NURS438 NCLEX-RN Exam Latest Updates, Exams of Nursing

Download NURS438 NCLEX-RN Exam Latest Updates and more Exams Nursing in PDF only on Docsity! NURS438 NCLEX-RN Exam Latest Updates 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 development? You Selected: • a 4-year-old is whose speech is understood 50% of the time Correct response: • a 4-year-old is whose speech is understood 50% of the time Explanation: At age 4 a child’s speech should be understood most of the time even by people who do not know the child. According to the Denver Developmental Screening Examination, a child age 2 years should have a vocabulary of 300 words, be able to combine two or three words, and ask for what he or she wants by name. By age 3, the child should have a vocabulary of 900 words and can use a complete sentence of three or four words. A 1-year-old has a vocabulary of at least eight words and can reference people and objects. Question 6 See full question • 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 doesn't affect cough and gag reflexes, although these reflexes may be slightly decreased from the administration of sedation. These findings don't require immediate intervention. Blood-tinged stools are a normal finding after colonoscopy, especially if the client had a biopsy. Remediation: Oximetry Question 16 See full question The nurse is caring for an adult with a grade III compound fracture of the right femur; the client has been placed in skeletal traction. The intended outcome of the traction is to: You Selected: • reduce and immobilize the fracture. Correct response: • reduce and immobilize the fracture. Explanation: Skeletal traction is often used to regain normal length of the bone, but in this situation the main purpose of the traction is to reduce and immobilize the fracture. This type of traction allows the client to move in bed without dislocating the fracture. This client has an open fracture, but skeletal traction will not prevent further skin breakdown. Remediation: Traction, Care of Patient Question 17 See full question The nurse is assessing the client’s understanding of the use of medications. Which medication may cause a complication with the treatment plan of a client with diabetes? You Selected: • steroids Correct response: • steroids Explanation: Steroids can cause hyperglycemia because of their effects on carbohydrate metabolism, making diabetic control more difficult. Aspirin is not known to affect glucose metabolism. Sulfonylureas 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 disease. During pregnancy, the gallbladder is under the influence of progesterone, which is a smooth muscle relaxant. Because bile does not move through the system as quickly during pregnancy, bile stasis and gallstone formation can occur. Although education should be a continuous strategy, with pain at this level, a brief explanation is most appropriate. Major emphasis should be placed on determining the cause and treating the pain. It is not appropriate for the nurse to diagnose pain at this level as heartburn. Discussing nutritional strategies to prevent heartburn are appropriate during pregnancy, but not in this situation. Acetaminophen is an acceptable medication to take during pregnancy but should not be used on a regular basis as it can mask other problems. Remediation: Abdominal Pain Question 26 See full question A nurse is teaching the mother of an infant. The nurse should instruct the mother to introduce her infant to solid foods at what age? You Selected: • 6 months Correct response: • 6 months Explanation: Solid foods are typically introduced around age 6 months. They aren't recommended at an earlier age because of the protrusion and sucking reflexes and the immaturity of the infant's GI tract and immune system. By age 8 months, the infant usually has been introduced to iron- fortified infant cereal and vegetables and will begin to try fruits. Question 27 See full question A client diagnosed with thyroid cancer signed a living will that states he doesn't want ventilatory support if his condition deteriorates. As his condition worsens, the client states, "I changed my mind. I want everything done for me." Which response by the nurse is best? You Selected: • "What exactly do you mean by wanting 'everything' done for you?" Correct response: • "What exactly do you mean by wanting 'everything' done for you?" Explanation: Asking the client what he means is the best response. The nurse should clarify the client's request and get as much information as she can before notifying the physician of the client's wishes. Asking the physician to revoke the client's do-not-resuscitate (DNR) order makes an assumption about the client's wishes without obtaining clarification of his statement. The client might want aggressive treatment without reversing the DNR order. Asking the client if he understands that he'll be placed on a ventilator places him on the defensive. Telling the client to talk with his family is an inappropriate response; the client has the right to change his treatment plan without input from his family. Remediation: Advance Directives Question 28 See full question Two days after being placed in a cast for a fractured femur, the client suddenly has chest pain and dyspnea. The client is confused and has an elevated temperature. The nurse should assess the client for: You Selected: • fat embolism syndrome. Correct response: • fat embolism syndrome. Explanation: Clients with fractures of the long bones such as the femur are particularly susceptible to fat embolism syndrome (FES). Signs and symptoms include chest pain, dyspnea, tachycardia, and cyanosis. Changes in mental status are caused by hypoxemia and can be the first symptoms 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. Question 35 See full question A client is taking methotrexate for severe rheumatoid arthritis. The nurse instructs the client that it will be necessary to monitor: You Selected: • complete blood count (CBC) with differential and platelet count. Correct response: • complete blood count (CBC) with differential and platelet count. Explanation: This client should be monitored for blood dyscrasias, evidenced by decreased platelet count and white blood cell count with changes in the CBC differential. Question 36 See full question After many years of advanced practice nursing, a nurse has recently enrolled in a nurse practitioner (NP) program. This nurse has been attracted to the program by the potential after graduation to provide primary care for clients, an opportunity that is most likely to exist in which of the following settings? You Selected: • A rural health center. Correct response: • A rural health center. Explanation: Many rural health centers employ few healthcare providers, and primary care is often provided by an NP. An NP may provide care in a long-term care facility or hospital, but in these settings, the NP is less likely to be the provider of primary care to clients. Question 37 See full question Which class of medication protects the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation? You Selected: • Beta-adrenergic blockers Correct response: • Beta-adrenergic blockers Explanation: Beta-adrenergic blockers work by blocking beta receptors in the myocardium, reducing the response to catecholamines and sympathetic nerve stimulation. They protect the myocardium, helping to reduce the risk of another infarction by decreasing myocardial oxygen demand. Calcium channel blockers reduce the heart's workload by decreasing the heart rate. Opioids reduce myocardial oxygen demand, promote vasodilation, and decrease anxiety. Nitrates reduce myocardial oxygen consumption by decreasing left ventricular end-diastolic pressure (preload) and systemic vascular resistance (afterload). Remediation: Myocardial Infarction Pharmacology: Drug Binding Question 38 See full question In the process of dealing with the intense feelings about being raped, victims commonly verbalize that they were afraid they would be killed during the rape and wish that they had been. The nurse should decide that further counseling is needed if the client makes which statement? You Selected: • "I get so angry at times that I have to have a couple of drinks before I sleep." Correct response: • "I get so angry at times that I have to have a couple of drinks before I sleep." Explanation: Use of alcohol reflects unhealthy coping mechanisms. The client’s report of needing alcohol to calm down needs to be addressed. Survival is the most important goal during a rape. The client’s acknowledging this indicates that she is aware that she made the right choice. Although suicidal thoughts are common, the statement that suicide is an easy escape but the client would be unable to do it indicates low risk. Fantasies of revenge, such as giving the death penalty to all rapists, are natural reactions and are a problem only if the client intends to carry them out directly. Remediation: Rape-Trauma Syndrome Question 39 See full question A young client has been arrested for assault and battery. The client has been admitted to the forensic psychiatric facility for a pretrial evaluation. Which of the following client goals is most appropriate for the client? You Selected: • Participate in group therapy. Correct response: • Accept responsibility for personal behavior. Explanation: Accepting responsibility indicates an insight into the reasons for his/her hospitalization. This client is not hospitalized to receive treatment but for an evaluation, so group therapies would not be a goal. Verbalizing ways to express 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 • 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. Explanation: The most important intervention for infection control is to continue meticulous catheter site care. Dressings are to be changed two to three times per week depending on institutional policies. Temperature should be monitored at least once a day in someone with a vascular access device. Hand washing before and after irrigation or any manipulation of the site is a must for infection prevention. Remediation: IV Dressing Change Question 47 See full question A nurse is caring for a family whose infant has anencephaly. The most appropriate nursing intervention is to: You Selected: • help the family prepare for the infant's imminent death. Correct response: • help the family prepare for the infant's imminent death. Explanation: Anencephaly is incompatible with life. The nurse should support family members as they prepare for the infant's imminent death. Facilitating the attachment process, helping the family to adjust to the infant's problems, and preparing the family for extensive surgical procedures are inappropriate because the infant can't survive. Remediation: Dying Patient Care Neural Tube Defects, Pediatric Question 48 See full question A nurse on a labor and birth unit goes to the cafeteria for lunch with colleagues. One colleague begins talking about a newer staff member and says, “I heard that she does not have any labor and birth nursing experience.” Which of the following is the nurse’s most appropriate action? You Selected: • Discuss the colleague’s behavior in private. Correct response: • Discuss the colleague’s behavior in private. Explanation: This behavior is unprofessional and breaches client confidentiality as per the American Nurses Association (Canadian Nurses' Association) Code of Ethics. The nurse is obligated to approach the colleague and discuss inappropriate behaviors. Therefore, it is inappropriate to ignore the comment. Discussing this in private demonstrates professional conduct rather than confronting the colleague immediately. It is inappropriate to ask the colleague how he/she knows this information because doing so would contribute to the unprofessional behavior. Question 49 See full question A multipara who gave birth to a viable male neonate 12 hours ago plans to breastfeed her baby, although she bottle-fed her first two children. The client tells the nurse that she has cramps every time she breastfeeds. What should the nurse do? You Selected: • Offer the client a prescribed analgesic. Correct response: • Offer the client a prescribed analgesic. Explanation: An analgesic is most commonly offered to provide relief from discomfort. Multiparas tend to experience cramps while breastfeeding more frequently than do primiparas because breastfeeding releases oxytocin, causing uterine muscles to contract. The uterine muscles tend to be more tonically contracted after childbirth in primiparas. Breastfeeding more often is not indicated because this would increase the client’s cramping. Ambulation is not helpful because the cramps are due to the release of oxytocin, not gas accumulation. The client is experiencing cramping due to hormonal stimulation of the uterus, not from gas or constipation. Therefore, a stool softener would not help to alleviate the cramping. Remediation: Breast-Feeding Assistance Question 50 See full question 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 Question 57 See full question A client with a UTI exhibits the following vital signs; blood pressure of 90/60 mm Hg, respiratory rate of 24 breaths per minute, heart rate 100 beats per minute. Which nursing action would be most appropriate for this client? You Selected: • Assisting the client to the lithotomy position Correct response: • Placing the client in modified Trendelenberg position Explanation: This client has a low blood pressure and the best position would be the modified Trendelenberg to increase blood flow to the brain. Lithotomy position would be indicated for a vaginal exam, semi-Fowler's would be indicated for dyspnea, and the lateral position would be indicated for vomiting to prevent aspiration. Remediation: Shock (Hypovolemic) Question 58 See full question The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal birth. The mother is bottle-feeding her baby. Which client finding indicates a problem at this time? You Selected: • firm fundus at the symphysis Correct response: • firm fundus at the symphysis Explanation: By 4 to 6 weeks postpartum, the fundus should be deep in the pelvis and the size of a nonpregnant uterus. Subinvolution, caused by infection or retained placental fragments, is a problem associated with a uterus that is larger than expected at this time. Normal expectations include a white, thick vaginal discharge, striae that are beginning to fade to silver, and breasts that are soft without evidence of milk production (in a bottle-feeding mother). Remediation: Fundal Assessment, Postpartum Question 59 See full question The nurse teaches a client who had cystoscopy about the urge to void when the procedure is over. What other teaching should be included? You Selected: • Increase intake of fluids. Correct response: • Increase intake of fluids. Explanation: After a scope or catheter has been inserted into the urethra, the mucosal membrane is irritated and the client feels the need to void even though the bladder may not be full. The nurse should encourage the client to force fluids to make the urine dilute. The client should not ignore the urge to void. The client should be encouraged to use the bathroom; there is no need to use the bedpan. The client does not need assistance to the bathroom because this procedure does not require any anesthesia except a topical anesthetic for the male client. Question 60 See full question A client with moderate Alzheimer's-related dementia is being prepared for discharge. What statement by the caregiver demonstrates that discharge teaching about client safety has been effective? You Selected: • "Someone should supervise him at all times." Correct response: • "Someone should supervise him at all times." Explanation: The caregiver stating that someone should supervise the client at all times demonstrates effective teaching. Alzheimer's disease causes progressive 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: Hypertension Hypertension 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: Haloperidol Schizophrenia Question 68 See full question The nurse manager on a pediatric floor is updating safety recommendations for the unit. Which strategy would help reduce pediatric medication errors? Select all that apply. You Selected: • Reduce the available concentrations or dose strengths of high-alert medications to the minimum. • Limit the size of IV fluid bags that can be hung on small children. • Avoid using parenteral syringes when administering liquid oral medications. Correct response: • Avoid using parenteral syringes when administering liquid oral medications. • Limit the size of IV fluid bags that can be hung on small children. • Reduce the available concentrations or dose strengths of high-alert medications to the minimum. Explanation: Using only oral syringes to administer oral medications reduces the chance that the medication will be given intravenously. The use of smart pumps alone is not enough to prevent IV fluid administration. An additional measure that pediatric floors can institute to prevent accidental fluid overload is to use smaller IV fluid bags, such as 250 mL. Whenever a medication comes in multiple concentrations and doses, there is risk of administering the wrong dose. The use of pediatric satellite pharmacies with pediatric pharmacists greatly increases the safety of medication administration. Any time steps are added to the medication administration process, there is one more place where an error might occur. Remediation: Enteral Drug Administration, Pediatric IV Catheter Insertion, 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 circulation, and the client could have a drop in blood pressure. The client will have dry, warm skin and absence of sweating. Remediation: Spinal Injury Question 79 See full question The nurse is caring for a client following a cystocele and rectocele repair. The nurse has just received the client from the post anesthesia care unit (PACU). Which healthcare provider orders would the nurse question? Select all that apply. 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 listening for air at the end of the catheter. The nurse should then apply suction. After suctioning, the nurse should disconnect the catheter from the suction source and administer oxygen by face mask. The nurse can repeat the procedure if needed and then withdraw the catheter while applying suction. Remediation: Nasotracheal Suctioning 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. What should the nurse do? You Selected: • Make every attempt to contact the physician that ordered the insulin for clarification. Correct response: • Consult the physician's partner since he is readily available. Explanation: A nurse should never make assumptions or second-guess a physician order. Based on this client's symptoms, asking the attending physician's partner would not be out of line. It would take care of the problem and the original order can be clarified later. Remediation: Safe Medication Administration Question 95 See full question The charge nurse finds the mother of a child with a chronic bladder condition requiring clean intermittent catheterization (CIC) visibly upset. The mother states, "That other nurse said parents are not allowed to perform CIC in the hospital because of increased infection risk." The charge nurse should tell the parent: You Selected: • "You can use CIC on your child. I will talk with your nurse to clarify the policy." Correct response: • "You can use CIC on your child. I will talk with your nurse to clarify the policy." Explanation: The charge nurse should assure the parent that it is okay to use CIC and discuss the conversation with the nurse. It is possible that the nurse was unaware of current research findings or unit policies. The charge nurse should also determine if the parent has the supplies and uses a new catheter each time, but the insertion principles would not change. Parents are frequently taught how to do CIC while a child is in the hospital. Therefore, the rationale that it