a.

Check the Babinski reflex

1. A client with a diagnosis of passive-aggressive personality disorder is b. Listen to the heart and lung sounds
seen at the local mental health clinic. A common characteristic of c. Palpate the abdomen
persons with passive-aggressive personality disorder is: d. Check tympanic membranes
a. Superior intelligence Answer B is correct.
b. Underlying hostility The first action that the nurse should take when beginning to examine the
c. Dependence on others infant is to listen to the heart and lungs. If the nurse elicits the Babinski
d. Ability to share feelings reflex, palpates the abdomen, or looks in the child’s ear first, the child will
Answer B is correct. begin to cry and it will be difficult to obtain an objective finding while
The client with passive-aggressive personality disorder often has listening to the heart and lungs. Therefore, answers A, C, and D are
underlying hostility that is exhibited as acting-out behavior. Answers A, C, incorrect.
and D are incorrect. Although these individuals might have a high IQ, it
cannot be said that they have superior intelligence. They also do not 7. In terms of cognitive development, a 2-year-old would be expected
necessarily have dependence on others or an inability to share feelings. to:
a. Think abstractly
2. The client is admitted for evaluation of aggressive behavior and b. Use magical thinking
diagnosed with antisocial personality disorder. A key part of the care c. Understand conservation of matter
of such clients is: d. See things from the perspective of others
a. Setting realistic limits Answer B is correct.
b. Encouraging the client to express remorse for behavior A 2-year-old is expected only to use magical thinking, such as believing that
c. Minimizing interactions with other clients a toy bear is a real bear. Answers A, C, and D are not expected until the
d. Encouraging the client to act out feelings of rage child is much older. Abstract thinking, conservation of matter, and the
Answer A is correct. ability to look at things from the perspective of others are not skills for
Clients with antisocial personality disorder must have limits set on their small children.
behavior because they are artful in manipulating others. Answer B is not
correct because they do express feelings and remorse. Answers C and D 8. Which of the following best describes the language of a 24-month-
are incorrect because it is unnecessary to minimize interactions with old?
others or encourage them to act out rage more than they already do. a. Doesn’t understand yes and no
b. Understands the meaning of words
3. An important intervention in monitoring the dietary compliance of a c. Able to verbalize needs
client with bulimia is: d. Asks “why?” to most statements
a. Allowing the client privacy during mealtimes Answer C is correct.
b. Praising her for eating all her meal Children at 24 months can verbalize their needs. Answers A and B are
c. Observing her for 1–2 hours after meals incorrect because children at 24 months understand yes and no, but they
d. Encouraging her to choose foods she likes and to eat in do not understand the meaning of all words. Answer D is incorrect; asking
moderation “why?” comes later in development.
Answer C is correct.
To prevent the client from inducing vomiting after eating, the client should 9. A client who has been receiving urokinase has a large bloody bowel
be observed for 1–2 hours after meals. Allowing privacy as stated in movement. Which action would be best for the nurse to take
answer A will only give the client time to vomit. Praising the client for immediately?
eating all of a meal does not correct the psychological aspects of the a. Administer vitamin K IM
disease; thus, answer B is incorrect. Encouraging the client to choose b. Stop the urokinase
favorite foods might increase stress and the chance of choosing foods that c. Reduce the urokinase and administer heparin
are low in calories and fats so D is not correct. d. Stop the urokinase and call the doctor
Answer D is correct.
4. Assuming that all have achieved normal cognitive and emotional Urokinase is a thrombolytic used to destroy a clot following a myocardial
development, which of the following children is at greatest risk for infraction. If the client exhibits overt signs of bleeding, the nurse should
accidental poisoning? stop the medication, call the doctor immediately, and prepare the
a. A 6-month-old antidote, which is Amicar. Answer B is not correct because simply stopping
b. A 4-year-old the urokinase is not enough. In answer A, vitamin K is not the antidote for
c. A 12-year-old urokinase, and reducing the urokinase, as stated in answer B, is not
d. A 13-year-old enough.
Answer B is correct.
The 4-year-old is more prone to accidental poisoning because children at 10. The client has a prescription for a calcium carbonate compound to
this age are much more mobile. Answers A, C, and D are incorrect because neutralize stomach acid. The nurse should assess the client for:
the 6-month-old is still too small to be extremely mobile, the 12-year-old a. Constipation
has begun to understand risk, and the 13-year-old is also aware that b. Hyperphosphatemia
injuries can occur and is less likely to become injured than the 4-year-old. c. Hypomagnesemia
d. Diarrhea
5. Which of the following examples represents parallel play? Answer A is correct.
a. Jenny and Tommy share their toys. The client taking calcium preparations will frequently develop constipation.
b. Jimmy plays with his car beside Mary, who is playing with Answers B, C, and D do not apply.
her doll.
c. Kevin plays a game of Scrabble with Kathy and Sue. 11. Heparin has been ordered for a client with pulmonary emboli. Which
d. Mary plays with a handheld game while sitting in her statement, if made by the graduate nurse, indicates a lack of
mother’s lap. understanding of the medication?
Answer B is correct. a. “I will administer the medication 1-2 inches away from the
Parallel play is play that is demonstrated by two children playing side by umbilicus.”
side but not together. The play in answers A and C is participative play b. “I will administer the medication in the abdomen.”
because the children are playing together. The play in answer D is solitary c. “I will check the PTT before administering the
play because the mother is not playing with Mary. medication.”
d. “I will need to aspirate when I give Heparin.”
6. The nurse is ready to begin an exam on a 9-month-old infant. The Answer C is correct.
child is sitting in his mother’s lap. Which should the nurse do first?
C indicates a lack of understanding of the correct method of administering 17. A client with a femoral popliteal bypass graft is assigned to a
heparin. A, B, and D indicate understanding and are, therefore, incorrect semiprivate room. The most suitable roommate for this client is the
answers. client with:
a. Hypothyroidism
12. The nurse is caring for a client with peripheral vascular disease. To b. Diabetic ulcers
correctly assess the oxygen saturation level, the monitor may be c. Ulcerative colitis
placed on the: d. Pneumonia
a. Hip Answer A is correct.
b. Ankle The best roommate for the post-surgical client is the client with
c. Earlobe hypothyroidism. This client is sleepy and has no infectious process.
d. Chin Answers B, C, and D are incorrect because the client with a diabetic ulcer,
Answer C is correct. ulcerative colitis, or pneumonia can transmit infection to the post-surgical
If the finger cannot be used, the next best place to apply the oxygen client.
monitor is the earlobe. It can also be placed on the forehead, but the
choices in answers A, B, and D will not provide the needed readings. 18. The nurse is teaching the client regarding use of sodium warfarin.
Which statement made by the client would require further teaching?
13. While caring for a client with hypertension, the nurse notes the a. “I will have blood drawn every month.”
following vital signs: BP of 140/20, pulse 120, respirations 36, b. “I will assess my skin for a rash.”
temperature 100.8°F. The nurse’s initial action should be to: c. “I take aspirin for a headache.”
a. Call the doctor d. “I will use an electric razor to shave.”
b. Recheck the vital signs Answer C is correct.
c. Obtain arterial blood gases The client taking an anticoagulant should not take aspirin because it will
d. Obtain an ECG further increase bleeding. He should return to have a Protime drawn for
Answer A is correct. bleeding time, report a rash, and use an electric razor. Therefore, answers
The client is exhibiting a widened pulse pressure, tachycardia, and A, B, and D are incorrect.
tachypnea. The next action after obtaining these vital signs is to notify the
doctor for additional orders. Rechecking the vital signs, as in answer B, is 19. The client returns to the recovery room following repair of an
wasting time. The doctor may order arterial blood gases and an ECG. abdominal aneurysm. Which finding would require further
investigation?
14. The nurse is preparing a client with an axillo-popliteal bypass graft for a. Pedal pulses regular
discharge. The client should be taught to avoid: b. Urinary output 20mL in the past hour
a. Using a recliner to rest c. Blood pressure 108/50
b. Resting in supine position d. Oxygen saturation 97%
c. Sitting in a straight chair Answer B is correct.
d. Sleeping in right Sim’s position Because the aorta is clamped during surgery, the blood supply to the
Answer C is correct. kidneys is impaired. This can result in renal damage. A urinary output of
The client with a femoral popliteal bypass graft should avoid activities that 20mL is oliguria. In answer A, the pedal pulses that are thready and regular
can occlude the femoral artery graft. Sitting in the straight chair and are within normal limits. For answer C, it is desirable for the client’s blood
wearing tight clothes are prohibited for this reason. Resting in a supine pressure to be slightly low after surgical repair of an aneurysm. The oxygen
position, resting in a recliner, or sleeping in right Sim’s are allowed, as saturation of 97% in answer D is within normal limits and, therefore,
stated in answers A, B, and D. incorrect.

15. The doctor has ordered antithrombolic stockings to be applied to the 20. The nurse is doing bowel and bladder retraining for the client with
legs of the client with peripheral vascular disease. The nurse knows paraplegia. Which of the following is not a factor for the nurse to
antithrombolic stockings should be applied: consider?
a. Before rising in the morning a. Diet pattern
b. With the client in a standing position b. Mobility
c. After bathing and applying powder c. Fluid intake
d. Before retiring in the evening d. Sexual function
Answer A is correct. Answer D is correct.
The best time to apply antithrombolytic stockings is in the morning before When assisting the client with bowel and bladder training, the least helpful
rising. If the doctor orders them later in the day, the client should return to factor is the sexual function. Dietary history, mobility, and fluid intake are
bed, wait 30 minutes, and apply the stockings. Answers B, C, and D are important factors; these must be taken into consideration because they
incorrect because there is likely to be more peripheral edema if the client relate to constipation, urinary function, and the ability to use the urinal or
is standing or has just taken a bath; before retiring in the evening is wrong bedpan. Therefore, answers A, B, and C are incorrect.
because late in the evening, more peripheral edema will be present.
21. A 20-year-old is admitted to the rehabilitation unit following a
16. The nurse has just received the shift report and is preparing to make motorcycle accident. Which would be the appropriate method for
rounds. Which client should be seen first? measuring the client for crutches?
a. The client with a history of a cerebral aneurysm with an a. Measure five finger breadths under the axilla
oxygen saturation rate of 99% b. Measure 3 inches under the axilla
b. The client three days post–coronary artery bypass graft c. Measure the client with the elbows flexed 10°
with a temperature of 100.2°F d. Measure the client with the crutches 20 inches from the
c. The client admitted 1 hour ago with shortness of breath side of the foot
d. The client being prepared for discharge following a Answer B is correct.
femoral popliteal bypass graft To correctly measure the client for crutches, the nurse should measure
Answer C is correct. approximately 3 inches under the axilla. Answer A allows for too much
The client admitted 1 hour ago with shortness of breath should be seen distance under the arm. The elbows should be flexed approximately 35°,
first because this client might require oxygen therapy. The client in answer not 10°, as stated in answer C. The crutches should be approximately 6
A with an oxygen saturation of 99% is stable. Answer B is incorrect because inches from the side of the foot, not 20 inches, as stated in answer D.
this client will have some inflammatory process after surgery, so a
temperature of 100.2°F is not unusual. The client in answer D is stable and 22. The nurse is caring for the client following a cerebral vascular
can be seen later. accident. Which portion of the brain is responsible for taste, smell,
and hearing?
 a. Occipital might be ordered, but it will not directly help the scrotal edema.
b. Frontal Therefore, answers A, C, and D are incorrect.
c. Temporal
d. Parietal 28. The client with an abdominal aortic aneurysm is admitted in
Answer C is correct. preparation for surgery. Which of the following should be reported to
The temporal lobe is responsible for taste, smell, and hearing. The occipital the doctor?
lobe is responsible for vision. The frontal lobe is responsible for judgment, a. An elevated white blood cell count
foresight, and behavior. The parietal lobe is responsible for ideation, b. An abdominal bruit
sensory functions, and language. Therefore, answers A, B, and D are c. A negative Babinski reflex
incorrect. d. Pupils that are equal and reactive to light
Answer A is correct.
23. The client is admitted to the unit after a motor vehicle accident with The elevated white blood cell count should be reported because this
a temperature of 102°F rectally. The most likely explanations for the indicates infection. A bruit will be heard if the client has an aneurysm, and
elevated temperature is that: a negative Babinski is normal in the adult, as are pupils that are equal and
a. There was damage to the hypothalamus. reactive to light and accommodation; thus, answers B, C, and D are
b. He has an infection from the abrasions to the head and incorrect.
face.
c. He will require a cooling blanket to decrease the 29. If the nurse is unable to elicit the deep tendon reflexes of the patella,
temperature. the nurse should ask the client to:
d. There was damage to the frontal lobe of the brain. a. Pull against the palms
Answer A is correct. b. Grimace the facial muscles
Damage to the hypothalamus can result in an elevated temperature c. Cross the legs at the ankles
because this portion of the brain helps to regulate body temperature. d. Perform Valsalva maneuver
Answers B, C, and D are incorrect because there is no data to support the Answer A is correct.
possibility of an infection, a cooling blanket might not be required, and the If the nurse cannot elicit the patella reflex (knee jerk), the client should be
frontal lobe is not responsible for regulation of the body temperature. asked to pull against the palms. This helps the client to relax the legs and
makes it easier to get an objective reading. Answers B, C, and D will not
24. The client is admitted to the hospital in chronic renal failure. A diet help with the test.
low in protein is ordered. The rationale for a low-protein diet is:
a. Protein breaks down into blood urea nitrogen and other 30. The physician has ordered atropine sulfate 0.4mg IM before surgery.
waste. The medication is supplied in 0.8mg per milliliter. The nurse should
b. High protein increases the sodium and potassium levels. administer how many milliliters of the medication?
c. A high-protein diet decreases albumin production. a. 0.25mL
d. A high-protein diet depletes calcium and phosphorous. b. 0.5mL
Answer A is correct. c. 1.0mL
A low-protein diet is required because protein breaks down into d. 1.25mL
nitrogenous waste and causes an increased workload on the kidneys. Answer B is correct.
Answers B, C, and D are incorrect. If the doctor orders 0.4mg IM and the drug is available in
0.8mg/1mL, the nurse should make the calculation: (0.4mg/ 0.8mg) x 1
25. The client who is admitted with thrombophlebitis has an order for mL= 0.5 mL. Answers A, C, and D are incorrect.
heparin. The medication should be administered using a/an:
a. Buretrol 31. The nurse is evaluating the client’s pulmonary artery pressure. The
b. Infusion controller nurse is aware that this test evaluates:
c. Intravenous filter a. Pressure in the left ventricle
d. Three-way stop-cock b. The systolic, diastolic, and mean pressure of the
Answer B is correct. pulmonary artery
To safely administer heparin, the nurse should obtain an infusion c. The pressure in the pulmonary veins
controller. Too rapid infusion of heparin can result in hemorrhage. d. The pressure in the right ventricle
Answers A, C, and D are incorrect. It is not necessary to have a buretrol, an Answer B is correct.
infusion filter, or a three-way stop-cock. The pulmonary artery pressure will measure the pressure during systole,
diastole, and the mean pressure in the pulmonary artery. It will not
26. The nurse is taking the blood pressure of the obese client. If the measure the pressure in the left ventricle, the pressure in the pulmonary
blood pressure cuff is too small, the results will be: veins, or the pressure in the right ventricle. Therefore, answers A, C, and D
a. A false elevation are incorrect.
b. A false low reading
c. A blood pressure reading that is correct 32. A client is being monitored using a central venous pressure monitor.
d. A subnormal finding If the pressure is 2cm of water, the nurse should:
Answer A is correct. a. Call the doctor immediately
If the blood pressure cuff is too small, the result will be a blood pressure b. Slow the intravenous infusion
that is a false elevation. Answers B, C, and D are incorrect. If the blood c. Listen to the lungs for rales
pressure cuff is too large, a false low will result. Answers C and D have d. Administer a diuretic
basically the same meaning. Answer A is correct.
The normal central venous pressure is 5–10cm of water. A reading of 2cm
27. A 4-year-old male is admitted to the unit with nephotic syndrome. He is low and should be reported. Answers B, C, and D indicate that the
is extremely edematous. To decrease the discomfort associated with nursebelieves that the reading is too high and is incorrect.
scrotal edema, the nurse should:
a. Apply ice to the scrotum 33. The nurse identifies ventricular tachycardia on the heart monitor. The
b. Elevate the scrotum on a small pillow nurse should immediately:
c. Apply heat to the abdominal area a. Administer atropine sulfate
d. Administer an analgesic b. Check the potassium level
Answer B is correct. c. Prepare to administer an antiarrhythmic such as lidocaine
The child with nephotic syndrome will exhibit extreme edema. Elevating d. Defibrillate at 360 joules
the scrotum on a small pillow will help with the edema. Applying ice is Answer C is correct.
contraindicated; heat will increase the edema. Administering a diuretic
The treatment for ventricular tachycardia is lidocaine. A precordial thump 39. The nurse is taking the vital signs of the client admitted with cancer
is sometimes successful in slowing the rate, but this should be done only if of the pancreas. The nurse is aware that the fifth vital sign is:
a defibrillator is available. In answer A, atropine sulfate will speed the rate a. Anorexia
further; in answer B, checking the potassium is indicated but is not the b. Pain
priority; and in answer D, defibrillation is used for pulseless ventricular c. Insomnia
tachycardia or ventricular fibrillation. Also, defibrillation should begin at d. Fatigue
200 joules and be increased to 360 joules. Answer B is correct.
The fifth vital sign is pain. Nurses should assess and record pain just as they
34. The doctor is preparing to remove chest tubes from the client’s left would temperature, respirations, pulse, and blood pressure. Answers A, C,
chest. In preparation for the removal, the nurse should instruct the and D are included in the charting but are not considered to be the fifth
client to: vital sign and are, therefore, incorrect.
a. Breathe normally
b. Hold his breath and bear down 40. The 84-year-old male has returned from the recovery room following
c. Take a deep breath a total hip repair. He complains of pain and is medicated with
d. Sneeze on command morphine sulfate and promethazine. Which medication should be
Answer B is correct. kept available for the client being treated with opoid analgesics?
The client should be asked to perform the Valsalva maneuver while the a. Naloxone (Narcan)
chest tube is being removed. This prevents changes in pressure until an b. Ketorolac (Toradol)
occlusive dressing can be applied. Answers A and C are not recommended, c. Acetylsalicylic acid (aspirin)
and sneezing is difficult to perform on command. d. Atropine sulfate (Atropine)
Answer A is correct.
35. The doctor has ordered 80mg of furosemide (Lasix) two times per Narcan is the antidote for the opoid analgesics. Toradol (answer B) is a
day. The nurse notes the patient’s potassium level to be 2.5meq/L. nonopoid analgesic; aspirin (answer C) is an analgesic, anticoagulant, and
The nurse should: antipyretic; and atropine (answer D) is an anticholengergic.
a. Administer the Lasix as ordered
b. Administer half the dose 41. The doctor has ordered a patient-controlled analgesia (PCA) pump for
c. Offer the patient a potassium-rich food the client with chronic pain. The client asks the nurse if he can
d. Withhold the drug and call the doctor become overdosed with pain medication using this machine. The
Answer D is correct. nurse demonstrates understanding of the PCA if she states:
The potassium level of 2.5meq/L is extremely low. The normal is 3.5– a. “The machine will administer only the amount that you
5.5meq/L. Lasix (furosemide) is a nonpotassium sparing diuretic, so answer need to control your pain without any action from you.”
A is incorrect. The nurse cannot alter the doctor’s order, as stated in b. “The machine has a locking device that prevents
answer B, and answer C will not help with this situation. overdosing.”
c. “The machine will administer one large dose every 4 hours
36. Which of the following lab studies should be done periodically if the to relieve your pain.”
client is taking warfarin sodium (Coumadin)? d. “The machine is set to deliver medication only if you need
a. Stool specimen for occult blood it.”
b. White blood cell count Answer B is correct.
c. Blood glucose The client is concerned about overdosing himself. The machine will deliver
d. Erthyrocyte count a set amount as ordered and allow the client to self-administer a small
Answer A is correct. amount of medication. PCA pumps usually are set to lock out the amount
An occult blood test should be done periodically to detect any intestinal of medication that the client can give himself at 5- to 15-minute intervals.
bleeding on the client with Coumadin therapy. Answers B, C, and D are not Answer A does not address the client’s concerns, answer C is incorrect, and
directly related to the question. answer D does not address the client’s concerns.
37. The client has an order for heparin to prevent post-surgical thrombi. 42. The doctor has ordered a Transcutaneous Electrical Nerve
Immediately following a heparin injection, the nurse should: Stimulation (TENS) unit for the client with chronic back pain. The
a. Aspirate for blood nurse teaching the client with a TENS unit should tell the client:
b. Check the pulse rate a. “You may be electrocuted if you use water with this unit.”
c. Massage the site b. “Please report skin irritation to the doctor.”
d. Check the site for bleeding c. “The unit may be used anywhere on the body without fear
Answer D is correct. of adverse reactions.”
After administering any subcutaneous anticoagulant, the nurse should d. “A cream should be applied to the skin before applying
check the site for bleeding. Answers A and C are incorrect because the unit.”
aspirating and massaging the site are not done. Checking the pulse is not Answer B is correct.
necessary, as in answer B. Skin irritation can occur if the TENS unit is used for prolonged periods of
time. To prevent skin irritations, the client should change the location of
38. The client with AIDS tells the nurse that he has been using the electrodes often. Electrocution is not a risk because it uses a battery
acupuncture to help with his pain. The nurse should question the pack; thus, answer A is incorrect. Answer C is incorrect because the unit
client regarding this treatment because acupuncture uses: should not be used on sensitive areas of the body. Answer D is incorrect
a. Pressure from the fingers and hands to stimulate the because no creams are to be used with the device.
energy points in the body
b. B. Oils extracted from plants and herbs 43. The nurse asked the client if he has an advance directive. The reason
c. Needles to stimulate certain points on the body to treat for asking the client this question is:
pain a. She is curious about his plans regarding funeral
d. Manipulation of the skeletal muscles to relieve stress and arrangements.
pain b. Much confusion can occur with the client’s family if he
Answer C is correct. does not have an advanced directive.
Acupuncture uses needles, and because HIV is transmitted by blood and c. An advanced directive allows the medical personnel to
body fluids, the nurse should question this treatment. Answer A describes make decisions for the client.
acupressure, and answers B and D describe massage therapy with the use d. An advanced directive allows active euthanasia to be
of oils. carried out if the client is unable to care for himself.
Answer B is correct.
 An advanced directive allows the client to make known his wishes Answer A is correct.
regarding care if he becomes unable to act on his own. Much The best diagnostic tool for cancer is the biopsy. Other assessment
confusion regarding life-saving measures can occur if the client does includes checking the lymph nodes. Answers B, C, and D will not confirm a
not have an advanced directive. Answers A, C, and D are incorrect diagnosis of oral cancer.
because the nurse doesn’t need to know about funeral plans and
cannot make decisions for the client, and active euthanasia is illegal 49. The nurse is caring for the patient following removal of a large
in most states in the United States. posterior oral lesion. The priority nursing measure would be to:
a. Maintain a patent airway
44. A client who has chosen to breastfeed tells the nurse that her nipples b. Perform meticulous oral care every 2 hours
became very sore while she was breastfeeding her older child. Which c. Ensure that the incisional area is kept as dr y as possible
measure will help her to avoid soreness of the nipples? d. Assess the client frequently for pain
a. Feeding the baby during the first 48 hours after deliver y Answer A is correct.
b. Breaking suction by placing a finger between the baby’s Maintaining a patient’s airway is paramount in the post-operative period.
mouth and the breast when she terminates the feeding This is the priority of nursing care. Answers B, C, and D are applicable but
c. Applying hot, moist soaks to the breast several times per are not the priority.
day
d. Wearing a support bra 50. The registered nurse is conducting an in-ser vice for colleagues on the
Answer B is correct. subject of peptic ulcers. The nurse would be correct in identifying
To decrease the potential for soreness of the nipples, the client should be which of the following as a causative factor?
taught to break the suction before removing the baby from the breast. a. N. gonorrhea
Answer A is incorrect because feeding the baby during the first 48 hours b. H. influenza
after delivery will provide colostrum but will not help the soreness of the c. H. pylori
nipples. Answers C and D are incorrect because applying hot, moist soaks d. E. coli
several times per day might cause burning of the breast and cause further Answer C is correct.
dr ying. Wearing a support bra will help with engorgement but will not H. pylori bacteria has been linked to peptic ulcers. Answers A, B, and D are
help the nipples. not typically cultured within the stomach, duodenum, or esophagus, and
are not related to the development of peptic ulcers.
45. The nurse is performing an assessment of an elderly client with a
total hip repair. Based on this assessment, the nurse decides to 51. The patient states, “My stomach hurts about 2 hours after I eat.”
medicate the client with an analgesic. Which finding most likely Based upon this information, the nurse suspects the patient likely has
prompted the nurse to decide to administer the analgesic? a:
a. The client’s blood pressure is 130/86. a. Gastric ulcer
b. The client is unable to concentrate. b. Duodenal ulcer
c. The client’s pupils are dilated. c. Peptic ulcer
d. The client grimaces during care. d. Curling’s ulcer
Answer D is correct. Answer B is correct.
Facial grimace is an indication of pain. The blood pressure in answer A is Individuals with ulcers within the duodenum typically complain of
within normal limits. The client’s inability to concentrate and dilated pain occurring 2–3 hours after a meal, as well as at night. The pain is
pupils, as stated in answers B and C, may be related to the anesthesia that usually relieved by eating. The pain associated with gastric ulcers,
he received during surgery. answer A, occurs 30 minutes after eating. Answer C is too vague and
does not distinguish the type of ulcer. Answer D is associated with a
46. An obstetrical client decides to have an epidural anesthetic to relieve stress ulcer.
pain during labor. Following administration of the anesthesia, the
nurse should monitor the client for: 52. The nurse is caring for a patient with suspected diverticulitis. The
a. Seizures nurse would be most prudent in questioning which of the following
b. Postural hypertension diagnostic tests?
c. Respiratory depression a. Abdominal ultrasound
d. Hematuria b. Barium enema
Answer C is correct. c. Complete blood count
Epidural anesthesia involves injecting an anesthetic into the epidural d. Computed tomography (CT) scan
space. If the anesthetic rises above the respiratory center, the client will Answer B is correct.
have impaired breathing; thus, monitoring for respiratory depression is A barium enema is contraindicated in the client with diverticulitis because
necessary. Answer A, seizure activity, is not likely after an epidural. Answer it can cause bowel perforation. Answers A, C, and D are appropriate
B, postural hypertension, is not likely. Answer D, hematuria, is not related diagnostic studies for the client with suspected diverticulitis.
to epidural anesthesia.
53. The nurse is planning care for the patient with celiac disease. In
47. The nurse is assessing the client admitted for possible oral cancer. teaching about the diet, the nurse should instruct the patient to
The nurse identifies which of the following to be a late-occurring avoid which of the following for breakfast?
symptom of oral cancer? a. Puffed wheat
a. Warmth b. Banana
b. Odor c. Puffed rice
c. Pain d. Cornflakes
d. Ulcer with flat edges Answer A is correct.
Answer C is correct. Clients with celiac disease should refrain from eating foods containing
Pain is a late sign of oral cancer. Answers A, B, and D are incorrect because gluten. Foods with gluten include wheat barley, oats, and rye. The other
a feeling of warmth, odor, and a flat ulcer in the mouth are all early foods are allowed.
occurrences of oral cancer.
54. The nurse is teaching about irritable bowel syndrome (IBS). Which of
48. The nurse understands that the diagnosis of oral cancer is confirmed the following would be most important?
with: a. Reinforcing the need for a balanced diet
a. Biopsy b. Encouraging the client to drink 16 ounces of fluid with
b. Gram Stain each meal
c. Oral culture c. Telling the client to eat a diet low in fiber
d. Oral washings for cytology
 d. Instructing the client to limit his intake of fruits and d. “Don’t worry about that. You will be able to live just like
vegetables you did before.”
Answer A is correct. Answer A is correct.
The nurse should reinforce the need for a diet balanced in all nutrients and The client with a colostomy can swim and carry on activities as before the
fiber. Foods that often cause diarrhea and bloating associated with irritable colostomy. Answers B and C are incorrect, and answer D shows a lack of
bowel syndrome include fried foods, caffeinated beverages, alcohol, and empathy.
spicy foods. Therefore, answers B, C, and D are incorrect.
60. The nurse is assisting in the care of a patient who is 2 days post-
55. In planning care for the patient with ulcerative colitis, the nurse operative from a hemorroidectomy. The nurse would be correct in
identifies which nursing diagnosis as a priority? instructing the patient to:
a. Anxiety a. Avoid a high-fiber diet
b. Impaired skin integrity b. Continue to use ice packs
c. Fluid volume deficit c. Take a laxative daily to prevent constipation
d. Nutrition altered, less than body requirements d. Use a sitz bath after each bowel movement
Answer C is correct. Answer D is correct.
Fluid volume deficit can lead to metabolic acidosis and electrolyte loss. The The use of a sitz bath will help with the pain and swelling associated with a
other nursing diagnoses in answers A, B, and D might be applicable but are hemorroidectomy. The client should eat foods high in fiber, so answer A is
of lesser priority. incorrect. Ice packs, as stated in answer B, are ordered immediately after
surgery only. Answer C is incorrect because taking a laxative daily can
56. The patient is prescribed metronidazole (Flagyl) for adjunct result in diarrhea.
treatment for a duodenal ulcer. When teaching about this
medication, the nurse would include: 61. The nurse is assisting in the care of a client with diverticulosis. Which
a. “This medication should be taken only until you begin to of the following assessment findings must necessitate an immediate
feel better.” report to the doctor?
b. “This medication should be taken on an empty stomach to a. Bowel sounds are present
increase absorption.” b. Intermittent left lower-quadrant pain
c. “While taking this medication, you do not have to be c. Constipation alternating with diarrhea
concerned about being in the sun.” d. Hemoglobin 26% and hematocrit 32
d. “While taking this medication, alcoholic beverages and Answer D is correct.
products containing alcohol should be avoided.” Low hemoglobin and hematocrit might indicate intestinal bleeding.
Answer D is correct. Answers A, B, and C are incorrect, because they do not require immediate
Alcohol will cause extreme nausea if consumed with Flagyl. Answer A is action.
incorrect because the full course of treatment should be taken. The
medication should be taken with a full 8 oz. of water, with meals, and the 62. The client is newly diagnosed with juvenile onset diabetes. Which of
client should avoid direct sunlight because he will most likely be the following nursing diagnoses is a priority?
photosensitive; therefore, answers A, B, and C are incorrect. a. Anxiety
b. Pain
57. The nurse is preparing to administer a feeding via a nasogastric tube. c. Knowledge deficit
The nurse would perform which of the following before initiating the d. Altered thought process
feeding? Answer C is correct.
a. Assess for tube placement by aspirating stomach content The new diabetic has a knowledge deficit. Answers A, B, and D are not
b. Place the patient in a left-lying position supported within the stem and so are incorrect.
c. Administer feeding with 50% Dextrose
d. Ensure that the feeding solution has been warmed in a 63. The nurse is asked by the nurse aide, “Are peptic ulcers really caused
microwave for 2 minutes by stress?” The nurse would be correct in replying with the following:
Answer A is correct. a. “Peptic ulcers result from overeating fatty foods.”
Before beginning feedings, an x-ray is often obtained to check for b. “Peptic ulcers are always caused from exposure to
placement. Aspirating stomach content and checking the pH for acidity is continual stress.”
the best method of checking for placement. Other methods include placing c. “Peptic ulcers are like all other ulcers, which all result
the end in water and checking for bubbling, and injecting air and listening from stress.”
over the epigastric area. Answers B and C are not correct. Answer D is d. “Peptic ulcers are associated with H. pylori, although there
incorrect because warming in the microwave is contraindicated. are other ulcers that are associated with stress.”
Answer D is correct.
58. Which is true regarding the administration of antacids? Peptic ulcers are not always related to stress but are a component of the
a. Antacids should be administered without regard to disease. Answers A and B are incorrect because peptic ulcers are not
mealtimes. caused by overeating or continued exposure to stress. Answer C is
b. Antacids should be administered with each meal and incorrect because peptic ulcers are related to but not directly caused by
snack of the day. stress.
c. Antacids should not be administered with other
medications. 64. The nurse is assisting in the assessment of the patient admitted with
d. Antacids should be administered with all other “extreme abdominal pain.” The nurse asks the client about the
medications, for maximal absorption. medication that he has been taking because:
Answer C is correct. a. Interactions between medications will cause abdominal
Antacids should be administered with other medications. If antacids are pain.
taken with many medications, they render the other medications inactive. b. Various medications taken by mouth can affect the
All other answers are incorrect. alimentary tract.
c. This will provide an opportunity to educate the patient
59. The nurse is caring for a patient with a colostomy. The patient asks, regarding the medications used.
“Will I ever be able to swim again?” The nurse’s best response would d. The types of medications might be attributable to an
be: abdominal pathology not already identified.
a. “Yes, you should be able to swim again, even with the Answer B is correct.
colostomy.” Many medications can irritate the stomach and contribute to abdominal
b. “You should avoid immersing the colostomy in water.” pain. For answer A, not all interactions between medications will cause
c. “No, you should avoid getting the colostomy wet.” abdominal pain. Although this might provide an opportunity for teaching,
this is not the best time to teach. Therefore, answer C is incorrect. Answer C, and D are all indicated for caring for the client. The arm should be
D is incorrect because medication may not be the cause of the pain. elevated to decrease edema. It is best to position the client on the
unaffected side and perform a dextrostix on the unaffected side.
65. The nurse is assessing the abdomen. The nurse knows the best
sequence to perform the assessment is: 70. The client has an order for gentamycin to be administered. Which lab
a. Inspection, auscultation, palpation results should be reported to the doctor before beginning the
b. Auscultation, palpation, inspection medication?
c. Palpation, inspection, auscultation a. Hematocrit
d. Inspection, palpation, auscultation b. Creatinine
Answer A is correct. c. White blood cell count
The nurse should inspect first, then auscultate, and finally palpate. If the d. Erythrocyte count
nurse palpates first the assessment might be unreliable. Therefore, Answer B is correct.
answers B, C, and D are incorrect. Gentamycin is an aminoglycocide. These drugs are toxic to the auditory
nerve and the kidneys. The hematocrit is not of significant consideration in
66. The nurse is caring for the client who has been in a coma for 2 this client; therefore, answer A is incorrect. Answer C is incorrect because
months. He has signed a donor card, but the wife is opposed to the we would expect the white blood cell count to be elevated in this client
idea of organ donation. How should the nurse handle the topic of because gentamycin is an antibiotic. Answer D is incorrect because the
organ donation with the wife? erythrocyte count is also particularly significant to check.
a. Tell the wife that the hospital will honor her wishes
regarding organ donation, but contact the organ-retrieval 71. Which of the following is the best indicator of the diagnosis of HIV?
staff a. White blood cell count
b. Tell her that because her husband signed a donor card, b. ELISA
the hospital has the right to take the organs upon the c. Western Blot
death of her husband d. Complete blood count
c. Explain that it is necessary for her to donate her Answer C is correct.
husband’s organs because he signed the permit The most definitive diagnostic tool for HIV is the Western Blot. The white
d. Refrain from talking about the subject until after the blood cell count, as stated in answer A, is not the best indicator, but a
death of her husband white blood cell count of less than 3,500 requires investigation. The ELISA
Answer A is correct. test, answer B, is a screening exam. Answer D is not specific enough.
The hospital will certainly honor the wishes of family members even if the
patient has signed a donor card. Answer B is incorrect, answer C is not 72. The client presents to the emergency room with a “bull’s eye” rash.
empathetic to the family and is untrue, and answer D is not good nursing Which question would be most appropriate for the nurse to ask the
etiquette and, therefore, is incorrect. client?
a. “Have you found any ticks on your body?”
67. The client with cancer refuses to care for herself. Which action by the b. “Have you had any nausea in the last 24 hours?”
nurse would be best? c. “Have you been outside the country in the last 6
a. Alternate nurses caring for the client so that the staff will months?”
not get tired of caring for this client d. “Have you had any fever for the past few days?”
b. B. Talk to the client and explain the need for self-care Answer A is correct.
c. C. Explore the reason for the lack of motivation seen in The “bull’s eye” rash is indicative of Lyme’s disease, a disease spread by
the client ticks. The signs and symptoms include elevated temperature, headache,
d. D. Talk to the doctor about the client’s lack of motivation nausea, and the rash. Although answers B and D are important, the
Answer C is correct. question asked which question would be best. Answer C has no
The nurse should explore the cause for the lack of motivation. The client significance.
might be anemic and lack energy, or the client might be depressed.
Alternating staff, as stated in answer A, will prevent a bond from being 73. Which client should be assigned to the nursing assistant?
formed with the nurse. Answer B is not enough, and answer D is not a. The 18-year-old with a fracture to two cervical vertebrae
necessary. b. The infant with meningitis
c. The elderly client with a thyroidectomy 4 days ago
68. The charge nurse is making assignments for the day. After accepting d. The client with a thoracotomy 2 days ago
the assignment to a client with leukemia, the nurse tells the charge Answer C is correct.
nurse that her child has chickenpox. Which initial action should the The client that needs the least-skilled nursing care is the client with the
charge nurse take? thyroidectomy 4 days ago. Answers A, B, and D are incorrect because the
a. Change the nurse’s assignment to another client other clients are less stable and require a registered nurse.
b. Explain to the nurse that there is no risk to the client
c. Ask the nurse if the chickenpox have scabbed 74. The client presents to the emergency room with a hyphema. Which
d. Ask the nurse if she has ever had the chickenpox action by the nurse would be best?
Answer D is correct. a. Elevate the head of the bed and apply ice to the eye
The nurse who has had the chickenpox has immunity to the illness and will b. Place the client in a supine position and apply heat to the
not transmit chickenpox to the client. Answer A is incorrect because there knee
could be no need to reassign the nurse. Answer B is incorrect because the c. Insert a Foley catheter and measure the intake and output
nurse should be assessed before coming to the conclusion that she cannot d. Perform a vaginal exam and check for a discharge
spread the infection to the client. Answer C is incorrect because there is Answer A is correct.
still a risk, even though chickenpox has formed scabs. Hyphema is blood in the anterior chamber of the eye and around the eye.
The client should have the head of the bed elevated and ice applied.
69. The nurse is caring for the client with a mastectomy. Which action Answers B, C, and D are incorrect and do not treat the problem.
would be contraindicated?
a. Taking the blood pressure in the side of the mastectomy 75. The client has an order for FeSO 4 liquid. Which method of
b. Elevating the arm on the side of the mastectomy administration would be best?
c. Positioning the client on the unaffected side a. Administer the medication with milk
d. Performing a dextrostix on the unaffected side b. Administer the medication with a meal
Answer A is correct. c. Administer the medication with orange juice
The nurse should not take the blood pressure on the affected side. Also, d. Administer the medication undiluted
venopunctures and IVs should not be used in the affected area. Answers B, Answer C is correct.
FeSO4 or iron should be given with ascorbic acid (vitamin C). This helps b. 3 months
with the absorption. It should not be given with meals or milk because this c. 1 year
decreases the absorption; thus, answers A and B are incorrect. Giving it d. 2 years
undiluted, as stated in answer D, is not good because it tastes bad. Answer A is correct.
Household contacts should take INH approximately 6 months. Answers B,
76. The client with an ileostomy is being discharged. Which teaching C, and D are incorrect because they indicate either too short or too long of
should be included in the plan of care? a time to take the medication.
a. Using Karaya powder to seal the bag.
b. Irrigating the ileostomy daily. 82. A 4-year-old with cystic fibrosis has a prescription for Viokase
c. Using stomahesive as the best skin protector. pancreatic enzymes to prevent malabsorption. The correct time to
d. Using Neosporin ointment to protect the skin. give pancreatic enzyme is:
Answer C is correct. a. 1 hour before meals
The best protector for the client with an ileostomy to use is stomahesive. b. 2 hours after meals
Answer A is not correct because the bag will not seal if the client uses c. With each meal and snack
Karaya powder. Answer B is incorrect because there is no need to irrigate d. On an empty stomach
an ileostomy. Neosporin, answer D, is not used to protect the skin because Answer C is correct.
it is an antibiotic. Viokase is a pancreatic enzyme that is used to facilitate digestion. It should
be given with meals and snacks, and it works well in foods such as
77. Vitamin K is administered to the newborn shortly after birth for which applesauce. Answers A, B, and D are incorrect.
of the following reasons?
a. To stop hemorrhage 83. A client with osteomylitis has an order for a trough level to be done
b. To treat infection because he is taking Gentamycin. When should the nurse call the lab
c. To replace electrolytes to obtain the trough level?
d. To facilitate clotting a. Before the first dose
Answer D is correct. b. 30 minutes before the fourth dose
Vitamin K is given after delivery because the newborn’s intestinal tract is c. 30 minutes after the first dose
sterile and lacks vitamin K needed for clotting. Answer A is incorrect d. 30 minutes before the first dose
because vitamin K is not directly given to stop hemorrhage. Answers B and Answer B is correct.
C are incorrect because vitamin K does not prevent infection or replace Trough levels are the lowest blood levels and should be done 30 minutes
electrolytes. before the third IV dose or 30 minutes before the fourth IM dose. Answers
A, C, and D are incorrect.
78. Before administering Methyltrexate orally to the client with cancer, the
nurse should check the: 84. A new diabetic is learning to administer his insulin. He receives 10U of
a. IV site NPH and 12U of regular insulin each morning. Which of the following
b. Electrolytes statements reflects understanding of the nurse’s teaching?
c. Blood gases a. “When drawing up my insulin, I should draw up the
d. Vital signs regular insulin first.”
Answer D is correct. b. “When drawing up my insulin, I should draw up the NPH
The vital signs should be taken before any chemotherapy agent. If it is an insulin first.”
IV infusion of chemotherapy, the nurse should check the IV site as well. c. “It doesn’t matter which insulin I draw up first.”
Answers B and C are incorrect because it is not necessary to check the d. “I cannot mix the insulin, so I will need two shots.”
electrolytes or blood gasses. Answer A is correct.
Regular insulin should be drawn up before the NPH. They can be given
79. The nurse is teaching a group of new graduates about the safety needs together, so there is no need for two injections, making answer D
of the client receiving chemotherapy. Before administering incorrect. Answer B is obviously incorrect, and answer C is incorrect
chemotherapy, the nurse should: because it certainly does matter which is drawn first: Contamination of
a. Administer a bolus of IV fluid NPH into regular insulin will result in a hypoglycemic reaction at
b. Administer pain medication unexpected times.
c. Administer an antiemetic
d. Allow the patient a chance to eat 85. The client is scheduled to have an intravenous cholangiogram. Before
Answer C is correct. the procedure, the nurse should assess the patient for:
Before chemotherapy, an antiemetic should be given because most a. Shellfish allergies
chemotherapy agents cause nausea. It is not necessary to give a bolus of IV b. Reactions to blood transfusions
fluids, medicate for pain, or allow the client to eat; therefore, answers A, B, c. Gallbladder disease
and D are incorrect. d. Egg allergies
Answer A is correct.
80. The client is admitted to the postpartum unit with an order to continue Clients having dye procedures should be assessed for allergies to iodine or
the infusion of Pitocin. The nurse is aware that Pitocin is working if shellfish. Answers B and D are incorrect because there is no need for the
the fundus is: client to be assessed for reactions to blood or eggs. Because an IV
a. Deviated to the left. cholangiogram is done to detect gallbladder disease, there is no need to
b. Firm and in the midline. ask about answer C.
c. Boggy.
d. Two finger breadths below the umbilicus. 86. Shortly after the client was admitted to the postpartum unit, the nurse
Answer B is correct. notes heavy lochia rubra with large clots. The nurse should anticipate
Pitocin is used to cause the uterus to contract and decrease bleeding. A an order for:
uterus deviated to the left, as stated in answer A, indicates a full bladder. It a. Methergine
is not desirable to have a boggy uterus, making answer C incorrect. This b. Stadol
lack of muscle tone will increase bleeding. Answer D is incorrect because c. Magnesium sulfate
Pitocin does not affect the position of the uterus. d. Phenergan
Answer A is correct.
81. A 5-year-old is a family contact to the client with tuberculosis. Isoniazid Methergine is a drug that causes uterine contractions. It is used for
(INH) has been prescribed for the client. The nurse is aware that the postpartal bleeding that is not controlled by Pitocin. Answers B, C, and D
length of time that the medication will be taken is: are incorrect: Stadol is an analgesic; magnesium sulfate is used for
a. 6 months preeclampsia; and phenergan is an antiemetic.
 c. Prednisone is absorbed best with
87. The client with a recent liver transplant asks the nurse how long he will the breakfast meal.
have to take an immunosuppressant. Which response would be d. Morning administration mimics the
correct? body’s natural secretion of corticosteroid.
a. 1 year Answer D is correct.
b. 5 years Taking corticosteroids in the morning mimics the body’s natural release of
c. 10 years cortisol. Answer A is not necessarily true, and answers B and C are not
d. The rest of his life true.
Answer D is correct.
Cyclosporin is an immunosuppressant, and the client with a liver transplant 93. The client is taking rifampin 600mg po daily to treat his tuberculosis.
will be on immunosuppressants for the rest of his life. Answers A, B, and C, Which action by the nurse indicates understanding of the
then, are incorrect. medication?
a. Telling the client that the medication will need to be taken
88. The client is admitted from the emergency room with multiple injuries with juice
sustained from an auto accident. His doctor prescribes a histamine b. Telling the client that the medication will change the color
blocker. The nurse is aware that the reason for this order is to: of the urine
a. Treat general discomfort c. Telling the client to take the medication before going to
b. Correct electrolyte imbalances bed at night
c. Prevent stress ulcers d. Telling the client to take the medication if the night
d. Treat nausea sweats occur
Answer C is correct. Answer B is correct.
Histamine blockers are frequently ordered for clients who are hospitalized Rifampin can change the color of the urine and body fluid. Teaching the
for prolonged periods and who are in a stressful situation. They are not client about these changes is best because he might think this is a
used to treat discomfort, correct electrolytes, or treat nausea; therefore, complication. Answer A is not necessary, answer C is not true, and answer
answers A, B, and D are incorrect. D is not true because this medication should be taken regularly during the
course of the treatment.
89. The physician prescribes regular insulin, 5 units subcutaneous. Regular
insulin begins to exert an effect: 94. The client is diagnosed with multiple myloma. The doctor has ordered
a. In 5–10 minutes cyclophosphamide (Cytoxan). Which instruction should be given to
b. In 10–20 minutes the client?
c. In 30–60 minutes a. “Walk about a mile a day to prevent calcium loss.”
d. In 60–120 minutes b. “Increase the fiber in your diet.”
Answer C is correct. c. “Report nausea to the doctor immediately.”
The time of onset for regular insulin is 30–60 minutes. Answers A, B, and D d. “Drink at least eight large glasses of water a day.”
are incorrect because they are not the correct times. Answer D is correct.
Cytoxan can cause hemorrhagic cystitis, so the client should drink at least
90. A 60-year-old diabetic is taking glyburide (Diabeta) 1.25mg daily to eight glasses of water a day. Answers A and B are not necessary and, so,
treat Type II diabetes mellitus. Which statement indicates the need are incorrect. Nausea often occurs with chemotherapy, so answer C is
for further teaching? incorrect.
a. “I will keep candy with me just in case my blood sugar
drops.” 95. An elderly client is diagnosed with ovarian cancer. She has surgery
b. “I need to stay out of the sun as much as possible.” followed by chemotherapy with a fluorouracil (Adrucil) IV. What
c. “I often skip dinner because I don’t feel hungr y.” should the nurse do if she notices crystals in the IV medication?
d. “I always wear my medical identification.” a. Discard the solution and order a new bag
Answer C is correct. b. Warm the solution
The client should be taught to eat his meals even if he is not hungry, to c. Continue the infusion and document the finding
prevent a hypoglycemic reaction. Answers A, B, and D are incorrect d. Discontinue the medication
because they indicate knowledge of the nurse’s teaching. Answer A is correct.
Crystals in the solution are not normal and should not be administered to
91. A 20-year-old female has a prescription for tetracycline. While teaching the client. Discard the bad solution immediately. Answer B is incorrect
the client how to take her medicine, the nurse learns that the client is because warming the solution will not help. Answer C is incorrect, and
also taking Ortho-Novum oral contraceptive pills. Which instructions answer D requires a doctor’s order.
should be included in the teaching plan?
a. The oral contraceptives will decrease the effectiveness of 96. The 10-year-old is being treated for asthma. Before administering
the tetracycline. Theodur, the nurse should check the:
b. Nausea often results from taking oral contraceptives and a. Urinary output
antibiotics. b. Blood pressure
c. Toxicity can result when taking these two medications c. Pulse
together. d. Temperature
d. Antibiotics can decrease the effectiveness of oral Answer C is correct.
contraceptives, so the client should use an alternate Theodur is a bronchodilator, and a side effect of bronchodilators is
method of birth control. tachycardia, so checking the pulse is important. Extreme tachycardia
Answer D is correct. should be reported to the doctor. Answers A, B, and D are not necessary.
Taking antibiotics and oral contraceptives together decreases the
effectiveness of the oral contraceptives. Answers A, B, and C are not 97. Which information obtained from the mother of a child with cerebral
necessarily true. palsy correlates to the diagnosis?
a. She was born at 40 weeks gestation.
92. The client is taking prednisone 7.5mg po each morning to treat his b. She had meningitis when she was 6 months
systemic lupus erythematosis. Which statement best explains the old.
reason for taking the prednisone in the morning? c. She had physiologic jaundice after delivery.
a. There is less chance of forgetting d. She has frequent sore throats.
the medication if taken in the morning. Answer B is correct.
b. There will be less fluid retention if The diagnosis of meningitis at age 6 months correlates to a diagnosis of
taken in the morning. cerebral palsy. Cerebral palsy, a neurological disorder, is often associated
 with birth trauma or infections of the brain or spinal column. Answers A, C C. Heart block
and D are not related to the question. D. Ventricular brachycardia
Answer B is correct.
98. A 6-year-old with cerebral palsy functions at the level of an 18-month- Lidocaine is used to treat ventricular tachycardia. This medication slowly exerts
old. Which finding would support that assessment? an antiarrhythmic effect by increasing the electric stimulation threshold of the
a. She dresses herself. ventricles without depressing the force of ventricular contractions. It is not used
b. She pulls a toy behind her. for atrial arrhythmias; thus, answer A is incorrect. Answers C and D are incorrect
c. She can build a tower of eight blocks. because it slows the heart rate, so it is not used for heart block or brachycardia.
d. She can copy a horizontal or vertical line.
Answer B is correct. 104. The doctor orders 2% nitroglycerin ointment in a 1-inch dose every 12
Children at 18 months of age like push-pull toys. Children at approximately hours. Proper application of nitroglycerin ointment includes:
3 years of age begin to dress themselves and build a tower of eight blocks. A. Rotating application sites
At age four, children can copy a horizontal or vertical line. Therefore, B. Limiting applications to the chest
answers A, C, and D are incorrect. C. Rubbing it into the skin
D. Covering it with a gauze dressing
99. A 5-year-old is admitted to the unit following a tonsillectomy. Which of Answer A is correct.
the following would indicate a complication of the surgery? Sites for the application of nitroglycerin should be rotated, to prevent skin
a. Decreased appetite irritation. It can be applied to the back and upper arms, not to the lower
b. A low-grade fever extremities, making answer B incorrect. Answer C is incorrect because
c. Chest congestion nitroglycerine should not be rubbed into the skin, and answer D is incorrect
d. Constant swallowing because the medication should be covered with a prepared dressing made of a
Answer D is correct. thin paper substance, not gauze.
A complication of a tonsillectomy is bleeding, and constant swallowing may
indicate bleeding. Decreased appetite is expected after a tonsillectomy, as 105. The physician prescribes captopril (Capoten) 25mg po tid for the client with
is a low-grade temperature; thus, answers A and B are incorrect. In answer hypertension. Which of the following adverse reactions can occur with
C, chest congestion is not normal but is not associated with the administration of Capoten?
tonsillectomy. A. Tinnitus
B. Persistent cough
100. The child with seizure disorder is being treated with phenytoin C. Muscle weakness
(Dilantin). Which of the following statements by the patient’s mother D. Diarrhea
indicates to the nurse that the patient is experiencing a side effect of Answer B is correct.
Dilantin therapy? A persistent cough might be related to an adverse reaction to Captoten.
a. “She is very irritable lately.” Answers A and D are incorrect because tinnitus and diarrhea are not associated
b. “She sleeps quite a bit of the time.” with the medication. Muscle weakness might occur when beginning the
c. “Her gums look too big for her teeth.” treatment but is not an adverse effect; thus, answer C is incorrect.
d. “She has gained about 10 pounds in the last six months.”
Answer C is correct. 106. The client is admitted with a BP of 210/100. Her doctor orders furosemide
Hyperplasia of the gums is associated with Dilantin therapy. Answer A is (Lasix) 40mg IV stat. How should the nurse administer the prescribed
not related to the therapy; answer B is a side effect; and answer D is not furosemide to this client?
related to the question. A. By giving it over 1–2 minutes
B. By hanging it IV piggyback
101. The physician has prescribed tranylcypromine sulfate (Parnate) 10mg bid. C. With normal saline only
The nurse should teach the client to refrain from eating foods containing D. With a filter
tyramine because it may cause: Answer A is correct.
A. Hypertension Lasix should be given approximately 1mL per minute to prevent hypotension.
B. Hyperthermia Answers B, C, and D are incorrect because it is not necessar y to be given in an IV
C. Hypotension piggyback, with saline, or through a filter.
D. Urinary retention
Answer A is correct. 107. The client is receiving heparin for thrombophlebitis of the left lower
If the client eats foods high in tyramine, he might experience malignant extremity. Which of the following drugs reverses the effects of heparin?
hypertension. Tyramine is found in cheese, sour cream, Chianti wine, sherry, A. Cyanocobalamine
beer, pickled herring, liver, canned figs, raisins, bananas, avocados, chocolate, B. Protamine sulfate
soy sauce, fava beans, and yeast. These episodes are treated with Regitine, an C. Streptokinase
alpha-adrenergic blocking agent. Answers B, C, and D are not related to the D. Sodium warfarin
question. Answer B is correct.
The antidote for heparin is protamine sulfate. Cyanocobalamine is B12,
102. The client is admitted to the emergency room with shortness of breath, Streptokinase is a thrombolytic, and sodium warfarin is an anticoagulant.
anxiety, and tachycardia. His ECG reveals atrial fibrillation with a ventricular Therefore, answers A, C, and D are incorrect.
response rate of 130 beats per minute. The doctor orders quinidine sulfate.
While he is receiving quinidine, the nurse should monitor his ECG for: 108. The nurse is making assignments for the day. Which client should be
A. Peaked P wave assigned to the pregnant nurse?
B. Elevated ST segment A. The client receiving linear accelerator radiation therapy for lung cancer
C. Inverted T wave B. The client with a radium implant for cer vical cancer
D. Prolonged QT interval C. The client who has just been administered soluble brachytherapy for thyroid
Answer D is correct. cancer
Quinidine can cause widened Q-T intervals and heart block. Other signs of D. The client who returned from placement of iridium seeds for prostate cancer
myocardial toxicity are notched P waves and widened QRS complexes. The most Answer A is correct.
common side effects are diarrhea, nausea, and vomiting. The client might The pregnant nurse should not be assigned to any client with radioactivity
experience tinnitus, vertigo, headache, visual disturbances, and confusion. present. The client receiving linear accelerator therapy is not radioactive
Answers A, B, and C are not related to the use of quinidine. because he travels to the radium department for therapy, and the radiation
stays in the department. The client in answer B does pose a risk to the pregnant
103. Lidocaine is a medication frequently ordered for the client experiencing: nurse. The client in answer C is radioactive in ver y small doses. For
A. Atrial tachycardia approximately 72 hours, the client should dispose of urine and feces in special
B. Ventricular tachycardia
containers and use plastic spoons and forks. The client in answer D is also D. A calcium of 8mg/dL
radioactive in small amounts, especially upon return from the procedure. Answer B is correct.
Cystic fibrosis is a disease of the exocrine glands. The child with cystic fibrosis
109. The nurse is planning room assignments for the day. Which client should be will be salty. A sweat test result of 60meq/L and higher is considered positive.
assigned to a private room if only one is available? Answers A, C, and D are incorrect because these test results are within the
A. The client with Cushing’s disease normal range and are not reported on the sweat test.
B. The client with diabetes
C. The client with acromegaly 115. The nurse caring for the child with a large meningomylocele is aware that
D. The client with myxedema the priority care for this client is to:
Answer A is correct. A. Cover the defect with a moist, sterile saline gauze
The client with Cushing’s disease has adrenocortical hypersecretion. This B. Place the infant in a supine position
increase in the level of cortisone causes the client to be immune suppressed. In C. Feed the infant slowly
answer B, the client with diabetes poses no risk to other clients. The client in D. Measure the intake and output
answer C has an increase in growth hormone and poses no risk to himself or Answer A is correct.
others. The client in answer D has hyperthyroidism or myxedema, and poses no A meningomylocele is an opening in the spine. The nurse should keep the defect
risk to others or himself. covered with a sterile saline gauze until the defect can be repaired. Answer B is
incorrect because the child should be placed in the prone position. Answer C is
110. The charge nurse witnesses the nursing assistant hitting the client in the incorrect because feeding the child slowly is not necessary. Answer D is not
long-term care facility. The nursing assistant can be charged with: correct because this is not the priority of care.
A. Negligence
B. Tort 116. The nurse is caring for an infant admitted from the deliver y room. Which
C. Assault finding should be reported?
D. Malpractice A. Acyanosis
Answer C is correct. B. Acrocyanosis
Assault is defined as striking or touching the client inappropriately, so a nurse C. Halequin sign
assistant striking a client could be charged with assault. Answer A, negligence, is D. Absent femoral pulses
failing to perform care for the client. Answer B, a tort, is a wrongful act Answer D is correct.
committed on the client or their belongings. Answer D, malpractice, is failure to Absent femoral pulses indicates coarctation of the aorta. This defect causes
perform an act that the nurse assistant knows should be done, or the act of strong bounding pulses and elevated blood pressure in the upper body, and low
doing something wrong that results in harm to the client. blood pressure in the lower extremities. Answers A, B, and C are incorrect
because they are normal findings in the newborn.
111. Which assignment should not be performed by the licensed practical
nurse? 117. The nurse is aware that a common mode of transmission of clostridium
A. Inserting a Foley catheter difficile is:
B. Discontinuing a nasogastric tube A. Use of unsterile surgical equipment
C. Obtaining a sputum specimen B. Contamination with sputum
D. Starting a blood transfusion C. Through the urinary catheter
Answer D is correct. D. Contamination with stool
The licensed practical nurse cannot start a blood transfusion, but can assist the Answer D is correct.
registered nurse with identifying the client and taking vital signs. Answers A, B, Clostrium dificille is primarily spread through the GI tract, resulting from poor
and C are duties that the licensed practical nurse can perform. hand washing and contamination with stool containing clostridium dificille.
Answers A, B, and C are incorrect because the mode of transmission is not by
112. The client returns to the unit from surgery with a blood pressure of 90/50, sputum, through the urinar y tract, or by unsterile surgical equipment.
pulse 132, respirations 30. Which action by the nurse should receive priority?
A. Continue to monitor the vital signs 118. The nurse has just received the change of shift report. Which client should
B. Contact the physician the nurse assess first?
C. Ask the client how he feels A. A client 2 hours post-lobectomy with 150ml drainage
D. Ask the LPN to continue the post-op care B. A client 2 days post-gastrectomy with scant drainage
Answer B is correct. C. A client with pneumonia with an oral temperature of 102°F
The vital signs are abnormal and should be reported to the doctor immediately. D. A client with a fractured hip in Buck’s traction
Answer A, continuing to monitor the vital signs, can result in deterioration of the Answer A is correct.
client’s condition. Answer C, asking the client how he feels, would supply only The first client to be seen is the one who recently returned from surgery. The
subjective data. Involving the LPN, in Answer D, is not the best solution to help other clients in answers B, C, and D are more stable and can be seen later.
this client because he is unstable.
119. A client has been receiving cyanocobalamine (B12) injections for the past
113. The nurse is caring for a client with B-Thalassemia major. Which therapy is six weeks. Which laboratory finding indicates that the medication is having the
used to treat Thalassemia? desired effect?
A. IV fluids A. Neutrophil count of 60%
B. Frequent blood transfusions B. Basophil count of 0.5%
C. Oxygen therapy C. Monocyte count of 2%
D. Iron therapy D. Reticulocyte count of 1%
Answer B is correct. Answer D is correct.
Thalasemia is a genetic disorder that causes the red blood cells to have a shorter Cyanocolamine is a B12 medication that is used for pernicious anemia, and a
life span. Frequent blood transfusions are necessary to provide oxygen to the reticulocyte count of 1% indicates that it is having the desired effect. Answers A,
tissues. Answer A is incorrect because fluid therapy will not help; answer C is B, and C are white blood cells and have nothing to do with this medication.
incorrect because oxygen therapy will also not help; and answer D is incorrect
because iron should be given sparingly because these clients do not use iron 120. The nurse is providing discharge teaching for a client taking dissulfiram
stores adequately. (Antabuse). The nurse should instruct the client to avoid eating:
A. Peanuts, dates, raisins
114. The child with a history of respiratory infections has an order for a sweat B. Figs, chocolate, eggplant
test to be done. Which finding would be positive for cystic fibrosis? C. Pickles, salad with vinaigrette dressing, beef
A. A serum sodium of 135meq/L D. Milk, cottage cheese, ice cream
B. A sweat analysis of 69 meq/L Answer C is correct.
C. A potassium of 4.5meq/L
The client taking antabuse should not eat or drink anything containing alcohol or D. A 28-year-old male with ulcerative colitis
vinegar. The other foods in answers A, B, and D are allowed. Answer B is correct.
The best client to transport to the postpartum unit is the 40-year-old female
121. A 70-year-old male who is recovering from a stroke exhibits signs of with a hysterectomy. The nurses on the postpartum unit will be aware of normal
unilateral neglect. Which behavior is suggestive of unilateral neglect? amounts of bleeding and will be equipped to care for this client. The clients in
A. The client is observed shaving only one side of his face. answers A and D will be best cared for on a medical-surgical unit. The client with
B. The client is unable to distinguish between two tactile stimuli presented depression in answer C should be transported to the psychiatric unit.
simultaneously.
C. The client is unable to complete a range of vision without turning his head 127. A client with glomerulonephritis is placed on a low-sodium diet. Which of
side to side. the following snacks is suitable for the client with sodium restriction?
D. The client is unable to carry out cognitive and motor activity at the same time. A. Peanut butter cookies
Answer A is correct. B. Grilled cheese sandwich
The client with unilateral neglect will neglect one side of the body. Answers B, C, C. Cottage cheese and fruit
and D are not associated with unilateral neglect. D. Fresh peach
Answer D is correct.
122. A client with acute leukemia develops a low white blood cell count. In The fresh peach is the lowest in sodium of these choices. Answers A, B, and C
addition to the institution of isolation, the nurse should: have much higher amounts of sodium.
A. Request that foods be served with disposable utensils
B. Ask the client to wear a mask when visitors are present 128. A home health nurse is making preparations for morning visits. Which one
C. Prep IV sites with mild soap and water and alcohol of the following clients should the nurse visit first?
D. Provide foods in sealed, single-serving packages A. A client with a stroke with tube feedings
Answer D is correct. B. A client with congestive heart failure complaining of night time dyspnea
Because the client is immune suppressed, foods should be served in sealed C. A client with a thoracotomy six months ago
containers, to avoid food contaminants. Answer B is incorrect because of D. A client with Parkinson’s disease
possible infection from visitors. Answer A is not necessary, but the utensils Answer B is correct.
should be cleaned thoroughly and rinsed in hot water. Answer C might be a The client with congestive heart failure who is complaining of nighttime dyspnea
good idea, but alcohol can be drying and can cause the skin to break down. should be seen because air way is number one in nursing care. In answers A, C,
and D, the clients are more stable. A brain attack in answer A is the new
123. A new nursing graduate indicates in charting entries that he is a licensed terminology for a stroke.
registered nurse, although he has not yet received the results of the licensing
exam. The graduate’s action can result in a charge of: 129. A client with cancer develops xerostomia. The nurse can help alleviate the
A. Fraud discomfort the client is experiencing associated with xerostomia by:
B. Tort A. Offering hard candy
C. Malpractice B. Administering analgesic medications
D. Negligence C. Splinting swollen joints
Answer A is correct. D. Providing saliva substitute
Identifying oneself as a nurse without a license defrauds the public and can be Answer D is correct.
prosecuted. A tort is a wrongful act; malpractice is failing to act appropriately as Xerostomia is dry mouth, and offering the client a saliva substitute will help the
a nurse or acting in a way that harm comes to the client; and negligence is failing most. Eating hard candy in answer A can further irritate the mucosa and cut the
to per form care. Therefore, answers B, C, and D are incorrect. tongue and lips. Administering an analgesic might not be necessary; thus,
answer B is incorrect. Splinting swollen joints, in answer C, is not associated with
124. The nurse is assigning staff for the day. Which client should be assigned to xerostomia.
the nursing assistant?
A. A 5-month-old with bronchiolitis 130. The nurse is making assignments for the day. The staff consists of an RN, an
B. A 10-year-old 2-day post-appendectomy LPN, and a nursing assistant. Which client could the nursing assistant care for?
C. A 2-year-old with periorbital cellulitis A. A client with Alzheimer’s disease
D. A 1-year-old with a fractured tibia B. A client with pneumonia
Answer B is correct. C. A client with appendicitis
The client with the appendectomy is the most stable of these clients and can be D. A client with thrombophlebitis
assigned to a nursing assistant. The client with bronchiolitis has an alteration in Answer A is correct.
the airway; the client with periorbital cellulitis has an infection; and the client The client with Alzheimer’s disease is the most stable of these clients and can be
with a fracture might be an abused child. Therefore, answers A, C, and D are assigned to the nursing assistant, who can perform duties such as feeding and
incorrect. assisting the client with activities of daily living. The clients in answers B, C, and
D are less stable and should be attended by a registered nurse.
125. During the change of shift, the oncoming nurse notes a discrepancy in the
number of percocette listed and the number present in the narcotic drawer. The 131. The nurse is caring for a client with cerebral palsy. The nurse should provide
nurse’s first action should be to: frequent rest periods because:
A. Notify the hospital pharmacist A. Grimacing and writhing movements decrease with relaxation and rest.
B. Notify the nursing supervisor B. Hypoactive deep tendon reflexes become more active with rest.
C. Notify the Board of Nursing C. Stretch reflexes are increased with rest.
D. Notify the director of nursing D. Fine motor movements are improved by rest.
Answer B is correct. Answer A is correct.
The first action the nurse should take is to report the finding to the nurse Frequent rest periods help to relax tense muscles and preserve energy. Answers
supervisor and follow the chain of command. If it is found that the pharmacy is B, C, and D are incorrect because they are untrue statements about cerebral
in error, it should be notified, as stated in answer A. Answers C and D, notifying palsy.
the director of nursing and the Board of Nursing, might be necessary if theft is
found, but not as a first step; thus, these are incorrect for this question. 132. The physician has ordered a culture for the client with suspected
gonorrhea. The nurse should obtain a culture of:
126. Due to a high census, it has been necessary for a number of clients to be A. Blood
transferred to other units within the hospital. Which client should be transferred B. Nasopharyngeal secretions
to the postpartum unit? C. Stool
A. A 66-year-old female with gastroenteritis D. Genital secretions
B. A 40-year-old female with a hysterectomy Answer D is correct.
C. A 27-year-old male with severe depression
A culture for gonorrhea is taken from the genital secretions. The culture is Sodium warfarin is administered in the late afternoon, at approximately 1700
placed in a warm environment, where it can grow nisseria gonorrhea. Answers hours. This allows for accurate bleeding times to be drawn in the morning.
A, B, and C are incorrect because these cultures do not test for gonorrhea. Therefore, answers A, B, and D are incorrect.

133. Which of the following post-operative diets is most appropriate for the 139. A 25-year-old male is brought to the emergency room with a piece of metal
client who has had a hemorrhoidectomy? in his eye. The first action the nurse should take is:
A. High-fiber A. Use a magnet to remove the object.
B. Lactose free B. Rinse the eye thoroughly with saline.
C. Bland C. Cover both eyes with paper cups.
D. Clear-liquid D. Patch the affected eye.
Answer D is correct. Answer C is correct.
After surgery, the client will be placed on a clear-liquid diet and progressed to a Covering both eyes prevents consensual movement of the affected eye. Answer
regular diet. Stool softeners will be included in the plan of care, to avoid A is incorrect because the nurse should not attempt to remove the object from
constipation. Later, a high-fiber diet, in answer A, is encouraged, but this is not the eye because this might cause trauma. Rinsing the eye, as stated in answer B,
the first diet after surgery. Answers B and C are not diets for this type of surgery. might be ordered by the doctor, but this is not the first step for the nurse.
Answer D is not correct because often when one eye moves, the other also
134. The client delivered a 9-pound infant two days ago. An effective means of moves.
managing discomfort from an episiotomy is:
A. Medicated suppository 140. To ensure safety while administering a nitroglycerine patch, the nurse
B. Taking showers should:
C. Sitz baths A. Wear gloves while applying the patch.
D. Ice packs B. Shave the area where the patch will be applied.
Answer C is correct. C. Wash the area thoroughly with soap and rinse with hot water.
A sitz bath will help with swelling and improve healing. Ice packs, in answer D, D. Apply the patch to the buttocks.
can be used immediately after delivery, but answers A and B are not used in this Answer A is correct.
instance. To protect herself, the nurse should wear gloves when applying a nitroglycerine
patch or cream. Answer B is incorrect because shaving the shin might abrade the
135. The nurse is assessing the client recently returned from surgery. The nurse area. Answer C is incorrect because washing with hot water will vasodilate and
is aware that the best way to assess pain is to: increase absorption. The patches should be applied to areas above the waist,
A. Take the blood pressure, pulse, and temperature making answer D incorrect.
B. Ask the client to rate his pain on a scale of 0–5
C. Watch the client’s facial expression 141. The client with Cirrhosis is scheduled for a pericentesis. Which instruction
D. Ask the client if he is in pain should be given to the client before the exam?
Answer B is correct. A. “You will need to lay flat during the exam.”
The best way to evaluate pain levels is to ask the client to rate his pain on a B. “You need to empty your bladder before the procedure.”
scale. In answer A, the blood pressure, pulse, and temperature can alter for C. “You will be asleep during the procedure.”
other reasons than pain. Answers C and D are not as effective in determining D. “The doctor will inject a medication to treat your illness during the
pain levels. procedure.”
Answer B is correct.
136. The client is admitted with chronic obstructive pulmonary disease. Blood The client scheduled for a pericentesis should be told to empty the bladder, to
gases reveal pH 7.36, CO45, O284, bicarb 28. The nurse would assess the client prevent the risk of puncturing the bladder when the needle is inserted. A
to be in: pericentesis is done to remove fluid from the peritoneal cavity. The client will be
A. Uncompensated acidosis positioned sitting up or leaning over an overbed table, making answer A
B. Compensated alkalosis incorrect. The client is usually awake during the procedure, and medications are
C. Compensated respiratory acidosis not commonly instilled during the procedure; thus answers C and D are
D. Uncompensated metabolic acidosis incorrect.
Answer C is correct.
The client is experiencing compensated metabolic acidosis. The pH is within the 142. The client is scheduled for a Tensilon test to check for Myasthenia Gravis.
normal range but is lower than 7.40, so it is on the acidic side. The CO 2 level is Which medication should be kept available during the test?
elevated, the oxygen level is below normal, and the bicarb level is slightly A. Atropine sulfate
elevated. In respiratory disorders, the pH will be the inverse of the CO2 B. Furosemide
and bicarb levels. This means that if the pH is low, the CO 2 and bicarb levels will C. Prostigmin
be elevated. D. Promethazine
Answers A, B, and D are incorrect because they do not fall into the range of Answer A is correct.
symptoms. Atropine sulfate is the antidote for Tensilon and is given to treat cholenergic
crises. Furosemide (answer B) is a diuretic; Prostigmin (answer C) is the
137. The schizophrenic client has become disruptive and requires seclusion. treatment for myasthenia gravis; and Promethazine (answer D) is an antiemetic,
Which staff member can institute seclusion? antianxiety medication. Thus, answers B, C, and D are incorrect.
A. The security guard
B. The registered nurse 143. The first exercise that should be performed by the client who had a
C. The licensed practical nurse mastectomy 1 day earlier is:
D. The nursing assistant A. Walking the hand up the wall
Answer B is correct. B. Sweeping the floor
The registered nurse is the only one of these who can legally put the client in C. Combing her hair
seclusion. The only other healthcare worker who is allowed to initiate seclusion D. Squeezing a ball
is the doctor; therefore, answers A, C, and D are incorrect. Answer D is correct.
The first exercise that should be done by the client with a mastectomy is
138. The physician has ordered sodium warfarin for the client with squeezing the ball. Answers A, B, and C are incorrect as the first step; they are
thrombophlebitis. The order should be entered to administer the medication at: implemented later.
A. 0900
B. 1200 144. Which woman is not a candidate for RhoGam?
C. 1700 A. A gravida 4 para 3 that is Rh negative with an Rh-positive baby
D. 2100 B. A gravida 1 para 1 that is Rh negative with an Rh-positive baby
Answer C is correct. C.A gravida II para 0 that is Rh negative admitted after a stillbirth delivery
D.A gravida 4 para 2 that is Rh negative with an Rh-negative baby If the dialysate returns cloudy, infection might be present and must be
Answer D is correct. evaluated. Documenting the finding, as stated in answer A, as not enough;
The mothers in answers A, B, and C all require RhoGam and, thus, are incorrect. straining the urine, in answer C, is incorrect; and dialysate, in answer D, is not
Answer D is the only mother who does not require a RhoGam injection. urine at all. However, the physician might order a white blood cell count.

145. Which laboratory test would be the least effective in making the diagnosis 151. The nurse employed in the emergency room is responsible for triage of four
of a myocardial infarction? clients injured in a motor vehicle accident. Which of the following clients should
A. AST receive priority in care?
B.Troponin A. A 10-year-old with lacerations of the face
C.CK-MB B. A 15-year-old with sternal bruises
D. Myoglobin C. A 34-year-old with a fractured femur
Answer A is correct. D. A 50-year-old with dislocation of the elbow
Answer A, AST, is not specific for myocardial infarction. Troponin, CK-MB, and Answer B is correct.
Myoglobin, in answers B, C, and D, are more specific, although myoglobin is also The teenager with sternal bruising might be experiencing airway and
elevated in burns and trauma to muscles. oxygenation problems and, thus, should be seen first. In answer A, the 10 year
old with lacerations has superficial bleeding. The client in answer C with a
146. The client with a myocardial infarction comes to the nurse’s station stating fractured femur should be immobilized but can be seen after the client with
that he is ready to go home because there is nothing wrong with him. Which sternal bruising. The client in answer D with the dislocated elbow can be seen
defense mechanism is the client using? later as well.
A. Rationalization
B. Denial 152. Which of the following roommates would be most suitable for the client
C. Projection with myasthenia gravis?
D. Conversion reaction A. A client with hypothyroidism
Answer B is correct. B. A client with Crohn’s disease
The client who says he has nothing wrong is in denial about his myocardial C. A client with pylonephritis
infarction. Rationalization is making excuses for what happened, projection is D. A client with bronchitis
projecting feeling or thoughts onto others, and conversion reaction is converting Answer A is correct.
a psychological trauma into a physical illness; thus, answers A, C, and D are The most suitable roommate for the client with myasthenia gravis is the client
incorrect. with hypothyroidism because he is quiet. The client with Crohn’s disease in
answer B will be up to the bathroom frequently; the client with pylonephritis in
147. The client is receiving total parenteral nutrition (TPN). Which lab test answer C has a kidney infection and will be up to urinate frequently. The client in
should be evaluated while the client is receiving TPN? answer D with bronchitis will be coughing and will disturb any roommate.
A. Hemoglobin
B. Creatinine 153. The nurse is observing a graduate nurse as she assesses the central venous
C. Blood glucose pressure. Which observation would indicate that the graduate needs further
D. White blood cell count teaching?
Answer C is correct. A. The graduate places the client in a supine position to read the manometer.
When the client is receiving TPN, the blood glucose level should be drawn. TPN B. The graduate turns the stop-cock to the off position from the IV fluid to the
is a solution that contains large amounts of glucose. Answers A, B, and D are not client.
directly related to the question and are incorrect. C. The graduate instructs the client to perform the Valsalva manuever during the
CVP reading.
148. The client with diabetes is preparing for discharge. During discharge D. The graduate notes the level at the top of the meniscus.
teaching, the nurse assesses the client’s ability to care for himself. Which Answer C is correct.
statement made by the client would indicate a need for follow-up after The client should not be instructed to do the Valsalva maneuver during central
discharge? venous pressure reading. If the nurse tells the client to perform the Valsalva
A.“I live by myself.” maneuver, he needs further teaching. Answers A, B, and D are incorrect because
B. “I have trouble seeing.” they indicate that the nurse understands the correct way to check the CVP.
C. “I have a cat in the house with me.”
D. “I usually drive myself to the doctor.” 154. The nurse is working with another nurse and a patient care assistant.
Answer B is correct. Which of the following clients should be assigned to the registered nurse?
A client with diabetes who has trouble seeing would require follow-up after A. A client 2 days post-appendectomy
discharge. The lack of visual acuity for the client preparing and injecting insulin B. A client 1 week post-thyroidectomy
might require help. Answers A, C, and D will not prevent the client from being C. A client 3 days post-splenectomy
able to care for himself and, thus, are incorrect. D. A client 2 days post-thoracotomy
Answer D is correct.
149. The client with cirrhosis of the liver is receiving Lactulose. The nurse is The most critical client should be assigned to the registered nurse; in this case,
aware that the rationale for the order for Lactulose is: that is the client 2 days post-thoracotomy. The clients in answers A and B are
A. To lower the blood glucose level ready for discharge, and the client in answer C who had a splenectomy 3 days
B. To lower the uric acid level ago is stable enough to be assigned to a PN.
C. To lower the ammonia level
D. To lower the creatinine level 155. Which of the following roommates would be best for the client newly
Answer C is correct. admitted with gastric resection?
Lactulose is administered to the client with cirrhosis to lower ammonia levels. A. A client with Crohn’s disease
Answers A, B, and D are incorrect because they do not have an effect on the B. A client with pneumonia
other lab values. C. A client with gastritis
D. A client with phlebitis
150. The client is receiving peritoneal dialysis. If the dialysate returns cloudy, the Answer D is correct.
nurse should: The most suitable roommate for the client with gastric reaction is the client with
A. Document the finding phlebitis because the client with phlebitis will not transmit any infection to the
B. Send a specimen to the lab surgical client. Crohn’s disease clients, in answer A, have frequent stools and
C. Strain the urine might transmit infections. The client in answer B with pneumonia is coughing
D. Obtain a complete blood count and will disturb the gastric client. The client with gastritis, in answer C, is
Answer B is correct. vomiting and has diarrhea, which also will disturb the gastric client.
156. The nurse is preparing a client for mammography. To prepare the client for
a mammogram, the nurse should tell the client: 162. The nurse notes the patient care assistant looking through the personal
A. To restrict her fat intake for 1 week before the test items of the client with cancer. Which action should be taken by the registered
B. To omit creams, powders, or deodorants before the exam nurse?
C. That mammography replaces the need for self-breast exams A. Notify the police department as a robbery
D. That mammography requires a higher dose of radiation than x-rays B. Report this behavior to the charge nurse
Answer B is correct. C. Monitor the situation and note whether any items are missing
The client having a mammogram should be instructed to omit deodorants or D. Ignore the situation until items are reported missing
powders beforehand because these could cause a false positive reading. Answer Answer B is correct.
A is incorrect because there is no need to restrict fat. Answer C is incorrect The best action at this time is to report the incident to the charge nurse. Further
because doing a mammogram does not replace the need for self-breast exams. action might be needed, but it will be done by the charge nurse. Answers A, C,
Answer D is incorrect because a mammogram does not require a higher dose of and D are incorrect because notifying the police is overreacting at this time, and
radiation than an x-ray. monitoring or ignoring the situation is an inadequate response.

157. Which action by the novice nurse indicates a need for further teaching? 163. Which client can best be assigned to the newly licensed nurse?
A. The nurse fails to wear gloves to remove a dressing. A. The client receiving chemotherapy
B. The nurse applies an oxygen saturation monitor to the ear lobe. B. The client post–coronary bypass
C. The nurse elevates the head of the bed to check the blood pressure. C. The client with a TURP
D. The nurse places the extremity in a dependent position to acquire a D. The client with diverticulitis
peripheral blood sample. Answer D is correct.
Answer A is correct. The best client to assign to the newly licensed nurse is the most stable client; in
The nurse who fails to wear gloves to remove a contaminated dressing needs this case, it is the client with diverticulitis. The client receiving chemotherapy
further instruction. Answers B, C, and D are incorrect because these answers and the client with a coronar y bypass both need nurses experienced in these
indicate understanding by the nurse. areas, so answers A and B are incorrect. Answer C is incorrect because the client
with a transurethral prostatectomy might bleed, so this client should be
158. The graduate nurse is assigned to care for the client on ventilator support, assigned to a nurse who knows how much bleeding is within normal limits.
pending organ donation. Which goal should receive priority?
A. Maintaining the client’s systolic blood pressure at 70mmHg or greater 164. The nurse has an order for medication to be administered intrathecally. The
B. Maintaining the client’s urinary output greater than 300cc per hour nurse is aware that medications will be administered by which method?
C. Maintaining the client’s body temperature of greater than 33°F rectal A. Intravenously
D. Maintaining the client’s hematocrit at less than 30% B. Rectally
Answer A is correct. C. Intramuscularly
When the cadaver client is being prepared to donate an organ, the systolic blood D. Into the cerebrospinal fluid
pressure should be maintained at 70mmHg or greater, to ensure a blood supply Answer D is correct.
to the donor organ. Answers B, C, and D are incorrect because these actions are Intrathecal medications are administered into the cerebrospinal fluid. This
not necessary for the donated organ to remain viable. method of administering medications is reserved for the client metastases, the
client with chronic pain, or the client with cerebrospinal infections. Answers A,
159. The nurse is assigned to care for an infant with physiologic jaundice. B, and C are incorrect because intravenous, rectal, and intramuscular injections
Which action by the nurse would facilitate elimination of the bilirubin? are entirely different procedures.
A. Increasing the infant’s fluid intake
B. Maintaining the infant’s body temperature at 98.6°F 165. The client is admitted to the unit after a cholescystectomy. Montgomery
C. Minimizing tactile stimulation straps are utilized with this client. The nurse is aware that Montgomery straps
D. Decreasing caloric intake are utilized on this client because:
Answer A is correct. A. The client is at risk for evisceration.
Bilirubin is excreted through the kidneys, thus the need for increased fluids. B. The client will require frequent dressing changes.
Maintaining the body temperature is important but will not assist in eliminating C. The straps provide support for drains that are inserted into the incision.
bilirubin; therefore, answer B is incorrect. Answers C and D are incorrect D. No sutures or clips are used to secure the incision.
because they do not relate to the question. Answer B is correct.
Montgomery straps are used to secure dressings that require frequent dressing
160. A home health nurse is planning for her daily visits. Which client should the changes because the client with a cholecystectomy usually has a large amount of
home health nurse visit first? draining on the dressing. Montgomery straps are also used for clients who are
A. A client with AIDS being treated with Foscarnet allergic to several types of tape. This client is not at higher risk of evisceration
B.A client with a fractured femur in a long leg cast than other clients, so answer A is incorrect. Montgomery straps are not used to
C.A client with laryngeal cancer with a laryngectomy secure the drains, so answer C is incorrect. Sutures or clips are used to secure
D.A client with diabetic ulcers to the left foot the wound of the client who has had gallbladder surgery, so answer D is
Answer C is correct. incorrect.
The client with laryngeal cancer has a potential airway alteration and should be
seen first. The clients in answers A, B, and D are not in immediate danger and 166. A client with pancreatitis has been transferred to the intensive care unit.
can be seen later in the day. Which order would the nurse anticipate?
A. Blood pressure every 15 minutes
161. The charge nurse overhears the patient care assistant speaking harshly to B. Insertion of a Levine tube
the client with dementia. The charge nurse should: C. Cardiac monitoring
A. Change the nursing assistant’s assignment D. Dressing changes two times per day
B. Explore the interaction with the nursing assistant Answer B is correct.
C. Discuss the matter with the client’s family The client with pancreatitis frequently has nausea and vomiting. Lavage is often
D. Initiate a group session with the nursing assistant used to decompress the stomach and rest the bowel, so the insertion of a Levine
Answer B is correct. tube should be anticipated. Answers A and C are incorrect because blood
The best action for the nurse to take is to explore the interaction with the pressures are not required ever y 15 minutes, and cardiac monitoring might be
nursing assistant. This will allow for clarification of the situation. Changing the needed, but this is individualized to the client. Answer D is incorrect because
assignment in answer A might need to be done, but talking to the nursing there are no dressings to change on this client.
assistant is the first step. Answer C is incorrect because discussing the incident
with the family is not necessary at this time; it might cause more problems than 167. The nurse is caring for a client with a diagnosis of hepatitis who is
it solves. Answer C is not a first step, even though initiating a group session experiencing pruritis. Which would be the most appropriate nursing
might be a plan for the future. intervention?
A. Suggest that the client take warm showers two times per day 173. The nurse on the 3–11 shift is assessing the chart of a client with an
B. Add baby oil to the client’s bath water abdominal aneurysm scheduled for surgery in the morning and finds that the
C. Apply powder to the client’s skin consent form has been signed, but the client is unclear about the surgery and
D. Suggest a hot-water rinse after bathing possible complications. Which is the most appropriate action?
Answer B is correct. A. Call the surgeon and ask him or her to see the client to clarify the information
Oils can be applied to help with the dry skin and to decrease itching, so adding B. Explain the procedure and complications to the client
baby oil to bath water is soothing to the skin. Answer A is incorrect because two C. Check in the physician’s progress notes to see if understanding has been
baths per day is too frequent and can cause more dryness. Answer C is incorrect documented
because powder is also drying. Rinsing with hot water, as stated in answer D, D. Check with the client’s family to see if they understand the procedure fully
dries out the skin as well. Answer A is correct.
It is the responsibility of the physician to explain and clarify the procedure to the
168. The nurse recognizes that which of the following would be most client, so the nurse should call the surgeon to explain to the client. Answers B, C,
appropriate to wear when providing direct care to a client with a cough? and D are incorrect because they are not within the nurse’s responsibility.
A. Mask
B. Gown 174. The nurse is preparing a client for surgery. Which item is most important to
C. Gloves remove before sending the client to surgery?
D. Shoe covers A. Hearing aid
Answer A is correct. B. Contact lenses
If the nurse is exposed to the client with a cough, the best item to wear is a C. Wedding ring
mask. If the answer had included a mask, gloves, and a gown, all would be D. Artificial eye
appropriate, but in this case, only one item is listed; therefore, answers B and C Answer B is correct.
are incorrect. Shoe covers are not necessar y, so answer D is incorrect. It is most important to remove the contact lenses because leaving them in can
lead to corneal drying, particularly with contact lenses that are not extended-
169. A client visits the clinic after the death of a parent. Which statement made wear lenses. Leaving in the hearing aid or artificial eye will not harm the client.
by the client’s sister signifies abnormal grieving? Leaving the wedding ring on is also allowed; usually, the ring is covered with
A. “My sister still has episodes of crying, and it’s been three months since Daddy tape. Therefore, answers A, C, and D are incorrect.
died.”
B. “Sally seems to have forgotten the bad things that Daddy did in his lifetime.” 175. A client is 2 days post-operative colon resection. After a coughing episode,
C. “She really had a hard time after Daddy’s funeral. She said that she had a the client’s wound eviscerates. Which nursing action is mostappropriate?
sense of longing.” A. Reinsert the protruding organ and cover with 4×4s
D. “She has not been saddened at all by Daddy’s death. She acts like nothing has B. Cover the wound with a sterile 4×4 and ABD dressing
happened.” C. Cover the wound with a sterile saline-soaked dressing
Answer D is correct. D. Apply an abdominal binder and manual pressure to the wound
Abnormal grieving is exhibited by a lack of feeling sad; if the client’s sister Answer C is correct.
appears not to grieve, it might be abnormal grieving. She thinks the client might If the client eviscerates, the abdominal content should be covered with a sterile
be suppressing feelings of grief. Answers A, B, and C are all normal expressions saline-soaked dressing. Reinserting the content should not be the action and will
of grief and, therefore, incorrect. require that the client return to surgery; thus, answer A is incorrect. Answers B
and D are incorrect because they not appropriate to this case.
170. The nurse is obtaining a history on an 80-year-old client. Which statement
made by the client might indicate a potential for fluid and electrolyte 176. The nurse is caring for a client with a malignancy. The classification of the
imbalance? primary tumor is Tis. The nurse should plan care for a tumor:
A.“My skin is always so dry.” A. That cannot be assessed
B. “I often use laxatives.” B. That is in situ
C. “I have always liked to drink a lot of ice tea.” C. With increasing lymph node involvement
D. “I sometimes have a problem with dribbling urine.” D. With distant metastasis
Answer B is correct. Answer B is correct.
Frequent use of laxatives can lead to diarrhea and electrolyte loss. Answers A, C, Cancer in situ means that the cancer is still localized to the primary site.
and D are not of particular significance in this case and, therefore, are incorrect. T stands for “tumor” and the IS for “in situ.” Cancer is graded in terms of tumor,
grade, node involvement, and mestatasis. Answers A, C, and D pertain to these
171. A client is admitted to the acute care unit. Initial laboratory values reveal other classifications.
serum sodium of 170meq/L. What behavior changes would be most common for
this client? 177. A client with cancer is to undergo an intravenous pyelogram. The nurse
A. Anger should:
B. Mania A. Force fluids 24 hours before the procedure
C. Depression B. Ask the client to void immediately before the study
D. Psychosis C. Hold medication that affects the central nervous system for 12 hours pre- and
Answer B is correct. post-test
The client with serum sodium of 170meq/L has hypernatremia and might exhibit D. Cover the client’s reproductive organs with an x-ray shield.
manic behavior. Answers A, C, and D are not associated with hypernatremia and Answer B is correct.
are, therefore, incorrect. A full bladder or bowel can obscure the visualization of the kidney ureters and
urethra. Answer A is incorrect because there is no need to force fluids before
172. When assessing a client for risk of hyperphosphatemia, which piece of the test. Answer C is incorrect because there is no need to withhold medication
information is most important for the nurse to obtain? for 12 hours before the test. Answer D is incorrect because the client’s
A. A history of radiation treatment in the neck region reproductive organs should not be covered.
B. Any history of recent orthopedic surgery
C. A history of minimal physical activity 178. A client arrives in the emergency room with a possible fractured femur.
D. A history of the client’s food intake The nurse should anticipate an order for:
Answer A is correct. A. Trendelenburg position
Radiation to the neck might have damaged the parathyroid glands, which are B. Ice to the entire extremity
located on the thyroid gland, interferes with calcium and phosphorus regulation. C. Buck’s traction
Answer B has no significance to this case; answers C and D are more related to D. An abduction pillow
calcium only, not to phosphorus regulation. Answer C is correct.
The client with a fractured femur will be placed in Buck’s traction to realign the
leg and to decrease spasms and pain. The Trendelenburg position is the wrong
position for this client, so answer A is incorrect. Ice might be ordered after 184. Six hours after birth, the infant is found to have an area of swelling over the
repair, but not for the entire extremity, so answer B is incorrect. An abduction right parietal area that does not cross the suture line. The nurse should chart
pillow is ordered after a total hip replacement, not for a fractured femur; this finding as:
therefore, answer D is incorrect. A. A cephalhematoma
B. Molding
179. The nurse is performing an assessment on a client with possible pernicious C. Subdural hematoma
anemia. Which data would support this diagnosis? D. Caput succedaneum
A. A weight loss of 10 pounds in 2 weeks Answer A is correct.
B. Complaints of numbness and tingling in the extremities A swelling over the right parietal area is a cephalhematoma, an area of bleeding
C. A red, beefy tongue outside the cranium. This type of hematoma does not cross the suture line.
D. A hemoglobin level of 12.0gm/dL Answer B, molding, is overlapping of the bones of the cranium and, thus,
Answer C is correct. incorrect. In answer C, a subdural hematoma, or intracranial bleeding, is
A red, beefy tongue is characteristic of the client with pernicious anemia. ominous and can be seen only on a CAT scan or x-ray. A caput succedaneum, in
Answer A, a weight loss of 10 pounds in 2 weeks, is abnormal but is not seen in answer D, crosses the suture line and is edema.
pernicious anemia. Numbness and tingling, in answer B, can be associated with
ane- mia but are not particular to pernicious anemia. This is more likely 185. A removal of the left lower lobe of the lung is performed on a client with
associated with peripheral vascular diseases involving vasculature. In answer D, lung cancer. Which post-operative measure would usually be included in the
the hemoglobin is normal and does not support the diagnosis. plan?
A. Closed chest drainage
180. A client with suspected renal disease is to undergo a renal biopsy. The B. A tracheostomy
nurse plans to include which statement in the teaching session? C. A Swan Ganz Monitor
A. “You will be sitting for the examination procedure.” D. Percussion vibration and drainage
B. “Portions of the procedure will cause pain or discomfort.” Answer A is correct.
C. “You will be asleep during the procedure.” The client with a lung resection will have chest tubes and a drainage-collection
D. “You will not be able to drink fluids for 24 hours following the study.” device. He probably will not have a tracheostomy or Swanz Ganz monitoring,
Answer B is correct. and he will not have an order for percussion, vibration, or drainage. Therefore,
Portions of the exam are painful, especially when the sample is being answers B, C, and D are incorrect.
withdrawn, so this should be included in the session with the client. Answer A is
incorrect because the client will be positioned prone, not in a sitting position, for 186. The nurse is caring for a client with laryngeal cancer. Which finding
the exam. Anesthesia is not commonly given before this test, making answer C ascertained in the health history would not be common for this diagnosis?
incorrect. Answer D is incorrect because the client can eat and drink following A. Foul breath
the test. B. Dysphagia
C. Diarrhea
181. The nurse is caring for a client scheduled for a surgical repair of a sacular D. Chronic hiccups
abdominal aortic aneurysm. Which assessment is most crucial during the Answer C is correct.
preoperative period? The client with mouth and throat cancer will have all the findings in answers A,
A. Assessment of the client’s level of anxiety B, and D except the correct answer of diarrhea.
B. Evaluation of the client’s exercise tolerance
C. Identification of peripheral pulses 187. The nurse is caring for a new mother. The mother asks why her baby has
D. Assessment of bowel sounds and activity lost weight since he was born. The best explanation of the weight loss is:
Answer C is correct. A. The baby is dehydrated.
The assessment that is most crucial to the client is the identification of B. The baby is hypoglycemic.
peripheral pulses because the aorta is clamped during surgery. This decreases C. The baby is allergic to the formula the mother is giving him.
blood circulation to the kidneys and lower extremities. The nurse must also D. A loss of 10% is normal in the first week due to meconium stools.
assess for the return of circulation to the lower extremities. Answer A is of lesser Answer D is correct.
concern, answer B is not advised at this time, and answer D is of lesser concern A loss of 10% is normal due to meconium stool and water loss. There is no
than answer A. evidence to indicate dehydration, hypoglycemia, or allergy to the infant formula;
thus, answers A, B, and C are incorrect.
182. A client in the cardiac step-down unit requires suctioning for excess mucous
secretions. The dysrhythmia most commonly seen during suctioning is: 188. The nurse is performing discharge teaching on a client with diverticulitis
A. Bradycardia who has been placed on a low-roughage diet. Which food would have to be
B. Tachycardia eliminated from this client’s diet?
C. Premature ventricular beats A. Roasted chicken
D. Heart block B. Noodles
Answer A is correct. C. Cooked broccoli
Suctioning can cause a vagal response, lowering the heart rate and causing D. Custard
bradycardia. Answers B, C and D can occur as well, but they are less likely. Answer C is correct.
The client with diverticulitis should avoid eating foods that are gas forming and
183. The nurse is performing discharge instruction to a client with an that increase abdominal discomfort, such as cooked broccoli. Foods such as
implantable defibrillator. What discharge instruction is essential? those listed in answers A, B, and D are allowed.
A. “You cannot eat food prepared in a microwave.”
B. “You should avoid moving the shoulder on the side of the pacemaker site for 189. A client has rectal cancer and is scheduled for an abdominal perineal
6 weeks.” resection. What should be the priority nursing care during the post-op period?
C. “You should use your cell phone on your right side.” A. Teaching how to irrigate the illeostomy
D. “You will not be able to fly on a commercial airliner with the defibrillator in B. Stopping electrolyte loss in the incisional area
place.” C. Encouraging a high-fiber diet
Answer C is correct. D. Facilitating perineal wound drainage
The client with an internal defibrillator should learn to use any battery-operated Answer D is correct.
machinery on the opposite side. He should also take his pulse rate and report The client with a perineal resection will have a perineal incision. Drains will be
dizziness or fainting. Answers A, B, and D are incorrect because the client can eat used to facilitate wound drainage. This will help prevent infection of the surgical
food prepared in the microwave, move his shoulder on the affected side, and fly site. The client will not have an illeostomy, as in answer A; he will have some
in an airplane. electrolyte loss, but treatment is not focused on preventing the loss, so answer
B is incorrect. A high-fiber diet, in answer C, is not ordered at this time.
190. The nurse is assisting a client with diverticulosis to select appropriate foods. C. Take the medication with water only.
Which food should be avoided? D. Allow at least 1 hour between taking the medicine and taking other
A. Bran medications.
B. Fresh peaches Answer C is correct.
C. Cucumber salad Fosamax should be taken with water only. The client should also remain upright
D. Yeast rolls for at least 30 minutes after taking the medication. Answers A, B, and D are not
Answer C is correct. applicable to taking Fosamax and, thus, are incorrect.
The client with diverticulitis should avoid foods with seeds. The foods in answers
A, B, and D are allowed; in fact, bran cereal and fruit will help prevent 197. The nurse is working in the emergency room when a client arrives with
constipation. severe burns of the left arm, hands, face, and neck. Which action should receive
priority?
191. A. Starting an IV
A 6-month-old client is admitted with possible intussuception. Which question B. Applying oxygen
during the nursing history is least helpful in obtaining information regarding this C. Obtaining blood gases
diagnosis? D. Medicating the client for pain
A. “Tell me about his pain.” Answer B is correct.
B. “What does his vomit look like?” The client with burns to the neck needs airway assessment and supplemental
C. “Describe his usual diet.” oxygen, so applying oxygen is the priority. The next action should be to start an
D. “Have you noticed changes in his abdominal size?” IV and medicate for pain, making answers A and C incorrect. Answer D,
Answer C is correct. obtaining blood gases is of less priority.
The least-helpful questions are those describing his usual diet. Answers A, B, and
D are useful in determining the extent of disease process and, thus, are 198. A 24-year-old female client is scheduled for surgery in the morning. Which
incorrect. of the following is the primary responsibility of the nurse?
A. Taking the vital signs
192. The nurse is caring for a client with epilepsy who is being treated with B. Obtaining the permit
carbamazepine (Tegretol). Which laboratory value might indicate a serious side C. Explaining the procedure
effect of this drug? D. Checking the lab work
A. Uric acid of 5mg/dL Answer A is correct.
B. Hematocrit of 33% The primar y responsibility of the nurse is to take the vital signs before any
C. WBC 2000 per cubic millimeter surgery. The actions in answers B, C, and D are the responsibility of the doctor
D. Platelets 150,000 per cubic millimeter and, therefore, are incorrect for this question.
Answer C is correct.
Tegretol can suppress the bone marrow and decrease the white blood cell 199. A client with cancer is admitted to the oncology unit. Stat lab values reveal
count; thus, a lab value of WBC 2,000 per cubic millimeter indicates side effects Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The
of the drug. Answers A and D are within normal limits, and answer B is a lower nurse evaluates that the client is experiencing which of the following?
limit of normal; therefore answers A, B, and D are incorrect. A. Hypernatremia
B. Hypokalemia
193. A client is admitted with a Ewing’s sarcoma. Which symptoms would be C. Myelosuppression
expected due to this tumor’s location? D. Leukocytosis
A. Hemiplegia Answer B is correct.
B. Aphasia The only lab result that is abnormal is the potassium. A potassium level of 1.9
C. Nausea indicates hypokalemia. The findings in answers A, C, and D are not revealed in
D. Bone pain the stem.
Answer D is correct.
Sarcoma is a type of bone cancer; therefore, bone pain would be expected. 200. The nurse is caring for a client scheduled for removal of the pituitary gland.
Answers A, B, and C are not specific to this type of cancer and are incorrect. The nurse should be particularly alert for:
A. Nasal congestion
194. A infant weighs 7 pounds at birth. The expected weight by 1 year should be: B. Abdominal tenderness
A. 10 pounds C. Muscle tetany
B. 12 pounds D. Oliguria
C. 18 pounds Answer A is correct.
D. 21 pounds Removal of the pituitary gland is usually done by a transphenoidal approach,
Answer D is correct. through the nose. Nasal congestion further interferes with the airway. Answers
A birth weight of 7 pounds would indicate 21 pounds in 1 year, or triple his birth B, C, and D are not correct because they are not directly associated with the
weight. Answers A, B, and C therefore are incorrect. pituitary gland.

195. The nurse is making initial rounds on a client with a C5 fracture and 201. A client has cancer of the liver. The nurse should be most concerned about
crutchfield tongs. Which equipment should be kept at the bedside? which nursing diagnosis?
A. A pair of forceps A. Alteration in nutrition
B. A torque wrench B. Alteration in urinary elimination
C. A pair of wire cutters C. Alteration in skin integrity
D. A screwdriver D. Ineffective coping
Answer B is correct. Answer A is correct.
A torque wrench is kept at the bedside to tighten and loosen the screws of Cancer of the liver frequently leads to severe nausea and vomiting, thus the
crutchfield tongs. This wrench controls the amount of pressure that is placed on need for altering nutritional needs. The problems in answers B, C, and D are of
the screws. A pair of forceps, wire cutters, and a screwdriver, in answers A, C, lesser concern and, thus, are incorrect in this instance.
and D, would not be used and, thus, are incorrect. Wire cutters should be kept
with the client who has wired jaws. 202. The nurse is caring for a client with ascites. Which is the best method to use
for determining early ascites?
196. The nurse is visiting a home health client with osteoporosis. The client has a A. Inspection of the abdomen for enlargement
new prescription for alendronate (Fosamax). Which instruction should be given B. Bimanual palpation for hepatomegaly
to the client? C. Daily measurement of abdominal girth
A. Rest in bed after taking the medication for at least 30 minutes. D. Assessment for a fluid wave
B. Avoid rapid movements after taking the medication. Answer C is correct.
Daily measuring of the abdominal girth is the best method of determining early 208. A client being treated with sodium warfarin has an INR of 8.0. Which
ascites. Measuring with a paper tape measure and marking the measured area is intervention would be most important to include in the nursing care plan?
the most objective method of estimating ascites. Inspection and checking for A. Assess for signs of abnormal bleeding
fluid waves, in answers A and D, are more subjective and, thus, are incorrect for B. Anticipate an increase in the Coumadin dosage
this question. Palpation of the liver, in answer B, will not tell the amount of C. Instruct the client regarding the drug therapy
ascites. D. Increase the frequency of neurological assessments
Answer A is correct.
203. The client arrives in the emergency department after a motor vehicle An INR of 8 indicates that the blood is too thin. The normal INR is 2.0–3.0, so
accident. Nursing assessment findings include BP 68/34, pulse rate 130, and answer B is incorrect because the doctor will not increase the dosage of
respirations 18. Which is the client’s most appropriate priority nursing coumadin. Answer C is incorrect because now is not the time to instruct the
diagnosis? client about the therapy. Answer D is not correct because there is no need to
A. Alteration in cerebral tissue perfusion increase the neurological assessment.
B. Fluid volume deficit
C. Ineffective airway clearance 209. Which snack selection by a client with osteoporosis indicates that the client
D. Alteration in sensory perception understands the dietary management of the disease?
Answer B is correct. A. A granola bar
The vital signs indicate hypovolemic shock or fluid volume deficit. In answers A, B. A bran muffin
C, and D, cerebral tissue perfusion, airway clearance, and sensory perception C. Yogurt
alterations are not symptoms and, therefore, are incorrect. D. Raisins
Answer C is correct.
204. The home health nurse is visiting a 15-year-old with sickle cell disease. The food indicating the client’s understanding of dietary management of
Which information obtained on the visit would cause the most concern? The osteoporosis is the yogurt, with approximately 400mg of calcium. The other
client: foods are good choices, but not as good as the yogurt; therefore, answers A, B,
A. Likes to play baseball and D are incorrect.
B. Drinks several carbonated drinks per day
C. Has two sisters with sickle cell trait 210. The client with preeclampsia is admitted to the unit with an order for
D. Is taking Tylenol to control pain magnesium sulfate IV. Which action by the nurse indicates a lack of
Answer A is correct. understanding of magnesium sulfate?
The client with sickle cell is likely to experience symptoms of hypoxia if he A. The nurse places a sign over the bed not to check blood pressures in the left
becomes dehydrated or lacks oxygen. Extreme exercise, especially in warm arm.
weather, can exacerbate the condition, so the fact that the client plays baseball B. The nurse obtains an IV controller.
should be of great concern to the visiting nurse. Answers B, C, and D are not C. The nurse inserts a Foley catheter.
factors for concern with sickle cell disease. D. The nurse darkens the room.
Answer A is correct.
205. The nurse on oncology is caring for a client with a white blood count of 600. There is no need to avoid taking the blood pressure in the left arm. Answers B, C,
During evening visitation, a visitor brings a potted plant. What action should the and D are all actions that should be taken for the client receiving magnesium
nurse take? sulfate for preeclampsia.
A. Allow the client to keep the plant
B. Place the plant by the window 211. The nurse is caring for a 12-year-old client with appendicitis. The client’s
C. Water the plant for the client mother is a Jehovah’s Witness and refuses to sign the blood permit. What
D. Tell the family members to take the plant home nursing action is most appropriate?
Answer D is correct. A. Give the blood without permission
The client with neutropenia should not have potted or cut flowers in the room. B. Encourage the mother to reconsider
Cancer patients are extremely susceptible to bacterial infections. Answers A, B, C. Explain the consequences without treatment
and C will not help to prevent bacterial invasions and, therefore, are incorrect. D. Notify the physician of the mother’s refusal
Answer D is correct.
206. The nurse is caring for the client following a thyroidectomy when suddenly If the client’s mother refuses the blood transfusion, the doctor should be
the client becomes nonresponsive and pale, with a BP of 60 systolic. The nurse’s notified. Because the client is a minor, the court might order treatment. Answer
initial action should be to: A is incorrect because the mother is the legal guardian and can refuse the blood
A. Lower the head of the bed transfusion to be given to her daughter. Answers B and C are incorrect because
B. Increase the infusion of normal saline it is not the primary responsibility of the nurse to encourage the mother to
C. Administer atropine IV consent or explain the consequences.
D. Obtain a crash cart
Answer B is correct. 212. A client is admitted to the unit 2 hours after an injury with second-degree
Clients who have not had surgery to the face or neck would benefit from burns to the face, trunk, and head. The nurse would be most concerned with the
lowering the head of the bed, as in answer A. However, in this situation lowering client developing what?
the client’s head could further interfere with the airway. Therefore, the best A. Hypovolemia
answer is answer B, increasing the infusion and placing the client in supine B. Laryngeal edema
position. Answers C and D are not necessar y at this time. C. Hypernatremia
D. Hyperkalemia
Answer B is correct.
207. The client pulls out the chest tube and fails to report the occurrence to the The nurse should be most concerned with laryngeal edema because of the area
nurse. When the nurse discovers the incidence, he should take which initial of burn. Answer A is of secondary priority. Hyponatremia and hypokalemia are
action? also of concern but are not the primary concern; thus, answers C and D are
A. Order a chest x-ray incorrect.
B. Reinsert the tube
C. Cover the insertion site with a Vaseline gauze 213. The nurse is evaluating nutritional outcomes for an elderly client with
D. Call the doctor anorexia nervosa. Which data best indicates that the plan of care is effective?
Answer C is correct. A. The client selects a balanced diet from the menu.
If the client pulls the chest tube out of the chest, the nurse should first cover the B. The client’s hematocrit improves.
insertion site with an occlusive dressing, such as a Vaseline gauze. Then the C. The client’s tissue turgor improves.
nurse should call the doctor, who will order a chest x-ray and possibly reinsert D. The client gains weight.
the tube. Answers A, B, and D are not the first priority in this case. Answer D is correct.
The client with anorexia shows the most improvement by weight gain. Selecting
a balanced diet is useless if the client does not eat the diet, so answer A is 219. The nurse is teaching the mother regarding treatment for enterobiasis.
incorrect. The hematocrit, in answer B, might improve by several means, such as Which instruction should be given regarding the medication?
blood transfusion, but that does not indicate improvement in the anorexic A. Treatment is not recommended for children less than 10 years of age.
condition, so B is incorrect. The tissue turgor indicates fluid, not improvement of B. The entire family should be treated.
anorexia, so answer C is incorrect. C. Medication therapy will continue for 1 year.
D. Intravenous antibiotic therapy will be ordered.
214. The client is admitted following repair of a fractured tibia and cast Answer B is correct.
application. Which nursing assessment should be reported to the doctor? Erterobiasis, or pinworms, is treated with Vermox (mebendazole) or Antiminth
A. Pain beneath the cast (pyrantel pamoate). The entire family should be treated, to ensure that no eggs
B. Warm toes remain. Because a single treatment is usually sufficient, there is usually good
C. Pedal pulses weak and rapid compliance. The family should then be tested again in 2 weeks, to ensure that
D. Paresthesia of the toes no eggs remain. Answers A, C, and D are inappropriate for this treatment and,
Answer D is correct. therefore, incorrect.
Paresthesia of the toes is not normal and can indicate compartment syndrome.
At this time, pain beneath the cast is normal and, thus, would not be reported as 220. The registered nurse is making assignments for the day. Which client should
a concern. The client’s toes should be warm to the touch, and pulses should be not be assigned to the pregnant nurse?
present. Answers A, B, and C, then, are incorrect. A. The client receiving linear accelerator radiation therapy for lung cancer
B. The client with a radium implant for cer vical cancer
215. The client is having a cardiac catheterization. During the procedure, the C. The client who has just been administered soluble brachytherapy for thyroid
client tells the nurse, “I’m feeling really hot.” Which response would be best? cancer
A. “You are having an allergic reaction. I will get an order for Benadryl.” D. The client who returned from an intravenous pyelogram
B. “That feeling of warmth is normal when the dye is injected.” Answer B is correct.
C. “That feeling of warmth indicates that the clots in the coronary vessels are The pregnant nurse should not be assigned to any client with radioactivity
dissolving.” present, and the client with a radium implant poses the most risk to the
D. “I will tell your doctor and let him explain to you the reason for the hot pregnant nurse. The clients in answers A, C, and D are not radioactive; therefore,
feeling that you are experiencing.” these answers are incorrect.
Answer B is correct.
The best response from the nurse is to let the client know that it is normal to 221. Which client is at risk for opportunistic diseases such as pneumocystis
have a warm sensation when dye is injected for this procedure. Answers A, C, pneumonia?
and D indicate that the nurse believes that the hot feeling is abnormal and, so, A. The client with cancer who is being treated with chemotherapy
are incorrect. B. The client with Type I diabetes
C. The client with thyroid disease
216. Which action by the healthcare worker indicates a need for further D. The client with Addison’s disease
teaching? Answer A is correct.
A. The nursing assistant wears gloves while giving the client a bath. The client with cancer being treated with chemotherapy is immune suppressed
B. The nurse wears goggles while drawing blood from the client. and is at risk for opportunistic diseases such as pneumocystis. Answers B, C, and
C. The doctor washes his hands before examining the client. D are incorrect because these clients are not at a higher risk for opportunistic
D. The nurse wears gloves to take the client’s vital signs. diseases than other clients.
Answer D is correct.
It is not necessary to wear gloves when taking the vital signs of the client, thus 222. The nurse caring for a client in the neonatal intensive care unit administers
indicating further teaching for the nursing assistant. If the client has an active adult-strength Digitalis to the 3-pound infant. As a result of her actions, the baby
infection with methicillin-resistant staphylococcus aureus, gloves should be suffers permanent heart and brain damage. The nurse can be charged with:
worn, but this is not indicated in this instance. The actions in answers A, B, and C A. Negligence
are incorrect because they are indicative of infection control not mentioned in B. Tort
the question. C. Assault
D. Malpractice
217. The client is having electroconvulsive therapy for treatment of severe Answer D is correct.
depression. Which of the following indicates that the client’s ECT has been Injecting an infant with an adult dose of Digitalis is considered malpractice, or
effective? failing to perform or per forming an act that causes harm to the client. In answer
A. The client loses consciousness. A, negligence is failing to perform care for the client and, thus, is incorrect. In
B. The client vomits. answer B, a tort is a wrongful act committed on the client or his belongings but,
C. The client’s ECG indicates tachycardia. in this case, was accidental. Assault, in answer C, is not pertinent to this incident.
D. The client has a grand mal seizure.
Answer D is correct. 223. Which assignment should not be performed by the registered nurse?
During ECT, the client will have a grand mal seizure. This indicates completion of A. Inserting a Foley catheter
the electroconvulsive therapy. Answers A, B, and C are incorrect because they B. Inserting a nasogastric tube
do not indicate that the ECT has been completed. C. Monitoring central venous pressure
D. Inserting sutures and clips in surgery
218. The 5-year-old is being tested for enterobiasis (pinworms). To collect a Answer D is correct.
specimen for assessment of pinworms, the nurse should teach the mother to: The registered nurse cannot insert sutures or clips unless specially trained to do
A. Place tape on the child’s perianal area before putting the child to bed so, as in the case of a nurse practitioner skilled to perform this task. The
B. Scrape the skin with a piece of cardboard and bring it to the clinic registered nurse can insert a Foley catheter, insert a nasogastric tube, and
C. Obtain a stool specimen in the afternoon monitor central venous pressure.
D. Bring a hair sample to the clinic for evaluation
Answer A is correct. 224. The client returns to the unit from surgery with a blood pressure of 90/50,
An infection with pinworms begins when the eggs are ingested or inhaled. The pulse 132, respirations 30. Which action by the nurse should receive priority?
eggs hatch in the upper intestine and mature in 2–8 weeks. The females then A. Document the finding.
mate and migrate out the anus, where they lay up to 17,000 eggs, causing B. Contact the physician.
intense itching. The mother should be told to use a flashlight to examine the C. Elevate the head of the bed.
rectal area about 2–3 hours after the child is asleep. Placing clear tape on a D. Administer a pain medication.
tongue blade will allow the eggs to adhere to the tape. The specimen should Answer B is correct.
then be evaluated in a lab. There is no need to scrape the skin, collect a stool The vital signs are abnormal and should be reported to the doctor immediately.
specimen, or bring a sample of hair; therefore, answers B, C, and D are incorrect. A, B, and D are incorrect actions.
 B. The child should be allowed to instill his own eyedrops.
225. Which nurse should be assigned to care for the postpartal client with C. Allow the mother to instill the eyedrops.
preeclampsia? D. If the eye is clear from any redness or edema, the eyedrops should be held.
A. The RN with 2 weeks of experience in postpartum Answer A is correct.
B. The RN with 3 years of experience in labor and delivery Before instilling eyedrops, the nurse should cleanse the area with warm water. A
C. The RN with 10 years of experience in surgery 6-year-old child is not developmentally ready to instill his own eyedrops, so
D. The RN with 1 year of experience in the neonatal intensive care unit answer B is incorrect. The mother cannot be allowed to administer the eye
Answer B is correct. drops in the hospital setting so answer C incorrect. Although the eye might
The nurse in answer B has the most experience in knowing possible appear to be clear, the nurse should instill the eyedrops, as ordered (answer D).
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 231. To assist with the prevention of urinary tract infections, the teenage girl
postpartum client. should be taught to:
A. Drink citrus fruit juices
226. Which medication is used to treat iron toxicity? B. Avoid using tampons
A. Narcan (naloxane) C. Take showers instead of tub baths
B. Digibind (digoxin immune Fab) D. Clean the perineum from front to back
C. Desferal (deferoxamine) Answer D is correct.
D. Zinecard (dexrazoxane) To prevent urinary tract infections, the girl should clean the perineum from front
Answer C is correct. to back to prevent e. coli contamination. Answer A is incorrect because drinking
Desferal is used to treat iron toxicity. Answers A, B, and D are incorrect because citrus juices will not prevent UTIs. Answers B and C are incorrect because UTI’s
they are antidotes for other drugs: Narcan is used to treat narcotic overdose; are not associated with the use of tampons or with tub baths.
Digibind is used to treat dioxin toxicity; and Zinecard is used to treat doxorubicin
toxicity. 232. A 2-year-old toddler is admitted to the hospital. Which of the following
nursing interventions would you expect?
227. The nurse is suspected of charting medication administration that he did A. Ask the parent/guardian to leave the room when assessments are being
not give. The nurse can be charged with: performed.
A. Fraud B. Ask the parent/guardian to take the child’s favorite blanket home because
B. Malpractice anything from the outside should not be brought into the hospital.
C. Negligence C. Ask the parent/guardian to room-in with the child.
D. Tort D. If the child is screaming, tell him this is inappropriate behavior.
Answer A is correct. Answer C is correct.
If the nurse charts information that he did not perform, she can be charged with The nurse should encourage rooming in, to promote parent-child attachment. It
fraud. Answer B is incorrect because malpractice is harm that results to the is okay for the parents to be in the room for assessment of the child, so answer
client due to an erroneous action taken by the nurse. Answer C is incorrect A is incorrect. Allowing the child to have items that are familiar to him is allowed
because negligence is failure to perform a duty that the nurse knows should be and encouraged; thus, answer B is incorrect. Answer D is incorrect and shows a
performed. Answer D is incorrect because a tort is a wrongful act to the client or lack of empathy for the child’s distress; it is an inappropriate response from the
his belongings. nurse.

228. The home health nurse is planning for the day’s visits. Which client should 233. Which instruction should be given to the client who is fitted for a behind-
be seen first? the-ear hearing aid?
A. The client with renal insufficiency A. Remove the mold and clean every week.
B. The client with Alzheimer’s B. Store the hearing aid in a warm place.
C. The client with diabetes who has a decubitus ulcer C. Clean the lint from the hearing aid with a toothpick.
D. The client with multiple sclerosis who is being treated with IV cortisone D. Change the batteries weekly.
Answer D is correct. Answer B is correct.
The client who should receive priority is the client with multiple sclerosis and The hearing aid should be stored in a warm, dry place and should be cleaned
who is being treated with IV cortisone. This client is at highest risk for daily. A toothpick is inappropriate to clean the aid because it might break off in
complications. Answers A, B, and C are incorrect because these clients are more the hearing aide. Changing the batteries weekly is not necessary; therefore,
stable and can be seen later. answers A, C, and D are incorrect.

229. The emergency room is flooded with clients injured in a tornado. Which 234. A priority nursing diagnosis for a child being admitted from surgery
clients can be assigned to share a room in the emergency department during the following a tonsillectomy is:
disaster? A. Body image disturbance
A. A schizophrenic client having visual and auditory hallucinations and the client B. Impaired verbal communication
with ulcerative colitis C. Risk for aspiration
B. The client who is six months pregnant with abdominal pain and the client with D. Pain
facial lacerations and a broken arm Answer C is correct.
C. A child whose pupils are fixed and dilated and his parents, and a client with a Always remember your ABC’s (air way, breathing, circulation) when selecting an
frontal head injury answer. Although answers B and D might be appropriate for this child, answer C
D. The client who arrives with a large puncture wound to the abdomen and the should have the highest priority. Answer A does not apply for a child who has
client with chest pain undergone a tonsillectomy.
Answer B is correct.
Out of all of these clients, it is best to place the pregnant client and the client 235. A client with bacterial pneumonia is admitted to the pediatric unit. What
with a broken arm and facial lacerations in the same room. These two clients would the nurse expect the admitting assessment to reveal?
probably do not need immediate attention and are least likely to disturb each A. High fever
other. The clients in answers A, C, and D need to be placed in separate rooms B. Nonproductive cough
because their conditions are more serious, they might need immediate C. Rhinitis
attention, and they are more likely to disturb other patients. D. Vomiting and diarrhea
Answer A is correct.
230. The nurse is caring for a 6-year-old client admitted with the diagnosis of If the child has bacterial pneumonia, a high fever is usually present. Bacterial
conjunctivitis. Before administering eyedrops, the nurse should recognize that it pneumonia usually presents with a productive cough, so answer B is incorrect.
is essential to consider which of the following? Rhinitis, as stated in answer C, is often seen with viral pneumonia and is
A. The eye should be cleansed with warm water, removing any exudate, before incorrect for this case. Vomiting and diarrhea are usually not seen with
instilling the eyedrops. pneumonia; thus, answer D is incorrect.
 Answer D is correct.
236. The nurse is caring for a client admitted with acute The client is usually given epidural anesthesia at approximately three
laryngotracheobronchitis (LTB). Because of the possibility of complete centimeters dilation. Answer A is vague, answer B would indicate the end of the
obstruction of the airway, which of the following should the nurse have first stage of labor, and answer C indicates the transition phase, not the latent
available? phase of labor.
A. Intravenous access supplies
B. Emergency intubation equipment 242. The client is having fetal heart rates of 100–110 beats per minute during
C. Intravenous fluid-administration pump the contractions. The first action the nurse should take is to:
D. Supplemental oxygen A. Apply an internal monitor
Answer B is correct. B. Turn the client to her side
For a child with LTB and the possibility of complete obstruction of the airway, C. Get the client up and walk her in the hall
emergency intubation equipment should always be kept at the bedside. D. Move the client to the delivery room
Intravenous supplies and fluid will not treat an obstruction, nor will Answer B is correct.
supplemental oxygen; therefore, answers A, C, and D are incorrect. The normal fetal heart rate is 120–160bpm. A heart rate of 100–110bpm is
bradycardia. The first action would be to turn the client to the left side and apply
237. A 5-year-old client with hyperthyroidism is admitted to the pediatric unit. oxygen. Answer A is not indicated at this time. Answer C is not the best action
What would the nurse expect the admitting assessment to reveal? for clients experiencing bradycardia. There is no data to indicate the need to
A. Bradycardia move the client to the delivery room at this time, so answer D is incorrect as
B. Decreased appetite well.
C. Exophthalmos
D. Weight gain 243. In evaluating the effectiveness of IV Pitocin for a client with secondary
Answer C is correct. dystocia, the nurse should expect:
Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. The A. A rapid delivery
client with hyperthyroidism will often exhibit tachycardia, increased appetite, B. Cervical effacement
and weight loss. Answers A, B, and D are not associated with hyperthyroidism. C. Infrequent contractions
D. Progressive cervical dilation
238. The nurse is providing dietary instructions to the mother of an 8-year-old Answer D is correct.
child diagnosed with celiac disease. Which of the following foods, if selected by The expected effect of Pitocin is progressive cer vical dilation. Pitocin causes
the mother, would indicate her understanding of the dietary instructions? more intense contractions, which can increase the pain; thus, answer A is
A. Whole-wheat bread incorrect. Answers B and C are incorrect because cervical effacement is caused
B. Spaghetti by pressure on the presenting part and there are not infrequent contractions.
C. Hamburger on wheat bun with ketchup
D. Cheese omelet 244. A vaginal exam reveals a breech presentation in a newly admitted client.
Answer D is correct. The nurse should take which of the following actions at this time?
The child with celiac disease should be on a gluten-free diet. Answer D is the A. Prepare the client for a caesarean section
only choice of foods that do not contain gluten. Therefore, answers A, B, and C B. Apply the fetal heart monitor
are incorrect. C. Place the client in the Trendelenburg position
D. Perform an ultrasound exam
239. The nurse is caring for a 9-year-old child admitted with asthma. Upon the Answer B is correct.
morning rounds, the nurse finds an O2 sat of 78%. Which of the following Applying a fetal heart monitor is the appropriate action at this time. Preparing
actions should the nurse take first? for a caesarean section is premature; placing the client in Trendelenburg is also
A. Notify the physician not an indicated action, and an ultrasound is not needed based on the finding.
B. Do nothing; this is a normal O2 sat for a 9-year-old Therefore, answer B is the best answer, and answers A, C, and D are
C. Apply oxygen incorrect.
D. Assess the child’s pulse
Answer C is correct. 245. The nurse is caring for a client admitted to labor and delivery. The nurse is
Remember the ABC’s (air way, breathing, circulation) when answering this aware that the infant is in distress if she notes:
question. Before notifying the physician or assessing the child’s pulse, oxygen A. Contractions every three minutes
should be applied to increase the child’s oxygen saturation. The normal oxygen B. Absent variability
saturation for a child is 92%–100%. Answer A is important but not the priority, C. Fetal heart tone accelerations with movement
answer B is inappropriate, and answer D is also not the priority. D. Fetal heart tone 120–130bpm
Answer B is correct.
240. A gravida II para 0 is admitted to the labor and delivery unit. The doctor Absent variability is not normal and could indicate a neurological problem.
performs an amniotomy. Which observation would the nurse expect to make Answers A, C, and D are normal findings.
immediately after the amniotomy?
A. Fetal heart tones 160 beats per minute 246. The following are all nursing diagnoses appropriate for a gravida 4 para 3 in
B. A moderate amount of clear fluid labor. Which one would be most appropriate for the client as she completes the
C. A small amount of greenish fluid latent phase of labor?
D. A small segment of the umbilical cord A. Impaired gas exchange related to hyperventilation
Answer B is correct. B. Alteration in placental perfusion related to maternal position
Normal amniotic fluid is straw colored and odorless, so this is the observation C. Impaired physical mobility related to fetal-monitoring equipment
the nurse should expect. An amniotomy is artificial rupture of membranes, D. Potential fluid volume deficit related to decreased fluid intake
causing a straw-colored fluid to appear in the vaginal area. Fetal heart tones of Answer D is correct.
160 indicate tachycardia, and this is not the observation to watch for. Greenish Clients admitted in labor are told not to eat during labor, to avoid nausea and
fluid is indicative of meconium, not amniotic fluid. If the nurse notes the vomiting. Ice chips might be allowed, although this amount of fluid might not be
umbilical cord, the client is experiencing a prolapsed cord. This would need to be sufficient to prevent fluid volume deficit. In answer A, impaired gas exchange
reported immediately. For this question, answers A, C, and D are incorrect. related to hyperventilation would be indicated during the transition phase, not
the early phase of labor. Answers B and C are not correct because clients during
241. The client is admitted to the unit. A vaginal exam reveals that she is 3cm labor are allowed to change position as she desires.
dilated. Which of the following statements would the nurse expect her to make?
A. “I can’t decide what to name the baby.” 247. As the client reaches 8cm dilation, the nurse notes a pattern on the fetal
B. “It feels good to push with each contraction.” monitor that shows a drop in the fetal heart rate of 30bpm beginning at the
C. “Don’t touch me. I’m tr ying to concentrate.” peak of the contraction and ending at the end of the contraction. The FHR
D. “When can I get my epidural?”
baseline is 165–175bpm with variability of 0–2bpm. What is the most likely
explanation of this pattern?
A. The baby is asleep.
B. The umbilical cord is compressed.
C. There is a vagal response.
D. There is uteroplacental insufficiency.
Answer D is correct.
This information indicates a late deceleration. This type of deceleration is caused
by uteroplacental insufficiency, or lack of oxygen. Answer A is incorrect because
there is no data to support the conclusion that the baby is asleep; answer B
results in a variable deceleration; and answer C is indicative of an early
deceleration.

248. The nurse notes variable decelerations on the fetal monitor strip. The most
appropriate initial action would be to:
A. Notify her doctor
B. Increase the rate of IV fluid
C. Reposition the client
D. Readjust the monitor
Answer C is correct.
The initial action by the nurse observing a variable deceleration should be to
turn the client to the side, preferably the left side. Administering oxygen is also
indicated. Answer A is not called for at this time. Answer B is incorrect because it
is not needed, and answer D is incorrect because there is no data to indicate
that the monitor has been applied incorrectly.

249. Which of the following is a characteristic of a reassuring fetal heart rate

pattern?
A. A fetal heart rate of 180bpm
B. A baseline variability of 35bpm
C. A fetal heart rate of 90 at the baseline
D. Acceleration of FHR with fetal movements
Answer D is correct.
Answers A, B, and C indicate ominous findings on the fetal heart monitor and so
are incorrect in this instance. Accelerations with movement are normal, so
answer D is the reassuring pattern.

250. The nurse asks the client with an epidural anesthesia to void every hour
during labor. The rationale for this intervention is:
A. The bladder fills more rapidly because of the medication used for the
epidural.
B. Her level of consciousness is altered.
C. The sensation of the bladder filling is diminished or lost.
D. She is embarrassed to ask for the bedpan that frequently.
Answer C is correct.
Epidural anesthesia decreases the urge to void and sensation of a full bladder. A
full bladder decreases the progression of labor. Answers A, B, and D are
incorrect because the bladder does not fill more rapidly due to the epidural, the
client is not in a trancelike state, and the client’s level of consciousness is not
altered, and there is no evidence that the client is too embarrassed to ask for a
bedpan.
 The client taking calcium preparations will frequently develop constipation.
Answers B, C, and D do not apply.

11. Answer C is correct.

C indicates a lack of understanding of the correct method of administering
heparin. A, B, and D indicate understanding and are, therefore, incorrect
answers.

12. Answer C is correct.

If the finger cannot be used, the next best place to apply the oxygen monitor is
Answers and Rationales the earlobe. It can also be placed on the forehead, but the choices in answers A,
1. Answer B is correct.
B, and D will not provide the needed readings.
The client with passive-aggressive personality disorder often has underlying
hostility that is exhibited as acting-out behavior. Answers A, C, and D are
13. Answer A is correct.
incorrect. Although these individuals might have a high IQ, it cannot be said that
The client is exhibiting a widened pulse pressure, tachycardia, and tachypnea.
they have superior intelligence. They also do not necessarily have dependence
The next action after obtaining these vital signs is to notify the doctor for
on others or an inability to share feelings.
additional orders. Rechecking the vital signs, as in answer B, is wasting time. The
doctor may order arterial blood gases and an ECG.
2. Answer A is correct.
Clients with antisocial personality disorder must have limits set on their behavior
14. Answer C is correct.
because they are artful in manipulating others. Answer B is not correct because
The client with a femoral popliteal bypass graft should avoid activities that can
they do express feelings and remorse. Answers C and D are incorrect because it
occlude the femoral artery graft. Sitting in the straight chair and wearing tight
is unnecessary to minimize interactions with others or encourage them to act
clothes are prohibited for this reason. Resting in a supine position, resting in a
out rage more than they already do.
recliner, or sleeping in right Sim’s are allowed, as stated in answers A, B, and D.
3. Answer C is correct.
15. Answer A is correct.
To prevent the client from inducing vomiting after eating, the client should be
The best time to apply antithrombolytic stockings is in the morning before rising.
observed for 1–2 hours after meals. Allowing privacy as stated in answer A will
If the doctor orders them later in the day, the client should return to bed, wait
only give the client time to vomit. Praising the client for eating all of a meal does
30 minutes, and apply the stockings. Answers B, C, and D are incorrect because
not correct the psychological aspects of the disease; thus, answer B is incorrect.
there is likely to be more peripheral edema if the client is standing or has just
Encouraging the client to choose favorite foods might increase stress and the
taken a bath; before retiring in the evening is wrong because late in the evening,
chance of choosing foods that are low in calories and fats so D is not correct.
more peripheral edema will be present.
4. Answer B is correct.
16. Answer C is correct.
The 4-year-old is more prone to accidental poisoning because children at this
The client admitted 1 hour ago with shortness of breath should be seen first
age are much more mobile. Answers A, C, and D are incorrect because the 6-
because this client might require oxygen therapy. The client in answer A with an
month-old is still too small to be extremely mobile, the 12-year-old has begun to
oxygen saturation of 99% is stable. Answer B is incorrect because this client will
understand risk, and the 13-year-old is also aware that injuries can occur and is
have some inflammatory process after surgery, so a temperature of 100.2°F is
less likely to become injured than the 4-year-old.
not unusual. The client in answer D is stable and can be seen later.
5. Answer B is correct.
17. Answer A is correct.
Parallel play is play that is demonstrated by two children playing side by side but
The best roommate for the post-surgical client is the client with hypothyroidism.
not together. The play in answers A and C is participative play because the
This client is sleepy and has no infectious process. Answers B, C, and D are
children are playing together. The play in answer D is solitary play because the
incorrect because the client with a diabetic ulcer, ulcerative colitis, or
mother is not playing with Mar y.
pneumonia can transmit infection to the post-surgical client.
6. Answer B is correct.
18. Answer C is correct.
The first action that the nurse should take when beginning to examine the infant
The client taking an anticoagulant should not take aspirin because it will further
is to listen to the heart and lungs. If the nurse elicits the Babinski reflex, palpates
increase bleeding. He should return to have a Protime drawn for bleeding time,
the abdomen, or looks in the child’s ear first, the child will begin to cry and it will
report a rash, and use an electric razor. Therefore, answers A, B, and D are
be difficult to obtain an objective finding while listening to the heart and lungs.
incorrect.
Therefore, answers A, C, and D are incorrect.
19. Answer B is correct.
7. Answer B is correct.
Because the aorta is clamped during surgery, the blood supply to the kidneys is
A 2-year-old is expected only to use magical thinking, such as believing that a toy
impaired. This can result in renal damage. A urinary output of 20mL is oliguria. In
bear is a real bear. Answers A, C, and D are not expected until the child is much
answer A, the pedal pulses that are thready and regular are within normal limits.
older. Abstract thinking, conservation of matter, and the ability to look at things
For answer C, it is desirable for the client’s blood pressure to be slightly
from the perspective of others are not skills for small children.
low after surgical repair of an aneurysm. The oxygen saturation of 97% in answer
D is within normal limits and, therefore, incorrect.
8. Answer C is correct.
Children at 24 months can verbalize their needs. Answers A and B are incorrect
20. Answer D is correct.
because children at 24 months understand yes and no, but they do not
When assisting the client with bowel and bladder training, the least helpful
understand the meaning of all words. Answer D is incorrect; asking “why?”
factor is the sexual function. Dietary history, mobility, and fluid intake are
comes later in development.
important factors; these must be taken into consideration because they relate
to constipation, urinary function, and the ability to use the urinal or bedpan.
9. Answer D is correct.
Therefore, answers A, B, and C are incorrect.
Urokinase is a thrombolytic used to destroy a clot following a myocardial
infraction. If the client exhibits overt signs of bleeding, the nurse should stop the
21. Answer B is correct.
medication, call the doctor immediately, and prepare the antidote, which is
To correctly measure the client for crutches, the nurse should measure
Amicar. Answer B is not correct because simply stopping the urokinase is not
approximately 3 inches under the axilla. Answer A allows for too much distance
enough. In answer A, vitamin K is not the antidote for urokinase, and reducing
under the arm. The elbows should be flexed approximately 35°, not 10°, as
the urokinase, as stated in answer B, is not enough.
stated in answer C. The crutches should be approximately 6 inches from the side
of the foot, not 20 inches, as stated in answer D.
10. Answer A is correct.
22. Answer C is correct. ventricular fibrillation. Also, defibrillation should begin at 200 joules and be
The temporal lobe is responsible for taste, smell, and hearing. The occipital lobe increased to 360 joules.
is responsible for vision. The frontal lobe is responsible for judgment, foresight,
and behavior. The parietal lobe is responsible for ideation, sensory functions, 34. Answer B is correct.
and language. Therefore, answers A, B, and D are incorrect. The client should be asked to perform the Valsalva maneuver while the chest
tube is being removed. This prevents changes in pressure until an occlusive
23. Answer A is correct. dressing can be applied. Answers A and C are not recommended, and sneezing is
Damage to the hypothalamus can result in an elevated temperature because difficult to perform on command.
this portion of the brain helps to regulate body temperature. Answers B, C, and
D are incorrect because there is no data to support the possibility of an 35. Answer D is correct.
infection, a cooling blanket might not be required, and the frontal lobe is not The potassium level of 2.5meq/L is extremely low. The normal is 3.5–5.5meq/L.
responsible for regulation of the body temperature. Lasix (furosemide) is a nonpotassium sparing diuretic, so answer A is incorrect.
The nurse cannot alter the doctor’s order, as stated in answer B, and answer C
24. Answer A is correct. will not help with this situation.
A low-protein diet is required because protein breaks down into nitrogenous
waste and causes an increased workload on the kidneys. Answers B, C, and D are 36. Answer A is correct.
incorrect. An occult blood test should be done periodically to detect any intestinal
bleeding on the client with Coumadin therapy. Answers B, C, and D are not
25. Answer B is correct. directly related to the question.
To safely administer heparin, the nurse should obtain an infusion controller. Too
rapid infusion of heparin can result in hemorrhage. Answers A, C, and D are 37. Answer D is correct.
incorrect. It is not necessary to have a buretrol, an infusion filter, or a three-way After administering any subcutaneous anticoagulant, the nurse should check the
stop-cock. site for bleeding. Answers A and C are incorrect because aspirating and
massaging the site are not done. Checking the pulse is not necessary, as in
26. Answer A is correct. answer B.
If the blood pressure cuff is too small, the result will be a blood pressure that is a
false elevation. Answers B, C, and D are incorrect. If the blood pressure cuff is 38. Answer C is correct.
too large, a false low will result. Answers C and D have basically the same Acupuncture uses needles, and because HIV is transmitted by blood and body
meaning. fluids, the nurse should question this treatment. Answer A describes
acupressure, and answers B and D describe massage therapy with the use of
27. Answer B is correct. oils.
The child with nephotic syndrome will exhibit extreme edema. Elevating the
scrotum on a small pillow will help with the edema. Applying ice is 39. Answer B is correct.
contraindicated; heat will increase the edema. Administering a diuretic might be The fifth vital sign is pain. Nurses should assess and record pain just as they
ordered, but it will not directly help the scrotal edema. Therefore, answers A, C, would temperature, respirations, pulse, and blood pressure. Answers A, C, and D
and D are incorrect. are included in the charting but are not considered to be the fifth vital sign and
are, therefore, incorrect.
28. Answer A is correct.
The elevated white blood cell count should be reported because this indicates 40. Answer A is correct.
infection. A bruit will be heard if the client has an aneurysm, and a negative Narcan is the antidote for the opoid analgesics. Toradol (answer B) is a nonopoid
Babinski is normal in the adult, as are pupils that are equal and reactive to light analgesic; aspirin (answer C) is an analgesic, anticoagulant, and antipyretic; and
and accommodation; thus, answers B, C, and D are incorrect. atropine (answer D) is an anticholengergic.

29. Answer A is correct. 41. Answer B is correct.

If the nurse cannot elicit the patella reflex (knee jerk), the client should be asked The client is concerned about overdosing himself. The machine will deliver a set
to pull against the palms. This helps the client to relax the legs and makes it amount as ordered and allow the client to self-administer a small amount of
easier to get an objective reading. Answers B, C, and D will not help with the medication. PCA pumps usually are set to lock out the amount of medication
test. that the client can give himself at 5- to 15-minute intervals. Answer A does not
address the client’s concerns, answer C is incorrect, and answer D does not
30. Answer B is correct. address the client’s concerns.
If the doctor orders 0.4mgm IM and the drug is available in
0.8/1mL, the nurse should make the calculation: ?mL = 1mL / 0.8mgm; 42. Answer B is correct.
× Skin irritation can occur if the TENS unit is used for prolonged periods of time. To
.4mg / 1 = prevent skin irritations, the client should change the location of the electrodes
0.5m:. Answers A, C, and D are incorrect. often. Electrocution is not a risk because it uses a battery pack; thus, answer A is
incorrect. Answer C is incorrect because the unit should not be used on sensitive
31. Answer B is correct. areas of the body. Answer D is incorrect because no creams are to be used with
The pulmonary artery pressure will measure the pressure during systole, the device.
diastole, and the mean pressure in the pulmonary artery. It will not measure the
pressure in the left ventricle, the pressure in the pulmonary veins, or the 43. Answer B is correct.
pressure in the right ventricle. Therefore, answers A, C, and D are incorrect. An advanced directive allows the client to make known his wishes regarding care
if he becomes unable to act on his own. Much confusion regarding life-saving
32. Answer A is correct. measures can occur if the client does not have an advanced directive. Answers
The normal central venous pressure is 5–10cm of water. A reading of 2cm is low A, C, and D are incorrect because the nurse doesn’t need to know about
and should be reported. Answers B, C, and D indicate that the nursebelieves that funeral plans and cannot make decisions for the client, and active euthanasia is
the reading is too high and is incorrect. illegal
in most states in the United States.
33. Answer C is correct.
The treatment for ventricular tachycardia is lidocaine. A precordial thump is 44. Answer B is correct.
sometimes successful in slowing the rate, but this should be done only if a To decrease the potential for soreness of the nipples, the client should be taught
defibrillator is available. In answer A, atropine sulfate will speed the rate further; to break the suction before removing the baby from the breast. Answer A is
in answer B, checking the potassium is indicated but is not the priority; and in incorrect because feeding the baby during the first 48 hours after delivery will
answer D, defibrillation is used for pulseless ventricular tachycardia or provide colostrum but will not help the soreness of the nipples. Answers C and D
are incorrect because applying hot, moist soaks several times per day might
cause burning of the breast and cause further dr ying. Wearing a support bra will of checking for placement. Other methods include placing the end in water and
help with engorgement but will not help the nipples. checking for bubbling, and injecting air and listening over the epigastric area.
Answers B and C are not correct. Answer D is incorrect because warming in the
45. Answer D is correct. microwave is contraindicated.
Facial grimace is an indication of pain. The blood pressure in answer A is within
normal limits. The client’s inability to concentrate and dilated pupils, as stated in 58. Answer C is correct.
answers B and C, may be related to the anesthesia that he received during Antacids should be administered with other medications. If antacids are taken
surgery. with many medications, they render the other medications inactive. All other
answers are incorrect.
46. Answer C is correct.
Epidural anesthesia involves injecting an anesthetic into the epidural space. If 59. Answer A is correct.
the anesthetic rises above the respiratory center, the client will have impaired The client with a colostomy can swim and carry on activities as before the
breathing; thus, monitoring for respiratory depression is necessary. Answer A, colostomy. Answers B and C are incorrect, and answer D shows a lack of
seizure activity, is not likely after an epidural. Answer B, postural hypertension, empathy.
is not likely. Answer D, hematuria, is not related to epidural anesthesia.
60. Answer D is correct.
47. Answer C is correct. The use of a sitz bath will help with the pain and swelling associated with a
Pain is a late sign of oral cancer. Answers A, B, and D are incorrect because a hemorroidectomy. The client should eat foods high in fiber, so answer A is
feeling of warmth, odor, and a flat ulcer in the mouth are all early occurrences incorrect. Ice packs, as stated in answer B, are ordered immediately after
of oral cancer. surgery only. Answer C is incorrect because taking a laxative daily can result in
diarrhea.
48. Answer A is correct.
The best diagnostic tool for cancer is the biopsy. Other assessment includes 61. Answer D is correct.
checking the lymph nodes. Answers B, C, and D will not confirm a diagnosis of Low hemoglobin and hematocrit might indicate intestinal bleeding. Answers A,
oral cancer. B, and C are incorrect, because they do not require immediate action.

49. Answer A is correct. 62. Answer C is correct.

Maintaining a patient’s airway is paramount in the post-operative period. This is The new diabetic has a knowledge deficit. Answers A, B, and D are not
the priority of nursing care. Answers B, C, and D are applicable but are not the supported within the stem and so are incorrect.
priority.
63. Answer D is correct.
50. Answer C is correct. Peptic ulcers are not always related to stress but are a component of the
H. pylori bacteria has been linked to peptic ulcers. Answers A, B, and D are not disease. Answers A and B are incorrect because peptic ulcers are not caused by
typically cultured within the stomach, duodenum, or esophagus, and are not overeating or continued exposure to stress. Answer C is incorrect because peptic
related to the development of peptic ulcers. ulcers are related to but not directly caused by stress.

51. Answer B is correct. 64. Answer B is correct.

Individuals with ulcers within the duodenum typically complain of pain occurring Many medications can irritate the stomach and contribute to abdominal pain.
2–3 hours after a meal, as well as at night. The pain is usually relieved by eating. For answer A, not all interactions between medications will cause abdominal
The pain associated with gastric ulcers, answer A, occurs 30 minutes after pain. Although this might provide an opportunity for teaching, this is not the
eating. Answer C is too vague and does not distinguish the type of ulcer. best time to teach. Therefore, answer C is incorrect. Answer D is incorrect
Answer D is associated with a stress ulcer. because medication may not be the cause of the pain.

52. Answer B is correct. 65. Answer A is correct.

A barium enema is contraindicated in the client with diverticulitis because it can The nurse should inspect first, then auscultate, and finally palpate. If the nurse
cause bowel perforation. Answers A, C, and D are appropriate diagnostic studies palpates first the assessment might be unreliable. Therefore, answers B, C, and
for the client with suspected diverticulitis. D are incorrect.

53. Answer A is correct. 66. Answer A is correct.

Clients with celiac disease should refrain from eating foods containing gluten. The hospital will certainly honor the wishes of family members even if the
Foods with gluten include wheat barley, oats, and rye. The other foods are patient has signed a donor card. Answer B is incorrect, answer C is not
allowed. empathetic to the family and is untrue, and answer D is not good nursing
etiquette and, therefore, is incorrect.
54. Answer A is correct.
The nurse should reinforce the need for a diet balanced in all nutrients and fiber. 67. Answer C is correct.
Foods that often cause diarrhea and bloating associated with irritable bowel The nurse should explore the cause for the lack of motivation. The client might
syndrome include fried foods, caffeinated beverages, alcohol, and spicy foods. be anemic and lack energy, or the client might be depressed. Alternating staff, as
Therefore, answers B, C, and D are incorrect. stated in answer A, will prevent a bond from being formed with the nurse.
Answer B is not enough, and answer D is not necessary.
55. Answer C is correct.
Fluid volume deficit can lead to metabolic acidosis and electrolyte loss. The 68. Answer D is correct.
other nursing diagnoses in answers A, B, and D might be applicable but are of The nurse who has had the chickenpox has immunity to the illness and will not
lesser priority. transmit chickenpox to the client. Answer A is incorrect because there could be
no need to reassign the nurse. Answer B is incorrect because the nurse should
56. Answer D is correct. be assessed before coming to the conclusion that she cannot spread the
Alcohol will cause extreme nausea if consumed with Flagyl. Answer A is incorrect infection to the client. Answer C is incorrect because there is still a risk, even
because the full course of treatment should be taken. The medication should be though chickenpox has formed scabs.
taken with a full 8 oz. of water, with meals, and the client should avoid direct
sunlight because he will most likely be photosensitive; therefore, answers 69. Answer A is correct.
A, B, and C are incorrect. The nurse should not take the blood pressure on the affected side. Also,
venopunctures and IVs should not be used in the affected area. Answers B, C,
57. Answer A is correct. and D are all indicated for caring for the client. The arm should be elevated to
Before beginning feedings, an x-ray is often obtained to check for placement. decrease edema. It is best to position the client on the unaffected side and
Aspirating stomach content and checking the pH for acidity is the best method perform a dextrostix on the unaffected side.
 Viokase is a pancreatic enzyme that is used to facilitate digestion. It should be
70. Answer B is correct. given with meals and snacks, and it works well in foods such as applesauce.
Gentamycin is an aminoglycocide. These drugs are toxic to the auditory nerve Answers A, B, and D are incorrect.
and the kidneys. The hematocrit is not of significant consideration in this client;
therefore, answer A is incorrect. Answer C is incorrect because we would expect 83. Answer B is correct.
the white blood cell count to be elevated in this client because gentamycin is an Trough levels are the lowest blood levels and should be done 30 minutes before
antibiotic. Answer D is incorrect because the erythrocyte count is also the third IV dose or 30 minutes before the fourth IM dose. Answers A, C, and D
particularly significant to check. are incorrect.

71. Answer C is correct. 84. Answer A is correct.

The most definitive diagnostic tool for HIV is the Western Blot. The white blood Regular insulin should be drawn up before the NPH. They can be given together,
cell count, as stated in answer A, is not the best indicator, but a white blood cell so there is no need for two injections, making answer D incorrect. Answer B is
count of less than 3,500 requires investigation. The ELISA test, answer B, is a obviously incorrect, and answer C is incorrect because it certainly does matter
screening exam. Answer D is not specific enough. which is drawn first: Contamination of NPH into regular insulin will result in a
hypoglycemic reaction at unexpected times.
72. Answer A is correct.
The “bull’s eye” rash is indicative of Lyme’s disease, a disease spread by ticks. 85. Answer A is correct.
The signs and symptoms include elevated temperature, headache, nausea, and Clients having dye procedures should be assessed for allergies to iodine or
the rash. Although answers B and D are important, the question asked which shellfish. Answers B and D are incorrect because there is no need for the client
question would be best. Answer C has no significance. to be assessed for reactions to blood or eggs. Because an IV cholangiogram is
done to detect gallbladder disease, there is no need to ask about answer C.
73. Answer C is correct.
The client that needs the least-skilled nursing care is the client with the 86. Answer A is correct.
thyroidectomy 4 days ago. Answers A, B, and D are incorrect because the other Methergine is a drug that causes uterine contractions. It is used for postpartal
clients are less stable and require a registered nurse. bleeding that is not controlled by Pitocin. Answers B, C, and D are incorrect:
Stadol is an analgesic; magnesium sulfate is used for preeclampsia; and
74. Answer A is correct. phenergan is an antiemetic.
Hyphema is blood in the anterior chamber of the eye and around the eye. The
client should have the head of the bed elevated and ice applied. Answers B, C, 87. Answer D is correct.
and D are incorrect and do not treat the problem. Cyclosporin is an immunosuppressant, and the client with a liver transplant will
be on immunosuppressants for the rest of his life. Answers A, B, and C, then, are
75. Answer C is correct. incorrect.
FeS04 or iron should be given with ascorbic acid (vitamin C). This helps with the
absorption. It should not be given with meals or milk because this decreases the 88. Answer C is correct.
absorption; thus, answers A and B are incorrect. Giving it undiluted, as stated in Histamine blockers are frequently ordered for clients who are hospitalized for
answer D, is not good because it tastes bad. prolonged periods and who are in a stressful situation. They are not used to
treat discomfort, correct electrolytes, or treat nausea; therefore, answers A, B,
76. Answer C is correct. and D are incorrect.
The best protector for the client with an ileostomy to use is stomahesive.
Answer A is not correct because the bag will not seal if the client uses Karaya 89. Answer C is correct.
powder. Answer B is incorrect because there is no need to irrigate an ileostomy. The time of onset for regular insulin is 30–60 minutes. Answers A, B, and D are
Neosporin, answer D, is not used to protect the skin because it is an antibiotic. incorrect because they are not the correct times.

77. Answer D is correct. 90. Answer C is correct.

Vitamin K is given after delivery because the newborn’s intestinal tract is sterile The client should be taught to eat his meals even if he is not hungry, to prevent
and lacks vitamin K needed for clotting. Answer A is incorrect because vitamin K a hypoglycemic reaction. Answers A, B, and D are incorrect because they
is not directly given to stop hemorrhage. Answers B and C are incorrect because indicate knowledge of the nurse’s teaching.
vitamin K does not prevent infection or replace electrolytes.
91. Answer D is correct.
78. Answer D is correct. Taking antibiotics and oral contraceptives together decreases the effectiveness
The vital signs should be taken before any chemotherapy agent. If it is an IV of the oral contraceptives. Answers A, B, and C are not necessarily true.
infusion of chemotherapy, the nurse should check the IV site as well. Answers B
and C are incorrect because it is not necessary to check the electrolytes or blood 92. Answer D is correct.
gasses. Taking corticosteroids in the morning mimics the body’s natural release of
cortisol. Answer A is not necessarily true, and answers B and C are not true.
79. Answer C is correct.
Before chemotherapy, an antiemetic should be given because most 93. Answer B is correct.
chemotherapy agents cause nausea. It is not necessary to give a bolus of IV Rifampin can change the color of the urine and body fluid. Teaching the client
fluids, medicate for pain, or allow the client to eat; therefore, answers A, B, and about these changes is best because he might think this is a complication.
D are incorrect. Answer A is not necessary, answer C is not true, and answer D is not true
because this medication should be taken regularly during the course of the
80. Answer B is correct. treatment.
Pitocin is used to cause the uterus to contract and decrease bleeding. A uterus
deviated to the left, as stated in answer A, indicates a full bladder. It is not 94. Answer D is correct.
desirable to have a boggy uterus, making answer C incorrect. This lack of muscle Cytoxan can cause hemorrhagic cystitis, so the client should drink at least eight
tone will increase bleeding. Answer D is incorrect because Pitocin does not glasses of water a day. Answers A and B are not necessary and, so, are incorrect.
affect the position of the uterus. Nausea often occurs with chemotherapy, so answer C is incorrect.

81. Answer A is correct. 95. Answer A is correct.

Household contacts should take INH approximately 6 months. Answers B, C, and Crystals in the solution are not normal and should not be administered to the
D are incorrect because they indicate either too short or too long of a time to client. Discard the bad solution immediately. Answer B is incorrect because
take the medication. warming the solution will not help. Answer C is incorrect, and answer D requires
a doctor’s order.
82. Answer C is correct.
96. Answer C is correct. 108. Answer A is correct.
Theodur is a bronchodilator, and a side effect of bronchodilators is tachycardia, The pregnant nurse should not be assigned to any client with radioactivity
so checking the pulse is important. Extreme tachycardia should be reported to present. The client receiving linear accelerator therapy is not radioactive
the doctor. Answers A, B, and D are not necessary. because he travels to the radium department for therapy, and the radiation
stays in the department. The client in answer B does pose a risk to the pregnant
97. Answer B is correct. nurse. The client in answer C is radioactive in ver y small doses. For
The diagnosis of meningitis at age 6 months correlates to a diagnosis of cerebral approximately 72 hours, the client should dispose of urine and feces in special
palsy. Cerebral palsy, a neurological disorder, is often associated with birth containers and use plastic spoons and forks. The client in answer D is also
trauma or infections of the brain or spinal column. Answers A, C and D are not radioactive in small amounts, especially upon return from the procedure.
related to the question.
109. Answer A is correct.
98. Answer B is correct. The client with Cushing’s disease has adrenocortical hypersecretion. This
Children at 18 months of age like push-pull toys. Children at approximately 3 increase in the level of cortisone causes the client to be immune suppressed. In
years of age begin to dress themselves and build a tower of eight blocks. At age answer B, the client with diabetes poses no risk to other clients. The client in
four, children can copy a horizontal or vertical line. Therefore, answers A, C, and answer C has an increase in growth hormone and poses no risk to himself or
D are incorrect. others. The client in answer D has hyperthyroidism or myxedema, and poses no
risk to others or himself.
99. Answer D is correct.
A complication of a tonsillectomy is bleeding, and constant swallowing may 110. Answer C is correct.
indicate bleeding. Decreased appetite is expected after a tonsillectomy, as is a Assault is defined as striking or touching the client inappropriately, so a nurse
low-grade temperature; thus, answers A and B are incorrect. In answer C, chest assistant striking a client could be charged with assault. Answer A, negligence, is
congestion is not normal but is not associated with the tonsillectomy. failing to perform care for the client. Answer B, a tort, is a wrongful act
committed on the client or their belongings. Answer D, malpractice, is failure to
100. Answer C is correct. perform an act that the nurse assistant knows should be done, or the act of
Hyperplasia of the gums is associated with Dilantin therapy. Answer A is not doing something wrong that results in harm to the client.
related to the therapy; answer B is a side effect; and answer D is not related to
the question. 111. Answer D is correct.
The licensed practical nurse cannot start a blood transfusion, but can assist the
101. Answer A is correct. registered nurse with identifying the client and taking vital signs. Answers A, B,
If the client eats foods high in tyramine, he might experience malignant and C are duties that the licensed practical nurse can perform.
hypertension. Tyramine is found in cheese, sour cream, Chianti wine, sherry,
beer, pickled herring, liver, canned figs, raisins, bananas, avocados, chocolate, 112. Answer B is correct.
soy sauce, fava beans, and yeast. These episodes are treated with Regitine, an The vital signs are abnormal and should be reported to the doctor immediately.
alpha-adrenergic blocking agent. Answers B, C, and D are not related to the Answer A, continuing to monitor the vital signs, can result in deterioration of the
question. client’s condition. Answer C, asking the client how he feels, would supply only
subjective data. Involving the LPN, in Answer D, is not the best solution to help
102. Answer D is correct. this client because he is unstable.
Quinidine can cause widened Q-T intervals and heart block. Other signs of
myocardial toxicity are notched P waves and widened QRS complexes. The most 113. Answer B is correct.
common side effects are diarrhea, nausea, and vomiting. The client might Thalasemia is a genetic disorder that causes the red blood cells to have a shorter
experience tinnitus, vertigo, headache, visual disturbances, and confusion. life span. Frequent blood transfusions are necessary to provide oxygen to the
Answers A, B, and C are not related to the use of quinidine. tissues. Answer A is incorrect because fluid therapy will not help; answer C is
incorrect because oxygen therapy will also not help; and answer D is incorrect
103. Answer B is correct. because iron should be given sparingly because these clients do not use iron
Lidocaine is used to treat ventricular tachycardia. This medication slowly exerts stores adequately.
an antiarrhythmic effect by increasing the electric stimulation threshold of the
ventricles without depressing the force of ventricular contractions. It is not used 114. Answer B is correct.
for atrial arrhythmias; thus, answer A is incorrect. Answers C and D are incorrect Cystic fibrosis is a disease of the exocrine glands. The child with cystic fibrosis
because it slows the heart rate, so it is not used for heart block or brachycardia. will be salty. A sweat test result of 60meq/L and higher is considered positive.
Answers A, C, and D are incorrect because these test results are within the
104. Answer A is correct. normal range and are not reported on the sweat test.
Sites for the application of nitroglycerin should be rotated, to prevent skin
irritation. It can be applied to the back and upper arms, not to the lower 115. Answer A is correct.
extremities, making answer B incorrect. Answer C is incorrect because A meningomylocele is an opening in the spine. The nurse should keep the defect
nitroglycerine should not be rubbed into the skin, and answer D is incorrect covered with a sterile saline gauze until the defect can be repaired. Answer B is
because the medication should be covered with a prepared dressing made of a incorrect because the child should be placed in the prone position. Answer C is
thin paper substance, not gauze. incorrect because feeding the child slowly is not necessary. Answer D is not
correct because this is not the priority of care.
105. Answer B is correct.
A persistent cough might be related to an adverse reaction to Captoten. 116. Answer D is correct.
Answers A and D are incorrect because tinnitus and diarrhea are not associated Absent femoral pulses indicates coarctation of the aorta. This defect causes
with the medication. Muscle weakness might occur when beginning the strong bounding pulses and elevated blood pressure in the upper body, and low
treatment but is not an adverse effect; thus, answer C is incorrect. blood pressure in the lower extremities. Answers A, B, and C are incorrect
because they are normal findings in the newborn.
106. Answer A is correct.
Lasix should be given approximately 1mL per minute to prevent hypotension. 117. Answer D is correct.
Answers B, C, and D are incorrect because it is not necessar y to be given in an IV Clostrium dificille is primarily spread through the GI tract, resulting from poor
piggyback, with saline, or through a filter. hand washing and contamination with stool containing clostridium dificille.
Answers A, B, and C are incorrect because the mode of transmission is not by
107. Answer B is correct. sputum, through the urinar y tract, or by unsterile surgical equipment.
The antidote for heparin is protamine sulfate. Cyanocobalamine is B12,
Streptokinase is a thrombolytic, and sodium warfarin is an anticoagulant. 118. Answer A is correct.
Therefore, answers A, C, and D are incorrect. The first client to be seen is the one who recently returned from surgery. The
other clients in answers B, C, and D are more stable and can be seen later.
 Frequent rest periods help to relax tense muscles and preserve energy. Answers
119. Answer D is correct. B, C, and D are incorrect because they are untrue statements about cerebral
Cyanocolamine is a B12 medication that is used for pernicious anemia, and a palsy.
reticulocyte count of 1% indicates that it is having the desired effect. Answers A,
B, and C are white blood cells and have nothing to do with this medication. 132. Answer D is correct.
A culture for gonorrhea is taken from the genital secretions. The culture is
120. Answer C is correct. placed in a warm environment, where it can grow nisseria gonorrhea. Answers
The client taking antabuse should not eat or drink anything containing alcohol or A, B, and C are incorrect because these cultures do not test for gonorrhea.
vinegar. The other foods in answers A, B, and D are allowed.
133. Answer D is correct.
121. Answer A is correct. After surgery, the client will be placed on a clear-liquid diet and progressed to a
The client with unilateral neglect will neglect one side of the body. Answers B, C, regular diet. Stool softeners will be included in the plan of care, to avoid
and D are not associated with unilateral neglect. constipation. Later, a high-fiber diet, in answer A, is encouraged, but this is not
the first diet after surgery. Answers B and C are not diets for this type of surgery.
122. Answer D is correct.
Because the client is immune suppressed, foods should be served in sealed 134. Answer C is correct.
containers, to avoid food contaminants. Answer B is incorrect because of A sitz bath will help with swelling and improve healing. Ice packs, in answer D,
possible infection from visitors. Answer A is not necessary, but the utensils can be used immediately after delivery, but answers A and B are not used in this
should be cleaned thoroughly and rinsed in hot water. Answer C might be a instance.
good idea, but alcohol can be drying and can cause the skin to break down.
135. Answer B is correct.
123. Answer A is correct. The best way to evaluate pain levels is to ask the client to rate his pain on a
Identifying oneself as a nurse without a license defrauds the public and can be scale. In answer A, the blood pressure, pulse, and temperature can alter for
prosecuted. A tort is a wrongful act; malpractice is failing to act appropriately as other reasons than pain. Answers C and D are not as effective in determining
a nurse or acting in a way that harm comes to the client; and negligence is failing pain levels.
to per form care. Therefore, answers B, C, and D are incorrect.
136. Answer C is correct.
124. Answer B is correct. The client is experiencing compensated metabolic acidosis. The pH is within the
The client with the appendectomy is the most stable of these clients and can be normal range but is lower than 7.40, so it is on the acidic side. The CO 2 level is
assigned to a nursing assistant. The client with bronchiolitis has an alteration in elevated, the oxygen level is below normal, and the bicarb level is slightly
the airway; the client with periorbital cellulitis has an infection; and the client elevated. In respiratory disorders, the pH will be the inverse of the CO2
with a fracture might be an abused child. Therefore, answers A, C, and D are and bicarb levels. This means that if the pH is low, the CO 2 and bicarb levels will
incorrect. be elevated.
Answers A, B, and D are incorrect because they do not fall into the range of
125. Answer B is correct. symptoms.
The first action the nurse should take is to report the finding to the nurse
supervisor and follow the chain of command. If it is found that the pharmacy is 137. Answer B is correct.
in error, it should be notified, as stated in answer A. Answers C and D, notifying The registered nurse is the only one of these who can legally put the client in
the director of nursing and the Board of Nursing, might be necessary if theft is seclusion. The only other healthcare worker who is allowed to initiate seclusion
found, but not as a first step; thus, these are incorrect for this question. is the doctor; therefore, answers A, C, and D are incorrect.

126. Answer B is correct. 138. Answer C is correct.

The best client to transport to the postpartum unit is the 40-year-old female Sodium warfarin is administered in the late afternoon, at approximately 1700
with a hysterectomy. The nurses on the postpartum unit will be aware of normal hours. This allows for accurate bleeding times to be drawn in the morning.
amounts of bleeding and will be equipped to care for this client. The clients in Therefore, answers A, B, and D are incorrect.
answers A and D will be best cared for on a medical-surgical unit. The client with
depression in answer C should be transported to the psychiatric unit. 139. Answer C is correct.
Covering both eyes prevents consensual movement of the affected eye. Answer
127. Answer D is correct. A is incorrect because the nurse should not attempt to remove the object from
The fresh peach is the lowest in sodium of these choices. Answers A, B, and C the eye because this might cause trauma. Rinsing the eye, as stated in answer B,
have much higher amounts of sodium. might be ordered by the doctor, but this is not the first step for the nurse.
Answer D is not correct because often when one eye moves, the other also
128. Answer B is correct. moves.
The client with congestive heart failure who is complaining of nighttime dyspnea
should be seen because air way is number one in nursing care. In answers A, C, 140. Answer A is correct.
and D, the clients are more stable. A brain attack in answer A is the new To protect herself, the nurse should wear gloves when applying a nitroglycerine
terminology for a stroke. patch or cream. Answer B is incorrect because shaving the shin might abrade the
area. Answer C is incorrect because washing with hot water will vasodilate and
129. Answer D is correct. increase absorption. The patches should be applied to areas above the waist,
Xerostomia is dry mouth, and offering the client a saliva substitute will help the making answer D incorrect.
most. Eating hard candy in answer A can further irritate the mucosa and cut the
tongue and lips. Administering an analgesic might not be necessary; thus, 141. Answer B is correct.
answer B is incorrect. Splinting swollen joints, in answer C, is not associated with The client scheduled for a pericentesis should be told to empty the bladder, to
xerostomia. prevent the risk of puncturing the bladder when the needle is inserted. A
pericentesis is done to remove fluid from the peritoneal cavity. The client will be
130. Answer A is correct. positioned sitting up or leaning over an overbed table, making answer A
The client with Alzheimer’s disease is the most stable of these clients and can be incorrect. The client is usually awake during the procedure, and medications are
assigned to the nursing assistant, who can perform duties such as feeding and not commonly instilled during the procedure; thus answers C and D are
assisting the client with activities of daily living. The clients in answers B, C, and incorrect.
D are less stable and should be attended by a registered nurse.
142. Answer A is correct.
131. Answer A is correct. Atropine sulfate is the antidote for Tensilon and is given to treat cholenergic
crises. Furosemide (answer B) is a diuretic; Prostigmin (answer C) is the
treatment for myasthenia gravis; and Promethazine (answer D) is an antiemetic, The most suitable roommate for the client with gastric reaction is the client with
antianxiety medication. Thus, answers B, C, and D are incorrect. phlebitis because the client with phlebitis will not transmit any infection to the
surgical client. Crohn’s disease clients, in answer A, have frequent stools and
143. Answer D is correct. might transmit infections. The client in answer B with pneumonia is coughing
The first exercise that should be done by the client with a mastectomy is and will disturb the gastric client. The client with gastritis, in answer C, is
squeezing the ball. Answers A, B, and C are incorrect as the first step; they are vomiting and has diarrhea, which also will disturb the gastric client.
implemented later.
156. Answer B is correct.
144. Answer D is correct. The client having a mammogram should be instructed to omit deodorants or
The mothers in answers A, B, and C all require RhoGam and, thus, are incorrect. powders beforehand because these could cause a false positive reading. Answer
Answer D is the only mother who does not require a RhoGam injection. A is incorrect because there is no need to restrict fat. Answer C is incorrect
because doing a mammogram does not replace the need for self-breast exams.
145. Answer A is correct. Answer D is incorrect because a mammogram does not require a higher dose of
Answer A, AST, is not specific for myocardial infarction. Troponin, CK-MB, and radiation than an x-ray.
Myoglobin, in answers B, C, and D, are more specific, although myoglobin is also
elevated in burns and trauma to muscles. 157. Answer A is correct.
The nurse who fails to wear gloves to remove a contaminated dressing needs
146. Answer B is correct. further instruction. Answers B, C, and D are incorrect because these answers
The client who says he has nothing wrong is in denial about his myocardial indicate understanding by the nurse.
infarction. Rationalization is making excuses for what happened, projection is
projecting feeling or thoughts onto others, and conversion reaction is converting 158. Answer A is correct.
a psychological trauma into a physical illness; thus, answers A, C, and D are When the cadaver client is being prepared to donate an organ, the systolic blood
incorrect. pressure should be maintained at 70mmHg or greater, to ensure a blood supply
to the donor organ. Answers B, C, and D are incorrect because these actions are
147. Answer C is correct. not necessary for the donated organ to remain viable.
When the client is receiving TPN, the blood glucose level should be drawn. TPN
is a solution that contains large amounts of glucose. Answers A, B, and D are not 159. Answer A is correct.
directly related to the question and are incorrect. Bilirubin is excreted through the kidneys, thus the need for increased fluids.
Maintaining the body temperature is important but will not assist in eliminating
148. Answer B is correct. bilirubin; therefore, answer B is incorrect. Answers C and D are incorrect
A client with diabetes who has trouble seeing would require follow-up after because they do not relate to the question.
discharge. The lack of visual acuity for the client preparing and injecting insulin
might require help. Answers A, C, and D will not prevent the client from being 160. Answer C is correct.
able to care for himself and, thus, are incorrect. The client with laryngeal cancer has a potential airway alteration and should be
seen first. The clients in answers A, B, and D are not in immediate danger and
149. Answer C is correct. can be seen later in the day.
Lactulose is administered to the client with cirrhosis to lower ammonia levels.
Answers A, B, and D are incorrect because they do not have an effect on the 161. Answer B is correct.
other lab values. The best action for the nurse to take is to explore the interaction with the
nursing assistant. This will allow for clarification of the situation. Changing the
150. Answer B is correct. assignment in answer A might need to be done, but talking to the nursing
If the dialysate returns cloudy, infection might be present and must be assistant is the first step. Answer C is incorrect because discussing the incident
evaluated. Documenting the finding, as stated in answer A, as not enough; with the family is not necessary at this time; it might cause more problems than
straining the urine, in answer C, is incorrect; and dialysate, in answer D, is not it solves. Answer C is not a first step, even though initiating a group session
urine at all. However, the physician might order a white blood cell count. might be a plan for the future.

151. Answer B is correct. 162. Answer B is correct.

The teenager with sternal bruising might be experiencing airway and The best action at this time is to report the incident to the charge nurse. Further
oxygenation problems and, thus, should be seen first. In answer A, the 10 year action might be needed, but it will be done by the charge nurse. Answers A, C,
old with lacerations has superficial bleeding. The client in answer C with a and D are incorrect because notifying the police is overreacting at this time, and
fractured femur should be immobilized but can be seen after the client with monitoring or ignoring the situation is an inadequate response.
sternal bruising. The client in answer D with the dislocated elbow can be seen
later as well. 163. Answer D is correct.
The best client to assign to the newly licensed nurse is the most stable client; in
152. Answer A is correct. this case, it is the client with diverticulitis. The client receiving chemotherapy
The most suitable roommate for the client with myasthenia gravis is the client and the client with a coronar y bypass both need nurses experienced in these
with hypothyroidism because he is quiet. The client with Crohn’s disease in areas, so answers A and B are incorrect. Answer C is incorrect because the client
answer B will be up to the bathroom frequently; the client with pylonephritis in with a transurethral prostatectomy might bleed, so this client should be
answer C has a kidney infection and will be up to urinate frequently. The client in assigned to a nurse who knows how much bleeding is within normal limits.
answer D with bronchitis will be coughing and will disturb any roommate.
164. Answer D is correct.
153. Answer C is correct. Intrathecal medications are administered into the cerebrospinal fluid. This
The client should not be instructed to do the Valsalva maneuver during central method of administering medications is reserved for the client metastases, the
venous pressure reading. If the nurse tells the client to perform the Valsalva client with chronic pain, or the client with cerebrospinal infections. Answers A,
maneuver, he needs further teaching. Answers A, B, and D are incorrect because B, and C are incorrect because intravenous, rectal, and intramuscular injections
they indicate that the nurse understands the correct way to check the CVP. are entirely different procedures.

154. Answer D is correct. 165. Answer B is correct.

The most critical client should be assigned to the registered nurse; in this case, Montgomery straps are used to secure dressings that require frequent dressing
that is the client 2 days post-thoracotomy. The clients in answers A and B are changes because the client with a cholecystectomy usually has a large amount of
ready for discharge, and the client in answer C who had a splenectomy 3 days draining on the dressing. Montgomery straps are also used for clients who are
ago is stable enough to be assigned to a PN. allergic to several types of tape. This client is not at higher risk of evisceration
than other clients, so answer A is incorrect. Montgomery straps are not used to
155. Answer D is correct. secure the drains, so answer C is incorrect. Sutures or clips are used to secure
the wound of the client who has had gallbladder surgery, so answer D is for 12 hours before the test. Answer D is incorrect because the client’s
incorrect. reproductive organs should not be covered.

166. Answer B is correct. 178. Answer C is correct.

The client with pancreatitis frequently has nausea and vomiting. Lavage is often The client with a fractured femur will be placed in Buck’s traction to realign the
used to decompress the stomach and rest the bowel, so the insertion of a Levine leg and to decrease spasms and pain. The Trendelenburg position is the wrong
tube should be anticipated. Answers A and C are incorrect because blood position for this client, so answer A is incorrect. Ice might be ordered after
pressures are not required ever y 15 minutes, and cardiac monitoring might be repair, but not for the entire extremity, so answer B is incorrect. An abduction
needed, but this is individualized to the client. Answer D is incorrect because pillow is ordered after a total hip replacement, not for a fractured femur;
there are no dressings to change on this client. therefore, answer D is incorrect.

167. Answer B is correct. 179. Answer C is correct.

Oils can be applied to help with the dry skin and to decrease itching, so adding A red, beefy tongue is characteristic of the client with pernicious anemia.
baby oil to bath water is soothing to the skin. Answer A is incorrect because two Answer A, a weight loss of 10 pounds in 2 weeks, is abnormal but is not seen in
baths per day is too frequent and can cause more dryness. Answer C is incorrect pernicious anemia. Numbness and tingling, in answer B, can be associated with
because powder is also drying. Rinsing with hot water, as stated in answer D, ane- mia but are not particular to pernicious anemia. This is more likely
dries out the skin as well. associated with peripheral vascular diseases involving vasculature. In answer D,
the hemoglobin is normal and does not support the diagnosis.
168. Answer A is correct.
If the nurse is exposed to the client with a cough, the best item to wear is a 180. Answer B is correct.
mask. If the answer had included a mask, gloves, and a gown, all would be Portions of the exam are painful, especially when the sample is being
appropriate, but in this case, only one item is listed; therefore, answers B and C withdrawn, so this should be included in the session with the client. Answer A is
are incorrect. Shoe covers are not necessar y, so answer D is incorrect. incorrect because the client will be positioned prone, not in a sitting position, for
the exam. Anesthesia is not commonly given before this test, making answer C
169. Answer D is correct. incorrect. Answer D is incorrect because the client can eat and drink following
Abnormal grieving is exhibited by a lack of feeling sad; if the client’s sister the test.
appears not to grieve, it might be abnormal grieving. She thinks the client might
be suppressing feelings of grief. Answers A, B, and C are all normal expressions 181. Answer C is correct.
of grief and, therefore, incorrect. The assessment that is most crucial to the client is the identification of
peripheral pulses because the aorta is clamped during surgery. This decreases
170. Answer B is correct. blood circulation to the kidneys and lower extremities. The nurse must also
Frequent use of laxatives can lead to diarrhea and electrolyte loss. Answers A, C, assess for the return of circulation to the lower extremities. Answer A is of lesser
and D are not of particular significance in this case and, therefore, are incorrect. concern, answer B is not advised at this time, and answer D is of lesser concern
than answer A.
171. Answer B is correct.
The client with serum sodium of 170meq/L has hypernatremia and might exhibit 182. Answer A is correct.
manic behavior. Answers A, C, and D are not associated with hypernatremia and Suctioning can cause a vagal response, lowering the heart rate and causing
are, therefore, incorrect. bradycardia. Answers B, C and D can occur as well, but they are less likely.

172. Answer A is correct. 183. Answer C is correct.

Radiation to the neck might have damaged the parathyroid glands, which are The client with an internal defibrillator should learn to use any battery-operated
located on the thyroid gland, interferes with calcium and phosphorus regulation. machinery on the opposite side. He should also take his pulse rate and report
Answer B has no significance to this case; answers C and D are more related to dizziness or fainting. Answers A, B, and D are incorrect because the client can eat
calcium only, not to phosphorus regulation. food prepared in the microwave, move his shoulder on the affected side, and fly
in an airplane.
173. Answer A is correct.
It is the responsibility of the physician to explain and clarify the procedure to the 184. Answer A is correct.
client, so the nurse should call the surgeon to explain to the client. Answers B, C, A swelling over the right parietal area is a cephalhematoma, an area of bleeding
and D are incorrect because they are not within the nurse’s responsibility. outside the cranium. This type of hematoma does not cross the suture line.
Answer B, molding, is overlapping of the bones of the cranium and, thus,
174. Answer B is correct. incorrect. In answer C, a subdural hematoma, or intracranial bleeding, is
It is most important to remove the contact lenses because leaving them in can ominous and can be seen only on a CAT scan or x-ray. A caput succedaneum, in
lead to corneal drying, particularly with contact lenses that are not extended- answer D, crosses the suture line and is edema.
wear lenses. Leaving in the hearing aid or artificial eye will not harm the client.
Leaving the wedding ring on is also allowed; usually, the ring is covered with 185. Answer A is correct.
tape. Therefore, answers A, C, and D are incorrect. The client with a lung resection will have chest tubes and a drainage-collection
device. He probably will not have a tracheostomy or Swanz Ganz monitoring,
175. Answer C is correct. and he will not have an order for percussion, vibration, or drainage. Therefore,
If the client eviscerates, the abdominal content should be covered with a sterile answers B, C, and D are incorrect.
saline-soaked dressing. Reinserting the content should not be the action and will
require that the client return to surgery; thus, answer A is incorrect. Answers B 186. Answer C is correct.
and D are incorrect because they not appropriate to this case. The client with mouth and throat cancer will have all the findings in answers A,
B, and D except the correct answer of diarrhea.
176. Answer B is correct.
Cancer in situ means that the cancer is still localized to the primary site. 187. Answer D is correct.
T stands for “tumor” and the IS for “in situ.” Cancer is graded in terms of tumor, A loss of 10% is normal due to meconium stool and water loss. There is no
grade, node involvement, and mestatasis. Answers A, C, and D pertain to these evidence to indicate dehydration, hypoglycemia, or allergy to the infant formula;
other classifications. thus, answers A, B, and C are incorrect.

177. Answer B is correct. 188. Answer C is correct.

A full bladder or bowel can obscure the visualization of the kidney ureters and The client with diverticulitis should avoid eating foods that are gas forming and
urethra. Answer A is incorrect because there is no need to force fluids before that increase abdominal discomfort, such as cooked broccoli. Foods such as
the test. Answer C is incorrect because there is no need to withhold medication those listed in answers A, B, and D are allowed.
189. Answer D is correct. fluid waves, in answers A and D, are more subjective and, thus, are incorrect for
The client with a perineal resection will have a perineal incision. Drains will be this question. Palpation of the liver, in answer B, will not tell the amount of
used to facilitate wound drainage. This will help prevent infection of the surgical ascites.
site. The client will not have an illeostomy, as in answer A; he will have some
electrolyte loss, but treatment is not focused on preventing the loss, so answer 203. Answer B is correct.
B is incorrect. A high-fiber diet, in answer C, is not ordered at this time. The vital signs indicate hypovolemic shock or fluid volume deficit. In answers A,
C, and D, cerebral tissue perfusion, airway clearance, and sensory perception
190. Answer C is correct. alterations are not symptoms and, therefore, are incorrect.
The client with diverticulitis should avoid foods with seeds. The foods in answers
A, B, and D are allowed; in fact, bran cereal and fruit will help prevent 204. Answer A is correct.
constipation. The client with sickle cell is likely to experience symptoms of hypoxia if he
becomes dehydrated or lacks oxygen. Extreme exercise, especially in warm
191. Answer C is correct. weather, can exacerbate the condition, so the fact that the client plays baseball
The least-helpful questions are those describing his usual diet. Answers A, B, and should be of great concern to the visiting nurse. Answers B, C, and D are not
D are useful in determining the extent of disease process and, thus, are factors for concern with sickle cell disease.
incorrect.
205. Answer D is correct.
192. Answer C is correct. The client with neutropenia should not have potted or cut flowers in the room.
Tegretol can suppress the bone marrow and decrease the white blood cell Cancer patients are extremely susceptible to bacterial infections. Answers A, B,
count; thus, a lab value of WBC 2,000 per cubic millimeter indicates side effects and C will not help to prevent bacterial invasions and, therefore, are incorrect.
of the drug. Answers A and D are within normal limits, and answer B is a lower
limit of normal; therefore answers A, B, and D are incorrect. 206. Answer B is correct.
Clients who have not had surgery to the face or neck would benefit from
193. Answer D is correct. lowering the head of the bed, as in answer A. However, in this situation lowering
Sarcoma is a type of bone cancer; therefore, bone pain would be expected. the client’s head could further interfere with the airway. Therefore, the best
Answers A, B, and C are not specific to this type of cancer and are incorrect. answer is answer B, increasing the infusion and placing the client in supine
position. Answers C and D are not necessar y at this time.
194. Answer D is correct.
A birth weight of 7 pounds would indicate 21 pounds in 1 year, or triple his birth 207. Answer C is correct.
weight. Answers A, B, and C therefore are incorrect. If the client pulls the chest tube out of the chest, the nurse should first cover the
insertion site with an occlusive dressing, such as a Vaseline gauze. Then the
195. Answer B is correct. nurse should call the doctor, who will order a chest x-ray and possibly reinsert
A torque wrench is kept at the bedside to tighten and loosen the screws of the tube. Answers A, B, and D are not the first priority in this case.
crutchfield tongs. This wrench controls the amount of pressure that is placed on
the screws. A pair of forceps, wire cutters, and a screwdriver, in answers A, C, 208. Answer A is correct.
and D, would not be used and, thus, are incorrect. Wire cutters should be kept An INR of 8 indicates that the blood is too thin. The normal INR is 2.0–3.0, so
with the client who has wired jaws. answer B is incorrect because the doctor will not increase the dosage of
coumadin. Answer C is incorrect because now is not the time to instruct the
196. Answer C is correct. client about the therapy. Answer D is not correct because there is no need to
Fosamax should be taken with water only. The client should also remain upright increase the neurological assessment.
for at least 30 minutes after taking the medication. Answers A, B, and D are not
applicable to taking Fosamax and, thus, are incorrect. 209. Answer C is correct.
The food indicating the client’s understanding of dietary management of
197. Answer B is correct. osteoporosis is the yogurt, with approximately 400mg of calcium. The other
The client with burns to the neck needs airway assessment and supplemental foods are good choices, but not as good as the yogurt; therefore, answers A, B,
oxygen, so applying oxygen is the priority. The next action should be to start an and D are incorrect.
IV and medicate for pain, making answers A and C incorrect. Answer D,
obtaining blood gases is of less priority. 210. Answer A is correct.
There is no need to avoid taking the blood pressure in the left arm. Answers B, C,
198. Answer A is correct. and D are all actions that should be taken for the client receiving magnesium
The primar y responsibility of the nurse is to take the vital signs before any sulfate for preeclampsia.
surgery. The actions in answers B, C, and D are the responsibility of the doctor
and, therefore, are incorrect for this question. 211. Answer D is correct.
If the client’s mother refuses the blood transfusion, the doctor should be
199. Answer B is correct. notified. Because the client is a minor, the court might order treatment. Answer
The only lab result that is abnormal is the potassium. A potassium level of 1.9 A is incorrect because the mother is the legal guardian and can refuse the blood
indicates hypokalemia. The findings in answers A, C, and D are not revealed in transfusion to be given to her daughter. Answers B and C are incorrect because
the stem. it is not the primary responsibility of the nurse to encourage the mother to
consent or explain the consequences.
200. Answer A is correct.
Removal of the pituitary gland is usually done by a transphenoidal approach, 212. Answer B is correct.
through the nose. Nasal congestion further interferes with the airway. Answers The nurse should be most concerned with laryngeal edema because of the area
B, C, and D are not correct because they are not directly associated with the of burn. Answer A is of secondary priority. Hyponatremia and hypokalemia are
pituitary gland. also of concern but are not the primary concern; thus, answers C and D are
incorrect.
201. Answer A is correct.
Cancer of the liver frequently leads to severe nausea and vomiting, thus the 213. Answer D is correct.
need for altering nutritional needs. The problems in answers B, C, and D are of The client with anorexia shows the most improvement by weight gain. Selecting
lesser concern and, thus, are incorrect in this instance. a balanced diet is useless if the client does not eat the diet, so answer A is
incorrect. The hematocrit, in answer B, might improve by several means, such as
202. Answer C is correct. blood transfusion, but that does not indicate improvement in the anorexic
Daily measuring of the abdominal girth is the best method of determining early condition, so B is incorrect. The tissue turgor indicates fluid, not improvement of
ascites. Measuring with a paper tape measure and marking the measured area is anorexia, so answer C is incorrect.
the most objective method of estimating ascites. Inspection and checking for
214. Answer D is correct. The nurse in answer B has the most experience in knowing possible
Paresthesia of the toes is not normal and can indicate compartment syndrome. complications involving preeclampsia. The nurse in answer A is a new nurse to
At this time, pain beneath the cast is normal and, thus, would not be reported as the unit, and the nurses in answers C and D have no experience with the
a concern. The client’s toes should be warm to the touch, and pulses should be postpartum client.
present. Answers A, B, and C, then, are incorrect.
226. Answer C is correct.
215. Answer B is correct. Desferal is used to treat iron toxicity. Answers A, B, and D are incorrect because
The best response from the nurse is to let the client know that it is normal to they are antidotes for other drugs: Narcan is used to treat narcotic overdose;
have a warm sensation when dye is injected for this procedure. Answers A, C, Digibind is used to treat dioxin toxicity; and Zinecard is used to treat doxorubicin
and D indicate that the nurse believes that the hot feeling is abnormal and, so, toxicity.
are incorrect.
227. Answer A is correct.
216. Answer D is correct. If the nurse charts information that he did not perform, she can be charged with
It is not necessary to wear gloves when taking the vital signs of the client, thus fraud. Answer B is incorrect because malpractice is harm that results to the
indicating further teaching for the nursing assistant. If the client has an active client due to an erroneous action taken by the nurse. Answer C is incorrect
infection with methicillin-resistant staphylococcus aureus, gloves should be because negligence is failure to perform a duty that the nurse knows should be
worn, but this is not indicated in this instance. The actions in answers A, B, and C performed. Answer D is incorrect because a tort is a wrongful act to the client or
are incorrect because they are indicative of infection control not mentioned in his belongings.
the question.
228. Answer D is correct.
217. Answer D is correct. The client who should receive priority is the client with multiple sclerosis and
During ECT, the client will have a grand mal seizure. This indicates completion of who is being treated with IV cortisone. This client is at highest risk for
the electroconvulsive therapy. Answers A, B, and C are incorrect because they complications. Answers A, B, and C are incorrect because these clients are more
do not indicate that the ECT has been completed. stable and can be seen later.

218. Answer A is correct. 229. Answer B is correct.

An infection with pinworms begins when the eggs are ingested or inhaled. The Out of all of these clients, it is best to place the pregnant client and the client
eggs hatch in the upper intestine and mature in 2–8 weeks. The females then with a broken arm and facial lacerations in the same room. These two clients
mate and migrate out the anus, where they lay up to 17,000 eggs, causing probably do not need immediate attention and are least likely to disturb each
intense itching. The mother should be told to use a flashlight to examine the other. The clients in answers A, C, and D need to be placed in separate rooms
rectal area about 2–3 hours after the child is asleep. Placing clear tape on a because their conditions are more serious, they might need immediate
tongue blade will allow the eggs to adhere to the tape. The specimen should attention, and they are more likely to disturb other patients.
then be evaluated in a lab. There is no need to scrape the skin, collect a stool
specimen, or bring a sample of hair; therefore, answers B, C, and D are incorrect. 230. Answer A is correct.
Before instilling eyedrops, the nurse should cleanse the area with warm water. A
219. Answer B is correct. 6-year-old child is not developmentally ready to instill his own eyedrops, so
Erterobiasis, or pinworms, is treated with Vermox (mebendazole) or Antiminth answer B is incorrect. The mother cannot be allowed to administer the eye
(pyrantel pamoate). The entire family should be treated, to ensure that no eggs drops in the hospital setting so answer C incorrect. Although the eye might
remain. Because a single treatment is usually sufficient, there is usually good appear to be clear, the nurse should instill the eyedrops, as ordered (answer D).
compliance. The family should then be tested again in 2 weeks, to ensure that
no eggs remain. Answers A, C, and D are inappropriate for this treatment and, 231. Answer D is correct.
therefore, incorrect. To prevent urinary tract infections, the girl should clean the perineum from front
to back to prevent e. coli contamination. Answer A is incorrect because drinking
220. Answer B is correct. citrus juices will not prevent UTIs. Answers B and C are incorrect because UTI’s
The pregnant nurse should not be assigned to any client with radioactivity are not associated with the use of tampons or with tub baths.
present, and the client with a radium implant poses the most risk to the
pregnant nurse. The clients in answers A, C, and D are not radioactive; therefore, 232. Answer C is correct.
these answers are incorrect. The nurse should encourage rooming in, to promote parent-child attachment. It
is okay for the parents to be in the room for assessment of the child, so answer
221. Answer A is correct. A is incorrect. Allowing the child to have items that are familiar to him is allowed
The client with cancer being treated with chemotherapy is immune suppressed and encouraged; thus, answer B is incorrect. Answer D is incorrect and shows a
and is at risk for opportunistic diseases such as pneumocystis. Answers B, C, and lack of empathy for the child’s distress; it is an inappropriate response from the
D are incorrect because these clients are not at a higher risk for opportunistic nurse.
diseases than other clients.
233. Answer B is correct.
222. Answer D is correct. The hearing aid should be stored in a warm, dry place and should be cleaned
Injecting an infant with an adult dose of Digitalis is considered malpractice, or daily. A toothpick is inappropriate to clean the aid because it might break off in
failing to perform or per forming an act that causes harm to the client. In answer the hearing aide. Changing the batteries weekly is not necessary; therefore,
A, negligence is failing to perform care for the client and, thus, is incorrect. In answers A, C, and D are incorrect.
answer B, a tort is a wrongful act committed on the client or his belongings but,
in this case, was accidental. Assault, in answer C, is not pertinent to this incident. 234. Answer C is correct.
Always remember your ABC’s (air way, breathing, circulation) when selecting an
223. Answer D is correct. answer. Although answers B and D might be appropriate for this child, answer C
The registered nurse cannot insert sutures or clips unless specially trained to do should have the highest priority. Answer A does not apply for a child who has
so, as in the case of a nurse practitioner skilled to perform this task. The undergone a tonsillectomy.
registered nurse can insert a Foley catheter, insert a nasogastric tube, and
monitor central venous pressure. 235. Answer A is correct.
If the child has bacterial pneumonia, a high fever is usually present. Bacterial
224. Answer B is correct. pneumonia usually presents with a productive cough, so answer B is incorrect.
The vital signs are abnormal and should be reported to the doctor immediately. Rhinitis, as stated in answer C, is often seen with viral pneumonia and is
A, B, and D are incorrect actions. incorrect for this case. Vomiting and diarrhea are usually not seen with
pneumonia; thus, answer D is incorrect.
225. Answer B is correct.
236. Answer B is correct.
For a child with LTB and the possibility of complete obstruction of the airway, results in a variable deceleration; and answer C is indicative of an early
emergency intubation equipment should always be kept at the bedside. deceleration.
Intravenous supplies and fluid will not treat an obstruction, nor will
supplemental oxygen; therefore, answers A, C, and D are incorrect. 248. Answer C is correct.
The initial action by the nurse observing a variable deceleration should be to
237. Answer C is correct. turn the client to the side, preferably the left side. Administering oxygen is also
Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. The indicated. Answer A is not called for at this time. Answer B is incorrect because it
client with hyperthyroidism will often exhibit tachycardia, increased appetite, is not needed, and answer D is incorrect because there is no data to indicate
and weight loss. Answers A, B, and D are not associated with hyperthyroidism. that the monitor has been applied incorrectly.

238. Answer D is correct. 249. Answer D is correct.

The child with celiac disease should be on a gluten-free diet. Answer D is the Answers A, B, and C indicate ominous findings on the fetal heart monitor and so
only choice of foods that do not contain gluten. Therefore, answers A, B, and C are incorrect in this instance. Accelerations with movement are normal, so
are incorrect. answer D is the reassuring pattern.

239. Answer C is correct. 250. Answer C is correct.

Remember the ABC’s (air way, breathing, circulation) when answering this Epidural anesthesia decreases the urge to void and sensation of a full bladder. A
question. Before notifying the physician or assessing the child’s pulse, oxygen full bladder decreases the progression of labor. Answers A, B, and D are
should be applied to increase the child’s oxygen saturation. The normal oxygen incorrect because the bladder does not fill more rapidly due to the epidural, the
saturation for a child is 92%–100%. Answer A is important but not the priority, client is not in a trancelike state, and the client’s level of consciousness is not
answer B is inappropriate, and answer D is also not the priority. altered, and there is no evidence that the client is too embarrassed to ask for a
bedpan.
240. Answer B is correct.
Normal amniotic fluid is straw colored and odorless, so this is the observation
the nurse should expect. An amniotomy is artificial rupture of membranes,
causing a straw-colored fluid to appear in the vaginal area. Fetal heart tones of
160 indicate tachycardia, and this is not the observation to watch for. Greenish
fluid is indicative of meconium, not amniotic fluid. If the nurse notes the
umbilical cord, the client is experiencing a prolapsed cord. This would need to be 127, 141, 142, 147, 149, 155, 164, 167, 200, 201, 202, 203, 204, 205, 206, 237.
reported immediately. For this question, answers A, C, and D are incorrect. 238

241. Answer D is correct.

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

242. Answer B is correct.

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

243. Answer D is correct.

The expected effect of Pitocin is progressive cer vical dilation. Pitocin causes
more intense contractions, which can increase the pain; thus, answer A is
incorrect. Answers B and C are incorrect because cervical effacement is caused
by pressure on the presenting part and there are not infrequent contractions.

244. Answer B is correct.

Applying a fetal heart monitor is the appropriate action at this time. Preparing
for a caesarean section is premature; placing the client in Trendelenburg is also
not an indicated action, and an ultrasound is not needed based on the finding.
Therefore, answer B is the best answer, and answers A, C, and D are
incorrect.

245. Answer B is correct.

Absent variability is not normal and could indicate a neurological problem.
Answers A, C, and D are normal findings.

246. Answer D is correct.

Clients admitted in labor are told not to eat during labor, to avoid nausea and
vomiting. Ice chips might be allowed, although this amount of fluid might not be
sufficient to prevent fluid volume deficit. In answer A, impaired gas exchange
related to hyperventilation would be indicated during the transition phase, not
the early phase of labor. Answers B and C are not correct because clients during
labor are allowed to change position as she desires.

247. Answer D is correct.

This information indicates a late deceleration. This type of deceleration is caused
by uteroplacental insufficiency, or lack of oxygen. Answer A is incorrect because
there is no data to support the conclusion that the baby is asleep; answer B