NCLEX-PN NGN Exam Test Bank (SOLVED QUESTIONS AND ANSWERS GRADED A + UPDATED 2024), Exams of Nursing

Download NCLEX-PN NGN Exam Test Bank (SOLVED QUESTIONS AND ANSWERS GRADED A + UPDATED 2024) and more Exams Nursing in PDF only on Docsity! NCLEX-PN NGN Exam Test Bank SOLVED QUESTIONS & ANSWERS with Rationales GRADED A + UPDATED 2023/2024 NCLEX-PN NGN Exam Test Bank 1. The nurse is caring for a client scheduled for removal of a pituitary tumor using the transsphenoidal approach. The nurse should be particularly alert for: A. Nasal congestion B. Abdominal tenderness C. Muscle tetany D. Oliguria Answer A: Removal of the pituitary gland is usually done by a transsphenoidal 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. 2. 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 Answer B: Hypokalemia is evident from the lab values listed. The other laboratory findings are within normal limits, making answers A, C, and D incorrect. Answer D: 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. 8. 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 Answer D: 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 incorrect. 9. The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a serious side effect of this drug? A. Uric acid of 5mg/dL B. Hematocrit of 33% C. WBC 2,000 per cubic millimeter D. Platelets 150,000 per cubic millimeter Answer C: 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. 10. A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis? A. “Tell me about his pain.” B. “What does his vomit look like?” C. “Describe his usual diet.” D. “Have you noticed changes in his abdominal size?” Answer C: The least-helpful questions are those describing his usual diet. A, B, and D are useful in determining the extent of disease process and, thus, are incorrect. 11. The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided? A. Bran B. Fresh peaches C. Cucumber salad D. Yeast rolls Answer C: 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 prevent constipation. 12. A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period? A. Teaching how to irrigate the illeostomy B. Stopping electrolyte loss in the incisional area C. Encouraging a high-fiber diet D. Facilitating perineal wound drainage Answer D: 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. 13. The nurse is performing discharge teaching on a client with diverticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client’s diet? A. Roasted chicken B. Noodles C. Cooked broccoli D. Custard Answer C: 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. 14. The nurse is caring for a new mother. The mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is: A. The baby is dehydrated due to polyuria. B. The baby is hypoglycemic due to lack of glucose. C. The baby is allergic to the formula the mother is giving him. D. The baby can lose up to 10% of weight due to meconium stool, loss of extracellular 17. Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as: A. A cephalohematoma B. Molding C. Subdural hematoma D. Caput succedaneum Answer A: A swelling over the right parietal area is a cephalohematoma, an area of bleeding outside the cranium. This type of hematoma does not cross the suture line because it is outside the cranium but beneath the periosteum. Answer B, molding, is overlapping of the bones of the cranium and, thus, incorrect. In answer C, a subdural hematoma, or intracranial bleeding, is ominous and can be seen only on a CAT scan or x-ray. A caput succedaneum, in answer D, crosses the suture line and is edema. 18. The nurse is assisting the RN with discharge instructions for a client with an implantable defibrillator. What discharge instruction is essential? A. “You cannot eat food prepared in a microwave.” B. “You should avoid moving the shoulder on the side of the pacemaker site for 6 weeks.” C. “You should use your cellphone on your right side.” D. “You will not be able to fly on a commercial airliner with the defibrillator in place.” Answer C: The client with an internal defibrillator should learn to use any battery-operated machinery on the opposite side. He should also take his pulse rate and report dizziness or fainting. Answers A, B, and D are incorrect because the client can eat food prepared in the microwave, move his shoulder on the affected side, and fly in an airplane. 19. A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The nurse should be most careful to monitor the client for which dysrhythmia during this procedure? A. Bradycardia B. Tachycardia C. Premature ventricular beats D. Heart block Answer A: Suctioning can cause a vagal response and bradycardia. Answer B is unlikely and, therefore, not most important, although it can occur. Answers C and D can occur as well, but they are less likely. 20. The nurse is caring for a client scheduled for a surgical repair of a sacular 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 Answer C: The assessment that is most crucial to the client is the identification of peripheral pulses because the aorta is clamped during surgery. This decreases blood circulation to the kidneys and lower extremities. The nurse must also assess for the return of circulation to the lower extremities. Answer A is of lesser concern, answer B is not advised at this time, and answer D is of lesser concern than answer A. 21. 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 given some medication to anesthetize the area.” because a tumor that is in situ is not metastasized. 26. 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 Answer C: If the client eviscerates, the abdominal content should be covered with a sterile saline-soaked dressing. Reinserting the content should not be the action and will require that the client return to surgery; thus, answer A is incorrect. Answers B and D are incorrect because they are not appropriate to this case. 27. 