NCLEX RN Practice Test 2 with Rationale

NCLEX-RN Practice Test 2 with Rationale

Question 1.    
The nurse is caring for a client with systemic lupus erythematosus (SLE). The major complication associated with systemic lupus erythematosus is:
(a) Nephritis 
(b) Cardiomegaly 
(c) Desquamation 
(d) Meningitis
Answer:
(a) Nephritis 

Rationale:
The major complication of SLE is lupus nephritis, which results in end-stage renal disease. SLE affects the musculoskeletal, integumentary, renal, nervous, and cardiovascular systems, but the major complication is renal involvement; therefore, answers (b) and (d) are incorrect. Answer (c) is incorrect because the SLE produces a “butterfly” rash, not desquamation.

Question 2.    
A client with benign prostatic hypertrophy has been started on Proscar (finasteride). The nurse’s discharge teaching should include:
(a) Telling the client’s wife not to touch the tablets
(b) Explaining that the medication should be taken with meals
(c) Telling the client that symptoms will improve in 1-2 weeks
(d) Instructing the client to take the medication at bedtime, to prevent nocturia
Answer:
(a) Telling the client’s wife not to touch the tablets

Rationale:
Finasteride is an androgen inhibitor; therefore, women who are pregnant or who might become pregnant should be told to avoid touching the tablets. Answer (b) is incorrect because there are no benefits to giving the medication with food. Answer (c) is incorrect because the medication can take six months to a year to be effective. Answer (d) is not an accurate statement; therefore, it is incorrect.

Question 3.    
A five-year-old child is hospitalized for correction of congenital hip dysplasia. During the assessment of the child, the nurse can expect to find the presence of:
(a) Scarf sign
(b) Harlequin sign
(c) Cullen’s sign
(d) Trendelenburg sign
Answer:
(d) Trendelenburg sign

Rationale:
The nurse can expect to find the presence of Trendelenburg sign. (While bearing weight on the affected hip, the pelvis tilts downward on the unaffected side instead of tilting upward, as expected with normal stability). Scarf sign is a characteristic of the preterm newborn; therefore, answer (a) is incorrect. Harlequin sign can be found in normal newborns and indicates transient changes in circulation; therefore, answer (b) is incorrect. Answer (c) is incorrect because Cullen’s sign is an indication of intra-abdominal bleeding.

Question 4.
Which diet is associated with an increased risk of colorectal cancer?
(a) Low protein, complex carbohydrates
(b) High protein, simple carbohydrates
(c) High tat, refined carbohydrates
(d) Low carbohydrates, complex proteins
Answer:
(c) High tat, refined carbohydrates

Rationale:
A diet that is high in fat and refined carbohydrates increases the risk of colorectal cancer. High fat content results in an increase in fecal bile acids, which facilitate carcinogenic changes. Refined carbohydrates increase the transit time of food through the gastrointestinal tract and increase the exposure time of the intestinal mucosa to cancer-causing substances. Answers (a), (b), and (d) do not relate to the question; therefore, they are incorrect.

Question 5.    
The nurse is caring for an infant following a cleft lip repair. While  comforting the infant, the nurse should avoid:    
(a) Holding the infant
(b) Offering a pacifier
(c) Providing a mobile
(d) Offering sterile water
Answer:
(b) Offering a pacifier

Rationale:
The nurse should avoid giving the infant a pacifier or bottle because sucking is not permitted. Holding the infant cradled in the arms, providing a mobile, and offering sterile water using a Breck feeder are permitted; therefore, answers (a), (c), and (d) are incorrect.

Question 6.    
The physician has diagnosed a client with cirrhosis characterized by asterixis. If the nurse assesses the client with asterixis, he can expect to find:
(a) Irregular movement of the wrist
(b) Enlargement of the breasts
(c) Dilated veins around the umbilicus 
(d) Redness of the palmar surfaces
Answer:
(a) Irregular movement of the wrist

Rationale:
The client with asterixis or “flapping tremors” will have irregular flexion and extension of the wrists when the arms are extended and the wrist is hyper extended with the fingers separated. Asterixis is associated with hepatic encephalopathy. Answers (b), (c), and (d) do not relate to asterixis; therefore, they are incorrect.

Question 7.    
The physician has ordered Amoxil (amoxicillin) 500mg capsules for a client with esophageal varices. The nurse can best care for the client’s needs by:
(a) Giving the medication as ordered 
(b) Providing extra water with the medication
(c) Giving the medication with an antacid
(d) Requesting an alternate form of the medication
Answer:
(d) Requesting an alternate form of the medication

Rationale:
The client with esophageal varices might develop spontaneous bleeding from the mechanical irritation caused by taking capsules; therefore, the nurse should request the medication in an alternative form such as a suspension. Answer (a) is incorrect because it does not best meet the client’s needs. Answer (b) is incorrect because it is not the best means of preventing bleeding. Answer (c) is incorrect because the medications should not be given with milk or antacids.

Question 8.    
A client with an inguinal hernia asks the nurse why he should have surgery when he has had a hernia for years. The nurse under stands that surgery is recommended to:
(a) Prevent strangulation of the bowel 
(b) Prevent malabsorptive disorders 
(c) Decrease secretion of bile salts 
(d) Increase intestinal motility 
Answer:
(a) Prevent strangulation of the bowel 

Rationale:
Surgical repair of an inguinal hernia is recommended to prevent strangulation of the bowel, which could result in intestinal obstruction and necrosis. Answer (b) does not relate to an inguinal hernia; therefore, it is incorrect. Bile salts, which are important to the digestion of fats, are produced by the liver, not the intestines; therefore, answer (c) is incorrect. Repair of the inguinal hernia will prevent swelling and obstruction associated with strangulation, but it will not increase intestinal motility; therefore, answer (d) is incorrect.

Question 9.    
The nurse is providing dietary instructions for a client with iron- deficiency anemia. Which food is a poor source of iron?
(a) Tomatoes
(b) Legumes
(c) Dried fruits
(d) Nuts
Answer:
(a) Tomatoes

Rationale:
 Tomatoes are a poor source of iron, although they are an excellent  source of vitamin (c), which increases iron absorption. Answers (b), (c), and (d) are good sources of iron; therefore, they are incorrect.

Question 10.    
A client is admitted with suspected acute pancreatitis. Which lab finding confirms the diagnosis?
(a) Blood glucose of 260mg/dL 
(b) White cell count of 21 .OOOcu/mm 
(c) Platelet count of 250,000cu/mm 
(d) Serum amylase level of 600 units/dL
Answer:
(d) Serum amylase level of 600 units/dL

Rationale:
Serum amylase levels greater than 200 units/dL help confirm the diagnosis of acute pancreatitis. Elevations of blood glucose occur with conditions other than acute pancreatitis; therefore, answer (a) is incorrect. Elevations in WBC are associated with infection and are not specific to acute pancreatitis; therefore, answer (b) is incorrect. Answer (c) is within the normal range; therefore, it is incorrect.

Question 11.    
The nurse is teaching a client with Parkinson’s disease ways to prevent curvatures of the spine associated with the disease. To prevent spinal flexion, the nurse should tell the client to:
(a) Periodically lie prone without a neck pillow.
(b) Sleep only in dorsal recumbent position.
(c) Rest in supine position with his head elevated.
(d) Sleep on either side, but keep his back straight.
Answer:
(a) Periodically lie prone without a neck pillow.

Rationale:
Periodically lying in a prone position without a pillow will help prevent the flexion of the spine that occurs with Parkinson’s disease. Answers (b) and (c) flex the spine; therefore, they are incorrect. Answer (d) is not realistic because position changes during sleep; therefore, it is incorrect.

Question 12.    
The physician has ordered Dilantin (phenytoin) 100mg intravenously for a client with generalized tonic clonic seizures. The nurse should administer the medication:
(a) Rapidly with an IV push 
(b) With IV dextrose 
(c) Slowly over 2-3 minutes 
(d) Through a small vein
Answer:
(c) Slowly over 2-3 minutes 

Rationale:
The medication should be administered slowly (no more than 50mg per minute); otherwise, cardiac arrhythmias can occur. Answer A is incorrect because the medication must be given slowly. Dextrose solutions cause the medication to crystallize in the line and the medication should be given through a large vein to prevent “purple glove” syndrome; therefore, answers (b) and (d) are incorrect.

Question 13.    
The nurse is planning dietary changes for a client following an episode of acute pancreatitis. Which diet is suitable for the client?
(a) Low calorie, low carbohydrate 
(b) High calorie, low fat 
(c) High protein, high fat 
(d) Low protein, high carbohydrate 
Answer:
(b) High calorie, low fat 

Rationale:
The client recovering from acute pancreatitis needs a diet that is high in calories and low in fat. Answers (a), (c), and (d) are incorrect because they can increase the client’s discomfort.

Question 14.    
A client is admitted with a diagnosis of polycythemia vera. The nurse should closely monitor the client for:    
(a) Increased blood pressure 
(b) Decreased respirations        
(c) Increased urinary output        
(d) Decreased oxygen saturation        
Answer:
(a) Increased blood pressure 

Rationale:
The client with polycythemia vera has an abnormal increase in the number of circulating red blood cells that results in increased viscosity of the blood. Increases in blood pressure further tax the overworked heart. Answers (b), (c), and (d) do not directly relate to the condition; therefore, they are incorrect.

Question 15.    
A client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if she:    
(a) Uses an electric blanket at night 
(b) Dresses in extra layers of clothing 
(c) Applies a heating pad to her feet 
(d) Takes a hot bath morning and evening        
Answer:
(b) Dresses in extra layers of clothing 

Rationale:
Dressing in extra layers of clothing will help decrease the feeling of being cold that is experienced by the client with hypothyroidism. Decreased sensation and decreased alertness are common in the client with hypothyroidism. The use of electric blankets and heating pads can result in burns, making answers (a) and (c) incorrect. Answer (d) is incorrect because the client with hypothyroidism has dry skin, and a hot bath morning and evening would make her condition worse

Question 16.    
The nurse caring for a client with a closed head injury obtains an intracranial pressure (ICP) reading of 17mmHg. The nurse recognizes that:    
(a) The ICP is elevated and the doctor should be notified.        
(b) The ICP is normal; therefore, no further action is needed.        
(c) The ICP is low and the client needs additional IV fluids.        
(d) The ICP reading is not as reliable as the Glascow coma scale.        
Answer:
(a) The ICP is elevated and the doctor should be notified.    

Rationale:
An ICP of 17mmHg should be reported to the doctor because it is elevated. (The ICP normally ranges from 4mmHg to 10mmHg, with upper limits of 15mmHg.) Answer (b) is incorrect because the pressure is not normal. Answer (c) is incorrect because the pressure is not low. Answer (D) is incorrect because the ICP reading provides a more reliable measurement than the Glascow coma scale.

Question 17.
A client has been hospitalized with a diagnosis of laryngeal cancer. Which factor is most significant in the development of laryngeal cancer?
(a) A family history of laryngeal cancer
(b) Chronic inhalation of noxious fumes
(c) Frequent straining of the vocal cords
(d) A history of frequent alcohol and tobacco use
Answer:
(d) A history of frequent alcohol and tobacco use

Rationale:
A history of frequent alcohol and tobacco use is the most significant factor in the development of cancer of the larynx. Answers (a), (b), and (c) are also factors in the development of laryngeal cancer but they are not the most significant; therefore, they are incorrect.

Question 18. 
The nurse is completing an assessment history of a client with pernicious anemia. Which complaint differentiates pernicious anemia from other types of anemia?
(a) Difficulty in breathing after exertion 
(b) Mumbness and tingling in the extremities 
(c) A faster than usual heart rate 
(d) Feelings of lightheadedness 
Answer:
(b) Mumbness and tingling in the extremities 

Rationale:
Numbness and tingling in the extremities is common in the client with pernicious anemia, but not those with other types of anemia. Answers (a), (c), and (d) are incorrect because they are symptoms of all types of anemia.

 Question 19.    
 A client with rheumatoid arthritis is beginning to develop flexion contractures of the knees. The nurse should tell the client to:
(a) Lie  prone and let her feet hang over the mattress edge
(b) Lie supine, with her feet rotated inward
(c) Lie on her right side and point her toes downward
(d) Lie on her left side and allow her feet to remain in a neutral position
Answer:
(a) Lie prone and let her feet hang over the mattress edge

Rationale:
Lying prone and allowing the feet to hang over the end of the mattress will help prevent flexion contractures. The client should be told to do this several times a day. Answers (b), (c), and (d) do not help prevent flexion contractures; therefore, they are incorrect.

 Question 20.    
The chart of a client with schizophrenia states that the client has echolalia. The nurse can expect the client to:
(a) Speak using words that rhyme 
(b) Repeat words or phrases used by others 
(c) Include irrelevant details in conversation
(d) Make up new words with new meanings
Answer:
(b) Repeat words or phrases used by others 

Rationale:
The client with echolalia will repeat words or phrases used by others. Answer (a) is incorrect because it refers to clang association. Answer (c) is incorrect because it refers to circumstantiality. Answer (d) is incorrect because it refers to neologisms.

Question 21.
The mother of a one-year-old with sickle cell anemia wants to know why the condition didn’t show up in the nursery. The nurse’s response is based on the knowledge that:
(a) There is no test to measure abnormal hemoglobin in newborns.
(b) Infants do not have insensible fluid loss before a year of age.
(c) Infants rarely have infections that would cause them to have a sickling crises.
(d) The presence of fetal hemoglobin protects the infant.
Answer:
(d) The presence of fetal hemoglobin protects the infant.

Rationale:
The presence of fetal hemoglobin until about six months of age protects affected infants from episodes of sickling. Answer (a) is incorrect because it is an untrue statement. Answer (b) is incorrect because infants do have insensible fluid loss. Answer (c) is incorrect because respiratory infections such as bronchiolitis and otitis media can cause fever and dehydration, which cause sickle cell crisis.

Question 22.
Which early morning activity helps to reduce the symptoms associated with rheumatoid arthritis?
(a) Brushing the teeth
(b) Drinking a glass of juice
(c) Holding a cup of coffee
(d) Brushing the hair
Answer:
(c) Holding a cup of coffee

Rationale:
The warmth from holding a cup of coffee or hot chocolate helps to relieve the pain and stiffness in the hands of the client with rheumatoid arthritis. Answers (a), (b), and (d) do not relieve the symptoms of rheumatoid arthritis; therefore, they are incorrect.

Question 23.
A client with B negative blood requires a blood transfusion during surgery. If no B negative blood is available, the client should be transfused with:
(a) A positive blood
(b) B positive blood
(c) negative blood
(d) AB negative blood
Answer:
(c) negative blood

Rationale:
If the client’s own blood type and Rh are not available, the safest transfusion is 0 negative blood. Answers (a), (b), and (d) are incorrect because they can cause reactions that can prove fatal to the client.

Question 24.
The nurse notes that a post-operative client’s respirations have dropped from 14 to 6 breaths per minute. The nurse administers Narcan (naloxone) per standing order. Following administration of the medication, the nurse should assess the client for:
(a) Pupillary changes
(b) Projectile vomiting
(c) Wheezing respirations
(d) Sudden, intense pain
Answer:
(d) Sudden, intense pain

Rationale:
Narcan is a narcotic antagonist that blocks the effects of the client’s pain medication; therefore, the client will experience sudden, intense pain. Answers (a), (b), and (c) do not relate to the client’s condition and the administration of Narcan; therefore, they are incorrect.

Question 25.
A newborn weighed seven pounds at birth. At six months of age, the infant could be expected to weigh:
(a) 14 pounds
(b) 18 pounds
(c) 25 pounds
(d) 30 pounds
Answer:
(a) 14 pounds

Rationale:
The infant’s birth weight should double by six months of age. Answers (b), (c), and (d) are incorrect because they are greater than the expected weight gain by six months of age.

Question 26.    
A client with nontropical sprue has an exacerbation of symptoms. Which meal selection is responsible for the recurrence of the client’s symptoms?
(a) Tossed salad with oil and vinegar dressing 
(b) Baked potato with sour cream and chives 
(c) Cream of tomato soup and crackers 
(d) Mixed fruit and yogurt
Answer:
(c) Cream of tomato soup and crackers 

Rationale:
The symptoms of nontropical sprue as well as those of celiac are caused by the ingestion of gluten, found in wheat, oats, barley, and rye. Creamed soup and crackers as well as some cold cuts contain gluten. Answers (a), (b), and (d) do not contain gluten; therefore, they are incorrect.

Question 27.    
A client with congestive heart failure has been receiving digoxin (Laxoxin). Which finding indicates that the medication is having a desired effect?
(a) Increased urinary output
(b) Stabilized weight
(c) Improved appetite
(d) Increased pedal edema
Answer:
(a) Increased urinary output

Rationale:
Lanoxin slows and strengthens the contraction of the heart. An increase in urinary output shows that the medication is having a desired effect by eliminating excess fluid from the body. Answer B is incorrect because the weight would decrease. Answer (c) is not related to the medication; therefore, it is incorrect. Answer (d) is incorrect because pedal edema would decrease, not increase.

Question 28. 
Which play activity is best suited to the gross motor skills of the toddler?
(a) Coloring book and crayons
(b) Ball
(c) Building cubes
(d) Swing set
Answer:
(b) Ball

Rationale:
The toddler has gross motor skills suited to playing with a ball, which can be kicked forward or thrown overhand. Answers (a) and (c) are incorrect because they require fine motor skills. Answer (d) is incorrect because the toddler lacks gross motor skills for play on the swing set.

Question 29. 
A client in labor admits to using alcohol throughout the pregnancy. The most recent use was the day before. Based on the client’s history, the nurse should give priority to assessing the newborn for:
(a) Respiratory depression
(b) Wide-set eyes
(c) Jitteriness
(d) Low-set ears
Answer:
(c) Jitteriness

Rationale:
Jitteriness and irritability are signs of alcohol withdrawal in the newborn. Answer (a) is incorrect because it would be associated with use more recent than one day ago. Answers (b) and (d) are characteristics of a newborn with fetal alcohol syndrome, but they are not a priority at this time; therefore, they are incorrect.

Question 30.
The physician has ordered Basaljel (aluminum carbonate gel) for a client with recurrent indigestion. The nurse should teach the client common side effects of the medication, which include:
(a) Constipation
(b) Urinary retention
(c) Diarrhea
(d) Confusion
Answer:
(a) Constipation

Rationale:
Antacids containing aluminum tend to cause constipation. Answers (b), (c), and (d) are not common side effects of the medication.

Question 31.    
A client is admitted with suspected abdominal aortic aneurysm (AAA). A common complaint of the client with an abdominal aortic aneurysm is:
(a) Loss of sensation in the lower extremities 
(b) Back pain that lessens when standing 
(c) Decreased urinary output 
(d) Pulsations in the periumbilical area
Answer:
(d) Pulsations in the periumbilical area

Rationale:
The client with an abdominal aortic aneurysm frequently complains of pulsations or feeling the heart beat in the abdomen. Answers (a) and (c) are incorrect because they are not associated with abdominal aortic aneurysm. Answer (b) is incorrect because back pain is not affected by changes in position.

Question 32.    
The nurse is caring for a client hospitalized with nephrotic syndrome. Based on the client’s treatment, the nurse should:
(a) Limit the number of visitors.
(b) Provide a low-protein diet.
(c) Discuss the possibility of dialysis.
(d) Offer the client additional fluids.
Answer:
(a) Limit the number of visitors.

