NCLEX-RN 515 Exam Review Questions And Answers With Detailed Explanations, Exams of Nursing

Download NCLEX-RN 515 Exam Review Questions And Answers With Detailed Explanations and more Exams Nursing in PDF only on Docsity! NCLEX-RN 515 Exam Review Questions And Answers With Detailed Explanations Sections 1. Questions Set A 2. Question Set B 3. Questions Set C 4. Questions Set D 5. Questions Set E 6. Questions Set F 7. Questions Set G Exam A QUESTION 1 To appropriately monitor therapy and client progress, the nurse should be aware that increased myocardial work and O2 demand will occur with which of the following? A. Positive inotropic therapy B. Negative chronotropic therapy C. Increase in balance of myocardial O2 supply and demand D. Afterload reduction therapy Correct Answer: A Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Inotropic therapy will increase contractility, which will increase myocardial O2 demand. (B) Decreased heart rate to the point of bradycardia will increase coronary artery filling time. This should be used cautiously because tachycardia may be a compensatory mechanism to increase cardiac output. (C) The goal in the care of the MI client with angina is to maintain a balance between myocardial O2 supply and demand. (D) Decrease in systemic vascular resistance by drug therapy, such as IV nitroglycerin or nitroprusside, or intra-aortic balloon pump therapy, would decrease myocardial work and O2 demand. QUESTION 2 The nurse would need to monitor the serum glucose levels of a client receiving which of the following medications, owing to its effects on glycogenolysis and insulin release? A. Norepinephrine (Levophed) B. Dobutamine (Dobutrex) C. Propranolol (Inderal) D. Epinephrine (Adrenalin) Correct Answer: D Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Norepinephrine’s side effects are primarily related to safe, effective care environment and include decreased peripheral perfusion and bradycardia. (B) Dobutamine’s side effects include increased heart rate and blood pressure, ventricular ectopy, nausea, and headache. (C) Propranolol’s side effects include elevated blood urea nitrogen, serum transaminase, alkaline phosphatase, and lactic dehydrogenase. (D) Epinephrine increases serum glucose levels by increasing glycogenolysis and inhibiting insulin release. Prolonged use can elevate serum lactate levels, leading to metabolic acidosis, increased urinary catecholamines, false elevation of blood urea nitrogen, and decreased coagulation time. QUESTION 3 Which of the following medications requires close observation for bronchospasm in the client with chronic obstructive pulmonary disease or asthma? A. Verapamil (Isoptin) B. Amrinone (Inocor) C. Epinephrine (Adrenalin) D. Propranolol (Inderal) Correct Answer: D Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Verapamil has the respiratory side effect of nasal or chest congestion, dyspnea, shortness of breath (SOB), and wheezing. (B) Amrinone has the effect of increased contractility and dilation of the vascular smooth muscle. It has no noted respiratory side effects. (C) Epinephrine has the effect of bronchodilation through β stimulation. (D) Propranolol, esmolol, and labetalol are all β- blocking agents, which can increase airway resistance and cause bronchospasms. QUESTION 4 The following medications were noted on review of the client’s home medication profile. Which of the medications would most likely potentiate or elevate serum digoxin levels? A. KCl B. Thyroid agents C. Quinidine D. Theophylline Correct Answer: C Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Hypokalemia can cause digoxin toxicity. Administration of KCl would prevent this. (B) Thyroid agents decrease digoxin levels. (C) Quinidine increases digoxin levels dramatically. (D) Theophylline is not noted to have an effect on digoxin levels. QUESTION 5 In the client with a diagnosis of coronary artery disease, the nurse would anticipate the complication of bradycardia with occlusion of which coronary artery? A. Right coronary artery B. Left main coronary artery C. Circumflex coronary artery D. Left anterior descending coronary artery Correct Answer: A Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Sinus bradycardia and atrioventricular (AV) heart block are usually a result of right coronary artery occlusion. The right coronary artery perfuses the sinoatrial and AV nodes in Correct Answer: C Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) No S3 or S4 are noted with pericarditis. (B) No change in pulse pressure occurs. (C) The symptoms of pericarditis vary with the cause, but they usually include chest pain, dyspnea, tachycardia, rise in temperature, and friction rub caused by fibrin or other deposits. The pain seen with pericarditis typically worsens with deep inspiration. (D) Tamponade is not typically seen early on, and no change in pulse pressure occurs. QUESTION 12 Clinical manifestations seen in left-sided rather than in right-sided heart failure are: A. Elevated central venous pressure and peripheral edema B. Dyspnea and jaundice C. Hypotension and hepatomegaly D. Decreased peripheral perfusion and rales Correct Answer: D Section: Questions Set A Explanation Explanation/Reference: Explanation: (A, B, C) Clinical manifestations of right-sided heart failure are weakness, peripheral edema, jugular venous distention, hepatomegaly, jaundice, and elevated central venous pressure. (D) Clinical manifestations of left-sided heart failure are left ventricular dysfunction, decreased cardiac output, hypotension, and the backward failure as a result of increased left atrium and pulmonary artery pressures, pulmonary edema, and rales. QUESTION 13 Which classification of drugs is contraindicated for the client with hypertrophic cardiomyopathy? A. Positive inotropes B. Vasodilators C. Diuretics D. Antidysrhythmics Correct Answer: A Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Positive inotropic agents should not be administered owing to their action of increasing myocardial contractility. Increased ventricular contractility would increase outflow tract obstruction in the client with hypertrophic cardiomyopathy. (B) Vasodilators are not typically prescribed but are not contraindicated. (C) Diuretics are used with caution to avoid causing hypovolemia. (D) Antidysrhythmics are typically needed to treat both atrial and ventricular dysrhythmias. QUESTION 14 To ensure proper client education, the nurse should teach the client taking SL nitroglycerin to expect which of the following responses with administration? A. Stinging, burning when placed under the tongue B. Temporary blurring of vision C. Generalized urticaria with prolonged use D. Urinary frequency Correct Answer: A Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Stinging or burning when nitroglycerin is placed under the tongue is to be expected. This effect indicates that the medication is potent and effective for use. Failure to have this response means that the client needs to get a new bottle of nitroglycerin. (B, C, D) The other responses are not expected in this situation and are not even side effects. QUESTION 15 When a client is receiving vasoactive therapy IV, such as dopamine (Intropin), and extravasation occurs, the nurse should be prepared to administer which of the following medications directly into the site? A. Phentolamine (Regitine) B. Epinephrine C. Phenylephrine (Neo-Synephrine) D. Sodium bicarbonate Correct Answer: A Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Phentolamine is given to counteract the-adrenergic effects that cause ischemia and necrosis of local tissue. (B) Epinephrine is an endogenous catecholamine that produces vasoconstriction and increases heart rate and contractility. (C) Phenylephrine causes constriction of arterioles of skin, mucous membranes, and viscera, which in turn can cause ischemia and necrosis. (D) Sodium bicarbonate is an alkalinizing agent that is incompatible with dopamine. QUESTION 16 Which of the following would differentiate acute from chronic respiratory acidosis in the assessment of the trauma client? A. Increased PaCO2 B. Decreased PaO2 C. Increased HCO3 D. Decreased base excess Correct Answer: C Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Increased CO2 will occur in both acute and chronic respiratory acidosis. (B) Hypoxia does not determine acid-base status. (C) Elevation of HCO3 is a compensatory mechanism in acidosis that occurs almost immediately, but it takes hours to show any effect and days to reach maximum compensation. Renal disease and diuretic therapy may impair the ability of the kidneys to compensate. (D) Base excess is a nonrespiratory contributor to acid-base balance. It would increase to compensate for acidosis. QUESTION 17 Which of the following signs and symptoms indicates a tension pneumothorax as compared to an open pneumothorax? sympathetic control. This loss leads to vasodilation of the vascular beds, bradycardia resulting from the lack of sympathetic balance to parasympathetic stimuli from the vagus nerve, and the loss of the ability to sweat below the level of injury. In neurogenic shock, the client is hypotensive but bradycardiac with warm, dry skin. (B) In hypovolemic shock, the client ishypotensive and tachycardiac with cool skin. (C) In hypovolemic shock, the capillary refill would be>5 seconds. (D) In neurogenic shock, there is no capillary delay, the vascular beds are dilated, and peripheral flow is good. QUESTION 23 Which of the following would have the physiological effect of decreasing intracranial pressure (ICP)? A. Increased core body temperature B. Decreased serum osmolality C. Administration of hypo-osmolar fluids D. Decreased PaCO2 Correct Answer: D Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) An increase in core body temperature increases metabolism and results in an increase in ICP. (B) Decreased serum osmolality indicates a fluid overload and may result in an increase in ICP. (C) Hypo- osmolar fluids are generally voided in the neurologically compromised. Using IV fluids such as D5W results in the dextrose being metabolized, releasing free water that is absorbed by the brain cells, leading to cerebral edema. (D) Hypercapnia and hypoventilation, which cause retention of CO2 and lead to respiratory acidosis, both increase ICP. CO2 is the most potent vasodilator known. QUESTION 24 A client who has sustained a basilar skull fracture exhibits blood-tinged drainage from his nose. After establishing a clear airway, administering supplemental O2, and establishing IV access, the next nursing intervention would be to: A. Pass a nasogastric tube through the left nostril B. Place a 4 X 4 gauze in the nares to impede the flow C. Gently suction the nasal drainage to protect the airway D. Perform a halo test and glucose level on the drainage Correct Answer: D Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Basilar skull fracture may cause dural lacerations, which result in CSF leaking from the ears or nose. Insertion of a tube could lead to CSF going into the brain tissue or sinuses. (B) Tamponading flow could worsen the problem and increase ICP. (C) Suction could increase brain damage and dislocate tissue. (D) Testing the fluid from the nares would determine the presence of CSF. Elevation of the head, notification of the medical staff, and prophylactic antibiotics are appropriate therapy. QUESTION 25 A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report: A. Dizziness and tachypnea B. Circumoral pallor and lightheadedness C. Headache and facial flushing to edema, sodium shifting into the cells, and later, diuresis. (B) Hypocalcemia occurs because of calcium loss to edema fluid at the burned site (third space fluid). (C) Protein loss occurs at the burn site owing to increased capillary permeability. Serum protein levels remain low until healing occurs. (D) Hematocrit level is elevated owing to hemoconcentration from hypovolemia. Anemia is present in the postburn stage owing to blood loss and hemolysis, but it cannot be assessed until the client is adequately hydrated. QUESTION 31 The nurse notes hyperventilation in a client with a thermal injury. She recognizes that this may be a reaction to which of the following medications if applied in large amounts? A. Neosporin sulfate B. Mafenide acetate C. Silver sulfadiazine D. Povidone-iodine Correct Answer: B Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) The side effects of neomycin sulfate include rash, urticaria, nephrotoxicity, and ototoxicity. (B) The side effects of mafenide acetate include bone marrow suppression, hemolytic anemia, eosinophilia, and metabolic acidosis. The hyperventilation is a compensatory response to the metabolic acidosis. (C) The side effects of silver sulfadiazine include rash, itching, leukopenia, and decreased renal function. (D) The primary side effect of povidone- iodine is decreased renal function. QUESTION 32 The primary reason for sending a burn client home with a pressure garment, such as a Jobst garment, is that the garment: A. Decreases hypertrophic scar formation B. Assists with ambulation C. Covers burn scars and decreases the psychological impact during recovery D. Increases venous return and cardiac output by normalizing fluid status Correct Answer: A Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Tubular support, such as that received with a Jobst garment, applies tension of 10–20 mm Hg. This amount of uniform pressure is necessary to prevent or reduce hypertrophic scarring. Clients typically wear a pressure garment for 6–12 months during the recovery phase of their care. (B) Pressure garments have no ambulatory assistive properties. (C) Pressure garments can worsen the psychological impact of burn injury, especially if worn on the face. (D) Pressure garments do not normalize fluid status. QUESTION 33 A client with emphysema is placed on diuretics. In order to avoid potassium depletion as a side effect of the drug therapy, which of the following foods should be included in his diet? A. Celery B. Potatoes C. Tomatoes D. Liver Correct Answer: B Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Celery is high in sodium. (B) Potatoes are high in potassium. (C) Tomatoes are