rationale Question: 14 Correct Answer: The nurse is caring for a client who has been pronounced brain dead. The client is a registered organ donor. The client's family is voicing concerns about the possibility of disfigurement because they want to have an open casket funeral. How should the nurse respond? 1. "If the family is not in complete agreement about organ donation, we won't be able to proceed." 2. "Once the body is dressed, there is no evidence of organ removal. An open casket will be fine." 3. "Some organ procurement leaves evidence on the body. You may want to consider a closed casket." 4. "Your family member consented to be an organ donor. You should really honor this wish." Rationale Question: 15 Correct Answer: Four pediatric clients are brought to the emergency department at the same time. Which client should be seen first? 1. Child who is unable to eat or drink without vomiting 2. Child with a recently placed tympanostomy tube that has fallen out 3. Child with bruising behind the ears after a football injury 4. Child with increased pain at skeletal pin insertion sites on the leg Rationale Question: 16 Correct Answer: A nurse receives change-of-shift report on 4 clients. Which client should the nurse assess first? 1. Client who experienced a transient ischemic attack 2 days ago and is due to receive scheduled aspirin 2. Client who had a subdural hemorrhage 36 hours ago and is requesting a breakfast tray 3. Client with a bowel resection receiving total parenteral nutrition who had 4,800 mL of urine output during the last shift 4. Client with a stroke receiving tissue plasminogen activator whose Glasgow Coma Scale changed from 9 to 13 Rationale Question: 17 Correct Answer: When the nurse provides education about starting risperidone, which statement by the client's caregiver indicates a need for further teaching? 1. "I will call the clinic if the client has a fever or muscle stiffness." 2. "I will remind the client to move slowly and not stand up too quickly." 3. "I won't worry if the client sleeps more often when taking this medicine." 4. "It is normal for the client to become shaky and restless when agitated." Rationale Question: 18 Correct Answer: A nurse is preparing to administer a unit of packed red blood cells to a client with hemoglobin of 7 g/dL (70 g/L). The unit secretary retrieved the blood 25 minutes ago. When entering the client's room, the nurse notes that the client's IV is not patent and is unsuccessful at inserting the new IV. What should the nurse do next? 1. Have another nurse attempt to restart the IV 2. Notify the health care provider of the delay 3. Place the blood in the unit refrigerator 4. Return the blood to the blood bank Rationale Question: 19 Correct Answer: The nurse cares for a client with an established ascending colostomy. Which statement made by the client indicates that further teaching is required? 1. "I always try to drink 3 liters of water each day." 2. "I avoid eating beans, onions, broccoli, and cauliflower." 3. "I change the appliance and bag every other day." 4. "I empty the bag when it is about one-third full." Rationale Question: 20 Correct Answer: The nurse is preparing to administer a continuous dopamine infusion at 5 mcg/kg/min. The client weighs 187 lb and the available medication contains 400 mg of dopamine in 250 mL of D5W. At what rate in milliliters per hour (mL/hr) should the nurse program the infusion pump? Record the answer using a whole number. Rationale Question: 21 Correct Answer: The nurse is caring for a client with tracheal cancer. At 9:00 PM, an on- call health care provider (HCP) rounds on the client and is alarmed to find the client bradypneic, hypotensive, and somnolent. The HCP requests that the nurse give the client naloxone. Which of the following is the best action by the nurse? 1. Approach the client's family to discuss whether to give naloxone in light of the client's wishes 2. Call the palliative HCP who prescribed the morphine sulfate to discuss the change in prescription 3. Describe the client's assessment data and plan of care, and do not give naloxone 4. Place the morphine infusion on standby and obtain the naloxone prescription Rationale Question: 22 Correct Answer: A client is receiving packed red blood cells intravenously through a double-lumen peripherally inserted central catheter (PICC) line. During the transfusion, the nurse receives a new prescription to begin amphotericin B IVPB. What is the nurse's best action? 1. Administer amphotericin B through the unused lumen of the PICC line 2. Insert a peripheral IV line to begin infusion of amphotericin B 3. Interrupt the blood transfusion to infuse amphotericin B, then resume after infusion 4. Wait 1 hour after transfusion finishes before administering amphotericin B Rationale Question: 23 Correct Answer: The charge nurse is educating a new nurse on IV start technique for a 6- year-old with autism spectrum disorder. Which statement by the new nurse indicates that further teaching is required? 1. "I will explain the procedure with the use of pictures." 2. "I will have the child's caregiver at the bedside to provide comfort." 3. "I will hold the child's hand as a soothing measure." 4. "I will limit the number of hospital staff in the room to ease anxiety." Rationale Question: 24 Correct Answer: The nurse receives report on 4 clients. Which client should the nurse see first? 1. Client with a right-sided ischemic stroke who is confused and is repeatedly getting out of bed without assistance 2. Client with an asthma exacerbation who was administered albuterol 15 minutes ago and has a heart rate of 110/min 3. Client with diabetes who has a blood glucose of 290 mg/dL (16.1 mmol/L) and has a scheduled dose of insulin aspart due 4. Client with obstructive sleep apnea who is 12 hours postoperative and maintaining an oxygen saturation of 92% on room air Rationale Question: 25 Correct Answer: The nurse helps a client with end-stage renal disease and a serum potassium level of 5.2 mEq/L (5.2 mmol/L) to plan menu choices. Which items would be best to include in the meal plan? 1. Black beans and rice, sliced tomatoes, half a cantaloupe 2. Grilled chicken sandwich on white bread, applesauce 3. Hamburger patty on whole wheat bun, carrot sticks, chocolate pudding 4. Poached salmon, green peas, baked potato, strawberries Rationale Question: 26 Correct Answer: While the nurse and unlicensed assistive personnel are turning an intubated and heavily sedated client during a bath, the client coughs and expels the endotracheal tube. What is the priority nursing action? 1. Assess respiratory rate and breath sounds to ensure ventilation is occurring 2. Deliver rescue breathing with a bag-valve-mask attached to 100% oxygen 3. Immediately alert the health care provider and prepare for reintubation 4. Initiate a code blue to prepare for potential cardiac arrest due to hypoxemia Rationale Question: 27 Correct Answer: A client arrives in the emergency department with right-sided paralysis and slurred speech. The nurse understands that the client cannot receive thrombolytic therapy due to which reason? 1. Client had gallbladder surgery 2 months ago 2. Client has experienced loss of the gag reflex 3. Client has platelet count of 130,000/mm3 [130 × 109/L] 4. Client has symptoms that started 12 hours earlier Rationale Question: 28 Correct Answer: The nurse is performing a medication reconciliation during a clinic visit with a client recently prescribed lithium. Which medication would cause the nurse to be most concerned? 1. Acetaminophen 2. Hydrochlorothiazide 3. Metformin 4. Sulfadiazine Rationale Question: 29 Correct Answer: A nurse is caring for a client with unstable angina. After 5 minutes on a nitroglycerin IV infusion, the client reports relief of chest pain but a new dull, throbbing headache. What is the appropriate nursing action? 1. Decrease the infusion rate and reassess the client's report of pain 2. Document the finding and administer prescribed acetaminophen 3. Notify the health care provider and request a CT scan of the head 4. Stop the infusion immediately and notify the health care provider Rationale Question: 30 Correct Answer: The nurse is caring for a client who has come to the emergency department with new-onset dyspnea and cough. The nurse auscultates the lung sounds. Based on the sounds heard, which prescription would the nurse anticipate? 1. Albuterol nebulization 2. Chest physiotherapy 3. Furosemide IV 4. Incentive spirometry Rationale Question: 31 Correct Answer: A pregnant client at 38 weeks gestation is admitted to the labor and delivery unit reporting contractions, severe abdominal pain, and dark vaginal bleeding. What is the nurse's priority action? 1. Initiate large-bore (18-gauge) peripheral IV line 2. Notify operating room staff of emergency cesarean birth 3. Palpate abdomen and apply fetal heart rate monitor 4. Perform vaginal examination to assess cervical dilation Rationale Question: 32 Correct Answer: The nurse in the emergency department is assessing telemetry strips for assigned clients. Which client tracing is a priority for the nurse to assess? 1. 2. 3. Rationale Question: 33 Correct Answer: A nurse hears various alarms sounding from different client rooms. Which alarm will the nurse address first? 1. Distal occlusion alarm on an infusion pump infusing heparin 2. Low-pressure limit alarm on a ventilator 3. Monitor alarm for a low respiratory rate of 11 breaths/min 4. Occlusion alarm on a continuous enteral feeding pump Rationale Question: 34 Correct Answer: A student nurse is accompanying the charge nurse when conducting daily rounds. Which personal protective measure by the charge nurse does the student nurse question? 1. Dons a mask with eye shield before irrigating a draining wound for a client on standard precautions 2. Places a "soap and water only" sign on the door of a client with Clostridium difficile 3. Wears 2 pairs of gloves when emptying the urinary catheter collection bag of a client with HIV 4. Wears an N95 respirator before entering the room of a client with active varicella-zoster Rationale Question: 35 Correct Answer: The staff nurse caring for a client with a history of drug abuse approaches the charge nurse and says, "My client is constantly requesting pain medicine. I had to administer normal saline instead of morphine because it is too early for another dose of morphine." Which action by the charge nurse is the priority at this time? 1. Document the incident in the nurse's employee file and review it with the unit manager 2. Follow institutional protocol for filing an incident or variance report 3. Instruct the nurse to notify the health care provider about the lack of pain relief 4. Report the incident to the hospital's ethics committee for evaluation Rationale Question: 36 Correct Answer: The nurse walking through a mall parking lot witnesses the collapse of a child. The child is not breathing and has a pulse of 50/min. After the nurse calls emergency services and delivers rescue breaths for 2 minutes, the child is still not breathing and is pale with a pulse of 52/min. What is the nurse's next action? 1. Begin chest compressions 2. Continue rescue breathing 3. Perform abdominal thrusts 4. Retrieve defibrillator Rationale Question: 37 Correct Answer: The nurse on the antepartum unit is performing shift assessments of several pregnant clients. Which client assessment is the priorityto report to the health care provider? 1. Client with gestational diabetes mellitus reporting dysuria 2. Client with hyperemesis gravidarum with a blood pressure of 90/48 mm Hg 3. Client with oligohydramnios and a reactive fetal nonstress test 4. Client with preeclampsia with 3+ reflexes and 2 beats of clonus Rationale Question: 38 Correct Answer: The nurse is caring for an African American client with disseminated intravascular coagulation. Which locations are best to assess for the presence of petechiae? 1. Buccal mucosae and conjunctivae of the eyes 2. Nail beds of the fingers and toes 3. Palms of the hands and soles of the feet 4. Skin over the sacrum and behind the heels Rationale Question: 39 Correct Answer: The nurse in an ambulatory surgery center triages telephone messages from clients. Which client should the nurse call back first? 1. Client who had a colonoscopy with polypectomy who reports abdominal cramping and a small amount of rectal bleeding 2. Client who had a lumbar laminectomy with spinal fusion 3 days ago who reports straining to have a bowel movement 3. Client who underwent laparoscopic inguinal hernia repair yesterday who reports difficulty urinating 4. Client who underwent placement of an arteriovenous graft who reports a temperature of 100.9 F (38.3 C) Rationale Question: 40 Correct Answer: The charge nurse is making client assignments for the oncoming shift. Which client assignment is most appropriate for a nurse who is 10 weeks pregnant? 1. Client receiving brachytherapy for endometrial cancer 2. Client with an infected surgical wound positive for methicillin- resistant Staphylococcus aureus 3. Client with a herpes zoster rash on the face and scalp 4. Client with pneumonia who recently traveled to a region with the Zika virus Rationale Question: 41 Correct Answer: A nurse is caring for a client at 37 weeks gestation who is undergoing a contraction stress test. Which fetal strip should the nurse associate with a negative contraction stress test? Rationale Question: 42 Correct Answer: A nurse is performing cardiopulmonary resuscitation (CPR) on an adult at a swimming pool. A bystander brings the automated external defibrillator (AED). The nurse notes that the victim is wet, lying in a small pool of water, and wearing a transdermal medication patch on the upper right chest. What is the most appropriate action at this time? 1. Do not use the AED and continue CPR until paramedics arrive 2. Move the client away from the pool of water before applying AED pads 3. Remove the transdermal patch and wipe the chest dry before using the AED 4. Wipe the chest dry and apply the AED pads over the transdermal patch Rationale Question: 43 Correct Answer: The nurse is caring for a pediatric client with osteomyelitis. Prior to the nurse administering IV antibiotics, the client's parent states, "We don't believe in antibiotics. Healing comes from within, and medications are toxic to that process." What is the nurse's priority response? 1. "Please tell me how medications are toxic to the healing process." 2. "Please tell me your understanding of your child's condition." 3. "What type of healing practices would you prefer for your child?" 4. "Without this medication, your child can get worse and could die." Rationale Question: 44 Correct Answer: A new nurse is providing hospice care for a terminally ill client who reports dyspnea. Which intervention would cause the charge nurse to intervene? 1. Administering oxygen via a nonrebreather mask 2. Administering prescribed morphine PRN 3. Providing a portable fan to improve air flow in the room 4. Providing relaxation strategies such as music and guided imagery Rationale Question: 45 Correct Answer: A client with bipolar disorder experiencing an episode of acute mania has recently been admitted to the psychiatric unit. Which nursing diagnosis is the priority at this time? 1. Imbalanced nutrition 2. Impaired social interaction 3. Risk-prone health behavior 4. Self-neglect Rationale Question: 46 Correct Answer: An older adult client takes multiple prescription medications plus several over-the-counter medications. Which intervention by the clinic nurse is most important in reducing the risk for drug interactions? 1. Assist client with making a list of all medications, doses, and times to be taken 2. Encourage client to obtain all prescription medications from the same pharmacy 3. Have client bring all medications taken regularly or occasionally to each appointment 4. Instruct client to use a pill organizer to separate pills by day and time Rationale Question: 47 Correct Answer: The nurse is caring for a client with cellulitis of the leg. At 11:00 AM, the client reported itching and received a PRN dose of diphenhydramine. At 9:00 PM, the client reports trouble sleeping and requests another dose of diphenhydramine to help with sleep. Which action is most appropriate? 1. Administer a dose of diphenhydramine as it is within the specified time interval 2. Administer a dose of lorazepam to encourage relaxation 3. Inform the client that no medications can be administered for sleep at this time 4. Request a prescription for a sleep aid from the health care provider Rationale Question: 48 Correct Answer: A nurse in the cardiac intensive care unit assesses a client with diabetes who had a percutaneous coronary intervention with stent placement via the left femoral artery 3 hours ago. Which assessment finding requires priority notification of the health care provider? 1. 1+ palpable pedal pulses bilaterally 2. 2-cm area of ecchymosis in the left groin 3. Angina rated as 4 on pain scale of 0-10 4. Blood glucose of 220 mg/dL (12.2 mmol/L) Rationale Question: 49 Correct Answer: The charge nurse on a medical-surgical unit is helping a student nurse formulate a care plan for a client with constipation. Which intervention in the care plan would cause the charge nurse to intervene? 1. Allow the client to ambulate in the hall as tolerated 2. Encourage the client to increase intake of nuts and seeds 3. Leave the client alone in the room when using the restroom 4. Request coffee to be included with breakfast trays Rationale Question: 50 Correct Answer: The health care provider has explained the risks and benefits of a planned surgical procedure and asks the nurse to witness the client's signature on the consent form. Which situation would affect the legitimacy of the signature? 1. Client asks whether a blood transfusion will be required during surgery 2. Client expresses a fear of postoperative pain 3. Client received a dose of hydrocodone for pain 12 hours ago 4. Client wishes to wait to sign the consent until the spouse is present Rationale Question: 51 Correct Answer: The nurse is reviewing client phone messages. Which client should the nurse call back first? 1. Client asking whether to take the morning dose of phenytoin before surgery the next day 2. Client taking dabigatran who reports heavier bleeding with her menstrual cycle 3. Client taking metronidazole who reports abdominal cramping and diarrhea 4. Client who has taken the last dose of insulin glargine and needs a refill Rationale Question: 52 Correct Answer: The nurse on the cardiac unit reviews a current rhythm strip from a client who experienced an inferior wall myocardial infarction. What action should the nurse take first? 1. Document the rhythm as an expected finding 2. Obtain the transcutaneous pacemaker 3. Prepare to administer adenosine IV 4. Review medications the client is receiving Rationale Question: 1 Correct Answer: A nurse is administering a rituximab infusion to a client with lymphoma in an oncology clinic. Which client symptom would be a priority to report to the health care provider? 1. Dizziness and sudden diarrhea 2. Nausea and onset of vomiting 3. New-onset tachypnea and dyspnea 4. Temperature of 101 F (38.3 C) Rationale Question: 2 Correct Answer: The student nurse plans postmortem care for an Orthodox Jewish client hospitalized for the last week with heart failure who did not sign consents for any postmortem actions. Which statement by the student would require further education by the supervising nurse? 1. "I will allow the family to remain with the client at all times." 2. "I will call the next of kin before providing any postmortem care." 3. "I will prepare the client for transfer to the morgue for autopsy." 4. "I will provide a sheet to be placed over the client's face." Rationale Question: 3 Correct Answer: The nurse is caring for a client with chronic pancreatitis. Which meal should the nurse recommend when assisting the client in selecting food items from a menu? 1. Baked tilapia with lemon wedge, sweet potatoes, and green peas 2. Cream of potato soup and roast beef sandwich on a croissant 3. Sauteed salmon, macaroni and cheese, string beans, and a biscuit 4. Shrimp enchiladas with tomato salsa, rice, cornbread, and refried beans Rationale Question: 4 Correct Answer: Four clients enter the pediatric emergency department at the same time. Which client should the nurse see first? 1. 2-week-old with tricuspid atresia who has dusky lips and nailbeds 2. 5-week-old with forceful vomiting after every feeding who is crying 3. 12-month-old who was wheezing at home and is now lethargic with no wheezing 4. 3-year-old with fever who had a brief seizure at home and is asleep Rationale Question: 5 Correct Answer: The unlicensed assistive personnel (UAP) reports being splashed in the eye while emptying urine from the catheter bag of a client with AIDS. The UAP is afraid of becoming infected with HIV and requests immediate testing. What is the nurse's priority action? 1. Direct the UAP to immediately flush the eye with water at the unit's eyewash station 2. Reassure the UAP that the risk for HIV is low as urine does not transmit the virus 3. Refer the UAP to the occupational health department for postexposure prophylaxis 4. Send the UAP to the facility's emergency department for medical evaluation Rationale Question: 6 Correct Answer: The nurse is caring for a client taking escitalopram who reports no improvement of depressive feelings since starting the medication 2 months ago. What is the best response by the nurse? 1. "Have you had any recent changes or added stresses in your life?" 2. "It is too early to notice any difference. Please continue to take the medicine as prescribed." 3. "Let's talk more about how you have been taking this medication." 4. "We will talk with your health care provider about changing the prescription." Rationale Question: 7 Correct Answer: The nurse reinforces teaching to the parents of a 12-month-old who has begun weaning from breastfeeding. Which statement by the parents indicates that teaching has been effective? 1. "I can allow my child to sleep with a bottle for comfort while weaning." 2. "I can start substituting breastfeeding sessions with whole cow's milk." 3. "I should discourage my child from drinking milk to increase solid food intake." 4. "I will stop breastfeeding completely to expedite the weaning process." Rationale Question: 8 Correct Answer: The home health nurse is discussing the care needs of a client in the last stage of Huntington disease with the family. When the nurse recommends a hospital bed, the client's spouse becomes visibly upset and says, "No hospital bed. I'm just not ready for it yet." What is the best response by the nurse? 1. "A hospital bed will make your spouse's care easier." 2. "Are you not ready for this particular change?" 3. "What upsets you about having a hospital bed?" 4. "You seem upset. We don't have to talk about this right now." Rationale Question: 9 Correct Answer: The client admitted to the psychiatric unit with severe anxiety is pacing rapidly in the room, crying, and hyperventilating. The client yells, "I can't believe you took my belongings! Where are you keeping them? This is so frustrating!" What is the appropriate response by the nurse? 1. "I understand that you are frustrated. I will give you some time to yourself to decompress." 2. "This is frustrating for me too. I wish I could give you your belongings right now, but I can't." 3. "Would you like to sit down so we can talk? Pacing like this will make you feel worse." 4. "Your belongings are locked in a safe place to ensure that they are protected while you are here." Rationale Question: 10 Correct Answer: The nurse is caring for a client who is 2 days postoperative craniotomy with bone flap removal. The nurse notes clear wound drainage saturating the dressing over the incision. Which action by the nurse is most appropriate at this time? 1. Cleanse the incision site with saline and apply a new, sterile dressing 2. Mark the edges of the drainage on the dressing and continue to monitor 3. Notify the health care provider of the color and amount of drainage 4. Turn the client onto the nonoperative side using the log-rolling technique Rationale Question: 11 Correct Answer: 3 A nurse caring for a client following a right femoral angiogram is unable to palpate the right pedal pulse. What should the nurse do next? 1. Apply a heating pad to increase circulation 2. Call the health care provider 3. Document "0" for right pedal pulse strength 4. Obtain a Doppler ultrasound Rationale Question: 12 Correct Answer: The following 4 clients are assigned to the emergency department nurse. Which client should the nurse see first? 1. Client in a motor vehicle collision whose head hit the steering wheel 2. Client who is 6 months pregnant and slipped and fell on icy stairs 3. Client who sustained a stab wound through the hand during a fight 4. Client with a 1-in (2.5 cm) leg laceration acquired during a soccer game Rationale Question: 13 Correct Answer: What nursing intervention is most appropriate when caring for a client with impairment to cranial nerve II? 1. Ensure that the client has a mechanical soft diet 2. Raise the head of the bed to prevent aspiration 3. Use pen and paper to write instructions 4. Verbally explain nursing interventions in detail Rationale Question: 14 Correct Answer: After assessing 4 clients in the pediatric emergency department, the nurse should alert the health care provider to see which client first? 1. 4-month-old who is lethargic with fever and vomiting 2. 2-year-old who is alert and calm with an occasional barking cough 3. 8-year-old with cola-colored urine and generalized edema 4. 15-year-old who is withdrawn and having painful urination Rationale Question: 15 Correct Answer: A nurse is preparing to administer a unit of packed red blood cells to a critically ill client. Two nurses have performed the verification process, and the unit label indicates that it is in-date and unexpired. On inspection, the nurse notices a large air bubble at the top of the bag. What is the appropriate action by the nurse at this time? 1. Call the blood bank to verify the expiration date and the safety of the blood for administration 2. Call the health care provider for further instruction and file an incident report 3. Proceed with administration as any air will be caught by the drip chamber of the tubing 4. Return the blood to the bank, notify them that air is present, and obtain a new bag Rationale Question: 16 Correct Answer: The nurse checks a client's blood pressure using an automatic, noninvasive machine. The nurse notes that the machine inflates for an unusually long amount of time, and the client reports intense pain in the arm with the cuff. The device suddenly stops inflation and displays an error message. Which action by the nurse is appropriate? 1. Place a soft washcloth under the cuff and repeat the measurement 2. Repeat the measurement after moving the cuff to the opposite arm 3. Repeat the measurement using a new cuff that is a size larger than the client needs 4. Send the machine for maintenance and repeat the measurement manually Rationale Question: 17 Correct Answer: An elderly client with diabetes comes to the clinic in winter reporting numbness of the feet. After removing the client's shoes and socks, the nurse notes that the feet are ice cold to the touch and appear waxy and pale. What is the appropriate nursing action? 1. Assist the client with ambulation to promote circulation 2. Bring the client warm blankets and a warm beverage 3. Massage the client's hands and feet to promote warming 4. Soak the client's lower legs in a warm water bath Rationale Question: 18 Correct Answer: The nurse has just received report on 4 clients. Which client should the nurse see first? 1. Client 2 days post hip replacement who is reporting intense itching at the incision site 2. Client receiving normal saline IV at 250 mL/hr who is reporting puffy legs and a new cough 3. Client who is becoming increasingly angry due to a 2-hour delay in being discharged 4. Client with a potassium level of 5.0 mEq/L (5.0 mmol/L) receiving NS with 20 mEq/L (20 mmol/L) potassium chloride Rationale Question: 19 Correct Answer: The nurse is teaching a seminar about atypical presentation of myocardial infarction. The nurse teaches about which factor that increases a client's risk of experiencing atypical symptoms? 1. Female gender 2. History of smoking 3. Hyperlipidemia 4. Hypertension Rationale Question: 20 Correct Answer: Which client presenting to the women's health clinic should the nurse assess first? 1. Client at 9 weeks gestation who reports intractable nausea and vomiting for past 6 hours 2. Client at 37 weeks gestation with twins who reports irregular contractions 3. Client whose last menstrual period was 7 weeks ago and reports severe pelvic pain 4. Primigravida client at 19 weeks gestation who has not yet felt fetal movement Rationale Question: 21 Correct Answer: A female client is visiting the clinic for an annual well-woman examination. The client reports having had sex with women. Which question will help the nurse determine the client's risk for sexually transmitted infections? 1. "Are you a lesbian, or do you have sex with both men and women?" 2. "Are you in a monogamous relationship with a female partner?" 3. "What barrier methods do you and your partner(s) use?" 4. "What types of sexual acts do you engage in with your partner(s)?" Rationale Question: 22 Correct Answer: The nurse in a psychiatric unit is approached by an aggressive client who grabs the nurse's stethoscope and attempts to strangle the nurse with it. The nurse is able to escape the client's grasp unharmed. Which action should the nurse take first? 1. Begin escorting other clients out of the room 2. Calmly ask the client to verbally express feelings 3. Escort the client into a secluded room 4. Place the client in restraints until calm Rationale Question: 23 Correct Answer: The clinic nurse is listening to voicemail messages in the office. Which client should the nurse call back first? 1. Client started on capsaicin cream 2 days ago reports sudden burning in the eyes 2. Client started on carbidopa-levodopa a day ago reports dizziness on standing 3. Client started on hydroxyzine 3 days ago reports urinary difficulty and hesitancy 4. Client started on phenytoin a week ago reports blistered lesions on the face and trunk Rationale Question: 24 Correct Answer: The nurse responds to a neighbor's calls for help and finds the neighbor's infant is choking but still responsive. Which intervention is most appropriate at this time? 1. Call 911 and begin cardiopulmonary resuscitation 2. Perform 5 back slaps followed by 5 downward chest thrusts 3. Perform a finger sweep of the mouth to assess for foreign objects 4. Place the infant on the nurse's lap and perform abdominal thrusts Rationale Question: 25 Correct Answer: The nurse is teaching a client about newly prescribed cyclosporine. Which client statement indicates a need for further teaching? 1. "I am going to a concert with my friends this weekend." 2. "I can use a hair removal cream for excess hair growth." 3. "I will need to check my blood pressure regularly at home." 4. "I will stop drinking grapefruit juice every morning." Rationale Question: 26 Correct Answer: The clinic nurse is caring for a 76-year-old client who has heart failure and is experiencing sudden weight gain and orthopnea. Which question would be the most beneficial for the nurse to ask at this time? 1. "Are you continuing to exercise regularly?" 2. "Do you check your heart rate before taking your medications?" 3. "When are you taking each of your medications?" 4. "When was your most recent visit to the primary care clinic?" Rationale Question: 27 Correct Answer: The home health nurse visits a client with inflammatory bowel disease who recently underwent a total colectomy with ileostomy creation. Which statement by the client indicates that the client understands ileostomy care? 1. "I can irrigate the stoma daily to help regulate stool drainage." 2. "I change the ostomy appliance and bag every morning." 3. "I cut the appliance opening slightly larger than my stoma." 4. "I restrict how much I drink to make the stool drainage less watery." Rationale Question: 28 Correct Answer: A nurse is providing teaching to a client newly prescribed verapamil for chronic migraine headaches. Which statement by the client indicates the need for further teaching? 1. "I will avoid taking this medication with grapefruit or grapefruit juice." 2. "I will make sure my pulse is greater than 60 before I take this medicine." 3. "I will take this medication at the first sign of a migraine." 4. "I will take this medicine with plenty of water and increase my intake of fiber." Rationale Question: 29 Correct Answer: The nurse assesses the heart sounds of a 77-year-old client with chronic heart failure. Which heart sound should the nurse document? 1. Pericardial friction rub 2. S1, S2, no adventitious sounds 3. S3 extra heart sound 4. Systolic murmur Rationale Question: 30 Correct Answer: The new nurse, caring for a 3-month-old client who is sedated in the intensive care unit following surgery, needs to prevent skin breakdown. Which action performed by the new nurse would cause the charge nurse to intervene? 1. Applying barrier cream when changing the diaper 2. Changing the pulse oximetry site 3. Elevating the head of the bed 30 degrees 4. Placing a donut pillow under the head Rationale Question: 31 Correct Answer: The nurse is speaking with the children of a client being treated for alcoholism. The client's 17- year-old child tells the nurse that the parent's disease and behavior have been difficult for the whole family, but particularly for a 13-year-old sibling who is having trouble in school. Which resource should the nurse recommend to this child? 1. Adult Children of Alcoholics 2. Al-Anon 3. Alateen 4. Alcoholics Anonymous Rationale Question: 32 Correct Answer: A client comes to the emergency department after being bitten by a bat. The nurse observes 2 small, nondraining puncture wounds resembling pinpricks on the fingertip. Which action should the nurse implement first? 1. Administer an intramuscular injection of human rabies vaccine 2. Administer an intramuscular tetanus toxoid vaccine if client not immunized within 5 years 3. Inject human rabies immunoglobulin into the proximal wound area 4. Scrub the wound with povidone-iodine solution or soap and water Rationale Question: 33 Correct Answer: The nurse is caring for a client with non-Hodgkin lymphoma who is starting chemotherapy. What assessment findings alert the nurse that the client is developing the potential complication of tumor lysis syndrome? 1. Facial and upper body edema 2. Generalized edema and hyponatremia 3. Hyperkalemia and hyperuricemia 4. Hypotension and elevated lactic acid Rationale Question: 34 Correct Answer: The infection control nurse observes a new graduate nurse in the intensive care unit. Which action by the graduate nurse requires intervention by the infection control nurse? 1. Graduate nurse removes gloves prior to removing mask when leaving client's room 2. Graduate nurse scrubs underneath artificial nails while performing hand hygiene 3. Graduate nurse uses alcohol-based hand sanitizer when entering client's room 4. Graduate nurse washes hands with soap and water for 20 seconds Rationale Question: 35 Correct Answer: A nurse is caring for a client with sickle cell crisis who has just finished receiving a blood transfusion. When forming a plan of care, which nursing diagnosis should the nurse address first? 1. Activity intolerance related to chronic anemia as evidenced by dyspnea on exertion 2. Acute pain related to vasoocclusive crisis as evidenced by pain rated 9 of 10 3. Excess fluid volume related to blood transfusion as evidenced by bilateral lung crackles 4. Impaired comfort related to itching as evidenced by client scratching at arms Rationale Question: 36 Correct Answer: The nurse on a medical-surgical unit prepares scheduled daily medications for a client and places them in a pill cup. After receiving the pill cup, the client states, "I take a whole tablet of metoprolol at home. Why did you cut this one in half?" What is the best response by the nurse? 1. "Do you know how many milligrams of metoprolol you normally take at home every day?" 2. "Show me which pill you're talking about so I can verify your prescriptions again." 3. "This is the same dose you received the past 3 days in the hospital, so we know it's safe to take." 4. "Your health care provider has prescribed a half-dose of metoprolol while you're in the hospital." Rationale Question: 37 Correct Answer: The nurse assesses a client who is intubated and mechanically ventilated after a cerebrovascular accident. Which assessment finding is most important for the nurse to report to the health care provider? 1. Flaccid right hand and arm 2. Impaired gag reflex when suctioning 3. Presence of urinary incontinence 4. Rigid flexion of arms at the elbows Rationale Question: 38 Correct Answer: The nurse is reviewing telemetry strips of clients. Which rhythm requires further assessment by the nurse? 1. 2. 3. 4. Rationale Question: 39 Correct Answer: After a traumatic head injury, a 36-year-old client on a mechanical ventilator is declared brain dead. The client's spouse states, "Maybe this happened for a reason. Do you think organ donation is possible?" Which response by the nurse is appropriate? 1. "A specialized team reviews each case for eligibility. I will contact them to review your spouse's history." 2. "It depends on whether your spouse gave consent to be an organ donor before the injury." 3. "Organ donation often provides comfort to family members who are grieving the loss of a loved one." 4. "You seem to be thinking the worst. Your spouse was young and healthy, and we are doing everything we can." Rationale Question: 40 Correct Answer: The nurse is performing a 12-lead ECG on a client suspected of having a myocardial infarction. The nurse notes significant interference on lead V2. Which electrode will the nurse troubleshoot? Rationale Question: 41 Correct Answer: The nurse working in a gastrointestinal clinic is reviewing the list of walk-in clients. Which client should the nurse see first? 1. Client reporting constipation since having a barium enema 3 days ago 2. Client reporting moderate flatulence after a resolved bowel obstruction 3. Client with irritable bowel syndrome reporting 3 or 4 loose stools a day for the past 3 days 4. Client with ulcerative colitis reporting 2 or 3 loose, bloody stools a day Rationale Question: 42 Correct Answer: The staff nurse is preparing a presentation about strategies to reduce horizontal violence. The nurse educator is reviewing the presentation beforehand. Which recommendation included in the presentation indicates a need for further teaching? 1. Creating a behavior code of conduct outlining communication 2. Creating a suggestion box for anonymously reporting bullying 3. Providing consistent education regarding bullying 4. Working toward diversification of staff age and gender Rationale Question: 43 Correct Answer: Using SBAR (Situation, Background, Assessment, Recommendation/Request) to communicate with the health care provider, which statement should the nurse include to describe the situation? 1. "I'm calling about the client in 711 who has low blood pressure and is symptomatic." 2. "The client has a limited code status and requests no intubation or compressions." 3. "The client was admitted for acute respiratory failure and intubated on September 16." 4. "The client's blood pressure was 97/45 mm Hg an hour ago and is now 88/40 mm Hg." Rationale Question: 44 Correct Answer: An unconscious 22-year-old client is brought to the emergency department after being hit in the head by a steel rod. The nurse should monitor for which assessment findings that are most characteristic of markedly increased intracranial pressure with impending brainstem herniation? 1. Bradycardia and widening pulse pressure 2. Irregular respirations and hypothermia 3. Sluggish pupil response and otorrhea 4. Sudden increase in alertness and hypertension Rationale Question: 45 Correct Answer: Four clients enter the emergency department at the same time. Which client should the nurse alert the health care provider to see first? 1. 6-year-old who is crying and reports a headache after hitting the head 2. 17-year-old who cannot raise arm above head after a football injury 3. 40-year-old with a first-degree burn and singed beard from a campfire 4. 70-year-old experiencing severe diarrhea and a poor appetite Rationale Question: 46 Correct Answer: The emergency department nurse is assigned 4 clients. Which client needs to be seen first? 1. 1-week-old with redness and swelling at the umbilicus and temperature of 100.1 F (37.8 C) 2. 2-year-old with a cough and post-tussive emesis with a respiratory rate of 27/min 3. 9-year-old with recent pacemaker insertion with dizziness and purulent drainage at the incision site 4. 14-year-old who reports a dull and constant headache after hitting the head while ice skating Rationale Question: 47 Correct Answer: A client's family member reports to the charge nurse that the nurses on the unit are not responding appropriately to the client's report of pain. What is the charge nurse's priority action? 1. Ask the client to rate current pain on a scale of 0-10 2. Discuss the concerns with the nurse assigned to the client 3. Evaluate the client's medication administration record 4. Review the narcotic count and look for discrepancies Rationale Question: 48 Correct Answer: The nurse is caring for an older adult client who has a blistering rash newly diagnosed as disseminated herpes zoster. What personal protective equipment should the nurse wear while assisting the client with a shower and linen change? 1. Eye shield, gloves, gown, and N95 respirator mask 2. Eye shield, gloves, gown, and surgical mask 3. Gloves, gown, N95 respirator mask, and surgical cap 4. Gloves, gown, surgical cap, and surgical mask Rationale Question: 49 Correct Answer: A 16-year-old client arrives at the emergency department experiencing an asthma exacerbation. The client's parent is visibly upset and shouts that the client smells like cigarette smoke. What is the nurse's best action? 1. Allow the client and parent to finish the conversation privately 2. Ask the parent to leave the room until able to remain calm 3. Redirect the parent to instruct the client to perform deep-breathing techniques 4. Reinforce education about the importance of smoking cessation Rationale Question: 50 Correct Answer: The nurse is teaching a group of clients about the use of complementary and alternative therapies. Which client statement indicates that further teaching is needed? 1. Client on apixaban who states, "I think I will try acupuncture for my arthritis." 2. Client on atorvastatin who states, "I have been taking garlic to help with my cholesterol." 3. Client with lupus who states, "I see a massage therapist for my muscle pain and stiffness." 4. Postpartum client who states, "I found a biofeedback coach for pelvic muscle training." Rationale Question: 51 Correct Answer: The nurse receives report on a client with chronic atrial fibrillation who had an episode of torsades de pointes during the night. The client spontaneously converted back to the baseline rhythm of atrial fibrillation and is now stable. Which information should the nurse immediately report to the health care provider? 1. Client is scheduled to receive a dose of sotalol this morning 2. Client is scheduled to receive a dose of warfarin this afternoon 3. Client's magnesium level is 2.2 mEq/L (1.1 mmol/L) 4. Client's potassium level is 4.5 mEq/L (4.5 mmol/L) Rationale Question: 52 Correct Answer: Which of the following methods would the nurse use to collect a urine sample for culture and sensitivity testing in a 16-month-old client? 1. Apply a urine collection bag to the perineum 2. Aspirate a specimen from an indwelling catheter collection bag 3. Insert a sterile intermittent urinary catheter 4. Place cotton balls inside the diaper Rationale Question: 53 Correct Answer: The nurse is caring for a client diagnosed with acute pericarditis. Which assessment finding would cause the nurse to immediately contact the health care provider? 1. Chest pain, worse when in supine position 2. Muffled heart sounds and narrow pulse pressure 3. Pericardial friction rub on auscultation 4. ST-segment elevation on all ECG leads Rationale Question: 54 Correct Answer: The charge nurse is rounding on clients in restraints. Which of the following situations would require immediate intervention by the nurse? 1. Client in a belt restraint in the semi-Fowler position 2. Client in mitten restraints in the side-lying position 3. Client in soft wrist restraints in the supine position 4. Client in vest restraint in the high-Fowler position Rationale Question: 55 Correct Answer: The emergency department nurse assesses an intubated client with multiple trauma injuries who recently arrived via emergency medical services. Which intervention should the nurse perform first? 1. Administer PRN pain medication 2. Assist with central line placement 3. Cover with warm blankets 4. Obtain prescribed x-rays Rationale Question: 56 Correct Answer: When performing a head-to-toe assessment, the nurse has difficulty hearing the client's heart sounds. What should the nurse do to better auscultate the S1 and S2 heart sounds? 1. Ask the client to lean forward in a sitting position 2. Have the client inhale deeply and hold the breath 3. Instruct the client to raise the left arm over the head 4. Use the bell of the stethoscope instead of the diaphragm Rationale Question: 57 Correct Answer: The nurse is caring for a client with chronic kidney disease who has a scheduled dose of epoetin alfa. Which of the following laboratory results would cause the nurse to hold the medication and contact the health care provider? 1. Blood urea nitrogen: 26 mg/dL (9.3 μmol/L) 2. Creatinine: 2.5 mg/dL (221 μmol/L) 3. Hemoglobin: 13 g/dL (130 g/L) 4. Platelets: 120,000/mm 3 (120 × 109/L) Rationale Question: 1 Correct Answer: 4 A 25-year-old client is about to undergo a unilateral orchiectomy for treatment of testicular cancer. The client says to the nurse, "I'm so worried that my future spouse is going to call off our engagement." What is the best response by the nurse? 1. "Are you concerned about how the surgery will affect your sexuality?" 2. "If you are concerned about infertility, you could always bank your sperm." 3. "The cancer is at an early stage. You are going to be fine." 4. "What have you and your future spouse discussed about your condition?" Rationale A diagnosis of testicular cancer is very often a source of anxiety for a client and can cause concern about sexual performance and fertility. How a client's sexuality is affected by this diagnosis depends on how advanced the cancer is and the course of prescribed treatment. Decisions about sperm banking and/or whether the client wants to procreate in the future are best made prior to surgery, radiation, and/or chemotherapy. The client and significant others need to be given counseling and the opportunity to discuss the potential effects of treatment and the options for preserving sperm. In this scenario, the client's stated concern about the future with the partner may be the way of voicing concern about how the surgery will affect sexuality. In order to determine what counseling or information this client needs, it is most important for the nurse to first assess the client's knowledge of the condition and what the client and the future spouse have already discussed. In addition, by using the therapeutic communication techniques of presenting a general lead and exploration, the nurse can facilitate the conversation and the nurse-client relationship. (Option 1) This is not the best response as it requires a short, single answer from the client and does not provide the opportunity for exploration or elaboration. "Yes" or "no" questions are useful and necessary in some client-nurse interactions. However, generally they are considered to be nontherapeutic as they are not conversation enhancers. (Option 2) Banking sperm is an option for clients with testicular cancer. However, it is more important for the nurse to first explore the client's concerns and knowledge about the condition. (Option 3) This statement by the nurse may be giving false reassurance to the client. In addition, it blocks further discussion or exploration of the client's knowledge about the condition and related concerns. Educational objective: A diagnosis of cancer is a cause of anxiety for any client due to concerns about prognosis. A client with a diagnosis of testicular cancer will have additional concerns about sexual performance and fertility. Using therapeutic communication techniques, such as a broad opening and a general lead and exploration, will facilitate the nurse-client relationship and a meaningful discussion about the condition and concerns. Question: 2 Correct Answer: 4 The nurse is preparing to administer the fourth dose of IV vancomycin to a client. Which set of laboratory values would alert the nurse to hold the vancomycin and notify the health care provider? 1. Vancomycin trough 10 mg/L (6.9 μmol/L), creatinine 1.1 mg/dL (97.2 μmol/L), BUN 6 mg/dL (2.1 mmol/L) 2. Vancomycin trough 14 mg/L (9.7 μmol/L), creatinine 1.2 mg/dL (106.1 μmol/L), BUN 10 mg/dL (3.6 mmol/L) 3. Vancomycin trough 18 mg/L (12.4 μmol/L), creatinine 0.6 mg/dL (53 μmol/L), BUN 18 mg/dL (6.4 mmol/L) 4. Vancomycin trough 23 mg/L (15.9 μmol/L), creatinine 1.5 mg/dL (132.6 μmol/L), BUN 24 mg/dL (8.6 mmol/L) Rationale Vancomycin (Vancocin) is a potent antibiotic used to treat gram-positive bacterial infections (eg, Staphylococcus aureus, Clostridium difficile). To lower the risk of doserelated nephrotoxicity, especially in clients with renal impairment and those who are >60 years of age, serum vancomycin trough levels should be monitored to assess for therapeutic range (10- 20 mg/L [6.9-13.8 μmol/L]). A vancomycin trough level above the normal range and/or elevated creatinine and blood urea nitrogen (BUN) values should be reported to the health care provider (HCP) as this may indicate nephrotoxicity. (Options 1, 2, and 3) Normal laboratory values do not need to be reported to the HCP. Baseline and ongoing monitoring for normal levels of creatinine (0.6-1.3 mg/dL [53-115 μmol/L]) and BUN (6-20 mg/dL [2.1-7.1 mmol/L]) are necessary in clients receiving vancomycin. Educational objective: The normal therapeutic level of vancomycin is 10-20 mg/L (6.9-13.8 μmol/L). Elevated vancomycin trough levels (>20 mg/L [>13.8 μmol/L]), creatinine (>1.3 mg/dL [>115 μmol/L]), and blood urea nitrogen (>20 mg/dL [>7.1 mmol/L]) are associated with nephrotoxicity and should be reported to the health care provider. Question: 3 Correct Answer: 4 Which client is at greatest risk for respiratory depression when receiving opioids for pain control? 1. 20-year-old client with bronchitis receiving inhaled bronchodilator therapy every 4 hours 2. 30-year-old client with heroin addiction with rotator cuff repair surgery this morning 3. 50-year-old client with sleep apnea and left foot cellulitis and scheduled for a bone scan 4. 70-year-old client with chronic obstructive pulmonary disease (COPD) with knee replacement this morning Rationale The following are at greatest risk for respiratory depression related to opioid use for analgesia: the elderly; those with underlying pulmonary disease, history of snoring (with or without apnea), obesity, or smoking (more than 20-pack-year history); the opiate naive, especially if treated for acute pain; and post surgery (first 24 hours). The 70-year old client has 3 significant risk factors: advanced age, COPD, and surgery within 24 hours. COPD clients who have hypercarbia and hypoxemia are at even greater risk for respiratory depression when receiving opioids. (Option 1) This client has 1 risk factor, pulmonary disease. (Option 2) This client has 1 risk factor, surgery within 24 hours. His addiction to heroin gives him a higher tolerance for opioids. (Option 3) This client has 1 risk factor, sleep apnea. Educational objective: Factors that increase risk for respiratory depression related to opioid use for pain control include advanced age, underlying pulmonary disease, snoring, obesity, smoking, opiate naive, and surgery. Question: 4 Correct Answer: 4 The flight nurse assesses an alert and oriented client at an industrial accident scene who was impaled in the abdomen by a pair of scissors. Which nursing action is the immediate priority on arrival at the scene? 1. Insert a large-bore IV line and infuse normal saline 2. Obtain blood for type and crossmatch and hemoglobin 3. Remove constrictive clothing to enhance circulation 4. Stabilize the scissors with sterile bulky dressings Rationale A sharp object that pierces the skin and lodges in the body may result in penetrating trauma to nearby tissue and organs. Common types of impaled (embedded) objects include bullets or blast fragments from firearms as well as sharp objects such as scissors, nails, or knives. The embedded object creates a puncture wound and then controls potential bleeding by putting pressure on the wound. First responders should not manipulate or remove the impaled object. Manipulation or removal may cause further trauma and bleeding; therefore, stabilization of the object is the first priority to prevent it from moving during initial client assessment (Option 4) and later during transport to a health care facility where skilled trauma care is available. Exception to the rule: First responders (EMS providers) may remove the impaled object if it obstructs the airway and prevents effective cardiopulmonary resuscitation. (Option 1) An IV line may be inserted and fluids begun on scene after stabilization of the object and initial assessment. (Option 2) Blood may be drawn after stabilization of the object and initial assessment. (Option 3) Clothing may be removed on scene after stabilization of the object and initial assessment. Educational objective: An impaled object should not be manipulated or removed at the scene as further trauma and bleeding of soft tissue and surrounding organs may occur. The embedded object is stabilized on scene to allow for initial client assessment and later transport to a health care facility where skilled trauma care is available. Question: 5 Correct Answer: 2 The nurse is caring for a new mother whose infant has been diagnosed with Down syndrome. The client says to the nurse, "I'm so worried. My husband is so devastated that he won't even look at the baby." What is the best response by the nurse? 1. "Both of you will benefit from supportive counseling." 2. "How are you feeling about your baby?" 3. "I will have the doctor speak to your husband." 4. "Why do you think your husband feels this way?" Rationale Learning that their newborn has a genetic disorder (eg, Down syndrome) is an overwhelming experience for most parents. They may initially react with shock, disbelief, and/or denial. Once they accept the diagnosis, parents may be filled with uncertainty and doubt and experience an array of emotions, including guilt, depression, and anger about the presumed loss of their perfect child. When helping the family cope with the crisis, the nurse needs to keep the lines of communication open and offer support. The nurse should use open-ended therapeutic communication techniques that encourage the family members to verbalize what they are feeling or experiencing (Option 2). (Option 1) This is a true statement; supportive counseling is usually beneficial to new parents of children with disabilities. The nurse can refer clients to family support groups or even make the initial phone call for them. However, the nurse should first encourage the parents to express how they are feeling. (Option 3) This is not the best response. The nurse has a role and responsibility to offer support to clients experiencing a crisis. (Option 4) This is accusatory and nontherapeutic. The nurse should avoid asking "why" questions when attempting to gain more information. Educational objective: Parents of newborns diagnosed with Down syndrome or other developmental disabilities may experience shock or disbelief along with a wide array of emotions. Nurses should be supportive by using therapeutic communication techniques that encourage the family to talk about what they are experiencing and/or feeling. Question: 6 Correct Answer: 2 A client with schizophrenia says to the nurse, "The world turns as the world turns on a ball at the beach. But all the world's a stagecoach and I took the bus home." The nurse recognizes this statement as an example of which of the following? 1. Concrete thinking 2. Loose associations 3. Tangentiality 4. Word salad Rationale Disturbance in logical form of thought is characteristic and one of the positive symptoms of schizophrenia. The client will often have trouble concentrating and maintaining a train of thought. Thought disturbances are often accompanied by a high level of functional impairment, and the client may also be agitated and behave aggressively. Types of impaired thought processes seen in individuals with schizophrenia include the following: • Neologisms – made-up words or phrases usually of a bizarre nature; the words have meaning to the client only. Example: "I would like to have a phjinox." • Concrete thinking – literal interpretation of an idea; the client has difficulty with abstract thinking. Example: The phrase, "The grass is always greener on the other side," would be interpreted to mean that the grass somewhere else is literally greener (Option 1). • Loose associations – rapid shifting from one idea to another, with little or no connection to logic or rationality (Option 2) • Echolalia – repetition of words, usually uttered by someone else • Tangentiality – going from one topic to the next without getting to the point of the original idea or topic (Option 3) • Word salad – a mix of words and/or phrases having no meaning except to the client. Example: "Here what comes table, sky, apple." (Option 4) • Clang associations – rhyming words in a meaningless, illogical manner. Example: "The pike likes to hike and Mike fed the bike near the tyke." • Perseveration – repeating the same words or phrases in response to different questions Educational objective: Disturbance in thought process (form of thought) is one of the positive symptoms of schizophrenia. The nurse needs to be able to recognize and identify the various types of thought disturbances experienced by clients with schizophrenia. These include loose associations, neologisms, word salad, echolalia, tangentiality, clang association, and perseveration. Question: 7 Correct Answer: 3 A nurse on the behavioral health unit is reviewing medication prescriptions for 4 clients. Which combination of medications does the nurse question? 1. A client with anxiety prescribed escitalopram and alprazolam 2. A client with bipolar disorder prescribed risperidone and lithium 3. A client with depression prescribed escitalopram and selegiline 4. A client with depression prescribed sertraline and zolpidem Rationale Clients are often prescribed medications from more than one class to effectively treat anxiety and depression; however, monoamine oxidase inhibitors (MAOIs) (eg, selegiline [Emsam]) interact with many medications, including many antidepressants. Concurrent use of MAOIs with selective serotonin reuptake inhibitors (SSRIs) (eg, escitalopram [Lexapro]) may precipitate life-threatening adverse reactions (eg, serotonin syndrome, neuroleptic malignant syndrome, hypertensive crisis). If a client's prescribed medication regimen will change to or from an MAOI, the existing medication should be tapered and discontinued, followed by a 2-week "washout" period without either medication. The client can then begin taking the new medication. (Options 1 and 4) SSRIs (eg, citalopram [Celexa], escitalopram, sertraline [Zoloft]) can be given safely with benzodiazepines (eg, alprazolam [Xanax], lorazepam [Ativan]) or hypnotics (eg, zolpidem [Ambien]). Benzodiazepines control acute anxiety and SSRIs help treat long-term anxiety without abuse potential. (Option 2) Clients with bipolar disorder often need antipsychotic medication (eg, risperidone [Risperdal], haloperidol [Haldol]) to control acute psychosis and lithium for long-term maintenance therapy. Educational objective: Monoamine oxidase inhibitors (MAOIs) (eg, selegiline [Emsam]) interact with many medications, including many antidepressants. MAOIs and selective serotonin reuptake inhibitors should not be given within 2 weeks of each other to prevent adverse reactions (eg, serotonin syndrome, neuroleptic malignant syndrome, hypertensive crisis). Question: 8 Correct Answer: 1 The nurse is assessing a 4-day-old, term neonate who is breastfed exclusively. Which assessment finding should the nurse report to the health care provider for further assessment regarding possible formula supplementation? 1. 10% weight loss since birth 2. Cracked, peeling skin 3. Feeds every 2-3 hours 4. Runny, seedy, yellow stools Rationale During the first 3-4 days of life, a weight loss of approximately 5%- 6% of birth weight is expected due to fluid excretion (eg, urine, stool, respirations). Weight loss usually ceases around 5 days of life in healthy newborns, who return to their birth weight by 7- 14 days of life. A weight loss of >7% of birth weight warrants further evaluation. The nurse should assess the newborn, review intake and output, observe breastfeeding technique (eg, positioning, effective latching), and notify the health care provider. To prevent further weight loss, breastfeeding support and formula supplementation (eg, via spoon or syringe) may be indicated until exclusive breastfeeding is adequate (Option 1). (Option 2) Peeling of the term newborn's skin is a sign of physical maturity and is expected around the third day of life. Cracked, peeling skin may be present at birth in post-term (ie, >42 weeks gestation) newborns. (Option 3) Feeding every 2-3 hours is normal for breastfed newborns; breastmilk is easily digested and more frequent feeding is noted than in formula-fed newborns. (Option 4) After passing meconium, newborns produce transitional stools that are thin and yellowish-brown or yellowish-green. Stools of breastfed newborns progress to a seedy, yellow paste. Bottle-fed newborns have firmer, light brown stools. Educational objective: During the first 3-4 days of life, a weight loss of approximately 5%-6% of birth weight is expected due to fluid excretion through urine, stool, and respirations. Weight loss >7% may indicate the need for breastfeeding support and formula supplementation and require evaluation. Question: 9 Correct Answer: 1 The nurse is preparing to assess a client visiting the women's health clinic. The client's obstetric history is documented as G5T1P2A1L2. Which interpretation of this notation is correct? 1. The client had 1 birth at 37 wk 0 d gestation or beyond 2. The client had 3 births between 20 wk 0 d and 36 wk 6 d gestation 3. The client has 3 currently living children 4. The client is currently not pregnant Rationale The GTPAL system is a shorthand system of documenting a client's obstetric history. This client (G5T1P2A1L2) has been pregnant 5 times (G5); had 1 term birth (T1), 2 preterm births (P2), and 1 abortion (A1); and has 2 currently living children (L2). The client's term birth is indicated by the T1 portion of the GTPAL notation (Option 1). (Option 2) The client had 2 preterm births, indicated by the P2 portion of the GTPAL notation. (Option 3) The client has 2 currently living children, as indicated by the L2 portion of the GTPAL notation. If a child born full- or preterm is not living (due to stillbirth from 20 wk 0 d and beyond or infant/child death after birth), that birth and subsequent death is counted toward T or P (term or preterm) but is not notated under L (currently living children); T and P record total number of births without regard to current living status. This client has 2 currently living children (L2), which is 1 less than the client's total notation for term + preterm (T1 + P2 = 3). Therefore, the client has experienced the death of 1 child who had been born at 20 wk 0 d gestation or beyond. (Option 4) If a client is currently pregnant, the number of pregnancies (gravida) will be greater than the number of births (term, preterm, and abortions combined). This client is a G5, and T1 + P2 + A1 = 4. Therefore, the client is currently pregnant. Educational objective: The GTPAL system notational components are G - gravida (number of pregnancies, regardless of outcome and including current pregnancies), T - term (37 wk 0 d gestation and beyond), P - preterm (20 wk 0 d through 36 wk 6 d gestation), A - abortions (before 20 wk 0 d gestation; spontaneous or induced), and L - currently living children. Question: 10 Correct Answer: 4 The nurse is caring for a client with gestational diabetes mellitus during the second stage of labor. After birth of the head, the nurse notes retraction of the fetal head against the maternal perineum. Which action should the nurse anticipate? 1. Administering a tocolytic 2. Initiating fundal pressure during a contraction 3. Obtaining the vacuum extractor 4. Pressing downward on the symphysis pubis Rationale Shoulder dystocia is an obstetrical emergency in which the fetal head emerges but the anterior shoulder remains wedged behind the maternal symphysis pubis. The nurse may initially observe the fetal head retracting back toward the maternal perineum after birth of the head (ie, turtle sign). The condition is frequently associated with macrosomia (fetal weight >8 lb 13 oz [4000 g]) secondary to gestational diabetes mellitus. However, the occurrence of shoulder dystocia is unpredictable and may be related to maternal factors, such as suboptimal pelvic shape, obesity, or short stature, rather than fetal size. The nurse's primary responsibilities during shoulder dystocia include performing the McRoberts maneuver (ie, sharp flexion of maternal thighs toward abdomen to widen space between pubic bone and sacrum) and applying suprapubic pressure (ie, downward pressure applied to maternal pubic bone to dislodge fetal shoulder) (Option 4). (Option 1) Administering a tocolytic agent to stop contractions or relax the uterus is not recommended and does not resolve shoulder dystocia. (Option 2) Fundal pressure is contraindicated, as it may wedge the fetal shoulder further into the symphysis pubis or cause uterine rupture. (Option 3) Application of a vacuum extractor is contraindicated because it may further wedge the fetal shoulder into the symphysis pubis, increasing the risk for brachial plexus injury. Educational objective: Shoulder dystocia occurs when the fetal head emerges but the anterior shoulder remains wedged behind the maternal symphysis pubis. The nurse should be prepared to perform McRoberts maneuver and apply suprapubic pressure. Question: 11 Correct Answer: 1 The nurse reviews laboratory test results for a pregnant client at 32 weeks gestation. What is the nurse's best action based on these results ? 1. Complete the client assessment and documentation 2. Draw another sample for repeat complete blood count 3. Prepare for transfusion of packed red blood cells 4. Request a prescription for iron supplementation Rationale Pregnant women experience a 40%-45% increase in total blood volume during pregnancy to meet the increased oxygen demand and nutritional needs of the growing fetus and maternal tissues. Because the increase in plasma volume is greater than the increase in red blood cells, a hemodiluted state called physiologic anemia of pregnancy occurs, and is reflected in lower hemoglobin and hematocrit values. It is also normal for the white blood cell count to increase during pregnancy; counts can be as high as 15,000/mm3 (15.0 x 109/L). These laboratory results are within the normal ranges for a pregnant client in the third trimester, and no intervention is required (Options 1 and 2). (Option 3) A blood transfusion should not be considered in pregnancy unless severe anemia (hemoglobin <7.0 g/dL [<70 g/L]) is suspected. (Option 4) Iron is frequently prescribed for pregnant women to prevent or treat iron deficiency anemia (hemoglobin ≤11 g/dL [110 g/L] and hematocrit ≤33% [0.33]). However, this pregnant client's laboratory results are within normal ranges, and iron supplementation is not necessary. Educational objective: Pregnant women experience an increase in total blood volume to meet the increased oxygen demand and nutritional needs of the growing fetus and maternal tissues. The increase in plasma volume is greater than the increase in red blood cells, creating a hemodiluted state termed physiologic anemia of pregnancy, which is reflected in decreased hemoglobin (>11.0 g/dL [>110 g/L]) and hematocrit (>33% [0.33]) values. Question: 12 Correct Answer: 1 What is the most therapeutic intervention the nurse should complete when admitting a 10- month-old to the pediatric unit? 1. Allow the child to sit on the primary caregiver's lap while auscultating breath sounds 2. Instruct the primary caregiver to restrain the child's arm while obtaining intravenous access 3. Provide the option for the child to complete the admission in the room or the designated play area 4. Request that the primary caregiver leave the child's room during the physical assessment Rationale Separation anxiety is common during infancy and toddlerhood. Allowing the child to be with the primary caregiver when appropriate will decrease the stress caused by separation. (Option 2) It is not recommended that caregivers restrain a child for a procedure. Medical personnel are most appropriate for this duty. The caregiver can be a source of comfort after the procedure is complete. (Option 3) A 10-month-old is not at an appropriate age to make this decision. The assessment should be completed in a quiet environment with the caregiver present to promote calmness. Health history should be obtained in a private area to avoid violations of the Health Insurance Portability and Accountability Act. (Option 4) It is appropriate for the caregiver to remain with the child during the physical assessment as a source of comfort. Educational objective: Separation anxiety is common during infancy and toddlerhood and may be very stressful for the child. Allowing the child to remain with the caregiver when appropriate will promote calmness and decrease the child's stress. Question: 13 Correct Answer: 3 A client with multidrug-resistant tuberculosis (MDR-TB) has a 1-month follow up visit after beginning medication therapy. The client states, "I've had really bad nausea and fatigue, but because my cough has already improved, I knew it would be alright to stop taking the medications." The nurse identifies which priority nursing diagnosis (ND) in this client's care plan? 1. Activity intolerance 2. Imbalanced nutrition, less than body requirements 3. Knowledge deficit of prescribed therapeutic regimen 4. Nausea Rationale Knowledge deficit is the lack of adequate information required for health recovery, maintenance, and promotion. The priority ND is knowledge deficit of the prescribed therapeutic regimen manifested by the client's verbalization of nonadherence to the prescribed MDR-TB therapy. Medication to treat MDR-TB usually must be taken for 6 to 9 months. The length of the treatment regiment, the cost and amount of medications that must be taken, and the unpleasant side effects all contribute to clients becoming nonadherent with treatment. If clients do not properly complete the entire medication regimen, they risk reactivating the MDR-TB disease, increasing the bacteria's drug-resistance, and spreading the disease to others. The medications cannot be discontinued until therapy is complete. (Option 1) Activity intolerance is an insufficient physiological or psychological energy to complete daily activities. In this client, it is related to side effects of the medications and a deconditioned state and is manifested as fatigue or weakness. This is appropriate to include in the care plan but is not the priority ND. (Option 2) Imbalanced nutrition, less than body requirements, is an insufficient intake of nutrients to meet metabolic needs. In this client, it is related to inability to ingest foods secondary to nausea, fatigue, and anorexia and is manifested by inadequate caloric intake and a loss of appetite. This is appropriate to include in the care plan but is not the priority ND. (Option 4) In this client, nausea is related to medication side effects and is suggested by a verbal report of nausea and loss of appetite. It is appropriate to include this in the care plan but is not the priority ND. Educational objective: The ND, knowledge deficit of the prescribed therapeutic regimen, is appropriate in a client with MDR-TB who is nonadherent to the prescribed medication therapy. Nonadherence increases the risk for recurrence, development of drug-resistant organisms, and spread of TB disease to others. Question: 14 Correct Answer: 4 A newborn had a bowel resection with temporary colostomy for Hirschsprung's disease. The nurse should alert the health care provider (HCP) for which assessment finding postoperatively? 1. Moderate amount of blood-tinged mucus from the stoma on postoperative day 2 2. Small amount of non-formed stool in the colostomy bag on postoperative day 6 3. Stoma bleeds a small amount during colostomy bag change on postoperative day 3 4. Stoma is gray-tinged at the edges but pink at the center on postoperative day 5 Rationale In Hirschsprung's disease, a portion of the colon has no innervation and must be removed. Some children require a temporary colostomy. The stoma created from the surgery should remain beefy red in the immediate postoperative period. Any paleness or graying of the stoma indicates decreased blood supply to that area. (Option 1) Due to irritation of the intestinal mucosa during surgery, blood-tinged mucus would be expected the first few days after surgery. (Option 2) By postoperative day 6, stool would be expected from the colostomy as part of the fluid-absorbing portion of the large intestine has been removed. (Option 3) It is not uncommon for a stoma to bleed a small amount with manipulation in the postoperative period. Educational objective: The colostomy stoma should be beefy red in the immediate postoperative period. Any discoloration to the stoma could indicate decreased blood supply to the area; the nurse should notify the HCP. Question: 15 Correct Answer: 2 The nurse is caring for a client newly admitted with an acute manic episode of bipolar disorder. The nurse identifies which dinner selection as the most appropriate to promote client nutrition? 1. Baked sweet potato, kale, yeast roll, water 2. Cheeseburger, apple, vanilla milkshake 3. Spaghetti with meatballs, fruit salad, milk 4. Vegetable soup, salad, dinner roll, iced tea Rationale Bipolar disorder is a psychiatric condition characterized by cycling periods of depression and mania. Clients with acute mania often display elevated mood, increased and excessive activity levels, and altered decision-making that can result in high-risk behavior (eg, hypersexuality, excessive spending). Clients with mania are also easily distractible, leading to neglect of personal needs (eg, hydration, nutrition, sleep, hygiene) and the need for medical intervention. When managing the nutritional needs of clients with mania, the nurse should frequently offer energy- and protein-dense foods that are easily carried and consumed (eg, sandwiches, shakes, hamburgers, pizza slices, burritos, fruit juices, granola bars). These "on-the-go" foods promote nutritional intake in clients who are unable to sit down and complete a traditional meal (Option 2). (Option 1) Sweet potatoes and kale are low in energy and protein and difficult to eat on the go. (Option 3) Spaghetti with meatballs and fruit salad are difficult to eat on the go. (Option 4) Vegetable soups and salads are often low in protein and energy and difficult to eat on the go. Caffeinated drinks (eg, soda, tea, coffee) should be avoided as they may increase mania and activity. Educational objective: Clients with acute mania often have elevated activity levels that increase their risk for malnutrition and dehydration. Nurses should provide easily carried and consumed foods high in energy and protein (eg, burgers, sandwiches, shakes) to promote adequate nutritional intake. Question: 16 Correct Answer: 4 A 9-year-old has terminal cancer, but the parents do not want the child to know the prognosis. The child has been asking questions such as what dying is like and whether the child will die. Which action by the nurse is most appropriate? 1. Encourage the child to ask the parents these questions 2. Notify the health care provider (HCP) about the child's questions 3. Reassure the child that everyone is trying to help the child get better 4. Tell the parents about the child's questions Rationale A 9-year-old's understanding of death is the same as that of an adult. The parents try to "protect" the child, but the child senses the truth at some level and wants to discuss it. A child may be aware of impending death even before being told. Not being told may make the child feel isolated. Children sometimes feel a need to "protect" parents because they fear that their understanding will burden them. The nurse can offer self or other appropriate people to talk to the child if the parents cannot do it themselves. However, the nurse should first discuss the child's concerns with the parents and not talk with the minor child on the nurse's own initiative. Discussing the child's questions about death would support the parents' autonomy and advocate for the child's needs. (Option 1) The child is probably hesitant to talk about death because the child senses the parents' reluctance to discuss it. It is worth considering why the child is asking others instead of the parents in the first place. It might be helpful for the nurse to bridge the communication gap initially. (Option 2) Although the HCP should be informed, the parents need to handle the situation with their minor child. (Option 3) This action minimizes the child's concerns and does not deal with the issue raised. The child is terminally ill. Educational objective: The nurse's role with a dying client is to aid communication. When a dying child asks about death, the parents should know about the child's concerns. Question: 17 Correct Answer: 1 The parent of a 2-year-old tells the nurse at the well-child clinic, "I am concerned because my child does not like to be cuddled, does not respond when called by name, and does not make eye contact when being fed." What is the priority question for the nurse to ask when completing the health history? 1. "How many words can your child say?" 2. "Is your child potty trained?" 3. "What are your child's favorite foods?" 4. "What kind of toys does your child like to play with?" Rationale The concerns presented by this child's parent are suggestive of a developmental delay and very possibly autism spectrum disorder(ASD). ASD is a complex neurodevelopmental disorder characterized by the onset of abnormal functioning before age 3. The 2 core symptoms of ASD are abnormalities in social interactions and communication (verbal and nonverbal), and patterns of behavior, interests, or activities that can be restricted and repetitive. Social skills, especially communication, are delayed more significantly than other developmental functioning and are the focus during client assessment. The vast majority of children diagnosed with ASD lack the acquisition of communication skills during the first 2 years of life. A healthy 2-year-old should have a vocabulary of about 300 words and should be able to string 2 or more words together in a meaningful phrase. Assessing this child's language abilities would be the priority. (Option 2) Assessing any 2-year-old's progress in toilet training is appropriate. However, it is not the priority assessment given the parent's concerns. (Option 3) A nutrition assessment is part of every well-child visit, but it is not the priority in this situation. (Option 4) Although not the priority assessment, it would be important to ask the parent about the child's play activities. Children with ASD often have a restricted interest in and preoccupation with a single toy, exhibit repetitive behaviors when playing with the toy, and insist on the same play routine. Educational objective: The 2 core symptoms of autism spectrum disorder are abnormalities in social interactions and communication (verbal and nonverbal), and patterns of behavior, interests, or activities that can be restricted and repetitive. Social skills, especially communication, are delayed more significantly than other developmental functioning. Question: 18 Correct Answer: 3 The nurse is caring for a client after percutaneous placement of a coronary stent for a myocardial infarction. The client reports 5/10 lower back pain and has a blood pressure of 140/92 mm Hg. The cardiac monitor shows normal sinus rhythm with occasional premature ventricular contractions. Which prescription should the nurse administer first? Click on the exhibit button for additional information. 1. Captopril PO every 8 hours 2. Morphine IV PRN for pain 3. Potassium chloride IV once 4. Regular insulin subcutaneous with meals Rationale Clients with myocardial infarction (MI) are at risk for life-threatening dysrhythmias (eg, heart block, ventricular tachycardia, ventricular fibrillation) both during the MI and following reperfusion therapy (eg, coronary artery stenting). Myocardial ischemia damages cardiac muscle cells, causing electrical irritability (eg, premature ventricular contractions) that can be exacerbated by electrolyte imbalances (eg, hypokalemia). Hypokalemia hyperpolarizes cardiac electrical conduction pathways, increasing the risk for dysrhythmias. Therefore, prompt potassium replacement is the priority in these clients (Option 3). (Option 1) ACE inhibitors (eg, captopril, enalapril) reduce blood pressure and cardiac workload, inhibit ventricular remodeling, and reduce the risk of future MIs. However, dysrhythmias pose a higher risk to the client. (Option 2) Administering morphine is an appropriate intervention to address the client's back pain, but it is not a priority. (Option 4) Strict glycemic control in the resolution phase of an acute MI is associated with better long-term outcomes (eg, reduced morbidity/mortality), but it does not take priority at this time. Educational objective: Prompt potassium replacement is the priority action for hypokalemic clients with myocardial infarction because they are at increased risk for life-threatening dysrhythmias (eg, heart block, ventricular tachycardia, ventricular fibrillation) and cardiac arrest. Question: 19 Correct Answer: 2 The health care provider (HCP) prescribes paroxetine to a client with depression. What statement by the client indicates proper understanding of the medication? 1. "I can discontinue the medication if my symptoms improve." 2. "I need a healthy diet and regular exercise to combat weight gain." 3. "If I don't feel better in 1-2 weeks, then the medication is not working." 4. "This medication might increase my sexual performance." Rationale Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) often prescribed for major depression and anxiety disorders. Other SSRIs include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), and sertraline (Zoloft). Weight gain is a common side effect of long-term SSRI use. The nurse should teach the client to eat a healthy diet and engage in regular exercise to combat the weight gain. Other major side effects of SSRIs include increased suicide risk (at the beginning of therapy), sexual dysfunction, and serotonin syndrome when taken in excess doses. (Option 1) SSRIs should not be stopped abruptly without discussion with the HCP. Dosages should be gradually tapered before discontinuation to avoid withdrawal symptoms. (Option 3) Most clients will start to see symptom improvement in 1-2 weeks. However, some may take several weeks and require dose adjustments. Clients should continue to take the medication and discuss it with the HCP. (Option 4) SSRIs can cause sexual dysfunction. Clients should notify the HCP for a change of medication or to add medications to increase sexual performance. Educational objective: The major side effects of SSRIs include increased suicide risk (at the beginning of therapy), sexual dysfunction, weight gain, and serotonin syndrome (excess doses). It may take several weeks for the therapeutic effects of SSRIs to begin; they should never be discontinued abruptly. Question: 20 Correct Answer: 4 A charge nurse is monitoring a newly licensed registered nurse. What action by the new nurse would warrant intervention by the charge nurse? 1. Administers hydromorphone 1 mg to a client who rates pain at 7 on a 1 to 10 scale 2. Notifies physician of occasional premature ventricular beats in a client with myocardial infarction 3. Positions a postoperative pneumonectomy client on the affected side 4. Prepares to administer IVPB potassium chloride via gravity infusion for a client with hypokalemia Rationale Treatment of hypokalemia may require an IV infusion of potassium chloride (KCL). The infusion rate should not exceed 10 mEq/hr(10 mmol/hr). Therefore, IVPB KCL must be given via an infusion pump so the rate can be regulated. IV KCL should be diluted and never given in a concentrated amount. Furthermore, too rapid infusion can cause cardiac arrest. The charge nurse would need to intervene if the new nurse was attempting to administer IVPB KCL via gravity infusion instead of a pump. (Option 1) Hydromorphone is indicated for moderate to severe pain. A pain rating of 7 would warrant its administration. (Option 2) Occasional premature ventricular contractions (PVCs) in the normal heart are not significant. PVCs in the client with coronary artery disease or myocardial infarction indicate ventricular irritability and may lead to life-threatening dysrhythmia such as ventricular tachycardia. (Option 3) With the complete removal of the lung in a pneumonectomy, the client should be positioned on the surgical side to promote adequate expansion and ventilation of the remaining lung. Educational objective: IV infusion of potassium must be administered via a pump to prevent too rapid infusion, which could cause cardiac arrest. Question: 21 Correct Answer: 3 A client with chronic kidney disease has received a continuous intravenous infusion of heparin for 5 days. The nurse reviews the coagulation studies and the medication administration record. Which prescription would the nurse question? 1. Epoetin 2. Sodium polystyrene sulfonate 3. Vitamin K 4. Warfarin Rationale Vitamin K (phytonadione) is a fat-soluble vitamin that is administered as an antidote for warfarin-related bleeding. This medication prescription should be questioned as vitamin K reverses the anticoagulant effect of warfarin, and the client's coagulation studies are in the therapeutic range (aPTT 46-70 sec, INR 2-3). (Option 1) Epoetin (Procrit) is a synthetic hormone that stimulates the production of erythropoietin and is used to treat anemia associated with chronic kidney disease. This is an appropriate prescription. (Option 2) Sodium polystyrene sulfonate (Kayexalate) is a sodium exchange resin administered to reduce elevated serum potassium levels in clients with chronic kidney disease and hyperkalemia. This is an appropriate prescription for this client. (Option 4) Warfarin (Coumadin) is a vitamin K antagonist used for long-term anticoagulation that is started about 5 days before a continuous heparin infusion is discontinued. An overlap of the parenteral and oral anticoagulant is required for about 5 days as this is the time it takes warfarin to reach therapeutic level. This is an appropriate prescription for this client. Educational objective: Anticoagulants stop thrombus formation by interfering with the coagulation cascade. Parenteral heparin and oral warfarin affect the clotting cascade differently; therefore, a 5-day overlap for the 2 drugs is required. This allows warfarin to reach a therapeutic level before the continuous heparin infusion is stopped. Question: 22 Correct Answer: A 3-month-old client has stopped breathing. Identify the area where the nurse should check the client's pulse. Rationale The American Heart Association's guidelines for infant cardiopulmonary resuscitation (CPR) are used on children age <1 year. To check a pulse on an infant, the nurse should palpate the brachial artery by placing 2 or 3 fingers halfway between the shoulder and elbow on the medial aspect of the arm. The pulse should be assessed for 5-10 seconds to determine its presence and quality before CPR is initiated. The brachial pulse is preferred in infants as the brachial artery is close to the surface and is easily palpable. The carotid pulse can be difficult to assess due to a child's shorter neck. Extending an infant's neck to attempt to palpate the carotid pulse can cause injury. This pulse is recommended for clients age >1 year. The femoral pulse may be used for all clients; however, it is often not easily accessible for palpation due to diapers and clothing. The radial pulse is used in responsive clients age >1 year. It is not a recommended method of pulse detection in an unresponsive client as a weak or thready pulse is difficult to palpate at this location. Educational objective: According to the infant cardiopulmonary resuscitation guidelines of the American Heart Association, the brachial artery is used to detect a pulse in an unresponsive client age <1 year. Question: 23 Correct Answer: 4 Which client should the nurse assess first? 1. Client with atrial fibrillation with a new prescription for warfarin 2. Client with chronic obstructive pulmonary disease with an oxygen saturation of 91% 3. Client with postoperative pain rated 8 out of 10 4. Client with third-degree heart block with a pulse of 42/min Rationale Third-degree atrioventricular (AV) block, or complete heart block, occurs when electrical conduction from the atria to the ventricles is blocked, causing decreased cardiac output (eg, dizziness, syncope, mental status changes, heart failure, hypotension, bradycardia). The client with third-degree AV block is a high priority, as the client may decompensate to cardiogenic shock and even periods of asystole. Treatment includes administration of atropine and temporary pacing (eg, transcutaneous) until a permanent pacemaker can be placed. (Option 1) Atrial fibrillation puts clients at risk for development of atrial thrombi, which can embolize and cause a stroke. Administration of warfarin (a long-term anticoagulant) is important to prevent thrombus formation; however, symptomatic third-degree AV block is a higher priority. (Option 2) Clients with chronic obstructive pulmonary disease often have pulse oximetry readings that are lower than normal (eg, 91%). The goal in this client population is to keep the oxygen saturation >90%. (Option 3) The client experiencing severe postoperative pain should be assessed for surgical complications (eg, infection), and the pain should be treated (eg, with hydrocodone). However, severe pain does not take priority over third-degree AV block. The nurse can see the client as soon as possible or ask another nurse for help. Educational objective: Clients with third-degree atrioventricular (AV) block should be assessed immediately due to the potential for life-threatening consequences (eg, shock, syncope, asystole) caused by decreased cardiac output and severe bradycardia. The client with third-degree AV block requires a permanent pacemaker. Question: 24 Correct Answer: 4 Which client is most appropriate for the charge nurse in the postpartum unit to assign to the float nurse from the intensive care unit? 1. Client experiencing fever and pain with mastitis 2. Client preparing for discharge after cesarean birth 3. Client showing disinterest in caring for the newborn 4. Client with hysterectomy after postpartum hemorrhage Rationale The client with blood loss leading to a hysterectomy would require close observation of hemodynamic status. Signs could be subtle, and the nurse floating from the intensive care unit would have the assessment skills needed to recognize any changes. (Option 1) Mastitis is a very painful infection. A postpartum nurse would be most familiar with the comfort measures associated with mastitis. (Option 2) A client preparing for discharge after cesarean birth would require an experienced postpartum nurse as discharge instructions would involve teaching related to both the newborn and the client. (Option 3) Psychosocial adjustment after giving birth can be complex. An experienced postpartum nurse would be trained to assess for signs of adjustment issues. Educational objective: Float nurses should be assigned to clients who most reflect the client population with which they are familiar. Safety is a priority when making client assignments. Question: 25 Correct Answer: 4 The long-term care nurse is caring for a client diagnosed with macular degeneration. Which client statement supports this diagnosis? 1. "I have been seeing small flashes of light." 2. "I have trouble threading my sewing needle. I have to hold it far away to see it." 3. "I notice that my peripheral vision is becoming worse." 4. "I see a blurry spot in the middle of the page when I read." Rationale Macular degeneration is a progressive, incurable disease of the eye in which the central portion of the retina, the macula, begins to deteriorate. This deterioration causes distortion (blurred or wavy visual disturbances) or loss of the central field of vision, whereas the peripheral vision remains intact (Option 4). Macular degeneration has two different etiologies. "Dry" macular degeneration involves ischemia and atrophy of the macula that results from blockage of the retinal microvasculature. "Wet" macular degeneration involves the abnormal growth of new blood vessels in the macula that bleed and leak fluid, eventually destroying the macula. Progression of macular degeneration may be slowed with smoking cessation, intake of specific supplements (eg, carotenoids, vitamins C and E), laser therapy, and injection of antineoplastic medications. Risk factors for macular degeneration include advanced age, family history, hypertension, smoking, and long-term poor intake of carotenoid-containing fruits and vegetables. (Option 1) Seeing small flashes of light is associated with retinal detachment. (Option 2) Inability to see things close up, known as presbyopia, occurs when the lens of the eye becomes less elastic with age and therefore unable to adjust to near and far vision. (Option 3) Poor peripheral vision, also called tunnel vision, can result from optic nerve damage seen in glaucoma. Educational objective: Macular degeneration is a progressive, incurable eye disease that occurs when the central portion of the retina deteriorates, giving rise to distortion (blurred or wavy visual disturbances) or loss in the center of the visual field. Question: 26 Correct Answer: 3 A nurse is teaching a postpartum client about cord care for the newborn. Which statement by the client indicates a need for further teaching? 1. "I can expect the cord to turn black in a few days." 2. "I should let the cord fall off by itself, in about 1-2 weeks." 3. "I should use a cotton swab to gently apply alcohol to the cord." 4. "I will fold the diaper below the cord to allow the cord to dry." Rationale The primary goal of cord care is to keep the cord stump clean and dry to facilitate healing and reduce infection risk. Additional teaching points regarding cord care include: • Keep the cord stump open to air when possible to allow for adequate drying. • Do not apply antiseptics (eg, alcohol, triple dye, chlorhexidine) to the cord stump, which can cause skin irritation (Option 3). • Report any signs of infection (eg, redness, purulent drainage, swelling) to the health care provider. (Option 1) The umbilical cord is usually clamped and cut a few minutes after birth. The clamp is left in place until the cord begins to dry, usually around 24 hours after birth. The remaining cord stump begins to shrivel and turn black in 2-3 days. (Option 2) The cord usually separates spontaneously from the umbilicus around 1-2 weeks after birth. Parents should be instructed to not pull on the cord stump or attempt to hasten cord separation, which could result in bleeding or other complications. (Option 4) The diaper should be folded below the cord to keep the cord dry and prevent contamination with urine or feces. Educational objective: The primary goal of cord care is to keep the cord stump clean and dry. Parents should keep the umbilical area dry, not apply antiseptics to the stump, and report any signs of infection. Question: 27 Correct Answer: 2 An emergency department nurse is assigned to triage. Which client should the nurse assess first? 1. Five-year-old with a superficial leg laceration 2. Lethargic 3-month-old with diarrhea for the past 12 hours 3. Seven-year-old with a elevated temperature of 101 F (38.3 C) and hematuria 4. Seventeen-year-old with severe, acute abdominal pain Rationale Triaging clients involves decision-making about whose needs/problems are most urgent and create the greatest risk to survival. Two popular frameworks can assist the nurse in making these decisions and setting priorities. In the "First, Second, and Third" priority level framework, the priority needs progress from the first (most immediate) to the third (least) level of risk. They include: 1. ABCs plus V – airway, breathing, circulation, and vital signs 2. Mental status changes, acute pain, unresolved medical issues, acute elimination problems, abnormal laboratory values, and risk 3. Longer-term issues such as health education, rest, and coping Maslow's Hierarchy of Needs is a 5-level framework in which the priority needs progress from the bottom to the top level of the pyramid. Infants have a high percentage of body water (70%-80% of body weight) and become dehydrated rapidly. This client is at increased risk for fluid and electrolyte disturbances. In addition, the infant is lethargic (listless), indicating a change in level of consciousness. This client would be assessed first (Option 2). (Option 1) Because this client's laceration is superficial, excessive bleeding is an unlikely risk and is a relatively minor problem. (Option 3) The hematuria and elevated temperature may be associated with a urinary tract infection or glomerulonephritis in this client and do not present an immediate threat to survival. (Option 4) Acute abdominal pain can be a medical emergency that could indicate appendicitis, ovarian cyst, ectopic pregnancy, ureteral colic, or bowel obstruction. This client would be seen second. Educational objective: The "First, Second, and Third" priority level framework is used in emergency and nonemergency settings to prioritize client needs from the highest to the lowest level of risk as follows: 1. ABCs plus V – airway, breathing, circulation, and vital signs 2. Mental status changes, acute pain, unresolved medical issues, acute elimination problems, abnormal laboratory values, and risks 3. Longer-term issues such as health education, rest, and coping Question: 28 Correct Answer: 1 The nurse is triaging clients from the waiting room. The care of which client is a priority? 1. 2-year-old who ingested a button battery approximately 30 minutes ago and is asymptomatic 2. 4-year-old who started crying and suddenly won’t use the left arm after being swung by the arms 3. Child with cerebral palsy and a baclofen pump who has increased muscular spasms 4. Child with osteogenesis imperfecta who walks in reporting being hit on the front of the head with a baseball Rationale Foreign body aspiration can be life-threatening depending on the object's location, type, and size. Up to 50% of children with foreign body ingestion are asymptomatic at the beginning. Alkaline batteries can be corrosive to the esophageal and intestinal mucosa; if ingested, they must be removed emergently by endoscopy as perforation can occur. (Option 2) This client likely has nursemaid's elbow due to the mechanism (swinging by the arms) by which the injury occurred. This condition is common in children and characterized by a subluxation of the radial head. It can seem like an urgent condition due to the suddenness of the child's inability to use the arm. A simple reduction of the arm by a health care provider should reposition the radial head. (Option 3) Clients with cerebral palsy commonly have an implanted baclofen pump to help control muscle spasms. Increased spasms indicate a possible problem with the pump, such as infection or displacement. Baclofen should not be stopped abruptly. This client needs prompt evaluation, but the condition is not immediately life-threatening. (Option 4) Osteogenesis imperfecta (imperfect bones) is a condition in which bones are brittle and fracture easily. Head trauma indicates a possible skull fracture and alerts the need to assess for intracranial hemorrhage. This child is walking, and so bleeding is unlikely. However, the child should be examined for fracture. Educational objective: Foreign body aspiration can be life-threatening. Alkaline battery ingestion can cause corrosive (caustic) damage to the esophagus and intestine and result in perforation. Therefore, batteries must be removed emergently by endoscopy. Question: 29 Correct Answer: 4 The nurse in the emergency department receives report on 4 clients. Which client should be seen first? 1. 5-year-old with an accidental epinephrine auto-injector stick and a heart rate of 124/min 2. 7-year-old who is crying, has vaginal lacerations and bruising, and has a heart rate of 118/min 3. 10-year-old with a large, draining abscess on the left buttock and a temperature of 101.2 F (38.4 C) 4. 14-year-old who is lethargic after playing a football game and has a temperature of 104.1 F (40.1 C) Rationale Heatstroke occurs when excessive environmental heat exposure and/or overexertion (eg, athletics) cause hyperthermia and depletion of fluid and electrolytes (sweating, increased respirations), specifically sodium. Eventually, hypothalamic thermoregulation fails and sweat production stops, causing a rapid elevation of core temperature. Symptoms include: • Temperature ≥104 F (40 C) • Hot, dry skin • Hemodynamic instability (tachycardia, hypotension) • Altered mental status/neurological symptoms (confusion, lethargy, coma) Risk for permanent neurological injury or death from heatstroke is related directly to the degree and duration of hyperthermia. Treatment involves stabilization of ABCs and rapid cooling interventions (eg, cool water immersion, cool IV fluid infusion). Antipyretics are ineffective as hyperthermia is unrelated to the inflammatory process (infection). (Option 1) Epinephrine auto-injectors (eg, EpiPen) for emergency treatment of allergic reactions can be accidentally injected, potentially causing adverse effects related to adrenergic activation (eg, tachycardia and hypertension). This client requires monitoring and supportive care (eg, antihypertensive medications). (Option 2) A child with vaginal lacerations requires evaluation for possible sexual abuse (ie, physical examination, evidence collection, mandatory reporting). This client needs treatment but is not the priority. (Option 3) An abscess requires treatment with antibiotics and, possibly, surgical intervention. However, this client is presently stable and not the priority. Educational objective: Heatstroke is a medical emergency characterized by a body temperature ≥104 F (40 C); hot, dry skin; tachycardia and hypotension; altered mental status; and neurological dysfunction. Clients require rapid cooling interventions to decrease the risk of permanent neurological injury or death. Question: 30 Correct Answer: 3 The charge nurse is making assignments for the oncoming shift. Which client assignments should be avoided by the nurse who is pregnant? 1. 2-year-old client who is combative on postoperative day 2 for tonsillectomy and adenoidectomy 2. 5-year-old client admitted for dehydration secondary to severe throat pain associated with group A Streptococcus 3. 9-year-old client with parvovirus B-19 infection admitted for observation after a febrile seizure 4. 14-year-old client with acute lymphocytic leukemia who received intrathecal chemotherapy 4 days ago and was admitted for a blood transfusion Rationale Parvovirus B-19 is a common childhood infection also known as "fifth disease." Infected clients display a characteristic "slapped cheek" rash on the face. Symptoms range in severity; however, most children do not require intervention. Transmission of the infection is usually through person-to-person contact, especially with respiratory secretions. Although rare, infection with parvovirus B-19 during pregnancy can cause fetal anomalies (eg, hydrops fetalis, stillbirth). It is recognized as a TORCH infection (Toxoplasmosis, Other [parvo-B19/varicella zoster], Rubella, Cytomegalovirus, Herpes simplex virus), a group of infections that cause fetal abnormalities. Delegation of this client to a pregnant nurse is inappropriate due to potential harm to the fetus. (Option 1) A combative toddler should not be a hazard to the pregnant nurse. Appropriate precautions should be taken to ensure safety around combative clients. (Option 2) Group A Streptococcus infection requires droplet precautions; however, it does not pose a perinatal infection risk. Group A Streptococcus may manifest as sore throat. (Option 4) Extreme caution should be taken while handling cytotoxic medications; however, intrathecal administration days prior to contact should not pose a risk to the pregnant nurse. The nurse should use standard precautions if contact with the client's blood or bodily fluids is anticipated. Educational objective: Clients with infectious diseases that can be transmitted to the fetus (eg, TORCH infections) should not be assigned to a pregnant nurse. These infections, including parvovirus B19, can cause severe anomalies in the developing fetus. Question: 31 Correct Answer: 2 The nurse is reviewing new laboratory values. Which client would be the priority to report to the health care provider? 1. Client 2 days after a hip arthroplasty with a white blood cell count of 12,000/mm3 (12x109/L) 2. Client admitted for cocaine overdose with a creatine kinase of 30,000 U/L (501 μkat/L) 3. Client admitted for end-stage renal disease with a creatinine of 3.6 mg/dL (274.5 mmol/L) 4. Client in heart failure exacerbation with a brain natriuretic peptide of 600 pg/mL (600 pmol/L) Rationale Rhabdomyolysis occurs when muscle tissue is damaged and myoglobin (protein found in muscle tissue) is released into the blood, usually after an injury from overexertion, dehydration, severe vasoconstriction (eg, cocaine use), heat stroke, or trauma. Acute kidney injury can occur when myoglobin overwhelms the kidneys' filtration ability. As myoglobin is excreted, the urine becomes very dark and is described as being a cola-brown color. Severely elevated creatine kinase levels, typically >15,000 U/L (>250 μkat/L), are observed with severe muscle damage and can be a precursor to kidney injury (Option 2). Forced saline diuresis with intravenous fluids (to prevent blockage of the renal tubules with myoglobin) is necessary to prevent permanent kidney damage. (Option 1) Postoperative leukocytosis (leukocytes >11,000 mm3 [>11X109/L]) is common in the first 48 hours after orthopedic surgery from normal inflammatory immune responses. (Option 3) Clients with end-stage renal disease commonly have elevated creatinine and blood urea nitrogen levels. These are expected findings. (Option 4) Increased brain natriuretic peptide levels can indicate stretching of the chambers of the heart in heart failure. Levels >100 pg/mL (>100 pmol/L) can indicate heart failure and would be expected in this client. Educational objective: Rhabdomyolysis occurs when large amounts of muscle tissue break down and is associated with elevated creatine kinase levels, myoglobinemia, and myoglobinuria. Acute kidney injury, a complication of rhabdomyolysis, can be prevented by prompt administration of intravenous fluids. Question: 32 Correct Answer: 2 The nurse is caring for a client who had surgery yesterday. When administering omeprazole, the client asks "What is that for? I don't take it at home." Which reply by the nurse is most appropriate? 1. "Omeprazole helps prevent nausea by making your stomach empty faster." 2. "Omeprazole helps prevent you from developing an ulcer due to the stress of surgery." 3. "Omeprazole protects you from getting an infection while on antibiotics." 4. "This medication will treat your gastroesophageal reflux disease (GERD)." Rationale Omeprazole is a proton pump inhibitor (PPI) that suppresses the production of gastric acid by inhibiting the proton pump in the parietal cells of the stomach. In most hospitalized clients without a history of GERD or ulcers, PPIs are prescribed to prevent stress ulcers from developing during surgery or a major illness. Although evidence has shown that two-thirds of clients who receive PPIs do not need them, these medications are still widely prescribed in hospitalized clients. PPIs can be identified by their "- prazole" ending (eg, pantoprazole, lansoprazole, esomeprazole). (Option 1) Metoclopramide (Reglan) is not a PPI. It decreases postoperative nausea by promoting gastric emptying. (Option 3) PPIs may be associated with an increased risk of Clostridium difficile infection with antibiotic use. (Option 4) The client does not take this medication at home. The nurse is assuming that the client has a history of GERD rather than assessing for this condition first. Educational objective: PPIs such as omeprazole are often prescribed to hospitalized clients without GERD or ulcers to prevent stress ulcers from developing during surgery or a major illness. Question: 33 Correct Answer: 890 The nurse cares for a client receiving intermittent peritoneal dialysis who is prescribed strict intake and output monitoring with calculation of net fluid balance each shift. Calculate the total net fluid balance for the shift. Record the answer using a whole number. Rationale Peritoneal dialysis allows waste products to be removed from the bloodstream through the semipermeable membrane of the peritoneum. Dialysate (ie, dialysis fluid) is infused into the peritoneal cavity, retained for a prescribed dwell time (eg, 20 minutes), and then drained as dialysate outflow. For clients on peritoneal dialysis, fluid balance should be tracked closely with daily weights and strict intake and output monitoring. Net fluid balance is calculated by subtracting total output from total intake. The following steps are used to calculate the net fluid balance: 1. Calculate total intake o Oral intake: 240 mL+120 mL+180 mL=540 mLOral intake: 240 mL+120 mL+180 mL=540 mL o Parenteral intake: 150 mL+100 mL=250 mLParenteral intake: 150 mL+100 mL=250 mL o Other intake: 1500 mLOther intake: 1500 mL o Total intake: 540 mL oral+250 mL parenteral+1500 mL dialysate=2290 mLTotal intake: 540 mL oral+250 mL parenteral+1500 mL dialysate=2290 mL 2. Calculate total output o Total output: 1400 mL dialysate outflowTotal output: 1400 mL dialysate outflow 3. Calculate the net fluid balance o Total intake−total output=net fluid balanceTotal intake-total output=net fluid balance o 2290 mL−1400 mL=890 mL2290 mL-1400 mL=890 mL Educational objective: For clients on peritoneal dialysis, fluid balance should be tracked closely with daily weights and strict intake and output monitoring. Net fluid balance is calculated by subtracting total output from total intake. Question: 34 Correct Answer: 3 A client is brought to the emergency department after his face slammed into a brick wall during a gang fight. Which client assessment finding is most important for the nurse to consider before inserting a nasogastric tube? 1. An ecchymotic area on the forehead 2. Frontal headache rated as 10 on a 1-10 scale 3. Nasal drainage on gauze has a red spot surrounded by serous fluid 4. Small amount of bright red blood oozing from cheek laceration Rationale Cerebrospinal fluid (CSF) rhinorrhea (or CSF otorrhea) can confirm that a skull fracture has occurred and transversed the dura. If the drainage is clear, dextrose testing can determine if it is CSF. However, the presence of blood would make this test unreliable as blood also contains glucose. In this case, the halo/ring test should be performed by adding a few drops of the bloodtinged fluid to gauze and assessing for the characteristic pattern of coagulated blood surrounded by CSF. Identification of this pattern is very important as CSF leakage places the client at risk for infection. The client's nose should not be packed. No nasogastric or oral gastric tube should be inserted blindly when a basilar skull fracture is suspected as there is a risk of penetrating the skull through the fracture site and having the tube ascend into the brain. These tubes are placed under fluoroscopic guidance in clients with such fractures. (Option 1) A bruise is an expected finding after direct trauma. It would be a concern if the ecchymosis were around the eyes (periorbital, "raccoon eyes") or postauricular (Battle's sign) as this generally indicates a basilar skull fracture, a tear in the dura, and a potential CSF leak. (Option 2) A headache is an expected finding after trauma. It would be a concern if it were unrelieved by non-narcotic analgesics or accompanied by signs of increased intracranial pressure. (Option 4) The head is highly vascular and it is not unusual to have blood oozing after trauma. This is not as concerning as a potential CSF leak. However, it can become a problem if the nurse is unable to eventually stop the bleeding as substantial total blood loss is a concern. Educational objective: A nasogastric tube should not be inserted when a basilar skull fracture is suspected. CSF leakage is an indication of this and can be evidenced by a positive halo/ring test of the blood-tinged nasal drainage (coagulated blood surrounded by CSF). Question: 35 Correct Answer: 3 The nurse enters a client's room and finds that the client and spouse are crying. The spouse states that the health care provider just diagnosed the client with Alzheimer disease. What is the best response by the nurse? 1. "Do you have any questions about the diagnosis?" 2. "There are medications available to treat Alzheimer disease." 3. "This new diagnosis must be frightening for you." 4. "We can help you make decisions about your care." Rationale Reflecting is a therapeutic communication technique that reiterates the feeling, idea, or message conveyed by the client. Therapeutic communication encourages the client and family to express feelings and thoughts, increases the nurse's understanding, and conveys support. Emotional expression is an important part of the coping process for the client and family. The nurse provides support by expressing empathy, actively listening, and encouraging open communication. Nontherapeutic responses can block communication by shifting the receiver's focus away from the expression of feelings and thoughts. (Option 1) Questions or statements that prevent the client from expressing feelings (eg, changing the subject) when a client and family are trying to cope with a new diagnosis are not therapeutic and can block communication. Once the nurse understands the client's thoughts and feelings, information can be provided. (Option 2) Providing false reassurance is not therapeutic and can block communication. A client and family may not fully understand the progression of Alzheimer disease immediately after receiving the diagnosis. Stating that medications are available to treat the disease may lead to a false belief that it can be cured. (Option 4) A client diagnosed with Alzheimer disease may need assistance with care planning, but the nurse should first support the process of coping when the client receives the life-changing diagnosis. Educational objective: When clients and families are faced with significant life changes, the nurse should support the process of coping by encouraging emotional expression. The nurse provides support by expressing empathy, actively listening, and encouraging therapeutic communication. Question: 36 Correct Answer: 3 The nurse is caring for a client with asthma exacerbation. Blood pressure is 146/86 mm Hg, pulse is 110/min, and respirations are 32/min. The respiratory therapist administers nebulized albuterol as prescribed. One hour after the treatment, the nurse assesses which finding that indicates the drug is producing the therapeutic effect? 1. Constricted pupils 2. Heart rate of 120/min 3. Respirations of 24/min 4. Tremor Rationale Albuterol (Proventil) is a short-acting inhaled beta-2 agonist used to control airway obstruction caused by chronic obstructive pulmonary disease, asthma, or bronchitis. It also is used to prevent exercise-induced asthma. The therapeutic effect is relaxation of the smooth muscles of the airways, which results in immediate bronchodilation. Bronchodilation decreases airway resistance, facilitates mucus drainage (expectorates mucus plugs), decreases the work of breathing, and increases oxygenation. As a result of these actions, the respiratory rate will decrease and peak flow will be increased (if tested). However, short-acting beta-2 agonists are associated with the following side effects (not therapeutic effects): tremor (most frequent), tachycardia and palpitations, restlessness, and hypokalemia. These side effects are due to the oral deposition of medication (subsequent systemic absorption) and can be reduced with the use of a spacer or chamber device. (Option 1) The presence of constricted pupils is neither a side effect nor therapeutic effect of the drug. Constricted pupils are often seen with opioid medications (eg, morphine, oxycodone). Educational objective: Albuterol (Proventil) is a short-acting beta-2 agonist that produces immediate bronchodilation by relaxing smooth muscles. Bronchodilation decreases airway resistance, facilitates mucus drainage, decreases the work of breathing, and increases oxygenation. Peak flow will improve. The most frequent side effects are tremor, tachycardia, restlessness, and hypokalemia. Question: 37 Correct Answer: 2 The nurse is conducting an educational community outreach program on melanoma screening. Which statement by a resident would indicate the need for further education? 1. Abrupt changes in the size or color of a mole are warning signs. 2. All new growths and pigmentations must be biopsied to rule out cancer. 3. Melanoma can occur as any color. 4. Melanoma does not always occur as a new mole. Rationale Client education on early detection of skin cancer is important as most cases of malignant melanoma are discovered by the client. A full medical workup of every mole is unnecessary. Routine self-evaluation followed by medical assessment of questionable growths is sufficient. Clients with advanced age or reduced mobility may need to see a dermatologist for a full-body skin survey. (Option 1) Rapid changes in a mole should be evaluated immediately. (Option 3) Amelanotic melanomas are pink growths similar to basal cell carcinomas of the skin. Blue, white, and red colorations can occur in melanoma. (Option 4) Malignant expansions of previous growths (moles, nevi) are common. Educational objective: Skin cancer screening should cover the basics - uneven, large, blotchy moles, or any sudden changes in mole size or color need to be checked out by a health care provider. Question: 38 Correct Answer: 1 The office nurse instructs a client newly diagnosed with asthma about the use of the peak flow meter to evaluate airflow. Which statement made by the client indicates an understanding of the nurse's teaching? 