EXAM PREPARATION | ||
QUESTIONS | ANSWER AND EXPLANATION | MORE EXPLANATION |
1 A client exposed to Mycobacterium tuberculosis Correct answer: 1 To prevent active tuberculosis after exposure, the client is initiated on a single agent regimen, starts on chemoprophylaxis. The nurse provides what usually isoniazid (INH). For newly diagnosed active disease (option 2), a combination of instruction to the client? antitubercular agents is used for at least the first several weeks: isoniazid (INH), rifampin (Rifadin), and pyrazinamide (Tebrazid). The combination therapy lessens the risk of drug resistance (option 3). Except for streptomycin, which is for IM use, the antitubercular agents are administered orally (option 4).
| The critical words in the stem of the question are exposed and chemoprophylaxis. Differentiate exposure from infection as the key concept being tested. Recall that if active infection requires multi‐drug therapy, exposure can be managed with a single agent alone. | |
2 The nurse delegates an unlicensed assistive person Correct answer: 2 The nurse ensures that the UAP understands the importance of reporting immediately any (UAP) to assist a client with a clean urinary difficulties during the procedure such as bleeding. This provides for safe and effective care. catheterization procedure. The client had formerly Option 1 is incorrect because the client cannot do the procedure because of arthritis. Option 3 been able to do the procedure but because of arthritis, is unnecessary if the UAP is qualified to do the procedure. Option 4 is a function of the nurse, he has been unable to perform the catheterization. not the UAP. Although the UAP has done this procedure before, which of the following must the nurse emphasize to the UAP?
| The core issue of the question is the appropriate procedure for the nurse to use when delegating care to a UAP. Eliminate option 4 first because it is the role of the nurse. Eliminate options 1 and 3 next, because they are not indicated or unnecessary, respectively. | |
3 The client is in the operating room for a surgical Correct answer: 4 Only option 4 relates to the client’s physiological integrity. Options 1 and 2 pertain to the procedure. The nurse in the operating room is psychological aspects of client care, while option 3 relates to the safety in the environment. monitoring the physiological integrity of the client. Which of the following activities is most appropriate?
| The core issue of the question is knowledge of physiological assessment priorities in the perioperative client. Fluid loss directly relates to cardiovascular status, which is one of the ABCs (airway, breathing, and circulation). Use nursing knowledge and the process of elimination to make a selection. | |
4 The clinic nurse is conducting health screenings. Correct answer: 1, 2, 4 Obesity, hypertension, and smoking are modifiable risk factors for stroke. Which of the following client assessment findings Hypercholesterolemia (cholesterol level greater than 200 mg) would also be a risk factor, but indicates that client teaching is needed about the risk this client’s level is less than 200 mg/dL. Eating a diet containing fiber helps keep cholesterol for stroke? Select all that apply. levels low and is not a risk factor for stroke.
| The core issue of the question is knowledge of risk factors for stroke. Recall that these are similar to the risk factors for cardiac disease to help make your selections. |
5 Which of the following actions would the nurse take Correct answer: 1, 2, 5 Options 1, 2, and 5 are core principles of medical asepsis. Option 3 violates principles of to maintain medical asepsis when caring for a client medical asepsis. Option 4 uses principles of surgical asepsis. Option 6 is unrelated to the needs with diabetes mellitus on the medical nursing unit who of this client. requires irrigation of a leg ulcer and insulin injections? Select all that apply.
| Use knowledge of medical versus surgical asepsis as essential core concepts. Eliminate options that utilize surgical asepsis or are unrelated to the needs of the client. |
‐ Change the dressing for a diabetic ulcer using sterile gloves. ‐ Wipe the rubber stopper on the insulin vial before withdrawing dose. | |
6 Laboratory test results indicate a client is in the nadir Correct answer: 2 Red blood cells, white blood cells, and platelet counts may be decreased during the nadir period that follows administration of a chemotherapy period following administration of chemotherapy that has hematological toxicity. Medications drug. Which drug should the nurse avoid administering that inhibit platelet aggregation should be avoided during the nadir period following to this client at this time? antineoplastic therapy. Aspirin, ibuprofen, and indomethacin are examples of some of these agents. Tylenol is the drug of choice for mild pain and fever. Benadryl is often used for sinus drainage or as an antihistamine and Robitussin is used to manage cough.
| The core issue of the question is the ability to determine which drugs could increase the risk of bleeding when a client’s blood counts may be low. Use the process of elimination and knowledge of drug actions and adverse effects to make a selection. |
7 The newborn nursery has recently formed a unit Correct answer: 4 A situational leader recognizes that leadership style depends on the readiness and willingness policy and procedure committee. The nurse, while of the group or the individuals to perform the assigned tasks. The democratic or participative attending and participating in the meetings, leader offers suggestions, asks questions, and guides the group toward achieving the group determines that which nurse exemplifies a situational goals. The laissez‐faire leader recognizes the group’s need for autonomy and abdicates leader? responsibility. A bureaucratic leader relies on the organization’s rules, policies, and procedures to direct the group’s work.
| The core issue of the question is knowledge of various leadership styles. Use this knowledge and the process of elimination to make a selection. |
8 The nurse places highest priority on taking which of Correct answer: 1 Hand hygiene is a core principle of standard precautions. Using gloves is appropriate when the following actions to reduce the spread of there is a risk of exposure to blood, body fluids, secretions, and excretions. However, microorganisms when caring for a client at risk for handwashing should be done after removal of gloves. Not all clients require transmission‐ infection? based precautions (option 3) or a private room (option 4).
| Use the process of elimination based on nursing knowledge of standard precautions. Elements of transmission‐based precautions are not initiated with all clients. |
9 The nurse would report to the physician which of the Correct answer: 1, 4 The white blood cell count is elevated (normal 5,000–10,000/mm<sup>3</sup>), following abnormal laboratory values for a 58‐year‐old as is the BUN (0.8–22 mg/dL). These changes would be expected with infection (noted by client newly admitted to the nursing unit with fever fever) and possibly accompanying dehydration from diarrhea. The sodium (135–145 mEq/L), and diarrhea? Select all that apply. potassium (3.5–5.1 mEq/L), and serum creatinine (0.8–1.6 mg/dL) are all within normal limits.
| The core issue of the question is the ability to discriminate between normal and abnormal laboratory values. Note the critical symptoms fever and diarrhea, which could lead you to select elevated white count for infection and elevated BUN with fluid loss from diarrhea. |
10 The mental health nurse working with children Correct answer: 3 According to Erikson’s stages of development, a 10‐year‐old child is experiencing industry vs. anticipates that unrealistic expectations or a sense of inferiority. Shame (option 1), guilt (option 2), and role confusion (option 4) occur at other failure to meet standards would cause a 10‐year‐old developmental levels. child to develop a sense of which of the following? 1.‐ Shame | The core issue of the question is the ability to anticipate levels of growth and development in a 10‐year‐old child. Use knowledge of Erikson’s theory to make a selection. |
‐ Guilt ‐ Inferiority ‐ Role confusion | |
11 A postoperative client who has an order for 5,000 Correct answer: 4 Low‐dose heparin therapy is indicated in many postoperative clients to prevent the units of heparin SubQ for three doses wants to know development of thromboembolic episodes. It is not used in every postoperative situation why this drug is being ordered. What information (option 1), but it is usually used for clients who have orthopedic surgery or are anticipated to would the nurse provide to the client to best answer be immobilized for a time following surgery. Short‐term therapy is not given to maintain the question? adequate blood clotting levels (option 2) but merely to intervene as a preventative measure. While the statement that heparin is given SC into the abdomen and is not usually painful is factual, it is not the reason for the medication being given to the client (option 3).
| The critical words in the stem of the question are best answer the question. This tells you that the correct answer is one that responds to the client’s concern, rather than just reciting a fact about the medication. Use nursing knowledge and the process of elimination to answer the question. |
12 The Emergency Department has recently experienced Correct answer: 1 Shared leadership recognizes that there are many leaders within a group so the leader a significant increase in client visits. The year‐to‐date encourages the formation of self‐directed work teams. In transformational leadership, the census reveals a 20% increase in admission from the leader encourages risk taking such as trying out nursing approaches that are evidence‐based or same period last year. In an effort to reduce staff research‐based. A transactional leader uses incentives to promote productivity such as giving stress and burnout by empowering the staff, the nurse rewards for excellent performance. A democratic leader provides constructive criticism and manager uses which of the following approaches to facilitates the group to meet their goals. demonstrate shared leadership?
| The core issue of the question is knowledge of various leadership styles. Use this knowledge and the process of elimination to make a selection. |
13 A 56‐year‐old client reports to the nurse that his sleep Correct answer: 2 Middle‐aged adults have a decrease in deep sleep, stage IV NREM. Option 1 is an expected patterns are different than when he was younger. The pattern in older adults; option 3 is expected in young adults, and option 4 is expected in nurse anticipates that this client is likely to be neonates. experiencing which normal developmental pattern?
| The core issue of the question is knowledge of age‐related changes in sleep pattern. Use this knowledge and the process of elimination to make a selection. |
14 The nurse concludes that teaching has been effective Correct answer: 3 Crowning is the point in time when the perineum is thin and stretching around the fetal head when the laboring client’s partner shouts, “She’s both between and during contractions. Delivery is imminent when crowning occurs. Crowning crowning!” as: occurs later than the first sight of the infant’s head. A head that recedes upward between contractions is not crowning. The mouth and nose cannot be suctioned during crowning because they are not accessible, nor is it timely.
| The critical word in the stem of the question is crowning. Use knowledge of what occurs during crowning and the process of elimination to make a selection. Visualize the word crown and select the answer that matches the part of the head that a crown would sit on. |
15 A client questions the surgical nurse about the Correct answer: 4 Option 4 gives the client an opportunity to explain to the nurse the reason for asking the personnel in the operating room. Which of the question. This helps the nurse understand the client’s frame of reference and allows the nurse following initial responses by a nurse to the client’s to best address the client’s concern. Options 1 and 3 offer false reassurance and can give the concern is most therapeutic? impression that the nurse did not listen to or address the client’s concerns. Option 2 is a close‐ ended question and may not help the nurse explore the client’s concerns.
| The core issue of the question is knowledge of communication techniques that are effective when working with a client who will undergo surgery. Use knowledge of communication theory and the process of elimination to make a selection. |
16 After three defibrillation attempts, the client Correct answer: 3 Lidocaine is the primary medication used to treat ventricular dysrhythmias. Lidocaine continues to be in a pulseless ventricular tachycardia. suppresses automaticity in the HIS‐Purkinje system by elevating electrical stimulation A lidocaine bolus of 100 mg IV is administered. The threshold of the ventricle during diastole, thus decreasing ventricular irritability. Ventricular nurse would expect to see which of the following as a fibrillation (option 1) is a worsening dysrhythmia. Slowing the heart rate (option 2) without therapeutic response to lidocaine? converting the rhythm to an atrial or sinus rhythm is not therapeutic. An increase in level of consciousness (option 4) would only occur once the ventricular rhythm is terminated.
| The core issue of the question is knowledge that Lidocaine is an antidysrhythmic that should reduce the irritability of the ventricle, thus making it more amenable to shock therapy. The reduction in ventricular irritability could manifest as a conversion to a supraventricular rhythm. |
17 The nurse is assigned to a client diagnosed with head Correct answer: 4 The UAP is qualified to complete simple procedures, such as bathing a client and changing and neck cancer who is receiving enteral feedings via bed linens. While the UAP could possibly administer mouth care to this client, the nurse must gastrostomy tube. When the nurse is called away to assess the oral cavity (option 2) and should be the one to assess tube feeding residual (option care for another client, which task for this client could 1). UAPs are not trained in therapeutic communication skills and techniques (option 3). most appropriately be delegated to the unlicensed assistive person (UAP)?
| The core issue of the question is an appropriate activity to delegate to an unlicensed assistant. Keep in mind that any activity that involves assessment is retained by the RN, so eliminate options 1 and 2. Choose option 4 over 3 because it is procedural in nature. |
18 A client with metabolic acidosis is admitted. Which of Correct answer: 3 A client in metabolic acidosis may also be hyperkalemic. As the hydrogen ions shift from the the following laboratory values would the nurse expect ECF to the ICF, potassium enters the ECF, leading to an increased serum potassium. pH values to find in this client? of &lt; 7.35 are associated with acidosis (option 2). Options 3 and 4 have K<sup>+</sup> levels above 5.5 mEq/ L that are associated with acidosis, but option 3 contains the higher value. Option 1 has a normal pH and serum potassium level.
| Note the critical word acidosis in the question. Use this to eliminate options 1 and 2 because the pH is not low in either option. Focus on the critical word metabolic to pick the option that contains a cation with the highest value since hydrogen ions can enter the cell, which in this case is option 3. |
19 A client has a BUN of 68 mg/dL and a creatinine level Correct answer: 4 Potassium (KCL) is contraindicated in clients with renal dysfunctions. It can not be filtered out of 6.0 mg/dL. The IV fluid is 5% dextrose in 0.9% if there is decreased renal filtration. With increased damage in tissues additional potassium is sodium chloride with 40 mEq KCL @ 100 mL/hour. released, causing an even greater level of potassium that can be life‐threatening. Encouraging Which action would be most appropriate for the nurse protein, ambulation, and taking vital signs do not safeguard the client from the danger of this to take? potential electrolyte imbalance.
| Protein creates more potassium in the body and the lab shows that the kidneys are not filtering as they should. Additional potassium from protein metabolism may cause death. Activities, such as ambulation, will not change the BUN or creatinine since they reflect filtration of the renal system and not the rate of circulation of the blood. Taking the vital signs every hour only tells you information about the circulatory status and does not explain or improve the renal functions. Action needs to be taken immediately to discontinue the IV with the potassium to minimize the buildup of potassium to toxic levels that could be life‐threatening. |
20 The nurse concludes that a child is in Piaget’s Correct answer: 1 In Piaget’s theory on development the conservation is a hallmark sign in the concrete concrete operations stage after observing which of the operational stage. Options 2, 3, and 4 are not characteristic of this stage. following traits in the child?
| The core issue of the question is knowledge of characteristics of various cognitive developmental levels according to Piaget. Use this knowledge and the process of elimination to make a selection. |
21 A 60‐year‐old client has been prescribed rabeprazole Correct answer: 3 Omeprazole, pantoprazole, and rabeprazole must be swallowed whole. Lansoprazole and (Aciphex) for symptoms of gastroesophageal reflux esomeprazole capsules may be opened and sprinkled on applesauce or dissolved in 40 mL of disease (GERD). He has trouble swallowing pills. What juice. alternate medication should the nurse plan to request for this client?
| The core issue of the question is knowledge of which medications used for GERD can be opened because they come in capsule form. Use knowledge of pharmacology to answer this question, which tests specific nursing knowledge of drug forms. |
22 At the start of the shift there were only three Correct answer: 4 It is an RN’s responsibility to do assessments, analyze the data, plan and implement care and newborns in the nursery, so staffing consisted of one teaching, and evaluate the outcomes. A second RN needs to be assigned to the nursery to RN and one LPN. Within two hours, three more safely manage the care of the Level I newborns. newborns were admitted to the nursery, one requiring Level II care, and the parents of two newborns needed discharge teaching so they could go home. The RN was needed full time in the Level II nursery as the newborn was stabilized. What staffing is needed to provide appropriate care in this situation?
| Recognize that assessment and client education are part of the professional scope of practice. The correct answer would be the option that safely retains these functions for the RN given the change in unit census. |
23 The nurse is working with a client suffering from Correct answer: 3 Anxiety or anger increases peristalsis leading to subsequent diarrhea. Excessive intake of chronic diarrhea. In teaching ways to reduce diarrhea, cheese or eggs, ignoring the urge to defecate, and lack of exercise can lead to the development the nurse would encourage the client to avoid which of of constipation. the following that contribute to the development of diarrhea? | The core issue of the question is knowledge of ordinary factors that can contribute to diarrhea. Evaluate each of the options in turn and determine whether it is likely to aggravate diarrhea. Note that anxiety and anger stimulate the sympathetic nervous system, which then increases peristalsis; this will help you to choose correctly. |
‐ Excessive intake of cheese and eggs ‐ Habitually ignoring the urge to defecate ‐ Anxiety or anger ‐ Lack of exercise | |
24 The fetal head is determined to be presenting in a Correct answer: 2 The normal attitude of the fetal head is one of moderate flexion. Changes in fetal attitude, position of complete extension. After learning of this, particularly the position of the head, present larger diameters to the maternal pelvis, which the nurse anticipates which of the following? contributes to a prolonged and difficult labor and increases the likelihood of cesarean delivery.
| The core issue of the question is the significance of moderate flexion of the fetal head. Recognize that changes in the position of the fetal head affect delivery to choose the correct option. |
25 The nurse notices that an elderly nursing home Correct answer: 3 Mental status changes and concentrated urine are common signs of dehydration in the resident has not been eating or drinking as much as elderly. Tenting and dry, flaky skin are consistent changes seen with normal aging. Hand veins usual. Which assessment finding would best indicate that fill within 3 to 5 seconds and clear lungs sounds with unlabored breathing are normal the presence of fluid volume deficit? findings.
| Note the critical words in the question are not eating or drinking and deficit. With this in mind, look for a physical assessment finding that is consistent with dehydration. Eliminate options 1 and 2 first because of the words clear and dry respectively. Choose option 3 over 4 recalling that neurological symptoms are often present with altered fluid balance because sodium imbalance may occur simultaneously. |
26 Following a liver transplant the client is taking Correct answer: 4 Liver function includes the regulation of blood clotting and corticosteroids can impair wound prednisone among other medications to prevent organ healing and irritate the GI tract. Thus, the client should be instructed to report signs and rejection. The nurse should instruct the client to make symptoms of bleeding. Option 1 is a side effect of corticosteroids but is not the priority from a it a priority to report which of the following signs and physiological basis. Options 2 and 3 do not reflect the associated risk of bleeding with symptoms to the health care provider? corticosteroid medications.
| The core issue of the question is knowledge that the liver is a vascular organ and that some medications used to suppress the immune system to prevent rejection, such as corticosteroids, can lead to bleeding. |
27 The nurse would place highest priority on which of Correct answer: 1 Frequent coughing and deep breathing is an easy maneuver that has great benefit to optimize the following nursing interventions when planning to ventilation in the postoperative client. Good pain management facilitates effective coughing prevent atelectasis in the newly admitted and deep breathing. Getting the client out of bed and administering oxygen and postoperative client? bronchodilators are all appropriate interventions for preventing or treating atelectasis, but clearly the best option is to prevent its occurrence by simple maneuvers such as coughing and deep breathing.
| Note the client in the question has newly arrived to the nursing unit following surgery. The critical words “nursing interventions” help you to eliminate options 3 and 4, which require a medical order. Choose option 1 over 2 because of the word “hourly” and because there is not enough information in the stem to determine whether the client can safely get out of bed at this time. |
28 A 14‐year‐old client has been diagnosed with bipolar Correct answer: 4 Children with bipolar disorders are often misdiagnosed as having conduct disorder or ADHD. disorder. The nurse would expect to see which of the Intense mood swings (option 1), inflated self‐esteem (option 2), and spending sprees (option 3) following problems? occur more often in adults.
| The core issue of the question is knowledge of how bipolar disorders may present in a child that is in early adolescence. Use nursing knowledge and the process of elimination to make a selection. |
‐ Spending sprees ‐ Fire‐setting and gang behavior | |
29 A client’s hemoglobin level is 14 grams/dL. Which Correct answer: 2 The laboratory value given is within normal limits (12–16.5 grams/dL). All the other interpretation of the laboratory value by the nurse is statements are inaccurate. The client is not malnourished (option 1), at nutritional risk (option most accurate? 3), and does not have polycythemia (high level) as indicated by option 4.
| The core issue of the question is knowledge of normal and abnormal hematological laboratory values. Use specific nursing knowledge and the process of elimination to make a selection. Note that options 1 and 3 are somewhat similar so you may eliminate both of those initially. |
30 Which of the following care measures should the Correct answer: 1 Crusting of dried exudate is common with bacterial conjunctivitis and it is important for the nurse include in the discussion when teaching home child’s vision and safety that the crusts are removed. Warm, moist wipes aid in comfort and care measures to the parents of a child who has they need to be disposable to reduce the risk of transmitting the infection to others in the bilateral bacterial conjunctivitis? home. Oral antihistamines, ophthalmic corticosteroids, and topical anesthetics are not indicated in the management of bacterial conjunctivitis.
| Note the critical word conjunctivitis in the stem of the question. Recall that this infection is highly contagious. Then determine the correct option by associating the word disposable in the correct option with the concept of infection in the stem of the question. |
31 After a client has experienced a seizure, what is the Correct answer: 2 After the seizure, the client will be postictal, which is a deep sleeping state. She/he could most appropriate position in which the nurse should aspirate secretions unless side‐lying to promote drainage from the upper airway. Positioning place the client? the client on the back (option 1) increases risk of aspiration. Positioning the client on the abdomen (option 3) or upright in chair (option 4) is unrealistic given the client’s postictal state.
| The core issue of the question is knowledge of a position that will reduce the risk of aspiration following seizure activity. Use nursing knowledge and the process of elimination to make a selection. Recall that the side‐lying position is commonly used in any situation in which aspiration is a risk. |
32 After correctly positioning a client for a wound Correct answer: 1 A client fall is a potential medical emergency; however, the nurse’s responsibility is ensuring dressing change, the nurse sets up a sterile field, the safety of the client being attended to. Option 2 ignores the safety of the potentially injured placing the wound supplies in the field. The nurse client. Option 3 wastes supplies. Option 4 could lead to a contaminated sterile field. hears a page to respond to another client who has fallen in the hallway. Which of the following is the most appropriate nursing action for the nurse to take?
| Options 1 and 4 are incorrect, sterile equipment is considered contaminated if left unattended and therefore must be thrown away. Option 2 is incorrect; the nurse needs to prioritize care appropriately. Thus the nurse needs to respond to the client who fell rather than continue with the wound dressing change. |
33 A client recently diagnosed with type 1 diabetes Correct answer: 4 The American Diabetes Association Exchange Lists divide food into groups with similar mellitus is learning to use the American Diabetes content (milk, vegetables, fruit, starch/bread, meat, and fat). All foods within a list are similar Association exchange lists. The nurse determines that in calories, protein, fat, and carbohydrates if eaten in a certain size portion. Foods may be the teaching has been effective if the client chooses exchanged within the same list. Rice and bread are starches, egg is meat, tomato is vegetable, which of the following as an appropriate exchange for and orange is fruit. white rice?
| First recall the basic food groups that are part of the American Diabetes Association Exchange Lists. Then compare each food choice identified with the list. Eliminate options 2 and 3 first as vegetables and fruits, then pick option 4 over 1 because it is a starch/bread. |
‐ Orange ‐ Bread | |
34 The nurse is teaching a group of adults about health Correct answer: 1, 3 Genetic screening can identify markers for several types of cancer. One method to remind screenings for cancer. The nurse would include in the men to perform self‐checks for cancer is to mark a calendar to monthly check for changes. Self discussion which of the following points? Select all that exams as well as regular medical tests and exams uncover tumors. After a total mastectomy, apply. women do not need mammograms. Skin cancer risk increases with age.
