250-ITEM NOVEMBER 2014 NURSE LICENSURE EXAM (NLE) PRACTICE TEST
The test will cover the following topics:
- Blood Disorders
- Endocrine Disorders
- Cardiovascular Disorders
- Neurolgical Disorders
- Pregnacy, Labor and Delivery
- Burns
- Psychological Disorders
- Immobility
- Digestive Disorders
- Wounds
1. A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use?
A.Body temperature of 99°F or
less
B. Toes moved in active range
of motion
C. Sensation reported when
soles of feet are touched
D.Capillary refill of < 3
seconds
2. A 30-year-old male from
Haiti is brought to the emergency department in sickle cell crisis. What is the
best position for this client?
A.Side-lying with knees flexed
B. Knee-chest
C. High Fowler's with knees
flexed
D.Semi-Fowler's with legs
extended on the bed
3. A 25-year-old male is
admitted in sickle cell crisis. Which of the following interventions would be
of highest priority for this client?
A.Taking hourly blood
pressures with mechanical cuff
B. Encouraging fluid intake of
at least 200mL per hour
C. Position in high Fowler's
with knee gatch raised
D.Administering Tylenol as
ordered
4. Which of the following foods
would the nurse encourage the client in sickle cell crisis to eat?
A.Peaches
B. Cottage cheese
C. Popsicle
D.Lima beans
5. A newly admitted client has
sickle cell crisis. The nurse is planning care based on assessment of the
client. The client is complaining of severe pain in his feet and hands. The
pulse oximetry is 92. Which of the following interventions would be implemented
first? Assume that there are orders for each intervention.
A.Adjust the room temperature
B. Give a bolus of IV fluids
C. Start O2
D.Administer meperidine
(Demerol) 75mg IV push
6. The nurse is instructing a
client with iron-deficiency anemia. Which of the following meal plans would the
nurse expect the client to select?
A.Roast beef, gelatin salad,
green beans, and peach pie
B. Chicken salad sandwich,
coleslaw, French fries, ice cream
C. Egg salad on wheat bread,
carrot sticks, lettuce salad, raisin pie
D.Pork chop, creamed potatoes,
corn, and coconut cake
7. Clients with sickle cell
anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which
of the following activities would the nurse recommend?
A.A family vacation in the
Rocky Mountains
B. Chaperoning the local boys
club on a snow-skiing trip
C. Traveling by airplane for
business trips
D.A bus trip to the Museum of
Natural History
8. The nurse is conducting an
admission assessment of a client with vitamin B12 deficiency. Which of the
following would the nurse include in the physical assessment?
A.Palpate the spleen
B. Take the blood pressure
C. Examine the feet for
petechiae
D.Examine the tongue
9. An African American female
comes to the outpatient clinic. The physician suspects vitamin B12 deficiency
anemia. Because jaundice is often a clinical manifestation of this type of
anemia, what body part would be the best indicator?
A.Conjunctiva of the eye
B. Soles of the feet
C. Roof of the mouth
D.Shins
10. The nurse is conducting a
physical assessment on a client with anemia. Which of the following clinical
manifestations would be most indicative of the anemia?
A.BP 146/88
B. Respirations 28 shallow
C. Weight gain of 10 pounds in
6 months
D.Pink complexion
A."I will drink 500mL of
fluid or less each day."
B. "I will wear support
hose when I am up."
C. "I will use an electric
razor for shaving."
D."I will eat foods low
in iron."
12. A 33-year-old male is being
evaluated for possible acute leukemia. Which of the following would the nurse
inquire about as a part of the assessment?
A.The client collects stamps
as a hobby.
B. The client recently lost his
job as a postal worker.
C. The client had radiation for
treatment of Hodgkin's disease as a teenager.
D.The client's brother had
leukemia as a child.
13. An African American client
is admitted with acute leukemia. The nurse is assessing for signs and symptoms
of bleeding. Where is the best site for examining for the presence of
petechiae?
A.The abdomen
B. The thorax
C. The earlobes
D.The soles of the feet
14. A client with acute leukemia
is admitted to the oncology unit. Which of the following would be most important
for the nurse to inquire?
A."Have you noticed a
change in sleeping habits recently?"
B. "Have you had a
respiratory infection in the last 6 months?"
C. "Have you lost weight
recently?"
D."Have you noticed
changes in your alertness?"
15. Which of the following would
be the priority nursing diagnosis for the adult client with acute leukemia?
A.Oral mucous membrane,
altered related to chemotherapy
B. Risk for injury related to
thrombocytopenia
C. Fatigue related to the
disease process
D.Interrupted family processes
related to life-threatening illness of a family member
16. A 21-year-old male with
Hodgkin's lymphoma is a senior at the local university. He is engaged to be
married and is to begin a new job upon graduation. Which of the following
diagnoses would be a priority for this client?
A.Sexual dysfunction related
to radiation therapy
B. Anticipatory grieving
related to terminal illness
C. Tissue integrity related to
prolonged bed rest
D.Fatigue related to
chemotherapy
17. A client has autoimmune
thrombocytopenic purpura. To determine the client's response to treatment, the
nurse would monitor:
A.Platelet count
B. White blood cell count
C. Potassium levels
D.Partial prothrombin time
(PTT)
18. The home health nurse is
visiting a client with autoimmune thrombocytopenic purpura (ATP). The client's
platelet count currently is 80, It will be most important to teach the client
and family about:
A.Bleeding precautions
B. Prevention of falls
C. Oxygen therapy
D.Conservation of energy
19. A client with a pituitary
tumor has had a transphenoidal hyposphectomy. Which of the following interventions
would be appropriate for this client?
A.Place the client in
Trendelenburg position for postural drainage
B. Encourage coughing and deep
breathing every 2 hours
C. Elevate the head of the bed
30°
D.Encourage the Valsalva
maneuver for bowel movements
20. The client with a history of
diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion.
The priority intervention for this client is:
A.Measure the urinary output
B. Check the vital signs
C. Encourage increased fluid
intake
D.Weigh the client
21. A client with hemophilia has
a nosebleed. Which nursing action is most appropriate to control the bleeding?
A.Place the client in a
sitting position with the head hyperextended
B. Pack the nares tightly with
gauze to apply pressure to the source of bleeding
C. Pinch the soft lower part of
the nose for a minimum of 5 minutes
D.Apply ice packs to the
forehead and back of the neck
22. A client has had a
unilateral adrenalectomy to remove a tumor. To prevent complications, the most
important measurement in the immediate post-operative period for the nurse to
take is:
A.Blood pressure
B. Temperature
C. Output
D.Specific gravity
23. A client with Addison's
disease has been admitted with a history of nausea and vomiting for the past 3
days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the
following interventions would the nurse implement?
A.Glucometer readings as
ordered
B. Intake/output measurements
C. Sodium and potassium levels
monitored
D.Daily weights
24. A client had a total
thyroidectomy yesterday. The client is complaining of tingling around the mouth
and in the fingers and toes. What would the nurses' next action be?
A.Obtain a crash cart
B. Check the calcium level
C. Assess the dressing for
drainage
D.Assess the blood pressure
for hypertension
25. A 32-year-old mother of
three is brought to the clinic. Her pulse is 52, there is a weight gain of 30
pounds in 4 months, and the client is wearing two sweaters. The client is
diagnosed with hypothyroidism. Which of the following nursing diagnoses is of
highest priority?
A.Impaired physical mobility related
to decreased endurance
B. Hypothermia r/t decreased
metabolic rate
C. Disturbed thought processes
r/t interstitial edema
D.Decreased cardiac output r/t
bradycardia
26. The client presents to the
clinic with a serum cholesterol of 275mg/dL and is placed on rosuvastatin
(Crestor). Which instruction should be given to the client?
A.Report muscle weakness to
the physician.
B. Allow six months for the
drug to take effect.
C. Take the medication with
fruit juice.
D.Ask the doctor to perform a
complete blood count before starting the medication.
27. The client is admitted to
the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During
administration, the nurse should:
A.Utilize an infusion pump
B. Check the blood glucose
level
C. Place the client in
Trendelenburg position
D.Cover the solution with foil
28. The 6-month-old client with
a ventral septal defect is receiving Digitalis for regulation of his heart
rate. Which finding should be reported to the doctor?
A.Blood pressure of 126/80
B. Blood glucose of 110mg/dL
C. Heart rate of 60bpm
D.Respiratory rate of 30 per
minute
29. The client admitted with
angina is given a prescription for nitroglycerine. The client should be
instructed to:
A.Replenish his supply every 3
months
B. Take one every 15 minutes if
pain occurs
C. Leave the medication in the
brown bottle
D.Crush the medication and
take with water
30. The client is instructed
regarding foods that are low in fat and cholesterol. Which diet selection is
lowest in saturated fats?
A.Macaroni and cheese
B. Shrimp with rice
C. Turkey breast
D.Spaghetti
31. The client is admitted with
left-sided congestive heart failure. In assessing the client for edema, the
nurse should check the:
A.Feet
B. Neck
C. Hands
D.Sacrum
32. The nurse is checking the
client's central venous pressure. The nurse should place the zero of the
manometer at the:
A.Phlebostatic axis
B. PMI
C. Erb's point
D.Tail of Spence
33. The physician orders
lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to
the client with hypertension. The nurse should:
A.Question the order
B. Administer the medications
C. Administer separately
D.Contact the pharmacy
34. The best method of
evaluating the amount of peripheral edema is:
A.Weighing the client daily
B. Measuring the extremity
C. Measuring the intake and
output
D.Checking for pitting
35. A client with vaginal cancer
is being treated with a radioactive vaginal implant. The client's husband asks
the nurse if he can spend the night with his wife. The nurse should explain
that:
A.Overnight stays by family
members is against hospital policy.
B. There is no need for him to
stay because staffing is adequate.
C. His wife will rest much
better knowing that he is at home.
D.Visitation is limited to 30
minutes when the implant is in place.
36. The nurse is caring for a
client hospitalized with a facial stroke. Which diet selection would be suited
to the client?
A.Roast beef sandwich, potato
chips, pickle spear, iced tea
B. Split pea soup, mashed
potatoes, pudding, milk
C. Tomato soup, cheese toast,
Jello, coffee
D.Hamburger, baked beans,
fruit cup, iced tea
37. The physician has prescribed
Novalog insulin for a client with diabetes mellitus. Which statement indicates
that the client knows when the peak action of the insulin occurs?
A."I will make sure I eat
breakfast within 10 minutes of taking my insulin."
B. "I will need to carry
candy or some form of sugar with me all the time."
C. "I will eat a snack
around three o'clock each afternoon."
D."I can save my dessert
from supper for a bedtime snack."
38. The nurse is teaching basic
infant care to a group of first-time parents. The nurse should explain that a
sponge bath is recommended for the first 2 weeks of life because:
A.New parents need time to
learn how to hold the baby.
B. The umbilical cord needs
time to separate.
C. Newborn skin is easily
traumatized by washing.
D.The chance of chilling the
baby outweighs the benefits of bathing.
39. A client with leukemia is receiving
Trimetrexate. After reviewing the client's chart, the physician orders
Wellcovorin (leucovorin calcium). The rationale for administering leucovorin
calcium to a client receiving Trimetrexate is to:
A.Treat iron-deficiency anemia
caused by chemotherapeutic agents
B. Create a synergistic effect
that shortens treatment time
C. Increase the number of
circulating neutrophils
D.Reverse drug toxicity and
prevent tissue damage
40. A 4-month-old is brought to
the well-baby clinic for immunization. In addition to the DPT and polio
vaccines, the baby should receive:
A.Hib titer
B. Mumps vaccine
C. Hepatitis B vaccine
D.MMR
41. The physician has prescribed
Nexium (esomeprazole) for a client with erosive gastritis. The nurse should
administer the medication:
A.30 minutes before meals
B. With each meal
C. In a single dose at bedtime
D.30 minutes after meals
42. A client on the psychiatric
unit is in an uncontrolled rage and is threatening other clients and staff.
What is the most appropriate action for the nurse to take?
A.Call security for assistance
and prepare to sedate the client.
B. Tell the client to calm down
and ask him if he would like to play cards.
C. Tell the client that if he
continues his behavior he will be punished.
D.Leave the client alone until
he calms down.
43. When the nurse checks the
fundus of a client on the first postpartum day, she notes that the fundus is
firm, is at the level of the umbilicus, and is displaced to the right. The next
action the nurse should take is to:
A.Check the client for bladder
distention
B. Assess the blood pressure
for hypotension
C. Determine whether an
oxytocic drug was given
D.Check for the expulsion of
small clots
44. A client is admitted to the
hospital with a temperature of 99.8°F, complaints of blood-tinged hemoptysis,
fatigue, and night sweats. The client's symptoms are consistent with a
diagnosis of:
A.Pneumonia
B. Reaction to antiviral
medication
C. Tuberculosis
D.Superinfection due to low
CD4 count
45. The client is seen in the
clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan
succinate) is prescribed for the client. Which of the following in the client's
history should be reported to the doctor?
A.Diabetes
B. Prinzmetal's angina
C. Cancer
D.Cluster headaches
46. The client with suspected
meningitis is admitted to the unit. The doctor is performing an assessment to
determine meningeal irritation and spinal nerve root inflammation. A positive
Kernig's sign is charted if the nurse notes:
A.Pain on flexion of the hip
and knee
B. Nuchal rigidity on flexion
of the neck
C. Pain when the head is turned
to the left side
D.Dizziness when changing
positions
47. The client with Alzheimer's
disease is being assisted with activities of daily living when the nurse notes
that the client uses her toothbrush to brush her hair. The nurse is aware that
the client is exhibiting:
A.Agnosia
B. Apraxia
C. Anomia
D.Aphasia
48. The client with dementia is
experiencing confusion late in the afternoon and before bedtime. The nurse is
aware that the client is experiencing what is known as:
A.Chronic fatigue syndrome
B. Normal aging
C. Sundowning
D.Delusions
49. The client with confusion
says to the nurse, "I haven't had anything to eat all day long. When are
they going to bring breakfast?" The nurse saw the client in the day room
eating breakfast with other clients 30 minutes before this conversation. Which
response would be best for the nurse to make?
A."You know you had
breakfast 30 minutes ago."
B. "I am so sorry that
they didn't get you breakfast. I'll report it to the charge nurse."
C. "I'll get you some
juice and toast. Would you like something else?"
D."You will have to wait
a while; lunch will be here in a little while."
50. The doctor has prescribed
Exelon (rivastigmine) for the client with Alzheimer's disease. Which side
effect is most often associated with this drug?
A.Urinary incontinence
B. Headaches
C. Confusion
D.Nausea
51. A client is admitted to the
labor and delivery unit in active labor. During examination, the nurse notes a
papular lesion on the perineum. Which initial action is most appropriate?
A.Document the finding
B. Report the finding to the
doctor
C. Prepare the client for a
C-section
D.Continue primary care as prescribed
52. A client with a diagnosis of
HPV is at risk for which of the following?
A.Hodgkin's lymphoma
B. Cervical cancer
C. Multiple myeloma
D.Ovarian cancer
53. During the initial
interview, the client reports that she has a lesion on the perineum. Further
investigation reveals a small blister on the vulva that is painful to touch.
The nurse is aware that the most likely source of the lesion is:
A.Syphilis
B. Herpes
C. Gonorrhea
D.Condylomata
54. A client visiting a family
planning clinic is suspected of having an STI. The best diagnostic test for
treponema pallidum is:
A.Venereal Disease Research
Lab (VDRL)
B. Rapid plasma reagin (RPR)
C. Florescent treponemal
antibody (FTA)
D.Thayer-Martin culture (TMC)
55. A 15-year-old primigravida
is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory
finding is associated with HELLP syndrome?
A.Elevated blood glucose
B. Elevated platelet count
C. Elevated creatinine
clearance
D.Elevated hepatic enzymes
56. The nurse is assessing the
deep tendon reflexes of a client with preeclampsia. Which method is used to
elicit the biceps reflex?
A.The nurse places her thumb
on the muscle inset in the antecubital space and taps the thumb briskly with
the reflex hammer.
B. The nurse loosely suspends
the client's arm in an open hand while tapping the back of the client's elbow.
C. The nurse instructs the
client to dangle her legs as the nurse strikes the area below the patella with
the blunt side of the reflex hammer.
D.The nurse instructs the
client to place her arms loosely at her side as the nurse strikes the muscle
insert just above the wrist.
57. A primigravida with diabetes
is admitted to the labor and delivery unit at 34 weeks gestation. Which
doctor's order should the nurse question?
A.Magnesium sulfate 4gm (25%)
IV
B. Brethine 10mcg IV
C. Stadol 1mg IV push every 4
hours as needed prn for pain
D.Ancef 2gm IVPB every 6 hours
58. A diabetic multigravida is
scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio
and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of
phosphatidylglycerol is noted. The nurse's assessment of this data is:
A.The infant is at low risk
for congenital anomalies.
B. The infant is at high risk
for intrauterine growth retardation.
C. The infant is at high risk
for respiratory distress syndrome.
D.The infant is at high risk
for birth trauma.
59. Which observation in the
newborn of a diabetic mother would require immediate nursing intervention?
A.Crying
B. Wakefulness
C. Jitteriness
D.Yawning
60. The nurse caring for a
client receiving intravenous magnesium sulfate must closely observe for side
effects associated with drug therapy. An expected side effect of magnesium
sulfate is:
A.Decreased urinary output
B. Hypersomnolence
C. Absence of knee jerk reflex
D.Decreased respiratory rate
61. The client has elected to
have epidural anesthesia to relieve labor pain. If the client experiences
hypotension, the nurse would:
A.Place her in Trendelenburg
position
B. Decrease the rate of IV
infusion
C. Administer oxygen per nasal
cannula
D.Increase the rate of the IV
infusion
62. A client has cancer of the
pancreas. The nurse should be most concerned about which nursing diagnosis?
A.Alteration in nutrition
B. Alteration in bowel
elimination
C. Alteration in skin integrity
D.Ineffective individual
coping
63. The nurse is caring for a
client with ascites. Which is the best method to use for determining early
ascites?
A.Inspection of the abdomen
for enlargement
B. Bimanual palpation for
hepatomegaly
C. Daily measurement of
abdominal girth
D.Assessment for a fluid wave
64. The client arrives in the
emergency department after a motor vehicle accident. Nursing assessment
findings include BP 80/34, pulse rate 120, and respirations 20. Which is the
client's most appropriate priority nursing diagnosis?
