NCLEX-RN Practice Test 3 with Rationale
Question 1.
A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every two hours. Which of the following outcome criteria would the nurse use?
(a) Body temperature of 99°F or less
(b) Toes moved in active range of motion
(c) Sensation reported when soles of feet are touched
(d) Capillary refill of < 3 seconds
Answer:
(d) Capillary refill of < 3 seconds
Rationale:
It is important to assess the extremities for blood vessel occlusion in the client with sickle cell anemia because a change in capillary refill would indicate a change in circulation. Body temperature, motion, and sensation would not give information regarding peripheral circulation; therefore, answers (a), (b), and (c) are incorrect.
Question 2.
A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client?
(a) Side-lying with knees flexed
(b) Knee-chest
(c) High Fowler’s with knees flexed
(d) Semi-Fowler’s with legs extended on the bed
Answer:
(d) Semi-Fowler’s with legs extended on the bed
Rationale:
Placing the client in semi-Fowler’s position provides the best oxygenation for this client. Flexion of the hips and knees, which includes the knee-chest position, impedes circulation and is not correct positioning for this client. Therefore, answers (a), (b), and (c) are incorrect.
Question 3.
A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?
(a) Taking hourly blood pressures with mechanical cuff
(b) Encouraging fluid intake of at least 200mL per hour
(c) Position in high Fowler’s with knee gatch raised
(d) Administering Tylenol as ordered
Answer:
(b) Encouraging fluid intake of at least 200mL per hour
Rationale:
It is important to keep the client in sickle cell crisis hydrated to prevent further sickling of the blood. Answer (a) is incorrect because a mechanical cuff places too much pressure on the arm. Answer (c) is incorrect because raising the knee gatch impedes circulation. Answer (d) is incorrect because Tylenol is too mild an analgesic for the client in crisis.
Question 4.
Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?
(a) Steak
(b) Cottage cheese
(c) Popsicle
(d) Lima beans
Answer:
(c) Popsicle
Rationale:
Hydration is important in the client with sickle cell disease to prevent thrombus formation. Popsicles, gelatin, juice, and pudding have high fluid content. The foods in answers (a), (b), and (d) do not aid in hydration and are, therefore, incorrect.
Question 5.
A newly admitted client has sickle cell crisis. He is complaining of pain in his feet and hands. The nurse’s assessment findings include a pulse oximetry of 92. Assuming that all the following interventions are ordered, which should be done first?
(a) Adjust the room temperature
(b) Give a bolus of IV fluids
(c) Start O2
(d) Administer meperidine (Demerol) 75mg IV push
Answer:
(c) Start O2
Rationale:
The pulse oximetry indicates that oxygen levels are low; thus, oxygenation takes precedence over pain relief. Answer (a) is incorrect because although a warm environment reduces pain and minimizes sickling, it would not be a priority. Answer (b) is incorrect because although hydration is important, it would not require a bolus. Answer (d) is incorrect because Demerol is acidifying to the blood and increases sickling.
Question 6.
The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?
(a) Roast beef, gelatin salad, green beans, and peach pie
(b) Chicken salad sandwich, coleslaw, French fries, ice cream
(c) Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie
(d) Pork chop, creamed potatoes, corn, and coconut cake
Answer:
(c) Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie
Rationale:
Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in iron, which is an important mineral for this client. Roast beef, cabbage, and pork chops are also high in iron, but the side dishes accompanying these choices are not; therefore, answers (a), (b), and (d) are incorrect.
Question 7.
Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?
(a) A family vacation in the Rocky Mountains
(b) Chaperoning the local boys club on a snow-skiing trip
(c) Traveling by airplane for business trips
(d) A bus trip to the Museum of Natural History
Answer:
(d) A bus trip to the Museum of Natural History
Rationale:
Taking a trip to the museum is the only answer that does not pose a threat. A family vacation in the Rocky Mountains at high altitudes, cold temperatures, and airplane travel can cause sickling episodes and should be avoided; therefore, answers (a), (b), and (c) are incorrect.
Question 8.
The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which finding reinforces the diagnosis of B12 deficiency?
(a) Enlarged spleen
(b) Elevated blood pressure
(c) Bradycardia
(d) Beefy tongue
Answer:
(d) Beefy tongue
Rationale:
The tongue of the client with B12 insufficiency is red and beefy. Answers (a), (b), and (c) incorrect because enlarged spleen, elevated BP, and bradycardia are not associated with B12 deficiency.
Question 9.
The body part that would most likely display jaundice in the dark skinned individual is the:
(a) Conjunctiva of the eye
(b) Soles of the feet
(c) Roof of the mouth
(d) Shins
Answer:
(c) Roof of the mouth
Rationale:
The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in dark-skinned persons. The conjunctiva can have normal deposits of fat, which give a yellowish hue; thus, answer (a) is incorrect. The soles of the feet can be yellow if they are calloused, making answer (b) incorrect: the shins would be an area of darker pigment, so answer (d) is incorrect.
Question 10.
The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?
(a) BP 146/88
(b) Respirations 28 shallow
(c) Weight gain of 10 pounds in six months
(d) Pink complexion
Answer:
(b) Respirations 28 shallow
Rationale:
When there are fewer red blood cells, there is less hemoglobin and less oxygen. Therefore, the client is often short of breath, as indicated in answer (b). The client with anemia is often pale in color, has weight loss, and may be hypotensive. Answers (a), (c), and (d) are within normal and, therefore, are incorrect.
Question 11.
The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?
(a) “I will drink 500mL of fluid or less each day.”
(b) “I will wear support hose.”
(c) “I will check my blood pressure regularly.”
(d) “I will report ankle edema.”
Answer:
(a) “I will drink 500mL of fluid or less each day.”
Rationale:
The client with polycythemia vera is at risk for thrombus formation. Hydrating the client with at least 3L of fluid per day is important in preventing clot formation, so the statement to drink less than 500mL is incorrect. Answers (b), (c), and (d) are incorrect because they all contribute to the prevention of complications. Support hose promotes venous return, the electric razor prevents bleeding due to injury, and a diet low in iron is essential to preventing further red cell formation.
Question 12.
A 33-year-old male is being evaluated for possible acute leukemia. Which of the following findings is most likely related to the diagnosis of leukemia?
(a) The client collects stamps as a hobby.
(b) The client recently lost his job as a postal worker.
(c) The client had radiation for treatment of Hodgkin’s disease as a teenager.
(d) The client’s brother had leukemia as a child.
Answer:
(c) The client had radiation for treatment of Hodgkin’s disease as a teenager.
Rationale:
Radiation treatment for other types of cancer can contribute to the development of leukemia. Some hobbies and occupations involving chemicals are linked to leukemia, but not the ones in these answers; therefore, answers (a) and (b) are incorrect. Answer (d) is incorrect because the incidence of leukemia is higher in twins not siblings
Question 13.
Where is the best site for examining for the presence of petechiae in an African American client?
(a) The abdomen
(b) The thorax
(c) The earlobes
(d) The soles of the feet
Answer:
(d) The soles of the feet
Rationale:
Petechiae are not usually visualized on dark skin. The soles of the feet and palms of the hand provide a lighter surface for assessing the client for petichiae. Answers (a), (b), and (c) are incorrect because the skin may be too dark to make an assessment.
Question 14.
The client inquiry by is being evaluated for possible acute leukemia. Which the nurse is most important?
(a) “Have you noticed a change in sleeping habits recently?”
(b) “Have you had a respiratory infection in the last six months?”
(c) “Have you lost weight recently?”
(d) “Have you noticed changes in your alertness?”
Answer:
(b) “Have you had a respiratory infection in the last six months?”
Rationale:
The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous six months. Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations; therefore, answers (a), (c), and (d) are incorrect.
Question 15.
Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?
(a) Oral mucous membrane, altered related to chemotherapy
(b) Risk for injury related to thrombocytopenia
(c) Fatigue related to the disease process
(d) Interrupted family processes related to life-threatening illness of a family member
Answer:
(b) Risk for injury related to thrombocytopenia
Rationale:
The client with acute leukemia has bleeding tendencies due to decreased platelet counts, and any injury would exacerbate the problem. The client would require close monitoring for hemorrhage, which is of higher priority than the diagnoses in answers (a), (c), and (d), which are incorrect.
Question 16.
A 21-year-old male with Hodgkin’s lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client?
(a) Sexual dysfunction related to radiation therapy
(b) Anticipatory grieving related to terminal illness
(c) Tissue integrity related to prolonged bed rest
(d) Fatigue related to chemotherapy
Answer:
Rationale:
Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the client are important to address in light of the age and life choices. Hodgkin’s disease, however, has a good prognosis when diagnosed early. Answers (b), (c), and (d) are incorrect because they are of lesser priority.
Question 17.
A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor:
(a) Platelet count
(b) White blood cell count
(c) Potassium levels
(d) Partial prothrombin time (PTT)
Answer:
(a) Platelet count
Rationale:
Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts, making answer (a) the correct answer. White cell counts, potassium levels, and PTT are not affected in ATP; thus, answers (b), (c), and (d) are incorrect.
Question 18.
The home health nurse is visiting a client with autoimmune thrombo-cytopenic purpura (ATP). The client’s platelet count currently is 80,000. It will be most important to teach the client and family about:
(a) Bleeding precautions
(b) Prevention of falls
(c) Oxygen therapy
(d) Conservation of energy
Answer:
(a) Bleeding precautions
Rationale:
The normal platelet count is 120,000-400,000. Bleeding occurs in clients with low platelets. The priority is to prevent and minimize bleeding. Oxygenation in answer (c) is important, but platelets do not carry oxygen. Answers (b) and (d) are of lesser priority and are incorrect in this instance.
Question 19.
The client has surgery for removal of a Prolactinoma. Which of the following interventions would be appropriate for this client?
(a) Place the client in Trendelenburg position for postural drainage.
(b) Encourage coughing and deep breathing every two hours.
(c) Elevate the head of the bed 30°.
(d) Encourage the Valsalva maneuver for bowel movements.
Answer:
(c) Elevate the head of the bed 30°.
Rationale:
A prolactinoma is a type of pituitary tumor. Elevating the head of the bed 30° avoids pressure on the sella turcica and helps to prevent headaches. Answers (a), (b), and (d) are incorrect because Trendelenburg, Valsalva maneuver, and coughing all increase the intracranial pressure.
Question 20.
The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:
(a) Measure the urinary output.
(b) Check the vital signs.
(c) Encourage increased fluid intake.
(d) Weigh the client.
Answer:
(b) Check the vital signs.
Rationale:
The large amount of fluid loss can cause fluid and electrolyte imbalance that should be corrected. The loss of electrolytes would be reflected in the vital signs. Measuring the urinary output is important, but the stem already says that the client has polyuria, so answer (a) is incorrect. Encouraging fluid intake will not correct the problem, making answer (c) incorrect. Answer (d) is incorrect because weighing the client is not necessary at this time.
Question 21.
A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?
(a) Place the client in a sitting position.
(b) Administer acetaminophen (Tylenol).
(c) Pinch the soft lower part of the nose.
(d) Apply ice packs to the forehead.
Answer:
(c) Pinch the soft lower part of the nose.
Rationale:
(c) is correct because direct pressure to the nose stops the bleeding. Answers (a), (b), and (d) are incorrect because they do not stop bleeding.
Question 22.
A client has had a unilateral adrenalectomy to remove a tumor.
The most important measurement in the immediate post-operative period for the nurse to take is:
(a) The blood pressure
(b) The temperature
(c) The urinary output
(d) The specific gravity of the urine
Answer:
(a) The blood pressure
Rationale:
Blood pressure is the best indicator of cardiovascular collapse in the client who has had an adrenal gland removed. The remaining gland might have been suppressed due to the tumor activity. Temperature would be an indicator of infection, decreased output would be a clinical manifestation but would take longer to occur than blood pressure changes, and specific gravity changes occur with other disorders; therefore, answers (b), (c), and (d) are incorrect.
Question 23.
A client with Addison’s disease has been admitted with a history of nausea and vomiting for the past three days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement?
(a) Glucometer readings as ordered
(b) Intake/output measurements
(c) Evaluating the sodium and potassium levels
(d) Daily weights
Answer:
(a) Glucometer readings as ordered
Rationale:
IV glucocorticoids raise the glucose levels and often require coverage with insulin. Answer (b) is not necessary at this time, sodium and potassium levels would be monitored when the client is receiving mineral corticoids, and daily weights is unnecessary; therefore, answers (b), (c), and (d) are incorrect.
Question 24.
A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses’ next action be?
(a) Obtain a crash cart.
(b) Check the calcium level.
(c) Assess the dressing for drainage.
(d) Assess the blood pressure for hypertension.
Answer:
(b) Check the calcium level.
Rationale:
The parathyroid glands are responsible for calcium production and can be damaged during a thyroidectomy. The tingling can be due to low calcium levels. The crash cart would be needed in respiratory distress but would not be the next action to take; thus, answer (a) is incorrect. Hypertension occurs in thyroid storm and the drainage would occur in hemorrhage, so answers (c) and (d) are incorrect.
Question 25.
A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in four months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?
(a) Impaired physical mobility related to decreased endurance
(b) Hypothermia r/t decreased metabolic rate
(c) Disturbed thought processes r/t interstitial edema
(d) Decreased cardiac output r/t bradycardia
Answer:
(d) Decreased cardiac output r/t bradycardia
Rationale:
The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices; therefore, answers (a), (b), and (c) are incorrect.
Question 26.
The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client taking rosuvastatin (Crestor)? Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?
(a) Blood pressure of 126/80
(b) Blood glucose of 11 Omg/dL
(c) Heart rate of 60bpm
(d) Respiratory rate of 30 per minute
Answer:
(a) Blood pressure of 126/80
Rationale:
The client taking antilipidemics should be encouraged to report muscle weakness because this is a sign of rhabdomyolysis. The medication takes effect within one month of beginning therapy, so answer (b) is incorrect. The medication should be taken with water because fruit juice, particularly grapefruit, can decrease the effectiveness, making answer (c) incorrect. Liver function studies should be checked before beginning the medication, not after the fact, making answer (d) incorrect.
Question 27.
The client Diazoxide should is admitted to the hospital with hypertensive crises. (Hyperstat) is ordered. During administration, the nurse
(a) Utilize an infusion pump.
(b) Check the blood glucose level.
(c) Place the client in Trendelenburg position.
(d) Cover the solution with foil.
Answer:
(b) Check the blood glucose level.
Rationale:
Hyperstat is given IV push for hypertensive crises, but it often causes hyperglycemia. The glucose level will drop rapidly when stopped. Answer (a) is incorrect because the hyperstat is given by IV push. The client should be placed in dorsal recumbent position, not Trendelenburg position, as stated in answer (c). Answer (d) is incorrect because the medication does not have to be covered with foil.
Question 28.
The six-month-old client with a ventral septal defect is receiving
(a) Report muscle weakness to the physician.
(b) Allow six months for the drug to take effect.
(c) Take the medication with fruit juice.
(d) Report difficulty sleeping.
Answer:
Rationale:
A heart rate of 60 in the baby should be reported immediately. The dose should be held if the heart rate is below 100bpm. The blood glucose, blood pressure, and respirations are within normal limits; thus answers (a), (b), and (d) are incorrect.
Question 29.
The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:
(a) Replenish his supply every three months.
(b) Take one every 15 minutes if pain occurs.
(c) Leave the medication in the brown bottle.
(d) Crush the medication and take with water.
Answer:
(c) Leave the medication in the brown bottle.
Rationale:
Nitroglycerine should be kept in a brown bottle (or even a special air- and water-tight, solid or plated silver or gold container) because of its instability and tendency to become less potent when exposed to air, light, or water. The supply should be replenished every six months, not three months, and one tablet should be taken every five minutes until pain subsides, so answers (a) and (b) are incorrect. If the pain does not subside, the client should report to the emergency room. The medication should be taken sublingually and should not be crushed, as stated in answer (d).
Question 30.
The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?
(a) Macaroni and cheese
(b) Shrimp with rice
(c) Turkey breast
(d) Spaghetti with meat sauce
Answer:
(c) Turkey breast
Rationale:
Turkey contains the least amount of fats and cholesterol. Liver, eggs, beef, cream sauces, shrimp, cheese, and chocolate should be avoided by the client; thus, answers (a), (b), and (d) are incorrect. The client should bake meat rather than frying to avoid adding fat to the meat during cooking.
Question 31.
The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:
(a) Feet
(b) Neck
(c) Hands
(d) Sacrum
Answer:
(b) Neck
Rationale:
The jugular veins in the neck should be assessed for distension. The other parts of the body will be edematous in right-sided congestive heart failure, not left-sided; thus, answers (a), (c), and (d) are incorrect.
Question 32.
The nurse is checking the client’s central venous pressure. The nurse should place the zero of the manometer at the:
(a) Phlebostatic axis
(b) PMI
(c) Erb’s point
(d) Tail of Spence
Answer:
(a) Phlebostatic axis
Rationale:
The phlebostatic axis is located at the fifth intercostals space midaxillary line and is the correct placement of the manometer. The PMI or point of maximal impulse is located at the fifth intercostals space midclavicular line, so answer (b) is incorrect. Erb’s point is the point at which you can hear the valves close simultaneously, making answer (c) incorrect. The Tail of Spence (the upper outer quadrant of the breast) is the area where most breast cancers are located and has nothing to do with placement of a manometer; thus, answer (d) is incorrect.
Question 33.
The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:
(a) Question the order.
(b) Administer the medications.
(c) Administer separately.
(d) Contact the pharmacy.
Answer:
(b) Administer the medications.
Rationale:
Zestril is an ACE inhibitor and is frequently given with a diuretic such as Lasix for hypertension. Answers (a), (c), and (d) are incorrect because the order is accurate. There is no need to question the order, administer the medication separately, or contact the pharmacy.
Question 34.
The best method of evaluating the amount of peripheral edema is:
(a) Weighing the client daily
(b) Measuring the extremity
(c) Measuring the intake and output
(d) Checking for pitting
Answer:
(b) Measuring the extremity
Rationale:
The best indicator of peripheral edema is measuring the extremity. A paper tape measure should be used rather than one made of plastic or cloth, and the area should be marked with a pen, providing the most objective assessment. Answer (a) is incorrect because weighing the client will not indicate peripheral edema. Answer (c) is incorrect because checking the intake and output will not indicate peripheral edema. Answer (d) is incorrect because checking for pitting edema is less reliable than measuring with a paper tape measure
Question 35.
A client with vaginal cancer is being treated with a radioactive vaginal implant. The client’s husband asks the nurse if he can spend the night with his wife. The nurse should explain that:
(a) Overnight stays by family members is against hospital policy.
(b) There is no need for him to stay because staffing is adequate.
(c) His wife will rest much better knowing that he is at home.
(d) Visitation is limited to 30 minutes when the implant is in place.
Answer:
(d) Visitation is limited to 30 minutes when the implant is in place.
Rationale:
Clients with radium implants should have close contact limited to 30 minutes per visit. The general rule is limiting time spent exposed to radium, putting distance between people and the radium source, and using lead to shield against the radium. Teaching the family member these principles is extremely important. Answers (a), (b), and (c) are not empathetic and do not address the question; therefore, they are incorrect.
Question 36.
The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?
(a) Roast beef sandwich, potato chips, pickle spear, iced tea
(b) Split pea soup, mashed potatoes, pudding, milk
(c) Tomato soup, cheese toast, Jello, coffee
(d) Hamburger, baked beans, fruit cup, iced tea
Answer:
(b) Split pea soup, mashed potatoes, pudding, milk
Rationale:
The client with a facial stroke will have difficulty swallowing and chewing, and the foods in answer B provide the least amount of chewing. The foods in answers (a), (c), and (d) would require more chewing and, thus, are incorrect.
Question 37.
The physician has prescribed Novalog insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?
(a) “I will make sure I eat breakfast within 10 minutes of taking my insulin.”
(b) “I will need to carry candy or some form of sugar with me all the time.”
(c) “I will eat a snack around three o’clock each after noon.”
(d) “I can save my dessert from supper for a bedtime snack.”
Answer:
(a) “I will make sure I eat breakfast within 10 minutes of taking my insulin.”
Rationale:
Novalog insulin onsets very quickly, so food should be available within 10-15 minutes of taking the insulin. Answer (b) does not address a particular type of insulin, so it is incorrect. I\IPH insulin peaks in 8-12 hours, so a snack should be eaten at the expected peak time. It may not be 3 p.m. as stated in answer (c).
Question 38.
The nurse is teaching basic infant care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first two weeks of life because:
(a) New parents need time to learn how to hold the baby.
(b) The umbilical cord needs time to separate.
(c) Newborn skin is easily traumatized by washing.
(d) The chance of chilling the baby outweighs the benefits of bathing.
Answer:
(b) The umbilical cord needs time to separate.
Rationale:
The umbilical cord needs time to dry and fall off before putting the infant in the tub. Although answers (a), (c), and (d) might be important, they are not the primary answer to the question.
Question 39.
A client with leukemia is receiving Trimetrexate. After reviewing the client’s chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:
(a) Treat iron-deficiency anemia caused by chemotherapeutic agents
(b) Create a synergistic effect that shortens treatment time
(c) Increase the number of circulating neutrophils
(d) Reverse drug toxicity and prevent tissue damage
Answer:
(d) Reverse drug toxicity and prevent tissue damage
Rationale:
Leucovorin is the antidote for Methotrexate and Trimetrexate which are folic acid antagonists. Leucovorin is a folic acid derivative. Answers (a), (b), and (c) are incorrect because Leucovorin does not treat iron deficiency, increase neutrophils, or have a synergistic effect.
Question 40.
A four-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should
(a) Hib titer
(b) Mumps vaccine
(c) Hepatitis B vaccine
(d) MMR
Answer:
(a) Hib titer
Rationale:
The Hemophilus influenza vaccine is given at four months with the polio vaccine. Answers (b), (c), and (d) are incorrect because these vaccines are given later in life.
Question 41.
The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. The nurse should administer the medication:
(a) 30 minutes before a meal
(b) With each meal
(c) In a single dose at bedtime
(d) 30 minutes after meals
Answer:
(a) 30 minutes before a meal
Rationale:
Proton pump inhibitors should be taken prior to the meal. Answers (b), (c), and (d) are incorrect times for giving proton pump inhibitors like Nexium.
Question 42.
A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?
(a) Call security for assistance and prepare to sedate the client.
(b) Tell the client to calm down and ask him if he would like to play cards.
(c) Tell the client that if he continues his behavior he will be punished.
(d) Leave the client alone until he calms down.
Answer:
(a) Call security for assistance and prepare to sedate the client.
Rationale:
If the client is a threat to the staff and to other clients the nurse should call for help and prepare to administer a medication such as Haldol to sedate him. Answer (b) is incorrect because simply telling the client to calm down will not work. Answer (c) is incorrect because telling the client that if he continues he will be punished is a threat and may further anger him. Answer (d) is incorrect because if the client is left alone he might harm himself.
Question 43.
When the nurse checks the fundus of a client on the first postpartum day, she notes that the fundus is firm, is at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to:
(a) Check the client for bladder distention.
(b) Assess the blood pressure for hypotension.
(c) Determine whether an oxytocic drug was given.
(d) Check for the expulsion of small clots.
Answer:
(a) Check the client for bladder distention.
Rationale:
If the fundus of the client is displaced to the side, this might indicate a full bladder. The next action by the nurse should be to check for bladder distention and catheterize, if necessary. The answers in (b), (c), and (d) are actions that relate to postpartal hemorrhage.
Question 44.
A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood-tinged hemoptysis, fatigue, and night sweats. The client’s symptoms are consistent with a diagnosis of:
(a) Pneumonia
(b) Reaction to antiviral medication
(c) Tuberculosis
(d) Superinfection due follow CD4 count
Answer:
(c) Tuberculosis
Rationale:
A low-grade temperature, blood-tinged sputum, fatigue, and night sweats are symptoms consistent with tuberculosis. If the answer in (a) had said Pneumocystis pneumonia, answer (a) would have been consistent with the symptoms given in the stem, but just saying pneumonia isn’t specific enough to diagnose the problem. Answers (b) and (d) are not directly related to the stem.
Question 45.
The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client’s history should be reported to the doctor?
(a) Diabetes
(b) Prinzmetal’s angina
(c) Cancer
(d) Cluster headaches
Answer:
(b) Prinzmetal’s angina
Rationale:
If the client has a history of Prinzmetal’s angina, he should not be prescribed triptan preparations because they cause vasoconstriction and coronary spasms. There is no contraindication for taking triptan drugs in clients with diabetes, cancer, or cluster headaches making answers (a), (c), and (d) incorrect.
Question 46.
The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig’s sign is charted if the nurse notes:
(a) Pain on flexion of the hip and knee
(b) Nuchal rigidity on flexion of the neck
(c) Pain when the head is turned to the left side
(d) Dizziness when changing positions
Answer:
(a) Pain on flexion of the hip and knee
Rationale:
Kernig’s sign is positive if pain occurs on flexion of the hip and knee. The Brudzinski reflex is positive if pain occurs on flexion of the head and neck onto the chest so answer (b) is incorrect. Answers (c) and (d) might be present but are not related to Kernig’s sign.
Question 47.
The client with Alzheimer’s disease is being assisted with activities of daily living when the nurse notes that the client uses her tooth brush to brush her hair. The nurse is aware that the client is exhibiting:
(a) Agnosia
(b) Apraxia
(c) Anomia
(d) Aphasia
Answer:
(b) Apraxia
Rationale:
Apraxia is the inability to use objects appropriately. Agnosia is loss of sensory comprehension, anomia is the inability to find words, and aphasia is the inability to speak or understand so answers (a), (c), and (d) are incorrect.
Question 48.
The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:
(a) Chronic fatigue syndrome
(b) Normal aging
(c) Sundowning
(d) Delusions
Answer:
(c) Sundowning
Rationale:
Increased confusion at night is known as “sundowning" syndrome. This increased confusion occurs when the sun begins to set and continues during the night. Answer (a) is incorrect because fatigue is not necessarily present. Increased confusion at night is not part of normal aging; therefore, answer (b) is incorrect. A delusion is a firm, fixed belief; therefore, answer (d) is incorrect.
Question 49.
The client with confusion says to the nurse, “I haven’t had any thing to eat all day long. When are they going to bring breakfast?” The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make?
(a) “You know you had breakfast 30 minutes ago.”
(b) “I am so sorry that they didn’t get you breakfast. I'll report it to the charge nurse.”
(c) “I'll get you some juice and toast. Would you like something else?”
(d) “You will have to wait a while; lunch will be here in a little while.”
Answer:
(c) “I'll get you some juice and toast. Would you like something else?”
Rationale:
The client who is confused might forget that he ate earlier. Don’t argue with the client. Simply get him something to eat that will satisfy him until lunch. Answers (a) and (d) are incorrect because the nurse is dismissing the client. Answer (b) is validating the delusion.
Question 50.
The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer’s disease. Which side effect is most often associated with this drug?
(a) Urinary incontinence
(b) Headaches
(c) Confusion
(d) Nausea
Answer:
(d) Nausea
Rationale:
Nausea and gastrointestinal upset are very common in clients taking acetylcholinesterase inhibitors such as Exelon. Other side effects include liver toxicity, dizziness, unsteadiness, and clumsiness. The client might already be experiencing urinary incontinence or headaches, but they are not necessarily associated; and the client with Alzheimer’s disease is already confused. Therefore, answers (a), (b), and (c) are incorrect.
Question 51.
A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
(a) Document the finding.
(b) Report the finding to the doctor.
(c) Prepare the client for a C-section.
(d) Continue primary care as prescribed.
Answer:
(b) Report the finding to the doctor.
Rationale:
Any lesion should be reported to the doctor. This can indicate a herpes lesion. Clients with open lesions related to herpes are delivered by Cesarean section because there is a possibility of transmission of the infection to the fetus with direct contact to lesions. It is not enough to document the finding, so answer (a) is incorrect. The physician must make the decision to perform a C-section, making answer (c) incorrect. It is not enough to continue primary care, so answer (d) is incorrect.
Question 52.
A client with a diagnosis of HPV is at risk for which following?
(a) Hodgkin’s lymphoma
(b) Cervical cancer
(c) Multiple myeloma
(d) Ovarian cancer
Answer:
(b) Cervical cancer
Rationale:
The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the other cancers mentioned in answers (a), (c), and (d), so those are incorrect.
Question 53.
During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:
(a) Syphilis
(b) Herpes
(c) Gonorrhea
(d) Condylomata
Answer:
(b) Herpes
Rationale:
A lesion that is painful is most likely a herpetic lesion. A chancre lesion associated with syphilis is not painful, so answer (a) is incorrect. Condylomata lesions are painless warts, so answer (d) is incorrect. In answer (c), gonorrhea does not present as a lesion, but is exhibited by a yellow discharge.
Question 54.
A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is:
(a) Venereal Disease Research Lab (VDRL)
(b) Rapid plasma reagin (RPR)
(c) Florescent treponemal antibody (FA)
(d) Thayer-Martin culture (TMC)
Answer:
(c) Florescent treponemal antibody (FA)
Rationale:
Florescent treponemal antibody (FTA) is the test for treponema pallidum. VDRL and RPR are screening tests done for syphilis, so answers (a) and (b) are incorrect. The Thayer-Martin culture is done for gonorrhea, so answer (d) is incorrect.
Question 55.
A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?
(a) Elevated blood glucose
(b) Elevated platelet count
(c) Elevated creatinine clearance
(d) Elevated hepatic enzymes
Answer:
(d) Elevated hepatic enzymes
Rationale:
The criteria for HELLP is hemolysis, elevated liver enzymes, and low platelet count. In answer (a), an elevated blood glucose level is not associated with HELLP. Platelets are decreased, not elevated, in HELLP syndrome as stated in answer (b). The creatinine levels are elevated in renal disease and are not associated with HELLP syndrome so answer (c) is incorrect.
Question 56.
The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?
(a) The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.
(b) The nurse loosely suspends the client’s arm in an open hand while tapping the back of the client’s elbow.
(c) The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.
(d) The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.
Answer:
(a) The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.
Rationale:
Answer (b) elicits the triceps reflex, so it is incorrect. Answer (c) elicits the patella reflex, making it incorrect. Answer (d) elicits the radial nerve, so it is incorrect.
Question 57.
A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor’s order should the nurse question?
(a) Magnesium sulfate 4gm (25%) IV
(b) Brethine 10mcg IV
(c) Stadol 1 mg IV push every 4 hours as needed prn for pain
(d) Ancef 2gm IVPB every 6 hours
Answer:
(b) Brethine 10mcg IV
Rationale:
Brethine is used cautiously because it raises the blood glucose levels. Answers (a), (c), and (d) are all medications that are commonly used in the diabetic client, so they are incorrect.
Question 58.
A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L7S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidyl- glycerol is noted. The nurse’s assessment of this data is:
(a) The infant is at low risk for congenital anomalies.
(b) The infant is at high risk for intrauterine growth retardation.
(c) The infant is at high risk for respiratory distress syndrome.
(d) The infant is at high risk for birth trauma.
Answer:
Rationale:
When the L/S ratio reaches 2:1, the lungs are considered to be mature. The infant will most likely be small for gestational age and will not be at risk for birth trauma, so answer (d) is incorrect. The L/S ratio does not indicate congenital anomalies, as stated in answer (a), and the infant is not at risk for intrauterine growth retardation, making answer (b) incorrect.
Question 59.
Which observation in the newborn of a diabetic mother would require immediate nursing intervention?
(a) Crying
(b) Wakefulness
(c) Jitteriness
(d) Yawning
Answer:
(c) Jitteriness
Rationale:
Jitteriness is a sign of seizure in the neonate. Crying, wakefulness, and yawning are expected in the newborn, so answers (a), (b), and (d) are incorrect.
Question 60.
The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:
(a) Decreased urinary output
(b) Hypersomnolence
(c) Absence of knee jerk reflex
(d) Decreased respiratory rate
Answer:
(b) Hypersomnolence
Rationale:
The client is expected to become sleepy, have hot flashes, and be lethargic. A decreasing urinary output, absence of the knee-jerk reflex, and decreased respirations indicate toxicity, so answers (a), (c), and (d) are incorrect.
Question 61.
The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse would:
(a) Place her in Trendelenburg position.
(b) Decrease the rate of IV infusion.
(c) Administer oxygen per nasal cannula.
(d) Increase the rate of the IV infusion.
Answer:
(d) Increase the rate of the IV infusion.
Rationale:
If the client experiences hypotension after an injection of epidural anesthetic, the nurse should turn her to the left side, apply oxygen by mask, and speed the IV infusion. If the blood pressure does not return to normal, the physician should be contacted. Epinephrine should be kept for emergency administration. Answer (a) is incorrect because placing the client in Trendelenburg position (head down) will allow the anesthesia to move up above the respiratory center, thereby decreasing the diaphragm’s ability to move up and down and ventilate the client. In answer (b), the IV rate should be increased, not decreased. In answer (c), the oxygen should be applied by mask, not cannula.
Question 62.
A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis?
(a) Alteration in nutrition
(b) Alteration in bowel elimination
(c) Alteration in skin integrity
(d) Ineffective individual coping
Answer:
(a) Alteration in nutrition
Rationale:
Cancer of the pancreas frequently leads to severe nausea and vomiting and altered glucose levels. The other problems are of lesser concern; thus, answers (b), (c), and (d) are incorrect.
Question 63.
The nurse aware that is caring for a client with uremic frost. The nurse is uremic frost is often seen in clients with:
(a) Severe anemia
(b) Arteriosclerosis
(c) Liver failure
(d) Parathyroid disorder
Answer:
(c) Liver failure
Rationale:
Uremic frost is most likely related to liver disease. It is not related to anemia, arteriosclerosis, or parathyroid disorders, therefore (a), (b), and (d) are incorrect.
Question 64.
The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client’s most appropriate priority nursing diagnosis?
(a) Alteration in cerebral tissue perfusion
(b) Fluid volume deficit
(c) Ineffective airway clearance
(d) Alteration in sensory perception
Answer:
(b) Fluid volume deficit
Rationale:
The vital signs indicate hypovolemic shock. They do not indicate cerebral tissue perfusion, airway clearance, or sensory perception alterations, so answers (a), (c), and (d) are incorrect.
Question 65.
The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:
(a) Likes to play football
(b) Drinks carbonated drinks
(c) Has two sisters
(d) Is taking acetaminophen for pain
Answer:
(a) Likes to play football
Rationale:
The client with osteogenesis imperfecta is at risk for pathological fractures and is likely to experience these fractures if he participates in contact sports. Answers (b), (c), and (d)are not factors for concern.
Question 66.
The nurse working the organ transplant unit is caring for a client with a white blood cell count of 450. During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?
(a) Allow the client to keep the fruit.
(b) Place the fruit next to the bed for easy access by the client.
(c) Offer to wash the fruit for the client.
(d) Ask the family members to take the fruit home.
Answer:
(d) Ask the family members to take the fruit home.
Rationale:
The client with neutropenia should not have fresh fruit because it should be peeled and/or cooked before eating. Any source of bacteria should be eliminated, if possible. Answers (a), (b), and (c) will not help prevent bacterial invasions.
Question 67.
The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40. The initial nurse’s action should be to:
(a) Place the client in Trendelenburg position.
(b) Increase the infusion of normal saline.
(c) Administer atropine intravenously.
(d) Move the emergency cart to the bedside.
Answer:
(b) Increase the infusion of normal saline.
Rationale:
The client’s BP is low so increasing the IV is priority. Answers (a), (c), and (d) are not the first priority therefore they are incorrect.
Question 68.
The client admitted two days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?
(a) Order a chest x-ray.
(b) Reinsert the tube.
(c) Cover the insertion site with a Vaseline gauze.
(d) Call the doctor.
Answer:
(c) Cover the insertion site with a Vaseline gauze.
Rationale:
If the client pulls the chest tube out of the chest, the nurse’s first action should be to cover the insertion site with an occlusive dressing. Afterward, the nurse should call the doctor, who will order a chest x-ray and possibly reinsert the tube. Answers (a), (b), and (d) are not the first action to be taken.
Question 69.
A client being treated with sodium warfarin (Coumadin) has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?
(a) Assess for signs of abnormal bleeding.
(b) Anticipate an increase in the Coumadin dosage.
(c) Instruct the client regarding the drug therapy.
(d) Increase the frequency of neurological assessments.
Answer:
(a) Assess for signs of abnormal bleeding.
Rationale:
The normal Protime is approximately 12-20 seconds. A Protime of 120 seconds indicates an extremely prolonged Protime and can result in a spontaneous bleeding episode. Answers (b), (c), and (d) may be needed at a later time but are not the most important actions to take first.
Question 70.
Which selection would provide the most calcium for the client who is four months pregnant?
(a) A granola bar
(b) A bran muffin
(c) A cup of yogurt
(d) A glass of fruit juice
Answer:
(c) A cup of yogurt
Rationale:
The food with the most calcium is the yogurt. Answers (a), (b), and (d) are good choices, but not as good as the yogurt, which has approximately 400mg of calcium.
Question 71.
The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates the understanding of magnesium toxicity?
(a) The nurse performs a vaginal exam every 30 minutes.
(b) The nurse places a padded tongue blade at the bed side.
(c) The nurse inserts a Foley catheter.
(d) The nurse darkens the room.
Answer:
(c) The nurse inserts a Foley catheter.
Rationale:
The client receiving magnesium sulfate should have a Foley catheter in place, and hourly intake and output should be checked. Answers (a), (b), and (d) are incorrect because they do not indicate understanding of MgSO4 toxicity.
Question 72.
The best size cathlon for administration of a blood transfusion to a six-year-old is:
(a) 18 gauge
(b) 19 gauge
(c) 22 gauge
(d) 20 gauge
Answer:
(d) 20 gauge
Rationale:
(d) is correct because the best size cathlon to use in a child receiving blood is a 20 gauge. (a), (b), and (c) are incorrect because the size is either too large or too small.
Question 73.
A client is admitted to the unit two hours after an explosion caus¬es burns to the face. The nurse would be most concerned with the client developing which of the following?
(a) Hypovolemia
(b) Laryngeal edema
(c) Hypernatremia
(d) Hyperkalemia
Answer:
(b) Laryngeal edema
Rationale:
The nurse should be most concerned with laryngeal edema because of the area of burn. The next priority should be answer (a), as well as hyponatremia and hypokalemia in (c) and (d), but these answers are not of primary concern so are incorrect.
Question 74.
The client has recently been diagnosed with diabetes. Which of the following indicates understanding of the management of diabetes?
(a) The client selects a balanced diet from the menu.
(b) The client can tell the nurse the normal blood glucose level.
(c) The client asks for brochures on the subject of diabetes.
(d) The client demonstrates correct insulin injection technique.
Answer:
(d) The client demonstrates correct insulin injection technique.
Rationale:
The client with diabetes indicates understanding of his illness by correctly demonstrating the technique for administration. (a), (b), and (c) are incorrect because they do not indicate understanding.
Question 75.
The client is admitted following cast application for a fractured ulna. Which finding should be reported to the doctor?
(a) Pain at the site
(b) Warm fingers
(c) Pulses rapid
(d) Paresthesia of the fingers
Answer:
(d) Paresthesia of the fingers
Rationale:
At this time, pain beneath the cast is normal. The client’s fingers should be warm to the touch, and pulses should be present. Paresthesia is not normal and might indicate compartment syndrome. Therefore, answers (a), (b), and (c) are incorrect.
Question 76.
The client with AIDS should be taught to:
(a) Avoid warm climates.
(b) Refrain from taking herbals.
(c) Avoid exercising.
(d) Report any changes in skin color.
Answer:
(b) Refrain from taking herbals.
Rationale:
Herbals can prolong bleeding times or interfere with antiviral medications, therefore the client should avoid the use of herbals. (a) and (d) are not contraindicated for the client with AIDS. (c) is incorrect because there is no need to report all changes in skin color.
Question 77.
Which action by the healthcare worker indicates a need for further teaching?
(a) The nursing assistant ambulates the elderly client using a gait belt.
(b) The nurse wears goggles while performing a venop-uncture.
(c) The nurse washes his hands after changing a dressing.
(d) The nurse wears gloves to monitor the IV infusion rate.
Answer:
(d) The nurse wears gloves to monitor the IV infusion rate.
Rationale:
It is not necessary to wear gloves to check the IV drip rate. The healthcare workers in answers (a), (b), and (c) indicate knowledge by their actions.
Question 78.
The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT the nurse should:
(a) Apply a tourniquet to the client’s arm.
(b) Administer an anticonvulsant medication.
(c) Ask the client if he is allergic to shell fish.
(d) Apply a blood pressure cuff to the arm.
Answer:
(d) Apply a blood pressure cuff to the arm.
Rationale:
The client that is having ECT is given a sedative. When the blood pressure cuff is inflated the fingers twitch when he has a grand mal seizure. (a), (b), and (c) are incorrect because there is no need for the nurse to take these interventions prior to ECT.
Question 79.
The five-year-old is being tested for enterobiasis (pinworms). Which symptom is associated with enterobiasis?
(a) Rectal itching
(b) Nausea
(c) Oral ulcerations
(d) Scalp itching
Answer:
(a) Rectal itching
Rationale:
Pinworms cause rectal itching. (b), (c), and (d) are incorrect because they are not signs of pinworms.
Question 80.
The nurse is teaching the mother regarding treatment for pedicalosis capitis. Which instruction should be given regarding the medication?
(a) Treatment is not recommended for children less than 10 years of age.
(b) Bed linens should be washed in hot water.
(c) Medication therapy will continue for one year.
(d) Intravenous antibiotic therapy will be ordered.
Answer:
(b) Bed linens should be washed in hot water.
Rationale:
Bed linen should be washed in hot water. (a) is incorrect because special shampoos can be used by children under age 10. Answers (c) and (d) are incorrect statements therefore they are wrong.
Question 81.
The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?
(a) The client with HIV
(b) The client with a radium implant for cervical cancer
(c) The client with RSV (respiratory synctial virus)
(d) The client with cytomegalovirus
Answer:
(a) The client with HIV
Rationale:
The pregnant nurse can care for the client with HIV if she uses standard precautions. The clients in answers (b), (c), and (d) pose a risk to the pregnant nurse.
Question 82.
The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
(a) The client with methicillin resistant-staphylococcus aureas (MRSA)
(b) The client with diabetes
(c) The client with pancreatitis
(d) The client with Addison’s disease
Answer:
(a) The client with methicillin resistant-staphylococcus aureas (MRSA)
Rationale:
The client with MRSA is placed on contact precautions. The clients in answers (b), (c), and (d) pose no risk to themselves or others.
Question 83.
The doctor accidentally cuts the bowel during surgery. As a result of this action, the client develops an infection and suffers brain damage. The doctor can be charged with:
(a) Negligence
(b) Tort
(c) Assault
(d) Malpractice
Answer:
(d) Malpractice
Rationale:
The doctor could be charged with malpractice, which is failing to perform, or performing an act that causes harm to the client. Answers (a), (b), and (c) are incorrect because they apply to other wrongful acts. Negligence is failing to perform care for the client; a tort is a wrongful act committed on the client or their belongings; and assault is a violent physical or verbal attack.
Question 84.
Which assignment should not be performed by the nursing assistant?
(a) Feeding the client
(b) Bathing the client
(c) Obtaining a stool
(d) Administering a fleet enema
Answer:
(d) Administering a fleet enema
Rationale:
The nursing assistant should not be assigned to administer a Fleets enema. They can administer a soap suds or tap water enema. The other tasks can be performed by the nursing assistant, therefore (a), (b), and (c) are incorrect.
Question 85.
The mother calls the clinic to report that her newborn has a rash on his forehead and face. Which action is most appropriate?
(a) Tell the mother to wash the face with soap and apply powder.
(b) Tell her that 30% of newborns have a rash that will go away by one month of life.
(c) Report the rash to the doctor immediately.
(d) Ask the mother if anyone else in the family has had a rash in the last six months.
Answer:
(b) Tell her that 30% of newborns have a rash that will go away by one month of life.
Rationale:
The mother is most likely describing a newborn rash. About 30% of all newborns have a rash on the face and forehead that dissipates in approximately one month. (a), (c), and (d) are incorrect actions.
Question 86.
Which nurse should not be assigned to care for the client with a radium implant for vaginal cancer?
(a) The LPN who is six months postpartum
(b) The RN who is pregnant
(c) The Rl\l who is allergic to iodine
(d) The RN with a three-year-old at home
Answer:
(b) The RN who is pregnant
Rationale:
The nurse who is pregnant should not be assigned to the client with a radium implant. The other nurses are not at risk when caring for this client, so (a), (c), and (d) are incorrect.
Question 87.
Which information should be reported to the state Board of Nursing?
(a) The facility fails to provide literature in both Spanish and English.
(b) The narcotic count has been incorrect on the unit for the past three days.
(c) The client fails to receive an itemized account of his bills and services received during his hospital stay.
(d) The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.
Answer:
(b) The narcotic count has been incorrect on the unit for the past three days.
Rationale:
The Joint Commission on Accreditation of Hospitals will probably be interested in the problems in answers (a) and (c). The failure of the nursing assistant to care for the client with hepatitis might result in termination, but is not of interest to the Joint Commission.
Question 88.
The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:
(a) Call the Board of Nursing.
(b) File a formal reprimand.
(c) Terminate the nurse.
(d) Charge the nurse with a tort.
Answer:
(b) File a formal reprimand.
Rationale:
The next action after discussing the problem with the nurse is to document the incident by filing a formal reprimand. If the behavior continues or if harm has resulted to the client, the nurse may be terminated and reported to the Board of Nursing, but these are not the first actions requested in the stem. A tort is a wrongful act to the client or his belongings and is not indicated in this instance. Therefore, Answers (a), (c), and (d) are incorrect.
Question 89.
The home health nurse is planning for the day’s visits. Which client should be seen first?
(a) The 78-year-old who had a gastrectomy three weeks ago and has a PEG tube
(b) The five-month-old discharged one week ago with pneumonia who is being treated with amoxicillin liquid suspension
(c) The 50-year-old with MRSA being treated with Vancomycin via a PICC line
(d) The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter
Answer:
(d) The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter
Rationale:
The client at highest risk for complications is the client with multiple sclerosis who is being treated with cortisone via the central line. The clients in answers (a), (b), and (c) are more stable and can be seen later.
Question 90.
The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?
(a) A client having auditory hallucinations and the client with ulcerative colitis
(b) The client who is pregnant and the client with a broken arm
(c) A child who is cyanotic with severe dypsnea and a client with a frontal head injury
(d) The client who arrives with a large puncture wound to the abdomen and the client with chest pain
Answer:
(b) The client who is pregnant and the client with a broken arm
Rationale:
The pregnant client and the client with a broken arm are the best choices for placing in the same room. The clients in answers (a), (c), and (d) need to be placed in separate rooms due to the serious natures of their injuries.
Question 91.
Before ognize administering eardrops to a toddler, the nurse should recthat it is essential to consider which of the following?
(a) The age of the child
(b) The child’s weight
(c) The developmental level of the child
(d) The IQ of the child
Answer:
(a) The age of the child
Rationale:
Before instilling the eardrops, the nurse should consider the age of the child because the ear should be pulled down and out to best deliver the drops in the ear canal. (b), (c), and (d) are not considerations when instilling eardrops in a small child.
Question 92.
The nurse is discussing meal planning with the mother of a two- year-old. Which of the following statements, if made by the mother, would require a need for further instruction?
(a) “It is okay to give my child white grape juice for breakfast.”
(b) “My child can have a grilled cheese sandwich for lunch."
(c) “We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch.”
(d) “For a snack, my child can have ice cream.”
Answer:
(c) “We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch.”
Rationale:
Remember the ABCs (airway, breathing, circulation) when answering this question. Answer (c) is correct because a hotdog is the size and shape of the child’s trachea and poses a risk of aspiration. Answers (a), (b), and (d) are incorrect because white grape juice, a grilled cheese sandwich, and ice cream do not pose a risk of aspiration for a child.
Question 93.
A client with AIDS has a viral load of 200 copies per ml. The nurse should interpret this finding as:
(a) The client is at risk for opportunistic diseases.
(b) The client is no longer communicable.
(c) The client’s viral load is extremely low so he is relatively free of circulating virus.
(d) The client’s T-cell count is extremely low.
Answer:
(c) The client’s viral load is extremely low so he is relatively free of circulating virus.
Rationale:
A viral load of 200 is extremely low. This indicates that the client has a low risk for opportunistic illnesses. (a), (b), and (d) do not indicate understanding.
Question 94.
The client has an order for sliding scale insulin at 1900 hours and Lantus insulin at the same hour. The nurse should:
(a) Administer the two medications together.
(b) Administer the medications in two injections.
(c) Draw up the Lantus insulin and then the regular insulin and administer them together.
(d) Contact the doctor because these medications should not be given to the same client.
Answer:
(b) Administer the medications in two injections.
Rationale:
Lantus insulin cannot be mixed with other insulins, but can be taken by the client taking regular insulin. (a), (c), and (d) are not correct methods of administering Lantus insulin with regular insulin.
Question 95.
A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:
(a) Altered nutrition
(b) Impaired communication
(c) Risk for injury/aspiration
(d) Altered urinary elimination
Answer:
(c) Risk for injury/aspiration
Rationale:
Always remember your ABCs (airway, breathing, circulation) when selecting an answer. (a), (b), and (d) are incorrect because they are not the priority.
Question 96.
What would the nurse expect the admitting assessment to reveal in a client with glomerulonephritis?
(a) Hypertension
(b) Lassitude
(c) Fatigue
(d) Vomiting and diarrhea
Answer:
(a) Hypertension
Rationale:
The client with glomerulonephritis will probably have hypertension. (b) and (c) are vague answers and are therefore incorrect. (d) does not directly relate to glomerulonephritis.
Question 97.
Which action is contraindicated in the client with epiglottis?
(a) Ambulation
(b) Oral airway assessment using a tongue blade
(c) Placing a blood pressure cuff on the arm
(d) Checking the deep tendon reflexes.
Answer:
(b) Oral airway assessment using a tongue blade
Rationale:
A child with epiglottis has the possibility of complete obstruction of the airway. For this reason the nurse should not evaluate the airway using a tongue blade. (a), (c), and (d) are allowed actions and are therefore incorrect.
Question 98.
A 25-year-old client with a goiter is admitted to the unit. What would the nurse expect the admitting assessment to reveal?
(a) Slow pulse
(b) Anorexia
(c) Bulging eyes
(d) Weight gain
Answer:
(c) Bulging eyes
Rationale:
Exophthalmos (protrusion of eyeballs) often occurs with hyper thyroidism. The client with hyperthyroidism will often exhibit tachycardia, increased appetite, and weight loss; therefore, answers (a), (b), and (d) are incorrect.
Question 99.
Which of the following foods, if selected by the mother with a child with celiac, would indicate her understanding of the dietary instructions?
(a) Whole-wheat toast
(b) Angel hair pasta
(c) Reuben on rye
(d) Rice cereal
Answer:
(d) Rice cereal
Rationale:
The child with celiac disease should be on a gluten-free diet. Answers (a), (b), and (c) all contain gluten, while answer (d) gives the only choice of foods that does not contain gluten.
Question 100.
The first action that the nurse should take if she finds the client has an 02 saturation of 68% is:
(a) Elevate the head.
(b) Recheck the O2 saturation in 30 minutes.
(c) Apply oxygen by mask.
(d) Assess the heart rate.
Answer:
(c) Apply oxygen by mask.
Rationale:
Remember the ABCs (airway, breathing, circulation) when answering this question. Before notifying the physician or assessing the pulse, oxygen should be applied to increase the oxygen saturation, so answers (a) and (d) are incorrect. The normal oxygen saturation is 92%-100%, making answer (b) incorrect.
Question 101.
Which observation would the nurse expect to make after an amniotomy?
(a) Dark yellow amniotic fluid
(b) Clear amniotic fluid
(c) Greenish amniotic fluid
(d) Red amniotic fluid
Answer:
(b) Clear amniotic fluid
Rationale:
An amniotomy is an artificial rupture of membranes and normal amniotic fluid is straw-colored and odorless. (a), (c), and (d) are abnormal findings.
Question 102.
The client taking Glyburide (Diabeta) should be cautioned to
(a) Avoid eating sweets.
(b) Report changes in urinary pattern.
(c) Allow three hours for onset.
(d) Check the glucose daily.
Answer:
(d) Check the glucose daily.
Rationale:
Diabeta is an antidiabetic medication that can result in hypoglycemia. (a), (b), and (d) are incorrect because they are not related to Diabeta.
Question 103.
The obstetric client’s fetal heart rate is 80-90 during the contractions. The first action the nurse should take is:
(a) Reposition the monitor.
(b) Turn the client to her left side.
(c) Ask the client to ambulate.
(d) Prepare the client for delivery.
Answer:
(b) Turn the client to her left side.
Rationale:
The normal fetal heart rate is 120-160bpm; 100-110bpm is bradycardia. The first action would be to turn the client to the left side and apply oxygen. Answer (a) is not indicated at this time. Answer (c) is not the best action for clients experiencing bradycardia. There is no data to indicate the need to move the client to the delivery room at this time.
Question 104.
Arterial ulcers are best described as ulcers
(a) Are smooth in texture
(b) Have irregular borders
(c) Are cool to touch
(d) Are painful to touch
Answer:
(d) Are painful to touch
Rationale:
Arterial ulcers are painful. (a), (b), and (c) are incorrect because they do not describe arterial ulcers.
Question 105.
A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?
(a) Anticipate the need for a Caesarean section.
(b) Apply an internal fetal monitor.
(c) Place the client in Genu Pectoral position.
(d) Perform an ultrasound.
Answer:
(b) Apply an internal fetal monitor.
Rationale:
Applying a fetal heart monitor is the correct action at this time. There is no need to prepare for a Caesarean section or to place the client in Genu Pectoral position (knee-chest), so answers (a) and (c) are incorrect. Answer (d) is incorrect because there is no need for an ultrasound based on the finding.
Question 106.
A vaginal exam reveals that the cervix is 4cm dilated, with intact membranes and a fetal heart tone rate of 160-170bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is:
(a) The cervix is closed.
(b) The membranes are still intact.
(c) The fetal heart tones are within normal limits.
(d) The contractions are intense enough for insertion of an internal monitor.
Answer:
(b) The membranes are still intact.
Rationale:
The nurse decides to apply an external monitor because the membranes are intact. Answers (a), (c), and (d) are incorrect. The cervix is dilated enough to use an internal monitor, if necessary. An internal monitor can be applied if the client is at 0-station. Contraction intensity has no bearing on the application of the fetal monitor.
Question 107.
The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primagravida as she completes the early phase of labor?
(a) Impaired gas exchange related to hyperventilation
(b) Alteration in placental perfusion related to maternal position
(c) Impaired physical mobility related to fetal-monitoring equipment
(d) Potential fluid volume deficit related to decreased fluid intake
Answer:
(d) Potential fluid volume deficit related to decreased fluid intake
Rationale:
Clients admitted in labor are told not to eat during labor, to avoid nausea and vomiting. Ice chips may be allowed, but this amount of fluid might not be sufficient to prevent fluid volume deficit. In answer (a), impaired gas exchange related to hyperventilation would be indicated during the transition phase. Answers (b) and (c) are not correct in relation to the stem.
Question 108.
As the client reaches 6cm dilation, the nurse notes late decelerations on the fetal monitor. What is the most likely explanation of this pattern?
(a) The baby is sleeping.
(b) The umbilical cord is compressed.
(c) There is head compression.
(d) There is uteroplacental insufficiency.
Answer:
(d) There is uteroplacental insufficiency.
Rationale:
This information indicates a late deceleration. This type of deceleration is caused by uteroplacental lack of oxygen. Answer (a) has no relation to the readings, so it’s incorrect; answer (b) results in a variable deceleration; and answer (c) is indicative of an early deceleration.
Question 109.
The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
(a) Notify her doctor.
(b) Start an IV.
(c) Reposition the client.
(d) Readjust the monitor.
Answer:
(c) Reposition the client.
Rationale:
The initial action by the nurse observing a late deceleration should be to turn the client to the side preferably, the left side. Administering oxygen is also indicated. Answer (a) might be necessary but not before turning the client to her side. Answer (b) is not necessary at this time. Answer (d) is incorrect because there is no data to indicate that the monitor has been applied incorrectly.
Question 110.
Which of the following is a characteristic of an ominous periodic change in the fetal heart rate?
(a) A fetal heart rate of 120-130bpm
(b) A baseline variability of 6-10bpm
(c) Accelerations in FHR with fetal movement
(d) A recurrent rate of 90-100bpm at the end of the contractions
Answer:
(d) A recurrent rate of 90-100bpm at the end of the contractions
Rationale:
A deceleration to 90-100bpm at the end of contractions are late decelerations. This finding is ominous (bad) and should be reported. (a), (b), and (d) are normal findings and are therefore incorrect.
Question 111.
The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:
(a) The bladder fills more rapidly because of the medication used for the epidural.
(b) Her level of consciousness is such that she is in a trancelike state.
(c) The sensation of the bladder filling is diminished or lost.
(d) She is embarrassed to ask for the bedpan that frequently.
Answer:
(c) The sensation of the bladder filling is diminished or lost.
Rationale:
Epidural anesthesia decreases the urge to void and sensation of a full bladder. A full bladder will decrease the progression of labor. Answers (a), (b), and (d) are incorrect for the stem.
Question 112.
A client in the family planning clinic asks the nurse about the most likely time for her to conceive. The nurse explains that conception is most likely to occur when:
(a) Estrogen levels are low
(b) Lutenizing hormone is high
(c) The endometrial lining is thin
(d) The progesterone level is low
Answer:
(b) Lutenizing hormone is high
Rationale:
Lutenizing hormone released by the pituitary is responsible for ovulation. At about day 14, the continued increase in estrogen stimulates the release of lutenizing hormone from the anterior pituitary. The LH surge is responsible for ovulation, or the release of the dominant follicle in preparation for conception, which occurs within the next 10-12 hours after the LH levels peak. Answers (a), (c), and (d) are incorrect because estrogen levels are high at the beginning of ovulation, the endometrial lining is thick, not thin, and the progesterone levels are high, not low.
Question 113.
A client tells the nurse that she plans to use the rhythm method of birth control. The nurse is aware that the success of the rhythm method depends on the:
(a) Age of the client
(b) Frequency of intercourse
(c) Regularity of the menses
(d) Range of the client’s temperature
Answer:
(c) Regularity of the menses
Rationale:
The success of the rhythm method of birth control is dependent on the client’s menses being regular. It is not dependent on the age of the client, frequency of intercourse, or range of the client’s temperature; therefore, answers (a), (b), and (d) are incorrect.
Question 114.
A client with diabetes asks the nurse for advice regarding methods of birth control. Which method of birth control is most suitable for the client with diabetes?
(a) Intrauterine device
(b) Oral contraceptives
(c) Diaphragm
(d) Contraceptive sponge
Answer:
(c) Diaphragm
Rationale:
The best method of birth control for the client with diabetes is the diaphragm. A permanent intrauterine device can cause a continuing inflammatory response in diabetics that should be avoided, oral contraceptives tend to elevate blood glucose levels, and contraceptive sponges are not good at preventing pregnancy. Therefore, answers (a), (b), and (d) are incorrect.
Question 115.
The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of a ruptured ectopic pregnancy?
(a) Painless vaginal bleeding
(b) Abdominal cramping
(c) Throbbing pain in the upper quadrant
(d) Sudden, stabbing pain in the lower quadrant
Answer:
(d) Sudden, stabbing pain in the lower quadrant
Rationale:
The signs of an ectopic pregnancy are vague until the fallopian tube ruptures. The client will complain of sudden, stabbing pain in the lower quadrant that radiates down the leg or up into the chest. Painless vaginal bleeding is a sign of placenta previa, abdominal cramping is a sign of labor, and throbbing pain in the upper quadrant is not a sign of an ectopic pregnancy, making answers (a), (b), and (c) incorrect.
Question 116.
The nurse is teaching a pregnant client about nutritional needs during pregnancy. Which menu selection will best meet the nutritional needs of the pregnant client?
(a) Hamburger patty, green beans, French fries, and iced tea
(b) Roast beef sandwich, potato chips, baked beans, and cola
(c) Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea
(d) Fish sandwich, gelatin with fruit, and coffee
Answer:
(c) Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea
Rationale:
All of the choices are tasty, but the pregnant client needs a diet that is balanced and has increased amounts of calcium. Answer (a) is lacking in fruits and milk. Answer (b) contains the potato chips, which contain a large amount of sodium. Answer (c) contains meat, fruit, potato salad, and yogurt, which has about 360mg of calcium. Answer (d) is not the best diet because it lacks vegetables and milk products.
Question 117.
The client with hyperemesis gravidarum is at risk for developing:
(a) Respiratory alkalosis without dehydration
(b) Metabolic acidosis with dehydration
(c) Respiratory acidosis without dehydration
(d) Metabolic alkalosis with dehydration
Answer:
(b) Metabolic acidosis with dehydration
Rationale:
The client with hyperemesis has persistent nausea and vomiting. With vomiting comes dehydration. When the client is dehydrated, she will have metabolic acidosis. Answers (a) and (c) are incorrect because they are respiratory dehydration. Answer (d) is incorrect because the client will not be in alkalosis with persistent vomiting.
Question 118.
A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:
(a) Elevated human chorionic gonadatropin
(b) The presence of fetal heart tones
(c) Uterine enlargement
(d) Breast enlargement and tenderness
Answer:
(b) The presence of fetal heart tones
Rationale:
The most definitive diagnosis of pregnancy is the presence of fetal heart tones. The signs in answers (a), (c), and (d) are subjective and might be related to other medical conditions. Answers (a) and (c) may be related to a hydatidiform mole, and answer (d) is often present before menses or with the use of oral contraceptives.
Question 119.
The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:
(a) Hypoglycemic, small for gestational age
(b) Hyperglycemic, large for gestational age
(c) Hypoglycemic, large for gestational age
(d) Hyperglycemic, small for gestational age
Answer:
(c) Hypoglycemic, large for gestational age
Rationale:
The infant of a diabetic mother is usually large for gestational age. After birth, glucose levels fall rapidly due to the absence of glucose from the mother. Answer (a) is incorrect because the infant will not be small for gestational age. Answer (b) is incorrect because the infant will not be hyperglycemic. Answer (d) is incorrect because the infant will be large, not small, and will be hypoglycemic, not hyperglycemic.
Question 120.
Which of the following instructions should be included in the nurse’s teaching regarding oral contraceptives?
(a) Weight gain should be reported to the physician.
(b) An alternate method of birth control is needed when taking antibiotics.
(c) If the client misses one or more pills, two pills should be taken per day for one week.
(d) Changes in the menstrual flow should be reported to the physician.
Answer:
(b) An alternate method of birth control is needed when taking antibiotics.
Rationale:
When the client is taking oral contraceptives and begins antibiotics, another method of birth control should be used. Antibiotics decrease the effectiveness of oral contraceptives. Approximately 5-10 pounds of weight gain is not unusual, so answer (a) is incorrect. If the client misses a birth control pill, she should be instructed to take the pill as soon as she remembers the pill. Answer (c) is incorrect. If she misses two, she should take two; if she misses more than two, she should take the missed pills but use another method of birth control for the remainder of the cycle. Answer (d) is incorrect because changes in menstrual flow are expected in clients using oral contraceptives. Often these clients have lighter menses.
Question 121.
The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client with:
(a) Diabetes
(b) HIV
(c) Hypertension
(d) Thyroid disease
Answer:
(b) HIV
Rationale:
Clients with HIV should not breastfeed because the infection can be transmitted to the baby through breast milk. The clients in answers (a), (c), and (d) those with diabetes, hypertension, and thyroid disease can be allowed to breastfeed.
Question 122.
A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse’s first action should be to:
(a) Assess the fetal heart tones.
(b) Check for cervical dilation.
(c) Check for firmness of the uterus.
(d) Obtain a detailed history.
Answer:
(a) Assess the fetal heart tones.
Rationale:
The symptoms of painless vaginal bleeding are consistent with placenta previa. Answers (b), (c), and (d) are incorrect. Cervical check for dilation is contraindicated because this can increase the bleeding. Checking for firmness of the uterus can be done, but the first action should be to check the fetal heart tones. A detailed history can be done later.
Question 123.
A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:
(a) Her contractions are two minutes apart.
(b) She has back pain and a bloody discharge.
(c) She experiences abdominal pain and frequent urination.
(d) Her contractions are five minutes apart.
Answer:
(d) Her contractions are five minutes apart.
Rationale:
The client should be advised to come to the labor and delivery unit when the contractions are every five minutes and consistent. She should also be told to report to the hospital if she experiences rupture of membranes or extreme bleeding. She should not wait until the contractions are every two minutes or until she has bloody discharge, so answers (a) and (b) are incorrect. Answer (c) is a vague answer and can be related to a urinary tract infection.
Question 124.
The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy?
(a) Low birth weight
(b) Large for gestational age
(c) Preterm birth, but appropriate size for gestation
(d) Growth retardation in weight and length
Answer:
(a) Low birth weight
Rationale:
Infants of mothers who smoke are often low in birth weight. Infants who are large for gestational age are associated with diabetic mothers, so answer (b) is incorrect. Preterm births are associated with smoking, but not with appropriate size for gestation, making answer (c) incorrect. Growth retardation is associated with smoking, but this does not affect the infant length; therefore, answer (d) is incorrect.
Question 125.
The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is 0 positive. To provide postpartum prophylaxis, RhoGam should be administered:
(a) Within 72 hours of delivery
(b) Within one week of delivery
(c) Within two weeks of delivery
(d) Within one month of delivery
Answer:
(a) Within 72 hours of delivery
Rationale:
To provide protection against antibody production, RhoGam should be given within 72 hours. The answers in (b), (c), and (d) are too late to provide antibody protection. RhoGam can also be given during pregnancy.
Question 126.
After the physician performs an amniotomy, the nurse’s first action should be to assess the:
(a) Degree of cervical dilation
(b) Fetal heart tones
(c) Client’s vital signs
(d) Client’s level of discomfort
Answer:
(b) Fetal heart tones
Rationale:
When the membranes rupture, there is often a transient drop in the fetal heart tones. The heart tones should return to baseline quickly. Any alteration in fetal heart tones, such as bradycardia or tachycardia, should be reported. After the fetal heart tones are assessed, the nurse should evaluate the cervical dilation, vital signs, and level of discomfort, making answers (a), (c), and (d) incorrect.
Question 127.
A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client’s cervix is 5cm dilated with 75% effacement. Based on the nurse’s assessment the client is in which phase of labor?
(a) Active
(b) Latent
(c) Transition
(d) Early
Answer:
(a) Active
Rationale:
The active phase of labor occurs when the client is dilated 4-7cm. The latent or early phase of labor is from 1cm to 3cm in dilation, so answers (b) and (d) are incorrect. The transition phase of labor is 8-1 Ocm in dilation, making answer (c) incorrect.
Question 128.
A newborn with narcotic abstinence syndrome is admitted to the nursery. Nursing care of the newborn should include:
(a) Teaching the mother to provide tactile stimulation
(b) Wrapping the newborn snugly in a blanket
(c) Placing the newborn in the infant seat
(d) Initiating an early infant-stimulation program
Answer:
(b) Wrapping the newborn snugly in a blanket
Rationale:
The infant of an addicted mother will undergo withdrawal. Snugly wrapping the infant in a blanket will help prevent the muscle irritability that these babies often experience. Teaching the mother to provide tactile stimulation or provide for early infant stimulation are incorrect because he is irritable and needs quiet and little stimulation at this time, so answers (a) and (d) are incorrect. Placing the infant in an infant seat in answer (c) is incorrect because this will also cause movement that can increase muscle irritability.
Question 129.
A client elects to have epidural anesthesia to relieve the discomfort of labor. Following the initiation of epidural anesthesia, the nurse should give priority to:
(a) Checking for cervical dilation
(b) Placing the client in a supine position
(c) Checking the client’s blood pressure
(d) Obtaining a fetal heart rate
Answer:
(c) Checking the client’s blood pressure
Rationale:
Following epidural anesthesia, the client should be checked for hypotension and signs of shock every five minutes for 15 minutes. The client can be checked for cervical dilation later after she is stable. The client should not be positioned supine because the anesthesia can move above the respiratory center and the client can stop breathing. Fetal heart tones should be assessed after the blood pressure is checked. Therefore, answers (a), (b), and (d) are incorrect.
Question 130.
The nurse is aware that the best way to prevent post-operative wound infection in the surgical client is to:
(a) Administer a prescribed antibiotic.
(b) Wash her hands for two minutes before care.
(c) Wear a mask when providing care.
(d) Ask the client to cover her mouth when she coughs.
Answer:
(b) Wash her hands for two minutes before care.
Rationale:
The best way to prevent post-operative wound infection is hand washing. Use of prescribed antibiotics will treat infection, not prevent infections, mak¬ing answer (a) incorrect. Wearing a mask and asking the client to cover her mouth are good practices but will not prevent wound infections; therefore, answers (c) and (d) are incorrect.
Question 131.
The elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip most likely to exhibit?
(a) Pain
(b) Disalignment
(c) Cool extremity
(d) Absence of pedal pulses
Answer:
(b) Disalignment
Rationale:
The client with a hip fracture will most likely have disalignment. Answers (a), (c), and (d) are incorrect because all fractures cause pain, and coolness of the extremities and absence of pulses are indicative of compartment syndrome or peripheral vascular disease.
Question 132.
The nurse knows that a 60-year-old female client’s susceptibility to osteoporosis is most likely related to:
(a) Lack of exercise
(b) Hormonal disturbances
(c) Lack of calcium
(d) Genetic predisposition
Answer:
(b) Hormonal disturbances
Rationale:
After menopause, women lack hormones necessary to absorb and utilize calcium. Doing weight-bearing exercises and taking calcium supplements can help to prevent osteoporosis but are not causes, so answers (a) and (c) are incorrect. Body types that frequently experience osteoporosis are thin Caucasian females, but they are not most likely related to osteoporosis, so answer (d) is incorrect.
Question 133.
A two-year-old is admitted for repair of a fractured femur and is placed in Bryant’s traction. Which finding by the nurse indicates that the traction is working properly?
(a) The infant no longer complains of pain.
(b) The buttocks are 15° off the bed.
(c) The legs are suspended in the traction.
(d) The pins are secured within the pulley.
Answer:
(b) The buttocks are 15° off the bed.
Rationale:
The infant’s hips should be off the bed approximately 15° in Bryant’s traction. Answer (a) is incorrect because this does not indicate that the traction is working correctly, nor does (c). Answer (d) is incorrect because Bryant’s traction is a skin traction, not a skeletal traction.
Question 134.
Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:
(a) Utilizes a Steinman pin
(b) Requires that both legs be secured
(c) Utilizes Kirschner wires
(d) Is used primarily to heal the fractured hips
Answer:
(a) Utilizes a Steinman pin
Rationale:
Balanced skeletal traction uses pins and screws. A Steinman pin goes through large bones and is used to stabilize large bones such as the femur. Answer (b) is incorrect because only the affected leg is in traction. Kirschner wires are used to stabilize small bones such as fingers and toes, as in answer (c). Answer (d) is incorrect because this type of traction is not used for fractured hips.
Question 135.
The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the:
(a) Serum collection (Davol) drain
(b) Client’s pain
(c) Nutritional status
(d) Immobilizer
Answer:
(a) Serum collection (Davol) drain
Rationale:
Bleeding is a common complication of orthopedic surgery. The blood-collection device should be checked frequently to ensure that the client is not hemorrhaging. The client’s pain should be assessed, but this is not life-threatening. When the client is in less danger, the nutritional status should be assessed and an immobilizer is not used; thus, answers (b), (c), and (d) are incorrect.
Question 136.
Which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates understanding of the nurse’s teaching?
(a) “I must flush the tube with water after feedings and clamp the tube.”
(b) “I must check placement four times per day.”
(c) “I will report to the doctor any signs of indigestion.”
(d) “If my father is unable to swallow, I will discontinue the feeding and call the clinic.”
Answer:
(a) “I must flush the tube with water after feedings and clamp the tube.”
Rationale:
The client’s family member should be taught to flush the tube after each feeding and clamp the tube. The placement should be checked before feedings, and indigestion can occur with the PEG tube, just as it can occur with any client, so answers (b) and (c) are incorrect. Medications can be ordered for indigestion, but it is not a reason for alarm. A percutaneous endoscopy gastrostomy tube is used for clients who have experienced difficulty swallowing. The tube is inserted directly into the stomach and does not require swallowing; therefore, answer (d) is incorrect.
Question 137.
The nurse is assessing the client with a total knee replacement two hours post-operative. Which information requires notification of the doctor?
(a) Scant bleeding on the dressing
(b) Low-grade temperature
(c) Hemoglobin of 7gm
(d) The urinary output has been 120ml during the last hour
Answer:
(c) Hemoglobin of 7gm
Rationale:
The client with a total knee replacement should be assessed for anemia. An hgb of 7 is extremely low and might require a blood transfusion. Scant bleeding on the dressing is not extreme. Circle and date and time the bleeding and monitor for changes in the client’s status. A low-grade temperature is not unusual after surgery. Ensure that the client is well hydrated, and recheck the temperature in one hour. Voiding after surgery is also not uncommon and no need for concern; therefore, answers (a), (b), and (d) are incorrect.
Question 138.
The nurse is caring for the client with a five-year-old diagnosis of plumbism. Which information in the health history is most likely related to the development of plumbism?
(a) The client has traveled out of the country in the last six months.
(b) The client’s parents are skilled stained-glass artists.
(c) The client lives in a house built in 1990.
(d) The client has several brothers and sisters.
Answer:
(b) The client’s parents are skilled stained-glass artists.
Rationale:
The parents make stained glass as a hobby. Stained glass is put together with lead, which can drop on the work area, where the child can consume the lead beads. Answers (a), (c), and (d) do not pose a threat to the child.
Question 139.
A client with a total hip replacement requires special equipment. Which equipment would assist the client with a total hip replacement with activities of daily living?
(a) High-seat commode
(b) Recliner
(c) TENS unit
(d) Abduction pillow
Answer:
(a) High-seat commode
Rationale:
The equipment that can help with activities of daily living is the high-seat commode. The hip should be kept higher than the knee. The recliner is good because it prevents 90° flexion but does not help with daily activities. A TENS (Transcutaneous Electrical Nerve Stimulation) unit helps with pain management and an abduction pillow is used to prevent adduction of the hip and possibly dislocation of the prosthesis; therefore, answers (b), (c), and (d) are incorrect.
Question 140.
An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should:
(a) Administer oxygen via nasal cannula.
(b) Have narcan (naloxane) available.
(c) Prepare to administer blood products.
(d) Prepare to do cardioresuscitation.
Answer:
(b) Have narcan (naloxane) available.
Rationale:
Narcan is the antidote for narcotic overdose. If hypoxia occurs, the client should have oxygen administered by mask, not cannula. There is no data to support the administration of blood products or cardio resuscitation, so answers (a), (c), and (d) are incorrect.
Question 141.
Which roommate would be most suitable for the six-year-old male with a fractured femur in Russell’s traction?
(a) 16-year-old female with scoliosis
(b) 12-year-old male with a fractured femur
(c) 10-year-old male with sarcoma
(d) 6-year-old male with osteomylitis
Answer:
(b) 12-year-old male with a fractured femur
Rationale:
The 6-year-old should have a roommate as close to the same age as possible, so the 12-year-old is the best match. The 10-year-old with sarcoma has cancer and will be treated with chemotherapy that makes him immune suppressed, the 6-year-old with osteomylitis is infected, and the client in answer (a) is too old and is female; therefore, answers (a), (c), and (d) are incorrect.
Question 142.
A client with osteoarthritis has a prescription for Celebrex (cele- coxib). Which instruction should be included in the discharge teaching?
(a) Take the medication with milk.
(b) Report chest pain.
(c) Remain upright after taking for 30 minutes.
(d) Allow six weeks for optimal effects.
Answer:
(b) Report chest pain.
Rationale:
Cox II inhibitors have been associated with heart attacks and strokes. Any changes in cardiac status or signs of a stroke should be reported immediately, along with any changes in bowel or bladder habits because bleeding has been linked to use of Cox II inhibitors. The client does not have to take the medication with milk, remain upright, or allow six weeks for optimal effect, so answers (a), (c), and (d) are incorrect.
Question 143.
A client with a fractured tibia has a plaster-of-Paris cast applied to immobilize the fracture. Which action by the nurse indicates understanding of a plaster-of-Paris cast? The nurse:
(a) Handles the cast with the fingertips
(b) Petals the cast
(c) Dries the cast with a hair dryer
(d) Allows 24 hours before bearing weight
Answer:
(d) Allows 24 hours before bearing weight
Rationale:
A plaster-of-Paris cast takes 24 hours to dry, and the client should not bear weight for 24 hours. The cast should be handled with the palms, not the fingertips, so answer (a) is incorrect. Petaling a cast is covering the end of the cast with cast batting or a sock, to prevent skin irritation and flaking of the skin under the cast. (b) is incorrect because petaling the cast is done by the health care provider who applied the cast. The client should be told not to dry the cast with a hair dryer because this causes hot spots and could burn the client. This also causes unequal drying; thus, answer (c) is incorrect.
Question 144.
The teenager with a fiberglass cast asks the nurse if it will be okay to allow his friends to autograph his cast. Which response would be best?
(a) “It will be alright for your friends to autograph the cast.”
(b) “Because the cast is made of plaster, autographing can weaken the cast.”
(c) “If they don’t use chalk to autograph, it is okay.”
(d) “Autographing or writing on the cast in any form will harm the cast.”
Answer:
(a) “It will be alright for your friends to autograph the cast.”
Rationale:
There is no reason that the client’s friends should not be allowed to autograph the cast; it will not harm the cast in any way, so answers (b), (c), and (d) are incorrect.
Question 145.
The nurse is assigned to care for the client with a Steinman pin. During pin care, she notes that the LPN uses sterile gloves and Q- tips to clean the pin. Which action should the nurse take at this time?
(a) Assisting the LPN with opening sterile packages and peroxide
(b) Telling the LPN that clean gloves are allowed
(c) Telling the LPN that the registered nurse should perform pin care
(d) Asking the LPN to clean the weights and pulleys with peroxide
Answer:
(a) Assisting the LPN with opening sterile packages and peroxide
Rationale:
The nurse is performing the pin care correctly when she uses sterile gloves and Q-tips. Clean gloves are not acceptable. A licensed practical nurse can perform pin care, there is no need to clean the weights; therefore, answers (b), (c), and (d) are incorrect
Question 146.
A child cific to with scoliosis has a spica cast applied. Which action spe the spica cast should be taken?
(a) Check the bowel sounds.
(b) Assess the blood pressure.
(c) Offer pain medication.
(d) Check for swelling.
Answer:
(a) Check the bowel sounds.
Rationale:
A body cast or spica cast extends from the upper abdomen to the knees or below. Bowel sounds should be checked to ensure that the client is not experiencing a paralytic ileus. Checking the blood pressure is a treatment for any client, offering pain medication is not called for, and checking for swelling isn’t specific to the stem, so answers (b), (c), and (d) are incorrect.
Question 147.
The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?
(a) Russell’s traction
(b) Buck’s traction
(c) Halo traction
(d) Crutchfield tong traction
Answer:
(c) Halo traction
Rationale:
Halo traction will be ordered for the client with a cervical fracture. Russell’s traction is used for bones of the lower extremities, as is Buck’s traction. Cruchfield tongs are used while in the hospital and the client is immobile; therefore, answers (a), (b), and (d) are incorrect.
Question 148.
A client with a total knee replacement has a CPM (continuous passive motion device) applied during the post-operative period. Which statement made by the nurse indicates understanding of the CPM machine?
(a) “Use of the CPM will permit the client to ambulate during the therapy.”
(b) “The CPM machine controls should be positioned distal to the site.”
(c) “If the client complains of pain during the therapy, I will turn off the machine and call the doctor.”
(d) “Use of the CPM machine will alleviate the need for physical therapy after the client is discharged.”
Answer:
(b) “The CPM machine controls should be positioned distal to the site.”
Rationale:
The controller for the continuous passive-motion device should be placed away from the client. Many clients complain of pain while having treatments with the CPM, so they might turn off the machine. The CPM flexes and extends the leg. The client is in the bed during CPM therapy, so answer (a) is incorrect. Answer (c) is incorrect because clients will experience pain with the treatment. Use of the CPM does not alleviate the need for physical therapy, as suggested in answer (d).
Question 149.
A client with a fractured hip is being taught correct use of the walker. The nurse is aware that the correct use of the walker is achieved if the:
(a) Palms rest lightly on the handles
(b) Elbows are flexed 0°
(c) Client walks to the front of the walker
(d) Client carries the walker
Answer:
(a) Palms rest lightly on the handles
Rationale:
The client’s palms should rest lightly on the handles. The elbows should be flexed no more than 30° but should not be extended. Answer (b) is incorrect because 0° is not a relaxed angle for the elbows and will not facilitate correct walker use. The client should walk to the middle of the walker, not to the front of the walker, making answer (c) incorrect. The client should be taught not to carry the walker because this would not provide stability; thus, answer (d) is incorrect.
Question 150.
When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should:
(a) Attempt to replace the cord.
(b) Place the client on her left side.
(c) Elevate the client’s hips.
(d) Cover the cord with a dry, sterile gauze.
Answer:
(c) Elevate the client’s hips.
Rationale:
The client with a prolapsed cord should be treated by elevating the hips and covering the cord with a moist, sterile saline gauze. The nurse should use her fingers to push up on the presenting part until a Cesarean section can be performed. Answers (a), (b), and (d) are incorrect. The nurse should not attempt to replace the cord, turn the client on the side, or cover with a dry gauze.
Question 151.
The nurse is caring for a 30-year-old male admitted with a stab wound. While in the emergency room, a chest tube is inserted. Which of the following explains the primary rationale for insertion of chest tubes?
(a) The tube will allow for equalization of the lung expansion.
(b) Chest tubes serve as a method of draining blood and serous fluid and assist in reinflating the lungs.
(c) Chest tubes relieve pain associated with a collapsed lung.
(d) Chest tubes assist with cardiac function by stabilizing lung expansion.
Answer:
(b) Chest tubes serve as a method of draining blood and serous fluid and assist in reinflating the lungs.
Rationale:
Chest tubes work to reinflate the lung and drain serous fluid. The tube does not equalize expansion of the lungs. Pain is associated with collapse of the lung, and insertion of chest tubes is painful, so answers (a) and (c) are incorrect. Answer (d) is true, but this is not the primary rationale for performing chest tube insertion.
Question 152.
A client who delivered this morning tells the nurse that she plans to breastfeed her baby. The nurse is aware that successful breastfeeding is most dependent on the:
(a) Mother’s educational level
(b) Infant’s birth weight
(c) Size of the mother’s breast
(d) Mother’s desire to breastfeed
Answer:
(d) Mother’s desire to breastfeed
Rationale:
Success with breastfeeding depends on many factors, but the most dependable reason for success is desire and willingness to continue the breastfeeding until the infant and mother have time to adapt. The educational level, the infant’s birth weight, and the size of the mother’s breast have nothing to do with success, so answers (a), (b), and (c) are incorrect.
Question 153.
The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately?
(a) The presence of scant bloody discharge
(b) Frequent urination
(c) The presence of green-tinged amniotic fluid
(d) Moderate uterine contractions
Answer:
(c) The presence of green-tinged amniotic fluid
Rationale:
Green-tinged amniotic fluid is indicative of meconium staining. This finding indicates fetal distress. The presence of scant bloody discharge is normal, as are frequent urination and moderate uterine contractions, making answers (a), (b), and (d) incorrect.
Question 154.
The nurse is measuring the duration of the client’s contractions. Which statement is true regarding the measurement of the duration of contractions?
(a) Duration is measured by timing from the beginning of one contraction to the beginning of the next contraction.
(b) Duration is measured by timing from the end of one contraction to the beginning of the next contraction.
(c) Duration is measured by timing from the beginning of one contraction to the end of the same contraction.
(d) Duration is measured by timing from the peak of one contraction to the end of the same contraction.
Answer:
(c) Duration is measured by timing from the beginning of one contraction to the end of the same contraction.
Rationale:
Duration is measured from the beginning of one contraction to the end of the same contraction. Answer (a) refers to frequency. Answer (b) is incorrect because we do not measure from the end of one contraction to the beginning of the next contraction. Duration is not measured from the peak of the contraction to the end, as stated in (d).
Question 155.
The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin, the nurse should monitor for:
(a) Maternal hypoglycemia
(b) Fetal bradycardia
(c) Maternal hyperreflexia
(d) Fetal movement
Answer:
(b) Fetal bradycardia
Rationale:
The client receiving Pitocin should be monitored for decelerations. There is no association with Pitocin use and hypoglycemia, maternal hyper- reflexia, or fetal movement; therefore, answers (a), (c), and (d) are incorrect.
Question 156.
A client with diabetes visits the prenatal clinic at 28 weeks gestation. Which statement is true regarding insulin needs during pregnancy?
(a) Insulin requirements moderate as the pregnancy progresses.
(b) A decreased need for insulin occurs during the second trimester.
(c) Elevations in human chorionic gonadotrophin decrease the need for insulin.
(d) Fetal development depends on adequate insulin regulation.
Answer:
(d) Fetal development depends on adequate insulin regulation.
Rationale:
Fetal development depends on adequate nutrition and insulin regulation. Insulin needs increase during the second and third trimesters, insulin requirements do not moderate as the pregnancy progresses, and elevated human chorionic gonadotrophin elevates insulin needs, not decreases them; therefore, answers (a), (b), and (c) are incorrect.
Question 157.
A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to:
(a) Providing a calm environment
(b) Obtaining a diet history
(c) Administering an analgesic
(d) Assessing fetal heart tones
Answer:
(a) Providing a calm environment
Rationale:
A calm environment is needed to prevent seizure activity. Any stimulation can precipitate seizures. Obtaining a diet history should be done later, and administering an analgesic is not indicated because there is no data in the stem to indicate pain. Therefore, answers (b) and (c) are incorrect. Assessing the fetal heart tones is important, but this is not the highest priority in this situation as stated in answer (d).
Question 158.
A primigravida, age 42, is six weeks pregnant. Based on the client’s age, her infant is at risk for:
(a) Down syndrome
(b) Respiratory distress syndrome
(c) Turner’s syndrome
(d) Pathological jaundice
Answer:
(a) Down syndrome
Rationale:
The client who is age 42 is at risk for fetal anomalies such as Down syndrome and other chromosomal aberrations. Answers (b), (c), and (d) are incorrect because the client is not at higher risk for respiratory distress syndrome or pathological jaundice, and Turner’s syndrome is a genetic disorder.
Question 159.
A client with a missed abortion at 29 weeks gestation is admitted to the hospital. The client will most likely be treated with:
(a) Magnesium sulfate
(b) Calcium gluconate
(c) Dinoprostone (Prostin E.)
(d) Bromocrystine (Parlodel)
Answer:
(c) Dinoprostone (Prostin E.)
Rationale:
The client with a missed abortion will have induction of labor. Prostin E. is a form of prostaglandin used to soften the cervix. Magnesium sulfate is used for preterm labor and preeclampsia, calcium gluconate is the antidote for magnesium sulfate, and Parlodel is a dopamine receptor stimulant used to treat Parkinson’s disease; therefore, answers (a), (b), and (d) are incorrect. Parlodel was used at one time to dry breast milk.
Question 160.
A client with preeclampsia has been receiving an infusion containing magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes are 1 plus, and the urinary output for the past hour is 100mL. The nurse should:
(a) Continue the infusion of magnesium sulfate while monitoring the client’s blood pressure.
(b) Stop the infusion of magnesium sulfate and contact the physician.
(c) Slow the infusion rate and turn the client on her left side.
(d) Administer calcium gluconate IV push and continue to monitor the blood pressure.
Answer:
(a) Continue the infusion of magnesium sulfate while monitoring the client’s blood pressure.
Rationale:
The client’s blood pressure and urinary output are within normal limits. The only alteration from normal is the decreased deep tendon reflexes. The nurse should continue to monitor the blood pressure and check the magnesium level. The therapeutic level is 4.8-9.6mg/dL. Answers (b), (c), and (d) are incorrect because there is no need to stop the infusion at this time or slow the rate. Calcium gluconate is the antidote for magnesium sulfate, but there is no data to indicate toxicity.
Question 161.
Which statement made by the nurse describes the inheritance pattern of autosomal recessive disorders?
(a) An affected newborn has unaffected parents.
(b) An affected newborn has one affected parent.
(c) Affected parents have a one in four chance of passing on the defective gene.
(d) Affected parents have unaffected children who are carriers.
Answer:
(c) Affected parents have a one in four chance of passing on the defective gene.
Rationale:
Autosomal recessive disorders can be passed from the parents to the infant. If both parents pass the trait, the child will get two abnormal genes and the disease results. Parents can also pass the trait to the infant. Answer (a) is incorrect because, to have an affected newborn, the parents must be carriers. Answer (b) is incorrect because both parents must be carriers. Answer (d) is incorrect because the parents might have affected children.
Question 162.
A pregnant client, age 32, asks the nurse why her doctor has rec-ommended a serum alpha fetoprotein. The nurse should explain that the doctor has recommended the test:
(a) Because it is a state law
(b) To detect cardiovascular defects
(c) Because of her age
(d) To detect neurological defects
Answer:
(d) To detect neurological defects
Rationale:
Alpha fetoprotein is a screening test done to detect neural tube defects such as spina bifida. The test is not mandatory, as stated in answer (a). It does not indicate cardiovascular defects, and the mother’s age has no bearing on the need for the test, so answers (b) and (c) are incorrect.
Question 163.
A client with hypothyroidism asks the nurse if she will still need to take thyroid medication during the pregnancy. The nurse’s response is based on the knowledge that:
(a) There is no need to take thyroid medication because the fetus’s thyroid produces a thyroid-stimulating hormone.
(b) Regulation of thyroid medication is more difficult because the thyroid gland increases in size during pregnancy.
(c) It is more difficult to maintain thyroid regulation during pregnancy due to a slowing of metabolism.
(d) Fetal growth is arrested if thyroid medication is continued during pregnancy.
Answer:
(b) Regulation of thyroid medication is more difficult because the thyroid gland increases in size during pregnancy.
Rationale:
During pregnancy, the thyroid gland triples in size. This makes it more difficult to regulate thyroid medication. Answer (a) is incorrect because there could be a need for thyroid medication during pregnancy. Answer (c) is incorrect because the thyroid function does not slow. Fetal growth is not arrested if thyroid medication is continued, so answer (d) is incorrect.
Question 164.
The nurse is responsible for performing a neonatal assessment on a full-term infant. At one minute, the nurse could expect to find:
(a) An apical pulse of 100
(b) An absence of tonus
(c) Cyanosis of the feet and hands
(d) Jaundice of the skin and sclera
Answer:
(c) Cyanosis of the feet and hands
Rationale:
Cyanosis of the feet and hands is acrocyanosis. This is a normal finding one minute after birth. An apical pulse should be 120-160, and the baby should have muscle tone, making answers (a) and (b) incorrect. Jaundice immediately after birth is pathological jaundice and is abnormal, so answer (d) is incorrect.
Question 165.
A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The nurse should anticipate the client’s need for:
(a) Supplemental oxygen
(b) Fluid restriction
(c) Blood transfusion
(d) Delivery by Caesarean section
Answer:
(a) Supplemental oxygen
Rationale:
Clients with sickle cell crises are treated with heat, hydration, oxygen, and pain relief. Fluids are increased, not decreased. Blood transfusions are usually not required, and the client can be delivered vaginally; thus, answers (b), (c), and (d) are incorrect.
Question 166.
A client with diabetes has an order for ultrasonography. preparation for an ultrasound includes:
(a) Increasing fluid intake
(b) Limiting ambulation
(c) Administering an enema
(d) Withholding food for eight hours
Answer:
(a) Increasing fluid intake
Rationale:
Before ultrasonography, the client should be taught to drink plenty of fluids and not void. The client may ambulate, an enema is not needed, and there is no need to withhold food for eight hours. Therefore, answers (b), (c), and (d) are incorrect.
Question 167.
An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at one year?
(a) 14 pounds
(b) 16 pounds
(c) 18 pounds
(d) 24 pounds
Answer:
(d) 24 pounds
Rationale:
By one year of age, the infant is expected to triple his birth weight. Answers (a), (b), and (c) are incorrect because they are too low.
Question 168.
A pregnant client with a history of alcohol addiction is scheduled for a nonstress test. The nonstress test:
(a) Determines the lung maturity of the fetus
(b) Measures the activity of the fetus
(c) Shows the effect of contractions on the fetal heart rate
(d) Measures the neurological well-being of the fetus
Answer:
(b) Measures the activity of the fetus
Rationale:
A nonstress test is done to evaluate periodic movement of the fetus. It is not done to evaluate lung maturity as in answer (a). An oxytocin challenge test shows the effect of contractions on fetal heart rate and a nonstress test does not measure neurological well-being of the fetus, so answers (c) and (d) are incorrect.
Question 169.
A full-term male has hypospadias. Which statement describes hypospadias?
(a) The urethral opening is absent
(b) The urethra opens on the top side of the penis
(c) The urethral opening is enlarged
(d) The urethra opens on the under side of the penis
Answer:
(d) The urethra opens on the under side of the penis
Rationale:
Hypospadias is a condition in which there is an opening on the under side of the penis. Answers (a), (b), and (c) do not describe hypospadias therefore they are incorrect.
Question 170.
A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client’s cervix is 8cm dilated, with complete effacement. The priority nursing diagnosis at this time is:
(a) Alteration in coping related to pain
(b) Potential for injury related to precipitate delivery
(c) Alteration in elimination related to anesthesia
(d) Potential for fluid volume deficit related to NPO status
Answer:
(a) Alteration in coping related to pain
Rationale:
Transition is the time during labor when the client loses concen¬tration due to intense contractions. Potential for injury related to precipitate delivery has nothing to do with the dilation of the cervix, so answer (b) is incorrect. There is no data to indicate that the client has had anesthesia or fluid volume deficit, making answers (c) and (d) incorrect.
Question 171.
The client with varicella will most likely have an order for which category of medication?
(a) Antibiotics
(b) Antipyretics
(c) Antivirals
(d) Anticoagulants
Answer:
(c) Antivirals
Rationale:
Varicella is chicken pox. This herpes virus is treated with antiviral medications. The client is not treated with antibiotics or anticoagulants as stated in answers (a) and (d). The client might have a fever before the rash appears, but when the rash appears, the temperature is usually gone, so answer (b) is incorrect.
Question 172.
A client is admitted complaining of chest pain. Which of the following drug orders should the nurse question?
(a) Nitroglycerin
(b) Ampicillin
(c) Propranolol
(d) Verapamil
Answer:
(b) Ampicillin
Rationale:
Clients with chest pain can be treated with nitroglycerin, a beta blocker such as propranolol, or Verapamil. There is no indication for an antibiotic such as Ampicillin, so answers (a), (c), and (d) are incorrect.
Question 173.
Which of the following instructions should be included in the teaching for the client with rheumatoid arthritis?
(a) Avoid exercise because it fatigues the joints.
(b) Take prescribed anti-inflammatory medications with meals.
(c) Alternate hot and cold packs to affected joints.
(d) Avoid weight-bearing activity.
Answer:
(b) Take prescribed anti-inflammatory medications with meals.
Rationale:
Anti-inflammatory drugs should be taken with meals to avoid stomach upset. Answers (a), (c), and (d) are incorrect. Clients with rheumatoid arthritis should exercise, but not to the point of pain. Alternating hot and cold is not necessary, especially because warm, moist soaks are more useful in decreasing pain. Weight¬bearing activities such as walking are useful but is not the best answer for the stem.
Question 174.
A client with acute pancreatitis is experiencing severe abdominal pain. Which of the following orders should be questioned by the nurse?
(a) Meperidine 100mg IM m 4 hours PRN pain
(b) Mylanta 30 ccs m 4 hours via NG
(c) Cimetadine 300mg PO m.i.d.
(d) Morphine 8mg IM m 4 hours PRN pain
Answer:
(d) Morphine 8mg IM m 4 hours PRN pain
Rationale:
Morphine is contraindicated in clients with gallbladder disease and pancreatitis because morphine causes spasms of the Sphincter of Oddi. Meperidine, Mylanta, and Cimetadine are ordered for pancreatitis, making answers (a), (b), and (c) incorrect.
Question 175.
The client is admitted to the chemical dependence unit with an order for continuous observation. The nurse is aware that the doctor has ordered continuous observation because:
(a) Hallucinogenic drugs create both stimulant and depressant effects.
(b) Hallucinogenic drugs induce a state of altered perception.
(c) Hallucinogenic drugs produce severe respiratory depression.
(d) Hallucinogenic drugs induce rapid physical dependence.
Answer:
(b) Hallucinogenic drugs induce a state of altered perception.
Rationale:
Hallucinogenic drugs can cause hallucinations. Continuous observation is ordered to prevent the client from harming himself during withdrawal. Answers (a), (c), and (d) are incorrect because hallucinogenic drugs don’t create both stimulant and depressant effects or produce severe respiratory depression. However, they do produce psychological dependence rather than physical dependence.
Question 176.
A client with a history of abusing barbiturates abruptly stops taking the medication. The nurse should give priority to assessing the client for:
(a) Depression and suicidal ideation
(b) Tachycardia and diarrhea
(c) Muscle cramping and abdominal pain
(d) Tachycardia and euphoric mood
Answer:
(b) Tachycardia and diarrhea
Rationale:
Barbiturates create a sedative effect. When the client stops taking barbiturates, he will experience tachycardia, diarrhea, and tachypnea. Answer (a) is incorrect even though depression and suicidal ideation go along with barbiturate use; it is not the priority. Muscle cramps and abdominal pain are vague symptoms that could be associated with other problems. Tachycardia is associated with stopping barbiturates, but euphoria is not.
Question 177.
During the assessment of a laboring client, the nurse notes that the FHT are loudest in the upper-right quadrant. The infant is most likely in which position?
(a) Right breech presentation
(b) Right occipital anterior presentation
(c) Left sacral anterior presentation
(d) Left occipital transverse presentation
Answer:
(a) Right breech presentation
Rationale:
If the fetal heart tones are heard in the right upper abdomen, the infant is in a breech presentation. If the infant is positioned in the right occipital anterior presentation, the FHTs will be located in the right lower quadrant, so answer (b) is incorrect. If the fetus is in the sacral position, the FHTs will be located in the center of the abdomen, so answer (c) is incorrect. If the FHTs are heard in the left lower abdomen, the infant is most likely in the left occipital transverse position, making answer (d) incorrect.
Question 178.
The primary physiological alteration in the development of asthma is:
(a) Bronchiolar inflammation and dyspnea
(b) Hypersecretion of abnormally viscous mucus
(c) Infectious processes causing mucosal edema
(d) Spasm of bronchiolar smooth muscle
Answer:
(d) Spasm of bronchiolar smooth muscle
Rationale:
Asthma is the presence of bronchiolar spasms. This spasm can be brought on by allergies or anxiety. Answer (a) is incorrect because the primary physiological alteration is not inflammation. Answer (b) is incorrect because there is the production of abnormally viscous mucus, not a primary alteration. Answer (c) is incorrect because infection is not primary to asthma.
Question 179.
A client with mania is unable to finish her dinner. To help her maintain sufficient nourishment, the nurse should:
(a) Serve high-calorie foods she can carry with her.
(b) Encourage her appetite by sending out for her favorite foods.
(c) Serve her small, attractively arranged portions.
(d) Allow her in the unit kitchen for extra food whenever she pleases.
Answer:
(a) Serve high-calorie foods she can carry with her.
Rationale:
The client with mania is seldom sitting long enough to eat and burns many calories for energy. Answer (b) is incorrect because the client should be treated the same as other clients. Small meals are not a correct option for this client. Allowing her into the kitchen gives her privileges that other clients do not have and should not be allowed, so answer (d) is incorrect.
Question 180.
To maintain Bryant’s traction, the nurse must make certain that the child’s:
(a) Hips are resting on the bed, with the legs suspended at a right angle to the bed
(b) Hips are slightly elevated above the bed and the legs are suspended at a right angle to the bed
(c) Hips are elevated above the level of the body on a pillow and the legs are suspended parallel to the bed
(d) Hips and legs are flat on the bed, with the traction positioned at the foot of the bed
Answer:
(b) Hips are slightly elevated above the bed and the legs are suspended at a right angle to the bed
Rationale:
Bryant’s traction is used for fractured femurs and dislocated hips. The hips should be elevated 15° off the bed. Answer (a) is incorrect because the hips should not be resting on the bed. Answer (c) is incorrect because the hips should not be above the level of the body. Answer (d) is incorrect because the hips and legs should not be flat on the bed.
Question 181.
Which action by the nurse indicates understanding of herpes zoster?
(a) The nurse covers the lesions with a sterile dressing.
(b) The nurse wears gloves when providing care.
(c) The nurse administers a prescribed antibiotic.
(d) The nurse administers oxygen.
Answer:
(b) The nurse wears gloves when providing care.
Rationale:
Herpes zoster is shingles. Clients with shingles should be placed in contact precautions. Wearing gloves during care will prevent transmission of the virus. Covering the lesions with a sterile gauze is not necessary, antibiotics are not prescribed for herpes zoster, and oxygen is not necessary for shingles; therefore, answers (a), (c), and (d) are incorrect.
Question 182.
There is an order for a trough to be drawn on the client receiving Vancomycin. The nurse is aware that he should contact the lab for them to collect the blood:
(a) 15 minutes after the infusion
(b) 30 minutes before the fourth infusion
(c) one hour after the infusion
(d) two hours after the infusion
Answer:
(b) 30 minutes before the fourth infusion
Rationale:
A trough level should be drawn 30 minutes before the third or fourth dose. The times in answers (a), (c), and (d) are incorrect times to draw blood levels.
Question 183.
The client using a diaphragm should be instructed to:
(a) Refrain from keeping the diaphragm in longer than four hours
(b) Keep the diaphragm in a cool location
(c) Have the diaphragm resized if she gains five pounds
(d) Have the diaphragm resized if she has any surgery
Answer:
(b) Keep the diaphragm in a cool location
Rationale:
The client using a diaphragm should keep the diaphragm in a cool location. Answers (a), (c), and (d) are incorrect. She should refrain from leaving the diaphragm in longer than eight hours, not four hours. She should have the diaphragm resized when she gains or loses 10 pounds or has abdominal surgery.
Question 184.
The nurse is providing postpartum teaching for a mother planning to breastfeed her infant. Which of the client’s statements indicates the need for additional teaching?
(a) “I’m wearing a support bra.”
(b) “I’m expressing milk from my breast.”
(c) “I’m drinking four glasses of fluid during a 24-hour period.”
(d) “While I’m in the shower, I’ll allow the water to run over my breasts.”
Answer:
(c) “I’m drinking four glasses of fluid during a 24-hour period.”
Rationale:
Mothers who plan to breastfeed should drink plenty of liquids, and four glasses is not enough in a 24-hour period. Wearing a support bra is a good practice for the mother who is breastfeeding as well as the mother who plans to bottle-feed, so answer (a) is incorrect. Expressing milk from the breast will stimulate milk production, making answer (b) incorrect. Allowing the water to run over the breast will also facilitate “letdown,” when the milk begins to be produced; thus, answer (d) is incorrect.
Question 185.
Damage to the VII cranial nerve results in:
(a) Facial pain
(b) Absence of ability to smell
(c) Absence of eye movement
(d) Tinnitus
Answer:
(a) Facial pain
Rationale:
The facial nerve is cranial nerve VII. If damage occurs, the client will experience facial pain. The auditory nerve is responsible for hearing loss and tinnitus, eye movement is controlled by the Trochear or C IV, and the olfactory nerve controls smell; therefore, answers (b), (c), and (d) are incorrect.
Question 186.
A client is receiving Pyridium (phenazopyridine hydrochloride) for a urinary tract infection. The client should be taught that the medication may:
(a) Cause diarrhea
(b) Change the color of her urine
(c) Cause mental confusion
(d) Cause changes in taste
Answer:
(b) Change the color of her urine
Rationale:
Clients taking Pyridium should be taught that the medication will turn the urine orange or red. It is not associated with diarrhea, mental confusion, or changes in taste; therefore, answers (a), (c), and (d) are incorrect. Pyridium can also cause a yellowish color to skin and sclera if taken in large doses.
Question 187.
Which of the following tests should be performed before beginning a prescription of Accutane?
(a) Check the calcium level.
(b) Perform a pregnancy test.
(c) Monitor apical pulse.
(d) Obtain a creatinine level.
Answer:
(b) Perform a pregnancy test.
Rationale:
Accutane is contraindicated for use by pregnant clients because it causes teratogenic effects. Calcium levels, apical pulse, and creatinine levels are not necessary; therefore, answers (a), (c), and (d) are incorrect.
Question 188.
A client with AIDS is taking Zovirax (acyclovir). Which nursing intervention is most critical during the administration of acyclovir?
(a) Limit the client’s activity.
(b) Encourage a high-carbohydrate diet.
(c) Utilize an incentive spirometer to improve respiratory function.
(d) Encourage fluids.
Answer:
(d) Encourage fluids.
Rationale:
Clients taking Acyclovir should be encouraged to drink plenty of fluids because renal impairment can occur. Limiting activity is not necessary, nor is eating a high-carbohydrate diet. Use of an incentive spirometer is not specific to clients taking Acyclovir; therefore, answers (a), (b), and (c) are incorrect.
Question 189.
A client is admitted for an CAT scan. The nurse should question the client regarding:
(a) Pregnancy
(b) A titanium hip replacement
(c) Allergies to antibiotics
(d) Inability to move his feet
Answer:
(a) Pregnancy
Rationale:
Clients who are pregnant should not have a CAT because radioactive isotopes are used. However, clients with a titanium hip replacement can have an MRI or CAT scan so answer (b) is incorrect. No antibiotics are used with this test and the client should remain still only when instructed, so answers (c) and (d) are not specific to this test.
Question 190.
The nurse is caring for the client receiving Amphotericin B. Which of the following indicates that the client has experienced toxicity to this drug?
(a) Changes in vision
(b) Nausea
(c) Urinary frequency
(d) Changes in skin color
Answer:
(d) Changes in skin color
Rationale:
Clients taking Amphotericin B should be monitored for liver, renal, and bone marrow function because this drug is toxic to the kidneys and liver, and causes bone marrow suppression. Jaundice is a sign of liver toxicity and is not specific to the use of Amphotericin B. Changes in vision are not related, and nausea is a side effect, not a sign of toxicity; nor is urinary frequency. Thus, answers (a), (b), and (c) are incorrect.
Question 191.
The nurse should visit which of the following clients first?
(a) The client with diabetes with a blood glucose of 95mg/dL
(b) The client with hypertension being maintained on Lisinopril
(c) The client with chest pain and a history of angina
(d) The client with Raynaud’s disease
Answer:
(c) The client with chest pain and a history of angina
Rationale:
The client with chest pain should be seen first because this could indicate a myocardial infarction. The client in answer (a) has a blood glucose within normal limits. The client in answer (b) is maintained on blood pressure medication. The client in answer (d) is in no distress.
Question 192.
A client with cystic fibrosis is taking pancreatic enzymes. The nurse should administer this medication:
(a) Once per day in the morning
(b) Three times per day with meals
(c) Once per day at bedtime
(d) Four times per day
Answer:
(b) Three times per day with meals
Rationale:
Pancreatic enzymes should be given with meals for optimal effects. These enzymes assist the body in digesting needed nutrients. Answers (a), (c), and (d) are incorrect methods of administering pancreatic enzymes.
Question 193.
Cataracts result in opacity of the crystalline lens. Which of the following best explains the functions of the lens?
(a) The lens controls stimulation of the retina.
(b) The lens orchestrates eye movement.
(c) The lens focuses light rays on the retina.
(d) The lens magnifies small objects.
Answer:
(c) The lens focuses light rays on the retina.
Rationale:
The lens allows light to pass through the pupil and focus light on the retina. The lens does not stimulate the retina, assist with eye movement, or magnify small objects, so answers (a), (b), and (d) are incorrect.
Question 194.
A client who has glaucoma is to have miotic eyedrops instilled in both eyes. The nurse knows that the purpose of the medication is to:
(a) Anesthetize the cornea
(b) Dilate the pupils
(c) Constrict the pupils
(d) Paralyze the muscles of accommodation
Answer:
(c) Constrict the pupils
Rationale:
Miotic eyedrops constrict the pupil and allow aqueous humor to drain out of the Canal of Schlemm. They do not anesthetize the cornea, dilate the pupil, or paralyze the muscles of the eye, making answers (a), (b), and (d) incorrect.
Question 195.
A client with a severe corneal ulcer has an order for Gentamicin gtt. q 4 hours and Neomycin 1 gtt q 4 hours. Which of the following schedules should be used when administering the drops?
(a) Allow five minutes between the two medications.
(b) The medications may be used together.
(c) The medications should be separated by a cycloplegic drug.
(d) The medications should not be used in the same client.
Answer:
(a) Allow five minutes between the two medications.
Rationale:
When using eyedrops, allow five minutes between the two medications; therefore, answer (b) is incorrect. These medications can be used by the same client but it is not necessary to use a cyclopegic with these medications, making answers (c) and (d) incorrect.
Question 196.
The client with color blindness will most likely have problems dis-tinguishing which of the following colors?
(a) Orange
(b) Violet
(c) Red
(d) White
Answer:
(b) Violet
Rationale:
Clients with color blindness will most likely have problems dis¬tinguishing violets, blues, and green. The colors in answers (a), (c), and (d) are less commonly affected.
Question 197.
The client with a pacemaker should be taught to:
(a) Report ankle edema
(b) Check his blood pressure daily
(c) Refrain from using a microwave oven
(d) Monitor his pulse rate
Answer:
(d) Monitor his pulse rate
Rationale:
The client with a pacemaker should be taught to count and record his pulse rate. Answers (a), (b), and (c) are incorrect. Ankle edema is a sign of right-sided congestive heart failure. Although this is not normal, it is often present in clients with heart disease. If the edema is present in the hands and face, it should be reported. Checking the blood pressure daily is not necessary for these clients. The client with a pacemaker can use a microwave oven, but he should stand about five feet from the oven while it is operating.
Question 198.
The client with enuresis is being taught regarding bladder retraining. The nurse should advise the client to refrain from drinking after:
(a) 1900
(b) 1200
(c) 1000
(d) 0700
Answer:
(a) 1900
Rationale:
Clients who are being retrained for bladder control should be taught to withhold fluids after about 7 p.m., or 1900. The times in answers (b), (c), and (d) are too early in the day.
Question 199.
Which of the following diet instructions should be given to the client with recurring urinary tract infections?
(a) Increase intake of meats.
(b) Avoid citrus fruits.
(c) Perform pericare with hydrogen peroxide.
(d) Drink a glass of cranberry juice every day.
Answer:
(d) Drink a glass of cranberry juice every day.
Rationale:
Cranberry juice is more alkaline and, when metabolized by the body, is excreted with acidic urine. Bacteria does not grow freely in acidic urine. Increasing intake of meats is not associated with urinary tract infections, so answer (a) is incorrect. The client does not have to avoid citrus fruits and pericare should be done, but hydrogen peroxide is drying, so answers (b) and (c) are incorrect.
Question 200.
The physician has prescribed NPH insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?
(a) “I will make sure I eat breakfast within two hours of taking my insulin.”
(b) “I will need to carry candy or some form of sugar with me all the time.”
(c) “I will eat a snack around three o’clock each afternoon.”
(d) “I can save my dessert from supper for a bedtime snack.”
Answer:
(c) “I will eat a snack around three o’clock each afternoon.”
Rationale:
NPH insulin peaks in 8-12 hours, so a snack should be offered at that time. NPH insulin onsets in 90-120 minutes, so answer (a) is incorrect. Answer (b) is untrue because NPH insulin is time released and does not usually cause sudden hypoglycemia. Answer (d) is incorrect, but the client should eat a bedtime snack.
Question 201.
A client with pneumacystis carinii pneumonia is receiving Methotrexate. The rationale for administering leucovorin calcium to a client receiving Methotrexate is to:
(a) Treat anemia
(b) Create a synergistic effect
(c) Increase the number of white blood cells
(d) Reverse drug toxicity
Answer:
(d) Reverse drug toxicity
Rationale:
Methotrexate is a folic acid antagonist. Leucovorin is the drug given for toxicity to this drug. It is not used to treat iron-deficiency anemia, create a synergistic effects, or increase the number of circulating neutrophils. Therefore, answers (a), (b), and (c) are incorrect.
Question 202.
A client tells the nurse that she is allergic to eggs, dogs, rabbits, and chicken feathers. Which order should the nurse question?
(a) TB skin test
(b) Rubella vaccine
(c) ELISA test
(d) Chest x-ray
Answer:
(b) Rubella vaccine
Rationale:
The client who is allergic to dogs, eggs, rabbits, and chicken feathers is most likely allergic to the rubella vaccine. The client who is allergic to neomycin is also at risk. There is no danger to the client if he has an order for a TB skin test, ELISA test, or chest x-ray; thus, answers (a), (c), and (d) are incorrect.
Question 203.
The physician has prescribed ranitidine (Zantac) for a client with erosive gastritis. The nurse should administer the medication:
(a) 30 minutes before meals
(b) With each meal
(c) In a single dose at bedtime
(d) 60 minutes after meals
Answer:
(b) With each meal
Rationale:
Zantac (rantidine) is a histamine blocker that should be given with meals for optimal effect, not before meals. However, Tagamet (cimetidine) is a histamine blocker that can be given in one dose at bedtime. Neither of these drugs should be given before or after meals, so answers (a) and (d) are incorrect.
Question 204.
A temporary colostomy is performed on the client with colon cancer. The nurse is aware that the proximal end of a double barrel colostomy:
(a) Is the opening on the client’s left side
(b) Is the opening on the distal end on the client’s left side
(c) Is the opening on the client’s right side
(d) Is the opening on the distal right side
Answer:
(c) Is the opening on the client’s right side
Rationale:
The proximal end of the double-barrel colostomy is the end toward the small intestines. This end is on the client's right side. The distal end, as in answers (a), (b), and (d), is on the client’s left side.
Question 205.
While assessing the postpartal client, the nurse notes that the fundus is displaced to the right. Based on this finding, the nurse should:
(a) Ask the client to void.
(b) Assess the blood pressure for hypotension
(c) Administer oxytocin.
(d) Check for vaginal bleeding.
Answer:
(a) Ask the client to void.
Rationale:
If the nurse checks the fundus and finds it to be displaced to the right or left, this is an indication of a full bladder. This finding is not associated with hypotension or clots, as stated in answer (b). Oxytoxic drugs (Pitocin) are drugs used to contract the uterus, so answer (c) is incorrect. It has nothing to do with displacement of the uterus. Answer (d) is incorrect because displacement is associated with a full bladder, not vaginal bleeding.
Question 206.
The physician has ordered an MRI for a client with an ortho pedicailment. An MRI should not be done if the client has:
(a) The need for oxygen therapy
(b) A history of claustrophobia
(c) A permanent pacemaker
(d) Sensory deafness
Answer:
(c) A permanent pacemaker
Rationale:
Clients with an internal defibrillator or a pacemaker should not have an MRI because it can cause dysrhythmias in the client with a pacemaker. If the client has a need for oxygen, is claustrophobic, or is deaf, he can have an MRI, but provisions such as extension tubes for the oxygen, sedatives, or a signal system should be made to accommodate these problems. Therefore, answers (a), (b), and (d) are incorrect.
Question 207.
A six-month-old client is placed on strict bed rest following a hernia repair. Which toy is best suited to the client?
(a) Colorful crib mobile
(b) Hand-held electronic games
(c) Cars in a plastic container
(d) 30-piece jigsaw puzzle
Answer:
(c) Cars in a plastic container
Rationale:
A six-month-old is too old for the colorful mobile. He is too young to play with the electronic game or the 30-piece jigsaw puzzle. The best toy for this age is the cars in a plastic container, so answers (a), (b), and (d) are incorrect.
Question 208.
The nurse is preparing to discharge a client with a long history of polio. The nurse should tell the client that:
(a) Taking a hot bath will decrease stiffness and spasticity.
(b) A schedule of strenuous exercise will improve muscle strength.
(c) Rest periods should be scheduled throughout the day.
(d) Visual disturbances can be corrected with prescription glasses.
Answer:
(c) Rest periods should be scheduled throughout the day.
Rationale:
The client with polio has muscle weakness. Periods of rest throughout the day will conserve the client’s energy. A hot bath can cause burns; however, a warm bath would be helpful, so answer (a) is incorrect. Strenuous exercises are not advisable, making answer (b) incorrect. Visual disturbances that are directly associated with polio cannot be corrected with glasses; therefore, answer (d) is incorrect.
Question 209.
A client on the postpartum unit has a proctoepisiotomy. The nurse should anticipate administering which medication?
(a) Dulcolax suppository
(b) Docusate sodium (Colace)
(c) Methyergonovine maleate (Methergine)
(d) Bromocriptine sulfate (Parlodel)
Answer:
(b) Docusate sodium (Colace)
Rationale:
The client with a protoepisiotomy will need stool softeners such as docusate sodium. Suppositories are given only with an order from the doctor, Methergine is a drug used to contract the uterus, and Parlodel is an anti-Parkinsonian drug; therefore, answers (a), (c), and (d) are incorrect.
Question 210.
A client with pancreatic cancer has an infusion of TPN (Total Parenteral Nutrition). The doctor has ordered for sliding-scale insulin. The most likely explanation for this order is:
(a) Total Parenteral Nutrition leads to negative nitrogen balance and elevated glucose levels.
(b) Total Parenteral Nutrition cannot be managed with oral hypoglycemics.
(c) Total Parenteral Nutrition is a high-glucose solution that often elevates the blood glucose levels.
(d) Total Parenteral Nutrition leads to further pancreatic disease.
Answer:
(c) Total Parenteral Nutrition is a high-glucose solution that often elevates the blood glucose levels.
Rationale:
Total Parenteral Nutrition is a high-glucose solution. This therapy often causes the glucose levels to be elevated. Because this is a common complication, insulin might be ordered. Answers (a), (b), and (d) are incorrect. TPN is used to treat negative nitrogen balance; it will not lead to negative nitrogen balance. Total Parenteral Nutrition can be managed with oral hypoglycemic drugs, but it is difficult to do so. Total Parenteral Nutrition will not lead to further pancreatic disease.
Question 211.
An adolescent primigravida who is 10 weeks pregnant attends the antepartal clinic for a first check-up. To develop a teaching plan, the nurse should initially assess:
(a) The client’s knowledge of the signs of preterm labor
(b) The client’s feelings about the pregnancy
(c) Whether the client was using a method of birth control
(d) The client’s thought about future children
Answer:
(b) The client’s feelings about the pregnancy
Rationale:
The client who is 10 weeks pregnant should be assessed to determine how she feels about the pregnancy. It is too early to discuss preterm labor, too late to discuss whether she was using a method of birth control, and after the client delivers, a discussion of future children should be instituted. Thus, answers (a), (c), and (d) are incorrect.
Question 212.
An obstetric client is admitted with dehydration. Which IV fluid would be most appropriate for the client?
(a) 45 normal saline
(b) Dextrose 1% in water
(c) Lactated Ringer’s
(d) Dextrose 5% in 45 normal saline
Answer:
(a) 45 normal saline
Rationale:
The best IV fluid for correction of dehydration is normal saline because it is most like normal serum. Dextrose pulls fluid from the cell, lactated Ringer’s contains more electrolytes than the client’s serum, and dextrose with normal saline will also alter the intracellular fluid. Therefore, answers (b), (c), and (d) are incorrect.
Question 213.
The physician has ordered a thyroid scan to confirm the diagnosis of a goiter. Before the procedure, the nurse should:
(a) Assess the client for allergies.
(b) Bolus the client with IV fluid.
(c) Tell the client he will be asleep.
(d) Insert a urinary catheter.
Answer:
A thyroid scan uses a dye, so the client should be assessed for allergies to iodine. The client will not have a bolus of fluid, will not be asleep, and will not have a urinary catheter inserted, so answers (b), (c), and (d) are incorrect.
Rationale:
(a) Assess the client for allergies.
Question 214.
The physician has ordered an injection of RhoGam for a client with blood type A negative. The nurse understands that RhoGam is given to:
(a) Provide immunity against Rh isoenzymes
(b) Prevent the formation of Rh antibodies
(c) Eliminate circulating Rh antibodies
(d) Convert the Rh factor from negative to positive
Answer:
(b) Prevent the formation of Rh antibodies
Rationale:
RhoGam is used to prevent formation of Rh antibodies. It does not provide immunity to Rh isoenzymes, eliminate circulating Rh antibodies, or convert the Rh factor from negative to positive; thus, answers (a), (c), and (d) are incorrect.
Question 215.
The nurse is caring for a client admitted to the emergency room after a fall. X-rays reveal that the client has several fractured bones in the foot. Which treatment should the nurse anticipate for the fractured foot?
(a) Application of a short inclusive spica cast
(b) Stabilization with a plaster-of-Paris cast
(c) Surgery with Kirschner wire implantation
(d) A gauze dressing only
Answer:
(b) Stabilization with a plaster-of-Paris cast
Rationale:
A client with a fractured foot often has a short leg cast applied to stabilize the fracture. A spica cast is used to stabilize a fractured pelvis or vertebral fracture. Kirschner wires are used to stabilize small bones such as toes and the client will most likely have a cast or immobilizer, so answers (a), (c), and (d) are incorrect.
Question 216.
A client with bladder cancer is being treated with iridium seed implants. The nurse’s discharge teaching should include telling the client to:
(a) Strain his urine
(b) Increase his fluid intake
(c) Report urinary frequency
(d) Avoid prolonged sitting
Answer:
(a) Strain his urine
Rationale:
Iridium seeds can be expelled during urination, so the client should be taught to strain his urine and report to the doctor if any of the seeds are expelled. Increasing fluids, reporting urinary frequency, and avoiding prolonged sitting are not necessary; therefore, answers (b), (c), and (d) are incorrect.
Question 217.
Following a heart transplant, a client is started on medication to prevent organ rejection. Which category of medication prevents the formation of antibodies against the new organ?
(a) Antivirals
(b) Antibiotics
(c) Immunosuppressants
(d) Analgesics
Answer:
(c) Immunosuppressants
Rationale:
Immunosuppressants are used to prevent antibody formation. Antivirals, antibiotics, and analgesics are not used to prevent antibody production, so answers (a), (b), and (d) are incorrect.
Question 218.
The nurse is preparing a client for cataract surgery. The nurse is aware that the procedure will use:
(a) Mydriatics to facilitate removal
(b) Miotic medications such as Timoptic
(c) A laser to smooth and reshape the lens
(d) Silicone oil injections into the eyeball
Answer:
(a) Mydriatics to facilitate removal
Rationale:
Before cataract removal, the client will have Mydriatic drops instilled to dilate the pupil. This will facilitate removal of the lens. Miotics constrict the pupil and are not used in cataract clients. A laser is not used to smooth and reshape the lens; the diseased lens is removed. Silicone oil is not injected in this client; thus, answers (b), (c), and (d) are incorrect.
Question 219.
A client with Alzheimer’s disease is awaiting placement in a skilled nursing facility. Which long-term plans would be most therapeutic for the client?
(a) Placing mirrors in several locations in the home
(b) Placing a picture of herself in her bedroom
(c) Placing simple signs to indicate the location of the bedroom, bathroom, and so on
(d) Alternating healthcare workers to prevent boredom
Answer:
(c) Placing simple signs to indicate the location of the bedroom, bathroom, and so on
Rationale:
Placing simple signs that indicate the location of rooms where the client sleeps, eats, and bathes will help the client be more independent. Providing mirrors and pictures is not recommended with the client who has Alzheimer's disease because mirrors and pictures tend to cause agitation, and alternating healthcare workers confuses the client; therefore, answers (a), (b), and (d) are incorrect.
Question 220.
A client with an abdominal cholecystectomy returns from surgery with a Jackson-Pratt drain. The chief purpose of the Jackson-Pratt drain is to:
(a) Prevent the need for dressing changes
(b) Reduce edema at the incision
(c) Provide for wound drainage
(d) Keep the common bile duct open
Answer:
(c) Provide for wound drainage
Rationale:
A Jackson-Pratt drain is a serum-collection device commonly used in abdominal surgery. A Jackson-Pratt drain will not prevent the need for dressing changes, reduce edema of the incision, or keep the common bile duct open, so answers (a), (b), and (d) are incorrect. A t-tube is used to keep the common bile duct open.
Question 221.
The nurse is performing an initial assessment of a newborn Caucasian male delivered at 32 weeks gestation. The nurse can expect to find the presence of:
(a) Mongolian spots
(b) Scrotal rugae
(c) Head lag
(d) Polyhydramnios
Answer:
(c) Head lag
Rationale:
The infant who is 32 weeks gestation will not be able to control his head, so head lag will be present. Mongolian spots are common in African American infants, not Caucasian infants; the client at 32 weeks will have scrotal rugae or redness. There is no alteration in the amount of amniotic fluid; therefore, answers (a), (b), and (d) are incorrect.
Question 222.
The nurse is caring for a client admitted with multiple trauma. Fractures include the pelvis, femur, and ulna. Which finding should be reported to the physician immediately?
(a) Hematuria
(b) Muscle spasms
(c) Dizziness
(d) Nausea
Answer:
(a) Hematuria
Rationale:
Hematuria in a client with a pelvic fracture can indicate trauma to the bladder or impending bleeding disorders. It is not unusual for the client to complain of muscles spasms with multiple fractures, so answer (b) is incorrect. Dizziness can be associated with blood loss and is nonspecific, making answer (c) incorrect. Nausea, as stated in answer (d), is also common in the client with multiple traumas.
Question 223.
A client is brought to the emergency room by the police. He is combative and yells, “I have to get out of here. They are trying to kill me.” Which assessment is most likely correct in relation to this statement?
(a) The client is experiencing an auditory hallucination.
(b) The client is having a delusion of grandeur.
(c) The client is experiencing paranoid delusions.
(d) The client is intoxicated.
Answer:
(c) The client is experiencing paranoid delusions.
Rationale:
The client’s statement “They are trying to kill me” indicates paranoid delusions. There is no data to indicate that the client is hearing voices or is intoxicated, so answers (a) and (d) are incorrect. Delusions of grandeur are fixed beliefs that the client is superior or perhaps a famous person, making answer (b) incorrect.
Question 224.
The nurse is preparing to suction the client with a tracheotomy. The nurse notes a previously used bottle of normal saline on the client’s bedside table. There is no label to indicate the date or time of initial use. The nurse should:
(a) Lip the bottle and use a pack of sterile 4 x 4 for the dressing.
(b) Obtain a new bottle and label it with the date and time of first use.
(c) Ask the ward secretary when the solution was requested.
(d) Label the existing bottle with the current date and time.
Answer:
(b) Obtain a new bottle and label it with the date and time of first use.
Rationale:
Because the nurse is unaware of when the bottle was opened or whether the saline is sterile, it is safest to obtain a new bottle. Answers (a), (c), and (d) are not safe practices.
Question 225.
An infant’s Apgar score is 9 at five minutes. The nurse is aware that the most likely cause for the deduction of one point is:
(a) The baby is hypothermic.
(b) The baby is experiencing bradycardia.
(c) The baby’s hands and feet are blue.
(d) The baby is lethargic.
Answer:
(c) The baby’s hands and feet are blue.
Rationale:
Infants with an Apgar of 9 at five minutes most likely have acry- ocyanosis, a normal physiologic adaptation to birth. It is not related to the infant being hypothermic, experiencing bradycardia, or being lethargic; thus, answers (a), (b), and (d) are incorrect.
Question 226.
The primary reason for rapid continuous re warming of the area affected by frostbite is to:
(a) Lessen the amount of cellular damage
(b) Prevent the formation of blisters
(c) Promote movement
(d) Prevent pain and discomfort
Answer:
(a) Lessen the amount of cellular damage
Rationale:
Rapid continuous rewarming of a frostbite primarily lessens cellular damage. It does not prevent formation of blisters. It does promote movement, but this is not the primary reason for rapid rewarming. It might increase pain for a short period of time as the feeling comes back into the extremity; therefore, answers (b), (c), and (d) are incorrect
Question 227.
A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse’s response is based on the knowledge that hemodialysis works by:
(a) Passing water through a dialyzing membrane
(b) Eliminating plasma proteins from the blood
(c) Lowering the pH by removing nonvolatile acids
(d) Filtering waste through a dialyzing membrane
Answer:
(d) Filtering waste through a dialyzing membrane
Rationale:
Hemodialysis works by using a dialyzing membrane to filter waste that has accumulated in the blood. It does not pass water through a dialyzing membrane nor does it eliminate plasma proteins or lower the pH, so answers (a), (b), and (c) are incorrect.
Question 228.
During a home visit, a client with AIDS tells the nurse that he has been exposed to measles. Which action by the nurse is most appropriate?
(a) Administer an antibiotic.
(b) Contact the physician for an order for immune globulin.
(c) Administer an antiviral.
(d) Tell the client that he should remain in isolation for two weeks.
Answer:
(b) Contact the physician for an order for immune globulin.
Rationale:
The client who is immune-suppressed and is exposed to measles should be treated with medications to boost his immunity to the virus. An antibiotic or antiviral will not protect the client and it is too late to place the client in isolation, so answers (a), (c), and (d) are incorrect.
Question 229.
A client hospitalized with MRSA is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact?
(a) The client should be placed in a room with negative pressure.
(b) Infection Requires close contact; therefore, the door may remain open.
(c) Transmission is highly likely, so the client should wear a mask at all times.
(d) Infection Requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown.
Answer:
(d) Infection Requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown.
Rationale:
The client with MRSA should be placed in isolation. Gloves, a gown, and a mask should be used when caring for the client and hand washing is very important. The door should remain closed, but a negative-pressure room is not necessary, so answers (a) and (b) are incorrect. MRSA is spread by contact with blood or body fluid or by touching the skin of the client. It is cultured from the nasal passages of the client, so the client should be instructed to cover his nose and mouth when he sneezes or coughs. It is not necessary for the client to wear the mask at all times; the nurse should wear the mask, so answer (c) is incorrect.
Question 230.
A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates understanding of phantom limb pain?
(a) “The pain will go away in a few days.”
(b) “The pain is due to peripheral nervous system interruptions. I will get you some pain medication.”
(c) “The pain is psychological because your foot is no longer there.”
(d) “The pain and itching are due to the infection you had before the surgery.”
Answer:
(b) “The pain is due to peripheral nervous system interruptions. I will get you some pain medication.”
Rationale:
Pain related to phantom limb syndrome is due to peripheral nervous system interruption. Answer (a) is incorrect because phantom limb pain can last several months or indefinitely. Answer (c) is incorrect because it is not psychological. It is also not due to infections, as stated in answer (d).
Question 231.
A client with cancer of the pancreas has undergone a Whipple procedure. The nurse is aware that during the Whipple procedure, the doctor will remove the:
(a) Head of the pancreas
(b) Proximal third section of the small intestines
(c) Stomach and duodenum
(d) Esophagus and jejunum
Answer:
(a) Head of the pancreas
Rationale:
During a Whipple procedure the head of the pancreas, which is a part of the stomach, the jejunum, and a portion of the stomach are removed and reanastomosed. Answer (b) is incorrect because the proximal third of the small intestine is not removed. The entire stomach is not removed, as in answer (c), and in answer (d), the esophagus is not removed.
Question 232.
The physician has ordered a minimal-bacteria diet for a client with neutropenia. The client should be taught to avoid eating:
(a) Fruits
(b) Salt
(c) Pepper
(d) Ketchup
Answer:
(c) Pepper
Rationale:
Pepper is not processed and contains bacteria. Answers (a), (b), and (d) are incorrect because fruits should be cooked or washed and peeled, and salt and ketchup are allowed.
Question 233.
A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to:
(a) Have a Protime done monthly.
(b) Eat more fruits and vegetables
(c) Drink more liquids.
(d) Avoid crowds.
Answer:
(a) Have a Protime done monthly.
Rationale:
Coumadin is an anticoagulant. One of the tests for bleeding time is a Protime. This test should be done monthly. Eating more fruits and vegetables is not necessary, and dark-green vegetables contain vitamin K, which increases clotting, so answer (b) is incorrect. Drinking more liquids and avoiding crowds is not necessary, so answers (c) and (d) are incorrect.
Question 234.
The nurse is assisting the physician with removal of a central venous catheter. To facilitate removal, the nurse should instruct the client to:
(a) Perform the Valsalva maneuver as the catheter is advanced
(b) Turn his head to the left side and hyperextend the neck
(c) Take slow, deep breaths as the catheter is removed
(d) Turn his head to the right while maintaining a sniffing position
Answer:
(a) Perform the Valsalva maneuver as the catheter is advanced
Rationale:
The client who is having a central venous catheter removed should be told to hold his breath and bear down. This prevents air from entering the line. Answers (b), (c), and (d) will not facilitate removal.
Question 235.
A client has an order for streptokinase. Before administering the medication, the nurse should assess the client for:
(a) Allergies to pineapples and bananas
(b) A history of streptococcal infections
(c) Prior therapy with phenytoin
(d) A history of alcohol abuse
Answer:
(b) A history of streptococcal infections
Rationale:
Clients with a history of streptococcal infections could have antibodies that render the streptokinase ineffective. There is no reason to assess the client for allergies to pineapples or bananas, there is no correlation to the use of phenytoin and streptokinase, and a history of alcohol abuse is also not a factor in the order for streptokinase; therefore, answers (a), (c), and (d) are incorrect.
Question 236.
The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:
(a) Using oil- or cream-based soaps
(b) Flossing between the teeth
(c) The intake of salt
(d) Using an electric razor
Answer:
(b) Flossing between the teeth
Rationale:
The client who is immune-suppressed and has bone marrow suppression should be taught not to floss his teeth because platelets are decreased. Using oils and cream-based soaps is allowed, as is eating salt and using an electric razor; therefore, answers (a), (c), and (d) are incorrect.
Question 237.
The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to:
(a) Apply the new tie before removing the old one.
(b) Have a helper present.
(c) Hold the tracheotomy with the nondominant hand while removing the old tie.
(d) Ask the doctor to suture the tracheostomy in place.
Answer:
(a) Apply the new tie before removing the old one.
Rationale:
The best method and safest way to change the ties of a tracheotomy is to apply the new ones before removing the old ones. (b) is incorrect because having a helper is good, but the helper might not prevent the client from coughing out the tracheotomy. Answer (c) is not the best way to prevent the client from coughing out the tracheotomy. (d) is incorrect because asking the doctor to suture the tracheotomy in place is not appropriate.
Question 238.
The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse should give priority to:
(a) Turning the client to the left side
(b) Milking the tube to ensure patency
(c) Slowing the intravenous infusion
(d) Notifying the physician
Answer:
(d) Notifying the physician
Rationale:
The output of 300mL is indicative of hemorrhage and should be reported immediately. Answer (a) does nothing to help the client. Milking the tube is done only with an order and will not help in this situation, and slowing the intravenous infusion is not correct; thus, answers (b) and (c) are incorrect.
Question 239.
The infant is admitted to the unit with tetralogy of Fallot. The nurse would anticipate an order for which medication?
(a) Digoxin
(b) Epinephrine
(c) Aminophyline
(d) Atropine
Answer:
(a) Digoxin
Rationale:
The infant with tetralogy of Fallot has four heart defects. He will be treated with digoxin to slow and strengthen the heart. Epinephrine, aminophyline, and atropine will speed the heart rate and are not used in this client; therefore, answers (b), (c), and (d) are incorrect.
Question 240.
The nurse is educating the lady’s club in self-breast exam. The nurse is aware that most malignant breast masses occur in the Tail of Spence. On the diagram, place an X on the Tail of Spence
Answer:
Rationale:
The Tail of Spence is located in the upper outer quadrant of the breast.
Question 241.
The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:
(a) Tire easily
(b) Grow normally
(c) Need more calories
(d) Be more susceptible to viral infections
Answer:
(a) Tire easily
Rationale:
The toddler with a ventricular septal defect will tire easily. He will not grow normally but will not need more calories. He will be susceptible to bacterial infection, but he will be no more susceptible to viral infections than other children. Therefore, answers (b), (c), and (d) are incorrect.
Question 242.
The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to:
(a) Determine lung maturity
(b) Measure the fetal activity
(c) Show the effect of contractions on fetal heart rate
(d) Measure the well-being of the fetus
Answer:
(b) Measure the fetal activity
Rationale:
A nonstress test determines periodic movement of the fetus. It does not determine lung maturity, show contractions, or measure neurological wellbeing, making answers (a), (c), and (d) incorrect.
Question 243.
The nurse is evaluating the client who was admitted eight hours ago for induction of labor. The following graph is noted on the monitor. Which action should be taken first by the nurse?
(a) Instruct the client to push.
(b) Perform a vaginal exam.
(c) Turn off the Pitocin infusion.
(d) Place the client in a semi-Fowler’s position
Answer:
(c) Turn off the Pitocin infusion.
Rationale:
The monitor indicates variable decelerations caused by cord compression. If Pitocin is infusing, the nurse should turn off the Pitocin. Instructing the client to push is incorrect because pushing could increase the decelerations and because the client is 8cm dilated, making answer (a) incorrect. Performing a vaginal exam should be done after turning off the Pitocin, and placing the client in a semi-Fowler’s position is not appropriate for this situation; therefore, answers (b) and (d) are incorrect.
Question 244.
The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as:
(a) Atrial flutter
(b) A sinus rhythm
(c) Ventricular tachycardia
(d) Atrial fibrillation
Answer:
(c) Ventricular tachycardia
Rationale:
The graph indicates ventricular tachycardia. The answers in (a), (b), and (d) are not noted on the ECG strip.
Question 245.
A client with clotting disorder has an order to continue Lovenox (enoxaparin) injections after discharge. The nurse should teach the client that Lovenox injections should:
(a) Be injected into the deltoid muscle
(b) Be injected into the abdomen
(c) Aspirate after the injection
(d) Clear the air from the syringe before injections
Answer:
(b) Be injected into the abdomen
Rationale:
Lovenox injections should be given in the abdomen, not in the deltoid muscle. The client should not aspirate after the injection or clear the air from the syringe before injection. Therefore, answers (a), (c), and (d) are incorrect.
Question 246.
The nurse has a preop order to administer Valium (diazepam) 10mg and Phenergan (promethazine) 25mg. The correct method of administering these medications is to:
(a) Administer the medications together in one syringe
(b) Administer the medication separately
(c) Administer the Valium, wait five minutes, and then inject the Phenergan
(d) Question the order because they cannot be given at the same time
Answer:
(b) Administer the medication separately
Rationale:
Valium is not given in the same syringe with other medications, so answer (a) is incorrect. These medications can be given to the same client, so answer (d) is incorrect. In answer (c), it is not necessary to wait to inject the second medication. Valium is an antianxiety medication, and Phenergan is used as an antiemetic.
Question 247.
A client with frequent urinary tract infections asks the nurse how she can prevent the reoccurrence. The nurse should teach the client to:
(a) Douche after intercourse
(b) Void every three hours
(c) Obtain a urinalysis monthly
(d) Wipe from back to front after voiding
Answer:
(b) Void every three hours
Rationale:
Voiding every three hours prevents stagnant urine from collecting in the bladder, where bacteria can grow. Douching is not recommended and obtaining a urinalysis monthly is not necessary, making answers (a) and (c) incorrect. The client should practice wiping from front to back after voiding and bowel movements, so answer (d) is incorrect.
Question 248.
Which task should be assigned to the nursing assistant?
(a) Placing the client in seclusion
(b) Emptying the Foley catheter of the preeclamptic client
(c) Feeding the client with dementia
(d) Ambulating the client with a fractured hip
Answer:
(c) Feeding the client with dementia
Rationale:
Of these clients, the one who should be assigned to the care of the nursing assistant is the client with dementia. Only an Rll or the physician can place the client in seclusion, so answer (a) is incorrect. The nurse should empty the Foley catheter of the preeclamptic client because the client is unstable, making answer (b) incorrect. A nurse or physical therapist should ambulate the client with a fractured hip, so answer (d) is incorrect.
Question 249.
The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside?
(a) A tracheotomy set
(b) A padded tongue blade
(c) An endotracheal tube
(d) An airway
Answer:
(a) A tracheotomy set
Rationale:
The client who has recently had a thyroidectomy is at risk for tracheal edema. A padded tongue blade is used for seizures and not for the client with tracheal edema, so answer (b) is incorrect. If the client experiences tracheal edema, the endotracheal tube or airway will not correct the problem, so answers (c) and (d) are incorrect.
Question 250.
The physician has ordered a histoplasmosis test for the elderly client. The nurse is aware that histoplasmosis is transmitted to humans by:
(a) Cats
(b) Dogs
(c) Turtles
(d) Birds
Answer:
(d) Birds
Rationale:
Histoplasmosis is a fungus carried by birds. It is not transmitted to humans by cats, dogs, or turtles. Therefore, answers (a), (b), and (C) are incorrect