NR 322 passpoint review nclex Questions and Answers,100% CORRECT

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NR 322 passpoint review nclex Questions and Answers Question 1 See full question What is the nurse’s most important intervention for a client having a tonic-clonic seizure? You Selected: • Pro... tect the client from further injury Correct response: • Protect the client from further injury Explanation: The priority during and after a seizure is to protect the person from injury by keeping them from falling to the floor. Furniture or other objects that be a source of injury during the seizure should be moved out of the client’s way. Timing the seizure, and noting the origin of the seizure are important, but are not the priority. Nothing should be placed in the client’s mouth during a seizure because teeth may be dislodged or the tongue pushed back, further obstructing the airway. Remediation: • Seizure management Question 2 See full question The nurse is caring for a neonate weighing 4,536 g (10 lb) who was born via cesarean section 1 hour ago to a mother with insulin-dependent diabetes. She asks the nurse, “Why is my baby in the neonatal intensive care unit?” The nurse bases a response on the understanding that neonates of mothers with diabetes commonly develop which condition? You Selected: • hypoglycemia Correct response: • hypoglycemia Explanation: Hypoglycemia is caused by the rapid depletion of glucose stores. In addition, neonates born to class women with insulin dependent diabetes are about seven times more likely to suffer from respiratory distress syndrome than neonates born to nondiabetic women. This neonate should be closely monitored for symptoms of hypoglycemia and respiratory distress. Neonates of diabetic mothers commonly have polycythemia, not anemia. Anemia and hemolytic disease are associated with erythroblastosis fetalis. Persistent pulmonary hypertension is associated with meconium aspiration syndrome. Remediation: • Glucose management, neonatal Question 3 See full question After knee replacement surgery, a client is being discharged with acetaminophen with codeine 30 mg tablets for pain. During discharge preparation, the nurse should include which instruction? You Selected: • "Avoid driving a car while taking this medication." Correct response: • "Avoid driving a car while taking this medication." Explanation: Clients taking codeine should avoid driving because the medication can impair mental alertness. Fluid restriction isn't indicated, especially after surgery. To prevent adverse GI effects such as nausea, vomiting, anorexia, and constipation, the client shouldn't take codeine on an empty stomach. Codeine may cause dizziness, drowsiness, and seizures but doesn't cause fine motor tremors. Remediation: • Codeine phosphate–acetaminophen Question 4 See full question The nurse manager has noticed a sharp increase in medication errors associated with IV antibiotic administration over the past 2 months. The nurse manager should discuss the situation with each nurse involved and then: You Selected: • ask them to attend in-service training for administration of IV medications. Correct response: • ask them to attend in-service training for administration of IV medications. Explanation: Identification of causes of medication errors requires in-service education to inform the staff of strategies to decrease these errors. Errors are frequently the result of systemic problems that can be identified and rectified through problem-solving techniques and changes in procedures. Documenting or reporting the situation would not directly assist the nurses in eliminating errors. Reporting the incidents to the hospital attorney is unnecessary. Remediation: • Safe medication administration practices Question 5 See full question Clients receiving a monoamine oxidase inhibitor must avoid tyramine, a compound found in which foods? You Selected: • Aged cheese and Chianti wine Correct response: • Aged cheese and Chianti wine Explanation: Aged cheese and Chianti wine contain high concentrations of tyramine. Green, leafy or yellow vegetables, figs, cream cheese, and fruit are low in tyramine. Remediation: • Tranylcypromine Question 6 See full question A client with a diagnosis of schizophrenia and who is paranoid asks the nurse, "How do I know what is really in those pills?" The best response is to: You Selected: • allow the client to open the individual medication wrappers. Correct response: • allow the client to open the individual medication wrappers. Explanation: Allowing a paranoid client to open his medication can help reduce his suspiciousness. Telling the client that he should know the pills are his medicine is incorrect because the client doesn't know this information for sure; he's obviously suspicious that it isn't. Telling the client not to worry or ignoring his comment isn't supportive and doesn't reassure him. Remediation: • Oral drug administration, psychiatric patient Question 7 See full question When instilling erythromycin ointment into the eyes of a neonate 1 hour old, the nurse would explain to the parents that the medication is used to prevent which problem? You Selected: • cataracts from beta-hemolytic streptococcus Correct response: • blindness secondary to gonorrhea Explanation: The instillation of erythromycin into the neonate’s eyes provides prophylaxis for ophthalmia neonatorum, or neonatal blindness caused by gonorrhea in the mother. Erythromycin is also effective in the prevention of infection and conjunctivitis from Chlamydia trachomatis. The medication may result in redness of the neonate’s eyes, but this redness will eventually disappear. Erythromycin ointment is not effective in treating neonatal chorioretinitis from cytomegalovirus. No effective treatment is available for a mother with cytomegalovirus. Erythromycin ointment is not effective in preventing cataracts. Additionally, neonatal infection with beta-hemolytic streptococcus results in pneumonia, bacterial meningitis, or death. Cataracts in the neonate may be congenital or may result from maternal exposure to rubella. Erythromycin ointment is also not effective for preventing and treating strabismus (crossed eyes). Infants may exhibit intermittent strabismus until 6 months of age. Remediation: • Neonatal eye prophylaxis Question 8 See full question For the client who has difficulty falling asleep at night because of withdrawal symptoms from alcohol, which are abating, which nursing intervention is likely to be most effective? You Selected: • teaching the client relaxation exercises to use before bedtime Correct response: • teaching the client relaxation exercises to use before bedtime Explanation: The best action by the nurse to help a client who has difficulty falling asleep would be to teach the client relaxation exercises to use before bedtime to reduce anxiety and promote relaxation. This activity will also be useful for the client when out of the hospital. Inviting the client to play a board game is inappropriate because this activity can be competitive and thus stimulate the client. Allowing the client to sit in the community room until she feels sleepy is inappropriate because it does nothing to help the client relax. Taking frequent naps can worsen the ability to fall asleep at night. Remediation: • Relaxation and stress management techniques • Alcoholism Question 9 See full question An 18-year-old is highly dependent on her parents and fears leaving home to attend college. Shortly before the fall semester starts, she complains that her legs are paralyzed and is rushed to the emergency department. When physical examination rules out a physical cause for her paralysis, the physician admits the woman to the psychiatric unit, where she is diagnosed with functional neurologic symptom disorder. She asks the nurse, "Why has this happened to me?" What is the nurse's best response? You Selected: • "Your problem is real but, there is no physical basis for it. We'll work on what is going on in your life to find out why it's happened." Correct response: • "Your problem is real but, there is no physical basis for it. We'll work on what is going on in your life to find out why it's happened." Explanation: The nurse must be honest by telling the client that her paralysis has no physiologic cause while also conveying empathy and acknowledging that her symptoms are real. The client will benefit from psychiatric treatment, which will help her understand the underlying cause of her symptoms. After her psychological conflict is resolved, her symptoms will disappear. Telling the client that being unable to move her legs must be awful wouldn't answer the client's question; knowing that the cause is psychological rather than physical wouldn't necessarily make her feel better. Telling the client that she has developed paralysis to avoid leaving her parents or that her personality caused her disorder wouldn't help her understand and resolve the underlying conflict. Remediation: • Conversion disorder patient care • Psychiatric nursing assessment Question 10 See full question A client periodically has acute panic attacks. These attacks are unpredictable and have no apparent association with a specific object or situation. During an acute panic attack, the client may experience: You Selected: • a decreased perceptual field. Correct response: • a decreased perceptual field. Explanation: Panic is the most severe level of anxiety. During a panic attack, a client's perceptual field, narrows. He becomes more focused on himself, less aware of surroundings, and unable to process information from his environment. His decreased perceptual field impairs his attention and ability to concentrate. During an acute panic attack, the client may experience an increase, not a decrease, in heart and respiratory rates, resulting from stimulation of the sympathetic nervous system. Remediation: • Panic disorder Question 11 See full question A nurse obtained a client’s fasting blood sugar (FBS) at 0700, which was 144 mg/dL (8 mmol/L). The client has an order for regular insulin 8 units every morning. What should the nurse do next? You Selected: • Administer the insulin as ordered. Correct response: • Administer the insulin as ordered. Explanation: The nurse should know that a normal fasting blood sugar is between 72 and 108 mg/dL (4 and 6 mmol/L). The result of 144 mg/dL indicates that the client requires insulin to lower the blood glucose level. The other options are incorrect because they do not reflect the nurse's understanding of diabetes and its treatment. Remediation: • Blood glucose monitoring • Insulins (short-acting) • Hormonal Control of Blood Glucose Question 12 See full question A nurse is providing discharge teaching to a client who is immunosuppressed. Which statement by the client indicates the need for additional teaching? You Selected: • "I can eat whatever I want as long as it's low in fat." Correct response: • "I can eat whatever I want as long as it's low in fat." Explanation: The client requires additional teaching if he states that he can eat whatever he wants. Immunosuppressed clients should avoid raw fruit and vegetables because they may contain bacteria that could increase the risk of infection; foods must be thoroughly cooked. Avoiding people who are sick, products containing alcohol, and people who have just received vaccines are appropriate actions for an immunosuppressed client. Remediation: • Neutropenia Question 13 See full question The client with acute renal failure is recovering and asks the nurse, "Will my kidneys ever function normally again?" The nurse's response is based on knowledge that the client's renal status will most likely: You Selected: • continue to improve over a period of weeks. Correct response: • continue to improve over a period of weeks. Explanation: The kidneys have a remarkable ability to recover from serious insult. Recovery may take 3 to 12 months. The client should be taught how to recognize the signs and symptoms of decreasing renal function and to notify the health care provider (HCP) if such problems occur. In a client who is recovering from acute renal failure, there is no need for renal transplantation or permanent hemodialysis. Chronic renal failure develops before end-stage renal failure. Remediation: • Renal failure, acute • Urinary: Renal Function Question 14 See full question Which is the most important initial postprocedure nursing assessment for a client who has had a cardiac catheterization? You Selected: • Observe the puncture site for swelling and bleeding. Correct response: • Observe the puncture site for swelling and bleeding. Explanation: Assessment of circulatory status, including observation of the puncture site, is of primary importance after a cardiac catheterization. Laboratory values and skin warmth and turgor are important to monitor but are not the most important initial nursing assessment. Neurologic assessment every 15 minutes is not required. Remediation: • Cardiac catheterization Question 15 See full question The nurse is administering packed red blood cells (PRBCs) to a client. The nurse should first: You Selected: • stay with the client during the first 15 minutes of infusion. Correct response: • stay with the client during the first 15 minutes of infusion. Explanation: The most likely time for a blood transfusion reaction to occur is during the first 15 minutes or first 50 ml of the infusion. If a blood transfusion reaction does occur, it is imperative to keep an established I.V. line so that medication can be administered to prevent or treat cardiovascular collapse in case of anaphylaxis. PRBCs should be administered through a 19-gauge or larger needle; a peripherally inserted central catheter line is not recommended, in order to avoid a slow flow. RBCs will hemolyze in dextrose or lactated Ringer's solution and should be infused with only normal saline solution. Remediation: • Blood product transfusion management • Blood product transfusion Question 16 See full question A nurse is performing a sterile dressing change. Which action contaminates the sterile field? You Selected: • Pouring solution onto a sterile field cloth Correct response: • Pouring solution onto a sterile field cloth Explanation: Pouring solution onto a sterile field cloth contaminates the sterile field because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. Holding sterile objects above the waist, leaving a 1″ edge around the sterile field, and opening the outermost flap of a sterile package away from the body maintain the sterile field. Remediation: • Sterile field management, OR • Cleaning a Wound and Applying a Sterile Dressing Question 17 See full question The nurse administers a tap water enema to a client. While the solution is being infused, the client has abdominal cramping. What should the nurse do first? You Selected: • Temporarily stop the infusion, and have the client take deep breaths. Correct response: • Temporarily stop the infusion, and have the client take deep breaths. Explanation: If the client begins to experience abdominal cramping during administration of the enema fluid, the nurse’s first action is to temporarily stop the infusion and have the client take a few deep breaths. After the cramping subsides, the nurse can continue with the enema solution. If the cramping does not subside, the nurse should clamp the tubing and remove it. Raising the height of the container will increase the flow of fluid and cause the cramping to increase. Rubbing the abdomen while infusing the enema fluid will not stop the cramping. Remediation: • Enema administration Question 18 See full question The nurse is admitting a hospital client who does not speak English and who is accompanied by the client's school-aged child. The client appears to be in pain, but the nurse is unable to assess the character or history of the client's pain. How should the nurse best communicate with the client? You Selected: • Ask the client's child to describe the client's pain to the best of the client's ability. Correct response: • Enlist the help of a hospital interpreter; ask the son to translate if none is readily available. Explanation: Whenever possible, interpreters should be used to communicate with clients who do not speak English. If none is available, however, it may be necessary to have a family member translate. It would be unsafe to put off an emergency assessment pending the arrival of an interpreter. Remediation: • Cultural assessment Question 19 See full question A client with a diagnosis of schizophrenia is admitted to the inpatient unit of the mental health center. He's shouting that the government of France is trying to assassinate him. Which response is most appropriate? You Selected: • "A foreign government is trying to kill you? Please tell me more about it." Correct response: • "I don't see evidence that a foreign government or anyone else is trying to hurt you. You must feel frightened by this." Explanation: Responses should focus on reality while acknowledging the client's feelings. It isn't therapeutic for the nurse to argue with the client or deny his belief. Arguing can also inhibit development of a trusting relationship. Continuing to talk about delusions may aggravate the client's psychosis. Asking the client if a foreign government is trying to kill him may increase his anxiety level and can reinforce his delusions. Remediation: • Delusions, care of patient Question 20 See full question The nurse administers fat emulsion solution during TPN as prescribed based on the understanding that this type of solution: You Selected: • provides essential fatty acids. Correct response: • provides essential fatty acids. Explanation: The administration of fat emulsion solution provides additional calories and essential fatty acids to meet the body’s energy needs. Fatty acids are lipids, not carbohydrates. Fatty acids do not aid in the metabolism of glucose. Although they are necessary for meeting the complete nutritional needs of the client, fatty acids do not necessarily help a client maintain normal body weight. Remediation: • Parenteral nutrition administration • Fat emulsions Question 21 See full question A nurse is caring for a client in the first 4 weeks of pregnancy. The nurse should expect to collect which assessment findings? You Selected: • Breast sensitivity Correct response: • Breast sensitivity Explanation: Breast sensitivity is the only sign assessed within the first 4 weeks of pregnancy. Amenorrhea, not the presence of menses, is expected during this time. Uterine enlargement and fetal heart tones don't occur until after the first 4 weeks of pregnancy. Remediation: • Breast care for non-nursing mothers Question 22 See full question The nurse is teaching a client with stomatitis about mouth care. Which instruction is most appropriate? You Selected: • Eat a soft, bland diet. Correct response: • Eat a soft, bland diet. Explanation: Clients with stomatitis (inflammation of the mouth) have significant discomfort, which impacts their ability to eat and drink. They will be most comfortable eating soft, bland foods, and avoiding temperature extremes in their food and liquids. Gargling with an antiseptic mouthwash will be irritating to the mucosa. Mouth care should include gentle brushing with a soft toothbrush and flossing. Remediation: • Mouth lesions • Stomatitis Question 23 See full question A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement? You Selected: • Related to impaired balance Correct response: • Related to impaired balance Explanation: A client with a cerebellar brain tumor may suffer injury from impaired balance as well as disturbed gait and incoordination. Visual field deficits, difficulty swallowing, and psychomotor seizures may result from dysfunction of the pituitary gland, pons, occipital lobe, parietal lobe, or temporal lobe — not from a cerebellar brain tumor. Difficulty swallowing suggests medullary dysfunction. Psychomotor seizures suggest temporal lobe dysfunction. Remediation: • Brain tumor, malignant Question 24 See full question The nursing team on an oncology unit consists of a registered nurse (RN), a licensed practical/vocational nurse (LPN/VN), and one unlicensed assistive personnel (UAP). Which client should be assigned to the RN? You Selected: • a 28-year-old client being evaluated for a bone marrow transplant Correct response: • a 52-year-old client with lung cancer admitted for acute dyspnea Explanation: Ongoing assessment by the RN is required to evaluate the client with dyspnea to monitor for potential deterioration of the respiratory status. If the RN is the care provider, the RN will have greater interaction with the individual client. The RN is responsible for assessment of all the clients. The other clients would not be considered unstable, and maintaining a patent airway is always the priority in providing care. Care for the other clients could be assigned safely, according to the abilities of the LPN/VN and UAP. Remediation: • Lung cancer Question 25 See full question A mother is visiting her neonate in the neonatal intensive care unit. Her baby is fussy and the mother wants to know what to do. In order to quiet a sick neonate, what can the nurse teach the mother to do? You Selected: • Use constant, gentle touch. Correct response: • Use constant, gentle touch. Explanation: Neonates that are sick do not have the physical resources or energy to respond to all elements of the environment. The use of a constant touch provides comfort and only requires one response to a stimulus. To comfort a sick neonate, the care provider applies gentle, constant physical support or touch. Toys for distraction are not developmentally appropriate for a neonate. Sick neonates react to any stimulus; in responding, the sick neonate may have increased energy demands and increased oxygen requirements. A musical mobile may be too much audio stimulation and thus increases energy and oxygen demands. Repetitive touching with a hand going off and on the neonate, as with stroking or patting, requires the neonate to respond to every touch, thus increasing energy and oxygen demands. Remediation: • Therapeutic touch, neonatal Question 26 See full question A nurse is preparing to administer an I.V. containing dextrose 10% in ¼ normal saline solution to a 6- month-old infant. The nurse should select which tubing to safely administer the solution? You Selected: • I.V. tubing with a volume-control chamber Correct response: • I.V. tubing with a volume-control chamber Explanation: Because infants have a small circulating blood volume, inadvertent administration of extra I.V. fluid can cause fluid volume excess. To prevent this from occurring, I.V. tubing with a volume-control chamber should always be used for infants and children to closely regulate the amount of fluid infused. The volume-control chamber should be filled only with enough I.V. fluid for the next two 2 hours. A microdrip chamber that allows for 60 drops/ml (as opposed to a macrodrip chamber, which allows for 10 to 20 drops/ml, depending on the manufacturer) should be used to infuse the smaller amounts of I.V. fluids an infant needs. A filter is typically used only for the administration of total parenteral nutrition and certain blood products. Standard I.V. tubing for adults should be avoided for infants because of the inability to closely regulate the amount of fluid infused. Question 27 See full question A client is hospitalized for severe preeclampsia and complete placenta previa. The husband tells the nurse that he is frustrated to have been waiting for 3 hours for the physician to discuss his wife’s condition and plan of care with them. What is the nurse’s most appropriate action? You Selected: • Notify the physician that the husband has been waiting to discuss his wife’s condition. Correct response: • Notify the physician that the husband has been waiting to discuss his wife’s condition. Explanation: Because of the client’s severe and deteriorating condition, the nurse is obligated to advocate for the family and to notify the physician of the husband’s request for a meeting and information. It is not appropriate to tell a client or family not to worry or that the physician is too busy to come. While it may be appropriate to inquire about family supports, in this context it is crucial that the nurse respond to the client and husband’s concerns. The nurse should ensure his/her practice aligns with the American Nurses Association (Canadian Nurses' Association) Code of Ethics, ensuring that the nurse is advocating for the family and promoting and respecting informed decision making. Remediation: • Labor, care during Question 28 See full question A nurse, a licensed practical nurse (LPN), and a nursing assistant are caring for a group of clients. The nurse asks the nursing assistant to check the pulse oximetry level of a client who underwent laminectomy. The nursing assistant reports that the pulse oximetry reading is 89%. The client Kardex contains an order for oxygen application at 2 L/min should the pulse oximetry level fall below 92%. The nurse is currently assessing a postoperative client who just returned from the postanesthesia care unit. How should the nurse proceed? You Selected: • Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy. Correct response: • Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy. Explanation: Because it's important to get more information about the client with a decreased pulse oximetry level, the nurse should ask the LPN to obtain vital signs and administer oxygen as ordered. The nurse must attend to the newly admitted client without delaying treatment to the client who is already in her care. The nurse can effectively do this by delegating tasks to an appropriate health team member such as an LPN. The nurse doesn't need to immediately attend to the client with a decreased pulse oximetry level; she may wait until she completes the assessment of the newly admitted client. The physician doesn't need to be notified at this time because an order for oxygen administration is already on record. Question 29 See full question The nurse is instructing a competent client in his legal rights regarding ECT (electroconvulsive therapy). Which statement by the client suggests further explanation is needed? You Selected: • "I do not need a legal guardian to assist me in this process." Correct response: • "Since I was an Emergency Involuntary Commitment, I will be unable to sign the ECT form myself." Explanation: There are some instances where a client may not sign for treatments as in a ECT treatment. If the client had been judged incompetent in a court of law, then a legal guardian will sign the form. Otherwise, the client must sign an informed consent. Options a, b, and d are incorrect as the family cannot sign as they are not guardians or health care power of attorney. Also, the client doesn't need a guardian as the client is competent. Option c is correct. Regardless of the manner in which the client has been admitted, voluntary or involuntary, as the client understands the risks and benefits of the ECT treatment and there has been no coercion in the process, the client may sign the consent form. Remediation: • Electroconvulsive therapy Question 30 See full question A client newly diagnosed with diabetes mellitus asks why he needs ketone testing when the disease affects his blood glucose levels. How should the nurse respond? You Selected: • "Ketones will tell us if your body is using other tissues for energy." Correct response: • "Ketones will tell us if your body is using other tissues for energy." Explanation: The nurse should tell the client that ketones are a byproduct of fat metabolism and that ketone testing can determine whether the body is breaking down fat to use for energy. The spleen doesn't release ketones when the body can't use glucose. Although ketones can damage the eyes and kidneys and help the physician evaluate the severity of a client's diabetes, these responses by the nurse are incomplete. Remediation: • Ketone tests • Ketones, urine • Diabetes Question 31 See full question For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis? You Selected: • Imbalanced nutrition: Less than body requirements Correct response: • Deficient fluid volume Explanation: Dark, concentrated urine, dry mucous membranes, and a urine output of less than 30 ml/hour (720 ml/24 hours) are symptoms of dehydration or Deficient fluid volume. Decreased urine output is related to deficient fluid volume, not Impaired urinary elimination. Nothing in the scenario suggests a nutritional problem. If a fluid volume excess were present, manifestations would most likely include signs of fluid overload such as edema. Remediation: • Intake and output assessment • Fluid and Electrolytes Question 32 See full question The mother of a client who has a radium implant asks why so many nurses are involved in her daughter’s care. She states, “The doctor said I can be in the room for up to 2 hours each day, but the nurses say they are restricted to 30 minutes.” The nurse explains that this variation is based on the fact that nurses: You Selected: • work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation. Correct response: • work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation. Explanation: The three factors related to radiation safety are time, distance, and shielding. Nurses on radiation oncology units work with radiation frequently and so must limit their contact. Nurses are physically closer to clients than are visitors, who are often asked to sit 6 feet (182.9 cm) away from the client. Touching the client does not increase the amount of radiation exposure. Aseptic technique and isolation prevent the spread of infection. Age is a risk factor for people in their reproductive years. Remediation: • Radiation safety, oncology • Radiation implant therapy Question 33 See full question A nurse is caring for a client with bruises on her face and arms. Her husband refuses to leave the client's bedside and answers all of the questions for the client. Which intervention by the nurse would be most appropriate? You Selected: • Collaborate with the physician to make a referral to social services. Correct response: • Collaborate with the physician to make a referral to social services. Explanation: Collaborating with the physician to make a referral to social services helps the client by creating a plan and providing support. Additionally, by law, the nurse or nursing supervisor must report the suspected abuse to the police, and follow up with a written report. Although confrontation can be used therapeutically, this action will most likely provoke anger in the suspected abuser. Questioning the client in front of her spouse does not allow her the privacy required to address this issue and may place her in greater danger. If the woman is not in imminent danger, there is no need to call hospital security. Remediation: • Cultural needs assessment during pregnancy • Suspected domestic abuse assessment • Risk for ineffective childbearing process Question 34 See full question When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nursing implementing? You Selected: • SOAP charting. Correct response: • SOAP charting. Explanation: The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress. Focus charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation. Remediation: • Documentation Question 35 See full question A nurse is providing dietary instructions to a client with a history of pancreatitis. Which of the following instructions would be most appropriate? You Selected: • Maintain a high-carbohydrate, low-fat diet. Correct response: • Maintain a high-carbohydrate, low-fat diet. Explanation: A client with a history of pancreatitis should avoid foods and beverages that stimulate the pancreas, such as fatty foods, caffeine, and gas-forming foods; should avoid eating large meals; and should eat plenty of carbohydrates, which are easily metabolized. Therefore, the only correct instruction is to maintain a high-carbohydrate, low-fat diet. An increased sodium or fluid intake is not necessary because chronic pancreatitis is not associated with hyponatremia or fluid loss. Remediation: • Pancreatitis Question 36 See full question A nurse works with a client diagnosed with bulimia. What is the most appropriate long-term client goal for this client? You Selected: • Manage stresses in life without binging or purging. Correct response: • Manage stresses in life without binging or purging. Explanation: A successful outcome for a bulimic client is to avoid using the eating disorder as a coping measure when dealing with stress. Being able to attend college, eat at home, and eat out without binging and purging are important goals, but they do not address the primary problem of stress management and its connection to eating. Remediation: • Bulimia nervosa Question 37 See full question A client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by: You Selected: • turning the client's head suddenly while holding the eyelids open. Correct response: • turning the client's head suddenly while holding the eyelids open. Explanation: To elicit the oculocephalic response, which detects cranial nerve compression, the nurse turns the client's head suddenly while holding the eyelids open. Normally, the eyes move from side to side when the head is turned; in an abnormal response, the eyes remain fixed. The nurse introduces ice water into the external auditory canal when testing the oculovestibular response; normally, the client's eyes deviate to the side of ice water introduction. The nurse touches the client's cornea with a wisp of cotton to elicit the corneal reflex response, which reveals brain stem function; blinking is the normal response. Shining a bright light into the client's pupil helps evaluate brain stem and cranial nerve III function; normally, the client's pupil responds by constricting. Remediation: • Doll Question 38 See full question Which finding is the best indication that fluid replacement for the client in hypovolemic shock is adequate? You Selected: • urine output greater than 30 ml/hour Correct response: • urine output greater than 30 ml/hour Explanation: Urine output provides the most sensitive indication of the client’s response to therapy for hypovolemic shock. Urine output should be consistently greater than 35 mL/h. Blood pressure is a more accurate reflection of the adequacy of vasoconstriction than of tissue perfusion. Respiratory rate is not a sensitive indicator of fluid balance in the client recovering from hypovolemic shock. Remediation: • Shock, hypovolemic Question 39 See full question When developing the postoperative plan of care for an adolescent who has undergone an appendectomy for a ruptured appendix, in which position should the nurse expect to place the client during the early postoperative period? You Selected: • semi-Fowler's position Correct response: • semi-Fowler's position Explanation: After an appendectomy for a ruptured appendix, assuming the semi-Fowler’s or a right side-lying position helps localize the infection. These positions promote drainage from the peritoneal cavity and decrease the incidence of subdiaphragmatic abscess. Remediation: • Appendicitis • Appendectomy Question 40 See full question A child with suspected rheumatic fever is admitted to the pediatric unit. When obtaining the child's history, the nurse considers which information to be most important? You Selected: • A recent episode of pharyngitis Correct response: • A recent episode of pharyngitis Explanation: A recent episode of pharyngitis is the most important factor in establishing the diagnosis of rheumatic fever. Although the child may have a history of fever or vomiting or lack interest in food, these findings aren't specific to rheumatic fever. Remediation: • Acute rheumatic fever, pediatric • Pharyngitis Question 41 See full question A client with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acid–base balance? You Selected: • Returning bicarbonate to the body's circulation Correct response: • Returning bicarbonate to the body's circulation Explanation: The kidney performs two major functions to assist in acid–base balance. The first is to reabsorb and return to the body's circulation any bicarbonate from the urinary filtrate; the second is to excrete acid in the urine. Retaining bicarbonate will counteract an acidotic state. The nephrons do not sequester free hydrogen ions. Question 42 See full question A boy, age 3, develops a fever and rash and is diagnosed with rubella. His mother has just given birth to a baby girl. Which statement by the mother best indicates that she understands the implications of rubella? You Selected: • "I told my husband to give my son aspirin for his fever." Correct response: • "I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my son." Explanation: By saying she'll call her pregnant neighbor, the mother demonstrates that she understands the implications of rubella. Fetal defects can occur during the first trimester of pregnancy if the pregnant woman contracts rubella. Aspirin shouldn't be given to young children because aspirin has been implicated in the development of Reye's syndrome. Acetaminophen should be used instead of aspirin. Rubella immunization isn't recommended for children until ages 12 to 15 months. Having the measles (rubeola) won't provide immunity for rubella. Remediation: • Rubella vaccine administration • Rubella, pediatric Question 43 See full question The nurse is developing a teaching plan for a client with stress incontinence. Which instruction should be included? You Selected: • Avoid activities that are stressful and upsetting. Correct response: • Avoid caffeine and alcohol. Explanation: Clients with stress incontinence are encouraged to avoid substances that are bladder irritants, such as caffeine and alcohol. Emotional stressors do not cause stress incontinence. It is most commonly caused by relaxed pelvic musculature. Wearing girdles is not contraindicated. Although clients may want to limit physical exertion to avoid incontinence episodes, they should be encouraged to seek treatment instead of limiting their activities. Remediation: • Stress urinary incontinence Question 44 See full question A nurse is caring for a client with a central venous pressure (CVP) of 4 mm Hg. Which nursing intervention is appropriate? You Selected: • Continue to monitor the client as ordered. Correct response: • Continue to monitor the client as ordered. Explanation: Normal CVP ranges from 3 to 7 mm Hg. The nurse doesn't need to take any action other than to monitor the client. It isn't necessary to rezero the equipment. Calling a physician and obtaining an order for a fluid bolus would be an appropriate intervention if the client has a CVP less than 3 mm Hg. Administering a diuretic would be appropriate if the client had excess fluid, as demonstrated by a CVP greater than 7 mm Hg. Remediation: • Central venous pressure measurement, water manometer • Central venous pressure monitoring, transducer Question 45 See full question What is the nurse expected to do when filing a report about an incident of finding an elderly client with mild dementia on the floor? You Selected: • The nurse must file an incident or adverse event report. Correct response: • The nurse must file an incident or adverse event report. Explanation: Nurses who witnessed the event are responsible for entering the information. Adverse reporting is a mechanism to find persistent problems; it is confidential and nonpunitive. Question 46 See full question A client is admitted for an exacerbation of irritable bowel syndrome who insists on being allowed to keep a head covering on at all times. The best response by the nurse is: You Selected: • “Tell me why is this so important to you.” Correct response: • “Please help me to understand this practice.” Explanation: The nurse should demonstrate respect for the client’s request. Asking the client to explain the need for this practice in the hospital will lead to a discussion where a reasonable solution can be determined. Demanding the client tell you why this is so important is antagonistic and disrespectful. Resorting to standard responses such as hospital policy or infection control presumes prejudgment and no room for discussion. These responses are also disrespectful. Remediation: • Irritable bowel syndrome Question 47 See full question A homeless client comes to the clinic coughing up blood and is diagnosed with active tuberculosis (TB). Which of the following interventions by the nurse will be most effective in ensuring adherence with the pharmacological treatment regimen? You Selected: • Arrange for the client to come to a community center each day to receive a meal and medication Correct response: • Arrange for the client to come to a community center each day to receive a meal and medication Explanation: Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen for tuberculosis. Providing the client with a daily meal will help ensure the client will come to receive the medication. It is not cost effective to keep the client hospitalized, TB medication regime may last one or more years. A homeless client probably will not have the financial resources to pick up the medication at a pharmacy so a prescription and/or written instructions will not be an effective way to ensure adherence. Question 48 See full question A client with schizophrenia who receives fluphenazine develops pseudoparkinsonism and akinesia. What drug should the nurse administer as ordered to minimize this client's extrapyramidal symptoms? You Selected: • Benztropine Correct response: • Benztropine Explanation: Benztropine is an anticholinergic administered to reduce extrapyramidal adverse effects in the client taking antipsychotic drugs. It works by restoring the equilibrium between the neurotransmitters acetylcholine and dopamine in the central nervous system (CNS). Dantrolene, a hydantoin that reduces the catabolic processes, is administered to alleviate the symptoms of neuroleptic malignant syndrome, a potentially fatal adverse effect of antipsychotic drugs. Clonazepam, a benzodiazepine that depresses the CNS, is administered to control seizure activity. Diazepam, a benzodiazepine, is administered to reduce anxiety. Remediation: • Dantrolene sodium • Clonazepam • Fluphenazine decanoate • Benztropine mesylate Question 49 See full question Following an eclamptic seizure, the nurse should assess the client for which complication? You Selected: • polyuria Correct response: • uterine contractions Explanation: After an eclamptic seizure, the client commonly falls into a deep sleep or coma. The nurse must continually monitor the client for signs of impending labor because the client will not be able to verbalize that contractions are occurring. Oliguria is more common than polyuria after an eclamptic seizure. Facial flushing is not common unless it is caused by a reaction to a medication. Typically, the client remains hypertensive unless medications such as magnesium sulfate are administered. Remediation: • Uterine contraction palpation Question 50 See full question After administering a prescribed medication to a client who becomes restless at night and has difficulty falling asleep, which nursing action is most appropriate? You Selected: • sitting quietly with the client at the bedside until the medication takes effect Correct response: • sitting quietly with the client at the bedside until the medication takes effect Explanation: To promote adequate rest (6 to 8 hours per night) and to eliminate hyposomnia, the nurse should sit with the client at the bedside until the medication takes effect. The presence of a caring nurse provides the client with comfort and security and helps to decrease the client’s anxiety. Engaging the client in interaction until the client falls asleep, reading to the client, or encouraging the client to watch television may be too stimulating for the client, consequently increasing rather than decreasing the client’s restlessness. Remediation: • Insomnia Question 51 See full question A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which physician order? You Selected: • "Infuse I.V. fluids at 83 ml/hour." Correct response: • "Infuse I.V. fluids at 83 ml/hour." Explanation: Because shock signals a severe fluid volume loss of (750 to 1,300 ml), its treatment includes rapid I.V. fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. infusion rate of 83 ml/hour wouldn't begin to replace the necessary fluids and reverse the problem. Monitoring urine output every hour, administering oxygen by nasal cannula at 3 L/minute, and drawing samples for hemoglobin and hematocrit every 6 hours are appropriate orders for this client. Remediation: • Shock, hypovolemic Question 52 See full question A client is receiving chemotherapy for the diagnosis of brain cancer. When teaching the client about contamination from excretion of the chemotherapy drugs within 48 hours, the nurse should instruct the client that: You Selected: • any contaminated linens should be washed separately and then washed a second time, if necessary. Correct response: • any contaminated linens should be washed separately and then washed a second time, if necessary. Explanation: The client may excrete the chemotherapeutic agent for 48 hours or more after administration. Blood, emesis, and excretions may be considered contaminated during this time, and the client should not share a bathroom with children or pregnant women. Any contaminated linens or clothing should be washed separately and then washed a second time, if necessary. All contaminated disposable items should be sealed in plastic bags and disposed of as hazardous waste. Remediation: • Chemotherapeutic drugs Question 53 See full question A couple admitted to the labor and birth unit show the nurse their birth plan. The nurse inquires about their specific choices and wishes for the birth of their first baby. Which of the following best describes why the nurse is asking questions about the family’s birth plan? You Selected: • Recognizing the family as active participants in their care Correct response: • Recognizing the family as active participants in their care Explanation: The nurse recognizes the family as active participants in their care by discussing and inquiring about their birth plans, fostering a collaborative relationship with the family. After acknowledging the family as active participants, the nurse is then able to advocate for the family throughout the labor and birth experience. Considering principles of family-centered maternity and newborn care, nurses must advocate for clients to have autonomy in decision making and provide respect and informed choice to ensure that clients and their families are empowered to take responsibility to make decisions. It is the nurse’s role to guide and support choices rather than direct or correct. Question 54 See full question A client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. Which nursing diagnosis takes priority with this client? You Selected: • Ineffective breathing pattern related to tissue trauma Correct response: • Ineffective breathing pattern related to tissue trauma Explanation: Although all of these nursing diagnoses are appropriate for this client, ineffective breathing pattern takes priority. According to Maslow's hierarchy of needs, air is essential to maintain life and is assigned the highest priority, along with the other physiologic needs, such as food, elimination, temperature control, sex, movement, rest, and comfort. Remediation: • Pulmonary embolism Question 55 See full question Which is a risk factor for cervical cancer? You Selected: • sedentary lifestyle Correct response: • adolescent pregnancy Explanation: Young age at first pregnancy is a risk factor for cervical cancer. Other risk factors include a family history of the disease, sexual experience with multiple partners, and a history of sexually transmitted disease (e.g., syphilis, human papillomavirus infection, gonorrhea). Cigarette smoking, promiscuous male partner, human immunodeficiency virus infection or other immunosuppression, and low socioeconomic status are other risk factors. Sexual relations with one partner, sedentary lifestyle, and obesity are not risk factors for cervical cancer. Remediation: • Cervical cancer Question 56 See full question The parents of a child with occasional generalized seizures want to send the child to summer camp. The parents contact the nurse for advice on planning for the camping experience. Which type of activity should the nurse and family decide the child should avoid? You Selected: • hiking Correct response: • rock climbing Explanation: A child who has generalized seizures should not participate in activities that are potentially hazardous. Even if accompanied by a responsible adult, the child could be seriously injured if a seizure were to occur during rock climbing. Someone also should accompany the child during activities in the water. At summer camps, hiking and swimming would occur most commonly as group activities, so someone should be with the child. Tennis would be considered an appropriate, nonhazardous activity for a child with generalized seizures. Remediation: • Seizure management, pediatric • Seizure disorder, pediatric • Seizure disorder Question 57 See full question A client continues to improve after a left hemisphere cerebrovascular accident (CVA). The interprofessional team is planning a transfer to a rehabilitation unit for follow-up care. Which of the following is the priority nursing diagnosis? You Selected: • Decreased gastrointestinal motility Correct response: • Impaired swallowing Explanation: Impaired swallowing is the priority nursing diagnosis for this client because there is a risk for aspiration. The other choices are appropriate, but not the priority. Remediation: • Stroke Question 58 See full question A client with respiratory complications of multiple sclerosis (MS) is admitted to the intensive care unit. Which equipment is most important for the nurse to keep at the client's bedside? You Selected: • Sphygmomanometer Correct response: • Suction machine with catheters Explanation: MS weakens the respiratory muscles and impairs swallowing, putting the client at risk for aspiration. To ensure a patent oral airway, the nurse should keep a suction machine and suction catheters at the bedside. A sphygmomanometer is no more important for this client than for any other. A padded tongue blade is an appropriate seizure precaution, but should not be used in this client because its large size could cause oral airway obstruction. A nasal cannula and oxygen would be ineffective to ensure adequate oxygen delivery; this client requires a mechanical ventilator. Remediation: • Multiple sclerosis Question 59 See full question Assessment of a school-age child with Guillain-Barré syndrome reveals absent gag and cough reflexes. Which problem should receive the highest priority during the acute phase? You Selected: • ineffective breathing pattern related to neuromuscular impairment Correct response: • ineffective breathing pattern related to neuromuscular impairment Explanation: An ineffective breathing pattern caused by the ascending paralysis of the disorder interferes with the child’s ability to maintain an adequate oxygen supply. Therefore, this nursing diagnosis takes precedence. Additionally, as the neurologic impairment progresses, it will probably have an effect on the child’s ability to maintain respirations. An increased risk for infection related to an altered immune system is not associated with Guillain-Barré syndrome. Although impaired swallowing and incontinence may occur with the ascending paralysis of this disorder, oxygenation is the priority. Remediation: • Guillain-Barré syndrome, pediatric • Guillain-Barré syndrome, pediatric, care planning • Respirations, shallow Question 60 See full question The nurse is making a postpartum visit at the home of a client who delivered 14 days earlier. After assessing the vital signs (temperature, 99° F [37.2° C]; pulse, 88 bpm; respiration rate, 20 breaths/min; and blood pressure, 112/60 mm Hg), the nurse records other findings in the chart above. Which finding indicates delayed involution? You Selected: • fundus Correct response: • fundus Explanation: The fundus descends at the rate of one to two cms per day and by 2 weeks is no longer a pelvic organ. The vital signs, breasts, heart, lungs, abdomen (with exception of fundus), lochia, perineum, and extremities are within normal limits. Question 61 See full question Which of the following assessment questions is most likely to yield clinically meaningful data about a female client’s sexual identity? You Selected: • "How do you feel about yourself as a woman?" Correct response: • "How do you feel about yourself as a woman?" Explanation: Sexual identity is a broad concept that includes, but supersedes, sexual functioning. However, it is more specific than simply asking about the quality of relationships. Asking an open-ended question about how the client feels about herself as a woman is likely to elicit important insights. Assessing the client’s history of STIs does not directly address her sexual identity. Remediation: • Health history interview and physical assessment Question 62 See full question A nurse is caring for a client with lower back pain who is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the client in which position? You Selected: • Head of the bed elevated 45 degrees Correct response: • Head of the bed elevated 45 degrees Explanation: After a myelogram, positioning depends on the dye injected. When a water-soluble dye such as metrizamide is injected, the head of the bed is elevated to a 45-degree angle to slow the upward dispersion of the dye. The prone and supine positions are contraindicated when a water-soluble contrast dye is used. The client should be positioned supine with the head lower than the trunk after an air- contrast study. Remediation: • Herniated intervertebral disk Question 63 See full question The nurse is assessing a client for heroin addiction. Which finding indicates the client has used heroin? You Selected: • pupils large and dilated Correct response: • pupils small and constricted Explanation: Heroin causes pinpoint pupils. Marijuana causes the eyes to appear red and bloodshot. Cocaine use causes pupils to dilate. Drooping of the eyelids is not typically associated with the use of any substance. Remediation: • Admission of a patient with a history of drug abuse Question 64 See full question The nurse is creating a medication list for a client and notes that he takes saw palmetto. What should the nurse assess next? You Selected: • “Tell me about your normal voiding patterns.” Correct response: • “Tell me about your normal voiding patterns.” Explanation: It would be important to assess about the client’s ability to void. Saw palmetto is used to relieve symptoms of benign prostatic hypertrophy. Joint pain would be important if the client was taking glucosamine. Niacin could be used to lower cholesterol, and melatonin would be appropriate for insomnia. Question 65 See full question When should a nurse introduce information about the end of the nurse-client relationship? You Selected: • During the orientation phase Correct response: • During the orientation phase Explanation: Preparation for ending the nurse-client relationship should begin during the orientation phase, when realistic limits of the relationship are established. Termination should also be discussed as goals are achieved and the relationship nears an end. Although the nurse should remind the client when only one or two sessions remain, she must not wait until then to prepare the client for termination. The client's ability to tolerate the end of a relationship shouldn't dictate its timing. Because many clients have had negative experiences when ending relationships, the nurse may use termination of the nurse-client relationship to prepare the client for and work the client through positive termination experiences with others. Question 66 See full question The charge nurse in the newborn nursery has an unlicensed assistive personnel (UAP) with her for the shift. Under their care are 8 babies rooming in with their mothers, and 1 infant in the nursery for the night on tube feedings. There is a new client whose infant will be brought to the nursery in 15 minutes. Which tasks would the nurse assign to the UAP? Select all that apply. You Selected: • vital signs on all stable infants • document feedings of infants • record voids/stools Correct response: • vital signs on all stable infants • document feedings of infants • record voids/stools Explanation: The role of the UAP allows this member of the health care team to take vital signs on clients, record feedings, and voids and stools of infants according to hospital guidelines. The newborn assessment is completed by a licensed care provider as is the tube feeding. Bathing of the newborn is within the scope of practice for the UAP, but the initial assessment of patency of the gastrointestinal tract, which is initiated by the first feeding, is within the scope of licensed care providers. If there is a trachea esophageal fistula, this is the time when it may become evident. Question 67 See full question A client is scheduled for a cardiac catheterization. The nurse should do which preprocedure tasks? Select all that apply. You Selected: • Verify that written consent has been obtained. • Withhold food and oral fluids before the procedure. • Check for iodine sensitivity. Correct response: • Check for iodine sensitivity. • Verify that written consent has been obtained. • Withhold food and oral fluids before the procedure. Explanation: For clients scheduled for a cardiac catheterization it is important to assess for iodine sensitivity, verify written consent, and instruct the client to take nothing by mouth for 6 to 18 hours before the procedure. Oral medications are withheld unless specifically prescribed. A urinary drainage catheter is rarely required for this procedure. Remediation: • Cardiac catheterization • Preoperative Nursing Care on the Day of Surgery Question 68 See full question The nurse is assessing children at risk for phenylketonuria (PKU). Which child is at greatest risk? You Selected: • child with dark complexion who is overweight and has labile personalities Correct response: • blond, blue-eyed, fair-skinned child with eczema Explanation: Infants with PKU are usually blond, blue-eyed, and fair, and often have eczema. The other physical assessment findings are not typically found in children with PKU. Question 69 See full question A nurse hears a client state, “I have had it with this marriage. It would be so much easier to just hire someone to kill my husband!” What action should the nurse take? You Selected: • The nurse must start the process to warn the client’s husband. Correct response: • The nurse must start the process to warn the client’s husband. Explanation: Confidentiality must be broken if there are credible threats made against another person’s safety. Confidentiality does not override the safety of other persons. Remediation: • Confidentiality, maintaining Question 70 See full question The nurse is caring for a client who has been diagnosed with pernicious anemia. Which statement by the client indicates an understanding of the treatment of pernicious anemia? You Selected: • "I will receive my first injection of vitamin B12 tomorrow, and I will return for a follow-up injection in 1 month." Correct response: • "I will need to take vitamin B12 replacements for the rest of my life." Explanation: Clients who have been diagnosed with pernicious anemia are lacking adequate amounts of the intrinsic factor (IF) that is secreted by the gastric mucosa. IF is necessary for the absorption of cobalamin (vitamin B12) in the distal ileum. Without the presence of IF, dietary intake of vitamin B12 is useless because it cannot be absorbed. Treatment of pernicious anemia includes IM injections of cobalamin, at first daily for 2 weeks, then weekly until the anemia is corrected. A maintenance schedule of monthly injections is then implemented. The injections will need to be continued for the rest of the client’s life. Remediation: • Anemia, pernicious Question 71 See full question What is an expected outcome for a client during the first 2 weeks who is recovering from an abdominal- perineal resection with a colostomy? The client will: You Selected: • maintain a fluid intake of 3,000 mL/day. Correct response: • maintain a fluid intake of 3,000 mL/day. Explanation: An expected outcome is that the client will maintain a fluid intake of 3,000 mL/day unless contraindicated. There is no need to eliminate fiber from the diet; the client can eat whatever foods are desired, avoiding those that are bothersome. Physical activity does not need to be limited to light exercise. The client can resume normal activities as tolerated, usually within 6 to 8 weeks. The client’s sexual activity may be affected, but it does not need to be diminished. Remediation: • Bowel resection Question 72 See full question Which of the following actions most clearly demonstrates a nurse’s commitment to social justice? You Selected: • Lobbying for an expansion of Medicare eligibility and benefits. Correct response: • Lobbying for an expansion of Medicare eligibility and benefits. Explanation: Social justice is a professional value that encompasses efforts to promote universal access to healthcare, such as the expansion of publicly funded programs like Medicare. Culturally competent care is a reflection of human dignity while answering clients’ questions and documenting accurately are expressions of the value of integrity. Question 73 See full question Three years ago, a client was diagnosed with multiple sclerosis. He now presents with lower extremity weakness and heaviness. During the admission process, the client presents his advance directive that states he doesn't want intubation, mechanical ventilation, or tube feedings, should his condition deteriorate. How should the nurse respond? You Selected: • "It's important for us to have this information. You should review the document with your physician at every admission." Correct response: • "It's important for us to have this information. You should review the document with your physician at every admission." Explanation: An advance directive should be part of the client's medical record. The client should review the document with the physician at every admission because some conditions may be reversible and temporary, making portions of the advance directive inappropriate. Simply telling the client that the document will be included in his permanent record doesn't address the need to review the directive with the physician. Advance directives are appropriate for clients of any age. Remediation: • Advance directives Question 74 See full question A client with chronic hepatitis C is experiencing nausea, anorexia, and fatigue. During the health history the client states that he is homosexual, drinks one to two glasses of wine with dinner, is taking St. John’s Wort for a “bit of depression,” and takes acetaminophen for frequent headaches. What should the nurse do? Select all that apply. You Selected: • Encourage the client to obtain sufficient rest. • Instruct the client to ask the health care provider (HCP) about taking any other medications as they may interact with medications the client is currently taking. • Advise the client of the need for additional testing for HIV. Correct response: • Instruct the client to ask the health care provider (HCP) about taking any other medications as they may interact with medications the client is currently taking. • Advise the client of the need for additional testing for HIV. • Encourage the client to obtain sufficient rest. Explanation: Clients with chronic hepatitis C should abstain from alcohol as it can speed cirrhosis and end-stage liver disease. Clients should also check with their HCPs before taking any nonprescription or prescription medications, or herbal supplements. It is also important that clients who are infected with HCV be tested for HIV, as clients who have both HIV and HCV have a more rapid progression of liver disease than those who have HCV alone. Clients with HCV and nausea should be instructed to eat four to five times a day to help reduce anorexia and nausea. The client should obtain sufficient rest to manage the fatigue. Remediation: • Hepatitis, viral • Acquired immunodeficiency syndrome and human immunodeficiency virus • Liver failure Question 75 See full question A nursing supervisor asks a pediatric nurse to work temporarily (float) in the intensive care unit (ICU) because there are few clients in the pediatric unit. The pediatric nurse has never worked in ICU and has no intensive care experience. Which action should this nurse take? You Selected: • Notify the nursing supervisor that she feels unqualified and untrained for the assignment. Correct response: • Notify the nursing supervisor that she feels unqualified and untrained for the assignment. Explanation: The pediatric nurse should notify the nursing supervisor about feeling unqualified and untrained to float in the ICU. The nursing supervisor can advise the pediatric nurse about tasks she is qualified to perform in the ICU without jeopardizing her nursing license. When the census on a unit is low, many facilities use staff to float to another unit as a cost-effective and reasonable way for managing resources. Having the ICU nurses determine what tasks the pediatric nurse can perform makes the ICU nurses responsible for the pediatirc nurse's performance. However, the nursing supervisor should make those decisions because the supervisor knows the overall needs of the facility and can, therefore, best allocate nursing resources. A nurse should never accept responsibility for a total client care assignment if she doesn't have the skills to plan and deliver care. Question 76 See full question When caring for a client who has overdosed on phencyclidine (PCP), the nurse should be especially cautious about which client behavior? You Selected: • visual hallucinations Correct response: • violent behavior Explanation: The nurse must be especially cautious when providing care to a client who has taken phencyclidine (PCP) because of unpredictable, violent behavior. The client can appear to be in a calm state or even in a coma, then become violent, and then return to a calm or comatose state. Visual hallucinations, bizarre behavior, and loud screaming are associated with PCP-intoxicated clients. However, the unpredictable, violent behavior presents a major issue of safety for clients and staff. Remediation: • Admission of a patient with a history of drug abuse Question 77 See full question The nurse assesses a client with a 5 × 2 stasis ulcer just above the left malleolus. The wound is open with irregular, reddened, swollen edges and there is a moderate amount of yellowish tan drainage coming from the wound. The client verbalizes pressure-type pain and rates the discomfort at 7 on a scale of 0 to 10. To maintain tissue integrity, the primary nursing goal should focus on: You Selected: • keeping pressure of bed linens off the area. Correct response: • keeping pressure of bed linens off the area. Explanation: The nurse should keep bed linens off of the stasis ulcer to decrease the amount of pressure that the linens exert upon the lower extremity and prevent further tissue breakdown. Administering prescribed analgesics would be an intervention for reducing the pain. Applying lanolin lotions to the left ankle ulcer will not promote healing. Encouraging the client to sit up in a chair four times per day is an intervention to promote activity. The nurse would elevate the involved extremity while the client is sitting up to reduce venous stasis and capillary pressure. Remediation: • Impaired skin integrity Question 78 See full question A client with diverticular disease is receiving psyllium hydrophilic mucilloid. The drug has been effective when the client: You Selected: • passes stool without cramping. Correct response: • passes stool without cramping. Explanation: Diverticular disease is treated with a high-fiber diet and bulk laxatives such as psyllium hydrophilic mucilloid. Fiber decreases the intraluminal pressure and makes it easier for stool to pass through the colon. Bulk laxatives do not manage diarrhea or relieve gas formation. The stool should remain soft and easy to expel. Remediation: • Psyllium powder • Diverticular disease Question 79 See full question What is the priority nursing intervention for a client experiencing a dysrhythmia that continues to deteriorate and requires converting? You Selected: • Defibrillate Correct response: • Defibrillate Explanation: To attempt to convert the rhythm, the nurse should first defibrillate the client. If this is unsuccessful, then CPR should be initiated. Epinephrine and vasopressin may be given, but only after two defibrillation attempts. Remediation: • Defibrillation Question 80 See full question A client has signed a document indicating a wish not to be resuscitated. During morning rounds, the nurse finds the client without vital signs. What is the most appropriate action for the nurse to take? You Selected: • Notify the physician that the client has no vital signs. Correct response: • Notify the physician that the client has no vital signs. Explanation: The resident has signed a document indicating the client's wish not to be resuscitated. The other options are incorrect because the nurse should be aware of the client's “do not resuscitate” (DNR) status and should not need to go to the desk to confirm this. The nurse should notify the physician so he/she can pronounce the death and notify the family. Remediation: • Advance directives Question 81 See full question A client with chronic pancreatitis should be assessed for which finding? You Selected: • Nausea and vomiting Correct response: • Nausea and vomiting Explanation: Common manifestations of chronic pancreatitis include nausea, vomiting, and intermittent pain. Chronic pancreatitis does not cause confusion or agitation. There is no change in vital signs, and there are no musculoskeletal manifestations such as muscle twitching. Remediation: • Abdominal pain Question 82 See full question Which finding would most likely alert the nurse to the possibility that a preschooler is experiencing moderate dehydration? You Selected: • absence of tear formation Correct response: • absence of tear formation Explanation: The absence of tears is typically found when moderate dehydration is observed as the body attempts to conserve fluids. Other typical findings associated with moderate dehydration include a dry mouth, sunken eyes, poor skin turgor, and an increased pulse rate. Deep, rapid respirations are associated with severe dehydration. Decreased perspiration, not diaphoresis, would be seen with moderate dehydration. The specific gravity of urine increases with decreased output in the presence of dehydration. Remediation: • Calculating fluid requirements, pediatric Question 83 See full question To prevent pulmonary embolism in a client who has had abdominal surgery, the nurse should: You Selected: • have the client wear antiembolism stockings when out of bed. Correct response: • have the client perform leg exercises every hour while awake. Explanation: Performing leg exercises, including ankle pumping, ankle rotation, and quadriceps setting exercises, will help prevent stasis of blood in the lower extremities, which can lead to blood clot formation. Encouraging the client to cough and deep breathe is an important postoperative intervention; however, it is directed at preventing pneumonia, not pulmonary emboli. The nurse should not massage the calves because a deep vein thrombus could dislodge and travel to the pulmonary vasculature. Antiembolism stockings should be worn continuously during the postoperative period. Remediation: • Pulmonary embolism Question 84 See full question The nurse is monitoring a client, who is six hours post embolectomy, for an acute arterial occlusion of the left leg. When a Doppler ultrasound fails to detect a pedal pulse, the nurse notifies the surgeon who requests that the client be prepared for immediate surgery. The client refuses to consider additional surgery. What is the nurse’s initial intervention? You Selected: • Notify the provider immediately Correct response: • Notify the provider immediately Explanation: The nurse should notify the health care provider. The health care provider is responsible for providing information regarding the procedure, risks, benefits and expected outcomes. After notifying the provider, the nurse should document the situation and client response in the client’s record. Remediation: • Postoperative care Question 85 See full question The nurse is caring for a child with an acute exacerbation of asthma. Oral methylprednisolone has been ordered. Which of the following actions is most important for the nurse to take when administering this medication? You Selected: • Do not give other medications with methylprednisolone. Correct response: • Give the medication with food. Explanation: Giving the medication with food helps reduce gastric irritation. Oral doses of corticosteroids should be given in the morning. Remediation: • methylPREDNISolone Question 86 See full question The parent of a toddler with nephrotic syndrome asks the nurse what can be done about the child's swollen eyes. Which measure should the nurse suggest? You Selected: • Elevate the head of the child's bed. Correct response: • Elevate the head of the child's bed. Explanation: The child’s swollen eyes are caused by fluid accumulation. Elevating the head of the bed allows gravity to increase the downward flow of fluids in the body, away from the face. Applying cool compresses or eye drops, or limiting television, may be comforting but will not relieve the swelling. Remediation: • Nephrotic syndrome, pediatric Question 87 See full question A psychotic client tells the evening nurse that the day nurse put something suspicious in his water with his medication. The nurse replies, "You're worried about your medication?" The nurse's communication is: You Selected: • reinforcing the client's delusions. Correct response: • focusing on emotional content. Explanation: The nurse should help the client focus on emotional content rather than delusional material. Presenting reality isn't helpful because doing so can lead to confrontation and disengagement. Agreeing with the client and supporting his beliefs reinforce delusions. Mind reading isn't a therapeutic technique. Remediation: • Psychiatric nursing assessment Question 88 See full question The client with peripheral vascular disease and a history of hypertension is to be discharged on a low-fat, low-cholesterol, low-sodium diet. Which should be the nurse's first step in planning the dietary instructions? You Selected: • Determine the client's knowledge level about cholesterol. Correct response: • Assess the family's food preferences. Explanation: Before beginning dietary interventions, the nurse must assess the client's pattern of food intake, life style, food preferences, and ethnic, cultural, and financial influences. Remediation: • Deficient knowledge: diet Question 89 See full question The school nurse assesses a 10-year-old girl who excessively cleans and categorizes. Her parents report that she has always been orderly, but since her brother died of cancer 6 months ago, her cleaning and categorizing have escalated. In school, she reads instead of playing with other children. These behaviors are now interfering with homework and leisure activities. To bolster her self-esteem, the nurse should encourage the child to: You Selected: • be a library helper. Correct response: • be a library helper. Explanation: This child is demonstrating signs of anxiety and withdrawal. Being a library helper enables the client to use an interest (reading) when interacting with others and gaining pride in helping others. Most interaction will be one-to-one and with adults, which is likely to be more comfortable for her in her state of anxiety. Organizing a class party, a group project with her peers, and a kickball team involve multiple peer interactions, which are likely to be difficult for her at this time. Also, there is no mention of the child liking sports, so kickball would not be an appropriate activity. Remediation: • Generalized anxiety disorder Question 90 See full question A client is scheduled for urinary diversion surgery to treat bladder cancer. Before surgery, the health care team — consisting of a nurse, dietitian, social worker, enterostomal therapist, surgeon, client educator, and mental health worker — meets with the client. After the meeting, the client states, "My life won't ever be the same. What am I going to do?" Which health care team member should the nurse consult to help with the client's concerns? You Selected: • Client educator Correct response: • Client educator Explanation: The nurse should consult the client educator to help the client with his fears and concerns. Providing the client with information can greatly allay the client's fears. The social worker can provide the client with services he may need after discharge. Although the surgeon tells the client about the surgery, he isn't the best person to help the client with fears and concerns. The dietitian can help with dietary concerns but can't provide help with direct concerns about the surgery. Question 91 See full question To prevent the spread of infection in the home healthcare environment, the nurse should follow appropriate technique by: You Selected: • Donning a mask and gown before greeting the client's family members. Correct response: • Placing equipment back on a liner when setting it down in the client's home. Explanation: To prevent the spread of infection, nurses should use appropriate technique when handling their equipment bags by performing hand hygiene before reaching into the bag for supplies, cleaning any equipment removed from the bag before returning it to the bag, and placing the bag on a liner when setting it down in the client's home. Donning gloves, a mask, or gown when greeting the client or family members is not necessary and will interfere with the greeting process. Remediation: • Standard precautions Question 92 See full question A home health nurse is providing care to a palliative care client with liver cancer. Which classifications of medications are anticipated on the medication administration record? Select all that apply. You Selected: • Narcotics • Stool softeners • Antiemetic Correct response: • Narcotics • Stool softeners • Antiemetic Explanation: The client with liver cancer who is also a palliative care client has decided to focus on quality of life and symptom management instead of curative treatment. Narcotics for pain relief, stool softeners to maintain a bowel regiment in light of narcotic use and antiemetics to control nausea and vomiting all assist the client to meet their goals. Chemotherapeutic agents are aggressive therapy to kill liver cancer cells. Antidepressants are used for symptoms of depression. Question 93 See full question A client was admitted to the hospital with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client's activity intolerance? You Selected: • "What daily activities were you able to do 6 months ago compared with the present?" Correct response: • "What daily activities were you able to do 6 months ago compared with the present?" Explanation: It is difficult to determine activity intolerance without objectively comparing activities from one time frame to another. Because iron deficiency anemia can occur gradually and individual endurance varies, the nurse can best assess the client's activity tolerance by asking the client to compare activities 6 months ago and at present. Asking a client how long a problem has existed is a very open-ended question that allows for too much subjectivity for any definition of the client's activity tolerance. Also, the client may not even identify that a "problem" exists. Asking the client whether he is staying abreast of usual activities addresses whether the tasks were completed, not the tolerance of the client while the tasks were being completed or the resulting condition of the client after the tasks were completed. Asking the client if he is more tired now than usual does not address his activity tolerance. Tiredness is a subjective evaluation and again can be distorted by factors such as the gradual onset of the anemia or the endurance of the individual. Remediation: • Anemia iron deficiency Question 94 See full question Upon assessment of third-degree heart block on the monitor, what should the nurse do first? You Selected: • Place transcutaneous pads on the client. Correct response: • Place transcutaneous pads on the client. Explanation: Transcutaneous pads should be placed on the client with third-degree heart block. For a client who is symptomatic, transcutaneous pacing is the treatment of choice. The hemodynamic stability and pulse should be assessed prior to calling a code or initiating CPR. Defibrillation is performed for ventricular fibrillation or ventricular tachycardia with no pulse. Remediation: • Pacemaker insertion Question 95 See full question Benzathine penicillin G, 2.4 million units IM, is prescribed as treatment for an adult client with primary syphilis. The nurse should administer the injection in the: You Selected: • midlateral aspect of the thigh. Correct response: • upper outer quadrant of the buttock. Explanation: Because of the large dose, the upper outer quadrant of the buttocks is the recommended site. The deltoid and the quadriceps lateralis of the thigh are not large enough for the recommended dose. In infants and small children, the midlateral aspect of the thigh may be preferred. Remediation: • Penicillin G benzathine (benzathine benzylpenicillin) Question 96 See full question The nurse is preparing to discharge a client with asthma. Which intervention is most important for the nurse to perform prior to discharge? You Selected: • Obtain additional equipment and medication that can be provided at the school Correct response: • Obtain additional equipment and medication that can be provided at the school Explanation: The child needs to have equipment and medication available at school to treat and prevent asthma attacks. A discussion should be held with the child and family to motivate the child to be involved in as many normal childhood activities as possible. The house should be kept as clean as possible to prevent exacerbations due to dust and pet dander. If the child is allergic to the family pet, the nurse should provide counseling on ways to minimize the risks. Remediation: • Asthma, pediatric Question 97 See full question A nurse can auscultate for heart sounds more easily if the client is: You Selected: • holding his breath. Correct response: • leaning forward. Explanation: The nurse can best auscultate for heart sounds by asking the client to lean forward and exhale forcefully. This position enables the nurse to listen for heart sounds without the sound of expiration interfering. Using the supine position to visually inspect the precordium allows the nurse to observe the chest wall for movement, pulsations, and exaggerated lifts or strong outward thrusts over the chest during systole. Placing the client in a left lateral decubitus position may make it easier for the nurse to hear low-pitched sounds related to atrioventricular valve problems. Remediation: • Health history interview and physical assessment Question 98 See full question A 35-year-old married client is admitted to the psychiatric unit. During the nurse’s interview the client states, “I can’t live this lie anymore. I wish I were a woman. I can’t live one more day feeling this way.” What is the nurse’s priority intervention? You Selected: • Initiate suicide precautions to ensure safety Correct response: • Initiate suicide precautions to ensure safety Explanation: This client reveals that he is under severe stress with suicidal ideation. His arrival at the hospital for admission represents a true crisis situation. Sitting down with the client and exploring his feelings would allow the nurse to assess the client, and is a necessary next step. Assuring safety is the highest priority. Discussions should not focus on gender conflict issues as these are more long-term, and cannot be quickly assessed or resolved. The primary health care provider shouldn’t be notified until an assessment is completed. The client should not speak to his wife until he has processed his feelings and is ready to face the associated challenges. Question 99 See full question In the emergency department, a client reveals to the nurse a lethal plan for committing suicide and agrees to a voluntary admission to the psychiatric unit. Which information would the nurse discuss with the client to answer the question “How long do I have to stay here?” Select all that apply. You Selected: • “Because you have stated that you want to hurt yourself, you must be safe before being discharged.” • “You may leave the hospital at any time unless you’re suicidal or homicidal or unable to meet your basic needs.” • “Let’s talk more after the health care team has assessed you.” Correct response: • “You may leave the hospital at any time unless you’re suicidal or homicidal or unable to meet your basic needs.” • “Let’s talk more after the health care team has assessed you.” • “Because you have stated that you want to hurt yourself, you must be safe before being discharged.” Explanation: A person who is admitted to a psychiatric hospital may voluntarily sign out of the hospital unless the health care team determines that the person is harmful to himself or others. The health care team evaluates the client’s condition before discharge. If there is reason to believe that the client may be harmful to himself or others, a hearing can be held to determine if the admission status should be changed from voluntary to involuntary. Not all discharges require a hearing. The client still has rights after committing himself to a psychiatric unit. The client does not need a lawyer to leave the hospital. A court hearing is held only if the client may pose a threat to himself or others and requires further treatment. Remediation: • Suicide precautions • 72-hour legal hold Question 100 See full question A client with autoimmune thrombocytopenia and a platelet count of 8,000/μl develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, "I don't need surgery — this will go away on its own." In considering her response to the client, the nurse must depend on the ethical principle of: You Selected: • autonomy. Correct response: • autonomy. Explanation: Autonomy is the right of the individual to make his own decisions. In this case, the client is capable of making his own decision and the nurse should support his autonomy. Beneficence, promoting and doing good, and justice (being fair) aren't the principles that directly relate to the situation. Advocacy is the nurse's role in supporting the principle of autonomy. Question 101 See full question A client who is blind is admitted for treatment of gastroenteritis. Which intervention takes highest priority for this client? You Selected: • Fall prevention Correct response: • Replacing fluid volume Explanation: Because the client has gastroenteritis and is probably dehydrated, replacing fluid volume takes highest priority. A sensory deficit, such as blindness, puts the client at risk for injury from the environment; however, a potential problem does not take highest priority. Although Activity intolerance or Impaired physical mobility also may be