| Elimination of number 4 and looking suspiciously at the phrase most tumors will help to discriminate between the options. When in doubt, identify alternatives with most or all in the answer as false. |
35 During a coffee break, the nurse notices two Correct answer: 2 The nurse should speak privately to the coworkers about their behavior and the impact on coworkers arguing about how to handle a difficult the nurse overhearing them. It does not help the climate of the unit to let it pass (option 1). client. Their voices are raised and body postures are The nurse is not in a position to confront and reprimand coworkers (option 3). Option 4 is tense and defensive. Which would be the most somewhat plausible but option 2 personalizes the discussion between the nurse and the appropriate approach for the nurse to use to address coworkers, and thus is best to diffuse the situation. this conflict between staff members?
| Options 1, 3, and 4 are incorrect. To effectively manage conflict between staff members, address the conflict within an appropriate timeframe; do not let it pass unattended. Do not openly and publicly reprimand staff in front of other staff members or clients. Finally, address staff members privately but keep in mind what behavior is acceptable on the unit. |
36 The school nurse is assessing a muscular 17‐year‐old Correct answer: 2 The student’s age, along with symptoms of hair loss and edema indicate that this is not a female who is coming to the high school health service stage of puberty. The symptoms are not indicated in abuse of barbiturates or marijuana use. for complaints of edema, voice changes, and hair loss. By the process of elimination, the correct answer is option 2. The nurse’s primary analysis based on the subjective and objective data is that the student:
| The core issue of the question is knowledge of adverse effects of steroid use. Use this information and the process of elimination to make a selection. |
37 A 4‐year‐old child has been exposed to chickenpox. Correct answer: 1 The prodomal period refers to the period of time between the initial symptoms and the After the nurse has provided information about presence of the full‐blown disease. The rash would not be apparent during this time. All the chickenpox, the nurse asks the mother to repeat the other statements are correct. information. Which statement by the mother indicates a need for additional information?
| The critical words in the stem of the question are need for additional information. This tells you that the correct option is an incorrect statement. Use knowledge of this communicable viral infection and the process of elimination to make a selection. |
38 The school health nurse is interested in promoting Correct answer: 2 Adolescents tend to feel that they are invulnerable and that if anything bad will happen, it will safety in the high school population. In planning safety affect others but not themselves. They also tend to feel immortal, as it is difficult for them to education for this age group and their parents, the comprehend their own death. Option 1 is a factor related to the adult, option 3 is related to nurse would recognize that which of the following is a school‐age children, and option 4 is related to the elderly. developmental risk factor for adolescents?
| Focus on the developmental level of the client. To answer this question correctly, it is necessary to understand growth and development and apply this knowledge to the needs of the adolescent for safety. |
39 When giving directions to a 24‐year‐old female with Correct answer: 3 A full bladder is necessary to bounce the sound waves off to compare other tissues or possible appendicitis who is about to undergo a pelvic structures are being assessed. If done during pregnancy, the fetus must be over 26 weeks to sonogram, which statement should the nurse make to not have the restriction for the full bladder, since the amniotic fluid would be used at that the client? point. It would not be helpful to be NPO, because this would deprive the client of fluids. Enemas and refraining from medications are unnecessary.
| Fluids are needed to fill the bladder and are not withheld prior to testing. Bowel structures do not interfere with the assessment of structures and an enema is not required. Medications do not impact on sound waves and holding medications is not necessary for any reason. |
40 The nurse is conducting an initial interview with a 10‐ Correct answer: 2 Children at 10 years of age are egocentric and concerned with themselves. Asking about year‐old boy who has been brought to the mental interests and hobbies is likely to foster establishment of rapport. Focusing on behavioral health clinic by his parents. The nurse can establish symptoms (option 1) could lead to an adversarial relationship. Children often are rapport and credibility with the child by asking the uncomfortable talking about friends and family (option 3) until they get to know a person child about his: better. Most children are unconcerned about past medical problems (option 4); they are focused on the here‐and‐now.
| The core issue of the question is knowledge of communication strategies that are likely to be effective in developing a therapeutic relationship. Focus on the age of the child and cognitive developmental level to make a selection. |
41 The nurse is providing medication instructions to a Correct answer: 3 Spironolactone is a potassium‐sparing diuretic used to treat hypertension. Gynecomastia is client. The nurse informs the client that persistent one of its adverse reactions. Adverse reactions usually disappear after the drug is gynecomastia can result from taking which of the discontinued; however, gynecomastia may persist after discontinuing spironolactone. following newly prescribed diuretics?
| The core issue of the question is knowledge of adverse drug effects of spironolactone. Use specific drug knowledge and the process of elimination to make a selection. |
42 As the nursing unit representative member serving on Correct answer: 3 Client and family satisfaction surveys are a formal set of activities that can be used to remedy the hospital quality management committee, the deficiencies identified in the quality of direct patient care, administrative, and support services. nurse has been asked to evaluate the quality of nursing Incident reports (option 1) serve as an indicator of risk. Documentation of time and activities services on the unit. What would be an appropriate related to direct care may be done as part of time and motion studies. Acuity relates to the quality improvement activity for the nurse to ask team need for nursing staff on the unit. members to participate in?
| Note the critical word services in the stem of the question. With this in mind, the correct option is one that gathers data from the recipients of services. Options 1, 2, and 4 are not quality service measures. |
43 When a female client preparing for surgery suddenly Correct answer: 3 Option 3 is best because it represents a communication with the client and is open‐ended. bursts into tears, the preoperative holding unit nurse Options 1 and 2 are not the most appropriate initial approaches since the client is not should take which of the following actions? encouraged to share her concerns, although later on in the interaction these may be appropriate. Option 4 ignores the client and does not address the client’s concerns.
| The core issue of the question is the ability of the nurse to care for the emotional needs of a perioperative client. Since this is potentially an anxiety‐producing time for clients, choose the option in which the nurse provides a therapeutic response to the client. |
44 After reviewing the client’s health history, the nurse Correct answer: 3 Cigarette smoking is the leading cause of lung cancer. Smokeless tobacco is more often concludes that which of the following is the most associated with oral cancer. Air pollution may also be a contributing factor to development of significant factor related to the development of lung cancer. History of asthma is not associated with greater risk of lung cancer. bronchogenic carcinoma for this client?
| Eliminate option 1 first because it is a health problem, not a risk factor. From there, choose cigarette smoking over the other options because it is highly associated with lung cancer. |
45 The nurse is setting up the breakfast tray for a client Correct answer: 3 Foods that reduce lower esophageal sphincter (LES) pressure will increase reflux symptoms. with gastroesophageal reflux disease (GERD) and These include coffee, fatty foods, alcohol, and chocolate. All the other items can be given to notices one food that the client should not eat. Which the client. food should the nurse remove from the meal tray?
| The core issue of the question is knowing that certain types of foods lower LES pressure, and then being able to take it a step further and identify what types of foods those are. Eliminate each option systematically by reasoning that any foods high in fat (such as the cream in the coffee) can have this effect. |
46 The nurse is assessing a 30‐year‐old client with a prior Correct answer: 2 Theophylline is a xanthine that causes bronchial dilation due to smooth muscle relaxation. history of smoking who takes theophylline (Theo‐Dur) Increased levels of theophylline occur with liver disease and congestive heart failure. Option 3 for chronic obstructive pulmonary disease. Additional is incorrect because the client is young and therefore the age is insignificant. The smoking diagnoses include liver disease and congestive heart history (option 1) is not an issue; in fact, smokers metabolize theophylline more quickly and failure. The client is experiencing tremors, dizziness, may need increased doses. There is no data about the client’s weight (option 4) in the stem. tachycardia, and nausea. The nurse explains to the client that these symptoms may be the result of:
| The core issue of the question is knowledge that adverse effects of xanthine medication such as theophylline are increased in liver disease. Use specific knowledge of drug adverse effects and the process of elimination to make a selection. |
47 The nurse has admitted to the surgical unit a client Correct answer: 1, 2, 4, The LPN/LVN is trained to collect data that is then reported to the registered nurse (RN). who just underwent open reduction and internal 5 However, assessment remains the responsibility of the RN. For these reasons, the LPN/LVN can fixation of a severely fractured right radius and ulna. be expected to take vital signs, report drainage, administer medication, and elevate the casted Which nursing care activities would be appropriate for limb. The RN should retain the responsibility for assessing neurovascular status to the casted the nurse to delegate to the Licensed extremity in the immediate postoperative period. Practical/Vocational Nurse (LPN/LVN)? Select all that apply. 1.‐ Measure vital signs every 30 minutes. | Recall that procedures and simple data collection can be delegated to the LPN/LVN. With this in mind, eliminate each of the incorrect options systematically. |
‐ Report drainage on the cast if it appears. ‐ Assess neurovascular status of the fingers of the casted arm hourly. ‐ Elevate the casted arm above heart level. ‐ Administer the prescribed intramuscular analgesic as ordered. | |
48 Which of the following actions would the nurse Correct answer: 1 Tuberculosis is a respiratory infection, transmitted via airborne droplet nuclei less than 5 institute that is specific to the care of the assigned microns in size. client who has tuberculosis?
| Specific knowledge of the mode of transmission of Mycobacterium tuberculosis and the types of transmission‐based precautions is needed to select the correct answer. Eliminate 2 and 3 as tuberculosis is transmitted via air currents. Choose option 1 over option 4 because tuberculosis is transmitted via airborne droplet nuclei less than 5 microns in size. |
49 A client has a potassium level of 6.8 mEq/L. Which Correct answer: 1 The potassium level is abnormally high (normal 3.5–5.1 mEq/L). Since potassium is an sign or symptom would the nurse expect to find when intracellular ion, higher levels will alter the electrical pattern of the EKG. “Peaking of a T wave” assessing this client? is an indication that potassium is too high. With hyperkalemia (higher than normal potassium levels), muscle weakness, flaccidity of muscles, diarrhea, abdominal cramping, cerebral irritability/restlessness are present. Therefore, bowel sounds would be hyperactive and not silent, such as with an ileus. Muscles are weak and flaccid, not in a cramping state. Cerebral functions are stimulated and somnolence (sleeping, sluggishness) is not present.
| The core issue of the question is accurate interpretation of the potassium level and its significance. From there, associate the symptoms of hyperkalemia to make a selection. |
50 The nurse is preparing to take a client to the Correct answer: 3 The client should be NPO before the procedure in order to be given anesthesia for the electroconvulsive therapy (ECT) treatment suite. The procedure (options 3 and 4). The client, not the husband, should sign the consent form (option nurse must ensure that which of the following 1). The client should be wearing loose‐fitting clothing (option 2). pretreatment processes has been completed?
| The core issue of the question is knowledge that ECT requires anesthesia, which leads to loss of airway protective reflexes. Use this knowledge to reason that the client must be NPO to prevent the risk of aspiration during the procedure. |
51 To minimize the pain related to intramuscular Correct answer: 4 Administering very thick preparations such as penicillin G with benzathine (Bicillin LA) can be injection of 2 mL of penicillin G benzathine (Bicillin LA) painful. To lessen the pain, intramuscular injection into a larger gluteal muscle should be in an adult client, the nurse would take which of the administered over 12 to 15 seconds to separate the muscle fibers more gradually. Cold following actions? compresses to the injection site would delay absorption of the drug (option 1). Aspiration for blood return with all IM injections is necessary for safety since muscles contain larger blood vessels (option 3). Injection into the deltoid may also result in prolonged discomfort resulting in limited motion of the upper extremities (option 2). Rotating sites, light massage, and warm compress to site may also be employed to limit discomfort.
| The core issue of the question is knowledge of proper administration technique for thick liquid parenteral medications. Use knowledge of intramuscular injection techniques and knowledge of drug absorption principles to make a selection. |
52 The nurse is assigned to the care of an obese client Correct answer: 4 Teaching and assessment are within the domain of the registered nurse (RN) and cannot be who has gastroesophageal reflux disease (GERD). delegated to a UAP. The UAP is also not trained in therapeutic communication or counseling Which of the following activities could the nurse techniques. These ancillary caregivers can complete tasks under the supervision and direction appropriately delegate to the unlicensed assistant of the nurse, and report simple data when asked to do so. With this in mind, the only activity person (UAP)? that can be delegated is the simple direction to the client to remain upright after eating.
| The core issue of the question is knowledge of the appropriate tasks to delegate to a UAP. Recalling that teaching, counseling, and assessment remain the RN’s responsibility assists in eliminating each of the incorrect options. |
53 The nurse is admitting a client with thermal burns to Correct answer: 1 Clients should remain NPO upon admission to the clinical setting with a major burn. Initial both arms and anterior trunk. The client asks for a fluid replacement is started via the parenteral route. NPO status is maintained because the drink of water. What is the most appropriate response client may be in shock with blood flow directed away from the digestive organs to more vital for the nurse to make? tissues. In addition it is possible that the client suffered burn injuries that could cause internal damage to body structures, and aspiration is also a risk initially. Options 2, 3, and 4 are incorrect—fluids and food via the mouth would be restricted at this time.
| The core issue of the question is knowledge that the client who has experienced burn injury is under severe physiological stress, and as such, blood flow is directed away from the digestive tract. Focus on the need to stabilize the client physiologically and provide fluids by the IV route to help you choose correctly. |
54 A mother brings a 3‐year‐old child to the clinic for a Correct answer: 4 Every time a child enters the healthcare system, the immunization status should be checked. well‐child checkup. The child has not been to the clinic Some children have uncertain history of immunization because of parental noncompliance or since 6 months of age. The nurse determines that special circumstances such as being refugees. Once immunization status has been determined, which of the following is the priority of care for this the nurse can go on to assess growth and development and hearing, and to teach the parents child? about dental care as necessary.
| The critical word in the stem of the question is priority. This tells you that more than one option is likely to be a correct nursing action, but that one is more important than the others. Note the age of the child to help you choose immunizations as the priority, especially noting that the child has not received healthcare for 2.5 years, during a time when vaccinations should be kept up to date. |
55 A client who has pancreatitis is experiencing pain. Correct answer: 4 The pain in pancreatitis is usually aggravated by lying in a recumbent position, but improved After administering an analgesic, the nurse should by sitting up and leaning forward or in the fetal position with the knees pulled up to the chest. place the client in which of the following positions to This position reduces pressure caused by contact of the inflamed pancreas with the posterior promote comfort? abdominal wall.
| The core issue of the question is knowledge of proper positioning techniques to reduce the pain of inflammation that can be aggravated by movement. Use the process of elimination to select the position in which the pancreas is not as likely to be compressed against other body structures. |
56 The nurse would be most careful to assess for Correct answer: 1 Although many chemotherapy agents can cause stomatitis, the antimetabolites are stomatitis in a client receiving which of the following commonly known for causing this side effect. Fluorouracil is the only drug listed in this class. chemotherapeutic agents? Cisplatin is an alkylating agent; bleomycin is an antitumor antibiotic; and vincristine is a plant (vinca) alkaloid.
| The core issue of the question is knowledge of which antineoplastic agents cause stomatitis as an adverse effect. Use nursing knowledge and the process of elimination to answer the question. |
57 The nurse will be working with an unlicensed assistive Correct answer: 1 Safe and effective delegation is based on knowledge of the laws governing nursing practice person (UAP) for the work shift. Prior to delegating and knowledge about job duties and responsibilities. Nurses must understand the care to the UAP, the nurse places high priority on competencies and training of unlicensed assistive personnel. which of the following?
| Option 2 is incorrect; it is not necessary to provide written directions when delegating tasks to UAPs as long as verbal directions are clear and expectations are understood. Option 3 is incorrect; your responsibility is not preparing the supplies for a delegated task but rather to ensure the delegated task is completed safely and correctly. Option 4 is incorrect; it is not necessary to inform the client about the tasks or assignments delegated to non‐staff members. It is however, the responsibility of the staff member to inform the client prior to the assigned task what will be accomplished. |
58 The nurse believes a client has slight one‐sided Correct answer: 1 This assessment may be done to detect small changes in muscle strength that might not weakness and further tests the client’s muscle otherwise be noted. Pronator drift occurs when a client cannot maintain the hands in a strength. The nurse asks the client to hold the arms up supinated position with the arms extended and eyes closed. Nystagmus is the presence of fine, with hands supinated, as if holding a tray, and then involuntary eye movements. Hyperreflexia is an excessive reflex action. Ataxia is a disturbance asks the client to close the eyes. The client’s right hand in gait. moves downward slightly and turns. The nurse documents and reports that the client has which of the following findings on assessment?
| Specific knowledge of physical assessment techniques is needed to answer the question. Note the association between the terms supinated in the question and pronator in the correct answer, in response to the client’s change in hand position. |
59 When a client has arterial blood gases drawn from Correct answer: 3 Packing the sample in ice will minimize the changes in gas levels during the transportation of the radial artery, the nurse should plan to do which of the specimen to the lab. The arterial site should be held for 5 minutes or longer if the client is the following? receiving anticoagulant therapy. The blood is drawn originally in a heparinized syringe and does not need to be transferred to one. A second specimen is not necessary.
| The wording of the question tells you that the correct answer is also a true statement of fact. Eliminate option 1 first as being factually incorrect. Next, eliminate option 2 because the syringe is heparinized and the blood is not transferred to a test tube. Finally, eliminate option 4 because it is unnecessary. |
60 The nurse knows that a client in the long‐term care Correct answer: 2 For clients with dysthymia, a major concern is social isolation. Option 1 is contraindicated, as unit suffers from dysthymia. The most important is option 3. If the client has a poor appetite, assigning 2 liters of liquid intake (option 4) is not nursing intervention to include in the nursing care plan therapeutic, nor is planning three regular meals per day (option 3). is:
| The core issue of the question is knowledge of strategies to reduce the risk of isolation in a client with dysthymia. Use nursing knowledge and the process of elimination to make a selection. |
61 A client who is receiving intravenous heparin by Correct answer: 3 The effectiveness of a heparin protocol is monitored by trending APTT results to achieve a protocol orders has an activated partial therapeutic level. An APTT of 140 is above the therapeutic level of anticoagulation and thromboplastin time (APTT) level of 140 seconds therefore the infusion should be stopped per protocol, and resumed at a decreased dose in (control time is 36 seconds). What is the priority action one hour’s time with a repeat APTT ordered in 2–3 hours per protocol. The dose should not be that the nurse should institute? increased, as this would cause serious consequence to the client. Stopping the medication for a total 6 hours would undermine the anticoagulation control that the physician is trying to achieve. Ordering another APTT and continuing to run the infusion could also cause serious consequences to the client.
| The core issue of the question is recognition that this is a critically high value for the APTT and that the action that will maintain client safety is to turn off the heparin for a period of time. Use the process of elimination and knowledge of the effects of heparin on APTT times to answer the question. |
62 The nurse has admitted to the intermediate care unit Correct answer: 1, 3 The UAP can perform tasks or nursing care activities under the direct supervision of the a client who sustained a spinal cord injury at T1 in a registered nurse (RN). The nurse retains responsibility for assessment (options 2 and 5) and motor vehicle accident. Which of the following nursing teaching (option 4). care activities can the nurse delegate to the unlicensed assistive person (UAP) when working with this client? Select all that apply.
| The core issue of the question is the ability to discriminate between what the RN may delegate and what he or she may not. Evaluate each option and either choose it because it is a simple procedure or task, or choose not to select it because it involves assessment or teaching. |
63 The nurse has been instructed to have a surgical Correct answer: 4 The client’s right to withdraw consent is necessary to be part of the consent and it means that consent form signed by a client who will be undergoing coercion was not utilized in obtaining the signature. It is the physician’s responsibility, not the a surgical procedure. What is the most essential nurse’s, to explain the diagnosis (option 1) and the need for the surgical procedure (option 2). information to include in the discussion prior to the Cost (option 2) is not an important aspect for informed consent. The technical aspects of the client signing the permission? procedure are not needed by the client, although an overview of the procedure should be included (option 3), but again this is the role of the physician. All preparation for the procedure should include information about what the client will see, feel, and hear.
| The core issue of the question is knowledge of the nurse’s role in obtaining informed consent. Keep in mind that the nurse reinforces explanations already given by the physician and use the process of elimination to make a selection. |
64 The pregnant client is 7 centimeters, 100% effaced, Correct answer: 1 Presentation refers to the part of the fetus that is coming through the cervix and birth canal and at a +1 station. The fetus is in a face presentation. first. Thus a face presentation occurs when the face is coming through first. The nurse concludes that teaching has been effective when the client’s husband states:
| Associate the word face in the question with the word face in the correct response. The word presentation helps you to choose option 1 over option 2, which also contains the word face, but in an inappropriate context to this question. |
65 A client is scheduled to have a transverse colostomy Correct answer: The correct area is the proximal stoma, not the distal one that is nearer to the distal colon performed. While doing client teaching, the nurse and rectum. Coming from the small bowel in the center of the diagram, the stomas represent, points to which stoma on the diagram to show the in anatomical order, an ileostomy, cecostomy, ascending colostomy, transverse colostomy, client the location of the stoma? Select the correct descending colostomy, and sigmoidoscopy. stoma. | To answer this question correctly, recall the names of the anatomic portions of bowel. It will also help you to choose correctly if you recall that the prefix trans means across. This might help you select the stoma that is halfway across the abdomen. |
66 A child diagnosed with deficiency of growth hormone Correct answer: 2 Children with growth hormone deficiency are smaller than their peers and frequently who needs replacement drug therapy comes to the experience problems with self‐esteem and body image. Option 1 would be the opposite clinic for treatment. Which one of the following problem of what the client is experiencing. The nursing diagnoses in options 3 and 4 are nursing diagnoses would be most appropriate for this unrelated to the client in this question. client?
| The core issue of the question is knowledge that deficiency of growth hormone leads to short stature and often disturbed body image in the child. Use nursing knowledge and the process of elimination to make a selection. |
67 The nursing unit is understaffed and a nurse from the Correct answer: 3, 4 The intermediate care surgical nurse should be most comfortable assuming the care of surgical intermediate care unit has been floated to the surgical clients. Heart failure, diabetes, and thyrotoxicosis are medical problems, and the client unit for the day shift. Which of the following two with diabetes will also require extensive teaching. The client with nephrolithiasis may also clients should the nurse assign to this RN float nurse? require teaching about the procedure, but since the client will undergo moderate sedation, the Select all that apply. nurse would be completing typical preoperative care.
| Note the critical word surgical in the description of the work setting of the float nurse. With this in mind, choose the two clients that have procedures that are surgical in nature. |
68 The nurse would conclude that hypomagnesemia has Correct answer: 2 Effects of hypomagnesemia are mainly due to increased neuromuscular responses. Paralysis, not resolved if which of the following neuromuscular flaccidity, and decreased reflexes may be present with hypermagnesemia. signs is still present after treatment?
| Recall that options that have similarities are not likely to be correct. Examine the options from the viewpoint of neurological stimulation. Eliminate each of the incorrect responses because they reflect abnormally low activity of the nervous system. |
69 A client presents to the Emergency Department with Correct answer: 2 Troponin is a sensitive test that indicates damage to the myocardial cells. A CK‐MM a complaint of chest pain. Which serum laboratory test isoenzyme elevation would indicate skeletal muscle damage. The LDH<sup>4</sup> does the nurse check off on the laboratory slip as part isoenzyme is utilized to determine hepatic function and amylase is a digestive enzyme. of a protocol order to rule out an acute myocardial infarction?
