1. A gravida III para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse be expected to make after the amniotomy?
A. Fetal heart tones 160bpm
B. A moderate amount of straw-colored fluid
C. A small amount of greenish fluid
D. A small segment of the umbilical cord
2. The client is admitted to the unit. A vaginal exam reveals that she is 2cm dilated. Which of the following statements would the nurse expect her to make?
A. "We have a name picked out for the baby."
B. "I need to push when I have a contraction."
C. "I can't concentrate if anyone is touching me."
D. "When can I get my epidural?"
3. The client is having fetal heart rates of 90–110bpm 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
4. In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia, the nurse should expect:
A. A painless delivery
B. Cervical effacement
C. Infrequent contractions
D. Progressive cervical dilation
5. A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?
A. Anticipate the need for a Caesarean section
B. Apply the fetal heart monitor
C. Place the client in Genu Pectoral position
D. Perform an ultrasound exam
6. 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.
7. 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
8. As the client reaches 8cm dilation, the nurse notes late decelerations on the fetal monitor. The FHR baseline is 165–175bpm with variability of 0–2bpm. What is the most likely explanation of this pattern?
A. The baby is asleep.
B. The umbilical cord is compressed.
C. There is a vagal response.
D. There is uteroplacental insufficiency.
9. 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
10. Which of the following is a characteristic of a reassuring fetal heart rate pattern?
A. A fetal heart rate of 170–180bpm
B. A baseline variability of 25–35bpm
C. Ominous periodic changes
D. Acceleration of FHR with fetal movements
11. 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.
12. 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.
13. 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
14. 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
D. Contraceptive sponge
15. The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of ectopic pregnancy?
A. Painless vaginal bleeding
B. Abdominal cramping
C. Throbbing pain in the upper quadrant
D. Sudden, stabbing pain in the lower quadrant
16. 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 pattie, 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
17. 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
18. 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
19. 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
20. Which of the following instructions should be included in the nurse's teaching regarding oral contraceptives?
A. Weight gain should be reported to the physician.
B. An alternate method of birth control is needed when taking antibiotics.
C. If the client misses one or more pills, two pills should be taken per day for 1 week.
D. Changes in the menstrual flow should be reported to the physician.
21. The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client with:
B. Positive HIV
D. Thyroid disease
22. 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
23. A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:
A. Her contractions are 2 minutes apart.
B. She has back pain and a bloody discharge.
C. She experiences abdominal pain and frequent urination.
D. Her contractions are 5 minutes apart.
24. 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
25. The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered:
A. Within 72 hours of delivery
B. Within 1 week of delivery
C. Within 2 weeks of delivery
D. Within 1 month of delivery
26. 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
27. 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?
28. 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
29. 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
30. 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 2 minutes before care
C. Wear a mask when providing care
D. Ask the client to cover her mouth when she coughs
31. The elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip most likely to exhibit?
C. Cool extremity
D. Absence of pedal pulses
32. 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
33. A 2-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.
34. A client with a fractured hip has been placed in Buck's traction. 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
35. 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
36. 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."
37. The nurse is assessing the client with a total knee replacement 2 hours post-operative. Which information requires notification of the doctor?
A. Bleeding on the dressing is 3cm in diameter.
B. The client has a temperature of 6°F.
C. The client's hematocrit is 26%.
D. The urinary output has been 60 during the last 2 hours.
38. The nurse is caring for the client with a 5-year-old diagnosis of plumbism. Which information in the health history is most likely related to the development of plumbism?
A. The client has traveled out of the country in the last 6 months.
B. The client's parents are skilled stained-glass artists.
C. The client lives in a house built in 1
D. The client has several brothers and sisters.
39. 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
C. TENS unit
D. Abduction pillow
40. 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
41. Which roommate would be most suitable for the 6-year-old male with a fractured femur in Russell's traction?
A. 16-year-old female with scoliosis
B. 12-year-old male with a fractured femur
C. 10-year-old male with sarcoma
D. 6-year-old male with osteomylitis
42. A client with osteoarthritis has a prescription for Celebrex (celecoxib). Which instruction should be included in the discharge teaching?
A. Take the medication with milk.
B. Report chest pain.
C. Remain upright after taking for 30 minutes.
D. Allow 6 weeks for optimal effects.
43. 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
44. 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."
45. The nurse is assigned to care for the client with a Steinmen 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
46. A child with scoliosis has a spica cast applied. Which action specific to the spica cast should be taken?
A. Check the bowel sounds
B. Assess the blood pressure
C. Offer pain medication
D. Check for swelling
47. 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
48. 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."
49. 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
50. 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
51. 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.
52. 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
53. 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
54. 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.
55. 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
56. 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.
57. 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
58. A primigravida, age 42, is 6 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
59. 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 (Pardel)
60. 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
61. 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.
62. A pregnant client, age 32, asks the nurse why her doctor has recommended 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
63. 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.