1. "I will exhale as quickly and forcibly as possible through the mouthpiece of the device to obtain a peak flow reading." 2. "I will move the indicator to the desired reading on the numbered scale before using the device." 3. "I will record my personal best reading, which is the average of 3 consecutive peak flow readings." 4. "I will remember to use the device after taking my fluticasone metered-dose inhaler (MDI)." Rationale The peak flow meter is a hand-held device used to measure peak expiratory flow rate (PEFR) and is most helpful for clients with moderate to severe asthma. Exhaling as quickly and forcibly as possible through the mouthpiece of the device evaluates the degree of airway narrowing by measuring the volume of air that can be exhaled in one breath. Use of the device permits self-management and provides information to guide and evaluate treatment. (Option 2) The client moves the indicator on the numbered scale to 0 or to the lowest number on the scale before using the device. (Option 3) The personal best reading is the highest peak flow reading the client can attain, usually over a 2-week period, when asthma is in good control. (Option 4) The peak flow meter is used after a short-acting bronchodilator rescue MDI to evaluate response, not after a corticosteroid MDI. Educational objective: The peak flow meter is used to measure PEFR and is most helpful for clients with moderate to severe asthma. A reading is obtained by exhaling as quickly and forcibly as possible through the mouthpiece of the device. Question: 39 Correct Answer: 3 A nurse is caring for a group of clients on a medical surgical unit. Which client is most at risk for contracting a nosocomial infection? 1. 51-year-old client who received a permanent pacemaker 48 hours ago 2. 60-year-old client who had a myocardial infarction 24 hours ago 3. 74-year-old client with stroke and an indwelling urinary catheter for 3 days 4. 75-year-old client with dementia and dehydration who is on IV fluids Rationale A nosocomial infection occurs in a hospital (hospital-acquired) or other health care setting and is not the reason for the client's admission. Many nosocomial infections are caused by multidrug resistant organisms. These infections occur 48 hours or more after admission or up to 90 days after discharge. Clients at greater risk include young children, the elderly, and those with compromised immune systems. Other risk factors include long hospital stays, being in the intensive care unit, the use of indwelling catheters, failure of health care workers to wash their hands, and the overuse of antibiotics. The most common nosocomial infection is urinary tract infection, followed by surgical site infections, pneumonia, and bloodstream infections. The 74-year-old client is most at risk due to age and the presence of the urinary catheter. The nurse will need to be on high alert for this complication and should follow infection control procedures diligently. (Option 1) This client does have a surgical incision, which poses a risk for infection. However, this client is younger and does not have any underlying chronic condition to compromise the immune system. (Option 2) This client does not fall in the category of elderly and has no surgical incision or indwelling catheters other than a possible IV site. (Option 4) This client is at risk due to age and presence of an IV catheter. However, the risk is not as high as the client with the urinary catheter. Educational objective: The nurse should be aware of the risk for nosocomial infections in young children, elderly, and immunocompromised clients, especially those with long hospital stays, indwelling catheters, and surgical incisions. Question: 40 Correct Answer: 2 A client started a 24-hour urine collection test at 6:00 AM. The unlicensed assistive personnel (UAP) reports discarding a urine specimen of 250 mL at 10:00 AM by mistake but adding all specimens to the collection container before and after that time. What action should the nurse take? 1. Add 250 mL to the total output after the 24-hour urine collection is complete tomorrow morning 2. Discard urine and container, and restart the 24-hour urine collection tomorrow morning 3. Discard urine and container, have client void, add urine to new container, and then restart test 4. Relabel the same collection container, and change the start time from 6:00 AM to 10:00 AM Rationale Timed urine collection tests are usually done to assess kidney function and measure substances excreted in the urine (eg, creatinine, protein, uric acid, hormones). These tests require the collection of all urine produced in a specified time period (a crucial step) to ensure accurate test results. The proper container (with or without preservative) for any specific test is obtained from the laboratory. The collection container must be kept cool (eg, on ice, refrigerated) to prevent bacterial decomposition of the urine. Not all of the client's urine was saved during the collection period. Therefore, the nurse or UAP must discard the urine and container and restart the specimen collection procedure. Although a 24-hour urine collection can begin at any time of the day after the client empties the bladder, it is common practice to start the collection in the morning after the client's first morning voiding and to end it at the same hour the next morning after the morning voiding (Option 2). (Option 1) Adding 250 mL to the total output when the test is completed is not an appropriate action as the actual urine output from the 24-hour period is needed for accurate results. (Option 3) To start the collection period, the nurse asks the client to void and discards this specimen (it is not added to the collection container). The 24-hour period starts at the time of the client's first voiding. (Option 4) Relabeling the same container and changing the start time from 6:00 AM to 10:00 AM is not an appropriate action. The container would include part of the urine produced in a 28- hour period, and the test results would be inaccurate. Educational objective: It is common practice to start a 24-hour urine collection test at the time of the client's first voiding in the morning. If any urine is discarded by accident during the test period, the procedure must be restarted. All produced urine should be placed in the same container and kept cool (on ice). Question: 41 Correct Answer: 1 The nurse has received report on the following clients. Which client should the nurse assess first? 1. Client 4 hours postoperative colon resection who has a blood pressure of 90/74 mm Hg 2. Client receiving palliative care who has Cheyne-Stokes respiration with 20-second periods of apnea 3. Client with anemia and hemoglobin level of 7 g/dL (70 g/L) who has a pulse of 110/min after ambulation 4. Client with diabetic ketoacidosis who has rapid, deep respirations at a rate of 32/min Rationale The nurse should first assess the client who had bowel surgery as hypotension can be a manifestation of bleeding, hypovolemia, and early septic shock. The nurse should check vital signs and perform a cardiovascular assessment. (Option 2) Cheyne-Stokes respiration is a repetitive, abnormal, irregular breathing pattern characterized by alternating deep and shallow respirations followed by periods of apnea (10-20 seconds). The pattern is usually associated with certain neurologic conditions (eg, stroke, increased intracranial pressure) and with end of life; it would be expected in this client. (Option 3) Shortness of breath and tachycardia with activity related to decreased hemoglobin level, red cells, and oxygen-carrying capacity would be expected in a client with moderate to severe anemia. (Option 4) Kussmaul breathing is characterized by regular but rapid, deep respirations and is associated with conditions that cause metabolic acidosis (eg, renal failure, diabetic ketoacidosis, shock). Kussmaul breathing would be expected in this client as it is a compensatory action by the lungs to excrete excess acid from the body by hyperventilating, thereby blowing off carbon dioxide (acid gas). Educational objective: Postoperative hypotension can be a manifestation of bleeding, hypovolemia, and sepsis. Changes in vital signs (eg, decreased systolic pressure, tachycardia, tachypnea) and cool, pale skin can indicate decreased cardiac output and altered tissue perfusion Question: 42 Correct Answer: 2 The nurse cares for a client who just had surgical excision and biopsy of a tumor. The biopsy results show that the tumor is malignant, but the client has not yet been informed by the health care provider. The client asks the nurse, "Am I going to die?" Which statement by the nurse is appropriate? 1. "I know how anxious you must be. Watching some television might help you relax." 2. "Tell me more about your thoughts and feelings regarding the situation." 3. "The biopsy result shows that you have cancer, but many cancers are treatable." 4. "Waiting for test results can be stressful. I am sorry I cannot tell you more." Rationale Clients with life-limiting diagnoses often experience anxiety, frustration, and the phases of grief. The nurse must assess the client's knowledge and feelings regarding the illness. Use of therapeutic communication (eg, active listening, reflection, focusing) allows the nurse to determine client needs and strengthens the nurse-client relationship, which is instrumental in helping the client cope with difficult information (Option 2). The health care provider (HCP) should inform the client of biopsy results so that the prognosis and plan of treatment can be discussed. Although a cancer diagnosis may be difficult for the client to receive, a complete, factual discussion of the diagnosis can help the client feel more in control. (Option 1) Indicating knowledge of the client's feelings and changing the subject weaken the nurse-client relationship by making the nurse seem uncomfortable with the situation, minimizing the client's feelings, and disregarding client concerns. (Option 3) The HCP should be involved in informing the client about the biopsy results. It is best that both the HCP and nurse be present to address all questions and concerns the client may have. (Option 4) An automatic response is a nontherapeutic communication technique that deflects the client's feelings, thereby weakening the nurse-client relationship. The nurse should encourage the client to share their thoughts. Educational objective: Clients with life-limiting diagnoses experience anxiety, frustration, and grief as they cope. The nurse should use therapeutic communication (eg, active listening, reflection, focusing) to determine the client's understanding and strengthen the nurse-client relationship before discussing difficult news (eg, new cancer diagnosis). Question: 43 Correct Answer: 4 The nurse is evaluating a client with liver cirrhosis who received IV albumin after a paracentesis to drain ascites. Which assessment finding indicates that the albumin has been effective? 1. Abdominal circumference reduced from admission recording 2. Flapping tremor no longer visible with arm extension 3. Shortness of breath no longer experienced in supine position 4. Vital signs remain within the client's normal parameters Rationale Ascites is the accumulation of fluid in the peritoneal space that often occurs in clients with liver cirrhosis. Ascitic fluid increases abdominal pressure, resulting in weight gain, abdominal distension and discomfort, and shortness of breath. Paracentesis (ie, needle insertion through the abdomen into the peritoneum to remove ascitic fluid) is often performed to reduce symptoms of ascites. However, clients undergoing paracentesis must be monitored closely for hypotension as changes in abdominal pressure often result in systemic vasodilation. Clients may receive IV albumin (a colloid) after paracentesis, which increases intravascular oncotic pressure resulting in increased intravascular fluid volume. Albumin administration prevents hypotension and tachycardia by mitigating hemodynamic changes associated with paracentesis (Option 4). (Options 1 and 3) Decreased abdominal circumference and improved respiratory effort occur in clients with ascites after ascitic fluid is removed via paracentesis. Albumin does not directly reduce ascitic fluid volume. (Option 2) Asterixis (ie, flapping hand tremors during arm extension) occurs due to elevated blood ammonia levels. Lactulose is commonly used to treat asterixis as it promotes ammonia excretion. Albumin does not affect ammonia excretion. Educational objective: Clients undergoing paracentesis to alleviate symptoms related to ascites are at risk for hypotension due to changes in abdominal pressure. IV albumin increases intravascular fluid volume and may be used to prevent hypotension associated with paracentesis. Question: 44 Correct Answer: 3 A client with a permanent pacemaker with continuous telemetry calls the nurse and reports feeling lightheaded and dizzy. The client's blood pressure is 75/55 mm Hg. What is the nurse's priority action? Click the exhibit button for additional information. 1. Administer atropine 0.5 mg IV 2. Administer dopamine 5 mcg/kg/min IV 3. Initiate transcutaneous pacing 4. Notify the health care provider Rational The client is experiencing failure to capture from the permanent pacemaker with subsequent bradycardia and hypotension. Failure to capture appears on the cardiac monitor as pacemaker spikes that are not followed by QRS complexes. Pacemaker malfunction may be caused by a failing battery, malpositioned lead wires, or fibrosis at the tip of lead wire(s) preventing adequate voltage for depolarization. This client is symptomatic (eg, hypotension, dizziness) from insufficient perfusion. The nurse's priority is to use transcutaneous pacemaker pads to normalize the heart rate, stabilize blood pressure, and adequately perfuse organs until the permanent pacemaker is repaired or replaced (Option 3). Administer analgesia and/or sedation as prescribed as transcutaneous pacing is very uncomfortable for the client. (Option 1) Atropine is administered to clients with symptomatic bradycardia; however, this client's symptoms are caused by failure to capture. Therefore, obtaining capture via transcutaneous pacing should resolve the client's symptoms. (Option 2) Dopamine is an inotrope used to treat hypotension due to bradycardia. This client is bradycardic and hypotensive due to failure to capture. If hypotension persists after transcutaneous pacing is initiated, an inotrope may be necessary. (Option 4) The health care provider needs to be notified, but the nurse should first use the transcutaneous pacemaker to stabilize the client. Educational objective: Signs and symptoms of a failing pacemaker include failure to capture (pacer spikes without associated QRS complexes) with bradycardia and hypotension. The nurse should use a transcutaneous pacemaker to stabilize the client until the internal pacemaker can be repaired or replaced Question: 45 Correct Answer: 1 The nurse is caring for the assigned clients on a pediatric inpatient unit. Which client is the priority? 1. 8-year-old with sickle cell crisis who has sudden-onset unilateral arm weakness 2. 11-year-old with viral meningitis requesting pain medication for headache 3. Male child scheduled for surgery for intussusception who has reddish mucoid stool 4. Male child with hemophilia who has hemarthrosis and is receiving desmopressin Rationale Children can have strokes. Ischemic strokes are more common in children with sickle cell disease. Other causes can include carotid abnormalities/dissection. The most common presentation of an ischemic stroke is the sudden onset of numbness or weakness of an arm and/or leg. These are handled with a similar emergent approach as for stroke in an adult. Children may require exchange blood transfusion to prevent the stroke from worsening. (Option 2) Viral meningitis can cause fever, headache, and meningeal signs (neck stiffness). Headache is expected and not a priority over a client with stroke. (Option 3) Intussusception occurs when one portion of the intestine prolapses and then telescopes into another. It is a frequent cause of intestinal obstruction during infancy. Onset is abrupt, initially with pain and brown stool. The condition then progresses to bilious emesis, palpable abdominal mass, and stools with a red, "currant jelly" appearance due to blood and mucus. This is an expected finding for this condition, and surgery is already scheduled to address it. (Option 4) Hemophilia is seen primarily in males and is due to a lack of clotting factors. Symptoms include spontaneous bleeding (hemarthrosis) into the joints, especially the knee, ankle, or elbow. Treatment includes replacing the missing clotting factor. Desmopressin (DDAVP) stimulates the release of factor VIII. The child is receiving treatment already and joint rest has been prescribed. The sudden neurological change in the child with sickle cell crisis is a priority. Educational objective: Children can have strokes. These usually are caused by clotting or vascular issues and require similar emergent care as adults. Desmopressin (DDAVP) is used to treat hemophilia. Question: 46 Correct Answer: 3 The nurse is caring for a client with a history of tonic-clonic seizures. After a seizure lasting 25 seconds, the nurse notes that the client is confused for 20 minutes. The client does not know the current location, does not know the current season, and has a headache. The nurse documents the confusion and headache as which phase of the client's seizure activity? 1. Aural phase 2. Ictal phase 3. Postictal phase 4. Prodromal phase Rationale A seizure is an uncontrolled electrical discharge of neurons in the brain that interrupts normal function. Seizure manifestations generally are classified into 4 phases: 1. The prodromal phase is the period with warning signs that precede the seizure (before the aural phase). 2. The aural phase is the period before the seizure when the client may experience visual or other sensory changes. Not all clients experience or can recognize a prodromal or aural phase before the seizure. 3. The ictal phase is the period of active seizure activity. 4. During the postictal phase, the client may experience confusion while recovering from the seizure. The client may also experience a headache. Postictal confusion can help identify clients by differentiating seizures from syncope. In syncope, there will be only a brief loss of consciousness without prolonged post-event confusion. Educational objective: Clients may experience confusion after a seizure during the postictal phase. The client should be observed for safety and abnormalities documented before and during this phase. Question: 47 Correct Answer: 3 A client is seen in the clinic for the third time for a nonhealing, infected diabetic foot ulcer. The client is able to verbalize the correct procedure for wound care but reports not adhering to the ordered routine at home. What intervention does the nurse prioritize to promote proper self care? 1. Assess the client's feelings about placement at a skilled nursing facility for care 2. Educate the client on the risks of tissue death if not properly cared for at home 3. Explore the client's abilities and motivation to perform care at home 4. Provide the client with the supplies needed to change dressings as recommended Rationale Self care is a critical component of health. However, barriers to self care are multifactorial, and include: • Knowledge (lack of experience, cognitive abilities) • Skills/supplies (lack of dexterity, experience, financial barriers) • Motivation (lack of assumed threat to health, denial, hopelessness) The nurse must assess for adequate knowledge and ability to perform self-care activities and the desire to complete such activities (Option 3). Once the barriers have been identified, the nurse can work with the client to create an individualized plan to meet health care needs. (Option 1) Without understanding the barriers to self care, the nurse cannot identify proper resources to assist the client in meeting needs. Placement for skilled nursing may be excessive for a client who lives independently. (Option 2) Education on tissue death may be perceived as threatening and not therapeutic. (Option 4) Financial resources or supplies may not be the barrier; therefore, this intervention may not effectively assist the client in performing self care successfully. Educational objective: The nurse must assess a client's knowledge, skills, and motivation to identify barriers to self care. Through this identification, the nurse can help develop an individualized plan to meet health care needs. Question: 48 Correct Answer: 1 A client with massive trauma and possible spinal cord injury is admitted to the emergency department following a dirt bike accident. Which clinical manifestation does the nurse assess to help best confirm a diagnosis of neurogenic shock? 1. Apical heart rate 48/min 2. Blood pressure 186/92 mm Hg 3. Cool, clammy skin 4. Temperature 100 F (37.7 C) tympanic Rationale Neurogenic shock belongs to the group of distributive (vasodilatory) shock. It affects the vasomotor center in the medulla and causes a disruption in the sympathetic nervous system (SNS); the parasympathetic nervous system (PNS) remains intact. The imbalance of activity between the SNS and PNS results in massive vasodilation and pooling of blood in the venous circulation, causing hypotension and bradycardia, the characteristic manifestations of neurogenic shock. (Option 2) Hypotension, not hypertension, is characteristic of neurogenic shock. (Option 3) Warm, dry skin is more likely to be present in neurogenic shock; cool, clammy skin is not a characteristic manifestation. (Option 4) Although thermoregulation may be impaired (poikilothermia) in neurogenic shock, a low-grade temperature of 100 F (37.7 C) is not a characteristic manifestation. Educational objective: Neurogenic shock (a form of distributive shock) causes a disruption in the function of the sympathetic, but not parasympathetic, nervous system. Bradycardia, a characteristic manifestation of neurogenic shock, occurs as a result of this alteration in neural activity between the 2 systems. Question: 49 Correct Answer: 3 The nurse is educating a client newly diagnosed with rheumatoid arthritis about the disease process and home management. Which statement by the client indicates comprehension of teaching? 1. "Even with appropriate treatment joint damage and disability are inevitable." 2. "My arthritis can be resolved if I can improve my diet and lose weight." 3. "My methotrexate should be taken even when my joints aren't hurting." 4. "When my joints hurt, I should rest frequently and try not to move them." Rationale Rheumatoid arthritis (RA) is a chronic, relapsing autoimmune disorder causing painful inflammation of synovial joints and fibrosis and stiffening of synovial membranes. Contracture of ligaments and joint remodeling may occur, resulting in weakness and deformity. Clients with RA require education on prevention of disease progression, including: • Joint protection – Fibrosis from RA can shorten tendons and ligaments when joints are flexed for prolonged periods. Body aligners or immobilizers should be used when resting to keep extremities straight (especially with advanced disease). • Medications – RA is often treated using a regimen of disease- modifying antirheumatic drugs (eg, methotrexate), and clients should take their medication as prescribed regardless of symptoms (Option 3). (Option 1) Joint deformity can be prevented with appropriate treatment, including use of disease-modifying antirheumatic drugs and joint protection. (Option 2) Obesity is a risk factor for osteoarthritis, in which mechanical erosion of joint cartilage occurs. However, obesity is unrelated to RA, and clients with RA experience chronic fatigue and pain that may limit oral intake and cause weight loss. The nurse should ensure that clients with RA have access to adequate nutrition. (Option 4) During painful episodes, periods of rest are encouraged; however, clients should frequently perform range of motion exercises to prevent loss of function. Educational objective: Rheumatoid arthritis (RA) is a chronic autoimmune disorder that causes pain and joint deformity. Clients with RA should be taught to remain active to prevent contracture, take immunosuppressant medications consistently, use body aligners to prevent joint contracture, and eat a balanced diet. Question: 50 Correct Answer: 3 When an unlicensed assistive personnel (UAP) assists a client with a chest tube back to bed from the bedside commode, the plastic chest drainage unit accidently falls over and cracks. The UAP immediately reports this incident to the nurse. What is the nurse's immediate action? 1. Clamp the tube close to the client's chest until a new chest drainage unit is set up 2. Notify the health care provider (HCP) 3. Place the distal end of the chest tube into a bottle of sterile saline 4. Position the client on the left side Rationale If the chest tube disconnects from the drainage tubing without contamination, wipe the end of the chest tube with an antiseptic and immediately reconnect it. To prevent accidental disconnection of the chest tube from the tubing, secure all connections with tape or bands, according to hospital policy and procedure. If the chest tube is disconnected with contamination and cannot be immediately reattached, or if the chest drainage unit breaks, cracks, or malfunctions, submerge the distal end of the chest tube 1-2 in (2-4 cm) below the surface of a 250 mL bottle of sterile water or saline. This creates an immediate water seal and prevents air from entering into the pleural space as the new chest drainage system is established (Option 3). To be prepared for this contingency, emergency equipment should be kept at the bedside, which includes 2 chest tube clamps, a 250 mL bottle of sterile water or saline solution, and antiseptic wipes. (Option 1) Unless prescribed by the HCP, chest tube clamping time should not exceed 1 minute as it raises intrapleural pressure and can lead to a tension pneumothorax. Clamping briefly is acceptable when checking for an air leak in the system or when changing the disposable collection unit. (Option 2) It is not necessary to notify the HCP when replacing a chest drainage system unless the client develops respiratory distress. (Option 4) Positioning the client on the left side is appropriate if a central line is inadvertently pulled out so that any air that may have been sucked in will rise to the right atrium. It is not an appropriate intervention for a chest tube disconnection or crack or malfunction in a chest drainage unit. Educational objective: If a chest tube disconnects from the chest drainage system and cannot be reattached quickly, or if a chest drainage unit cracks or malfunctions, submerge the distal end of the chest tube 1-2 in (2-4 cm) below the surface of a 250 mL bottle of sterile water or saline solution. Question: 51 Correct Answer: 4 The nurse reviews laboratory data for a client admitted to the emergency department with chest pain. Which serum value requires the most immediate action by the nurse? 1. Glucose 200 mg/dL (11.1 mmol/L) 2. Hematocrit 38% (0.38) 3. Potassium 3.4 mEq/L (3.4 mmol/L) 4. Troponin 0.7 ng/mL (0.7 mcg/L) Rationale Serum cardiac markers are proteins released into the bloodstream from necrotic heart tissue after a myocardial infarction (MI). Troponin is a highly specific cardiac marker for the detection of MI. It has greater sensitivity and specificity for myocardial injury than creatine kinase (CK) MB. Serum levels of troponin increase 4–6 hours after the onset of MI, peak at 10–24 hours, and return to baseline after 10–14 days. A troponin value of 0.7 ng/mL (0.7 mcg/L) indicates cardiac muscle damage and should be the priority and immediate focus of the nurse. Normal values: troponin I <0.5 ng/mL (<0.5 mcg/L); troponin T <0.1 ng/mL (<0.1 mcg/L). (Option 1) The glucose is elevated (normal random glucose 70-110 mg/dL [3.9-6.1 mmol/L]) but is not the priority in this situation. The nurse will need to assess whether the client has a history of diabetes and time of the last meal. (Option 2) Normal hematocrit for a male is 39%–50% [0.39-0.50] and 35%-47% [0.35-0.47] for a female. The hematocrit value is not the priority. (Option 3) The potassium is slightly below normal (3.5–5.0 mEq/L [3.5- 5.0 mmol/L]). This should be the nurse's second priority. A low potassium level can precipitate dysrhythmias. Educational objective: An elevated troponin value holds the highest priority for intervention when a client is experiencing chest pain. Positive troponin levels are indicative of myocardial injury and require immediate attention by the nurse. Normal values are <0.5 ng/mL (<0.5 mcg/L) for troponin I and <0.1 ng/mL (<0.1 mcg/L) for troponin T. Question: 52 Correct Answer: 3 The nurse is educating a client recently diagnosed with rheumatoid arthritis about home care and symptom management. Which of the following client statements indicates a need for further teaching? 1. "Daily range-of-motion exercises are important to keep my joints flexible." 2. "I can use a moist heat pack to help with joint stiffness." 3. "I should elevate my knees with pillows when I'm sleeping." 4. "I will make sure to rest in between activities throughout the day." Rationale Rheumatoid arthritis (RA) is a chronic, autoimmune disorder characterized by inflammation and damage to synovial joints; progressive fibrosis of joint membranes results in pain, deformity, and stiffness. Over time, remodeling of joint capsules and associated pain reduce the ability to perform activities of daily living (eg, toileting, bathing, dressing) and engage in routine tasks (eg, walking, opening doors). To maximize functional ability and quality of life, the nurse should educate clients with RA about home-care and symptom-management strategies: • Perform gentle range-of-motion exercises daily to maintain joint flexibility (Option 1). • Apply moist heat packs to stiff joints and ice packs to painful joints (Option 2). • Plan frequent rest periods to reduce fatigue and inflammation of affected joints during activities (Option 4). (Option 3) Clients with RA should be instructed to sleep and rest in a flat, neutral position. Body aligners or immobilizers may be used to keep joints straight, but prolonged flexion of joints (eg, elevating knees on pillows) increases the risk of contracture and may hasten decline of joint function. Educational objective: Rheumatoid arthritis, a chronic autoimmune disorder, causes inflammation and remodeling of synovial joints, with progressive loss of functional capacity. Clients should be educated to protect the joints with range-of-motion exercises, allow for periods of rest during activities, use moist heat for stiffness and cold packs for pain, and sleep in a flat, neutral position. Question: 53 Correct Answer: 1 The spouse of an immunocompromised client is diagnosed with influenza virus infection. The spouse asks the office nurse how long contact with the client should be avoided to prevent the infection from spreading. What is the nurse's most appropriate response? 1. "Avoid close contact for about a week." 2. "It's impossible to avoid contact with the client. Just wash your hands often." 3. "You are sick already, and so you are not contagious anymore." 4. "You don't have to worry as long as the client has received the influenza vaccination." Rationale The influenza virus has an incubation period of 1-4 days, with peak transmission starting at about 1 day before symptoms appear and lasting up to 5-7 days after the illness stage begins (Option 1). (Option 2) Influenza is transmitted by inhaling droplets that an infected individual exhales into the air when sneezing, coughing, or speaking. If contact with others is unavoidable, wearing a mask can offer some protection against virus transmission. (Option 3) Individuals with the influenza virus can transmit the virus during the incubation period and illness stage of the infection. It is not appropriate to assume that the spouse can no longer transmit the infection. (Option 4) Although vaccination provides immunity against influenza in about 2 weeks after inoculation, it does not offer complete protection against all virus strains. Therefore, close contact with others should be avoided during the illness stage, especially those with an impaired immune system. Educational objective: Influenza is a highly contagious respiratory infection transmitted by airborne droplets and direct contact. It has an incubation period of 1-4 days, with peak transmission starting at about 1 day before symptoms appear and lasting up to 5-7 days after the illness stage begins. Vaccination does not offer complete protection against all virus strains. Question: 54 Correct Answer: 3 The home care nurse visits the house of an elderly client. Which assessment finding requires immediate intervention? 1. The client cannot remember what was done yesterday 2. The client has a painful red area on the buttocks 3. The client has new dependent edema of the feet 4. The client has strong, foul smelling urine Rationale New onset of dependent edema of the feet could represent congestive heart failure. This is an urgent medical condition that needs prompt evaluation for characteristic signs (eg, weight gain, lung crackles) and treatment. (Option 1) Loss of short-term memory could be an early sign of dementia. It is important to assess clients' mental status to ensure safety in their homes. Further intervention is required, but this condition is not life-threatening. (Option 2) A painful red area on the buttocks represents the beginning stages of a pressure injury. Although not emergent, this does require further intervention. It is important to recognize pressure injuries early and start treatment promptly before they progress to advanced stages. Advanced pressure injuries are more difficult to treat and heal slower in the elderly. (Option 4) Strong, foul smelling urine is likely due to a urinary tract infection. This does require treatment to prevent further complications but is not a priority over suspected heart failure. Urinary tract infections can cause fever with confusion in the elderly. Educational objective: New onset of dependent edema in an elderly client could be due to heart failure; the client needs further assessment for characteristic signs such as lung crackles and increased body weight (fluid retention). Practice Bank 21 Ref # 981 When planning the therapeutic milieu, a nurse should select actions for activity groups with what intent in mind? A. are consistent with clients’ skills B. achieve the clients’ therapeutic goals C. build skills of individual participation in groups D. match the clients’ preferences Answers Correct B Student's B Review Information: The correct answer is B: achieve the clients’ therapeutic goals Learning Objective: Lesson 4 Psychosocial Integrity Activity groups are used to enhance the therapeutic milieu and to meet the clinical and social needs of clients, e.g., to minimize withdrawal and regression, to develop self care skills, etc. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Keltner, N.L., Bostrom, C.E., & Schwecke, L.H. (2006). Psychiatric nursing (5th ed.). St. Louis, MO: Mosby. Ref # 4485 Where should the nurse administer the annual purified protein derivative (PPD) to the client with a left arm Permcath™? Use your cursor to select an area on the image below. Answers Correct Student's Review Information: The correct answer is Learning Objective: Lesson 6 Pharmacological Therapies The arm with the shunt should never be used for anything other than dialysis; therefore, the nurse should administer the PPD in this client's right forearm. The injection site is approximately 2 to 4 inches below the elbow. Ref # 832 A nurse is caring for a client who has been diagnosed with the development of cardiac tamponade. Which finding should the nurse consider as the greatest concern? A. drop in the hourly urine output B. changes in mental status C. weakened, irregular pulses D. decline in the blood pressure readings Answers Correct D Student's D Review Information: The correct answer is D: decline in the blood pressure readings Learning Objective: Lesson 8 Physiological Adaptation In cardiac tamponade, intrapericardiac pressures rise to a point at which venous blood cannot flow into the heart. This leads to a drop in the preload and then the decrease in cardiac output, reflected in blood pressure drops. This is a high priority concern for the nurse. Weakened, irregular pulses, a drop in the urine output and changes in mental status can occur with cardiac tamponade but are secondary in importance to hypotensive trends. Test-taking Tips: If guessing, narrow the options down to the two that are similar but dissimilar. This would lead to the two options that both focus on vital signs. Whereas both answers are appropriate, declining blood pressure would be the cause of weakened pulses. Since declining blood pressure readings must occur first, it must be the answer to this question. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 897 A client is admitted with the diagnosis of testicular cancer. Which of these factors in the client’s history would be associated with the disease? Answers Correct D Student's C A. early age sexual relations B. epididymitis C. seminal vesiculitis D. undescended testis Review Information: The correct answer is D: undescended testis Learning Objective: Lesson 8 Physiological Adaptation A history of undescended testis or cryptorchidism is a known risk factor for testicular cancer. Black, J., & Hawks, J. (2008). Medical surgical nursing: Clinical management for positive outcomes (8th ed.). St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 745 A nurse is asked about chiropractic treatment for illnesses. The nurse should know that it focuses on which approach? A. mind - body balance B. spinal column manipulation C. exercise of joints D. electrical energy fields Answers Correct B Student's B Review Information: The correct answer is B: spinal column manipulation Learning Objective: Lesson 3 Health Promotion and Maintenance The underlying theory of chiropractic medicine is that interference with transmission of mental or electrical impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the subluxation or misalignment. Test-taking Tips: This is a specific question and requires a specific answer. Two of the options are general answers. In narrowing the choices to two options, pay attention to the word “manipulation”and the word "exercise". Return to the question to look for a clue to help with the choices. Focus on the words "treatment for illness" rather than "chiropractic." Go with what is known. An educated guess for "treatment of illness" is more likely to be "manipulation." Berman, A., Snyder, S., Kozier, B., & Erb, G. (2008). Kozier & Erb's fundamentals of nursing: Concepts, process, and practice (8th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 833 A nurse is assigned to a client who develops pulmonary edema and exhibits sudden anxiety, diaphoresis and auditory crackles. Which nursing intervention should be performed first? Answers Correct D Student's D A. give the prescribed diuretic B. instruct the client to deep breathe then clear the airway C. check the client's SpO2 pulse oximetry D. sit the client in an upright position Review Information: The correct answer is D: sit the client in an upright position Learning Objective: Lesson 8 Physiological Adaptation Placing the client in a sitting position enhances lung expansion and decreases the volume of blood to the heart to minimize the acute heart failure. SpO2 assessment is more important in this given situation to evaluate the effectiveness of therapy. Pulmonary edema effects the lower airways, so coughing will not improve the client's airway status. Diuretics will promote clearing of the pulmonary edema once the client is repositioned upright. Test-taking Tips: Ask: what is the problem? In this case, the problem is sudden respiratory distress, which would be associated with shortness of breath. There is only one option that would have an immediate effect on the described observations. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 877 A client who is taking lithium works in lawn maintenance, cutting grass and trimming bushes. The client asks about good snacks to pack during the summer. A nurse should recommend which food? A. watermelon B. pretzels C. yogurt D. applesauce Answers Correct B Student's C Review Information: The correct answer is B: pretzels Learning Objective: Lesson 6 Pharmacological Therapies Activities that cause excess sodium loss, such as sweating and heavy exertion, will cause an increase in lithium levels. Therefore, clients must maintain an adequate intake of sodium to prevent fluctuations in medication levels. Think of a see-saw with one side the down – the sodium loss from sweating – and one side up – the higher levels of lithium. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 742 An 18 month-old child is on peritoneal dialysis in preparation for a renal transplant in the near future. When a nurse obtains the child's health history, the mother indicates that the child has not had the first measles, mumps, rubella (MMR) immunization. The priority nursing action should be based on which understanding? Answers Correct B Student's B A. an inactivated form of the vaccine can be given at any time B. the MMR vaccine should be given now, prior to the renal transplant C. the risk of vaccine side effects precludes giving the vaccine D. live vaccines are withheld in children with chronic renal illness Review Information: The correct answer is B: the MMR vaccine should be given now, prior to the renal transplant Learning Objective: Lesson 3 Health Promotion and Maintenance MMR is a live virus vaccine, and should be given at this time. Posttransplant, immunosuppressive drugs will be given and the administration of the live vaccine at that time would be contraindicated because of the compromised immune system. Test-taking Tips: Two of the options address the timing of giving the vaccine. This makes those two options similar, but dissimilar answers. If guessing, choose one of the similar but dissimilar options. Note: there is only one option where the content of the question (MMR) appears in the answer options. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 876 A client has been receiving lithium (Lithane) for the past two weeks for the treatment of bipolar illness. When reviewing information, what point should a nurse make with the client? A. take a diuretic with lithium B. have blood lithium levels drawn frequently during the summer months C. maintain a low sodium diet D. come in for evaluation of serum lithium levels every 1-3 months Answers Correct B Student's C Review Information: The correct answer is B: have blood lithium levels drawn frequently during the summer months Learning Objective: Lesson 6 Pharmacological Therapies Clients taking lithium therapy need to be aware that hot weather may cause excessive perspiration, a loss of sodium and consequently an increase in serum lithium concentration. Test-taking Tips: If guessing, notice that two of the options are similar/dissimilar in that both speak about drawing lithium levels and are different as to the time of when to do this. The option "come in for evaluation of serum lithium levels every 1-3 months" sounds like it might be the best option. However, notice the absolute ‘every’ one to three months which is too restrictive. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. Ref # 4483 Which is the appropriate injection site for an adult receiving enoxaparin (Lovenox)? Use your cursor to select an area on the image below. Answers Correct Student's Review Information: The correct answer is Learning Objective: Lesson 6 Pharmacological Therapies Lovenox is a low-density anticoagulant that can cause significant bruising if not administered correctly. The nurse needs to avoid the area 2 inches (5 cm) from the umbilicus. The manufacturer recommends gently pinching the skin on one of the anterolateral surfaces of the abdomen (think "love handles") and holding the skin fold throughout the injection. The injection site should not be rubbed after completion of the injection. Wilson, B., Shannon, M., & Shields, K. (2009). Pearson nurse's drug guide 2010. Upper Saddle River, New Jersey: Prentice Hall. Nettina, S. (2009). The Lippincott manual of nursing practice (9th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 896 A young adult male is admitted with a diagnosis of testicular cancer. The nurse would expect the client to have A. scrotal discoloration B. inability to achieve erection C. sustained painful erection D. heaviness in the affected testicle Answers Correct D Student's A Review Information: The correct answer is D: heaviness in the affected testicle Learning Objective: Lesson 8 Physiological Adaptation The feeling of heaviness in the scrotum is a classic finding related to testicular cancer and not epididymitis. Erectile dysfunction and scrotal discoloration are not expected manifestations of testicular cancer. Test-taking Tips: The content of this question is “testicular cancer.” Eliminate three of the options that address other content. One option addresses the scrotum; two options address the penis. Notice that only one option addresses the testicles. If guessing, simply match the content in the question with the option that has the same content. Black, J., & Hawks, J. (2008). Medical surgical nursing: Clinical management for positive outcomes (8th ed.). St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 827 Which finding should a nurse anticipate in a client with extracellular fluid volume deficit? Answers Correct B Student's B A. neck veins are distended at 35 degree elevation B. concentrated urine on the last voiding C. pedal pulses +3 bilateral D. sustained rapid respirations Review Information: The correct answer is B: concentrated urine on the last voiding Learning Objective: Lesson 8 Physiological Adaptation Kidneys maintain fluid volume through adjustments in urine volume and concentration. By holding onto water, the urine produced by the kidneys is concentrated. In fluid volume deficit situations, peripheral pulses are weak and neck veins are flattened. Respiratory rate is not a reliable indicator of the fluid volume status. Test-taking Tips: Read this question carefully and note that it regards fluid volume deficit. One option is a vascular answer, not an extracellular answer. One option is a respiratory answer and another is a cardiovascular answer. There is only one option can be directly associated with fluid volume deficit. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Hogan, M.A., Gingrich, M.M., Ricci, M.J., & Overby, P. (2006). Fluids, electrolytes, and acid-base balance: Reviews and rationales (2nd ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 878 A nurse should have knowledge to monitor blood pressure in clients who receive antipsychotic medications for what reason? A. orthostatic hypotension is a common side effect B. it will indicate the need to institute antiparkinsonian medications C. this provides information on the amount of sodium allowed in the diet D. most antipsychotic medications cause elevated blood pressure Answers Correct A Student's A Review Information: The correct answer is A: orthostatic hypotension is a common side effect Learning Objective: Lesson 6 Pharmacological Therapies Clients should be made aware of the possibility of dizziness and syncope from postural hypotension for about an hour or two after ingestion of this type of medication. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. Ref # 741 A six year-old child is diagnosed with recurrent urinary tract infections (UTI). Which instruction is the best for a nurse to discuss with the caregiver? A. child should wear any kind of underwear B. have the child use antibacterial soaps while bathing Answers Correct C Student's C C. use plain water for a tub bath and shampoo the hair last D. when laundering clothing, rinse several times Review Information: The correct answer is C: use plain water for a tub bath and shampoo the hair last Learning Objective: Lesson 3 Health Promotion and Maintenance Hair should be shampooed last and followed by rinsing plain water over the genital area. The oils in soaps and bubble bath can cause irritation of the urinary meatus, which often leads to UTIs in young children. Test-taking Tips: The key words here are “best instructions” for recurrent UTI. If guessing, narrow down to the two similar but dissimilar answers, which are the options that both speak to “bathing.” Notice that three options all have the potential to cause irritation and/or infection. The phrase “plain water” is a hint to being a non-irritant. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 744 A client asks a nurse to reinforce an understanding of the basic ideas of homeopathic medicine. Which information best explains the purpose of homeopathic remedies? A. to maintain fluid balance B. to boost the immune system C. to increase bodily energy D. to destroy organisms causing disease Answers Correct B Student's B Review Information: The correct answer is B: to boost the immune system Learning Objective: Lesson 3 Health Promotion and Maintenance The homeopathic practitioner treats with minute doses of plant, mineral or animal substances that provide a gentle stimulus to the body's own defenses in the immune system. Test-taking Tips: When guessing, find the two options that are similar, both are “increase” answers, but dissimilar in what increases. Then ask, “Which would cause the worst consequence if lacking: better energy or immune system?” Berman, A., Snyder, S., Kozier, B., & Erb, G. (2008). Kozier & Erb's fundamentals of nursing: Concepts, process, and practice (8th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Karch, A.M. (2009). Lippincott's 2009 nursing drug guide (5th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 865 When reinforcing information about the difference between tardive dyskinesia and neuromalignant syndrome to a client, a nurse should explain that tardive dyskinesia Answers Correct B Student's B A. develops within hours to years of continued antipsychotic medication use in people under 20 and over 30 B. can occur in clients taking antipsychotic medications longer than two years C. occurs within minutes of the first dose of antipsychotic medications and is reversible D. can easily be treated with anticholinergic medications Review Information: The correct answer is B: can occur in clients taking antipsychotic medications longer than two years Learning Objective: Lesson 6 Pharmacological Therapies Tardive dyskinesia is an extrapyramidal side effect that appears after prolonged treatment with antipsychotic medication. Early findings of tardive dyskinesia include involuntary movements of the face, jaw, or tongue and jerky movements of the upper extremities. Constant smacking of the lips is one example. Anticholinergics are often given to minimize these side effects. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. Ref # 973 A victim of domestic violence states to the nurse, "If only I could change and be how my partner wants me to be, I know things would be different." Which would be the best response by the nurse? A. "The violence is temporarily caused by unusual circumstances. Don’t stop hoping for a change." B. "Perhaps, if you understood the need to abuse, you possibly could intercept the violence." C. "No one deserves to be beaten. Are you doing anything to provoke your partner into such behaviors?" D. "Batterers lose self-control because of internal reasons, not because of what the partner did or did not do." Answers Correct D Student's D Review Information: The correct answer is D: "Batterers lose self- control because of internal reasons, not because of what the partner did or did not do." Learning Objective: Lesson 4 Psychosocial Integrity Only the perpetrator has the ability to stop the violence. A change in the victim’s behavior will not cause the abuser to become nonviolent. Victims only have control over their responses and actions. Notice that three of the options imply that the victim can change the circumstances. Only the correct response places the responsibility for the abuse with the batterer. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 826 A client is unconscious after a tonic-clonic seizure. What should a nurse do at this time? Answers Correct B Student's C A. place an airway in the mouth B. place the client in a side-lying position C. administer the ordered anticonvulsant D. check the pulse for irregularity Review Information: The correct answer is B: place the client in a side- lying position Learning Objective: Lesson 8 Physiological Adaptation Place the client in a side-lying position to maintain an open airway, drain secretions, and prevent aspiration if vomiting occurs. Avoid the action that may stimulate seizure activity. The other actions are incorrect at this time. Test-taking Tips: The key objective in this question is to determine what to do first after a seizure. Remember that when a safety option is a choice, it is likely the correct answer since safety comes first. Read the options closely and find the safety answer. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 974 Domestic violence remains extensively undetected because of which factor(s)? A. little knowledge of trends is currently known B. complaints of the abused person may be vague C. police involvement and court costs D. few battered individuals seek medical care Answers Correct B Student's B Review Information: The correct answer is B: complaints of the abused person may be vague Learning Objective: Lesson 4 Psychosocial Integrity Signs of abuse may not be clearly manifested and a series of vague complaints such as headache, abdominal pain, insomnia, back pain, and dizziness may be covert indications of undetected abuse. Test-taking Tips: The key words in this question are “domestic violence” and “remains undetected.” Notice that only two options focus on the content of this question. They both include content about domestic violence (“battered” and “complaints”). One of the options doesn’t make sense – how is it known “how few?” Eby, L., & Brown, N.J. (2008). Mental health nursing care (2nd ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Keltner, N.L., Bostrom, C.E., & Schwecke, L.H. (2006). Psychiatric nursing (5th ed.). St. Louis, MO: Mosby. Ref # 982 A priority goal of involuntary hospitalization of the client diagnosed with severe mental illness is Answers Correct A Student's A A. protection from harm to self and others B. return to independent functioning C. elimination of findings D. re-orientation to reality Review Information: The correct answer is A: protection from harm to self and others Learning Objective: Lesson 4 Psychosocial Integrity Involuntary hospitalization may be required for persons considered dangerous to self or others or for individuals who are considered gravely disabled. Test-taking Tips: The key words in this question are “priority goal,” "severe," and “involuntary hospitalization." Remember that safety is always a priority and only one option is associated with safety. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Practice Bank 22 Ref # 947 Which focus should be included when a nurse reinforces information with a client about chlorpromazine HCL (Thorazine)? The client should avoid which item? A. direct sunlight B. canned citrus fruit drinks C. foods fermented with yeast D. foods containing tyramine Answers Correct A Student's A Review Information: The correct answer is A: direct sunlight Learning Objective: Lesson 6 Pharmacological Therapies Phenothiazine increases sensitivity to the sun and makes clients especially susceptible to sunburn. Recall that photosensitivity has an "s" in it, so it is associated with "s"kin "s"ensitivity. Test-taking Tips: This is an “exception question” that does not have the word “except” in the stem. Instead, in the stem the key word is “avoid.” If guessing, remember that the correct answer in an “exception” question is the “odd” answer. Ask, which three options have associations or can be clustered under a theme? The answer that is not one of those three would be the “avoidance.” Notice that options three options are all food options (this is the association or theme). One option does not include food, making it the “odd” answer. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 900 A client with testicular cancer has had a unilateral orchiectomy. Prior to discharge the client expresses Answers Correct B his fears related to the prognosis. Which statement should be the initial response by a nurse? A. "Chemotherapy is most likely to be started right away." B. "Testicular cancer has a very high cure rate with early diagnosis." C. "Self-examination needs to be continued in order to prevent and detect recurrences." D. "Adoption may be a consideration if you want children." Student's C Review Information: The correct answer is B: "Testicular cancer has a very high cure rate with early diagnosis." Learning Objective: Lesson 8 Physiological Adaptation With aggressive treatment and early detection/diagnosis the cure rate is 90%. The other comments are correct about testicular cancer but would not be the initial response to the client's question. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Christensen, B., & Kockrow, E. (2010). Foundations of nursing and adult health nursing (6th ed.). St. Louis: Mosby. Ref # 943 A client is taking a mood stabilizer. A nurse should recognize that early signs of toxicity include which of these findings? A. vomiting, diarrhea, lethargy B. pruritus, rash, photosensitivity C. ataxia, course hand tremors, irritability D. electrolyte imbalance, cardiac arrhythmias, dysrhythmias Answers Correct A Student's A Review Information: The correct answer is A: vomiting, diarrhea, lethargy Learning Objective: Lesson 6 Pharmacological Therapies These are early signs of lithium toxicity. In the presence of low sodium lithium has a risk of becoming toxic. Lithium is the mood stabilizer used for bipolar disorders. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 919 In clients diagnosed with severe mitral stenosis, the nurse should most anticipate performing nursing interventions that have which focus? A. relieve chest pain B. clear the airway C. reduce edema D. promote cardiac output Answers Correct D Student's D Review Information: The correct answer is D: promote cardiac output Learning Objective: Lesson 8 Physiological Adaptation The major concern in severe mitral stenosis is adequate cardiac output. Airway clearance is not an issue in mitral stenosis. Edema can likely occur with mitral stenosis if backflow is a problem but is not as significant an issue as poor cardiac output. Chest pain can occur in severe mitral stenosis. However, improvement in cardiac output will likely minimize or eliminate chest pain. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 794 A couple attempting to conceive asks a nurse when ovulation occurs. The woman reports a regular 32 day cycle. The nurse should respond that ovulation for her from the beginning of her cycle probably occurs within A. 7 to 10 days B. 14 to 16 days C. 17 to 19 days D. 10 to 13 days Answers Correct C Student's C Review Information: The correct answer is C: 17 to 19 days Learning Objective: Lesson 3 Health Promotion and Maintenance Ovulation occurs 14 days prior to menses. Considering that the woman's cycle is 32 days, subtracting 14 from 32 suggests ovulation is at about the 18th day. Test-taking Tips: This question requires to know that ovulation occurs 14 days prior to menses. It also requires to know to subtract 14 from whatever number of days is in a woman’s cycle. Another approach is to use common sense that two of the options would be too soon in the cycle. Then to decide between the other two options, note that one option would be in the range where half of 32 days = 16 days. Eliminate that since it is unlikely that the body would be so exact to have ovulation fall midway. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ramont, R.P., & Niedringhaus, D.M. (2007). Fundamental nursing care (2nd ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 4500 The nurse is reviewing the lab results for a male client on a heparin infusion to treat a deep vein thrombosis (DVT) and cellulitis of the right lower Answers Correct D Student's D leg. Which of the lab results would the nurse be most concerned about? Lab results White blood cells (WBC) - 15,100 per microliter Platelet count - 50,000 per microliter Hemoglobin - 14 g/dL Hematocrit - 45% Partial Thromboplastin Time (PTT) - 55 seconds A. White blood cells B. Hematocrit C. Partial thromboplastin time (PTT) D. Platelet count E. Hemoglobin Review Information: The correct answer is D: Platelet count Learning Objective: Lesson 6 Pharmacological Therapies Thrombocytopenia (abnormally low amount of platelets) and heparin- induced thrombocytopenia can occur in clients on heparin therapy. In an adult, a normal platelet count is about 150,000 to 450,000 platelets per microliter of blood. The PTT is within a therapeutic range. It is expected that the white blood cells would be slightly elevated in a client with an infection (cellulitis). Adams, M., Holland, L., & Bostwick, P. (2008). Pharmacology for nurses: A pathophysiologic approach (2nd ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Deglin, J., Vallerand, A., & Sanoski, C. (2010). Davis’s drug guide for nurses (12th ed.). Philadelphia: F. A. Davis Company. Ref # 793 A nurse assists with the reinforcement of information about breast self-examination to a group of college students. A female student asks when to perform the monthly exam. The appropriate reply by the nurse should include which statement? A. "Do the exam at the same time every month." B. "Right after the period, when your breasts are less tender." C. "The first of every month, because it will be easiest to remember." D. "Ovulation, or mid-cycle is the best time to detect changes." Answers Correct B Student's B Review Information: The correct answer is B: "Right after the period, when your breasts are less tender." Learning Objective: Lesson 3 Health Promotion and Maintenance The best time for a breast self exam (BSE) is at the end of a menstrual cycle, when the breasts are no longer swollen and tender from hormone elevation. BSE is to be avoided during the first two days of the menses. Altman, G.B. (2009). Delmar's fundamental and advanced nursing skills (3rd ed.). Clifton Park, NY: Delmar Cengage Learning. Christensen, B., & Kockrow, E. (2010). Foundations of nursing and adult health nursing (6th ed.). St. Louis: Mosby. Ref # 990 An eight year-old client is admitted to the child mental health unit for evaluation. After the mother’s departure, the client cries and refuses dinner. The best approach by a nurse is to take which action? Answers Correct A Student's A A. spend time with the child and offer to play games B. explain the need for food to maintain energy C. remind the child that the mother will return D. discuss the expectations of both the child and the nurse Review Information: The correct answer is A: spend time with the child and offer to play games Learning Objective: Lesson 4 Psychosocial Integrity Play is both distracting and an avenue for a child’s communication. Play facilitates mastery of feelings and expression of thoughts. Children of this age group enjoy games with rules. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Keltner, N.L., Bostrom, C.E., & Schwecke, L.H. (2006). Psychiatric nursing (5th ed.). St. Louis, MO: Mosby. Ref # 885 Clients taking which of these drugs are at risk for depression? A. diuretics for heart failure B. folic acid for cirrhosis of the liver C. steroids for chronic obstructive pulmonary disease D. aspirin for peripheral vascular disease Answers Correct C Student's C Review Information: The correct answer is C: steroids for chronic obstructive pulmonary disease Learning Objective: Lesson 6 Pharmacological Therapies Medication side effects can cause a syndrome that may or may not abate when the medication is discontinued. Examples include: phenothiazines, steroids, and reserpine. Test-taking Tips: This question is asking about which medications are more likely to cause depression as a side effect. As the options are read, ask: which of these medications is the most potent or which of these medications effect most body systems? Side effects are usually a result of the most potent medications. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. Ref # 4488 Which injection site would be appropriate to use when vaccinating a toddler? Use your cursor to select an area on the image below. Answers Correct Student's Review Information: The correct answer is Learning Objective: Lesson 6 Pharmacological Therapies Since the deltoid muscle is too small yet and the sciatic nerve hasn't reached its final placement, it's best to avoid these sites. The anterolateral thigh muscle is easily accessible and provides a position where the parent or caregiver can make eye contact and provide comfort to the toddler. It's located at the outer middle third of the thigh. Harkreader, H., Hogan, M.A., & Thobaben, M. (2007). Fundamentals of nursing: Caring and clinical judgment (3rd ed.). Philadelphia: Saunders. Hockenberry, M.J. (2008).Wong's nursing care of infants and children (8th ed.). St. Louis, MO: Mosby Ref # 762 A nurse is caring for a client who is four days postop after a transverse colostomy was done. The client, to be discharged in the morning, asks the nurse to empty the colostomy pouch. How should the nurse best respond to the client? A. "Show me what you have learned about emptying your pouch." B. "Let me demonstrate how to empty the pouch for you." C. "You should be emptying the pouch yourself." D. "Tell me what have you learned about emptying your pouch." Answers Correct A Student's A Review Information: The correct answer is A: "Show me what you have learned about emptying your pouch." Learning Objective: Lesson 3 Health Promotion and Maintenance Most adult learners obtain skills by participating in the activities. Anxiety about discharge can be causing the client to forget the mastered skill of emptying the pouch. The client should show the nurse how they empty the pouch as the nurse observes and reinforces any steps in the process. Altman, G.B. (2009). Delmar's fundamental and advanced nursing skills (3rd ed.). Clifton Park, NY: Delmar Cengage Learning. Christensen, B., & Kockrow, E. (2010). Foundations of nursing and adult health nursing (6th ed.). St. Louis: Mosby. Ref # 746 The family member tells an admitting nurse that the client values the practice of Chinese medicine. The nurse must understand that for this family and client a priority goal should take which focus? Answers Correct D Student's C A. respect life in old age B. maintain energy balance C. achieve harmony D. restore yin and yang Review Information: The correct answer is D: restore yin and yang Learning Objective: Lesson 3 Health Promotion and Maintenance For followers of Chinese medicine, health is maintained through balance between the forces of yin and yang. Test-taking Tips: The key here is the term “Chinese medicine.” The word “restore” in one option can be associated with the word “medicine” in the stem since medicine restores function. Another hint is that two options are similar in that they both speak to “energy,” but dissimilar answers in the description of the energy. Craven, R.F., & Hirnle, C.J. (2008). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia: Lippincott Williams & Wilkins. Christensen, B., & Kockrow, E. (2010). Foundations of nursing and adult health nursing (6th ed.). St. Louis: Mosby. Ref # 986 Which nursing intervention should be most effective in helping a withdrawn client to begin development of relationship skills? A. initiate client interactions with one or two other clients B. assist the client to analyze the meaning of behaviors C. offer the client frequent opportunities to interact with the nurse D. remind the client frequently to interact with other clients Answers Correct C Student's C Review Information: The correct answer is C: offer the client frequent opportunities to interact with the nurse Learning Objective: Lesson 4 Psychosocial Integrity The withdrawn client is uncomfortable in social interaction. The nurse- client relationship is a corrective relationship in which the client learns both tolerance and skills for relationships within safe realms. To offer frequent interactions initiates the development of relationship skills. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 1118 A nurse recognizes fluid sounds during the auscultation of a client’s lung. These sounds should be documented as A. shrill and crowing. B. low-pitched and rumbling. Answers Correct B Student's B C. dry and grating. D. high-pitched and musical. Review Information: The correct answer is B: low-pitched and rumbling. Learning Objective: Lesson 8 Physiological Adaptation Crackles, which indicate moisture or fluid in the lung, are described as low-pitched rumbling sounds that are hyperresonant. One incorrect response describes a friction rub of the pericardial sac or the pleural lining. Another incorrect response describes stridor which is a result of a larger, upper airway constriction. The final incorrect response is consistent with wheezing which indicates narrowed lower airway such as the bronchials. Altman, G.B. (2009). Delmar's fundamental and advanced nursing skills (3rd ed.). Clifton Park, NY: Delmar Cengage Learning. Christensen, B., & Kockrow, E. (2010). Foundations of nursing and adult health nursing (6th ed.). St. Louis, MO: Mosby. Ref # 918 In a client diagnosed with mitral regurgitation the nurse should expect to see documentation of which of these factors in the notes? A. ascites B. low red blood cell count C. exertional dyspnea D. pulse deficit Answers Correct C Student's C Review Information: The correct answer is C: exertional dyspnea Learning Objective: Lesson 8 Physiological Adaptation Fluid retention and diminished heart function cause exertional dyspnea in clients with mitral regurgitation as heart failure worsens. This is due to a rise in left atrial pressure and subsequent pulmonary and venous congestion. Mitral regurgitation does not cause anemia or a pulse deficit. Black, J., & Hawks, J. (2008). Medical surgical nursing: Clinical management for positive outcomes (8th ed.). St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 983 To obtain data related to psychosocial needs, a nurse should include which action? A. allow clients to talk about whatever they want B. observe the client’s nonverbal behaviors carefully C. elicit the client's description of experiences, thoughts, and behaviors Answers Correct C Student's C D. adhere to pre-planned interview goals and structure Review Information: The correct answer is C: elicit the client's description of experiences, thoughts, and behaviors Learning Objective: Lesson 4 Psychosocial Integrity The nurse’s understanding of the client is more comprehensive if obtained by listening to the client’s self revelation. Test-taking Tips: This is a specific question and requires a specific response. As the options are read compare the verbs: observe, adhere, allow, elicit. One option is the most client centered to nonphysical items. Notice that three of the options are general responses. Relate the words “obtain data” in the stem of the question with the word “elicit” in one option which is to collect further data. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 985 The nurse is working to establish a therapeutic relationship with a client. A therapeutic nurse-client interaction occurs when a nurse takes which approach? A. Interprets any covert communications B. Advises about resources to resolve problems C. Clarifies the meaning of client communication D. Praises the client for appropriate behavior Answers Correct C Student's A Review Information: The correct answer is C: Clarifies the meaning of client communication Learning Objective: Lesson 4 Psychosocial Integrity Clarification is both a facilitating and therapeutic communication strategy. Approval, changing the focus or subject, and advising are non-therapeutic or barriers to effective communication. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 888 When reviewing medications with a client, the client asks "How long will it take before the effects of lithium take place?" A nurse should include which timeframe in the response? A. "Two weeks" B. "One month" C. "Immediately" Answers Correct A Student's A D. "Several days" Review Information: The correct answer is A: "Two weeks" Learning Objective: Lesson 6 Pharmacological Therapies Lithium is started immediately to treat bipolar disorder because it is quite effective in controlling mania but it takes approximately two weeks to effect change in a client’s behaviors. Test-taking Tips: If guessing, eliminate the shortest time given and the longest time given. This would narrow the options down to two options. Ask: Are “days” or “weeks” more reasonable in relation to effecting a change in behavior? The common sense answer is ”weeks." Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 972 The nurse is caring for a victim of domestic abuse. Which of these behavioral characteristics is commonly associated with a domestic abuser? A. low self-esteem B. Overconfident C. High tolerance for frustration D. Alcoholic Answers Correct A Student's A Review Information: The correct answer is A: low self-esteem Learning Objective: Lesson 4 Psychosocial Integrity Batterers are usually physically or psychologically abused as children or have had experiences of parental violence. Batterers are also manipulative, tend to have a low self-esteem, and have a need to exercise control or power over a partner. Although some abusers may abuse alcohol, being an alcoholic does not necessarily lead to domestic abuse. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 941 During a home visit a nurse observes a client who takes chlorprozamine HCL (Thorazine) smacking the lips alternately with grinding of the teeth. The nurse should document this finding as which term? A. akathisia B. bradykinesia C. tardive dyskinesia Answers Correct C Student's A D. dystonia Review Information: The correct answer is C: tardive dyskinesia Learning Objective: Lesson 6 Pharmacological Therapies Signs of tardive dyskinesia include involuntary movements such as smacking lips, grinding of teeth and "fly catching" tongue movements. Anticholinergics are often prescribed to minimize these side effects. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Practice Bank 23 Ref # 997 At the geriatric day care program a client who started the program a few weeks ago is crying and repeating "I want to go home. Call my daddy to come for me." Which action should the nurse initiate? A. give the client simple information about the available activities for that day B. tell the client you will call someone to come for the client C. firmly direct the client to an assigned group activity D. call the client by name and invite the client to join the exercise group Answers Correct D Student's D Review Information: The correct answer is D: call the client by name and invite the client to join the exercise group Learning Objective: Lesson 4 Psychosocial Integrity Engaging the client through name use and invitation to a concrete activity in the here and now will redirect the client and increase security and a sense of belonging. The exercise will provide an outlet for the emotional distress. One option is non-therapeutic for client and family. It reinforces the fear and insecure feeling that this is not a good place to be. One option is non-therapeutic. A distressed, crying, and disoriented client is unable to listen to information about what is going to happen later today, simple or not. This client needs to feel a sense of belonging now. Understanding time and the future is an abstract and confusing for this client. Firm direction is not as engaging or comforting for this client as personal invitation and activity involvement. Eby, L., & Brown, N.J. (2008). Mental health nursing care (2nd ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 995 A client diagnosed with depression has recently been acting suicidal and suddenly becomes more social and energetic than usual. During a clinic visit the client smiles and says to a nurse "I have made some decisions about my life." What should be the nurse’s initial response? A. "I’m so glad to hear that you’ve made some decisions." B. "You’ve made some decisions. Let’s talk about them." C. "Be sure to discuss your decisions with your therapist." D. "Do those decisions include thoughts about killing yourself?" Answers Correct D Student's D Review Information: The correct answer is D: "Do those decisions include thoughts about killing yourself?" Learning Objective: Lesson 4 Psychosocial Integrity Sudden mood elevation and energy may signal increased risk of imminent suicide. The nurse must validate suicide ideation as a beginning step in evaluating the seriousness of the risk. One option would be the initial response if the client had not had the sudden change in energetic behavior. When clients exhibit sudden changes in behavior and verbal expressions they are at greatest risk for suicide. Test-taking Tips: The key words in this question are “been suicidal,” “suddenly energetic and smiling,” ”I have made some decisions about my life” and “nurse’s initial response.” The best answer is going to be client centered and one that further collects data. There is only one option that does this as well as addresses the “suicide”. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 967 When excess or chronic alcohol consumption is abruptly reduced or stopped, physiologic dependence is accompanied by which characteristic? A. neuro overactivity B. seizures C. cravings D. hallucinations Answers Correct A Student's C Review Information: The correct answer is A: neuro overactivity Learning Objective: Lesson 6 Pharmacological Therapies The early signs of alcohol withdrawal, neuro overactivity, develop within 48 hours after cessation or reduction of alcohol intake. These include anxiety, agitation, and irritability. Options one and four are later findings of withdrawal. Test-taking Tips: The key words in this question are “alcohol consumption reduced or stopped.” Associate the word “withdrawal” with the words “reduced or stopped” in the stem of the question. The timeframe is the clue since two of the options occur later. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 4461 A nurse is assigned to a client diagnosed with multiple trauma and head injury with a blood pressure on admission of 140/70 mm Hg. Four hours later the blood pressure is 179/68 mm Hg. Answers Correct 41 Student's 41 What is the difference in the pulse widths or pulse pressures that would lead the nurse to suspect the client may be developing increased intracranial pressure? (Answer the question using whole numbers). . Review Information: The correct answer is : 41 Learning Objective: Lesson 7 Reduction of Risk Potential The first pulse width is (140 - 70) = 70. The second pulse width is (179 - 68) = 111. The difference between them is 41, which is an increase that is called a widened pulse pressure. Smeltzer, S.C., Bare, B.G., Hinkle, J., & Cheever, K.H. (2009). Brunner- Suddarth's textbook of medical surgical nursing (12th ed.). Philadelphia: Lippincott Williams & Wilkins. Altman, G. B. (2009). Delmar's fundamental and advanced nursing skills (3rd ed.). Clifton Park, NY: Delmar Cengage Learning. Ref # 795 A client telephones the clinic to ask about a home pregnancy test she used that morning. A nurse understands that the presence of which hormone strongly suggests that any woman is pregnant? A. estrogen B. progesterone C. human chorionic gonadotropin (HCG) D. alpha-fetoprotein Answers Correct C Student's C Review Information: The correct answer is C: human chorionic gonadotropin (HCG) Learning Objective: Lesson 3 Health Promotion and Maintenance Human chorionic gonadotropin (HCG) is the biologic marker on which pregnancy tests are based. Reliability is about 98%, but the test does not positively confirm pregnancy. This same hormone is the stimulus for morning sickness. Lowdermilk, D., & Perry, S. (2007). Maternity & women's health care (9th ed.). St. Louis, MO: Mosby. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 1192 A couple experiences intense anxiety after their home was destroyed by a fire. One of the partners escaped from the fire with only minor injuries. A nurse knows that the most important initial intervention should be to take which approach? A. explore with the couple the feelings of grief associated with the loss. B. suggest that the clients rent an apartment with a sprinkler system. Answers Correct C Student's C C. determine available community and personal resources. D. provide a brochure on methods to promote relaxation. Review Information: The correct answer is C: determine available community and personal resources. Learning Objective: Lesson 4 Psychosocial Integrity The couple has experienced a sudden loss event that has resulted in disequilibrium. The most important initial crisis intervention focuses on identifying resources and obtaining assistance for housing and other immediate needs. Information on home safety, relaxation exercises, and grief counseling are of value after meeting the initial needs for shelter. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 1032 Which statement, if made by a client, indicates teaching about propranolol (Inderal) has been effective? “I should not stop taking the Inderal suddenly because it may cause A. a heart attack." B. decreased blood pressure." C. nervousness." D. seizures." Answers Correct A Student's B Review Information: The correct answer is A: a heart attack." Learning Objective: Lesson 6 Pharmacological Therapies Discontinuing beta blockers suddenly can cause angina, hypertension, dysrhythmias, or a myocardial infarction. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 4482 Use the cursor to indicate the correct hand placement used to relieve an obstructed airway on a conscious person who is obese. Answers Correct Student's Review Information: The correct answer is Learning Objective: Lesson 8 Physiological Adaptation The Heimlich is usually performed on a conscious person who is in an upright position. In the event that the rescuer cannot encircle the victim's belly to reach the space between the navel and the xiphoid notch, the hands should be placed around the chest so that the fists lie at the mid-nipple line to relieve the obstruction. The chest area has a smaller circumference so it is more accessible on a larger person; the same technique would be used on a pregnant female. Should the person become unconscious, the rescuer would begin chest compressions. Black, J., & Hawks, J. (2008). Medical surgical nursing: Clinical management for positive outcomes (8th ed.). St. Louis, MO: Elsevier. Nettina, S. (2009). The Lippincott manual of nursing practice (9th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 1163 A client has a diagnosis of heart failure. Which intervention is most important for a nurse to implement prior to the initial administration of digoxin? A. use the pulse reading from the electronic blood pressure device B. assess the apical pulse, counting for a full 60 seconds C. take a radial pulse, counting for a full 60 seconds D. check for a pulse deficit at least twice with another nurse Answers Correct B Student's C Review Information: The correct answer is B: assess the apical pulse, counting for a full 60 seconds Learning Objective: Lesson 8 Physiological Adaptation It is the nurse’s responsibility to take the client’s pulse before administering digoxin. The correct technique for taking an apical pulse is to use the stethoscope, the diaphragm side, and listen for a full 60 seconds. Digoxin is held for a pulse below 60 beats per minute or greater than 120 beats per minute and less than 100 and greater than 160 in infants and younger children. Radial pulse or blood pressure are not part of the initial assessment before administration of an initial dose of digoxin. Altman, G.B. (2009). Delmar's fundamental and advanced nursing skills (3rd ed.). Clifton Park, NY: Delmar Cengage Learning. Christensen, B., & Kockrow, E. (2010). Foundations of nursing and adult health nursing (6th ed.). St. Louis, MO: Mosby. Ref # 797 A pregnant client comes to the clinic for a first visit. A nurse gathers data about her obstetric history, which includes: three year-old twins at home and a miscarriage at 12 weeks gestation ten years ago. Which documentation should the nurse make? Answers Correct D Student's D A. gravida 3 para 2 B. gravida 2 para 1 C. gravida 4 para 2 D. gravida 3 para 1 Review Information: The correct answer is D: gravida 3 para 1 Learning Objective: Lesson 3 Health Promotion and Maintenance Gravida is the number of pregnancies and parity or para is the number of pregnancies that reach viability which is considered 20 weeks (not the number of fetuses). This woman is now pregnant, had two prior pregnancies, and one pregnancy that reached viability (the twins). If asked to chart with the use of the five number system it would be 3-1-0-1-2 [gravida, term pregnancies, preterm, abortions, living children] Test-taking Tips: Read the question carefully and count the number of pregnancies, as well as the number of pregnancies that reached viability. Avoid confusing twins, two children, with the number of viable births. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 799 A pregnant client asks a nurse about the scheduled blood test for alpha-fetoprotein (AFP). The nurse's explanation should include which of these comments? A. "The results help determine if the baby is growing normally." B. "The placental exchange of oxygen is measured." C. "Possible neurological defects may be identified." D. "It tells us how far along your pregnancy is." Answers Correct C Student's C Review Information: The correct answer is C: "Possible neurological defects may be identified." Learning Objective: Lesson 3 Health Promotion and Maintenance A fetus with neural tube defects loses AFP to the amniotic fluid and hence the maternal blood. High levels indicate the possibility of defects such as spina bifida, meningocele or anenecephaly. Further tests are indicated if an AFP test is positive. It is also used for the determination of Down’s syndrome risk. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 1188 After the death of a client, the family approaches a nurse and requests that a family member be allowed to perform a ritual bath on the deceased before the body is moved. How should the nurse respond? Answers Correct C Student's C A. "A ritual bath will have to wait until after post-mortem care" B. "I will have to check on hospital regulations and policies." C. "Is there anything you need from me to perform the ritual bath?" D. "These procedures have to be carried out by our staff." Review Information: The correct answer is C: "Is there anything you need from me to perform the ritual bath?" Learning Objective: Lesson 4 Psychosocial Integrity In some religious traditions, a ritual bath is performed by a family member or a ritual burial society. Nurses should inquire about rituals or observances following death and respect these. Three of the options are inappropriate and insensitive. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 1162 A client has just returned from the Post-Anesthesia Care Unit (PACU) to the surgical unit following a cholecystectomy. When initial vital signs are taken the nurse notes a tympanic temperature of 94.8 degrees Fahrenheit. Which nursing intervention is appropriate at this time? A. apply a warm blanket and recheck the temperature in ten minutes B. call the health care provider and obtain further orders for warming C. ask the PACU nurse more details of what happened in PACU D. continue to monitor the vital signs per routine postop protocol Answers Correct A Student's A Review Information: The correct answer is A: apply a warm blanket and recheck the temperature in ten minutes Learning Objective: Lesson 8 Physiological Adaptation A client’s postoperative oral temperature should be at least 95 degrees Fahrenheit. If the temperature does not increase within 10 minutes, the nurse should call the provider about an order for an electric warming blanket or other measures. To continue monitoring per protocol is incorrect since the low temperature is a problem and action is required. Craven, R.F., & Hirnle, C.J. (2008). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia: Lippincott Williams & Wilkins. Christensen, B., & Kockrow, E. (2010). Foundations of nursing and adult health nursing (6th ed.). St. Louis, MO: Mosby. Ref # 1169 An older adult client diagnosed with active tuberculosis has difficulty in appropriately coughing Answers Correct C up secretions for a sputum specimen. Which nursing intervention might be the most helpful at this time? A. ask the client to drink a warm liquid B. force fluids for the next eight hours C. raise the head of the bed to at least 45 degrees D. spray the oropharynx with saline Student's C Review Information: The correct answer is C: raise the head of the bed to at least 45 degrees Learning Objective: Lesson 8 Physiological Adaptation Placing the client in semi or high-Fowler’s position will promote lung expansion and effective coughing. While drinking liquids helps to loosen secretions over time, they should not be given when collecting a specimen. Spraying the throat with saline may cause irritation, coughing, and reduce oxygenation and is not a nursing intervention. Linton, A.D. (2007). Introduction to medical surgical nursing (4th ed.). Philadelphia: Saunders. - (2006). Best practices: Evidence-based nursing procedures (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 1168 The nurse discovers an unresponsive client and determines there is no pulse. This nurse then activates the code notification button to alert all personnel about the code and begins chest compressions. What is the function of the second nurse on the scene? A. Participate with the compressions or breathing as requested by the first nurse B. Bring the code cart C. Validate the client's advanced directive D. Relieve the first nurse on the scene and continue single person CPR Answers Correct B Student's C Review Information: The correct answer is B: Bring the code cart Learning Objective: Lesson 8 Physiological Adaptation Typically, the second person on the scene brings the code cart and then assists with CPR. In larger facilities, a code team assists with the code and each nurse has a specific duty. Cardiopulmonary resuscitation should not be started on a client who is a DNR, but if it is started, then CPR has to be continued. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. - (2006). American Heart Association basic life support for healthcare providers (2006). Dallas: American Heart Association. Ref # 964 An adolescent female is newly diagnosed with bulimia. A nurse is reinforcing instructions about the therapeutic benefits of Tofranil (imipramine) to the client and her parents. Which statement demonstrates an understanding about the medication by the client? Answers Correct C Student's C A. "I only need to take this medication until I can control my binging." B. "I can double the medication if I miss a dose that is at least 12 hours late." C. "I will need to take the medication for at least two weeks before I can see any benefit." D. "I will begin to feel better after a few days." Review Information: The correct answer is C: "I will need to take the medication for at least two weeks before I can see any benefit." Learning Objective: Lesson 6 Pharmacological Therapies Therapeutic medication effects may not be noticed for at least two weeks. Therapy is usually prolonged and individual and family counseling are helpful in identifying and addressing issues such as self-esteem. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1034 A client with chronic obstructive pulmonary disease (COPD) and a history of coronary artery disease is receiving an IV drip of aminophylline 25mg/hour. Which finding by a nurse would require immediate intervention? A. restlessness and palpitations B. flushing and headache C. increased heart rate and sweating D. changes in blood pressure and respirations Answers Correct A Student's A Review Information: The correct answer is A: restlessness and palpitations Learning Objective: Lesson 6 Pharmacological Therapies Side effects of aminophylline include restlessness and palpitations which commonly are above a heart rate of 120. Muscle twitching or nausea are associated with toxicity of this medication. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 796 A nurse is gathering data from a client who states her last menstrual period was March 16, and she has missed one period. She reports episodes of nausea and vomiting. After confirmation of pregnancy is made by other tests, which date should the nurse determine as the estimated date of delivery (EDD)? A. December 23 B. January 15 Answers Correct A Student's A C. April 8 D. February 11 Review Information: The correct answer is A: December 23 Learning Objective: Lesson 3 Health Promotion and Maintenance The use of Naegele's rule to calculate the EDD will give an approximate date. This rule is: add seven days and subtract three months from the first day of the last regular menstrual period to calculate the estimated date of delivery. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 798 A nurse's first step in planning to review nutrition with a pregnant woman would be to take which action? A. explain the changes in diet necessary for pregnant women B. conduct a diet history to determine her normal eating routines C. address how to meet the needs of self and her family D. question her understanding and the use of the food pyramid Answers Correct B Student's B Review Information: The correct answer is B: conduct a diet history to determine her normal eating routines Learning Objective: Lesson 3 Health Promotion and Maintenance Collection of more data is always the first step in the reinforcement of teaching for any client. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 996 At the day treatment center a client diagnosed with schizophrenia - paranoid type sits alone alertly watching the activities of clients and staff. The client is hostile when approached with medication and asserts that the medication controls the mind. A nurse understands that this behavior is related to Answers Correct A Student's A A. social isolation related to altered thought processes B. impaired verbal communication related to impaired judgment C. feelings of increased anxiety related to paranoia D. sensory perceptual alteration related to withdrawal from environment Review Information: The correct answer is A: social isolation related to altered thought processes Learning Objective: Lesson 4 Psychosocial Integrity Hostility and absence of involvement are data supporting a diagnosis of social isolation. The psychiatric diagnosis and the client’s idea of the purpose of the medication suggests altered thinking processes. Test-taking Tips: Compare the data in the stem to each option. Notice that three options can be immediately eliminated since no information is given about anxiety, sensory or verbal communication difficulties. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Practice Bank 24 Ref # 808 A practical nurse (PN) team member identifies that the fundus is boggy for a woman who is gravida 4 para 4 and is 2 hours after a spontaneous vaginal delivery. The fundus is displaced slightly above and to the right of the umbilicus. What should be the initial nursing action? A. check lochia for color and amount B. call the registered nurse (RN) immediately C. monitor the pulse and blood pressure D. assist the woman to empty her bladder Answers Correct D Student's D Review Information: The correct answer is D: assist the woman to empty her bladder Learning Objective: Lesson 3 Health Promotion and Maintenance A full bladder can displace the uterus and prevent contraction. After the woman empties the bladder, the fundus should be assessed again. The more common deviation of the fundus by a full bladder is upward and to the right. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 1035 A client is taking prednisone and aspirin as part of the treatment for rheumatoid arthritis. Which intervention would be an appropriate action by a nurse? Answers Correct A Student's A A. test the stools for occult blood. B. check the pulse rate every four hours. C. monitor the level of consciousness every shift. D. discuss fiber in the diet to prevent constipation. Review Information: The correct answer is A: test the stools for occult blood. Learning Objective: Lesson 6 Pharmacological Therapies Both prednisone and aspirin increase the risk for bleeding from the mucus membranes. Therefore, monitoring for bleeding from the gastrointestinal tract would be appropriate. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 804 A nurse is monitoring the contractions of a woman in labor. A contraction is recorded as beginning at 10:00 am and ending at 10:01am. Another begins at 10:15 am. The nurse would document the frequency of the contractions as every A. 9 minutes B. 15 minutes C. 14 minutes D. 1 minute Answers Correct B Student's B Review Information: The correct answer is B: 15 minutes Learning Objective: Lesson 3 Health Promotion and Maintenance Frequency is the time from the beginning of one contraction to the beginning of the next contraction. Test-taking Tips: Read this question carefully. The question being asked is about the “frequency of contractions” not the “duration of the contraction.” Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 1038 A client tells a nurse "I have decided to stop taking sertraline (Zoloft) because I don't like the nightmares, sex dreams and obsessions I have experienced since I started on the medication." An appropriate response by the nurse is to caution the client about which process? Answers Correct B Student's B A. this medication should be continued despite unpleasant symptoms B. it is unsafe to abruptly stop taking any prescribed medication C. many medications have potential side effects D. side effects and benefits should be discussed with the provider Review Information: The correct answer is B: it is unsafe to abruptly stop taking any prescribed medication Learning Objective: Lesson 6 Pharmacological Therapies Abrupt withdrawal the short-acting SSRI sertraline (Zoloft) causes SSRI Discontinuation Syndrome. A slow tapering of the medication will be prescribed to avoid the symptoms associated with this syndrome, which may include insomnia, headache, dizziness, nausea, vomiting, and diarrhea. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 994 A client diagnosed with schizophrenia talks animatedly with clarity of pronunciation. The client is then observed mumbling to self and speaking to the radio. A desirable outcome for this client’s care should include which action by the client? A. engage in meaningful and understandable verbal communication B. demonstrate improved social relationships C. accurately interpret events and behaviors of others D. express feelings appropriately through verbal interactions Answers Correct A Student's A Review Information: The correct answer is A: engage in meaningful and understandable verbal communication Learning Objective: Lesson 4 Psychosocial Integrity The data supports impaired verbal communication. The outcome must be related to the diagnosis and supporting data. No data presented is related to feelings or to thinking processes. Test-taking Tips: If guessing, narrow the options down to the two similar but dissimilar answers. That would lead to the two options that both focus on “verbal” communication and interaction. Notice the word “feelings” in one option and ask: Are feelings in the stem of this question? Remember, content cannot be in your answer that is not in the question. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 1180 During a daily cleaning of a tracheostomy, the client coughs and displaces the tracheostomy tube. A nurse could have avoided this complication by having taken which action? Answers Correct D Student's D A. sitting the client upright during the cleaning procedure B. placing an obturator at the client’s bedside C. having another nurse assist with the procedure D. fastening the clean tracheostomy ties before removing the old ties Review Information: The correct answer is D: fastening the clean tracheostomy ties before removing the old ties Learning Objective: Lesson 8 Physiological Adaptation Fastening the clean tracheostomy ties before removing the old ones will ensure that the tracheostomy is secured during the entire cleaning procedure. The obturator is useful to keep the airway open only after the tracheostomy outer tube is coughed out. A second nurse is not needed during this procedure. The client’s position is unrelated to the prevention of a dislodged tracheostomy. Altman, G.B. (2009). Delmar's fundamental and advanced nursing skills (3rd ed.). Clifton Park, NY: Delmar Cengage Learning. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1036 A nurse is caring for a client with a new order for bupropion (Wellbutrin). A health care provider’s order reads "200 mg BID.” What is an appropriate action by the nurse? A. observe the client for mood swings B. monitor neuro signs frequently C. question this medication dose D. give the medication as ordered Answers Correct C Student's D Review Information: The correct answer is C: question this medication dose Learning Objective: Lesson 6 Pharmacological Therapies Bupropion (Wellbutrin) should be administered in doses of no more than 150 mg, as there is a risk of seizures with doses above this. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1040 During reinforcement of discharge teaching, a nurse should emphasize which finding as a common side effect of clozapine (Clozaril) therapy? A. dry skin B. extreme salivation C. dry mouth D. rhinitis Answers Correct B Student's B Review Information: The correct answer is B: extreme salivation Learning Objective: Lesson 6 Pharmacological Therapies A significant number of clients who take clozapine (Clozaril) therapy have a side effect of extreme salivation. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1172 A client diagnosed with amyotrophic lateral sclerosis (ALS) has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate for a nurse to perform during the care of this client? A. squeeze the tube before using it to break up stagnant liquids B. flush adequately with sufficient water before and after using the tube C. pulverize all medications to a powdery condition D. cleanse the skin around the tube daily with hydrogen peroxide Answers Correct B Student's B Review Information: The correct answer is B: flush adequately with sufficient water before and after using the tube Learning Objective: Lesson 8 Physiological Adaptation Flushing the tube before and after use not only provides for good flow and keeps the tube patent, it also provides water to maintain hydration. While medications should be crushed to pass through the tube, it is flushing that moves them through. Be aware that sustained release medications cannot be crushed and an alternative medication will need to be ordered. Stagnant liquids are reduced by flushing after the tube use. Cleansing is important, but soap and water are sufficient without the added irritation of hydrogen peroxide which should not be used full strength in any situation. Full strength damages traumatized cells. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 809 For which of these mother-baby pairs should a nurse review the Coombs' test in anticipation to administer Answers Correct B Student's B Rho (D) immune globulin within 72 hours of the birth? A. Rh positive mother with Rh negative baby B. Rh negative mother with Rh positive baby C. Rh positive mother with Rh positive baby D. Rh negative mother with Rh negative baby Review Information: The correct answer is B: Rh negative mother with Rh positive baby Learning Objective: Lesson 3 Health Promotion and Maintenance An Rh negative mother who delivers an Rh positive baby may develop antibodies to the fetal red cells to which she may be exposed during pregnancy or at placental separation. If the Coombs' test is negative, no sensitization has occurred. The Rho(D) immune globulin is given to block antibody formation in the mother. Test-taking Tips: Notice that two options have a “Rh negative mother” and the other two options have a “Rh positive mother.” Notice that two options have “Rh negative babies” and two options have “Rh positive babies.” Ask this question: is there a problem if the mother and baby have the same Rh factor or is there a problem if the mother has one factor and the baby has a different factor? Use common sense. If both are the same it is unlikely a problem. Thus, the options have been narrowed. If guessing, think that negative beginnings lead to risk. Thus, the mother being negative occurs at the beginning of the baby’s life. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 1039 A client with a diagnosis of schizophrenia has been treated with quetiapine (Seroquel) for one month. Today the client calls the clinic nurse to report increased agitation and complaints of muscle stiffness. The nurse should question the client in order to collect data about what other findings? A. mental confusion and general weakness B. muscle spasms and seizures C. elevated temperature and sweating D. decreased pulse and blood pressure Answers Correct C Student's C Review Information: The correct answer is C: elevated temperature and sweating Learning Objective: Lesson 6 Pharmacological Therapies Neuroleptic malignant syndrome (NMS) is a rare disorder characterized by muscular rigidity, tachycardia, hyperthermia, sweating, altered consciousness, autonomic dysfunction, and increase in creatine phosphokinase (CPK) levels. This is a life-threatening complication that can occur anytime during therapy with antipsychotic medications. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 807 A nurse is caring for a woman two hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. Which of these nursing diagnoses should the nurse expect the charge nurse to have as a priority at this time? Answers Correct B Student's B A. risk for fluid volume deficit B. risk for infection C. risk for excessive bleeding D. altered tissue perfusion Review Information: The correct answer is B: risk for infection Learning Objective: Lesson 3 Health Promotion and Maintenance Membranes ruptured over 24 hours prior to birth greatly increases the risk of infection to both mother and the newborn. Test-taking Tips: Think that membranes ruptured 36 hours prior to delivery = possible infection. Given the information in the question, "risk for infection" would be the “priority.” Note that all of the other options are of an acute focus and would more likely occur sooner than in 36 hours. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 1037 A client tells a nurse about an Internet site which claimed that Wellbutrin was taken off the market because it caused seizures. An appropriate response by the nurse would be to tell the client which information? A. "Ask your friend about the source of this information." B. "Your health care provider knows the best medication for your condition." C. "There were problems and the recommended dose was changed." D. "Omit the next doses until you talk with the health care provider." Answers Correct C Student's C Review Information: The correct answer is C: "There were problems and the recommended dose was changed." Learning Objective: Lesson 6 Pharmacological Therapies Wellbutrin was introduced in the U.S. in 1985 and then withdrawn because of the occurrence of seizures in some clients taking the medication. The medication was reintroduced in 1989 with specific recommendations regarding dose ranges to limit the occurrence of seizures. The risk of seizure appears to be strongly associated with higher doses. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 805 A nurse is checking a woman in early labor. During the positioning of the woman for a vaginal exam, the woman complains of dizziness and nausea and appears pale. Her blood pressure has dropped slightly. What is the appropriate nursing action? Answers Correct B Student's C A. encourage deep breathing B. turn her to her left side C. call the health care provider D. elevate the foot of the bed Review Information: The correct answer is B: turn her to her left side Learning Objective: Lesson 3 Health Promotion and Maintenance The weight of the uterus can put pressure on the inferior vena cava when a pregnant woman is flat on her back causing supine hypotension from a decreased preload. Action is needed to relieve the pressure on the vena cava . Turning the woman to the side reduces this pressure, increases preload and relieves the postural hypotension. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 1177 A client reports some discomfort on the day after a below-the-knee amputation. Which intervention by a nurse is appropriate to do first? A. Administer opioid narcotics as ordered B. Conduct guided imagery or distraction C. Wrap the stump snugly with an elastic bandage D. Ensure that the stump is elevated Answers Correct D Student's D Review Information: The correct answer is D: Ensure that the stump is elevated Learning Objective: Lesson 8 Physiological Adaptation The priority is to elevate the stump in the initial 24 hours to prevent pressure caused by the pooling of blood if left in a dependent position. Thus, the pain is minimized. After this time elevation of the stump should be avoided to prevent contracture of the limb at the hip. Without this action, a firm elastic bandage, opioid narcotics, or guided imagery will have little effect. The opioid narcotics would be given for severe pain. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 4360 The nurse is caring for a client undergoing chemotherapy for colon cancer. Which of the following statements, made by the client, would the nurse be most concerned about? A. "I take ten multivitamin tablets daily to help my immune system fight the cancer." Answers Correct A Student's A B. "I am using relaxation techniques when needed for coping with the stress of having cancer." C. "I think the green tea I'm drinking is helping me to fight cancer." D. "I pray several hours a day to God to help me with dealing with this cancer." Review Information: The correct answer is A: "I take ten multivitamin tablets daily to help my immune system fight the cancer." Learning Objective: Lesson 8 Physiological Adaptation While the other common complementary therapies may or may not have a direct beneficial effect on the cancer, the megadoses of vitamins may interfere with the chemotherapeutic agents. Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: Saunders. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1047 During the preparation of medications for a client with a gastrostomy tube, a home health nurse should contact the health care provider before the administration of which medication through the tube? A. Os-cal tablet (calcium carbonate) B. Cardizem SR tablet (diltiazem) C. Lanoxin liquid D. Tylenol liquid (acetaminophen) Answers Correct B Student's B Review Information: The correct answer is B: Cardizem SR tablet (diltiazem) Learning Objective: Lesson 6 Pharmacological Therapies Cardizem SR is a "sustained-release" medication form. Sustained release (controlled-release; long-acting) medication formulations are designed to release the medication over an extended period of time. If crushed, as would be required for gastrostomy tube administration, sustained-release properties and blood levels of the medication will be altered. The health care provider must be contacted to order a substitute medication. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1223 A nurse discusses with a family the best type of care for their 80 year-old mother who has a cognitive impairment. To assist the family with decision making the nurse should first ask which question? A. "What type of assistance does your mother require?" Answers Correct A Student's A B. "Are you able to assist with the care of your mother in any manner?" C. "What is your opinion of nursing homes or assisted living facilities?" D. "Is your mother taking any over the counter or prescription medications at the present time?" Review Information: The correct answer is A: "What type of assistance does your mother require?" Learning Objective: Lesson 4 Psychosocial Integrity The initial question should focus on the client's needs as the family sees them. Since the client is cognitively impaired the client is not a reliable source of information for decision making. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 1174 A client diagnosed with amyotrophic lateral sclerosis (ALS) is scheduled for 160 mL of enteral feeding as a bolus every four hours. Before flushing with water the nurse aspirates the gastric feeding tube and gets back 180 mL of undigested feeding or residual. What is the appropriate intervention guided by a health care agency protocol? A. reinsert the residual and then flush with sterile water B. reinsert the residual and hold the next feeding C. discard the residual and hold the next feeding D. discard the residual and administer the feeding Answers Correct B Student's B Review Information: The correct answer is B: reinsert the residual and hold the next feeding Learning Objective: Lesson 8 Physiological Adaptation A common protocol is that if a residual is greater than 150 mL, then the next feeding should be held. The reinsertion of the 180 mL should be done by the nurse. Administration of water or the next feeding does not help with the digestion of this feeding. Discarding the feeding that was aspirated depletes the body of enzymes and electrolytes that have been mixed with the feeding. If residuals are consistently discarded the outcome may be the acid-base imbalance of metabolic alkalosis from the significant loss of acid. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Practice Bank 25 Ref # 821 During the history of a pregnant woman, which factor should a nurse recognize as a priority contraindication for breast feeding? A. lactose intolerance B. uses cocaine on weekends C. age of 40 years-old D. drinks 4 ounces of wine daily Answers Correct B Student's B Review Information: The correct answer is B: uses cocaine on weekends Learning Objective: Lesson 3 Health Promotion and Maintenance Binge use of cocaine can be just as harmful to the breastfed newborn as regular daily use of cocaine. Alcohol is also contraindicated. However, between the two substances cocaine is the more dangerous. Test-taking Tips: The key words in this question are “priority factor which should be a contraindication for breast- feeding.” As each response is read, ask: which of these would lead to the worst outcome for the infant who is breastfed? This leads to the selection of the correct response. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 811 A nurse observes a newborn whose Apgar score was 8 at one minute and then 9 at the five minute evaluation. These scores would be more commonly related to abnormalities in which of these areas? Answers Correct C Student's C A. muscle tone B. cry C. color D. heart rate Review Information: The correct answer is C: color Learning Objective: Lesson 3 Health Promotion and Maintenance Acrocyanosis (blue hands and feet) is the most common Apgar score deduction, and is a normal adaptation in the newborn in response to the environment. If the environment is cool then the hands and feet would display a more bluish discoloration. It lasts on average for 48 to 72 hours. Test-taking Tips: The clue in the question is "more commonly." This question requires an approach to ask several questions: Is this a low Apgar score? If there was a problem with heart rate, muscle tone, and cry, would a lower score than 8 or 9 be expected? Recall that the maximum score is 10 for Apgar. The next question: Would a newborn be expected to have some discoloration of the extremities? This is associated with color changes which is most common with newborns. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 1201 During a dialysate exchange for a client who gets acute peritoneal dialysis, which finding would alert a nurse that the client has developed an acute complication? A. the client sleeps throughout the fluid exchange B. the dressing around the catherter becomes saturated with clear fluid C. a pulse of 86 and blood pressure of 112/74 D. a respiratory rate of 30 with crackles Answers Correct D Student's D Review Information: The correct answer is D: a respiratory rate of 30 with crackles Learning Objective: Lesson 8 Physiological Adaptation The development of an increased respiratory rate with crackles indicates fluid overload, which is an acute complication of peritoneal dialysis. In one incorrect response the vital signs are within normal parameters. Sleeping throughout the fluid exchange is a normal expectation and indicates that the client is comfortable. Clear fluid on the dressing around the catheter indicates leakage of the dialysate fluid and can be controlled by instilling less fluid with each exchange. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 810 In checking a postpartum client, a nurse palpates a firm fundus. Also observed is a constant trickle of bright red blood from the vaginal opening. The nurse should suspect which complication? Answers Correct D Student's D A. clotting disorder B. retained placenta C. uterine atony D. vaginal lacerations Review Information: The correct answer is D: vaginal lacerations Learning Objective: Lesson 3 Health Promotion and Maintenance Continuous bleeding in the absence of a boggy fundus indicates undetected vaginal tract lacerations. Test-taking Tips: The key to this answer is that the amount of bleeding is small (trickle). Three of the options would result in excessive bleeding. Therefore by process of elimination, the answer is vaginal lacerations. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 1054 A postoperative client is admitted to the postanesthesia care unit. An anesthetist reported that malignant hyperthermia occurred during surgery. A nurse should recognize that this complication is related to which condition? A. allergy to general anesthesia B. preexisting bacterial infection C. a genetic predisposition D. selected surgical procedures Answers Correct C Student's A Review Information: The correct answer is C: a genetic predisposition Learning Objective: Lesson 6 Pharmacological Therapies Malignant hyperthermia is a rare, potentially fatal adverse reaction to inhaled anesthetics. There is a genetic predisposition to this disorder. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1055 A client being discharged from the cardiac stepdown unit after a myocardial infarction (MI), is given a prescription for a beta-blocking medication. A nursing student asks a nurse why this medication would be used by a client who is not hypertensive. What is the appropriate response by the nurse? A. "This medication will decrease the workload on the heart." B. "Beta-blockers increase the strength of heart contractions." Answers Correct A Student's A C. "A beta-blocker will prevent orthostatic hypotension." D. "Most people develop hypertension following an MI." Review Information: The correct answer is A: "This medication will decrease the workload on the heart." Learning Objective: Lesson 6 Pharmacological Therapies One action of beta-blockers is to decrease systemic vascular resistance by dilating arterioles. This is useful for the client with coronary artery disease, and will reduce the risk of another MI or sudden death. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1050 The client is newly diagnosed with angina and the nurse is reinforcing information about wearing a nitroglycerin patch. The client asks why each patch can only be worn for about 12 hours. Which response by the nurse is the best? A. Postural hypotension B. Skin irritation C. Severe headaches D. Medication tolerance Answers Correct D Student's D Review Information: The correct answer is D: Medication tolerance Learning Objective: Lesson 6 Pharmacological Therapies Removing a nitroglycerine patch for a period of 10 to 12 hours daily prevents medication tolerance which can occur with continuous patch use. Some of the more common side effects of nitroglycerin are headache, dizziness, lightheadedness, nausea, redness or irritation of the skin that was covered by the patch and flushing. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1048 A client with a history of heart disease takes daily prophylactic aspirin. A nurse should monitor which finding that might indicate aspirin toxicity? A. Sore throat B. Tinnitus C. Papular rash Answers Correct B Student's C D. Fatigue Review Information: The correct answer is B: Tinnitus Learning Objective: Lesson 6 Pharmacological Therapies Tinnitus, or ringing in the ears, is a potential side effect of aspirin therapy. If a client is experiencing tinnitus, the medication should be withheld and the health care provider notified. In order to help prevent side effects, the client should understand the correct dosage (usually a prophylactic dose is a 81 mg tablet taken once a day). Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1199 A nurse is caring for a client diagnosed with endstage renal disease. What action should the nurse take to assess for patency in a fistula that is used for hemodialysis? A. palpate the skin over the fistula for a thrill B. check color and warmth in the extremity C. observe for edema proximal to the fistula site D. irrigate with 5 mLs of sterile 0.9% normal saline Answers Correct A Student's A Review Information: The correct answer is A: palpate the skin over the fistula for a thrill Learning Objective: Lesson 8 Physiological Adaptation To assess for patency in a fistula or graft, the nurse auscultates for a bruit and palpates for a thrill. The incorrect responses may be correct actions; however, they are not related to evaluation for patency. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 1198 Which of these findings during the care of a client diagnosed with uncontrolled hypertension should prompt a nurse to take an immediate action? A. bilateral lower extremity pitting edema B. weakness in left arm with a duration of one hour Answers Correct B Student's B C. jugular vein distention at 30 degrees elevation D. bilateral rales in the lower lobes Review Information: The correct answer is B: weakness in left arm with a duration of one hour Learning Objective: Lesson 8 Physiological Adaptation In a client with hypertension, weakness in the extremities is a neurological sign of cerebral involvement with the risk of a cerebral infarction or stroke. Cerebral infarctions account for about 80% of the strokes in clients with hypertension. The remaining three choices indicate mild fluid overload and are not considered emergencies. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 4491 A 30 year-old primigravida arrives at the labor and delivery unit to be admitted for severe preeclampsia. She states she has a headache. Lab results indicate elevated liver enzymes. Place the cursor over the area of the client’s body that would provide you with more information about her laboratory results. Answers Correct Student's Review Information: The correct answer is Learning Objective: Lesson 8 Physiological Adaptation Elevated liver enzymes occur from blood flow obstructed by fibrin deposits found when hemolysis occurs in severe preeclampsia. Subsequent liver distention follows and results in epigastric pain. The liver is located in the right upper quadrant of the abdomen. Davidson, M., London, M., & Ladewig, P. (2008). Olds' maternal- newborn nursing & women’s health across the lifespan (8th ed.). Upper Saddle River, NJ: Prentice Hall. Hockenberry, M.J. (2008).Wong's nursing care of infants and children (8th ed.). St. Louis, MO: Mosby Ref # 1051 A nurse practicing in a long term care facility recognizes that the older clients are at greater risk for medication toxicity than younger adults because of which information? Answers Correct D Student's D A. older adults are often malnourished and anemic B. more rapid hepatic metabolism occurs C. absorption of medications occur more readily from the GI tract D. less body water and more fat are found in older adults Review Information: The correct answer is D: less body water and more fat are found in older adults Learning Objective: Lesson 6 Pharmacological Therapies Because elderly persons have decreased lean body tissue/water in which to distribute medications, more medication remains in the circulatory system with potential for medication toxicity. Increased body fat results in greater amounts of fat-soluble medications being absorbed, leaving less in circulation, and thus increasing the duration of action of the medication. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1200 A nurse is caring for a client who is diagnosed with chronic renal failure and has hemodialysis three times per week. The client becomes confused and irritable six hours before the next treatment. Which of these findings might explain the reason for the client’s behavior? A. elevated blood urea nitrogen (BUN) B. metabolic alkalosis C. potassium loss with a deficit D. low calcium levels from depletion Answers Correct A Student's C Review Information: The correct answer is A: elevated blood urea nitrogen (BUN) Learning Objective: Lesson 8 Physiological Adaptation Confusion and irritability are findings of renal encephalopathy secondary to elevated levels of BUN and creatinine in the blood. Potassium levels are generally high in renal failure along with phosphate levels. Calcium may be low in chronic renal failure. However, the side effects of low calcium levels are exhibited as abdominal or muscle cramping, parasthesias of the extremities, and hyperactive reflexes. Metabolic acidosis, not alkalosis, results from renal failure. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 1049 A client has a new prescription for an selective serotonin reuptake inhibitor (SSRI) antidepressant. In reviewing the admission history and physical, which data should lead a nurse to question the safety of this medication? Answers Correct D Student's D A. diagnosis of vascular disease B. takes antacids frequently C. history of obesity D. prescribed use of an MAO inhibitor Review Information: The correct answer is D: prescribed use of an MAO inhibitor Learning Objective: Lesson 6 Pharmacological Therapies SSRIs should not be taken concurrently with MAO inhibitors because serious, life-threatening reactions may occur with this combination of medications. There should be at least 14 days in between these two types of medications. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 4490 The nurse is caring for a client who had a laparoscopy with excision of endometriosis. Where would the nurse expect to find the incision? Use your cursor to select an area on the image below. Answers Correct Student's Review Information: The correct answer is Learning Objective: Lesson 8 Physiological Adaptation Laparoscopy is the most common procedure used to diagnose and treat endometriosis. A small incision is made near the belly button and the abdomen is filled with CO2 gas; the lighted laparoscope is then inserted into the abdomen. (Two other small incisions are also typically made in the abdomen). Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: Saunders. Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O'Brien, P.G., & Bucher, L. (2009). Medical-surgical nursing: Assessment & management of clinical problems (7th ed.). St. Louis, MO: Mosby. Ref # 820 A nurse is speaking with a woman who is planning a pregnancy. Which statement suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome? A. "I understand that a glass of wine with dinner is healthy for my heart." B. "If I drink, my baby may be harmed even before I know I am pregnant." C. "Drinking alcohol during meals reduces the effects of the alcohol." Answers Correct B Student's B D. "Beer is not really hard alcohol, so I guess I can drink some." Review Information: The correct answer is B: "If I drink, my baby may be harmed even before I know I am pregnant." Learning Objective: Lesson 3 Health Promotion and Maintenance Alcohol has the greatest teratogenic effect during organogenesis which occurs within the first weeks of pregnancy. Therefore, women considering a pregnancy should not drink any alcoholic beverages. Test-taking Tips: If guessing, compare the options to group or cluster the options under a common theme or action. In this case it is ‘OK to drink.” Three of the options are grouped under the theme of OK. Select the odd option. Another approach is to ask yourself: if a client is planning a pregnancy, should she consume alcohol? Read the answers carefully and you will note that one option shows an understanding by the client about alcohol and fetal alcohol syndrome. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 812 A 52 year-old woman who is postmenopausal asks a nurse “How frequently should I have a mammogram?” The nurse's best response should be which comment? A. "Your health care provider will advise you about your risks." B. "Once a woman reaches 40 years of age, she should have a screening mammogram yearly." C. "Yearly mammograms are advised for all women over 35." D. "Unless you had previous problems, every 2 years is best." Answers Correct B Student's B Review Information: The correct answer is B: "Once a woman reaches 40 years of age, she should have a screening mammogram yearly." Learning Objective: Lesson 3 Health Promotion and Maintenance The National Cancer Institute recommends a screening mammogram at 40 and then every one to two years if a woman is healthy with no risk for breast cancer. The American Cancer Society recommends a screening mammogram at 40 and then every year if a woman is healthy with no risk for breast cancer. Black, J., & Hawks, J. (2008). Medical surgical nursing: Clinical management for positive outcomes (8th ed.). St. Louis, MO: Mosby. Smeltzer, S.C., Bare, B.G., Hinkle, J., & Cheever, K.H. (2009). Brunner- Suddarth's textbook of medical surgical nursing (12th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 1053 A postoperative client has a prescription for acetaminophen with codeine. A nurse should recognize that a primary effect of this combination is what action? Answers Correct B Student's B A. medication tolerance prevention B. enhanced pain relief C. minimized side effects D. faster onset of action Review Information: The correct answer is B: enhanced pain relief Learning Objective: Lesson 6 Pharmacological Therapies Combination of analgesics with different mechanisms of action can afford greater pain relief. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1202 A nurse admits a client with a three day history of fever, bilateral flank pain, and an elevated blood pressure. Which data obtained in the admission interview alerts the nurse that this may be acute glomerulonephritis? A. history of mild hypertension B. diabetes mellitus type 1 since age 15 C. travel to a foreign country D. severe sore throat three weeks ago Answers Correct D Student's D Review Information: The correct answer is D: severe sore throat three weeks ago Learning Objective: Lesson 8 Physiological Adaptation In the many cases of acute glomerulonephritis there is a history of a group beta streptococcal infection of the throat that precedes the onset of the renal infection by two-to-three weeks. The incorrect responses do not suggest acute glomerulonephritis. Travel to a foreign country may result in a gastrointestinal infection such as giardia, dysentery – a severe form of diarrhea, or cholera if contaminated water is ingested. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 1194 To prevent unnecessary hypoxia during suctioning through a tracheostomy, a nurse should use which action? A. lubricate three to four inches of the catheter tip B. apply suction for no more than ten seconds Answers Correct B Student's B C. withdraw catheter in a circular motion D. maintain sterile technique Review Information: The correct answer is B: apply suction for no more than ten seconds Learning Objective: Lesson 8 Physiological Adaptation Applying suction for more than ten seconds may result in hypoxia. The clue was to read the question correctly - it asked about prevention of hypoxia as associated with suctioning. Although the incorrect responses are important and correct to do during suctioning through a tracheostomy, hypoxia results from actions that decrease the oxygen supply. The clue was to read the question correctly - it asked about prevention of hypoxia as associated with suctioning. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Christensen, B., & Kockrow, E. (2010). Foundations of nursing and adult health nursing (6th ed.). St. Louis, MO: Mosby. Practice Bank 26 Ref # 1206 During a fluid exchange for a client who is 48 hours postinsertion of an abdominal Tenckhoff catheter for peritoneal dialysis, a nurse knows that the appearance of which finding needs to be reported to the health care provider immediately? A. slight pink - tinged drainage B. cloudy drainage C. abdominal discomfort D. muscle weakness Answers Correct B Student's B Review Information: The correct answer is B: cloudy drainage Learning Objective: Lesson 8 Physiological Adaptation Cloudy drainage is a finding that indicates infection which can lead to peritonitis, an inflammation of the peritoneum. The incorrect responses are expected side effects during the exchanges of the peritoneal dialysis procedure. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Linton, A.D. (2007). Introduction to medical surgical nursing (4th ed.). Philadelphia: Saunders. Ref # 1059 A client has an order for home antibiotic therapy after hospital treatment of a staph infection. Which priority information should a nurse reinforce on discharge? Answers Correct A Student's C A. complete the full course of medications B. visit the health care provider in a few weeks C. monitor for signs of recurrent infection D. schedule follow-up blood cultures with the health care provider Review Information: The correct answer is A: complete the full course of medications Learning Objective: Lesson 6 Pharmacological Therapies In order for antibiotic therapy to be effective in the eradication of an infection, the client must complete the entire course of prescribed therapy. When findings subside, stopping the medication may lead to recurrence or subsequent medication resistance. The other options may or may not be done. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1204 When visiting in the home of a client diagnosed with urinary incontinence, which content should be reinforced to the client? A. restrict fluid to prevent incontinence accidents B. avoid taking antihistamines at any time C. hold the urine to increase bladder capacity D. avoid eating foods high in sodium Answers Correct B Student's B Review Information: The correct answer is B: avoid taking antihistamines at any time Learning Objective: Lesson 8 Physiological Adaptation Antihistamines can aggravate urinary incontinence and should be avoided in clients with urinary incontinence. To hold the urine, avoid high sodium foods, and restrict fluids have not been shown to reduce urinary incontinence. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Williams, L. (2007). Understanding medical surgical nursing (3rd ed.). Philadelphia: F.A. Davis Company. Ref # 1228 A client who had a left arterial revascularization of the leg four hours ago developed increasing pain in the left lower extremity. Upon assessment the nurse notes increased swelling and tenderness with other findings that suggest compartment syndrome. Which of these nursing interventions should take priority? A. notify the surgeon immediately B. repeat the neurovascular assessment Answers Correct A Student's C C. place the extremity at the level of the heart D. loosen the dressing at the incision site Review Information: The correct answer is A: notify the surgeon immediately Learning Objective: Lesson 8 Physiological Adaptation The health care provider should be informed immediately in order to intervene for the prevention of the loss of the limb. After notification the nurse should continue to assess until the surgeon arrives. The client with an arterial disorder should not have that extremity elevated higher than the heart since this type of position will decrease the blood to the distal extremity. Christensen, B., & Kockrow, E. (2010). Foundations of nursing and adult health nursing (6th ed.). St. Louis: Mosby. Williams, L. (2007). Understanding medical surgical nursing (3rd ed.). Philadelphia: F.A. Davis Company. Ref # 1222 A nurse notes cloudy drainage two days postinsertion of a Tenckhoff catheter for peritoneal dialysis, what other data should a nurse collect before reporting this finding? A. urine output B. bowel sounds C. breath sounds D. temperature Answers Correct D Student's D Review Information: The correct answer is D: temperature Learning Objective: Lesson 8 Physiological Adaptation This finding may indicate infection so the temperature is essential to evaluate before notification of the care provider. Another vital sign that needs to be checked would be the heart rate which with fever increases. Christensen, B., & Kockrow, E. (2010). Foundations of nursing and adult health nursing (6th ed.). St. Louis: Mosby. Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: Saunders. Ref # 822 A client is in her third month of her first pregnancy. During the interview, she states: "I have had sexual relations with several partners and am unsure of the identity of the baby's father.” Which nursing intervention should be a priority? A. ask about tests for sexually transmitted infections B. refer the client to a family planning clinic Answers Correct C Student's C C. request the RN to counsel the woman to consent for HIV screening D. discuss with her the risk for cervical cancer Review Information: The correct answer is C: request the RN to counsel the woman to consent for HIV screening Learning Objective: Lesson 3 Health Promotion and Maintenance The client's behavior places her at risk for infection with HIV. Testing is the first step. If the woman is HIV positive, the earlier treatment begins, the better the outcome for her and the newborn. Test-taking Tips: The key words in this question are “several partners,” “third month of pregnancy” and “priority” for the nursing intervention. These words immediately allow for the consideration of two of the options. Between the two options ask: which one is the worst scenario? Which one is more dangerous to the fetus and the mother in the long term and least likely to be effectively treated? Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 1058 A nurse should emphasize to a client diagnosed with tuberculosis and prescribed INH and rifampin that follow-up appointments must be kept for critical lab tests of which organ? A. pancreas B. kidney C. liver D. heart Answers Correct C Student's C Review Information: The correct answer is C: liver Learning Objective: Lesson 6 Pharmacological Therapies INH and rifampin can cause hepatocellular injury and hepatitis. This side effect is age-related and can be detected with regular assessment of liver enzymes, which are released into the blood from damaged liver cells. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1061 A client has been taking furosemide (Lasix) for the past week. A nurse should recognize which finding as an indication that the client is experiencing a negative side effect from the medication? A. decreased appetite B. weight gain of five pounds C. edema of the ankles Answers Correct A Student's A D. gastric irritability Review Information: The correct answer is A: decreased appetite Learning Objective: Lesson 6 Pharmacological Therapies Lasix causes a loss of potassium if a supplement is not taken. Findings of hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, dysrhythmias. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 881 The major developmental task that a woman must accomplish during the first trimester of pregnancy is the acceptance of which issue? A. the satisfactory resolution of fears related to giving birth B. the potential risk for a termination of the pregnancy C. the pregnancy and the physical changes that are involved D. the fetus as a separate and unique being Answers Correct C Student's C Review Information: The correct answer is C: the pregnancy and the physical changes that are involved Learning Objective: Lesson 3 Health Promotion and Maintenance During the first trimester the maternal focus is directed toward acceptance of the pregnancy and adjustment to the minor discomforts. Ambivalence is a normal, expected emotion. Test-taking Tips: The key words in this question are “major task during the first trimester.” Eliminate one of the options since it has nothing to do with the question. As the options are read, compare and ask: “What trimester would these occur in?" One option would occur in the second trimester, and another option would occur in the third. The question asks about the first trimester so select the remaining option. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 1205 A client diagnosed with cystitis has been on oral antibiotics for 72 hours. Which report from the client requires further assessments by a nurse? Answers Correct D Student's D A. “It burns when I go to the bathroom to pass my urine.” B. “My urine smells bad when I go to the bathroom.” C. “I have been sick at my stomach and don’t feel like eating much the past few days.” D. “I felt hot, took my temperature and it has been elevated for the past 24 hours.” Review Information: The correct answer is D: “I felt hot, took my temperature and it has been elevated for the past 24 hours.” Learning Objective: Lesson 8 Physiological Adaptation Elevated temperature after 72 hours of being on an antibiotic indicates that the antibiotic is not effective in destruction of the offending organism. The provider should be informed immediately so that a different and more effective medication can be prescribed and so that complications such as pyelonephritis are prevented. Two incorrect responses are expected with cystitis. The other incorrect response may be related to the antibiotics as a side effect and should also be reported to the provider. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: Saunders. Ref # 4495 The client has been recently diagnosed with gastroesophageal reflux disease (GERD) and is reviewing information about the disease with the nurse. The nurse identifies which area of the gastrointestinal tract as the cause of GERD? Use your cursor to select an area on the image below. Answers Correct Student's Review Information: The correct answer is Learning Objective: Lesson 8 Physiological Adaptation In most people diagnosed with GERD, the pathophysiology involves a relaxation of the lower esophageal sphincter (LES). This allows reflux of stomach acid into the esophagus, which produces the symptoms and damage to the esophagus. The LES is a ring of smooth muscle fibers located at the junction of the stomach and the esophagus. Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: Saunders. Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O'Brien, P.G., & Bucher, L. (2009). Medical-surgical nursing: Assessment & management of clinical problems (7th ed.). St. Louis, MO: Mosby. Ref # 866 What observation signifies that a child has attained the stage of concrete operations (Piaget)? A. talks about thinking in mental images or word pictures B. makes the moral judgment that "stealing is wrong" Answers Correct B Student's A C. reasons that homework is time-consuming but necessary D. explores the environment using sight and movement Review Information: The correct answer is B: makes the moral judgment that "stealing is wrong" Learning Objective: Lesson 3 Health Promotion and Maintenance The stage of concrete operations, commonly defined as ages 7 to 12 years-old, is depicted by logical thinking and moral judgments. However, they can only think about actual physical objects. They cannot handle abstract reasoning. This stage is also characterized by a loss of egocentric thinking. One incorrect response is a characteristic of the sensorimotor phase from birth to about two years of age. Another incorrect response is part of the second phase, preoperational which can be associated with preschooler. The final incorrect response describes a characteristic of the formal operations phase during adolescence. Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 1203 A nurse is caring for a client with a vascular access for hemodialysis. Which of these findings necessitates immediate action by the nurse? A. dry, hacking cough B. pruritic rash C. chronic fatigue D. elevated temperature Answers Correct D Student's D Review Information: The correct answer is D: elevated temperature Learning Objective: Lesson 8 Physiological Adaptation It is a priority to report this finding since clients on hemodialysis are prone to infection and the first finding of infection is an elevated temperature. Further data collection is needed to identify the source of the infection. Other findings should be reported to the care provider as well but do not require immediate action. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 1057 To prevent medication resistance common to a tubercle bacilli infection, a nurse should be aware that clients with tuberculosis are often treated using which approach? A. higher than normal doses B. an aminoglycoside antibiotic C. an anti-inflammatory agent Answers Correct D Student's D D. two or more anti-tuberculosis medications Review Information: The correct answer is D: two or more anti- tuberculosis medications Learning Objective: Lesson 6 Pharmacological Therapies Resistance of the tubercle bacilli often occurs with the use of a single antimicrobial agent. Therefore, therapy with multiple medications over a long period of time, usually at least six months to two years, helps to ensure eradication of the organism. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 883 Which finding is an expected variation in the newborn resulting from the presence of maternal hormones in the newborn? A. edema of the scrotum B. lanugo on the extremities C. engorgement of the breasts D. Mongolian spots Answers Correct C Student's C Review Information: The correct answer is C: engorgement of the breasts Learning Objective: Lesson 3 Health Promotion and Maintenance Breast engorgement occurs in both sexes as a result of maternal hormones. Test-taking Tips: This is an “exception question” that does not have the word “except” in the stem. Instead, in the stem the keyword is “variation” in a newborn. If guessing, remember that the correct answer in an “exception” question is the “odd” answer. Ask , which three options have associations or can be clustered as being usual in the newborn? The answer that is not one of those three would be the “variation.” Notice that three of the options are more usual in newborns (this is the association). One option is specifically associated with “maternal hormones”, as addressed in the stem of the question. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 1056 A client taking isoniazide (INH) for tuberculosis asks a nurse about side effects of the medication. The nurse should emphasize the need to immediately report which findings? Answers Correct C Student's B A. confusion and lightheadedness B. double vision and visual halos C. extremity tingling and numbness D. photophobia and photosensitivity Review Information: The correct answer is C: extremity tingling and numbness Learning Objective: Lesson 6 Pharmacological Therapies Peripheral neuropathy is the most common side effect of INH and should be reported to the health care provider. It can be reversed or minimized with B6 vitamin or adequate amounts of foods with B6. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 4492 The nurse is caring for a client following a thyroidectomy. The laboratory results indicate hypocalcemia, probably related to parathyroid gland damage when the thyroid gland was removed. Identify the part of the body the nurse should check to assess Chvostek's sign. Use your cursor to select an area on the image below. Answers Correct Student's Review Information: The correct answer is Learning Objective: Lesson 8 Physiological Adaptation A positive Chvostek's sign is a finding in severe hypocalcemia,(low calcium level) which frequently occurs after thyroid surgery due to incidental parathyroid tissue removal during the surgery. A positive Chvostek's sign is twitching of the mouth lips and or cheek with stimulation of the facial nerve. Perform this test by tapping about 2 centimeters anterior to the earlobe, just below the zygomatic arch on the cheek. Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O'Brien, P.G., & Bucher, L. (2009). Medical-surgical nursing: Assessment & management of clinical problems (7th ed.). St. Louis, MO: Mosby. Smeltzer, S.C., Bare, B.G., Hinkle, J., & Cheever, K.H. (2009). Brunner- Suddarth's textbook of medical surgical nursing (12th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 880 A woman who is pregnant has been advised to alter her diet during pregnancy by increasing the intake of protein and vitamin C to meet the needs of the growing fetus. Which diet choice would best meet the woman’s needs? Answers Correct D Student's C A. 3 oz. chicken, . cup of corn, lettuce salad, small banana B. scrambled egg, hash browned potatoes, halfglass of buttermilk, large nectarine C. 1 cup of macaroni, . cup peas, glass whole milk, medium pear D. beef, . cup lima beans, glass of skim milk, . cup of strawberries Review Information: The correct answer is D: beef, . cup lima beans, glass of skim milk, . cup of strawberries Learning Objective: Lesson 3 Health Promotion and Maintenance Beef and beans are an excellent source of protein as is skim milk. Strawberries are a good source of vitamin C. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 1060 A client is receiving digoxin (Lanoxin) 0.25 mg daily. A health care provider has written a new order to give metoprolol (Lopressor) 25 mg BID. In checking the client prior to administering the medications, which finding should a nurse report immediately to the registered nurse (RN) charge nurse? A. urine output 50 mL/hour B. heart rate 76 C. respiratory rate 16 D. blood pressure 94/60 Answers Correct D Student's C Review Information: The correct answer is D: blood pressure 94/60 Learning Objective: Lesson 6 Pharmacological Therapies Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60-100; systolic BP over 100) in order to safely administer both medications. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 872 Which statement made by a female client indicates a need for additional discussion about the impact of body-image alterations after a mastectomy? A. "It really isn't much of a problem for me, I never had large breasts anyway." Answers Correct C Student's C B. "I plan to volunteer and work with others who have had mastectomies in Reach for Recovery." C. "I can't bear to look at myself in the mirror. What will my partner think?" D. "I guess it's time for me to quit wearing a bikini anyway." Review Information: The correct answer is C: "I can't bear to look at myself in the mirror. What will my partner think?" Learning Objective: Lesson 3 Health Promotion and Maintenance This statement illustrates the client's anxiety. A nurse should recognize this, and help the client to begin to identify anxiety and the assault to her self image. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Practice Bank 27 Ref # 1143 A primigravida’s membranes spontaneously ruptured (ROM) four hours ago. At the time of the ROM the vital signs were T-99.8 degrees Fahrenheit, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor? A. temperature 100 degrees Fahrenheit B. FHT 168 beats/min C. BP 138/88 D. cervical dilation of 4 cm Answers Correct B Student's B Review Information: The correct answer is B: FHT 168 beats/min Learning Objective: Lesson 3 Health Promotion and Maintenance An increase in FHT may indicate fetal compromise from the beginning of a maternal infection. The other assessment findings are within normal parameters. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 901 The clinic nurse is performing the intake assessment for a 74 year-old male. The client has a history of benign prostatic hypertrophy (BPH) and reports having trouble voiding. After the client uses the bathroom to void, how would the nurse practitioner best assess distention of the bladder? Answers Correct A Student's A A. Scan the bladder using a portable ultrasound scanner B. Check for rebound tenderness C. Insert an intermittent urinary catheter D. Look for rounded swelling above the pubis Review Information: The correct answer is A: Scan the bladder using a portable ultrasound scanner Learning Objective: Lesson 3 Health Promotion and Maintenance Urinary retention and incomplete bladder emptying can result from urethral obstruction, as seen in BPH. The nurse can palpate the area from the umbilicus towards the symphysis pubis; an empty bladder rests behind the symphysis pubis and should not be palpable. The nurse can also percuss this area; a urine-filled bladder produces a dull sound. But a bladder ultrasound scanner is usually more effective than manual palpation since it registers bladder volume digitally. Routine catheterization to check for post void residual is not recommended; but if bladder distention is greater than 200 mL, the client may need to be catheterized. Black, J., & Hawks, J. (2008). Medical surgical nursing: Clinical management for positive outcomes (8th ed.). St. Louis, MO: Mosby. Smeltzer, S.C., Bare, B.G., Hinkle, J., & Cheever, K.H. (2009). Brunner- Suddarth's textbook of medical surgical nursing (12th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 1186 A client being discharged today and has been taking K-dur 20mEq per day by mouth. A nurse should reinforce that potassium levels will be decreased by which substance? A. occasional use of a nonsteroidal antiinflammatory medication (NSAID) B. frequent daily snacks of black licorice C. prescribed potassium-sparing diuretics D. foods seasoned with salt substitute Answers Correct B Student's B Review Information: The correct answer is B: frequent daily snacks of black licorice Learning Objective: Lesson 6 Pharmacological Therapies Excessive intake of black licorice can lead to decreased K+ levels due to the effect of glyceric acid (aldosterone effect). The excessive intake of salt substitutes, K+ sparing diuretics and NSAIDs all have the potential for raising the K+ level. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 4498 The nurse is using the image below to explain and clarify information about the client's colostomy. Based on this image, which of the following statements about the consistency of the drainage is correct? A. The feces are semiformed to formed Answers Correct A Student's A B. The feces have a normal, formed consistency C. The feces are mushy (liquid to semiformed) D. The feces are liquid to semiliquid and the discharge is often irritating to the skin around the stoma Review Information: The correct answer is A: The feces are semiformed to formed Learning Objective: Lesson 8 Physiological Adaptation This is an image of a descending colostomy. The feces will be semiformed to formed because much of the water has already been absorbed. Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O'Brien, P.G., & Bucher, L. (2009). Medical-surgical nursing: Assessment & management of clinical problems (7th ed.). St. Louis, MO: Mosby. Smeltzer, S.C., Bare, B.G., Hinkle, J., & Cheever, K.H. (2009). Brunner- Suddarth's textbook of medical surgical nursing (12th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 1069 A client on warfarin (Coumadin) therapy after coronary artery stent placement calls the health clinic to ask "Can I take Alka-Seltzer for an upset stomach?" A nurse should respond to this client with what comment? A. "Take Alka-Seltzer at a different time of day than the warfarin." B. "Use one-half the recommended dose of Alka-Seltzer." C. "Select another antacid that does not interfere with warfarin." D. "Avoid Alka-Seltzer because it contains aspirin." Answers Correct D Student's D Review Information: The correct answer is D: "Avoid Alka-Seltzer because it contains aspirin." Learning Objective: Lesson 6 Pharmacological Therapies Alka-Seltzer is an over-the-counter aspirin-antacid combination. Aspirin, an antiplatelet medication, will potentiate the anticoagulant effect of warfarin and may result in increased bleeding tendencies. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1068 What should a nurse emphasize to avoid for a client who takes Coumadin (warfarin) at home? A. exposure to sunlight B. large indoor gatherings Answers Correct C Student's C C. foods rich in vitamin K D. active physical exercise Review Information: The correct answer is C: foods rich in vitamin K Learning Objective: Lesson 6 Pharmacological Therapies Vitamin K acts as an antidote to the pharmacologic action of Coumadin therapy to decrease the medication's effectiveness. Foods high in vitamin K include dark greens, tomatoes, bananas, cheese, and fish. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1230 Five days post op after a total hip replacement a client is ambulating with a walker. The client is to be discharged later in the day. Which finding documented in the morning nurse's notes requires priority attention? A. hip discomfort rated as 3/10 on the pain scale of 1/10 B. serous drainage with crusting at one corner of the surgical site C. a new onset of agitation and confusion for 15 minutes D. redness with minimal swelling around the incision site Answers Correct C Student's A Review Information: The correct answer is C: a new onset of agitation and confusion for 15 minutes Learning Objective: Lesson 8 Physiological Adaptation Agitation along with confusion may alert the nurse to an alteration in cerebral tissue perfusion. This may suggest an embolus to the lung from the lower extremity. Pulmonary embolism, often from a fat embolism, is a more common complication after hip replacement. The other responses are expected findings at this time postoperative. Williams, L. (2007). Understanding medical surgical nursing (3rd ed.). Philadelphia: F.A. Davis Company. Christensen, B., & Kockrow, E. (2010). Foundations of nursing and adult health nursing (6th ed.). St. Louis: Mosby. Ref # 1077 Which over-the-counter (OTC) medication should a nurse recognize as having the most elemental calcium per tablet? Answers Correct B Student's B A. calcium chloride B. calcium carbonate C. calcium citrate D. calcium gluconate Review Information: The correct answer is B: calcium carbonate Learning Objective: Lesson 6 Pharmacological Therapies Calcium carbonate contains 400mg of elemental calcium in 1 gram of calcium carbonate. Thus, this is the recommended type for persons who need calcium replacement. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1226 A client has been taking nifedipine (Procardia) for a diagnoses of Raynaud’s disease and hypertension. Which finding would indicate that the client may be having a side effect of the medication? A. cyanosis of the lips B. increased pain in fingers C. facial flushing D. decreased urinary output Answers Correct C Student's C Review Information: The correct answer is C: facial flushing Learning Objective: Lesson 6 Pharmacological Therapies Treatment for Raynaud’s and for hypertension is the use of a vasodilator such as Procardia. As a result of the vasodilating effect facial flushing can occur. Cyanosis of the lips is not a documented finding. The urinary output may increase due to the vasodilation and the resulting increased blood flow through the kidneys. The pain in the fingers should decrease. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1062 A client has been newly diagnosed with hypothyroidism and takes levothyroxine (Synthroid) 50 mcg/day by mouth. A nurse should emphasize that this medication has what specific guideline? A. will decrease the client's heart rate B. must be stored in a dark container C. should be taken in the morning Answers Correct C Student's A D. may decrease the client's energy level Review Information: The correct answer is C: should be taken in the morning Learning Objective: Lesson 6 Pharmacological Therapies Thyroid supplement should be taken on an empty stomach in the morning. Morning dosing minimizes the side effects of insomnia and an empty stomach facilitates absorption. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1208 A client is placed on sulfamethoxazole-trimethoprim (Bactrim) for a recurrent urinary tract infection. Which comment is correct information reinforcement of information by a nurse? A. "Drink at least eight glasses of water a day." B. "Stop the medication after five days." C. "It is safe to take with oral contraceptives." D. "Be sure to take the medication with food." Answers Correct A Student's A Review Information: The correct answer is A: "Drink at least eight glasses of water a day." Learning Objective: Lesson 6 Pharmacological Therapies Bactrim is a highly insoluble medication and requires a large volume of fluid intake. Taking with food is not necessary. Two of the options are incorrect instructions with use of Bactrim. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1215 A home health nurse received a call about an older adult client who had a sudden onset of confusion. The nurse should immediately check the client’s medications for which of these classifications? A. diuretics B. antihistamines C. thyroid medications D. steroids Answers Correct B Student's C Review Information: The correct answer is B: antihistamines Learning Objective: Lesson 6 Pharmacological Therapies Many antihistamines often cause sudden confusion in older adults. Other common medication groups that may result in sudden confusion in this group are anticholinergics, benzodiazepines, NSAIDs, histamine 2 blockers (especially Tagamet) and antihypertensives. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1066 A nurse notes an abrupt onset of confusion in an older adult client. Which recently ordered medication would most likely have contributed to this change in mental status? A. liquid antacid B. cardiac glycoside C. anticoagulant D. antihistamine Answers Correct D Student's D Review Information: The correct answer is D: antihistamine Learning Objective: Lesson 6 Pharmacological Therapies Older adults are susceptible to the side effect of anticholinergic medications, such as antihistamines. Antihistamines often cause confusion, especially at higher doses. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 984 A client has just been diagnosed with breast cancer. As a nurse enters the room, the client states "You are stupid." The most therapeutic response by the nurse is to take which approach? A. explore what is going on with the client B. accept the client’s statement C. tell the client that the comment is inappropriate Answers Correct A Student's A D. make no comment or response Review Information: The correct answer is A: explore what is going on with the client Learning Objective: Lesson 3 Health Promotion and Maintenance The nurse should assist this verbally aggressive client to put angry feelings into words and then to engage in problem solving. The client exhibits being in the angry stage of loss. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 1065 A client who is terminally ill and in hospice has been receiving high doses of an opioid analgesic for the past month. As death approaches and the client becomes unresponsive to verbal stimuli, a nurse should expect that pain management will be of which approach? A. continue the same analgesic dosage B. discontinue the analgesic C. prescribe a less potent medication D. decrease the analgesic dosage by half Answers Correct A Student's C Review Information: The correct answer is A: continue the same analgesic dosage Learning Objective: Lesson 6 Pharmacological Therapies Dying clients who have been in chronic pain will probably continue to experience pain even though they are unresponsive. Pain medication should be continued at the same dosage that was deemed effective when the level of conscious was normal. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1067 A nurse is caring for an older adult client who is diagnosed with heart failure and is receiving digoxin (Lanoxin) therapy. Which finding suggests that the nurse needs to have the registered nurse (RN) check the client? A. constipation B. increased appetite Answers Correct C Student's C C. extreme fatigue D. intense itching Review Information: The correct answer is C: extreme fatigue Learning Objective: Lesson 6 Pharmacological Therapies Extreme fatigue and weakness are common, early signs of digitalis toxicity, which would be evident in serum lab data. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1224 A client who has been receiving heparin for five days has an order to begin taking warfarin (Coumadin) in the evening. Which intervention should a nurse take next? A. discontinue the heparin completely, then administer the Coumadin B. administer the Coumadin in the evening as prescribed C. hold the dose of Coumadin until the provider is reminded that the client is on heparin D. stop the heparin for one hour, them administer the Coumadin Answers Correct B Student's B Review Information: The correct answer is B: administer the Coumadin in the evening as prescribed Learning Objective: Lesson 6 Pharmacological Therapies Coumadin takes two to three days before its anticoagulant effect begins to peak at a therapeutic level. Therefore, the heparin is continued until that point. The prothrombin time (PT) or international normalized ratio (INR) is for the Coumadin monitoring and activated partial thromboplastin time (aPTT) for the heparin will still be monitored daily. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1231 A nurse is assigned to a client diagnosed with a deep vein thrombosis who has been on heparin for five days. The nurse notices that enoxaparin (Lovenox) is added to the medication administration record. Which action should the nurse take? Answers Correct B Student's C A. plan to check the PTT result after the Lovenox is given B. notify the charge nurse that the client is already receiving heparin C. stop the heparin and begin the Lovenox 30 minutes later D. monitor the urine, stool and skin for bleeding Review Information: The correct answer is B: notify the charge nurse that the client is already receiving heparin Learning Objective: Lesson 6 Pharmacological Therapies Enoxaparin (Lovenox) and heparin should not be given together because of the increased anticoagulant effect. The Lovenox can be given 30 minutes after the heparin is discontinued. The given sites in option 4 will be monitored for bleeding. The PTT is not routinely assessed while on enoxaparin (Lovenox). Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1197 A client diagnosed with heart failure has a prescription for digoxin. A nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication may have which effect? A. results in irritability and anxiety B. can predispose to dysrhythmias C. sometimes alters consciousness D. may lead to oliguria Answers Correct B Student's B Review Information: The correct answer is B: can predispose to dysrhythmias Learning Objective: Lesson 6 Pharmacological Therapies The nurse should be aware of a decrease in the client’s potassium levels. Low potassium can enhance the effects of digoxin and predispose the client to digoxin toxicity with dysrhythmias. The other options are seen in hyperkalemia. Muscle weakness occurs in both hyperkalemia and hypokalemia. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Practice Bank 28 Ref # 1221 A practical nurse (PN) is reinforcing discharge teaching to a 65 year-old female client who had been admitted with a diagnosis of renal calculi. Which information should be reinforced as dietary recommendations to prevent any stone recurrence? A. increase foods high in protein B. increase the intake of dietary calcium C. consume foods high in vitamin E D. boost daily sources of vitamin C Answers Correct B Student's B Review Information: The correct answer is B: increase the intake of dietary calcium Learning Objective: Lesson 3 Health Promotion and Maintenance Low calcium diets are not generally recommended. Evidence shows that limiting calcium, especially in women, can lead to osteoporosis and does not prevent renal stones. Research suggests that a higher intake of dietary calcium is strongly associated with a decreased risk of calcium-based renal stones. New theories propose that calcium stone formation in the kidney may be linked to a diet high in protein. Dietary restrictions of purines aid in the prevention of recurrence of renal calculi. Dietary recommendations for prevention of kidney stones include restricting protein to 60 grams every day to decrease urinary excretion of calcium and uric acid. There is no evidence that increasing vitamins E or C affects or prevents the formation of urinary stones. Increases in vitamin C or citrus juices minimizes risk for urinary tract infections. Black, J., & Hawks, J. (2008). Medical surgical nursing: Clinical management for positive outcomes (8th ed.). St. Louis, MO: Mosby. Smeltzer, S.C., Bare, B.G., Hinkle, J., & Cheever, K.H. (2009). Brunner- Suddarth's textbook of medical surgical nursing (12th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 1078 A client diagnosed with anemia has a new prescription for ferrous sulfate (iron). When reviewing the teaching plan with the client, which Answers Correct D Student's D substance should be taken with the medication to enhance its absorption? A. Caffeinated beverages B. Low fat milk C. An antacid D. Tomato juice Review Information: The correct answer is D: Tomato juice Learning Objective: Lesson 6 Pharmacological Therapies Ascorbic acid, found in citrus juices, enhances the absorption of iron. The client should avoid using tea or coffee when taking ferrous sulfate since they decrease the absorption of iron. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1079 A client is admitted to the hospital with a diagnosis of liver failure with ascites. A health care provider orders spironolactone (Aldactone). A nurse should care for the client based on knowledge that this medication has what effect? A. combines safely with antihypertensives B. increases aldosterone levels C. promotes sodium and chloride excretion D. depletes potassium reserves Answers Correct C Student's C Review Information: The correct answer is C: promotes sodium and chloride excretion Learning Objective: Lesson 6 Pharmacological Therapies Spironolactone promotes sodium and chloride excretion while sparing potassium and decreasing aldosterone levels. This medication assists to decrease the fluid accumulation in the abdomen, ascites. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1154 A primigravida in the third trimester is hospitalized for mild preeclampsia. A nurse determines that the client’s diastolic blood pressure has significantly increased. Which action should the nurse take first? A. check the protein level in urine B. take the temperature C. have the client turn to the left side Answers Correct C Student's C D. monitor the urine output Review Information: The correct answer is C: have the client turn to the left side Learning Objective: Lesson 3 Health Promotion and Maintenance A priority action is to turn the client to the left side to decrease pressure on the vena cava and promote adequate circulation to the placenta and the woman's kidneys. Urine protein level and the volume of urine output should be checked with each voiding. Temperature should be monitored every four hours or more often for elevations of more than one degree. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 1216 A resident in a nursing home appears to be forgetful. A nurse suspects short-term memory loss. When collecting data about short-term memory loss, the nurse should take which action first? A. Suggest the client read from a newspaper B. Observe the client during an activity C. Ask the client to state when he was born D. Confirm that a hearing loss is absent Answers Correct D Student's C Review Information: The correct answer is D: Confirm that a hearing loss is absent Learning Objective: Lesson 3 Health Promotion and Maintenance Hearing loss may result in the client answering questions inappropriately, which may be misinterpreted as a short-term memory loss. Asking the client to state his birthdate is used to assess long term memory. Observing the client during activity may be done for mobility concerns or deficits. Having the client read something can be used to assess vision problems. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Miller, C.A. (2008). Nursing for wellness in older adults (5th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 1095 Which information should a nurse reinforce during a discussion about captopril (Capoten) with a client? A. take the medication with meals B. avoid the use of salt substitutes C. restrict fluids to 1000 mL/day Answers Correct B Student's B D. avoid green leafy vegetables Review Information: The correct answer is B: avoid the use of salt substitutes Learning Objective: Lesson 6 Pharmacological Therapies Captopril can cause an accumulation of potassium or hyperkalemia. Clients should avoid the use of salt substitutes, which are generally potassium-based. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1080 A nurse is reinforcing information about the importance to recognize the findings of digoxin toxicity to a client. Which statement made by the client is correct and indicates no need for further teaching? A. "I will experience a loss of appetite." B. "I will report a slower pulse." C. "I may experience nausea and vomiting." D. "I don't have to report blurred vision." Answers Correct B Student's C Review Information: The correct answer is B: "I will report a slower pulse." Learning Objective: Lesson 6 Pharmacological Therapies A slow heart rate is related to increased cardiac output and an intended effect of digoxin. No reporting of heart rate is needed unless the pulse rate is D 60 or D 120 beats per minute for an adult or D 100 or D160 beats per minute for infants and younger children. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1089 A client is receiving total parenteral nutrition (TPN) via a Hickman catheter. The catheter accidentally becomes dislodged from the site. Which intervention by a nurse should take priority? A. check that the catheter tip is intact B. apply a pressure dressing to the site C. check for mental status changes Answers Correct B Student's B D. monitor respiratory status Review Information: The correct answer is B: apply a pressure dressing to the site Learning Objective: Lesson 6 Pharmacological Therapies The client is at risk of bleeding or the development of an air embolus if the catheter exit site is not covered immediately. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1191 A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client reports having itchy and watery eyes, increased anxiety, and difficulty breathing. What should the nurse anticipate the first action in the sequence of care for this client to be at this time? A. Administer epinephrine 1:1000 as ordered B. Maintain the airway C. Monitor for hypotension with shock D. Give diphenhydramine as ordered Answers Correct A Student's C Review Information: The correct answer is A: Administer epinephrine 1:1000 as ordered Learning Objective: Lesson 3 Health Promotion and Maintenance All of the answers are correct actions to perform in this circumstance. The correct sequence of care is to administer the epinephrine, then maintain the airway. In the early stages of anaphylaxis when the client has not lost consciousness and is normotensive, the sequence should be administration of epinephrine, application of the oxygen and then observe for hypotension and shock both of which are later severe allergic reactions. Think of the use of diphenhydramine as a medication with a preventative focus for a severe allergic reactions. - (2008). Prentice Hall real nursing skills essentials [CD-ROM]. Upper Saddle River, NJ: Pearson Prentice Hall. Karch, A.M. (2009). Lippincott's 2009 nursing drug guide (5th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 1179 A newborn who is having difficulty maintaining a temperature above 98 degrees Fahrenheit has been placed into a warming Isolette. Which action is appropriate for a nurse to implement? Answers Correct A Student's A A. monitor the neonate’s temperature continuously B. protect the eyes with patches C. avoid touching the neonate with cold hands D. warm all medications and liquids before administration Review Information: The correct answer is A: monitor the neonate’s temperature continuously Learning Objective: Lesson 3 Health Promotion and Maintenance When using a warming device the neonate’s temperature should be continuously monitored for undesired elevations. Eye patches are used with the bili light for the reduction of jaundice. Warming medications and fluids is not indicated. Touching with cold hands can startle the infant but it does not pose a safety risk. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 1083 A client diagnosed with advanced cirrhosis is started on lactulose (Cephulac). What should a nurse understand about the main purpose of the medication? A. portal hypertension is better controlled B. peristalsis is stimulated C. ammonia levels are reduced D. dietary fiber is added Answers Correct C Student's C Review Information: The correct answer is C: ammonia levels are reduced Learning Objective: Lesson 6 Pharmacological Therapies Lactulose, digested by colon bacteria, forms acids that causes ammonia from the blood to pass into the colon. A secondary action is to stimulate bowel elimination in automatic fashion by pulling water into the colon. Clients often have loose or watery diarrhea stools from this medication. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1211 A home health nurse is making an initial visit to a 70 year-old client. What should be the first action to promote health? A. Review the list of medications B. Assist with planning for meals C. Discuss past health history D. Identify learning needs Answers Correct D Student's D Review Information: The correct answer is D: Identify learning needs Learning Objective: Lesson 3 Health Promotion and Maintenance With the focus on health promotion, the nurse should first identify any learning needs. Once learning needs are identified, the nurse would know if meal planning assistance is needed. Reviewing medications and discussing health history are part of the initial assessment. Helpful hint: since this is a very general question, you should look for a response that's more general. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: Saunders. Ref # 1081 A client with tuberculosis is started on Rifampin. Which statement by a nurse is most appropriate to include when reinforcing information? A. "You may notice an orange-red color to your urine." B. "You may have occasional problems sleeping." C. "You may experience an increase in appetite." D. "You can take the medication with food." Answers Correct A Student's A Review Information: The correct answer is A: "You may notice an orange-red color to your urine." Learning Objective: Lesson 6 Pharmacological Therapies Discoloration of the urine and other body fluids may occur. It is a harmless response to the medication, but the client needs to be aware of it. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1096 A client is started on atenolol (Tenormin). A nurse should emphasize to the client to immediately report which finding? A. Rapid breathing B. Weight gain C. Slow, bounding pulse Answers Correct C Student's C D. Jaundiced sclera Review Information: The correct answer is C: Slow, bounding pulse Learning Objective: Lesson 6 Pharmacological Therapies Atenolol (Tenormin) is a beta-blocker that can cause side effects including bradycardia and hypotension. A tip to recognize this group of medication is that they end in “lol.” They are also give cautiously in clients diagnosed with asthma since they may stimulate bronchospasm as a side effect. Atenolol (Tenormin) is a beta blocker. Side effects of this medication include bradycardia and hypotension, which is why the client should report a slow, bounding pulse. Some beta blockers should be used cautiously in clients diagnosed with asthma because they may stimulate bronchospasm, but this is not the same as "rapid breathing". The spelling of the generic name of beta blockers often end with "lol." Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1178 A newborn who has hyperbilirubinemia is undergoing phototherapy with a blanket. Which safety measure is correct during this therapy? A. withhold feedings while getting the phototherapy B. regulate the neonate’s temperature using a radiant heater C. provide water feedings at least every two hours D. protect the eyes of neonate from the phototherapy Answers Correct C Student's C Review Information: The correct answer is C: provide water feedings at least every two hours Learning Objective: Lesson 3 Health Promotion and Maintenance Frequent water feedings are given every two hours to help with the excretion of the bilirubin within stool. Since the blanket will be up to, but not above, the neck the eyes do not need to be protected when a blanket is used for phototherapy. Protection of the eyes of the neonates is needed if ultraviolet lights are used above an Isolette. These are often called “bili lights.” The neonate’s skin is exposed to the light and the temperature is monitored, and a radiant heater may not be necessary. There is no reason to withhold feedings during this type of therapy. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 1082 A nurse administers cimetidine (Tagamet) to an older adult client diagnosed with a gastric ulcer. Which function may be affected by this medication, and should be closely monitored by the nurse? Answers Correct A Student's A A. mental status B. blood pressure C. liver function D. red blood cells Review Information: The correct answer is A: mental status Learning Objective: Lesson 6 Pharmacological Therapies Older adults are at risk for developing confusion when taking cimetidine. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1189 A client referred for a mammography asks a nurse about the cancer risks from radiation exposure. What is an appropriate response by the nurse? A. "Exposure to mammography every two years is not dangerous." B. "The radiation from a mammography is equivalent to one hour of sun exposure." C. "You have nothing to worry about; it is less than tanning in the nude." D. "A chest x-ray gives you more radiation exposure.” Answers Correct B Student's C Review Information: The correct answer is B: "The radiation from a mammography is equivalent to one hour of sun exposure." Learning Objective: Lesson 3 Health Promotion and Maintenance A client would have to have numerous procedures in a year’s time to be at risk for cancer. This answer is concise and gives the client a point of reference. One of the options is judgmental and non-therapeutic. Another option is not accurate and can cause further concern about radiation exposure. Another option does not clearly address the client’s question. Craven, R.F., & Hirnle, C.J. (2008). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia: Lippincott Williams & Wilkins. Berman, A., Snyder, S., Kozier, B., & Erb, G. (2008). Kozier & Erb's fundamentals of nursing: Concepts, process, and practice (8th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1156 At a community health fair the blood pressure (BP) of a 62 year-old client is screened at 160/96. The client states “My blood pressure is usually much lower.” A nurse should respond based on knowledge indicated by which of these protocol? Answers Correct D Student's D A. check BP in two or three weeks B. visit the health care provider within one week for another BP check C. see a health care provider immediately D. recheck the BP within the next 48 to 72 hours Review Information: The correct answer is D: recheck the BP within the next 48 to 72 hours Learning Objective: Lesson 3 Health Promotion and Maintenance The blood pressure reading is moderately high with the need to have it rechecked within a few days. The client states it is "usually much lower." Thus, a concern exists for complications such as stroke or transient ischemic attacks. However, an immediate recheck by the provider of care is not warranted. Waiting two or three weeks for followup is too long of a time. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Practice Bank 29 Ref # 1099 A client receives high doses of a potassium bolus IV over a 30 minute period. Which focus is a priority to check prior to giving this medication? A. oral fluid intake B. bowel sounds C. grip strength D. urine output Answers Correct D Student's D Review Information: The correct answer is D: urine output Learning Objective: Lesson 6 Pharmacological Therapies Potassium chloride should only be administered after adequate urine output (greater than 20 mL for 2 consecutive hours) has been established. Impaired ability to excrete potassium via the kidneys can result in hyperkalemia. In children, urine output should be 1 to 2 mL/kg/hr as a minimum urine output. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1129 A client has an order for 1000 mL of D5W over an eight hour period. A nurse discovers that 800 mL has been infused after 4 hours. What is the priority nursing action at this time? A. auscultate the lungs B. have the client void as much as possible Answers Correct A Student's A C. ask the client if any breathing problems D. check the vital signs Review Information: The correct answer is A: auscultate the lungs Learning Objective: Lesson 6 Pharmacological Therapies All of the options are correct actions and would be part of the evaluation for the effects of the large amount of fluid in a short period of time. However, the most serious result is heart failure with lung congestion which makes the auscultation of the lungs the priority action. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1136 A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make? A. “That was done correctly. Did you have any problems with the insertion?” B. "Why don’t we now have the client turn back to the left side.” C. “Let’s check to see if the suppository is in far enough.” D. “Did you feel any stool in the intestinal tract?” Answers Correct A Student's A Review Information: The correct answer is A: “That was done correctly. Did you have any problems with the insertion?” Learning Objective: Lesson 6 Pharmacological Therapies Left side-lying position is the optimal position for the client receiving rectal medications. Due to the position of the descending colon, left side-lying allows the medication to be inserted and move along the natural curve of the intestine and facilitates retention of the medication. After a short time it will not hurt the client to turn in any manner. The suppository should be somewhat melted after 10 to 15 minutes. The other responses are incorrect since no data is in the stem to support such comments. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1149 An older adult client is scheduled to have a cardioversion. A nurse reviews the client’s Answers Correct D medication administration record. The nurse should notify the health care provider if the client received which medication during the preceding 24 hours? A. metoprolol tartrate (Toprol XL) B. diltiazem (Cardizem) C. nitroglycerine ointment D. digoxin (Lanoxin) Student's D Review Information: The correct answer is D: digoxin (Lanoxin) Learning Objective: Lesson 6 Pharmacological Therapies Digoxin increases ventricular irritability and increases the risk of ventricular fibrillation following cardioversion. The other medications do not increase ventricular irritability. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1130 A health care provider orders digoxin (Lanoxin) 0.125 mg PO and furosemide 40 mg every day. Which of these foods would a nurse reinforce for the client to eat at least daily? A. a whole fresh tomato B. four ounces of chicken C. a small plate of spaghetti D. slice of watermelon Answers Correct D Student's C Review Information: The correct answer is D: slice of watermelon Learning Objective: Lesson 6 Pharmacological Therapies A slice of watermelon is the highest in potassium and will replace any potassium lost by the diuretic. A tomato has high potassium but not as much as a slice of watermelon. The other foods in the other options do not have high potassium. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 2476 A mother with a Roman Catholic belief system has given birth in an ambulance on the way to the hospital. The neonate is in very critical condition with little expectation of surviving the trip to the hospital. Which of these requests should the nurse in the ambulance anticipate and be prepared to encounter? A. Pour fluid over the forehead backwards towards the back of the head and say "I baptize you in the name of the father, the son and the holy spirit. Amen." Answers Correct A Student's C B. The refusal of any treatment for the mother and the neonate until a reader is consulted. C. Arrange for a church elder to be at the emergency department when the ambulance arrives so a "laying on hands" can be done. D. The placement of a rosary necklace around the neonate's neck that is not to be removed unless absolutely necessary. Review Information: The correct answer is A: Pour fluid over the forehead backwards towards the back of the head and say "I baptize you in the name of the father, the son and the holy spirit. Amen." Learning Objective: Lesson 7 Reduction of Risk Potential Infant baptism is mandatory according to Roman Catholic beliefs, especially if a neonate is not expected to live. Anyone may perform this if an infant or child is gravely ill. One option refers to the Christian Science belief system. Another option is a belief of Russian Orthodoxy. Mormons believe in divine healing with the laying on of hands, as represented in one of the options. Delaune, S., & Ladner, P. (2010). Fundamentals in nursing: Standards and practice (4th ed.). Clinton Park, NY: Delmar Cengage Learning. Altman, G.B. (2009). Delmar's fundamental and advanced nursing skills (3rd ed.). Clifton Park, NY: Delmar Cengage Learning. Ref # 1182 A client is recovering from a hip replacement and takes Tylenol #3 every 3 hours for pain. When checking the client, which finding suggests a side effect of the analgesic? A. bruising at the operative site B. decreased platelet count C. elevated heart rate D. no bowel movement for three days Answers Correct D Student's D Review Information: The correct answer is D: no bowel movement for three days Learning Objective: Lesson 6 Pharmacological Therapies With opioid analgesics observe for the side effects of respiratory depression, sedation, and constipation. Bruising is not related to the analgesic, but could be the result of corticosteroids or previously used anticoagulants. Elevated heart rate could be the result of bronchodilators. Some antibiotics can lower platelet count. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1131 A client diagnosed with heart failure has digoxin (Lanoxin) ordered. What should a nurse expect to find when evaluating for the therapeutic effectiveness of this medication? A. diaphoresis with decreased urinary output B. decreased chest pain and decreased blood pressure Answers Correct C Student's C C. improved respiratory status and increased urinary output D. increased heart rate with increase respirations Review Information: The correct answer is C: improved respiratory status and increased urinary output Learning Objective: Lesson 6 Pharmacological Therapies Digoxin, a cardiac glycoside, is used in clients with heart failure to slow the heart rate and strengthen the cardiac muscle contraction. As cardiac output is improved, renal perfusion is improved and urinary output increases. Clients can become toxic on this medication. The findings of toxicity are bradycardia, dysrhythmia, visual and GI disturbances. Clients being treated with digoxin should have their apical pulse evaluated for one full minute prior to the administration of the medication. The pulse should be between 60 and 120 beats per minute. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1139 An antibiotic intramuscular (IM) injection for a toddler is ordered. The total volume of the injection equals 2 mL. What is the correct nursing intervention? A. check with pharmacy for a by mouth liquid form of the medication B. administer the medication in two separate injections C. call to get a smaller volume ordered for the injection D. give the medication in the dorsal gluteal site Answers Correct B Student's B Review Information: The correct answer is B: administer the medication in two separate injections Learning Objective: Lesson 6 Pharmacological Therapies Intramuscular injections should not exceed a volume of 1 mL for small children. Medication doses exceeding this volume should be split into two separate injections of 1 mL each. In adults the maximum intramuscular injection volume is commonly 5 mL depending on the characteristics of the site. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1098 A nurse is talking to a client diagnosed with chronic renal failure about medications. The client questions the purpose of aluminum hydroxide (Amphojel) in the medication regimen. What is the best explanation for the nurse to give the client for the use of this medication? This medication is given to Answers Correct A Student's A A. decrease serum phosphate B. reduce serum calcium C. control gastric acid secretion D. increase urine output Review Information: The correct answer is A: decrease serum phosphate Learning Objective: Lesson 6 Pharmacological Therapies Aluminum binds phosphates in the gastrointestinal tract. Phosphates tend to accumulate in the client with chronic renal failure due to decreased filtration capacity of the kidney. Antacids such as Amphojel and Basaljel are commonly used to accomplish a lowered phosphate. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1148 A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethazine hydrochloride (Phenergan) 50 mg IM to a preoperative client. Which action should the nurse take initially? A. place the bed in the low position B. instruct the client to remain in bed C. have the client empty his/her bladder D. place the call bell within reach Answers Correct C Student's C Review Information: The correct answer is C: have the client empty his/her bladder Learning Objective: Lesson 6 Pharmacological Therapies The first step in the process is to have the client void prior to administering the preoperative medication. The bladder needs to be emptied so that the client won’t have to do so after the preoperative medication has been given. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1105 An older adult client is to receive IV gentamicin. What diagnostic finding indicates the client may have difficulty in the excretion of the medication? A. borderline renal function B. protein deficiency C. reduced peristalsis Answers Correct A Student's A D. gastric acid reflux Review Information: The correct answer is A: borderline renal function Learning Objective: Lesson 6 Pharmacological Therapies Reduced renal function will delay the excretion of many medications. This is an aminoglycoside, which is highly toxic to the kidney. It is given every 12 to 18 hours and requires close monitoring of renal function, the creatinine levels. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1117 A nurse monitors a client after the treatment of bradycardia with intravenous atropine sulfate. Which finding should be reported to a health care provider immediately? A. frequent urination B. increased salivation C. frequent palpitations D. bronchial spasms Answers Correct C Student's C Review Information: The correct answer is C: frequent palpitations Learning Objective: Lesson 6 Pharmacological Therapies Atropine sulfate is an anticholinergic medication that increases the heart rate by stimulating alpha receptors in the heart. Side effects of atropine sulfate include ventricular tachycardia, palpitations, irritability, dry mouth, and headache. Three of the options are incorrect because they are opposite reactions than those expected with atropine. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1134 A client received 3 units of Humalog insulin at 11 am to cover a finger stick of 322 mg/dL. This type of insulin will begin to act at which time? A. 1:00 pm B. 3:00 pm C. 12 noon Answers Correct D Student's C D. 11:15 am Review Information: The correct answer is D: 11:15 am Learning Objective: Lesson 6 Pharmacological Therapies The onset of action and peak for Humalog or fast acting insulin is 10 to 15 minutes and for a short acting insulin such as regular. Humulin R or Semilente has an onset of action from 1/2 to 1 hour. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1138 A nurse receives an order to give a client iron by deep injection. The nurse knows that the reason for this route is for what purpose? A. prevent the medication from tissue irritation B. ensure that the entire dose of medication is given C. provide more even distribution of the drug D. enhance absorption of the medication Answers Correct A Student's A Review Information: The correct answer is A: prevent the medication from tissue irritation Learning Objective: Lesson 6 Pharmacological Therapies Deep injection or Z-track is a special method of giving medications via the intramuscular route. Use of this technique prevents irritating or staining medications from being tracked through tissue. Use of Z-track does not affect dose, absorption, or distribution of the medication. Oil based or thick medication is commonly given in this manner for the same reason. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 2475 When an infant car seat is properly installed, the infant should face A. the side window, to increase sensory stimulation B. backward, so child faces the seat C. forward, so child may look out window Answers Correct B Student's B D. upward, as child lies on back with seat installed sideways Review Information: The correct answer is B: backward, so child faces the seat Learning Objective: Lesson 7 Reduction of Risk Potential Nurses are now responsible for promoting the continued safety of infants and children outside of the hospital. Emergency Department and Women’s Services staff are trained in child seat placement. Growth and development data indicate that infants still require support of the head. Therefore, they should be positioned reclining and facing the rear until their leg muscles are strong enough to kick away from the backseat (about 10-12 months-old) for the greatest protection. Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Perry, S., Hockenberry, M., Lowdermilk, D.L., & Wilson, D. (2009). Maternal child nursing care (4th ed.). St. Louis, MO: Mosby. Ref # 1097 A nurse is caring for a client who is receiving alteplase (TPA) and diagnosed with an acute cerebral vascular accident (CVA). Which nursing intervention should receive priority consideration? A. monitor vital signs B. maintain bedrest C. check the mental status D. protect invasive lines or tubes Answers Correct D Student's C Review Information: The correct answer is D: protect invasive lines or tubes Learning Objective: Lesson 6 Pharmacological Therapies TPA is a potent thrombolytic enzyme. Because bleeding is the most common side effect, it is essential to protect invasive lines from accidental dislodgement and monitor for any bleeding. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 1107 A client is receiving a nitroglycerin (NTG) infusion for a diagnosis of unstable angina. What should be a priority focus to monitor for the effects of this medication? A. rhythm strips B. respiratory rate C. cardiac labs D. blood pressure Answers Correct D Student's C Review Information: The correct answer is D: blood pressure Learning Objective: Lesson 6 Pharmacological Therapies Since an effect of this medication is vasodilation, the client must be monitored for hypotension. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Practice Bank 30 Ref # 4623 The nurse receives a telephone call from a health care provider who wants to give a telephone order for a client. Which of the following actions should the nurse take? (Select all that apply.) A. Begin the order with the abbreviation "P.O." to indicate that it was a "phone order" B. Request that the order is signed by the provider before implementation C. Ask a second nurse to listen on another extension while the order is being given D. Record the order word-for-word and sign the order E. Verify understanding by reading the order back to the provider before hanging up Answers Correct D , E Student's C Review Information: The correct answer is D, E : Record the order word-for-word and sign the order, Verify understanding by reading the order back to the provider before hanging up Learning Objective: Lesson 1 Management of Care Reading the order back allows the provider to correct any misunderstanding and is a Joint Commission read-back requirement. The order should be immediately written and signed by the nurse. The order should clearly state "telephone order" because abbreviations can be misunderstood (P.O. could be interpreted as "by mouth"). Having a second person listen in on the conversation is not required unless the nurse cannot understand the health care provider. The order may be implemented right away, but it must be countersigned within the time limits set by the facility. Ref # 4563 An obese client tells the nurse: "I just started a diet and I am eating no more than 800 calories a day." What information is most important for the nurse to know in order to therapeutically respond to this statement? Answers Correct A Student's A A. Individuals following a very low-calorie diet need professional monitoring B. Very low-calorie diets often have severe and irreversible side effects C. A very low-calorie diet is never a successful weight loss program and should be discouraged D. This diet is classified as low calorie and adequate if balanced with 1 meat, 1 fruit, and 2 fat exchanges Review Information: The correct answer is A: Individuals following a very low-calorie diet need professional monitoring Learning Objective: Lesson 5 Basic Care and Comfort A very low-calorie diet (VLCD) is a short-term weight loss method for obese people (BMI greater than 30) and can result in a loss of about 3 to 5 pounds per week. Anyone considering this type of diet should be under the care of health professionals. VLCDs are generally considered safe and common side effects (such as fatigue, constipation or diarrhea) are usually minor and improve within a few weeks. Of course, the best way to maintain weight loss is through a combination of behavioral therapy, exercise and more modest dietary restrictions. The exchange diet, which groups food together by nutritional content, is typically reserved for individuals with diabetes. Ref # 4599 The nurse, who is caring for a client with complex and unique health needs, describes the nature of the illness in an online social forum for nurses. Neither the client's real name nor any other personal identifiers are used. What, if any, consequence could result from posting this information online? A. The nurse could be fired for breach of confidentiality B. The nurse could be reprimanded for not clearing the information first with hospital administration C. There won't be any consequences because the information was posted on a website for nursing professionals D. There won't be any consequences because the client's real name was not used Answers Correct A Student's A Review Information: The correct answer is A: The nurse could be fired for breach of confidentiality Learning Objective: Lesson 1 Management of Care Even though the client was not identified by name, someone could probably figure out who the nurse was writing about. Many health care facilities have adopted a social media policy; it is important to understand that nurses can be fired for posting personal information about clients online, because this is an invasion of privacy. In addition to being a HIPAA violation, the Health Information Technology for Economic and Clinical Health Act (HITECH Act) gives states attorneys the right to pursue violations of patient privacy. Ref # 4626 A child is admitted to the unit with findings of nasal congestion and cough with periods of cyanosis and dehydration. The suspected diagnosis is pertussis (whooping cough). What is the priority nursing intervention for this child? A. Implement droplet precautions along with standard precautions Answers Correct A Student's C B. Initiate anti-infective therapy C. Maintain hydration and encourage fluids D. Monitor heart rate, respiratory rate and oxygen saturation Review Information: The correct answer is A: Implement droplet precautions along with standard precautions Learning Objective: Lesson 2 Safety and Infection Control Although all the responses are correct actions, it is most important to implement strict droplet precautions in addition to standard precautions because pertussis is spread via close contact. Therapeutic management focuses on providing respiratory support and eradicating the bacterial infection (macrolides, such as erythromycin, are the drug of choice). Fluids are encouraged to help thin secretions. Monitoring heart rate and oxygen saturation, especially during coughing paroxysms, is indicated. Ref # 4608 A woman dressed in a business suit with no visible identification is at the nurses station looking at client charts. What nursing action is most appropriate? A. Ignore the person; many outside vendors check charts to set up a transfer or to coordinate care B. Immediately call security for this breach in client confidentiality C. Report to the nurse manager about the witnessed suspicious activity D. Request to see an ID and an explanation as to why the woman is viewing the charts Answers Correct D Student's D Review Information: The correct answer is D: Request to see an ID and an explanation as to why the woman is viewing the charts Learning Objective: Lesson 1 Coordinated Care Nurses have a duty to protect the confidentiality of client records. In fact, HIPAA and other confidentiality laws require nurses to verify the identity and authority of individuals requesting information. Acceptable verification may include a photo ID and a copy of the documentation supporting legal authority to access information. The nurse needs to determine who the person is, ask to see a valid ID, and ask for the reason for reading the chart. Security may need to be called, but the nurse first needs more information. It is each nurse's duty to do this and no one should pass it off to a manager or ignore the situation. Ref # 4606 The nurse observes a nursing assistant using antiseptic hand rub and rubbing the hands vigorously after leaving the room of a client diagnosed with clostridium difficile. Which action is most appropriate by the nurse? A. Ensure that visitors wash hands thoroughly before and after visiting B. Praise the nursing assistant for proper use of antiseptic hand rub Answers Correct D Student's D C. Tell the client to ask caregivers if they have washed their hands D. Require the nursing assistant to wash hands again with soap and water Review Information: The correct answer is D: Require the nursing assistant to wash hands again with soap and water Learning Objective: Lesson 2 Safety and Infection Control Clostridium difficile (C. diff) is one of the few pathogens that require soap and water for cleansing the hands; antiseptic hand rub is not effect against the hardy spores produced by this bacterium. The nurse is responsible for supervising the assistant's practice, correcting practice errors, and educating about proper procedure. The client should be encouraged to advocate for caregiver hand hygiene and visitors need to practice good hand washing, but neither is as important as correcting the nursing assistant's incorrect use of hand sanitizer. Ref # 4617 A client calls the clinic and states to the triage nurse: "I had an upset stomach and took Pepto-Bismol and now my tongue looks black. What's happening to me?" What would be the nurse's best response? A. "Are your stools also black?" B. "Come to the clinic so you can be seen by the health care provider." C. "How long have you had an upset stomach?" D. "This is a common and temporary side effect of this medication." Answers Correct D Student's D Review Information: The correct answer is D: "This is a common and temporary side effect of this medication." Learning Objective: Lesson 6 Pharmacological Therapies The best response would be to explain that a dark tint of the tongue is a common and temporary side effect of bismuth subsalicylate (Pepto-Bismol). Although it may also turn stools a darker color, do not confuse this with black, tarry stools, which is a sign of bleeding in the intestinal tract. After addressing the client's initial concern and the reason for the call, the nurse can ask about the upset stomach and then ask the client to come to the clinic if necessary. Ref # 4609 A client is diagnosed with rheumatoid arthritis (RA). Which types of drugs might the nurse expect to be ordered as a combination drug therapy regimen? (Select all that apply.) A. Glucocorticoids B. Diuretics C. Antimicrobial agents D. Biological-response modifiers Answers Correct D, E Student's D, E E. Anti-inflammatory drugs Review Information: The correct answer is D, E: Biological-response modifiers, Anti-inflammatory drugs Learning Objective: Lesson 6 Pharmacological Therapies Rheumatoid arthritis is a chronic, systemic autoimmune disorder that results in symmetric joint destruction. Research shows that multiple drug therapy is most effective in protecting against further destruction and promoting function. Analgesics and anti-inflammatory drugs are used. Disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate help slow or stop progression of RA. Biological response modifiers are used to help stop inflammation. Glucocorticoids can also be used for severe RA or when RA symptoms flare to ease the pain and stiffness of affected joints. Because RA is not an infectious disease, antimicrobials are ineffective. Although there is swelling in the joints, it is not fluid, so diuretics are not part of the treatment plan. Ref # 4581 A nurse is to collect data about a six month-old child diagnosed with nonorganic failure-to-thrive (NOFTT). Upon entering the room, the nurse would expect the baby to have which characteristics? A. "I may experience postpartum depression up to a year after delivery." B. "I will make an effort to talk with someone about my feelings if I start to feel overwhelmed." C. "Women with postpartum depression have feelings of guilt and worthlessness." D. "It's common for women with postpartum depression to have delusions about the infant." Answers Correct D Student's D Review Information: The correct answer is D: "It's common for women with postpartum depression to have delusions about the infant." Learning Objective: Lesson 4 Psychosocial Integrity Postpartum depression symptoms include sleep and appetite disturbances, uncontrolled crying, with feelings of guilt and/or worthlessness. Although postpartum depression typically occurs within the first three months after delivery, it can occur up to a year later. A new mother who has symptoms of postpartum depression should take steps to get help right away. Delusions are associated with postpartum psychosis, not depression. Ref # 4611 The client is newly diagnosed with gastroesophageal reflux disease (GERD). Which statement made by the client indicates a need for further information about this disease? (Select all that apply.) A. "I'll be sure to wait a while after eating before I go exercise at the gym." B. "If I have heartburn, I'll take my omeprazole (Prilosec)." Answers Correct B, D, F Student's C, D, E C. "I will drink more water and less cola and other carbonated beverages." D. "I can't wait to leave the hospital, so I can get a good cup of coffee." E. "I am going to enroll in a smoking cessation class." F. "A bedtime snack may help me to sleep better." Review Information: The correct answer is B, D, F: "If I have heartburn, I'll take my omeprazole (Prilosec).", "I can't wait to leave the hospital, so I can get a good cup of coffee.", "A bedtime snack may help me to sleep better." Learning Objective: Lesson 8 Physiological Adaptation GERD occurs as a result of gastric secretions being refluxed back up into the esophagus causing esophageal irritation and burning. This usually occurs because the lower esophageal sphincter is too relaxed. The client should eat meals several hours before lying down and give up late night snacks. Food and beverages that may trigger symptoms, such as caffeine and carbonated beverages, should be avoided. Proton pump inhibitors such as omeprazole take one to four days to work, and should not be used as needed for heartburn. Instead, they should be taken routinely to prevent symptoms. Rapid-acting antacids can be used as needed to help relieve heartburn. Avoiding tobacco and losing weight may also help improve heartburn. Ref # 4621 The client states to the nurse: "I am ready to stop all of these treatments. I just want to go home and enjoy my family for the little bit of time I have left." Which action is most appropriate? A. Encourage the client to discuss this decision with the health care provider and family B. Call in a referral to a social worker and explain that the request will need to be discussed in more detail at a later time C. No action is needed at this time unless the client repeats the statement to another caregiver D. Tell the family members that the client's preference is to go home to die Answers Correct A Student's A Review Information: The correct answer is A: Encourage the client to discuss this decision with the health care provider and family Learning Objective: Lesson 1 Coordinated Care The client has the right to stop treatment and should be supported in clearly communicating this decision with the health care provider and family. The nurse needs to act as an advocate for the client. It is factually incorrect to wait until the request is repeated; clients should not need to express their wishes repeatedly before caregivers listen to them. The nurse should not be the one to share sensitive information with the family; the client controls that information. Social services may get involved but time is of the essence for those who are terminally ill. Ref # 4624 Which of the following methods are used to correctly identify a client? (Select all that apply.) A. Compare the person to a labeled photograph B. Ask clients to state their name C. Ask a family member or visitor Answers Correct B, D, E Student's B, D, E D. Check the client identification bracelet E. Have clients state their birth date Review Information: The correct answer is B, D, E: Ask clients to state their name, Check the client identification bracelet, Have clients state their birth date Learning Objective: Lesson 2 Safety and Infection Control Two pieces of identification are required prior to any procedure, including medication administration. Because client identification bracelets are not routinely used in long- term care facilities, nurses use a photograph to identify a resident. Asking the client or the client's family can be unreliable depending on the responder's cognitive and/or developmental status. Ref # 4613 The nurse is reviewing the medication administration record for a newly admitted client. The client is prescribed the beta blocker propranolol (Inderal), but is not diagnosed with hypertension and does not have a history of heart disease. Which health issue might best explain the reason for prescribing propranolol? A. Parkinson's disease B. Raynaud's disease C. Schizophrenia D. Essential tremors Answers Correct D Student's C Review Information: The correct answer is D: Essential tremors Learning Objective: Lesson 6 Pharmacological Therapies Propranolol is used to help control essential tremors. These tremors are the most common type of tremor; they are usually mild and not associated with any known pathology. Parkinson's tremor usually improves with dopaminergic and anticholinergic medications. Antipsychotic medications can cause tremors and they can be treated with benztropine. Beta blockers can aggravate symptoms of Raynaud's disease. Ref # 4605 A 40 year-old Bosnian Muslim woman who does not speak English seeks care at a community center. Through physical gestures, the woman indicates that she has pain originating in either the pelvic or genital region. Assuming several people are available to interpret, who would be the most appropriate choice? A. The client's adult daughter B. A female from the client's community C. A female interpreter who does not know the client Answers Correct C Student's C D. A Bosnian male, who is a certified medical interpreter Review Information: The correct answer is C: A female interpreter who does not know the client Learning Objective: Lesson 1 Coordinated Care When the nurse and the client do not speak the same language, or have limited fluency, the services of an interpreter are needed. But, it may be inappropriate to have a male interpreter for a female client because the client will not be as forthcoming. The client may also feel it is inappropriate to have private matters interpreted by her daughter (especially if they are of a sexual nature or involve infidelity). To avoid a breach of confidentiality, the nurse should avoid using an interpreter from the same community as the client. The best response is to have a female interpreter who does not know the client. Ref # 4625 Which situation requires hand washing? (Select all that apply.) A. After making a chart entry B. After cleaning a wound C. After contact with inanimate objects in the immediate vicinity of the client D. Prior to eating E. Before having direct contact with a client Answers Correct B, C, D, E Student's B, C, A, E Review Information: The correct answer is B, C, D, E: After cleaning a wound, After contact with inanimate objects in the immediate vicinity of the client, Prior to eating, Before having direct contact with a client Learning Objective: Lesson 2 Safety and Infection Control Hand washing is still the simplest and most effective strategy to prevent the spread of infection. It is necessary to wash one's hands to protect oneself prior to eating, after removing gloves following any client procedure, and even after having contact with intact skin or objects in the client's room. However, it is not necessary to wash hands after handling every chart (although using an alcohol-based hand rub would be advisable). Ref # 4575 The RN is working in a clinic where a client presents with a painful, blistering rash on the hip. The health care provider diagnoses shingles (herpes zoster). What would be the priority nursing diagnosis? A. Risk for impaired skin integrity related to skin lesions B. Pain related to nerve root inflammation and skin lesions C. Risk for infection related to skin lesions Answers Correct B Student's B D. Knowledge deficit related to disease process Review Information: The correct answer is B: Pain related to nerve root inflammation and skin lesions Learning Objective: Lesson 8 Physiological Adaptation Shingles is a reactivation of the herpes zoster virus responsible for chickenpox. It is characterized by a vesicular rash in a unilateral dermatomal distribution. The first symptom of shingles is usually pain, tingling, or burning before the blisters form. The pain and burning may be severe, and can lead to longterm residual pain, known as postherpetic neuralgia. Early appropriate treatment with an antiviral medication such as acyclovir can reduce these long-term complications, as well as the duration and severity of the initial symptoms. Pain is the priority nursing diagnosis. It is important for the client keeps the sores clean and avoids contact with people who haven't gotten the herpes zoster vaccine or who haven't had chickenpox, as well as people with weakened immune systems, until the rash crusts over and heals. Ref # 4550 Which nursing practice best reduces the chance of communication errors that might otherwise lead to negative client outcomes? A. Use standardized forms for client handoffs B. Speak using a professional tone on the telephone C. Keep good working relationships with staff members D. Document nursing care at the end of the shift Answers Correct A Student's A Review Information: The correct answer is A: Use standardized forms for client handoffs Learning Objective: Lesson 1 Standardized forms improve information for communication between caregivers. Most problems/poor outcomes involve some element of poor communication. The options of keeping good working relationships and using a professional tone of voice on the phone is good practice but not as useful for minimizing the chance of errors. Documenting at the end of the shift is incorrect practice and may lead to poor communication, as critical findings may be forgotten and not recorded. Ref # 4559 The nurse is discharging a client after a laparoscopic cholecystectomy. Which occurrence should the client be instructed to report to the primary care provider? A. Seeing spots of blood on the Band-Aids B. Temperature of 101 F (38.3 C) C. Decrease in appetite D. Experiencing shoulder pain Answers Correct B Student's C Review Information: The correct answer is B: Temperature of 101 F (38.3 C) Learning Objective: Lesson 7 Reduction of Risk Potential Laparoscopic surgery allows quick discharge and recovery. However, clients need to know what to expect and which post-op discomforts are reportable. A temperature of 101 F (38.3 C) and above may signal infection and should be reported. The other listed symptoms are expected after this surgery. Shoulder pain (ranging from mild to severe) is due to the CO2 gas injected during surgery; it will dissipate within days. Band-Aids or other small dressings will be placed over the small incision sites and may have some spots of blood on them. It may take a day or two before appetite returns to normal. Practice Bank 31 Ref # 4615 The nurse attends an interdisciplinary meeting on the topic of fall prevention. What specific tactics can be used to reduce falls in health care settings? (Select all that apply.) A. Raise side rails B. Use a "two to transfer" policy C. Use "low beds" for at-risk clients D. Install and use bed alarms E. Regularly reorient clients F. Identify vulnerable clients Answers Correct B, C, D, F Student's B, C, D, F Review Information: The correct answer is B, C, D, F : Use a "two to transfer" policy, Use "low beds" for at-risk clients, Install and use bed alarms, Identify vulnerable clients Learning Objective: Lesson 2 Fall prevention involves managing a client's underlying fall risk factors and then implementing strategies to reduce falls. Using restraints, including side rails, can actually increase the risk of fall-related injuries and deaths. Clients with dementia cannot process the information we provide when we attempt to reorient them to our reality. The other techniques listed are used (in combination) to help prevent falls in health care facilities. Ref # 4545 The client is diagnosed with post-traumatic stress disorder (PTSD). What are the some of the more common treatment options for PTSD? (Select all that apply.) A. Opioid analgesics B. Selective serotonin reuptake inhibitors (SSRIs) C. Eye movement desensitization and reprocessing (EMDR) D. Cognitive behavioral therapies Answers Correct B, C, D Student's B, C, D Review Information: The correct answer is B, C, D: Selective serotonin reuptake inhibitors (SSRIs), Eye movement desensitization and reprocessing (EMDR), Cognitive behavioral therapies Learning Objective: Lesson 4 The only two FDA approved medications for the treatment of PTSD are the SSRIs sertraline (Zoloft) and paroxetine (Paxil). There are other medications that are helpful for specific PTSD symptoms, but narcotics should not be used since they don't relieve psychogenic pain and there's a risk of dependence. Most people who experience PTSD undergo some type of psychotherapy, most commonly cognitive-behavioral therapy and/or group psychotherapy, EMDR and hypnotherapy. Ref # 2490 A client is recently diagnosed with Barrett’s esophagus. Which of the following statements made by the client demonstrates that further teaching is needed about this illness? A. “I should avoid eating anything for two hours before I go to sleep.” B. “I should try to sleep lying on my right side.” C. “I will have to cut back on my smoking." D. “I will need regular endoscopies to monitor this illness.” Answers Correct C Student's C Review Information: The correct answer is C: “I will have to cut back on my smoking." Learning Objective: Lesson 8 Barrett’s esophagus is a complication of gastroesophageal reflux disease (GERD) and is associated with an increased risk for esophageal cancer. Endoscopies are scheduled regularly to monitor the progression of the disease and to catch any cancer in its earliest stages. Treatment for Barrett’s esophagus is the same as for GERD. Lifestyle changes include weight loss, avoiding acidic foods and fluids, not eating 90-120 minutes before bedtime, and sleeping with the head of the bed elevated or in a right side-lying position. Cutting back on smoking is too ambiguous; since smoking aggravates GERD and is linked to the development of cancer, this client should be advised about smoking cessation programs. Ref # 2479 The nurse is making rounds with the pediatrician on the postpartum unit. Which of the following newborns should the pediatrician see first? A. The newborn, delivered eight hours ago, whose clamped umbilical cord has two arteries and one vein B. The term infant whose blood glucose is 50 mg/dL Answers Correct D Student's C C. The newborn delivered sixteen hours ago, who has yet to pass the first meconium stool D. The newborn with widely spaced cranial suture lines Review Information: The correct answer is D: The newborn with widely spaced cranial suture lines Learning Objective: Lesson 3 Part of the examination of a newborn is to palpate suture lines; they should be palpable and separated. In cases where there is molding present, they may overlap. If suture lines are widely spaced it may be an indication of hydrocephaly or growth restriction. All the other findings are within normal limits for newborns at term: they usually pass their first meconium stool within 12 to 24 hours after birth; normal blood glucose is 40-60 mg/dL (hypoglycemia is anything < 40 mg) and umbilical cords have two arteries and one vein (only one artery can be indicative of a renal anomaly in the newborn.) Ref # 4517 The 86 year-old client will be participating in a transitional care program after discharge from the hospital. What is the primary purpose of a transitional care program? A. Increase client understanding of discharge instructions B. Increase satisfaction with nursing care C. Reduce insurance costs D. Reduce readmissions to the hospital Answers Correct D Student's D Review Information: The correct answer is D: Reduce readmissions to the hospital Learning Objective: Lesson 1 Older adults who complete a transitional care program after being discharged from the hospital are much less likely to be readmitted to the hospital. The Affordable Care Act mandates that each facility have a "quality assurance and performance improvement program", designed to help reduce unnecessary hospital readmissions. Ref # 4632 During a discussion with the nurse manager, a staff nurse confides that she is attracted to a client regularly assigned to her. Which of the following actions should be implemented following this discussion? A. The nurse waits until after discharge to tell the client about her feelings B. The nurse continues to provide care for the client C. The nurse transfers the care of the client to another nurse Answers Correct C Student's C D. The nurse reassigns all personal care of the client to the nursing assistant Review Information: The correct answer is C: The nurse transfers the care of the client to another nurse Learning Objective: Lesson 1 Nurses must practice in a manner consistent with professional standards and be knowledgeable about professional boundaries. A nurse’s challenge is to be aware of feelings and to always act in the best interest of the client, avoiding inappropriate involvement. In this case, the nurse did all the right things - aware of her feelings, she consulted with her supervisor and together they decided it would be best if this client were no longer assigned to this nurse. If the nurse had acted on her feelings, this would have been a boundary violation and she could have been subject to board of nursing disciplinary action. Ref # 4630 The nurse is setting up a client's dinner tray. When the nurse turns her back to the client, the client grabs the nurse's buttocks and states he is hungry for much more than dinner. Which of the following responses by the nurse is indicated? A. Ignore the behavior B. Call the health care provider C. Quickly leave the room and ask the UAP to assist the client D. Complete an incident report Answers Correct D Student's C Review Information: The correct answer is D: Complete an incident report Learning Objective: Lesson 2 To keep the therapeutic relationship intact, a nurse needs to set limits on inappropriate behavior and not ignore bad behavior. Sexual harassment is a form of violence and is never part of the job. The nurse should report the incident to her supervisor and complete an incident report. The nurse has the right to ask not to be assigned to this client. Ref # 4540 A 54 year-old female explains to the health care provider that she experiences approximately 10 vasomotor symptoms of menopause ("hot flashes") throughout the day and night. Different treatment options are discussed. Which statement by the client indicates she needs further instruction from the nurse? A. "I should avoid spicy foods, alcohol, and caffeine." B. "I may need to take estrogen and progesterone for many years." C. "I will take gabapentin ER at bedtime." Answers Correct B Student's B D. "I can use a fan at home and in the workplace." Review Information: The correct answer is B: "I may need to take estrogen and progesterone for many years." Learning Objective: Lesson 8 In addition to menopausal hormone therapy (MHT), medications for epilepsy (gabapentin), depression (SSRIs) and hypertension can be used to treat hot flashes. Extended release gabapentin is taken at bedtime to treat insomnia due to hot flashes. Although the risk of low-dose estrogen is small, there is still a risk of breast cancer, heart attack, and blood clots with menopausal hormone therapy (MHT), which is why it should only be a short-term treatment option. Non-medical interventions include avoiding spicy foods, alcohol, and caffeine. Clients should also dress in layers, use fans for cooling and try taking slow, deep breaths when a hot flash starts. Ref # 4628 The client, who lives in a long term care facility, was placed on contact precautions when drainage from a wound tested positive for MRSA (methicillin-resistant Staphylococcus aureus). When can contact precautions be discontinued? A. If wound drainage can be contained by a dressing B. After treatment is completed and three consecutive cultures are negative C. If the client is asymptomatic after treatment is completed D. When the wound is no longer draining Answers Correct B Student's C Review Information: The correct answer is B: After treatment is completed and three consecutive cultures are negative Learning Objective: Lesson 2 Contact precautions are recommended for MRSA when there's a risk for transmission or wounds that cannot be contained by dressings. Contact precautions are usually discontinued when there is documentation of 3 consecutive negative screens from previously positive sites. Screens should be obtained no sooner than 72 hours after completion of decolonization and/or treatment of infection; the screens should be at least 5 days apart. If screening cultures are positive, continued treatment is needed. Ref # 4629 A severely injured client is moved into an examination area of the emergency department. The family member who accompanied the client to the ED is screaming at the nurse, saying that someone better start doing something right away. What is the best response by the nurse? A. "I'm going to give you a few minutes alone so you can calm down." Answers Correct C Student's C B. "I need you to go to the waiting area. You can come back when you're more in control." C. "I know you are upset. But please control yourself and sit down. Otherwise I will have to call security." D. "I can't think when you are yelling at me. Talk to me in a normal voice." Review Information: The correct answer is C: "I know you are upset. But please control yourself and sit down. Otherwise I will have to call security." Learning Objective: Lesson 2 Most violent behavior is preceded by warning signs, such as yelling or swearing. The challenge for nurses is to apply interventions that de-escalate a person's response to stressful or traumatic events. The keys to effective limit setting are using commands to express the desired behavior and providing logical and enforceable consequences for noncompliance. Nurses should acknowledge the agitated person's feelings and be empathetic, reminding him or her that they are there to help. Ref # 4513 The charge nurse reviews nursing roles and functions with a newly-hired licensed practical nurse (LPN). The LPN asks for more information about the role of the Minimum Data Set (MDS) coordinator. Which statement best explains the role of the MDS coordinator? A. Interacts with health care staff to coordinate care processes of client assessment and care planning B. Reviews admissions, diagnostic tests and treatments ordered by physicians C. Works with families to help their loved ones transition into the nursing home D. Reviews charts to maximize the cost efficiency of services Answers Correct A Student's A Review Information: The correct answer is A: Interacts with health care staff to coordinate care processes of client assessment and care planning Learning Objective: Lesson 1 The MDS Coordinator is typically an RN who potentially interacts with staff across the nursing home to coordinate care processes of resident assessment and care planning. This person will complete and submit the federally-mandated MDS form to the Center for Medicare and Medicaid Services (CMS). A utilization review committee reviews admissions, diagnostic procedures, and treatments. Ref # 4515 The MDS coordinator, who is a full time registered nurse, completes the minimum data set (MDS) for a new admission to a skilled nursing facility. Why does the nurse complete the MDS? (Select all that apply.) A. It will be used to measure outcomes of nursing care B. It is required by the board of trustees Answers Correct C, E Student's C, E C. It provides a standardized set of essential clinical and functional status measures D. It's used to direct the care that may be performed by nursing assistants E. It is required for all clients in a Medicare- or Medicaid-certified nursing facility Review Information: The correct answer is C, E : It provides a standardized set of essential clinical and functional status measures, It is required for all clients in a Medicare- or Medicaid-certified nursing facility Learning Objective: Lesson 1 The Minimum Data Set (MDS) is a standardized uniform comprehensive assessment of all residents in Medicare or Medicaid certified facilities mandated by federal law (P.L.100-203). It is a component of the federally-mandated Resident Assessment Instrument (RAI) and must be completed for any individual staying more than 14 days in that facility. The MDS is designed to help nursing homes thoroughly assess individuals in a standardized, comprehensive and reproducible manner; potential problems, strengths and preferences are identified using the MDS. The MDS cannot measure outcomes of care. Ref # 4512 A 90 year-old is readmitted to the hospital, less than 2 weeks after being discharged, for the same health concern. What factors contribute to hospital readmissions among older adults? (Select all that apply.) A. Reconciliation of medications B. Client health status C. Family preferences D. Poor communication among providers E. Excellent primary care Answers Correct B, C, D Student's B, C, D Review Information: The correct answer is B, C, D : Client health status, Family preferences, Poor communication among providers Learning Objective: Lesson 1 Avoidable hospitalization, especially among older adults living in skilled nursing facilities, usually results from multiple system failures. The reasons most often cited include inadequate primary care (including inadequate discharge planning and lack of reconciliation of medications), poor care coordination, poor skilled nursing facility quality of care, poor communication among providers and even family preferences. Not all illnesses can be anticipated and clients with more complex health issues are readmitted more often, regardless of quality or coordination of care. Ref # 2491 The 54 year old client is scheduled for a coronary angiography. The client’s medical history includes angina, type 2 diabetes mellitus and mild renal insufficiency. Which of the following orders does the nurse anticipate? A. Monitor serum creatinine levels pre- and post-procedure B. Metformin (Glucophage) 500 mg by mouth pre-procedure Answers Correct A Student's A C. Ibuprofen (Motrin) 800 mg by mouth PRN for pain post-procedure D. Restrict oral fluid intake post-procedure Review Information: The correct answer is A: Monitor serum creatinine levels pre- and post-procedure Learning Objective: Lesson 7 Coronary angiography requires the use of a contrast dye. Persons with diabetes and/or impaired kidney function are at high risk for developing contrast media-induced nephrotoxicity (CIN). Adequate hydration helps maintain renal blood flow and reduces the time the contrast media is in contact with the renal tubules and, therefore, will help prevent CIN. Serum creatinine levels are used to monitor for the development of CIN. Nephrotoxic drugs, such as ibuprofen, should not be used for procedures requiring contrast media. The oral hypoglycemic drug metformin increases the risk of lactic acidosis if CIN were to occur; it should be held the day of the procedure until kidney function returns to baseline (as determined by serum creatinine). Ref # 4603 The client is observed falling out of bed when reaching for something on the overbed table. The client then states: "Don't just stand there. I feel fine - help me up." What is the correct order of actions the nurse should take? A. Obtain a complete set of vital signs B. Complete an incident report C. Call the health care provider D. Assist the client back to bed, with help from other staff Answers Correct A, D, C, B Student's A, D, C, B Review Information: The correct answer is A, D, C, B : Obtain a complete set of vital signs, Assist the client back to bed, with help from other staff, Call the health care provider, Complete an incident report Learning Objective: Lesson 2 The first step is always to assess the client for any obvious injuries and to obtain a complete set of vital signs (especially blood pressure) and neurologic assessments. If the client does not appear to be injured, staff members can assist the client back into bed. The nurse should then call the health care provider to report the incident. Finally, the nurse should complete the incident report. Of course, personal items should be placed close to the client so that s/he can reach them. Ref # 4602 The geriatric social worker is working with the nurse to assess the client's ability to perform instrumental activities of daily living (IADL). Which of the following skills are considered instrumental activities of daily living? (Select all that apply.) A. Ability to take medications B. Ability to eat independently/feed self C. Ability to write checks Answers Correct A, C, E Student's A, C, E D. Ability to bathe self E. Ability to cook meals Review Information: The correct answer is A, C, E : Ability to take medications, Ability to write checks, Ability to cook meals Learning Objective: Lesson 3 Activities of daily living (ADLs) are basic self-care tasks, such as feeding, toileting, grooming, bathing, putting on clothes. Instrumental activities of daily living (IADLs) are slightly more complex skills and include a series of life functions necessary for living independently, such as the ability to use a telephone, shopping, doing housework, preparing meals, handling finances, and being responsible to take medications. ADLs and IADLs are part of an older adult's functional assessment. Ref # 4543 The nurse suspects that the client is in cardiogenic shock. Which of the following findings supports this information? A. Decreased or muffled heart sounds B. Bradycardia C. Bounding pulses D. Increased cardiac output Answers Correct A Student's C Review Information: The correct answer is A: Decreased or muffled heart sounds Learning Objective: Lesson 8 Cardiogenic shock involves decreased cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume; it is the leading cause of death in acute MI. Findings of cardiogenic shock include hypotension, rapid and faint peripheral pulses, distant-sounding heart sounds, cool and mottled skin, oliguria and altered mental status. Ref # 2489 The interdisciplinary team is reviewing charts for potential candidates for hospice care. Which of the following clients meet the criteria for hospice care? (Select all that apply.) A. 72 year-old with prostate cancer metastasized to the bone, who is receiving palliative radiation therapy B. 46 year-old with end stage liver disease, on a wait list for a donor organ C. 8 year-old client with acute myelogenous leukemia, for whom all treatment options have failed D. 91 year-old with Alzheimer’s disease, who is no longer able to eat or drink oral fluids Answers Correct A, C, D Student's A, D, E E. 53 year-old client with chronic, unrelieved pain, who is addicted to narcotics following a back injury Review Information: The correct answer is A, C, D: 72 year-old with prostate cancer metastasized to the bone, 8 year-old client with acute myelogenous leukemia, for whom all treatment options have failed, 91 year-old with Alzheimer’s disease, who is no longer able to eat or drink oral fluids Learning Objective: Lesson 4 Hospice care provides services for clients who are at the end of their life, usually with less than 6 months to live. There are no age requirements. Palliative care is provided by a multi-disciplinary team in a variety of settings, including the home, hospital or extended-care facilities. Clients actively seeking a cure or treatment for their disease do not meet the criteria for hospice care. Ref # 4511 Two members of the interdisciplinary team are arguing about the plan of care for a client. Which action could any one of the members of the team use as a de-escalation strategy? A. Adjourn the meeting and reschedule when everyone has calmed down B. Bring the communication focus back to the client C. Interrupt, apologize for interruption, and change the subject D. Tell the violators they must calm down and be reasonable Answers Correct B Student's B Review Information: The correct answer is B: Bring the communication focus back to the client Learning Objective: Lesson 1 Bringing the subject of the communication back to the client refocuses attention on the client's care, instead of the manner of communication. It is the most effective strategy because it is an example of collaboration. The other options are non-productive and may even make matters worse. Ref # 4631 During a 12-hour night shift, the nurse has a "near miss" and catches an error before giving a new medication. Which statement might explain the reason for the near miss? (Select all that apply.) A. The nurse has worked on the same unit for 5 years B. The nurse works in the intensive care unit (ICU) C. The nurse is sleep-deprived Answers Correct B, C, D, E Student's B, C, D, E D. The nurse is interrupted when preparing the medication E. The unit is short-staffed Review Information: The correct answer is B, C, D, E : The nurse works in the intensive care unit (ICU), The nurse is sleep-deprived, The nurse is interrupted when preparing the medication, The unit is shortstaffed Learning Objective: Lesson 2 There are a number of reasons for near misses and making medication errors, including heavy workload and inadequate staffing, distractions, interruptions, and inexperience. Fatigue and sleep loss are also factors, especially for nurses working in units with high acuity clients. Practice Bank 32 Ref # 4332 A 28 year-old is transferred to the emergency department (ED) via ambulance with a traumatic head injury. The client is awake and reports having a headache and some amnesia. What are the priority nursing interventions for this client? (Select all that apply.) A. Assess the airway B. Prepare for CT imaging of the head C. Position this client in high Fowler’s position D. Assess vital signs and neurological function E. Assess the wound for presence of drainage or bruising on the head Answers Correct A, B, D, E Student's A, B, D, E Review Information: The correct answer is A, B, D, E : Assess the airway, Prepare for CT imaging of the head, Assess vital signs and neurological function, Assess the wound for presence of drainage or bruising on the head Learning Objective: Lesson 8 Remember primary emergency trauma assessment using “A, B, C, D and E”. The ED nurse will assess airway, breathing, circulation, and disability/neurological function on a person who has experienced a traumatic head injury. The nurse will also examine the client for the presence of any bruising or drainage, particularly of the ears and nose. A supine position is best; the head of the bed may be elevated slightly if not contraindicated. A CT scan is required if the client presents with an abnormal mental status, clinical signs of skull fracture, history of vomiting, or headache. Ref # 4321 The health care provider has ordered to administer an osmotic diuretic for a client diagnosed with a traumatic brain injury (TBI). Why was this medication ordered for this client? Answers Correct C Student's C A. Prevent seizures B. Reduce pulmonary edema C. Reduce intracranial pressure D. Prevent electrolyte imbalance Review Information: The correct answer is C: Reduce intracranial pressure Learning Objective: Lesson 6 Osmotic diuretics, such as mannitol, are used to reduce intracranial or intraocular pressure. Osmotic diuretics reduce the amount of water normally reabsorbed by the renal tubules and loop of Henle, so urinary output is increased. Osmotic diuretics can cause excessive loss of water and electrolytes, which can lead to serious electrolyte imbalances. In addition to water intoxication and dehydration, adverse reactions of osmotic diuretics include pulmonary edema and circulatory overload. Anticonvulsants prevent seizures. Ref # 4330 There is an order to administer an intramuscular influenza vaccine to an adult. What actions should the nurse take prior to administration of the injection? (Select all that apply.) A. Record the client’s reaction to the injection B. Provide the client with the federal Vaccine Information Statement (VIS) C. Record the site and time of injection D. Check the expiration date on the vaccination bottle E. Ask the client if she or he can eat eggs without adverse effects F. Record the manufacturer of the vaccine and lot number Answers Correct B, D, E Student's B, D, E Review Information: The correct answer is B, D, E : Provide the client with the federal Vaccine Information Statement (VIS), Check the expiration date on the vaccination bottle, Ask the client if she or he can eat eggs without adverse effects Learning Objective: Lesson 6 Prior to administration, the nurse should identify the expiration date on the bottle and give a current copy of the federal Vaccine Information Statement to the client. The nurse should also verify any allergies, particularly hypersensitivity to eggs, prior to administering the vaccine. Observing for a reaction to the injection and recording the site, time of injection, the manufacturer and lot number are performed after administering the medication. Ref # 1313 During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would a nurse anticipate since it is associated with this problem? Answers Correct B Student's B A. "I have constant blurred vision." B. "I have to turn my head to see my room." C. "I have specks floating in my eyes." D. "I can't see on my left side." Review Information: The correct answer is B: "I have to turn my head to see my room." Learning Objective: Lesson 8 Intraocular pressure becomes elevated which slowly produces a progressive loss of the peripheral visual field in the affected eye along with rainbow halos around lights. Intraocular pressure becomes elevated from the microscopic obstruction of the trabeculae meshwork. If undetected, or left untreated, blindness results in the affected eye. Ref # 1633 A three year-old child diagnosed with celiac disease attends a day care center. Which food would be an appropriate snack? A. Vanilla cookies B. Cheese crackers C. Potato chips D. Peanut butter sandwich Answers Correct C Student's C Review Information: The correct answer is C: Potato chips Learning Objective: Lesson 5 Children with celiac disease should eat a gluten free diet. Gluten is found mainly in grains of wheat and rye and in smaller quantities in barley and oats. Corn, rice, soybeans and potatoes are digestible by persons diagnosed with celiac disease. Ref # 4333 A 34 year-old female, who has been experiencing widespread muscle pain and fatigue, is diagnosed with fibromyalgia (FM). Which statement by the client indicates she does not understand the treatment options and needs further instruction? A. "I will take an exercise class – maybe I’ll sign up for a yoga class." B. "I should take duloxetine (Cymbalta) once a day, every day." C. "If I forget to take the pregabalin (Lyrica) in the morning, I can take it with my evening dose." D. "I will avoid caffeine, sugar, and alcohol before bedtime." Answers Correct C Student's D Review Information: The correct answer is C: "If I forget to take the pregabalin (Lyrica) in the morning, I can take it with my evening dose." Learning Objective: Lesson 8 Treatment of fibromyalgia is multifaceted and individualized. Both conventional and alternatives treatments must be considered. Pain management includes medications such as pregabalin (Lyrica) and duloxetine (Cymbalta). Pregabalin, which is an anticonvulsant, is usually prescribed twice a day; if a client forgets to take a dose, she can take it as soon as she remembers but should never take 2 or more at the same time. Duloxetine, a SNRI, is the only antidepressant approved by the FDA to treat fibromyalgia pain and is taken once a day. Ref # 4319 The order states: acetaminophen (Tylenol) suspension 6 mL by mouth four times a day. The label on the container states: acetaminophen 80 mg per 5 mL. How many milligrams will the nurse administer? mg. Answers Correct 96 Student's 96 Review Information: The correct answer is : 96 Learning Objective: Lesson 6 Dimensional analysis: 6 mL/1 x 80 mg/5 mL = 480/5 = 96 mg Or Ratio: 80 mg/5 mL = x/6 mL 5x = 480 x = 96 mg Ref # 1236 A client is admitted with low T3 and T4 levels and an elevated thyroid stimulating hormone (TSH) level. On initial assessment, a nurse should anticipate which of these findings? A. Heat intolerance B. Lethargy C. Skin eruptions Answers Correct B Student's B D. Diarrhea Review Information: The correct answer is B: Lethargy Learning Objective: Lesson 8 In hypothyroidism the metabolic activity of all cells of the body decreases, reducing oxygen consumption, decreasing oxidation of nutrients for energy, and producing less body heat. Therefore, the nurse can expect the client to report being constipated, tired and unable to get warm. Ref # 1443 Which statement by a client would require the most immediate action by a nurse? A. "The pain came on after dinner. That soup seemed very spicy." B. "I feel pressure in the middle of my chest like an elephant is sitting on my chest." C. "When I take in a deep breath, it stabs like a knife." D. "When I turn in bed to reach the remote for the TV, my chest hurts." Answers Correct B Student's B Review Information: The correct answer is B: "I feel pressure in the middle of my chest like an elephant is sitting on my chest." Learning Objective: Lesson 8 This is a classic description of chest pain in men caused by myocardial ischemia. Women experience vague feelings of fatigue and back and jaw pain. Pain after spicy food is often the result of irritation and gastric indigestion. The pain with a deep breath is typically from an inflammation of the pleural covering of the lung, call pleurisy. Ref # 1293 A nurse is caring for a client who is receiving methyldopa hydrochloride (Aldomet) intravenously. Which assessment finding would indicate to the nurse that the client may be having an adverse reaction to the medication? A. Palpitations B. Headache C. Mood changes D. Hyperkalemia Answers Correct C Student's C Review Information: The correct answer is C: Mood changes Learning Objective: Lesson 6 The nurse should assess the client for alterations in mental status such as mood changes which are considered adverse effects. These changes should be reported promptly. Ref # 1317 A client is receiving intravenous heparin therapy. What medication should a nurse have available in the event of an overdose of heparin? A. Protamine B. Amicar C. Diltiazem D. Imferon Answers Correct A Student's B Review Information: The correct answer is A: Protamine Learning Objective: Lesson 6 Protamine binds heparin to make it ineffective with a prevention of spontaneous bleeding. Ref # 4320 The order is for ibuprofen (Motrin) oral drops 10 mg/kg of body weight. The client weighs 62 lbs. Motrin oral drops are supplied in bottles containing 40 mg/mL. How many milliliters will the nurse administer? (Report to the nearest whole number.) mL. Answers Correct 7 Student's 7 Review Information: The correct answer is : 7 Learning Objective: Lesson 6 Dimensional analysis: X mL = 1 mL/40 mg X 10 mg/kg X 1 kg/2.2 lbs X 62 lbs = 620/88 = 7.05 or 7 mL Ratio: 62 lbs/x = 1 kg/2.2 lbs = 28.19 kg 10 mg/x = 1 mL/40 mg = 10/40 = 0.25 0.25 X 28.19 = 7.05 or 7 mL Ref # 4325 A healthy 18 year-old is entering college in the fall. Which immunization would the health care provider recommend prior to college? (Select all that apply.) A. Pneumococcal polysaccharide vaccine (PPSV23) B. Tetanus, Diphtheria, Pertussis vaccine (Tdap) C. Shingles vaccine D. Seasonal influenza vaccine E. Meningococcal conjugate vaccine (MCV4) F. Human papillomavirus (HPV) vaccine Answers Correct B, D, D, E, F Student's B, D, D, E, F Review Information: The correct answer is B, D, D, E, F: Tetanus, Diphtheria, Pertussis vaccine (Tdap), Seasonal influenza vaccine, Meningococcal conjugate vaccine (MCV4), Human papillomavirus (HPV) vaccine Learning Objective: Lesson 3 Adults older than age 50 should get the shingles vaccine. The PPSC23 is given to adults older than age 65. (The pneumococcal vaccine PCV13 is routinely given to infants/children.) An 18 year-old who is going to college should receive the TDAP, MCV4 and seasonal influenza vaccine. He or she should also receive the HPV vaccine if s/he has not already received it. Ref # 4514 The client returned from the cardiac catheterization lab four hours ago. The groin was used as the insertion site. Which of the assessment findings would the nurse immediately report to the health care provider? (Select all that apply.) A. Trace amount of serosanguineous drainage on the groin dressing B. Pale color of the affected limb Answers Correct B, C, D Student's B, C, D C. Capillary refill 6 seconds on the affected toes D. Nonpalpable pedal pulse on the affected limb E. Bruising or lump at the insertion site Review Information: The correct answer is B, C, D : Pale color of the affected limb, Capillary refill 6 seconds on the affected toes, Nonpalpable pedal pulse on the affected limb Learning Objective: Lesson 7 A trace of serosanguineous drainage on the dressing is common. Some bruising or a small lump is expected at the insertion site. Reportable conditions include significant reports of pain; abnormal lab values; abnormal ECG strip; post-procedure bleeding or swelling; color, temperature or pulse changes, especially to the affected limb. Capillary refill should be about 3 seconds. Ref # 1566 Which finding is a classic finding in clients diagnosed with panic disorder? A. Predictable episodes B. Sense of impending doom C. Fear of common activities D. Compulsive behavior Answers Correct B Student's C Review Information: The correct answer is B: Sense of impending doom Learning Objective: Lesson 4 The feeling of overwhelming and uncontrollable doom is a classic characteristic of a panic attack. The other options may be associated with panic disorder and may be unique to individuals. Ref # 4516 The nurse listens to report about a newly admitted client who has a skin ulcer that’s tested positive for MRSA (methicillin-resistant Staphylococcus aureus). What precautions must be taken for this hospitalized client? (Select all that apply.) A. Place the client in a single room B. Keep all equipment in the client’s room for his/her sole use C. Keep the door to the room closed, with a notice for visitors D. Perform hand hygiene after direct contact with the client and before leaving the room E. Wear mask when providing routine care to the client Answers Correct A, B, C, D Student's A, B, C, D Review Information: The correct answer is A, B, C, D : Keep all equipment in the client’s room for his/her sole use , Keep the door to the room closed, with a notice for visitors, Perform hand hygiene after direct contact with the client and before leaving the room, Wear mask when providing routine care to the client Learning Objective: Lesson 2 Contact precautions are recommended in acute care settings for MRSA when there’s a risk for transmission or wounds that cannot be contained by dressings. The client should be in a single room, with the door closed; the sign on the door instructs visitors to report to the nurse before entering the room. All equipment, such as stethoscopes and blood pressure devices, should be for the client’s sole use and kept in the room. Health care workers must perform hand hygiene (wash hands with soap and water) after direct contact with the client and his/her environment and before leaving the isolation room. Contact precautions require health care workers to wear gloves and a gown; a face mask is not necessary for routine care. Ref # 1484 Nurse colleagues are discussing their practice during lunch. Which statement is correct? A. National nurses’ associations work collaboratively to update the social policy statement for nursing. B. The employing agency is ultimately responsible to provide practice guidelines for licensed nurses. C. The federal government ensures the safety of clients by defining the scope of nursing practice. D. Each state has specific regulations for licensed registered nurses (RNs) and practical nurses (PNs). Answers Correct D Student's C Review Information: The correct answer is D: Each state has specific regulations for licensed registered nurses (RNs) and practical nurses (PNs). Learning Objective: Lesson 1 This is the only correct statement. State governmental agencies license nurses in each state. Ref # 4317 The client is instructed to collect stool specimens at home using the guaiac test. In addition to explaining how to collect the specimens, the nurse instructs the client to avoid certain substances prior to obtaining the stool specimens. Which of the following substances should the client avoid? (Select all that apply.) A. Broiled or wood-grilled salmon B. Grilled sirloin steak C. Marinated cauliflower and broccoli Answers Correct B, C, D Student's B, C, D D. Oranges E. Barbecued pork chops F. Acetaminophen Review Information: The correct answer is B, C, D : Grilled sirloin steak, Marinated cauliflower and broccoli, Oranges Learning Objective: Lesson 7 Foods like beef, which contain hemoglobin, will result in a false positive test and should be avoided for at least 3 days before the fecal occult blood test; chicken, pork and seafood can be consumed. Fruits and vegetables with high peroxidase activity, such as red radishes, broccoli, and cauliflower should also be avoided several days prior to obtaining specimens. Clients should also limit their intake of vitamin C because too much can lead to a false negative result. Aspirin and other nonsteroidal anti-inflammatory drugs can cause bleeding and should be avoided at least 7 days before the test; acetaminophen does not affect the test. Ref # 1242 An ambulatory client reports edema during the day in the feet and ankles that disappears while the client sleeps during the night. What is the most appropriate follow-up question for a nurse to ask? A. "Do you become short of breath during your normal daily activities?" B. "Have you had a recent heart attack?" C. "How many pillows do you use at night to sleep comfortably?" D. "Do you smoke daily or every other day?” Answers Correct A Student's C Review Information: The correct answer is A: "Do you become short of breath during your normal daily activities?" Learning Objective: Lesson 8 Edema and shortness of breath with exertion are the findings of right- sided heart failure, which causes increased pressure in the systemic venous system due to poor right heart cardiac output. To equalize this pressure, fluid backing up from the right heart shifts into the interstitial spaces causing peripheral edema. The lower extremities are first affected by edema in the ambulatory client due to gravity, with a pattern of worsening edema during that day that improves when the client is supine while sleeping. The supine posture causes redistribution of the fluid, as well as facilitating renal perfusion and increased diuresis, which often causes nocturia. This question would elicit information to confirm the nursing diagnosis of activity intolerance and fluid volume excess, both associated with right-sided heart failure. Assessment for orthopnea, which is associated with left-heart failure, would be an appropriate follow-up question. Recent myocardial infarction and smoking history will not provide as much relevant information in this situation. A broader question about a history of heart problems would also be appropriate in determining whether this client is at risk of developing heart failure. Ref # 1424 A nurse is caring for an acutely ill 10 year-old client. Which assessment finding would require the nurse's immediate attention? Answers Correct C Student's C Rapid bounding pulse Profuse diaphoresis Slow, irregular respirations Temperature of 101.3 F (38.5 C) Review Information: The correct answer is C: Slow, irregular respirations Learning Objective: Lesson 8 A slow and irregular respiratory rate is a sign of fatigue in an acutely ill child. Fatigue can rapidly lead to respiratory arrest. Practice Bank 1 Ref # 371 While providing home care to a client with heart failure, a nurse is asked how long diuretics must be taken. What is the best response by the nurse to this client? A. "The medication must be continued so the fluid problem is controlled." B. "You will have to take this medication for about a year." C. "Please talk to your health care provider about medications and treatments." D. "As you urinate more, you will need less medication to control fluid." Answers Correct A Student's C Review Information: The correct answer is A: "The medication must be continued so the fluid problem is controlled." Learning Objective: Lesson 6 Pharmacological Therapies This is the most therapeutic response and gives the client accurate information. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 291 A client, scheduled for coronary artery bypass surgery, makes these statements. Which statement is incorrect and should alert a nurse that reinforcement of information is needed? A. "Participation in a cardiac rehabilitation program will help prevent further heart disease." B. "A low sodium diet will help decrease the workload of my heart." C. "I must take my pulse before taking my medication and notify the health care provider if it is less than 60 beats per minute or greater than 120 beats per minute." D. "I will need to change positions slowly to prevent my blood pressure from rising." Answers Correct D Student's C Review Information: The correct answer is D: "I will need to change positions slowly to prevent my blood pressure from rising." Learning Objective: Lesson 3 Health Promotion and Maintenance Note the clue at the end of the statement “rising” which is incorrect information. Medications such as antihypertensives, vasodilators, and beta blockers tend to reduce the workload of the heart and can cause orthostatic hypotension which is a drop in systolic blood pressure (BP) of greater than 20 mmHg with changes in a position from lying to sitting or standing. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Kee, J.L., Hayes, E.R., & McCuistion, L. (2008). Pharmacology: A nursing process approach (6th ed.). St. Louis, MO: Saunders Elsevier. Ref # 405 A nurse is caring for a newborn diagnosed with a neural tube defect (myelomeningocele). What would be the best covering for the lesion? A. dry sterile gauze only dressing B. moist sterile nonadherent dressing C. telfa dressing with antibiotic ointment D. sterile occlusive pressure dressing Answers Correct B Student's B Review Information: The correct answer is B: moist sterile nonadherent dressing Learning Objective: Lesson 8 Physiological Adaptation Before surgical closure of the sac the focus is to prevent the area from drying by the application of a sterile, moist, nonadherent dressing over the defect. Dressings are changed by sterile technique frequently to keep them moist. Lowdermilk, D., & Perry, S. (2007). Maternity & women's health care (9th ed.). St. Louis, MO: Mosby. Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 400 A nurse is to collect data about a six month-old child diagnosed with nonorganic failure-to-thrive (NOFTT). Upon entering the room, the nurse would expect the baby to have which characteristics? A. alert, laughing and playing with a rattle, sitting with support B. irritable and "colicky" with no attempts to pull to standing Answers Correct C Student's C C. pale, thin arms and legs along with no interest in the surroundings D. skin color dusky with poor skin turgor over abdomen Review Information: The correct answer is C: pale, thin arms and legs along with no interest in the surroundings Learning Objective: Lesson 8 Physiological Adaptation Diagnosis of NOFTT is made on findings of documented growth retardation which would lead the nurse to expect muscle-wasting and paleness. In cases of NOFTT, the cause may be a variety of psychosocial factors and these children may be below normal in intellectual development, language and social interactions for age. Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 369 When caring for a client who is receiving a thrombolytic agent to open a clot-occluded coronary artery after the diagnosis of a myocardial infarction, which finding would be of greatest concern to a nurse? A. hematemesis B. serosanguinous drainage from the IV site C. slight rust-colored urine D. pink-tinged saliva Answers Correct A Student's A Review Information: The correct answer is A: hematemesis Learning Objective: Lesson 6 Pharmacological Therapies Frank bleeding should be of the greatest concern to the nurse. Even though the other types of bleeding are not considered acute and severe, they would still be of concern. Test-taking Tips: Read this question carefully and be clear that the content on which is being tested is about the thrombolytic agent. Think, with these agents, bleeding is the greatest concern – leading to two options. One option has the word “slight” in it making it less significant than the other option. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 753 Nurses, who work with clients from many different cultures, should recognize which approach as a priority? Answers Correct B Student's B A. learn about many cultural beliefs B. recognize personal attitudes and biases C. refer to others from specific countries D. speak other languages of the local clients Review Information: The correct answer is B: recognize personal attitudes and biases Learning Objective: Lesson 4 Psychosocial Integrity The nurse must discover personal attitudes, prejudices and biases. Sensitivity to these will affect interactions with clients and families across cultures. Test-taking Tips: Note that one of the options speaks to “others” and the question is about “the nurse.” Therefore, that option should be eliminated immediately. Two of the options may or may not be realistic for every nurse to attain. However, "recognizing personal attitudes and biases" is obtainable by any nurse. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Taylor, C.R., Lillis, C., LeMone, P., & Lynn, P. (2006). Fundamentals of nursing: The art and science of nursing care (6th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 788 A client, diagnosed with active tuberculosis (TB), has a history of medication noncompliance. Which action by the nurse indicates an understanding of the appropriate care needed for this client? A. Schedule weekly clinic visits for the client with a focus on medication follow-up B. Ask the health care provider to change the regimen to a fewer number of medications C. Ask a family member to supervise daily medication compliance D. Instruct the client to wear a high efficiency particulate air mask in public places Answers Correct C Student's C Review Information: The correct answer is C: Ask a family member to supervise daily medication compliance Learning Objective: Lesson 4 Psychosocial Integrity Direct-observed therapy is a recognized method for ensuring client compliance to any medication regimen. The program can be set up to directly observe the client taking the medication in the clinic, home, workplace or other convenient location. Notice the word “compliance” the correct option, which matches the content in the question. Remember that contacting a health care provider would not normally be considered a correct option unless the information in the question is life- threatening, potentially lifethreatening, or if a health care provider’s order is needed. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 514 A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Answers Correct D Which finding should take priority in the plan of care? A. fatigue B. esophagitis C. skin irritation D. leukopenia Student's D Review Information: The correct answer is D: leukopenia Learning Objective: Lesson 7 Reduction of Risk Potential Clients develop leukopenia due to the depressant effect of radiation therapy on bone marrow function. Infection is the most frequent cause of morbidity and death in clients who receive cancer therapy. The secondary concern should be the esophagitis with a risk for aspiration with swallowing. Skin irritation is third with the risk of infection and then fatigue should be the last concern. Williams, L. (2007). Understanding medical surgical nursing (3rd ed.). Philadelphia: F.A. Davis Company. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 364 A nurse is teaching a client who has a new prescription for sublingual nitroglycerin. Which focus should be included during reinforcement of information? A. carry the nitroglycerin with you at all times B. take the medication at the same time each day C. keep the medication bottle in the refrigerator D. rest in bed for 30 minutes after taking medication Answers Correct A Student's C Review Information: The correct answer is A: carry the nitroglycerin with you at all times Learning Objective: Lesson 6 Pharmacological Therapies Nitroglycerin should be carried with the client in and out of the home, so it can be used when angina pain occurs. Test-taking Tips: The key words in this question are “what must be emphasized when teaching about nitroglycerin (NTG) sublingual (SL).” Go with what is known about NTG given SL in that it is usually prn as contrast to NTG ointment that is given routinely. Then read the answers carefully and you will notice that immediately that two of the options can be eliminated. Ask yourself: What is more important—resting after taking the medication or having it available to take when needed. Notice that one option has the clue "rest in bed" which makes it unrealistic and not the best answer. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 407 A nurse is assisting in the plan of care for a ten month-old infant diagnosed with bacterial meningitis. The nurse would expect the plan of care to include which intervention? Answers Correct C Student's A A. put infant in contact isolation B. provide for active range of motion C. observe for a decrease in play activity D. place an over-the-crib mobile Review Information: The correct answer is C: observe for a decrease in play activity Learning Objective: Lesson 8 Physiological Adaptation When treating meningitis, neurological deterioration should be assessed frequently. In children, a decrease in play activity is equivalent to a decreased level of consciousness. The type of isolation is respiratory, not contact isolation. Test-taking Tips: The problem in this question is an infant with a meningeal infection. The question asks what action is expected in the plan of care. When a problem exists further data collection is needed. There is only option that is data collection. Another approach is to identify that this is a neurological question and requires a neurological answer. This allows immediate elimination of two options. One of the options is a distracter because of the word “isolation” in it, but if read carefully the word ”contact” will be seen as incorrect. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 519 A nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. What should the initial action of the nurse be? A. verify correct placement of the tube B. aspirate gastric contents to determine the amount of the residual C. check that the feeding solution matches the dietary order D. ensure that feeding solution is at room temperature Answers Correct C Student's A Review Information: The correct answer is C: check that the feeding solution matches the dietary order Learning Objective: Lesson 5 Basic Care and Comfort Tube feedings are similar to medications and verification of correct feeding is the first action. Altman, G.B. (2009). Delmar's fundamental and advanced nursing skills (3rd ed.). Clifton Park, NY: Delmar Cengage Learning. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 400 The nurse receives a telephone order from the health care provider for acetaminophen (Tylenol) 1000 mg by mouth for a client's headache. What should the nurse add to the following order when documenting it in the chart? (Write the answer using lower case letters). Answers Correct Student's Acetaminophen (Tylenol) 1000 mg by mouth for headache, one time dose. Dr. Smith 10/1/2012 at 2:30 pm (1430) by N. Nurse, RN. Review Information: The correct answer is ORDER: telephone order, Telephone order, TELEPHONE ORDER, Telephone Order Learning Objective: Lesson 1 The words "telephone order" must be written out to differentiate it from a verbal order or one written by the health care provider directly in the chart. Abbreviations should not be used. The health care provider needs to countersign the order according to the facility policy. Ref # 522 Which information should be included during the discussion of home care for a client who has had a hip prosthesis implantation? A. do not cross your legs at any time B. ambulate using crutches C. avoid climbing stairs for three months D. sleep on your back Answers Correct A Student's A Review Information: The correct answer is A: do not cross your legs at any time Learning Objective: Lesson 7 Reduction of Risk Potential Hip flexion should not exceed 60 degrees. Test-taking Tips: If guessing, narrow the options down to the two that are the most similar but dissimilar. This would lead to options two of the options because both focus on “not” doing something with the legs (“avoid” and “do not”). Ask: which position would be contraindicated with a hip prostheses or the hip joint—climbing or crossing legs? Cross your legs now and feel how the hip joint is a little stressed. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 754 A client of the Hispanic heritage refuses emergency room treatment until a curandero is called. What should the nurse understand about the practices of a curandero? Answers Correct D Student's C A. Curandero offer spiritual advising B. The client believes in witchcraft C. Herbal preparations will be used D. Curandero use holistic healing practices Review Information: The correct answer is D: Curandero use holistic healing practices Learning Objective: Lesson 4 Psychosocial Integrity A curanderos is a traditional folk healer who uses a holistic approach that includes herbs, aromas and rituals, to treat the ills of the body, mind and spirit. Many times, the curandero works with traditional health care providers to restore health. Craven, R.F., & Hirnle, C.J. (2008). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia: Lippincott Williams & Wilkins. Christensen, B., & Kockrow, E. (2010). Foundations of nursing and adult health nursing (6th ed.). St. Louis: Mosby. Ref # 295 When talking to a client about human immunodeficiency virus (HIV) prevention, which action should the nurse emphasize as increasing risks of the disease? A. use of public bathrooms B. donation of blood C. kissing a person with acquired immunodeficiency syndrome D. the practice of unprotected sex Answers Correct D Student's D Review Information: The correct answer is D: the practice of unprotected sex Learning Objective: Lesson 3 Health Promotion and Maintenance Because HIV is spread through exposure to bodily fluids, unprotected intercourse and shared drug paraphernalia remain the highest risk for this infection. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Herlihy, B. (2006). The human body in health and illness (3rd ed.). Philadelphia: Saunders. Ref # 513 A client newly admitted with a diagnosis of a sickle cell crisis is talking on the telephone but stops as a nurse enters the room and requests something for pain. The nurse notices that the nasal oxygen is lying on the client’s bed. What action should the nurse take first? A. reapply the prescribed nasal oxygen B. encourage increased fluid intake C. administer the prescribed analgesia Answers Correct A Student's C D. recommend relaxation exercises for pain control Review Information: The correct answer is A: reapply the prescribed nasal oxygen Learning Objective: Lesson 5 Basic Care and Comfort Relief of pain is the expected outcome for treatment of sickle cell crisis. The oxygen needs to be reapplied first and then the client should receive the analgesic. After the analgesic is given the nurse should encourage fluids and recommend relaxation exercises. Pain may be present even without overt signs. Pain is what clients say it is. The fact that the client is on the phone is a distracter. Test-taking Tips: The key words in this question are “sickle cell crisis” and “what the nurse would do first.” Thus, all of the options are conceivably correct and the task is to select the “best of 4.” As the options are read, compare the verbs first: reapply, encourage, administer, recommend. Note the problem in the situation is pain. Oxygen is critical to maintain cell integrity. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 529 The nurse is assisting a client who complains of watery diarrhea with meal planning. During the discussion which of these foods should the nurse identify for the client to avoid? A. orange juice B. tuna C. eggs D. macaroni Answers Correct A Student's C Review Information: The correct answer is A: orange juice Learning Objective: Lesson 5 Basic Care and Comfort Orange juice is contraindicated for a client with diarrhea. Given the choices, it would have more tendency to increase the motility of the gastrointestinal tract more than the other foods listed. - (2006). Best practices: Evidence-based nursing procedures (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 520 A client with a fracture of the radius had a plaster cast applied two days ago. The client calls the clinic to report constant pain and swelling of the fingers since the cast was applied. What should be the next action of a nurse? A. ask if numbness is present in the fingers and if the client can move the fingers B. suggest to elevate the arm higher than heart level Answers Correct A Student's A C. have the client make an appointment with the surgeon for the next day D. approve the application of a cool cloth to the fingers of the affected arm Review Information: The correct answer is A: ask if numbness is present in the fingers and if the client can move the fingers Learning Objective: Lesson 7 Reduction of Risk Potential A deterioration in neurovascular status indicates the development of compartment syndrome (elevated tissue pressure within a confined area with resultant of nerve and vessel compression) which requires immediate pressure reducing interventions such as a fasciotomy. The nurse should question the client about impaired neuro findings such as numbness, tingling and inability to move fingers. Test-taking Tips: Remember the first action is to gather data. The word “ask” in one of the options is a data collection word, suggesting that it is the correct answer. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 4466 The nurse is performing pulmonary assessment on a client. Indicate the correct sequence of pulmonary assessment by dragging and dropping the steps below into the correct order. A. Auscultation B. Palpation C. Percussion D. Inspection Answers Correct Student's Review Information: The correct answer is ORDER: Inspection , Palpation, Percussion, Auscultation Learning Objective: Lesson 3 Health Promotion and Maintenance Inspection is first, observing for pattern of breathing, symmetry, anteroposterior and transverse chest diameters, as well as skin color, sounds and odors. The nurse will then palpate the posterior and anterior chest, noting any tenderness, crepitus, or tactile fremitus. The next step is percussion, which is performed in a systematic manner, usually from side to side from apex (top) of lungs to base (bottom), listening to changes in tone from one area to another. Lastly, the lungs are auscultated, listening over the anterior, posterior, and lateral chest for expected or adventitious sounds. Ref # 296 When discussing sexually transmitted infections (STIs) with adolescents, which etiology should a nurse emphasize as the most common infection associated with STIs? A. herpes simplex 2 B. chlamydia C. gonorrhea D. human immunodeficiency virus Answers Correct B Student's C Review Information: The correct answer is B: chlamydia Learning Objective: Lesson 3 Health Promotion and Maintenance Chlamydia has the highest incidence of any sexually transmitted infection in this country. Prevention is similar to safe sex practices taught to prevent any STI: use of a condom for protection during intercourse. Test-taking Tips: This is a question where content is needed. To help you recall that content associate the ‘C’ in Chlamydia with the ‘C’ in common to remember it as the most common STI . Herlihy, B. (2006). The human body in health and illness (3rd ed.). Philadelphia: Saunders. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Practice Bank 2 Ref # 314 A nurse has been reinforcing information about cardiac risks to adult clients as they visit a hypertension clinic. Which approach would best assist in the evaluation of their learning? A. reported behavioral changes B. completion of a mailed survey C. responses to verbal questions D. performance on written tests Answers Correct A Student's A Review Information: The correct answer is A: reported behavioral changes Learning Objective: Lesson 3 Health Promotion and Maintenance If the client alters behaviors such as smoking, drinking alcohol, and stress management, these suggest that learning has occurred. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Linton, A.D. (2007). Introduction to medical surgical nursing (4th ed.). Philadelphia: Saunders. Ref # 420 Which statement by a parent would alert a nurse to check with the registered nurse (RN) about iron deficiency anemia in a 14 month-old child? A. "I know there is a problem since my child is always constipated." B. "My child doesn't like many fruits and vegetables, but really loves milk." Answers Correct B Student's B C. "My child doesn't drink a whole glass of juice or water." D. "I can't understand why my child is not eating as much as 4 months ago." Review Information: The correct answer is B: Learning Objective: Lesson 8 Physiological Adaptation Two to three cups of milk a day are sufficient for the young child's needs. Sometimes excess milk intake, a habit carried over from infancy, may exclude many solid foods from the diet. As a result, the child may lack iron and develop a so-called milk anemia. Although the majority of infants with iron deficiency are underweight, many are overweight because of excessive milk ingestion. Test-taking Tips: If guessing, narrow the options down to the two that are similar but dissimilar. This will lead to two options in that they both focus on “my child” and “drinking.” Associate the word “deficiency” in the stem of the question with “deficiency of fruits and vegetables” in one option. If guessing, match the problem or words in the stem with words in the option. Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 311 Which neurological finding for a young adult in an accident would be the priority to report? A. unilateral flaccid paralysis B. diminished reflexes C. pupils fixed and dilated D. reduced sensory responses Answers Correct C Student's C Review Information: The correct answer is C: Learning Objective: Lesson 3 Health Promotion and Maintenance Pupils that are fixed and dilated are too late to be of concern and too late for intervention. Thus, they need to be reported first. Abnormal pupillary responses may indicate severe trauma to the neurological system in the brain. Smeltzer, S.C., Bare, B.G., Hinkle, J., & Cheever, K.H. (2009). Brunner- Suddarth's textbook of medical surgical nursing (12th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 4484 A client had a left upper-lobectomy. Which site should the nurse listen to in order to assess the client is meeting this goal, "Lung sounds clear following chest physiotherapy." Answers Correct Student's Review Information: The correct answer is : Learning Objective: Lesson 3 Health Promotion and Maintenance Always auscultate breath sounds after chest physiotherapy for changes. These changes should be found in the base of the left lung if the goal is to clear consolidation, as in pneumonia. Ref # 534 A client has been diagnosed with mild dysphagia. What is the appropriate nursing intervention for this client? A. position client in an upright position while eating B. alternate a clear liquid diet with a soft diet C. offer finger foods such as crackers or pretzels D. tilt head back to facilitate the swallowing process Answers Correct A Student's A Review Information: The correct answer is A: position client in an upright position while eating Learning Objective: Lesson 5 Basic Care and Comfort An upright position facilitates proper chewing and swallowing. To prevent aspiration, thicker foods should be offered or thickening should be added to liquids. Tilting the chin down helps swallowing. Dry foods such as crackers or pretzels may increase the risk for choking. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 556 An older adult client calls the clinic hotline with complaints of generalized muscle aches and pains. What should be the initial action by a nurse who answered the phone? A. obtain details of the severity and location of the pain Answers Correct A Student's C B. find out what the client usually takes for discomfort C. encourage the client to walk daily for at least 15 minutes D. reassure the client that this is not unusual in the client’s age group Review Information: The correct answer is A: obtain details of the severity and location of the pain Learning Objective: Lesson 5 Basic Care and Comfort Most older adults have one or more chronic painful illnesses, and in fact, they often must be asked about discomfort (rather than "pain") to reveal the presence of pain. No evidence exists that pain in older adults is less intense than in younger adults. Application of the nursing process directs a nurse to collect data about the pain thoroughly before recommendations. The interventions for pain relief measures should be based on the hotline protocols. Christensen, B., & Kockrow, E. (2010). Foundations of nursing and adult health nursing (6th ed.). St. Louis: Mosby. Ramont, R.P., & Niedringhaus, D.M. (2007). Fundamental nursing care (2nd ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 817 A clinic nurse is counseling about the risks of continued cocaine use to a postpartum client who is a known drug user. In order to provide continuity of care, which nursing diagnosis should the nurse anticipate to be identified as a priority? A. ineffective coping B. altered parenting C. sexual dysfunction D. social isolation Answers Correct B Student's B Review Information: The correct answer is B: altered parenting Learning Objective: Lesson 4 Psychosocial Integrity The cocaine abusing mother puts her newborn and other children at risk for negligence and abuse. Continued use of drugs has the potential to impact parenting behaviors. Social service referrals are indicated. Test-taking Tips: Read this question very closely. The correct answer must address both the mother and the newborn for the ”continuity of care.” Three of the options only address the mother. One option addresses both mother and newborn. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Lowdermilk, D., & Perry, S. (2007). Maternity & women's health care (9th ed.). St. Louis, MO: Mosby. Ref # 313 Which action would be the best strategy for a nurse to use when reinforcing insulin injection techniques to an adult client newly diagnosed with diabetes mellitus type 1? Answers Correct C Student's C A. listen to client’s verbalized understanding B. ask the client questions after practice sessions C. observe a return demonstration D. ask the client questions during practice sessions Review Information: The correct answer is C: observe a return demonstration Learning Objective: Lesson 3 Health Promotion and Maintenance Since this is a psychomotor skill, this is the best way to know or evaluate if the client has learned the proper technique. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Williams, L. (2007). Understanding medical surgical nursing (3rd ed.). Philadelphia: F.A. Davis Company. Ref # 381 A client is being maintained on heparin therapy. A nurse must closely monitor which laboratory value? A. activated PTT B. platelet count C. bleeding time D. clotting time Answers Correct A Student's C Review Information: The correct answer is A: activated PTT Learning Objective: Lesson 6 Pharmacological Therapies Heparin is used to prevent further clots from being formed and to prevent the present clot from enlarging. The activated partial thromboplastin time (APTT) test is a highly sensitive test to monitor the effects to the clients on heparin. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. Pagana, K.D., & Pagana, T.J. (2008). Mosby's diagnostic and laboratory test reference (9th ed.). St.Louis, MO: Mosby. Ref # 701 A child has severe burns to the lower extremities. A diet high in protein and carbohydrates is recommended. A nurse should care for this client with the knowledge that the most important reason for such a diet is to achieve which result? A. stimulate increased peristalsis and nutrient absorption B. spare protein catabolism to meet metabolic and healing needs Answers Correct B Student's C C. promote healing and strengthen the immune system D. provide a well balanced nutritional intake Review Information: The correct answer is B: spare protein catabolism to meet metabolic and healing needs Learning Objective: Lesson 5 Basic Care and Comfort Because of the severe burn injury, the child has an increased metabolism and catabolism. By providing a high carbohydrate diet, the breakdown of protein for energy is avoided. Proteins are then used to restore and aid in the healing of tissues. Test-taking Tips: This is a specific question and requires a specific answer as it relates to the content of this question (major burns and diet of protein and carbohydrate). Two of the options are general answers. Notice that one option contains part of the question (protein). Also look at the verbs – promote, provide, stimulate and spare. The last one is a clue when associating it to the problem in the stem. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 375 A client is discharged on warfarin sulfate (Coumadin). A nurse recognizes that additional teaching is needed if the client makes which incorrect comment? A. "I plan to use an electric razor for shaving." B. "I know I must avoid crowds." C. "I will report any bruises for bleeding." D. "I will keep all laboratory appointments." Answers Correct B Student's B Review Information: The correct answer is B: "I know I must avoid crowds." Learning Objective: Lesson 6 Pharmacological Therapies There are no specific reasons for the client on Coumadin to avoid crowds. General instructions for any postop client is to limit exposure to infection. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 573 A client diagnosed with a spontaneous pneumothorax has a chest tube inserted. What explanation should a nurse reinforce? "The tube will A. control the amount of air that enters your chest." B. drain fluid from your chest." C. remove excess air from your chest." Answers Correct C Student's C D. seal the hole in your lung." Review Information: The correct answer is C: remove excess air from your chest." Learning Objective: Lesson 7 Reduction of Risk Potential The purpose of the chest tube is to create negative pressure and allow the removal of the air that has accumulated in the pleural space in a pneumothorax. In a hemothorax pleural effusion or empyema the purpose is to primarily remove the blood or other fluid. Williams, L. (2007). Understanding medical surgical nursing (3rd ed.). Philadelphia: F.A. Davis Company. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 373 An older adult client on digitalis (Lanoxin) and bumetanide (Bumex) reports nausea, vomiting, and abdominal cramps. Which serum lab result should a nurse check first? A. pH B. glucose C. magnesium D. potassium Answers Correct D Student's C Review Information: The correct answer is D: potassium Learning Objective: Lesson 6 Pharmacological Therapies The most common cause of digitalis toxicity is a low potassium level. Clients must be taught that it is important to have adequate potassium intake while taking diuretics which cause potassium loss, the loop and thiazide types. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 553 A nurse is collecting data on a newborn delivered at home. The mother admits to being addicted to heroin. Which findings should the nurse expect to observe in the newborn? A. jitteriness in one to two days B. hypertonic neuro reflex C. central nervous system depression Answers Correct A Student's A D. lethargy with sleepiness Review Information: The correct answer is A: jitteriness in one to two days Learning Objective: Lesson 7 Reduction of Risk Potential Withdrawal signs may not be evident for one to two days after birth. Irritability and poor feeding also are expected at that time. Test-taking Tips: Note that two options are alike in that they are “increased” answers. As opposed to the other options, which are “decreased” answers. Common sense indicates that since the mother is a heroin addict, the newborn will also go through withdrawal. In withdrawal, increased activity is more likely. Thus eliminate two options. Reread the options and pay attention to the second part of each – one option is “reflex” and another option is a timeframe. Ask: what do I know about withdrawal from medication or drugs or alcohol? Is this more related to reflexes or timeframes? Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 594 A nurse is caring for a preschooler two hours after tonsillectomy and adenoidectomy. Which observation must be reported immediately to the RN? A. complaints of throat pain B. apical heart rate of 110 C. increased restlessness D. vomiting of dark brown emesis Answers Correct C Student's C Review Information: The correct answer is C: increased restlessness Learning Objective: Lesson 7 Reduction of Risk Potential Restlessness and increased respiratory and heart rates are often early signs of hemorrhage. Recall that a change in consciousness indicates initial hypoxia in this situation from a decreased cardiac output and volume of blood. Dark brown emesis is expected within a few hours after surgery from the old blood that may have been swallowed. Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 814 A nurse is caring for a mother who has just delivered a stillborn baby. The most therapeutic comment by the nurse to this grieving mother would be which comment? A. "Tell me about your experience and feelings." B. "You have an angel in heaven watching over you now." Answers Correct A Student's A C. "Let's talk about your physical pain, now." D. "Nature has a way of dealing with problems." Review Information: The correct answer is A: "Tell me about your experience and feelings." Learning Objective: Lesson 4 Psychosocial Integrity The nurse must help the mother actualize the loss by encouraging her to talk about it. Advice and cliches are not comforting. A general guide in therapeutic communication is to focus on feelings initially and then behavior secondly. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 414 A nurse is checking an infant diagnosed with developmental hip dysplasia. Which finding should the nurse anticipate to observe? A. unequal leg length B. symmetrical gluteal folds C. diminished femoral pulses D. limited adduction Answers Correct A Student's C Review Information: The correct answer is A: unequal leg length Learning Objective: Lesson 8 Physiological Adaptation A shortening of the affected leg is a finding with developmental hip dysplasia along with an asymmetry of the gluteal folds. Test-taking Tips: Eliminate one of the options since the problem is with the hip and not the vessels. Eliminate another option since the content in the stem is not about movement. The key words in this question are “developmental hip dysplasia” and an “anticipated finding.” Notice two of the options (leg length and gluteal folds) both address developmental dysplasia and hip problems. However, read both options carefully and notice the word “symmetrical” in one of the options is opposite from the word “unequal” in the other option. Ask: does the word “symmetrical,” which is considered a normal finding, connect with the word “dysplasia?" Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 4489 A client is admitted to the telemetry unit with a diagnosis of mitral stenosis. The nurse is assessing the client’s heart sounds. Indicate on the diagram where the nurse should place the stethoscope to best assess the mitral valve. Answers Correct Student's Review Information: The correct answer is : Learning Objective: Lesson 3 Health Promotion and Maintenance Auscultation of heart sounds is a key component of the physical assessment. It is important that the nurse is able to identify the area on the chest that corresponds to each of the four valves. The mitral area or apex of the heart is located at the fifth intercostal space, left midclavicular line. Ref # 415 A six month-old infant is being treated for developmental dysplasia of the hip and has been placed in a hip spica plaster cast. A nurse should reinforce what information on discharge to the parents? A. turn the baby every two hours with the use of the abduction stabilizer bar B. check frequently for swelling in the baby's feet C. place favorite books and push-pull toys in the crib D. gently rub the skin with a cotton swab to relieve itching Answers Correct B Student's B Review Information: The correct answer is B: check frequently for swelling in the baby's feet Learning Objective: Lesson 8 Physiological Adaptation A child in an initial hip spica cast must be checked for circulatory impairment first. Observe extremities for swelling, discoloration, movement and sensation. For children beyond the neonatal period, traction and/or surgery followed by hip spica casting is usually needed. Test-taking Tips: The content of this question regards a hip spica cast. Ask: what do the parents most likely need to know about the cast? Notice that only two options focus on the cast. What would indicate a problem with a new cast? The word “swelling” in one of the options is your hint. Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 824 A nurse in an outpatient clinic occasionally visits with a client who has a history of substance abuse. During an evaluation of the client's progress, the Answers Correct A Student's C nurse should recognize that the most revealing resistant behavior is which of these? A. continuing drug use B. recurring crises C. rationalizing comments D. missing appointments Review Information: The correct answer is A: continuing drug use Learning Objective: Lesson 4 Psychosocial Integrity Continuing to use the drug demonstrates lack of commitment to the treatment program. This fact must be understood by the nurse as part of the disease of addiction. Test-taking Tips: The question is about “resistant” behavior. Read the verbs in the options vertically: recurring, continuing, rationalizing, and missing. It is obvious that continuing use is most closely related to “resistant behavior.” Associate the word “substance abusing client” in the stem of this question with the words “drug use” in one of the options. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Practice Bank 3 Ref # 423 A teenage client with a history of sickle cell disease is admitted to the hospital with a diagnosis of sickle cell crisis. Which statement by the client indicates the most likely cause of this event? A. "I really enjoyed my fishing trip yesterday. I caught two fish." B. "I knew this would happen. I've been eating too much red meat lately." C. "I went to the health care provider last week for a cold and I have gotten worse." D. "I have really been working hard practicing with the debate team at school." Answers Correct A Student's A Review Information: The correct answer is A: "I went to the health care provider last week for a cold and I have gotten worse." Learning Objective: Lesson 8 Physiological Adaptation Any condition that increases the body's need for oxygen or alters the transport of oxygen, such as infection, trauma, acute dehydration or even cold weather, may cause a sickle cell crisis. Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 398 A nurse is caring for an older adult client diagnosed with colorectal cancer. The client's pain has been managed with acetaminophen with codeine until now. Because of more severe pain, the order is changed to a narcotic analgesic. The nurse should recognize that this order is Answers Correct C Student's C A. inappropriate and anticipates poor pain control. B. inappropriate because of potential respiratory depression. C. appropriate pain management around-the-clock. D. appropriate despite the expected effect of mental confusion. Review Information: The correct answer is C: appropriate pain management around-the-clock. Learning Objective: Lesson 6 Pharmacological Therapies Older adult clients with cancer pain are frequently under-medicated. This management is appropriate, and should be offered throughout the day and night. Test-taking Tips: The first decision is to choose which set of similar, but dissimilar answers relates most to the question’s stem. Ask: is it appropriate or inappropriate to change an analgesic that is no longer controlling pain? Use common sense and narrow the choices down to two options. Then ask: what is the problem in the stem (increased pain)? Therefore make an educated guess to find the best answer. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 4494 The nurse is assessing the uterine fundus of a client who delivered a healthy neonate 10 hours ago. Identify the area where the nurse would expect to feel the fundus. Answers Correct Student's Review Information: The correct answer is C: Learning Objective: Lesson 3 Health Promotion and Maintenance The uterus should be felt at the level of the umbilicus from about 1 to 24 hours after birth. The fundus (top of the uterus) will fall approximately 1 centimeter (or 1 fingerbreadth) each day for the next 10 days. Ref # 845 The nurse is working on an inpatient psychiatric unit. Which statement made by a client indicates that the client may have a thought disorder? A. "I'm fine. It's my daughter who has the problem." B. "I'm so angry about this. Wait until my partner hears about this!" C. "I'm a little confused. What time is it?" Answers Correct D Student's D D. "I can't find my 'mesmer' shoes. Have you seen them?" Review Information: The correct answer is D: "I can't find my 'mesmer' shoes. Have you seen them?" Learning Objective: Lesson 4 Psychosocial Integrity A neologism is a new word that's self invented by a person and not readily understood by another person. The use of neologisms is often associated with a thought disorder. The other statements reflect appropriate connections between the expressed thoughts. Thought disorders are associated with schizophrenia, delusions and hallucinations of psychosis. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Ref # 427 A two year-old child is brought to the emergency room at 2:00 pm. The mother states that the child has not had a wet diaper all day. The child is pale and the heart rate is 132. What data should a nurse obtain next? A. the types of foods and eating patterns over the past week B. a description of any seizure activity in the past 24 hours C. the status of the child’s play activity that day D. a history of any difficulties with attempts to potty train Answers Correct C Student's C Review Information: The correct answer is C: the status of the child’s play activity that day Learning Objective: Lesson 8 Physiological Adaptation Clinical findings of acute dehydration in children include lethargy, decreased play activity, sunken eyes, increased pulse and dry mucous membranes and skin. The normal pulse rate in this age of child is 70-110. Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 613 Arterial blood gases have been ordered for a confused client. The respiratory therapist draws the blood and then asks a nurse to apply pressure to the site so the therapist can take the specimen to the lab. How many minutes should the nurse apply pressure to the site? Answers Correct A Student's C A. 5 B. 10 C. 3 D. 8 Review Information: The correct answer is A: 5 Learning Objective: Lesson 7 Reduction of Risk Potential It is necessary to apply pressure to the area for at least 5 minutes to prevent bleeding or the formation of hematomas and to allow for clotting. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 421 A nurse is assigned to care for a ten month-old infant with the new diagnosis of anemia. Which of these findings should the nurse anticipate? A. pale mucosa inside the mouth B. a slow heart rate with sleeping C. behavior consistent with hyperactivity D. a high hemoglobin level Answers Correct A Student's C Review Information: The correct answer is A : pale mucosa inside the mouth Learning Objective: Lesson 8 Physiological Adaptation In iron-deficiency anemia, the physical exam reveals a pale, tired- appearing child with mild to severe tachycardia. The skin may have a waxy appearance. When clients diagnosed with anemia lack oxygen, the skin color becomes an ashen, dusky gray instead of the classic skin color of cyanosis with oxygen deficiency. Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 841 A nurse discusses the healthy use of both conscious and unconscious defense mechanisms with a group of clients. An appropriate goal for these clients would be to use these mechanisms for which purpose? A. foster independence with better communication B. reduce fear and protect self-esteem Answers Correct B Student's C C. avoid conflict and unpleasant consequences D. eliminate anxiety and apprehension Review Information: The correct answer is B: reduce fear and protect self-esteem Learning Objective: Lesson 4 Psychosocial Integrity Ego defense mechanisms are unconscious proactive barriers that are used to manage instinct and affect the presence of stressful situations. Healthy reactions that use both types of defense mechanisms are those in which clients admit that they are feeling various emotions. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Ref # 346 A client asks a nurse about including her two yearold and 12 year-old sons in the care of their newborn sister. Which would be an appropriate initial statement by the nurse? A. "Focus on your sons' needs during the first few days at home." B. "Suggest that the father spend more time with the boys." C. "Tell each child what he can do to help with the baby." D. "Ask the children what they would like to do for the newborn." Answers Correct A Student's A Review Information: The correct answer is A: "Focus on your sons' needs during the first few days at home." Learning Objective: Lesson 3 Health Promotion and Maintenance In an expanded family, it is important for parents to reassure older children that they are loved and as important as the newborn especially in the first few days after the baby is brought home. Test-taking Tips: The key here is to look for an “initial” statement. Note that all of the options would be correct and appropriate to do . If guessing, read the answers carefully and notice that the “sons” in the stem of the question only appears in one option. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 345 A client tells a nurse that she is planning a pregnancy in the near future. She asks about Answers Correct C recommended preconception dietary needs. Which statement should the nurse include in a response? A. "Drink a glass of milk with each meal" B. "Include fibers in your daily diet" C. "Increase the intake of green leafy vegetables " D. "Eat at least one serving of fish weekly" Student's C Review Information: The correct answer is C: "Increase the intake of green leafy vegetables " Learning Objective: Lesson 3 Health Promotion and Maintenance Folic acid sources should be included in the diet and are critical in the preconceptual and early gestational periods to foster neural tube development and prevent birth defects such as spina bifida and Down's syndrome. At least 0.4 milligrams of folic acid are needed about 30 days before conception and continued through the first trimester. Test-taking Tips: Read this question and the answer options carefully. Note that the content is preconception diet changes. This question implies that the present diet is going to be added to. The hint in the answer options is the word “increase.” "Increase” is an “addition” word. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 422 A nurse is caring for a client diagnosed with sickle cell crisis. The client is scheduled to receive two units of packed red blood cells. Which action is appropriate for the nurse when monitoring the infusion? A. slow the rate of infusion if the client develops fever or chills B. limit the infusion time of each of the unit to a maximum of four hours C. check vital signs every 15 minutes throughout the entire infusion D. store the packed red cells in the medicine refrigerator while the registered nurse (RN) is starting the IV Answers Correct B Student's C Review Information: The correct answer is B: limit the infusion time of each of the unit to a maximum of four hours Learning Objective: Lesson 6 Pharmacological Therapies Whole blood and packed cells should be infused within four hours of being started. If the infusion is expected to exceed this time, the blood should be divided into appropriately sized quantities prior to starting the therapy. Vital signs would be checked per agency protocols and after the initial 15 minutes of direct observation for any anaphylactic reaction. Vital signs typically are monitored every 30 to 60 minutes during blood transfusion therapy. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 611 Upon admission to an intensive care unit, a client diagnosed with an acute myocardial infarction (MI) Answers Correct D is ordered nasal oxygen at 4L/min. A nurse knows that the major reason that oxygen is administered in this situation is which purpose? A. saturate the red blood cells B. return skin color to normal tones C. relieve dyspnea on exertion D. increase oxygen to ischemic cardiac cells Student's C Review Information: The correct answer is D: increase oxygen to ischemic cardiac cells Learning Objective: Lesson 7 Reduction of Risk Potential Anoxia of the myocardium occurs in MI. Oxygen administration may help relieve dyspnea on exertion and cyanosis associated with the condition. However, the major purpose is to increase the oxygen concentration in the ischemic, viable damaged myocardial cells. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 430 Which finding should the nurse expect to observe during the data collection about an eight month-old child diagnosed with cerebral palsy? A. unable to follow objects with eyes B. does not respond to touch C. unable to roll from back to stomach D. does not turn toward loud sounds Answers Correct C Student's C Review Information: The correct answer is C: unable to roll from back to stomach Learning Objective: Lesson 8 Physiological Adaptation Cerebral palsy is known as a condition whereby motor dysfunction occurs secondary to damage in the motor centers of the brain. Inability to roll over by eight months of age would illustrate one delay in the infant's attainment of developmental milestones. The other findings are not associated with this condition. Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 609 A client diagnosed with depression is scheduled for electroconvulsive therapy treatments (ECT). One hour before the first treatment is scheduled, the client becomes anxious and states “I do not want to go through with this!” Which statement by the nurse is most appropriate? A. "You have the right to change your mind. You seem anxious about the treatment. Can we talk about it?" B. "I’ll go with you and will be there with you during the treatment." Answers Correct A Student's C C. "I’ll call the health care provider and let him know that you have changed your mind about the treatment." D. "You’ll be asleep and won’t remember anything." Review Information: The correct answer is A: "You have the right to change your mind. You seem anxious about the treatment. Can we talk about it?" Learning Objective: Lesson 7 Reduction of Risk Potential This response indicates acknowledgment of the client’s rights and the opportunity for the client to clarify and ventilate concerns. Further exploration or assessment would need to be done prior to notification of the health care provider. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 425 A nurse is caring for a hospitalized 12 year-old client who is diagnosed with hemophilia A. Which intervention should the nurse plan on implementing as a priority? A. bleeding precautions B. stool checks for blood C. intake and output D. protective isolation Answers Correct A Student's A Review Information: The correct answer is A: bleeding precautions Learning Objective: Lesson 8 Physiological Adaptation The risk associated with hemophilia A is hemorrhage. Therefore, the client should be on bleeding precautions. The stool checks would be secondary since prevention is a priority and bleeding precautions are preventive. Test-taking Tips: Associate the content of this question (hemophilia A) with the word “bleeding” in one option. If the diagnosis is unknown make an educated guess based on general knowledge that the term "hemo" is related to blood. Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 351 A client has been diagnosed with postpartum hemorrhage eight hours after the birth of twins. Following the administration of IV fluids and 500 mL of whole blood, the hemoglobin and hematocrit are within normal limits. She asks a nurse whether Answers Correct A Student's A she should continue to breast feed the infants. Which statement by the nurse is based on sound rationale? A. "Nursing will help contract the uterus and reduce your risk of bleeding." B. "Lactation should be delayed until the 'real milk' is secreted." C. "The blood transfusion may increase the risks to you and the babies." D. "Breastfeeding twins will take too much energy after the hemorrhage." Review Information: The correct answer is A: "Nursing will help contract the uterus and reduce your risk of bleeding." Learning Objective: Lesson 3 Health Promotion and Maintenance Stimulation of the breast during breast feeding by the newborns releases oxytocin, which contracts the uterus. This contraction is especially important following an episode of hemorrhage. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 393 A nurse is caring for a trauma victim with a significant blood loss. Immediately following multiple blood transfusions, what is the most accurate indicator for adequate oxygenation? A. hematocrit B. pulse oximetry C. blood gases D. hemoglobin Answers Correct C Student's C Review Information: The correct answer is C: blood gases Learning Objective: Lesson 6 Pharmacological Therapies Arterial blood gases are the most accurate measure of oxygenation at this time. Pulse oximetry would not be as accurate during and after blood replacement therapy since it is a peripheral test and when in shock the peripheral extremities are typically vasoconstricted. Test-taking Tips: The question being asked is for the “most accurate indicator of oxygenation.” This would narrow the options down to two options. Ask yourself: what would be the most accurate –an oximeter finding which is an external measurement or blood gases which are internal measurements? Internal measurements would be more accurate than external measurements. If guessing, associate the word “gases” in the option with the word oxygen from the question, which is a gas. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 830 A client expresses anger when the call light is not answered promptly. How should the nurse respond? Answers Correct D Student's D A. "Let's talk about this situation." B. "I am surprised that you are upset." C. "I apologize for the delay. I was busy with an emergency." D. "I see this is frustrating for you." Review Information: The correct answer is D: "I see this is frustrating for you." Learning Objective: Lesson 4 Psychosocial Integrity This is the most appropriate answer because the response gives credence to the client's concerns. The nurse is validating the client's feelings to provide feedback that the nurse has listened. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 424 During the care of a client during the acute phase of a sickle cell vaso-occlusive crisis, which intervention by a nurse would be most important? A. provide temperature control measures B. administer analgesic therapy as ordered C. offer clear liquids every two hours D. reinforce bedrest regimen Answers Correct B Student's C Review Information: The correct answer is B: administer analgesic therapy as ordered Learning Objective: Lesson 8 Physiological Adaptation The main general objectives in the treatment of a sickle cell crisis is analgesics for pain, hydration, oxygenation, bed rest, electrolyte and blood replacement, and antibiotics to treat any existing infection. Since pain causes sympathetic stimulation which results in vasoconstriction, pain management is the most important nursing action among the given choices. Clear liquids, bed rest, and temperature control measures assist to reduce the ischemia associated with a sickle cell crisis. Test-taking Tips: This is a specific question and requires a specific answer. Also, as it is written, all of the options are correct actions. The task is to pick the best of the four options supplied. As the options are read, compare the verbs: offer, reinforce, administer, and provide. Then compare the objects of the verbs: liquids, bedrest, analgesic, and temperature. Pain relief is typically a priority over the other options with consideration of the verbs and the object of the action. Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Practice Bank 4 Ref # 434 A nurse is caring for an infant diagnosed with roseola. Which characteristics of the skin lesions would the nurse expect to find? A. erythema on the face, primarily on cheeks giving a "slapped face" appearance B. macule that rapidly progresses to papule and then vesicles C. Koplick's spots appear first followed by a rash that appears first on the face and spreads downward D. discrete rose pink macules that appear first on the trunk and when pressure is applied they fade in color Answers Correct D Student's C Review Information: The correct answer is D: discrete rose pink macules that appear first on the trunk and when pressure is applied they fade in color Learning Objective: Lesson 8 Physiological Adaptation The characteristic rash of an infant with roseola will appear as discrete rose pink macules. These macules will first be seen on the trunk and will fade when pressure is applied. Option three is a finding that is characteristic of Fifth's disease. Test-taking Tips: The key words in this question are “roseola” and “expected characteristics of the skin lesions." Associate the word “rose” in one option with the content of this question (roseola). When guessing, sometimes matching the word or concept in the stem with a similar word in an option will lead to the right answer. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 846 A client says, "It's raining outside and it's raining in my heart. Did you know that St. Patrick drove the snakes out of Ireland? I've never been to Ireland." A nurse reviews this data and determines that this client has a speech pattern commonly seen in manic episodes. The nurse should document this as which item? A. perseveration B. flight of ideas C. neologisms D. circumstantiality Answers Correct B Student's B Review Information: The correct answer is B: flight of ideas Learning Objective: Lesson 4 Psychosocial Integrity Flight of ideas is characterized by over-productivity of talk and verbally skipping from one idea to another. It is classic with clients diagnosed with bipolar disorder and occurs in the manic state of this disease. Flight of ideas can also occur in schizophrenia and intoxication with toxic psychoactive substances. Perseveration is persistent repetition of words or ideas (e.g., "I'll think I'll put on my hat, my hat, my hat, my hat, my hat..."). Neologisms is the making of new words that others do not understand such as ‘iggule.’ Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 616 A male client is admitted with the diagnosis of a spinal cord injury at level C-4. A nurse should reinforce the client's understanding as to how the injury is going to affect any sexual function by which statement? A. "Erections will be possible." B. "Sexual functioning will not be impaired at all." C. "Normal sexual function is not possible." D. "Ejaculation will be normal." Answers Correct A Student's C Review Information: The correct answer is A: "Erections will be possible." Learning Objective: Lesson 7 Reduction of Risk Potential Erections can be stimulated by stroking the genitalia because it is a reflex action. Williams, L. (2007). Understanding medical surgical nursing (3rd ed.). Philadelphia: F.A. Davis Company. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 848 A nurse is working in a psychiatric unit setting. For what reason should the nurse limit the use of touch or physical contact with clients to handshaking? A. Handshaking allows the use of touch in a professional manner Answers Correct A Student's C B. Refusal to touch a client denotes lack of concern C. Touching a client inappropriately can set off a violent episode D. Some clients misconstrue hugs as an invitation to sexual advances Review Information: The correct answer is A: Handshaking allows the use of touch in a professional manner Learning Objective: Lesson 4 Psychosocial Integrity Touch usually denotes positive feelings for another person, but it can cause some anxiety in the psychiatric client or even precipitate a violent episode. The client may misinterpret physical contact, such as hugging and holding hands, as sexual advances. The best answer for the question being asked is that shaking someone's hand is an appropriate and universally accepted greeting that may assist with establishing a rapport with the client. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 849 Which statement by a nurse reflects the best use of therapeutic interaction techniques? A. "You look very sad. How long have you been this way? Have you been taking care of yourself?" B. "You look upset. Tell me what's been happening?" C. "I understand that you lost your partner. Let's talk about how you can go on." D. "I'd like to know more about your children. Tell me about them." Answers Correct B Student's C Review Information: The correct answer is B: "You look upset. Tell me what's been happening?" Learning Objective: Lesson 4 Psychosocial Integrity Giving broad opening statements and making observations are examples of therapeutic communication. Closed-ended questions that require a “Yes” or “No” response often block further communication about concerns or issues. In certain situations ‘yes’ ‘no’ questions are appropriate: severely depressed clients during admission, cognitively impaired clients and situations of respiratory distress. Jarvis, C. (2007). Physical examination & health assessment (5th ed.). Philadelphia: Saunders. Taylor, C.R., Lillis, C., LeMone, P., & Lynn, P. (2006). Fundamentals of nursing: The art and science of nursing care (6th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 615 A client with a nasogastric (NG) tube complains of nausea. What should be the first action of a nurse? A. position the client in Fowler’s B. report the findings to the registered nurse (RN) charge nurse Answers Correct D Student's D C. administer the ordered prn antiemetic D. check for the patency of the tube Review Information: The correct answer is D: check for the patency of the tube Learning Objective: Lesson 7 Reduction of Risk Potential A first indication that the NG tube is obstructed is often a client’s complaint of nausea. NG tubes may become obstructed with mucus or sediment. The other options are correct and may be done afterwards. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 851 The nurse has established a therapeutic relationship with a client. Which observation would indicate that the nurse-client relationship has passed from the orienting phase to the working phase? A. The client expresses a desire to be mothered and pampered B. The client recognizes feelings and expresses them appropriately C. The client revitalizes a relationship with the family to help in coping with a child's death D. The client recognizes regression as a part of a defense mechanism Answers Correct B Student's B Review Information: The correct answer is B: The client recognizes feelings and expresses them appropriately Learning Objective: Lesson 4 Psychosocial Integrity During the working phase, problems are identified and the client is able to focus on unpleasant feelings and express them appropriately. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 402 The parents of a school-age child are providing information to the nurse about their child. Which of these concerns would the nurse recognize as a finding that could suggest type 1 diabetes? A. Being a picky eater B. Weight gain Answers Correct D Student's D C. Oily and acne-prone skin D. Bed wetting Review Information: The correct answer is D: Bed wetting Learning Objective: Lesson 3 Health Promotion and Maintenance In school-aged children, warning signs of type 1 diabetes include: fatigue, frequent urination (also bed wetting), unusual thirst, extreme hunger, and weight loss. Also, diabetics usually have dry skin. The parents may not initially think anything of the polyphagia or polydipsia, but bed wetting in a school-age child (who previously did not wet the bed at night) would prompt the parents to seek medical intervention. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 441 A nurse is caring for an adolescent who is prescribed albuterol (Proventil) for asthma. The adolescent asks: ”Why do I have to take this medication?” The nurse should explain that Albuterol is prescribed for what reason? A. relax the smooth muscles in the airways. B. stimulate the respiratory center in the brain that controls respirations. C. decrease the swelling in the airways. D. reduce the secretions blocking the airways. Answers Correct A Student's C Review Information: The correct answer is A: relax the smooth muscles in the airways. Learning Objective: Lesson 6 Pharmacological Therapies Albuterol (beta-adrenergic agonist) is the medication of choice in treating asthma because it allows the smooth muscle in the airway to relax. This relaxation results in airways that dilate with the outcome of an increased airflow. Test-taking Tips: Notice that three of the options all have “airways” in them. The answer is likely to be one of these. Ask: what kind of muscle is in the airway? The information in the stem does not mention secretions or any inflammation; eliminating two options. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 443 A nurse is assigned to a child diagnosed with an acute episode of reactive airway disease and a Answers Correct A Student's C history of asthma. Which finding should the nurse expect to observe during the child’s care? A. wheezing on expiration B. inspiratory stridor C. periods of apnea D. a productive cough Review Information: The correct answer is A: wheezing on expiration Learning Objective: Lesson 8 Physiological Adaptation In an acute episode of reactive airway disease, breathing is likely to be characterized by wheezing on expiration. This sound is made as air is forced through the narrowed smaller airway passages. Test-taking Tips: Notice that two of the options are opposites in that one focuses on inspiration and one on expiration. Also note that the word “asthma” in the stem of the question can be associated with the word “wheezing” in one option. Also recall the anatomy of the lung associated with asthma – the constriction of the smaller airways would be associated with wheezing and constriction of the larger airways would more likely result in inspiratory stridor. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 617 When a client returns from surgery after an open reduction with cast application for a femur fracture, a small blood stain is noted on the cast by a nurse. Four hours later, the nurse observes that the stain has doubled in size. What is the initial action for the nurse to take at this time? A. report the finding to the registered nurse (RN) charge nurse B. ask the family to call you when they notice the spot getting larger C. outline the spot with a pencil and note the time and date on the cast D. record the findings in the nurse's notes Answers Correct C Student's C Review Information: The correct answer is C: outline the spot with a pencil and note the time and date on the cast Learning Objective: Lesson 7 Reduction of Risk Potential This is a good way to assess the amount of bleeding over a period of time. The bleeding does not appear to be excessive and some bleeding is expected with open reduction surgeries. The bleeding should also be documented in the nurse’s notes. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 355 A nurse should take the initial blood pressure of a client newly diagnosed with hypertension by what process? A. after exercising for two minutes B. in both arms C. while supine D. in a standing and a sitting position Answers Correct B Student's C Review Information: The correct answer is B: in both arms Learning Objective: Lesson 3 Health Promotion and Maintenance Blood pressure should be taken in both arms due to the fact that one subclavian artery may be stenosed, which may cause a false high in that arm. The different positions are lying/supine and then sitting or standing. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Williams, L. (2007). Understanding medical surgical nursing (3rd ed.). Philadelphia: F.A. Davis Company. Ref # 4442 An immobile hospitalized client is eating less than 25% of served meals. The client gains 5 pounds (2.27 kg) in two days. The most likely explanation for this is the retention of how many milliliters of fluid? mL. Answers Correct Student's Review Information: The correct answer is : 2500, 2270 Learning Objective: Lesson 5 Basic Care and Comfort 454g = 1 lb (1g ~ 1 mL) or 500 mL = 1 lb. 1 kg ~ 1 liter. However, you don't really need to do any math to calculate the answer to this question if you remember this saying: "a pint is a pound the world around." Ref # 357 When checking a client with a history of hypertension at a walk-in clinic, what is a priority question that a nurse should ask? A. "Describe your family's cardiac history." B. "Tell me about your usual diet." C. "Describe your usual exercise and activity patterns." D. "What over-the-counter medications do you take?" Answers Correct D Student's C Review Information: The correct answer is D: "What over-the-counter medications do you take?" Learning Objective: Lesson 3 Health Promotion and Maintenance Over-the-counter medications, especially those that contain cold preparations, can increase the blood pressure to the point of acute hypertension or hypertensive crisis. The other options are correct questions to ask. However note that the question asks about the priority. Christensen, B., & Kockrow, E. (2010). Foundations of nursing and adult health nursing (6th ed.). St. Louis: Mosby. Linton, A.D. (2007). Introduction to medical surgical nursing (4th ed.). Philadelphia: Saunders. Ref # 395 A nurse is participating in a community health fair. As part of the health promotion process, the nurse should conduct a mental status examination when A. Any health screening is done B. There are obvious findings of depression C. An individual reports memory lapses D. An individual displays restlessness Answers Correct A Student's A Review Information: The correct answer is A: Any health screening is done Learning Objective: Lesson 3 Health Promotion and Maintenance A mental status check is a critical part of baseline information, and should be a part of every examination, whether general or specific. Test-taking Tips: Notice that three of the options all indicate a problem with mental status. However, this is a “health promotion” question, not an “illness” question. Associate the word “health” in one option with the “health promotion.” Another approach if guessing is to notice that the question is a general question and there is only general answer in this list of options. Christensen, B., & Kockrow, E. (2010). Foundations of nursing and adult health nursing (6th ed.). St. Louis: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 442 A nurse is administering albuterol (Proventil) to a child with asthma. Which intervention should be included in the plan of care? Answers Correct A Student's A monitor heart rate check oral cavity for thrush observe for lethargy and fatigue strict bedrest during administration Review Information: The correct answer is A: monitor heart rate Learning Objective: Lesson 6 Pharmacological Therapies One of the most common adverse effects of beta adrenergic medications is an increase in heart rate. Test-taking Tips: If guessing at this question, identify the two options that are similar but dissimilar. Two of the options both contain data collection words (observe and monitor). Ask: which would be more important? Using common sense, the heart would take a priority over fatigue. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 444 A nurse is caring for a child diagnosed with acute severe airway obstruction. Which finding should the nurse monitor for as expected? A. chest pain aggravated by respiratory movement B. retractions in the soft tissues of the thorax C. rapid, shallow respirations D. mottling of the skin on the trunk Answers Correct B Student's B Review Information: The correct answer is B: retractions in the soft tissues of the thorax Learning Objective: Lesson 8 Physiological Adaptation Slight intercostal retractions are normal. However, in disease states, especially in severe airway obstruction, retractions become exaggerated and deeper. These may be accompanied with sternal retractions. Test-taking Tips: If guessing, notice that this is a respiratory question and requires a respiratory response. This leads to consideration of two options as possible correct answers. Associate the clue in the stem, “severe,” with the word “retractions” in one option. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 4443 During a 12-hour shift, a client who underwent a transurethral resection of the prostate (TURP), had an IV intake of 1200 mL, oral intake of 400 mL, continuous bladder irrigation of 2400 mL, 2 syringe flushes of 50 mL each, and Foley catheter output of 3000 mL. Answers Correct 4100 Student's 4000 What is the end of shift fluid intake? (Write the answer using a whole number.) mL. Review Information: The correct answer is : 4100 Learning Objective: Lesson 5 Basic Care and Comfort (1200 mL + 400 mL + 2400 mL + 100 mL) = 4100 mL. The amount of irrigation fluid must be included in intake; only the urine collected from the Foley catheter is considered output (subtract the amount of irrigation fluid from the amount in the Foley). Ref # 614 A client is scheduled for an intravenous pyelogram (IVP). After the contrast material is injected, which client reaction should require immediate interventions? A. feeling warm B. hives C. salty taste D. face flushing Answers Correct B Student's C Review Information: The correct answer is B: hives Learning Objective: Lesson 7 Reduction of Risk Potential Hives are one sign of anaphylaxis and require immediate action with an injection of epinephrine. The other listed reactions are considered normal and the client should be reminded that they may occur. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Pagana, K.D., & Pagana, T.J. (2008). Mosby's diagnostic and laboratory test reference (9th ed.). St.Louis, MO: Mosby. Ref # 438 A nurse is reinforcing information about the application of a pediculicide to parents for their child's head lice. Which of these instructions indicate proper application? Apply the shampoo A. to the head, repeat daily until nits are no longer seen B. from head to toe, leave on for eight-to-ten hours Answers Correct C Student's C C. to the head, may repeat in one week and no sooner D. from head to toe, leave on for ten minutes Review Information: The correct answer is C: to the head, may repeat in one week and no sooner Learning Objective: Lesson 6 Pharmacological Therapies Treatment of head lice consists of applying the shampoo to the head only and repeating the treatment in one week if nits are still present. If the shampoo is left on longer than directed there is a risk of neurological deterioration. In addition to the shampooing of the head, the hair will need to be combed with a special nit comb to get the eggs off of the hair shafts. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Practice Bank 5 Ref # 432 A mother asks a nurse: “Should I be concerned about the tendency of my child to stutter?” What focus should be the most useful for responding to the parent? A. expected difficulties rooted into age groups B. sibling position in the family C. parental discipline strategies D. stressful family events Answers Correct A Student's A Review Information: The correct answer is A: expected difficulties rooted into age groups Learning Objective: Lesson 3 Health Promotion and Maintenance During the preschool period children are using their rapidly growing vocabulary faster than they can produce their words. This failure to master sensorimotor integrations results in stuttering. This disfluency in speech pattern is a normal characteristic of language development at this age period. Therefore, knowing the child's age is most important in determining if any true dysfunction might be occurring. Test-taking Tips: The key words in this question are “child with a tendency to stutter” and “most useful focus needed in responding.” Notice that only two of the options are about the child. Therefore, eliminate the other options immediately. Compare these options in that one option will change over time and the other option is fixed without ever changing. Select the option that will change since education typically focuses on changes that will be experienced or can be made. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 868 Why should the nurse be informed about cultural issues related to the client's background? A. Developmental mental stages enhance a nurse’s knowledge base B. Patterns of behavior of another culture may be labeled as bizarre or immoral C. The meaning of the client's behavior can be derived from conventional wisdom D. The nurse should rely on personal values and other staff member observations Answers Correct B Student's C Review Information: The correct answer is B: Patterns of behavior of another culture may be labeled as bizarre or immoral Learning Objective: Lesson 4 Psychosocial Integrity Conventional wisdom looks at things from one point of view, without regard to cultural variations. An attitude that beliefs differing from one's own are strange, bizarre or unenlightened, and therefore wrong, is known as ethnocentrism. Developing cultural competence in nursing requires an awareness of and understanding that many different belief systems exist. Linton, A.D. (2007). Introduction to medical surgical nursing (4th ed.). Philadelphia: Saunders. Monahan, F., Sands, J., Neighbors, N., Marek, J. F., & Green-Nigro, C. (2006). Phipp's medical-surgical nursing: Health and illness perspectives (8th ed.). St. Louis, MO: Mosby. Ref # 4444 A client is receiving standard concentration Heparin IV of 25,000 units in 250 mL D5W. The infusion is running on an IV pump. The infusion rate is increased from 9 mL/hour to 12 mL/hour. What is the new dosage of Heparin? (Write the answer using whole numbers.) units/hour. Answers Correct 1200 Student's 1209 Review Information: The correct answer is : 1200 Learning Objective: Lesson 6 Pharmacological Therapies 25000 units/250 mL = (100 units/1mL) x (12 mL/hr) = 1200 units/hr Ref # 867 A Chinese client, admitted with the diagnosis of generalized anxiety disorder, is unable to care for self. According to Chinese folk medicine, health is regulated by the opposing forces of yin and yang. Based on this cultural belief, a nurse would expect the client’s family to attribute the illness to which explanation? A. a failure to use homeopathy correctly B. yin, the negative force that represents darkness, cold, and emptiness C. yang, the positive force that represents light, warmth, and fullness D. too many hot spicy foods and herbs Answers Correct B Student's B Review Information: The correct answer is B: yin, the negative force that represents darkness, cold, and emptiness Learning Objective: Lesson 4 Psychosocial Integrity Chinese folk medicine proposes that yin is the negative female force characterized by darkness, cold and emptiness. Excessive yin predisposes one to nervousness. Test-taking Tips: Notice that the content of this question “yin and yang” appear in two of the options. Since the client is experiencing more negative items “anxiety” and “cannot care for self,” eliminate the “positive force” in one option and choose the negative force option as the correct answer. Taylor, C.R., Lillis, C., LeMone, P., & Lynn, P. (2006). Fundamentals of nursing: The art and science of nursing care (6th ed.). Philadelphia: Lippincott Williams & Wilkins. Craven, R.F., & Hirnle, C.J. (2008). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 664 A nurse is collecting data on a client diagnosed with a stage 2 skin ulcer. Which treatment should the nurse expect to be most effective to promote healing? A. leaving the area open to dry B. covering the wound with a dry dressing C. using hydrogen peroxide soaks D. applying a transparent film cover Answers Correct D Student's D Review Information: The correct answer is D: applying a transparent film cover Learning Objective: Lesson 7 Reduction of Risk Potential For this type of ulcer, the most effective treatment is a transparent cover. National Pressure Ulcer Advisory Panel (NPUAP) classifications: Stage I - erythema of intact skin which does not blanch with pressure. It may be the heralding lesion of skin ulceration. Stage 2 - partial skin loss involving the epidermis, dermis, or both. The ulcer is superficial and presents as an abrasion, blister, or wound with a shallow center. Stage 3 - an entire thickness skin loss. It may involve damage to or necrosis of subcutaneous tissue that may extend down to underlying fascia. The ulcer presents as a deep crater with or without undermining of adjacent intact tissues. Stage 4 - entire thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Tendons, and joints may also be exposed or involved. There may be undermining and holes or sinus tracts associated with ulcers at this stage. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Linton, A.D. (2007). Introduction to medical surgical nursing (4th ed.). Philadelphia: Saunders. Ref # 630 A client has had a positive reaction to purified protein derivative (PPD). A nurse should know the client has understood the teaching by the registered nurse (RN) if the client makes which statement? A. "I have never had tuberculosis." B. "I have never been infected with mycobacterium tuberculosis." C. "I have been exposed to mycobacterium tuberculosis." D. "I have active tuberculosis." Answers Correct C Student's C Review Information: The correct answer is C: "I have been exposed to mycobacterium tuberculosis." Learning Objective: Lesson 7 Reduction of Risk Potential The PPD skin test is used to determine the presence of tuberculosis antibodies and a positive result indicates that the person has been exposed to mycobacterium tuberculosis. Additional tests, specifically a sputum culture or smear for an acid-fast bacillus (AFB), are needed to determine if active tuberculosis is present. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 665 In checking the healing of a client's wound during a home visit, which finding is the best indicator of expected progress in healing? A. green drainage B. eschar development C. reddened tissue D. white patches Answers Correct C Student's C Review Information: The correct answer is C: reddened tissue Learning Objective: Lesson 7 Reduction of Risk Potential As the wound granulates, redness indicates healing. The other findings indicate delayed healing. Test-taking Tips: The key words in this question are “expected progress in wound healing.” Notice that all but one of the options would delay healing. Another hint would be that three of the options are similar but dissimilar in that they all refer to a “color.” Usually one of the similar/dissimilar options tends to be the likely answer. A last clue, if guessing, is that the red color would indicate blood or sufficient circulation. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Linton, A.D. (2007). Introduction to medical surgical nursing (4th ed.). Philadelphia: Saunders. Ref # 450 A community clinic nurse assists with a toddler after being diagnosed with a first episode of otitis media. Which reinforcement of information should the nurse include in instructions to the child's parents? Answers Correct C Student's C A. provide them with a handout describing the purpose of myringotomy tubes B. describe the tympanocentesis used to detect persistent infections C. emphasize the importance of a return visit after completion of antibiotics D. explain that the child should complete the full five days of antibiotics Review Information: The correct answer is C: emphasize the importance of a return visit after completion of antibiotics Learning Objective: Lesson 6 Pharmacological Therapies The usual treatment for otitis media is oral antibiotics for seven to ten days. The child should be examined again after completion of the full course of antibiotics to assess for persistent infection or middle ear effusion. Test-taking Tips: Notice that two of the options are similar but dissimilar in that they both refer to “antibiotics.” If guessing, choose one of them. Ask: how long are most antibiotics administered? Seven to ten days. So go with what is known - one of the options is going to be the most correct information. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 852 The nurse is working in an inpatient mental health unit. Which focus is an important goal in the development of a therapeutic inpatient milieu? A. A testing ground for new patterns of behavior for which clients takes responsibility B. A group forum in which clients decide on the unit rules, regulations, and policies C. Discouragement for expressions of anger because angry clients can be disruptive to other clients D. A businesslike atmosphere where clients can work on individual goals Answers Correct A Student's C Review Information: The correct answer is A: A testing ground for new patterns of behavior for which clients takes responsibility Learning Objective: Lesson 4 Psychosocial Integrity A therapeutic milieu is purposeful and planned to provide safety and a testing ground for new patterns of behavior. The other responses are incorrect statements. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 464 A toddler diagnosed with acquired immune deficiency syndrome (AIDS) was given intravenous gamma globulin. The parents ask: “Why is this medication being given?” The best response by a nurse should include which comment? Answers Correct C Student's C A. "This medication will improve your child's overall health status." B. "It will slow down the replication of the virus." C. "This medication is used to prevent bacterial infections." D. "It will increase the effectiveness of the other medications your child receives." Review Information: The correct answer is C: "This medication is used to prevent bacterial infections." Learning Objective: Lesson 6 Pharmacological Therapies Intravenous gamma globulin is given to help prevent as well as to fight bacterial infections in young children with AIDS, or in any immunosuppressed client. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 426 A 15 year-old client with a lengthy confining illness is at risk for altered growth and development related to which issue? A. dependence B. insecurity C. lack of trust D. loss of control Answers Correct A Student's A Review Information: The correct answer is A: dependence Learning Objective: Lesson 3 Health Promotion and Maintenance The client role in any long term illness fosters dependency. Adolescents may react to dependency with rejection, uncooperativeness, or withdrawal. Test-taking Tips: Notice that two options are the only “developmental options” given. One option would relate to an earlier age group than adolescence. Two options are personality issues. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 447 A nurse is caring for a child who has just returned from a tonsillectomy and adenoidectomy surgery. Which intervention by the nurse is most important? A. do not allow the child to drink through a straw B. offer popsicles frequently C. place the child in a sitting position Answers Correct D Student's D D. observe swallowing patterns and ability Review Information: The correct answer is D: observe swallowing patterns and ability Learning Objective: Lesson 8 Physiological Adaptation The nurse should observe for increased swallowing frequency or inability to swallow, which usually indicates bleeding with a risk of hemorrhage or excessive swelling at the surgical site. All the other actions are appropriate but are not the best answer. Test-taking Tips: The question being asked is about the “most important action” with a client who is immediately postop for a tonsillectomy. Ask: what your first concern would be during the immediate postop period? If the answer to that question is “bleeding,” then ask: which answer focuses on bleeding and where would the bleeding be following a tonsillectomy? This line of thinking leads to one correct option. If guessing, try to determine which of these answers is a data collection answer, usually the first step in client care. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 458 A nurse is reinforcing information to the parents of a child diagnosed with cystic fibrosis. The nurse should emphasize that pancreatic enzymes should be taken at which time? A. each time carbohydrates are eaten B. once each day in the morning C. with each meal or snack D. three times daily after meals Answers Correct C Student's C Review Information: The correct answer is C: with each meal or snack Learning Objective: Lesson 6 Pharmacological Therapies Pancreatic enzymes should be taken with each meal and every snack to allow for digestion of the foods that are eaten. If taken on an empty stomach they may cause irritation and ulcers in the stomach. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 635 A nurse is collecting data on a client with portal hypertension. Which finding should the nurse expect? A. ascites B. expiratory wheezes C. obesity D. blurred vision Answers Correct A Student's C Review Information: The correct answer is A: ascites Learning Objective: Lesson 7 Reduction of Risk Potential Portal hypertension can occur in a client with right-sided heart failure or cirrhosis of the liver. Portal hypertension can lead to ascites due to the increased portal pressure as well as a lowered osmotic pressure. Test-taking Tips: The key in this question is the word “portal.” Notice three of the options address organs other than the liver. One option addresses the liver, which is associated with “portal.” LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 418 For a 14 year-old adolescent diagnosed with scoliosis, which consequence will be the most challenging? the length of the treatment regimen the compliance with treatment regimens lacking independence in activities looking different from the peers Answers Correct D Student's D Review Information: The correct answer is : looking different from the peers Learning Objective: Lesson 3 Health Promotion and Maintenance Conformity to peer influences peaks at around age 14. Since many persons view any disability as deviant, the teen will need help in learning how to deal with reactions of others. Treatment of scoliosis is long-term and involves bracing and/or surgery. The key here is to associate “adolescent” with the word “peers” in one option. If you read one of the options too quickly you might see “dependence” instead of “independence.” Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 465 A nurse is reinforcing information to a mother who is breastfeeding a newborn infant diagnosed with oral candidiasis. Which statement by the mother would be incorrect and indicate a need for reinforcement of information? Answers Correct B Student's B A. "Nystatin should be given four times a day after my baby eats." B. "The therapy can be discontinued when the spots disappear." C. "I will boil the nipples and pacifiers for 20 minutes." D. "Expressed breast milk should be used immediately and not frozen." Review Information: The correct answer is B: "The therapy can be discontinued when the spots disappear." Learning Objective: Lesson 6 Pharmacological Therapies The therapy should be continued for two weeks, and for at least two days after lesions have disappeared. Test-taking Tips: The key words in this question are “newborn with oral candidiasis” and “breast-feeding mother.” The question being asked is to select the answer, which is incorrect information (needs further teaching). If guessing, narrow the options down to the two that are similar but dissimilar. This would lead to two of the options in that they both refer to “treatment.” Then remember to pick the incorrect statement. Go with what is known - that antibiotics are usually given for a specific time and not just until the findings disappear. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 854 Parents of a four year-old boy have just been informed that their son has a congenital neurologic demyelinating disorder that is terminal. A nurse should anticipate that their reaction should be at which phase of the crisis process? A. impact B. resolution C. recovery D. pre-crisis Answers Correct A Student's C Review Information: The correct answer is A: impact Learning Objective: Lesson 4 Psychosocial Integrity The impact of crisis is indicative of high levels of stress, sense of helplessness, confusion, disorganization, and the inability to apply problem solving behavior. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Keltner, N.L., Bostrom, C.E., & Schwecke, L.H. (2006). Psychiatric nursing (5th ed.). St. Louis, MO: Mosby. Ref # 452 Which finding by the nurse in a toddler diagnosed with croup indicates early respiratory problems? A. mild inspiratory stridor B. increased severe dyspnea C. inability of the family to calm the child Answers Correct C Student's C D. decreased breath sounds Review Information: The correct answer is C: inability of the family to calm the child Learning Objective: Lesson 8 Physiological Adaptation Other subtle findings in toddlers include increased restlessness and increased respiratory effort. The other options are later findings of respiratory problems. Test-taking Tips: Note to look for an “early” finding of respiratory problems. Three of the options would not be considered “early.” They have the clues of "inspiratory stridor," "severe" and "decreased." One option indicates the baby is restless, a first finding of hypoxia in any age group. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 453 A nurse is assisting in the discharge of a child who was admitted with a diagnosis of acute spasmodic croup. What topic should be reinforced with the parents for home care? A. provide humidified air with increased oral fluids B. use sedation as needed to prevent exhaustion C. administer antibiotic therapy for 10-14 days D. give antihistamines to minimize allergic response Answers Correct A Student's C Review Information: The correct answer is A: provide humidified air with increased oral fluids Learning Objective: Lesson 8 Physiological Adaptation The most important aspect of home care for a child with acute spasmodic croup is to provide humidified air and increased oral fluids. Moisture soothes inflamed membranes. Adequate systemic hydration aids in mucociliary clearance and keeps secretions thin, white, watery, and easily removed with minimal coughing. Test-taking Tips: Compare the information in the option with the information provided in the stem. Remember to look at the whole picture. Note that the stem of this question does not include any information that leads to the selection of sedation, antibiotics, or antihistamines. However, the correct response can be associated with croup, as it suggests the use of humidified air and fluids. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 4445 The client has received fentanyl, atropine, and benzocaine for an endoscopic procedure. The nurse Answers Correct atropine, Atropine, ATROPINE is monitoring the client and notes the pulse has increased from the pre-procedure baseline. Which medication could cause an increased pulse rate? (Write the name of the medication). Student's Atrip, atreop, Atropin Review Information: The correct answer is : atropine, Atropine, ATROPINE Learning Objective: Lesson 6 Pharmacological Therapies Atropine is anticholinergic drug that dries secretions. However, it can also increase heart rate and dilate the pupils. Fentanyl is a short-term CNS depressant and should provide some relief from anxiety and discomfort during the procedure; it slows breathing and often lowers heart rate and blood pressure. Benzocaine is a topical anesthetic and should not affect heart rate. Black, J., & Hawks, J. (2008). Medical surgical nursing: Clinical management for positive outcomes (8th ed.). St. Louis, MO: Elsevier. Wilson, B., Shannon, M., & Shields, K. (2009). Pearson nurse's drug guide 2010. Upper Saddle River, New Jersey: Prentice Hall. Practice Bank 6 Ref # 466 A nurse is collecting data about the growth and development of a toddler diagnosed with acquired immune deficiency syndrome (AIDS). Which finding should the nurse expect? A. Delayed musculoskeletal development B. Difficulty with speech development C. Delayed achievement of all developmental milestones D. Achievement of developmental milestones at normal rates Answers Correct C Student's C Review Information: The correct answer is C: Delayed achievement of all developmental milestones Learning Objective: Lesson 8 Physiological Adaptation The majority of children with AIDS have neurological involvement. There is decreased brain growth, as evidenced by microcephaly and abnormal neurologic findings. Developmental delays are common; some children may experience some normal developmental milestones but then experience a reversal or decline of those achievements. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 498 A client refuses to take the medication prescribed because the client prefers to take an herbal preparation. What is the first action a nurse should take? Answers Correct C Student's C A. Contact the client's health care provider about the refusal B. Explain the importance of the medication to the client C. Talk with the client to find out about the preferred herbal preparation D. Report the behavior to the charge nurse Review Information: The correct answer is C: Talk with the client to find out about the preferred herbal preparation Learning Objective: Lesson 6 Pharmacological Therapies Remember, the collection of additional data is typically the initial approach when problems arise. The correct option is the only response that addresses data collection ("find out about"). Craven, R.F., & Hirnle, C.J. (2008). Fundamentals of nursing: Human health and function (6th ed.). Philadelphia: Lippincott Williams & Wilkins. DeWit, S. (2008). Fundamental concepts and skills for nursing (3rd ed.). Philadelphia: Saunders. Ref # 479 A nurse assigned to a nine year-old child with a fractured femur is told that a medication error occurred. The child received twice the ordered dose of morphine an hour ago. Which nursing diagnosis on the plan of care is a priority at this time? A. risk for fluid volume alteration related to change in peristalsis B. decreased gastrointestinal mobility related to narcotic effects C. altered nutrition related to inability to control nausea and vomiting D. ineffective breathing patterns related to central nervous system depression Answers Correct D Student's C Review Information: The correct answer is D: ineffective breathing patterns related to central nervous system depression Learning Objective: Lesson 6 Pharmacological Therapies Respiratory depression is a life-threatening risk in narcotic overdoses. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 489 A client had 20 mg of furosemide (Lasix) PO at 10 am. Which data of the client should be a priority for a nurse to include at the change of shift report? A. a serum potassium of 4 mEq/liter B. to receive another dose of Lasix at 10 pm Answers Correct C Student's C C. a urine output of 1500 mL over the last five hours D. lost 2 pounds since yesterday Review Information: The correct answer is C: a urine output of 1500 mL over the last five hours Learning Objective: Lesson 6 Pharmacological Therapies Although all of these are appropriate data to include in report, the essential piece would be the urine output which reflects the effectiveness or ineffectiveness of the diuretic. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 467 The nurse is providing care for an 18 month-old child. What information should be used when assisting with developing the care plan for this child? A. Encourage the child to eat finger foods B. Engage the child in games with other children C. Hold and cuddle the child often D. Allow the child to walk independently in the nursing unit Answers Correct A Student's A Review Information: The correct answer is A: Encourage the child to eat finger foods Learning Objective: Lesson 3 Health Promotion and Maintenance According to Erikson, the toddler is in the stage of autonomy versus shame and doubt. The nurse should encourage increasingly independent activities of daily living, especially feeding and dressing self. It is unsafe to allow the toddler to walk on the unit. Holding and cuddling is more appropriate for infants. Playing games with other children would be associated with the developmental stage of the school-aged child. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 874 A nurse's primary intervention for a client who is experiencing a panic attack is which action? A. teach the client to control behaviors B. assist the client to describe the experience in detail Answers Correct C Student's C C. maintain safety for the client D. develop a trusting relationship Review Information: The correct answer is C: maintain safety for the client Learning Objective: Lesson 4 Psychosocial Integrity Clients who display signs of severe anxiety need to be supervised closely until the anxiety is decreased because they may harm themselves or others. A panic attack is suspected when a client has the feeling that something bad will happen or a feeling of doom. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 870 A nurse collects data about a 16 year-old’s use of coping mechanisms. The teen had multiple serious injuries after a motor vehicle accident. Which characteristics are most likely to be displayed by an individual of this age with this situation? A. intellectualization, rationalization, repression B. denial, projection, regression C. ambivalence, dependence, indecision D. identification, assimilation, day-dreaming Answers Correct B Student's B Review Information: The correct answer is B: denial, projection, regression Learning Objective: Lesson 4 Psychosocial Integrity Helplessness and hopelessness may contribute to regressive, dependent behavior. Denying or minimizing the seriousness of the injuries is used to avoid facing the worst situation or consequence of the accident. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 478 A 14 month-old child ingested half a bottle of baby aspirin (81 mg) tablets. Which finding should a nurse expect to see in the child? A. dyspnea B. hypothermia C. epistaxis Answers Correct C Student's C D. edema Review Information: The correct answer is C: epistaxis Learning Objective: Lesson 6 Pharmacological Therapies With large doses of aspirin, clotting time is prolonged. With the large ingestion of the aspirin, which is an acid, the temperature may rise from the severe acidosis that increases metabolic rate. Hyperventilation may be present from the attempt of the body to rid the acid via carbon dioxide. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 456 A nurse is caring for a child who has been recently diagnosed with cystic fibrosis. Which finding should the nurse anticipate? dry, non-productive cough frequent urinary infections poor appetite ribbon-like stools Answers Correct A Student's A Review Information: The correct answer is A: Learning Objective: Lesson 8 Physiological Adaptation Noisy respirations and a dry non-productive cough are usually the first respiratory findings to appear in a newly diagnosed cystic fibrosis client. Test-taking Tips: This is a question about the respiratory system. Three of the options address other systems. Only one option addresses the respiratory system. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ref # 4447 The order reads: administer Premarin 1.25 mg daily. The only available tablet strength is 625 mcg. How much medication will the nurse administer? tablet(s). Answers Correct 2 Student's 2 Review Information: The correct answer is 2 Learning Objective: Lesson 6 Pharmacological Therapies 1.25 mg = 12500 mcg 12500 mcg/625 mcg = 2 or 2 tablets Using Dimensional Analysis: tablet = (1.25 mg/625 mcg) X (1000 mcg/1 mg) = 2 Deglin, J., Vallerand, A., & Sanoski, C. (2010). Davis’s drug guide for nurses (12th ed.). Philadelphia: F.A. Davis Company. Kee, J.L., Hayes, E.R., & McCuistion, L. (2008). Pharmacology: A nursing process approach (6th ed.). St. Louis, MO: Saunders Elsevier. Ref # 463 The nurse should care for a newborn who was infected with human immunodeficiency virus (HIV) in utero based upon knowledge of which information? A. careful monitoring of renal function is indicated B. the disease will incubate longer and progress more slowly in this infant C. the infant is more susceptible to infections D. growth and development patterns will proceed at a normal rate Answers Correct C Student's C Review Information: The correct answer is C: the infant is more susceptible to infections Learning Objective: Lesson 3 Health Promotion and Maintenance HIV infected children are susceptible to opportunistic infections. Test-taking Tips: If guessing, notice that one option is the only one that refers to the infant (“newborn”). In addition, match the word “infections” in one option with “HIV in utero” which is an infection. One option would be eliminated immediately because of the word “normal” in it. One option would also be immediately eliminated because the newborn already has HIV (no need for “incubation”). Use common sense to eliminate option 3 since growth and development depends on many nutritional and environmental factors. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 869 A nurse should be aware that which of these psychosocial needs are more commonly found in an adolescent? Answers Correct C Student's C A. group sports, competition, being right B. school performance, reading, journal writing C. privacy, autonomy, peer interactions D. independence, confidence, narcissism Review Information: The correct answer is C: privacy, autonomy, peer interactions Learning Objective: Lesson 4 Psychosocial Integrity Adolescents display the need for privacy, autonomy and peer interaction concurrent with an evolving sense of identity. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 682 While monitoring the client's initial postoperative condition after a total thyroidectomy, which findings should a nurse expect as complications and report immediately to the registered nurse (RN)? A. irritability and insomnia B. parasthesia and muscle cramping C. mild dysphagia and hoarseness D. headache and nausea Answers Correct B Student's C Review Information: The correct answer is B: parasthesia and muscle cramping Learning Objective: Lesson 7 Reduction of Risk Potential Because the parathyroid gland may be damaged in this surgery, secondary acute hypocalcemia may occur. Findings of hypoparathyroidism include tetany, paresthesia, muscle cramps and seizures. Mild dysphagia and hoarseness is an expected postoperative findings and may last for six to eight weeks after surgery. Christensen, B., & Kockrow, E. (2010). Foundations of nursing and adult health nursing (6th ed.). St. Louis: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 468 A nurse is participating in the planning of care for an eight year-old child. Which focus should be included ? talk with the child to allow expressions of opinions promote independence in activities of daily living provide frequent reassurance and cuddling Answers Correct D Student's D encourage child to engage in activities with others in the playroom Review Information: The correct answer is D: Learning Objective: Lesson 3 Health Promotion and Maintenance According to Erikson, the school-age child is in the stage of industry versus inferiority. To help the age group achieve industry, the nurse should encourage tasks and activities in their hospital room or in the playroom. Test-taking Tips: With child-based questions, look at the age and put it into a category – eight years-old is school-age. Then think of what school-age children like to do – interact with other children. Look at the option that promotes interaction with other children. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 4446 The order reads: infuse IV of 1000 mL D5W with 100 mEq KCl at a rate of 50 mL/hour. Which component of this order should the nurse question? Answers Correct 100 mEq KCl Student's 100 mEq KCl Review Information: The correct answer is 100 mEq KCl Learning Objective: Lesson 6 Pharmacological Therapies This dose of potassium is too high for a routine infusion. If not sufficiently agitated (mixed) in solution it will burn the vein and can cause cardiac arrhythmias. Black, J., & Hawks, J. (2008). Medical surgical nursing: Clinical management for positive outcomes (8th ed.). St. Louis, MO: Elsevier. Harkreader, H., Hogan, M.A., & Thobaben, M. (2007). Fundamentals of nursing: Caring and clinical judgment (3rd ed.). Philadelphia: Saunders. Ref # 496 Lactulose (Kristalose, Chronulac) has been prescribed for a client with advanced liver disease. Which finding should a nurse use to evaluate the effectiveness of this treatment? A. Decreased fluid retention B. Increased ability to concentrate C. Reduction of jaundice D. Increased appetite Answers Correct B Student's B Review Information: The correct answer is B: Increased ability to concentrate Learning Objective: Lesson 6 Pharmacological Therapies Lactulose is used to treat constipation (it's a cathartic). It is used to treat or prevent complications of liver disease, such as hepatic encephalopathy. In liver disease, ammonia builds up in the blood; lactulose works by reducing the amount of ammonia in the blood. Early symptoms of hepatic encephalopathy include confusion, problems with memory or thinking, sleep problems, loss of coordination; later symptoms range from agitation and disorientation to unconsciousness and coma. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 679 The nurse is reviewing the data on a client who is suspected of having diabetes insipidus. What finding should the nurse anticipate following a water deprivation test? A. Rapid protein excretion B. Increased edema and weight gain C. Unchanged urine specific gravity D. Decreased blood potassium Answers Correct C Student's C Review Information: The correct answer is C: Unchanged urine specific gravity Learning Objective: Lesson 7 Reduction of Risk Potential Diabetes insipidus is a condition in which the kidneys are unable to conserve water. It is caused by a lack of antiduretic hormone (ADH). When fluids are restricted, the client with diabetes insipidus continues to excrete large amounts of diluted urine. Normally, urine will be more concentrated with reduced fluid intake. Don't confuse this condition with diabetes mellitus, which is a disorder of the pancreas. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Pagana, K.D., & Pagana, T.J. (2008). Mosby's diagnostic and laboratory test reference (9th ed.). St.Louis, MO: Mosby. Ref # 871 The nurse is providing care for an adolescent. Which intervention best demonstrates nurses’ sensitivity to an adolescent's appropriate need for autonomy? A. Allow young siblings to interact via various communication routes B. Express identification of feelings about body image Answers Correct C Student's C C. Provide discussion of concerns without the presence of parents D. Explore an adolescent’s feelings of resentment to identify causes Review Information: The correct answer is C: Provide discussion of concerns without the presence of parents Learning Objective: Lesson 4 Psychosocial Integrity While the family is an important component in the care of an adolescent, it is also important to spend time alone with the adolescent. This is an opportunity for the nurse to hear the teen's perspective and to really listen to his/her concerns. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 457 A two year-old child has recently been diagnosed with cystic fibrosis. A nurse is reinforcing aspects of home care for the child with the parents. Which information is appropriate for the nurse to include? A. limit exposure to other children B. restrict activities to inside the house C. schedule frequent rest periods D. continue with the child’s normal activities Answers Correct D Student's D Review Information: The correct answer is D: continue with the child’s normal activities Learning Objective: Lesson 3 Health Promotion and Maintenance Physical activity is important in a two year-old who is developing autonomy. Physical activity is a valuable adjunct to chest physical therapy. Exercise tends to stimulate mucous secretion and help develop normal breathing patterns. Test-taking Tips: Notice that two of the options are opposites—one states to “restrict” activities and the other states to “continue normal activities.” Ask : which answer is more realistic for a “two year-old?” If guessing, notice the verbs in three of the options – schedule, limit, and restrict - can be associated or clustered with the theme of restriction. The verb in one option, continue, is different or the "odd" one to be selected. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 873 An appropriate goal for clients with anxiety would be which of these? Answers Correct A Student's C A. learn self-help techniques for anxiety reduction B. express feelings to the nurse on a daily basis C. establish contact with reality situations D. become desensitized to past trauma and issues Review Information: The correct answer is A: learn self-help techniques for anxiety reduction Learning Objective: Lesson 4 Psychosocial Integrity Exploration of alternative coping mechanisms will decrease present anxiety to a manageable level. To assist clients with learning self-help techniques facilitates increased abilities to cope with anxiety. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Practice Bank 7 Ref # 684 The nurse is caring for a client in a long leg synthetic cast. The most important reason for a nurse to elevate the casted leg is for what reason? A. improve venous return B. reduce the drying time C. decrease irritation to the skin D. promote the client's comfort Answers Correct A Student's A Review Information: The correct answer is A: improve venous return Learning Objective: Lesson 7 Reduction of Risk Potential Elevation of the leg both improves venous return and minimizes swelling. Secondary benefits of the elevation are the other options. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Christensen, B., & Kockrow, E. (2010). Foundations of nursing and adult health nursing (6th ed.). St. Louis: Mosby. Ref # 470 A nurse would expect finding that a four month-old infant should be able to have which behavior? A. hold a rattle B. wave "bye-bye" C. bang two blocks Answers Correct A Student's C D. drink from a cup Review Information: The correct answer is A: hold a rattle Learning Objective: Lesson 3 Health Promotion and Maintenance The age at which a baby will develop the skill of grasping a toy with help is four to six months. The infant would use a palmar grasp since the pincer grasp does not develop until around nine months of age. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 683 A nurse is caring for a school-aged child with a diagnosis of secondary hyperparathyroidism after being treated for chronic renal disease. Which serum lab data should receive priority attention? A. calcium and phosphorus levels B. creatinine clearance C. blood urea nitrogen D. blood sugar level Answers Correct A Student's A Review Information: The correct answer is A: calcium and phosphorus levels Learning Objective: Lesson 7 Reduction of Risk Potential Calcium levels will be elevated from the hyperparathyroidism and phosphorus levels will be elevated from the chronic renal disease until the client is stabilized. If guessing, eliminate two of the options that are used for determination of renal failure. They are too close for either one to be correct. Eliminate one of the options since glucose is not commonly associated with kidney or parathyroid issues. Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 491 A client has been admitted to the coronary care unit with a diagnosis of myocardial infarction. Which of theses nursing diagnoses should a nurse be sure to discuss as a priority during a client care conference? A. risk for complications: dysrhythmias B. pain related to ischemia Answers Correct B Student's B C. activity intolerance D. risk for anxiety Review Information: The correct answer is B: pain related to ischemia Learning Objective: Lesson 8 Physiological Adaptation Pain is related to ischemia, and relief of pain will decrease myocardial oxygen demands, reduce blood pressure and heart rate and relieve anxiety. Pain also stimulates the sympathetic nervous system and increases preload to further increase the myocardial oxygen demands. This is a best of 4 question where all of the options are correct and the task is to select the priority. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: Saunders. Ref # 886 A nurse and client are discussing the client’s progress toward understanding the client’s behavioral responses to stressful events. This is typical of which phase in the therapeutic relationship? A. Termination B. Working C. Orientation D. Preinteraction Answers Correct B Student's B Review Information: The correct answer is B : Working Learning Objective: Lesson 4 Psychosocial Integrity During the working phase alternative behaviors and techniques are explored. The nurse and the client discuss the meaning behind the behavior. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 488 Which topic should be included in the plan of care to reduce leg pain for a client with peripheral arterial insufficiency of the lower extremities? A. lower the legs to a dependent position B. elevate the legs above the heart C. increase ingestion of caffeine products Answers Correct A Student's A D. supply cold compresses Review Information: The correct answer is A: lower the legs to a dependent position Learning Objective: Lesson 8 Physiological Adaptation Ischemic pain is relieved by placing feet in a dependent position. This position improves peripheral perfusion. Leg elevation, cold compresses and caffeine ingestion can all reduce peripheral circulation. Therefore, they are contraindicated. Black, J., & Hawks, J. (2008). Medical surgical nursing: Clinical management for positive outcomes (8th ed.). St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 875 A client states, "People think I’m no good. You know what I mean?" Which nursing response would be most therapeutic for this client? A. "Let's explore what you may have done to create this impression on people." B. "Let's identify and compare a few people who like you and those that don’t." C. "People often take their own feelings of inadequacy out on others." D. "I’m not sure what you mean. Tell me a bit more about that comment." Answers Correct D Student's C Review Information: The correct answer is D: "I’m not sure what you mean. Tell me a bit more about that comment." Learning Objective: Lesson 4 Psychosocial Integrity Therapeutic communication techniques are those that elicit more information in an open non-judgmental fashion. Verification of what was said and the meaning of a statement is an initial step in therapeutic communication. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 469 During reinforcement about the care after heart surgery the nurse should provide a ten year-old child with which interaction approach? A. a booklet to read about the surgery B. a model of the heart to explain the surgery Answers Correct B Student's B C. a verbal explanation just prior to the surgery D. an introduction to another child who had heart surgery Review Information: The correct answer is B: a model of the heart to explain the surgery Learning Objective: Lesson 3 Health Promotion and Maintenance According to Piaget, the school-age child is in the concrete operations stage of cognitive development. Using something concrete, like a model, will help the child understand the explanation of the heart surgery. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 472 The parents of a toddler ask: ”How long will our child have to sit in a car seat when riding in a car?” The best response by a nurse is that, "The use of a car or booster seat is required until the child is at least five years-old." is 50 inches tall." weighs at least 40 pounds." is content to use a regular seat belt." Answers Correct C Student's C Review Information: The correct answer is C: weighs at least 40 pounds." Learning Objective: Lesson 3 Health Promotion and Maintenance Transition of a child from a booster seat to lap-shoulder belts should not occur until the child reaches at least four years of age, 40 pounds, and/or is 40 inches in height. A booster seat is not appropriate until a child weighs at least 30 pounds. Test-taking Tips: Read the question carefully – this is about a toddler, not a five year-old, allowing the elimination of one option immediately. One option offers a choice, which is inappropriate to do with a toddler when it comes to safety. Also recall that toddler years are characterized by the ”negative stage” or “no” stage. Two options are similar in that they both address the child’s size, but dissimilar in the type of measurement. Then think and ask, if in a car accident which has greater influence for potential injury – height or weight? Weight is more of a factor since it adds to the force of a forward motion or movement. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 512 A nurse is discussing with a client the precautions with warfarin (Coumadin). The nurse should tell the Answers Correct A Student's C client to avoid foods with excessive amounts of what substance? A. vitamin K B. vitamin E C. Iron D. calcium Review Information: The correct answer is A: vitamin K Learning Objective: Lesson 6 Pharmacological Therapies Eating foods with excessive amounts of vitamin K contained in green leafy vegetables may alter anticoagulant effects. Test-taking Tips: Note that two options are both fat soluble vitamins, making them similar, but dissimilar answers. If guessing, choose one of those as the correct response. Think: vitamin K (blood-vascular) and vitamin E (heart-cardiac). Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. - Ref # 716 Following surgery for the placement of a ventriculoperitoneal (VP) shunt as treatment for hydrocephalus of their child, the parents ask a nurse to reinforce the registered nurse’s (RN) explanation as to why the infant has a small abdominal incision. The best response by the nurse would be to explain that the incision was made in order to insert the A. tubing into the urinary bladder B. catheter into the abdominal cavity C. catheter into the stomach D. camera for catheter placement Answers Correct B Student's B Review Information: The correct answer is B: catheter into the abdominal cavity Learning Objective: Lesson 7 Reduction of Risk Potential The preferred procedure in the surgical treatment of hydrocephalus is placement of a ventriculoperitoneal (VP) shunt. This shunt procedure provides primary drainage of the cerebrospinal fluid from the ventricles to an extracranial compartment, usually the peritoneum. A small incision is made in the upper quadrant of the abdomen so the shunt can be guided into the peritoneal cavity. Test-taking Tips: If guessing, compare the problem and the word “ventriculoperitoneal” in the stem of the question with the word “cavity” in one option (peritoneal cavity). Also, a match could be made with the site of the incision “abdominal” with the same word in one option. Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 471 A nurse would anticipate that an eight month-old should be able to display which behavior? Answers Correct C Student's C A. pull up to stand B. say two words C. sit without support D. use a spoon Review Information: The correct answer is C: sit without support Learning Objective: Lesson 3 Health Promotion and Maintenance The age that a normal child develops the ability to sit steadily without support is from seven to eight months. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 492 The CNA informs the nurse that a client's condition has changed. Which assessment finding is the earliest indication of inadequate oxygen transport? A. Somnolence B. Confusion C. Restlessness D. Crackles in the lungs Answers Correct C Student's C Review Information: The correct answer is C: Restlessness Learning Objective: Lesson 8 Physiological Adaptation Neurological changes are early findings of inadequate oxygenation, which should prompt immediate intervention. Restlessness is one of the earliest findings of inadequate oxygenation. Next, the nurse would expect to find some confusion. Somnolence is a more terminal finding. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: Saunders. Ref # 4448 The nurse has an order for a post-surgical client to receive enoxeparin (Lovenox) 40 mg subcutaneously once a day as prophylaxis for deep vein thrombosis. Enoxeparin (Lovenox) is supplied from the pharmacy as 60 mg/mL. How much Lovenox will the nurse administer? (Round the number to the nearest 10th and write only the number). mL. Answers Correct 0.7 Student's 0.6 Review Information: The correct answer is 0.7 Learning Objective: Lesson 6 Desired: 40 mg in ? mL Supplied: 60 mg in 1 mL 60 mg/1mL = 40 mg/X mL 60X = 40 (40/60) x 1 = 0.66 or 0.7 x = 0.7 mL Ref # 879 A nurse and client are discussing the client’s progress toward understanding the client’s behavioral responses to stressful events. This is typical of which phase in the therapeutic relationship? preinteraction orientation termination working Answers Correct D Student's D Review Information: The correct answer is D: working Learning Objective: Lesson 4 Psychosocial Integrity During the working phase alternative behaviors and techniques are explored. The nurse and the client discuss the meaning behind the behavior. Test-taking Tips: The key words in this question are “nurse and client discussing… progress and behavior.” Notice that two of the options would have happened in an earlier stage and one option happens at the end of the therapeutic relationship. Use common sense with the process of elimination to select the correct option. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 515 A client who received chemotherapy through a central line is admitted to the hospital with a diagnosis of sepsis. Which nursing intervention should receive priority? Answers Correct A Student's A A. inspect all sites that may serve as entry ports for bacteria B. restrict contact with persons having known or recent infections C. change the dressing over the site of the central line D. place the client in reverse isolation Review Information: The correct answer is A: inspect all sites that may serve as entry ports for bacteria Learning Objective: Lesson 6 Pharmacological Therapies Prompt recognition of source of infection and subsequent initiation of therapy will reduce morbidity and mortality. This is the first action to do. Test-taking Tips: Pay attention to the word “priority.” Remember gathering data comes before any other action. The word “inspect” refers to data collection. The words “place,” “change,” and “restrict” in three of the options are “action” or intervention words. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 884 A nursing intervention that "best" describes approaches to deal with the behaviors of clients diagnosed with personality disorders include those that A. have limit-setting enforced 24 hours per day B. accept the client and the client's behavior unconditionally C. encourage dependency in order to develop ego controls D. point out inconsistencies in speech patterns to correct thought disorders Answers Correct A Student's A Review Information: The correct answer is A: have limit-setting enforced 24 hours per day Learning Objective: Lesson 4 Psychosocial Integrity Treatment approaches include: to restructure the personality, assist the person with developmental level and set limits for maladaptive behavior such as acting out. These intervention are required continuously. Test-taking Tips: The key words in this question are “best nursing intervention in the approach….of personality disorders.” Rephrase one option to say: thought disorders can be changed by pointing out irregularity in speech patterns. Common sense leads to think that this is a false statement. The clue in one option that suggests extremes or absolutes is the word “unconditionally.” Eliminate this option. Also notice that two of the options are opposites in that one “unconditionally accepts” the behavior and one “sets limits” on behavior. Associate “personality behaviors” with the need for “limit setting.” Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 526 A nurse is assigned to a client with clinical depression who is receiving an MAO inhibitor. During reinforcement of instructions about Answers Correct A Student's A precautions with this medication, the nurse should remind the client to avoid which actions? A. ingestion of chocolate and cheese B. ingestion of foods high in sodium C. prolonged sun exposure D. walking without assistance Review Information: The correct answer is A: ingestion of chocolate and cheese Learning Objective: Lesson 6 Pharmacological Therapies Foods high in tryptophan, tyramine and caffeine, such as chocolate and cheese may precipitate a hypertensive crisis. They also need to avoid aged meats and foods such as anchovies. The two types of cheeses these clients can eat are cream cheese and cottage cheese, which are not aged cheeses. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 700 On the burn unit, a nurse is assigned to a child who weighs 30 kg. Adequate fluid replacement is best indicated by which observation? A. moist mouth mucus membranes B. no complaints of thirst C. normal skin turgor D. urinary output of 32 cc per hour Answers Correct D Student's C Review Information: The correct answer is D: urinary output of 32 cc per hour Learning Objective: Lesson 7 Reduction of Risk Potential For a child of this weight, this is adequate output, and it does not suggest overload. Note that the question is asking the best of four correct observations. Kidney function is the most precise and best indicator in this situation. Test-taking Tips: The key words in this question are “child that weighs 30 kg” and “adequate fluid replacement.” Think about the fact that when there is intake, there must be output. This line of thinking leads directly to one of the options. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 1733 A client states: "I do not want to be interrupted for breakfast because it interferes with my meditation time." What is the next action for a nurse to take? Answers Correct A Student's C A. Talk with the client to work out a mutual plan B. Contact the client's provider C. Consult with the nurse manager to get suggestions D. Contact the nutritionist or dietitian Review Information: The correct answer is A: Talk with the client to work out a mutual plan Learning Objective: Lesson 1 A nurse should talk with the client to determine how the practice of meditation can be incorporated into the morning schedule. Respect for differences must be incorporated into a client's plan of care. Practice Bank 8 Ref # 527 A nurse is preparing a client for discharge following inpatient treatment for pulmonary tuberculosis. The nurse should remind the client to take which action? A. continue medication use as prescribed B. continue medication use as prescribed until symptoms are relieved C. avoid contact with children, pregnant women or immunosuppressed persons D. take medication with Amphojel if epigastric distress occurs Answers Correct A Student's A Review Information: The correct answer is A: continue medication use as prescribed Learning Objective: Lesson 6 Pharmacological Therapies Early cessation of treatment may lead to development of medication resistant bacteria. The other options do not apply to this situation. Test-taking Tips: If guessing, narrow the options down to the two that are similar but dissimilar. That would lead to two options that both focus on ”continuing the medication.” Ask: aren’t most medications that are given for an infection taken long after the findings disappear? Eliminate one option. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 892 A client is admitted to a mental health unit with the diagnosis of delusional thinking. A nurse should expect to observe which findings? Answers Correct D Student's C A. panic and multiple physical complaints B. anorexia and hopelessness C. flight of ideas and hyperactivity D. suspiciousness and resistance to therapy Review Information: The correct answer is D: suspiciousness and resistance to therapy Learning Objective: Lesson 4 Psychosocial Integrity Clinical features of delusional disorder include extreme suspiciousness, jealousy, distrust, belief that others intend to harm. One incorrect response reflects behaviors with a bipolar diagnosis during the manic state. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 497 A nurse is caring for a client diagnosed with acute pancreatitis. Which topic, after pain management, should be discussed for reinforcement during a client conference? A. institute seizure precautions B. provide a diet high in protein C. cough and deep breathe every two hours D. place the client in contact isolation Answers Correct C Student's C Review Information: The correct answer is C: cough and deep breathe every two hours Learning Objective: Lesson 8 Physiological Adaptation Respiratory infections are common with this diagnosis because of fluid in the retroperitoneum pushing up against the diaphragm causes shallow respirations. Encouraging the client to cough and deep breathe every two hours will diminish the occurrence and risk of this complication. Test-taking Tips: The key words in this question are “after pain management” and “acute pancreatitis.” Read the answer options carefully and ask: which option can be associated with “after pain management?” This would leave only one option as the correct answer. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 530 An older adult client with a diagnosis of osteomyelitis requires a six week course of intravenous antibiotics. In helping to plan for home care, which item needs to be determined first before the other actions can be done by a nurse? Answers Correct D Student's D A. investigation of the client's insurance to see if it covers home IV antibiotic therapy B. find out if there are adequate hand washing facilities in the home C. select an appropriate venous dressing method D. determine the client's ability to participate in self care and/or the presence of a reliable caregiver Review Information: The correct answer is D: determine the client's ability to participate in self care and/or the presence of a reliable caregiver Learning Objective: Lesson 3 Health Promotion and Maintenance The cognitive, physical, emotional, social ability and the environmental status of the client as well as the availability and reliability of a caregiver must be assessed to determine if home care is a feasible option. Eliopoulos, C. (2009). Gerontological nursing (7th ed.). Philadelphia: Lippincott Williams & Wilkins. Smeltzer, S.C., Bare, B.G., Hinkle, J., & Cheever, K.H. (2009). Brunner- Suddarth's textbook of medical surgical nursing (12th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 560 A nurse is assigned to a client with Parkinson's disease who is experiencing hallucinations. Which of these medications may have been a contributing factor? A. baclofen (generic) B. benztropine (Cogentin) C. carbidopa/levodopa (Sinemet) D. diphenhydramine (Benadryl Allergy) Answers Correct C Student's C Review Information: The correct answer is C: carbidopa/levodopa (Sinemet) Learning Objective: Lesson 6 Pharmacological Therapies While it is unclear whether some one-third of clients with Parkinson's disease have dementia, the nurse should ask about hallucinations. Parkinson's disease medications can cause hallucinations when the dosage is too high. The nurse should ask clients and family members about hallucinations (and other adverse effects) during each home care or clinic visit. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 536 An 82 year-old client is prescribed eye drops for treatment of glaucoma. What other data is needed before a nurse begins to reinforce proper administration of the eye drops? A. proximity to health care services B. ability to use visual assistive devices C. other medical problems Answers Correct D Student's C D. manual dexterity Review Information: The correct answer is D: manual dexterity Learning Objective: Lesson 3 Health Promotion and Maintenance Inability to self administer eye drops is a common problem among the elderly due to decreased finger dexterity from the process of aging. Test-taking Tips: The key here is to recognize that the content is “administration of eye drops by the client.” Ask: What would the client need most in order to self-administer eye drops? Miller, C.A. (2008). Nursing for wellness in older adults (5th ed.). Philadelphia: Lippincott Williams & Wilkins. Linton, A.D. (2007). Introduction to medical surgical nursing (4th ed.). Philadelphia: Saunders. Ref # 476 The nurse is assisting with the physical assessment of adolescents. When comparing information about growth in boys and girls, what should the nurse anticipate? A. At puberty, hormones are responsible for the growth spurt and other changes B. Both genders have about the same rate of growth throughout puberty C. Girls experience a growth spurt about two years later than boys D. Height increases by roughly 10.1 cm (4 inches) each year in boys and girls Answers Correct A Student's A Review Information: The correct answer is A: At puberty, hormones are responsible for the growth spurt and other changes Learning Objective: Lesson 3 Health Promotion and Maintenance Normally, female teens years experience a growth spurt about two years earlier than their male peers. The beginning of puberty is about age 11 in boys and age 9 in girls. The average growth spurt lasts about 24 to 36 months; girls average about 9 cm/year and boys average about 12-13 cm/year during the growth spurt. The growth spurt is influenced by a variety of hormones, including the growth hormone, thyroxine, insulin, corticosteroids and gonadal sex steroids. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 532 A client is being transfused with one unit of packed cells. Thirty minutes after the transfusion was initiated, the client complains of chills and headache. What should be the initial action of the practical nurse (PN)? Answers Correct B Student's B A. obtain a urine specimen B. stop the transfusion C. notify the registered nurse (RN) D. check the client's temperature Review Information: The correct answer is B: stop the transfusion Learning Objective: Lesson 6 Pharmacological Therapies The first action when a client exhibits signs of a potential transfusion reaction is to discontinue the transfusion immediately. Then the RN should be notified. Test-taking Tips: Ask: could this client be having a reaction to blood? If so, the first action has to be "stop the transfusion". Then you would perform the other options per agency policy. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 770 For a client diagnosed with asthma, which action should be reinforced to monitor on a daily basis by a nurse during a teaching session? A. skin color B. peak air flow volumes C. respiratory rate D. pulse oximetry Answers Correct B Student's B Review Information: The correct answer is B: peak air flow volumes Learning Objective: Lesson 7 Reduction of Risk Potential The peak air flow volumes decrease about 24 hours before clinical findings occur for acute asthma attacks. A peak flow meter is a small, hand-held device used to manage asthma by monitoring air flow through the bronchi and thus the degree of restriction in the airways. The peak flow meter measures the client's maximum ability to expel air from the lungs, or peak expiratory flow rate (PEFR or PEF). Peak flow readings are higher when clients have normal airways and lower when the airways are constricted. Most have colors of green = good or 80 to 100% of normal air flow yellow = therapy (inhaler) needed 50 to 80% of normal air flow red = rapid response needed/medical alert or less than 50% of normal air flow LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 890 A nurse should be aware that the most frequent cause for suicide in adolescents is Answers Correct A Student's C A. feelings of alienation or isolation from peers B. progressive failure to adapt to peer pressure C. reunion wish or a fantasy of some sort D. feelings of anger or hostility toward others Review Information: The correct answer is A: feelings of alienation or isolation from peers Learning Objective: Lesson 4 Psychosocial Integrity The isolation may occur gradually resulting in a loss of all meaningful social contacts. Isolation can be self imposed or can occur as a result of the inability to express feelings. Test-taking Tips: If guessing, narrow the options down to the two similar but dissimilar answers that both focus on “feelings.” Think that in the teen years “feelings” are one of many dominant characteristics. Ask: which feelings would “most frequently” lead to suicide—anger or isolation? Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 887 Which therapeutic communication skill is likely to encourage a client treated for depression to express feelings? A. silence with active listening behaviors B. reality orientation with reinforcement C. projective identification with questioning D. direct confrontation with discussion Answers Correct A Student's A Review Information: The correct answer is A: silence with active listening behaviors Learning Objective: Lesson 4 Psychosocial Integrity Use of therapeutic communication skills such as silence and active listening behaviors encourages verbalization of feelings. Test-taking Tips: The key words in this question are “most likely therapeutic communication skill to encourage the expression of feelings.” Notice that two options are opposites in that one focuses on “silence” and “listening” and the other on “questioning.” Two other options would immediately be eliminated because neither would be therapeutic in the “expression of feelings." Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 773 A nurse is reinforcing the information to a newly diagnosed asthma client on how to use a peak flow meter. The nurse should explain that this pleak flow meter is to be used to measure what parameters? A. forced expiratory volume B. oxygen saturation Answers Correct A Student's D C. presence of allergens D. doses for inhaled bronchodilator Review Information: The correct answer is A: forced expiratory volume Learning Objective: Lesson 7 Reduction of Risk Potential The peak flow meter is used to measure peak expiratory flow volume. It provides useful information about the presence and/or severity of airway obstruction. A peak flow meter is a small, hand-held device used to manage asthma by monitoring air flow through the bronchi and thus the degree of restriction in the airways. The peak flow meter measures the client's maximum ability to expel air from the lungs, or peak expiratory flow rate (PEFR or PEF). Peak flow readings are higher when clients are well and lower when the airways are constricted. green = good or 80 to 100% of normal air flow yellow = therapy (inhaler) needed 50 to 80% of normal air flow red = rapid response needed/medical alert or less than 50% of normal air flow LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 889 When discussing suicide prevention with the parents of a 15 year-old who recently attempted suicide, a nurse should include which behavioral cue or signal to discuss? A. angry outbursts at significant others B. excessive sulking to peers and family C. giving away valued personal items D. fears of being left alone in the home Answers Correct C Student's C Review Information: The correct answer is C: giving away valued personal items Learning Objective: Lesson 4 Psychosocial Integrity Eighty percent of all potential suicide victims give some type of clue or signal with behavioral and verbal actions. These clues might lead one to suspect that a client is holding suicidal thoughts, developing or having a plan. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 4451 The health care provider writes an order for vancomycin (Vancocin) 2 grams every 12 hours IV for a client with pneumonia. The pharmacy sends the medication mixed in a 200 milliliter (mL) bag with directions to infuse it over 1.5 hours. The nurse will use an infusion pump to deliver the medication. What is the infusion rate for the vancomycin (Vancocin)? (Round to the nearest whole number and write only the number). mL/hour. Answers Correct 133 Student's 130 Review Information: The correct answer is 133 Learning Objective: Lesson 6 Vancomycin must be run with an infusion pump; thus it is essential that the nurse have the ability to calculate the correct rate to set the pump. 200 mL/1.5 hours = X mL/hour X = 133 mL/hour Ref # 495 When caring for a client with advanced cirrhosis of the liver, which finding should receive immediate follow-up by the nurse? A. anorexia B. jaundice C. hematemesis D. ascites Answers Correct C Student's C Review Information: The correct answer is C: hematemesis Learning Objective: Lesson 8 Physiological Adaptation The vomiting of blood may indicate hemorrhage, especially from esophageal varices. This condition can be life threatening. Test-taking Tips: The content of this question is “cirrhosis of the liver” and the question being asked is what finding would be an emergency (immediate attention). Ask: what takes priority? Designate a theme to each option: bleeding, not eating, fluid , or yellow skin. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Linton, A.D. (2007). Introduction to medical surgical nursing (4th ed.). Philadelphia: Saunders. Ref # 717 The parents of a newborn male with hypospadias want their child circumcised. The best response by a nurse to reinforce the registered nurse’s (RN) instruction is to inform them of what information? A. there is no medical indication to perform a circumcision on their child B. the procedure may be performed as soon as their infant is stable C. this procedure is contraindicated because of the permanent defect D. circumcision is delayed so the foreskin can be used for the surgical repair Answers Correct D Student's C Review Information: The correct answer is D: circumcision is delayed so the foreskin can be used for the surgical repair Learning Objective: Lesson 7 Reduction of Risk Potential Even if mild hypospadias is suspected, circumcision is not done after birth in order to save the foreskin in case it is needed for the surgical repair. Test-taking Tips: If guessing note that the key words in this question are “hypospadias” and “circumcised” as well as "best response.” Read the answers carefully and note that only one option includes both of the key words (surgical repair/hypospadias and circumcision). Price, D.L., & Gwin, J.F. (2007). Pediatric nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 475 During observation of the growth of children during their school-age years, a nurse should expect to see which change? A. little change in body appearance from year to year B. progressive height increase of 4 inches each year C. yearly weight gain of about 5.5 pounds per year D. decreasing amounts of body fat and muscle mass Answers Correct C Student's C Review Information: The correct answer is C: yearly weight gain of about 5.5 pounds per year Learning Objective: Lesson 3 Health Promotion and Maintenance School age children gain about 5.5 pounds each year and increase about 2 inches per year in height. Test-taking Tips: Notice that two options indicate no change in growth. Ask: during the school-aged years, do children change or remain the same? This narrows the options. Carefully read these options. Note that 4 inches of growth in a year is excessive and that a 5 pound weight gain over a year is a little less than 0.4 of a pound a month. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Ball, J., Bindler, R., & Cowen, K. (2009). Child health nursing: Partnering with children of families (2nd ed.). New Jersey: Pearson Prentice Hall. Ref # 516 A nurse is caring for a client diagnosed with multiple myeloma who is undergoing radiation therapy. Which side effect should be reported to the registered nurse (RN) immediately? Answers Correct A Student's C A. elevated temperature B. mouth ulcers C. excessive vomiting D. erythema around the radiation site Review Information: The correct answer is A: elevated temperature Learning Objective: Lesson 8 Physiological Adaptation Elevated temperature is the first finding of infection. Radiation suppresses the body's production of white blood cells, which increases the risk for infection. Test-taking Tips: Note that the content of this question is “radiation therapy," not “multiple myeloma.” The question being asked is about “which side effect would you immediately report?” Remember that multiple myeloma is generalized in the body, so the radiation therapy would be as well. Thus, eliminate all the options dealing with specific locations. More likely would be a generalized symptom such as temperature elevation. Associate the elevated temperature in one option with infection, which is a possibility due to the immunosuppression effects of the radiation therapy. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Christensen, B., & Kockrow, E. (2010). Foundations of nursing and adult health nursing (6th ed.). St. Louis: Mosby. Ref # 2441 The nurse is to administer a new medication to a client. Which of these actions best demonstrates an awareness of safe, proficient nursing practice? A. Verify the client's allergies on the admission sheet and order. Verify the client's name on the name plate outside the room then as the nurse enters the room ask the client "What is your first, middle and last name?" B. Verify the order for the medication. Prior to giving the medication the nurse should say, "Please state your name." C. Upon entering the room the nurse should ask: "What is your name? What allergies do you have?" and then check the client's name band and allergy band. D. As the room is entered say "What is your name?" then check the client's name band. Answers Correct C Student's C Review Information: The correct answer is C: Upon entering the room the nurse should ask: "What is your name? What allergies do you have?" and then check the client's name band and allergy band. Learning Objective: Lesson 2 A dual check is always done for a client's name. This would involve verbal and visual checks. Since this is a new medication an allergy check is appropriate. The other options have parts that might be correct actions. However, to be the correct answer all of the parts of an option need to be correct. Practice Bank 9 Ref # 780 A female client is scheduled for abdominal surgery. Which information would indicate that this client is at a risk for thrombus formation in the postoperative period? A. Hormonal replacement therapy for more than three years B. Hypersensitivity to heparin 20 years ago C. History of acute hepatitis A five years ago D. 10% less than ideal body weight for the past year Answers Correct A Student's A Review Information: The correct answer is A: Hormonal replacement therapy for more than three years Learning Objective: Lesson 7 Reduction of Risk Potential Hormonal replacement therapy containing estrogen increases the hypercoagulability of the blood and increases the risk for developing thrombophlebitis. The platelets become sticky, which increases the risk of clot formation. This risk increases with a woman who also smokes and/or is overweight. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 543 A nurse in a newborn nursery should recognize that the postmature infant is primarily at risk for complications from which situation? Answers Correct C Student's C A. excessive fetal weight B. low blood sugar levels C. progressive placental insufficiency D. depletion of subcutaneous fat Review Information: The correct answer is C: progressive placental insufficiency Learning Objective: Lesson 3 Health Promotion and Maintenance The placenta functions less efficiently as pregnancy continues beyond 42 weeks. Immediate and long term effects may be associated with hypoxia. Test-taking Tips: Notice that three of the options are all “decrease” answers (low, depletion, and insufficiency) and are more of risks than weight. Therefore, eliminate one option first. Then give a theme word to each option that remains - one option is lab data or glucose, another option is skin, and another is circulation. It is obvious that insufficiency in circulation is most risky for complications. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 568 A nurse is discussing with an older adult client the proper use of metered dose inhalers (MDI's). The nurse is concerned that the client is unable to coordinate the release of the medication during the inhalation phase. The nurse should recommend the use of what approach for the client? A. request a visiting nurse to follow the client at home B. asking a family member to assist the client with the MDI C. nebulized treatments for home care D. adding a spacer device to the MDI canister Answers Correct D Student's D Review Information: The correct answer is D: adding a spacer device to the MDI canister Learning Objective: Lesson 6 Pharmacological Therapies The spacer which the client puts in the mouth allows for concentration of inhalation and exhalation, not as a measure to keep the MDI from the oral cavity. The majority of pulmonary medications for COPD are delivered by inhalation. This is often preferred over oral administration because a lower medication dose is needed and systemic side effects are reduced. In addition, the onset of action of bronchodilator medication given via inhalation is faster since the medicine is absorbed through the mucous membranes. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 895 A client was admitted to the eating disorder unit with a diagnosis of bulimia nervosa. When a nurse gathers data about a history of any complications, which of these findings should the nurse expect? Answers Correct B Student's B A. respiratory distress, dyspnea B. dental erosion, parotid gland enlargement C. bacterial gastrointestinal infections, overhydration D. metabolic acidosis, constricted colon Review Information: The correct answer is B: dental erosion, parotid gland enlargement Learning Objective: Lesson 4 Psychosocial Integrity Dental erosion and parotid gland enlargement are associated with the frequent purging. The acid from the stomach is damaging to the enamel on the teeth. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 562 The client is prescribed alendronate (Fosamax). What information about medication administration should the nurse be sure to reinforce? A. Take with milk, two hours after meals B. Take after meals C. Take on an empty stomach D. Take with calcium Answers Correct C Student's C Review Information: The correct answer is C: Take on an empty stomach Learning Objective: Lesson 6 Pharmacological Therapies Fosamax should be taken first thing in the morning with water at least 30 minutes before other medication or food. Fosamax, a bone reabsorption inhibitor, is used for postmenopausal bone thinning osteoporosis, and to treat Paget's disease. Clients should remain in an upright position for at least 1 to 2 hours after ingestion of this medication. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 4454 Following craniotomy surgery the client develops a cardiac arrhythmia. The provider orders lidocaine (Xylocaine) infusion at 3 mg/minute. The label states the 500 mL IV bag contains 2 grams of lidocaine (Xylocaine). What is the flow rate setting (milliliter/hour)? (Round to the nearest whole number and write only the number). mL/hour. Answers Correct 45 Student's 45 Review Information: The correct answer is 45 Learning Objective: Lesson 6 Pharmacological Therapies Using dimensional analysis to solve: since the final answer will be in mL/hour begin the equation with milliliters on top. Multiply by known factors to cancel out unwanted units until only mL/hour remains. (500 mL/2 gram) X (1 gram/1000 mg) X (3 mg/min) X (60 min/hr) = 90,000/2,000 = 45 mL/hour Deglin, J., Vallerand, A., & Sanoski, C. (2010). Davis’s drug guide for nurses (12th ed.). Philadelphia: F.A. Davis Company. Kee, J.L., Hayes, E.R., & McCuistion, L. (2008). Pharmacology: A nursing process approach (6th ed.). St. Louis, MO: Saunders Elsevier. Ref # 894 A client with a history of anorexia nervosa is hospitalized on a medical unit with the diagnosis of "electrolyte imbalance and cardiac dysrhythmias." Which additional findings should a nurse expect to observe during the admission process? A. diarrhea, nausea, vomiting B. brittle hair, lanugo, amenorrhea C. excessive anxiety about findings, dental erosion, osteoporosis D. hyperthermia, tachycardia, increased metabolic rate Answers Correct B Student's B Review Information: The correct answer is B: brittle hair, lanugo, amenorrhea Learning Objective: Lesson 4 Psychosocial Integrity Physical findings associated with anorexia nervosa are brittle hair, lanugo, dehydration, lowered metabolic rate and abnormal vital signs. Dental erosion is often associated with bulemia from the frequent passage of acid contents over the teeth during the self-induced purging. Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 544 A nurse is assisting in the exam of a pregnant client in the third trimester. The parents have been informed that the ultrasound suggests that the baby is small for gestational age (SGA). An earlier ultrasound indicated normal growth. The nurse understands that this change is most likely associated with what condition? Answers Correct C Student's A A. chromosomal abnormalities B. sexually transmitted infection C. maternal hypertension D. exposure to teratogens Review Information: The correct answer is C: maternal hypertension Learning Objective: Lesson 3 Health Promotion and Maintenance Pregnancy induced hypertension is a common cause of late pregnancy fetal growth retardation. Vasoconstriction reduces placental exchange of oxygen and nutrients. Test-taking Tips: The key words here are “third trimester,” “normal growth in earlier part of pregnancy,” and “SGA at this time.” This content helps to eliminate two of the options. Notice one option includes the mother’s health and would be more of an ongoing problem whereas the infection would be intermittent. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 4455 The client with lung cancer is 1 day post-op lobectomy and demonstrates symptoms of infection. The health care provider orders 900 mg of Nafcillin. There is powder in a vial labeled "Nafcillin 1 gram" with instructions "to dilute with 3.4 mL of sterile water to produce 1 gram in 4 mL." How many milliliters does the nurse administer? (Round to the nearest tenth and write only the number). mL. Answers Correct 3.6 Student's 3.6 Review Information: The correct answer is 3.6 Learning Objective: Lesson 6 Pharmacological Therapies Using Dimensional Analysis - since the answer is in milliliters, begin with milliliters on top, then multiply by known factors to cancel unwanted units until only the answer unit remains. (4 mL/1 gram) X (1 gram/1000 mg) X (900 mg/1) = 3600/1000 = 3.6 mL Deglin, J., Vallerand, A., & Sanoski, C. (2010). Davis’s drug guide for nurses (12th ed.). Philadelphia: F.A. Davis Company. Kee, J.L., Hayes, E.R., & McCuistion, L. (2008). Pharmacology: A nursing process approach (6th ed.). St. Louis, MO: Saunders Elsevier. Ref # 518 A nurse is caring for a client who had a nailing of a proximal right femur fracture. Which position is the best for the client's recovery? A. either side with legs abducted B. client's position of comfort C. right side-lying Answers Correct B Student's B D. left side-lying Review Information: The correct answer is B: client's position of comfort Learning Objective: Lesson 8 Physiological Adaptation After a hip nailing the position postop is whatever is comfortable to the client. In the case of a hip prosthesis placement, a client would need to keep the legs in an abducted position (positioned away from the mid-line of the body) for three-to-five days postoperative. Test-taking Tips: Ask: are there any restrictions for this client postop? If not, this answer leads to the correct answer. A clue that hints to the absence of restrictions is ”nailing,” which means a plate has been nailed to the long bone to stabilize the fractured bone. Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: Saunders. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 523 A client is in the physical therapy room and tells a nurse "I'm having one of those seizure auras." Which intervention is most appropriate for a nurse to take? A. move the client away from hazards B. reduce the noise and dim the lights in the room C. stay with the client and continually observe D. instruct a coworker to notify the registered nurse (RN) Answers Correct A Student's C Review Information: The correct answer is A: move the client away from hazards Learning Objective: Lesson 8 Physiological Adaptation The most important action is to place the client in a safe place so that if a seizure occurs, the client will not be injured. Staying with the client is necessary and would be done after. At this point, notification is not necessary as no seizure has occurred. Noise reduction and light dimming may be beneficial but are not the priority. Test-taking Tips: Remember, any quotation in the stem of the question is extremely important. One option relates specifically to the dangers of seizure. Remember the ABCs method, which ranks the importance of Airway, Breathing, Circulation, and Safety issues, in that order. Since the question does not specify airway, breathing, or circulation problems, personal safety of the client will be the most important consideration. When all options could be correct answers, as is the case here, associate “most important” with the action that would be performed first. Black, J., & Hawks, J. (2008). Medical surgical nursing: Clinical management for positive outcomes (8th ed.). St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 533 A nurse is caring for a client with status epilepticus. Which of the following is most important to monitor? Answers Correct B Student's B A. injuries to the extremities B. level of consciousness C. pulse and respiration D. amount of intravenous fluid infused Review Information: The correct answer is B: level of consciousness Learning Objective: Lesson 8 Physiological Adaptation Cerebral blood flow undergoes a 250% increase during seizure activity with a depletion of oxygen at the neuronal level. Cerebral anoxia may result in progressive brain tissue injury and destruction. The nurse should monitor the client’s level of consciousness continuously. Even when seizures are controlled, the client may be unconscious for a period of time. Test-taking Tips: Note that this is a neurological question and requires a neurological answer. This leads to the option that is the only neurological response. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 790 A client is receiving oxygen therapy via a nasal cannula. When providing nursing care, which intervention would be most appropriate? A. maintain clean technique when handling the cannula B. inspect the nares and ears for skin breakdown C. determine that adequate mist is supplied D. lubricate the tips of the cannula before insertion Answers Correct B Student's B Review Information: The correct answer is B: inspect the nares and ears for skin breakdown Learning Objective: Lesson 7 Reduction of Risk Potential Oxygen therapy can cause drying of the nasal mucosa. Pressure from the tubing can cause skin irritation. Test-taking Tips: Read the answer options carefully and notice that the only one answer that addresses the nose. Two options address the cannula, not the client, and one option, the mist. Also, note that further data collection is more frequently the correct answer. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 563 An older adult client is on an anticholinergic metered dose inhaler (MDI) for chronic obstructive pulmonary disease. A nurse should suggest a spacer for what purpose? Answers Correct C Student's C A. prevent an exacerbation of COPD B. increase client compliance C. improve the aerosol delivery from the MDI D. enhance the effects of the medication Review Information: The correct answer is C: improve the aerosol delivery from the MDI Learning Objective: Lesson 6 Pharmacological Therapies Spacers improve the medication delivery in clients who are unable to coordinate the MDI. They are commonly used by children and older adults, both of whom may have difficulty with coordination. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 545 A nurse caring for premature newborns carefully monitors oxygen concentration. The most important reason for this monitoring is to prevent which complication? A. Bronchial pulmonary dysplasia B. Retinopathy of prematurity C. Necrotizing enterocolitis D. Intraventricular hemorrhage Answers Correct B Student's C Review Information: The correct answer is B: Retinopathy of prematurity Learning Objective: Lesson 3 Health Promotion and Maintenance While there are other causes for retinal damage in the premature infant, maintaining the oxygen concentration below 40% reduces the risk for retrolental fibroplasia. Test-taking Tips: “Monitoring oxygen concentration” is the content of this question. The question being asked is for the “most important reason” for this action. If guessing, associate the word “prematurity” in one option with the stem words “premature newborns.” Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 535 A client is admitted for treatment of a frontal lobe brain tumor and undergoes a craniotomy for tumor removal. The client is comatose afterwards. Which post-op nursing intervention would have the highest priority? A. observe the dressing for blood B. monitor the pupillary reaction to light Answers Correct A Student's A C. keep the client's head elevated D. turn the client routinely Review Information: The correct answer is A: observe the dressing for blood Learning Objective: Lesson 8 Physiological Adaptation Because of the client's risk for hemorrhage, it is vital to monitor the dressing for evidence of bleeding. Positioning, keeping the head elevated (to prevent increased intracranial pressure) and monitoring the pupils are all necessary postcraniotomy interventions. However, observation for bleeding is the highest priority. Test-taking Tips: The key words in this question are “craniotomy” and “highest priority.” Identify that this is the type of question where the task is to select the best of 4 correct options. Since all of these actions are appropriate for this client, ask: which one is first? Remember that data collection takes precedent and narrow the options to two. Bleeding would indicate a more immediate and serious problem, and therefore should be given highest priority. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: Saunders. Ref # 786 A nurse is caring for a client suspected to have tuberculosis (TB). Which diagnostic test is the definitive test to determine the presence of active TB? A. acid fast bacillus smear B. tuberculin skin testing C. chest x-ray D. white blood cell count Answers Correct A Student's C Review Information: The correct answer is A: acid fast bacillus smear Learning Objective: Lesson 7 Reduction of Risk Potential The acid fast bacillus smear or sputum culture is the most accurate method for determining the presence of active TB. Test-taking Tips: The key word in this question is “definitive” which means: which would be used to diagnose TB? That would lead to two options as possibilities. One option is a screening test, not a definitive test. One option is a general white count test. Ask: would a chest x-ray or a sputum culture (identification of organisms) be the most definitive response? Use common sense: since TB produces sputum, the sputum option is the best answer. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 893 A client diagnosed with bipolar disorder refuses to take the prescribed medication. Which is the most therapeutic response by a nurse to the client’s refusal of the medication? Answers Correct D Student's D A. "You need to take your medicine. This is how you get better." B. "I can see that you are uncomfortable right now; let's talk about it tomorrow." C. "If you refuse your medicine, tell me how do you think you will get better?" D. "What is it about the medicine that you don’t like?" Review Information: The correct answer is D: "What is it about the medicine that you don’t like?" Learning Objective: Lesson 4 Psychosocial Integrity The best response when clients refuse medications is to do further data collection about the problem from the client. Additional nursing interventions for clients with psychotic disorders are aimed to establish a trusting relationship, establish clear communications, present reality and reinforce appropriate behavior. These approaches should be completed after the data collection. Test-taking Tips: Two options can be immediately eliminated because they are punitive responses. The word “tomorrow” in one option eliminates that option since the question asks how to deal with it now. By the process of elimination, option 3 is left as the “most therapeutic response.” Notice that it also is the option that “collects further information” and is the most “client centered.” Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby. Ref # 541 A newborn delivered at home without a birth attendant is admitted to the hospital for observation. The initial axillary temperature is 95 F (35 C). What should the nurse recognize about this situation? A. Lethargy B. Reduced PaO2 C. Lowered basal metabolic rate (BMR) D. Metabolic alkalosis Answers Correct B Student's A Review Information: The correct answer is B: Reduced PaO2 Learning Objective: Lesson 3 Health Promotion and Maintenance The maintenance of temperature is considered one of the most important aspects of effective neonatal care. A drop in temperature can cause the infant to display subtle signs of distress such as tachycardia, tachypnea, pallor and metabolic acidosis. If it is a preterm newborn, it could be suffering from cold stress and hypothermia; this will cause an increased risk for respiratory distress (reduced PaO2). The baby delivered under such circumstances needs careful monitoring. In this situation, the newborn must be immediately warmed to increase its temperature to at least 97 F (36 C). Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 569 A nurse is reinforcing instruction to a client with moderate persistent asthma on the proper method for using a dry powder inhaler (DPI). Which medication should be administered first? A. anticholinergic B. beta agonist Answers Correct B Student's B C. mast cell stabilizer D. steroid Review Information: The correct answer is B: beta agonist Learning Objective: Lesson 6 Pharmacological Therapies The beta-agonist is taken first to open the airway with bronchodilation. Metered-dose inhaler (MDI) products contain therapeutically active ingredients dissolved or suspended in a propellant, a mixture of propellants, or a mixture of solvents, propellants, and/or other substances in compact pressurized aerosol dispensers. A dry powder inhaler is similar to a metered dose inhaler. Both are handheld devices that deliver a precisely measured dose of asthma medicine into the lungs. The advantage of using a dry powder inhaler is that it is breath-activated, so you don't have to coordinate activating the inhaler (spraying the medicine) while at the same time inhaling the medication. Instead, you simply breathe in quickly to activate the flow of medication. In this way, the breath-activated discharge of medicine is always coordinated with your inhalation effort. In a DPI, the asthma medication comes in a dry powder form - inside a small capsule, a disk or a compartment inside your inhaler. The dry powder in some inhalers has no taste, while in others the medication is mixed with lactose (a simple sugar), giving it a sweet taste. Most people find dry powder inhalers easy to use. Because the capsules need to stay dry, they should not be stored in a damp place such as a bathroom Test-taking Tips: First identify that the problem is with the lungs. Two of the options are associated with direct lung action. Of these two options, a recall tip is that “B”eta agonists = “B”ronchodilate. One option is for ”prevention” not treatment of asthma attacks. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Practice Bank 10 Ref # 4481 Which is the appropriate injection site to give an influenza vaccine to an adult? Use your cursor to select an area on the image below. Answers Correct Student's Review Information: The correct answer is Learning Objective: Lesson 6 An influenza (or flu) vaccine is less than 1 mL of fluid, so it is acceptable to administer this injection in the deltoid muscle. Locate the lower edge of the acromial process and measure 2-3 finger widths in the middle of the arm. Ref # 551 A nurse practicing in a maternity setting recognizes that neonatal sepsis is most often related to which problem? A. precipitous vaginal birth B. maternal diabetes C. cesarean delivery Answers Correct D Student's D D. prolonged rupture of membranes (PROM) Review Information: The correct answer is D: prolonged rupture of membranes (PROM) Learning Objective: Lesson 3 Health Promotion and Maintenance PROM is a leading cause of newborn sepsis. If amniotic fluid leaks for 12 to 24 hours, a common action to reduce the risk of infection to the mother and the fetus/newborn is often a cesarean section or enhancement of the laboring process. A precipitous vaginal birth is a fast birth which has minimal infection risk. Test-taking Tips: Note that this question requires an answer about the newborn (neonatal sepsis). Ask: Which options don’t have anything to do with infection? Two of the options should be evident. So then narrow the options down to two. Then ask: Aren’t there sterile conditions during cesarean deliveries? So this can be eliminated to finally select the right option. Remember that the clue is most often in the question. So reread the question to get the focus. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 924 A female client admitted for a breast biopsy says tearfully to a nurse, "If this turns out to be cancer and I have to have my breast removed, my companion will never come near me." The nurse's best response would be A. "You sound worried that the surgery will change you?" B. "Are you questioning the depth of your relationship?" C. "Why are you concerned that you will be rejected?" D. "I'm sure your companion will understand." Answers Correct A Student's C Review Information: The correct answer is A: "You sound worried that the surgery will change you?" Learning Objective: Lesson 4 Psychosocial Integrity This is a response that encourages further discussion by making an observation without focusing on an area that the nurse feels is a problem. The client has the control to direct the focus of the conversation. One incorrect response - elicits a “yes” or “no” answer which blocks rather than supports further discussion. Another incorrect response is confrontational and requires an explanation of a specific focus, rather than prompting client control of topic. The third incorrect response offers false reassurance and does not engage the client in further discussion. Taylor, C.R., Lillis, C., LeMone, P., & Lynn, P. (2006). Fundamentals of nursing: The art and science of nursing care (6th ed.). Philadelphia: Lippincott Williams & Wilkins. Shives, L.R. (2009). Basic concepts of psychiatric-mental health nursing (7th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 599 A school nurse checks a child after several days of treatment for a documented strep throat. Which statement suggests that further reinforcement of information is needed? Answers Correct A Student's A A. "Sometimes I take the pills in the morning and at night." B. "My mother makes me take my medicine right after school." C. "Sometimes I take my medicine with fruit juice." D. "I am feeling much better than I did last week." Review Information: The correct answer is A: "Sometimes I take the pills in the morning and at night." Learning Objective: Lesson 6 Pharmacological Therapies Inconsistency in taking the prescribed medication indicates that reinforcement of medication administration is needed. Test-taking Tips: The question being asked is for the statement that is incorrect. As each option is read, compare the timeframes and ask: is there anything wrong with this statement? The word clue in one option is "sometimes" which indicates that no specific schedule is adhered to for the child. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 546 A newborn presents with a pronounced cephalohematoma after being born in a posterior position. The licensed practical nurse (LPN) anticipates that the plan for care will address which nursing diagnosis? A. Impaired mobility related to bleeding B. Pain related to periosteal injury C. Parental anxiety related to knowledge deficit D. Injury related to intracranial hemorrhage Answers Correct C Student's C Review Information: The correct answer is C: Parental anxiety related to knowledge deficit Learning Objective: Lesson 3 Health Promotion and Maintenance This hematoma is caused by pressure and/or trauma during labor; it is often caused by forceps used in the delivery. This painless condition is usually benign and resolves on its own in four to six weeks. The swelling does not cross the suture lines. Parental anxiety must be addressed by listening to their fears and reinforcing the information provided by the health care team. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 561 Which activity should be most effective in meeting the growth and development needs for older adult residents in a long term care setting? A. reminiscence groups B. aerobic exercise classes Answers Correct A Student's A C. regularly scheduled social activities D. transportation for shopping trips Review Information: The correct answer is A: reminiscence groups Learning Objective: Lesson 3 Health Promotion and Maintenance According to Erikson's theory, older adults need to find and accept the meaningfulness of their lives, or they may become depressed, angry, and fear death. Reminiscing contributes to successful adaptation by maintaining self-esteem, reaffirming identity, and working through losses. Eliopoulos, C. (2009). Gerontological nursing (7th ed.). Philadelphia: Lippincott Williams & Wilkins. Christensen, B., & Kockrow, E. (2010). Foundations of nursing and adult health nursing (6th ed.). St. Louis, MO: Mosby. Ref # 554 A preterm baby develops nasal flaring, cyanosis and diminished breath sounds on one side of the chest wall. The health care provider's diagnosis is spontaneous pneumothorax. Which should the nurse prepare for first? A. cardiopulmonary resuscitation B. oxygen therapy C. insertion of a chest tube D. assisted ventilation Answers Correct C Student's C Review Information: The correct answer is C: insertion of a chest tube Learning Objective: Lesson 8 Physiological Adaptation Because a portion of the lung has collapsed, a chest tube will be inserted to restore negative pressure in the chest cavity. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 539 A client with spinal cord injury at the C-6 level complains of a pounding headache. The blood pressure is 180/120. A nurse should take which actions first? A. place the client into a sitting position B. check the urinary catheter tubing for kinking Answers Correct B Student's A C. ask the registered nurse (RN) to assess the client D. evaluate the client for nuchal rigidity Review Information: The correct answer is B: check the urinary catheter tubing for kinking Learning Objective: Lesson 8 Physiological Adaptation A distended bladder or bowel is the most common cause of autonomic dysreflexia. A sitting position will not resolve the problem. Nuchal rigidity is associated with meningitis or a cerebral bleed, not autonomic dysreflexia. Test-taking Tips: The key to this question is to identify that data collection is the first action to be done. Two options have the data collection words “check and evaluate.” Ask: which option, distended bladder/urine retention or a stiff neck, is associated with the content in the stem: pounding headache and hypertension? LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ramont, R.P., & Niedringhaus, D.M. (2007). Fundamental nursing care (2nd ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 791 A nurse should know that the most precise noninvasive oxygen delivery system available is which item? A. the venturi mask B. simple face mask C. partial non-rebreather mask D. nasal cannula Answers Correct A Student's A Review Information: The correct answer is A: the venturi mask Learning Objective: Lesson 7 Reduction of Risk Potential The most precise way to deliver oxygen to the client is through a venturi system such as the venti mask. The venti mask is a high flow device that entrains room air into a reservoir device on the mask and mixes the room air with 100% oxygen. The size of the opening to the reservoir determines the concentration of oxygen. The client’s respiratory rate and respiratory pattern do not affect the concentration of oxygen delivered. The maximum amount of oxygen that can be delivered by this system is 55%. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 813 A nurse collects data on several postpartum women in the clinic. Which woman is at highest risk for puerperal infection? A. Two days postpartum, temperature is 100 F (37.8 C) this morning B. Five days postpartum, temperature is 99.6 F (37.6 C) since delivery Answers Correct D Student's D C. Seven days postpartum, temperature is 99 F (37.2 C) since delivery D. Three days postpartum, temperature is 100.8 F (38.2 C) the past two days Review Information: The correct answer is D: Three days postpartum, temperature is 100.8 F (38.2 C) the past two days Learning Objective: Lesson 7 Reduction of Risk Potential A temperature of 100.4 F (38 C) or higher on two successive days, not counting the initial 24 hours after birth, indicates a postpartum infection. The other women are not at risk for infection because their temperatures are within the expected normal findings for the time period. Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Lowdermilk, D., & Perry, S. (2007). Maternity & women's health care (9th ed.). St. Louis, MO: Mosby. Ref # 570 A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 liters/minute. Postoperatively the client is complaining of chest tightness. The peak flow is now 200 liters/minute. What should a nurse do first? A. repeat the peak flow reading in 30 minutes B. apply oxygen at 2 liters per nasal cannula C. notify the registered nurse (RN) D. administer the prn dose of Albuterol Answers Correct D Student's D Review Information: The correct answer is D: administer the prn dose of Albuterol Learning Objective: Lesson 6 Pharmacological Therapies Peak flow monitoring during exacerbations of asthma is recommended for clients with moderate-to-severe persistent asthma to determine the severity of the exacerbation and to guide the treatment. A peak flow reading of less than 50% of the client's baseline reading is a medical alert condition and a short-acting beta-agonist should be taken immediately. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 557 A nurse is assisting in the discharge of a client diagnosed with benign prostatic hypertrophy. Which statement by the client demonstrates an understanding of the condition? A. "I will expect to urinate frequently throughout the day." B. "I should expect my urine to be dark and concentrated." Answers Correct A Student's A C. "I should restrict my fluid intake to control the frequency of urination." D. "Pain with urination should be expected for a few weeks." Review Information: The correct answer is A: "I will expect to urinate frequently throughout the day." Learning Objective: Lesson 8 Physiological Adaptation Clients with benign prostatic hypertrophy have overflow incontinence with frequent urination in small amounts day and night. Test-taking Tips: The key words in this question are “benign prostatic hypertrophy.” Think about the anatomy of what the problem is. Two of the options would be abnormal for this condition. Ask: would I restrict fluid with this condition? Use common sense to answer “no.” When renal type problems occur, fluid restriction is unlikely. By process of elimination, one option is left as the only one that is associated with this condition. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Timby, B., & Smith, N. (2010). Introductory medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ref # 920 A teenager is admitted with the diagnosis of anorexia nervosa. Upon admission, a nurse finds a bottle of assorted pills in the client’s drawer. The client tells the nurse "those are antacids for stomach pains." How should the nurse respond? A. "Are you taking different pills to lose weight?" B. "Tell me more about the different pills." C. "Some teenagers use herbs to lose or maintain a certain weight." D. "Tell me about yourself." Answers Correct D Student's A Review Information: The correct answer is D: "Tell me about yourself." Learning Objective: Lesson 4 Psychosocial Integrity Asking clients to tell something about themselves is an open-ended statement that allows them to direct the conversation. It is non-threatening and allows for further discussion and exploration of the client's feelings and behaviors prior to hospitalization. This is the best way to establish trust for the initial step of the nurse-client relationship. The nurse should eventually ask about the pills (and remove them from this client's drawer). Townsend, M., & Pedersen, D. (2008). Psychiatric mental health nursing: Concepts of care in evidencebased practice (6th ed.). Philadelphia: F.A. Davis Company. Keltner, N.L., Bostrom, C.E., & Schwecke, L.H. (2006). Psychiatric nursing (5th ed.). St. Louis, MO: Mosby. Ref # 922 A 12 year-old child, admitted with a broken arm, is waiting for a scheduled surgery. The nurse finds the child crying and unwilling to talk. What would be the most appropriate INITIAL response by the nurse? Answers Correct A Student's A A. Provide privacy with encouragement to work through feelings B. Distract the child with a choice of activities to do while waiting for surgery C. Make arrangements for friends to visit as soon as possible D. Reassure the child that the surgery will go fine with no problems Review Information: The correct answer is A: Provide privacy with encouragement to work through feelings Learning Objective: Lesson 4 Psychosocial Integrity A 12 year-old child needs the opportunity to express emotions privately. Distraction is best when used for a toddler or a child younger than 4 years old. Regardless of age, no one should be reassured that everything will be okay. It would be appropriate for friends to visit after the surgery. Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Morrison-Valfre, M. (2008). Foundations of mental health care (4th ed.). St. Louis, MO: Mosby Ref # 4459 The provider ordered 500 mg erythromycin oral suspension every six hours for a client diagnosed with pneumonia. The client has a gastrostomy tube. The pharmacy sends up the medication in a liquid suspension of 250 mg/5 mL. How much medication will the nurse administer every 6 hours? mL. Answers Correct 10 Student's 8 Review Information: The correct answer is 10 Learning Objective: Lesson 6 250 mg/5 mL = 500 mg/X mL 250x = 2500 x = 2500/250 = 10 mL Ref # 802 A pregnant woman in the third trimester is admitted with a report of painless vaginal bleeding over the last several hours. A nurse should prepare this client for what procedure? A. non-stress test B. pelvic exam C. C-section D. abdominal ultrasound Answers Correct D Student's D Review Information: The correct answer is D: abdominal ultrasound Learning Objective: Lesson 7 Reduction of Risk Potential The standard for the diagnosis of placenta previa, which is suggested in the client's complaints, is an abdominal ultrasound. Ricci, S.S. (2008). Essentials of maternity, newborn, and women's health nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Lowdermilk, D., & Perry, S. (2007). Maternity & women's health care (9th ed.). St. Louis, MO: Mosby. Ref # 550 During a check of a newborn from a mother with a history of type 1 diabetes mellitus, the nurse should understand that any hypoglycemia in the newborn is related to which factor? A. pancreatic insufficiency of the newborn B. maternal insulin dependency C. reduced glycogen reserves in the newborn D. disruption of fetal glucose supply after delivery Answers Correct D Student's D Review Information: The correct answer is D: disruption of fetal glucose supply after delivery Learning Objective: Lesson 3 Health Promotion and Maintenance After delivery, the high glucose levels which crossed the placenta to the fetus are suddenly stopped. The newborn continues to secrete insulin in anticipation of glucose. When oral feedings begin, the newborn will adjust insulin production within a day or two. Test-taking Tips: Note that the big clue is that the answer to this question has to be about the newborn, not the mother. Remember to "read the question." Many times it is also helpful to rephrase the question. In this case “hypoglycemia in the newborn is related to?” Leifer, G. (2007). Maternity nursing: An introductory text (10th ed.). Philadelphia: Saunders. Towle, M.A., & Adams, E.D. (2007). Maternal-child nursing care. Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 835 Which action should a nurse implement to prepare a client for a kidney, ureter, bladder (KUB) radiographic test? Answers Correct A Student's C A. take no special interventions for this examination B. keep the client NPO before the examination for two hours C. administer an enema 24 hours prior to the examination D. plan to give Demerol 25 mg IM 30 minutes prior to the test Review Information: The correct answer is A: take no special interventions for this examination Learning Objective: Lesson 7 Reduction of Risk Potential No special preparation is necessary for this examination. Test-taking Tips: Note that two of the options are GI options, which differ from the renal content in the stem of the question. Also note that one option speaks to narcotic analgesia, whereas the test mentioned in the question is neither an invasive nor painful procedure. It is a radiographic test which is a simple x-ray. Pagana, K.D., & Pagana, T.J. (2008). Mosby's diagnostic and laboratory test reference (9th ed.). St.Louis, MO: Mosby. Christensen, B., & Kockrow, E. (2010). Foundations of nursing and adult health nursing (6th ed.). St. Louis: Mosby. Ref # 589 A nurse is assisting with a pre-kindergarten history and physical on a five year-old child. The last MMR vaccine needs to be administered. Allergy to which substance would require the nurse to hold this vaccine for the child? A. strawberries B. peanut butter C. gelatin D. chocolate Answers Correct C Student's C Review Information: The correct answer is C: gelatin Learning Objective: Lesson 6 Pharmacological Therapies Allergic reactions to the MMR vaccine are much more likely to be due to the gelatin in the vaccine. Individuals with anaphylactic reactions to neomycin or gelatin should not receive this vaccine. It has been determined that the MMR vaccine does not contain significant amounts of egg protein, and can be safely given to children with true allergy to eggs. However, it is recommended that these children are monitored for at least 90 minutes in the office after the injection and to have resuscitation equipment and epinephrine available. Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2011. St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Ref # 537 Which finding would a nurse expect in a client in the late stages of amyotrophic lateral sclerosis (ALS)? A. tonic-clonic seizures B. confusion C. shallow respirations Answers Correct C Student's B D. loss of half of visual field Review Information: The correct answer is C: shallow respirations Learning Objective: Lesson 8 Physiological Adaptation ALS is a chronic progressive disease that results in loss of voluntary and involuntary muscular function with outcomes of muscular weakness. When the intercostal muscles and diaphragm become involved, the respirations become shallow and coughing is often ineffective. Confusion may occur if the client is hypoxic, but this is not an expected finding. Seizures and visual field disturbances are also not expected findings. Test-taking Tips: The key here is that the question being asked is to identify an “expected finding” with "late" ALS. This is a specific question and requires a specific answer. Three options are neither specific nor expected of the content (ALS) in this question. Only one option focuses on muscular weakness, which would be more of an expected finding. This answer refers to a weakening of the respiratory muscles. Black, J., & Hawks, J. (2008). Medical surgical nursing: Clinical management for positive outcomes (8th ed.). St. Louis, MO: Mosby. LeMone, P., & Burke, K.M. (2007). Medical-surgical nursing: Critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. 09/26/2018 08:23:32 PM Exam-25 Completed Question: 1 Correct Answer: 4 The nurse is assigned to care for 4 clients. Which client should the nurse assess first? 1. A client who has a tympanic temperature of 99.8°F 2. A client who has a regular radial pulse of 96 beats/minute 3. A client who has a supine resting blood pressure of 148/90 mm Hg 4. A client who has a peripheral (index finger) oxygen saturation percentage of 85% Question: 2 Correct Answer:4 The nurse is performing an assessment of a 7-year-old child who is suspected of having episodes of absence seizures. Which assessment question to the mother will assist in providing information that will identify the symptoms associated with this type of seizure? 1. "Does twitching occur in the face and neck?" 2. "Does the muscle twitching occur on one side of the body?" 3. "Does the muscle twitching occur on both sides of the body?" 4. "Does the child have a blank expression during these episodes?" Question: 3 Correct Answer: 3 The nurse has a prescription to administer diazepam 5 mg by the intravenous (IV) route to a client. The nurse should administer the medication over a period of at least how long? 1. 15 seconds 2. 30 seconds 3. 1 minute 4. 5 minutes Question: 4 Correct Answer: 1,2,3 A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply. 1. Broth 2. Coffee 3. Gelatin 4. Pudding 5. Vegetable juice 6. Pureed vegetables Question: 5 Correct Answer: 1 The nurse has provided home care instructions to a client after blepharoplasty. Which statement by the client indicates a need for further instruction? 1. "I need to keep ice on my eyes for at least 3 days." 2. "I need to avoid vigorous activities for about 1 month." 3. "I need to sleep on my back with at least 2 pillows under my head." 4. "I need to avoid activities requiring bending over at the waist for at least 48 hours." Question: 6 Correct Answer: 4 The nurse provided education about the tetanus toxoid and administered it to the client via injection after stepping on a nail while walking on the beach. Which statement by the client indicates successful teaching? 1. "The tetanus toxoid is caused by viruses." 2. "The tetanus toxoid is caused by parasites." 3. "The tetanus toxoid is an optional treatment so I really don't have to have this." 4. "The tetanus toxoid are toxins that have been altered so that they are no longer toxic." Question: 7 Correct Answer:3 The nurse is caring for a terminally ill client who is experiencing dyspnea. When caring for this client, the nurse should place the client in which position? 1. Prone 2. Supine 3. Lateral 4. Trendelenburg's Question: 8 Correct Answer: 3 The nurse is caring for a client with Addison's disease. The client asks the nurse about the risks associated with this disease, specifically about addisonian crisis. Regarding prevention of this complication, how should the nurse inform the client? 1. "You can take either hydrocortisone or fludrocortisone for replacement." 2. "You need to take your fludrocortisone 3 times a day to prevent a crisis." 3. "You need to increase salt in your diet, particularly during stressful situations." 4. "You need to decrease your dosages of glucocorticoids and mineralocorticoids during stressful situations." Question: 9 Correct Answer: 3 The nurse is performing an assessment on a client with suspected Paget's disease. On assessment the nurse would expect the client to report which as the most common symptom of this disease? 1. Tinnitus 2. Fatigue 3. Bone pain 4. Difficulty with ambulating Question: 10 Correct Answer: 4 The nurse is conducting a session about nutrition with a group of adolescents who are pregnant. Which measure is most appropriate to teach these adolescents? 1. Eat only when hungry. 2. Eliminate snacks during the day. 3. Avoid meals in fast-food restaurants. 4. Monitor for appropriate weight gain patterns. Question: 11 Correct Answer: 1 The nurse is caring for a client with a Penrose drain from an abdominal incision. Which is an appropriate nursing intervention for this client? 1. Ensure that a sterile safety pin is through the drain. 2. Measure the amount of drainage in a measuring container. 3. Establish that the drain is at the prescribed amount of suction. 4. Squeeze the suction device and close the port after emptying the drain. Question: 12 Correct Answer: 4 The nurse is caring for a client with a nasogastric tube connected to continuous suction. During assessment the nurse observes that the client is mouth-breathing, has dry mucous membranes, and has a foul breath odor. In planning care, which intervention would be most appropriate to maintain the integrity of this client's oral mucosa? 1. Offer small sips of water frequently. 2. Encourage the client to suck on sour hard candy. 3. Use lemon glycerin swabs to provide oral hygiene. 4. Brush the teeth frequently; use mouthwash and water. Question: 13 Correct Answer: 1 A registered nurse (RN) is supervising a licensed practical nurse (LPN) administering an intramuscular (IM) injection of iron to an assigned client. The RN would intervene if the LPN is observed performing which action? 1. Using a Z-track method for injection 2. Massaging the injection site after injection 3. Preparing an air lock when drawing up the medication 4. Changing the needle after drawing up the dose and before injection Question: 14 Correct Answer: 2 Lactulose is prescribed for a hospitalized client with a diagnosis of hepatic encephalopathy. Which assessment finding indicates that the client is responding to this medication therapy as anticipated? 1. Vomiting occurs. 2. The fecal pH is acidic. 3. The client experiences diarrhea. 4. The client is able to tolerate a full diet. Question: 15 Correct Answer: 2 The nurse is providing instructions to the parents of an infant with a ventriculoperitoneal shunt. The nurse should include which instruction? 1. Expect an increased urine output from the shunt. 2. Notify the health care provider if the infant is fussy. 3. Call the health care provider if the infant has a high-pitched cry. 4. Position the infant on the side of the shunt when the infant is put to bed. Question: 16 Correct Answer: 1 A child with an autism spectrum disorder (ASD) is being admitted to the hospital for diagnostic tests. Which room assignment is the most appropriate for the child? 1. Private room 2. Semiprivate room 3. 4-bed ward room 4. Contact isolation room Question: 17 Correct Answer: 1,4,5,6 The nurse is assisting in monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs). Before leaving the room, the nurse tells the client to immediately report which symptoms of a transfusion reaction? Select all that apply. 1. Chills 2. Fatigue 3. Sleepiness 4. Chest pain 5. Lower back pain 6. Difficulty breathing Question: 18 Correct Answer: 3 The nurse has conducted medication instructions with a client receiving lovastatin. Which periodic blood study will be necessary and included in the client's instructions? 1. Bleeding time 2. Blood glucose levels 3. Liver function studies 4. Complete blood cell count Question: 19 Correct Answer: 2 The client with gastroesophageal reflux disease (GERD) has a new prescription for pantoprazole. Which instruction should the nurse provide to the client? 1. Chew the pill thoroughly. 2. Swallow the tablet whole. 3. Headache is expected to occur. 4. Crush the pill if it is difficult to swallow. Question: 20 Correct Answer: 2 The nurse is providing discharge instructions to a client who has undergone treatment of cervical cancer with a radiation (cesium) implant. Which instruction should the nurse provide to the client? 1. Avoid douching for at least 1 year. 2. Use a vaginal dilator 3 times a week. 3. Sexual activity can be resumed in about 2 months. 4. Bed rest is recommended for at least 1 week after discharge. Question: 21 Correct Answer: 1 The health care provider (HCP) has written a prescription to start progressive ambulation as tolerated in a hospitalized client who experiences periods of confusion because of bed rest and prolonged confinement to the hospital room. Which nursing intervention would be appropriate when planning to implement the HCP's prescription and address the needs of the client? 1. Progressively ambulate the client in the hall three times daily. 2. Ambulate the client in the room for short distances frequently. 3. Ambulate the client to the bathroom in his or her room three times daily. 4. Assist with range-of-motion exercises three times daily to increase strength. Question: 22 Correct Answer: 1 The nurse is providing instructions for a client who will collect a stool specimen for an occult blood test. The nurse instructs the client that it is best to avoid which food for 3 days before collection of the stool specimen? 1. Turnips 2. Hard cheese 3. Milk products 4. Cottage cheese Question: 23 Correct Answer: 3 The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy? 1. Restrict all visitors. 2. Restrict fluid intake. 3. Teach the client and family about the need for hand hygiene. 4. Insert an indwelling urinary catheter to prevent skin breakdown. Question: 24 Correct Answer: 1,2,5 The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. 1. Maintain NPO (nothing by mouth) status. 2. Encourage coughing and deep breathing. 3. Give small, frequent high-calorie feedings. 4. Maintain the client in a supine and flat position. 5. Give hydromorphone intravenously as prescribed for pain. 6. Maintain intravenous fluids at 10 mL/hour to keep the vein open. Question: 25 Correct Answer: 3 The nurse is collecting data on a pregnant client in the first trimester of pregnancy diagnosed with iron deficiency anemia. The nurse should monitor the client to detect which manifestation indicating that this problem has not yet resolved? 1. Pink mucous membranes 2. Increased vaginal secretions 3. Complaints of daily headaches and fatigue 4. Complaints of increased frequency of voiding ORDER 09/26/2018 08:26:15 PM Exam-10 Completed Question: 26 Correct Answer: 2, 4, 3, 1, 5, 6 The nurse is preparing to suction the airway of a client who has a tracheostomy tube and gathers the supplies needed for the procedure. In order of priority, which actions should the nurse take to perform this procedure? Arrange the actions in the order that they should be performed. All options must be used. 1. Hyperoxygenate the client. 2. Place the client in a semi Fowler's position. 3. Attach the suction tubing to the suction catheter. 4. Turn on the suction device and set the regulator at 80 mm Hg. 5. Insert the catheter into the tracheostomy until resistance is met, and then pull it back 1 cm. 6. Apply intermittent suction and slowly withdraw the catheter while rotating it back and forth. Question: 27 Correct Answer: 5, 6, 2, 4, 3, 1 A client involved in a head-on automobile crash has awakened from a coma and asks for her husband, who was killed in the same accident. The family does not want the client to know at this time that her husband has died. The family wants all nursing staff to tell the client that the husband was taken by helicopter to another hospital, has a head injury, and is in the intensive care unit (ICU). Because the American Nurses Association Code of Ethics requires the nurse to preserve integrity, but the nurse wants to follow the family's instruction, the nurse faces an ethical dilemma. Which steps should the nurse take to systematically process this ethical dilemma? Arrange in order the steps for systematic processing of the ethical dilemma. All options must be used. 1. Evaluate the action. 2. Verbalize the problem. 3. Negotiate the outcome. 4. Consider possible courses of action. 5. Gather all information relevant to the case 6. Examine and determine one's own values on the issues Question: 28 Correct Answer: 1, 3, 2, 4 The nurse is caring for a client diagnosed with cirrhosis of the liver with portal hypertension. The client vomited 500 mL bright red emesis and states that he is feeling lightheaded. In which priority order should the nurse perform these interventions? Arrange the actions in the order they should be performed. All options must be used. 1. Apply oxygen. 2. Check the client's blood pressure. 3. Ensure that 2 large-bore intravenous lines are present with an isotonic solution infusing. 4. Ask the client if he is taking any nonsteroidal antiinflammatory medications. Question: 29 Correct Answer: 1, 4, 2, 3, 5, 6 A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, the nurse takes the following actions. Arrange the actions in the order they should be performed. All options must be used. 1. Raise the head of the bed 2. Check for bladder distention. 3. Contact the health care provider (HCP). 4. Loosen tight clothing on the client. 5. Administer an antihypertensive medication. 6. Document the occurrence, treatment, and response. Question: 30 Correct Answer: 3, 4, 1, 2, 5, 6 A hospitalized client with type 1 diabetes mellitus received Humulin N and Humulin R insulin 2 hours ago (at 7:30 a.m.). The client calls the nurse and reports that he is feeling hungry, shaky, and weak. The client ate breakfast at 8 a.m. and is due to eat lunch at noon. Arrange the actions that the nurse will take in the order that they should be performed. All options must be used. 1. Take the client's vital signs. 2. Retest the blood glucose level. 3. Check the client's blood glucose level. 4. Give the client . cup (118 mL) of fruit juice to drink. 5. Give the client a small snack of carbohydrate and protein. 6. Document the client's complaints, actions taken, and outcome. Question: 31 Correct Answer: 5, 3, 4, 2, 6, 1 A unit of packed red blood cells has been prescribed for a client with low hemoglobin and hematocrit typing and cross matching. The nurse receives a telephone call from the blood bank and is informed that the unit of blood is ready for administration. In order of priority, how should the nurse plan the actions to take? Arrange the actions in the order that they should be performed. All options must be used. 1. Hang the bag of blood. 2. Obtain the unit of blood from the blood bank. 3. Ensure that an informed consent has been signed. 4. Insert an 18- or 19-gauge intravenous catheter into the client. 5. Verify the health care provider's (HCP's) prescription for the blood transfusion. 6. Ask a licensed nurse to assist in confirming vital signs and blood compatibility and verifying client identity. Question: 32 Correct Answer: 5, 2, 2, 1, 3, 6 A home health care nurse is planning client visits and nursing activities for the day. The nurse begins the visits at 9 a.m. All clients live within a 5-mile radius. In order of priority, how the nurse should plan the assignments for the day? Arrange the actions in the order that they should be performed. All options must be used. 1. A client requiring supervision of a dressing change 2. A client being visited by the home health aide at 1030 3. A client requiring an admission assessment to home health care 4. The first dressing change for a client requiring twice-daily dressing changes 5. A client with diabetes mellitus who needs a fasting blood glucose level drawn 6. The second dressing change for a client requiring twice-daily dressing changes Question: 33 Correct Answer: 2, 1, 5, 3, 4, 6 The nurse is monitoring a client in labor who is receiving oxytocin and notes that the client is experiencing hypertonic uterine contractions. In order of priority, how should the nurse plan the actions to take? Arrange the actions in the order that they should be performed. All options must be used. 1. Reposition the client. 2. Stop the oxytocin infusion. 3. Perform a vaginal examination. 4. Check the client's blood pressure. 5. Administer oxygen by face mask at 8 to 10 L/min 6. Administer medication as prescribed to reduce uterine activity Question: 34 Correct Answer: 2, 5, 3, 1, 4 A client has a prescription to begin an infusion of 1000 mL of 5% dextrose in lactated Ringer's solution. The client has an intravenous (IV) cannula inserted, and the nurse prepares the solution and IV tubing. Arrange the actions in the order that they should be performed. All options must be used. 1. Uncap the distal end of the tubing. 2. Close the roller clamp on the IV tubing. 3. Open the roller clamp and fill the tubing. 4. Attach the distal end of the tubing to the client. 5. Spike the IV bag and half-fill the drip chamber. Question: 35 Correct Answer: 1, 4, 6, 5, 3, 2 A mother brings her child to the emergency department. Based on the child's sitting position, drooling, and apparent respiratory distress, a diagnosis of epiglottitis is suspected. In anticipation of the health care provider's prescriptions, in which order of priority would the nurse implement the actions? Arrange the actions in the order that they should be performed. All options must be used. 1. Maintain a patent airway. 2. Administer an antipyretic. 3. Obtain an axillary temperature. 4. Assess breath sounds by auscultation. 5. Insert an intravenous line for fluid administration. 6. Obtain an oxygen saturation level using pulse oximetry. SATA 09/26/2018 08:28:41 PM Exam-25 Completed Question: 36 Correct Answer: 3, 5 The nurse is performing an assessment of a newborn admitted to the nursery after birth. On assessment of the newborn's head, what should the nurse anticipate to be the most likely findings related to the fontanels? Select all that apply. 1. A bulging anterior fontanel 2. A depressed anterior fontanel 3. A soft and flat anterior fontanel 4. A triangular-shaped anterior fontanel 5. A triangular-shaped posterior fontanel 6. Size of posterior fontanel is 4 cm by 6 cm Question: 37 Correct Answer:4, 5 A nursing student is preparing to instruct a pregnant client in performing Kegel exercises. The nursing instructor asks the student the purpose of Kegel exercises. Which response made by the student indicates an understanding of the purpose? Select all that apply. 1. "The exercises will help reduce backaches." 2. "The exercises will help prevent ankle edema." 3. "The exercises will help prevent urinary tract infections." 4. "The exercises will help strengthen the pelvic floor in preparation for delivery." 5. "The exercises will help strengthen the muscles that support the bladder and urethra." Question: 38 Correct Answer: 1, 2, 3, 5 The nurse is collecting data from a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings are associated with abruptio placentae? Select all that apply. 1. Uterine tenderness 2. Acute abdominal pain 3. A hard, "boardlike" abdomen 4. Painless, bright red vaginal bleeding 5. Increased uterine resting tone on fetal monitoring Question: 39 Correct Answer: 1, 2, 4, 6 Butorphanol tartrate by intravenous push is prescribed for a client in labor. The nurse recognizes which assessment findings to be side or adverse effects of this medication? Select all that apply. 