Rationale:
The client with nephotic syndrome will be treated with immuno suppressive  immuno suppressive drugs. Limiting visitors will decrease the chance of infection. Answer (b) is incorrect because the client needs additional protein. Answer (c) is incorrect because dialysis is not indicated for the client with nephrotic syndrome. Answer (d) is incorrect because additional fluids are not needed until the client begins diuresis.

Question 33.    
A client is admitted with acute adrenal crisis. During the intake assessment, the nurse can expect to find that the client has:
(a) Low blood pressure
(b) A slow, regular pulse
(c) Warm, flushed skin
(d) Increased urination
Answer:
(a) Low blood pressure

Rationale:
The client with acute adrenal crisis has symptoms of hypovolemia and shock; therefore, the blood pressure would be low. Answer (b) is incorrect because the pulse would be rapid and irregular. Answer (c) is incorrect because the skin would be cool and pale. Answer (d) is incorrect because the urinary output would be decreased.

Question 34.    
A five-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
(a) Periorbital edema
(b) Tenseness of the anterior fontanel
(c) Positive Babinski reflex
(d) Negative scarf sign
Answer:
(b) Tenseness of the anterior fontanel

Rationale:
Tenseness of the anterior fontanel indicates an increase in intracranial pressure. Answer (a) is incorrect because periorbital edema is not associated with meningitis. Answer (c) is incorrect because a positive Babinski reflex is normal in the infant. Answer (d) is incorrect because it relates to the preterm infant, not the infant with meningitis.

Question 35.    
A client with pneumocystis jiroveci pneumonia is receiving intravenous Pentam (pentamidine). While administering the medication, the nurse should give priority to checking the client’s:
(a) Deep tendon reflexes
(b) Blood pressure
(c) Urine output
(d) Tissue turgor
Answer:
(b) Blood pressure

Rationale:
The nurse should give priority to checking the client’s blood pressure since pentamidine, if infused too rapidly, can cause severe hypotension and hypoglycemia. Answers (a), (c), and (d) do not relate specifically to the medication therefore they are incorrect choices.

Question 36.    
The doctor has ordered Ampicillin 100mg every six hours IV push    for an infant weighing 7kg. The suggested dose for infants is 25-50mg/kg/day in equally divided doses. The nurse should:
(a) Give the medication as ordered.
(b) Give half the amount ordered.
(c) Give the ordered amount 12 hrs.
(d) Check the order with the doctor.
Answer:
(d) Check the order with the doctor.

Rationale:
The recommended dose ranges from 175mg to 350mg per day based on the infant’s weight. The order as written calls for 400mg per day for an infant weighing 7kg; therefore, the nurse should check the order with the doctor before giving the medication. Answer (a) is incorrect because the dosage exceeds the recommended amount. Answers (b) and (c) are incorrect choices because they involve changing the doctor’s order.

Question 37.    
An elderly client is hospitalized for a transurethral prostatectomy. Which finding should be reported to the doctor immediately?
(a) Hourly urinary output of 40-50mL 
(b) Bright red urine with many clots 
(c) Dark red urine with few clots 
(d) Requests for pain med every four hrs.
Answer:
(b) Bright red urine with many clots 

Rationale:
Bright red bleeding with many clots indicates arterial bleeding that requires surgical intervention. Answer (a) is within normal limits, answer (c) indicates venous bleeding, which can be managed by nursing intervention, and answer (d) does not indicate excessive need for pain management that requires the doctor’s attention; therefore, they are incorrect.
 
Question 38.    
Which statement by the parent of a child with sickle cell anemia indicates an understanding of the disease?
(a) “The pain he has is due to the presence of too many red blood cells.”
(b) “He will be able to go snow-skiing with his friends as long as he stays warm.”
(c) “He will need extra fluids in summer to prevent dehydration.”
(d) “There is very little chance that his brother will have sickle cell.”
Answer:
(c) “He will need extra fluids in summer to prevent dehydration.”

Rationale:
The child will need additional fluids in summer to prevent dehydration that could lead to a sickle cell crises. Answer (a) is not a true statement; therefore, it is incorrect. Answer (b) is incorrect because the activity will create a greater oxygen demand and precipitate sickle cell crises. Answer (d) is not a true statement: therefore, it is incorrect.

Question 39.    
A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to:
(a) Determine whether the ear infection has affected her hearing.
(b) Make sure that she has taken all the antibiotic.
(c) Document that the infection has completely cleared.
(d) Obtain a new prescription, in case the infection recurs.
Answer:
(c) Document that the infection has completely cleared.

Rationale:
The client should be assessed following completion of antibiotic therapy to determine whether the infection has cleared. Answer (a) would be done if there are repeated instances of otitis media, answer (b) is incorrect because it will not determine whether the child has completed the medication, and answer (d) is incorrect because the purpose of the recheck is to determine whether the infection is gone.

Question 40.    
A nine-year-old is admitted with suspected rheumatic fever. Which finding is suggestive of Sydenham’s chorea?
(a) Irregular movements of the extremities and facial grimacing
(b) Painless swellings over the extensor surfaces of the joints
(c) Faint areas of red demarcation over the back and abdomen
(d)  Swelling, inflammation, and effusion of the joints
Answer:
(a) Irregular movements of the extremities and facial grimacing

Rationale:
The child with Sydenham’s chorea will exhibit irregular movements of the extremities, facial grimacing, and labile moods. Answer (b) is incorrect because it describes subcutaneous nodules. Answer (c) is incorrect because it describes erythema marginatum. Answer (d) is incorrect because it describes polymigratory arthritis.

Question 41.    
A child with croup is placed in a cool, high-humidity tent connected to room air. The primary purpose of the high-humidity tent is to:
(a) Prevent insensible water loss
(b) Provide a moist environment with oxygen at 30%
(c) Prevent dehydration and reduce fever
(d) Liquefy secretions and relieve laryngeal spasm 
Answer:
(d) Liquefy secretions and relieve laryngeal spasm 

Rationale:
The primary reason for placing a child with croup under a high humidity mist tent is to liquefy secretions and relieve laryngeal spasms. Answers (a), (b), and (c) are inaccurate statements; therefore, they are incorrect.

Question 42.    
The nurse is suctioning the tracheostomy of an adult client. The Quick Answer: 141 recommended pressure setting for performing tracheostomy sutioning on the adult client is:
(a) 40-60mmHg 
(b) 60-80mmHg 
(c) 80-120mmHg 
(d) 120-140mmHg
Answer:
(c) 80-120mmHg 

Rationale:
The recommended setting for performing tracheostomy suction¬ing on the adult client is 80-120mmHg. Answers (a) and (b) are incorrect because the amount of suction is too low. Answer (d) is incorrect because the amount of suction is excessive.

Question 43.    
A client is admitted with a diagnosis of myxedema. An initial assessment of the client would reveal the symptoms of:    
(a) Slow pulse rate, weight loss, diarrhea, and cardiac failure    
(b) Weight gain, lethargy, slowed speech, and decreased respiratory rate
(c) Rapid pulse, constipation, and bulging eyes
(d) Decreased body temperature, weight loss, and increased respirations
Answer:
(b) Weight gain, lethargy, slowed speech, and decreased respiratory rate

Rationale:
Symptoms of myxedema include weight gain, lethargy, slow speech, and decreased respirations. Answers (a) and (d) do not describe symptoms associated with myxedema; therefore, they are incorrect. Answer (c) describes symptoms associated with Graves disease.

Question 44.    
Which statement describes the contagious stage of varicella?
(a) The contagious stage is one day before the onset of the rash until the appearance of vesicles.
(b) The contagious stage lasts during the vesicular and crusting stages of the lesions.
(c) The contagious stage is from the onset of the rash until the rash disappears.
(d) The contagious stage is one day before the onset of the rash until all the lesions are crusted.
Answer:
(d) The contagious stage is one day before the onset of the rash until all the lesions are crusted.

Rationale:
The contagious stage of varicella begins 24 hours before the onset of the rash and lasts until all the lesions are crusted. Answers (a), (b), and (c) are inaccurate regarding the time of contagion.

Question 45.    
The nurse is reviewing the results of a sweat test taken from  child with cystic fibrosis. Which finding supports the client’s diagnosis?
(a) A sweat potassium concentration less than 40mEq/L 
(b) A sweat chloride concentration greater than 60mEq/L
(c) A sweat potassium concentration greater than 40mEq/L
(d) A sweat chloride concentration less than 40mEq/L 
Answer:
(b) A sweat chloride concentration greater than 60mEq/L

Rationale:
The child with cystic fibrosis has sweat concentrations of chloride greater than 60mEq/L. Answers (a) and (c) are incorrect because they refer to potas¬sium concentrations that are not used in making a diagnosis of cystic fibrosis. Answer (d) is incorrect because the sweat concentration of chloride is too low to be diagnostic.

Question 46.    
A client in labor has an order for Demerol (meperidine) 75 mg. IM to be administered 10 minutes before delivery. The nurse should:
(a) Wait until the client is placed on the delivery table and administer the medication.
(b) Question the order.
(c) Give the medication IM during the delivery to prevent pain from the episiotomy.
(d) Give the medication as ordered.
Answer:
(b) Question the order.

Rationale:
The nurse should question the order because administering a narcotic so close to the time of delivery can result in respiratory depression in the newborn. Answers (a), (c), and (d) are incorrect because giving the medication prior to or during delivery can cause respiratory depression in the newborn.

Question 47.    
Which of the following statements describes Piaget’s stage of concrete operations?
(a) Reflex activity proceeds to imitative behavior.
(b) The ability to see another’s point of view increases.
(c) Thought processes become more logical and coherent.
(d) The ability to think abstractly leads to logical conclusion.
Answer:
(c) Thought processes become more logical and coherent.

Rationale:
During concrete operations, the child's thought processes become more logical and coherent. Answers (a), (b), and (d) are incorrect because they describe other types of development: sensorimotor, intuitive, and formal.

Question 48.    
A client admitted to the psychiatric unit claims to be the Pope and insists that he will not be kept away from his subjects. The most likely explanation for the client’s delusion is:
(a) A reaction formation 
(b) A stressful event 
(c) Low self-esteem 
(d) Overwhelming anxiety
Answer:
(c) Low self-esteem 

Rationale:
Delusions of grandeur are associated with feelings of low selfesteem. Answer (a) is incorrect because reaction formation, a defense mechanism, is characterized by outward emotions that are the opposite of internal feelings. Answers (b) and (d) can cause an increase in the client’s delusions but do not explain their purpose; therefore, they are incorrect.

Question 49.    
Which of the following statements reflects Kohlberg’s theory of the moral development of the preschool-age child?
(a) Obeying adults is seen as correct behavior.
(b) Showing respect for parents is seen as important.
(c) Pleasing others is viewed as good behavior.
(d) Behavior is determined by consequences.
Answer:
(d) Behavior is determined by consequences.

Rationale:
According to Kohlberg, in the preconventional stage of development, the behavior of the preschool child is determined by the consequences of the behavior. Answers (a), (b), and (c) describe other stages of moral development; therefore, they are incorrect.

Question 50.    
The nurse is caring for an eight-year-old following a routine tonsil-lectomy. Which finding should be reported immediately?
(a) Reluctance to swallow 
(b) Drooling of blood-tinged saliva 
(c) An axillary temperature of 99°F 
(d) Respiratory stridor 
Answer:
(d) Respiratory stridor 

Rationale:
Respiratory stridor is a symptom of partial airway obstruction. Answers (a), (b), and (c) are expected with a tonsillectomy; therefore, they are incorrect

Question 51.    
The nurse is admitting a client with a suspected duodenal ulcer. The client will most likely report that his abdominal discomfort decreases when he:
(a) Avoids eating
(b) Rests in a recumbent position
(c) Eats a meal or snack
(d) Sits upright after eating
Answer:
(c) Eats a meal or snack

Rationale:
Pain associated with duodenal ulcers is lessened if the client eats a meal or snack. Answer (a) is incorrect because it makes the pain worse. Answer (b) lessens the discomfort of dumping syndrome; therefore, it is incorrect. Answer (d) lessens the discomfort of gastroesophageal reflux; therefore, it is incorrect.

Question 52.    
The nurse is assessing a newborn in the well-baby nursery. Which finding should alert the nurse to the possibility of a cardiac anomaly?
(a) Diminished femoral pulses
(b) Harlequin’s sign
(c) Circumoral pallor
(d) Acrocyanosis
Answer:
(a) Diminished femoral pulses

Rationale:
Diminished femoral pulses are a sign of coarctation of the aorta. Answers (b), (c), and (d) are found in normal newborns and are not associated with cardiac anomaly.

Question 53.    
A two-year-old is hospitalized with a diagnosis of Kawasaki’s disease. A severe complication of Kawasaki’s disease is:    
(a) The development of Brushfield spots 
(b) The eruption of Hutchinson’s teeth 
(c) The development of coxa plana 
(d) The creation of a giant aneurysm
Answer:
(d) The creation of a giant aneurysm

Rationale:
A severe complication associated with Kawasaki’s disease is the development of a giant aneurysm. Answers (a), (b), and (c) are incorrect because they have no relationship to Kawasaki’s disease.

Question 54.    
The charge nurse is formulating a discharge teaching plan for a client with mild preeclampsia. The nurse should give priority to:
(a) Teaching the client to report a nosebleed
(b) Instructing the client to maintain strict bed rest 
(c) Telling the client to notify the doctor of pedal edema 
(d) Advising the client to avoid sodium sources in the diet
Answer:
(a) Teaching the client to report a nosebleed

Rationale:
A nosebleed in the client with mild preeclampsia may indicate that the client’s blood pressure is elevated. Answers (b), (c), and (d) are incorrect because the client will not need strict bed rest, pedal edema is common in the client with preeclampsia, and the client does not need to avoid sodium, although the client should limit or avoid high-sodium foods.

Question 55.    
The nurse is preparing to discharge a client who is taking an MAOI. The nurse should instruct the client to:    
(a) Wear protective clothing and sunglasses when outside.
(b) Avoid over-the-counter cold and hay fever preparations.
(c) Drink at least eight glasses of water a day.
(d) Increase his intake of high-quality protein. 
Answer:
(b) Avoid over-the-counter cold and hay fever preparations.

Rationale:
The client taking an MAO inhibitor should avoid over-the-counter medications for colds and hay fever because many contain pseudoephedrine. Combining an MAO inhibitor with pseudoephedrine can result in extreme elevations in blood pressure. Answer (a) is incorrect because it refers to the client taking an antipsychotic medication such as Thorazine. Answer (c) is not specific to the client taking an MAO inhibitor and answer (d) does not apply to the question.

Question 56.
Which of the following meal selections is appropriate for the client with celiac disease?    
(a) Toast, jam, and apple juice    
(b) Peanut butter cookies and milk    
(c) Rice Krispies bar and milk    
(d) Cheese pizza and Kool-Aid    
Answer:
(c) Rice Krispies bar and milk

Rationale:
Foods containing rice or millet are permitted in the diet of the client with celiac disease. Answers (a), (b), and (d) are not permitted because they contain gluten, which exacerbates the symptoms of celiac disease; therefore, they are incorrect.

Question 57.    
A client with hyperthyroidism is taking lithium carbonate to inhibit  thyroid hormone release. Which complaint by the client  should  alert the nurse to a problem with the client’s medication?
(a) The client complains of blurred vision.
(b) The client complains of increased thirst and increased urination.
(c) The client complains of increased weight gain over the past year.
(d) The client complains of rhinorrhea.
Answer:
(b) The client complains of increased thirst and increased urination.

Rationale:
Increased thirst and increased urination are signs of lithium toxicity. Answers (a) and (d) are not associated with the use of lithium; therefore, they are incorrect. Answer (c) is an expected side effect of the medication; therefore, it is incorrect.

Question 58.    
The physician has ordered intravenous fluid with potassium for a client admitted with gastroenteritis and dehydration. Before adding potassium to the intravenous fluid, the nurse should:
(a) Assess the urinary output.
(b) Obtain arterial blood gases.
(c) Perform a dextrostick.
(d) Obtain a stool culture.
Answer:
(a) Assess the urinary output.

Rationale:
During dehydration, the kidneys compensate for electrolyte imbalance by retaining potassium. The nurse should check for urinary output before adding potassium to the IV fluid. Answer (b) is incorrect because it measures respiratory compensation caused by dehydration. Answers (c) and (d) do not apply to the use of intravenous fluid with potassium; therefore, they are incorrect.

Question 59.    
A two-month-old infant has just received her first Tetramune injection. The nurse should tell the mother that the immunization:    
(a) Will need to be repeated when the child is four years of age.
(b) Is given to determine whether the child is susceptible to pertussis.
(c) Is one of a series of injections that protects against diphtheria, pertussis, tetanus and H.influenzae b.
(d) Is a one-time injection that protects against measles, mumps, rubella and varicella.
Answer:
(c) Is one of a series of injections that protects against diphtheria, pertussis, tetanus and H.influenzae b.

Rationale:
The immunization protects the child against diphtheria, pertussis, tetanus, and H. influenzae b. Answer (a) is incorrect because a second injection is given before four years of age. Answer (b) is not a true statement and answer (d) is not a one-time injection, nor does it protect against measles, mumps, rubella, or varicella.

Question 60.    
A client with Addison’s disease has been receiving glucocorticoid therapy. Which finding indicates a need for dosage adjustment?    
(a) Dryness of the skin and mucus membranes
(b) Dizziness when rising to a standing position 
(c) A weight gain of six pounds in the past week 
(d) Difficulty in remaining asleep
Answer:
(c) A weight gain of six pounds in the past week 

Rationale:
A weight gain of six pounds in a week in the client taking glucocorticoids indicates that the dosage should be modified. Answers (a) and (b) are not specific to the question; therefore, they are incorrect. Answer (d) is an expected side effect of the medication; therefore, it is incorrect. 

Question 61.    
The nurse is caring for an obstetrical client in early labor. After the rupture of membranes, the nurse should give priority to:
(a) Applying an internal monitor 
(b) Assessing fetal heart tones 
(c) Assisting with epidural anesthesia 
(d) Inserting a Foley catheter
Answer:
(b) Assessing fetal heart tones 

Rationale:
Assessing fetal heart tones reveals whether fetal distress occurred with rupture of the membranes. Answers (a), (c), and (d) are later interventions; therefore, they are incorrect.

Question 62.    
The physician has prescribed Synthroid (levothyroxine) for a client with myxedema. Which statement indicates that the client understands the nurse’s teaching regarding the medication?
(a) “I will take the medication each morning after breakfast.”
(b) “I will check my heart rate before taking the medication.”
(c) “I will report visual disturbances to my doctor.”
(d) “I will stop the medication if I develop gastric upset.”
Answer:
(b) “I will check my heart rate before taking the medication.”

Rationale:
Synthroid (levothyroxine) increases metabolic rate and cardiac output. Adverse reactions include tachycardia and dysrhythmias; therefore, the client should be taught to check her heart rate before taking the medication. Answer (a) is incorrect because the client does not have to take the medication after breakfast. Answer (c) does not relate to the medication; therefore, it is incorrect. The medication should not be stopped because of gastric upset; therefore, answer (d) is incorrect.

Question 63.    
The nurse is caring for a client with a radium implant for the treatment of cervical cancer. While caring for the client with a radioactive implant, the nurse should:
(a) Provide emotional support by spending additional time with the client.
(b) Stand at the foot of the bed when talking to the client.
(c) Avoid handling items used by the client.
(d) Wear a badge to monitor the amount of time spent in the client's room.
Answer:
(d) Wear a badge to monitor the amount of time spent in the client's room.

Rationale:
The nurse should wear a special badge when taking care of the client with a radioactive implant, to measure the amount of time spent in the room. The nurse should limit the time of radiation exposure; therefore, answer (a) is incorrect. Standing at the foot of the bed of a client with a radioactive cervical implant increases the nurse’s exposure to radiation; therefore, answer (b) is incorrect. The nurse does not have to avoid handling items used by the client; therefore, answer (c) is incorrect.

Question 64.    
The nurse is caring for a client hospitalized with bipolar disorder, manic phase, who is taking lithium. Which of the following snacks would be best for the client with mania?
(a) Potato chips
(b) Diet cola
(c) Apple
(d) Milkshake 
Answer:
(d) Milkshake 

Rationale:
The milkshake will provide needed calories and nutrients for the client with mania. Answers (a), (b), and (c) are incorrect choices because they do not provide as many calories or nutrients as the milkshake.

Question 65.
The physician has prescribed imipramine (Tofranil) for a client with depression. The nurse should continue to monitor the client’s affect because the maximal effects of tricyclic antidepressant medication do not occur for:
(a) 48-72 hours
(b) 5-7 days
(c) 2-4 weeks
(d) 3-6 months
Answer:
(d) 3-6 months

Rationale:
The maximal effects from tricyclic antidepressants might not be achieved for up to six months after the medication is started. Answers (a) and (b) are incorrect because the time for maximal effects is too brief. Answer (c) is incorrect because it refers to the initial symptomatic relief rather than maximal effects.

Question 66.
An elderly client with glaucoma has been prescribed Timoptic (timolol maleate) eyedrops. Timoptic should be used with caution in clients with a history of:
(a) Diabetes
(b) Gastric ulcers
(c) Emphysema
(d) Pancreatitis
Answer:
(c) Emphysema

Rationale:
Beta blockers such as timolol (Timoptic) can cause bron- chospasms in the client with chronic obstructive lung disease. Timoptic is not contraindicated for use in the client with diabetes, gastric ulcers, or pancreatitis; therefore, answers (a), (b), and (d) are incorrect.

Question 67.
A two-year-old is hospitalized with suspected intussusception. Which finding is associated with intussusception?
(a) “Currant jelly” stools
(b) Projectile vomiting
(c) “Ribbonlike” stools
(d) Palpable mass over the flank
Answer:
(a) “Currant jelly” stools

Rationale:
The child with intussusception has stools that contain blood and t    mucus, which are described as “currant jelly” stools. Answer (b) is a symptom of pyloric stenosis; therefore, it is incorrect. Answer (c) is a symptom of Hirschsprungs, therefore, it is incorrect. Answer (d) is a symptom of Wilms tumor; therefore, it is incorrect.

Question 68.    
Which of the following findings would be expected in the infant with biliary atresia?
(a) Rapid weight gain and hepatomegaly
(b) Dark stools and poor weight gain
(c) Abdominal distention and poor weight gain
(d) Abdominal distention and rapid weight gain
Answer:
(c) Abdominal distention and poor weight gain

Rationale:
The infant with biliary atresia has abdominal distention, poor weight gain, and clay-colored stools. Answers (a), (b), and (d) do describe the symptoms associated with biliary atresia; therefore, they are incorrect.

Question 69.    
A client is being treated for cancer with linear acceleration radiation. The physician has marked the radiation site with a blue marking pen. The nurse should:
(a) Remove the unsightly markings with acetone or alcohol.
(b) Cover the radiation site with loose gauze dressing.
(c) Sprinkle baby powder over the radiated area.
(d) Refrain from using soap or lotion on the marked area.
Answer:
(d) Refrain from using soap or lotion on the marked area.

Rationale:
The nurse should not use water, soap, or lotion on the area marked for radiation therapy. Answer (a) is incorrect because it would remove the marking. Answers (b) and (c) are not necessary for the client receiving radiation; therefore, they are incorrect.

 Question 70.    
The blood alcohol concentration of a client admitted following a motor vehicle accident is 460mg/dL. The nurse should give priority to monitoring the client for:
(a) Loss of coordination 
(b) Respiratory depression 
(c) Visual hallucinations 
(d) Tachycardia
Answer:
(b) Respiratory depression 

Rationale:
Blood alcohol concentrations of 400-600mg/dL are associated with respiratory depression, coma, and death. Answer (a) occurs with blood alcohol concentrations of 50mg/dL, which affects coordination and speech but does not cause respiratory depression; therefore, it is incorrect. Answers (c) and (d) are associated with alcohol withdrawal, not overdose; therefore, they are incorrect.

Question 71.    
The nurse is caring for a client with acromegaly. Following a transphenoidal hypophysectomy, the nurse should:    
(a) Monitor the client’s blood sugar.
(b) Suction the mouth and pharynx every hour.
(c) Place the client in low Trendelenburg position.
(d) Encourage the client to cough.
Answer:
(a) Monitor the client’s blood sugar.

Rationale:
Following a hypophysectomy, the nurse should check the client's blood sugar because insulin levels may rise rapidly resulting in hypoglycemia. Answer (b) is incorrect because suctioning should be avoided. Answer (c) is incorrect because the client’s head should be elevated to reduce pressure on the operative site. Answer (d) is incorrect because coughing increases pressure on the operative site that can lead to a leak of cerebral spinal fluid.

Question 72.    
A client newly diagnosed with diabetes is started on Precose (acarbose). The nurse should tell the client that the medication should be taken:
(a) one hour before meals
(b) 30 minutes after meals 
(c) With the first bite of a meal 
(d) Daily at bedtime
Answer:
(c) With the first bite of a meal 

Rationale:
Acarbose is to be taken with the first bite of a meal. Answers (a) (b), and (d) are incorrect because they specify the wrong schedule for taking the medication.

Question 73.    
A client with a deep decubitus ulcer is receiving therapy in the hyperbaric oxygen chamber. Before therapy, the nurse should:    
(a) Apply a lanolin-based lotion to the skin.
(b) Wash the skin with water and pat dry.
(c) Cover the area with a petroleum gauze.
(d) Apply an occlusive dressing to the site.
Answer:
(b) Wash the skin with water and pat dry.

Rationale:
The client going for therapy in the hyperbaric oxygen chamber requires no special skin care; therefore, washing the skin with water and patting it dry are suitable. Lotions, petroleum products, perfumes, and occlusive dressings interfere with oxygenation of the skin; therefore, answers (a), (c), and (d) are incorrect.

Question 74.    
The physician has ordered DDAVP (desmopressin acetate) for a client with diabetes insipidus. Which finding indicates that the medication is having its intended effect?
(a) The client’s appetite has improved.
(b) The client’s morning blood sugar was 120mg/dL.
(c) The client’s urinary output has decreased.
(d) The client’s activity level has increased.
Answer:
(c) The client’s urinary output has decreased.

Rationale:
Diabetes insipidus is characterized by excessive production of dilute urine. A decline in urinary output shows that the medication is having its intended effect. Answers (a) and (d) do not relate to the question; therefore, they are incorrect. Answer (b) refers to diabetes mellitus; therefore, it is incorrect.

Question 75.
A client with pregnancy-induced hypertension is scheduled for a C-section. Before surgery, the nurse should keep the client:
(a) On her right side
(b) Supine with a small pillow
(c) On her left side
(d) In knee chest position
Answer:
(c) On her left side

Rationale:
Positioning the client on her left side will take pressure off the vena cava and allow better oxygenation of the fetus. Answers (a) and (b) do not relieve pressure on the vena cava; therefore, they are incorrect. Answer (d) is the preferred position for the client with a prolapsed cord; therefore, it is incorrect for this situation.

Question 76.
The physician has prescribed Coumadin (sodium warfarin) for a client having transient ischemic attacks. Which laboratory test measures the therapeutic level of Coumadin?
(a) Prothrombin time
(b) Clot retraction time
(c) Partial thromboplastin time
(d) Bleeding time
Answer:
(a) Prothrombin time

Rationale:
Prothrombin time measures the therapeutic level of Coumadin. Answer (b) is incorrect because it measures the quantity of each specific clotting factor. Answer (c) is incorrect because it measures the therapeutic level of heparin. Answer (d) is incorrect because it evaluates the vascular and platelet factors associated with hemostasis.

Question 77.
An adolescent client with cystic acne has a prescription for Accutane (isotretinoin). Which lab work is needed before beginning the medication?
(a) Complete blood count
(b) Clean-catch urinalysis
(c) Liver profile
(d) Thyroid function test
Answer:
(c) Liver profile

Rationale:
Accutane is made from concentrated vitamin A, a fat-soluble vitamin. Fat-soluble vitamins have the potential of being hepatotoxic, so a liver panel is needed. Answers (a), (b), and (d) do not relate to therapy with Accutane; therefore, they are incorrect.

Question 78.    
Twenty-four hours after an uncomplicated labor and delivery, a client’s WBC is 12,000cu/mm. The elevation in the client’s WBC is most likely an indication of:
(a) A normal response to the birth process
(b) An acute bacterial infection
(c) A sexually transmitted virus
(d) Dehydration from being NPO during labor
Answer:
(a) A normal response to the birth process

Rationale:
The client’s WBC is only slightly elevated and is most likely due to the birth process. Answer (b) is incorrect because the WBC would be more elevated if an acute bacterial infection was present. Answer (c) is incorrect because viral infections usually do not cause elevations in WBC. Answer (d) is incorrect because dehydration is not reflected by changes in the WBC.

Question 79.    
The home health nurse is visiting a client who plans to deliver her baby at home. Which statement by the client indicates an understanding regarding screening for phenylketonuria (PKU)?
(a) “I will need to take the baby to the clinic within 24 hours of delivery to have blood drawn.”
(b) “I will need to schedule a home visit for PKU screening when the baby is three days old.”
(c) “I will remind the midwife to save a specimen of cord blood for the PKU test.”
(d) “I will have the PKU test done when I take her for her first immunizations.”
Answer:
(b) “I will need to schedule a home visit for PKU screening when the baby is three days old.”

Rationale:
 PKU screening is usually done on the third day of life. Answer (a) is incorrect because the baby will not have had sufficient time to ingest protein sources of phenylalanine. Answer (c) is incorrect because blood is obtained from a heel stick, not from cord blood. Answer (d) is incorrect because the first immunizations are done at six weeks of age, and by that time, brain damage will already have occurred if the baby has PKU.
 
Question 80.    
The physician has ordered intubation and mechanical ventilation for a client with periods of apnea following a closed head injury. Arterial blood gases reveal a pH of 7.47, PCO₂ of 28, and HCO₃ of 23. These findings indicate that the client has:
(a) Respiratory acidosis 
(b) Respiratory alkalosis 
(c) Metabolic acidosis 
(d) Metabolic alkalosis
Answer:
(b) Respiratory alkalosis 

Rationale:
The client’s blood gases indicate respiratory alkalosis. Answers (a), (c), and (d) are not reflected by the client’s blood gases or present condition; therefore, they are incorrect.

Question 81.    
A client is diagnosed with emphysema and cor pulmonale. Which findings are characteristic of cor pulmonale?
(a) Hypoxia, shortness of breath, and exertional fatigue 
(b) Weight loss, increased RBC, and fever 
(c) Rales, edema, and enlarged spleen
(d) Edema of the lower extremities and distended neck veins
Answer:
(d) Edema of the lower extremities and distended neck veins

Rationale:
Cor pulmonale, or right-sided heart failure, is characterized by edema of the legs and feet, enlarged liver, and distended neck veins. Answer (a) is incorrect because the symptoms are those of left-sided heart failure and pulmonary edema. Answer (b) is not specific to the question; therefore, it is incorrect. Answer (c) is incorrect because it does not relate to cor pulmonale.

Question 82.    
A client with a laryngectomy returns from surgery with a nasogas- Quick Answer: 141 trie tube in place. The primary reason for placement of the nasogastric tube is to:
(a) Prevent swelling and dysphagia
(b) Decompress the stomach
(c) Prevent contamination of the suture line
(d) Promote healing of the oral mucosa
Answer:
(c) Prevent contamination of the suture line

Rationale:
The primary reason for the N₆ to is to allow for nourishment without contamination of the suture line. Answer (a) is not a true statement; therefore, it is incorrect. Answer (b) is incorrect because there is no mention of suction. Answer (d) is incorrect because the oral mucosa was not involved in the laryngectomy.

Question 83.    
The physician orders the removal of an in-dwelling catheter the second post-operative day for a client with a prostatectomy. The client complains of pain and dribbling of urine the first time he voids. The nurse should tell the client that:
(a) Using warm compresses over the bladder will lessen the discomfort.
(b) Perineal exercises will be started in a few days to help relieve his symptoms.
(c) If the symptoms don’t improve, the catheter will have to be reinserted.
(d) His complaints are common and will improve over the next few days. 
Answer:
(d) His complaints are common and will improve over the next few days. 

Rationale:
The client’s complaints are due to swelling associated with surgery and catheter placement. Answer (a) is incorrect because it will not relieve the client’s symptoms of pain and dribbling. Answer (b) is incorrect because perineal exercises will not help relieve the post-operative pain. Answer (c) is incorrect because the client’s complaints do not indicate the need for catheter reinsertion.

Question 84.    
A client with a right lobectomy is being transported from the intensive care unit to a medical unit. The nurse understands that the client’s chest drainage system:
(a) Can be disconnected from suction if the chest tube is clamped
(b) Can be disconnected from suction, but the chest tube should remain unclamped
(c) Must remain connected by means of a portable suction
(d) Must be kept even with the client’s shoulders during the transport
Answer:
(b) Can be disconnected from suction, but the chest tube should remain unclamped

Rationale:
The chest-drainage system can be disconnected from suction, but the chest tube should remain unclamped to prevent a tension pneumothorax. Answer (a) is incorrect because it could result in a tension pneumothorax. Answer (c) is not a true statement; therefore, it is not correct. Answer (d) is incorrect because the chest-drainage system should be kept lower than the client's chest and shoulders.

Question 85.    
A nurse is caring for a client with a myocardial infarction. The nurse recognizes that the most common complication in the client following a myocardial infarction is:
(a) Right ventricular hypertrophy
(b) Cardiac dysrhythmia
(c) Left ventricular hypertrophy
(d) Hyperkalemia
Answer:
(b) Cardiac dysrhythmia

Rationale:
Cardiac dysrhythmias are the most common complication for the client with a myocardial infarction. Answers (a) and (c) do not relate to myocardial infarction; therefore, they are incorrect. Answer (d) is incorrect because it is not the most common complication following a myocardial infarction.

Question 86.    
A client develops a temperature of 102°F following coronary artery bypass surgery. The nurse should notify the physician immediately because elevations in temperature:
(a) Increase cardiac output
(b) Indicate cardiac tamponade
(c) Decrease cardiac output
(d) Indicate graft rejection
Answer:
(a) Increase cardiac output

Rationale:
Elevations in temperature increase the cardiac output. Answer (b) is incorrect because temperature elevations are not associated with cardiac tamponade. Answer (c) is incorrect because temperature elevation does not decrease cardiac output. Answer (d) is incorrect because elevations in temperature in the client with a coronary artery bypass graft indicate inflammation, not necessarily graft rejection.

Question 87.    
The chart indicates that a client has expressive aphasia following stroke. The nurse understands that the client will have difficulty with:
(a) Speaking and writing
(b) Comprehending spoken words
(c) Carrying out purposeful motor activity
(d) Recognizing and using an object correctly
Answer:
(a) Speaking and writing

Rationale:
The client with expressive aphasia has trouble forming words that are understandable. Answer (b) is incorrect because it describes receptive aphasia. Answer (c) refers to apraxia and answer (d) refers to agnosia, so they are incorrect.

Question 88.    
A client receiving Parnate (tranylcypromine) is admitted in a     hypertensive crisis. Which food is most likely to produce a hypertensive crisis when taken with the medication?
(a) Processed cheese
(b) Cottage cheese
(c) Cream cheese
(d) Cheddar cheese
Answer:
(d) Cheddar cheese

Rationale:
The client taking MAOI, including Parnate, should avoid eating aged cheeses, such as Cheddar cheese, because a hypertensive crisis can result. Answer (a) is incorrect because processed cheese is less likely to produce a hypertensive crisis. Answers (b) and (c) do not cause a hypertensive crisis in the client taking an MAOI; therefore, they are incorrect.

Question 89.    
To prevent deformities of the knee joints in a client with an exacerbation of rheumatoid arthritis, the nurse should:    
(a) Tell the client to remain on bed rest until swelling subsides.
(b) Discourage passive range of motion because it will cause further swelling.
(c) Encourage motion of the joint within the limits of pain.
(d) Tell the client she will need joint immobilization for 2-3 weeks.
Answer:
(c) Encourage motion of the joint within the limits of pain.

Rationale:
The client with rheumatoid arthritis needs to continue moving affected joints within the limits of pain. Answer (a) and (d) are incorrect because they will increase stiffness and joint disuse. Answer (b) is incorrect because, if done correctly, passive range-of-motion exercises will improve the use of affected joints.

Question 90.    
The nurse is assessing a trauma client in the emergency room when she notes a penetrating abdominal wound with exposed viscera. The nurse should:
(a) Apply a clean dressing to protect the wound.
(b) Cover the exposed viscera with a sterile saline gauze.
(c) Gently replace the abdominal contents.
(d) Cover the area with a petroleum gauze.
Answer:
(b) Cover the exposed viscera with a sterile saline gauze.

Rationale:
Exposed abdominal viscera should be covered with a sterile saline-soaked gauze, and the doctor should be notified immediately. Answer (a) is incorrect because the dressing should be sterile, not clean. Answer (c) is incorrect because attempting to replace abdominal contents can cause greater injury and should be done only surgically. Answer (d) is incorrect because the area is kept moist only with sterile normal saline.

Question 91.    
A client is admitted to the emergency room with multiple injuries. What is the proper sequence for managing the client?    
(a) Assess for head injuries, control hemorrhage, establish an airway, prevent hypovolemic shock
(b) Control hemorrhage, prevent hypovolemic shock, establish an airway, assess for head injuries
(c) Establish an airway, control hemorrhage, prevent hypovolemic shock, assess for head injuries
(d) Prevent hypovolemic shock, assess for head injuries, establish an airway, control hemorrhage 
Answer:
(c) Establish an airway, control hemorrhage, prevent hypovolemic shock, assess for head injuries

Rationale:
Using the ABCD approach to the client with multiple trauma the nurse in the ER would: establish an airway, determine whether the client is breathing, check circulation (control hemorrhage), and check for deficits (head injuries). Answers (a), (b), and (d) are incorrect because they are not in the appropriate sequence for maintaining life.

Question 92.    
The nurse is teaching the mother of a child with attention deficit disorder regarding the use of Ritalin (methylphenidate). The nurse recognizes that the mother understands her teaching when she states the importance of:
(a) Offering high-calorie snacks 
(b) Watching for signs of infection 
(c) Observing for signs of oversedation 
(d) Using a sunscreen with an SPF of 30 
Answer:
(a) Offering high-calorie snacks 

Rationale:
Stimulant medications such as Ritalin tend to cause anorexia and weight loss in some children with ADHD. Providing high-calorie snacks will help the child maintain an appropriate weight. Answer (b) is incorrect because the medication does not mask infection. Answer (c) is incorrect because the medication is a central nervous system stimulant, not a depressant. Answer (d) has no relationship to the medication; therefore, it is incorrect.

Question 93.    
A home health nurse has several elderly clients in her case load. Which of the following clients is most likely to be a victim of elder abuse?        
(a) A 76-year-old female with Alzheimer’s dementia
(b) A 70-year-old male with diabetes mellitus
(c) A 64-year-old female with a hip replacement
(d) A 72-year-old male with Parkinson’s disease
Answer:
(a) A 76-year-old female with Alzheimer’s dementia

Rationale:
The most likely victim of elder abuse is the elderly female with a chronic, debilitating illness such as Alzheimer’s dementia. Answers (b), (c), and (d) are less likely to be victims of elder abuse; therefore, they are incorrect.

Question 94.    
A camp nurse is applying sunscreen to a group of children enrolled in swim classes. Chemical sunscreens are most effective when applied:
(a) Just before sun exposure
(b) five minutes before sun exposure
(c) 15 minutes before sun exposure
(d) 30 minutes before sun exposure
Answer:
(d) 30 minutes before sun exposure

Rationale:
Sunscreens of at least an SPF of 15 should be applied 20-30 minutes before going into the sun. Answers (a), (b), and (c) are incorrect because they do not allow sufficient time for sun protection.

Question 95.    
The physician has made a diagnosis of “shaken child” syndrome for a 13-month-old who was brought to the emergency room after a reported fall from his highchair. Which finding supports the diagnosis of “shaken child” syndrome?
(a) Fracture of the clavicle 
(b) Periorbital bruising 
(c) Retinal hemorrhages 
(d) Fracture of the humerus
Answer:
(c) Retinal hemorrhages 

Rationale:
Retinal hemorrhages are characteristically found in the child who has been violently shaken. Answers (a), (b), and (d) may result from trauma other than that related to abuse; therefore, they are incorrect.

Question 96.    
A post-operative client has an order for Demerol (meperidine) 75mg and Phenergan (promethazine) 25mg IM every 3-4 hours as needed for pain. The combination of the two medications produces a/an:
(a) Agonist effect 
(b) Synergistic effect
(c) Antagonist effect 
(d) Excitatory effect 
Answer:
(b) Synergistic effect

Rationale:
The combination of the two medications produces a synergistic effect (an effect greater than that of either drug used alone). Agonist effects are similar to those produced by chemicals normally present in the body; therefore, answer (a) is incorrect. Antagonist effects are those in which the actions of the drugs oppose one another; therefore, answer (c) is incorrect. Answer (d) is incorrect because the drugs would have a combined depressing, not excitatory effect.

Question 97.    
Which obstetrical client is most likely to have an infant with respiratory distress Syndrome?    Detailed Answer: 152
(a) A 28-year-old with a history of alcohol use during the pregnancy
(b) A 24-year-old with a history of diabetes mellitus
(c) A 30-year-old with a history of smoking during the pregnancy
(d) A 32-year-old with a history of pregnancy-induced hypertension
Answer:
(b) A 24-year-old with a history of diabetes mellitus

Rationale:
The client with a history of diabetes is most likely to deliver a preterm large for gestational age newborn. These newborns often lack sufficient surfactant levels to prevent respiratory distress syndrome. Answers (a), (c), and (d) are less likely to have newborns with respiratory distress syndrome so they are incorrect choices.

Question 98.    
A client with a C₄ spinal cord injury has been placed in traction with cervical tongs. Nursing care should include:    
(a) Releasing the traction for five minutes each shift 
(b) Loosening the pins if the client complains of headache 
(c) Elevating the head of the bed 90°
(d) Performing sterile pin care as ordered
Answer:
(d) Performing sterile pin care as ordered

Rationale:
Nursing care of the client with cervical tongs includes performance of sterile pin care and assessment of the site. Answers (a), (b), and (c) alter the traction and could result in serious injury or death of the client; therefore, they are incorrect.

Question 99.    
The nurse is assessing a client following a coronary artery bypass graft (CABG). The nurse should give priority to reporting:    
(a) Chest drainage of 150mL in the past hour
(b) Confusion and restlessness
(c) Pallor and coolness of skin
(d) Urinary output of 40mL per hour
Answer:
(a) Chest drainage of 150mL in the past hour

Rationale:
Chest drainage greater than 100mL per hour is excessive, and the doctor should be notified regarding possible hemorrhage. Confusion and restlessness could be in response to pain, changes in oxygenation, or the emergence from anesthesia; therefore, answer (b) is incorrect. Answer (c) is incorrect because it is an expected finding in the client recently returning from a CABG. Answer (d) is within normal limits; therefore, it is incorrect.

Question 100.    
Before administering a client's morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:
(a) Record the pulse rate and administer the medication 
(b) Administer the medication and monitor the heart rate 
(c) Withhold the medication and notify the doctor 
(d) Withhold the medication until the heart rate increases
Answer:
(c) Withhold the medication and notify the doctor 

Rationale:
The medication should be withheld and the doctor should be notified. Answers (a), (b), and (d) are incorrect because they do not provide for the client’s safety.

Question 101.    
What information should the nurse give a new mother regarding the introduction of solid foods for her infant?    
(a) Solid foods should not be given until the extrusion reflex disappears at 8-10 months of age.
(b) Solid foods should be introduced one at a time, with 4 to 7 day intervals.
(c) Solid foods can be mixed in a bottle or infant feeder, to make feeding easier.
(d) Solid foods should begin with fruits and vegetables. 
Answer:
(b) Solid foods should be introduced one at a time, with 4 to 7 day intervals.

Rationale:
Solid foods should be added to the diet one at a time, with intervals of 4-7 days between new foods. The extrusion reflex fades at 3-4 months of age; therefore, answer (a) is incorrect. Answer (c) is incorrect because solids should not be added to the bottle and the use of infant feeders is discouraged. Answer (d) is incorrect because the first food added to the infant’s diet is rice cereal.

Question 102.    
When performing Leopold maneuvers on a client at 32 weeks gestation, the nurse would expect to find:
(a) No fetal movement
(b) Minimal fetal movement
(c) Moderate fetal movement
(d) Active fetal movement
Answer:
(d) Active fetal movement

Rationale:
At 32 weeks gestation the fetus can be expected to be active. Answers (a), (b), and (c) are not typical findings during the Leopold maneuver of a client who is 32 weeks gestation; therefore, they are incorrect.

Question 103.    
A client with a history of phenylketonuria (PKU) is seen in the local family planning clinic. While completing the intake history, the nurse provides information for a healthy pregnancy. Which statement indicates that the client needs further teaching?
(a) “I can use artificial sweeteners to keep me from gaining too much weight when I get pregnant.”
(b) “I need to go back on a low-phenylalanine diet before I get pregnant.”
(c) ‘‘Fresh fruits and raw vegetables will make good between-meal snacks for me.”
(d) “My baby could be mentally retarded if I don’t stick to a diet eliminating phenylalanine.”
Answer:
(a) “I can use artificial sweeteners to keep me from gaining too much weight when I get pregnant.”

Rationale:
The client needs to avoid using sweeteners containing aspartame. Answers (b), (c), and (d) indicate that the client understands the nurse’s teaching; therefore, they are incorrect.

Question 104.    
The nurse is teaching the mother of an infant with galactosemia. Which information should be included in the nurse’s teaching?
(a) Check food and drug labels for the presence of lactose.
(b) Foods containing galactose can be gradually added.
(c) Future children will not be affected.
(d) Sources of galactose are essential for growth.
Answer:
(a) Check food and drug labels for the presence of lactose.

Rationale:
The treatment of galactosemia consists of eliminating all milk and lactose-containing foods, including breast milk. Answers (b) and (d) contain inaccurate information; therefore, they are incorrect. Galactosemia is inherited as an autosomal recessive disorder. There is a one-in-four chance that future children will be affected; therefore, answer (c) is incorrect.

Question 105.    
Which finding is associated with Tay Sachs disease?
(a) Pallor of the conjunctiva 
(b) Cherry-red spots on the macula 
(c) Blue-tinged sclera 
(d) White flecks in the iris
Answer:
(b) Cherry-red spots on the macula 

Rationale:
The child with Tay Sachs disease has cherry-red spots on the macula of the eye. Answer (a) is incorrect because it is associated with anemia. Answer (c) is incorrect because it is associated with osteogenesis imperfecta. Answer (d) is incorrect because it is associated with Down syndrome.

Question 106.    
A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to:
(a) Withholding all morning medications 
(b) Ordering a CBC and CPK
(c) Administering prescribed anti-Parkinsonian medication 
(d) Transferring the client to a medical unit 
Answer:
(c) Administering prescribed anti-Parkinsonian medication 

Rationale:
The client’s symptoms suggest an adverse reaction to the medication known as neuroleptic malignant syndrome. Answers (a), (b), and (d) are not appropriate interventions for the client; therefore, they are incorrect.

Question 107.    
A client with human immunodeficiency syndrome has gastroin¬testinal symptoms, including diarrhea. The nurse should teach the client to avoid:
(a) Calcium-rich foods
(b) Canned or frozen vegetables
(c) Processed meat
(d) Raw fruits and vegetables
Answer:
(d) Raw fruits and vegetables

Rationale:
The client with HIV should adhere to a low-bacteria diet by avoiding raw fruits and vegetables. Answers (a), (b), and (c) are incorrect because they are permitted in the client’s diet.

Question 108.    
A four-year-old is admitted with acute leukemia. It will be most important to monitor the child for:
(a) Abdominal pain and anorexia 
(b) Fatigue and bruising 
(c) Bleeding and pallor 
(d) Petechiae and mucosal ulcers
Answer:
(c) Bleeding and pallor 

Rationale:
The child with leukemia has low platelet counts, which contribute to spontaneous bleeding. Answers (a), (b), and (d), common in the child with leukemia, are not life-threatening.

Question 109.    
A five-month-old is diagnosed with atopic dermatitis. Nursing interventions will focus on:
(a) Preventing infection 
(b) Administering antipyretics 
(c) Keeping the skin free of moisture 
(d) Limiting oral fluid intake
Answer:
(a) Preventing infection 

Rationale:
The nurse should prevent the infant with atopic dermatitis (eczema) from scratching, which can lead to skin infections. Answer (b) is incorrect because fever is not associated with atopic dermatitis. Answers (c) and (d) are incorrect because they increase dryness of the skin, which worsens the symptoms of atopic dermatitis.

Question 110.    
A client on a mechanical ventilator begins to fight the ventilator. Which medication will be ordered for the client?
(a) Sublimaze (fentanyl)
(b) Pavulon (pancuronium bromide)
(c) Versed (midazolam)
(d) Atarax (hydroxyzine)
Answer:
(b) Pavulon (pancuronium bromide)

Rationale:
Pavulon is a neuromuscular blocking agent that paralyzes skeletal muscles, making it impossible for the client to fight the ventilator. Sublimaze is an analgesic used to control operative pain; therefore, answer (a) is incorrect. Versed is a benzodiazepine used to produce conscious sedation; therefore, answer (c) is incorrect. Answer (d) is wrong because Atarax is used to treat post-operative nausea.

Question 111.    
A client with a history of diverticulitis complains of abdominal pain, fever, and diarrhea. Which food is responsible for the client’s symptoms?
(a) Mashed potatoes
(b) Steamed carrots
(c) Baked fish
(d) Whole-grain cereal
Answer:
(d) Whole-grain cereal

Rationale:
Symptoms associated with diverticulitis are usually reported after eating foods like popcorn, celery, raw vegetables, whole grains, and nuts. Answers (a), (b), and (c) are incorrect because they are allowed in the diet of the client with diverticulitis.

Question 112.    
The home health nurse is visiting a client with Paget’s disease. An important part of preventive care for the client with Paget’s disease is:
(a) Keeping the environment free of clutter 
(b) Advising the client to see the dentist regularly 
(c) Encouraging the client to take the influenza vaccine 
(d) Telling the client to take a daily multivitamin
Answer:
(a) Keeping the environment free of clutter 

Rationale:
The client with Paget’s disease has problems with mobility. Keeping the environment free of clutter will help prevent falls. Answers (b), (c), and (d) will improve the client’s overall health but are not specific to Paget’s disease; therefore, they are incorrect.

Question 113.    
The physician has scheduled a Whipple procedure for a client with pancreatic cancer. The nurse recognizes that the client’s cancer is located in:
(a) The tail of the pancreas 
(b) The head of the pancreas
(c) The body of the pancreas
(d) The entire pancreas
Answer:
(b) The head of the pancreas

Rationale:
The Whipple procedure is performed for cancer located in the head of the pancreas. Answers (a), (c), and (d) are not correct because of the location of the cancer.

Question 114.    
A child with cystic fibrosis is being treated with inhalation therapy with Pulmozyme (dornase alfa). A side effect of the medication is:
(a) Weight gain
(b) Hair loss
(c) Sore throat
(d) Brittle nails
Answer:
(c) Sore throat

Rationale:
Side effects of Pulmozyme include sore throat, hoarseness, and laryngitis. Answers (a), (b), and (d) are not associated with Pulmozyme; therefore, they are incorrect.

Question 115.    
Four days after delivery, a client develops complications of postpartat hemorrhage. The most common cause of late postparta hemorrhage is:
(a) Uterine atony
(b) Retained placental fragments
(c) Cervical laceration
(d) Perineal tears
Answer:
(b) Retained placental fragments

Rationale:
Retained placental fragments are the major cause of late postpartal hemorrhage. Uterine atony is the major cause of early postpartal hemorrhage; therefore, answer (a) is incorrect. Answers (c) and (d) result in slow, steady bleeding; therefore, they are incorrect.

Question 116.    
On a home visit, the nurse finds four young children alone. The youngest of the children has bruises on the face and back and circular burns on the inner aspect of the right forearm. The nurse should:    
(a) Contact child welfare services
(b) Transport the child to the emergency room
(c) Take the children to an abuse shelter
(d) Stay with the children until an adult arrives
Answer:
(a) Contact child welfare services

Rationale:
The nurse has a legal responsibility to report suspected abuse and neglect. The nurse does not have the authority to remove the children from the home; therefore, answers (b) and (c) are Incorrect. Answer (d) is incorrect because it is unrealistic.

Question 117.    
A client is diagnosed with post-traumatic stress disorder following a rape by an unknown assailant. The nurse should give priority to:    
(a) Providing a supportive environment 
(b) Controlling the client’s feelings of anger 
(c) Discussing the details of the attack
(d) Administering a hypnotic for sleep
Answer:
(a) Providing a supportive environment 

Rationale:
Providing a caring attitude and supportive environment will make the client feel safe. Answer (b) is incorrect because the client needs to feel free to express anger. Answer (c) is incorrect because it will increase the client’s anxiety. Answer (d) is incorrect because it is not the most important aspect of care for the client with PTSD.

Question 118.    
The doctor has ordered Percocet (oxycodone) for a client following abdominal surgery. The primary objective of nursing care for the client receiving an opiate analgesic is:
(a) Preventing addiction 
(b) Alleviating pain 
(c) Facilitating mobility 
(d) Preventing nausea
Answer:
(b) Alleviating pain 

Rationale:
The nurse should be concerned with alleviating the client’s pain. Answers (a), (c), and (d) are not primary objectives in the care of the client receiving an opiate analgesic; therefore, they are incorrect.

Question 119.    
A client with emphysema is receiving intravenous aminophylline. Which aminophylline level is associated with signs of toxicity? 
(a) 5 micrograms/mL 
(b) 10 micrograms/mL 
(c) 20 micrograms/mL 
(d) 25 micrograms/mL
Answer:
(d) 25 micrograms/mL

Rationale:
The therapeutic range for aminophylline is 10-20 micrograms/mL. Levels greater than 20 micrograms/mL can produce signs of toxicity. Answer (a) is incorrect because it is too low to be therapeutic. Answers (b) and (c) are within the therapeutic range; therefore, they are incorrect.

Question 120.    
Which finding is the best indication that a client with ineffective airway clearance needs suctioning?    
(a) Oxygen saturation 
(b) Respiratory rate 
(c) Breath sounds 
(d) Arterial blood gases
Answer:
(c) Breath sounds 

Rationale:
Changes in breath sounds are the best indication of the need for suctioning in the client with ineffective airway clearance. Answers A, B, and D are incorrect because they can be altered by other conditions.

Question 121.    
A client with tuberculosis has a prescription for Myambutol (ethambutol HCI). The nurse should tell the client to notify the doctor immediately if he notices:
(a) Gastric distress
(b) Changes in hearing
(c) Red discoloration of body fluids
(d) Changes in color vision
Answer:
(d) Changes in color vision

Rationale:
An adverse reaction to Myambutol is changes in visual acuity or color vision. Answer (a) is incorrect because it does not relate to the medication. Answer (b) is incorrect because it is an adverse reaction to Streptomycin. Answer (c) is incorrect because it is a side effect of Rifampin.

Question 122. 
The primary cause of anemia in a client with chronic renal failure    is:        
(a) Poor iron absorption    
(b) Destruction of red blood cells    
(c) Lack of intrinsic factor    
(d) Insufficient erythropoietin    
Answer:
(d) Insufficient erythropoietin    

Rationale:
Insufficient erythropoietin production is the primary cause of anemia in the client with chronic renal failure. Answers (a), (b), and (c) do not relate to the anemia seen in clients with chronic renal failure; therefore, they are incorrect.

Question 123.
Which ity for of the following nursing interventions has the highest prior the client scheduled for an intravenous pyelogram?    
(a) Providing the client with a favorite meal for dinner    
(b) Asking if the client has allergies to shellfish    
(c) Encouraging fluids the evening before the test    
(d) Telling the client what to expect during the test
Answer:
(b) Asking if the client has allergies to shellfish    

Rationale:
The nurse’s highest priority should be asking the client about allergies to shellfish and iodine. The contrast media used during an intravenous pyelo- gram contains iodine, which can result in an anaphylactic reaction. Answers (a), (c), and (d) do not relate specifically to the test; therefore, they are incorrect

Question 124.    
A client has ataxia following a cerebral vascular accident. The  nurse should:    
(a) Supervise the client’s ambulation.
(b) Measure the client’s intake and output.
(c) Request a consult for speech therapy.
(d) Provide the client with a magic slate.
Answer:
(a) Supervise the client’s ambulation.

Rationale:
Ataxia affects the client’s mobility, making falls more likely. Answers (b), (c), and (d) are incorrect because they do not relate to the problem of ataxia.

Question 125.    
The doctor has prescribed aspirin 325mg daily for a client with    transient ischemic attacks. The nurse explains that aspirin was prescribed to:
(a) Prevent headaches
(b) Boost coagulation
(c) Prevent cerebral anoxia
(d) Decrease platelet aggregation
Answer:
(d) Decrease platelet aggregation

Rationale:
Aspirin decreases platelet aggregation or clumping, thereby preventing clots. Answer (a) is incorrect because the low-dose aspirin will not prevent headaches. Answers (b) and (c) are untrue statements; therefore, they are incorrect.

Question 126.    
The nurse is preparing to administer regular insulin by continuous IV infusion to a client with diabetic ketoacidosis. The nurse should:
(a) Mix the insulin with Dextrose 5% in water.
(b) Flush the IV tubing with the insulin solution and discard the first 50mL.
(c) Avoid using a pump or controller with the infusion.
(d) Mix the insulin with Ringer’s lactate. 
Answer:
(b) Flush the IV tubing with the insulin solution and discard the first 50mL.

Rationale:
Insulin molecules adhere to glass and plastic; therefore, the IV set and entire tubing should be flushed and 50mL discarded before administering the infusion to the client. Answers (a) and (d) are incorrect because insulin is mixed using 0.9% or 0.45% normal saline. Answer (c) is incorrect because the infusion is given using a pump or controller.

Question 127.    
While reviewing the chart of a client with a history of hepatitis B, the nurse finds a serologic marker of HB8 AG. The nurse recognizes that the client:
(a) Has chronic hepatitis B 
(b) Has recovered from hepatitis B infection
(c) Has immunity to infection with hepatitis C
(d) Has no chance of spreading the infection to others
Answer:
(a) Has chronic hepatitis B 

Rationale:
A serologic marker of HB8 AG that is present six months after acute infection with hepatitis B indicates that the client is a carrier or has chronic hepatitis. Answer (b) is incorrect because the HB8 AG would normally decline and disappear. Answer (c) is incorrect because the client can still be infected with hepatitis c. Answer (d) is incorrect because the client is a carrier.

Question 128.    
A client with tuberculosis who has been on combined therapy with rifampin and isoniazid asks the nurse how long he will have to take medication. The nurse should tell the client that:
(a) Medication is rarely needed after two weeks.
(b) He will need to take medication the rest of his life.
(c) The course of therapy is usually six months.
(d) He will be re-evaluated in one month to see if further medication is needed.
Answer:
(c) The course of therapy is usually six months.

Rationale:
The usual course of treatment using combined therapy with isoniazid and rifampin is six months. Answers (a) and (d) are incorrect because the treatment time is too brief. Answer (b) is incorrect because the medication is not needed for life.

Question 129.    
Which developmental milestone puts the four-month-old infant at greatest risk for injury?
(a) Switching objects from one hand to another
(b) Crawling
(c) Standing
(d) Rolling over
Answer:
(d) Rolling over

Rationale:
At four months of age, the infant can roll over, which makes it vulnerable to falls from dressing tables or beds without rails. Answer (a) is incorrect because it does not prove a threat to safety. Answers (b) and (c) are incorrect choices because the four-month-old is not capable of crawling or standing.

Question 130.    
A newborn is diagnosed with congenital syphilis. Classic signs of congenital syphilis are:
(a) Red papular rash, desquamation, white strawberry tongue
(b) Rhinitis, maculopapular rash, hepatosplenomegaly
(c) Red edematous cheeks, maculopapular rash on the trunk and extremities
(d) Epicanthal folds, low-set ears, protruding tongue
Answer:
(b) Rhinitis, maculopapular rash, hepatosplenomegaly

Rationale:
Rhinitis, maculopapular rash, and hepatosplenomegaly are associated with congenital syphilis. Answer (a) is incorrect because it describes symptoms of scarlet fever. Answer (c) is incorrect because it describes symptoms of Fifth’s disease. Answer (d) is incorrect because it describes the symptoms of Down syndrome.

Question 131.    
Infants should be restrained in a car seat in a semi-reclined position facing the rear of the car until they weigh:
(a) 10 pounds
(b) 15 pounds
(c) 20 pounds
(d) 25 pounds
Answer:
(c) 20 pounds

Rationale:
It is recommended that infants up to 20 pounds be restrained in a car seat in a semi-reclining position facing the rear of the car. Answers (a) and (b) are incorrect because the child is young enough to require the rear-facing position. Answer (d) is incorrect because the child can be placed in an upright position in an approved safety seat facing forward.

Question 132.    
The nurse is caring for a client with irritable bowel syndrome. Irritable bowel syndrome is characterized by:
(a) Development of pouches in the wall of the intestine 
(b) Alternating bouts of constipation and diarrhea 
(c) Swelling, thickening, and abscess formation 
(d) Hypocalcemia and iron-deficiency anemia
Answer:
(b) Alternating bouts of constipation and diarrhea 

Rationale:
The client with irritable bowel syndrome has bouts of constipation and diarrhea. Answer (a) is incorrect because it describes changes associated with diverticulosis. Answer (c) is incorrect because it describes changes associated with Crohn’s disease. Answer (d) is incorrect because it describes findings associated with ulcerative colitis.

Question 133.    
A client taking Dilantin (phenytoin) for tonic-clonic seizures is preparing for discharge. Which information should be included in the client’s discharge care plan?
(a) The medication can cause dental staining.
(b) The client will need to avoid a high-carbohydrate diet. 
(c) The client will need a regularly scheduled blood work. 
(d) The medication can cause problems with drowsiness.
Answer:
(c) The client will need a regularly scheduled blood work. 

Rationale:
Adverse side effects of Dilantin include agranulocytosis and aplastic anemia; therefore, the client will need regularly scheduled blood work. Answer (a) is incorrect because the medication does not cause dental staining. Answer (b) is incorrect because the medication does not interfere with the metabolism of carbohydrates. Answer (d) is incorrect because the medication does not cause drowsiness.

Question 134.    
Assessment of a newborn male reveals that the infant has hypospadias. The nurse knows that:
(a) The infant should not be circumcised.
(b) Surgical correction will be done by six months of age. 
(c) Surgical correction is delayed until six years of age.
(d) The infant should be circumcised to facilitate voiding.
Answer:
(a) The infant should not be circumcised.

Rationale:
The infant with hypospadias should not be circumcised because the foreskin is used in reconstruction. Answers (b) and (c) are incorrect because surgical correction is done when the infant is 16 to 18 months of age. Answer (d) is incorrect because the infant with hypospadias should not be circumcised.

Question 135.    
The nurse is providing dietary teaching for a client with elevated cholesterol levels. Which cooking oil is not suggested for the client on a low-cholesterol diet?
(a) Safflower oil 
(b) Sunflower oil 
(c) Coconut oil 
(d) Canola oil
Answer:
(a) Safflower oil 
(b) Sunflower oil 
(d) Canola oil

Rationale:
Coconut oil is high in saturated fat and is not appropriate for the client on a low-cholesterol diet. Answers (a), (b), and (d) are incorrect because they are suggested for the client with elevated cholesterol levels.

Question 136.    
A client is hospitalized with signs of transplant rejection following a recent renal transplant. Assessment of the client would be expected to reveal:
(a) A weight loss of two pounds in one day 
(b) A serum creatinine 1.25mg/dL 
(c) Urinary output of 50mL/hr 
(d) Rising blood pressure 
Answer:
(d) Rising blood pressure 

Rationale:
Increased blood pressure following a renal transplant is an early sign of transplant failure. Answers (a), (b), and (c) are expected with successful renal transplant; therefore, they are incorrect.

Question 137.    
A client is admitted with a blood alcohol level of 180mg/dL. The nurse recognizes that the alcohol in the client’s system should be fully metabolized within:
(a) three hours
(b) five hours
(c) seven hours
(d) nine hours
Answer:
(d) nine hours

Rationale:
The time it takes for alcohol to be fully metabolized is calculated by dividing the blood alcohol level on admission by 20mg/dL (amount metabolized in an hour). Answers (a), (b), and (c) are incorrect because there has not been sufficient time for the alcohol to be fully metabolized.

Question 138.    
The nurse is caring for a client with stage III Alzheimer’s disease.
A characteristic of this stage is:
(a) Memory loss
(b) Failing to recognize familiar objects
(c) Wandering at night
(d) Failing to communicate
Answer:
(b) Failing to recognize familiar objects

Rationale:
In stage III of Alzheimer’s disease, the client develops agnosia, or failure to recognize familiar objects. Answer (a) is incorrect because it appears in stage I. Answer (c) is incorrect because it appears in stage II. Answer (d) is incorrect because it appears in stage IV.

Question 139.    
The doctor has prescribed Cortone (cortisone) for a client with systemic lupus erythematosis. Which instruction should be given to the client?
(a) Take the medication 30 minutes before eating.
(b) Report changes in appetite and weight.
(c) Wear sunglasses to prevent cataracts.
(d) Schedule a time to take the influenza vaccine.
Answer:
(d) Schedule a time to take the influenza vaccine.

Rationale:
The client taking steroid medication should receive an annual influenza vaccine. Answer (a) is incorrect because the medication should be taken with food. Answer (b) is incorrect because increased appetite and weight gain are expected side effects of the medication. Answer (c) is incorrect because wearing sunglasses will not prevent the development of cataracts in the client taking steroids.

Question 140.    
The nurse is caring for a client with an above-the-knee amputation (AKA). To prevent hip flexion contractures, the nurse should:
(a) Place the client in a prone position 15-30 minutes twice a day.
(b) Keep the foot of the bed elevated on shock blocks.
(c) Place trochanter rolls on either side of the affected leg.
(d) Keep the client’s leg elevated on two pillows.
Answer:
(a) Place the client in a prone position 15-30 minutes twice a day.

Rationale:
The client with an above-the-knee amputation should be placed in a prone position 15-30 minutes twice a day to prevent hip flexion contractures. Answers (b) and (d) are incorrect choices because elevation of the extremity one day post amputation promotes the development of contractures. Use of a trochanter roll will prevent rotation of the extremity but will not prevent contracture; therefore, answer (c) is incorrect.

Question 141.    
The mother of a six-month-old asks when her child will have all his baby teeth. The nurse knows that most children have all their primary teeth by age:
(a) 12 months
(b) 18 months
(c) 24 months
(d) 30 months
Answer:
(d) 30 months

Rationale:
All 20 primary, or deciduous, teeth should be present by age 30 months. Answers (a), (b), and (c) are incorrect because the ages are wrong.

Question 142.    
A client with an esophageal tamponade develops symptoms of respiratory distress, including inspiratory stridor. The nurse should give priority to:
(a) Applying oxygen at 4L via nasal cannula 
(b) Removing the tube after deflating the balloons 
(c) Elevating the head of the bed to 45°
(d) Increasing the pressure in the esophageal balloon
Answer:
(b) Removing the tube after deflating the balloons 

Rationale:
Displacement of the esophageal balloon is the most likely cause of respiratory distress in the client with an esophageal tamponade. The nurse should deflate both the gastric and esophageal balloons before removing the tube. Answers (a) and (c) are incorrect because applying nasal oxygen and elevating the head will not relieve airway obstruction. Answer D is incorrect because it would cause further obstruction of the airway.

Question 143.    
The nurse is assessing the heart sounds of a client with mitral stenosis following a history of rheumatic fever. To hear a mitral murmur, the nurse should place the stethoscope at:
(a) The third intercostal space right of the sternum 
(b) The third intercostal space left of the sternum 
(c) The fourth intercostal space beneath the sternum 
(d) The fourth intercostal space mid-clavicular line
Answer:
(d) The fourth intercostal space mid-clavicular line

Rationale:
The mitral valve is heard loudest at the fourth intercostal space midclavicular line, which is the apex of the heart. Answer (a) is incorrect because it is the location for the aortic valve. Answer (b) is incorrect because it is the location for the pulmonic valve. Answer (c) is wrong because it is the location for the tricuspid valve.

Question 144.    
While caring for a client with cervical cancer, the nurse notes that the radioactive implant is lying in the bed. The nurse should:
(a) Place the implant in a biohazard bag and return it to the lab.
(b) Give the client a pair of gloves and ask her to reinsert the implant.
(c) Use tongs to pick up the implant and return it to a lead-lined container.
(d) Discard the implant in the commode and double-flush.
Answer:
(c) Use tongs to pick up the implant and return it to a lead-lined container.

Rationale:
The radioactive implant should be picked up with tongs and returned to the lead-lined container. Answer (a) is incorrect because radioactive materials are placed in lead-lined containers, not plastic ones, and they are returned to the radiation department, not the lab. Answer (b) is incorrect because the client should not touch the implant or try to reinsert it. Answer (d) is incorrect because the implant should not be placed in the commode for disposal.

Question 145.    
The nurse is preparing to discharge a client following a laparoscopic cholecystectomy. The nurse should:
(a) Tell the client to avoid a tub bath for 48 hours.
(b) Tell the client to expect clay-colored stools.
(c) Tell the client that she can expect lower abdominal pain for the next week.
(d) Tell the client to report pain in the back or shoulders.
Answer:
(a) Tell the client to avoid a tub bath for 48 hours.

Rationale:
Following a laparoscopic cholecystectomy, the client should avoid a tub bath for 48 hours. Answer B(b)is incorrect because the stools should not be clay-colored. Answer (c) is incorrect because pain is usually in the shoulders. Answer (d) is incorrect because pain in the back and shoulders is expected following laparoscopic surgery.

Question 146.    
A high school student returns to school following a three-week absence due to mononucleosis. The school nurse knows it will be important for the client:
(a) To drink additional fluids throughout the day 
(b) To avoid contact sports for 1-2 months
(c) To have a snack twice a day to prevent hypoglycemia
(d) To continue antibiotic therapy for six months 
Answer:
(b) To avoid contact sports for 1-2 months

Rationale:
The client recovering from mononucleosis should avoid contact sports and other activities that could result in injury or rupture of the spleen. Answer (a) is incorrect because the client does not need additional fluids. Hypoglycemia is not associated with mononucleosis; therefore, answer (c) is incorrect. Answer (d) is incorrect because antibiotics are not usually indicated in the treatment of mononucleosis.

Question 147.    
An adolescent with cystic fibrosis has an order for pancreatic enzyme replacement. The nurse knows that the medication should be given:
(a) At bedtime 
(b) With meals and snacks 
(c) Twice daily 
(d) Daily in the morning
Answer:
(b) With meals and snacks 

Rationale:
Pancreatic enzyme replacement is given with meals and snacks. Answers (a), (c), and (d) do not specify a relationship to meals; therefore, they are incorrect.

Question 148.    
The doctor has prescribed a diet high in vitamin B₁₂ for a client with pernicious anemia. Which foods are good sources of B₁₂?
(a) Meat, eggs, dairy products
(b) Peanut butter, raisins, molasses 
(c) Broccoli, cauliflower, cabbage 
(d) Shrimp, legumes, bran cereals
Answer:
(a) Meat, eggs, dairy products

Rationale:
Meat, eggs, and dairy products are good sources of vitamin B₁₂. Answer (b) is incorrect because peanut butter, raisins, and molasses are good sources of iron. Answer (c) is incorrect because broccoli, cauliflower, and cabbage are good sources of vitamin K. Answer (d) is incorrect because shrimp, legumes, and bran cereals are good sources of magnesium.

Question 149.    
A client with hypertension has begun an aerobic exercise program. The nurse should tell the client that the recommended exercise regimen should begin slowly and build up to:
(a) 20-30 minutes three times a week 
(b) 45 minutes two times a week 
(c) one hour four times a week 
(d) one hour two times a week
Answer:
(a) 20-30 minutes three times a week 

Rationale:
The client’s aerobic workout should be 20-30 minutes long three times a week. Answers (b), (c), and (d) exceed the recommended time for the client beginning an aerobic program; therefore, they are incorrect.

Question 150.    
A home health nurse is visiting a client who is receiving diuretic therapy for congestive heart failure. Which medication places the client at risk for the development of hypokalemia?
(a) Aldactone (spironolactone)
(b) Demadex (torsemide)
(c) Dyrenium (triamterene)
(d) Midamor (amiloride hydrochloride)
Answer:
(b) Demadex (torsemide)

Rationale:
Demadex is a loop diuretic that depletes potassium. Answers (a), (c), and (d) are incorrect because they are potassium sparing diuretics.

Question 151.    
A client with breast cancer is returned to the room following a right total mastectomy. The nurse should:
(a) Elevate the client’s right arm on pillows.
(b) Place the client’s right arm in a dependent sling.
(c) Keep the client’s right arm on the bed beside her. 
(d) Place the client’s right arm across her body. 
Answer:
(a) Elevate the client’s right arm on pillows.

Rationale:
Following a total mastectomy, the client’s right arm should be elevated on pillows to facilitate lymph drainage. Answers (b), (c), and (d) are incorrect because they would not help facilitate lymph drainage and would create increased edema in the affected extremity.

Question 152.    
The physician has ordered nitroglycerin buccal tablets for a client with stable angina. The nurse knows that nitroglycerin
(a) Slows contractions of the heart
(b) Dilates coronary blood vessels
(c) Increases the ventricular fill time
(d) Strengthens contractions of the heart
Answer:
(b) Dilates coronary blood vessels

Rationale:
Nitroglycerin is used to dilate coronary blood vessels, which provides improved circulation to the myocardium. Answers (a), (c), and (d) describe the effects of digoxin, not nitroglycerin; therefore, they are incorrect.

Question 153.
A trauma client is admitted to the emergency room following a motor vehicle accident. Examination reveals that the left side of the chest moves inward when the client inhales. The finding is suggestive of:
(a) Pneumothorax
(b) Mediastinal shift
(c) Pulmonary contusion
(d) Flail chest
Answer:
(d) Flail chest

Rationale:
The client with flail chest will exhibit paradoxical respirations. (With inspiration, the affected side will move inward; with expiration, the affected side will move outward. Flail chest is frequently associated with high-speed motor vehicle accidents.) Answer (a) is incorrect because air or blood would be present in the thoracic cavity. Answer (b) is incorrect because the trachea would be shifted to the affected side. Answer (c) is incorrect because interstitial edema would be present.

Question 154.    
A neurological consult has been ordered for a pediatric client with suspected absence seizures. The client with absence seizures can be expected to have:
(a) Short, abrupt muscle contractions 
(b) Quick, severe bilateral jerking movements 
(c) Abrupt loss of muscle tone 
(d) Brief lapse in consciousness
Answer:
(d) Brief lapse in consciousness

Rationale:
Absence seizures, formerly known as petit mal seizures, are characterized by brief lapses in consciousness accompanied by rapid eye blinking, lip smacking, and minor myoclonus of the upper extremities. Answer (a) refers to myoclonic seizures; therefore, it is incorrect. Answer (b) refers to tonic clonic seizures, formerly known as grand mal seizures; therefore, it is incorrect. Answer (c) refers to atonic seizures; therefore, it is incorrect.

Question 155.    
To decrease the likelihood of seizures and visual hallucinations in a client with alcohol withdrawal, the nurse should:
(a) Keep the room darkened by pulling the curtains.
(b) Keep the light over the bed on at all times.
(c) Keep the room quiet and dim the lights.
(d) Keep the television or radio turned on.
Answer:
(c) Keep the room quiet and dim the lights.

Rationale:
Keeping the room quiet and the lights dimmed will decrease sensory stimulation and help keep the client oriented during withdrawal from alcohol. Answer (a) is incorrect because darkness would increase confusion and disorientation in the client during withdrawal. Answers (b) and (d) are incorrect because they can contribute to the development of seizures.

Question 156.    
A client with schizoaffective disorder is exhibiting Parkinsonian symptoms. Which medication is responsible for the development of Parkinsonian symptoms?
(a) Zyprexa (olanzapine)
(b) Cogentin (benzatropine mesylate)
(c) Benadryl (diphenhydramine)
(d) Depakote (divalproex sodium)
Answer:
(a) Zyprexa (olanzapine)

Rationale:
A side effect of antipsychotic medication is the development of Parkinsonian symptoms. Answers (b) and (c) are incorrect choices because they are used to reverse Parkinsonian symptoms in the client taking antipsychotic medication. Answer (d) is incorrect because the medication is an anticonvulsant used to stabilize mood. Parkinsonian symptoms are not associated with anticonvulsant medication.