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 Answer B: It is most important to remove the contact lenses because leaving them in can lead to corneal drying, particularly with contact lenses that are not extended-wear lenses. Leaving in the hearing aid or artificial eye will not harm the client. Leaving the wedding ring on is also allowed; usually, the ring is covered with tape. Therefore, answers A, C, and D are incorrect. 28. 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 understanding has been documented D. Check with the client’s family to see if they understand the procedure fully Answer A: It is the responsibility of the physician to explain and clarify the procedure to the client. Answers B, C, and D are incorrect because they are not within the nurse’s purview. 29. 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. A history of recent orthopedic surgery C. A history of minimal physical activity D. A history of the client’s food intake Answer A: Previous radiation to the neck might have damaged the parathyroid glands, which are located on the thyroid gland, and interfered with calcium and phosphorus regulation. Answer B has no significance to this case; answers C and D are more related to calcium only, not to phosphorus regulation. 30. 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 35. A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate? A. Blood pressure every 15 minutes B. Insertion of a Levine tube C. Cardiac monitoring D. Dressing changes two times per day Answer B: 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 needed, but this is individualized to the client. Answer D is incorrect because there are no dressings to change on this client. 36. The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because: A. The client is at risk for evisceration. B. The client will require frequent dressing changes. C. The straps provide support for drains that are inserted in the incision. D. No sutures or clips are used to secure the incision. Answer B: Montgomery straps are used to secure dressings that require frequent dressing changes because the client with a cholecystectomy usually has a large amount of drainage 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. 37. The physician has ordered that the client’s medication be administered intrathecally. The nurse is aware that medications will be administered by which method? A. Intravenously B. Rectally C. Intramuscularly D. Into the cerebrospinal fluid Answer D: Intrathecal medications are administered into the cerebrospinal fluid. This method of administering medications is reserved for the client with 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. 38. Which client can best be assigned to the newly licensed practical nurse? A. The client receiving chemotherapy B. The client post–coronary bypass C. The client with a TURP D. The client with diverticulitis Answer D: 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 D 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. 39. The nurse notes the patient care assistant looking through the personal items of the client with cancer. Which action should be taken by the registered nurse? A. Notify the police department as a robbery B. Report this behavior to the charge nurse C. Monitor the situation and note whether any items are missing D. Ignore the situation until items are reported missing Answer B: The best action at this time is to report the incident to the charge nurse. Further action might be needed, but it should be determined 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. 40. The nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should: A. Change the nursing assistant’s assignment B. Explore the interaction with the nursing assistant C. Discuss the matter with the client’s family D. Initiate a group session with the nursing assistant Answer B: 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 assistant 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. Answer C is not a first step, even though initiating a group session might be a plan for the future. 41. A home health nurse is planning for her daily visits. Which client should the home health nurse visit first? Answer B: The client having a mammogram should be instructed to omit deodorants or powders beforehand because powders and deodorants can be interpreted as abnormal. Answer A is incorrect because there is no need for dietary restrictions before a mammogram. Answer C is incorrect because the mammogram does not replace the need for self-breast exams. Answer D is incorrect because a mammogram does not require higher doses of radiation than an x-ray. 46. 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 Answer D: The most suitable roommate for the client with gastric resection is the client with phlebitis because phlebitis is an inflammation of the blood vessel and is not infectious. Crohn’s disease clients, in answer A, have frequent stools that might spread infections to the surgical client. The client in answer B with pneumonia is coughing and will disturb the gastric client. The client with gastritis, in answer C, is vomiting and has diarrhea, which also will disturb the gastric client. 