NCLEX-PN Test Prep Questions and Answers with Explanations V4 PRACTICE EXAM 2 (STUDY MODE), Exams of Nursing

Download NCLEX-PN Test Prep Questions and Answers with Explanations V4 PRACTICE EXAM 2 (STUDY MODE) and more Exams Nursing in PDF only on Docsity! 2020/2021 NCLEX-PN Test Prep Questions and Answers with Explanations V4 PRACTICE EXAM 2 (STUDY MODE) 1. A post-operative client has called the nurse’s station with complaints of pain. The first action by the nurse should be to: A. Check to see when the client received pain medication B. Administer the prescribed pain medication C. Notify the charge nurse of the client’s complaints D. Assess the location and character of the client’s pain Answer D: The nurse should first assess the client to determine the location and character of the pain. Answers A, B, and C are incorrect because they are not the first action that the nurse should take. 2. The nurse is observing a developmental assessment of an infant. Which of the following is an example of cephalocaudal development? A. The infant is able to make rudimentary vocalizations before using language. B. The infant can control arm movements before she can control finger movements. C. The infant is able to raise her head before sitting. D. The infant responds to pain with her whole body before she can localize pain. Answer C: Cephalocaudal development refers to head-to-tail (toe) development; therefore, the infant can raise her head before she can sit. Answer A is an example of simple-to-complex development; therefore, it is incorrect. Answer B is an example of proximodistal development; therefore, it is incorrect. Answer D is an example of general-to-specific development; therefore, it is incorrect. 3. The physician has ordered a straight catheterization for a female client. When performing a straight catheterization on a female client, the nurse should: A. Use medical asepsis when doing the catheterization B. Insert the catheter 4–6 inches C. Inflate and deflate the balloon before insertion D. Hold the catheter in place while the bladder empties Answer D: When performing a straight catheterization, the nurse should hold the catheter in place as the bladder empties to prevent it from slipping out. Answer A is incorrect because surgical, not medical, asepsis is used when performing a catheterization. Answer B is incorrect because the catheter should be inserted 2–3 inches. Answer C is incorrect because the straight catheter does not have a balloon for inflation. 4. Before moving a client up in bed, the nurse lowers the head of the bed. The purpose of lowering the head of the bed is: A. To avoid working against gravity as the client is moved B. To prevent getting wrinkles in the client’s linen C. To eliminate needing additional help to move the client D. To relieve pressure on the client’s sacrum Answer A: Moving the client up in the bed is easier with the head of the bed lowered because the nurse does not have to work against the force of gravity. Answer B is incorrect because lowering the head of the bed will not prevent wrinkles in the linen. Answer C is incorrect because lowering the head of the bed will not eliminate the need for additional help to move the client. Answer D is incorrect because lowering the head of the bed will not relieve pressure on the client’s sacrum. 5. A client has returned from having an arteriogram. The nurse should give priority to: A. Checking the radial pulse B. Assessing the site for bleeding C. Offering fluids D. Administering pain medication Answer B: During an arteriogram, contrast media is injected directly into the artery. The nurse should give priority to assessing the site for bleeding. finding is associated with degenerative joint disease? A. Joint pain that intensifies with activity and diminishes with rest B. Bilateral and symmetric joint involvement C. Involvement of the fingers and hands D. Complaints of early-morning stiffness Answer A: Degenerative joint disease (osteoarthritis) is characterized by joint pain that intensifies with activity and diminishes with rest. Answers B, C, and D are typical findings in the client with rheumatoid arthritis; therefore, they are incorrect. 