| Specific knowledge is needed to answer this question. Recall that troponin is a newer enzyme that can be measured very early during myocardial damage and is an indicator of myocardial damage and thus myocardial infarction. |
70 The nurse is planning for a multidisciplinary team Correct answer: 2 The client’s level of risk for self‐harm is a major concern. The client may need a private room meeting concerning a client with bipolar disorder. In (option 1) and restricted visitors (option 3) if in a manic state. The client should not be discussing the client’s safety needs, the nurse would be overstimulated (option 4). sure to include: 1.‐ Placement of the client in a four‐bed room. | Critical words in the stem of the question are safety and bipolar disorder. Use nursing knowledge to associate depression as part of bipolar disorder with the threat to safety with suicide as a form of self‐harm. This will lead you to the correct answer. |
‐ The client’s risk level for self‐harm. ‐ Unrestricted visitors. ‐ The need of the client to participate daily in many concentrated activities. | |
71 A nurse is teaching a female client newly diagnosed Correct answer: 4 Ciprofloxacin is not recommended for Helicobacter pylori infection during pregnancy. The with Helicobacter pylori infection. The nurse other medications can be used after consulting with the physician. anticipates that which of the following medications will not be used after learning the client is pregnant?
| The core issue of the question is knowledge of the pregnancy categories of the specific drugs listed. Use the process of elimination to make a selection, realizing that specific drug knowledge is needed to answer the question. |
72 The nurse admitting a client with a history of Correct answer: 2 Trigeminal neuralgia is manifested by spasms of pain that begin suddenly and last anywhere trigeminal neuralgia (tic Douloureux) would question from seconds to minutes. Clients often describe the pain as stabbing or similar to an electric the client about which of the following manifestations? shock. It is accompanied by spasms of facial muscles, which cause closure of the eye and/or twitching of parts of the face or mouth.
| Note the critical word neuralgia in the question, which tells you the pain is of nervous system origin. Recalling that this type of pain is usually sharp, stabbing, and possibly burning may help you to eliminate some incorrect options. Distinguish between spasm associated with this disorder and paralysis (an opposite finding) to discriminate between options 2 and 4. |
73 Which of the following would be an appropriate Correct answer: 1 Abuse of laxatives and diuretics is a frequent purging behavior for bulimic clients. Options 2 intervention for the nurse to include in a plan of care and 3 pertain to anorexia nervosa clients. In regard to option 4, food should never be used as a for a client with clinical diagnosis of bulimia? reward.
| The critical word in the question is bulimia. Recall that this disorder has the classic features of binging and purging to guide you to the correct answer, which in this question is one that signifies agents that help one to purge. |
74 A client has a strong family tendency toward Correct answer: 3 Lifestyle modifications and recognition of risk factors are important parts of prevention of hypertension. He denies that he will get hypertension long‐term complications. Family history is a very strong risk factor but encouraging the client because he watches what he eats, gets plenty of to maintain his current lifestyle and following up with health screening would be the best plan exercise, and keeps his weight within normal range. of action. False reassurance that he will never be hypertensive and prophylactic When implementing the plan of care, the nurse would antihypertensive medications are inappropriate. do which of the following?
| The core issue of the question is lifestyle management to reduce the risk of developing hypertension. Select the option that focuses on prevention while addressing the continued risk that the client faces. |
75 A parent asks the nurse what to do with rough edges Correct answer: 4 When a cast is dry, edges that are not smooth or covered by a piece of stockinette should be of her child’s cast, which are beginning to cause covered to prevent skin irritation. This can be done by petaling the cast edges with strips of excoriation on the child’s skin. Which of the following adhesive tape, beginning each strip on the inside of the cast, and folding over the edge to the responses by the nurse describes the appropriate outside of the cast. action to take?
| The wording of the question indicates that the correct response is a true statement. Eliminate options 1 and 3 first as least plausible after visualizing these options, then discard option 2 as unrealistic, since the procedure would be completed at the time of application. |
‐ “Tape a soft towel to the edge of the cast to provide some protection from the rough edges.” ‐ “Petal the cast edges with strips of adhesive tape, placing the tape from just inside the cast over the edge to outside the cast.” | |
76 A 3‐month‐old infant is diagnosed with leukemia. Correct answer: 3 Immunizations should be withheld during leukemia exacerbations because the immune Which of the following does the nurse anticipate will system is compromised and the client cannot manage an appropriate response to the be part of the plan of care for this infant? immunization. There is no need to place the client in isolation without added evidence of immunosuppression (option 1). Options 2 and 4 are irrelevant to the issue of the question.
| The core issue of the question is knowledge that leukemia adversely affects the immune system. With this in mind, the nurse needs to be mindful that immunizations will need to be withheld during an exacerbation. Use nursing knowledge and the process of elimination to make a selection. |
77 The registered nurse (RN) is assigned to the Correct answer: 1 The RN is responsible for delegating tasks appropriately and is responsible for the actions of postpartum unit. Which task could the RN safely unlicensed personnel. Ambulating a postoperative client is the only task from those listed that delegate to a beginning student nurse? the RN could delegate to a novice student. The other tasks require higher level assessment and critical thinking skills and should be performed by the RN.
| Note the critical word beginning to describe the student nurse. With this in mind, select the delegation assignment that is simple and procedural in nature, and does not require assessment, teaching, or advanced knowledge in nursing. |
78 A client presents to the Emergency Department with Correct answer: 2 The primary organ in the right upper quadrant of the abdominal cavity is the liver. Because of a stab wound to the right upper abdominal quadrant. the early shock symptoms, which are presented, it would be expected that this organ has The client’s vital signs are BP 85/60, pulse 125, and possibly been lacerated, causing extensive uncontrolled internal bleeding. The other organ respiratory rate of 28 breaths/minute. The nurse systems would not be located in this area. should immediately suspect damage to what organ?
| First analyze the client’s vital signs to determine that the client’s status is consistent with a shock state. Then determine which organs are located in the right upper quadrant. Associate the liver, which is a vascular organ, and the location to determine the correct option. |
79 The client is scheduled for a barium enema and is Correct answer: 2 The client will, in most cases, return to the unit with barium still present in the bowel. The expressing concern that the barium will not be physician will order laxatives or enemas if the client is potentially not able to expel the barium evacuated and a bowel obstruction will occur. What on his or her own. The nurse should encourage the client to increase fluid intake if possible as would be the best response for the nurse to make to well. This is a common concern for many clients undergoing this procedure, and their feelings the client? should not be ignored or belittled.
| Note the critical words best response in the stem of the question. This tells you that the correct response is a true statement of fact. Recall that this test can cause constipation from residual barium to aid in selecting the correct option. |
80 The nurse is conducting an educational group on an Correct answer: 1 The only respectful therapeutic response here is option 1. The others are contraindicated for inpatient unit. One of the clients has not spoken during any group process. Everyone does not need to participate in every session (option 2). It is the group. An effective therapeutic response by the inappropriate to focus the group’s attention on one individual because of level of participation nurse would include: (option 3). The client should be allowed to remain part of the group until the client is ready to participate (option 4).
| The core issue of the question is knowledge of group process and conduct of a group meeting. Use knowledge of this treatment modality and the process of elimination to make a selection. |
4.‐ Stopping the group and asking the client to leave. | |
81 A client is experiencing seizure activity. The nurse Correct answer: 3 Phenytoin is a first‐line anticonvulsant medication that is used to control seizure activity. should prepare to administer which of the following Selegilene (option 1) is used to treat Parkinson’s disease. Diclofenac (option 2) is an NSAID, medications according to protocol? while sumatriptan (option 4) is used to treat headaches.
| The core issue of the question is knowledge of medications that are effective against seizure activity. Use specific drug knowledge and the process of elimination to make a selection. |
82 As part of the ongoing assessment of a client who has Correct answer: 1 After burn injuries, an elevated potassium level (normal 3.5–5.1 mEq) is expected because of an electrical burn, a complete blood count (CBC), cellular tissue damage with release of intracellular potassium into the bloodstream. The electrolyte panel, and renal panel were ordered. The hematocrit will be elevated (not decreased as in option 4) due to hemoconcentration, and the nurse would expect to find which of the following white blood cell count will be elevated as part of the inflammatory response to injury. results?
| First visualize what happens when cells are destroyed—intracellular contents are released into the circulation. Secondly, with burn injury fluid is lost through the burn surface and can lead to hemoconcentration. With this in mind, eliminate each option except potassium, which increases for both of the reasons just stated. |
83 A client with congestive heart failure (CHF) has been Correct answer: 2 In a 2‐gram sodium diet, foods high in sodium content should be eliminated. It is not enough advised to follow a low‐sodium diet. Which statement to stop adding salt or to go only by taste; clients should also be taught to read food labels for by the client indicates to the nurse that diet teaching hidden sodium content. Added salt while cooking is allowed in a 4‐gram sodium diet, not a 2‐ has been effective? gram sodium diet.
| The critical words in the question are low‐sodium. With this in mind, eliminate options 3 and 4 first because they are the least restrictive. Then eliminate option 1 because it is less comprehensive than option 2 and because option 2 addresses other sources of hidden sodium. |
84 After delivery, a Chinese client states she needs to Correct answer: 2 Chinese clients may perceive an imbalance in the hot and cold forces in the body after restore the balance between hot and cold forces in her delivery. They will avoid sources of cold, such as wind, cold beverages, and water (even if body and refuses to bathe. The most appropriate warmed) to regain a sense of balance between these extremes. A client’s culture plays a very nursing intervention is to: important part in who they are, and nurses should respect the client’s wishes as long as it will not result in harm to the client or others.
| Use principles of culturally competent care to answer this question. If using a multicultural perspective rather than one centered in a Western health care approach, you will be able to eliminate each incorrect response easily. |
85 While talking with a client the nurse notes that the Correct answer: 3 When a client’s level of anxiety markedly increases the nurse can relieve the anxiety by client rapidly becomes more uncomfortable and altering the focus of the discussion. Asking the client more details or abruptly stopping the anxious. What action should the nurse take? interview will probably increase the client’s anxiety level. Asking the client to relax may or may not be effective in reducing the client’s anxiety.
| The core issue of the question is the ability to recognize escalating anxiety in a client and determining the best means to effectively reduce it. Use knowledge of therapeutic measures for anxious clients and the process of elimination to make a selection. |
86 The nurse is preparing a client for discharge who will Correct answer: 4 Option 4 is correct because the client is honest, has an understanding of how to take the be taking lithium carbonate. Which of the following medication and what the side effects are, and knows that the side effect will subside statements indicates that the client is feeling eventually. Options 1 and 2 indicate that the client is feeling forced to take the medication but comfortable with being discharged on an antimanic has no desire or understanding of the benefits of the daily routine and dosages. Option 3 medication? indicates that the client has memorized the actions but does not understand the benefits or side effects of the medications.
| The core issue of the question is which statement indicates correct understanding of lithium as a medication. Use specific drug knowledge and the process of elimination to make a selection. |
87 A client has just finished a dose of intravesicular Correct answer: 2 For 6 hours following intravesicular chemotherapy, the toilet should be disinfected after each chemotherapy as treatment for bladder cancer. When use. This will help ensure that the biohazard of excreted chemotherapy drug is contained. The giving instructions to the unlicensed assistive toilet may also be double‐flushed. Options 1 and 3 are insufficient, while option 4 is personnel (UAP) who will give routine care to this unnecessary and does not address the biohazardous aspect of chemicals remaining in the client, what statement should the nurse make? toilet.
| The core issue of the question is how to prevent unintentional exposure of other people to biohazardous chemicals in the client’s urine following intravesicular chemotherapy. With this principle in mind, eliminate options 1 and 3 first because they are ordinary measures that do not provide additional protection. Eliminate option 4 next because of the word sterile. Clean gloves are needed only. |
88 The nurse is caring for a young child who has mitt Correct answer: 1 It is important that circulation is checked regularly. Typically the restraints are removed, one restraints. Which of the following priority actions at a time, every 2 hours to evaluate skin condition and circulation. Although options 3 and 4 needs to be done regularly to ensure that the child’s are correct, they are not the best response as they do not have to be checked as regularly as needs are met? the circulation and skin condition. Option 2 applies to an elbow restraint.
| Focus on the word priority in the stem of the question. Recalling that many aspects of restraint care are important, use the ABCs (airway, breathing, and circulation) to focus on the correct option—which addresses the child’s circulation to the restrained limb. |
89 The client is to undergo an extensive process of Correct answer: 1 Emergency airway and resuscitation equipment should be readily accessible whenever allergy allergy testing as an outpatient. The nurse would testing is administered because of the potential for hypersensitivity response and anaphylactic complete which of the following as a priority reaction. Because of the potential for a serious reaction, the client will be asked to wait in the intervention during the initial testing? office for a period of time so he or she can be monitored for any untoward responses. Visibility of the tested areas is important but not immediately essential. The room should be set up prior to the arrival of the client but it is not a priority.
| Note the critical word priority in the stem of the question. This tells you that the correct answer is the most important option and that more than one may be technically correct. Recall that allergic reaction is a risk with skin testing to guide you to the correct answer. |
90 A client who has been experiencing panic attacks asks Correct answer: 3 Symptoms associated with a number of medical conditions are very similar to the symptoms why the physician has ordered several laboratory tests. associated with panic attacks. When a medical condition is present, it should be identified and The nurse’s answer should incorporate which of the treated. The other options are inaccurate responses to the client’s question. following pieces of information?
| The core issue of the question is knowledge that physiological symptoms need to be ruled out as having a medical basis before they can be attributed strictly to psychological origins. Use this information and the process of elimination to choose correctly. |
91 A female client has been taking norethindrone Correct answer: 2 Norethindrone (Micronor) contains only progestin and no estrogen. Because estrogen may (Micronor) oral contraceptive pills. Which of the decrease lactation, progestin‐only pills are commonly used in lactating women. The other following items is most likely to be found in her health options do not address the issue of contraception during lactation. history?
| The core issue of the question is which oral contraceptive is safe to use while breastfeeding. Use knowledge of the estrogen component of norethindrone and the process of elimination to make a selection. |
92 The nurse in the emergency department is caring for Correct answer: 1 It is essential that the client’s spinal cord be immobilized to prevent further injury and loss of a client who has fallen 20 feet from a roof. While function. Assessing for lacerations, exposure of the client, and performing a full mental status performing the primary assessment, the most exam are all part of the secondary assessment. important nursing intervention will be which of the following?
| Focus on the critical words most important. Whenever a client has suffered a traumatic injury, the nurse must first address the ABCs and then address neurological status and needs. With this in mind, select option 1 over 4 as the priority because it safeguards the client. |
93 Which breakfast option indicates to the nurse that Correct answer: 3 The American Heart Association recommends a diet with reduced saturated fats and the client with coronary artery disease requires further cholesterol for clients with coronary artery disease. Canned peaches are high in concentrated diet instruction? sugars, which increase triglyceride levels. Egg yolks are high in cholesterol and whole milk is high in saturated fats. The other options reflect appropriate food selections that are low in saturated fat and cholesterol content.
| The wording of the question tells you that the correct answer to the question is the one that contains incorrect items. Correlate the words coronary artery disease with fat‐ containing foods to begin the elimination process. Choose option 3 because it contains eggs and whole milk, two sources of fat and cholesterol. |
94 The nurse would encourage the new mother to use Correct answer: 3 The football, or clutch, position provides the mother with more control of the newborn’s which breast‐feeding position to enable the mother to head and full view of face. The lying‐down position is usually done in bed (option 1). The cradle have optimal control of the newborn’s head while position often causes the newborn’s head to wobble around on the mother’s arm (option 2). giving the mother a full view of the infant’s cheeks and Options 1, 2, and 4 do not allow full view of the infant’s face. jaw?
| Visualize each of the options and systematically eliminate those that do not promote visualization of the face while maintaining control of the head. |
95 The nurse observes a sinus rhythm pattern on the Correct answer: 1 PEA is associated with what appears to be a normal electrical conduction pattern but there is cardiac monitor of a client admitted with diarrhea and no mechanical pumping of the myocardium. Ventricular fibrillation, ventricular tachycardia, vomiting. On physical assessment, the nurse is unable and asystole will not demonstrate an effective electrical conduction pattern on the cardiac to palpate a central pulse. The nurse would suspect monitor. that the client is demonstrating which of the following?
| Associate the words unable to palpate in the stem of the question with the word pulseless in the correct option. Otherwise, it is necessary to understand the pathophysiology involved in this question. |
96 While teaching a client about the proper Correct answer: 3 To promote absorption, the client should not blink for 30 seconds after the administration of administration of dipivefrine (Propine), the nurse dipivefrine. Options 1, 2, and 4 are incorrect for the administration of dipiveprine. would provide which of the following instructions?
| The core issue of the question is knowledge of proper administration technique for dipivefrine. Use specific drug knowledge and the process of elimination to make a selection. |
97 The nursing unit is short‐staffed for the shift and a Correct answer: 1 Pediatric clients can be diagnosed with diabetes and the float nurse should be familiar with registered nurse (RN) from the pediatric unit has been this health problem and could do client teaching. The nurse is not as likely to have recent floated to the nursing unit. Which of the following experience in working with clients with Guillain‐Barré syndrome or who have had prostate clients should the nurse assign to the float nurse? gland surgery. The client with dementia who is being transferred will require transfer paperwork to be completed, and the pediatric nurse may not be as familiar with these types of forms because of the pediatric population usually worked with.
| Review the diagnoses of each of the possible clients and choose the one that the pediatric nurse is most likely to have experience working with. |
98 A client has experienced a near‐drowning event in salt Correct answer: 3 Pulmonary edema occurs as a result of fluid shifts caused by the ingestion of the hypertonic water. The nurse anticipates that one of the salt water. The result is fluid collecting in the interstitial spaces causing pulmonary edema. complications this client may experience is: Hypoxia, hypovolemia, and acidosis occur as a result of near‐drowning incidents.
| Note the critical words salt water and consider concepts and dynamics of fluid movement in the body. Because of the hypertonic water entering the client’s lungs, envision that the client’s own body fluid would move into the alveoli to equalize the tonicity. |
99 The nurse has just read the results of a client’s Correct answer: 1 A positive TB test means that the organism is present in the body in either an active or a tuberculin (TB) test at a health fair. An induration is dormant state. It should not be ignored nor should further testing be deferred for several apparent. The client asks what this means. The nurse’s months. The client can expect to be scheduled for sputum tests for the presence of the bacillus best response would be: and a chest x‐ray to determine the presence of lesions or active disease. Medications and isolation are not instituted until a probable or definitive diagnosis has been made.
| Note the presence of the critical word best. This tells you that the correct answer is a true statement of fact. Use knowledge of this test and the process of elimination to make a selection. |
100 An anxious client begins to yell and interrupt other Correct answer: 1 Speaking slowly and softly reduces stress‐related emotions. Instructing the clients to ignore clients. The client’s speech is rapid and pressured. the behavior will not assist them in reducing anxiety. A client experiencing severe or panic What action should the nurse take? anxiety will be unable to focus on identifying behaviors of anxiety. Reminding a client of the need to use good manners when talking with other clients ignores the client’s anxiety and may only increase the symptoms of anxiety.
| The core issue of the question is knowledge of therapeutic communication techniques with a client whose anxiety is escalating. Select the option that is most likely to have a calming effect on the client from a behavioral perspective. |
101 The nurse suspects that hepatotoxicity is developing Correct answer: 2 Jaundice in the dark‐skinned client can best be observed by assessing the hard palate. in a dark‐skinned client who is on an antibiotic. In what Normally fat may be deposited in the layer beneath the conjunctivae that can reflect as a area of the body should the nurse assess for jaundice? yellowish hue of the conjunctivae and the adjacent sclera in contrast to the dark periorbital skin. In these clients, palms and soles may appear jaundiced, but calluses on the surface of their skin can also make the skin appear yellow.
| The core issue of the question is how to assess for jaundice in a client with dark skin. Keep in mind that the oral cavity is a good choice to help guide you to a correct response. |
102 The nurse on the oncology unit has received intershift Correct answer: 2, 1, 4, The nurse should assess first the client who has the low platelet count (normal reports on 4 clients. In what order should the nurse 3 150,000–450,000/mm<sup>3</sup>), and then the client who has the borderline assess these clients? Place in order of priority by low WBC count, because these represent greater and then lesser threat to physiological status. clicking and dragging the options below to move them From there, the nurse should answer the questions for the client going for chemotherapy, and up or down. finally see the client who is upset so that the nurse can plan to spend time with this client.
| Remember that physiological needs take priority over psychosocial and learning needs. Choose the client with the most serious physiological need first (which is the client with the most abnormal labs) followed by the other client with a physiological concern. Then use time as a means of setting priorities for the remaining clients, since the client who is in psychological distress would benefit from greater interaction time with the nurse. |
103 Which nutritional measure would help a client with Correct answer: 3 A client with GERD should limit (or possibly eliminate) the intake of coffee because this can gastroesophageal reflux disease (GERD) to minimize relax LES pressure and lead to symptoms. The other options would not be warranted because the risk of symptoms? all would contribute to the development of symptoms: large meals, spicy foods (extra garlic), and peppermint (which would relax LES pressure).
| Recall that coffee, chocolate, and fatty foods lower LES pressure and therefore increase the risk of reflux. Knowing that these types of food choices need to be limited helps guide you to select option 3. |
104 A client who is 20 weeks gestation is concerned about Correct answer: 3 The child should be included in planning for the new baby. Children may feel threatened by a how to tell her 3‐year‐old son about her pregnancy. new sibling and so may need extra time and attention. Parents should avoid putting too much Which of the following would be the best statement responsibility on the child. when counseling this client?
| Use knowledge of growth and development principles and communication skills to make a selection. The correct answer is the option that includes the needs of the child as a client as well as the parents. |
105 A nurse is caring for a client with pneumonia. ABG Correct answer: 3 The pH is elevated, HCO<sub>3</sub><sup>‐</sup> is elevated, and results are pH 7.49, PaCO<sub>2</sub> 32 PaCO<sub>2</sub> is low. This indicates that there is a mixed respiratory and mmHg, HCO<sub>3</sub><sup>‐ metabolic alkalosis. Clients with pneumonia are prone to develop respiratory alkalosis. Option </sup> 28 mEq/L, PaO<sub>2</sub> 1 is incorrect because the HCO<sub>3</sub><sup>‐</sup> level alone 89 mmHg. This nurse analyzes these results as: would be decreased. Options 2 and 4 are incorrect because the ABG values do not reflect these conditions.
| Note the critical word pneumonia in the question. With this in mind, reason that the disorder is likely to be respiratory in origin, which allows you to eliminate options 1 and 2. |
106 A client experiences severe nausea for up to 2 weeks Correct answer: 3 A client at risk for nausea should not lie down for at least 30 minutes after meals to avoid following her chemotherapy treatment. Which aspiration. The physician should be notified of excessive weight loss (option 1). Foods and statement indicates a need for further instruction on beverages are better tolerated when they are neither hot nor cold (option 2). Option 4 is a management of nausea? good client action if other measures fail (option 4).
| The core issue of the question is knowledge of factors that will relieve or aggravate nausea caused by cancer chemotherapeutic agents. Use knowledge of the effect of gravity upon digestion as well as general measures of managing nausea to make a selection. |
107 While assessing the chest tube drainage system of a Correct answer: 3 The movement of the fluid, also referred to as tidaling, in the water indicates normal lung client, the nurse observes a slight rise and fall in the expansion. The physician should not be called unless the movement ceases. Coughing will water level in the water seal. The nurse should take increase the movement and repositioning the chest tube will have no effect on the oscillation. which of the following actions?
| To answer this question it is necessary to have a basic understanding of chest tube function. Beyond that, note the critical word slight in the stem of the question, which helps to eliminate option 1. Eliminate option 4 because it is not within the scope of nursing practice. Choose option 3 over 2 because there is no reason to ask the client to cough. |
108 During which of the following procedures should the Correct answer: 2 According to standard precautions, the caregiver should wear goggles when contamination labor and delivery nurse wear protective goggles in from splashing is possible, as when the membranes are artificially ruptured (amniotomy). The addition to gloves? other options place the nurse at risk for contamination from skin contact, necessitating the use of gloves.
| The core issue of the question is knowledge of when to use various personal protective equipment items. Recall that amniotomy refers to rupture of the amniotic membrane and then reason that this could involve splash and require the use of goggles. |
109 A client with cancer has a calcium level of 11.8 mg/dL. Correct answer: 4 The normal calcium level is 9.0–11.0 mg/dL, making this client hypercalcemic. Muscle Which of the following symptoms would indicate a weakness is a key feature of hypercalcemia due to alterations in excitable membranes. This need for the nurse to call the physician for treatment occurs as a complication in some clients with cancer. Peaked T waves, muscle spasm, and orders? increased gastric motility are signs of hyperkalemia.
| The core issue of the question is knowledge of electrolyte imbalance (hypercalcemia in this case) and the associated manifestations. Recall that calcium plays a key role in nervous system function to help guide you to the correct option. |
110 When evaluating the effectiveness of nursing care Correct answer: 2 Anxiety can be a healthy protective response to an actual threat. Defense mechanisms are plans used for an anxious client, it is important to unconscious psychological responses designed to diminish or delay anxiety. Anxiety, at times, validate that the client understands that: cannot be avoided and is a healthy adaptive reaction when it alerts the person to impending threats.
| The core issue of the question is knowledge that anxiety can exist to a greater or lesser state at any given time, and that some anxiety may be helpful as it increases alertness and performance. Use this background knowledge to select the correct option. |
111 In assessing a hospitalized client 1 hour after Correct answer: 2 Apresoline is a vasodilator and if the client becomes dehydrated, hypotension will result. In receiving hydralazine (Apresoline) 20 mg PO, the nurse other words, during dehydration both preload and afterload are reduced, causing the tank to notes that the BP is 68/42. The client has been taking get larger with less volume. The normal dose of hydralazine is 5 to 25 mg PO. Serum potassium this medication for several years at home without is high but unrelated to apresoline. The increased heart rate is a reflexive response to the low difficulty. Which of the following factors most likely cardiac output to compensate with decreased preload and afterload. contributed to this episode of hypotension?
| The core issue of the question is knowledge of factors that will compound or worsen a low blood pressure in a client taking an antihypertensive medication. Recall that factors that cause vasodilation or reduce the circulating volume (such as dehydration) can cause a drop in blood pressure. Use the process of elimination to systematically discard options that do not have this causative influence. |
112 A client with a history of heart failure suddenly Correct answer: 4 In a client whose condition is deteriorating, the RN should delegate the task that is most exhibits shortness of breath, a respiratory rate of 30, procedural in nature (in this case the urinary catheter). The LPN is able to collect data to report crackles auscultated bilaterally, and frothy sputum. to the RN, but in a client whose acuity is changing, it is better for the RN to make the After telephoning the physician for medical orders, assessments (option 2). The RN should also insert the IV line and immediately administer the IV which action should the nurse delegate to the Licensed medication. Practical/Vocational Nurse (LPN/LVN)?
| Use knowledge of the principles of delegation. Eliminate the options that address IV and IV medication, because these should be retained by the RN. Choose the catheter over vital signs because the RN would need to interpret the significance of the vital signs, not merely measure them. |
113 An 86‐year‐old client will be undergoing a surgical Correct answer: 1 Older clients need time to digest the information and ask questions. Option 2 is incorrect procedure. Which of the following changes would the because most older clients are able to make decisions for themselves. Option 3 can be nurse make in the informed consent process for this considered coercion, while option 4 can be appropriate but is not the best option since clients elderly client? need more than reading material for an informed consent.
| The core issue of the question is the need for the older adult undergoing surgery to have sufficient time to process information. Choose the option that takes into consideration age‐ related changes of older adults. |
114 The labor and delivery nurse would make it a priority Correct answer: 4 To begin life, the infant must make the adaptations to establish respirations and circulation. to assess which of the following two newborn body These two changes are crucial to life. All other body systems become established over a longer systems immediately after birth? period of time (options 1, 2, 3).
| Use the ABCs—airway, breathing, and circulation—as the strategy for answering this question. |
115 The nurse is caring for the client who is recovering Correct answer: 2 The eggs provide 24 grams of protein and the whole milk adds calories. The other options are from partial thickness burns. Which of the following lower in protein and calories. A client recovering from burns requires a high‐protein, high‐ breakfast options indicates client understanding of the calorie diet. Option 1 does not reflect an adequate protein source. Option 3 reflects an recommended diet? increased carbohydrate source and bacon is considered a fat, not protein. Option 4 does not reflect a high‐protein, high‐calorie meal but rather a low‐calorie meal selection with a greater carbohydrate content.
| First recall that clients with burn injury need to take in foods that are high in protein and calories. With this in mind, compare each option against this need to eliminate each of the incorrect options systematically. |
116 An adult client with diabetes insipidus who has been Correct answer: 1 Signs of overdosage of desmopressin, an antidiuretic hormone, include blood pressure and taking desmopressin (DDAVP) intranasally comes to pulse elevation, mental status changes, and water and sodium retention. Because the the clinic for a regularly scheduled appointment. The medication therapy needs to be interrupted, the nurse should notify the physician. Option 2 nurse assesses the client’s mental status and notes would place the client at risk because of lack of timely treatment. Options 3 and 4 would not some disorientation and behavioral changes. address the current complication. Significant pedal edema is also present. What should be the nurse’s next action?
| The core issue of the question is knowledge that fluid retention is an adverse drug effect and that this client is showing signs of excessive drug therapy. Use drug knowledge and the process of elimination to answer the question. |
117 The nurse is assigned to the care of a client receiving Correct answer: 2, 5 Simple activities and nursing procedures can be delegated to the UAP. For this client, this radiation therapy for cancer. Which of the following would include ambulation and documentation of intake and output. The RN retains activities needed in the care of a client receiving responsibility for assessment, teaching, and counseling the client. For this reason, the nurse external beam radiation therapy could be safely should not delegate assessment of the skin at the treatment site, patterns of fatigue, or how delegated to an unlicensed assistive person (UAP) the client is coping with the diagnosis and treatment. working on the nursing unit? Select all that apply.
| Recall that the RN does not delegate assessment, teaching, and counseling and evaluate each of the options in relation to these guidelines. |
118 A 76‐year‐old woman visits the ambulatory clinic with Correct answer: 4 Visual difficulty caused by distortions and impairment of central vision is common with reports of having difficulty reading and doing macular degeneration. Peripheral vision in most cases is normal. The symptoms are not needlework because of visual distortions with blurring characteristic of glaucoma (loss of peripheral vision), cataracts (gradual deterioration of vision of images directly in the line of vision. The peripheral with opacity of lens), or detached retina (sudden change in vision with a sense of a curtain vision assessment by the nurse yields normal findings. falling over the field of vision). The nurse suspects that this client is experiencing which of the following visual problems?
| Specific knowledge of the various visual disorders is needed to answer the question. Eliminate options 2 and 4 first because of the client’s description. Then choose correctly from the remaining two options because of the nature of the disorder. |
119 A female client states that she will not undergo any Correct answer: 1 An ultrasound is the only noninvasive procedure listed. The others require swallowing (option invasive testing for her “stomach pain.” The nurse 2) or injecting (option 4) contrast, or insertion of an endoscope (option 3). explains that which of the following tests could be completed to assess the abdomen and still meet the client’s wishes?
| The core issue of the question is knowledge of noninvasive diagnostic tests for the gastrointestinal system. Eliminate each of the incorrect options because of the words or suffixes swallow in option 2, ‐oscopy in option 3, and contrast in option 4. These all imply that the test will be intrusive to the body. |
120 Certain that her stomach pain is a symptom of Correct answer: 2 When a client with a somatization disorder does not receive symptom relief, anxiety cancer, a female client with somatization disorder increases (as evidenced by her current symptoms). Although the client may experience pain, exhibits pressured, rapid speech; elevated pulse and hopelessness, and disturbed body image, the major issue is anxiety. blood pressure; palpitations; and preoccupation with her pain, despite negative results from a gastroscopy. The nurse formulates which of the following as the priority nursing diagnosis?
| The core issue of the question is the ability to determine that the basis for the client’s agitation is anxiety. The critical words in the stem of the question are somatization disorder. Review this topic area if this question was difficult. |
121 A client is taking an over‐the‐counter preparation Correct answer: 1 Bismuth‐containing preparations, such as Pepto‐Bismol, can cause all the listed side effects, containing bismuth subsalicylate (Pepto‐Bismol) for but transient darkening of the tongue and stool is a specific side effect to bismuth. diarrhea. Which of the following side effects would a nurse monitor for that is unique to the bismuth portion of this drug?
| The critical word in the stem of the question is unique. With this in mind, use the process of elimination and knowledge of drug components to determine which side effect is caused by bismuth. As an alternative strategy, select option 1 because it is the only one that is located in the very upper GI tract. |
122 The nurse is taking a nursing history from the mother Correct answer: 1 Acute episodes are characterized by bulky, frothy stools and steatorrhea because of of a child being admitted with flare‐up of celiac malabsorption, anorexia, and irritability. The client would not exhibit increased appetite disease. What piece of information would the nurse (option 2), cheerful behavior (option 3), or soft, formed stools (option 4). expect the mother to report?
| The core issue of the question is the manifestations of celiac disease that occur because of the underlying pathophysiology. Recall that this disorder is characterized by malabsorption of key nutrients to help eliminate incorrect options. |
123 A nurse is discussing the home maintenance regimen Correct answer: 1 Regular exercise can help to normalize bowel function. Cigarette smoking and gum chewing with a client who has irritable bowel syndrome. Which increase swallowed air; fresh vegetables are gas‐producing. of the following statements indicates client understanding?
| Use knowledge of healthy lifestyle habits that stimulate normal bowel function as a means of answering this question. Eliminate options 2 and 3 first as least helpful in health promotion. Choose option 1 over 4 because excessive fresh fruits and vegetables could aggravate irritable bowel syndrome. |
124 A primigravida client of 16 weeks gestation states Correct answer: 4 The embryo’s muscles spontaneously contract beginning at 7 weeks. The mother perceives that she has not yet felt fetal movement. The nurse’s sensations of movement of the fetus from 16 to 20 weeks gestation. A primigravida usually best response is: perceives movement closer to 20 weeks.
| The core issue of the question is knowledge of fetal growth and development. An easy way to remember this information is to equate 4 weeks to be one month and then remember movements are felt at 4 to 5 months (16 to 20 weeks). |
125 The mother of an infant who underwent surgery to Correct answer: 1 A double‐diapering technique will help to protect a urinary stent following repair of repair hypospadias asks the nurse why the infant is hypospadias or epispadias. The inner diaper collects the infant’s stool, while the outer one diapered as shown. The nurse would respond that this collects urine. method of diapering will help to:
| The core issue of the question is the rationale for a specific diapering technique following surgery to correct hypospadias. Eliminate option 2 first as least realistic and choose the correct option after determining which option best reflects safety considerations and protection of the surgical area. |
126 Following the administration of a Correct answer: 1 An inspiratory stridor is indicative of a hypersensitivity reaction to the DPT immunization and diphtheria/pertussis/tetanus (DPT) immunization the epinephrine should be administered to counteract the symptoms of the allergic response. nurse notes that the infant has inspiratory stridor. The Options 2 and 3 are irrelevant, and option 4 places the infant at risk for injury or death. nurse should take which of the following actions?
| The core issue of the question is recognition that stridor following immunization is a sign of hypersensitivity to the drug. With this in mind, use the process of elimination to select option 1 as the answer, since epinephrine is the drug treatment of choice. |
127 The nurse is talking with the unlicensed assistive Correct answer: 4 To coach is to give direction and suggestions for improvement. Option 4 illustrates this person (UAP) about time management skills and concept. Option 1 is threatening rather than coaching. Option 2 is a criticism without a techniques. Which of the following statements would suggestion for improvement. Option 3 is helpful as a statement of positive reinforcement but the nurse make if intending to act as a coach? does not specifically give direction for future actions.
| The critical word in the stem of the question is coach. Use the ordinary definition of the word and choose the option that gives suggestions or advice to improve performance. |
128 A nurse is explaining to a woman considering Correct answer: 3 The nurse would determine that the client understood the information if the client stated pregnancy how rubella is transmitted. The nurse rubella is transmitted by the droplet route. Clients with rubella are placed in droplet determines that the teaching session had the desired precautions, as the causative agent is transmitted by particle droplets larger than 5 microns. outcome if the client states that rubella is transmitted The other responses are factually incorrect. by:
| Knowledge about the transmission of rubella and the elements of each type of transmission‐based precautions is required. Select an option based on nursing knowledge. |
129 A female client has been successfully resuscitated Correct answer: 2 A pH of 7.6 indicates an alkalotic state. The administration of bicarbonate would be the best after cardiac arrest. Her arterial blood gas reveals a pH answer. Anaerobic metabolism and the production of lactic acid lead to an acidotic state, of 7.6. The nurse attributes this result to which of the explaining why blood gases drawn during a code usually show acidosis. This pH is not within following? normal limits. | First recall that a pH of 7.6 is alkalotic to eliminate options 1 and 3. Next eliminate option 4 because the result is not normal. Alternatively associate the high pH with the drug sodium bicarbonate, which raises pH. |
‐ Anaerobic metabolism, which caused lactic acid production ‐ Excess sodium bicarbonate, which was administered during the resuscitation ‐ Repeat blood gases, which are performed during a code, frequently show acidosis ‐ Normal blood gas results | |
130 The nurse would anticipate finding which of the Correct answer: 2 Characteristics of a client with pain disorder include believing there is a physical cause for following client characteristics when working with a distress when there is no organic basis, the need to use analgesics or drugs to reduce pain, and client who has a pain disorder? impaired role performance.
| The critical words in the stem of the question are anticipate and pain disorder. With this in mind, determine that the core issue of the question is characteristics that are compatible with this disorder. Use nursing knowledge and the process of elimination to make a selection. |
131 Which of the following should be the highest priority Correct answer: 1 The client must understand the medication information as a priority item. Option 2 is a false of the education plan for a client being treated with statement. Effective medication dosing should control seizure activity (option 4). Teaching that medication therapy for a generalized seizure disorder? urine may turn pink to brown may be included if appropriate, but is not the highest priority.
| The critical words in the stem of the question are highest priority. This tells you that more than one option may be factually correct and that you must choose the most important item. Recall that insufficient drug therapy may lead to seizure recurrence to help you select appropriately. |
132 The pediatric nurse needs to rearrange room Correct answer: 2, 5 The child with the low white blood cell count (normal assignments of clients to accommodate three 5,000–10,000/mm<sup>3</sup>) and the child receiving chemotherapy are at risk additional clients who will be admitted during the day. for infection and could be cohorted together because they should both be on neutropenic Which two of the following clients would be best for precautions. The child who underwent appendectomy should be separated from the children the nurse to place together in the same room? Select with viral encephalitis and scarlet fever. The children with infections should not be cohorted all that apply. because one is viral (encephalitis) and one is bacterial (scarlet fever) in origin.
| Examine the clients in the question and determine similarities and differences among them. The two that are the most similar and that have the most similar needs from an infection control perspective are the ones who should be placed together. |
133 A 32‐year‐old female client who is HIV‐positive is Correct answer: 4 A client who is HIV‐positive (regardless of sex) is likely to lose weight due to repeated cycle of receiving treatment at an outpatient clinic. The nurse wasting and malnutrition. The client, who may be unable to merely increase caloric intake, reviewing the dietary assessment record notes that should be instructed in dietary techniques that maximize quality of intake. Option 1 is the client has been skipping meals and progressively incorrect—even though a food diary would provide pertinent information, the response allows losing weight. What dietary interventions would be for a delay in treatment that could result in further weight loss for the client. The priority is to best for the nurse to suggest to promote weight gain? intervene early on to prevent the onset of wasting. Option 2 is incorrect because it provides the client with a false belief that fluid retention changes associated with the menstrual cycle may have an impact on nutritional status. Option 3 is incorrect—even though increased salt in the diet can lead to fluid retention and weight, it does not address the underlying issue of nutritional balance.
| Analyze each of the options and choose the one that has the most direct and positive impact on weight gain. Using this strategy, you can systematically eliminate each of the incorrect options. |
134 The nurse would assess a 76‐year‐old client for which Correct answer: 4 Polypharmacy is using multiple doctors and multiple pharmacies to get the health care common problems that most increases the risk for needed often from a variety of specialists. The overall problem is that different doctors may major complications of heart and lung disease? not know what other doctors had ordered. Some drugs may interact with others and others may be the same drug in a different form. Overdosing and interactions become more common with this problem.
| Although taking medications on one’s own in combination with prescriptive meds can lead to problems, a greater problem is the polypharmacy issue. Sharing meds is also done in some adults when they want to assist another by offering them a medication that helped in their case. Financial issues may come into play as adults share meds, but this is also a smaller issue than polypharmacy. Taking the medications as ordered will not increase the risk of complications; it should reduce that risk. |
135 A client with acute respiratory distress syndrome Correct answer: 4 Placing the client with ARDS in a prone position allows for expansion of the posterior chest (ARDS) shows no improvement despite increases in the wall, which may be effective in enhancing oxygenation. Transfusing red blood cells or albumin concentration of oxygen administered. What does not increase oxygenation in ARDS. Option 3 should have been done as an initial measure. intervention should the nurse attempt which may improve ventilation‐perfusion matching?
| The core issue of the question is an intervention that may increase oxygenation in a client with ARDS. Note the critical words nursing intervention to eliminate options 1 and 2, which require a physician’s order. Choose option 4 over 3 because it allows for expansion of the back side of the client’s lungs, and redistribution of blood flow using gravity. |
136 The nurse is giving general information about Correct answer: 3 Because ACE inhibitors can cause fetal harm or death, they should be discontinued as soon as antihypertensive medications to a young female client pregnancy is detected. Their effect on breastfeeding infants is unknown. The effect of other with a history of hypertension. The nurse includes that medications is unknown during pregnancy. which of the following types of antihypertensives should not be used if the client becomes pregnant?
| The core issue of the question is knowledge that ACE inhibitors need to be avoided during pregnancy because they are harmful to the fetus. Use knowledge of drug therapy and the process of elimination to make a selection. |
137 A nurse from the pediatric intensive care unit has Correct answer: 2 The pediatric intensive care nurse is more likely to have experience working with heart floated to the cardiovascular intermediate care unit failure, since children can experience heart failure secondary to cardiac defects. Myocardial for the shift. Which of the following clients would the infarction, stent placement, and coronary atherectomy are problems and procedures done for nurse assign to the float nurse for the shift? adult clients.
| Note the critical words pediatric intensive care in the stem of the question. Then determine which client has the health problem that could also be experienced in the pediatric population. |
138 A client is admitted to the pre‐surgical area before Correct answer: 1 The priority nursing intervention is one that maintains contact of the retina with the choroid undergoing surgery to repair a detached retina. The by positioning the client so the detached area falls against the choroid. It is unnecessary to admitting nurse would take which of the following darken the client’s immediate environment. A preoperative medication may be ordered, but actions first? has lesser priority than maintaining proper position of the head to protect the eye. Both eyes, not just the affected eye, are patched to minimize eye movement.
| The critical words in the question are actions and first. This indicates that more than one option may be correct but that one is more important than the others. Use knowledge of pathophysiology to make the correct selection. |
4.‐ Cover the affected eye. | |
139 A client has been admitted to the nursing unit with a Correct answer: 3 Loss of potassium caused by vomiting and diarrhea, in addition to lack of replacement intake, three‐day history of severe nausea and vomiting with will lead to a risk for hypokalemia (normal range is 3.5–5.1 mEq/L). Calcium levels (normal diarrhea. The client is experiencing fatigue, anorexia, 9–11 mg/dL) are not affected by vomiting and diarrhea and the sodium level (normal 135–145 and muscle weakness. Based on this history, which mEq/L) will be elevated with the loss of potassium. laboratory findings should the nurse expect to find?
| Critical words in the question are vomiting and diarrhea. With this in mind, recall that potassium may be lost from the GI tract. Eliminate option 2 first because it is within normal range, and then eliminate the calcium levels as less relevant to the question than potassium. |
140 The nurse would select which of the following as a Correct answer: 1 The client who has many physical complaints with no organic basis is not conscious of priority nursing diagnosis for a client who has many conflicts and stressors, and is, therefore, unable to use other means to cope with anxiety. physical complaints that are not supported by There is no evidence of impaired adjustment or verbal communication. Nothing in the stem of diagnostic test evidence? the question specifically states that the client is in pain.
| A key phrase is many physical complaints and a critical word is priority. With these in mind, use the process of elimination to select the nursing diagnosis that is compatible with the client information as stated. It is important not to read into the question. |
141 A client presents to the Emergency Department with Correct answer: 2 Epinephrine is a beta‐adrenergic agent that has beta 1 adrenergic action, causing increased inspiratory and expiratory wheezes and intercostal heart rate and increased force of myocardial contraction. The results of subcutaneous retractions. A diagnosis of acute bronchospasm epinephrine should be seen in 5 minutes. The effects may last up to 4 hours. The other options secondary to acute bronchitis is made. Epinephrine are incorrect. (Bronkaid) is ordered to be given subcutaneously. The nurse would anticipate seeing the intended effect of the medication in:
| The core issue of the question is knowledge of the timeframe for the onset of action with epinephrine. Use specific drug knowledge and the process of elimination to make a selection. |
142 During a scheduled exam the client’s glycosylated Correct answer: 1 Glycosylated hemoglobin is elevated due to long‐term hyperglycemia. Values greater than 8 hemoglobin was found to be 9%. The client has had percent indicate consistently poor control of blood glucose and the need to assess the client’s diabetes mellitus for 3 years. The nurse should do dietary pattern for the past several months in relation to the treatment plan. The other which of the following? options do not apply.