A.Alteration in cerebral
tissue perfusion
B. Fluid volume deficit
C. Ineffective airway clearance
D.Alteration in sensory
perception
65. The home health nurse is
visiting an 18-year-old with osteogenesis imperfecta. Which information
obtained on the visit would cause the most concern? The client:
A.Likes to play football
B. Drinks several carbonated
drinks per day
C. Has two sisters with sickle
cell tract
D.Is taking acetaminophen to
control pain
66. The nurse working the organ
transplant unit is caring for a client with a white blood cell count of During
evening visitation, a visitor brings a basket of fruit. What action should the
nurse take?
A.Allow the client to keep the
fruit
B. Place the fruit next to the
bed for easy access by the client
C. Offer to wash the fruit for
the client
D.Tell the family members to
take the fruit home
67. The nurse is caring for the
client following a laryngectomy when suddenly the client becomes nonresponsive
and pale, with a BP of 90/40 systolic. The initial nurse's action should be to:
A.Place the client in
Trendelenburg position
B. Increase the infusion of
Dextrose in normal saline
C. Administer atropine
intravenously
D.Move the emergency cart to
the bedside
68. The client admitted 2 days
earlier with a lung resection accidentally pulls out the chest tube. Which
action by the nurse indicates understanding of the management of chest tubes?
A.Order a chest x-ray
B. Reinsert the tube
C. Cover the insertion site
with a Vaseline gauze
D.Call the doctor
69. A client being treated with
sodium warfarin has a Protime of 120 seconds. Which intervention would be most
important to include in the nursing care plan?
A.Assess for signs of abnormal
bleeding
B. Anticipate an increase in
the Coumadin dosage
C. Instruct the client
regarding the drug therapy
D.Increase the frequency of
neurological assessments
70. Which selection would
provide the most calcium for the client who is 4 months pregnant?
A.A granola bar
B. A bran muffin
C. A cup of yogurt
D.A glass of fruit juice
71. The client with preeclampsia
is admitted to the unit with an order for magnesium sulfate. Which action by
the nurse indicates understanding of the possible side effects of magnesium
sulfate?
A.The nurse places a sign over
the bed not to check blood pressure in the right arm.
B. The nurse places a padded
tongue blade at the bedside.
C. The nurse inserts a Foley
catheter.
D.The nurse darkens the room.
72. A 6-year-old client is
admitted to the unit with a hemoglobin of 6g/dL. The physician has written an
order to transfuse 2 units of whole blood. When discussing the treatment, the
child's mother tells the nurse that she does not believe in having blood
transfusions and that she will not allow her child to have the treatment. What
nursing action is most appropriate?
A.Ask the mother to leave
while the blood transfusion is in progress
B. Encourage the mother to
reconsider
C. Explain the consequences
without treatment
D.Notify the physician of the
mother's refusal
73. A client is admitted to the
unit 2 hours after an explosion causes burns to the face. The nurse would be
most concerned with the client developing which of the following?
A.Hypovolemia
B. Laryngeal edema
C. Hypernatremia
D.Hyperkalemia
74. The nurse is evaluating
nutritional outcomes for an elderly client with bulimia. Which data best
indicates that the plan of care is effective?
A.The client selects a
balanced diet from the menu.
B. The client's hemoglobin and
hematocrit improve.
C. The client's tissue turgor
improves.
D.The client gains weight.
75. The client is admitted
following repair of a fractured tibia and cast application. Which nursing
assessment should be reported to the doctor?
A.Pain beneath the cast
B. Warm toes
C. Pedal pulses weak and rapid
D.Paresthesia of the toes
76. The client is having an
arteriogram. During the procedure, the client tells the nurse, "I'm feeing
really hot." Which response would be best?
A."You are having an
allergic reaction. I will get an order for Benadryl."
B. "That feeling of warmth
is normal when the dye is injected."
C. "That feeling of warmth
indicates that the clots in the coronary vessels are dissolving."
D."I will tell your
doctor and let him explain to you the reason for the hot feeling that you are
experiencing."
77. The nurse is observing
several healthcare workers providing care. Which action by the healthcare
worker indicates a need for further teaching?
A.The nursing assistant wears
gloves while giving the client a bath.
B. The nurse wears goggles
while drawing blood from the client.
C. The doctor washes his hands
before examining the client.
D.The nurse wears gloves to
take the client's vital signs.
78. The client is having
electroconvulsive therapy for treatment of severe depression. Which of the
following indicates that the client's ECT has been effective?
A.The client loses
consciousness.
B. The client vomits.
C. The client's ECG indicates
tachycardia.
D.The client has a grand mal
seizure.
79. The 5-year-old is being
tested for enterobiasis (pinworms). To collect a specimen for assessment of
pinworms, the nurse should teach the mother to:
A.Examine the perianal area
with a flashlight 2 or 3 hours after the child is asleep
B. Scrape the skin with a piece
of cardboard and bring it to the clinic
C. Obtain a stool specimen in
the afternoon
D.Bring a hair sample to the
clinic for evaluation
80. The nurse is teaching the
mother regarding treatment for enterobiasis. Which instruction should be given
regarding the medication?
A.Treatment is not recommended
for children less than 10 years of age.
B. The entire family should be
treated.
C. Medication therapy will
continue for 1 year.
D.Intravenous antibiotic
therapy will be ordered.
81. The registered nurse is
making assignments for the day. Which client should be assigned to the pregnant
nurse?
A.The client receiving linear
accelerator radiation therapy for lung cancer
B. The client with a radium
implant for cervical cancer
C. The client who has just been
administered soluble brachytherapy for thyroid cancer
D.The client who returned from
placement of iridium seeds for prostate cancer
82. The nurse is planning room
assignments for the day. Which client should be assigned to a private room if
only one is available?
A.The client with Cushing's
disease
B. The client with diabetes
C. The client with acromegaly
D.The client with myxedema
83. The nurse caring for a
client in the neonatal intensive care unit administers adult-strength Digitalis
to the 3-pound infant. As a result of her actions, the baby suffers permanent
heart and brain damage. The nurse can be charged with:
A.Negligence
B. Tort
C. Assault
D.Malpractice
84. Which assignment should not
be performed by the licensed practical nurse?
A.Inserting a Foley catheter
B. Discontinuing a nasogastric
tube
C. Obtaining a sputum specimen
D.Starting a blood transfusion
85. The client returns to the
unit from surgery with a blood pressure of 90/50, pulse 132, and respirations
30. Which action by the nurse should receive priority?
A.Continuing to monitor the
vital signs
B. Contacting the physician
C. Asking the client how he
feels
D.Asking the LPN to continue
the post-op care
86. Which nurse should be
assigned to care for the postpartal client with preeclampsia?
A.The RN with 2 weeks of
experience in postpartum
B. The RN with 3 years of
experience in labor and delivery
C. The RN with 10 years of
experience in surgery
D.The RN with 1 year of
experience in the neonatal intensive care unit
87. Which information should be
reported to the state Board of Nursing?
A.The facility fails to provide
literature in both Spanish and English.
B. The narcotic count has been
incorrect on the unit for the past 3 days.
C. The client fails to receive
an itemized account of his bills and services received during his hospital
stay.
D.The nursing assistant
assigned to the client with hepatitis fails to feed the client and give the
bath.
88. The nurse is suspected of
charting medication administration that he did not give. After talking to the
nurse, the charge nurse should:
A.Call the Board of Nursing
B. File a formal reprimand
C. Terminate the nurse
D.Charge the nurse with a tort
89. The home health nurse is
planning for the day's visits. Which client should be seen first?
A.The 78-year-old who had a
gastrectomy 3 weeks ago and has a PEG tube
B. The 5-month-old discharged 1
week ago with pneumonia who is being treated with amoxicillin liquid suspension
C. The 50-year-old with MRSA
being treated with Vancomycin via a PICC line
D.The 30-year-old with an
exacerbation of multiple sclerosis being treated with cortisone via a centrally
placed venous catheter
90. The emergency room is
flooded with clients injured in a tornado. Which clients can be assigned to
share a room in the emergency department during the disaster?
A.A schizophrenic client
having visual and auditory hallucinations and the client with ulcerative
colitis
B. The client who is 6 months
pregnant with abdominal pain and the client with facial lacerations and a
broken arm
C. A child whose pupils are
fixed and dilated and his parents, and a client with a frontal head injury
D.The client who arrives with
a large puncture wound to the abdomen and the client with chest pain
91. The nurse is caring for a
6-year-old client admitted with a diagnosis of conjunctivitis. Before
administering eyedrops, the nurse should recognize that it is essential to
consider which of the following?
A.The eye should be cleansed
with warm water, removing any exudate, before instilling the eyedrops.
B. The child should be allowed
to instill his own eyedrops.
C. The mother should be allowed
to instill the eyedrops.
D.If the eye is clear from any
redness or edema, the eyedrops should be held.
92. The nurse is discussing meal
planning with the mother of a 2-year-old toddler. Which of the following
statements, if made by the mother, would require a need for further
instruction?
A."It is okay to give my
child white grape juice for breakfast."
B. "My child can have a
grilled cheese sandwich for lunch."
C. "We are going on a
camping trip this weekend, and I have bought hot dogs to grill for his
lunch."
D."For a snack, my child
can have ice cream."
93. A 2-year-old toddler is
admitted to the hospital. Which of the following nursing interventions would
you expect?
A.Ask the parent/guardian to
leave the room when assessments are being performed.
B. Ask the parent/guardian to
take the child's favorite blanket home because anything from the outside should
not be brought into the hospital.
C. Ask the parent/guardian to
room-in with the child.
D.If the child is screaming,
tell him this is inappropriate behavior.
94. Which instruction should be
given to the client who is fitted for a behind-the-ear hearing aid?
A.Remove the mold and clean
every week.
B. Store the hearing aid in a
warm place.
C. Clean the lint from the
hearing aid with a toothpick.
D.Change the batteries weekly.
95. A priority nursing diagnosis
for a child being admitted from surgery following a tonsillectomy is:
A.Body image disturbance
B. Impaired verbal
communication
C. Risk for aspiration
D.Pain
96. A client with bacterial
pneumonia is admitted to the pediatric unit. What would the nurse expect the
admitting assessment to reveal?
A.High fever
B. Nonproductive cough
C. Rhinitis
D.Vomiting and diarrhea
97. The nurse is caring for a
client admitted with epiglottis. Because of the possibility of complete
obstruction of the airway, which of the following should the nurse have
available?
A.Intravenous access supplies
B. A tracheostomy set
C. Intravenous fluid
administration pump
D.Supplemental oxygen
98. A 25-year-old client with
Grave's disease is admitted to the unit. What would the nurse expect the
admitting assessment to reveal?
A.Bradycardia
B. Decreased appetite
C. Exophthalmos
D.Weight gain
99. The nurse is providing
dietary instructions to the mother of an 8-year-old child diagnosed with celiac
disease. Which of the following foods, if selected by the mother, would
indicate her understanding of the dietary instructions?
A.Ham sandwich on whole-wheat
toast
B. Spaghetti and meatballs
C. Hamburger with ketchup
D.Cheese omelet
100. The nurse is caring for an
80-year-old with chronic bronchitis. Upon the morning rounds, the nurse finds
an O2 sat of 76%. Which of the following actions should the nurse
take first?
A.Notify the physician
B. Recheck the O2
saturation level in 15 minutes
C. Apply oxygen by mask
D.Assess the child's pulse
101. A gravida III para 0 is
admitted to the labor and delivery unit. The doctor performs an amniotomy.
Which observation would the nurse be expected to make after the amniotomy?
A.Fetal heart tones 160bpm
B. A moderate amount of
straw-colored fluid
C. A small amount of greenish
fluid
D.A small segment of the
umbilical cord
102. The client is admitted to
the unit. A vaginal exam reveals that she is 2cm dilated. Which of the
following statements would the nurse expect her to make?
A."We have a name picked
out for the baby."
B. "I need to push when I
have a contraction."
C. "I can't concentrate if
anyone is touching me."
D."When can I get my
epidural?"
103. The client is having fetal
heart rates of 90–110bpm during the contractions. The first action the nurse
should take is:
A.Reposition the monitor
B. Turn the client to her left
side
C. Ask the client to ambulate
D.Prepare the client for
delivery
104. In evaluating the
effectiveness of IV Pitocin for a client with secondary dystocia, the nurse
should expect:
A.A painless delivery
B. Cervical effacement
C. Infrequent contractions
D.Progressive cervical
dilation
105. A vaginal exam reveals a
footling breech presentation. The nurse should take which of the following actions
at this time?
A.Anticipate the need for a
Caesarean section
B. Apply the fetal heart
monitor
C. Place the client in Genu
Pectoral position
D.Perform an ultrasound exam
106. A vaginal exam reveals that
the cervix is 4cm dilated, with intact membranes and a fetal heart tone rate of
160–170bpm. The nurse decides to apply an external fetal monitor. The rationale
for this implementation is:
A.The cervix is closed.
B. The membranes are still
intact.
C. The fetal heart tones are
within normal limits.
D.The contractions are intense
enough for insertion of an internal monitor.
107. The following are all
nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would
be most appropriate for the primagravida as she completes the early phase of
labor?
A.Impaired gas exchange related
to hyperventilation
B. Alteration in placental
perfusion related to maternal position
C. Impaired physical mobility
related to fetal-monitoring equipment
D.Potential fluid volume
deficit related to decreased fluid intake
108. As the client reaches 8cm
dilation, the nurse notes late decelerations on the fetal monitor. The FHR
baseline is 165–175bpm with variability of 0–2bpm. What is the most likely
explanation of this pattern?
A.The baby is asleep.
B. The umbilical cord is
compressed.
C. There is a vagal response.
D.There is uteroplacental
insufficiency.
109. The nurse notes variable
decelerations on the fetal monitor strip. The most appropriate initial action
would be to:
A.Notify her doctor
B. Start an IV
C. Reposition the client
D.Readjust the monitor
110. Which of the following is a
characteristic of a reassuring fetal heart rate pattern?
A.A fetal heart rate of
170–180bpm
B. A baseline variability of
25–35bpm
C. Ominous periodic changes
D.Acceleration of FHR with
fetal movements
111. The rationale for inserting
a French catheter every hour for the client with epidural anesthesia is:
A.The bladder fills more
rapidly because of the medication used for the epidural.
B. Her level of consciousness
is such that she is in a trancelike state.
C. The sensation of the bladder
filling is diminished or lost.
D.She is embarrassed to ask
for the bedpan that frequently.
112. A client in the family
planning clinic asks the nurse about the most likely time for her to conceive.
The nurse explains that conception is most likely to occur when:
A.Estrogen levels are low.
B. Lutenizing hormone is high.
C. The endometrial lining is
thin.
D.The progesterone level is
low.
113. A client tells the nurse
that she plans to use the rhythm method of birth control. The nurse is aware
that the success of the rhythm method depends on the:
A.Age of the client
B. Frequency of intercourse
C. Regularity of the menses
D.Range of the client's
temperature
114. A client with diabetes asks
the nurse for advice regarding methods of birth control. Which method of birth
control is most suitable for the client with diabetes?
A.Intrauterine device
B. Oral contraceptives
C. Diaphragm
D.Contraceptive sponge
115. The doctor suspects that the
client has an ectopic pregnancy. Which symptom is consistent with a diagnosis
of ectopic pregnancy?
A.Painless vaginal bleeding
B. Abdominal cramping
C. Throbbing pain in the upper
quadrant
D.Sudden, stabbing pain in the
lower quadrant
116. The nurse is teaching a
pregnant client about nutritional needs during pregnancy. Which menu selection
will best meet the nutritional needs of the pregnant client?
A.Hamburger pattie, green
beans, French fries, and iced tea
B. Roast beef sandwich, potato
chips, baked beans, and cola
C. Baked chicken, fruit cup,
potato salad, coleslaw, yogurt, and iced tea
D.Fish sandwich, gelatin with
fruit, and coffee
117. The client with hyperemesis
gravidarum is at risk for developing:
A.Respiratory alkalosis
without dehydration
B. Metabolic acidosis with
dehydration
C. Respiratory acidosis without
dehydration
D.Metabolic alkalosis with
dehydration
118. A client tells the doctor
that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:
A.Elevated human chorionic
gonadatropin
B. The presence of fetal heart
tones
C. Uterine enlargement
D.Breast enlargement and
tenderness
119. The nurse is caring for a
neonate whose mother is diabetic. The nurse will expect the neonate to be:
A.Hypoglycemic, small for gestational
age
B. Hyperglycemic, large for
gestational age
C. Hypoglycemic, large for
gestational age
D.Hyperglycemic, small for
gestational age
120. Which of the following
instructions should be included in the nurse's teaching regarding oral
contraceptives?
A.Weight gain should be
reported to the physician.
B. An alternate method of birth
control is needed when taking antibiotics.
C. If the client misses one or
more pills, two pills should be taken per day for 1 week.
D.Changes in the menstrual
flow should be reported to the physician.
121. The nurse is discussing
breastfeeding with a postpartum client. Breastfeeding is contraindicated in the
postpartum client with:
A.Diabetes
B. Positive HIV
C. Hypertension
D.Thyroid disease
122. A client is admitted to the
labor and delivery unit complaining of vaginal bleeding with very little
discomfort. The nurse's first action should be to:
A.Assess the fetal heart tones
B. Check for cervical dilation
C. Check for firmness of the
uterus
D.Obtain a detailed history
123. A client telephones the
emergency room stating that she thinks that she is in labor. The nurse should
tell the client that labor has probably begun when:
A.Her contractions are 2
minutes apart.
B. She has back pain and a
bloody discharge.
C. She experiences abdominal
pain and frequent urination.
D.Her contractions are 5 minutes
apart.
124. The nurse is teaching a
group of prenatal clients about the effects of cigarette smoke on fetal
development. Which characteristic is associated with babies born to mothers who
smoked during pregnancy?
A.Low birth weight
B. Large for gestational age
C. Preterm birth, but
appropriate size for gestation
D.Growth retardation in weight
and length
125. The physician has ordered an
injection of RhoGam for the postpartum client whose blood type is A negative
but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should
be administered:
A.Within 72 hours of delivery
B. Within 1 week of delivery
C. Within 2 weeks of delivery
D.Within 1 month of delivery
126. After the physician performs
an amniotomy, the nurse's first action should be to assess the:
A.Degree of cervical dilation
B. Fetal heart tones
C. Client's vital signs
D.Client's level of discomfort
127. A client is admitted to the
labor and delivery unit. The nurse performs a vaginal exam and determines that
the client's cervix is 5cm dilated with 75% effacement. Based on the nurse's
assessment the client is in which phase of labor?
A.Active
B. Latent
C. Transition
D.Early
128. A newborn with narcotic
abstinence syndrome is admitted to the nursery. Nursing care of the newborn
should include:
A.Teaching the mother to
provide tactile stimulation
B. Wrapping the newborn snugly
in a blanket
C. Placing the newborn in the
infant seat
D.Initiating an early
infant-stimulation program
129. A client elects to have
epidural anesthesia to relieve the discomfort of labor. Following the
initiation of epidural anesthesia, the nurse should give priority to:
A.Checking for cervical
dilation
B. Placing the client in a
supine position
C. Checking the client's blood
pressure
D.Obtaining a fetal heart rate
130. The nurse is aware that the
best way to prevent post- operative wound infection in the surgical client is
to:
A.Administer a prescribed
antibiotic
B. Wash her hands for 2 minutes
before care
C. Wear a mask when providing
care
D.Ask the client to cover her
mouth when she coughs
131. The elderly client is
admitted to the emergency room. Which symptom is the client with a fractured
hip most likely to exhibit?
A.Pain
B. Disalignment
C. Cool extremity
D.Absence of pedal pulses
132. The nurse knows that a
60-year-old female client's susceptibility to osteoporosis is most likely
related to:
A.Lack of exercise
B. Hormonal disturbances
C. Lack of calcium
D.Genetic predisposition
133. A 2-year-old is admitted for
repair of a fractured femur and is placed in Bryant's traction. Which finding
by the nurse indicates that the traction is working properly?
A.The infant no longer
complains of pain.
B. The buttocks are 15° off the
bed.
C. The legs are suspended in
the traction.
D.The pins are secured within
the pulley.
134. A client with a fractured
hip has been placed in Buck's traction. Which statement is true regarding
balanced skeletal traction? Balanced skeletal traction:
A.Utilizes a Steinman pin
B. Requires that both legs be
secured
C. Utilizes Kirschner wires
D.Is used primarily to heal
the fractured hips
135. The client is admitted for
an open reduction internal fixation of a fractured hip. Immediately following
surgery, the nurse should give priority to assessing the:
A.Serum collection (Davol)
drain
B. Client's pain
C. Nutritional status
D.Immobilizer
136. Which statement made by the
family member caring for the client with a percutaneous gastrostomy tube
indicates understanding of the nurse's teaching?
A."I must flush the tube
with water after feedings and clamp the tube."
B. "I must check placement
four times per day."
C. "I will report to the
doctor any signs of indigestion."
D."If my father is unable
to swallow, I will discontinue the feeding and call the clinic."
137. The nurse is assessing the
client with a total knee replacement 2 hours post-operative. Which information
requires notification of the doctor?
A.Bleeding on the dressing is
3cm in diameter.
B. The client has a temperature
of 6°F.
C. The client's hematocrit is
26%.
D.The urinary output has been
60 during the last 2 hours.
138. The nurse is caring for the
client with a 5-year-old diagnosis of plumbism. Which information in the health
history is most likely related to the development of plumbism?
A.The client has traveled out
of the country in the last 6 months.
B. The client's parents are
skilled stained-glass artists.
C. The client lives in a house
built in 1
D.The client has several
brothers and sisters.
139. A client with a total hip
replacement requires special equipment. Which equipment would assist the client
with a total hip replacement with activities of daily living?
A.High-seat commode
B. Recliner
C. TENS unit
D.Abduction pillow
140. An elderly client with an
abdominal surgery is admitted to the unit following surgery. In anticipation of
complications of anesthesia and narcotic administration, the nurse should:
A.Administer oxygen via nasal
cannula
B. Have narcan (naloxane)
available
C. Prepare to administer blood
products
D.Prepare to do
cardioresuscitation
141. Which roommate would be most
suitable for the 6-year-old male with a fractured femur in Russell's traction?
A.16-year-old female with
scoliosis
B. 12-year-old male with a
fractured femur
C. 10-year-old male with
sarcoma
D.6-year-old male with
osteomylitis
142. A client with osteoarthritis
has a prescription for Celebrex (celecoxib). Which instruction should be
included in the discharge teaching?
A.Take the medication with
milk.
B. Report chest pain.
C. Remain upright after taking
for 30 minutes.
D.Allow 6 weeks for optimal
effects.
143. A client with a fractured
tibia has a plaster-of-Paris cast applied to immobilize the fracture. Which
action by the nurse indicates understanding of a plaster-of-Paris cast? The
nurse:
A.Handles the cast with the
fingertips
B. Petals the cast
C. Dries the cast with a hair
dryer
D.Allows 24 hours before
bearing weight
144. The teenager with a
fiberglass cast asks the nurse if it will be okay to allow his friends to
autograph his cast. Which response would be best?
A."It will be alright for
your friends to autograph the cast."
B. "Because the cast is
made of plaster, autographing can weaken the cast."
C. "If they don't use
chalk to autograph, it is okay."
D."Autographing or
writing on the cast in any form will harm the cast."
145. The nurse is assigned to
care for the client with a Steinmen pin. During pin care, she notes that the
LPN uses sterile gloves and Q-tips to clean the pin. Which action should the
nurse take at this time?
A.Assisting the LPN with
opening sterile packages and peroxide
B. Telling the LPN that clean
gloves are allowed
C. Telling the LPN that the registered
nurse should perform pin care
D.Asking the LPN to clean the
weights and pulleys with peroxide
146. A child with scoliosis has a
spica cast applied. Which action specific to the spica cast should be taken?
A.Check the bowel sounds
B. Assess the blood pressure
C. Offer pain medication
D.Check for swelling
147. The client with a cervical
fracture is placed in traction. Which type of traction will be utilized at the
time of discharge?
A.Russell's traction
B. Buck's traction
C. Halo traction
D.Crutchfield tong traction
148. A client with a total knee
replacement has a CPM (continuous passive motion device) applied during the
post-operative period. Which statement made by the nurse indicates
understanding of the CPM machine?
A."Use of the CPM will
permit the client to ambulate during the therapy."
B. "The CPM machine
controls should be positioned distal to the site."
C. "If the client
complains of pain during the therapy, I will turn off the machine and call the
doctor."
D."Use of the CPM machine
will alleviate the need for physical therapy after the client is
discharged."
149. A client with a fractured
hip is being taught correct use of the walker. The nurse is aware that the
correct use of the walker is achieved if the:
A.Palms rest lightly on the
handles
B. Elbows are flexed 0°
C. Client walks to the front of
the walker
D.Client carries the walker
150. When assessing a laboring
client, the nurse finds a prolapsed cord. The nurse should:
A.Attempt to replace the cord
B. Place the client on her left
side
C. Elevate the client's hips
D.Cover the cord with a dry,
sterile gauze
151. The nurse is caring for a
30-year-old male admitted with a stab wound. While in the emergency room, a
chest tube is inserted. Which of the following explains the primary rationale
for insertion of chest tubes?
A.The tube will allow for
equalization of the lung expansion.
B. Chest tubes serve as a
method of draining blood and serous fluid and assist in reinflating the lungs.
C. Chest tubes relieve pain
associated with a collapsed lung.
D.Chest tubes assist with
cardiac function by stabilizing lung expansion.
152. A client who delivered this
morning tells the nurse that she plans to breastfeed her baby. The nurse is
aware that successful breastfeeding is most dependent on the:
A.Mother's educational level
B. Infant's birth weight
C. Size of the mother's breast
D.Mother's desire to breastfeed
153. The nurse is monitoring the
progress of a client in labor. Which finding should be reported to the
physician immediately?
A.The presence of scant bloody
discharge
B. Frequent urination
C. The presence of green-tinged
amniotic fluid
D.Moderate uterine contractions
154. The nurse is measuring the
duration of the client's contractions. Which statement is true regarding the
measurement of the duration of contractions?
A.Duration is measured by
timing from the beginning of one contraction to the beginning of the next contraction.
B. Duration is measured by
timing from the end of one contraction to the beginning of the next
contraction.
C. Duration is measured by
timing from the beginning of one contraction to the end of the same
contraction.
D.Duration is measured by
timing from the peak of one contraction to the end of the same contraction.
155. The physician has ordered an
intravenous infusion of Pitocin for the induction of labor. When caring for the
obstetric client receiving intravenous Pitocin, the nurse should monitor for:
A.Maternal hypoglycemia
B. Fetal bradycardia
C. Maternal hyperreflexia
D.Fetal movement
156. A client with diabetes
visits the prenatal clinic at 28 weeks gestation. Which statement is true
regarding insulin needs during pregnancy?
A.Insulin requirements
moderate as the pregnancy progresses.
B. A decreased need for insulin
occurs during the second trimester.
C. Elevations in human
chorionic gonadotrophin decrease the need for insulin.
D.Fetal development depends on
adequate insulin regulation.
157. A client in the prenatal
clinic is assessed to have a blood pressure of 180/96. The nurse should give
priority to:
A.Providing a calm environment
B. Obtaining a diet history
C. Administering an analgesic
D.Assessing fetal heart tones
158. A primigravida, age 42, is 6
weeks pregnant. Based on the client's age, her infant is at risk for:
A.Down syndrome
B. Respiratory distress
syndrome
C. Turner's syndrome
D.Pathological jaundice
159. A client with a missed
abortion at 29 weeks gestation is admitted to the hospital. The client will
most likely be treated with:
A.Magnesium sulfate
B. Calcium gluconate
C. Dinoprostone (Prostin E.)
D.Bromocrystine (Pardel)
160. A client with preeclampsia
has been receiving an infusion containing magnesium sulfate for a blood
pressure that is 160/80; deep tendon reflexes are 1 plus, and the urinary
output for the past hour is 100mL. The nurse should:
A.Continue the infusion of
magnesium sulfate while monitoring the client's blood pressure
B. Stop the infusion of
magnesium sulfate and contact the physician
C. Slow the infusion rate and
turn the client on her left side
D.Administer calcium gluconate
IV push and continue to monitor the blood pressure
161. Which statement made by the
nurse describes the inheritance pattern of autosomal recessive disorders?
A.An affected newborn has
unaffected parents.
B. An affected newborn has one
affected parent.
C. Affected parents have a one
in four chance of passing on the defective gene.
D.Affected parents have
unaffected children who are carriers.
162. A pregnant client, age 32,
asks the nurse why her doctor has recommended a serum alpha fetoprotein. The
nurse should explain that the doctor has recommended the test:
A.Because it is a state law
B. To detect cardiovascular
defects
C. Because of her age
D.To detect neurological
defects
163. A client with hypothyroidism
asks the nurse if she will still need to take thyroid medication during the
pregnancy. The nurse's response is based on the knowledge that:
A.There is no need to take
thyroid medication because the fetus's thyroid produces a thyroid-stimulating
hormone.
B. Regulation of thyroid
medication is more difficult because the thyroid gland increases in size during
pregnancy.
C. It is more difficult to
maintain thyroid regulation during pregnancy due to a slowing of metabolism.
D.Fetal growth is arrested if
thyroid medication is continued during pregnancy.
164. The nurse is responsible for
performing a neonatal assessment on a full-term infant. At 1 minute, the nurse
could expect to find:
A.An apical pulse of 100
B. An absence of tonus
C. Cyanosis of the feet and
hands
D.Jaundice of the skin and
sclera
165. A client with sickle cell
anemia is admitted to the labor and delivery unit during the first phase of
labor. The nurse should anticipate the client's need for:
A.Supplemental oxygen
B. Fluid restriction
C. Blood transfusion
D.Delivery by Caesarean
section
166. A client with diabetes has
an order for ultrasonography. Preparation for an ultrasound includes:
A.Increasing fluid intake
B. Limiting ambulation
C. Administering an enema
D.Withholding food for 8 hours
167. An infant who weighs 8
pounds at birth would be expected to weigh how many pounds at 1 year?
A.14 pounds
B. 16 pounds
C. 18 pounds
D.24 pounds
168. A pregnant client with a
history of alcohol addiction is scheduled for a nonstress test. The nonstress
test:
A.Determines the lung maturity
of the fetus
B. Measures the activity of the
fetus
C. Shows the effect of
contractions on the fetal heart rate
D.Measures the neurological
well-being of the fetus
169. A full-term male has
hypospadias. Which statement describes hypospadias?
A.The urethral opening is
absent.
B. The urethra opens on the
dorsal side of the penis.
C. The penis is shorter than
usual.
D.The urethra opens on the
ventral side of the penis.
170. A gravida III para II is
admitted to the labor unit. Vaginal exam reveals that the client's cervix is
8cm dilated, with complete effacement. The priority nursing diagnosis at this
time is:
A.Alteration in coping related
to pain
B. Potential for injury related
to precipitate delivery
C. Alteration in elimination
related to anesthesia
D.Potential for fluid volume
deficit related to NPO status
171. The client with varicella
will most likely have an order for which category of medication?
A.Antibiotics
B. Antipyretics
C. Antivirals
D.Anticoagulants
172. A client is admitted
complaining of chest pain. Which of the following drug orders should the nurse
question?
A.Nitroglycerin
B. Ampicillin
C. Propranolol
D.Verapamil
173. Which of the following
instructions should be included in the teaching for the client with rheumatoid
arthritis?
A.Avoid exercise because it
fatigues the joints.
B. Take prescribed
anti-inflammatory medications with meals.
C. Alternate hot and cold packs
to affected joints.
D.Avoid weight-bearing
activity.
174. A client with acute
pancreatitis is experiencing severe abdominal pain. Which of the following
orders should be questioned by the nurse?
A.Meperidine 100mg IM q 4
hours PRN pain
B. Mylanta 30 ccs q 4 hours via
NG
C. Cimetadine 300mg PO q.i.d.
D.Morphine 8mg IM q 4 hours
PRN pain
175. The client is admitted to
the chemical dependence unit with an order for continuous observation. The
nurse is aware that the doctor has ordered continuous observation because:
A.Hallucinogenic drugs create
both stimulant and depressant effects.
B. Hallucinogenic drugs induce
a state of altered perception.
C. Hallucinogenic drugs produce
severe respiratory depression.
D.Hallucinogenic drugs induce
rapid physical dependence.
176. A client with a history of
abusing barbiturates abruptly stops taking the medication. The nurse should
give priority to assessing the client for:
A.Depression and suicidal
ideation
B. Tachycardia and diarrhea
C. Muscle cramping and
abdominal pain
D.Tachycardia and euphoric
mood
177. During the assessment of a
laboring client, the nurse notes that the FHT are loudest in the upper-right
quadrant. The infant is most likely in which position?
A.Right breech presentation
B. Right occipital anterior
presentation
C. Left sacral anterior
presentation
D.Left occipital transverse
presentation
178. The primary physiological
alteration in the development of asthma is:
A.Bronchiolar inflammation and
dyspnea
B. Hypersecretion of abnormally
viscous mucus
C. Infectious processes causing
mucosal edema
D.Spasm of bronchiolar smooth
muscle
179. A client with mania is
unable to finish her dinner. To help her maintain sufficient nourishment, the
nurse should:
A.Serve high-calorie foods she
can carry with her
B. Encourage her appetite by
sending out for her favorite foods
C. Serve her small,
attractively arranged portions
D.Allow her in the unit
kitchen for extra food whenever she pleases
180. To maintain Bryant's
traction, the nurse must make certain that the child's:
A.Hips are resting on the bed,
with the legs suspended at a right angle to the bed
B. Hips are slightly elevated
above the bed and the legs are suspended at a right angle to the bed
C. Hips are elevated above the
level of the body on a pillow and the legs are suspended parallel to the bed
D.Hips and legs are flat on
the bed, with the traction positioned at the foot of the bed
181. Which action by the nurse
indicates understanding of herpes zoster?
A.The nurse covers the lesions
with a sterile dressing.
B. The nurse wears gloves when
providing care.
C. The nurse administers a
prescribed antibiotic.
D.The nurse administers
oxygen.
182. The client has an order for
a trough to be drawn on the client receiving Vancomycin. The nurse is aware
that the nurse should contact the lab for them to collect the blood:
A.15 minutes after the
infusion
B. 30 minutes before the
infusion
C. 1 hour after the infusion
D.2 hours after the infusion
183. The client using a diaphragm
should be instructed to:
A.Refrain from keeping the
diaphragm in longer than 4 hours
B. Keep the diaphragm in a cool
location
C. Have the diaphragm resized
if she gains 5 pounds
D.Have the diaphragm resized
if she has any surgery
184. The nurse is providing
postpartum teaching for a mother planning to breastfeed her infant. Which of
the client's statements indicates the need for additional teaching?
A."I'm wearing a support
bra."
B. "I'm expressing milk
from my breast."
C. "I'm drinking four
glasses of fluid during a 24-hour period."
D."While I'm in the
shower, I'll allow the water to run over my breasts."
185. Damage to the VII cranial
nerve results in:
A.Facial pain
B. Absence of ability to smell
C. Absence of eye movement
D.Tinnitus
186. A client is receiving
Pyridium (phenazopyridine hydrochloride) for a urinary tract infection. The
client should be taught that the medication may:
A.Cause diarrhea
B. Change the color of her
urine
C. Cause mental confusion
D.Cause changes in taste
187. Which of the following tests
should be performed before beginning a prescription of Accutane?
A.Check the calcium level
B. Perform a pregnancy test
C. Monitor apical pulse
D.Obtain a creatinine level
188. A client with AIDS is taking
Zovirax (acyclovir). Which nursing intervention is most critical during the
administration of acyclovir?
A.Limit the client's activity
B. Encourage a
high-carbohydrate diet
C. Utilize an incentive
spirometer to improve respiratory function
D.Encourage fluids
189. A client is admitted for an
MRI. The nurse should question the client regarding:
A.Pregnancy
B. A titanium hip replacement
C. Allergies to antibiotics
D.Inability to move his feet
190. The nurse is caring for the
client receiving Amphotericin B. Which of the following indicates that the
client has experienced toxicity to this drug?
A.Changes in vision
B. Nausea
C. Urinary frequency
D.Changes in skin color
191. The nurse should visit which
of the following clients first?
A.The client with diabetes
with a blood glucose of 95mg/dL
B. The client with hypertension
being maintained on Lisinopril
C. The client with chest pain
and a history of angina
D.The client with Raynaud's disease
192. A client with cystic
fibrosis is taking pancreatic enzymes. The nurse should administer this
medication:
A.Once per day in the morning
B. Three times per day with
meals
C. Once per day at bedtime
D.Four times per day
193. Cataracts result in opacity
of the crystalline lens. Which of the following best explains the functions of
the lens?
A.The lens controls
stimulation of the retina.
B. The lens orchestrates eye
movement.
C. The lens focuses light rays
on the retina.
D.The lens magnifies small
objects.
194. A client who has glaucoma is
to have miotic eyedrops instilled in both eyes. The nurse knows that the
purpose of the medication is to:
A.Anesthetize the cornea
B. Dilate the pupils
C. Constrict the pupils
D.Paralyze the muscles of
accommodation
195. A client with a severe
corneal ulcer has an order for Gentamycin gtt. q 4 hours and Neomycin 1 gtt q 4
hours. Which of the following schedules should be used when administering the
drops?
A.Allow 5 minutes between the
two medications.
B. The medications may be used
together.
C. The medications should be
separated by a cycloplegic drug.
D.The medications should not
be used in the same client.
196. The client with color
blindness will most likely have problems distinguishing which of the following
colors?
A.Orange
B. Violet
C. Red
D.White
197. The client with a pacemaker
should be taught to:
A.Report ankle edema
B. Check his blood pressure
daily
C. Refrain from using a
microwave oven
D.Monitor his pulse rate
198. The client with enuresis is
being taught regarding bladder retraining. The nurse should advise the client
to refrain from drinking after:
A.1900
B. 1200
C. 1000
D.0700
199. Which of the following diet
instructions should be given to the client with recurring urinary tract
infections?
A.Increase intake of meats.
B. Avoid citrus fruits.
C. Perform pericare with
hydrogen peroxide.
D.Drink a glass of cranberry
juice every day.
200. The physician has prescribed
NPH insulin for a client with diabetes mellitus. Which statement indicates that
the client knows when the peak action of the insulin occurs?
A."I will make sure I eat
breakfast within 2 hours of taking my insulin."
B. "I will need to carry
candy or some form of sugar with me all the time."
C. "I will eat a snack
around three o'clock each afternoon."
D."I can save my dessert
from supper for a bedtime snack."
201. A client with pneumacystis
carini pneumonia is receiving trimetrexate. The rationale for administering
leucovorin calcium to a client receiving Methotrexate is to:
A.Treat anemia.
B. Create a synergistic effect.
C. Increase the number of white
blood cells.
D.Reverse drug toxicity.
202. A client tells the nurse
that she is allergic to eggs, dogs, rabbits, and chicken feathers. Which order
should the nurse question?
A.TB skin test
B. Rubella vaccine
C. ELISA test
D.Chest x-ray
203. The physician has prescribed
rantidine (Zantac) for a client with erosive gastritis. The nurse should
administer the medication:
A.30 minutes before meals
B. With each meal
C. In a single dose at bedtime
D.60 minutes after meals
204. A temporary colostomy is
performed on the client with colon cancer. The nurse is aware that the proximal
end of a double barrel colostomy:
A.Is the opening on the client's
left side
B. Is the opening on the distal
end on the client's left side
C. Is the opening on the
client's right side
D.Is the opening on the distal
right side
205. While assessing the
postpartal client, the nurse notes that the fundus is displaced to the right. Based
on this finding, the nurse should:
A.Ask the client to void
B. Assess the blood pressure
for hypotension
C. Administer oxytocin
D.Check for vaginal bleeding
206. The physician has ordered an
MRI for a client with an orthopedic ailment. An MRI should not be done if the
client has:
A.The need for oxygen therapy
B. A history of claustrophobia
C. A permanent pacemaker
D.Sensory deafness
207. A 6-month-old client is
placed on strict bed rest following a hernia repair. Which toy is best suited
to the client?
A.Colorful crib mobile
B. Hand-held electronic games
C. Cars in a plastic container
D.30-piece jigsaw puzzle
208. The nurse is preparing to
discharge a client with a long history of polio. The nurse should tell the
client that:
A.Taking a hot bath will
decrease stiffness and spasticity.
B. A schedule of strenuous
exercise will improve muscle strength.
C. Rest periods should be
scheduled throughout the day.
D.Visual disturbances can be
corrected with prescription glasses.
209. A client on the postpartum
unit has a proctoepisiotomy. The nurse should anticipate administering which
medication?
A.Dulcolax suppository
B. Docusate sodium (Colace)
C. Methyergonovine maleate
(Methergine)
D.Bromocriptine sulfate
(Parlodel)
210. A client with pancreatic
cancer has an infusion of TPN (Total Parenteral Nutrition). The doctor has
ordered for sliding-scale insulin. The most likely explanation for this order
is:
A.Total Parenteral Nutrition
leads to negative nitrogen balance and elevated glucose levels.
B. Total Parenteral Nutrition
cannot be managed with oral hypoglycemics.
C. Total Parenteral Nutrition
is a high-glucose solution that often elevates the blood glucose levels.
D.Total Parenteral Nutrition
leads to further pancreatic disease.
211. An adolescent primigravida
who is 10 weeks pregnant attends the antepartal clinic for a first check-up. To
develop a teaching plan, the nurse should initially assess:
A.The client's knowledge of
the signs of preterm labor
B. The client's feelings about
the pregnancy
C. Whether the client was using
a method of birth control
D.The client's thought about
future children
212. An obstetric client is
admitted with dehydration. Which IV fluid would be most appropriate for the
client?
A..45 normal saline
B. Dextrose 1% in water
C. Lactated Ringer's
D.Dextrose 5% in .45 normal
saline
213. The physician has ordered a
thyroid scan to confirm the diagnosis. Before the procedure, the nurse should:
A.Assess the client for
allergies
B. Bolus the client with IV
fluid
C. Tell the client he will be
asleep
D.Insert a urinary catheter
214. The physician has ordered an
injection of RhoGam for a client with blood type A negative. The nurse
understands that RhoGam is given to:
A.Provide immunity against Rh
isoenzymes
B. Prevent the formation of Rh
antibodies
C. Eliminate circulating Rh
antibodies
D.Convert the Rh factor from
negative to positive
215. The nurse is caring for a
client admitted to the emergency room after a fall. X-rays reveal that the
client has several fractured bones in the foot. Which treatment should the
nurse anticipate for the fractured foot?
A.Application of a short
inclusive spica cast
B. Stabilization with a
plaster-of-Paris cast
C. Surgery with Kirschner wire
implantation
D.A gauze dressing only
216. A client with bladder cancer
is being treated with iridium seed implants. The nurse's discharge teaching
should include telling the client to:
A.Strain his urine
B. Increase his fluid intake
C. Report urinary frequency
D.Avoid prolonged sitting
217. Following a heart
transplant, a client is started on medication to prevent organ rejection. Which
category of medication prevents the formation of antibodies against the new
organ?
A.Antivirals
B. Antibiotics
C. Immunosuppressants
D.Analgesics
218. The nurse is preparing a
client for cataract surgery. The nurse is aware that the procedure will use:
A.Mydriatics to facilitate
removal
B. Miotic medications such as
Timoptic
C. A laser to smooth and
reshape the lens
D.Silicone oil injections into
the eyeball
219. A client with Alzheimer's
disease is awaiting placement in a skilled nursing facility. Which long-term
plans would be most therapeutic for the client?
A.Placing mirrors in several
locations in the home
B. Placing a picture of herself
in her bedroom
C. Placing simple signs to
indicate the location of the bedroom, bathroom, and so on
D.Alternating healthcare
workers to prevent boredom
220. A client with an abdominal
cholecystectomy returns from surgery with a Jackson-Pratt drain. The chief
purpose of the Jackson-Pratt drain is to:
A.Prevent the need for
dressing changes
B. Reduce edema at the incision
C. Provide for wound drainage
D.Keep the common bile duct
open
221. The nurse is performing an
initial assessment of a newborn Caucasian male delivered at 32 weeks gestation.
The nurse can expect to find the presence of:
A.Mongolian spots
B. Scrotal rugae
C. Head lag
D.Vernix caseosa
222. The nurse is caring for a
client admitted with multiple trauma. Fractures include the pelvis, femur, and
ulna. Which finding should be reported to the physician immediately?
A.Hematuria
B. Muscle spasms
C. Dizziness
D.Nausea
223. A client is brought to the
emergency room by the police. He is combative and yells, "I have to get
out of here. They are trying to kill me." Which assessment is most likely
correct in relation to this statement?
A.The client is experiencing
an auditory hallucination.
B. The client is having a
delusion of grandeur.
C. The client is experiencing
paranoid delusions.
D.The client is intoxicated.
224. The nurse is preparing to
suction the client with a tracheotomy. The nurse notes a previously used bottle
of normal saline on the client's bedside table. There is no label to indicate
the date or time of initial use. The nurse should:
A.Lip the bottle and use a
pack of sterile 4x4 for the dressing
B. Obtain a new bottle and
label it with the date and time of first use
C. Ask the ward secretary when
the solution was requested
D.Label the existing bottle
with the current date and time
225. An infant's Apgar score is 9
at 5 minutes. The nurse is aware that the most likely cause for the deduction of
one point is:
A.The baby is cold.
B. The baby is experiencing
bradycardia.
C. The baby's hands and feet
are blue.
D.The baby is lethargic.
226. The primary reason for rapid
continuous rewarming of the area affected by frostbite is to:
A.Lessen the amount of
cellular damage
B. Prevent the formation of
blisters
C. Promote movement
D.Prevent pain and discomfort
227. A client recently started on
hemodialysis wants to know how the dialysis will take the place of his kidneys.
The nurse's response is based on the knowledge that hemodialysis works by:
A.Passing water through a
dialyzing membrane
B. Eliminating plasma proteins
from the blood
C. Lowering the pH by removing
nonvolatile acids
D.Filtering waste through a
dialyzing membrane
228. During a home visit, a
client with AIDS tells the nurse that he has been exposed to measles. Which
action by the nurse is most appropriate?
A.Administer an antibiotic
B. Contact the physician for an
order for immune globulin
C. Administer an antiviral
D.Tell the client that he
should remain in isolation for 2 weeks
229. A client hospitalized with
MRSA (methicillin-resistant staph aureus) is placed on contact precautions.
Which statement is true regarding precautions for infections spread by contact?
A.The client should be placed
in a room with negative pressure.
B. Infection requires close contact;
therefore, the door may remain open.
C. Transmission is highly
likely, so the client should wear a mask at all times.
D.Infection requires
skin-to-skin contact and is prevented by hand washing, gloves, and a gown.
230. A client who is admitted
with an above-the-knee amputation tells the nurse that his foot hurts and
itches. Which response by the nurse indicates understanding of phantom limb
pain?
A."The pain will go away
in a few days."
B. "The pain is due to
peripheral nervous system interruptions. I will get you some pain
medication."
C. "The pain is
psychological because your foot is no longer there."
D."The pain and itching
are due to the infection you had before the surgery."
231. A client with cancer of the
pancreas has undergone a Whipple procedure. The nurse is aware that during the
Whipple procedure, the doctor will remove the:
A.Head of the pancreas
B. Proximal third section of
the small intestines
C. Stomach and duodenum
D.Esophagus and jejunum
232. The physician has ordered a
minimal-bacteria diet for a client with neutropenia. The client should be
taught to avoid eating:
A.Fruits
B. Salt
C. Pepper
D.Ketchup
233. A client is discharged home
with a prescription for Coumadin (sodium warfarin). The client should be
instructed to:
A.Have a Protime done monthly
B. Eat more fruits and
vegetables
C. Drink more liquids
D.Avoid crowds
234. The nurse is assisting the
physician with removal of a central venous catheter. To facilitate removal, the
nurse should instruct the client to:
A.Perform the Valsalva
maneuver as the catheter is advanced
B. Turn his head to the left
side and hyperextend the neck
C. Take slow, deep breaths as
the catheter is removed
D.Turn his head to the right
while maintaining a sniffing position
235. A client has an order for
streptokinase. Before administering the medication, the nurse should assess the
client for:
A.Allergies to pineapples and
bananas
B. A history of streptococcal
infections
C. Prior therapy with phenytoin
D.A history of alcohol abuse
236. The nurse is providing
discharge teaching for the client with leukemia. The client should be told to
avoid:
A.Using oil- or cream-based
soaps
B. Flossing between the teeth
C. The intake of salt
D.Using an electric razor
237. The nurse is changing the
ties of the client with a tracheotomy. The safest method of changing the
tracheotomy ties is to:
A.Apply the new tie before
removing the old one.
B. Have a helper present.
C. Hold the tracheotomy with
the nondominant hand while removing the old tie.
D.Ask the doctor to suture the
tracheostomy in place.
238. The nurse is monitoring a
client following a lung resection. The hourly output from the chest tube was 300mL.
The nurse should give priority to:
A.Turning the client to the
left side
B. Milking the tube to ensure
patency
C. Slowing the intravenous
infusion
D.Notifying the physician
239. The infant is admitted to
the unit with tetrology of falot. The nurse would anticipate an order for which
medication?
A.Digoxin
B. Epinephrine
C. Aminophyline
D.Atropine
240. The nurse is educating the
lady's club in self-breast exam. The nurse is aware that most malignant breast
masses occur in the Tail of Spence. On the diagram, place an X on the Tail of
Spence.
241. The toddler is admitted with
a cardiac anomaly. The nurse is aware that the infant with a ventricular septal
defect will:
A.Tire easily
B. Grow normally
C. Need more calories
D.Be more susceptible to viral
infections
242. The nurse is monitoring a
client with a history of stillborn infants. The nurse is aware that a nonstress
test can be ordered for this client to:
A.Determine lung maturity
B. Measure the fetal activity
C. Show the effect of
contractions on fetal heart rate
D.Measure the well-being of
the fetus
243. The nurse is evaluating the
client who was admitted 8 hours ago for induction of labor. The following graph
is noted on the monitor. Which action should be taken first by the nurse?
A.Instruct the client to push
B. Perform a vaginal exam
C. Turn off the Pitocin infusion
D.Place the client in a
semi-Fowler's position
244. The nurse notes the
following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia
as:
A.Atrial flutter
B. A sinus rhythm
C. Ventricular tachycardia
D.Atrial fibrillation
245. A client with clotting
disorder has an order to continue Lovenox (enoxaparin) injections after
discharge. The nurse should teach the client that Lovenox injections should:
A.Be injected into the deltoid
muscle
B. Be injected into the abdomen
C. Aspirate after the injection
D.Clear the air from the
syringe before injections
246. The nurse has a preop order
to administer Valium (diazepam) 10mg and Phenergan (promethazine) 25mg. The
correct method of administering these medications is to:
A.Administer the medications
together in one syringe
B. Administer the medication
separately
C. Administer the Valium, wait
5 minutes, and then inject the Phenergan
D.Question the order because
they cannot be given at the same time
247. A client with frequent
urinary tract infections asks the nurse how she can prevent the reoccurrence.
The nurse should teach the client to:
A.Douche after intercourse
B. Void every 3 hours
C. Obtain a urinalysis monthly
D.Wipe from back to front
after voiding
248. Which task should be
assigned to the nursing assistant?
A.Placing the client in
seclusion
B. Emptying the Foley catheter
of the preeclamptic client
C. Feeding the client with
dementia
D.Ambulating the client with a
fractured hip
249. The client has recently
returned from having a thyroidectomy. The nurse should keep which of the
following at the bedside?
A.A tracheotomy set
B. A padded tongue blade
C. An endotracheal tube
D.An airway
250. The physician has ordered a
histoplasmosis test for the elderly client. The nurse is aware that
histoplasmosis is transmitted to humans by:
A.Cats
B. Dogs
C. Turtles
D.Birds
Answers and Rationales for Comprehensive
Examination Part 2
1. Answer D is correct. It is
important to assess the extremities for blood vessel occlusion in the client
with sickle cell anemia because a change in capillary refill would indicate a
change in circulation. Body temperature, motion, and sensation would not give
information regarding peripheral circulation; therefore, answers A, B, and C
are incorrect.
2. Answer D is correct. Placing
the client in semi-Fowler’s position provides the best oxygenation for this
client. Flexion of the hips and knees, which includes the knee-chest position,
impedes circulation and is not correct positioning for this client. Therefore,
answers A, B, and C are incorrect.
3. Answer B is correct. It is
important to keep the client in sickle cell crisis hydrated to prevent further
sickling of the blood. Answer A is incorrect because a mechanical cuff places
too much pressure on the arm. Answer C is incorrect because raising the knee
gatch impedes circulation. Answer D is incorrect because Tylenol is too mild an
analgesic for the client in crisis.
4. Answer C is correct.
Hydration is important in the client with sickle cell disease to prevent
thrombus formation. Popsicles, gelatin, juice, and pudding have high fluid
content. The foods in answers A, B, and D do not aid in hydration and are,
therefore, incorrect.
5. Answer C is correct. The
most prominent clinical manifestation of sickle cell crisis is pain. However,
the pulse oximetry indicates that oxygen levels are low; thus, oxygenation
takes precedence over pain relief. Answer A is incorrect because although a
warm environment reduces pain and minimizes sickling, it would not be a
priority. Answer B is incorrect because although hydration is important, it
would not require a bolus. Answer D is incorrect because Demerol is acidifying
to the blood and increases sickling.
6. Answer C is correct. Egg
yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high
in iron, which is an important mineral for this client. Roast beef, cabbage,
and pork chops are also high in iron, but the side dishes accompanying these
choices are not; therefore, answers A, B, and D are incorrect.
7. Answer D is correct. Taking
a trip to the museum is the only answer that does not pose a threat. A family
vacation in the Rocky Mountains at high altitudes, cold temperatures, and
airplane travel can cause sickling episodes and should be avoided; therefore,
answers A, B, and C are incorrect.
8. Answer D is correct. The
tongue is smooth and beefy red in the client with vitamin B12 deficiency, so
examining the tongue should be included in the physical assessment. Bleeding,
splenomegaly, and blood pressure changes do not occur, making answers A, B, and
C incorrect.
9. Answer C is correct. The
oral mucosa and hard palate (roof of the mouth) are the best indicators of
jaundice in dark-skinned persons. The conjunctiva can have normal deposits of
fat, which give a yellowish hue; thus, answer A is incorrect. The soles of the
feet can be yellow if they are calloused, making answer B incorrect; the shins
would be an area of darker pigment, so answer D is incorrect.
10. Answer B is correct. When
there are fewer red blood cells, there is less hemoglobin and less oxygen.
Therefore, the client is often short of breath, as indicated in answer B. The
client with anemia is often pale in color, has weight loss, and may be
hypotensive. Answers A, C, and D are within normal and, therefore, are
incorrect.
11. Answer A is correct. The
client with polycythemia vera is at risk for thrombus formation. Hydrating the
client with at least 3L of fluid per day is important in preventing clot
formation, so the statement to drink less than 500mL is incorrect. Answers B,
C, and D are incorrect because they all contribute to the prevention of
complications. Support hose promotes venous return, the electric razor prevents
bleeding due to injury, and a diet low in iron is essential to preventing
further red cell formation.
12. Answer C is correct.
Radiation treatment for other types of cancer can result in leukemia. Some
hobbies and occupations involving chemicals are linked to leukemia, but not the
ones in these answers; therefore, answers A and B are incorrect. Answer D is
incorrect because the incidence of leukemia is higher in twins than in
siblings.
13. Answer D is correct.
Petechiae are not usually visualized on dark skin. The soles of the feet and
palms of the hand provide a lighter surface for assessing the client for
petichiae. Answers A, B, and C are incorrect because the skin might be too dark
to make an assessment.
14. Answer B is correct. The
client with leukemia is at risk for infection and has often had recurrent
respiratory infections during the previous 6 months. Insomnolence, weight loss,
and a decrease in alertness also occur in leukemia, but bleeding tendencies and
infections are the primary clinical manifestations; therefore, answers A, C,
and D are incorrect.
15. Answer B is correct. The
client with acute leukemia has bleeding tendencies due to decreased platelet
counts, and any injury would exacerbate the problem. The client would require
close monitoring for hemorrhage, which is of higher priority than the diagnoses
in answers A, C, and D, which are incorrect.
16. Answer A is correct.
Radiation therapy often causes sterility in male clients and would be of
primary importance to this client. The psychosocial needs of the client are
important to address in light of the age and life choices. Hodgkin’s disease,
however, has a good prognosis when diagnosed early. Answers B, C, and D are
incorrect because they are of lesser priority.
17. Answer A is correct. Clients
with autoimmune thrombocytopenic purpura (ATP) have low platelet counts, making
answer A the correct answer. White cell counts, potassium levels, and PTT are
not affected in ATP; thus, answers B, C, and D are incorrect.
18. Answer A is correct. The
normal platelet count is 120,000–400,000. Bleeding occurs in clients with low
platelets. The priority is to prevent and minimize bleeding. Oxygenation in
answer C is important, but platelets do not carry oxygen. Answers B and D are
of lesser priority and are incorrect in this instance.
19. Answer C is correct.
Elevating the head of the bed 30° avoids pressure on the sella turcica and
alleviates headaches. Answers A, B, and D are incorrect because Trendelenburg,
Valsalva maneuver, and coughing all increase the intracranial pressure.
20. Answer B is correct. The
large amount of fluid loss can cause fluid and electrolyte imbalance that
should be corrected. The loss of electrolytes would be reflected in the vital
signs. Measuring the urinary output is important, but the stem already says
that the client has polyuria, so answer A is incorrect. Encouraging fluid
intake will not correct the problem, making answer C incorrect. Answer D is
incorrect because weighing the client is not necessary at this time.
21. Answer C is correct. The
client should be positioned upright and leaning forward, to prevent aspiration
of blood. Answers A, B, and D are incorrect because direct pressure to the nose
stops the bleeding, and ice packs should be applied directly to the nose as
well. If a pack is necessary, the nares are loosely packed.
22. Answer A is correct. Blood
pressure is the best indicator of cardiovascular collapse in the client who has
had an adrenal gland removed. The remaining gland might have been suppressed
due to the tumor activity. Temperature would be an indicator of infection,
decreased output would be a clinical manifestation but would take longer to
occur than blood pressure changes, and specific gravity changes occur with
other disorders; therefore, answers B, C, and D are incorrect.
23. Answer A is correct. IV
glucocorticoids raise the glucose levels and often require coverage with
insulin. Answer B is not necessary at this time, sodium and potassium levels
would be monitored when the client is receiving mineral corticoids, and daily
weights is unnecessary; therefore, answers B, C, and D are incorrect.
24. Answer B is correct. The
parathyroid glands are responsible for calcium production and can be damaged
during a thyroidectomy. The tingling is due to low calcium levels. The crash
cart would be needed in respiratory distress but would not be the next action
to take; thus, answer A is incorrect. Hypertension occurs in thyroid storm and
the drainage would occur in hemorrhage, so answers C and D are incorrect.
25. Answer D is correct. The
decrease in pulse can affect the cardiac output and lead to shock, which would
take precedence over the other choices; therefore, answers A, B, and C are
incorrect.
26. Answer A is correct. The
client taking antilipidemics should be encouraged to report muscle weakness
because this is a sign of rhabdomyositis. The medication takes effect within 1
month of beginning therapy, so answer B is incorrect. The medication should be
taken with water because fruit juice, particularly grapefruit, can decrease the
effectiveness, making answer C incorrect. Liver function studies should be
checked before beginning the medication, not after the fact, making answer D
incorrect.
27. Answer B is correct.
Hyperstat is given IV push for hypertensive crises, but it often causes
hyperglycemia. The glucose level will drop rapidly when stopped. Answer A is
incorrect because the hyperstat is given by IV push. The client should be
placed in dorsal recumbent position, not a Trendelenburg position, as stated in
answer C. Answer D is incorrect because the medication does not have to be
covered with foil.
28. Answer C is correct. A heart
rate of 60 in the baby should be reported immediately. The dose should be held
if the heart rate is below 100bpm. The blood glucose, blood pressure, and
respirations are within normal limits; thus answers A, B, and D are incorrect.
29. Answer C is correct.
Nitroglycerine should be kept in a brown bottle (or even a special air- and
water-tight, solid or plated silver or gold container) because of its instability
and tendency to become less potent when exposed to air, light, or water. The
supply should be replenished every 6 months, not 3 months, and one tablet
should be taken every 5 minutes until pain subsides, so answers A and B are
incorrect. If the pain does not subside, the client should report to the
emergency room. The medication should be taken sublingually and should not be
crushed, as stated in answer D.
30. Answer C is correct. Turkey
contains the least amount of fats and cholesterol. Liver, eggs, beef, cream
sauces, shrimp, cheese, and chocolate should be avoided by the client; thus,
answers A, B, and D are incorrect. The client should bake meat rather than
frying to avoid adding fat to the meat during cooking.
31. Answer B is correct. The
jugular veins in the neck should be assessed for distension. The other parts of
the body will be edematous in right-sided congestive heart failure, not
left-sided; thus, answers A, C, and D are incorrect.
32. Answer A is correct. The
phlebostatic axis is located at the fifth intercostals space midaxillary line
and is the correct placement of the manometer. The PMI or point of maximal
impulse is located at the fifth intercostals space midclavicular line, so
answer B is incorrect. Erb’s point is the point at which you can hear the
valves close simultaneously, making answer C incorrect. The Tail of Spence (the
upper outer quadrant) is the area where most breast cancers are located and has
nothing to do with placement of a manometer; thus, answer D is incorrect.
33. Answer B is correct. Zestril
is an ACE inhibitor and is frequently given with a diuretic such as Lasix for
hypertension. Answers A, C, and D are incorrect because the order is accurate.
There is no need to question the order, administer the medication separately,
or contact the pharmacy.
34. Answer B is correct. The
best indicator of peripheral edema is measuring the extremity. A paper tape
measure should be used rather than one of plastic or cloth, and the area should
be marked with a pen, providing the most objective assessment. Answer A is
incorrect because weighing the client will not indicate peripheral edema.
Answer C is incorrect because checking the intake and output will not indicate
peripheral edema. Answer D is incorrect because checking for pitting edema is
less reliable than measuring with a paper tape measure.
35. Answer D is correct. Clients
with radium implants should have close contact limited to 30 minutes per visit.
The general rule is limiting time spent exposed to radium, putting distance
between people and the radium source, and using lead to shield against the
radium. Teaching the family member these principles is extremely important.
Answers A, B, and C are not empathetic and do not address the question;
therefore, they are incorrect.
36. Answer B is correct. The client
with a facial stroke will have difficulty swallowing and chewing, and the foods
in answer B provide the least amount of chewing. The foods in answers A, C, and
D would require more chewing and, thus, are incorrect.
37. Answer A is correct. Novalog
insulin onsets very quickly, so food should be available within 10–15 minutes
of taking the insulin. Answer B does not address a particular type of insulin,
so it is incorrect. NPH insulin peaks in 8–12 hours, so a snack should be eaten
at the expected peak time. It may not be 3 p.m. as stated in answer C. Answer D
is incorrect because there is no need to save the dessert until bedtime.
38. Answer B is correct. The
umbilical cord needs time to dry and fall off before putting the infant in the
tub. Although answers A, C, and D might be important, they are not the primary
answer to the question.
39. Answer D is correct.
Leucovorin is the antidote for Methotrexate and Trimetrexate which are folic
acid antagonists. Leucovorin is a folic acid derivative. Answers A, B, and C
are incorrect because Leucovorin does not treat iron deficiency, increase
neutrophils, or have a synergistic effect.
40. Answer A is correct. The
Hemophilus influenza vaccine is given at 4 months with the polio vaccine.
Answers B, C, and D are incorrect because these vaccines are given later in
life.
41. Answer B is correct. Proton
pump inhibitors such as Nexium and Protonix should be taken with meals, for
optimal effect. Histamine-blocking agents such as Zantac should be taken 30
minutes before meals, so answer A is incorrect. Tagamet can be taken in a
single dose at bedtime, making answer C incorrect. Answer D does not treat the
problem adequately and, therefore, is incorrect.
42. Answer A is correct. If the
client is a threat to the staff and to other clients the nurse should call for
help and prepare to administer a medication such as Haldol to sedate him.
Answer B is incorrect because simply telling the client to calm down will not
work. Answer C is incorrect because telling the client that if he continues he
will be punished is a threat and may further anger him. Answer D is incorrect
because if the client is left alone he might harm himself.
43. Answer A is correct. If the
fundus of the client is displaced to the side, this might indicate a full
bladder. The next action by the nurse should be to check for bladder distention
and catheterize, if necessary. The answers in B, C, and D are actions that
relate to postpartal hemorrhage.
44. Answer C is correct. A
low-grade temperature, blood-tinged sputum, fatigue, and night sweats are
symptoms consistent with tuberculosis. If the answer in A had said pneumocystis
pneumonia, answer A would have been consistent with the symptoms given in the
stem, but just saying pneumonia isn’t specific enough to diagnose the problem.
Answers B and D are not directly related to the stem.
45. Answer B is correct. If the
client has a history of Prinzmetal’s angina, he should not be prescribed
triptan preparations because they cause vasoconstriction and coronary spasms.
There is no contraindication for taking triptan drugs in clients with diabetes,
cancer, or cluster headaches making answers A, C, and D incorrect.
46. Answer A is correct.
Kernig’s sign is positive if pain occurs on flexion of the hip and knee. The
Brudzinski reflex is positive if pain occurs on flexion of the head and neck
onto the chest so answer B is incorrect. Answers C and D might be present but
are not related to Kernig’s sign.
47. Answer B is correct. Apraxia
is the inability to use objects appropriately. Agnosia is loss of sensory
comprehension, anomia is the inability to find words, and aphasia is the
inability to speak or understand so answers A, C, and D are incorrect.
48. Answer C is correct.
Increased confusion at night is known as "sundowning" syndrome. This
increased confusion occurs when the sun begins to set and continues during the
night. Answer A is incorrect because fatigue is not necessarily present.
Increased confusion at night is not part of normal aging; therefore, answer B
is incorrect. A delusion is a firm, fixed belief; therefore, answer D is
incorrect.
49. Answer C is correct. The
client who is confused might forget that he ate earlier. Don’t argue with the
client. Simply get him something to eat that will satisfy him until lunch.
Answers A and D are incorrect because the nurse is dismissing the client.
Answer B is validating the delusion.
50. Answer D is correct. Nausea
and gastrointestinal upset are very common in clients taking
acetylcholinesterase inhibitors such as Exelon. Other side effects include
liver toxicity, dizziness, unsteadiness, and clumsiness. The client might
already be experiencing urinary incontinence or headaches, but they are not
necessarily associated; and the client with Alzheimer’s disease is already
confused. Therefore, answers A, B, and C are incorrect.
51. Answer B is correct. Any
lesion should be reported to the doctor. This can indicate a herpes lesion.
Clients with open lesions related to herpes are delivered by Cesarean section
because there is a possibility of transmission of the infection to the fetus
with direct contact to lesions. It is not enough to document the finding, so
answer A is incorrect. The physician must make the decision to perform a
C-section, making answer C incorrect. It is not enough to continue primary
care, so answer D is incorrect.
52. Answer B is correct. The
client with HPV is at higher risk for cervical and vaginal cancer related to
this STI. She is not at higher risk for the other cancers mentioned in answers
A, C, and D, so those are incorrect.
53. Answer B is correct. A
lesion that is painful is most likely a herpetic lesion. A chancre lesion
associated with syphilis is not painful, so answer A is incorrect. Condylomata
lesions are painless warts, so answer D is incorrect. In answer C, gonorrhea
does not present as a lesion, but is exhibited by a yellow discharge.
54. Answer C is correct.
Florescent treponemal antibody (FTA) is the test for treponema pallidum. VDRL
and RPR are screening tests done for syphilis, so answers A and B are
incorrect. The Thayer-Martin culture is done for gonorrhea, so answer D is
incorrect.
55. Answer D is correct. The
criteria for HELLP is hemolysis, elevated liver enzymes, and low platelet
count. In answer A, an elevated blood glucose level is not associated with
HELLP. Platelets are decreased, not elevated, in HELLP syndrome as stated in
answer B. The creatinine levels are elevated in renal disease and are not
associated with HELLP syndrome so answer C is incorrect.
56. Answer A is correct. Answer
B elicits the triceps reflex, so it is incorrect. Answer C elicits the patella
reflex, making it incorrect. Answer D elicits the radial nerve, so it is
incorrect.
57. Answer B is correct.
Brethine is used cautiously because it raises the blood glucose levels. Answers
A, C, and D are all medications that are commonly used in the diabetic client,
so they are incorrect.
58. Answer C is correct. When
the L/S ratio reaches 2:1, the lungs are considered to be mature. The infant
will most likely be small for gestational age and will not be at risk for birth
trauma, so answer D is incorrect. The L/S ratio does not indicate congenital
anomalies, as stated in answer A, and the infant is not at risk for
intrauterine growth retardation, making answer B incorrect.
59. Answer C is correct.
Jitteriness is a sign of seizure in the neonate. Crying, wakefulness, and
yawning are expected in the newborn, so answers A, B, and D are incorrect.
60. Answer B is correct. The
client is expected to become sleepy, have hot flashes, and be lethargic. A
decreasing urinary output, absence of the knee-jerk reflex, and decreased respirations
indicate toxicity, so answers A, C, and D are incorrect.
61. Answer D is correct. If the
client experiences hypotension after an injection of epidural anesthetic, the
nurse should turn her to the left side, apply oxygen by mask, and speed the IV
infusion. If the blood pressure does not return to normal, the physician should
be contacted. Epinephrine should be kept for emergency administration. Answer A
is incorrect because placing the client in Trendelenburg position (head down)
will allow the anesthesia to move up above the respiratory center, thereby
decreasing the diaphragm’s ability to move up and down and ventilate the
client. In answer B, the IV rate should be increased, not decreased. In answer
C, the oxygen should be applied by mask, not cannula.
62. Answer A is correct. Cancer
of the pancreas frequently leads to severe nausea and vomiting and altered
nutrition. The other problems are of lesser concern; thus, answers B, C, and D
are incorrect.
63. Answer C is correct.
Measuring with a paper tape measure and marking the area that is measured is
the most objective method of estimating ascites. Inspecting and checking for
fluid waves are more subjective, so answers A and B are incorrect. Palpation of
the liver will not tell the amount of ascites; thus, answer D is incorrect.
64. Answer B is correct. The
vital signs indicate hypovolemic shock. They do not indicate cerebral tissue
perfusion, airway clearance, or sensory perception alterations, so answers A,
C, and D are incorrect.
65. Answer A is correct. The
client with osteogenesis imperfecta is at risk for pathological fractures and
is likely to experience these fractures if he participates in contact sports.
The client might experience symptoms of hypoxia if he becomes dehydrated or
deoxygenated; extreme exercise, especially in warm weather, can exacerbate the
condition. Answers B, C, and D are not factors for concern.
66. Answer D is correct. The
client with neutropenia should not have fresh fruit because it should be peeled
and/or cooked before eating. He should also not eat foods grown on or in the
ground or eat from the salad bar. The nurse should remove potted or cut flowers
from the room as well. Any source of bacteria should be eliminated, if
possible. Answers A, B, and C will not help prevent bacterial invasions.
67. Answer B is correct. In
clients who have not had surgery to the face or neck, the answer would be
answer A; however, in this situation, this could further interfere with the
airway. Increasing the infusion and placing the client in supine position would
be better. Answers C is incorrect because it is not necessary at this time and
could cause hyponatremia and further hypotension. Answer D is not necessary at
this time.
68. Answer C is correct. If the
client pulls the chest tube out of the chest, the nurse’s first action should
be to cover the insertion site with an occlusive dressing. Afterward, the nurse
should call the doctor, who will order a chest x-ray and possibly reinsert the
tube. Answers A, B, and D are not the first action to be taken.
69. Answer A is correct. The
normal Protime is 12–20 seconds. A Protime of 120 seconds indicates an
extremely prolonged Protime and can result in a spontaneous bleeding episode.
Answers B, C, and D may be needed at a later time but are not the most
important actions to take first.
70. Answer C is correct. The
food with the most calcium is the yogurt. Answers A, B, and D are good choices,
but not as good as the yogurt, which has approximately 400mg of calcium.
71. Answer C is correct. The
client receiving magnesium sulfate should have a Foley catheter in place, and
hourly intake and output should be checked. There is no need to refrain from
checking the blood pressure in the right arm. A padded tongue blade should be
kept in the room at the bedside, just in case of a seizure, but this is not
related to the magnesium sulfate infusion. Darkening the room is unnecessary,
so answers A, B, and D are incorrect.
72. Answer D is correct. If the
client’s mother refuses the blood transfusion, the doctor should be notified.
Because the client is a minor, the court might order treatment. Answer A is
incorrect. Because it is not the primary responsibility for the nurse to
encourage the mother to consent or explain the consequences, so answers B and C
are incorrect.
73. Answer B is correct. The
nurse should be most concerned with laryngeal edema because of the area of
burn. The next priority should be answer A, as well as hyponatremia and
hypokalemia in C and D, but these answers are not of primary concern so are
incorrect.
74. Answer D is correct. The
client with anorexia shows the most improvement by weight gain. Selecting a
balanced diet does little good if the client will not eat, so answer A is
incorrect. The hematocrit might improve by several means, such as blood
transfusion, but that does not indicate improvement in the anorexic condition;
therefore, answer B is incorrect. The tissue turgor indicates fluid stasis, not
improvement of anorexia, so answer C is incorrect.
75. Answer D is correct. At this
time, pain beneath the cast is normal. The client’s toes should be warm to the
touch, and pulses should be present. Paresthesia is not normal and might
indicate compartment syndrome. Therefore, Answers A, B, and C are incorrect.
76. Answer B is correct. It is
normal for the client to have a warm sensation when dye is injected. Answers A,
C, and D indicate that the nurse believes that the hot feeling is abnormal, so
they are incorrect.
77. Answer D is correct. It is
not necessary to wear gloves to take the vital signs of the client. If the
client has active infection with methicillin-resistant staphylococcus aureus,
gloves should be worn. The healthcare workers in answers A, B, and C indicate
knowledge of infection control by their actions.
78. Answer D is correct. During
ECT, the client will have a grand mal seize. This indicates completion of the
electroconvulsive therapy. Answers A, B, and C do not indicate that the ECT has
been effective, so are incorrect.
79. Answer A is correct.
Infection with pinworms begins when the eggs are ingested or inhaled. The eggs
hatch in the upper intestine and mature in 2–8 weeks. The females then mate and
migrate out the anus, where they lay up to 17,000 eggs. This causes intense
itching. The mother should be told to use a flashlight to examine the rectal
area about 2–3 hours after the child is asleep. Placing clear tape on a tongue
blade will allow the eggs to adhere to the tape. The specimen should then be
brought in to be evaluated. There is no need to scrap the skin, collect a stool
specimen, or bring a sample of hair, so answers B, C, and D are incorrect.
80. Answer B is correct.
Erterobiasis, or pinworms, is treated with Vermox (mebendazole) or Antiminth
(pyrantel pamoate). The entire family should be treated to ensure that no eggs
remain. Because a single treatment is usually sufficient, there is usually good
compliance. The family should then be tested again in 2 weeks to ensure that no
eggs remain. Answers A, C, and D are incorrect statements.
81. Answer A is correct. The
pregnant nurse should not be assigned to any client with radioactivity present.
The client receiving linear accelerator therapy travels to the radium
department for therapy. The radiation stays in the department, so the client is
not radioactive. The clients in answers B, C, and D pose a risk to the pregnant
nurse. These clients are radioactive in very small doses, especially upon
returning from the procedures. For approximately 72 hours, the clients should
dispose of urine and feces in special containers and use plastic spoons and
forks.
82. Answer A is correct. The
client with Cushing’s disease has adrenocortical hypersecretion. This increase
in the level of cortisone causes the client to be immune suppressed. In answer
B, the client with diabetes poses no risk to other clients. The client in
answer C has an increase in growth hormone and poses no risk to himself or
others. The client in answer D has hyperthyroidism or myxedema and poses no
risk to others or himself.
83. Answer D is correct. The
nurse could be charged with malpractice, which is failing to perform, or
performing an act that causes harm to the client. Giving the infant an overdose
falls into this category. Answers A, B, and C are incorrect because they apply
to other wrongful acts. Negligence is failing to perform care for the client; a
tort is a wrongful act committed on the client or their belongings; and assault
is a violent physical or verbal attack.
84. Answer D is correct. The
licensed practical nurse should not be assigned to begin a blood transfusion.
The licensed practical nurse can insert a Foley catheter, discontinue a nasogastric
tube, and collect sputum specimen; therefore, answers A, B, and C are
incorrect.
85. Answer B is correct. The
vital signs are abnormal and should be reported immediately. Continuing to
monitor the vital signs can result in deterioration of the client’s condition,
making answer A incorrect. Asking the client how he feels in answer C will only
provide subjective data, and the nurse in answer D is not the best nurse to
assign because this client is unstable.
86. Answer B is correct. The
nurse with 3 years of experience in labor and delivery knows the most about
possible complications involving preeclampsia. The nurse in answer A is a new
nurse to the unit, and the nurses in answers C and D have no experience with
the postpartum client.
87. Answer B is correct. The
Joint Commission on Accreditation of Hospitals will probably be interested in
the problems in answers A and C. The failure of the nursing assistant to care
for the client with hepatitis might result in termination, but is not of
interest to the Joint Commission.
88. Answer B is correct. The
next action after discussing the problem with the nurse is to document the
incident by filing a formal reprimand. If the behavior continues or if harm has
resulted to the client, the nurse may be terminated and reported to the Board
of Nursing, but these are not the first actions requested in the stem. A tort
is a wrongful act to the client or his belongings and is not indicated in this
instance. Therefore, Answers A, C, and D are incorrect.
89. Answer D is correct. The client
at highest risk for complications is the client with multiple sclerosis who is
being treated with cortisone via the central line. The others are more stable.
MRSA is methicillin-resistant staphylococcus aureus. Vancomycin is the drug of
choice and is given at scheduled times to maintain blood levels of the drug.
The clients in answers A, B, and C are more stable and can be seen later.
90. Answer B is correct. The
pregnant client and the client with a broken arm and facial lacerations are the
best choices for placing in the same room. The clients in answers A, C, and D
need to be placed in separate rooms due to the serious natures of their
injuries.
91. Answer A is correct. Before
instilling eyedrops, the nurse should cleanse the area with water. A 6-year-old
child is not developmentally ready to instill his own eyedrops, so answer B is
incorrect. Although the mother of the child can instill the eyedrops, the area
must be cleansed before administration, making answer C incorrect. Although the
eye might appear to be clear, the nurse should instill the eyedrops, as
ordered, so answer D is incorrect.
92. Answer C is correct.
Remember the ABCs (airway, breathing, circulation) when answering this
question. Answer C is correct because a hotdog is the size and shape of the child’s
trachea and poses a risk of aspiration. Answers A, B, and C are incorrect
because white grape juice, a grilled cheese sandwich, and ice cream do not pose
a risk of aspiration for a child.
93. Answer C is correct. The
nurse should encourage rooming-in to promote parent-child attachment. It is
okay for the parents to be in the room for assessment of the child. Allowing
the child to have items that are familiar to him is allowed and encouraged;
therefore, answers A and B are incorrect. Answer D is not part of the nurse’s
responsibilities.
94. Answer B is correct. The
hearing aid should be stored in a warm, dry place. It should be cleaned daily
but should not be moldy, so answer A is incorrect. A toothpick is inappropriate
to use to clean the aid; the toothpick might break off in the hearing aide,
making answer C incorrect. Changing the batteries weekly, as in answer D, is
not necessary.
95. Answer C is correct. Always
remember your ABCs (airway, breathing, circulation) when selecting an answer.
Although answers B and D might be appropriate for this child, answer C should
have the highest priority. Answer A does not apply for a child who has
undergone a tonsillectomy.
96. Answer A is correct. If the
child has bacterial pneumonia, a high fever is usually present. Bacterial
pneumonia usually presents with a productive cough, not a nonproductive cough,
making answer B incorrect. Rhinitis is often seen with viral pneumonia, and
vomiting and diarrhea are usually not seen with pneumonia, so answers C and D
are incorrect.
97. Answer B is correct. For a
child with epiglottis and the possibility of complete obstruction of the
airway, emergency tracheostomy equipment should always be kept at the bedside.
Intravenous supplies, fluid, and oxygen will not treat an obstruction;
therefore, answers A, C, and D are incorrect.
98. Answer C is correct.
Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. The
client with hyperthyroidism will often exhibit tachycardia, increased appetite,
and weight loss; therefore, answers A, B, and D are incorrect.
99. Answer D is correct. The
child with celiac disease should be on a gluten-free diet. Answers A, B, and C
all contain gluten, while answer D gives the only choice of foods that does not
contain gluten.
100.
Answer C is correct. Remember the ABCs (airway, breathing, circulation)
when answering this question. Before notifying the physician or assessing the
pulse, oxygen should be applied to increase the oxygen saturation, so answers A
and D are incorrect. The normal oxygen saturation for a child is 92%–100%,
making answer B incorrect.
101.
Answer B is correct. An amniotomy is an artificial rupture of membranes
and normal amniotic fluid is straw-colored and odorless. Fetal heart tones of
160 indicate tachycardia, and greenish fluid is indicative of meconium, so
answers A and C are incorrect. If the nurse notes the umbilical cord, the
client is experiencing a prolapsed cord, so answer D is incorrect and would
need to be reported immediately.
102.
Answer D is correct. Dilation of 2cm marks the end of the latent phase of
labor. Answer A is a vague answer, answer B indicates the end of the first
stage of labor, and answer C indicates the transition phase.
103.
Answer B is correct. The normal fetal heart rate is 120–160bpm;
100–110bpm is bradycardia. The first action would be to turn the client to the
left side and apply oxygen. Answer A is not indicated at this time. Answer C is
not the best action for clients experiencing bradycardia. There is no data to
indicate the need to move the client to the delivery room at this time.
104.
Answer D is correct. The expected effect of Pitocin is cervical dilation.
Pitocin causes more intense contractions, which can increase the pain, making
answer A incorrect. Cervical effacement is caused by pressure on the presenting
part, so answer B is incorrect. Answer C is opposite the action of Pitocin.
105.
Answer B is correct. Applying a fetal heart monitor is the correct action
at this time. There is no need to prepare for a Caesarean section or to place
the client in Genu Pectoral position (knee-chest), so answers A and C are
incorrect. Answer D is incorrect because there is no need for an ultrasound
based on the finding.
106.
Answer B is correct. The nurse decides to apply an external monitor
because the membranes are intact. Answers A, C, and D are incorrect. The cervix
is dilated enough to use an internal monitor, if necessary. An internal monitor
can be applied if the client is at 0-station. Contraction intensity has no
bearing on the application of the fetal monitor.
107.
Answer D is correct. Clients admitted in labor are told not to eat during
labor, to avoid nausea and vomiting. Ice chips may be allowed, but this amount
of fluid might not be sufficient to prevent fluid volume deficit. In answer A,
impaired gas exchange related to hyperventilation would be indicated during the
transition phase. Answers B and C are not correct in relation to the stem.
108.
Answer D is correct. This information indicates a late deceleration. This
type of deceleration is caused by uteroplacental lack of oxygen. Answer A has
no relation to the readings, so it’s incorrect; answer B results in a variable
deceleration; and answer C is indicative of an early deceleration.
109.
Answer C is correct. The initial action by the nurse observing a late
deceleration should turn the client to the side—preferably, the left side.
Administering oxygen is also indicated. Answer A might be necessary but not
before turning the client to her side. Answer B is not necessary at this time.
Answer D is incorrect because there is no data to indicate that the monitor has
been applied incorrectly.
110.
Answer D is correct. Accelerations with movement are normal. Answers A,
B, and C indicate ominous findings on the fetal heart monitor.
111.
Answer C is correct. Epidural anesthesia decreases the urge to void and
sensation of a full bladder. A full bladder will decrease the progression of
labor. Answers A, B, and D are incorrect for the stem.
112.
Answer B is correct. Lutenizing hormone released by the pituitary is
responsible for ovulation. At about day 14, the continued increase in estrogen
stimulates the release of lutenizing hormone from the anterior pituitary. The
LH surge is responsible for ovulation, or the release of the dominant follicle
in preparation for conception, which occurs within the next 10–12 hours after
the LH levels peak. Answers A, C, and D are incorrect because estrogen levels
are high at the beginning of ovulation, the endometrial lining is thick, not
thin, and the progesterone levels are high, not low.
113.
Answer C is correct. The success of the rhythm method of birth control is
dependent on the client’s menses being regular. It is not dependent on the age
of the client, frequency of intercourse, or range of the client’s temperature;
therefore, answers A, B, and D are incorrect.
114.
Answer C is correct. The best method of birth control for the client with
diabetes is the diaphragm. A permanent intrauterine device can cause a
continuing inflammatory response in diabetics that should be avoided, oral
contraceptives tend to elevate blood glucose levels, and contraceptive sponges
are not good at preventing pregnancy. Therefore, answers A, B, and D are
incorrect.
115.
Answer D is correct. The signs of an ectopic pregnancy are vague until
the fallopian tube ruptures. The client will complain of sudden, stabbing pain
in the lower quadrant that radiates down the leg or up into the chest. Painless
vaginal bleeding is a sign of placenta previa, abdominal cramping is a sign of
labor, and throbbing pain in the upper quadrant is not a sign of an ectopic
pregnancy, making answers A, B, and C incorrect.
116.
Answer C is correct. All of the choices are tasty, but the pregnant
client needs a diet that is balanced and has increased amounts of calcium.
Answer A is lacking in fruits and milk. Answer B contains the potato chips,
which contain a large amount of sodium. Answer C contains meat, fruit, potato
salad, and yogurt, which has about 360mg of calcium. Answer D is not the best
diet because it lacks vegetables and milk products.
117.
Answer B is correct. The client with hyperemesis has persistent nausea
and vomiting. With vomiting comes dehydration. When the client is dehydrated,
she will have metabolic acidosis. Answers A and C are incorrect because they
are respiratory dehydration. Answer D is incorrect because the client will not
be in alkalosis with persistent vomiting.
118.
Answer B is correct. The most definitive diagnosis of pregnancy is the
presence of fetal heart tones. The signs in answers A, C, and D are subjective
and might be related to other medical conditions. Answers A and C may be
related to a hydatidiform mole, and answer D is often present before menses or
with the use of oral contraceptives.
119.
Answer C is correct. The infant of a diabetic mother is usually large for
gestational age. After birth, glucose levels fall rapidly due to the absence of
glucose from the mother. Answer A is incorrect because the infant will not be
small for gestational age. Answer B is incorrect because the infant will not be
hyperglycemic. Answer D is incorrect because the infant will be large, not
small, and will be hypoglycemic, not hyperglycemic.
120.
Answer B is correct. When the client is taking oral contraceptives and
begins antibiotics, another method of birth control should be used. Antibiotics
decrease the effectiveness of oral contraceptives. Approximately 5–10 pounds of
weight gain is not unusual, so answer A is incorrect. If the client misses a
birth control pill, she should be instructed to take the pill as soon as she
remembers the pill. Answer C is incorrect. If she misses two, she should take
two; if she misses more than two, she should take the missed pills but use
another method of birth control for the remainder of the cycle. Answer D is
incorrect because changes in menstrual flow are expected in clients using oral
contraceptives. Often these clients have lighter menses.
121.
Answer B is correct. Clients with HIV should not breastfeed because the
infection can be transmitted to the baby through breast milk. The clients in
answers A, C, and D—those with diabetes, hypertension, and thyroid disease—can
be allowed to breastfeed.
122.
Answer A is correct. The symptoms of painless vaginal bleeding are
consistent with placenta previa. Answers B, C, and D are incorrect. Cervical
check for dilation is contraindicated because this can increase the bleeding.
Checking for firmness of the uterus can be done, but the first action should be
to check the fetal heart tones. A detailed history can be done later.
123.
Answer D is correct. The client should be advised to come to the labor
and delivery unit when the contractions are every 5 minutes and consistent. She
should also be told to report to the hospital if she experiences rupture of
membranes or extreme bleeding. She should not wait until the contractions are
every 2 minutes or until she has bloody discharge, so answers A and B are
incorrect. Answer C is a vague answer and can be related to a urinary tract
infection.
124.
Answer A is correct. Infants of mothers who smoke are often low in birth
weight. Infants who are large for gestational age are associated with diabetic
mothers, so answer B is incorrect. Preterm births are associated with smoking,
but not with appropriate size for gestation, making answer C incorrect. Growth
retardation is associated with smoking, but this does not affect the infant
length; therefore, answer D is incorrect.
125.
Answer A is correct. To provide protection against antibody production,
RhoGam should be given within 72 hours. The answers in B, C, and D are too late
to provide antibody protection. RhoGam can also be given during pregnancy.
126.
Answer B is correct. When the membranes rupture, there is often a
transient drop in the fetal heart tones. The heart tones should return to
baseline quickly. Any alteration in fetal heart tones, such as bradycardia or
tachycardia, should be reported. After the fetal heart tones are assessed, the
nurse should evaluate the cervical dilation, vital signs, and level of
discomfort, making answers A, C, and D incorrect.
127.
Answer A is correct. The active phase of labor occurs when the client is
dilated 4–7cm. The latent or early phase of labor is from 1cm to 3cm in
dilation, so answers B and D are incorrect. The transition phase of labor is
8–10cm in dilation, making answer C incorrect.
128.
Answer B is correct. The infant of an addicted mother will undergo
withdrawal. Snugly wrapping the infant in a blanket will help prevent the
muscle irritability that these babies often experience. Teaching the mother to
provide tactile stimulation or provide for early infant stimulation are
incorrect because he is irritable and needs quiet and little stimulation at this
time, so answers A and D are incorrect. Placing the infant in an infant seat in
answer C is incorrect because this will also cause movement that can increase
muscle irritability.
129.
Answer C is correct. Following epidural anesthesia, the client should be
checked for hypotension and signs of shock every 5 minutes for 15 minutes. The
client can be checked for cervical dilation later after she is stable. The
client should not be positioned supine because the anesthesia can move above
the respiratory center and the client can stop breathing. Fetal heart tones
should be assessed after the blood pressure is checked. Therefore, answers A,
B, and D are incorrect.
130.
Answer B is correct. The best way to prevent post-operative wound
infection is hand washing. Use of prescribed antibiotics will treat infection,
not prevent infections, making answer A incorrect. Wearing a mask and asking
the client to cover her mouth are good practices but will not prevent wound
infections; therefore, answers C and D are incorrect.
131.
Answer B is correct. The client with a hip fracture will most likely have
disalignment. Answers A, C, and D are incorrect because all fractures cause
pain, and coolness of the extremities and absence of pulses are indicative of
compartment syndrome or peripheral vascular disease.
132.
Answer B is correct. After menopause, women lack hormones necessary to
absorb and utilize calcium. Doing weight-bearing exercises and taking calcium
supplements can help to prevent osteoporosis but are not causes, so answers A
and C are incorrect. Body types that frequently experience osteoporosis are
thin Caucasian females, but they are not most likely related to osteoporosis,
so answer D is incorrect.
133.
Answer B is correct. The infant’s hips should be off the bed
approximately 15° in Bryant’s traction. Answer A is incorrect because this does
not indicate that the traction is working correctly, nor does C. Answer D is
incorrect because Bryant’s traction is a skin traction, not a skeletal
traction.
134.
Answer A is correct. Balanced skeletal traction uses pins and screws. A
Steinman pin goes through large bones and is used to stabilize large bones such
as the femur. Answer B is incorrect because only the affected leg is in
traction. Kirschner wires are used to stabilize small bones such as fingers and
toes, as in answer C. Answer D is incorrect because this type of traction is
not used for fractured hips.
135.
Answer A is correct. Bleeding is a common complication of orthopedic
surgery. The blood-collection device should be checked frequently to ensure
that the client is not hemorrhaging. The client’s pain should be assessed, but
this is not life-threatening. When the client is in less danger, the
nutritional status should be assessed and an immobilizer is not used; thus,
answers B, C, and D are incorrect.
136.
Answer A is correct. The client’s family member should be taught to flush
the tube after each feeding and clamp the tube. The placement should be checked
before feedings, and indigestion can occur with the PEG tube, just as it can
occur with any client, so answers B and C are incorrect. Medications can be
ordered for indigestion, but it is not a reason for alarm. A percutaneous
endoscopy gastrostomy tube is used for clients who have experienced difficulty
swallowing. The tube is inserted directly into the stomach and does not require
swallowing; therefore, answer D is incorrect.
137.
Answer C is correct. The client with a total knee replacement should be
assessed for anemia. A hematocrit of 26% is extremely low and might require a
blood transfusion. Bleeding of 2cm on the dressing is not extreme. Circle and
date and time the bleeding and monitor for changes in the client’s status. A
low-grade temperature is not unusual after surgery. Ensure that the client is
well hydrated, and recheck the temperature in 1 hour. If the temperature is
above 101°F, report this finding to the doctor. Tylenol will probably be
ordered. Voiding after surgery is also not uncommon and no need for concern;
therefore answers A, B, and D are incorrect.
138.
Answer B is correct. Plumbism is lead poisoning. One factor associated
with the consumption of lead is eating from pottery made in Central America or
Mexico that is unfired. The child lives in a house built after 1976 (this is
when lead was taken out of paint), and the parents make stained glass as a
hobby. Stained glass is put together with lead, which can drop on the work
area, where the child can consume the lead beads. Answer A is incorrect because
simply traveling out of the country does not increase the risk. In answer C,
the house was built after the lead was removed with the paint. Answer D is
unrelated to the stem.
139.
Answer A is correct. The equipment that can help with activities of daily
living is the high-seat commode. The hip should be kept higher than the knee.
The recliner is good because it prevents 90° flexion but not daily activities.
A TENS (Transcutaneous Electrical Nerve Stimulation) unit helps with pain
management and an abduction pillow is used to prevent adduction of the hip and
possibly dislocation of the prosthesis; therefore, answers B, C, and D are
incorrect.
140.
Answer B is correct. Narcan is the antidote for narcotic overdose. If
hypoxia occurs, the client should have oxygen administered by mask, not
cannula. There is no data to support the administration of blood products or
cardioresuscitation, so answers A, C, and D are incorrect.
141.
Answer B is correct. The 6-year-old should have a roommate as close to
the same age as possible, so the 12-year-old is the best match. The 10-year-old
with sarcoma has cancer and will be treated with chemotherapy that makes him
immune suppressed, the 6-year-old with osteomylitis is infected, and the client
in answer A is too old and is female; therefore, answers A, C, and D are
incorrect.
142.
Answer B is correct. Cox II inhibitors have been associated with heart
attacks and strokes. Any changes in cardiac status or signs of a stroke should
be reported immediately, along with any changes in bowel or bladder habits
because bleeding has been linked to use of Cox II inhibitors. The client does
not have to take the medication with milk, remain upright, or allow 6 weeks for
optimal effect, so answers A, C, and D are incorrect.
143.
Answer D is correct. A plaster-of-Paris cast takes 24 hours to dry, and
the client should not bear weight for 24 hours. The cast should be handled with
the palms, not the fingertips, so answer A is incorrect. Petaling a cast is
covering the end of the cast with cast batting or a sock, to prevent skin
irritation and flaking of the skin under the cast, making answer B incorrect.
The client should be told not to dry the cast with a hair dryer because this
causes hot spots and could burn the client. This also causes unequal drying;
thus, answer C is incorrect.
144.
Answer A is correct. There is no reason that the client’s friends should
not be allowed to autograph the cast; it will not harm the cast in any way, so
answers B, C, and D are incorrect.
145.
Answer A is correct. The nurse is performing the pin care correctly when
she uses sterile gloves and Q-tips. A licensed practical nurse can perform pin care,
there is no need to clean the weights, and the nurse can help with opening the
packages but it isn’t required; therefore, answers B, C, and D are incorrect.
146.
Answer A is correct. A body cast or spica cast extends from the upper
abdomen to the knees or below. Bowel sounds should be checked to ensure that
the client is not experiencing a paralytic illeus. Checking the blood pressure
is a treatment for any client, offering pain medication is not called for, and
checking for swelling isn’t specific to the stem, so answers B, C, and D are
incorrect.
147.
Answer C is correct. Halo traction will be ordered for the client with a
cervical fracture. Russell’s traction is used for bones of the lower
extremities, as is Buck’s traction. Cruchfield tongs are used while in the
hospital and the client is immobile; therefore, answers A, B, and D are
incorrect.
148.
Answer B is correct. The controller for the continuous passive-motion
device should be placed away from the client. Many clients complain of pain
while having treatments with the CPM, so they might turn off the machine. The
CPM flexes and extends the leg. The client is in the bed during CPM therapy, so
answer A is incorrect. Answer C is incorrect because clients will experience
pain with the treatment. Use of the CPM does not alleviate the need for
physical therapy, as suggested in answer D.
149.
Answer A is correct. The client’s palms should rest lightly on the
handles. The elbows should be flexed no more than 30° but should not be
extended. Answer B is incorrect because 0° is not a relaxed angle for the
elbows and will not facilitate correct walker use. The client should walk to
the middle of the walker, not to the front of the walker, making answer C
incorrect. The client should be taught not to carry the walker because this
would not provide stability; thus, answer D is incorrect.
150.
Answer C is correct. The client with a prolapsed cord should be treated
by elevating the hips and covering the cord with a moist, sterile saline gauze.
The nurse should use her fingers to push up on the presenting part until a
cesarean section can be performed. Answers A, B, and D are incorrect. The nurse
should not attempt to replace the cord, turn the client on the side, or cover
with a dry gauze.
151.
Answer B is correct. Chest tubes work to reinflate the lung and drain
serous fluid. The tube does not equalize expansion of the lungs. Pain is
associated with collapse of the lung, and insertion of chest tubes is painful,
so answers A and C are incorrect. Answer D is true, but this is not the primary
rationale for performing chest tube insertion.
152.
Answer D is correct. Success with breastfeeding depends on many factors,
but the most dependable reason for success is desire and willingness to
continue the breastfeeding until the infant and mother have time to adapt. The
educational level, the infant’s birth weight, and the size of the mother’s
breast have nothing to do with success, so answers A, B, and C are incorrect.
153.
Answer C is correct. Green-tinged amniotic fluid is indicative of
meconium staining. This finding indicates fetal distress. The presence of scant
bloody discharge is normal, as are frequent urination and moderate uterine
contractions, making answers A, B, and D incorrect.
154.
Answer C is correct. Duration is measured from the beginning of one
contraction to the end of the same contraction. Answer A refers to frequency.
Answer B is incorrect because we do not measure from the end of one contraction
to the beginning of the next contraction. Duration is not measured from the
peak of the contraction to the end, as stated in D.
155.
Answer B is correct. The client receiving Pitocin should be monitored for
decelerations. There is no association with Pitocin use and hypoglycemia,
maternal hyperreflexia, or fetal movement; therefore, answers A, C, and D are
incorrect.
156.
Answer D is correct. Fetal development depends on adequate nutrition and
insulin regulation. Insulin needs increase during the second and third
trimesters, insulin requirements do not moderate as the pregnancy progresses,
and elevated human chorionic gonadotrophin elevates insulin needs, not
decreases them; therefore, answers A, B, and C are incorrect.
157.
Answer A is correct. A calm environment is needed to prevent seizure
activity. Any stimulation can precipitate seizures. Obtaining a diet history
should be done later, and administering an analgesic is not indicated because
there is no data in the stem to indicate pain. Therefore, answers B and C are
incorrect. Assessing the fetal heart tones is important, but this is not the
highest priority in this situation as stated in answer D.
158.
Answer A is correct. The client who is age 42 is at risk for fetal
anomalies such as Down syndrome and other chromosomal aberrations. Answers B,
C, and D are incorrect because the client is not at higher risk for respiratory
distress syndrome or pathological jaundice, and Turner’s syndrome is a genetic
disorder.
159.
Answer C is correct. The client with a missed abortion will have
induction of labor. Prostin E. is a form of prostaglandin used to soften the
cervix. Magnesium sulfate is used for preterm labor and preeclampsia, calcium
gluconate is the antidote for magnesium sulfate, and Pardel is a dopamine
receptor stimulant used to treat Parkinson’s disease; therefore, answers A, B,
and D are incorrect. Pardel was used at one time to dry breast milk.
160.
Answer A is correct. The client’s blood pressure and urinary output are
within normal limits. The only alteration from normal is the decreased deep
tendon reflexes. The nurse should continue to monitor the blood pressure and
check the magnesium level. The therapeutic level is 4.8–9.6mg/dL. Answers B, C,
and D are incorrect. There is no need to stop the infusion at this time or slow
the rate. Calcium gluconate is the antidote for magnesium sulfate, but there is
no data to indicate toxicity.
161.
Answer C is correct. Autosomal recessive disorders can be passed from the
parents to the infant. If both parents pass the trait, the child will get two
abnormal genes and the disease results. Parents can also pass the trait to the
infant. Answer A is incorrect because, to have an affected newborn, the parents
must be carriers. Answer B is incorrect because both parents must be carriers.
Answer D is incorrect because the parents might have affected children.
162.
Answer D is correct. Alpha fetoprotein is a screening test done to detect
neural tube defects such as spina bifida. The test is not mandatory, as stated
in answer A. It does not indicate cardiovascular defects, and the mother’s age
has no bearing on the need for the test, so answers B and C are incorrect.
163.
Answer B is correct. During pregnancy, the thyroid gland triples in size.
This makes it more difficult to regulate thyroid medication. Answer A is
incorrect because there could be a need for thyroid medication during
pregnancy. Answer C is incorrect because the thyroid function does not slow.
Fetal growth is not arrested if thyroid medication is continued, so answer D is
incorrect.
164.
Answer C is correct. Cyanosis of the feet and hands is acrocyanosis. This
is a normal finding 1 minute after birth. An apical pulse should be 120–160,
and the baby should have muscle tone, making answers A and B incorrect.
Jaundice immediately after birth is pathological jaundice and is abnormal, so
answer D is incorrect.
165.
Answer A is correct. Clients with sickle cell crises are treated with
heat, hydration, oxygen, and pain relief. Fluids are increased, not decreased.
Blood transfusions are usually not required, and the client can be delivered
vaginally; thus, answers B, C, and D are incorrect.
166.
Answer A is correct. Before ultrasonography, the client should be taught
to drink plenty of fluids and not void. The client may ambulate, an enema is
not needed, and there is no need to withhold food for 8 hours. Therefore,
answers B, C, and D are incorrect.
167.
Answer D is correct. By 1 year of age, the infant is expected to triple
his birth weight. Answers A, B, and C are incorrect because they are too low.
168.
Answer B is correct. A nonstress test is done to evaluate periodic
movement of the fetus. It is not done to evaluate lung maturity as in answer A.
An oxytocin challenge test shows the effect of contractions on fetal heart rate
and a nonstress test does not measure neurological well-being of the fetus, so
answers C and D are incorrect.
169.
Answer B is correct. Hypospadia is a condition in which there is an
opening on the dorsal side of the penis. Answer A is incorrect because
hypospadia does not concern the urethral opening. Answer C is incorrect because
the size of the penis is not affected. Answer D is incorrect because the
opening is on the dorsal side, not the ventral side.
170.
Answer A is correct. Transition is the time during labor when the client
loses concentration due to intense contractions. Potential for injury related
to precipitate delivery has nothing to do with the dilation of the cervix, so
answer B is incorrect. There is no data to indicate that the client has had
anesthesia or fluid volume deficit, making answers C and D incorrect.
171.
Answer C is correct. Varicella is chicken pox. This herpes virus is
treated with antiviral medications. The client is not treated with antibiotics
or anticoagulants as stated in answers A and D. The client might have a fever
before the rash appears, but when the rash appears, the temperature is usually
gone, so answer B is incorrect.
172.
Answer B is correct. Clients with chest pain can be treated with
nitroglycerin, a beta blocker such as propanolol, or Varapamil. There is no
indication for an antibiotic such as Ampicillin, so answers A, C, and D are
incorrect.
173.
Answer B is correct. Anti-inflammatory drugs should be taken with meals
to avoid stomach upset. Answers A, C, and D are incorrect. Clients with
rheumatoid arthritis should exercise, but not to the point of pain. Alternating
hot and cold is not necessary, especially because warm, moist soaks are more
useful in decreasing pain. Weight-bearing activities such as walking are useful
but is not the best answer for the stem.
174.
Answer D is correct. Morphine is contraindicated in clients with
gallbladder disease and pancreatitis because morphine causes spasms of the Sphenter
of Oddi. Meperidine, Mylanta, and Cimetadine are ordered for pancreatitis,
making answers A, B, and C incorrect.
175.
Answer B is correct. Hallucinogenic drugs can cause hallucinations.
Continuous observation is ordered to prevent the client from harming himself
during withdrawal. Answers A, C, and D are incorrect because hallucinogenic
drugs don’t create both stimulant and depressant effects or produce severe
respiratory depression. However, they do produce psychological dependence
rather than physical dependence.
176.
Answer B is correct. Barbiturates create a sedative effect. When the
client stops taking barbiturates, he will experience tachycardia, diarrhea, and
tachpnea. Answer A is incorrect even though depression and suicidal ideation go
along with barbiturate use; it is not the priority. Muscle cramps and abdominal
pain are vague symptoms that could be associated with other problems.
Tachycardia is associated with stopping barbiturates, but euphoria is not.
177.
Answer A is correct. If the fetal heart tones are heard in the right
upper abdomen, the infant is in a breech presentation. If the infant is
positioned in the right occipital anterior presentation, the FHTs will be
located in the right lower quadrant, so answer B is incorrect. If the fetus is
in the sacral position, the FHTs will be located in the center of the abdomen,
so answer C is incorrect. If the FHTs are heard in the left lower abdomen, the
infant is most likely in the left occipital transverse position, making answer
D incorrect.
178.
Answer D is correct. Asthma is the presence of bronchiolar spasms. This
spasm can be brought on by allergies or anxiety. Answer A is incorrect because
the primary physiological alteration is not inflammation. Answer B is incorrect
because there is the production of abnormally viscous mucus, not a primary
alteration. Answer C is incorrect because infection is not primary to asthma.
179.
Answer A is correct. The client with mania is seldom sitting long enough
to eat and burns many calories for energy. Answer B is incorrect because the
client should be treated the same as other clients. Small meals are not a
correct option for this client. Allowing her into the kitchen gives her
privileges that other clients do not have and should not be allowed, so answer
D is incorrect.
180.
Answer B is correct. Bryant’s traction is used for fractured femurs and
dislocated hips. The hips should be elevated 15° off the bed. Answer A is
incorrect because the hips should not be resting on the bed. Answer C is
incorrect because the hips should not be above the level of the body. Answer D
is incorrect because the hips and legs should not be flat on the bed.
181.
Answer B is correct. Herpes zoster is shingles. Clients with shingles
should be placed in contact precautions. Wearing gloves during care will
prevent transmission of the virus. Covering the lesions with a sterile gauze is
not necessary, antibiotics are not prescribed for herpes zoster, and oxygen is
not necessary for shingles; therefore, answers A, C, and D are incorrect.
182.
Answer B is correct. A trough level should be drawn 30 minutes before the
third or fourth dose. The times in answers A, C, and D are incorrect times to
draw blood levels.
183.
Answer B is correct. The client using a diaphragm should keep the
diaphragm in a cool location. Answers A, C, and D are incorrect. She should
refrain from leaving the diaphragm in longer than 8 hours, not 4 hours. She
should have the diaphragm resized when she gains or loses 10 pounds or has
abdominal surgery.
184.
Answer C is correct. Mothers who plan to breastfeed should drink plenty
of liquids, and four glasses is not enough in a 24-hour period. Wearing a
support bra is a good practice for the mother who is breastfeeding as well as
the mother who plans to bottle-feed, so answer A is incorrect. Expressing milk
from the breast will stimulate milk production, making answer B incorrect.
Allowing the water to run over the breast will also facilitate
"letdown," when the milk begins to be produced; thus, answer D is
incorrect.
185.
Answer A is correct. The facial nerve is cranial nerve VII. If damage
occurs, the client will experience facial pain. The auditory nerve is
responsible for hearing loss and tinnitus, eye movement is controlled by the
Trochear or C IV, and the olfactory nerve controls smell; therefore, answers B,
C, and D are incorrect.
186.
Answer B is correct. Clients taking Pyridium should be taught that the
medication will turn the urine orange or red. It is not associated with
diarrhea, mental confusion, or changes in taste; therefore, answers A, C, and D
are incorrect. Pyridium can also cause a yellowish color to skin and sclera if
taken in large doses.
187.
Answer B is correct. Accutane is contraindicated for use by pregnant
clients because it causes teratogenic effects. Calcium levels, apical pulse,
and creatinine levels are not necessary; therefore, answers A, C, and D are
incorrect.
188.
Answer D is correct. Clients taking Acyclovir should be encouraged to
drink plenty of fluids because renal impairment can occur. Limiting activity is
not necessary, nor is eating a high-carbohydrate diet. Use of an incentive
spirometer is not specific to clients taking Acyclovir; therefore, answers A,
B, and C are incorrect.
189.
Answer A is correct. Clients who are pregnant should not have an MRI
because radioactive isotopes are used. However, clients with a titanium hip
replacement can have an MRI, so answer B is incorrect. No antibiotics are used
with this test and the client should remain still only when instructed, so
answers C and D are not specific to this test.
190.
Answer D is correct. Clients taking Amphotericin B should be monitored
for liver, renal, and bone marrow function because this drug is toxic to the
kidneys and liver, and causes bone marrow suppression. Jaundice is a sign of
liver toxicity and is not specific to the use of Amphotericin B. Changes in
vision are not related, and nausea is a side effect, not a sign of toxicity;
nor is urinary frequency. Thus, answers A, B, and C are incorrect.
191.
Answer C is correct. The client with chest pain should be seen first
because this could indicate a myocardial infarction. The client in answer A has
a blood glucose within normal limits. The client in answer B is maintained on
blood pressure medication. The client in answer D is in no distress.
192.
Answer B is correct. Pancreatic enzymes should be given with meals for
optimal effects. These enzymes assist the body in digesting needed nutrients.
Answers A, C, and D are incorrect methods of administering pancreatic enzymes.
193.
Answer C is correct. The lens allows light to pass through the pupil and
focus light on the retina. The lens does not stimulate the retina, assist with
eye movement, or magnify small objects, so answers A, B, and D are incorrect.
194.
Answer C is correct. Miotic eyedrops constrict the pupil and allow
aqueous humor to drain out of the Canal of Schlemm. They do not anesthetize the
cornea, dilate the pupil, or paralyze the muscles of the eye, making answers A,
B, and D incorrect.
195.
Answer A is correct. When using eyedrops, allow 5 minutes between the two
medications; therefore, answer B is incorrect. These medications can be used by
the same client but it is not necessary to use a cyclopegic with these
medications, making answers C and D incorrect.
196.
Answer B is correct. Clients with color blindness will most likely have
problems distinguishing violets, blues, and green. The colors in answers A, C,
and D are less commonly affected.
197.
Answer D is correct. The client with a pacemaker should be taught to
count and record his pulse rate. Answers A, B, and C are incorrect. Ankle edema
is a sign of right-sided congestive heart failure. Although this is not normal,
it is often present in clients with heart disease. If the edema is present in
the hands and face, it should be reported. Checking the blood pressure daily is
not necessary for these clients. The client with a pacemaker can use a
microwave oven, but he should stand about 5 feet from the oven while it is
operating.
198.
Answer A is correct. Clients who are being retrained for bladder control
should be taught to withhold fluids after about 7 p.m., or 1 The times in answers
B, C, and D are too early in the day.
199.
Answer D is correct. Cranberry juice is more alkaline and, when
metabolized by the body, is excreted with acidic urine. Bacteria does not grow
freely in acidic urine. Increasing intake of meats is not associated with
urinary tract infections, so answer A is incorrect. The client does not have to
avoid citrus fruits and pericare should be done, but hydrogen peroxide is
drying, so answers B and C are incorrect.
200.
Answer C is correct. NPH insulin peaks in 8–12 hours, so a snack should
be offered at that time. NPH insulin onsets in 90–120 minutes, so answer A is
incorrect. Answer B is untrue because NPH insulin is time released and does not
usually cause sudden hypoglycemia. Answer D is incorrect, but the client should
eat a bedtime snack.
201.
Answer D is correct. Methotrexate is a folic acid antagonist. Leucovorin
is the drug given for toxicity to this drug. It is not used to treat
iron-deficiency anemia, create a synergistic effects, or increase the number of
circulating neutrophils. Therefore, answers A, B, and C are incorrect.
202.
Answer B is correct. The client who is allergic to dogs, eggs, rabbits,
and chicken feathers is most likely allergic to the rubella vaccine. The client
who is allergic to neomycin is also at risk. There is no danger to the client
if he has an order for a TB skin test, ELISA test, or chest x-ray; thus,
answers A, C, and D are incorrect.
203.
Answer B is correct. Zantac (rantidine) is a histamine blocker that
should be given with meals for optimal effect, not before meals. However,
Tagamet (cimetidine) is a histamine blocker that can be given in one dose at
bedtime. Neither of these drugs should be given before or after meals, so
answers A and D are incorrect.
204.
Answer C is correct. The proximal end of the double-barrel colostomy is
the end toward the small intestines. This end is on the client’s right side.
The distal end, as in answers A, B, and D, is on the client’s left side.
205.
Answer A is correct. If the nurse checks the fundus and finds it to be
displaced to the right or left, this is an indication of a full bladder. This
finding is not associated with hypotension or clots, as stated in answer B.
Oxytoxic drugs (Pitocin) are drugs used to contract the uterus, so answer C is
incorrect. It has nothing to do with displacement of the uterus. Answer D is
incorrect because displacement is associated with a full bladder, not vaginal
bleeding.
206.
Answer C is correct. Clients with an internal defibrillator or a
pacemaker should not have an MRI because it can cause dysrhythmias in the
client with a pacemaker. If the client has a need for oxygen, is
claustrophobic, or is deaf, he can have an MRI, but provisions such as
extension tubes for the oxygen, sedatives, or a signal system should be made to
accommodate these problems. Therefore, answers A, B, and D are incorrect.
207.
Answer C is correct. A 6-month-old is too old for the colorful mobile. He
is too young to play with the electronic game or the 30-piece jigsaw puzzle.
The best toy for this age is the cars in a plastic container, so answers A, B,
and D are incorrect.
208.
Answer C is correct. The client with polio has muscle weakness. Periods
of rest throughout the day will conserve the client’s energy. A hot bath can
cause burns; however, a warm bath would be helpful, so answer A is incorrect.
Strenuous exercises are not advisable, making answer B incorrect. Visual
disturbances are directly associated with polio and cannot be corrected with
glasses; therefore, answer D is incorrect.
209.
Answer B is correct. The client with a protoepisiotomy will need stool
softeners such as docusate sodium. Suppositories are given only with an order
from the doctor, Methergine is a drug used to contract the uterus, and Parlodel
is an anti-Parkinsonian drug; therefore, answers A, C, and D are incorrect.
210.
Answer C is correct. Total Parenteral Nutrition is a high-glucose
solution. This therapy often causes the glucose levels to be elevated. Because
this is a common complication, insulin might be ordered. Answers A, B, and D
are incorrect. TPN is used to treat negative nitrogen balance; it will not lead
to negative nitrogen balance. Total Parenteral Nutrition can be managed with
oral hypoglycemic drugs, but it is difficult to do so. Total Parenteral
Nutrition will not lead to further pancreatic disease.
211.
Answer B is correct. The client who is 10 weeks pregnant should be
assessed to determine how she feels about the pregnancy. It is too early to
discuss preterm labor, too late to discuss whether she was using a method of
birth control, and after the client delivers, a discussion of future children
should be instituted. Thus, answers A, C, and D are incorrect.
212.
Answer A is correct. The best IV fluid for correction of dehydration is
normal saline because it is most like normal serum. Dextrose pulls fluid from
the cell, lactated Ringer’s contains more electrolytes than the client’s serum,
and dextrose with normal saline will also alter the intracellular fluid.
Therefore, answers B, C, and D are incorrect.
213.
Answer A is correct. A thyroid scan uses a dye, so the client should be
assessed for allergies to iodine. The client will not have a bolus of fluid,
will not be asleep, and will not have a urinary catheter inserted, so answers
B, C, and D are incorrect.
214.
Answer B is correct. RhoGam is used to prevent formation of Rh antibodies.
It does not provide immunity to Rh isoenzymes, eliminate circulating Rh
antibodies, or convert the Rh factor from negative to positive; thus, answers
A, C, and D are incorrect.
215.
Answer B is correct. A client with a fractured foot often has a short leg
cast applied to stabilize the fracture. A spica cast is used to stabilize a
fractured pelvis or vertebral fracture. Kirschner wires are used to stabilize
small bones such as toes and the client will most likely have a cast or
immobilizer, so answers A, C, and D are incorrect.
216.
Answer A is correct. Iridium seeds can be expelled during urination, so
the client should be taught to strain his urine and report to the doctor if any
of the seeds are expelled. Increasing fluids, reporting urinary frequency, and avoiding
prolonged sitting are not necessary; therefore, answers B, C, and D are
incorrect.
217.
Answer C is correct. Immunosuppressants are used to prevent antibody
formation. Antivirals, antibiotics, and analgesics are not used to prevent
antibody production, so answers A, B, and D are incorrect.
218.
Answer A is correct. Before cataract removal, the client will have
Mydriatic drops instilled to dilate the pupil. This will facilitate removal of
the lens. Miotics constrict the pupil and are not used in cataract clients. A
laser is not used to smooth and reshape the lens; the diseased lens is removed.
Silicone oil is not injected in this client; thus, answers B, C, and D are
incorrect.
219.
Answer C is correct. Placing simple signs that indicate the location of
rooms where the client sleeps, eats, and bathes will help the client be more
independent. Providing mirrors and pictures is not recommended with the client
who has Alzheimer’s disease because mirrors and pictures tend to cause
agitation, and alternating healthcare workers confuses the client; therefore,
answers A, B, and D are incorrect.
220.
Answer C is correct. A Jackson-Pratt drain is a serum-collection device
commonly used in abdominal surgery. A Jackson-Pratt drain will not prevent the
need for dressing changes, reduce edema of the incision, or keep the common
bile duct open, so answers A, B, and D are incorrect. A t-tube is used to keep
the common bile duct open.
221.
Answer C is correct. The infant who is 32 weeks gestation will not be
able to control his head, so head lag will be present. Mongolian spots are
common in African American infants, not Caucasian infants; the client at 32
weeks will have scrotal rugae or redness but will not have vernix caseosa, the
cheesy appearing covering found on most full-term infants. Therefore, answers
A, B, and D are incorrect.
222.
Answer A is correct. Hematuria in a client with a pelvic fracture can
indicate trauma to the bladder or impending bleeding disorders. It is not
unusual for the client to complain of muscles spasms with multiple fractures,
so answer B is incorrect. Dizziness can be associated with blood loss and is
nonspecific, making answer C incorrect. Nausea, as stated in answer D, is also
common in the client with multiple traumas.
223.
Answer C is correct. The client’s statement "They are trying to kill
me" indicates paranoid delusions. There is no data to indicate that the
client is hearing voices or is intoxicated, so answers A and D are incorrect.
Delusions of grandeur are fixed beliefs that the client is superior or perhaps
a famous person, making answer B incorrect.
224.
Answer B is correct. Because the nurse is unaware of when the bottle was
opened or whether the saline is sterile, it is safest to obtain a new bottle.
Answers A, C, and D are not safe practices.
225.
Answer C is correct. Infants with an Apgar of 9 at 5 minutes most likely
have acryocyanosis, a normal physiologic adaptation to birth. It is not related
to the infant being cold, experiencing bradycardia, or being lethargic; thus,
answers A, B, and D are incorrect.
226.
Answer A is correct. Rapid continuous rewarming of a frostbite primarily
lessens cellular damage. It does not prevent formation of blisters. It does
promote movement, but this is not the primary reason for rapid rewarming. It
might increase pain for a short period of time as the feeling comes back into
the extremity; therefore, answers B, C, and D are incorrect.
227.
Answer D is correct. Hemodialysis works by using a dialyzing membrane to
filter waste that has accumulated in the blood. It does not pass water through
a dialyzing membrane nor does it eliminate plasma proteins or lower the pH, so
answers A, B, and C are incorrect.
228.
Answer B is correct. The client who is immune-suppressed and is exposed
to measles should be treated with medications to boost his immunity to the
virus. An antibiotic or antiviral will not protect the client and it is too
late to place the client in isolation, so answers A, C, and D are incorrect.
229.
Answer D is correct. The client with MRSA should be placed in isolation.
Gloves, a gown, and a mask should be used when caring for the client and hand
washing is very important. The door should remain closed, but a
negative-pressure room is not necessary, so answers A and B are incorrect. MRSA
is spread by contact with blood or body fluid or by touching the skin of the
client. It is cultured from the nasal passages of the client, so the client
should be instructed to cover his nose and mouth when he sneezes or coughs. It
is not necessary for the client to wear the mask at all times; the nurse should
wear the mask, so answer C is incorrect.
230.
Answer B is correct. Pain related to phantom limb syndrome is due to
peripheral nervous system interruption. Answer A is incorrect because phantom
limb pain can last several months or indefinitely. Answer C is incorrect because
it is not psychological. It is also not due to infections, as stated in answer
D.
231.
Answer A is correct. During a Whipple procedure the head of the pancreas,
which is a part of the stomach, the jejunum, and a portion of the stomach are
removed and reanastomosed. Answer B is incorrect because the proximal third of
the small intestine is not removed. The entire stomach is not removed, as in
answer C, and in answer D, the esophagus is not removed.
232.
Answer C is correct. Pepper is not processed and contains bacteria.
Answers A, B, and D are incorrect because fruits should be cooked or washed and
peeled, and salt and ketchup are allowed.
233.
Answer A is correct. Coumadin is an anticoagulant. One of the tests for
bleeding time is a Protime. This test should be done monthly. Eating more
fruits and vegetables is not necessary, and dark-green vegetables contain
vitamin K, which increases clotting, so answer B is incorrect. Drinking more
liquids and avoiding crowds is not necessary, so answers C and D are incorrect.
234.
Answer A is correct. The client who is having a central venous catheter
removed should be told to hold his breath and bear down. This prevents air from
entering the line. Answers B, C, and D will not facilitate removal.
235.
Answer B is correct. Clients with a history of streptococcal infections
could have antibodies that render the streptokinase ineffective. There is no
reason to assess the client for allergies to pineapples or bananas, there is no
correlation to the use of phenytoin and streptokinase, and a history of alcohol
abuse is also not a factor in the order for streptokinase; therefore, answers
A, C, and D are incorrect.
236.
Answer B is correct. The client who is immune-suppressed and has bone
marrow suppression should be taught not to floss his teeth because platelets
are decreased. Using oils and cream-based soaps is allowed, as is eating salt
and using an electric razor; therefore, answers A, C, and D are incorrect.
237.
Answer A is correct. The best method and safest way to change the ties of
a tracheotomy is to apply the new ones before removing the old ones. Having a
helper is good, but the helper might not prevent the client from coughing out
the tracheotomy. Answer C is not the best way to prevent the client from
coughing out the tracheotomy. Asking the doctor to suture the tracheotomy in
place is not appropriate.
238.
Answer D is correct. The output of 300mL is indicative of hemorrhage and
should be reported immediately. Answer A does nothing to help the client.
Milking the tube is done only with an order and will not help in this
situation, and slowing the intravenous infusion is not correct; thus, answers B
and C are incorrect.
239.
Answer A is correct. The infant with tetrology of falot has five heart
defects. He will be treated with digoxin to slow and strengthen the heart.
Epinephrine, aminophyline, and atropine will speed the heart rate and are not
used in this client; therefore, answers B, C, and D are incorrect.
240.
The correct answer is marked by an X in the diagram. The Tail of Spence
is located in the upper outer quadrant of the breast.
241.
Answer A is correct. The toddler with a ventricular septal defect will
tire easily. He will not grow normally but will not need more calories. He will
be susceptible to bacterial infection, but he will be no more susceptible to viral
infections than other children. Therefore, answers B, C, and D are incorrect.
242.
Answer B is correct. A nonstress test determines periodic movement of the
fetus. It does not determine lung maturity, show contractions, or measure
neurological well-being, making answers A, C, and D incorrect.
243.
Answer C is correct. The monitor indicates variable decelerations caused
by cord compression. If Pitocin is infusing, the nurse should turn off the
Pitocin. Instructing the client to push is incorrect because pushing could
increase the decelerations and because the client is 8cm dilated, making answer
A incorrect. Performing a vaginal exam should be done after turning off the
Pitocin, and placing the client in a semi-Fowler’s position is not appropriate
for this situation; therefore, answers B and D are incorrect.
244.
Answer C is correct. The graph indicates ventricular tachycardia. The
answers in A, B, and D are not noted on the ECG strip.
245.
Answer B is correct. Lovenox injections should be given in the abdomen,
not in the deltoid muscle. The client should not aspirate after the injection
or clear the air from the syringe before injection. Therefore, answers A, C,
and D are incorrect.
246.
Answer B is correct. Valium is not given in the same syringe with other
medications, so answer A is incorrect. These medications can be given to the
same client, so answer D is incorrect. In answer C, it is not necessary to wait
to inject the second medication. Valium is an antianxiety medication, and
Phenergan is used as an antiemetic.
247.
Answer B is correct. Voiding every 3 hours prevents stagnant urine from
collecting in the bladder, where bacteria can grow. Douching is not recommended
and obtaining a urinalysis monthly is not necessary, making answers A and C
incorrect. The client should practice wiping from front to back after voiding
and bowel movements, so answer D is incorrect.
248.
Answer C is correct. Of these clients, the one who should be assigned to
the care of the nursing assistant is the client with dementia. Only an RN or
the physician can place the client in seclusion, so answer A is incorrect. The
nurse should empty the Foley catheter of the preeclamptic client because the
client is unstable, making answer B incorrect. A nurse or physical therapist
should ambulate the client with a fractured hip, so answer D is incorrect.
249.
Answer A is correct. The client who has recently had a thyroidectomy is
at risk for tracheal edema. A padded tongue blade is used for seizures and not
for the client with tracheal edema, so answer B is incorrect. If the client
experiences tracheal edema, the endotracheal tube or airway will not correct
the problem, so answers C and D are incorrect.
250.
Answer D is correct. Histoplasmosis is a fungus carried by birds. It is
not transmitted to humans by cats, dogs, or turtles. Therefore, answers A, B,
and C are incorrect.
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