NCLEX Exam 1 Questions and Answers with Rationales 2023 updates, Exams of Nursing

Download NCLEX Exam 1 Questions and Answers with Rationales 2023 updates and more Exams Nursing in PDF only on Docsity! NCLEX Exam 1 Questions and Answers with Rationales 2023 updates 1. 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 2. The client is admitted for evaluation of aggressive behavior and diagnosed with antisocial personality disorder. A key part of the care of such clients 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 3. 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 meal ❍ C. Observing her for 1–2 hours after meals ❍ D. Encouraging her to choose foods she likes and to eat in moderation 4. 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 12-year-old ❍ D. A 13-year-old 2 Chapter 1 5. 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. 6. The nurse is ready to begin an exam on a 9-month-old infant. The child is sitting in his mother’s lap. Which 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 7. 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 8. Which of the following best describes the language of a 24-month-old? ❍ A. Doesn’t understand yes and no ❍ B. Understands the meaning of words ❍ C. Able to verbalize needs ❍ D. Asks “why?” to most statements 9. A client who has been receiving urokinase has a large bloody bowel move- ment. Which action would be best for the nurse to take immediately? ❍ A. Administer vitamin K IM ❍ B. Stop the urokinase ❍ C. Reduce the urokinase and administer heparin ❍ D. Stop the urokinase and call the doctor 2018 Exam 1 and Rationales 5 20. The nurse is doing bowel and bladder retraining for the client with para- plegia. Which of the following is not a factor for the nurse to consider? ❍ A. Diet pattern ❍ B. Mobility ❍ C. Fluid intake ❍ D. Sexual function 21. A 20-year-old is admitted to the rehabilitation unit following a motorcycle accident. Which would be the appropriate method for measuring the client for crutches? ❍ A. Measure five finger breadths under the axilla ❍ B. Measure 3 inches under the axilla ❍ C. Measure the client with the elbows flexed 10° ❍ D. Measure the client with the crutches 20 inches from the side of the foot 22. The nurse is caring for the client following a cerebral vascular accident. Which portion of the brain is responsible for taste, smell, and hearing? ❍ A. Occipital ❍ B. Frontal ❍ C. Temporal ❍ D. Parietal 23. The client is admitted to the unit after a motor vehicle accident with a temperature of 102°F rectally. The most likely explanations for the elevat- ed temperature is that: ❍ A. There was damage to the hypothalamus. ❍ B. He has an infection from the abrasions to the head and face. ❍ C. He will require a cooling blanket to decrease the temperature. ❍ D. There was damage to the frontal lobe of the brain. 24. The client is admitted to the hospital in chronic renal failure. A diet low in protein is ordered. The rationale for a low-protein diet is: ❍ A. Protein breaks down into blood urea nitrogen and other waste. ❍ B. High protein increases the sodium and potassium levels. ❍ C. A high-protein diet decreases albumin production. ❍ D. A high-protein diet depletes calcium and phosphorous. 6 Chapter 1 25. The client who is admitted with thrombophlebitis has an order for heparin. The medication should be administered using a/an: ❍ A. Buretrol ❍ B. Infusion controller ❍ C. Intravenous filter ❍ D. Three-way stop-cock 26. The nurse is taking the blood pressure of the obese client. If the blood pressure cuff is too small, the results will be: ❍ A. A false elevation ❍ B. A false low reading ❍ C. A blood pressure reading that is correct ❍ D. A subnormal finding 27. 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 ❍ C. Apply heat to the abdominal area ❍ D. Administer an analgesic 28. The 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 29. If the nurse is unable to elicit 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 2018 Exam 1 and Rationales 7 30. The physician has ordered atropine sulfate 0.4mg IM before surgery. The medication is supplied in 0.8mg per milliliter. The nurse should adminis- ter how many milliliters of the medication? ❍ A. 0.25mL ❍ B. 0.5mL ❍ C. 1.0mL ❍ D. 1.25mL 31. The nurse is evaluating the client’s pulmonary artery pressure. The nurse is aware that this test evaluates: ❍ 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 32. 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 33. The nurse identifies ventricular tachycardia on the heart monitor. The nurse should immediately: ❍ A. Administer atropine sulfate ❍ B. Check the potassium level ❍ C. Prepare to administer an antiarrhythmic such as lidocaine ❍ D. Defibrillate at 360 joules 34. 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 10 Chapter 1 44. A client who has chosen to breastfeed tells 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 hot, moist soaks to the breast several times per day ❍ D. Wearing a support bra 45. 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. 46. An obstetrical client decides to have an epidural anesthetic to relieve pain during labor. Following administration of the anesthesia, the nurse should monitor the client for: ❍ A. Seizures ❍ B. Postural hypertension ❍ C. Respiratory depression ❍ D. Hematuria 47. The nurse is assessing the client admitted for possible oral cancer. The nurse identifies which of the following to be a late- occurring symptom of oral cancer? ❍ A. Warmth ❍ B. Odor ❍ C. Pain ❍ D. Ulcer with flat edges 48. The nurse understands that the diagnosis of oral cancer is confirmed with: ❍ A. Biopsy ❍ B. Gram Stain ❍ C. Oral culture ❍ D. Oral washings for cytology 2018 Exam 1 and Rationales 11 49. The nurse is caring for the patient following removal of a large posterior oral lesion. The priority nursing measure would be to: ❍ A. Maintain a patent airway ❍ B. Perform meticulous oral care every 2 hours ❍ C. Ensure that the incisional area is kept as dry as possible ❍ D. Assess the client frequently for pain 50. The registered nurse is conducting an in-service for colleagues on the subject of peptic ulcers. The nurse would be correct in identifying which of the following as a causative factor? ❍ A. N. gonorrhea ❍ B. H. influenza ❍ C. H. pylori ❍ D. E. coli 51. The patient states, “My stomach hurts about 2 hours after I eat.” Based upon this information, the nurse suspects the patient likely has a: ❍ A. Gastric ulcer ❍ B. Duodenal ulcer ❍ C. Peptic ulcer ❍ D. Curling’s ulcer 52. The nurse is caring for a patient with suspected diverticulitis. The nurse would be most prudent in questioning which of the following diagnostic tests? ❍ A. Abdominal ultrasound ❍ B. Barium enema ❍ C. Complete blood count ❍ D. Computed tomography (CT) scan 53. The nurse is planning care for the patient with celiac disease. In teaching about the diet, the nurse should instruct the patient to avoid which of the following for breakfast? ❍ A. Puffed wheat ❍ B. Banana ❍ C. Puffed rice ❍ D. Cornflakes 12 Chapter 1 54. The nurse is teaching about irritable bowel syndrome (IBS). Which of the following would be most important? ❍ A. Reinforcing the need for a balanced diet ❍ B. Encouraging the client to drink 16 ounces of fluid with each meal ❍ C. Telling the client to eat a diet low in fiber ❍ D. Instructing the client to limit his intake of fruits and vegetables 55. In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnosis as a priority? ❍ A. Anxiety ❍ B. Impaired skin integrity ❍ C. Fluid volume deficit ❍ D. Nutrition altered, less than body requirements 56. The patient is prescribed metronidazole (Flagyl) for adjunct treatment for a duodenal ulcer. When teaching about this medication, the nurse would include: ❍ 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 con- cerned about being in the sun.” ❍ D. “While taking this medication, alcoholic beverages and products containing alcohol should be avoided.” 57. 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% Dextrose ❍ D. Ensure that the feeding solution has been warmed in a microwave for 2 minutes 2018 Exam 1 and Rationales 15 ✓ 67. The client with cancer refuses to care for herself. Which action by the nurse would be best? ❍ A. Alternate nurses caring for the client so that the staff will not get tired of caring for this client ❍ B. Talk to the client and explain the need for self-care ❍ C. Explore the reason for the lack of motivation seen in the client ❍ D. Talk to the doctor about the client’s lack of motivation 68. 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 initial action should the charge nurse take? ❍ A. Change the nurse’s assignment to another client ❍ B. Explain to the nurse that there is no risk to the client ❍ C. Ask the nurse if the chickenpox have scabbed ❍ D. Ask the nurse if she has ever had the chickenpox 69. 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 70. The client has an order for gentamycin to be administered. Which lab results should be reported to the doctor before beginning the medica- tion? ❍ A. Hematocrit ❍ B. Creatinine ❍ C. White blood cell count ❍ D. Erythrocyte count 71. 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 16 Chapter 1 72. The client presents to 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?” 73. 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 74. The client presents to 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 75. 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 76. The client with an ileostomy is being discharged. Which teaching should be included in the plan of care? ❍ A. Using Karaya powder to seal the bag. ❍ B. Irrigating the ileostomy daily. ❍ C. Using stomahesive as the best skin protector. ❍ D. Using Neosporin ointment to protect the skin. 77. Vitamin K is administered to the newborn shortly after birth for which of the following reasons? ❍ A. To stop hemorrhage ❍ B. To treat infection ❍ C. To replace electrolytes ❍ D. To facilitate clotting 2018 Exam 1 and Rationales 17 78. Before administering Methyltrexate orally to the client with cancer, the nurse should check the: ❍ A. IV site ❍ B. Electrolytes ❍ C. Blood gases ❍ D. Vital signs 79. The nurse is teaching a group of new graduates about the safety needs of the client receiving chemotherapy. Before administering chemothera- py, the nurse should: ❍ A. Administer a bolus of IV fluid ❍ B. Administer pain medication ❍ C. Administer an antiemetic ❍ D. Allow the patient a chance to eat 80. The client is admitted to the postpartum unit with an order to continue the infusion of Pitocin. The nurse is aware that Pitocin is working if the fundus is: ❍ A. Deviated to the left. ❍ B. Firm and in the midline. ❍ C. Boggy. ❍ D. Two finger breadths below the umbilicus. 81. A 5-year-old is a family contact to the client with tuberculosis. Isoniazid (INH) has been prescribed for the client. The nurse is aware that the length of time that the medication will be taken is: ❍ A. 6 months ❍ B. 3 months ❍ C. 1 year ❍ D. 2 years 82. A 4-year-old with cystic fibrosis has a prescription for Viokase pancreatic enzymes to prevent malabsorption. The correct time to give pancreatic enzyme is: ❍ A. 1 hour before meals ❍ B. 2 hours after meals ❍ C. With each meal and snack ❍ D. On an empty stomach 20 Chapter 1 92. The client is taking prednisone 7.5mg po each morning to treat his sys- temic lupus erythematosis. Which statement best explains the reason for taking the prednisone in the morning? ❍ A. There is less chance of forgetting the medication if taken in the morning. ❍ B. There will be less fluid retention if taken in the morning. ❍ C. Prednisone is absorbed best with the breakfast meal. ❍ D. Morning administration mimics the body’s natural secretion of corticosteroid. 93. The client is taking rifampin 600mg po daily to treat his tuberculosis. Which action by the nurse indicates understanding of the medication? ❍ A. Telling the client that the medication will need to be taken with juice ❍ B. Telling the client that the medication will change the color of the urine ❍ C. Telling the client to take the medication before going to bed at night ❍ D. Telling the client to take the medication if the night sweats occur 94. The client is diagnosed with multiple myloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client? ❍ A. “Walk about a mile a day to prevent calcium loss.” ❍ B. “Increase the fiber in your diet.” ❍ C. “Report nausea to the doctor immediately.” ❍ D. “Drink at least eight large glasses of water a day.” 95. An elderly client is diagnosed with ovarian cancer. She has surgery fol- lowed by chemotherapy with a fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals in the IV medication? ❍ A. Discard the solution and order a new bag ❍ B. Warm the solution ❍ C. Continue the infusion and document the finding ❍ D. Discontinue the medication 2018 Exam 1 and Rationales 21 96. The 10-year-old is being treated for asthma. Before administering Theodur, the nurse should check the: ❍ A. Urinary output ❍ B. Blood pressure ❍ C. Pulse ❍ D. Temperature 97. Which information obtained from the mother of a child with cerebral palsy correlates to the diagnosis? ❍ A. She was born at 40 weeks gestation. ❍ B. She had meningitis when she was 6 months old. ❍ C. She had physiologic jaundice after delivery. ❍ D. She has frequent sore throats. 98. A 6-year-old with cerebral palsy functions at the level of an 18-month- old. 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. 99. 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 100. The child with seizure disorder is being treated with phenytoin (Dilantin). 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 six months.” 22 Chapter 1 101. The physician has prescribed tranylcypromine sulfate (Parnate) 10mg bid. The nurse should teach the client to refrain from eating foods con- taining tyramine because it may cause: ❍ A. Hypertension ❍ B. Hyperthermia ❍ C. Hypotension ❍ D. Urinary retention 102. The client is admitted to the emergency room with shortness of breath, anxiety, and tachycardia. His ECG reveals atrial fibrillation with a ventric- ular response rate of 130 beats per minute. The doctor orders quinidine sulfate. While he is receiving quinidine, the nurse should monitor his ECG for: ❍ A. Peaked P wave ❍ B. Elevated ST segment ❍ C. Inverted T wave ❍ D. Prolonged QT interval 103. Lidocaine is a medication frequently ordered for the client experiencing: ❍ A. Atrial tachycardia ❍ B. Ventricular tachycardia ❍ C. Heart block ❍ D. Ventricular brachycardia 104. The doctor orders 2% nitroglycerin ointment in a 1-inch dose every 12 hours. Proper application of nitroglycerin ointment includes: ❍ A. Rotating application sites ❍ B. Limiting applications to the chest ❍ C. Rubbing it into the skin ❍ D. Covering it with a gauze dressing 105. The physician prescribes captopril (Capoten) 25mg po tid for the client with hypertension. Which of the following adverse reactions can occur with administration of Capoten? ❍ A. Tinnitus ❍ B. Persistent cough ❍ C. Muscle weakness ❍ D. Diarrhea 2018 Exam 1 and Rationales 25 117. The nurse is aware that a common mode of transmission of clostridium difficile is: ❍ A. Use of unsterile surgical equipment ❍ B. Contamination with sputum ❍ C. Through the urinary catheter ❍ D. Contamination with stool 118. The nurse has just received the change of shift report. Which client should the nurse assess first? ❍ A. A client 2 hours post-lobectomy with 150ml drainage ❍ B. A client 2 days post-gastrectomy with scant drainage ❍ C. A client with pneumonia with an oral temperature of 102°F ❍ D. A client with a fractured hip in Buck’s traction 119. A client has been receiving cyanocobalamine (B12) injections for the past six weeks. Which laboratory finding indicates that the medication is hav- ing the desired effect? ❍ A. Neutrophil count of 60% ❍ B. Basophil count of 0.5% ❍ C. Monocyte count of 2% ❍ D. Reticulocyte count of 1% 120. The nurse is providing discharge teaching for a client taking dissulfiram (Antabuse). The nurse should instruct the client to avoid eating: ❍ A. Peanuts, dates, raisins ❍ B. Figs, chocolate, eggplant ❍ C. Pickles, salad with vinaigrette dressing, beef ❍ D. Milk, cottage cheese, ice cream 121. A 70-year-old male who is recovering from a stroke exhibits signs of uni- lateral neglect. Which behavior is suggestive of unilateral neglect? ❍ A. The client is observed shaving only one side of his face. ❍ B. The client is unable to distinguish between two tactile stimuli presented simultaneously. ❍ C. The client is unable to complete a range of vision without turning his head side to side. ❍ D. The client is unable to carry out cognitive and motor activity at the same time. 26 Chapter 1 122. A client with acute leukemia develops a low white blood cell count. In addition to the institution of isolation, the nurse should: ❍ A. Request that foods be served with disposable utensils ❍ B. Ask the client to wear a mask when visitors are present ❍ C. Prep IV sites with mild soap and water and alcohol ❍ D. Provide foods in sealed, single-serving packages 123. A new nursing graduate indicates in charting entries that he is a licensed registered nurse, although he has not yet received the results of the licensing exam. The graduate’s action can result in a charge of: ❍ A. Fraud ❍ B. Tort ❍ C. Malpractice ❍ D. Negligence 124. The nurse is assigning staff for the day. Which client should be assigned to the nursing assistant? ❍ A. A 5-month-old with bronchiolitis ❍ B. A 10-year-old 2-day post-appendectomy ❍ C. A 2-year-old with periorbital cellulitis ❍ D. A 1-year-old with a fractured tibia 125. During the change of shift, the oncoming nurse notes a discrepancy in the number of percocette listed and the number present in the narcotic drawer. The nurse’s first action should be to: ❍ A. Notify the hospital pharmacist ❍ B. Notify the nursing supervisor ❍ C. Notify the Board of Nursing ❍ D. Notify the director of nursing 126. Due to a high census, it has been necessary for a number of clients to be transferred to other units within the hospital. Which client should be transferred to the postpartum unit? ❍ A. A 66-year-old female with gastroenteritis ❍ B. A 40-year-old female with a hysterectomy ❍ C. A 27-year-old male with severe depression ❍ D. A 28-year-old male with ulcerative colitis 2018 Exam 1 and Rationales 27 127. A client with glomerulonephritis is placed on a low-sodium diet. Which of the following snacks is suitable for the client with sodium restriction? ❍ A. Peanut butter cookies ❍ B. Grilled cheese sandwich ❍ C. Cottage cheese and fruit ❍ D. Fresh peach 128. A home health nurse is making preparations for morning visits. Which one of the following clients should the nurse visit first? ❍ A. A client with a stroke with tube feedings ❍ B. A client with congestive heart failure complaining of night- time dyspnea ❍ C. A client with a thoracotomy six months ago ❍ D. A client with Parkinson’s disease 129. A client with cancer develops xerostomia. The nurse can help alleviate the discomfort the client is experiencing associated with xerostomia by: ❍ A. Offering hard candy ❍ B. Administering analgesic medications ❍ C. Splinting swollen joints ❍ D. Providing saliva substitute 130. The nurse is making assignments for the day. The staff consists of an RN, an LPN, and a nursing assistant. Which client could the nursing assistant care for? ❍ A. A client with Alzheimer’s disease ❍ B. A client with pneumonia ❍ C. A client with appendicitis ❍ D. A client with thrombophlebitis 131. The nurse is caring for a client with cerebral palsy. The nurse should pro- vide frequent rest periods because: ❍ A. Grimacing and writhing movements decrease with relaxation and rest. ❍ B. Hypoactive deep tendon reflexes become more active with rest. ❍ C. Stretch reflexes are increased with rest. ❍ D. Fine motor movements are improved by rest. 30 Chapter 1 143. The first exercise that should be performed by the client who had a mas- tectomy 1 day earlier is: ❍ A. Walking the hand up the wall ❍ B. Sweeping the floor ❍ C. Combing her hair ❍ D. Squeezing a ball 144. Which woman is not a candidate for RhoGam? ❍ A. A gravida 4 para 3 that is Rh negative with an Rh-positive baby ❍ B. A gravida 1 para 1 that is Rh negative with an Rh-positive baby ❍ C. A gravida II para 0 that is Rh negative admitted after a stillbirth delivery ❍ D. A gravida 4 para 2 that is Rh negative with an Rh-negative baby 145. Which laboratory test would be the least effective in making the diagno- sis of a myocardial infarction? ❍ A. AST ❍ B. Troponin ❍ C. CK-MB ❍ D. Myoglobin 146. The client with a myocardial infarction comes to the nurse’s station stat- ing that he is ready to go home because there is nothing wrong with him. Which defense mechanism is the client using? ❍ A. Rationalization ❍ B. Denial ❍ C. Projection ❍ D. Conversion reaction 147. The client is receiving total parenteral nutrition (TPN). Which lab test should be evaluated while the client is receiving TPN? ❍ A. Hemoglobin ❍ B. Creatinine ❍ C. Blood glucose ❍ D. White blood cell count 2018 Exam 1 and Rationales 31 148. The client with diabetes is preparing for discharge. During discharge teaching, the nurse assesses the client’s ability to care for himself. Which statement made by the client would indicate a need for follow-up after discharge? ❍ A. “I live by myself.” ❍ B. “I have trouble seeing.” ❍ C. “I have a cat in the house with me.” ❍ D. “I usually drive myself to the doctor.” 149. The client with cirrhosis of the liver is receiving Lactulose. The nurse is aware that the rationale for the order for Lactulose is: ❍ A. To lower the blood glucose level ❍ B. To lower the uric acid level ❍ C. To lower the ammonia level ❍ D. To lower the creatinine level 150. The client is receiving peritoneal dialysis. If the dialysate returns cloudy, the nurse should: ❍ A. Document the finding ❍ B. Send a specimen to the lab ❍ C. Strain the urine ❍ D. Obtain a complete blood count 151. The nurse employed in the emergency room is responsible for triage of four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care? ❍ A. A 10-year-old with lacerations of the face ❍ B. A 15-year-old with sternal bruises ❍ C. A 34-year-old with a fractured femur ❍ D. A 50-year-old with dislocation of the elbow 152. Which of the following roommates would be most suitable for the client with myasthenia gravis? ❍ A. A client with hypothyroidism ❍ B. A client with Crohn’s disease ❍ C. A client with pylonephritis ❍ D. A client with bronchitis 32 Chapter 1 153. The nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching? ❍ A. The graduate places the client in a supine position to read the manometer. ❍ B. The graduate turns the stop-cock to the off position from the IV fluid to the client. ❍ C. The graduate instructs the client to perform the Valsalva maneuver during the CVP reading. ❍ D. The graduate notes the level at the top of the meniscus. 154. The nurse is working with another nurse and a patient care assistant. Which of the following clients should be assigned to the registered nurse? ❍ A. A client 2 days post-appendectomy ❍ B. A client 1 week post-thyroidectomy ❍ C. A client 3 days post-splenectomy ❍ D. A client 2 days post-thoracotomy 155. Which of the following roommates would be best for the client newly admitted with gastric resection? ❍ A. A client with Crohn’s disease ❍ B. A client with pneumonia ❍ C. A client with gastritis ❍ D. A client with phlebitis 156. The nurse is preparing a client for mammography. To prepare the client for a mammogram, the nurse should tell the client: ❍ A. To restrict her fat intake for 1 week before the test ❍ B. To omit creams, powders, or deodorants before the exam ❍ C. That mammography replaces the need for self-breast exams ❍ D. That mammography requires a higher dose of radiation than x-rays 157. Which action by the novice nurse indicates a need for further teaching? ❍ A. The nurse fails to wear gloves to remove a dressing. ❍ B. The nurse applies an oxygen saturation monitor to the ear lobe. ❍ C. The nurse elevates the head of the bed to check the blood pressure. ❍ D. The nurse places the extremity in a dependent position to acquire a peripheral blood sample. 2018 Exam 1 and Rationales 35 168. The nurse recognizes that which of the following would be most appro- priate to wear when providing direct care to a client with a cough? ❍ A. Mask ❍ B. Gown ❍ C. Gloves ❍ D. Shoe covers 169. A client visits the clinic after the death of a parent. Which statement made by the client’s sister signifies abnormal grieving? ❍ A. “My sister still has episodes of crying, and it’s been three months since Daddy died.” ❍ B. “Sally seems to have forgotten the bad things that Daddy did in his lifetime.” ❍ C. “She really had a hard time after Daddy’s funeral. She said that she had a sense of longing.” ❍ D. “She has not been saddened at all by Daddy’s death. She acts like nothing has happened.” 170. The nurse is obtaining a history on an 80-year-old client. Which state- ment made by the client might indicate a potential for fluid and elec- trolyte imbalance? ❍ A. “My skin is always so dry.” ❍ B. “I often use laxatives.” ❍ C. “I have always liked to drink a lot of ice tea.” ❍ D. “I sometimes have a problem with dribbling urine.” 171. A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170meq/L. What behavior changes would be most common for this client? ❍ A. Anger ❍ B. Mania ❍ C. Depression ❍ D. Psychosis 172. When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain? ❍ A. A history of radiation treatment in the neck region ❍ B. Any history of recent orthopedic surgery ❍ C. A history of minimal physical activity ❍ D. A history of the client’s food intake 36 Chapter 1 173. The nurse on the 3–11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action? ❍ A. Call the surgeon and ask him or her to see the client to clarify the information ❍ B. Explain the procedure and complications to the client ❍ C. Check in the physician’s progress notes to see if understand- ing has been documented ❍ D. Check with the client’s family to see if they understand the procedure fully 174. The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery? ❍ A. Hearing aid ❍ B. Contact lenses ❍ C. Wedding ring ❍ D. Artificial eye 175. A client is 2 days post-operative colon resection. After a coughing episode, the client’s wound eviscerates. Which nursing action is most appropriate? ❍ A. Reinsert the protruding organ and cover with 44s ❍ B. Cover the wound with a sterile 44 and ABD dressing ❍ C. Cover the wound with a sterile saline-soaked dressing ❍ D. Apply an abdominal binder and manual pressure to the wound 176. The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor: ❍ A. That cannot be assessed ❍ B. That is in situ ❍ C. With increasing lymph node involvement ❍ D. With distant metastasis 2018 Exam 1 and Rationales 37 177. A client with cancer is to undergo an intravenous pyelogram. The nurse should: ❍ A. Force fluids 24 hours before the procedure ❍ B. Ask the client to void immediately before the study ❍ C. Hold medication that affects the central nervous system for 12 hours pre- and post-test ❍ D. Cover the client’s reproductive organs with an x-ray shield. 178. A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for: ❍ A. Trendelenburg position ❍ B. Ice to the entire extremity ❍ C. Buck’s traction ❍ D. An abduction pillow 179. The nurse is performing an assessment on a client with possible perni- cious anemia. Which data would support this diagnosis? ❍ A. A weight loss of 10 pounds in 2 weeks ❍ B. Complaints of numbness and tingling in the extremities ❍ C. A red, beefy tongue ❍ D. A hemoglobin level of 12.0gm/dL 180. A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session? ❍ A. “You will be sitting for the examination procedure.” ❍ B. “Portions of the procedure will cause pain or discomfort.” ❍ C. “You will be asleep during the procedure.” ❍ D. “You will not be able to drink fluids for 24 hours following the study.” 181. The nurse is caring for a client scheduled for a surgical repair of a sacu- lar abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period? ❍ A. Assessment of the client’s level of anxiety ❍ B. Evaluation of the client’s exercise tolerance ❍ C. Identification of peripheral pulses ❍ D. Assessment of bowel sounds and activity 40 Chapter 1 192. The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a seri- ous side effect of this drug? ❍ A. Uric acid of 5mg/dL ❍ B. Hematocrit of 33% ❍ C. WBC 2000 per cubic millimeter ❍ D. Platelets 150,000 per cubic millimeter 193. A client is admitted with a Ewing’s sarcoma. Which symptoms would be expected due to this tumor’s location? ❍ A. Hemiplegia ❍ B. Aphasia ❍ C. Nausea ❍ D. Bone pain 194. A infant weighs 7 pounds at birth. The expected weight by 1 year should be: ❍ A. 10 pounds ❍ B. 12 pounds ❍ C. 18 pounds ❍ D. 21 pounds 195. The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside? ❍ A. A pair of forceps ❍ B. A torque wrench ❍ C. A pair of wire cutters ❍ D. A screwdriver 196. The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the client? ❍ A. Rest in bed after taking the medication for at least 30 minutes. ❍ B. Avoid rapid movements after taking the medication. ❍ C. Take the medication with water only. ❍ D. Allow at least 1 hour between taking the medicine and taking other medications. 2018 Exam 1 and Rationales 41 197. The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. Which action should receive priority? ❍ A. Starting an IV ❍ B. Applying oxygen ❍ C. Obtaining blood gases ❍ D. Medicating the client for pain 198. A 24-year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nurse? ❍ A. Taking the vital signs ❍ B. Obtaining the permit ❍ C. Explaining the procedure ❍ D. Checking the lab work 199. A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following? ❍ A. Hypernatremia ❍ B. Hypokalemia ❍ C. Myelosuppression ❍ D. Leukocytosis 200. The nurse is caring for a client scheduled for removal of the pituitary gland. The nurse should be particularly alert for: ❍ A. Nasal congestion ❍ B. Abdominal tenderness ❍ C. Muscle tetany ❍ D. Oliguria 201. A client has cancer of the liver. The nurse should be most concerned about which nursing diagnosis? ❍ A. Alteration in nutrition ❍ B. Alteration in urinary elimination ❍ C. Alteration in skin integrity ❍ D. Ineffective coping 42 Chapter 1 202. 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 203. The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 68/34, pulse rate 130, and respirations 18. Which is the client’s most appropriate priority nurs- ing diagnosis? ❍ A. Alteration in cerebral tissue perfusion ❍ B. Fluid volume deficit ❍ C. Ineffective airway clearance ❍ D. Alteration in sensory perception 204. The home health nurse is visiting a 15-year-old with sickle cell disease. Which information obtained on the visit would cause the most concern? The client: ❍ A. Likes to play baseball ❍ B. Drinks several carbonated drinks per day ❍ C. Has two sisters with sickle cell trait ❍ D. Is taking Tylenol to control pain 205. The nurse on oncology is caring for a client with a white blood count of 600. During evening visitation, a visitor brings a potted plant. What action should the nurse take? ❍ A. Allow the client to keep the plant ❍ B. Place the plant by the window ❍ C. Water the plant for the client ❍ D. Tell the family members to take the plant home 206. The nurse is caring for the client following a thyroidectomy when sud- denly the client becomes nonresponsive and pale, with a BP of 60 sys- tolic. The nurse’s initial action should be to: ❍ A. Lower the head of the bed ❍ B. Increase the infusion of normal saline ❍ C. Administer atropine IV ❍ D. Obtain a crash cart 2018 Exam 1 and Rationales 45 217. The client is having electroconvulsive therapy for treatment of severe depres- sion. 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. 218. The 5-year-old is being tested for enterobiasis (pinworms). To collect a speci- men for assessment of pinworms, the nurse should teach the mother to: ❍ A. Place tape on the child’s perianal area before putting the child to bed ❍ 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 219. 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. 220. The registered nurse is making assignments for the day. Which client should not 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 brachyther- apy for thyroid cancer ❍ D. The client who returned from an intravenous pyelogram 221. Which client is at risk for opportunistic diseases such as pneumocystis pneumonia? ❍ A. The client with cancer who is being treated with chemotherapy ❍ B. The client with Type I diabetes ❍ C. The client with thyroid disease ❍ D. The client with Addison’s disease 46 Chapter 1 222. 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 223. Which assignment should not be performed by the registered nurse? ❍ A. Inserting a Foley catheter ❍ B. Inserting a nasogastric tube ❍ C. Monitoring central venous pressure ❍ D. Inserting sutures and clips in surgery 224. The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority? ❍ A. Document the finding. ❍ B. Contact the physician. ❍ C. Elevate the head of the bed. ❍ D. Administer a pain medication. 225. 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 226. Which medication is used to treat iron toxicity? ❍ A. Narcan (naloxane) ❍ B. Digibind (digoxin immune Fab) ❍ C. Desferal (deferoxamine) ❍ D. Zinecard (dexrazoxane) 227. The nurse is suspected of charting medication administration that he did not give. The nurse can be charged with: ❍ A. Fraud ❍ B. Malpractice ❍ C. Negligence ❍ D. Tort 2018 Exam 1 and Rationales 47 228. The home health nurse is planning for the day’s visits. Which client should be seen first? ❍ A. The client with renal insufficiency ❍ B. The client with Alzheimer’s ❍ C. The client with diabetes who has a decubitus ulcer ❍ D. The client with multiple sclerosis who is being treated with IV cortisone 229. 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 hallucina- tions and the client with ulcerative colitis ❍ B. The client who is six 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 230. The nurse is caring for a 6-year-old client admitted with the 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. Allow the mother to instill the eyedrops. ❍ D. If the eye is clear from any redness or edema, the eyedrops should be held. 231. To assist with the prevention of urinary tract infections, the teenage girl should be taught to: ❍ A. Drink citrus fruit juices ❍ B. Avoid using tampons ❍ C. Take showers instead of tub baths ❍ D. Clean the perineum from front to back 50 Chapter 1 242. The client is having fetal heart rates of 100–110 beats per minute during the contractions. The first action the nurse should take is to: ❍ A. Apply an internal monitor ❍ B. Turn the client to her side ❍ C. Get the client up and walk her in the hall ❍ D. Move the client to the delivery room 243. In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia, the nurse should expect: ❍ A. A rapid delivery ❍ B. Cervical effacement ❍ C. Infrequent contractions ❍ D. Progressive cervical dilation 244. A vaginal exam reveals a breech presentation in a newly admitted client. The nurse should take which of the following actions at this time? ❍ A. Prepare the client for a caesarean section ❍ B. Apply the fetal heart monitor ❍ C. Place the client in the Trendelenburg position ❍ D. Perform an ultrasound exam 245. The nurse is caring for a client admitted to labor and delivery. The nurse is aware that the infant is in distress if she notes: ❍ A. Contractions every three minutes ❍ B. Absent variability ❍ C. Fetal heart tone accelerations with movement ❍ D. Fetal heart tone 120–130bpm 246. The following are all nursing diagnoses appropriate for a gravida 4 para 3 in labor. Which one would be most appropriate for the client as she completes the latent 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 equip- ment ❍ D. Potential fluid volume deficit related to decreased fluid intake 2018 Exam 1 and Rationales 51 247. As the client reaches 8cm dilation, the nurse notes a pattern on the fetal monitor that shows a drop in the fetal heart rate of 30bpm beginning at the peak of the contraction and ending at the end of the contraction. 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. 248. The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to: ❍ A. Notify her doctor ❍ B. Increase the rate of IV fluid ❍ C. Reposition the client ❍ D. Readjust the monitor 249. Which of the following is a characteristic of a reassuring fetal heart rate pattern? ❍ A. A fetal heart rate of 180bpm ❍ B. A baseline variability of 35bpm ❍ C. A fetal heart rate of 90 at the baseline ❍ D. Acceleration of FHR with fetal movements 250. The nurse asks the client with an epidural anesthesia to void every hour during labor. The rationale for this intervention is: ❍ A. The bladder fills more rapidly because of the medication used for the epidural. ❍ B. Her level of consciousness is altered. ❍ C. The sensation of the bladder filling is diminished or lost. ❍ D. She is embarrassed to ask for the bedpan that frequently. 52 Chapter 1 Quick Check Answer Key 1. B 2. A 3. C 4. B 5. B 6. B 7. B 8. C 9. D 10. A 11. D 12. C 13. A 14. C 15. A 16. C 17. A 18. C 19. B 20. D 21. B 22. C 23. A 24. A 25. B 26. A 27. B 28. A 29. A 30. B 31. B 32. A 33. C 34. B 35. D 36. A 37. D 38. C 39. B 40. A 41. B 42. B 43. B 44. B 45. D 46. C 47. C 48. A 49. A 50. C 51. B 52. B 53. A 54. A 55. C 56. D 57. A 58. C 59. A 60. D 61. D 62. C 63. D 64. B 65. A 66. A 67. C 68. D 69. A 70. B 71. C 72. A 73. C 74. A 75. C 76. C 77. D 78. D 79. C 80. B 81. A 82. C 83. B 84. A 85. A 86. A 87. D 88. C 89. C 90. C 2018 Exam 1 and Rationales 55 Answers and Rationales 1. Answer B is correct. 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 oth- ers or an inability to share feelings. 2. Answer A is correct. Clients with antisocial personality disorder must have limits set on their behavior because they are artful in manipulating others. Answer B is not cor- rect 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. 3. Answer C is correct. 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 so D is not correct. 4. Answer B is correct. The 4-year-old is more prone to accidental poisoning because children at this age are much more mobile. Answers A, C, and D are incorrect because the 6-month-old is still too small to be extremely mobile, the 12-year-old has begun to understand risk, and the 13-year-old is also aware that injuries can occur and is less likely to become injured than the 4-year-old. 5. Answer B is correct. 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. 6. Answer B is correct. 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. 7. Answer B is correct. 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. 8. Answer C is correct. Children at 24 months can verbalize their needs. Answers A and B are incorrect because children at 24 months understand yes and no, but they do not understand the meaning of all words. Answer D is incorrect; asking “why?” comes later in development. 56 Chapter 1 9. Answer D is correct. Urokinase is a thrombolytic used to destroy a clot following a myocardial infraction. If the client exhibits overt signs of bleeding, the nurse should stop the medication, call the doctor immediately, and prepare the antidote, which is Amicar. Answer B is not correct because simply stopping the urokinase is not enough. In answer A, vitamin K is not the antidote for urokinase, and reducing the urokinase, as stated in answer B, is not enough. 10. Answer A is correct. The client taking calcium preparations will frequently develop constipation. Answers B, C, and D do not apply. 11. Answer C is correct. C indicates a lack of understanding of the correct method of administering heparin. A, B, and D indicate understanding and are, therefore, incorrect answers. 12. Answer C is correct. If the finger cannot be used, the next best place to apply the oxygen monitor is the earlobe. It can also be placed on the forehead, but the choices in answers A, B, and D will not provide the needed readings. 13. Answer A is correct. The client is exhibiting a widened pulse pressure, tachycardia, and tachypnea. The next action after obtaining these vital signs is to notify the doctor for additional orders. Rechecking the vital signs, as in answer B, is wasting time. The doctor may order arterial blood gases and an ECG. 14. Answer C is correct. 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, rest- ing in a recliner, or sleeping in right Sim’s are allowed, as stated in answers A, B, and D. 15. Answer A is correct. 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. 16. Answer C is correct. 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 an oxygen saturation of 99% is stable. Answer B is incorrect because this client will have some inflammatory process after surgery, so a temperature of 100.2°F is not unusual. The client in answer D is stable and can be seen later. 17. Answer A is correct. 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 pneu- monia can transmit infection to the post-surgical client. 18. Answer C is correct. The client taking an anticoagulant should not take aspirin because it will further increase bleeding. 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. 2018 Exam 1 and Rationales 57 19. Answer B is correct. 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 nor- mal 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. 20. Answer D is correct. 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 con- stipation, urinary function, and the ability to use the urinal or bedpan. Therefore, answers A, B, and C are incorrect. 21. Answer B is correct. To correctly measure the client for crutches, the nurse should measure approximately 3 inches under the axilla. Answer A allows for too much dis- tance under the arm. The elbows should be flexed approximately 35°, not 10°, as stat- ed in answer C. The crutches should be approximately 6 inches from the side of the foot, not 20 inches, as stated in answer D. 22. Answer C is correct. The temporal lobe is responsible for taste, smell, and hearing. The occipital lobe is responsible for vision. The frontal lobe is responsible for judg- ment, foresight, and behavior. The parietal lobe is responsible for ideation, sensory functions, and language. Therefore, answers A, B, and D are incorrect. 23. Answer A is correct. Damage to the hypothalamus can result in an elevated tempera- ture because this portion of the brain helps to regulate body temperature. Answers B, C, and D are incorrect because there is no data to support the possibility of an infec- tion, a cooling blanket might not be required, and the frontal lobe is not responsible for regulation of the body temperature. 24. Answer A is correct. A low-protein diet is required because protein breaks down into nitrogenous waste and causes an increased workload on the kidneys. Answers B, C, and D are incorrect. 25. Answer B is correct. To safely administer heparin, the nurse should obtain an infu- sion controller. Too rapid infusion of heparin can result in hemorrhage. Answers A, C, and D are incorrect. It is not necessary to have a buretrol, an infusion filter, or a three- way stop-cock. 26. Answer A is correct. If the blood pressure cuff is too small, the result will be a blood pressure that is a false elevation. Answers B, C, and D are incorrect. If the blood pres- sure cuff is too large, a false low will result. Answers C and D have basically the same meaning. 27. Answer B is correct. The child with nephotic syndrome will exhibit extreme edema. Elevating the scrotum on a small pillow will help with the edema. Applying ice is con- traindicated; heat will increase the edema. Administering a diuretic might be ordered, but it will not directly help the scrotal edema. Therefore, answers A, C, and D are incorrect. respiratory depression is necessary. Answer A, seizure activity, is not likely after an epidural. Answer B, postural hypertension, is not likely. Answer D, hematuria, is not related to epidural anesthesia. 60 Chapter 1 47. Answer C is correct. Pain is a late sign of oral cancer. Answers A, B, and D are incor- rect because a feeling of warmth, odor, and a flat ulcer in the mouth are all early occurrences of oral cancer. 48. Answer A is correct. The best diagnostic tool for cancer is the biopsy. Other assess- ment includes checking the lymph nodes. Answers B, C, and D will not confirm a diagnosis of oral cancer. 49. Answer A is correct. Maintaining a patient’s airway is paramount in the post- opera- tive period. This is the priority of nursing care. Answers B, C, and D are applicable but are not the priority. 50. Answer C is correct. H. pylori bacteria has been linked to peptic ulcers. Answers A, B, and D are not typically cultured within the stomach, duodenum, or esophagus, and are not related to the development of peptic ulcers. 51. Answer B is correct. Individuals with ulcers within the duodenum typically complain of pain occurring 2–3 hours after a meal, as well as at night. The pain is usually relieved by eating. The pain associated with gastric ulcers, answer A, occurs 30 min- utes after eating. Answer C is too vague and does not distinguish the type of ulcer. Answer D is associated with a stress ulcer. 52. Answer B is correct. A barium enema is contraindicated in the client with diverticuli- tis because it can cause bowel perforation. Answers A, C, and D are appropriate diag- nostic studies for the client with suspected diverticulitis. 53. Answer A is correct. Clients with celiac disease should refrain from eating foods con- taining gluten. Foods with gluten include wheat barley, oats, and rye. The other foods are allowed. 54. Answer A is correct. The nurse should reinforce the need for a diet balanced in all nutrients and fiber. Foods that often cause diarrhea and bloating associated with irrita- ble bowel syndrome include fried foods, caffeinated beverages, alcohol, and spicy foods. Therefore, answers B, C, and D are incorrect. 55. Answer C is correct. Fluid volume deficit can lead to metabolic acidosis and elec- trolyte loss. The other nursing diagnoses in answers A, B, and D might be applicable but are of lesser priority. 56. Answer D is correct. Alcohol will cause extreme nausea if consumed with Flagyl. Answer A is incorrect because the full course of treatment should be taken. The med- ication should be taken with a full 8 oz. 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. 57. Answer A is correct. 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. 2018 Exam 1 and Rationales 61 58. Answer C is correct. Antacids should be administered with other medications. If antacids are taken with many medications, they render the other medications inactive. All other answers are incorrect. 59. Answer A is correct. The client with a colostomy can swim and carry on activities as before the colostomy. Answers B and C are incorrect, and answer D shows a lack of empathy. 60. Answer D is correct. The use of a sitz bath will help with the pain and swelling asso- ciated 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 is incorrect because taking a laxative daily can result in diarrhea. 61. Answer D is correct. Low hemoglobin and hematocrit might indicate intestinal bleed- ing. Answers A, B, and C are incorrect, because they do not require immediate action. 62. Answer C is correct. The new diabetic has a knowledge deficit. Answers A, B, and D are not supported within the stem and so are incorrect. 63. Answer D is correct. Peptic ulcers are not always related to stress but are a compo- nent of the disease. Answers A and B are incorrect because peptic ulcers are not caused by overeating or continued exposure to stress. Answer C is incorrect because peptic ulcers are related to but not directly caused by stress. 64. Answer B is correct. Many medications can irritate the stomach and contribute to abdominal pain. For answer A, not all interactions between medications will cause abdominal pain. Although this might provide an opportunity for teaching, this is not the best time to teach. Therefore, answer C is incorrect. Answer D is incorrect because med- ication may not be the cause of the pain. 65. Answer A is correct. The nurse should inspect first, then auscultate, and finally pal- pate. If the nurse palpates first the assessment might be unreliable. Therefore, answers B, C, and D are incorrect. 66. Answer A is correct. The hospital will certainly honor the wishes of family members even if the patient has signed a donor card. Answer B is incorrect, answer C is not empathetic to the family and is untrue, and answer D is not good nursing etiquette and, therefore, is incorrect. 67. Answer C is correct. The nurse should explore the cause for the lack of motivation. The client might be anemic and lack energy, or the client might be depressed. Alternating staff, as stated in answer A, will prevent a bond from being formed with the nurse. Answer B is not enough, and answer D is not necessary. 68. Answer D is correct. The nurse who has had the chickenpox has immunity to the ill- ness and will not transmit chickenpox to the client. Answer A is incorrect because there could be no need to reassign the nurse. Answer B is incorrect because the nurse should be assessed before coming to the conclusion that she cannot spread the infec- tion to the client. Answer C is incorrect because there is still a risk, even though chick- enpox has formed scabs. 2018 Exam 1 and Rationales 63 79. Answer C is correct. Before chemotherapy, an antiemetic should be given because most chemotherapy agents cause nausea. It is not necessary to give a bolus of IV flu- ids, medicate for pain, or allow the client to eat; therefore, answers A, B, and D are incorrect. 80. Answer B is correct. Pitocin is used to cause the uterus to contract and decrease bleeding. A uterus deviated to the left, as stated in answer A, indicates a full bladder. It is not desirable to have a boggy uterus, making answer C incorrect. This lack of mus- cle tone will increase bleeding. Answer D is incorrect because Pitocin does not affect the position of the uterus. 81. Answer A is correct. Household contacts should take INH approximately 6 months. Answers B, C, and D are incorrect because they indicate either too short or too long of a time to take the medication. 82. Answer C is correct. Viokase is a pancreatic enzyme that is used to facilitate diges- tion. It should be given with meals and snacks, and it works well in foods such as applesauce. Answers A, B, and D are incorrect. 83. Answer B is correct. Trough levels are the lowest blood levels and should be done 30 minutes before the third IV dose or 30 minutes before the fourth IM dose. Answers A, C, and D are incorrect. 84. Answer A is correct. 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 certainly does matter which is drawn first: Contamination of NPH into regular insulin will result in a hypoglycemic reaction at unexpected times. 85. Answer A is correct. 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. 86. Answer A is correct. 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. 87. Answer D is correct. 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, then, are incorrect. 88. Answer C is correct. 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. 89. Answer C is correct. The time of onset for regular insulin is 30–60 minutes. Answers A, B, and D are incorrect because they are not the correct times. 64 Chapter 1 90. Answer C is correct. 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 knowledge of the nurse’s teaching. 91. Answer D is correct. Taking antibiotics and oral contraceptives together decreases the effectiveness of the oral contraceptives. Answers A, B, and C are not necessarily true. 92. Answer D is correct. Taking corticosteroids in the morning mimics the body’s natural release of cortisol. Answer A is not necessarily true, and answers B and C are not true. 93. Answer B is correct. Rifampin can change the color of the urine and body fluid. Teaching the client about these changes is best because he might think this is a com- plication. Answer A is not necessary, answer C is not true, and answer D is not true because this medication should be taken regularly during the course of the treatment. 94. Answer D is correct. Cytoxan can cause hemorrhagic cystitis, so the client should drink at least eight glasses of water a day. Answers A and B are not necessary and, so, are incorrect. Nausea often occurs with chemotherapy, so answer C is incorrect. 95. Answer A is correct. Crystals in the solution are not normal and should not be administered to the client. Discard the bad solution immediately. Answer B is incorrect because warming the solution will not help. Answer C is incorrect, and answer D requires a doctor’s order. 96. Answer C is correct. Theodur is a bronchodilator, and a side effect of bronchodilators is tachycardia, so checking the pulse is important. Extreme tachycardia should be reported to the doctor. Answers A, B, and D are not necessary. 97. Answer B is correct. The diagnosis of meningitis at age 6 months correlates to a diagnosis of cerebral palsy. Cerebral palsy, a neurological disorder, is often associated with birth trauma or infections of the brain or spinal column. Answers A, C and D are not related to the question. 98. Answer B is correct. Children at 18 months of age like push-pull toys. Children at approximately 3 years of age begin to dress themselves and build a tower of eight blocks. At age four, children can copy a horizontal or vertical line. Therefore, answers A, C, and D are incorrect. 99. Answer D is correct. A complication of a tonsillectomy is bleeding, and constant swallowing may indicate bleeding. Decreased appetite is expected after a tonsillecto- my, 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. 100. Answer C is correct. 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. 2018 Exam 1 and Rationales 65 101. Answer A is correct. If the client eats foods high in tyramine, he might experience malignant hypertension. Tyramine is found in cheese, sour cream, Chianti wine, sher- ry, beer, pickled herring, liver, canned figs, raisins, bananas, avocados, chocolate, soy sauce, fava beans, and yeast. These episodes are treated with Regitine, an alpha- adrenergic blocking agent. Answers B, C, and D are not related to the question. 102. Answer D is correct. Quinidine can cause widened Q-T intervals and heart block. Other signs of myocardial toxicity are notched P waves and widened QRS complexes. The most common side effects are diarrhea, nausea, and vomiting. The client might experi- ence tinnitus, vertigo, headache, visual disturbances, and confusion. Answers A, B, and C are not related to the use of quinidine. 103. Answer B is correct. Lidocaine is used to treat ventricular tachycardia. This medica- tion slowly exerts an antiarrhythmic effect by increasing the electric stimulation threshold of the ventricles without depressing the force of ventricular contractions. It is not used for atrial arrhythmias; thus, answer A is incorrect. Answers C and D are incorrect because it slows the heart rate, so it is not used for heart block or brachy- cardia. 104. Answer A is correct. Sites for the application of nitroglycerin should be rotated, to prevent skin irritation. It can be applied to the back and upper arms, not to the lower extremities, making answer B incorrect. Answer C is incorrect because nitroglycerine should not be rubbed into the skin, and answer D is incorrect because the medication should be covered with a prepared dressing made of a thin paper substance, not gauze. 105. Answer B is correct. A persistent cough might be related to an adverse reaction to Captoten. Answers A and D are incorrect because tinnitus and diarrhea are not associ- ated with the medication. Muscle weakness might occur when beginning the treatment but is not an adverse effect; thus, answer C is incorrect. 106. Answer A is correct. Lasix should be given approximately 1mL per minute to prevent hypotension. Answers B, C, and D are incorrect because it is not necessary to be given in an IV piggyback, with saline, or through a filter. 107. Answer B is correct. The antidote for heparin is protamine sulfate. Cyanocobalamine is B12, Streptokinase is a thrombolytic, and sodium warfarin is an anticoagulant. Therefore, answers A, C, and D are incorrect. 108. Answer A is correct. The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy is not radioactive because he travels to the radium department for therapy, and the radiation stays in the department. The client in answer B does pose a risk to the pregnant nurse. The client in answer C is radioactive in very small doses. For approximately 72 hours, the client should dispose of urine and feces in special containers and use plastic spoons and forks. The client in answer D is also radioactive in small amounts, especially upon return from the procedure. 2018 Exam 1 and Rationales 67 118. Answer A is correct. The first client to be seen is the one who recently returned from surgery. The other clients in answers B, C, and D are more stable and can be seen later. 