relevant, these interventions do not take precedence over the client's dehydration. Remediation: • Gastroenteritis • Deficient fluid volume Question 102 See full question A client receives a pacemaker to treat a recurring arrhythmia. When monitoring the cardiac rhythm strip, the nurse observes extra pacemaker spikes that do not precede a beat. What intervention would have the highest priority? You Selected: • Assess the client's cardiac output. Correct response: • Assess the client's cardiac output. Explanation: Extra pacemaker spikes that do not precede a beat may indicate failure to capture, in which the pacemaker fires, but the heart does not conduct the beat. The priority nursing intervention would be to assess the client to see if the client is tolerating the failure to capture or if the client has a decrease in cardiac output. Until the nurse knows how the client is tolerating this, it will not be useful to call the primary healthcare provider or call a code. Assessment is the first step in the nursing process, and the nurse should assess the client, not just the rhythm strip. Applying a magnet is not an appropriate action of failure to capture, but for loss of pacing. Remediation: • Pacemaker insertion Question 103 See full question When admitting a neonate whose mother received magnesium sulfate, the nurse should assess the baby for which complication? Select all that apply. You Selected: • increased temperature • decreased respirations • decreased muscle tone Correct response: • decreased muscle tone • decreased respirations Explanation: Magnesium sulfate decreases muscle contractility and crosses the placenta. Because of this, a neonate that has been exposed to this drug may have decreased muscle tone and decreased respirations. The Moro reflex will be decreased because of the decreased muscle tone. There are no findings that show magnesium sulfate has a direct effect on temperature. Remediation: • Magnesium sulfate Question 104 See full question The nurse is assessing an adult client with spina bifida to determine if she has obtained the recommended, preventive health screenings, and the client states, “I have not had a pelvic exam for over 15 years.” What is the most appropriate nursing intervention to facilitate this screening examination for the client? You Selected: • Communicate with the primary care provider to determine if the client can participate in the examination. Correct response: • Contact health care practitioners who provide the screening examination in an accessible environment. Explanation: Clients with disabilities have the right of access to care, and the nurse must assist clients to find health care practitioners who provide the needed health screening examinations in an accessible environment. Other assessments of the client and documentation of health information and the client’s physical limitations are important to share with the screening practitioner. Educating clients about their rights under the Americans with Disabilities Act would be a later nursing intervention. Question 105 See full question What priority intervention should the nurse implement when administering phenytoin to a client who has a nasogastric (NG) tube for feeding? You Selected: • Give phenytoin one hour before or two hours after NG tube feedings to ensure absorption Correct response: • Give phenytoin one hour before or two hours after NG tube feedings to ensure absorption Explanation: Phenytoin is protein bound .It is important to allow time for adequate absorption before resuming feedings. Nutritional supplements and milk interfere with the absorption of phenytoin, decreasing its effectiveness. Phenytoin levels are checked before giving the drug, and the drug is withheld for elevated levels to avoid compounding toxicity. The head of the bed is elevated when giving all drugs or solutions and isn’t specific to phenytoin administration. The nurse verifies NG tube placement by checking for stomach contents before giving drugs and feedings. If placed in water to check, the client could aspirate. Remediation: • phenytoin Question 106 See full question A female client who has a urinary diversion tells the nurse, "This urinary pouch is embarrassing. Everyone will know that I am not normal. I do not see how I can go out in public anymore." The most appropriate nursing goal for this client is to: You Selected: • express fears about the urinary diversion. Correct response: • express fears about the urinary diversion. Explanation: It is normal for clients to express fears and concerns about the body changes associated with a urinary diversion. Allowing the client time to verbalize concerns in a supportive environment and suggesting that she discuss these concerns with people who have successfully adjusted to ostomy surgery can help her begin coping with these changes in a positive manner. Although the client may be anxious about this situation and may be feeling worthless, the underlying problem is a disturbance in body image. There are no data to indicate that the client does not know how to care for the urinary diversion. Question 107 See full question Emergency restraints or seclusion may be implemented without a physician's order under which condition? You Selected: • When a licensed practitioner will do a face-to-face assessment within 1 hour Correct response: • When a licensed practitioner will do a face-to-face assessment within 1 hour Explanation: In an emergency, a client who is a threat to himself or others may be restrained without an order. If restraints are initiated without an order the client must be assessed within 1 hour of application by a licensed, independent practitioner. Voluntary clients have the right to leave against medical advice. A minor should be treated the same way as an adult regarding restraints. Remediation: • Restraint use for a patient on a psychiatric unit Question 108 See full question The nurse is evaluating infection control practices performed by a spouse on a loved one who has methicillin resistant Staphylococcus aureus (MRSA) in a right leg wound. Which actions indicate that the spouse requires further teaching? Select all that apply. You Selected: • The spouse places soiled dressing supplies in the kitchen garbage can. • Sheets with wound drainage are washed in lukewarm water. Correct response: • The spouse places soiled dressing supplies in the kitchen garbage can. • Sheets with wound drainage are washed in lukewarm water. Explanation: Methicillin resistant Staphylococcus aureus (MRSA) is a bacterium that causes infections in different parts of the body and is resistant to some commonly used antibiotics. Infection control practices prevent the spread of the infection. Further teaching is needed if a nurse notes that soiled dressing supplies are placed in a community garbage can such as one located in the kitchen. Soiled sheets need to be wash in hot water and dried in a clothes dryer. It is correct clean and disinfect the area where dressing supplies are prepared. Routine hand hygiene followed by wearing clean gloves is appropriate when removing the dressing. Sterile gloves may be needed when completing dressing care. Remediation: • Methicillin-resistant Staphylococcus aureus Question 109 See full question Which laboratory study is most relevant to treating a client who has sustained a pelvic fracture? You Selected: • Urinalysis Correct response: • Type and crossmatch Explanation: Because of the rich blood supply to the pelvis, fractures to this area can result in significant blood loss. Type and crossmatch is a priority laboratory test in preparing for fluid replacement. Urine isn't commonly analyzed for myoglobin with this injury unless the mechanism was a crush injury; even then, urinalysis isn't as high a priority as type and crossmatch. Urinalysis and serum ethanol, although part of a trauma workup, aren't relevant to treatment of a pelvic fracture. Remediation: • Blood and blood product transfusion • Fracture, arm or leg Question 110 See full question A client diagnosed with glaucoma and receiving beta-adrenergic blocking ophthalmic drops makes each of these comments. Which one requires immediate follow-up by a nurse? You Selected: • “My blood pressure runs a little high when I gain weight.” Correct response: • “My pulse rate is a little low today because I take digoxin.” Explanation: Beta-adrenergic blocking agents may decrease heart rate and blood pressure, and should be used cautiously in clients receiving digoxin. The other statements do not require immediate follow-up. Remediation: • Glaucoma Question 111 See full question A client diagnosed with acquired immunodeficiency syndrome (AIDS) is experiencing end-stage Kaposi's sarcoma. Concerned that the health care team is investing too much energy in keeping him alive, he asks that they not attempt any more interventions. How should a nurse respond to this client? You Selected: • "We have to make sure you've signed an advance directive." Correct response: • "We have to make sure you've signed an advance directive." Explanation: The nurse should tell the client he must sign an advance directive to prevent future health care interventions. This client has lived with AIDS for many years; suggesting that he talk with a therapist or reconsider his decision is disrespectful and disregards his experience of the disease. An advance directive doesn't require a physician's order. Remediation: • Dying patient care • Advance directives Question 112 See full question A nurse is caring for a client receiving the fentanyl transdermal system for pain management. When applying a new system, the nurse should: You Selected: • apply the system immediately after removal from a package. Correct response: • apply the system immediately after removal from a package. Explanation: The fentanyl transdermal system should be applied immediately after removal from the sealed package. The nurse should press the system firmly in place with the palm for 10 to 20 seconds, not 30 to 60 seconds, to make sure the contact is complete, especially around the edges. The system should be applied to nonirritated and nonirradiated skin on a flat surface of the upper torso. When reapplying a new system, the nurse should choose a different site. Hair at the application site should be clipped (not shaved) before application; the nurse should clean the site with clear water. Soaps, oils, lotions, alcohol, or other agents that might irritate the skin or alter its characteristics shouldn't be used; the skin should be dried completely before application. Remediation: • Fentanyl transdermal patch Question 113 See full question A nurse is caring for a family whose infant has anencephaly. The most appropriate nursing intervention is to: You Selected: • help the family prepare for the infant's imminent death. Correct response: • help the family prepare for the infant's imminent death. Explanation: Anencephaly is incompatible with life. The nurse should support family members as they prepare for the infant's imminent death. Facilitating the attachment process, helping the family to adjust to the infant's problems, and preparing the family for extensive surgical procedures are inappropriate because the infant can't survive. Remediation: • Dying patient care • Neural tube defects, pediatric Question 114 See full question A nurse on the labor-and-birth unit transfers a primiparous client and her term neonate to the mother- baby unit 2 hours after the client gave vaginal birth to the neonate. Which information is a priority for the nurse to report to the nurse receiving the client on the mother-baby unit? You Selected: • firm fundus when gentle massage is used Correct response: • firm fundus when gentle massage is used Explanation: The priority assessment is that the client has a firm fundus when gentle massage is used. This indicates that the client’s fundus may be soft or “boggy” when it is not massaged. The receiving nurse should assess the client’s fundus soon after admission and continue to monitor the client’s fundus, lochia, and pulse rate. Postpartum hemorrhage is associated with uterine atony. Maternal-infant bonding is a process that usually starts on day 2 and ends at week 1. A 12-hour labor is normal. The temperature and pulse are within normal limits. Remediation: • Transfer to another unit, pediatric • Fundal assessment, postpartum Question 115 See full question A breastfeeding primiparous client asks the nurse how breast milk differs from cow’s milk. The nurse responds by saying that breast milk is higher in which nutrient? You Selected: • fat Correct response: • fat Explanation: Breast milk has a higher fat content than cow’s milk. Thirty to fifty-five percent of the calories in breast milk are from fat. Breast milk contains less iron than cow’s milk does. However, the iron absorption from breast milk is greater in the neonate than with cow’s milk. Breast milk contains less sodium and calcium than cow’s milk. Remediation: • Breast milk handling and care Question 116 See full question A nurse is discharging a client with somatic symptom disorder. What is the nurse’s priority goal? You Selected: • Reduce the fear of illness Correct response: • Reduce the fear of illness Explanation: A client with somatic symptom disorder has a preoccupying fear of having a serious disease. Although hopelessness may be present, it is not the primary focus. While all persons can benefit from a goal to increase self-esteem, this is not a priority goal for these clients. Clients with this disorder are not prone to violence toward themselves or others. Remediation: • Somatic symptom disorder Question 117 See full question A primigravid client with severe preeclampsia exhibits hyperactive, very brisk patellar reflexes with two beats of ankle clonus present. How does the nurse document the patellar reflexes? You Selected: • 4+ Correct response: • 4+ Explanation: These findings would be documented as 4+. 1+ indicates a diminished response; 2+ indicates a normal response; 3+ indicates a response that is brisker than average but not abnormal. Mild clonus is said to be present when there are two movements. Remediation: • Chronic hypertension in pregnancy patient care Question 118 See full question When developing the plan of care for a newly admitted 2-year-old child with the diagnosis of Kawasaki disease, which intervention should be the priority? You Selected: • monitoring intake and output every hour Correct response: • monitoring intake and output every hour Explanation: Cardiac status must be monitored carefully in the initial phase of KD because the child is at high risk for congestive heart failure (CHF). Therefore, the nurse needs to assess the child frequently for signs of CHF, which would include respiratory distress and decreased urine output. Vital signs would be obtained more often than every 6 hours because of the risk of CHF. Although minimizing skin discomfort would be important, it does not take priority over monitoring the child’s hourly intake and output. Passive range- of-motion exercises would be done if the child develops arthritis. Remediation: • Kawasaki syndrome, pediatric Question 119 See full question A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. What is the most important action by the nurse? You Selected: • Preventing secondary acute tubular necrosis Correct response: • Preparing to administer hypertonic saline or mannitol per provider order Explanation: Hypertonic saline and mannitol promote osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Therefore these agents are often used as first-line agents to decrease ICP while preparing the client for surgery. Elevating the head of the bed can also help facilitate venous return, targeting a decrease in ICP, not intraocular pressure. Although it is important to closely monitor fluid and electrolytes, preventing acute kidney injury is secondary. Remediation: • mannitol Question 120 See full question A client’s laboratory tests indicate that the client has hypercalcemia. The nurse should assess the client for: You Selected: • depressed reflexes. Correct response: • depressed reflexes. Explanation: Calcium aids in nerve impulse transmission, muscle contractions, cardiac contraction, and development of bone and teeth. Clinical manifestations of hypercalcemia include lethargy, weakness, depressed reflexes, constipation, polyuria, and bone pain. Flushed skin is a symptom of hypernatremia. Tingling in the extremities is indicative of hypocalcemia. Constipation, not diarrhea, is seen with hypercalcemia. Remediation: • Hypercalcemia • Fluid and Electrolytes • Calcium in Muscles Question 121 See full question The nurse is obtaining a blood sample for a partial thromboplastin time test prescribed for a client who is taking heparin. It is 0500 when drawing the blood. What should the nurse do? Select all that apply. You Selected: • Awake the client. • Check the armband for client identification number and compare with the prescription. • Ask the client to state his/her name. • Label the sample vial in front of the client. Correct response: • Awake the client. • Check the armband for client identification number and compare with the prescription. • Label the sample vial in front of the client. • Ask the client to state his/her name. Explanation: When obtaining blood samples, the nurse must use two acceptable sources of identification (the client states his/her name; the nurse verifies the client’s name and identification number of the armband); verifying a room number is not acceptable as client’s can be easily reassigned to other rooms. The client must be awake to state his/her name. Blood samples must be labeled in front of the client. Remediation: • Venipuncture Question 122 See full question A graduate nurse receives an order to perform an IV insertion but has not performed this skill since the third year of the nursing program. What actions should the graduate nurse take at this time? You Selected: • Approach another nurse in the clinic to cover this skill. Correct response: • Explain that an in-service would need to be completed, as would practice sessions on IV insertions, prior to performing this skill. Explanation: This is a skill that requires knowledge and supervised practice, especially because of the invasive nature of the procedure. Honest acknowledgement of the nurse's lack of competency in a skill is an important professional responsibility, followed by actions to ensure the nurse can acquire the skill. Remediation: • IV catheter insertion Question 123 See full question The nurse is teaching a client with Parkinson’s disease about the nutritional modifications to make in the diet because the client is taking levodopa. The nurse should instruct the client to: You Selected: • increase the amount of protein in the diet. Correct response: • avoid foods high in pyridoxine (vitamin B12). Explanation: When taking levodopa, the client should avoid foods and vitamins high in pyridoxine, which interferes with the efficacy of the levodopa. The client should also avoid a high-protein diet for the same reason. There is no need to increase the amount of potassium in the diet or to implement a sodium-restricted diet. Remediation: • Levodopa and carbidopa Question 124 See full question A 19-year-old has struggled academically throughout high school and realizes during her last semester in school that she is not going to graduate with her class, which will delay her admission to college. In the past, she has intermittently used drugs and alcohol to deal with her anxiety, but now her involvement with substances escalates to daily use. In what order of priority from first to last should the nurse, who has become aware of the problem, take the actions? All options must be used. You Selected: • Refer her to an outpatient program that treats clients with chemical dependency issues. • Refer her to a program at the local community college to improve the client's readiness for college and decrease her anxiety. • Refer her to a psychiatric clinic so she can get an appropriate diagnosis and medication for her anxiety. • Refer her to the school authorities to address her academic issues so she can graduate next semester. Correct response: • Refer her to a psychiatric clinic so she can get an appropriate diagnosis and medication for her anxiety. • Refer her to an outpatient program that treats clients with chemical dependency issues. • Refer her to the school authorities to address her academic issues so she can graduate next semester. • Refer her to a program at the local community college to improve the client's readiness for college and decrease her anxiety. Explanation: The client’s anxiety seems to fuel her substance abuse, so treatment for her anxiety is paramount, followed by treatment for substance abuse. Those two interventions should increase her readiness to profit from academic aid offered by the school. Referral to a community college program would help her get ready for college, which will likely decrease her anxiety. Remediation: • Anxiety • Substance abuse and dependence Question 125 See full question A nurse is caring for a client following a thoracotomy. A physical assessment reveals the client has incisional pain, a poor cough effort, and scattered rhonchi throughout all lung fields bilaterally. Which of the following actions should the nurse take first? You Selected: • Assist the client to splint the chest and encourage them to cough Correct response: • Medicate the client with prescribed morphine Explanation: Minimizing incisional pain by medicating the client with morphine will allow effective coughing and deep breathing, facilitating increased airway clearance. The client should be medicated before sitting them up, assisting them to cough or completing any teaching. Remediation: • Teaching Coughing and Splinting Question 126 See full question Vasodilation or vasoconstriction produced by an external cause will interfere with a nurse's accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should: You Selected: • keep the client warm. Correct response: • keep the client warm. Explanation: The nurse should keep the client covered and expose only the portion of the client's body that she's assessing. The nurse should also keep the client warm by maintaining his room temperature between 68° F and 74° F (20° and 23.3° C). Extreme temperatures aren't good for clients with PVD. Keeping the client uncovered would cause him to become chilled. Matching the room temperature to the client's body temperature is inappropriate. Question 127 See full question After teaching the parents of a toddler about commonly aspirated foods, which food, if identified by the parents as easily aspirated, would indicate the need for additional teaching? You Selected: • crackers Correct response: • crackers Explanation: Crackers, because they crumble and easily dissolve, are not commonly aspirated. Because children commonly eat popcorn hulls or pieces that have not popped, popcorn can be easily aspirated. Toddlers frequently do not chew their food well, making raw vegetables a commonly aspirated food. Round candy is often difficult to chew and comes in large pieces, making it easily aspirated. Remediation: • Aspiration precautions, pediatric Question 128 See full question The nurse is administering amoxicillin/clavulante potassium to a child with cellulitis. The provider has ordered 40 mg/kg to be given three times a day over 24 hours. The child weighs 33 lb (15 kg), and the pharmacy has sent amoxicillin/clavulantate 200 mg/5 ml. How many milliliters per dose should the nurse administer? Record your answer using a whole number. Your Response: • 5 Correct response: • 5 Explanation: The dose is calculated by first multiplying the weight times the milligrams. It’s then divided by three even doses. The milligrams are then used to determine the milliliters based on the concentration of the medicine. 40 mg/kg x 15 kg = 600 mg 600 mg/3 doses = 200 mg/dose The concentration is 200 mg in every 5 ml. Question 129 See full question A nurse is monitoring a client following the administration of sotalol. Which of the following would be of greatest concern to the nurse? You Selected: • Bilateral inspiratory wheezing upon auscultation Correct response: • Bilateral inspiratory wheezing upon auscultation Explanation: Nonselective beta-blocking drugs may cause bradycardia, hypotension, heart block, heart failure, bronchoconstriction, and/or increased airway resistance. Any preexisting respiratory condition such as asthma might be worsened by the concurrent use of these medications. A weight gain of more than 3 lbs (1.36 kg) in 2 days or 5 lbs (2.26 kg) in a week should be reported. Remediation: • sotalol hydrochloride Question 130 See full question Metabolic screening of an infant revealed a high phenylketonuria (PKU) level. Which statement the infant’s mother indicates understanding of the disease and its management? Select all that apply. You Selected: • "We have to follow a strict low-phenylalanine diet." • "My baby cannot have milk-based formulas." • "A dietitian can help me plan a diet that keeps a safe phenylalanine level but lets my baby grow." Correct response: • "My baby cannot have milk-based formulas." • "We have to follow a strict low-phenylalanine diet." • "A dietitian can help me plan a diet that keeps a safe phenylalanine level but lets my baby grow." Explanation: Phenylketonuria, an inherited autosomal recessive disorder, involves the body’s inability to metabolize the amino acid phenylalanine. A diet low in phenylalanine must be followed. Such foods as meats, eggs, and milk are high in phenylalanine. Assistance from a dietitian is commonly necessary to keep phenylalanine levels low and to provide the essential amino acids necessary for cell function and tissue growth. With autosomal recessive disorders, future children will have a 25% chance of having the disease, a 50% chance of carrying the disease, and a 25% chance of being free of the disease. If a diet low in phenylalanine is followed until brain growth is complete (sometime in adolescence), the child should achieve normal intelligence. Remediation: • Phenylalanine screening • Metabolism of Amino Acids Question 131 See full question A nurse teaches a postpartum client about breast-feeding. Which statement best indicates that the client knows how to avoid breast engorgement? You Selected: • "I'll apply warm, moist compresses to my breasts." Correct response: • "I'll breast-feed whenever the baby is hungry." Explanation: The client demonstrates understanding of teaching when she states that she'll breast-feed whenever the neonate is hungry. Frequent breast-feeding keeps the breasts relatively empty and increases circulation, thereby helping to remove fluid that may lead to engorgement. Applying warm compresses to the breasts stimulates the let-down reflex, filling the breasts and increasing engorgement. An electric breast pump usually isn't used if the neonate can breast-feed frequently. Although a bra supports the breasts, it can't prevent engorgement. Remediation: • Breast-feeding assistance Question 132 See full question A nurse caring for a client who has just received chemotherapy infusion is wearing a disposable gown, gloves, and goggles for protection. The nurse knows that accidental exposure to chemotherapy agents can occur through: You Selected: • inhalation of aerosols. Correct response: • inhalation of aerosols. Explanation: Aerosol inhalation or absorption through the skin can cause accidental chemotherapy exposure. A nurse must wear a disposable gown and gloves when preparing and administering chemotherapy. She won't absorb chemicals through an intact gown, protective gloves, or goggles. Remediation: • Chemotherapeutic drug preparation and handling Question 133 See full question A client with a long history of ulcerative colitis takes sulfasalazine to control the condition. The nurse should evaluate the client for which nutritional deficit that can occur as a result of taking this drug? You Selected: • folic acid deficit Correct response: • folic acid deficit Explanation: Clients who take sulfasalazine are susceptible to developing impaired folic acid absorption. Common clinical manifestations of a folic acid deficiency are gastrointestinal disturbances, such as anorexia, nausea, vomiting, and a smooth, beefy red tongue. The client should be encouraged to eat food high in folic acid, such as green leafy vegetables, meat, fish, legumes, and whole grains. Cobalamin deficiency, niacin deficiency, and iron deficiency are not side effects of sulfasalazine. Remediation: • Sulfasalazine (salazosulfapyridine, sulphasalazine) • Folic acid (vitamin B9) • Ulcerative colitis Question 134 See full question A nine-year-old is brought to the emergency department with extensive burns sustained in a restaurant fire. What is the nurse’s most important intervention? You Selected: • Conduct a wound assessment Correct response: • Conduct a wound assessment Explanation: The most important aspect of care for a child with burns is wound management. The goals of wound care are to speed debridement, protect granulation tissue and new grafts, and conserve body heat and fluids. Antibiotics aren’t always administered prophylactically. Fluids are administered IV to replace fluid volume according to the child’s body weight. Enteral feedings, rather than meals, are initiated within the first 24 hours after the burn to support the child’s increased nutritional requirements. Remediation: • Burn wound care, pediatric • Wound assessment Question 135 See full question A nurse is caring for a woman who gave birth to a term neonate at 0600. At 1600, the woman has a distended bladder and is reporting pain of 5 on a scale of 1 to 10. The nurse reviews the client’s output record (see figure). What should the nurse do first? You Selected: • Administer acetaminophen with codeine. Correct response: • Use an in-and-out catheter to empty the bladder. Explanation: The client is not emptying her bladder after repeated attempts. The nurse should now use an in-and-out catheter to empty the bladder. While the other comfort measures may be helpful, this client has not completely emptied her bladder since childbirth and will be at risk for a urinary tract infection and postpartum hemorrhage. Question 136 See full question A six-month-old infant is being admitted with a diagnosis of bacterial meningitis. What considerations should be made, by the nurse, regarding the infant’s room assignment? Select all that apply. You Selected: • The child will need to be on droplet precautions. • The room should be near the nurses’ station. • A private room is required. Correct response: • The child will need to be on droplet precautions. • A private room is required. • The room should be near the nurses’ station. Explanation: An infant, diagnosed with bacterial meningitis, should be placed on droplet precautions in a private room until that child has received IV antibiotics for 24 hours. This infant would be contagious. Bacterial meningitis can be quite serious; therefore, the infant’s room should be near the nurses’ station for close monitoring and easier access. The infant’s parents would be permitted to visit as long as they wear the proper PPE. Although a window in the door is ideal, it is not a requirement. Remediation: • Droplet precautions • Meningitis, pediatric Question 137 See full question Which nursing intervention would most likely promote self-care behaviors in the client with a hiatal hernia? You Selected: • Ask the client to identify other situations in which the client changed health care habits. Correct response: • Ask the client to identify other situations in which the client changed health care habits. Explanation: Self-responsibility is the key to individual health maintenance. Using examples of situations in which the client has demonstrated self-responsibility can be reinforcing and supporting. The client has ultimate responsibility for personal health habits. Meeting other people who are managing their care and involving family members can be helpful, but individual motivation is more important. Reassurance can be helpful but is less important than individualization of care. Remediation: • Readiness for enhanced power Question 138 See full question During a routine health assessment, a mother tells the nurse that her 2-year-old child is using a potty seat but is still having problems toilet training. Which suggestion would be most appropriate? You Selected: • Offer the child more praise each time. Correct response: • Defer training until the child is developmentally ready. Explanation: The most common reason for failed toilet training is that the child is simply not developmentally ready for training. Even with appropriate rewards and proper equipment, the child who is not ready for training will not be able to learn voluntary control. Offering praise is important and using a potty chair may help, but these measures are only effective when the child is developmentally ready. “Accidents” during training should be ignored. They are usually caused by the child’s incomplete sphincter control and poor recognition of the impending need to defecate until it is too late to get to the potty chair. Question 139 See full question A 40-year-old client is admitted to the hospital with a diagnosis of acute cholecystitis. The nurse should contact the health care provider (HCP) to question which prescription? You Selected: • Administer meperidine hydrochloride 50 mg IM every 4 hours as needed for severe abdominal pain. Correct response: • Administer meperidine hydrochloride 50 mg IM every 4 hours as needed for severe abdominal pain. Explanation: A nurse should question the prescription for meperidine hydrochloride because it is believed to cause biliary spasm. An alternative pain medication will be necessary. IV fluid therapy is used to maintain fluid and electrolyte balance that may result from NPO status and gastric suctioning. NPO status and gastric decompression prevent further gallbladder stimulation. Remediation: • Meperidine hydrochloride • Cholelithiasis, cholecystitis, and related disorders Question 140 See full question A nurse is caring for a woman who delivered a term neonate at 6 a.m. At 4 p.m., the woman has a distended bladder and is reporting pain of 5 on a scale of 1 to 10. The nurse reviews the client’s output record (see accompanying image). What should the nurse do first? You Selected: • Use an in-and-out catheter to empty the bladder. Correct response: • Use an in-and-out catheter to empty the bladder. Explanation: The client is not emptying her bladder after repeated attempts. The nurse should now use an in-and-out catheter to empty the bladder. While the other comfort measures may be helpful, this client has not completely emptied her bladder since delivery and will be at risk for a urinary tract infection. Remediation: • Intermittent (straight) urinary catheter insertion, female Question 141 See full question A 13-month-old client is admitted to the pediatric unit with gastroenteritis. The toddler has experienced vomiting and diarrhea for the past 3 days, and laboratory tests reveal dehydration. Which nursing interventions are correct to prevent further dehydration? Select all that apply. You Selected: • Encourage the child to eat non-salty soups and broth. • Encourage the child to eat a balanced diet. • Give clear liquids in small amounts. • Monitor the intravenous (IV) solution per the physician's order. Correct response: • Give clear liquids in small amounts. • Encourage the child to eat non-salty soups and broth. • Monitor the intravenous (IV) solution per the physician's order. Explanation: A child experiencing nausea and vomiting would not be able to tolerate a regular diet. The child should be given sips of clear liquids, and the diet should be advanced as tolerated. Non-salty soups and broths are appropriate clear liquids. Milk should not be given, because it can worsen the child's diarrhea. The nurse should monitor IV fluids, which are administered to maintain the fluid status and help to rehydrate the child. Solid foods may be withheld throughout the acute phase; however, clear fluids should be encouraged in small amounts (3 to 4 tablespoons [45 to 60 mL] every half hour). Remediation: • Gastroenteritis Question 142 See full question When providing discharge teaching to a client with a fractured toe, the nurse should include which instruction? You Selected: • Apply ice to the fracture site. Correct response: • Apply ice to the fracture site. Explanation: Applying ice to the injury site soon after an injury causes vasoconstriction, helping to relieve or prevent swelling and bleeding; heat to the fracture site would not be used because it may increase swelling and bleeding. There is no evidence that this is an open fracture where there is a break in the skin warranting discharge instructions regarding signs of infection. Ankle dorsiflexion has no therapeutic use after a toe fracture. It is unlikely the client would need crutches after a toe fracture. Remediation: • Fracture, arm or leg Question 143 See full question A client with a UTI exhibits the following vital signs; blood pressure of 90/60 mm Hg, respiratory rate of 24 breaths per minute, heart rate 100 beats per minute. Which nursing action would be most appropriate for this client? You Selected: • Assisting the client to the lithotomy position Correct response: • Placing the client in modified Trendelenberg position Explanation: This client has a low blood pressure and the best position would be the modified Trendelenberg to increase blood flow to the brain. Lithotomy position would be indicated for a vaginal exam, semi- Fowler's would be indicated for dyspnea, and the lateral position would be indicated for vomiting to prevent aspiration. Remediation: • Shock (hypovolemic) Question 144 See full question A nurse is coordinating care for a client admitted to the psychiatric unit after his/her fiancé was killed accidentally at his work site. Several weeks after the accident, the client is unable to sleep, eat, or work. Which of the following interventions would be most therapeutic for the client? You Selected: • Anticipate and eliminate stress for the client. Correct response: • Assign the same staff as often as possible. Explanation: Traumatic stress can create symptoms such as an inability to sleep, eat, or work. The nurse can facilitate a trusting relationship with staff if the same staff can be assigned to him/her as often as possible. It is not realistic for the nurse to be able to anticipate and eliminate stress for the client. The nurse can discuss coping strategies for the client to deal with stress. Medication is practical for times of stress reactions, but does not give long-term solutions for stress responses. The nurse should encourage the client to talk about trauma at the client's own pace. Remediation: • Complicated grieving Question 145 See full question A client hospitalized for preterm labor tells the nurse that she’s having occasional contractions. Which nursing intervention would be the most appropriate? You Selected: • Notify anesthesia for immediate epidural placement to relieve the pain associated with contractions Correct response: • Encourage the client to empty her bladder, give IV fluids, and encourage oral fluids Explanation: An empty bladder and adequate hydration may help decrease or stop labor contractions. Teaching potential complications is likely to increase this client’s anxiety rather than help with relaxation. Walking may cause contractions to become stronger. It would be inappropriate to call anesthesia and have an epidural placed because further assessment of contractions is necessary. Remediation: • Labor (preterm) Question 146 See full question The parent of a 16-month-old child calls the clinic because the child has a low-grade fever, cold symptoms, and a hoarse cough. What should the nurse suggest that the parent do? You Selected: • Offer extra fluids frequently. Correct response: • Offer extra fluids frequently. Explanation: The toddler is exhibiting cold symptoms. A hoarse cough may be part of the upper respiratory tract infection. The best suggestion is to have the father offer the child additional fluids at frequent intervals to help keep secretions loose and membranes moist. There is no evidence presented to suggest that the child needs to be brought to the clinic immediately. Although having the father count the child’s respiratory rate may provide some additional information, it may lead the father to suspect that something is seriously wrong, possibly leading to undue anxiety. A hot air vaporizer is not recommended. However, a cool mist vaporizer would cause vasoconstriction of the respiratory passages, making it easier for the child to breathe and loosening secretions. Remediation: • Common cold Question 147 See full question While performing health screenings on fifth-grade students, the nurse notes that one child’s left hip is higher than the right. The child denies pain or a history of shortness of breath when asked. The mother asks what to expect as a likely treatment. Which should the nurse tell the mother to expect? You Selected: • Spinal fusion surgery to prevent further curvature Correct response: • Careful monitoring with X-rays until the child has stopped growing Explanation: A child with a hip that is higher than the other while bending at the waist likely is developing a scoliosis. Boys and girls experience mild scoliosis at about the same rate, but girls are more likely to experience moderate and severe scoliosis. The majority of children will only require monitoring of the scoliosis every 4–6 months with an X-ray. Moderate scoliosis may require an underarm brace to help prevent further curvature, but the brace will not correct the curvature. Spinal fusion is necessary for scoliosis that is likely to cause complications with the heart, lungs, or movement and is not needed frequently. A Pavlik harness is used in the treatment of developmental dysplasia of the hip and is not appropriate given the age and symptoms of the child. Remediation: • Scoliosis, pediatric Question 148 See full question A 2-year-old child is admitted to the pediatric unit with fever, seizures, and vomiting. He's awake and alert. As the nurse is putting a gown on the child, the nurse notices petechiae across the child's chest, abdomen, and back. The nurse should: You Selected: • evaluate the child's neurologic status. Correct response: • evaluate the child's neurologic status. Explanation: Petechiae across the child's chest, abdomen, and back are signs of meningitis. The priority is to evaluate neurologic status. Petechiae aren't allergic reactions, so the nurse shouldn't ask about allergies. Standard precautions should be used when there is risk of contacting body fluids. Contact precautions should be instituted for the client diagnosed with meningitis. Throat and ear examinations wouldn't be helpful in confirming a diagnosis of meningitis. Remediation: • Neurologic assessment, pediatric Question 149 See full question A nurse calls the unit manager to report that her purse has been stolen from the locked break room. The nurse says she thinks she knows which of the staff stole the purse. Which actions by the nurse manager would be appropriate? Select all that apply. You Selected: • Ask the nurse to document all the facts related to the missing purse. • Ask other staff to report any suspicious activity they may have observed. • Call hospital security to initiate an investigation. Correct response: • Call hospital security to initiate an investigation. • Ask the nurse to document all the facts related to the missing purse. • Alert nursing administration that a staff's purse has been stolen. • Ask other staff to report any suspicious activity they may have observed. Explanation: It is appropriate for the nurse manager to initiate a security investigation and ask the nurse to document all the facts