47. The licensed practical nurse is working with a registered nurse and a patient care assistant. Which of the following clients should be cared for by 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 Answer D: The most critical client should be assigned to the registered nurse; in this case, that is the client 2 days post-thoracotomy. The clients in answers A and B are ready for discharge, and the client in answer C who had a splenectomy 3 days ago is stable enough to be assigned to an LPN. 48. The licensed practical 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. Answer C: The client should breathe normally during a central venous pressure monitor reading. Answer A indicates understanding because the client should be placed supine if he can tolerate being in that position. Answers B and D indicate understanding because the stop-cock should be turned off to the IV fluid, and the reading should be done at the top of the meniscus. 49. 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 himself and, thus, are incorrect. 54. 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 Answer C: When the client is receiving TPN, the blood glucose level should be drawn. TPN is a solution that contains large amounts of glucose. Answers A, B, and D are not directly related to the question and are incorrect. 55. The client with a myocardial infarction comes to the nurse’s station stating 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 Answer B: The client who says he has nothing wrong is in denial about his myocardial infarction. Rationalization is making excuses for what happened, projection is projecting feeling or thoughts onto others, and conversion reaction is converting a psychological trauma into a physical illness; thus, answers A, C, and D are incorrect. 56. Which laboratory test would be the least effective in making the diagnosis of a myocardial infarction? A. AST B. Troponin C. CK-MB D. Myoglobin Answer A: Answer A, AST, is not specific for myocardial infarction. Troponin, CK-MB, and myoglobin, in answers B, C, and D, are more specific, although myoglobin is also elevated in burns and trauma to muscles. 57. The licensed practical nurse assigned to the post-partal unit is preparing to administer Rhogam to a postpartum client. Which woman is not a candidate for RhoGam? A. A gravida IV para 3 that is Rh negative with an Rh-positive baby B. A gravida I 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 IV para 2 that is Rh negative with an Rh-negative baby Answer D: The mothers in answers A, B, and C all require RhoGam and, thus, are incorrect. The mother in answer D is the only one who does not require a RhoGam injection. 58. The first exercise that should be performed by the client who had a mastectomy is: A. Walking the hand up the wall B. Sweeping the floor C. Combing her hair are not commonly inserted into the peritoneal cavity during this procedure; thus, answers C and D are incorrect (although this could depend on the circumstances). 61. To ensure safety while administering a nitroglycerine patch, the nurse should: A. Wear gloves B. Shave the area where the patch will be applied C. Wash the area thoroughly with soap and rinse with hot water D. Apply the patch to the buttocks Answer A: To protect herself, the nurse should wear gloves when applying a nitroglycerine patch or cream. Answer B is incorrect because shaving the shin might abrade the area. Answer C is incorrect because washing with hot water will vasodilate and increase absorption. The patches should be applied to areas above the waist, making answer D incorrect. 62. A 25-year-old male is brought to the emergency room with a piece of metal in his eye. Which action by the nurse is correct? A. Use a magnet to remove the object. B. Rinse the eye thoroughly with saline. C. Cover both eyes with paper cups. D. Patch the affected eye only. Answer C: Covering both eyes prevents consensual movement of the affected eye. The nurse should not attempt to remove the object from the eye because this might cause trauma, as stated in answer A. Rinsing the eye, as stated in answer B, might be ordered by the doctor, but this is not the first step for the nurse. Answer D is not correct because often when one eye moves, the other also does. 63. The physician has ordered sodium warfarin (Coumadin) for the client with thrombophlebitis. The order should be entered to administer the medication at: A. 0900 B. 1200 C. 1700 D. 2100 Answer C: 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. 64. The schizophrenic client has become disruptive and requires seclusion. Which staff member can institute seclusion? A. The security guard B. The registered nurse C. The licensed practical nurse D. The nursing assistant Answer B: 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. 65. The client is admitted with chronic obstructive pulmonary disease. Blood gases reveal pH 7.36, CO2 45, O2 84, HCO3 28. The nurse would assess the client to be in: A. Uncompensated acidosis B. Compensated alkalosis C. Compensated respiratory acidosis 70. The nurse is caring for a client with cerebral palsy. The nurse should provide 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. Answer A: Frequent rest periods help to relax tense muscles and preserve energy. Answers B, C, and D are incorrect because they are untrue statements. 71. The nurse is making assignments for the day. Which client should be assigned to the nursing assistant? A. A client with Alzheimer’s disease B. A client with pneumonia C. A client with appendicitis D. A client with thrombophebitis Answer A: 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. 72. A client with cancer develops xerostomia. The nurse can help alleviate the discomfort associated with xerostomia by: A. Offering hard candy B. Administering analgesic medications C. Splinting swollen joints D. Providing saliva substitute Answer D: Xerostomia is dry mouth, and offering the client a saliva substitute 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. 73. 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 brain attack (stroke) with tube feedings B. A client with congestive heart failure complaining of nighttime dyspnea C. A client with a thoracotomy 6 months ago D. A client with Parkinson’s disease Answer B: The client with congestive heart failure who is complaining of nighttime dyspnea should be seen first because airway is number one in nursing care. In answers A, C, and D, the clients are more stable. 74. 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 Answer D: The fresh peach is the lowest in sodium of these choices. Answers A, B, and C have much higher amounts of sodium. 75. 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 a 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 Answer B: 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. 76. During the change of shift, the oncoming nurse notes a discrepancy in the number of Percocet (Oxycodone) 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 81. 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 Answer C: The client taking antabuse should not eat or drink anything containing alcohol or vinegar. The other foods in answers A, B, and D are allowed. 82. A client has been receiving cyanocobalamine (B12) injections for the past 6 weeks. Which laboratory finding indicates that the medication is having the desired effect? A. Neutrophil count of 60% B. Basophil count of 0.5% C. Monocyte count of 2% D. Reticulocyte count of 1% Answer D: 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 medication. 83. The nurse has just received a change-of-shift report. Which client should the nurse assess first? A. A client 2 hours post-lobectomy with 150ccs 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 Answer A: 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. 84. Several clients are admitted to the emergency room following a three-car vehicle accident. Which clients can be assigned to share a room in the emergency department during the disaster? A. The schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm C. A child whose pupils are fixed and dilated and his parents, and the 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 Answer B: Out of all of these clients, it is best to hold the pregnant client and the client with a broken arm and facial lacerations in the same room. The clients in answer A need to be placed in separate rooms because these clients are disruptive or have infections. In the case of answer C, the child is terminal and should be in a private room with his parents. 85. The home health nurse is planning for the day’s visits. Which client should be seen first? A. The 78-year-old who had a gastrectomy 3 weeks ago with a PEG tube B. The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension immediately. Answer A, continuing to monitor the vital signs, can result in deterioration of the client’s condition. Answer C, asking the client how he feels, would supply only subjective data. Involving the LPN, in answer D, is not the best solution to help this client because he is unstable. 90. Which assignment should not be performed by the licensed practical nurse? A. Inserting a Foley catheter B. Discontinuing a nasogastric tube C. Obtaining a sputum specimen D. Initiating a blood transfusion Answer D: A licensed practical nurse should not be assigned to initiate a blood transfusion. The LPN can assist with the transfusion and check ID numbers for the RN. The licensed practical nurse can be assigned to insert Foley and French urinary catheters, discontinue Levine and Gavage gastric tubes, and obtain all types of specimens, so answers A, B, and C are incorrect. 91. The nurse witnesses the nursing assistant hitting the client in the long- term care facility. The nursing assistant can be charged with: A. Negligence B. Tort C. Assault D. Malpractice Answer C: Assault is defined as striking or touching the client inappropriately, so a nurse assistant striking a client could be charged with assault. Answer A, negligence, is failing to perform care for the client. Answer B, a tort, is a wrongful act committed on the client or their belongings. Answer D, malpractice, is failure to perform an act that the nursing assistant knows should be done, or the act of doing something wrong that results in harm to the client. 92. The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available? A. The client with Cushing’s disease B. The client with diabetes C. The client with acromegaly D. The client with myxedema Answer A: The client with Cushing’s disease has adrenocortical hypersecretion. This increase in the level of cortisone causes the client to be immune suppressed. In answer B, the client with diabetes poses no risk to other clients. The client in answer C has an increase in growth hormone and poses no risk to himself or others. The client in answer D has hyperthyroidism or myxedema, and poses no risk to others or himself. 93. The nurse is making assignments for the day. Which client should be assigned to the pregnant nurse? A. The client receiving linear accelerator radiation therapy for lung cancer B. The client with a radium implant for cervical cancer C. The client who has just been administered soluble brachytherapy for thyroid cancer D. The client who returned from placement of iridium seeds for prostate cancer Answer A: The pregnant nurse should not be assigned to any client with radioactivity present. Therefore, the client receiving linear accelerator therapy is correct because this client travels to the radium department for therapy, and the radiation stays in the department; the client is not radioactive. The client in answer B does pose a risk to the pregnant client. The client in answer C is radioactive in very small doses. For approximately 72 hours, the client should A. Atrial tachycardia B. Ventricular tachycardia C. Heart block D. Ventricular brachycardia Answer B: Lidocaine is used to treat ventricular tachycardia. This medication 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 brachycardia. 99. The client is admitted to the emergency room with shortness of breath, anxiety, and tachycardia. His ECG reveals atrial fibrillation with a ventricular 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 Answer D: 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 experience tinnitus, vertigo, headache, visual disturbances, and confusion. Answers A, B, and C are not related to the use of quinidine. 100. The physician has prescribed tranylcypromine sulfate (Parnate) 10mg bid. The nurse should teach the client to refrain from eating foods containing tyramine because it may cause: A. Hypertension B. Hyperthermia C. Melanoma D. Urinary retention Answer A: If the client eats foods high in tyramine, he might experience malignant hypertension. Tyramine is found in cheese, sour cream, Chianti wine, sherry, 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. 101. The child with seizure disorder is being treated with Dilantin (phenytoin). Which of the following statements by the patient’s mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy? A. “She is very irritable lately.” B. “She sleeps quite a bit of the time.” C. “Her gums look too big for her teeth.” D. “She has gained about 10 pounds in the last 6 months.” Answer C: Hyperplasia of the gums is associated with Dilantin therapy. Answer A is not related to the therapy; answer B is a side effect, and answer D is not related to the question. 102. 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 107. The client is diagnosed with multiple myoloma. 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.” Answer D: 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. 108. 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 night sweats occur Answer B: 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 complication. 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. 109. The client is taking prednisone 7.5mg po each morning to treat his systemic lupus errythymatosis. 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. Answer D: Taking corticosteroids in the morning mimics the body’s natural release of cortisol. Answers A is not necessarily true, and answers B and C are not true. 110. A 20-year-old female has a prescription for tetracycline. While teaching the client how to take her medicine, the nurse learns that the client is also taking Ortho-Novum oral contraceptive pills. Which instructions should be included in the teaching plan? A. The oral contraceptives will decrease the effectiveness of the tetracycline. B. Nausea often results from taking oral contraceptives and antibiotics. C. Toxicity can result when taking these two medications together. D. Antibiotics can decrease the effectiveness of oral contraceptives, so the client should use an alternate method of birth control. Answer D: Taking antibiotics and oral contraceptives together decreases the effectiveness of the oral contraceptives. Answers A, B, and C are not necessarily true. 111. A 60-year-old diabetic is taking glyburide (Diabeta) 1.25mg daily to treat Type II diabetes mellitus. Which statement indicates the need for further teaching? A. “I will keep candy with me just in case my blood sugar drops.” B. “I need to stay out of the sun as much as possible.” C. “I often skip dinner because I don’t feel hungry.” D. “I always wear my medical identification.” Answer C: The client should be taught to eat his meals even if he is not hungry, to prevent a hypoglycemic reaction. Answers A, B, and D are incorrect because they indicate an understanding of the nurse’s teaching. 112. The physician prescribes regular insulin, 5 units subcutaneous. Regular insulin begins to exert an effect: A. In 5–10 minutes B. In 10–20 minutes C. In 30–60 minutes D. In 60–120 minutes Answer C: The time of onset for regular insulin is 30–60 minutes; therefore, answers A, B, and D are incorrect. 113. The client is admitted from the emergency room with multiple injuries sustained from an auto accident. His doctor prescribes a histamine blocker. The reason for this order is: A. To treat general discomfort B. To correct electrolyte imbalances C. To prevent stress ulcers D. To treat nausea Answer C: Histamine blockers are frequently ordered for clients who are hospitalized for prolonged periods and who are in a stressful situation. They are not used to treat discomfort, correct electrolytes, or treat nausea; therefore, answers A, B, and D are incorrect. C. Gallbladder disease D. Egg allergies Answer A: Clients having dye procedures should be assessed for allergies to iodine or shellfish. Answers B and D are incorrect because there is no need for the client to be assessed for reactions to blood or eggs. Because an IV cholangiogram is done to detect gallbladder disease, there is no need to ask about answer C. 117. A new diabetic is learning to administer his insulin. He receives 10U of NPH and 12U of regular insulin each morning. Which of the following statements reflects understanding of the nurse’s teaching? A. “When drawing up my insulin, I should draw up the regular insulin first.” B. “When drawing up my insulin, I should draw up the NPH insulin first.” C. “It doesn’t matter which insulin I draw up first.” D. “I cannot mix the insulin, so I will need two shots.” Answer A: Regular insulin should be drawn up before the NPH. They can be given together, so there is no need for two injections, making answer D incorrect. Answer B is obviously incorrect, and answer C is incorrect because it does matter which is drawn first: Contamination of NPH into regular insulin will result in a hypoglycemic reaction at unexpected times. 118. A client with osteomylitis has an order for a trough level to be done because he is taking Gentamycin. When should the nurse call the lab to obtain the trough level? A. Before the first dose B. 30 minutes before the fourth dose C. 30 minutes after the first dose D. 30 minutes after the fourth dose Answer B: 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. 119. 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 Answer C: Viokase is a pancreatic enzyme that is used to facilitate digestion. It should be given with meals and snacks, and it works well in foods such as applesauce. Answers A, B, and D are incorrect times to administer this medication. 120. Isoniazid (INH) has been prescribed for a family member exposed to tuberculosis. The nurse is aware that the length of time that the medication will be taken is: A. 6 months B. 3 months C. 18 months D. 24 months Answer A: The expected time for contact to tuberculosis is 1 year. Therefore, answers B, C, and D are incorrect. 121. The client is admitted to the postpartum unit with an order to continue the infusion of Pitocin. Which finding indicates that the Pitocin is having the desired effect? A. The fundus is deviated to the left. B. The fundus is firm and in the midline. C. The fundus is boggy. D. The fundus is two finger breadths below the umbilicus. Answer B: 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 muscle tone will increase bleeding. Answer D is incorrect because the position of the uterus is not related to the use of Pitocin. 122. The nurse is teaching a group of new graduates about the safety needs of the client receiving chemotherapy. Before administering chemotherapy, 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 Answer C: Before chemotherapy, an antiemetic should be given because most chemotherapy agents cause nausea. It is not necessary to give a bolus of IV fluids, medicate for pain, or allow the client to eat; therefore, answers A, B, and D are incorrect. B. Place the client in a supine position and apply heat to the knee C. Insert a Foley catheter and measure the intake and output D. Perform a vaginal exam and check for a discharge Answer A: Hyphema is blood in the anterior chamber of the eye and around the eye. The client should have the head of the bed elevated and ice applied. Answers B, C, and D are incorrect and do not treat the problem. 128. The nurse is making assignments for the day. Which client should be assigned to the nursing assistant? A. The 18-year-old with a fracture to two cervical vertebrae B. The infant with meningitis C. The elderly client with a thyroidectomy 4 days ago D. The client with a thoracotomy 2 days ago Answer C: The most stable client is the client with the thyroidectomy 4 days ago. Answers A, B, and D are incorrect because the other clients are less stable and require a registered nurse. 129. The client arrives in the emergency room with a “bull’s eye” rash. Which question would be most appropriate for the nurse to ask the client? A. “Have you found any ticks on your body?” B. “Have you had any nausea in the last 24 hours?” C. “Have you been outside the country in the last 6 months?” D. “Have you had any fever for the past few days?” Answer A: The “bull’s eye” rash is indicative of Lyme’s disease, a disease spread by ticks. The signs and symptoms include elevated temperature, headache, nausea, and the rash. Although answers B and D are important, the question asks which would be best. Answer C has no significance. 130. Which of the following is the best indicator of the diagnosis of HIV? A. White blood cell count B. ELISA C. Western Blot D. Complete blood count Answer C: The most definitive diagnostic tool for HIV is the Western Blot. The white blood cell count, as stated in answer A, is not the best indicator, but a white blood cell count of less than 3,500 requires investigation. The ELISA test, answer B, is a screening exam. Answer D is not specific enough. 131. The client has an order for gentamycin to be administered. Which lab results should be reported to the doctor before beginning the medication? A. Hematocrit B. Creatinine C. White blood cell count D. Erythrocyte count Answer B: Gentamycin is a drug from the aminoglycocide classification. These drugs are toxic to the auditory nerve and the kidneys. The hematocrit is not of significant consideration in this client; therefore, answer A is incorrect. Answer C is incorrect because we would expect the white blood cell count to be elevated in this client because gentamycin is an antibiotic. Answer D is incorrect because the erythrocyte count is also particularly significant 136. The nurse is assessing the abdomen. The nurse knows the best sequence to perform the assessment is: A. Inspection, auscultation, palpation B. Auscultation, palpation, inspection C. Palpation, inspection, auscultation D. Inspection, palpation, auscultation Answer A: The nurse should inspect first, then auscultate, and finally palpate. If the nurse palpates first, the assessment might be unreliable. Therefore, answers B, C, and D are incorrect. 137. The nurse is assisting in the assessment of the patient admitted with abdominal pain. Why should the nurse ask about medications that the client is taking? A. Interactions between medications can be identified. B. Various medications taken by mouth can affect the alimentary tract. C. This will provide an opportunity to educate the patient regarding the medications used. D. The types of medications might be attributable to an abdominal pathology not already identified. Answer B: Many medications can irritate the stomach and contribute to abdominal pain. For answer A, the primary reason for asking about medications is not to identify interactions between medication. Although this might provide an opportunity for teaching, this is not the best time to teach. Therefore, answers C and D are incorrect. 138. The nurse is asked by the nurse aide, “Are peptic ulcers really caused by stress?” The nurse would be correct in replying with which of the following: A. “Peptic ulcers result from overeating fatty foods.” B. “Peptic ulcers are always caused from exposure to continual stress.” C. “Peptic ulcers are like all other ulcers, which all result from stress.” D. “Peptic ulcers are associated with H. pylori, although there are other ulcers that are associated with stress.” Answer D: H. pylori bacteria and stress are directly related to peptic ulcers. Answers A and B are incorrect because peptic ulcers are not caused by overeating or always caused by continued stress. Answer C is incorrect because peptic ulcers are related to but not directly caused by stress. 139. The client is newly diagnosed with juvenile onset diabetes. Which of the following nursing diagnoses is a priority? A. Anxiety B. Pain C. Knowledge deficit D. Altered thought process Answer C: The new diabetic has a knowledge deficit. Answers A, B, and D are not supported within the stem and so are incorrect. 140. The nurse understands that the diagnosis of oral cancer is confirmed with: A. Biopsy B. Gram Stain C. Scrape cytology D. Oral washings for cytology Answer A: The best diagnostic tool for cancer is the biopsy. Other assessment includes checking the lymph nodes. Answers B, C, and D will not confirm a diagnosis of oral cancer. 141. The nurse is assisting in the care of a patient who is 2 days post- operative from a hemorroidectomy. The nurse would be correct in instructing the patient to: A. Avoid a high-fiber diet because this can hasten the healing time B. Continue to use ice packs until discharge and then when at home C. Take 200mg of Colace bid to prevent constipation D. Use a sitz bath after each bowel movement to promote cleanliness and comfort Answer D: The use of a sitz bath will help with the pain and swelling associated with a hemorroidectomy. The client should eat foods high in fiber, so answer A is incorrect. Ice packs, as stated in answer B, are ordered immediately after surgery only. Answer C, a stool softener, can be ordered, but only by the doctor. 142. The nurse is caring for a patient with a colostomy. The patient asks, “Will I ever be able to swim again?” The nurse’s best response would be: A. “Yes, you should be able to swim again, even with the colostomy.” B. “You should avoid immersing the colostomy in water.” C. “No, you should avoid getting the colostomy wet.” D. “Don’t worry about that. You will be able to live just like you did before.” 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 Answer A: The nurse should reinforce the need for a diet balanced in all nutrients and fiber. Foods that often cause diarrhea and bloating associated with irritable bowel syndrome include fried foods, caffeinated beverages, alcohol, and spicy foods. Therefore, answers B, C, and D are incorrect. 148. 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. Cream of wheat B. Banana C. Puffed rice D. Cornflakes Answer A: Clients with celiac disease should refrain from eating foods containing gluten. Foods with gluten include wheat barley, oats, and rye. The other foods are allowed. 149. The nurse is caring for a patient with suspected diverticulitis. The nurse would be most prudent in questioning which of the following diagnostic tests ordered? A. Colonoscopy B. Barium enema C. Complete blood count D. Computed tomography (CT) scan Answer B: A barium enema is contraindicated in the client with diverticulitis because it can cause bowel perforation. Answers A, C, and D are appropriate diagnostic studies for the client with diverticulitis. 150. When the nurse is gathering information for the assessment, the patient states, “My stomach hurts about 2 hours after I eat.” Based upon this information, the nurse knows the patient likely has a: A. Gastric ulcer B. Duodenal ulcer C. Peptic ulcer D. Curling’s ulcer Answer B: 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 minutes after eating. Answer C is too vague and does not distinguish the type of ulcer. Answer D is associated with stress. 151. The registered nurse is conducting an in-service for colleagues about 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 Answer C: 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. 152. The nurse is caring for the patient’s post-surgical removal of a 6mm oral cancerous 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 using the visual analogue scale Answer A: Maintaining a patient’s airway is paramount in the post-operative period. This is the priority of nursing care. Answers B, C, and D are applicable but are not the priority. The nurse should instruct the client to perform mouth care using a soft sponge toothette or irrigate the mouth with normal saline. The incision should be kept as dry as possible, and pain should be treated. Pain medications should be administered PRN. 153. The nurse is assisting in the care of a patient with diverticulosis. Which of the following assessment findings would necessitate a report to the doctor? A. Bowel sounds of 5–20 seconds B. Intermittent left lower-quadrant pain C. Constipation alternating with diarrhea D. Hemoglobin 26% and hematocrit 32 and wearing a support bra will help with engorgement but will not help the nipples. 