NCLEX EXAM NCLEX-PN 2024, Exams of Nursing

Download NCLEX EXAM NCLEX-PN 2024 and more Exams Nursing in PDF only on Docsity! NCLEX EXAM NCLEX-PN WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED RATIONALES ANSWERS LATEST UPDATE 2023-2024 ALREADY GRADED A+ NCLEX EXAM NCLEX-PN Question No : 1 - Teaching the client with gonorrhea how to prevent reinfection and further spread is an example of: A. primary prevention. B. secondary prevention. C. tertiary prevention. D. primary health care prevention. Answer: B Explanation: Secondary prevention targets the reduction of disease prevalence and disease morbidity through early diagnosis and treatment. Physiological Adaptation Question No : 2 - Which of the following foods is a complete protein? A. corn B. eggs C. peanutsDsunflower seeds Answer: B Explanation: Eggs are a complete protein. The remaining options are incomplete proteins. Health Promotion and Maintenance D. some behaviors have no meaning and cannot be understood. Answer: B Explanation: Every person is worthy of dignity and respect. Every person has the potential to change and grow. All people have basic human needs in common with others. All behavior has meaning and can be understood from the client’s perspective. Psychosocial Integrity Question No : 8 - A teenage client is admitted to the hospital because of acetaminophen (Tylenol) overdose. Overdoses of acetaminophen can precipitate life- threatening abnormalities in which of the following organs? A. lungs B. liver C. kidneys D. adrenal glands Answer: B Explanation: Acetaminophen is extensively metabolized in the liver. Choices 1, 3, and 4 are incorrect because prolonged use of acetaminophen might result in an increased risk of renal dysfunction, but a single overdose does not precipitate life-threatening problems in the respiratory system, renal system, or adrenal glands. Pharmacological Therapies Question No : 9 - All of the following factors, when identified in the history of a family, are correlated with poverty except: A. high infant mortality rate. B. frequent use of Emergency Departments. C. consultation with folk healers. D. low incidence of dental problems. Answer: D Explanation: Dental problems are prevalent because of the lack of preventive care and access to care. High infant mortality is one of the most significant problems correlated with poverty. Pregnant women who do not have access to care might come to the Emergency Department when in labor. Those in poverty are likely to use Emergency Departments because they may not be turned away. Those in poverty might also turn to folk healers or other persons in their community for care who might be easier to access and might not demand payment. Health Promotion and Maintenance Question No : 10 - Acyclovir is the drug of choice for: A. HIV. B. HSV 1 and 2 and VZV. C. CMV. D. influenza A viruses. Answer: B Explanation: Acyclovir (Zovirax) is specific for treatment of herpes virus infections. There is no cure for herpes. Acyclovir is excreted unchanged in the urine and therefore must be used cautiously in the presence of renal impairment. Drugs that treat herpes inhibit viral DNA replication by competing with viral substrates to form shorter, ineffective DNA chains. Physiological Adaptation Question No : 11 - Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confused and has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley’s level of anxiety as: A. mild. B. moderate. C. severe. D. panic. Answer: C Explanation: The person whose anxiety is assessed as severe is unable to solve problems and has a poor grasp of what’s happening in his or her environment. Somatic symptoms such as those described by Ashley are usually present. Vital sign changes are observed. The individual with mild anxiety might report being mildly uncomfortable and might even find performance enhanced. The individual with moderate anxiety grasps less information about the situation, has some difficulty problem-solving, and might have mild changes in vital signs. The individual in panic demonstrates markedly disturbed behavior and might lose touch with reality. Psychosocial Integrity Question No : 12 - Which of the following methods of contraception is able to reduce the transmission of HIV and other STDs? A. intrauterine device (IUD) B. Norplant C. oral contraceptives D. vaginal sponge Answer: D Explanation: The vaginal sponge is a barrier method of contraception that, when used with foam or jelly contraception, reduces the transmission of HIV and other STDs as well as reducing the risk of pregnancy. IUDs, Norplant, and oral contraceptives can prevent pregnancy but not the transmission HIV and STDs. Which sign might the nurse see in a client with a high ammonia level? A. coma B. edema C. hypoxia D. polyuria Answer: A Explanation: Coma might be seen in a client with a high ammonia level. Reduction of Risk Potential Question No : 18 - What do the following ABG values indicate: pH 7.38, PO2 78 mmHg, PCO2 36mmHg, and HCO3 24 mEq/L? A. metabolic alkalosis B. homeostasis C. respiratory acidosis D. respiratory alkalosis Answer: B Explanation: These ABG values are within normal limits. Choices 1, 3, and 4 are incorrect because the ABG values indicate none of these acid-base disturbances. Physiological Adaptation Question No : 19 - Which of the following is the primary force in sex education in a child’s life? A. school nurse B. peers C. parents D. media Answer: C Explanation: Parents are the primary force in sex education in a child’s life. The school nurse is involved with formal sex education and counseling. Peers become more important in sex education during adolescence but might lack correct information. The media play a powerful role in what children learn about sex through movies, TV, and video games. Health Promotion and Maintenance Question No : 20 - The nurse is assessing the dental status of an 18-month-old child. How many teeth should the nurse expect to examine? A. 6 B. 8 C. 12 D. 16 Answer: C Explanation: In general, children begin dentition around 6 months of age. During the first 2 years of life, a quick guide to the number of teeth a child should have is as follows: Subtract the number 6 from the number of months in the age of the child. In this example, the child is 18 months old, so the formula is 18 – 6 = 12. An 18-month-old child should have approximately 12 teeth.Health Promotion and Maintenance Question No : 21 - Which of the following medications is a serotonin antagonist that might be used to relieve nausea and vomiting? A. metoclopramide (Reglan) B. onedansetron (Zofran) C. hydroxyzine (Vistaril) D. prochlorperazine (Compazine) Answer: B Explanation: Zofran is a serotonin antagonist that can be used to relieve nausea and vomiting. The other medications can be used for nausea and vomiting, but they have different mechanisms of action. Physiological Adaptation Question No : 22 - A client is complaining of difficulty walking secondary to a mass in the foot. The nurse should document this finding as: A. plantar fasciitis. B. hallux valgus. C. hammertoe. D. Morton’s neuroma. Answer: D Explanation: Morton’s neuroma is a small mass or tumor in a digital nerve of the foot. Hallux valgus is referred to in lay terms as abunion.Hammertoe is where one toe is cocked up over another toe. Plantar fasciitis is an inflammation of, or pain in, the arch of the foot.Basic Care and Comfort Question No : 23 - For a client with suspected appendicitis, the nurse should expect to find abdominal tenderness in which quadrant? A. upper right B. upper left Question No : 27 - Which of the following statements, if made by the parents of a newborn, does not indicate a need for further teaching about cord care? A. “I should put alcohol on my baby’s cord 3–4 times a day.” B. “I should put the baby’s diaper on so that it covers the cord.” C. “I should call the physician if the cord becomes dark.” D. “I should wash my hands before and after I take care of the cord.” Answer: D Explanation: Parents should be taught to wash their hands before and after providing cord care. This