1. A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use?
A. Body temperature of 99°F or less
B. Toes moved in active range of motion
C. Sensation reported when soles of feet are touched
D. Capillary refill of < 3 seconds
2. A 30-year-old male from Haiti
A. Side-lying with knees flexed
B. Knee-chest
C. High Fowler's with knees flexed
D. Semi-Fowler's with legs extended on the bed
3. A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?
A. Taking hourly blood pressures with mechanical cuff
B. Encouraging fluid intake of at least 200mL per hour
C. Position in high Fowler's with knee gatch raised
D. Administering Tylenol as ordered
4. Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?
A. Peaches
B. Cottage cheese
C. Popsicle
D. Lima beans
5. A newly admitted client has sickle cell crisis. The nurse is planning care based on assessment of the client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. Which of the following interventions would be implemented first? Assume that there are orders for each intervention.
A. Adjust the room temperature
B. Give a bolus of IV fluids
C. Start O2
D. Administer meperidine (Demerol) 75mg IV pus
6. The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?
A. Roast beef, gelatin salad, green beans, and peach pie
B. Chicken salad sandwich, coleslaw, French fries, ice cream
C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie
D. Pork chop, creamed potatoes, corn, and coconut cake
7. Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?
A. A family vacation in the Rocky Mountains
B. Chaperoning the local boys club on a snow-skiing trip
C. Traveling by airplane for business trips
D. A bus trip to the Museum of Natural History
8. The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which of the following would the nurse include in the physical assessment?
A. Palpate the spleen
B. Take the blood pressure
C. Examine the feet for petechiae
D. Examine the tongue
9. An African American female comes to the outpatient clinic. The physician suspects vitamin B12 deficiency anemia. Because jaundice is often a clinical manifestation of this type of anemia, what body part would be the best indicator?
A. Conjunctiva of the eye
B. Soles of the feet
C. Roof of the mouth
D. Shins
10. The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?
A. BP 146/88
B. Respirations 28 shallow
C. Weight gain of 10 pounds in 6 months
D. Pink complexion
11. The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?
A. "I will drink 500mL of fluid or less each day."
B. "I will wear support hose when I am up."
C. "I will use an electric razor for shaving."
D. "I will eat foods low in iron."
12. A 33-year-old male is being evaluated for possible acute leukemia. Which of the following would the nurse inquire about as a part of the assessment?
A. The client collects stamps as a hobby.
B. The client recently lost his job as a postal worker.
C. The client had radiation for treatment of Hodgkin's disease as a teenager.
D. The client's brother had leukemia as a child.
13. An African American client is admitted with acute leukemia. The nurse is assessing for signs and symptoms of bleeding. Where is the best site for examining for the presence of petechiae?
A. The abdomen
B. The thorax
C. The earlobes
D. The soles of the feet
14. A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire?
A. "Have you noticed a change in sleeping habits recently?"
B. "Have you had a respiratory infection in the last 6 months?"
C. "Have you lost weight recently?"
D. "Have you noticed changes in your alertness?"
15. Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?
A. Oral mucous membrane, altered related to chemotherapy
B. Risk for injury related to thrombocytopenia
C. Fatigue related to the disease process
D. Interrupted family processes related to life-threatening illness of a family member
16. A 21-year-old male with Hodgkin's lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client?
A. Sexual dysfunction related to radiation therapy
B. Anticipatory grieving related to terminal illness
C. Tissue integrity related to prolonged bed rest
D. Fatigue related to chemotherapy
17. A client has autoimmune thrombocytopenic purpura. To determine the client's response to treatment, the nurse would monitor:
A. Platelet count
B. White blood cell count
C. Potassium levels
D. Partial prothrombin time (PTT)
18. The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client's platelet count currently is 80, It will be most important to teach the client and family about:
A. Bleeding precautions
B. Prevention of falls
C. Oxygen therapy
D. Conservation of energy
19. A client with a pituitary tumor has had a transphenoidal hyposphectomy. Which of the following interventions would be appropriate for this client?
A. Place the client in Trendelenburg position for postural drainage
B. Encourage coughing and deep breathing every 2 hours
C. Elevate the head of the bed 30°
D. Encourage the Valsalva maneuver for bowel movements
20. The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:
A. Measure the urinary output
B. Check the vital signs
C. Encourage increased fluid intake
D. Weigh the client
21. A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?
A. Place the client in a sitting position with the head hyperextended
B. Pack the nares tightly with gauze to apply pressure to the source of bleeding
C. Pinch the soft lower part of the nose for a minimum of 5 minutes
D. Apply ice packs to the forehead and back of the neck
22. A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in the immediate post-operative period for the nurse to take is:
A. Blood pressure
B. Temperature
C. Output
D. Specific gravity
23. A client with Addison's disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement?
A. Glucometer readings as ordered
B. Intake/output measurements
C. Sodium and potassium levels monitored
D. Daily weights
24. A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses' next action be?
A. Obtain a crash cart
B. Check the calcium level
C. Assess the dressing for drainage
D. Assess the blood pressure for hypertension
25. A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?
A. Impaired physical mobility related to decreased endurance
B. Hypothermia r/t decreased metabolic rate
C. Disturbed thought processes r/t interstitial edema
D. Decreased cardiac output r/t bradycardia
26. The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client?
A. Report muscle weakness to the physician.
B. Allow six months for the drug to take effect.
C. Take the medication with fruit juice.
D. Ask the doctor to perform a complete blood count before starting the medication.
27. The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should:
A. Utilize an infusion pump
B. Check the blood glucose level
C. Place the client in Trendelenburg position
D. Cover the solution with foil
28. The 6-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?
A. Blood pressure of 126/80
B. Blood glucose of 110mg/dL
C. Heart rate of 60bpm
D. Respiratory rate of 30 per minute
29. The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:
A. Replenish his supply every 3 months
B. Take one every 15 minutes if pain occurs
C. Leave the medication in the brown bottle
D. Crush the medication and take with water
30. The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?
A. Macaroni and cheese
B. Shrimp with rice
C. Turkey
D. Spaghetti
31. The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:
A. Feet
B. Neck
C. Hands
D. Sacrum
32. The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the:
A. Phlebostatic axis
B. PMI
C. Erb's point
D. Tail of Spence
33. The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:
A. Question the order
B. Administer the medications
C. Administer separately
D. Contact the pharmacy
34. The best method of evaluating the amount of peripheral edema is:
A. Weighing the client daily
B. Measuring the extremity
C. Measuring the intake and output
D. Checking for pitting
35. A client with vaginal cancer is being treated with a radioactive vaginal implant. The client's husband asks the nurse if he can spend the night with his wife. The nurse should explain that:
A. Overnight stays by family members is against hospital policy.
B. There is no need for him to stay because staffing is adequate.
C. His wife will rest much better knowing that he is at home.
D. Visitation is limited to 30 minutes when the implant is in place.
36. The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?
A. Roast beef sandwich, potato chips, pickle spear, iced tea
B. Split pea soup, mashed potatoes, pudding, milk
C. Tomato soup, cheese toast, Jello, coffee
D. Hamburger, baked beans, fruit cup, iced tea
37. The physician has prescribed Novalog insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?
A. "I will make sure I eat breakfast within 10 minutes of taking my insulin."
B. "I will need to carry candy or some form of sugar with me all the time."
C. "I will eat a snack around three o'clock each afternoon."
D. "I can save my dessert from supper for a bedtime snack."
38. The nurse is teaching basic infant care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first 2 weeks of life because:
A. New parents need time to learn how to hold the baby.
B. The umbilical cord needs time to separate.
C. Newborn skin is easily traumatized by washing.
D. The chance of chilling the baby outweighs the benefits of bathing.
39. A client with leukemia is receiving Trimetrexate. After reviewing the client's chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:
A. Treat iron-deficiency anemia caused by chemotherapeutic agents
B. Create a synergistic effect that shortens treatment time
C. Increase the number of circulating neutrophils
D. Reverse drug toxicity and prevent tissue damage
40. A 4-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive:
A. Hib titer
B. Mumps vaccine
C. Hepatitis B vaccine
D. MMR
41. The physician has prescribed Nexium (esomeprazole) 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. 30 minutes after meals
42. A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?
A. Call security for assistance and prepare to sedate the client.
B. Tell the client to calm down and ask him if he would like to play cards.
C. Tell the client that if he continues his behavior he will be punished.
D. Leave the client alone until he calms down.
43. When the nurse checks the fundus of a client on the first postpartum day, she notes that the fundus is firm, is at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to:
A. Check the client for bladder distention
B. Assess the blood pressure for hypotension
C. Determine whether an oxytocic drug was given
D. Check for the expulsion of small clots
44. A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood-tinged hemoptysis, fatigue, and night sweats. The client's symptoms are consistent with a diagnosis of:
A. Pneumonia
B. Reaction to antiviral medication
C. Tuberculosis
D. Superinfection due to low CD4 count
45. The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client's history should be reported to the doctor?
A. Diabetes
B. Prinzmetal's angina
C. Cancer
D. Cluster headaches
46. The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig's sign is charted if the nurse notes:
A. Pain on flexion of the hip and knee
B. Nuchal rigidity on flexion of the neck
C. Pain when the head is turned to the left side
D. Dizziness when changing positions
47. The client with Alzheimer's disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting:
A. Agnosia
B. Apraxia
C. Anomia
D. Aphasia
48. The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:
A. Chronic fatigue syndrome
B. Normal aging
C. Sundowning
D. Delusions
49. The client with confusion says to the nurse, "I haven't had anything to eat all day long. When are they going to bring breakfast?" The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make?
A. "You know you had breakfast 30 minutes ago."
B. "I am so sorry that they didn't get you breakfast. I'll report it to the charge nurse."
C. "I'll get you some juice and toast. Would you like something else?"
D. "You will have to wait a while; lunch will be here in a little while."
50. The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer's disease. Which side effect is most often associated with this drug?
A. Urinary incontinence
B. Headaches
C. Confusion
D. Nausea
51. A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
A. Document the finding
B. Report the finding to the doctor
C. Prepare the client for a C-section
D. Continue primary care as prescribed
52. A client with a diagnosis of HPV is at risk for which of the following?
A. Hodgkin's lymphoma
B. Cervical cancer
C. Multiple myeloma
D. Ovarian cancer
53. During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:
A. Syphilis
B. Herpes
C. Gonorrhea
D. Condylomata
54. A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is:
A. Venereal Disease Research Lab (VDRL)
B. Rapid plasma reagin (RPR)
C. Florescent treponemal antibody (FTA)
D. Thayer-Martin culture (TMC)
55. A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?
A. Elevated blood glucose
B. Elevated platelet count
C. Elevated creatinine clearance
D. Elevated hepatic enzymes
56. The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?
A. The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.
B. The nurse loosely suspends the client's arm in an open hand while tapping the back of the client's elbow.
C. The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.
D. The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.
57. A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor's order should the nurse question?
A. Magnesium sulfate 4gm (25%) IV
B. Brethine 10mcg IV
C. Stadol 1mg IV push every 4 hours as needed prn for pain
D. Ancef 2gm IVPB every 6 hours
58. A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse's assessment of this data is:
A. The infant is at low risk for congenital anomalies.
B. The infant is at high risk for intrauterine growth retardation.
C. The infant is at high risk for respiratory distress syndrome.
D. The infant is at high risk for birth trauma.
59. Which observation in the newborn of a diabetic mother would require immediate nursing intervention?
A. Crying
B. Wakefulness
C. Jitteriness
D. Yawning
60. The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:
A. Decreased urinary output
B. Hypersomnolence
C. Absence of knee jerk reflex
D. Decreased respiratory rate
61. The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse would:
A. Place her in Trendelenburg position
B. Decrease the rate of IV infusion
C. Administer oxygen per nasal cannula
D. Increase the rate of the IV infusion
62. A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis?
A. Alteration in nutrition
B. Alteration in bowel elimination
C. Alteration in skin integrity
D. Ineffective individual coping
63. The nurse is caring for a client with ascites. Which is the best method to use for determining early ascites?
A. Inspection of the abdomen for enlargement
B. Bimanual palpation for hepatomegaly
C. Daily measurement of abdominal girth
D. Assessment for a fluid wave
64. The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client's most appropriate priority nursing diagnosis?
A. Alteration in cerebral tissue perfusion
B. Fluid volume deficit
C. Ineffective airway clearance
D. Alteration in sensory perception
65. The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:
A. Likes to play football
B. Drinks several carbonated drinks per day
C. Has two sisters with sickle cell tract
D. Is taking acetaminophen to control pain
66. The nurse working the organ transplant unit is caring for a client with a white blood cell count of During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?
A. Allow the client to keep the fruit
B. Place the fruit next to the bed for easy access by the client
C. Offer to wash the fruit for the client
D. Tell the family members to take the fruit home
67. The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40 systolic. The initial nurse's action should be to:
A. Place the client in Trendelenburg position
B. Increase the infusion of Dextrose in normal saline
C. Administer atropine intravenously
D. Move the emergency cart to the bedside
68. The client admitted 2 days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?
A. Order a chest x-ray
B. Reinsert the tube
C. Cover the insertion site with a Vaseline gauze
D. Call the doctor
69. A client being treated with sodium warfarin has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?
A. Assess for signs of abnormal bleeding
B. Anticipate an increase in the Coumadin dosage
C. Instruct the client regarding the drug therapy
D. Increase the frequency of neurological assessments
70. Which selection would provide the most calcium for the client who is 4 months pregnant?
A. A granola bar
B. A bran muffin
C. A cup of yogurt
D. A glass of fruit juice
71. The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates understanding of the possible side effects of magnesium sulfate?
A. The nurse places a sign over the bed not to check blood pressure in the right arm.
B. The nurse places a padded tongue blade at the bedside.
C. The nurse inserts a Foley catheter.
D. The nurse darkens the room.
72. A 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL. The physician has written an order to transfuse 2 units of whole blood. When discussing the treatment, the child's mother tells the nurse that she does not believe in having blood transfusions and that she will not allow her child to have the treatment. What nursing action is most appropriate?
A. Ask the mother to leave while the blood transfusion is in progress
B. Encourage the mother to reconsider
C. Explain the consequences without treatment
D. Notify the physician of the mother's refusal
73. A client is admitted to the unit 2 hours after an explosion causes burns to the face. The nurse would be most concerned with the client developing which of the following?
A. Hypovolemia
B. Laryngeal edema
C. Hypernatremia
D. Hyperkalemia
74. The nurse is evaluating nutritional outcomes for an elderly client with bulimia. Which data best indicates that the plan of care is effective?
A. The client selects a balanced diet from the menu.
B. The client's hemoglobin and hematocrit improve.
C. The client's tissue turgor improves.
D. The client gains weight.
75. The client is admitted following repair of a fractured tibia and cast application. Which nursing assessment should be reported to the doctor?
A. Pain beneath the cast
B. Warm toes
C. Pedal pulses weak and rapid
D. Paresthesia of the toes
76. The client is having an arteriogram. During the procedure, the client tells the nurse, "I'm feeing really hot." Which response would be best?
A. "You are having an allergic reaction. I will get an order for Benadryl."
B. "That feeling of warmth is normal when the dye is injected."
C. "That feeling of warmth indicates that the clots in the coronary vessels are dissolving."
D. "I will tell your doctor and let him explain to you the reason for the hot feeling that you are experiencing."
77. The nurse is observing several healthcare workers providing care. Which action by the healthcare worker indicates a need for further teaching?
A. The nursing assistant wears gloves while giving the client a bath.
B. The nurse wears goggles while drawing blood from the client.
C. The doctor washes his hands before examining the client.
D. The nurse wears gloves to take the client's vital signs.
78. The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client's ECT has been effective?
A. The client loses consciousness.
B. The client vomits.
C. The client's ECG indicates tachycardia.
D. The client has a grand mal seizure.
79. The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to:
A. Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep
B. Scrape the skin with a piece of cardboard and bring it to the clinic
C. Obtain a stool specimen in the afternoon
D. Bring a hair sample to the clinic for evaluation
80. The nurse is teaching the mother regarding treatment for enterobiasis. Which instruction should be given regarding the medication?
A. Treatment is not recommended for children less than 10 years of age.
B. The entire family should be treated.
C. Medication therapy will continue for 1 year.
D. Intravenous antibiotic therapy will be ordered.
81. The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?
A. The client receiving linear accelerator radiation therapy for lung cancer
B. The client with a radium implant for cervical cancer
C. The client who has just been administered soluble brachytherapy for thyroid cancer
D. The client who returned from placement of iridium seeds for prostate cancer
82. The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
A. The client with Cushing's disease
B. The client with diabetes
C. The client with acromegaly
D. The client with myxedema
83. The nurse caring for a client in the neonatal intensive care unit administers adult-strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with:
A. Negligence
B. Tort
C. Assault
D. Malpractice
84. Which assignment should not be performed by the licensed practical nurse?
A. Inserting a Foley catheter
B. Discontinuing a nasogastric tube
C. Obtaining a sputum specimen
D. Starting a blood transfusion
85. The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, and respirations 30. Which action by the nurse should receive priority?
A. Continuing to monitor the vital signs
B. Contacting the physician
C. Asking the client how he feels
D. Asking the LPN to continue the post-op care
86. Which nurse should be assigned to care for the postpartal client with preeclampsia?
A. The RN with 2 weeks of experience in postpartum
B. The RN with 3 years of experience in labor and delivery
C. The RN with 10 years of experience in surgery
D. The RN with 1 year of experience in the neonatal intensive care unit
87. Which information should be reported to the state Board of Nursing?
A. The facility fails to provide literature in both Spanish and English.
B. The narcotic count has been incorrect on the unit for the past 3 days.
C. The client fails to receive an itemized account of his bills and services received during his hospital stay.
D. The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.
88. The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:
A. Call the Board of Nursing
B. File a formal reprimand
C. Terminate the nurse
D. Charge the nurse with a tort
89. The home health nurse is planning for the day's visits. Which client should be seen first?
A. The 78-year-old who had a gastrectomy 3 weeks ago and has a PEG tube
B. The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension
C. The 50-year-old with MRSA being treated with Vancomycin via a PICC line
D. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter
90. The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?
A. A schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis
B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm
C. A child whose pupils are fixed and dilated and his parents, and a client with a frontal head injury
D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain
91. The nurse is caring for a 6-year-old client admitted with a diagnosis of conjunctivitis. Before administering eyedrops, the nurse should recognize that it is essential to consider which of the following?