about the missing purse. Alerting nursing administration is required. Seeking information from other staff will help with the investigation. It is inappropriate to confront any possible suspects while the investigation is ongoing. Question 150 See full question A nurse is talking with a delusional client when the fire alarm sounds and a staff member closes the door to the client's room. The client becomes very agitated and declares, "The aliens have arrived!" Which actions are appropriate for the nurse to take? Select all that apply. You Selected: • Staying with the client until she receives further instructions • Telling the client that there's no danger and that everything's fine • Continuing to speak to the client in a reassuring tone Correct response: • Staying with the client until she receives further instructions • Continuing to speak to the client in a reassuring tone Explanation: After the client's physical safety is ensured, his most immediate need is emotional reassurance and safety. Therefore, it's best for the nurse to remain with the client and continue speaking with him in a reassuring tone of voice until she receives further instructions. Assuring the client that everything is fine or that a fire drill is occurring may further agitate the client by invalidating his fear and attempting to appeal to logical thinking processes, which are impaired in a delusional client. Remediation: • Delusions, care of patient Question 151 See full question After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention should the nurse question? You Selected: • Performing a lumbar puncture Correct response: • Performing a lumbar puncture Explanation: The client's history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldn't be done because it can quickly decompress the central nervous system, causing additional damage. After a head injury, barbiturates may be given to prevent seizures; mechanical ventilation may be required if breathing deteriorates; and elevating the head of the bed may be used to reduce ICP. Remediation: • Lumbar puncture Question 152 See full question A nurse in the neonatal nursery is preparing to perform phenylketonuria (PKU) testing. Which neonate is ready for the nurse to test? You Selected: • A 2-day-old neonate who has been breast-fed Correct response: • A 2-day-old neonate who has been breast-fed Explanation: To test for PKU, a neonate must have had a sufficient intake of phenylalanine through the ingestion of either formula or breast milk for at least 2 days. A neonate who has been receiving I.V. fluids and hasn't yet received breast milk or formula isn't ready to be tested for PKU. A neonate who's discharged within 24 hours of birth will need to see the physician for PKU testing after receiving formula or breast milk for 48 hours. Remediation: • Neonatal screening Question 153 See full question A mother voices concern to the nurse that her toddler never seems to want to play with other children at the park. What would be the nurse's best response? You Selected: • "That would be anticipated at this age." Correct response: • "That would be anticipated at this age." Explanation: Two-year-olds engage in parallel play, in which they play side by side but rarely interact. Associative play is characteristic of preschoolers, in which they are all engaged in a similar activity but there is little organization. School-age children engage in cooperative play, which is organized and goal-directed. Therapeutic play is a technique that can be used to help understand a child's feelings; it consists of energy release, dramatic play, and creative play. Question 154 See full question The nurse is assisting a client to develop independence during a stay at a rehabilitation hospital. Which of the following should the nurse prioritize first in caring for this client? You Selected: • Demonstrate ways independence can be regained for activities. Correct response: • Reinforce success in tasks accomplished. Explanation: To aid motivation, the nurse should focus on the positive aspects of the client’s progress. Independence is a higher priority than demonstration. Long-term goals, although important, are not an immediate priority. Remediation: • Readiness for enhanced resilience Question 155 See full question What information would the nurse include when teaching post circumcision care to the parents of a neonate? Select all that apply. You Selected: • The parent must note that the neonate has voided. • The circumcision will require care for 2 to 4 days after discharge. • Petroleum jelly or antibiotic ointment would be applied to the glans of the penis with each diaper change. Correct response: • The parent must note that the neonate has voided. • Petroleum jelly or antibiotic ointment would be applied to the glans of the penis with each diaper change. • The circumcision will require care for 2 to 4 days after discharge. Explanation: Circumcision is a common surgical procedure when the foreskin of the penis is removed. The infant must void to ensure that the urethra is not obstructed. Parent need to be aware of the first void after circumcision. A lubricating or antibiotic ointment would be applied with each diaper change. Typically, the penis heals within 2 to 4 days, and circumcision care is needed for that period only. To prevent infection, the infant would not have tub baths until the circumcision is healed; sponge baths are appropriate. A small amount of bleeding is expected following a circumcision; parents would report only a large amount of bleeding. Remediation: • Neonatal circumcision, assisting • Diapering an infant Question 156 See full question A sexually active male client has burning on urination and a milky discharge from the urethral meatus. What documentation should be included on the client’s medical record? Select all that apply. You Selected: • history of unprotected sex (sex without a condom) • history of fever or chills • length of time since symptoms presented • presence of any enlarged lymph nodes on examination • allergies to any medications Correct response: • history of unprotected sex (sex without a condom) • length of time since symptoms presented • history of fever or chills • presence of any enlarged lymph nodes on examination • allergies to any medications Explanation: The client is suspected of having a sexually transmitted infection. Therefore, the client’s sexual history, assessment, and examination must be documented, including symptoms (such as fever, chills, and enlarged glands) and their onset and duration. Allergies are critical to document for every client, but are especially noteworthy in this case because antibiotics will be prescribed. If a sexually transmitted infection is confirmed, sexual contacts need to be treated. To protect privacy, the names and phone numbers should never be placed in the medical record. The public health department will also assist in obtaining information and treating known sexual contacts. Remediation: • Physical assessment, pediatric Question 157 See full question A nurse is caring for a client with history of heart failure and presenting with symptoms indicating a pulmonary embolism. The nurse documents admission findings of sudden shortness of breath, chest pain, and immobility. Which nursing diagnoses are admission priorities? Select all that apply. You Selected: • Activity intolerance related to inadequate oxygenation. • Anxiety related to breathlessness. • Risk for decreased cardiac output related to failure of the left ventricle. • Ineffective breathing pattern related to hypoxia. Correct response: • Activity intolerance related to inadequate oxygenation. • Anxiety related to breathlessness. • Ineffective breathing pattern related to hypoxia. • Risk for decreased cardiac output related to failure of the left ventricle. Explanation: When planning care, the nurse would select nursing diagnoses that anticipate pulmonary compromise secondary to reduction of air, blood, and gas exchange because these are ensuing complications that can develop from a pulmonary embolism, particularly in a client with a history of heart failure. The prudent nurse would analyze the client’s condition and anticipate the need for safe, supportive nursing interventions related to the client’s activity intolerance, anxiety, ineffective breathing, and risk for decreased oxygen output. The client history does not indicate that this client has difficulty sleeping, and although social isolation is important to consider, it is not a priority. Remediation: • Pulmonary embolism • Pulmonary embolism Question 158 See full question The nurse is preparing to measure central venous pressure (CVP). Mark the spot on the torso indicating the location for leveling the transducer. You Selected: • Your selection and the correct area, market by the green box. Explanation: Correct location: The zero point on the CVP transducer needs to be at the level of the right atrium. The right atrium is located at the midaxillary line at the fourth intercostal space. The phlebostatic axis is determined by drawing an imaginary vertical line from the fourth intercostal space at the sternal border to the right side of the chest (A). A secondary imaginary line is drawn horizontally at the level of the midpoint between the anterior and posterior surfaces of the chest (B). The phlebostatic axis is located at the intersection of points A and B. Remediation: • Central venous access catheter insertion, assisting Question 159 See full question When caring for a client who's being treated for hyperthyroidism, the nurse should: You Selected: • Monitor the client for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy. Correct response: • Balance the client's periods of activity and rest. Explanation: A client with hyperthyroidism needs to be encouraged to balance periods of activity and rest. Many clients with hyperthyroidism are hyperactive and complain of feeling very warm. Consequently, it's important to keep the environment cool and to teach the client how to manage the physical reactions to heat. Clients with hypothyroidism — not hyperthyroidism — complain of being cold and need warm clothing and blankets to maintain a comfortable temperature. They also receive thyroid replacement therapy, commonly feel lethargic and sluggish, and are prone to constipation. Gastrointestinal upset and diarrhea are not common side effects of medications for hyperthyroidism. Remediation: • Hyperthyroidism Question 160 See full question A client is transferred from the postanesthesia recovery unit to a medical-surgical unit. Which actions can the nurse delegate to unlicensed assistive personnel (UAP)? Select all that apply. You Selected: • recording the client’s urinary output • making sure the client’s call light is within reach • giving the client a cup of ice • obtaining the client’s admission vital signs Correct response: • obtaining the client’s admission vital signs • making sure the client’s call light is within reach • recording the client’s urinary output • giving the client a cup of ice Explanation: Tasks within the UAP’s scope of practice include obtaining vital signs and recording the urinary output, as well as placing the call light within reach and giving the client a cup of ice. Assessing the client on admission and assessing the client’s level of pain are nursing interventions that are in the RN’s scope of practice. Remediation: • Delegating care Question 161 See full question A nasogastric tube inserted during surgical correction of infant’s intussusception is no longer freely removing gastric secretions. What should the nurse do next? You Selected: • Irrigate the tube with distilled water. Correct response: • Aspirate the tube with a syringe. Explanation: The first action is to check the placement of the tube to ensure that it is in the correct position. To check tube position, the nurse should aspirate the tube with a syringe. A return of gastric contents indicates that the end of the tube is in the stomach. Another method is to inject a small amount of air while auscultating with a stethoscope over the epigastric area. The tube is irrigated with normal saline to prevent electrolyte imbalances, not distilled water, and only after the position of the tube is confirmed. The suction level should not be increased because doing so could damage the mucosa. Rotating the tube could irritate or traumatize the nasal mucosa. Remediation: • Nasogastric tube irrigation Question 162 See full question A client with schizophrenia, who has a history of being placed in seclusion for physically assaulting other clients, is showing signs of increased agitation. The nurse observes that he's scraping his face and eyes with his fingernails and injuring himself. All nursing attempts to reduce this behavior have failed. What should the nurse do next? You Selected: • Call security to restrain the client and put him in seclusion for the safety of the unit. Correct response: • Apply physical restraints to protect the client, then contact the physician for orders. Explanation: A nurse may place a client in physical restraints if he poses a threat to himself or others and all less- restrictive interventions have failed. A nurse may place a client in restraints without a physician's order but must obtain an order within 1 hour of restraint application. Secluding the client, with or without security involvement, doesn't protect him from injury. Remediation: • Restraints use for assaultive and violent behavior Question 163 See full question A nurse is discussing discharge instructions with a client. Which statement indicates that the client understands the resources and information available if needed after discharge? Select all that apply. You Selected: • “My mother is coming to help for a month, so I will be fine.” • “I know if I get fever or chills or change in lochia to call the health care provider.” • “If I have any breathing problems, chest pain, or pounding fast heart rate, I will seek medical assistance.” • “I have the hospital phone number if I have any questions.” • “I will continue my prenatal vitamins until my postpartum checkup or longer.” Correct response: • “My fertility can return as early as 21 days after my baby’s birth.” • “I have the hospital phone number if I have any questions.” • “If I have any breathing problems, chest pain, or pounding fast heart rate, I will seek medical assistance.” • “I know if I get fever or chills or change in lochia to call the health care provider.” • “I will continue my prenatal vitamins until my postpartum checkup or longer.” Explanation: The nurse is responsible for providing discharge instructions that include signs and symptoms that need to be reported to the health care provider (HCP) as well as resources and follow-up for home care if needed. Phone numbers and health practices to promote healing, such as the use of prenatal vitamins, are also essential pieces of information. Fertility can return in as little as 21 days, especially among women who are not breastfeeding. So it is important to discuss the client’s contraception plan. Although the client’s mother may be helpful, the client’s statement that she will be fine because her mother is coming indicates that she is unaware or ignoring information about valuable information and resources. Remediation: • Discharge planning, neonatal Question 164 See full question Which condition could a mother have and still be encouraged to breast-feed her child? You Selected: • Cardiac disease Correct response: • Endometritis Explanation: Of the listed conditions, endometritis is the only one in which a mother can continue to breast-feed provided that the antibiotics she's taking aren't contraindicated in breast-feeding. A mother who has HIV or active TB is strongly discouraged from breast-feeding because of concerns about transmitting the infection to the neonate. Clients with cardiac disease are also discouraged from breast-feeding because of the strain on the mother's defective heart. Remediation: • Breast-feeding assistance Question 165 See full question The nurse is caring for an 8-year-old child with a diagnosis of bronchial asthma who arrived in the emergency department with audible expiratory wheezes and intercostal retractions. After assessing the child’s condition, the nurse is concerned that a total obstruction of the airway will occur. To monitor for a total airway obstruction, which of the following becomes the priority assessment for the nurse? You Selected: • Stridorous coughing by the child Correct response: • Rapid loss of consciousness Explanation: A totally obstructed airway will quickly lead to a loss of consciousness in a child compared to rales, hypertension, or stridorous cough. Remediation: • Asthma, pediatric • Respiratory: Asthma Question 166 See full question A client is reporting feeling fatigued. The assessment findings include blood pressure of 110/80 mm Hg, respiration rate of 24 breaths per minute, and electrocardiogram with peaked T waves. Which of the following orders would the nurse question? You Selected: • Calcium gluconate IV Correct response: • Spironolactone PO Explanation: This client is experiencing hyperkalemia. Therefore, the nurse should question the order for spironolactone, which is a potassium-sparing diuretic. It would be appropriate for the nurse to give calcium to treat cardiac and skeletal muscle effects of hyperkalemia, the sodium polystyrene sulfonate, which causes a cationic exchange of Na for K+ in the intestines, and furosemide, which is potassium wasting and would help decrease symptoms of hyperkalemia. Remediation: • spironolactone Question 167 See full question The nurse is caring for a 22-year-old G2, P2 client who has disseminated intravascular coagulation after delivering a dead fetus. Which finding is the highest priority to report to the health care provider (HCP)? You Selected: • activated partial thromboplastin time (APTT) of 30 seconds Correct response: • urinary output of 25 mL in the past hour Explanation: Urinary output of less than 30 mL/h indicates renal compromise and would be the most important assessment finding to report to the HCP. The APTT is within normal limits and the hemoglobin is lower than values for an adult female but within normal limits for a pregnant female. Although the platelet level is slightly low and may impact blood clotting, when compared to renal failure, it is less important. Remediation: • Disseminated intravascular coagulation Question 168 See full question A postoperative client has an abdominal incision. While getting out of bed, the client reports feeling a "pulling" sensation in the abdominal wound. The nurse assesses the client's wound and finds that it has separated and that the abdominal organs are protruding. Which nursing interventions are most appropriate at this time? Select all that apply. You Selected: • Cover the wound with saline-soaked sterile guaze. • Notify the client's primary physician. • Cover the wound with sterile gauze. • Give the client a dose of antibiotics. Correct response: • Notify the client's primary physician. • Cover the wound with saline-soaked sterile guaze. Explanation: Dehiscence (separation of the surgical incision) and evisceration (protruding of the abdominal organs) are considered medical emergencies. Therefore, the client's physician should be notified immediately and the nurse should prepare the client for surgery. While the nurse is waiting for the physician to arrive, the wound and the abdominal organs should be covered with saline-soaked sterile gauze. Saline is an isotonic solution that prevents damage to the client's tissue, and sterile gauze is used to prevent wound infection. Even though wound infection is the most common cause of dehiscence, administering antibiotics without a physician's order is not permissible and can result in the loss of a nursing license. An abdominal binder may be appropriate but only after the client returns from the operating room and with a physician’s order. Pushing the organs back into the abdomen is inappropriate and could result in rupture, hemorrhage, or strangulation of the bowel. The nurse should also monitor the client's vital signs. Remediation: • Wound dehiscence management Question 169 See full question A nurse is teaching a client about nonpharmacologic comfort measures to alleviate postoperative pain. Which client statement indicates a need for further teaching? You Selected: • "Music therapy can help me relax, so the pain won't be so bad." Correct response: • "With patient-controlled analgesia, or PCA, I can control my pain by administering my own pain medication." Explanation: PCA allows the client to self-administer I.V. pain medication. This intervention is not a nonpharmacologic comfort measure. Music therapy, TENS units, and heat applications are nonpharmacologic pain-relieving strategies. Remediation: • Patient-controlled analgesia Question 170 See full question The nurse administers a bolus tube feeding to a client with cancer. To decrease the risk of aspiration, the nurse should: You Selected: • assist the client out of bed to sit upright in a chair for 1 hour. Correct response: • assist the client out of bed to sit upright in a chair for 1 hour. Explanation: As long as the client is able to get out of bed, the preferred position and time frame for preventing aspiration after a bolus tube feeding is sitting upright out of bed in a chair for 30 to 60 minutes. The client should have the head of the bed elevated more than 60 degrees; it is not necessary to remain in an upright position for more than an hour after the feeding. Placing the client on the right, not the left, side may facilitate gastric emptying, but this is not the preferred position. Elevating the bed 30 degrees decreases the risk of aspiration, but this elevation must be maintained for at least 45 to 60 minutes. Remediation: • Tube feedings, gastric Question 171 See full question A pregnant client at 32 weeks' gestation has mild preeclampsia. She is discharged to home with instructions to remain on bed rest. She should also be instructed to call her physician if she experiences which symptoms? Select all that apply. You Selected: • Blurred vision. • Epigastric pain. • Severe nausea and vomiting. Correct response: • Headache. • Blurred vision. • Epigastric pain. • Severe nausea and vomiting. Explanation: Headache, blurred vision, epigastric pain, and severe nausea and vomiting can indicate worsening maternal disease. Decreased, not increased, urine output is a concern because it could indicate renal impairment. Difficulty sleeping, a common complaint during the third trimester, is only a concern if it's caused by any of the other symptoms. Remediation: • Chronic hypertension in pregnancy patient care • Deep tendon reflex assessment, pregnant patient • Eclampsia Question 172 See full question Which drug delivery system most effectively reduces the likelihood of medication errors? You Selected: • Automated Correct response: • Automated Explanation: An automated drug delivery system most effectively reduces the likelihood of medication errors by automatically dispensing the drug. Medication errors can still occur with this method but are less likely than with floor stock, unit-dose, and individual prescription methods. Question 173 See full question A nurse is performing an admission assessment on a client diagnosed with diabetes insipidus. Which findings does the nurse anticipate during the assessment? Select all that apply. You Selected: • Extreme polyuria • Excessive thirst Correct response: • Extreme polyuria • Excessive thirst • Low urine specific gravity Explanation: Diabetes insipidus is a condition where the kidneys are unable to conserve water. Signs and symptoms of diabetes insipidus include an abrupt onset of extreme polyuria, excessive thirst, dry skin and mucous membranes, tachycardia, and hypotension. Diagnostic studies reveal low urine specific gravity and osmolarity and an elevated serum sodium level. The serum potassium level is likely to be decreased, not increased. Remediation: • Diabetes insipidus Question 174 See full question A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first? You Selected: • Ask the client if he has trouble breathing. Correct response: • Ask the client if he has trouble breathing. Explanation: The nurse should first assess the client's breathing. A complication of a carotid endarterectomy is an incisional hematoma, which could compress the trachea causing breathing difficulty for the client. Although the other measures are important actions, they aren't the nurse's top priority. Remediation: • Endarterectomy, carotid Question 175 See full question When caring for a primigravid client who is being induced with intravenous oxytocin because she is at 41 weeks’ gestation, the nurse observes that the fetal heart rate drops to 60 bpm at the end of the last two contractions and then rises to 120 bpm. What should the nurse do first? You Selected: • Discontinue the oxytocin infusion. Correct response: • Discontinue the oxytocin infusion. Explanation: Induction of labor with oxytocin is associated with risks. Hyperstimulation of the uterus can lead to fetal distress. A drop in the fetal heart rate to 60 bpm at the end of a contraction may be indicative of late decelerations due to placental insufficiency. Stopping the oxytocin infusion will reduce uterine activity and improve uteroplacental perfusion. Turning the client to her left side, not the right side, increases placental perfusion. Oxygen should be administered at 8 L, not 3 L. Oxytocin, a vasoconstrictor, is given to stimulate contractions. The primary care provider should be notified after the oxytocin is discontinued. Remediation: • Oxytocin administration during labor and delivery Question 176 See full question Assessment of a client progressing through labor reveals the following findings. Order the findings in the most likely sequence in which they would have occurred. Use all options. You Selected: • 100% cervical effacement. • Strong Braxton Hicks contractions. • Mild contractions lasting 20 to 40 seconds. • Cervical dilation of 7 cm. • Uncontrollable urge to push. Correct response: • Strong Braxton Hicks contractions. • Mild contractions lasting 20 to 40 seconds. • Cervical dilation of 7 cm. • 100% cervical effacement. • Uncontrollable urge to push. Explanation: Strong Braxton Hicks contractions typically occur before the onset of true labor and are considered a preliminary sign of labor. During the latent phase of the first stage of labor, contractions are mild, lasting approximately 20 to 40 seconds. As the client progresses through labor, contractions increase in intensity and duration. In addition, cervical dilation occurs. Cervical dilation of 7 cm indicates that the client has entered the active phase of the first stage of labor. Together with cervical dilation, cervical effacement occurs. Effacement of 100% characterizes the transition phase of the first stage of labor. Progression into the second stage of labor is noted by the client's uncontrollable urge to push. Remediation: • Labor, care during Question 177 See full question A nurse is monitoring a client receiving dobutamine for heart failure. During the past several hours the client’s heart rate has increased from 78 to 110 and the cardiac monitor shows an increased amount of premature ventricular contractions (PVCs) and couplets. What is the nurse’s best action? You Selected: • Administer PRN amiodarone to reduce the amount of premature ventricular contractions Correct response: • Discontinue the dobutamine and notify the physician. Explanation: During an administration of adrenergic drugs, adverse effects such as cardiac irregularities, hypertension, and tachycardia can occur. Stopping the drug should cause the toxic symptoms to subside because of the drug’s short half-life. Increasing the dosage will make the symptoms worse, administration of amiodarone will mask the symptoms of ventricular dysrhythmia. The symptoms are being caused by the medication, assessing the client for shock will not correct the problem. Remediation: • DOBUTamine hydrochloride Question 178 See full question A client is being admitted to a psychiatric outpatient program for counseling for his ongoing emotional symptoms. He is asked to rate the severity of his depression, anxiety, and anger. He states, “I do not have any anger any more. I lost my temper once and nearly hurt my wife. I never got angry again.” In which order of priority from first to last should the principles related to anger be shared with this client? All options must be used. You Selected: • "Anger is a natural emotion occurring in all human relationships." • "Holding your anger inside contributes to your depression." • "Unexpressed anger has a negative effect on the human body and mind." • "You can learn effective ways to discuss anger with others and still maintain control." Correct response: • "Anger is a natural emotion occurring in all human relationships." • "Unexpressed anger has a negative effect on the human body and mind." • "Holding your anger inside contributes to your depression." • "You can learn effective ways to discuss anger with others and still maintain control." Explanation: The clients need to understand that anger is a normal emotion, but if not expressed can have negative effects on the body and mind. Then, the nurse begins to focus on the client’s personal situation and help the client understand that holding anger in aggravates his depressive symptoms as well. One focus of outpatient counseling will be learning safe, effective ways to express anger. Question 179 See full question A client scheduled for hip replacement surgery wishes to receive his own blood for the upcoming surgery. The nurse should: You Selected: • document the client’s request on the medical record. Correct response: • notify the surgeon's office. Explanation: The nurse should call the surgeon’s office so that arrangements can be made for the client to donate a unit of his blood for possible future autotransfusion. This must be done in sufficient time before surgery so that the client is not at risk for being anemic at the time of the scheduled procedure. The client’s request must be scheduled through the surgeon’s office because the surgeon has ultimate responsibility for the client. The nurse can document that the surgeon’s office was notified of the client’s request. Notifying the hematology laboratory or blood bank is not an appropriate response. Remediation: • Autologous blood transfusion, perioperative Question 180 See full question A client has been compliant with her prescribed antipsychotic medication regimen for a number of years. With the addition of an antibiotic, the client reports distressing new symptoms. What is the most appropriate intervention by the nurse? You Selected: • Assess the client’s symptoms and reinforce medication teaching Correct response: • Assess the client’s symptoms and reinforce medication teaching Explanation: This client has been successful and reliable in carrying out her current medication regimen. The nurse should assume that competency includes self-administration of antibiotics if the instructions are understood. The nurse should assess the client’s symptoms and reinforce all medication teaching. No evidence exists that the client is experiencing relapse, so hospitalization would not be indicated. Having a community nurse give the medication encourages dependency as opposed to self-care. It is premature to direct the client to a provider without the results of the nursing assessment. Remediation: • Antipsychotic medication use, long-term care Question 181 See full question The obstetrical triage nurse is assessing a client with a term pregnancy. There has not been any change in the cervix for the past 2 hours despite irregular contractions. When discharging the client to her home, the nurse should tell the client to return to the hospital when which conditions occur? Select all that apply. You Selected: • She feels the urge to push. • She notices vaginal bleeding. • Contractions become more intense and closer together. • She notices an absence of fetal movement. • She thinks the membranes have ruptured. Correct response: • Contractions become more intense and closer together. • She notices vaginal bleeding. • She thinks the membranes have ruptured. • She notices an absence of fetal movement. • She feels the urge to push. Explanation: Because there have been no cervical changes, the client is not in labor. The client should understand to return to the hospital if the contractions become more intense and regular, if she has vaginal bleeding, if she thinks her membranes rupture, if the baby is not moving, or if she has an urge to push. Three contractions an hour would be too infrequent to indicate active labor. Remediation: • False labor assessment Question 182 See full question A physician orders terbutaline 2.5 mg by mouth four times a day, for a child with bronchitis. If the child receives an I.V. infusion of terbutaline, which serious adverse reaction is possible? You Selected: • Hypokalemia Correct response: • Hypokalemia Explanation: The nurse should monitor the client receiving an I.V. infusion of terbutaline for hypokalemia, lactic acidosis, chest pain, arrhythmias, dyspnea, bloating, chills, or anaphylactic shock. Terbutaline doesn't cause calcium imbalances. Remediation: • Terbutaline sulfate • Hypokalemia Question 183 See full question Which moral principle is a nurse applying when she decides what is best for a client and acting without consulting the individual? You Selected: • Autonomy Correct response: • Paternalism Explanation: Nurses and other health care workers employ paternalism when a client's loss of consciousness or other circumstances compel them to decide what is best for the client and to act without consulting the individual. Beneficence means that nurses should act in the client's interests always. Fidelity requires the nurse to be faithful and truthful and to keep promises to clients, families, coworkers, and employers. Autonomy refers to every individual's right to make rational decisions about his life. The nurse's belief in autonomy leads to a respect for the client's decisions. Question 184 See full question A female with uterine fibroids has dysmenorrhea and menorrhagia. After reviewing the laboratory reports, the nurse should report which results to the health care provider (HCP)? Select all that apply. You Selected: • hemoglobin, 9.0 g/dL (90 g/L) • hematocrit, 27.1% (0.27) Correct response: • hemoglobin, 9.0 g/dL (90 g/L) • hematocrit, 27.1% (0.27) Explanation: A woman with uterine fibroids and dysmenorrhea is at risk for iron deficiency anemia. The hemoglobin and hematocrit indicate the likelihood that the fibroids causing heavy menstrual blood loss have resulted in anemia. A hemoglobin of less than 12 g/dL (120 g/L) in women is considered low. The white blood cell count and potassium levels are within normal parameters, and normocytic red blood cells are normal. Remediation: • Dysmenorrhea • Menorrhagia Question 185 See full question The nurse is reviewing the following worksheet when prioritizing afternoon nursing care. Which order for administering client care at 1:00 pm (1300 hours) is best? You Selected: • Client 4, Client 3, Client 2, Client 1 Correct response: • Client 4, Client 1, Client 3, Client 2 Explanation: It is important for the nurse to prioritize care in an efficient manner. The highest priority for the afternoon is administering requested pain medication for a postoperative client. Next, a client on a toileting schedule would be taken to the restroom. The intravenous piggyback would be initiated and while infusing the wound dressing would be changed. Question 186 See full question A client is being discharged to a transitional rehabilitation care facility following a hip replacement due to degenerative arthritis. When reporting to the licensed practical/vocational nurse (LPN/VN), which nursing actions would the orthopedic nurse stress as essential? Select all that apply. You Selected: • Avoid any hip flexion exercises. • Place a raised toilet seat in the bathroom. • Place two pillows between the client’s knees. Correct response: • Avoid any hip flexion exercises. • Place two pillows between the client’s knees. • Place a raised toilet seat in the bathroom. Explanation: The hip is one of the body’s largest joints. In a total hip replacement, the damaged bone and cartilage are removed and replaced with prosthetic components. Until healing occurs, the legs must be spread outward (abducted) away from the body by placing pillows or an abductor foam wedge between the legs. Adduction of the hip or flexion greater than 90° may dislocate the prosthesis from the joint. Raising the head of the bed 90° creates excessive hip flexion. Using a raised toilet seat is appropriate to avoid bending. The client will be out of bed for physical therapy once to twice daily. Keeping the feet elevated is not part of the hip replacement protocol. Remediation: • Hip arthroplasty postprocedure care • Joint replacement (hip) Question 187 See full question The therapeutic team has identified the need to formulate strategies to maintain a safe environment for a client with schizophrenia displaying inappropriate behavior. Which strategy must be initiated immediately? You Selected: • Explore with the client's reasons for demonstrating this behavior. Correct response: • Monitor the client’s behavior. Explanation: The unit must be maintained as a safe environment for the client and the other clients; therefore, the client should never have unsupervised time on the unit. The nurse never attempts to do psychotherapy to delve into why a client exhibits behavior. Teaching interpersonal skills such as ways to communicate and interact with others is not the priority at this early stage. Remediation: • Schizophrenia patient care Question 188 See full question The nurse is teaching a client with diabetes insipidus about using desmopressin nasal spray. The therapeutic effects of desmopressin nasal spray are obtained when the client no longer has: You Selected: • polydipsia. Correct response: • polydipsia. Explanation: The therapeutic effects of desmopressin nasal spray are relief from polydipsia and control of polyuria and nocturia in the client with diabetes insipidus. Side effects include nasal congestion and headache. Blurred vision is not related to desmopressin. Remediation: • Desmopressin acetate • Diabetes insipidus Question 189 See full question A 19-year-old unmarried college student who is approximately 8 weeks pregnant asks the nurse, “If I have an abortion in the next 2 or 3 weeks, how will it be done?” The nurse instructs the client that at this gestational age, an abortion is usually performed by which technique? You Selected: • dilatation and vacuum extraction Correct response: • dilatation and curettage Explanation: When the gestation is less than 13 weeks, an elective abortion is usually performed by the dilatation and curettage method. Menstrual extraction, or suction evacuation, is the easiest method, but it is used only when the client is between 5 and 7 weeks’ gestation. Dilatation and vacuum extraction is used when clients are between 12 and 16 weeks’ gestation. Saline induction, used for clients between 16 and 24 weeks’ gestation, involves instillation of a hypertonic saline solution into the amniotic sac to initiate expulsion. Oxytocin infusion may also be used with saline induction. Remediation: • Dilatation and curettage, assisting Question 190 See full question A nurse is preparing a client for discharge after a prolonged hospitalization in which the client had a colostomy created because of colon cancer. The client's family has concerns about managing his care at home. Which factor plays the most important role in successful home care? You Selected: • Support from friends and family Correct response: • Support from friends and family Explanation: Home care success depends on support from friends and family. Ability to care for the colostomy, age of the client, and complexity of care aren't as important to success as support from friends and family. Remediation: • Discharge needs Question 191 See full question The nurse is developing a plan of care for the client with viral hepatitis. The nurse should instruct the client to: You Selected: • take antibiotic therapy as ordered. Correct response: • obtain adequate bed rest. Explanation: Treatment of hepatitis consists primarily of bed rest with bathroom privileges. Bed rest is maintained during the acute phase to reduce metabolic demands on the liver, thus increasing its blood supply and promoting liver cell regeneration. When activity is gradually resumed, the client should be taught to rest before becoming overly tired. Although adequate fluid intake is important, it is not necessary to force fluids to treat hepatitis. Antibiotics are not used to treat hepatitis. Electrolyte imbalances are not typical of hepatitis. Remediation: • Hepatitis, viral Question 192 See full question A child is admitted to the pediatric unit with a fracture of the hip. The physician orders Russell traction. This type of traction is: You Selected: • skin traction applied to an extended lower extremity. Correct response: • skin traction applied to a lower extremity, with the extremity suspended above the bed. Explanation: Russell traction is skin traction applied to a lower extremity, with the extremity suspended above the bed and a sling placed under the knee. Skeletal traction applied to a lower extremity is called 90-90 traction. Skin traction applied to an extended lower extremity is called Buck's extension traction. Skin traction applied bilaterally to the lower extremities is called Bryant's traction. Remediation: • Skin traction management, pediatric Question 193 See full question A client was transferring a load of fire wood from his front driveway to his backyard woodpile at 10 a.m.,when he experienced a heaviness in his chest and dyspnea. He stopped working and rested, and the pain subsided. At noon, the pain returned. At 1:30 p.m., his wife took him to the emergency department. Around 2:30 p.m., the emergency department physician diagnoses an anterior myocardial infarction (MI). The nurse should anticipate which orders by the physician? You Selected: • Sublingual nitroglycerin, tissue plasminogen activator (tPA), and telemetry Correct response: • Sublingual nitroglycerin, tissue plasminogen activator (tPA), and telemetry Explanation: The nurse should anticipate an order for sublingual nitroglycerin, tPA, and telemetry. (The client's chest pain began 4 hours before diagnosis.) The preferred choice is tPA, which is more specific for cardiac tissue than streptokinase. Stress testing should not be performed during an MI. The client does not exhibit symptoms that indicate the use of lidocaine. Remediation: • Myocardial infarction Question 194 See full question A two-year old with pneumonia is placed on oxygen. Which is the priority nursing action? You Selected: • Continually monitor oxygen saturation Correct response: • Avoid the use of equipment or toys that can produce sparks Explanation: While all the interventions are appropriate for caring for a child on oxygen, preventing a fire is the priority. All equipment and toys that may produce a spark should be avoided. Remediation: • Oxygen administration, pediatric Question 195 See full question The client is diagnosed with diverticular disease. Which of the following foods would the nurse include in the teaching to prevent complications? You Selected: • Cooked fish Correct response: • Wheat bread Explanation: Wheat bread is high in fiber. The client managing diverticulosis should maintain a high-fiber diet. Eggs, cooked fish, and white rice are low in fiber and would not be helpful in preventing complications. Remediation: • Diverticulitis Discharge Instructions Question 196 See full question Which status assessment must be completed before the client starts taking imipramine? You Selected: • electrocardiogram (ECG) Correct response: • electrocardiogram (ECG) Explanation: Because tricyclic antidepressants such as imipramine cause tachycardia and arrhythmias, an ECG should be done before the client takes the medication. While imipramine can cause urine retention, proteinuria is not an adverse effect. Imipramine is administered cautiously to clients receiving thyroid medication, but a pretreatment thyroid scan is not necessary. Imipramine does not interfere with kidney function, so a creatinine clearance test is not required. Remediation: • Imipramine hydrochloride Question 197 See full question Which action should the nurse take next after noting that an 8-month-old child’s posterior fontanel is slightly open? You Selected: • Document this as a normal finding. Correct response: • Check the child's head circumference. Explanation: This is not a normal finding because the posterior fontanel usually closes by age 2 months. Therefore, the nurse should measure the head circumference to determine if the child’s head is larger than the established norms because hydrocephalus can cause separation of the cranium sutures. Because the child is 8 months old, the labor and birth history probably would not be a significant factor. An x-ray (radiologic) examination is not necessary until other data are collected. Remediation: • Neurologic assessment, pediatric Question 198 See full question A 9-month-old is admitted because of dehydration. How should the nurse go about accurately monitoring fluid intake and output? Select all that apply. You Selected: • obtaining an accurate daily weight • weighing and recording all wet diapers • obtaining an accurate stool count Correct response: • weighing and recording all wet diapers • obtaining an accurate daily weight • obtaining an accurate stool count Explanation: Accurate intake and output recording includes noting all intake, including IV fluids; noting output, such as emesis and stool; weighing diapers; measuring weight daily; measuring urine specific gravity; monitoring serum electrolytes; and monitoring for signs of dehydration. Children who are dehydrated must receive sufficient fluid intake, but having a breast-feeding child switch to bottle-feeding will not promote intake. Restricting fluids just prior to weighing the child will not alter the accuracy of the weight, and the nurse should continue to encourage fluids for this dehydrated child. Remediation: • Physical assessment, pediatric • Intake and output assessment, pediatric Question 199 See full question When prepping a client for a hemorrhoidectomy, which of the following would be most important prior to the patient going to the operating room? You Selected: • Analgesics Correct response: • An enema Explanation: When preparing a client for a hemorrhoidectomy, the nurse should administer an enema, as ordered, and record the results. After surgery, the client may require antibiotics and analgesics. Remediation: • Hemorrhoidectomy • Administering a Cleansing Enema Question 200 See full question Which drugs are known to be effective in treating obsessive-compulsive disorder (OCD)? You Selected: • Fluvoxamine and clomipramine Correct response: • Fluvoxamine and clomipramine Explanation: The antidepressants fluvoxamine and clomipramine have been effective in the treatment of OCD. Chlordiazepoxide and diazepam may be helpful in treating OCD-related anxiety but aren't drugs of choice to treat the illness. Benztropine and diphenhydramine and divalproex and lithium aren't effective in treating of OCD. Remediation: Question 1 See full question A client is scheduled to have a graded exercise test. The nurse explains to the client that the test will determine how: You Selected: well the body reacts to controlled exercise stress. Correct response: well the body reacts to controlled exercise stress. Explanation: Graded exercise testing is a diagnostic and prognostic tool used to determine the physiologic responses to controlled exercise stress. Information gained from a graded exercise test can achieve diagnostic, functional, and therapeutic objectives for the client. Graded exercise tests involve the use of a treadmill, stationary bicycle, or arm ergometry. The information obtained from this test is not used to set the incline on the treadmill, and measuring the distance walked and the duration of the walk are not the purpose of a graded exercise test. Remediation: Question 2 See full question A nurse should include which discharge instruction for clients receiving tricyclic antidepressants? You Selected: Restrict fluid and sodium intake while using this medication. Correct response: Don't consume alcohol while using this medication. Explanation: Drinking alcohol can potentiate the sedating action of tricyclic antidepressants. Dry mouth and blurred vision are normal adverse effects of tricyclic antidepressants. Fluid and sodium intake must be monitored during lithium treatment, not during treatment with tricyclic antidepressants. Safe use of tricyclic antidepressants during pregnancy and breast-feeding hasn't been established. Remediation: Question 3 See full question The nurse prepares to administer promethazine 35 mg IM as prescribed PRN for a client with cholecystitis who has nausea. The ampule label reads that the medication is available in 25 mg/mL. How many milliliters should the nurse administer? Record your answer using one decimal place. Your Response: 0.7 Correct response: 1.4 Explanation: The following formula is used to calculate the correct dosage: 35 mg/X = 25 mg/1 mL X = (35/25) mL X = 1.4 mL. Question 4 See full question Levothyroxine 0.2 mg orally has been prescribed for a client diagnosed with hypothyroidism. The nurse has available 0.05-mg tablets. How many tablets should the nurse prepare to give the client? You Selected: two tablets Correct response: four tablets Explanation: 0.2 mg/x tablet = 0.05 mg/1 tablet. x = 4 tablets. Remediation: Question 5 See full question What is the nurse’s priority intervention for a toddler who has just had a hip-spica cast applied? You Selected: Assess sensation, circulation, and motion of the child’s feet and toes Correct response: Assess sensation, circulation, and motion of the child’s feet and toes Explanation: Assessing sensation, circulation, and motion is necessary in all children with a cast. Fluids should be encouraged, and careful diapering and padding will keep the child’s cast dry. Discharge instructions are not a priority, but should be shared at a later time. Children experiencing pain should receive medication as needed. Remediation: Question 6 See full question A child requires IV fluids to infuse at 27 ml/hr. The tubing delivers 60 gtts/ml. How many gtts/min should the nurse count to ensure that the fluid is safely infusing? You Selected: 27 gtts/min Correct response: 27 gtts/min Explanation: The nurse should count 27 gtts/min. 27 ml/h x 60 gtts/ml ÷ 60 min/h = 27 gtts/min Remediation: Question 7 See full question Before placement of a ventriculoperitoneal shunt for hydrocephalus, an infant is irritable, lethargic, and difficult to feed. To maintain the infant's nutritional status, which action would be most appropriate? You Selected: Give the infant small, frequent feedings. Correct response: Give the infant small, frequent feedings. Explanation: An infant with hydrocephalus is difficult to feed because of poor sucking, lethargy, and vomiting, which are associated with increased intracranial pressure. Small, frequent feedings given at times when the infant is relaxed and calm are tolerated best. Feeding an infant before any procedure is inappropriate because the stress of the procedure may lead to vomiting. Ideally, the infant should be held in a slightly vertical position when feeding to prevent backflow of formula into the eustachian tubes and subsequent development of ear infections. Giving large, less frequently feedings allows for rest, but typically results in more vomiting. Remediation: Question 8 See full question A 13-year-old child has seen the school nurse several times with headache, vomiting, and difficulty walking. When calling the adolescent's mother about these symptoms, what should the nurse suggest the mother do first? You Selected: Make an appointment with the adolescent's health care provider (HCP). Correct response: Make an appointment with the adolescent's health care provider (HCP). Explanation: A child who has symptoms of vomiting, headaches, and problems walking needs to be evaluated by a health care provider (HCP) to determine the cause. Unexplained headaches and vomiting along with difficulty walking (e.g., ataxia) may suggest a brain tumor. Evaluation by an eye HCP would be appropriate once a complete medical evaluation has been accomplished. Psychological counseling may be indicated for this adolescent, but only after medical evaluation to determine that she is physically healthy. Meeting with the child’s teachers would be appropriate after medical evaluation. Remediation: Question 9 See full question A client with hyperemesis gravidarum is on a clear liquid diet. The nurse should serve this client: You Selected: tea and gelatin dessert. Correct response: tea and gelatin dessert. Explanation: A clear liquid diet consists of foods that are clear liquids at room temperature or body temperature, such as ice pops, regular or decaffeinated coffee and tea, gelatin desserts, carbonated beverages, and clear juices. Milk, pasteurized eggs, egg substitutes, and oatmeal are part of a full liquid diet. Remediation: Question 10 See full question Clozapine therapy has been initiated for a client with schizophrenia who has been unresponsive to other antipsychotics. The client states, "Why do I have to have a blood test every week?" Which response by the nurse would be most appropriate? You Selected: "Weekly blood tests are necessary to determine safe dosage and to monitor the effect of the medication on the blood." Correct response: "Weekly blood tests are necessary to determine safe dosage and to monitor the effect of the medication on the blood." Explanation: The client needs specific information about the effects of the drug, specifically that the drug can cause agranulocytosis. The statement about weekly blood tests to determine safe dosage and monitoring for effects on the blood gives the client specific information to ensure follow-up with the required protocol for clozapine therapy. Lack of accurate knowledge can lead to noncompliance with necessary follow-up procedures and noncompliance with medication. The supply of medication is not dependent on blood testing. Telling the client that the health care provider (HCP) wants to know the progress does not provide specific information for this client. The blood tests are not required by the drug company. Remediation: Question 11 See full question A nurse is caring for a client who is recovering from a myocardial infarction (MI). The cardiologist refers him to cardiac rehabilitation. Which statement by the client indicates an understanding of cardiac rehabilitation? You Selected: "Rehabilitation will help me function as well as I physically can." Correct response: "Rehabilitation will help me function as well as I physically can." Explanation: The client demonstrates understanding of cardiac rehabilitation when he states that it helps the client reach his activity potential. Coronary artery disease, which typically causes an acute MI, is a chronic condition that isn't cured. Many clients who suffer an acute MI can eventually return to such activities as jogging, depending on the extent of cardiac damage. Cardiac rehabilitation involves physical activity as well as classroom education. Remediation: Question 12 See full question While caring for a client who's immobile, a nurse documents the following information in the client's chart: "Turned client from side to back every 2 hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." Which nursing diagnosis accurately reflects this information? You Selected: Risk for impaired skin integrity related to immobility Correct response: Risk for impaired skin integrity related to immobility Explanation: The information documented in the client's chart reflects the risk for impaired skin integrity. Because the client's skin is intact, the problem is only a potential one, not an actual one, which makes the nursing diagnosis of Impaired skin integrity inappropriate. If constipation were a problem, interventions would focus on diet and activity. If body image disturbance were a problem, interventions would focus on the client's feelings about himself and his disease. Remediation: Question 13 See full question A nurse is caring for an older client who has had a hemorrhagic stroke. The client has exhibited impulsive behavior and, despite reminders from the nurse, doesn't recognize his limitations. Which priority measure should the nurse implement to prevent injury? You Selected: Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed. Correct response: Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed. Explanation: The bed alarm will alert staff that the client is attempting to transfer, so they can come to assist. The nurse shouldn't encourage the family to reprimand the client. Instead, the nurse should ask the family to encourage the client to request assistance. The nurse should encourage the client to use the call light in all situations, not just emergencies. A vest and wrist restraints aren't appropriate unless less-restrictive measures have failed and the client is a danger to himself or others. Remediation: Question 14 See full question A nurse is caring for a client diagnosed with cardiomyopathy. The student nurse assigned to collaborate with the nurse begins data collection for the admission assessment. The student nurse violates information security when she: You Selected: writes the client's phone number on her clinical paperwork. Correct response: writes the client's phone number on her clinical paperwork. Explanation: Documenting identifying information taken outside the institution is violates information security. The student nurse has no need for the client's phone number on her clinical paperwork in order to provide care. Completing admission paperwork and data collection sheets is within the scope of practice for the student nurse and doesn't violate information security. Remediation: Question 15 See full question When obtaining a client's history, a nurse develops a genogram. What is the purpose of developing a genogram? You Selected: To identify genetic and familial health problems Correct response: To identify genetic and familial health problems Explanation: A genogram organizes a family's history into a diagram or flow chart. A nurse uses a genogram to identify genetic and familial health problems. A genogram doesn't identify previously undetected diseases and disorders, the client's reason for seeking care, or chronic health problems. Question 16 See full question A nurse is caring for a toddler who was diagnosed with an inoperable brain tumor. The parents are having difficulty deciding on a course of action for their child. Why is it important to have the nurse involved in an ethical discussion about a planned course of treatment? You Selected: The nurse can act as a liaison between the child, the child's parents, and the health care team. Correct response: The nurse can act as a liaison between the child, the child's parents, and the health care team. Explanation: It is important to involve the nurse because she can act as a liaison between all parties. The nurse has the most direct contact with the child and his parents, and she can listen to and communicate their wishes for treatment. She can also aid in interpreting information about the child's condition and course of treatment, helping the parents to make an informed decision. The nurse isn't viewed as the authority on ethical issues at the hospital. In fact, hospitals commonly employ ethicists to help with ethical dilemmas. Time shouldn't be a factor when it comes to helping parents make decisions about their child's care. Question 17 See full question Because antianxiety agents such as chlordiazepoxide can potentiate the effects of other drugs, the nurse should incorporate which instruction in her teaching plan? You Selected: Avoid mixing antianxiety agents with alcohol or other central nervous system (CNS) depressants. Correct response: Avoid mixing antianxiety agents with alcohol or other central nervous system (CNS) depressants. Explanation: Potentiating effect refers to a drug's ability to increase the potency of another drug if the two drugs are taken together. Therefore, the client should be instructed to avoid alcohol while taking chlordiazepoxide because alcohol potentiates the drug's CNS depressant effect. Taken at bedtime, this drug will induce sleep. Chlordiazepoxide comes in capsule form and can usually be taken with water. Aged cheese is restricted with monoamine oxidase inhibitors, not antianxiety agents. Remediation: Question 18 See full question A 30-year-old client comes to the office for a routine prenatal visit. After reading the chart entry below, the nurse would prepare the client for which test? You Selected: 1-Hour glucose tolerance test Correct response: 1-Hour glucose tolerance test Explanation: A 1-hour glucose tolerance test is recommended to screen for gestational diabetes if the client is obese, has glycosuria or a family history of diabetes, or lost a fetus for unexplained reasons or gave birth to a large-for-gestational-age neonate. A triple screen tests for chromosomal abnormalities. The indirect Coombs’ test screens maternal blood for red blood cell antibodies. Amniocentesis is used to detect fetal abnormalities. Remediation: Question 19 See full question A client’s family just completed a care conference with the health care team. The family has decided to withdraw treatment. What is the nurse’s next step? You Selected: Document the decision in the client’s electronic record. Correct response: Document the decision in the client’s electronic record. Explanation: After a decision has been made, the nurse should document the decision in the client’s electronic record. This will alert additional members of the health care team. The client should not be transferred to a different floor. The pharmacy will receive notification from the EMR. Family members should communicate to others about the decision. The nurse should be caring for the client. Remediation: Question 20 See full question The nurse is caring for a client in labor. The nurse notes variable decelerations on the fetal monitor strip. Which of the following interventions should the nurse include in the client’s plan of care? You Selected: Repositioning the client on her side Correct response: Repositioning the client on her side Explanation: Variable decelerations are caused by umbilical cord compression. These can occur with or without a contraction. Positioning the client on her side would provide optimal oxygenation to the fetus. Discontinuing the fetal monitor would be inappropriate for a client in labor who is having variable decelerations. Calling the healthcare provider without repositioning the client first would be inappropriate. Terbutaline may discontinue the uterine contractions but may not stop the variable decelerations. Remediation: Question 21 See full question A client is has presented to the emergency department with symptoms that are suggestive of appendicitis. The client admits to the nurse, "I am very nervous because I am in the country illegally and have been for several years." What is the nurse's best response? You Selected: "We are going to give you the treatment you need. The care team does not involve ourselves with your immigration status." Correct response: "We are going to give you the treatment you need. The care team does not involve ourselves with your immigration status." Explanation: A client's immigration status is highly significant, but this variable is not the responsibility of the nurse and the other members of the healthcare team. A nurse should never counsel a client towards secrecy. Question 22 See full question A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction? You Selected: "Avoid stimulants and alcohol for 24 to 48 hours before the test." Correct response: "Avoid stimulants and alcohol for 24 to 48 hours before the test." Explanation: For 24 to 48 hours before an EEG, the client should avoid coffee, cola, tea, alcohol, and cigarettes because these may interfere with the accuracy of test results. (For the same reason, the client also should avoid antidepressants, sedatives, and anticonvulsants.) To avoid a reduced serum glucose level, which may alter test results, the client should eat normal meals before the test. The hair should be washed before an EEG because the electrodes must be applied to a clean scalp. The client's thoughts don't affect the test results. Remediation: Question 23 See full question A client is in the manic phase of chronic bipolar disorder. The client has stopped taking the prescribed lithium carbonate 3 weeks ago and has not been eating or sleeping for 3 days. Which behaviors listed below will be of priority concern as the nurse begins a care plan for this client? You Selected: Hyperactivity, ignoring eating and sleeping Correct response: Hyperactivity, ignoring eating and sleeping Explanation: Safety needs are always the first priority in care planning. A client who has not eaten or slept for several days and has been extremely hyperactive may be at risk of exhaustion and malnutrition, and the implications of those states. Although thought disorder, expansive mood, and dress are important assessment information, priority interventions must center on the basic needs. Remediation: Question 24 See full question A client comes to the emergency department complaining of chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic does the nurse expect to see? You Selected: Elevated ST segment Correct response: Elevated ST segment Explanation: Ischemic myocardial tissue changes cause elevation of the ST segment, an inverted T wave, and a pathological Q wave. A prolonged PR interval occurs with first-degree heart block, the least dangerous atrioventricular heart block; this disorder may arise in healthy people but sometimes results from drug toxicity, electrolyte or metabolic disturbances, rheumatic fever, or chronic degenerative disease of the conduction system. An absent Q wave is normal; an MI may cause a significant Q wave. A widened QRS complex indicates a conduction delay in the His-Purkinje system. Remediation: Question 25 See full question A client with a history of renal calculi formation is being discharged after surgery to remove the calculus. What instructions should the nurse include in the client's discharge teaching plan? You Selected: Increase daily fluid intake to at least 2 to 3 L. Correct response: Increase daily fluid intake to at least 2 to 3 L. Explanation: A high daily fluid intake is essential for all clients who are at risk for calculi formation because it prevents urinary stasis and concentration, which can cause crystallization. Depending on the composition of the stone, the client also may be instructed to institute specific dietary measures aimed at preventing stone formation. Clients may need to limit purine, calcium, or oxalate. Urine may need to be either alkaline or acid. There is no need to strain urine regularly. Remediation: Question 26 See full question The nurse has provided an in-service presentation to ancillary staff about standard precautions on the birthing unit. The nurse determines that one of the staff members needs further instructions when the nurse makes which observation? You Selected: wearing of sterile gloves to bathe a neonate at 2 hours of age Correct response: wearing of sterile gloves to bathe a neonate at 2 hours of age Explanation: One of the staff members needs further instructions when the nurse observes the staff member wearing sterile gloves to bathe a neonate at 2 hours of age. Clean gloves should be worn, not sterile gloves. Sterile gloves are more expensive than clean gloves and are not necessary when bathing a neonate. Wearing protective goggles during a cesarean birth is a standard blood precaution. Bloody sheets should be placed in a designated container. Scalpel blades, needles, syringes, and other equipment used during birthing should be disposed of safely in appropriate, labeled containers. Remediation: Question 27 See full question A client’s arterial blood gas values are shown. The nurse should monitor the client for: You Selected: metabolic alkalosis Correct response: metabolic acidosis Explanation: The pH of 7.24 indicates that the client is acidotic. The carbon dioxide level is normal, but the HCO3- level is decreased. These findings indicate that the client is in metabolic acidosis. Remediation: Question 28 See full question Which finding indicates that a client who has been raped will have future adjustment problems and need additional counseling? You Selected: Her parents show shame and suspicion about her part in the rape. Correct response: Her parents show shame and suspicion about her part in the rape. Explanation: The potential for problems in adjusting after a rape will be increased when those around the victim treat her as though she is to blame for the rape, especially when she already may feel some guilt and shame about it. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims. Remediation: Question 29 See full question A client is at the end of her first postpartum day. The nurse is assessing the client's uterus. Which finding requires further evaluation? You Selected: Fundus two fingerbreadths above the umbilicus Correct response: Fundus two fingerbreadths above the umbilicus Explanation: Fundal height decreases about one fingerbreadth each postpartum day. Therefore, the fundus being two fingerbreadths above the umbilicus requires further evaluation. A firm, round uterus that's in the midline position is normal for a client who is 1 day postpartum. Remediation: Question 30 See full question A client experiencing a severe asthma attack has the following arterial blood gas results: pH 7.33; PCO2 48 (6.4 kPa); PO2 58 (7.7 kPa); HCO3 26 (26 mmol/L). Which prescriptions should the nurse implement first? You Selected: albuterol nebulizer Correct response: albuterol nebulizer Explanation: The arterial blood gas reveals a respiratory acidosis with hypoxia. A quick-acting bronchodilator, albuterol, should be administered via nebulizer to improve gas exchange. Ipratropium is a maintenance treatment for bronchospasm that can be used with albuterol. A chest x-ray and sputum sample can be obtained once the client is stable. Remediation: Question 31 See full question The nurse notes that a client is too busy investigating the unit and overseeing the activities of other clients to eat dinner. To help the client obtain sufficient nourishment, which plan would be best? You Selected: Allow her to enter the unit kitchen for extra food as necessary. Correct response: Serve foods that she can carry with her. Explanation: Because the client is very active, it would be best to give her food she can carry with her and eat as she moves. Neither allowing the client to send out for her favorite foods nor serving food in small, attractively arranged portions will address her need to be active. Allowing the client in the unit kitchen is impractical, and she most likely would be too busy to eat anyway. Question 32 See full question A nurse is assigned to care for a client with anorexia nervosa. During the first 48 hours of treatment, which nursing intervention is most appropriate for this client? You Selected: Providing one-on-one supervision during meals and for 1 hour afterward Correct response: Providing one-on-one supervision during meals and for 1 hour afterward Explanation: Because a client with anorexia nervosa may discard food or induce vomiting in the bathroom, the nurse should provide one-on-one supervision during meals and for 1 to 2 hours afterward. Letting the client eat with other clients wouldn't be therapeutic because other clients might urge the client to eat and give this client attention for not eating. Trying to persuade the client to eat would reinforce control issues, which are central to this client's underlying psychological problem. Instead of giving the client unlimited time to eat the nurse should set limits and let the client know what is expected. Remediation: Question 33 See full question A third-grade child is referred to the mental health clinic by the school nurse because he is fearful, anxious, and socially isolated. After meeting with the client, the nurse talks with his mother, who says, “It is that school nurse again. She has done nothing but try to make trouble for our family since my son started school. And now you are in on it.” The nurse should respond by saying: You Selected: "You sound pretty angry with the school nurse. Tell me what has happened." Correct response: "You sound pretty angry with the school nurse. Tell me what has happened." Explanation: The mother’s feelings are the priority here. Addressing the mother’s feelings and asking for her view of the situation is most important in building a relationship with the family. Ignoring the mother’s feelings will hinder the relationship. Defending the school nurse and the school puts the client’s mother on the defensive and stifles communication. Remediation: Question 34 See full question A charge nurse is completing day-shift client care assignments on the genitourinary floor. A new graduate is present for the first day on the unit. An agency nurse and an experienced nurse are also present. The charge nurse should assign the new graduate nurse to the care of which of the following clients? You Selected: Elderly client just admitted for an acute stroke Correct response: Middle-aged stable client with bladder cancer awaiting surgery Explanation: The charge nurse should assign the new nurse to the middle-aged client newly diagnosed with bladder cancer awaiting surgery, as this client has a condition common to the genitourinary floor and is of low acuity and stable. The charge nurse should assign the agency nurse to the client who had an ileo conduit. Their conditions have lesser acuity. The charge nurse should assign the experienced nurse to the most acute clients: the middle-age kidney-transplant recipient Remediation: Question 35 See full question While performing an assessment of a 75-year-old client in the emergency department, a nurse notes several areas of ecchymosis in various stages of healing on the client’s body. What is the nurse’s priority action? You Selected: Document the findings Correct response: Inquire how these bruises occurred Explanation: The nurse should obtain more information from the client first, in order to complete the initial assessment. The nurse should not assume that the bruises are a result of abuse, and she should not notify the nursing supervisor until additional facts are obtained. The nurse should inform the provider so an examination can be completed. She should follow the facility’s policy and procedure for reporting abuse and document the findings. Remediation: Question 36 See full question A nurse is instructing a client with bipolar disorder on proper use of lithium carbonate, the drug's adverse effects, and symptoms of lithium toxicity. Which client statement indicates that additional teaching is required? You Selected: "When my moods fluctuate, I'll increase my dose of lithium." Correct response: "When my moods fluctuate, I'll increase my dose of lithium." Explanation: A client who states that he'll increase his dose of lithium if his mood fluctuates requires additional teaching because increasing the dose of lithium without evaluating the client's laboratory values can cause serious health problems, such as lithium toxicity, overdose, and renal failure. Clients taking lithium don't need to limit their sodium intake. A low-sodium diet causes lithium retention. A therapeutic lithium blood level indicates that the drug concentration has stabilized. The client demonstrates effective teaching by stating his lithium levels will be affected by foods that have a diuretic effect, such as watermelon, cantaloupe, grapefruit juice, and cranberry juice. Remediation: Question 37 See full question An 8-year-old child, diagnosed with obsessive-compulsive disorder, is admitted by the nurse to a psychiatric facility. During the admission assessment, which behaviors would be characterized as compulsions? Select all that apply. You Selected: Repeatedly washing the hands. Checking and rechecking that the television is turned off before going to school. Routinely climbing up and down a flight of stairs three times before leaving the house. Correct response: Checking and rechecking that the television is turned off before going to school. Repeatedly washing the hands. Routinely climbing up and down a flight of stairs three times before leaving the house. Explanation: Compulsions involve symbolic rituals that relieve anxiety when they are performed. The disorder is caused by anxiety from obsessive thoughts, and acts are seen as irrational. Examples include repeatedly checking the television set, washing hands, or climbing stairs. An activity such as playing the same video game each night may be indicative of normal development for a school-age child. Frequent brushing of the teeth and feeding the dog a consistent meal are not abnormal. Remediation: Question 38 See full question A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has: You Selected: cirrhosis. Correct response: cirrhosis. Explanation: Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating. Appendicitis is characterized by a periumbilical pain that moves to the right lower quadrant and rebound tenderness. Cholelithiasis is characterized by severe abdominal pain that presents several hours after a large meal. Remediation: Question 39 See full question A client is to be discharged with a prescription for lactulose. The nurse teaches the client and the client’s spouse how to administer this medication. Which statement would indicate that the client has understood the information? You Selected: "I will mix it with apple juice." Correct response: "I will mix it with apple juice." Explanation: The taste of lactulose is a problem for some clients. Mixing it with fruit juice, water, or milk can make it more palatable. Lactulose should not be given with antacids, which may inhibit its action. Lactulose should not be taken with a laxative because increased stooling is an adverse effect of the drug and would be potentiated by using a laxative. Lactulose comes in the form of syrup for oral or rectal administration. Remediation: Question 40 See full question A client with suspected inhalation anthrax is admitted to the emergency department. Which action by the nurse takes the highest priority? You Selected: Suction the client as needed to obtain a sputum specimen for culture and sensitivity. Correct response: Monitor vital signs and oxygen saturation every 15 to 30 minutes. Explanation: Monitoring vital signs and oxygen saturation every 15 to 30 minutes takes priority. Suctioning the client as needed to obtain a sputum specimen may be necessary, but assessing the client for changes in his respiratory status takes priority. Assessing intake and output and providing adequate hydration are important steps for liquefying secretions; however, they don't take priority. Reassuring the client that intubation and mechanical ventilation is temporary is inappropriate. The client may not require intubation and mechanical ventilation; however, if he does, the nurse can't predict the length of time it may be necessary. Remediation: Question 41 See full question A client with renal insufficiency is admitted to the hospital with pneumonia. He's being treated with gentamicin. Which laboratory value should be closely monitored? You Selected: Blood urea nitrogen (BUN) Correct response: Blood urea nitrogen (BUN) Explanation: BUN and creatinine levels should be closely monitored to detect elevations caused by nephrotoxicity. Sodium level should be routinely monitored in all hospitalized clients. Alkaline phosphatase helps evaluate liver function. The WBC count should be monitored to evaluate the effectiveness of the antibiotic; it doesn't help evaluate kidney function. Remediation: Question 42 See full question A client with an exacerbation of chronic obstructive pulmonary disease (COPD) is admitted to the hospital. Which nursing diagnosis requires the nurse to collaborate with other health team members to achieve the best outcome for the client? You Selected: Impaired gas exchange Correct response: Impaired gas exchange Explanation: Impaired gas exchange requires collaboration between the nurse, physician, and respiratory therapist to help achieve the best respiratory outcome for the client. Medications, oxygen, nebulizer treatments, and arterial blood gas analyses all require a physician's order. The respiratory therapist administers the oxygen and nebulizer treatments. The nurse assesses the client's response to medications and respiratory treatments and provides feedback to the physician and respiratory therapist. Impaired skin integrity, Activity intolerance, and Imbalanced nutrition: Less than body requirements (when applied to the client with COPD) require independent nursing interventions without collaboration with other health team members. These interventions include skin care, pacing nursing care to promote rest and minimize fatigue, and providing small, frequent meals. Remediation: Question 43 See full question A client on vacation experiences severe allergy symptoms, headache, and sinusitis (without respiratory distress). This client adamantly declines any supportive medications when offered. The nurse questions the client and learns the client receives weekly acupuncture treatments for these symptoms. The nurse’s best response is: You Selected: “Let us try this until you can have acupuncture.” Correct response: “Let us try this until you can have acupuncture.” Explanation: The nurse should respect the client’s choice of alternative treatments. It is respectful to offer choices until the client can again access acupuncture treatment. Acupuncture is not experimental. The nurse is being disrespectful to offer medications when the client has declined them, and it is silly to compare acupuncture to injectable medications. Remediation: Question 44 See full question What should a nurse do to ensure a safe hospital environment for a toddler? You Selected: Move the equipment out of reach. Correct response: Move the equipment out of reach. Explanation: Moving the equipment out of reach ensures a safe environment because toddlers are curious and may try to play with items within their reach. Toddlers in a strange hospital environment still need the security of a crib. Stacking toys don't need to be moved out of reach because they don't present a safety hazard and are appropriate for this age-group. Padded crib rails are necessary only if seizure activity is present. Remediation: Question 45 See full question The client attends two sessions with the dietitian to learn about diet modifications to minimize gastroesophageal reflux. The teaching would be considered successful if the client decreases the intake of which foods? You Selected: fats Correct response: fats Explanation: Fats are associated with decreased esophageal sphincter tone, which increases reflux. Obesity contributes to the development of hiatal hernia, and a low-fat diet might also aid in weight loss. Carbohydrates and foods high in sodium or calcium do not affect gastroesophageal reflux. Remediation: Question 46 See full question A client has received an infusion of antibiotics and is now experiencing an anaphylactic reaction. What is the most important intervention by the nurse? You Selected: Maintain a patent airway Correct response: Maintain a patent airway Explanation: The first priority is to maintain a patent airway. The client will then require an epinephrine injection. If hypotension develops, a saline bolus may be given. The client’s vital signs should be monitored, but not as the first action. Remediation: Question 47 See full question The nurse is caring for a comatose, older adult with stage III pressure ulcers over two bony prominences. Which intervention should be added to the plan of care? You Selected: Place a foam pad on the existing mattress. Correct response: Place the client on a pressure redistribution bed. Explanation: A pressure redistribution bed will allow for constant motion of the client and prevent further breakdown. A foam pad will not be sufficient to prevent further breakdown in a patient this debilitated. Turning should be at a minimum of every 2 hours, and pain medication is not indicated unless the patient is demonstrating pain. Remediation: Question 48 See full question An older client reports episodes of severe anxiety resulting in shortness of breath, palpitations, chest pain, dizziness, and nausea. The physician prescribes lorazepam. What effect of this medication would be most important for the nurse to monitor on this client? You Selected: Hyponatremia Correct response: Sedation Explanation: Lorazepam use, especially in older adults, has a pronounced sedative effect. This puts the client at risk for injury and falls. Hyponatremia, paradoxical reactions, and sleep disturbances are less common adverse effects of lorazepam and would not be as acutely dangerous to the elderly client as sedation. Remediation: Question 49 See full question The nurse is analyzing the arterial blood gas (AGB) results of a client diagnosed with severe pneumonia. What ABG results are most consistent with this diagnosis? You Selected: pH: 7.20, PaCO2: 65 mm Hg, HCO3–: 26 mEq/L Correct response: pH: 7.20, PaCO2: 65 mm Hg, HCO3–: 26 mEq/L Explanation: Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3– occurs. It may be either acute or chronic. The ABG of pH: 7.32, PaCO2: 40 mm Hg, HCO3–: 18 mEq/L indicates metabolic acidosis. The ABGs of pH: 7.50, PaCO2: 30 mm Hg, and HCO3–: 24 mEq/L indicate respiratory alkalosis. The ABGs of pH 7.42, PaCO2: 45 mm Hg, and HCO3–: 22 mEq/L indicate a normal result/no imbalance. Remediation: Question 50 See full question A 26-year-old primigravida visiting the prenatal clinic for her regular visit at 34 weeks’ gestation tells the nurse that she takes mineral oil for occasional constipation. What should the nurse should instruct the client to do? You Selected: Avoid mineral oil because it interferes with the absorption of fat-soluble vitamins. Correct response: Avoid mineral oil because it interferes with the absorption of fat-soluble vitamins. Explanation: Mineral oil is a harsh laxative that is contraindicated during pregnancy because it interferes with absorption of the fat-soluble vitamins A, D, E, and K from the intestinal tract. Dietary measures, exercise, and increased fluid and fiber intake are better choices to prevent constipation. If necessary, a stool softener or mild laxative may be prescribed. Use of fruit juice is recommended for the client receiving iron supplementation to enhance its absorption. Mineral oil does not lead to vitamin C deficiency in pregnant clients. Mineral oil use is contraindicated during pregnancy and therefore should not be used. Increased fluids, fiber, and exercise are better choices to suggest for relief of constipation. Remediation: Question 51 See full question A client’s blood pressure is elevated at 160/90 mm Hg. The health care provider (HCP) prescribed “clonidine 1 mg by mouth now.” The nurse sent the prescription to pharmacy at 0710, but the medication still has not arrived at 0800. The nurse should do all except: You Selected: go to the pharmacy to obtain the drug. Correct response: go to the pharmacy to obtain the drug. Explanation: Although the nurse needs to obtain and administer the medication as soon as possible, it is inappropriate for the nurse to go to the pharmacy and request the drug without first calling the pharmacy and checking to see whether the medication was delivered. The drug may have been delivered to several appropriate spots on the unit, such as the client’s drug bin, the transport system, or the delivery box. The nurse should assess the client’s blood pressure to determine the immediacy of the condition for which the medication was prescribed. Remediation: Question 52 See full question A nurse-manager appropriately behaves as an autocrat in which situation? You Selected: Directing staff activities if a client experiences a cardiac arrest Correct response: Directing staff activities if a client experiences a cardiac arrest Explanation: In a crisis situation, the nurse-manager should take command for the benefit of the client. Planning vacation time and evaluating procedures and client resources require staff input and are actions characteristic of a democratic or participative manager. Question 53 See full question A client admitted to the inpatient psychiatric unit changes clothes eight or nine times a day, wears heavy eye makeup, is intrusive with other clients, and makes inappropriate sexual advances toward staff members. Which of the following client goals would be most appropriate? You Selected: The client will refrain from hugging other clients and change clothing only twice per day. Correct response: The client will refrain from hugging other clients and change clothing only twice per day. Explanation: The focus should be on symptom management and containment until the client recovers enough to participate in more structured nursing interventions. Small changes in hugging and wardrobe change behavior will be realistic, offer a measure of change/stability, and help decrease overall hypomanic behaviors. Recording the number of clothing changes per day is not realistic. Having staff members help the client choose appropriate dress is incorrect because this behavior will encourage continued inappropriate sexual advances. The client does not have difficulties with low self-esteem. Remediation: Question 54 See full question A nurse should monitor a client receiving lidocaine for toxicity. Which signs or symptoms in a client suggest lidocaine toxicity? You Selected: Confusion and restlessness Correct response: Confusion and restlessness Explanation: Confusion and restlessness are signs of lidocaine toxicity. Nausea and vomiting may occur with oral administration of mexiletine or tocainide — other class IB drugs. Pupillary changes and hypertension aren't signs of lidocaine toxicity, although visual changes and hypotension may occur as adverse reactions to class IB drugs. Remediation: Question 55 See full question A couple visiting the infertility clinic for the first time states that they have been trying to conceive for the past 2 years without success. After a history and physical examination of both partners, what would be the most appropriate outcome for the couple to accomplish by the end of this visit? You Selected: Describe each of the potential causes and possible treatment modalities. Correct response: Describe each of the potential causes and possible treatment modalities. Explanation: By the end of the first visit, the couple should be able to identify potential causes and treatment modalities for infertility. If their evaluation shows that a treatment or procedure may help them to conceive, the couple must then decide how to proceed, considering all of the various treatments before selecting one. Treatments can be difficult, painful, or risky. The first visit is not the appropriate time to decide on a treatment plan because the couple needs time to adjust to the diagnosis of infertility, a crisis for most couples. Although the couple may be in a hurry for definitive therapy, a thorough assessment of both partners is necessary before a treatment plan can be initiated. The success rate for achieving a pregnancy depends on both the cause and the effectiveness of the treatment, and in some cases it may be only as high as 30%. The couple may desire information about alternatives to treatment, but insufficient data are available to suggest that a specific treatment modality may not be successful. Suggesting that the couple consider adoption at this time may inappropriately imply that the couple has no other choice. If a specific therapy may result in a pregnancy, the couple should have time to consider their options. After a thorough evaluation, adoption may be considered by the couple as an alternative to the costly, time-consuming, and sometimes painful treatments for infertility. Remediation: Question 56 See full question A nurse is preparing to give an average-size 9-year-old child a preoperative I.M. injection. Which size needle should the nurse use? You Selected: 22G, 1″ Correct response: 22G, 1″ Explanation: The nurse should evaluate the muscle mass and amount of subcutaneous fat and then select the correct needle size. Without more information, the nurse would select the 22G, 1″ needle, appropriate for an average-size school-age child. The 20G, 1″ needle would be unnecessarily large. The 22G, 1½″ needle would be too long. The 20G, 1½″ needle would be too long and unnecessarily large. Remediation: Question 57 See full question The nurse is caring for a client who is a recent immigrant from China. Through the hospital interpreter, the client expresses an unwillingness to eat the fried fish that was on the meal tray, describing it as "too hot." What is the nurse's best action? You Selected: Ask the interpreter to ask the client about the specific meaning of the description of "hot." Correct response: Ask the interpreter to ask the client about the specific meaning of the description of "hot." Explanation: In many Asian cultures, foods are categorized on a continuum of cold to hot that is independent of their physical temperature. Consequently, it is important for the nurse to assess the precise meaning of the client's statement before taking further action such as changing the client's diet. It is appropriate to assess the client's food preferences, but this data should come from the client, not the interpreter. Remediation: Question 58 See full question A client has a history of schizophrenia. Because he has a history of noncompliance with antipsychotic therapy, he will receive fluphenazine decanoate injections every 4 weeks. Before discharge, what should the nurse include in her teaching plan? You Selected: Sitting up for a few minutes before standing to minimize orthostatic hypotension Correct response: Sitting up for a few minutes before standing to minimize orthostatic hypotension Explanation: The nurse should teach the client how to manage common adverse reactions, such as orthostatic hypotension and anticholinergic effects. Antipsychotic effects of the drug may not become evident for several weeks. Droperidol increases the risk of extrapyramidal effects when given in conjunction with phenothiazines such as fluphenazine. Tardive dyskinesia is a possible adverse reaction and should be reported immediately. Remediation: Question 59 See full question A client is admitted to the health care facility with acute chest pain. When obtaining the client's health history, which question would be most helpful for the nurse to ask? You Selected: "What were you doing when the pain started?" Correct response: "What were you doing when the pain started?" Explanation: Subjective data (data from the client) about the chest pain help the nurse determine the specific health problem. For example, asking about the setting in which the pain developed can provide helpful information about its cause. Asking about the history and medications will yield helpful information, but would not be the most helpful. Remediation: Question 60 See full question A nurse is assessing the family of an infant and observes that the parents are argumentative and appear fatigued. They indicate that the baby is not breastfeeding well and cries through the night. What would be the nurse’s priority nursing diagnosis for this infant? You Selected: Altered nutrition (less than body requirements) related to difficulty sucking Correct response: Altered nutrition (less than body requirements) related to difficulty sucking Explanation: The nurse’s initial priority should be to address the caloric intake of the baby through health teaching and support of the parents to ensure that the baby will meet age-appropriate growth and development milestones. Remediation: Question 61 See full question An elderly couple who have just relocated to a long-term care facility have been unable to obtain a shared room. A staff member at the facility states that this should not be a concern and implies that sexual activity between the couple likely ceased many years ago. How should the nurse best respond to this individual’s assertion? You Selected: "Actually it's not true that older people always stop having sexual activity when they get older." Correct response: "Actually it's not true that older people always stop having sexual activity when they get older." Explanation: Sexual activity need not be hindered by age. There is no evidence, however, that it becomes increasingly frequent in late adulthood. Question 62 See full question A nurse hears a client state, “I have had it with this marriage. It would be so much easier to just hire someone to kill my husband!” What action should the nurse take? You Selected: The nurse must start the process to warn the client’s husband. Correct response: The nurse must start the process to warn the client’s husband. Explanation: Confidentiality must be broken if there are credible threats made against another person’s safety. Confidentiality does not override the safety of other persons. Remediation: Question 63 See full question A client’s nutritional status has been severely compromised through prolonged episodes of nausea and vomiting. Which nutritional therapy will be the most effective in correcting nutritional deficits before surgery? You Selected: total parenteral nutrition (TPN) for several days Correct response: total parenteral nutrition (TPN) for several days Explanation: TPN bypasses the enteral route and provides total nutrition: protein, carbohydrates, fats, vitamins, minerals, and trace elements. The client is not able to tolerate oral feedings. Enteral feedings would enter the stomach and could increase feelings of fullness, nausea, and vomiting that the client may have had. IV isotonic saline, which contains only water, sodium, and chloride, provides incomplete nutrition. Remediation: Question 64 See full question A man brings his wife to the emergency department. He reports that since the death of their 7-month- old daughter 8 weeks earlier, his wife has been neglecting her housework and family, has lost 20 lb (9.1 kg), and has not left the house. Which of the following additional assessment findings would indicate to the nurse that the client may be experiencing extreme depression? Select all that apply. You Selected: Speaking in soft monotone voice Inconsolable weeping Obvious neglect of personal hygiene Correct response: Obvious neglect of personal hygiene Speaking in soft monotone voice Inconsolable weeping Explanation: Typically, a depressed client exhibits slow movements and fatigue and poor hygiene/grooming. Such a client also has difficulty interacting, speaking in a monotone voice, and avoiding eye contact. In extreme depression, the client may not communicate verbally at all, or the client may verbalize feelings of anger and lash out with irritability. Remediation: Question 65 See full question A client tells the nurse, "Everybody smiles at me because they know that I was chosen by God for this mission." The nurse interprets this statement as which finding? You Selected: idea of reference Correct response: idea of reference Explanation: An idea of reference is a person’s view that other people recognize that she has an important characteristic or power. Thought insertion refers to a person’s belief that others, or a specific other, can put thoughts into her mind. Visual hallucinations involve seeing objects or persons not based on reality. A neologism is a word or phrase that has meaning only to the person using it. Remediation: Question 66 See full question A nurse is caring for a client newly diagnosed with primary hypertension. Which activity best reflects the implementation phase of the nursing process? You Selected: Collaborating with the client to set exercise goals Correct response: Providing education about documenting blood pressure readings Explanation: Implementation involves providing actual nursing care. Education is an intervention that occurs during the implementation phase. Goal setting and formulation of nursing diagnosis do not occur during the implementation phase of the nursing process. Remediation: Question 67 See full question An overweight adolescent has been diagnosed with type 2 diabetes. To increase the client's self-efficacy to manage their disease, the nurse should: You Selected: provide the client with a written daily food and exercise plan. Correct response: utilize a peer with type 2 diabetes to role model lifestyle changes. Explanation: Self-efficacy, or the belief that one can act in a way to produce a desired outcome, can be promoted through the observation of role models. Peers are particularly effective role models because clients can more readily identify with them and believe they are capable of similar behaviors. Providing a written plan alone does not promote self-efficacy. Having parents eliminate junk food and having the school nurse weigh the adolescent can be part of the plan, but these actions do not empower the client. Remediation: Question 68 See full question While receiving phototherapy, a neonate begins to have frequent, loose, watery, green stools and is very irritable. The nurse interprets this as which situation? You Selected: The neonate may have a malabsorption problem. Correct response: This is a normal adverse effect of phototherapy. Explanation: Phototherapy increases gastric motility, causing the neonate to have many green, watery stools. The increased gastric motility also causes the neonate to be irritable. There is no evidence that the neonate has a lactose intolerance or malabsorption problem, nor is there evidence that the neonate's bilirubin levels are rising to dangerous levels. Remediation: Question 69 See full question A hospital nurse is on the safety committee. Which should the nurse recommend to the hospital administration to reduce needle-stick injuries at the institution? Select all that apply. You Selected: Purchase safety needle devices Encourage staff to plan safe handling and disposal of needles before initiating a procedure Post signs reminding staff to dispose of needles immediately after use Correct response: Purchase safety needle devices Encourage staff to plan safe handling and disposal of needles before initiating a procedure Post signs reminding staff to dispose of needles immediately after use Remind staff to use the “scoop” technique for recapping needles Explanation: The nurse should not recap needles. Choosing safety needle devices whenever possible and appropriate; planning in advance how to handle and dispose of needles; and discarding needles, safety needle systems, and sharps in sharps-disposal containers immediately after use are safe ways to handle sharps with less risk of needle-stick injuries. The nurse should use the one-handed needle-recapping technique only when absolutely necessary, such as when a sharps-disposal container is not readily available. Remediation: Question 70 See full question A client receiving total parenteral nutrition is ordered a 24-hour urine test. When initiating a 24-hour urine specimen, the collection time should: You Selected: start after a known voiding. Correct response: start after a known voiding. Explanation: When initiating a 24-hour urine specimen, have the client void, then start the timing. The collection should start on an empty bladder. The exact time the test starts isn't important but the test is commonly started in the morning. Remediation: Question 71 See full question A nurse is working in a rural health clinic that serves a large Amish population. The nurse is developing a program to address common health promotion strategies. Which aspect would be most important for the nurse to integrate into the program to promote its success? Select all that apply. You Selected: importance of the extended family in providing support focus on being in tune with nature for health maintenance need to ask for permission before physically touching a client Correct response: importance of the extended family in providing support focus on being in tune with nature for health maintenance need to ask for permission before physically touching a client Explanation: In the Amish culture, the extended family and community play important roles in supporting the client. They have a strong extended family social structure, and caring for the community is a strong value. Family structure is patriarchal, with the husband often the family spokesperson and decision maker. The Amish believe in the importance of nature to maintain health and often use natural remedies as a major part of care. Because touch is discouraged, permission is needed before touching a client. Remediation: Question 72 See full question The health care provider (HCP) prescribes intestinal decompression with a Cantor tube for a client with an intestinal obstruction. In order to determine effectiveness of intestinal decompression, the nurse should evaluate the client to determine if: You Selected: intestinal fluid and gas have been removed. Correct response: intestinal fluid and gas have been removed. Explanation: Intestinal decompression is accomplished with a Cantor, Harris, or Miller-Abbott tube. These 6- to 10- foot (180 to 300 cm) tubes are passed into the small intestine to the obstruction. They remove accumulated fluid and gas, relieving the pressure. The client will not have an adequate bowel movement until the obstruction is removed. The pressure from the distended intestine should not obstruct urinary output. While the client may be able to more easily sit up, and the pain caused by the intestinal pressure will be less, these are not the primary indicators for successful intestinal decompression. Remediation: Question 73 See full question An assessment of a client on the first day after a thoracotomy shows a temperature of 100° F (37.8° C); heart rate, 96 bpm; blood pressure, 136/86 mmHg; and shallow respirations at 30 breaths/min, with rhonchi at the bases. The client is diaphoretic, anxious, and reports of incisional pain. Which nursing action is priority? You Selected: Medicate the client for pain as ordered Correct response: Medicate the client for pain as ordered Explanation: Although all the interventions are incorporated in this client’s care plan, the priority is to relieve pain and make the client comfortable. This will relax the client, decrease his respirations, and make deep breathing and coughing more comfortable. In addition, this would give the client the energy and stamina to achieve the other objectives. Remediation: Question 74 See full question The nurse is taking care of a client with Clostridium difficile. To prevent the spread of infection, what should the nurse do? Select all that apply. You Selected: Wear a protective gown when in the client's room. Wash hands with soap and water. Wear sterile gloves when providing care. Correct response: Wash hands with soap and water. Wear a protective gown when in the client's room. Explanation: C. difficile is an organism that has developed very resistant and highly morbid strains. Universal precautions, most importantly handwashing, wearing personal protective gear, and modest use of antibiotics, are critical actions for stopping the spread. C. difficile is not spread via the respiratory tract; therefore, a mask is not needed. Alcohol-based hand sanitizers do not kill the spores of C. difficile; soap and water must be used. Sterile gloves are not needed to provide care; clean gloves may be worn. Remediation: Question 75 See full question A client is admitted to the oncology unit with an infection. It is suspected that the infection may be related to the vascular access device (VAD). The nurse should draw the blood cultures from which site? You Selected: a peripheral site only Correct response: a peripheral site and all lumens of the VAD Explanation: When an infection is suspected from a VAD, blood cultures should be drawn peripherally and from all lumens of the VAD to determine the source of the infection. If the number of organisms is greater from the VAD than in the peripheral culture, the source is determined to be the VAD. Remediation: Question 76 See full question The nurse is providing follow-up care with a client 10 days after birth of a newborn. The nurse would anticipate what outcomes for the new mother? Select all that apply. You Selected: The client feels tired but can care for herself and her new infant. The client has positive comments about her new infant. The family has adequate support from one another and others. Correct response: The client feels tired but can care for herself and her new infant. The family has adequate support from one another and others. Lochia is changing from red to pink and is smaller in amount. The client has positive comments about her new infant. Explanation: Outcome evaluation for a family about 7 days after childbirth would include a mother who is tired but is able to care for herself and her baby. Having adequate support systems enables the mother to care better for herself and family members, as they can provide the backup for situations that may arise and a resource for new families. The normal progression for lochia is to change from red to pink to off-white while decreasing in amount. This is within the usual time periods for a postpartum mother. The baby should be feeding more frequently than every 6 to 8 hours. It is expected that a 7-day old infant feeds every 3 to 4 hours if bottle-feeding and every 1½ to 3 hours if breastfeeding. Follow-up questions the nurse would ask to further evaluate this situation include, How many wet diapers the infant has daily? How alert the infant is? Did the infant gain any weight at the first checkup? It is expected that the mother has positive comments about the infant, but the nurse will evaluate to determine if there is at least one positive comment. Remediation: Question 77 See full question The nurse observes the cardiac rhythm (see above) for a client who is being admitted with a myocardial infarction. Which should the nurse do first? You Selected: Begin cardiopulmonary resuscitation (CPR). Correct response: Check for a pulse. Explanation: This ECG strip indicates the client has ventricular tachycardia. The nurse should first check the client for the presence of a pulse. The presence of a pulse determines the treatment for ventricular tachycardia. It is also important to assess the client’s heart rate and level of consciousness. Cardioversion may be used to treat hemodynamically unstable tachycardias. Assessment of instability is required before cardioversion. It is not appropriate to begin CPR unless the pulse is absent. Defibrillation is used to treat ventricular fibrillation or pulseless ventricular tachycardia. Remediation: Question 78 See full question What is the most important assessment for the nurse to make when administering tamsulosin to a client with benign prostatic hyperplasia (BPH)? You Selected: Voiding pattern Correct response: Voiding pattern Explanation: The alpha-adrenergic blocker tamsulosin relaxes the smooth muscle of the bladder neck and prostate, so the urinary voiding symptoms of BPH are reduced in many clients. These drugs do not affect the size of the prostate, renal function, or the production or metabolism of testosterone. Remediation: Question 79 See full question A neonate must receive an eye preparation to prevent ophthalmia neonatorum. How should the nurse administer this preparation? You Selected: By positioning the neonate so that the head remains still Correct response: By positioning the neonate so that the head remains still Explanation: After positioning the neonate securely so that the head remains still, the nurse should hold the eyelid open and instill the medication into the conjunctival sac. Holding the neonate in the football position doesn't secure the head. Remediation: Question 80 See full question The nurse is caring for a child with an acute exacerbation of asthma. Oral methylprednisolone has been ordered. Which of the following actions is most important for the nurse to take when administering this medication? You Selected: Give the medication 2 hours before meals. Correct response: Give the medication with food. Explanation: Giving the medication with food helps reduce gastric irritation. Oral doses of corticosteroids should be given in the morning. Remediation: Question 81 See full question A nurse assesses a client who is in cardiogenic shock. Which statement by the nurse best indicates an understanding of cardiogenic shock? You Selected: “A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume” Correct response: “A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume” Explanation: Shock may have different causes (e.g., hypovolemia, cardiogenic, septic), but always involves a decrease in blood pressure and failure of the peripheral circulation because of sympathetic nervous system involvement. Movement of plasma into the interstitial spaces could reflect dependent edema and sepsis. Decreased blood volume is an example of hypovolemia. A hypersensitivity reaction is an example of anaphylactic shock or distributive shock. Remediation: Question 82 See full question A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mm Hg and the ICP is 18 mm Hg; therefore his cerebral perfusion pressure (CPP) is: You Selected: 52 mm Hg. Correct response: 52 mm Hg. Explanation: To determine CPP, subtract the ICP from the mean arterial pressure (MAP). Question 83 See full question A health care provider prescribes carbamazepine 1,200 mg/po/q12h for a client with trigeminal neuralgia. Which action should the nurse take first? You Selected: The dose exceeds the recommended daily dose and should be questioned Correct response: The dose exceeds the recommended daily dose and should be questioned Explanation: The nurse should verify the dose with the provider as it exceeds the standard prescribed dosage. Clients with trigeminal neuralgia should receive no more than 1,200 mg/po/daily. After the nurse confirms the order, he should encourage the client to take the drug at the same time each day with food to avoid GI distress. The nurse should also encourage the client to promptly report unusual bleeding. The drug should be stored in a cool, dry place. Remediation: Question 84 See full question A client whose cervix is 10 cm dilated begins to push. The nurse notes early decelerations of the fetal heart rate. The nurse should interpret this finding as being caused by which factor? You Selected: cord compression Correct response: fetal head compression Explanation: Early decelerations are usually due to pressure on the fetal head as the fetus progresses through the birth canal. These decelerations mirror the contraction pattern and are usually benign, unless the pattern occurs in early labor. If this pattern is demonstrated in early labor, it may indicate cephalopelvic disproportion. Variable decelerations are associated with cord compression. Fetal bradycardia may occur as a result of analgesia and can occur at any time. Inadequate placental perfusion is associated with late fetal heart rate decelerations. Remediation: Question 85 See full question A nurse is caring for a young child who is experiencing verbal tics and motor tics such as eye blinking and protruding their tongue? Based on this assessment, which medication would the nurse consider administering? You Selected: Haloperidol Correct response: Haloperidol Explanation: Haloperidol is the drug of choice for treating Tourette syndrome. Fluoxetine, fluvoxamine, and paroxetine are antidepressants and are not used to treat Tourette syndrome. Remediation: Question 86 See full question The nurse assesses an infant who has a fever of 101° F (38.3° C) and who has an upper respiratory infection. The child is “fussy” and pulling on her ear. Which of the following are the nurse’s best actions? Select all that apply. You Selected: Schedule a follow-up appointment for 3 months. Perform an ear exam. Administer amoxicillin orally for 10 days. Correct response: Perform an ear exam. Administer amoxicillin orally for 10 days. Administer acetaminophen. Explanation: The symptoms that are described are for acute otitis media. The child has a temperature and meets criteria to be treated with antibiotics. The healthcare provider will diagnosis this finding with an otoscopy and encourages the use of acetaminophen for pain and fever. Follow-up should occur after the antibiotic treatment is completed, and the use of heat is encouraged. Remediation: Question 87 See full question An elderly client becomes confused and combative. The client's nurse receives an order for soft wrist restraints. When the client's family insists that he not be restrained, the nurse informs the family that the family must provide an around-the-clock attendant for the client to avoid use of restraints. The family spokesman replies, "You find the attendant; that is your responsibility." Which of the following would be the best response by the nurse? You Selected: "I recommend family members arrange to stay with the client." Correct response: "I recommend family members arrange to stay with the client." Explanation: Offering the family a solution to the situation is therapeutic and can advance rapport with the family. It can also facilitate the problem-solving process, which involves the client, family, and staff. Restating that finding an attendant is the family's responsibility and saying that family members are making the situation more difficult are confrontational approaches. Such statements don't increase rapport with the family or enhance problem-solving. The staff cannot renounce responsibility for the client if the family will not allow restraints. Remediation: Question 88 See full question While reviewing a client's chart, the nurse notices that the client has myasthenia gravis. Which statement about neuromuscular blocking agents is true for a client with this condition? You Selected: Succinylcholine shouldn't be used; pancuronium may be used in a lower dosage. Correct response: Pancuronium and succinylcholine both require cautious administration. Explanation: The nurse must cautiously administer pancuronium, succinylcholine, and any other neuromuscular blocking agent to a client with myasthenia gravis because of the potential for prolonged recovery times. Such a client isn't less sensitive to the effects of a neuromuscular blocking agent. Either succinylcholine or pancuronium can be administered in the usual adult dosage to a client with myasthenia gravis. Remediation: Question 89 See full question The parents of a child with occasional generalized seizures want to send the child to summer camp. The parents contact the nurse for advice on planning for the camping experience. Which type of activity should the nurse and family decide the child should avoid? You Selected: rock climbing Correct response: rock climbing Explanation: A child who has generalized seizures should not participate in activities that are potentially hazardous. Even if accompanied by a responsible adult, the child could be seriously injured if a seizure were to occur during rock climbing. Someone also should accompany the child during activities in the water. At summer camps, hiking and swimming would occur most commonly as group activities, so someone should be with the child. Tennis would be considered an appropriate, nonhazardous activity for a child with generalized seizures. Remediation: Question 90 See full question Which instructions should the nurse include in the teaching plan for a 30-year-old multiparous client who will be using an intrauterine device (IUD) for family planning? You Selected: Severe cramping may occur when the IUD is inserted. Correct response: Severe cramping may occur when the IUD is inserted. Explanation: Severe cramping and pain may occur as the device is passed through the internal cervical os. The insertion of the device is generally done when the client is having her menses, because it is unlikely that she is pregnant at that time. Common adverse effects of IUDs are heavy menstrual bleeding and subsequent anemia, not amenorrhea. Uterine infection or ectopic pregnancy may occur. The IUD has an effectiveness rate of 98%. Therefore, additional protection is not necessary to prevent pregnancy. IUDs generally are less costly than other forms of contraception because they do not require additional expense. Only one insertion is necessary, in comparison to daily doses of oral contraceptives or the need for spermicides in conjunction with diaphragm use. Remediation: Question 91 See full question The RN is administering intravenous chemotherapy to a client with cancer. Which precautions are necessary when administering chemotherapy? Select all that apply. You Selected: wearing gloves when handling the client’s urine Correct response: wearing gloves when handling the client’s urine disposing of chemotherapy waste as hazardous material wearing a long-sleeved gown when administering chemotherapy Explanation: Nurses preparing and administering chemotherapy wear gloves and a disposable, long-sleeved gown. Antineoplastic agents are disposed of as hazardous material and gloves are always worn when handling the excretions of clients who have received chemotherapy. It is not appropriate to tape IV tubing connections; antineoplastic agents are administered using Luer lock fittings on all intravenous tubing to minimize the risk of exposure from needle stick injury. Remediation: Question 92 See full question A triage nurse is completing an initial assessment of several clients in the waiting room. Which of the following clients would the nurse see first? You Selected: A client who is 12 days past her due date with cramping Correct response: A client with uterine contractions who reports, “they are getting stronger and closer now” Explanation: True labor is defined as the onset of regular uterine contractions that increase in frequency, intensity, and duration. The passing of the mucous plug (may be thick and red tinged) implies softening and effacement of the cervix, which is a sign of impending labor (24-48 hours prior), not true labor. Lightening (the fetus settles or drops into the pelvic inlet) is another sign of impending labor and may occur up to 2 weeks prior to birth. The client who is past her due date is showing no signs of distress. Remediation: Question 93 See full question Following an epidural and placement of internal monitors, a client's labor is augmented. Contractions are lasting greater than 90 seconds and occurring every 1½ minutes. The uterine resting tone is greater than 20 mm Hg with an atypical fetal heart rate and pattern. Which action should the nurse take first? You Selected: Turn off the oxytocin infusion. Correct response: Turn off the oxytocin infusion. Explanation: The client is experiencing uterine hyperstimulation from the oxytocin. The first intervention should be to stop the oxytocin infusion, which may be the cause of the long, frequent contractions, elevated resting tone, and abnormal fetal heart patterns. Only after turning off the oxytocin should the nurse turn the client to her left side to better perfuse the mother and fetus. Then she should increase the maintenance IV fluids to allow available oxygen to be carried to the mother and fetus. When all other interventions are initiated, she should notify the HCP. Remediation: Question 94 See full question While assessing a neonate at 4 hours after birth, the nurse observes an indentation with a small tuft of hair at the base of the neonate's spine. The nurse should document this finding as what finding? You Selected: spina bifida occulta Correct response: spina bifida occulta Explanation: A small tuft of hair and an indentation at the base of the neonate’s spine is termed spina bifida occulta. This condition usually occurs between the L5 and S1 vertebrae with failure of the vertebrae to completely fuse. There are usually no sensory or motor deficits with this condition. Spina bifida cystica includes meningocele, myelomeningocele, and lipomeningocele. Meningocele is characterized by a saclike protrusion filled with spinal fluid and meninges. Usually, this condition is associated with sensory and motor deficits. Myelomeningocele is characterized by a saclike protrusion filled with spinal fluid, meninges, nerve roots, and spinal cord. With myelomeningocele, there are usually sensory and motor deficits. Remediation: Question 95 See full question A client presents to a physician's office complaining of dyspnea with exertion, weakness, and coughing up blood. Further examination reveals peripheral edema, crackles, and jugular vein distention. The nurse anticipates the physician will make which diagnosis? You Selected: Pulmonary hypertension Correct response: Pulmonary hypertension Explanation: Dyspnea, weakness, hemoptysis, and right-sided heart failure are all signs of pulmonary hypertension. Clients with COPD present with chronic cough, dyspnea on exertion, and sputum production. Those with empyema are acutely ill and have signs of acute respiratory infection or pneumonia. Clients with pulmonary tuberculosis usually present with low-grade fever, night sweats, fatigue, cough, and weight loss. Remediation: Question 96 See full question A mother brings her 18-month-old child to the clinic because the child eats ashes, crayons, and paper. Which information would be most important to obtain about this toddler? You Selected: whether the toddler is experiencing changes in the home environment Correct response: whether the toddler is experiencing changes in the home environment Explanation: It is important to determine if the child is experiencing any change in the home environment that could cause anxiety that is relieved through oral gratification. A craving to eat nonfood substances is known as pica. Nutritional deficiencies, especially iron deficiency, were once thought to cause pica, but research has not substantiated this theory. Pica is unlikely to be caused by the growth spurts, the cutting of large teeth, or soft, low-roughage diets. Remediation: Question 97 See full question The nurse is caring for a client in labor who is 8 cm dilated. Which of the following interventions will the nurse include in the client's plan of care? Select all that apply. You Selected: Continue to encourage the client Offer ice chips as needed Encourage the client to push Correct response: Offer ice chips as needed Continue to encourage the client Explanation: During the transition phase (8–10 cm during labor), there is increased pain that will make the client withdrawn, irritable, and resistant to touch. Appropriate interventions are to offer ice chips as needed and continue to encourage the client. Giving IV medications this late in labor will not help with pain relief and cause respiratory depression in the fetus. Because of the state of the client, instruction during this time would not be appropriate and the client is not fully dilated to 10 cm and should not be encouraged to push. Remediation: Question 98 See full question During morning assessment, a nurse assesses four clients. Which client is the priority for follow up? You Selected: A 73-year-old client who has pneumonia with coarse crackles, is receiving 2 L/minute of oxygen, and has an I.V. line. Correct response: A 73-year-old client who has pneumonia with coarse crackles, is receiving 2 L/minute of oxygen, and has an I.V. line. Explanation: The 73-year-old client with pneumonia should be the nurse's priority because of the oxygenation complications and the audible crackles that may result from fluid overload from the I.V. line. The 42-year- old client is younger and more mobile than the others. The 84-year-old client doesn't have pressing needs at this time. The nurse should evaluate the 48-year-old client if he goes into atrial fibrillation, but he isn't a priority at this time. Question 99 See full question A client admitted with bacterial pneumonia develops a fever. Which of the following orders should the nurse implement first? You Selected: Obtain portable chest X-ray Correct response: Draw blood cultures from two sites Explanation: Blood cultures should be obtained before antibiotic administration in order to avoid altering the culture results—this is the priority. Both acetaminophen administration and portable chest x-ray can wait until the blood cultures are obtained and the antibiotics are started. Question 100 See full question When formulating a plan of care for the postterm neonate at discharge, which outcome would be most appropriate? You Selected: gain of 4 ounces (120 g) by the time of discharge Correct response: maintenance of normal body temperature Explanation: Hypothermia and temperature instability are primary problems in the postterm neonate, so maintaining a normal temperature pattern is the most appropriate goal. Postterm neonates have little subcutaneous fat, predisposing them to cold stress. Establishment of a deep respiratory pattern is inappropriate because all neonates tend to breathe in a shallow manner. A weight gain of 4 oz (120 g) may not be feasible because most neonates lose 5% to 15% of their birth weight during the first few days of life. All infants should be assessed for hyperbilirubinemia. Although polycythemia is common in postterm infants and may take a while to resolve, hyperbilirubinemia is not more common in the postterm neonate than it is in neonates born at term. Remediation: Question 101 See full question A multigravid client at 34 weeks' gestation with premature rupture of the membranes tests positive for group B streptococcus. The client is having contractions every 4 to 6 minutes. Her vital signs are as follows: blood pressure, 120/80 mm Hg; temperature, 100°F (37.8°C); pulse, 100 bpm; respirations, 18 breaths/minute. Which medication would the nurse expect the primary health care provider (HCP) to prescribe? You Selected: intravenous penicillin Correct response: intravenous penicillin Explanation: Because group B streptococcus is a gram-positive bacterium, the HCP probably will prescribe intravenous penicillin to treat the mother’s infection and prevent fetal infection. Gentamicin sulfate, which acts on gram-negative bacteria, would be inappropriate. Administering a corticosteroid, such as betamethasone, is inappropriate because the premature rupture of the membranes enhances fetal lung maturity. The lack of amniotic fluid causes early maturation of lung tissue. Cefaclor, which is available only in the oral form, is used for upper and lower respiratory tract infections and urinary tract infections by gram- negative staphylococci. Remediation: Question 102 See full question A physician orders meperidine, 1.1 mg/kg I.M., for a 16-month-old child who has just had abdominal surgery. When administering this drug, the nurse should use a needle of which size? You Selected: 23G Correct response: 23G Explanation: For an infant, the nurse should use a needle with the smallest appropriate gauge for the medication to be given. For an I.M. injection of meperidine, a 25G to 22G needle is appropriate. An 18G or 20G needle is too large, and the 27G needle too small. Remediation: Question 103 See full question A client at 36 weeks gestation has been admitted to the hospital for gestational hypertension. The client’s blood pressure is 188/98 mm Hg, and the client has no proteinuria. What is the priority nursing action at this time? You Selected: Perform relaxation techniques with the client and retake her blood pressure. Correct response: Notify the physician immediately. Explanation: Because of the markedly high blood pressure and the diagnosis, it is imperative that the physician is notified immediately. If it is outside of what is considered the appropriate parameters as decided by the physician, it is crucial that the nurse does not delay in notifying the physician. Therefore, it is inappropriate to wait another 15 minutes to rest and/or to recheck the client's blood pressure because doing so would delay communication and potentially put the client and baby at risk for negative health outcomes, including maternal seizure and fetal hypoxia or even death. In some situations, an emergency cesarean birth may be warranted if maternal and fetal conditions are deemed significantly compromised. It is appropriate to notify the charge nurse; however, the most immediate action should be to notify the physician. Remediation: Question 104 See full question A new antenatal G6, T4, P0, A1, L4 client attends her first prenatal visit with her partner. The nurse is assessing this couple's psychological response to their pregnancy. Which finding requires the most immediate follow up? You Selected: The father of the baby is irritated that the mother is not like she was before pregnancy. Correct response: The father of the baby is irritated that the mother is not like she was before pregnancy. Explanation: Pregnancy creates changes in the mother and father. Being considerate, accepting changes, and being supportive of the current situation are considered acceptable responses by the father, rather than feeling irritation about these changes. Expressing concern with the financial changes pregnancy and an expanded family include is normal. The first trimester involves the client and family feeling ambivalent about pregnancy and moving toward acceptance of the changes associated with pregnancy. Maternal acceptance of the pregnancy and a subsequent change in her focus are normal occurrences. Remediation: Question 105 See full question The nurse is admitting a client to the emergency department with symptoms of posttraumatic stress disorder (PTSD) after being in an earthquake. Which findings should the nurse anticipate? Select all that apply. You Selected: Has fears and anxiety over various things Experiences sleep disturbances and nightmares Hyper vigilance and poor concentration Correct response: Hyper vigilance and poor concentration Experiences sleep disturbances and nightmares Has fears and anxiety over various things Explanation: Survivors of earthquakes and other events outside the range of usual human experience produces significant distress in many people. PTSD is called that disorder in those people with the following symptoms: re-experiencing the event,nightmares,anxiety,phobias and marked arousal. Someone with symptoms of physical limitations and disabilities could have any number of problems but not PTSD. A person with PTSD may have memory problems related to the trauma but not to important information as their name or address. This maybe seen in someone with a dissociative disorder. Remediation: Question 106 See full question A home health nurse who sees a client with diverticulitis is evaluating teaching about dietary modifications necessary to prevent future episodes. Which statement by the client indicates effective teaching? You Selected: "I should increase my intake of fresh fruits and vegetables during remissions." Correct response: "I should increase my intake of fresh fruits and vegetables during remissions." Explanation: A client with diverticulitis needs to modify fiber intake to effectively manage the disease. During episodes of diverticulitis, he should follow a low-fiber diet to help minimize bulk in the stools. A client with diverticulosis should follow a high-fiber diet. Clients with diverticular disease don't need to modify their intake of protein and omega-3 fatty acids. Remediation: Question 107 See full question A client with a partial thickness burn injury has had Biobrane applied two weeks ago. The Biobrane is now separating from the wound. What nursing intervention is appropriate? You Selected: Trim away the Biobrane that has separated from the wound. Correct response: Trim away the Biobrane that has separated from the wound. Explanation: It is normal for the Biobrane to separate as the wound heals. It should be trimmed away as it separates. There is no need to apply a new dressing to the healing skin. The Biobrane should not be forcibly removed. It will slowly release as healing occurs. Remediation: Question 108 See full question As a client is being admitted to the facility, her husband asks the nurse why she must sign a statement confirming that she has been told of her rights to communicate her wishes about life support and resuscitation. How should the nurse respond? You Selected: "We make sure our clients know they have the right to specify advance directives and appoint someone to speak for them." Correct response: "We make sure our clients know they have the right to specify advance directives and appoint someone to speak for them." Explanation: Telling the client's husband that clients have the right to specify advance directives and appoint someone to speak for them provides factual information. The other options don't answer the husband's question or provide the information he requested. Remediation: Question 109 See full question The nurse is receiving shift report on four clients on an antenatal unit. The four clients are: (1) a 35-week- gestation mother with severe preeclampsia started on a maintenance dose of magnesium sulfate 1 hour ago; (2) a 30-week-gestation client with preterm labor on an oral tocolytic and having no contractions in 6 hours; (3) a hyperemesis client with emesis 4 times in the past 12 hours; and (4) a 33-week-gestation client with placenta previa who began to feel pelvic pressure during change of shift report. Which action should the nurse take first? You Selected: Assess the client with preterm labor for tolerance of tocolytics and the labor pattern. Correct response: Evaluate the placenta previa client without an exam. Explanation: The first action taken should be to evaluate the placenta previa client who has pelvic pressure. The pelvic pressure may be caused by a fetal head creating pressure in the pelvis indicating a potential birth. This client should be evaluated without a pelvic exam and then consult with the health care provider (HCP). A vaginal exam is contraindicated as it may stimulate bleeding of the placenta. The second action would be to complete an assessment on the client with preeclampsia and her fetus to evaluate for tolerance and effectiveness of the magnesium sulfate. The hyperemesis client needs to be evaluated for hydration status and for medication. The preterm labor client is stable on the oral medication and should be seen last. Question 110 See full question The pediatric nurse is providing care for an infant who has been diagnosed with respiratory syncytial virus (RSV). What action best prevents the spread of this infectious microorganism? You Selected: Wear a face mask when in close contact with the client. Correct response: Wear a face mask when in close contact with the client. Explanation: RSV infection necessitates droplet precautions, including the use of a facemask. Goggles are not normally included in droplet precautions. It is important to educate family members and visitors about the need for hand hygiene, but the similarities and differences between the two different methods of performing hand hygiene are not a priority. Antiviral medications such as ribavirin are not commonly used, and they do not directly prevent the spread of the infection. Remediation: Question 111 See full question The telemetry unit nurse is caring for a client who was just transferred from the coronary care unit (CCU). The client is anxious because he fears he will not be monitored as closely as he was in the CCU. How can the nurse allay his fears? You Selected: Remind the client he would not have been moved out of CCU if he was not stable. Correct response: Assign the same nurse to the client when possible. Explanation: Assigning the same nurse to the client when possible provides continuity of care and stability, thereby reducing his anxiety. An anxiolytic might be counter-productive and "overkill," he needs reassurance first. The client might have been the "most stable" choice in the event of an urgent need for a CCU bed. A room close to nurses' station would provide this client with a sense of security because the nurses are close by in the event of an emergency. Remediation: Question 112 See full question A client is admitted to the emergency department with severe epistaxis. The health care provider inserts posterior packing. Later, the client is anxious and says they do not feel they are breathing right. Which nursing action is priority? You Selected: Use a flashlight and inspect the client’s posterior oral cavity Correct response: Use a flashlight and inspect the client’s posterior oral cavity Explanation: The nurse must assess the patency of the client’s airway. The packing might have become dislodged. The nurse shouldn’t remove the packing or give the client false reassurance. The client is too anxious to explain what they mean. Question 113 See full question A 17-year-old male client is being admitted to the adolescent psychiatric unit. He was brought in by the police after beating up two male peers. The client says, "They said I was gay because I had sex with an older neighbor when I was 8 years old. I am not gay!" Which nursing interventions would be appropriate? Select all that apply. You Selected: Ask the client if he would like to attend a support group. Assist the client in processing his feelings about the sexual abuse. Monitor the client's level of anger and potential aggression. Help the client express anger safely. Correct response: Monitor the client's level of anger and potential aggression. Help the client express anger safely. Assist the client in processing his feelings about the sexual abuse. Ask the client if he would like to attend a support group. Explanation: Safety of others is a priority, and the nurse must monitor the client’s anger and potential for aggression. The nurse should also find safe ways for the client to express the client’s anger and any other feelings about the abuse. A referral to a support group is appropriate because anger management groups are one way to assist the client in learning to manage anger. Nothing about jail is mentioned in the question. Discussion of jail does not help the client address the client’s issues with anger and the abuse causing the anger. Remediation: Question 114 See full question The nurse is instructing the spouse of a client who had an incision and drainage procedure for an abscess how to care for the wound at home. The nurse should instruct the spouse to: You Selected: clean both sites independently. Correct response: clean both sites independently. Explanation: The sites should be treated as separate sites to avoid cross contamination. This adheres to the principle of cleaning from the least contaminated area to the most contaminated area. Each site is considered a separate area for wound care. Question 115 See full question A parent of a 7-year-old child with Hirschsprung’s Disease and chronic constipation asks about increasing dietary fiber in the child’s diet. Which food could the nurse recommend? You Selected: popcorn Correct response: popcorn Explanation: Popcorn is high in fiber. Foods high in fiber help the bowels move. Constipation may be managed initially with increased fiber and fluids. White bread, fruit juice and pancakes are foods that are not high in fiber. Question 116 See full question A nurse is caring for a client with burns on his legs. Which nursing intervention will help to prevent contractures? You Selected: Applying knee splints Correct response: Applying knee splints Explanation: Applying knee splints prevents leg contractures by holding the joints in a functional position. Elevating the foot of the bed doesn't prevent contractures. Hyperextending a body part for any length of time is inappropriate; doing so can cause contractures. Performing shoulder ROM exercises can prevent contractures in the shoulders but not in the legs. Remediation: Question 117 See full question A client with type 1 diabetes mellitus must learn how to self-administer insulin. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction? You Selected: "Rotate injection sites among different regions." Correct response: "Rotate injection sites within the same anatomic region." Explanation: The nurse should instruct the client to rotate injection sites within the same anatomical regions. The other answers are incorrect and would lead to changes in absorption. Remediation: Question 118 See full question A client with multiple sclerosis (MS) is receiving discharge instructions from the nurse. Which of the following statements by the client indicates that more instruction is required? You Selected: “I will watch my feet while walking.” Correct response: “I will walk with my feet close together.” Explanation: Clients with multiple sclerosis should walk with their feet wider apart, not close together to facilitate balance and reduce the risk of falls. The other options are correct statements as watching one’s feet while walking is beneficial to clients with MS. A voiding time schedule helps to prevent any episodes of incontinence. Dysphagia is a potentially serious complication and should be reported to the client’s primary healthcare provider. Remediation: Question 119 See full question The experienced licensed practical/vocational nurse (LPN/VN) under the supervision of the registered nurse (RN) team leader is providing nursing care for an infant with respiratory syncytial virus (RSV). Which tasks are appropriate for the RN to delegate to the LPN/VN? Select all that apply. You Selected: Auscultate breath sounds. Check oxygen saturation using pulse oximetry. Administer prescribed aerosolized medications. Correct response: Auscultate breath sounds. Administer prescribed aerosolized medications. Check oxygen saturation using pulse oximetry. Explanation: LPN/VNs work collaboratively with colleagues in health care to assess, plan, and deliver quality nursing services. The experienced LPN/VN is capable of gathering data and observations including breath sounds and pulse oximetry. Administering medications, such as aerosolized medications, is within the scope of practice for the LPN/LVN. The actions that are within the scope of practice for the professional RN include independently completing the admission assessment, initiating the nursing care plan, and evaluating a parent’s abilities, as these activities require additional education and skills. Remediation: Question 120 See full question A preschooler with pneumococcal meningitis is receiving intravenous antibiotic therapy. When discontinuing the intravenous therapy, the nurse allows the child to apply a dressing to the area where the catheter is removed. The nurse’s rationale for doing so is based on the interpretation that a child in this age group has a need to accomplish which goal? You Selected: Protect the image of an intact body. Correct response: Protect the image of an intact body. Explanation: Preschool-age children worry about having an intact body and become fearful of any threat to body integrity. Allowing the child to participate in required care helps protect her image of an intact body. Development of trust is the task typically associated with infancy. Additionally, allowing the child to apply a dressing over the intravenous insertion site is unrelated to the development of trust. Finding diversional activities is not a priority need for a child in this age group. Separation anxiety is more common in toddlers than in preschoolers. Question 121 See full question A client with a large goiter is scheduled for a subtotal thyroidectomy to treat thyrotoxicosis. Saturated solution of potassium iodide (SSKI) is prescribed preoperatively for the client. The expected outcome of using this drug is that it helps: You Selected: increase the body's ability to excrete thyroxine. Correct response: reduce the vascularity of the thyroid gland. Explanation: SSKI is frequently administered before a thyroidectomy because it helps decrease the vascularity of the thyroid gland. A highly vascular thyroid gland is very friable, a condition that presents a hazard during surgery. Preparation of the client for surgery includes depleting the gland of thyroid hormone and decreasing vascularity. SSKI does not decrease the progression of exophthalmos, and it does not decrease the body’s ability to store thyroxine or increase the body’s ability to excrete thyroxine. Remediation: Question 122 See full question A client has a history of osteoarthritis. Which signs and symptoms should the nurse expect to find on physical assessment? You Selected: Swelling, joint pain, and tenderness on palpation Correct response: Joint pain, crepitus, Heberden's nodes Explanation: Clinical findings for osteoarthritis include joint pain, crepitus, Heberden's nodes (bony growths at the distal interphalangeal joints), Bouchard's nodes (growths involving the proximal interphalangeal joints), and enlarged joints. The joint pain occurs with movement and is relieved by rest. As the disease progresses, pain may also occur at rest. Bouchard's nodes involve the proximal interphalangeal joints. Hot, inflamed joints rarely occur in osteoarthritis. Tophi are deposits of sodium urate crystals that occur in chronic gout — not osteoarthritis. Swelling, joint pain, and tenderness on palpation occur with a sprain injury. Remediation: Question 123 See full question A nurse is planning staffing for a nursing unit in which the primary need of the clients is learning how to manage their health problems. Which combination is the ideal mix of staff for this unit? You Selected: one LPN/VN and two unlicensed assistive personnel (UAPs) Correct response: three registered nurses (RNs) Explanation: The ideal staffing for a nursing unit focused on client teaching and learning is to have three registered nurses. It is within the scope of practice for the RN to assess, plan, implement, coordinate, and evaluate client learning. It is not within the scope of practice for LPNs/VNs and UAP to provide client teaching. Remediation: Question 124 See full question A nurse is providing dietary teaching for the parents of a child with celiac disease. Which statement by the parents indicates effective teaching? You Selected: "Our child should avoid eating rice." Correct response: "Our child should avoid eating prepared puddings." Explanation: Teaching is effective if the parents identify prepared puddings as a food their child should avoid. A child with celiac disease mustn't consume foods containing gluten and therefore should avoid prepared puddings, commercially prepared ice cream, malted milk, and all food and beverages containing wheat, rye, oats, or barley. The other options don't contain gluten and are permitted on a gluten-free diet. Remediation: Question 125 See full question A postpartum client has a temperature of 99.8° F (37.7.° C) during the first 24 hours after birth. Which nursing intervention is appropriate? You Selected: Encourage more fluid intake. Correct response: Encourage more fluid intake. Explanation: A slight temperature elevation from dehydration is common during the first 24 hours after giving birth. Infection should be suspected if the client's temperature exceeds 100.4° F (38° C) for 2 successive days after giving birth, excluding the first 24 hours. A slightly elevated temperature isn't an indication for the nurse to assess for odor in the lochia, breast-abnormalities, or puerperal infection. Remediation: Question 126 See full question The nurse is preparing to obtain an arterial blood gas (ABG) sample on a client. Which action should the nurse take first? You Selected: Perform an Allen’s test Correct response: Perform an Allen’s test Explanation: An Allen’s test to assess circulation should be performed first. Next, hands should be washed, gloves applied, and a rolled towel should be placed under the client’s wrist for support. The artery should be located, and assessed for a strong pulse. The puncture site should be cleaned with an alcohol or povidone-iodine pad. The artery should be palpated with the index and middle fingers of one hand while holding the syringe over the puncture site with the other hand. Holding the needle bevel at a 30 to 45- degree angle, the skin and arterial wall should be punctured in one smooth motion. Blood should backflow into the syringe to the 5-ml mark. After collecting the sample, press a gauze pad over the puncture site for at least five minutes. Question 127 See full question The client with peripheral vascular disease and a history of hypertension is to be discharged on a low-fat, low-cholesterol, low-sodium diet. Which should be the nurse's first step in planning the dietary instructions? You Selected: Assess the family's food preferences. Correct response: Assess the family's food preferences. Explanation: Before beginning dietary interventions, the nurse must assess the client's pattern of food intake, life style, food preferences, and ethnic, cultural, and financial influences. Remediation: Question 128 See full question After leading a class on intimate partner violence, which characteristic of abusers, if identified by the participants, would reflect the need for more teaching? You Selected: They often are college graduates with stable work histories. Correct response: They have empathetic relationships with partners. Explanation: Lack of empathy characterizes relationships in abusive families. It is more likely that the relationship is built around the abuser’s need for power and control. A history of family violence and low self-esteem are common among abusers. The idea that only poorly educated, poorly employed men are abusive is a myth. Batterers are more likely to abuse alcohol than to abstain from substances. Remediation: Question 129 See full question When developing a series of parent classes on fetal development, the nurse should include which feature as being developed by the end of the third month (9 to 12 weeks)? You Selected: external genitalia Correct response: external genitalia Explanation: Although sex is not easily discerned at 9 to 12 weeks, external genitalia are developed at this period of fetal development. Myelinization of the nerves begins at about 20 weeks' gestation. Brown fat stores develop at approximately 21 to 24 weeks. Air ducts and alveoli develop later in the gestational period, at approximately 25 to 28 weeks. Question 130 See full question An unemployed client, age 24, seeks help because she feels depressed and abandoned and doesn't know what to do with her life. She says she has quit her last five jobs because her coworkers didn't like her. Last week, her boyfriend broke up with her after she drove his car into a tree after an argument. The client's initial diagnosis is borderline personality disorder. Which behaviors by the client threaten the nurse-client relationship? You Selected: Low self-esteem, strong dependency needs, and impulsiveness Correct response: Low self-esteem, strong dependency needs, and impulsiveness Explanation: Borderline personality disorder is characterized by lack of self-esteem, strong dependency needs, and impulsive behavior. Instability in interpersonal relationships and mood and poor self-image are also common. Clients can't usually tolerate being alone and they express feelings of emptiness or boredom. Flat affect, social withdrawal, and unusual dress are characteristic of schizoid personality disorder. Suspiciousness, hypervigilance, and emotional coldness are seen in paranoid personality disorders. In antisocial personality disorder, clients are usually insensitive to others and act out sexually; they may also be violent. Remediation: Question 131 See full question A nurse is supervising a new nurse who is preparing to perform wound care for a client whose abdominal wound is infected with vancomycin-resistant enterococci. The supervising nurse should make sure that the new nurse: You Selected: wears a gown, gloves, a mask, and eye protection when entering the client's room. Correct response: wears a gown, gloves, a mask, and eye protection when entering the client's room. Explanation: Caring for client infected with vancomycin-resistant enterococci requires contact precautions. The nurse should wear a gown, gloves, a mask, and eye protection when entering the client's room. Gloves are most contaminated, so she should remove them first when exiting the room to prevent infection transmission. The nurse should assemble all needed supplies before putting on personal protective equipment and entering the client's room. Remediation: Question 132 See full question A child has been exposed to varicella. Which precaution should the nurse institute for infection control? You Selected: airborne precautions Correct response: airborne precautions Explanation: Children with varicella or suspected varicella should be treated under airborne precautions in addition to standard precautions. Varicella is transmitted by airborne nuclei. Droplet precautions are indicated for conditions such as pertussis, meningococcal pneumonia, and rubella. Contact precautions are indicated for conditions such as draining major abscesses, acute viral conjunctivitis, and Clostridium difficile gastroenteritis. Indirect contact is not a method of controlling infection. Rather, it is a mode of transmission involving contamination via some intermediate object, such as an instrument, needle, or dressing, or by hands that are not washed or gloves that are not changed between clients. Remediation: Question 133 See full question A 5-year-old preschooler suspected of having leukemia is admitted to the hospital for diagnosis and treatment. The physician orders a bone marrow aspiration. Place the interventions below in ascending chronological order according to their importance. Use all options. You Selected: Discuss the procedure with his parents. Check the biopsy site for hemorrhage and infection. Explain the discomforts he'll feel. Act out the procedure using a doll and biopsy kit. Assure the child that the pain will go away. Correct response: Discuss the procedure with his parents. Act out the procedure using a doll and biopsy kit. Explain the discomforts he'll feel. Assure the child that the pain will go away. Check the biopsy site for hemorrhage and infection. Explanation: The nurse must first discuss the procedure with the parents and encourage them to get involved with the plan for preparing the child. Next, the nurse should use play to teach the child about the procedure to help gain the child's confidence and put the child at ease. After the child is comfortable, the nurse can explain the discomfort he'll feel and then assure him that the pain will go away. Lastly, after the procedure, the nurse needs to check for bleeding, inflammation, and signs and symptoms of pain and infection. Remediation: Question 134 See full question The nurse is instructing parents how to tell if their child is using cocaine. The nurse should tell the parents: You Selected: "His pupils would be large." Correct response: "His pupils would be large." Explanation: Cocaine use causes pupils to dilate. Marijuana causes eyes to be red and appear bloodshot. Heroin causes pupils to be pinpoints. Having tired-looking eyes would not necessarily be caused by drug use. Remediation: Question 135 See full question In an initial screening for lead poisoning, a 2-year-old child is found to have a lead level just above 10 mcg/dL (0.48 µmol/L). The nurse should: You Selected: educate parents on ways to reduce lead in the environment. Correct response: educate parents on ways to reduce lead in the environment. Explanation: Treatment for children with minimally elevated lead levels should include family lead education, follow- up testing, and a social service consultation if needed. Waiting 6 months for a follow-up screening is too long because the effects of lead are irreversible. Oral chelation therapy is not begun until levels approach 45 mcg/dL (2.2 ?mol/L). There is no such thing as a “normal” lead level because there is no beneficial action in the body. Remediation: Question 136 See full question A client with a contusion has been admitted for observation following a motor vehicle accident when he was driving his pregnant wife to the hospital. The next morning, instead of asking about his wife and baby, he asked to see the football game on television that he thinks is starting in 5 minutes. He is agitated because the nurse will not turn on the television. What should the nurse do next? Select all that apply. You Selected: Ask the client if he has a headache. Determine if the client's pupils are equal and react to light. Correct response: Determine if the client's pupils are equal and react to light. Ask the client if he has a headache. Explanation: The nurse should determine if the client’s pupils are equal and react to light, and ask the client if he has a headache. Confusion, agitation, and restlessness are subtle clinical manifestations of increased intracranial pressure (ICP). At this time, it is not appropriate for the nurse to find a television or arrange for the client to see his wife and baby. Administering a sedative at this time will obscure assessment of increased ICP. Remediation: Question 137 See full question A nurse is caring for an infant with an intravenous (IV) line in the antecubital space. Which of the following findings would cause the nurse to intervene? Select all that apply. You Selected: Blood in the IV line when the intravenous solution is lowered below the arm Antecubital area that is cool to the touch Edematous site Correct response: Antecubital area that is cool to the touch Infant bending his arm freely Edematous site Explanation: The nurse should use a padded board because it is adequate to secure the extremity. A jacket restraint is not needed when the nurse needs only to secure the arm with the IV. Restraining all four extremities can be harmful and uncomfortable for the child. Restraining the extremity to the bed's side rail limits the child's movement; the child may bang against the rail and cause injury. Allowing the extremity to be loose increases the risk that the IV will infiltrate or be dislodged by the infant. Remediation: Question 138 See full question A nurse is admitting a client who fears being embarrassed in the presence of others and avoids being around people. Which of the following outcomes should the nurse promote for this client? Select all that apply. You Selected: Manage the client's fear in group situations Develop a plan for responding to stressful situations Verbalize feelings that occur in stressful situations Correct response: Manage the client's fear in group situations Verbalize feelings that occur in stressful situations Develop a plan for responding to stressful situations Explanation: The client has social anxiety disorder. In this disorder, the person has an intense fear of being embarrassed by others. Sometimes this leads to avoidance or panic attacks. Appropriate outcomes are to be able to manage the fear, verbalizing feelings, and anticipate and plan for stressful situations are all adaptive responses to stress. Avoidance, denial, and suppression are maladaptive defense mechanisms. Remediation: Question 139 See full question The client is receiving propantheline bromide to treat cholecystitis. The nurse should evaluate the client's response to the medication by observing for which adverse effect? You Selected: urine retention Correct response: urine retention Explanation: Propantheline bromide is an anticholinergic drug. Common adverse effects include urine retention and constipation; flushed, dry skin; and dry mouth, nose, and throat. Orthostatic hypotension may also occur. Diarrhea and diaphoresis are adverse effects of cholinergic drugs. Remediation: Question 140 See full question A nurse is caring for a client diagnosed with pneumonia, a urinary tract infection, dehydration, and temperature of 101.4°F;(38.6°C;). The health care provider orders 1,000 ml of D5W to infuse over 8 hours. The available drop factor is 20 gtt/ml. The nurse would regulate the intravenous flow rate to deliver how many drops per minute? Round your answer to the nearest whole number. Your Response: 42 Correct response: 42 Explanation: Calculate the flow rate using the formula below: (Total volume ordered) ÷(Number of hours) = Flow rate 1,000 ml/8 hours = 125 ml/h 125 ml/h X 1 h/60 min X 20 gtt/ml = 42 gtt/h. Remediation: Question 141 See full question The nurse is caring for a client newly diagnosed with human immunodeficiency virus (HIV) obtained from unprotected sex. The nurse is in the room when the client is explaining the disease to another person. Which statement by the client would the nurse clarify? Select all that apply. You Selected: “Medications can cure the disease.” “I am afraid that I will give this disease to my nephew.” Correct response: “I am afraid that I will give this disease to my nephew.” “Medications can cure the disease.” Explanation: Human immunodeficiency virus (HIV) is a sexually transmitted infection. Casual contact such as that with a family member will not spread the disease.Unfortunately, at this time, there is no cure for the disease. The client is correct in stating that sexual practices will have to change to prevent further spread of the disease, the disease can be spread by body fluids and can also be passed on to a fetus. Question 142 See full question A parent of a 7-year-old diagnosed with attention deficit hyperactivity disorder (ADHD) since he was 5 years old is talking to the nurse about her concerns about the son’s physical condition. The parent states that his medication, methylphenidate extended release, controls his symptoms well but is causing him to lose weight. It is difficult to get him up and ready for school in the morning unless he is given the medication as soon as he awakens. He does not eat breakfast or very much of his lunch at school; he eats dinner, but only an average amount of food. He has lost 3 lb (1.4 kg) in the last 2 weeks. Which action should the nurse suggest the parent do first? You Selected: Have the child eat a breakfast bar, banana, and a glass of milk at the same time he takes medication every morning. Correct response: Have the child eat a breakfast bar, banana, and a glass of milk at the same time he takes medication every morning. Explanation: Because weight loss is a common side effect of methylphenidate and because the child’s symptoms are controlled with the stimulant, the first action should be to increase the child’s oral intake before the medication’s side effects begin. Weight should be monitored, but since the child has already lost weight, a remedy is needed as well as monitoring. The weight loss is directly due to the medication’s side effects, so the child will continue to lose weight unless an intervention is made whether or not he is enrolled in school or on summer vacation. A high-protein drink could work, but then the child is taking in all his calories in the evening, which is not best nutritionally. A change of medication should be the last resort since methylphenidate is the most effective medication for ADHD and has been successful with this child. Remediation: Question 143 See full question A client being treated for complications of chronic obstructive pulmonary disease needs to be intubated. The client has previously discussed his wish to not be intubated with his girlfriend of 5 years, whom he's designated as his health care power of attorney. The client's children want their father to be intubated. A nurse caring for this client knows which of the following? Select all that apply. You Selected: The health care power of attorney will insure the client's wishes are carried out. Clients commonly confer health care power of attorney on someone who shares their personal values and beliefs. Correct response: Clients commonly confer health care power of attorney on someone who shares their personal values and beliefs. The health care power of attorney will insure the client's wishes are carried out. Explanation: The health care power of attorney is someone who can make decisions when the client cannot. That person is selected by the client. Question 144 See full question A nurse is preparing to help a client with weakness in his or her right leg move from the bed to a chair. Where should the nurse place the chair? You Selected: Perpendicular to the bed on the right side Correct response: 45 degrees to the bed on the left side Explanation: The nurse should place the wheelchair at a 45 degree angle or parallel to the bed on the client’s strong side to help prevent a fall. The nurse should not place the chair perpendicular to the bed because the client won't be able to support his weight on his right leg. Remediation: Question 145 See full question A child who has been treated for an acute episode of bronchial asthma is ready for discharge. The nurse is instructing the parents on medications that the child will need at home for the long-term treatment of asthma. Which of the following medications should the nurse expect to review with the parents regarding long-term treatment of the child’s asthma? You Selected: Montelukast Correct response: Montelukast Explanation: Leukotriene modifiers, such as montelukast, are the only long-term medications listed. They block inflammatory and bronchospasm effects and are not used to treat acute episodes. Oral systemic corticosteroids are used to treat moderate to severe exacerbations. They prevent progression and relapses to gain control of severe persistent asthma (3- to 10-day course). Anticholinergic agents block efferent vagal pathways that cause bronchoconstriction, and ß-adrenergic agonists are short-acting agents used to treat clients with acute attacks but are not recommended for daily use. Remediation: Question 146 See full question The nurse should integrate which principle when a client’s mental status interferes with the ability to participate in milieu activities? You Selected: balance. Correct response: schedule modification Explanation: When a client’s mental status interferes with the ability to participate in milieu activities, the nurse uses schedule modification to allow a flexible approach to treatment. Flexibility on the part of the nurse and the entire milieu is a necessary aspect of a therapeutic milieu. Norms, structure, and balance are necessary for an effective, therapeutic milieu. Norms are expectations of behavior that are communicated to clients in direct and indirect ways. Structure is the framework for the therapeutic environment. Balance refers to the negotiating of dependence versus independence found in psychiatric care. Remediation: Question 147 See full question A client who has ulcerative colitis has persistent diarrhea and has lost 12 lb (5.5 kg) since the exacerbation of the ulcerative colitis. Which approach will be most effective in helping the client meet nutritional needs? You Selected: total parenteral nutrition (TPN) Correct response: total parenteral nutrition (TPN) Explanation: Food will be withheld from the client with severe symptoms of ulcerative colitis to rest the bowel. To maintain the client’s nutritional status, the client will be started on TPN. Enteral feedings or dividing the diet into six small meals does not allow the bowel to rest. A high-calorie, high-protein diet will worsen the client’s symptoms. Remediation: Question 148 See full question The nurse is caring for an adolescent client who was brought to a mental health clinic by the parents. Upon interviewing the parents, the nurse is informed that the client has lost interest in activities, has experienced falling grades, and sleeps all day, all of which have become worse over the past 2 to 3 years. Which statement by the parents is of most concern to the nurse? You Selected: “We have had siblings who suffer from depression.” Correct response: “We feel that this is just a case of the blues.” Explanation: Downplaying the significance of the adolescent’s symptoms indicates that the parents need more detailed health teaching. The symptoms have become persistent and disruptive, and they interfere with social activities, interests, schoolwork, and family life. The symptoms suggest that the adolescent is suffering from depression. Remediation: Question 149 See full question A nurse is caring for a client newly diagnosed with hepatitis A. Which statement by the client indicates the need for further questioning and teaching? You Selected: "Sometimes I forget to wash my hands when I help in my child's preschool classroom." Correct response: "My partner had an affair years ago which caused us a lot of problems." Explanation: The client requires further teaching if they suggest that Hepatitis A was acquired through sexual contact. Hepatitis A is transmitted by the oral-fecal route or through ingested food or liquid that's contaminated with the virus. Hepatitis A is rarely transmitted through sexual contact. Clients with hepatitis A need to take every effort to avoid spreading the virus to other members of their family with precautions, such as preparing food carefully, washing hands often, and taking medications as ordered. Remediation: Question 150 See full question The nurse judges that the mother understands the diet restrictions for her child with chronic renal failure who is receiving peritoneal dialysis when she reports providing a diet involving which components? You Selected: protein and phosphorus restrictions Correct response: protein and phosphorus restrictions Explanation: Regulation of the diet is the most effective means, besides dialysis, for reducing renal excretion. Dietary phosphorus is restricted, which reduces the protein load on the kidneys. Clients are also given substances to bind phosphorus in the intestines to prevent absorption. Limited protein in the diet should include foods high in essential amino acids. Foods high in fat and carbohydrate are used to increase caloric intake. Sodium and water may not be restricted because of the continual loss of sodium and water through the dialysate. Iron-rich foods are commonly high in protein. Remediation: Question 151 See full question A client has been prescribed digoxin to increase the heart’s ability to contract effectively. The nurse is teaching a client about common side effects of digoxin. Of which side effects should this client be aware? Select all that apply. You Selected: Dizziness Anxiety Headache Diarrhea Correct response: Dizziness Anxiety Headache Diarrhea Explanation: Inotropic agents such as digoxin can trigger common side effects such as dizziness, anxiety, headache, and diarrhea. Changes in mood and alertness that include confusion and depression, rather than hyperactivity, may be observed. Weight loss is not associated with cardiac glycosides. The client should be instructed to notify their health care provider if any of these side effects become severe. Remediation: Question 152 See full question A client is admitted to the psychiatric unit with a diagnosis of unipolar disorder. When the client doesn't respond to antidepressant drugs, the physician orders