12. The physician has ordered an injection of Demerol (meperidine) for a client with pancreatitis. The nurse should: A. Administer the injection using the Z track method B. Hold pressure on the injection site for 3–5 minutes C. Administer the medication subcutaneously in the arm D. Prep the skin using a betadine wipe Answer B: The client with pancreatitis has decreased levels of vitamin K, making him more likely to have prolonged bleeding with injections; therefore, the nurse should hold pressure on the injection site for 3–5 minutes. Answer A is incorrect because the medication is not administered using the Z track method. Answer C is incorrect because the medication is not administered subcutaneously. Answer D is incorrect because alcohol, not betadine, is used to prep the skin. 13. The nurse is preparing a client with Addison’s disease for discharge. The nurse should explain that the client can help prevent complications by: A. Avoiding dietary sources of sodium B. Dressing in lightweight clothing C. Restricting foods rich in potassium D. Staying out of crowds Answer D: The client with Addison’s disease is treated with corticosteroid therapy that reduces the client’s immunity. The client needs to stay out of crowds to prevent complications posed by infection. Answers A and C are incorrect because the client needs additional sources of sodium and potassium in the diet. Answer B is incorrect because the client with Addison’s disease should dress in warm clothing to prevent easy chilling 14. A 10-year-old received an injury to his face and mouth in a bicycle accident. Examination reveals that a permanent tooth has been evulsed. Emergency care following evulsion of a permanent tooth includes: A. Rinsing the tooth in milk before reimplantation B. Wiping the tooth with gauze before reimplantation C. Holding the tooth by the root as it is rinsed D. Putting the tooth underneath the child’s tongue Answer A: The evulsed tooth should be rinsed in milk, in saline solution, or under running water before reimplantation. Answer B is incorrect because it will disturb the adhering periodontal membrane. Answer C is incorrect because the tooth should be held by the crown, not the root. Answer D is incorrect because the child might swallow or aspirate the tooth. 15. A 6-year-old is admitted with a diagnosis of leukemia. The most frequent presenting symptoms of leukemia include: A. Headache, nausea, and vomiting B. Pallor, easy bruising, and joint pain C. Delayed growth, anorexia, and alopecia D. Poor wound healing, polyuria, and fever Answer B: Presenting symptoms of leukemia include pallor, fatigue, anorexia, petechiae, and bone or joint pain. Answers A, C, and D are incorrect because they are not associated with leukemia. 16. The LPN is assigning tasks to the nursing assistant. Which task is beyond the scope of practice for the nursing assistant? A. Collecting a stool specimen for occult blood B. Obtaining a urine specimen for a routine urinalysis C. Performing a tape test for pinworms D. Aspirating nasogatric secretions for occult blood Answer D: The skill of aspirating nasogastric secretions is beyond the scope of practice of the nursing assistant. Answers A, B, and C are incorrect because they are within the scope of practice of the nursing assistant. 17. The nurse is caring for a client following an exploratory laparotomy. Which of the following assessment findings requires intervention? A. The abdominal dressing is clean, dry, and intact. B. The hourly urinary output of 20mL is dark amber in color. C. The nasogastric tube output of 15mL is bile colored. D. The IV is infusing with no signs of infiltration. Answer B: The hourly urinary output should be maintained between 30mL and 50mL per hour. The fact that the urine is dark amber indicates that the client is not receiving adequate fluids to prevent dehydration. Answers A, C, and D do not call for any interventions; therefore, they are incorrect. 18. The nurse is caring for a client following a colonoscopy in which conscious sedation was used. Initial assessment of the client reveals the following: BP 128/72, temperature 97, pulse 64, respirations 14, oxygen saturation 90%, and Glascow score of 13. An IV of normal saline is infusing at 20 drops per minute. Which nursing intervention should receive priority? A. Administering an analgesic B. Administering oxygen per standing order C. Covering the client with a blanket D. Discontinuing the IV fluid Answer B: The client’s oxygen saturation is low; therefore, the nurse should give priority to administering oxygen per standing order. Answer A is incorrect because there is nothing that indicates that the client needs an analgesic. Answer C is incorrect because the client’s temperature is satisfactory. Answer D is incorrect because the Glascow score of 13 indicates that the client is not fully recovered from the effects of conscious sedation; therefore, the IV should not be discontinued. 19. The physician has prescribed Phenergan (promethazine) with codeine for a client with pleurisy. The nurse recognizes that the medication was ordered for its: A. Expectorant effects Answer C: Diuretic therapy and restriction of fluids are ordered during the acute phase of a stroke to reduce cerebral edema. Answer A is incorrect because the orders are not intended to reduce cardiac output. Answer B is incorrect because the measures will not prevent an embolus. Answer D is incorrect because the measures are not intended to minimize incontinence. 