prevents transferring pathogens to and from the cord. Folding the diaper below the cord exposes the cord to air and allows for drying. It also prevents wet or soiled diapers from coming into contact with the cord. Current recommendations include cleaning the area around the cord 3–4 times a day with a cotton swab but do not include putting alcohol or other antimicrobials on the cord. It is normal for the cord to turn dark as it dries.Health Promotion and Maintenance Question No : 28 - A middle-aged woman tells the nurse that she has been experiencing irregular menses for the past six months. The nurse should assess the woman for other symptoms of: A. climacteric. B. menopause. C. perimenopause. D. postmenopause. Answer: C Explanation: Perimenopause refers to a period of time in which hormonal changes occur gradually, ovarian function diminishes, and menses become irregular. Perimenopause lasts approximately five years. Climacteric is a term applied to the period of life in which physiologic changes occur and result in cessation of a woman’s reproductive ability and lessened sexual activity in males. The term applies to both genders. Climacteric and menopause are interchangeable terms when used for females. Menopause is the period when permanent cessation of menses has occurred. Postmenopause refers to the period after the changes accompanying menopause are complete.Health Promotion and Maintenance Question No : 29 - Which of the following might be an appropriate nursing diagnosis for an epileptic client? A. Dysreflexia B. Risk for Injury C. Urinary Retention D. Unbalanced Nutrition Answer: B Explanation: The epileptic client is at risk for injury due to the complications of seizure activity, such as possible head trauma associated with a fall. The other choices are not related to the question.Reduction of Risk Potential Question No : 30 - Which of the following diseases or conditions is least likely to be associated with increased potential for bleeding? A. metastatic liver cancer B. gram-negative septicemia C. pernicious anemia D. iron-deficiency anemia Answer: C Explanation: Pernicious anemia results from vitamin B12 deficiency due to lack of intrinsic factor. This can result from inadequate dietary intake, faulty absorption from the GI tract due to a lack of secretion of intrinsic factor normally produced by gastric mucosal cells and certain disorders of the small intestine that impair absorption. The nurse should instruct the client in the need for lifelong replacement of vitamin B12, as well as the need for folic acid, rest, diet, and support.Physiological Adaptation Question No : 31 - When a client needs oxygen therapy, what is the highest flow rate that oxygen can be delivered via nasal cannula? A. 2 liters/minute B. 4 liters/minute C. 6 liters/minute D. 8 liters/minute Answer: C Explanation: The highest flow rate that oxygen can be delivered via nasal cannula is 6 liters/minute. Higher flow rates must be delivered by mask.Reduction of Risk Potential Question No : 32 - The kind of man who beats a woman is: Question No : 36 - Which of the following instructions should the nurse give a client who will be undergoing mammography? A. Be sure to use underarm deodorant. B. Do not use underarm deodorant. C. Do not eat or drink after midnight. D. Have a friend drive you home. Answer: B Explanation: Underarm deodorant should not be used because it might cause confusing shadows on the X-ray film. There are no restrictions on food or fluid intake. No sedation is used, so the client can drive herself home.Reduction of Risk Potential Question No : 37 - Teaching about the need to avoid foods high in potassium is most important for which client? A. a client receiving diuretic therapy B. a client with an ileostomy C. a client with metabolic alkalosis D. a client with renal disease Answer: D Explanation: Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in potassium. Choices 1, 2, and 3 are incorrect because clients receiving diuretics with ileostomy or with metabolic alkalosis are at risk for hypokalemia and should be encouraged to eat foods high in potassium.Physiological Adaptation Question No : 38 - A diet high in fiber content can help an individual to: A. lose body weight fast. B. reduce diabetic ketoacidosis. C. lower cholesterol. D. reduce the need for folate. Answer: C Explanation: Fiber-rich foods (such as grains, apples, potatoes, and beans) can help lower cholesterol.Nonpharmacological Therapies Question No : 39 - When administering intravenous electrolyte solution, the nurse should take which of the following precautions? A. Infuse hypertonic solutions rapidly. B. Mix no more than 80 mEq of potassium per liter of fluid. C. Prevent infiltration of calcium, which causes tissue necrosis and sloughing. D. As appropriate, reevaluate the client’s digitalis dosage. He might need an increased dosage because IV calcium diminishes digitalis’s action. Answer: C Explanation: Preventing tissue infiltration is important to avoid tissue necrosis. Choice 1 is incorrect because hypertonic solutions should be infused cautiously and checked with the RN if there is a concern. Choice 2 is incorrect because potassium, mixed in the pharmacy per physician order, is mixed at a concentration no higher than 60 mEq/L. Physiological Adaptation Question No : 40 - How often should the nurse change the intravenous tubing on total parenteral nutrition solutions? A. every 24 hours B. every 36 hours C. every 48 hours D. every 72 hours Answer: A Explanation: The nurse should change the intravenous tubing on total parenteral nutrition solutions every 24 hours, due to the high risk of bacterial growth.Health Promotion and Maintenance Question No : 41 - A woman asks, “How much alcohol can I safely drink while pregnant?” The nurse’s best response is: A. “The amount of alcohol that is safe during pregnancy is unknown.” B. “Consuming one or two beers or glasses of wine a day is considered safe for a healthy pregnant woman.” C. “Drinking three or more drinks on any given occasion is the only harmful type of drinking during pregnancy.” D. “You can have a drink to help you relax and get to sleep at night.” Answer: A Explanation: The amount of alcohol that is safe during pregnancy is unknown. Fetal alcohol syndrome is a combination of mental and physical abnormalities present in infants born to mothers who have consumed alcohol during pregnancy.Psychosocial Integrity Question No : 46 - Major competencies for the nurse giving end-oflife care include: A. demonstrating respect and compassion, and applying knowledge and skills in care of the family and the client. B. assessing and intervening to support total management of the family and client. C. setting goals, expectations, and dynamic changes to care for the client. D. keeping all sad news away from the family and client. Answer: A Explanation: There are many competencies that the nurse must have to care for families and clients at the end of life. Demonstration of respect and compassion as well as using knowledge and skills in the care of the client and family are major competencies.Basic Care and Comfort Question No : 47 - Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes a serosanguious drainage on the dressing. The most appropriate intervention is to: A. notify the physician of the drainage. B. change the dressing. C. reinforce the dressing. D. apply an abdominal binder. Answer: C Explanation: Serosanguious drainage is expected at this time. The dressing should be reinforced. Changing a new postop dressing increases the risk of infection. An abdominal binder interferes with visualization of the dressing.Basic Care and Comfort Question No : 48 - A client turns her ankle. She is diagnosed as having a Pulled Ligament. This should be documented as a: A. sprain. B. strain. C. subluxation. D. distoration. Answer: B Explanation: A strain is excessive stretching of a ligament. A sprain involves a twisting motion involving muscles.Basic Care and Comfort Question No : 49 - An appropriate intervention for the client with suspected genitourinary trauma and visible blood at the urethral meatus is: A. insertion of a Foley catheter. B. in and out catheter specimen for urinalysis. C. a voided urine specimen for urinalysis. D. a urologist consult. Answer: D Explanation: A urologist consult is appropriate for a client with visible blood at the urethral meatus and suspected trauma. Choices 1 and 2 are contraindicated. A urinalysis might be ordered by the physician, but the question does not provide enough information to make Choice 3 the correct answer.Physiological Adaptation Question No : 50 - A client with Kawasaki disease has bilateral congestion of the conjunctivae, dry cracked lips, a strawberry tongue, and edema of the hands and feet followed by desquamation of fingers and toes. Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image? A. administering immune globulin intravenously B. assessing the extremities for edema, redness and desquamation every 8 hours C. explaining progression of the disease to the client and his or her family D. assessing heart sounds and rhythm Answer: C Explanation: Teaching the client and family about progression of the disease includes explaining when symptoms can be expected to improve and resolve. Knowledge of the course of the disease can help them understand that no permanent disruption in physical appearance will occur that could negatively affect body image. Clients with Kawasaki disease might receive immune globulin intravenously to reduce the incidence of coronary artery lesions and aneurysms. Cardiac effects could be linked to body image, but Choice 3 is the most direct link to body image. The nurse assesses symptoms to assist in evaluation of treatment and progression of the disease.Health Promotion and Maintenance Question No : 51 - A client, age 28, was recently diagnosed with Hodgkin’s disease. After staging, therapy is planned to include combination radiation therapy and systemic chemotherapy with MOPP— nitrogen mustard, vincristine (Onconvin), Question No : 55 - A young boy is recently diagnosed with a seizure disorder. Which of the following statements by the boy’s mother indicates a need for further teaching by the nurse? A. “I should make sure he gets plenty of rest.” B. “I should get him a medic alert bracelet.” C. “I should lay him on his back during a seizure.” D. “I should loosen his clothing during a seizure.” Answer: C Explanation: A client having a seizure should be turned to the side to prevent aspiration of secretions. The other statements are correct and indicate adequate understanding of teaching.Reduction of Risk Potential Question No : 56 - To remove hard contact lenses from an unresponsive client, the nurse should: A. gently irrigate the eye with an irrigating solution from the inner canthus outward. B. grasp the lens with a gentle pinching motion. C. don sterile gloves before attempting the procedure. D. ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens. Answer: D Explanation: To remove hard contact lenses, the upper and lower eyelids are gently maneuvered to help loosen the lens and slide it out of the eye. The lens must be situated on the cornea, not the sclera, before removal. An attempt to grasp a hard lens might result in a scratch on the cornea. Clean gloves are an option if drainage is present.Basic Care and Comfort Question No : 57 - Which of the following foods might a client with a hypercholesterolemia need to decrease his or her intake of? A. broiled catfish B. hamburgers C. wheat bread D. fresh apples Answer: B Explanation: Due to the high cholesterol content of red meats, such as hamburger, intake needs to be decreased. The other options do not have high cholesterol content, so they do not need to be decreased.Reduction of Risk Potential Question No : 58 - Nurses caring for clients who have cancer and are taking opioids need to assess for all of the following except: A. tolerance. B. constipation. C. sedation. D. addiction. Answer: D Explanation: Addiction is not of primary concern when treating the pain of terminally ill clients. Clients with cancer who are taking opioid analgesics can develop tolerance, constipation, and sedation.Basic Care and Comfort Question No : 59 - Which of the following nursing actions is most effective when evaluating a kinetic family drawing? A. telling the child to draw their family doing something B. offering specific suggestions of what to include in the drawing C. discouraging the child from talking about the drawing D. noting the omission of any family members Answer: D Explanation: There are several guidelines for evaluating kinetic family drawings, including Choice 4. Effective nursing actions include asking the child to explain what each family member is doing, encouraging him or her to tell as much as possible about the drawing, noting physical intimacy or distance, noting placement of family members in the drawing, noting facial expressions of family members and noting if they are facing each other or turned away. Choice 1 is initial instruction, not evaluation. Only general encouragement should be given to avoid suggesting themes to the child.Health Promotion and Maintenance Question No : 60 - A client with an ileus is placed on intestinal tube suction. Which of the following electrolytes is lost with intestinal suction? A. calcium B. magnesium C. potassium D. sodium chloride Answer: D Explanation: D. unexplained vaginal bleeding Answer: D Explanation: Unexplained vaginal bleeding is a contraindication for hormone replacement therapy. Family history of stroke is not a contraindication for hormone replacement therapy. If the woman herself had a history of stroke or other blood-clotting events, hormone therapy could be contraindicated. Frequent hot flashes and/or night sweats can be relieved by hormone replacement therapy.Health Promotion and Maintenance Question No : 65 - A pregnant Asian client who is experiencing morning sickness wants to take ginger to relieve the nausea. Which of the following responses by the nurse is appropriate? A. “I will call your physician to see if we can start some ginger.” B. “We don’t use home remedies in this clinic.” C. “Herbs are not as effective as regular medicines.” D. “Just eat some dry crackers instead.” Answer: A Explanation: This statement reveals cultural sensitivity. Ginger is sometimes used to relieve nausea. The other statements are culturally insensitive and do not show an awareness of herbal pharmacology.Physiological Adaptation Question No : 66 - Which of the following physical findings indicates that an 11–12-month-old child is at risk for developmental dysplasia of the hip? A. refusal to walk B. not pulling to a standing position C. negative Trendelenburg sign D. negative Ortolani sign Answer: B Explanation: The nurse might be concerned about developmental dysplasia of the hip if an 11–12month- old child doesn’t pull to a standing position. An infant who does not walk by 15 months of age should be evaluated. Children should start walking between 11–15 months of age. Trendelenberg sign is related to weakness of the gluteus medius muscle, not hip dysplasia. Ortolani sign is used to identify congenital subluxation or dislocation of the hip in infants.Health Promotion and Maintenance Question No : 67 - A client with which of the following conditions is at risk for developing a high ammonia level? A. renal failure B. psoriasis C. lupus D. cirrhosis Answer: D Explanation: A client with cirrhosis is at risk for developing a high ammonia level.Reduction of Risk Potential Question No : 68 - What is the primary nutritional deficiency of concern for a strict vegetarian? A. vitamin C B. vitamin B12 C. vitamin E D. magnesium Answer: B Explanation: Vitamin B12 is the primary nutritional deficiency of concern for a strict vegetarian.Health Promotion and Maintenance Question No : 69 - Which of the following foods should be avoided by clients who are prone to develop heartburn as a result of gastroesophgeal reflux disease (GERD)? A. lettuce B. eggs C. chocolate D. butterscotch Answer: C