NCLEX RN Practice Test 1 with Rationale

NCLEX-RN Practice Test 1 with Rationale

Question 1.
A client with a renal failure is prescribed a low potassium diet. Which food choice would be best for this client?
(a) 1 cup beef broth
(b) 1 baked potato with the skin
(c) 1/2 cup raisins
(d) 1 cup rice
Answer:
(d) 1 cup rice

Rationale:
1 cup of rice is considered a low potassium food. The foods in Answers (a), (b), and (c) contain higher amounts of potassium based on a 2000-6000 meq of potassium per day.

Question 2.
The client is admitted for evaluation of aggressive behavior and diagnosed with antisocial personality disorder. A key part of the care of such clients is:
(a) Setting realistic limits
(b) Encouraging the client to express remorse for behavior
(c) Minimizing interactions with other clients
(d) Encouraging the client to act out feelings of rage
Answer:
(a) Setting realistic limits

Rationale:
Clients with antisocial personality disorder must have limits set on their behavior because they are artful in manipulating others. Answer (b) is not correct because they do express feelings and remorse. Answers (c) and (d) are incorrect because it is unnecessary to minimize interactions with others or encourage them to act out rage more than they already do.

Question 3.
An important intervention in monitoring the dietary compliance of a client with bulimia is:
(a) Allowing the client privacy during mealtimes
(b) Praising her for eating all her meal
(c) Observing her for 1-2 hours after meals
(d) Encouraging her to choose foods she likes and to eat in moderation
Answer:
(c) Observing her for 1-2 hours after meals

Rationale:
To prevent the client from inducing vomiting after eating, the client should be observed for 1-2 hours after meals. Allowing privacy as stated in answer A will only give the client time to vomit. Praising the client for eating all of a meal does not correct the psychological aspects of the disease; thus, answer (b) is incorrect. Encouraging the client to choose favorite foods might increase stress and the chance of choosing foods that are low in calories and fats so (d) is not correct.

Question 4.
Assuming that all have achieved normal cognitive and emotional development, which of the following children is at greatest risk for accidental poisoning?
(a) A 6-month-old
(b) A 4-year-old
(c) A 12-year-old
(d) A 13-year-old
Answer:
(b) A 4-year-old

Rationale:
The 4-year-old is more prone to accidental poisoning because children at this age are much more mobile. Answers (a), (c), and (d) are incorrect because the 6-month-old is still too small to be extremely mobile, the 12-year-old has begun to understand risk, and the 13-year-old is also aware that injuries can occur and is less likely to become injured than the 4-year-old.

Question 5.
Which of the following examples represents parallel play?
(a) Jenny and Tommy share their toys.
(b) Jimmy plays with his car beside Mary, who is playing with her doll.
(c) Kevin plays a game of Scrabble with Kathy and Sue.
(d) Mary plays with a handheld game while sitting in her mother’s lap.
Answer:
(b) Jimmy plays with his car beside Mary, who is playing with her doll.

Rationale:
Parallel play is demonstrated by two children playing side by side but not together. The play in answers (a) and (c) is participative play because the children are playing together. The play in answer (d) is solitary play because the mother is not playing with Mary.

Question 6.
The nurse is ready to begin an exam on a nine-month-old infant. The child is sitting in his mother’s lap. Which should the nurse do first?
(a) Check the Babinski reflex
(b) Listen to the heart and lung sounds
(c) Palpate the abdomen
(d) Check tympanic membranes
Answer:
(b) Listen to the heart and lung sounds

Rationale:
The first action that the nurse should take when beginning to examine the infant is to listen to the heart and lungs. If the nurse elicits the Babinski reflex, palpates the abdomen, or looks in the child’s ear first, the child will begin to cry and it will be difficult to obtain an objective finding while listening to the heart and lungs. Therefore, answers (a), (c), and (d) are incorrect.

Question 7.
In terms of cognitive development, a two-year-old would be expected to:
(a) Think abstractly
(b) Use magical thinking
(c) Understand conservation of matter
(d) See things from the perspective of others
Answer:
(b) Use magical thinking

Rationale:
A two-year-old is expected only to use magical thinking, such as believing that a toy bear is a real bear. Answers (a), (c), and (d) are not expected until the child is much older. Abstract thinking, conservation of matter, and the ability to look at things from the perspective of others are not skills for small children.

Question 8.
Which of the following best describes the language of a 24- month-old?
(a) Doesn’t understand yes and no 
(b) Understands the meaning of words
(c) Able to verbalize needs
(d) Asks “why?” to most statements
Answer:
(c) Able to verbalize needs

Rationale:
Children at 24 months can verbalize their needs. Answers (a) and (b) are incorrect because children at 24 months understand yes and no, but they do not understand the meaning of all words. Answer (d) is incorrect; asking “why?” comes later in development

Question 9.
A client who has been receiving urokinase has a large bloody bowel movement. Which action would be best for the nurse to take immediately?
(a) Administer vitamin K IM.
(b) Stop the urokinase.
(c) Reduce the urokinase and administer heparin.
(d) Stop the urokinase and call the doctor.
Answer:
(d) Stop the urokinase and call the doctor.

Rationale:
Urokinase is a thrombolytic used to destroy a clot following a myocardial infraction. If the client exhibits overt signs of bleeding, the nurse should stop the medication, call the doctor immediately, and prepare the antidote, which is Amicar. In answer (a), vitamin K is not the antidote for urokinase; answer (b) is not correct because simply stopping the urokinase is not enough; and answer (c) , administering heparin, may increase bleeding and is therefore wrong.

Question 10.    
The client has a prescription for a calcium carbonate compound to neutralize stomach acid. The nurse should assess the client for:
(a) Constipation 
(b) Hyperphosphatemia 
(c) Hypomagnesemia 
(d) Diarrhea
Answer:
(a) Constipation 

Rationale:
The client taking calcium preparations will frequently develop constipation. Answers (b), (c), and (d) do not apply.

Question 11.    
Heparin has been ordered for a client with a pulmonary embolis. Which statement, if made by the graduate nurse, indicates a lack of understanding of the medication?
(a) “I will administer the medication 1-2 inches away from the umbilicus.”
(b) “I will administer the medication in the abdomen.”
(c) “I will check the PTT before administering the medica-tion.”
(d) ‘‘I will need to aspirate when I give Heparin.”
Answer:
(d) ‘‘I will need to aspirate when I give Heparin.”

Rationale:
indicates a lack of understanding of the correct method of administering heparin. (a), (b), and (d) indicate understanding and are, therefore, incorrect answers.

Question 12.    
The nurse is caring for a client with peripheral vascular disease. To correctly assess the oxygen saturation level, the monitor may be placed on the:
(a) Hip
(b) Ankle
(c) Earlobe
(d) Chin
Answer:
(c) Earlobe

Rationale:
If the finger cannot be used, the next best place to apply the oxygen monitor is the earlobe. It can also be placed on the forehead, but the choices in answers (a), (b), and (d) will not provide the needed readings

Question 13.
While caring for a client with hypertension, the nurse notes the following vital signs: BP of 140/20, pulse 120, respirations 36, temperature 100.8°F. The nurse's initial action should be to:
(a) Call the doctor.
(b) Recheck the vital signs.
(c) Obtain arterial blood gases.
(d) Obtain an ECG.
Answer:
(a) Call the doctor.

Rationale:
The client is exhibiting a widened pulse pressure, tachycardia, and tachypnea. The next action after obtaining these vital signs is to notify the doctor for additional orders. Rechecking the vital signs, as in answer (b), is wasting time. The doctor may order arterial blood gases and an ECG.

Question 14.
The nurse is preparing a client with an axillo-popliteal bypass graft for discharge. The client should be taught to avoid:
(a) Using a recliner to rest
(b) Resting in supine position
(c) Sitting in a straight chair
(d) Sleeping in right Sim’s position
Answer:
(c) Sitting in a straight chair

Rationale:
The client with a axillo popliteal bypass graft should avoid activities that can occlude the femoral artery graft. Sitting in the straight chair and wearing tight clothes are prohibited for this reason. Resting in a supine position, resting in a recliner, or sleeping in right Sim’s are allowed, as stated in answers (a), (b), and (d).

Question 15.
The doctor has ordered antithrombolic stockings to be applied to the legs of the client with peripheral vascular disease. The nurse knows antithrombolic stockings should be applied:
(a) Before rising in the morning
(b) With the client in a standing position
(c) After bathing and applying powder
(d) Before retiring in the evening
Answer:
(a) Before rising in the morning

Rationale:
The best time to apply antithrombolytic stockings is in the morning before rising. If the doctor orders them later in the day, the client should return to bed, wait 30 minutes, and apply the stockings. Answers (b), (c), and (d) are incorrect because there is likely to be more peripheral edema if the client is standing or has just taken a bath; before retiring in the evening is wrong because late in the evening, more peripheral edema will be present.

Question 16.    
The nurse has just received the shift report and is preparing to make rounds. Which client should be seen first?
(a) The client with a history of a cerebral aneurysm with an oxygen saturation rate of 99%
(b) The client three days post-coronary artery bypass graft with a temperature of 100.2°F
(c) The client admitted one hour ago with shortness of breath
(d) The client being prepared for discharge following a femoral popliteal bypass graft
Answer:
(c) The client admitted one hour ago with shortness of breath

Rationale:
The client admitted one hour ago with shortness of breath should be seen first because this client might require oxygen therapy. The client in answer (a) with an oxygen saturation of 99% is stable. Answer B is incorrect because this client will have some inflammatory process after surgery, so a temperature of 100.2°F is not unusual. The client in answer (d) is stable and can be seen later.

Question 17.    
A client with a femoral popliteal bypass graft is assigned to a semiprivate room. The most suitable roommate for this client is the client with:
(a) Hypothyroidism
(b) Diabetic ulcers
(c) Ulcerative colitis
(d) Pneumonia
Answer:
(a) Hypothyroidism

Rationale:
The best roommate for the post-surgical client is the client with hypothyroidism. This client is sleepy and has no infectious process. Answers (b), (c), and (d) are incorrect because the client with a diabetic ulcer, ulcerative colitis, or pneumonia can transmit infection to the post-surgical client.

Question 18.
The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would require further teaching?
(a) “I will have blood drawn every month.
(b) “I will assess my skin for a rash.”
(c) "I take aspirin for a headache."
(d) “I will use an electric razor to shave.”
Answer:
(c) "I take aspirin for a headache."

Rationale:
The client taking an anticoagulant should not take aspirin because it will further increase bleeding. He should return to have a Protime drawn for bleeding time, report a rash, and use an electric razor. Therefore, answers (a), (b), and (d) are incorrect.

Question 19.
The client returns to the recovery room following repair of an abdominal aneurysm. Which finding would require further investigation?
(a)Pedal pulses regular
(b) Urinary output 20mL in the past hour
(c) Blood pressure 108/50
(d) Oxygen saturation 97%
Answer:
(b) Urinary output 20mL in the past hour

Rationale:
Because the aorta is clamped during surgery, the blood supply to the kidneys is impaired. This can result in renal damage. A urinary output of 20mL is oliguria. In answer (a), the pedal pulses that are thready and regular are within normal limits. For answer (c), it is desirable for the client’s blood pressure to be slightly low after surgical repair of an aneurysm. The oxygen saturation of 97% in answer (d) is within normal limits and, therefore, incorrect.

Question 20.
The nurse is doing bowel and bladder retraining for the client with paraplegia. Which of the following is not a factor for the nurse to consider?
(a) Diet pattern
(b) Mobility
(c) Fluid intake
(d) Sexual function
Answer:
(d) Sexual function

Rationale:
When assisting the client with bowel and bladder training, the least helpful factor is the sexual function. Dietary history, mobility, and fluid intake are important factors; these must be taken into consideration because they relate to constipation, urinary function, and the ability to use the urinal or bedpan. Therefore, answers (a), (b), and (c) are incorrect.

Question 21.    
A 20-year-old is admitted to the rehabilitation unit following a motorcycle accident. Which would be the appropriate method for measuring the client for crutches?
(a) Measure five finger breadths under the axilla.
(b) Measure 3 inches under the axilla.
(c) Measure the client with the elbows flexed 10°.
(d) Measure the client with the crutches 20 inches from the side of the foot.
Answer:
(b) Measure 3 inches under the axilla.

Rationale:
To correctly measure the client for crutches, the nurse should measure approximately 3 inches under the axilla. Answer (a) allows for too much distance under the arm. The elbows should be flexed approximately 35°, not 10°, as stated in answer (a). The crutches should be approximately 6 inches from the side of the foot, not 20 inches, as stated in answer 

Question 22.    
The nurse is caring for the client following a cerebral vascular accident. Which portion of the brain is responsible for taste, smell, and hearing?    
(a) Occipital
(b) Frontal
(c) Temporal
(d) Parietal
Answer:
(c) Temporal

Rationale:
The temporal lobe is responsible for taste, smell, and hearing. The occipital lobe is responsible for vision. The frontal lobe is responsible for judgment, foresight, and behavior. The parietal lobe is responsible for ideation, sensory functions, and language. Therefore, answers (a), (b), and (d) are incorrect.

Question 23. 
The client is admitted to the unit after a motor vehicle accident with a temperature of 102°F rectally. The most likely explanations for the elevated temperature is that:
(a) There was damage to the hypothalamus.
(b) He has an infection from the abrasions to the head and face.
(c) He will require a cooling blanket to decrease the tem-perature.
(d) There was damage to the frontal lobe of the brain.
Answer:
(a) There was damage to the hypothalamus.

Rationale:
Damage to the hypothalamus can result in an elevated temperature because this portion of the brain helps to regulate body temperature. Answers (b), (c), and (d) are incorrect because there is no data to support the possibility of an infection, a cooling blanket might not be required, and the frontal lobe is not responsible for regulation of the body temperature.

Question 24. 
The client is admitted to the hospital in chronic renal failure. A diet low in protein is ordered. The rationale for a low-protein diet is:
(a) Protein breaks down into blood urea nitrogen and other waste.
(b) High protein increases the sodium and potassium levels.
(c) A high-protein diet decreases albumin production.
(d) A high-protein diet depletes calcium and phosphorous.
Answer:
(a) Protein breaks down into blood urea nitrogen and other waste.

Rationale:
A low-protein diet is required because protein breaks down into nitrogenous waste and causes an increased workload on the kidneys. Answers (b), (c), and (d) are incorrect.

Question 25. 
The client who is admitted with thrombophlebitis has an order for heparin. The medication should be administered using a/an:
(a) Buretrol
(b) Infusion controller
(c) Intravenous filter
(d) Three-way stop-cock
Answer:
(b) Infusion controller

Rationale:
To safely administer heparin, the nurse should obtain an infusion controller. Too rapid infusion of heparin can result in hemorrhage. Answers (a), (c), and (d) are incorrect. It is not necessary to have a buretrol, an infusion filter, or a three-way stop-cock.

Question 26. 
The nurse is taking the blood pressure of the obese client. If the blood pressure cuff is too small, the results will be:
(a) A false elevation
(b) A false low reading
(c) A blood pressure reading that is correct
(d) A subnormal finding
Answer:
(a) A false elevation

Rationale:
If the blood pressure cuff is too small, the result will be a blood pressure that is a false elevation. Answers (b), (c), and (d) are incorrect. If the blood pres¬sure cuff is too large, a false low will result. Answers (c) and (d) have basically the same meaning.

Question 27.
A four-year-old male is admitted to the unit with nephotic syndrome. He is extremely edematous. To decrease the discomfort associated with scrotal edema, the nurse should:
(a) Apply ice to the scrotum
(b) Elevate the scrotum on a small pillow
(c) Apply heat to the abdominal area
(d) Administer an analgesic
Answer:
(b) Elevate the scrotum on a small pillow

Rationale:
The child with nephotic syndrome will exhibit extreme edema. Elevating the scrotum on a small pillow will help with the edema. Applying ice is contraindicated; heat will increase the edema. Administering a diuretic might be ordered, but it will not directly help the scrotal edema. Therefore, answers (a), (c), and (d) are incorrect.

Question 28.    
The client with an abdominal aortic aneurysm is admitted in preparation for surgery. Which of the following should be reported to the doctor?
(a) An elevated white blood cell count
(b) An abdominal bruit
(c) A negative Babinski reflex
(d) Pupils that are equal and reactive to light
Answer:
(a) An elevated white blood cell count

Rationale:
The elevated white blood cell count should be reported because this indicates infection. A bruit will be heard if the client has an aneurysm, and a nega¬tive Babinski is normal in the adult, as are pupils that are equal and reactive to light and accommodation; thus, answers (b), (c), and (d) are incorrect.

Question 29.    
If the nurse is unable to elicit the deep tendon reflexes of the patella, the nurse should ask the client to:
(a) Pull against the palms 
(b) Grimace the facial muscles 
(c) Cross the legs at the ankles
(d) Perform Valsalva    maneuver
Answer:
(a) Pull against the palms 

Rationale:
If the nurse cannot elicit the patella reflex (knee jerk), the client should be asked to pull against the palms. This helps the client to relax the legs and makes it easier to get an objective reading. Answers (b), (c), and (d) will not help with the test.

Question 30.    
The physician has ordered atropine sulfate 0.4mg IM before surgery. The medication is supplied in 0.8mg per milliliter. The nurse should administer how many milliliters of the medication?
(a) 0.25mL
(b) 0.5mL
(c) 1.0mL
(d) 1.25mL
Answer:
(b) 0.5mL

Rationale:
If the doctor orders 0.4mgm IM and the drug is available in 0.8/1 mL, the nurse should make the calculation: mL = 1mL/ 0.8mgm; ? ,4mg /1 = 0.5m:. Answers (a), (c), and (d) are incorrect.

Question 31.    
The nurse is evaluating the client’s pulmonary artery pressure. The nurse is aware that this test evaluates:
(a) Pressure in the left ventricle
(b) The systolic, diastolic, and mean pressure of the pulmonary artery
(c) The pressure in the pulmonary veins
(d) The pressure in the right ventricle
Answer:
(b) The systolic, diastolic, and mean pressure of the pulmonary artery

Rationale:
The pulmonary artery pressure will measure the pressure during systole, diastole, and the mean pressure in the pulmonary artery. It will not measure the pressure in the left ventricle, the pressure in the pulmonary veins, or the pressure in the right ventricle. Therefore, answers (a), (c), and (d) are incorrect.

Question 32.    
A client is being monitored using a central venous pressure moni tor. If the pressure is 2cm of water, the nurse should:
(a) Call the doctor immediately
(b) Slow the intravenous infusion
(c) Listen to the lungs for rales
(d) Administer a diuretic
Answer:
(a) Call the doctor immediately

Rationale:
The normal central venous pressure is 5-10cm of water. A reading of 2cm is low and should be reported. Answers (b), (c), and (d) indicate that the nurse believes that the reading is too high and is incorrect.

Question 33.    
The nurse identifies ventricular tachycardia on the heart monitor. The nurse should immediately:
(a) Administer atropine sulfate
(b) Check the potassium level
(c) Prepare to administer an antiarrhythmic such as lidocaine
(d) Defibrillate at 360 joules 
Answer:
(c) Prepare to administer an antiarrhythmic such as lidocaine

Rationale:
The treatment for ventricular tachycardia is lidocaine. A precordial thump is sometimes successful in slowing the rate, but this should be done only if a defibrillator is available. In answer (a), atropine sulfate will speed the rate further; in answer (b), checking the potassium is indicated but is not the priority; and in answer (d), defibrillation is used for pulseless ventricular tachycardia or ventricular fibrillation.

Question 34.    
The doctor is preparing to remove chest tubes from the client's left chest. In preparation for the removal, the nurse should instruct the client to:
(a) Breathe normally 
(b) Hold his breath and bear down 
(c) Take a deep breath 
(d) Sneeze on command
Answer:
(b) Hold his breath and bear down 

Rationale:
The client should be asked to perform the Valsalva maneuver while the chest tube is being removed. This prevents changes in pressure until an occlusive dressing can be applied. Answers (a) and (c) are not recommended, and sneezing is difficult to perform on command.

Question 35.    
The doctor has ordered 80mg of furosemide (Lasix) two times per day. The nurse notes the patient’s potassium level to be 2.5meq/L. The nurse should:
(a) Administer the Lasix as ordered 
(b) Administer half the dose 
(c) Offer the patient a potassium-rich food 
(d) Withhold the drug and call the doctor
Answer:
(d) Withhold the drug and call the doctor

Rationale:
The potassium level of 2.5meq/L is extremely low. The normal is 3.5-5.5meq/L. Lasix (furosemide) is a nonpotassium sparing diuretic, so answer (a) is incorrect. The nurse cannot alter the doctor’s order, as stated in answer (b), and answer (c) will not help with this situation.

Question 36.    
Which of the following lab studies should be done periodically if the client is taking warfarin sodium (Coumadin)?
(a) Stool specimen for occult blood 
(b) White blood cell count 
(c) Blood glucose 
(d) Erthyrocyte count
Answer:
(a) Stool specimen for occult blood 

Rationale:
An occult blood test should be done periodically to detect any intestinal bleeding on the client with Coumadin therapy. Answers (b), (c), and (d) are not directly related to the question.

Question 37.    
The client has an order for heparin to prevent post-surgical throm¬bi. Immediately following a heparin injection, the nurse should:
(a) Aspirate for blood
(b) Check the pulse rate
(c) Massage the site
(d) Check the site for bleeding
Answer:
(d) Check the site for bleeding

Rationale:
After administering any subcutaneous anticoagulant, the nurse should check the site for bleeding. Answers (a) and (c) are incorrect because aspirating and massaging the site are not done. Checking the pulse is not necessary, as in answer (b).

Question 38.    
The client with AIDS tells the nurse that he has been using acupuncture to help with his pain. The nurse should question the client regarding this treatment because acupuncture uses:
(a) Pressure from the fingers and hands to stimulate the energy points in the body
(b) Oils extracted from plants and herbs
(c) Needles to stimulate certain points on the body to treat pain
(d) Manipulation of the skeletal muscles to relieve stress and pain 
Answer:
(c) Needles to stimulate certain points on the body to treat pain

Rationale:
Acupuncture uses needles, and because HIV is transmitted by blood and body fluids, the nurse should question this treatment. Answer (a) describes acupressure, and answers (b) and (d) describe massage therapy with the use of oils.

Question 39.
The nurse is taking the vital signs of the client admitted with cancer of the pancreas. The nurse is aware that the fifth vital sign is:
(a) Anorexia
(b) Pain
(c) Insomnia
(d) Fatigue
Answer:
(b) Pain

Rationale:
The fifth vital sign is pain. Nurses should assess and record pain just as they would temperature, respirations, pulse, and blood pressure. Answers (a), (c), and (d) are included in the charting but are not considered to be the fifth vital sign and are, therefore, incorrect.

Question 40.    
The 84-year-old male has returned from the recovery room following a total hip repair. He complains of pain and is medicated with morphine sulfate and promethazine. Which medication should be kept available for the client being treated with opioid analgesics?
(a) Naloxone (Narcan)
(b) Ketorolac (Toradol)
(c) Acetylsalicylic acid (aspirin)
(d) Atropine sulfate (Atropine)
Answer:
(a) Naloxone (Narcan)

Rationale:
Narcan is the antidote for the opoid analgesics. Toradol (answer b) is a nonopoid analgesic; aspirin (answer c) is an analgesic, anticoagulant, and antipyretic; and atropine (answer d) is an anticholengergic.

Question 41.    
The doctor has ordered a patient- controlled analgesia (PCA) pump for the client with chronic pain. The client asks the nurse if he can become overdosed with pain medication using this machine. The nurse demonstrates understanding of the PCA if she states:
(a) “The machine will administer only the amount that you need to control your pain without any action from you.”
(b) “The machine has a locking device that prevents over-dosing.”
(c)  The machine will administer one large dose every four hours to relieve your pain.”
(d) The machine is set to deliver medication only if you need it."
Answer:
(b) “The machine has a locking device that prevents over-dosing.”

Rationale:
The client is concerned about overdosing himself. The machine will deliver a set amount as ordered and allow the client to self-administer a small amount of medication. PCA pumps usually are set to lock out the amount of medication that the client can give himself at 5- to 15-minute intervals. Answer (a) does not address the client’s concerns, answer (c) is incorrect, and answer (d) does not address the client’s concerns.

Question 42.    
The doctor has ordered a Transcutaneous Electrical Nerve Stimulation (TENS) unit for the client with chronic back pain. The nurse teaching the client with a TENS unit should tell the client:
(a) “You may be electrocuted if you use water with this unit.”
(b) “Please report skin irritation to the doctor.”
(c) “The unit may be used anywhere on the body without fear of adverse reactions."
(d) “A cream should be applied to the skin before applying the unit.” 
Answer:
(b) “Please report skin irritation to the doctor.”

Rationale:
Skin irritation can occur if the TEMS unit is used for prolonged periods of time. To prevent skin irritations, the client should change the location of the electrodes often. Electrocution is not a risk because it uses a battery pack; thus, answer (a) is incorrect. Answer (c) is incorrect because the unit should not be used on sensitive areas of the body. Answer (d) is incorrect because no creams are to be used with the device.

Question 43.    
The nurse asked the client if he has an advance directive. The reason for asking the client this question is:
(a) She is curious about his plans regarding funeral arrangements.
(b) Much confusion can occur with the client’s family if he does not have an advanced directive.
(c) An advanced directive allows the medical personnel to make decisions for the client.
(d) An advanced directive allows active euthanasia to be carried out if the client is unable to care for himself.
Answer:
(b) Much confusion can occur with the client’s family if he does not have an advanced directive.

Rationale:
An advanced directive allows the client to make known his wishes regarding care if he becomes unable to act on his own. Much confusion regarding life-saving measures can occur if the client does not have an advanced directive. Answers (a), (c), and (d) are incorrect because the nurse doesn’t need to know about funeral plans and cannot make decisions for the client, and active euthanasia is illegal in most states in the United States.

Question 44.    
A client who has chosen to breastfeed tells the nurse that her nipples became very sore while she was breastfeeding her older child. Which measure will help her to avoid soreness of the nippies?        
(a) Feeding the baby during the first 48 hours after delivery
(b) Breaking suction by placing a finger between the baby’s mouth and the breast when she terminates the feeding
(c) Applying hot, moist soaks to the breast several times per day
(d) Wearing a support bra
Answer:
(b) Breaking suction by placing a finger between the baby’s mouth and the breast when she terminates the feeding

Rationale:
suction before removing the baby from the breast. Answer (a) is incorrect because feeding the baby during the first 48 hours after delivery will provide colostrum but will not help the soreness of the nipples. Answers (c) and (d) are incorrect because applying hot, moist soaks several times per day might cause burning of the breast and cause further drying. Wearing a support bra will help with engorgement but will not help the nipples.

Question 45.    
The nurse is performing an assessment of an elderly client with a total hip repair. Based on this assessment, the nurse decides to medicate the client with an analgesic. Which finding most likely prompted the nurse to decide to administer the analgesic?
(a) The client’s blood pressure is 130/86.
(b) The client is unable to concentrate.
(c) The client’s pupils are dilated.
(d) The client grimaces during care.
Answer:
(d) The client grimaces during care.

Rationale:
Facial grimace is an indication of pain. The blood pressure in answer (a) is within normal limits. The client’s inability to concentrate and dilated pupils, as stated in answers (b) and (c), may be related to the anesthesia that he received during surgery.

Question 46.    
An obstetrical client decides to have an epidural anesthetic to relieve pain during labor. Following administration of the anesthesia, the nurse should monitor the client for:
(a) Seizures
(b) Postural hypertension
(C) Respiratory depression
(d) Hematuria 
Answer:
(C) Respiratory depression

Rationale:
Epidural anesthesia involves injecting an anesthetic into the epidural space. If the anesthetic rises above the respiratory center, the client will have impaired breathing; thus, monitoring for respiratory depression is necessary. Answer (a), seizure activity, is not likely after an epidural. Answer (b), postural hypertension, is not likely. Answer (d), hematuria, is not related to epidural anesthesia.
 
Question 47.    
 The nurse is assessing the client admitted for possible oral cancer. The nurse identifies which of the following to be a late-occurring symptom of oral cancer?
(a) Warmth 
(b) Odor 
(c) Pain
(d) Ulcer with flat edges
Answer:
(c) Pain

Rationale:
Pain is a late sign of oral cancer. Answers (a), (b), and (d) are incorrect because a feeling of warmth, odor, and a flat ulcer in the mouth are all early occurrences of oral cancer.

Question 48.    
The nurse understands that the diagnosis of oral cancer is confirmed with:
(a) Biopsy
(b) Gram Stain
(c) Oral culture
(d) Oral washings for cytology
Answer:
(a) Biopsy

Rationale:
The best diagnostic tool for cancer is the biopsy. Other assessment includes checking the lymph nodes. Answers (b), (c), and (d) will not confirm a diag¬nosis of oral cancer.

Question 49.    
The nurse is caring for the patient following removal of a large posterior oral lesion. The priority nursing measure would be to:
(a) Maintain a patent airway
(b) Perform meticulous oral care every two hours
(c) Ensure that the incisional area is kept as dry as possible
(d) Assess the client frequently for pain
Answer:
(a) Maintain a patent airway

Rationale:
Maintaining a patient’s airway is paramount in the post-operative period. This is the priority of nursing care. Answers (b), (c), and (d) are applicable but are not the priority.

Question 50.    
The registered nurse is conducting an in-service for colleagues on the subject of peptic ulcers. The nurse would be correct in identifying which of the following as a causative factor?
(a)  N. gonorrhea
(b) H. influenza
(c) H. pylori
(d) E. coli
Answer:
(c) H. pylori

Rationale:
pylori bacteria has been linked to peptic ulcers. Answers (a), (b), and (d) are not typically cultured within the stomach, duodenum, or esophagus, and are not related to the development of peptic ulcers.

Question 51. 
The patient states, “My stomach hurts about two hours after I eat.” Based upon this information, the nurse suspects the patient likely has a:
(a) Gastric ulcer
(b) Duodenal ulcer
(c) Peptic ulcer
(d) Curling’s ulcer
Answer:
(b) Duodenal ulcer

Rationale:
Individuals with ulcers within the duodenum typically complain of pain occurring 2-3 hours after a meal, as well as at night. The pain is usually relieved by eating. The pain associated with gastric ulcers, answer (a), occurs 30 minutes after eating. Answer (c) is too vague and does not distinguish the type of ulcer. Answer (d) is associated with a stress ulcer.

Question 52.    
The nurse is caring for a patient with suspected diverticulitis. The nurse would be most prudent in questioning which of the following diagnostic tests?
(a) Abdominal ultrasound
(b) Barium enema
(c) Complete blood count
(d) Computed tomography (CT) scan
Answer:
(b) Barium enema

Rationale:
A barium enema is contraindicated in the client with diverticulitis because it can cause bowel perforation. Answers (a), (c), and (d) are appropriate diagnostic studies for the client with suspected diverticulitis.

Question 53.    
The nurse is planning care for the patient with celiac disease. In teaching about the diet, the nurse should instruct the patient to avoid which of the following for breakfast?
(a) Puffed wheat
(b) Banana
(c) Puffed rice
(d) Cornflakes
Answer:
(a) Puffed wheat

Rationale:
Clients with celiac disease should refrain from eating foods containing gluten. Foods with gluten include wheat barley, oats, and rye. The other foods are allowed.

Question 54.    
The nurse is teaching about irritable bowel syndrome (IBS). Which of the following would be most important?
(a) Reinforcing the need for a balanced diet
(b) Encouraging the client to drink 16 ounces of fluid with each meal
(C) Telling the client to eat a diet low in fiber
(d) Instructing the client to limit his intake of fruits and vegetables
Answer:
(a) Reinforcing the need for a balanced diet

Rationale:
The nurse should reinforce the need for a diet balanced in all nutrients and fiber. Foods that often cause diarrhea and bloating associated with irritable bowel syndrome include fried foods, caffeinated beverages, alcohol, and spicy foods. Therefore, answers (b), (c), and (d) are incorrect.

Question 55.
In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnosis as a priority?
(a) Anxiety
(b) Impaired skin integrity
(c) Fluid volume deficit
(d) Nutrition altered, less than body requirements
Answer:
(c) Fluid volume deficit

Rationale:
Fluid volume deficit can lead to metabolic acidosis and elec¬trolyte loss. The other nursing diagnoses in answers A, B, and D might be applicable but are of lesser priority.

Question 56.    
The patient is prescribed metronidazole (Flagyl) for adjunct treatment for a duodenal ulcer. When teaching about this medication, the nurse would include:
(a) “This medication should be taken only until you begin to feel better."
(b) “This medication should be taken on an empty stom-ach to increase absorption.”
(c) “While taking this medication, you do not have to be concerned about being in the sun.”
(d) “While taking this medication, alcoholic beverages and products containing alcohol should be avoided.”
Answer:
(d) “While taking this medication, alcoholic beverages and products containing alcohol should be avoided.”

Rationale:
Alcohol will cause extreme nausea if consumed with Flagyl. Answer (a) is incorrect because the full course of treatment should be taken. The medication should be taken with a full 8 oz. of water, with meals, and the client should avoid direct sunlight because he will most likely be photosensitive; therefore, answers (a), (b), and (c) are incorrect.

Question 57.    
The nurse is preparing to administer a feeding via a nasogastric tube. The nurse would perform which of the following before initiating the feeding?
(a) Assess for tube placement by aspirating stomach content.
(b) Place the patient in a left-lying position.
(c) Administer feeding with 50% Dextrose.
(d) Ensure that the feeding solution has been warmed in a microwave for two minutes.
Answer:
(a) Assess for tube placement by aspirating stomach content.

Rationale:
Before beginning feedings, an x-ray is often obtained to check for placement. Aspirating stomach content and checking the pH for acidity is the best method of checking for placement. Other methods include placing the end in water and checking for bubbling, and injecting air and listening over the epigastric area. Answers (b) and (c) are not correct. Answer (d) is incorrect because warming in the microwave is contraindicated.

Question 58.    
Which is true regarding the administration of antacids?
(a) Antacids should be administered without regard to mealtimes.
(b) Antacids should be administered with each meal and snack of the day.
(c) Antacids should not be administered with other med-ications.
(d) Antacids should be administered with all other med-ications, for maximal absorption.
Answer:
(c) Antacids should not be administered with other med-ications.

Rationale:
Antacids should be administered with other medications. If antacids are taken with many medications, they render the other medications inactive. All other answers are incorrect.

Question 59.    
The nurse is caring for a patient with a colostomy. The patient asks, “Will I ever be able to swim again?” The nurse’s best response would be:
(a) “Yes, you should be able to swim again, even with the colostomy.”
(b) “You should avoid immersing the colostomy in water.”
(c) “No, you should avoid getting the colostomy wet.”
(d) “Don’t worry about that. You will be able to live just like you did before.” 
Answer:
(a) “Yes, you should be able to swim again, even with the colostomy.”

Rationale:
The client with a colostomy can swim and carry on activities as before the colostomy. Answers (b) and (c) are incorrect, and answer (d) shows a lack of empathy.

Question 60.    
The nurse is assisting in the care of a patient who is two days post-operative from a hemorroidectomy. The nurse would be correct in instructing the patient to:
(a) Avoid a high-fiber diet 
(b) Continue to use ice packs 
(c) Take a laxative daily to prevent constipation 
(d) Use a sitz bath after each bowel movement
Answer:
(d) Use a sitz bath after each bowel movement

Rationale:
The use of a sitz bath will help with the pain and swelling associated with a hemorroidectomy. The client should eat foods high in fiber, so answer (a) is incorrect. Ice packs, as stated in answer (b), are ordered immediately after surgery only. Answer (c) is incorrect because taking a laxative daily can result in diarrhea.

Question 61.    
The nurse is assisting in the care of a client with diverticulosis. Which of the following assessment findings must necessitate an immediate report to the doctor?
(a) Bowel sounds are present
(b) Intermittent left lower-quadrant pain
(c) Constipation alternating with diarrhea
(d) Hemoglobin 26% and hematocrit 32
Answer:
(d) Hemoglobin 26% and hematocrit 32

Rationale:
Low hemoglobin and hematocrit might indicate intestinal bleeding. Answers (a), (b), and (c) are incorrect, because they do not require immediate action.

Question 62.    
The client is newly diagnosed with juvenile onset diabetes. Which of the following nursing diagnoses is a priority?
(a) Anxiety
(b) Pain
(c) Knowledge deficit
(d) Altered thought process
Answer:
(c) Knowledge deficit

Rationale:
The new diabetic has a knowledge deficit. Answers (a), (b), and (d) are not supported within the stem and so are incorrect.

Question 63.
The nurse is asked by the nurse aide, “Are peptic ulcers really caused by stress?” The nurse would be correct in replying with the following:
(a) “Peptic ulcers result from overeating fatty foods.”
(b) “Peptic ulcers are always caused from exposure to continual stress.”
(c) “Peptic ulcers are like all other ulcers, which all result from stress.”
(d) “Peptic ulcers are associated with H. pylori, although there are other ulcers that are associated with stress.”
Answer:
(d) “Peptic ulcers are associated with H. pylori, although there are other ulcers that are associated with stress.”

Rationale:
Peptic ulcers are not always related to stress but are a compo¬nent of the disease. Answers (a) and (b) are incorrect because peptic ulcers are not caused by overeating or continued exposure to stress. Answer (C) is incorrect because peptic ulcers are related to but not directly caused by stress.

Question 64.    
The nurse is assisting in the assessment of the patient admitted with “extreme abdominal pain.” The nurse asks the client about the medication that he has been taking because:
(a) Interactions between medications will cause abdomi-nal pain.
(b) Various medications taken by mouth can affect the alimentary tract.
(c) This will provide an opportunity to educate the patient regarding the medications used.
(d) The types of medications might be attributable to an abdominal pathology not already identified.
Answer:
(b) Various medications taken by mouth can affect the alimentary tract.

Rationale:
Many medications can irritate the stomach and contribute to abdominal pain. For answer (a), not all interactions between medications will cause abdominal pain. Although this might provide an opportunity for teaching, this is not the best time to teach. Therefore, answer (c) is incorrect. Answer (d) is incorrect because medication may not be the cause of the pain.

Question 65.    
The nurse is assessing the abdomen. The nurse knows the best sequence to perform the assessment is:
(a) Inspection, auscultation, palpation
(b) Auscultation, palpation, inspection
(c) Palpation, inspection, auscultation
(d) Inspection, palpation, auscultation
Answer:
(a) Inspection, auscultation, palpation

Rationale:
The nurse should inspect first, then auscultate, and finally palpate. If the nurse palpates first the assessment might be unreliable. Therefore, answers (b), (c), and (d) are incorrect.

Question 66.    
The nurse is caring for the client who has been in a coma for two months. He has signed a donor card, but the wife is opposed to the idea of organ donation. How should the nurse handle the topic of organ donation with the wife?
(a) Tell the wife that the hospital will honor her wishes regarding organ donation, but contact the organ retrieval staff.
(b) Tell her that because her husband signed a donor card, the hospital has the right to take the organs upon the death of her husband.
(c) Explain that it is necessary for her to donate her husband’s organs because he signed the permit.
(d) Refrain from talking about the subject until after the death of her husband.
Answer:
(a) Tell the wife that the hospital will honor her wishes regarding organ donation, but contact the organ retrieval staff.

Rationale:
The hospital will certainly honor the wishes of family members even if the patient has signed a donor card. Answer (b) is incorrect, answer (c) is not empathetic to the family and is untrue, and answer (d) is not good nursing etiquette and, therefore, is incorrect.

Question 67.    
The client with cancer refuses to care for herself. Which action by the nurse would be best?
(a) Alternate nurses caring for the client so that the staff will not get tired of caring for this client.
(b) Talk to the client and explain the need for self-care.
(c) Explore the reason for the lack of motivation seen in the client.
(d) Talk to the doctor about the client’s lack of motivation. 
Answer:
(c) Explore the reason for the lack of motivation seen in the client.

Rationale:
The nurse should explore the cause for the lack of motivation. The client might be anemic and lack energy, or the client might be depressed. Alternating staff, as stated in answer (a), will prevent a bond from being formed with the nurse. Answer (b) is not enough, and answer (d) is not necessary.

Question 68.    
The charge nurse is making assignments for the day. After accepting the assignment to a client with leukemia, the nurse tells the charge nurse that her child has chickenpox. Which initial action
should the charge nurse take?
(a) Change the nurse’s assignment to another client.
(b) Explain to the nurse that there is no risk to the client.
(c) Ask the nurse if the chickenpox have scabbed.
(d) Ask the nurse if she has ever had the chickenpox.
Answer:
(d) Ask the nurse if she has ever had the chickenpox.

Rationale:
The nurse who has had the chickenpox has immunity to the illness and will not transmit chickenpox to the client. Answer (a) is incorrect because there could be no need to reassign the nurse. Answer (b) is incorrect because the nurse should be assessed before coming to the conclusion that she cannot spread the infection to the client. Answer (c) is incorrect because there is still a risk, even though chickenpox has formed scabs.

Question 69.    
The nurse is caring for the client with a mastectomy. Which action would be contraindicated?    
(a) Taking the blood pressure in the side of the mastectomy
(b) Elevating the arm on the side of the mastectomy 
(c) Positioning the client on the unaffected side 
(d) Performing a dextrostix on the unaffected side
Answer:
(a) Taking the blood pressure in the side of the mastectomy

Rationale:
The nurse should not take the blood pressure on the affected side. Also, venopunctures and IVs should not be used in the affected area. Answers (b), (c), and (d) are all indicated for caring for the client. The arm should be elevated to decrease edema. It is best to position the client on the unaffected side and perform a dextrostix on the unaffected side.

Question 70.    
The client has an order for gentamycin to be administered. Which  lab results should be reported to the doctor before beginning the medication?    
(a) Hematocrit        
(b) Creatinine        
(c) White blood cell count        
(d) Erythrocyte count    
Answer:
(b) Creatinine        

Rationale:
Gentamycin is an aminoglycocide. These drugs are toxic to the auditory nerve and the kidneys. The hematocrit is not of significant consideration in this client; therefore, answer (a) is incorrect. Answer (c) is incorrect because we would expect the white blood cell count to be elevated in this client because gentamycin is an antibiotic. Answer (d) is incorrect because the erythrocyte count is also particularly significant to check.
    
Question 71.    
Which of the following is the best indicator of the diagnosis of HIV?    
(a) White blood cell count        
(b) ELISA        
(c) Western Blot        
(d) Complete blood count        
Answer:
(c) Western Blot        

Rationale:
The most definitive diagnostic tool for HIV is the Western Blot. The white blood cell count, as stated in answer A, is not the best indicator, but a white blood cell count of less than 3,500 requires investigation. The ELISA test, answer (b), is a screening exam. Answer (d) is not specific enough.

Question 72.    
The client presents to the emergency room with a “bull’s eye” rash. Which question would be most appropriate for the nurse to 68 K ask the client?
(a) “Have you found any ticks on your body?”
(b) “Have you had any nausea in the last 24 hours?”
(c) “Have you been outside the country in the last six months?”
(d) “Have you had any fever for the past few days?” 
Answer:
(a) “Have you found any ticks on your body?”

Rationale:
The “bull’s eye” rash is indicative of Lyme’s disease, a disease spread by ticks. The signs and symptoms include elevated temperature, headache, nausea, and the rash. Although answers (b) and (d) are important, the question asked which question would be best. Answer (c) has no significance.

Question 73.    
Which client should be assigned to the nursing assistant?
(a) The 18-year-old with a fracture to two cervical vertebrae
(b) The infant with meningitis 
(c) The elderly client with a thyroidectomy four days ago 
(d) The client with a thoracotomy two days ago
Answer:
(c) The elderly client with a thyroidectomy four days ago 

Rationale:
The client that needs the least-skilled nursing care is the client with the thyroidectomy four days ago. Answers (a), (b), and (d) are incorrect because the other clients are less stable and require a registered nurse.

Question 74.    
The client presents to the emergency room with a hyphema. Which action by the nurse would be best?
(a) Elevate the head of the bed and apply ice to the eye.
(b) Place the client in a supine position and apply heat to the knee.
(c) Insert a Foley catheter and measure the intake and output.
(d) Perform a vaginal exam and check for a discharge.
Answer:
(a) Elevate the head of the bed and apply ice to the eye.

Rationale:
Hyphema is blood in the anterior chamber of the eye and around the eye. The client should have the head of the bed elevated and ice applied. 

Question 75.    
The client has an order for FeSO4 liquid. Which method of administration would be best?
(a) Administer the    medication with milk.
(b) Administer the medication with a meal.
(c) Administer the    medication with orange juice.
(d) Administer the medication undiluted.
Answer:
(c) Administer the    medication with orange juice.

Rationale:
FeS04 or iron should be given with ascorbic acid (vitamin C). This helps with the absorption. It should not be given with meals or milk because this decreases the absorption; thus, answers (a) and (b) are incorrect. Giving it undiluted, as stated in answer (d), is not good because it tastes bad.

Question 76.    
The client with an ileostomy is being discharged. Which teaching should be included in the plan of care?
(a) Using Karaya powder to seal the bag.
(b) Irrigating the ileostomy daily.
(c) Using stomahesive as the best skin protector.
(d) Using Neosporin ointment to protect the skin.
Answer:
(c) Using stomahesive as the best skin protector.

Rationale:
The best protector for the client with an ileostomy to use is stomahesive. Answer (a) is not correct because the bag will not seal if the client uses Karaya powder. Answer (b) is incorrect because there is no need to irrigate an ileosto my. Neosporin, answer (d), is not used to protect the skin because it is an antibiotic.

Question 77.    
Vitamin K is administered to the newborn shortly after birth for which of the following reasons?
(a) To stop hemorrhage 
(b) To treat infection 
(c) To replace electrolytes 
(d) To facilitate clotting 
Answer:
(d) To facilitate clotting

Rationale:
Vitamin K is given after delivery because the newborn’s intestinal tract is sterile and lacks vitamin K needed for clotting. Answer (a) is incorrect because vitamin K is not directly given to stop hemorrhage. Answers (b) and (c) are incorrect because vitamin K does not prevent infection or replace electrolytes.

Question 78.    
Before administering Methyltrexate orally to the client with cancer, the nurse should check the
(a) IV site
(b) Electrolytes
(c) Blood gases
(d) Vital signs
Answer:
(d) Vital signs

Rationale:
The vital signs should be taken before any chemotherapy agent. If it is an IV infusion of chemotherapy, the nurse should check the IV site as well. Answers (b) and (c) are incorrect because it is not necessary to check the electrolytes or blood gasses.

Question 79.    
The nurse is teaching a group of new graduates about the safety needs of the client receiving chemotherapy. Before administering chemotherapy, the nurse should
(a) Administer a bolus of IV fluid.
(b) Administer pain medication.
(c) Administer an antiemetic.
(d) Allow the patient a chance to eat.
Answer:
(c) Administer an antiemetic.

Rationale:
Before chemotherapy, an antiemetic should be given because most chemotherapy agents cause nausea. It is not necessary to give a bolus of IV fluids, medicate for pain, or allow the client to eat; therefore, answers (a), (b), and (d) are incorrect.

Question 80.    
The client is admitted to the postpartum unit with an order to continue the infusion of Pitocin. The nurse is aware that Pitocin is working if the fundus is:
(a) Deviated to the left 
(b) Firm and in the midline 
(c) Boggy
(d) Two finger breadths below the umbilicus
Answer:
(b) Firm and in the midline 

Rationale:
Pitocin is used to cause the uterus to contract and decrease bleeding. A uterus deviated to the left, as stated in answer (a), indicates a full bladder. It is not desirable to have a boggy uterus, making answer (c) incorrect. This lack of muscle tone will increase  bleeding. Answer (d) is incorrect because Pitocin does not affect the position of the uterus.

Question 81.    
A five-year-old is a family contact to the client with tuberculosis. Isoniazid (INH) has been prescribed for the client. The nurse is aware that the length of time that the medication will be taken is:
(a) six months 
(b) three months 
(c) one year 
(d) two years
Answer:
(a) six months 

Rationale:
Household contacts should take INH approximately six months. Answers (b), (c), and (d) are incorrect because they indicate either too short or too long of a time to take the medication.

Question 82.    
A four-year-old with cystic fibrosis has a prescription for Viokase pancreatic enzymes to prevent malabsorption. The correct time to give pancreatic enzyme is:
(a) one hour before meals
(b) two hours after meals
(c) With each meal and snack
(d) On an empty stomach
Answer:
(c) With each meal and snack

Rationale:
Viokase is a pancreatic enzyme that is used to facilitate digestion. It should be given with meals and snacks, and it works well in foods such as applesauce. Answers (a), (b), and (d) are incorrect.
 
Question 83.    
A client with osteomylitis has an order for a trough level to be done because he is taking Gentamycin. When should the nurse call the lab to obtain the trough level?
(a) Before the first dose
(b) 30 minutes before the fourth dose
(c) 30 minutes after the first dose
(d) 30 minutes before the first dose
Answer:
(b) 30 minutes before the fourth dose

Rationale:
Trough levels are the lowest blood levels and should be done 30 minutes before the third IV dose or 30 minutes before the fourth IM dose. Answers (a), (c), and (d) are incorrect.

Question 84. 
A new diabetic is learning to administer his insuhn. He receives 10U of NPH and 12U of regular insulin each morning. Which of the following statements reflects understanding of the nurse’s teaching?
(a) When drawing up my ,nsulin. I should draw up the regular insulin first.”
(b) “When drawing up my insulin. I should draw up the NPH insulin first.”
(c) “It doesn’t matter which insulin I draw up first.”
(d) "I cannot mix the insulin, so I will need two shots”
Answer:
(a) When drawing up my ,nsulin. I should draw up the regular insulin first.”

Rationale:
Regular insulin should be drawn up before the IIPH. They can be given together, so there is no need for two injections, making answer (d) incorrect, Answer (b) is obviously incorrect, and answer (c) is incorrect because it certainly does matter which is drawn first: Contamination of NPH into regular insulin will result in a hypoglycemic reaction at unexpected times.

Question 85. 
The client is scheduled to have an intravenous cholangiogram. Before the procedure, the nurse should assess the patient for
(a) Shellfish allergies
(b) Reactions to blood transfusions
(c) Gallbladder disease
(d) Egg allergies
Answer:
(a) Shellfish allergies

Rationale:
Clients having dye procedures should be assessed for allergies to iodine or shellfish. Answers (b) and (d) are incorrect because there is no need for the client to be assessed for reactions to blood or eggs. Because an IV cholangiogram is done to detect gallbladder disease, there is no need to ask about answer (c).

Question 86. 
Shortly after the client was admitted to the postpartum unit, the nurse notes heavy lochia rubra with large clots. The nurse should anticipate an order for
(a) Methergine
(b) Stadol
(c) Magnesium sulfate
(d) Phenergan
Answer:

Rationale:
Methergine is a drug that causes uterine contractions. It is used for postpartal bleeding that is not controlled by Pitocin. Answers (b), (c), and (d) are incorrect: Stadol is an analgesic; magnesium sulfate is used for preeclampsia; and phener-gan is an antiemetic.

Question 87. 
The client with a recent liver transplant asks the nurse how long he will have to take an immunosuppressant. Which response would be correct?
(a) one year
(b) five years
(c) 10 years
(d) The rest of his life
Answer:
(d) The rest of his life

Rationale:
Cyclosporin is an immunosuppressant, and the client with a liver transplant will be on immunosuppressants for the rest of his life. Answers (a), (b), and (c), then, are incorrect.
 
Question 88.    
The client is admitted from the emergency room with multiple injuries sustained from an auto accident. His doctor prescribes a histamine blocker. The nurse is aware that the reason for this order is to:
(a) Treat general discomfort
(b) Correct electrolyte imbalances
(c) Prevent stress ulcers
(d) Treat nausea
Answer:
(c) Prevent stress ulcers

Rationale:
Histamine blockers are frequently ordered for clients who are hospitalized for prolonged periods and who are in a stressful situation. They are not used to treat discomfort, correct electrolytes, or treat nausea; therefore, answers (a), (b), and (d) are incorrect.

Question 89.    
The physician prescribes regular insulin, five units subcutaneous. Regular insulin begins to exert an effect:
(a) In 5-10 minutes
(b) In 10-20 minutes
(c) In 30-60 minutes
(d) In 60-120 minutes
Answer:
(c) In 30-60 minutes

Rationale:
The time of onset for regular insulin is 30-60 minutes. Answers (a), (b), and (d) are incorrect because they are not the correct times.

Question 90.    
A 60-year-old diabetic is taking glyburide (Diabeta) 1.25mg daily to treat Type II diabetes mellitus. Which statement indicates the need for further teaching?
(a) “I will keep candy with me just in case my blood sugar drops.”
(b) “I need to stay out of the sun as much as possible.”
(c) “I often skip dinner because I don’t feel hungry.”
(d) “I always wear my medical identification.”
Answer:
(c) “I often skip dinner because I don’t feel hungry.”

Rationale:
The client should be taught to eat his meals even if he is not hungry, to prevent a hypoglycemic reaction. Answers (a), (b), and (d) are incorrect because they indicate knowledge of the nurse’s teaching.

Question 91.    
A 20-year-old female has a prescription for tetracycline. While teaching the client how to take her medicine, the nurse learns that the client is also taking Ortho-Novum oral contraceptive pills. Which instructions should be included in the teaching plan?
(a) The oral contraceptives will decrease the effectiveness of the tetracycline.
(b) Nausea often results from taking oral contraceptives and antibiotics.
(c) Toxicity can result when taking these two medications together.
(d) Antibiotics can decrease the effectiveness of oral con-traceptives, so the client should use an alternate method of birth control. 
Answer:
(d) Antibiotics can decrease the effectiveness of oral con-traceptives, so the client should use an alternate method of birth control. 

Rationale:
Taking antibiotics and oral contraceptives together decreases the effectiveness of the oral contraceptives. Answers (a), (b), and (c) are not necessarily true.

Question 92.    
The client is taking prednisone 7.5mg po each morning to treat his systemic lupus erythematosis. Which statement best explains the reason for taking the prednisone in the morning?
(a) There is less chance of forgetting the medication if taken in the morning.
(b) There will be less fluid retention if taken in the morning.
(c) Prednisone is absorbed best with the breakfast meal.
(d) Morning administration mimics the body’s natural secretion of corticosteroid.
Answer:
(d) Morning administration mimics the body’s natural secretion of corticosteroid.

Rationale:
Taking corticosteroids in the morning mimics the body’s natural release of cortisol. Answer (a) is not necessarily true, and answers (b) and (c) are not true.  ,

Question 93.    
The client is taking rifampin 600mg po daily to treat his tuberculosis. Which action by the nurse indicates understanding of the medication?
(a) Telling the client that the medication will need to be taken with juice
(b) Telling the client that the medication will change the color of the urine
(c) Telling the client to take the medication before going to bed at night
(d) Telling the client to take the medication if night sweats occur
Answer:
(b) Telling the client that the medication will change the color of the urine

Rationale:
Rifampin can change the color of the urine and body fluid. Teaching the client about these changes is best because he might think this is a complication. Answer (a) is not necessary, answer (c) is not true, and answer (d) is not true because this medication should be taken regularly during the course of the treatment.

Question 94.    
The client is diagnosed with multiple myloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client?
(a) “Walk about a mile a day to prevent calcium loss.”
(b) “Increase the fiber in your diet.”
(c) “Report nausea to the doctor immediately.”
(d) “Drink at least eight large glasses of water a day.”
Answer:
(d) “Drink at least eight large glasses of water a day.”

Rationale:
Cytoxan can cause hemorrhagic cystitis, so the client should drink at least eight glasses of water a day. Answers (a) and (b) are not necessary and, so, are incorrect. Nausea often occurs with chemotherapy, so answer (c) is incorrect.

Question 95.    
An elderly client is diagnosed with ovarian cancer. She has surgery followed by chemotherapy with a fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals in the IV medication?
(a) Discard the solution and order a new bag.
(b) Warm the solution.
(c) Continue the infusion and document the finding.
(d) Discontinue the medication. 
Answer:
(a) Discard the solution and order a new bag.

Rationale:
Crystals in the solution are not normal and should not be administered to the client. Discard the bad solution immediately. Answer (b) is incorrect because warming the solution will not help. Answer (c) is incorrect, and answer (d) requires a doctor’s order.

Question 96.    
The 10-year-old is being treated for asthma. Before administering Theodur, the nurse should check the
(a) Urinary output
(b) Blood pressure
(c) Pulse
(d) Temperature
Answer:
(c) Pulse

Rationale:
Theodur is a bronchodilator, and a side effect of bronchodilators is tachycardia, so checking the pulse is important. Extreme tachycardia should be reported to the doctor. Answers (a), (b), and (d) are not necessary.

Question 97.
Which information obtained from the mother of a child with cerebral palsy correlates to the diagnosis?
(a) She was born at 40 weeks gestation.
(b) She had meningitis when she was six months old.
(c) She had physiologic jaundice after delivery.
(d) She has frequent sore throats.
Answer:
(b) She had meningitis when she was six months old.

Rationale:
The diagnosis of meningitis at age six months correlates to a diagnosis of cerebral palsy. Cerebral palsy, a neurological disorder, is often associated with birth trauma or infections of the brain or spinal column. Answers (a), (c) and (d) are not related to the question.

Question 98.
A 6-year-old with cerebral palsy functions at the level of an 18- month-old. Which finding would support that assessment?
(a) She dresses herself.
(b) She pulls a toy behind her.
(c) She can build a tower of eight blocks.
(d) She can copy a horizontal or vertical line.
Answer:
(b) She pulls a toy behind her.

Rationale:
Children at 18 months of age like push-pull toys. Children at approximately three years of age begin to dress themselves and build a tower of eight blocks. At age four, children can copy a horizontal or vertical line. Therefore, answers (a), (c) and (d) are incorrect.

Question 99.
A five-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery?
(a) Decreased appetite
(b) A low-grade fever
(c) Chest congestion
(d) Constant swallowing
Answer:
(d) Constant swallowing

Rationale:
A complication of a tonsillectomy is bleeding, and constant swallowing may indicate bleeding. Decreased appetite is expected after a tonsillectomy, as is a low-grade temperature; thus, answers (a) and (b) are incorrect. In answer (c), chest congestion is not normal but is not associated with the tonsillectomy.

Question 100. 
The child with seizure disorder is being treated with phenytoin (Dilantin). Which of the following statements by the patient's mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy?
(a) “She is very irritable lately.”
(b) “She sleeps quite a bit of the time.”
(c) “Her gums look too big for her teeth.”
(d) “She has gained about 10 pounds in the last six months.”
Answer:
(c) “Her gums look too big for her teeth.”

Rationale:
Hyperplasia of the gums is associated with Dilantin therapy. Answer (a) is not related to the therapy; answer (b) is a side effect; and answer (d) is not related to the question.

Question 101.
The physician has prescribed tranylcypromine sulfate (Parnate) 10mg bid. The nurse should teach the client to refrain from eating foods containing tyramine because it may cause:
(a) Hypertension
(b) Hyperthermia
(c) Hypotension
(d) Urinary retention
Answer:
(a) Hypertension

Rationale:
If the client eats foods high in tyramine, he might experience malignant hypertension. Tyramine is found in cheese, sour cream, Chianti wine, sherry, beer, pickled herring, liver, canned figs, raisins, bananas, avocados, chocolate, soy sauce, fava beans, and yeast. These episodes are treated with Regitine, an alpha-adrenergic blocking agent. Answers (b), (c), and (d) are not related to the question.

Question 102.
The client is admitted to the emergency room with shortness of breath, anxiety, and tachycardia. His ECG reveals atrial fibrillation with a ventricular response rate of 130 beats per minute. The doctor orders quinidine sulfate. While he is receiving quinidine, the nurse should monitor his ECG for:
(a) Peaked P wave
(b) Elevated ST segment
(c) Inverted T wave
(d) Prolonged QT interval
Answer:
(d) Prolonged QT interval

Rationale:
Quinidine can cause widened Q-T intervals and heart block. Other signs of myocardial toxicity are notched P waves and widened QRS complexes. The most common side effects are diarrhea, nausea, and vomiting. The client might experience tinnitus, vertigo, headache, visual disturbances, and confusion. Answers (a), (b), and (c) are not related to the use of quinidine.

Question 103.
Lidocaine is a medication frequently ordered for the client experiencing:        
(a) Atrial tachycardia
(b) Ventricular tachycardia
(c) Heart block
(d) Ventricular brachycardia
Answer:
(b) Ventricular tachycardia

Rationale:
Lidocaine is used to treat ventricular tachycardia. This medication slowly exerts an antiarrhythmic effect by increasing the electric stimulation threshold of the ventricles without depressing the force of ventricular contractions. It is not used for atrial arrhythmias; thus, answer (a) is incorrect. Answers (c) and (d) are incorrect because it slows the heart rate, so it is not used for heart block or brachy-cardia.

Question 104.
The doctor orders 2% nitroglycerin ointment in a 1-inch dose every 12 hours. Proper application of nitroglycerin ointment
includes:    
(a) Rotating application sites
(b) Limiting applications to the chest
(c) Rubbing it into the skin
(d) Covering it with a gauze dressing
Answer:
(a) Rotating application sites

Rationale:
Sites for the application of nitroglycerin should be rotated, to prevent skin irritation. It can be applied to the back and upper arms, not to the lower extremities, making answer B incorrect. Answer (c) is incorrect because nitroglycerine should not be rubbed into the skin, and answer (d) is incorrect because the medication should be covered with a prepared dressing made of a thin paper substance, not gauze.

Question 105. 
The physician prescribes captopril (Capoten) 25mg po tid for the client with hypertension. Which of the following adverse reactions can occur with administration of Capoten?
(a) Tinnitus
(b) Persistent cough
(c) Muscle weakness
(d) Diarrhea 
 Answer:
(b) Persistent cough

Rationale:
A persistent cough might be related to an adverse reaction to Captoten. Answers (a) and (d) are incorrect because tinnitus and diarrhea are not associated with the medication. Muscle weakness might occur when beginning the treatment but is not an adverse effect; thus, answer (c) is incorrect.

Question 106. 
The client is admitted with a BP of 210/100. Her doctor orders furosemide (Lasix) 40mg IV stat. How should the nurse administer the prescribed furosemide to this client?
(a) By giving it over 1-2 minutes
(b) By hanging it IV piggyback
(c) With normal saline only
(d) With a filter
Answer:
(a) By giving it over 1-2 minutes

Rationale:
Lasix should be given approximately 1 mL per minute to prevent hypotension. Answers (b), (c), and (d) are incorrect because it is not necessary to be given in an IV piggyback, with saline, or through a filter.

Question 107. 
The client is receiving heparin for thrombophlebitis of the left lower extremity. Which of the following drugs reverses the effects of heparin?
(a) Cyanocobalamine
(b) Protamine sulfate
(c) Streptokinase
(d) Sodium warfarin
Answer:
(b) Protamine sulfate

Rationale:
The antidote for heparin is protamine sulfate. Cyanocobalamine is B12, Streptokinase is a thrombolytic, and sodium warfarin is an anticoagulant. Therefore, answers (a), (c), and (d) are incorrect.

Question 108.    
The 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) The client receiving linear accelerator radiation therapy for lung cancer

Rationale:
The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy is not radioactive because he travels to the radium department for therapy, and the radiation stays in the department. The client in answer (b) does pose a risk to the pregnant nurse. The client in answer (c) is radioactive in very small doses. For approximately 72 hours, the client should dispose of urine and feces in special containers and use plastic spoons and forks. The client in answer (d) is also radioactive in small amounts, especially upon return from the procedure.

Question 109.    
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) The client with Cushing’s disease

Rationale:
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.

Question 110.    
The charge nurse witnesses the nursing assistant hitting the client in the long-term care facility. The nursing assistant can be charged
(a) Negligence
(b) Tort
(c) Assault
(d) Malpractice
Answer:
(c) Assault

Rationale:
Assault is defined as striking or touching the client inappropriately, so a nurse assistant striking a client could be charged with assault. Answer (a), negligence, is failing to perform care for the client. Answer (b), a tort, is a wrongful act committed on the client or their belongings. Answer (d), malpractice, is failure to perform an act that the nurse assistant knows should be done, or the act of doing something wrong that results in harm to the client.

Question 111.    
Which assignment should not be performed by the licensed practical nurse?
(a) Inserting a Foley catheter 
(b) Discontinuing a nasogastric tube 
(c) Obtaining a sputum specimen 
(d) Starting a blood transfusion
Answer:
(d) Starting a blood transfusion

Rationale:
The licensed practical nurse cannot start a blood transfusion, but can assist the registered nurse with identifying the client and taking vital signs. Answers (a), (b), and (c) are duties that the licensed practical nurse can perform.

Question 112.    
The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?
(a) Continue to monitor the vital signs 
(b) Contact the physician 
(c) Ask the client how he feels 
(d) Ask the LPI\I to continue the postop care
Answer:
(b) Contact the physician 

Rationale:
The vital signs are abnormal and should be reported to the doctor immediately. Answer (a), continuing to monitor the vital signs, can result in deterioration of the client’s condition. Answer (c), asking the client how he feels, would supply only subjective data. Involving the LPN, in answer (d), is not the best solution to help this client because he is unstable.

Question 113.    
The nurse is caring for a client with B-Thalassemia major. Which therapy is used to treat Thalassemia?
(a) IV fluids
(b) Frequent blood transfusions 
(c) Oxygen therapy 
(d) Iron therapy
Answer:
(b) Frequent blood transfusions 

Rationale:
Thalasemia is a genetic disorder that causes the red blood cells to have a shorter life span. Frequent blood transfusions are necessary to provide oxygen to the tissues. Answer (a) is incorrect because fluid therapy will not help; answer (c) is incorrect because oxygen therapy will also not help; and answer (d) is incorrect because iron should be given sparingly because these clients do not use iron stores adequately. 

Question 114.    
The child with a history of respiratory infections has an order for a sweat test to be done. Which finding would be positive for cystic fibrosis?
(a) A serum sodium of 135meq/L 
(b) A sweat analysis of 69 meq/L 
(c) A potassium of 4.5meq/L 
(d) A calcium of 8mg/dL
Answer:
(b) A sweat analysis of 69 meq/L 

Rationale:
Cystic fibrosis is a disease of the exocrine glands. The child with cystic fibrosis will be salty. A sweat test result of 60meq/L and higher is considered positive. Answers (a), (c), and (d) are incorrect because these test results are within the normal range and are not reported on the sweat test.

Question 115.    
The nurse caring for the child with a large meningomylocele is aware that the priority care for this client is to
(a) Cover the defect with a moist, sterile saline gauze.
(b) Place the infant in a supine position.
(c) Feed the infant slowly.
(d) Measure the intake and output. 
Answer:
(a) Cover the defect with a moist, sterile saline gauze.

Rationale:
A meningomylocele is an opening in the spine. The nurse should keep the defect covered with a sterile saline gauze until the defect can be repaired. Answer (b) is incorrect because the child should be placed in the prone position. Answer (c) is incorrect because feeding the child slowly is not necessary. Answer (d) is not correct because this is not the priority of care.

Question 116.    
The nurse is caring for an infant admitted from the delivery room. Which finding should be reported?
(a) Acyanosis 
(b) Acrocyanosis 
(c) Halequin sign 
(d) Absent femoral pulses
Answer:
(d) Absent femoral pulses

Rationale:
Absent femoral pulses indicates coarctation of the aorta. This defect causes strong bounding pulses and elevated blood pressure in the upper body, and low blood pressure in the lower extremities. Answers (a), (b), and (c) are incorrect because they are normal findings in the newborn.

Question 117.    
The nurse is aware that a common mode of transmission of Clostridium difficile is
(a) Use of unsterile surgical equipment 
(b) Contamination with sputum
(c) Through the urinary catheter
(d) Contamination with stool
Answer:
(d) Contamination with stool

Rationale:
Clostridium dificille is primarily spread through the Gl tract, resulting from poor hand washing and contamination with stool containing Clostridium dificille. Answers (a), (b), and (c) are incorrect because the mode of transmission is not by sputum, through the urinary tract, or by unsterile surgical equipment.

Question 118.    
The nurse has just received the change of shift report. Which client should the nurse assess first?
(a) A client two hours post-lobectomy with 150ml drainage
(b) A client two days post-gastrectomy with scant drainage
(c) A client with pneumonia with an oral temperature of 102°F
(d) A client with a fractured hip in Buck’s traction
Answer:
(a) A client two hours post-lobectomy with 150ml drainage

Rationale:
The first client to be seen is the one who recently returned from surgery. The other clients in answers (b), (c), and (d) are more stable and can be seen later.

Question 119.    
A client has been receiving cyanocobalamine (B12) injections for the past six weeks. Which laboratory finding indicates that the medication is having the desired effect?
(a) Neutrophil count of 60%
(b) Basophil count of 0.5%
(c) Monocyte count of 2%
(d) Reticulocyte count of 1%
Answer:
(d) Reticulocyte count of 1%

Rationale:
Cyanocobalamine is a B12 medication that is used for pernicious anemia, and a reticulocyte count of 1% indicates that it is having the desired effect.
Answers (a), (b), and (c) are white blood cells and have nothing to do with this medication.

Question 120.    
The nurse is providing discharge teaching for a client taking dis-sulfiram (Antabuse). The nurse should instruct the client to avoid eating
(a) Peanuts, dates, raisins 
(b) Figs, chocolate, eggplant 
(c) Pickles, salad with vinaigrette dressing, beef 
(d) Milk, cottage cheese, ice cream 
Answer:
(c) Pickles, salad with vinaigrette dressing, beef 

Rationale:
The client taking antabuse should not eat or drink anything containing alcohol or vinegar. The other foods in answers (a), (b), and (d) are allowed.

Question 121.    
A 70-year-old male who is recovering from a stroke exhibits signs of unilateral neglect. Which behavior is suggestive of unilateral neglect?
(a) The client is observed shaving only one side of his face.
(b) The client is unable to distinguish between two tactile stimuli presented simultaneously.
(c) The client is unable to complete a range of vision without turning his head side to side.
(d) The client is unable to carry out cognitive and motor activity at the same time.
Answer:
(a) The client is observed shaving only one side of his face.

Rationale:
The client with unilateral neglect will neglect one side of the body. Answers (b), (c), and (d) are not associated with unilateral neglect.

Question 122.    
A client with acute leukemia develops a low white blood cell count. In addition to the institution of isolation, the nurse should:
(a) Request that foods be served with disposable utensils.
(b) Ask the client to wear a mask when visitors are present.
(c) Prep IV sites with mild soap and water and alcohol.
(d) Provide foods in sealed, single-serving packages.
Answer:
(d) Provide foods in sealed, single-serving packages.

Rationale:
Because the client is immune suppressed, foods should be served in sealed containers, to avoid food contaminants. Answer (b) is incorrect because of possible infection from visitors. Answer (a) is not necessary, but the utensils should be cleaned thoroughly and rinsed in hot water. Answer (c) might be a good idea, but alcohol can be drying and can cause the skin to break down.

Question 123.    
A new nursing graduate indicates in charting entries that he is a licensed registered nurse, although he has not yet received the results of the licensing exam. The graduate’s action can result in a charge of:
(a) Fraud
(b) Tort
(c) Malpractice
(d) Negligence
Answer:
(a) Fraud

Rationale:
Identifying oneself as a nurse without a license defrauds the public and can be prosecuted. A tort is a wrongful act; malpractice is failing to act appro¬priately as a nurse or acting in a way that harm comes to the client; and negligence is failing to perform care. Therefore, answers (b), (c), and (d) are incorrect.

Question 124.    
The nurse is assigning staff for the day. Which client should be assigned to the nursing assistant?
(a) A five-month-old with bronchiolitis 
(b) A 10-year-old two-day post-appendectomy 
(c) A two-year-old with periorbital cellulitis 
(d) A one-year-old with a fractured tibia 
Answer:
(b) A 10-year-old two-day post-appendectomy 

Rationale:
The client with the appendectomy is the most stable of these clients and can be assigned to a nursing assistant. The client with bronchiolitis has an alteration in the airway; the client with periorbital cellulitis has an infection; and the client with a fracture might be an abused child. Therefore, answers (a), (c), and (d) are incorrect.
  
Question 125.    
During the change of shift, the oncoming nurse notes a discrepan-cy in the number of percocet listed and the number present in the narcotic drawer. The nurse’s first action should be to
(a) Notify the hospital pharmacist
(b) Notify the nursing supervisor
(c) Notify the Board of Nursing
(d) Notify the director of nursing
Answer:
(b) Notify the nursing supervisor

Rationale:
The first action the nurse should take is to report the finding to the nurse supervisor and follow the chain of command. If it is found that the pharmacy is in error, it should be notified, as stated in answer A. Answers (c) and (d), notifying the director of nursing and the Board of Nursing, might be necessary if theft is found, but not as a first step; thus, these are incorrect for this question.

Question 126.    
Due to a high census, it has been necessary for a number of clients to be transferred to other units within the hospital. Which client should be transferred to the postpartum unit?
(a) A 66-year-old female with gastroenteritis 
(b) A 40-year-old female with a hysterectomy
(c) A 27-year-old male with    severe    depression
(d) A 28-year-old male with    ulcerative colitis
Answer:
(b) A 40-year-old female with a hysterectomy

Rationale:
The best client to transport to the postpartum unit is the 40-year-old female with a hysterectomy. The nurses on the postpartum unit will be aware of normal amounts of bleeding and will be equipped to care for this client. The clients in answers (a) and (d) will be best cared for on a medical-surgical unit. The client with depression in answer (c) should be transported to the psychiatric unit.

Question 127.    
A client with glomerulonephritis is placed on a low-sodium diet. Which of the following snacks is suitable for the client with sodium restriction?
(a) Peanut butter cookies
(b) Grilled cheese sandwich
(c) Cottage cheese and fruit
(d) Fresh peach
Answer:
(d) Fresh peach

Rationale:
The fresh peach is the lowest in sodium of these choices. Answers (a), (b), and (c) have much higher amounts of sodium.

Question 128.    
A home health nurse is making preparations for morning visits. Which one of the following clients should the nurse visit first?
(a) A client with a stroke with tube feedings
(b) A client with congestive heart failure complaining of nighttime dyspnea
(c) A client with a thoracotomy six months ago 
(d) A client with Parkinson’s disease
Answer:
(b) A client with congestive heart failure complaining of nighttime dyspnea

Rationale:
The client with congestive heart failure who is complaining of nighttime dyspnea should be seen because airway is number one in nursing care. In answers (a), (c), and (d), the clients are more stable. A brain attack in answer (a) is the new terminology for a stroke.

Question 129.    
A client with cancer develops xerostomia. The nurse can help alleviate the discomfort the client is experiencing associated with xerostomia by
(a) Offering hard candy 
(b) Administering analgesic medications 
(c) Splinting swollen joints
(d) Providing saliva substitute 
Answer:
(d) Providing saliva substitute 

Rationale:
Xerostomia is dry mouth, and offering the client a saliva substitute will help the most. Eating hard candy in answer (a) can further irritate the mucosa and cut the tongue and lips. Administering an analgesic might not be necessary; thus, answer (b) is incorrect. Splinting swollen joints, in answer (c), is not associated with xerostomia.

Question 130.    
The nurse is making assignments for the day. The staff consists of an RN, an LPN, and a nursing assistant. Which client could the nursing assistant care for?
(a) A client with Alzheimer’s disease 
(b) A client with pneumonia 
(c) A client with appendicitis 
(d) A client with thrombophlebitis
Answer:
(a) A client with Alzheimer’s disease 

Rationale:
The client with Alzheimer’s disease is the most stable of these clients and can be assigned to the nursing assistant, who can perform duties such as feeding and assisting the client with activities of daily living. The clients in answers (b), (c), and (d) are less stable and should be attended by a registered nurse.

Question 131.    
The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest periods because:
(a) Grimacing and writhing movements decrease with relaxation and rest.
(b) Hypoactive deep tendon reflexes become more active with rest.
(c) Stretch reflexes are increased with rest.
(d) Fine motor movements are improved by rest.
Answer:
(a) Grimacing and writhing movements decrease with relaxation and rest.

Rationale:
Frequent rest periods help to relax tense muscles and preserve energy. Answers (b), (c), and (d) are incorrect because they are untrue statements about cerebral palsy.

Question 132.    
The physician has ordered a culture for the client with suspected gonorrhea. The nurse should obtain a culture of:
(a) Blood
(b) Nasopharyngeal secretions 
(c) Stool 
(d) Genital secretions
Answer:
(d) Genital secretions

Rationale:
A culture for gonorrhea is taken from the genital secretions. The culture is placed in a warm environment, where it can grow nisseria gonorrhea. Answers (a), (b), and (c) are incorrect because these cultures do not test for gonorrhea.

Question 133.    
Which of the following post-operative diets is most appropriate for the client who has had a hemorrhoidectomy?
(a) High-fiber 
(b) Lactose free 
(c) Bland
(d) Clear-liquid
Answer:
(d) Clear-liquid

Rationale:
After surgery, the client will be placed on a clear-liquid diet and progressed to a regular diet. Stool softeners will be included in the plan of care, to avoid constipation. Later, a high-fiber diet, in answer (a), is encouraged, but this is not the first diet after surgery. Answers (b) and (c) are not diets for this type of surgery.

Question 134.    
The client delivered a nine-pound infant two days ago. An effective means of managing discomfort from an episiotomy is:
(a) Medicated suppository 
(b) Taking showers 
(c) Sitz baths 
(d) Ice packs 
Answer:
(c) Sitz baths 

Rationale:
A sitz bath will help with swelling and improve healing. Ice packs, in answer (d), can be used immediately after delivery, but answers (a) and (b) are not used in this instance.

Question 135.    
The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to:
(a) Take the blood pressure, pulse, and temperature.
(b) Ask the client to rate his pain on a scale of 0-5.
(c) Watch the client’s facial expression.
(d) Ask the client if he is in pain.
Answer:
(b) Ask the client to rate his pain on a scale of 0-5.

Rationale:
The best way to evaluate pain levels is to ask the client to rate his pain on a scale. In answer (a), the blood pressure, pulse, and temperature can alter for other reasons than pain. Answers (c) and (d) are not as effective in determining pain levels.

Question 136.    
The client is admitted with chronic obstructive pulmonary disease. Blood gases reveal pH 7.36, CO₂ 45, O₂ 84, bicarb 28. The nurse would assess the client to be in:
(a) Uncompensated acidosis 
(b) Compensated alkalosis 
(c) Compensated respiratory acidosis 
(d) Uncompensated metabolic acidosis 
Answer:
(c) Compensated respiratory acidosis 

Rationale:
The client is experiencing compensated metabolic acidosis. The pH is within the normal range but is lower than 7.40, so it is on the acidic side. The CO₂ level is elevated, the oxygen level is below normal, and the bicarb level is slightly elevated. In respiratory disorders, the pH will be the inverse of the CO₂ and bicarb levels. This means that if the pH is low, the CO₂ and bicarb levels will be elevated. Answers (a), (b), and (d) are incorrect because they do not fall into the range of symptoms.

Question 137.    
The schizophrenic client has become disruptive and requires seclusion. Which staff member can institute seclusion?
(a) The security guard
(b) The registered nurse
(c) The licensed practical nurse
(d) The nursing assistant
Answer:
(b) The registered nurse

Rationale:
The registered nurse is the only one of these who can legally put the client in seclusion. The only other healthcare worker who is allowed to initiate seclusion is the doctor; therefore, answers (a), (c), and (d) are incorrect.

Question 138.    
The physician has ordered sodium warfarin for the client with thrombophlebitis. The order should be entered to administer the medication at:
(a) 0900 
(b) 1200 
(c) 1700 
(d) 2100
Answer:
(c) 1700 

Rationale:
Sodium warfarin is administered in the late afternoon, at approximately 1700 hours. This allows for accurate bleeding times to be drawn in the morning. Therefore, answers (a), (b), and (d) are incorrect.

Question 139.    
A 25-year-old male is brought to the emergency room with a piece of metal in his eye. The first action the nurse should take is:
(a) Use a magnet to remove the object.
(b) Rinse the eye thoroughly with saline.
(c) Cover both eyes with paper cups.
(d) Patch the affected eye. 
Answer:
(c) Cover both eyes with paper cups.

Rationale:
Covering both eyes prevents consensual movement of the affected eye. Answer (a) is incorrect because the nurse should not attempt to remove the object from the eye because this might cause trauma. Rinsing the eye, as stated in answer (b), might be ordered by the doctor, but this is not the first step for the nurse. Answer (d) is not correct because often when one eye moves, the other also moves.

Question 140.    
To ensure safety while administering a nitroglycerine patch, the nurse should:
(a) Wear gloves while applying the patch.
(b) Shave the area where the patch will be applied.
(c) Wash the area thoroughly with soap and rinse with hot water.
(d) Apply the patch to the buttocks.
Answer:
(a) Wear gloves while applying the patch.

Rationale:
To protect herself, the nurse should wear gloves when applying a nitroglycerine patch or cream. Answer (b) is incorrect because shaving the shin might abrade the area. Answer (c) is incorrect because washing with hot water will vasodilate and increase absorption. The patches should be applied to areas above the waist, making answer (d) incorrect.

Question 141.    
The client with cirrhosis is scheduled for a pericentesis. Which instruction should be given to the client before the exam?
(a) “You will need to lay flat during the exam.”
(b) “You need to empty your bladder before the procedure.”
(c) “You will be asleep during the procedure.”
(d) “The doctor will inject a medication to treat your illness during the procedure.”
Answer:
(b) “You need to empty your bladder before the procedure.”

Rationale:
The client scheduled for a pericentesis should be told to empty the bladder, to prevent the risk of puncturing the bladder when the needle is inserted. A pericentesis is done to remove fluid from the peritoneal cavity. The client will be positioned sitting up or leaning over an overbed table, making answer (a) incorrect. The client is usually awake during the procedure, and medications are not commonly instilled during the procedure; thus answers (c) and (d) are incorrect.

Question 142.    
The client is scheduled for a Tensilon test to check for Myasthenia Gravis. Which medication should be kept available during the test?
(a) Atropine sulfate
(b) Furosemide
(c) Prostigmin
(d) Promethazine
Answer:
(a) Atropine sulfate

Rationale:
Atropine sulfate is the antidote for Tensilon and is given to treat cholenergic crises. Furosemide (answer b) is a diuretic; Prostigmin (answer c) is the treatment for myasthenia gravis; and Promethazine (answer d) is an antiemetic, antianxiety medication. Thus, answers (b), (c), and (d) are incorrect.

Question 143.
The first exercise that should be performed by the client who had a mastectomy one day earlier is
(a) Walking the hand up the wall
(b) Sweeping the floor
(c) Combing her hair
(d) Squeezing a ball
Answer:
(d) Squeezing a ball

Rationale:
The first exercise that should be done by the client with a mastectomy is squeezing the ball. Answers (a), (b), and (c) are incorrect as the first step; they are implemented later.

Question 144.
Which    woman is not a candidate for RhoGam?
(a) A gravida 4 para 3 that is Rh negative with an Rh-positive baby
(b) A gravida 1 para 1 that is Rh negative with an Rh-positive baby
(c) A gravida II para 0 that is Rh negative admitted after a stillbirth delivery
(d) A gravida 4 para 2 that is Rh negative with an Rh-negative baby
Answer:
(d) A gravida 4 para 2 that is Rh negative with an Rh-negative baby

Rationale:
The mothers in answers A, B, and C all require RhoGam and, thus, are incorrect. Answer D is the only mother who does not require a RhoGam injection.

Question 145.
Which laboratory test would be the least effective in making the diagnosis of a myocardial infarction?
(a) AST
(b) Troponin
(c) CK-MB
(d) Myoglobin
Answer:
(a) AST

Rationale:
AST, is not specific for myocardial infarction. Troponin, CK-MB, and Myoglobin, in answers (b), (c), and (d), are more specific, although myoglobin is also elevated in burns and trauma to muscles.

Question 146.
The client with a myocardial infarction comes to the nurse’s station stating that he is ready to go home because there is nothing wrong with him. Which defense mechanism is the client using?
(a) Rationalization
(b) Denial
(c) Projection
(d) Conversion reaction
Answer:
(b) Denial

Rationale:
The client who says he has nothing wrong is in denial about his myocardial infarction. Rationalization is making excuses for what happened, projection is projecting feeling or thoughts onto others, and conversion reaction is converting a psychological trauma into a physical illness; thus, answers (a), (c), and (d) are incorrect.

Question 147.
The client is receiving total parenteral nutrition (TPN). Which lab test should be evaluated while the client is receiving TPN?
(a) Hemoglobin
(b) Creatinine
(c) Blood glucose
(d) White blood cell count
Answer:
(c) Blood glucose

Rationale:
When the client is receiving TPN, the blood glucose level should be drawn. TPN is a solution that contains large amounts of glucose. Answers (a), (b), and (d) are not directly related to the question and are incorrect.

Question 148.
 The client with diabetes is preparing for discharge. During discharge teaching, the nurse assesses the client’s ability to care for himself. Which statement made by the client would indicate a need for follow-up after discharge?
(a) “I live by myself.”
(b) “I have trouble seeing.”
(c) “I have a cat in the house with me.”
(d) “I usually drive myself to the doctor"
Answer:
(b) “I have trouble seeing.”

Rationale:
A client with diabetes who has trouble seeing would require follow-up after discharge. The lack of visual acuity for the client preparing and injecting insulin might require help. Answers (a), (c), and (d) will not prevent the client from being able to care for himself and, thus, are incorrect.

Question 149. 
The client with cirrhosis of the liver is receiving Lactulose. The nurse is aware that the rationale for the order for Lactulose is:
(a)  To lower the blood glucose level 
(b) To lower the uric acid level 
(c) To lower the ammonia level 
(d) To lower the creatinine level
Answer:
(c) To lower the ammonia level 

Rationale:
Lactulose is administered to the client with cirrhosis to lower ammonia levels. Answers (a), (b), and (d) are incorrect because they do not have an effect on the other lab values.

Question 150.    
The client is receiving peritoneal dialysis. If the dialysate returns cloudy, the nurse should
(a) Document the finding.
(b) Send a specimen to the lab.
(c) Strain the urine.
(d) Obtain a complete blood count.
Answer:
(b) Send a specimen to the lab.

Rationale:
If the dialysate returns cloudy, infection might be present and must be evaluated. Documenting the finding, as stated in answer (a), is not enough; straining the urine, in answer (c), is incorrect; and dialysate, in answer (d), is not urine at all. However, the physician might order a white blood cell count.

Question 151.    
The nurse employed in the emergency room is responsible for triage of four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care?
(a) A 10-year-old with lacerations of the face 
(b) A 15-year-old with sternal bruises 
(c) A 34-year-old with a fractured femur
(d) A 50-year-old with dislocation of the elbow
Answer:
(b) A 15-year-old with sternal bruises 

Rationale:
The teenager with sternal bruising might be experiencing airway and oxygenation problems and, thus, should be seen first. In answer A, the 10-year- old with lacerations has superficial bleeding. The client in answer (c) with a fractured femur should be immobilized but can be seen after the client with sternal bruising. The client in answer (d) with the dislocated elbow can be seen later as well.

Question 152.    
Which of the following roommates would be most suitable for the client with myasthenia gravis?
(a) A client with hypothyroidism 
(b) A client with Crohn’s disease 
(c) A client with pylonephritis 
(d) A client with bronchitis
Answer:
(a) A client with hypothyroidism 

Rationale:
The most suitable roommate for the client with myasthenia gravis is the client with hypothyroidism because he is quiet. The client with Crohn’s disease in answer (b) will be up to the bathroom frequently; the client with pylonephritis in answer (c) has a kidney infection and will be up to urinate frequently. The client in answer (d) with bronchitis will be coughing and will disturb any roommate.

Question 153.    
The nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching?
(a) The graduate places the client in a supine position to read the manometer.
(b) The graduate turns the stop-cock to the off position from the IV fluid to the client.
(c) The graduate instructs the client to perform the Valsalva maneuver during the CVP reading.
(d) The graduate notes the level at the top of the meniscus.
Answer:
(c) The graduate instructs the client to perform the Valsalva maneuver during the CVP reading.

Rationale:
The client should not be instructed to do the Valsalva maneuver during central venous pressure reading. If the nurse tells the client to perform the Valsalva maneuver, he needs further teaching. Answers (a), (b), and (d) are incorrect because they indicate that the nurse understands the correct way to check the CVP.

Question 154.    
The nurse is working with another nurse and a patient care assistant. Which of the following clients should be assigned to the registered nurse?
(a) A client two days post-appendectomy 
(b) A client one week post-thyroidectomy 
(c) A client three days post-splenectomy 
(d) A client two days post-thoracotomy 
Answer:
(d) A client two days post-thoracotomy

Rationale:
The most critical client should be assigned to the registered nurse; in this case, that is the client two days post-thoracotomy. The clients in answers (a) and (b) are ready for discharge, and the client in answer (c) who had a splenectomy three days ago is stable enough to be assigned to a PN.

Question 155.    
Which of the following roommates would be best for the client newly admitted with gastric resection?
(a) A client with Crohn’s disease
(b) A client with pneumonia
(c) A client with gastritis
(d) A client with phlebitis
Answer:
(d) A client with phlebitis

Rationale:
The most suitable roommate for the client with gastric reaction is the client with phlebitis because the client with phlebitis will not transmit any infection to the surgical client. Crohn’s disease clients, in answer (a), have frequent stools and might transmit infections. The client in answer (b) with pneumonia is coughing and will disturb the gastric client. The client with gastritis, in answer (c), is vomiting and has diarrhea, which also will disturb the gastric client.

Question 156.    
The nurse is preparing a client for mammography. To prepare the client for a mammogram, the nurse should tell the client:
(a) To restrict her fat intake for one week before the test
(b) To omit creams, powders, or deodorants before the exam
(c) That mammography replaces the need for self-breast exams
(d) That mammography requires a higher dose of radiation than x-rays
Answer:
(b) To omit creams, powders, or deodorants before the exam

Rationale:
The client having a mammogram should be instructed to omit deodorants or powders beforehand because these could cause a false positive reading. Answer (a) is incorrect because there is no need to restrict fat. Answer (c) is incorrect because doing a mammogram does not replace the need for self-breast exams. Answer (d) is incorrect because a mammogram does not require a higher dose of radiation than an x-ray.

Question 157.    
Which action by the novice nurse indicates a need for further teaching?
(a) The nurse fails to wear gloves to remove a dressing.
(b) The nurse applies an oxygen saturation monitor to the ear lobe.
(c) The nurse elevates the head of the bed to check the blood pressure.
(d) The nurse places the extremity in a dependent position to acquire a peripheral blood sample.
Answer:
(a) The nurse fails to wear gloves to remove a dressing.

Rationale:
The nurse who fails to wear gloves to remove a contaminated dressing needs further instruction. Answers (b), (c), and (d) are incorrect because these answers indicate understanding by the nurse.

Question  158.    
The graduate nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority?
(a) Maintaining the client’s systolic blood pressure at 70mmHg or greater
(b) Maintaining the client’s urinary output greater than 300cc per hour
(c) Maintaining the client’s body temperature of greater than 33°F rectal
(d) Maintaining the client’s hematocrit at less than 30% 
Answer:
(a) Maintaining the client’s systolic blood pressure at 70mmHg or greater

Rationale:
When the cadaver client is being prepared to donate an organ, the systolic blood pressure should be maintained at 70mmHg or greater, to ensure a blood supply to the donor organ. Answers (b), (c), and (d) are incorrect because these actions are not necessary for the donated organ to remain viable.

Question 159.    
The nurse is assigned to care for an infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin?
(a) Increasing the infant’s fluid intake 
(b) Maintaining the infant’s body temperature at 98.6°F 
(c) Minimizing tactile stimulation 
(d) Decreasing caloric intake
Answer:
(a) Increasing the infant’s fluid intake 

Rationale:
Bilirubin is excreted through the kidneys, thus the need for increased fluids. Maintaining the body temperature is important but will not assist in eliminating bilirubin; therefore, answer (b) is incorrect. Answers (c) and (d) are incorrect because they do not relate to the question.

Question 160.    
A home health nurse is planning for her daily visits. Which client should the home health nurse visit first?
(a) A client with AIDS being treated with Foscarnet.
(b) A client with a fractured femur in a long leg cast.
(c) A client with laryngeal cancer with a laryngectomy.
(d) A client with diabetic ulcers to the left foot.
Answer:
(c) A client with laryngeal cancer with a laryngectomy.

Rationale:
The client with laryngeal cancer has a potential airway alteration and should be seen first. The clients in answers (a), (b), and (d) are not in immediate danger and can be seen later in the day.

Question 161.    
The charge nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should:
(a) Change the nursing assistant’s assignment 
(b) Explore the interaction with the nursing assistant 
(c) Discuss the matter with the client’s family 
(d) Initiate a group session with the nursing assistant
Answer:
(b) Explore the interaction with the nursing assistant 

Rationale:
The best action for the nurse to take is to explore the interaction with the nursing assistant. This will allow for clarification of the situation. Changing the assignment in answer A might need to be done, but talking to the nursing assistant is the first step. Answer (c) is incorrect because discussing the incident with the family is not necessary at this time; it might cause more problems than it solves. Answer (c) is not a first step, even though initiating a group session might be a plan for the future.

Question 162.    
The nurse notes the patient care assistant looking through the personal items of the client with cancer. Which action should be taken by the registered nurse?
(a) Motify the police department as a robbery.
(b) Report this behavior to the charge nurse.
(c) Monitor the situation and note whether any items are missing.
(d) Ignore the situation until items are reported missing.
Answer:
(b) Report this behavior to the charge nurse.

Rationale:
The best action at this time is to report the incident to the charge nurse. Further action might be needed, but it will be done by the charge nurse. Answers (a), (c), and (d) are incorrect because notifying the police is overreacting at this time, and monitoring or ignoring the situation is an inadequate response.

Question 163.    
Which client can best be assigned to the newly licensed nurse?
(a) The client receiving chemotherapy 
(b) The client post-coronary bypass 
(c) The client with a TURP 
(d) The client with diverticulitis 
Answer:
(d) The client with diverticulitis 

Rationale:
The best client to assign to the newly licensed nurse is the most stable client; in this case, it is the client with diverticulitis. The client receiving chemotherapy and the client with a coronary bypass both need nurses experienced in these areas, so answers (a) and (b) are incorrect. Answer (c) is incorrect because the client with a transurethral prostatectomy might bleed, so this client should be assigned to a nurse who knows how much bleeding is within normal limits.

Question 164.    
The nurse has an order for medication to be administered intrathecally. The nurse is aware that medications will be administered by which method?
(a) Intravenously
(b) Rectally
(c) Intramuscularly
(d) Into the cerebrospinal fluid
Answer:
(d) Into the cerebrospinal fluid

Rationale:
Intrathecal medications are administered into the cerebrospinal fluid. This method of administering medications is reserved for the client with metas- tases, the client with chronic pain, or the client with cerebrospinal infections. Answers (a), (b), and (c) are incorrect because intravenous, rectal, and intramuscular injections are entirely different procedures.

Question 165.    
The client is admitted to the unit after a cholescystectomy.    Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:
(a) The client is at risk for evisceration.
(b) The client will require frequent dressing changes.
(c) The straps provide support for drains that are inserted into the incision.
(d) No sutures or clips are used to secure the incision.
Answer:
(b) The client will require frequent dressing changes.

Rationale:
Montgomery straps are used to secure dressings that require frequent dressing changes because the client with a cholecystectomy usually has a large amount of draining on the dressing. Montgomery straps are also used for clients who are allergic to several types of tape. This client is not at higher risk of evisceration than other clients, so answer (a) is incorrect. Montgomery straps are not used to secure the drains, so answer (c) is incorrect. Sutures or clips are used to secure the wound of the client who has had gallbladder surgery, so answer (d) is incorrect.

Question 166.    
A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate?    
(a) Blood pressure every 15 minutes
(b) Insertion of a Levine tube
(c) Cardiac monitoring
(d) Dressing changes two times per day
Answer:
(b) Insertion of a Levine tube

Rationale:
The client with pancreatitis frequently has nausea and vomiting. Lavage is often used to decompress the stomach and rest the bowel, so the insertion of a Levine tube should be anticipated. Answers (a) and (c) are incorrect because blood pressures are not required every 15 minutes, and cardiac monitoring might be needed, but this is individualized to the client. Answer (d) is incorrect because there are no dressings to change on this client.

Question 167.    
The nurse is caring for a client with a diagnosis of hepatitis who is experiencing pruritis. Which would be the most appropriate nursing intervention?
(a) Suggest that the client take warm showers two times per day.
(b) Add baby oil to the client’s bath water.
(c) Apply powder to the client’s skin.
(d) Suggest a hot-water rinse after bathing.
Answer:
(b) Add baby oil to the client’s bath water.

Rationale:
Oils can be applied to help with the dry skin and to decrease itching, so adding baby oil to bath water is soothing to the skin. Answer (a) is incorrect because two baths per day is too frequent and can cause more dryness. Answer (c) is incorrect because powder is also drying. Rinsing with hot water, as stated in answer (d), dries out the skin as well.

Question 168.    
The nurse recognizes that which of the following would be most appropriate to wear when providing direct care to a client with a cough?
(a) Mask
(b) Gown
(c) Gloves
(d) shoe covers
Answer:
(a) Mask

Rationale:
If the nurse is exposed to the client with a cough, the best item to wear is a mask. If the answer had included a mask, gloves, and a gown, all would be appropriate, but in this case, only one item is listed; therefore, answers (b) and (c) are incorrect. Shoe covers are not necessary, so answer (d) is incorrect.

Question 169.    
A client visits the clinic after the death of a parent. Which statement made by the client’s sister signifies abnormal grieving?
(a) “My sister still has episodes of crying, and it’s been three months since Daddy died.”
(b) “Sally seems to have forgotten the bad things that Daddy did in his lifetime.”
(c) “She really had a hard time after Daddy’s funeral. She said that she had a sense of longing.”
(d) “She has not been saddened at all by Daddy’s death. She acts like nothing has happened.”
Answer:
(d) “She has not been saddened at all by Daddy’s death. She acts like nothing has happened.”

Rationale:
Abnormal grieving is exhibited by a lack of feeling sad; if the client’s sister appears not to grieve, it might be abnormal grieving. She thinks the client might be suppressing feelings of grief. Answers (a), (b), and (c) are all normal expressions of grief and, therefore, incorrect.

Question 170.    
The nurse is obtaining a history on an 80-year-old client. Which statement made by the client might indicate a potential for fluid and electrolyte imbalance?
(a) “My skin is always so dry.”
(b) “I often use laxatives.”
(c) “I have always liked to drink a lot of ice tea.”
(d) “I sometimes have a problem with dribbling urine.”
Answer:
(b) “I often use laxatives.”

Rationale:
Frequent use of laxatives can lead to diarrhea and electrolyte loss. Answers (a), (c), and (d) are not of particular significance in this case and, therefore, are incorrect.

Question 171.    
A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170meq/L. What behavior changes would be most common for this client?
(a) Anger
(b) Mania
(c) Depression
(d) Psychosis
Answer:
(b) Mania

Rationale:
The client with serum sodium of 170meq/L has hypernatremia and might exhibit manic behavior. Answers (a), (c), and (d) are not associated with hypernatremia and are, therefore, incorrect.

Question 172.    
When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain?
(a) A history of radiation treatment in the neck region 
(b) Any history of recent orthopedic surgery 
(c) A history of minimal physical activity 
(d) A history of the client’s food intake.
Answer:
(a) A history of radiation treatment in the neck region 

Rationale:
Radiation to the neck might have damaged the parathyroid glands, which are located on the thyroid gland, interferes with calcium and phosphorus regulation. Answer (b) has no significance to this case; answers (c) and (d) are more related to calcium only, not to phosphorus regulation.

Question 173.    
The nurse on the 3-11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action?
(a) Call the surgeon and ask him or her to see the client to clarify the information.
(b) Explain the procedure and complications to the client.
(c) Check in the physician’s progress notes to see if understanding has been documented.
(d) Check with the client’s family to see if they understand the procedure fully.
Answer:
(a) Call the surgeon and ask him or her to see the client to clarify the information.

Rationale:
It is the responsibility of the physician to explain and clarify the procedure to the client, so the nurse should call the surgeon to explain to the client. Answers (b), (c), and (d) are incorrect because they are not within the nurse’s responsibility.

Question 174.    
The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery?
(a) Hearing aid
(b) Contact lenses
(c) Wedding ring
(d) Artificial eye
Answer:
(b) Contact lenses

Rationale:
It is most important to remove the contact lenses because leaving them in can lead to corneal drying, particularly with contact lenses that are not extended-wear lenses. Leaving in the hearing aid or artificial eye will not harm the client. Leaving the wedding ring on is also allowed; usually, the ring is covered with tape. Therefore, answers 
(a), (c), and (d) are incorrect.

Question 175.    
A client is two days post-operative colon resection. After a coughing episode, the client’s wound eviscerates. Which nursing action is most appropriate?
(a) Reinsert the protruding organ and cover with 4 x 4s.
(b) Cover the wound with a sterile 4 x 4 and ABD dressing.
(c) Cover the wound with a sterile saline-soaked dressing.
(d) Apply an abdominal binder and manual pressure to the wound.
Answer:
(c) Cover the wound with a sterile saline-soaked dressing.

Rationale:
If the client eviscerates, the abdominal content should be covered with a sterile saline-soaked dressing. Reinserting the content should not be the action and will require that the client return to surgery; thus, answer (a) is incorrect. Answers (b) and (d) are incorrect because they not appropriate to this case.

Question 176.    
The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor:
(a) That cannot be assessed
(b) That is in situ
(c) With increasing lymph node involvement
(d) With distant metastasis 
Answer:
(b) That is in situ

Rationale:
Cancer in situ means that the cancer is still localized to the primary site. Tstands for “tumor” and the IS for “in situ." Cancer is graded in terms of tumor, grade, node involvement, and mestatasis. Answers (a), (c), and (d) pertain to these other classifications.

Question 177.
A client with cancer is to undergo an intravenous pyelogram. The nurse should:
(a) Force fluids 24 hours before the procedure.
(b) Ask the client to void immediately before the study.
(c) Hold medication that affects the central nervous system for 12 hours pre- and post-test.
(d) Cover the client’s reproductive organs with an x-ray shield.
Answer:
(b) Ask the client to void immediately before the study.

Rationale:
A full bladder or bowel can obscure the visualization of the kidney ureters and urethra. Answer (a) is incorrect because there is no need to force fluids before the test. Answer (c) is incorrect because there is no need to withhold medication for 12 hours before the test. Answer (d) is incorrect because the client’s reproductive organs should not be covered.

Question 178.
A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for:
(a) Trendelenburg position
(b) Ice to the entire extremity
(c) Buck’s traction
(d) An abduction pillow
Answer:
(c) Buck’s traction

Rationale:
The client with a fractured femur will be placed in Buck’s traction to realign the leg and to decrease spasms and pain. The Trendelenburg position is the wrong position for this client, so answer (a) is incorrect. Ice might be ordered after repair, but not for the entire extremity, so answer (b) is incorrect. An abduction pillow is ordered after a total hip replacement, not for a fractured femur; therefore, answer (d) is incorrect.

Question 179.
The nurse pernicious is performing an assessment on a client with possible anemia. Which data would support this diagnosis?
(a) A weight loss of 10 pounds in two weeks
(b) Complaints of numbness and tingling in the extremities
(c) A red, beefy tongue
(d) A hemoglobin level of 12.0gm/dL
Answer:
(c) A red, beefy tongue

Rationale:
A red, beefy tongue is characteristic of the client with pernicious anemia. Answer (a), a weight loss of 10 pounds in two weeks, is abnormal but is not seen in pernicious anemia. Numbness and tingling, in answer (b), can be associated with anemia but are not particular to pernicious anemia. This is more likely associated with peripheral vascular diseases involving vasculature. In answer (d), the hemoglobin is normal and does not support the diagnosis.

Question 180.
A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session?
(a) “You will be sitting for the examination procedure.”
(b) “Portions of the procedure will cause pain or discomfort.”
(c) “You will be asleep during the procedure.”
(d) “You will not be able to drink fluids for 24 hours fol-lowing the study.”
Answer:
(b) “Portions of the procedure will cause pain or discomfort.”

Rationale:
Portions of the exam are painful, especially when the sample is being withdrawn, so this should be included in the session with the client. Answer (a) is incorrect because the client will be positioned prone, not in a sitting position, for the exam. Anesthesia is not commonly given before this test, making answer (c) incorrect. Answer (d) is incorrect because the client can eat and drink following the test.

Question 181.    
The nurse is caring for a client scheduled for a surgical repair of a saccular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?
(a) Assessment of the client’s level of anxiety 
(b) Evaluation of the client’s exercise tolerance 
(c) Identification of peripheral pulses 
(d) Assessment of bowel sounds and activity 
Answer:
(c) Identification of peripheral pulses 

Rationale:
The assessment that is most crucial to the client is the identification of peripheral pulses because the aorta is clamped during surgery. This decreases blood circulation to the kidneys and lower extremities. The nurse must also assess for the return of circulation to the lower extremities. Answer (a) is of lesser concern, answer (b) is not advised at this time, and answer (d) is of lesser concern than answer (a).

Question 182.    
A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The dysrhythmia most commonly seen during suctioning is:
(a) Bradycardia
(b) Tachycardia
(c) Premature ventricular beats
(d) Heart block
Answer:
(a) Bradycardia

Rationale:
Suctioning can cause a vagal response, lowering the heart rate and causing bradycardia. Answers (b), (c) and (d) can occur as well, but they are less likely.

Question 183.    
The nurse is performing discharge instruction to a client with an implantable defibrillator. What discharge instruction is essential?
(a) “You cannot eat food prepared in a microwave.”
(b) “You should avoid moving the shoulder on the side of the pacemaker site for six weeks."
(c) “You should use your cell phone on your right side.”
(d) “You will not be able to fly on a commercial airliner with the defibrillator in place.”
Answer:
(c) “You should use your cell phone on your right side.”

Rationale:
The client with an internal defibrillator should learn to use any battery-operated machinery on the opposite side. He should also take his pulse rate and report dizziness or fainting. Answers (a), (b), and (d) are incorrect because the client can eat food prepared in the microwave, move his shoulder on the affected side, and fly in an airplane.

Question 184.
Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as:
(a) A cephalhematoma
(b) Molding
(c) Subdural hematoma
(d) Caput succedaneum
Answer:
(a) A cephalhematoma

Rationale:
A swelling over the right parietal area is a cephalhematoma, an area of bleeding outside the cranium. This type of hematoma does not cross the suture line. Answer (b), molding, is overlapping of the bones of the cranium and, thus, incorrect. In answer (c), a subdural hematoma, or intracranial bleeding, is ominous and can be seen only on a CAT scan or x-ray. A caput succedaneum, in answer (d), crosses the suture line and is edema.

Question 185.    
A removal of the left lower lobe of the lung is performed on a client with lung cancer. Which post-operative measure would usually be included in the plan?
(a) Closed chest drainage
(b) A tracheostomy
(c) A Swan Ganz Monitor
(d) Percussion vibration and drainage
Answer:
(a) Closed chest drainage

Rationale:
The client with a lung resection will have chest tubes and a drainage collection device. He probably will not have a tracheostomy or Swanz Ganz monitoring, and he will not have an order for percussion, vibration, or drainage. Therefore, answers (b), (c), and (d) are incorrect.

Question 186.    
The nurse is caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis?
(a) Foul breath
(b) Dysphagia
(c) Diarrhea
(d) Chronic hiccups 
Answer:
(c) Diarrhea

Rationale:
The client with mouth and throat cancer will have all the findings in answers (a), (b), and (d) except the correct answer of diarrhea.

Question 187.    
The nurse is caring for a new mother. The mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is:
(a) The baby is dehydrated.
(b) The baby is hypoglycemic.
(c) The baby is allergic to the formula the mother is giving him.
(d) A loss of 10% is normal in the first week due to meconium stools.
Answer:
(d) A loss of 10% is normal in the first week due to meconium stools.

Rationale:
A loss of 10% is normal due to meconium stool and water loss. There is no evidence to indicate dehydration, hypoglycemia, or allergy to the infant formula; thus, answers (a), (b), and (c) are incorrect.

Question 188.    
The nurse is performing discharge teaching on a client with diverticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client’s diet?
(a) Roasted chicken 
(b) Noodles 
(c) Cooked broccoli 
(d) Custard
Answer:
(c) Cooked broccoli 

Rationale:
The client with diverticulitis should avoid eating foods that are gas forming and that increase abdominal discomfort, such as cooked broccoli. Foods such as those listed in answers (a), (b), and (d) are allowed.

Question 189.    
A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the postop period?
(a) Teaching how to irrigate the ileostomy 
(b) Stopping electrolyte loss in the incisional area 
(c) Encouraging a high-fiber diet 
(d) Facilitating perineal wound drainage
Answer:
(d) Facilitating perineal wound drainage

Rationale:
The client with a perineal resection will have a perineal incision. Drains will be used to facilitate wound drainage. This will help prevent infection of the surgical site. The client will not have an illeostomy, as in answer (a); he will have some electrolyte loss, but treatment is not focused on preventing the loss, so answer (b) is incorrect. A high-fiber diet, in answer (c), is not ordered at this time.

Question 190.    
The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided?
(a) Bran
(b) Fresh peaches
(c) Cucumber salad
(d) Yeast rolls
Answer:
(c) Cucumber salad

Rationale:
The client with diverticulitis should avoid foods with seeds. The foods in answers (a), (b), and (d) are allowed; in fact, bran cereal and fruit will help prevent constipation.

Question 191.    
A six-month old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?
(a) “Tell me about his pain.”
(b) “What does his vomit look like?”
(c) “Describe his usual diet.”
(d) “Have you noticed changes in his abdominal size?” 
Answer:
(c) “Describe his usual diet.”

Rationale:
The least-helpful questions are those describing his usual diet. Answers (a), (b), and (d) are useful in determining the extent of disease process and, thus, are incorrect.

Question 192.    
The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a serious side effect of this drug?
(a) Uric acid of 5mg/dL 
(b) Hematocrit of 33%
(c) WBC 2000 per cubic millimeter 
(d) Platelets 150,000 per cubic millimeter
Answer:
(c) WBC 2000 per cubic millimeter 

Rationale:
Tegretol can suppress the bone marrow and decrease the white blood cell count; thus, a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug. Answers (a) and (d) are within normal limits, and answer B is a lower limit of normal; therefore answers (a), (b), and (d) are incorrect.

Question 193.    
A client is admitted with a Ewing’s sarcoma. Which symptoms would be expected due to this tumor’s location?
(a) Hemiplegia 
(b) Aphasia 
(c) Nausea 
(d) Bone pain
Answer:
(d) Bone pain

Rationale:
Sarcoma is a type of bone cancer; therefore, bone pain would be expected. Answers (a), B, and C are not specific to this type of cancer and are incorrect.

Question 194.    
An infant weighs seven pounds at birth. The expected weight by one year should be:
(a) 10 pounds 
(b) 12 pounds 
(c) 18 pounds 
(d) 21 pounds 
Answer:
(d) 21 pounds 

Rationale:
A birth weight of seven pounds would indicate 21 pounds in one year, or triple his birth weight. Answers (a), (b), and (c) therefore are incorrect.

Question 195. 
The nurse is making initial rounds on a client with a C₅ fracture and crutchfield tongs. Which equipment should be kept at the bedside?
(a) Apairof forceps
(b) A torque wrench
(c) A pair of wire cutters
(d) A screwdriver
Answer:
(b) A torque wrench

Rationale:
A torque wrench is kept at the bedside to tighten and loosen the screws of Crutchfield tongs. This wrench controls the amount of pressure that is placed on the screws. A pair of forceps, wire cutters, and a screwdriver, in answers (a), (c), and (d), would not be used and, thus, are incorrect. Wire cutters should be kept with the client who has wired jaws. 

Question 196. 
The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the client?
(a) Rest in bed after taking the medication for at least 30 minutes.
(b) Avoid rapid movements after taking the medication.
(c) Take the medication with water only.
(d) Allow at least one hour between taking the medicine and taking other medications.
Answer:
(c) Take the medication with water only.

Rationale:
Fosamax should be taken with water only. The client should also remain upright for at least 30 minutes after taking the medication. Answers (a), (b), and (d) are not applicable to taking Fosamax and, thus, are incorrect.

Question 197. 
The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. Which action should receive priority?
(a) Starting an IV
(b) Applying oxygen
(c) Obtaining blood gases
(d) Medicating the client for pain
Answer:
(b) Applying oxygen

Rationale:
The client with burns to the neck needs airway assessment and supplemental oxygen, so applying oxygen is the priority. The next action should be to start an IV and medicate for pain, making answers (a) and (c) incorrect. Answer (d), obtaining blood gases is of less priority.

Question 198. 
A 24-year-aid female client is scheduled far surgery in the morning. Which of the following Isthe primary responsibilityof the nurse?
(a) Taking thevital signs
(b) Obtaining the permit
(c) Explaining the procedure
(d) Checklngthelabwork
Answer:
(a) Taking thevital signs

Rationale:
The primary responsibility of the nurse is to take the vital signs before any surgery. The actions in answers (b), (c), and (d) are the responsibility of the doctor and, therefore, are incorrect for this question.

Question 199.    
A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6, WBC 6500, K⁺ 1.9, uric acid 7.0, Na⁺ 136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following?
(a) Hypernatremia 
(b) Hypokalemia 
(c) Myelosuppression 
(d) Leukocytosis
Answer:
(b) Hypokalemia 

Rationale:
The only lab result that is abnormal is the potassium. A potassium level of 1.9 indicates hypokalemia. The findings in answers (a), (c), and (d) are not revealed in the stem.

Question 200.    
The nurse is caring for a client scheduled for removal of the pituitary gland. The nurse should be particularly alert for:
(a) Nasal congestion
(b) Abdominal tenderness
(c) Muscle tetany
(d) Oliguria
Answer:
(a) Nasal congestion

Rationale:
Removal of the pituitary gland is usually done by a transphe noidal approach, through the nose. Nasal congestion further interferes with the airway. Answers (b), (c), and (d) are not correct because they are not directly associated with the pituitary gland.

Question 201.    
A client has cancer of the liver. The nurse should be most con-cerned about which nursing diagnosis?
(a) Alteration in nutrition
(b) Alteration in urinary elimination
(c) Alteration in skin integrity
(d) Ineffective coping
Answer:
(a) Alteration in nutrition

Rationale:
Cancer of the liver frequently leads to severe nausea and vomiting, thus the need for altering nutritional needs. The problems in answers(b), (c), and (d) are of lesser concern and, thus, are incorrect in this instance.

Question 202.    
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) Daily measurement of abdominal girth 

Rationale:
Daily measuring of the abdominal girth is the best method of determining early ascites. Measuring with a paper tape measure and marking the measured area is the most objective method of estimating ascites. Inspection and checking for fluid waves, in answers (a) and (d), are more subjective and, thus, are incorrect for this question. Palpation of the liver, in answer (b), will not tell the amount of ascites.

Question 203.    
The client arrives in the emergency department after a motor vehi¬cle accident. Nursing assessment findings include BP 68/34, pulse rate 130, and respirations 18. 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) Fluid volume deficit

Rationale:
The vital signs indicate hypovolemic shock or fluid volume deficit. In answers (a), (c), and (d), cerebral tissue perfusion, airway clearance, and senso¬ry perception alterations are not symptoms and, therefore, are incorrect.

Question 204.    
The home health nurse is visiting a 15-year-old with sickle cell disease. Which information obtained on the visit would cause the most concern? The client:
(a) Likes to play baseball
(b) Drinks several carbonated drinks per day
(c) Has two sisters with sickle cell trait
(d) Is taking Tylenol to control pain
Answer:
(a) Likes to play baseball

Rationale:
The client with sickle cell is likely to experience symptoms of hypoxia if he becomes dehydrated or lacks oxygen. Extreme exercise, especially in warm weather, can exacerbate the condition, so the fact that the client plays baseball should be of great concern to the visiting nurse. Answers (b), (c), and (d) are not factors for concern with sickle cell disease.

Question 205.    
The nurse on oncology is caring for a client with a white blood count of 600. During evening visitation, a visitor brings a potted plant. What action should the nurse take?
(a) Allow the client to keep the plant.
(b) Place the plant by the window.
(c) Water the plant for the client.
(d) Tell the family members to take the plant home.
Answer:
(d) Tell the family members to take the plant home.

Rationale:
The client with neutropenia should not have potted or cut flowers in the room. Cancer patients are extremely susceptible to bacterial infections. Answers (a), (b), and (c) will not help to prevent bacterial invasions and, therefore, are incorrect.

Question 206.    
The nurse is caring for the client following a thyroidectomy when suddenly the client becomes nonresponsive and pale, with a BP of 60 systolic. The nurse’s initial action should be to:
(a) Lower the head of the bed.
(b) Increase the infusion of normal saline.
(c) Administer atropine IV.
(d) Obtain a crash cart. 
Answer:
(b) Increase the infusion of normal saline.

Rationale:
Clients who have not had surgery to the face or neck would benefit from lowering the head of the bed, as in answer (a). Flowever, in this situation lowering the client’s head could further interfere with the airway. Therefore, the best answer is answer (b), increasing the infusion and placing the client in supine position. Answers (c) and (d) are not necessary at this time.

Question 207.    
The client pulls out the chest tube and fails to report the occurrence to the nurse. When the nurse discovers the incidence, he should take which initial action?
(a) Order a chest x-ray.
(b) Reinsert the tube.
(c) Cover the insertion site with a Vaseline gauze.
(d) Call the doctor.
Answer:
(c) Cover the insertion site with a Vaseline gauze.

Rationale:
If the client pulls the chest tube out of the chest, the nurse should first cover the insertion site with an occlusive dressing, such as a Vaseline gauze. Then the nurse should call the doctor, who will order a chest x-ray and possibly reinsert the tube. Answers (a), (b), and (d) are not the first priority in this case.

Question 208.    
A client being treated with sodium warfarin has an INR of 8.0. Which intervention would be most important to include in the nursing care plan?
(a) Assess for signs of abnormal bleeding.
(b) Anticipate an increase in the Coumadin dosage.
(c) Instruct the client regarding the drug therapy.
(d) Increase the frequency of neurological assessments.
Answer:
(a) Assess for signs of abnormal bleeding.

Rationale:
An INR of 8 indicates that the blood is too thin. The normal INR is 2.0-3.0, so answer (b) is incorrect because the doctor will not increase the dosage of coumadin. Answer (c) is incorrect because now is not the time to instruct the client about the therapy. Answer (d) is not correct because there is no need to increase the neurological assessment.

Question 209.    
Which snack selection by a client with osteoporosis indicates that the client understands the dietary management of the disease?
(a) A granola bar
(b) A bran muffin
(c) Yogurt
(d) Raisins
Answer:
(c) Yogurt

Rationale:
The food indicating the client’s understanding of dietary management of osteoporosis is the yogurt, with approximately 400mg of calcium. The other foods are good choices, but not as good as the yogurt; therefore, answers (a), (b), and (d) are incorrect.

Question 210.    
The client with preeclampsia is admitted to the unit with an order for magnesium sulfate IV. Which action by the nurse indicates a lack of understanding of magnesium sulfate?
(a) The nurse places a sign over the bed not to check blood pressures in the left arm.
(b) The nurse obtains an IV controller.
(c) The nurse inserts a Foley catheter.
(d) The nurse darkens the room.
Answer:
(a) The nurse places a sign over the bed not to check blood pressures in the left arm.

Rationale:
There is no need to avoid taking the blood pressure in the left arm. Answers (b), (c), and (d) are all actions that should be taken for the client receiving magnesium sulfate for preeclampsia.

Question 211.    
The nurse is caring fora 12-year-old client with appendicitis. The client’s mother is a Jehovah’s Witness and refuses to sign the blood permit. What nursing action is most appropriate?
(a) Give the blood without permission.
(b) Encourage the mother to reconsider.
(c) Explain the consequences without treatment.
(d) Notify the physician of the mother’s refusal. 
Answer:
(d) Notify the physician of the mother’s refusal. 

Rationale:
If the client’s mother refuses the blood transfusion, the doctor should be notified. Because the client is a minor, the court might order treatment. Answer (a) is incorrect because the mother is the legal guardian and can refuse the blood transfusion to be given to her daughter. Answers (b) and (c) are incorrect because it is not the primary responsibility of the nurse to encourage the mother to consent or explain the consequences.

Question 212.    
A client is admitted to the unit two hours after an injury with second-degree burns to the face, trunk, and head. The nurse would be most concerned with the client developing what?
(a) Hypovolemia
(b) Laryngeal edema
(c) Hypernatremia
(d) Hyperkalemia
Answer:
(b) Laryngeal edema

Rationale:
The nurse should be most concerned with laryngeal edema because of the area of burn. Answer (a) is of secondary priority. Hyponatremia and hypokalemia are also of concern but are not the primary concern; thus, answers (c) and (d) are incorrect.

Question 213.    
The nurse is evaluating nutritional outcomes for an elderly client with anorexia nervosa. Which data best indicates that the plan of care is effective?
(a) The client selects a balanced diet from the menu.
(b) The client’s hematocrit improves.
(c) The client’s tissue turgor improves.
(d) The client gains weight.
Answer:
(d) The client gains weight.

Rationale:
The client with anorexia shows the most improvement by weight gain. Selecting a balanced diet is useless if the client does not eat the diet, so answer (a) is incorrect. The hematocrit, in answer (b), might improve by several means, such as blood transfusion, but that does not indicate improvement in the anorexic condition, so (b) is incorrect. The tissue turgor indicates fluid, not improvement of anorexia, so answer (c) is incorrect.

Question 214.    
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) Paresthesia of the toes

Rationale:
Paresthesia of the toes is not normal and can indicate compartment syndrome. At this time, pain beneath the cast is normal and, thus, would not be reported as a concern. The client’s toes should be warm to the touch, and pulses should be present. Answers (a), (b), and (c), then, are incorrect.

Question 215.    
The client is having a cardiac catheterization. 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) “That feeling of warmth is normal when the dye is injected."

Rationale:
The best response from the nurse is to let the client know that it is normal to have a warm sensation when dye is injected for this procedure. Answers (a), (c), and (d) indicate that the nurse believes that the hot feeling is abnormal and, so, are incorrect.

Question 216.    
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) The nurse wears gloves to take the client’s vital signs.

Rationale:
It is not necessary to wear gloves when taking the vital signs of the client, thus indicating further teaching for the nursing assistant. If the client has an active infection with methicillin-resistant staphylococcus aureus, gloves should be worn, but this is not indicated in this instance. The actions in answers (a), (b). and (c) are incorrect because they are indicative of infection control not mentioned in the question.

Question 217.    
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) The client has a grand mal seizure.

Rationale:
During ECT, the client will have a grand mal seizure. This indicates completion of the electroconvulsive therapy. Answers (a), (b), and (c) are incorrect because they do not indicate that the ECT has been completed.

Question 218.    
The five-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to:
(a) Place tape on the child’s perianal area before putting the child to bed.
(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) Place tape on the child’s perianal area before putting the child to bed.

Rationale:
An 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, causing 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 evaluated in a lab. There is no need to scrape the skin, collect a stool specimen, or bring a sample of hair; therefore, answers (b), (c), and (d) are incorrect.

Question 219.    
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 one year.
(d) Intravenous antibiotic therapy will be ordered.
Answer:
(b) The entire family should be treated.

Rationale:
Enterobiasis, 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 two weeks, to ensure that no eggs remain. Answers (a), (c), and (d) are inappropriate for this treatment and, therefore, incorrect.

Question 220.    
The registered nurse is making assignments for the day. Which client should not 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 an intravenous pyelogram
Answer:
(b) The client with a radium implant for cervical cancer

Rationale:
The pregnant nurse should not be assigned to any client with radioactivity present, and the client with a radium implant poses the most risk to the pregnant nurse. The clients in answers (a), (c), and (d) are not radioactive; therefore, these answers are incorrect.

Question 221.    
Which client is at risk for opportunistic diseases such as pneumocystis pneumonia?
(a) The client with cancer who is being treated with chemotherapy
(b) The client with Type I diabetes
(c) The client with thyroid disease
(d) The client with Addison’s disease
Answer:
(a) The client with cancer who is being treated with chemotherapy

Rationale:
The client with cancer being treated with chemotherapy is immune suppressed and is at risk for opportunistic diseases such as pneumocystis. Answers (b), (c), and (d) are incorrect because these clients are not at a higher risk for opportunistic diseases than other clients.

Question 222.    
The nurse caring for a client in the neonatal intensive care unit administers adult-strength Digitalis to the three-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with:
(a) Negligence
(b) Tort
(c) Assault
(d) Malpractice
Answer:
(d) Malpractice

Rationale:
Injecting an infant with an adult dose of Digitalis is considered malpractice, or failing to perform or performing an act that causes harm to the client. In answer (a), negligence is failing to perform care for the client and, thus, is incorrect. In answer (b), a tort is a wrongful act committed on the client or his belongings but, in this case, was accidental. Assault, in answer (c), is not pertinent to this incident.

Question 223. 
Which assignment should not be performed by the registered nurse?
(a)  Inserting a Foley catheter
(b) Inserting a nasogastric tube
(c) Monitoring central venous pressure
(d) Inserting sutures and clips in surgery
Answer:
(d) Inserting sutures and clips in surgery

Rationale:
The registered nurse cannot insert sutures or clips unless specially trained to do so, as in the case of a nurse practitioner skilled to perform this task. The registered nurse can insert a Foley catheter, insert a nasogastric tube, and monitor central venous pressure.

Question 224.    
The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?
(a) Document the finding.
(b) Contact the physician.
(c) Elevate the head of the bed.
(d) Administer a pain medication. 
Answer:
(b) Contact the physician.

Rationale:
The vital signs are abnormal and should be reported to the doctor immediately. (a), (b), and (d) are incorrect actions.

Question 225.    
Which nurse should be assigned to care for the postpartal client with preeclampsia?
(a) The RN with two weeks of experience in postpartum
(b) The RN with three years of experience in labor and delivery
(c) The RN with 10 years of experience in surgery
(d) The RN with one year of experience in the neonatal intensive care unit
Answer:
(b) The RN with three years of experience in labor and delivery

Rationale:
The nurse in answer (b) has the most experience in knowing possible complications involving preeclampsia. The nurse in answer (a) is a new nurse to the unit, and the nurses in answers (c) and (d) have no experience with the postpartum client.

Question 226.    
Which medication is used to treat iron toxicity?
(a) Narcan (naloxone)
(b) Digibind (digoxin immune Fab)
(c) Desferal (deferoxamine)
(d) Zinecard (dexrazoxane)
Answer:
(c) Desferal (deferoxamine)

Rationale:
Desferal is used to treat iron toxicity. Answers (a), (b), and (d) are incorrect because they are antidotes for other drugs: Narcan is used to treat narcotic overdose; Digibind is used to treat dioxin toxicity; and Zinecard is used to treat doxorubicin toxicity

Question 227.    
The nurse is suspected of charting medication administration that he did not give. The nurse can be charged with:
(a) Fraud 
(b) Malpractice 
(c) Negligence 
(d) Tort
Answer:
(a) Fraud 

Rationale:
If the nurse charts information that he did not perform, she can be charged with fraud. Answer (b) is incorrect because malpractice is harm that results to the client due to an erroneous action taken by the nurse. Answer (c) is incorrect because negligence is failure to perform a duty that the nurse knows should be performed. Answer (d) is incorrect because a tort is a wrongful act to the client or his belongings.

Question 228.    
The home health nurse is planning for the day's visits. Which client should be seen first?
(a) The client with renal insufficiency
(b) The client with Alzheimer’s
(c) The client with diabetes who has a decubitus ulcer
(d) The client  with multiple sclerosis who  is being treated with IV cortisone
Answer:
(d) The client with multiple sclerosis who is being treated with IV cortisone

Rationale:
The client who should receive priority is the client with multiple sclerosis and who is being treated with IV cortisone. This client is at highest risk for complications. Answers (a), (b), and (c) are incorrect because these clients are more stable and can be seen later.

Question 229.    
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 six 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) The client who is six months pregnant with abdominal pain and the client with facial lacerations and a broken arm

Rationale:
Out of all of these clients, it is best to place the pregnant client and the client with a broken arm and facial lacerations in the same room. These two clients probably do not need immediate attention and are least likely to disturb each other. The clients in answers (a), (c), and (d) need to be placed in separate rooms because their conditions are more serious, they might need immediate attention, and they are more likely to disturb other patients.

Question 230.    
The nurse is caring for a six-year-old client admitted with the 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, remov-ing any exudate, before instilling the eyedrops.
(b) The child should be allowed to instill his own eye-drops.
(c) Allow the mother to instill the eyedrops.
(d) If the eye is clear from any redness or edema, the eye-drops should be held.
Answer:
(a) The eye should be cleansed with warm water, remov-ing any exudate, before instilling the eyedrops.

Rationale:
Before instilling eyedrops, the nurse should cleanse the area with warm water. A six-year-old child is not developmentally ready to instill his own eyedrops, so answer (b) is incorrect. The mother cannot be allowed to administer the eye drops in the hospital setting so answer (c) incorrect. Although the eye might appear to be clear, the nurse should instill the eyedrops, as ordered (answer d).

Question 231.    
To assist with the prevention of urinary tract infections, the teenage girl should be taught to:
(a) Drink citrus fruit juices 
(b) Avoid using tampons 
(c) Take showers instead of tub baths 
(d) Clean the perineum from front to back
Answer:
(d) Clean the perineum from front to back

Rationale:
To prevent urinary tract infections, the girl should clean the perineum from front to back to prevent e. coli contamination. Answer (a) is incorrect because drinking citrus juices will not prevent UTIs. Answers (b) and (c) are incorrect because UTIs are not associated with the use of tampons or with tub baths.

Question 232.    
A two-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) Ask the parent/guardian to room-in with the child.

Rationale:
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, so answer (a) is incorrect. Allowing the child to have items that are familiar to him is allowed and encouraged; thus, answer (b) is incorrect. Answer (d) is incorrect and shows a lack of empathy for the child’s distress; it is an inappropriate response from the nurse.

Question 233.    
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) Store the hearing aid in a warm place.

Rationale:
The hearing aid should be stored in a warm, dry place and should be cleaned daily. A toothpick is inappropriate to clean the aid because it might break off in the hearing aide. Changing the batteries weekly is not necessary; therefore, answers (a), (c), and (d) are incorrect.

Question 234.    
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) Risk for aspiration

Rationale:
Always remember your ABC’s (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.

Question 235.    
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) High fever

Rationale:
If the child has bacterial pneumonia, a high fever is usually present. Bacterial pneumonia usually presents with a productive cough, so answer (b) is incorrect. Rhinitis, as stated in answer (c), is often seen with viral pneumonia and is incorrect for this case. Vomiting and diarrhea are usually not seen with pneumonia; thus, answer (d) is incorrect. 

Question 236.    
The nurse is caring for a client admitted with acute laryngotra- cheobronchitis (LTB). Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?
(a) Intravenous access supplies
(b) Emergency intubation equipment
(c) Intravenous fluid-administration pump
(d) Supplemental oxygen
Answer:
(b) Emergency intubation equipment

Rationale:
For a child with LTB and the possibility of complete obstruction of the airway, emergency intubation equipment should always be kept at the bedside. Intravenous supplies and fluid will not treat an obstruction, nor will supplemental oxygen; therefore, answers (a), (c), and (d) are incorrect.
 

Question 237.
A five-year-old client with hyperthyroidism is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?
(a) Bradycardia
(b) Decreased appetite
(c) Exophthalmos
(d) Weight gain
Answer:
(c) Exophthalmos

Rationale:
Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. The client with hyperthyroidism will often exhibit tachycardia, increased appetite, and weight loss. Answers (a), (b), and (d) are not associated with hyperthyroidism.

Question 238.    
The nurse is providing dietary instructions to the mother of an eight-year-old child diagnosed with celiac disease. Which of the following foods, if selected by the mother, would indicate her understanding of the dietary instructions?
(a) Whole-wheat bread
(b) Spaghetti
(c) Hamburger on wheat bun with ketchup
(d) Cheese omelet 
Answer:
(d) Cheese omelet 

Rationale:
The child with celiac disease should be on a gluten-free diet. Answer (d) is the only choice of foods that do not contain gluten. Therefore, answers (a), (b), and (c) are incorrect.

Question 239.    
The nurse is caring for a nine-year-old child admitted with asthma. Upon the morning rounds, the nurse finds an O2 sat of 78%. Which of the following actions should the nurse take first?
(a) Notify the physician
(b) Do nothing; this is a normal O2 sat for a nine-year-old 
(c) Apply oxygen 
(d) Assess the child’s pulse
Answer:
(c) Apply oxygen 

Rationale:
Remember the (a)(b)(c)s (airway, breathing, circulation) when answering this question. Before notifying the physician or assessing the child’s pulse, oxygen should be applied to increase the child’s oxygen saturation. The normal oxygen saturation for a child is 92%-100%. Answer A is important but not the priority, answer (b) is inappropriate, and answer (d) is also not the priority.

Question 240.    
A gravida II para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse expect to make immediately after the amniotomy?
(a) Fetal heart tones 160 beats per minute 
(b) A moderate amount of clear fluid 
(c) A small amount of greenish fluid 
(d) A small segment of the umbilical cord
Answer:
(b) A moderate amount of clear fluid 

Rationale:
Normal amniotic fluid is straw colored and odorless, so this is the observation the nurse should expect. An amniotomy is artificial rupture of membranes, causing a straw-colored fluid to appear in the vaginal area. Fetal heart tones of 160 indicate tachycardia, and this is not the observation to watch for. Greenish fluid is indicative of meconium, not amniotic fluid. If the nurse notes the umbilical cord, the client is experiencing a prolapsed cord. This would need to be reported immediately. For this question, answers (a), (c), and (d) are incorrect.

Question 241.    
The client is admitted to the unit. A vaginal exam reveals that she is 3cm dilated. Which of the following statements would the nurse expect her to make?
(a) “I can’t decide what to name the baby.”
(b) “It feels good to push with each contraction.”
(c) “Don’t touch me. I’m trying to concentrate.”
(d) “When can I get my epidural?” 
Answer:
(d) “When can I get my epidural?” 

Rationale:
The client is usually given epidural anesthesia at approximately three centimeters dilation. Answer (a) is vague, answer B would indicate the end of the first stage of labor, and answer (c) indicates the transition phase, not the latent phase of labor.

Question 242.
The client ¡s having fetal heart rates of 100-110 beats per minute during the contractions. The first action the nurse should take is to:
(a) Apply an internal monitor
(b) Turn the client to her side
(c) Get the client up and walk her in the hail
(d) Move the client to the delivery room
 Answer:
(b) Turn the client to her side

Rationale:
The normal fetal heart rate is 120-160bpm. A heart rate of 100-110bpm is bradycardia. The first action would be to turn the client to the left side and apply oxygen. Answer (a) is not indicated at this time. Answer (c) is not the best action for clients experiencing bradycardia. There is no data to indicate the need to move the client to the delivery room at this time, so answer (d) is incorrect as well.

Question 243. 
In evaluating the effectiveness of IV Pitocin for a client with sec-ondary dystocia, the nurse should expect:
(a) A rapid delivery
(b) Cervical effacement
(c) Infrequent contractions
(d) Progressive cervical    dilation 
Answer:
(d) Progressive cervical    dilation 

Rationale:
The expected effect of Pitocin is progressive cervical dilation. Pitocin causes more intense contractions, which can increase the pain; thus, answer (a) is incorrect. Answers (b) and (c) are incorrect because cervical effacement is caused by pressure on the presenting part and there are not infrequent contractions.

Question 244. 
A vaginal exam reveals a breech presentation in a newly admitted client. The nurse should take which of the following actions at this time?
(a) Prepare the client for a caesarean section
(b) Apply the fetal heart monitor
(c) Place the client in the Trendelenburg position
(d) Perform an ultrasound exam
Answer:
(b) Apply the fetal heart monitor

Rationale:
Applying a fetal heart monitor is the appropriate action at this time. Preparing for a caesarean section is premature; placing the client in Trendelenburg is also not an indicated action, and an ultrasound is not needed based on the finding. Therefore, answer (b) is the best answer, and answers (a), (c), and (d) are incorrect.

Question 245.    
The nurse is caring for a client admitted to labor and delivery. The nurse is aware that the infant is in distress if she notes:
(a) Contractions every three minutes
(b) Absent variability
(c) Fetal heart tone accelerations with movement
(d) Fetal heart tone 120-130bpm
Answer:
(b) Absent variability

Rationale:
Absent variability is not normal and could indicate a neurological problem. Answers (a), (c), and (d) are normal findings. 

Question 246.    
The following are all nursing diagnoses appropriate for a gravida 4 para 3 in labor. Which one would be most appropriate for the client as she completes the latent phase of labor?
(a) Impaired gas exchange related to hyperventilation
(b) Alteration in placental perfusion related to maternal position
(c) Impaired physical mobility related to fetal-monitoring equipment
(d) Potential fluid volume deficit related to decreased fluid intake
Answer:
(d) Potential fluid volume deficit related to decreased fluid intake

Rationale:
Clients admitted in labor are told not to eat during labor, to avoid nausea and vomiting. Ice chips might be allowed, although 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, not the early phase of labor. Answers (b) and (c) are not correct because clients during labor are allowed to change position as they desire.

Question 247.    
As the client reaches 8cm dilation, the nurse notes a pattern on the fetal monitor that shows a drop in the fetal heart rate of 30bpm beginning at the peak of the contraction and ending at the end of the contraction. 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) There is uteroplacental insufficiency.

Rationale:
This information indicates a late deceleration. This type of deceleration is caused by uteroplacental insufficiency, or lack of oxygen. Answer (a) is incorrect because there is no data to support the conclusion that the baby is asleep; answer (b) results in a variable deceleration; and answer (c) is indicative of an early deceleration

Question 248.    
The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
(a) Notify her doctor.
(b) Increase the rate of IV fluid.
(c) Reposition the client.
(d) Readjust the monitor.
Answer:
(c) Reposition the client.

Rationale:
The initial action by the nurse observing a variable deceleration should be to turn the client to the side, preferably the left side. Administering oxygen is also indicated. Answer (a) is not called for at this time. Answer (b) is incorrect because it is not needed, and answer (d) is incorrect because there is no data to indicate that the monitor has been applied incorrectly.

Question 249.    
Which of the following is a characteristic of a reassuring fetal heart rate pattern?
(a) A fetal heart rate of 180bpm 
(b) A baseline variability of 35bpm
(c) A fetal heart rate of 90 at the baseline 
(d) Acceleration of FHR with fetal movements
Answer:
(d) Acceleration of FHR with fetal movements

Rationale:
Answers (a), (b), and (c) indicate ominous findings on the fetal heart monitor and so are incorrect in this instance. Accelerations with movement are normal, so answer (d) is the reassuring pattern.

Question 250.    
The nurse asks the client with an epidural anesthesia to void every hour during labor. The rationale for this intervention is:
(a) The bladder fills more rapidly because of the medication used for the epidural.
(b) Her level of consciousness is altered.
(c) The sensation of the bladder filling is diminished or lost.
(d) She is embarrassed to ask for the bedpan that frequently. 
Answer:
(c) The sensation of the bladder filling is diminished or lost.

Rationale:
Epidural anesthesia decreases the urge to void and sensation of a full bladder. A full bladder decreases the progression of labor. Answers (a), (b), and (d) are incorrect because the bladder does not fill more rapidly due to the epidural, the client is not in a trancelike state, and the client’s level of consciousness is not altered, and there is no evidence that the client is too embarrassed to ask for a bedpan.