| Recall that this test is a general indicator of diabetic control over several weeks. With this in mind, eliminate options 2 and 3 first. Choose option 1 over 4 because it relates to long‐ term control, not immediate control. |
143 A client is admitted to the hospital with a primary Correct answer: 4 Sjögren’s syndrome is an autoimmune disease that destroys exocrine glands in the body, and diagnosis of hip fracture and a secondary diagnosis of leads to a generalized “dryness” of body systems. The restriction of fluids is a concern because Sjögren’s syndrome. Which one of the following orders the use of fluids helps to keep the oral cavity moist. There is no information to suggest that the would be of most concern with regard to the client has a need for fluid restriction due to other disease processes so this order should be nutritional status of the client? clarified. All of the other options are reasonable for this client. 1.‐ NPO after midnight for surgery with a 7:30 a.m. case | To answer this question correctly, it is necessary to know the underlying pathophysiology of Sjögren’s syndrome. From there, analyze each of the options that could exacerbate or worsen the underlying disease state. |
‐ IV of lactated Ringer’s at 125 mL/hr ‐ Maintain diet as tolerated ‐ Restrict oral fluids to 1,000 mL/day | |
144 The nurse notes on the antepartal history that the Correct answer: 2 An android pelvic structure is narrow in both the anterior‐posterior diameter and the lateral client has an android pelvis. The nurse plans to assess diameter, and can cause a prolonged labor with a large fetus or a malpositioned fetus. this client carefully because of the increased risk of which of the following?
| First determine the significance of the critical word android in the stem of the question. Eliminate options 3 and 4 first because they relate least to risks during labor caused by bone structure. Choose option 2 over 1 because the prefix andr‐ refers to males and from there determine that it indicates a narrower pelvis. |
145 The nurse would utilize which of the following Correct answer: 1 Physical exercise, within the client’s ability level, reduces muscle tension and pain. interventions when caring for a client with chronic pain Additionally, exercise creates a feeling of greater self‐efficacy. Verbal expression of conflicts disorder to help that client cope with the disorder? and minimal use of analgesics are also indicated. Complete bedrest would not be indicated unless required by incapacitating conditions, but there is no evidence that this is the case in this question.
| Note that critical words in the question are chronic pain and cope. This indicates that the correct answer is an activity that will help the client tolerate the pain to a greater extent. Eliminate options 3 and 4 first as most extreme, and then choose option 1 over 2 because of the physiological benefits. |
146 A client receiving hydroxyamphetamine (Paredrine) Correct answer: 4 Confusion and increased heart rate are signs of toxicity or adverse side effects of for open‐angle glaucoma demonstrates an hydroxyamphetamine. Stinging, headache, and brow ache are usual side effects of understanding of the medication’s serious side effects hydroxyamphetamine. when informing the health care provider of which of the following symptoms?
| The core issue of the question is knowledge of adverse drug effects. Use specific drug knowledge and the process of elimination to make a selection. |
147 The nurse is seeking employment in a hospital that Correct answer: 3 Shared governance is based on the philosophy that nursing practice is best determined by uses a shared governance model. The nurse should nurses. Option 1 represents standard nursing practice. Option 2 is unrelated to governance. accept a job offer in the hospital that has which of the Option 4 represents leadership input into decision‐making for the organization. following attributes?
| The critical words in the question are shared governance. Choose the option that gives the best evidence of some kind of sharing. |
148 The nurse observes an unlicensed assistive person Correct answer: 4 The employee should limit the amount of time in the client’s room to minimize exposure. In (UAP) in the room of a client with severe acute option 1, the employee is wearing the correct combination of personal protective equipment. respiratory syndrome (SARS). Which of the following In option 3, the employee has followed the correct procedure for exiting the client’s room. actions by the UAP indicates intervention and further Equipment required for the care of the isolation client should remain in the client’s room to teaching by the nurse is needed? limit exposure to other clients on the nursing unit.
| The wording of the question indicates that something was done incorrectly. Use the process of elimination after noting that options 1, 2, and 3 are correct actions. Only option 4 identifies an incorrect action. |
4.‐ The UAP visits with the client for 25 minutes. | |
149 The nurse examines the white blood cell (WBC) Correct answer: 3 Eosinophils are responsible for responding to allergic reactions. Neutrophils and monocytes differential for a client who experienced a severe are primary responders to infection and tissue injury and inflammation. Lymphocytes assist in allergic reaction. The nurse anticipates that which of immune responses. the following values will be elevated?
| The core issue of the question is knowledge of the various components of the WBC differential and their significance. Specific knowledge is needed to answer the question so take time to review if you have the need. |
150 The partner of a client who has dissociative identity Correct answer: 1 All family members are affected by dissociative identity disorder. Children must also find ways disorder with several alters is puzzled about why the to understand and deal with what is occurring to a parent, rather than denying what is obvious children are included in family therapy. Which of the or proceeding on incorrect assumptions that are not challenged by accurate information. following would be the best explanation for the nurse to offer?
| The core issue of the question is an understanding of the purposes and benefits of family therapy. Use knowledge of family dynamics to choose the correct answer. |
151 The nurse assesses the results of a vancomycin Correct answer: 4 A serum specimen for peak level is drawn 15 to 30 minutes after IV administration to test for (Vancocin) blood level drawn just prior to the next toxicity. Trough drug levels are drawn just prior to administration of the next IV dose to scheduled intravenous (IV) dose. The nurse would measure whether satisfactory therapeutic levels are being maintained. If the peak is too high, collaborate with the prescriber after drawing which of toxicity can occur and the dose needs to be reduced and/or the frequency of administration the following correct conclusions about the result? extended. If the trough is too low, then the dosage and/or frequency of administration need to be increased.
| The core issue of the question is the ability to draw correct conclusions about the significance of serum drug level results. Focus on the words just prior to in the stem of the question, which tells you that it is the trough level that is being described. With this in mind, use the process of elimination to find the conclusion that is true of a need to collaborate about the trough level. |
152 In a child with acute renal failure, the nurse would Correct answer: 1 Potatoes, tomatoes, and oranges have a high level of potassium content. The others have help to prevent hyperkalemia by limiting which of the lesser amounts of potassium in them, when considering the groupings of foods in each option. following foods in the diet?
| The core issue of the question is knowledge of foods that are high in potassium. Eliminate options 3 and 4 first because of the carbonated beverages and sugars, respectively. Choose option 1 over 2 because these foods have a greater potassium content. |
153 A 28‐year‐old female client has recently been Correct answer: 4 A client who receives a diagnosis of SLE will be profoundly affected by the chronic nature of diagnosed with systemic lupus erythematosus (SLE). this autoimmune disease process. The establishment of a healthcare team using a Which of the following would be most helpful for the multidisciplinary approach will help the client to identify and realize individual goals. Even overall management of care? though the initiation of advance directives is important, it is not the priority concern at this point in time—there is no information provided to suggest that the client requires immediate activation of advance directives. Even though it is important to discuss the progressive effects of the disease, the priority is to establish a multidisciplinary team to assist the client. Option 3 is incorrect—telling the client to limit her work pattern may not be financially feasible or physically indicated at this time. | The core issue of the question is what are initial priorities of care when a client is diagnosed with a chronic illness in which the client’s condition is expected to worsen over time. With this in mind, choose the option that calls together the interdisciplinary team so that the client has the fullest range of resources at hand. |
‐ Have the client institute advance directives immediately. ‐ Discuss with the client lifestyle modifications that will be needed as the disease progresses. ‐ Ascertain information about the client’s working environment and suggest limiting work schedule to minimize potential stress. ‐ Establish the multidisciplinary healthcare team to help client identify goals. | |
154 The nurse is leading a support group for adult Correct answer: 2 Allowing independence as long as possible gives dignity and self‐worth to clients. Option 1 is children of aging parents who have come to live in not helpful because it does not foster independence within the scope of remaining abilities. their home because of deteriorating health. Which of Option 3 could result in harm to the parents. Option 4 could be degrading and does not foster the following principles does the nurse encourage the maintaining independence within limits of current ability. group members to follow to promote quality of life for all concerned?
| Completely taking over all aspects of an adult’s life does not give value or worth to those adults, especially if done too prematurely. Allowing them to do whatever they want to do may not be safe for them and harm may be done despite saving some self‐esteem. Financial issues are the most worrisome issues that must be dealt with, and taking them over also removes the independence of the client. A plan of care needs to be clarified when the adult is thinking clearly and can delegate or make an advanced directive. |
155 A client of 26 weeks gestation experiences a partial Correct answer: 1 One of the major functions of the placenta is provision of nutrients to the fetus across the placenta abruptio. She asks, “Will this harm my baby?” placenta membrane. An interference with the placenta circulation, such as abruptio placentae, The nurse responds that this may: impairs this ability. Another important function is removing metabolic waste from the fetus. While this takes place metabolically the fetus produces and excretes urine independently of the placenta. Hydrops is gross fetal edema related to hemolytic action, not placenta dysfunction. Anomalies usually occur in the first trimester when organogenesis occurs.
| To answer this question correctly, it is necessary to recall the function of the placenta to deliver oxygen and nutrients to the fetus. Focus on the critical word partial to aid in selecting the correct option. |
156 The nurse writes on the worksheet for the shift to Correct answer: 3 Clients who are taking cholestyramine (which is a bile resin) should be monitored for fat‐ assess a client taking cholestyramine (Questran) for soluble vitamin deficiencies (Vitamins A, D, E, and K), as the gastrointestinal side effects of the signs of possible deficiency of which vitamins? medication can lead to reduced absorption. Niacin, thiamine, folic acid, cyanocobalamin, and Vitamin C (options 1, 2, and 4) are all examples of water‐soluble vitamins.
| The core issue of the question is knowledge that cholestyramine places the client at risk for deficiency of fat‐soluble vitamins. Use the process of elimination and reason that this answer is correct because the action of cholestyramine is to bind onto cholesterol (fat) and prevent its absorption into the GI tract. |
157 Case management has become an important nursing Correct answer: 3 Clients with less complex and more common diagnoses are selected for case management. care model in the 21st century. Which of the following The clients in the remaining options have problems that are more likely to have variation in clients would most likely be selected for case their conditions (options 1 and 2) or have a less common diagnosis (option 4). management?
| Focus on the critical words case management. Use the common definition of this method to eliminate each option systematically. |
158 While making rounds, the nurse observes a client Correct answer: 2 The client in the photograph is receiving oxygen through a Venturi mask. Oxygen receiving oxygen by this mode. The nurse concludes administered by a Venturi mask can be regulated to deliver between 24% and 50%, which is a the client is using this mode of oxygen therapy because benefit for clients who require higher oxygen supplement without mechanical ventilation. The of which primary benefit? Venturi mask does not prevent rebreathing of carbon dioxide, as does a non‐rebreather mask. Oxygen concentration of 100% would be administered to COPD clients only in rare circumstances via mechanical ventilation.
| Specific knowledge is needed to answer the question. Reflect on the various modes of oxygen delivery and note that this type of device can be regulated easily because it is a mask and because the percentage of oxygen can be manipulated easily. |
159 A client diagnosed with hypochondria states an Correct answer: 1 MRI is the only diagnostic examination listed that does not possibly require the ingestion or allergy to the dyes used in diagnostic tests and “all” administration of contrast or radioactive material. Options 2 and 4 involve the use of contrast radioisotopes. The nurse explains that the client could dyes or agents, while option 3 uses a radioisotope. undergo which diagnostic procedure without risk of possible allergic response?
| The core issue of the question is knowledge of which tests do and do not require use of some form of contrast media. With this in mind, eliminate each of the incorrect options using basic knowledge of diagnostic tests. Take time to review this material if you had difficulty selecting. |
160 A client had assumed a new identity and gained Correct answer: 4 Fugue states are characterized by wandering or moving away from one’s familiar place with employment when he was found 400 miles away from an amnesia for the complete past, including self. The person often assumes a new identity for his home. The mental health nurse interprets that this the duration of the fugue. Amnesia is simply a loss of memory owing to brain damage or to client’s behavior is characteristic of: severe emotional trauma. Akathisia is an abnormal condition characterized by restlessness and agitation. Confabulation is replacement of gaps in memory with imaginary information.
| The core issue of the question is the ability to correctly interpret a client’s behavior as characteristic of a fugue state. Use knowledge of characteristics of this mental health disorder and the process of elimination to make a selection. |
161 The client is receiving a loading dose of lidocaine Correct answer: 1 Lidocaine is given via IV push in doses of 1 to 1.5 mg/kg. The initial loading dose (bolus) is (Xylocaine) 100 mg IV for treatment of ventricular intended to achieve adequate blood levels to suppress ventricular dysrhythmias and is tachycardia. The nurse prepares to take which action followed by an infusion of 1 to 4 mg/min via infusion pump. The initial bolus lasts next? approximately 10 minutes so the infusion must not be delayed. The dose may be repeated 1 time under certain conditions, but the total dose should not exceed 3mg/kg. Oral therapy and pacemaker insertion are not indicated at this time.
| The core issue of the question is knowledge of therapeutic protocols for intravenous antidysrhythmic medications such as Lidocaine. Use drug knowledge and the process of elimination to answer the question. |
162 The nurse on a cardiac medical unit has an unlicensed Correct answer: 2 The nurse should delegate the activity that is procedural in nature, which is within the scope assistive person (UAP) assigned to the nursing team. of training of the UAP. The nurse does not delegate teaching (options 1 and 3) or interventions The nurse would delegate which of the following client for chest pain (option 4). care activities to the UAP?
| Keep in mind the principles of delegation. Recall that the nurse does not delegate assessment, teaching, or medication administration to a UAP. |
163 A client recovering from Guillain‐Barré syndrome is Correct answer: 2 A client who is recovering from Guillain‐Barré syndrome will need a diet that promotes admitted to the rehabilitation unit for general positive nitrogen balance in order to counteract the effects of long periods of immobility on rehabilitative care. The nurse anticipates that which of the body. Option 1 is incorrect—there is no evidence to support that the client is experiencing the following methods will most likely be used to malabsorption at this time. Option 3 is incorrect because there is no clinical reason to limit provide nutritional support for the client during this fresh fruit. Even though the client may experience difficulty in chewing and swallowing, this is time? usually in the acute phase of the disease process. There is nothing to suggest that the client is experiencing problems in this area or is at risk for aspiration (option 4).
| The key words in the stem of the question are general rehabilitative care. This tells you that the client has no specific deficits that would affect nutritional status. With this in mind, choose the option that promotes the best nutrition for this client. Avoid reading into the question. |
164 Based on the highest risks during this period of life, Correct answer: 4 A healthy 30‐year‐old has the greatest risks of safety related to lifestyle behaviors: multiple what would be the focus of the nurse who is setting up sexual partners, “on the edge” lifestyle (thrill seekers), haphazard dietary intake, speeding, not a health promotion booth for healthy adults in their sleeping enough. thirties?
| Cancers of the breast, uterus, lung, or prostate are not the mindset of a 30‐year‐old. This problem is the center of thinking for the older adult. Bone density testing for osteoporosis is often not recommended nor tested for the female in her thirties. Most women will test for this near menopause. |
165 A client admitted with exacerbation of chronic Correct answer: 1 All of these nursing diagnoses are appropriate for the client with COPD; however, the primary obstructive pulmonary disease (COPD) has a alteration is related to impaired gas exchange because of the abnormal blood gas results. The respiratory rate of 18, a dry cough, and arterial blood breathing pattern is satisfactory because the rate is within normal limits, and there is no data gases that reveal a pH of 7.29, to support activity intolerance, although it is plausible. The client is at risk for infection but CO<sub>2</sub> of 50 mmHg, and actual problems take priority over potential ones. O<sub>2</sub> of 72 mmHg. The nurse identifies which nursing diagnosis as the priority?
| Compare the data in the question and use that as a means of selecting the priority nursing diagnosis. |
166 The nurse is caring for a client who has just been Correct answer: 4 Graves’ disease is caused by elevated levels of thyroid hormone. Clients experience diagnosed with Graves’ disease. Client education tachycardia, nervousness, insomnia, increased heat production, and weight loss. Medication regarding medication therapy needs to include which therapy with an agent such as propylthiouracil will help control the disorder. Option 1 is of the following? irrelevant, while option 2 is indicated for hypothyroidism. A client with this disorder does not need insulin, because the pancreas is not affected by Graves’ disease (option 3).
| The core issue of the question is that Graves’ disease is characterized by excessive function of the thyroid gland. From there, you need to determine which medication will reduce the function of the thyroid. Eliminate options 1 and 3 as irrelevant first, then choose option 4 over 2 by its action. |
167 The nurse has delegated to an unlicensed assistive Correct answer: 2 A client with right hemisphere stroke has left‐sided paralysis or paresis and may have person (UAP) the care of a client who had a right unilateral neglect. The UAP should keep all items on the right side so that the client is aware hemisphere thrombotic stroke with hemiplegia. The they exist in the environment. nurse would give further direction to the UAP after noting that the UAP did which of the following? | Recall that the manifestations of stroke appear on the opposite side of the body from the lesion. Use this principle to eliminate the incorrect responses after eliminating actions that are carried out correctly. |
‐ Provided passive range of motion exercises to the affected arm and leg ‐ Placed a chair for a visitor to the left of the bed ‐ Placed the overbed table to the right side of the bed ‐ Sat the client up slowly | |
168 The nurse determines that a client who has an Correct answer: 2 Transmission‐based precautions are required for all these organisms. Only penicillin‐resistant infection with which of the following antibiotic‐ Streptococcus pneumoniae is transmitted via respiratory droplets. The organisms specified in resistant microorganisms requires transmission‐based options 1, 3, and 4 are transmitted by direct contact. droplet precautions?
| Knowledge of droplet precautions is necessary to answer the question. Penicillin‐resistant Streptococcus pneumoniae suggests a microorganism that causes a type of pneumonia. Clients with pneumonia have increased respiratory secretions and coughing. Using a process of elimination, choose the microorganism that sounds as though it would cause a respiratory infection—option 2. |
169 The nurse is reviewing the results of a male client’s Correct answer: 1 HDL is felt to be a beneficial lipoprotein because of its protective function against coronary recent lipid profile. The nurse notes that the client is artery disease. An elevation in this level is healthy and indicates compliance with diet and experiencing beneficial effects of a heart healthy diet exercise recommendations. LDL and HDL are fractions of the total cholesterol level. and exercise after noting elevations in which Triglycerides and LDL have proven to be major contributors to and predictors of coronary laboratory value? artery disease, making elevations in all three remaining options threats to cardiovascular health in the future.
| The core issue of the question is knowledge of which lipid levels should be raised and lowered to achieve cardiovascular health. Recall that HDL has the letter H and associate this with the word healthy to make the positive association between these. |
170 The nurse concludes that client education about Correct answer: 3 When the client realizes the connection between stress, anxiety, and dissociation, he dissociation is effective when the dissociative client becomes able to modify his stressors or his response to them, thus preventing the dissociative states: process. The other responses in options 1, 2, and 4 do not reflect this concept.
| The core issue of the question is the ability to recognize triggers to a dissociative state. Recall that stress and anxiety can trigger this state to make the appropriate selection. |
171 A client is advised to take an antiemetic to prevent Correct answer: 3 Anticipatory prevention of nausea with antiemetics is effective if medication is taken 30 to 60 nausea and vomiting. The nurse explains that minutes before any activity causing nausea. The other options indicate incorrect timeframes. anticipatory dosing should be done how long prior to activities that generally cause nausea?
| The core issue of the question is knowledge of how soon to take medication prior to activities that cause nausea. Recall that many oral drugs act in 30 to 60 minutes to help you make a selection. |
172 The nurse working on a neuroscience unit has just Correct answer: 3 The client who had a hemorrhagic stroke and has a headache could be about to have another received an intershift report. Which of the following bleed. Headache is a classic sign with intracranial bleed, and a second bleed carries a higher assigned clients should the nurse assess first? mortality rate than the first. The other clients have less severe needs that can be attended to after the client who is at risk for a fatal complication is seen.
| When trying to decide priorities among clients who are acutely ill, it may help to analyze the complications each is at risk for or the consequences that could result from the current condition or complaint. The client with the most serious issue or who could experience the most severe complication is the one that takes priority. |
173 Which of the following statements made by a client Correct answer: 1 Contaminated foods are not a source of HIV/AIDS infection. While contaminated foods may regarding human immunodeficiency virus (HIV) and cause GI symptoms and food poisoning due to various etiologic agents, they do not cause the acquired immunodeficiency syndrome (AIDS) would transmission of this disease. The nurse should clarify this statement by the client in order to the nurse seek to further clarify? provide accurate information. All of the other client statements reflect information that is appropriate for the management of client with HIV/AIDS.
| The critical word in the stem of the question is clarify. This tells you that the correct answer is an incorrect statement on the part of the client. Use nursing knowledge and the process of elimination to make a selection. |
174 The registered nurse is assigned to the postpartum Correct answer: 1 The RN is responsible for delegating tasks appropriately and is responsible for the actions of unit. Which task could the RN safely delegate to an unlicensed employees. Ambulating a postoperative client is the only task that the RN could unlicensed assistive person (UAP)? delegate from those listed. The other tasks require higher level assessment and critical thinking skills and should be performed by the RN.
| Use principles of delegation and select the care activity that is the simplest and requires the least amount of high‐level judgment, especially since the level of the student is not identified. |
175 The client has undergone hypophysectomy using a Correct answer: 2 The presence of a halo effect indicates cerebrospinal fluid (CSF). Glucose present in the nasal transphenoidal approach. You change the mustache drainage also suggests that the drainage is CSF. A persistent headache indicates a CSF leak. The dressing, noting clear exudate with a pale yellow physician needs to be informed of these assessment findings and the client must be colored ring at the edge of the drainage on the maintained on bedrest to stop the leak. A spinal tap may be done to decrease CSF pressure. dressing. You should do which of the following next? Option 1 is incorrect because it does nothing for the client. Options 3 and 4 do not address the real problem, a probable CSF leak.
| To answer this question correctly, analyze the significance of the findings. Eliminate each of the incorrect responses systematically after noting that a risk after this type of surgery is CSF leak. |
176 The client is experiencing severe itching with a skin Correct answer: 3 Hydroxyzine hydrochloride is an antihistamine that is a competitive inhibitor of the disorder. Which of the following drugs, if ordered, H<sub>1</sub> receptor. It is used to treat various reactions that are mediated by would the nurse administer as an appropriate oral histamine. It will decrease the pruritus produced by the release of histamine. Cimetidine is an preparation to decrease the itching? H<sub>2</sub> histamine antagonist and these agents are not effective against hypersensitivity reactions. Lorazepam is a short‐acting benzodiazepine that is indicated for anxiety. Bupivacaine is a local anesthetic for nerve blocks.
| The core issue of the question is knowledge of which drug relieves itching. Use specific drug knowledge and the process of elimination to make a selection. |
177 A client who is legally blind has been admitted to the Correct answer: 1, 4 The UAP can perform procedures and nursing care activities. Client care that requires nursing unit. Which of the following activities should assessment (options 2, 3, and 5) are not within the scope of the functions of the UAP. the nurse delegate to the unlicensed assistive person (UAP)? Select all that apply.
| Recall that UAPs are trained and educated to perform simple care procedures. Use this framework to eliminate each of the incorrect options systematically. |
‐ Assist the client to ambulate in the hall. ‐ Ask the client what community services are being utilized. | |
178 A client who has a history of Graves’ disease Correct answer: 4 With exophthalmos, the eyelids may not cover and protect the cornea of the eye. Thus, eye accompanied by exophthalmos is arriving from protection from the sheets or preventing the hands from accidentally touching the eyes is surgery. Based on the observations as you note the needed while the client is in bed. With Graves’ disease, clients usually experience heat photo, what should you educate the unlicensed intolerance, thus less covering and a cool room are preferred (option 1). Hyperglycemia is not assistive person (UAP) to do? usually associated with Graves’ disease. The head of the bed should be elevated 30 degrees to minimize eye pressure (option 3).
| The core issue of the question is which need of the client with Graves’ disease can be met by the UAP. The need of the client with respect to eye safety can be met using ordinary nursing procedures, so this is the task that may be delegated to the UAP with education. |
179 A client with bone cancer receiving chemotherapy has Correct answer: 3 Most chemotherapeutic agents cause some degree of bone marrow suppression. This results developed bone marrow suppression. Which in a decrease in leukocyte and erythrocyte counts, both components of a hematology testing. laboratory report is of highest priority for the nurse to Calcium, phosphorus, and serum PSA levels are not specifically affected by bone marrow monitor at this time? suppression. The calcium level could change because of the underlying bone cancer, and this in turn could affect phosphorus, but this is not the focus of the question.
| The critical word in the question is priority. With this in mind, you need to determine which lab value has greatest importance in terms of monitoring. The core issue of the question is bone marrow suppression, which could affect production of red blood cells, white blood cells, and platelets. Choose the option that best correlates with this risk. |
180 Which of the following behaviors would the nurse Correct answer: 2 All of the options are dissociative responses. However, only localized amnesia is the inability conclude is expected in a client who suffers from to recall events in a circumscribed time period. localized amnesia?
| Focus on the critical words expected and localized amnesia. These words indicate that the correct option is one that is consistent with what is assessed in this state. Focus on the word localized in the question and the time‐bound nature of option 2 to choose correctly. |
181 The client will be discharged to home tomorrow on Correct answer: 3 Option 3 is correct because it acknowledges the client’s feelings and addresses his concerns an antidepressant medication that will be taken once while still allowing him to make decisions for his present and future. Options 1 and 2 disregard daily in the morning. He asks, “Do I have to take and negate the client’s feelings. Option 4 acknowledges his concern but takes away his medicine every day? How will I be able to sleep when I decision‐making options by having someone else (the nurse) make a plan for his daily activities, go home? Do you think I’ll be able to work, too, even rather than have him participate and make decisions for himself with help. though I have been in the hospital this long?” The nurse’s best response is:
| The best answer to communication questions is to choose the response that addresses the client’s issue or concern. Use the process of elimination and this principle of communication to make a selection. |
182 The client is admitted with all of the following orders Correct answer: 1 Fluid and electrolyte replacement is the highest priority. Hyperglycemia is treated with to treat diabetic ketoacidosis (DKA) with severe regular insulin rather than NPH insulin (option 3). Concurrent administration of IV regular metabolic acidosis. Which order would the nurse insulin would also be done as a priority. The items in the other options can be done after determine to be the first priority in managing this definitive treatment for dehydration is done. client?
| To answer this question correctly, it is necessary to understand the underlying pathophysiology. Determining that dehydration is a key issue will help you to focus on rehydration. Attend to regular care measures and monitoring after acute manifestations have been addressed. |
183 The nurse would include which of the following Correct answer: 3 Malnutrition is seen as a consequence of the HIV/AIDS virus because the disease process has statements when discussing nutritional status with a a progressive effect on client’s nutritional status. Option 1 is incorrect—even clients who are client who is infected with human immunodeficiency asymptomatic may already have nutrient deficiencies and could be experiencing subclinical virus (HIV) and is progressing toward acquired signs of malnutrition. Option 2 is incorrect because wasting syndrome occurs early in the immunodeficiency syndrome (AIDS)? disease process; current clinical research states that the maintenance and preservation of nutritional status is a priority in the clinical management of this condition. Option 4 is incorrect—clients can experience vitamin and mineral deficiencies early on during the disease process.
| The wording of the question tells you that the correct answer is a true statement of fact. Use nursing knowledge and the process of elimination to make a selection. |
184 The nurse is taking the health history of a 77‐year‐old Correct answer: 3 Bladder and sphincter weakness are normal with the aging process. Decreased tolerance to man. Which of the following symptoms reported by spicy foods also is reflected by decreased acidity and motility of the digestive processes that the client would the nurse consider to be an abnormal are common in the aging process. Circulatory instability can occur when getting up too quickly finding? since the vasoconstriction process of the legs can be slower as one ages. Also, dehydration can lead to slight dizziness when moving about. Increasing the process of isolation from others is not a healthy adaptation although it is common when one spouse dies that the other seems totally lost since most events include whole couples rather than newly singled again individuals.
| Understanding the expected changes at the various age brackets will allow you to anticipate what is within the normal range of changes and what is not. |
185 In planning care for a client with an axis II personality Correct answer: 1 Clients who are diagnosed with a personality disorder most frequently perceive their disorder, the nurse anticipates that the client will differ personality patterns as ego‐syntonic or a natural part of themselves rather than as ego‐ from clients with axis I disorders in that the client will: dystonic (option 3). This is one reason it is difficult to motivate individuals with personality disorders to try to change their maladaptive behavioral patterns. Individuals with personality disorders display problems living rather than clinical symptoms. Personality disorders are associated with concomitant disorders including substance abuse.
| The core issue of the question is the ability to discriminate among various types of mental health disorders using DSM‐IV criteria. Use this knowledge and the process of elimination to make a selection. |
186 The home health care nurse is visiting an elderly Correct answer: 2 Calcium channel blockers should be administered with a high‐fat meal; grapefruit should be client who is taking a prescribed calcium channel avoided before and after dosing due to its ability to alter drug effects. The foods listed in the blocker. In conducting dietary teaching, the nurse other options will not have a dose‐altering effect. instructs the client that what food is contraindicated to take with a calcium channel blocker?
| The core issue of the question is knowledge that grapefruit juice affects the availability of some drugs, such as calcium channel blockers, because of their action on enzyme systems. Use this knowledge and the process of elimination to make a selection. |
187 The client is admitted with thyroid storm. Assessment Correct answer: 4 Tachycardia, hypertension, and tachypnea increase stroke volume and tissue demand for reveals: BP 188/102, HR 132 regular, RR 28 full depth oxygen, leading to increased cardiac workload and possible heart failure. If fluid volume deficit and symmetrical, no urine output since admission to is present, there is an additional risk for decreased cardiac output. There is insufficient data to the Emergency Department 3 hours ago, alert, and determine fluid volume status. The tachypnea is a symptom of the increased metabolic rate. anxious. Which of the following would be the high priority nursing diagnosis for this client?
| Recall that physiological needs take priority over psychosocial needs. Also remember that the ABCs (airway, breathing, and circulation) are of highest priority in many cases. |
188 The nurse must assess the temperature and blood Correct answer: 1 Equipment for client care is dedicated to the client on contact precautions and kept in the pressure of a client on contact precautions for wound client’s room. Any other action does not uphold principles of infection control. infection every shift. Which is the appropriate nursing action to minimize the spread of microorganisms?
| The key word appropriate suggests there is only one correct answer. Look for the nursing action that would limit the spread of pathogenic microorganisms. |
189 A client presents to the clinic with a chief complaint Correct answer: 3 Clients with gout will usually have elevated serum uric acid levels. Laboratory findings as well of a swollen and painful great toe. He states that his as physical assessment will confirm the diagnosis. The joint of the great toe is usually involved brother has it, and he has the same symptoms. The in initial attacks of acute gouty arthritis as seen in the accompanying figure. There are many physician suspects gout. What specific laboratory test other factors that will affect the results of hematocrit, serum calcium, and sodium levels. would the nurse expect to be ordered for this client? Erythrocyte sedimentation rate (ESR or sed rate) and white blood cell (WBC) counts will also be elevated in cases of gout.
| The core issue of the question is knowledge of diagnostic testing for gout. Recall that the word gout contains the letter u to associate this with measurement of uric acid, which begins with u. |
190 A female client has been diagnosed with a dependent Correct answer: 4 It is difficult for individuals diagnosed with dependent personality disorder to make decisions personality disorder. Which statement is likely to be on their own (options 1 and 3); rather, they try to get others to make decisions for them. This her response to the nurse’s suggestion that she characteristic is reflected in DSM‐IV diagnostic criteria. They would be disinclined to make complete her morning care? critical remarks (option 2) related to their need for support from others.
| The critical word in the stem of the question is dependent. Focus on this word and look for an association between that word and the nature of the statement in each option. The option that most closely simulates a response that relies on another is the correct answer to the question. |
191 The nurse should question an order for which beta Correct answer: 3 Terbutaline, pirbuterol, and metaproterenol are all beta 2 stimulants. Isoproterenol agonist used to treat respiratory disease in a client stimulates beta 1 and beta 2 receptors and therefore is contraindicated and should not be with a history of atrial fibrillation accompanied by used with clients with tachydysrhythmias. intermittent heart rates of 100/minute or greater?
| The core issue of the question is knowledge that isoproterenol is contraindicated because it is a cardiac stimulant. Use specific drug knowledge and the process of elimination to make a selection. |
192 A client with osteoporosis who has experienced Correct answer: 1, 3 The nurse can delegate procedures to the UAP and retains responsibility for the outcomes of fractures in the past is now admitted for dizziness and those tasks that are delegated. Clearing the room of unnecessary objects and remaining with shortness of breath and has been determined to be at the client during ambulation are among those that can be delegated. The nurse needs to retain risk for falls. Which nursing intervention to assist this responsibility for assessment (option 2), teaching (option 5), and collaborating with the client can the nurse delegate to the unlicensed interdisciplinary team (option 4). assistive person (UAP)? Select all that apply.
| Use the principles of delegation to answer the question. Eliminate those options that represent assessment, teaching, or interdisciplinary communication or collaboration. |
193 A client is receiving radiation to the head and neck Correct answer: 4 Dry mouth can be a common complaint of clients undergoing radiation therapy. Using sugar‐ area for treatment of cancer. What interventions free candies or gum will help to stimulate the flow of saliva and ease the discomfort that the would you use to help the client’s complaint of a dry client is experiencing without contributing to dental caries or lack of appetite from sugar mouth? intake. Option 1 is incorrect—eating meals prior to radiation therapy may lead to increased nausea because the client would be lying down after eating the meal. It has no effect on complaints of a dry mouth. Option 2 is incorrect—eating larger portions of food will not help to ease complaints of a dry mouth. Furthermore, the client may not be able to increase the size of meals due to side effects experienced as a result of radiation therapy. Option 3 is incorrect—the use of mouthwash can further cause the mouth to be dry and intensify the client’s symptoms.
| The core issue of the question is determining a strategy to relieve dry mouth for a client with cancer that will not contribute to anorexia. Use general principles of nutrition and knowledge of the disease process to make a selection. |
194 The client experienced an 18‐hour labor with a Correct answer: 3 Although this client is not demonstrating positive signs of bonding at this time, it is important second stage that lasted 2 hours. When the nurse to look at her history before concluding that she is not bonding well with her infant. This client brings the infant into the room 1 hour after delivery, just experienced a long labor and the influence of fatigue on the attachment process should be the client tells the nurse to leave the infant in the crib considered. It is important to continue to assess infant bonding with this client throughout her and shows no interest in holding the newborn. The hospitalization to reach a nursing judgment based on evidence. nurse should record which of the following nursing diagnoses in the chart?
| Compare the nursing diagnoses with the information in the stem of the question. Eliminate each incorrect option based on lack of supporting data in the question. |
195 The nurse would expect to find a diminished Correct answer: 1 Carbon dioxide is eliminated from the body as exhaled gas. The faster the rate of breathing, pCO<sub>2</sub> level in the assigned the greater the quantity of carbon dioxide eliminated. client who has which of the following physical assessment findings?
| Note the stem of the question contains the words diminished pCO<sub>2</sub>, which indicates that the client is blowing off excessive CO<sub>2</sub>. Use knowledge of respiratory disorders to select the option that is consistent with excessive respiration, which is option 1. |
196 A client is scheduled for an ophthalmic examination. Correct answer: 3 Ophthalmic epinephrine is used to produce mydriasis for ocular examination. Dilation of pupil Before administering the prescribed epinephrine further constricts ocular fluid outflow, possibly causing an acute attack of glaucoma in a client solution, the nurse would assess for which of the with narrow‐angle glaucoma. Systemic absorption also causes hypertension and tachycardia. following conditions? Brow ache is a typical side effect of adrenergic agonists such as epinephrine (option 4).
| The core issue of the question is knowledge that angle‐closure glaucoma is a contraindication to use of epinephrine for mydriasis during an ocular examination. Use specific drug knowledge and the process of elimination to make a selection. |
197 The nurse is working on an orthopedic unit. After Correct answer: 4 The client that is the most stable and with the fewest needs that the nurse must attend to is receiving intershift report, which client should the the client who is 6 days postoperative and awaiting placement in a rehabilitation facility. The nurse assign to the unlicensed assistive person (UAP)? nurse could attend to this client’s discharge paperwork later in the shift. The nurse needs to assess the pain and neurovascular status of the client in option 1, since the client could be experiencing a complication of an overly tight cast. The nurse also needs to assess the client with the new spinal fracture. The nurse would need to teach and counsel the client who has phantom limb sensation.
| Recall the principles of delegation and that clients who need assessment or teaching need to remain under the direct responsibility of the nurse. |
198 An adult client arrives to the Emergency Department Correct answer: 1, 3, 5 Knowledge of the cardiovascular disease risk factors and associated symptoms can assist in with complaints of chest pain and shortness of breath. determining the origin of chest pain and direct the nurse to prioritize and implement The nurse concludes that which of the following appropriate care. Diabetes, smoking, and hypertension are known modifiable and non‐ points, if present in the client’s history, would indicate modifiable risk factors to cardiac disease. Chest pain that occurs during activity may indicate that this pain may be related to cardiac disease? Select cardiac ischemia due to the increased oxygen demand. Associated symptoms of nausea and all that apply. diaphoresis are known warning signs of cardiac ischemia. Chest pain that increases with breathing, especially taking a deep breath, is most likely pleuritic pain and travel out of the country is an unrelated factor.
| The core issue of the question is knowledge of risk factors of cardiac disease leading to chest pain. Eliminate option 2 as unrelated because of the critical word recent, recalling that chest pain from cardiac origin is not related to travel. Eliminate option 4 next because cardiac pain does not correlate with the respiratory cycle. |
199 A client asks the nurse to repeat what the physician Correct answer: 1 The definition of moderate sedation is that there is a minimal depression of the level of explained about the anesthesia planned for an consciousness in which the client is able to maintain a patent airway and respond upcoming procedure. The nurse understands the appropriately to verbal and physical stimuli. The pain threshold is increased so that the client procedure will be performed under moderate can tolerate pain (option 2). Amnesia is induced partially with conscious sedation (option 3). sedation. Which statement should the nurse make to Option 4 is false because the client is awake. the client concerning moderate sedation? | The core issue of the question is knowledge of moderate sedation and communication techniques that explain this clearly and accurately. Use knowledge of key features of moderate sedation and the process of elimination to make a selection. |
‐ “You will be able to breathe and respond appropriately to physical stimuli and words that are spoken.” ‐ “Your pain threshold will be decreased so you can tolerate the pain.” ‐ “You will have a patent airway and will be able to remember and comprehend what is happening.” ‐ “You will not be awake but you will still feel slight pain during the surgical intervention.” | |
200 A client is diagnosed with paranoid personality Correct answer: 3 These characteristics are reflected in DSM‐IV diagnostic criteria for paranoid personality disorder. Which of the following assessment data does disorder. They must be considered in planning and implementing care. Delusions and the nurse conclude are consistent with this diagnosis? hallucinations are consistent with schizophrenia or other psychotic disorders. Options 2 and 4 describe behavior traits but they are not consistent with paranoid personality disorder.
| The core issue of the question is knowledge of characteristics of paranoid personality disorder. Use nursing knowledge and the process of elimination to make a selection. Note the word paranoid in the stem and secretiveness in the correct option to help make an association between the two. |
201 The nurse is administering nitrogen mustard Correct answer: 2 The question indicates that extravasation may be occurring. Prompt nursing action in general (Mustargen) and notes swelling at the intravenous (IV) will minimize tissue damage; therefore nursing actions should be initially directed towards the site. The nurse should take which of the following suspicious site. The drug administration should be stopped, since failure to do so will further actions initially? disperse drug into the tissue. Clients can experience extravasation without pain, but not without swelling. Flushing the line with saline or dextrose is not advised, since there may still be vesicant drug remaining in the tubing.
| The core issue of the question is knowledge that nitrogen mustard is an antineoplastic agent and that these drugs may be vesicants. From there, you need to determine what action will reduce the risk of further damage, which is stopping the drug and trying to aspirate it out of tissue. |
202 The nurse working on adult medical‐surgical unit Correct answer: 3 The nurse should delegate the care of the 81‐year‐old client with heart failure and would assign which of the following clients to the emphysema. This client was admitted 3 days ago and has a stable medical status. The nurse licensed practical/vocational nurse (LPN/LVN) under would want to assess the client recently admitted with exacerbation of COPD and the 25‐year‐ the supervision of the RN? old with a concussion less than 24 hours ago. The newly diagnosed diabetic client would require teaching that should not be delegated to the LPN/LVN.
| Recall the principles of delegation. The nurse should not delegate the care of clients who require assessment due to changes in acuity or status and clients who require teaching. Stable clients may be delegated to the LPN/LVN under the RN’s supervision. |
203 A client has been referred for dietary teaching Correct answer: 4 Nutritional goals for a client with hepatitis are aimed at providing a diet that is high in calories regarding the management of hepatitis. The nurse (3,000–4,000 kcal) and high in quality protein (1.5–2.0 g/kg). The diet should also be adequate would base development of nutritional goals on which in carbohydrates to spare protein and fat, provide concentrated calories, and improve the of the following pieces of information? taste of food. Option 1 is incorrect—the nutritional management of hepatitis is the same for all types. Option 2 is incorrect—there is no clinical indication to place the client on tube feedings given the information that is provided. If the gut works, then the usual clinical model is to use it. Option 3 is incorrect because dietary fat should not be limited unless the client is experiencing problems with malabsorption (steatorrhea) and there is no evidence to support this.
| The critical word in the stem of the question is hepatitis. From this point, analyze that the client recovering from hepatitis needs a high‐calorie, high‐protein diet for healing to make the correct selection. |
204 The nurse is caring for a 15‐year‐old primipara who Correct answer: 3 Although all of the options may be appropriate, demonstrating newborn care will allow the delivered yesterday. The nurse identifies the following client to ask questions and gain confidence as she cares for her baby. Having her return the nursing diagnosis for this client: risk for altered demonstration will allow the nurse to evaluate the teaching. parenting related to knowledge deficit in newborn care. Which is the most appropriate intervention when planning this client’s discharge teaching?
| Recall principles of teaching and learning, and recall that active participation leads to most effective learning outcomes. |
205 To decrease skin irritation in children with the Correct answer: 4 The illustration shows the typical appearance of skin that has eczema. Use of a mild soap such condition illustrated, the nurse instructs the parents as Dove<sup>®</sup> or Tone<sup>®</sup> prevents the skin from do which of the following? excessive dryness. Hot water is drying to the skin so should be avoided. Fabric softeners and many lotions contain perfumes that are irritating to the skin so should also be avoided.
| To answer this question correctly, it is necessary to be familiar with the skin disorder in the picture. Beyond that, eliminate the incorrect options because of the words hot and daily in option 1, liberally and entire in option 2, and all in option 3. Although option 4 contains the word only, note that it is tempered when combined into the phrase only as needed. |
206 A client who is taking warfarin (Coumadin) therapy Correct answer: 3 Clients who are taking Coumadin should be alerted to the potential for drug interactions comes to the office for a follow‐up visit and states that when they are on long‐term anticoagulation therapy. Aspirin can potentiate the effect of he has taken propoxyphene with aspirin (Darvon Coumadin and interfere with the ability to maintain a therapeutic level. The use of Darvon, Compound 65) for aches and pains related to an old although previously prescribed, is not in the best interest of the client at this time due to back injury. How should the ambulatory care nurse Coumadin therapy. Telling the client to keep taking Darvon would lead to drug interactions respond to this information? (option 2). While a further assessment of the client’s back pain may be necessary (option 1), it is not the primary action that the nurse should be addressing at this time. Option 4 is a false statement, because the two drugs together could enhance bleeding.
| The core issue of the question is knowledge that drugs containing aspirin can have an interactive effect with warfarin, which increases the risk of bleeding. With this in mind, use the process of elimination to select the option that results in stopping pain therapy with an aspirin‐containing drug. |
207 Which of the following is an assessment finding with Correct answer: 3 All symptoms listed are clinical manifestations of developmental dysplasia of the hip, developmental dysplasia of the hip in a 5‐year‐old although the only one that would be found in a 5‐year‐old would be the telescoping of the child? femoral head into the pelvis. Other clinical signs in an older child would be lordosis and a waddling gait with a marked limp. A positive Ortolani‐Barlow maneuver is found in the infant younger than 2 to 3 months of age. Limited abduction is the sign most often used for an infant older than 3 months, along with asymmetry of thigh and gluteal folds.
| Specific knowledge about this disorder is needed to answer the question. Take time to review this disorder if you had difficulty with this question. |
208 The nurse would intervene after noting another Correct answer: 3 The postoperative care of the child undergoing repair of clubfoot would not include nursing staff member take which of the following administering pain medication immediately when due and covering the cast with blankets. actions in the care of a child who has had surgery for Medication for pain should be administered as needed, and the cast should not be covered clubfoot? with blankets because this will interfere with the cast drying and could enhance swelling if excessive heat is retained under the blanket. Use of ice bags, elevation, diversional activities, and assessment of neurovascular status, swelling, and drainage or bleeding are all appropriate interventions.
| The core issue of the question is knowledge that a client who underwent repair of clubfoot will have a cast in place. After determining this, evaluate each of the options in terms of their appropriateness as part of management of the client in a cast. |
209 An adolescent is undergoing a spinal fusion for Correct answer: 3 All of the information above is needed by the adolescent undergoing a spinal fusion but the scoliosis. Which of the following would not need to be physician, not the nurse, should explain the actual procedure. The nurse should focus on the included in the preoperative teaching completed by care of this child following surgery, the exercises for breathing, turning, moving extremities, the nurse? the tubes that will be placed—the nasogastric tube, urinary catheter, and intravenous lines. Ways that pain will be dealt with should also be explained in the preoperative period.
| The core issue of the question is knowledge of which information is within the domain of nursing practice and which information needs to be given by the physician to obtain informed consent. Choose the option that is not included by selecting the option that is within the surgeon’s scope of practice. |
210 The nurse interprets that which of the following Correct answer: 1 Individuals diagnosed with paranoid personality disorder frequently are critical or statements made by a coworker is a typical staff argumentative to maintain a safe distance between themselves and others related to their response when working with a client diagnosed with a inability to trust others. Nursing staff may need to remind themselves that criticism of nursing paranoid personality disorder? care may be a manifestation of a personality disorder. The other statements listed do not reflect behavior that is typical of a client with this disorder.
| The core issue of the question is knowledge of the behavioral characteristics of a client with paranoid personality disorder. Reflect on the common meaning of the word paranoid and evaluate each option for consistency to make an appropriate selection. |
211 A client has been admitted to the hospital with chest Correct answer: 3 The standard protocol is to administer up to three doses of NTG 5 minutes apart as long as pain. The pain has not been relieved after one dose of the vital signs remain stable. After three doses, the physician should be called if pain is nitroglycerine (NTG) sublingually. Upon monitoring the unrelieved. An electrocardiogram (ECG) may be ordered, but not an EEG (to measure brain vital signs (VS), the nurse notices that the blood waves). Using NTG paste, a longer acting form of the medication, is not appropriate at this pressure has dropped to 126/84 from 130/90. Which time. of the following actions should the nurse take next?
| The core issue of the question is knowledge that nitroglycerine can be repeated up to 3 doses as long as the pain continues and the blood pressure is stable. Use the process of elimination and safe drug action to answer the question. |
212 The nurse working on an adult medical‐surgical unit Correct answer: 2 The nurse should delegate the care of the 78‐year‐old client with diabetes and osteoarthritis. would assign which of the following clients to the This client has a stable medical status. The nurse would want to assess the client recently licensed practical/vocational nurse (LPN/LVN) under admitted following nephrectomy and the 32‐year‐old who fractured the pelvis. Since pelvic the supervision of the RN? exenteration is done to treat cancer, the nurse would want to assess this client and also address this client’s psychosocial needs in coping with the diagnosis and surgery.
| Recall the principles of delegation. The nurse should not delegate the care of clients who require assessment due to changes in acuity or status, and clients who require teaching. Stable clients may be delegated to the LPN/LVN under the RN’s supervision. |
‐ A 32‐year‐old client with a fractured pelvis from an auto accident 3 days ago ‐ A 62‐year old client who underwent pelvic exenteration receiving medication via patient‐controlled analgesia | |
213 The nurse anticipates which of the following Correct answer: 3 The development of ascites (third spacing) is a common complication of cirrhosis. With the regarding sodium restriction for a client diagnosed development of ascites, sodium restriction is instituted. Depending on the extent and response with ascites secondary to cirrhosis? to clinical treatment, the restrictions may be 500 to 1,000 mg per day if the client does not respond to customary diuretic therapy. Option 1 is incorrect—sodium is necessary for all individuals and the development of hyponatremia carries its own metabolic consequences. Option 2 is incorrect—even though paracentesis may sometimes be indicated, it is not the primary solution to the problem. It is important to look at the underlying fluid and electrolyte disturbances and correct them in order to prevent the recurring problem of ascites. While low‐ salt diets are often unpalatable, there is nothing to suggest that the client would be noncompliant with sodium restriction therapy. In addition, other seasonings can be used to provide taste to the client’s diet.
| The core issue of the question is the ability to correlate collection of ascetic fluid in the abdomen with an aggravating factor, sodium. Use this information and the process of elimination to choose correctly. |
214 A mother calls a clinic nurse to state that a letter had Correct answer: 3 Pediculosis capitis is head lice. The nits (eggs) are usually found at the nape of the neck or come home with her child from school stating she behind the ears. Head lice do not move away from the scalp to lay eggs; therefore, other should examine her child for the nits from pediculosis choices are not appropriate. capitis. She asks where she should look for these nits. The nurse would tell the mother to examine:
| Note that the word capitis refers to the head to eliminate options 2 and 4. Discriminate between the other two options by selecting the one where the nits would be harder to detect and to remove. |
215 Which of the following instructions would be Correct answer: 2 Activity restrictions should be followed for 6 to 8 months following a spinal fusion. Lying, appropriate for the nurse to include in the discharge standing, sitting, walking, normal stair climbing, and gentle swimming are generally allowed teaching of an adolescent following a spinal fusion? following spinal fusion. Bending and twisting at the waist is not recommended, along with lifting more than 10 pounds, household chores such as vacuuming, mowing the lawn, physical education classes, and any sports besides walking.
| To answer this question correctly, it is important to understand the disorder and the limitations in the postoperative period. Eliminate option 1 because the restriction is so extreme. Next, evaluate each of the options and choose the one that protects the spine immediately after discharge. |
216 The physician has prescribed Vitamin D for a client. Correct answer: 2 Vitamin D regulates calcium and phosphorus levels by increasing blood levels, increasing The client asks the nurse what the medication is for. intestinal absorption and mobilization from bone, and reducing renal excretion of both Which of the following is the best response by the elements. The statements in the other options are the opposites of the actions of Vitamin D. nurse?
| The core issue of the question is the purpose and intended effect of vitamin D. Use basic knowledge of nutrition and vitamin therapy and the process of elimination to make a selection. |
217 The nurse working on an adult medical‐surgical unit Correct answer: 4 The nurse should delegate the care of the 53‐year‐old client with hypertension and chronic would assign which of the following clients to the renal insufficiency. This client has a stable medical status. The nurse would want to assess the licensed practical/vocational nurse (LPN/LVN) under client recently admitted following adrenalectomy and the 24‐year‐old who has hemophilia and the supervision of the RN? fractured a leg the previous day. The nurse would want to provide teaching to the client being discharged to home following arthroscopy and pain management, limitations in activity, and follow‐up care.
| Recall the principles of delegation. The nurse should not delegate the care of clients who require assessment due to changes in acuity or status, and clients who require teaching. Stable clients may be delegated to the LPN/LVN under the RN’s supervision. |
218 A client with acquired immunodeficiency syndrome Correct answer: 1 Standard precautions are used with all clients, regardless of the medical diagnosis. Clients (AIDS) who has Pneumocystis carinii is being admitted with AIDS or Pneumocystis carinii pneumonia are not contagious and do not require to the nursing unit. The nurse should institute which of transmission‐based precautions. the following?
| Use the process of elimination based on nursing knowledge of standard precautions and the route of transmission for AIDS. |
219 A family member is sitting at bedside and observes Correct answer: 2 Wound infection is decreased by skin preparation when debris and transient microbes from the nurse admitting the client from the postanesthesia the skin are removed. The other possibilities are all incorrect since skin preparation will not care unit (PACU) following a surgical procedure. The prevent complications such as positioning injury or pressure ulcers. Dermatitis does not result family member asks why the area around the surgical if surgical skin preparation is omitted. wound is orange. Which of the following statements about surgical skin preparation is the best response to the family member?
| The core issues of the question are recognition of the family question as relating to surgical skin preparation and knowledge of the purposes and expected results of that prep. Use nursing knowledge and the process of elimination to make a selection. |
220 The nurse is planning care for a client recently Correct answer: 2 It would be counterproductive to confront and challenge a client’s paranoid ideation until admitted with paranoid ideation. The nurse trust has been developed. A consistent program schedule will cut down on the number of determines that it would be counterproductive to do surprises for the client and help develop trust in the staff (option 1). Orienting the client to the which of the following when working with this client? unit and introducing him to the staff will enable the client to start developing therapeutic relationships (option 3). Communicating clear expectations will prevent the client from being confused (option 4).
| The core issue of the question is knowledge of therapeutic communication techniques with a client who is paranoid. Note the word counterproductive in the stem and the word challenge in the correct option. It will help you to choose correctly if you can make an association between these words. |
221 Following the administration of a measles‐mumps‐ Correct answer: 1 The nurse should assess for signs and symptoms of hypersensitivity reaction following the rubella (MMR) vaccine, the nurse should make a administration of all vaccines. Wheezing is a sign of hypersensitivity reaction and warrants priority assessment for which of the following client immediate further assessment and emergency action to prevent possible death. Local manifestations? discomfort (option 1) may be expected and is treated if necessary with acetaminophen. Anxiety and vomiting (options 3 and 4) are not associated with administration.
| The core issue of the question is knowledge that the MMR vaccine may cause allergic reaction in clients who have hypersensitivity to egg yolks. Use specific drug knowledge and the process of elimination to make a selection. |
‐ Anxiety ‐ Vomiting | |
222 The nurse working on an adult medical‐surgical unit Correct answer: 3 The nurse should delegate the care of the 59‐year‐old client with hypertension and Paget’s would assign which of the following clients to the disease. This client has a stable medical status. The nurse would want to assess the client licensed practical/vocational nurse (LPN/LVN) under awaiting surgery and complete preoperative care and the preoperative checklist. The nurse the supervision of the RN? would also want to assess and care for the client in sickle cell crisis because of the acuity of the client’s condition. The nurse would want to collaborate and communicate with the pulmonary rehabilitation specialist to formulate the ongoing plan of care.
| Recall the principles of delegation. The nurse should not delegate the care of clients who require assessment due to changes in acuity or status, and clients who require teaching. Stable clients may be delegated to the LPN/LVN under the RN’s supervision. |
223 When assessing the genitourinary system of a 75‐year‐ Correct answer: 2 Benign prostatic hyperplasia (BPH) is the most common disorder of the aging male client. old male client, the nurse questions the client about Testicular cancer is the most common cancer in men between the ages of 15 and 35. Testicular symptoms of which of the following conditions that is torsion occurs at any age and gonorrhea is highest in occurrence during the sexually active common in older men? years. Women 15 to 19 years old and men 20 to 24 years old have the highest rate.
| The critical words in the stem of the question are older men. Recall that the prostate gland undergoes changes in later life to help select the correct option. |
224 The nurse is teaching a class on newborn care to a Correct answer: 4 At birth, the infant’s skin is thin with little subcutaneous fat. In addition, the infant has a group of expectant parents. In explaining why the greater proportion of body surface area relative to the amount of water present in the skin. parents need to protect the infant from heat loss, the Lanugo is shed within a few weeks of birth and has no relationship to heat loss. Sebaceous nurse should discuss that the characteristic of the glands and apocrine glands are immature in the infant but are not related to heat loss or infant’s skin that is responsible for heat loss is: temperature regulation.
| Specific information on the functions of the skin is needed to answer the question. Look at the critical word newborn and think about the characteristics of newborn skin to help make a selection. |
225 Which of the following statements indicates that a Correct answer: 3 PMS occurs only during the luteal phase of the menstrual cycle (7 to 10 days before client understands appropriate information about menstrual flow begins). Increasing sexual activity doesn’t prevent PMS, and caffeine can premenstrual syndrome (PMS)? worsen the symptoms.
| The critical word in the question is understands. This tells you that the correct option is one that contains a true statement. Use knowledge of PMS and that caffeine aggravates it to successfully eliminate incorrect options. |
226 Which of the following symptoms would the nurse Correct answer: 4 Tonic‐clonic seizures are the most common generalized seizures. Periods of inattention and assess for in a client with the most common daydreaming characterize an absence seizure. Sudden loss of muscle tone and falling generalized seizure disorder? characterize an atomic seizure. Repetitive small muscle group activity characterizes a partial seizure.
| The core issue is knowledge of the characteristics of the most common seizure disorder. Use the process of elimination and specific nursing knowledge to answer the question. |
4.‐ Tonic and clonic activity of the extremities | |
227 The nurse must assess the temperature and blood Correct answer: 1 Equipment for client care is dedicated to the client on contact precautions and kept in the pressure of a client on contact precautions every shift. client’s room. Which is the appropriate nursing action to minimize the spread of microorganisms?
| The key word appropriate suggests there is only one correct answer. Look for the nursing action that would limit the spread of pathogenic microorganisms. |
228 The nurse would implement which of the following as Correct answer: 4 Pulses are assessed frequently to ensure adequate circulation is present and an occlusion or the most important measure on the surgical unit on leakage of the graft has not occurred. Pulses should be marked preoperatively so the nurse has the first postoperative day following surgical repair of a comparison point postoperatively. Pulses may be absent for a short‐term postoperatively an abdominal aneurysm? due to vasospasm or hypothermia. Anticoagulant therapy is not indicated. Trendelenburg position could reduce blood flow to the affected lower extremities. Elastic stockings may or may not be ordered because they could interfere with neurovascular assessment of the lower extremities; however, pneumatic boots would help to prevent deep vein thrombosis and allow visualization of lower extremities.
| Note the critical words first postoperative day. This tells you that the client condition could change and that diligent assessment and ongoing monitoring is required. Use knowledge of the surgical procedure and routine postoperative care to make a selection. |
229 The nurse is preparing a client for surgery. Prior to Correct answer: 1 Abrasions, pustules, or other skin conditions have to be assessed and documented because completing the skin preparation, the nurse assesses these may interfere with wound healing. Hair growth—lack of it or presence of lanugo or fine the surgical site for which of the following? hair—will not interfere with the skin preparation. Pulsation is not always visible or available to assess depending upon the part of the body being operated on.
| The core issue of the question is knowledge that broken areas of skin are at risk for infection and need to be reported to the surgeon. Knowing that this is an important item helps to prioritize this as the item to assess. |
230 A client with schizophrenia is admitted to the Correct answer: 4 Option 4 provides the client with the choice of how he would like to take the medication, psychiatric unit. As the nurse approaches the client while being firm that he must take it; the choice gives the client a sense of control and helps to with medication, he refuses it, accusing the nurse of reduce the power struggle. Simply telling the client that the medication is not poison (option 1) trying to poison him. The nurse’s best response would would do little to persuade him to adhere. Option 2 provides no choice and implies be to tell him that: punishment. The client must take the medication; therefore, option 3 would be inappropriate.
| The core issue of the question is knowledge of therapeutic communication techniques when working with a client who has schizophrenia. Use nursing knowledge of this disorder and the process of elimination to make a selection. |
231 The nurse is making a plan of care for a client who is Correct answer: 3 Dry mouth occurs from the anticholinergic effects seen with fluphenazine. Options 1 and 2 prescribed fluphenazine (Prolixin) 1 mg daily at are incorrect because orthostatic hypotension is not a major side effect of fluphenazine. bedtime. The nurse will include which of the following Confusion (option 4) is not a side effect of this agent. to monitor for side effects of the medication? | The core issue of the question is knowledge of drug adverse effects and how to prevent them. Recall that anticholinergic effects are of concern with this medication and use the process of elimination to make a selection. |
‐ Remind him frequently to rise slowly when getting out of bed or from a chair. ‐ Assess for dizziness or lightheadedness frequently during the day. ‐ Make sugarless hard candy, gum, and water available during the day. ‐ Monitor for confusion frequently. | |
232 The nurse working on an adult medical unit would Correct answer: 4 The nurse should delegate the care of the 79‐year‐old who has chronic bronchitis and early assign which of the following clients to the licensed Alzheimer’s disease. This client has a stable medical status. The nurse would want to assess the practical/vocational nurse (LPN/LVN) under the client undergoing cardiac catheterization and complete the preparation activities for the supervision of the RN? procedure. The nurse would also want to assess the client with low back pain. The nurse would want to assess and monitor the client who had chest pain the previous evening because of the nature of the problem.
| Recall the principles of delegation. The nurse should not delegate the care of clients who require assessment due to changes in acuity or status, and clients who require teaching. Stable clients may be delegated to the LPN/LVN under the RN’s supervision. |
233 A client with venous stasis ulcers is being treated with Correct answer: 1 Elevation of the extremities promotes venous return. Pulses are assessed to ensure adequate an Unna boot. The nurse should include which of the circulation. Option 3 is unnecessary because the Unna boot is treating the ulcer and is changed following additional interventions in the plan of care? every 1 to 2 weeks.
| The core issue of the question is knowledge of the type of condition that requires the use of an Unna boot and then determining an intervention that meets the same need. To answer correctly, you need to determine that the underlying problem is venous in nature and that leg elevation aids in relieving symptoms of venous disease. |
234 A priority nursing action needed following a full body Correct answer: 4 Anxiety reduction is needed when the client is waiting for the outcome of tests to assist them scan would include which of the following actions by in processing their feelings and exploring their options based upon the results of the test. the nurse?
| The purpose of the test is to identify a possible problem and the client’s greatest fear is that the test will validate that something is wrong. Therefore, communication is the first priority in care of a post‐test client. Pain is a possibility of a problem since the test does require the client to lie still for a while. But fear will intensify pain even more if not addressed first. Only minimal radiation exposure does occur during a scan and not enough to cause any radiation sickness (nausea). Bleeding is not a possible outcome from the scan since the procedure is not invasive. |
235 The nurse is teaching a client and family about health Correct answer: 2 COPD places a client at risk to develop malnutrition due to reduction in muscle mass and fat maintenance with chronic obstructive pulmonary reserves. Option 1 is incorrect because COPD clients are more likely to suffer from respiratory disease (COPD). The nurse explains to the family that infections due to altered immune response (decreased cell‐mediated immunity, altered nutrition is important in managing this condition using immunoglobulin production, and impaired cellular resistance). Options 3 and 4 are incorrect which rationale? because COPD clients usually present with weight loss and are hypermetabolic (require additional calories due to increased energy requirements as a result of increased work of breathing).
| The wording of the question tells you the correct answer is a true statement of fact. Use general knowledge of nutritional concepts and COPD to eliminate each of the incorrect options. |
236 The nurse provides discharge instructions to the Correct answer: 3 In hypertensive urgencies, clients present with a systolic BP greater than 240 mmHg and client taking an antihypertensive medication. The diastolic BP greater than 120 mmHg. In hypertensive emergencies, the client’s diastolic BP is nurse should include in the teaching plan that a greater than 130 mmHg. hypertensive crisis will exist if the diastolic blood pressure (BP) is greater than which of the following?
| The core issue of the question is knowledge of the parameters of hypertensive crisis. Use this knowledge and the process of elimination to make a selection. |
237 Which of these statements if made by a client Correct answer: 1 Atherosclerosis indicates the need to adopt a low‐fat diet. Both butter and margarine have 4 receiving dietary instruction for atherosclerosis would grams of fat per serving, making the client’s statement incorrect and in need of further indicate a need for further discussion? clarification. The responses in the other options are correct.
| The critical words in the question are further discussion. With this in mind, evaluate each of the options in terms of how they relate to a low‐fat diet. |
238 The nurse would choose to use medical aseptic Correct answer: 3 Medical asepsis requires clean, not sterile, technique. Only option 3 requires medical aseptic technique when collecting which of the following technique. Collecting a wound culture (option 1), suctioning a tracheostomy (option 2), and specimens? catheterizing the client (option 4) all require the nurse to use sterile asepsis.
| Knowledge of medical versus surgical asepsis is essential. Look for similarities in the choices. Options 1, 2, and 4 require sterile technique. Option 3 is the only choice that requires medical aseptic technique. |
239 Following placement of a central venous line, which Correct answer: 3 Increased heart rate and/or respiratory rate within minutes to several hours following central information should the nurse report immediately to venous line insertion are symptoms of a pneumothorax caused by puncture of the pleura. The the physician? client will require a chest x‐ray to determine if a pneumothorax is present. If the client does have a pneumothorax, placement of a chest tube is likely. Pain at the central line insertion site, fever, and diminished breath sounds in lung bases will require intervention, but the etiology of these symptoms is not likely to be potentially life threatening as is the development of a pneumothorax.
| Consider an acute complication of central line insertion, which would include pneumothorax. Then consider how pneumothorax would manifest in the client to make a selection. Pain (option 1) might be expected to some degree. Fever (option 2) could occur with infection but this could not happen that quickly. Eliminate option 4 because of the qualifier bases with lung sounds, which indicates atelectasis, not pneumothorax. |
240 A client diagnosed with schizophrenia has improved Correct answer: 2 Ideas of reference or misinterpretation occurs when the client believes that an incident has a and is playing a card game with peers. The group personal reference to one’s self when, in fact, it is not at all related. A hallucination is the begins laughing at a joke told to them. The client jumps occurrence of a sight, sound, touch, smell, or taste without any external stimulus to the up and shouts, “You are all making fun of me.” The corresponding sensory organ; they are real to the person (option 1). Delusions are false beliefs nurse concludes that the client is displaying: that cannot be changed by logical reasoning or evidence (option 3). Loose association is a vague, unfocused, illogical flow or stream of thought (option 4).
| The core issue of the question is the ability to draw correct conclusions from the behavior of a client with schizophrenia. Use knowledge of the features of this diagnosis and the process of elimination to make a selection. |
241 A 70‐year‐old client with chronic obstructive Correct answer: 3 With increased age, there is an increased sensitivity to xanthines. Also, there could be other pulmonary disease (COPD) is taking theophylline (Theo‐ disease processes that may lead to this elevated value. The dose of theophylline should be Dur). A blood level is drawn and the result is 25 mg/dL. decreased to get the blood level to the 10 to 20 mg/dL range. Theophylline doses should be What explanation by the nurse helps the client based on lean body weight to prevent entering the medication into the adipose tissue. understand this lab result?
| The core issue of the question is knowledge that the drug level is high and knowledge of what factors can increase the drug level. Use concepts of the effects of age on pharmacokinetics and the process of elimination to make a selection. |
242 The mother of a 2‐month‐old receiving immunizations Correct answer: 3 Immunizations interrupt the chain of infection by generating immunity in a susceptible host for the first time will also be a beginning nursing by introducing a weakened or killed antigen into the body. Immunizations do not affect the student when the next semester starts. When the portal of entry, portal of exit, or the mode of transmission of a pathogenic organism. mother asks the nurse to relate the immunizations to what she learned in the microbiology class, the nurse states that administering childhood immunizations interrupts the chain of infection at what link?
| Knowledge of the chain of infection is required. Immunizations change the immunity status of the person receiving them. Option 3 is the only choice where that is possible. |
243 A 9‐year‐old child is being treated with methimazole Correct answer: 2 The thyroidectomy is the third alternative treatment used when medication and iodine‐based for Graves’ disease. She has not responded to the drug radiation therapy are unsuccessful. There is a great concern of causing hypothyroidism in the therapy as quickly as the physician expected so a client. The other statements are not reflective of the underlying concern with performing a thyroidectomy is being considered. The child’s mother thyroidectomy in a child. asks the nurse, “Why would the physician seem hesitant to encourage the surgery?” Which response by the nurse is best?
| Determine the core issue of the question, which is a disadvantage of performing a thyroidectomy in a child. Use knowledge about hyperthyroid state and age‐related concepts to eliminate each of the incorrect responses. |
244 The nurse doing health promotion in an ambulatory Correct answer: 2 Uterine prolapse is caused by weakened pelvic muscles, which can be strengthened by Kegel women’s health clinic would plan to teach Kegel exercises. The other conditions are not treated with Kegel exercises. exercises to a woman with which of the following conditions?
| The core issue of the question is knowledge that Kegel exercises can strengthen the pelvic floor. Evaluate each of the options to determine which condition could be improved by the use of these exercises. |
245 A client with a diagnosis of paranoid schizophrenia Correct answer: 2 With this client, being a danger only to himself (option 1) isn’t enough, he may not be a who threatened his parents with a knife was placed on danger to himself but he still may want to harm his parents (others). Although the goal is for a 48‐hour hold by the courts and the psychiatrist. The the client to continue to take his medication (option 3) and remain in treatment (option 4), nurse explains to the family that once the 48‐hour hold safety is a priority. Depending on state law, the length of hold may be either 48 or 72 hours. is expired, the psychiatrist and court must determine if the client is: | The core issue of the question is safety of all possible clients in the question. Note the association between the word knife in the stem and the word danger to narrow the possibilities to options 1 and 2. Choose option 2 over 1 because it is the most comprehensive option. |
‐ A danger to himself. ‐ A danger to himself and others. ‐ Agreeable to take his medications. ‐ Willing to remain in outpatient treatment. | |
246 Which of the following statements made by a client Correct answer: 1 Clients receiving ophthalmic corticosteroids have an increased risk of infection. Contact receiving ophthalmic corticosteroids indicates a need lenses should not be used during ophthalmic corticosteroid therapy. Options 2, 3, and 4 for further teaching? indicate an appropriate understanding of ophthalmic corticosteroid therapy.