64. The nurse is responsible for performing a neonatal assessment on a full-term infant. At 1 minute, the nurse could expect to find:
A. An apical pulse of 100
B. An absence of tonus
C. Cyanosis of the feet and hands
D. Jaundice of the skin and sclera
65. 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
66. A client with diabetes has an order for ultrasonography. Preparation for an ultrasound includes:
A. Increasing fluid intake
B. Limiting ambulation
C. Administering an enema
D. Withholding food for 8 hours
67. An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at 1 year?
A. 14 pounds
B. 16 pounds
C. 18 pounds
D. 24 pounds
68. 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
69. A full-term male has hypospadias. Which statement describes hypospadias?
A. The urethral opening is absent.
B. The urethra opens on the dorsal side of the penis.
C. The penis is shorter than usual.
D. The urethra opens on the ventral side of the penis.
70. 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
71. The client with varicella will most likely have an order for which category of medication?
72. A client is admitted complaining of chest pain. Which of the following drug orders should the nurse question?
73. 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.
74. 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 q 4 hours PRN pain
B. Mylanta 30 ccs q 4 hours via NG
C. Cimetadine 300mg
D. Morphine 8mg IM q 4 hours PRN pain
75. 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.
76. 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
77. 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
78. 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
79. 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
80. 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
81. 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.
82. The client has an order for a trough to be drawn on the client receiving Vancomycin. The nurse is aware that the nurse should contact the lab for them to collect the blood:
A. 15 minutes after the infusion
B. 30 minutes before the infusion
C. 1 hour after the infusion
D. 2 hours after the infusion
83. The client using a diaphragm should be instructed to:
A. Refrain from keeping the diaphragm in longer than 4 hours
B. Keep the diaphragm in a cool location
C. Have the diaphragm resized if she gains 5 pounds
D. Have the diaphragm resized if she has any surgery
84. 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."
85. Damage to the VII cranial nerve results in:
A. Facial pain
B. Absence of ability to smell
C. Absence of eye movement
86. 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
87. 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
88. 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
89. A client is admitted for an MRI. The nurse should question the client regarding:
B. A titanium hip replacement
C. Allergies to antibiotics
D. Inability to move his feet
90. 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
C. Urinary frequency
D. Changes in skin color
91. 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
92. 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
93. 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.
94. 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
95. A client with a severe corneal ulcer has an order for Gentamycin 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 5 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.
96. The client with color blindness will most likely have problems distinguishing which of the following colors?
97. 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
98. The client with enuresis is being taught regarding bladder retraining. The nurse should advise the client to refrain from drinking after:
99. 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.
100. The physician has prescribed NPH insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?
A. "I will make sure I eat breakfast within 2 hours of taking my insulin."
B. "I will need to carry candy or some form of sugar with me all the time."
C. "I will eat a snack around three o'clock each afternoon."
D. "I can save my dessert from supper for a bedtime snack."
101. A client with pneumacystis carini pneumonia is receiving trimetrexate. The rationale for administering leucovorin calcium to a client receiving Methotrexate is to:
A. Treat anemia.
B. Create a synergistic effect.
C. Increase the number of white blood cells.
D. Reverse drug toxicity.
102. 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
103. The physician has prescribed rantidine (Zantac) for a client with erosive gastritis. The nurse should administer the medication:
A. 30 minutes before meals
B. With each meal
C. In a single dose at bedtime
D. 60 minutes after meals
104. 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
105. 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
106. The physician has ordered an MRI for a client with an orthopedic ailment. An MRI should not be done if the client has:
A. The need for oxygen therapy
B. A history of claustrophobia
C. A permanent pacemaker
D. Sensory deafness
107. A 6-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
108. 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.
109. 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)
110. 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.
111. 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
112. 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
113. The physician has ordered a thyroid scan to confirm the diagnosis. Before the procedure, the nurse should:
A. Assess the client for allergies
B. Bolus the client with IV fluid
C. Tell the client he will be asleep
D. Insert a urinary catheter
114. 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
115. 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
116. 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
117. 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?
118. 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
119. 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
120. 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
121. The nurse is performing an initial assessment of a newborn Caucasian male delivered at 32 weeks gestation. The nurse can expect to find the presence of:
A. Mongolian spots
B. Scrotal rugae
C. Head lag
D. Vernix caseosa
122. 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?
B. Muscle spasms
123. 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.
124. 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 4x4 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
125. An infant's Apgar score is 9 at 5 minutes. The nurse is aware that the most likely cause for the deduction of one point is:
A. The baby is cold.
B. The baby is experiencing bradycardia.
C. The baby's hands and feet are blue.
D. The baby is lethargic.
126. The primary reason for rapid continuous rewarming 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
127. 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
128. 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 2 weeks
129. A client hospitalized with MRSA (methicillin-resistant staph aureus) is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact?
A. The client should be placed in a room with negative pressure.
B. Infection requires close contact; therefore, the door may remain open.
C. Transmission is highly likely, so the client should wear a mask at all times.
D. Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown.
130. 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."
131. 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
132. The physician has ordered a minimal-bacteria diet for a client with neutropenia. The client should be taught to avoid eating:
133. 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
134. 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
135. 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
136. 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
137. 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.
138. 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
139. The infant is admitted to the unit with tetrology of falot. The nurse would anticipate an order for which medication?
140. 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.