Explanation: Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure leading to reflux and clinical symptoms of GERD. The other foods do not affect LES pressure.Basic Care and Comfort Question No : 70 - A client has been taking alprazolam (Xanax) for four years to manage anxiety. The client reports taking 0.5 mg four times a day. Which statement indicates that the client understands the nurse’s teaching about discontinuing the medication? Clients with dumping syndrome should lie down after eating to decrease dumping syndrome. GERD clients should sit up to prevent backflow of acid into the esophagus.Basic Care and Comfort Question No : 74 - Which of the following organs of the digestive system has a primary function of absorption? A. stomach B. pancreas C. small intestine D. gallbladder Answer: C Explanation: The small intestine has a primary function of absorption. The remaining digestive organs have other primary functions.Physiological Adaptation Question No : 75 - Which of the following neurological disorders is characterized by writhing, twisting movements of the face and limbs? A. epilepsy B. Parkinson’s C. muscular sclerosis D. Huntington’s chorea Answer: D Explanation: Huntington’s chorea is characterized by writhing, twisting movements of the face and limbs. The remaining options are neurological disorders that do not have such movements as part of their disease process.Reduction of Risk Potential Question No : 76 - The nurse is teaching parents of a newborn about feeding their infant. Which of the following instructions should the nurse include? A. Use the defrost setting on microwave ovensto warm bottles. B. When refrigerating formula, don’t feed the baby partially used bottles after 24 hours. C. When using formula concentrate, mix two parts water and one part concentrate. D. If a portion of one bottle is left for the next feeding, go ahead and add new formula to fill it. Answer: A Explanation: Parents must be careful when warming bottles in a microwave oven because the milk can become superheated. When a microwave oven is used, the defrost setting should be chosen, and the temperature of the formula should be checked before giving it to the baby. Refrigerated, partially used bottles should be discarded after 4 hours because the baby might have introduced some pathogens into the formula. Returning the bottle to the refrigerator does not destroy pathogens. Formula concentrate and water are usually mixed in a 1:1 ratio of one part concentrate and one part water. Infants should be offered fresh formula at each feeding. Partially used bottles should not have fresh formula added to them. Pathogens can grow in partially used bottles of formula and be transferred to the new formula.Health Promotion and Maintenance Question No : 77 - A client who is immobilized secondary to traction is complaining of constipation. Which of the following medications should the nurse expect to be ordered? A. Advil B. Anasaid C. Clinocil D. Colace Answer: D Explanation: Colace is a stool softener that acts by pulling more water into the bowel lumen, making the stool soft and easier to evacuate.Basic Care and Comfort Question No : 78 - The nurse explains to a client who underwent gastric resection that which of the following meals is most likely to cause rapid emptying of the stomach? A. a high-protein meal B. a high-fat meal C. a large meal regardless of nutrient content D. a high-carbohydrate meal Answer: D Explanation: Meals that are high in carbohydrates promote rapid gastric emptying. The other options are associated with decreased emptying time.Basic Care and Comfort Question No : 79 - A batterer is usually someone who: A. grew up in a loving, secure home. B. was an only child. Thrill should be present. The client should be taught to check this daily at home. Pulsation is not typically visible. Percussion gives no information about the patency of a fistula. Blood pressure is not auscultated in a limb with an AVF. Auscultation of the AVF, for a bruit, is part of an assessment for patency.Physiological Adaptation Question No : 84 - James returns home from school angry and upset because his teacher gave him a low grade on an assignment. After returning home from school, he kicks the dog. This coping mechanism is known as: A. denial. B. suppression. C. displacement. D. fantasy. Answer: C Explanation: Displacement is the transference of anger to another. Anger is displaced on the dog as a convenient object. Psychosocial Integrity Question No : 85 - Which condition is associated with inadequate intake of vitamin C? A. rickets B. marasmus C. kwashiorkor D. scurvy Answer: D Explanation: Scurvy is associated with inadequate intake of vitamin C. The remaining choices refer to other nutritional deficiencies.Health Promotion and Maintenance Question No : 86 - Which is the proper hand position for performing chest percussion? A. cup the hands B. use the side of the hands C. flatten the hands D. spread the fingers of both hands Answer: A Explanation: The hands are cupped for performing percussion, producing a vibration that helps loosen respiratory secretions. The other hand positions do not accomplish this task.Reduction of Risk Potential Question No : 87 - Which of the following is likely to increase the risk of sexually transmitted disease? A. alcohol use B. certain types of sexual practices C. oral contraception use D. all of the above Answer: D Explanation: STDs affect certain groups in groups in greater numbers. Factors associated with risk include being younger than 25 years of age, being a member of a minority group, residing in an urban setting, being impoverished, and using crack cocaine.Physiological Adaptation Question No : 88 - Why might breast implants interfere with mammography? A. They might cause additional discomfort. B. They are contraindications to mammography. C. They are likely to be dislodged. D. They might prevent detection of masses. Answer: D Explanation: Breast implants can prevent detection of masses. Choices 1, 2, and 3 are not ways in which breast implants interfere with mammography.Reduction of Risk Potential Question No : 89 - A health care worker is concerned about a new mother being overwhelmed by caring for her infant. The health care worker should: A. immediately contact child protective services. B. provide the mother with literature about child care. C. consult a therapist to help the mother work out her fears. D. refer the mother to parenting classes. Answer: D Explanation: Prevention of child abuse is centered on teaching the parents how to care for their child and cope with the demands of infant care. Parenting classes can help build self-confidence, self- esteem, and coping skills. Parents benefit by understanding the developmental needs of their children, while learning how to manage their home environment more effectively. The classes also increase the parents’ social contacts and teach about community resources.Psychosocial Integrity A client is having a seizure; his blood oxygen saturation drops from 92% to 82%. What should the nurse do first? A. Open the airway. B. Administer oxygen. C. Suction the client. D. Check for breathing. Answer: A Explanation: The nurse needs to open the airway first when the oxygen saturation drops. The other actions might be appropriate, but the airway must be patent.Reduction of Risk Potential Question No : 95 - To remove a client’s gown when she has an intravenous line, the nurse should: A. temporarily disconnect the intravenous tubing at a point close to the client and thread it through the gown. B. cut the gown with scissors. C. thread the bag and tubing through the gown sleeve, keeping the line intact. D. temporarily disconnect the tubing from the intravenous container and thread it through the gown. Answer: C Explanation: Threading the bag and tubing through the gown sleeve keeps the system intact. Opening an intravenous line causes a break in a sterile system and introduces the potential for infection. Cutting a gown off is not an alternative except in an emergency. IV gowns, which open along sleeves, are widely available.Basic