25. The nurse is caring for a client with esophageal cancer. The client’s history will likely reveal: A. A diet high in fiber B. Presence of gastroesophageal reflux C. Occasional use of alcohol D. A diet low in fat Answer B: Long-term exposure to gastric contents such as that caused by gastroesophageal reflux plays a role in the development of esophageal cancer. Answers A and D are incorrect because they are not associated with esophageal cancer. A history of prolonged use of alcohol and tobacco is associated with esophageal cancer; therefore, answer C is incorrect. 26. Which food is the best source of calcium and potassium? A. Broccoli B. Sweet potato C. Spinach D. Avocado Answer C: Spinach is an excellent source of both calcium and potassium. Broccoli is a good source of calcium but not potassium; therefore, answer A is incorrect. Sweet potato and avocado are good sources of potassium but not calcium; therefore, answers B and D are incorrect. 27. The physician has ordered a PSA and acid phosphatase for a client admitted with complaints of dysuria. The nurse knows that a PSA and acid phosphatase are screening tests for: A. Cancer of the bladder B. Cancer of the prostate C. Cancer of the vas deferens D. Cancer of the testes Answer B: The PSA (prostate specific antigen) and acid phosphatase are valuable screening tests for cancer of the prostate. The PSA is not a screening test for cancers of the bladder, vas deferens, or testes; therefore, answers A, C, and D are incorrect. 28. The client’s morning lithium level is 1.2mEq/L. The nurse recognizes that: A. The level is too low to be therapeutic. B. The client can be expected to have signs of toxicity. C. The level is within the therapeutic range. D. The client needs to eat more sodium-rich foods. Answer C: The client’s lithium level is within the therapeutic range. Answer A is incorrect because the lithium level is not too low to be therapeutic. Answer B is incorrect because the client is not within the range of toxicity. Answer D is incorrect because eating more sodium-rich foods will reduce the lithium level. 29. Which emergency treatment is appropriate for the client who suddenly develops ventricular fibrillations? A. Cardioversion B. Intubation C. Defibrillation D. Anticonvulsant medication Answer C: The treatment for ventricular fibrillations (V-fib) is defibrillation (D-fib). Answers A, B, and D are not emergency treatments for the client who suddenly develops ventricular fibrillations. 30. The nurse is caring for a client following a stroke that left him with apraxia. The nurse knows that the client will: A. Be unable to communicate through speech B. Have difficulty swallowing C. Have difficulty with voluntary movements D. Be unable to perform previously learned skills Answer D: The client with apraxia is unable to recognize the purpose of familiar objects; therefore, he is unable to perform previously learned skills such as combing his hair. Answer A is incorrect because it refers to aphasia. Answer B is incorrect because it refers to dysphagia. Answer C is incorrect because it refers to ataxia. 31. The nurse is positioning a client with right hemiplegia. To prevent subluxation of the client’s right shoulder, the nurse should: A. Use a pillow to support the client’s arm when she is sitting in a chair B. Elevate the arm and hand above chest level when she is lying in bed C. Place a pillow under the axilla to elevate the elbow when she is lying in bed D. Use a pillow to support the client’s hand when she is sitting in a chair Answer A: Using a pillow or sling to support the client’s arm while she is sitting will help prevent subluxation of the affected shoulder. Answers B, C, and D are incorrect because they do not prevent subluxation of the client’s affected shoulder. 32. A client with thrombophlebitis is receiving Lovenox (enoxaparin). Which method is recommended for administering Lovenox? A. Z track in the dorsogluteal muscle B. Intramuscularly in the deltoid muscle C. Subcutaneously in the abdominal tissue D. Orally after breakfast Answer C: The recommended way of administering Lovenox (enoxaparin) is subcutaneously in the abdominal tissue. Answers A and B are not recommended ways of administering Lovenox (enoxaparin); therefore, they are incorrect. Answer D is incorrect because Lovenox (enoxaprin) is not available in an oral form. 33. A client with angina is to be discharged with a prescription for nitroglycerin tablets. The client should be instructed to: A. Take one tablet daily with a glass of water B. Leave the medication in a dark-brown bottle