NURSING MISC PRACTICE EXAM QUESTIONS AND ANSWERS BEST RATED A+ GUARANTEED SUCCESS NEW UPDA, Exams of Health sciences

Download NURSING MISC PRACTICE EXAM QUESTIONS AND ANSWERS BEST RATED A+ GUARANTEED SUCCESS NEW UPDA and more Exams Health sciences in PDF only on Docsity! NURSING MISC PRACTICE EXAM QUESTIONS AND ANSWERS BEST RATED A+ GUARANTEED SUCCESS NEW UPDATE 2022-2023 1. A nurse is instilling an otic solution into the adult client’s left ear. The nurse avoids doing which of the following as part of this procedure? Options: A) Warming the solution to room temperature B) Placing the client in a side-lying position with the ear facing up C) Pulling the auricle backward and upward D) Placing the tip of the dropper on the edge of the ear canal Correct Answer is: D Explanation : The dropper is not allowed to touch any object or any part of the client’s skin. The solution is warmed before use. The client is placed on the side with the affected ear upward. The nurse pulls the auricle backward and upward and instills the medication by holding the dropper about 1 cm above the ear canal. 2. Levothyroxine sodium (Synthroid) is administered to a hospitalized child with congenital hypothyroidism. The child vomits 10 minutes after administration of the dose. The most appropriate nursing action is to: Options: A) Repeat the prescribed dose B) Give two doses of the prescribed medicine on the next day C) Contact the physician immediately D) Hold the dose for today Correct Answer is: A Explanation : Levothyroxine sodium (Synthroid) is the medication of choice for hypothyroidism. The most P a g e 1 | 99 significant factor adversely affecting the eventual intelligence of children born with congenital hypothyroidism is inadequate treatment. Therefore, compliance with the medication regimen is essential. If the infant or child vomits within 1 hour of taking medication, the dose should be administered again. 3 A client diagnosed as having catatonic excitement has been pacing rapidly non-stop for several hours and is not eating or drinking. The nurse recognizes that in this situation: Options: A) There is an urgent need for physical and medical control B) There is an urgent need for restraint C) There is a need to encourage verbalization of feelings D) The client will soon become catatonic stuporous Correct Answer is: A Explanation : Catatonic excitement is manifested by a state of extreme psychomotor agitation. Clients urgently require physical and medical control because they are often destructive and violent to others, and their excitement can cause them to injure themselves or to collapse from complete exhaustion. Options 2, 3, and 4 are incorrect. 4A 52-year-old male client is seen in the physician’s office for a physical examination after experiencing unusual fatigue over the last several weeks. The client’s height is 5 feet, 8 inches, and weight is 220 pounds. Vital signs are temperature 98o F orally, pulse 86 beats per minute, and respirations 18 breaths per minute. The blood pressure (BP) is 184/100 mmHg. Random blood glucose is 122 mg/dL. Which of the following questions should the nurse ask the client first? Options: A) Do you exercise regularly? B) Are you considering trying to lose weight? C) Is there a history of diabetes mellitus in your family? D) When was the last time you had your blood pressure checked? P a g e 2 | 99 Correct Answer is: D Explanation : The client’s activity is kept to a minimum to prevent Valsalva maneuver. Clients often hold their breath and strain while pulling up to get out of bed. This exertion may cause a rise in blood pressure, which increases bleeding. Clients who have bleeding aneurysms in any vessel will have activity curtailed. Therefore, options 1, 2, and 3 are incorrect actions. 9A physician calls a nurse to obtain the daily laboratory results of a client receiving total parenteral nutrition (TPN). Which laboratory result would the nurse obtain from the client’s record because it would provide the most valuable information regarding the client’s status related to the TPN? Options: A) Serum electrolyte levels B) Arterial blood gas (ABG) levels C) White blood cell count (WBC) D) Complete blood cell count (CBC) Correct Answer is: A Explanation : TPN solutions contain amino acid and dextrose solutions, with electrolyte and trace elements added. The physician uses the electrolyte values to determine whether changes are needed in the composition of the TPN solutions that will be administered over the next 24 hours. This prevents the client from developing electrolyte imbalance, Options 2, 3, and 4 are not directly related to evaluating client status regarding TPN. 10A client who has episodes of bronchospasm and a history of tachydysrhythmias is admitted to the hospital. The nurse reviews the physician’s orders and contacts the physician to verify which medication, if prescribed by the physician? Options: A) Metaproterenol (Alupent) B) Albuterol (Proventil) C) Epinephrine (Primatene Mist) P a g e 5 | 99 D) Salmeterol (servent) P a g e 6 | 99 Correct Answer is: C Explanation : A client with a history of tachydysrhythmias should not be given bronchodilators that contain catecholamines, such as epinephrine and isoproterenol hydrochloride (Isuprel). Other sympathomimetics that are noncatecholamines should be used instead. These include metaproterenol, albuterol, and salmeterol. 11A client has a compulsive bed-making ritual in which the client makes and remakes a bed numerous times. The client often misses breakfast and some of the morning activities because of the ritual. Which nursing action would be most helpful? Options: A) Verbalize tactful, mild disapproval of the behavior B) Help the client to make the bed so that the task can be finished quicker C) Discuss the ridiculousness of the behavior D) Offer reflective feedback, such as “I see you have made your bed several times.” Correct Answer is: D Explanation : Verbalizing minimal disapproval would increase the client’s anxiety and reinforce the need to perform the ritual. Helping with the ritual is nontherapeutic and also reinforce the behavior. The client is usually aware of the irrationality (ridiculousness) of the behavior. Reflective feedback acknowledges the client’s behavior. 12An older client who has undergone internal fixation after fracturing a left hip as developed a reddened left heel. The nurse obtains which of the following as a priority item to manage this problem? Options: A) Bed cradle B) Sheepskin C) Trapeze D) Draw sheet P a g e 7 | 99 Explanation : The prone position with the neck hyper extended improves the child’s breathing. Options 1,2 and 3 are not appropriate positions. 17A nurse in the newborn nursery prepares to admit a newborn infant with spina bifida, meningomyelocele type. Which nursing action is most important in the care for this infant? Options: A) Monitoring blood pressure B) Monitoring specific gravity of the urine C) inspecting the anterior fontanel for bulging D) Monitoring temperature Correct Answer is: C Explanation : Intracranial pressure is complication associated with spina bifida. A sign of intracranial pressure in the newborn infant with spina bifida is a bulging anterior fontanel. The newborn infant is at risk for infection before the surgical procedure and closure of the gibbus, and monitoring the temperature is an important intervention; however, assessing the anterior fontanel for bulging is most important. A normal saline dressing is placed over the affected site to maintain moisture of the gibbus and its contents. This prevents tearing or breakdown of skin integrity at the site. Blood pressure is difficult to assess during the newborn period, and it is not the best indicator of infection or a potential complication. Urine concentration is not well developed in the newborn stage of development. 18On assessment of a child, a nurse notes that the child’s genitals are swollen. The nurse suspects that the child is being sexually abused. Which action by the nurse is of primary importance? Options: A) Document the child’s physical findings B) Report the case in which the abuse is suspected C) Refer the family to appropriate support groups D) Assist the family in identifying resources and support systems P a g e 10 | 99 Correct Answer is: B Explanation : The primary legal responsibility of the nurse when child abuse is suspected is to report to the case. All 50 states require health care professionals to report all cases of suspected abuse. Although documentation of assessment findings, assisting the family, and referring the family to appropriate resources and support groups is important, the primary legal responsibility is to report the case. 19A nurse is planning care for an infant with a diagnosis of encephalocele located in the occipital area. Which item would the nurse use to assist in positioning the child to avoid pressure on the encephalocele? Options: A) Sheep skin B) Foam half donut C) Feather pillows D) Sand bags Correct Answer is: B Explanation : The infant is positioned to avoid pressure on the lesion. If the encephalocele is in the occipital area, a foam half donut may be useful in positioning to prevent this pressure. A sheepskin, feather pillow, or sandbag will not protect the enecephalocele from pressure. 20A nurse is caring for a child with a head injury. On review of the record, the nurse notes that the physician has documented that the physician has documented decorticate posturing. On assessment of the child, the nurse notes extension of the upper extremities and internal rotation of the upper arm and wrist. The nurse also notes that the lower extremities are noted at the knees and feet. Based on these findings, which of the following is the appropriate nursing action? Options: A) Document the findings B) Continue to monitor for posturing of the child C) Attempt to flex the child’s lower extremities D) Notify the physician P a g e 11 | 99 Correct Answer is: D Explanation : Decorticate posturing refers to flexion of the upper extremities and extension of the lower extremities. Plantar flexion of the feet may also be observed. Decerebrate posturing involves upper arm and wrist. The lower extremities will extend with some internal rotation noted at the knees and feet. The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants physician notification. 21A child with a diagnosis of hepatitis b is being cared for at home. The mother of the child calls the health care clinic and tells the nurse that the jaundice seems to be worsening. The nurse makes which response to the mother? Options: A) The hepatitis may be spreading. B) You need to bring the child to the health care clinic to see the physician. C) The jaundice may appear to get worse before it resolves. D) It is necessary to isolate the child from the others. Correct Answer is: C Explanation : The parents should be instructed that jaundice may appear to get worse before it resolves. The parents of a child with hepatitis should also be taught the danger signs that could indicate a worsening of the child’s condition, specifically changes in neurological status, bleeding, and fluid retention. The statements in options 1,2, and 4 are incorrect. 