Nursing-Exam-Questions-12-ARNursing-Exam-Questions-12-AR, Exams of Nursing

Download Nursing-Exam-Questions-12-ARNursing-Exam-Questions-12-AR and more Exams Nursing in PDF only on Docsity! Nursing-Exam-Questions-12-AR 1. A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use? a. Body temperature of 99°F or less b. Toes moved in active range of motion c. Sensation reported when soles of feet are touched d. Capillary refill of < 3 seconds Answer D is correct. It is important to assess the extremities for blood vessel occlusion in the client with sickle cell anemia because a change in capillary refill would indicate a change in circulation. Body temperature, motion, and sensation would not give information regarding peripheral circulation; therefore, answers A, B, and C are incorrect. 2. A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client? a. Side-lying with knees flexed b. Knee-chest c. High Fowler's with knees flexed d. Semi-Fowler's with legs extended on the bed Answer D is correct. Placing the client in semi- Fowler’s position provides the best oxygenation for this client. Flexion of the hips and knees, which includes the knee- chest position, impedes circulation and is not correct positioning for this client. Therefore, answers A, B, and C are incorrect. 3. A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client? a. Taking hourly blood pressures with mechanical cuff b. Encouraging fluid intake of at least 200mL per hour c. Position in high Fowler's with knee gatch raised d. Administering Tylenol as ordered Answer B is correct. It is important to keep the client in sickle cell crisis hydrated to prevent further sickling of the blood. Answer A is incorrect because a mechanical cuff places too much pressure on the arm. Answer C is incorrect because raising the knee gatch impedes circulation. Answer D is incorrect because Tylenol is too mild an analgesic for the client in crisis. Nursing-Exam-Questions-12-AR 4. Which of the following foods would the nurse encourage the client in sickle cell crisis to eat? a. Peaches b. Cottage cheese c. Popsicle d. Lima beans Answer C is correct. Hydration is important in the client with sickle cell disease to prevent thrombus formation. Popsicles, gelatin, juice, and pudding have high fluid content. The foods in answers A, B, and D do not aid in hydration and are, therefore, incorrect. 5. A newly admitted client has sickle cell crisis. The nurse is planning care based on assessment of the client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. Which of the following interventions would be implemented first? Assume that there are orders for each intervention. a. Adjust the room temperature b. Give a bolus of IV fluids c. Start O2 d. Administer meperidine (Demerol) 75mg IV push Answer C is correct. The most prominent clinical manifestation of sickle cell crisis is pain. However, the pulse oximetry indicates that oxygen levels are low; thus, oxygenation takes precedence over pain relief. Answer A is incorrect because although a warm environment reduces pain and minimizes sickling, it would not be a priority. Answer B is incorrect because although hydration is important, it would not require a bolus. Answer D is incorrect because Demerol is acidifying to the blood and increases sickling. 6. The nurse is instructing a client with iron- deficiency anemia. Which of the following meal plans would the nurse expect the client to select? a. Roast beef, gelatin salad, green beans, and peach pie b. Chicken salad sandwich, coleslaw, French fries, ice cream c. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie d. Pork chop, creamed potatoes, corn, and coconut cake Answer C is correct. Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in iron, which is an important mineral for this client. Roast beef, cabbage, and pork chops are also high in iron, but the side dishes accompanying these choices are not; therefore, answers A, B, and D are incorrect. Nursing-Exam-Questions-12-AR bleeding. Where is the best site for examining for the presence of petechiae? a. The abdomen b. The thorax c. The earlobes d. The soles of the feet Answer D is correct. Petechiae are not usually visualized on dark skin. The soles of the feet and palms of the hand provide a lighter surface for assessing the client for petichiae. Answers A, B, and C are incorrect because the skin might be too dark to make an assessment. 14. A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire? a. "Have you noticed a change in sleeping habits recently?" b. "Have you had a respiratory infection in the last 6 months?" c. "Have you lost weight recently?" d. "Have you noticed changes in your alertness?" Answer B is correct. The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6 months. Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations; therefore, answers A, C, and D are incorrect. 15. Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia? a. Oral mucous membrane, altered related to chemotherapy b. Risk for injury related to thrombocytopenia c. Fatigue related to the disease process d. Interrupted family processes related to life-threatening illness of a family member Answer B is correct. The client with acute leukemia has bleeding tendencies due to decreased platelet counts, and any injury would exacerbate the problem. The client would require close monitoring for hemorrhage, which is of higher priority than the diagnoses in answers A, C, and D, which are incorrect. 16. A 21-year-old male with Hodgkin's lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client? a. Sexual dysfunction related to radiation therapy Nursing-Exam-Questions-12-AR b. Anticipatory grieving related to terminal illness c. Tissue integrity related to prolonged bed rest d. Fatigue related to chemotherapy Answer A is correct. Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the client are important to address in light of the age and life choices. Hodgkin’s disease, however, has a good prognosis when diagnosed early. Answers B, C, and D are incorrect because they are of lesser priority. 17. A client has autoimmune thrombocytopenic purpura. To determine the client's response to treatment, the nurse would monitor: a. Platelet count b. White blood cell count c. Potassium levels d. Partial prothrombin time (PTT) Answer A is correct. Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts, making answer A the correct answer. White cell counts, potassium levels, and PTT are not affected in ATP; thus, answers B, C, and D are incorrect. 18. The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client's platelet count currently is 80, It will be most important to teach the client and family about: a. Bleeding precautions b. Prevention of falls c. Oxygen therapy d. Conservation of energy Answer A is correct. The normal platelet count is 120,000–400, Bleeding occurs in clients with low platelets. The priority is to prevent and minimize bleeding. Oxygenation in answer C is important, but platelets do not carry oxygen. Answers B and D are of lesser priority and are incorrect in this instance. 19. A client with a pituitary tumor has had a transphenoidal hyposphectomy. Which of the following interventions would be appropriate for this client? a. Place the client in Trendelenburg position for postural drainage b. Encourage coughing and deep breathing every 2 hours c. Elevate the head of the bed 30° d. Encourage the Valsalva maneuver for bowel movements Answer C is correct. Elevating the head of the bed 30° avoids pressure on the sella turcica and Nursing-Exam-Questions-12-AR alleviates headaches. Answers A, B, and D are incorrect because Trendelenburg, Valsalva maneuver, and coughing all increase the intracranial pressure. 20. The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is: a. Measure the urinary output b. Check the vital signs c. Encourage increased fluid intake d. Weigh the client Answer B is correct. The large amount of fluid loss can cause fluid and electrolyte imbalance that should be corrected. The loss of electrolytes would be reflected in the vital signs. Measuring the urinary output is important, but the stem already says that the client has polyuria, so answer A is incorrect. Encouraging fluid intake will not correct the problem, making answer C incorrect. Answer D is incorrect because weighing the client is not necessary at this time. 21. A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding? a. Place the client in a sitting position with the head hyperextended b. Pack the nares tightly with gauze to apply pressure to the source of bleeding c. Pinch the soft lower part of the nose for a minimum of 5 minutes d. Apply ice packs to the forehead and back of the neck Answer C is correct. The client should be positioned upright and leaning forward, to prevent aspiration of blood. Answers A, B, and D are incorrect because direct pressure to the nose stops the bleeding, and ice packs should be applied directly to the nose as well. If a pack is necessary, the nares are loosely packed. 22. A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in the immediate post-operative period for the nurse to take is: a. Blood pressure b. Temperature c. Output d. Specific gravity Answer A is correct. Blood pressure is the best indicator of cardiovascular collapse in the client who has had an adrenal gland removed. The remaining gland might have been suppressed Nursing-Exam-Questions-12-AR c. Heart rate of 60bpm d. Respiratory rate of 30 per minute Answer C is correct. A heart rate of 60 in the baby should be reported immediately. The dose should be held if the heart rate is below 100bpm. The blood glucose, blood pressure, and respirations are within normal limits; thus answers A, B, and D are incorrect. 29. The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to: a. Replenish his supply every 3 months b. Take one every 15 minutes if pain occurs c. Leave the medication in the brown bottle d. Crush the medication and take with water Answer C is correct. Nitroglycerine should be kept in a brown bottle (or even a special air- and water-tight, solid or plated silver or gold container) because of its instability and tendency to become less potent when exposed to air, light, or water. The supply should be replenished every 6 months, not 3 months, and one tablet should be taken every 5 minutes until pain subsides, so answers A and B are incorrect. If the pain does not subside, the client should report to the emergency room. The medication should be taken sublingually and should not be crushed, as stated in answer D. 30. The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats? a. Macaroni and cheese b. Shrimp with rice c. Turkey breast d. Spaghetti Answer C is correct. Turkey contains the least amount of fats and cholesterol. Liver, eggs, beef, cream sauces, shrimp, cheese, and chocolate should be avoided by the client; thus, answers A, B, and D are incorrect. The client should bake meat rather than frying to avoid adding fat to the meat during cooking. 31. The client is admitted with left- sided congestive heart failure. In assessing the client for edema, the nurse should check the: a. Feet b. Neck c. Hands d. Sacrum Answer B is correct. The jugular veins in the neck should be assessed for distension. The other Nursing-Exam-Questions-12-AR parts of the body will be edematous in right- sided congestive heart failure, not left-sided; thus, answers A, C, and D are incorrect. 32. The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the: a. Phlebostatic axis b. PMI c. Erb's point d. Tail of Spence Answer A is correct. The phlebostatic axis is located at the fifth intercostals space midaxillary line and is the correct placement of the manometer. The PMI or point of maximal impulse is located at the fifth intercostals space midclavicular line, so answer B is incorrect. Erb’s point is the point at which you can hear the valves close simultaneously, making answer C incorrect. The Tail of Spence (the upper outer quadrant) is the area where most breast cancers are located and has nothing to do with placement of a manometer; thus, answer D is incorrect. 33. The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should: a. Question the order b. Administer the medications c. Administer separately d. Contact the pharmacy Answer B is correct. Zestril is an ACE inhibitor and is frequently given with a diuretic such as Lasix for hypertension. Answers A, C, and D are incorrect because the order is accurate. There is no need to question the order, administer the medication separately, or contact the pharmacy. 34. The best method of evaluating the amount of peripheral edema is: a. Weighing the client daily b. Measuring the extremity c. Measuring the intake and output d. Checking for pitting Answer B is correct. The best indicator of peripheral edema is measuring the extremity. A paper tape measure should be used rather than one of plastic or cloth, and the area should be marked with a pen, providing the most objective assessment. Answer A is incorrect because weighing the client will not indicate peripheral edema. Answer C is incorrect because checking the intake and output will not indicate peripheral edema. Answer D is incorrect because checking for pitting edema is less reliable than measuring with a paper tape measure. Nursing-Exam-Questions-12-AR 35. A client with vaginal cancer is being treated with a radioactive vaginal implant. The client's husband asks the nurse if he can spend the night with his wife. The nurse should explain that: a. Overnight stays by family members is against hospital policy. b. There is no need for him to stay because staffing is adequate. c. His wife will rest much better knowing that he is at home. d. Visitation is limited to 30 minutes when the implant is in place. Answer D is correct. Clients with radium implants should have close contact limited to 30 minutes per visit. The general rule is limiting time spent exposed to radium, putting distance between people and the radium source, and using lead to shield against the radium. Teaching the family member these principles is extremely important. Answers A, B, and C are not empathetic and do not address the question; therefore, they are incorrect. 