administered B. Use contact precautions only when opening the mist tent C. Temporarily stop administration of the medication when the mist tent needs to be opened D. Increase the rate of medication administration when the mist tent needs to be opened Answer C: The nurse should temporarily stop the administration of the Virazole when the mist tent needs to be opened to allow the medication particles to settle. Answer A is incorrect because contact precautions should be used even though the infant is receiving Virazole. Answer B is incorrect because contact precautions are used whether the mist tent is opened or closed. Answer D is incorrect because increasing or decreasing the rate of medication administration is not a nursing function. 39. Although children can develop allergies to a variety of foods, the most common food allergens are: A. Fruit, eggs, and corn B. Wheat, oats, and grain C. Cow’s milk, rice, and tomatoes D. Eggs, cow’s milk, and peanuts Answer D: The most common food allergens are proteins such as those contained in eggs, cow’s milk, and peanuts. Answers A, B, and C are incorrect because they are not the most common food allergens. 40. A 9-month-old is admitted with a diagnosis of eczema. The nurse would expect the 9-month-old to have eczematous lesions over: A. The abdomen, cheeks, and scalp B. The buttocks, abdomen, and back C. The back and flexor surfaces of the arms and legs D. The cheeks and extensor surfaces of arms and legs Answer D: Eczematous lesions are more common on the cheeks and extensor surfaces of the arms and legs. Answer A is incorrect because the abdomen is not a common site of eczematous lesions. Answer B is incorrect because the buttocks, abdomen, and back are not common sites of eczematous lesions. Answer C is incorrect because the back and flexor surfaces of the arms and legs are not common sites of eczematous lesions. 41. Which one of the following factors has the greatest influence on the recovery and sobriety of a client with a chemical addiction? A. The family’s understanding of the client’s addiction B. The quality of the treatment program and follow-up C. The client’s own desire to become drug-free D. The nursing staff’s attitude toward addiction Answer C: The client’s own desire to become drug-free has the most influence on recovery and sobriety. Answers A, B, and D are important factors, but they do not have the greatest influence on the client’s recovery; therefore, they are incorrect. 42. Which symptom differentiates chronic otitis media from acute otitis media? A. Elevated temperature B. Pain in the affected ear C. Nausea and vomiting D. Feelings of fullness in the ear Answer A: Acute otitis media is characterized by elevations in temperature as high as 104°F. Pain in the affected ear, nausea and vomiting, and feelings of fullness characterize both chronic otitis media and acute otitis media; therefore, answers B, C, and D are incorrect. 43. A 6-year-old is admitted with suspected rheumatic fever. Which finding is associated with rheumatic fever? A. A history of low birth weight B. A case of strep throat several weeks ago C. Presence of sickle cell trait D. Inability to digest certain grains Answer B: Rheumatic fever is associated with a history of a sequella to strep throat. Answers A, C, and D are not associated with rheumatic fever; therefore, they are incorrect. 44. Which of the following signs is characteristic of the child with Duchenne’s muscular dystrophy? A. The use of Gower’s maneuver to rise to a standing position B. Bilateral knee pain located at the tibial tubercle C. Concave curvature of the lumbar spine D. Aseptic necrosis of the head of the femur Answer A: The child with Duchenne’s muscular dystrophy must use Gower’s maneuver to rise to a standing position. The child puts his hands on his knees and moves the hands up the legs until he is standing. Answer B is incorrect because it refers to the child with Osgood-Schlatter disease. Answer C is incorrect because it refers to the child with lordosis. Answer D is incorrect because it refers to the child with Legg-Calve-Perthes disease. 45. An obstetrical client is admitted in active labor. When the membranes rupture, the nurse would expect to find: A. A large amount of bright-red discharge B. A moderate amount of straw-colored discharge C. A small amount of green-colored discharge D. A scant amount of dark-brown discharge Answer B: Amniotic fluid is straw colored in appearance. Answer A is incorrect because it indicates active bleeding. Answer C is incorrect because it indicates the passage of meconium, which is associated with fetal distress. Answer D is incorrect because the discharge should be straw colored, not dark brown in appearance. 46. Fetal heart tones can be heard using a fetoscope as early as: A. 5 weeks gestation B. 10 weeks gestation C. 15 weeks gestation D. 18 weeks gestation C. Restoration of bronchial compliance D. Relaxation of bronchial smooth muscle Answer D: Elixophylline (theophylline) is a bronchodilator that acts to relax bronchial smooth muscle. Answers A, B, and C are incorrect because they are not actions of theophylline. 53. The physician has ordered a low-calorie, low-fat, low-sodium diet for a client with hypertension. Which menu selection is appropriate for the client? A. Mixed green salad, blue cheese dressing, crackers, tea B. Frankfurter and roll, baked beans, celery and carrots, cola C. Taco salad, tortilla chips, sour cream, tea D. Baked chicken, apple, angel food cake, 1% milk Answer D: A meal of baked chicken, apple, angel food cake, and 1% milk is low in calories, low in fat, and low in sodium. Answer A is incorrect because blue cheese dressing and crackers are high in sodium. Answer B is incorrect because frankfurters are high in calories, fat, and sodium. Answer C is incorrect because taco seasoning, meat, chips, and sour cream are high in calories, fat, and sodium. 54. A postpartal client wants to know how the nutrient value of breast milk differs from that of cow’s milk. The nurse should tell the client that breast milk is: A. Higher in fat B. Higher in iron C. Higher in calcium D. Higher in sodium Answer A: Breast milk is higher in fat than cow’s milk. Answers B, C, and D are inaccurate statements regarding breast milk; therefore, they are incorrect. 55. The nurse is administering medication to a client with schizophrenia. The client accepts the medication but does not place it in his mouth. The nurse should: A. Tell the client that if he does not take the medication, he will have to get an injection B. Tell the client to put the medicine in his mouth and swallow it with the water C. Tell a nursing assistant to remain with the client until he takes the medication D. Tell the client he will have to take his medication or he cannot go with the others to recreation Answer B: The nurse should direct the client to put the medicine in his mouth and swallow it with some water. Answer A is incorrect because it is threatening to the client. Answer C is incorrect because medication administration and supervision is a responsibility of the nurse, not the nursing assistant. Answer D is incorrect because the nurse is threatening the client. 56. A client with Crohn’s disease has been started on Entocort EC (budesonide) 9mg daily. The nurse should tell the client to take the medication: A. With grapefruit juice B. On an empty stomach C. Between meals D. With meals or a snack Answer D: Entocort EC (budesonide) is a long-acting corticosteroid that should be taken with meals or a snack to prevent gastric upset. Answer A is incorrect because the medication should not be taken with grapefruit juice. Entocort EC (budesonide) should be taken with food; therefore, answers B and C are incorrect. 57. The nurse is teaching an obstetrical client regarding the appearance of edema in the last trimester. Which statement by the client indicates a need for further teaching? A. “I need to drink six to eight glasses of water a day.” B. “I can expect to have edema of my feet and ankles.” C. “Edema of my face and hands is a normal occurrence.” D. “It’s important for me to avoid prolonged standing.” Answer C: Edema of the face and hands is not a normal occurrence in pregnancy; therefore, the client needs further teaching. Answers A, B, and D indicate that the client understands the nurse’s teaching; therefore, they are incorrect. 58. While reviewing the client’s lab report, the nurse notes that the client has a potassium level of 3.0 mEq/L. What is the best source of potassium? A. One cup of apple juice B. One cup of orange juice C. One cup of cranberry juice D. One cup of prune juice Answer D: One cup of prune juice provides 707mg of potassium. Answers A, B, and C are incorrect because they provide less potassium than prune juice. (One cup of apple juice provides 295mg of potassium, one cup of orange juice provides 496mg of potassium, and one cup of cranberry juice provides 152mg of potassium.) 59. A client admitted with renal calculi is experiencing severe pain in the right flank and nausea. The immediate nursing intervention is to: A. Administer pain medication as ordered B. Encourage oral fluids C. Administer an antiemetic as ordered D. Evaluate the hydration status Answer A: The immediate nursing intervention is the administration of pain medication. Answers B, C, and D will be done later; therefore, they are incorrect. 