119. Answer D is correct. Cyanocolamine is a B12 medication that is used for pernicious anemia, and a reticulocyte count of 1% indicates that it is having the desired effect. Answers A, B, and C are white blood cells and have nothing to do with this medica- tion. 120. Answer C is correct. The client taking antabuse should not eat or drink anything con- taining alcohol or vinegar. The other foods in answers A, B, and D are allowed. 121. Answer A is correct. The client with unilateral neglect will neglect one side of the body. Answers B, C, and D are not associated with unilateral neglect. 122. Answer D is correct. Because the client is immune suppressed, foods should be served in sealed containers, to avoid food contaminants. Answer B is incorrect because of pos- sible infection from visitors. Answer A is not necessary, but the utensils should be cleaned thoroughly and rinsed in hot water. Answer C might be a good idea, but alcohol can be drying and can cause the skin to break down. 123. Answer A is correct. Identifying oneself as a nurse without a license defrauds the public and can be prosecuted. A tort is a wrongful act; malpractice is failing to act appropriately as a nurse or acting in a way that harm comes to the client; and negli- gence is failing to perform care. Therefore, answers B, C, and D are incorrect. 124. Answer B is correct. The client with the appendectomy is the most stable of these clients and can be assigned to a nursing assistant. The client with bronchiolitis has an alteration in the airway; the client with periorbital cellulitis has an infection; and the client with a fracture might be an abused child. Therefore, answers A, C, and D are incorrect. 125. Answer B is correct. The first action the nurse should take is to report the finding to the nurse supervisor and follow the chain of command. If it is found that the pharma- cy is in error, it should be notified, as stated in answer A. Answers C and D, notifying the director of nursing and the Board of Nursing, might be necessary if theft is found, but not as a first step; thus, these are incorrect for this question. 126. Answer B is correct. The best client to transport to the postpartum unit is the 40- year-old female with a hysterectomy. The nurses on the postpartum unit will be aware of normal amounts of bleeding and will be equipped to care for this client. The clients in answers A and D will be best cared for on a medical-surgical unit. The client with depression in answer C should be transported to the psychiatric unit. 127. Answer D is correct. The fresh peach is the lowest in sodium of these choices. Answers A, B, and C have much higher amounts of sodium. 128. Answer B is correct. The client with congestive heart failure who is complaining of nighttime dyspnea should be seen because airway is number one in nursing care. In answers A, C, and D, the clients are more stable. A brain attack in answer A is the new terminology for a stroke. 68 Chapter 1 129. Answer D is correct. Xerostomia is dry mouth, and offering the client a saliva substi- tute will help the most. Eating hard candy in answer A can further irritate the mucosa and cut the tongue and lips. Administering an analgesic might not be necessary; thus, answer B is incorrect. Splinting swollen joints, in answer C, is not associated with xerostomia. 130. Answer A is correct. The client with Alzheimer’s disease is the most stable of these clients and can be assigned to the nursing assistant, who can perform duties such as feeding and assisting the client with activities of daily living. The clients in answers B, C, and D are less stable and should be attended by a registered nurse. 131. Answer A is correct. Frequent rest periods help to relax tense muscles and preserve energy. Answers B, C, and D are incorrect because they are untrue statements about cerebral palsy. 132. Answer D is correct. A culture for gonorrhea is taken from the genital secretions. The culture is placed in a warm environment, where it can grow nisseria gonorrhea. Answers A, B, and C are incorrect because these cultures do not test for gonorrhea. 133. Answer D is correct. After surgery, the client will be placed on a clear-liquid diet and progressed to a regular diet. Stool softeners will be included in the plan of care, to avoid constipation. Later, a high-fiber diet, in answer A, is encouraged, but this is not the first diet after surgery. Answers B and C are not diets for this type of surgery. 134. Answer C is correct. A sitz bath will help with swelling and improve healing. Ice packs, in answer D, can be used immediately after delivery, but answers A and B are not used in this instance. 135. Answer B is correct. The best way to evaluate pain levels is to ask the client to rate his pain on a scale. In answer A, the blood pressure, pulse, and temperature can alter for other reasons than pain. Answers C and D are not as effective in determining pain levels. 136. Answer C is correct. The client is experiencing compensated metabolic acidosis. The pH is within the normal range but is lower than 7.40, so it is on the acidic side. The CO2 level is elevated, the oxygen level is below normal, and the bicarb level is slightly elevated. In respiratory disorders, the pH will be the inverse of the CO2 and bicarb lev- els. This means that if the pH is low, the CO2 and bicarb levels will be elevated. Answers A, B, and D are incorrect because they do not fall into the range of symp- toms. 137. Answer B is correct. The registered nurse is the only one of these who can legally put the client in seclusion. The only other healthcare worker who is allowed to initiate seclusion is the doctor; therefore, answers A, C, and D are incorrect. 138. Answer C is correct. Sodium warfarin is administered in the late afternoon, at approximately 1700 hours. This allows for accurate bleeding times to be drawn in the morning. Therefore, answers A, B, and D are incorrect. organ, the systolic blood pressure should be maintained at 70mmHg or greater, to ensure a blood supply to the donor organ. Answers B, C, and D are incorrect because these actions are not necessary for the donated organ to remain viable. 2018 Exam 1 and Rationales 71 159. Answer A is correct. Bilirubin is excreted through the kidneys, thus the need for increased fluids. Maintaining the body temperature is important but will not assist in eliminating bilirubin; therefore, answer B is incorrect. Answers C and D are incorrect because they do not relate to the question. 160. Answer C is correct. The client with laryngeal cancer has a potential airway alteration and should be seen first. The clients in answers A, B, and D are not in immediate dan- ger and can be seen later in the day. 161. Answer B is correct. The best action for the nurse to take is to explore the interaction with the nursing assistant. This will allow for clarification of the situation. Changing the assignment in answer A might need to be done, but talking to the nursing assis- tant is the first step. Answer C is incorrect because discussing the incident with the family is not necessary at this time; it might cause more problems than it solves. Answer C is not a first step, even though initiating a group session might be a plan for the future. 162. Answer B is correct. The best action at this time is to report the incident to the charge nurse. Further action might be needed, but it will be done by the charge nurse. Answers A, C, and D are incorrect because notifying the police is overreacting at this time, and monitoring or ignoring the situation is an inadequate response. 163. Answer D is correct. The best client to assign to the newly licensed nurse is the most stable client; in this case, it is the client with diverticulitis. The client receiving chemotherapy and the client with a coronary bypass both need nurses experienced in these areas, so answers A and B are incorrect. Answer C is incorrect because the client with a transurethral prostatectomy might bleed, so this client should be assigned to a nurse who knows how much bleeding is within normal limits. 164. Answer D is correct. Intrathecal medications are administered into the cerebrospinal fluid. This method of administering medications is reserved for the client metastases, the client with chronic pain, or the client with cerebrospinal infections. Answers A, B, and C are incorrect because intravenous, rectal, and intramuscular injections are entirely different procedures. 165. Answer B is correct. Montgomery straps are used to secure dressings that require frequent dressing changes because the client with a cholecystectomy usually has a large amount of draining on the dressing. Montgomery straps are also used for clients who are allergic to several types of tape. This client is not at higher risk of evisceration than other clients, so answer A is incorrect. Montgomery straps are not used to secure the drains, so answer C is incorrect. Sutures or clips are used to secure the wound of the client who has had gallbladder surgery, so answer D is incorrect. 166. Answer B is correct. The client with pancreatitis frequently has nausea and vomiting. Lavage is often used to decompress the stomach and rest the bowel, so the insertion of a Levine tube should be anticipated. Answers A and C are incorrect because blood pressures are not required every 15 minutes, and cardiac monitoring might be need- ed, but this is individualized to the client. Answer D is incorrect because there are no dressings to change on this client. 74 Chapter 1 185. Answer A is correct. The client with a lung resection will have chest tubes and a drainage-collection device. He probably will not have a tracheostomy or Swanz Ganz monitoring, and he will not have an order for percussion, vibration, or drainage. Therefore, answers B, C, and D are incorrect. 186. Answer C is correct. The client with mouth and throat cancer will have all the find- ings in answers A, B, and D except the correct answer of diarrhea. 187. Answer D is correct. A loss of 10% is normal due to meconium stool and water loss. There is no evidence to indicate dehydration, hypoglycemia, or allergy to the infant formula; thus, answers A, B, and C are incorrect. 188. Answer C is correct. The client with diverticulitis should avoid eating foods that are gas forming and that increase abdominal discomfort, such as cooked broccoli. Foods such as those listed in answers A, B, and D are allowed. 189. Answer D is correct. The client with a perineal resection will have a perineal incision. Drains will be used to facilitate wound drainage. This will help prevent infection of the surgical site. The client will not have an illeostomy, as in answer A; he will have some electrolyte loss, but treatment is not focused on preventing the loss, so answer B is incorrect. A high-fiber diet, in answer C, is not ordered at this time. 190. Answer C is correct. The client with diverticulitis should avoid foods with seeds. The foods in answers A, B, and D are allowed; in fact, bran cereal and fruit will help pre- vent constipation. 191. Answer C is correct. The least-helpful questions are those describing his usual diet. Answers A, B, and D are useful in determining the extent of disease process and, thus, are incorrect. 192. Answer C is correct. Tegretol can suppress the bone marrow and decrease the white blood cell count; thus, a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug. Answers A and D are within normal limits, and answer B is a lower limit of normal; therefore answers A, B, and D are incorrect. 193. Answer D is correct. Sarcoma is a type of bone cancer; therefore, bone pain would be expected. Answers A, B, and C are not specific to this type of cancer and are incor- rect. 194. Answer D is correct. A birth weight of 7 pounds would indicate 21 pounds in 1 year, or triple his birth weight. Answers A, B, and C therefore are incorrect. 195. Answer B is correct. A torque wrench is kept at the bedside to tighten and loosen the screws of crutchfield tongs. This wrench controls the amount of pressure that is placed on the screws. A pair of forceps, wire cutters, and a screwdriver, in answers A, C, and D, would not be used and, thus, are incorrect. Wire cutters should be kept with the client who has wired jaws. 196. Answer C is correct. Fosamax should be taken with water only. The client should also remain upright for at least 30 minutes after taking the medication. Answers A, B, and D are not applicable to taking Fosamax and, thus, are incorrect. 2018 Exam 1 and Rationales 75 197. Answer B is correct. The client with burns to the neck needs airway assessment and supplemental oxygen, so applying oxygen is the priority. The next action should be to start an IV and medicate for pain, making answers A and C incorrect. Answer D, obtaining blood gases is of less priority. 198. Answer A is correct. The primary responsibility of the nurse is to take the vital signs before any surgery. The actions in answers B, C, and D are the responsibility of the doctor and, therefore, are incorrect for this question. 199. Answer B is correct. The only lab result that is abnormal is the potassium. A potassi- um level of 1.9 indicates hypokalemia. The findings in answers A, C, and D are not revealed in the stem. 200. Answer A is correct. Removal of the pituitary gland is usually done by a transphe- noidal approach, through the nose. Nasal congestion further interferes with the airway. Answers B, C, and D are not correct because they are not directly associated with the pituitary gland. 201. Answer A is correct. Cancer of the liver frequently leads to severe nausea and vomiting, thus the need for altering nutritional needs. The problems in answers B, C, and D are of lesser concern and, thus, are incorrect in this instance. 202. Answer C is correct. Daily measuring of the abdominal girth is the best method of determining early ascites. Measuring with a paper tape measure and marking the measured area is the most objective method of estimating ascites. Inspection and checking for fluid waves, in answers A and D, are more subjective and, thus, are incorrect for this question. Palpation of the liver, in answer B, will not tell the amount of ascites. 203. Answer B is correct. The vital signs indicate hypovolemic shock or fluid volume deficit. In answers A, C, and D, cerebral tissue perfusion, airway clearance, and senso- ry perception alterations are not symptoms and, therefore, are incorrect. 204. Answer A is correct. The client with sickle cell is likely to experience symptoms of hypoxia if he becomes dehydrated or lacks oxygen. Extreme exercise, especially in warm weather, can exacerbate the condition, so the fact that the client plays baseball should be of great concern to the visiting nurse. Answers B, C, and D are not factors for concern with sickle cell disease. 205. Answer D is correct. The client with neutropenia should not have potted or cut flow- ers in the room. Cancer patients are extremely susceptible to bacterial infections. Answers A, B, and C will not help to prevent bacterial invasions and, therefore, are incorrect. 206. Answer B is correct. Clients who have not had surgery to the face or neck would benefit from lowering the head of the bed, as in answer A. However, in this situation lowering the client’s head could further interfere with the airway. Therefore, the best answer is answer B, increasing the infusion and placing the client in supine position. Answers C and D are not necessary at this time. 76 Chapter 1 207. Answer C is correct. If the client pulls the chest tube out of the chest, the nurse should first cover the insertion site with an occlusive dressing, such as a Vaseline gauze. Then the nurse should call the doctor, who will order a chest x-ray and possi- bly reinsert the tube. Answers A, B, and D are not the first priority in this case. 208. Answer A is correct. An INR of 8 indicates that the blood is too thin. The normal INR is 2.0–3.0, so answer B is incorrect because the doctor will not increase the dosage of coumadin. Answer C is incorrect because now is not the time to instruct the client about the therapy. Answer D is not correct because there is no need to increase the neurological assessment. 209. Answer C is correct. The food indicating the client’s understanding of dietary man- agement of osteoporosis is the yogurt, with approximately 400mg of calcium. The other foods are good choices, but not as good as the yogurt; therefore, answers A, B, and D are incorrect. 210. Answer A is correct. There is no need to avoid taking the blood pressure in the left arm. Answers B, C, and D are all actions that should be taken for the client receiving magnesium sulfate for preeclampsia. 211. 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 the mother is the legal guardian and can refuse the blood transfusion to be given to her daughter. Answers B and C are incorrect because it is not the primary responsibility of the nurse to encourage the mother to consent or explain the consequences. 212. Answer B is correct. The nurse should be most concerned with laryngeal edema because of the area of burn. Answer A is of secondary priority. Hyponatremia and hypokalemia are also of concern but are not the primary concern; thus, answers C and D are incorrect. 213. Answer D is correct. The client with anorexia shows the most improvement by weight gain. Selecting a balanced diet is useless if the client does not eat the diet, so answer A is incorrect. The hematocrit, in answer B, might improve by several means, such as blood transfusion, but that does not indicate improvement in the anorexic condition, so B is incorrect. The tissue turgor indicates fluid, not improvement of anorexia, so answer C is incorrect. 214. Answer D is correct. Paresthesia of the toes is not normal and can indicate compart- ment syndrome. At this time, pain beneath the cast is normal and, thus, would not be reported as a concern. The client’s toes should be warm to the touch, and pulses should be present. Answers A, B, and C, then, are incorrect. 215. Answer B is correct. The best response from the nurse is to let the client know that it is normal to have a warm sensation when dye is injected for this procedure. Answers A, C, and D indicate that the nurse believes that the hot feeling is abnormal and, so, are incorrect. 2018 Exam 1 and Rationales 79 234. Answer C is correct. Always remember your ABC’s (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. 235. Answer A is correct. If the child has bacterial pneumonia, a high fever is usually pres- ent. Bacterial pneumonia usually presents with a productive cough, so answer B is incorrect. Rhinitis, as stated in answer C, is often seen with viral pneumonia and is incorrect for this case. Vomiting and diarrhea are usually not seen with pneumonia; thus, answer D is incorrect. 236. Answer B is correct. For a child with LTB and the possibility of complete obstruction of the airway, emergency intubation equipment should always be kept at the bedside. Intravenous supplies and fluid will not treat an obstruction, nor will supplemental oxy- gen; therefore, answers A, C, and D are incorrect. 237. Answer C is correct. Exophthalmos (protrusion of eyeballs) often occurs with hyper- thyroidism. The client with hyperthyroidism will often exhibit tachycardia, increased appetite, and weight loss. Answers A, B, and D are not associated with hyperthy- roidism. 238. Answer D is correct. The child with celiac disease should be on a gluten-free diet. Answer D is the only choice of foods that do not contain gluten. Therefore, answers A, B, and C are incorrect. 239. Answer C is correct. Remember the ABC’s (airway, breathing, circulation) when answering this question. Before notifying the physician or assessing the child’s pulse, oxygen should be applied to increase the child’s oxygen saturation. The normal oxygen saturation for a child is 92%–100%. Answer A is important but not the priority, answer B is inappropriate, and answer D is also not the priority. 240. Answer B is correct. Normal amniotic fluid is straw colored and odorless, so this is the observation the nurse should expect. An amniotomy is artificial rupture of mem- branes, causing a straw-colored fluid to appear in the vaginal area. Fetal heart tones of 160 indicate tachycardia, and this is not the observation to watch for. Greenish fluid is indicative of meconium, not amniotic fluid. If the nurse notes the umbilical cord, the client is experiencing a prolapsed cord. This would need to be reported immediately. For this question, answers A, C, and D are incorrect. 241. Answer D is correct. The client is usually given epidural anesthesia at approximately three centimeters dilation. Answer A is vague, answer B would indicate the end of the first stage of labor, and answer C indicates the transition phase, not the latent phase of labor. 242. Answer B is correct. The normal fetal heart rate is 120–160bpm. A heart rate of 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, so answer D is incorrect as well. 80 Chapter 1 243. Answer D is correct. The expected effect of Pitocin is progressive cervical dilation. Pitocin causes more intense contractions, which can increase the pain; thus, answer A is incorrect. Answers B and C are incorrect because cervical effacement is caused by pressure on the presenting part and there are not infrequent contractions. 244. Answer B is correct. Applying a fetal heart monitor is the appropriate action at this time. Preparing for a caesarean section is premature; placing the client in Trendelenburg is also not an indicated action, and an ultrasound is not needed based on the finding. Therefore, answer B is the best answer, and answers A, C, and D are incorrect. 245. Answer B is correct. Absent variability is not normal and could indicate a neurological problem. Answers A, C, and D are normal findings. 246. Answer D is correct. Clients admitted in labor are told not to eat during labor, to avoid nausea and vomiting. Ice chips might be allowed, although 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, not the early phase of labor. Answers B and C are not correct because clients during labor are allowed to change position as she desires. 247. Answer D is correct. This information indicates a late deceleration. This type of decel- eration is caused by uteroplacental insufficiency, or lack of oxygen. Answer A is incor- rect because there is no data to support the conclusion that the baby is asleep; answer B results in a variable deceleration; and answer C is indicative of an early deceleration. 248. Answer C is correct. The initial action by the nurse observing a variable deceleration should be to turn the client to the side, preferably the left side. Administering oxygen is also indicated. Answer A is not called for at this time. Answer B is incorrect because it is not needed, and answer D is incorrect because there is no data to indicate that the moni- tor has been applied incorrectly. 249. Answer D is correct. Answers A, B, and C indicate ominous findings on the fetal heart monitor and so are incorrect in this instance. Accelerations with movement are nor- mal, so answer D is the reassuring pattern. 250. Answer C is correct. Epidural anesthesia decreases the urge to void and sensation of a full bladder. A full bladder decreases the progression of labor. Answers A, B, and D are incorrect because the bladder does not fill more rapidly due to the epidural, the client is not in a trancelike state, and the client’s level of consciousness is not altered, and there is no evidence that the client is too embarrassed to ask for a bedpan. 2018 Exam 2 and Rationales 1. The nurse is caring for a client with systemic lupus erythematosis (SLE). The major complication associated with systemic lupus ery- thematosis is: ❍ A. Nephritis ❍ B. Cardiomegaly ❍ C. Desquamation ❍ D. Meningitis 2. A client with benign prostatic hypertrophy has been started on Proscar (finasteride). The nurse’s discharge teaching should include: ❍ A. Telling the client’s wife not to touch the tablets ❍ B. Explaining that the medication should be taken with meals ❍ C. Telling the client that symptoms will improve in 1–2 weeks ❍ D. Instructing the client to take the medication at bedtime, to prevent nocturia 3. A 5-year-old child is hospitalized for correction of congenital hip dysplasia. During the assessment of the child, the nurse can expect to find the presence of: ❍ A. Scarf sign ❍ B. Harlequin sign ❍ C. Cullen’s sign ❍ D. Trendelenburg sign 4. Which diet is associated with an increased risk of colorectal cancer? ❍ A. Low protein, complex carbohydrates ❍ B. High protein, simple carbohydrates ❍ C. High fat, refined carbohydrates ❍ D. Low carbohydrates, complex proteins 84 Chapter 2 15. A client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if she: ❍ A. Uses an electric blanket at night ❍ B. Dresses in extra layers of clothing ❍ C. Applies a heating pad to her feet ❍ D. Takes a hot bath morning and evening 16. The nurse caring for a client with a closed head injury obtains an intracra- nial pressure (ICP) reading of 17mmHg. The nurse recognizes that: ❍ A. The ICP is elevated and the doctor should be notified. ❍ B. The ICP is normal; therefore, no further action is needed. ❍ C. The ICP is low and the client needs additional IV fluids. ❍ D. The ICP reading is not as reliable as the Glascow coma scale. 17. A client has been hospitalized with a diagnosis of laryngeal cancer. Which factor is most significant in the development of laryngeal cancer? ❍ A. A family history of laryngeal cancer ❍ B. Chronic inhalation of noxious fumes ❍ C. Frequent straining of the vocal cords ❍ D. A history of frequent alcohol and tobacco use 18. The nurse is completing an assessment history of a client with perni- cious anemia. Which complaint differentiates pernicious anemia from other types of anemia? ❍ A. Difficulty in breathing after exertion ❍ B. Numbness and tingling in the extremities ❍ C. A faster than usual heart rate ❍ D. Feelings of lightheadedness 19. A client with rheumatoid arthritis is beginning to develop flexion contrac- tures of the knees. The nurse should tell the client to: ❍ A. Lie prone and let her feet hang over the mattress edge ❍ B. Lie supine, with her feet rotated inward ❍ C. Lie on her right side and point her toes downward ❍ D. Lie on her left side and allow her feet to remain in a neutral position 2018 Exam 2 and Rationales 85 20. The chart of a client with schizophrenia states that the client has echolalia. The nurse can expect the client to: ❍ A. Speak using words that rhyme ❍ B. Repeat words or phrases used by others ❍ C. Include irrelevant details in conversation ❍ D. Make up new words with new meanings 21. The mother of a 1-year-old with sickle cell anemia wants to know why the condition didn’t show up in the nursery. The nurse’s response is based on the knowledge that: ❍ A. There is no test to measure abnormal hemoglobin in newborns. ❍ B. Infants do not have insensible fluid loss before a year of age. ❍ C. Infants rarely have infections that would cause them to have a sickling crises. ❍ D. The presence of fetal hemoglobin protects the infant. 22. Which early morning activity helps to reduce the symptoms associated with rheumatoid arthritis? ❍ A. Brushing the teeth ❍ B. Drinking a glass of juice ❍ C. Holding a cup of coffee ❍ D. Brushing the hair 23. A client with B negative blood requires a blood transfusion during surgery. If no B negative blood is available, the client should be transfused with: ❍ A. A positive blood ❍ B. B positive blood ❍ C. O negative blood ❍ D. AB negative blood 24. The nurse notes that a post-operative client’s respirations have dropped from 14 to 6 breaths per minute. The nurse administers Narcan (nalox- one) per standing order. Following administration of the medication, the nurse should assess the client for: ❍ A. Pupillary changes ❍ B. Projectile vomiting ❍ C. Wheezing respirations ❍ D. Sudden, intense pain 86 Chapter 2 25. A newborn weighed 7 pounds at birth. At 6 months of age, the infant could be expected to weigh: ❍ A. 14 pounds ❍ B. 18 pounds ❍ C. 25 pounds ❍ D. 30 pounds 26. A client with nontropical sprue has an exacerbation of symptoms. Which meal selection is responsible for the recurrence of the client’s symptoms? ❍ A. Tossed salad with oil and vinegar dressing ❍ B. Baked potato with sour cream and chives ❍ C. Cream of tomato soup and crackers ❍ D. Mixed fruit and yogurt 27. A client with congestive heart failure has been receiving digoxia (Laxoxin). Which finding indicates that the medication is having a desired effect? ❍ A. Increased urinary output ❍ B. Stabilized weight ❍ C. Improved appetite ❍ D. Increased pedal edema 28. Which play activity is best suited to the gross motor skills of the toddler? ❍ A. Coloring book and crayons ❍ B. Ball ❍ C. Building cubes ❍ D. Swing set 29. A client in labor admits to using alcohol throughout the pregnancy. The most recent use was the day before. Based on the client’s history, the nurse should give priority to assessing the newborn for: ❍ A. Respiratory depression ❍ B. Wide-set eyes ❍ C. Jitteriness ❍ D. Low-set ears 30. The physician has ordered Basalgel (aluminum carbonate gel) for a client with recurrent indigestion. The nurse should teach the client common side effects of the medication, which include: ❍ A. Constipation ❍ B. Urinary retention ❍ C. Diarrhea ❍ D. Confusion 2018 Exam 2 and Rationales 89 41. A child with croup is placed in a cool, high-humidity tent connected to room air. The primary purpose of the tent is to: ❍ A. Prevent insensible water loss ❍ B. Provide a moist environment with oxygen at 30% ❍ C. Prevent dehydration and reduce fever ❍ D. Liquefy secretions and relieve laryngeal spasm 42. The nurse is suctioning the tracheostomy of an adult client. The recom- mended pressure setting for performing tracheostomy suctioning on the adult client is: ❍ A. 40–60mmHg ❍ B. 60–80mmHg ❍ C. 80–120mmHg ❍ D. 120–140mmHg 43. A client is admitted with a diagnosis of myxedema. An initial assessment of the client would reveal the symptoms of: ❍ A. Slow pulse rate, weight loss, diarrhea, and cardiac failure ❍ B. Weight gain, lethargy, slowed speech, and decreased respiratory rate ❍ C. Rapid pulse, constipation, and bulging eyes ❍ D. Decreased body temperature, weight loss, and increased respirations 44. Which statement describes the contagious stage of varicella? ❍ A. The contagious stage is 1 day before the onset of the rash until the appearance of vesicles. ❍ B. The contagious stage lasts during the vesicular and crusting stages of the lesions. ❍ C. The contagious stage is from the onset of the rash until the rash disappears. ❍ D. The contagious stage is 1 day before the onset of the rash until all the lesions are crusted. 45. The nurse is reviewing the results of a sweat test taken from a child with cystic fibrosis. Which finding supports the client’s diagnosis? ❍ A. A sweat potassium concentration less than 40mEq/L ❍ B. A sweat chloride concentration greater than 60mEq/L ❍ C. A sweat potassium concentration greater than 40mEq/L ❍ D. A sweat chloride concentration less than 40mEq/L 90 Chapter 2 46. A client in labor has an order for Demerol (meperidine) 75 mg. IM to be administered 10 minutes before delivery. The nurse should: ❍ A. Wait until the client is placed on the delivery table and administer the medication ❍ B. Question the order ❍ C. Give the medication IM during the delivery to prevent pain from the episiotomy ❍ D. Give the medication as ordered 47. Which of the following statements describes Piaget’s stage of concrete operations? ❍ A. Reflex activity proceeds to imitative behavior. ❍ B. The ability to see another’s point of view increases. ❍ C. Thought processes become more logical and coherent. ❍ D. The ability to think abstractly leads to logical conclusion. 48. A client admitted to the psychiatric unit claims to be the Pope and insists that he will not be kept away from his subjects. The most likely explana- tion for the client’s delusion is: ❍ A. A reaction formation ❍ B. A stressful event ❍ C. Low self-esteem ❍ D. Overwhelming anxiety 49. Which of the following statements reflects Kohlberg’s theory of the moral development of the preschool-age child? ❍ A. Obeying adults is seen as correct behavior. ❍ B. Showing respect for parents is seen as important. ❍ C. Pleasing others is viewed as good behavior. ❍ D. Behavior is determined by consequences. 50. The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately? ❍ A. Reluctance to swallow ❍ B. Drooling of blood-tinged saliva ❍ C. An axillary temperature of 99°F ❍ D. Respiratory stridor 2018 Exam 2 and Rationales 91 51. The nurse is admitting a client with a suspected duodenal ulcer. The client will most likely report that his abdominal discomfort decreases when he: ❍ A. Avoids eating ❍ B. Rests in a recumbent position ❍ C. Eats a meal or snack ❍ D. Sits upright after eating 52. The nurse is assessing a newborn in the well-baby nursery. Which find- ing should alert the nurse to the possibility of a cardiac anomaly? ❍ A. Diminished femoral pulses ❍ B. Harlequin’s sign ❍ C. Circumoral pallor ❍ D. Acrocyanosis 53. A 2-year-old is hospitalized with a diagnosis of Kawasaki’s disease. A severe complication of Kawasaki’s disease is: ❍ A. The development of Brushfield spots ❍ B. The eruption of Hutchinson’s teeth ❍ C. The development of coxa plana ❍ D. The creation of a giant aneurysm 54. The charge nurse is formulating a discharge teaching plan for a client with mild preeclampsia. The nurse should give priority to: ❍ A. Teaching the client to report a nosebleed ❍ B. Instructing the client to maintain strict bed rest ❍ C. Telling the client to notify the doctor of pedal edema ❍ D. Advising the client to avoid sodium sources in the diet 55. The nurse is preparing to discharge a client who is taking an MAOI. The nurse should instruct the client to: ❍ A. Wear protective clothing and sunglasses when outside ❍ B. Avoid over-the-counter cold and hayfever preparations ❍ C. Drink at least eight glasses of water a day ❍ D. Increase his intake of high-quality protein 56. Which of the following meal selections is appropriate for the client with celiac disease? ❍ A. Toast, jam, and apple juice ❍ B. Peanut butter cookies and milk ❍ C. Rice Krispies bar and milk ❍ D. Cheese pizza and Kool-Aid