36. The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client? a. Roast beef sandwich, potato chips, pickle spear, iced tea b. Split pea soup, mashed potatoes, pudding, milk c. Tomato soup, cheese toast, Jello, coffee d. Hamburger, baked beans, fruit cup, iced tea Answer B is correct. The client with a facial stroke will have difficulty swallowing and chewing, and the foods in answer B provide the least amount of chewing. The foods in answers A, C, and D would require more chewing and, thus, are incorrect. 37. The physician has prescribed Novalog insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs? a. "I will make sure I eat breakfast within 10 minutes of taking my insulin." b. "I will need to carry candy or some form of sugar with me all the time." c. "I will eat a snack around three o'clock each afternoon." d. "I can save my dessert from supper for a bedtime snack." Answer A is correct. Novalog insulin onsets very quickly, so food should be available within 10–15 minutes of taking the insulin. Answer B does not address a particular type of insulin, so it is Nursing-Exam-Questions-12-AR Answer A is correct. If the fundus of the client is displaced to the side, this might indicate a full bladder. The next action by the nurse should be to check for bladder distention and catheterize, if necessary. The answers in B, C, and D are actions that relate to postpartal hemorrhage. 44. A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood-tinged hemoptysis, fatigue, and night sweats. The client's symptoms are consistent with a diagnosis of: a. Pneumonia b. Reaction to antiviral medication c. Tuberculosis d. Superinfection due to low CD4 count Answer C is correct. A low-grade temperature, blood-tinged sputum, fatigue, and night sweats are symptoms consistent with tuberculosis. If the answer in A had said pneumocystis pneumonia, answer A would have been consistent with the symptoms given in the stem, but just saying pneumonia isn’t specific enough to diagnose the problem. Answers B and D are not directly related to the stem. 45. The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client's history should be reported to the doctor? a. Diabetes b. Prinzmetal's angina c. Cancer d. Cluster headaches Answer B is correct. If the client has a history of Prinzmetal’s angina, he should not be prescribed triptan preparations because they cause vasoconstriction and coronary spasms. There is no contraindication for taking triptan drugs in clients with diabetes, cancer, or cluster headaches making answers A, C, and D incorrect. 46. The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig's sign is charted if the nurse notes: a. Pain on flexion of the hip and knee b. Nuchal rigidity on flexion of the neck c. Pain when the head is turned to the left side d. Dizziness when changing positions Answer A is correct. Kernig’s sign is positive if pain occurs on flexion of the hip and knee. The Nursing-Exam-Questions-12-AR Brudzinski reflex is positive if pain occurs on flexion of the head and neck onto the chest so answer B is incorrect. Answers C and D might be present but are not related to Kernig’s sign. 47. The client with Alzheimer's disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting: a. Agnosia b. Apraxia c. Anomia d. Aphasia Answer B is correct. Apraxia is the inability to use objects appropriately. Agnosia is loss of sensory comprehension, anomia is the inability to find words, and aphasia is the inability to speak or understand so answers A, C, and D are incorrect. 48. The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as: a. Chronic fatigue syndrome b. Normal aging c. Sundowning d. Delusions Answer C is correct. Increased confusion at night is known as "sundowning" syndrome. This increased confusion occurs when the sun begins to set and continues during the night. Answer A is incorrect because fatigue is not necessarily present. Increased confusion at night is not part of normal aging; therefore, answer B is incorrect. A delusion is a firm, fixed belief; therefore, answer D is incorrect. 49. The client with confusion says to the nurse, "I haven't had anything to eat all day long. When are they going to bring breakfast?" The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make? a. "You know you had breakfast 30 minutes ago." b. "I am so sorry that they didn't get you breakfast. I'll report it to the charge nurse." c. "I'll get you some juice and toast. Would you like something else?" d. "You will have to wait a while; lunch will be here in a little while." Answer C is correct. The client who is confused might forget that he ate earlier. Don’t argue with the client. Simply get him something to eat that Nursing-Exam-Questions-12-AR will satisfy him until lunch. Answers A and D are incorrect because the nurse is dismissing the client. Answer B is validating the delusion. 50. The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer's disease. Which side effect is most often associated with this drug? a. Urinary incontinence b. Headaches c. Confusion d. Nausea Answer D is correct. Nausea and gastrointestinal upset are very common in clients taking acetlcholinesterase inhibitors such as Exelon. Other side effects include liver toxicity, dizziness, unsteadiness, and clumsiness. The client might already be experiencing urinary incontinence or headaches, but they are not necessarily associated; and the client with Alzheimer’s disease is already confused. Therefore, answers A, B, and C are incorrect. 51. A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate? a. Document the finding b. Report the finding to the doctor c. Prepare the client for a C- section d. Continue primary care as prescribed Answer B is correct. Any lesion should be reported to the doctor. This can indicate a herpes lesion. Clients with open lesions related to herpes are delivered by Cesarean section because there is a possibility of transmission of the infection to the fetus with direct contact to lesions. It is not enough to document the finding, so answer A is incorrect. The physician must make the decision to perform a C-section, making answer C incorrect. It is not enough to continue primary care, so answer D is incorrect. 52. A client with a diagnosis of HPV is at risk for which of the following? a. Hodgkin's lymphoma b. Cervical cancer c. Multiple myeloma d. Ovarian cancer Answer B is correct. The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the other cancers mentioned in answers A, C, and D, so those are incorrect. 53. During the initial interview, the client reports that she has a lesion on the Nursing-Exam-Questions-12-AR 59. Which observation in the newborn of a diabetic mother would require immediate nursing intervention? a. Crying b. Wakefulness c. Jitteriness d. Yawning Answer C is correct. Jitteriness is a sign of seizure in the neonate. Crying, wakefulness, and yawning are expected in the newborn, so answers A, B, and D are incorrect. 60. The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is: a. Decreased urinary output b. Hypersomnolence c. Absence of knee jerk reflex d. Decreased respiratory rate Answer B is correct. The client is expected to become sleepy, have hot flashes, and be lethargic. A decreasing urinary output, absence of the knee-jerk reflex, and decreased respirations indicate toxicity, so answers A, C, and D are incorrect. 61. The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse would: a. Place her in Trendelenburg position b. Decrease the rate of IV infusion c. Administer oxygen per nasal cannula d. Increase the rate of the IV infusion Answer D is correct. If the client experiences hypotension after an injection of epidural anesthetic, the nurse should turn her to the left side, apply oxygen by mask, and speed the IV infusion. If the blood pressure does not return to normal, the physician should be contacted. Epinephrine should be kept for emergency administration. Answer A is incorrect because placing the client in Trendelenburg position (head down) will allow the anesthesia to move up above the respiratory center, thereby decreasing the diaphragm’s ability to move up and down and ventilate the client. In answer B, the IV rate should be increased, not decreased. In answer C, the oxygen should be applied by mask, not cannula. 62. A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis? a. Alteration in nutrition b. Alteration in bowel elimination Nursing-Exam-Questions-12-AR c. Alteration in skin integrity d. Ineffective individual coping Answer A is correct. Cancer of the pancreas frequently leads to severe nausea and vomiting and altered nutrition. The other problems are of lesser concern; thus, answers B, C, and D are incorrect. 63. The nurse is caring for a client with ascites. Which is the best method to use for determining early ascites? a. Inspection of the abdomen for enlargement b. Bimanual palpation for hepatomegaly c. Daily measurement of abdominal girth d. Assessment for a fluid wave Answer C is correct. Measuring with a paper tape measure and marking the area that is measured is the most objective method of estimating ascites. Inspecting and checking for fluid waves are more subjective, so answers A and B are incorrect. Palpation of the liver will not tell the amount of ascites; thus, answer D is incorrect. 64. The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client's most appropriate priority nursing diagnosis? a. Alteration in cerebral tissue perfusion b. Fluid volume deficit c. Ineffective airway clearance d. Alteration in sensory perception Answer B is correct. The vital signs indicate hypovolemic shock. They do not indicate cerebral tissue perfusion, airway clearance, or sensory perception alterations, so answers A, C, and D are incorrect. 65. The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client: a. Likes to play football b. Drinks several carbonated drinks per day c. Has two sisters with sickle cell tract d. Is taking acetaminophen to control pain Answer A is correct. The client with osteogenesis imperfecta is at risk for pathological fractures and is likely to experience these fractures if he participates in contact sports. The client might experience symptoms of hypoxia if he becomes Nursing-Exam-Questions-12-AR dehydrated or deoxygenated; extreme exercise, especially in warm weather, can exacerbate the condition. Answers B, C, and D are not factors for concern. 66. The nurse working the organ transplant unit is caring for a client with a white blood cell count of During evening visitation, a visitor brings a basket of fruit. What action should the nurse take? a. Allow the client to keep the fruit b. Place the fruit next to the bed for easy access by the client c. Offer to wash the fruit for the client d. Tell the family members to take the fruit home Answer D is correct. The client with neutropenia should not have fresh fruit because it should be peeled and/or cooked before eating. He should also not eat foods grown on or in the ground or eat from the salad bar. The nurse should remove potted or cut flowers from the room as well. Any source of bacteria should be eliminated, if possible. Answers A, B, and C will not help prevent bacterial invasions. 67. The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40 systolic. The initial nurse's action should be to: a. Place the client in Trendelenburg position b. Increase the infusion of Dextrose in normal saline c. Administer atropine intravenously d. Move the emergency cart to the bedside Answer B is correct. In clients who have not had surgery to the face or neck, the answer would be answer A; however, in this situation, this could further interfere with the airway. Increasing the infusion and placing the client in supine position would be better. Answers C is incorrect because it is not necessary at this time and could cause hyponatremia and further hypotension. Answer D is not necessary at this time. 68. The client admitted 2 days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes? a. Order a chest x-ray b. Reinsert the tube c. Cover the insertion site with a Vaseline gauze d. Call the doctor Nursing-Exam-Questions-12-AR client will not eat, so answer A is incorrect. The hematocrit might improve by several means, such as blood transfusion, but that does not indicate improvement in the anorexic condition; therefore, answer B is incorrect. The tissue turgor indicates fluid stasis, not improvement of anorexia, so answer C is incorrect. 75. The client is admitted following repair of a fractured tibia and cast application. Which nursing assessment should be reported to the doctor? a. Pain beneath the cast b. Warm toes c. Pedal pulses weak and rapid d. Paresthesia of the toes Answer D is correct. At this time, pain beneath the cast is normal. The client’s toes should be warm to the touch, and pulses should be present. Paresthesia is not normal and might indicate compartment syndrome. Therefore, Answers A, B, and C are incorrect. 76. The client is having an arteriogram. During the procedure, the client tells the nurse, "I'm feeling really hot." Which response would be best? a. "You are having an allergic reaction. I will get an order for Benadryl." b. "That feeling of warmth is normal when the dye is injected." c. "That feeling of warmth indicates that the clots in the coronary vessels are dissolving." d. "I will tell your doctor and let him explain to you the reason for the hot feeling that you are experiencing." Answer B is correct. It is normal for the client to have a warm sensation when dye is injected. Answers A, C, and D indicate that the nurse believes that the hot feeling is abnormal, so they are incorrect. 77. The nurse is observing several healthcare workers providing care. Which action by the healthcare worker indicates a need for further teaching? a. The nursing assistant wears gloves while giving the client a bath. b. The nurse wears goggles while drawing blood from the client. c. The doctor washes his hands before examining the client. d. The nurse wears gloves to take the client's vital signs. Answer D is correct. It is not necessary to wear gloves to take the vital signs of the client. If the client has active infection with methicillin- Nursing-Exam-Questions-12-AR resistant staphylococcus aureus, gloves should be worn. The healthcare workers in answers A, B, and C indicate knowledge of infection control by their actions. 78. The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client's ECT has been effective? a. The client loses consciousness. b. The client vomits. c. The client's ECG indicates tachycardia. d. The client has a grand mal seizure. Answer D is correct. During ECT, the client will have a grand mal seize. This indicates completion of the electroconvulsive therapy. Answers A, B, and C do not indicate that the ECT has been effective, so are incorrect. 79. The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to: a. Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep b. Scrape the skin with a piece of cardboard and bring it to the clinic c. Obtain a stool specimen in the afternoon d. Bring a hair sample to the clinic for evaluation Answer A is correct. Infection with pinworms begins when the eggs are ingested or inhaled. The eggs hatch in the upper intestine and mature in 2–8 weeks. The females then mate and migrate out the anus, where they lay up to 17,000 eggs. This causes intense itching. The mother should be told to use a flashlight to examine the rectal area about 2–3 hours after the child is asleep. Placing clear tape on a tongue blade will allow the eggs to adhere to the tape. The specimen should then be brought in to be evaluated. There is no need to scrap the skin, collect a stool specimen, or bring a sample of hair, so answers B, C, and D are incorrect. 80. The nurse is teaching the mother regarding treatment for enterobiasis. Which instruction should be given regarding the medication? a. Treatment is not recommended for children less than 10 years of age. b. The entire family should be treated. c. Medication therapy will continue for 1 year. d. Intravenous antibiotic therapy will be ordered. Nursing-Exam-Questions-12-AR Answer B is correct. Erterobiasis, or pinworms, is treated with Vermox (mebendazole) or Antiminth (pyrantel pamoate). The entire family should be treated to ensure that no eggs remain. Because a single treatment is usually sufficient, there is usually good compliance. The family should then be tested again in 2 weeks to ensure that no eggs remain. Answers A, C, and D are incorrect statements. 81. The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse? a. The client receiving linear accelerator radiation therapy for lung cancer b. The client with a radium implant for cervical cancer c. The client who has just been administered soluble brachytherapy for thyroid cancer d. The client who returned from placement of iridium seeds for prostate cancer Answer A is correct. The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy travels to the radium department for therapy. The radiation stays in the department, so the client is not radioactive. The clients in answers B, C, and D pose a risk to the pregnant nurse. These clients are radioactive in very small doses, especially upon returning from the procedures. For approximately 72 hours, the clients should dispose of urine and feces in special containers and use plastic spoons and forks. 82. The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available? a. The client with Cushing's disease b. The client with diabetes c. The client with acromegaly d. The client with myxedema Answer A is correct. The client with Cushing’s disease has adrenocortical hypersecretion. This increase in the level of cortisone causes the client to be immune suppressed. In answer B, the client with diabetes poses no risk to other clients. The client in answer C has an increase in growth hormone and poses no risk to himself or others. The client in answer D has hyperthyroidism or myxedema and poses no risk to others or himself. 83. The nurse caring for a client in the neonatal intensive care unit administers adult-strength Digitalis to Nursing-Exam-Questions-12-AR b. The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension c. The 50-year-old with MRSA being treated with Vancomycin via a PICC line d. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter Answer D is correct. The client at highest risk for complications is the client with multiple sclerosis who is being treated with cortisone via the central line. The others are more stable. MRSA is methicillin- resistant staphylococcus aureus. Vancomycin is the drug of choice and is given at scheduled times to maintain blood levels of the drug. The clients in answers A, B, and C are more stable and can be seen later. 90. The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster? a. A schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis b. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm c. A child whose pupils are fixed and dilated and his parents, and a client with a frontal head injury d. The client who arrives with a large puncture wound to the abdomen and the client with chest pain Answer B is correct. The pregnant client and the client with a broken arm and facial lacerations are the best choices for placing in the same room. The clients in answers A, C, and D need to be placed in separate rooms due to the serious natures of their injuries. 91. The nurse is caring for a 6-year-old client admitted with a diagnosis of conjunctivitis. Before administering eyedrops, the nurse should recognize that it is essential to consider which of the following? a. The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops. b. The child should be allowed to instill his own eyedrops. c. The mother should be allowed to instill the eyedrops. Nursing-Exam-Questions-12-AR d. If the eye is clear from any redness or edema, the eyedrops should be held. Answer A is correct. Before instilling eyedrops, the nurse should cleanse the area with water. A 6- year-old child is not developmentally ready to instill his own eyedrops, so answer B is incorrect. Although the mother of the child can instill the eyedrops, the area must be cleansed before administration, making answer C incorrect. Although the eye might appear to be clear, the nurse should instill the eyedrops, as ordered, so answer D is incorrect. 92. The nurse is discussing meal planning with the mother of a 2- year-old toddler. Which of the following statements, if made by the mother, would require a need for further instruction? a. "It is okay to give my child white grape juice for breakfast." b. "My child can have a grilled cheese sandwich for lunch." c. "We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch." d. "For a snack, my child can have ice cream." Answer C is correct. Remember the ABCs (airway, breathing, circulation) when answering this question. Answer C is correct because a hotdog is the size and shape of the child’s trachea and poses a risk of aspiration. Answers A, B, and C are incorrect because white grape juice, a grilled cheese sandwich, and ice cream do not pose a risk of aspiration for a child. 93. A 2-year-old toddler is admitted to the hospital. Which of the following nursing interventions would you expect? a. Ask the parent/guardian to leave the room when assessments are being performed. b. Ask the parent/guardian to take the child's favorite blanket home because anything from the outside should not be brought into the hospital. c. Ask the parent/guardian to room-in with the child. d. If the child is screaming, tell him this is inappropriate behavior. Answer C is correct. The nurse should encourage rooming-in to promote parent- child attachment. It is okay for the parents to be in the room for assessment of the child. Allowing the child to have items that are familiar to him is allowed and encouraged; therefore, answers A and B are incorrect. Answer D is not part of the nurse’s responsibilities. Nursing-Exam-Questions-12-AR 94. Which instruction should be given to the client who is fitted for a behind- the-ear hearing aid? a. Remove the mold and clean every week. b. Store the hearing aid in a warm place. c. Clean the lint from the hearing aid with a toothpick. d. Change the batteries weekly. Answer B is correct. The hearing aid should be stored in a warm, dry place. It should be cleaned daily but should not be moldy, so answer A is incorrect. A toothpick is inappropriate to use to clean the aid; the toothpick might break off in the hearing aide, making answer C incorrect. Changing the batteries weekly, as in answer D, is not necessary. 95. A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is: a. Body image disturbance b. Impaired verbal communication c. Risk for aspiration d. Pain Answer C is correct. Always remember your ABCs (airway, breathing, circulation) when selecting an answer. Although answers B and D might be appropriate for this child, answer C should have the highest priority. Answer A does not apply for a child who has undergone a tonsillectomy. 96. A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal? a. High fever b. Nonproductive cough c. Rhinitis d. Vomiting and diarrhea Answer A is correct. If the child has bacterial pneumonia, a high fever is usually present. Bacterial pneumonia usually presents with a productive cough, not a nonproductive cough, making answer B incorrect. Rhinitis is often seen with viral pneumonia, and vomiting and diarrhea are usually not seen with pneumonia, so answers C and D are incorrect. 97. The nurse is caring for a client admitted with epiglottis. Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available? a. Intravenous access supplies b. A tracheostomy set c. Intravenous fluid administration pump Nursing-Exam-Questions-12-AR c. Infrequent contractions d. Progressive cervical dilation Answer D is correct. The expected effect of Pitocin is cervical dilation. Pitocin causes more intense contractions, which can increase the pain, making answer A incorrect. Cervical effacement is caused by pressure on the presenting part, so answer B is incorrect. Answer C is opposite the action of Pitocin. 105. A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time? a. Anticipate the need for a Caesarean section b. Apply the fetal heart monitor c. Place the client in Genu Pectoral position d. Perform an ultrasound exam Answer B is correct. Applying a fetal heart monitor is the correct action at this time. There is no need to prepare for a Caesarean section or to place the client in Genu Pectoral position (knee- chest), so answers A and C are incorrect. Answer D is incorrect because there is no need for an ultrasound based on the finding. 106. A vaginal exam reveals that the cervix is 4cm dilated, with intact membranes and a fetal heart tone rate of 160– 170bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is: a. The cervix is closed. b. The membranes are still intact. c. The fetal heart tones are within normal limits. d. The contractions are intense enough for insertion of an internal monitor. Answer B is correct. The nurse decides to apply an external monitor because the membranes are intact. Answers A, C, and D are incorrect. The cervix is dilated enough to use an internal monitor, if necessary. An internal monitor can be applied if the client is at 0-station. Contraction intensity has no bearing on the application of the fetal monitor. 107. The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primagravida as she completes the early phase of labor? a. Impaired gas exchange related to hyperventilation b. Alteration in placental perfusion related to maternal position Nursing-Exam-Questions-12-AR c. Impaired physical mobility related to fetal-monitoring equipment d. Potential fluid volume deficit related to decreased fluid intake Answer D is correct. Clients admitted in labor are told not to eat during labor, to avoid nausea and vomiting. Ice chips may be allowed, but this amount of fluid might not be sufficient to prevent fluid volume deficit. In answer A, impaired gas exchange related to hyperventilation would be indicated during the transition phase. Answers B and C are not correct in relation to the stem. 108. As the client reaches 8cm dilation, the nurse notes late decelerations on the fetal monitor. The FHR baseline is 165– 175bpm with variability of 0–2bpm. What is the most likely explanation of this pattern? a. The baby is asleep. b. The umbilical cord is compressed. c. There is a vagal response. d. There is uteroplacental insufficiency. Answer D is correct. This information indicates a late deceleration. This type of deceleration is caused by uteroplacental lack of oxygen. Answer A has no relation to the readings, so it’s incorrect; answer B results in a variable deceleration; and answer C is indicative of an early deceleration. 109. The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to: a. Notify her doctor b. Start an IV c. Reposition the client d. Readjust the monitor Answer C is correct. The initial action by the nurse observing a late deceleration should turn the client to the side— preferably, the left side. Administering oxygen is also indicated. Answer A might be necessary but not before turning the client to her side. Answer B is not necessary at this time. Answer D is incorrect because there is no data to indicate that the monitor has been applied incorrectly. 110. Which of the following is a characteristic of a reassuring fetal heart rate pattern? a. A fetal heart rate of 170– 180bpm b. A baseline variability of 25– 35bpm c. Ominous periodic changes d. Acceleration of FHR with fetal movements Answer D is correct. Accelerations with movement are normal. Answers A, B, and C indicate ominous findings on the fetal heart monitor. Nursing-Exam-Questions-12-AR 111. The rationale for inserting a French catheter every hour for the client with epidural anesthesia is: a. The bladder fills more rapidly because of the medication used for the epidural. b. Her level of consciousness is such that she is in a trancelike state. c. The sensation of the bladder filling is diminished or lost. d. She is embarrassed to ask for the bedpan that frequently. Answer C is correct. Epidural anesthesia decreases the urge to void and sensation of a full bladder. A full bladder will decrease the progression of labor. Answers A, B, and D are incorrect for the stem. 112. A client in the family planning clinic asks the nurse about the most likely time for her to conceive. The nurse explains that conception is most likely to occur when: a. Estrogen levels are low. b. Lutenizing hormone is high. c. The endometrial lining is thin. d. The progesterone level is low. Answer B is correct. Lutenizing hormone released by the pituitary is responsible for ovulation. At about day 14, the continued increase in estrogen stimulates the release of lutenizing hormone from the anterior pituitary. The LH surge is responsible for ovulation, or the release of the dominant follicle in preparationfor conception, which occurs within the next 10–12 hours after the LH levels peak. Answers A, C, and D are incorrect because estrogen levels are high at the beginning of ovulation, the endometrial lining is thick, not thin, and the progesterone levels are high, not low. 113. A client tells the nurse that she plans to use the rhythm method of birth control. The nurse is aware that the success of the rhythm method depends on the: a. Age of the client b. Frequency of intercourse c. Regularity of the menses d. Range of the client's temperature Answer C is correct. The success of the rhythm method of birth control is dependent on the client’s menses being regular. It is not dependent on the age of the client, frequency of intercourse, or range of the client’s temperature; therefore, answers A, B, and D are incorrect. 114. A client with diabetes asks the nurse for advice regarding methods of birth Nursing-Exam-Questions-12-AR 120. Which of the following instructions should be included in the nurse's teaching regarding oral contraceptives? a. Weight gain should be reported to the physician. b. An alternate method of birth control is needed when taking antibiotics. c. If the client misses one or more pills, two pills should be taken per day for 1 week. d. Changes in the menstrual flow should be reported to the physician. Answer B is correct. When the client is taking oral contraceptives and begins antibiotics, another method of birth control should be used. Antibiotics decrease the effectiveness of oral contraceptives. Approximately 5–10 pounds of weight gain is not unusual, so answer A is incorrect. If the client misses a birth control pill, she should be instructed to take the pill as soon as she remembers the pill. Answer C is incorrect. If she misses two, she should take two; if she misses more than two, she should take the missed pills but use another method of birth control for the remainder of the cycle. Answer D is incorrect because changes in menstrual flow are expected in clients using oral contraceptives. Often these clients have lighter menses. 121. The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client with: a. Diabetes b. Positive HIV c. Hypertension d. Thyroid disease Answer B is correct. Clients with HIV should not breastfeed because the infection can be transmitted to the baby through breast milk. The clients in answers A, C, and D—those with diabetes, hypertension, and thyroid disease—can be allowed to breastfeed. 122. A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse's first action should be to: a. Assess the fetal heart tones b. Check for cervical dilation c. Check for firmness of the uterus d. Obtain a detailed history Answer A is correct. The symptoms of painless vaginal bleeding are consistent with placenta previa. Answers B, C, and D are incorrect. Cervical check for dilation is contraindicated Nursing-Exam-Questions-12-AR because this can increase the bleeding. Checking for firmness of the uterus can be done, but the first action should be to check the fetal heart tones. A detailed history can be done later. 123. A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when: a. Her contractions are 2 minutes apart. b. She has back pain and a bloody discharge. c. She experiences abdominal pain and frequent urination. d. Her contractions are 5 minutes apart. Answer D is correct. The client should be advised to come to the labor and delivery unit when the contractions are every 5 minutes and consistent. She should also be told to report to the hospital if she experiences rupture of membranes or extreme bleeding. She should not wait until the contractions are every 2 minutes or until she has bloody discharge, so answers A and B are incorrect. Answer C is a vague answer and can be related to a urinary tract infection. 124. The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy? a. Low birth weight b. Large for gestational age c. Preterm birth, but appropriate size for gestation d. Growth retardation in weight and length Answer A is correct. Infants of mothers who smoke are often low in birth weight. Infants who are large for gestational age are associated with diabetic mothers, so answer B is incorrect. Preterm births are associated with smoking, but not with appropriate size for gestation, making answer C incorrect. Growth retardation is associated with smoking, but this does not affect the infant length; therefore, answer D is incorrect. 125. The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered: a. Within 72 hours of delivery b. Within 1 week of delivery c. Within 2 weeks of delivery Nursing-Exam-Questions-12-AR d. Within 1 month of delivery After the physician Answer A is correct. To provide protection against antibody production, RhoGam should be given within 72 hours. The answers in B, C, and D are too late to provide antibody protection. RhoGam can also be given during pregnancy. 126. performs an amniotomy, the nurse's first action should be to assess the: a. Degree of cervical dilation b. Fetal heart tones c. Client's vital signs d. Client's level of discomfort Answer B is correct. When the membranes rupture, there is often a transient drop in the fetal heart tones. The heart tones should return to baseline quickly. Any alteration in fetal heart tones, such as bradycardia or tachycardia, should be reported. After the fetal heart tones are assessed, the nurse should evaluate the cervical dilation, vital signs, and level of discomfort, making answers A, C, and D incorrect. 127. A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client's cervix is 5cm dilated with 75% effacement. Based on the nurse's assessment the client is in which phase of labor? a. Active b. Latent c. Transition d. Early Answer A is correct. The active phase of labor occurs when the client is dilated 4– 7cm. The latent or early phase of labor is from 1cm to 3cm in dilation, so answers B and D are incorrect. The transition phase of labor is 8–10cm in dilation, making answer C incorrect. 128. A newborn with narcotic abstinence syndrome is admitted to the nursery. Nursing care of the newborn should include: a. Teaching the mother to provide tactile stimulation b. Wrapping the newborn snugly in a blanket c. Placing the newborn in the infant seat d. Initiating an early infant- stimulation program Answer B is correct. The infant of an addicted mother will undergo withdrawal. Snugly wrapping the infant in a blanket will help prevent the muscle irritability that these babies often experience. Teaching the mother to provide tactile stimulation or provide for early infant Nursing-Exam-Questions-12-AR 135. The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the: a. Serum collection (Davol) drain b. Client's pain c. Nutritional status d. Immobilizer Answer A is correct. Bleeding is a common complication of orthopedic surgery. The blood- collection device should be checked frequently to ensure that the client is not hemorrhaging. The client’s pain should be assessed, but this is not life-threatening. When the client is in less danger, the nutritional status should be assessed and an immobilizer is not used; thus, answers B, C, and D are incorrect. 136. Which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates understanding of the nurse's teaching? a. "I must flush the tube with water after feedings and clamp the tube." b. "I must check placement four times per day." c. "I will report to the doctor any signs of indigestion." d. "If my father is unable to swallow, I will discontinue the feeding and call the clinic." Answer A is correct. The client’s family member should be taught to flush the tube after each feeding and clamp the tube. The placement should be checked before feedings, and indigestion can occur with the PEG tube, just as it can occur with any client, so answers B and C are incorrect. Medications can be ordered for indigestion, but it is not a reason for alarm. A percutaneous endoscopy gastrostomy tube is used for clients who have experienced difficulty swallowing. The tube is inserted directly into the stomach and does not require swallowing; therefore, answer D is incorrect. 137. The nurse is assessing the client with a total knee replacement 2 hours post- operative. Which information requires notification of the doctor? a. Bleeding on the dressing is 3cm in diameter. b. The client has a temperature of 6°F. c. The client's hematocrit is 26%. d. The urinary output has been 60 during the last 2 hours. Answer C is correct. The client with a total knee replacement should be assessed for anemia. A Nursing-Exam-Questions-12-AR hematocrit of 26% is extremely low and might require a blood transfusion. Bleeding of 2cm on the dressing is not extreme. Circle and date and time the bleeding and monitor for changes in the client’s status. A low-grade temperature is not unusual after surgery. Ensure that the client is well hydrated, and recheck the temperature in 1 hour. If the temperature is above 101°F, report this finding to the doctor. Tylenol will probably be ordered. Voiding after surgery is also not uncommon and no need for concern; therefore answers A, B, and D are incorrect. 138. The nurse is caring for the client with a 5-year-old diagnosis of plumbism. Which information in the health history is most likely related to the development of plumbism? a. The client has traveled out of the country in the last 6 months. b. The client's parents are skilled stained-glass artists. c. The client lives in a house built in 1 d. The client has several brothers and sisters. Answer B is correct. Plumbism is lead poisoning. One factor associated with the consumption of lead is eating from pottery made in Central America or Mexico that is unfired. The child lives in a house built after 1976 (this is when lead was taken out of paint), and the parents make stained glass as a hobby. Stained glass is put together with lead, which can drop on the work area, where the child can consume the lead beads. Answer A is incorrect because simply traveling out of the country does not increase the risk. In answer C, the house was built after the lead was removed with the paint. Answer D is unrelated to the stem. 139. A client with a total hip replacement requires special equipment. Which equipment would assist the client with a total hip replacement with activities of daily living? a. High-seat commode b. Recliner c. TENS unit d. Abduction pillow Answer A is correct. The equipment that can help with activities of daily living is the high-seat commode. The hip should be kept higher than the knee. The recliner is good because it prevents 90° flexion but not daily activities. A TENS (Transcutaneous Electrical Nerve Stimulation) unit helps with pain management and an abduction pillow is used to prevent adduction of the hip and possibly dislocation of the prosthesis; therefore, answers B, C, and D are incorrect. Nursing-Exam-Questions-12-AR 140. An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should: a. Administer oxygen via nasal cannula b. Have narcan (naloxane) available c. Prepare to administer blood products d. Prepare to do cardioresuscitation Answer B is correct. Narcan is the antidote for narcotic overdose. If hypoxia occurs, the client should have oxygen administered by mask, not cannula. There is no data to support the administration of blood products or cardioresuscitation, so answers A, C, and D are incorrect. 141. Which roommate would be most suitable for the 6-year-old male with a fractured femur in Russell's traction? a. 16-year-old female with scoliosis b. 12-year-old male with a fractured femur c. 10-year-old male with sarcoma d. 6-year-old male with osteomylitis Answer B is correct. The 6- year-old should have a roommate as close to the same age as possible, so the 12- year-old is the best match. The 10-year- old with sarcoma has cancer and will be treated with chemotherapy that makes him immune suppressed, the 6-year-old with osteomylitis is infected, and the client in answer A is too old and is female; therefore, answers A, C, and D are incorrect. 142. A client with osteoarthritis has a prescription for Celebrex (celecoxib). Which instruction should be included in the discharge teaching? a. Take the medication with milk. b. Report chest pain. c. Remain upright after taking for 30 minutes. d. Allow 6 weeks for optimal effects. Answer B is correct. Cox II inhibitors have been associated with heart attacks and strokes. Any changes in cardiac status or signs of a stroke should be reported immediately, along with any changes in bowel or bladder habits because bleeding has been linked to use of Cox II inhibitors. The client does not have to take the medication with milk, remain upright, or allow 6 weeks for optimal effect, so answers A, C, and D are incorrect. Nursing-Exam-Questions-12-AR CPM flexes and extends the leg. The client is in the bed during CPM therapy, so answer A is incorrect. Answer C is incorrect because clients will experience pain with the treatment. Use of the CPM does not alleviate the need for physical therapy, as suggested in answer D. 149. A client with a fractured hip is being taught correct use of the walker. The nurse is aware that the correct use of the walker is achieved if the: a. Palms rest lightly on the handles b. Elbows are flexed 0° c. Client walks to the front of the walker d. Client carries the walker Answer A is correct. The client’s palms should rest lightly on the handles. The elbows should be flexed no more than 30° but should not be extended. Answer B is incorrect because 0° is not a relaxed angle for the elbows and will not facilitate correct walker use. The client should walk to the middle of the walker, not to the front of the walker, making answer C incorrect. The client should be taught not to carry the walker because this would not provide stability; thus, answer D is incorrect. 150. When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should: a. Attempt to replace the cord b. Place the client on her left side c. Elevate the client's hips d. Cover the cord with a dry, sterile gauze Answer C is correct. The client with a prolapsed cord should be treated by elevating the hips and covering the cord with a moist, sterile saline gauze. The nurse should use her fingers to push up on the presenting part until a cesarean section can be performed. Answers A, B, and D are incorrect. The nurse should not attempt to replace the cord, turn the client on the side, or cover with a dry gauze. 151. The nurse is caring for a 30-year- old male admitted with a stab wound. While in the emergency room, a chest tube is inserted. Which of the following explains the primary rationale for insertion of chest tubes? a. The tube will allow for equalization of the lung expansion. b. Chest tubes serve as a method of draining blood and serous fluid and assist in reinflating the lungs. c. Chest tubes relieve pain associated with a collapsed lung. Nursing-Exam-Questions-12-AR d. Chest tubes assist with cardiac function by stabilizing lung expansion. Answer B is correct. Chest tubes work to reinflate the lung and drain serous fluid. The tube does not equalize expansion of the lungs. Pain is associated with collapse of the lung, and insertion of chest tubes is painful, so answers A and C are incorrect. Answer D is true, but this is not the primary rationale for performing chest tube insertion. 152. A client who delivered this morning tells the nurse that she plans to breastfeed her baby. The nurse is aware that successful breastfeeding is most dependent on the: a. Mother's educational level b. Infant's birth weight c. Size of the mother's breast d. Mother's desire to breastfeed Answer D is correct. Success with breastfeeding depends on many factors, but the most dependable reason for success is desire and willingness to continue the breastfeeding until the infant and mother have time to adapt. The educational level, the infant’s birth weight, and the size of the mother’s breast have nothing to do with success, so answers A, B, and C are incorrect. 153. The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately? a. The presence of scant bloody discharge b. Frequent urination c. The presence of green-tinged amniotic fluid d. Moderate uterine contractions Answer C is correct. Green-tinged amniotic fluid is indicative of meconium staining. This finding indicates fetal distress. The presence of scant bloody discharge is normal, as are frequent urination and moderate uterine contractions, making answers A, B, and D incorrect. 154. The nurse is measuring the duration of the client's contractions. Which statement is true regarding the measurement of the duration of contractions? a. Duration is measured by timing from the beginning of one contraction to the beginning of the next contraction. b. Duration is measured by timing from the end of one contraction to Nursing-Exam-Questions-12-AR the beginning of the next contraction. c. Duration is measured by timing from the beginning of one contraction to the end of the same contraction. d. Duration is measured by timing from the peak of one contraction to the end of the same contraction. Answer C is correct. Duration is measured from the beginning of one contraction to the end of the same contraction. Answer A refers to frequency. Answer B is incorrect because we do not measure from the end of one contraction to the beginning of the next contraction. Duration is not measured from the peak of the contraction to the end, as stated in D. 155. The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin, the nurse should monitor for: a. Maternal hypoglycemia b. Fetal bradycardia c. Maternal hyperreflexia d. Fetal movement Answer B is correct. The client receiving Pitocin should be monitored for decelerations. There is no association with Pitocin use and hypoglycemia, maternal hyperreflexia, or fetal movement; therefore, answers A, C, and D are incorrect. 156. A client with diabetes visits the prenatal clinic at 28 weeks gestation. Which statement is true regarding insulin needs during pregnancy? a. Insulin requirements moderate as the pregnancy progresses. b. A decreased need for insulin occurs during the second trimester. c. Elevations in human chorionic gonadotrophin decrease the need for insulin. d. Fetal development depends on adequate insulin regulation. Answer D is correct. Fetal development depends on adequate nutrition and insulin regulation. Insulin needs increase during the second and third trimesters, insulin requirements do not moderate as the pregnancy progresses, and elevated human chorionic gonadotrophin elevates insulin needs, not decreases them; therefore, answers A, B, and C are incorrect. 157. A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to: a. Providing a calm environment Nursing-Exam-Questions-12-AR 163. A client with hypothyroidism asks the nurse if she will still need to take thyroid medication during the pregnancy. The nurse's response is based on the knowledge that: a. There is no need to take thyroid medication because the fetus's thyroid produces a thyroid- stimulating hormone. b. Regulation of thyroid medication is more difficult because the thyroid gland increases in size during pregnancy. c. It is more difficult to maintain thyroid regulation during pregnancy due to a slowing of metabolism. d. Fetal growth is arrested if thyroid medication is continued during pregnancy. Answer B is correct. During pregnancy, the thyroid gland triples in size. This makes it more difficult to regulate thyroid medication. Answer A is incorrect because there could be a need for thyroid medication during pregnancy. Answer C is incorrect because the thyroid function does not slow. Fetal growth is not arrested if thyroid medication is continued, so answer D is incorrect. 164. The nurse is responsible for performing a neonatal assessment on a full-term infant. At 1 minute, the nurse could expect to find: a. An apical pulse of 100 b. An absence of tonus c. Cyanosis of the feet and hands d. Jaundice of the skin and sclera Answer C is correct. Cyanosis of the feet and hands is acrocyanosis. This is a normal finding 1 minute after birth. An apical pulse should be 120– 160, and the baby should have muscle tone, making answers A and B incorrect. Jaundice immediately after birth is pathological jaundice and is abnormal, so answer D is incorrect. 165. A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The nurse should anticipate the client's need for: a. Supplemental oxygen b. Fluid restriction c. Blood transfusion d. Delivery by Caesarean section Answer A is correct. Clients with sickle cell crises are treated with heat, hydration, oxygen, and pain relief. Fluids are increased, not decreased. Blood transfusions are usually not required, and the client can be delivered vaginally; thus, answers B, C, and D are incorrect. Nursing-Exam-Questions-12-AR 166. A client with diabetes has an order for ultrasonography. Preparation for an ultrasound includes: a. Increasing fluid intake b. Limiting ambulation c. Administering an enema d. Withholding food for 8 hours Answer A is correct. Before ultrasonography, the client should be taught to drink plenty of fluids and not void. The client may ambulate, an enema is not needed, and there is no need to withhold food for 8 hours. Therefore, answers B, C, and D are incorrect. 167. An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at 1 year? a. 14 pounds b. 16 pounds c. 18 pounds d. 24 pounds Answer D is correct. By 1 year of age, the infant is expected to triple his birth weight. Answers A, B, and C are incorrect because they are too low. 168. A pregnant client with a history of alcohol addiction is scheduled for a nonstress test. The nonstress test: a. Determines the lung maturity of the fetus b. Measures the activity of the fetus c. Shows the effect of contractions on the fetal heart rate d. Measures the neurological well- being of the fetus Answer B is correct. A nonstress test is done to evaluate periodic movement of the fetus. It is not done to evaluate lung maturity as in answer A. An oxytocin challenge test shows the effect of contractions on fetal heart rate and a nonstress test does not measure neurological well-being of the fetus, so answers C and D are incorrect. 169. A full-term male has hypospadias. Which statement describes hypospadias? a. The urethral opening is absent. b. The urethra opens on the dorsal side of the penis. c. The penis is shorter than usual. d. The urethra opens on the ventral side of the penis. Answer B is correct. Hypospadia is a condition in which there is an opening on the dorsal side of the penis. Answer A is incorrect because hypospadia does not concern the urethral opening. Answer C is incorrect because the size of the penis is not affected. Answer D is incorrect Nursing-Exam-Questions-12-AR because the opening is on the dorsal side, not the ventral side. 170. A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client's cervix is 8cm dilated, with complete effacement. The priority nursing diagnosis at this time is: a. Alteration in coping related to pain b. Potential for injury related to precipitate delivery c. Alteration in elimination related to anesthesia d. Potential for fluid volume deficit related to NPO status Answer A is correct. Transition is the time during labor when the client loses concentration due to intense contractions. Potential for injury related to precipitate delivery has nothing to do with the dilation of the cervix, so answer B is incorrect. There is no data to indicate that the client has had anesthesia or fluid volume deficit, making answers C and D incorrect. 171. The client with varicella will most likely have an order for which category of medication? a. Antibiotics b. Antipyretics c. Antivirals d. Anticoagulants Answer C is correct. Varicella is chicken pox. This herpes virus is treated with antiviral medications. The client is not treated with antibiotics or anticoagulants as stated in answers A and D. The client might have a fever before the rash appears, but when the rash appears, the temperature is usually gone, so answer B is incorrect. 172. A client is admitted complaining of chest pain. Which of the following drug orders should the nurse question? a. Nitroglycerin b. Ampicillin c. Propranolol d. Verapamil Answer B is correct. Clients with chest pain can be treated with nitroglycerin, a beta blocker such as propanolol, or Varapamil. There is no indication for an antibiotic such as Ampicillin, so answers A, C, and D are incorrect. 173. Which of the following instructions should be included in the teaching for the client with rheumatoid arthritis? a. Avoid exercise because it fatigues the joints. b. Take prescribed anti- inflammatory medications with meals. Nursing-Exam-Questions-12-AR sufficient nourishment, the nurse should: a. Serve high-calorie foods she can carry with her b. Encourage her appetite by sending out for her favorite foods c. Serve her small, attractively arranged portions d. Allow her in the unit kitchen for extra food whenever she pleases Answer A is correct. The client with mania is seldom sitting long enough to eat and burns many calories for energy. Answer B is incorrect because the client should be treated the same as other clients. Small meals are not a correct option for this client. Allowing her into the kitchen gives her privileges that other clients do not have and should not be allowed, so answer D is incorrect. 180. To maintain Bryant's traction, the nurse must make certain that the child's: a. Hips are resting on the bed, with the legs suspended at a right angle to the bed b. Hips are slightly elevated above the bed and the legs are suspended at a right angle to the bed c. Hips are elevated above the level of the body on a pillow and the legs are suspended parallel to the bed d. Hips and legs are flat on the bed, with the traction positioned at the foot of the bed Answer B is correct. Bryant’s traction is used for fractured femurs and dislocated hips. The hips should be elevated 15° off the bed. Answer A is incorrect because the hips should not be resting on the bed. Answer C is incorrect because the hips should not be above the level of the body. Answer D is incorrect because the hips and legs should not be flat on the bed. 181. Which action by the nurse indicates understanding of herpes zoster? a. The nurse covers the lesions with a sterile dressing. b. The nurse wears gloves when providing care. c. The nurse administers a prescribed antibiotic. d. The nurse administers oxygen. Answer B is correct. Herpes zoster is shingles. Clients with shingles should be placed in contact precautions. Wearing gloves during care will prevent transmission of the virus. Covering the lesions with a sterile gauze is not necessary, antibiotics are not prescribed for herpes zoster, Nursing-Exam-Questions-12-AR and oxygen is not necessary for shingles; therefore, answers A, C, and D are incorrect. 182. The client has an order for a trough to be drawn on the client receiving Vancomycin. The nurse is aware that the nurse should contact the lab for them to collect the blood: a. 15 minutes after the infusion b. 30 minutes before the infusion c. 1 hour after the infusion d. 2 hours after the infusion Answer B is correct. A trough level should be drawn 30 minutes before the third or fourth dose. The times in answers A, C, and D are incorrect times to draw blood levels. 183. The client using a diaphragm should be instructed to: a. Refrain from keeping the diaphragm in longer than 4 hours b. Keep the diaphragm in a cool location c. Have the diaphragm resized if she gains 5 pounds d. Have the diaphragm resized if she has any surgery Answer B is correct. The client using a diaphragm should keep the diaphragm in a cool location. Answers A, C, and D are incorrect. She should refrain from leaving the diaphragm in longer than 8 hours, not 4 hours. She should have the diaphragm resized when she gains or loses 10 pounds or has abdominal surgery. 184. The nurse is providing postpartum teaching for a mother planning to breastfeed her infant. Which of the client's statements indicates the need for additional teaching? a. "I'm wearing a support bra." b. "I'm expressing milk from my breast." c. "I'm drinking four glasses of fluid during a 24-hour period." d. "While I'm in the shower, I'll allow the water to run over my breasts." Answer C is correct. Mothers who plan to breastfeed should drink plenty of liquids, and four glasses is not enough in a 24-hour period. Wearing a support bra is a good practice for the mother who is breastfeeding as well as the mother who plans to bottle- feed, so answer A is incorrect. Expressing milk from the breast will stimulate milk production, making answer B incorrect. Allowing the water to run over the breast will also facilitate "letdown," when the milk begins to be produced; thus, answer D is incorrect. Nursing-Exam-Questions-12-AR 185. Damage to the VII cranial nerve results in: a. Facial pain b. Absence of ability to smell c. Absence of eye movement d. Tinnitus Answer A is correct. The facial nerve is cranial nerve VII. If damage occurs, the client will experience facial pain. The auditory nerve is responsible for hearing loss and tinnitus, eye movement is controlled by the Trochear or C IV, and the olfactory nerve controls smell; therefore, answers B, C, and D are incorrect. 186. A client is receiving Pyridium (phenazopyridine hydrochloride) for a urinary tract infection. The client should be taught that the medication may: a. Cause diarrhea b. Change the color of her urine c. Cause mental confusion d. Cause changes in taste Answer B is correct. Clients taking Pyridium should be taught that the medication will turn the urine orange or red. It is not associated with diarrhea, mental confusion, or changes in taste; therefore, answers A, C, and D are incorrect. Pyridium can also cause a yellowish color to skin and sclera if taken in large doses. 187. Which of the following tests should be performed before beginning a prescription of Accutane? a. Check the calcium level b. Perform a pregnancy test c. Monitor apical pulse d. Obtain a creatinine level Answer B is correct. Accutane is contraindicated for use by pregnant clients because it causes teratogenic effects. Calcium levels, apical pulse, and creatinine levels are not necessary; therefore, answers A, C, and D are incorrect. 188. A client with AIDS is taking Zovirax (acyclovir). Which nursing intervention is most critical during the administration of acyclovir? a. Limit the client's activity b. Encourage a high- carbohydrate diet c. Utilize an incentive spirometer to improve respiratory function d. Encourage fluids Answer D is correct. Clients taking Acyclovir should be encouraged to drink plenty of fluids because renal impairment can occur. Limiting activity is not necessary, nor is eating a high- carbohydrate diet. Use of an incentive spirometer Nursing-Exam-Questions-12-AR 196. The client with color blindness will most likely have problems distinguishing which of the following colors? a. Orange b. Violet c. Red d. White Answer B is correct. Clients with color blindness will most likely have problems distinguishing violets, blues, and green. The colors in answers A, C, and D are less commonly affected. 197. The client with a pacemaker should be taught to: a. Report ankle edema b. Check his blood pressure daily c. Refrain from using a microwave oven d. Monitor his pulse rate Answer D is correct. The client with a pacemaker should be taught to count and record his pulse rate. Answers A, B, and C are incorrect. Ankle edema is a sign of right- sided congestive heart failure. Although this is not normal, it is often present in clients with heart disease. If the edema is present in the hands and face, it should be reported. Checking the blood pressure daily is not necessary for these clients. The client with a pacemaker can use a microwave oven, but he should stand about 5 feet from the oven while it is operating. 198. The client with enuresis is being taught regarding bladder retraining. The nurse should advise the client to refrain from drinking after: a. 1900 b. 1200 c. 1000 d. 0700 Answer A is correct. Clients who are being retrained for bladder control should be taught to withhold fluids after about 7 p.m., or 1 The times in answers B, C, and D are too early in the day. 199. Which of the following diet instructions should be given to the client with recurring urinary tract infections? a. Increase intake of meats. b. Avoid citrus fruits. c. Perform pericare with hydrogen peroxide. d. Drink a glass of cranberry juice every day. Answer D is correct. Cranberry juice is more alkaline and, when metabolized by the body, is excreted with acidic urine. Bacteria does not grow freely in acidic urine. Increasing intake of meats is not associated with urinary tract infections, so Nursing-Exam-Questions-12-AR answer A is incorrect. The client does not have to avoid citrus fruits and pericare should be done, but hydrogen peroxide is drying, so answers B and C are incorrect. 200. The physician has prescribed NPH insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs? a. "I will make sure I eat breakfast within 2 hours of taking my insulin." b. "I will need to carry candy or some form of sugar with me all the time." c. "I will eat a snack around three o'clock each afternoon." d. "I can save my dessert from supper for a bedtime snack." Answer C is correct. NPH insulin peaks in 8– 12 hours, so a snack should be offered at that time. NPH insulin onsets in 90–120 minutes, so answer A is incorrect. Answer B is untrue because NPH insulin is time released and does not usually cause sudden hypoglycemia. Answer D is incorrect, but the client should eat a bedtime snack. 201. A client with pneumacystis carini pneumonia is receiving trimetrexate. The rationale for administering leucovorin calcium to a client receiving Methotrexate is to: a. Treat anemia. b. Create a synergistic effect. c. Increase the number of white blood cells. d. Reverse drug toxicity. Answer D is correct. Methotrexate is a folic acid antagonist. Leucovorin is the drug given for toxicity to this drug. It is not used to treat iron- deficiency anemia, create a synergistic effects, or increase the number of circulating neutrophils. Therefore, answers A, B, and C are incorrect. 202. A client tells the nurse that she is allergic to eggs, dogs, rabbits, and chicken feathers. Which order should the nurse question? a. TB skin test b. Rubella vaccine c. ELISA test d. Chest x-ray Answer B is correct. The client who is allergic to dogs, eggs, rabbits, and chicken feathers is most likely allergic to the rubella vaccine. The client who is allergic to neomycin is also at risk. There is no danger to the client if he has an order for a TB skin test, ELISA test, or chest x-ray; thus, answers A, C, and D are incorrect. Nursing-Exam-Questions-12-AR 203. The physician has prescribed rantidine (Zantac) for a client with erosive gastritis. The nurse should administer the medication: a. 30 minutes before meals b. With each meal c. In a single dose at bedtime d. 60 minutes after meals Answer B is correct. Zantac (rantidine) is a histamine blocker that should be given with meals for optimal effect, not before meals. However, Tagamet (cimetidine) is a histamine blocker that can be given in one dose at bedtime. Neither of these drugs should be given before or after meals, so answers A and D are incorrect. 204. A temporary colostomy is performed on the client with colon cancer. The nurse is aware that the proximal end of a double barrel colostomy: a. Is the opening on the client's left side b. Is the opening on the distal end on the client's left side c. Is the opening on the client's right side d. Is the opening on the distal right side Answer C is correct. The proximal end of the double-barrel colostomy is the end toward the small intestines. This end is on the client’s right side. The distal end, as in answers A, B, and D, is on the client’s left side. 205. While assessing the postpartal client, the nurse notes that the fundus is displaced to the right. Based on this finding, the nurse should: a. Ask the client to void b. Assess the blood pressure for hypotension c. Administer oxytocin d. Check for vaginal bleeding Answer A is correct. If the nurse checks the fundus and finds it to be displaced to the right or left, this is an indication of a full bladder. This finding is not associated with hypotension or clots, as stated in answer B. Oxytoxic drugs (Pitocin) are drugs used to contract the uterus, so answer C is incorrect. It has nothing to do with displacement of the uterus. Answer D is incorrect because displacement is associated with a full bladder, not vaginal bleeding. 206. The physician has ordered an MRI for a client with an orthopedic ailment. An MRI should not be done if the client has: a. The need for oxygen therapy Nursing-Exam-Questions-12-AR c. Lactated Ringer's d. Dextrose 5% in .45 normal saline Answer A is correct. The best IV fluid for correction of dehydration isnormal saline because it is most like normal serum. Dextrose pulls fluid from the cell, lactated Ringer’s contains more electrolytes than the client’s serum, and dextrose with normal saline will also alter the intracellular fluid. Therefore, answers B, C, and D are incorrect. 213. The physician has ordered a thyroid scan to confirm the diagnosis. Before the procedure, the nurse should: a. Assess the client for allergies b. Bolus the client with IV fluid c. Tell the client he will be asleep d. Insert a urinary catheter Answer A is correct. A thyroid scan uses a dye, so the client should be assessed for allergies to iodine. The client will not have a bolus of fluid, will not be asleep, and will not have a urinary catheter inserted, so answers B, C, and D are incorrect. 214. The physician has ordered an injection of RhoGam for a client with blood type A negative. The nurse understands that RhoGam is given to: a. Provide immunity against Rh isoenzymes b. Prevent the formation of Rh antibodies c. Eliminate circulating Rh antibodies d. Convert the Rh factor from negative to positive Answer B is correct. RhoGam is used to prevent formation of Rh antibodies. It does not provide immunity to Rh isoenzymes, eliminate circulating Rh antibodies, or convert the Rh factor from negative to positive; thus, answers A, C, and D are incorrect. 215. The nurse is caring for a client admitted to the emergency room after a fall. X-rays reveal that the client has several fractured bones in the foot. Which treatment should the nurse anticipate for the fractured foot? a. Application of a short inclusive spica cast b. Stabilization with a plaster-of- Paris cast c. Surgery with Kirschner wire implantation d. A gauze dressing only Answer B is correct. A client with a fractured foot often has a short leg cast applied to stabilize the fracture. A spica cast is used to stabilize a fractured pelvis or vertebral fracture. Kirschner Nursing-Exam-Questions-12-AR wires are used to stabilize small bones such as toes and the client will most likely have a cast or immobilizer, so answers A, C, and D are incorrect. 216. A client with bladder cancer is being treated with iridium seed implants. The nurse's discharge teaching should include telling the client to: a. Strain his urine b. Increase his fluid intake c. Report urinary frequency d. Avoid prolonged sitting Answer A is correct. Iridium seeds can be expelled during urination, so the client should be taught to strain his urine and report to the doctor if any of the seeds are expelled. Increasing fluids, reporting urinary frequency, and avoiding prolonged sitting are not necessary; therefore, answers B, C, and D are incorrect. 217. Following a heart transplant, a client is started on medication to prevent organ rejection. Which category of medication prevents the formation of antibodies against the new organ? a. Antivirals b. Antibiotics c. Immunosuppressants d. Analgesics Answer C is correct. Immunosuppressants are used to prevent antibody formation. Antivirals, antibiotics, and analgesics are not used to prevent antibody production, so answers A, B, and D are incorrect. 218. The nurse is preparing a client for cataract surgery. The nurse is aware that the procedure will use: a. Mydriatics to facilitate removal b. Miotic medications such as Timoptic c. A laser to smooth and reshape the lens d. Silicone oil injections into the eyeball Answer A is correct. Before cataract removal, the client will have Mydriatic drops instilled to dilate the pupil. This will facilitate removal of the lens. Miotics constrict the pupil and are not used in cataract clients. A laser is not used to smooth and reshape the lens; the diseased lens is removed. Silicone oil is not injected in this client; thus, answers B, C, and D are incorrect. 219. A client with Alzheimer's disease is awaiting placement in a skilled nursing facility. Which long-term plans would be most therapeutic for the client? a. Placing mirrors in several locations in the home Nursing-Exam-Questions-12-AR b. Placing a picture of herself in her bedroom c. Placing simple signs to indicate the location of the bedroom, bathroom, and so on d. Alternating healthcare workers to prevent boredom Answer C is correct. Placing simple signs that indicate the location of rooms where the client sleeps, eats, and bathes will help the client be more independent. Providing mirrors and pictures is not recommended with the client who has Alzheimer’s disease because mirrors and pictures tend to cause agitation, and alternating healthcare workers confuses the client; therefore, answers A, B, and D are incorrect. 220. A client with an abdominal cholecystectomy returns from surgery with a Jackson-Pratt drain. The chief purpose of the Jackson- Pratt drain is to: a. Prevent the need for dressing changes b. Reduce edema at the incision c. Provide for wound drainage d. Keep the common bile duct open Answer C is correct. A Jackson-Pratt drain is a serum-collection device commonly used in abdominal surgery. A Jackson-Pratt drain will not prevent the need for dressing changes, reduce edema of the incision, or keep the common bile duct open, so answers A, B, and D are incorrect. A t-tube is used to keep the common bile duct open. 221. The nurse is performing an initial assessment of a newborn Caucasian male delivered at 32 weeks gestation. The nurse can expect to find the presence of: a. Mongolian spots b. Scrotal rugae c. Head lag d. Vernix caseosa Answer C is correct. The infant who is 32 weeks gestation will not be able to control his head, so head lag will be present. Mongolian spots are common in African American infants, not Caucasian infants; the client at 32 weeks will have scrotal rugae or redness but will not have vernix caseosa, the cheesy appearing covering found on most full-term infants. Therefore, answers A, B, and D are incorrect. 222. The nurse is caring for a client admitted with multiple trauma. Fractures include the pelvis, femur, and ulna. Which finding should be reported to the physician immediately? Nursing-Exam-Questions-12-AR c. Administer an antiviral d. Tell the client that he should remain in isolation for 2 weeks Answer B is correct. The client who is immune- suppressed and is exposed to measles should be treated with medications to boost his immunity to the virus. An antibiotic or antiviral will not protect the client and it is too late to place the client in isolation, so answers A, C, and D are incorrect. 229. A client hospitalized with MRSA (methicillin-resistant staph aureus) is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact? a. The client should be placed in a room with negative pressure. b. Infection requires close contact; therefore, the door may remain open. c. Transmission is highly likely, so the client should wear a mask at all times. d. Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown. Answer D is correct. The client with MRSA should be placed in isolation. Gloves, a gown, and a mask should be used when caring for the client and hand washing is very important. The door should remain closed, but a negative-pressure room is not necessary, so answers A and B are incorrect. MRSA is spread by contact with blood or body fluid or by touching the skin of the client. It is cultured from the nasal passages of the client, so the client should be instructed to cover his nose and mouth when he sneezes or coughs. It is not necessary for the client to wear the mask at all times; the nurse should wear the mask, so answer C is incorrect. 230. A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates understanding of phantom limb pain? a. "The pain will go away in a few days." b. "The pain is due to peripheral nervous system interruptions. I will get you some pain medication." c. "The pain is psychological because your foot is no longer there." d. "The pain and itching are due to the infection you had before the surgery." Answer B is correct. Pain related to phantom limb syndrome is due to peripheral nervous system interruption. Answer A is incorrect because Nursing-Exam-Questions-12-AR phantom limb pain can last several months or indefinitely. Answer C is incorrect because it is not psychological. It is also not due to infections, as stated in answer D. 231. A client with cancer of the pancreas has undergone a Whipple procedure. The nurse is aware that during the Whipple procedure, the doctor will remove the: a. Head of the pancreas b. Proximal third section of the small intestines c. Stomach and duodenum d. Esophagus and jejunum Answer A is correct. During a Whipple procedure the head of the pancreas, which is a part of the stomach, the jejunum, and a portion of the stomach are removed and reanastomosed. Answer B is incorrect because the proximal third of the small intestine is not removed. The entire stomach is not removed, as in answer C, and in answer D, the esophagus is not removed. 232. The physician has ordered a minimal- bacteria diet for a client with neutropenia. The client should be taught to avoid eating: a. Fruits b. Salt c. Pepper d. Ketchup Answer C is correct. Pepper is not processed and contains bacteria. Answers A, B, and D are incorrect because fruits should be cooked or washed and peeled, and salt and ketchup are allowed. 233. A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to: a. Have a Protime done monthly b. Eat more fruits and vegetables c. Drink more liquids d. Avoid crowds Answer A is correct. Coumadin is an anticoagulant. One of the tests for bleeding time is a Protime. This test should be done monthly. Eating more fruits and vegetables is not necessary, and dark-green vegetables contain vitamin K, which increases clotting, so answer B is incorrect. Drinking more liquids and avoiding crowds is not necessary, so answers C and D are incorrect. 234. The nurse is assisting the physician with removal of a central venous catheter. To facilitate removal, the nurse should instruct the client to: Nursing-Exam-Questions-12-AR a. Perform the Valsalva maneuver as the catheter is advanced b. Turn his head to the left side and hyperextend the neck c. Take slow, deep breaths as the catheter is removed d. Turn his head to the right while maintaining a sniffing position Answer A is correct. The client who is having a central venous catheter removed should be told to hold his breath and bear down. This prevents air from entering the line. Answers B, C, and D will not facilitate removal. 235. A client has an order for streptokinase. Before administering the medication, the nurse should assess the client for: a. Allergies to pineapples and bananas b. A history of streptococcal infections c. Prior therapy with phenytoin d. A history of alcohol abuse Answer B is correct. Clients with a history of streptococcal infections could have antibodies that render the streptokinase ineffective. There is no reason to assess the client for allergies to pineapples or bananas, there is no correlation to the use of phenytoin and streptokinase, and a history of alcohol abuse is also not a factor in the order for streptokinase; therefore, answers A, C, and D are incorrect. 236. The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid: a. Using oil- or cream-based soaps b. Flossing between the teeth c. The intake of salt d. Using an electric razor Answer B is correct. The client who is immune- suppressed and has bone marrow suppression should be taught not to floss his teeth because platelets are decreased. Using oils and cream- based soaps is allowed, as is eating salt and using an electric razor; therefore, answers A, C, and D are incorrect. 237. The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to: a. Apply the new tie before removing the old one. b. Have a helper present. c. Hold the tracheotomy with the nondominant hand while removing the old tie. d. Ask the doctor to suture the tracheostomy in place. Nursing-Exam-Questions-12-AR Answer C is correct. The monitor indicates variable decelerations caused by cord compression. If Pitocin is infusing, the nurse should turn off the Pitocin. Instructing the client to push is incorrect because pushing could increase the decelerations and because the client is 8cm dilated, making answer A incorrect. Performing a vaginal exam should be done after turning off the Pitocin, and placing the client in a semi- Fowler’s position is not appropriate for this situation; therefore, answers B and D are incorrect. 244. The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as: a. Atrial flutter b. A sinus rhythm c. Ventricular tachycardia d. Atrial fibrillation Answer C is correct. The graph indicates ventricular tachycardia. The answers in A, B, and D are not noted on the ECG strip. 245. A client with clotting disorder has an order to continue Lovenox (enoxaparin) injections after discharge. The nurse should teach the client that Lovenox injections should: a. Be injected into the deltoid muscle b. Be injected into the abdomen c. Aspirate after the injection d. Clear the air from the syringe before injections Answer B is correct. Lovenox injections should be given in the abdomen, not in the deltoid muscle. The client should not aspirate after the injection or clear the air from the syringe before injection. Therefore, answers A, C, and D are incorrect. 246. The nurse has a preop order to administer Valium (diazepam) 10mg and Phenergan (promethazine) 25mg. The correct method of administering these medications is to: a. Administer the medications together in one syringe b. Administer the medication separately c. Administer the Valium, wait 5 minutes, and then inject the Phenergan Nursing-Exam-Questions-12-AR d. Question the order because they cannot be given at the same time Answer B is correct. Valium is not given in the same syringe with other medications, so answer A is incorrect. These medications can be given to the same client, so answer D is incorrect. In answer C, it is not necessary to wait to inject the second medication. Valium is an antianxiety medication, and Phenergan is used as an antiemetic. 247. A client with frequent urinary tract infections asks the nurse how she can prevent the reoccurrence. The nurse should teach the client to: a. Douche after intercourse b. Void every 3 hours c. Obtain a urinalysis monthly d. Wipe from back to front after voiding Answer B is correct. Voiding every 3 hours prevents stagnant urine from collecting in the bladder, where bacteria can grow. Douching is not recommended and obtaining a urinalysis monthly is not necessary, making answers A and C incorrect. The client should practice wiping from front to back after voiding and bowel movements, so answer D is incorrect. 248. Which task should be assigned to the nursing assistant? a. Placing the client in seclusion b. Emptying the Foley catheter of the preeclamptic client c. Feeding the client with dementia d. Ambulating the client with a fractured hip Answer C is correct. Of these clients, the one who should be assigned to the care of the nursing assistant is the client with dementia. Only an RN or the physician can place the client in seclusion, so answer A is incorrect. The nurse should empty the Foley catheter of the preeclamptic client because the client is unstable, making answer B incorrect. A nurse or physical therapist should ambulate the client with a fractured hip, so answer D is incorrect. 249. The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside? a. A tracheotomy set b. A padded tongue blade c. An endotracheal tube d. An airway Answer A is correct. The client who has recently had a thyroidectomy is at risk for tracheal edema. A padded tongue blade is used for seizures and not for the client with tracheal edema, so answer Nursing-Exam-Questions-12-AR B is incorrect. If the client experiences tracheal edema, the endotracheal tube or airway will not correct the problem, so answers C and D are incorrect. 250. The physician has ordered a histoplasmosis test for the elderly client. The nurse is aware that histoplasmosis is transmitted to humans by: a. Cats b. Dogs c. Turtles d. Birds Answer D is correct. Histoplasmosis is a fungus carried by birds. It is not transmitted to humans by cats, dogs, or turtles. Therefore, answers A, B, and C are incorrect. 1. A client is admitted to the emergency room with a gunshot wound to the right arm. After dressing the wound and administering the prescribed antibiotic, the nurse should: A.Ask the client if he has any medication allergies B.Check the client’s immunization record C.Apply a splint to immobilize the arm D.Administer medication for pain Answer B is correct. The nurse should check the client’s immunization record to determine the date of the last tetanus immunization. The nurse should question the client regarding allergies to medications before administering medication; therefore,answer A is incorrect. Answer C is incorrect because a sling, not a spint, should be applied to imimobilize the arm and prevent dependent edema. Answer D is incorrect because pain medication would be given before cleaning and dressing the wound, not after ward. 2. The nurse is caring for a client with suspected endometrial cancer. Which symptom is associated with endometrial cancer? A.Frothy vaginal discharge B.Thick, white vaginal discharge C.Purulent vaginal discharge D.Watery vaginal discharge Answer D is correct. Watery vaginal discharge and painless bleeding are associated with endometrial cancer. Frothy vaginal discharge describes trichomonas infection; thick, white vaginal discharge describes infection with candida albicans; and purulent vaginal discharge describes pelvic inflammatory Nursing-Exam-Questions-12-AR are difficult to control. Answers A, B, and D are incorrect because they do not focus on autistic disorder. 9. The parents of a child with cystic fibrosis ask what determines the prognosis of the disease. The nurse knows that the greatest determinant of the prognosis is: A.The degree of pulmonary involvement B.The ability to maintain an ideal weight C.The secretion of lipase by the pancreas D.The regulation of sodium and chloride excretion Answer A is correct. The degree of pulmonary involvement is the greatest determinant in the prognosis of cystic fibrosis. Answers B, C, and D are affected by cystic fibrosis; however, they are not major determinants of the prognosis of the disease 10. The nurse is assessing a client hospitalized with duodenal ulcer. Which finding should be reported to the doctor immediately? A.BP 82/60, pulse 120 B.Pulse 68, respirations 24 C.BP 110/88, pulse 56 D.Pulse 82, respirations 16 Answer A is correct. Decreased blood pressure and increased pulse rate are associated with bleeding and shock. Answers B, C, and D are within normal limits; thus, incorrect. 11. While caring for a client in the second stage of labor, the nurse notices a pattern of early decelerations. The nurse should: A.Notify the physician immediately B.Turn the client on her left side C.Apply oxygen via a tight face mask D.Document the finding on the flow sheet Answer D is correct. Early decelerations during the second stage of labor are benign and are the result of fetal head compression that occurs during normal contractions. No action is necessary other than documenting the finding on the flow sheet. Answers A, B, and C are interventions for the client with late decelerations, which reflect ureteroplacental insufficiency. 12. The nurse is teaching the client with AIDS regarding needed changes in food preparation. Which statement indicates that the client understands the nurse’s teaching? Nursing-Exam-Questions-12-AR A.“Adding fresh ground pepper to my food will improve the flavor.” B.“Meat should be thoroughly cooked to the proper temperature.” C.“Eating cheese and yogurt will prevent AIDS- related diarrhea.” D.“It is important to eat four to five servings of fresh fruits and vegetables a day.” Answer B is correct. The client’s statement that meat should be thoroughly cooked to the appropriate temperature indicates an understanding of the nurse’s teaching regarding food preparation. Undercooked meat is a source of toxoplasmosis cysts. Toxoplasmosis is a major cause of encephalitis in clients with AIDS. Answer A is incorrect because fresh- ground pepper contains bacteria that can cause illness in the client with AIDS. Answer C is an incorrect choice because cheese contains molds and yogurt contains live cultures that the client with AIDS must avoid. Answer D is incorrect because fresh fruit and vegetables contain microscopic organisms that can cause illness in the client with AIDS. 13. The sputum of a client remains positive for the tubercle bacillus even though the client has been taking Laniazid (isoniazid). The nurse recognizes that the client should have a negative sputum culture within: A.2 weeks B.6 weeks C.8 weeks D.12 weeks Answer D is correct. The client taking isoniazid should have a negative sputum culture within 3 months. Continued positive cultures reflect noncompliance with therapy or the development of strains resistant to the medication. Answers A, B, and C are incorrect because there has not been sufficient time for the medication to be effective. 14. Which person is at greatest risk for developing Lyme’s disease? A.Computer programmer B.Elementary teacher C.Veterinarian D.Landscaper Answer D is correct. Lyme’s disease is transmitted by ticks found on deer and mice in wooded areas. The people in answers A and B have little risk of the disease. Nursing-Exam-Questions-12-AR Veterinarians are exposed to dog ticks, which carry Rocky Mountain Spotted Fever, so answer C is incorrect. 15. The mother of a 1-year-old wants to know when she should begin toilet-training her child. The nurse’s response is based on the knowledge that sufficient sphincter control for toilet training is present by: A. 2–15 months of age B.18–24 months of age C.26–30 months of age D.32–36 months of age Answer B is correct. Children ages 18–24 months normally have sufficient sphincter control necessary for toilet training. Answer A is incorrect because the child is not developmentally capable of toilet training. Answers C and D are incorrect choices because toilet training should already be established. 16. The nurse is developing a plan of care for a client with an ileostomy. The priority nursing diagnosis is: A.Fluid volume deficit B.Alteration in body image C.Impaired oxygen exchange D.Alteration in elimination Answer A is correct. Large amounts of fluid and electrolytes are lost in the stools of the client with an ileostomy. The priority of nursing care is meeting the client’s fluid and electrolyte needs. Answers B and D do apply to clients with an ileostomy, but they are not the priority nursing diagnosis. Answer C does not apply to the client with an ileostomy and is, therefore, incorrect. 17. The physician has prescribed Cobex (cyanocobalamin) for a client following a gastric resection. Which lab result indicates that the medication is having its intended effect? A.Neutrophil count of 4500 B.Hgb of 14.2g C.Platelet count of 250,000 D.Eosinophil count of 200 Answer B is correct. Cobex is an injectable form of cyanocobalamin or vitamin B12. Increased Hgb levels reflect the effectiveness of the medication. Answers A, C, and D do not reflect the effectiveness of the medication; therefore, they are incorrect. Nursing-Exam-Questions-12-AR 24. A client scheduled for disc surgery tells the nurse that she frequently uses the herbal supplement kava-kava (piper methysticum). The nurse should notify the doctor because kava- kava: A. Increases the effects of anesthesia and post- operative analgesia B.Eliminates the need for antimicrobial therapy following surgery C. Increases urinary output, so a urinary catheter will be needed post-operatively D.Depresses the immune system, so infection is more of a problem Answer A is correct. Kava-kava can increase the effects of anesthesia and post-operative analgesia. Answers B, C, and D are not related to the use of kava-kava; therefore, they are incorrect. 25. The physician has ordered 50mEq of potassium chloride for a client with a potassium level of 2.5mEq. The nurse should administer the medication: A.Slow, continuous IV push over 10 minutes B.Continuous infusion over 30 minutes C.Controlled infusion over 5 hours D.Continuous infusion over 24 hours Answer C is correct. The maximum recommended rate of an intravenous infusion of potassium chloride is 5– 10mEq per hour, never to exceed 20mEq per hour. An intravenous infusion controller is always used to regulate the flow. Answer A is incorrect because potassium chloride is not given IV push. Answer B is incorrect because the infusion time is too brief. Answer D is incorrect because the infusion time is too long. 26. The nurse reviewing the lab results of a client receiving Cytoxan (cyclophasphamide) for Hodgkin’s lymphoma finds the following: WBC 4,200, RBC 3,800,000, platelets 25,000, and serum creatinine 1.0mg. The nurse recognizes that the greatest risk for the client at this time is: A.Overwhelming infection B.Bleeding C.Anemia D.Renal failure Answer B is correct. The normal platelet count is 150,000– 400,000; therefore, the client is at high risk for spontaneous bleeding. Answer A is incorrect because the WBC is a low normal; therefore, over Nursing-Exam-Questions-12-AR whelming infection is not a risk at this time. The RBC is low, but anemia at this point is not life threatening; therefore, answer C is incorrect. Answer D is incorrect because the serum creatinine is within normal limits. 27. While administering a chemotherapeutic vesicant, the nurse notes that there is a lack of blood return from the IV catheter. The nurse should: A.Stop the medication from infusing B.Flush the IV catheter with normal saline C.Apply a tourniquet and call the doctor D.Continue the IV and assess the site for edema Answer A is correct. The nurse should stop the infusion. The medication should be restarted through a new IV access. Answer B is incorrect because IV catheters are not to be flushed. Answer C is incorrect because a tourniquet would not be applied to the area. Answer D is incorrect because the IV should not be allowed to continue infusing because the medication is a vesicant and, in the event of infiltration, the tissue would be damaged or destroyed. 28. A client with cervical cancer has a radioactive implant. Which statement indicates that the client understands the nurse’s teaching regarding radioactive implants? A.“I won’t be able to have visitors while getting radiation therapy.” B.“I will have a urinary catheter while the implant is in place.” C.“I can be up to the bedside commode while the implant is in place.” D.“I won’t have any side effects from this type of therapy.” Answer B is correct. The client will have a urinary catheter inserted to keep the bladder empty during radiation therapy. Answer A is incorrect because visitors are allowed to see the client for short periods of time, as long as they maintain a distance of 6 feet from the client. Answer C is incorrect because the client is on bed rest. Side effects from radiation therapy include pain, nausea, vomiting, and dehydration; therefore, answer D is incorrect. 29. The nurse is teaching circumcision care to the mother of a newborn. Which statement indicates that the mother needs further teaching? Nursing-Exam-Questions-12-AR A.“I will apply a petroleum gauze to the area with each diaper change.” B.“I will clean the area carefully with each diaper change.” C.“I can place a heat lamp to the area to speed up the healing process.” D."I should carefully observe the area for signs of infection.” Answer C is correct. The mother does not need to place an external heat source near the newborn. It will not promote healing, and there is a chance that the newborn could be burned, so the mother needs further teaching. Answers A, B, and D indicate correct care of the newborn who has been circumcised and are incorrect. 30. A client admitted for treatment of bacterial pneumonia has an order for intravenous ampicillin. Which specimen should be obtained prior to administering the medication? A.Routine urinalysis B.Complete blood count C.Serum electrolytes D.Sputum for culture and sensitivity Answer D is correct. A sputum specimen for culture and sensitivity should be obtained before the antibiotic is administered to determine whether the organism is sensitive to the prescribed medication. A routine urinalysis, complete blood count and serum electrolytes can be obtained after the medication is initiated; therefore, Answers A, B, and C are incorrect. 31. While obtaining information about the client’s current medication use, the nurse learns that the client takes ginkgo to improve mental alertness. The nurse should tell the client to: A.Report signs of bruising or bleeding to the doctor B.Avoid sun exposure while using the herbal C.Purchase only those brands with FDA approval D.Increase daily intake of vitamin E Answer A is correct. Ginkgo interacts with many medications to increase the risk of bleeding; therefore, bruising or bleeding should be reported to the doctor. Photosensitivity is not a side effect of ginkgo; therefore, answer B is incorrect. Answer C is incorrect because the FDA does not regulate herbals and natural products. The client does not Nursing-Exam-Questions-12-AR C.Check for a hissing sound as the inhaler is used D.Press the inhaler and watch for the mist Answer B is correct. The client can check the inhaler by dropping it into a container of water. If the inhaler is half full, it will float upside down with one- fourth of the container remaining above the water line. Answers A, C, and D do not help determine the amount of medication remaining. 39. The nurse is caring for a client following a right nephrolithotomy. Post-operatively, the client should be positioned: A.On the right side B.Supine C.On the left side D.Prone Answer C is correct. Following a nephrolithotomy, the client should be positioned on the unoperative side. Answers A, B, and D are incorrect positions for the client following a nephrolithotomy. 40. A client is admitted with sickle cell crises and sequestration. Upon assessing the client, the nurse would expect to find: A.Decreased blood pressure B.Moist mucus membranes C.Decreased respirations D.Increased blood pressure Answer A is correct. The client with sickle cell crisis and sequestration can be expected to have signs of hypovolemia, including decreased blood pressure. Answer B is incorrect because the client would have dr y mucus membranes. Answer C is incorrect because the client would have increased respirations because of pain associated with sickle cell crisis. Answer D is incorrect because the client’s blood pressure would be decreased. 41. A healthcare worker is referred to the nursing office with a suspected latex allergy. The first symptom of latex allergy is usually: A.Oral itching after eating bananas B.Swelling of the eyes and mouth C.Difficulty in breathing D.Swelling and itching of the hands Answer D is correct. The first sign of latex allergy is usually contact dermatitis, which includes swelling and itching of Nursing-Exam-Questions-12-AR the hands. Answers A, B, and C can also occur but are not the first signs of latex allergy. 42. A client is admitted with disseminated herpes zoster. According to the Centers for Disease Control Guidelines for Infection Control: A.Airborne precautions will be needed. B.No special precautions will be needed. C.Contact precautions will be needed. D.Droplet precautions will be needed. Answer A is correct. The nurse caring for the client with disseminated herpes zoster (shingles) should use airborne precautions as outlined by the CDC. Answer B is incorrect because precautions are needed to prevent transmission of the disease. Answer C and D are incorrect because airborne precautions are used, not contact or droplet precautions. 43. Acticoat (silver nitrate) dressings are applied to the legs of a client with deep partial thickness burns. The nurse should: A.Change the dressings once per shift B.Moisten the dressing with sterile water C.Change the dressings only when they become soiled D.Moisten the dressing with normal saline Answer B is correct. Acticoat, a commercially prepared dressing, should be moistened with sterile water. Answers A and C are incorrect because Acticoat dressings remain in place up to 5 days. Answer D is incorrect because normal saline should not be used to moisten the dressing. 44. The nurse is preparing to administer an injection to a 6-month-old when she notices a white dot in the infant’s right pupil. The nurse should: A.Report the finding to the physician immediately B.Record the finding and give the infant’s injection C.Recognize that the finding is a variation of normal D.Check both eyes for the presence of the red reflex Answer A is correct. The presence of a white or gray dot (a cat’s eye reflex) in the pupil is associated with retinoblastoma, a highly malignant tumor of the eye. The nurse should report the finding to the physician immediately so that it can be further evaluated. Simply recording the finding can delay Nursing-Exam-Questions-12-AR diagnosis and treatment; therefore, answer B is incorrect. Answer C is incorrect because it is not a variation of normal. Answer D is incorrect because the presence of the red reflex is a normal finding. 45. A client is diagnosed with stage II Hodgkin’s lymphoma. The nurse recognizes that the client has involvement: A. In a single lymph node or single site B. In more than one node or single organ on the same side of the diaphragm C. In lymph nodes on both sides of the diaphragm D. In disseminated organs and tissues Answer B is correct. Stage II indicates that multiple lymph nodes or organs are involved on the same side of the diaphragm. Answer A refers to stage I Hodgkin’s lymphoma, answer C refers to stage III Hodgkin’s lymphoma, and answer D refers to stage IV Hodgkin’s lymphoma. 46. A client has been receiving Rheumatrex (methotrexate) for severe rheumatoid arthritis. The nurse should tell the client to avoid taking: A.Aspirin B.Multivitamins C.Omega 3 fish oils D.Acetaminophen Answer B is correct. The client taking methotrexate should avoid multivitaminsbecause multivitamins contain folic acid. Methotrexate is a folic acid antagonist.Answers A and D are incorrect because aspirin and acetaminophen are given to relieve pain and inflammation associated with rheumatoid arthritis. Answer C is incorrect because omega 3 and omega 6 fish oils have proven beneficial for the client with rheumatoid arthritis. 47. The physician has ordered a low- residue diet for a client with Crohn’s disease. Which food is not permitted in a low-residue diet? A.Mashed potatoes B.Smooth peanut butter C.Fried fish D.Rice Answer C is correct. Fried foods are not permitted on a low-residue diet. Answers A, B, and D are all allowed on a low- residue diet and, therefore, are incorrect.