NCLEX-PN Test Prep Questions and Answers with Explanations V1 Practice Exam 2 (Study Mode), Exams of Nursing

Download NCLEX-PN Test Prep Questions and Answers with Explanations V1 Practice Exam 2 (Study Mode) and more Exams Nursing in PDF only on Docsity! 2024 NCLEX-PN TEST PREP QUESTIONS AND ANSWERS WITH EXPLANATIONS V1 PRACTICE EXAM 2 (STUDY MODE) 1. The child with seizure disorder is being treated with Dilantin (phenytoin). Which of the following statements by the patient’s mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy? A. “She is very irritable lately.” B. “She sleeps quite a bit of the time.” C. “Her gums look too big for her teeth.” D. “She has gained about 10 pounds in the last 6 months.” Answer C: Hyperplasia of the gums is associated with Dilantin therapy. Answer A is not related to the therapy; answer B is a side effect, and answer D is not related to the question. 2. A 5-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery? A. Decreased appetite B. A low-grade fever C. Chest congestion D. Constant swallowing Answer D: A complication of a tonsillectomy is bleeding, and constant swallowing may indicate bleeding. Decreased appetite is expected after a tonsillectomy, as is a low-grade temperature; thus, answers A and B are incorrect. In answer C, chest congestion is not normal but is not associated with the tonsillectomy. 3. A 6-year-old with cerebral palsy functions at the level of an 18-monthold. Which finding would support that assessment? A. She dresses herself. B. She pulls a toy behind her. C. She can build a tower of eight blocks. D. She can copy a horizontal or vertical line. D. Morning administration mimics the body’s natural secretion of corticosteroid. Answer D: Taking corticosteroids in the morning mimics the body’s natural release of cortisol. Answers A is not necessarily true, and answers B and C are not true. 10. A 20-year-old female has a prescription for tetracycline. While teaching the client how to take her medicine, the nurse learns that the client is also taking Ortho-Novum oral contraceptive pills. Which instructions should be included in the teaching plan? A. The oral contraceptives will decrease the effectiveness of the tetracycline. B. Nausea often results from taking oral contraceptives and antibiotics. C. Toxicity can result when taking these two medications together. D. Antibiotics can decrease the effectiveness of oral contraceptives, so the client should use an alternate method of birth control. Answer D: Taking antibiotics and oral contraceptives together decreases the effectiveness of the oral contraceptives. Answers A, B, and C are not necessarily true. 11. A 60-year-old diabetic is taking glyburide (Diabeta) 1.25mg daily to treat Type II diabetes mellitus. Which statement indicates the need for further teaching? A. “I will keep candy with me just in case my blood sugar drops.” B. “I need to stay out of the sun as much as possible.” C. “I often skip dinner because I don’t feel hungry.” D. “I always wear my medical identification.” Answer C: The client should be taught to eat his meals even if he is not hungry, to prevent a hypoglycemic reaction. Answers A, B, and D are incorrect because they indicate an understanding of the nurse’s teaching. 12. The physician prescribes regular insulin, 5 units subcutaneous. Regular insulin begins to exert an effect: A. In 5–10 minutes B. In 10–20 minutes C. In 30–60 minutes D. In 60–120 minutes Answer C: The time of onset for regular insulin is 30–60 minutes; therefore, answers A, B, and D are incorrect. 13. The client is admitted from the emergency room with multiple injuries sustained from an auto accident. His doctor prescribes a histamine blocker. The reason for this order is: A. To treat general discomfort B. To correct electrolyte imbalances C. To prevent stress ulcers D. To treat nausea Answer C: Histamine blockers are frequently ordered for clients who are hospitalized for prolonged periods and who are in a stressful situation. They are not used to treat discomfort, correct electrolytes, or treat nausea; therefore, answers A, B, and D are incorrect. 14. The client with a recent liver transplant asks the nurse how long he will have to take cyclosporine (Sandimmune). Which response is correct? A. 1 year B. 5 years C. 10 years D. The rest of his life Answer D: Cyclosporin is an immunosuppressant, and the client with a liver transplant will be on immunosuppressants for the rest of his life. Answers A, B, and C, therefore, are incorrect. 