NCLEX-RN Exam Latest Updates Questions And Answers RATED A+, Exams of Nursing

Download NCLEX-RN Exam Latest Updates Questions And Answers RATED A+ and more Exams Nursing in PDF only on Docsity! NCLEX-RN Exam Latest Updates Questions And Answers RATED A+ Question 1 See full question The family cannot go with the surgical client past the doors that separate the public from the restricted area of the operating room suite. These measures are designed to: You Selected: • provide for an aseptic environment to prevent infection. Correct response: • provide for an aseptic environment to prevent infection. Explanation: The purpose of separating the public from the restricted-attire area of the operating room is to provide an aseptic environment and prevent contamination of the environment by organisms. The client’s privacy is protected, but the main purpose is infection control. Anesthetics currently in use do not pose a risk of being ignited. Remediation: Preoperative Care Question 2 See full question A client reports left calf pain after undergoing renal arteriogram, in which the left groin was accessed. Which intervention should the nurse perform first? You Selected: • Assess peripheral pulses in the left leg. Correct response: • Assess peripheral pulses in the left leg. Explanation: The nurse should begin by assessing peripheral pulses in the left leg to determine if blood flow was interrupted by the procedure. The client may also have thrombophlebitis. Applying elastic compression stockings will not relieve pain and inflammation if thrombophlebitis is suspected. The leg should remain straight after the procedure. Calf pain is not a symptom of an allergic reaction. Remediation: Femoral Popliteal Bypass Question 3 See full question A nurse is inserting a urinary catheter into a client who is extremely anxious about the procedure. The nurse can facilitate the insertion by asking the client to: You Selected: • breathe deeply. Correct response: • breathe deeply. Explanation: When inserting a urinary catheter, the nurse can facilitate insertion by asking the client to breathe deeply. Breathing deeply will relax the urinary sphincter. Initiating a stream of urine isn't recommended during catheter insertion. Turning to the side or holding the labia or penis won't ease insertion, and doing so may contaminate the sterile field. Remediation: Indwelling Urinary Catheter (Foley) Insertion, Male Catheterizing The Male Urinary Bladder: Indwelling And Intermittent Catheters Catheterizing The Female Urinary Bladder Question 4 See full question A client, hospitalized for pulmonary embolism, is being discharged on warfarin therapy. The client asks the nurse to explain how warfarin works. What is the nurse’s best response? You Selected: • It inhibits the formation of blood clots. Correct response: • It inhibits the formation of blood clots. Explanation: Warfarin inhibits clot formation by interfering with clotting factors that are dependent on vitamin K. Warfarin doesn’t dissolve clots, and won’t reduce the size of a pulmonary embolus. It doesn’t reduce blood pressure and won’t prevent venous stasis. Coagulation studies will be performed every 2 to 4 weeks while the client is receiving warfarin. Remediation: Warfarin Sodium Pulmonary Embolism Question 5 See full question Which child should be referred for further assessment regarding language Correct response: • "I am glad that my report turned out normal." Explanation: The client who states that the test results are normal has only heard that the bone marrow is functioning. The etiology is in the destruction of circulating platelets. Further tests must be completed to determine the cause (e.g., a coating of the platelets with antibodies that are seen as foreign bodies). The bone marrow result does rule out other potential diagnoses such as anemia, leukemia, or myeloproliferative disorders that involve bone marrow depression. The client needs to stop flossing and throw away his hard toothbrush, which can lead to bleeding of the gums. The destruction of the circulating platelets accounts for the easy bruising and the need to protect oneself from further bruising. The client should not jump or increase exertion of joints, which may lead to bleeding in the joints and joint pain. Remediation: Bone Biopsy Question 10 See full question Which topic would be most important to include when teaching the parents how to promote overall toddler development? You Selected: • Safety is a priority concern for this age-group. Correct response: • Safety is a priority concern for this age-group. Explanation: Because of toddlers’ high energy and poor impulse control, safety is a priority concern for this age-group. Language is important in toddler development, but not the most important at this time. While parents should set clear guidelines for behavior, the priority for toddlers is ensuring safety. Diet habits should be developed at this time, but the most important subject to teach parents of toddlers is safety. Question 11 See full question The nurse should dispose of a used needle and syringe by: You Selected: • Placing uncapped, used needles and syringes immediately in the universal precaution container in the client's room. Correct response: • Placing uncapped, used needles and syringes immediately in the universal precaution container in the client's room. Explanation: The nurse should dispose of any used needle and syringe by immediately placing uncapped, used needles and syringes in the precaution container. Remediation: Standard Precautions Standard Precautions Question 12 See full question An adolescent presents to a community clinic for treatment of vulvar lesions associated with Type 2 herpes simplex. The nurse should: You Selected: • show the adolescent to a private examination room. Correct response: • show the adolescent to a private examination room. Explanation: The nurse should take the client to an examination room to provide privacy. Federal law states that adolescents may obtain treatment for sexually transmitted diseases without parental notification. This adolescent is guaranteed the same confidentiality as older clients. It isn't appropriate for the nurse to ask the adolescent if her parents know she's promiscuous; doing so could undermine the therapeutic relationship. Remediation: Herpes Simplex Question 13 See full question A nurse is providing care to a client with cancer. The client tells that nurse that the care provider is not giving enough information about the client's condition. Which behavior by the nurse demonstrates advocacy? You Selected: • helping the client create a list of questions to ask the care provider Correct response: • helping the client create a list of questions to ask the care provider Explanation: Advocacy refers to taking the client’s side and supports the client’s right to information necessary to make his or her own decisions. However, sometimes client advocacy conflicts with the care provider’s viewpoint, but the nurse must make sure to maintain a collaborative working relationship with the car provider and not intrude on the care provider-client relationship. In this situation, the nurse demonstrates advocacy by helping the client assert himself by developing a list of questions to ask the care provider. Confronting the care provider would be inappropriate and detrimental to the collaborative relationship. Telling the client the information also violates the care provider-client boundaries and could be detrimental to the collaborative relationship. Advising the client to get a second opinion is inappropriate because it does not address the client’s need for information. Question 14 See full question A woman in her first trimester of pregnancy comes to the prenatal clinic and states, "I feel nauseous and I'm vomiting all the time. I can't even keep down water." This client should be evaluated for what condition? You Selected: • Hyperemesis gravidarum. Correct response: • Hyperemesis gravidarum. Explanation: Hyperemesis gravidarum differs from the nausea and vomiting (morning sickness) that normally occur during pregnancy. It's characterized by excessive vomiting that can lead to dehydration and starvation. Without treatment, metabolic changes can lead to severe complications, even death, of the fetus or mother. Eclampsia is the most serious form of gestational hypertension. It's characterized by hypertension, seizures, coma, edema, and proteinuria. Hydramnios is an overproduction of amniotic fluid that causes uterine distension. Remediation: Hyperemesis Gravidarum Patient Care Question 15 See full question A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention? You Selected: • Oxygen saturation (SaO2) of 89% Correct response: • Oxygen saturation (SaO2) of 89% Explanation: Normal SaO2 is 95% to 100%. Oxygen saturation below 94% indicates inadequate oxygenation, which may be a consequence of the moderate sedation. Appropriate nursing actions include rousing the client, if necessary, assisting the client with coughing and deep breathing, and evaluating the need for additional oxygen. A heart rate of 84 beats/minute is within normal limits. Colonoscopy A client is transferred from the coronary care unit to the step-down unit. Which information should be included in the transfer report? Select all that apply. You Selected: • The client needs oxygen at 2 L/minute. • The client has been in normal sinus rhythm for 6 hours. • The client has a "do not resuscitate" prescription. Correct response: • The client needs oxygen at 2 L/minute. • The client has a "do not resuscitate" prescription. • The client uses the bedpan. • The client has been in normal sinus rhythm for 6 hours. Explanation: The nurse should report that the client is using oxygen, has a “do not resuscitate” prescription, can use the bedpan, and is in normal sinus rhythm. Information about having four grandchildren is not needed to help with the client’s continuity of care. Remediation: Transfer Within A Facility Question 21 See full question The mother of a toddler asks the nurse what she should do with her toddler when he has a temper tantrum. Which suggestion would be most appropriate? You Selected: • Leave the toddler alone during the tantrum as long as he is safe. Correct response: • Leave the toddler alone during the tantrum as long as he is safe. Explanation: Toddlers have temper tantrums in their attempt to develop autonomy. Toddlers should be left alone as long as they are safe during a tantrum. Moving the child to a time-out chair or punishing the child reinforces the behavior and is to be avoided. Attempting to talk to the toddler also reinforces the behavior. Additionally, at this cognitive level, toddlers do not understand as well as older children do. Question 22 See full question The nurse is to draw a blood sample for glucose testing from a term neonate during the first hour after birth. The nurse should obtain the blood sample from the neonate’s foot near which area? You Selected: • Correct response: • Explanation: In a neonate, the lateral aspect of the heel is the most appropriate site for obtaining a blood specimen. Using this area prevents damage to the calcaneus bone, which is located in the middle of the heel. The middle of the heel is to be avoided because of the increased risk for damaging the calcaneus bone located there. The middle of the foot contains the medial plantar nerve and the medial plantar artery, which could be injured if this site is selected. Using the base of the big toe as the site for specimen collection would cause a great deal of discomfort for the neonate; therefore, it is not the preferred site. Remediation: Finger And Heel Sticks, Pediatric Question 23 See full question Two days after placement of a pleural chest tube, the tube is accidentally pulled out of the chest wall. The nurse should first: You Selected: • apply an occlusive dressing such as petroleum jelly gauze. Correct response: • apply an occlusive dressing such as petroleum jelly gauze. Explanation: If the chest tube is accidentally pulled out (a rare occurrence), a petroleum jelly gauze and sterile 4×4 inch dressing should be applied over the chest wall insertion site immediately. The dressing should be covered with adhesive tape and be occlusive, and the surgeon should be notified. The lungs can be auscultated and vital signs can be taken after the dressing is in place and the surgeon has been called. Placing the tube in sterile water will not reestablish a seal to prevent air entering the insertion site of the chest tube. Remediation: Chest Tube Drainage System Monitoring And Care Question 24 See full question A nurse is counseling a mother with young children after the mother left her abusive husband 6 months ago. The mother says, “My 6-year-old is starting to act just like his father. I just do not know how to handle this.” Which response by the nurse is most appropriate? You Selected: • "Counseling for your son would be helpful." Correct response: • "Counseling for your son would be helpful." Explanation: Children who witness domestic violence commonly grow up to be victims or abusers. Counseling helps interrupt the pattern of violence in families. Limiting contact between the father and child does not address the child’s behavior, and outgrowing violent behaviors is not likely without other interventions. Setting limits on violent behaviors alone does not address the child’s feelings and needs. Question 25 See full question A woman at 22 weeks' gestation has right upper quadrant pain radiating to her back. She rates the pain as 9 on a scale of 1 to 10 and says that it has occurred 2 times in the last week for about 4 hours at a time. She does not associate the pain with food. Which nursing measure is the highest priority for this client? You Selected: • Refer the client to her health care provider for evaluation and treatment of the pain. Correct response: • Refer the client to her health care provider for evaluation and treatment of the pain. Explanation: The nurse seeing this client should refer her to a health care provider for further evaluation of the pain. This referral would allow a more definitive diagnosis and medical interventions that may include surgery. Referral would occur because of her high pain rating as well as the other symptoms, which suggest gallbladder • arranging for the client to attend day treatment at the clinic Correct response: • arranging for the client to attend day treatment at the clinic Explanation: Because the client can live in an apartment setting, further development of independent functioning and the skills to gain as much independence as he is capable of need to be fostered, including getting out and developing new friendships. Arranging for participation in day treatment is most beneficial at this time. Family visits and daily nursing visits do not encourage the client to do this. Making an appointment for 2 weeks later puts the client’s needs off. Lack of social relationships is not a sufficient reason for rehospitalization. Remediation: Schizophrenia Question 30 See full question A client has been hospitalized with a diagnosis of myasthenia gravis. A friend is visiting the client during lunch. The nurse enters the room after the client recovered from choking on lunch. What should the nurse do next? You Selected: • Tell the client to swallow when her chin is tipped down on her chest. Correct response: • Tell the client to swallow when her chin is tipped down on her chest. Explanation: Bending the chin down toward the chest decreases the risk of food entering the trachea and causing aspiration into the lungs. The client should sit up at a 90- degree angle when eating. Although eating and talking increase the risk of aspiration as well as muscle fatigue, the nurse should encourage the client to have visitors but avoid talking while chewing and swallowing. The client should rest before eating because muscle fatigue can contribute to choking. Remediation: Myasthenia Gravis Question 31 See full question A client tells the nurse that she has been raped but has not reported it to the police. After determining whether the client was injured, whether it is still possible to collect evidence, and whether the client wants to file a report, the nurse's next priority is to offer which intervention to the client? You Selected: • crisis intervention Correct response: • crisis intervention Explanation: The experience of rape is a crisis. Crisis intervention services, especially with a rape crisis nurse, are essential to help the client begin dealing with the aftermath of a rape. Legal assistance may be recommended if the client decides to report the rape and only after crisis intervention services have been provided. A rape support group can be helpful later in the recovery process. Medications for sleep disturbance, especially benzodiazepines, should be avoided if possible. Benzodiazepines are potentially addictive and can be used in suicide attempts, especially when consumed with alcohol. Remediation: Rape-Trauma Syndrome Question 32 See full question A client who has skeletal traction to stabilize a fractured femur has not had a bowel movement for 2 days. The nurse should: You Selected: • increase the client’s fluid intake to 3,000 mL/day. Correct response: • increase the client’s fluid intake to 3,000 mL/day. Explanation: The most appropriate nursing action is to first increase the client’s fluid intake to 3,000 mL/day to soften stool. A stool softener would be prescribed before resorting to an enema. Oil retention enemas are used to soften and lubricate impacted stool. Placing the client on the bedpan every 3 to 4 hours is not enough to stimulate a bowel movement. While activity can stimulate peristalsis, passive range of motion is not likely to provide enough stimulation to the abdominal muscles to stimulate a bowel movement. Remediation: Constipation Management, Oncology Question 33 See full question The nurse is preparing a laboring client for internal electronic fetal monitoring (EFM). Which finding requires nursing intervention? You Selected: • The membranes are intact. Correct response: • The membranes are intact. Explanation: Internal EFM can be used only after the client's membranes rupture, when the cervix is dilated at least 2 cm and when the presenting part is at least at –1 station. Anesthesia is not required for internal EFM. Remediation: Fetal Monitoring, Internal Fetal Heart Rate Monitoring Question 34 See full question A group of nursing students are reviewing current nursing Codes of Ethics. Such a code is important in the nursing profession because: You Selected: • Nursing practice involves numerous interactions between laws and individual values. Correct response: • Nursing practice involves numerous interactions between laws and individual values. Explanation: A code of ethics is necessary to guide nurses’ conduct, especially with regard to the interaction between laws and individual values. Diversity and legal liability do not provide the main justification for a code of ethics, though each is often a relevant consideration. The fact that nurses often carry out the orders of others is not the justification for a code of ethics. anger, such as playing age-appropriate video games is not indicated, as video games could be a further stimulus for violent behavior. The client should be assessed before a treatment plan is begun. Avoiding contact with others on the psychiatric forensic unit is not indicated, and interaction would be useful for assessment. Further, the client has the right to interact with other clients on the unit. Remediation: Involuntary Admission To A Psychiatric Unit Question 40 See full question Which goal is the priority for a client in Addisonian crisis? You Selected: • preventing irreversible shock Correct response: • preventing irreversible shock Explanation: Addison’s disease is caused by a deficiency of adrenal corticosteroids and can result in severe hypotension and shock because of uncontrolled loss of sodium in the urine and impaired mineralocorticoid function. This results in loss of extracellular fluid and dangerously low blood volume. Glucocorticoids must be administered to reverse hypotension. Preventing infection is not an appropriate goal of care in this life-threatening situation. Relieving anxiety is appropriate when the client’s condition is stabilized, but the calm, competent demeanor of the emergency department staff will be initially reassuring. Remediation: Adrenal Hypofunction Question 41 See full question A client who has been chronically unemployed with a history of explosive anger and depression is now experiencing significant hopelessness. What would be most appropriate for the nurse to include in the client's treatment plan? Select all that apply. You Selected: • Identify personal goals. • Gain insight into feelings. • Assess for suicidal ideation. Correct response: • Identify personal goals. • Gain insight into feelings. • Assess for suicidal ideation. Explanation: Identifying personal goals will assist the client to be active and forward looking. At the same time, gaining insight into the feeling will help to develop a plan for the client to move forward. Due to the expression of hopelessness, it is important to rule out any suicidal ideation. Teaching new skills and role-playing are not appropriate interventions at this time. Remediation: Major Depression Question 42 See full question The nurse is making a postpartum visit at the home of a client who delivered 14 days earlier. After assessing the vital signs (temperature, 99° F [37.2° C]; pulse, 88 bpm; respiration rate, 20 breaths/min; and blood pressure, 112/60 mm Hg), the nurse records other findings in the chart above. Which finding indicates delayed involution? You Selected: • fundus Correct response: • fundus Explanation: The fundus descends at the rate of one to two cms per day and by 2 weeks is no longer a pelvic organ. The vital signs, breasts, heart, lungs, abdomen (with exception of fundus), lochia, perineum, and extremities are within normal limits. Question 43 See full question What should be readily available at the bedside of a client with a chest tube in place? You Selected: • a bottle of sterile water Correct response: • a bottle of sterile water Explanation: A bottle of sterile water should be readily available and in view when a client has a chest tube so that the tube can be immediately submersed in the water if the chest tube system becomes disconnected. The chest tube should be reconnected to the water-seal system as soon as a sterile functioning system can be reestablished. There is no need for a tracheostomy tray, another chest tube, or a spirometer to be placed at the bedside for emergency use. Remediation: Chest Tube Insertion, Assisting Question 44 See full question A 22-month-old infant is to have moderate sedation for an outpatient procedure. The nurse knows that: You Selected: • the infant should respond to gentle tactile or verbal stimulation. Correct response: • the infant should respond to gentle tactile or verbal stimulation. Explanation: An infant under moderate sedation should respond to verbal or tactile stimuli. Infants under general anesthesia have decreased or absent reflexes. Infants who undergo general or moderate sedation rarely remember the procedure. PCA pumps aren't used during sedation. Remediation: Moderate Sedation, Pediatric Question 45 See full question When prepping a client for a hemorrhoidectomy, which of the following would be most important prior to the patient going to the operating room? You Selected: • An enema Correct response: • An enema Explanation: When preparing a client for a hemorrhoidectomy, the nurse should administer an enema, as ordered, and record the results. After surgery, the client may require antibiotics and analgesics. Remediation: Hemorrhoidectomy Administering A Cleansing Enema Question 46 See full question When teaching about prevention of infection to a client with a long-term venous catheter, the nurse determines that the client has understood discharge instructions when the client states: You Selected: • "My husband will change the dressing three times per week, using sterile technique. Correct response: • "My husband will change the dressing three times per week, using sterile technique. An elderly female client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, the nurse should suspect which disorder? You Selected: • Hyperparathyroidism Correct response: • Hyperparathyroidism Explanation: Hyperparathyroidism is most common in older women and is characterized by bone pain and weakness from excess parathyroid hormone. Clients also exhibit hypercalciuria-causing polyuria. Although clients with diabetes mellitus and diabetes insipidus have polyuria, they don't have bone pain and increased sleeping. Hypoparathyroidism is characterized by urinary frequency rather than by polyuria. Remediation: Hyperparathyroidism Question 51 See full question Which nursing intervention would most likely promote self-care behaviors in the client with a hiatal hernia? You Selected: • Ask the client to identify other situations in which the client changed health care habits. Correct response: • Ask the client to identify other situations in which the client changed health care habits. Explanation: Self-responsibility is the key to individual health maintenance. Using examples of situations in which the client has demonstrated self-responsibility can be reinforcing and supporting. The client has ultimate responsibility for personal health habits. Meeting other people who are managing their care and involving family members can be helpful, but individual motivation is more important. Reassurance can be helpful but is less important than individualization of care. Question 52 See full question The health care provider (HCP) has determined that a primigravid client in active labor requires a cesarean birth because of cephalopelvic disproportion. After the birth of a healthy neonate, which assessment should the nurse make first? You Selected: • nasopharyngeal secretions Correct response: • nasopharyngeal secretions Explanation: A neonate born by cesarean section has not had the benefit of the chest- squeezing action of a vaginal birth, which helps remove some of the nasopharyngeal secretions. The nurse should place the neonate under the radiant warmer and suction the mouth and nares with a bulb syringe to remove nasopharyngeal secretions. A high-pitched cry is associated with neurologic involvement or neonatal drug withdrawal and is unrelated to cesarean birth. Skull fractures may occur with difficult vaginal births and are not typically seen with cesarean births. Decreased muscle tone is associated with oversedation, neurologic impairment, or use of general anesthesia. Remediation: Cesarean Birth, Emergent, Assisting Delivery Room Resuscitation, Neonatal Question 53 See full question The nurse is caring for a client with a third heart sound. Which action is indicated? You Selected: • Assess the client’s lungs for crackles Correct response: • Assess the client’s lungs for crackles Explanation: A third heart sound indicates fluid volume excess (FVE) or heart failure; crackles are an additional finding and will further refine the assessment. Placing the client with FVE or heart failure flat in bed may cause respiratory distress by decreasing expansion. A cardiac monitor will determine heart rhythm, but it will not give information related to FVE. Sluggish skin turgor is a sign of fluid volume deficit or dehydration. Remediation: Heart Failure Question 54 See full question To prepare the irrigation solution used for removal of cerumen, the nurse should use: You Selected: • Warm tap water. Correct response: • Normal saline. Explanation: Normal saline is the solution that is generally used to irrigate the ear. Sterile water will cause tissue damage. An antiseptic solution is not typically used unless an infection is present. Warm tap water may cause tissue damage. Remediation: Cerumen Impaction Removal Question 55 See full question During assessment of a small infant admitted with a diagnosis of meningitis, the infant becomes less responsive to stimuli and exhibits bradycardia, slight hypertension, irregular respirations, and a temperature of 103.2° F (39.6° C). The infant’s fontanel is more tense than at the last assessment. What should the nurse do first? You Selected: • Raise the head of the bed. Correct response: • Raise the head of the bed. Explanation: Signs such as a decrease in the level of consciousness, bradycardia, hypertension, irregular respirations, and a tense fontanel strongly suggest increased intracranial pressure. The first action should be to attempt to lower the pressure by raising the head of the bed, which should improve venous return and decrease the pressure. Asking another nurse to verify the findings is unnecessary because temperature, pulse, and respirations are fairly objective data and not subject to interpretation. Additionally, asking for verification would waste valuable time. After elevating the infant’s head by raising the bed, the nurse can notify the primary care provider and administer the antipyretic. Remediation: Positioning A Patient With Increased Intracranial Pressure (ICP), Pediatric Meningitis Question 56 See full question A client with a history of heart failure is receiving a lidocaine I.V. infusion at 2 psychological and physiological deterioration; someone needs to be in attendance at all times to ensure the client's safety. Allowing the client to do as much as he can and posting signs to orient him to his surroundings are important strategies that help to provide optimal independence and create familiarity in the environment, but they don't specifically contribute to personal safety. Although ensuring that the client remains seated and holds onto safety bars while showering provides a measure of safety, the client shouldn't be allowed to shower without supervision. Remediation: Dementia, Care Of Patient Alzheimer Question 61 See full question The nurse is developing an education plan for clients with hypertension. The nurse should emphasize which long-term goal? You Selected: • Commit to lifelong therapy. Correct response: • Commit to lifelong therapy. Explanation: The most appropriate long-term goal for the client with hypertension is to commit to lifelong therapy. A significant problem in the long-term management of hypertension is compliance with the treatment plan. It is essential that the client understand the reasons for modifying lifestyle, taking prescribed medications, and obtaining regular health care. Limiting stress, losing weight, and monitoring blood pressure are important aspects of care for the client with hypertension; however, the treatment plan must be individualized to include aspects of care that are appropriate for each client. Remediation: Hypertensi on Hypertensi on Question 62 See full question After surgery to repair a tracheoesophageal fistula, an infant receives gastrostomy tube feedings. The nurse continues holding the infant for about 15 minutes after the feeding primarily to help accomplish what need? You Selected: • Associate eating with a pleasurable experience. Correct response: • Associate eating with a pleasurable experience. Explanation: The nurse can help meet the psychological needs of an infant being fed through a gastrostomy tube by rocking the infant after a feeding. The infant soon learns to associate eating with a pleasurable experience and learns to trust the caregiver. Rocking the infant will not promote peristalsis or prevent regurgitation. Holding the baby will not relieve pressure on the surgical site. However, holding the child right after feeding promotes comfort and pleasure. Remediation: Tube Feedings, Neonatal Question 63 See full question A client is diagnosed with gout. Which foods should the nurse instruct the client to avoid? Select all that apply. You Selected: • Cod • Sardines • Liver Correct response: • Liver • Cod • Sardines Explanation: The client with gout should avoid foods that are high in purines, such as liver, cod, and sardines. Other foods to avoid include anchovies, kidneys, sweetbreads, lentils, and alcoholic beverages, especially beer and wine. Green leafy vegetables, chocolate, eggs, and whole milk are not high in purines and, therefore, not restricted in the diet of a client with gout. Remediation: Gout Question 64 See full question A client who had a gastrectomy has been in the postanesthesia recovery room for 30 minutes when the vital signs suddenly change. The nurse checks the recovery room record (see chart). In addition to notifying the health care provider (HCP), what other action should the nurse take immediately? You Selected: • Administer dantrolene. Correct response: • Administer dantrolene. Explanation: The client is demonstrating signs of malignant hyperthermia. Unless the body is cooled and the influx of calcium into the muscle cells is reversed, lethal cardiac arrhythmia and hypermetabolism occur. The client’s body temperature can rise as high as 109° F (42.8° C) as body muscles contract. Dantrolene, an IV skeletal muscle relaxant, is used to reverse muscle rigidity. Elevating the head of the bed will not reverse the hyperthermia. Adding fluids and inserting an indwelling urinary catheter are not immediately beneficial steps in reversing the progression of malignant hyperthermia. Remediation: Dantrolene Sodium Malignant Hyperthermia Question 65 See full question The charge nurse is preparing for the day shift on the labor and birth unit. Which would be included in the responsibilities for this position? Select all that apply. You Selected: • Review the current status of each labor patient with the primary nurse. • Complete report of unit with the oncoming charge nurse. • Follow up with the primary nurse after a birth. Correct response: • Review the current status of each labor patient with the primary nurse. • Follow up with the primary nurse after a birth. • Complete report of unit with the oncoming charge nurse. Explanation: In most settings, the charge nurse coordinates and directs the activities of the unit. Prior to the change of shift, the nurse will review and update the status of Pediatric Care Of The Hospitalized Child: Medication Administration Question 69 See full question A physician has asked a nurse to use written forms of communication to share the client's health status with other medical personnel. Which of the following is an example of a written form of communication? You Selected: • Checklists. Correct response: • Checklists. Explanation: Nurses can use the checklist method to share the client's health status with other health personnel involved in the client's care. Some other examples of written forms of communication include the nursing care plan, the nursing Kardex, and flow sheets. Notepads, e- mails, and SMSes are not examples of written forms of communication that nurses should follow. Question 70 See full question A client is talking to the nurse about the client's new diet of juicing. The client loves the diet but tells the nurse there is a bit of a constipation issue. Which statement is a solution for the constipation? You Selected: • Add a fiber agent like psyllium to your diet every day. Correct response: • Supplement the extracted pulp back into the mixture and ingest it. Explanation: When you juice, you do not get the fiber that is in whole fruits and vegetables. Juicing machines extract the juice and leave behind the pulp, which has fiber. Add some of the pulp back into the juice or use it in cooking. Remediation: Nutritional Screening Question 71 See full question What would the nurse expect to find in the psychologic history of a client who has an eating disorder? Select all that apply. You Selected: • Depressed mood • Distorted body image • Rigidity of thinking Correct response: • Rigidity of thinking • Depressed mood • Distorted body image Explanation: Clients will typically be withdrawn, secretive, and isolative. Their thinking pattern will be black and white. They are often depressed and have a distorted sense of their body. An easy-going, laisssez-faire attitude, and striving to please others are not in the psychologic profile of a client with an eating disorder. Remediation: Anorexia Nervosa Bulimia Nervosa Question 72 See full question When planning diet teaching for the client with a colostomy, the nurse should develop a plan that emphasizes which dietary instruction? You Selected: • Clients should experiment to find the diet that is best for them. Correct response: • Clients should experiment to find the diet that is best for them. Explanation: It is best to adjust the diet of a client with a colostomy in a manner that suits the client rather than trying special diets. Severe restriction of roughage is not recommended. The client is encouraged to drink 2 to 3 L of fluid per day. A high-fiber diet may produce loose stools. Remediation: Bowel Resection Question 73 See full question A female client with paranoid schizophrenia has been hearing negative voices and “getting special messages from various sources.” Which intervention is most appropriate for the client's symptoms? You Selected: • Monitor her reactions to television programs. Correct response: • Monitor her reactions to television programs. Explanation: A client who is “getting special messages” (ideas of reference) commonly misinterprets content presented on television as containing messages for the client. Therefore, it is important for the nurse to monitor the client’s reactions to television programs. Remediation: Active Hallucinations Patient Care Schizophrenia Patient Care Question 74 See full question The nurse is caring for a client in labor who is worried about having an episiotomy. Which of the following interventions will the nurse include in the client’s plan of care? Select all that apply. You Selected: • Avoiding the lithotomy position while pushing • Placing warm or hot compresses on the perineum • Encouraging immediate pushing after epidural placement Correct response: • Avoiding the lithotomy position while pushing • Placing warm or hot compresses on the perineum • Encouraging a gradual expulsion of the infant Explanation: Avoiding the lithotomy position while pushing, placing warm or hot compresses on the perineum, and gradual expulsion of the infant are recommendations to prevent an episiotomy. Encouraging pushing after an epidural placement is inappropriate because the client will not be able to feel where to push. The side- lying position is recommended for prevention of an episiotomy. Remediation: Episiotomy Question 75 See full question The nurse is showing the parent of a child with Hirschsprung’s disease where the aganglionic area is located. Identify the area the nurse should point out as being aganglionic. You Selected: • Advance diet as tolerated • Piperacillin and tazobactam 2 G IVPB every 8 hours • Colace 100 mg PO BID Correct response: • Discontinue Foley catheter • Maintain sitting position Explanation: Clients following a cystocele and rectocele repair may have a Foley catheter in place for days until the edema decreases. Having the client maintain a sitting position would not be comfortable due to the perineal trauma. The client is immediately postoperative and will need the fluid after surgery. Advancing the diet as tolerated is a routine order following surgery and is based on the nursing judgment. Because of the manipulation of the bladder and the involvement of the rectum, antibiotics will be prescribed as a preventive measure. Remediation: Colporrhaphy Question 80 See full question A client with detachment of the retina is to patch both eyes. The expected outcome of patching is to: You Selected: • reduce rapid eye movements. Correct response: • reduce rapid eye movements. Explanation: Patching the eyes helps decrease random eye movements that could enlarge and worsen retinal detachment. Although clients with eye injuries frequently are light sensitive, and preventing infection is important, the specific goal is to reduce rapid eye movements. Using the uninvolved eye would not cause eye strain, but random movements of one eye will involve the other eye. Remediation: Retinal Detachment Question 81 See full question A home health agency is seeing an increase in the number of clients with GI disorders. How can the staff education coordinator ensure that the staff is knowledgeable about advances in GI care? Select all that apply. You Selected: • Allow time off for educational programs and conferences • Ask the staff what their needs are • Make instructional videos and educational materials accessible Correct response: • Incorporate bi-annual competencies • Allow time off for educational programs and conferences • Make instructional videos and educational materials accessible Explanation: The goal is to educate the staff and insure competency. Assigning nurses who are most comfortable does not fix the problem on a long-term basis; nor does asking the staff what their needs are. Staff changes and mechanisms need to be in place for continued education. Question 82 See full question A client who is newly diagnosed with schizophrenia tells the nurse, "The aliens are telling me that I am defective and need to be eliminated." Which response by the nurse is most appropriate initially? You Selected: • "I want you to agree to tell staff when you hear these voices." Correct response: • "I want you to agree to tell staff when you hear these voices." Explanation: The client may act on command hallucinations and harm himself or others. Therefore, the staff needs to know when the client is hearing such commands, to ensure safety first. Telling the client that the voices are real but that the nurse does not hear them would be an appropriate response later in the client’s hospitalization when the client’s safety is no longer an issue because antipsychotics are beginning to take effect. Telling the client that the hallucinations are part of the illness or that medications will help control the voices would be appropriate once the client has developed some insight into the symptoms of the illness. Remediation: Active Hallucinations Patient Care Suicide Precautions Question 83 See full question A postoperative client is experiencing urinary retention, and the nurse is inserting an indwelling catheter. Immediately, 750 mL of clear yellow urine is collected in the drainage bag. What should the nurse do next? You Selected: • Continue to drain the bladder until empty. Correct response: • Clamp the catheter for 20 minutes. Explanation: Taking a large amount of urine from the bladder over a short period of time puts the client at risk for hypovolemic shock. The other options would not prevent hypovolemic shock. The only way to gradually remove urine is to clamp and unclamp the catheter. Remediation: Indwelling Urinary Catheter (Foley) Insertion, Male Indwelling Urinary Catheter (Foley) Insertion, Female Catheterizing The Male Urinary Bladder: Indwelling And Intermittent Catheters Question 84 See full question A nurse is performing nasotracheal suctioning on a client who has pneumonia. In what order should the nurse perform the steps of the procedure? Place in order from first to last. All options must be used. You Selected: • Place the client in a sitting position. • Apply oxygen with a face mask. • Pass the catheter into the trachea. • Apply suction. Correct response: • Place the client in a sitting position. • Pass the catheter into the trachea. • Apply suction. • Apply oxygen with a face mask. Explanation: Nasotracheal suctioning is used to remove secretions from clients who cannot cough them up. After explaining the procedure to the client, the nurse should first assist the client to an upright position. Next, the nurse should pass the catheter into the trachea and assure that the catheter is in the trachea by • Ask about the marital problems leading to the divorce. Explanation: The nurse should first assess the client’s risk for harm, especially because the client could direct her anger toward her ex-husband or the nurse. Then it is important to know more about her current situation and her immediate needs. Obtaining information from the ex-husband’s case manager might help clarify the risk of harm to the client. Problems leading to the divorce are less important than the situation following the divorce. Remediation: Schizophrenia Patient Care Schizophrenia Question 89 See full question An Asian-American client is scheduled for discharge after being diagnosed with type 1 diabetes mellitus. Before leaving the health care facility, the nurse demonstrates the technique of self- administration of insulin and explains the importance of the client’s prescribed insulin regimen in controlling blood glucose levels. What may the nurse conclude if the client continues to stare blankly? You Selected: • The client disapproves of the insulin treatment. Correct response: • The client disapproves of the insulin treatment. Explanation: The nurse should conclude that the client disapproves of the treatment. It may indicate that the client disapproves of the procedure but, due to cultural practices, does not openly verbalize disapproval. Asian Americans may not openly disagree with authority figures, such as physicians and nurses, because of their respect for harmony. Such reticence can conceal disagreement or potential non- compliance with a particular therapeutic regimen that is unacceptable from their perspective. The client, however, does not show any sign of understanding the procedure, nor does he openly make any comments on the procedure. He also does not give any indication of surprise with regard to the complexity of the procedure. Question 90 See full question The nurse is caring for a client during the second stage of labor. Which of the following would the nurse include in the client’s plan of care? Select all that apply. You Selected: • Explaining the pushing techniques • Asking visitors to leave the room • Continuing to monitor fetal heart tones Correct response: • Explaining the pushing techniques • Continuing to monitor fetal heart tones Explanation: The second stage of labor is when the client is completely dilated and will end with the birth of the fetus. Administration of pain medication at this point in labor could potentially cause respiratory distress of the fetus. Ambulation is an inappropriate intervention as the fetus could be born on the floor. The client will need extra support during this time and asking visitors to leave would be inappropriate. Due to the pushing efforts, fetal distress can still occur and continued monitoring of fetal heart tones is needed. Remediation: Labor, Care During Vaginal Birth Question 91 See full question After teaching the parent of a child newly diagnosed with Type I diabetes about signs of hyperglycemia, which sign, if stated by the parent, indicates teaching has been successful? Select all that apply. You Selected: • nausea • thirst • sweating Correct response: • nausea • thirst Explanation: Signs of hyperglycemia include lethargy, thirst, headache, confusion, abdominal pain, nausea, and vomiting. Signs of hypoglycemia include irritability, headache, dizziness, pallor, sweating, and tremors. It is important for parents to know the difference so correction of the problem can be initiated. Remediation: Skin, Clammy Dizziness Tremors Question 92 See full question The nurse is providing client education during the rehabilitation phase of a burn injury. Which of the following statements by the client indicates that more instruction is required? You Selected: • “I will use mild soap and water when bathing.” Correct response: • “I will report any skin discoloration to the primary healthcare provider immediately.” Explanation: Skin discoloration is expected for months after a burn injury so there is no need to notify the primary healthcare provider. Clients recovering from burn injuries should massage scars with lotions and creams to minimize permanent scarring. Taking pain medications 30 minutes prior to wound care procedures can reduce pain. It is recommended that clients with burn injuries use mild soap and water when bathing. Remediation: Burns Question 93 See full question The nurse is caring for a client with a PICC line that requires flushing. The nurse has not previously performed this skill. What is the most appropriate action by the nurse to ensure safe care? You Selected: • Contact the nurse educator for the unit to help guide the nurse through the skill. Correct response: • Request a different client assignment and arrange a session on the care of a PICC line. Explanation: The nurse recognizes that he/she lacks the knowledge, skill, and competency to flush the PICC line and needs further education. Gaining the appropriate knowledge, skill, and competency to complete this skill will require further education and practice, not just a bedside session. The other options are incorrect because they are neither appropriate nor safe and do not address the nurse’s need for further education. Question 94 See full question A physician writes a stat order for insulin and leaves the hospital. The nurse's client assessment includes fruity swelling breath, weakness, nausea, vomiting, and shortness of breath. The nurse cannot determine the dosage, but is familiar with this physician's routine and habit of writing insulin sliding scales orders. • the client’s desire to return home or go elsewhere after discharge • the client’s desire to leave or remain in the gang Correct response: • the client’s current level of suicidal risk • the client’s desire to leave or remain in the gang • the client’s desire to return home or go elsewhere after discharge • the client’s father’s reasons for kicking him out of the house Explanation: The client’s safety is the first priority, followed by his feelings about leaving the gang. If he chooses to remain in the gang, the remaining issues are moot. If he wishes to leave the gang, the issue of where he will live becomes significant. If he wishes to return home, it would be important to discover the reasons for the rift between him and his father and to explore if that rift can be repaired. If he desires to live elsewhere, it would need to be a place safe from the gang. It is unlikely he would be placed in foster or adoptive care since he is 18 years of age when he could live away from home and be responsible for himself. Remediation: Suicide Precautions Admission Of A Patient With A History Of Drug Abuse Question 98 See full question A nurse assesses a client who gave birth 24 hours earlier. Which finding reveals the need for further evaluation? You Selected: • Scant lochia rubra Correct response: • Scant lochia rubra Explanation: During the early postpartum period, lochia rubra should be moderate to significant. Scant lochia rubra suggests that large clots are blocking the lochial flow. After birth, vasomotor changes may cause a shaking chill, this is a normal finding. Thirst, fatigue, and a temperature of up to 100.4° F (38° C) also are common at 24 hours postpartum. Remediation: Puerperal Infection Care Postpartum Hemorrhage Management Question 99 See full question The nurse is educating a client with a new colostomy on how to regain bowel control. Which of the following would the nurse emphasize as a priority? You Selected: • A soft, low-residue diet that will allow three formed bowel movements per day Correct response: • An irrigation routine of the ostomy Explanation: Colostomy irrigations are done daily at the same time to help establish normal patterns of bowel evacuation. The other answers are incorrect because they are not reflective of bowel control. A diet high in protein is essential but doesn’t improve control; a low-residue diet reduces fecal contents but not movements per day. Remediation: Colostomy Irrigation Question 100 See full question When assessing a child diagnosed with rheumatic fever, the nurse should determine if the child has which signs or symptoms? Select all that apply. You Selected: • chorea • arthralgia Correct response: • arthralgia • pericardial friction rub • chorea Explanation: Signs and symptoms of rheumatic fever include arthralgia, carditis, pericardial friction rub, polyarthritis, chorea, erythema marginatum, subcutaneous nodules, and fever. Vomiting, diarrhea, and seizures are not typically associated with rheumatic fever. Remediation: Acute Rheumatic Fever, Pediatric