141. 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
142. 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
143. The nurse is evaluating the client who was admitted 8 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
144. 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
145. 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
146. The nurse has a preop order to administer Valium (diazepam) 10mg and Phenergan (promethazine) 25mg. The correct method of administering these medications is to:
A. Administer the medications together in one syringe
B. Administer the medication separately
C. Administer the Valium, wait 5 minutes, and then inject the Phenergan
D. Question the order because they cannot be given at the same time
147. A client with frequent urinary tract infections asks the nurse how she can prevent the reoccurrence. The nurse should teach the client to:
A. Douche after intercourse
B. Void every 3 hours
C. Obtain a urinalysis monthly
D. Wipe from back to front after voiding
148. 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
149. 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
150. The physician has ordered a histoplasmosis test for the elderly client. The nurse is aware that histoplasmosis is transmitted to humans by:
1. Answer B is correct. An amniotomy is an artificial rupture of membranes and normal amniotic fluid is straw-colored and odorless. Fetal heart tones of 160 indicate tachycardia, and greenish fluid is indicative of meconium, so answers A and C are incorrect. If the nurse notes the umbilical cord, the client is experiencing a prolapsed cord, so answer D is incorrect and would need to be reported immediately.
2. Answer D is correct. Dilation of 2cm marks the end of the latent phase of labor. Answer A is a vague answer, answer B indicates the end of the first stage of labor, and answer C indicates the transition phase.
3. Answer B is correct. 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.
4. Answer D is correct. The expected effect of Pitocin is cervical dilation. Pitocin causes more intense contractions, which can increase the pain, making answer A incorrect. Cervical effacement is caused by pressure on the presenting part, so answer B is incorrect. Answer C is opposite the action of Pitocin.
5. Answer B is correct. Applying a fetal heart monitor is the correct action at this time. There is no need to prepare for a Caesarean section or to place the client in Genu Pectoral position (knee-chest), so answers A and C are incorrect. Answer D is incorrect because there is no need for an ultrasound based on the finding.
6. Answer B is correct. The nurse decides to apply an external monitor because the membranes are intact. Answers A, C, and D are incorrect. The cervix is dilated enough to use an internal monitor, if necessary. An internal monitor can be applied if the client is at 0-station. Contraction intensity has no bearing on the application of the fetal monitor.
7. Answer D is correct. Clients admitted in labor are told not to eat during labor, to avoid nausea and vomiting. Ice chips may be allowed, but this amount of fluid might not be sufficient to prevent fluid volume deficit. In answer A, impaired gas exchange related to hyperventilation would be indicated during the transition phase. Answers B and C are not correct in relation to the stem.
8. Answer D is correct. This information indicates a late deceleration. This type of deceleration is caused by uteroplacental lack of oxygen. Answer A has no relation to the readings, so it’s incorrect; answer B results in a variable deceleration; and answer C is indicative of an early deceleration.
9. Answer C is correct. The initial action by the nurse observing a late deceleration should turn the client to the side—preferably, the left side. Administering oxygen is also indicated. Answer A might be necessary but not before turning the client to her side. Answer B is not necessary at this time. Answer D is incorrect because there is no data to indicate that the monitor has been applied incorrectly.
10. Answer D is correct. Accelerations with movement are normal. Answers A, B, and C indicate ominous findings on the fetal heart monitor.
11. Answer C is correct. Epidural anesthesia decreases the urge to void and sensation of a full bladder. A full bladder will decrease the progression of labor. Answers A, B, and D are incorrect for the stem.
12. Answer B is correct. Lutenizing hormone released by the pituitary is responsible for ovulation. At about day 14, the continued increase in estrogen stimulates the release of lutenizing hormone from the anterior pituitary. The LH surge is responsible for ovulation, or the release of the dominant follicle in 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.
13. Answer C is correct. The success of the rhythm method of birth control is dependent on the client’s menses being regular. It is not dependent on the age of the client, frequency of intercourse, or range of the client’s temperature; therefore, answers A, B, and D are incorrect.
14. Answer C is correct. 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.
15. Answer D is correct. 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.
16. Answer C is correct. 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.
17. Answer B is correct. 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.
18. Answer B is correct. 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.
19. Answer C is correct. 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.
20. Answer B is correct. When the client is taking oral contraceptives and begins antibiotics, another method of birth control should be used. Antibiotics decrease the effectiveness of oral contraceptives. Approximately 5–10 pounds of weight gain is not unusual, so answer A is incorrect. If the client misses a birth control pill, she should be instructed to take the pill as soon as she remembers the pill. Answer C is incorrect. If she misses two, she should take two; if she misses more than two, she should take the missed pills but use another method of birth control for the remainder of the cycle. Answer D is incorrect because changes in menstrual flow are expected in clients using oral contraceptives. Often these clients have lighter menses.
21. Answer B is correct. Clients with HIV should not breastfeed because the infection can be transmitted to the baby through breast milk. The clients in answers A, C, and D—those with diabetes, hypertension, and thyroid disease—can be allowed to breastfeed.
22. Answer A is correct. The symptoms of painless vaginal bleeding are consistent with placenta previa. Answers B, C, and D are incorrect. Cervical check for dilation is contraindicated 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.
23. Answer D is correct. The client should be advised to come to the labor and delivery unit when the contractions are every 5 minutes and consistent. She should also be told to report to the hospital if she experiences rupture of membranes or extreme bleeding. She should not wait until the contractions are every 2 minutes or until she has bloody discharge, so answers A and B are incorrect. Answer C is a vague answer and can be related to a urinary tract infection.
24. Answer A is correct. Infants of mothers who smoke are often low in birth weight. Infants who are large for gestational age are associated with diabetic mothers, so answer B is incorrect. Preterm births are associated with smoking, but not with appropriate size for gestation, making answer C incorrect. Growth retardation is associated with smoking, but this does not affect the infant length; therefore, answer D is incorrect.
25. Answer A is correct. To provide protection against antibody production, RhoGam should be given within 72 hours. The answers in B, C, and D are too late to provide antibody protection. RhoGam can also be given during pregnancy.
26. Answer B is correct. When the membranes rupture, there is often a transient drop in the fetal heart tones. The heart tones should return to baseline quickly. Any alteration in fetal heart tones, such as bradycardia or tachycardia, should be reported. After the fetal heart tones are assessed, the nurse should evaluate the cervical dilation, vital signs, and level of discomfort, making answers A, C, and D incorrect.
27. Answer A is correct. The active phase of labor occurs when the client is dilated 4–7cm. The latent or early phase of labor is from 1cm to 3cm in dilation, so answers B and D are incorrect. The transition phase of labor is 8–10cm in dilation, making answer C incorrect.
28. Answer B is correct. The infant of an addicted mother will undergo withdrawal. Snugly wrapping the infant in a blanket will help prevent the muscle irritability that these babies often experience. Teaching the mother to provide tactile stimulation or provide for early infant 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.
29. Answer C is correct. Following epidural anesthesia, the client should be checked for hypotension and signs of shock every 5 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.
30. Answer B is correct. The best way to prevent post-operative wound infection is hand washing. Use of prescribed antibiotics will treat infection, not prevent infections, making 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.
31. Answer B is correct. 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.
32. Answer B is correct. 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.
33. Answer B is correct. 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.
34. Answer A is correct. 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.
35. Answer A is correct. Bleeding is a common complication of orthopedic surgery. The blood-collection device should be checked frequently to ensure that the client is not hemorrhaging. The client’s pain should be assessed, but this is not life-threatening. When the client is in less danger, the nutritional status should be assessed and an immobilizer is not used; thus, answers B, C, and D are incorrect.
36. Answer A is correct. The client’s family member should be taught to flush the tube after each feeding and clamp the tube. The placement should be checked before feedings, and indigestion can occur with the PEG tube, just as it can occur with any client, so answers B and C are incorrect. Medications can be ordered for indigestion, but it is not a reason for alarm. A percutaneous endoscopy gastrostomy tube is used for clients who have experienced difficulty swallowing. The tube is inserted directly into the stomach and does not require swallowing; therefore, answer D is incorrect.
37. Answer C is correct. The client with a total knee replacement should be assessed for anemia. A hematocrit of 26% is extremely low and might require a blood transfusion. Bleeding of 2cm on the dressing is not extreme. Circle and date and time the bleeding and monitor for changes in the client’s status. A low-grade temperature is not unusual after surgery. Ensure that the client is well hydrated, and recheck the temperature in 1 hour. If the temperature is above 101°F, report this finding to the doctor. Tylenol will probably be ordered. Voiding after surgery is also not uncommon and no need for concern; therefore answers A, B, and D are incorrect.
38. Answer B is correct. Plumbism is lead poisoning. One factor associated with the consumption of lead is eating from pottery made in Central America or
that is unfired. The child lives in a house built after 1976 (this is when lead was taken out of paint), and the parents make stained glass as a hobby. Stained glass is put together with lead, which can drop on the work area, where the child can consume the lead beads. Answer A is incorrect because simply traveling out of the country does not increase the risk. In answer C, the house was built after the lead was removed with the paint. Answer D is unrelated to the stem. Mexico
39. Answer A is correct. The equipment that can help with activities of daily living is the high-seat commode. The hip should be kept higher than the knee. The recliner is good because it prevents 90° flexion but not daily activities. A TENS (Transcutaneous Electrical Nerve Stimulation) unit helps with pain management and an abduction pillow is used to prevent adduction of the hip and possibly dislocation of the prosthesis; therefore, answers B, C, and D are incorrect.
40. Answer B is correct. Narcan is the antidote for narcotic overdose. If hypoxia occurs, the client should have oxygen administered by mask, not cannula. There is no data to support the administration of blood products or cardioresuscitation, so answers A, C, and D are incorrect.
41. Answer B is correct. The 6-year-old should have a roommate as close to the same age as possible, so the 12-year-old is the best match. The 10-year-old with sarcoma has cancer and will be treated with chemotherapy that makes him immune suppressed, the 6-year-old with osteomylitis is infected, and the client in answer A is too old and is female; therefore, answers A, C, and D are incorrect.
42. Answer B is correct. Cox II inhibitors have been associated with heart attacks and strokes. Any changes in cardiac status or signs of a stroke should be reported immediately, along with any changes in bowel or bladder habits because bleeding has been linked to use of Cox II inhibitors. The client does not have to take the medication with milk, remain upright, or allow 6 weeks for optimal effect, so answers A, C, and D are incorrect.
43. Answer D is correct. 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, making answer B incorrect. 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.
44. Answer A is correct. 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.
45. Answer A is correct. The nurse is performing the pin care correctly when she uses sterile gloves and Q-tips. A licensed practical nurse can perform pin care, there is no need to clean the weights, and the nurse can help with opening the packages but it isn’t required; therefore, answers B, C, and D are incorrect.
46. Answer A is correct. 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 illeus. 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.
47. Answer C is correct. 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.
48. Answer B is correct. 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.
49. Answer A is correct. The client’s palms should rest lightly on the handles. The elbows should be flexed no more than 30° but should not be extended. Answer B is incorrect because 0° is not a relaxed angle for the elbows and will not facilitate correct walker use. The client should walk to the middle of the walker, not to the front of the walker, making answer C incorrect. The client should be taught not to carry the walker because this would not provide stability; thus, answer D is incorrect.
50. Answer C is correct. The client with a prolapsed cord should be treated by elevating the hips and covering the cord with a moist, sterile saline gauze. The nurse should use her fingers to push up on the presenting part until a cesarean section can be performed. Answers A, B, and D are incorrect. The nurse should not attempt to replace the cord, turn the client on the side, or cover with a dry gauze.
51. Answer B is correct. Chest tubes work to reinflate the lung and drain serous fluid. The tube does not equalize expansion of the lungs. Pain is associated with collapse of the lung, and insertion of chest tubes is painful, so answers A and C are incorrect. Answer D is true, but this is not the primary rationale for performing chest tube insertion.
52. Answer D is correct. Success with breastfeeding depends on many factors, but the most dependable reason for success is desire and willingness to continue the breastfeeding until the infant and mother have time to adapt. The educational level, the infant’s birth weight, and the size of the mother’s breast have nothing to do with success, so answers A, B, and C are incorrect.
53. Answer C is correct. Green-tinged amniotic fluid is indicative of meconium staining. This finding indicates fetal distress. The presence of scant bloody discharge is normal, as are frequent urination and moderate uterine contractions, making answers A, B, and D incorrect.
54. Answer C is correct. Duration is measured from the beginning of one contraction to the end of the same contraction. Answer A refers to frequency. Answer B is incorrect because we do not measure from the end of one contraction to the beginning of the next contraction. Duration is not measured from the peak of the contraction to the end, as stated in D.
55. Answer B is correct. The client receiving Pitocin should be monitored for decelerations. There is no association with Pitocin use and hypoglycemia, maternal hyperreflexia, or fetal movement; therefore, answers A, C, and D are incorrect.
56. Answer D is correct. Fetal development depends on adequate nutrition and insulin regulation. Insulin needs increase during the second and third trimesters, insulin requirements do not moderate as the pregnancy progresses, and elevated human chorionic gonadotrophin elevates insulin needs, not decreases them; therefore, answers A, B, and C are incorrect.
57. Answer A is correct. 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.
58. Answer A is correct. 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.
59. Answer C is correct. 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 Pardel is a dopamine receptor stimulant used to treat Parkinson’s disease; therefore, answers A, B, and D are incorrect. Pardel was used at one time to dry breast milk.
60. Answer A is correct. 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. 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.
61. Answer C is correct. 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.
62. Answer D is correct. 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.
63. Answer B is correct. During pregnancy, the thyroid gland triples in size. This makes it more difficult to regulate thyroid medication. Answer A is incorrect because there could be a need for thyroid medication during pregnancy. Answer C is incorrect because the thyroid function does not slow. Fetal growth is not arrested if thyroid medication is continued, so answer D is incorrect.
64. Answer C is correct. Cyanosis of the feet and hands is acrocyanosis. This is a normal finding 1 minute after birth. An apical pulse should be 120–160, and the baby should have muscle tone, making answers A and B incorrect. Jaundice immediately after birth is pathological jaundice and is abnormal, so answer D is incorrect.
65. Answer A is correct. Clients with sickle cell crises are treated with heat, hydration, oxygen, and pain relief. Fluids are increased, not decreased. Blood transfusions are usually not required, and the client can be delivered vaginally; thus, answers B, C, and D are incorrect.
66. Answer A is correct. Before ultrasonography, the client should be taught to drink plenty of fluids and not void. The client may ambulate, an enema is not needed, and there is no need to withhold food for 8 hours. Therefore, answers B, C, and D are incorrect.
67. Answer D is correct. By 1 year of age, the infant is expected to triple his birth weight. Answers A, B, and C are incorrect because they are too low.
68. Answer B is correct. A nonstress test is done to evaluate periodic movement of the fetus. It is not done to evaluate lung maturity as in answer A. An oxytocin challenge test shows the effect of contractions on fetal heart rate and a nonstress test does not measure neurological well-being of the fetus, so answers C and D are incorrect.
69. Answer B is correct. Hypospadia is a condition in which there is an opening on the dorsal side of the penis. Answer A is incorrect because hypospadia does not concern the urethral opening. Answer C is incorrect because the size of the penis is not affected. Answer D is incorrect because the opening is on the dorsal side, not the ventral side.
70. Answer A is correct. Transition is the time during labor when the client loses concentration due to intense contractions. Potential for injury related to precipitate delivery has nothing to do with the dilation of the cervix, so answer B is incorrect. There is no data to indicate that the client has had anesthesia or fluid volume deficit, making answers C and D incorrect.
71. Answer C is correct. Varicella is chicken pox. This herpes virus is treated with antiviral medications. The client is not treated with antibiotics or anticoagulants as stated in answers A and D. The client might have a fever before the rash appears, but when the rash appears, the temperature is usually gone, so answer B is incorrect.
72. Answer B is correct. Clients with chest pain can be treated with nitroglycerin, a beta blocker such as propanolol, or Varapamil. There is no indication for an antibiotic such as Ampicillin, so answers A, C, and D are incorrect.
73. Answer B is correct. 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.
74. Answer D is correct. Morphine is contraindicated in clients with gallbladder disease and pancreatitis because morphine causes spasms of the Sphenter of Oddi. Meperidine, Mylanta, and Cimetadine are ordered for pancreatitis, making answers A, B, and C incorrect.
75. Answer B is correct. 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.
76. Answer B is correct. Barbiturates create a sedative effect. When the client stops taking barbiturates, he will experience tachycardia, diarrhea, and tachpnea. 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.
77. Answer A is correct. 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.
78. Answer D is correct. 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.
79. Answer A is correct. The client with mania is seldom sitting long enough to eat and burns many calories for energy. Answer B is incorrect because the client should be treated the same as other clients. Small meals are not a correct option for this client. Allowing her into the kitchen gives her privileges that other clients do not have and should not be allowed, so answer D is incorrect.
80. Answer B is correct. Bryant’s traction is used for fractured femurs and dislocated hips. The hips should be elevated 15° off the bed. Answer A is incorrect because the hips should not be resting on the bed. Answer C is incorrect because the hips should not be above the level of the body. Answer D is incorrect because the hips and legs should not be flat on the bed.
81. Answer B is correct. Herpes zoster is shingles. Clients with shingles should be placed in contact precautions. Wearing gloves during care will prevent transmission of the virus. Covering the lesions with a sterile gauze is not necessary, antibiotics are not prescribed for herpes zoster, and oxygen is not necessary for shingles; therefore, answers A, C, and D are incorrect.
82. Answer B is correct. A trough level should be drawn 30 minutes before the third or fourth dose. The times in answers A, C, and D are incorrect times to draw blood levels.
83. Answer B is correct. The client using a diaphragm should keep the diaphragm in a cool location. Answers A, C, and D are incorrect. She should refrain from leaving the diaphragm in longer than 8 hours, not 4 hours. She should have the diaphragm resized when she gains or loses 10 pounds or has abdominal surgery.
84. Answer C is correct. Mothers who plan to breastfeed should drink plenty of liquids, and four glasses is not enough in a 24-hour period. Wearing a support bra is a good practice for the mother who is breastfeeding as well as the mother who plans to bottle-feed, so answer A is incorrect. Expressing milk from the breast will stimulate milk production, making answer B incorrect. Allowing the water to run over the breast will also facilitate "letdown," when the milk begins to be produced; thus, answer D is incorrect.
85. Answer A is correct. The facial nerve is cranial nerve VII. If damage occurs, the client will experience facial pain. The auditory nerve is responsible for hearing loss and tinnitus, eye movement is controlled by the Trochear or C IV, and the olfactory nerve controls smell; therefore, answers B, C, and D are incorrect.
86. Answer B is correct. Clients taking Pyridium should be taught that the medication will turn the urine orange or red. It is not associated with diarrhea, mental confusion, or changes in taste; therefore, answers A, C, and D are incorrect. Pyridium can also cause a yellowish color to skin and sclera if taken in large doses.
87. Answer B is correct. Accutane is contraindicated for use by pregnant clients because it causes teratogenic effects. Calcium levels, apical pulse, and creatinine levels are not necessary; therefore, answers A, C, and D are incorrect.
88. Answer D is correct. Clients taking Acyclovir should be encouraged to drink plenty of fluids because renal impairment can occur. Limiting activity is not necessary, nor is eating a high-carbohydrate diet. Use of an incentive spirometer is not specific to clients taking Acyclovir; therefore, answers A, B, and C are incorrect.
89. Answer A is correct. Clients who are pregnant should not have an MRI because radioactive isotopes are used. However, clients with a titanium hip replacement can have an MRI, 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.
90. Answer D is correct. 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.
91. Answer C is correct. 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.
92. Answer B is correct. 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.
93. Answer C is correct. 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.
94. Answer C is correct. Miotic eyedrops constrict the pupil and allow aqueous humor to drain out of the
. They do not anesthetize the cornea, dilate the pupil, or paralyze the muscles of the eye, making answers A, B, and D incorrect. Canal of Schlemm
95. Answer A is correct. When using eyedrops, allow 5 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.
96. Answer B is correct. Clients with color blindness will most likely have problems distinguishing violets, blues, and green. The colors in answers A, C, and D are less commonly affected.
97. Answer D is correct. The client with a pacemaker should be taught to count and record his pulse rate. Answers A, B, and C are incorrect. Ankle edema is a sign of right-sided congestive heart failure. Although this is not normal, it is often present in clients with heart disease. If the edema is present in the hands and face, it should be reported. Checking the blood pressure daily is not necessary for these clients. The client with a pacemaker can use a microwave oven, but he should stand about 5 feet from the oven while it is operating.
98. Answer A is correct. Clients who are being retrained for bladder control should be taught to withhold fluids after about 7 p.m., or 1 The times in answers B, C, and D are too early in the day.
99. Answer D is correct. Cranberry juice is more alkaline and, when metabolized by the body, is excreted with acidic urine. Bacteria does not grow freely in acidic urine. Increasing intake of meats is not associated with urinary tract infections, so 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.
100. Answer C is correct. NPH insulin peaks in 8–12 hours, so a snack should be offered at that time. NPH insulin onsets in 90–120 minutes, so answer A is incorrect. Answer B is untrue because NPH insulin is time released and does not usually cause sudden hypoglycemia. Answer D is incorrect, but the client should eat a bedtime snack.
101. Answer D is correct. Methotrexate is a folic acid antagonist. Leucovorin is the drug given for toxicity to this drug. It is not used to treat iron-deficiency anemia, create a synergistic effects, or increase the number of circulating neutrophils. Therefore, answers A, B, and C are incorrect.
102. Answer B is correct. The client who is allergic to dogs, eggs, rabbits, and chicken feathers is most likely allergic to the rubella vaccine. The client who is allergic to neomycin is also at risk. There is no danger to the client if he has an order for a TB skin test, ELISA test, or chest x-ray; thus, answers A, C, and D are incorrect.
103. Answer B is correct. Zantac (rantidine) is a histamine blocker that should be given with meals for optimal effect, not before meals. However, Tagamet (cimetidine) is a histamine blocker that can be given in one dose at bedtime. Neither of these drugs should be given before or after meals, so answers A and D are incorrect.
104. Answer C is correct. The proximal end of the double-barrel colostomy is the end toward the small intestines. This end is on the client’s right side. The distal end, as in answers A, B, and D, is on the client’s left side.
105. Answer A is correct. If the nurse checks the fundus and finds it to be displaced to the right or left, this is an indication of a full bladder. This finding is not associated with hypotension or clots, as stated in answer B. Oxytoxic drugs (Pitocin) are drugs used to contract the uterus, so answer C is incorrect. It has nothing to do with displacement of the uterus. Answer D is incorrect because displacement is associated with a full bladder, not vaginal bleeding.
106. Answer C is correct. 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.
107. Answer C is correct. A 6-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.
108. Answer C is correct. 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 are directly associated with polio and cannot be corrected with glasses; therefore, answer D is incorrect.
109. Answer B is correct. 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.
110. Answer C is correct. 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.
111. Answer B is correct. 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.
112. Answer A is correct. 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.
113. Answer A is correct. A thyroid scan uses a dye, so the client should be assessed for allergies to iodine. The client will not have a bolus of fluid, will not be asleep, and will not have a urinary catheter inserted, so answers B, C, and D are incorrect.
114. Answer B is correct. RhoGam is used to prevent formation of Rh antibodies. It does not provide immunity to Rh isoenzymes, eliminate circulating Rh antibodies, or convert the Rh factor from negative to positive; thus, answers A, C, and D are incorrect.
115. Answer B is correct. A client with a fractured foot often has a short leg cast applied to stabilize the fracture. A spica cast is used to stabilize a fractured pelvis or vertebral fracture. Kirschner 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.
116. Answer A is correct. Iridium seeds can be expelled during urination, so the client should be taught to strain his urine and report to the doctor if any of the seeds are expelled. Increasing fluids, reporting urinary frequency, and avoiding prolonged sitting are not necessary; therefore, answers B, C, and D are incorrect.
117. Answer C is correct. Immunosuppressants are used to prevent antibody formation. Antivirals, antibiotics, and analgesics are not used to prevent antibody production, so answers A, B, and D are incorrect.
118. Answer A is correct. Before cataract removal, the client will have Mydriatic drops instilled to dilate the pupil. This will facilitate removal of the lens. Miotics constrict the pupil and are not used in cataract clients. A laser is not used to smooth and reshape the lens; the diseased lens is removed. Silicone oil is not injected in this client; thus, answers B, C, and D are incorrect.
119. Answer C is correct. Placing simple signs that indicate the location of rooms where the client sleeps, eats, and bathes will help the client be more independent. Providing mirrors and pictures is not recommended with the client who has Alzheimer’s disease because mirrors and pictures tend to cause agitation, and alternating healthcare workers confuses the client; therefore, answers A, B, and D are incorrect.
120. Answer C is correct. A Jackson-Pratt drain is a serum-collection device commonly used in abdominal surgery. A Jackson-Pratt drain will not prevent the need for dressing changes, reduce edema of the incision, or keep the common bile duct open, so answers A, B, and D are incorrect. A t-tube is used to keep the common bile duct open.
121. Answer C is correct. The infant who is 32 weeks gestation will not be able to control his head, so head lag will be present. Mongolian spots are common in African American infants, not Caucasian infants; the client at 32 weeks will have scrotal rugae or redness but will not have vernix caseosa, the cheesy appearing covering found on most full-term infants. Therefore, answers A, B, and D are incorrect.
122. Answer A is correct. 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.
123. Answer C is correct. 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.
124. Answer B is correct. 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.
125. Answer C is correct. Infants with an Apgar of 9 at 5 minutes most likely have acryocyanosis, a normal physiologic adaptation to birth. It is not related to the infant being cold, experiencing bradycardia, or being lethargic; thus, answers A, B, and D are incorrect.
126. Answer A is correct. 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.
127. Answer D is correct. 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.
128. Answer B is correct. The client who is immune-suppressed and is exposed to measles should be treated with medications to boost his immunity to the virus. An antibiotic or antiviral will not protect the client and it is too late to place the client in isolation, so answers A, C, and D are incorrect.
129. Answer D is correct. The client with MRSA should be placed in isolation. Gloves, a gown, and a mask should be used when caring for the client and hand washing is very important. The door should remain closed, but a negative-pressure room is not necessary, so answers A and B are incorrect. MRSA is spread by contact with blood or body fluid or by touching the skin of the client. It is cultured from the nasal passages of the client, so the client should be instructed to cover his nose and mouth when he sneezes or coughs. It is not necessary for the client to wear the mask at all times; the nurse should wear the mask, so answer C is incorrect.
130. Answer B is correct. 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.
131. Answer A is correct. During a Whipple procedure the head of the pancreas, which is a part of the stomach, the jejunum, and a portion of the stomach are removed and reanastomosed. Answer B is incorrect because the proximal third of the small intestine is not removed. The entire stomach is not removed, as in answer C, and in answer D, the esophagus is not removed.
132. Answer C is correct. Pepper is not processed and contains bacteria. Answers A, B, and D are incorrect because fruits should be cooked or washed and peeled, and salt and ketchup are allowed.
133. Answer A is correct. Coumadin is an anticoagulant. One of the tests for bleeding time is a Protime. This test should be done monthly. Eating more fruits and vegetables is not necessary, and dark-green vegetables contain vitamin K, which increases clotting, so answer B is incorrect. Drinking more liquids and avoiding crowds is not necessary, so answers C and D are incorrect.
134. Answer A is correct. The client who is having a central venous catheter removed should be told to hold his breath and bear down. This prevents air from entering the line. Answers B, C, and D will not facilitate removal.
135. Answer B is correct. Clients with a history of streptococcal infections could have antibodies that render the streptokinase ineffective. There is no reason to assess the client for allergies to pineapples or bananas, there is no correlation to the use of phenytoin and streptokinase, and a history of alcohol abuse is also not a factor in the order for streptokinase; therefore, answers A, C, and D are incorrect.
136. Answer B is correct. The client who is immune-suppressed and has bone marrow suppression should be taught not to floss his teeth because platelets are decreased. Using oils and cream-based soaps is allowed, as is eating salt and using an electric razor; therefore, answers A, C, and D are incorrect.
137. Answer A is correct. The best method and safest way to change the ties of a tracheotomy is to apply the new ones before removing the old ones. 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. Asking the doctor to suture the tracheotomy in place is not appropriate.
138. Answer D is correct. 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.
139. Answer A is correct. The infant with tetrology of falot has five 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.
140. The correct answer is marked by an X in the diagram. The Tail of Spence is located in the upper outer quadrant of the breast.
141. Answer A is correct. 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.
142. Answer B is correct. A nonstress test determines periodic movement of the fetus. It does not determine lung maturity, show contractions, or measure neurological well-being, making answers A, C, and D incorrect.
143. Answer C is correct. The monitor indicates variable decelerations caused by cord compression. If Pitocin is infusing, the nurse should turn off the Pitocin. Instructing the client to push is incorrect because pushing could increase the decelerations and because the client is 8cm dilated, making answer A incorrect. Performing a vaginal exam should be done after turning off the Pitocin, and placing the client in a semi-Fowler’s position is not appropriate for this situation; therefore, answers B and D are incorrect.
144. Answer C is correct. The graph indicates ventricular tachycardia. The answers in A, B, and D are not noted on the ECG strip.
145. Answer B is correct. Lovenox injections should be given in the abdomen, not in the deltoid muscle. The client should not aspirate after the injection or clear the air from the syringe before injection. Therefore, answers A, C, and D are incorrect.
146. Answer B is correct. Valium is not given in the same syringe with other medications, so answer A is incorrect. These medications can be given to the same client, so answer D is incorrect. In answer C, it is not necessary to wait to inject the second medication. Valium is an antianxiety medication, and Phenergan is used as an antiemetic.
147. Answer B is correct. Voiding every 3 hours prevents stagnant urine from collecting in the bladder, where bacteria can grow. Douching is not recommended and obtaining a urinalysis monthly is not necessary, making answers A and C incorrect. The client should practice wiping from front to back after voiding and bowel movements, so answer D is incorrect.
148. Answer C is correct. Of these clients, the one who should be assigned to the care of the nursing assistant is the client with dementia. Only an RN or the physician can place the client in seclusion, so answer A is incorrect. The nurse should empty the Foley catheter of the preeclamptic client because the client is unstable, making answer B incorrect. A nurse or physical therapist should ambulate the client with a fractured hip, so answer D is incorrect.
149. Answer A is correct. The client who has recently had a thyroidectomy is at risk for tracheal edema. A padded tongue blade is used for seizures and not for the client with tracheal edema, so answer 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.
150. Answer D is correct. Histoplasmosis is a fungus carried by birds. It is not transmitted to humans by cats, dogs, or turtles. Therefore, answers A, B, and C are incorrect.