15. Shortly after the client was admitted to the postpartum unit, the nurse notes heavy lochia rubra with large clots. The nurse should anticipate an order for: A. Methergine B. Stadol C. Magnesium sulfate D. Phenergan Answer A: Methergine is a drug that causes uterine contractions. It is used for postpartal bleeding that is not controlled by Pitocin. Answers B, C, and D are incorrect: Stadol is an analgesic; magnesium sulfate is used for preeclampsia; and phenergan is an antiemetic. 16. The client is scheduled to have an intravenous cholangiogram. Before the procedure, the nurse should assess the patient for: A. Shellfish allergies B. Reactions to blood transfusions C. Gallbladder disease D. Egg allergies Answer A: Clients having dye procedures should be assessed for allergies to iodine or shellfish. Answers B and D are incorrect because there is no need for the client to be assessed for reactions to blood or eggs. Because an IV cholangiogram is done to detect gallbladder disease, there is no need to ask about answer C. 17. A new diabetic is learning to administer his insulin. He receives 10U of NPH and 12U of regular insulin each morning. Which of the following statements reflects understanding of the nurse’s teaching? A. “When drawing up my insulin, I should draw up the regular insulin first.” B. “When drawing up my insulin, I should draw up the NPH insulin first.” C. “It doesn’t matter which insulin I draw up first.” D. “I cannot mix the insulin, so I will need two shots.” Answer A: Regular insulin should be drawn up before the NPH. They can be given together, so there is no need for two injections, making answer D incorrect. Answer B is obviously incorrect, and answer C is incorrect because it does matter which is drawn first: Contamination of NPH into regular insulin will result in a hypoglycemic reaction at unexpected times. 18. A client with osteomylitis has an order for a trough level to be done because he is taking Gentamycin. When should the nurse call the lab to obtain the trough level? A. Before the first dose B. To treat infection C. To replace electrolytes D. To facilitate clotting Answer D: Vitamin K is given after delivery because the newborn’s intestinal tract is sterile and lacks vitamin K needed for clotting. Answer A is incorrect because vitamin K is not directly given to prevent dehydration, but will facilitate clotting. Answers B and C are incorrect because vitamin K does not prevent infection or replace electrolytes. 25. The client with an ileostomy is being discharged. Which teaching should be included in the plan of care? A. Use Karaya powder to seal the bag. B. Irrigate the ileostomy daily. C. Stomahesive is the best skin protector. D. Neosporin ointment can be used to protect the skin. Answer C: The best protector for the client with an ileostomy to use is stomahesive. Answer A is not correct because the bag will not seal if the client uses Karaya powder. Answer B is incorrect because there is no need to irrigate an ileostomy. Neosporin, answer D, is not used to protect the skin because it is an antibiotic. 126. The client has an order for FeSo4 liquid. Which method of administration would be best? A. Administer the medication with milk B. Administer the medication with a meal C. Administer the medication with orange juice D. Administer the medication undiluted Answer C: FeSO4 or iron should be given with ascorbic acid (vitamin C). This helps with the absorption. It should not be given with meals or milk because this decreases the absorption; thus, answers A and B are incorrect. Giving it undiluted, as stated in answer D, is not good because it tastes bad. 27. The client arrives in the emergency room with a hyphema. Which action by the nurse would be best? A. Elevate the head of the bed and apply ice to the eye B. Place the client in a supine position and apply heat to the knee C. Insert a Foley catheter and measure the intake and output D. Perform a vaginal exam and check for a discharge Answer A: Hyphema is blood in the anterior chamber of the eye and around the eye. The client should have the head of the bed elevated and ice applied. Answers B, C, and D are incorrect and do not treat the problem. 28. The nurse is making assignments for the day. Which client should be assigned to the nursing assistant? A. The 18-year-old with a fracture to two cervical vertebrae B. The infant with meningitis C. The elderly client with a thyroidectomy 4 days ago D. The client with a thoracotomy 2 days ago Answer C: The most stable client is the client with the thyroidectomy 4 days ago. Answers A, B, and D are incorrect because the other clients are less stable and require a registered nurse. 29. The client arrives in the emergency room with a “bull’s eye” rash. Which question would be most appropriate for the nurse to ask the client? A. “Have you found any ticks on your body?” B. “Have you had any nausea in the last 24 hours?” C. “Have you been outside the country in the last 6 months?” D. “Have you had any fever for the past few days?” Answer A: The “bull’s eye” rash is indicative of Lyme’s disease, a disease spread by ticks. The signs and symptoms include elevated temperature, headache, nausea, and the rash. Although answers B and D are important, the question asks which would be best. Answer C has no significance. 30. Which of the following is the best indicator of the diagnosis of HIV? A. White blood cell count B. ELISA C. Western Blot D. Complete blood count Answer C: The most definitive diagnostic tool for HIV is the Western Blot. The white blood cell count, as stated in answer A, is not the best indicator, but a white blood cell count of less than 3,500 requires investigation. The ELISA test, answer B, is a screening exam. Answer D is not specific enough. 31. The client has an order for gentamycin to be administered. Which lab results should be reported to the doctor before beginning the medication? A. Hematocrit B. Creatinine C. White blood cell count D. Erythrocyte count Answer B: Gentamycin is a drug from the aminoglycocide classification. These drugs are toxic to the auditory nerve and the kidneys. The hematocrit is not of significant consideration in this client; therefore, answer A is incorrect. Answer C is incorrect because we would expect the white blood cell count to be elevated in this client because gentamycin is an antibiotic. Answer D is incorrect because the erythrocyte count is also particularly significant 32. The nurse is caring for the client with a mastectomy. Which action would be contraindicated? A. Taking the blood pressure in the side of the mastectomy B. Elevating the arm on the side of the mastectomy C. Positioning the client on the unaffected side D. Performing a dextrostix on the unaffected side Answer A: The nurse should not take the blood pressure on the affected side. Also, venopunctures and IVs should not be used in the affected area. Answers B, C, and D are all indicated for caring for the client. The arm should be elevated to decrease edema. It is best to position the client on the unaffected side and perform a dextrostix on the unaffected side. 33. The charge nurse is making assignments for the day. After accepting the assignment to a client with leukemia, the nurse tells the charge nurse that her child has chickenpox. Which action should the charge nurse take? A. Change the nurse’s assignment to another client B. “Peptic ulcers are always caused from exposure to continual stress.” C. “Peptic ulcers are like all other ulcers, which all result from stress.” D. “Peptic ulcers are associated with H. pylori, although there are other ulcers that are associated with stress.” Answer D: H. pylori bacteria and stress are directly related to peptic ulcers. Answers A and B are incorrect because peptic ulcers are not caused by overeating or always caused by continued stress. Answer C is incorrect because peptic ulcers are related to but not directly caused by stress. 139. The client is newly diagnosed with juvenile onset diabetes. Which of the following nursing diagnoses is a priority? A. Anxiety B. Pain C. Knowledge deficit D. Altered thought process Answer C: The new diabetic has a knowledge deficit. Answers A, B, and D are not supported within the stem and so are incorrect. 40. The nurse understands that the diagnosis of oral cancer is confirmed with: A. Biopsy B. Gram Stain C. Scrape cytology D. Oral washings for cytology Answer A: The best diagnostic tool for cancer is the biopsy. Other assessment includes checking the lymph nodes. Answers B, C, and D will not confirm a diagnosis of oral cancer. 41. The nurse is assisting in the care of a patient who is 2 days postoperative from a hemorroidectomy. The nurse would be correct in instructing the patient to: A. Avoid a high-fiber diet because this can hasten the healing time B. Continue to use ice packs until discharge and then when at home C. Take 200mg of Colace bid to prevent constipation D. Use a sitz bath after each bowel movement to promote cleanliness and comfort Answer D: The use of a sitz bath will help with the pain and swelling associated with a hemorroidectomy. The client should eat foods high in fiber, so answer A is incorrect. Ice packs, as stated in answer B, are ordered immediately after surgery only. Answer C, a stool softener, can be ordered, but only by the doctor. 42. The nurse is caring for a patient with a colostomy. The patient asks, “Will I ever be able to swim again?” The nurse’s best response would be: A. “Yes, you should be able to swim again, even with the colostomy.” B. “You should avoid immersing the colostomy in water.” C. “No, you should avoid getting the colostomy wet.” D. “Don’t worry about that. You will be able to live just like you did before.” Answer A: The client with a colostomy can swim and carry on activities as before the colostomy; therefore, answers B and C are incorrect. Answer D shows a lack of empathy. 43. Which is true regarding the administration of antacids? A. Antacids should be administered without regard to mealtimes. B. Antacids should be administered with each meal and snack of the day. C. Antacids should be administered within 1–2 hours of all other medications. D. Antacids should be administered with all other medications, for maximal absorption. Answer C: Antacids should be administered within 1–2 hours of other medications. If antacids are taken with many medications, they render the other medications inactive. All other answers are incorrect. 44. The nurse is preparing to administer a feeding via a nasogastric tube. The nurse would perform which of the following before initiating the feeding? A. Assess for tube placement by aspirating stomach content B. Place the patient in a left-lying position C. Administer feeding with 50% H20 concentration D. Ensure that the feeding solution has been warmed in a microwave for 2 minutes Answer A: Before beginning feedings, an x-ray is often obtained to check for placement. Aspirating stomach content and checking the pH for acidity is the best method of checking for placement. Other methods include placing the end in water and checking for bubbling, and injecting air and listening over the epigastric area. Answers B and C are not correct. Answer D is incorrect because warming in the microwave is contraindicated. 45. The patient is prescribed metronidazole (Flagyl) for adjunct treatment for a duodenal ulcer. When teaching about this medication, the nurse would say: A. “This medication should be taken only until you begin to feel better.” B. “This medication should be taken on an empty stomach to increase absorption.” C. “While taking this medication, you do not have to be concerned about being in the sun.” D. “While taking this medication, alcoholic beverages and products containing alcohol should be avoided.” Answer D: Alcohol will cause extreme nausea if consumed with Flagyl. Answer A is incorrect because the full course of treatment should be taken. The medication should be taken with a full 8oz. of water, with meals, and the client should avoid direct sunlight because he will most likely be photosensitive; therefore, answers A, B, and C are incorrect. 46. In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnoses as a priority? A. Anxiety B. Impaired skin integrity C. Fluid volume deficit D. Nutrition altered, less than body requirements Answer C: Fluid volume deficit can lead to metabolic acidosis and Answer A: Maintaining a patient’s airway is paramount in the post- operative period. This is the priority of nursing care. Answers B, C, and D are applicable but are not the priority. The nurse should instruct the client to perform mouth care using a soft sponge toothette or irrigate the mouth with normal saline. The incision should be kept as dry as possible, and pain should be treated. Pain medications should be administered PRN. 53. The nurse is assisting in the care of a patient with diverticulosis. Which of the following assessment findings would necessitate a report to the doctor? A. Bowel sounds of 5–20 seconds B. Intermittent left lower-quadrant pain C. Constipation alternating with diarrhea D. Hemoglobin 26% and hematocrit 32 Answer D: Low hemoglobin and hematocrit might indicate intestinal bleeding. Answers A, B, and C are normal lab values. 54. The nurse is assessing the client admitted for possible oral cancer. The nurse identifies which of the following as a late-occurring symptom of oral cancer? A. Warmth B. Odor C. Pain D. Ulcer with flat edges Answer C: Pain is a late sign of oral cancer. Answers A, B, and D are incorrect because a feeling of warmth, odor, and a flat ulcer in the mouth are all early occurrences of oral cancer. 55. An obstetrical client decides to have an epidural anesthetic to relieve pain during labor. Following administration of the anesthesia, the nurse should: A. Monitor the client for seizures B. Monitor the client for orthostatic hypotension C. Monitor the client for respiratory depression D. Monitor the client for hematuria Answer C: Epidural anesthesia involves injecting an anesthetic into the epidural space. If the anesthetic rises above the respiratory center, the client will have impaired breathing; thus, monitoring for respiratory depression is necessary. Answer A, seizure activity, is not likely after an epidural. Answer B, orthostatic hypotension, occurs when the client stands up but is not a monitoring action. The client with an epidural anesthesia must remain flat on her back and should not stand up for 24 hours. Answer D, hematuria, is not related to epidural anesthesia. 56. The nurse is performing an assessment of an elderly client with a total hip repair. Based on this assessment, the nurse decides to medicate the client with an analgesic. Which finding most likely prompted the nurse to decide to administer the analgesic? A. The client’s blood pressure is 130/86. B. The client is unable to concentrate. C. The client’s pupils are dilated. D. The client grimaces during care. Answer D: Facial grimace is an indication of pain. The blood pressure in answer A is within normal limits. The client’s inability to concentrate, along with dilated pupils, as stated in answers B and C, may be related to the anesthesia that he received during surgery. 57. A client who has chosen to breastfeed complains to the nurse that her nipples became very sore while she was breastfeeding her older child. Which measure will help her to avoid soreness of the nipples? A. Feeding the baby during the first 48 hours after delivery B. Breaking suction by placing a finger between the baby’s mouth and the breast when she terminates the feeding C. Applying warm, moist soaks to the breast several times per day D. Wearing a support bra Answer B: To decrease the potential for soreness of the nipples, the client should be taught to break the suction before removing the baby from the breast. Answer A is incorrect because feeding the baby during the first 48 hours after delivery will provide colostrum but will not help the soreness of the nipples. Answers C and D are incorrect because applying warm, moist soaks and wearing a support bra will help with engorgement but will not help the nipples. 58. The nurse asked the client if he has an advance directive. The reason for asking the client this question is: A. She is curious about his plans regarding funeral arrangements. B. Much confusion can occur with the client’s family if he does not have an advanced directive. C. An advanced directive allows the medical personnel to make all decisions for the client. D. An advanced directive allows active euthanasia. Answer B: An advanced directive allows the client to make known his wishes regarding care if he becomes unable to act on his own. Much confusion regarding life-saving measures can occur if the client does not have an advanced directive. Answers A, C, and D are incorrect because the nurse doesn’t need to know about funeral plans and cannot make decisions for the client, and active euthanasia is illegal in most states in the United States. 59. The doctor has ordered a Transcutaneous Electrical Nerve Stimulation (TENS) unit for the client with chronic back pain. The nurse teaching the client with a TENS unit should tell the client: A. “You may be electrocuted if you use water with this unit.” B. “Please report skin irritation to the doctor.” C. “The unit may be used anywhere on the body without fear of adverse reactions.” D. “A cream should be applied to the skin before applying the unit.” Answer B: Skin irritation can occur if the TENS unit is used for prolonged periods of time. To prevent skin irritations, the client should change the location of the electrodes often. Electrocution is not a risk because it uses a battery pack; thus, answer A is incorrect. Answer C is incorrect because the unit should not be used on sensitive areas of the body. Answer D is incorrect because no creams are to be used with the device. 60. The doctor has ordered a patient-controlled analgesia (PCA) pump for the client with chronic pain. The client asks the nurse if he can become Answer A: An occult blood test should be done periodically to detect any intestinal bleeding on the client with coumadin therapy. Answers B, C, and D are not directly related to the question. 66. The doctor has ordered 80mg of furosemide (Lasix) two times per day. The nurse notes the patient’s potassium level to be 2.5meq/L. The nurse should: A. Administer the Lasix as ordered B. Administer half the dose C. Offer the patient a potassium-rich food D. Withhold the drug and call the doctor Answer D: The potassium level of 2.5meq/L is extremely low. The normal is 3.5–5.5meq/L. Lasix (furosemide) is a nonpotassium sparing diuretic, so answer A is incorrect. The nurse cannot alter the doctor’s order, as stated in answer B, and answer C will not help with this situation. 67. The doctor is preparing to remove chest tubes from the client’s left chest. In preparation for the removal, the nurse should instruct the client to: A. Breathe normally B. Hold his breath and bear down C. Take a deep breath D. Sneeze on command Answer B: The client should be asked to perform Valsalva maneuver while the chest tube is being removed. This prevents changes in pressure until an occlusive dressing can be applied. Answers A and C are not recommended, and sneezing is difficult to perform on command. 68. The nurse identifies ventricular tachycardia on the heart monitor. Which action should the nurse prepare to take? A. Administer atropine sulfate B. Check the potassium level C. Administer an antiarrythmic medication such as Lidocaine D. Defibrillate at 360 joules Answer C: The treatment for ventricular tachycardia is lidocaine. A precordial thump is sometimes successful in slowing the rate, but this should be done only if a defibrillator is available. In answer A, atropine sulfate will speed the rate further; in answer B, checking the potassium is indicated but is not the priority; and in answer D, defibrillation is used for pulseless ventricular tachycardia or ventricular fibrillation. Also, defibrillation should begin at 200 joules and be increased to 360 joules. 69. A client is being monitored using a central venous pressure monitor. If the pressure is 2cm of water, the nurse should: A. Call the doctor immediately B. Slow the intravenous infusion C. Listen to the lungs for rales D. Administer a diuretic Answer A: The normal central venous pressure is 5–10cm of water. A reading of 2cm is low and should be reported. Answers B, C, and D indicate that the nurse believes that the reading is too high and is incorrect. 70. The nurse is evaluating the client’s pulmonary artery pressure. The nurse is aware that this test will evaluate: A. Pressure in the left ventricle B. The systolic, diastolic, and mean pressure of the pulmonary artery C. The pressure in the pulmonary veins D. The pressure in the right ventricle Answer B: The pulmonary artery pressure will measure the pressure during systole, diastole, and the mean pressure in the pulmonary artery. It will not measure the pressure in the left ventricle, the pressure in the pulmonary veins, or the pressure in the right ventricle. Therefore, answers A, C, and D are incorrect. 71. The physician has ordered atropine sulfate 0.4mg IM before surgery. The medication is supplied in 0.8mg per milliliter. The nurse should administer how many milliliters of the medication? A. 0.25mL B. 0.5mL C. 1mL D. 1.25mL Answer B: If the doctor orders 0.4mgm IM and the drug is available in 0.8/1mL, the nurse should make the calculation: ?mL = 1mL / 0.8mgm; × 0.4mg / 1 = 0.5m:. Answers A, C, and D are incorrect. 72. If the nurse is unable to illicit the deep tendon reflexes of the patella, the nurse should ask the client to: A. Pull against the palms B. Grimace the facial muscles C. Cross the legs at the ankles D. Perform Valsalva maneuver Answer A: If the nurse cannot elicit the patella reflex (knee jerk), the client should be asked to pull against the palms. This helps the client to relax the legs and makes it easier to get an objective reading. Answers B, C, and D will not help with the test. 73. A client with an abdominal aortic aneurysm is admitted in preparation for surgery. Which of the following should be reported to the doctor? A. An elevated white blood cell count B. An abdominal bruit C. A negative Babinski reflex D. Pupils that are equal and reactive to light Answer A: The elevated white blood cell count should be reported because this indicates infection. A bruit will be heard if the client has an aneurysm, and a negative Babinski is normal in the adult, as are pupils that are equal and reactive to light and accommodation; thus, answers B, C, and D are incorrect. 74. A 4-year-old male is admitted to the unit with nephotic syndrome. He is extremely edematous. To decrease the discomfort associated with scrotal edema, the nurse should: A. Apply ice to the scrotum B. Elevate the scrotum on a small pillow the client for crutches? A. Measuring five finger breaths under the axilla B. Measuring 3 inches under the axilla C. Measuring the client with the elbows flexed 10° D. Measuring the client with the crutches 20 inches from the side of the foot Answer B: To correctly measure the client for crutches, the nurse should measure approximately 3 inches under the axilla. Answer A allows for too much distance under the arm. The elbows should be flexed approximately 35°, not 10°, as stated in answer C. The crutches should be approximately 6 inches from the side of the foot, not 20 inches, as stated in answer D. 81. The nurse is doing bowel and bladder retraining for the client with paraplegia. Which of the following is not a factor for the nurse to consider? A. Dietary patterns B. Mobility C. Fluid intake D. Sexual function Answer D: When assisting the client with bowel and bladder training, the least helpful factor is the sexual function. Dietary history, mobility, and fluid intake are important factors; these must be taken into consideration because they relate to constipation, urinary function, and the ability to use the urinal or bedpan. Therefore, answers A, B, and C are incorrect. 82. The client returns to the recovery room following repair of an intrathoracic aneurysm. Which finding would require further investigation? A. Pedal pulses bounding and regular B. Urinary output 20mL in the past hour C. Blood pressure 108/50 D. Oxygen saturation 97% Answer B: Because the aorta is clamped during surgery, the blood supply to the kidneys is impaired. This can result in renal damage. A urinary output of 20mL is oliguria. In answer A, the pedal pulses that are thready and regular are within normal limits. For answer C, it is desirable for the client’s blood pressure to be slightly low after surgical repair of an aneurysm. The oxygen saturation of 97% in answer D is within normal limits and, therefore, incorrect. 83. The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would require further teaching? A. “I will have blood drawn every month.” B. “I will assess my skin for a rash.” C. “I take aspirin for a headache.” D. “I will use an electric razor to shave.” Answer C: The client taking an anticoagulant should not take aspirin because it will further thin the blood. He should return to have a Protime drawn for bleeding time, report a rash, and use an electric razor. Therefore, answers A, B, and D are incorrect. 84. A client with a femoral popliteal bypass graft is assigned to a semiprivate room. The most suitable roommate for this client is the client with: A. Hypothyroidism B. Diabetic ulcers C. Ulcerative colitis D. Pneumonia Answer A: The best roommate for the post-surgical client is the client with hypothyroidism. This client is sleepy and has no infectious process. Answers B, C, and D are incorrect because the client with a diabetic ulcer, ulcerative colitis, or pneumonia can transmit infection to the post-surgical client. 85. The nurse has just received shift report and is preparing to make rounds. Which client should be seen first? A. The client who has a history of a cerebral aneurysm with an oxygen saturation rate of 99% B. The client who is three days post–coronary artery bypass graft with a temperature of 100.2°F C. The client who was admitted 1 hour ago with shortness of breath D. The client who is being prepared for discharge following a femoral popliteal bypass graft Answer C: The client admitted 1 hour ago with shortness of breath should be seen first because this client might require oxygen therapy. The client in answer A with a low-grade temperature can be assessed after the client with shortness of breath. The client in answer B can also be seen later. This client will have some inflammatory process after surgery, so a temperature of 100.2°F is not unusual. The low-grade temperature should be re-evaluated in 1 hour. The client in answer D can be reserved for later. 86. The doctor has ordered antithrombolic stockings to be applied to the legs of the client with peripheral vascular disease. The nurse knows that the proper method of applying the stockings is: A. Before rising in the morning B. With the client in a standing position C. After bathing and applying powder D. Before retiring in the evening Answer A: The best time to apply antithrombolytic stockings is in the morning before rising. If the doctor orders them later in the day, the client should return to bed, wait 30 minutes, and apply the stockings. Answers B, C, and D are incorrect because there is likely to be more peripheral edema if the client is standing or has just taken a bath; before retiring in the evening is wrong because, late in the evening, more peripheral edema will be present. 87. The nurse is preparing a client with an axillo-popliteal bypass graft for discharge. The client should be taught to avoid: A. Using a recliner to rest B. Resting in supine position C. Sitting in a straight chair D. Sleeping in right Sim’s position Answer C: The client with a femoral popliteal bypass graft should avoid activities that can occlude the femoral artery graft. Sitting in the straight chair and wearing tight clothes are prohibited for this reason. Resting in a supine position, resting in a recliner, or sleeping in right Sim’s are allowed, as stated in answers A, B, and D. simple words such as cookie to express what they want. They already understand “yes” and “no,” so answer A is incorrect. Simple language patterns begin to develop after this age, even though children at this age might understand some words; therefore, answer B is not a good choice. Later, at about age 3 or 4, they begin to ask “Why?,” making answer D incorrect. 94. In terms of cognitive development, a 2-year-old would be expected to: A. Think abstractly B. Use magical thinking C. Understand conservation of matter D. See things from the perspective of others Answer B: A 2-year-old is expected only to use magical thinking, such as believing that a toy bear is a real bear. Answers A, C, and D are not expected until the child is much older. Abstract thinking, conservation of matter, and the ability to look at things from the perspective of others are not skills for small children. 95. The nurse is ready to begin an exam on a 9-month-old infant. The child is sitting in his mother’s lap. What should the nurse do first? A. Check the Babinski reflex B. Listen to the heart and lung sounds C. Palpate the abdomen D. Check tympanic membranes Answer B: The first action that the nurse should take when beginning to examine the infant is to listen to the heart and lungs. If the nurse elicits the Babinski reflex, palpates the abdomen, or looks in the child’s ear first, the child will begin to cry and it will be difficult to obtain an objective finding while listening to the heart and lungs. Therefore, answers A, C, and D are incorrect. 96. Which of the following examples represents parallel play? A. Jenny and Tommy share their toys. B. Jimmy plays with his car beside Mary, who is playing with her doll. C. Kevin plays a game of Scrabble with Kathy and Sue. D. Mary plays with a handheld game while sitting in her mother’s lap. Answer B: Parallel play is play that is demonstrated by two children playing side by side but not together. The play in answers A and C is participative play because the children are playing together. The play in answer D is solitary play because the mother is not playing with Mary. 97. Assuming that all have achieved normal cognitive and emotional development, which of the following children is at greatest risk for accidental poisoning? A. A 6-month-old B. A 4-year-old C. A 10-year-old D. A 13-year-old Answer B: The 4-year-old is more prone to accidental poisoning because children at this age are much more mobile and this makes them more likely to ingest poisons than the other children. Answers A, C, and D are incorrect because the 6-month-old is still too small to be extremely mobile, the 10- year-old has begun to understand risk, and the 13-year-old is also aware of the risks of poisoning and is less likely to ingest poisons than the 4-year- old. 98. An important intervention in monitoring the dietary compliance of a client with bulimia is: A. Allowing the client privacy during mealtimes B. Praising her for eating all her meals C. Observing her for 1–2 hours after meals D. Encouraging her to choose foods she likes and to eat in moderation Answer C: To prevent the client from inducing vomiting after eating, the client should be observed for 1–2 hours after meals. Allowing privacy as stated in answer A will only give the client time to vomit. Praising the client for eating all of a meal does not correct the psychological aspects of the disease; thus, answer B is incorrect. Encouraging the client to choose favorite foods might increase stress and the chance of choosing foods that are low in calories and fats. 99. The client is admitted for evaluation of aggressive behavior and diagnosed with antisocial personality disorder. A key part of the care of such a client is: A. Setting realistic limits B. Encouraging the client to express remorse for behavior C. Minimizing interactions with other clients D. Encouraging the client to act out feelings of rage Answer A: Clients with antisocial personality disorder must have limits set on their behavior because they are artful in manipulating others. Answer B is not correct because they do express feelings and remorse. Answers C and D are incorrect because it is unnecessary to minimize interactions with others or encourage them to act out rage more than they already do. 100. A client with a diagnosis of passive-aggressive personality disorder is seen at the local mental health clinic. A common characteristic of persons with passive-aggressive personality disorder is: A. Superior intelligence B. Underlying hostility C. Dependence on others D. Ability to share feelings Answer B: The client with passive-aggressive personality disorder often has underlying hostility that is exhibited as acting-out behavior. Answers A, C, and D are incorrect. Although these individuals might have a high IQ, it cannot be said that they have superior intelligence. They also do not necessarily have dependence on others or an inability to share feelings