Question 157.    
Which activity is best suited to the 12-year-old with juvenile rheumatoid arthritis?
(a) Playing video games
(b) Swimming
(c) Working crossword puzzles
(d) Playing slow-pitch softball
Answer:
(b) Swimming

Rationale:
Exercises, such as swimming, that provide light passive resist¬ance are best for the child with juvenile rheumatoid arthritis. Answers (a) and (c) require movement of the hands and fingers that could be too painful for the child with juvenile rheumatoid arthritis; therefore, they are incorrect. Answer (d) is incorrect because it requires the use of larger joints affected by the disease.

Question 158.    
The home health nurse is scheduled to visit four clients. Which client should she visit first?
(a) A client with acquired immunodeficiency syndrome with a cough and reported temperature of 101 °F
(b) A client with peripheral vascular disease with an ulcer on the left lower leg
(c) A client with diabetes mellitus who needs a diabetic control index drawn
(d) A client with an autograft to burns of the chest and trunk
Answer:
(a) A client with acquired immunodeficiency syndrome with a cough and reported temperature of 101 °F

Rationale:
Reports of cough and fever in the client with AIDS suggest infection with pneumocystis carinii, which requires immediate intervention. Answers (b), (c), and (d) have conditions with more predictable outcomes; therefore, they are incorrect.

Question 159.    
The glycosylated hemoglobin of a 40-year-old client with diabetes mellitus is 2.5%. The nurse understands that:
(a) The client can have a higher-calorie diet.
(b) The client has good control of her diabetes.
(c) The client requires adjustment in her insulin dose.
(d) The client has poor control of her diabetes.
Answer:
(b) The client has good control of her diabetes.

Rationale:
The client’s diabetes is well under control. Answer (a) is incorrect because it will lead to elevated glucose levels. Answer (c) is incorrect because the diet and insulin dose are appropriate for the client. Answer (d) is incorrect because the desired range for glycosylated hemoglobin in the adult client is 2.5%-5.9%. 

Question 160.    
A dexamethasone-suppression test has been ordered for a client with severe depression. The purpose of the dexamethasone suppression test is to:
(a) Determine which social intervention will be best for the client
(b) Help diagnose the seriousness of the client's clinical symptoms
(c) Determine whether the client will benefit from electroconvulsive therapy
(d) Reverse the depressive symptoms the client is experiencing 
Answer:
(c) Determine whether the client will benefit from electroconvulsive therapy

Rationale:
The purpose of the dexamethasone-suppression test is to identify clients who will benefit from therapy with antidepressants and electroconvulsive therapy rather than psychological or social interventions. Answers (a), (b), and (d) contain inaccurate statements; therefore, they are incorrect.

Question 161.    
The physician has ordered Stadol (butorphanol) fora post-operative client. The nurse knows that the medication is having its intended effect if the client:
(a) Is asleep 30 minutes after the injection 
(b) Asks for extra servings on his meal tray 
(c) Has an increased urinary output 
(d) States that he is feeling less nauseated
Answer:
(a) Is asleep 30 minutes after the injection 

Rationale:
Stadol reduces the perception of pain, which allows the postoperative client to rest. Answers (b) and (c) are not affected by the medication; therefore, they are incorrect. Relief of pain generally results in less nausea, but it is not the intended effect of the medication; therefore, answer (d) is incorrect.

Question 162.    
The mother of a child with cystic fibrosis tells the nurse that her child makes “snoring” sounds when breathing. The nurse is aware that many children with cystic fibrosis have:
(a) Choanal atresia
(b) Nasal polyps
(c) Septal deviations
(d) Enlarged adenoids
Answer:
(b) Nasal polyps

Rationale:
Children with cystic fibrosis are susceptible to chronic sinusitis and nasal polyps, which might require surgical removal. Answer (a) is incorrect because it is a congenital condition in which there is a bony obstruction between the nares and the pharynx. Answers (c) and (d) are not specific to the child with cystic fibrosis; therefore, they are incorrect.

Question 163.
The nurse is caring for a client with full thickness burns to the lower half of the torso and lower extremities. During the emergent phase of injury, the primary nursing diagnosis would focus on:
(a) Imbalanced nutrition less than body requirements related to hypermetabolic state
(b) Risk for infection related to altered skin integrity
(c) Risk for fluid volume imbalance related to intracom- partmental fluid shift
(d) Acute pain related to burn injury
Answer:
(c) Risk for fluid volume imbalance related to intracom- partmental fluid shift

Rationale:
During the emergent phase, the nursing priority for a client with burns confined to the lower body would focus on the risk for fluid volume imbalance. Answers (a), (b), and (d) are incorrect because they do not take priority over the risk for fluid volume imbalance or hypovolemia during the emergent phase.

Question 164.
A client is hospitalized with hepatitis A. Which of the client’s regu¬lar medications is contraindicated due to the current illness?
(a) Prilosec (omeprazole)
(b) Synthroid (levothyroxine)
(c) Premarin (conjugated estrogens)
(d) Lipitor (atorvastatin)
Answer:
(d) Lipitor (atorvastatin)

Rationale:
Lipid-lowering agents are contraindicated in the client with active liver disease. Answers (a), (b), and (c) are incorrect because they are not contraindicated in the client with active liver disease. 

Question 165.    
Which activity is suitable for a client who suffered an uncomplicated myocardial infarction (Ml) two days ago?
(a) Sitting in the bedside chair for 15 minutes three times a day
(b) Remaining on strict bed rest with bedside commode privileges
(c) Ambulating in the room and hall as tolerated
(d) Sitting on the bedside for five minutes three times a day with assistance 
Answer:
(d) Sitting on the bedside for five minutes three times a day with assistance 

Rationale:
An appropriate activity for the client who has recently had an Ml is sitting on the side of the bed for five minutes three times a day with assistance. Answers (a) and (c) are incorrect because they increase the workload on the heart too soon after the Ml. Answer (b) is incorrect because it does not allow the client enough activity.

Question 166.    
The nurse has been teaching the role of diet in regulating blood pressure to a client with hypertension. Which meal selection indicates the client understands his new diet?
(a) Cornflakes, whole milk, banana, and coffee 
(b) Scrambled eggs, bacon, toast, and coffee 
(c) Oatmeal, apple juice, dry toast, and coffee 
(d) Pancakes, ham, tomato juice, and coffee
Answer:
(c) Oatmeal, apple juice, dry toast, and coffee 

Rationale:
The client with hypertension should be placed on a low sodium, low cholesterol, high fiber diet. Oatmeal is low in sodium and high in fiber. Answer (a) is incorrect because cornflakes and whole milk are higher in sodium and are poor sources of fiber. Answers (b) and (d) are incorrect choices because they contain animal proteins that are high in both cholesterol and sodium.

Question 167.    
An 18-month-old is being discharged following hypospadias repair. Which instruction should be included in the nurse’s discharge teaching?
(a) The child should not play on his rocking horse.
(b) Applying warm compresses will decrease pain.
(c) Diapering should be avoided for 1-2 weeks.
(d) The child will need a special diet to promote healing.
Answer:
(a) The child should not play on his rocking horse.

Rationale:
Following hypospadias repair, the child will need to avoid straddle toys, such as a rocking horse, until allowed by the surgeon. Answers (b), (c), and (d) do not relate to the post-operative care of the child with hypospadias; therefore, they are incorrect.

Question 168.    
An obstetrical client calls the clinic with complaints of morning sickness. The nurse should tell the client to:
(a) Keep crackers at the bedside for eating before she arises
(b) Drink a glass of whole milk before going to sleep at night
(c) Skip breakfast but eat a larger lunch and dinner
(d) Drink a glass of orange juice after adding a couple of teaspoons of sugar
Answer:
(a) Keep crackers at the bedside for eating before she arises

Rationale:
Eating carbohydrates such as dry crackers or toast before arising helps to alleviate morning sickness. Answer (b) is incorrect because the additional fat might increase the client’s nausea. Answer (c) is incorrect because the client does not need to skip meals. Answer (d) is the treatment of hypoglycemia, not morning sickness; therefore, it is incorrect

Question 169.    
The nurse is making assignments for the day. The staff consists of an RN, a novice RN, an LPN, and a nursing assistant. Which client should be assigned to the RN?
(a) A client with peptic ulcer disease 
(b) A client with skeletal traction for a fractured femur 
(c) A client with an abdominal cholecystectomy 
(d) A client with an esophageal tamponade
Answer:
(d) A client with an esophageal tamponade

Rationale:
An esophageal tamponade is used to control bleeding in the client with esophageal varices. Answers (a), (b), and (c) are incorrect because they can be assigned to either the novice RI/l or the LPN with assisted care by the nursing assistant.

Question 170.    
A child with Tetralogy of Fallot is scheduled for a modified Blalock Taussig procedure. The nurse understands that the surgery will:
(a) Reverse the direction of the blood flow 
(b) Allow better blood supply to the lungs 
(c) Relieve pressure on the ventricles 
(d) Prevent the need for further correction 
Answer:
(b) Allow better blood supply to the lungs 

Rationale:
The modified Blalock Taussig procedure is a palliative procedure in which the subclavian artery is joined to the pulmonary artery, thus allowing more blood to reach the lungs. Answers (a), (c), and (d) contain inaccurate statements: therefore, they are incorrect. 

Question 171.    
The nurse has taken the blood pressure of a client hospitalized with methicillin-resistant staphylococcus aureus (MRSA). Which action by the nurse indicates an understanding regarding the care of clients with MRSA?
(a) The nurse leaves the stethoscope in the client's room for future use.
(b) The nurse cleans the stethoscope with alcohol and returns it to the exam room.
(c) The nurse uses the stethoscope to assess the blood pressure of other assigned clients.
(d) The nurse cleans the stethoscope with water, dries it, and returns it to the nurse’s station.
Answer:
(a) The nurse leaves the stethoscope in the client's room for future use.

Rationale:
The stethoscope should be left in the client’s room for future use. The stethoscope should not be returned to the exam room or the nurse’s station; therefore, answers (b) and (d) are incorrect. The stethoscope should not be used to assess other clients; therefore, answer (c) is incorrect.

Question 172.    
The physician has discussed the need for medication with the parents of an infant with congenital hypothyroidism. The nurse can reinforce the physician’s teaching by telling the parents that:
(a) The medication will be needed only during times of rapid growth.
(b) The medication will be needed throughout the child’s lifetime.
(c) The medication schedule can be arranged to allow for drug holidays.
(d) The medication is given one time daily every other day.
Answer:
(b) The medication will be needed throughout the child’s lifetime.

Rationale:
The medication will be needed throughout the child’s lifetime. Answers (a), (c), and (d) contain inaccurate statements; therefore, they are incorrect.

Question 173.    
A client with diabetes mellitus has a prescription for Glucotrol XL (glipizide). The client should be instructed to take the medication:
(a) At bedtime
(b) With breakfast
(c) Before lunch
(d) After dinner
Answer:
(b) With breakfast

Rationale:
Glucotrol XL is given once a day with breakfast. Answer (a) is incorrect because the client would develop hypoglycemia while sleeping. Answers (c) and (d) are incorrect choices because the client would develop hypoglycemia later in the day or evening.

Question 174.    
The nurse is caring for a client admitted with suspected myasthenia gravis. Which finding is usually associated with a diagnosis of myasthenia gravis?
(a) Visual disturbances, including diplopia 
(b) Ascending paralysis and loss of motor function
(c) Cogwheel rigidity and    loss    of    coordination
(d) Progressive weakness that is worse at the day’s end 
Answer:
(d) Progressive weakness that is worse at the day’s end 

Rationale:
The client with myasthenia develops progressive weakness that worsens during the day. Answer (a) is incorrect because it refers to symptoms of multiple sclerosis. Answer (b) is incorrect because it refers to symptoms of Guillain Barre syndrome. Answer (c) is incorrect because it refers to Parkinson’s disease.

Question 175.    
A preterm infant with sepsis is receiving Gentamycin (garamycin). Which physiological alteration places the preterm infant at increased risk for toxicity related to aminoglycoside therapy?
(a) Lack of subcutaneous fat deposits 
(b) Immature central nervous system 
(c) Presence of fetal hemoglobin 
(d) Immaturity of the renal system
Answer:
(d) Immaturity of the renal system

Rationale:
Immaturity of the kidneys places the preterm infant at greater risk for toxicity to aminoglycosides. Answers (a), (b), and (c) are true regarding the preterm infant, but they do not increase the risk for toxicity to the drug; therefore, they are incorrect.

Question 176.    
The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should tell the parents:
(a) That the infant will need daily calcium supplements
(b) That it is best to lift the infant by the buttocks when diapering
(c) That the condition is a temporary one
(d) That only the bones of the infant are affected by the disease
Answer:
(b) That it is best to lift the infant by the buttocks when diapering

Rationale:
To prevent fractures, the parents should lift the infant by the buttocks rather than the ankles when diapering. Answer (a) is incorrect because infants with osteogenesis imperfecta have normal calcium and phosphorus levels. Answer (c) is incorrect because the condition is not temporary. Answer (d) is incorrect because the teeth and the sclera are also affected.

Question 177.    
The home health nurse is visiting an elderly client following a hip replacement. Which finding requires further teaching?
(a) The client shares her apartment with a cat.
(b) The client has a grab bar near the commode.
(c) The client usually sits on a soft, low sofa.
(d) The client wears supportive shoes with nonskid soles.
Answer:
(c) The client usually sits on a soft, low sofa.

Rationale:
Following a hip replacement, the client should avoid hip flexion. Sitting on a soft, low sofa permits hip flexion and increases the difficulty of standing. Having a pet is important to the client’s emotional well-being; therefore, answer (a) is incorrect. Answers (b) and (d) indicate that the nurse’s teaching has been effective; therefore, they are incorrect

Question 178.    
Physician’s orders for a client with acute pancreatitis include the following: strict NPO and nasogastric tube to low intermittent suction. The nurse recognizes that withholding oral intake will:
(a) Reduce the secretion of pancreatic enzymes 
(b) Decrease the client’s need for insulin 
(c) Prevent the secretion of gastric acid 
(d) Eliminate the need for pain medication
Answer:
(a) Reduce the secretion of pancreatic enzymes 

Rationale:
Withholding oral intake will help stop the inflammatory process by reducing the secretion of pancreatic enzymes. Answer (b) is incorrect because the client requires exogenous insulin. Answer (c) is incorrect because it does not prevent the secretion of gastric acid. Answer (d) is incorrect because it does not eliminate the need for pain medication.

Question 179.    
A client with diverticulitis is admitted with nausea, vomiting, and dehydration. Which finding suggests a complication of diverticulitis?
(a) Pain in the left lower quadrant
(b) Boardlike abdomen
(c) Low-grade fever
(d) Abdominal distention 
Answer:
(b) Boardlike abdomen

Rationale:
A rigid or boardlike abdomen is suggestive of peritonitis, which is a complication of diverticulitis. Answers (a), (c), and (d) are common findings in diverticulitis; therefore, they are incorrect.

Question 180.    
The physician has ordered Vancocin (vancomycin) 500mg IV every six hours for a client with MRSA. The medication should be administered:
(a) IV push
(b) Over 15 minutes
(c) Over 30 minutes
(d) Over 60 minutes
Answer:
(d) Over 60 minutes

Rationale:
Vancomycin should be administered slowly to prevent “redman” syndrome. Answer (a) is incorrect because the medication is not given IV push. Answers (b) and (c) are incorrect choices because they allow the medication to be given too rapidly.

Question 181.    
The diagnostic work-up of a client hospitalized with complaints of progressive weakness and fatigue confirm a diagnosis of myasthenia gravis. The medication used to treat myasthenia gravis is:
(a) Prostigmine (neostigmine)
(b) Atropine (atropine sulfate)
(c) Didronel (etidronate)
(d) Tensilon (edrophonium)
Answer:
(a) Prostigmine (neostigmine)

Rationale:
Prostigmine (neostigmine) is used to treat clients with myasthenia gravis. Answer (b) is incorrect because it is used to reverse the effects of neostigmine. Answer (c) is incorrect because the drug is unrelated to the treatment of myasthenia gravis. Answer (d) is incorrect because it is the test for myasthenia gravis.

Question 182.    
A client with AIDS complains of a weight loss of 20 pounds in the past month. Which diet is suggested for the client with AIDS?
(a) High calorie, high protein, high fat 
(b) High calorie, high carbohydrate, low protein 
(c) High calorie, low carbohydrate, high fat 
(d) High calorie, high protein, low fat
Answer:
(d) High calorie, high protein, low fat

Rationale:
The suggested diet for the client with AIDS is one that is high calorie, high protein, and low fat. Clients with AIDS have a reduced tolerance to fat because of the disease, as well as side effects from some antiviral medications; therefore, answers (a) and (c) are incorrect. Answer (b) is incorrect because the client needs a high-protein diet.

Question 183.    
The nurse is caring for a four-year-old with cerebral palsy. Which nursing intervention will help ready the child for rehabilitative services?
(a) Patching one of the eyes to help strengthen the ocular muscles
(b) Providing suckers and pinwheels to help strengthen tongue movement
(c) Providing musical tapes to provide auditory training
(d) Encouraging play with a video game to improve mus-cle coordination
Answer:
(b) Providing suckers and pinwheels to help strengthen tongue movement

Rationale:
The nurse can help ready the child with cerebral palsy for speech therapy by providing activities that help the child develop tongue control. Most children with cerebral palsy have visual and auditory difficulties that require glasses or hearing devices rather than rehabilitative training; therefore, answers (a) and (c) are incorrect. Answer (d) is incorrect because video games are not appropriate to the age or developmental level for the child with cerebral palsy.

Question 184.    
A client is admitted with a diagnosis of duodenal ulcer. A common complaint of the client with a duodenal ulcer is:
(a) Epigastric pain that is relieved by eating 
(b) Weight loss
(c) Epigastric pain that is worse after eating 
(d) Vomiting after eating 
Answer:
(a) Epigastric pain that is relieved by eating 

Rationale:
The client with duodenal ulcers commonly complains of epigastric pain that is relieved by eating a meal or snack. Answer (b) is incorrect because the client with a duodenal ulcer frequently reports weight gain. Answers (c) and (d) are incorrect because they describe symptoms associated with gastric ulcers.

Question 185.    
A client with otosclerosis is scheduled for a stapedectomy. Which finding suggests a complication involving the seventh cranial nerve?
(a) Diminished hearing 
(b) Sensation of fullness in the ear 
(c) Inability to move the tongue side to side 
(d) Changes in facial sensation
Answer:
(d) Changes in facial sensation

Rationale:
Complications following a stapedectomy include damage to the seventh cranial nerve that results in changes in taste or facial sensation. Answers (a) and (b) are incorrect because they are expected immediately following a stapedectomy. Answer (c) is incorrect because it involves the twelfth cranial nerve (hypoglossal nerve).

Question 186.    
At the six-week check-up, the mother asks when she can expect the baby to sleep all night. The nurse should tell the mother that most infants begin to sleep all night by age:
(a) one month 
(b) two months 
(c) 3-4 months 
(d) 5-6 months
Answer:
(c) 3-4 months 

Rationale:
Most infants begin nocturnal sleep lasting 9-11 hours by 3-4 months of age. Answers (a) and (b) are incorrect because the infant is still waking for nighttime feedings. Answer (d) is incorrect because most infants begin nocturnal sleep by three to four months of age.

Question 187.    
A client with emphysema has been receiving oxygen at 3L per minute by nasal cannula. The nurse knows that the goal of the client’s oxygen therapy is achieved when the client’s Pa02 reading is:
(a) 50-60mm Hg 
(b) 70-80mm Hg 
(c) 80-90mm Hg 
(d) 90-98mm Hg
Answer:
(a) 50-60mm Hg 

Rationale:
The goal of oxygen therapy for the client with emphysema is maintaining a Pa02 of 50 to 60mmHg. Answers (b), (c), and (d) are incorrect because the Pa02 levels are too high.

Question 188.    
A client with diabetes insipidus is receiving DDAVP (desmopressin acetate). Which lab finding indicates that the medication is having its intended effect?
(a) Blood glucose 92mg/dL
(b) Urine specific gravity 1.020
(c) White blood count of 7,500
(d) Glycosylated hemoglobin 3.5mg/dL
Answer:
(b) Urine specific gravity 1.020

Rationale:
The medication is having its intended effect when the client’s urine specific gravity is within the normal range. Answers (a) and (d) refer to the client with diabetes mellitus not diabetes insipidus; therefore, they are incorrect. Answer (c) is incorrect because it is not related to diabetes insipidus.

Question 189.
Which of the following pediatric clients is at gre allergy?
(a) The child with a myelomeningocele
(b) The child with epispadias
(c) The child with coxa plana
(d) The child with rheumatic fever
Answer:
(a) The child with a myelomeningocele

Rationale:
The child with myelomeningocele is at greatest risk for the development of latex allergy because of repeated exposure to latex products during surgery and from numerous urinary catheterizations. The clients in answers (b), (c), and (d) are much less likely to be exposed to latex; therefore, they are incorrect.

Question 190. 
The physician has ordered a serum aminophylline level for a client with chronic obstructive lung disease. The nurse knows that the therapeutic range for aminophylline is: 
(a) 1-3 micrograms/mL
(b) 4-6 micrograms/mL
(c) 7-9 micrograms/mL
(d) 10-20 micrograms/mL
Answer:
(d) 10-20 micrograms/mL

Rationale:
The therapeutic range for aminophylline is 10-20 micrograms/mL. Answers (a), (b), and (c) are incorrect because they are too low to be therapeutic

Question 191.
The nurse is developing a plan of care for a client with acromegaly. Which nursing diagnosis should receive priority?
(a) Alteration in body image related to change in facial features
(b) Risk for immobility related to joint pain
(c) Risk for ineffective airway clearance related to obstruction of airway by tongue
(d) Sexual dysfunction related to altered hormone secretion
Answer:
(c) Risk for ineffective airway clearance related to obstruction of airway by tongue

Rationale:
The priority nursing diagnosis for a client with acromegaly focuses on the risk for ineffective airway clearance. Answers (a), (b), and (d) apply to the client with acromegaly but do not take priority; therefore, they are incorrect.

Question 192.    
A client with acute respiratory distress syndrome (ARDS) is placed on mechanical ventilation. To increase ventilation and perfusion to all areas of the lungs, the nurse should:
(a) Tell the client to inhale deeply during the inspiratory cycle.
(b) Increase the positive end expiratory pressure (PEEP). 
(c) Turn the client every hour.
(d) Administer medication to prevent the client from fight-ing the ventilator.
Answer:
(c) Turn the client every hour.

Rationale:
The nurse can help increase ventilation and perfusion to all areas of the lungs by turning the client every hour. Rocking beds can also be used to keep the client in constant motion. Answer (a) is incorrect because the client with ARDS will have respirations controlled by the ventilator. Answer (b) is incorrect because the nurse must have a physician’s order to increase the PEEP. Answer (d) is incorrect because it will not increase ventilation and perfusion.

Question 193.    
The nurse is teaching the mother of a child with cystic fibrosis how to do chest percussion. The nurse should tell the mother to:
(a) Use the heel of her hand during percussion.
(b) Change the child’s position every 20 minutes during percussion sessions.
(c) Do percussion after the child eats and at bedtime.
(d) Use cupped hands during percussion.
Answer:
(d) Use cupped hands during percussion.

Rationale:
The nurse or parent should use a cupped hand when performing chest percussion. Answer (a) is incorrect because the hand should be cupped. Answer (b) is incorrect because the child’s position should be changed every 5-10 minutes, and the whole session should be limited to 20 minutes. Answer (c) is incorrect because chest percussion should be done before meals.

Question 194.    
A client with Addison’s disease asks the nurse what he needs to know to manage his condition. The nurse should give priority to:
(a) Emphasizing the need for strict adherence to his medication regimen
(b) Teaching the client to avoid lotions and skin preparations containing alcohol
(c) Explaining the need to avoid extremes of temperature
(d) Assisting the client to choose a diet that contains adequate protein, fat, and carbohydrates
Answer:
(a) Emphasizing the need for strict adherence to his medication regimen

Rationale:
The client with Addison’s disease requires lifetime management with steroids. The nurse should stress the importance of taking the medication exactly as directed by the physician, as well as reporting adverse reactions to the medication. The client should be cautioned not to skip doses or to abruptly discontinue the medication. Answers (b), (c), and (d) should be included in the client’s teaching but do not pose life-threatening consequences; therefore, they are incorrect.

Question 195.    
The nurse is caring for a client following the removal of a central line catheter when the client suddenly develops dyspnea and complains of substernal chest pain. The client is noticeably confused and fearful. Based on the client’s symptoms, the nurse should suspect which complication of central line use?
(a) Myocardial infarction
(b) Air embolus
(c) Intrathoracic bleeding
(d) Vagal response
Answer:
(b) Air embolus

Rationale:
Air embolus can occur with insertion, maintenance, and removal of central line catheters. The client’s history of recent removal of a central line and the development of dyspnea, substernal chest pain, confusion, and fear suggest an air embolus. Answer (a) is incorrect because it is not associated with central line use. Answer (c) is incorrect because the symptoms do not suggest bleeding. Answer (d) is incorrect because it is not a complication of central line use.

Question 196.    
The nurse calculates the amount of an antibiotic for injection to be given to an infant. The amount of medication to be administered is 1.25mL. The nurse should:
(a) Divide the amount into two injections and administer in each vastus lateralis muscle.
(b) Give the medication in one injection in the dorsog- luteal muscle.
(c) Divide the amount in two injections and give one in the ventrogluteal muscle and one in the vastus lateralis muscle.
(d) Give the medication in one injection in the ventrog-luteal muscle.
Answer:
(a) Divide the amount into two injections and administer in each vastus lateralis muscle.

Rationale:
No more than 1mL should be given in the vastus lateralis of the infant. Answers (b), (c), and (d) are incorrect because the dorsogluteal and ventrogluteal muscles are not used for injections in the infant.

Question 197.    
A client with schizophrenia is receiving depot injections of Haldol Decanoate (haloperidol decanoate). The client should be told to return for his next injection in:
(a) one week
(b) two weeks
(c) four weeks
(d) six weeks 
Answer:
(c) four weeks

Rationale:
Depot injections of Haldol are administered every four weeks. Answers (a) and (b) are incorrect because the medication is still in the client’s system. Answer (d) is incorrect because the medication has been eliminated from the client’s system, which allows the symptoms of schizophrenia to return.

Question 198.    
The physician is preparing to remove a central line. The nurse should tell the client to:
(a) Breathe normally
(b) Take slow, deep breaths
(c) Take a deep breath and hold it
(d) Breathe as quickly as possible
Answer:
(c) Take a deep breath and hold it

Rationale:
The client should take a deep breath and hold it (Valsalva maneuver) when the central line is being removed. This increases the intrathoracic pressure and decreases the likelihood of having an air embolus. Answers (a) and (b) do not increase intrathoracic pressure; therefore, they are incorrect for the situation. Answer (d) increases the likelihood of air embolus; therefore, it is incorrect.

Question 199.    
Cystic fibrosis is an exocrine disorder that affects several systems of the body. The earliest sign associated with a diagnosis of cystic fibrosis is:
(a) Steatorrhea
(b) Frequent respiratory infections
(c) Increased sweating
(d) Meconium ileus
Answer:
(d) Meconium ileus

Rationale:
The earliest sign of cystic fibrosis is meconium ileus, which may be present in the newborn with the disease. Answers (a), (b), and (c) are later manifestations; therefore, they are incorrect.

Question 200.    
A three-year-old is immobilized in a hip spica cast. Which discharge instruction should be given to the parents?
(a) Keep the bed flat, with a small pillow beneath the cast. 
(b) Provide crayons and a coloring book for play activity. 
(c) Increase her intake of high-calorie foods for healing.
(d) Tuck a disposable diaper beneath the cast at the per-ineal opening.
Answer:
(d) Tuck a disposable diaper beneath the cast at the per-ineal opening.

Rationale:
Tucking a disposable diaper at the perineal opening will help prevent soiling of the cast by urine and stool. Answer (a) is incorrect because the head of the bed should be elevated. Answer (b) is incorrect because the child can place the crayons beneath the cast, causing pressure areas to develop. Answer (c) is incorrect because the child does not need high-calorie foods that would cause weight gain while she is immobilized by the cast.

Question 201.    
The nurse is caring for a client following the reimplantation of the thumb and index finger. Which finding should be reported to the physician immediately?
(a) Temperature of 100°F 
(b) Coolness and discoloration of the digits 
(c) Complaints of pain 
(d) Difficulty moving the digits
Answer:
(b) Coolness and discoloration of the digits 

Rationale:
Coolness and discoloration of the reimplanted digits indicates compromised circulation, which should be reported immediately to the physician. The temperature should be monitored, but the client would receive antibiotics to prevent infection; therefore, answer (a) is incorrect. Answers (c) and (d) are expected following amputation and reimplantation; therefore, they are incorrect.

Question 202.    
Which client is at greatest risk for a Caesarean section due to cephalopelvic disproportion (CPD)?
(a) A 25-year-old gravida 2, para 1
(b) A 30-year-old gravida 3, para 2
(c) A 17-year-old gravida 1, para 0
(d) A 32-year-old gravida 1, para 0 
Answer:
(c) A 17-year-old gravida 1, para 0

Rationale:
The obstetrical client under age 18 is at greatest risk for CPD because pelvic growth is not fully completed. Answers (a), (b), and (d) are incorrect because these clients are not as likely to have CPD.

Question 203.    
The nurse is caring for a client with amyotrophic lateral sclerosis (ALS, Lou Gehrig’s disease). The nurse should give priority to:
(a) Assessing the client’s respiratory status
(b) Providing an alternate means of communication
(c) Referring the client and family to community support groups
(d) Instituting a routine of active range-of-motion exercises
Answer:
(a) Assessing the client’s respiratory status

Rationale:
Priority of care should focus on maintaining the client's airway. Answers (b) and (c) are important to the client’s care, but they do not take priority over maintaining the client’s airway; therefore, they are incorrect. Answer (d) is incorrect because the client will require a passive range of motion exercise.

Question 204.    
The physician has ordered Claforan (cefotaxime) 1g every six hours. The pharmacy sends the medication premixed in 100mL of D₅W with instructions to infuse the medication over one hour. The IV set delivers 20 drops per milliliter. The nurse should set the IV rate at:        
(a) 50 drops per minute
(b) 33 drops per minute
(c) 25 drops per minute
(d) 12 drops per minute
Answer:
(b) 33 drops per minute

Rationale:
Answers (a), (c), and (d) are incorrect because they are inaccurate amounts.

Question 205.    
When assessing the urinary output of a client who has had extra corporeal lithotripsy, the nurse can expect to find:
(a) Cherry-red urine that gradually becomes clearer
(b) Orange-tinged urine containing particles of calculi
(c) Dark red urine that becomes cloudy in appearance
(d) Dark, smoky-colored urine with high specific gravity
Answer:
(a) Cherry-red urine that gradually becomes clearer

Rationale:
Following extracorporeal lithotripsy, the urine will appear cherry red in color but will gradually change to clear urine. Answer (b) is incorrect because the urine will be red, not orange. Answer (c) is incorrect because the urine will be not be dark red or cloudy in appearance. Answer (d) is incorrect because it describes the urinary output of the client with acute glomerulonephritis.

Question 206.    
A client scheduled for an atherectomy asks the nurse about the procedure. The nurse understands that:
(a) Plaque will be removed by rotational or directional catheters.
(b) Plaque will be destroyed by a laser.
(c) A balloon-tipped catheter will compress fatty lesions against the vessel wall.
(d) Medication will be used to dissolve the build-up of plaque. 
Answer:
(a) Plaque will be removed by rotational or directional catheters.

Rationale:
Special rotational or directional catheters will be used to remove the plaque. Answer (b) is incorrect because it describes ablation. Answer (c) is incorrect because it describes percutaneous transluminal coronary angioplasty. Answer (d) is incorrect because it refers to lipid-lowering agents.

Question 207.    
An elderly client has a stage II pressure ulcer on her sacrum. During assessment of the client’s skin, the nurse would expect to find:
(a) A deep crater with a nonpainful wound base 
(b) A craterous area with a nonpainful wound base 
(c) Cracks and blisters with redness and induration 
(d) Nonblanchable redness with tenderness and pain
Answer:
(c) Cracks and blisters with redness and induration 

Rationale:
A stage II pressure ulcer has cracks and blisters with areas of redness and induration. Answer (a) is incorrect because it describes the appearance of a stage IV pressure ulcer. Answer (b) is incorrect because it describes the appearance of a stage III pressure ulcer. Answer (d) is incorrect because it describes the appearance of a stage I pressure ulcer.

Question 208.    
The physician has prescribed Cognex (tacrine) for a client with dementia. The nurse should monitor the client for adverse reactions, which include:
(a) Hypoglycemia
(b) Jaundice
(c) Urinary retention
(d) Tinnitus
Answer:
(b) Jaundice

Rationale:
An adverse reaction to Cognex is drug-induced hepatitis. The nurse should monitor the client for signs of jaundice. Answers (a), (c), and (d) are incorrect because they are not associated with the use of Cognex.

Question 209.    
The suggested diet for a child with cystic fibrosis is one that contains:
(a) High calories, high protein, moderate fat 
(b) High calories, moderate protein, low fat
(c) Moderate calories, moderate protein, moderate fat 
(d) Low calories, high protein, low fat
Answer:
(a) High calories, high protein, moderate fat 

Rationale:
The child with cystic fibrosis needs a diet that is high in calories, with high protein and moderate amounts of fat. Answers (b), (c), and (d) are incorrect because they do not meet the nutritional requirements imposed by the disease.

Question 210.    
The physician has ordered a low-potassium diet for a client with acute glomerulonephritis. Which snack is suitable for the client with potassium restrictions?
(a) Raisins 
(b) Orange 
(c) Apple
(d) Banana
Answer:
(c) Apple

Rationale:
Apples are low in potassium; therefore, this is a suitable snack for the client on a potassium-restricted diet. Raisins, oranges, and bananas are all high in potassium; therefore, answers (a), (b), and (d) are incorrect.

Question 211.    
A client with increased intracranial pressure is placed on mechanical ventilation with hyperventilation. The nurse knows that the purpose of the hyperventilation is to:
(a) Prevent the development of acute respiratory failure 
(b) Decrease cerebral blood flow 
(c) Increase systemic tissue perfusion 
(d) Prevent cerebral anoxia 
Answer:
(b) Decrease cerebral blood flow 

Rationale:
Hyperventilation reduces swelling and increased intracranial pressure by decreasing cerebral blood flow. Answers (a), (c), and (d) do not pertain to the situation; therefore, they are incorrect.

Question 212.    
The physician has ordered a blood test for H. pylori. The nurse should prepare the client by:
(a) Withholding oral intake after midnight 
(b) Telling the client that no special preparation is needed
(c) Explaining that a small dose of radioactive isotope will be used
(d) Giving an oral suspension of glucose one hour before the test
Answer:
(b) Telling the client that no special preparation is needed

Rationale:
No special preparation is needed for the blood test for H. pylori. Answer (a) is incorrect because the client is not NPO before the test. Answer (c) is incorrect because it refers to preparation for the breath test. Answer (d) is incorrect because glucose is not administered before the test.

Question 213.    
The nurse is preparing to give an oral potassium supplement. The nurse should give the medication:
(a) Without diluting it 
(b) With 4lb of juice 
(c) With water only 
(d) On an empty stomach
Answer:
(b) With 4lb of juice 

Rationale:
Oral potassium supplements should be given in at least 4lb of juice or other liquid such as fruit punch to disguise the unpleasant taste. Answers (a), (c), and (d) are incorrect because they cause gastric upset.

Question 214.    
A client with acute alcohol intoxication is being treated for hypo magnesemia. During assessment of the client, the nurse would expect to find:
(a) Bradycardia
(b) Negative Chvostek’s sign
(c) Hypertension
(d) Positive Trousseau’s sign
Answer:
(d) Positive Trousseau’s sign

Rationale:
The client with hypomagnesemia will have a positive Trousseau’s sign. Answer (a) is incorrect because the client would have tachycardia. Answer (b) is incorrect because the client would have a positive Chvostek’s sign. Answer (c) is incorrect because the client would have hypotension.

Question 215.    
The physician has ordered cultures for cytomegalovirus (CMV). Which statement is true of the collection of cultures for cytomegalovirus?
(a) Stool cultures are preferred for definitive diagnosis.
(b) Pregnant caregivers may obtain cultures.
(c) Collection of one specimen is sufficient.
(d) Accurate diagnosis depends on fresh specimens.
Answer:
(d) Accurate diagnosis depends on fresh specimens.

Rationale:
Fresh specimens are essential for an accurate diagnosis of CMV. Answer (a) is incorrect because cultures of urine, sputum, and oral swab are preferred. Answer (b) is incorrect because pregnant caregivers should not be assigned to care for clients with suspected or known infection with CMV. Answer (c) is incorrect because a convalescent culture is obtained 2-4 weeks after diagnosis.

Question 216.    
A home health nurse has four clients assigned for morning visits. The nurse should give priority to visiting the client with:
(a) Diabetes mellitus with a nongranulated ulcer of the right foot
(b) Congestive heart failure who reports coughing up frothy sputum
(c) Hemiplegia with tenderness in the right flank and cloudy urine
(d) Rheumatoid arthritis with soft tissue swelling behind the right knee 
Answer:
(b) Congestive heart failure who reports coughing up frothy sputum

Rationale:
The client with congestive heart failure who reports coughing up frothy sputum should be carefully evaluated for increasing pulmonary edema, which requires immediate treatment. Answers (a), (c), and (d) involve chronic conditions with complications that require skilled nursing care and assessment, but they do not present immediate life-threatening situations; therefore, they are incorrect.

Question 217.    
Four clients are admitted to a medical unit. If only one private room is available, it should be assigned to:
(a) The client with ulcerative colitis
(b) The client with neutropenia
(c) The client with cholecystitis
(d) The client with polycythemia vera
Answer:
(b) The client with neutropenia

Rationale:
The client with neutropenia needs to be placed in a private room in protective isolation. The other clients can be placed in the room with other clients; therefore, answers (a), (c), and (d) are incorrect.

Question 218.
The RN is should be making assignments for the morning staff. Which client cared for by the RN?
(a) A client with hemianopsia
(b) A client with asterixis
(c) A client with akathesia
(d) A client with hemoptysis
Answer:
(b) A client with asterixis

Rationale:
Asterixis is a symptom of impending liver failure, so the client should be cared for by the RN. The remaining clients can be cared for by the LPN; therefore, answers (a), (c), and (d) are incorrect.

Question 219.    
The nurse is reviewing the lab reports on several clients. Which one should be reported to the physician immediately?
(a) A serum creatinine of 5.2mg/dL in a client with chron-ic renal failure
(B) A positive C reactive protein in a client with rheumatic fever
(c) A hematocrit of 52% in a client with gastroenteritis
(d) A white cell count of 2,200cu/mm in a client taking Dilantin (phenytoin)
Answer:
(d) A white cell count of 2,200cu/mm in a client taking Dilantin (phenytoin)

Rationale:
Adverse reactions to phenytoin include agranulocytosis. The client’s WBC is abnormally low and should be reported to the physician immediately. Answer (a) is incorrect because elevations in serum creatinine are expected in the client with chronic renal failure. Answer (b) is wrong because a positive C reactive protein is usually present in those with rheumatic fever. Answer (c) is wrong because a hematocrit of 52% in a client with gastroenteritis can be expected due to dehydration.

Question 220.    
The following clients are to be assigned for daily care. The newly licensed nurse should not be assigned to provide primary care for the client with:
(a) Full-thickness burns of the abdomen and upper thighs
(b) A fractured hip scheduled for hip replacement 
(c) Ileal reservoir following a cystectomy 
(d) Noncardiogenic pulmonary edema (ARDS)
Answer:
(d) Noncardiogenic pulmonary edema (ARDS)

Rationale:
The newly licensed nurse should not be assigned to provide primary care for the client with noncardiogenic pulmonary edema (ARDS) because the client’s condition warrants care by an experienced RN. Answers (a), (b), and (c) are incorrect because the newly licensed nurse could assume primary care for clients with those conditions.

Question 221.    
The RN is making assignments for clients hospitalized on a neurological unit. Which client should be assigned to the LPN?
(a) A client with a C₃ injury immobilized by Crutchfield tongs
(b) A client with exacerbation of multiple sclerosis
(c) A client with a lumbar laminectomy 
(d) A client with hemiplegia and a urinary tract infection 
Answer:
(c) A client with a lumbar laminectomy 

Rationale:
The client with a lumbar laminectomy can be safely cared for by the LPN. Answer (a) is incorrect because the client with a high cervical injury immobilized by skeletal traction is best cared for by the RN. Answers (b) and (d) are incorrect choices because these clients have conditions that require intravenous medication, which requires the skill of the RN.

Question  222.    
The nurse has just received the change of shift report. The nurse should give priority to assessing the client with:
(a) A thoracotomy with 11 OmL of drainage in the past hour
(b) A cholecystectomy with an oral temperature of 100°F
(c) A transurethral prostatectomy who complains of urgency to void
(d) A stapedectomy who reports diminished hearing in the past hour
Answer:
(a) A thoracotomy with 11 OmL of drainage in the past hour

Rationale:
The client with a thoracotomy who has 110mL of drainage in the past hour has excessive bleeding that should be evaluated and reported to the physician immediately. A temperature of 100°F following a surgery is not unusual; therefore, answer (b) is incorrect. Feelings of urinary urgency are normal after a transurethral prostatectomy; therefore, answer (c) is incorrect. Diminished loss of hearing in the hours following a stapedectomy is expected due to the swelling and accumulation of blood in the inner ear; therefore, answer (d) is incorrect.

Question 223.    
A client with primary sclerosing cholangitis has received a liver transplant. The nurse should give priority to assessing the client for complications. Which findings are associated with an acute rejection of the new liver?
(a) Increased jaundice and prolonged prothrombin time
(b) Fever and foul-smelling bile drainage 
(c) Abdominal distention and clay-colored stools 
(d) Increased uric acid and increased creatinine
Answer:
(a) Increased jaundice and prolonged prothrombin time

Rationale:
Increased jaundice and prolonged prothrombin time are indications that the liver is not working. Answer (b) is incorrect because the symptoms sug¬gest infection. Answer (c) is incorrect because the symptoms suggest obstruction. Answer (d) is incorrect because the symptoms are associated with renal failure.

Question 224.    
The nurse is planning care for a client with adrenal insufficiency. The nurse should give priority to?
(a) Monitoring the client for signs of dehydration 
(b) Promoting sleep and rest 
(c) Providing high calorie snacks 
(d) Promoting a healthy body image
Answer:
(a) Monitoring the client for signs of dehydration 

Rationale:
The client with adrenal insufficiency frequently suffers from fluid volume deficit and acidosis; therefore, the nurse should give priority to monitoring for signs of dehydration. Answers (b), (c), and (d) are incorrect because they do not pose a life-threatening situation; therefore, they do not take priority..

Question 225.    
A pediatric client with burns to the hands and arms has dressing changes with Sulfamylon (mafenide acetate) cream. The nurse is aware that the medication:
(a) Will cause dark staining of the surrounding skin 
(b) Produces a cooling sensation when applied 
(c) Can alter the function of the thyroid 
(d) Produces a burning sensation when applied
Answer:
(d) Produces a burning sensation when applied

Rationale:
Sulfamylon produces a burning sensation when applied; therefore, the client should receive pain medication 30 minutes before application. Answer (a) is incorrect because it refers to therapy with silver nitrate. Answer (b) is incorrect because it refers therapy with Silvadene. Answer (c) is incorrect because it refers therapy with to Betadine.

Question 226.    
The physician has ordered Dilantin (phenytoin) for a client with generalized seizures. When planning the client’s care the nurse should:
(a) Maintain strict intake and output.
(b) Check the pulse before giving the medication.
(c) Administer the medication 30 minutes before meals.
(d) Provide oral hygiene and gum care every shift. 
Answer:
(d) Provide oral hygiene and gum care every shift. 

Rationale:
Gingival hyperplasia is a side effect of Dilantin, so the nurse should provide oral hygiene and gum care every shift. Answers (a), (b), and (c) do not apply to the medication; therefore, they are incorrect.

Question 227.
The nurse is caring for a client receiving Capoten (captopril). The nurse should be alert for adverse reactions to the drug, which include:    
(a) Increased red cell count
(b) Decreased sodium level
(c) Decreased white cell count
(d) Increased calcium level
Answer:
(c) Decreased white cell count

Rationale:
Adverse reactions to Capoten include a decreased white cell count. Answers (a), (b), and (d) are incorrect because they are associated with the medication.

Question 228.    
A client receiving chemotherapy for breast cancer has an order for Zofran (ondansetron) 8mg PO to be given 30 minutes before induction of the chemotherapy. The purpose of the medication is to:        
(a) Prevent anemia
(b) Promote relaxation
(c) Prevent nausea
(d) Increase neutrophil counts
Answer:
(c) Prevent nausea

Rationale:
Zofran is given before chemotherapy to prevent nausea. Answers (a), (b), and (d) are not associated with the medication; therefore, they are incorrect.

Question 229.    
The physician has ordered Cortisporin ear drops for a two-year- old. To administer the ear drops, the nurse should:
(a) Pull the ear down and back.
(b) Pull the ear straight out.
(c) Pull the ear up and back.
(d) Leave the ear undisturbed.
Answer:
(a) Pull the ear down and back.

Rationale:
When administering ear drops to a child under three years of age, the nurse should pull the ear down and back to straighten the ear canal. Answers (b) and (d) are incorrect positions for administering ear drops. Answer (c) is used for administering ear drops to the adult client.

Question 230.    
A client with Lyme’s disease is being treated with Achromycin (tetracycline HCI). The nurse should tell the client that the medication will be rendered ineffective if taken with:
(a) Antacids
(b) Salicylates
(c) Antihistamines
(d) Sedative-hypnotics
Answer:
(a) Antacids

Rationale:
Antibiotics such as Achromycin should not be taken with antacids. Answers (b), (c), and (d) may be taken with antibiotics; therefore, they are incorrect.

Question 231.    
A client with schizophrenia has been taking Thorazine (chlorpro- mazine) 200mg four times a day. Which finding should be reported to the doctor immediately?
(a) The client complains of thirst.
(b) The client has gained four pounds in the past two months.
(c) The client complains of a sore throat.
(d) The client naps throughout the day. 
Answer:
(c) The client complains of a sore throat.

Rationale:
The nurse should carefully monitor the client taking Thorazine for signs of infection that can quickly become overwhelming. Answers (a), (b), and (d) are incorrect because they are expected side effects of the medication

Question 232.    
The doctor has prescribed Claritin (loratidine) for a client with sea¬sonal allergies. The feature that separates Claritin from other anti histamines such as Benadryl (diphenhydramine) is that the medication:        
(a) Is nonsedating
(b) Stimulates appetite
(c) Is used for motion sickness
(d) Is less expensive
Answer:
(a) Is nonsedating

Rationale:
Claratin does not produce sedation like other antihistamines. Answers (b), (c), and (d) are inaccurate statements; therefore, they are incorrect.

Question 233.    
The doctor has prescribed Claritin (loratidine) for a client with seasonal allergies. The feature that separates Claritin from other anti histamines such as Benadryl (diphenhydramine) is that the medication:        
(a) Is nonsedating
(b) Stimulates appetite
(c) Is used for motion sickness
(d) Is less expensive
Answer:
(b) Stimulates appetite

Rationale:
A cotton-tipped swab is used to apply the suspension to the affected areas. Answers (a), (c), and (d) are incorrect because they do not ensure that the medication reaches the affected areas.

Question 234.    
A client with iron deficiency anemia is taking an oral iron supplement. The nurse should tell the client to take the medication with:
(a) Orange juice 
(b) Water only 
(c) Milk 
(d) Apple juice
Answer:
(a) Orange juice 

Rationale:
Iron is better absorbed when taken with ascorbic acid. Orange juice is an excellent source of ascorbic acid. Answer (b) is incorrect because the medication should be taken with orange juice or tomato juice. Answer (c) is incorrect because iron should not be taken with milk because it interferes with absorption. Answer (d) is incorrect because apple juice does not contain high amounts of ascorbic acid.

Question 235.    
A child is admitted to the emergency room following ingestion of a bottle of Children’s Tylenol. The nurse is aware that Tylenol (acetaminophen) overdose is treated with:
(a) Acetylcysteine
(b) Deferoxamine
(c) Edetate calcium disodium
(d) Activated charcoal
Answer:
(a) Acetylcysteine

Rationale:
Acetylcysteine (Mucomyst) or N-Acetyl-1 -Cysteine (NAC) is the antidote for acetaminophen overdose. Answer (b) is incorrect because it is the antidote for iron poisoning. Answer (c) is incorrect because it is the treatment for lead poisoning. Answer (d) is incorrect because it is used for noncorrosive poisonings.

Question 236.    
The nurse knows that a client with right-sided hemiplegia understands teaching regarding ambulation with a cane if she states:
(a) “I will hold the    cane in my right hand.”
(b) “I will advance my cane and my right leg at the same time.”
(c) “I will be able to walk only by using a walker.”
(d) “I will hold the cane in my left hand.”
Answer:
(d) “I will hold the cane in my left hand.”

Rationale:
The client should hold the cane on the unaffected side. Answer (a) is incorrect because this answer instructs the client to hold the cane on the affected side. It will not be necessary for the client to use a walker, and advancing the cane with the affected leg is not correct; thus, answers (b) and (c) are incorrect.
 
Question 237.    
A nursing assistant assigned to care for a client receiving linear accelerator radium therapy for laryngeal cancer states, ‘‘I don’t want to be assigned to that radioactive patient.” The best response by the nurse is to:
(a) Tell the nursing assistant that the client is not radio active.
(b) Tell the nursing assistant to wear a radiation badge to detect the amount of radiation that she is receiving.
(c) Instruct her regarding the use of a lead-lined apron.
(d) Ask a coworker to care for the client.
Answer:
(a) Tell the nursing assistant that the client is not radio active.

Rationale:
Linear accelerator therapy is done in the radium department and does not make the client radioactive. Answer (b) is incorrect because there is no radiation emitted from the client. Answer (c) is incorrect because it is not necessary for the nursing assistant to wear an apron when caring for this client. Answer (d) is incorrect because there is no need to reassign the nursing assistant.

Question 238.    
The nurse caring for a client scheduled for an angiogram should prepare the client for the procedure by telling him to expect:    
(a) Dizziness as the dye is injected 
(b) Nausea and vomiting after the procedure is completed
(c) A decreased heart rate for several hours after the pro-cedure is completed
(d) A warm sensation as the dye is injected
Answer:
(d) A warm sensation as the dye is injected

Rationale:
The client undergoing an angiogram will experience a warm sensation as the dye is injected. Answers (a), (b), and (c) are not associated with an angiogram.

Question 239.
A client with Parkinson’s disease complains of “choking” when he swallows. Which intervention will improve the client’s ability to swallow?    
(a) Withholding liquids until after meals
(b) Providing semi-liquids when possible
(c) Providing a full liquid diet
(d) Offering small, more frequent meals
Answer:
(b) Providing semi-liquids when possible

Rationale:
Semi-liquids are more easily swallowed by the client with dysphagia than either liquids or solids. Answers (a), (c), and (d) do not improve the client’s ability to swallow, so they are incorrect choices.

Question 240.
Which of the following statements best explains the rationale for placing the client in Trendelenburg position during the insertion of a central line catheter?
(a) It will facilitate catheter insertion.
(b) It will make the client more comfortable during the insertion.
(c) It will prevent the occurrence of ventricular tachy-cardia.
(d) It will prevent the development of pulmonary emboli.
Answer:
(a) It will facilitate catheter insertion.

Rationale:
Placing the client in the Trendelenburg position will engorge the vessels, make insertion of the catheter easier, and lessen the likelihood of air entering the central line. Answer (b) is incorrect because the client will not be more comfortable in the Trendelenburg position. Answers (c) and (d) are not correct statements.

Question 241.    
The doctor has ordered the removal of a Davol drain. Which of the following instructions should the nurse give to the client before removing the drain?
(a) The client should be told to breathe normally.
(b) The client should be told to take two or three deep breaths as the drain is being removed.
(c) The client should be told to hold his breath as the drain is being removed.
(d) The client should breathe slowly as the drain is being removed.
Answer:
(b) The client should be told to take two or three deep breaths as the drain is being removed.

Rationale:
Taking deep breaths will decrease the discomfort experienced during removal of the drain. Answers (a), (c), and (d) are incorrect statements because they do not decrease the discomfort during removal of the drain.

Question 242.    
Which of the following findings is associated with right-sided heart failure?
(a) Shortness of breath
(b) Nocturnal polyuria
(c) Daytime oliguria
(d) Crackles in the lungs
Answer:
(b) Nocturnal polyuria

Rationale:
Increased voiding at night is a symptom of right-sided heart failure. Answers (a), (c), and (d) are incorrect because they are symptoms of left-sided heart failure.

Question 243.    
A client returns from surgery with a total knee replacement. Which of the following findings requires immediate nursing intervention?
(a) Bloody drainage of 30mL from the Davol drain is present.
(b) The CPM is set on 90° flexion.
(c) The client is unable to ambulate to the bathroom.
(d) The client is complaining of muscle spasms.
Answer:
(b) The CPM is set on 90° flexion.

Rationale:
The CPM machine should not be set at 90° flexion until the fifth post-operative day. Answers (a), (c), and (d) are expected findings and do not require immediate nursing intervention; therefore, they are incorrect.

Question 244.    
Which of the following postpartal clients is at greatest risk for hemorrhage?
(a) A gravida 1 para 1 with an uncomplicated delivery of a 7-pound infant
(b) A gravida 1 para 0 with a history of polycystic ovarian disease
(c) A gravida 3 para 3 with a history of low-birth weight infants
(d) A gravida 4 para 3 with a Caesarean section 
Answer:
(d) A gravida 4 para 3 with a Caesarean section 

Rationale:
The multiparous client with a large newborn has the greatest risk for postpartal hemorrhage. Answers (a), (b), and (c) are incorrect choices because they do not have a greater risk for postpartal hemorrhage.

Question 245.    
An infant with a ventricular septal defect is discharged with a prescription for Lanoxin (digoxin) elixir 0.01 mg POQ 12hrs. The bottle is labeled 0.10mg per 1/2 tsp. The nurse should instruct the mother to:
(a) Administer the    medication    using a nipple.
(b) Administer the medication using the calibrated dropper in the bottle.
(c) Administer the    medication    using a plastic baby spoon.
(d) Administer the medication in a baby bottle with 1lb of water.
Answer:
(b) Administer the medication using the calibrated dropper in the bottle.

Rationale:
The medication should be administered using the calibrated dropper that comes with the medication. Answers (a) and (c) are incorrect because part or all of the medication could be lost during administration. Answer (d) is incorrect because part or all of the medication will be lost if the child does not finish the bottle.

Question 246.    
An elderly client with glaucoma is scheduled for a cholecystectomy. Which medication order should the nurse question?
(a) Demerol (meperidine)
(b) Tagamet (cimetidine)
(c) Atropine (atropine)
(d) Phenergan (promethazine)
Answer:
(c) Atropine (atropine)

Rationale:
Atropine is contraindicated in the client with glaucoma because the medication increases intraocular pressure. Answers (a), (b), and (d) are not contraindicated in the client with glaucoma; therefore, they are incorrect answers.

Question 247.    
Which instruction would not be included in the discharge teaching of the client receiving Thorazine (chlorpromazine)?
(a) “You will need to wear protective clothing or a sun-screen when you are outside.”
(b) “You will need to avoid eating aged cheese.”
(c) “You should carry hard candy with you to decrease dryness of the mouth.”
(d) “You should report a sore throat immediately.”
Answer:
(b) “You will need to avoid eating aged cheese.”

Rationale:
Aged cheese, wine, and smoked or pickled meats should be avoided by the client taking an MAOI, not a phenothiazine. Answers (a), (c), and (d) are included in the discharge teaching of a client receiving chlorpromazine (Thorazine).

Question 248.    
An elderly client who experiences nighttime confusion wanders from his room into the room of another client. The nurse can best help with decreasing the client’s confusion by:
(a) Assigning a nursing assistant to sit with him until he falls asleep
(b) Allowing the client to room with another elderly client
(c) Administering a bedtime sedative
(d) Leaving a nightlight on during the evening and night shifts 
Answer:
(d) Leaving a nightlight on during the evening and night shifts 

Rationale:
Leaving a nightlight on during the evening and night shifts helps the client remain oriented to the environment and fosters independence. Answers (a) and (b) will not decrease the client’s confusion. Answer (c) will increase the likelihood of confusion in an elderly client.

Question 249.    
A four-year-old is scheduled for a routine tonsillectomy. Which of the following lab findings should be reported to the doctor?
(a) A hemoglobin of 12Gm
(b) A platelet count of 200,000
(c)  A white blood cell count of 16,000
(d) A urine specific gravity of 1.010
Answer:
(c)  A white blood cell count of 16,000

Rationale:
Elevations in white cell count indicate the presence of infection, which requires treatment before surgery. Answers (a), (b), and (d) are within normal limits and require no intervention.

Question 250.    
A client with psychotic depression is receiving Haldol (haloperidol). Which one of the following adverse effects is associated with the use of haloperidol?
(a) Akathisia
(b) Cataracts
(c) Diaphoresis
(d) Polyuria
Answer:
(a) Akathisia

Rationale:
Akathisia is an adverse extrapyramidal side effect of many older antipsychotic medications such as haloperidol and chlorpromazine. Answers (b), (c), and (d) are not associated with the use of haloperidol.