60. The physician has ordered a sterile urine specimen from a client with an in-dwelling catheter. The nurse should: A. Open the spout on the urine bag and allow urine to flow into a sterile specimen cup B. Disconnect the drainage tube from the collection bag and allow urine to drain into a sterile specimen cup C. Disconnect the drainage tube from the catheter and allow urine to drain 66. A client refuses to take the medication prescribed for her. Which action should the nurse take first? A. Encourage the client to take the medication B. Ask the client her reasons for refusing the medication C. Document that the client refused her medication D. Report the client’s refusal to take the medication to the charge nurse Answer B: The nurse should first try to determine the client’s reason for refusing the medication so that she can decide what action needs to be taken. The nurse should not encourage the client to do anything she does not want to do; therefore, answer A is incorrect. Answers C and D are incorrect because they are not the first action the nurse should take. 67. A nurse complains that a client is noncompliant because she prefers to take herbs prescribed by her herbalist rather than taking “real medicine.” The nurse’s statement is an example of: A. Ethnicity B. Cultural sensitivity C. Ethnocentrism D. Cultural tolerance Answer C: The nurse believes that her way of treating illness (real medication) is superior to the client’s way of treating illness (herbals). Answer A refers to belonging to a particular ethnic group; therefore, it is incorrect. Answers B and D are incorrect choices because the nurse’s statement did not reflect cultural sensitivity or cultural tolerance. 68. The nurse is checking the fetal heart rates of a client in labor. The normal range for fetal heart rates is: A. 90–110 beats per minute B. 110–160 beats per minute C. 160–200 beats per minute D. 200–250 beats per minute Answer B: The normal range for fetal heart tones is 110–160bpm. Answer A is incorrect because the heart rate is too slow. Answers C and D are incorrect choices because the heart rate is too rapid. 69. Which one of the following measures decreases abdominal discomfort when the post-operative client is asked to cough? A. Exhaling forcefully between coughs B. Splinting the incision with a pillow C. Maintaining muscle tension in the operative site D. Taking panting respirations between coughs Answer B: The client can decrease abdominal discomfort by splinting the incision with a pillow. Answers A and C are incorrect because they increase abdominal discomfort. Answer D is incorrect because it does not decrease abdominal discomfort. 70. The nurse is caring for a client with arteriosclerotic heart disease. The nurse recognizes that a nonmodifiable risk factor in the development of arteriosclerotic heart disease is: A. Family history B. Hypertension C. Diet D. Exercise Answer A: A family history of arteriosclerotic heart disease is a nonmodifiable risk factor in the development of arteriorsclerotic heart disease. Answers B, C, and D are incorrect because the risk of developing arteriosclerotic heart disease can be modified or altered by controlling hypertension, eliminating high cholesterol and high saturated fats from the diet, and enrolling in a program of regular exercise. 71. The physician has ordered Nardil (phenelzine), an MAO inhibitor for a client who is currently taking Paxil (paroxetine). The nurse should: A. Give the medications together as ordered B. Clarify the orders with the physician C. Request an order for anti-Parkinsonian medication D. Administer the medications at different times Answer B: The concurrent use of an MAO inhibitor such as Nardil and an SSRI such as Paxil is contraindicated because it can result in serotonin syndrome. Answers A and D are incorrect because the concurrent use of the medications is contraindicated. Answer C is incorrect because antiParkinsonian medication is used for the client with neuroleptic malignant syndrome, not serotonin syndrome. 72. Which technique should the nurse use to prevent air from entering the stomach during a nasogastric tube feeding? A. Pour all the formula into the syringe barrel before opening the clamp B. Open the clamp and pour the formula in a continuous flow down the side of the syringe barrel C. Release the clamp before pouring all the formula into the syringe barrel D. Open the clamp and allow a small amount of formula to enter the stomach before adding more formula Answer A: To prevent air from entering the stomach, the nurse should pour all the formula into the syringe barrel before opening the clamp. Answers B, C, and D are incorrect because they do not prevent air from entering the stomach during nasogastric tube feeding. 73. The nurse is assessing a client who has undergone a right lobectomy. Which assessment should alert the nurse to the possibility of internal bleeding? A. Urinary output of 200mL during the past 3 hours B. Sanguineous chest tube drainage at a rate of 50mL per hour for the past 3 hours C. Restless and shortness of breath D. Decreased pulse rate and decreased respirations Answer C: Signs of possible internal bleeding include restless and shortness of breath. Answer A is incorrect because the urinary output is within normal limits. Answer B is incorrect because the color and rate of chest tube drainage is within the expected range following a lobectomy. Answer D is incorrect because the pulse rate and respiratory rate would be increased with internal bleeding. Answer C: The client with Addison’s disease needs an increased sodium intake. Bouillon and juices such as tomato juice are high in sodium. Answers A, B, and D are incorrect because they do not contain high levels of sodium. 80. The nurse is preparing to administer a DTP, Hib, and hepatitis B immunizations to an infant. The nurse should: A. Administer all the immunizations in one site B. Administer the DTP in one leg, and the Hib and the hepatitis B in the other leg C. Administer the DTP in the leg, the Hib in the other leg, and the hepatitis B in the arm D. Administer the DTP and Hib in one leg, and the hepatitis B in the arm Answer B: When administering the DTP, Hib, and hepatitis B vaccines, it is recommended that the DTP be administered in one leg and the Hib and hepatitis B vaccine be administered in the other leg. Answer A is incorrect because all the immunizations are not given in one site. No immunizations are to be given in the infant’s arm; therefore, answers C and D are incorrect. 81. Lab results indicate that a client receiving heparin has a prolonged bleeding time. Which medication is the antidote for heparin? A. Aquamephyton (phytonadione) B. Ticlid (ticlopidine) C. Protamine sulfate (protamine sulfate) D. Amicar (aminocaproic acid) Answer C: Protamine sulfate is the antidote for heparin overdose. Aquamephyton is the antidote for sodium warfarin overdose; therefore, answer A is incorrect. Ticlid is used to inhibit platelet aggregation and decrease the incidence of strokes; therefore, answer B is incorrect. Amicar is used in the management of hemorrhage caused by thrombolytic agents; therefore, answer D is incorrect. 82. A newborn of 32 weeks gestation is diagnosed with respiratory distress syndrome 3 hours after birth. An assessment finding in the newborn with respiratory distress syndrome is: A. Feeding difficulties B. Nasal flaring C. Increased blood pressure D. Temperature instability Answer B: Assessment findings in the newborn with respiratory distress syndrome include nasal flaring, grunting respirations, and retractions. Answers A, C, and D are not associated with respiratory distress syndrome; therefore, they are incorrect. 83. To reduce the risk of SIDS (sudden infant death syndrome), the nurse should tell parents to place the infant: A. Prone while he is sleeping B. Side-lying while he is awake C. On his back while he is sleeping D. Prone while he is awake Answer C: Placing the infant on his back while he is sleeping helps to reduce the risk of SIDS. Answers A, B, and D are incorrect because they have not been shown to reduce the risk of SIDS. 84. Which of the following play activities is most developmentally appropriate for the toddler? A. Watching cartoons B. Pulling a toy wagon C. Watching a mobile D. Coloring with crayons in a coloring book Answer B: Pulling a toy wagon is the most developmentally appropriate play activity for the toddler. Answer A is incorrect because the toddler’s attention span is too short for watching cartoons. Watching a mobile is developmentally appropriate for the infant, not the toddler; therefore, answer C is incorrect. Answer D is incorrect because the toddler lacks the fine motor development needed for using a coloring book and crayons. 85. The physician has discharged a client with diverticulitis with a prescription for Metamucil (psyllium). When teaching the client how to prepare the medication, the nurse should tell the client to: A. Dissolve the medication in gelatin or applesauce B. Mix the medication with water and drink it immediately C. Sprinkle the medication on ice cream or sherbet D. Take the medication with an ounce of antacid Answer B: Metamucil should be mixed with the recommended amount of water and drunk immediately. Answers A, C, and D are improper ways of preparing the medication; therefore, they are incorrect. 86. Young children living in housing that was built before the 1970s are at risk for: A. Lead poisoning B. Pernicious anemia C. Iron poisoning D. Sprue Answer A: Before the mid-1970s, lead-based paint was used extensively. Children living in housing built before that time are at risk for lead poisoning. Answer B is incorrect because it is due to a lack of intrinsic factor needed for the production of red blood cells. Answer C is incorrect because it is related to the overuse of iron supplements or vitamins containing iron. Answer D is incorrect because it is related to the ingestion of grains such as oats, barley, wheat, and rye. 87. Which of the following findings is associated with fluid overload in the child with renal disease? A. Sluggish capillary refill and slow heart rate B. Distention of the jugular veins and pitting edema C. Decreased blood pressure and increased heart rate D. Increased blood pressure and bilateral wheezes Answer B: Distention of the jugular veins and pitting edema are findings associated with fluid overload in the child with renal disease. Answers A, C, and D are not characteristics of fluid overload; therefore, they are incorrect. C. 35 and 40 D. 40 and 45 Answer C: According to the American Cancer Society, women should have a baseline mammogram done between the ages of 35 and 40. After age 40, women should have an annual mammogram. Answers A, B, and D are incorrect because they do not follow the recommendations of the American Cancer Society. 94. The nurse is caring for a 6-year-old following revision of a ventriculoperitoneal shunt. An expected nursing intervention is: A. Request for an x-ray to evaluate shunt placement B. Daily measurement of head circumference C. Frequent palpation of the fontanels D. Maintaining the child in a prone position Answer B: The nurse should measure the child’s head circumference daily to determine the effectiveness of the shunt. Answer A is incorrect because it is a medical intervention. Answer C is incorrect because the fontanels would be closed. Answer D is incorrect because it is not necessary to maintain the child in a prone position. 95. Stranger anxiety is defined as the distress that occurs when the infant is separated from the parents or caregivers. Stranger anxiety first peaks at: A. 1–3 months of age B. 3–6 months of age C. 7–9 months of age D. 12–15 months of age Answer C: Stranger anxiety first peaks when the infant is 7–9 months of age. Stranger anxiety does not peak before age 7 months; therefore, answers A and B are incorrect. Answer D is incorrect because stranger anxiety first peaks before 12 months of age. 96. The nurse is assessing an infant with coarctation of the aorta. The nurse can expect to find: A. Deep cyanosis B. Clubbing of the fingers and toes C. Loud cardiac murmur D. Diminished femoral pulses Answer D: Coarctation of the aorta is an acyanotic heart defect characterized by the presence of diminished femoral pulses and bounding radial and brachial pulses. Answers A, B, and C are incorrect because they describe the child with a cyanotic heart defect. 97. Which client is most likely to be affected with Cooley’s anemia? A. A child of Mediterranean descent B. A child of Asian descent C. A child of African descent D. A child of European descent Answer A: Cooley’s anemia, also known as thalassemia major, is a genetic disease primarily affecting those of Mediterranean descent. Answers B, C, and D are incorrect because they are not likely to be affected with Cooley’s anemia. 98. The primary nursing consideration when working with a newly admitted adolescent with anorexia nervosa is: A. Identifying stressors that contributed to the disorder B. Including family members in the client’s care C. Establishing a trusting relationship D. Restoring the client’s nutritional status Answer D: The primary nursing consideration is restoring the client’s nutritional status. Answers A, B, and C are an important part of the client’s care but are not the primary nursing considerations of the newly admitted client with anorexia nervosa; therefore, they are incorrect. 99. The nurse is palpating the fontanels of a 2-month-old. The fontanels should feel: A. Tense and bulging B. Soft and sunken C. Flat and firm D. Flat and tense Answer C: The fontanels of a 2-month-old should feel flat and firm to the touch. Tense, bulging fontanels indicate increased intracranial pressure; therefore, answers A and D are incorrect. Soft, sunken fontanels indicate dehydration; therefore, answer B is incorrect. 100. An infant born at 25 weeks gestation was treated with prolonged oxygen therapy. Prolonged oxygen therapy places the infant at risk for: A. Cerebral palsy B. Retinitis pigmentosa C. Hydrocephalus D. Retinopathy of prematurity Answer D: Retinopathy of prematurity is caused by damage to immature blood vessels in the retina, which can be the result of high levels of oxygen. Answers A, B, and C are not associated with prolonged oxygen therapy; therefore, they are incorrect.