Care and Comfort Question No : 96 - Which of the following is most likely to impact the body image of an infant newly diagnosed with Hemophilia? A. immobility B. altered growth and development C. hemarthrosis D. altered family processes Answer: D Explanation: Altered Family Processes is a potential nursing diagnosis for the family and client with a new diagnosis of Hemophilia. Infants are aware of how their caregivers respond to their needs. Stresses can have an immediate impact on the infant’s development of trust and how others relate to them because of their diagnosis. The longterm effects of hemophilia can include problems related to immobility. Altered growth and development could not have developed in a newly diagnosed client. Hemarthrosis is acute bleeding into a joint space that is characteristic of hemophilia. It does not have an immediate effect on the body image of a newly diagnosed hemophiliac.Health Promotion and Maintenance Question No : 97 - Which of the following values should the nurse monitor closely while a client is on total parenteral nutrition? A. calcium B. magnesium C. glucose D. cholesterol Answer: C Explanation: Glucose is monitored closely when a client is on total parenteral nutrition, due to high glucose concentration in the solutions. The other values are not monitored as closely.Health Promotion and Maintenance Question No : 98 - A client with stress incontinence should be advised: A. to purchase absorbent undergarments. B. that Kegel exercises might help. C. that effective surgical treatments are nonexistent. D. that behavioral therapy is ineffective. Answer: B Explanation: Kegel exercises, tightening and releasing the pelvic floor muscles, might improve stress incontinence. Choice 1 is not an appropriate treatment for stress incontinence. Several effective surgical treatments exist. Lifestyle and dietary modifications can also be helpful.Physiological Adaptation Question No : 99 - Diagnostic genetic counseling, for procedures such as amniocentesis and chorionic villus sampling, allows clients to make all of the following choices except: A. terminating the pregnancy. B. preparing for the birth of a child with special needs. C. accessing support services before the birth. D. completing the grieving process before the birth. Answer: D Explanation: If findings are ominous, the grieving process will not be completed before birth. If the couple elects to terminate a pregnancy based on diagnostic tests, Answer: A Explanation: Alkylating agents are highly reactive chemicals that introduce alkyl radicals into biologically active molecules and thereby prevent their proper functioning, replication, and transcription. Choice 2 is incorrect because alkylating agents have numerous side effects including alopecia, nausea, vomiting, and myelosuppression. Choice 3 is incorrect because nitrogen mustards have a broad spectrum of activity against chronic lymphocytic leukemia, non-Hodgkin’s lymphoma, and breast and ovarian cancer, but they are effective chemotherapeutic agents because of DNA crosslinkage. Choice 4 is incorrect because alkylating agents are non-cell- cyclespecific agents.PharmacologicalTherapies Question No : 104 - Using clichés in therapeutic communication leads the client toward: A. viewing the nurse as human. B. accepting himself as human. C. self-disclosing. D. feeling discounted. Answer: D Explanation: The use of clichés in therapeutic communication is commonly construed by the client as the nurse’s lack of understanding, involvement, and caring, so the client might feel demeaned and discounted.Psychosocial Integrity Question No : 105 - Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep? A. exercising vigorously for 20 minutes each night beginning at 9:30 p.m. B. taking a cool shower and drinking a hot cup of tea C. watching TV nightly until midnight D. getting a back rub and drinking a glass of warm milk Answer: D Explanation: These are appropriate measure to promote sleep. Choices 1, 2, and 3 are all stimulation actions that increase arousal and wakefulness.Basic Care and Comfort Question No : 106 - Ethical and moral issues concerning restraints include all of the following except: A. emotional impact on the client and family. B. dignity of the client. C. client’s quality of life. D. policies and procedures. Answer: D Explanation: Policies and procedures, though important, are not in the category of ethical and moral issues. The other options are ethical and moral issues.Safety and Infection Control Question No : 107 - A client is told that his test is positive, but in fact, the client does not have the disease tested for. Which type of false report is this an example of? A. positive B. false positive C. negative D. false negative Answer: B Explanation: A false-positive result occurs when a test result is labeled positive in error, when the actual result is negative. Safety and Infection Control Question No : 108 - A nurse observes a client sitting alone and talking. When asked, the client reports that he is “talking to the voices.” The nurse’s next action should be: A. touching the client to help him return to reality. B. leaving the client alone until reality returns. C. asking the client to describe what is happening. D. telling the client there are no voices. Answer: C Explanation: Nurses might observe behavioral cues that can indicate the presence of hallucinations. Talking about the hallucinations is reassuring and validating to the client who has them. Focusing on the symptoms and asking about the hallucinations helps the client gain control.Psychosocial Integrity Question No : 109 - A client with massive chest and head injuries is admitted to the ICU from the Emergency Department. All of the following are true except: A. B.the physician in charge of the case is the only person allowed to decide whether organ donation can occur. C. the supervisor wants to control the style in which a staff member correctly performs a task. D. the supervisor does not delegate. Answer: A Explanation: Facilitating the development of staff members is an important goal for a supervisor. Micromanagement, intolerance for individual differences in style, and inability to delegate all interfere with team building and overall effectiveness.Coordinated Care Question No : 114 - The nurse is caring for a client who is dying. While assessing the client for signs of impending death, the nurse observes the client for: A. elevated blood pressure. B. Cheyne-Stokes respiration. C. elevated pulse rate. D. decreased temperature. Answer: B Explanation: Cheyne-Stokes respirations are rhythmic waxing and waning of respirations from very deep breathing to very shallow breathing with periods of temporary apnea, often associated with cardiac failure. This can be a sign of impending death.Psychosocial Integrity Question No : 115 - A client with asthma develops respiratory acidosis. Based on this diagnosis, what should the nurse expect the client’s serum potassium level to be? A. normal B. elevated C. low D. unrelated to the pH Answer: B Explanation: Hyperkalemia occurs in a state of acidosis because potassium moves from injured cells into the bloodstream. Physiological Adaptation Question No : 116 - The nurse should teach parents of small children that the most common type of first-degree burn is: A. scalding from hot bath water or spills. B. contact with hot surfaces such as stoves and fireplaces. C. contact with flammable liquids or gases resulting in flash burns. D. sunburn from lack of protection and overexposure. Answer: D Explanation: The most common type of first-degree burn is sunburn, underscoring the need for education regarding the use of sunscreens and avoiding exposure.Safety and Infection Control Question No : 117 - A 57-year-old woman is recently widowed. She states, “I will never be able to learn how to manage the finances. My husband did all of that.” Select the nurse’s response that could help raise the client’s self-esteem. A. “You feel inadequate because you have never learned to balance a checkbook.” B. “You should have insisted your husband teach you about the finances.” C. “You are strong and will learn how to manage your finances after awhile.” D. “Why don’t you take a class in basic finance from the local college?” Answer: C Explanation: The nurse can raise the client’s self-esteem by communicating confidence the client can participate in actively finding solutions to the problem. The nurse also conveys the client is a worthwhile person by listening and accepting the client’s feelings and praising the client for seeking assistance.Psychosocial Integrity Question No : 118 - Following the change of shift report, the nurse should analyze the information and set priorities accordingly. When the plan has been formulated, at what point during the shift can or should the nurse’s plan be altered or modified? A. halfway through the shift B. at the end of the shift before the nurse reports off C. when needs change D. after the top-priority tasks have been completed Answer: C Explanation: The nurse changes the plan to respond to changes in needs.Coordinated Care Question No : 119 - Signs of impaired breathing in infants and children include all of the following except: A. nasal flaring. B. grunting. C. seesaw breathing. Therapies Question No : 123 - The nurse is teaching a client about erythema infectiosum. Which of the following factors are not correct? A. There is no rash. B. The disorder is uncommon in adults. C. There is no fever. D. There is sometimes a “slapped face” appearance. Answer: B Explanation: Fifth’s disease, erythema infectiosum, is uncommon in adults. All the other statements are correct.Safety and Infection Control Question No : 124 - In conducting a health screening for 12-month-old children, the nurse expects them to have been immunized against which of the following diseases? A. measles, polio, pertussis, hepatitis B B. diptheria, pertussis, polio, tetanus C. rubella, polio, pertussis, hepatitis A D. measles, mumps, rubella, polio Answer: B Explanation: By 12 months of age, the child should have had DtaP and polio. MMR is not administered until a child is 12 months of age.Health Promotion and Maintenance Question No : 125 - A client states, “I eat a well-balanced diet. I do not smoke. I exercise regularly, and I have a yearly checkup with my physician. What else can I do to help prevent cancer?” The nurse should respond with which of the following statements? A. Sleep at least 6–8 hours a night. B. Practice monthly self-breast examination. C. Reduce stress. D. All of the above. Answer: D Explanation: All of the choices are methods of preventing cancer. Sleep is important in maintaining homeostasis, which helps the body respond to disease. Monthly breast examination can indicate cancer or fibrocystic disease. The body has a physiological response to stress that can decrease the immune response and increase the risk of disease.Health Promotion and Management Question No : 126 - A 65-year-old female client is experiencing postmenopausal bleeding. Which type of physician should this client be encouraged to see? A. a radiologist B. a gynecologist C. a physiatrist D. an oncologist Answer: B Explanation: A gynecologist is the physician who treats and manages disease of the female reproductive organs. A radiologist evaluates X-rays. A physiatrist is the physician manager of a rehabilitation team. An oncologist treats clients with cancer.Coordinated Care Question No : 127 - Which of the following observations is most important when assessing a client’s breathing? A. presence of breathing and pulse rate B. breathing pattern and adequacy of breathing C. presence of breathing and adequacy of breathing D. patient position and adequacy of breathing Answer: C Explanation: It is not enough to simply make sure the client is breathing. The client must be breathingadequately. Physiological Adaptation Question No : 128 - Several passengers aboard an airliner suddenly become weak and suffer breathing difficulty. The diagnosis is likely to be: A. outbreak of Asian flu. B. Chemical exposure. C. bacterial pneumonia. D. allergic reaction. Answer: B Explanation: The most likely cause of groups of individuals suddenly experiencing similar signs of illness all at once is a chemical exposure.Safety and Infection Control B. identification of transference phenomenon C. placement of the client within the client’s family structure D. client agreement that the nurse has the authority in the relationship Answer: B Explanation: Transference phenomena are intensified in relationships with authority, such as physicians and nurses. Common positive transferences include desire for affection and gratification of dependency needs. Common negative transferences include hostility and competitiveness. These transferences must be recognized and resolved before growth and positive change can be undertaken in the working stage.Psychosocial Integrity Question No : 133 - Which of the following ethnic groups is at highest risk in the United States for pesticiderelated injuries? A. Native American B. Asian-Pacific C. Norwegian D. Hispanic Answer: D Explanation: Because Hispanic people represent a large percentage of migrant workers in the United States, many work in agricultural settings and might be exposed to pesticides, putting them at higher risk than the other groups.Safety and Infection Control Question No : 134 - The nurse wishes to decrease a client’s use of denial and increase the client’s expression of feelings. To do this the nurse should: A. tell the client to stop using the defense mechanism of denial. B. positively reinforce each expression of feelings. C. instruct the client to express feelings. D. challenge the client each time denial is used. Answer: B Explanation: The nurse should positively reinforce each expression of feelings.Psychosocial Integrity Question No : 135 - A corporate executive works 60–80 hours a week. The client is experiencing some physical signs of stress. The nurse teaches the client biofeedback techniques. This is an example of which of the following health-promotion interventions? A. structure B. relaxation technique C. time management D. regular exercise Answer: B Explanation: Biofeedback techniques can be used to quiet the mind, release tension, and counteract responses of general adaptation syndrome or stress syndrome. Nurses teaching relaxation techniques should encourage use of these techniques in stressful situations.Psychosocial Integrity Question No : 136 - The focus of a nurse case manager is: A. nursing care needs at discharge. B. the comprehensive care needs of the client for continuity of care. C. client education needs upon discharge. D. financial resources for needed care. Answer: B Explanation: By definition, case management is a process of providing for the comprehensive care needs of a client for continuity of care throughout the health care experience.Coordinated Care Question No : 137 - A 17-year-old female was raped by a young man in her neighborhood. She is in the Emergency Department for evaluation and tests. After the procedure is completed, a rape crisis counselor (nurse specialist) talks to the client in a conference room regarding the rape. Implementing counseling by the nurse specialist for the raped victim represents: A. assessment. B. crisis intervention. C. empathetic concern. D. unwarranted intrusion. Answer: B Explanation: Choice 2 is part of the Crisis Intervention Model. Counseling by a nurse specialist at the time of a stressful event (rape) can strengthen the client’s coping. A nurse specialist in rape crisis intervention is educationally prepared in counseling and crisis intervention specific to rape victims.Coordinated Care Question No : 138 - An elderly client denies that abuse is occurring. Which of the following factors Support-system enhancement includes all of the following except: A. determining the barriers to using support systems. B. discussing ways to help with others who are concerned. C. exploring life problems of the support-team members. D. involving spouse, family, and friends in the care and