A. The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops.
B. The child should be allowed to instill his own eyedrops.
C. The mother should be allowed to instill the eyedrops.
D. If the eye is clear from any redness or edema, the eyedrops should be held.
92. The nurse is discussing meal planning with the mother of a 2-year-old toddler. Which of the following statements, if made by the mother, would require a need for further instruction?
A. "It is okay to give my child white grape juice for breakfast."
B. "My child can have a grilled cheese sandwich for lunch."
C. "We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch."
D. "For a snack, my child can have ice cream."
93. A 2-year-old toddler is admitted to the hospital. Which of the following nursing interventions would you expect?
A. Ask the parent/guardian to leave the room when assessments are being performed.
B. Ask the parent/guardian to take the child's favorite blanket home because anything from the outside should not be brought into the hospital.
C. Ask the parent/guardian to room-in with the child.
D. If the child is screaming, tell him this is inappropriate behavior.
94. Which instruction should be given to the client who is fitted for a behind-the-ear hearing aid?
A. Remove the mold and clean every week.
B. Store the hearing aid in a warm place.
C. Clean the lint from the hearing aid with a toothpick.
D. Change the batteries weekly.
95. A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:
A. Body image disturbance
B. Impaired verbal communication
C. Risk for aspiration
D. Pain
96. A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?
A. High fever
B. Nonproductive cough
C. Rhinitis
D. Vomiting and diarrhea
97. The nurse is caring for a client admitted with epiglottis. Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?
A. Intravenous access supplies
B. A tracheostomy set
C. Intravenous fluid administration pump
D. Supplemental oxygen
98. A 25-year-old client with Grave's disease is admitted to the unit. What would the nurse expect the admitting assessment to reveal?
A. Bradycardia
B. Decreased appetite
C. Exophthalmos
D. Weight gain
99. The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed with celiac disease. Which of the following foods, if selected by the mother, would indicate her understanding of the dietary instructions?
A. Ham sandwich on whole-wheat toast
B. Spaghetti and meatballs
C. Hamburger with ketchup
D. Cheese omelet
100. The nurse is caring for an 80-year-old with chronic bronchitis. Upon the morning rounds, the nurse finds an O2 sat of 76%. Which of the following actions should the nurse take first?
A. Notify the physician
B. Recheck the O2 saturation level in 15 minutes
C. Apply oxygen by mask
D. Assess the child's pulse
Answers and Rationales
1. Answer D is correct. It is important to assess the extremities for blood vessel occlusion in the client with sickle cell anemia because a change in capillary refill would indicate a change in circulation. Body temperature, motion, and sensation would not give information regarding peripheral circulation; therefore, answers A, B, and C are incorrect.
2. Answer D is correct. Placing the client in semi-Fowler’s position provides the best oxygenation for this client. Flexion of the hips and knees, which includes the knee-chest position, impedes circulation and is not correct positioning for this client. Therefore, answers A, B, and C are incorrect.
3. Answer B is correct. It is important to keep the client in sickle cell crisis hydrated to prevent further sickling of the blood. Answer A is incorrect because a mechanical cuff places too much pressure on the arm. Answer C is incorrect because raising the knee gatch impedes circulation. Answer D is incorrect because Tylenol is too mild an analgesic for the client in crisis.
4. Answer C is correct. Hydration is important in the client with sickle cell disease to prevent thrombus formation. Popsicles, gelatin, juice, and pudding have high fluid content. The foods in answers A, B, and D do not aid in hydration and are, therefore, incorrect.
5. Answer C is correct. The most prominent clinical manifestation of sickle cell crisis is pain. However, the pulse oximetry indicates that oxygen levels are low; thus, oxygenation takes precedence over pain relief. Answer A is incorrect because although a warm environment reduces pain and minimizes sickling, it would not be a priority. Answer B is incorrect because although hydration is important, it would not require a bolus. Answer D is incorrect because Demerol is acidifying to the blood and increases sickling.
6. Answer C is correct. Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in iron, which is an important mineral for this client. Roast beef, cabbage, and pork chops are also high in iron, but the side dishes accompanying these choices are not; therefore, answers A, B, and D are incorrect.
7. Answer D is correct. Taking a trip to the museum is the only answer that does not pose a threat. A family vacation in the Rocky Mountains at high altitudes, cold temperatures, and airplane travel can cause sickling episodes and should be avoided; therefore, answers A, B, and C are incorrect.
8. Answer D is correct. The tongue is smooth and beefy red in the client with vitamin B12 deficiency, so examining the tongue should be included in the physical assessment. Bleeding, splenomegaly, and blood pressure changes do not occur, making answers A, B, and C incorrect.
9. Answer C is correct. The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in dark-skinned persons. The conjunctiva can have normal deposits of fat, which give a yellowish hue; thus, answer A is incorrect. The soles of the feet can be yellow if they are calloused, making answer B incorrect; the shins would be an area of darker pigment, so answer D is incorrect.
10. Answer B is correct. When there are fewer red blood cells, there is less hemoglobin and less oxygen. Therefore, the client is often short of breath, as indicated in answer B. The client with anemia is often pale in color, has weight loss, and may be hypotensive. Answers A, C, and D are within normal and, therefore, are incorrect.
11. Answer A is correct. The client with polycythemia vera is at risk for thrombus formation. Hydrating the client with at least 3L of fluid per day is important in preventing clot formation, so the statement to drink less than 500mL is incorrect. Answers B, C, and D are incorrect because they all contribute to the prevention of complications. Support hose promotes venous return, the electric razor prevents bleeding due to injury, and a diet low in iron is essential to preventing further red cell formation.
12. Answer C is correct. Radiation treatment for other types of cancer can result in leukemia. Some hobbies and occupations involving chemicals are linked to leukemia, but not the ones in these answers; therefore, answers A and B are incorrect. Answer D is incorrect because the incidence of leukemia is higher in twins than in siblings.
13. Answer D is correct. Petechiae are not usually visualized on dark skin. The soles of the feet and palms of the hand provide a lighter surface for assessing the client for petichiae. Answers A, B, and C are incorrect because the skin might be too dark to make an assessment.
14. Answer B is correct. The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6 months. Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations; therefore, answers A, C, and D are incorrect.
15. Answer B is correct. The client with acute leukemia has bleeding tendencies due to decreased platelet counts, and any injury would exacerbate the problem. The client would require close monitoring for hemorrhage, which is of higher priority than the diagnoses in answers A, C, and D, which are incorrect.
16. Answer A is correct. Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the client are important to address in light of the age and life choices. Hodgkin’s disease, however, has a good prognosis when diagnosed early. Answers B, C, and D are incorrect because they are of lesser priority.
17. Answer A is correct. Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts, making answer A the correct answer. White cell counts, potassium levels, and PTT are not affected in ATP; thus, answers B, C, and D are incorrect.
18. Answer A is correct. The normal platelet count is 120,000–400, Bleeding occurs in clients with low platelets. The priority is to prevent and minimize bleeding. Oxygenation in answer C is important, but platelets do not carry oxygen. Answers B and D are of lesser priority and are incorrect in this instance.
19. Answer C is correct. Elevating the head of the bed 30° avoids pressure on the sella turcica and alleviates headaches. Answers A, B, and D are incorrect because Trendelenburg, Valsalva maneuver, and coughing all increase the intracranial pressure.
20. Answer B is correct. The large amount of fluid loss can cause fluid and electrolyte imbalance that should be corrected. The loss of electrolytes would be reflected in the vital signs. Measuring the urinary output is important, but the stem already says that the client has polyuria, so answer A is incorrect. Encouraging fluid intake will not correct the problem, making answer C incorrect. Answer D is incorrect because weighing the client is not necessary at this time.
21. Answer C is correct. The client should be positioned upright and leaning forward, to prevent aspiration of blood. Answers A, B, and D are incorrect because direct pressure to the nose stops the bleeding, and ice packs should be applied directly to the nose as well. If a pack is necessary, the nares are loosely packed.
22. Answer A is correct. Blood pressure is the best indicator of cardiovascular collapse in the client who has had an adrenal gland removed. The remaining gland might have been suppressed due to the tumor activity. Temperature would be an indicator of infection, decreased output would be a clinical manifestation but would take longer to occur than blood pressure changes, and specific gravity changes occur with other disorders; therefore, answers B, C, and D are incorrect.
23. Answer A is correct. IV glucocorticoids raise the glucose levels and often require coverage with insulin. Answer B is not necessary at this time, sodium and potassium levels would be monitored when the client is receiving mineral corticoids, and daily weights is unnecessary; therefore, answers B, C, and D are incorrect.
24. Answer B is correct. The parathyroid glands are responsible for calcium production and can be damaged during a thyroidectomy. The tingling is due to low calcium levels. The crash cart would be needed in respiratory distress but would not be the next action to take; thus, answer A is incorrect. Hypertension occurs in thyroid storm and the drainage would occur in hemorrhage, so answers C and D are incorrect.
25. Answer D is correct. The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices; therefore, answers A, B, and C are incorrect.
26. Answer A is correct. The client taking antilipidemics should be encouraged to report muscle weakness because this is a sign of rhabdomyositis. The medication takes effect within 1 month of beginning therapy, so answer B is incorrect. The medication should be taken with water because fruit juice, particularly grapefruit, can decrease the effectiveness, making answer C incorrect. Liver function studies should be checked before beginning the medication, not after the fact, making answer D incorrect.
27. Answer B is correct. Hyperstat is given IV push for hypertensive crises, but it often causes hyperglycemia. The glucose level will drop rapidly when stopped. Answer A is incorrect because the hyperstat is given by IV push. The client should be placed in dorsal recumbent position, not a Trendelenburg position, as stated in answer C. Answer D is incorrect because the medication does not have to be covered with foil.
28. Answer C is correct. A heart rate of 60 in the baby should be reported immediately. The dose should be held if the heart rate is below 100bpm. The blood glucose, blood pressure, and respirations are within normal limits; thus answers A, B, and D are incorrect.
29. Answer C is correct. Nitroglycerine should be kept in a brown bottle (or even a special air- and water-tight, solid or plated silver or gold container) because of its instability and tendency to become less potent when exposed to air, light, or water. The supply should be replenished every 6 months, not 3 months, and one tablet should be taken every 5 minutes until pain subsides, so answers A and B are incorrect. If the pain does not subside, the client should report to the emergency room. The medication should be taken sublingually and should not be crushed, as stated in answer D.
30. Answer C is correct. Turkey
31. Answer B is correct. The jugular veins in the neck should be assessed for distension. The other parts of the body will be edematous in right-sided congestive heart failure, not left-sided; thus, answers A, C, and D are incorrect.
32. Answer A is correct. The phlebostatic axis is located at the fifth intercostals space midaxillary line and is the correct placement of the manometer. The PMI or point of maximal impulse is located at the fifth intercostals space midclavicular line, so answer B is incorrect. Erb’s point is the point at which you can hear the valves close simultaneously, making answer C incorrect. The Tail of Spence (the upper outer quadrant) is the area where most breast cancers are located and has nothing to do with placement of a manometer; thus, answer D is incorrect.
33. Answer B is correct. Zestril is an ACE inhibitor and is frequently given with a diuretic such as Lasix for hypertension. Answers A, C, and D are incorrect because the order is accurate. There is no need to question the order, administer the medication separately, or contact the pharmacy.
34. Answer B is correct. The best indicator of peripheral edema is measuring the extremity. A paper tape measure should be used rather than one of plastic or cloth, and the area should be marked with a pen, providing the most objective assessment. Answer A is incorrect because weighing the client will not indicate peripheral edema. Answer C is incorrect because checking the intake and output will not indicate peripheral edema. Answer D is incorrect because checking for pitting edema is less reliable than measuring with a paper tape measure.
35. Answer D is correct. Clients with radium implants should have close contact limited to 30 minutes per visit. The general rule is limiting time spent exposed to radium, putting distance between people and the radium source, and using lead to shield against the radium. Teaching the family member these principles is extremely important. Answers A, B, and C are not empathetic and do not address the question; therefore, they are incorrect.
36. Answer B is correct. The client with a facial stroke will have difficulty swallowing and chewing, and the foods in answer B provide the least amount of chewing. The foods in answers A, C, and D would require more chewing and, thus, are incorrect.
37. Answer A is correct. Novalog insulin onsets very quickly, so food should be available within 10–15 minutes of taking the insulin. Answer B does not address a particular type of insulin, so it is incorrect. NPH insulin peaks in 8–12 hours, so a snack should be eaten at the expected peak time. It may not be 3 p.m. as stated in answer C. Answer D is incorrect because there is no need to save the dessert until bedtime.
38. Answer B is correct. The umbilical cord needs time to dry and fall off before putting the infant in the tub. Although answers A, C, and D might be important, they are not the primary answer to the question.
39. Answer D is correct. Leucovorin is the antidote for Methotrexate and Trimetrexate which are folic acid antagonists. Leucovorin is a folic acid derivative. Answers A, B, and C are incorrect because Leucovorin does not treat iron deficiency, increase neutrophils, or have a synergistic effect.
40. Answer A is correct. The Hemophilus influenza vaccine is given at 4 months with the polio vaccine. Answers B, C, and D are incorrect because these vaccines are given later in life.
41. Answer B is correct. Proton pump inhibitors such as Nexium and Protonix should be taken with meals, for optimal effect. Histamine-blocking agents such as Zantac should be taken 30 minutes before meals, so answer A is incorrect. Tagamet can be taken in a single dose at bedtime, making answer C incorrect. Answer D does not treat the problem adequately and, therefore, is incorrect.
42. Answer A is correct. If the client is a threat to the staff and to other clients the nurse should call for help and prepare to administer a medication such as Haldol to sedate him. Answer B is incorrect because simply telling the client to calm down will not work. Answer C is incorrect because telling the client that if he continues he will be punished is a threat and may further anger him. Answer D is incorrect because if the client is left alone he might harm himself.
43. Answer A is correct. If the fundus of the client is displaced to the side, this might indicate a full bladder. The next action by the nurse should be to check for bladder distention and catheterize, if necessary. The answers in B, C, and D are actions that relate to postpartal hemorrhage.
44. Answer C is correct. A low-grade temperature, blood-tinged sputum, fatigue, and night sweats are symptoms consistent with tuberculosis. If the answer in A had said pneumocystis pneumonia, answer A would have been consistent with the symptoms given in the stem, but just saying pneumonia isn’t specific enough to diagnose the problem. Answers B and D are not directly related to the stem.
45. Answer B is correct. If the client has a history of Prinzmetal’s angina, he should not be prescribed triptan preparations because they cause vasoconstriction and coronary spasms. There is no contraindication for taking triptan drugs in clients with diabetes, cancer, or cluster headaches making answers A, C, and D incorrect.
46. Answer A is correct. Kernig’s sign is positive if pain occurs on flexion of the hip and knee. The Brudzinski reflex is positive if pain occurs on flexion of the head and neck onto the chest so answer B is incorrect. Answers C and D might be present but are not related to Kernig’s sign.
47. Answer B is correct. Apraxia is the inability to use objects appropriately. Agnosia is loss of sensory comprehension, anomia is the inability to find words, and aphasia is the inability to speak or understand so answers A, C, and D are incorrect.
48. Answer C is correct. Increased confusion at night is known as "sundowning" syndrome. This increased confusion occurs when the sun begins to set and continues during the night. Answer A is incorrect because fatigue is not necessarily present. Increased confusion at night is not part of normal aging; therefore, answer B is incorrect. A delusion is a firm, fixed belief; therefore, answer D is incorrect.
49. Answer C is correct. The client who is confused might forget that he ate earlier. Don’t argue with the client. Simply get him something to eat that will satisfy him until lunch. Answers A and D are incorrect because the nurse is dismissing the client. Answer B is validating the delusion.
50. Answer D is correct. Nausea and gastrointestinal upset are very common in clients taking acetlcholinesterase inhibitors such as Exelon. Other side effects include liver toxicity, dizziness, unsteadiness, and clumsiness. The client might already be experiencing urinary incontinence or headaches, but they are not necessarily associated; and the client with Alzheimer’s disease is already confused. Therefore, answers A, B, and C are incorrect.
51. Answer B is correct. Any lesion should be reported to the doctor. This can indicate a herpes lesion. Clients with open lesions related to herpes are delivered by Cesarean section because there is a possibility of transmission of the infection to the fetus with direct contact to lesions. It is not enough to document the finding, so answer A is incorrect. The physician must make the decision to perform a C-section, making answer C incorrect. It is not enough to continue primary care, so answer D is incorrect.
52. Answer B is correct. The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the other cancers mentioned in answers A, C, and D, so those are incorrect.
53. Answer B is correct. A lesion that is painful is most likely a herpetic lesion. A chancre lesion associated with syphilis is not painful, so answer A is incorrect. Condylomata lesions are painless warts, so answer D is incorrect. In answer C, gonorrhea does not present as a lesion, but is exhibited by a yellow discharge.
54. Answer C is correct. Florescent treponemal antibody (FTA) is the test for treponema pallidum. VDRL and RPR are screening tests done for syphilis, so answers A and B are incorrect. The Thayer-Martin culture is done for gonorrhea, so answer D is incorrect.
55. Answer D is correct. The criteria for HELLP is hemolysis, elevated liver enzymes, and low platelet count. In answer A, an elevated blood glucose level is not associated with HELLP. Platelets are decreased, not elevated, in HELLP syndrome as stated in answer B. The creatinine levels are elevated in renal disease and are not associated with HELLP syndrome so answer C is incorrect.
56. Answer A is correct. Answer B elicits the triceps reflex, so it is incorrect. Answer C elicits the patella reflex, making it incorrect. Answer D elicits the radial nerve, so it is incorrect.
57. Answer B is correct. Brethine is used cautiously because it raises the blood glucose levels. Answers A, C, and D are all medications that are commonly used in the diabetic client, so they are incorrect.
58. Answer C is correct. When the L/S ratio reaches 2:1, the lungs are considered to be mature. The infant will most likely be small for gestational age and will not be at risk for birth trauma, so answer D is incorrect. The L/S ratio does not indicate congenital anomalies, as stated in answer A, and the infant is not at risk for intrauterine growth retardation, making answer B incorrect.
59. Answer C is correct. Jitteriness is a sign of seizure in the neonate. Crying, wakefulness, and yawning are expected in the newborn, so answers A, B, and D are incorrect.
60. Answer B is correct. The client is expected to become sleepy, have hot flashes, and be lethargic. A decreasing urinary output, absence of the knee-jerk reflex, and decreased respirations indicate toxicity, so answers A, C, and D are incorrect.
61. Answer D is correct. If the client experiences hypotension after an injection of epidural anesthetic, the nurse should turn her to the left side, apply oxygen by mask, and speed the IV infusion. If the blood pressure does not return to normal, the physician should be contacted. Epinephrine should be kept for emergency administration. Answer A is incorrect because placing the client in Trendelenburg position (head down) will allow the anesthesia to move up above the respiratory center, thereby decreasing the diaphragm’s ability to move up and down and ventilate the client. In answer B, the IV rate should be increased, not decreased. In answer C, the oxygen should be applied by mask, not cannula.
62. Answer A is correct. Cancer of the pancreas frequently leads to severe nausea and vomiting and altered nutrition. The other problems are of lesser concern; thus, answers B, C, and D are incorrect.
63. Answer C is correct. Measuring with a paper tape measure and marking the area that is measured is the most objective method of estimating ascites. Inspecting and checking for fluid waves are more subjective, so answers A and B are incorrect. Palpation of the liver will not tell the amount of ascites; thus, answer D is incorrect.
64. Answer B is correct. The vital signs indicate hypovolemic shock. They do not indicate cerebral tissue perfusion, airway clearance, or sensory perception alterations, so answers A, C, and D are incorrect.
65. Answer A is correct. The client with osteogenesis imperfecta is at risk for pathological fractures and is likely to experience these fractures if he participates in contact sports. The client might experience symptoms of hypoxia if he becomes dehydrated or deoxygenated; extreme exercise, especially in warm weather, can exacerbate the condition. Answers B, C, and D are not factors for concern.
66. Answer D is correct. The client with neutropenia should not have fresh fruit because it should be peeled and/or cooked before eating. He should also not eat foods grown on or in the ground or eat from the salad bar. The nurse should remove potted or cut flowers from the room as well. Any source of bacteria should be eliminated, if possible. Answers A, B, and C will not help prevent bacterial invasions.
67. Answer B is correct. In clients who have not had surgery to the face or neck, the answer would be answer A; however, in this situation, this could further interfere with the airway. Increasing the infusion and placing the client in supine position would be better. Answers C is incorrect because it is not necessary at this time and could cause hyponatremia and further hypotension. Answer D is not necessary at this time.
68. Answer C is correct. If the client pulls the chest tube out of the chest, the nurse’s first action should be to cover the insertion site with an occlusive dressing. Afterward, the nurse should call the doctor, who will order a chest x-ray and possibly reinsert the tube. Answers A, B, and D are not the first action to be taken.
69. Answer A is correct. The normal Protime is 12–20 seconds. A Protime of 120 seconds indicates an extremely prolonged Protime and can result in a spontaneous bleeding episode. Answers B, C, and D may be needed at a later time but are not the most important actions to take first.
70. Answer C is correct. The food with the most calcium is the yogurt. Answers A, B, and D are good choices, but not as good as the yogurt, which has approximately 400mg of calcium.
71. Answer C is correct. The client receiving magnesium sulfate should have a Foley catheter in place, and hourly intake and output should be checked. There is no need to refrain from checking the blood pressure in the right arm. A padded tongue blade should be kept in the room at the bedside, just in case of a seizure, but this is not related to the magnesium sulfate infusion. Darkening the room is unnecessary, so answers A, B, and D are incorrect.
72. Answer D is correct. If the client’s mother refuses the blood transfusion, the doctor should be notified. Because the client is a minor, the court might order treatment. Answer A is incorrect. Because it is not the primary responsibility for the nurse to encourage the mother to consent or explain the consequences, so answers B and C are incorrect.
73. Answer B is correct. The nurse should be most concerned with laryngeal edema because of the area of burn. The next priority should be answer A, as well as hyponatremia and hypokalemia in C and D, but these answers are not of primary concern so are incorrect.
74. Answer D is correct. The client with anorexia shows the most improvement by weight gain. Selecting a balanced diet does little good if the client will not eat, so answer A is incorrect. The hematocrit might improve by several means, such as blood transfusion, but that does not indicate improvement in the anorexic condition; therefore, answer B is incorrect. The tissue turgor indicates fluid stasis, not improvement of anorexia, so answer C is incorrect.
75. Answer D is correct. At this time, pain beneath the cast is normal. The client’s toes should be warm to the touch, and pulses should be present. Paresthesia is not normal and might indicate compartment syndrome. Therefore, Answers A, B, and C are incorrect.
76. Answer B is correct. It is normal for the client to have a warm sensation when dye is injected. Answers A, C, and D indicate that the nurse believes that the hot feeling is abnormal, so they are incorrect.
77. Answer D is correct. It is not necessary to wear gloves to take the vital signs of the client. If the client has active infection with methicillin-resistant staphylococcus aureus, gloves should be worn. The healthcare workers in answers A, B, and C indicate knowledge of infection control by their actions.
78. Answer D is correct. During ECT, the client will have a grand mal seize. This indicates completion of the electroconvulsive therapy. Answers A, B, and C do not indicate that the ECT has been effective, so are incorrect.
79. Answer A is correct. Infection with pinworms begins when the eggs are ingested or inhaled. The eggs hatch in the upper intestine and mature in 2–8 weeks. The females then mate and migrate out the anus, where they lay up to 17,000 eggs. This causes intense itching. The mother should be told to use a flashlight to examine the rectal area about 2–3 hours after the child is asleep. Placing clear tape on a tongue blade will allow the eggs to adhere to the tape. The specimen should then be brought in to be evaluated. There is no need to scrap the skin, collect a stool specimen, or bring a sample of hair, so answers B, C, and D are incorrect.
80. Answer B is correct. Erterobiasis, or pinworms, is treated with Vermox (mebendazole) or Antiminth (pyrantel pamoate). The entire family should be treated to ensure that no eggs remain. Because a single treatment is usually sufficient, there is usually good compliance. The family should then be tested again in 2 weeks to ensure that no eggs remain. Answers A, C, and D are incorrect statements.
81. Answer A is correct. The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy travels to the radium department for therapy. The radiation stays in the department, so the client is not radioactive. The clients in answers B, C, and D pose a risk to the pregnant nurse. These clients are radioactive in very small doses, especially upon returning from the procedures. For approximately 72 hours, the clients should dispose of urine and feces in special containers and use plastic spoons and forks.
82. Answer A is correct. The client with Cushing’s disease has adrenocortical hypersecretion. This increase in the level of cortisone causes the client to be immune suppressed. In answer B, the client with diabetes poses no risk to other clients. The client in answer C has an increase in growth hormone and poses no risk to himself or others. The client in answer D has hyperthyroidism or myxedema and poses no risk to others or himself.
83. Answer D is correct. The nurse could be charged with malpractice, which is failing to perform, or performing an act that causes harm to the client. Giving the infant an overdose falls into this category. Answers A, B, and C are incorrect because they apply to other wrongful acts. Negligence is failing to perform care for the client; a tort is a wrongful act committed on the client or their belongings; and assault is a violent physical or verbal attack.
84. Answer D is correct. The licensed practical nurse should not be assigned to begin a blood transfusion. The licensed practical nurse can insert a Foley catheter, discontinue a nasogastric tube, and collect sputum specimen; therefore, answers A, B, and C are incorrect.
85. Answer B is correct. The vital signs are abnormal and should be reported immediately. Continuing to monitor the vital signs can result in deterioration of the client’s condition, making answer A incorrect. Asking the client how he feels in answer C will only provide subjective data, and the nurse in answer D is not the best nurse to assign because this client is unstable.
86. Answer B is correct. The nurse with 3 years of experience in labor and delivery knows the most about possible complications involving preeclampsia. The nurse in answer A is a new nurse to the unit, and the nurses in answers C and D have no experience with the postpartum client.
87. Answer B is correct. The Joint Commission on Accreditation of Hospitals will probably be interested in the problems in answers A and C. The failure of the nursing assistant to care for the client with hepatitis might result in termination, but is not of interest to the Joint Commission.
88. Answer B is correct. The next action after discussing the problem with the nurse is to document the incident by filing a formal reprimand. If the behavior continues or if harm has resulted to the client, the nurse may be terminated and reported to the Board of Nursing, but these are not the first actions requested in the stem. A tort is a wrongful act to the client or his belongings and is not indicated in this instance. Therefore, Answers A, C, and D are incorrect.
89. Answer D is correct. The client at highest risk for complications is the client with multiple sclerosis who is being treated with cortisone via the central line. The others are more stable. MRSA is methicillin-resistant staphylococcus aureus. Vancomycin is the drug of choice and is given at scheduled times to maintain blood levels of the drug. The clients in answers A, B, and C are more stable and can be seen later.
90. Answer B is correct. The pregnant client and the client with a broken arm and facial lacerations are the best choices for placing in the same room. The clients in answers A, C, and D need to be placed in separate rooms due to the serious natures of their injuries.
91. Answer A is correct. Before instilling eyedrops, the nurse should cleanse the area with water. A 6-year-old child is not developmentally ready to instill his own eyedrops, so answer B is incorrect. Although the mother of the child can instill the eyedrops, the area must be cleansed before administration, making answer C incorrect. Although the eye might appear to be clear, the nurse should instill the eyedrops, as ordered, so answer D is incorrect.
92. Answer C is correct. Remember the ABCs (airway, breathing, circulation) when answering this question. Answer C is correct because a hotdog is the size and shape of the child’s trachea and poses a risk of aspiration. Answers A, B, and C are incorrect because white grape juice, a grilled cheese sandwich, and ice cream do not pose a risk of aspiration for a child.
93. Answer C is correct. The nurse should encourage rooming-in to promote parent-child attachment. It is okay for the parents to be in the room for assessment of the child. Allowing the child to have items that are familiar to him is allowed and encouraged; therefore, answers A and B are incorrect. Answer D is not part of the nurse’s responsibilities.
94. Answer B is correct. The hearing aid should be stored in a warm, dry place. It should be cleaned daily but should not be moldy, so answer A is incorrect. A toothpick is inappropriate to use to clean the aid; the toothpick might break off in the hearing aide, making answer C incorrect. Changing the batteries weekly, as in answer D, is not necessary.
95. Answer C is correct. Always remember your ABCs (airway, breathing, circulation) when selecting an answer. Although answers B and D might be appropriate for this child, answer C should have the highest priority. Answer A does not apply for a child who has undergone a tonsillectomy.
96. Answer A is correct. If the child has bacterial pneumonia, a high fever is usually present. Bacterial pneumonia usually presents with a productive cough, not a nonproductive cough, making answer B incorrect. Rhinitis is often seen with viral pneumonia, and vomiting and diarrhea are usually not seen with pneumonia, so answers C and D are incorrect.
97. Answer B is correct. For a child with epiglottis and the possibility of complete obstruction of the airway, emergency tracheostomy equipment should always be kept at the bedside. Intravenous supplies, fluid, and oxygen will not treat an obstruction; therefore, answers A, C, and D are incorrect.
98. Answer C is correct. Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. The client with hyperthyroidism will often exhibit tachycardia, increased appetite, and weight loss; therefore, answers A, B, and D are incorrect.
99. Answer D is correct. The child with celiac disease should be on a gluten-free diet. Answers A, B, and C all contain gluten, while answer D gives the only choice of foods that does not contain gluten.
100. Answer C is correct. Remember the ABCs (airway, breathing, circulation) when answering this question. Before notifying the physician or assessing the pulse, oxygen should be applied to increase the oxygen saturation, so answers A and D are incorrect. The normal oxygen saturation for a child is 92%–100%, making answer B incorrect.
Post a Comment