158. The nurse asked the client if he has an advance directive. The reason for asking the client this question is: A. She is curious about his plans regarding funeral arrangements. B. Much confusion can occur with the client’s family if he does not have an advanced directive. C. An advanced directive allows the medical personnel to make all decisions for the client. D. An advanced directive allows active euthanasia. Answer B: An advanced directive allows the client to make known his wishes regarding care if he becomes unable to act on his own. Much confusion regarding life-saving measures can occur if the client does not have an advanced directive. Answers A, C, and D are incorrect because the nurse doesn’t need to know about funeral plans and cannot make decisions for the client, and active euthanasia is illegal in most states in the United States. 159. The doctor has ordered a Transcutaneous Electrical Nerve Stimulation (TENS) unit for the client with chronic back pain. The nurse teaching the client with a TENS unit should tell the client: A. “You may be electrocuted if you use water with this unit.” B. “Please report skin irritation to the doctor.” C. “The unit may be used anywhere on the body without fear of adverse reactions.” D. “A cream should be applied to the skin before applying the unit.” Answer B: Skin irritation can occur if the TENS unit is used for prolonged periods of time. To prevent skin irritations, the client should change the location of the electrodes often. Electrocution is not a risk because it uses a battery pack; thus, answer A is incorrect. Answer C is B and D describe massage therapy with the use of oils. 164. The client has an order for heparin to prevent post-surgical thrombi. Immediately following a heparin injection, the nurse should: A. Aspirate for blood B. Check the pulse rate C. Massage the site D. Check the site for bleeding Answer D: After administering any subcutaneous anticoagulant, the nurse should check the site for bleeding. Answers A and C are incorrect because aspirating and massaging the site are not done. Checking the pulse is not necessary, as in answer B. 165. Which of the following lab studies should be done periodically if the client is taking sodium warfarin (Coumadin)? A. Stool specimen for occult blood B. White blood cell count C. Blood glucose D. Erthyrocyte count Answer A: An occult blood test should be done periodically to detect any intestinal bleeding on the client with coumadin therapy. Answers B, C, and D are not directly related to the question. 166. The doctor has ordered 80mg of furosemide (Lasix) two times per day. The nurse notes the patient’s potassium level to be 2.5meq/L. The nurse should: B. The systolic, diastolic, and mean pressure of the pulmonary artery C. The pressure in the pulmonary veins D. The pressure in the right ventricle Answer B: The pulmonary artery pressure will measure the pressure during systole, diastole, and the mean pressure in the pulmonary artery. It will not measure the pressure in the left ventricle, the pressure in the pulmonary veins, or the pressure in the right ventricle. Therefore, answers A, C, and D are incorrect. 171. The physician has ordered atropine sulfate 0.4mg IM before surgery. The medication is supplied in 0.8mg per milliliter. The nurse should administer how many milliliters of the medication? A. 0.25mL B. 0.5mL C. 1mL D. 1.25mL Answer B: If the doctor orders 0.4mgm IM and the drug is available in 0.8/1mL, the nurse should make the calculation: ?mL = 1mL / 0.8mgm; × 0.4mg / 1 = 0.5m:. Answers A, C, and D are incorrect. 172. If the nurse is unable to illicit the deep tendon reflexes of the patella, the nurse should ask the client to: A. Pull against the palms B. Grimace the facial muscles C. Cross the legs at the ankles D. Perform Valsalva maneuver Answer A: If the nurse cannot elicit the patella reflex (knee jerk), the client should be asked to pull against the palms. This helps the client to relax the legs and makes it easier to get an objective reading. Answers B, C, and D will not help with the test. 173. A client with an abdominal aortic aneurysm is admitted in preparation for surgery. Which of the following should be reported to the doctor? A. An elevated white blood cell count B. An abdominal bruit C. A negative Babinski reflex D. Pupils that are equal and reactive to light Answer A: The elevated white blood cell count should be reported because this indicates infection. A bruit will be heard if the client has an aneurysm, and a negative Babinski is normal in the adult, as are pupils that are equal and reactive to light and accommodation; thus, answers B, C, and D are incorrect. 174. 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 a diuretic Answer B: The child with nephotic syndrome will exhibit extreme edema. Elevating the scrotum on a small pillow will help with the edema. Applying ice is contraindicated; 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. 175. The nurse is taking the blood pressure of an 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 Answer A: 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 pressure cuff is too large, a false low will result. Answers C and D have basically the same meaning. 176. The client is admitted with thrombophlebitis and an order for heparin. The medication should be administered using: A. Buretrol B. A tuberculin syringe C. Intravenous controller D. Three-way stop-cock Answer B: To safely administer heparin, the nurse should obtain an infusion 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. 177. 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: