HESI_Exit_Exam_2[ more THAN 160 QUIZ WITH CORRECT ANSWERS VERIFIED 100%]

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Name: ________________________ Class: ___________________ Date: __________ ID: A 1 TEST 2 Multiple Choice Identify the letter of the choice that best completes the statement or answers the questio... n. ____ 1. The nurse should question a prescription for docusate sodium (Colace) for a client with which problem? a. First day post myocardial infarction. b. Two days following a knee replacement. c. Abdominal pain of unknown etiology. d. History of liver disease. ____ 2. The nurse working on a medical unit is assigned to care for four clients. Which client should the nurse assess first? a. A client who is quadriplegic and is complaining of a severe headache. b. A client who had a stroke and now has right-sided weakness. c. A client who has a pressure ulcer and now has a temperature of 102.3° F. d. An elderly client who is requesting medication for constipation. ____ 3. A male client is accompanied to the emergency department by the police after trying to jump off a bridge. As the nurse begins the initial evaluation, what is the priority assessment? a. Assess to see if the client is having command hallucinations. b. Determine where the client usually seeks healthcare treatment. c. Assess if the client has a history of aggression. d. Determine if the client has a history of depression. ____ 4. Prior to discharge, the parents of a child with cystic fibrosis are demonstrating chest physiotherapy (CPT) that they will perform for their child at home. Which action requires intervention by the nurse? a. A bronchodilator is administered before starting CPT. b. The child is placed in a supine position to begin percussions. c. A cupped hand is used when percussing the lung fields. d. Plan to perform CPT when the child awakens in the morning. ____ 5. A client at 29-weeks gestation is receiving magnesium sulfate 3 grams/hour for pre-term labor. After administering the loading dose, what assessment finding should the nurse report to the healthcare provider immediately? a. A decrease in respirations from 20 to 17 breaths/minute. b. An increase in temperature from 98.9° to 99.9° F. c. An increase in blood pressure from 110/65 to 120/85. d. A decrease in deep tendon reflexes from 3+ to 1+. ____ 6. Based on the change of shift report, the client with which signs and symptoms should be assessed by the nurse first? a. Epigastric pain, no bowel sounds. b. Chest pressure, diaphoresis, nausea. c. Chest tightness, wheezing, coughing. d. Calf pain, positive Homan's sign. Name: ________________________ ID: A 2 ____ 7. A client who is diaphoretic and talking incoherently presents in the emergency department triage area. What assessment should the triage nurse obtain first? a. A finger-stick glucose. b. A blood pressure. c. Temperature d. Arterial blood gases. ____ 8. A 59-year-old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, how should the nurse characterize the client's condition? a. He is in a coma, and has a very poor prognosis. b. This client is conscious, but is not oriented to time and place. c. He has a good prognosis for recovery. d. The client has increased intracranial pressure. ____ 9. Three days postoperative, a client's wound drainage changes in appearance from sanguineous to serous. Based on this finding, what nursing intervention should the nurse implement? a. Continue to monitor the wound. b. Monitor the client's vital signs. c. Apply pressure to the wound. d. Obtain a wound culture. ____ 10. A client with heart failure has developed a large pleural effusion and the healthcare provider plans to perform a thoracentesis. In preparing the client for this procedure, what intervention should the nurse implement? a. Notify the operating room personnel to schedule the procedure. b. Contact the client's next of kin to sign the operative consent. c. Determine if the client is allergic to antibiotics. d. Instruct the client to remain immobile during the procedure. ____ 11. A young adult male client is admitted to the emergency room with a bleeding abdominal wound following a motor vehicle collision. He is crying out with pain. His friends report that he often uses cocaine. What nursing diagnosis has the greatest priority? a. High risk for injury related to cocaine withdrawal. b. High risk for injury related to hemorrhage. c. Pain related to injuries. d. Anxiety related to trauma of motor vehicle accident. ____ 12. Which action should the nurse take first when performing tracheostomy care? a. Cleanse around the stoma. b. Suction the tracheostomy. c. Oxygenate with 100% oxygen. d. Secure the new neck strap. ____ 13. Which assessment finding would indicate to the nurse the need for intramuscular administration of vitamin K to a client with cirrhosis? a. Hemoccult positive stool. b. Anorexia and nausea. c. Increasing ascites. d. Decreased level of consciousness. Name: ________________________ ID: A 3 ____ 14. Prior to removing the upper plate of a confused client to perform denture care, which action should the nurse take? a. Scrub the dentures with a foam swab. b. Move the plate up and down slightly. c. Fill the denture cup with hot water. d. Carefully insert an oral airway. ____ 15. A 45-year-old female client who had a hysterectomy one week ago asks the nurse when she will start to experience hot flashes. Before responding to the client's question, what information should the nurse obtain? a. The reason why the hysterectomy was performed. b. The type of birth control used preoperatively. c. Whether the client's ovaries were also removed. d. The type of hysterectomy that was performed. ____ 16. A 68-year-old male client is admitted to the medical unit, and one of his nursing diagnoses is, "Altered urinary elimination." The nurse knows that acute renal failure may be due to a variety of causes that can be classified as prerenal, renal, and postrenal. What is an example of a causative factor that is classified as "renal?" a. Hemorrhage from a chest wound. b. Malignancy of the kidneys. c. Renal calculi blocking the ureters. d. Benign prostatic hypertrophy. ____ 17. When developing a teaching plan on tuberculosis, which information would be accurate for the nurse to include? a. Those with a positive tuberculin test can expect to eventually develop active tuberculosis. b. Isoniazid (INH) is the drug of choice for prevention therapy. c. A slightly elevated temperature at mid-morning is a cardinal sign of tuberculosis. d. A tuberculin skin test should be read 24 hours after administration. ____ 18. Following a vaginal delivery, a postpartum client complains of severe cramping after breastfeeding her newborn. Which explanation describes the most likely reason for the client's pain? a. A retained placenta. b. Problems with the process of involution. c. The release of oxytocin hormone. d. A possible ileus. ____ 19. What nursing diagnosis has the highest priority for a client with severe ascites as a result of liver disease? a. Sleep pattern disturbance. b. Body image disturbance. c. Ineffective breathing pattern. d. Fear of dying. Name: ________________________ ID: A 4 ____ 20. The nurse obtains a blood sample from a gravid client for determination of alpha-fetoprotein (AFP). What information will this laboratory value provide? a. Determination of the existence of spina bifida. b. Screening for possible neural tube defects. c. Determination of fetal lung maturity. d. Screening for Tay-Sachs disease. ____ 21. A hospitalized client with peripheral arterial disease (PAD) is instructed regarding leg and foot care. Which statement by the client indicates to the nurse that effective learning has occurred? a. "I will use my swimming pool early in the day while the water is still very cool." b. "Whenever I am sitting in a chair I will keep my legs up to reduce swelling." c. "I will try to keep moving if leg pain occurs to help promote good circulation." d. "I can use a mirror to check the bottoms of my feet for any signs of breakdown." ____ 22. A 14-year-old male client arrives at the emergency room in status epilepticus. He was diagnosed with a seizure disorder in childhood. What is the most likely cause of his present condition? a. Increasing intracranial pressure. b. Acute withdrawal from anticonvulsant medication. c. A closed head injury. d. A central nervous system infection. ____ 23. A 75-year-old female client had a total hip replacement two days ago. She has never been in the hospital before. She has just called for the bedpan. How should the nurse place the pan under this client? a. Ask her to grab her overbed trapeze, push both heels into the mattress, and raise her buttocks off the bed so the bedpan can be slipped under her. b. Ask her to roll to the unoperated side and slide the bedpan under her, then roll her back onto the pan. c. Ask her to roll to the operated side and slide the bedpan under her, then roll her back onto the pan. d. Ask her to flex her knees, spread her legs, and lift her buttocks with the flat part of her feet, then push the bedpan under her from the front. ____ 24. In caring for a client who is receiving peritoneal dialysis, the nurse should be alert for what complications? a. Abdominal pain, tenderness, and rigidity. b. Clear dialysate drainage and burning on urination. c. An occluded vascular access device and flank pain. d. Increased serum albumin level, decreased BUN, and increased hematocrit. ____ 25. A nurse seeks to alter a provision of a state's Nurse Practice Act regarding nurse-client ratios, which the nurse believes to be unsafe. What action is most likely to impact a ruling by the state's Board of Nursing? a. Send an anonymous letter of concern to the local newspaper. b. Meet with the nurse's representative to the state legislature. c. Send documentation of the problem to the American Nurses' Association. d. File a grievance at the medical center where the nurse is employed. Name: ________________________ ID: A 5 ____ 26. While teaching a female Korean-American client about her medications, the nurse observes that she appears very serious, does not smile, and avoids looking at the nurse. Which expected outcome statement best directs this client's plan of care? The client will a. express her feelings of anxiety/fear. b. be relaxed and confident about her medication regimen. c. state that she understands her medication regimen. d. describe her medication regimen correctly. ____ 27. A client newly diagnosed with Type 1 diabetes received 28 units of Humulin N at 0700. The nurse is making rounds at 1330. Which client statement requires the most immediate follow-up intervention by the nurse? a. "I get so nervous when I have to give my shot." b. "I didn't sleep well last night. I am going to take a nap." c. "I get dizzy when I get up out of the bed too fast." d. "I let my wife eat my lunch since I wasn't hungry." ____ 28. The nurse has identified four nursing problems for a 13-year-old admitted for depression and anxiety. What is the priority problem? a. Ineffective health maintenance related to substance abuse and unsafe sex. b. Risk for self-directed violence related to history of self-mutilation. c. Ineffective coping related to post-traumatic stress of fire that killed siblings. d. Knowledge deficit regarding purpose of medications and side effects. ____ 29. A client diagnosed with nephrotic syndrome is treated with the glucocorticoid steroid prednisone (Cortef). The nurse recognizes that the treatment is having the desired effect when the client exhibits which serum lab value? a. Increased serum magnesium. b. Increased glycosuria. c. Decreased serum albumin. d. Decreased proteinuria. ____ 30. The nurse assesses a newborn who experienced shoulder dystocia. An asymmetric response to which developmental reflex could indicate clavicular fracture? a. Moro b. Trunk incurvation. c. Rooting. d. Tonic neck. ____ 31. The nurse is evaluating an asthmatic client's response to an inhaled corticosteroid medication. What assessment finding indicates that the medication has been effective in controlling the asthma symptoms? The client has increased a. peak flow meter rates. b. retraction of the chest muscles. c. viscosity of tracheal secretions. d. volume of expiratory wheezes. Name: ________________________ ID: A 6 ____ 32. The drainage from a client's colostomy changes from light yellow-brown to a black tarry appearance. What serum lab values are most important for the nurse to monitor? a. Sodium and Potassium. b. WBC count and Differential. c. Hemoglobin and Hematocrit. d. Creatinine and BUN. ____ 33. A 28-year-old client is in the emergency room following a spinal cord injury (SCI) at the T4 level. The nurse should frequently assess for spinal shock by assessing for which signs and symptoms? a. Bradycardia and hypotension. b. A narrow pulse pressure. c. Cool skin and an elevated SVR. d. Distended neck veins and an elevated CVP. ____ 34. Which nursing diagnosis has the highest priority when caring for a client receiving methylprednisolone (Solu-Medrol)? a. Body image disturbance related to cushingoid appearance. b. Altered nutrition, greater than body needs related to increased appetite. c. Self-care deficit related to muscle wasting. d. Risk for infection related to immunosuppression. ____ 35. A client needs to take 1.2 grams of calcium daily. The client currently takes eight 200 mg tablets each day. What instruction should the nurse provide? a. Reduce the daily dose by two tablets. b. Take half as many tablets. c. Continue with the current daily dose. d. Take two additional tablets daily. ____ 36. A female client tells the nurse how happy she is that her family brought a small bag of home-grown herbs to the hospital and placed them under her pillow. What action should the nurse take? a. Remove the herbs from under the pillow for proper disposal. b. Discuss why herbs are not allowed in a healthcare facility. c. Direct the family member to the charge nurse before leaving the herbs. d. Inquire about the intended purpose of placing the herbs under the pillow. ____ 37. When conducting a nursing assessment of a client with a nasal fracture, which finding is most significant? a. Diminished sense of smell. b. Localized pain and tenderness. c. Clear fluid draining from the nose. d. Bilateral ecchymosis. Name: ________________________ ID: A 7 ____ 38. A low phenylalanine diet is prescribed for a 4-year-old with phenylketonuria. The nurse evaluates that the mother understands her child's dietary restrictions if she eliminates which food from the child's diet? a. Sliced apples. b. French fries. c. Fruit juices. d. Cheese sandwich. ____ 39. On the fourth hospital day following abdominal surgery, a male client complains of right calf pain, and becomes restless and disoriented. Vital sign assessment reveals tachycardia and dyspnea. The nurse suspects development of a pulmonary embolism (PE). Which additional assessment findings indicate that a pulmonary embolism has occurred? a. Fever and inflammation of the abdominal incision. b. Chest pain and an increase in the respiratory rate. c. Increased severity of abdominal pain and hypotension. d. Positive Homan's sign and diminished left pedal pulse. ____ 40. The nurse arrives at the scene of a motor vehicle collision and finds a young woman with serious injuries. The woman asks the nurse if she is going to die. Which response would be best for the nurse to make? a. "I don't know, but we are doing everything we can to get you the best care possible." b. "It's hard to tell at this time, but an ambulance is on the way right now." c. "No! We are doing everything we can to get you to the hospital so that you can be cared for properly." d. "An ambulance is on its way, and the paramedics will assess your condition when they arrive." ____ 41. A client who is immunosuppressed because of treatment for systemic lupus erythematosus (SLE) delivers a viable infant at 37-weeks gestation by cesarean section. Four days later she has a fever of 102.6° F and diarrhea. A stool specimen is positive for Clostridium Difficile. What action should the nurse take? a. Place the client in enteric isolation. b. Remove the infant from the mother's room. c. Put the mother and infant in separate isolation rooms. d. Do not allow visitors until the diarrhea has stopped. ____ 42. In planning secondary levels of prevention for children, what action should the nurse take? a. Present an educational program on the importance of handwashing to all students. b. Teach pre-adolescents about growth and development changes that occur in adolescence. c. Conduct a spinal screening clinic for all 6th grade students. d. Develop a nutrition education program for kindergarten students. Name: ________________________ ID: A 8 ____ 43. The nurse working in a prenatal clinic is aware that a growing number of women from different cultures are seeking prenatal care at the clinic. What action should the nurse take first to meet the clients' individual nutritional needs? a. Ask the clients to keep a food diary and then discuss modifications within a cultural context. b. Instruct the clients about the food pyramid and adapt to the clients' culture as much as possible. c. Develop a list of foods common to each culture and help the client select nutritious foods from the list. d. Determine the extent to which culture influences the client's beliefs about food and pregnancy. ____ 44. The nurse is evaluating the effectiveness of a client's plan of care prior to a client's discharge. Which action has the highest priority? a. Establish whether the goal was achieved. b. Determine which interventions were effective. c. Review the effect of medical treatment on the care plan. d. Measure the length of time needed to complete the plan of care. ____ 45. The nurse is developing a plan of care for a client who has a prescription for the calcium channel-blocker nifedipine (Procardia) to treat angina pectoris. What is the purpose for administration of this medication? a. Reduce the incidence of clot formation. b. Stimulate the vagus nerve to increase heart rate. c. Decrease myocardial oxygen demands. d. Increase heart rate and force of contraction. ____ 46. The nurse should carefully assess the client with which urinary problem for fluid volume deficit? a. Frequency b. Dysuria c. Enuresis. d. Polyuria. ____ 47. The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is complaining of low back pain. What additional information about the client would be important for the nurse to impart to the healthcare provider? a. Hematocrit and blood pressure. b. White blood count and pulse rate. c. Serum amylase and level of consciousness. d. Calcium level and skin condition. ____ 48. Which dietary change should the nurse recommend to a client who has recently been diagnosed with a goiter? a. Avoid eating oysters in winter months. b. Increase use of iodized salt. c. Eat liver at least once a week. d. Eat almonds as a snack food. Name: ________________________ ID: A 9 ____ 49. Two tablets of hydrocodone bitartrate 5 mg/acetaminophen 500mg (Vicodin) q4h PRN are prescribed for a client with back pain. Based on which laboratory result should the nurse question this prescription? a. Alanine Aminotransferase (ALT) level is 4 times greater than the normal value. b. Serum levels of lipase and urinary amylase levels are 5 times greater than the normal value. c. Glucose-6-Phosphate-Dehydrogenase (G-6-PD) and erythrocyte protoporphyrin (FEP) deficiencies. d. Serum magnesium is deficient. ____ 50. The nurse feels a shock when plugging in an intravenous pump. After unplugging the pump, what action should the nurse implement? a. Place a label on the pump indicating that it is defective. b. Plug the pump into a different electric outlet in the room. c. Ask another nurse to try the pump to detect a shock. d. Leave the pump in the room and obtain another one. ____ 51. What nursing intervention is of greatest benefit in preventing postpartum thrombophlebitis? a. Encourage use of supportive stockings. b. Apply moist heat to varicose veins. c. Encourage early prenatal care. d. Promote early postpartum ambulation. ____ 52. The LPN reports the patterns of urinary frequency and volume for several clients. Which finding necessitates further assessment by the RN? a. 400 ml amber urine by straight catheter q6h. b. Voiding 50 ml cloudy urine every hour. c. Total indwelling catheter output of 1800 ml in 24 hours. d. Voiding 300 ml clear yellow urine q4h. ____ 53. The nurse is preparing a teaching plan for a client diagnosed with Raynaud's disease. What is the primary objective in controlling Raynaud's disease? a. Improving circulation to the extremities. b. Maintenance of a cool environment to enhance cardiac output. c. Avoiding stimuli that provokes vasoconstriction. d. Taking precautions to reduce the risk of infection. ____ 54. Within four weeks of childbirth, a client is admitted to the hospital for disorganized speech, bizarre behavior, and strange thoughts about her infant being possessed by demons. The nurse identifies a nursing diagnosis of, "Altered thought processes, secondary to" what condition? a. Postpartum psychosis. b. Postpartum depression. c. Adjustment disorder. d. Paranoid personality. Name: ________________________ ID: A 10 ____ 55. Which strategy is most important for the nurse to use when assisting a client with myasthenia gravis to devise a daily routine? a. Select a physical diversional activity to promote endurance. b. Protect extremities from injury resulting from decreased sensation. c. Perform necessary physically demanding tasks in the morning. d. Set up a daily physical exercise regimen to promote muscle strength. ____ 56. The nurse working on a pediatric unit takes two 8-year-old girls to the playroom. Which activity is best for the nurse to plan for these girls? a. Playing doctor and nurse. b. Selecting a board game. c. Watching cartoons on television. d. Coloring, cutting, and pasting. ____ 57. The nurse is caring for a one-year-old child following surgical correction of hypospadias. What nursing action has the highest priority? a. Monitor urinary output. b. Record percent of diet eaten. c. Observe appearance of stool. d. Auscultate bowel sounds. ____ 58. The nurse is evaluating a client's understanding of teaching regarding chemotherapy. What statement indicates that the client has an accurate understanding of the potential risk for infection secondary to chemotherapy administration? a. "If my IV site looks swollen, I will call the nurse." b. "Infection is not a problem unless I'm running a fever." c. "I will have to be careful about infections for the rest of my life." d. "The risk for infection is pretty high, but at least it's temporary." ____ 59. Thirty minutes after initiating an infusion of packed red blood cells, the nurse notes that the blood bag is labeled Type O+ and the client's record indicates that his blood type is B+. The nurse assesses the client's vital signs: temperature 98.8° F, pulse 100/minute, respirations 22/minute, and BP 136/80. What action should the nurse take? a. Stop the infusion immediately. b. Administer a stat PRN prescription for epinephrine. c. Notify the healthcare provider and file an incident report. d. Continue to observe the client carefully. ____ 60. The nurse plans to obtain a urine specimen for culture from a client's indwelling catheter. The nurse enters the room with the syringe and notes that there is 100 ml of urine in the drainage bag, but no urine is in the tubing. What action should the nurse take? a. Clamp the tubing until urine is observed in the tubing. b. Remove the urine specimen from the drainage bag. c. Obtain sterile normal saline to irrigate the catheter. d. Separate the tubing from the catheter and withdraw a urine specimen. Name: ________________________ ID: A 11 ____ 61. What is a priority nursing diagnosis for a client with restless legs syndrome? a. Altered tissue perfusion. b. Impaired mobility. c. Self-care deficit. d. Altered sleep patterns. ____ 62. After the nurse administers a low volume hypertonic cleansing enema to a male client, the client reports to the nurse that he was only able to hold the enema contents for five minutes before defecating. What action should the nurse take first? a. Assess the client's bowel sounds and vital signs. b. Observe the appearance of the client's bowel movement. c. Instruct the client that he will require another enema. d. Document the client's statement in his medical record. ____ 63. A mental health nurse is admitting a female adolescent who is accompanied by her mother and father. The nurse received report from the emergency department that the client has a medical diagnosis of depression and has attempted to harm herself. Which task should the nurse assign to the mental health technician? a. Search all of the client's belongings. b. Begin completing the admission assessment form. c. Determine if there is a need for a safety contract. d. Ask the family members how the client tried to harm herself. ____ 64. When developing an initial plan of care for a hospitalized client with bipolar disorder who is in the manic phase, what nursing intervention has the highest priority? a. Set firm limits. b. Orient the client to reality. c. Increase the client's level of activity. d. Initiate a health teaching plan. ____ 65. The charge nurse is assessing the morning lab work on four clients. Which client's laboratory findings should prompt the charge nurse to contact the healthcare provider immediately? a. A 50-year-old diagnosed with myocardial infarction who has an elevated CPK-MB on serial cardiac isoenzymes. b. A 35-year-old diagnosed with pneumonia having a white blood cell (WBC) of 13,000 mm3. c. A 29-year-old diagnosed with ulcerative colitis having a serum potassium level of 3.1 mEq/L. d. A 74-year-old diagnosed with COPD who has ABGs of pH 7.35, PaC02 49, Pa02 74, HC03 26. ____ 66. A client returns to the nursing unit following pulmonary angiography. The report given to the nurse includes information that the client is alert and oriented, and that the left antecubital fossa area was used to perform the procedure. What action should the nurse take first? a. Assess for left-sided jugular vein distention. b. Monitor pedal pulses bilaterally. c. Encourage oral fluid intake. d. Observe pressure dressing. Name: ________________________ ID: A 12 ____ 67. The epidemiological triad can be used to frame strategies for the prevention of traffic injuries. Which action should the nurse initiate to focus on the host? a. Encourage driver's education in high school curriculums. b. Promote the improvement of road surfaces. c. Discuss the need for new stop signs near the library. d. Initiate a program for zero tolerance for speeding. ____ 68. A client is undergoing intracranial surgery. What intervention to decrease periorbital edema should the nurse include in this client's plan of care? a. Apply moist heat over the eyes. b. Patch both eyes for 36 hours. c. Apply light, cold compresses over the eyes. d. Put the client in a Trendelenburg position. ____ 69. An elderly female client with fragile veins has a prescription for the insertion of an IV. Which action by a new graduate nurse demonstrates that the nurse places a high value on nonmalfeasance? a. Explains the steps of the IV insertion procedure to the client. b. Asks the client in which arm she would like the IV to be inserted. c. Documents the client's tolerance of the IV insertion procedure. d. Requests that a more experienced nurse insert the client's IV. ____ 70. A middle-aged alcoholic male client is admitted to the hospital with early stage cirrhosis of the liver. He tells the nurse that he knows he cannot stop drinking. What response is best for the nurse to provide? a. "You have to stop drinking so that your liver has a chance to heal." b. "I understand what you are going through, but you can stop drinking if you make up your mind to do it." c. "Tell me what you think will happen to you if you do continue to drink." d. "May I call a counselor who can help you understand why it is necessary for you to quit drinking?" ____ 71. On the first postoperative day, a male client with a left above-the-knee amputation (AKA) cries out, "My left foot is killing me. You've got to do something!" What action should the nurse take first? a. Explain to the client that he is experiencing phantom pain and that it will go away. b. Elevate the stump and notify the surgeon immediately of the client's complaints. c. Try to calm the client and encourage him to listen to relaxation tapes. d. Rule out complications and administer prescribed analgesics. ____ 72. A client with suspected cardiogenic shock is admitted to the emergency room. Which assessment should the nurse obtain first? a. Breath sounds. b. Heart sounds. c. Vital signs. d. Peripheral pulses. Name: ________________________ ID: A 13 ____ 73. The nurse assesses a client in active labor and observes the fetal head crowning. After calling for assistance, what intervention should the nurse implement? a. Gently apply counterpressure to the fetal head. b. Place warm packs on the perineum to prevent tearing. c. Apply downward pressure on the uterine fundus. d. Ask the laboring client to assume the knee-chest position. ____ 74. When infusing a large number of banked packed red blood cells (PRBCs) over a short period of time, why should the nurse plan to administer a calcium replacement? a. The preservative in the product binds with calcium. b. Excessive GI bleeding causes hypocalcemia. c. Extra calcium is needed during a stressful event. d. Hypoperfusion to the parathyroid affects serum calcium. ____ 75. The charge nurse is implementing a quality assurance policy and accompanies a nurse while administering medications. The nurse identifies a male client by asking him to state his name prior to administering the medication. Which action should the charge nurse implement? a. Correct the nurse's action while administering the medication to the client. b. Take no action since the nurse is administering the medication correctly. c. Provide a medication irregular occurrence form for the nurse to complete. d. Tell the nurse in a private area that the client identification was incomplete. ____ 76. A 12-month-old boy is admitted to the hospital with severe eczema. The mother informs the nurse that her son has numerous allergies, including milk. The nurse knows to offer the child which formula? a. Lofenalac b. Isomil. c. Goat's milk. d. Similac. ____ 77. A male client with a kidney stone is complaining of severe discomfort in the left flank area. He grimaces upon movement, is hesitant to move about, and has shallow respirations at 20/minute. His wife expresses concern over his expected absence from work and loss of revenue. What diagnosis has the highest priority at this time? a. Acute pain related to presence of stone. b. Activity intolerance related to severe flank discomfort. c. Alteration in respiratory pattern related to stress. d. Family processes, altered related to loss of revenue. ____ 78. Which technique should be used to obtain a sterile urine specimen using a straight catheter? a. Use a sterile syringe to obtain the specimen from the port. b. Drain the urine from the catheter into a sterile container. c. Drain the urine from the collection bag into a sterile container. d. Discard the first specimen, clamp the catheter, then collect the next specimen. Name: ________________________ ID: A 14 ____ 79. The nurse notes that a client has a positive Chvostek's sign. Which additional manifestation supports this finding? a. Slowed capillary refill. b. Finger numbness and tingling. c. Dependent pitting edema. d. Unilateral pupillary dilation. ____ 80. Three days after surgery, a male client who had a laryngectomy has an elevated pulse and respiratory rates. His skin is dry to touch and he is beginning to thrash about in the bed. What intervention should the nurse implement first? a. Call the healthcare provider. b. Suction the client's tracheostomy. c. Apply restraints to the client's hands to prevent injury. d. Administer a sedative prescribed PRN for restlessness. ____ 81. The nurse administers acetaminophen (Tylenol) 650 mg orally to an elderly client who has diabetes and urosepsis, and whose oral temperature is 104° F (40° C). One hour later, the client is diaphoretic. Based on this finding, which intervention should the nurse implement? a. Obtain a repeat temperature. b. Administer a 200 ml IV fluid bolus of 0.9% normal saline. c. Assess the client's pain level using a 0 to 10 scale. d. Give the client a glass of fruit juice. ____ 82. The nurse administers two newly prescribed medications, isosorbide dinitrate (Isodril), a nitrate, and hydrochlorothiazide (HydroDIRUIL), a diuretic, to a client. Which follow-up assessment is most important for the nurse to perform? a. Observe the client's skin for bruising. b. Monitor the client's blood pressure. c. Assess the client's pedal pulses. d. Palpate the client's bladder. ____ 83. A 7-year-old child is admitted to the hospital with acute glomerulonephritis (AGN). When obtaining the nursing history, which finding should the nurse expect to obtain? a. A recent DPT immunization. b. A recent strep throat infection. c. Increased thirst and urination. d. High blood cholesterol levels on routine screening. ____ 84. A client with gout has been treated with allopurinol (Zyloprim) for approximately 6 months. What laboratory datum would indicate that this medication has been effective in treating gout? a. An increase in the urine glucocorticoid level. b. A therapeutic serum allopurinol level. c. A decrease in the serum uric acid level. d. An increase in the pH (alkalinity) of the urine. Name: ________________________ ID: A 15 ____ 85. The nurse is performing a chest assessment of a client with a long-standing history of chronic obstructive pulmonary disease (COPD) and identifies an anteroposterior-to-transverse chest diameter ratio of 1:1. What is the interpretive value of this finding? a. Normal chest wall parameters. b. Chest barreling resulting from chronic hyperinflation. c. Kyphotic posterior changes related to osteoporosis. d. Asymmetrical chest expansion due to atelectasis. ____ 86. What recommendation is best for the nurse to provide to an elderly client who is concerned about constipation? a. "Use stool softeners as needed for constipation." b. "Decrease fat content in your diet." c. "Increase fluid in your diet." d. "Use rectal glycerine suppositories when needed." ____ 87. A client with a permanent pacemaker develops loss of capture resulting in symptomatic sinus bradycardia at a rate of 38/minute. Which intravenous medication should the nurse prepare to administer immediately? a. Atenolol (Tenormin). b. Atropine sulfate (Atropine). c. Amiodarone (Cordarone). d. Adenosine (Adenocard). ____ 88. The nurse is evaluating preoperative teaching. What statement by the client indicates an understanding of the need to remain NPO prior to surgery? a. "I will be less likely to vomit after surgery." b. "There's less chance I will vomit during surgery." c. "My intestines need to be empty during surgery." d. "Less fluid will collect in my lungs." ____ 89. A 50-year-old male client tells the nurse that he is having difficulty starting his stream of urine and fears that he may have prostate cancer. The nurse's reply to this client should be based on what information? a. Early signs of prostate cancer include urinary frequency and blood in the urine. b. The client is exhibiting symptoms of benign prostatic hyperplasia. c. Unless the client is experiencing urinary retention, prostate cancer is not a likely possibility. d. A change in the stream of the urine is a common, age-related symptom, and does not need to be reported. ____ 90. The nurse plans to place a sensor for a pulse oximeter. Which placement ensures the best measurement of oxygen saturation? a. Right lower extremity with a 1+ pedal pulse. b. Left lower extremity with a 3+ dorsalis pedis pulse. c. Right upper extremity with 2+ pitting edema. d. Left upper extremity with capillary refill > 3 seconds. Name: ________________________ ID: A 16 ____ 91. The nurse is developing the plan of care for a client who is returning from surgery after a total colectomy and ileostomy. Which nursing diagnosis has the highest priority for this client during the immediate postoperative period? a. Risk for electrolyte imbalance related to ileostomy. b. Knowledge deficit related to surgical bowel diversion. c. Risk for sexual dysfunction related to pelvic nerve injury. d. Risk for impaired skin integrity related to fecal drainage. ____ 92. The healthcare provider prescribes 20% mannitol 100 g/24 hours to be administered via a subclavian catheter. Which assessment finding is most important for the nurse to evaluate when administering mannitol? a. Heart rate. b. Ankle circumference. c. Urinary output. d. Dietary intake. ____ 93. The home health nurse is visiting a client with heart failure. The client is receiving the cardiac glycoside digitalis (Digoxin) 0.25 mg PO daily. Which statement should indicate to the nurse that the client may be experiencing digitalis toxicity? a. "I feel sick to my stomach." b. "I've got a charley horse in the calf of my leg." c. "My gums seem to be getting thicker, and they bleed when I floss my teeth." d. "I've been so constipated lately." ____ 94. Which statement by the community health nurse is most helpful to an adult who is in a crisis situation? a. "I will be your primary resource person, and will gather the information you need to get through this situation." b. "Based on past coping, I believe you will be able to deal with future problems successfully." c. "I have a plan of action that I think will help you. Would you like to see if it will work for you?" d. "You seem to be more tense these days. Would you like to talk about the problem and how you are dealing with it?" ____ 95. The nurse asks a female client with a borderline personality disorder, "How do you feel about your children not coming to visit this weekend?" The client looks out the window and replies, "I really don't care." Which response is best for the nurse to provide? a. "I think you're lying and it bothers you that your children aren't coming." b. "I noticed you were looking out the window when discussing your feelings." c. "I think you should discuss your children not coming in the group meeting." d. "Why do you think your children didn't want to come visit you this weekend?" ____ 96. A client diagnosed with hypothyroidism has been taking the thyroid hormone levothyroxine (Synthroid) for three months. Which client statement warrants intervention by the nurse? a. "I have a bowel movement every other day." b. "I have lost ten pounds since I started this medication." c. "My hands seem to shake all the time." d. "I have a lot of energy and am less tired than before." Name: ________________________ ID: A 17 ____ 97. In caring for a client with a fracture of the femur, the nurse should be alert for compartment syndrome. What symptom is characteristic of this complication? a. Tachycardia and petechiae over the chest wall and buccal membranes. b. Deep, throbbing, unrelenting pain which is not controlled with opioids. c. Acute anxiety, diaphoresis, and elevated blood pressure. d. Positive Homan's sign with calf tenderness and warmth. ____ 98. A 30-week gestation primigravida complains of increased swelling in her lower extremities. Assessment findings include a blood pressure of 150/95 mmHg, repeated 142/92 mmHg 30 minutes later, respirations of 18 breaths/minute, pulse rate of 72 beats/minute, and 2+ pretibial pitting edema. Data obtained from which diagnostic test is most important in planning this client's care? a. Non-stress test with a biophysical profile. b. Amniocentesis to determine the lecithin-sphingomyelin ratio. c. A 24-hour urine specimen to determine total protein excreted. d. Complete blood count with differential. ____ 99. After ensuring an open airway and providing ventilation to a 6-month-old infant, the nurse determines that the infant's heart rate is in the 70s. What action should the nurse take? a. Prepare to administer epinephrine. b. Plan to use automatic defibrillator. c. Start chest compressions at rate of 5/1. d. Prepare to administer lidocaine. ____ 100. What instruction is most important for the nurse to provide a client with neutropenia? a. Take precautions to minimize bleeding. b. Schedule regular rest periods. c. Avoid exposure to excessive ultraviolet light. d. Avoid sources of potential infection. ____ 101. A new mother tells the nurse that she does not want her newborn to receive any immunizations. It is the hospital's policy to routinely administer immunizations to all newborns. What intervention should the nurse implement? a. Administer the immunizations after first explaining the hospital policy to the mother. b. Screen the baby for immunization sensitivity before administering the immunizations. c. Do not administer the immunizations and document that the mother has refused permission. d. Advise the mother to sign out of the hospital AMA if wishing to refuse the immunizations. Name: ________________________ ID: A 18 ____ 102. A "Code Pink" is announced over the hospital intercom system, indicating that a baby has been abducted from the nursery. What action should the charge nurse on a medical surgical unit implement first? a. Instruct the nursing staff to check every client's room, bathroom, and treatment room. b. Assign one staff member to stay at each of the emergency exits and stairwell doors. c. Stay alert for further announcements because a code pink primarily affects maternity units. d. Assign one UAP to report to the nursery to assist with the search. ____ 103. A 16-year-old female student, with a history of asthma controlled with both an oral antihistamine and an albuterol (Proventil) metered-dose inhaler (MDI), comes to the school nurse. The student complains that she cannot sleep at night, feels shaky, and her heart feels like it is "beating a mile a minute." Which information is most important for the nurse to obtain? a. How often the MDI is used daily. b. When her last asthma attack occurred. c. Duration of most asthma attacks. d. When she last took the antihistamine. ____ 104. A 13-year-old with nephrotic syndrome is receiving prednisone (Deltasone). What client teaching is most important for the nurse to provide? a. It is advisable to restrict dietary fat intake while taking this type of medication. b. When discontinuing the medication, follow the directions to reduce the dose gradually. c. Rounding of the face is a common side effect that will disappear when the medication is stopped. d. Increased hair growth and worsening of acne can occur during treatment with prednisone. ____ 105. A client is receiving morphine sulfate 1 mg q10 minutes with a lockout dose of 24 mg per 4 hours via an intravenous patient-controlled analgesia (PCA) pump. Which record, found on the PCA pump history, indicates that the client has used the PCA pump effectively during the previous hour? a. 1 attempt: 10 mg administered. b. 5 attempts: 5 mg administered. c. 4 attempts: 24 mg administered. d. 12 attempts: 6 mg administered. ____ 106. A postmenopausal client, who smokes a pack of cigarettes a day, is taking estrogen (Premarin) daily. What instruction should the nurse provide to this client? a. Do not stop the drug abruptly. b. Drink 8 glasses of fluid daily. c. Stop the drug if a beta-blocker or thiazide diuretic is prescribed. d. Observe for swelling and calf pain. Name: ________________________ ID: A 19 ____ 107. What is the best technique for the nurse to use when assessing for jaundice in a 48-hours-old infant? a. Lightly pinch the soft area of the chin. b. Press on the middle of the sternum. c. Palpate just below the umbilicus. d. Push gently on the vastus lateralis. ____ 108. A public health nurse teaching a class on diabetes plans to discuss risk factors for developing Type 2 diabetes. Which individual has the greatest risk for developing Type 2 diabetes? a. A 24-year-old Caucasian male whose father is a Type 2 diabetic. b. A 48-year-old Hispanic female who is 5' 2" and weighs 230 lbs. c. A 36-year-old Italian male who eats a diet high in carbohydrates. d. A 72-year-old African-American who has a history of hypertension. ____ 109. A client with an exacerbation of systemic lupus erythematosus (SLE) is admitted for parenteral corticosteroid therapy. What factor is most important for the nurse to consider when assigning a room for this client? The client a. needs a stimulating environment with sufficient lighting. b. should not share a room with a client who is immunocompromised. c. should not share a room with a client who has an infection. d. should share a room with a client with a similar cultural heritage. ____ 110. In caring for a client receiving normal saline solution via a central venous catheter, what action by the nurse is most important? a. Secure all the IV tubing connections. b. Keep the head of the bed elevated. c. Monitor the client's serum sodium. d. Assess the client's skin turgor. ____ 111. What statement, made by a client diagnosed with gastroesophageal reflux disease (GERD), indicates successful learning about management of the symptoms of GERD? a. "I should no longer participate in touch football games with my buddies." b. "I need to limit my carbonated beverages to three colas a day." c. "I will use a binder to support the weakened muscles until they heal." d. "I will place blocks under the head of my bed so it is elevated." ____ 112. A 6-year-old boy was hit with a bat while playing at school. He has a splinter of wood imbedded in his eye. Which action should the school nurse take? a. Rinse the eye and gently remove the object. b. Remove the object and patch the eye. c. Call the parent and send the child home. d. Have the parent take the child for emergency help. ____ 113. The nurse caring for a client with a closed chest drainage system notes a rise and fall of fluid in the water seal chamber. What action should the nurse take first? a. None because the system is functioning normally. b. Increase the amount of suction to promote drainage. c. Notify the healthcare provider that the chest tube is occluded. d. Clamp the chest tube and replace the drainage system. Name: ________________________ ID: A 20 ____ 114. A client who is receiving chemotherapy for lung cancer with brain metastasis is scheduled for cranial radiation therapy (RT) today. The nurse should provide which information about the procedure to the client? a. A radioisotope is implanted into the tumor that limits chemotherapy side effects for up to 30 days. b. Radiation precautions are implemented to limit exposure for everyone who enters the client's room. c. A high dose beam of radiation may cause a brief tingling sensation but will not cause pain. d. Skin markings and head positioning devices are used to ensure that only the tumor site is radiated. ____ 115. A child is admitted to the hospital with diarrhea and vomiting. Potassium chloride is prescribed for inclusion with rehydration IV fluids. Prior to administering the potassium, the nurse should ensure that which condition exits? a. The client has had no cardiac arrhythmias in the last 24 hours. b. The oxygen saturation level per pulse oximeter is greater than 95%. c. The client is able to void, assuring kidney function is present. d. The client has stopped vomiting before the potassium is added to the IV fluids. ____ 116. A 25-year-old female client, a dancer, has just had an ileostomy as a result of Crohn's disease. In evaluating the client's response to this life change, which behavior would indicate to the nurse that she is coping effectively? The client a. discusses modified costume designs. b. calls the nurse when her ostomy bag is half-full. c. asks the nurse to teach her mother how to do ostomy care. d. notifies her employer that she will return to work within one week of the surgery. ____ 117. In assessing community needs, which demographic variable is likely to have the greatest influence on the number of in-hospital beds needed in a community? a. The average age of residents in the community is 45.4 years. b. The heat index goes above 100° F at least ten days per year. c. The average educational level of residents in the community is 12 years. d. The main recreation in the area involves water activities at a local lake. ____ 118. A client has a history of dealing with depression by abusing substances, which results in extreme changes in mood and increased feelings of depression. Which problem should have the highest priority on the nursing problem list? a. Readiness for enhanced self-concept. b. Readiness for enhanced community coping. c. Knowledge deficit. d. Ineffective coping. Name: ________________________ ID: A 21 ____ 119. The mental health nurse receives morning shift report for five clients. All five clients need vital signs taken, two need an alcohol detoxification assessment completed as soon as possible, one needs belongings returned for discharge, and another wants to smoke a cigarette. Which activity should the nurse tell the unlicensed assistive personnel (UAP) to do first? a. Take morning vital signs. b. Observe for detoxification symptoms. c. Secure belongings for discharge. d. Accompany the client to smoke. ____ 120. A female nurse describes her social life, including alcohol drinking and sexual activities, at the nurses' station in a voice that can be heard by clients on the unit. What action is best for her co-worker to take? a. Report the situation to the nursing supervisor. b. Suggest to the nurse that she lower her voice. c. Tell the nurse that clients can hear her. d. Ask the colleague to change the topic. ____ 121. A 6-month-old male with bronchiolitis is admitted to the hospital. In monitoring the respiratory status of this child, which symptom indicates to the nurse that he is experiencing respiratory distress? a. Abdominal breathing. b. A high pitched cry. c. Dry, flushed skin. d. Respiratory rate of 62 breaths/minute. ____ 122. A 6-year-old was recently diagnosed with sickle cell anemia. When conducting family education about methods for preventing a sickle cell crisis, it is most important for the nurse to include which subject? a. Pain relief b. Platelet transfusion. c. Use of oxygen therapy at home. d. Maintenance of adequate hydration. ____ 123. The nurse is caring for a client who is on a ventilator. Which assessment finding indicates that the client is ready to be weaned off the ventilator? a. No significant drop in the oxygen saturation rates during tracheostomy care. b. The ventilator setting for respirations is the same as the client's respiratory rate. c. The client is demonstrating good inspiratory force. d. Breath sounds are clear and equal bilaterally. ____ 124. In assessing a client diagnosed with left-sided heart failure, the nurse observes new findings of jugular vein distention and pedal edema. What action should the nurse implement? a. Prepare to administer an intravenous vasoconstricting agent. b. Position the client in a left lateral Trendelenburg position. c. Advise the client that thrombolytic therapy will be started immediately. d. Notify the healthcare provider of the onset of right-sided failure Name: ________________________ ID: A 22 ____ 125. During a health assessment, a 79-year-old male client tells the nurse that he has no complaints about his health. Which finding requires further assessment by the nurse? a. Kyphosis with a reduction in height. b. Increase in diastolic blood pressure. c. An increased preference for spicy foods. d. Absence of the right nasolabial fold. ____ 126. The epidemiological triad can be used to frame strategies for the prevention of traffic injuries. Which action should the nurse initiate to focus on the host? a. Encourage driver's education in high school curriculums. b. Promote the improvement of road surfaces. c. Discuss the need for new stop signs near the library. d. Initiate a program for zero tolerance for speeding. ____ 127. Which nursing diagnosis has the highest priority when caring for a client receiving methylprednisolone (Solu-Medrol)? a. Body image disturbance related to cushingoid appearance. b. Altered nutrition, greater than body needs related to increased appetite. c. Self-care deficit related to muscle wasting. d. Risk for infection related to immunosuppression. ____ 128. The nurse assesses the contraction pattern of a client whose labor is being induced and finds that she is contracting every 1 to 1½ minutes with little relaxation between contractions. Which intervention should the nurse implement first? a. Turn off the oxytocin (Pitocin) drip. b. Turn the client to a side-lying position. c. Administer oxygen per face mask at 10 L/min. d. Notify the healthcare provider. ____ 129. The client in which situation requires the most immediate nursing intervention? a. Recent onset of migraines, experiencing vomiting and tinnitus. b. Diagnosed with Parkinson's disease, with new onset dyskinesia. c. Previously diagnosed with epilepsy, experiencing status epilepticus. d. History of multiple sclerosis, experiencing an acute relapse. ____ 130. The charge nurse in the Intensive Care Department is making client assignments. The team consists of 4 RNs of varying degrees of nursing experience. Which client should the charge nurse assign to the RN who graduated three months ago and just completed the internship program? The client a. with esophageal varices who has an inflated Sengstaken-Blakemore tube. b. with an acute exacerbation of Crohn's disease who is on hyperalimentation. c. complaining of shortness of breath who has a pulse oximeter reading of 90%. d. with acute diverticulitis who has a tender, hard, rigid abdomen and is febrile. Name: ________________________ ID: A 23 ____ 131. A client newly diagnosed with Type 1 diabetes received 28 units of Humulin N at 0700. The nurse is making rounds at 1330. Which client statement requires the most immediate follow-up intervention by the nurse? a. "I get so nervous when I have to give my shot." b. "I didn't sleep well last night. I am going to take a nap." c. "I get dizzy when I get up out of the bed too fast." d. "I let my wife eat my lunch since I wasn't hungry." ____ 132. The charge nurse is assessing the morning lab work on four clients. Which client's laboratory findings should prompt the charge nurse to contact the healthcare provider immediately? a. A 50-year-old diagnosed with myocardial infarction who has an elevated CPK-MB on serial cardiac isoenzymes. b. A 35-year-old diagnosed with pneumonia having a white blood cell (WBC) of 13,000 mm3. c. A 29-year-old diagnosed with ulcerative colitis having a serum potassium level of 3.1 mEq/L. d. A 74-year-old diagnosed with COPD who has ABGs of pH 7.35, PaC02 49, Pa02 74, HC03 26. ____ 133. The nurse is assessing a 2-week-old breastfeeding infant. To obtain information about adequate nutrition, which question should the nurse ask the breastfeeding mother? a. "How satisfied does the infant seem with each feeding?" b. "How long does the baby nurse at each feeding?" c. "How many times does the baby nurse in a 24-hour period?" d. "How many diapers does the infant wet daily?" ____ 134. An Italian-American client is being discharged from the hospital following surgical repair of a sacral pressure sore. Which Italian meal would be best for this client? a. Spaghetti marinara. b. Fettuccini alfredo. c. Spaghetti and meatballs. d. Eggplant parmesan. ____ 135. In evaluating a client's plan of care, the nurse determines that the goals were not achieved despite the implementation of the planned interventions. What should the nurse do next? a. Document that the care plan is invalid. b. Establish new priorities of care. c. Revise the nursing diagnoses. d. Modify any unrealistic expected outcomes. ____ 136. A client who had a craniotomy yesterday develops an oral temperature of 103° F. The nurse gives the client a tepid sponge bath. While instituting measures to reduce the client's fever, what additional action should be taken to prevent an increase in intracranial pressure? a. Maintain the client in a supine position. b. Check rectal temperature only. c. Measure urinary output q1h. d. Limit exposure to prevent shivering. Name: ________________________ ID: A 24 ____ 137. A 47-year-old fair-skinned female client is seeing the nurse for a well-woman exam. The nurse notes several discrete, smooth, dome-shaped red papules on the client's trunk and several light-brown smooth-surfaced lesions on the client's lower extremities. The client denies recent changes in the color or shape of the lesions, but admits to unprotected sun exposure, including blistering sunburns, during her youth. What are the mostly likely diagnoses for this client's lesions? a. Solar lentigo and sebaceous hyperplasia. b. Malignant melanoma and basal cell carcinoma. c. Cherry angiomas and actinic keratoses. d. Squamous cell carcinoma and dermatosis papulosa nigra. ____ 138. Which method of anchoring an intravenous infusion catheter demonstrates sound nursing judgment? a. Wrap a strip of tape around the entire circumference of the arm for the length of the catheter inserted. b. Use one strip of tape to secure the hub of the catheter and one strip of tape to secure the tubing. c. Elevate the hub of the catheter with a 2x2 gauze sponge, then tape the catheter and tube securely on the top of the extremity. d. Secure the catheter and place a sterile, transparent dressing over the skin insertion site. ____ 139. Two days following a colon resection and anastomosis, an adult client's abdomen is distended. The nurse notes that the Saleum sump nasogastric tube (NGT) to low intermittent suction has no drainage in the tubing, and the client has no bowel sounds. What action should the nurse take? a. Clamp the nasogastric tube while auscultating for paralytic ileus. b. Irrigate the NGT with 30 ml of normal saline then aspirate the fluid. c. Instill saline into the blue pigtail air vent of the NGT and connect to suction. d. Reinsert a new NGT to the documented length of the previous insertion. ____ 140. What intervention is most important to include in the nursing care plan of a client who is receiving chemotherapy and has a platelet count of 30,000/mm3? a. Place the client in reverse isolation. b. Frequently assess the client's blood pressure. c. Observe for signs of dehydration. d. Assess the client for abnormal bleeding. ____ 141. The nurse is responding to telephone messages at a psychiatric day clinic. Which client situation requires the most immediate intervention by the nurse? a. A young adult diagnosed with a somatoform disorder reports having a severe headache that has become unbearable. b. The wife of a client with post-traumatic stress syndrome reports that her husband is threatening to kill her. c. A client with depression who is crying and tells the nurse that he has had suicidal thoughts. d. An adult heroin abuser who reports the onset of withdrawal and requests a refill for a prescription for methadone. Name: ________________________ ID: A 25 ____ 142. The nurse is teaching a client about dietary measures to manage the symptoms of restless legs syndrome. Which evening beverage choice is best for this client to select? a. Hot chocolate. b. Lemonade. c. Diet cola. d. Iced tea. ____ 143. A 16-year-old female client diagnosed with acromegaly has been successfully treated for a pituitary neoplasm. She tells the nurse that she hates being five inches taller than the boys and is glad that she will stop growing. Based on the nursing diagnosis, "Altered body image," what is the best response for the nurse to provide? a. "Try to accept who you are now and be grateful that the therapy worked." b. "Why don't you like being tall? Basketball players and models are tall." c. "Boys continue to grow until about 20 years of age, and can become six feet and taller." d. "I understand that most women like to date men who are at least as tall as they are." ____ 144. The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non-English speaking male client. The client gives verbal consent and the healthcare provider leaves, instructing the nurse to witness the signature on the consent form. The client and interpreter then speak together in the foreign language for an additional 3 minutes until the interpreter concludes, "He says it is OK." What action should the nurse take next? a. Have the client sign the consent and the interpreter witness the signature. b. Have the client sign the consent and the nurse witness the signature. c. Ask the interpreter to explain the discussion that just took place. d. Validate the client's consent through the use of gestures and simple terms. ____ 145. A client with a cervical spinal cord injury is brought to the emergency center. What should be the nurse's priority assessment? a. Check the blood pressure. b. Assess the respiratory pattern. c. Obtain injury and health history. d. Assess ability to move extremities. ____ 146. In assessing a client who has just undergone a lung biopsy, the nurse is unable to auscultate breath sounds on the biopsied side and observes that the client is dyspneic and has slight hemoptysis. While contacting the healthcare provider to report these findings, what intervention should the nurse implement? a. Obtain a sputum specimen. b. Prepare the client for a chest x-ray. c. Assess for jugular vein distension. d. Position the client with feet elevated. Name: ________________________ ID: A 26 ____ 147. A man convicted of raping two women is included in a counseling group for sex offenders. What is the priority outcome for this client? a. Reports reduced anxiety related to social interactions. b. Obtains court permission to contact victims to apologize. c. Acknowledges control and humiliation as the motivation for rape. d. States sexual desire is significantly reduced following group sessions. ____ 148. A female college student tells the health center nurse that her male sexual partner has a positive urine test for chlamydia, but that she is symptom-free. Further assessment reveals that the couple frequently engages in unprotected sexual intercourse. The nurse prepares the client to implement which intervention? a. Initiate treatment with an antimicrobial oral medication. b. Recommend treatment for the partner with chlamydia. c. Use condoms during the infectious period. d. Screen for the duration of the asymptomatic period. ____ 149. Pain medication was administered one hour ago to a 3-year-old child who had a short arm cast applied to the left arm three hours ago. The child continues to cry, the fingers are cold and dusky, and the capillary refill is five seconds. Which intervention should the nurse implement? a. Prepare to bivalve the cast. b. Request a portable STAT x-ray. c. Administer additional pain medication. d. Assess the child's fingers hourly. ____ 150. What is the most important instruction for the nurse to provide to a 12-year-old who is receiving long-term and rescue medications for routine management of asthma? a. Drink a large amount of cold fluids after exercising to restore hydration. b. Avoid swimming, which increases the need for oxygen while underwater. c. Use albuterol (Proventil) for prevention of exercise-induced bronchospasm. d. Keep a prescription for a premeasured dose of epinephrine (Epipen) available ____ 151. While assisting a postpartum client with perineal care, the nurse notes that her vaginal bleeding spurts rather than trickles from the vagina. The uterine fundus is firm, and the client's vital signs are: pulse, 88 beats/minute; respiratory rate, 21 breaths/minute; and blood pressure, 104/68 mmHg. What action should the nurse take next? a. Palpate the bladder for distention. b. Compare current vital signs with previous vital signs. c. Initiate an hourly perineal pad count. d. Review the client's record for evidence of birth trauma. ____ 152. When evaluating the preoperative teaching of a client scheduled for arthroscopic anterior cruciate ligament repair, which statement by the client indicates that the teaching was effective? a. "I can use the trapeze bar and side rails on the bed to help me turn regularly." b. "I can put my full weight on my foot starting the day after surgery." c. "I will use crutches to keep my weight off my knee." d. "I will stay home until a wheelchair is delivered." Name: ________________________ ID: A 27 ____ 153. The nurse identifies that a bedfast female client has a nursing diagnosis of, "High risk for impaired skin integrity." Which serum laboratory finding best supports this nursing diagnosis? a. Hematocrit of 38%. b. Albumin of 2 mg/100 ml. c. Calcium of 12 mg/dl. d. White blood cell count of 6,500 mm3. ____ 154. What intervention should the postpartum nurse implement for a mother who is breastfeeding and complains of nipple soreness? a. Limit the time the infant nurses on each breast. b. Give supplemental formula until soreness lessens. c. Evaluate positioning and latch-on at next feeding. d. Obtain a breast pump for use until soreness subsides. ____ 155. The healthcare provider prescribes morphine sulfate sustained release tablets q12h for a client with cancer. It is important for the nurse to consult with the provider regarding the need for what additional medication? a. Calcium citrate (Citracal), a calcium supplement. b. Ducosate (Colace), a stool softener. c. Clopidogrel (Plavix), an antiplatelet agent. d. Sucralfate (Carafate), an antiulcer agent. Completion Complete each sentence or statement. 156. A client has a prescription for enoxaparin (Lovenox) 50 mg. The medication comes prepared in a syringe labeled "60 mg/0.6 ml." How many ml should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.) 157. The nurse plans to administer diphenhydramine (Benadryl) 37.5 mg IV to client who is experiencing pruritis. The medication is available in a 50 mg/ml vial. How many ml of the medication should the nurse waste? (Enter numerical value only. If rounding is required, round to the nearest hundredth.) 158. A child is to receive ampicillin 30 mg/kg/day divided equally every six hours. The child weighs 66 pounds. How many mg should the child receive with each dose of medication? (Enter numerical value only.) 159. The nurse is administering a 100 ml intravenous solution over 30 minutes. The infusion pump should be set to infuse how many ml per hour? (Enter numerical value only.) 160. The healthcare provider prescribes heparin 7,500 units subcutaneously. The cartridge is labeled 10,000 units/ml. How many ml should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest hundredth.) ID: A 1 TEST 2 Answer Section MULTIPLE CHOICE 1. ANS: C Docusate sodium (Colace) is a stool softener. Stool softeners and laxatives are contraindicated in clients experiencing abdominal pain of unknown etiology (C), since they may exacerbate an unknown problem. Stool softeners such as Colace are often used for (A and B) to prevent straining. (D) is not a contraindication for the use of Colace. 2. ANS: A A severe headache (A) is a symptom of autonomic dysreflexia, a possible life-threatening complication of quadriplegia, which is due to an exaggerated autonomic response that often is the result of a full bladder. A pressure ulcer and an elevated temperature (C) indicate some type of infection and need to be further assessed, but are not potentially life-threatening complications. Right-sided weakness is an expected complication of stroke (B). Constipation (D) does not have the priority of (A). 3. ANS: A The priority assessment is to determine the presence of command hallucinations (A), which may be encouraging the client to harm himself or others. (B, C, and D) are important evaluations, but they do not have the priority of (A). 4. ANS: B Chest physiotherapy (CPT) incorporates percussion to loosen secretions and various positions to facilitate gravitational drainage of secretions mobilized by percussion. CPT is best achieved with the head lower than the lung fields and a supine position (B) is not conducive for achieving the benefit of CPT. Administering a bronchodilator before CPT (A) helps to open the lower airways and facilitate removal of secretions. Using a cupped hand to percuss the chest wall provides adequate force (C) to loosen secretions in the bronchial tree. Performing CPT in the morning helps 5. ANS: D A decrease in the deep tendon reflexes occurs prior to respiratory depression, which is a sign of magnesium sulfate toxicity (D) and needs to be reported to the healthcare provider immediately. (A) needs to be monitored closely, but does not need to be reported immediately. (B and C) are not related to the administration of magnesium sulfate. 6. ANS: B Chest pain or pressure is usually cardiac in origin, plus diaphoresis and nausea point to myocardial infarction (MI), which can be life-threatening and must be ruled out first (B). The client with (A) is likely to have a gastrointestinal problem, which is not life-threatening. The client with (C) presents a pattern more consistent with asthma or bronchoconstriction, which can be life-threatening if not treated, but does not have the priority of cardiac damage. (D) is indicative of thrombophlebitis, which can result in a potentially life-threatening pulmonary embolism (PE), but signs of a PE are not described. ID: A 2 7. ANS: A Since the client is speaking, he is not likely to be experiencing low oxygen levels, and assessing the blood glucose level can be done quickly, using a finger-stick, to determine if this is the etiology of the client's behavior (A). The brain is the most sensitive organ to abnormally low oxygen and glucose. (B, C, and D), if needed, can be done later. 8. ANS: A A score of 7 would indicate that the client was in a coma and a score of 3 to 4 indicates a very poor prognosis (A). The Glasgow Coma Scale is an objective documentation of level of consciousness. A maximum score of 15 and a minimum score of 3 can be obtained; the lower the score, the poorer the condition of the client. (B and C) reflect an inaccurate analysis of the data provided by the scale. This scale is not a measure of increased intracranial pressure (D). 9. ANS: A This is a normal and expected change, indicating a decrease in bloody drainage. The only nursing action warranted is continued monitoring (A). (B and C) would be appropriate if the sanguineous drainage was increasing. (D) would be appropriate if purulent drainage, indicating an infection, was present. 10. ANS: D It is paramount that the client remain immobile during the procedure (D) to prevent movement of the thoracentesis needle which could result in a pneumothorax. The client is usually awake and is positioned upright during the procedure. (A) is not necessary. The procedure is frequently done at the bedside or in a treatment room. Unless declared incompetent, the client should sign his/her own consent form (B). (C) is not specifically indicated for this procedure, but the nurse should be alert for any allergies to local anesthetics or skin antiseptics (Betadine). 11. ANS: B (B) has the highest priority, in that hemorrhage could be life-threatening. It takes 72 hours for (A) to occur. (C and D) are important, but do not at this time have the same serious implications as (B). 12. ANS: C Hyperinflation with 100% oxygen (C) helps minimize hypoxia and atelectasis during the suctioning procedure, so the nurse should take this action first, before (A, B, or D). 13. ANS: A Indications of overt bleeding such as a hemoccult positive test on the client's stool sample (A) support the need for administration of vitamin K, because the administration of vitamin K promotes improvement in clotting times. (B, C, and D) are conditions associated with cirrhosis, but are not treated by the administration of vitamin K. 14. ANS: B To break the suction that holds the plate to the roof of the mouth, the nurse should move the plate up and down slightly (B). The dentures are cleaned after removal (A). Hot water (C) may change the shape of some dentures. (D) is not needed to safely remove dentures. 15. ANS: C The nurse needs to determine if the client's ovaries were also removed (bilateral oophorectomy) (C), since this would result in the onset of menopausal symptoms such as hot flashes. As long as the client's ovaries are intact, (A, B, and D) will not impact the onset of menopausal symptoms. ID: A 3 16. ANS: B Causes of acute renal failure that are classified as "renal" are those directly involving the kidneys (B), such as glomerulonephritis or carcinoma of the kidneys. (A) is "prerenal" which refers to causes of reduced blood flow to the kidneys that occur before the blood gets to the kidneys, such as hemorrhage or arterial occlusion. (C and D) are "postrenal" causes which refer to blockages that occur after the urine leaves the kidneys, such as blocked ureters or bladder passages. 17. ANS: B Isoniazid (INH) is used for prevention of TB (B). Only 1 out of 10 persons with a positive tuberculin test will ever develop active TB (A), and the incidence is much lower among those who receive preventive therapy with INH. Night sweats caused by an increased temperature is a cardinal sign of TB--not a mid-morning increased temperature (C). A tuberculin skin test is effective 8 to 12 weeks after an exposure (D)--it takes this long for the client to convert from a negative to a positive reaction. 18. ANS: C During breastfeeding, oxytocin is released and will cause uterine contractions and cramping (C). This process speeds up the natural process of involution (B). In the case of a retained placenta, the most notable complaint is excessive bleeding (A). An ileus would not likely occur after a vaginal delivery (D), but would be more likely to occur following a caesarian section. 19. ANS: C With severe ascites, eight liters or more of fluid can accumulate in the peritoneal space, causing pressure on the diaphragm, which can result in ineffective breathing (C) (the priority concern). Though (A) will most likely be problematic, it does not have the priority of maintaining an open airway (several pillows under the head and a Semi-Fowler's position are helpful in promoting sleep for clients with ascites). (B and D) are psychosocial needs (addressed through listening and offering verbal support), but again do not have the priority of (C). 20. ANS: B The source of AFP in amniotic fluid is fetal urine and some of the protein crosses fetal membranes into maternal circulation. Elevated levels are associated with neural tube defects, such as spina bifida and anencephaly. AFP is a screening test (B) and is not a determination of the existence or non-existence of such defects (A). (C) is determined by a lecithin/sphingomyelin (L/S) ratio (greater than 2:1 indicates adequate lung maturity for extrauterine life). Genetic studies of amniotic fluid provide information about the existence of Tay-Sachs disease (D). 21. ANS: D Checking the feet (D) is essential to detect early signs of skin breakdown and prevent ulcer formation. Cool temperatures (A) cause vasoconstriction and should be avoided by those with peripheral arterial disease. Elevating the legs is more consistent with interventions for venous disorders and may decrease arterial circulation to the affected extremities (B). The client should rest, rather than keep moving, if leg pain occurs (C) to reduce the risk of worsening ischemic changes. ID: A 4 22. ANS: B Noncompliance (B) is the most common cause of seizure activity; sudden withdrawal from anticonvulsant therapy will bring on status epilepticus. (A, C, and D) could be correct; however, based on this client's age (a teenager), the best answer is (B). As an act of rebellion, teenagers sometimes stop taking their medication. 23. ANS: B The goal in this maneuver is to keep the operated hip as immobile and uncompromised as possible. It is less painful and dangerous for her to roll toward the unoperated side (B). Any action which allows her to put pressure on the right leg and hip is prohibited (A, C, and D), because this type of action can cause the prosthesis to dislodge. 24. ANS: A Abdominal pain, tenderness, and rigidity (A) are signs and symptoms of peritonitis, which is the most common and most serious complication associated with peritoneal dialysis. Clear dialysate drainage is a desired outcome of peritoneal dialysis (cloudy drainage indicates an infection), and burning on urination is a sign of a urinary tract infection (B). (C) is used with hemodialysis. A decreased (not increased) serum albumin level is a complication of peritoneal dialysis (D). 25. ANS: B The authority to promulgate rules and regulations that have the weight of law is delegated to a state's Board of Nursing by the state legislature, so the nurse should try and meet with the legislative representatives (B). Anonymous letters (A) generally have little validity and are unlikely to be influential. The American Nurses' Association (C) is a professional organization that lobbies for change, but has no direct authority over state Boards of Nursing. (D) may impact the agency's policies, but will not impact rulings of the state Board of Nursing. 26. ANS: D Describing the medication regimen correctly (D) offers the most objective assessment of learning. The client's behaviors are appropriate to her cultural values of showing respect, and do not indicate anxiety or lack of confidence (A and B). (C) is a more subjective measure of learning than (D). 27. ANS: D Since the client skipped lunch, the nurse's priority action should be to provide the client with food immediately (D). Humulin N, an intermediate acting insulin, peaks in 6 to 8 hours, so the client must have lunch to prevent hypoglycemia. (A and B) do not warrant immediate intervention by the nurse. (C) needs to be addressed, but it does not have the priority of preventing hypoglycemia. 28. ANS: B The priority nursing problem is risk for self-harm (B) because safety, even if it is only a risk, should be a priority nursing problem. (A) may be important to address prior to discharge. (C and D) are important problems, but safety is the priority concern. 29. ANS: D Nephrotic syndrome results in massive proteinuria, edema, and hypoalbuminemia, so a decreased proteinuria indicates that the medication is effective (D). (A and B) are not seriously altered by the nephrotic syndrome, nor are they changed significantly by the use of prednisone (Cortef). An increase, not a decrease, in the client's serum albumin indicates that the medication is having the desired effect (C). ID: A 5 30. ANS: A An asymmetric Moro response at birth (A) could indicate an injury to the brachial plexus, clavicle, or humerus. The Moro, or startle reflex, is a symmetric abduction and extension of the arms with the fingers fanning outward. Usually a slight tremor can be noted. This reflex is present at birth and is an indication of neurological integrity. Absence of (B) indicates spinal cord lesion or CNS depression. Absence of (C) occurs with neurological deficits. (D) can be normally absent or incomplete immediately after birth. 31. ANS: A Increased peak flow meter rates (A) indicate an improvement of the client's air flow, meaning the medication is having the desired effect. (B, C, and D) all indicate worsening of the asthma symptoms. 32. ANS: C Stool with a black tarry appearance indicates the presence of bleeding in the GI tract so it is most important for the nurse to monitor lab values that reflect the degree of hemorrhage, such as hemoglobin and hematocrit (C). (A, B, and D) are of less importance at this time than (C). 33. ANS: A Clients who lose both neurologic function and autonomic tone below the level of a spinal cord injury are in a state of spinal shock. In addition to flaccid paralysis and loss of sensory input as well as deep tendon reflexes, these clients are often bradycardic and hypotensive (A). (B, C, and D) do not include symptoms characteristic of spinal shock. 34. ANS: D Although all of these nursing diagnoses may be important for the client receiving corticosteroids, the risk for infection (D) places the client at highest risk for life-threatening problems, and this reflects the highest priority when planning nursing care. (A, B, and C) should also be used in the plan of care for this client, but do not have the priority of (D). 35. ANS: A 1.2 grams = 1,200 mg. The client currently takes 1,600 mg (8 x 200). The client is currently receiving 400 mg in excess of the needed amount. Since each tablet is 200 mg, the client should reduce intake by 2 tablets (A). (B) will provide a daily dose of only 800 mg. (C) provides 1,600 mg. (D) provides 2,000 mg, or 2 grams. 36. ANS: D The nurse should first inquire about the purpose and use of the herbs (D) and clarify their cultural implications. Removing the herbs without communicating with the client does not honor the client's beliefs regarding folk medicine and may be regarded as an invasion of privacy, especially if the nurse disposes of them (A). Many herbal medicines interact with prescriptions and are not allowed without the healthcare provider's prescription (B). The nurse may refer the family to the charge nurse (D), after initially inquiring about the client's intended purpose for the herbal therapy. 37. ANS: C Clear fluid draining from the nose (C) is an indicator of skull trauma or CNS damage resulting in leakage of spinal fluid and requires immediate further evaluation. (A, B, and D) are all expected manifestations following a nasal fracture. ID: A 6 38. ANS: D Phenylalanine, an essential amino acid, is found in protein-containing foods, especially milk, dairy products such as cheese (D), and meat. Fruits, vegetables, and breads are low in phenylalanine. (A), or fruit in general, is allowed on a phenylalanine diet. (B) is high in fat and has little food value, but is within the dietary restrictions. (C) would be allowed on a low phenylalanine diet. 39. ANS: B If a pulmonary embolism (PE) occurs, the client frequently experiences chest pain and tachypnea due to the alterations in ventilation and perfusion within the pulmonary system (B). (A) lists signs/symptoms of infection at the surgical site. (C) may be indicative of internal hemorrhaging. (D) lists symptoms of the deep vein thrombosis (DVT) that initially caused the PE. 40. ANS: A (A) is an honest answer that provides reassurance that everything possible is being done at that time. Although (B) is very likely an honest answer, it is not as reassuring as (A). (C) is dishonest. (D) avoids answering the client's question. 41. ANS: A When the bacterium Clostridium Difficile is present, the client should be placed in enteric isolation (A), which protects against infections being transmitted by direct or indirect contact with fecal material. (C) is not indicated. The nurse should instruct the client to use excellent handwashing when handling her infant, but (B) is not necessary. The client should be allowed to have visitors (D), but good handwashing should be encouraged and visitors should be prohibited from using the toilet in the client's room. 42. ANS: C Screening programs (C) are considered secondary prevention because they provide early identification of a health problem so that early treatment can be obtained, which assists in minimizing the detrimental health effects associated with the problem. Educational programs (A and D) are considered primary prevention, which is designed to prevent associated health problems from ever occurring. Anticipatory guidance (B) is considered educational preparation, and as such is primary prevention. 43. ANS: D The nurse should first assess the extent to which clients' culture influences their beliefs about food and pregnancy (D). (A, B, and C) are ways to incorporate clients' beliefs about food and teach about nutrition during pregnancy, but the nurse must first assess how, or if, the clients' cultures affects their food choices. It is also important to individualize care for each person within a specific culture, because they may not have the same beliefs about food and pregnancy as others. 44. ANS: A It is most important for the nurse to establish that the goal was achieved (A) because lack of goal achievement requires revision of the plan of care. (B, C, and D) all provide useful information about the effectiveness of the plan of care, but if the goal was achieved, are of less immediate relevance than (A). 45. ANS: C Procardia improves the blood supply to the myocardium by dilating coronary arteries and decreasing the workload of the heart (C). (A) is the purpose of anticoagulants, and (B) of atropine. (D) is the result of sympathetic stimulation of beta receptors. ID: A 7 46. ANS: D A client with polyuria voids excessive amounts of urine, increasing the risk for fluid volume deficit (D). A client with (A) voids often, but in small amounts. (B) refers to painful urination. (C) refers to repeated involuntary urination, but not with excessive output. 47. ANS: A Indications of a rupturing AAA include a constant intense back pain, hypotension, and decreasing hematocrit (A). Low back pain is a serious symptom for a client with AAA, usually indicating that the aneurysm is expanding rapidly and is about to rupture. (B) are important data for a client with an infection. (C) might be particularly related to a client with pancreatitis or liver disease. (D) might be important information for a client with a thyroid condition. 48. ANS: B Goiter is an enlargement of the thyroid gland caused by a deficiency of iodine, and iodine is involved in the synthesis of the thyroid hormone thyroxine. Iodized table salt (B) contains 76 mcg of iodine per 1 gram of salt and is a reliable source of iodine. (A) is an excellent source of zinc, (C) is a recommended source of iron, and (D) contains magnesium. 49. ANS: A Tylenol is extensively metabolized in the liver; ALT is a liver enzyme, and an elevation is a concern because it reflects liver tissue damage (A). (B) are pancreatic enzymes, and are not related to administration of Tylenol. G-6-PD (C) is an erythrocyte enzyme and FEP detects iron deficiency: both can lead to anemia. (D) is seen in chronic malnutrition (alcoholism), diarrhea, or diabetes, but is not a primary indication of liver or kidney function. 50. ANS: A To prevent potential electrical injury to others, the pump should be labeled as defective (A) and returned to the bioengineering department. Leaving the pump in the room and unlabeled places the nurse (B) or others (C and D) in danger. 51. ANS: D Early ambulation (D) increases venous return and prevents thrombophlebitis. Clotting factors are normally elevated in the postpartum period to heal the placental site, thereby predisposing clients to thrombus formation. (A and B) are treatment measures for thrombophlebitis. (C) helps identify the client at risk of thrombophlebitis. 52. ANS: B The symptom of voiding cloudy urine, at frequent intervals, in small amounts (B) is abnormal and may indicate urinary retention and infection. (A, B, and C) are all normal variations of urinary output based on either micturition or catheterization. 53. ANS: C Typically, Raynaud's disease is exhibited by pallor brought on by vasoconstriction, so anything that causes vasoconstriction should be avoided (C). (A) is the primary objective in treatment of atherosclerotic peripheral vascular disease. (B) would cause vasoconstriction, which is contraindicated, and is not related to increasing cardiac output. (D) is true, but this is not the primary objective in treatment of Raynaud's disease. ID: A 8 54. ANS: A These are symptoms of psychosis (A), which include disorganized speech, disorganized behavior, and delusions--in this case about her infant. (B and C) can result from psychosocial stresses such as childbirth, but these symptoms indicate a break with reality, which is an indication of psychosis. The client is experiencing paranoid ideation, but (D) is an ongoing pattern of behavior--this client is experiencing one episode. 55. ANS: C Scheduling necessary and physically demanding tasks in the morning (C) helps increase success in performing those tasks because muscles are generally strongest in the morning and deteriorate throughout the day. The primary feature of myasthenia gravis is fluctuating weakness of skeletal muscles. Rest generally restores muscle strength and (A and D) should be avoided. Sensation is unaffected, so (B) is unwarranted. 56. ANS: B The school-aged child enjoys companionship, and play is typically competitive. A board game (B) meets both needs. (A and D) are activities that are more appropriate for preschoolers. Since (C) is a passive activity, this is not the best choice. 57. ANS: A The highest priority is to monitor urinary output (A) because postoperative complications may include urethral obstruction from swelling or a blood clot. (B, C, and D) are also important postoperative nursing actions, but do not have the priority of (A) for this client. 58. ANS: D Chemotherapy typically results in neutropenia, making infection a frequent cause of death for clients with cancer. (D) best defines the risk involved. It is important to report (A), which may or may not be an indication of a local infection. (B) is an incorrect understanding, because neutropenic clients frequently do not exhibit the classic signs of infection. Once the client is no longer immunocompromised, the risk for infection returns to normal (C). 59. ANS: D The nurse should continue to observe the client carefully (D), as any client receiving blood should be observed. The client's vital signs are within normal limits. The blood types are compatible because Type O negative is the universal donor and since this client is positive, he can receive O+ blood. (A and B) would be indicated if the client exhibited signs of a transfusion reaction such as an increased temperature, chills, etc. (C) is not indicated. 60. ANS: A A urine specimen should be obtained from the tubing port to ensure a fresh, sterile specimen. This may require clamping the tubing (A) until urine is present in the tubing. Removing the specimen from the drainage bag increases the risk of obtaining a contaminated specimen (B). (C) will dilute any specimen obtained. A break in the closed system (D) increases the client's risk for infection. 61. ANS: D The discomfort associated with restless legs syndrome most commonly manifests at night when the client is sedentary, frequently resulting in sleep disruptions (D). (A, B, and C) are problems not commonly associated with this syndrome. 62. ANS: B First, the nurse should observe the results of the enema (B) before implementing (C or D). (A) is not necessary unless the client expresses symptoms indicating a problem after the enema. ID: A 9 63. ANS: A The nurse should ask the mental health technician to search the client's belongings (A). (B, C, and D) should be completed by the nurse because they require nursing judgment. 64. ANS: A Manic clients are manipulative and attention seeking. Setting firm limits (A) and being consistent in the consequences related to these limits assists in decreasing manipulative behaviors. (B) is needed when the client is delusional (in such cases, antipsychotic medications would be needed). This client is in the manic phase and does not need (C), but rather the reverse. Although (D) is an important part of this client's care, it does not have the priority of (A) for the initial plan of care. 65. ANS: C A potassium level of 3.1 mEq/L (C) is below the normal of 3.5 to 5.5 mEq/L so the client is at risk for cardiac dysrhythmias, and needs potassium replacement immediately. (A) would be expected following an MI. (B) also shows an expected finding. (D) is typical for a client with COPD. 66. ANS: D Since a pressure dressing is applied over the catheter insertion site to prevent postprocedure bleeding, assessment of the pressure dressing by the nurse is a priority (D). (A and B) can be completed during routine assessment of the client. Since the client is alert, (C) can be implemented, but this does not have the same priority as (D). 67. ANS: A The epidemiological triad includes agent, host, and environment. Encouraging driver's education (A) influences students, i. e., the host, in terms of the triad. (B and C) are related to environment, and (D) conveys actions about the agent. 68. ANS: C Applying light, cold compresses over the eyes causes vasoconstriction, thereby decreasing edema (C). (A) causes vasodilatation; thereby increasing edema. (B) will not help decrease periorbital edema; but will increase sensory deprivation. The client should be in a semi-Fowler's position to facilitate drainage, not Trendelenburg (D). 69. ANS: D Nonmalfeasance is the ethical concept that focuses on doing no harm. By recognizing the need for a more experienced nurse to perform a difficult and potentially harmful procedure (D), the nurse demonstrates this ethical principle. (A, B, and C) are important nursing actions, but do not reflect this ethical concept. 70. ANS: C (C) allows the nurse to explore the client's degree of knowledge of his problem so that planning can proceed from this point. (A) is "preaching," the client knows he should stop drinking. (B) is patronizing, and unless the nurse is an alcoholic suffering cirrhosis, he or she cannot "understand" what the client is going through. (D) offers an option (the counselor), but providing information about "why" the client should quit drinking is probably not the problem. ID: A 10 71. ANS: D The nurse should treat the client's pain (D) even though the left foot has been amputated; the pain is due to irritation and edema at the amputated site. Pain may occur as a result of the surgery, or it can be an indication of other complications. (A) negates the client's perception of pain. (B) will not decrease pain, and if no complications are noted, it is not necessary to notify the healthcare provider immediately. The pain must be controlled first, then relaxation tapes might be introduced to calm the client after the pain medication has been administered (C). 72. ANS: C Vital signs (C) provide the most critical information for a client with suspected shock, and provide the basis for initial treatment of the client. (A, B, and D) will provide additional information, but are of lesser priority than (C). 73. ANS: A Applying gentle counterpressure to the fetal head (A) will guide the birth and will prevent a rapid change in fetal intracranial pressure as well as help prevent perineal tearing. (B) is not a priority over protecting the fetus from injury and there will not be time for warm packs to soften the perineum before the birth. (C) would only hasten the birth and cause potential problems such as lodging the anterior shoulder under the pubic bone. (D) is indicated in umbilical cord prolapse, but this is not an identified problem in this situation. 74. ANS: A Citrate prevents banked blood from clotting, but it also reduces the ionized calcium levels in the blood, which can cause an increased parathyroid hormone, affecting bone calcium stores, if calcium is not replaced (A). (B, C, and D) do not correctly describe the effect of calcium depletion caused by the preservative, citrate, in banked blood. 75. ANS: D The Joint Commission of Accreditation of Hospital Organizations (JCAHO) National Patient Safety Goals requires two forms of identification when administering medications, which may include the client's name, the hospital identification number on the wrist band, or asking the client's date of birth (D). (A) is demeaning to the nurse and causes the client to lose confidence in the nurse. The charge nurse should take action (B) to correct the nurse's behavior according to policy. (C) should be completed if the medication is not administered as prescribed. 76. ANS: B Isomil (B) is a soybean-based formula used with infants who are allergic to milk. (A) is a low phenylalanine formula and is used for infants with PKU. (C) is a milk-based formula. (D) is inappropriate because it too contains milk. 77. ANS: A Acute pain (A), the client's highest priority problem, must be addressed first because until it is alleviated, interventions directed at the other diagnoses are not likely to be effective. (B) is occurring, but is secondary to (A). (C) reflects a high normal, but does not indicate acute distress and should decrease as the client's pain is controlled. (D) will be addressed as part of holistic nursing care, but this may be done after the priority diagnosis is addressed. 78. ANS: B B) provides effective sterile specimen collection. A straight catheter does not have a port or collection bag (A or C). (D) is not necessary and increases the risk of infection by leaving the catheter inserted for a prolonged period of time. ID: A 11 79. ANS: B A positive Chvostek's sign may be an indicator of hypocalcemia or hypomagnesemia. (B) lists other manifestations of hypocalcemia. (A, C, and D) are not manifestations of either condition. 80. ANS: B The nurse's first action should be to suction the tracheostomy (B), and then reassess the client. An elevated pulse and respiratory rate are often indications of airway obstruction caused by secretions in the trachea. (A and C) are overreactions to the situation described. (D) may be appropriate if suctioning does not relieve the restlessness, but (B) should be the first action taken. 81. ANS: A The peak effect of acetaminophen's antipyretic actions (peripheral vasodilation, sweating, and dissipation of heat) is 30 minutes to 2 hours after administration. The client's temperature has probably lowered (A). There is no evidence of dehydration or shock, both of which would necessitate the administration of fluids (B). There is no evidence that the client is in pain, so the analgesic effect of acetaminophen was probably already experienced (C). No signs of hypoglycemia are described, which if present might necessitate the administration of fruit juice (D). 82. ANS: B The additive effects of concomitant use of nitrates, such as Isordil, which produce vasodilation, and diuretics, such as HydroDIRUIL, which reduce blood volume, can cause hypotension, so it is important to monitor the client's blood pressure (B) during such treatment. (A, C, and D) provide less useful information related to the administration of these medications. 83. ANS: B AGN, an immune complex disease, frequently occurs 10 to 14 days following a Group A, beta-hemolytic streptococcal infection (B). There is no correlation between AGN and (A and D). (C) is indicative of diabetes mellitus. 84. ANS: C A decrease in serum uric acid indicates that the medication is effective in treating the gout (C). Gout occurs when the uric acid production exceeds its excretion by the kidneys. As a result, sodium urate is deposited in synovium and other tissues, causing pain and inflammation. (A) is not affected by antigout medications. (B) is not routinely assessed with standard laboratory analysis. Allopurinol (Zyloprim) does affect (D), although increased purine intake increases the excretion of urates, which can decrease urine pH. 85. ANS: B COPD produces a barrel chest, which increases the AP diameter of the chest (B) due to long-standing increased functional residual capacity. The normal thoracic configuration is elliptical with an anteroposterior-to-transverse diameter of 1:2 or 5:7 (A). Kyphosis is an exaggerated posterior thoracic curvature of the spine (C). The expansion of the chest is likely to be decreased, but symmetrical (D) in those with COPD. 86. ANS: C Fluid (C) assists in moving food quickly through the intestines, thereby preventing constipation. (A and D) are not the best recommendations because they are treatments, not preventive measures. (B) might help reduce serum cholesterol, but does not affect constipation. ID: A 12 87. ANS: B IV push atropine sulfate (B) is used to increase the client's heart rate, and should be given immediately. (A, C and D) are not used in the treatment of sinus bradycardia. 88. ANS: B The primary reason for NPO status is to ensure that the stomach is empty during surgery, to prevent vomiting and possible aspiration while the client is unconscious (B). (A) is a secondary benefit. Enemas and laxatives are used if the intestines need to be cleansed prior to surgery, so (C) is incorrect. (D) is not related to NPO status. 89. ANS: B Benign prostatic hyperplasia (B) is often first noted by the client as a change in the stream of urine or dysuria. Prostate cancer is asymptomatic in the early stages, and males over the age of 40 should be counseled to have annual digital exams and a serum PSA to help with early detection. (A) lists signs of a bladder infection. (C) is a late sign of both BPH and prostatic cancer. All changes in urinary patterns need to be reported to the healthcare provider (D). 90. ANS: B A pulse oximeter must be placed on a site with good arterial circulation. (B) demonstrates a site with a strong peripheral pulse. (A) indicates a weak pulse. (C) may lessen the accuracy of the oximeter reading. (D) indicates a site with decreased circulation (capillary refill should be < 3 seconds). 91. ANS: A A client with an ileostomy post total colectomy is at risk for fluid and electrolyte imbalance (A). During the initial postoperative period, the reabsorptive process of the large intestine is lost, and the ileum has not adapted in fluid and electrolyte homeostatic process. Once peristalsis returns, an ileostomy will have a high volume output, placing the client at risk for fluid volume deficits. (B, C, and D) are diagnoses that are addressed when ileal output returns and the client is ready to assume self-care. 92. ANS: C Mannitol is a diuretic, and infusion must be stopped if urinary output (C) is low, because congestive heart failure and fluid volume overload could result. By the time mannitol affects (A), it may be too late to reverse the problem. (B) may be an indicator of edema, but does not provide a specific evaluation of mannitol effectiveness. (D) is essential in monitoring a client with renal failure, but is not directly related to administration of mannitol. 93. ANS: A The most common symptoms of digitalis toxicity are anorexia, nausea, and vomiting (A). (B) is a symptom of hypokalemia, possibly due to a drug such as a loop diuretic. Digitalis is not associated with (C or D). 94. ANS: D D) acknowledges the stress and encourages the client to discuss options to deal with the problems. Recognizing early signs/symptoms of heightened stress can help to avert a crisis. (A and C) deny the client the opportunity to take control of the problem and use problem solving techniques to resolve the situation. (B) may be offering false reassurance. ID: A 13 95. ANS: B The nurse should give feedback about non-verbal behavior (B) because those with borderline personality disorders usually lack communication skills, such as maintaining eye contact, active listening, and taking turns. The nurse is responsible for teaching the client these basic communication skills. (A) is a hostile, accusatory response. (C) is not addressing the client's current behavior. Asking the client for a reason why (D) is not a therapeutic response. 96. ANS: C Fine hand tremors are a symptom of hyperthyroidism, which indicates that the prescribed dose of levothyroxine (Synthroid) (C) is too high. The nurse should notify the healthcare provider so that the dosage can be adjusted. The client reported a regular bowel pattern (A) which does not indicate a need for intervention. Weight gain occurs with hypothyroidism, so a ten-pound weight-loss over a three month period would be expected as the client achieves an euthyroid state (B). (D) is an expected outcome. 97. ANS: B B) describes symptoms associated with compartment syndrome, which is a problem that develops when tissue perfusion in the muscles is less than that required for tissue viability. Permanent function can be lost if the situation continues for more than 6 to 8 hours. (A) is indicative of a fat embolism, (C) of cast syndrome, which occurs in clients immobilized in large casts, and (D) of deep vein thrombosis. 98. ANS: C It is most important to monitor for pregnancy induced hypertension (PIH) or preeclampsia, which is indicated by a blood pressure of 140/90 mm Hg or higher in women of 20 or more weeks gestation and 0.3 grams of protein in a 24-hour urine specimen collection (C). (A and B) are used to determine fetal well-being, but first PIH should be ruled out. (D) is used to monitor for hemoconcentration and a low platelet count, which are indications of HELLP syndrome, a life-threatening sequela of PIH. 99. ANS: A Bradycardia in infants is typically caused by vagal stimulation, hypoxia, or increased intracranial pressure and usually responds to ventilation. According to AHA guidelines, the next nursing action should be preparing to give epinephrine (A) or atropine. (B) is used for other arrhythmias, not bradycardia. The infant has a heart beat so (C) is not needed yet. (D) is used for ventricular arrhythmias rather than bradycardia. 100. ANS: D Neutrophils are a type of white blood cell needed to fight infection, so a lack of neutrophils (neutropenia) would require that the client avoid sources of potential infection (D). (A) is an instruction that might be given to a client with a prolonged bleeding time. (B) might be helpful to a client with anemia, or decreased hemoglobin. (C) would be indicated for a client with lupus or a client taking certain drugs, such as thorazine. 101. ANS: C Parental rights supersede hospital protocol (C) and the mother's wishes should be respected. (A, B, and D) do not consider the mother's rights. ID: A 14 102. ANS: B In the event of a baby abduction, the charge nurse should secure all exits on the medical surgical unit by assigning staff members to physically remain at the doorways until the alert has been cancelled (B). Staff members may discretely check rooms on the unit, but only after the exits have been adequately covered (A). All hospital employees in all departments are affected by the alert, and should notify security officers of suspicious persons in their areas (C). (D) is likely to increase confusion. 103. ANS: A Insomnia, tremors, tachycardia, and anxiety occur with overuse of this beta agonist albuterol MDI, so it is most important for the school nurse to determine the number of times the student uses the MDI daily (A). (B, C, and D) provide pertinent information in managing asthma, but do not account for the symptoms the adolescent is describing. 104. ANS: B Although all of these provide important and correct information, it is most important that the client understand that the dose of corticosteroid medication must be reduced gradually to prevent potentially serious complications, such as adrenal insufficiency, resulting from corticosteroid withdrawal (B). Since corticosteroids often cause an increase in appetite with resultant weight gain, (A) will help control weight gain. (C and D) will help the teenager understand that changes in appearance are the result of the medication and are temporary, which is very important to the adolescent, but they do not have the priority of (A). 105. ANS: B (B) indicates that the client used the PCA pump five times and received 5 doses within one hour, which indicates effective use of the pump. (A and C) show inaccuracies, since one attempt can only administer 1 mg. (D) demonstrates that the client attempted to use the pump twice as often as allowed, indicating ineffective pain management. 106. ANS: D Clients taking estrogen, especially those who smoke, are at increased risk for developing emboli. This client should be observed for symptoms of a deep vein thrombosis (D). (A) is an instruction typically given to someone taking steroids, and (B) to someone taking sulfa drugs. Estrogen is not contraindicated for those taking beta-blockers or diuretics (C). 107. ANS: B Jaundice is best assessed over bony prominences. Blanching the sternum (B) would provide the best indication of jaundice. (A, C and D) are not bony prominences, so they are not the best sites to assess for jaundice. 108. ANS: B Type 2 diabetes is prevalent in the Hispanic population and being overweight places (B) at greatest risk for developing Type 2 diabetes. Having a history of Type 2 diabetes is a risk factor (A), but at age 24 this client does not have the risk of (B). (C and D) are not risk factors for Type 2 diabetes. 109. ANS: C The client is at high risk for infection because corticosteroids cause immunosuppression, so the highest priority is to avoid contact with an infectious client (C). (A, B, and D) are not important considerations with regard to the client's diagnosis of SLE. ID: A 15 110. ANS: A It is essential that all IV tubing connections be secured (A) with Luer-Loc connectors to reduce the risk of a potentially fatal air embolism in a client with a central line. (B) is not necessary during fluid administration, but could be implemented for client comfort. (C and D) provide useful information about fluid and electrolyte balance, but are of less priority than protecting the client from air embolism. 111. ANS: D The head of the bed should be elevated on 6 inch blocks (D) because the client should avoid situations that decrease lower esophageal sphincter pressure, such as lying flat. (A) is not necessary. (B) should be eliminated, not limited, because they cause esophageal irritation, thereby exacerbating GERD. GERD is not the result of weakened muscles, and abdominal pressure should be avoided (C). 112. ANS: D Eye injuries require immediate care (D). Removing the object from the eye should not be done (A), but rinsing the eye may wash the object out if it is not imbedded. Patching the eye keeps the child from rubbing the eye (which is likely to cause further damage), but an imbedded object should not be removed (B). If a child is sent home (C) without instructions regarding the need for additional care, the parents may not realize the urgency of the situation. 113. ANS: A The rise and fall of fluid in the water seal chamber indicates that the chest drainage system is working properly, so no action is needed at this time (A). (B, C and D) are not necessary. Additionally, (B and D) are potentially hazardous interventions. 114. ANS: D Teletherapy (external beam) must be delivered to the same area, and skin markings identify the exact portal while the head is held still using position fixation devices (D). RT may enhance the effectiveness of chemotherapy (CT), but it does not limit chemotherapy side effects (A). (B) is observed when the client has a radioisotope source inside the body (brachytherapy). Radiation does not create a sensation (C) when penetrating the body. 115. ANS: C Prior to administering potassium, kidney functioning needs to be validated to ensure that excess potassium will be excreted (C). Low potassium causes arrhythmias and so would be an indication for administration of potassium (A). (B) is not related to potassium administration. Vomiting is an indication for potassium administration (D). 116. ANS: A Modifying her costume designs (A) indicates that the client is dealing with the body image change and attempting to make necessary adaptations. (B) is not necessary and indicates an over-concern with the ostomy bag. (C) may indicate that the client is not accepting her new responsibility. (D) is unrealistic. 117. ANS: A When planning care, the most significant of these factors is the age of the residents (A), which is higher than the average population. Based on the choices provided, this appears to be a retirement community of well-educated individuals in a warm part of the country, with water activities readily available. As one ages, health problems become more prevalent and the need for in-hospital beds increases. (B, C, and D) are all factors to consider when assessing the community needs, but they do not have the significance of (A). ID: A 16 118. ANS: D Ineffective coping (D) is the priority problem because the client is using substances to cope with feelings rather than using constructive ways of coping. (A and B) suggest that the client is maintaining adequate health and is ready to achieve a higher level of wellness. (C) is important for education about mood disorders and coping methods, but it is not the priority problem at this time. 119. ANS: A Vital signs (A) can be delegated to the UAP, and this has the highest priority. (B) requires the judgment of the nurse. The UAP can implement (C and D), but these are not priority activities. 120. ANS: D The colleague should ask the nurse to change the topic (D) in order to end the inappropriate behavior as soon as possible in the most amicable manner possible. (A) is premature; the managerial lines of communication should be followed. While (B and C) may protect clients from hearing the nurse, it does not stop her inappropriate behavior at the nursing station. 121. ANS: D A respiratory rate of 62 breaths/min (D) exceeds the expected normal respiratory rate for infants of 25 to 35/minute. (A) is normal for infants. (B) is indicative of central nervous damage and is not a specific symptom of respiratory distress. (C) is a symptom of fever. 122. ANS: D Hydration (D), a top priority in sickle cell crisis prevention, promotes hemodilution and increases blood flow. (A) is important during a crisis, but not for prevention. (B) is inappropriate, since sickle cell anemia does not cause bleeding. (C) may be used during an acute crisis in the hospital. 123. ANS: C A client must have good inspiratory force before being weaned from the ventilator. The muscles must be strong enough to inflate the lungs adequately (C). Many clients can tolerate short periods off the ventilator, for example, for tracheostomy care, but are not ready to be weaned (A). The same ventilator and client respiratory rates indicates that the client is not taking any breaths spontaneously, so is not ready to be weaned (B). Clear and equal bilateral breath sounds is an indicator that good pulmonary care is being given, but is not an indicator that the client is ready to be weaned from the ventilator (D). 124. ANS: D Jugular vein distention and pedal edema are signs of right-sided heart failure, which often follows left-sided heart failure. The healthcare provider should be notified of this change in the client's symptoms (D). Vasodilators may be used in the treatment of CHF, but (A) will increase the workload of the heart. (B) is used for suspected air embolus, but is likely to worsen the dyspnea associated with heart failure. (C) is used in the immediate treatment of MI. 125. ANS: D Dysfunction of the cranial nerves VII (CN VII), which innervates the facial muscles, is indicated by facial asymmetry, a drooping mouth, absence of the nasolabial fold (D), and impaired eyelid movement. Kyphosis and height reduction (A) due to bone loss, an increase in blood pressure (B) related to reduced elasticity of the arteries, and altered taste (C) related to sensory loss are expected changes in older adults. ID: A 17 126. ANS: A The epidemiological triad includes agent, host, and environment. Encouraging driver's education (A) influences students, i. e., the host, in terms of the triad. (B and C) are related to environment, and (D) conveys actions about the agent. 127. ANS: D Although all of these nursing diagnoses may be important for the client receiving corticosteroids, the risk for infection (D) places the client at highest risk for life-threatening problems, and this reflects the highest priority when planning nursing care. (A, B, and C) should also be used in the plan of care for this client, but do not have the priority of (D). 128. ANS: A Pitocin is used to stimulate contractions and this client's contraction pattern demonstrates hyperstimulation, so the first action the nurse should take is (A). (B and C) might also be implemented, especially if the FHR pattern is abnormal, but the first action should be (A). Report of the client's progress should be provided to the healthcare provider (D), but this intervention has less priority than taking steps to ensure the safety of the client and her infant. 129. ANS: C Status epilepticus (C) is considered a medical emergency since continuous seizure activity can result in brain damage. (A, B, and D) require prompt intervention by the nurse but involve problems that are less likely to be life-threatening. 130. ANS: B (B) is the best assignment for the new graduate because hyperalimentation, also known as Total Parenteral Nutrition, is administered through a subclavian line and the client is likely to be having diarrhea, which is not a critical situation. (A, C, and D) should be assigned to more experienced RNs because these clients are unstable and critically ill. 131. ANS: D Since the client skipped lunch, the nurse's priority action should be to provide the client with food immediately (D). Humulin N, an intermediate acting insulin, peaks in 6 to 8 hours, so the client must have lunch to prevent hypoglycemia. (A and B) do not warrant immediate intervention by the nurse. (C) needs to be addressed, but it does not have the priority of preventing hypoglycemia. 132. ANS: C A potassium level of 3.1 mEq/L (C) is below the normal of 3.5 to 5.5 mEq/L so the client is at risk for cardiac dysrhythmias, and needs potassium replacement immediately. (A) would be expected following an MI. (B) also shows an expected finding. (D) is typical for a client with COPD. 133. ANS: D The best way to assess adequate nutrition of a breastfeeding infant is by determining how many diapers the child wets daily (D) (6 to 8 indicates adequate nutrition). (A) is a subjective measurement. (B) is not a good indication of nutritional intake because the infant will often suckle for comfort and pleasure rather than for food. (C) can be dependent on the infant's feeding schedule, but does not necessarily indicate nutritional status. 134. ANS: C Individuals with pressure sores require increased energy and protein intake for wound healing. Spaghetti and meatballs (C) is the only choice that contains complete proteins plus an energy source. (A, B, and D) contain energy but are not good sources of protein. ID: A 18 135. ANS: D The plan of care should be modified to reflect any unrealistic expected outcomes (D). If the goals of the care plan are not achieved, the nurse should determine if the interventions were implemented and if the initial expected outcomes were realistic. The plan of care should be continued after being modified, not considered invalid (A). (B and C) are not indicated in this situation. 136. ANS: D Shivering (D) should be avoided when the nurse attempts fever-reducing measures because it increases the body's temperature, causing cerebral irritation. (A and B) also increase intracranial pressure and should be avoided when caring for this client. (C) is necessary for assessment of the client's fluid status and cardiac output, but is not an intervention designed to prevent increased ICP. 137. ANS: C The trunk lesions are most characteristic of cherry angioma, commonly found in adults over 30 years of age, and the lower extremity lesions are most likely actinic keratoses, which are also markers of aging, and are benign (C). While the client is at risk for all types of skin cancer due to her fair complexion, age, and unprotected sun exposure, (A, B, and D) are not diagnoses that are consistent with the descriptions of the lesions. 138. ANS: D (D) identifies the correct procedure. The method of choice in anchoring an IV is to place a piece of tape under the catheter with the adhesive side up and cross over the catheter hub in a V-shape. (A) could result in cutting off circulation, thereby compromising the extremity. (B) would usually be inadequate to secure an IV infusion. The hub of the catheter should never be elevated (C) because this creates an angle which can cause the needle to puncture through the vein. 139. ANS: B The NGT has no drainage and the client's abdomen is distended so the nurse should irrigate the tube with normal saline (B) and aspirate the fluid to ensure its patency. (A) ensures accurate assessment, but does not enhance its function. (C) is not recommended. (D) is not indicated at this time. 140. ANS: D A client with a platelet count of 30,000/mm3 would be at risk for bleeding because the blood would be unable to clot normally (D). The normal platelet count is 100,000 to 400,000/mm3. (A) would be appropriate for a client with neutropenia (decreased WBCs), (B) for a client with a decreased hemoglobin or hematocrit, and (C) for a client with continuous vomiting (often a side effect of chemotherapy). With a low platelet count, (D) has a greater priority than (C). 141. ANS: B A client who is a threat to others (B) requires the most immediate intervention by the nurse. Since the client expressing a desire to commit suicide is seeking help (C), this is of less immediacy than a homicidal client. (A and D) require prompt intervention, but are of less priority than (B). 142. ANS: B The symptoms of restless legs syndrome occur primarily during the night. To promote sleep, the client should be instructed to avoid caffeinated beverages in the evening. (B) is the only beverage choice that does not contain caffeine. ID: A 19 143. ANS: C Males grow until age 18 or 20, and this fact should offer hope for the teenager that she will not always be taller than her male counterparts (C). (A) tells her she should feel a certain way and inhibits therapeutic communication. A "why" question (B) is often non-therapeutic, and in this case, dismisses the teenager's concerns. (D) is a preconceived notion, and is not particularly helpful to this 16-year-old. 144. ANS: C The interpreter's role is to literally translate exactly what the client indicates. The role does not allow the interpreter to ad lib any explanation or recommendation. Further information is needed about what was said during that lengthy conversation before proceeding (C). The nurse's concern should be the client's understanding, questions and concerns, not (A and B). If the client's English was not satisfactory for the original explanation and consent, it is not now adequate for confirmation of that consent (D). 145. ANS: B The first priority for a client with a cervical spinal cord injury is assessing the respiratory pattern (B) and ensuring an adequate airway. A cervical spinal cord injury places the client at risk for respiratory compromise because the phrenic nerve, which controls the diaphragm, branches from the cervical-brachial plexus. Although the nurse should implement (A, C, and D) relative to assessing for complete, incomplete, and level of cord injury, respiratory arrest and need for intubation is the priority. 146. ANS: B Following lung biopsy, the client is at risk for pneumothorax. This client is exhibiting signs of this condition, which requires prompt intervention, beginning with a chest x-ray (B) to confirm the pneumothorax prior to chest tube insertion. (A) should be obtained if an infection is suspected, and (C) if fluid overload is suspected. (D) should be performed if the client is in shock. 147. ANS: C Rape motivation is predominantly related to the need to control and humiliate another person and coming to terms with this fact is basic to the client developing adaptive behaviors to feelings of powerlessness (C). (A) is of little relevance, as is (D). (B) should not be permitted. 148. ANS: A An asymptomatic female who engages in unprotected sexual intercourse with an individual who tests positive for chlamydia should be treated (A) with azithromycin (Zithromax), the first-line drug treatment. (B and C) should also be considered, but the nurse should address the client's risk for chlamydia infection as the priority and prepare the client for prescribed antiinfectants. Chlamydia infection is often asymptomatic (D) in females, and requires diagnostic confirmation and treatment. 149. ANS: A This child is exhibiting signs of pain and neurovascular compromise of the fingers that could result in development of compartment syndrome because the cast is too tight, so bivalving of the cast (A) to relieve pressure is required. (B and C) do not address this life-threatening complication. These assessment findings require the nurse to intervene, and (D) constitutes failure to rescue. ID: A 20 150. ANS: C When used before exercise, the beta-adrenergic agonist albuterol can prevent an asthma attack (C). Cold fluids can precipitate bronchospasms (A). (B) is a good exercise for children with asthma because of the moist environment (swimming pool area) and while swimming the child takes deep breaths and exhales slowly. A premixed dose of epinephrine solution (Epipen) should be readily accessible for a child, and a prescription (D) does not provide such accessibility. 151. ANS: B Vaginal bleeding that is discharged in spurts may indicate a cervical or vaginal wall laceration. The nurse should compare the current vital signs to the previous set of vital signs (B) to evaluate the risk of shock related to hemorrhage. (A, C, and D) may need to be initiated, but the nurse must first evaluate the client's hemodynamic status to make decisions concerning subsequent actions. 152. ANS: C Crutches are used to maintain minimal weight-bearing (C) for several weeks after ACL repair. (A and D) are not indicated and can present many risks. (B) is harmful to the joint healing process if initiated too early. 153. ANS: B A poor nutritional state, reflected by a low serum albumin (B), places the client at risk for impaired skin integrity. (A, C, and D) do not reflect any risk factors for impaired skin integrity. 154. ANS: C The primary causes of nipple soreness are related to infant positioning and latch-on to the breast during feedings (C). The nurse should assess the mother-infant dyad at the next feeding and intervene as needed. Assisting the infant to grasp the nipple correctly is more beneficial for sore nipples than (A). (B) does not address the problem and may sabotage the mother's milk supply. While breast pumps are used to obtain and store milk in many circumstances, (D) does not address the source of the soreness and may, in fact, increase it. 155. ANS: B Regular use of opioid analgesics often results in constipation, so the nurse should consult with the healthcare provider about the need for a stool softener or laxative such as ducosate (B). Mobility and nutritional intake may be impacted by the morphine, but the need for (A and C) is less likely than for a stool softener/laxative. Morphine may cause nausea and vomiting, but sucralfate (D) is unlikely to prevent these side effects. COMPLETION 156. ANS: 0.5 Using the formula, D/H X V: 50 mg/60 mg X 0.6 ml = 0.5 ml ID: A 21 157. ANS: 0.25 50 mg : 1 ml :: 37.5 mg : x 50x = 37.5 x = 0.75 1 ml - 0.75 ml = 0.25 ml 158. ANS: 225 First, convert the child's weight into kilograms: 66 pounds/2.2 kg = 30 lbs. Next, calculate the daily dose of ampicillin: 30 mg X 30 lbs/day = 900 mg/day. Last, calculate the individual dose: 900 mg/4 doses (every six hours) = 225 mg per dose 159. ANS: 200 100 ml/30 minutes = x ml/60 minutes. 100 x 60 = 30x x = 200 ml/hour 160. ANS: 0.75 The nurse should administer 0.75 ml. Using equivalent fractions: 10,000 units/ 1 ml = 7500 units/ x ml 10,000x = 7500 x = 0.75 ml [Show More]

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