planning. Answer: C Explanation: The exploration of life problems of support-team members is not necessary to enhance the support system. Choices 1, 2, and 4 are all enhancements for a support system.Psychosocial Integrity Question No : 143 - The intent of the Patient Self Determination Act (PSDA) of 1990 is to: A. enhance personal control over legal care decisions. B. encourage medical treatment decision making prior to need. C. give one federal standard for living wills and durable powers of attorney. D. emphasize client education. Answer: B Explanation: The purpose of the PSDA is to promote decision-making prior to need. Choices 1, 3 and 4 are incorrect. The focus of the PSDA is individual health care decision-making. A federal standard for advance directives does not exist. Each state has jurisdiction regarding these policies and protocols.Coordinated Care Question No : 144 - A 4-year-old client is unable to go to sleep at night in the hospital. Which nursing intervention best promotes sleep for the child? A. turning out the room light and closing the door B. tiring the child during the evening with play exercises C. identifying the child’s home bedtime rituals and following them D. encouraging visitation by friends during the evening Answer: C Explanation: Preschool-age children require bedtime rituals that should be followed in the hospital if possible. Choice 1 increases a child’s fear. Choices 2 and 4 do not promote sleep.Basic Care and Comfort Question No : 145 - In a disaster situation, the nurse assessing a diabetic client on insulin assesses for all of the following except: A. diabetic signs and symptoms. B. nutritional status. C. bleeding problems. D. availability of insulin. Answer: C Explanation: Bleeding problems are not characteristic of diabetes. All the other options are appropriate areas of assessment. Safety and Infection Control Question No : 146 - Fat emulsions are frequently administered as a part of total parenteral nutrition. Which statement is true regarding fat emulsions? A. They have a high energy-to-fluid-volume ratio. B. Even though hypertonic, they are well tolerated. C. They are a basic solution secondary to the addition of sodium hydroxide (NaOH). D. The pH is alkaline, making them compatible with most medications. Answer: A Explanation: They have a high energy-to-fluid-volume ratio. Fat emulsions are formulated in 10%, 20%, and 30% solutions and supply 1.1, 2, and 3 kilocalories respectively for each milliliter. A milliliter of 5% dextrose only supplies 0.17 kilocalories. Choices 2, 3, and 4 are incorrect because fat emulsions are essentially pH neutral and isotonic.Pharmacological Therapies Question No : 147 - What is the primary theory that explains a family’s concept of health and illness? A. Health Belief Model B. Education-School-Completing Factor C. Family Health Expert Factor D. Disconnected Family Factor Answer: A Explanation: The Health Belief Model describes readiness factors; the perceived feelings of susceptibility and seriousness of the health problem (the threat); and positive motivation to maintain, regain, or attain wellness.Health Promotion and Maintenance Question No : 148 - The most common cause of injury from a house fire is: A. explosion. Rehabilitation services should begin when the client enters the health care system.Health Promotion and Maintenance Question No : 153 - Which of the following individuals may legally give informed consent? A. an 86-year-old male with advanced Alzheimer’s disease B. a 14-year-old girl needing an appendectomy who isnotan emancipated minor C. a 72-year-old female scheduled for a heart transplant D. a 6-month-old baby needing bowel surgery Answer: C Explanation: The 72-year-old client scheduled for heart transplant surgery may give informed consent for the surgery. There are no age limitations with the exception of minors. Choices 1, 2, and 4 are incorrect. An individual with advanced Alzheimer’s disease is incompetent to make decisions. Only an emancipated minor may give consent (a 14-year-old child who lives alone, away from family, and is totally independent). Infants are unable to give consent.Coordinated Care Question No : 154 - Which isolation procedure will be followed for secretions and blood? A. Respiratory B. Standard Precautions C. Contact Isolation D. Droplet Answer: B Explanation: Standard precautions are taken in all situations for all clients and involve all body secretions except sweat and are designed to reduce the rate of transmission of microbes from one host to another or one source (environment such as the client’s bedside table) to another.Safety and Infection Control Question No : 155 - Medication bound to protein can have which of the following effects? A. enhancement of drug availability B. rapid distribution of the drug to receptor sites C. less availability to produce desired medicinal effects D. increased metabolism of the drug by the liver Answer: C Explanation: Only an unbound drug can be distributed to active receptor sites. Therefore, the more of a drug that is bound to protein, the less it is available for the desired drug effect. Choice 1 is incorrect because less drug is available if it is bound to protein. Choice 2 is incorrect because distribution to receptor sites is irrelevant if the drug, which is bound to protein, cannot bind with a receptor site. Choice 4 is incorrect because metabolism is not increased. The liver first has to remove the drug from the protein molecule before metabolism can occur. The protein is then free to return to circulation and be used again.Pharmacological Therapies Question No : 156 - All of the following are common reasons that nurses are reluctant to delegate except: A. lack of self-confidence. B. desire to maintain authority. C. confidence in subordinates. D. getting trapped in the “I can do it better myself” mindset. Answer: C Explanation: If a delegator has confidence in his subordinates and feels that a task will be performed correctly, he is more likely to delegate. Reasons that delegators are reluctant to delegate include their own lack of confidence, fear of losing authority or personal satisfaction, and feeling that the task can only be performed correctly if they do it themselves.Coordinated Care Question No : 157 - Mr. H. is upset regarding being in the hospital for another day because he states it costs too much. The rights he is likely to demand include all of the following except: A. the right to examine and question the bill. B. the right to reasonable response to requests. C. the right to refuse treatment. D. the right to confidentiality. Answer: D Explanation: Confidentiality is the maintenance of privacy of information. The question does not suggest that confidentiality has been breached. The client is likely to demand the other rights and may exercise them in choosing to leave the hospital early.Coordinated Care Question No : 158 - A wrong committed by one person against another (or against the property of another) that might result in a civil trial is: Question No : 162 - Client self-determination is the primary focus of: A. malpractice insurance. B. nursing’s advocacy for clients. C. confidentiality. D. health care. Answer: B Explanation: Advocacy for clients by nurses is the primary focus of the client’s right to autonomy and self-determination. Confidentiality involves the maintenance of the privacy of the client and information regarding him or her. Malpractice insurance is a type of insurance for professionals.Coordinated Care Question No : 163 - A client begins a regimen of chemotherapy. Her platelet counts falls to 98,000. Which action is least likely to increase the risk of hemorrhage? A. Test all excreta for occult blood. B. Use a soft toothbrush or foam cleaner for oral hygiene. C. Implement reverse isolation. D. Avoid IM injections. Answer: C Explanation: Reverse isolation does not affect the risk of hemorrhage.Physiological Adaptation Question No : 164 - The family carries out its health care functions in which of the following ways? A. Family provides very little preventive health care to its members at home. B. Family provides sick care to its members. C. Family pays for most health services. D. Family decides when and where to hospitalize its members. Answer: B Explanation: The family provides sick care to its members. The other options are incorrect.Prevention and Early Detection of Disease Question No : 165 - A concern regarding maternal and infant mortality and morbidity is that: A. a segment of the population is not receiving prenatal care. B. families appear unconcerned about quality health care. C. the personnel shortage in the maternity field will increase. D. maternal-child health workers are not adequately prepared. Answer: A Explanation: There is a concern that a segment of the population is not accessing prenatal care, affecting infant and maternal mortality and morbidity.Health Promotion and Maintenance Question No : 166 - Which of the following solutions is routinely used to flush an IV device before and after the administration of blood to a client? A. 0.9% sodium chloride B. 5% dextrose in water solution C. sterile water D. Heparin sodium Answer: A Explanation: Normal saline is 0.9% sodium chloride. This solution has the same osmolarity as blood. Its use does not cause lysis of cells. Choices 2 and 3 are hypotonic solutions that can cause cell lysis. Choice 4 is an anticoagulant. Pharmacological Therapies Question No : 167 - A couple from the Philippines living in the United States is expecting their first child. In providing culturally competent care, the nurse must first: A. review their own cultural beliefs and biases. B. respectfully request that the couple utilize only medically approved health care providers. C. realize that the clients have to learn their new country’s accepted medical practices. D. study family dynamics to understand the male and female gender roles in the clients’ culture. Answer: A Explanation: The nurse needs to recognize her own beliefs and biases and learn about the client’s cultural beliefs. Psychosocial Integrity Question No : 168 - The nurse is teaching a client about the use of Rifampin for prophylaxis after A. emotional behavioral indicator B. spiritual indicator C. sociocultural indicator D. intellectual indicator Answer: C Explanation: Stress can alter a person’s relationships with others.Psychosocial Integrity Question No : 173 - A client can receive the mumps, measles, rubella (MMR) vaccine if he or she: A. is pregnant. B. is immunocompromised. C. is allergic to neomycin. D. has a cold. Answer: D Explanation: A simple cold without fever does not preclude vaccination. Choices 1 and 2 are incorrect because pregnant women and immunocompromised individuals cannot have the MMR vaccine because the rubella component is a live virus and might cause birth defects and/or disease. Choice 3 is incorrect because the American Academy of Pediatrics states, “Persons who have experienced anaphylactic reactions to topically or systemically administered neomycin should not receive measles vaccine.”Pharmacological Therapies Question No : 174 - Quality is defined as a combination of all of the following except: A. conforming to standards. B. performing at the minimally acceptable level. C. meeting or exceeding customer requirements. D. exceeding customer expectations. Answer: B Explanation: Compliance or performance at the minimally acceptable level is not considered quality care.Coordinated Care Question No : 175 - According to the ANA Code of Ethics for Nurses, professional nurses have an ethical obligation to: A. clients (patients). B. the profession of nursing. C. provide high-quality care. D. all of the above. Answer: D Explanation: All the choices are elements of the ANA Code of Ethics for Nurses.Coordinated Care Question No : 176 - A 2-year-old child diagnosed with HIV comes to a clinic for immunizations. Which of the following vaccines should the nurse expect to administer in addition to the scheduled vaccines? A. pneumococcal vaccine B. hepatitis A vaccine C. Lyme disease vaccine D. typhoid vaccine Answer: A Explanation: Pneumococcal vaccine should be administered as a supplemental vaccine. Hepatitis A vaccine is for travelers and individuals with chronic liver disease. The Lyme disease vaccine is for people between the ages of 15 and 70 who are at risk for Lyme disease (transmitted by ticks primarily). The typhoid vaccine is for workers in microbiology laboratories who frequently work with Salmonella typhi.Health Promotion and Maintenance Question No : 177 - Social support systems include of the following except: A. call-in help lines. B. emotional assistance provided by others. C. community support groups. D. use of coping skills and verbalization for anger management. Answer: D Explanation: Use of coping skills and verbalization for anger management are personal strategies, not examples of social support systems. Choices 1, 2, and 3 are all social support systems.Psychosocial Integrity Question No : 178 - Narrow therapeutic index medications: A. are drug formulations with limited pharmacokinetic variability. B. have limited value and require no monitoring of blood levels. C. have less than a twofold difference in minimum toxic levels and minimum can correctly identify those who do not have a given disease is: A. specific. B. sensitive. C. negative culture. D. marginal finding. Answer: A Explanation: Testing that identifies clients without a disease is said to be specific, while testing that identifies clients with a disease is said to be sensitive. Safety and Infection Control Question No : 183 - Which is the best way to position a client’s neck for palpation of the thyroid? A. flexed toward the side being examined B. hyperextended directly backward C. flexed away from the side being examined D. flexed directly forward Answer: A Explanation: Flexed toward the side being examined.Health Promotion and Maintenance Question No : 184 - A chemical reaction between drugs prior to their administration or absorption is known as: A. a drug incompatibility. B. a side effect. C. an adverse event. D. an allergic response. Answer: A Explanation: This occurs most often when drug solutions are combined before they are given intravenously but can occur with orally administered drugs as well. Choices 2, 3, and 4 are incorrect because drugs can cause these events after administration and absorption.Pharmacological Therapies Question No : 185 - As part of a routine health screening, the nurse notes the play of a 2-year-old child. Which of the following is an example of age-appropriate play at this age? A. builds towers with several blocks B. tries to color within the lines C. says “Mine!” when playing with toys D. tries to jump rope Answer: C Explanation: Toddlers are possessive and struggle for independence. The other play activities are too advanced for a 2-year-old child.Health Promotion and Maintenance Question No : 186 - In an obstetrical emergency, which of the following actions should the nurse perform first after the baby delivers? A. Place extra padding under the mother to absorb blood from the delivery. B. Cut the umbilical cord using sterile scissors. C. Suction the baby’s mouth and nose. D. Wrap the baby in a clean blanket to preserve warmth. Answer: C Explanation: After the baby delivers, the nurse should clear the mouth and nose of the infant first. Choice 4 is the next step. Choices 1 and 2 might be performed depending on the situation.Safety and Infection Control Question No : 187 - Vaccines provide what type of immunity? A. active B. passive C. transplacental D. active and passive Answer: A Explanation: Vaccines provide active immunity. Passive immunity comes from antibodies produced in another human or host. Transplacental immunity comes from passive immunity transferred from mother to infant.Health Promotion and Maintenance Question No : 188 - Central venous access devices (CVADs) are frequently utilized to administer chemotherapy. What is an advantage of using CVADs for chemotherapeutic agent administration? A. CVADs are less expensive than a peripheral IV.