1. Tinnitus 2. Syncope 3. Bradycardia 4. Palpitations 5. Increased thirst 6. Nausea and vomiting Question: 40 Correct Answer: 1, 2 , 5 The nurse is preparing a client with thrombocytopenia for discharge. Which statement by the client about measures minimizing injury indicates that discharge teaching was effective? Select all that apply. 1. "I may continue to use an electric shaver." 2. "I will not blow my nose if I get a cold." 3. "I should use an enema instead of laxatives for constipation." 4. "I definitely will play football with my friends this weekend." 5. "I should use a soft-bristled toothbrush to avoid mouth trauma." Question: 41 Correct Answer: 1, 2, 5 The nurse is monitoring a client receiving levothyroxine sodium for hypothyroidism. Which findings indicate the presence of a side effect associated with this medication? Select all that apply. 1. Insomnia 2. Weight loss 3. Bradycardia 4. Constipation 5. Mild heat intolerance Question: 42 Correct Answer: 1, 2, 4, 5 The nurse is working in an illness prevention clinic. An important component of the nurse's practice is to advise high-risk clients to receive an influenza vaccination. Which clients are at high risk for influenza and would benefit from vaccination? Select all that apply. 1. A 47-year-old mother of a child with cystic fibrosis 2. A 54-year-old man scheduled for a routine diabetes check 3. A 43-year-old factory worker with symptoms of influenza 4. A 35-year-old registered nurse scheduled for an annual pelvic exam 5. An 87-year-old woman from a nursing home scheduled for a surgical follow-up Question: 43 Correct Answer: 2, 3, 6 The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply. 1. Scarring is less severe in a child than in an adult. 2. A delay in growth may occur after a burn injury. 3. An immature immune system presents an increased risk of infection for infants and young children. 4. Fluid resuscitation is unnecessary unless the burned area is more than 25% of the total body surface area. 5. The lower proportion of body fluid to body mass in a child increases the risk of cardiovascular problems. 6. Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults. Question: 44 Correct Answer: 2, 3, 4, 6 Which are risk factors for chronic obstructive pulmonary disease (COPD)? Select all that apply. 1. Purified air 2. Cigarette smoking 3. Genetic risk factor 4. Environmental factors 5. Eating plenty of fruits and vegetables 6. Alpha-1 antitrypsin (AAT) deficiency Question: 45 Correct Answer: 4, 5 A 67-year-old man is receiving outpatient radiation treatments for carcinoma of the oropharynx and has developed dysphagia. The nurse develops a teaching plan regarding dysphagia and includes which interventions in the plan? Select all that apply. 1. Teach the man to speak slowly. 2. Teach the man to enunciate clearly. 3. Encourage the man to drink only thin liquids. 4. Teach the man to examine his oral mucosa daily. 5. Encourage the man to use artificial saliva to manage dryness. Question: 46 Correct Answer: 1, 2, 3 The nurse works with high-risk clients in an urban outpatient setting. Which groups should be tested for human immunodeficiency virus (HIV)? Select all that apply. 1. Injection drug abusers 2. Prostitutes and their clients 3. People with sexually transmitted infections (STIs) 4. People who have had frequent episodes of pneumonia 5. People who recently received a blood transfusion for a surgical procedure Question: 47 Correct Answer: 2, 3, 4 The nurse is administering mouth care to an unconscious client. The nurse should perform which actions in the care of this person? Select all that apply. 1. Use products that contain alcohol. 2. Position the client on his or her side. 3. Brush the teeth with a small, soft toothbrush. 4. Cleanse the mucous membranes with soft sponges. 5. Use lemon glycerin swabs when performing mouth care. Question: 48 Correct Answer: 1, 2, 4 The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. 1. The client is aphasic. 2. The client has weakness on the right side of the body. 3. The client has complete bilateral paralysis of the arms and legs. 4. The client has weakness on the right side of the face and tongue. 5. The client has lost the ability to move the right arm but is able to walk independently. 6. The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance. Question: 49 Correct Answer: 1, 2, 4 A client with a neurological problem is experiencing hyperthermia. Which measures would be appropriate for the nurse to use in trying to lower the client's body temperature? Select all that apply. 1. Giving tepid sponge baths 2. Applying a hypothermia blanket 3. Covering the client with blankets 4. Administering acetaminophen per protocol 5. Placing ice packs over the client's abdomen and in the axilla and groin Question: 50 Correct Answer:2, 3, 5 The nurse is preparing to provide care for a client who will need an ear irrigation to remove impacted cerumen. Which interventions should the nurse take when performing the irrigation? Select all that apply. 1. Apply some force when instilling the irrigation solution. 2. Position the client with the affected side down after the irrigation. 3. Warm the irrigating solution to a temperature that is close to body temperature. 4. Position the client to turn the head so that the ear to be irrigated is facing upward. 5. Direct a slow, steady stream of irrigation solution toward the upper wall of the ear canal. Question: 51 Correct Answer: 1, 2, 5 The nurse reviews the laboratory results for a child with rheumatic fever and would expect to note which findings? Select all that apply. 1. Elevated C-reactive protein 2. Elevated antistreptolysin O titer 3. Presence of Reed-Sternberg cell 4. Decreased erythrocyte sedimentation rate 5. Presence of group A beta-hemolytic strep Question: 52 Correct Answer: 1, 2, 3, 5 A 4-year-old child is diagnosed with otitis media. The mother asks the nurse about the causes of this illness. Which risk factors should the nurse include in response to this mother? Select all that apply. 1. Bottle-feeding 2. Household smoking 3. Exposure to illness in other children 4. A history of urinary tract infections 5. Congenital conditions such as cleft palate Question: 53 Correct Answer:2, 3, 5 A client who has had a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the nurse should take which actions? Select all that apply. 1. Giving the client thin liquids 2. Thickening liquids to the consistency of oatmeal 3. Placing food on the unaffected side of the mouth 4. Allowing plenty of time for chewing and swallowing 5. Leave the client alone so that the client will gain independence by feeding self Question: 54 Correct Answer: 2, 4, 5 Clients with which diagnoses are commonly prescribed interventions to manage anxiety? Select all that apply. 1. Dementia 2. Panic disorder 3. Multiple personality disorder 4. Posttraumatic stress disorder 5. Obsessive-compulsive disorder Question: 55 Correct Answer:1, 2, 4, 5 A client who has undergone radical neck dissection for a tumor has a potential problem of obstruction related to postoperative edema, drainage, and secretions. To promote adequate respiratory function in this client, the nurse should implement which activities? Select all that apply. 1. Suctioning the client as needed 2. Encouraging coughing every 2 hours 3. Placing the bed in low Fowler's position 4. Supporting the neck incision when the client coughs 5. Monitoring the respiratory status frequently as prescribed Question: 56 Correct Answer: 1, 2, 4 A client with acute kidney injury has a serum potassium level of 7.0 mEq/L (7.0 mmol/L). The nurse should plan which actions as a priority?Select all that apply. 1. Place the client on a cardiac monitor. 2. Notify the health care provider (HCP). 3. Put the client on NPO (nothing by mouth) status except for ice chips. 4. Review the client's medications to determine if any contain or retain potassium. 5. Allow an extra 500 mL of intravenous fluid intake to dilute the electrolyte concentration. Question: 57 Correct Answer: 2, 3, 4, 5 A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. Which are interventions to aid the client in relieving the spasm? Select all that apply. 1. Ice 2. Heat 3. Analgesics 4. Muscle relaxers 5. Intermittent traction Question: 58 Correct Answer: 2, 5 A nursing instructor asks a nursing student to describe the process of quickening. Which statements by the student indicate an understanding of this term? Select all that apply. 1. "It is the thinning of the lower uterine segment." 2. "It is the fetal movement that is felt by the mother." 3. "It is irregular, painless contractions that occur throughout pregnancy." 4. "It is the soft blowing sound that can be heard when the uterus is auscultated." 5. "It is a process that occurs in the pregnant woman as early as 16 weeks but definitely by week 20." Question: 59 Correct Answer: 1, 3, 5 Which assessments should the nurse closely monitor when caring for a hospitalized client diagnosed with bulimia nervosa? Select all that apply. 1. Electrolyte levels 2. Exercise patterns 3. Intake and output 4. Pupillary response 5. Elimination patterns 6. Deep tendon reflexes Question: 60 Correct Answer: 2, 3, 4, 5 Which tasks should the registered nurse (RN) delegate to the licensed practical nurse (LPN)? Select all that apply. 1. Assessment 2. Urinary catheterization 3. Endotracheal suctioning 4. Intramuscular medication administration 5. Subcutaneous medication administration 6. Intravenous push medication administration CLIENT NEED 09/26/2018 08:38:50 PM Exam-50 Completed Question: 61 Correct Answer: 1 A nurse is caring for a client with a diagnosis of hyperthyroidism. Laboratory studies are performed and the serum calcium level is 12.0 mg/dL (3 mmol/L). Which medication should the nurse anticipate to be prescribed for the client? 1. Calcitonin 2. Calcium chloride 3. Calcium gluconate 4. Large doses of vitamin D Question: 62 Correct Answer: 2 A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which intravenous (IV) solution from the IV storage area to hang with the blood product at the client's bedside? 1. Lactated Ringer's 2. 0.9% sodium chloride 3. 5% dextrose in 0.9% sodium chloride 4. 5% dextrose in 0.45% sodium chloride Question: 63 Correct Answer: 3 On assessment during a well-baby visit, the nurse notes that a 6-month- old infant has crossed eyes. Which interpretation would the nurse make based on this finding? 1. The condition will resolve without treatment. 2. The condition is normal up to the age of 2 years. 3. Surgical intervention may be necessary to realign weak eye muscles. 4. Once the child begins to read, eye muscles strengthen and the condition will resolve. Question: 64 Correct Answer:3 The nurse is planning care for a client returning to the nursing unit after a bone biopsy. Which nursing action would be contraindicated in the postprocedure care for this client? 1. Monitor vital signs. 2. Administer oral analgesics as needed. 3. Place the limb in a dependent position for 24 hours. 4. Monitor biopsy site for swelling, bleeding, or hematoma. Question: 65 Correct Answer: 3 An adult female client has a hemoglobin level of 10.8 g/dL (108 mmol/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history? 1. Dehydration 2. Heart failure 3. Iron deficiency anemia 4. Chronic obstructive pulmonary disease Question: 66 Correct Answer: 2 The community nurse is conducting a health promotion program, and the topic of the discussion relates to the risk factors for gastric cancer. Which item, if identified as a risk factor by a client, indicates a need for further discussion? 1. Smoking 2. A low-fat diet 3. Foods containing nitrates 4. A diet of smoked, highly salted, and spiced foods Question: 67 Correct Answer: 4 The nurse is providing instructions to the client with trigeminal neuralgia regarding measures to take to prevent the episodes of pain. Which should the nurse instruct the client to do? 1. Prevent stressful situations. 2. Avoid activities that may cause fatigue. 3. Avoid contact with people with an infection. 4. Avoid activities that may cause pressure near the face. Question: 68 Correct Answer: 3 The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client? 1. Roast pork 2. Cheese omelet 3. Pasta with sauce 4. Tuna fish sandwich Question: 69 Correct Answer: 1 The nurse administers 20 units of insulin isophane recombinant to a hospitalized client with diabetes mellitus at 7:00 a.m. The nurse should monitor the client most closely for a hypoglycemic reaction at which time? 1. 4:00 p.m. 2. 9:00 a.m. 3. 10:00 a.m. 4. 12:00 midnight Question: 70 Correct Answer: 2 Diagnostic studies are prescribed for a client with suspected Paget's disease. In reviewing the client's record, the nurse would expect to note that the health care provider has prescribed which laboratory study? 1. Platelet count 2. Alkaline phosphatase 3. White blood cell count 4. Complete blood cell count Question: 71 Correct Answer: 3 The nurse is preparing the client assignment. Which should be assigned to a licensed practical nurse (LPN)? 1. A client who requires teaching about an insulin pump 2. Completing an admission assessment on a newly admitted client 3. Administration of a new oral medication to a client with Alzheimer's disease 4. An assessment of a client whose pulse oximetry reading is 85% and who is having difficulty breathing Question: 72 Correct Answer: 2 The nurse creates a plan of care for a client with a cervical-uterine radiation implant. Which intervention would be appropriate for the nurse to include in the plan? 1. Restrict all visitors. 2. Place a lead shield at the bedside. 3. Keep the client's room door open. 4. Place the client in a semi-private room. Question: 73 Correct Answer: 2 The nurse would anticipate that the health care provider (HCP) would add which medication to the regimen of the client receiving isoniazid? 1. Niacin 2. Pyridoxine 3. Gabapentin 4. Cyanocobalamin Question: 74 Correct Answer: 3 The health care provider writes a prescription to apply a heating pad to a client's back. Which intervention is contraindicated and is unsafe? 1. Setting the heating pad on a low setting 2. Assessing the skin frequently for burns 3. Placing the heating pad under the client 4. Using tape to hold heating pad in place Question: 75 Correct Answer: 4 The nurse is creating a plan of care for a newborn diagnosed with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care? 1. Allow the newborn to establish own sleep-rest pattern. 2. Maintain the newborn in a brightly lighted area of the nursery. 3. Encourage frequent handling of the newborn by staff and parents. 4. Monitor the newborn's response to feedings and weight gain pattern. Question: 76 Correct Answer: 1 A client is receiving phenobarbital sodium. Which finding on the nursing assessment would indicate that the client is experiencing a common side or adverse effect of this medication? 1. Drowsiness 2. Hypocalcemia 3. Blurred vision 4. Seizure activity Question: 77 Correct Answer: 4 The nurse is preparing a client who is scheduled to undergo cerebral angiography. The nurse should assess the client for which finding? 1. Claustrophobia 2. Excessive weight 3. Allergy to salmon 4. Allergy to iodine or shellfish Question: 78 Correct Answer: 4 Vasopressin is prescribed for a client with diabetes insipidus. The nurse should be particularly cautious in monitoring a client receiving this medication if the client has which preexisting condition? 1. Depression 2. Endometriosis 3. Pheochromocytoma 4. Coronary artery disease Question: 79 Correct Answer: 2 The nurse is reviewing the results of the electrolyte panel for a client seen in the health care clinic. The nurse determines that the client's potassium level is normal if which value is noted? 1. 2.0 mEq/L (2.0 mmol/L) 2. 4.0 mEq/L (4.0 mmol/L) 3. 5.3 mEq/L (5.3 mmol/L) 4. 6.0 mEq/L (6.0 mmol/L) Question: 80 Correct Answer: 2 A client with a burn injury is applying mafenide acetate cream to the wound. The client calls the health care provider's (HCP's) office and tells the nurse that the medication is uncomfortable and is causing a burning sensation. The nurse should instruct the client to take which action? 1. Discontinue the medication. 2. Continue with the treatment, as this is expected. 3. Apply a thinner film than prescribed to the burn site. 4. Come to the office to see the HCP immediately. Question: 81 Correct Answer: 1 The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention? 1. Notify the health care provider (HCP). 2. Administer the prescribed pain medication. 3. Call and ask the operating room team to perform surgery as soon as possible. 4. Reposition the client and apply a heating pad on the warm setting to the client's abdomen. Question: 82 Correct Answer: 3 The nurse is reviewing the laboratory test results for a client and notes that the differential white blood cell (WBC) count indicates a shift to the right. The nurse suspects that the client's diagnosis is most likely to be which one? 1. Sepsis 2. Pneumonia 3. Pernicious anemia 4. Coronary artery disease Question: 83 Correct Answer: 2 The nurse evaluates that the family of a client newly diagnosed with diabetes mellitus correctly understands the reason for having glucagon on hand for emergency home use if the family indicates that the purpose of the medication is to treat which complication? 1. Diabetic ketoacidosis 2. Hypoglycemia from insulin overdose 3. Hyperglycemia from insufficient insulin 4. Hyperglycemia occurring on "sick days" Question: 84 Correct Answer: 2 The ambulatory care nurse is preparing a client who is scheduled for a liver biopsy. The nurse reviews the client's record and expects to note which laboratory results documented in the client's chart? 1. Uric acid level 2. Prothrombin time 3. Blood urea nitrogen 4. White blood cell count Question: 85 Correct Answer: 2 The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the blood urea nitrogen (BUN) level is normal if which value is noted on the laboratory report? 1. 4 mg/dL (1.4 mmol/L) 2. 20 mg/dL (7.1 mmol/L) 3. 30 mg/dL (10.7 mmol/L) 4. 39 mg/dL (14.0 mmol/L) Question: 86 Correct Answer: 1 The nurse is caring for a client with a chest tube drainage system. During repositioning of the client, the chest tube accidentally pulls out of the pleural cavity. Which is the initial nursing action? 1. Apply an occlusive dressing. 2. Reinsert the chest tube quickly. 3. Contact the respiratory therapist. 4. Contact the health care provider (HCP). Question: 87 Correct Answer: 2 The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem? 1. Lack of knowledge 2. Inadequate fluid volume 3. Compromised family coping 4. Inadequate consumption of nutrients Question: 88 Correct Answer: 4 A client is being discharged on warfarin sodium, and the nurse provides instructions to the client regarding the medication. Which statement, if made by the client, indicates to the nurse that the client understands the teaching provided? 1. "I'll stop my medication if I see bruising." 2. "Stiff joints are common while taking warfarin." 3. "This medication will prevent me from having a stroke." 4. "If I notice blood-tinged urine, I will call the health care provider." Question: 89 Correct Answer: 2 The nurse is caring for an infant with a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, the nurse should plan which intervention? 1. Cover the bladder with petroleum jelly gauze. 2. Cover the bladder with a nonadhering plastic wrap. 3. Apply sterile distilled water dressings over the bladder mucosa. 4. Keep the bladder tissue dry by covering it with dry sterile gauze. Question: 90 Correct Answer: 4 What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session? 1. Ask the client to leave the group for this session only. 2. Refer the client to another group that includes other manic clients. 3. Tell the client to stop monopolizing in a firm but compassionate manner. 4. Thank the client for the input, but inform the client that others now need a chance to contribute. Question: 91 Correct Answer: 2 The nurse is providing a health promotion session to a group of teenagers and is discussing the abuse of barbiturates. The nurse should provide which information to the teenagers? 1. Barbiturate use commonly results in a rush of energy. 2. Barbiturate abuse is the cause of many drug overdose deaths. 3. The primary outcome of barbiturate abuse is psychological dependency. 4. A dangerous increase in blood pressure (BP) occurs with barbiturate abuse. Question: 92 Correct Answer:1 The home care nurse provides instructions regarding basic infection control to the parent of an infant with human immunodeficiency virus (HIV) infection. Which statement, if made by the parent, indicates the need for further instruction? 1. "I will clean up any spills from the diaper with diluted alcohol." 2. "I will wash baby bottles, nipples, and pacifiers in the dishwasher." 3. "I will be sure to prepare foods that are high in calories and high in protein." 4. "I will be sure to wash my hands carefully before and after caring for my infant." Question: 93 Correct Answer: 4 The nurse in an ambulatory clinic is preparing to administer a tuberculin skin test to a client who may have been exposed to a person with tuberculosis (TB). The client reports having received the bacillus Calmette-Guerin (BCG) vaccine before moving to the United States from a foreign country. Which interpretation should the nurse make? 1. The client has no risk of acquiring TB and needs no further workup. 2. The client is at increased risk for acquiring TB and needs immediate medication therapy. 3. The client's test result will be negative, and a sputum culture will be required for diagnosis. 4. The client's test result will be positive, and a chest x-ray study will be required for evaluation. Question: 94 Correct Answer: 4 The registered nurse (RN) is educating a new RN on how to interpret vision tests using a Snellen chart. After the client's vision is tested with a Snellen chart, the results of testing are documented as 20/40. Which statement by the new RN indicates that the teaching has been effective? 1. "The client's vision is normal, but the client may require reading glasses." 2. "The client is legally blind, and glasses or contact lenses will not be helpful." 3. "The client can read at a distance of 40 feet (12 meters) what a person with normal vision can read at 20 feet (6 meters)." 4. "The client can read at a distance of 20 feet (6 meters) what a person with normal vision can read at 40 feet (12 meters)." Question: 95 Correct Answer: 3 A nursing student is asked about the procedure used to elicit Homans' sign. Which response by the student indicates an understanding of this assessment technique? 1. "I will ask the client to raise the legs up to the waist and then to lower the legs slowly." 2. "I will ask the client to raise the legs and to try to lower them against pressure from my hand." 3. "I will ask the client to extend the legs flat on the bed, and I will gently dorsiflex the foot forward." 4. "I will ask the client to extend the legs flat on the bed, and I will grasp the foot and sharply extend it backward." Question: 96 Correct Answer: 1, 3, 4 A child diagnosed with scarlet fever is being cared for at home. The home health nurse performs an assessment on the child and checks for which clinical manifestations of this disease? Select all that apply. 1. Pastia's sign 2. Koplik's spots 3. White strawberry tongue 4. Edematous and beefy-red pharynx 5. Petechial red, pinpoint spots on the soft palate 6. Small red spots with a bluish-white center and a red base located on the buccal mucosa Question: 97 Correct Answer: 4 A hospitalized client has a diagnosis of pelvic inflammatory disease (PID). The nurse should encourage the client to assume which therapeutic position when in bed? 1. Left side-lying 2. Right side-lying 3. Prone with the head flat 4. Supine in semi Fowler's Question: 98 Correct Answer: 4 The oncology nurse specialist provides an educational session for nursing staff regarding the characteristics of Hodgkin's disease. The nurse determines that further teaching is needed if a nursing staff member states that which is a characteristic of the disease? 1. Reed-Sternberg cells are present. 2. The lymph nodes, spleen, and liver are involved. 3. The prognosis depends on the stage of the disease. 4. The disease occurs most often in those older than 75 years of age. Question: 99 Correct Answer: 4 A homeless client comes to the emergency department complaining of severe pain in the toes of both feet. On assessment, it is found that all of the toes are black in color and that amputation is necessary. The client refuses the surgery and insists on returning to street living. Which describes the next appropriate action to take? 1. Obtain a court order for the surgical procedure. 2. Restrain the client and transport to the operating room for surgery. 3. Call the police to identify the client and to arrest the client until permission for surgery is granted. 4. Discuss the surgical procedure and its purpose with the client, and encourage the client to talk about concerns and feelings. Question: 100 Correct Answer: 3 A client received 20 units of Humulin N insulin subcutaneously at 08:00. At what time should the nurse plan to assess the client for a hypoglycemic reaction? 1. 10:00 2. 11:00 3. 17:00 4. 24:00 Question: 101 Correct Answer: 2 The clinic nurse is reviewing the record of a client scheduled to be seen in the clinic. The nurse notes that the client is taking selegiline hydrochloride. The nurse suspects that the client has which disorder? 1. Diabetes mellitus 2. Parkinson's disease 3. Alzheimer's disease 4. Coronary artery disease Question: 102 Correct Answer: 2 A topical corticosteroid is prescribed for an infant with dermatitis in the gluteal area. The nurse provides instructions to the mother regarding the use of the medication. Which statement by the mother indicates an understanding of the use of the medication? 1. "I should not rub the medication into the skin." 2. "The medication will help relieve the inflammation." 3. "I need to apply the medication in a thick layer to protect the skin." 4. "I should protect the area by covering it with a diaper and plastic pants." Question: 103 Correct Answer: 1, 3, 6 The nurse is caring for a client with acute back pain. Which are the most likely causes of this problem? Select all that apply. 1. Twisting of the spine 2. Curvature of the spine 3. Hyperflexion of the spine 4. Sciatic nerve inflammation 5. Degeneration of the facet joints 6. Herniation of an intervertebral disk Question: 104 Correct Answer: Correct Answer: 600 mL The nurse hangs a 1000-mL intravenous (IV) bag of 5% dextrose in water (D5W) at 0700. The IV solution is to infuse at 80 mL/hour. At 1200, how much solution will be left to infuse? Fill in the blank. The nurse hangs a 1000-mL intravenous (IV) bag of 5% dextrose in water (D5W) at 0700. The IV solution is to infuse at 80 mL/hour. At 1200, how much solution will be left to infuse? Fill in the blank. Question: 105 Correct Answer: 1 A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide? 1. 3.2 mEq/L (3.2 mmol/L) 2. 3.8 mEq/L (3.8 mmol/L) 3. 4.2 mEq/L (4.2 mmol/L) 4. 4.8 mEq/L (4.8 mmol/L) Question: 106 Correct Answer: 3 During a home care visit, an adult client complains of chronic constipation. What should the nurse tell the client to do? 5. Increase potassium in the diet. 6. Include rice and bananas in the diet. 7. Increase fluid and dietary fiber intake. 8. Increase the intake of sugar-free products. Question: 107 Correct Answer: 3 The nurse is assessing a client with fragile X syndrome. The nurse anticipates noting which physical assessment finding? 1. Low, straight palate 2. Short, narrow protruding ears 3. Long, narrow face with a prominent jaw 4. Short, rounded face with an indiscernible jaw Question: 108 Correct Answer: 3 The nurse provides instructions to a malnourished client regarding iron supplementation during pregnancy. Which statement, if made by the client, indicates an understanding of the instructions? 1. "Iron supplements will give me diarrhea." 2. "Meat does not provide iron and should be avoided." 3. "The iron is best absorbed if taken on an empty stomach." 4. "My body has all of the iron it needs, and I don't need to take supplements." Question: 109 Correct Answer: 2,4,5 The client questions the nurse as to why the health care provider switched the usual prescription from a metered-dose inhaler (MDI) to a dry powder inhaler (DPI). The nurse should respond correctly by providing which facts? Select all that apply. 1. Dry powder inhalers have fewer side effects. 2. Dry powder inhalers pose no environmental risks. 3. Dry powder inhalers can be administered more frequently. 4. Dry powder inhalers deliver more medication to the lungs. 5. Dry powder inhalers require less hand-to-lung coordination. Question: 110 Correct Answer: 1 The nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. The nurse immediately applies sterile gauze over the chest tube insertion site. Which is the nurse's next action? 1. Call the health care provider. 2. Replace the chest tube system. 3. Obtain a pulse oximetry reading. 4. Place the client in a Trendelenburg's position. PHARM 09/26/2018 08:46:51 PM Exam-25 Completed Question: 111 Correct Answer: 3 A client receiving long-term therapy with lithium carbonate has a serum lithium level of 1.0 mEq/L. Which nursing intervention should the nurse be prepared to implement based on this result? 1. Monitor the client for signs of coarse hand tremors. 2. Assess the client for possible short-term memory loss. 3. Provide positive support for the client's compliance with the therapy. 4. Educate the client regarding risk for injury associated with drowsiness. Question: 112 Correct Answer: 4 A client who has begun taking betaxolol demonstrates an effective response to the medication as indicated by which nursing assessment finding? 1. Increase in edema to 3+ 2. Weight gain of 5 pounds 3. Decrease in pulse rate from 74 beats/min to 58 beats/min 4. Decrease in blood pressure from 142/94 mm Hg to 128/82 mm Hg Question: 113 Correct Answer: 2 A client is prescribed imipramine once daily. The nurse determines that additional teaching is needed on the basis of which statement by the client? 1. "I need to avoid alcohol while taking this medication." 2. "I'll take the medication in the morning before breakfast." 3. "I won't notice any medication effects for at least 2 weeks." 4. "I'll be sure to take a missed medication dose as soon as possible unless it is almost time for the next dose." Question: 114 Correct Answer: 4 The nurse has completed giving medication instructions to a client receiving benazepril. Which client statement indicates to the nurse that the client needs further instruction? 1. "I need to change positions slowly." 2. "I will monitor my blood pressure every week." 3. "I will report signs and symptoms of infection immediately." 4. "I can use salt substitutes freely and eat foods high in potassium." Question: 115 Correct Answer: 4 The diabetes nurse specialist conducts a teaching session to a group of nursing students regarding sulfonylureas, oral hypoglycemic medications used for type 2 diabetes mellitus. Which statement, describing the primary action of these medications, should the nurse include in the teaching session? 1. "Sulfonylureas decrease insulin resistance." 2. "Sulfonylureas inhibit carbohydrate digestion." 3. "Sulfonylureas decrease glucose production by the liver." 4. "Sulfonylureas promote insulin secretion by the pancreas." Question: 116 Correct Answer: 4 A client began taking amantadine approximately 2 weeks ago. The client reports to the clinic for a follow-up evaluation. The nurse determines that the client is experiencing a side or adverse effect related to the use of this medication if which is noted? 1. Decreased rigidity 2. Decreased akinesia 3. A blood pressure of 118/74 mm Hg 4. Client complaints of urinary retention Question: 117 Correct Answer: 4 A client diagnosed with peptic ulcer disease is prescribed an over-the counter antacid suspension containing aluminum hydroxide, magnesium hydroxide, and simethicone. What should the nurse include in the client instructions for time of administration of this medication? 1. Just before each meal 2. An hour before breakfast 3. Immediately after each meal 4. 1 and 3 hours after meals Question: 118 Correct Answer: 2 Intravenous heparin therapy is prescribed for a client. While implementing this prescription, the nurse ensures that which medication is available on the nursing unit? 1. Vitamin K 2. Protamine sulfate 3. Potassium chloride 4. Aminocaproic acid Question: 119 Correct Answer: 3 A client is diagnosed with iron deficiency anemia, and ferrous sulfate is prescribed. The nurse should tell the client that it would be best to take the medication with which food? 1. Milk 2. Boiled egg 3. Tomato juice 4. Pineapple juice Question: 120 Correct Answer: 3 Amikacin is prescribed for a client with a bacterial infection. The nurse instructs the client to contact the health care provider (HCP) immediately if which occurs? 1. Nausea 2. Lethargy 3. Hearing loss 4. Muscle aches Question: 121 Correct Answer: 4 Which medication, if prescribed for the client with glaucoma, should the nurse question? 1. Betaxolol 2. Pilocarpine 3. Erythromycin 4. Atropine sulfate Question: 122 Correct Answer: 2 A client has recently begun medication therapy with propranolol. The long-term care nurse should plan to notify the health care provider (HCP) if which assessment finding is noted? 1. Complaints of insomnia 2. Audible expiratory wheezes 3. Decrease in heart rate from 86 to 78 beats/min 4. Decrease in blood pressure from 162/90 to 136/84 mm Hg Question: 123 Correct Answer: 2 A client taking verapamil has been given information about side effects of this medication. The nurse determines that the client understands the information if the client states to watch for which most common side effect of this medication? 1. Weight loss 2. Constipation 3. Nasal stuffiness 4. Abdominal cramping Question: 124 Correct Answer: 2 Colchicine is prescribed for a client with a diagnosis of gout. The nurse reviews the client's record, knowing that this medication would be used with caution in which disorder? 1. Myxedema 2. Kidney disease 3. Hypothyroidism 4. Diabetes mellitus Question: 125 Correct Answer: 3 A client is being treated for moderate hypertension and has been taking diltiazem for several months. The client schedules an appointment with the health care provider because of episodes of chest pain, and Prinzmetal's angina is diagnosed. The client asks the nurse which therapeutic effects the medication will provide and the nurse provides education. Which statement by the client indicates that the teaching has been effective? 1. "It increases the force of contraction of heart tissues." 2. "It increases oxygen demands within the myocardium." 3. "It prevents an influx of calcium ions in the smooth muscle." 4. "It leads to an increase in calcium absorption in the smooth muscle." Question: 126 Correct Answer: 1 The nurse is reviewing the health care provider's prescriptions for an adult client who has been admitted to the hospital after a back injury. Carisoprodol is prescribed for the client to relieve the muscle spasms. The health care provider has prescribed 350 mg to be administered four times a day. What should the nurse conclude? 1. The prescription is the normal adult dosage. 2. The prescription is lower than normal dosage. 3. The prescription is higher than normal dosage. 4. The dosage prescribed requires further clarification with the health care provider. Question: 127 Correct Answer: 4 Itraconazole is prescribed for a client with a fungal infection of the hands. The nurse provides instructions to the client about the medication. Which statement by the client indicates an understanding of the instructions? 1. "I should take the medication on an empty stomach." 2. "I should decrease my fluid intake while taking the medication." 3. "I may become unusually fatigued while taking this medication." 4. "If my urine becomes very dark in color, I should contact my health care provider (HCP)." Question: 128 Correct Answer: 3 The nurse asks a nursing student about the uses of the medication dantrolene. The nursing student correctly states that dantrolene is used to manage hypermetabolism of skeletal muscle that occurs in which condition? 1. Low back pain 2. General anesthesia 3. Malignant hyperthermia 4. Hyperplasia of the prostate Question: 129 Correct Answer: 2 A client has just been given a prescription for diphenoxylate with atropine. The nurse determines that the client understands important information about this medication if the client makes what statement? 1. "It's best to take this medication with a laxative." 2. "This medication contains a habit-forming ingredient." 3. "I might drool frequently from taking this medication." 4. "I will probably become irritable from taking this medication." Question: 130 Correct Answer: 4 On assessment, a newborn is exhibiting cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the health care provider (HCP) prescribes surfactant replacement therapy. Through which route should the nurse prepare to administer this medication? 1. Orally mixed in water 2. Intravenously through a burette 3. Subcutaneously in the anterior thigh 4. Endotracheally through the endotracheal tube Question: 131 Correct Answer: 3 The client in the preoperative holding area has been given a dose of scopolamine. Which intended effect is this medication likely being used for with this client? 1. Obstetric amnesia 2. Suppression of emesis 3. Preanesthetic amnesia 4. Production of cycloplegia Question: 132 Correct Answer: 3 The nurse has provided instructions to a client who will receive alteplase for the treatment of acute myocardial infarction. The nurse determines that teaching was effective if the client states that the main action of alteplase is what? 1. "It will slow the clotting of my blood." 2. "It will keep my blood thin to prevent clotting." 3. "It will dissolve any clots that are obstructing the coronary arteries." 4. "It will prevent any further clots from forming anywhere in the body." Question: 133 Correct Answer: 4 A client is seen in the hospital emergency department after injury to the right ankle. The client tells the nurse that she twisted her ankle while playing volleyball. The health care provider (HCP) has prescribed a topical analgesic cream for the injury. The nurse providing instruction about the medication should provide the client with which information? 1. To avoid hazardous activities while using the cream because it causes drowsiness 2. To apply the medication three times a day and place a heating pad on top of the area 3. That the onset of headache indicates a systemic reaction and the HCP must be notified 4. That the medication contains a combination of medications, one of which is an analgesic Question: 134 Correct Answer: 3 The nurse is caring for a client receiving codeine sulfate for pain. The nurse determines that the client is experiencing a side or adverse effect of the medication based on which finding? 1. Distended jugular veins 2. Bounding peripheral pulses 3. No bowel movement in 3 days 4. Change in blood pressure from 120/60 mm Hg to 140/80 mm Hg Question: 135 Correct Answer: 4 The nurse provides instructions to a client who has a prescription for ticlopidine. Which statement made by the client indicates a need for further teaching? 1. "I'll take my medicine with meals." 2. "Blood work will be done every 2 weeks for the first 3 months." 3. "I should not stop the medication without talking to my doctor first." 4. "Food will affect the medication, so I need to take the medication on an empty stomach." OTHER SOURCES Question: 136 Answer: 2,4,3,1 6. The police bring the client to the emergency department after she threatens to kill her exhusband the client states emphatically. ”The police should bring him in, not me. He is paranoid about my dating and has been stalking me for weeks. He is probably off his medicines. His case manager and the police will not do anything.” In what order should the following nursing actins be done from first to last? All options must be used. 1. Ask about the material problems leading to the divorce. 2. Assess the clients risk for harm to self- and others. 3. Obtain the name of her ex- husband’s case manager. 4. Interview the client about her current needs and situation. Question: 137 Answer: 12. Which is the correct order, from first to last, for proper placement of urinary catheter? All options must be used. 1. Lubricate the catheter adequately with a water-soluble lubricant. 2. Ensure free flow of urine. 3. Insert the catheter far enough into the bladder to prevent trauma to the urethral tissue. 4. Prepare a sterile field. Question: 138 Answer: 13. A client with colon cancer has developed ascites. The nurse should conduct a focused assessment for which signs and symptoms? Select all that apply. 1. Respiratory distress. 2. Bleeding 3. Fluid and electrolyte imbalance. 4. Weight gain. 5. Infection. Question: 139 Answer: 30. When beginning IV erythropoietin therapy, what actions should the nurse take? Select all that apply. 1. Check the hemoglobin levels before administering subsequent doses. 2. Shake the vial thoroughly to mix the concentrated white, milky solution. 3. Keep the multi dose vial refrigerated between scheduled twice a day doses. 4. Administer the medication through the IV line without other medications. 5. Adjust the initial doses according to the client’s changes in blood pressure. 6. Instruct the client to avoid driving and performing hazardous activity during the initial treatment. Question: 140 Answer: 30. After teaching a primigravid client at 10 weeks gestation about recommendations for exercise during pregnancy, which client statement indicates successful teaching? 1. “While pregnant, I should avoid contact sports.” 2. “Even though I am pregnant, I can learn to ski next month.” 3. “While we are on vacation next month, I can continue to scuba dive.” 4. ‘Sitting in a hot tub after exercise will help me to relax.” Question: 141 Answer: 31. The healthcare provider (HCP) has prescribed a chemotherapy drug to be administered to a client every day for the next week. The client is on adult medical- surgical floor, but the nurse assigned to the client has not been trained to handle chemotherapy agents. What is the nurse most appropriate response? 1. Send the client to the oncology floor for administration for the medication. 2. Ask a nurse from the oncology floor to come to the client and administer the medication. 3. Ask another nurse to help mix the chemotherapy agent. 4. Ask the pharmacy to mix the chemotherapy agent and administer it. Question: 142 Answer: 31. A client is afraid of receiving vitamin B12 injections. Which is the nurse’s best response to relieve these fears? 1. “vitamin B12 will cause ringing in the ears before a toxic level is reached.” 2. “vitamin B12 may cause a very mild rash initially.” 3. “vitamin B12 cause mild nausea but nothing toxic.” 4. “vitamin B12 is generally free of toxicity because it is water soluble.” Question: 143 Answer: 32. Which is an appropriate outcome for a client with rheumatoid arthritis? 1. The client will manage joint pain and fatigue to perform activities of daily living. 2. The client will maintain full range of motion in joints. 3. The clients will prevent the development of further pain and joint deformity. 4. The clients will take anti-inflammatory medications as indicated by presence of disease symptoms. Question: 144 Answer: 34. A client with chronic hepatitis C is experiencing nausea, anorexia, and fatigue. During the health history, the client states that he is homosexual, drinks one or two glass of wine with dinner, is taking St, John’s wort for a “bit of depression,” and takes acetaminophen for frequent headaches. What should the nurse do? Select all that apply. 1. Instruct the client that the wine with meals can be beneficial for cardiovascular health. 2. Instruct the client to ask the health care provider (HCP) about taking any other medications the client is currently taking. 3. Instruct the client to increase the protein in his diet and eat less frequently. 4. Advice the client of the need for additional testing for HIV. 5. Encourage the client to obtain sufficient rest. Question: 145 Answer: 36. The nurse is caring for a 5-year-old boy who is taking prednisolone for nephritic syndrome. The child is at the 75th percentile for height and has a blood pressure of 114/73 mm Hg. The nurse compares the reading to the below blood pressure levels for boys age and height percentiles. The nurse determines that the blood pressure represents a change and notifies the healthcare provider (HCP) of the assessment of: 1. Hypotension. 2. prehypertension. 3. hypertension. 4. hypertension stage II. Systolic BP Reading Diastolic BP Reading Percentile for height Percentile for height Age Percentile 5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th 50th 90 91 93 95 96 98 98 51 51 52 53 54 55 55 90th 104 105 106 108 110 111 112 66 66 67 68 69 69 70 95th 108 109 110 112 114 115 116 70 70 71 72 73 74 74 99th 115 116 118 120 121 123 123 78 78 79 80 81 81 82 Question: 146 Answer: 36. A client is receiving monthly doses of chemotherapy for treatment of stage III colon. Which laboratory result should the nurse report the oncologist before the next dose of chemotherapy is administered? Select all that apply. 1. Hemoglobin of 14.5 g/dL (145 g/L) 2. Platelet count of 40000/mm3 (40x 109/L) 3. Blood urea nitrogen (BUN) level of 12 mg (4.3 mmol/L) 4. White blood cells count of 2300/mm3 (2.3x 109/L) 5. Temperature of 101.2 °F (38.4 °C) 6. Urine specific gravity of 1.020. Question: 147 Answer: 55. After a total laryngectomy, the client has a feeding tube. The feeding tube is effective if the tube feedings: 1. Meet the fluid and nutritional needs of the client. 2. Prevent aspirations. 3. Prevent fistula formation. 4. Maintain an open airway. Question: 148 Answer: 56. Complications associated with having a tracheostomy tube include: 1. Decreased cardiac output. 2. Damage to the laryngeal nerve. 3. Pneumothorax. 4. Acute respiratory distress syndrome (ARDS). Question: 149 Answer: 57. A priority goal for the hospitalized client who 2 days earlier had a total laryngectomy with creation of new tracheostomy is to: 1. Decrease secretions. 2. Learn to care for tracheostomy. 3. Relieve anxiety related to tracheostomy. 4. Maintain a patient airway. Question: 150 Answer: 59. A 25-year old primiparous client who gave birth 2 hours ago has decided to breast-feed her neonate. Which instructions should the nurse address as the highest priority in the teaching plan about preventing nipple soreness? 1. Keeping plastic liners in the brassiere to keep the nipple drier 2. Placing as much of the areola as possible into the baby’s mouth 3. Smoothly pulling the nipple out of the mouth after 10 minutes 4. Removing any remaining milk left on the nipple with a soft washcloth. Question: 151 Answer: 60. A client attempting to get out of bed stops midway because of low back pain radiating down to the right heel and lateral foot. What should the nurse do in order of priority from first to last? All options must be used. 1. Apply a warm compress to the clients back. 2. Notify the healthcare provider (HCP). 3. Assist the client to lie down. 4. Administer the prescribed celecoxib. Question: 152 Answer: 61. A health care provider (HCP) has prescribed carbidopa-levodopa four times per day for a client with Parkinson’s disease. The client wants “to end it all now that the Parkinson’s disease has progressed.” What should the nurse do? Select all that apply. 1. Explain that the new prescription for carbidopa-levodopa will treat the depression. 2. Encourage the client to discuss feelings as the carbidopa-levodopa is being administering the carbidopa-levodopa. 3. Determine if the client is on antidepressants or monoamine oxidase (MAO) inhibitors. 4. Contact the HCP Before administering the carbidopa-levodopa. 5. Determine if the client is at risk for suicide. Question: 153 Answer: 63. A young adult is diagnosed with infectious mononucleosis. The white blood cell (WBC) count is 19,000/uL (19 x 109/L). The client has a streptococcal throat infection, enlarged spleen, and aching muscles. Which instructions should the nurse include in discharge planning with the client? Select all that apply. 1. Stay on bed rest until the temperature is normal. 2. Gargle with warm saline while the throat is irritated. 3. Increase intake of fluids until the infection subsides. 4. Wear a mask if others are present. 5. Avoid contact sports while the spleen is enlarged. Question: 154 Answer: 63. A client is being treated for deep vein thrombosis (DTV) in the left femoral artery. The healthcare provider (HCP) has prescribed 60-mg of enoxaparin subcutaneously. Before administering the drug, the nurse checks the client’s laboratory results, noted below Laboratory Results Test Result Prothrombin time 12.5s INR 2.0s Platelet count 50,000/uL (50 x 109/L) Based on these results, what should the nurse do? 1. Contact the pharmacist for a lower dose of the medication. 2. Administer the medication as prescribed. 3. Assess the client for signs of bruising on the extremities. 4. Withhold the dose of the medication and contact the healthcare provider (HCP). Question: 155 Answer: 66. A nurse is caring for a client who is 3 days postpartum and breast- deeding her baby girl. The following assessment is made by the nurse: Episiotomy area: red and edematous; firm 2 finger breaths below umbilicus. What nursing actions are indicated? Select all that apply 1. Suggest the client apply cool compress to breasts. 2. Encourage the client to sit on a supportive device. 3. Ask the client how often the baby feeds. 4. Suggest the client take cool sitz baths twice a day. Question: 156 Answer: 69. A nurse is teaching a parenting class about how to prevent thrush ( oral candidiasis). Which statement by a parent indicates more teaching is required? 1. ‘I will sterilize pacifiers.” 2. “I should rinse my childs mouth after using a corticosteroid.” 3. ‘If my child uses a spacer with asthma medications, I need to rinse it after each use.” 4. “I should rinse my childs glass after each use.” Question: 157 Answer: 69. The nurse is assessing a multigravid client at 12 weeks’ gestation who has been admitted to the emergency department with sharp right-sided abdominal pain and vaginal spotting. Which information should the nurse obtain about the Clint’s history? Select all that apply. 1. History of sexually transmitted infections 2. Number of sexual partners 3. Last menstrual period. 4. Cesarean section. 5. Contraceptive use. Question: 158 Answer: 70. A 10 years old with a history of recent respiratory infection has swelling around the eyes in the morning and dark urine. What question should nurse ask first? 1. “Has the child had a rash and fever?” 2. “Has a child had a sore throat?” 3. “Does the child have any Allergies?” 4. “Does the child drink lots of liquids?” Question: 159 Answer: 71. Which nursing interventions is the highest priority during the first 24 hours postoperatively for the client who had a total laryngectomy due to cancer of the larynx? 1. Provide adequate nourishment. 2. Prevent skin breakdown around the stoma. 3. Maintain proper bowel elimination. 4. Maintain a patient airway. Question: 160 Answer: 72. It has been 5 months since a client lost his wife and child in a car- train accident. The nurse should determine that the client needs continuing counseling if he makes which statement. 1. “I am sleeping, eating, and working pretty well, but I still get so sad at times.” 2. “I miss them so much, but u can tell I am getting better day by day.” 3. “I wish I did not have to sleep. I hate the nightmares about what the car looked like.” 4. “I never thought I would get over this, but I am working with my legislator for the train crossing safety.” Question: 161 Answer: 74. A client request a narcotic analgesic shortly after the oncoming nurse receives change- ofshift report. The nurse who is leaving reported that the client had received morphine 10 mg (IM) within the past hour. In what order from the first to last should oncoming registered nurse (RN) perform actions? All options must be used. 1. Validate with the outgoing RN that morphine 10 mg (IM) had been administered. 2. Assess the client for manifestations of pain. 3. Check the medications documentation as to when morphine 10 mg (IM) was dispensed and to whom. 4. Check to ascertain if any discrepancy had been documented with accompanying reason(s). Question: 162 Answer: 83. A client has an emergency embolectomy for an embolus in the femoral artery. After the client returns from the recovery room, in what order, from first to last, should the nurse provide care? All options must be used 1. Administer pain medication 2. Draw blood for laboratory studies 3. Regulate the IV infusion. 4. Monitor the pulses. 5. Inspect the dressing. Question: 163 Answer: 86. The nurse notices that a client who has just given birth is short of breath, is ashen in color, and begins to cough. She becomes limp on the birthing table. At last assessment . hour ago, here temperature was 98-F (36.7-C), pulse was 78-beats/min, and respirations were 16-breaths/min, Determine the nursing actions in the order they should occur. All options must be used. 1. Open airway using head tilt-chin lift. 2. Ask staff to activate emergency response 3. Establish unresponsiveness. 4. Give tow breaths. 5. Begin compressions. Question: 164 Answer: 87. Which strategies would be helpful in preventing suicide for clients about to be discharged from psychiatric inpatient unit? Select all that apply. 1. At the discharged, give all depressed clients a card containing the crisis phone line numbers for their area. 2. Have all clients who have expressed suicidal ideation just prior to or during hospitalization make a written personal suicide prevention plan. 3. Require that all clients who have gad previous suicidal ideation, plans, or attemps refill their medication every 2 weeks rather than monthly. 4. Educate family and friends of previously suicidal clients in ways to help clients remain safe after discharge. 5. Suggest the family and friends of previously suicidal clients to know the clients whereabouts al all times. Question: 165 Answer: 97. As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. The nurse should do which in order of priority from first to last? All options must be used. 1. Call for immediate assistance. 2. Turn the client to her side. 3. Assess for ruptured membranes. 4. Maintain airway. Question: 166 Answer: 99. In consultations with his outpatient psychiatrist, a client is admitted for detoxification from methadone. He states, “I got addicted to morphine for my chronic knee pain. Methadone worked for a long time. Since I had my knee replacement surgery 3 months ago and physical therapy, I do not think I need methadone anymore,” it is important to discuss which information with this client? Select all that apply. 1. Detoxification will likely occur with slowly decreasing doses of methadone.” 2. “Oxycodone will be available if needed for breakthrough pain.” 3. “You will be monitored and treated as needed.” 4. “Physical therapy and nonchemical pain management techniques can be prescribed if needed.” 5. “If you have knee stiffness or pain, it is likely to be managed by nonnarcotic pain medicines.” Question: 167 Answer: 100. A client approaches the medications nurse and states “I cannot believe you are NOT helping me with my cravings for my fentanyl patches! When I got off alcohol 2 years ago, they gave me naltex-one for my craving, and it really helped me. I cannot stand the craving and back pain anymore, and I am getting angry” Which response by the nurse would be helpful for this client? Select all that apply: 1. “Naltrexone does help decrease the craving for alcohol.” 2. “Naltrexone can interfere with opiate cravings in some clients.” 3. “Cravings are hard to deal with, especially when you are in pain to.” 4. “I am positive naltrexone can help with your craving for fentanyl.” 5. “I hear your frustration about how your detoxification is going.” 6. “I can ask your healthcare provider (HCP) if he thinks naltrexone might help you.” Question: 168 Answer: 106. What should the nurse do for a client who is receiving a hormone replacement for prostate cancer? Select all that apply. 1. Inform the client that increased libido is expected with hormone therapy. 2. Reassure the client that erectile dysfunction will not occur as a consequence of hormone therapy. 3. Provide the client the opportunity to communicate concerns and needs. 4. Utilize communications strategies that enable the client to gain some feeling of control. 5. Suggest that an appointment be made to see a psychiatrist. Question: 169 Answer: 107. When teaching a client about self-care following placement of a new permanent pacemaker to the left upper chest, the nurse should include which information? Select all that apply. 1. Take and record daily pulse rate. 2. Avoid air travel because of airport security alarms. 3. Immobilize the affected arm for 4 to 6 weeks 4. Avoid using a microwave oven. 5. Avoid lifting anything heavier than 3 Ib (1.36 kg) Question: 170 Answer: 108. A client has been admitted to the coronary care unit. The nurse observes third-degree heart block at a rate of 35 bpm on the client’s cardiac monitor. The nurse should first: 1. Prepare for transcutaneous pacing. 2. Prepare to defibrillate the client at 200 J. 3. Administer an IV lidocaine infusion. 4. Schedule the operating room for insertion of a permanent pacemaker. Question: 171 Answer: 109. A client has atrial fibrillation and a heat rate of 165 bpm. In which order from first to last should the nurse implement these prescriptions? All options must be used 1. Administer oxygen via nasal cannula. 2. Gather supplies for an IV insertion. 3. Place client on a cardiac monitor (ECG) 4. Obtain vital signs including BP, P, R, T, and O2 saturation Question: 172 Answer: 110. A client who has been taking warfarin has been admitted with severe acute rectal bleeding and the following laboratory result: international normalized ratio (INR), 8; hemoglobin,11 g/dL (110 g/L); and hematocrit,33% (0.33). In which order, from first to last, should the nurse implement the healthcare provider’s prescriptions? All options must be used. 1. Give 1 unit fresh frozen plasma (FFP). 2. Administer vitamin K 2.5 mg by mouth. 3. Schedule the client for sigmoidoscopy. 4. Administer IV dextrose 5% in 0.45% normal saline. Question: 173 Answer: 110. A client who has been taking warfarin has been admitted with severe acute rectal bleeding and the following laboratory results: international normalized ration (INR), 8; hemoglobin, 11- g/dL (110g/L); and hematocrit, 33% (0.33). In which order, from first to last, should the nurse implement the healthcare provider’s prescriptions? Question: Answer: 1. Give 1 unit fresh frozen plasma (FFP). 2. Administer vitamin K 2.5 mg by mouth 3. Schedule the client for sigmoidoscopy. 4. Administer IV dextrose 5% in 0.45% normal saline. Question: 174 Answer: 113. An 85-years old client is admitted to the emergency department (ED) at 2000 hours with syncope, shortness of breath, and reported palpitations (see nurse’s notes below). At 2015, the nurse places the client on the ECG monitor and identifies the following rhythm (see below). What should the nurse do? Select all that apply. Nurse’s Progress Notes Admitted to emergency department 2000 Pulse 150 BP 90/62 Oxygen saturation 92% on room air RR 22 Progress notes Client has shortness of breath and states, “My heart is jumping out of my chest and hurts some. I am having trouble catching my breath, I don’t want to faint again,” R, Black RN 1. Apply oxygen. 2. Prepare to defibrillate the client. 3. Monitor vital signs 4. Have the client sign consent for cardioversion as prescribed. 5. Teach the client about warfarin treatment and the need for frequent blood testing. 6. Draw blood for a CBC count and thyroid function study. Question: 175 Answer: 129. A nurse working the day shift on a cardiac unit receives the following shift report: 1. Client 1: Admitted yesterday morning with hypokalemia. Awaiting repeat electrolyte lab results drawn at 06:00. 2. Client 2: Experienced chest pain at 06:30. Pain resolved after 2 sublingual nitroglycerin tablets. 3. Client 3: Scheduled for oral antihypertensive medications at 0900. Incontinent of urine during the night 4. Client 4: Scheduled for coronary artery bypass surgery at 0800. The client’s family is in the client’s room. Question: 176 Answer: 131. The unlicensed assistive personnel (UAP) reports to the nurse that a client is “feeling short of breath.” The client’s blood pressure was 124/78 mmHg 2 hours age with a heart rate of 82 bpm; the unlicensed assistive personnel reports that blood pressure is now 84/44 mm Hg with a heart rate of 54 bpm, and the client stated, “I just do not feel good. What actions should the nurse take? Select all that apply. 1. Confirm the client’s vital signs and complete a quick assessment. 2. Inform the charge nurse of the change in condition, and initiate the hospital’s rapid emergency response team. 3. Make a quick check on other assigned clients before spending the amount of time required to take care of this client. 4. Position the client in semi-Fowler’s position. 5. Stay with the client, and reassure the client. 6. Call the healthcare provider (HCP). And report the situation using SBAR format. Question: 177 Answer: 136. A client with acute respiratory distress syndrome (ARDS) is showing signs of increased dyspnea. The nurse reviews a report a blood gas values that recently arrived (see report) Laboratory results Blood Chemistry Result pH 7.35 PaCO2 25 mm Hg (3.3 kPa) Hco3 22 mEq/L (22 mmoI/L) PaO2 95 mm Hg (12.6 kPa) Which findings is Abnormal? 1. pH 2. PaCO2 3. HCO3 4. PaO2 Question: 178 Answer: 155. The nurse is caring for a client with pneumonia who is confused about time and place and has intravenous fluids infusing. Despite the nurses attempt to reorient the client and then provide distraction, the client has begun to pull at the IV tubing. After increasing the frequency of observations, in which order should the nurse implement interventions to ensure the clients safety? All options must be used. 1. Review the clients medications for interactions that may cause or increase confusion. 2. Assess the client’s respiratory status including oxygen saturation. 3. Ensure the client does not need toileting or pain medications. 4. Contact the healthcare provider (HCP), and request a prescription for soft wrist restraints. Practice Bank 52 Item #1370 Question: 179 Answer: B A child is treated with succimer (Chemet) for lead poisoning. Which of these assessments should the nurse perform first? A. Check serum potassium level B. Check complete blood count (CBC) with differential C. Check blood calcium level D. Test deep tendon reflexes Item # 1350 Question: 180 Answer: C A nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a herpes simplex virus type 2 infection. Which of these instructions should the nurse give the client? A. Stop treatment if she thinks she may be pregnant to prevent birth defects B. Continue to take prophylactic doses for at least five years after the diagnosis C. Begin treatment with acyclovir at the onset of symptoms of recurrence D. Complete the entire course of the medication for an effective cure Item #1438 Question: 181 Answer: B A client is admitted to the hospital because of heart failure and digoxin toxicity. At home, the client was taking digoxin (Lanoxin) and furosemide (Lasix). Which finding should a nurse anticipate on an initial assessment? A. Blood in the urine B. Muscle weakness or cramping C. Confusion D. Tinnitus Item #1425 Question: 182 Answer: B A nurse is teaching a client with asthma about the correct use of the Azmacort (triamcinolone) inhaler. Which statements, if made by the client, would indicate that the teaching was effective? A. "I should not use a spacer with my Azmacort." B. "If I forget a dose, I can double up on the next dose." C. "The inhaler can be used whenever I feel short of breath." D. "I should rinse my mouth after using the inhaler." Item #1351 Question: 183 Answer: D A nurse has been teaching a client with type 1 diabetes mellitus. Which statement by the client is incorrect and indicates a need for further teaching? A. "Since my eyesight is so bad, I ask the nurse to fill several syringes." B. "I use a sliding scale to adjust regular insulin to my sugar level." C. "I keep my regular insulin bottle in the refrigerator." D. "I always make sure to shake the NPH bottle hard to mix it well." Practice Bank 53 Item #1692 Question: 184 Answer: C A nurse is giving instructions to the parents of a child with cystic fibrosis. The nurse should emphasize that pancreatic enzymes should be taken in which manner? A. Three times daily after meals B. Each time carbohydrates are eaten C. With each meal or snack D. Once each day Item #1574 Question: 185 Answer: C What would a nurse expect to see in a client who reports symptoms associated with tardive dyskinesia? A. Behavioral changes B. Uncontrolled hand tremors during meals C. Rapid tongue movements D. Repetitive slapping movements Item # 1541 Question: 186 Answer: D When teaching a client with a new prescription for lithium (Lithane) for treatment of a bipolar disorder, which of these points should the nurse emphasize? A. Maintain a salt restricted diet B. Take other medication as usual C. Substitute generic form if desired D. Report vomiting or diarrhea Item #1588 Question: 187 Answer: A What characteristic of a 75 year-old client may influence the effects of antihypertensive drug therapy? A. Decreased gastrointestinal motility B. Increased splanchnic blood flow C. Altered peripheral resistance D. Poor nutritional status Practice Bank 54 Item #4460 Question: 188 Answer: 4 The nurse is to give phenytoin (Dilantin) right away. How long should it take for the nurse to administer 100 mg of phenytoin IV push to an elderly client? (Use a whole number to answer the question and write only the number). minutes. Question: 189 Answer: A Item #1797 An older adult client is on an anticholinergic metered dose inhaler (MDI) for chronic obstructive pulmonary disease (COPD). A nurse would suggest a spacer to for what purpose? A. Improve aerosol delivery in clients with poor coordination B. Prevent exacerbation of COPD C. Enhance the administration of the medication D. Increase client compliance Item #1802 Question: 190 Answer: A A nurse is teaching an older adult client how to use multi-dose inhalers (MDI's). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. What should the nurse recommend to improve the delivery of the medication? A. Add a spacer device to the MDI canister B. Ask a family member to assist the client with the MDI C. Request a visiting nurse to follow the client at home D. Nebulized treatments for home care Item #1730 Question: 191 Answer: C Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which assessment should a nurse use to evaluate the effectiveness of this treatment? A. An increase in appetite B. A reduction in jaundice C. A decrease in lethargy D. A decrease in fluid retention Item # 1761 Question: 192 Answer: A A nurse is preparing a client for discharge following inpatient treatment for pulmonary tuberculosis (TB). Which of these instructions should be given to the client? A. Continue taking medications as prescribed B. Avoid contact with children, pregnant women or immunosuppressed persons C. Continue taking medications until findings are relieved D. Take medication with Amphojel if epigastric distress occurs Item #1796 Question: 193 Answer: D A client is to begin taking alendronate (Fosamax). Which of these instructions should the nurse emphasize when teaching about this medication? A. "It is recommended that you take this medication with calcium and a glass of juice." B. "Take the medication with a full glass of milk two hours after meals." C. "You may take this medication after any meal, at the same time every day." D. "Be sure to take this medication on an empty stomach." Item #1713 Question: 194 Answer: B A nurse caring for a nine year-old child with a fractured femur is told that a medication error occurred. The child received twice the ordered dose of morphine an hour ago. Which nursing diagnosis is a priority at this time? A. Decreased gastrointestinal mobility related to mucosal irritation B. Ineffective breathing patterns related to central nervous system depression C. Risk for fluid volume deficit related to morphine overdose D. Altered nutrition related to inability to control nausea and vomiting Item #1712 Question: 195 Answer: B A 14 month-old child ingested half a bottle of aspirin tablets. Which finding should a nurse expect to see in this child? A. Edema B. Epistaxis C. Hypothermia D. Dyspnea Item # 1766 Question: 196 Answer: B A 52 year-old client is being transfused with one unit of packed cells. A half hour after the transfusion was initiated, the client reports having chills and a headache. Which action should a nurse implement first? A. Check the client's temperature B. Stop the transfusion C. Obtain a urine specimen D. Notify the health care provider Item #1823 Question: 197 Answer: B A nurse is performing a pre-kindergarten physical on a five year-old. The last series of vaccines will be administered. What is the preferred site for injection by the nurse? A. vastus intermedius B. vastus lateralis C. dorsogluteal D. gluteus maximus Item #1804 Question: 198 Answer: A A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client reports chest tightness. The peak flow is now 200 liters/minute. What action should the nurse now take? A. Administer the prn dose of albuterol B. Repeat the peak flow reading in 30 minutes C. Apply oxygen at two liters per nasal cannula D. Notify both the surgeon and provider You answer: Item #1833 Question: 199 Answer: D A nurse is assessing a seven year-old after several days of treatment for a documented strep throat. Which statement is incorrect and suggests that further teaching is needed? A. "Sometimes I take my medicine with fruit juice." B. "My mother makes me take my medicine right after school." C. "I am feeling much better than I did last week." D. "Sometimes I take the pills in the morning and other times at night." Question: 200 Correct Answer: A The client, who is diagnosed with a mild traumatic brain injury (MTBI), is experiencing migrainetype posttraumatic headaches. The health care provider has ordered almotriptan (Axert). What should the nurse understand about this medication? A. This medication must be given as soon as the client begins to experience migraine symptoms B. The medication will help reduce the number of migraine attacks C. The client should be reminded to restrict fluids while taking this medication D. This medication is used prophylactically to prevent headaches Post test 12/02/2016 09:44:56 PM Post-Test Completed Question: 1 Correct Answer: 1 A client who is scheduled for cataract surgery requires preoperative instillation of cyclopentolate eye drops as prescribed. The client asks the nurse why this medication is needed, and the nurse provides education. Which statement by the client indicates that teaching has been effective? 1. "The medication dilates the pupil of the operative eye." 2. "The medication constricts the pupil of the operative eye." 3. "The medication is needed for the initiation of miosis in the operative eye." 4. "The medication provides the necessary lubrication to the nonoperative eye." Question: 2 Correct Answer: 2 The nursing care plan indicates a problem of self-directed violence and the risk for suicide, related to suicidal ideations with a specific plan. The nurse develops a plan of care for the client and identifies which expected client outcome? 1. Displays less anxiety and agitation 2. Denies presence of suicidal ideations 3. Develops adequate problem solving skills 4. Establishes a relationship with staff and peers Question: 3 Correct Answer: 1 The nurse in a maternity unit is providing emotional support to a client and her significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? 1. "We want to attend a support group." 2. "We never want to try to have a baby again." 3. "We are going to try to adopt a child immediately." 4. "We are okay, and we are going to try to have another baby immediately." Question: 4 Correct Answer: 4 Which activity should the nurse include in the plan of care for a client who is experiencing psychomotor agitation? 1. Playing checkers with members of the staff 2. Reading in a quiet, low-stimulus environment 3. Engaging in a card game with other clients on the unit 4. Attending a clay-molding class that is scheduled for today Question: 5 Correct Answer: 4 The nurse provides instructions to a preoperative client about the use of an incentive spirometer. The nurse determines that the client needs further instruction if the client indicates that he or she will take which action? 1. Sit upright when using the device. 2. Inhale slowly, maintaining a constant flow. 3. Place the lips completely over the mouthpiece. 4. After maximal inspiration, hold the breath for 10 seconds and then exhale. Question: 6 Correct Answer: 3 The nurse employed in an emergency department is monitoring a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. How should the nurse interpret this finding? 1. Extreme fatigue 2. The presence of pain 3. An airway obstruction 4. The presence of dehydration Question: 7 Correct Answer: 2 When a client develops neuroleptic malignant syndrome, the nurse ensures that which medication is available on the unit to address this complication? 1. Phytonadione 2. Bromocriptine 3. Protamine sulfate 4. Enalapril maleate Question: 8 Correct Answer: 4 The nurse is reviewing an adult male's serum creatinine level of 4.0 mg/dL (353 mcmol/L). What does this level indicate? 1. Low 2. Normal 3. Slightly elevated and needs referral 4. Very high, indicating severe renal failure Question: 9 Correct Answer: 4 On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? 1. The client taking diuretics and has tenting of the skin 2. The client with an ileostomy from a recent abdominal surgery 3. The client who requires intermittent gastrointestinal suctioning 4. The client with kidney disease and a 12-year history of diabetes mellitus Question: 10 Correct Answer: 2 The nurse is conducting a prepared childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the women to perform the procedure by doing which action? 1. Contracting and then consciously relaxing different muscle groups 2. Massaging the abdomen during contractions, using both hands in a circular motion 3. Instructing her partner to stroke or massage a tightened muscle by the use of touch 4. Contracting an area of the body, such as an arm or leg, and then concentrating on letting tension go from the rest of the body Question: 11 Correct Answer: 3 A client with cancer is receiving intravenous morphine sulfate for pain. When writing the plan of care for this client, the nurse should include which action as the priority action? 1. Monitor temperature. 2. Monitor urine output. 3. Monitor respiratory status. 4. Encourage increased fluids Question: 12 Correct Answer: 1, 2, 3, 5 The nurse is caring for an older client who is complaining of insomnia. What are some of the contributing factors to insomnia in the acute and long-term care setting? Select all that apply. 1. Pain 2. Chronic disease 3. Staff conversations 4. Daily laboratory diagnostic tests 5. Environmental noise and lighting 6. Giving pain medications with supper Question: 13 Correct Answer: 2 A client with a history of anxiety appears to be in the second phase of crisis response. The nurse prepares for which client behavior? 1. The client will show the initial signs that coping methods are failing. 2. The client will employ new coping methods that will resolve the problem. 3. The client will experience severe anxiety as a result of failed coping methods. 4. The client will begin to implement coping methods that have been successful in the past. Question: 14 Correct Answer: 2 The nurse is providing home care instructions to the mother of an infant who has just been found to have hemophilia. The nurse should tell the mother that care of the infant should include which appropriate measure? 1. Use aspirin for pain relief. 2. Pad crib rails and table corners. 3. Use a soft toothbrush for dental hygiene. 4. Use a generous amount of lubricant when taking a temperature rectally. Question: 15 Correct Answer: A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? 1. Performing a procedure without consent 2. Threatening to give a client a medication 3. Telling the client that he or she cannot leave the hospital 4. Observing care provided to the client without the client's permission Question: 16 Correct Answer: 3 The nurse is planning discharge teaching for a client diagnosed and treated for compartment syndrome. Which information should the nurse include in the teaching? 1. "A bone fragment has injured the nerve supply in the area." 2. "An injured artery caused impaired arterial perfusion through the compartment." 3. "Bleeding and swelling caused increased pressure in an area that couldn't expand." 4. "The fascia expanded with injury, causing pressure on underlying nerves and muscles." Question: 17 Correct Answer: 1 A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high- pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition? 1. Right pneumothorax 2. Pulmonary embolism 3. Displaced endotracheal tube 4. Acute respiratory distress syndrome Question: 18 Correct Answer: 2 The nurse is performing the oculocephalic response (doll's eyes maneuver) on an unconscious client. The nurse turns the client's head and notes movement of the eyes in the same direction as the head. How should the nurse document these findings? 1. Normal 2. Abnormal 3. Insignificant 4. Inconclusive Question: 19 Correct Answer: 3 A client is taking lansoprazole. The nurse anticipates that the health care provider will advise the client to take which product if needed for a headache? 1. Naproxen 2. Ibuprofen 3. Acetaminophen 4. Acetylsalicylic acid Question: 20 Correct Answer: 2 The nurse is caring for an 8-month-old infant. A urinalysis has been prescribed, and the nurse plans to collect the specimen. Which method should be used for urine collection in an infant? 1. Catheterizing the infant using a Foley catheter 2. Attaching a urine collection device to the infant's perineum 3. Obtaining the specimen from the diaper, using a syringe, after the infant voids 4. Monitoring the urinary patterns and preparing to collect the specimen into a cup when the infant voids Question: 21 Correct Answer: 4 A clinic nurse is instructing a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse tells the client about the importance of an adequate daily fluid intake. Which client statement best indicates an understanding of the daily fluid requirement? 1. "I should drink 12 glasses of fruit juices and milk every day." 2. "I should drink 8 to 10 glasses of fluid a day, and I can drink as many diet soft drinks as I want." 3. "I should drink 12 glasses of fluid a day, and I can include the coffee or tea that I drink in the count." 4. "I should drink at least 8 to 10 glasses of fluid each day, of which at least 6 glasses should be water." Question: 22 Correct Answer: 4 The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? 1. A client complaining of muscle aches, a headache, and history of seizures 2. A client who twisted her ankle when rollerblading and is requesting medication for pain 3. A client with a minor laceration on the index finger sustained while cutting an eggplant 4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce Question: 23 Correct Answer: 1, 2, 4, 5 The nurse is working in an illness prevention clinic. An important component of the nurse's practice is to advise high-risk clients to receive an influenza vaccination. Which clients are at high risk for influenza and would benefit from vaccination? Select all that apply. 1. A 47-year-old mother of a child with cystic fibrosis 2. A 54-year-old man scheduled for a routine diabetes check 3. A 43-year-old factory worker with symptoms of influenza 4. A 35-year-old registered nurse scheduled for an annual pelvic exam 5. An 87-year-old woman from a nursing home scheduled for a surgical follow-up Question: 24 Correct Answer: 1 The nurse asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed about administration of the eye medication? 1. "I will flush the eyes after instilling the ointment." 2. "I will clean the newborn's eyes before instilling ointment." 3. "I need to administer the eye ointment within 1 hour after delivery." 4. "I will instill the eye ointment into each of the newborn's conjunctival sacs." Question: 25 Correct Answer: 2 After performing an assessment of an infant with bladder exstrophy, the nurse prepares a plan of care. The nurse identifies which problem as the priority for the infant? 1. Urinary incontinence 2. Impaired tissue integrity 3. Inability to suck and swallow 4. Lack of knowledge about the disease (parents) Question: 26 Correct Answer: 2 The nurse is providing discharge instructions to the mother of a child who has been prescribed tetracycline hydrochloride. The nurse stresses to the mother the importance of which measure in giving this medication to the child? 1. Give the medication with milk. 2. Use a straw when giving the medication. 3. Give the medication with chocolate milk. 4. Dilute the medication with water in a Styrofoam cup. Question: 27 Correct Answer: 3 A film-coated form of diflunisal, a nonsteroidal antiinflammatory medication, has been prescribed for a client to treat chronic rheumatoid arthritis. The client calls the clinic nurse because of difficulty swallowing the tablets. Which instruction should the nurse provide to the client? 1. Crush the tablets and mix with food. 2. Open the tablet and mix the contents with food. 3. Swallow the tablets with large amounts of water or milk. 4. Notify the health care provider for a medication change. Question: 28 Correct Answer: 3 The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. When analyzing the results of the urinalysis, which should the nurse most likely expect to note? 1. Hematuria 2. Proteinuria 3. Bacteriuria 4. Glucosuria Question: 29 Correct Answer: 4 A child is admitted to the hospital after being seen in the emergency department with complaints of right lower quadrant abdominal pain, nausea and vomiting, fever, and chills. The health care provider (HCP) suspects appendicitis. Which assessment finding should the nurse immediately report to the HCP? 1. Decreasing oral temperature 2. Increasing complaints of pain 3. Refusal to take fluids by mouth 4. Sudden relief of abdominal pain RN Practice Question Banks 1-15 (Not Required) Question: 30 Correct Answer: 1, 2, 5, 6 During a yearly health screening, a 54 year-old female reports having irregular menstrual cycles, mood swings and hot flashes. She requests a more natural approach to manage these symptoms of perimenopause. What education about non-pharmacological interventions will the nurse include in client teaching? (Select all that apply.) 1. "You should drink at least 8-10 glasses of water a day." 2. "Yoga may help you manage stress and relieve symptoms." 3. "A glass or two of red wine with dinner can help you manage stress." 4. "Try exercising just before bedtime to help you sleep more soundly." 5. "Incorporate more vegetables and legumes in your diet." 6. "Use deep breathing exercises when you start having a hot flash." Rationale Measures that have been found to be effective in helping manage symptom of hot flashes include exercise, stress reduction and getting enough sleep at night. Reducing the temperature in the room at night and taking a warm bath or shower before bedtime can help clients get a better night's sleep. Slow abdominal breathing (6-8 breaths a minute) at the onset of hot flashes can help. Other measures that can lessen the number of and severity of hot flashes include yoga, as well as avoiding alcohol, spicy foods and caffeine. Eating a more plant- based diet can also help. Question: 31 Correct Answer: 1, 3, 4 A new task force has been created at a hospital to address a recent increase in patient falls. The first meeting is scheduled with members from several departments. Which of the following statements by the nurse leader indicate intent to increase meeting effectiveness? (Select all that apply.) 1. "During our meeting today we will share the information we have on falls." 2. "Let's discuss when next we should meet and what information we will bring." 3. "Please introduce yourselves and your departments." 4. "Let's focus on the number of falls first and then we can talk about staffing." 5. "Today I will review the problem with falls on our units." 6. "This meeting can go as long as needed to get things done." Rationale A leader increases meeting effectiveness by not permitting one person not to dominate the discussion, encouraging brainstorming, encouraging others to further develop ideas and helping to engage the team in future discussions. An effective team leader will periodically summarize the information and ensure that all ideas are recorded for all to see (for example, on a whiteboard) and then follow up with minutes of the meeting. Beginning and ending on time is also important to keep everyone focused on the task at hand and to demonstrate respect team members' other commitments. Question: 32 Correct Answer: 2, 5, 6 The nurse is preparing to administer a feeding through a percutaneous endoscopic gastrostomy (PEG) tube. What nursing action is needed before starting the infusion? (Select all that apply.) 1. Palpate the abdomen 2. Verify the length and placement of the tube 3. Milk or massage the tube 4. Keep the feeding product refrigerated until ready to use 5. Elevate the head of the bed 30-45 degrees 6. Flush the tube with 30 mL of warm water Rationale Prior to starting every feeding, the nurse should verify the length and placement of the tube, flush the tube with 30 mL of warm (not hot and not cold) water, and elevate the head of the client's bed at least 30 degrees. The nurse should also verify the presence of bowel sounds before starting the infusion. There's no need to milk the tube unless it's obstructed. Feeding products should be brought to room temperature before the infusion to prevent gastrointestinal discomfort. Question: 33 Correct Answer: 1, 2 The client needs to be moved up in bed. The client is able to partially assist and weighs 135 pounds. Which action by the nursing staff best supports an awareness of ergonomics and safe client handling? (Select all that apply.) 1. Adjust the height of the bed for caregivers 2. Move the bed into the flat position 3. Pull the client up from the head of the bed 4. Use a friction-reducing device 5. Coordinate lifting the client by counting to 3 Rationale The algorithm for safe client handling and repositioning a client from side-to-side or up in bed states: use 2 to 3 caregivers for a client who can partially assist and who weighs less than 200 pounds, use a friction-reducing device, move the bed so that it's flat and at a comfortable height for the caregivers. The client should not be pulled from the head of the bed. There really is no safe method to manually lift another adult Question: 34 Correct Answer: 1, 2, 4 Following a surgical procedure, a pneumatic compression device is applied to the adult client. The client reports that the device is hot and the client is sweating and itching. Which of the following steps should the nurse take? (Select all that apply.) 1. Check for appropriate fit 2. Confirm pressure setting of 45 mm Hg 3. Explain that the health care provider ordered the device and it cannot be removed 4. Collaborate with health care provider for anti-embolism stockings to be worn under the sleeves of the device 5. Inform the client that removing the device will likely result in the formation of deep vein thrombosis Rationale In any situation in which a client has discomfort associated with a medical device, the nurse should ensure it is applied correctly and functioning safely. The usual safe and effective pressure range is 35 to 55 mm Hg. Explanations to the clients should support their informed decisionmaking capabilities and should not be phrased to intimidate or remove client autonomy. Applying anti-embolism stockings under the disposable sleeves of the device may help with the sweating and itching. Question: 35 An 88 year-old client is admitted to the telemetry unit following a minor surgical procedure. The client's history includes insulin dependent diabetes and a previous myocardial infarction. The nurse responds to the client's ECG alarm and finds the client's rhythm shows asystole and the client obtunded but responsive. Prioritize the actions of the nurse (with 1 being the top priority). 1. Look at a different ECG lead to confirm rhythm 2. Assess respirations and pulse 3. Check a blood glucose level 4. Initiate emergency response system if indicated 1. Correct answer 1. Assess respirations and pulse 2. Initiate emergency response system if indicated 3. Look at a different ECG lead to confirm rhythm 4. Check a blood glucose level Rationale After checking responsiveness, establishing a patent airway and then assessing breathing and circulation are the next priorities (ABCs). This assessment would provide information to decide whether the emergency response team is needed. Because the client is responsive, the monitor rhythm is not correct, as a client with asystole would be unresponsive. Asystole on a rhythm strip may simply be a loose lead; a quick way to check this is to select another lead. The client's obtunded state indicates that ion is needed, so assessment of a central pulse and blood pressure is indicated to determine whether cardiovascular compromise is responsible for this condition. If no evidence of an immediate cardiac event is present, the blood glucose should be checked. Stress and changes in food or fluid consumption secondary to surgery increase the risk of glucose imbalance in the person with diabetes. Question: 36 A nurse who cares for clients undergoing treatment for cancer might expect clients diagnosed with cancer to make the following statements. Based on an understanding of the stages of the grieving process, place the statements in the correct order. 1. “I don’t know where to go and what to do” 2. “I am so sad at everyone for always reminding me that I have it” 3. “I think test got mixed up.” 4. “If I eat a more balanced diet, I can live longer” Correct answer 1. “I think test got mixed up.” 2. “I am so sad at everyone for always reminding me that I have it” 3. “If I eat a more balanced diet, I can live longer” 4. “I don’t know where to go and what to do” Rationale The phases of loss or the grief process according to Dr. Kubler-Ross are: denial, anger, negotiation, depression and acceptance Post test 12/02/2016 09:44:56 PM Post-Test Completed Question: 37 Correct Answer: 4 The nurse is providing instructions to a client with psoriasis who will be receiving ultraviolet (UV) light therapy. Which statement would be most appropriate for the nurse to include in the client's instructions? 1. "Each treatment will last at least 30 minutes." 2. "Your entire body will be exposed to the light treatment." 3. "You will need to wear cotton clothes during the treatment." 4. "You will need to wear dark eye goggles during the treatment." Question: 38 Correct Answer: 3 The nurse is providing instructions to a client about diaphragmatic breathing. The nurse tells the client that this technique is helpful because in normal respiration, as the diaphragm contracts, it takes which action? 1. Aids in exhalation 2. Moves up and inward 3. Moves downward and out 4. Makes the thoracic cage smaller Question: 39 Correct Answer: 3 The nurse notes that the health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action should the nurse take? 1. Speak loudly, but mumble or slur the words. 2. Speak loudly and clearly while facing the client. 3. Speak at normal tone and pitch, slowly and clearly. 4. Speak loudly and directly into the client's affected ear. Question: 40 Correct Answer: 2 The nurse is providing instructions regarding skin care to a client after removal of a leg cast. The nurse should instruct the client to take which measure? 1. Avoid the use of sunscreen on the skin for at least 2 years. 2. Apply an emollient lotion to the skin to enhance softening. 3. Scrub the skin vigorously with soap and water to remove the dead skin. 4. Soak the skin for 1 hour 6 times daily to assist in removing any dry scales. Question: 41 Correct Answer: 4 The nurse is preparing to care for a newborn infant following creation of a colostomy for the treatment of imperforate anus. In the immediate postoperative period, the nurse plans to inspect the stoma and expects to note which finding in the colostomy? 1. Bleeding 2. Gray in color 3. Dark blue in color 4. Red and edematous Question: 42 Correct Answer: 1 A client begins to experience drainage of small amounts of bright red blood from the tracheostomy tube 24 hours after a supraglottic laryngectomy. Which is the best nursing action? 1. Notify the health care provider (HCP). 2. Increase the frequency of suctioning. 3. Add moisture to the oxygen delivery system. 4. Document the character and amount of drainage. Question: 43 Correct Answer: 1 The nurse caring for a client who underwent intracranial surgery is suspected of having diabetes insipidus. Which finding noted by the nurse is consistent with this complication of surgery? 1. Complaints of excessive thirst 2. Urine specific gravity of 1.030 3. Urine output of 10 to 15 mL/hour 4. Systolic blood pressures running consistently over 150 mm Hg Question: 44 Correct Answer: 1 The nurse is monitoring a client receiving glipizide. The nurse knows that which finding would indicate a therapeutic outcome for this client? 1. A decrease in polyuria 2. An increase in appetite 3. A glycosylated hemoglobin of 10% 4. A fasting blood glucose of 220 mg/dL (12.6 mmol/L) Question: 45 Correct Answer: 3 The nurse is talking to the parents of a child newly diagnosed with diabetes mellitus. Which statement by the parents indicates an understanding of preventing and managing hyperglycemia? 1. "I will give 8 oz of diet cola at the first sign of weakness." 2. "I will administer glucagon immediately if shakiness is felt." 3. "I will check for ketones when my child is suffering from an illness." 4. "I will report to the emergency department if the blood glucose level is over 150 mg/dL (8.6 mmol/L)." Question: 46 Correct Answer: 1 A child is scheduled for a tonsillectomy. The nurse plans care, knowing that which condition would be a priority because it presents the highest risk of aspiration during surgery? 1. Presence of loose teeth 2. Bleeding during surgery 3. Difficulty in swallowing 4. Exudate in the throat area Question: 47 Correct Answer: 1 During a support group session, a client says, "My husband hit me a lot, but when he threatened to start hitting our kids, I stabbed him. No jury will believe me because my husband can lie to anyone and be believed." If no one in the group responds, which statement is the therapeutic response by the nurse? 1. "Abuse is a horribly difficult thing to experience. Can anyone in the group relate to what she's feeling?" 2. "Yes. Everyone here was ill-used and abused, but what makes you think that this is a reason to stab someone?" 3. "Everyone agrees that you couldn't let him hurt your children. But is there anything you would do differently?" 4. "Your story is very much like every woman's here. The problem is getting a jury to see that you were justified in stabbing him." Question: 48 Correct Answer: 4 The spouse of a client prescribed an antidepressant tells the home health nurse, "Now that the antidepressant is working, the suicidal risk is over and you can stop making these home visits." How does the nurse appropriately respond? 1. "I need to continue with my visits since this disease tends to run in families." 2. "I agree with you that the medication will greatly reduce the risk for suicidal behavior." 3. "I agree with you that continuing to visit would reintroduce the possibility of suicidal ideations." 4. "I need to continue visiting since the client may now have the energy to act on suicidal intentions." Question: 49 Correct Answer: 2 A client is having the dosage of clonazepam adjusted. The nurse should plan to perform which action? 1. Weigh the client daily. 2. Institute seizure precautions. 3. Monitor blood glucose levels. 4. Observe for areas of ecchymosis. Question: 50 Correct Answer: 3 The nurse has instructed a client with myasthenia gravis about strategies for self-management at home. The nurse determines a need for further teaching if the client makes which statement? 1. "Here's the MedicAlert bracelet I obtained." 2. "I should take my medications an hour before mealtime." 3. "Going to the beach will be a nice, relaxing form of activity." 4. "I've made arrangements to get a portable resuscitation bag and home suction equipment." Question: 51 Correct Answer: 2 The nurse has collected the following data on a client in labor. The fetal heart rate (FHR) is 154 beats/min and is regular, and contractions have moderate intensity, occur every 5 minutes, and have a duration of 35 seconds. Using this information, what is the appropriate action for the nurse to take? 1. Prepare for imminent delivery. 2. Continue to monitor the client. 3. Report the FHR to the anesthesiologist on call. 4. Report the findings to the health care provider (HCP). Question: 52 Correct Answer: 2 The nurse has observed that an older client has episodes of extreme agitation. Which measure is most appropriate for the nurse to implement to avoid episodes of agitation? 1. Wait until the client's agitation has subsided before approaching the client. 2. Speak and move slowly toward the client while assessing the client's needs. 3. Speak to the client at the entrance of the room to avoid any episodes of agitation. 4. Walk up behind the client and gently put a hand on the client's shoulder while speaking. Question: 53 Correct Answer: 4 Daily administration of dipyridamole has been prescribed for the client, and the nurse teaches the client about the medication. Which client statement indicates an understanding of the instructions? 1. "This medication will prevent a stroke." 2. "This medication will prevent a heart attack." 3. "This medication will help keep my blood pressure down." 4. "If I take this medicine with my warfarin, it will protect my artificial heart valve." Question: 54 Correct Answer: 1, 2, 5 The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. 1. Maintain NPO (nothing by mouth) status. 2. Encourage coughing and deep breathing. 3. Give small, frequent high-calorie feedings. 4. Maintain the client in a supine and flat position. 5. Give hydromorphone intravenously as prescribed for pain. 6. Maintain intravenous fluids at 10 mL/hour to keep the vein open. Question: 55 Correct Answer: 2 A client is to undergo weekly intravesical chemotherapy for bladder cancer for the next 8 weeks. What instruction should the nurse provide to the client regarding management of the urine as a biohazard? 1. Void into a bedpan and then empty the urine into the toilet. 2. Disinfect the toilet with bleach after voiding for 6 hours after a treatment. 3. Purchase extra bottles of scented disinfectant for daily bathroom cleansing. 4. Have one bathroom strictly set aside for the client's use for the next 2 months. Question: 56 Correct Answer: 1 The nurse is developing a plan of care for an infant after surgical intervention for imperforate anus. The nurse should include in the plan that which position is the most appropriate one for the infant in the postoperative period? 1. Prone position 2. Supine with no head elevation 3. Side-lying with the legs extended 4. Supine with the head elevated 45 degrees Question: 57 Correct Answer: 3 An operating room nurse is positioning a client on the operating room table to prevent the client's extremities from dangling over the sides of the table. A nursing student who is observing for the day asks the nurse why this is so important. The nurse responds that this is done primarily to prevent which condition? 1. An increase in pulse rate 2. A drop in blood pressure 3. Nerve and muscle damage 4. Muscle fatigue in the extremities Question: 58 Correct Answer: 1 A client receiving total parenteral nutrition (TPN) experiences sudden development of chest pain, dyspnea, tachycardia, cyanosis, and a decreased level of consciousness. What should the nurse suspect as a complication of the TPN? 1. Air embolism 2. Hyperglycemia 3. Catheter-related sepsis 4. Allergic reaction to the catheter Question: 59 Correct Answer: 1 The nurse assists the health care provider to perform an amniotomy on a client in labor. Which is the priority nursing action after this procedure? 1. Assess the fetal heart rate. 2. Check the client's temperature. 3. Change the pads under the client. 4. Check the client's respiratory rate. Question: 60 Correct Answer: 1 The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? 1. 3 days postpartum 2. 7 days postpartum 3. On the day of birth 4. Within 2 weeks postpartum Question: 61 Correct Answer: 1 A client being discharged to home with a prescription for eye drops to be given in the left eye has received instructions regarding self-administration of the drops. The nurse determines that the client needs further instruction if, on return demonstration, the client takes which action? 1. Lies supine, pulls up on the upper lid, and puts the drop in the upper lid 2. Lies supine, pulls down on the lower lid, and puts the drop in the lower lid 3. Tilts the head back, pulls down on the lower lid, and puts the drop in the lower lid 4. Lies with head to the right, puts the drop in the inner canthus, and slowly turns to the left while blinking Question: 62 Correct Answer: 2 The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication? 1. Peritonitis 2. Hyperglycemia 3. Hyperphosphatemia 4. Disequilibrium syndrome Question: 63 Correct Answer: 1 The nurse is caring for a client with a low thrombin level as a result of liver dysfunction. Based on this finding it is most important for the nurse to monitor the client for signs and symptoms of which potential complication? 1. Bleeding 2. Infection 3. Dehydration 4. Malnutrition Question: 64 Correct Answer: 3 The nurse plans to administer a medication by intravenous (IV) bolus through the primary IV line. The nurse notes that the medication is incompatible with the primary IV solution. Which is the appropriate nursing action to safely administer the medication? 1. Start a new IV line for the medication. 2. Flush the tubing after the medication with sterile water. 3. Flush the tubing before and after the medication with normal saline. 4. Call the health care provider for a prescription to change the route of the medication. Question: 65 Correct Answer: 1, 2, 3, 5 The nurse is obtaining a health history from a client and is assessing for risk factors associated with osteoporosis. The nurse would be most concerned if which data were obtained? Select all that apply. 1. The client reports that she doesn't exercise much at all. 2. The client reports that she smokes a few cigarettes a day. 3. The client reports that she is taking phenytoin to treat a seizure disorder. 4. The client reports that she consumes calcium and vitamin foods and supplements daily. 5. The client reports that she takes a daily low dose of prednisone to treat a chronic respiratory condition. Question: 66 Correct Answer: 1 A supervisor reprimands the charge nurse for not adhering to the unit budget. What behavior by the charge nurse is an example of displacement? 1. The charge nurse blames staff for wasting supplies. 2. The charge nurse claims that administration wasn't critical. 3. The charge nurse refuses to believe the supervisor's criticisms. 4. The charge nurse smiles and nods in agreement when reprimanded. RN Practice Question Banks 31-45 (Not Required) Question: 67 Correct Answer: 1, 4 A client is scheduled for a CT scan with contrast. What interventions should be taken by the nurse prior to sending the client to the imaging department? (Select all that apply.) 1. Reassess the client's allergies 2. Administer prescribed medication to sedate the client 3. Confirm that a signed consent is in the chart 4. Ask the client to remove all metal jewelry 5. Ensure the client is well-hydrated Rationale Usually the client is NPO prior to a CT scan, particularly when contrast material is being used. Allergies and past reactions to contrast media should be reviewed with the client. Any metal, including body piercings, jewelry, hearing aids and removable dental work should be removed and safely stored prior to the test. Sedation is necessary only in cases of extreme anxiety. Question: 68 Correct Answer: 3, 5 A nurse is caring for a 13 year-old after a spinal fusion to treat scoliosis. Which nursing intervention is appropriate in the immediate postoperative period? (Select all that apply.) 1. Maintain bedrest with the head of the bed elevated at least 30 degrees 2. Assist the client to stand and walk to the bathroom as needed 3. Encourage passive leg and ankle exercises 4. Position the client flat in bed and logroll every 2 to 4 hours 5. Encourage use of patient-controlled analgesia 6. Perform neurovascular checks every 8 hours Rationale The client should remain flat in bed for at least 6 hours and turned from side to side every 2 to 4 hours. The day after surgery, the client can sit up in bed a few times; the client will get out of bed to sit in a chair on the second or third day after surgery. Clients should be encouraged to perform isometric exercises right after surgery. Neuro checks will be performed every 2 hours for the first 24 hours. Question: 69 Correct Answer: 3, 4, 5 The health care provider writes a new order for a fentanyl (Sublimaze) patch to manage the chronic pain experienced by the client in hospice care. The nurse is teaching a client and family members about the fentanyl patch and knows that teaching was effective when the client makes which of the following statements? (Select all that apply.) 1. "I can soak in a hot tub to help decrease my pain." 2. "I should cut up the patch before I throw it away so no one else can use it." 3. "It may take up to a half day or longer for the patch to start working, the first time I use it." 4. "If my pain is too great while I am on the patch, I can take a supplemental pain medication." 5. "I will take the old patch off before I apply the new patch on." Rationale Fentanyl patches are slowly absorbed via the subcutaneous tissue at a predetermined rate for up to 72 hours. Due to the slow absorption rate, the first patch may take 12 to 24 hours before effective analgesia is felt; a short-acting opioid may be given for breakthrough pain. The client can shower or bathe with the patch, but it should not be exposed to heat (hot tubs, heating pads) because it speeds up the absorption of the medication. Old patches are removed and the new patch is applied to a different skin area. Old patches are disposed by folding the old patch in half, not by cutting them up and throwing them in the trash (which may be dangerous for people and pets). Question: 70 Correct Answer: 2, 3, 5 The nurse is assessing a client who sustained multiple fractures, contusions, and lacerations in a motor vehicle accident three days ago. The client suddenly becomes confused. Which of the following findings would support the nurse's suspicion that the client has developed a fat embolism? (Select all that apply.) 1. Hypertension 2. Petechiae on the upper anterior chest 3. Elevated temperature 4. Dyspnea 5. Low oxygen saturation Rationale Manifestations of acute confusion, hypoxia, fever and hypotension may indicate fat embolism in a client who has sustained multiple fractures, particularly fractures of the long bones. The occlusion of dermal capillaries by fat with increased friability of the capillaries can result in skin petechiae. This is most common on the chest, neck, upper arm, axilla, shoulder, oral mucous membranes and conjunctiva. Question: 71 Correct Answer: 1, 3, 5, 6 A client with a history of asthma and kidney stones is admitted with a diagnosis of recurrent renal calculi. The client experiences shortness of breath following a lithotripsy. The nurse auscultates the client's lungs and finds decreased air movement but no wheezing. The arterial blood gas (ABG) results are pH 7.31, PaO2 53 mm Hg, PaCO2 50 mm Hg, and O2 sat 82%. Which of the following actions are appropriate for the nurse to take? (Select all that apply.) 1. Call respiratory therapy 2. Administer a short-acting bronchodilator via nebulizer 3. Start high flow oxygen via face mask 4. Start oxygen via nasal cannula 5. Increase IV fluids 6. Contact the health care provider 7. Prepare for possible intubation Rationale This client needs emergency treatment to open the airways and improve gas exchange. The absence of lung sounds without wheezing indicates a severe narrowing of the airways in asthma with minimal air movement. Emergent intervention to open the closed airway including possible intubation are indicated. The high PaCO and low pH indicate respiratory acidosis due to inadequate gas exchange. The low oxygen saturation and PaO2 indicate severe hypoxemia requiring high flow oxygen via mask. Question: 72 Correct Answer: 1, 2, 5 The geriatric social worker is working with the nurse to assess the client's ability to perform instrumental activities of daily living (IADL). Which of the following skills are considered instrumental activities of daily living? (Select all that apply.) 1. Ability to take medications 2. Ability to cook meals 3. Ability to eat independently/feed self 4. Ability to bathe self 5. Ability to write checks Rationale Activities of daily living (ADLs) are basic self-care tasks, such as feeding, toileting, grooming, bathing, putting on clothes. Instrumental activities of daily living (IADLs) are slightly more complex skills and include a series of life functions necessary for living independently, such as the ability to use a telephone, shopping, doing housework, preparing meals, handling finances, and being responsible to take medications. ADLs and IADLs are part of an older adult's functional assessment. Question: 73 Correct Answer: 1, 2, 4 The charge nurse is making assignments on the day shift for a registered nurse (RN), a licensed practical nurse (LPN) and a certified nursing assistant (CNA). Which assignments are the most appropriate for a client who fell during the night and now has a skin tear on his arm and a hematoma on his hip, and is scheduled for an x-ray of his hip? (Select all that apply.) 1. Assign medication administration to the LPN 2. Assign wound care to the RN 3. Assign complete care to the LPN 4. Assign the CNA to assist with personal hygiene tasks 5. Assign the LPN to report confusion or headache Rationale The RN can assign clients to LPNs as long as the care of the client is not too complex and there is a low likelihood of an emergency. Since this client fell during the night, the RN should not assign complete care to the LPN. But the LPN could administer medications to this client and should report observations and assessment data to the RN. The CNA can assist the client with personal care activities. Question: 74 The nurse is performing pulmonary assessment on a client. Indicate the correct sequence of pulmonary assessment by dragging and dropping the steps below into the correct order. 1. Auscultation 2. Inspection 3. Palpation 4. Percussion Correct Answer 1. Inspection 2. Palpation 3. Percussion 4. Auscultation Rationale Inspection is first, observing for pattern of breathing, symmetry, anteroposterior and transverse chest diameters, as well as skin color, sounds and odors. The nurse will then palpate the posterior and anterior chest, noting any tenderness, crepitus, or tactile fremitus. The next step is percussion, which is performed in a systematic manner, usually from side to side from apex (top) of lungs to base (bottom), listening to changes in tone from one area to another. Lastly, the lungs are auscultated, listening over the anterior, posterior, and lateral chest for expected or adventitious sounds. Question: 75 The nurse is preparing to administer total parenteral nutrition (TPN) through a central line. Indicate the correct order in which the following nursing actions should be performed by dragging and dropping the options below. 1. Set the infusion pump at the prescribed rate 2. Use aseptic technique when handling the injection cap 3. Select and prime the correct tubing and filter 4. Thread the intravenous tubing through an infusion pump 5. Connect the tubing to the central line 6. Check the solution for cloudiness or sediment Correct Answer 1. Check the solution for cloudiness or sediment 2. Select and prime the correct tubing and filter 3. Thread the intravenous tubing through an infusion pump 4. Use aseptic technique when handling the injection cap 5. Connect the tubing to the central line 6. Set the infusion pump at the prescribed rate Rationale TPN solution should not be cloudy or have any kind of particles or sediment. The nurse should prepare the equipment by priming the tubing and threading it through the pump. To prevent infection, the nurse must use aseptic technique when inserting the connector into the injection cap and connecting the tubing to the central line. The nurse should then set the pump at the prescribed rate. Post test 12/02/2016 09:44:56 PM Post-Test Completed Question: 76 Correct Answer: 3 A client is scheduled to receive a daily morning dose of furosemide. Which client laboratory result warrants a call to the health care provider (HCP) prior to the medication administration? 1. Serum sodium of 135 mEq/L (135 mmol/L) 2. Serum calcium of 10.4 mg/dL (2.6 mmol/L) 3. Serum potassium of 2.8 mEq/L (2.8 mmol/L) 4. Fasting blood glucose of 110 mg/dL (6 mmol/L) Question: 77 Correct Answer: 4 The nurse is caring for a client at home with a diagnosis of actinic keratosis. The client tells the nurse that her skin is very dry and irritated. The treatment includes diclofenac sodium. The nurse teaches the client that this medication is from which class of medications? 1. Antiinfectives 2. Vitamin A lotions 3. Coal tar preparations 4. Nonsteroidal antiinflammatory drugs (NSAIDs) Question: 78 Correct Answer: 4 The nurse caring for a child with suspected absence seizures is collecting data from the parents on how to manage the disorder. Which statement, if made by the parents, indicates the presence of signs congruent with this disorder? 1. "My child does well with group activities." 2. "My child leads the other children during group play." 3. "My child is doing really well in school and has high grades." 4. "My child's teacher mentioned that he seems to daydream a lot." Question: 79 Correct Answer: 2, 4, 5, 6 Which characteristics would the nurse expect to note for a client with seasonal affective disorder? Select all that apply. 1. Affects males more often than females 2. Is related to abnormal melatonin metabolism 3. Usually results in debilitating symptomatology 4. Improves during the spring and summer months 5. Is a result of alterations in the available amounts of sunlight 6. A craving for carbohydrates lessens during sunnier and spring months Question: 80 Correct Answer: 1, 2, 3, 4, 5 The nurse is caring for a terminally ill toddler. When interacting with the toddler's parents, the nurse should implement which interventions? Select all that apply. 1. Retain ritualism. 2. Avoid significant changes in lifestyle. 3. Maintain sensitivity toward the parents. 4. .Encourage the parents to be near the child. 5. Encourage as normal an environment as possible. 6. Discourage the parents from verbalizing their feelings. Question: 81 Correct Answer: 2 A client with type 1 diabetes mellitus is admitted to the emergency department with suspected diabetic ketoacidosis (DKA). Which laboratory result would be expected with this diagnosis? 1. Urine is negative for ketones. 2. Serum potassium is 6.8 mEq/L (6.8 mmol/L). 3. Serum osmolality is 260 mOsm/kg (260 mmol/kg) H20. 4. Arterial blood gas values are pH 7.52, PCO2 44 mm Hg, HCO3- 30 mEq/L (30 mmol/L). Question: 82 Correct Answer: 2 The mental health nurse is meeting with a client who has a long history of abusing drugs. During the session the client says to the nurse, "I'm feeling much better now, and I'm ready to go straight." Which response by the nurse would be therapeutic? 1. "You have said this many times before!" 2. "Tell me what makes you feel that you are ready." 3. "I need to see changes in you to believe that you are ready to go straight." 4. "I'm so glad to hear you talking this way. I will let your health care provider know." Question: 83 Correct Answer: 2 A client is being weaned from parenteral nutrition (PN) and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hour. The nurse anticipates that which prescription regarding the PN solution will accompany the diet prescription? 1. Discontinue the PN. 2. Decrease PN rate to 50 mL/hour. 3. Start 0.9% normal saline at 25 mL/hour. 4. Continue current infusion rate prescriptions for PN. Question: 84 Correct Answer: 4, 5 A nursing student is preparing to instruct a pregnant client in performing Kegel exercises. The nursing instructor asks the student the purpose of Kegel exercises. Which response made by the student indicates an understanding of the purpose? Select all that apply. 1. "The exercises will help reduce backaches." 2. "The exercises will help prevent ankle edema." 3. "The exercises will help prevent urinary tract infections." 4. "The exercises will help strengthen the pelvic floor in preparation for delivery." 5. "The exercises will help strengthen the muscles that support the bladder and urethra." Question: 85 Correct Answer: 1 The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? 1. Protecting the client from infection 2. Providing emotional support to decrease fear 3. Encouraging discussion about lifestyle changes 4. Identifying factors that decreased the immune function Question: 86 Correct Answer: 1 The nurse is planning care for a child with hemolytic-uremic syndrome who has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to implement which measure? 1. Restrict fluids as prescribed. 2. Care for the arteriovenous fistula. 3. Encourage foods high in potassium. 4. Administer analgesics as prescribed. Question: 87 Correct Answer: 10 pack-years The clinic nurse is performing an assessment for a client who is complaining of shortness of breath. The client admits to smoking 1 pack of cigarettes per day for the past 10 years. The nurse determines that the client has a smoking history of how many pack- years? Fill in the blank. Question: 88 Correct Answer: 4 An infant is born to a mother with hepatitis B. Which prophylactic measure is indicated for the infant? 1. Hepatitis B vaccine given within 24 hours after birth 2. Immune globulin (IG) given as soon as possible after delivery 3. Hepatitis B immune globulin (HBIG) given within 14 days after birth 4. Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth Question: 89 Correct Answer: 2 A home health nurse is visiting a client who has been started on therapy with clotrimazole. The nurse determines the effectiveness of the medication by noting a decrease in which problem? 1. Pain 2. Rash 3. Fever 4. Sneezing Question: 90 Correct Answer: 3 Sulfisoxazole, 1 g orally twice daily, is prescribed for an adolescent with a urinary tract infection. The medication label reads "500-mg tablets." The nurse has determined that the dosage prescribed is safe. The nurse administers how many tablets per dose to the adolescent? 1. 1⁄2 tablet 2. 1 tablet 3. 2 tablets 4. 3 tablets Question: 91 Correct Answer: 3 A homeless shelter has sustained severe damage as a result of a fire, and most of the structure and people's belongings were destroyed. Ten of the individuals who are being displaced have a history of chronic mental illness. The mental health team coordinating support initially should focus their efforts on which action? 1. Assessing the clients' need for supportive therapy 2. Evaluating the clients for signs of stress overload 3. Providing the clients with shelter, clothing, and food 4. Planning means for the clients to receive their medications Pharm 11/10/2018 01:54:50 PM Exam-25 Completed Question: 92 Correct Answer: 4 Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adverse effects of the medication. Which finding indicates that the client is experiencing an adverse effect? 1. Pruritus 2. Tachycardia 3. Hypertension 4. Impaired voluntary movements Question: 93 Correct Answer: 3 The nurse is caring for a client who is receiving growth hormone replacement therapy. The nurse monitors the client for which option as an adverse effect of this therapy? 1. Hypocalciuria 2. Hypoglycemia 3. Hyperglycemia 4. Hyperthyroidism Question: 94 Correct Answer: 1 A client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L (2.5 mmol/L). The nurse plans care based on which representation of this level? 1. Toxic 2. Normal 3. Slightly above normal 4. Excessively below normal Question: 95 Correct Answer: 1 The nurse monitors the client taking octreotide acetate for acromegaly for which most common side or adverse effect of this medication? 1. Diarrhea 2. Dyspnea 3. Constipation 4. Bradycardia Question: 96 Correct Answer: 1 The school nurse has provided instructions regarding the use of permethrin rinse to the parents of children diagnosed with pediculosis capitis (head lice). Which statement by one of the parents indicates a need for further instruction? 1. "It is applied to the hair and then shampooed out." 2. "The hair should not be shampooed for 24 hours after treatment." 3. "The permethrin rinse can be obtained over the counter in a local pharmacy." 4. "It is applied to the hair after shampooing, left on for 10 minutes, and then rinsed out." Question: 97 Correct Answer: 4 A client with schizophrenia has been started on medication therapy with clozapine. The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication? 1. Platelet count 2. Blood glucose level 3. Liver function studies 4. White blood cell count Question: 98 Correct Answer: 3 The nurse suspects that a client prescribed clomipramine hydrochloride has been noncompliant with taking the medication as prescribed. Which client behavior would support the nurse's suspicion? 1. Tired, fatigued appearance 2. Complaints of hunger and fatigue 3. Frequently checking for the car key 4. Slight dizziness when standing up quickly Question: 99 Correct Answer: 2 Dapsone is prescribed for a client with acquired immunodeficiency syndrome (AIDS) for the treatment of toxoplasmosis. The nurse provides medication instructions and determines that the client understands the instructions if the client states that which action is necessary? 1. Discontinue the medication if nausea develops. 2. Report a sore throat to the health care provider (HCP). 3. Plan to take the medication every 4 hours around the clock. 4. Expect that abdominal pain and jaundice will occur as normal side effects. Question: 100 Correct Answer: 3 A client with portosystemic encephalopathy is receiving oral lactulose daily. The nurse should check which item to determine that this medication has been effective? 1. Lung sounds 2. Blood pressure 3. Blood ammonia level 4. Serum potassium level Question: 101 Correct Answer: 1 A client has developed paroxysmal nocturnal dyspnea. Which medication should the nurse anticipate will be prescribed by the health care provider? 1. Bumetanide 2. Amiodarone 3. Propranolol 4. Streptokinase Question: 102 Correct Answer: 4 A client with gastrointestinal hypermotility has a prescription to receive atropine sulfate. The nurse should withhold the medication and question the prescription if the client has a history of which disease process? 1. Biliary colic 2. Sinus bradycardia 3. Peptic ulcer disease 4. Narrow-angle glaucoma Question: 103 Correct Answer: 4 A client taking an oral laxative wants to obtain a rapid effect from the medication. How should the nurse instruct the client to take the medication? 1. At bedtime 2. With breakfast 3. With the noon meal 4. On an empty stomach Question: 104 Correct Answer: 4 The health care provider is planning to prescribe a medication for a client with major depression. Which medication should the nurse expect to be prescribed? 1. Diazepam 2. Lorazepam 3. Phenobarbital 4. Paroxetine hydrochloride Question: 105 Correct Answer: 1 A client with a history of duodenal ulcer is taking calcium carbonate chewable tablets. Which finding indicates that the client is experiencing optimal effects of the medication? 1. Heartburn is relieved. 2. Muscle twitching stops. 3. The serum calcium level increases. 4. The serum phosphorus level decreases. Question: 106 Correct Answer: 4 The nurse is speaking with a client taking phenytoin for seizure control. The client states that she has started using birth control pills to prevent pregnancy. Which would be an important point for the nurse to emphasize to the client? 1. Oral contraceptives decrease the effectiveness of phenytoin. 2. Severe gastrointestinal side effects can occur when phenytoin and oral contraceptives are taken together. 3. There is an increased risk of thrombophlebitis when phenytoin and oral contraceptives are taken at the same time. 4. Phenytoin may decrease the effectiveness of birth control pills, and additional measures should be taken to avoid pregnancy. Question: 107 Correct Answer: 4 A client has been given a prescription for a course of azithromycin. The nurse should tell the client that this medication will relieve which problem? 1. Pain 2. Joint inflammation 3. High blood pressure 4. Signs and symptoms of infection Question: 108 Correct Answer: 1 A client is prescribed tranylcypromine. The nurse educating a client about tranylcypromine should instruct the client to avoid which activity? 1. Drinking any amount of wine 2. Consuming any fresh dairy products 3. Exposing the skin of the face to sunlight 4. Eating either fresh or frozen green leafy vegetables Question: 109 Correct Answer: 4 A home care nurse is visiting a client who was discharged to home with a prescription for continued administration of enoxaparin subcutaneously. What is the nurse's priority assessment for this client? 1. Constipation 2. Fear of needles 3. Nausea or vomiting 4. Bleeding gums or bruising Question: 110 Correct Answer: 3 A man has developed atrial fibrillation and has been placed on warfarin. The nurse is doing discharge dietary teaching with the client and determines that the client needs additional education if he states that he would choose which food while taking this medication? 1. Cherries 2. Potatoes 3. Broccoli 4. Spaghetti Question: 111 Correct Answer: 4 The ambulatory care nurse is providing instructions to a client with a urinary tract infection (UTI) being started on nitrofurantoin. The nurse should provide the client with which information? 1. It can cause urinary retention. 2. It will cause the urine to become clear. 3. The sun should be avoided because it is a sulfa-based medication. 4. If taken with meals, it will help decrease the risk for gastrointestinal (GI) upset. Question: 112 Correct Answer: 1, 4 A client has a prescription for valproic acid. To maximize the client's safety, the nurse should plan to monitor for which potential complications of this medication? Select all that apply. 1. Pancreatitis 2. Hypotension 3. Renal failure 4. Hepatotoxicity 5. Cardiotoxicity Question: 113 Correct Answer: 4 A client has a wound with a moderate amount of drainage and is scheduled for a dressing change. Which dressing, if selected by the student nurse, requires further intervention by the nursing instructor? 1. Foam 2. Alginate dressing 3. Hydrocolloid dressing 4. Semipermeable transparent film Question: 114 Correct Answer: 4 The nurse is collecting subjective and objective data from a client and notes that the client is taking abacavir. The nurse determines that this medication has been prescribed to treat which condition? 1. Otitis media 2. Heart failure 3. Urinary tract infection 4. Human immunodeficiency virus (HIV) infection Question: 115 Correct Answer: 1 Insulin glargine is prescribed for a client with diabetes mellitus. The nurse should tell the client that it is best to take the insulin at which time? 1. At bedtime every day 2. 1 hour after each meal 3. 15 minutes before the morning and evening meals 4. Before each meal, on the basis of the blood glucose level Question: 116 Correct Answer: 1 The nurse is caring for a client who is receiving heparin sodium intravenously as a continuous infusion. Which laboratory finding requires immediate nursing intervention? 1. Platelet count of 100,000 mm3 (100 × 109/L) 2. Red blood cell count of 4.2 cells (4.2 × 1012/L) 3. International normalized ratio (INR) of 1.2 (1.2) 4. Activated partial thromboplastin time (aPTT) of 60 seconds (60 seconds) RN Practice Question Banks 61-75 (Not Required) Question: 117 Correct Answer: 1, 2, 5 A healthy 18 year-old is entering college in the fall. Which immunization would the health care provider recommend prior to college? (Select all that apply.) 1. Seasonal influenza vaccine 2. Tetanus, Diphtheria, Pertussis vaccine (Tdap) 3. Pneumococcal polysaccharide vaccine (PPSV23) 4. Meningococcal conjugate vaccine (MCV4) 5. Shingles vaccine 6. Human papillomavirus (HPV) vaccine Rationale Adults older than age 50 should get the shingles vaccine. The PPSV23 is given to adults older than age 65. (The pneumococcal vaccine PCV13 is routinely given to infants/children.) An 18 year-old who is going to college should receive the TDAP, MCV4 and seasonal influenza vaccine. He or she should also receive the HPV vaccine if s/he has not already received it. Question: 118 Correct Answer: 1, 2, 4 A client is being prepared for an above-the-knee amputation. Which of the following measures are part of the nurse's responsibilities, which are designed to protect the client? (Select all that apply.) 1. Verify any allergies 2. Verify that the informed consent form is signed 3. Have the client confirm his or her identity, the surgical site and the procedure before administration of any medications 4. Verify the surgical leg is marked with indelible marker over, or as close as possible to, the surgical incision site 5. Explain the procedure, including any risks, before the client signs the surgical consent form Rationale Prior to surgery, the nurse can witness the client's signature on the consent form, but explanation of the procedure, including risks and benefits, needs to come from the health care provider. Any allergies must be noted and verified prior to surgery. The surgeon must use an indelible marker on the surgical leg to indicate the incision site; sometimes the nonsurgical leg will be marked with a "NO." In the operating room, a surgical checklist is completed with a nurse and anesthesiologist. Prior to administration of anesthesia, there is another check with the client to verify identify, the correct surgical site and procedure. Question: 119 Correct Answer: 1, 2, 3, 5 The client is being treated for complications of a chronic disease on a medical-surgical unit. Who can have access to the client's medical record? (Select all that apply.) 1. The nursing instructor planning clinical assignments 2. The facility researcher collecting data for a study to which the client consented 3. The certified nursing assistant documenting vital signs 4. The emergency department nurse who originally admitted the client and now wants to know the client's current status 5. The person who has health care power of attorney 6. The client's spouse or other close family member Rationale Safeguarding client privacy requires strict adherence to the ethical standards of confidentiality and need-to-know access. Only those individuals who are directly involved in the client's care should have access to his or her information. The ED nurse is no longer directly involved in the client's care and should not have access to information about the client. Without valid authorization, such as health care power of attorney, a spouse or other family members cannot access the client's medical records. Question: 120 Correct Answer: 1, 2, 3 A newly admitted client reports taking phenytoin for several months. Which of the following assessments should the nurse be sure to include in the admission report? (Select all that apply.) 1. Report of unsteady gait, rash and diplopia 2. Report of any seizure activity 3. Serum phenytoin levels 4. Report of anorexia, numbness and tingling of the extremities Rationale Serious adverse outcomes of antiseizure medications such as phenytoin (Dilantin) are unsteady gait, slurred speech, extreme fatigue, blurred vision or feelings of suicide. Increased hunger (not anorexia), increased thirst or increased urination are additional serious side effects. Question: 121 Correct Answer: 1, 4, 5 The nurse compares the third postoperative assessment findings to the first two postoperative assessments. What action should the nurse take to provide optimal care for this client? (Select all that apply.) 1. Elevate the client's lower extremities 2. Move the bed into Trendelenburg position 3. Assist the client to use the incentive spirometer 4. Administer an intravenous fluid bolus 5. Inspect the surgical incision site 6. Administer pain medication Rationale Hypovolemia due to blood loss should be considered in the postoperative client who develops tachycardia and hypotension (a systolic BP reading below 90 in an adult indicates possible shock.) The nurse should check the incision site and any area dependent of the site for any blood loss. Evidence supports elevating the lower extremities in hypotensive episodes, to bring fluid from the lower body to the core; there is no evidence to support using the Trendelenburg position. An IV fluid bolus can also be used to increase volume. Although hypotension and tachycardia may also indicate pain, the nurse should ensure that the client's ABCs are stable before medicating for pain. Assisting the client to use the incentive spirometer can be done later. Blood Pressure Pulse Respiratory Rate Oxygen Saturation 1st Postop Assessment 110/80 mm Hg 80 10 98% 2nd Postop Assessment 100/72 mm Hg 88 16 97% 3rd Postop Assessment 92/64 mm Hg 106 24 95% RN Practice Question Banks 76-90 (Not Required) Question: 122 Correct Answer: 2, 3 The home care nurse is admitting a new client with a diagnosis of COPD, atrial fibrillation and gout. After reviewing the client's medication list, the nurse would arrange for periodic monitoring of blood drug levels for which of the following medications? (Select all that apply.) 1. Beclomethasone inhaled (Qvar) 2. Digoxin (Lanoxin) 3. Theophylline (Elixophyllin, Theo-24, Uniphyl) 4. Allopurinol (Aloprim, Zyloprim) 5. Glipizide (Glucotrol) Rationale It is necessary to monitor blood levels for the client taking theophylline and digoxin to prevent the client from developing toxicity. Question: 123 Correct Answer: 1, 2, 3, 5, 6 The nurse is to review the topic of caring for clients with Guillain-Barre syndrome with other staff members at a monthly meeting. Which of these findings should the nurse include in the discussion? (Select all that apply.) 1. Weakness, tingling or loss of sensation in legs and feet occur first 2. Rapidly progressive ascending paralysis of the legs, arms, respiratory muscles and face 3. Difficulty with bladder control or intestinal functions 4. Hypertension 5. Difficulty with eye movement, facial movement, speaking, chewing or swallowing 6. Numbness, tingling, prickling sensation or moderate pain throughout the body Rationale Guillian-Barre is an autoimmune disease. The symptoms of weakness or tingling sensation begins in the legs and progresses to the arms and upper body, resulting in almost complete paralysis. The client is often put on a ventilator during the worst part of the disease to assist breathing. The client may have low blood pressure or poor blood pressure control. Question: 124 Correct Answer: 1, 2 A client who has returned from surgery reports feeling nauseated and later has an emesis. The nurse administers promethazine per standing orders. In addition to relief from nausea, what other effects of this medication does the nurse expect? (Select all that apply.) 1. Dry mouth 2. Sedation 3. Pinpoint pupils 4. Heart palpitations 5. Runny nose Rationale Promethazine (Phenergan) is used as an antihistamine, sedative and antiemetic. It produces anticholinergic effects, such as dry mouth and nasal congestion, dilated pupils and urinary retention. Although promethazine is a sedative, the nurse should understand that it can cause some people to have heart palpitations and to feel restless and unable to sleep. Question: 125 Correct Answer: 1, 3 The nurse is evaluating a stage III pressure ulcer while performing a dressing change. Which wound assessment findings indicate that the prescribed treatment is appropriate to support wound healing? (Select all that apply.) 1. The wound base is moderately moist, shiny and red 2. Clumps of soft yellow tissue adhere to the wound bed 3. The size of the wound is decreasing 4. The periwound texture is moist and soft 5. The edge of the wound appears rolled or curled under 6. A fruity odor is noted on the dressing Rationale A wound base that's moist, shiny and "beefy" red indicates good blood flow, new tissue growth and healing. Slough is clumps or strings of moist and soft tissue and can be yellow, tan or green in color – slough will impede healing. A fruity odor indicates infection. Soft and denuded tissues in the periwound indicate tissue breakdown due to excessive moisture from wound drainage. Curled or rolled wound edges (epibole) prevents epithelial cells from migrating to close the wound. Question: 126 Correct Answer: 1, 4 A client has been given a prescription for alendronate. Which of the following statements indicate the client understands how to safely take this medication? (Select all that apply.) 1. "I will notify the health care provider if I have any difficulty swallowing." 2. "I will take the pill immediately preceding weight-bearing exercise." 3. "I will swallow it with 8 ounces of water." 4. "I will stand or sit quietly for 30 minutes after taking it." 5. "I will always eat breakfast before taking it." Rationale Alendronate (Fosamax) can cause esophagitis or esophageal ulcers unless precautions are followed. The client must be able to sit upright or stand for at least 30 minutes after taking the tablet. The client should take the tablet first thing in the morning, with a full glass of water, at least 30 minutes before eating or drinking anything or taking any other medication. Question: 127 Correct Answer: 1, 3, 5 The client undergoes a laparoscopic removal of the appendix. Which postoperative instructions will the nurse reinforce? (Select all that apply.) 1. No showering for 48 hours after surgery 2. Maintain bedrest for 24 hours before gradually resuming regular activities 3. Some shoulder discomfort can be expected 4. Use 2 tablespoons of Milk of Magnesia if no bowel movement 3 days after surgery 5. Restrict diet to bland, easily digestible food for a few days 6. Gently scrub off the "skin glue" when you feel able Rationale Laparoscopic surgery involves using carbon dioxide gas to open the inside of the abdomen, which pushes up the diaphragm; this may cause shoulder discomfort postoperatively. Clients should keep the dressings clean and dry for 48 hours before they can shower, but no tub baths for a few weeks. If "skin glue" is used over the incision(s), the client should not try to scrub it off because it will wear off on its own. Clients may resume normal activities as soon as they are able but no heavy lifting or aerobic exercise for about 2 weeks. If they do not have a BM after 2-3 days, clients can take 2 tablespoons of MOM several times a day until they have a BM. Diet can be advanced as tolerated but it's best to stick to non-greasy, non-spicy foods for a few days. Question: 128 Correct Answer: 1, 3, 4, 5 During a 12-hour night shift, the nurse has a "near miss" and catches an error before giving a new medication. Which statement might explain the reason for the near miss? (Select all that apply.) 1. The nurse works in the intensive care unit (ICU) 2. The nurse has worked on the same unit for 5 years 3. The unit is short-staffed 4. The nurse is interrupted when preparing the medication 5. The nurse is sleep-deprived Rationale There are a number of reasons for near misses and making medication errors, including heavy workload and inadequate staffing, distractions, interruptions, and inexperience. Fatigue and sleep loss are also factors, especially for nurses working in units with high acuity clients. Question: 129 Correct Answer: 1, 2, 4, 5 A parent asks the nurse about a Guthrie Bacterial Inhibition test that was ordered for her newborn. Which of the following points should the nurse discuss with the client prior to this test? (Select all that apply.) 1. The test will be delayed if the baby's weight is less than 5 pounds 2. Positive tests require dietary control for prevention of brain damage 3. This test identifies an inherited disease 4. The urine test can be done after six weeks of age 5. Best results occur after the baby has been breast-feeding or drinking formula for two full days 6. Routine screening of newborn infants is not mandatory in the United States Rationale Screening for PKU is mandated in all 50 states, though methods of screening vary. The Guthrie Bacterial Inhibition Assay (BIA) is one test used to diagnose phenylketonuria (PKU), a disease characterized by an enzyme deficiency. A blood sample is taken from the baby's heel shortly after birth, with a follow-up test 7 to 10 days later. Test results are more accurate if the baby weighs more than 5 pounds and has been regularly drinking milk for more than 24 hours. A urine test is normally done after six weeks of age if a baby did not have the blood test. Question: 130 Correct Answer: 1, 2, 5 The client returned from the cardiac catheterization lab four hours ago. The groin was used as the insertion site. Which of the assessment findings would the nurse immediately report to the health care provider? (Select all that apply.) 1. Capillary refill 6 seconds on the affected toes 2. Pale color of the affected limb 3. Trace amount of serosanguineous drainage on the groin dressing 4. Bruising or lump at the insertion site 5. Nonpalpable pedal pulse on the affected limb Rationale A trace of serosanguineous drainage on the dressing is common. Some bruising or a small lump is expected at the insertion site. Reportable conditions include significant reports of pain; abnormal lab values; abnormal ECG strip; post-procedure bleeding or swelling; color, temperature or pulse changes, especially to the affected limb. Capillary refill should be about 3 seconds. Question: 131 Correct Answer: 3, 4 A 12 year-old pediatric cancer client is distraught about the alopecia that occurred after the last chemotherapy treatment. Which nursing interventions are appropriate for this side effect of chemotherapy? (Select all that apply.) 1. Practice and teach thorough hand washing 2. Administer prescribed antiemetic medication before nausea is too severe 3. Encourage visits from friends before discharge from the hospital 4. Allow the child to choose a cap, scarf, wig or other head cover to use Rationale Alopecia is the loss of hair, which is a frequent side effect of certain types of chemotherapy. Although it is not life-threatening, the body image change is difficult for many individuals, particularly children and adolescents. Encouraging visits from friends before discharge helps the young client and friends adjust. Wearing preferred forms of head cover- ups increases comfort and decreases embarrassment. The other options are proper interventions for chemotherapy, but do not help the client with hair loss. Question: 132 The client returns from the post anesthesia care unit (PACU) in stable condition following abdominal surgery. While planning immediate postoperative care, the nurse identifies the nursing diagnoses listed below. Prioritize these diagnoses by placing them in order of importance (with 1 being the most important). 1. Acute pain related to surgical procedure 2. Risk for ineffective airway clearance related to anesthesia 3. Risk for imbalanced nutrition: less than body requirement related to NPO status 4. Impaired reality related to intensive equipment Correct Answer: 1. Risk for ineffective airway clearance related to anesthesia 2. Acute pain related to surgical procedure 3. Impaired reality related to intensive equipment 4. Risk for imbalanced nutrition: less than body requirement related to NPO status Rationale Airway is the highest priority, especially in the immediate postoperative period. Pain control is the next priority because this client will most likely experience significant pain. Although impaired mobility is expected, it does increase the client's risk for postoperative complications. The client's risk for nutrition imbalance is the lowest priority and is to be expected for a client who has had abdominal surgery; hydration is provided intravenously. Question: 133 A woman in early labor puts her call light on and tells the nurse "I think my water bag just broke and I feel like something came out with the water." A visual exam by the nurse reveals a prolapsed umbilical cord. List in order of priority the actions the nurse should perform in this obstetrical emergency. 1. Place the Clint in the knee-chest position on the bed 2. Administrator oxygen to the mother via mask at 10 L/min 3. Gloves and place two fingers into the cervical opening, beside the umbilical cord, to relieve pressure 4. Cal for assistant, asking that the health care provider is notified Correct Answer: 5. Gloves and place two fingers into the cervical opening, beside the umbilical cord, to relieve pressure 6. Cal for assistant, asking that the health care provider is notified 7. Place the Clint in the knee-chest position on the bed 8. Administrator oxygen to the mother via mask at 10 L/min Rationale A prolapsed cord is a medical emergency; the blood flow from the placenta to the fetus will be occluded with each contraction if the umbilical cord is compressed against the presenting part of the fetus and the dilated cervix which is why the priority intervention is to apply gloves and place two fingers to one side of the cord (or entire hand) to relieve pressure. The nurse is also calling for assistance so that someone can notify the health care provider and staff can prepare for emergent cesarean. Placing the client in a modified Sims or knee- chest position will allow gravity to help decrease pressure on the cord from the presenting part, but the primary relief from pressure on the umbilical cord is the gloved fingers. Oxygen administration will help once the circulation of blood to the fetus is re-established. Client Needs 11/10/2018 01:57:29 PM Exam-25 Completed Question: 134 Correct Answer: 4 On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? 1. The client taking diuretics and has tenting of the skin 2. The client with an ileostomy from a recent abdominal surgery 3. The client who requires intermittent gastrointestinal suctioning 4. The client with kidney disease and a 12-year history of diabetes mellitus Question: 135 Correct Answer: 1 The nurse has provided medication instructions to a client with an iron deficiency anemia who will be taking iron supplements. Which statement made by the client indicates an understanding of this medication? 1. "I need to increase my fluid intake." 2. "I should eliminate fiber foods from my diet." 3. "I need to take the medication with water before a meal." 4. "I should be sure to chew the tablet thoroughly before swallowing it." Question: 136 Correct Answer: 2 A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic? 1. "Do you think that having asthma will kill you?" 2. "You seem very distressed over learning you have asthma." 3. "Asthma is a treatable condition when medications are taken properly, so let's practice with your inhalant." 4. "It will be difficult to work with you if you can't view this as a challenge rather than ‘a nail in your coffin.' " Question: 137 Correct Answer: 3 The nurse is caring for a post-term, small for gestational age (SGA) newborn infant immediately after admission to the nursery. What should the nurse monitor as the priority? 1. Urinary output 2. Total bilirubin levels 3. Blood glucose levels 4. Hemoglobin and hematocrit levels Question: 138 Correct Answer: 3 The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse notes that the red blood cell (RBC) count is increased. The nurse interprets that this finding may be related to which condition or treatment? 1. Iron deficiency 2. Vitamin deficiency 3. Corticosteroid therapy 4. Bone marrow depression Question: 139 Correct Answer: 2 The registered nurse (RN) is planning client assignments and cannot take a client assignment today. Two unlicensed assistive personnel (UAP) and a licensed practical nurse (LPN) also are assigned to the unit. Which client should the RN most appropriately assign to the LPN? 1. A client requiring frequent ambulation 2. A client scheduled for a cardiac catheterization 3. A client requiring range-of-motion (ROM) exercises 4. A client with a 24-hour urine collection who is on strict bed rest Question: 140 Correct Answer: 2 The ambulatory care nurse is providing discharge instructions to a female client who underwent cryosurgery with laser therapy because of a positive Papanicolaou test. Which statement by the client indicates an understanding of the instructions? 1. "I should take sitz baths every 4 hours for the next week." 2. "I should expect the vaginal discharge to be clear and watery." 3. "Very strong pain medications will be needed to relieve any discomfort I may have." 4. "If I note any odor to the vaginal discharge, I should call the health care provider immediately." Question: 141 Correct Answer: 4 The nurse monitors the client receiving parenteral nutrition (PN) for complications of the therapy and should assess the client for which manifestations of hyperglycemia? 1. Fever, weak pulse, and thirst 2. Nausea, vomiting, and oliguria 3. Sweating, chills, and abdominal pain 4. Weakness, thirst, and increased urine output Question: 142 Correct Answer: 2 A client is diagnosed with Bell's palsy. The nurse assessing the client expects to note which symptom? 1. A symmetrical smile 2. Difficulty closing the eyelid on the affected side 3. Narrowing of the palpebral fissure on the affected side 4. Paroxysms of excruciating pain in the lips and cheek on the affected side Question: 143 Correct Answer: 3 The nurse is providing instructions to the mother of a child with human immunodeficiency virus infection regarding immunizations. Which statement by the mother indicates an understanding of the immunization schedule? 1. "The hepatitis B vaccine is not to be given to my child." 2. "My child will receive all the vaccines like any other child." 3. "Family members in the household need to receive the influenza vaccine." 4. "Blood tests are needed before any immunizations are given to my child." Question: 144 Correct Answer: 3 A client asks the nurse to explain what is involved in an intravenous fluorescein angiography study of the eye. The nurse should incorporate which statement in the reply? 1. "No contrast dye is used." 2. "Food is restricted for 4 hours before the procedure." 3. "Dilating drops will be instilled before the procedure." 4. "The study predicts the success of radial keratotomy." Question: 145 Correct Answer: 1 A client with an endocrine disorder has experienced recent weight loss and exhibits tachycardia. Based on the clinical manifestations, the nurse should suspect dysfunction of which endocrine gland? 1. Thyroid 2. Pituitary 3. Parathyroid 4. Adrenal cortex Question: 146 Correct Answer: 1 While eating lunch in the hospital cafeteria, a nursing student overhears 2 nurses talking about a client. Which is the important information for the nurses to remember when talking about the client? 1. Talking about clients in public places is a violation of the client's confidentiality. 2. The client's rights to confidentiality do not apply to the break time of employees. 3. It is acceptable for the nurses to talk about a client because they are on the same treatment team. 4. The nurses taking care of the client should not share information with each other that the client has told them separately. Question: 147 Correct Answer: 1 The nurse is caring for a client with acute pancreatitis. Which finding should the nurse expect to note when reviewing the laboratory results? 1. Elevated serum lipase level 2. Elevated serum bilirubin level 3. Decreased serum trypsin level 4. Decreased serum amylase level Question: 148 Correct Answer: 3 The nurse is caring for a group of clients on the clinical nursing unit. The nurse interprets that which of these clients is at most risk for the development of pulmonary embolism? 1. A 25-year-old woman with diabetic ketoacidosis 2. A 65-year-old man out of bed 1 day after prostate resection 3. A 73-year-old woman who has just had pinning of a hip fracture 4. A 38-year-old man with pulmonary contusion sustained in an automobile crash Question: 149 Correct Answer: 3 The nurse collects a 24-hour urine specimen for catecholamine testing from a client with suspected pheochromocytoma. The results of the catecholamine test are reported as epinephrine 20 mcg (109 nmol) and norepinephrine 100 mcg (590 nmol). The nurse should make which interpretation about this result? 1. Insignificant and unrelated to pheochromocytoma 2. Lower than normal, ruling out pheochromocytoma 3. Higher than normal, indicating pheochromocytoma 4. Normal results for a client with pheochromocytoma Question: 150 Correct Answer: 2 The nurse is preparing the morning medications to be administered to assigned clients and is reviewing the health care provider's prescriptions. Which medication prescription should the nurse question? 1. Lanoxin 0.25 mg orally daily 2. Hydrochlorothiazide orally twice daily 3. Docusate sodium 100 mg orally twice daily 4. Enoxaparin sodium 20 mg subcutaneously daily Question: 151 Correct Answer: 3 The nurse is caring for a child with a diagnosis of a right-to-left cardiac shunt. On review of the child's record, the nurse should expect to note documentation of which most common assessment finding? 1. Severe bradycardia 2. Asymptomatic after feeding 3. Bluish discoloration of the skin 4. Higher than normal body weight Question: 152 Correct Answer: 3 A client is diagnosed with a rib fracture and asks the nurse why strapping of the ribs is not being done. Which response by the nurse is most appropriate? 1. "Strapping is useful only if the ribs are fractured in several places at once." 2. "That's a good idea. I'll ask the health care provider for a prescription for the needed supplies." 3. "That isn't done because people often would develop pneumonia from the constricting effect on the lungs." 4. "That might help you to breathe better, but this facility does not carry the necessary supplies in the stockroom. When you get home, you can purchase them at the medical supply store." Question: 153 Correct Answer: 1, 2, 3, 5 The nurse is preparing to administer medication using a client's nasogastric tube. Which actions should the nurse take before administering the medication? Select all that apply. 1. Check the residual volume. 2. Aspirate the stomach contents. 3. Turn off the suction to the nasogastric tube. 4. Remove the tube and place it in the other nostril. 5. Test the stomach contents for a pH indicating acidity. Question: 154 Correct Answer: 3 A nurse is caring for a client with thyrotoxicosis who is at risk for the development of thyroid storm. To detect this complication, the nurse should assess for which sign or symptom? 1. Bradycardia 2. Constipation 3. Hypertension 4. Low-grade temperature Question: 155 Correct Answer: 1 The nurse is caring for a client with common bile duct obstruction. The nurse should anticipate that the health care provider (HCP) will prescribe which diet for this client? 1. Low fat 2. High protein 3. High carbohydrate 4. Low in water-soluble vitamins Question: 156 Correct Answer: 1 The nurse is assessing the skin of a client with a history of malabsorption deficiency and discovers brittle nails. What type of nutritional deficiency should the nurse suspect based on this observation? 1. Iron deficiency 2. Protein deficiency 3. Fatty acid deficiency 4. Vitamin K deficiency Question: 157 Correct Answer: 2 The nurse has a prescription to give dexamethasone by the intravenous (IV) route to a client with cerebral edema. How should the nurse prepare this medication? 1. Diluting the medication in 500 mL of 5% dextrose 2. Preparing an undiluted direct injection of the medication 3. Diluting the medication in 1 mL of lactated Ringer's solution for direct injection 4. Diluting the medication in 10% dextrose in water and administering it as a direct injection Question: 158 Correct Answer: 1 The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement? 1. "I no longer feel that I deserve the beatings my husband inflicts on me." 2. "My attendance at the meetings has helped me to see that I provoke my husband's violence." 3. "I enjoy attending the meetings because they get me out of the house and away from my husband." 4. "I can tolerate my husband's destructive behaviors now that I know they are common among alcoholics." NCSBN Practice Bank 53 Item #1692 Question: 159 Correct Answer: 3 A nurse is giving instructions to the parents of a child with cystic fibrosis. The nurse should emphasize that pancreatic enzymes should be taken in which manner? 1. Three times daily after meals 2. Each time carbohydrates are eaten 3. With each meal or snack 4. Once each day Ref # 1692 Answer Key The correct answer is C: With each meal or snack Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Pancreatic enzymes should be taken with each meal and every snack to allow for digestion of all foods that are eaten. The enzyme is sprinkled on the food prior to eating. Perry, S., Hockenberry, M., Lowdermilk, D.L., & Wilson, D. (2009). Maternal child nursing care (4th ed.). St. Louis, MO: Mosby. Kee, J.L., Hayes, E.R., & McCuistion, L. (2008). Pharmacology: A nursing process approach (6th ed.). St. Louis, MO: Saunders Elsevier. Item #1574 Question: 160 Correct Answer: 3 What would a nurse expect to see in a client who reports symptoms associated with tardive dyskinesia? 1. Behavioral changes 2. Uncontrolled hand tremors during meals 3. Rapid tongue movements 4. Repetitive slapping movements Ref # 1574 Answer Key The correct answer is C: Rapid tongue movements Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Tardive dyskinesia is a syndrome of involuntary movements of the face, mouth, tongue, trunk, and limbs that may occur after years of treatment with neuroleptic agents. Predisposing factors include older age, many years of cigarette smoking, long-term phenothiazine treatment and a diagnosis of diabetes mellitus. Deglin, J., Vallerand, A., & Sanoski, C. (2010). Davis’s drug guide for nurses (12th ed.). Philadelphia: F.A. Davis Company. McPhee, S., Papadakis, M., & Rabow, M. (2010). Current medical diagnosis and treatment 2011 (50th ed.). Los Altos, CA: McGraw-Hill Medical. Item # 1541 Question: 161 Correct Answer: 4 When teaching a client with a new prescription for lithium (Lithane) for treatment of a bipolar disorder, which of these points should the nurse emphasize? 1. Maintain a salt restricted diet 2. Take other medication as usual 3. Substitute generic form if desired 4. Report vomiting or diarrhea Ref # 1541 Answer Key The correct answer is D: Report vomiting or diarrhea Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies If dehydration results from vomiting, diarrhea or excessive perspiration, tolerance to the drug may be altered and findings of toxicity may be exhibited. Deglin, J., Vallerand, A., & Sanoski, C. (2010). Davis’s drug guide for nurses (12th ed.). Philadelphia: F.A. Davis Company. Wilson, B.A., Shannon, M.T., & Stang, C.L. (2008). Prentice Hall nurse’s drug guide 2009. Upper Saddle River, NJ: Prentice Hall. Item #1588 Question: 162 Correct Answer: 1 What characteristic of a 75 year-old client may influence the effects of antihypertensive drug therapy? 1. Decreased gastrointestinal motility 2. Increased splanchnic blood flow 3. Altered peripheral resistance 4. Poor nutritional status Ref # 1588 Answer Key The correct answer is A: Decreased gastrointestinal motility Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies With the shrinkage of the gastric mucosa, and the changes in the levels of hydrochloric acid, both factors will decrease the absorption of medications and interfere with their actions. Smeltzer, S.C., Bare, B.G., Hinkle, J., & Cheever, K.H. (2009). Brunner- Suddarth's textbook of medical surgical nursing (12th ed.). Philadelphia: Lippincott Williams & Wilkins. Delaune, S., & Ladner, P. (2010). Fundamentals in nursing: Standards and practice (4th ed.). Clinton Park, NY: Delmar Cengage Learning. Item #4446 Question: 163 Correct Answer: 100 mEq KCl The order reads: infuse IV of 1000 mL D5W with 100 mEq KCl at a rate of 50 mL/hour. Which component of this order should the nurse question? Ref # 4446 Answer Key The correct answer is : 100 mEq KCl Learning Objective: Lesson 6 Pharmacological Therapies This dose of potassium is too high for a routine infusion. If not sufficiently agitated (mixed) in solution it will burn the vein and can cause cardiac arrhythmias. Black, J., & Hawks, J. (2008). Medical surgical nursing: Clinical management for positive outcomes (8th ed.). St. Louis, MO: Elsevier. Harkreader, H., Hogan, M.A., & Thobaben, M. (2007). Fundamentals of nursing: Caring and clinical judgment (3rd ed.). Philadelphia: Saunders. Item #1632 Question: 164 Correct Answer: 3 A nurse is caring for an 81 year-old client with colorectal cancer. The client's pain has been managed until now with acetaminophen with codeine. Because of increased pain, intravenous morphine is added. What should the nurse recognize about the validity of this order? 1. Inappropriate and demonstrates poor knowledge of pain control 2. Inappropriate because of potential respiratory depression 3. Appropriate pain management around-the-clock 4. Appropriate despite the expected effect of mental confusion Ref # 1632 Answer Key The correct answer is C: Appropriate pain management around-the- clock Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Older adult clients with cancer pain are frequently under-medicated. This management is appropriate, and should be offered throughout the day and night. Delaune, S., & Ladner, P. (2010). Fundamentals in nursing: Standards and practice (4th ed.). Clinton Park, NY: Delmar Cengage Learning. Smeltzer, S.C., Bare, B.G., Hinkle, J., & Cheever, K.H. (2009). Brunner- Suddarth's textbook of medical surgical nursing (12th ed.). Philadelphia: Lippincott Williams & Wilkins. Item # 1684 Question: 165 Correct Answer: 2 A nurse is caring for a 15 month-old child with a first episode of otitis media. Which intervention should the nurse include in the instructions to the child's parents? 1. Explain that the child should complete the full five days of antibiotics 2. Emphasize the importance of a return visit after completion of antibiotics 3. Provide them with handout describing care of myringotomy tubes 4. Describe the tympanocentesis to detect persistent infections Ref # 1684 Answer Key The correct answer is B: Emphasize the importance of a return visit after completion of antibiotics Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies The usual treatment for otitis media is oral antibiotics for 10 to 14 days. The child should be examined again after completion of the full course of antibiotics to assess for persistent infection or middle ear effusion. Perry, S., Hockenberry, M., Lowdermilk, D.L., & Wilson, D. (2009). Maternal child nursing care (4th ed.). St. Louis, MO: Mosby. Potts, N.L., & Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. Clifton Park, NY: Delmar Cengage Learning. Item #1512 Question: 166 Correct Answer: 2 A nurse prepares to administer eye drops to a six year-old child. Which of these descriptions describe the correct method for the instillation of eye drops? 1. Under the upper lid as it is pulled upward 2. In the conjunctival sac as the lower lid is pulled down 3. In the corner where the lids meet 4. Directly on the anterior surface of the eyeball Ref # 1512 Answer Key The correct answer is B: In the conjunctival sac as the lower lid is pulled down Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Eye drops should be placed in the sac between the eye and the lower lid. This sac is formed by pulling the lower lid down. Perry, S., Hockenberry, M., Lowdermilk, D.L., & Wilson, D. (2009). Maternal child nursing care (4th ed.). St. Louis, MO: Mosby. Potts, N.L., & Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. Clifton Park, NY: Delmar Cengage Learning. Item #1656 Question: 167 Correct Answer: 3 A nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of packed red blood cells. Which is an appropriate action for the nurse during the administration of the infusion? 1. Assess vital signs every 15 minutes throughout the entire infusion 2. Store the packed red cells in the medicine refrigerator while starting IV line 3. Limit the infusion time of the unit to a maximum of four hours 4. Slow the rate of infusion if the client develops a fever or chills Ref # 1656 Answer Key The correct answer is C: Limit the infusion time of the unit to a maximum of four hours Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Infuse the specified amount of blood within four hours. If the infusion will exceed this time, the packed cells should be divided into appropriately sized quantities. Blood is not to be infused for longer than four hours because of the risk of bacterial growth in the bag. Similarly, blood should not be stored in an unapproved refrigerator because the concern of bacteria growth with changes in or elevated temperatures in unapproved refrigeration units. If the client develops fever or chills, the nurse does not slow the rate of infusion. This would be considered a reaction and the blood should be stopped and the blood bank and health care provider notified. Vital signs are per agency protocol and usually are not this frequent. Hockenberry, M.J. (2008). Wong's nursing care of infants and children (8th ed.). St. Louis, MO: Mosby. Swearingen, P. (2007). All-in-one care planning resource: Medical- surgical, pediatric, maternity, and psychiatric nursing care plans (2nd ed.). St. Louis, MO: Mosby. Item #1627 Question: 168 Correct Answer: 3 A nurse is caring for a trauma victim with a significant blood loss. Immediately after multiple transfusions, what is the most accurate indicator of oxygenation? 1. Hematocrit 2. Pulse oximetry 3. Blood gases 4. Hemoglobin Ref # 1627 Answer Key The correct answer is C: Blood gases Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Arterial blood gases are the most accurate measure of oxygenation at this time. Smeltzer, S.C., Bare, B.G., Hinkle, J., & Cheever, K.H. (2009). Brunner- Suddarth's textbook of medical surgical nursing (12th ed.). Philadelphia: Lippincott Williams & Wilkins. Delaune, S., & Ladner, P. (2010). Fundamentals in nursing: Standards and practice (4th ed.). Clinton Park, NY: Delmar Cengage Learning. Item #1532 Question: 169 Correct Answer: 4 A client with bi-polar disorder is taking lithium (Lithane). What should a nurse emphasize when teaching about this medication? 1. Reduce fluid intake to minimize diuresis 2. Use antacids to prevent heartburn 3. Take the medication before meals 4. Maintain adequate daily salt intake Ref # 1532 Answer Key The correct answer is D: Maintain adequate daily salt intake Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Salt intake affects fluid volume as well as the excretion rate of lithium and thus, can affect lithium (Lithane) levels. Therefore, to maintain adequate salt intake is advised. Deglin, J., Vallerand, A., & Sanoski, C. (2010). Davis’s drug guide for nurses (12th ed.). Philadelphia: F.A. Davis Company. Smeltzer, S.C., Bare, B.G., Hinkle, J., & Cheever, K.H. (2009). Brunner- Suddarth's textbook of medical surgical nursing (12th ed.). Philadelphia: Lippincott Williams & Wilkins. Item #1605 Question: 170 Correct Answer: 3 While providing home care to a client with heart failure, a nurse is asked by the client about how long diuretics must be taken. What point should the nurse include in a response? 1. "As you urinate more, you will need less medication to control fluid." 2. "Please talk to your health care provider about medications and treatments." 3. "The medication must be continued as long as the the fluid problem needs to be controlled." 4. "You will have to take this medication for about a year." Ref # 1605 Answer Key The correct answer is C: "The medication must be continued as long as the the fluid problem needs to be controlled." Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies The most therapeutic response is the one that addresses the client's health condition and gives the client accurate information. Smeltzer, S.C., Bare, B.G., Hinkle, J., & Cheever, K.H. (2009). Brunner- Suddarth's textbook of medical surgical nursing (12th ed.). Philadelphia: Lippincott Williams & Wilkins. Kee, J.L., Hayes, E.R., & McCuistion, L. (2008). Pharmacology: A nursing process approach (6th ed.). St. Louis, MO: Saunders Elsevier. Item #1607 Question: 171 Correct Answer: 3 An 80 year-old client on digoxin (Lanoxin) reports nausea, vomiting, abdominal cramps and halo vision. Which laboratory result should the nurse analyze first? 1. Blood urea nitrogen 2. Magnesium levels 3. Potassium levels 4. Blood pH Ref # 1607 Answer Key The correct answer is C: Potassium levels Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Nausea, vomiting, abdominal cramps and halo vision are classic signs of digitalis toxicity . The most common cause of digitalis toxicity is a low potassium level. Clients are to be taught that it is important to have adequate potassium intake especially if taking loop or thiazide diuretics that enhance the loss of potassium. Deglin, J., Vallerand, A., & Sanoski, C. (2010). Davis’s drug guide for nurses (12th ed.). Philadelphia: F.A. Davis Company. Kee, J.L., Hayes, E.R., & McCuistion, L. (2008). Pharmacology: A nursing process approach (6th ed.). St. Louis, MO: Saunders Elsevier. Item #1542 Question: 172 Correct Answer: 2 A nurse is teaching the administration of albuterol inhalation to an adult diagnosed with asthma. Which statement demonstrates proper teaching? 1. "Use this medication at bedtime to promote rest." 2. "Notify the health care provider if you need the drug more often." 3. "Discontinue the inhalation if you are dizzy." 4. "Inhale this medication after other asthma sprays." Ref # 1542 Answer Key The correct answer is B: "Notify the health care provider if you need the drug more often." Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies If the client notices that the albuterol inhalation is used more frequently, the health care provider should be notified so that a change in dose or medication can be ordered. The use of more medication may indicate a situation for refractory to treatment or a subtherapeutic response. Deglin, J., Vallerand, A., & Sanoski, C. (2010). Davis’s drug guide for nurses (12th ed.). Philadelphia: F.A. Davis Company. Wilson, B.A., Shannon, M.T., & Stang, C.L. (2008). Prentice Hall nurse’s drug guide 2009. Upper Saddle River, NJ: Prentice Hall. Item #4458 Question: 173 Correct Answer: 85 A 187 pound client with a subdural hematoma and findings of increased intracranial pressure has been prescribed 25% solution mannitol (Osmitrol) 0.25 g/kg to be administered by intravenous push right away. The pharmacy has sent up four 50 milliliter bottles (12.5 g/50 mL is written on the label). How many milliliters should the nurse prepare to give the client? (Write the answer using whole numbers). mL. Ref # 4458 Answer Key The correct answer is : 85 Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Convert pounds to kilograms, calculate the dose this client requires based on his weight. Convert from pounds to kilograms: 187 lbs/2.2 = 85 kg 0.25 g x 85 kg = 21.25 g (12.5 g/50 mL) = (21.25 g/x mL) x = 1062.50/12.5 = 85 mL An alternate method for solving the problem is to use Dimensional Analysis. Since the answer will be milliliters, begin the equation with milliliters on top, then multiply to cancel unwanted units until only the milliliters remain. (50 mL/12.5 g) X (0.25 g/kg) X (1 kg/2.2 lbs) X (187 lb/1) = 85 Item #1672 Question: 174 Correct Answer: 2 A parent asks a school nurse how to eliminate lice from their child. What is the appropriate response by the nurse? 1. Wash the child's linen and clothing in a bleach solution 2. Application of pediculicides as directed 3. Apply warm soaks to the head twice daily 4. Cut the child's hair short to remove the nits Ref # 1672 Answer Key The correct answer is B: Application of pediculicides as directed Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Treatment of head lice consists of application of pediculicides. Pediculicides vary and the directions must be followed carefully. Perry, S., Hockenberry, M., Lowdermilk, D.L., & Wilson, D. (2009). Maternal child nursing care (4th ed.). St. Louis, MO: Mosby. Potts, N.L., & Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. Clifton Park, NY: Delmar Cengage Learning. Item #1675 Question: 175 Correct Answer: 2 A nurse is caring for a child receiving albuterol (Proventil) for asthma. The parents ask the nurse why their child is receiving this medication. Which explanation by the nurse is correct? 1. "The medication is given to reduce the secretions that block the airways." 2. "Proventil will relax the smooth muscles in the airways." 3. "It will decrease the swelling in the airways." 4. " The respiratory center in the brain that control respirations will be stimulated." Ref # 1675 Answer Key The correct answer is B: "Proventil will relax the smooth muscles in the airways." Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Albuterol (a beta-adrenergic agonist) is the drug of choice in treating asthma because it allows the smooth muscle in the airway to relax. The airway can then dilate to increase airflow. Deglin, J., Vallerand, A., & Sanoski, C. (2010). Davis’s drug guide for nurses (12th ed.). Philadelphia: F.A. Davis Company. Perry, S., Hockenberry, M., Lowdermilk, D.L., & Wilson, D. (2009). Maternal child nursing care (4th ed.). St. Louis, MO: Mosby. Item #1514 Question: 176 Correct Answer: 1 A nurse is planning to administer otic drops to a six year-old child. Which action is part of a correct procedure? 1. Hold the pinna up and back to instill the drops 2. Assist the child to lie on the affected side afterwards 3. Place several drops in the outer ear 4. Insert cotton in the outer ear after giving medication Ref # 1514 Answer Key The correct answer is A: Hold the pinna up and back to instill the drops Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies The external auditory canal should be straightened by gently pulling the pinna up and back for otic drop administration. In children who are under three years of age, the pinna should be pulled down and back. Perry, S., Hockenberry, M., Lowdermilk, D.L., & Wilson, D. (2009). Maternal child nursing care (4th ed.). St. Louis, MO: Mosby. Potts, N.L., & Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. Clifton Park, NY: Delmar Cengage Learning. Item #1615 Question: 177 Correct Answer: 4 A client is being maintained on heparin therapy for deep vein thrombosis (DVT). A nurse must closely monitor which of these following laboratory values? 1. Platelet count 2. Bleeding time 3. Clotting time 4. Activated PTT Ref # 1615 Answer Key The correct answer is D: Activated PTT Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Heparin is used to prevent further clots from being formed and to prevent the present clot from enlarging. The activated prothromboplastin time (APTT) test is a highly sensitive test to monitor the client on heparin. Daniels, R. (2009). Delmar’s manual of laboratory and diagnostic tests (2nd ed.). Albany, NY: Delmar Cengage Learning. Deglin, J., Vallerand, A., & Sanoski, C. (2010). Davis’s drug guide for nurses (12th ed.). Philadelphia: F.A. Davis Company. Item #1531 Question: 178 Correct Answer: 3 Before the administration of digoxin (Lanoxin) to a client, which nursing assessment is required? 1. Auscultate breath sounds 2. Measure the blood pressure 3. Validate the heart rate 4. Check for bowel sounds Ref # 1531 Answer Key The correct answer is C: Validate the heart rate Learning Objective: Lesson 6 Pharmacological and Parenteral Therapies Lanoxin, a cardiac glycoside used in heart failure, helps the heart beat more effectively (+ inotropic), and decreases the heart rate (- chronotropic). Because digoxin slows the heart rate, the medication should be held if the heart rate is below 60 or greater than 120. Delaune, S., & Ladner, P. (2010). Fundamentals in nursing: Standards and practice (4th ed.). Clinton Park, NY: Delmar Cengage Learning. Kee, J.L., Hayes, E.R., & McCuistion, L. (2008). Pharmacology: A nursing process approach (6th ed.). St. Louis, MO: Saunders Elsevier. Item #4315 Question: 179 Correct Answer: 1, 2, 3 A 32 year-old female with human epidermal growth factor receptor 2- positive (HER2-positive) metastatic breast cancer is scheduled to begin therapy with pertuzumab (Perjeta). What information is important for the nurse to reinforce and discuss with the client? (Select all that apply.) 1. Report chills, fatigue, or headache during treatment 2. Use contraception during and for 6 months following the use of this drug 3. Report shortness of breath, lightheadedness, dizziness, cough, or swelling of the feet 4. Take the medication at the same time every day on an empty stomach 5. Other therapies for cancer treatment are no longer needed Ref # 4315 Answer Key The correct answer is :A,B,C Learning Objective: Lesson 6 Pertuzumab (Perjeta) is used in combination with trastuzumab (Herceptin) as a targeted therapy for HER2+ metastatic breast cancer; these meds are used in combination with chemotherapy and radiation. The most common side effects are fatigue, loss of taste, muscle pain, and vomiting; sometimes slowing the infusion rate can help. It is best to eat a small meal before receiving the infusion. Serious side effects include birth defects and fetal death; women of child-bearing age must use a form of effective contraception during and for 6 months following treatment. Drugs that block HER2+ activity decrease left ventricular ejection fraction (LVEF) and will worsen symptoms of congestive heart failure; heart function must be tested before and monitored during treatment. Item #4330 Question: 180 Correct Answer: 2, 3, 4 There is an order to administer an intramuscular influenza vaccine to an adult. What actions should the nurse take prior to administration of the injection? (Select all that apply.) 1. Record the site and time of injection 2. Provide the client with the federal Vaccine Information Statement (VIS) 3. Check the expiration date on the vaccination bottle 4. Ask the client if she or he can eat eggs without adverse effects 5. Record the manufacturer of the vaccine and lot number 6. Record the client’s reaction to the injection Ref # 4330 Answer Key The correct answer is :B,C,D Learning Objective: Lesson 6 Prior to administration, the nurse should identify the expiration date on the bottle and give a current copy of the federal Vaccine Information Statement to the client. The nurse should also verify any allergies, particularly hypersensitivity to eggs, prior to administering the vaccine. Observing for a reaction to the injection and recording the site, time of injection, the manufacturer and lot number are performed after administering the medication. Item #4313 Question: 181 Correct Answer: 1, 4, 5 The oncology nurse is preparing to administer the initial dose of vincristine (Oncovin) to a child diagnosed with acute lymphocytic leukemia (ALL). Which intervention is most appropriate to add to the plan of care? (Select all that apply). 1. Apply ice to the injection site if extravasation occurs 2. Monitor liver function tests 3. Select appropriate catheter for intrathecal administration 4. Monitor for numbness or tingling in the fingers and toes 5. Verify blood return before, during and after intravenous administration Ref # 4313 Answer Key The correct answer is :A,DE Learning Objective: Lesson 6 ALL is the most common type of cancer in children and treatment protocols include vincristine. Vincristine is for intravenous use only; intrathecal administration can be fatal. Vincristine is a vesicant that can cause significant local damage if extravasation occurs; treatment includes subcutaneous injection of an antidote and warm compresses (topical cooling may worsen the effect). Peripheral neuropathy is a major side effect associated with vincristine. The nurse should monitor for decreased hepatic functioning because vincristine is metabolized in the liver. Item #2487 Question: 182 Correct Answer: 2, 3, 4 The health care provider writes a new order for a fentanyl (Sublimaze) patch to manage the chronic pain experienced by the client in hospice care. The nurse is teaching a client and family members about the fentanyl patch and knows that teaching was effective when the client makes which of the following statements? (Select all that apply.) 1. “I can soak in a hot tub to help decrease my pain.” 2. “If my pain is too great while I am on the patch, I can take a supplemental pain medication.” 3. “It may take up to a half day or longer for the patch to start working, the first time I use it.” 4. “I will take the old patch off before I apply the new patch on.” 5. “I should cut up the patch before I throw it away so no one else can use it.” Ref # 2487 Answer Key The correct answer is :B,C,D Learning Objective: Lesson 6 Fentanyl patches are slowly absorbed via the subcutaneous tissue at a predetermined rate for up to 72 hours. Due to the slow absorption rate, the first patch may take 12 to 24 hours before effective analgesia is felt; a short-acting opioid may be given for breakthrough pain. The client can shower or bathe with the patch, but it should not be exposed to heat (hot tubs, heating pads) because it speeds up the absorption of the medication. Old patches are removed and the new patch is applied to a different skin area. Old patches are disposed by folding the old patch in half, not by cutting them up and throwing them in the trash (which may be dangerous for people and pets). LPC book - Exam_3_Combo_Questions & Anwers_corrected Management of Care Question: 183 Correct Answer: 1, 3, 4 Which of the following is true with regard to delegation of client care responsibilities? Select all that apply. 1. The nurse must know the nursing model that underlies care at the institution. 2. The nurse delegates in accordance with demands on his/her time. 3. The nurse validates with the nonregistered nurse (non-RN) caregiver that he/she has performed the same activity before. 4. The nurse retains the right to determine which tasks are delegated. 5. The nurse must document that the task has been delegated and to whom. Question: 184 Correct Answer: 1, 2, 4, 5 The nurse is serving on a task force to update the medical record. The task force should ensure that the revisions of the medical record will do which of the following? Select all that apply. 1. Aid in client care. 2. Serve as a legal document. 3. Have sufficient room for charting nurses’ notes. 4. Facilitate data collection for clinical research. 5. Guide performance improvement. 6. Be written so the client can understand what is written. Question: 185 Correct Answer: 1, 2, 4, 5, 6 The nursing assistant reports to the nurse that a client is “feeling short of breath.” The client’s blood pressure was 124/78 2 hours ago with a heart rate of 82; the nursing assistant reports that blood pressure is now 84/44 with a heart rate of 54 and the client stated, “I just don’t feel good.” Which of the following interventions should the nurse initiate? Select all that apply. 1. Confirm the client’s vital signs and complete a quick assessment. 2. Inform the charge nurse of the change in condition and initiate the hospital’s rapid/emergency response team. 3. Make a quick check on other assigned clients before spending the amount of time required to take care of this client. 4. Position client in semi-Fowler’s position. 5. Stay with the client and reassure the client. 6. Call the physician and report the situation using SBAR format. Question: 186 Correct Answer: 2, 4, 5 When planning care for a client with ulcerative colitis who is experiencing an exacerbation of symptoms, which client care activities can the nurse appropriately delegate to an unlicensed assistant? Select all that apply. 1. Assessing the client’s bowel sounds. 2. Providing skin care following bowel movements. 3. Evaluating the client’s response to antidiarrheal medications. 4. Maintaining intake and output records. 5. Obtaining the client’s weight. Question: 187 Correct Answer: 1, 2, 3, 4, 5 A nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following are goals for the care for this client? Select all that apply. 1. Preventing constipation. 2. Administering lactulose to reduce blood ammonia levels. 3. Monitoring coordination while walking. 4. Checking the pupil reaction. 5. Providing food and fluids high in carbohydrate. 6. Encouraging physical activity. Safety and Infection Control (12%) Question: 188 Correct Answer: 1, 2, 3, 4, 6 A client with early acute renal failure has anemia, tachycardia, hypotension, and shortness of breath. The physician has prescribed 2 units of packed red blood cells (RBCs). Prior to initiating the blood transfusion the nurse should determine if: (Select all that apply.) There is an IV access with the appropriate tubing and normal saline as the priming solution. There is a signed informed consent for transfusion therapy. Blood typing and cross-matching are documented in the medical record. The vital signs have been taken and documented in accordance with facility policy and procedure. There is the second unit of blood in the medication room. The client has an identification bracelet and red blood band. Question: 189 Correct Answer: 1, 2, 3, 7 Which pressure point area(s) should the nurse monitor for an unconscious client positioned on the left side (see figure)? Choose all that apply. 1. Ankles. 2. Ear. 3. Greater trochanter. 4. Heels. 5. Occiput. 6. Sacrum. 7. Shoulder. Health Promotion and Maintenance Question: 190 Correct Answer: 2-6-4-5-1-3 A client diagnosed with asthma has been prescribed fluticasone (Flovent) one puff every 12 hours per inhaler. Place in correct order the statements the nurse would use when teaching the client how to properly use the inhaler with a spacer. 1. “Hold your breath for at least 10 seconds, then breathe in and out slowly.” 2. “Take off the cap and shake the inhaler.” 3. “Rinse your mouth.” 4. “Breathe out all of your air. Hold the mouthpiece of your inhaler and spacer between your teeth with your lips closed around it.” 5. “Press down on the inhaler once and breathe in slowly.” 6. “Attach the spacer.” Pharmacological and Parenteral Therapies Question: 191 Correct Answer: 1, 2, 4, 6 A client with lung cancer is being cared for by his wife at home. His pain is increasing in severity. The nurse recognizes that teaching has been effective when the wife does which of the following? Select all that apply. 1. Administers long-acting or sustained-release oral pain medication (OxyContin) regularly around the clock. 2. Administers immediate-release medication (oxycodone) for breakthrough pain. 3. Avoids long-acting opioids due to her concern about addiction. 4. Uses music for distraction as well as heat or cold in combination with medications. 5. Substitutes acetaminophen (Tylenol) to avoid tolerance to the medications. 6. Has her husband use a pain-rating scale to measure the effectiveness at reaching his individual pain goal? Physiological Adaptation Question: 192 Correct Answer: 4-1-2-3 A client has massive bleeding from esophageal varices. In what order should the nurse and care team provide care for this client? 1. Control hemorrhaging. 2. Replace fluids. 3. Relieve the client’s anxiety. 4. Maintain a patent airway. Question: 193 Correct Answer: 1-4-3-2-5 A client is experiencing alcohol withdrawal. He wakes up and screams, “There’s something crawling under my skin. Help me.” In which order, from first to last, should the following nursing actions be done? 1. Remind the client that he is having withdrawal symptoms and that these will be treated. 2. Administer a dose of lorazepam (Ativan) depending on the severity of the withdrawal symptoms. 3. Assess the client for other withdrawal symptoms. 4. Take the client’s vital signs. 5. Chart the details of the episode on the electronic health record. 09/12/2017 06:54:16 AM Exam-10 Completed Priority Order (Ordered Response) 10 Questions Question: 194 Correct Answer: 3, 4, 2, 1 A client who is a gravida 3, para 3 had a cesarean section 1 day ago. She is being treated prophylactically for endometritis. She is complaining of abdominal cramping at a 6 on a pain level scale of 1 to 10 (with 10 being the greatest amount of pain) and fears having her first bowel movement. These medications are prescribed and due now. Based on priority, in which order should the nurse administer the medications? Arrange the medications in the order that they should be administered. All options must be used. 1. Prenatal vitamin 1 tablet orally daily 2. Docusate sodium 100 mg orally daily 3. Ketorolac 30 mg by intravenous (IV) push over 3 minutes 4. Ampicillin sodium 1 g IV piggyback over 60 minutes Question: 195 Correct Answer: 1, 4, 6, 5, 3, 2 A mother brings her child to the emergency department. Based on the child's sitting position, drooling, and apparent respiratory distress, a diagnosis of epiglottitis is suspected. In anticipation of the health care provider's prescriptions, in which order of priority would the nurse implement the actions? Arrange the actions in the order that they should be performed. All options must be used. 1. Maintain a patent airway. 2. Administer an antipyretic. 3. Obtain an axillary temperature. 4. Assess breath sounds by auscultation. 5. Insert an intravenous line for fluid administration. 6. Obtain an oxygen saturation level using pulse oximetry. Question: 196 Correct Answer: 3, 1, 5, 2, 4 In order of priority, how should the nurse perform abdominal thrusts on an unconscious adult? Arrange the actions in the order that they should be performed. All options must be used. 1. Open the airway. 2. Attempt ventilation. 3. Assess unconsciousness. 4. Perform abdominal thrusts. 5. Look in the mouth and remove the object blocking the airway, if seen. Question: 197 Correct Answer: 4, 2, 1, 3 The nurse has determined that a postpartum client has physical findings consistent with uterine atony. The nurse should take action in which priority order? Arrange the action in the priority order that they should be done. All options must be used. 1. Monitor vital signs. 2. Contact the health care provider. 3. Check the amount of drainage on the peripad. 4. Massage the uterus attempting to achieve firmness. Question: 198 Correct Answer: 4, 1, 2, 5, 3 A confrontation test is prescribed for a client seen in the eye and ear clinic. How should the nurse perform this test? Arrange the actions in the order that they should be performed. All options must be used. 1. Asks the client to cover 1 eye 2. Examiner covers eye opposite to the eye covered by the client 3. Asks the client to report when object is first noted 4. Stands 2 to 3 feet (60 to 90 cm) in front of and faces the client 5. The examiner brings in an object gradually from periphery Question: 199 Correct Answer: 2, 4, 1, 3 After receiving report at the beginning of the 0700 shift, the nurse must decide in what order the clients should be assessed. How should the nurse plan assessments? Arrange the clients in the order that they should be assessed. All options must be used. 1. An 8-hour post–vaginal delivery gravida 2, para 2 client who is scheduled for a bilateral tubal ligation at 1200 today and has a continuous peripheral intravenous (IV) solution of 5% 2. A 12-hour post–cesarean section delivery gravida 3, para 3 who reports a return of feeling in her lower extremities as well as a sensation of wetness underneath her buttocks. 3. A 48-hour post–cesarean section delivery gravida 1, para 1 who reports not yet having a bowel movement since delivery and requests a stool softener. 4. A 24-hour post–vaginal delivery gravida 4, para 4 who is complaining of abdominal cramping after nursing her baby and requesting ibuprofen. Question: 200 Correct Answer: 1, 4, 2, 3, 5, 6 A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, the nurse takes the following actions. Arrange the actions in the order they should be performed. All options must be used. 1. Raise the head of the bed. 2. Check for bladder distention 3. Contact the health care provider (HCP). 4. Loosen tight clothing on the client. 5. Administer an antihypertensive medication. 6. Document the occurrence, treatment, and response. RN Practice Question Banks 1-15 (Not Required) Question: 1 Correct Answer: 1, 2, 5, 6 During a yearly health screening, a 54 year-old female reports having irregular menstrual cycles, mood swings and hot flashes. She requests a more natural approach to manage these symptoms of perimenopause. What education about non-pharmacological interventions will the nurse include in client teaching? (Select all that apply.) 7. "You should drink at least 8-10 glasses of water a day." 8. "Yoga may help you manage stress and relieve symptoms." 9. "A glass or two of red wine with dinner can help you manage stress." 10. "Try exercising just before bedtime to help you sleep more soundly." 11. "Incorporate more vegetables and legumes in your diet." 12. "Use deep breathing exercises when you start having a hot flash." Rationale Measures that have been found to be effective in helping manage symptom of hot flashes include exercise, stress reduction and getting enough sleep at night. Reducing the temperature in the room at night and taking a warm bath or shower before bedtime can help clients get a better night's sleep. Slow abdominal breathing (6-8 breaths a minute) at the onset of hot flashes can help. Other measures that can lessen the number of and severity of hot flashes include yoga, as well as avoiding alcohol, spicy foods and caffeine. Eating a more plant- based diet can also help. Question: 2 Correct Answer: 1, 3, 4 A new task force has been created at a hospital to address a recent increase in patient falls. The first meeting is scheduled with members from several departments. Which of the following statements by the nurse leader indicate intent to increase meeting effectiveness? (Select all that apply.) 7. "During our meeting today we will share the information we have on falls." 8. "Let's discuss when next we should meet and what information we will bring." 9. "Please introduce yourselves and your departments." 10. "Let's focus on the number of falls first and then we can talk about staffing." 11. "Today I will review the problem with falls on our units." 12. "This meeting can go as long as needed to get things done." Rationale A leader increases meeting effectiveness by not permitting one person not to dominate the discussion, encouraging brainstorming, encouraging others to further develop ideas and helping to engage the team in future discussions. An effective team leader will periodically summarize the information and ensure that all ideas are recorded for all to see (for example, on a whiteboard) and then follow up with minutes of the meeting. Beginning and ending on time is also important to keep everyone focused on the task at hand and to demonstrate respect team members' other commitments. Question: 3 Correct Answer: 2, 5, 6 The nurse is preparing to administer a feeding through a percutaneous endoscopic gastrostomy (PEG) tube. What nursing action is needed before starting the infusion? (Select all that apply.) 7. Palpate the abdomen 8. Verify the length and placement of the tube 9. Milk or massage the tube 10. Keep the feeding product refrigerated until ready to use 11. Elevate the head of the bed 30-45 degrees 12. Flush the tube with 30 mL of warm water Rationale Prior to starting every feeding, the nurse should verify the length and placement of the tube, flush the tube with 30 mL of warm (not hot and not cold) water, and elevate the head of the client's bed at least 30 degrees. The nurse should also verify the presence of bowel sounds before starting the infusion. There's no need to milk the tube unless it's obstructed. Feeding products should be brought to room temperature before the infusion to prevent gastrointestinal discomfort. Question: 4 Correct Answer: 1, 2 The client needs to be moved up in bed. The client is able to partially assist and weighs 135 pounds. Which action by the nursing staff best supports an awareness of ergonomics and safe client handling? (Select all that apply.) 6. Adjust the height of the bed for caregivers 7. Move the bed into the flat position 8. Pull the client up from the head of the bed 9. Use a friction-reducing device 10. Coordinate lifting the client by counting to 3 Rationale The algorithm for safe client handling and repositioning a client from side-to-side or up in bed states: use 2 to 3 caregivers for a client who can partially assist and who weighs less than 200 pounds, use a friction-reducing device, move the bed so that it's flat and at a comfortable height for the caregivers. The client should not be pulled from the head of the bed. There really is no safe method to manually lift another adult Question: 5 Correct Answer: 1, 2, 4 Following a surgical procedure, a pneumatic compression device is applied to the adult client. The client reports that the device is hot and the client is sweating and itching. Which of the following steps should the nurse take? (Select all that apply.) 6. Check for appropriate fit 7. Confirm pressure setting of 45 mm Hg 8. Explain that the health care provider ordered the device and it cannot be removed 9. Collaborate with health care provider for anti-embolism stockings to be worn under the sleeves of the device 10. Inform the client that removing the device will likely result in the formation of deep vein thrombosis Rationale In any situation in which a client has discomfort associated with a medical device, the nurse should ensure it is applied correctly and functioning safely. The usual safe and effective pressure range is 35 to 55 mm Hg. Explanations to the clients should support their informed decisionmaking capabilities and should not be phrased to intimidate or remove client autonomy. Applying anti-embolism stockings under the disposable sleeves of the device may help with the sweating and itching. Question: 6 Correct Answer: Correct order An 88 year-old client is admitted to the telemetry unit following a minor surgical procedure. The client's history includes insulin dependent diabetes and a previous myocardial infarction. The nurse responds to the client's ECG alarm and finds the client's rhythm shows asystole and the client obtunded but responsive. Prioritize the actions of the nurse (with 1 being the top priority). 5. Assess respirations and pulse 6. Initiate emergency response system if indicated 7. Look at a different ECG lead to confirm rhythm 8. Check a blood glucose level Rationale After checking responsiveness, establishing a patent airway and then assessing breathing and circulation are the next priorities (ABCs). This assessment would provide information to decide whether the emergency response team is needed. Because the client is responsive, the monitor rhythm is not correct, as a client with asystole would be unresponsive. Asystole on a rhythm strip may simply be a loose lead; a quick way to check this is to select another lead. The client's obtunded state indicates that ion is needed, so assessment of a central pulse and blood pressure is indicated to determine whether cardiovascular compromise is responsible for this condition. If no evidence of an immediate cardiac event is present, the blood glucose should be checked. Stress and changes in food or fluid consumption secondary to surgery increase the risk of glucose imbalance in the person with diabetes. Question: 7 Correct Answer: Correct order A nurse who cares for clients undergoing treatment for cancer might expect clients diagnosed with cancer to make the following statements. Based on an understanding of the stages of the grieving process, place the statements in the correct order. 5. “I think test got mixed up.” 6. “I am so sad at everyone for always reminding me that I have it” 7. “If I eat a more balanced diet, I can live longer” 8. “I don’t know where to go and what to do” Rationale The phases of loss or the grief process according to Dr. Kubler-Ross are: denial, anger, negotiation, depression and acceptance . RN Practice Question Banks 16-30 (Not Required) Question: 1 Correct Answer: 1, 2, 5 The client is admitted in stable condition from the emergency department. Based on the ECG strip, the nurse anticipates which of the following types of medications will be ordered? (Select all that apply.) 1. Calcium channel blocker 2. Beta blocker 3. Diuretic 4. Vasodilator 5. Cardiac glycoside Rationale This ECG depicts atrial flutter, when the atria beat excessively fast (250- 300 BPM). Medications used to slow the heart include calcium channel blockers (such as diltiazem), beta-adrenergic blockers (such as propranolol), and a cardiac glycoside (digoxin). An anticoagulant (such as warfarin) may also be ordered. Vasodilators and diuretics are used to lower blood pressure; vasodilators will increase heart rate. Question: 2 Correct Answer: 1, 2, 4 A client is transported by a family member to the emergency department following a boating accident. The client is conscious, shivering, and confused. The client is still wearing wet clothes. Which interventions does the nurse implement? (Select all that apply.) 1. Apply warm blankets 2. Monitor vital signs 3. Infuse warm IV solutions as ordered 4. Remove wet clothes 5. Massage cold extremities 6. Give sips of warm fluids Rationale This client is at risk for hypothermia. In a conscious client, wet clothing should be removed carefully. External rewarming, using blankets or heat packs placed under the arms and on the neck, chest, and groin, is appropriate. In-hospital treatment also includes monitoring core temperature and cardiac rhythm, ventilating with warm humidified air/oxygen to help stabilize core temperature and administering warm IV fluids. Sips of warm fluids may be given to the conscious and alert client only after his condition is stabilized. Extremities should never be massaged. Question: 3 Correct Answer: 2, 5 A respiratory therapist (RT) is collecting an arterial blood gas (ABG) sample. The RT must respond to an emergency and asks the nurse to manage the puncture site. Which actions should be completed? (Select all that apply.) 1. Thoroughly wash the site with saline, then apply an antibacterial solution 2. Check for distal capillary refill 3. Apply snug gauze and secure with tape 4. Remove dressing in one hour 5. Apply pressure for 5 to 10 minutes Rationale Five to 10 minutes of pressure ensures adequate coagulation at the site. Checking capillary refill indicates if there are any changes to blood flow to the hand. The dressing can be removed prior to the next stick or within 24 hours. Question: 4 Correct Answer: 1, 2, 5 The nurse is caring for a military veteran in a psychiatric in-patient unit. The client was in combat one year ago and experienced a personal traumatic event. Based on the client’s history, which of the following considerations will the nurse consider as a contributor to the development of PTSD? (Select all that apply.) 1. Experienced physical injury in combat 2. History of prior psychiatric disorder 3. Delay in counseling after the event 4. Identifies with a defined religion and culture 5. Prior suicide attempt 6. Employment in a physically-demanding occupation Rationale PTSD occurs approximately three months or more after trauma. Factors that contribute to the development of PTSD include whether the patient experienced physical injury, a prior history of a psychiatric diagnosis and/or suicide attempt and a delay in receiving counseling. Identification with culture and religion appears to be a protective factor. Employment in a physicallydemanding occupation does not affect the development of PTSD. Question: 5 Correct Answer: 1, 3, 5 The nurse attends an interdisciplinary meeting on the topic of fall prevention. What specific tactics can be used to reduce falls in health care settings? (Select all that apply.) 1. Use "low beds" for at-risk clients 2. Raise all side rails 3. Install and use bed alarms 4. Identify vulnerable clients 5. Use a "two to transfer" policy 6. Regularly reorient clients Rationale Fall prevention involves managing a client's underlying fall risk factors and then implementing strategies to reduce falls. Using restraints, including side rails, can actually increase the risk of fall-related injuries and deaths. Clients with neurocognitive disorders cannot process the information we provide when we attempt to reorient them to our reality. The other techniques listed are used (in combination) to help prevent falls in health care facilities. Question: 6 Correct Answer: 2, 3, 5 A client with chronic kidney disease (CKD) is scheduled for hemodialysis at 9 am. It is now 6:30 am and the client is eating breakfast. How should the nurse help the client to prepare for hemodialysis? (Select all that apply.) 1. Hold all oral medications 2. Administer prescribed vitamin D 3. Administer prescribed phosphate binder 4. Weigh the client 5. Assess patency of the access site 6. Ensure the client eats a high fiber, high protein breakfast Rationale The nurse should administer a phosphate binder, such as sevelamer, with breakfast. Vitamin D may be prescribed with the phosphate binder to help control both serum calcium and phosphate levels. Some medications will be withheld; dialyzable meds and meds that lower blood pressure are held until after the procedure. The client should eat an easily digestible meal at least 2 hours before treatment begins, avoiding foods high in fiber or protein. The nurse should assess the patency of the access site (for presence of bruit, palpable thrill, distal pulses, and circulation), weigh the client, and measure vital signs. Question: 7 Correct Answer: 2, 4, 5 The agency utilizes an electronic medical record (EMR) for documentation. What actions increase the security risk for inappropriate access to patient care information? (Select all that apply.) 1. The nurse changes his personal password for the medical record more frequently than required 2. The nurse writes down her current password on a list that’s kept in the manager’s office 3. The system administration monitors the medical records accessed by the nurses 4. The nurse relies on the automatic sign-off to close the medical record 5. The nurse reviews the medical records of all clients on the unit before accepting an assignment Rationale Practices that support EMR security include frequently changing passwords (using a combination of letters, numbers and symbols) and not sharing passwords with other staff. Nurses should also not record passwords in non-secure areas. Nurses should only review medical records for their assigned clients and any unauthorized access will be discovered by the system administrator during a routine check of the system. Best practices is to sign off when leaving the computer screen and not rely on an automatic timeout because this can leave the system temporarily open for others to view client information. Question: 8 Correct Answer: 5, 6 The client underwent a total hip arthroplasty 48 hours ago. The client has been up in a chair and is prescribed physical therapy twice daily. What type of nursing care is needed for this client? (Select all that apply.) 1. Remind the client not to bend the knee of the affected leg when sitting 2. Empty the wound suction drainage device every 4 hours 3. Place a soft foam triangular pillow between the client's legs when in bed 4. Assist the client with a clear liquid diet 5. Provide a seat riser for the toilet or commode 6. Encourage client to perform leg exercises when in bed Rationale On the first post-operative day following a total hip arthroplasty, the client will be up in a chair. The client should bend the affected leg at the knee when sitting in a chair - not keep it straight. Two days after surgery, the client will be walking in the hallway. When in bed, the client should continue to perform leg exercises and use a pillow or foam wedge between his or her legs (to keep the legs abducted.) The drain is usually removed the second day after surgery; there should be little-to-no drainage on the second post-op day. The client can eat a regular diet after surgery. RN Practice Question Banks 31-45 (Not Required) Question: 1 Correct Answer: 1, 4 A client is scheduled for a CT scan with contrast. What interventions should be taken by the nurse prior to sending the client to the imaging department? (Select all that apply.) 6. Reassess the client's allergies 7. Administer prescribed medication to sedate the client 8. Confirm that a signed consent is in the chart 9. Ask the client to remove all metal jewelry 10. Ensure the client is well-hydrated Rationale Usually the client is NPO prior to a CT scan, particularly when contrast material is being used. Allergies and past reactions to contrast media should be reviewed with the client. Any metal, including body piercings, jewelry, hearing aids and removable dental work should be removed and safely stored prior to the test. Sedation is necessary only in cases of extreme anxiety. Question: 2 Correct Answer: 3, 5 A nurse is caring for a 13 year-old after a spinal fusion to treat scoliosis. Which nursing intervention is appropriate in the immediate postoperative period? (Select all that apply.) 7. Maintain bedrest with the head of the bed elevated at least 30 degrees 8. Assist the client to stand and walk to the bathroom as needed 9. Encourage passive leg and ankle exercises 10. Position the client flat in bed and logroll every 2 to 4 hours 11. Encourage use of patient-controlled analgesia 12. Perform neurovascular checks every 8 hours Rationale The client should remain flat in bed for at least 6 hours and turned from side to side every 2 to 4 hours. The day after surgery, the client can sit up in bed a few times; the client will get out of bed to sit in a chair on the second or third day after surgery. Clients should be encouraged to perform isometric exercises right after surgery. Neuro checks will be performed every 2 hours for the first 24 hours. Question: 3 Correct Answer: 3, 4, 5 The health care provider writes a new order for a fentanyl (Sublimaze) patch to manage the chronic pain experienced by the client in hospice care. The nurse is teaching a client and family members about the fentanyl patch and knows that teaching was effective when the client makes which of the following statements? (Select all that apply.) 6. "I can soak in a hot tub to help decrease my pain." 7. "I should cut up the patch before I throw it away so no one else can use it." 8. "It may take up to a half day or longer for the patch to start working, the first time I use it." 9. "If my pain is too great while I am on the patch, I can take a supplemental pain medication." 10. "I will take the old patch off before I apply the new patch on." Rationale Fentanyl patches are slowly absorbed via the subcutaneous tissue at a predetermined rate for up to 72 hours. Due to the slow absorption rate, the first patch may take 12 to 24 hours before effective analgesia is felt; a short-acting opioid may be given for breakthrough pain. The client can shower or bathe with the patch, but it should not be exposed to heat (hot tubs, heating pads) because it speeds up the absorption of the medication. Old patches are removed and the new patch is applied to a different skin area. Old patches are disposed by folding the old patch in half, not by cutting them up and throwing them in the trash (which may be dangerous for people and pets). Question: 4 Correct Answer: 2, 3, 5 The nurse is assessing a client who sustained multiple fractures, contusions, and lacerations in a motor vehicle accident three days ago. The client suddenly becomes confused. Which of the following findings would support the nurse's suspicion that the client has developed a fat embolism? (Select all that apply.) 6. Hypertension 7. Petechiae on the upper anterior chest 8. Elevated temperature 9. Dyspnea 10. Low oxygen saturation Rationale Manifestations of acute confusion, hypoxia, fever and hypotension may indicate fat embolism in a client who has sustained multiple fractures, particularly fractures of the long bones. The occlusion of dermal capillaries by fat with increased friability of the capillaries can result in skin petechiae. This is most common on the chest, neck, upper arm, axilla, shoulder, oral mucous membranes and conjunctiva. Question: 5 Correct Answer: 1, 3, 5, 6 A client with a history of asthma and kidney stones is admitted with a diagnosis of recurrent renal calculi. The client experiences shortness of breath following a lithotripsy. The nurse auscultates the client's lungs and finds decreased air movement but no wheezing. The arterial blood gas (ABG) results are pH 7.31, PaO2 53 mm Hg, PaCO2 50 mm Hg, and O2 sat 82%. Which of the following actions are appropriate for the nurse to take? (Select all that apply.) 8. Call respiratory therapy 9. Administer a short-acting bronchodilator via nebulizer 10. Start high flow oxygen via face mask 11. Start oxygen via nasal cannula 12. Increase IV fluids 13. Contact the health care provider 14. Prepare for possible intubation Rationale This client needs emergency treatment to open the airways and improve gas exchange. The absence of lung sounds without wheezing indicates a severe narrowing of the airways in asthma with minimal air movement. Emergent intervention to open the closed airway including possible intubation are indicated. The high PaCO and low pH indicate respiratory acidosis due to inadequate gas exchange. The low oxygen saturation and PaO2 indicate severe hypoxemia requiring high flow oxygen via mask. Question: 6 Correct Answer: 1, 2, 5 The geriatric social worker is working with the nurse to assess the client's ability to perform instrumental activities of daily living (IADL). Which of the following skills are considered instrumental activities of daily living? (Select all that apply.) 6. Ability to take medications 7. Ability to cook meals 8. Ability to eat independently/feed self 9. Ability to bathe self 10. Ability to write checks Rationale Activities of daily living (ADLs) are basic self-care tasks, such as feeding, toileting, grooming, bathing, putting on clothes. Instrumental activities of daily living (IADLs) are slightly more complex skills and include a series of life functions necessary for living independently, such as the ability to use a telephone, shopping, doing housework, preparing meals, handling finances, and being responsible to take medications. ADLs and IADLs are part of an older adult's functional assessment. Question: 7 Correct Answer: 1, 2, 4 The charge nurse is making assignments on the day shift for a registered nurse (RN), a licensed practical nurse (LPN) and a certified nursing assistant (CNA). Which assignments are the most appropriate for a client who fell during the night and now has a skin tear on his arm and a hematoma on his hip, and is scheduled for an x-ray of his hip? (Select all that apply.) 6. Assign medication administration to the LPN 7. Assign wound care to the RN 8. Assign complete care to the LPN 9. Assign the CNA to assist with personal hygiene tasks 10. Assign the LPN to report confusion or headache Rationale The RN can assign clients to LPNs as long as the care of the client is not too complex and there is a low likelihood of an emergency. Since this client fell during the night, the RN should not assign complete care to the LPN. But the LPN could administer medications to this client and should report observations and assessment data to the RN. The CNA can assist the client with personal care activities. Question: 8 Correct Answer: Correct Order The nurse is performing pulmonary assessment on a client. Indicate the correct sequence of pulmonary assessment by dragging and dropping the steps below into the correct order. 5. Inspection 6. Palpation 7. Percussion 8. Auscultation Rationale Inspection is first, observing for pattern of breathing, symmetry, anteroposterior and transverse chest diameters, as well as skin color, sounds and odors. The nurse will then palpate the posterior and anterior chest, noting any tenderness, crepitus, or tactile fremitus. The next step is percussion, which is performed in a systematic manner, usually from side to side from apex (top) of lungs to base (bottom), listening to changes in tone from one area to another. Lastly, the lungs are auscultated, listening over the anterior, posterior, and lateral chest for expected or adventitious sounds. Question: 9 Correct Answer: Correct Order The nurse is preparing to administer total parenteral nutrition (TPN) through a central line. Indicate the correct order in which the following nursing actions should be performed by dragging and dropping the options below. 7. Check the solution for cloudiness or sediment 8. Select and prime the correct tubing and filter 9. Thread the intravenous tubing through an infusion pump 10. Use aseptic technique when handling the injection cap 11. Connect the tubing to the central line 12. Set the infusion pump at the prescribed rate Rationale TPN solution should not be cloudy or have any kind of particles or sediment. The nurse should prepare the equipment by priming the tubing and threading it through the pump. To prevent infection, the nurse must use aseptic technique when inserting the connector into the injection cap and connecting the tubing to the central line. The nurse should then set the pump at the prescribed rate. RN Practice Question Banks 46-60 (Not Required) Question: 1 Correct Answer: 1, 2, 4 The nurse needs to start an IV on an oriented adult. Which supplies will the nurse select? (Select All That Apply) 1. IV starter kit 2. IV catheter 3. Rolled gauze 4. Saline flush or ordered solution 5. Labels for insertion site and tubing 6. Arm board Rationale An arm board or rolled gauze are only necessary for a person that cannot keep the arm straight or picks at the IV site, often because of confusion or other altered level of consciousness. All the other supplies listed are standard. Question: 2 Correct Answer: 1, 2, 3, 5 The nurse works with clients in an outpatient substance abuse treatment program. Which intervention is indicated to prevent relapse and promote a successful recovery? (Select all that apply.) 1. Medication-assisted treatment 2. Participate in group psychotherapy 3. Refer clients for mental health assessments 4. Discharge clients who fail random drug tests 5. Counseling about alternative coping skills Rationale Treatment for substance use disorder (SUD) includes medications, especially for alcohol and opioid abuse, counseling and group psychotherapy, attendance at mutual help groups, such as Alcoholics Anonymous or Narcotics Anonymous, and learning new ways to cope with cravings and urges to use. Many drug-addicted individuals also have other mental disorders and should be assessed by health care professionals. Like other chronic diseases, relapse is likely and some individuals may fail random drug tests. This doesn't mean that treatment is a failure but that additional modifications and treatment are needed. Question: 4 Correct Answer: 1, 2, 5 A client is diagnosed with rheumatoid arthritis (RA). Which types of drugs might the nurse expect to be ordered as a combination drug therapy regimen? (Select all that apply.) 1. Glucocorticoids 2. Biological-response modifiers 3. Antimicrobial agents 4. Diuretics 5. Anti-inflammatory drugs Rationale Rheumatoid arthritis is a chronic, systemic autoimmune disorder that results in symmetric joint destruction. Research shows that multiple drug therapy is most effective in protecting against further destruction and promoting function. Analgesics and anti- inflammatory drugs are used. Disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate help slow or stop progression of RA. Biological response modifiers are used to help stop inflammation. Glucocorticoids can also be used for severe RA or when RA symptoms flare to ease the pain and stiffness of affected joints. Because RA is not an infectious disease, antimicrobials are ineffective. Although there is swelling in the joints, it is not fluid, so diuretics are not part of the treatment plan. Question: 5 Correct Answer: 1, 2, 3, 5 Sputum culture results for a client admitted with a cough and fever indicate a methicillinresistant Staphylococcus aureus (MRSA) infection in the nares. What nursing intervention must now be taken? (Select all that apply.) 1. Move the client to a private room 2. Place a mask on the client if the client needs to leave the room 3. Place the client in a room with another client colonized with MRSA 4. Staff will wear N-99 or N-100 particulate respirators when in the client's room 5. Dedicate the use of personal and noncritical medical equipment to the client Rationale When possible, a private room would be best, but cohorting is often used for multidrug resistant organisms such as MRSA. If the client needs to be transported to another area, the client should wear a mask, especially if there's a productive cough. Staff should practice excellent hand hygiene and other standard precautions, but a respirator is not needed for MRSA in the nares. To minimize the risk of spreading infection, equipment or personal items should kept in the client's room and dedicated for his/her use. Question: 6 Correct Answer: 1, 4 A client has been taking rosuvastatin for six weeks as part of a treatment plan to reduce hyperlipidemia. The clinic nurse is reviewing and reinforcing information about the medication with the client. Which statement by the client indicates an understanding about the medication? (Select all that apply.) 1. "I will need to call my doctor if I have any muscle weakness or pain, especially in my legs." 2. "I will need to come back to have my liver and kidney labs checked." 3. "I need to be careful when I get up because this medication can make my blood pressure drop." 4. "I add some nuts and fresh fruit to my oatmeal in the morning and I can't remember when I last ate a steak." 5. "This medication has to be taken first thing in the morning, before I eat breakfast." Rationale Clients taking rosuvastatin need to be monitored for alteration in liver function. An adverse effect of rosuvastatin is muscle pain and weakness (rhabdomyolysis). Left untreated, rhabdomyolysis can lead to renal impairment. The medication does not affect blood pressure or cause orthostatic hypotension. The client should be taught to follow a low-cholesterol diet, which includes increasing intake of whole grains and limiting intake of foods high in saturated fats, trans fats and dietary cholesterol. The medication is ordered once a day. The client can take it at any time of day, preferably at the same time of day each day, before or after eating. Question: 7 Correct Answer: 2, 4, 5 A 32 year-old female with human epidermal growth factor receptor 2- positive (HER2-positive) metastatic breast cancer is scheduled to begin therapy with pertuzumab. What information is important for the nurse to reinforce and discuss with the client? (Select all that apply.) 1. Other therapies for cancer treatment are no longer needed 2. Use contraception during and for 6 months following the use of this drug 3. Take the medication at the same time every day on an empty stomach 4. Report shortness of breath, lightheadedness, dizziness, cough, or swelling of the feet 5. Report chills, fatigue, or headache during treatment Rationale Pertuzumab (Perjeta) is used in combination with trastuzumab (Herceptin) as a targeted therapy for HER2+ metastatic breast cancer; these meds are used in combination with chemotherapy and radiation. The most common side effects are fatigue, loss of taste, muscle pain, and vomiting; sometimes slowing the infusion rate can help. It is best to eat a small meal before receiving the infusion. Serious side effects include birth defects and fetal death; women of child-bearing age must use a form of effective contraception during and for 6 months following treatment. Drugs that block HER2+ activity decrease left ventricular ejection fraction (LVEF) and will worsen symptoms of congestive heart failure; heart function must be tested before and monitored during treatment. Question: 8 Correct Answer: Correct order The oncology client is using patient controlled analgesia (PCA) with morphine for pain control. The client reports having pain and states it is a 7 (on a scale of 0 to 10). Indicate the correct sequence of nursing interventions by dragging and dropping the sentences in the correct order. 1. Ensure the Clint is using PCA equipment properly 2. Conform that there is power to the pump and the tubing is patent 3. Asses the level of consciousness and respiratory status 4. Check the chart for orders for treating breakthrough pain 5. Consult with the health care provider Rationale The nurse must ensure that the client understands how to use the PCA and should have the client demonstrate how to push the button. If indeed the client is using the PCA properly, then the nurse must ensure the machine is mechanically sound, i.e., the power is on, tubing connected and not kinked, etc. Because narcotics can cause sedation and respiratory suppression, the nurse must determine that these are not problems. The nurse can then check to see if there is an order for breakthrough pain. The last step would be to consult with the health care provider, possibly for further orders. RN Practice Question Banks 61-75 (Not Required) Question: 1 Correct Answer: 1, 2, 5 A healthy 18 year-old is entering college in the fall. Which immunization would the health care provider recommend prior to college? (Select all that apply.) 7. Seasonal influenza vaccine 8. Tetanus, Diphtheria, Pertussis vaccine (Tdap) 9. Pneumococcal polysaccharide vaccine (PPSV23) 10. Meningococcal conjugate vaccine (MCV4) 11. Shingles vaccine 12. Human papillomavirus (HPV) vaccine Rationale Adults older than age 50 should get the shingles vaccine. The PPSV23 is given to adults older than age 65. (The pneumococcal vaccine PCV13 is routinely given to infants/children.) An 18 year-old who is going to college should receive the TDAP, MCV4 and seasonal influenza vaccine. He or she should also receive the HPV vaccine if s/he has not already received it. Question: 2 Correct Answer: 1, 2, 4 A client is being prepared for an above-the-knee amputation. Which of the following measures are part of the nurse's responsibilities, which are designed to protect the client? (Select all that apply.) 6. Verify any allergies 7. Verify that the informed consent form is signed 8. Have the client confirm his or her identity, the surgical site and the procedure before administration of any medications 9. Verify the surgical leg is marked with indelible marker over, or as close as possible to, the surgical incision site 10. Explain the procedure, including any risks, before the client signs the surgical consent form Rationale Prior to surgery, the nurse can witness the client's signature on the consent form, but explanation of the procedure, including risks and benefits, needs to come from the health care provider. Any allergies must be noted and verified prior to surgery. The surgeon must use an indelible marker on the surgical leg to indicate the incision site; sometimes the nonsurgical leg will be marked with a "NO." In the operating room, a surgical checklist is completed with a nurse and anesthesiologist. Prior to administration of anesthesia, there is another check with the client to verify identify, the correct surgical site and procedure. Question: 3 Correct Answer: 1, 2, 3, 5 The client is being treated for complications of a chronic disease on a medical-surgical unit. Who can have access to the client's medical record? (Select all that apply.) 7. The nursing instructor planning clinical assignments 8. The facility researcher collecting data for a study to which the client consented 9. The certified nursing assistant documenting vital signs 10. The emergency department nurse who originally admitted the client and now wants to know the client's current status 11. The person who has health care power of attorney 12. The client's spouse or other close family member Rationale Safeguarding client privacy requires strict adherence to the ethical standards of confidentiality and need-to-know access. Only those individuals who are directly involved in the client's care should have access to his or her information. The ED nurse is no longer directly involved in the client's care and should not have access to information about the client. Without valid authorization, such as health care power of attorney, a spouse or other family members cannot access the client's medical records. Question: 4 Correct Answer: 1, 2, 3 A newly admitted client reports taking phenytoin for several months. Which of the following assessments should the nurse be sure to include in the admission report? (Select all that apply.) 5. Report of unsteady gait, rash and diplopia 6. Report of any seizure activity 7. Serum phenytoin levels 8. Report of anorexia, numbness and tingling of the extremities Rationale Serious adverse outcomes of antiseizure medications such as phenytoin (Dilantin) are unsteady gait, slurred speech, extreme fatigue, blurred vision or feelings of suicide. Increased hunger (not anorexia), increased thirst or increased urination are additional serious side effects. Question: 5 Correct Answer: 1, 4, 5 The nurse compares the third postoperative assessment findings to the first two postoperative assessments. What action should the nurse take to provide optimal care for this client? (Select all that apply.) 7. Elevate the client's lower extremities 8. Move the bed into Trendelenburg position 9. Assist the client to use the incentive spirometer 10. Administer an intravenous fluid bolus 11. Inspect the surgical incision site 12. Administer pain medication Rationale Hypovolemia due to blood loss should be considered in the postoperative client who develops tachycardia and hypotension (a systolic BP reading below 90 in an adult indicates possible shock.) The nurse should check the incision site and any area dependent of the site for any blood loss. Evidence supports elevating the lower extremities in hypotensive episodes, to bring fluid Blood Pressure Pulse Respiratory Rate Oxygen Saturation 1st Postop Assessment 110/80 mm Hg 80 10 98% 2nd Postop Assessment 100/72 mm Hg 88 16 97% 3rd Postop Assessment 92/64 mm Hg 106 24 95% from the lower body to the core; there is no evidence to support using the Trendelenburg position. An IV fluid bolus can also be used to increase volume. Although hypotension and tachycardia may also indicate pain, the nurse should ensure that the client's ABCs are stable before medicating for pain. Assisting the client to use the incentive spirometer can be done later. RN Practice Question Banks 76-90 (Not Required) Question: 1 Correct Answer: 2, 3 The home care nurse is admitting a new client with a diagnosis of COPD, atrial fibrillation and gout. After reviewing the client's medication list, the nurse would arrange for periodic monitoring of blood drug levels for which of the following medications? (Select all that apply.) 6. Beclomethasone inhaled (Qvar) 7. Digoxin (Lanoxin) 8. Theophylline (Elixophyllin, Theo-24, Uniphyl) 9. Allopurinol (Aloprim, Zyloprim) 10. Glipizide (Glucotrol) Rationale It is necessary to monitor blood levels for the client taking theophylline and digoxin to prevent the client from developing toxicity. Question: 2 Correct Answer: 1, 2, 3, 5, 6 The nurse is to review the topic of caring for clients with Guillain-Barre syndrome with other staff members at a monthly meeting. Which of these findings should the nurse include in the discussion? (Select all that apply.) 7. Weakness, tingling or loss of sensation in legs and feet occur first 8. Rapidly progressive ascending paralysis of the legs, arms, respiratory muscles and face 9. Difficulty with bladder control or intestinal functions 10. Hypertension 11. Difficulty with eye movement, facial movement, speaking, chewing or swallowing 12. Numbness, tingling, prickling sensation or moderate pain throughout the body Rationale Guillian-Barre is an autoimmune disease. The symptoms of weakness or tingling sensation begins in the legs and progresses to the arms and upper body, resulting in almost complete paralysis. The client is often put on a ventilator during the worst part of the disease to assist breathing. The client may have low blood pressure or poor blood pressure control. Question: 3 Correct Answer: 1, 2 A client who has returned from surgery reports feeling nauseated and later has an emesis. The nurse administers promethazine per standing orders. In addition to relief from nausea, what other effects of this medication does the nurse expect? (Select all that apply.) 6. Dry mouth 7. Sedation 8. Pinpoint pupils 9. Heart palpitations 10. Runny nose Rationale Promethazine (Phenergan) is used as an antihistamine, sedative and antiemetic. It produces anticholinergic effects, such as dry mouth and nasal congestion, dilated pupils and urinary retention. Although promethazine is a sedative, the nurse should understand that it can cause some people to have heart palpitations and to feel restless and unable to sleep. Question: 4 Correct Answer: 1, 3 The nurse is evaluating a stage III pressure ulcer while performing a dressing change. Which wound assessment findings indicate that the prescribed treatment is appropriate to support wound healing? (Select all that apply.) 7. The wound base is moderately moist, shiny and red 8. Clumps of soft yellow tissue adhere to the wound bed 9. The size of the wound is decreasing 10. The periwound texture is moist and soft 11. The edge of the wound appears rolled or curled under 12. A fruity odor is noted on the dressing Rationale A wound base that's moist, shiny and "beefy" red indicates good blood flow, new tissue growth and healing. Slough is clumps or strings of moist and soft tissue and can be yellow, tan or green in color – slough will impede healing. A fruity odor indicates infection. Soft and denuded tissues in the periwound indicate tissue breakdown due to excessive moisture from wound drainage. Curled or rolled wound edges (epibole) prevents epithelial cells from migrating to close the wound. Question: 5 Correct Answer: 1, 4 A client has been given a prescription for alendronate. Which of the following statements indicate the client understands how to safely take this medication? (Select all that apply.) 6. "I will notify the health care provider if I have any difficulty swallowing." 7. "I will take the pill immediately preceding weight-bearing exercise." 8. "I will swallow it with 8 ounces of water." 9. "I will stand or sit quietly for 30 minutes after taking it." 10. "I will always eat breakfast before taking it." Rationale Alendronate (Fosamax) can cause esophagitis or esophageal ulcers unless precautions are followed. The client must be able to sit upright or stand for at least 30 minutes after taking the tablet. The client should take the tablet first thing in the morning, with a full glass of water, at least 30 minutes before eating or drinking anything or taking any other medication. Question: 6 Correct Answer: 1, 3, 5 The client undergoes a laparoscopic removal of the appendix. Which postoperative instructions will the nurse reinforce? (Select all that apply.) 7. No showering for 48 hours after surgery 8. Maintain bedrest for 24 hours before gradually resuming regular activities 9. Some shoulder discomfort can be expected 10. Use 2 tablespoons of Milk of Magnesia if no bowel movement 3 days after surgery 11. Restrict diet to bland, easily digestible food for a few days 12. Gently scrub off the "skin glue" when you feel able Rationale Laparoscopic surgery involves using carbon dioxide gas to open the inside of the abdomen, which pushes up the diaphragm; this may cause shoulder discomfort postoperatively. Clients should keep the dressings clean and dry for 48 hours before they can shower, but no tub baths for a few weeks. If "skin glue" is used over the incision(s), the client should not try to scrub it off because it will wear off on its own. Clients may resume normal activities as soon as they are able but no heavy lifting or aerobic exercise for about 2 weeks. If they do not have a BM after 2-3 days, clients can take 2 tablespoons of MOM several times a day until they have a BM. Diet can be advanced as tolerated but it's best to stick to non-greasy, non-spicy foods for a few days. Question: 7 Correct Answer: 1, 3, 4, 5 During a 12-hour night shift, the nurse has a "near miss" and catches an error before giving a new medication. Which statement might explain the reason for the near miss? (Select all that apply.) 6. The nurse works in the intensive care unit (ICU) 7. The nurse has worked on the same unit for 5 years 8. The unit is short-staffed 9. The nurse is interrupted when preparing the medication 10. The nurse is sleep-deprived Rationale There are a number of reasons for near misses and making medication errors, including heavy workload and inadequate staffing, distractions, interruptions, and inexperience. Fatigue and sleep loss are also factors, especially for nurses working in units with high acuity clients. Question: 8 Correct Answer: 1, 2, 4, 5 A parent asks the nurse about a Guthrie Bacterial Inhibition test that was ordered for her newborn. Which of the following points should the nurse discuss with the client prior to this test? (Select all that apply.) 7. The test will be delayed if the baby's weight is less than 5 pounds 8. Positive tests require dietary control for prevention of brain damage 9. This test identifies an inherited disease 10. The urine test can be done after six weeks of age 11. Best results occur after the baby has been breast-feeding or drinking formula for two full days 12. Routine screening of newborn infants is not mandatory in the United States Rationale Screening for PKU is mandated in all 50 states, though methods of screening vary. The Guthrie Bacterial Inhibition Assay (BIA) is one test used to diagnose phenylketonuria (PKU), a disease characterized by an enzyme deficiency. A blood sample is taken from the baby's heel shortly after birth, with a follow-up test 7 to 10 days later. Test results are more accurate if the baby weighs more than 5 pounds and has been regularly drinking milk for more than 24 hours. A urine test is normally done after six weeks of age if a baby did not have the blood test. Question: 9 Correct Answer: 1, 2, 5 The client returned from the cardiac catheterization lab four hours ago. The groin was used as the insertion site. Which of the assessment findings would the nurse immediately report to the health care provider? (Select all that apply.) 6. Capillary refill 6 seconds on the affected toes 7. Pale color of the affected limb 8. Trace amount of serosanguineous drainage on the groin dressing 9. Bruising or lump at the insertion site 10. Nonpalpable pedal pulse on the affected limb Rationale A trace of serosanguineous drainage on the dressing is common. Some bruising or a small lump is expected at the insertion site. Reportable conditions include significant reports of pain; abnormal lab values; abnormal ECG strip; post-procedure bleeding or swelling; color, temperature or pulse changes, especially to the affected limb. Capillary refill should be about 3 seconds. Question: 10 Correct Answer: 3, 4 A 12 year-old pediatric cancer client is distraught about the alopecia that occurred after the last chemotherapy treatment. Which nursing interventions are appropriate for this side effect of chemotherapy? (Select all that apply.) 5. Practice and teach thorough hand washing 6. Administer prescribed antiemetic medication before nausea is too severe 7. Encourage visits from friends before discharge from the hospital 8. Allow the child to choose a cap, scarf, wig or other head cover to use Rationale Alopecia is the loss of hair, which is a frequent side effect of certain types of chemotherapy. Although it is not life-threatening, the body image change is difficult for many individuals, particularly children and adolescents. Encouraging visits from friends before discharge helps the young client and friends adjust. Wearing preferred forms of head cover- ups increases comfort and decreases embarrassment. The other options are proper interventions for chemotherapy, but do not help the client with hair loss. Question: 11 Correct Answer: Correct Order The client returns from the post anesthesia care unit (PACU) in stable condition following abdominal surgery. While planning immediate postoperative care, the nurse identifies the nursing diagnoses listed below. Prioritize these diagnoses by placing them in order of importance (with 1 being the most important). 5. Risk for ineffective airway clearance related to anesthesia 6. Acute pain related to surgical procedure 7. Impaired reality related to intensive equipment 8. Risk for imbalanced nutrition: less than body requirement related to NPO status Rationale Airway is the highest priority, especially in the immediate postoperative period. Pain control is the next priority because this client will most likely experience significant pain. Although impaired mobility is expected, it does increase the client's risk for postoperative complications. The client's risk for nutrition imbalance is the lowest priority and is to be expected for a client who has had abdominal surgery; hydration is provided intravenously. Question: 12 Correct Answer: Correct Order A woman in early labor puts her call light on and tells the nurse "I think my water bag just broke and I feel like something came out with the water." A visual exam by the nurse reveals a prolapsed umbilical cord. List in order of priority the actions the nurse should perform in this obstetrical emergency. 9. Gloves and place two fingers into the cervical opening, beside the umbilical cord, to relieve pressure 10. Cal for assistant, asking that the health care provider is notified 11. Place the Clint in the knee-chest position on the bed 12. Administrator oxygen to the mother via mask at 10 L/min Rationale A prolapsed cord is a medical emergency; the blood flow from the placenta to the fetus will be occluded with each contraction if the umbilical cord is compressed against the presenting part of the fetus and the dilated cervix which is why the priority intervention is to apply gloves and place two fingers to one side of the cord (or entire hand) to relieve pressure. The nurse is also calling for assistance so that someone can notify the health care provider and staff can prepare for emergent cesarean. Placing the client in a modified Sims or knee- chest position will allow gravity to help decrease pressure on the cord from the presenting part, but the primary relief from pressure on the umbilical cord is the gloved fingers. Oxygen administration will help once the circulation of blood to the fetus is re-established. RN Practice Question Banks 91-105 (Not Required) Question: 1 Correct Answer: 1, 3, 5 The nurse is performing a prekindergarten physical on a 4 year-old child and will administer a series of scheduled vaccines, including the DTaP, IPV, MMR and VAR. What information does the nurse need to know about these vaccinations? (Select all that apply.) 1. Either the deltoid muscle of the arm or anterolateral thigh muscle can be used 2. A 20 gauge needle is used to administer the varicella (VAR) vaccine intramuscularly (IM) 3. A 5/8 inch needle length is often used for subcutaneous (SubQ) injections 4. The vaccines contain the preservative thimerosal 5. Multiple immunizations should be administered a minimum of 1 inch apart 6. The vaccines all contain weakened live viruses Rationale A 4-6 year-old should get the Diphtheria-Tetanus-Pertussis (DTaP), Inactivated Polio (IPV), Measles-Mumps-Rubella (MMR), and Varicella (VAR) vaccines. DTaP is given IM; VAR and MMR are administered SubQ (using a 5/8 inch, 25-gauge needle); IPV can be given either SubQ or IM. The IPV contains inactivated viruses; the MMR and VAR contain live viruses and DTaP is made up of dead bacteria. Vaccines no longer contain thimerosal, which is a form of mercury. Multiple immunizations should be spaced a minimum of 1 inch apart. Either the deltoid muscle of the arm or the anterolateral thigh muscle can be used. Question: 2 Correct Answer: 3, 4, 5 A client is brought to the emergency department with a blood sugar of 52 mg/dL (2.89 mmol/L). The client is weak and diaphoretic but awake, and the client's blood sugar does not rise above 70 mg/dL (3.89 mmol/L) after drinking one 4-ounce (118 mL) glass of orange juice. Which of the following actions should be taken? (Select all that apply.) 1. Offer a 12-ounce (355 mL) can of cola with added sugar 2. Instruct the client to not take more insulin today 3. Offer 8-ounce (237 mL) glass of milk 4. Recheck blood sugar in 15 minutes 5. Determine blood sugar management medications Rationale Treatment for hypoglycemia is to consume approximately 15-20 grams of glucose or simple carbohydrates. Common examples of 15 grams of simple carbohydrates include: 2 tablespoons of raisins; 118 mL of juice or regular soda (not diet); 237 mL of nonfat or 1% milk; and 1 tablespoon of honey. In a clinical setting, the client may also be given glucose tablets. If after 15 minutes the blood sugar is still below 70 mg/dL (3.89 mmol/L), the client can be given another 15-20 grams of simple carbohydrates (this is also known as the "15 - 15 rule.") It's always a good idea to confirm how the client manages his/her diabetes. Question: 3 Correct Answer: 2, 5 A female client diagnosed with genital herpes simplex virus 2 (HSV-2) reports having dysuria, dyspareunia, leukorrhea and lesions on the labia and perianal skin. Which intervention will provide symptomatic relief? (Select all the apply.) 1. Soak in a tub of hot water 2. Local application of ice packs 3. Dry the genital area with a blow dryer on the cool setting 4. Echinacea juice extract capsules twice daily 5. Over-the-counter medications such as ibuprofen 6. Increase fluid intake Rationale Symptomatic relief includes lukewarm (not hot) baths and applying cold packs to the genital area. Sometimes using a hair dryer set to a low or cool setting can help relieve symptoms. Overthe- counter medications such as ibuprofen and acetaminophen can help with local tenderness. A client with HSV-2 should increase their fluid intake when using acyclovir, but increasing fluids will not directly relieve symptoms. There's no evidence that echinacea can relieve the symptoms of HSV-2. Question: 4 Correct Answer: 1, 5 The nurse is participating in a quality improvement (QI) project with a focus on improving pain management on a surgical unit. What processes are included in quality improvement? (Select all that apply.) 1. Pain management protocols will be reviewed to consider evidence- based practice 2. A nurse researcher will design a study to confirm evidence supporting a specific pain management intervention 3. The quality improvement committee will review the patient satisfaction data related to pain management 4. Pain management interventions will be determined by the pharmacist and health care provider 5. The entire health care team participates in the process Rationale QI is directed at improving processes and client outcomes. QI includes monitoring client outcomes to determine if changes are needed and then reviewing evidence-based practice and client satisfaction surveys to determine if there's a better way manage pain on the unit. A critical component of QI is teamwork and the team should include many different members of the health care team and not just administrators or health care providers. A nursing research project is a process of systematic inquiry intended to contribute to the general body of knowledge for the profession rather than a QI project. Question: 5 Correct Answer: 1, 2, 4 Which of the following methods are used to correctly identify a client? (Select all that apply.) 1. Check the client identification bracelet 2. Compare the client to a labeled photograph 3. Ask clients to state their name 4. Have clients state their birth date 5. Ask a family member or visitor Rationale Two pieces of identification are required prior to any procedure, including medication administration. Because client identification bracelets are not routinely used in long-term care facilities, nurses use a photograph to identify a resident. Visitors and even family members should not be asked to identify clients. RN Practice Questions Banks 106-120 (Not Required) Question: 1 Correct Answer: 3, 4, 6 A 62 year-old male arrives at the emergency department and reports having chest pain. Based on standing orders, which intervention does the nurse expect to be implemented within the first 10 minutes of his arrival in the ED? (Select all that apply.) 1. Intravenous thrombolysis 2. Supplemental oxygen 3. Focused cardiovascular history-taking and physical exam 4. 12- lead ECG with continuous monitoring 5. Blood draw for cardiac troponin 6. Intravenous access Rationale All clients reporting chest pain should be managed as if the pain were ischemic in origin. Treatment in the ED begins with a focused cardiovascular history-taking and screening for alternative causes of chest pain. IV access will be established, labs drawn for cardiac markers and a 12-lead ECG (with continuous monitoring) will be used to help confirm if it is a MI. Further treatment will depend on whether the chest pain is due to a MI and the type of MI. IV thrombolysis would be used once a ST segment elevation myocardial infarction (STEMI) is confirmed. Pulse oximetry should be performed and supplemental oxygen given only to maintain oxygen saturation above 90%; supplemental oxygen may harm nonhypoxic clients with STEMI. Question: 2 Correct Answer: 1, 4, 5, 6 The client is admitted with a diagnosis of ulcerative colitis. Which laboratory values should the nurse be sure to check? (Select all that apply.) 1. Hematocrit and hemoglobin 2. Blood urea nitrogen (BUN) 3. T3 and T4 count 4. Erythrocyte sedimentation rate (ESR) 5. White blood cell count (WBC) 6. Albumin Rationale Basilar skull fractures often result from automobile accidents (including auto/bike accidents) or abuse. Clinical findings of a BSF include Raccoon's eyes and Battle's sign, but these don't show up until several hours or even days after the injury. Battle's sign is bruising seen behind the ear. Raccoon's eyes result from fracture of the base of the sphenoid sinus. Other findings may include vision changes, hearing loss and facial numbness or paralysis. Purulent drainage is associated with infection. Redness, swelling or tenderness over the mastoid bone indicates mastoiditis, which is usually caused by a middle ear infection. Question: 3 Correct Answer: Correct Order The nurse is educating a client about how to use a metered-dose inhaler with spacer. Drag and drop the options below in the order that demonstrates correct use of a metered-dose inhaler with spacer. 1. Release the medication into the spacer 2. Breath in deeply 3. Remove the mouth place from the lips 4. Hold breath for 10 second 5. Breath out slowly Rationale Release the medication into the spacer. Breathe in deeply. Remove the mouthpiece, then hold breath for 10 seconds, then breathe out slowly. Spacers are highly recommended when inhalers are used because they increase the availability of the medication to the client. Question: 4 Correct Answer: Correct Order There is an order to obtain an aerobic wound culture from a client's wound. Place the nursing actions in the correct order. Click and hold the reorder icon to drag and drop the steps into the correct order. 1. Remove the existence dressing 2. Perform hand hygiene and apply clean gloves and face shield 3. Irrigate the wound 4. Wipe the Wound 5. Perform hand hygiene and apply clean gloves 6. Obtain a Culture by rotating a sterile swab in the open wound. Rationale Cultures are obtained from wounds after irrigation. The edges are cleaned since the exudate may be contaminated with normal skin flora. Hand hygiene and application of new gloves is done after removing the dressing and before irrigation to prevent contamination of the wound. A face shield is worn to protect the nurse from spraying during irrigation. RN Practice Questions Banks 121-131 (Not Required) Question: 1 Correct Answer: 1, 2, 3, 6 The client was admitted 2 days ago after a CT scan of the head revealed a basilar skull fracture (BSF). What assessment findings does the nurse anticipate with a BSF? (Select all that apply). 1. Bruising behind the ear (Battle's sign) 2. Bruising around both eyes (Raccoon eyes) 3. Hearing loss 4. Purulent drainage from the ear 5. Unilateral redness and swelling over the mastoid bone 6. Facial numbness Rationale Basilar skull fractures often result from automobile accidents (including auto/bike accidents) or abuse. Clinical findings of a BSF include Raccoon's eyes and Battle's sign, but these don't show up until several hours or even days after the injury. Battle's sign is bruising seen behind the ear. Raccoon's eyes result from fracture of the base of the sphenoid sinus. Other findings may include vision changes, hearing loss and facial numbness or paralysis. Purulent drainage is associated with infection. Redness, swelling or tenderness over the mastoid bone indicates mastoiditis, which is usually caused by a middle ear infection. Question: 2 Correct Answer: 1, 2, 3 The child diagnosed with central diabetes insipidus (DI) is being treated with desmopressin nasal. What information is important to reinforce with the family? (Select all that apply.) 1. The child should wear MedicAlertR identification 2. It is important to decrease intake of water and other fluids while taking this medication 3. Using the nasal preparation may cause a stuffy nose 4. A parent or other responsible adult should supervise and help the child use the medication 5. Muscle weakness, spasms or cramps are expected and harmless effects of the medication 6. The medication increases urine production Rationale DI results from reduced secretion of the antidiuretic hormone, vasopressin. Desmopressin (DDAVP) is a synthetic analogue of the natural pituitary hormone vasopressin that will help prevent the loss of water from the body by reducing urine output and helping the kidneys reabsorb water. All clients taking desmopressin must limit drinking of water and other fluids; drinking too much water can result in hyponatremia, which can cause muscle weakness, spasms or cramping as well as loss of appetite, severe headaches, confusion, loss of consciousness and seizures. Anyone with central DI should wear a MedicAlertR ID and carry an emergency medical information card. Question: 3 Correct Answer: 1, 3, 5 On the second postoperative day, a 79 year-old female (who was previously cognitively intact) becomes agitated when she begins having auditory and visual hallucinations. The client later demands to leave the hospital. What action does the nurse take next? (Select all that apply.) 1. Contact the primary physician to evaluate the client 2. Inform the client that insurance will deny payment for leaving against medical advice (AMA) 3. Discuss the situation with the durable power of attorney for healthcare (DPOAHC) 4. Review the release from liability form with the client and witness her signature 5. Describe the risks and benefits of leaving the hospital to the client Rationale A client has the right to leave AMA. As long as the client is competent and understands the risk of leaving, the client can sign a release from liability form and leave. The nurse cannot coerce the client into staying; it is not true that insurance will deny payment when someone leaves AMA. When there is reason to believe the client does not have the capacity to make decisions (which is the case for this client), the nurse should contact the primary physician, who will then evaluate the client. If the physician determines the client is not functionally competent and the client cannot explain the risks of leaving the hospital AMA, the client can be detained. The nurse should also contact the DPOAHC. Question: 4 Correct Answer: 1, 2, 4 The nurse is caring for a client diagnosed with substance use disorder (SUD). The client states, "I just drink occasionally. I don't know why my wife and the judge think that I need to be in an alcohol treatment program." Which of the following behaviors are consistent with SUD? (Select all that apply.) 1. Craving and inability to abstain from alcohol 2. Prone to act impulsively 3. Able to identify problem behaviors 4. Insecurity in relationships 5. Internally motivated to change 6. Inability to suppress memories Rationale SUD is a chronic disease where a person persistently uses alcohol or drugs. Individuals with SUD have a craving for the addictive substance and are unable to abstain from it. Despite the negative consequences of abusing drugs or alcohol, they typically are not internally motivated to change. They often demonstrate an inability to identify problem behaviors. They are anxious, insecure and often have family and work problems. They may experience blackouts and cannot remember what happened when they were drinking, but the inability to suppress memories is not an issue with SUD. Question: 5 Correct Answer: 1, 4, 5 The staff nurse prepares an 88 year-old female for discharge and confirms that follow up care for a home health nurse is scheduled. During the medication reconciliation process, the client's husband states he hopes that his wife has "learned her lesson" and will take her medications as ordered. What action by the staff nurse is indicated? (Select all that apply.) 1. Notify the home health agency nurse about the husband's statement 2. Notify the health care provider of the need to delay discharge 3. Ask the husband to manage his wife's medication at home 4. Write a schedule with days and times for the client to take her medication 5. Ask the husband why he thinks his wife is not taking her medications properly Rationale The staff nurse should first determine what the husband meant and directly ask why he thinks his wife is not taking her medications properly. The staff nurse should help the client understand her medications - why she's taking them, when and how to take them, as well as side effects - because assisting older adults in managing their medications can help prevent hospital readmissions. Since medication management requires a multidisciplinary approach, the staff nurse should also alert the home health nurse about potential problems. Question: 6 Correct Answer: 3, 5 The nurse reviews the client's plan of care after an exacerbation of chronic obstructive pulmonary disease (COPD). Which primary prevention strategies are recommended to reduce the risk of further complications? (Select all that apply.) 1. Teach the client about the proper use of prescribed salmeterol inhaler 2. Arrange for portable oxygen therapy for home care 3. Educate the client about washing hands and avoiding crowds 4. Make a referral to a pulmonary rehabilitation program in the community 5. Discuss with the client about scheduling an annual influenza vaccination Rationale Primary prevention includes a wide range of strategies or interventions that will prevent disease or injury before it occurs. This is accomplished by preventing exposure to pathogens, altering unhealthy or unsafe behaviors that can lead to disease or injury, and increasing resistance to disease or injury. Salmeterol and oxygen therapy are secondary prevention interventions for the treatment of COPD. They are intended to reduce the impact of the disease that has already occurred. Pulmonary rehabilitation is an example of tertiary prevention. Tertiary interventions are intended to help clients manage long-term, often complex health problems or injuries. Question: 7 Correct Answer: 1, 2, 4 The nurse cares for a client diagnosed with pneumonia. During the admission interview, the client explains that her husband died a few months ago and states, "I don't seem to be able to sleep or eat now. I'm not sure I have anything to live for." Which of the following reflects an appropriate nursing response? (Select all that apply.) 1. "Are you thinking of ending your life?" 2. and each person experiences grief differently." 3. "You are grieving and if you don't feel better in another month, you should seek help for depression." 4. "I'd like to know more about how you are doing and what you have used for support after your husband's death." 5. "I need to pass medications, but I will call your daughter to come and talk to you." Rationale A client who has experienced the recent death of a spouse will express symptoms of grief that are similar to symptoms of depression. The nurse may not have the expertise or time to differentiate between grief and depression but, based on the client's statement, the nurse should recognize there's a potential for suicide; the nurse should directly ask the client if she is contemplating suicide. Using therapeutic communication and offering of self, the nurse should acknowledge the client's feelings. Offering to call a social worker or family member may be a part of a conversation (and plan of care) after the nurse has engaged in a therapeutic exchange with the client. Question: 8 Correct Answer: 1, 2, 5 The nurse is making rounds, checking oxygen equipment and assessing clients receiving oxygen therapy. Which of the following situations require intervention by the nurse? (Select all that apply.) 1. Humidified oxygen delivery system contains water from condensation in the tubing 2. Valves and flaps in the nonrebreather mask will not open 3. Oxygen tubing that will allow ambulation to the bathroom is 25 feet (7.6 meters) in length 4. Humidifier is documented as having been changed 12 hours ago 5. The reservoir bag on a nonrebreather mask is inflated 6. Nasal cannula tubing is documented as having been changed eight days ago Rationale Clients receiving humidified oxygen need equipment monitored for condensation in the tubing so that water does not empty into the client mask. Frequent emptying of the tubing away from the client is necessary. Valves and flaps in nonrebreather masks must be patent and able to open during expiration and close during inhalation to maintain FiO2. A mask with valves that do not open must be replaced. In a nonrebreather mask, the reservoir bag should be inflated; if it deflates the client will breathe in exhaled carbon dioxide. Nasal cannula tubing must be changed at least every seven days and humidifiers changed every 24 hours. Oxygen tubing extensions that allow clients to ambulate to bathroom should not exceed 50 feet. Question: 9 Correct Answer: 1, 4, 5 The nurse is caring for a client with the nursing diagnosis of complicated grieving. Which of the following interventions should be included in the client's plan of care? (Select all that apply.) 1. Determine which stage of grief in which the client is fixed 2. Encourage fine motor activities requiring concentration 3. Discourage client expressions of anger over the loss 4. Communicate that crying is acceptable 5. Teach the client about the normal stages of grief 6. Encourage the client to identify weaknesses that have prevented grieving Rationale Complicated grieving is a nursing diagnosis that is an extended, unsuccessful use of intellectual and emotional responses needed to work through the process of grieving and the perception of loss. Priority interventions would be to first assess the stage of grief in which the client is currently fixed. It will also be helpful to teach the client about the grieving process. Other interventions are to communicate the therapeutic value of crying and the therapeutic value of expressing anger. Instead of having to concentrate on fine motor activities, gross motor activities such as walking may be helpful. The nurse should help the client identify strengths, not weaknesses, they will need to work through the process of grieving. Question: 10 Correct Answer: 2, 3, 5 The client is a 74-year-old male client who is recovering on a medical unit after a suicide attempt that involved carbon monoxide poisoning. The client states that his wife died one year ago and he lives alone. Which of the following questions will best assess available client support systems? (Select all that apply.) 1. "Have you thought about joining a Christian church?" 2. "Who are you closest to in your family?" 3. "What kinds of support has been helpful to you in the past?" 4. "Why haven't you attended a grief support group?" 5. "Let's discuss the resources available to you after you are discharged." 6. "I informed your neighbor how best to support you after discharge." Rationale Many resources and studies identify social support systems as an essential part of suicide assessment (SAD PERSONS scale). Since nurses are responsible for assessing client needs and continuity of care, they should be familiar with the importance of identifying support systems and helping the client to engage with those systems. The nurse should identify family members or close friends and review how these individuals have provided support in the past. However, family and friends should be involved in this situation only after the client has given permission to share information with them (in compliance with privacy laws). It's important to discuss available resources in the community. While many clients find support in religious communities, a nurse should never suggest a specific sect or denomination. Questions beginning with "why" usually create a defensive response and should be rephrased. Question: 11 Correct Answer: Correct Order A nurse is assigned to care for four clients. After listening to change-of- shift report, how would the nurse prioritize care for the following clients? (Drag the responses into the correct order.) 1. The Clint with a tracheostomy 2. The Clint scheduled for a colonoscopy 3. The Clint who is in skeletal traction 4. The Postoperative Clint who has an ordered to be discharged at home Rationale The nurse will check on the client with a tracheostomy (airway) first. The nurse would then check on the client who is to undergo a procedure (to ensure the prep was completed and the results of the bowel movements are clear). Next, the nurse would check on the client in skeletal traction, and finally the nurse would prepare the client who is ready for discharge. Question: 1 Answer: 1-4-3-2-5 A client is experiencing alcohol withdrawal. He wakes up and screams, “There’s something crawling under my skin. Help me.” In which order, from first to last, should the following nursing actions be done? 1. Remind the client that he is having withdrawal symptoms and that these will be treated. 2. Administer a dose of lorazepam (Ativan) depending on the severity of the withdrawal symptoms. 3. Assess the client for other withdrawal symptoms. 4. Take the client’s vital signs. 5. Chart the details of the episode on the electronic health record. Question: 2 Answer: 2, 3, 4 A client who has undergone a mitral valve replacement has persistent bleeding from the sternal incision during the early postoperative period. The nurse should do which of the following? Select all that apply. Administer warfarin. 1. Check the postoperative CBC, INR, PTT, and platelet levels. 2. Confirm availability of blood products. 3. Monitor the mediastinal chest tube drainage. 4. Start a dopamine drip for a systolic BP less than 100. Question: 3 Answer: 3 A client has an intracapsular hip fracture. The nurse should conduct a focused assessment to detect: 1. Internal rotation. 2. Muscle flaccidity. 3. Shortening of the affected leg. 4. Absence of pain in the fracture area. Question: 4 Answer: 1 A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records findings from the initial assessment in the client’s chart, as shown below. At 10:30 am, the client has sharp midchest pain after having a bowel movement. What should the nurse do first? 1. Assess the client’s vital signs. 2. Administer a bolus of lactated Ringer’s solution. 3. Assess the client’s neurologic status. 4. Contact the physician. Question: 5 Answer: 1, 4 The nurse determines that a newborn is hypoglycemic based on which of the following findings? Select all that apply. 1. A blood glucose reading of less than 30 mg/dL (1.7 mmol/L) at 1 hour. 2. Family history of insulin-dependent diabetes. 3. Internal fetal monitor tracing. 4. Irregular respirations, tremors, and hypothermia. 5. Large for gestational age. Question: 6 Answer: 4-1-2-3 A client has massive bleeding from esophageal varices. In what order should the nurse and care team provide care for this client? 1. Control hemorrhaging. 2. Replace fluids. 3. Relieve the client’s anxiety. 4. Maintain a patent airway. Question: 7 Answer: 1 To protect a client who has received tissue plasminogen activator (t-PA) or alteplase recombinant (Activase) therapy, the nurse should: 1. Use the radial artery to obtain blood gas samples. 2. Maintain arterial pressure for 10 seconds. 3. Administer IM injections. 4. Encourage physical activity. Question: 8 Answer: 3 Which of the following rehabilitative measures should the nurse teach the client to perform after chest surgery to prevent shoulder ankylosis? 1. Turn from side to side. 2. Raise and lower the head. 3. Raise the arm on the affected side over the head. 4. Flex and extend the elbow on the affected side. Question: 9 Answer: 2-3-1-4 The health care team has noticed an increase in IV infiltrations on the pediatric floor. As part of a Plan, Do, Study, Act quality improvement plan the team should do the following in which order? 1. Analyze the data. 2. Decide to monitor IV gauges. 3. Perform chart audits. 4. Write a new IV insertion policy. Question: 10 Answer: 3 An adolescent with chest pain goes to the school nurse. The nurse determines that the teenager has a history of asthma but has had no problems for years. Which of the following should the nurse do next? 1. Call the adolescent’s parent. 2. Have the adolescent lie down for 30 minutes. 3. Obtain a peak flow reading. 4. Give two puffs of a short-acting bronchodilator. Question: 11 Answer: 0.03mg A newborn weighing 6. lb (2,950 g) is to be given naloxone hydrochloride (Narcan) due to respiratory depression as a result of a narcotic given to the mother shortly before birth. The drug is to be given 0.01 mg/kg into the umbilical vein. The vial is marked 0.4 mg/mL. How many milligrams would the newborn receive? Round off to two decimals. mg. Question: 12 Answer: 3 A primiparous client who underwent a cesarean birth 30 minutes ago is to receive Rho (D) immune globulin (RhoGAM). The nurse should administer the medication within which of the following time frames after birth? 1. 8 hours. 2. 24 hours. 3. 72 hours. 4. 96 hours. Question: 13 Answer: 3 A client is admitted at 30 weeks’ gestation with contractions every 3 minutes. Her cervix is 1 to 2 cm dilated and 75% effaced. Following a 4-g bolus dose, IV magnesium sulfate is infusing at 2 g/h. How will the nurse know the medication is having the intended effect? 1. Contractions will increase in frequency, leading to birth. 2. The client will maintain a respiratory rate greater than12 breaths/min. 3. Contractions will decrease in frequency, intensity, and duration. 4. The client will maintain blood pressure readings of 120/80 mm Hg. Question: 14 Answer: 2 When developing a teaching plan for a primigravid client with insulin- dependent diabetes about monitoring blood glucose control and insulin dosages at home, which of the following would the nurse expect to include as a desired target range for blood glucose levels? 1. 40 to 60 mg/dL (2.2 to 3.3 mmol/L) between 2:00 and 4:00 pm 2. 70 to 100 mg/dL (3.3 to 5.6 mmol/L) before meals and bedtime snacks. 3. 110 to 140 mg/dL (6.2 to 7.8 mmol/L) before meals and bedtime snacks. 4. 140 to 160 mg/dL (7.8 to 8.9 mmol/L) 1 hour after meals. Question: 15 Answer: 4 Griseofulvin was prescribed to treat a child’s ringworm of the scalp. The nurse instructs the parents to use the medication for several weeks for which of the following reasons? 1. A sensitivity to the drug is less likely if it is used over a period of time. 2. Fewer side effects occur as the body slowly adjusts to a new substance over time. 3. Fewer allergic reactions occur if the drug is maintained at the same level long-term. 4. The growth of the causative organism into new cells is prevented with long-term use. Question: 16 Answer: 24 Ml/h A client is receiving an IV infusion of heparin sodium at 1,200 units/h. The dilution is 25,000 units/500 mL. How many milliliters per hour will this client receive? mL/h. Question: 17 Answer: 750 mL/hour Using the Parkland formula, calculate the hourly rate of fluid replacement with lactated Ringer’s solution during the first 8 hours for a client weighing 75 kg with total body surface area (TBSA) burn of 40%. mL/hour. Question: 18 Answer: 1, 2, 4, 6 A client with lung cancer is being cared for by his wife at home. His pain is increasing in severity. The nurse recognizes that teaching has been effective when the wife does which of the following? Select all that apply. 1. Administers long-acting or sustained-release oral pain medication (OxyContin) regularly around the clock. 2. Administers immediate-release medication (oxycodone) for breakthrough pain. 3. Avoids long-acting opioids due to her concern about addiction. 4. Uses music for distraction as well as heat or cold in combination with medications. 5. Substitutes acetaminophen (Tylenol) to avoid tolerance to the medications. 6. Has her husband use a pain-rating scale to measure the effectiveness at reaching his individual pain goal. Question: 19 Answer: 2 A client with chronic cancer pain has been receiving opiates for 4 months. She rated the pain as an 8 on a 10-point scale before starting the opioid medication. Following thorough examination, there is no new evidence of increased disease, yet the pain is close to 8 again. The most likely explanation for the increasing pain is: 1. Development of an addiction to the opioids. 2. Tolerance to the opioid. 3. Withdrawal from the opioid. 4. Placebo effect has decreased. Question: 20 Answer: 2 Which of the following statements is most accurate regarding the long- term toxic effects of cancer treatments on the immune system? 1. Clients with persistent immunologic abnormalities after treatment are at a much greater risk for infection than clients with a history of splenectomy. 2. The use of radiation and combination chemo-therapy can result in more frequent and more severe immune system impairment. 3. Long-term immunologic effects have been studied only in clients with breast and lung cancer. 4. The helper T cells recover more rapidly than the suppressor T cells, which results in positive helper cell balance that can last 5 years. Question: 21 Answer: 2 A woman who is Rh-negative has given birth to an Rh-positive infant. The nurse explains to the client that she will receive Rho (D) Immune Globulin (RhoGAM). The nurse determines that the client understands the purpose of RhoGAM when she states: 1. “RhoGAM will protect my next baby if it is Rh-negative.” 2. “RhoGAM will prevent antibody formation in my blood.” 3. “RhoGAM will be given to prevent German measles.” 4. “RhoGAM will be used to prevent bleeding in my newborn.” Question: 22 Answer: 2 A multigravid laboring client has an extensive documented history of drug addiction. Her last reported usage was 5 hours ago. She is 2 cm dilated with contractions every 3 minutes of moderate intensity. The primary health care provider prescribes nalbuphine 15 mg slow IV push for pain relief followed by an epidural when the client is 4 cm dilated. Within 10 minutes of receiving the nalbuphine, the client states she thinks she is going to have her baby now. Of the following drugs available at the time of the birth, which should the nurse avoid using with this client in this situation? 1. 1% lidocaine (Xylocaine). 2. Naloxone hydrochloride (Narcan). 3. Local anesthetic. 4. Pudendal block. Question: 23 Answer: 1,2,4 The nurse is conducting a counseling session with a client experiencing posttraumatic stress disorder (PSTD) using a 2-way video telehealth system from the hospital to the client’s home, which is 2 hours away from the nearest mental health facility. Which of the following are expected outcomes of using telehealth as a venue to provide health care to this client? Select all that apply. The client will: 1. Save travel time from the house to the health care facility. 2. Avoid reliving a traumatic event that might be precipitated by visiting a health care facility. 3. Experience a shorter recovery time than being treated on-site at a health care facility. 4. Receive health care for this mental health problem. Question: 24 Answer: 4 At what time should the blood be drawn in relation to the administration of the IV dose of gentamicin sulfate (Garamycin)? 1. 2 hours before the administration of the next IV dose. 2. 3 hours before the administration of the next IV dose. 3. 4 hours before the administration of the next IV dose. 4. Just before the administration of the next IV dose. Question: 25 Answer: 3 A client’s chest tube is connected to a drain-age system with a water seal. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. The fluctuation means that: 1. There is an obstruction in the chest tube. 2. The client is developing subcutaneous emphysema. 3. The chest tube system is functioning properly. 4. There is a leak in the chest tube system Question: 25 Answer: Question: 26 Answer: Question: 27 Answer: Question: 28 Answer: Question: 29 Answer: Question: 30 Answer: Question: 31 Answer: Question: 32 Answer: Question: 33 Answer: Question: 34 Answer: Question: 35 Answer: Question: 36 Answer: Question: 37 Answer: Question: 38 Answer: Question: 39 Answer: Question: 40 Answer: Question: 41 Answer: Question: 42 Answer: Question: 43 Answer: Question: 44 Answer: Question: 45 Answer: Question: 46 Answer: Question: 47 Answer: Question: 48 Answer: Question: 49 Answer: Question: 50 Answer: Final Comprehensive Exam FULL NAME DATE 2. The nurse is conducting a counseling session with a client experiencing posttraumatic stress disorder (PSTD) using a 2-way video telehealth system from the hospital to the client’s home, which is 2 hours away from the nearest mental health facility. Which of the following are expected outcomes of using telehealth as a venue to provide health care to this client? Select all that apply. The client will: 1. Save travel time from the house to the health care facility. 2. Avoid reliving a traumatic event that might be precipitated by visiting a health care facility. 3. Experience a shorter recovery time than being treated on-site at a health care facility. 4. Receive health care for this mental health problem. 5. Obtain group support from others with a similar health problem. 3. The nurse walks into the room of a client who has a “do not resuscitate” prescription and finds the client without a pulse, respirations, or blood pressure. The nurse should first? 1. Stay in the room and call the nursing team for assistance. 2. Push the emergency alarm to call a code. 3. Page the client’s physician. 4. Pull the curtain and leave the room. 4. When creating a program to decrease the primary cause of disability and death in children, which of the following is most effective for the com-munity health nurse to do? 1. Encourage legislators to draft legislation to promote prenatal care. 2. Require all children to be immunized. 3. Teach accident prevention and safety practices to children and their parents. 4. Hire a nurse practitioner for each of the schools in the community. 5. A client’s chest tube is to be removed by the physician. Which of the following items should the nurse have ready to be placed directly over the wound when the chest tube is removed? 1. Butterfly dressing. 2. Montgomery strap. 3. Fine mesh gauze dressing. 4. Petrolatum gauze dressing. 6. A school nurse interviews the parent of a middle school student, who is exhibiting behavioral problems, including substance abuse, following a sibling’s suicide. The parent says, “I am a single parent who has to work hard to support my family and now, I’ve lost my only son and my daughter is acting out and making me crazy! I just can’t take all this stress!” Which of the following issues is the priority? 1. Parent’s ability to emotionally support the adolescent in this crisis. 2. Potential suicidal thoughts/plans of both family members. 3. The adolescent’s anger. 4. The parent’s frustration. 7. A client in cardiac rehabilitation would like to eat the right foods to ensure adequate endurance on the treadmill. Which of the following nutrients is most helpful for promoting endurance during sustained activity? 1. Protein. 2. Carbohydrate. 3. Fat. 4. Water. 8. When developing the plan of care for a 14-year-old boy who is bored due to being immobilized in a cast, which of the following activities is most appropriate? 1. Playing a card game with a boy the same age. 2. Putting together a puzzle with his mother. 3. Playing video games with a 9-year-old. 4. Watching a movie with his younger brother. 9. When a client with alcohol dependency begins to talk about not having a problem with alcohol, the nurse should use which of the following approaches? 1. Questioning the client about how much alcohol the client consumes each day. 2. Confronting the client about being intoxicated 2 days ago. 3. Pointing out how alcohol has gotten the client into trouble. 4. Listening to what the client states and then asking the client about plans for staying sober 10. Which of the following actions is most appropriate when dealing with a client who is expressing anger verbally, is pacing, and is irritable? 1. Conveying empathy and encouraging ventilation. 2. Using calm, firm directions to get the client to a quiet room. 3. Putting the client in restraints. 4. Discussing alternative strategies for when the client is angry in the future. 11. A client newly diagnosed with bulimia is attending a nurse-led group at the mental health center. She tells the group that she only came because her husband said he would divorce her if she didn’t get help. Which of the following responses by the nurse is most appropriate? 1. “You sound angry with your husband. Is that correct?” 2. “You will find that you like coming to group. These people are a lot of fun.” 3. “Tell me more about why you are here and how you feel about that.” 4. “Tell me something about what has caused you to be bulimic.” 12. After surgery to create a urinary diversion, the client is at risk for a urinary tract infection. The nurse should plan to incorporate which of the following interventions into the client’s care? 1. Clamp the urinary appliance at night. 2. Empty the urinary appliance when one-third full. 3. Administer prophylactic antibiotics. 4. Change the urinary appliance daily. 13. A client is prescribed atropine 0.4 mg intra-muscularly. The atropine vial is labeled 0.5 mg/mL. How many milliliters should the nurse plan to administer? mL. 14. At what time should the blood be drawn in relation to the administration of the IV dose of gen-tamicin sulfate (Garamycin)? 1. 2 hours before the administration of the next IV dose. 2. 3 hours before the administration of the next IV dose. 3. 4 hours before the administration of the next IV dose. 4. Just before the administration of the next IV dose. 15. When teaching a client with bipolar disorder who has started to take valproic acid about possible side effects of this medication, the nurse should instruct the client to report: 1. Increased urination. 2. Slowed thinking. 3. Sedation. 4. Weight loss. 16. A nulligravid client calls the clinic and tells the nurse that she forgot to take her oral contraceptive this morning. Which of the following should the nurse instruct the client to do? 1. Take the medication immediately. 2. Restart the medication in the morning.3. 3. Use another form of contraception for 2 weeks. 4. Take two pills tonight before bedtime. 17. A health care provider has been exposed to hepatitis B through a needle stick. Which of the following drugs should the nurse anticipate administering as post exposure prophylaxis? 1. Hepatitis B immune globulin. 2. Interferon. 3. Hepatitis B surface antigen. 4. Amphotericin B. 18. After abdominal surgery, a client has a prescription for meperidine (Demerol) IM 100 mg every 3 to 4 hours and acetaminophen (Tylenol) with codeine 30 mg. The client has been taking meperidine every 4 hours for the past 48 hours but tells the nurse that the meperidine is no longer lasting 4 hours and that the client needs to have it every 3 hours. Which of the following nursing actions is most appropriate? 1. Realizing that the client is developing tolerance to the meperidine, the nurse administers the meperidine every 3 hours. 2. The nurse urges the client to take the acetaminophen with codeine to prevent addiction to the meperidine. 3. The nurse requests a prescription from the physician to change the dose to an equianalgesic dose of morphine. 4. The nurse encourages the client to do relaxation exercises to provide distraction from the pain. 19. A diabetic client has been diagnosed with hypertension, and the physician has prescribed atenolol (Tenormin), a beta-blocker. When performing discharge teaching, it is important for the client to recognize that the addition of Tenormin can cause: 1. A decrease in the hypoglycemic effects of insulin. 2. An increase in the hypoglycemic effects of insulin. 3. An increase in the incidence of ketoacidosis. 4. A decrease in the incidence of ketoacidosis. 20. An infant is born with facial abnormalities, growth retardation, mental retardation, and vision abnormalities. These abnormalities are likely caused by maternal: 1. Alcohol consumption. 2. Vitamin B6 deficiency. 3. Vitamin A deficiency. 4. Folic acid deficiency. 21. A client’s chest tube is connected to a drain-age system with a water seal. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. The fluctuation means that: 1. There is an obstruction in the chest tube. 2. The client is developing subcutaneous emphysema. 3. The chest tube system is functioning properly. 4. There is a leak in the chest tube system 22. A client is scheduled to have surgery to relieve an intestinal obstruction. Prior to surgery the nurse should verify that the client has: 1. Discontinued use of blood thinners. 2. Followed a low-residue diet. 3. Performed abdominal tightening exercises. 4. Signed a last will and testament. 23. Which of the following is a priority goal after surgical repair of a cleft lip? 1. Managing pain. 2. Preventing infection. 3. Increasing mobility. 4. Developing parenting skills. 24. Which of the following baseline laboratory data should be established before a client is started on tissue plasminogen activator or alteplase recombinant (Activase)? 1. Potassium level. 2. Lee-White clotting time.3. 3. Hemoglobin level, hematocrit, and platelet count. 4. Blood glucose level. 25. While assisting the physician with an amniocentesis on a multi gravid client at 38 weeks’ gestation, the nurse observes that the fluid is very cloudy and thick. The nurse interprets this finding as indicating which of the following? 1. Intrauterine infection. 2. Fetal meconium staining. 3. Erythroblastosis fetalis. 4. Normal amniotic fluid. 26. A client who had a transurethral resection of the prostate (TURP) 1 day earlier has a threeway Foley catheter inserted for continuous bladder irrigation. Which of the following statements best explains why continuous irrigation is used after TURP? 1. To control bleeding in the bladder. 2. To instill antibiotics into the bladder. 3. To keep the catheter free from clot obstruction.4. 4. To prevent bladder distention. 27. Sequential compression therapy is to be used postoperatively on the client’s legs. The nurse must take which of the following actions first when the client returns to the room? 1. Confirm the client’s identity using two client identifiers. 2. Wash hands. 3. Explain the sequential compression therapy to the client. 4. Determine the size of sleeve that is needed. 28. A client is having elective surgery under general anesthesia. Who is responsible for obtaining the informed consent? 1. The nurse. 2. The surgeon.3. 3. The anesthesiologist. 4. The nurse anesthetist. 29. A nursing assistant recorded a client’s 6:00 am blood glucose level as 126 (7 mmol/L) instead of 216 (12 mmol/L). The nursing assistant did not recognize the error until 9:00 am but reported it to the nurse right away. The nurse should next: 1. Reassign the nursing assistant to another client. 2. Wait and observe the client for symptoms of hyperglycemia. 3. Reprimand the nursing assistant for the error. 4. Call the physician and complete an incident report. 30. Which of the following dietary strategies best meets the nutritional needs of a client with acquired immunodeficiency syndrome (AIDS)? 1. Tell the client to eat large meals frequently. 2. Encourage mega doses of nutritional supplements. 3. Instruct the client to cook foods thoroughly and adhere to safe food- handling practices. 4. Tell the client to prepare food in advance and leave it out to eat small amounts throughout the day. 31. A child has been exposed to varicella. Which of the following should the nurse institute for infection control? 1. Airborne precautions. 2. Droplet precautions. 3. Contact precautions. 4. Indirect contact precautions. 32. The nurse is auscultating S1 and S2 in a client. Identify the area where the nurse should hear S1 the loudest. 33. The heart rate of a newly born term neonate is regular at 142 bpm. Which of the following should the nurse do next? 1. Notify the neonate’s pediatrician. 2. Check for the presence of cyanosis. 3. Assess the heart rate again in 3 hours. 4. Document this as a normal neonatal finding. 34. An adolescent primigravid client at 26 weeks’ gestation has gained 25 lb since becoming pregnant. Which of the following is the recommended amount of weight gain during the third trimester? 1. 1 lb (0.45 kg) per week. 2. 2 lbs (0.9 kg) per week. 3. 7 lbs (3.2 kg per week). 4. 5 to 6 lbs (2.3 to 2.7 kg) for the trimester. 35. A client at 40+ weeks’ gestation visits the emergency department because she thinks she is in labor. Which of the following is the best indication that the client is in true labor? 1. Fetal descent into the pelvic inlet. 2. Cervical dilation and effacement. 3. Painful contractions every 3 to 5 minutes. 4. Leaking amniotic fluid clear in color. 36. A neonate circumcised with a Plastibell 1 hour ago is brought to his mother for feeding. The nurse should instruct the mother to do which of the following?1. 1. Read a pamphlet about circumcision care. 2. Remove the petroleum jelly gauze in 24 hours. 3. Tell the nurse when the neonate voids. 4. Place petroleum jelly over the site every 2 hours. 37. A client is anxious following a robbery. The client is worried about identity theft and states, “I could lose everything. I can’t stand the fears I have. I reported everything, but I still can’t eat or sleep.” Which of the following interventions should the nurse implement first? 1. Request a prescription for an antianxiety medication. 2. Provide a list of free legal resources. 3. Refer the client to a support group. 4. Listen empathetically while the client discusses the fears. 38. A man of Chinese descent is admitted to the hospital with multiple injuries after a motor vehicle accident. His pain is not under control. The client states, “If I could be with my people, I could receive acupuncture for this pain.” The nurse should under-stand that acupuncture in the Asian culture is based on the theory that it: 1. Purges evil spirits. 2. Promotes tranquility. 3. Restores the balance of energy. 4. Blocks nerve pathways to the brain. 39. Which of the following measures is contra-indicated when the nurse assists a child who has leukemia with oral hygiene? 1. Applying petroleum jelly to the lips. 2. Cleaning the teeth with a toothbrush. 3. Swabbing the mouth with moistened cotton swabs. 4. Rinsing the mouth with a nonirritating mouthwash. 40. Which of the following statements by a client taking valproic acid for bipolar disorder indicates that further teaching about this medication is necessary? 1. “I need to take the pills at the same time each day.” 2. “I can chew the pills if necessary.” 3. “I can take the pills with food.” 4. “I need to call my doctor if I start bruising easily.” 41. The nurse instructs a client with coronary artery disease in the proper use of nitroglycerin (Nitrostat). At the onset of chest pain, the client should: 1. Call 911 when three nitroglycerin tablets taken every 5 minutes are ineffective. 2. Call 911 when five nitroglycerin tablets taken every 5 minutes are ineffective. 3. Take three nitroglycerin tablets, 10 minutes apart, and call 911. 4. Go to the emergency department if three nitroglycerin tablets are ineffective. 42. A client is receiving a unit of packed red blood cells. Before the transfusion started, the client’s blood pressure was 90/50 mm Hg, pulse rate 100 bpm, respirations 20 breaths/min, and temperature 98°F (36.7°C). Fifteen minutes after the transfusion starts, the client’s blood pressure is 92/54 mm Hg, pulse 100 bpm, respirations 18 breaths/min, and temperature is 101.4°F (38.6°C). The nurse should first: 1. Stop the transfusion. 2. Raise the head of the bed. 3. Obtain a prescription for antibiotics. 4. Offer the client a cool washcloth. 43. A 10-year-old diagnosed with attention deficit hyperactivity disorder (ADHD) has been switched from a stimulant to atomoxetine (Strattera) 40 mg two times a day. The nurse is instructing the client and the mother about the change in medication. Which statement indicates that the client’s mother needs further education about the medication? Select all that apply. 1. “I have to give her both doses before lunch.” 2. “I’ll have to make sure she’s gaining weight appropriately.” 3. “She may have nausea or dizziness for 1 or 2 months.” 4. “If she has mood swings, I should call her psychiatrist.” 5. “She can’t take monoamine oxidase inhibitors while on Strattera.” 6. “If her ADHD symptoms don’t improve in 2 to 3 weeks, I should stop the Strattera.” 44. The nurse is teaching a client who is taking dexamethasone (Decadron) for cerebral edema about early symptoms of Cushing’s disease. The nurse should advise the client to report which of the following is a symptom of hyperadrenocorticism? 1. Hypotension. 2. Increased urinary frequency. 3. Increased muscle mass. 4. Easy bruising. 45. The nurse should complete which of the following assessments on a client who has received tissue plasminogen activator or alteplase recombinant (Activase) therapy? 1. Neurologic signs frequently throughout the course of therapy. 2. Excessive bleeding every hour for the first 8 hours. 3. Blood glucose level. 4. Arterial blood gas values. 46. A client is taking steroids to treat ulcerative colitis. The nurse should assess the client for which of the following? 1. Peptic ulcer. 2. Hypoglycemia. 3. Tachycardia. 4. Renal failure. 47. The nurse who is caring for a client with type 1 diabetes mellitus should use which of the following to determine how well the insulin, diet, and exercise are balanced? 1. Fasting serum glucose level. 2. 1-week dietary recall. 3. Home log of blood glucose levels. 4. Glycosylated hemoglobin level. 48. After the application of an arm cast, the client has pain on passive stretching of the fingers, finger swelling and tightness, and loss of function. Based on these data, the nurse anticipates that the client may be developing which of the following? 1. Delayed bone union. 2. Compartment syndrome. 3. Fat embolism. 4. Osteomyelitis. 49. Which of the following factors can most alter tissue tolerance and lead to the development of a pressure ulcer? 1. The client’s age. 2. Exposure to moisture. 3. Presence of hypertension. 4. Smoking. 50. A primigravid client at 35 weeks’ gestation is scheduled for a biophysical profile. After instructing the client about the test, which of the following, if stated by the client as one of the parameters of this test, indicates effective teaching? 1. Amniotic fluid volume. 2. Placement of the placenta. 3. Amniotic fluid color. 4. Fetal gestational age. 51. The nurse is assessing a child with suspected juvenile hypothyroidism. Which of the following should the nurse expect this child to manifest? 1. Short attention span and weight loss. 2. Weight loss and flushed skin. 3. Rapid pulse and heat intolerance. 4. Dry skin and constipation. 52. A client with emphysema has been admitted to the hospital. The nurse should assess the client further for: 1. Frequent coughing. 2. Bronchospasms. 3. Underweight appearance. 4. Copious sputum. 53. Which of the following actions should the nurse anticipate using when caring for a term neonate diagnosed with transient tachypnea at 2 hours after birth? 1. Monitoring the neonate’s color and cry every 4 hours. 2. Feeding the neonate with a bottle every 3 hours. 3. Obtaining extracorporeal membrane oxygenation equipment. 4. Providing warm, humidified oxygen in a warm environment. 54. A client with paranoid schizophrenia is withdrawn, suspicious of others and projects blame. The client’s behavior reflects problems in which of the following stages of development as identified by Erikson? 1. Trust versus mistrust. 2. Autonomy versus shame and doubt. 3. Initiative versus guilt. 4. Intimacy versus isolation. 55. After an episode of severe pain, a client says to the nurse, “The pain really frightened me. I thought I was going to die.” Which statement is the most appropriate response from the nurse? 1. “I understand that pain can be a frightening experience.” 2. “Why were you frightened? You have had pain before.” 3. “There’s no need to be frightened of pain.” 4. “Pain can’t cause you to die. Try to relax.” 56. A mother reports she cannot afford the antibiotic azithromycin (Zithromax), which was prescribed by the physician for her toddler’s otitis media. The nurse’s best response is to: 1. Instruct the mother on the importance of the medication. 2. Ask the mother if she knows anyone who could loan her the money. 3. Confer with the physician about whether a less expensive drug could be prescribed. 4. Consult with the social worker. 57. Which of the following is appropriate to include in an incident report? 1. An interpretation of the likely cause of the incident. 2. What the nurse saw and did. 3. The client’s statement about the incident that occurred. 4. The extenuating circumstances involved in the situation. 58. A client’s blood pressure is elevated at 160/90 mm Hg. The physician prescribed “clonidine (Catapres) 1 mg by mouth now.” The nurse sent the prescription to pharmacy at 7:10 am, but the medication still has not arrived at 8:00 am. The nurse should do all except which of the following? 1. Check all appropriate places on the unit to which the drug could have been delivered. 2. Check the client’s blood pressure. 3. Call the pharmacy. 4. Go to the pharmacy to obtain the drug. 59. The nurse on the antenatal unit is planning care for four clients. The nurse should assess which of the following clients first? 1. A 29-year-old G3 P2 carrying twins, being treated for preterm labor at 29 weeks’ gestation. She is receiving magnesium sulfate at 2 g/h. She has had no contractions for the past 2 hours and both twins appear stable, according to the nurse’s shift report. 2. A 19-year-old 18 weeks’ intrauterine pregnancy (IUP) who is now 12 hours post motor vehicle accident with bright red vaginal bleeding. 3. A G8 P4 Ab3 at 38 weeks’ gestation hospitalized frequently during this pregnancy for placenta previa. Two days ago, she was admitted with severe bright red vaginal bleeding that has tapered off now. 4. A 9-week IUP hospitalized for hyperemesis gravidarum who has not vomited for the last 12 hours. 60. The mother of a 7-month-old child born 6 weeks early asks the nurse what play activities and toys is appropriate for her child. Which of the following should the nurse suggest? 1. Picture books. 2. Peek-a-boo. 3. Rattle. 4. Colored blocks. 61. Which of the following is the most effective strategy for a nurse to use to reduce the number of children involved in automobile accidents who were not wearing seat belts? 1. Contact the local government representative to discuss new legislation about child seat belts. 2. Attend a school board meeting to advocate for classes teaching children seat belt safety. 3. Call the town mayor’s office with this information so that the mayor can discuss it with the media. 4. Start a letter-writing campaign to the school superintendent about seat belt importance. 62. A first-time mother is concerned that her 6-month-old infant is not gaining enough weight. The best response for the nurse to make is which of the following? 1. “Birth weight doubles by 6 months of age.” 2. “Birth weight doubles by 3 months of age.” 3. “The baby will eat what he needs.” 4. “You need to make sure the baby finishes each bottle.” 63. The nurse is teaching a client with rheumatoid arthritis about how to manage the fatigue associated with this disease. Which statement indicates the client understands how to manage the fatigue? 1. “I sleep for 8 to 10 hours every night so that I’ll have the energy to care for my children during the day.” 2. “I schedule afternoon rest periods for myself in addition to sleeping 10 hours every night.” 3. “I spend one weekend day a week resting in bed while my husband cares for the children.” 4. “I get up early in the morning and get all my household chores completed before my children wake up.” 64. The nurse is developing a discharge plan for a client who has had a myocardial infarction. Planning for discharge for this client should begin: 1. On discharge from the hospital. 2. On discharge from the cardiac care unit. 3. On admission to the hospital. 4. 4 weeks after the onset of illness. 65. A nulliparous client visiting the clinic tells the nurse that she stopped taking oral contraceptives 6 months ago but doesn’t think she is ovulating. Which of the following should the nurse anticipate that the physician would prescribe if the client is anovulatory? 1. Dienestrol. 2. Clomiphene citrate. 3. Medroxyprogesterone. 4. Norgestrel. 66. A woman is taking oral contraceptives. The nurse teaches the client to report which of the following danger signs? 1. Breakthrough bleeding. 2. Severe calf pain. 3. Mild headache. 4. Weight gain of 3 lb (1.4 kg). 67. Which of the following demonstrates that the client needs further instruction after being taught about ciprofloxacin (Cipro)? 1. “I must drink 500 to 1,500 mL of water a day.” 2. “I shouldn’t take an antacid before taking the Cipro.” 3. “I should let the doctor know if I start vomiting from the Cipro.” 4. “I may get light-headed from the Cipro.” 68. A child diagnosed with tinea is being treated with griseofulvin (Grifulvin V). Which of the following instructions should the nurse give to the parents? 1. Give the medication before a meal. 2. Have the child avoid intense sunlight.3. 3. Give the medication for 10 days. 4. Encourage increased fluid intake. 69. A client is prescribed buspirone (Buspar) 5 mg two times a day. Which of the following statements indicates that the client has understood the nurse’s teaching about this drug? Select all that apply. 1. “This medicine will make me sleepy.” 2. “Buspar will relax my muscles.” 3. “My anxiety will be completely gone by tomorrow.” 4. “Buspar will help me not to worry so much.” 5. “I’ll be able to focus better.” 70. Which of the following discharge instructions about thermal injury should be given to a client with peripheral vascular disease? Select all that apply. 1. “Warm the fingers or toes by using an electric heating pad.” 2. “Avoid sunburn during the summer.” 3. “Wear extra socks in the winter.” 4. “Choose loose, soft, cotton socks.” 5. “Use an electric blanket when you are sleeping.” 71. A client is being treated for acute low back pain. The nurse should report which of these clinical manifestations to the physician immediately? 1. Diffuse, aching sensation in the L4 to L5 area. 2. New onset of foot drop. 3. Pain in the lower back when the leg is lifted. 4. Pain in the lower back that radiates to the hip. 72. After teaching the mother of a 7-month-old diagnosed with bronchiolitis, the nurse determines that the teaching has been effective when the mother states which of the following as a sign to report immediately? 1. Seven wet diapers a day. 2. Temperature of 100°F (37.8°C) for 2 days. 3. Clear nasal discharge for longer than 2 days. 4. Longer periods of sleep than usual. 73. The results of which of the following serologic tests should the nurse have on the chart before a client is started on tissue plasminogen activator or alteplase recombinant (Activase)? 1. Partial thromboplastin time. 2. Potassium level. 3. Lee-White clotting time. 4. Fibrin split product. 74. When assessing for oxygenation in a client with dark skin, the nurse should examine the client’s: 1. Skin. 2. Buccal mucosa. 3. Nape of the neck. 4. Forehead. 75. The nurse has received change-of-shift report. The nurse should assess which of the following clients first? 1. A 72-year-old admitted 2 days ago with a blood alcohol level of 0.08. 2. A 36-year-old with chest tube due to spontaneous pneumothorax with current respiratory rate 18 breaths/min, oxygen saturation 95% on oxygen at 2 L per nasal cannula. 3. A 28-year-old who is 2 days postappendec-tomy with discharge prescriptions written and whose husband is waiting to take her home. 4. A 62-year-old admitted with a recent gastro-intestinal (GI) bleeding whose hemoglobin is 13.8 g/dL (138 g/L). 76. A hospitalized adolescent with type 1 diabetes mellitus is weak and nauseated with poor skin turgor. The nurse notes a fruity odor to the client’s breath. The client uses Lispro insulin. The last meal was lunch, 2 hours ago. Place the following nursing actions in the order in which the nurse should perform them. 1. Obtain a finger stick test for blood glucose. 2. Start an IV infusion with normal saline solution. 3. Administer Lispro. 4. Notify the physician. 77. The client has severe vulvar pruritus and a yellow-green, malodorous vaginal discharge. The nurse recognizes that the symptoms suggest: 1. Gonorrhea. 2. Syphilis. 3. Chlamydia. 4. Trichomoniasis. 78. The nurse is reviewing the laboratory results of a client with hypothyroidism. An expected finding is: 1. Decreased thyroxine (T4) and increased thyroid-stimulating hormone (TSH) levels. 2. Decreased TSH and increased T4 levels. 3. Decreased creatine phosphokinase levels. 4. Absence of antithyroid antibodies. 79. A client with a chronic mental illness who does not always take her medications is separated from her husband and receives public assistance funds. She lives with her mother and older sister and manages her own medication. The client’s mother is in poor health and also receives public assistance benefits. The client’s sister works outside the home, and the client’s father is dead. Which of the following issues should the nurse need to address first? 1. Family. 2. Marital. 3. Financial. 4. Medication. 80. The parent of a young child diagnosed with low-dose lead exposure asks about long-term effects. Which of the following should the nurse mention as possible long-term effects to this mother? Select all that apply. 1. Seizures. 2. Depression. 3. Hyperactivity. 4. Aggression. 5. Impulsiveness. 81. Immediately following an automobile accident, a 21-year-old client has severe pain in the right chest from hitting the steering wheel and a compound fracture of the right tibia and fibula and multiple lacerations and contusions. The priority for care is to first: 1. Reduce the client’s anxiety. 2. Maintain adequate oxygenation. 3. Decrease chest pain. 4. Maintain adequate circulating volume. 82. The nurse is auscultating the lung sounds of a client with long- standing emphysema. The nurse should determine if the client has: 1. Fine crackles. 2. Diminished breath sounds. 3. Stridor. 4. Pleural friction rub. 83. A child is admitted to the emergency department with dyspnea related to Bronchospasms. The nurse should place the client in which of the following positions? 1. High Fowler’s. 2. Side-lying. 3. Prone. 4. Supine. 84. A female client with paranoid schizophrenia has been hearing negative voices and “getting special messages from various sources.” Which of the following interventions is most appropriate for the client’s symptoms? 1. Asking her to make simple decisions. 2. Being matter-of-fact with her. 3. Monitoring her reactions to television programs. 4. Reinforcing appropriate dress and hygiene. 85. The nurse is examining a client with possible rheumatoid arthritis. Which of the following symptoms should the nurse assess at this time? 1. Nausea. 2. Joint swelling. 3. Fatigue. 4. Limitation of movement. 86. The nurse is assessing home care needs for a group of clients. Which clients qualify for home care services? The client who: (Select all that apply.) 1. Requires monitoring of prothrombin time due to Coumadin (warfarin) therapy. 2. Needs additional instruction regarding preparation of food on a low- sodium diet. 3. Has episodes of vertigo that result in falls. 4. Has multiple sclerosis with an open, draining lesion on a foot. 5. Needs stronger lenses for glasses. 87. The nurse on the orthopedic unit is receiving a client from the Post Anesthesia Care Unit (PACU). Which of the following must occur to ensure a safe “hand-off”? 1. An e-mail on the intranet from the nurse in the PACU to the receiving nurse on the orthopedic unit. 2. A page from a transporter who is bringing the client to the receiving nurse. 3. Interactive communication between the nurse from the PACU and the nurse from the orthopedic unit. 4. Delegation of registered nurse (RN) responsibility and accountability to a non-RN on the receiving unit. 88. The nurse is teaching an unlicensed assistive personnel about the care of clients with selfmutilation. Which of the following, if stated by the unlicensed personnel about selfmutilation, demonstrates that the teaching has been effective? 1. “It is a means of getting what the person wants.” 2. “It is a non serious event that can be ignored.” 3. “It is a way to express anger and rage.” 4. “It is a form of manipulation.” 89. The nurse is performing the initial assessment on a middle age woman recently diagnosed with Cushing’s syndrome. The nurse reviews the history and physical (See chart). The nurse should develop a plan with the client to manage which of the following? Select all that apply. 1. Low blood volume. 2. Risk for injury. 3. Slow healing. 4. Changes in physical appearance. 5. Risk for infection. 90. The nurse is evaluating a female client’s understanding of how to prevent sexually transmitted diseases (STDs). Which of the following statements indicates that the client understands how to protect herself? 1. “I will be sure my partner uses a condom.” 2. “I need to be sure to take my birth control pills.” 3. “I will always douche after sexual intercourse.” 4. “I will be sure to take antibiotics to prevent an STD.” 91. An older infant who has been injured in an automobile accident is to wear a splint on the injured leg. The mother reports that the infant has become mobile even while wearing the splint. The nurse should advise the mother to do which of the following? 1. Notify the physician immediately to adjust the treatment plan. 2. Confine the infant to one room in the apartment. 3. Keep the infant in the splint at night, removing it during the day. 4. Remove any unsafe items from the area in which the infant is mobile. 92. A “read-back” procedure has been implemented on a nursing unit to prevent discrepancies in telephone prescriptions and reports. This procedure should be implemented when the: 1. Float nurse gives a written report to the oncoming nurse. 2. Nurse receives a critical lab value via phone or in person from the lab. 3. Lab report shows up on the computerized health record. 4. Unit clerk takes a telephone prescription for a stat lab test. 93. During the clinical breast examination, which of the following is a normal finding? 1. Pronounced unilateral venous pattern. 2. Peau d’orange breast tissue. 3. Long-term, bilateral nipple inversion. 4. Breast tissue that is darker than the areolae. 94. While assessing a multigravid client at 10 weeks’ gestation, the nurse notes a purplish color to the vagina and cervix. The nurse documents this finding as which of the following? 1. Goodell’s sign. 2. Chadwick’s sign. 3. Hegar’s sign. 4. Melasma. 95. The mother of a 3-year-old child tells the nurse her child is “fussy” and not as “easygoing” as her other children. She is having difficulty feeding the child because he fusses and cries when she serves a meal. The nurse should instruct the mother to: 1. Allow the child to determine when feeding should occur. 2. Not feed the child if he cries. 3. Provide structured feeding times and routines. 4. Give the child finger foods and let him eat when he wants. 96. A client claims to have a “special mission from God.” The nurse incorporates this religious delusion of grandeur into the client’s plan of care based on the understanding that the primary purpose of such a delusion is to provide which of the following? 1. Sexual outlet. 2. Comfort. 3. Safety. 4. Self-esteem. 97. A client with bipolar disorder, mania, has flight of ideas and grandiosity and becomes easily agitated. To prevent harmful behaviors, which of the following should the nurse do initially? 1. Encourage the client to stay in his room. 2. Seclude the client at the first sign of agitation. 3. Tell the client to seek out staff when feeling agitated. 4. Instruct the client to ask for medication when agitated. 98. While preparing a client for surgery, the nurse assesses for psychosocial problems that may cause preoperative anxiety. Which of the following is believed to be the most distressing fear a preoperative client is likely to experience? 1. Fear of the unknown. 2. Fear of changes in body image. 3. Fear of the effects of anesthesia. 4. Fear of being in pain. 99. A client with acute stress disorder is telling the nurse about the tornado that leveled his house and killed his wife and baby while he was out of town on business. He states, “If only I’d been at home, I could have saved them.” Which of the following responses would be most appropriate? 1. “Don’t blame yourself; you’ll only feel worse.” 2. “It’s not your fault; so stop feeling so guilty.” 3. “You might not have been at home.” 4. “You couldn’t have prevented the tornado; it just happened.” 100. A family may request to have a client who is Vietnamese transferred to die at home because it is traditionally believed that: 1. It is disloyal to leave their loved one in the hospital. 2. The hospital cannot be trusted. 3. The family can provide more comfort at home. 4. Reincarnation will not occur in the hospital. 101. When fluids by mouth are appropriate for the infant after surgery to correct intussusception, the nurse most likely would initiate feeding with: 1. Cereal-thickened formula. 2. Full-strength formula. 3. Half-strength formula. 4. Oral electrolyte solution. 102. The nurse is performing a respiratory assessment on a client who has a pleural effusion. The nurse should determine if the client has: 1. Decreased chest movement on the affected side. 2. Normal bronchial breath sounds. 3. Hyper resonance on percussion. 4. Fever. 103. A client with asthma asks the nurse if she should use her salmeterol inhaler when she exercises and experiences wheezing and shortness of breath. The nurse’s best response is which of the following? 1. “Yes, use the inhaler immediately for these symptoms.” 2. “No, this drug is a maintenance drug, not a rescue inhaler.” 3. “Use the inhaler 5 minutes before you exercise to prevent the wheezing.” 4. “This inhaler is for allergic rhinitis, not asthma.” 104. A nurse is caring for a client who is having an allergic reaction to a blood transfusion. In what order should the nurse provide care for this client? 1. Stop the transfusion. 2. Send the blood bag and blood slip to the blood bank. 3. Keep the vein open with normal saline solution. 4. Administer an antihistamine as directed. 105. A primiparous client at 48 hours postpartum is to be given Medroxyprogesterone acetate (Depo-Provera) before discharge. Which of the following should the nurse include in the teaching plan before administering this medication? 1. There is an increased risk of ovarian cancer with use of this drug. 2. Amenorrhea is common during the first 6 months. 3. Heavy menstrual bleeding may occur. 4. The client may experience periods of increased energy. 106. The nurse should instruct a client who is taking dexamethasone (Decadron) and furosemide (Lasix) to report: 1. Excitability. 2. Muscle weakness. 3. Diarrhea. 4. Increased thirst. 107. Which of the following nursing interventions would best accomplish the goal of preventing atelectasis and pneumonia in a postoperative client? 1. Administering oxygen therapy as needed to maintain adequate oxygenation. 2. Offering pain medication before having the client deep-breathe and use incentive spirometry. 3. Encouraging the client to cough, deep-breathe, and turn in bed once every 4 hours. 4. Forcing fluids to 2,000 mL every 24 hours. 108. The nurse establishes the goal of preventing the development of a stress ulcer in a burn client. Which of the following interventions would most likely contribute to the achievement of this goal? 1. Implementing relaxation exercises. 2. Administering a sedative as needed. 3. Providing a soft, bland diet. 4. Administering famotidine (Pepcid) as prescribed. 109. When giving a client a tube feeding, the nurse should: 1. Warm the feeding solution before administration. 2. Place the client in a left side-lying position. 3. Aspirate residual gastric contents before the feeding and discard. 4. Verify position of the tube before beginning feeding. 110. A client is scheduled for a creatinine clearance test. Which one of the following preparations is appropriate for the nurse to make? 1. Instruct the client about the need to collect urine for 24 hours. 2. Prepare to insert an indwelling urethral catheter. 3. Provide the client with a sterile urine collection container. 4. Instruct the client to force fluids to 3,000 mL/day. 111. The nurse is caring for a client who has experienced severe multiple trauma. The client’s arterial blood gases reveal low arterial oxygen levels that are not responsive to high concentrations of oxygen. This finding is an indicator of the development of which of the following conditions? 1. Hospital-acquired pneumonia. 2. Hypovolemic shock. 3. Acute respiratory distress syndrome (ARDS). 4. Asthma. 112. A 24-year-old client, diagnosed with acute Osteomyelitis in the left leg, has acute pain in the leg that intensifies on movement. The client has a temperature of 101°F (38.3°C) and a reddened, warm area in the midcalf region over the shaft of the tibia. Based on this information, the nurse should do which of the following frst? 1. Prepare the client for possible left lower leg amputation. 2. Instruct the client to keep the leg immobile. 3. Develop a plan for pain management. 4. Obtain a prescription for fluid replacement. 113. A client who has been vomiting for 2 days has a nasogastric tube inserted. The nurse notes that over the past 10 hours the tube has drained 2 L of fluid. The nurse should further assess the client for: 1. Hypermagnesemia. 2. Hypernatremia. 3. Hypokalemia. 4. Hypocalcemia. 114. A 32-year-old woman recently diagnosed with Hodgkin’s disease is admitted for staging by undergoing a bone marrow aspiration and biopsy. To obtain more information about the client’s nutrition status, the nurse should review the results of which of the following tests? 1. Red blood cell count. 2. Direct and indirect bilirubin levels. 3. Reticulocyte count. 4. Albumin level. 115. A client appears flushed and has shallow respirations. The arterial blood gas report shows the following: pH, 7.24; partial pressure of arterial car-bon dioxide (Paco2), 49 mm Hg (6.5 kPa); bicarbonate (HCO3), 24 mEq/L (24 mmol/L). These findings are indicative of which of the following acid-base imbalances? 1. Metabolic acidosis. 2. Metabolic alkalosis. 3. Respiratory acidosis. 4. Respiratory alkalosis. 116. The nurse is assessing fetal position in a 32-year-old woman in her 8th month of pregnancy. From the figure below, the fetal position can be described as: 1. Left occipital transverse. 2. Left occipital anterior. 3. Right occipital transverse. 4. Right occipital anterior. 117. After a child returns from the post anesthesia care unit after surgery, which of the following should the nurse assess first? 1. The IV fluid access site. 2. The child’s level of pain. 3. The surgical site dressing. 4. The functioning of the nasogastric tube. 118. The nurse is planning to complete the following assessments during the last half hour of the shift. Which of the following assessments has the highest priority and should be accomplished first? 1. A postpartum couplet with the infant who has had transient tachypnea of the newborn (TTN) at birth and now has a respiratory rate of 60 breaths/min. 2. A newly admitted postpartum client who is receiving magnesium sulfate at 3 g an hour initiated 10 hours ago for preeclampsia; her infant ate poorly previously and has not eaten for 4 hours. 3. A mother who had a cesarean section and is 6 hours after birth with the baby in special care nursery; the mother has not yet seen her baby. 4. A couplet with baby born at 36 weeks’ gestation; the 5-lb (2,268-g) infant had initial blood glucose of 35 mg/dL (1.9 mmol/L) and when taken to the room had a glucose of 46 mg/dL (2.6 mmol/L). 119. The charge nurse on an antepartal unit is making staffing assignments for the day. There is a registered nurse (RN), licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) to care for 15 clients. The nurse should assign which of the following clients to the LPN? 1. A newly admitted G5 P2 Ab 2 with second trimester bleeding, reportedly currently saturating one to two pads in 12 hours. 2. A 22-year-old G2 P1 with urinary retention who is being catheterized with an intermittent in and out every 4 to 6 hours PRN while awaiting urine cultures to be returned. 3. A G4 P2 with a twin pregnancy who was admitted in preterm labor and is now able to ambulate two to three times daily and having no contractions. 4. A 30-year-old G4 P0 who was admitted with sickle cell crisis currently receiving blood and pain medication. 120. Which of the following is true with regard to delegation of client care responsibilities? Select all that apply. 1. The nurse must know the nursing model that underlies care at the institution. 2. The nurse delegates in accordance with demands on his/her time. 3. The nurse validates with the nonregistered nurse (non-RN) caregiver that he/she has performed the same activity before. 4. The nurse retains the right to determine which tasks are delegated. 5. The nurse must document that the task has been delegated and to whom. 121. The nurse observes a nursing assistant sharing extensive stories of her own mother’s death with a dying client’s husband. Which of the following is appropriate feedback for the nurse to offer to the nursing assistant? 1. “I thought that was really great how you talked with him; he seemed really scared.” 2. You provided excellent client education by sharing your stories.” 3. “I think it helps clients to see us as real people, and friends too, when you share your own stories.” 4. “It is probably best to avoid talking about your personal experience very much; keep communication client-centered.” 122. Which of the following would be true regard-ing medication reconciliation? Select all that apply. 1. Medication reconciliation is an important patient safety goal. 2. Medication reconciliation is designed to obtain and communicate an accurate list of a client’s home medications across the continuum of care. 3. Only nurses or health care providers can be involved in medication reconciliation. 4. Medications are considered reconciled if a medication prescription exists that is therapeutically equivalent to the one prior to admission. 5. A medication is considered to be any medication prescribed by a primary care provider. 123. A multigravid client at 36 weeks’ gestation who is visiting the clinic for a routine visit begins to sob and tells the nurse, “My boyfriend has been beating me up once in a while since I became pregnant, but I can’t bring myself to leave him because I don’t have a job and I don’t know how I would take care of my other children.” Which of the following actions should be the priority by the nurse at this time? 1. Contact a social worker for assistance and family counseling. 2. Help the client make concrete plans for the safety of herself and her children. 3. Tell the client that she shouldn’t allow any-one to hit her or her children. 4. Provide the client with brochures on the statistics about violence against women. 124. When teaching a group of parents about the potential for febrile seizures in children, which of the following facts should the nurse include? 1. The exact cause is known. 2. The seizures occur as the fever rises. 3. Children older than age 3 are most at risk. 4. These seizures commonly occur after immunization administration. 125. The nurse is instructing a Hindu client to increase protein in the diet. Which of the following foods are appropriate to include in this client’s diet? Select all that apply. 1. Lentil soup. 2. Hamburger. 3. Steak. 4. Veal cutlet. 5. Broiled fish sandwich. 126. The nurse is counseling a client about the prevention of coronary heart disease. Which of the following vitamins should the nurse recommend the client include in his diet to reduce homocysteine levels? Select all that apply. 1. Vitamin K. 2. Vitamin B6. 3. Folate. 4. Vitamin B12. 5. Vitamin D. 127. A client tells the nurse that her bra fits more snugly at certain times of the month and she is concerned this may be a sign of breast cancer. The best response for the nurse is to explain that: 1. A change in breast size should be checked by her primary care provider. 2. Benign cysts tend to cause the breast to vary in size. 3. It is normal for the breast to increase in size before menstruation begins. 4. A difference in the size of her breasts is related to normal growth and development. 128. Which of the following techniques is best for the nurse to use in evaluating the parents’ ability to administer eardrops correctly? 1. Observe the parents instilling the drops in the child’s ear. 2. Listen to the parents as they describe the procedure. 3. Ask the parents to list the steps in the procedure. 4. Ask the parents whether they have read the handout on the procedure. 129. A client at 12 weeks’ gestation tells the nurse that she is a vegan and eats “lots of rice.” To help meet the client’s need for protein during pregnancy, the nurse suggests that the client combine the rice with which of the following? 1. Beans. 2. Soy milk. 3. Yogurt. 4. Corn. 130. Which statement would most likely be made by a Mexican client with pain? 1. “Enduring pain is a part of God’s will.” 2. “This pain is killing me.” 3. “I’ve got to see a doctor right away.” 4. “I can’t go on in pain like this any longer.” 131. When assessing a child receiving tobramycin sulfate, which findings would indicate that the child is experiencing adverse effects? Select all that apply. 1. Increased blood pressure. 2. Weight gain. 3. Rash. 4. Fever. 5. Ringing in the ears. 6. Decreased heart rate. 132. A client has received an overdose of sym-pathomimetic agents. The nurse should assess the client for which of the following late signs of an overdose? Select all that apply. 1. Hypotension. 2. Bradycardia. 3. Seizures. 4. Profound pyrexia. 5. Hypertension. 133. A nulliparous client says that she and her husband plan to use a diaphragm with spermicide to prevent conception. Which of the following should the nurse include as the action of spermicides when teaching the client? 1. Destruction of spermatozoa before they enter the cervix. 2. Prevention of spermatozoa from entering the uterus. 3. A change in vaginal pH from acidic to alkaline. 4. Slowing of the movement of the migrating spermatozoa. 134. A client has been diagnosed with multi-infarct (or vascular) dementia (MID). When preparing a teaching plan for the client and family, which of the following should the nurse indicate as the most critical factor for slowing MID? 1. Administering anticoagulants such as warfarin (Coumadin). 2. Administering benzodiazepines such as lorazepam (Ativan) to decrease choreiform movements. 3. Managing related symptoms such as depression. 4. Managing the symptoms by increasing dopamine availability. 135. A 7-year-old has been diagnosed with bacterial meningitis. Which of the following should receive chemoprophylaxis? 1. All children at the school.2. 2. All household contacts and close contacts. 3. The entire community. 4. Household contacts only. 136. A client with a history of peptic ulcer disease is admitted to the hospital. Initial assessment reveals that his blood pressure is 96/60 mm Hg, his pulse rate is 120 bpm, and he has vomited coffee-ground material. Based on this assessment, what is the nurse’s priority action? 1. Administer an antiemetic. 2. Prepare to insert a nasogastric (NG) tube. 3. Collect data regarding recent client stressors.4. 4. Place the client in a modified Trendelenburg position. 137. The nurse instills 5 mL of normal saline before suctioning a client’s tracheostomy tube. The instillation is effective when: 1. The secretions are thinned. 2. The client coughs. 3. There is minimal friction when the catheter is passed into the tracheostomy tube. 4. There is humidification for the respiratory tract. 138. A client has had a cardiac catheterization. The left femoral dressing has a moderate amount of bloody drainage, and the client has severe pain in that area. The nurse should first: 1. Assess the airway. 2. Administer oxygen. 3. Apply pressure to the site. 4. Assess the pulse in the left extremity. 139. The father of an 18-month-old with no previous illness, who has been admitted to a surgery center for repair of an inguinal hernia, tells the nurse that his child is having trouble breathing. The father does not think the child choked. After telling the clerk to call the rapid response team, the nurse should do which of the following? Place in order from first to last. 1. Notify the surgeon. 2. Start an intravenous infusion. 3. Assess the effectiveness of the abdominal thrusts. 4. Perform the abdominal thrust maneuver. 5. Listen for breath sounds. 140. The nurse makes a home visit to a primiparous client and her neonate at 1 week after a vaginal birth. Which of the following findings should be reported to the primary care provider? 1. A scant amount of maternal lochia serosa. 2. The presence of a neonatal tonic neck reflex. 3. A nonpalpable maternal fundus. 4. Neonatal central cyanosis. 141. A client with emphysema is receiving continuous oxygen therapy. Depressed ventilation is likely to occur unless the nurse ensures that the oxygen is administered in which of the following ways? 1. Cooled. 2. Humidified. 3. At a low flow rate. 4. Through nasal cannula. 142. The nurse assesses for euphoria in a client with multiple sclerosis, looking for which of the following characteristic clinical manifestations? 1. Inappropriate laughter. 2. An exaggerated sense of well-being. 3. Slurring of words when excited. 4. Visual hallucinations. 143. Which of the following assessment finding is expected in a client with bacterial pneumonia? 1. Increased fremitus. 2. Bilateral expiratory wheezing. 3. Resonance on percussion. 4. Vesicular breath sounds. 144. A primiparous client who is breast-feeding develops endometritis on the third postpartum day. Which of the following instructions should the nurse give to the mother? 1. The neonate will need to be bottle-fed for the next few days. 2. The condition typically is treated with IV antibiotic therapy. 3. The client’s uterus may become “boggy,” requiring frequent massage and oxytocics. 4. The client needs to remain in bed in a side-lying position as much as possible. 145. Which of the following examples should the nurse use to describe bulimia to a group of parents at a local community center? 1. An adolescent male who uses calorie-counting to maintain his weight in the desirable range for his height. 2. A college-age male who uses regular exercise to be able to eat and drink what he wants without gaining weight. 3. A middle-aged female who uses diet pills occasionally to help her lose small amounts of weight. 4. A college-age female who binges and then purges to prevent weight gain. 146. A client is voiding small amounts of urine every 30 to 60 minutes. Which of the following actions is the nurse’s first priority? 1. Palpate for a distended bladder. 2. Catheterize the client for residual urine. 3. Request a urine specimen for culture. 4. Encourage an increased fluid intake. 147. The nurse is giving care to an infant in an oxygen hood (see figure). The nurse should do which of the following? Select all that apply. 1. Assure that the oxygen is not blowing directly on the infant’s face. 2. Place the butterfly mobile on the outside of the hood. 3. Immobilize the infant with restraints. 4. Remove the hood for 10 minutes every hour. 5. Encourage the parents to visit the child. 148. A client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. Within 1 hour of admission, the client’s legs are numb all the way up to the hips. The nurse should do which of the following next? Select all that apply. 1. Call the family to come in to visit. 2. Notify the health care provider of the change. 3. Place respiratory resuscitation equipment in the client’s room. 4. Check for advancing levels of paresthesia. 5. Have the client perform ankle pumps. 149. A nurse is caring for a woman who gave birth to a term neonate at 6 am. At 4 pm, the woman has a distended bladder and is reporting pain of 5 on a scale of 1 to 10. The nurse reviews the client’s out-put record. What should the nurse do first? 1. Apply a warm, moist towel over the bladder. 2. Ask the woman to sit on the toilet while the nurse runs water from the faucet. 3. Administer Tylenol with codeine. 4. Use an in-and-out catheter to empty the bladder. 150. A multiparous client gives birth to a neonate at 24 weeks’ gestation. After 12 hours, the neonate’s condition deteriorates, and death appears likely within the next few minutes. The parents are Roman Catholic, and they request that the neonate be baptized. Which of the following actions would be most appropriate? 1. Contact the hospital chaplain to perform the baptism. 2. Alert the hospital’s director that a neonatal death is imminent. 3. Find a health care provider who is Roman Catholic to perform the baptism. 4. Baptize the neonate, regardless of the nurse’s own religious beliefs. 151. A 17-year-old male client is being admitted to the adolescent psychiatric unit. He was brought in by the police after beating up two male peers. The client says, “They said I was gay because I had sex with an older neighbor when I was 8 years old. I am not gay!” Which of the following nursing interventions would be appropriate? Select all that apply. 1. Monitor the client’s level of anger and potential aggression. 2. Help the client express anger safely. 3. Assist the client in processing his feelings about the sexual abuse. 4. Ask the client if he would like to attend a support group. 5. Discuss the client’s attitude about going to jail after discharge. 152. The nurse is working on a birthing unit that has several unlicensed assistive personnel (UAP). The nurse determines that the UAP understands the type of information to report to the nurse when the UAP reports which of the following about one of the clients? 1. An episode of nausea after administration of an epidural anesthetic. 2. Contractions 3 minutes apart and lasting 40 seconds. 3. Evidence of spontaneous rupture of the membranes. 4. Sleeping after administration of IV nalbuphine (Nubain). 153. A client is admitted to the emergency department (ED) experiencing syncope. The nurse speaks with the family concerning the client’s condition and current medications. The client’s family states that the client takes several medications and has brought all the client’s medications with them. To determine the correct medications required for this client, the nurse performs which step of the required process to ensure safe administration of medications? 1. Verification. 2. Clarification. 3. Documentation. 4. Reconciliation. 154. A nursing assistant is taking care of a child in the arm restraint shown below. To provide care for this child, what should the assistant do? 1. Unpin the restraint and perform range-of-motion exercises. 2. Unwrap the restraint and bathe the arm using warm water. 3. Leave the restraint in its current position. 4. Remove one tape at a time while bathing the child’s arm. 155. A client in surgery has an endotracheal tube (ET) in place. The nurse should call a time-out if which of the following requirements is not in place? Select all that apply. 1. An identification band. 2. Postoperative pain medication. 3. An IV line. 4. Oxygen administration. 5. An anesthesiologist. 156. The physician is calling in a prescription for ampicillin for a neonate. The nurse should do which of the following? Select all that apply. 1. Write down the prescription. 2. Ask the physician to come to the hospital and write the prescription on the chart. 3. Repeat the prescription to the physician over the telephone. 4. Ask the physician to confirm that the prescription is correct. 5. Ask the nursing supervisor to cosign the telephone prescription as transcribed by the nurse. 157. Which of the following are reasons for the nurse to encourage women to have a “Pap test” (Papanicolaou smear)? Select all that apply. 1. To detect precancerous and cancerous cells of the uterus. 2. To assess the effects of sex hormonal replacement. 3. To identify viral, fungal, and parasitic conditions. 4. To evaluate the response to chemotherapy or radiation therapy to the cervix. 5. To detect a diminished blood flow to the perineal mucous membrane. 158. After birth of a male neonate at 38 weeks’ gestation, the nurse dries the neonate and places him under the radiant warmer. The nurse performs this action based on the understanding that one neonatal response to cold stress involves which of the following? 1. Metabolism of brown adipose tissue. 2. Decreased utilization of glycogen stores. 3. Decreased utilization of calorie stores. 4. Increased shivering to keep warm. 159. The nurse is assessing a teenage girl. According to the figure below, the nurse should note that the girl has: 1. Kyphosis. 2. Arthritis. 3. Developmental dysplasia of the hip. 4. Scoliosis. 160. The nurse is planning a program about women’s health and cancer prevention for a community health fair. The nurse should include information about which of the following? Select all that apply. 1. Regular self-exams of the breast and vulva are important self-care activities. 2. Cancer can be prevented by removing precancerous lesions of the vulva, cervix, or endometrium. 3. Girls, age 11 to 12, should receive immunization for human papilloma virus (HPV) to prevent cervical cancer. 4. Smoking cessation reduces the risk of cervical cancer. 5. There is limited evidence that cancer in women is inherited. 161. The nurse is conducting health assessments for school-age children. A characteristic behavior of a 7-year-old girl is that she: 1. Likes to play only with other girls. 2. Prefers to play with her sister. 3. Prefers to play team games. 4. Likes to play alone. 162. A 12-year-old client says, “Give me my pajamas. I’m not putting your silly gown on.” An appropriate response by the nurse should be: 1. “I know they’re funny but everyone here wears them.” 2. “You don’t mean that, now. A big guy like you knows how hospitals are.” 3. “You’re upset because you feel awkward and embarrassed in these gowns.” 4. “You’re upset because you think we’re unreasonable.” 163. A 4-year-old child continues to come to the nurses’ station after being told children are not allowed there. What behavior is the child exhibiting? 1. Attention-seeking behavior. 2. Aggressive behavior. 3. Resistive behavior. 4. Exaggerated stress behavior. 164. A client who underwent cardiac surgery 2 days ago is recovering well. His wife, who is assisting with his care, says, “He is doing too much. I told him to let me help, but he won’t let me.” The nurse says to the wife, “It sounds like you need to feel you can be more helpful to him.” In order to make the nonverbal behavior complement the words, the nurse should: 1. Direct the eyes at the client. 2. Direct the body and eyes at the wife and client. 3. Avoid direct eye contact with the client and wife. 4. Shift the eyes back and forth between the client and wife. 165. Twenty-four hours after an appendectomy, a 16-year-old adolescent of Asian ethnicity has no pain but is frowning and has the legs drawn to the fetal position. The nurse should: 1. Administer pain medication. 2. Ask the adolescent what is troubling him. 3. Discuss the adolescent’s behavior with the parents. 4. Offer a distracting activity such as a video game. 166. A nurse is taking a medication history on a client with multiple sclerosis before administering an initial dose of baclofen (Lioresal). What should the nurse check before administering the drug? Select all that apply. 1. Presence of muscle weakness. 2. History of muscle spasms. 3. Serum creatinine level. 4. Serum potassium level.5. Blood glucose. 167. A nurse is instructing a client about the use of nitroglycerin patches. The nurse should instruct the client to: 1. Remove the patch every night. 2. Use the patch only when chest pain occurs. 3. Change the site of the patch every day. 4. Apply the patch only on alternate days. 168. The nurse is preparing to give an IM injection. Which of the following sites has the least amount of blood vessels and major nerves located in the area? 1. Deltoid. 2. Dorsogluteal. 3. Vastus lateralis. 4. Triceps. 169. The nurse is administering eye drops to a client with glaucoma. Which of the following is a correct technique for instilling the eye drops? The eye drops are placed: 1. In the lower conjunctival sac. 2. Near the opening of the lacrimal ducts. 3. On the cornea. 4. On the scleral surface. 170. The nurse is preparing to start an IV infusion. Before inserting the needle into a vein, the nurse should apply a tourniquet to the client’s arm to accomplish which of the following? 1. Distend the veins. 2. Stabilize the veins. 3. Immobilize the arm. 4. Occlude arterial circulation. 171. The sudden onset of which of the following indicates a potentially serious complication for the client receiving an IV infusion? 1. Noisy respirations. 2. Pupillary constriction. 3. Halitosis. 4. Moist skin. 172. A 36-month-old child weighing 20 kg (44 lb) is to receive ceftriaxone 2 g IV every 12 hours. The recommended dose of ceftriaxone is 50 to 75 mg/kg/day in divided doses. The nurse should: 1. Administer the medication as prescribed. 2. Administer half the prescribed dose. 3. Call the laboratory to check the therapeutic serum level of ceftriaxone. 4. Withhold administering the ceftriaxone and notify the child’s primary care provider. 173. A family has taken home their newborn and later received a call from the pediatrician that the phenylketonuria (PKU) levels for their newborn daughter are abnormally high. Additional testing confirmed the diagnosis of phenylketonuria. The parents refuse to believe the results as no one else in their family has the disease. The nurse explains that the disease: 1. Is carried on recessive genes contributed by each parent. 2. Is caused by a recessive gene contributed by either parent. 3. Is cured by eliminating dietary protein for this child. 4. Will not impact future childbearing for the family. 174. A primiparous client at 4 hours after a vaginal birth and manual removal of the placenta voids for the first time. The nurse palpates the fundus, noting it to be 1 cm above the umbilicus, slightly firm, and deviated to the left side, and notes a moderate amount of lochia rubra. The nurse notifies the physician based on the interpretation that the assessment indicates which of the following? 1. Perineal lacerations. 2. Retained placental fragments. 3. Cervical lacerations. 4. Urine retention. 175. An adult client has bacterial conjunctivitis. What should the nurse teach the client to do? Select all that apply. 1. Use warm saline soaks four times per day to remove crusting. 2. Apply topical antibiotic without touching the tip of the tube to the eye. 3. Wash the hands after touching the eyes. 4. Avoid touching the eyes. 5. Observe isolation procedures by staying in the bedroom until the redness in the eye disappears. 176. The nurse is planning care for a client who has sustained a spinal cord injury. The nurse should assess the client for: 1. Anesthesia below the level of the injury. 2. Tingling in the fingers. 3. Pain below the site of the injury. 4. Loss of vibratory sense. 177. A nurse is assessing a client with a brain injury. What is a client’s cerebral perfusion pressure (CPP) when the blood pressure (BP) is 90/50 mm Hg and the intracranial pressure (ICP) is 21? mm Hg. 178. A woman with a history of a left radical mastectomy is being admitted for abdominal surgery. The woman has a swollen left arm. The nurse should: 1. Take the blood pressure only in the unaffected arm. 2. Start an IV line in the affected arm. 3. Encourage a dependent position of the affected arm. 4. Allow blood draws in the affected arm. 179. A neonate born to a primiparous client at 36 weeks’ gestation in a small, rural hospital is to be transferred by ambulance to a level III nursery. To prepare the parents for the transfer, which of the following should the nurse include in the plan of care? 1. Instruct the parents that the neonate is in critical condition. 2. Obtain the mother’s consent for the neonate’s transfer. 3. Allow the parents to touch the neonate before transfer. 4. Ask the father if he desires to ride in the ambulance during the transfer. 180. The nurse has been assigned to care for several postpartum clients and their neonates on a birthing unit. Which of the following clients should the nurse assess first? 1. A multiparous client at 48 hours postpartum who is being discharged. 2. A primiparous client at 2 hours postpartum who gave vaginal birth to a term neonate. 3. A multiparous client at 24 hours postpartum whose infant is in the special care nursery. 4. A primiparous client at 48 hours after cesarean birth of a term neonate. 181. The nurse is monitoring a client receiving a blood transfusion when the client develops a cough with shortness of breath. The client also has a head-ache and a racing heart. What should the nurse do first? 1. Slow the infusion rate. 2. Replace the blood with saline. 3. Administer an antihistamine. 4. Place the client flat with the feet elevated. 182. Clients who are receiving total parenteral nutrition (TPN) are at risk for development of which of the following complications? 1. Hypostatic pneumonia. 2. Pulmonary hypertension. 3. Orthostatic hypotension. 4. Fluid imbalances. 183. Which of the following conditions is a potential consequence of a prolonged QT interval? 1. Serious electrolyte imbalance. 2. Predisposition to torsades de pointes. 3. Predisposition to atrial fibrillation. 4. Development of orthostatic hypotension. 184. A client has nephrotic syndrome. To aid in the resolution of the client’s edema, the physician prescribes 25% albumin. In addition to an absence of edema, the nurse should evaluate the client for which expected outcome? 1. Crackles in the lung bases. 2. Blood pressure elevation. 3. Cerebral edema. 4. Cool skin temperature in lower extremities. 185. The nurse is teaching two nursing assistants who are new to the inpatient unit about caring for a client who is suicidal. The nurse determines that additional teaching is needed when which of the following statements is made? 1. “I need to check the client precisely at 15-minute intervals.” 2. “Documenting suicide checks is absolutely necessary.” 3. “Clients on one-to-one suicide precautions can never be left alone.” 4. “All clients 186. A client who overdosed on barbiturates is being transferred to the inpatient psychiatric unit from the intensive care unit. Assessing the client for which of the following needs should be a priority for the nurse receiving the client in the intensive care unit? 1. Nutrition. 2. Sleep. 3. Safety. 4. Hygiene. 187. A client comes to the mental health clinic for a follow-up visit for a diagnosis of major depressive disorder. He says that he has been taking his escitalopram oxalate as prescribed since his second hospitalization 3 months ago. He tells the nurse that he is feeling “like my old self again.” Now he wants to stop taking medication. “I don’t want to be dependent on meds like my father.” What is the nurse’s best initial response to him? 1. “After another 3 months of stability, it might be safe for you to go off the escitalopram.” 2. “After two significant episodes, you will need to take an antidepressant indefinitely.” 3. “Research indicates that individuals who have had two major depressive episodes have a 70% chance of having a third episode.” 4. “It is likely that you can learn to manage your depression with a regular exercise regime and a healthy diet.” 188. Which of the following statements by a client taking trazodone (Desyrel) as prescribed by the primary health care provider indicates to the nurse that further teaching about the medication is needed? 1. “I will continue to take my medication after a light snack.” 2. “Taking Desyrel at night will help me to sleep.” 3. “My depression will be gone in about 5 to 7 days.” 4. “I won’t drink alcohol while taking Desyrel.” 189. When developing a teaching plan for a client about the medications prescribed for depression, which of the following components is most important for the nurse to include? 1. Pharmacokinetics of the medication. 2. Current research related to the medication. 3. Management of common adverse effects. 4. Dosage regulation and adjustment. 190. When planning care for a client with schizophrenia who lacks motivation to shower and dress, which of the following outcomes should the nurse expect the client to achieve by the end of 4 days? 1. Verbalize the need to shower and dress herself. 2. Recognize the need to shower and dress herself. 3. Explain reasons for showering and dressing herself. 4. Perform showering and dressing for herself. 191. When developing a community-based service program for clients with chronic mental illnesses, which of the following is the least important? 1. Partial programs. 2. Psychiatric home care. 3. Residential services. 4. Long-term hospitals. 192. The client with an Axis I diagnosis of schizophrenia, undifferentiated type, is acutely psychotic and exhibits religious delusions and hallucinations, loose associations, and concrete thinking. When the nurse offers the client her medication, the client states, “I don’t need that. God will heal me.” The nurse should respond to the client by saying: 1. “God helps those who help themselves.” 2. “God wants you to take your medicine.” 3. “God is important in your life, but the medicine will help you too.” 4. “This medicine will help clear your thoughts and decrease anxiety.” 193. The parent of a young adult client diagnosed with paranoid schizophrenia is asking questions about his son’s antipsychotic medication, ziprasidone. Which of the following statements by the father reflects a need for further teaching? 1. “If he experiences restlessness or muscle stiffness, he should tell the doctor.” 2. “I should give him benztropine to help prevent constipation from the ziprasidone.” 3. “If he becomes dizzy, I’ll make sure he doesn’t drive.” 4. “The ziprasidone should help him be more motivated and less withdrawn.” 194. The husband of a nurse who is being con-fronted by a group about her problem with alcohol asks the nurse acting as the group leader what he should say to his wife during the meeting. The nurse leader directs the husband to use which of the following statements to facilitate his wife’s entrance into treatment? 1. “The children and I want you to get help.” 2. “If your parents were alive, they would be extremely disappointed in you.” 3. “Either you get help or the kids and I will move out of the house.” 4. “You need to enter treatment now or be a drunk if that’s what you want.” 195. While caring for a client who has a dual diagnosis of bipolar disorder and alcohol dependency, which of the following areas is the priority for daily assessment? 1. Sleep pattern. 2. Mental status. 3. Eating habits. 4. Self-care ability. 196. The client who has a history of using angry outbursts when frustrated begins to curse at the nurse during an appointment after being informed that she will have to wait to have her medication refilled. Which of the following responses by the nurse is most appropriate? 1. “You’re being very childish.” 2. “I’m sorry if you can’t wait.” 3. “I will not continue to talk with you if you curse.” 4. “Come back tomorrow and your medication will be ready.” 197. A client who chronically snorts cocaine is brought to the emergency department due to a cocaine overdose. The client is experiencing delusions, hallucinations, mild respiratory distress, and mild tachycardia initially. The nurse should do which of the following? Select all that apply. 1. Induce vomiting. 2. Place seizure pads on the bed. 3. Administer PRN haloperidol (Haldol) as prescribed. 4. Monitor for respiratory acidosis. 5. Encourage deep breathing. 6. Monitor for metabolic acidosis. 198. A client brought by ambulance to the emergency department after taking an overdose of barbiturates is comatose. The nurse should assess the client for: 1. Kidney failure. 2. Cerebrovascular accident. 3. Status epilepticus. 4. Respiratory failure. 199. While teaching a group of volunteers for a crisis hotline, a volunteer asks, “What if I’m not sure why someone is calling?” Which of the following statements by the nurse is most helpful? 1. “Ask the caller to tell you why he or she is calling you today.” 2. “Tell the caller to make an appointment at the walk-in crisis clinic.” 3. “Instruct the caller to go to the nearest emergency room.” 4. “Tell the caller to let you speak to anyone else in the house.” 200. A distraught father is waiting for his son to come out of surgery. He accidentally backed the car into his son, causing multiple fractures and a serious head injury. Which of the following statements by the father should alert the nurse to the need for a psychiatric consultation? 1. “My son will be fine, but I may be charged with reckless driving.” 2. “His mother is going to kill me when she finds out about this.” 3. “I just didn’t see him run behind the car.” 4. “If he dies, there will be nothing for me to do but join him.” 201. One of the myths about sexual abuse of young children is that it usually involves physically violent acts. Which of the following behaviors is more likely to be used by the abusers? 1. Tying the child down. 2. Bribery with money. 3. Coercion as a result of the trusting relationship. 4. Asking for the child’s consent for sex. 202. At the admission interview, the father of a 4-year-old boy with attention deficit hyperactivity disorder (ADHD) says to the nurse, “I know that my wife or I must have caused this disease.” Which of the following is the nurse’s best response? 1. “ADHD is more common within families, but there is no evidence that problems with parenting cause this disorder.” 2. “What do you think you might have done that could have led to causing this disorder to develop in your son?” 3. “Many parents feel this way, but I doubt there is anything that you did that caused ADHD to develop in your child.” 4. “Let’s not focus on the cause but rather on what needs to be done to help your son get better. I know that you and your wife are very interested in helping him to improve his behavior.” Answers: 2. 1,2,4 3. 1 4. 3 5. 4 6. 2 7. 2 8. 1 9. 3 10. 1 11. 3 12. 2 13. 0.8 mL 14. 4 15. 3 16. 1 17. 1 18. 3 19. 2 20. 1 21. 3 22. 1 23. 2 24. 3 25. 1 26. 3 27. 1 28. 2 29. 4 30. 3 31. 1 32. S1 is loudest at the mitral area. 33. 4 34. 1 35. 2 36. 3 37. 4 38. 3 39. 2 40. 2 41. 1 42. 1 43. 1,6 44. 4 45. 1 46. 1 47. 4 48. 2 49. 2 50. 1 51. 4 52. 3 53. 4 54. 1 55. 1 56. 3 57. 2 58. 4 59. 2 60. 3 61. 2 62. 1 63. 2 64. 3 65. 2 66. 2 67. 1 68. 2 69. 4,5 70. 2,3,4 71. 2 72. 4 73. 1 74. 2 75. 1 76. 2,1,4,3 77. 4 78. 1 79. 4 80. 3,4,5 81. 2 82. 2 83. 1 84. 3 85. 3 86. 3,4 87. 3 88. 3 89. 2,3,4,5 90. 1 91. 4 92. 2 93. 3 94. 2 95. 3 96. 4 97. 3 98. 1 99. 4 100 . 3 101. 4 102. 1 103. 2 104. 1,3,4,2 105. 3 106. 2 107. 2 108. 4 109. 4 110. 1 111. 3 112. 3 113. 3 114. 4 115. 3 116. 4 117. 3 118. 2 119. 2 120. 1,3,4 121. 4 122. 1,2,4 123. 2 124. 2 125. 1,5 126. 2,3,4 127. 3 128. 1 129. 1 130. 1 131. 3,4,5 132. 1,3,4 133. 1 134. 1 135. 2 136. 2 137. 1 138. 3 139. 5,4,3,2,1 140. 4 141. 3 142. 2 143. 1 144. 2 145. 4 146. 1 147. 1,2,5 148. 2,3,4 149. 4 150. 4 151. 1,2,3,4 152. 3 153. 2 154. 3 155. 1 156. 1,3,4 157. 1,2,3,4 158. 1 159. 4 160. 1,2,3,4 161. 1 162. 3 163. 1 164. 2 165. 1 166. 1,2,3,5 167. 1 168. 3 168. 1 170. 1 171. 1 172. 4 173. 1 174. 2 175. 1,2,3,4 176. 1 177. 42.3 mm Hg 178. 1 179. 3 180. 2 181. 1 182. 4 183. 2 184. 2 185. 1 186. 3 187. 3 188. 3 189. 3 190. 4 191. 4 192. 3 193. 2 194. 3 195. 2 196. 3 197. 2,3,4,5,6 198. 4 199. 1 200. 4 201. 3 202. 1 [Show More]

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