high in sodium. (D) Liver is high in iron. QUESTION 34 Which of the following would the nurse expect to find following respiratory assessment of a client with advanced emphysema? A. Distant breath sounds B. Increased heart sounds C. Decreased anteroposterior chest diameter D. Collapsed neck veins Correct Answer: A Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Distant breath sounds are found in clients with emphysema owing to increased anteroposterior chest diameter, overdistention, and air trapping. (B) Deceased heart sounds arepresent because of the increased anteroposterior chest diameter. (C) A barrel- shaped chest is characteristic of emphysema. (D) Increased distention of neck veins is found owing to right-sided heart failure, which may be present in advanced emphysema. QUESTION 35 The nurse assists a client with advanced emphysema to the bathroom. The client becomes extremely short of breath while returning to bed. The nurse should: A. Increase his nasal O2 to 6 L/min B. Place him in a lateral Sims’ position C. Encourage pursed-lip breathing D. Have him breathe into a paper bag Correct Answer: C Section: Questions Set A Explanation Explanation/Reference: Explanation: (A)Giving too high a concentration of O2 to a client with em-physema may remove his stimulus to breathe. (B)The client should sit forward with his hands on his knees or an overbed table and with shoulders elevated. (C) Pursed-lip breathing helps the client to blow off CO2 and to keep air passages open. (D) Covering the face of a client extremely short of breath may cause anxiety and further increase dyspnea. QUESTION 36 Signs and symptoms of an allergy attack include which of the following? A. Wheezing on inspiration B. Increased respiratory rate (A) Aspirin is hepatotoxic, may increase bleeding, and should be avoided. (B) Blood should not be donated by a client who has had hepatitis C because of the possibility of transmission of disease. (C) Alcohol is detoxified in the liver. (D) Hepatitis C is not spread through the oral route. QUESTION 42 A 27-year-old man was diagnosed with type I diabetes 3 months ago. Two weeks ago he complained of pain, redness, and tenderness in his right lower leg. He is admitted to the hospital with a slight elevation of temperature and vague complaints of “not feeling well.” At 4:30 PM on the day of his admission, his blood glucose level is 50 mg; dinner will be served at 5:00 PM. The best nursing action would be to: A. Give him 3 tbsp of sugar dissolved in 4 oz of grape juice to drink B. Ask him to dissolve three pieces of hard candy in his mouth C. Have him drink 4 oz of orange juice D. Monitor him closely until dinner arrives Correct Answer: C Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) The combination of sugar and juice will increase the blood sugar beyond the normal range. (B) Concentrated sweets are not absorbed as fast as juice; consequently, they elevate the blood sugar beyond the normal limit. (C) Four ounces of orange juice will act immediately to raise the blood sugar to a normal level and sustain it for 30 minutes until supper is served. (D) There is an increased potential for the client’s blood sugar to decrease even further, resulting in diabetic coma. QUESTION 43 A male client receives 10 U of regular human insulin SC at 9:00 AM. The nurse would expect peak action from this injection to occur at: A. 9:30 AM B. 10:30 AM C. 12 noon D. 4:00 PM Correct Answer: C Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) This is too early for peak action to occur. (B) This is too early for peak action to occur. (C) Regular insulin peak action occurs 2–4 hours after administration. (D) This is too late for peak action to occur. QUESTION 44 A type I diabetic client is diagnosed with cellulitis in his right lower extremity. The nurse would expect which of the following to be present in relation to his blood sugar level? A. A normal blood sugar level B. A decreased blood sugar level C. An increased blood sugar level D. Fluctuating levels with a predawn increase Correct Answer: C Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Blood sugar levels increase when the body responds to stress and illness. (B) Blood sugar levels increase when the body responds to stress and illness. (C) Hyperglycemia occurs because glucose is produced as the body responds to the stress and illness of cellulitis. (D) Blood sugar levels remain elevated as long as the body responds to stress and illness. QUESTION 45 The physician has ordered that a daily exercise program be instituted by a client with type I diabetes following his discharge from the hospital. Discharge instructions about exercise should include which of the following? A. Exercise should be performed 30 minutes before meals. B. A snack may be needed before and/or during exercise. C. Hyperglycemia may occur 2–4 hours after exercise. D. The blood glucose level should be 100 mg or below before exercise is begun. Correct Answer: B Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) Exercise should not be performed before meals because the blood sugar is usually lower just prior to eating; therefore, there is an increased risk for hypoglycemia. (B) Exercise lowers blood sugar levels; therefore, a snack may be needed to maintain the appropriate glucose level. (C) Exercise lowers blood sugar levels. (D) Exercise lowers blood sugar levels. If the blood glucose level is 100 mg or below at the start of exercise, the potential for hypoglycemia is greater. QUESTION 46 Dietary planning is an essential part of the diabetic client’s regimen. The American Diabetes Association recommends which of the following caloric guidelines for daily meal planning? A. 50% complex carbohydrate, 20%–25% protein, 20%–25% fat B. 45% complex carbohydrate, 25%–30% protein, 30%–35% fat C. 70% complex carbohydrate, 20%–30% protein, 10%–20% fat D. 60% complex carbohydrate, 12%–15% protein, 20%–25% fat Correct Answer: D Section: Questions Set A Explanation Explanation/Reference: Explanation: (A) The percentage of carbohydrates is too low to maintain blood sugar levels. The percent range of protein is too high and may cause extra workload on the kidney as it is metabolized. (B) The percentage of carbohydrates is too low to maintain blood sugar levels. The percent range of protein is too high and may cause extra workload on the kidney. (C) The percentage of carbohydrates is too high; the percent range of protein is too high, and of fat, too low. (D) This combination provides enough carbohydrates to maintain blood glucose levels, enough protein to maintain body repair, and enough fat to ensure palatability. QUESTION 47 A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has been progressing well. While the nurse is in the room, the client states, “Oh dear, I feel like I have to urinate again!” Which of the following is the most appropriate initial nursing response? Correct Answer: D Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Eggs and hash browns do not provide much fiber and bulk, so they do not effectively prevent constipation. (B) Pancakes and syrup also have little fiber and bulk, so they do not effectively prevent constipation. (C) Bagel and cream cheese do not provide intestinal bulk. (D) A combination of oatmeal and fresh fruit will provide fiber and intestinal bulk. QUESTION 53 One of the medications that is prescribed for a male client is furosemide (Lasix) 80 mg bid. To reduce his risk of falls, the nurse would teach him to take this medication: A. On arising and no later than 6 PM B. At evenly spaced intervals, such as 8 AM and 8 PM C. With at least one glass of water per pill D. With breakfast and at bedtime Correct Answer: A Section: Question Set B Explanation Explanation/Reference: Explanation: (A) This option provides adequate spacing of the medication and will limit the client’s need to get up to go to the bathroom during the night hours, when he is especially at high risk for falls. (B) This option would result in the need to get up during the night to urinate and would thus increase the risk of falls. This option also does not take into consideration the client’s usual daily routine. (C) Taking this medication with at least one glass of water would not have an impact on the risk of falls. (D) This option would result in the need to get up during the night to urinate and would thus increase the risk of falls. QUESTION 54 The nurse teaches a male client ways to reduce the risks associated with furosemide therapy. Which of the following indicates that he understands this teaching? A. “I’ll be sure to rise slowly and sit for a few minutes after lying down.” B. “I’ll be sure to walk at least 2–3 blocks every day.” C. “I’ll be sure to restrict my fluid intake to four or five glasses a day.” D. “I’ll be sure not to take any more aspirin while I amon this drug.” Correct Answer: A Section: Question Set B Explanation Explanation/Reference: Explanation: (A) This response will help to prevent the occurrence of postural hypotension, a common side effect of this drug and a common reason for falls. (B) Although walking is an excellent exercise, it is not specific to the reduction of risks associated with diuretic therapy. (C) Clients on diuretic therapy are generally taught to ensure that their fluid intake is at least 2000–3000 mL daily, unless contraindicated. (D) Aspirin is a safe drug to take along with furosemide. QUESTION 55 A client is taught to eat foods high in potassium. Which food choices would indicate that this teaching has been successful? A. Pork chop, baked acorn squash, brussel sprouts B. Chicken breast, rice, and green beans C. Roast beef, baked potato, and diced carrots D. Tuna casserole, noodles, and spinach Correct Answer: A Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Both acorn squash and brussels sprouts are potassium-rich foods. (B) None of these foods is considered potassium rich. (C) Only the baked potato is a potassium-rich food. (D) Spinach is the only potassium-rich food in this option. QUESTION 56 The nurse would be sure to instruct a client on the signs and symptoms of an eye infection and hemorrhage. These signs and symptoms would include: A. Blurred vision and dizziness B. Eye pain and itching C. Feeling of eye pressure and headache D. Eye discharge and hemoptysis Correct Answer: B Section: Question Set B Explanation Explanation/Reference: Explanation: (A)Although blurred vision may occur, dizziness would not be associated with an infection or hemorrhage. (B)Eye pain is a symptom of hemorrhage within the eye, and itching is associated with infection. (C) Nausea and headache would not be usual symptoms of eye hemorrhage or infection. (D) Some eye discharge might be anticipated if an infection is present; hemoptysis would not. QUESTION 57 The nurse would teach a male client ways to minimize the risk of infection after eye surgery. Which of the following indicates the client needs further teaching? A. “I will wash my hands before instilling eye medications.” B. “I will wear sunglasses when going outside.” C. “I will wear an eye patch for the first 3 postoperative days.” D. “I will maintain the sterility of the eye medications.” Correct Answer: C Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Hand washing would be an important action designed to prevent transmission of pathogens from the hands to the eye. (B) Wearing sunglasses when going outside will prevent airborne pathogens from entering the eye. (C) Eye patches are most frequently ordered to be worn while the client sleeps or naps, not constantly for this length of time. (D) Eye medications are sterile; clients need to be taught how to maintain this sterility. Section: Question Set B Explanation Explanation/Reference: Explanation: (A, B, D) Cigarettes, cigars, and chewing gum would stimulate gastric acid secretion. (C) Smoking on a full stomach minimizes effect of nicotine on gastric acid. QUESTION 64 Iron dextran (Imferon) is a parenteral iron preparation. The nurse should know that it: A. Is also called intrinsic factor B. Must be given in the abdomen C. Requires use of the Z-track method D. Should be given SC Correct Answer: C Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Intrinsic factor is needed to absorb vitamin B12.(B) Iron dextran is given parenterally, but Z-track in a large muscle. (C) A Ztrack method of injection is required to prevent staining and irritation of the tissue. (D) An SC injection is not deep enough and may cause subcutaneous fat abscess formation. QUESTION 65 A nasogastric (NG) tube inserted preoperatively is attached to low, intermittent suctions. A client with an NG tube exhibits these symptoms: He is restless; serum electrolytes are Na 138, K 4.0, blood pH 7.53. This client is most likely experiencing: A. Hyperkalemia B. Hyponatremia C. Metabolic acidosis D. Metabolic alkalosis Correct Answer: D Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Sodium level is within normal limits. (B) Sodium level is within normal limits. (C) pH level is consistent with alkalosis. (D) With an NG tube attached to low, intermittent suction, acids are removed and a client will develop metabolic alkalosis. QUESTION 66 A client is experiencing muscle weakness and lethargy. His serum K+is 3.2. What other symptoms might he exhibit? A. Tetany B. Dysrhythmias C. Numbness of extremities D. Headache Correct Answer: B Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Tetany is seen with low calcium. (B) Low potassium causes dysrhythmias because potassium is responsible for cardiac muscle activity. (C) Numbness of extremities is seen with high potassium. (D) Headache is not associated with potassium excess or deficiency. QUESTION 67 Following a gastric resection, which of the following actions would the nurse reinforce with the client in order to alleviate the distress from dumping syndrome? A. Eating three large meals a day B. Drinking small amounts of liquids with meals C. Taking a long walk after meals D. Eating a low-carbohydrate diet Correct Answer: D Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Six small meals are recommended. (B) Liquids after meals increase the time food empties from the stomach. (C) Lying down after meals is recommended to prevent gravity from producing dumping. (D) A low-carbohydrate diet will prevent a hypertonic bolus, which causes dumping. QUESTION 68 Azulfidine (Sulfasalazine) may be ordered for a client who has ulcerative colitis. Which of the following is a nursing implication for this drug? A. Limit fluids to 500 mL/day. B. Administer 2 hours before meals. C. Observe for skin rash and diarrhea. D. Monitor blood pressure, pulse. Correct Answer: C Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Fluids up to 2500–3000 mL/day are needed to prevent kidney stones. (B) The client should be instructed to take oral preparations with meals or snacks to lessen gastric irritation. (C) Sulfasalazine causes skin rash and diarrhea. (D) Blood pressure and pulse are not altered by sulfasalazine. QUESTION 69 Other drugs may be ordered to manage a client’s ulcerative colitis. Which of the following medications, if ordered, would the nurse question? A. Methylprednisolone sodium succinate (Solu-Medrol) B. Loperamide (Imodium) C. Psyllium D. 6-Mercaptopurine Correct Answer: D Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Methylprednisolone sodium succinate is used for its anti-inflammatory effects. (B) Loperamide would be used to control diarrhea. (C) Psyllium may improve consistency of stools by providing bulk. (D) An immunosuppressant such as 6-mercaptopurine is used for chronic unrelenting Crohn’s disease. QUESTION 70 A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should: A. Explain that he will be kept NPO for 24 hours before the exam B. Practice with him so he will be able to hold his breath for 1 minute C. Explain that he will be receiving a laxative to prevent a distended bowel from applying pressure on the liver D. Explain that his vital signs will be checked frequently after the test Correct Answer: D Section: Question Set B Explanation Explanation/Reference: Explanation: (A) There is no NPO restriction prior to a liver biopsy. (B) The client would need to hold his breath for 5–10 seconds. (C) There is no pretest laxative given. (D) Following the test, the client is watched for hemorrhage and shock. QUESTION 71 After a liver biopsy, the best position for the client is: A. High Fowler B. Prone C. Supine D. Right lateral Correct Answer: D Section: Question Set B Explanation Explanation/Reference: Explanation: (A) This position does not help to prevent bleeding. (B) This position does not help to prevent bleeding. (C) This position does not help to prevent bleeding. (D) The right lateral position would allow pressure on the liver to prevent bleeding. QUESTION 72 A complication for which the nurse should be alert following a liver biopsy is: A. Hepatic coma B. Jaundice (A) Blood pressure changes are predominantly due to pressure of the gravid uterus. (B) Pressure of the gravid uterus on the inferior vena cava decreases blood return from lower extremities. (C) Inferior vena cava syndrome is experienced in the latter months of pregnancy regardless of parity. (D) There are no medications useful in the treatment of interior vena cava syndrome; alleviating pressure by position changes is effective. QUESTION 78 A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the GTPAL system to record her obstetrical history, the nurse should record: A. 3-2-0-0-2 B. 2-2-0-2-2 C. 3-1-1-0-2 D. 2-1-1-0-2 Correct Answer: C Section: Question Set B Explanation Explanation/Reference: Explanation: (A) This answer is an incorrect application of the GTPAL method. One prior pregnancy was a preterm birth at 36 weeks (T =1, P= 1; not T = 2). (B) This answer is an incorrect application of the GTPAL method. The client is currently pregnant for the third time (G = 3, not 2), one prior pregnancy was preterm (T= 1, P= 1; not T= 2), and she has had no prior abortions (A =0). (C) This answer is the correct application of GTPAL method. The client is currently pregnant for the third time (G =3), her first pregnancy ended at term (>37 weeks) (T = 1), her second pregnancy ended preterm 20– 33 weeks) (P = 1), she has no history of abortion (A=0), and she has two living children (L = 2). (D) This answer is an incorrect application of the GTPAL method. The client is currently pregnant for the third time (G =3, not 2). QUESTION 79 A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the gravida and para system to record the client’s obstetrical history, the nurse should record: A. Gravida 3 para 1 B. Gravida 3 para 2 C. Gravida 2 para 1 D. Gravida 2 para 2 Correct Answer: B Section: Question Set B Explanation Explanation/Reference: Explanation: (A) This answer is an incorrect application of gravida and para. The client has had two prior deliveries of more than 20 weeks’ gestation; therefore, para equals 2, not 1. (B) This answer is the correct application of gravida and para. The client is currently pregnant for the third time (G = 3), regardless of the length of the pregnancy, and has had two prior pregnancies with birth after the 20th week (P = 2), whether infant was alive or dead. (C) This answer is an incorrect application of gravida and para. The client is currently pregnant for the third time (G = 3, not 2); prior pregnancies lasted longer than 20 weeks (therefore, P = 2, not 1). (D) This is an incorrect application of gravida and para. Client is currently pregnant for third time (G = 3, not 2). QUESTION 80 A gravida 2 para 1 client is hospitalized with severe preeclampsia. While she receives magnesium sulfate (MgSO4) therapy, the nurse knows it is safe to repeat the dosage if: A. Deep tendon reflexes are absent B. Urine output is 20 mL/hr C. MgSO4serum levels are>15 mg/dL D. Respirations are>16 breaths/min Correct Answer: D Section: Question Set B Explanation Explanation/Reference: Explanation: (A) MgSO4is a central nervous system depressant. Loss of reflexes is often the first sign of developing toxicity. (B) Urinary output at <25 mL/hr or 100 mL in 4 hours may result in the accumulation of toxic levels of magnesium. (C) The therapeutic serum range for MgSO4is 6– 8 mg/dL. Higher levels indicate toxicity. (D) Respirations of>16 breaths/min indicate that toxic levels of magnesium have not been reached. Medication administration would be safe. QUESTION 81 Prenatal clients are routinely monitored for early signs of pregnancy-induced hypertension (PIH). For the prenatal client, which of the following blood pressure changes from baseline would be most significant for the nurse to report as indicative of PIH? A. 136/88 to 144/93 B. 132/78 to 124/76 C. 114/70 to 140/88 D. 140/90 to 148/98 Correct Answer: C Section: Question Set B Explanation Explanation/Reference: Explanation: (A) These blood pressure changes reflect only an 8 mm Hg systolic and a 5 mm Hg diastolic increase, which is insufficient for blood pressure changes indicating PIH. (B) These blood pressure changes reflect a decrease in systolic pressure of 8 mm Hg and diastolic pressure of 2 mm Hg; these values are not indicative of blood pressure increases reflecting PIH. (C) The definition of PIH is an increase in systolic blood pressure of 30 mm Hg and/or diastolic blood pressure of 15 mm Hg. These blood pressures reflect a change of 26 mm Hg systolically and 18mm Hg diastolically. (D) These blood pressures reflect a change of only 8 mm Hg systolically and 8 mm Hg diastolically, which is insufficient for blood pressure changes indicating PIH. QUESTION 82 In assisting preconceptual clients, the nurse should teach that the corpus luteum secretes progesterone, which thickens the endometrial lining in which of the phases of the menstrual cycle? A. Menstrual phase B. Proliferative phase C. Secretory phase D. Ischemic phase Correct Answer: C Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Menses occurs during the menstrual phase, during which levels of both estrogen and progesterone are decreased. (B) The ovarian hormone responsible for the proliferative phase, during which the uterine endometrium enlarges, is estrogen. (C) The ovarian hormone responsible for the secretory phase is progesterone, which is secreted by the corpus luteum and causes marked swelling in the uterine endometrium. (D) The corpus luteum begins to degenerate in the ischemic phase, causing a fall in both estrogen and progesterone. QUESTION 83 A client decided early in her pregnancy to breast-feed her first baby. She gave birth to a normal, full-term girl and is now progressing toward the establishment of successful lactation. To remove the baby from her breast, she should be instructed to: A. Gently pull the infant away B. Withdraw the breast from the infant’s mouth C. Compress the areolar tissue until the infant drops the nipple from her mouth D. Insert a clean finger into the baby’s mouth beside the nipple Correct Answer: D Section: Question Set B Explanation Explanation/Reference: Explanation: (A) In pulling the infant away from the breast without breaking suction, nipple trauma is likely to occur. (B) In pulling the breast away from the infant without breaking suction, nipple trauma is likely to occur. (C) Compressing the maternal tissue does not break the suction of the infant on the breast and can cause nipple trauma. (D) By inserting a finger into the infant’s mouth beside the nipple, the lactating mother can break the suction and the nipple can be removed without trauma. QUESTION 84 A gravida 2 para 1 client delivered a full-term newborn 12 hours ago. The nurse finds her uterus to be boggy, high, and deviated to the right. The most appropriate nursing action is to: A. Notify the physician B. Place the client on a pad count C. Massage the uterus and re-evaluate in 30 minutes D. Have the client void and then re-evaluate the fundus Correct Answer: D Section: Question Set B Explanation Explanation/Reference: Explanation: (A) The nurse should initiate actions to remove the most frequent cause of uterine displacement, which involves emptying the bladder. Notifying the physician is an inappropriate nursing action. (B) The pad count gives an estimate of blood loss, which is likely to increase with a boggy uterus; but this action does not remove the most frequent cause of uterine displacement, which is a full bladder. (C) Massage may firm the uterus temporarily, but if a full bladder is not emptied, the uterus will remain displaced and is likely to relax again. (D) The most common cause of uterine displacement is a full bladder. QUESTION 90 A client is admitted to the labor unit. On vaginal examination, the presenting part in a cephalic presentation was at station plus two. Station 12 means that the: A. Presenting part is 2 cm above the level of the ischial spines B. Biparietal diameter is at the level of the ischial spines C. Presenting part is 2 cm below the level of the ischial spines D. Biparietal diameter is 5 cm above the ischial spines Correct Answer: C Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. If the presenting part is above the ischial spines, the station is negative. (B) When the biparietal diameter is at the level of the ischial spines, the presenting part is generally at a +4 or +5 station. (C) Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. If the presenting part is below the ischial spines, the station is positive. Thus, 2 cm below the ischial spines is the station +2. (D) When the biparietal diameter is above the ischial spines by 5 cm, the presenting part is usually engaged or at station 0. QUESTION 91 A pregnant client is at the clinic for a third trimester prenatal visit. During this examination, it has been determined that her fetus is in a vertex presentation with the occiput located in her right anterior quadrant. On her chart this would be noted as: A. Right occipitoposterior B. Right occipitoanterior C. Right sacroanterior D. LOA Correct Answer: B Section: Question Set B Explanation Explanation/Reference: Explanation: (A) The fetus in the right occipitoposterior position would be presenting with the occiput in the maternal right posterior quadrant. (B) Fetal position is defined by the location of the fetal presenting part in the four quadrants of the maternal pelvis. The right occipitoanterior is a fetus presenting with the occiput in mother’s right anterior quadrant. (C) The fetus in right sacroanterior position would be presenting a sacrum, not an occiput. (D) The fetus in left occipitoanterior position would be presenting with the occiput in the mother’s left anterior quadrant. QUESTION 92 Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last 4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the presenting fetal head is described. The physician orders, “Begin oxytocin induction at 1 mU/min.” The nurse should: A. Begin the oxytocin induction as ordered B. Increase the dosage by 2 mU/min increments at15-minute intervals C. Maintain the dosage when duration of contractions is 40–60 seconds and frequency is at 21⁄2–4 minute intervals D. Question the order Correct Answer: D Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Oxytocin stimulates labor but should not be used until CPD (cephalopelvic disproportion) is ruled out in a dysfunctional labor. (B) This answer is the correct protocol for oxytocin administration, but the medication should not be used until CPD is ruled out. (C) This answer is the correct manner to interpret effective stimulation, but oxytocin should not be used until CPD is ruled out. (D) This answer is the appropriate nursing action because the scenario presents adysfunctional labor pattern that may be caused by CPD. Oxytocin administration is contraindicated in CPD. QUESTION 93 A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse? A. “Keep breathing with your abdominal muscles as long as you can.” B. “Make sure you take a deep cleansing breath as the contractions start, focus on an object, and breathe about 16–20 times a minute with shallow chest breaths.” C. “Find a comfortable position before you start a contraction. Once the contraction has started, take slow breaths using your abdominal muscles.” D. “If a woman in labor listens to her body and takes rapid, deep breaths, she will be able to deal with her contractions quite well.” Correct Answer: B Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Lamaze childbirth preparation teaches the use of chest, not abdominal, breathing. (B) In Lamaze preparation, every patterned breath is preceded by a cleansing breath; as labor progresses, shallow, paced breathing is found to be effective. (C) It is important to assume a comfortable position in labor, but the Lamazeprepared laboring woman is taught to breathe with her chest, not abdominal, muscles. (D) When deep chest breathing patterns are used in Lamaze preparation, they are slowly paced at a rate of 6–9 breaths/min. QUESTION 94 A client is being discharged and will continue enteral feedings at home. Which of the following statements by a family member indicates the need for further teaching? A. “If he develops diarrhea lasting for more than 2–3 days, I will contact the doctor or nurse.” B. “I should anticipate that he will gain about 1 lb/day now that he is on continuous feedings.” C. “It is important to keep the head of his bed elevated or sit him in the chair during feedings.” D. “I should use prepared or open formula within 24 hours and store unused portions in the refrigerator.” Correct Answer: B Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Diarrhea is a complication of tube feedings that can lead to dehydration. Diarrhea may be the result of hypertonic formulas that can draw fluid into the bowel. Other causes of diarrhea may be bacterial contamination, fecal impaction, medications, and low albumin. (B) A consistent weight gain of more than To prevent fungal infections of the mouth and throat, the nurse should teach clients on inhaled steroids to: A. Rinse the plastic holder that aerosolizes the drug with hydrogen peroxide every other day B. Rinse the mouth and gargle with warm water after each use of the inhaler C. Take antacids immediately before inhalation to neutralize mucous membranes and prevent infection D. Rinse the mouth before each use to eliminate colonization of bacteria Correct Answer: B Section: Question Set B Explanation Explanation/Reference: Explanation: (A) It is sufficient to rinse the plastic holders with warm water at least once per day. (B) It is important to rinse the mouth after each use to minimize the risk of fungal infections by reducing the droplets of the glucocorticoid left in the oral cavity. (C) Antacids act by neutralizing or reducing gastric acid, thus decreasing the pH of the stomach. “Neutralizing” the oral mucosa prior to inhalation of a steroid inhaler does not minimize the risk of fungal infections. (D) Rinsing prior to the use of the glucocorticoid will not eliminate the droplets left on the oral mucous membranes following the use of the inhaler. QUESTION 101 Which of the following would indicate the need for further teaching for the client with COPD? The client verbalizes the need to: A. Eat high-calorie, high-protein foods B. Take vitamin supplementation C. Eliminate intake of milk and milk products D. Eat small, frequent meals Correct Answer: C Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Protein is vital for the maintenance of muscle to aid in breathing. A high-calorie diet using higher fat than carbohydrate content is given because clients are unable to breathe off the excess CO2that is an end product of carbohydrate metabolism. (B) Inadequate nutritional status, in particular, deficiencies in vitamins A and C, decreases resistance to infection. (C) Milk does not make mucus thicker. It may coat the back of the throat and make it feel thicker. Rinsing the mouth with water after drinking milk will prevent this problem. (D) Small, frequent meals minimize a fullness sensation and reduce pressure on the diaphragm. The work of breathing and SOB are also reduced. QUESTION 102 A dose of theophylline may need to be altered if a client with COPD: A. Is allergic to morphine B. Has a history of arthritis C. Operates machinery D. Is concurrently on cimetidine for ulcers Correct Answer: D Section: Question Set B Explanation Explanation/Reference: Explanation: (A) The effects of morphine or an allergic response to the drug will not affect theophylline clearance. (B) Xanthines are used cautiously in clients with severe cardiac disease, liver disease, cor pulmonale, hypertension, or hyperthyroidism. Arthritis does not influence the dosage of theophylline. (C) Theophylline does not cause sedation or drowsiness. Conversely, its side effects may be exhibited by central nervous system stimulation. (D) Cimetidine decreases theophylline clearance from the system and increases theophylline levels in the blood, thus increasing the risk of toxicity. QUESTION 103 The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because: A. Immediate treatment of mild PIH includes the administration of a variety of medications B. Psychological counseling is indicated to reduce the emotional stress causing the blood pressure elevation C. Self-discipline is required to control caloric intake throughout the pregnancy D. The client may not recognize the early symptoms of PIH Correct Answer: D Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Mild PIH is not treated with medications. (B) Emotional stress is not the cause of blood pressure elevation in PIH. (C) Excessive caloric intake is not the cause of weight gain in PIH. (D) The client most frequently is not aware of the signs and symptoms in mild PIH. QUESTION 104 Which of the following changes in blood pressure readings should be of greatest concern to the nurse when assessing a prenatal client? A. 130/88 to 144/92 B. 136/90 to 148/100 C. 150/96 to 160/104 D. 118/70 to 130/88 Correct Answer: D Section: Question Set B Explanation Explanation/Reference: Explanation: (A, B, C) The individual’s systolic and diastolic changes are more significant than the relatively high initial blood pressure readings. (D) The systolic pressure went up 12 mm Hg and the diastolic pressure 18 mm Hg. This is a more significant rise than the increases in A– C choices, and client should receive more frequent evaluations and care. QUESTION 105 A 16-year-old client comes to the prenatal clinic for her monthly appointment. She has gained 14 lb from her 7th to 8th month; her face and hands indicate edema. She is diagnosed as having PIH and referred to the high-risk prenatal clinic. The client’s weight increase is most likely due to: A. Overeating and subsequent obesity B. Obesity prior to conception C. Hypertension due to kidney lesions edema and/or edema to the fetal scalp; both of these could contribute to increased risk of complications. QUESTION 111 In addition to changing the mother’s position to relieve cord pressure, the nurse may employ the following measure (s) in the event that she observes the cord out of the vagina: A. Immediately pour sterile saline on the cord, and repeat this every 15 minutes to prevent drying. B. Cover the cord with a wet sponge. C. Apply a cord clamp to the exposed cord, and cover with a sterile towel. D. Keep the cord warm and moist by continuous applications of warm, sterile saline compresses. Correct Answer: D Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Saline should be warmed; waiting 15 minutes may not keep the cord moist. (B) This choice does not specify what the sponge was “wet” with. (C) This measure would stop circulation to the fetus. (D) The cord should be kept warm and moist to maintain fetal circulation. This measure is an accepted nursing action. QUESTION 112 Which of the following signs might indicate a complication during the labor process with vertex presentation? A. Fetal tachycardia to 170 bpm during a contraction B. Nausea and vomiting at 8–10 cm dilation C. Contraction lasting 60 seconds D. Appearance of dark-colored amniotic fluid Correct Answer: D Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Fetal tachycardia may indicate fetal hypoxia; however, 170 bpm is only mild tachycardia. (B) Nausea and vomiting occur frequently during transition and are not a complication. (C) Contractions frequently last 60–90 seconds during the transitional phase of labor and are not considered a complication as long as the uterus relaxes completely between contractions. (D) Passage of meconium in a vertex presentation is a sign of fetal distress; this may be normal in a breech presentation owing to pressure on the presenting part. QUESTION 113 A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin. The nurse’s first intervention should be to: A. Check FHT B. Notify the attending physician C. Turn off the IV oxytocin D. Prepare for the delivery because the client is probably in transition Correct Answer: C Section: Question Set B Explanation Explanation/Reference: Explanation: (A)FHT should be monitored continuously with an induction of labor; this is an accepted standard of care. (B)The physician should be notified, but this is not the first intervention the nurse should do. (C) The standard of care for an induction according to the Association of Women’s Health, Obstetric, and Neonatal Nurses and American College of Obstetrics and Gynecology is that contractions should not exceed 60 seconds in an induction. Inductions should simulate normal labor; 70-second contractions during the latent phase (3 cm) are not the norm. The next contractions can be longer and increase risks to the mother and fetus. (D) Contractions lasting 60–90 seconds during transition are typical; this provides a good distractor. The nurse needs to be knowledgeable of the phases and stages of labor. QUESTION 114 During a client’s first postpartum day, the nurse assessed that the fundus was located laterally to the umbilicus. This may be due to: A. Endometritis B. Fibroid tumor on the uterus C. Displacement due to bowel distention D. Urine retention or a distended bladder Correct Answer: D Section: Question Set B Explanation Explanation/Reference: Explanation: (A, B) Endometritis, urine retention, or bladder distention provide good distractors because they may delay involution but do not usually cause the uterus to be lateral. (C) Bowel distention and constipation are common in the postpartum period but do not displace the uterus laterally. (D) Urine retention or bladder distention commonly displaces the uterus to the right and may delay involution. QUESTION 115 The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay? A. Pulse rate of 50–70 bpm by her third postpartum day B. Diuresis by her second or third postpartum day C. Vaginal discharge or rubra, serosa, then rubra D. Diaphoresis by her third postpartum day Correct Answer: C Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Bradycardia is an expected assessment during the postpartum period. (B) Diuresis can occur during labor and the postpartum period and is an expected physiological adaptation. (C) A return of rubra after the serosa period may indicate a postpartal complication. (D) Diaphoresis, especially at night, is an expected physiological change and does not indicate an infectious process. Bradycardia, diuresis, and diaphoresis are normal postpartum physiological responses to adjust the cardiac output and blood volume to the nonpregnant state. QUESTION 116 A postpartum client complains of rectal pressure and severe pain in her perineum; this may be absorption. (B) The pinch technique is the most effective method for obtaining skin tightness to allow easy entrance of the needle to subcutaneous tissues. (C) Massaging the site of injection facilitates absorption of the insulin. (D) Changing the needle will break the sterility of the system. It has become acceptable practice to reuse disposable needles and syringes for 3–7 days. QUESTION 119 In assessing the nature of the stool of a client who has cystic fibrosis, what would the nurse expect to see? A. Clay-colored stools B. Steatorrhea stools C. Dark brown stools D. Blood-tinged stools Correct Answer: B Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Clay-colored stools indicate dysfunction of the liver or biliary tract. (B) In the early stages of cystic fibrosis, fat absorption is primarily affected resulting in fat, foul, frothy, bulky stools. (C) Dark brown stools indicate normal passage through the colon. (D) Blood-tinged stools indicate dysfunction of the gastrointestinal (GI) tract. QUESTION 120 A group of nursing students at a local preschool day care center are going to screen each child’s fine and gross motor, language, and social skills. The students will use which one of the most widely used screening tests? A. Revised Prescreening Developmental Questionnaire B. Goodenough Draw-a-Person Screening Test C. Denver Development Screening Test D. Caldwell Home Inventory Correct Answer: C Section: Question Set B Explanation Explanation/Reference: Explanation: (A) The Revised Prescreening Developmental Questionnaire is more age appropriate and offers simplified parent scoring and easier comparison. It is used by parents instead of professionals. (B) The Goodenough Draw-a-Person test is used to assess intellectual development. (C) The Denver Developmental Screening Test is one of the most widely used screening tests. It offers a concise, easy-to-administer, systematic approach to assessing the preschool child. It is widely used because of its reliability and validity. (D) The Caldwell Home Inventory is used to assess the home environment in areas of social, emotional, and cognitive supports. QUESTION 121 A mother came to the pediatric clinic with her 17- month-old child. The mother would like to begin toilet training. What should the nurse teach her about implementing toilet training? A. Take two or three favorite toys with the child. B. Have a child-sized toilet seat or training potty on hand. C. Explain to the child she is going to “void” and “defecate.” D. Show disapproval if she does not void or defecate. Correct Answer: B Section: Question Set B Explanation Explanation/Reference: Explanation: (A)Giving her toys will distract her and interfere with toilet training because of inappropriate reinforcement. (B)A child-sized toilet seat or training potty gives a child a feeling of security. (C) She should use words that are age appropriate for the child. (D) Children should be praised for cooperative behavior and/or successful evacuation. QUESTION 122 A mother is unsure about the type of toys for her 17-month-old child. Based on knowledge of growth and development, what toy would the nurse suggest? A. A pull toy to encourage locomotion B. A mobile to improve hand-eye coordination C. A large toy with movable parts to improve pincer grasp D. Various large colored blocks to teach visual discrimination Correct Answer: A Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Increased locomotive skills make push-pull toys appropriate for the energetic toddler. (B) Infants progress from reflex activity through simple repetitive behaviors to imitative behavior. Hand-eye coordination forms the foundation of other movements. (C) At age 8 months, infants begin to have pincer grasp. Toys that help infants develop the pincer grasp are recommended for this age group. (D) Various large colored blocks are suggested toys for infants 6–12 months of age to help visual stimulation. QUESTION 123 A 16-year-old student has a long history of bronchial asthma and has experienced several severe asthmatic attacks during the school year. The school nurse is required to administer 0.2 mL of 1/1000 solution of epinephrine SC during an asthma attack. How does the school nurse evaluate the effectiveness of this intervention? A. Increased pulse rate B. Increased expectorate of secretions C. Decreased inspiratory difficulty D. Increased respiratory rate Correct Answer: C Section: Question Set B Explanation Explanation/Reference: Explanation: (A) A side effect of epinephrine is fatal ventricular fibrillation owing to its effects on cardiac stimulation. (B) Medications used to treat asthma are designed to decrease bronchospasm, not to increase expectorate of secretions. (C) Epinephrine decreased inspiratory difficulty by stimulating α-, β1, and β2-receptors causing sympathomimetic stimulation (e.g., bronchodilation). (D) The person with asthma fights to inspire sufficient air thus increasing respiratory rate. QUESTION 124 C. “Provide supplements for the child between breastfeeding so you will have enough milk.” D. “Wait 4 hours between feedings so that your breasts will fill up.” Correct Answer: B Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Solid foods introduced before 4–6 months of age are not compatible with the abilities of the GI tract and the nutritional needs of the infant. (B) Production of milk is supply and demand. A common growth spurt occurs at 3 months of age, and more frequent nursing will increase the milk supply to satisfy the infant. (C) Supplementation will decrease the infant’s appetite and in turn decrease the milk supply. When the infant nurses less often or with less vigor, the amount of milk produced decreases. (D) Rigid feeding schedules lead to a decreased milk supply, whereas frequent nursing signals the mother’s body to produce a correspondingly increased amount of milk. QUESTION 130 An 8-week-old infant has been diagnosed with gastroesophageal reflux. The nurse is teaching the infant’s mother to care for the infant at home. Which one of the following statements by the nurse is appropriate regarding the infant’s home care? A. “Lay the infant flat on her left side after feeding.” B. “Feed the infant every 4 hours with half-strength formula.” C. “Antacids need to be given an hour before feeding.” D. “Play activities should be carried out before instead of after feedings.” Correct Answer: D Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Elevating the child’s head to a 30-degree angle is the recommended position for gastroesophageal reflux. The supine position predisposes the child to aspiration. (B) Small, frequent feedings with thickened formula are recommended to minimize vomiting. (C) Antacids should be given at the same time as the feeding to improve their buffering action. (D) The infant should be kept still after feedings to reduce the risk of vomiting and aspiration. Vigorous activities should be carried out before feedings. QUESTION 131 The nurse is preparing a 6-year-old child for an IV insertion. Which one of the following statements by the nurse is appropriate when preparing a child for a potentially painful procedure? A. “Some say this feels like a pinch or a bug bite. You tell me what it feels like.” B. “This is going to hurt a lot; close your eyes and hold my hand.” C. “This is a terrible procedure, so don’t look.” D. “This will hurt only a little; try to be a big boy.” Correct Answer: A Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Educating the child about the pain may lessen anxiety. The child should be prepared for a potentially painful procedure but avoid suggesting pain. The nurse should allow the child his own sensory perception and evaluation of the procedure. (B) The nurse should avoid absolute descriptive statements and allow the child his own perception of the procedure. (C) The nurse should avoid evaluative statements or descriptions and give the child control in describing his reactions. (D) False statements regarding a painful procedure will cause a loss of trust between the child and the nurse. QUESTION 132 The nurse enters the playroom and finds an 8-year-old child having a grand mal seizure. Which one of the following actions should the nurse take? A. Place a tongue blade in the child’s mouth. B. Restrain the child so he will not injure himself. C. Go to the nurses station and call the physician. D. Move furniture out of the way and place a blanket under his head. Correct Answer: D Section: Question Set B Explanation Explanation/Reference: Explanation: (A) The nurse should not put anything in the child’s mouth during a seizure; this action could obstruct the airway. (B) Restraining the child’s movements could cause constrictive injury. (C) Staying with the child during a seizure provides protection and allows the nurse to observe the seizure activity. (D) The nurse should provide safety for the child by moving objects and protecting the head. QUESTION 133 A six-month-old infant is receiving ribavirin for the treatment of respiratory syncytial virus. Ribavirin is administered via which one of the following routes? A. Oral B. IM C. IV D. Aerosol Correct Answer: D Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Ribavirin is not supplied in an oral form. (B) Ribavirin is administered by aerosol in order to decrease the duration of viral shedding within the infected tissue. (C) Ribavirin is not approved for IV use to treat respiratory syncytial virus. (D) Ribavirin is a synthetic antiviral agent supplied as a crystalline powder that is reconstituted with sterile water. A Small Aerosol Particle Generator unit aerosolizes the medication for delivery by oxygen hood, croup tent, or aerosol mask. QUESTION 134 A 5-year-old child has suffered second-degree thermal burns over 30% of her body. Forty- eight hours after the burn injury, the nurse must begin to monitor the child for which one of the following complications? A. Fluid volume deficit B. Fluid volume excess C. Decreased cardiac output D. Severe hypotension Correct Answer: B Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Fluid volume deficit resulting from fluid shifts to the interstitial spaces occurs in the first 48 hours. (B) Forty-eight hours to 72 hours after the burn injury and fluid resuscitation, capillary permeability is restored and fluid requirements decrease. Interstitial fluid returns rapidly to the vascular compartment, and the nurse must monitor the child for signs and symptoms of hypervolemia. (C) Increased cardiac output results as fluids shift back to the vascular compartment. (D) Hypertension is the result of hypervolemia. QUESTION 135 Which one of the following is considered a reliable indicator for assessing the adequacy of fluid resuscitation in a 3-year-old child who suffered partial- and fullthickness burns to 25% of her body? A. Urine output B. Edema C. Hypertension D. Bulging fontanelle Correct Answer: A Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Urinary output is a reliable indicator of renal perfusion, which in turn indicates that fluid resuscitation is adequate. IV fluids are adjusted based on the urinary output of the child during fluid resuscitation. (B) Edema is an indication of increased capillary permeability following a burn injury. (C) Hypertension is an indicator of fluid volume excess. (D) Fontanelles close by 18 months of age. QUESTION 136 A 4-year-old child is being discharged from the hospital after being treated for severe croup. Which one of the following instructions should the nurse give to the child’s mother for the home treatment of croup? A. Take him in the bathroom, turn on the hot water, and close the door. B. Give him a dose of antihistamine. C. Give large amounts of clear liquids if drooling occurs. D. Place him near a cool mist vaporizer and encourage crying. Correct Answer: A Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Initial home treatment of croup includes placing the child in an environment of high humidity to liquefy and mobilize secretions. (B) Antihistamines should be avoided because they can cause thickening of secretions. (C) Drooling is a characteristic sign of airway obstruction and the child should be taken directly to the emergency room. (D) Crying increases respiratory distress and hypoxia in the child with croup. The nurse should promote methods that will calm the child. QUESTION 137 A 7-year-old child is brought to the ER at midnight by his mother after symptoms appeared abruptly. The nurse’s initial assessment reveals a temperature of 104.5◦F (40.3◦C), difficulty Section: Question Set B Explanation Explanation/Reference: Explanation: (A) A person in crisis needs support, assistance, and direction from a caregiver rather than just an instruction. (B) A battered person may feel guilt and think that they cause the abuser’s behavior; however, the abuser has the problem and goes through phases of violence. (C) The nurse should provide support and guidance to the client in crisis by offering alternatives and assist in referrals. (D) Focusing on help from law enforcement may be a very temporary solution, because the victim may be fearful of pressing charges. This answer does not address the crisis of going home. QUESTION 140 A 26-year-old client is in a treatment center for aprazolam (Xanax) abuse and continues to manifest moderate levels of anxiety 3 weeks into the rehabilitation program, often requesting medication for “his nerves.” Included in the client’s plan of care is to identify alternate methods of coping with stress and anxiety other than use of medication. After intervening with assistance in stress reduction techniques, identifying feelings and past coping, the nurse evaluates the outcome as being met if: A. Client promises that he will not abuse aprazolam after discharge B. Client demonstrates use of exercise or physical activity to handle nervous energy following conflicts of everyday life C. Client is able to verbalize effects of substance abuse on the body D. Client has remained substance free during hospitalization and is discharged Correct Answer: B Section: Question Set B Explanation Explanation/Reference: Explanation: (A) This client response does not address stress reduction techniques. Verbal response focuses only on the problem. (B) Exercise or physical activity is a common strategy or coping technique used to reduce stress and anxiety. (C) Verbalizing effects of substance abuse on the body may help with insight and break through denial, but it is not a strategy to reduce anxiety. (D)Remaining substance-free does indicate motivation to change lifestyle of substance abuse or dependence, and it is not a stress reduction strategy in itself. QUESTION 141 A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self- mutilation. A few hours after admission, she requests special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room. The nurse should respond to this behavior by: A. Placing her in seclusion until the behavior is under control B. Walking up to the client and touching her on the arm to get her attention C. Communicating a desire to assist the client to regain control, offering a one-to-one session in a quiet area D. Confronting the client, letting her know the consequences for getting angry and disrupting the unit Correct Answer: C Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Threatening a client with punitive action is violating a client’s rights and could escalate the client’s anger. (B) Angry clients need respect for personal space, and physical contact may be perceived as a threatening gesture escalating anger. (C) Client lacks sufficient self- control to limit own maladaptive behavior; she may need assistance from staff. (D) Confronting an angry client may escalate her anger to further acting out, and consequences are for acting out anger aggressively, not for getting angry or feeling angry. QUESTION 142 A 56-year-old client is admitted to the psychiatric unit in a state of total despair. She feels hopeless and worthless, has a flat affect and very sad appearance, and is unable to feel pleasure from anything. Her husband has been assisting her at home with the housework and cooking; however, she has not been eating much, lies around or sits in a chair most of the day, and is becoming confused and thinks her family does not want her around anymore. In assessing the client, the nurse determines that her behavior is consistent with: A. Transient depression B. Mild depression C. Moderate depression D. Severe depression Correct Answer: D Section: Question Set B Explanation Explanation/Reference: Explanation: (A) Transient depression manifests as sadness or the “blues” as seen with everyday disappointments and is not necessarily dysfunctional. (B) Mild depression manifests as symptoms seen with grief response, such as denial, sadness, withdrawal, somatic symptoms, and frequent or continuous thoughts of the loss. (C) Moderate depression manifests as feelings of sadness, negativism; low self-esteem; rumination about life’s failures; decreased interest in grooming and eating; and possibly sleep disturbances. These symptoms are consistent with dysthymia. (D) Severe depression manifests as feelings of total despair, hopelessness, emptiness, inability to feel pleasure; possibly extreme psychomotor retardation; inattention to