electroconvulsive therapy (ECT). The mechanism of action for ECT is: You Selected: similar to that of antidepressant drugs. Correct response: unknown. Explanation: The exact mechanism of action of ECT is unknown, although various theories exist. One theory, which isn't widely accepted among medical authorities, suggests that a depressed client's underlying guilt feelings are relieved by the perception of ECT as a punishment. Another suggests that ECT increases the levels of certain chemicals in the brain, such as the neurotransmitters acetylcholine, norepinephrine, and serotonin. Although authorities agree that ECT doesn't cause permanent brain damage, they don't necessarily recognize a connection between increased chemical levels in the brain and ECT. No similarity between the action of ECT and that of antidepressant medication has been proven. Remediation: Question 153 See full question A child has been admitted to the hospital following a severe concussion. Which nursing interventions are important while caring for this child? Select all that apply. You Selected: Implement seizure precautions Keep the head of the bed slightly elevated Frequently assess vital and neurological signs Correct response: Implement seizure precautions Frequently assess vital and neurological signs Keep the head of the bed slightly elevated Explanation: Seizure precautions are an important safety measure. Frequent assessment of vital and neurological signs are important to detect any deterioration in condition. Bed rest with the head slightly elevated will minimize headache and reduce ICP. Heavy sedation is contraindicated as this may mask signs of deterioration in condition. There is no indication for NPO status. Remediation: Question 154 See full question Which hormonal effects do antipsychotic medications have? You Selected: Retrograde ejaculation and gynecomastia Correct response: Retrograde ejaculation and gynecomastia Explanation: Antipsychotic medications can cause decreased libido, retrograde ejaculation, and gynecomastia. Reassure the client that the effects can be reversed or that his physician may be able to change his medication. Polydipsia, akinesia, and dysphasia aren't hormonal effects. Question 155 See full question Oral methylprednisolone was recently started for a 10-year-old client with asthma. He begins to vomit and reports that his stomach hurts. Which nursing intervention is appropriate? You Selected: Take no action; methylprednisolone can cause nausea Correct response: Call the health care provider to change the medication form to IV Explanation: Nausea and GI upset are adverse effects of methylprednisolone. The treatment of asthma requires treatment of the inflammation that is a hallmark of the disease. If the child cannot tolerate oral corticosteroids, an IV dose is warranted. Remediation: Question 156 See full question The nurse is planning care with the parents of a child who requires continuous peritoneal dialysis. Which finding should be discussed with the health care provider (HCP)? You Selected: The child reports having a previous surgery for a ruptured appendix. Correct response: The child reports having a previous surgery for a ruptured appendix. Explanation: A client who has had a ruptured appendix may have peritoneal scarring that may alter the effectiveness of treatment. Living a long distance from a medical facility is typically a reason to select peritoneal dialysis. Attending a large school is not a problem, but the school nurse needs to be included as part of the health care team. Typically the treatment schedule can be planned to allow for uninterrupted sleep at night. Remediation: Question 157 See full question A nurse is assessing a client’s extraocular eye movements as part of evaluating neurological functioning. Which cranial nerve status is documented? Select all that apply. You Selected: Oculomotor (III). Abducens (VI). Trochlear (IV). Correct response: Oculomotor (III). Trochlear (IV). Abducens (VI). Explanation: Assessing extraocular eye movements helps evaluate the function of cranial nerves III (oculomotor), IV (trochlear), and VI (abducens). The oculomotor nerve originates in the brain stem and controls the movement of the eyeball up, down, and inward; raises the eyelid; and constricts the pupil. The trochlear nerve rotates the eyeball downward and outward. The abducens nerve originates in the pons and rotates the eyeball laterally. Assessing the client’s vision helps evaluate cranial nerve II (optic). Cranial nerve V (trigeminal) has three branches: assessing the corneal reflex helps the nurse evaluate the ophthalmic branch functions; assessing sensation to the cheek, upper jaw, teeth, lips, hard palate, maxillary sinus, and part of the nasal mucosa helps evaluate the maxillary branch functions; and assessing sensation to the lower lip, chin, ear, mucous membrane, lower teeth, and tongue helps evaluate the mandibular branch functions. Assessing hearing and balance helps evaluate the cochlear and vestibular branches of cranial nerve VIII (acoustic). Question 158 See full question Which of the goals is collaboratively established by the client with Parkinson's disease, nurse, and physical therapist? You Selected: to maintain joint flexibility Correct response: to maintain joint flexibility Explanation: The primary goal of physical therapy and nursing interventions is to maintain joint flexibility and muscle strength. Parkinson’s disease involves a degeneration of dopamine-producing neurons; therefore, it would be an unrealistic goal to attempt to build muscles or increase endurance. The decrease in dopamine neurotransmitters results in ataxia secondary to extrapyramidal motor system effects. Attempts to reduce ataxia through physical therapy would not be effective. Remediation: Question 159 See full question The nurse should instruct the client who has had nasal surgery to implement which nasal care measure after the nasal packing is removed? You Selected: Irrigate the nares with normal saline solution daily. Correct response: Lubricate the membranes with a water-soluble lubricant. Explanation: A water-soluble lubricant offsets dryness and enhances comfort during healing. The lubricant also prevents secretions from drying and crusting in the nose. Irrigating the nares is not recommended as it may initiate bleeding by dislodging clots. The client should be cautioned not to disturb clots because bleeding may occur. Nares may be gently cleaned after removal of the packing. Remediation: Question 160 See full question A nurse is feeling the apical impulse of a 28-month-old child. Identify the area where the nurse would assess the apical impulse. You Selected: Your selection and the correct area, market by the green box. Explanation: The heart's apex for a toddler is located at the fourth intercostal space immediately to the left of the midclavicular line. It is one or two intercostal spaces above what's considered normal for the adult because the heart's position in a child of this age is more horizontal and larger in diameter than that of an adult. Remediation: Question 161 See full question A nurse is providing teaching to the parents of a child diagnosed with muscular dystrophy. Which statements, by the nurse, are correct? Select all that apply. You Selected: Monitoring for spinal deformities is very important as they can interfere with respiratory function. Eventually your child will have to depend upon a wheelchair for mobility. Braces and mobility aids will be needed to maintain flexibility in the joints. Correct response: Braces and mobility aids will be needed to maintain flexibility in the joints. Monitoring for spinal deformities is very important as they can interfere with respiratory function. Eventually your child will have to depend upon a wheelchair for mobility. Explanation: Without braces and mobility aids contractures will readily develop. As spinal deformities such as kyphosis develop, the lungs will not be able to fully expand. There is no treatment to prevent the progression of the disease, and the child will ultimately require a wheelchair. Although exercises will help maintain some mobility, the disease cannot be halted. Standing will help maintain muscle tone rather than putting undue stress on the extremities. Remediation: Question 162 See full question The nurse is providing care for a client who has had a stroke. Since the onset of symptoms, the client has been experiencing left-sided hemianopsia. Which nursing interventions are appropriate? Select all that apply. You Selected: Place the client’s belongings on the right side of the bed. Stand on the right side of the bed when providing care. Correct response: Place the client’s belongings on the right side of the bed. Stand on the right side of the bed when providing care. Explanation: Hemianopsia is a condition in which the client has lost half of the visual field. It is most often associated with a stroke. In this case, the stroke has affected the client’s left side; therefore, placing belongings on the right side of the bed will enable the client to best see them. Standing on the right side of the bed when providing care will ensure the client is able to see the nurse. Approaching the client from the left side is counterproductive because the client would not be able to adequately see the nurse. Using an eye patch or dimming the lights will not help with treating or managing the condition. Remediation: Question 163 See full question A client calls the public health nurse at 3 weeks postpartum to tell her that her infant, who is breastfed, is not gaining weight as rapidly as her friend’s newborn, who is the same age and is formula fed. Which of the following is the most appropriate response from the nurse? You Selected: “Bottle-fed babies generally gain weight faster than breastfed babies.” Correct response: “Bottle-fed babies generally gain weight faster than breastfed babies.” Explanation: Babies do gain weight at different times. However, in general, formula-fed infants do gain weight faster than breastfed infants due to the greater amount of protein. The baby is not ill, nor is it likely that the friend is overfeeding her infant. Remediation: Question 164 See full question A client who has recently had a fractured hip repaired must be transferred from the bed to a wheelchair. Which of the following should the nurse consider while assisting the client? You Selected: The appropriate proximity and visual relationship of the wheelchair to the bed must be maintained. Correct response: The appropriate proximity and visual relationship of the wheelchair to the bed must be maintained. Explanation: The wheelchair should be angled close to the bed so the client can pivot on the stronger leg. When the wheelchair is within the client’s visual field, the client will be aware of the distance and direction the body must navigate to transfer safely and avoid falling. During a transfer, the knees need to be extended to support the weight, the bed needs to be in low position, and pivoting needs to be accomplished on the unaffected leg. Remediation: Question 165 See full question A client has been reading about the benefits of ingesting bee pollen in a magazine and asks the nurse, “Why would a person take bee pollen?” What is the nurse’s most appropriate response? You Selected: “Often people use it when on a diet since it contains amino acids and vitamins.” Correct response: “Some people claim that it increases their stamina and performance.” Explanation: Bee pollen is used to enhance energy, stamina and performance, however there is little evidence to support these uses. It does contain amino acids, vitamins, minerals, and phytochemicals, but it is not associated with weight loss. People who consume bee pollen for longer than three weeks have an increased likelihood of developing chronic allergy symptoms. It is true that gastrointestinal symptoms are side effects that may be experienced. Question 166 See full question A nurse reports to the physician that a client receiving a blood transfusion has a temperature that is 1°C greater than the baseline and reports of a headache. The physician says to continue the blood infusion. What is the most appropriate action by the nurse to ensure the safety of the client? You Selected: Inform the physician of hospital policy for managing transfusion reactions. Correct response: Inform the physician of hospital policy for managing transfusion reactions. Explanation: The nurse is aware that a spike in temperature of 1°C or a headache is a significant symptom in a client receiving blood and should take further initiative to advocate for the client. The nurse must be aware that harm could come to the client as a result of not advocating for the client. Remediation: Question 167 See full question What should be part of the nurse's teaching plan for a child with epilepsy being discharged on a regimen of phenytoin? You Selected: Brush teeth after each meal. Correct response: Brush teeth after each meal. Explanation: Phenytoin can cause gingival hyperplasia. Children taking phenytoin should brush their teeth after every meal and at bedtime, and visit their dentist on a regular basis. Drinking plenty of fluids is not required while taking phenytoin. A child on phenytoin does not need to be observed during waking hours because the seizures should be under control. Infections do not occur with an increased incidence in clients receiving phenytoin. Remediation: Question 168 See full question Discharge teaching for a 3-month-old infant with a cardiac defect who is to receive digoxin should include which information? Select all that apply. You Selected: Give the medication at regular intervals. Notify the HCP if more than two consecutive doses are missed. Notify the health care provider (HCP) of poor feeding or vomiting. Correct response: Give the medication at regular intervals. Notify the health care provider (HCP) of poor feeding or vomiting. Notify the HCP if more than two consecutive doses are missed. Explanation: To achieve optimal therapeutic levels, digoxin should be given at regular intervals without variation, usually every 12 hours. Vomiting and poor feeding are signs of toxicity. If more than two consecutive doses are missed, interventions may be needed to assure therapeutic drug levels. The medication should not be mixed with any other fluid as refusal may result in inaccurate intake of the medication. Taking make-up doses, or taking the medication at times other than scheduled, may adversely affect serum levels. Remediation: Question 169 See full question Before discharge, which instruction should a nurse give to a client receiving digoxin? You Selected: "Call the physician if your heart rate is above 90 beats/minute." Correct response: "Call the physician if your heart rate is above 90 beats/minute." Explanation: The nurse should instruct the client to notify the physician if his heart rate is greater than 90 beats/minute because cardiac arrhythmias may occur with digoxin toxicity. To prevent toxicity, the nurse should instruct the client never to take an extra dose of digoxin if he misses a dose. The nurse should show the client how to take his pulse and tell him to call the physician if his pulse rate drops below 60 beats/minute — not 80 beats/minute, which is a normal pulse rate and doesn't warrant action. The client shouldn't take digoxin with meals; doing so slows the absorption rate. Remediation: Question 170 See full question A client comes to the emergency department complaining of a fast and irregular heartbeat. After examining the client, a physician gives a verbal order for digoxin, 1 mg I.V. in four divided doses over the next 24 hours, with the first dose administered stat. How should the nurse respond to this order? You Selected: Write and sign the order as dictated; then repeat it aloud for the physician's verification. Correct response: Write and sign the order as dictated; then repeat it aloud for the physician's verification. Explanation: In urgent situations, such as the one described here, the nurse should write and sign a verbal order as dictated by the prescriber and then repeat the order aloud for the prescriber's verification. She should ask the prescriber to spell the drug name if necessary. Although verbally repeating the order for verification is appropriate, the nurse must write the order to prevent errors. In an urgent situation, insisting that the physician write the order would take valuable time away from crucial interventions and client evaluation. Refusing to carry out the order would be appropriate only if the nurse felt the order was unsafe. Remediation: Question 171 See full question A client is withdrawing from heroin and is experiencing muscle aches. Which approach by the nurse would be most effective? You Selected: Encourage the client to take warm baths. Correct response: Encourage the client to take warm baths. Explanation: It is helpful to the client for the nurse to explain that alternative methods such as warm baths can help with discomfort and are useful in easing muscle aches and cramps experienced during withdrawal. Being empathetic but firm decreases attempts at manipulation but does not help the discomfort. It is not possible for the nurse to fulfill the promise to eliminate the client’s discomfort during withdrawal. Preparing clients in advance for discomforts associated with heroin withdrawal may help decrease anxiety and fear, but will not address the discomfort the client is currently experiencing. Remediation: Question 172 See full question A family may request to have a client who is Vietnamese transferred to die at home because it is traditionally believed that: You Selected: it is disloyal to leave their loved one in the hospital. Correct response: the family can provide more comfort at home. Explanation: The traditional belief of Vietnamese Americans is that the family can provide more comfort for their loved one at home. It is not seen as being disloyal if their loved one dies in the hospital. The request is not based on a feeling that the hospital cannot be trusted. Vietnamese Americans accept death as a part of life and do not think that reincarnation is prevented in the hospital. Question 173 See full question The nurse is to apply a sequential compression device (intermittent pneumatic compression). Identify the area of the compression device that is placed on the client’s calf. You Selected: Your selection and the correct area, market by the green box. Explanation: The air cell should be centered on the back of the client’s calf. Remediation: Question 174 See full question What information about vision would be most important for the nurse to include in the discharge plan of a client who had cataract removal? You Selected: ”You will need to wear glasses only until the eye heals.” Correct response: ”You will need to relearn to judge distances accurately.” Explanation: Although clients who have had cataract surgery should be informed of the need to wear glasses or contact lenses to correct visual acuity, it is more important to inform them of potential changes in depth perception, since that presents a potential safety issue. The client may need to relearn to judge distances accurately to walk safely. There is no need to wear glasses that magnify objects. Remediation: Question 175 See full question A client who is 29 weeks’ pregnant comes to the labor and childbirth unit. She states that she is having contractions every 8 minutes. The client is also 3 cm dilated. Which of the following can the nurse expect to administer? Select all that apply. You Selected: A β-2 agonist. Intravenous fluids. Betamethasone. Correct response: A β-2 agonist. Betamethasone. Intravenous fluids. Explanation: The nurse can expect that a β-2 agonist that relaxes smooth muscle, will be administered to halt contractions; that betamethasone, a corticosteroid, will be administered to decrease the risk of respiratory distress to the neonate if preterm birth occurs; and that intravenous fluids will be given to expand the intravascular volume and decrease contractions if dehydration is the cause. Folic acid is a mineral recommended throughout pregnancy (especially in the first trimester) to decrease the risk of neural tube defects. RhoGam is given to Rh-negative clients who have been, or may have been, exposed to Rh-positive fetal blood. Nalbuphine is an opioid analgesic used during labor and childbirth. Remediation: Question 176 See full question Which test is useful in diagnosing depression? You Selected: Dexamethasone suppression test (DST) Correct response: Dexamethasone suppression test (DST) Explanation: The DST is a blood test that determines the serum cortisol level after administration of dexamethasone, an agent that usually suppresses the serum cortisol level. The DST has gained considerable attention in the mental health field as a diagnostic marker for endogenous depression as well as for its implications for the treatment and prognosis of this disorder. Most studies have found that 40% to 50% of clients with endogenous depression or major depression with melancholia don't have a suppressed late-afternoon serum cortisol level after dexamethasone administration. A coagulation profile, the protein uptake test, amitriptyline level, and creatinine and TSH levels aren't useful in diagnosing depression. However, the amitriptyline level is monitored in clients receiving the drug. Remediation: Question 177 See full question A 6-year-old child was admitted to the pediatric unit after sustaining a broken leg in a motor vehicle accident. Which specialist would be most important to involve in this child's care during hospitalization? You Selected: Home care nurse Correct response: Social worker Explanation: The nurse should collaborate with the social worker to provide care for the child involved in a motor vehicle accident. After such a traumatic life event, this child's care will involve dealing with his emotional health as well as his physical recovery. Home health care isn't usually needed for this type of injury, and nutrition isn't a top priority problem for this child. There's nothing to suggest that the infectious disease nurse is required to care for this child. Remediation: Question 178 See full question A mother states to the nurse in her health care provider’s (HCP’s) office that she is frustrated regarding her 7-year-old son’s nightly enuresis for the past 3 years. She says she has limited his evening fluids, eliminated all caffeine and soft drinks from his diet, and has had him wash his own sheets, but he still wets the bed almost every night. Her husband has told her he was a bed wetter as a child. He thinks the son will “get over it.” The mother is worried that it could negatively affect the son’s peer relationships as he grows older. Which action should the nurse take? You Selected: Discuss a behavioral treatment plan for the child focusing on the improvement of his social skills. Correct response: Suggest that the mother ask the HCP about medication to deal with the enuresis. Explanation: The mother’s distress and length of time the problem has existed combined with the efforts she has made to address the problem demonstrate that medication treatment should be considered. The absence of any other symptoms makes a renal workup unnecessary at this time. It is unlikely that social skills training alone will change his nocturnal enuresis. Just waiting for the behavior to stop is likely to further tax the mother and son. Remediation: Question 179 See full question A nurse is talking with a delusional client when the fire alarm sounds and a staff member closes the door to the client's room. The client becomes very agitated and declares, "The aliens have arrived!" Which actions are appropriate for the nurse to take? Select all that apply. You Selected: Continuing to speak to the client in a reassuring tone Staying with the client until she receives further instructions Correct response: Staying with the client until she receives further instructions Continuing to speak to the client in a reassuring tone Explanation: After the client's physical safety is ensured, his most immediate need is emotional reassurance and safety. Therefore, it's best for the nurse to remain with the client and continue speaking with him in a reassuring tone of voice until she receives further instructions. Assuring the client that everything is fine or that a fire drill is occurring may further agitate the client by invalidating his fear and attempting to appeal to logical thinking processes, which are impaired in a delusional client. Remediation: Question 180 See full question A 3-year-old is recovering from a concussion. The persistence of which finding would the nurse consider as being a normal finding for a 3-year old? You Selected: change in eating habits Correct response: inability to hop Explanation: The inability to hop is not concerning because it is a milestone for a 4-year-old, not a 3-year-old. Lack of interest in toys, changes in eating habits, and increased temper tantrums that persist several weeks all require an evaluation by a neurologist or other specialist. Remediation: Question 181 See full question A client diagnosed with depression tells a nurse that she won't allow herself to cry, "because my crying upsets the whole family." This is an example of: You Selected: repression. Correct response: rationalization. Explanation: Rationalization is a defense mechanism used to justify actions or feelings with seemingly reasonable explanations. Insight is comprehension of one's own behavior, commonly followed by an attempt to change it. Repression is involuntary exclusion from awareness of painful and conflicting thoughts or feelings. Based on the information provided, the client doesn't seem to be manipulating those around her. Question 182 See full question The triage nurse is giving a telephone report to the receiving nurse in the labor and birth unit. The multigravida client is 8 cm dilated and is being transferred to the labor and birth unit. How should the labor and birth nurse manage the next ten minutes with the client? Select all that apply. You Selected: Assess comfort needs of the client. Begin fetal monitoring. Determine support systems for the client. Call other staff to set up the birthing table. Correct response: Begin fetal monitoring. Call other staff to set up the birthing table. Assess comfort needs of the client. Determine support systems for the client. Explanation: Assuring the safety of this client is the top priority. The nurse should begin either intermittent or continuous fetal and contraction monitor depending on the client’s risk status. Since the client is 8 cm dilated and a multigravid client, asking other staff members to set up the birthing table would be in order. This client is not a candidate for medication as this may have an influence on the baby. This client is past the point of offering an epidural as she may have given birth by the time the medication is in effect, but comfort measures such as warm or cool cloths, back rubs, etc. may be helpful. The support system is an important aspect of the birthing process and is an easily settled situation. Preparing to give an early report to the oncoming nurse does not apply in this situation. Remediation: Question 183 See full question Which intervention has the highest priority when providing skin care to a bedridden client? You Selected: Keeping the skin clean and dry without using harsh soaps Correct response: Keeping the skin clean and dry without using harsh soaps Explanation: Keeping the skin clean and dry is always the highest priority. Changing the client's position frequently and gently massaging the skin around the pressure areas are also important, but only after the skin is cleaned. The nurse should rub lotion around, not directly over, pressure areas to avoid skin breakdown. Question 184 See full question A primigravida experiences spontaneous rupture of the membranes. What should the nurse do? Select all that apply. You Selected: Perform a nitrazine test to confirm that the membranes are ruptured. Assess maternal temperature. Monitor the fetal heart rate and pattern. Correct response: Perform a nitrazine test to confirm that the membranes are ruptured. Monitor the fetal heart rate and pattern. Assess maternal temperature. Explanation: When membranes rupture, the nurse should immediately check fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. He or she should also perform a nitrazine test to confirm that the membranes are ruptured. Maternal temperature should be assessed every 1 to 2 hours so infection can be identified early. Membranes may rupture any time during labor. In some cases, 24 hours may pass between rupture and onset of labor, so the nurse does not need to prepare for childbirth at this time. Remediation: Question 185 See full question When administering gentamicin to a preschooler, plasma levels should be monitored. In determining the effectiveness of the medication, the nurse assesses: You Selected: a serum trough and peak level around the third dose. Correct response: a serum trough and peak level around the third dose. Explanation: Aminoglycosides such as gentamicin have a narrow range between therapeutic and toxic serum levels. A serum peak and trough level, taken 30 minutes before the dose and 30 minutes after the third dose has been administered, is the most accurate way to determine the correct serum values because the third dose provides enough medication buildup in the bloodstream to be measured. A trough level every morning, a serum peak level after the second dose, and serial serum trough levels will not provide sufficient data about the effectiveness of the antibiotic. Remediation: Question 186 See full question A nurse completes an afternoon assessment of a client who is a nurse and who is visiting the area on vacation. The client states that the nurse must be having a busy shift and asks about the maximum number of clients that the nurse is allowed to care for. What is the nurse's best response? You Selected: “Some jurisdictions have staffing laws which allow for nurses to be involved in staffing ratios.” Correct response: “Some jurisdictions have staffing laws which allow for nurses to be involved in staffing ratios.” Explanation: Staffing laws exist in some jurisdiction, but not others. Staffing laws tend to fall into one of three general approaches: The first is to require hospitals to have a nurse driven staffing committee which create staffing plans that reflect the needs of the patient population and match the skills and experience of the staff. The second approach is for legislators to mandate specific nurse to patient ratios in legislation or regulation. A third approach is requiring facilities to disclose staffing levels to the public and/or a regulatory body. A facility is required to disclose staffing levels to the public. Remediation: Question 187 See full question A home health nurse visits a client with chronic obstructive pulmonary disease who requires oxygen. Which statement by the client indicates the need for additional teaching about home oxygen use? You Selected: "I make sure my oxygen mask is on tightly so it won't fall off while I nap." Correct response: "I make sure my oxygen mask is on tightly so it won't fall off while I nap." Explanation: The client requires additional teaching if he states that he fits his mask tightly. Applying the oxygen mask too tightly can cause skin breakdown, so the client should be cautioned against wearing it too tightly. Oxygen therapy is drying to the oral and nasal mucosa; therefore, the client should be encouraged to apply a water-soluble lubricant, such as a topical emollient, to prevent drying. Smoking is contraindicated wherever oxygen is in use; posting of a "no smoking" sign warns people against smoking in the client's house. Cleaning the mask with water two or three times per day removes secretions and decreases the risk of infection. Remediation: Question 188 See full question After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention should the nurse question? You Selected: Performing a lumbar puncture Correct response: Performing a lumbar puncture Explanation: The client's history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldn't be done because it can quickly decompress the central nervous system, causing additional damage. After a head injury, barbiturates may be given to prevent seizures; mechanical ventilation may be required if breathing deteriorates; and elevating the head of the bed may be used to reduce ICP. Remediation: Question 189 See full question While providing care for a hospitalized infant, a nurse is summoned to the phone. The caller requests information about the infant's condition. Which of the following is the correct action by the nurse? You Selected: Divulge no information to the caller at all. Correct response: Determine if the infant's parents want information released to the caller. Explanation: Due to patient privacy laws, the nurse must identify whether the caller is on an approved list prior to giving information or refusing to give information. The nurse should provide information, even nonspecific information only to those callers identified on the approved list. Transferring the call to the infant’s room is not appropriate. Remediation: Question 190 See full question A nurse in the neonatal nursery is preparing to perform phenylketonuria (PKU) testing. Which neonate is ready for the nurse to test? You Selected: A 3-day-old neonate who has been fed I.V. since birth Correct response: A 2-day-old neonate who has been breast-fed Explanation: To test for PKU, a neonate must have had a sufficient intake of phenylalanine through the ingestion of either formula or breast milk for at least 2 days. A neonate who has been receiving I.V. fluids and hasn't yet received breast milk or formula isn't ready to be tested for PKU. A neonate who's discharged within 24 hours of birth will need to see the physician for PKU testing after receiving formula or breast milk for 48 hours. Remediation: Question 191 See full question Which nursing action is appropriate when planning care for a client who is being battered? Select all that apply. You Selected: Teach the client about the cycle of violence. Provide a cell phone and the crisis help line telephone number. Discuss the client's legal and personal rights. Give information about a safe home. Correct response: Give information about a safe home. Provide a cell phone and the crisis help line telephone number. Teach the client about the cycle of violence. Discuss the client's legal and personal rights. Explanation: When working with a battered client, the nurse should give information about a safe home and provide a cell phone and information about the crisis help line. The nurse should also help the client understand the cycle of violence as well as personal and legal rights. The nurse should help the client share and discuss her anger, frustration, guilt, shame, and other feelings. Displacing, that is, placing feelings onto another person or object, is not helpful to the client and is not a healthy way to handle feelings. Remediation: Question 192 See full question A multigravid client diagnosed with a probable ruptured ectopic pregnancy is scheduled for emergency surgery. In addition to monitoring the client's blood pressure before surgery, which factor is most important for the nurse to assess? You Selected: pulse rate Correct response: pulse rate Explanation: Fallopian tube rupture is an emergency situation because of extensive bleeding into the peritoneal cavity. Shock soon develops if precautionary measures are not taken. The nurse readying a client for surgery should be especially careful to monitor blood pressure and pulse rate for signs of impending shock. The nurse should be prepared to administer fluids, blood, or plasma expanders as necessary through an intravenous line that should already be in place. Because the fertilized ovum has implanted outside the uterus, uterine cramping is unlikely. However, abdominal tenderness or knife-like pain may occur. Abdominal fullness may be present, but abdominal distention is rare unless peritonitis has developed. Although the hemoglobin and hematocrit may be checked routinely before surgery, the laboratory results may not truly reflect the presence or degree of acute hemorrhage. Remediation: Question 193 See full question The nurse notes that a client taking antipsychotic medications becomes agitated, fearful, and panicky when his neck twists to one side and his eyes forcefully draw upward toward the ceiling. Which medication should be administered to the client? You Selected: Haloperidol Correct response: Benztropine Explanation: Benztropine is an anticholinergic drug used to counteract the dystonic reactions and adverse reactions of antipsychotic drugs. If the client experiences difficulty swallowing, benztropine may be administered by injection. Haloperidol is an antipsychotic medication used to control tics and vocal utterances that are part of Tourette’s syndrome. Paliperidone is used to treat mania, and at low dosage, is used as a maintenance medication for bipolar disorder, schizophrenia and schizoaffective disorder. Diazepam is a benzodiazepine. Each of these medications require a provider’s order. Remediation: Question 194 See full question Nursing care for a client in Addisonian crisis should include which intervention? You Selected: Placing the client in a private room Correct response: Placing the client in a private room Explanation: The client in Addisonian crisis has a reduced ability to cope with stress as a result of an inability to produce corticosteroids. A private room is easy to keep quiet, dimly lit, and temperature controlled. Also, visitors can be limited to reduce noise, promote rest, and decrease the risk of infection. The client should be kept on bed rest, receiving total assistance with ADLs to avoid stress as much as possible. Because extremes of temperature should be avoided, measures to raise the body temperature, such as extra blankets and turning up the heat, should be avoided. Remediation: Question 195 See full question A person visiting with a client asks the nurse what's wrong with the client. The nurse's best response is: You Selected: "I'm not allowed to disclose that information." Correct response: "Let me see if you're on the list of people I may speak with." Explanation: Because the nurse doesn't know the visitor's identity, it's most appropriate for her to ask if the person is a relative or friend before determining whether she should share information or refer the visitor directly to the client. Declining to provide information or asking if the visitor is related to the client could be construed as rude and inhibits communication. Question 196 See full question A client who had received 25 ml of packed red blood cells (PRBCs) has low back pain and pruritus. After stopping the infusion, the nurse should take what action next? You Selected: Collect blood and urine samples and send to the lab. Correct response: Collect blood and urine samples and send to the lab. Explanation: ABO- and Rh-incompatible blood causes an antigen-antibody reaction that produces hemolysis or agglutination of red blood cells (RBCs). At the first indication of any sign/symptom of reaction, the blood transfusion is stopped. Blood and urine samples are obtained from the client and sent to the lab along with the remaining untransfused blood. Hemoglobin in the urine and blood samples taken at the time of the reaction provides evidence of a hemolytic blood transfusion reaction. Antihistamine, antipyretics, diuretics, and vasopressors may be administered with different types of transfusion reactions. Remediation: Question 197 See full question In a children's unit team meeting, the staff is working on protocols for dealing with clients with autism spectrum disorder (ASD). Which protocols would be most important? Select all that apply. You Selected: reinforcements for appropriate interactions with peers and staff protections from harm to self and others preparation for any changes in unit routines Correct response: protections from harm to self and others preparation for any changes in unit routines reinforcements for appropriate interactions with peers and staff Explanation: Children with autism may have behaviors, such as head banging or pinching, that harm themselves or others. They have a strong need for sameness and need to be prepared for changes. Any client efforts to interact appropriately need to be reinforced because social behaviors are typically limited. What toys these clients have is not as important as what they do with them, such as throwing them at others. Depending on the severity of the autism, the clients’ verbalizations vary significantly, so a protocol for this is not possible. Question 198 See full question After an inguinal herniorrhaphy, the nurse should assess the client carefully for which complication? You Selected: urine retention Correct response: urine retention Explanation: The most common complication after an inguinal hernia repair is the inability to void, especially in men. The nurse should evaluate the client carefully for urine retention. Hypostatic pneumonia, deep vein thrombosis, and paralytic ileus are potential postoperative problems with any surgical client but are not as likely to occur after an inguinal hernia repair as is urine retention. Remediation: Question 199 See full question The nurse is providing breastfeeding teaching to a client 36 hours postpartum prior to discharge. The nurse recognizes an audible suck–swallow cycle during breastfeeding. Which of the following interventions should the nurse perform next? You Selected: Reinforce the technique with the mother. Correct response: Reinforce the technique with the mother. Explanation: An audible suck–swallow cycle indicates that the nipple is at the back of the baby’s palate and the baby is swallowing milk quickly at first, and then more slowly, as his/her appetite is satisfied. This is a positive finding for breast feeding, and the infant should not be removed. When the baby begins to receive milk, his/her jaw will work all the way back to the ear. Dimpling of the baby’s cheeks may indicate there is an insufficient amount of breast tissue in the newborn’s mouth. The newborn should have a significant amount of the areola (not just the nipple) in the mouth, and typically with a good latch the newborn is not easily removed from the breast. Remediation: Question 200 See full question A client who has diabetes is taking metoprolol for hypertension. What should the nurse instruct the client to do? Select all that apply. You Selected: Do not crush or chew the tablets. Have a blood glucose level drawn every 6 to 12 months during therapy. Report any fainting spells to the health care provider (HCP). Take the tablets with food at same time each day. Correct response: Take the tablets with food at same time each day. Do not crush or chew the tablets. Have a blood glucose level drawn every 6 to 12 months during therapy. Report any fainting spells to the health care provider (HCP). Explanation: Metoprolol is a beta-adrenergic blocker indicated for hypertension, angina, and myocardial infarction. The tablets should be taken with food at same time each day; they should not be chewed or crushed. The HCP should be notified if pulse falls below 50 for several days. Blood glucose should be checked regularly during therapy since increased episodes of hypoglycemia may occur. It may mask evidence of hypoglycemia such as palpitations, tachycardia, and tremor. Use of any OTC decongestants, asthma and cold remedies, and herbal preparations must be avoided. Fainting spells may occur due to exercise or stress, and the dosage of the drug may need to be reduced or discontinued. Remediation: [Show More]

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