22A nurse is preparing to suction a tracheotomy on an infant. The nurse prepares the equipment for the procedure and turns the suction to which setting? Options: A) 60 mmHg B) 90 mmHg C) 110 mmHg P a g e 12 | 99 C) Asking if the client has any last-minute questions D) Telling the client to try to void before leaving the unit Correct Answer is: A Explanation : Because of the risk of allergy to contrast medium, the nurse place highest priority on assessing whether the client has an allergy to iodine or shellfish. The nurse also reinforces information about the test and reminds the client about the need to remain still during the procedure. It is helpful to have the client void before the procedure for comfort. 27A nurse responds to a call bell and finds a client lying on the floor after a fall. The nurse suspects that the client’s arm may broken. The nurse takes which immediate action? Options: A) Tells the client that there is no permanent damage B) Immobilizes the arm C) Take a set of vital signs D) Calls the radiology department Correct Answer is: B Explanation : When a fracture is suspected, it is imperative that the area is splinted before the client moved. Emergency help should be called for if the client is external to a hospital. The nurse should remain with the client and provide realistic reassurance. The client would not told that there is no permanent damage. Vital signs would be taken, but this is not the immediate action. The physician (not the nurse) prescribes X-rays. 28A nurse in the post-partum unit checks a client’s temperature who delivered a healthy newborn infant 4 hours ago. The mother’s temperature is 100.8oF. The nurse provides oral hydration to the mother and encourages fluids. Four hours later, the nurse rechecks the temperature and notes that it is still 100.8oF. Which nursing action is most appropriate? Options: A) Notify the physician P a g e 15 | 99 B) Continue hydration and recheck the temperature 4 hours later C) Document the temperature D) Increased the intravenous fluids Correct Answer is: A Explanation : A temperature greater than 100.4 F in two consecutive reading is considered febrile, and the physician should be notified. Option 2, 3 and 4 are inappropriate actions at this time. 29A nurse is checking the fundus in a postpartum woman and notes that the uterus is soft and spongy. Which nursing action is appropriate initially? Options: A) Massage the fundus gently until firm B) Document fundal position and consistency and height C) Encourage the mother to ambulate D) Notify the physician Correct Answer is: A Explanation : If the fundus is boggy (soft), it should massaged gently until firm, observing for increased bleeding or cots. Option 3 is an inappropriate action at this time. The nurse should document fundal position, consistency and height, the need to perform fundla massage, and the client’s response to the intervention. The physician will need to be notified if uterine massage is not helpful. 30A primipara is being evaluated in the clinic during her second trimester pregnancy. The nurse checks the fetal heart rate (FHR) and notes that it is 190 beats per minute. The appropriate nursing action would be to: Options: A) Document the finding B) Consult with the physician P a g e 16 | 99 C) Tell the client that the FHR is normal D) Recheck the FHR with the client in the standing position Correct Answer is: B Explanation : The fetal heart rate should be 120 to 160 beats per minute throughout pregnancy. In this situation, the FHR is elevated from the normal range, and the nurse should consult with the physician. The GHR would be documented, but option 2 is appropriate action. The nurse would not tell the client that the FHR is normal because this is not true information. Option 4 is an inappropriate action. 31A female client tells the clinic nurse that her skin is very dry and irritated. Which product would the nurse suggest that the client apply to the dry skin? Options: A) Glycering emollient B) Aspercreme C) Myoflex D) Acetic acid solution Correct Answer is: A Explanation : Glycerin is an emollient that is used for dry, cracked, and irritated skin. Aspercreame and myoflex are used to treat muscular aches. Acetic acid solution is used for irrigating cleansing, and packing wounds infected by Pseudomonas aeruginosa. A client with a history of hypertension has been prescribed triamterene (Dyrenium). The nurse provides information to the client about the medication and tells the client to avoid consuming which of the following fruits? Options: A) Apples B) Pears P a g e 17 | 99 D) Ketones in the urine. Correct Answer is: A Explanation : Urine specific gravity measures the concentration of the urine. During the first stage of labor, the renal system has a tendency to concentrate urine. Labor and birth require hydration and caloric intake to replenish energy expenditure and promote efficient uterine function. An elevated blood pressure and ketones in the urine are not expected outcomes related to labor and hydration. Once membranes are ruptured, it is expected that amniotic fluid may continue to leak. 34A postpartum client has a nursing diagnosis of Risk for Infection. A goal has been developed that states: “The client will remain free of infection during her hospital stay. “Which assessment data would support that the goal has been met? Options: A) Presence of chills B) Abdominal tenderness C) Absence of fever D) Loss of appetite Correct Answer is: C Explanation : Fever is the first indication of an infection. Chills abdominal tenderness, and loss of appetite can indicate the presence of infection. Therefore, the absence of a fever indicates that an infection is not present. 35A nurse is monitoring the nutritional status of the client receiving enteral nutrition because of dysphagia that resulted from a head injury. The nurse monitors which of the following to best determine the effectiveness of the feedings for this client? Options: A) Calorie count B) Daily intake and output P a g e 20 | 99 C) Daily weight D) Serum protein level Correct Answer is: C Explanation : The most accurate measurement of the effectiveness of nutritional management of the client is through monitoring of daily weight. This should be done at the same time (preferably early morning), in the same clothes, and using the same scale. Options 1, 2, and 4 assist in measuring nutrition and hydration status. However, the effectiveness of the diet is measures by maintenance of body weight. 36An adult client with a critically high potassium level has received sodium polystyrene sulfonate (Kayexalate). The nurse evaluates that the medication was most effective if the client’s repeat serum potassium level is: Options: A) 6.2 mEq/L B) 5.8 mEq/L C) 5.4 mEq/L D) 4.9 mEq/L Correct Answer is: D Explanation : The normal serum potassium level in the adult is 3.5 to 5.1 mEq/L. Option 4 is the only option reflecting a value that has dropped down into the normal range. Options 1, 2, and 3 identify elevated potassium levels. 37A nurse assesses a client after abdominal surgery who has a nasogastric tube (NG) in place that is connected to suction. Which observation by the nurse indicates most reliably that the tube is functioning properly? Options: A) The suction gauge reads low intermittent suction. B) The distal end of the NG tube is pinned to the client’s gown. P a g e 21 | 99 C) The client indicates that pain is a 3 on a scale of 1 to 10 D) The client denies nausea and has 250 mL of fluid in the suction collection container. Correct Answer is: D Explanation : An NG tube connected to suction is used postoperatively to decompress and rest the bowel. The gastrointestinal tract lacks peristaltic activity because of manipulation during surgery. Although the nurse makes pertinent observation of the tube to ensure that it is secure and connected to suction properly, the client is assessed for the effect. The client should not experience symptoms of ileus (nausea and vomiting) if the tube is functioning properly. A pain indicator of 3 is an expected finding in a postoperative client. 38A nurse is caring for the client who has returned from the post-anesthesia care unit following prostatectomy. The client has a three-way Foley catheter with an infusion of continuous bladder irrigation (CBI). The nurse determines that the flow rate is adequate if the color of the urinary drainage is: Options: A) Dark cherry colored B) Concentrated yellow with small clots C) Clear as water D) Pale yellow or slightly pink Correct Answer is: D Explanation : The infusion of bladder irrigant is not at a preset rate, But rather it is increased or decreased to maintain urine that is a clear pale yellow color or that has just a slight pink tinge. The infusion rate should be increased if the drainage is cherry colored or if clots are seen. Correspondingly, the rate can be slowed down slightly if the return are as clear as water. 39A nurse who is caring for a client with Graves’ disease notes a nursing diagnosis of “Imbalanced Nutrition: less than body requirements related to the effects of the hypercatabolic state.” In the care plan. Which of the following indicates a successful outcome for this diagnosis? Options: P a g e 22 | 99 43A client has had a laryngectomy for throat cancer and has started oral intake. The nurse evaluates that the client has tolerated the first stage of dietary advancement if the client takes which of the following type of diet without aspiration or choking? Options: A) Bland B) Clear liquids C) Full liquids D) Semi-solid foods Correct Answer is: D Explanation : Oral intake after laryngectomy is started with semi-solid foods. Once the client can manage this type of food, liquids may be introduced. Thin liquids are not given until the risk of aspiration is negligible. A bland diet is not appropriate. The client may not be able to tolerate the texture of some of the solid foods that would be included in a bland diet. 44An older male client who is a victim of elder abuse and his family have been seen in the counselling center weekly for the past month. Which statement, if made by the abusive family member, would indicate that he or she has learned more positive coping skills? Options: A) I will be more careful to make sure that my father’s needs are 100 percent met. B) I am so sorry and embarrassed that the abusive event occurred. It won’t happen again. C) I feel better equipped to care for my father now that I know where to turn if I need assistance. D) Now that my father is moving into may home, I will have to stop drinking alcohol. Correct Answer is: C Explanation : Elder abuse is sometimes the result of family members who are being expected to care for their aging parents. This care can cause the family to become overextended, frustrated, or financially depleted. Knowing where to turn in the community for assistance in caring for an aging family member P a g e 25 | 99 can bring much-needed relief. Using these alternatives is a positive coping skill for many families. Options 1, 2, and 4 are statements of good faith or promises, which may or may not be kept in the future. 45A nurse is caring for a term infant who is 24 hours old who had a confirmed episode of hypoglycemia at 1 hour of age. Which observation by the nurse would indicate the need for further evaluation? Options: A) Blood glucose level of 40 mg/dL before the last feeding B) High-pitched cry, eating 10 to 15 mL of formula per feeding C) Weight loss of 4 ounces and dry, peeling skin D) Breast-feeding for 20 minutes or greater, strong sucking Correct Answer is: B Explanation : At 24 hours of age, a term infant should be take able to consume at least one ounce of formula per feeding. A high-pitched cry is indicative of neurological involvement. Blood glucose levels are acceptable at 40 mg/dL in the first few days of life. Weight loss over the first few days of life and dry, peeling skin are normal finding for term infants. Breast-feeding for 20 minutes with a strong suck is an excellent finding. Hypoglycemia causes central nervous system symptoms (high-pitched cry) and also is exhibited by lack of strength in eating enough for growth. 46A home care nurse visits a child with a diagnosis of celiac disease. Which finding best indicates that a gluten-free diet is being maintained and has been effective? Options: A) The child is free of diarrhea. B) The child is free of bloody stools. C) The child tolerates dietary wheat and rye. D) A balanced fluid and electrolyte status is noted on the laboratory results. Correct Answer is: A P a g e 26 | 99 Explanation : Watery diarrhea is a frequent clinical manifestation of celiac disease. The absence of diarrhea indicates effective treatment. Bloody stools is not associated with this disease. The grains of wheat and rye contain gluten and are not allowed. A balance in fluids and electrolytes does not necessarily demonstrate improved status of celiac disease. 47A nurse is assisting in caring for a woman in labor who is receiving oxytocin (Pitocin) by intravenous (IV) infusion. The nurse monitors the client, knowing that which of the following indicates an adequate contraction pattern? Options: A) Three to five contractions in a 10-minute period, with resultant cervical dilatation B) One contraction per minute, with resultant cervical dilatation C) Four contractions every 5 minutes, with resultant cervical dilatation D) One contraction every 10 minutes without resultant cervical dilatation. Correct Answer is: A Explanation : The preferred oxytocin dosage is the minimal amount necessary to maintain an adequate contraction pattern characterized by three to five contractions in a 10-minute period, with resultant cervical dilatation. If contractions are more frequent than every 2 minutes, contraction quality may be decreased. 48A home care nurse is assigned to visit a preschooler who has a diagnosis of scarlet fever and is on bed rest. What data obtained by the nurse would indicate that the child is coping with the illness and bed rest? Options: A) The mother keeps providing new activities for the child to do B) The child is coloring and drawing pictures in a notebook. C) The child insists that mother stay in the room D) The child sucks the thumb whenever the child does not get what is asked for P a g e 27 | 99 failure, P a g e 30 | 99 such as weight gain and increased edema. 53A nurse has taught a client taking a xanthine bronchodilator about beverages to avoid. The nurse determines that the client understands the information if the client chooses which of the following beverages from the dietary menu? Options: A) Chocolate milk B) Cranberry juice C) Coffee D) Cola Correct Answer is: B Explanation : Cola, coffee, and chocolate contain xanthine and should be avoided by the client taking a xanthine bronchodilator. This could lead to an increased incidence of cardiovascular and central nervous system side effects that can occur with use of these type of bronchodilators. 54A client is started on tolbutamide (Orinase) once daily. The nurse observes for which of the following intended effects of this medication? Options: A) Decreased blood pressure B) Decreased blood glucose C) Weight loss D) Resolution of infection Correct Answer is: B Explanation : Tolbutamide is an oral hypoglycemic agent that is taken in the morning. It is not used to decrease blood pressure, enhance weight loss, or treat infection. P a g e 31 | 99 55A client who regularly takes nonsteroidal anti-inflammatory drugs (NSAIDs) has been taking misoprostol (Cytotec). The nurse would monitor the client to see if the client experienced relief of which of the following symptoms? Options: A) Epigastric pain B) Diarrhea C) Bleeding D) Infection Correct Answer is: A Explanation : The client who regularly takes NSAIDs is prone to gastric mucosal injury, which gives the client epigastric pain as s symptom. Misoprostol is administered to prevent this occurrence. Diarrhea can be side effect of the medication, but is not an intended effect. Bleeding and infection are unrelated to the question. 56A client has received a dose of a prn medication called loperamide (Imodium). The nurse evaluates the client after administration to see if the client has relief of: Options: A) Constipation B) Diarrhea C) Tarry stools D) Abdominal pain Correct Answer is: B Explanation : Loperamide is an antidiarrheal agent. It is commonly administered after loose stools. It is used in the management of acute diarrhea and also in chronic diarrhea, such as with inflammatory bowel disease. It can also be used to reduce the volume of drainage from an ileostomy. 57A nurse has reinforced discharge instructions to a parent of a child following heart surgery. Which P a g e 32 | 99 61A nurse reviews the nursing care plan of a hospitalized child who is immobilized because of skeletal traction. The nurse notes a nursing diagnosis of Delayed Growth and Development related to immobilization and hospitalization. Which evaluative statement indicates a positive outcome for the child? Options: A) The fracture heals without complications. B) The child displays age-appropriate developmental behaviors. C) The caregivers verbalize safe and effective home care. D) The child maintains normal joint and muscle integrity. Correct Answer is: B Explanation : Regression and inappropriate developmental behaviours may be displayed in response to immobilization and hospitalization. With individualized care planning, a positive outcome of age- appropriate behavior can be achieved. Options 1, 3, and 4 are appropriate evaluate statements for an immobilized child but do not directly address the nursing diagnosis, Delayed Growth and Development. 62A nurse is evaluating the effects of care for the client with nephritic syndrome. The nurse determines that the client showed the least amount of improvement if which of the following improvement if which of the following information was obtained serially over 2 days of care? Options: A) Initial weight 208 pounds, down to 203 pounds B) Daily intake and output record of 2100 mL intake and 1900 mL output, and 2000 mL intake and 2900 mL output C) Blood pressure 160/90 mmHg, down to 130/78 mmHg D) Serum albumin 1.9 g/dL up to 2.0 g/dL Correct Answer is: D Explanation : The goal of therapy in nephritic syndrome is to heal the leaking glomerular membrane. The would then control edema by stopping the loss of protein in the urine. Fluid balance and albumin levels are monitored to determine effectiveness of therapy. Option 1 represents a loss of fluid that slightly P a g e 35 | 99 exceeds 2 liters and represents a significant improvement. Option 2 represents a total fluid loss of 700 mL over the 2 days, which is also helpful. Option 3 shows improvement because both systolic and diastolic blood pressures are lower. The least amount of improvement is in the serum albumin level, because the normal albumin level is 3.5 to 5.0 g/dL 63A client is being discharged to home after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client states to: Options: A) Avoid getting the cast wet B) Use the fingertips to lift and move the leg C) Cover the casted leg with warm blankets D) Use a padded coat hanger end to scratch under the cast Correct Answer is: A Explanation : A plaster cast must remain dry to keep its strength. The cast should be handled using the palms of the hands, not the fingertips, until fully dry. Air should circulate freely around the cast to help it dry. Additionally, the cast also gives off heat as it dries. The client should never scratch under the cast. A cool hair dryer may be used to relieve an itch. 64A client is being discharged to home while recovering from acute renal failure (ARF). The client indicates an understanding of the therapeutic dietary regimen if the client states to eat foods that are lower in: Options: A) Vitamins B) Potassium C) Carbohydrates D) Fats Correct Answer is: B P a g e 36 | 99 Explanation : Most of the excretion of potassium and the control of potassium balance are normal functions of the kidneys. In the client with renal failure, potassium intake must be restricted as much as possible (30 to 50 mEq/day). The primary mechanism of potassium removal during ARF is dialysis. Options 1, 3, and 4 are not normally restricted in the client with ARF unless a secondary health problem warrants the need to do so. 65A client being discharged from the mental health unit has a history of anxiety and command hallucinations to harm self or others. The nurse teaches the client about interventions for hallucinations and anxiety. The nurse determines that the client understands these measures when the client says: Options: A) If I take my medication, I won’t be anxious. B) I can call my clinical specialist when I’m hallucinating so that I can talk about my feelings and plans and not hurt anyone. C) I can go to group and talk about my feelings. D) If I get enough sleep and eat well, I won’t get anxious and hear things Correct Answer is: B Explanation : There may be an increased risk for impulsive and/or aggressive behavior if a client is receiving command hallucinations to harm self or others. The client should be asked if he or she has intentions to hurt self or others. Talking about auditory hallucinations can interfere with subvocal muscular activity associated with a hallucination. Options 1, 3, and 4 are general interventions but are not specific to anxiety and hallucinations. 66A perinatal client has been instructed on the prevention of genital tract infections. Which statement by the client indicates an understanding of these preventive measures? Options: A) I should avoid the use of condoms. B) I can douche anytime I want. C) I can wear my tight-fitting jeans. D) I should wear underwear with a cotton panel liner. P a g e 37 | 99 B) Now that this problem is taken care of, I’m sure you’ll be fine. C) How could your home care nurse let this happen? D) I have some time if you would like to talk about what happened to you. Correct Answer is: D Explanation : Option 4 encourages the client to discuss feelings. Option 1 and 3 shows disapproval and option 2 provides false reassurance. These are non therapeutic techniques. 71While assisting a spinal cord injury client with activities of daily living, the client states, “I can’t do this; I wish I were dead.” The nurse makes which therapeutic response to the client? Options: A) Let’s wash your back now. B) You wish you were dead? C) I’m sure you are frustrated, but things will work out just fine for you. D) Why do you day that? Correct Answer is: B Explanation : Clarifying is a therapeutic technique involving restating what was said to obtain addition information. Option 1 changes the subject. In option 3, false reassurance is offered. By asking “why” (option 4), the nurse puts the client on the defensive. Options 1,3, and 4 are nontherapeutic and block communication. 72Family members who are awaiting the outcome of a suicide attempt are tearful. Which statement by the nurse would be therapeutic to the family at this time? Options: A) Don’t worry, you have nothing to feel guilty about. B) Everything possible is being done. C) Let me check to see how long it will be before you can see your loved one. P a g e 40 | 99 D) I can see you are worried. Correct Answer is: D Explanation : Options 1, 2, and 3 are communication blocks. Option 1 labels the family’s behavior without their validation. Option 2 uses clichés and false reassurance. Option 3 focuses on an important issue at an inappropriate time. Option 4 addresses the family’s feelings and displays empathy. 73A nurse is caring for an 11-year-old child who has been abused. The nurse includes which therapeutic action in the plan of care? Options: A) Encourage the child to fear the abuser B) Provide a care environment that allows for the development of trust C) Teach the child to make wise choices when confronted with an abusive situation D) Have the child point out the abuser if he or she should visit while the child is hospitalized Correct Answer is: B Explanation : The abusive child usually requires long-term therapeutic support. The environment provided during the child’s healing must include one in which trust and empathy are modeled and provided for the child. Option 1 reinforces fear, which should not be encouraged. Option 3 and 4 ask the child to behave with a maturity beyond that which would be expected for an 11-year-old. Option 2 is therapeutic because it provides the child with a nurturing and supportive environment in which to begin the healing process. 74A nurse assesses on older client for signs of potential abuse. Which of the following psychosocial factors obtained during the assessment place the client at risk for abuse? Options: A) The client is completely dependent upon family members for receiving food and medicine. B) The client shows signs and symptoms of depression. C) The client resides in a low-income neighborhood. P a g e 41 | 99 D) the client has a chronic illness. Correct Answer is: A Explanation : Elder abuse is sometimes the result of frustrated adult children who find themselves caring for dependent parents. Increasing demands by parents for care and financial support can cause resentment and burden. Option 2 relates to depression rather than the risk for abuse. Option 4 relates to a physical factor. The issues of abuse are not bound to socioeconomic status. 75A nurse is caring for a dying client who says, “What would you say if I asked you to be the executor for my will?” Which nursing response would be therapeutic? Options: A) Why, I’d be honored to be the executor of your will. B) Is there any money in it? I adore money, but I am honest. C) Your confidence in me is an honor, but I would like to understand more about your thinking. D) I’d say, great! No worries. I’ll carry out your will just as your will just as you want me to. Correct Answer is: C Explanation : In option 3, this nurse is seeking clarification and empathy. The client’s question reflects the fact that the client has been thinking bout the will and how best to obtain an executor. What is unknown is why the client is asking the nurse to be executor of the will and other specific and important information. In addition, the nurse would want to investigate the legal ramifications, which could arise if such a position was accepted. In option 1, the nurse responds with a social communication with no assessment of the consequences, which is lacking critical thinking and exploration of motivation or client needs. In option 2, the nurse uses histrionic language and crass ideation. In option 4, the nurse provides false reassurance, which h is nontherapeutic. 76A client who is suffering from urticaria (hives)and pruritus says to the nurse, “What am I going to do? I’m getting married next week and I’ll probably be covered in this rash and itching like crazy.” The nurse makes which therapeutic response to the client? Options: A) You’ve very troubled that this will extend into your wedding? P a g e 42 | 99 old fractures. The child states, “I’m afraid to go home! My stepfather will be angry with me for telling on him!” The nurse makes which therapeutic response to the child? Options: A) I am sorry that this has happened to you, but you will be safe here. Your physician has admitted you until further plans can be made. B) You can’t go back there with that man. How do you think your mother will react? C) You must know that your presence in the house will only tease your stepfather more. D) Let’s keep this between you, me, and the physician until we can formulate further plans to assist you. Correct Answer is: A Explanation : A child who has been physically and sexually abused should be admitted to the hospital. This will provide time for a more comprehensive evaluation while protecting the child from further abusiveness. The correct option also provides an empathic statement that supports the child to appropriately perceive self as the victim, while assuring the child of protection from abuse. In option 2, the nurse does not respond with calm and reassuring communication style, nor does the nurse maintain a professional attitude. Option 3, which holds an innuendo, appears to accuse the victim of teasing the stepfather and is incorrect. It is also judgmental, controlling, and demeaning. The nurse’s suggestion in option 4 is not only incorrect but is also passive in its stance. 81A nurse is caring for a 12-year-old female client who has been admitted to the hospital with a diagnosis of physical and sexual abuse by her father. That evening, the father angrily approaches the nurse and says, I’m taking my daughter home. She’s told me what you people are up to and we’re out of here!” The nurse makes which therapeutic response to the child’s father? Options: A) Over my dead body you will!” She’s here and here shy stays until the doctor says different. So get off my floor or I’ll call hospital security and the police!” B) Listen to me. If you attempt to take your daughter from this unit, the police will only bring her back. C) Your daughter is ill and needs to be here. I know you want to help her to recover and that you will work to help everyone straighten out the circumstances that caused this. Go to the chapel and pray for your daughter and for your soul D) You seem very upset. Let’s talk at the nurse’s station. I want to help you. I know you’re very concerned and want to help your daughter. It will be best if you agree to let your daughter stay here for P a g e 45 | 99 now. P a g e 46 | 99 Correct Answer is: D Explanation : When a suspected abused child is admitted to the hospital for further evaluation and protection, the physician will usually work with the parents so they will agree to the admission, the hospital can request an immediate court order to retain the child for a specific length of time. In option 1, the nurse is angry and verbally abusive. It is clear that the nurse has decided that the father is guilty of child abuse. In addition, the nurse is aggressive and of violence as well. In option 2, the command to listen is some what demanding. Option 3 seems somewhat pompous and lecturing. 82A client with peripheral arterial disease is being discharged to home. The client is occasionally forgetful about medication, exercise, and diet instructions; needs daily dressing changes to a small open area on the leg; has limited endurance for activities of daily living (ADLs); and lives alone in a one- story house. To best assist the client to adapt to self-care and disease management, the nurse initiates a request to the physician for which follow-up services to be provided in the home? Options: A) Nursing, home health aide, physical therapy B) Nursing, home health aide, speech therapy C) Home health aide, physical therapy, and occupational therapy D) Nursing, physical therapy, and occupational therapy Correct Answer is: A Explanation : Home health care agencies provide a variety of services to clients, depending on the individual need. The multidisciplinary team includes nurse, home health aides, social workers, and physical, occupational, and speech therapists. Nurses provide skilled nursing services including assessments. Home health aides can assist clients with ADLs, and physical therapists assist in rehabilitation and increasing musculoskeletal endurance. The occupational therapist would train clients to adapt to physical handicaps through new vocational skills and adaptive techniques for ADLs. 83A client with chronic arterial leg ulcers complains of pain and tells the nurse. “I’m so discouraged. I have had this pain for over a year now. The pain never seems to go away. I can’t do anything, and I feel as though I’ll never get better.” The nurse formulates which nursing diagnosis for this client? Options: P a g e 47 | 99 87A home care nurse is caring for a client with acute cancer pain. The most appropriate assessment of the client’s pain would include which of the following? Options: A) The client’s pain rating B) The nurse’s impression of the client’s pain C) Verbal and nonverbal clues from client D) Pain relief after appropriate nursing intervention Correct Answer is: A Explanation : The client’s perception of pain is the hallmark of pain assessment. Usually noted by the client rating on a scale of 1 to 10, the assessments is documented and followed with appropriate medical and nursing intervention. The nurse’s impression and the verbal and nonverbal clues are subjective data. Pain relief following intervention is appropriate but relates to evaluation. 88A prenatal client has been told during a physician office visit that she is positive for human immunodeficiency virus (HIV). The client cried and was significantly distressed regarding this news. Which nursing diagnosis would this data best support? Options: A) Acute Pain B) Noncompliance C) High Risk for Infection D) Anticipatory Grieving Correct Answer is: D Explanation : A life-threatening diagnosis such as HIV will stimulate the anticipatory grief response. Anticipatory grief occurs when the client, family, and loved ones know that the client will die. The prenatal HIV client is forced to make important changes in her life, frequently resulting in grief related to lost future dreams and diminished self-esteem because of an inability to achieve life goals. Although options 1, 2, and 3 may be appropriate nursing diagnoses at some point, they do not address the information in the question P a g e 50 | 99 89A nurse is assessing a client’s suicide potential. The nurse asks the client which most important question? Options: A) Why do you want to hurt yourself? B) Can you describe how you are feeling right now? C) Has anyone in your family committed suicide? D) Do you have a plan to commit suicide? Correct Answer is: D Explanation : When assessing for suicide risk, the nurse must evaluate if the client has suicide plan. Clients who have a definitive plan pose a greater risk for suicide. Options 2 and 3 may also be questions that the nurse would ask but are not the most important. The nurse avoids the use of the word “why” when communicating with a client. The use of this word may place the client on the defensive; additionally, the client may not even know the reason “why” he or she wants to hurt self. 90A nurse is caring for a client who is receiving electroconvulsive therapy (ECT) for a major depressive disorder. Which assessment finding would the nurse identify as an unexpected side effect of ECT requiring notifying the physician? Options: A) Memory loss B) Disorientation C) Confusion D) Hypertension Correct Answer is: D Explanation : The major side effects of ECT are confusion, disorientation, and memory loss. A change in blood pressure would not be an anticipated side effect and would be a cause for concern. If hypertension occurred following ECT, the physician should be notified. P a g e 51 | 99 91During the admission assessment of a client admitted to the hospital for esophageal varices, the client says, “I deserve this. I bought it on myself.” The nurse makes which therapeutic response to the client? Options: A) Would you like to talk to the caplain? B) Not all esophageal varices are caused by alcohol. C) Is there some reason you feel you deserve this? D) That is something to think about when you leave the hospital Correct Answer is: C Explanation : Ruptured esophageal varices are often a complication of cirrhosis of the liver, and the most common type of cirrhosis is caused by chronic alcohol abuse. It is important o obtain an accurate history about alcohol intake form the client. If the client is ashamed or embarrassed, he or she may not respond accurately. Option 3 is open-ended and allows the client to discuss feelings about drinking. Option 1 blocks the nurse-client communication process. Options 2 and 4 are somewhat judgmental. 92A nurse is performing a neurological assessment on a client with dementia and is assessing the function of the frontal lobes of the brain. Assessment of which of the following items by the nurse would yield the best information about this area of functioning? Options: A) Level of consciousness B) Insight, judgment, and planning C) Feelings or emotions D) Eye movements Correct Answer is: B Explanation : Insight, judgment, and planning are part of the function of the frontal lobe. Level of consciousness is controlled by the reticular activating system. Feelings and emotions are part of the role of the limbic system. Eye movements are under the control of cranial nerves III, IV, and VI. P a g e 52 | 99 nurse would institute bleeding precautions. Neutropenic precautions would be instituted for a client with a low neutrophil count. Contact precautions is initiated in a client who has drainage from wounds that may be infectious. Respiratory precautions are instituted for a client with a respiratory infection that is transmitted by the airborne route. 97A client with a leaking intracranial aneurysm has been placed on aneurysm precautions. A visiting family member wants to take the client to the unit lounge for “just a few minutes.” The nurse would use which of the following concepts when explaining why the client must remain in the room? Options: A) Clients with aneurysms need isolation to cope with photosensitivity. B) Reduced environmental stimuli is needed to prevent aneurysm rupture. C) A quiet environment promotes more rapid healing of the aneurysm. D) The client has disturbed thought processes and needs reduced stimulation. Correct Answer is: B Explanation : Subarachnoid precautions (or aneurysm precautions) are intended to minimize environmental stimuli, which could increase intracranial pressure and trigger bleeding or rupture of the aneurysm. The client does not need isolation to “cope” with photosensitivity (although Photosensitivity may be a problem). The aneurysm will not heal more rapidly with reduced stimuli, and no data indicates that the client has disturbed thought processes. 98A postoperative client is anemic from blood loss during a recent surgery. The nurse interprets that which symptom exhibited by the client is most likely associated with the anemia? Options: A) Bradycardia B) Fatigue. C) Increased respiratory rate D) Muscle cramps P a g e 55 | 99 Correct Answer is: B Explanation : The client with anemia is likely to complain of fatigue, caused by decreased ability of the body to carry oxygen to tissues to meet metabolic demands. The client is likely to have tachycardia, not Bradycardia because of efforts by the body to compensate for the effects of anemia. Increased respiratory rate is not an associated finding, although some clients may have shortness of breath. Muscle cramps are an unrelated finding. 99A nurse employed in a rehabilitation center is planning the client assignments for the day. Which client would the nurse assign to the nursing assistant? Options: A) A client who had a below-the-knee amputation B) A client on a 24-hour urine collection who is also on strict bed rest C) A client scheduled for transfer to the hospital for coronary artery bypass surgery D) A client scheduled for transfer to the hospital for an invasive diagnostic procedure. Correct Answer is: B Explanation : The nurse must assign tasks based on the guidelines of Nursing Practice Acts and the job description of the employing agency. A client who had a below-the-knee amputation, a client scheduled to be transferred to the hospital for coronary artery bypass surgery, and a client scheduled for an invasive diagnostic procedure will require both physiological and psychosocial needs. The nursing assistant has been trained to care for a client on bed rest and on urine collections. The nurse would provide instructions to the nursing assistant regarding the tasks, but the tasks required for this client are within the role description of a nursing assistant. 100A nurse is in the room with a client when a seizure begins. The client’s entire body becomes rigid, and the muscles in all four extremities alternate between relaxation and contraction. Following the seizure, the nurse documents that the client has experienced a(n): Options: A) Absence seizure B) Tonic-clonic seizure C) Partial seizure P a g e 56 | 99 D) Complex partial seizure Correct Answer is: B Explanation : Tonic-clonic seizures are characterized by body rigidity (tonic phase) followed by rhythmic jerky contraction and relaxation of all body muscles, especially hose of the extremities (clonic phase). There are two types of complex partial seizures complex partial seizures with automatisms and partial seizures evolving into generalized seizures. Complex partial seizures with automatisms include purposeless repetitive activities such as lip smacking, chewing, or patting the body. Partial seizures evolving into a generalized seizure begin locally and then spread through the body. Absence seizures are characterized by a sudden lapse of consciousness for approximately 2 to 10 seconds and a blank facial expression. 101A nurse is reviewing the nursing care plan for a client with a right cerebrovascular accident (CVA) who has left-sided deficits. The nurse notes a nursing diagnosis of Unilateral Neglect. The nurse would tell a family member who is assisting the client that it would be least helpful to do which of the following? Options: A) Approach the client from the right side B) Teach the client to scan the environment C) Move the commode and chair to the left side D) Place bedside articles on the left side Correct Answer is: A Explanation : Unilateral neglect is an unawareness of the paralyzed side of the body, which increases the client’s risk for injury. The nurse’s role is to refocus the client’s attention to the affected side. Personal care items, belongings, a bedside chair, and a commode are all placed on the affected side. The client is taught to scan the environment to become aware of that half of the body and is approached on that side by family and caregivers as well. 102A nurse is evaluating the status of client with myasthenia gravis. The nurse interprets that the client’s medication regime may not be optimal if the client continues to experience fatigue that occurs: P a g e 57 | 99 postoperative pain will be: Options: A) The lower abdominal incision B) Bleeding within the bladder C) Bladder spasms D) Tension on the Foley catheter Correct Answer is: C Explanation : Bladder spasms can occur after this surgery because of postoperative bladder distention or irritation from the balloon on the indwelling urinary catheter. The nurse administers antispasmodic medications, such as belladonna and opium, to treat this type of pain. There is no incision with a TRUP (option 1). Options 2 and 4 are not frequent causes of pain. Some surgeons purposefully apply tension to the catheter for a few hours postoperatively to control bleeding. 107A client with gastroesophageal reflux disease (GERD) has just received a breakfast tray. The nurse setting up the tray for the client notices that which of the following foods is the only one that will increase the lower esophageal sphincter (LES) pressure and thus lessen the client’s symptoms? Options: A) Fresh scrambled eggs B) Nonfat milk C) Whole wheat toast with butter D) Coffee Correct Answer is: B Explanation : Foods that increase the LES pressure will decrease reflux and lessen the symptoms of GERD. The food substance that will increase the LES pressure is nonfat milk. The other substances listed decrease the LES pressure, thus increasing reflux symptoms. Aggravating substances include chocolate, coffee, fatty foods, and alcohol and should be avoided in the diet of a client with GERD. P a g e 60 | 99 108A nurse is reviewing the serum laboratory test for a client with sickle cell anemia. The nurse anticipates finding that which of the following values is elevated? Options: A) Hemoglobin F B) Hemoglobin S C) Hemoglobin C D) Hemoglobin A1 Correct Answer is: B Explanation : Sickle cell anemia is a severe anemia that predominantly affects African Americans. It is characterized by the presence of only hemoglobin S. The client must have two abnormal genes yielding hemoglobin S to have sickle cell anemia. A client could have sickle cell trait by carrying one hemoglobin A gene and one hemoglobin S gene. Options 1, 3, and 4 are unrelated to sickle cell anemia. 109A client wishes to donate blood for a family member for an upcoming surgery and asks the nurse, “How will I know if our blood types will match?” In formulating a response, the nurse incorporates that which test will be used to test compatibility? Options: A) Eosinophil count B) Monocyte count C) Direct Coombs’ D) Indirect Coombs’ Correct Answer is: D Explanation : The indirect Coombs’ test detects circulating antibodies against red blood cells (RBCs) and is the “Screening” component of the order to “type and screen” a client’s blood. This test is used in addition to the ABO typing, which is normally done to determine blood type. The direct Coombs’ test is used to detect idiopathic hemolytic anemia by detecting the presence of autoantibodies against the client’s RBCs. Eosinophil and monocyte counts are part of a complete blood count, a routine hematologic screening test. P a g e 61 | 99 110A client is being discharged to home after undergoing a transurethral prostatectomy (TURP). The nurse teaches the client to expect which variation in normal urine color for several days following the procedure? Options: A) Clear yellow B) Cloudy amber C) Pink-tinged D) Dark red Correct Answer is: C Explanation : The client should expect that the urine will be pink-tinged for several days following this procedure. Dark red urine may be present initially, especially with inadequate bladder irrigation, and if it occurs, it must be corrected. Options 1 and 2 are incorrect because urine of these colors is not generally expected for several days following surgery. 111A client is admitted to the hospital with sickle cell crisis. The nurse monitors this client for which most frequent symptom of the disorder? Options: A) Bradycardia B) Pain C) Diarrhea D) Blurred vision Correct Answer is: B Explanation : Sickle cell crisis often causes pain in the bones and joints, accompanied by joint swelling is a classic symptom and may require large doses of narcotic analgesics when it is severe. The symptoms listed in the other options are not associated with sickle cell crisis. P a g e 62 | 99 management of vasospasm associated with cerebral hemorrhage. Docusate sodium is a stool softener, which helps prevent straining. Straining would raise intracranial pressure. 113A client who has a history of chronic ulcerative colitis is diagnosed with anemia. The nurse interprets that which factor is most likely responsible for the anemia? Options: A) Decreased intake of dietary iron B) Intestinal malabsorption C) Blood loss D) Intestinal hookworm Correct Answer is: C Explanation : The client with ulcerative colitis is most likely anemic as a result of chronic blood loss in small amounts that occurs with exacerbations of the disease. These clients often have bloody stools and are at increased risk for anemia. There is no information in the question to support options 1 or 4. In ulcerative colitis, the large intestine is involved, not the small intestine where vitamin B12 and folic acid are absorbed (option 2). 114A physician has prescribed nimodipine (Nimotop) for a client with subarachnoid hemorrhage. The nurse administering the first dose tells the client that this medication is a: Options: A) Calcium-channel blocker used to decrease the blood pressure B) Calcium-channel blocker used to decrease cerebral blood vessel spasm C) Beta-adrenergic blocker used to decrease blood pressure. D) Vasodilator that has an affinity for cerebral blood vessels. Correct Answer is: B Explanation : Nimodipine is a calcium-channel blocking agent that has an affinity for cerebral blood vessels. It is used to prevent or control vasospasm in cerebral blood vessels, thereby reducing the chance P a g e 65 | 99 for rebleeding of the aneurysm. Options 1, 3, and 4 are incorrect. 115A nurse is monitoring a client who is receiving a blood transfusion. The client begins to complain of a sweaty and warm feeling and a backache. The nurse notes that the client’s skin is flushed and suspects that the client is having a transfusion reaction. The nurse immediately stops the blood transfusion and then: Options: A) Discontinues the intravenous (IV) line B) Changes the continuous IV to an intermittent needle device C) Hangs an IV bag of 5% dextrose in water D) Hang an IV bag of normal saline Correct Answer is: D Explanation : If a transfusion reaction is suspected, the transfusion is stopped and then normal saline is infused pending further physician orders. This maintains a patent IV access line and ids in maintaining the client’s intravascular volume. The IV line would not be discontinued because there would be no IV access route. Normal saline is the solution of choice over solutions containing dextrose because saline does not cause clumping of red blood cells. 116A client has been taking lisinopril (Prinivil) for 3 months. The client complains to the nurse of a persistent dry cough that began about 1 month ago. The nurse interprets that this is most likely: Options: A) Caused by a concurrent upper respiratory infection B) Caused by neutropenia as a result of therapy C) An expected, though bothersome, side effect of therapy D) An indication that the client will show signs of heart failure Correct Answer is: C Explanation : A frequent side effect of therapy with any of the angiotensin converting enzyme (ACE) P a g e 66 | 99 inhibitors, such as lisinopril, is the appearance of persistent, dry cough. The cough generally does not improve while the client is taking the medication. Clients are advised to notify the physician if the cough becomes very troublesome to them. The other options are incorrect. 117A client has been given a prescription to begin using nitroglycerin transdermal patches in the management of angina pectoris. The nurse instructs the client about this medication administration system and tells the client to: Options: A) Apply a new system every 7 days B) Apply the system in the morning and leave it in place for 12 to 16 hours as directed C) Place the system in the area of a skin fold to promote better adherence D) Wait 1 day to apply a new system if it becomes dislodged Correct Answer is: B Explanation : Nitroglycerin is a coronary vasodilator used in the management of coronary artery disease. The client is generally advised to apply a new system each morning and leave it in place for 12 to 16 hours as per physician directions. This prevents the client from developing tolerance (as happens with 24-hour use). The client should avoid placing the system in skin folds or excoriated areas. The client can apply a new system if it becomes dislodged because the dose is released continuously in small amounts through the skin. 119. A nurse is visiting a client who has been started on therapy with clotrimazole (Lotrimin). The nurse tells the client that this medication will alleviate: Options: A) Sneezing B) Rash C) Fever D) Pain P a g e 67 | 99 D) Use a dehumidifier in the home Correct Answer is: B Explanation : The client should take in increased fluids (2000 to 3000 mL/day unless contraindicated) to make secretions less viscous. This may help the client to expectorate secretions. This is standard advice given to clients receiving any of the adrenergic bronchodilators, such as albuterol, unless the client has another health problem that could be worsened by increased fluid intake a dehumidifier will dry secretions. The client would not be advised to take additional medication. Additional exercise will not effectively clear bronchial secretions. 124. A nurse is reviews the serum laboratory results for a client taking chlorothiazide (Diuril). The nurse specifically monitors for which of the following most frequent medication side effects on a regular basis? Options: A) Hyperphosphatemia B) Hypocalcemia C) Hypernatremia D) Hypokalemia Correct Answer is: D Explanation : The client taking a potassium-wasting diuretic such as chlorothiazide (Diuril) needs to be monitored for decreased potassium levels. Other fluid and electrolyte imbalances that occur with the use of this medication include hyponatremia, hypercalcemia, hypomagnesemia, and hypophosphtemia. 125. A nurse has administered a dose of diazepam (Valium) to the client. The nurse would take which most important action before leaving the client’s room? Options: A) Draw the shades closed B) Put up the side rails on the bed C) Give the client a bedpan P a g e 70 | 99 D) Turn the volume on the television set down Correct Answer is: B Explanation : Diazepam is a sedative/hypnotic with anticonvulsant and skeletal muscle relaxant properties. The nurse should institute safety measures before leaving the client’s room to ensure that the client does not injure self. The most frequent side effects of this medication are dizziness, drowsiness, and lethargy. For this reason, the nurse puts the side rails up on the bed before leaving the room to prevent falls. Options 1, 3, and 4 may be helpful measures that provide a comfortable, restful environment. However, option 2 provides for the client’s safety needs. 126. A nurse provides home care instructions to a client who is taking lithium carbonate (Eskalith). Which statement by the client indicates a need for further instructions? Options: A) My blood levels must be monitored very closely. B) I need to withhold the medication if I have excessive diarrhea, vomiting or diaphoresis. C) I need to take the lithium with meals. D) I need to decrease my salt and fluid intake while taking the lithium. Correct Answer is: D Explanation : Because therapeutic and toxic dosage ranges are so close, lithium blood levels must be monitored very closely, more frequently at first, then once every several months after that. The client should be instructed to withhold the medication if excessive diarrhea, vomiting, or diaphoresis occurs, and to inform the physician if any of these problems occur. Lithium is irritating to the gastric mucosa; therefore, lithium should be taken with meals. A normal diet and normal salt and fluid intake (1500 to 3000 mL per day) should be maintained because lithium decreases sodium reabsorption by the renal tubules, which could cause sodium depletion. A low-sodium intake causes a relative increase in lithium retention and could lead to toxicity. 127. A client is brought to the emergency room following a severe burn caused by a fire at home. The burns are extensive, covering greater than 25% of the total body surface area (TBSA). The nurse reviews the laboratory results drawn on the client and would most likely expect to note which of the following? P a g e 71 | 99 Options: A) White blood cell (WBC) count 6,000/ul B) Hematocrit 65% C) Albumin 4.0g/dL D) Sodium 140 mEq/L Correct Answer is: B Explanation : Extensive burns covering greater than 25% of the TBSA result in generalized body edema in both burned and nonburned tissues and a decrease in circulating intravascular blood volume. Hematocrit levels elevate in the first 24 hours post-injury as a result of hemoconcentration from the loss of intravascular fluid. The normal WBC count is 5,000 to 1,000/ul. The normal sodium level is 135 to 145 mEq/L. The normal albumin is 3.4 to 5 g/dL. The normal hematocrit is 40% to 54% in the male and 38% to 47% in the female. 128. A nurse is caring for a client with Parkinson’s disease who is taking benztropine mesylate (Cogentin) daily. The nurse assesses the client for side effects of this medication and specifically monitors: Options: A) Pupil response B) Skin temperature C) Intake and output D) Prothrombin time Correct Answer is: C Explanation : Urinary retention is a side effect of benztropine mesylate. The nurse needs to observe for dysuria, distened abdomen, voiding in small amounts, and overflow incontinence. Options 1, 2, and 4 are not side effects of this medication 129. A client has received electroconvulsive therapy (ECT). In the post-treatment area and upon the client’s awakening. The nurse will perform which intervention first? P a g e 72 | 99 133. Vasopressin (Pitressin) is prescribed for a client with diabetes insipidus, and the client asks the nurse about the purpose of the medication. The nurse responds, knowing that the action of the medication is to: Options: A) Inhibit contraction of smooth muscle B) Produce vasodilation C) Decrease urinary output D) Decrease peristalsis Correct Answer is: C Explanation : Vasopressin is a vasopressor and an antidiuretic. It directly stimulates contraction of smooth muscle, causes vaso-constriction, stimulates peristalsis, and increases reabsorption of water by the renal tubules, resulting in decreased urinary flow rate. 134. A client is seen in the health care clinic. The client has diabetes mellitus that has been well controlled with glyburide (Diabeta), but recently, the client’s fasting blood glucose has bee reported to be 180 to 200 mg/dL. Which of the following medications, if noted in the client’s record, may be contributing to the elevated blood glucose level? Options: A) Cimetidine (Tagamet) B) Ranitidine (Zantac) C) Ciprofloxacin hydrochloride (Cipro) D) Prednisone (Deltasone) Correct Answer is: D Explanation : Corticosteroids, thiazide diuretics, and lithium may decrease the effect of glyburide, causing hyperglycemia. Options 1, 2, and 3 may increase the effect of glyburide, leading to hypoglycemia. P a g e 75 | 99 135. A nurse is caring for a client in the postpartum unit who suddenly exhibits signs of a pulmonary embolism. The nurse immediately prepares to: Options: A) Administer oxygen by face mask at 8 to 10 liters per minute B) Administer pain medication C) Administer antianxiety medication D) Monitor the vital signs Correct Answer is: A Explanation : Because pulmonary circulation is compromised in the presence of an embolus, cardiorespiratory support is initiated by oxygen administration. Although option 4 may be a component of care for the client with pulmonary embolism, the immediate action is to prepare to administer oxygen. Options 2 and 3 are not immediate interventions. 136. Buspirone hydrochloride (BuSpar) is prescribed for a client with an anxiety disorder. The nurse instructs the client regarding the medication and tells the client that: Options: A) The medication can produce a sedating effect B) Tolerance can occur with the medication C) The medication is addicting D) Dizziness and nervousness may occur. Correct Answer is: D Explanation : Buspirone hydrochloride is used in the management of anxiety disorders. The advantages of this medication is that it is not sedating, tolerance does not develop, and it is not addicting. The medication has a more favorable side effect profile than do the benzodiazepines. Dizziness, nausea, headaches, nervousness, lightheadedness, and excitement, which generally are not major problems, are side effects of the effects of the medication. P a g e 76 | 99 137. A nurse provides instructions to a new mother who is about to breastfeed her newborn infant. The nurse observes the new mother as she breastfeeds for the first time and intervenes if the new mother: Options: A) Turns the newborn infant on his side facing the mother B) Draws the newborn the rest of the way onto the breast when the newborn opens his mouth C) Tilts up the nipple or squeezes the areola, pushing it into the newborn’s mouth D) Places a clean finger in the side of the newborn’s mouth to break the suction before removing the newborn from the breast Correct Answer is: C Explanation : The mother is instructed to avoid tilting up the nipple or squeezing the areola and pushing it into the newborn’s mouth. This action does not facilitate the breastfeeding process or flow of milk. Options 1, 2, and 4 are correct procedures for breastfeeding. 138. A clinic nurse provides instructions to a mother regarding the care of her child who is diagnosed with croup. Which statement by the mother indicates a need for further instructions? Options: A) I will place a cool mist humidifier next to my child’s bed. B) Sips of warm fluids during a croup attack will help. C) I will give Tylenol for the fever D) I will give cough syrup every night at bedtime Correct Answer is: D Explanation : The mother needs to be instructed that cough syrup and cold medicines are not to be administered because they may dry and thicken secretions. Sips of warm fluid will relax the vocal cords and thin mucus. A cool mist humidifier rather than a steam vaporizer is recommended because of the danger of the child pulling the machine over and causing a burn. Acetaminophen (Tylenol) will reduce P a g e 77 | 99 A nurse provides discharge instructions to the mother of a child who was hospitalized for heart surgery. The nurse tells the mother that: Options: A) The child may return to school one week after hospital discharge B) After bathing rub lotion and sprinkle powder on the incision C) The child can play outside for short periods of time D) The physician is to be notified if the child develops a fever greater than 100.5o F Correct Answer is: D Explanation : Following heart surgery, the child should not return to school until 3 weeks after hospital discharge, at which time the child should go to school for half days for the first few days. No creams lotions, or powders should be placed o the incision until it is completely healed and without scabs. The mother is instructed to omit play outside for several weeks. The physician needs to be notified if the child develops a fever greater than 100.5oF. A clinic nurse provides instructions to a client who will begin on oral contraceptives. Which statement by the client indicates the need for further instructions? Options: A) I will take on pill daily at the same time every day. B) I will not need to use an additional birth control method once I start these pills. C) If I miss a pill, I need to take it as soon as I remember. D) If I miss two pills, I will the them both as soon as I remember and I will take two pills the next day also. Correct Answer is: B Explanation : The clients needs to be instructed to use a second birth control method during the first pill cycle. Options 1, 3, and 4 are correct. Additionally, the client needs to be instructed that if she misses three pills, she will need to discontinue use for that cycle and use another birth control method. P a g e 80 | 99 A nurse is providing dietary instructions to the client hospitalized for pancreatitis. Which of the following foods would the nurse instruct the client to avoid? Options: A) Lentil soup B) Bagel C) Chili D) Watermelon Correct Answer is: C Explanation : The client needs to avoid alcohol, coffee and tea, spicy foods, and heavy meals, which stimulate pancreatic secretions and produce attacks of pancreatitis. The client is instructed in the benefit of eating small frequent meals that are high in protein, low in fat, and moderate to high in carbohydrates. A home care nurse visits a client who was recently diagnosed with cirrhosis. The nurse provides home care management instructions to the client. Which statement by the client indicates a need for further instructions? Options: A) I will take acetaminophen (Tylenol) if I get a headache. B) I will obtain adequate rest. C) I should include sufficient carbohydrates in my diet. D) I should monitor my weight regularly Correct Answer is: A Explanation : Acetaminophen (Tylenol) is avoided because it can cause fetal liver damage in the client with cirrhosis. Adequate rest and nutrition is important. The diet should supply sufficient carbohydrates with a total daily calorie intake of 2000 to 3000. The client’s weight should be monitored regularly. A client who has a history of gout is also diagnosed with urolithiasis. The stones are determined to be of P a g e 81 | 99 uric acid type. The nurse gives the client instructions in foods to limit, which includes: Options: A) Liver B) Apples C) Carrots D) Milk Correct Answer is: A Explanation : Foods containing high amounts of purines should be avoided in the client with uric acid stones. This includes limiting or avoiding organ meats, such a s liver, brain heart, and kidney. Other foods to avoid include sweetbreads, herring, sardines, anchovies, meat extracts, consommés, and gravies. Food that are low in purines include all fruits, many vegetables, milk, choose eggs, refined cereals, coffee tea, chocolate and carbonated beverages. A client tells the nurse that he gets dizzy and lightheaded with each use of the incentive spirometer. The nurse asks the client to demonstrate use of the device, expecting that the client is: Options: A) No forming a tight seal around the mouthpiece B) Inhaling too slowly C) Not resting adequately between breaths D) Exhaling too slowly Correct Answer is: C Explanation : If the client does not breathe normally between incentive spirometer breaths, hyperventilation and fatigue can result. Hyperventilation is the most common cause of respiratory alkalosis, which is characterized by lightheadedness and dizziness. Options 1, 2, and 4 would not be a cause of lightheadedness and dizziness. P a g e 82 | 99 monitor pattern of variable decelerations during contractions followed by a brief acceleration. Then, there is a return to baseline until the next contraction, when the pattern is repeated. Based on this data, the nurse prepares to initially. Options: A) Take the clients vital signs B) Perform a manual sterile vaginal exam C) Perform a Leopold’s maneuver D) Test the vaginal fluid with a nitrazine strip Correct Answer is: B Explanation : Variable deceleration with brief acceleration after a gush of amniotic fluid is a common clinical manifestation of cord compression caused by occult or frank prolapse of the umbilical cord. A manual vaginal exam can detect the presence of the cord in the vagina, confirming the problem. Based on the data in the question, options 1, 3, and 4 are not initial actions. A nurse is preparing to administer a feeding to a client receiving enteral nutrition through a nasogastric tube. The nurse takes which most important action before administering the feeding? Options: A) Measuring intake and output B) Weighing the client C) Adding blue food coloring formula D) Determining tube placement Correct Answer is: D Explanation : Initiating a tube feeding before determining tube place. Options can lead to serious complications such as aspiration. Options 1 and 2 are part of the total plan of care for a client on enteral feedings. Option 3 is instituted for a client who has been identified as a high risk for aspiration. Option 4 is the priority nursing action. P a g e 85 | 99 A nurse teaches a client with a rib fracture to cough and deep breathe. The client resists directions by the nurse because of the pain. The nurse most appropriately: Options: A) Continues to give the client gentle encouragement to do so B) Requests that the physician perform a nerve block deaden the pain C) Explains in detail the potential complications from lack of coughing and deep breathing D) Premedicates the client and assists the client to splint the area during these exercises. Correct Answer is: D Explanation : Shallow respirations that occur with rib fracture predispose the client to developing atelectasis and pneumonia. It is essential that the client perform coughing and deep breathing exercises to prevent these complications. The nurse accomplishes this most effectively by premedicating the client with pain medication and assisting the client with splinting during the exercises. Options 2 and 3 are inappropriate. Option 2 is an extreme measure, and the nurse would not explain in detail potential complications as identified in option 3. Because the client is resisting directions, “gentle encouragement” may not be adequate. A nurse is caring for a 14-year-old child who is hospitalized and placed in Crutch field traction. The child is having difficulty adjusting to the length or the hospital confinement. Which nursing action would be most appropriate to meet the child’s needs? Options: A) Allow the child to have his or her hair dyed if the parent agrees B) Allow the child to play loud music in the hospital room C) Let the child wear his or her own clothing when friends visit D) Allow the child to keep the shades closed and the room darkened at all times Correct Answer is: C Explanation : An adolescent needs to identify with peers and has a strong need to belong to a group. The child should be allowed to wear his or her own clothes to feel a sense of belonging to the group. The adolescent likes to dress like the group and wear similar hairstyles. Because Crutch field traction uses P a g e 86 | 99 skeletal pins, hair dye is not appropriate. Loud music may disturb others in the hospital. The child’s request for a darkened room is indicative of a possible problem with depression that may need further evaluation and intervention. A nurse receives a telephone call from the emergency room and is told that a client in leg traction will be admitted to the nursing unit. The nurse prepares for the arrival of the client and asks the nursing assistant to obtain which item that will be essential for helping the client move in bed while in the leg traction? Options: A) An electric bed B) A bed trapeze C) Extra pillows D) A foot board Correct Answer is: B Explanation : A trapeze is essential to allow the client to lift straight up while being moved so the amount of pull exerted on the limb in traction is not altered. Either an electric bed or manual bed can be used for traction, but this does not specifically assist the client to move in bed. A foot board and extra pillows do not facilitate moving. 154. A female client is being discharged from the hospital to home with an indwelling urinary catheter following surgical repair of the bladder following trauma. The nurse determines that the client understands the principles of catheter management if the client states to: Options: A) Cleanse the perineal area with soap and water once a day B) Keep the drainage bag lower than the level of the bladder C) Limit fluid intake so the bag won’t become full so quickly D) Coil the tubing and place it under the thigh when sitting to avoid tugging on the bladder P a g e 87 | 99 Explanation : After surgery, measures are taken to prevent venous stasis. They include applying elastic stockings or leg wraps, use of pneumatic compression boots, discouraging leg crossing, avoiding the use of the knee gatch, performing passive and active ROM, and vomiting the use of pillows in the popliteal space. Leg elevation while sitting will promote venous drainage and help prevent postoperative edema. 157. A nurse is planning to teach a client with atrial fibrillation about the need to begin long-term anticoagulant therapy. Which explanation would the nurse use to best describe the reasoning for this therapy? Options: A) Because of this dysrhythmia, blood backs up in the legs and puts you at risk for blood clots, also called deep vein thrombosis. B) The antidysrhythmic medications you are taking cause blood clots as a side effect, so you need this medication to prevent them. C) Because the atria are quivering, blood flows sluggishly through them, and clots can form along the heart wall, which could then loosen and travel to the lungs or brain. D) This dysrhythmia decreases the amount of blood flow coming from the heart, which can lead to blood clots forming in the brain. Correct Answer is: C Explanation : A severe complication of atrial fibrillation is the development of mural thrombi. The blood stagnates in the “quivering” atria, because of the loss of organized atrial muscle contraction and “atrial kick.” The blood that pools in the atria can then clot, which increases the risk of pulmonary and cerebral emboli. 158. A clinic nurse is providing instructions to a client in the third trimester of pregnancy regarding relief measures related to heartburn. Which instruction would the nurse provide to the client? Options: A) Eat fatty foods once a day in the morning only B) Eat three large meals a day rather than small, frequent meals C) Sip on milk or tea P a g e 90 | 99 D) Use antacids that contain sodium P a g e 91 | 99 Correct Answer is: C Explanation : Measures to provide relief of heartburn include eating small, frequent meals and avoiding fatty fried foods, coffee, and cigarettes. Mild antacids can be used if they do not contain aspirin or sodium. Frequent sips of milk or hot tea is helpful. 159.A nurse provides instructions regarding home care to a parent of a 3-years old child hospitalized with hemophilia. Which statement by the parent indicates a need for further instructions? Options: A) I should not leave my child unattended. B) I need to pad table corners in my home. C) I need to remove household items that can tip over. D) My child should not have any immunizations Correct Answer is: D Explanation : The nurse needs to stress the importance of immunizations dental hygiene, and routine well-child care. Options 1, 2, and 3 are appropriate. The parents are also instructed in measures to implement if blunt trauma occurs, especially trauma involving the joints, and how to apply prolonged pressure to superficial wounds until the bleeding has stopped. 160. A nurse provides instructions to the client taking clorazepate (Tranxene) for management of an anxiety disorder. The nurse tells the client that: Options: A) Drowsiness is a side effect that usually disappears with continued therapy B) If dizziness occurs, call the physician C) Smoking increases the effectiveness of the medication D) If gastrointestinal (GI) disturbances occur, discontinue the medication P a g e 92 | 99 sufficient medication and is at risk for seizure activity. In this case, the medication dose should be adjusted upward. A level above the therapeutic range indicates that the clients is entering the toxic range and is at risk for toxic side effects of the medication. In this case, the dose should be adjusted downward. 165 A nurse is conducting a prostate screening clinic and is discussing prevention and risk factors for prostate cancer. The nurse determines that a client understands the educational information that was shared if the nurse overhears the client tell another participant that: Options: A) Green and yellow vegetables should be limited in the diet to prevent prostate cancer B) A low-fiber diet should be followed to prevent prostate cancer C) An annual prostate exam and a prostate-specific antigen (PSA) test should be done beginning at the age of 50 D) Eating foods high in fat is not a risk factor for prostate cancer Correct Answer is: C Explanation : An annual prostate exam and a PSA test should be done beginning at the age of 50 and beginning at the age of 45 if the client is at high risk for this type of cancer. Increased intake of green or yellow vegetables or lycopenes contained in tomatoes may be helpful in reducing risk. A low-fat, high- fiber diet diminishes prostate cancer risk. 166. A client is being discharged to home without an indwelling urinary catheter following prostatectomy. The nurse plans to teach the client which of the following points as part of discharge teaching? Options: A) Drink at least 15 glasses of water a day to minimize clot formation B) Mowing the lawn in allowed after 1 week C) Notify the physician if fever, increased pain, or inability to void occurs D) Avoid lifting more than 50 pounds for 4 to 6 weeks after surgery P a g e 95 | 99 Correct Answer is: C Explanation : The client should notify the physician if there are any signs of infection, bleeding, increased pain, or urinary obstruction. Lifting more than 20 pounds is prohibited for 4 to 6 weeks after surgery. Other strenuous activities that could increase intraabdominal tension are also restricted, such as mowing the lawn. The client should take in 6 to 8 glasses of water or nonalcoholic beverages per day to minimize the risk of clot formation. 167. A nurse is teaching a client with acute renal failure to include proteins in the diet that are considered high quality. Which food item would the nurse discourage because it is a low-quality protein source? Options: A) Eggs B) Broccoli C) Chicken D) Fish Correct Answer is: B Explanation : High-quality proteins come from animal sources and include such foods as eggs, chicken, meat, and fish. Low-quality proteins derive from plant sources and include vegetables and foods made from grains. Because the renal diet is limited in protein, it is important that the proteins ingested are of high quality. 168. A home care nurse visits a client who had a cerebrovascular accident (CVA) with resultant unilateral neglect who was recently discharged from the hospital. The nurse provides instructions to the family regarding care and tells the family to: Options: A) Place personal items directly in front of the client B) Assist the client from the affected side C) Assist the client to groom the unaffected side first D) Discourage the client from scanning the environment P a g e 96 | 99 Correct Answer is: B Explanation : Unilateral neglect is a pattern of lack of awareness of body parts such as paralyzed arms or legs. Initially, the environment is adapted to the deficit by focusing on the client’s unaffected side, and the client’s personal items are placed on the unaffected side. Gradually, the client’s attention is focused to the affected side. The client is assisted from the affected side, and the client grooms the affected side first. The client needs to scan the entire environment. 169. A nurse has completed discharge teaching with a client who has had surgery for lung cancer. The nurse determines that the client has misunderstood essential elements of home management if the client verbalizes to: Options: A) Sit up and lean forward to breathe more easily B) Deal with any increases in pain independently C) Avoid exposure to crowds D) Call the physician for increased temperature or shortness of breath Correct Answer is: B Explanation : Health teaching includes using positions that facilitate respiration, such as sitting up and leaning forward. Health teaching also includes avoiding exposure to crowds or persons with respiratory infections and reporting signs and symptoms of respiratory infection or increases in pain. The client should not be expected to deal with increases in pain independently. 170. A nurse is evaluating the nutritional status of a client after radical neck dissection. The nurse determines that the client has maintained adequate nutritional status if the client maintains body weight or loses less than: Options: A) 5 pounds B) 8 pounds C) 10 pounds P a g e 97 | 99