hygiene; delusional thinking; confusion; self-blame; and suicidal thoughts. These symptoms are consistent with major depression. QUESTION 143 A 56-year-old psychiatric inpatient has had recurring episodes of depression and chronic low self-esteem. She feels that her family does not want her around, experiences a sense of helplessness, and has a negative view of herself. To assist the client in focusing on her strengths and positive traits, a strategy used by the nurse would be to: A. Tell the client to attend all structured activities on the unit B. Encourage or direct client to attend activities that offer simple methods to attain success C. Increase the client’s self-esteem by asking that she make all decisions regarding attendance in group activities D. Not allow any dependent behaviors by the client because she must learn independence and will have to ask for any assistance from staff Correct Answer: B Section: Question Set B Explanation Explanation/Reference: Explanation: (A) The nurse should encourage activities gradually, as client’s energy level and tolerance for shared activities improve. (B) Activities that focus on strengths and accomplishments, with uncomplicated tasks, minimize failure and increase self-worth. (C) Asking a client to set a goal to make all decisions about attending group activities is unrealistic, and such decisions are not always under the client’s control; this sets up the client for further failure and possibly decreased self-worth. (D) Encouragement toward independence does promote increased feelings of selfworth; however, clients may need assistance with (A) Impaired communication refers to decreased ability or inability to use or understand language in an interaction. (B) In sensory-perceptual alterations an individual has distorted, impaired, or exaggerated responses to incoming stimuli (i.e., a hallucination, which is a false sensory perception that is not associated with real external stimuli). (C) An altered thought processes problem statement is used when an individual experiences a disruption in cognitive operations and activities (i.e., delusions, loose associations, ideas of reference). (D) In impaired social interaction, the individual participates too little or too much in social interactions. QUESTION 149 A schizophrenic client who is experiencing thoughts of having special powers states that “I am a messenger from another planet and can rule the earth.” The nurse assesses this behavior as: A. Ideas of reference B. Delusions of persecution C. Thought broadcasting D. Delusions of grandeur Correct Answer: D Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) Clients experiencing ideas of reference believe that information from the environment (e.g., the television) is referring to them. (B) Clients experiencing delusions of persecution believe that others in the environment are plotting against them. (C) Clients experiencing thought broadcasting perceive that others can hear their thoughts. (D) Clients experiencing delusions of grandeur think that they are omnipotent and have superhuman powers. QUESTION 150 A client experiencing delusions states, “I came here because there were people surrounding my house that wanted to take me away and use my body for science.” The best response by the nurse would be: A. “Describe the people surrounding your house that want to take you away.” B. “I need more information on why you think others want to use your body for science.” C. “There were no people surrounding your house, your relatives brought you here, and no one really wants your body for science.” D. “I know that must be frightening for you; let the staff know when you are having thoughts that trouble you.” Correct Answer: D Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) Focusing on the delusional content does not reinforce reality. (B) Pursuing details or more information on the delusion reinforces the false belief and further distances the client from reality. (C) Challenging the client’s delusional system may force the client to defend it, and you cannot change the delusion through logic. (D) Focusing on the feeling can reinforce reality and discourage the false belief. Seeking out staff when thoughts are troublesome can help to decrease anxiety. QUESTION 151 A 16-year-old client with anorexia nervosa is on an inpatient psychiatric unit. She has a fear of gaining weight and is refusing to eat sufficient amounts to maintain body weight for her age, height, and stature. To assist with the problem of powerlessness and plan for the client to no longer need to withhold food to feel in control, the nurse uses the following strategy: A. Establish a structured environment with routine tasks and activities. Also, serve meals at the same time each day. B. Distract the client during meals to get her to eat because she must take in sufficient amounts to keep from starving. C. Do frequent room checks to be sure that the client is not hiding food or throwing it away. D. Listen attentively and participate in in-depth discussions about food, because these actions may encourage her to eat. Correct Answer: A Section: Questions Set C Explanation Explanation/Reference: Explanation: (A)Anorexia nervosa clients feel out of control. Providing a structured environment offers safety and comfort and can help them to develop internal control, thus reducing their need to control by self-starvation. (B) Distraction does not focus on the client’s need for control. (C) Doing frequent room checks reinforces feelings of powerlessness and the need to continue with the dysfunctional behavior. (D) Participating in long discussions about food does not make the client want to eat, but rather this strategy allows her to indulge in her preoccupation and to continue with the dysfunctional behavior. QUESTION 152 A 45-year-old male client was admitted to a chemical dependency treatment center following legal problems related to alcohol abuse. He states, “I know that alcohol is a problem for some people, but I can stop whenever I want to. I’m never sick or miss work, and no one can complain about me.” During the initial assessment, the best response by the nurse would be: A. “The fact is you are an alcoholic or you wouldn’t be here.” B. “I understand it took strength to admit yourself to the unit, and I will do my part to help you to stay alcohol- free.” C. “If you can stop drinking when you want to, why don’t you stop?” D. “It’s good that you can stop drinking when you want to.” Correct Answer: B Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) Direct confrontation initially is nontherapeutic and may result in the client becoming frustrated and wanting to leave. (B) A positive, supportive attitude builds trust, and identifying positive strength raises self- esteem. Offering help allows the client to feel that he is not alone in dealing with problems. (C) Asking the client why or to give an explanation for his behavior puts him in a position of having to justify his behavior to the nurse. (D) Giving approval or placing a value on feelings or a behavior may limit the client’s freedom to behave in a way that may displease another. This response may lead to seeking praise instead of progress. QUESTION 153 A 79-year-old client with Alzheimer’s disease is exhibiting significant memory impairment, cognitive impairment, extremely impaired judgment in social situations, and agitation when placed in a new situation or around unfamiliar people. The nurse should include the following strategy in the client’s care: A. Maintain routines and usual structure and adhere to schedules. B. Encourage the client to attend all structured activities on the unit, whether she wants to or not. Explanation/Reference: Explanation: (A) Ceasing to use humor and sarcasm is a more appropriate goal, because this client uses these behaviors covertly to express aggression instead of being open with anger. (B) Use of “I” messages demonstrates proper use of assertive behavior to express anger instead of passive-aggressive behavior. (C) Client is expected to complete share of work in therapeutic community because he has often obstructed other’s efforts by failing to do his share. (D) Client has used conveniently forgetting or withholding information as a passive-aggressive behavior, which is not acceptable. QUESTION 156 A client calls the prenatal clinic to schedule an appointment. She states she has missed three menstrual periods and thinks she might be pregnant. During her first visit to the prenatal clinic, it is confirmed that she is pregnant. The registered nurse (RN) learns that her last menstrual period began on June 10. According to Nägele’s rule, the estimated date of confinement is: A. March 17 B. June 3 C. August 30 D. January 10 Correct Answer: A Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) Using Nägele’s rule, count back 3 calendar months from the first day of the last menstrual period. The answer is March 10. Then add 7 days and 1 year, which would be March 17 of the following year. (B, C, D) This date is incorrect. QUESTION 157 At 16 weeks’ gestation, a pregnant client is admitted to the maternity unit to have a McDonald procedure (cerclage) done. She tells the RN who is admitting her to the unit that her physician had explained what this procedure was, but that she did not understand. The RN explains to the client that the purpose for this procedure is to: A. Reinforce an incompetent cervix B. Repair the amniotic sac C. Evaluate cephalopelvic disproportion D. Dilate the cervix Correct Answer: A Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) The treatment most commonly uses the Shirodkar-Barter procedure (McDonald procedure) or cerclage to enforce the weakened cervix by encircling it with a suture at the level of the internal os. (B) There is no known procedure that is used to repair the amniotic sac. (C) Cephalopelvic disproportion is evaluated later in pregnancy. It is not related to this procedure. (D) No procedure is done to dilate the cervix at 16 weeks’ gestation unless the pregnancy is to be terminated. QUESTION 158 A pregnant client continues to visit the clinic regularly during her pregnancy. During one of her visits while lying supine on the examining table, she tells the RN that she is becoming light-headed. The RN notices that the client has pallor in her face and is perspiring profusely. The first intervention the RN should initiate is to: A. Place the examining table in the Trendelenburg position B. Assess the client to see if she is having vaginal bleeding C. Obtain the client’s vital signs immediately D. Help the client to a sitting position Correct Answer: D Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) This position would cause the gravid uterus to bear the increased pressure of the vena cava, which could lead to maternal hypotension, in turn causing the client to continue to have pallor and to feel light- headed. (B) This would not be the first intervention the RN should initiate. TheRN should understand the supine position and its effect on the gravid uterus and vena cava. (C) The RN’s first intervention should be one that helps to alleviate the client’s symptoms. Obtaining her vital signs will not alleviate her symptoms. (D) This would move the gravid uterus off of the client’s vena cava, which would alleviate the maternal hypotension that is the cause of her symptoms. QUESTION 159 At 30 weeks’ gestation, a client is admitted to the unit in premature labor. Her contractions are every 5 minutes and last 60 seconds, her cervix is closed, and the suture placed around her cervix during her 16th week of gestation, when she had the MacDonald procedure, can still be felt by the physician. The amniotic sac is still intact. She is very concerned about delivering prematurely. She asks the RN, “What is the greatest risk to my baby if it is born prematurely?” The RN’s answer should be: A. Hyperglycemia B. Hypoglycemia C. Lack of development of the intestines D. Lack of development of the lungs Correct Answer: D Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) Any infant would be at risk for hyperglycemia because the infant’s liver is missing the islets of Langerhans, which secrete insulin to break down glucose for cellular use. Prematurity is not an added risk for hyperglycemia. (B) Both premature and mature infants can be at risk for hypoglycemia if their mother had gestational diabetes during pregnancy or entered the pregnancy with diabetes mellitus. These infants are exposed to high levels of maternal glucose while in utero, which causes the islets of Langerhans in the infant’s liver to produce insulin. After birth when the umbilical cord is severed, the generous amount of maternal blood glucose is eliminated; however, there is continued islet cell hyperactivity in the infant’s liver, which can lead to excessive insulin levels and depleted blood glucose. (C) Mature infants are born with an immature GI system. The nervous control of the stomach is incomplete at birth, salivary glands are immature at birth, and the intestinal tract is sterile. This is not the greatest risk to the premature infant. (D) Infants born before 37 weeks’ gestation are at greatest risk for an insufficient amount of surfactant in the alveoli system of the lungs. Surfactant helps to prevent lung collapse and ensures stability of the respiratory system so that the infant can maintain his own respirations once the umbilical cord is severed at birth. QUESTION 160 At 30 weeks’ gestation, a client is admitted to the unit in premature labor. Her physician orders that an IV be started with 500 mL D5W mixed with 150 mg of ritodrine stat. The RN prepares the IV solution with the medication. The RN knows that clients receiving the medication ritodrine IV should be observed closely for which one of the following side Explanation: (A) A nonstress test that shows at least two accelerations of the fetal heart rate of 15 bpm with fetal activity, lasting ≥15 seconds over a 20-minute period. (B) Reactive criteria are not met. The accelerations of the fetal heart rate are not at least 15 bpm and do not last 15 seconds. This could mean fetal well-being is compromised. Usually a contraction stress test is ordered if the nonstress test results are negative. (C) An unsatisfactory test means the data cannot be interpreted, or there was inadequate fetal activity. If this happens, usually the test is ordered to be done at a later date. (D) A negative test is a term used to describe the results of a contraction stress test. QUESTION 163 At 38 weeks’ gestation, a client is in active labor. She is using her Lamaze breathing techniques. The RN is coaching her breathing and encouraging her to relax and work with her contractions. Which one of the following complaints by the client will alert the RN that she is beginning to hyperventilate with her breathing? A. “I am cold.” B. “I have a backache.” C. “I feel dizzy.” D. “I am nauseous.” Correct Answer: C Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) Cold is not a symptom of hyperventilation. This could be due to the temperature of the room. (B) Backache is not a symptom of hyperventilation. This is probably due to the gravid uterus and its effect on the back muscles, or it may be due to the client’s position in bed. (C) Dizziness is the first symptom of hyperventilation. It occurs because the body is eliminating too much CO2. (D) Nausea is not a symptom of hyperventilation. It could be a symptom of pain. QUESTION 164 After performing a sterile vaginal exam on a client who has just been admitted to the unit in active labor and placed on an electronic fetal monitor, the RN assesses that the fetal head is at 21 station. She documents this on the monitor strip. Fetal head at 21 station means that the fetal head is located where in the pelvis? A. One centimeter below the ischial spines B. One centimeter above the ischial spines C. Has not entered the pelvic inlet yet D. Located in the pelvic outlet Correct Answer: B Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) The ischial spines are located on both sides of the midpelvis. These spines mark the diameter of the narrowest part of the pelvis that the fetus will encounter. They are not sharp protrusions that will harm the fetus. Station refers to the relationship between the ischial spines in the pelvis and the fetus. The ischial spines are designated at 0 station. If the presenting part of the fetus is located above the ischial spines, a negative number is assigned, noting the number of centimeters above the ischial spines. Therefore, 1 centimeter below the ischial spines is designated as +1 station. (B) See explanation in A. One centimeter above the ischial spines is designated as +1 station. (C) The pelvic inlet is the first part of the pelvis that the fetus enters in routine delivery. The midpelvis is the second part of the pelvis to be entered by the fetus. The ischial spines are located on both sides of the midpelvis. (D) The pelvic outlet is the last part of the pelvis that the fetus will enter. When the fetus reaches this part of the pelvis, birth is near. QUESTION 165 A client has been admitted to the labor and delivery unit in active labor. After assessing her, the RN notes that the client’s fetus position is left occipital posterior. Which of the following statements best describes what this means to the labor process: A. Decreases the overall time of the labor process B. Prolongs the client’s first stage of labor C. Decreases the time of the client’s first stage of labor D. Prolongs the client’s third stage of labor Correct Answer: B Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) Posterior position causes a larger diameter of the fetal head to enter the pelvis than an anterior position. Pressure on the sacral nerves is increased, and it takes the fetus a longer time to enter the pelvic inlet. (B) This position will prolong the first stage of labor. When the larger diameter of the fetal head enters the pelvis first, it will have a more difficult time accommodating to the pelvis; therefore, it will take a longer time for the fetus to move through the pelvis. (C) It will increase the time of labor because the larger diameter of the fetal head will have a more difficult time accommodating to the pelvic inlet and thus will move through the pelvis slower. (D) In the third stage of labor the placenta is delivered; therefore, the infant has been delivered. QUESTION 166 A client is in active labor and has been admitted to the labor and delivery unit. The RN has just done a sterile vaginal exam and determines that the client is dilated 5 cm, effaced 85%, and the fetus’s head is at 0 station. She asks if she could have a lumbar epidural now. The epidural is started, and the anesthetic agent used is bupivacaine (Marcaine). After the client has received her lumbar epidural, it is important for the RN to monitor her for which of the following side effects: A. Hypertension B. Hypotension C. Hypoglycemia D. Hyperglycemia Correct Answer: B Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) The medication bupivacaine will cause vasodilation in the vascular system, and this does not result in elevation of the ma-ternal blood pressure. (B) The medication bupivacaine will cause vasodilation in the vascular system, and this will result in lowering the maternal blood pressure. (C) Bupivacaine does not interfere with the functioning of the endocrine system. (D) Bupivacaine does not interfere with the functioning of the endocrine system. QUESTION 167 A client has been in labor for 10 hours. Her contractions have become hypoactive and slowed in duration. The fetus is at 0 station, cervix is dilated 8 cm and effaced 90%. The physician orders an oxytocin (Pitocin) infusion to be started at once. The RN begins the oxytocin infusion. It is important that the RN discontinue the infusion if which one of the following occur? A. The client’s contractions are <2 minutes apart. B. Duration of the contractions are 60 seconds. C. The uterus relaxes between contractions. D. The client complains that she is tired. Correct Answer: A Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) It is very important that there is a resting phase or relaxation period between the contractions. During this period, the uterus, placenta, and umbilical vessels re-establish blood flow. No resting phase between contractions can lead to fetal bradycardia, fetal hypoxia, and acidosis. It can also result in a tetanic contraction, which can cause uterine rupture. (B) The goal of the oxytocin infusion is to help establish a contraction pattern lasting 45–60 seconds occurring every 2 minutes and a uterine tonus of 60–70 mm Hg. (C) This choice is correct. The uterus has time to recover from the contraction. (D) The client’s tiring is no indication to stop the infusion. She will be tired even without the infusion. QUESTION 168 The client has been in active labor for the last 12 hours. During the last 3 hours, labor has been augmented with oxytocin because of hypoactive uterine contractions. Her physician assesses her cervix as 95% effaced, 8 cm dilated, and the fetus is at 0 station. Her oral temperature is 100.2F at this time. The physician orders that she be prepared for a cesarean delivery. In preparing the client for the cesarean delivery, which one of the following physician’s orders should the RN question? A. Administer meperidine (Demerol) 100 mg IM 1 hour prior to the delivery. B. Discontinue the oxytocin infusion. C. Insert an indwelling Foley catheter prior to delivery. D. Prepare abdominal area from below the nipples to below the symphysis pubis area. Correct Answer: A Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) Meperidine is a narcotic analgesic medication that crosses the placental barrier and reaches the fetus, causing respiratory depression in the fetus. A narcotic medication should never be included in the preoperative order for a cesarean delivery. (B) Oxytocin infusion would be discontinued if client is being prepared for a cesarean delivery because the medication would not be needed. (C) The bladder is always emptied prior to and during the surgical intervention to prevent the urinary bladder from accidentally being incised while the uterine incision is made. (D) The abdominal area is always prepared to rid the area of hair before the abdominal incision is made. Abdominal hair cannot be sterilized and could become a source for postoperative incisional infection. QUESTION 169 After an infant is delivered by cesarean delivery and placed on the warmer, the RN dries and assesses the infant. At 1 and 5 minutes after birth, the RN does the Apgar scoring of the infant. The RN knows that because this infant was delivered by cesarean section, he is at increased risk for having which one of the following: A. Cold stress B. Cyanosis C. Respiratory distress syndrome D. Seizures over the bottom leg, and the RN raises the upper buttocks to fully expose the perineum and anus. (B) Fowler’s position is a sitting position, and the perineum and anus would not be exposed. (C) The prone position would have the mother on her back, and her perineum and anus would not be exposed. (D) The position of choice should always be the Sims’. QUESTION 172 While the RN is assessing a mother’s perineum on her 2nd postpartum day after having a vaginal delivery, the RN notes a large ecchymotic area located to the left of the mother’s perineum. Which one of the following interventions should the RN initiate at this time? A. Have the client expose the area to air. B. Apply ice to the perineum. C. Encourage the client to take warm sitz baths. D. Inform the physician. Correct Answer: C Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) The area is bruised and painful. This action would do nothing to help with the healing process of the perineum or to provide comfort. (B) Ice is effective immediately after birth to reduce edema and discomfort, but not on the 2nd postpartum day. (C) Sitz baths are useful if the perineum has been traumatized, because the moist heat increases circulation to the area to promote healing, relaxes tissue, and decreases edema. (D) The physician is not notified of bruising, but if a hematoma is present, then the physician is notified. QUESTION 173 A mother who is breast-feeding her newborn asks the RN, “How can I express milk from my breasts manually?” The RN tells her that the correct method for manual milk expression includes using the thumb and the index finger to: A. Alternately compress and release each nipple B. Roll the nipple and gently pull the nipple forward C. Slide the thumb and index finger forward from the outer border of the areola toward the end of the nipple D. Compress and release each breast at the outer border of the areola Correct Answer: D Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) Manipulation of nipples will cause soreness and trauma. (B) Pulling the nipples will cause discomfort and soreness. (C) Sliding the thumb and index finger forward over the nipple will cause soreness. (D) The best method to express milk from the breast is to position the thumb and index finger at the outer border of the areola and compress. This is the location of the milk sinuses. QUESTION 174 A client had a vaginal delivery 3 days ago and is discharged from the hospital on the 2nd day postpartum. She told the RN, “I need to start exercising so that I can get back into shape. Could you suggest an exercise I could begin with?’’ The RN could suggest which one of the following? A. Push-ups B. Jumping jacks C. Leg lifts D. Kegel exercises Correct Answer: D Section: Questions Set C Explanation Explanation/Reference: Explanation: (A, B, C) This exercise is too strenuous at this time. (D) This exercise is recommended for the first few days after delivery. It helps to stimulate muscle tonus in the area of the perineum and the area around the urinary meatus and vagina. QUESTION 175 A 60-year-old male client was hospitalized 3 days ago with the diagnosis of acute anterior wall myocardial infarction. Today he has been complaining of increasing weakness and shortness of breath. Crackles in both lung bases are audible on auscultation. He is developing: A. An extension of his myocardial infarction B. Pneumonia C. Pulmonary edema D. Pulmonary emboli Correct Answer: C Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) Extensions of his myocardial infarction would be chest pain unrelieved with nitroglycerin, cardiac enzyme elevations, and electrocardiographic changes. (B) Persons with pneumonia may complain of weakness and shortness of breath and have crackles in their lung bases. However, they would also have sputum production and leukocytosis. (C) Persons who have had myocardial infarctions (especially anterior wall) are at risk of developing left ventricular heart failure, which is a major cause of pulmonary edema. Pulmonary edema is manifest by shortness of breath, weakness, and crackles on auscultation of the lung fields. (D) Pulmonary emboli may be accompanied by shortness of breath, weakness, and crackles. However, the pulmonary hypertension that accompanies pulmonary emboli results in signs of increased systemic venous pressure as well. QUESTION 176 On admission, the client has signs and symptoms of pulmonary edema. The nurse places the client in the most appropriate position for a client in pulmonary edema, which is: A. High Fowler B. Lying on the left side C. Sitting in a chair D. Supine with feet elevated Correct Answer: A Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) High Fowler position decreases venous return to the heart and permits greater lung expansion so that oxygenation is maximized. (B) Lying on the left side may improve perfusion to the left lung but does not promote lung expansion. (C) Sitting in a chair will decrease venous return and promote maximal lung expansion. However, clients with pulmonary edema can deteriorate quickly and require intubation and mechanical ventilation. If a client is sitting in achair when this deterioration happens, it will be difficult to intervene quickly. (D) The supine with feet elevated position increases venous return and will worsen pulmonary edema. QUESTION 177 A male client has been hospitalized with congestive heart failure. Medical management of heart failure focuses on improving myocardial contractility. This can be achieved by administering: A. Digoxin (Lanoxin) 0.25 mg po every day B. Furosemide (Lasix) 40 mg po every morning C. O22 L/min via nasal cannula D. Nitroglycerin (Nitrol) 1 inch topically every 4 hours Correct Answer: A Section: Questions Set C Explanation Explanation/Reference: Explanation: (A)Digoxin is a cardiac glycoside given to clients in heart failure to improve their myocardial contractility. (B)Furosemide is a loop diuretic given to clients in heart failure to promote diuresis. (C) O2is given to clients in heart failure to increase oxygenation and to prevent or treat hypoxemia. (D) Nitroglycerin is a nitrate given to clients in heart failure to increase their cardiac output by decreasing the peripheral resistance that the left ventricle must pump against. QUESTION 178 A client’s congestive heart failure has been treated, and he will soon be discharged. Discharge teaching should include instruction to call the physician if he notices a 2-lb weight gain in a 24-hour period. Increased weight gain may indicate: A. A diet too high in calories and saturated fat B. Decreasing cardiac output C. Decreasing renal function D. Development of diabetes insipidus Correct Answer: B Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) Increased calories may result in weight gain, but there is no indication in this question that this man’s diet has changed in a way that would result in increased calories. (B) Decreasing cardiac output stimulates the renin-angiotensin-aldosterone cycle and results in fluid retention, which is reflected by weight gain. (C) Decreasing renal function may result in fluid retention, but this question gives no indication that this man has any renal problems. (D) Profound diuresis occurs with diabetes insipidus, which results in weight loss. QUESTION 179 A client was not using his seat belt when involved in a car accident. He fractured ribs 5, 6, and 7 on the left and developed a left pneumothorax. Assessment findings include: A. Crackles and paradoxical chest wall movement B. Decreased breath sounds on the left and chest pain with movement (A) Pneumonia may be reflected by patchy infiltrates. In addition, fever, an increasing white blood cell count, and copious sputum production would be present. (B) Blunt chest traumacauses a bruising process in which interstitial and alveolar edema and hemorrhage occur. This is manifest by gradual deterioration over 24 hours of arterial blood gases and the continued production of bloody sputum. Patchy infiltrates are evident on chest xray 24 hours postinjury. (C) Pulmonary edema usually results from left heart failure. It is manifest by pink, frothy sputum; increasing dyspnea; tachycardia; and crackles on auscultation. (D) Tension pneumothorax is a potential complication for someone with rib fractures and a chest tube. It is manifest by diminished breath sounds on the affected side, rapidly deteriorating arterial blood gases in the presence of an open airway, and shock that is unexplained by other injuries. QUESTION 182 A 66-year-old female client has smoked 2 packs of cigarettes per day for 20 years. Her arterial blood gases on room air are as follows: pH 7.35; PO2 70 mm Hg; PCO2 55 mm Hg; HCO3 32 mEq/L. These blood gases reflect: A. Compensated metabolic acidosis B. Compensated respiratory acidosis C. Compensated respiratory alkalosis D. Uncompensated respiratory acidosis Correct Answer: B Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) In compensated metabolic acidosis, the pH level is normal, the PCO2level is decreased, and the HCO3level is decreased. The client’s primary alteration is an inability to remove excess acid via the kidneys. The lungs compensate by hyperventilating and decreasing PCO2. (B) In compensated respiratory acidosis, the pH level is normal, the PCO2level is elevated, and the HCO3level is elevated. The client’s primary alteration is an inability to remove CO2from the lungs, so over time, the kidneys increase reabsorption of HCO3to buffer the CO2. (C) In compensated respiratory alkalosis, the pH level is normal, the PCO2level is decreased, and the HCO3level is decreased. The client’s primary alteration is hyperventilation, which decreases PCO2. The client compensates by increasing the excretion of HCO3from the body. (D) In uncompensated respiratory acidosis, the pH level is decreased, the PCO2level is increased, and the HCO3level is normal. The client’s primary alteration is an inability to remove CO2from the lungs. The kidneys have not compensated by increasing HCO3reabsorption. QUESTION 183 A female client who has chronic obstructive pulmonary disease (COPD) has presented in the emergency department with cough productive of yellow sputum and increasing shortness of breath. On room air, her blood gases are as follows: pH 7.30 mm Hg, PCO2 60 mm Hg, PO2 55 mm Hg, HCO3 32 mEq/L. These arterial blood gases reflect: A. Compensated respiratory acidosis B. Normal blood gases C. Uncompensated metabolic acidosis D. Uncompensated respiratory acidosis Correct Answer: D Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) In compensated respiratory acidosis, the pH level is normal, the PCO2level is elevated, and the HCO3level is elevated. The client’s primary alteration is an inability to remove CO2from the lungs, so over time, the kidneys increase reabsorption of HCO3to buffer the CO2. (B) Normal ranges for arterial blood gases for adults and children are as follows: pH 7.35–7.45, PO280–100 mm Hg, PCO235–45 mm Hg, HCO321–28 mEq/L. (C) In uncompensated metabolic acidosis the pH level is decreased, the PCO2level is normal, and the HCO3level is decreased. The client’s primary alteration is an inability to remove excess acid via the kidneys. The lungs are unable to clear the increased acid. (D) In uncompensated respiratory acidosis, the pH level is decreased, the PCO2level is increased, and the HCO3level is normal. In a person with long-standing COPD, the HCO3level will rise gradually over time to compensate for the gradually increasing PCO2, and the person’s pH level will be normal. When a person with COPD becomes acutely ill, the kidneys do not have time to increase the reabsorption of HCO3, so the person’s pH level will reflect acidosis even though the HCO3is elevated. QUESTION 184 A 19-year-old client has sustained a C-7 fracture, which resulted in his spinal cord being partially transected. By 2 weeks’ postinjury, his neck has been surgically stabilized, and he has been transferred from the intensive care unit. A potential life-threatening complication the nurse monitors the client for is: A. Autonomic dysreflexia B. Bradycardia C. Central cord syndrome D. Spinal shock Correct Answer: A Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) Autonomic dysreflexia is the exaggerated sympathetic nervous system response to various stimuli in the anesthetized area. Sympathetic stimulation results in severe, uncontrolled hypertension, which may result in myocardial infarction or cerebral hemorrhage. (B) Bradycardia occurs as a result of sympathetic blockade in the immediate postinjury period. After spinal shock recedes, cardiovascular stability returns, but the client will be bradycardiac for life. (C) Central cord syndrome is a specific type of spinal cord injury that occurs as a result of either hyperextension injuries or disrupted blood flow to the spinal cord. (D) Spinal shock occurs in the immediate postinjury phase and usually resolves in approximately 72 hours. QUESTION 185 A 17-year-old client has a T-4 spinal cord injury. At present, he is learning to catheterize himself. When he says, “This is too much trouble. I would rather just have a Foley.’’ An appropriate response for the RN teaching him would be: A. “I know. It is a lot to learn. In the long run, though, you will be able to reduce infections if you do an intermittent catheterization program.’’ B. “It is not too much trouble. This is the best way to manage urination.’’ C. “OK. I’ll ask your physician if we can replace the Foley.’’ D. “You need to learn this because your doctor ordered it.’’ Correct Answer: A Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) This response acknowledges the client’s feelings, gives him factual information, and acknowledges that the final decision is his. (B) This response is judgmental and discourages the client from expressing his feelings about the procedure. (C) Catheterization is a procedure thattakes time to learn, but which, for the spinal cord–injured client, can significantly reduce the incidence of urinary tract infections. A young client with a T-4 injury has the hand function to learn this procedure fairly easily. (D) The final decision about bladder elimination management ultimately rests with the client and not the physician. for air bubbles when the tip is held under water is an unreliable means to determine correct tube placement for all types of nasogastric tubes. Air may come from both the respiratory tract and the stomach, and the client who is breathing shallowly may not force air out of the tube into the water. QUESTION 191 A 70-year-old client is almost finished receiving her second unit of packed red blood cells. The client, who weighs 80 lb, has started complaining of being short of breath and now has crackles in the bases of her lungs. After slowing or stopping the transfusion, the most appropriate initial nursing action would be to: A. Raise the client’s head and place her feet in a dependent position B. Notify the physician C. Place the client on 2 liters of O2 via nasal cannula D. Administer furosemide (Lasix) 20 mg IV push Correct Answer: A Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) Raising the client’s head and placing her feet in a dependent position is an independent nursing action that can be taken to decrease venous return and to reduce pulmonary congestion. (B) Notifying the physician is an appropriate action that should be taken after the client is positioned to maximize her respiratory status. (C) Placing the client on O2may be done with a physician’s order or according to an institution’s standing orders; however, other actions should be taken first. (D) Furosemide 20 mg IV push is an appropriate medication for the client, but it must be ordered by her physician. QUESTION 192 A 52-year-old client’s abdominal aortic aneurysm ruptured. She received rapid massive blood transfusions for bleeding. One potential complication of blood administration for which she is especially at risk is: A. Air embolus B. Circulatory overload C. Hypocalcemia D. Hypokalemia Correct Answer: C Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) Air embolism is a potential complication of blood administration, but it is fairly rare and can be prevented by using good IV technique. (B) Circulatory overload is a potential complication of blood administration, but because this client is actively bleeding, she is not at high risk for overload. (C) Hypocalcemia is a potential complication of blood administration that occurs in situations where massive transfusion has occurred over a short period of time. It occurs because the citrate in stored blood binds with the client’s calcium. Another potential complication for which this client is especially at risk is hypothermia, which can be prevented by using a blood warmer to administer the blood. (D) Hypokalemia is not a complication of blood administration. QUESTION 193 A 67-year-old client will be undergoing a coronary arteriography in the morning. Client teaching about postprocedure nursing care should include that: A. Bed rest with bathroom privileges will be ordered B. He will be kept NPO for 8–12 hours C. Some oozing of blood at the arterial puncture site is normal D. The leg used for arterial puncture should be keptstraight for 8–12 hours Correct Answer: D Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) Bed rest will be ordered for 8–12 hours postprocedure. Flexing of the leg at the arterial puncture site will occur if the client gets out of bed, and this is contraindicated after arteriography. (B) The client will be able to eat as soon as he is alert enough to swallow safely and that will depend on what medications areused for sedation during the procedure. (C) Oozing at the arterial puncture site is not normal and should be closely evaluated. (D) The leg where the arterial puncture occurred must be kept straight for 8–12 hours to minimize the risk of bleeding. QUESTION 194 A client had a myocardial infarction 5 days ago. His physician has ordered an echocardiogram to determine how his myocardial infarction has affected his ventricular wall motion. When the client asks if this test is painful, an appropriate response is: A. “No, but you must be able to ride on a stationary bicycle while the test is being performed.” B. “No, but you will have to lie still and the gel that is used may be cool.” C. “Yes, but your physician will be there and will order pain medicine for you.” D. “Your physician has ordered medicine, which you will be given before you go for the test, which will make you sleepy.” Correct Answer: B Section: Questions Set C Explanation Explanation/Reference: Explanation: (A) Riding a stationary bicycle or walking on a treadmill is done during a stress test. (B) During an echocardiogram, the client must lie supine while a technician performs the test. To perform the test, the technician uses a conductive gel and a transducer to obtain ultrasound tracings of the heart. (C) A physician need not be present during an echocardiogram, and it is neither invasive nor painful. (D) There is no premedication required for an echocardiogram. QUESTION 195 A 55-year-old man has recently been diagnosed with hypertension. His physician orders a low-sodium diet for him. When he asks, “What does salt have to do with high blood pressure?’’ the nurse’s initial response would be: A. “The reason is not known why hypertension is associated with a high-salt diet.” B. “Large amounts of salt in your diet can cause you to retain fluid, which increases your blood pressure.” C. “Salt affects your blood vessels and causes your blood pressure to be high.” D. “Salt is needed to maintain blood pressure, but too much causes hypertension.” Correct Answer: B Section: Questions Set C Explanation Explanation/Reference: Explanation: