NCLEX Exam NCLEX-PN National Council Licensure Examination(NCLEX-PN) Version: 5.0

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NCLEX Exam NCLEX-PN National Council Licensure Examination(NCLEX-PN) Version: 5.0 NCLEX Exam NCLEX-PN National Council Licensure Examination(NCLEX-PN) Version: 5.0 Question No : 1 - Teaching th... e client with gonorrhea how to prevent reinfection and further spread is an example of: A. primary prevention. B. secondary prevention. C. tertiary prevention. D. primary health care prevention. Answer: B Explanation: Secondary prevention targets the reduction of disease prevalence and disease morbidity through early diagnosis and treatment. Physiological Adaptation Question No : 2 - Which of the following foods is a complete protein? A. corn B. eggs C. peanutsDsunflower seeds Answer: B Explanation: Eggs are a complete protein. The remaining options are incomplete proteins. Health Promotion and MaintenanceQuestion No : 3 - Broccoli, oranges, dark greens, and dark yellow vegetables can be eaten to: A. supplement vitamin pills. B. balance body molecules. C. cure many diseases. D. help improve body defenses. Answer: D Explanation: Controversy over what types of food to eat and not eat is still under investigation. Certain foods can help improve body defenses to possibly prevent certain diseases. Nonpharmacological Therapies Question No : 4 - The major electrolytes in the extracellular fluid are: A. potassium and chloride. B. potassium and phosphate. C. sodium and chloride. D. sodium and phosphate. Answer: C Explanation: Sodium and chloride are the major electrolytes in the extracellular fluid. Physiological Adaptation Question No : 5 - Which of the following nursing diagnoses might be appropriate as Parkinson’s disease progresses and complications develop? A. Impaired Physical Mobility B. DysreflexiaC. Hypothermia D. Impaired Dentition Answer: A Explanation: The client with Parkinson’s disease can develop a shuffling gait and rigidity, causing impaired physical mobility. The other diagnoses do not necessarily relate to a client with Parkinson’s disease. Reduction of Risk Potential Question No : 6 - Which of the following is an inappropriate item to include in planning care for a severely neutropenic client? A. Transfuse netrophils (granulocytes) to prevent infection. B. Exclude raw vegetables from the diet. C. Avoid administering rectal suppositories. D. Prohibit vases of fresh flowers and plants in the client’s room. Answer: A Explanation: Granulocyte transfusion is not indicated to prevent infection. Produced in the bone marrow, granulocytes normally comprise 70% of all WBCs. They are subdivided into three types based on staining properties: neutrophils, eosinophils, and basophils. They can be beneficial in a selected population of infected, severely granulocytopenic clients (less than 500/mm3) who do not respond to antibiotic therapy and who are expected to experience prolonged suppression of granulocyte production. Physiological Adaptation Question No : 7 - A primary belief of psychiatric mental health nursing is: A. most people have the potential to change and grow. B. every person is worthy of dignity and respect. C. human needs are individual to each person.D. some behaviors have no meaning and cannot be understood. Answer: B Explanation: Every person is worthy of dignity and respect. Every person has the potential to change and grow. All people have basic human needs in common with others. All behavior has meaning and can be understood from the client’s perspective. Psychosocial Integrity Question No : 8 - A teenage client is admitted to the hospital because of acetaminophen (Tylenol) overdose. Overdoses of acetaminophen can precipitate lifethreatening abnormalities in which of the following organs? A. lungs B. liver C. kidneys D. adrenal glands Answer: B Explanation: Acetaminophen is extensively metabolized in the liver. Choices 1, 3, and 4 are incorrect because prolonged use of acetaminophen might result in an increased risk of renal dysfunction, but a single overdose does not precipitate life-threatening problems in the respiratory system, renal system, or adrenal glands. Pharmacological Therapies Question No : 9 - All of the following factors, when identified in the history of a family, are correlated with poverty except: A. high infant mortality rate. B. frequent use of Emergency Departments. C. consultation with folk healers.D. low incidence of dental problems. Answer: D Explanation: Dental problems are prevalent because of the lack of preventive care and access to care. High infant mortality is one of the most significant problems correlated with poverty. Pregnant women who do not have access to care might come to the Emergency Department when in labor. Those in poverty are likely to use Emergency Departments because they may not be turned away. Those in poverty might also turn to folk healers or other persons in their community for care who might be easier to access and might not demand payment. Health Promotion and Maintenance Question No : 10 - Acyclovir is the drug of choice for: A. HIV. B. HSV 1 and 2 and VZV. C. CMV. D. influenza A viruses. Answer: B Explanation: Acyclovir (Zovirax) is specific for treatment of herpes virus infections. There is no cure for herpes. Acyclovir is excreted unchanged in the urine and therefore must be used cautiously in the presence of renal impairment. Drugs that treat herpes inhibit viral DNA replication by competing with viral substrates to form shorter, ineffective DNA chains. Physiological Adaptation Question No : 11 - Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confusedand has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley’s level of anxiety as: A. mild. B. moderate. C. severe. D. panic. Answer: C Explanation: The person whose anxiety is assessed as severe is unable to solve problems and has a poor grasp of what’s happening in his or her environment. Somatic symptoms such as those described by Ashley are usually present. Vital sign changes are observed. The individual with mild anxiety might report being mildly uncomfortable and might even find performance enhanced. The individual with moderate anxiety grasps less information about the situation, has some difficulty problem-solving, and might have mild changes in vital signs. The individual in panic demonstrates markedly disturbed behavior and might lose touch with reality. Psychosocial Integrity Question No : 12 - Which of the following methods of contraception is able to reduce the transmission of HIV and other STDs? A. intrauterine device (IUD) B. Norplant C. oral contraceptives D. vaginal sponge Answer: D Explanation: The vaginal sponge is a barrier method of contraception that, when used with foam or jelly contraception, reduces the transmission of HIV and other STDs as well as reducing the risk of pregnancy. IUDs, Norplant, and oral contraceptives can prevent pregnancy but not the transmission HIV and STDs.Clients using the contraceptive methods in Choices 1, 2, and 3 should be counseled to use a chemical or barrier contraceptive to decrease transmission of HIV or STDs. Health Promotion and Maintenance Question No : 13 - Which fetal heart monitor pattern can indicate cord compression? A. variable decelerations B. early decelerations C. bradycardia D. tachycardia Answer: A Explanation: Variable decelerations can be related to cord compression. The other patterns are not.Reduction of Risk Potential Question No : 14 - The nurse teaching about preventable diseases should emphasize the importance of getting the following vaccines: A. human papilloma virus, genital herpes, measles. B. pneumonia, HIV, mumps. C. syphilis, gonorrhea, pneumonia. D. polio, pertussis, measles. Answer: D Explanation: Vaccines are one of the most effective methods of preventing and controlling certain communicable diseases. The smallpox vaccine is not currently in use because the smallpox virus has been declared eradicated from the world’s population. Diseases such as polio, diphtheria, pertussis, and measles are mostly controlled by routine childhood immunization. They have not, however, been eradicated, so children need tobe immunized against these diseases. Physiological Adaptation Question No : 15 - Which of the following conditions is mammography used to detect? A. pain B. tumor C. edema D. epilepsy Answer: B Explanation: Mammography is used to detect tumors or cysts in the breasts, not the other conditions. Reduction of Risk Potential Question No : 16 - When the nurse is determining the appropriate size of an oropharyngeal airway to insert, what part of a client’s body should she measure? A. corner of the mouth to the tragus of the ear B. corner of the eye to the top of the ear C. tip of the chin to the sternum D. tip of the nose to the earlobe Answer: A Explanation: An oropharyngeal airway is measured from the corner of the client’s mouth, to the tragus of the ear. Reduction of Risk Potential Question No : 17 -Which sign might the nurse see in a client with a high ammonia level? A. coma B. edema C. hypoxia D. polyuria Answer: A Explanation: Coma might be seen in a client with a high ammonia level. Reduction of Risk Potential Question No : 18 - What do the following ABG values indicate: pH 7.38, PO2 78 mmHg, PCO2 36mmHg, and HCO3 24 mEq/L? A. metabolic alkalosis B. homeostasis C. respiratory acidosis D. respiratory alkalosis Answer: B Explanation: These ABG values are within normal limits. Choices 1, 3, and 4 are incorrect because the ABG values indicate none of these acid-base disturbances. Physiological Adaptation Question No : 19 - Which of the following is the primary force in sex education in a child’s life? A. school nurse B. peersC. parents D. media Answer: C Explanation: Parents are the primary force in sex education in a child’s life. The school nurse is involved with formal sex education and counseling. Peers become more important in sex education during adolescence but might lack correct information. The media play a powerful role in what children learn about sex through movies, TV, and video games. Health Promotion and Maintenance Question No : 20 - The nurse is assessing the dental status of an 18-month-old child. How many teeth should the nurse expect to examine? A. 6 B. 8 C. 12 D. 16 Answer: C Explanation: In general, children begin dentition around 6 months of age. During the first 2 years of life, a quick guide to the number of teeth a child should have is as follows: Subtract the number 6 from the number of months in the age of the child. In this example, the child is 18 months old, so the formula is 18 – 6 = 12. An 18-month-old child should have approximately 12 teeth.Health Promotion and Maintenance Question No : 21 - Which of the following medications is a serotonin antagonist that might be used to relieve nausea and vomiting? A. metoclopramide (Reglan)B. onedansetron (Zofran) C. hydroxyzine (Vistaril) D. prochlorperazine (Compazine) Answer: B Explanation: Zofran is a serotonin antagonist that can be used to relieve nausea and vomiting. The other medications can be used for nausea and vomiting, but they have different mechanisms of action. Physiological Adaptation Question No : 22 - A client is complaining of difficulty walking secondary to a mass in the foot. The nurse should document this finding as: A. plantar fasciitis. B. hallux valgus. C. hammertoe. D. Morton’s neuroma. Answer: D Explanation: Morton’s neuroma is a small mass or tumor in a digital nerve of the foot. Hallux valgus is referred to in lay terms as abunion.Hammertoe is where one toe is cocked up over another toe. Plantar fasciitis is an inflammation of, or pain in, the arch of the foot.Basic Care and Comfort Question No : 23 - For a client with suspected appendicitis, the nurse should expect to find abdominal tenderness in which quadrant? A. upper right B. upper leftC. lower right D. lower left Answer: C Explanation: The nurse should expect to find abdominal tenderness in the lower-right quadrant in a client with appendicitis. Physiological Adaptation Question No : 24 - Assessment of a client with a cast should include: A. capillary refill, warm toes, no discomfort. B. posterior tibial pulses, warm toes. C. moist skin essential, pain threshold. D. discomfort of the metacarpals. Answer: A Explanation: Assessment for adequate circulation is necessary. Signs of impaired circulation include slow capillary refill, cool fingers or toes, and pain.Basic Care and Comfort Question No : 25 - Which of the following injuries, if demonstrated by a client entering the Emergency Department, is the highest priority? A. open leg fracture B. open head injury C. stab wound to the chest D. traumatic amputation of a thumbAnswer: C Explanation: A stab wound to the chest might result in lung collapse and mediastinal shift that, if untreated, could lead to death. Treatment of an obstructed airway or a chest wound is a higher priority than hemorrhage. The principle of ABC (airway, breathing, and circulation) prioritizes care decisions.Physiological Adaptation Question No : 26 - Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma? A. The clothing is the property of another and must be treated with care. B. Such care facilitates repair and salvage of the clothing. C. The clothing of a trauma victim is potential evidence with legal implications. D. Such care decreases trauma to the family members receiving the clothing. Answer: C Explanation: Trauma in any client, living or dead, has potential legal and/or forensic implications. Clothing, patterns of stains, and debris are sources of potential evidence and must be preserved. Nurses must be aware of state and local regulations that require mandatory reporting of cases of suspected child and elder abuse, accidental death, and suicide. Each Emergency Department has written policies and procedures to assist nurses and other health care providers in making appropriate reports. Physical evidence is real, tangible, or latent matter that can be visualized, measured, or analyzed. Emergency Department nurses can be called on to collect evidence. Health care facilities have policies governing the collection of forensic evidence. The chain of evidence custody must be followed to ensure the integrity and credibility of the evidence. The chain of evidence custody is the pathway that evidence follows from the time it is collected until is has served its purpose in the legal investigation of an incident.Physiological AdaptationQuestion No : 27 - Which of the following statements, if made by the parents of a newborn, does not indicate a need for further teaching about cord care? A. “I should put alcohol on my baby’s cord 3–4 times a day.” B. “I should put the baby’s diaper on so that it covers the cord.” C. “I should call the physician if the cord becomes dark.” D. “I should wash my hands before and after I take care of the cord.” Answer: D Explanation: Parents should be taught to wash their hands before and after providing cord care. This prevents transferring pathogens to and from the cord. Folding the diaper below the cord exposes the cord to air and allows for drying. It also prevents wet or soiled diapers from coming into contact with the cord. Current recommendations include cleaning the area around the cord 3–4 times a day with a cotton swab but do not include putting alcohol or other antimicrobials on the cord. It is normal for the cord to turn dark as it dries.Health Promotion and Maintenance Question No : 28 - A middle-aged woman tells the nurse that she has been experiencing irregular menses for the past six months. The nurse should assess the woman for other symptoms of: A. climacteric. B. menopause. C. perimenopause. D. postmenopause. Answer: CExplanation: Perimenopause refers to a period of time in which hormonal changes occur gradually, ovarian function diminishes, and menses become irregular. Perimenopause lasts approximately five years. Climacteric is a term applied to the period of life in which physiologic changes occur and result in cessation of a woman’s reproductive ability and lessened sexual activity in males. The term applies to both genders. Climacteric and menopause are interchangeable terms when used for females. Menopause is the period when permanent cessation of menses has occurred. Postmenopause refers to the period after the changes accompanying menopause are complete.Health Promotion and Maintenance Question No : 29 - Which of the following might be an appropriate nursing diagnosis for an epileptic client? A. Dysreflexia B. Risk for Injury C. Urinary Retention D. Unbalanced Nutrition Answer: B Explanation: The epileptic client is at risk for injury due to the complications of seizure activity, such as possible head trauma associated with a fall. The other choices are not related to the question.Reduction of Risk Potential Question No : 30 - Which of the following diseases or conditions is least likely to be associated with increased potential for bleeding?A. metastatic liver cancer B. gram-negative septicemia C. pernicious anemia D. iron-deficiency anemia Answer: C Explanation: Pernicious anemia results from vitamin B12 deficiency due to lack of intrinsic factor. This can result from inadequate dietary intake, faulty absorption from the GI tract due to a lack of secretion of intrinsic factor normally produced by gastric mucosal cells and certain disorders of the small intestine that impair absorption. The nurse should instruct the client in the need for lifelong replacement of vitamin B12, as well as the need for folic acid, rest, diet, and support.Physiological Adaptation Question No : 31 - When a client needs oxygen therapy, what is the highest flow rate that oxygen can be delivered via nasal cannula? A. 2 liters/minute B. 4 liters/minute C. 6 liters/minute D. 8 liters/minute Answer: C Explanation: The highest flow rate that oxygen can be delivered via nasal cannula is 6 liters/minute. Higher flow rates must be delivered by mask.Reduction of Risk Potential Question No : 32 - The kind of man who beats a woman is:A. from a minority culture in a low-income group. B. from a majority culture in a middle-income group. C. one who was never allowed to compete as a child. D. from any walk of life, race, income group, or profession. Answer: D Explanation: Batterers cannot be predicted by demographic features related to age, ethnicity, race, religious denomination, education, socioeconomic status, or class. Ninety-five percent of domestic abuse cases involve male perpetrators and female victims.Psychosocial Integrity Question No : 33 - All of the following should be performed when fetal heart monitoring indicates fetal distress except: A. increase maternal fluids. B. administer oxygen. C. decrease maternal fluids. D. turn the mother. Answer: C Explanation: Decreasing maternal fluids is the only intervention that shouldnotbe performed when fetal distress is indicated.Reduction of Risk Potential Question No : 34 - What interpersonal relief behavior is Ashley using? A. acting outB. somatizing C. withdrawal D. problem-solving Answer: B Explanation: Somatizing means one experiences an emotional conflict as a physical symptom. Ashley manifests several physical symptoms associated with severe anxiety. Acting out refers to behaviors such as anger, crying, laughter, and physical or verbal abuse. Withdrawal is a reaction in which psychic energy is withdrawn from the environment and focused on the self in response to anxiety. Problem-solving takes place when anxiety is identified and the unmet need is met.Psychosocial Integrity Question No : 35 - A client comes to the clinic for assessment of his physical status and guidelines for starting a weight-reduction diet. The client’s weight is 216 pounds and his height is 66 inches. The nurse identifies the BMI (body mass index) as: A. within normal limits, so a weight-reduction diet is unnecessary. B. lower than normal, so education about nutrient-dense foods is needed. C. indicating obesity because the BMI is 35. D. indicating overweight status because the BMI is 27. Answer: C Explanation: Obesity is defined by a BMI of 30 or more with no co-morbid conditions. It is calculated by utilizing a chart or nomogram that plots height and weight. This client’s BMI is 35, indicating obesity. Goals of diet therapy are aimed at decreasing weight and increasing activity to healthy levels based on a client’s BMI, activity status, and energy requirements.Physiological AdaptationQuestion No : 36 - Which of the following instructions should the nurse give a client who will be undergoing mammography? A. Be sure to use underarm deodorant. B. Do not use underarm deodorant. C. Do not eat or drink after midnight. D. Have a friend drive you home. Answer: B Explanation: Underarm deodorant should not be used because it might cause confusing shadows on the X-ray film. There are no restrictions on food or fluid intake. No sedation is used, so the client can drive herself home.Reduction of Risk Potential Question No : 37 - Teaching about the need to avoid foods high in potassium is most important for which client? A. a client receiving diuretic therapy B. a client with an ileostomy C. a client with metabolic alkalosis D. a client with renal disease Answer: D Explanation: Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in potassium. Choices 1, 2, and 3 are incorrect because clients receiving diuretics with ileostomy or with metabolic alkalosis are at risk for hypokalemia and should be encouraged to eat foods high in potassium.Physiological AdaptationQuestion No : 38 - A diet high in fiber content can help an individual to: A. lose body weight fast. B. reduce diabetic ketoacidosis. C. lower cholesterol. D. reduce the need for folate. Answer: C Explanation: Fiber-rich foods (such as grains, apples, potatoes, and beans) can help lower cholesterol.Nonpharmacological Therapies Question No : 39 - When administering intravenous electrolyte solution, the nurse should take which of the following precautions? A. Infuse hypertonic solutions rapidly. B. Mix no more than 80 mEq of potassium per liter of fluid. C. Prevent infiltration of calcium, which causes tissue necrosis and sloughing. D. As appropriate, reevaluate the client’s digitalis dosage. He might need an increased dosage because IV calcium diminishes digitalis’s action. Answer: C Explanation: Preventing tissue infiltration is important to avoid tissue necrosis. Choice 1 is incorrect because hypertonic solutions should be infused cautiously and checked with the RN if there is a concern. Choice 2 is incorrect because potassium, mixed in the pharmacy per physician order, is mixed at a concentration no higher than 60 mEq/L. Physiological AdaptationQuestion No : 40 - How often should the nurse change the intravenous tubing on total parenteral nutrition solutions? A. every 24 hours B. every 36 hours C. every 48 hours D. every 72 hours Answer: A Explanation: The nurse should change the intravenous tubing on total parenteral nutrition solutions every 24 hours, due to the high risk of bacterial growth.Health Promotion and Maintenance Question No : 41 - A woman asks, “How much alcohol can I safely drink while pregnant?” The nurse’s best response is: A. “The amount of alcohol that is safe during pregnancy is unknown.” B. “Consuming one or two beers or glasses of wine a day is considered safe for a healthy pregnant woman.” C. “Drinking three or more drinks on any given occasion is the only harmful type of drinking during pregnancy.” D. “You can have a drink to help you relax and get to sleep at night.” Answer: A Explanation: The amount of alcohol that is safe during pregnancy is unknown. Fetal alcohol syndrome is a combination of mental and physical abnormalities present in infants born to mothers who have consumed alcohol during pregnancy.Psychosocial IntegrityQuestion No : 42 - A 10-month-old child is brought to the Emergency Department because he is difficult to awaken. The nurse notes bruises on both upper arms. These findings are most consistent with: A. wearing clothing that is too small for the child. B. the child being shaken. C. falling while learning to walk. D. parents trying to awaken the child. Answer: B Explanation: Children who are shaken are frequently grasped by both upper arms. Symptoms of brain injury associated with shaking include decreased level of consciousness.Psychosocial Integrity Question No : 43 - For which of the following conditions might blood be drawn for uric acid level? A. asthma B. gout C. diverticulitis D. meningitis Answer: B Explanation: Uric acid levels are indicated for clients with gout.Reduction of Risk Potential Question No : 44 - A client has been diagnosed with Disseminated Intravascular Coagulation (DIC) and transferred to the medical intensive care unit (ICU) subsequent to an acute bleeding episode. In the ICU, continuous Heparin drip therapy is initiated. Which of the following assessment findings indicates a positiveresponse to Heparin therapy? A. increased platelet count B. increased fibrinogen C. decreased fibrin split products D. decreased bleeding Answer: B Explanation: Effective Heparin therapy should stop the process of intravascular coagulation and result in increased availability of fibrinogen. Heparin administration interferes with thrombin-induced conversion of fibrinogen to fibrin. Bleeding should cease due to the increased availability of platelets and coagulation factors.Physiological Adaptation Question No : 45 - Which of the following is an appropriate nursing goal for a client at risk for nutritional problems? A. provide oxygen B. promote healthy nutritional practices C. treat complications of malnutrition D. increase weight Answer: B Explanation: Promoting healthy nutritional practices is an appropriate nursing goal for a client at risk for nutritional problems. Choice 1 is incorrect because it is a nursing intervention, not a goal statement. Choice 3 is incorrect because it is a therapeutic treatment. Choice 4 is incorrect because weight gain is an appropriate goal only if the client is underweight.Basic Care and ComfortQuestion No : 46 - Major competencies for the nurse giving end-oflife care include: A. demonstrating respect and compassion, and applying knowledge and skills in care of the family and the client. B. assessing and intervening to support total management of the family and client. C. setting goals, expectations, and dynamic changes to care for the client. D. keeping all sad news away from the family and client. Answer: A Explanation: There are many competencies that the nurse must have to care for families and clients at the end of life. Demonstration of respect and compassion as well as using knowledge and skills in the care of the client and family are major competencies.Basic Care and Comfort Question No : 47 - Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes a serosanguious drainage on the dressing. The most appropriate intervention is to: A. notify the physician of the drainage. B. change the dressing. C. reinforce the dressing. D. apply an abdominal binder. Answer: C Explanation: Serosanguious drainage is expected at this time. The dressing should bereinforced. Changing a new postop dressing increases the risk of infection. An abdominal binder interferes with visualization of the dressing.Basic Care and Comfort Question No : 48 - A client turns her ankle. She is diagnosed as having a Pulled Ligament. This should be documented as a: A. sprain. B. strain. C. subluxation. D. distoration. Answer: B Explanation: A strain is excessive stretching of a ligament. A sprain involves a twisting motion involving muscles.Basic Care and Comfort Question No : 49 - An appropriate intervention for the client with suspected genitourinary trauma and visible blood at the urethral meatus is: A. insertion of a Foley catheter. B. in and out catheter specimen for urinalysis. C. a voided urine specimen for urinalysis. D. a urologist consult. Answer: D Explanation: A urologist consult is appropriate for a client with visible blood at the urethral meatus and suspected trauma. Choices 1 and 2 are contraindicated. A urinalysis might be ordered by thephysician, but the question does not provide enough information to make Choice 3 the correct answer.Physiological Adaptation Question No : 50 - A client with Kawasaki disease has bilateral congestion of the conjunctivae, dry cracked lips, a strawberry tongue, and edema of the hands and feet followed by desquamation of fingers and toes. Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image? A. administering immune globulin intravenously B. assessing the extremities for edema, redness and desquamation every 8 hours C. explaining progression of the disease to the client and his or her family D. assessing heart sounds and rhythm Answer: C Explanation: Teaching the client and family about progression of the disease includes explaining when symptoms can be expected to improve and resolve. Knowledge of the course of the disease can help them understand that no permanent disruption in physical appearance will occur that could negatively affect body image. Clients with Kawasaki disease might receive immune globulin intravenously to reduce the incidence of coronary artery lesions and aneurysms. Cardiac effects could be linked to body image, but Choice 3 is the most direct link to body image. The nurse assesses symptoms to assist in evaluation of treatment and progression of the disease.Health Promotion and Maintenance Question No : 51 - A client, age 28, was recently diagnosed with Hodgkin’s disease. After staging, therapy is planned to include combination radiation therapy and systemic chemotherapy with MOPP— nitrogen mustard, vincristine (Onconvin),prednisone, and procarbazine. In planning care for this client, the nurse should anticipate which of the following side effects to contribute to a sense of altered body image? A. cushingoid appearance B. alopecia C. temporary or permanent sterility D. pathologic fractures Answer: D Explanation: Pathologic fractures are not common to the disease process. Its treatment through osteoporosis is a potential complication of steroid use. Hodgkin’s disease most commonly affects young adults (males), is spread through lymphatic channels to contiguous nodes, and also might spread via the hematogenous route to extradal sites (GI, bone marrow, skin, and other organs). A working staging classification is performed for clinical use and care. Physiological Adaptation Question No : 52 - While undergoing fetal heart monitoring, a pregnant Native-American woman requests that a medicine woman be present in the examination room. Which of the following is an appropriate response by the nurse? A. “I will assist you in arranging to have a medicine woman present.” B. “We do not allow medicine women in exam rooms.” C. “That does not make any difference in the outcome.” D. “It is old-fashioned to believe in that.” Answer: A Explanation: This statement reflects cultural awareness and acceptance that receiving support from a medicine woman is important to the client. The other statements are culturally insensitive and unprofessional.Reduction of Risk PotentialQuestion No : 53 - The goals of palliative care include all of the following except: A. giving clients with life-threatening illnesses the best quality of life possible. B. taking care of the whole person—body, mind, spirit, heart, and soul. C. no interventions are needed because the client is near death. D. support of needs of the family and client. Answer: C Explanation: The goals of palliative care include choices 1, 2, and 4. Choice 3 is not part of palliative care. All aspects of medical, emotional, social, and spiritual needs of the dying client should be focused on until the end of life.Basic Care and Comfort Question No : 54 - When helping a client gain insight into anxiety, the nurse should: A. help relate anxiety to specific behaviors. B. ask the client to describe events that precede increased anxiety. C. instruct the client to practice relaxation techniques. D. confront the client’s resistive behavior. Answer: B Explanation: To gain insight, the client needs to recognize causal events. The other activities focus on recognition of anxiety.Psychosocial IntegrityQuestion No : 55 - A young boy is recently diagnosed with a seizure disorder. Which of the following statements by the boy’s mother indicates a need for further teaching by the nurse? A. “I should make sure he gets plenty of rest.” B. “I should get him a medic alert bracelet.” C. “I should lay him on his back during a seizure.” D. “I should loosen his clothing during a seizure.” Answer: C Explanation: A client having a seizure should be turned to the side to prevent aspiration of secretions. The other statements are correct and indicate adequate understanding of teaching.Reduction of Risk Potential Question No : 56 - To remove hard contact lenses from an unresponsive client, the nurse should: A. gently irrigate the eye with an irrigating solution from the inner canthus outward. B. grasp the lens with a gentle pinching motion. C. don sterile gloves before attempting the procedure. D. ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens. Answer: D Explanation: To remove hard contact lenses, the upper and lower eyelids are gently maneuvered to help loosen the lens and slide it out of the eye. The lens must be situated on the cornea, not the sclera, before removal. An attempt to grasp a hard lens might result in a scratch on the cornea. Clean gloves are an option if drainage is present.Basic Care and ComfortQuestion No : 57 - Which of the following foods might a client with a hypercholesterolemia need to decrease his or her intake of? A. broiled catfish B. hamburgers C. wheat bread D. fresh apples Answer: B Explanation: Due to the high cholesterol content of red meats, such as hamburger, intake needs to be decreased. The other options do not have high cholesterol content, so they do not need to be decreased.Reduction of Risk Potential Question No : 58 - Nurses caring for clients who have cancer and are taking opioids need to assess for all of the following except: A. tolerance. B. constipation. C. sedation. D. addiction. Answer: D Explanation: Addiction is not of primary concern when treating the pain of terminally ill clients. Clients with cancer who are taking opioid analgesics can develop tolerance, constipation, and sedation.Basic Care and ComfortQuestion No : 59 - Which of the following nursing actions is most effective when evaluating a kinetic family drawing? A. telling the child to draw their family doing something B. offering specific suggestions of what to include in the drawing C. discouraging the child from talking about the drawing D. noting the omission of any family members Answer: D Explanation: There are several guidelines for evaluating kinetic family drawings, including Choice 4. Effective nursing actions include asking the child to explain what each family member is doing, encouraging him or her to tell as much as possible about the drawing, noting physical intimacy or distance, noting placement of family members in the drawing, noting facial expressions of family members and noting if they are facing each other or turned away. Choice 1 is initial instruction, not evaluation. Only general encouragement should be given to avoid suggesting themes to the child.Health Promotion and Maintenance Question No : 60 - A client with an ileus is placed on intestinal tube suction. Which of the following electrolytes is lost with intestinal suction? A. calcium B. magnesium C. potassium D. sodium chloride Answer: D Explanation:Duodenal intestinal fluid is rich in K+, NA+, and bicarbonate. Suctioning to remove excess fluids decreases the client’s K+ and NA+ levels.Basic Care and Comfort Question No : 61 - Which of the following terms refers to soft-tissue injury caused by blunt force? A. contusion B. strain C. sprain D. dislocation Answer: A Explanation: A contusion is a soft-tissue injury caused by blunt force. It is an injury that does not break the skin, is caused by a blow and is characterized by swelling, discoloration, and pain. The immediate application of cold might limit the development of a contusion. A strain is a muscle pull from overuse, overstretching, or excessive stress. A sprain is caused by a wrenching or twisting motion. A dislocation is a condition in which the articular surfaces of the bones forming a joint are no longer in anatomic contact.Physiological Adaptation Question No : 62 - Which of the following indicates a hazard for a client on oxygen therapy? A. A No Smoking sign is on the door. B. The client is wearing a synthetic gown. C. Electrical equipment is grounded. D. Matches are removed. Answer: BExplanation: A synthetic gown might generate sparks of static electricity, which can be a fire hazard, particularly in the presence of oxygen. The client on oxygen therapy should wear a cotton gown. The remaining options are appropriate safety measures.Reduction of Risk Potential Question No : 63 - Erythropoietin used to treat anemia in clients with renal failure should be given in conjunction with: A. iron, folic acid, and B12. B. an increase of protein in the diet. C. vitamins A and C. D. an increase of calcium in the diet. Answer: A Explanation: The kidneys of a client in renal failure produce no erythropoietin, a hormone necessary for RBC production. Erythropoietin can be given as replacement, but the client needs adequate iron, folate, and B12 to increase the effectiveness of EPO. Choice 2 is not necessary for RBC production and can increase uremia. Choices 3 and 4 are not necessary for RBC production.Physiological Adaptation Question No : 64 - When obtaining a health history on a menopausal woman, which information should a nurse recognize as a contraindication for hormone replacement therapy? A. family history of stroke B. ovaries removed before age 45 C. frequent hot flashes and/or night sweatsD. unexplained vaginal bleeding Answer: D Explanation: Unexplained vaginal bleeding is a contraindication for hormone replacement therapy. Family history of stroke is not a contraindication for hormone replacement therapy. If the woman herself had a history of stroke or other blood-clotting events, hormone therapy could be contraindicated. Frequent hot flashes and/or night sweats can be relieved by hormone replacement therapy.Health Promotion and Maintenance Question No : 65 - A pregnant Asian client who is experiencing morning sickness wants to take ginger to relieve the nausea. Which of the following responses by the nurse is appropriate? A. “I will call your physician to see if we can start some ginger.” B. “We don’t use home remedies in this clinic.” C. “Herbs are not as effective as regular medicines.” D. “Just eat some dry crackers instead.” Answer: A Explanation: This statement reveals cultural sensitivity. Ginger is sometimes used to relieve nausea. The other statements are culturally insensitive and do not show an awareness of herbal pharmacology.Physiological Adaptation Question No : 66 - Which of the following physical findings indicates that an 11–12-month-old child is at risk for developmental dysplasia of the hip?A. refusal to walk B. not pulling to a standing position C. negative Trendelenburg sign D. negative Ortolani sign Answer: B Explanation: The nurse might be concerned about developmental dysplasia of the hip if an 11–12month-old child doesn’t pull to a standing position. An infant who does not walk by 15 months of age should be evaluated. Children should start walking between 11–15 months of age. Trendelenberg sign is related to weakness of the gluteus medius muscle, not hip dysplasia. Ortolani sign is used to identify congenital subluxation or dislocation of the hip in infants.Health Promotion and Maintenance Question No : 67 - A client with which of the following conditions is at risk for developing a high ammonia level? A. renal failure B. psoriasis C. lupus D. cirrhosis Answer: D Explanation: A client with cirrhosis is at risk for developing a high ammonia level.Reduction of Risk Potential Question No : 68 - What is the primary nutritional deficiency of concern for a strict vegetarian?A. vitamin C B. vitamin B12 C. vitamin E D. magnesium Answer: B Explanation: Vitamin B12 is the primary nutritional deficiency of concern for a strict vegetarian.Health Promotion and Maintenance Question No : 69 - Which of the following foods should be avoided by clients who are prone to develop heartburn as a result of gastroesophgeal reflux disease (GERD)? A. lettuce B. eggs C. chocolate D. butterscotch Answer: C Explanation: Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure leading to reflux and clinical symptoms of GERD. The other foods do not affect LES pressure.Basic Care and Comfort Question No : 70 - A client has been taking alprazolam (Xanax) for four years to manage anxiety. The client reports taking 0.5 mg four times a day. Which statement indicates that the client understands the nurse’s teaching about discontinuing the medication?A. “I can drink alcohol now that I am decreasing my Xanax.” B. “I should not take another Xanax pill. Here is what is left of my last prescription.” C. “I should take three pills per day next week, then two pills for one week, then one pill for one week.” D. “I can expect to be sleepy for several days after stopping the medicine.” Answer: C Explanation: Xanax, like other benzodiazepines, can cause withdrawal symptoms that include agitation, insomnia, hypertension, seizures, and abdominal pain. The drug must be slowly decreased to prevent withdrawal symptoms. Psychosocial Integrity Question No : 71 - A client is taking hydrocodone (Vicodin) for chronic back pain. The client has required an increase in the dose and asks whether this means he is addicted to Vicodin. The nurse should base her reply on the knowledge that: A. the client’s body has developed tolerance, requiring more drug to produce the same effect. B. the client is preoccupied with getting the drug and is experiencing loss of control, indicating drug dependence. C. addiction is the term used to describe physical dependence with withdrawal symptoms and tolerance. D. the client has a dual diagnosis of substance abuse and chronic back pain. Answer: A Explanation: Drug tolerance is characterized by the ability to ingest a larger dose without adverse effect and decreased sensitivity to the substance. Substance dependence is a severe condition indicating physical problems and disruption of the person’s social, family, and work life. The psychological behaviors related to substance use are termed addiction. Dual diagnosis is the coexistence of substance abuse and psychiatric disorders.PsychosocialIntegrity Question No : 72 - A safety measure to implement when transferring a client with hemiparesis from a bed to a wheelchair is: A. standing the client and walking him or her to the wheelchair. B. moving the wheelchair close to client’s bed and standing and pivoting the client on his unaffected extremity to the wheelchair. C. moving the wheelchair close to client’s bed and standing and pivoting the client on his affected extremity to the wheelchair. D. having the client stand and push his body to the wheelchair. Answer: B Explanation: Moving the wheelchair close to client’s bed and having him stand and pivot on his unaffected extremity to the wheelchair is safer because it provides support with the unaffected limb.Basic Care and Comfort Question No : 73 - A client with dumping syndrome should ___________ while a client with GERD should ___________. A. sit up 1 hour after meals; lie flat 30 minutes after meals B. lie down 1 hour after eating; sit up at least 30 minutes after eating C. sit up after meals; sit up after meals D. lie down after meals; lie down after meals Answer: B Explanation:Clients with dumping syndrome should lie down after eating to decrease dumping syndrome. GERD clients should sit up to prevent backflow of acid into the esophagus.Basic Care and Comfort Question No : 74 - Which of the following organs of the digestive system has a primary function of absorption? A. stomach B. pancreas C. small intestine D. gallbladder Answer: C Explanation: The small intestine has a primary function of absorption. The remaining digestive organs have other primary functions.Physiological Adaptation Question No : 75 - Which of the following neurological disorders is characterized by writhing, twisting movements of the face and limbs? A. epilepsy B. Parkinson’s C. muscular sclerosis D. Huntington’s chorea Answer: D Explanation: Huntington’s chorea is characterized by writhing, twisting movements of the face and limbs.The remaining options are neurological disorders that do not have such movements as part of their disease process.Reduction of Risk Potential Question No : 76 - The nurse is teaching parents of a newborn about feeding their infant. Which of the following instructions should the nurse include? A. Use the defrost setting on microwave ovensto warm bottles. B. When refrigerating formula, don’t feed the baby partially used bottles after 24 hours. C. When using formula concentrate, mix two parts water and one part concentrate. D. If a portion of one bottle is left for the next feeding, go ahead and add new formula to fill it. Answer: A Explanation: Parents must be careful when warming bottles in a microwave oven because the milk can become superheated. When a microwave oven is used, the defrost setting should be chosen, and the temperature of the formula should be checked before giving it to the baby. Refrigerated, partially used bottles should be discarded after 4 hours because the baby might have introduced some pathogens into the formula. Returning the bottle to the refrigerator does not destroy pathogens. Formula concentrate and water are usually mixed in a 1:1 ratio of one part concentrate and one part water. Infants should be offered fresh formula at each feeding. Partially used bottles should not have fresh formula added to them. Pathogens can grow in partially used bottles of formula and be transferred to the new formula.Health Promotion and Maintenance Question No : 77 - A client who is immobilized secondary to traction is complaining of constipation. Which of the following medications should the nurse expect to be ordered?A. Advil B. Anasaid C. Clinocil D. Colace Answer: D Explanation: Colace is a stool softener that acts by pulling more water into the bowel lumen, making the stool soft and easier to evacuate.Basic Care and Comfort Question No : 78 - The nurse explains to a client who underwent gastric resection that which of the following meals is most likely to cause rapid emptying of the stomach? A. a high-protein meal B. a high-fat meal C. a large meal regardless of nutrient content D. a high-carbohydrate meal Answer: D Explanation: Meals that are high in carbohydrates promote rapid gastric emptying. The other options are associated with decreased emptying time.Basic Care and Comfort Question No : 79 - A batterer is usually someone who: A. grew up in a loving, secure home. B. was an only child.C. was physically or psychologically abused. D. admits he has a problem with anger. Answer: C Explanation: Many batterers report having been abused as children.Psychosocial Integrity Question No : 80 - A 20-year-old obese female client is preparing to have gastric bypass surgery for weight loss. She says to the nurse, “I need this surgery because nothing else I have done has helped me to lose weight.” Which response by the nurse is most appropriate? A. “If you eat less, you can save some money.” B. “Exercise is a healthier way to lose weight.” C. “You should try the Atkins diet first.” D. “I respect your decision to choose surgery.” Answer: D Explanation: This statement is most appropriate, as it shows respect and empathy. The other statements are both insensitive and unprofessional.Physiological Adaptation Question No : 81 - In teaching clients with Buck’s Traction, the major areas of importance should be: A. nutrition, ROM exercises. B. ROM exercises, transportation. C. nutrition, elimination, comfort, safety. D. elimination, safety, isotonic exercises.Answer: C Explanation: Nutrition, elimination, comfort, and safety are the major areas of importance. The diet should be high in protein with adequate fluids.Basic Care and Comfort Question No : 82 - Light therapy can be effective for: A. overcoming weight problems. B. helping with allergies. C. use in alternative medical treatments. D. working with sleep patterns. Answer: D Explanation: Light therapy can be effective in treating problems associated with sleep patterns, stress, moods, jaundice in newborns, and seasonal affective disorders.Nonpharmacological Therapies Question No : 83 - Assessment of the client with an arteriovenous fistula for hemodialysis should include: A. inspection for visible pulsation. B. palpation of thrill. C. percussion for dullness. D. auscultation of blood pressure. Answer: B Explanation:Thrill should be present. The client should be taught to check this daily at home. Pulsation is not typically visible. Percussion gives no information about the patency of a fistula. Blood pressure is not auscultated in a limb with an AVF. Auscultation of the AVF, for a bruit, is part of an assessment for patency.Physiological Adaptation Question No : 84 - James returns home from school angry and upset because his teacher gave him a low grade on an assignment. After returning home from school, he kicks the dog. This coping mechanism is known as: A. denial. B. suppression. C. displacement. D. fantasy. Answer: C Explanation: Displacement is the transference of anger to another. Anger is displaced on the dog as a convenient object. Psychosocial Integrity Question No : 85 - Which condition is associated with inadequate intake of vitamin C? A. rickets B. marasmus C. kwashiorkor D. scurvy Answer: D Explanation: Scurvy is associated with inadequate intake of vitamin C. The remainingchoices refer to other nutritional deficiencies.Health Promotion and Maintenance Question No : 86 - Which is the proper hand position for performing chest percussion? A. cup the hands B. use the side of the hands C. flatten the hands D. spread the fingers of both hands Answer: A Explanation: The hands are cupped for performing percussion, producing a vibration that helps loosen respiratory secretions. The other hand positions do not accomplish this task.Reduction of Risk Potential Question No : 87 - Which of the following is likely to increase the risk of sexually transmitted disease? A. alcohol use B. certain types of sexual practices C. oral contraception use D. all of the above Answer: D Explanation: STDs affect certain groups in groups in greater numbers. Factors associated with risk include being younger than 25 years of age, being a member of a minority group, residing in an urban setting, being impoverished, and using crack cocaine.Physiological AdaptationQuestion No : 88 - Why might breast implants interfere with mammography? A. They might cause additional discomfort. B. They are contraindications to mammography. C. They are likely to be dislodged. D. They might prevent detection of masses. Answer: D Explanation: Breast implants can prevent detection of masses. Choices 1, 2, and 3 are not ways in which breast implants interfere with mammography.Reduction of Risk Potential Question No : 89 - A health care worker is concerned about a new mother being overwhelmed by caring for her infant. The health care worker should: A. immediately contact child protective services. B. provide the mother with literature about child care. C. consult a therapist to help the mother work out her fears. D. refer the mother to parenting classes. Answer: D Explanation: Prevention of child abuse is centered on teaching the parents how to care for their child and cope with the demands of infant care. Parenting classes can help build self-confidence, self-esteem, and coping skills. Parents benefit by understanding the developmental needs of their children, while learning how to manage their home environment more effectively. The classes also increase the parents’ social contacts and teach about community resources.Psychosocial IntegrityQuestion No : 90 - Which is the proper hand position for performing chest vibration? A. cup the hands B. use the side of the hands C. flatten the hands D. spread the fingers of both hands Answer: C Explanation: The hands are flattened over the area of the body where chest percussion is used to conduct vibration through to the chest and loosen secretions. The other hand positions do not accomplish this task.Reduction of Risk Potential Question No : 91 - Which of the following lab values is associated with a decreased risk of cardiovascular disease? A. high HDL cholesterol B. low HDL cholesterol C. low total cholesterol D. low triglycerides Answer: A Explanation: High HDL cholesterol and low LDL cholesterol are associated with a decreased risk of cardiovascular disease.Reduction of Risk Potential Question No : 92 -When making an occupied bed, it is important for the nurse to: A. keep the bed in the low position. B. use a bath blanket or top sheet for warmth and privacy. C. constantly keep side rails raised on both sides. D. move back and forth from one side to the other when adjusting the linens. Answer: B Explanation: Using a bath blanket or top sheet keeps the client warm and provides privacy. Keeping the bed in the low position and working above raised side rails might strain the nurse’s back. Continually moving back and forth to tuck and arrange linen is time-consuming and disorganized.Basic Care and Comfort Question No : 93 - When a client informs the nurse that he is experiencing hypoglycemia, the nurse provides immediate intervention by providing: A. one commercially prepared glucose tablet. B. two hard candies. C. 4–6 ounces of fruit juice with 1 teaspoon of sugar added. D. 2–3 teaspoons of honey. Answer: D Explanation: The usual recommendation for treatment of hypoglycemia is 10–15 grams of a fast-acting simple carbohydrate, orally, if the client is conscious and able to swallow (for example, 3–4 commercially prepared glucose tablets or 4–6 oz of fruit juice). It is not necessary to add sugar to juice, even if it is labeled as unsweetened juice because the fruit sugar in juice contains enough simple carbohydrate to raise the blood glucose level. Addition of sugar might result in a sharp rise in blood sugar that could last for several hours.Physiological Adaptation Question No : 94 -A client is having a seizure; his blood oxygen saturation drops from 92% to 82%. What should the nurse do first? A. Open the airway. B. Administer oxygen. C. Suction the client. D. Check for breathing. Answer: A Explanation: The nurse needs to open the airway first when the oxygen saturation drops. The other actions might be appropriate, but the airway must be patent.Reduction of Risk Potential Question No : 95 - To remove a client’s gown when she has an intravenous line, the nurse should: A. temporarily disconnect the intravenous tubing at a point close to the client and thread it through the gown. B. cut the gown with scissors. C. thread the bag and tubing through the gown sleeve, keeping the line intact. D. temporarily disconnect the tubing from the intravenous container and thread it through the gown. Answer: C Explanation: Threading the bag and tubing through the gown sleeve keeps the system intact. Opening an intravenous line causes a break in a sterile system and introduces the potential for infection. Cutting a gown off is not an alternative except in an emergency. IV gowns, which open along sleeves, are widely available.Basic Care and ComfortQuestion No : 96 - Which of the following is most likely to impact the body image of an infant newly diagnosed with Hemophilia? A. immobility B. altered growth and development C. hemarthrosis D. altered family processes Answer: D Explanation: Altered Family Processes is a potential nursing diagnosis for the family and client with a new diagnosis of Hemophilia. Infants are aware of how their caregivers respond to their needs. Stresses can have an immediate impact on the infant’s development of trust and how others relate to them because of their diagnosis. The longterm effects of hemophilia can include problems related to immobility. Altered growth and development could not have developed in a newly diagnosed client. Hemarthrosis is acute bleeding into a joint space that is characteristic of hemophilia. It does not have an immediate effect on the body image of a newly diagnosed hemophiliac.Health Promotion and Maintenance Question No : 97 - Which of the following values should the nurse monitor closely while a client is on total parenteral nutrition? A. calcium B. magnesium C. glucose D. cholesterol Answer: C Explanation: Glucose is monitored closely when a client is on total parenteral nutrition, due to high glucose concentrationin the solutions. The other values are not monitored as closely.Health Promotion and Maintenance Question No : 98 - A client with stress incontinence should be advised: A. to purchase absorbent undergarments. B. that Kegel exercises might help. C. that effective surgical treatments are nonexistent. D. that behavioral therapy is ineffective. Answer: B Explanation: Kegel exercises, tightening and releasing the pelvic floor muscles, might improve stress incontinence. Choice 1 is not an appropriate treatment for stress incontinence. Several effective surgical treatments exist. Lifestyle and dietary modifications can also be helpful.Physiological Adaptation Question No : 99 - Diagnostic genetic counseling, for procedures such as amniocentesis and chorionic villus sampling, allows clients to make all of the following choices except: A. terminating the pregnancy. B. preparing for the birth of a child with special needs. C. accessing support services before the birth. D. completing the grieving process before the birth. Answer: D Explanation: If findings are ominous, the grieving process will not be completed before birth. If the couple elects to terminate a pregnancy based on diagnostic tests,there will be grief and concerns for future pregnancies. Couples might choose to access support services and prepare for the birth of an infant with special needs. Some fetal conditions can be treated in utero.Health Promotion and Maintenance Question No : 100 - A client who is experiencing infertility says to the nurse, “I feel I will be incomplete as a man/woman if I cannot have a child.” Which of the following nursing diagnoses is likely to be appropriate for this client? A. Risk for Self Harm B. Body Image Disturbance C. Ineffective Role Performance D. Powerlessness Answer: B Explanation: Of the nursing diagnoses listed, the client’s statement most represents Body Image Disturbance because it directly refers to loss of the function of having a child. Nothing in the statement indicates that the client is at risk for harming herself. Ineffective Role Performance could be correct but is not the best choice because the statement does not reflect a disruption of the parent’s role. Powerlessness could be an appropriate nursing diagnosis if the client described feeling powerless about the infertility.Health Promotion and Maintenance Topic 2, Questions Set B Question No : 101 - An assessment of the skull of a normal 10-monthold baby should identify which of the following? A. closure of the posterior fontanel.B. closure of the anterior fontanel. C. overlap of cranial bones. D. ossification of the sutures. Answer: A Explanation: The posterior fontanel should close by the age of 2 months.Health Promotion and Maintenance Question No : 102 - Attaching a restraint to a side rail or other movable part of the bed can: A. do nothing to the client. B. injure the client if the rail or bed is moved. C. help the client stay in the bed without falling out. D. help the client with better posture. Answer: B Explanation: Attaching a restraint to a movable part of the bed can cause client injury if that part of the bed is moved before releasing restraints.Safety and Infection Control Question No : 103 - The chemotherapeutic DNA alkylating agents such as nitrogen mustards are effective because they: A. cross-link DNA strands with covalent bonds between alkyl groups on the drug and guanine bases on DNA. B. have few, if any, side effects. C. are used to treat multiple types of cancer. D. are cell-cycle-specific agents.Answer: A Explanation: Alkylating agents are highly reactive chemicals that introduce alkyl radicals into biologically active molecules and thereby prevent their proper functioning, replication, and transcription. Choice 2 is incorrect because alkylating agents have numerous side effects including alopecia, nausea, vomiting, and myelosuppression. Choice 3 is incorrect because nitrogen mustards have a broad spectrum of activity against chronic lymphocytic leukemia, non-Hodgkin’s lymphoma, and breast and ovarian cancer, but they are effective chemotherapeutic agents because of DNA crosslinkage. Choice 4 is incorrect because alkylating agents are non-cell-cyclespecific agents.PharmacologicalTherapies Question No : 104 - Using clichés in therapeutic communication leads the client toward: A. viewing the nurse as human. B. accepting himself as human. C. self-disclosing. D. feeling discounted. Answer: D Explanation: The use of clichés in therapeutic communication is commonly construed by the client as the nurse’s lack of understanding, involvement, and caring, so the client might feel demeaned and discounted.Psychosocial Integrity Question No : 105 - Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep?A. exercising vigorously for 20 minutes each night beginning at 9:30 p.m. B. taking a cool shower and drinking a hot cup of tea C. watching TV nightly until midnight D. getting a back rub and drinking a glass of warm milk Answer: D Explanation: These are appropriate measure to promote sleep. Choices 1, 2, and 3 are all stimulation actions that increase arousal and wakefulness.Basic Care and Comfort Question No : 106 - Ethical and moral issues concerning restraints include all of the following except: A. emotional impact on the client and family. B. dignity of the client. C. client’s quality of life. D. policies and procedures. Answer: D Explanation: Policies and procedures, though important, are not in the category of ethical and moral issues. The other options are ethical and moral issues.Safety and Infection Control Question No : 107 - A client is told that his test is positive, but in fact, the client does not have the disease tested for. Which type of false report is this an example of? A. positive B. false positiveC. negative D. false negative Answer: B Explanation: A false-positive result occurs when a test result is labeled positive in error, when the actual result is negative. Safety and Infection Control Question No : 108 - A nurse observes a client sitting alone and talking. When asked, the client reports that he is “talking to the voices.” The nurse’s next action should be: A. touching the client to help him return to reality. B. leaving the client alone until reality returns. C. asking the client to describe what is happening. D. telling the client there are no voices. Answer: C Explanation: Nurses might observe behavioral cues that can indicate the presence of hallucinations. Talking about the hallucinations is reassuring and validating to the client who has them. Focusing on the symptoms and asking about the hallucinations helps the client gain control.Psychosocial Integrity Question No : 109 - A client with massive chest and head injuries is admitted to the ICU from the Emergency Department. All of the following are true except: A. B.the physician in charge of the case is the only person allowed to decide whether organ donation can occur.B. C.the client’s legally responsible party may make the decision for organ donation for the donor if the client is unable to do so. C. D.the organ procurement organization makes the decision regarding which organs to harvest. Answer: C Explanation: The client’s legally responsible party may make the decision for organ donation if the client is unable to do so. The donor (or legally responsible party for the donor), the physician, and the organprocurement organization are all involved in the process regarding whether organ donation is appropriate for a specific donor.Coordinated Care Question No : 110 - High uric acid levels can develop in clients who are receiving chemotherapy. This can be caused by: A. the inability of the kidneys to excrete the drug metabolites. B. rapid cell catabolism. C. toxic effects of the prophylactic antibiotics that are given concurrently. D. the altered blood pH from the acid medium of the drugs. Answer: B Explanation: Chemotherapy causes damage to cells, and uric acid is a cell metabolite.Physiological Adaptation Question No : 111 - A nurse is planning a brief treatment program for a client who was raped. A realistic, shortterm goal is to: A. identify all psychosocial problems.B. eliminate the client’s enticing behaviors. C. resolve feelings of trauma and fear. D. verbalize feeling about the event. Answer: D Explanation: A realistic short-term goal is for the client to verbalize feelings about the event. A brief treatment program is not designed to identify or resolve problems. The focus is on managing acute symptoms. If in-depth psychological problems are identified, the nurse might make referrals for treatment.Psychosocial Integrity Question No : 112 - The vast majority of deaths resulting from unintentional poisoning occur in: A. infants. B. toddlers. C. teens. D. adults. Answer: B Explanation: The vast majority of deaths resulting from unintentional poisoning occur in toddlers.Safety and Infection Control Question No : 113 - Common problems for supervisors include all of the following except: A. the supervisor facilitates development of staff members. B. the supervisor micromanages staff members.C. the supervisor wants to control the style in which a staff member correctly performs a task. D. the supervisor does not delegate. Answer: A Explanation: Facilitating the development of staff members is an important goal for a supervisor. Micromanagement, intolerance for individual differences in style, and inability to delegate all interfere with team building and overall effectiveness.Coordinated Care Question No : 114 - The nurse is caring for a client who is dying. While assessing the client for signs of impending death, the nurse observes the client for: A. elevated blood pressure. B. Cheyne-Stokes respiration. C. elevated pulse rate. D. decreased temperature. Answer: B Explanation: Cheyne-Stokes respirations are rhythmic waxing and waning of respirations from very deep breathing to very shallow breathing with periods of temporary apnea, often associated with cardiac failure. This can be a sign of impending death.Psychosocial Integrity Question No : 115 - A client with asthma develops respiratory acidosis. Based on this diagnosis, what should the nurse expect the client’s serum potassium level to be? A. normalB. elevated C. low D. unrelated to the pH Answer: B Explanation: Hyperkalemia occurs in a state of acidosis because potassium moves from injured cells into the bloodstream. Physiological Adaptation Question No : 116 - The nurse should teach parents of small children that the most common type of first-degree burn is: A. scalding from hot bath water or spills. B. contact with hot surfaces such as stoves and fireplaces. C. contact with flammable liquids or gases resulting in flash burns. D. sunburn from lack of protection and overexposure. Answer: D Explanation: The most common type of first-degree burn is sunburn, underscoring the need for education regarding the use of sunscreens and avoiding exposure.Safety and Infection Control Question No : 117 - A 57-year-old woman is recently widowed. She states, “I will never be able to learn how to manage the finances. My husband did all of that.” Select the nurse’s response that could help raise the client’s self-esteem. A. “You feel inadequate because you have never learned to balance a checkbook.” B. “You should have insisted your husband teach you about the finances.”C. “You are strong and will learn how to manage your finances after awhile.” D. “Why don’t you take a class in basic finance from the local college?” Answer: C Explanation: The nurse can raise the client’s self-esteem by communicating confidence the client can participate in actively finding solutions to the problem. The nurse also conveys the client is a worthwhile person by listening and accepting the client’s feelings and praising the client for seeking assistance.Psychosocial Integrity Question No : 118 - Following the change of shift report, the nurse should analyze the information and set priorities accordingly. When the plan has been formulated, at what point during the shift can or should the nurse’s plan be altered or modified? A. halfway through the shift B. at the end of the shift before the nurse reports off C. when needs change D. after the top-priority tasks have been completed Answer: C Explanation: The nurse changes the plan to respond to changes in needs.Coordinated Care Question No : 119 - Signs of impaired breathing in infants and children include all of the following except: A. nasal flaring. B. grunting. C. seesaw breathing.D. quivering lips. Answer: D Explanation: Lip quivering is a distracter. Signs of impaired breathing in infants and children include all the other options. Physiological Adaptation Question No : 120 - On first meeting, a new nurse manager makes eye contact, smiles, initiates conversation about the previous work experience of nurses, and encourages active participation by nurses in the dialogue. Her behavior is an example of: A. aggressiveness. B. passive aggressiveness. C. passiveness. D. assertiveness. Answer: D Explanation: This nurse manager is demonstrating assertive behavior. Aggressive behavior dominates or embarrasses. Passive behavior is nervous or timid. Passive-aggressive behavior is dominating or manipulative without directness. Coordinated Care Question No : 121 - A 35-year-old Latin-American client wishes to lose weight to reduce her chances of developing heart disease and diabetes. The client states, “I do not know how to make my diet work with the kind of foods that my family eats.” What should the nurse do first to help the client determine a suitable diet for disease prevention? A. Provide her with copies of the approved dietary guidelines for theAmerican Diabetic Association and the American Heart Association. B. Ask the client to provide a list of the types of foods she eats to determine how to best meet her needs. C. Provide a high-protein diet plan for the client. D. Provide the client with information related to risk factors for heart disease and diabetes. Answer: B Explanation: Assessment is the first step. Assessing what the client eats helps the nurse determine a plan for dietary recommendations based on the ADA and AHA guidelines. Providing the client with a copy of the guidelines is important but is not the first priority. Based on the client’s wish to reduce her chances of heart disease and diabetes, a high-protein diet plan might not be appropriate. Providing information to the client related to risk factors for heart disease and diabetes is important but is not the first step.Health Promotion and Management Question No : 122 - A client is given an opiate drug for pain relief following general anesthesia. The client becomes extremely somnolent with respiratory depression. The physician is likely to order the administration of: A. naloxone (Narcan). B. labetalol (Normodyne). C. neostigmine (Prostigmin). D. thiothixene (Navane). Answer: B Explanation: Tolerance is the capacity to ingest an increasing amount of a substance without effect and the experience of decreased sensitivity to the substance. Tolerance can develop with long-term use of many drugs. Choice 1 is the dose required to produce a defined magnitude of drug effect. Choice 3 binds to a receptor and causes an action. Choice 4 is the maximal response produced by a drug.PharmacologicalTherapies Question No : 123 - The nurse is teaching a client about erythema infectiosum. Which of the following factors are not correct? A. There is no rash. B. The disorder is uncommon in adults. C. There is no fever. D. There is sometimes a “slapped face” appearance. Answer: B Explanation: Fifth’s disease, erythema infectiosum, is uncommon in adults. All the other statements are correct.Safety and Infection Control Question No : 124 - In conducting a health screening for 12-month-old children, the nurse expects them to have been immunized against which of the following diseases? A. measles, polio, pertussis, hepatitis B B. diptheria, pertussis, polio, tetanus C. rubella, polio, pertussis, hepatitis A D. measles, mumps, rubella, polio Answer: B Explanation: By 12 months of age, the child should have had DtaP and polio. MMR is not administered until a child is 12 months of age.Health Promotion and MaintenanceQuestion No : 125 - A client states, “I eat a well-balanced diet. I do not smoke. I exercise regularly, and I have a yearly checkup with my physician. What else can I do to help prevent cancer?” The nurse should respond with which of the following statements? A. Sleep at least 6–8 hours a night. B. Practice monthly self-breast examination. C. Reduce stress. D. All of the above. Answer: D Explanation: All of the choices are methods of preventing cancer. Sleep is important in maintaining homeostasis, which helps the body respond to disease. Monthly breast examination can indicate cancer or fibrocystic disease. The body has a physiological response to stress that can decrease the immune response and increase the risk of disease.Health Promotion and Management Question No : 126 - A 65-year-old female client is experiencing postmenopausal bleeding. Which type of physician should this client be encouraged to see? A. a radiologist B. a gynecologist C. a physiatrist D. an oncologist Answer: B Explanation: A gynecologist is the physician who treats and manages disease of the female reproductive organs. A radiologist evaluates X-rays. A physiatrist is thephysician manager of a rehabilitation team. An oncologist treats clients with cancer.Coordinated Care Question No : 127 - Which of the following observations is most important when assessing a client’s breathing? A. presence of breathing and pulse rate B. breathing pattern and adequacy of breathing C. presence of breathing and adequacy of breathing D. patient position and adequacy of breathing Answer: C Explanation: It is not enough to simply make sure the client is breathing. The client must be breathingadequately. Physiological Adaptation Question No : 128 - Several passengers aboard an airliner suddenly become weak and suffer breathing difficulty. The diagnosis is likely to be: A. outbreak of Asian flu. B. Chemical exposure. C. bacterial pneumonia. D. allergic reaction. Answer: B Explanation: The most likely cause of groups of individuals suddenly experiencing similar signs of illness all at once is a chemical exposure.Safety and Infection ControlQuestion No : 129 - The nurse observes bilateral bruises on the arms of an elderly client in a longterm care facility. Which of the following questions should the nurse ask this client? A. “How did you get those bruises?” B. “Did someone grab you by your arms?” C. “Do you fall often?” D. “What did you bump against?” Answer: B Explanation: Using a direct approach is best when asking about suspected abuse. Clients are reluctant to report abuse because of shame and fear of reprisal.Psychosocial Integrity Question No : 130 - In performing a psychosocial assessment, the nurse begins by asking questions that encourage the client to describe problematic behaviors and situations. The next step is to elicit the client’s: A. feelings about what has been described. B. thoughts about what has been described. C. possible solutions to the problem. D. intent in sharing the description. Answer: B Explanation: Questions should be asked in a precise order (specifically, from the mostsimple description to the moredifficult disclosure of feelings). When the problems have been described, eliciting the client’s thoughts about the dilemmas provides further assessment data as well as the client’s interpretation of what has happened. Feelings, solutions and articulatingintent are more complex processes.Psychosocial Integrity Question No : 131 - A 12-year-old male is brought to his primary care provider to determine whether sexual abuse has occurred. The mother states, “Because there is no permanent physical damage, he does not need any more treatment.” The nurse’s response should be based on which of the following pieces of information? A. Male victims of sexual abuse seldom have long-term psychological problems. B. Survivors of male sexual abuse might become confused about their sexual identity. C. Unless treated, all male sex abuse survivors grow up to abuse other children. D. All children who have been sexually abused have the same needs, regardless of gender. Answer: B Explanation: Male children are sexually abused nearly as often as female children. Perpetrators are usually men but can be women. Needs of male children who have been sexually abused might be different from the needs of female survivors. Male survivors might respond in anger, question their sexuality, use alcohol and other drugs, and might try to prove their masculinity by performing daring acts.Psychosocial Integrity Question No : 132 - What significant event occurs in the orientation phase of a nurse-client relationship? A. establishment of rolesB. identification of transference phenomenon C. placement of the client within the client’s family structure D. client agreement that the nurse has the authority in the relationship Answer: B Explanation: Transference phenomena are intensified in relationships with authority, such as physicians and nurses. Common positive transferences include desire for affection and gratification of dependency needs. Common negative transferences include hostility and competitiveness. These transferences must be recognized and resolved before growth and positive change can be undertaken in the working stage.Psychosocial Integrity Question No : 133 - Which of the following ethnic groups is at highest risk in the United States for pesticiderelated injuries? A. Native American B. Asian-Pacific C. Norwegian D. Hispanic Answer: D Explanation: Because Hispanic people represent a large percentage of migrant workers in the United States, many work in agricultural settings and might be exposed to pesticides, putting them at higher risk than the other groups.Safety and Infection Control Question No : 134 - The nurse wishes to decrease a client’s use of denial and increase the client’s expression of feelings. To do this the nurse should:A. tell the client to stop using the defense mechanism of denial. B. positively reinforce each expression of feelings. C. instruct the client to express feelings. D. challenge the client each time denial is used. Answer: B Explanation: The nurse should positively reinforce each expression of feelings.Psychosocial Integrity Question No : 135 - A corporate executive works 60–80 hours a week. The client is experiencing some physical signs of stress. The nurse teaches the client biofeedback techniques. This is an example of which of the following health-promotion interventions? A. structure B. relaxation technique C. time management D. regular exercise Answer: B Explanation: Biofeedback techniques can be used to quiet the mind, release tension, and counteract responses of general adaptation syndrome or stress syndrome. Nurses teaching relaxation techniques should encourage use of these techniques in stressful situations.Psychosocial Integrity Question No : 136 - The focus of a nurse case manager is:A. nursing care needs at discharge. B. the comprehensive care needs of the client for continuity of care. C. client education needs upon discharge. D. financial resources for needed care. Answer: B Explanation: By definition, case management is a process of providing for the comprehensive care needs of a client for continuity of care throughout the health care experience.Coordinated Care Question No : 137 - A 17-year-old female was raped by a young man in her neighborhood. She is in the Emergency Department for evaluation and tests. After the procedure is completed, a rape crisis counselor (nurse specialist) talks to the client in a conference room regarding the rape. Implementing counseling by the nurse specialist for the raped victim represents: A. assessment. B. crisis intervention. C. empathetic concern. D. unwarranted intrusion. Answer: B Explanation: Choice 2 is part of the Crisis Intervention Model. Counseling by a nurse specialist at the time of a stressful event (rape) can strengthen the client’s coping. A nurse specialist in rape crisis intervention is educationally prepared in counseling and crisis intervention specific to rape victims.Coordinated Care Question No : 138 - An elderly client denies that abuse is occurring. Which of the following factorscould be a barrier for the client to admit being a victim? A. knowledge that elder abuse is rare B. personal belief that abuse is deserved C. lack of developmentally appropriate screening tools D. fear of reprisal or further violence if the incident is reported Answer: D Explanation: Barriers to reporting elder abuse include victim shame, fear of reprisals, fear of loss of caregiver, and lack of knowledge of agencies that provide services. Many elders fear that reporting abuse results in their placement in long-term care because the current caregiver is the abuser. Choices 1 and 3 are incorrect. Choice 2 might be true but is not the best choice.Psychosocial Integrity Question No : 139 - The death of a beloved spouse places the surviving partner in which type of crisis? A. maturational B. reactive C. nonreactive D. situational Answer: D Explanation: A situational crisis is an unexpected, unplanned event, such as the death of a spouse. Option 1 is a normal maturational crisis; Choices 2 and 3 are not recognized crisis states.Coordinated Care Question No : 140 - At what point in the nurse-client relationship should termination first beaddressed? A. in the working phase B. in the termination phase C. in the orientation phase D. when the client initially brings up the topic Answer: C Explanation: The client has a right to know the parameters of the nurse-client relationship. If the relationship is to be time limited, the client should be informed of the number of sessions. If it is open-ended, the termination date is not known at the outset, and the client should know that this is an issue that is negotiated at a later date.Coordinated Care Question No : 141 - The drug of choice to decrease uric acid levels is: A. prednisone (Colisone). B. allopurinol (Zyloprim). C. indomethacin (Indocin). D. hydrochlorothiazide (HydroDiuril). Answer: B Explanation: Allopurinol is a drug used to treat gout, and it decreases uric acid formation. Prednisone is a corticosteroid used to decrease inflammation. Indomethacin is an analgesic, anti-inflammatory, and antipyretic agent. Hydrochlorothiazide is a thiazide diuretic used to treat hypertension and edema.Physiological Adaptation Question No : 142 -Support-system enhancement includes all of the following except: A. determining the barriers to using support systems. B. discussing ways to help with others who are concerned. C. exploring life problems of the support-team members. D. involving spouse, family, and friends in the care and planning. Answer: C Explanation: The exploration of life problems of support-team members is not necessary to enhance the support system. Choices 1, 2, and 4 are all enhancements for a support system.Psychosocial Integrity Question No : 143 - The intent of the Patient Self Determination Act (PSDA) of 1990 is to: A. enhance personal control over legal care decisions. B. encourage medical treatment decision making prior to need. C. give one federal standard for living wills and durable powers of attorney. D. emphasize client education. Answer: B Explanation: The purpose of the PSDA is to promote decision-making prior to need. Choices 1, 3 and 4 are incorrect. The focus of the PSDA is individual health care decision-making. A federal standard for advance directives does not exist. Each state has jurisdiction regarding these policies and protocols.Coordinated Care Question No : 144 - A 4-year-old client is unable to go to sleep at night in the hospital. Which nursing intervention best promotes sleep for the child? A. turning out the room light and closing the door B. tiring the child during the evening with play exercisesC. identifying the child’s home bedtime rituals and following them D. encouraging visitation by friends during the evening Answer: C Explanation: Preschool-age children require bedtime rituals that should be followed in the hospital if possible. Choice 1 increases a child’s fear. Choices 2 and 4 do not promote sleep.Basic Care and Comfort Question No : 145 - In a disaster situation, the nurse assessing a diabetic client on insulin assesses for all of the following except: A. diabetic signs and symptoms. B. nutritional status. C. bleeding problems. D. availability of insulin. Answer: C Explanation: Bleeding problems are not characteristic of diabetes. All the other options are appropriate areas of assessment. Safety and Infection Control Question No : 146 - Fat emulsions are frequently administered as a part of total parenteral nutrition. Which statement is true regarding fat emulsions? A. They have a high energy-to-fluid-volume ratio. B. Even though hypertonic, they are well tolerated. C. They are a basic solution secondary to the addition of sodium hydroxide (NaOH). D. The pH is alkaline, making them compatible with most medications.Answer: A Explanation: They have a high energy-to-fluid-volume ratio. Fat emulsions are formulated in 10%, 20%, and 30% solutions and supply 1.1, 2, and 3 kilocalories respectively for each milliliter. A milliliter of 5% dextrose only supplies 0.17 kilocalories. Choices 2, 3, and 4 are incorrect because fat emulsions are essentially pH neutral and isotonic.Pharmacological Therapies Question No : 147 - What is the primary theory that explains a family’s concept of health and illness? A. Health Belief Model B. Education-School-Completing Factor C. Family Health Expert Factor D. Disconnected Family Factor Answer: A Explanation: The Health Belief Model describes readiness factors; the perceived feelings of susceptibility and seriousness of the health problem (the threat); and positive motivation to maintain, regain, or attain wellness.Health Promotion and Maintenance Question No : 148 - The most common cause of injury from a house fire is: A. explosion.B. falls from second-story windows. C. thermal damage to skin and body surfaces. D. inhalation injury. Answer: D Explanation: Inhalation is the most common cause of injury from a house fire.Accident Prevention Question No : 149 - Legal protection of confidentiality: A. extends only to written documentation. B. extends to the electronic dissemination of information not identifiable to a specific client. C. is important only within the court system. D. extends to both written and verbal information. Answer: D Explanation: Legal protection of confidentiality extends to both written and verbal information identifiable as individual private health information.Coordinated Care Question No : 150 - A 45-year-old client with type I diabetes is in need of support services upon discharge from a skilled rehabilitation unit. Which of the following services is an example of a skilled support service? A. shopping for groceries B. house cleaning C. transportation to physician’s visitsD. medication instruction Answer: D Explanation: The only skilled service listed is medication instruction. Grocery shopping, house-cleaning services, and transportation services are all examples of unskilled services offered by volunteer and feefor-service agencies. Coordinated Care Question No : 151 - The 24-hour day-night cycle is known as: A. circadian rhythm. B. infradium rhythm. C. ultradian rhythm. D. non-REM rhythm. Answer: A Explanation: Circadian rhythm is rhythmic repetition of patterns each 24 hours. The other options are incorrect.Basic Care and Comfort Question No : 152 - Rehabilitation services begin: A. when the client enters the health care system. B. after the client requests rehabilitation services. C. after the client’s physical condition stabilizes. D. when the client is discharged from the hospital. Answer: A Explanation:Rehabilitation services should begin when the client enters the health care system.Health Promotion and Maintenance Question No : 153 - Which of the following individuals may legally give informed consent? A. an 86-year-old male with advanced Alzheimer’s disease B. a 14-year-old girl needing an appendectomy who isnotan emancipated minor C. a 72-year-old female scheduled for a heart transplant D. a 6-month-old baby needing bowel surgery Answer: C Explanation: The 72-year-old client scheduled for heart transplant surgery may give informed consent for the surgery. There are no age limitations with the exception of minors. Choices 1, 2, and 4 are incorrect. An individual with advanced Alzheimer’s disease is incompetent to make decisions. Only an emancipated minor may give consent (a 14-year-old child who lives alone, away from family, and is totally independent). Infants are unable to give consent.Coordinated Care Question No : 154 - Which isolation procedure will be followed for secretions and blood? A. Respiratory B. Standard Precautions C. Contact Isolation D. Droplet Answer: BExplanation: Standard precautions are taken in all situations for all clients and involve all body secretions except sweat and are designed to reduce the rate of transmission of microbes from one host to another or one source (environment such as the client’s bedside table) to another.Safety and Infection Control Question No : 155 - Medication bound to protein can have which of the following effects? A. enhancement of drug availability B. rapid distribution of the drug to receptor sites C. less availability to produce desired medicinal effects D. increased metabolism of the drug by the liver Answer: C Explanation: Only an unbound drug can be distributed to active receptor sites. Therefore, the more of a drug that is bound to protein, the less it is available for the desired drug effect. Choice 1 is incorrect because less drug is available if it is bound to protein. Choice 2 is incorrect because distribution to receptor sites is irrelevant if the drug, which is bound to protein, cannot bind with a receptor site. Choice 4 is incorrect because metabolism is not increased. The liver first has to remove the drug from the protein molecule before metabolism can occur. The protein is then free to return to circulation and be used again.Pharmacological Therapies Question No : 156 - All of the following are common reasons that nurses are reluctant to delegate except: A. lack of self-confidence.B. desire to maintain authority. C. confidence in subordinates. D. getting trapped in the “I can do it better myself” mindset. Answer: C Explanation: If a delegator has confidence in his subordinates and feels that a task will be performed correctly, he is more likely to delegate. Reasons that delegators are reluctant to delegate include their own lack of confidence, fear of losing authority or personal satisfaction, and feeling that the task can only be performed correctly if they do it themselves.Coordinated Care Question No : 157 - Mr. H. is upset regarding being in the hospital for another day because he states it costs too much. The rights he is likely to demand include all of the following except: A. the right to examine and question the bill. B. the right to reasonable response to requests. C. the right to refuse treatment. D. the right to confidentiality. Answer: D Explanation: Confidentiality is the maintenance of privacy of information. The question does not suggest that confidentiality has been breached. The client is likely to demand the other rights and may exercise them in choosing to leave the hospital early.Coordinated Care Question No : 158 - A wrong committed by one person against another (or against the property of another) that might result in a civil trial is:A. a tort. B. a crime. C. a misdemeanor. D. a felony. Answer: A Explanation: Torts are wrongs committed by one person against another person (or against the property of another), which might result in civil trials. A crime is also defined as a wrong against a person or their property but is considered to be against the public as well. Misdemeanors are crimes that are commonly punishable with fines or imprisonment for less than one year, with both or with parole. A felony is a serious crime punishable by imprisonment in a State or Federal penitentiary for more than one year.Coordinated Care Question No : 159 - The greatest time savers when planning client care include all of the following except: A. reacting to the crisis of the moment. B. setting goals. C. planning. D. specifying priorities. Answer: A Explanation: The greatest time-savers when planning client care are activities that facilitate focus and completion of priority items. Time-savers include setting goals, establishing priorities, planning tasks, delegating where appropriate, reassessment, and ongoing evaluation of needs.Coordinated CareQuestion No : 160 - A client goes to the Emergency Department with acute respiratory distress and the following arterial blood gases (ABGs): pH 7.35, PCO2 40 mmHg, PO2 63mmHg, HCO3 23, and oxygenation saturation ( SaO2) 93%. Which of the following represents the best analysis of the etiology of these ABGs? A. tuberculosis (TB) B. pneumonia C. pleural effusion D. hypoxia Answer: D Explanation: A combined low PO2 and lowSaO2 indicates hypoxia. The pH, PCO2, and HCO3 are normal. ABGs are not necessarily altered in TB or pleural effusion. Depending on the degree of the pneumonia, the PO2 and PCO2 might be low because hypoxia stimulates hyperventilation.Physiological Adaptation Question No : 161 - A client is given an opiate drug for pain relief following general anesthesia. The client becomes extremely somnolent with respiratory depression. The physician is likely to order the administration of: A. naloxone (Narcan). B. labetalol (Normodyne). C. neostigmine (Prostigmin). D. thiothixene (Navane). Answer: A Explanation: Naloxone is an opiate antagonist. It attaches to opiate receptors and blocks or reverses the action of narcotic analgesics. Choice 2 is incorrect because Labetalol is a beta blocker. Choice 3 is incorrect because Neostigmine is an anticholinesterase agent. Choice 4 is incorrect because Thiothixene is an antipsychotic agent.Pharmacological TherapiesQuestion No : 162 - Client self-determination is the primary focus of: A. malpractice insurance. B. nursing’s advocacy for clients. C. confidentiality. D. health care. Answer: B Explanation: Advocacy for clients by nurses is the primary focus of the client’s right to autonomy and self-determination. Confidentiality involves the maintenance of the privacy of the client and information regarding him or her. Malpractice insurance is a type of insurance for professionals.Coordinated Care Question No : 163 - A client begins a regimen of chemotherapy. Her platelet counts falls to 98,000. Which action is least likely to increase the risk of hemorrhage? A. Test all excreta for occult blood. B. Use a soft toothbrush or foam cleaner for oral hygiene. C. Implement reverse isolation. D. Avoid IM injections. Answer: C Explanation: Reverse isolation does not affect the risk of hemorrhage.Physiological AdaptationQuestion No : 164 - The family carries out its health care functions in which of the following ways? A. Family provides very little preventive health care to its members at home. B. Family provides sick care to its members. C. Family pays for most health services. D. Family decides when and where to hospitalize its members. Answer: B Explanation: The family provides sick care to its members. The other options are incorrect.Prevention and Early Detection of Disease Question No : 165 - A concern regarding maternal and infant mortality and morbidity is that: A. a segment of the population is not receiving prenatal care. B. families appear unconcerned about quality health care. C. the personnel shortage in the maternity field will increase. D. maternal-child health workers are not adequately prepared. Answer: A Explanation: There is a concern that a segment of the population is not accessing prenatal care, affecting infant and maternal mortality and morbidity.Health Promotion and Maintenance Question No : 166 - Which of the following solutions is routinely used to flush an IV device before and after the administration of blood to a client?A. 0.9% sodium chloride B. 5% dextrose in water solution C. sterile water D. Heparin sodium Answer: A Explanation: Normal saline is 0.9% sodium chloride. This solution has the same osmolarity as blood. Its use does not cause lysis of cells. Choices 2 and 3 are hypotonic solutions that can cause cell lysis. Choice 4 is an anticoagulant. Pharmacological Therapies Question No : 167 - A couple from the Philippines living in the United States is expecting their first child. In providing culturally competent care, the nurse must first: A. review their own cultural beliefs and biases. B. respectfully request that the couple utilize only medically approved health care providers. C. realize that the clients have to learn their new country’s accepted medical practices. D. study family dynamics to understand the male and female gender roles in the clients’ culture. Answer: A Explanation: The nurse needs to recognize her own beliefs and biases and learn about the client’s cultural beliefs. Psychosocial Integrity Question No : 168 - The nurse is teaching a client about the use of Rifampin for prophylaxis afteran exposure to meningitis. What change in bodily functions should the nurse advise the client about? A. The client’s urine might turn blue. B. The client remains infectious to others for 48 hours. C. The client’s contact lenses might be stained orange. D. The client’s skin might take on a crimson glow. Answer: C Explanation: Rifampin has the unusual effect of turning body fluids an orange color. Soft contact lenses might become permanently stained. Clients should be taught about these side effects to avoid unnecessary concern.Safety and Infection Control Question No : 169 - The nurse is teaching a teenage female about preventing the transmission of genital herpes. Which of the following statements should the nurse include? A. “Do not sit on toilet seats without protection.” B. “Oral sex does not transmit the virus.” C. “This infection can be transmitted via intercourse even when you do not feel ill.” D. “Try to drink lots of fluids after sex to flush the reproductive tract.” Answer: C Explanation: Genital herpes can be transmitted by oral, genital, and anal sex. The other statements are myths.Safety and Infection Control Question No : 170 -Someone who has received a recent tattoo should be screened for: A. tuberculosis. B. herpes. C. hepatitis. D. syphilis. Answer: C Explanation: Tattooing puts a client at risk for blood-borne hepatitis B or C if strict sterile procedures are not followed. Tuberculosis is an airborne pathogen, while herpes and syphilis are spread directly (such as through sexual contact).Safety and Infection Control Question No : 171 - How often must physical restraints be released? A. every 2 hours B. between 1 and 3 hours C. every 30 minutes D. at least every 4 hours Answer: A Explanation: Restraints must be released every 2 hours, and the client must be assessed every 30 minutes while restrained. Safety and Infection Control Question No : 172 - A client recently lost a child due to poisoning. The client tells the nurse, “I don’t want to make any new friends right now.” This is an example of which of the following indicators of stress?A. emotional behavioral indicator B. spiritual indicator C. sociocultural indicator D. intellectual indicator Answer: C Explanation: Stress can alter a person’s relationships with others.Psychosocial Integrity Question No : 173 - A client can receive the mumps, measles, rubella (MMR) vaccine if he or she: A. is pregnant. B. is immunocompromised. C. is allergic to neomycin. D. has a cold. Answer: D Explanation: A simple cold without fever does not preclude vaccination. Choices 1 and 2 are incorrect because pregnant women and immunocompromised individuals cannot have the MMR vaccine because the rubella component is a live virus and might cause birth defects and/or disease. Choice 3 is incorrect because the American Academy of Pediatrics states, “Persons who have experienced anaphylactic reactions to topically or systemically administered neomycin should not receive measles vaccine.”Pharmacological Therapies Question No : 174 - Quality is defined as a combination of all of the following except:A. conforming to standards. B. performing at the minimally acceptable level. C. meeting or exceeding customer requirements. D. exceeding customer expectations. Answer: B Explanation: Compliance or performance at the minimally acceptable level is not considered quality care.Coordinated Care Question No : 175 - According to the ANA Code of Ethics for Nurses, professional nurses have an ethical obligation to: A. clients (patients). B. the profession of nursing. C. provide high-quality care. D. all of the above. Answer: D Explanation: All the choices are elements of the ANA Code of Ethics for Nurses.Coordinated Care Question No : 176 - A 2-year-old child diagnosed with HIV comes to a clinic for immunizations. Which of the following vaccines should the nurse expect to administer in addition to the scheduled vaccines? A. pneumococcal vaccine B. hepatitis A vaccine C. Lyme disease vaccineD. typhoid vaccine Answer: A Explanation: Pneumococcal vaccine should be administered as a supplemental vaccine. Hepatitis A vaccine is for travelers and individuals with chronic liver disease. The Lyme disease vaccine is for people between the ages of 15 and 70 who are at risk for Lyme disease (transmitted by ticks primarily). The typhoid vaccine is for workers in microbiology laboratories who frequently work with Salmonella typhi.Health Promotion and Maintenance Question No : 177 - Social support systems include of the following except: A. call-in help lines. B. emotional assistance provided by others. C. community support groups. D. use of coping skills and verbalization for anger management. Answer: D Explanation: Use of coping skills and verbalization for anger management are personal strategies, not examples of social support systems. Choices 1, 2, and 3 are all social support systems.Psychosocial Integrity Question No : 178 - Narrow therapeutic index medications: A. are drug formulations with limited pharmacokinetic variability. B. have limited value and require no monitoring of blood levels. C. have less than a twofold difference in minimum toxic levels and minimumeffective concentration in the blood. D. have limited potency and side effects. Answer: C Explanation: The therapeutic index is the ratio between the median lethal dose and median effective dose of a drug. It provides a general indication of the margin of safety of a drug. Choice 1 is incorrect because pharmacokinetics is the process of adsorption, distribution, metabolism, and elimination. Choice 2 is incorrect because narrow therapeutic index drugs require close monitoring since there is often little difference between the desired drug effect and toxicity. Choice 4 is incorrect because narrow therapeutic index drugs have the potential for severe toxic effects with only slight increases in the dose or slight decreases in elimination. Pharmacological Therapies Question No : 179 - In an emergency situation, the nurse determines whether a client has an airway obstruction. Which of the following does the nurse assess? A. ability to speak B. ability to hear C. oxygen saturation D. adventitious breath sounds Answer: A Explanation: Ability to speak is a major way to identify an airway obstruction.Safety and Infection Control Question No : 180 - Health promotion activities are designed to help clients: A. reduce the risk of illness. B. maintain maximal function.C. promote healthy habits related to health care. D. all of the above. Answer: D Explanation: Health promotion activities are designed to help clients reduce the risk of illness, maintain maximum function, and promote health habits related to health care.Health Promotion and Maintenance Question No : 181 - The physician orders the antibiotics ampicillin (Omnipen) and gentamicin (Garamycin) for a newly admitted client with an infection. The nurse should: A. administer both medications simultaneously. B. give the medications sequentially, and flush well between them. C. ask the physician or pharmacy which medication to give first and how long to wait before giving the other drug. D. start one medication now and begin the other medication in 2–4 hours. Answer: B Explanation: A client with an infection needs both antibiotics as soon a possible. However, the pH of ampicillin is 8–10, and the pH of gentamicin is 3–5.5 (making them incompatible when given together). Flushing well between drugs is necessary. Choice 3 is incorrect because the PN determines the correct steps and consults with the pharmacist and the physician as necessary. Choice 4 is incorrect because delaying the second medication by several hours slows the treatment of the client’s infection.Pharmacological Therapies Question No : 182 - The client’s lab culture report is negative for a suspected infection. A test thatcan correctly identify those who do not have a given disease is: A. specific. B. sensitive. C. negative culture. D. marginal finding. Answer: A Explanation: Testing that identifies clients without a disease is said to be specific, while testing that identifies clients with a disease is said to be sensitive. Safety and Infection Control Question No : 183 - Which is the best way to position a client’s neck for palpation of the thyroid? A. flexed toward the side being examined B. hyperextended directly backward C. flexed away from the side being examined D. flexed directly forward Answer: A Explanation: Flexed toward the side being examined.Health Promotion and Maintenance Question No : 184 - A chemical reaction between drugs prior to their administration or absorption is known as: A. a drug incompatibility. B. a side effect.C. an adverse event. D. an allergic response. Answer: A Explanation: This occurs most often when drug solutions are combined before they are given intravenously but can occur with orally administered drugs as well. Choices 2, 3, and 4 are incorrect because drugs can cause these events after administration and absorption.Pharmacological Therapies Question No : 185 - As part of a routine health screening, the nurse notes the play of a 2-year-old child. Which of the following is an example of age-appropriate play at this age? A. builds towers with several blocks B. tries to color within the lines C. says “Mine!” when playing with toys D. tries to jump rope Answer: C Explanation: Toddlers are possessive and struggle for independence. The other play activities are too advanced for a 2-year-old child.Health Promotion and Maintenance Question No : 186 - In an obstetrical emergency, which of the following actions should the nurse perform first after the baby delivers? A. Place extra padding under the mother to absorb blood from the delivery.B. Cut the umbilical cord using sterile scissors. C. Suction the baby’s mouth and nose. D. Wrap the baby in a clean blanket to preserve warmth. Answer: C Explanation: After the baby delivers, the nurse should clear the mouth and nose of the infant first. Choice 4 is the next step. Choices 1 and 2 might be performed depending on the situation.Safety and Infection Control Question No : 187 - Vaccines provide what type of immunity? A. active B. passive C. transplacental D. active and passive Answer: A Explanation: Vaccines provide active immunity. Passive immunity comes from antibodies produced in another human or host. Transplacental immunity comes from passive immunity transferred from mother to infant.Health Promotion and Maintenance Question No : 188 - Central venous access devices (CVADs) are frequently utilized to administer chemotherapy. What is an advantage of using CVADs for chemotherapeutic agent administration? A. CVADs are less expensive than a peripheral IV.B. Weekly administration is possible. C. Chemotherapeutic agents can be caustic to smaller veins. D. The client or family can administer the drug at home. Answer: C Explanation: Many chemotherapeutic drugs are vesicants (highly active corrosive materials that can produce tissue damage even in low concentrations). Administration into a large vein is optimal. Choice 1 is incorrect because CVADs are more expensive than a peripheral IV. Choice 2 is incorrect because dosing depends on the drug. Choice 4 is incorrect because IV chemotherapeutic agents are not routinely administered at home; they are usually given in a hospital or in an outpatient or clinic setting.Pharmacological Therapies Question No : 189 - Nursing considerations when caring for African- American clients include that: A. families are generally distant and unsupportive. B. special hair, skin, and nail care might be required. C. fad diets are a cultural norm. D. clients are generally future-oriented. Answer: B Explanation: Special hair, skin, and nail care might be required for African-American clients.Psychosocial Integrity Question No : 190 - The role of the incident report in risk management is: A. liability protection.B. to provide data for analysis by a risk manager to determine how future problems can be avoided. C. to discipline staff for errors. D. all of the above. Answer: B Explanation: Incident reports are a tool for determining how future problems can be avoided. Incident reports do not provide liability protection. Incident reports are not meant to be used for disciplining staff.Safety and Infection Control Question No : 191 - A hospitalized client has just been informed that he has terminal cancer. He says to the nurse, “There must be some mistake in the diagnosis.” The nurse determines that the client is demonstrating which of the following? denial anger bargaining acceptance Answer: A Explanation: Denial (Kübler-Ross’s Stages of Grieving) is the refusal to believe that loss is happening.Psychosocial Integrity Question No : 192 - A child comes to the clinic with a skin rash. The maculopapular lesions are distributed around the mouth and have honey-colored drainage. The caregiver states that the rash is getting worse and seems to spread with the child’s scratching. Which of the following advisory comments should be given? A. The history and presentation might indicate chickenpox, a highly contagious disease. B. The lesions might indicate a noncontagious infection that does not require isolation.C. The history and presentation might indicate an infectious illness called impetigo. D. The lesions are not contagious unless others have open wounds or lesions themselves. Answer: C Explanation: The scenario describes classic impetigo for which the physician is likely to order antibiotic therapy. Chickenpox is highly contagious but presents with a history of high fever followed by a vesicular rash.Safety and Infection Control Question No : 193 - The nurse teaching an obese client about nutritional needs and weight loss should include all of the following except: A. knowledge of food and food products. B. development of a positive mental attitude. C. adequate exercise. D. starting a fast weight-loss diet. Answer: D Explanation: Start a fast weight-loss diet.Health Promotion and Maintenance Question No : 194 - A nurse observes a client sitting alone and talking. When asked, the client reports that he is “talking to the voices.” The nurse’s next action should be: A. touching the client to help him return to reality.B. leaving the client alone until reality returns. C. asking the client to describe what is happening. D. telling the client there are no voices. Answer: A Explanation: Nurses need to inform clients that there is a difference in perceptions and pay attention to the content of hallucinations. The other options are not therapeutic.Psychosocial Integrity Question No : 195 - A syringe pump is a type of electronic infusion pump used to infuse fluids or medications directly from a syringe. This device is commonly used for: solutions administered in obstetrics. dilute antibiotics. large volumes of IV solution. the neonatal and pediatric populations. Answer: D Explanation: Small volumes of medication or fluids are delivered and sometimes at slow rates to neonates and pediatric clients. The syringe pump allows precise infusion of small volumes. Choice 1 is incorrect because a syringe pump can be used in almost any setting, but is not generally for adult clients. Choices 2 and 3 are incorrect because large volumes of fluids are not administered with a syringe pump.Pharmacological Therapies Question No : 196 - People who live in poverty are most likely to obtain health care from: A. their primary care physician (family doctor). B. a neighborhood clinic. C. specialists. D. Emergency Departments or urgent care centers.Answer: D Explanation: Statistical patterns of health care utilization indicate that Emergency Departments and urgent care centers provide a large portion of health care to those who live in poverty.Coordinated Care Question No : 197 - A client has chronic respiratory acidosis caused by end-stage chronic obstructive pulmonary disease (COPD). Oxygen is delivered at 1 L/min per nasal cannula. The nurse teaches the family that the reason for this is to avoid respiratory depression, based on which of the following explanations? COPD clients are stimulated to breathe by hypoxia. COPD clients depend on a low carbon dioxide level. COPD clients tend to retain hydrogen ions if they are given high doses of oxygen. COPD clients thrive on a high oxygen level. Answer: A Explanation: COPD clients are compensating for low oxygen and high carbon dioxide levels. Hypoxia is the main stimulus to breathe in persons with chronic hypercapnia. Increasing the level of oxygen decreases the stimulus to breathe. Physiological Adaptation Question No : 198 - A client is diagnosed with HIV. Which of the following are antiviral drug classes used in the treatment of HIV/AIDS? A. nucleoside reverse transcriptase inhibitors B. protease inhibitors C. HIV fusion inhibitors D. all of the above. Answer: D Explanation:All of the choices are anti-HIV drugs.Safety and Infection Control Question No : 199 - The most effective nursing strategy to assist a client in recognizing and using personal strength includes: encouraging the client’s self-identification of strengths. promoting the client’s active external thinking. listening to the client and providing advice as needed. assisting the client in maintaining an external locus of control. Answer: A Explanation: Encouraging the client to identify his own strengths is the most effective strategy.Psychosocial Integrity Question No : 200 - Distribution of a drug to various tissues is dependent on the amount of cardiac output to each type of tissue. Which tissue would receive the highest amount of cardiac output and thus the highest amount of a drug? A. skin B. adipose tissue C. skeletal muscle D. myocardium Answer: D Explanation: Highly perfused tissue includes all vital organs: the brain, heart, kidneys, adrenal glands, and liver. Choices 1, 2, and 3 are incorrect because the skin and adipose tissue are poorly perfused, while the skeletal muscle is better perfused.Pharmacological TherapiesTopic 3, Questions Set C [Show More]

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