| The core issue of the question is knowledge that corticosteroids increase risk of infection and how to reduce this risk when taking ophthalmic corticosteroids. Use nursing knowledge and the process of elimination to make a selection. |
247 A nurse is teaching a new group of hospital teen Correct answer: 4 Sneezing and coughing are examples of modes of transmission, whereby droplet nuclei can be volunteers about the chain of infection. Which of the transmitted directly to a susceptible host. following items would the nurse include as an example of how an infection would spread through droplets?
| Look for commonalities among the options in order to eliminate choices. Options 1, 2, and 3 are inanimate objects that serve as vehicles to transmit infectious microorganisms. Choose option 4, as direct transmission of microorganisms occurs. |
248 A 12‐year‐old boy has signs of precocious puberty. He Correct answer: 3 The premature secretion of testosterone promotes the closure of the epiphyseal growth is 5 feet 7 inches tall, has a deep voice, and has started plates. Many of these children appear very tall around sixth grade, but their friends eventually to shave his facial hair. His friends are envious of his catch up and surpass them in linear growth. tall stature and basketball skills. The boy comments on the fact that he expects to be over 6 feet tall and become a professional basketball player. What will the nurse use as information in explaining that the client will probably not reach that height?
| To answer this question, it is necessary to have an understanding of the underlying pathophysiology. Take time to review this information if you have the need. |
249 The client was taught calf‐pumping exercises prior to Correct answer: 1 Calf pumping exercises involve contracting and then relaxing the leg muscles in an alternating surgery to decrease the possibility of thrombophlebitis fashion. Options 2, 3, and 4 do not exercise the calf muscles, including the gastrocnemius developing postoperatively. The nurse observes the muscles. client performing the procedure and notes that the client correctly understands the technique when the client is observed doing which of the following?
| The core issue of the question is knowledge of correct implementation of leg exercises in the perioperative period. Use this knowledge and the process of elimination to make a selection. |
250 The nurse determines that the highest priority action Correct answer: 4 When intervening in delirium, highest priority is given to nursing interventions that will when caring for a client who has alcohol‐withdrawal maintain life. Fluid and electrolyte loss caused by nausea and vomiting can be a life‐ delirium would be: threatening condition during alcohol withdrawal, requiring replacement by intravenous therapy.
| The core issue of the question is knowledge that a state of delirium is characterized by some type of metabolic imbalance. Recall that questions that address priorities of care in unstable clients often focus on physiological needs first. With this in mind, eliminate options 1 and 3 first. Choose option 4 over 2 because it assists in correcting the client’s internal metabolic state, and thus meets a physiological need. Option 2 addresses a safety need. |
251 The nurse working the evening shift on an adult Correct answer: 3 The nurse should delegate the care of the 62‐year‐old who had surgery 3 days ago to repair surgical unit would assign which of the following the fractured femur. This client has a stable medical status. The nurse would want to assess clients to the licensed practical/vocational nurse the client returning to the unit following gastric surgery and the client who had wisdom teeth (LPN/LVN) under the supervision of the RN? extraction. The nurse would want to complete discharge teaching with the client who had the cholecystectomy.
| Recall the principles of delegation. The nurse should not delegate the care of clients who require assessment due to changes in acuity or status, and clients who require teaching. Stable clients may be delegated to the LPN/LVN under the RN’s supervision. |
252 The nurse should implement contact precautions with Correct answer: 3 A wound infection can be spread by direct contact with the wound. Scarlet fever, pertussis, the client with which of the following health and rubella involve the spread of infection by respiratory particle droplets larger than 5 problems? microns.
| Look for commonalities among the options in order to eliminate choices. Options 1, 2, and 4 are contagious infections characterized by coughing. Choose option 3, as direct transmission of microorganisms occurs by direct contact with the client. |
253 The nurse is caring for a 68‐year‐old male diagnosed Correct answer: 4 The statements in the first three options correctly describe signs of BPH. Option 4 indicates with benign prostatic hyperplasia (BPH). Which of the the need for further teaching because the client should increase his fluid intake (unless following statements by the client indicates the need contraindicated) to prevent urinary tract infections and lessen dysuria. for further teaching?
| The critical words in the stem of the question are need for further teaching. This tells you that the correct answer is an incorrect statement made by the client. Use the process of elimination and knowledge of the disorder to make a selection. |
254 Parents of a 10‐year‐old boy with mild cerebral palsy Correct answer: 2 While work or industry is the primary developmental task of children this age, emphasis ask the nurse about having their son join a Boy Scout should not be placed exclusively on school. Recreational activities are an integral part of troop that meets after school. The boy attends a growing up, and all efforts should be made to provide access to such programs. Scouting regular grade school class. The nurse considers which programs provide recognition of individual successes and strengths and can do much to of the following when formulating a response? enhance a child’s self‐esteem.
| Consider the word mild in the stem of the question and choose the response that is the broadest and most encompassing. |
255 The nurse should assess carefully a 79‐year‐old client Correct answer: 1 Elderly clients have slower metabolism and elimination of drugs, causing an increased who has been frequently sedated with haloperidol susceptibility to side effects. Extrapyramidal side effects are most common with haloperidol, a (Haldol) for signs of which of the following? high‐potency antipsychotic. Frequent sedation of this elderly client with haloperidol can lead to the development of tardive dyskinesia, and requires careful monitoring by the nurse.
| The core issue of the question is knowledge of adverse effects of the drug haloperidol. Use specific nursing knowledge and the process of elimination to make a selection. |
256 A new staff nurse wants to clarify her responsibilities Correct answer: 4 The state nurse practice act defines the scope of nursing practice in each state. Although regarding delegation. To which of the following there are general principles that apply to all, each state retains the right to formulate its own documents would the nurse mentor refer this nurse? regulations about nursing practice, including delegation. The ANA standards of practice apply to care given to clients. Job descriptions and policy manuals are agency‐specific and do not address the state regulations directly.
| Use knowledge of the source of various regulations to answer the question. If needed, review concepts related to legal governance of nursing practice. |
257 The nurse is preparing to enter the room of a client Correct answer: 4, 3, 1, The gown is applied first, as it takes the most time to don. The mask is donned next, followed with pneumonia caused by penicillin‐resistant 2 by eye protection. These items can be more securely applied with ungloved hands. Gloves are Streptococcus pneumoniae (PRSP). The client has a donned last, so the gloves can be pulled up to cover the cuffs of the gown. tracheostomy and requires suctioning. Put the following personal protective equipment in order of donning. Click and drag the options below to move them up or down.
| Rationalize the ordering based on nursing knowledge of standard precautions and surgical asepsis. |
258 A school‐age child has recently been diagnosed as Correct answer: 2 The teacher is most aware of the varied reactions of the classmates and together the parents having a seizure disorder. The parents express a and teacher can plan strategies to promote acceptance of this child. A Medic Alert bracelet is concern about what will happen if the child has a appropriate but will not improve self‐esteem. A psychiatrist might be consulted if the child seizure at school. The parents are afraid other children shows symptoms of altered self‐esteem, but this is not required now. will make fun of their child. Which of the following responses by the nurse would be most helpful?
| The focus of the question is on how to maintain the client’s self‐esteem and the location of the concern centers around being at school. With this in mind, select the option that directly addresses the concern. |
259 The nurse is preparing to administer a purified Correct answer: 2 The client who has had a positive PPD test in the past should be evaluated with a chest x‐ray, protein derivative (PPD) tuberculin skin test to a client. which is the screening test of choice in this case. The arm should be cleansed with alcohol and Before administration, the nurse should take which of allowed to air dry prior to the administration of the test. The test is usually read in 48 to 72 the following actions? hours and the client may wash the area as usual.
| The core issue of the question is knowledge of proper procedure and concerns when administering a PPD test. Recall that this is a skin test for tuberculosis to help you recall that assessment of a client’s past reaction is a key first action. |
260 The nurse determines that an appropriate outcome Correct answer: 3 Initially, the delirious client is dazed, drowsy, and perceptions will be disturbed, making it criterion for the initial nursing care of a client with difficult for the client to sustain attention to any mental task. Delirium is characterized by acute delirium would be which of the following? alternating periods of confusion with lucidity; therefore, option 3 is an appropriate initial outcome criterion. Options 1, 2, and 4 are appropriate outcome criteria once the client has been stabilized.
| The core issue of the question is understanding of the condition of delirium. The critical word in the stem of the question is initial. With this in mind, choose the option that shows the beginnings of return of neurological status to normal. |
261 A child is admitted to the nursing unit with acute Correct answer: 3 Dehydration results in hypovolemia, which can precipitate acute renal failure in infants and renal failure (ARF). When reviewing the nursing children. The other responses are incorrect because they don’t directly impact renal perfusion. history, the nurse notes a history of all of the following health problems. The nurse concludes that which item in the child’s history most likely precipitated the onset of ARF?
| Consider the various etiologies of acute renal failure. Recall that the kidneys need a minimum glomerular filtration rate to function properly. Use the concept to choose correctly. |
262 The nurse concludes client teaching about infection Correct answer: 1 A client with tuberculosis must wear a particulate respiratory mask if transportation to control measures has been effective when a client with another hospital department is unavoidable. This is an element of airborne precautions tuberculosis states, necessary to limit the transmission of the microorganism. Tuberculosis is not transmitted via eating utensils (option 3) or urine (option 4). Removal and disposal of respiratory secretions is important but does not require the client to wear gloves.
| Knowledge of how tuberculosis is transmitted is essential. Eliminate options 3 and 4 because they do not address transmission via the respiratory tract. Select option 1 over 2 as clients would not wear gloves to protect themselves from their own infections. |
263 An 18‐year‐old client is seen in the Emergency Correct answer: 4 Severe scrotal pain, nausea, and absent cremasteric reflex are characteristic of testicular Department with sudden onset of severe scrotal pain, torsion. Severe pain and an absent cremasteric reflex are not typical symptoms of the nausea, and an absent cremasteric reflex. The nurse disorders listed in the other options. should suspect which of the following conditions?
| Note the critical word sudden in the stem of the question. Eliminate options 1 and 3, which are not as sudden in onset. Choose between Options 2 and 4, noting that the word torsion indicates twisting, which is compatible with the symptoms described by the client. |
264 Evidence that the outcome of “restore tissue Correct answer: 4 A goal of venous ulcer care is for the client to experience no signs of inflammation or integrity” has been met in a client with a venous stasis infection. This is the goal directly related to tissue integrity. The other options are good ulcer includes: outcomes but do not relate directly to the question as stated.
| Focus on the term skin integrity to compare the options. Eliminate options 2 and 3 first because they are not associated with skin integrity. Choose option 4 over option 1 because it is a more global or encompassing item, which is typical when determining an outcome. |
265 A 58‐year‐old client reports to the nurse during a Correct answer: 2 The onset of dementia symptoms for this client was at or before 58 years of age. When health history that the physician recently diagnosed a Alzheimer’s disease occurs in people under the age of 65, it is called presenile dementia. type of dementia. The nurse checks in the medical record for documentation related to which of the following most likely disorders?
| The core issue of the question is the association of the age of 58 with the appropriate type of dementia. Use nursing knowledge of the types of dementia and the process of elimination to make a selection. |
266 A client is brought to the emergency department Correct answer: 2 The jaw thrust maneuver is used whenever head or cervical spine injury is suspected to avoid awake and alert following a fall from a ladder from a causing further physiological damage. The head‐tilt‐chin‐lift method (option 1) is the standard height of 15 feet. While the nurse is conducting an method for opening the airway when there is no suspected cervical spine injury. The tongue‐ initial assessment, the client becomes unresponsive jaw lift (option 3) aids in visualizing foreign bodies in the airway. The client does not need and stops breathing. Which method should the nurse emergency intubation (option 4). use to open the airway?
| Note key information in the stem, which indicates the client has suffered a traumatic injury and is therefore at risk of cervical spine injury. Next use knowledge of basic CPR procedures to select the option for opening the airway in a client with suspected head or neck injury. |
267 The nurse has begun CPR on a 5‐year‐old child. The Correct answer: 3 The proper ventilation rate for a child or infant is 12 to 20 breaths per minute, which is the nurse times the rate of ventilation to achieve how same as delivering one breath every 3 to 5 seconds. Ventilation rates of 8 (option 1) or 10 many breaths per minute? (option 2) do not provide sufficient oxygenation for the child during cardiopulmonary arrest. A rate of 30 breaths/min (option 4) is excessive and could be harmful. 1.‐ 8 2.‐ 10 3.‐ 20 4.‐ 30 | Use the process of elimination and knowledge of basic CPR procedures to make the proper selection. Remember that compressions and ventilation rates need to be higher in children than in adults to help you choose correctly. |
268 A nurse has begun to resuscitate a 10‐month‐old Correct answer: 1 The brachial artery is the correct location for determining whether an infant under one year infant. After delivering breaths, the nurse next checks of age has a pulse. The radial artery would not generate enough pulsation in an infant to be the pulse at which of the following locations? reliable (option 2) and is also more difficult to palpate. The carotid pulse is not as easily located in an infant with a small neck and neck folds (option 3), while the temporal pulse is not used in CPR for an individual of any age.
| Eliminate options 2 and 4 first because they are not used in CPR. Choose option 1 (brachial) over option 3 (carotid) using knowledge of infant anatomy and accessibility of the site. |
269 The nurse on a surgical nursing unit has just called a Correct answer: 3 In an adult, the sternum should be depressed during CPR to a depth of 1.5 to 2 inches. The code blue using the telephone in the room of an head‐tilt‐chin‐lift method of opening the airway is used for the client who has no head or neck unresponsive client who had abdominal surgery. injury (option 1). The nurse should deliver two breaths to initiate ventilation (option 2). The Which of the following actions would be appropriate nurse should reevaluate the client’s status after approximately 1 minute (option 4). during initiation of CPR?
| Use knowledge of basic CPR procedures to answer the question. Eliminate options 1 and 2 because they indicate incorrect procedure. Eliminate option 4 because the time frame is excessively long. |
270 The nurse who is doing the documentation during a Correct answer: 3 On an adult client, chest compressions should be done to a depth of 1.5 to 2 inches to be code blue on an adult client observes an unlicensed effective. Options 2 and 4 are excessively deep and could lead to injury, while option 4 is not assistive personnel (UAP) doing CPR. The nurse deep enough to provide effective circulation. interprets that the UAP is performing CPR correctly after noting that the UAP is depressing the sternum how many inches? 1.‐ 2.5 to 3.5
| Use the process of elimination and knowledge of basic CPR procedures to answer the question. Recall that compressions are never deeper than 2 inches to eliminate options 1 and 2. Recall that there is only a half inch variability in compression depth to choose option 3 over 4. |
271 The nurse is performing CPR on a 10‐month‐old Correct answer: 3 The rate of compressions for an infant during CPR is at least 100 per minute. Options 1 and 2 infant. The nurse times the rate of compressions to are higher than the minimum number of compressions per minute, while option 4 does not achieve a total number of approximately how many deliver a sufficient number of compressions per minute. compressions per minute? 1.‐ 180 2.‐ 120 3.‐ 100 4.‐ 80 | Use knowledge of basic CPR procedures to answer the question. Eliminate options 1 and 2 because they are too excessive for any client. Note that the client in the question is an infant to choose option 3 over 4. |
272 A nurse witnesses an adult male collapse at the Correct answer: 4 The client should not be lying in water or other liquid, which could lead to burns or to airport and an automated external defibrillator (AED) defibrillating another individual who comes in contact with the liquid during AED shock is brought to the scene. The nurse should do which of delivery. The electrodes should not be placed on hairy areas, or the site should be shaved the following in utilizing the device? (option 1). All people should stand clear of the individual during an AED shock to avoid being defibrillated themselves (option 2). CPR is initiated after 1 minute or whenever the series of shocks is terminated, as indicated by client condition. However, 5 minutes is too excessive and could lead to permanent brain damage if the client survives (option 3).
| First eliminate option 1 because hair interferes with good skin contact of any type of electrode. Next eliminate option 3 because brain death can occur within 4 to 6 minutes if CPR is not initiated. Use general principles of electrical safety to choose option 4 over option 2. |
273 A nurse is eating in a restaurant when a woman who Correct answer: 1 In a pregnant client, the Heimlich maneuver is performed in a manner that avoids causing is 8 months pregnant at the next table begins to choke. injury to the fetus. For this reason, the hand placement is at the midsternum rather than at the Which of the following hand placements should the abdomen (options 3 and 4). The lower sternum (option 1) should be avoided to prevent nurse use to perform the Heimlich maneuver? accidental fracture of the xiphoid process, which could lead to internal injury.
| Note key information in the question that the client is pregnant. Then use knowledge of basic CPR procedures to answer the question. Eliminate options 3 and 4 first because they involve the abdomen, and eliminate option 2 next as possibly unsafe. |
274 The long‐term care nurse has been called to the aid of Correct answer: 2 There is a specific sequence of actions that is performed as part of basic life support when a a resident who has become unconscious after choking client is choking. After positioning the client on the back, the nurse would observe the oral in the dining room. After positioning the client on the cavity to detect any foreign body that may be removed immediately. Next, the nurse would back, which of the following actions should the nurse open the airway and attempt to ventilate (option 1). If unsuccessful, this process would be take next? repeated. Finally the nurse would perform abdominal thrusts (option 3). Chest thrusts (option 4) are performed in the adult only for pregnant or obese clients.
| Remember the ABCs of life support to answer this question. Choose the option that attempts to clear the airway before taking any other actions. |
‐ Perform five abdominal thrusts ‐ Perform five chest thrusts | |
275 A nurse enters an adult client’s room and says, “Good Correct answer: 3, 1, 2, The first action of the nurse is to establish unresponsiveness. This can be done by shaking the morning!” while doing initial shift rounds after 4 shoulder and asking if the client is okay. The subsequent actions of the nurse would be to call receiving report. The client does not respond. Put the for help (option 1), open the airway (option 2), and ventilate the client (option 4). nurse’s actions in order of priority. Click and drag the options below to move them up or down.
| Specific knowledge of the sequence of events is needed to answer the question. Using the ABCs (airway, breathing, and circulation) will be of assistance once unresponsiveness has been determined. |
276 An adult client arrives to the Emergency Department Correct answer: 1, 3, 4, An awareness of the risk factors for cardiovascular disease and associated symptoms can with complaints of chest pain, and shortness of breath. 5 assist the nurse in analyzing the origin of chest pain and prioritizing and implementing The nurse concludes that which of the following appropriate care. Diabetes (option 1), smoking (option 4), and hypertension are known points, if present in the client’s history, would indicate modifiable and non‐modifiable risk factors. Chest pain that occurs during activity (option 3) that this pain may be related to cardiac disease? may indicate cardiac ischemia due to the increased oxygen demand. The associated symptom Select all that apply. of diaphoresis is a known warning sign of cardiac ischemia. Chest pain that worsens with a deep breath, is most likely pleuritic pain and suggests a diagnosis of pleurisy and the nurse should next listen for a pleural friction rub.
| The core issue of the question is knowledge of risk factors of cardiac disease leading to chest pain. Eliminate option 2 as unrelated because cardiac pain does not correlate with the respiratory cycle. |
277 A nurse who is walking through a parking lot at the Correct answer: 3, 2, 4, Current BLS guidelines include establishing responsiveness as the first step to avoid mall notices an adult male who calls out for help 1, 5 performing CPR unnecessarily. With the use of AEDs and the benefit of early defibrillation, before collapsing on the ground. What should the requesting to get the AED or defibrillator equipment is initiated early in the BLS sequence. nurse do to perform basic life support correctly? Place Opening the airway, rescue breaths, and assessing circulation follow the recommended the following steps in the correct sequence by clicking sequence. and dragging the options below to move them up or down.
| Never initiate CPR on someone until trying to establish responsiveness and determining that the client is not breathing, or is pulseless. Time is critical, and clearly clients in this critical state will need a higher level of care, warranting early notification of emergency personnel, early defibrillation, and maintaining the ABCs of cardiopulmonary support. |
278 A nurse who normally works on an adult medical unit Correct answer: 2 The rate of rescue breathing for a child is 20 breaths/minute, compared with 12 has floated to the pediatric unit for the day. One of the breaths/minute for an adult. seriously ill children codes shortly after report. The nurse responds to the code, incorporating the understanding that the procedure for initiating basic life support, unlike for an adult, is:
| A child’s respiratory rate is faster than an adult’s, which makes this option the best choice. A blind finger sweep should not be performed in infants and children, since the foreign body could be pushed back into the airway. The airway always must be established, and rescue breathing before compressions. The BLS guidelines recommend two rescue breaths, not one. |
279 The nurse is called to assist with the resuscitation of a Correct answer: 2 The jaw thrust maneuver is used when there is suspicion of a neck injury. Diving into shallow 16‐year‐old who dove into the shallow end of a water is a known cause of spinal cord injuries. Despite the unconsciousness of the client and swimming pool. He is unconscious, and currently is the inability to assess for spinal injury, a neck injury is to be suspected in this client. In all other lying on his back out of the water near the pool. What scenarios, the head‐tilt chin‐lift is appropriate to open the airway. method would the nurse use to open the airway?
| The critical concept in this question is the history of diving into shallow water. Also, the client is an unconscious accident victim. Neck and spinal cord injury should be assumed in this circumstance, thus warranting the use of the jaw‐thrust method for opening the airway. |
280 The nurse responds to a code of an adult client on the Correct answer: 1 The bent arms will displace the downward force and make the chest compressions less hospital unit. In the room are two students performing effective. Bouncing movements decrease effectiveness of resuscitation, and most likely will cardiopulmonary resuscitation (CPR). The nurse cause injuries. Using the heel of one hand is appropriate for CPR in the child. notices the person performing compressions kneeling in a straddled position over the client. To which position would the nurse direct the student to change in order to improve the depression of the sternum?
| Eliminate option 3, since it is an adult client, and 2 and 4 because the positions do not follow the BLS guidelines for correct positioning, and could cause injury to the client. |
281 While performing CPR using a bag‐valve mask on an Correct answer: 1, 5 Proper positioning of the airway is essential for rescue breathing, and might not be adult client, the nurse observes that the chest is not established with the first attempt. BLS guidelines recommend a second attempt to open the rising and falling with ventilations. What interventions airway. A good seal over the mouth and nose is necessary to ensure ventilations are being could be used to improve ventilations? Select all that delivered to the client. These two interventions must be established before any other steps are apply. taken to ventilate the client.
| Remember to have an open airway and a good seal of the mask to assure proper rescue breathing. Increasing rate, force, and adding oxygen will be ineffective if the airway is not open and there is not a good seal. |
282 While recording interventions during a code for an Correct answer: 2 The rate of rescue breathing for an adult client is 12/minute, or 1 every 5 seconds. adult client, the nurse notices that the unlicensed assistive person (UAP) is ventilating at a rate of 1 breath for every 2 seconds. What rate for ventilations would the nurse direct the UAP to perform?
| Use knowledge of BLS guidelines to identify that option 1 is too slow, 3 is the rate for children, and that the selection in the stem is still too fast for an adult. |
283 The nurse has been performing CPR on an adult Correct answer: 4 Once breathing and circulation return, the recommended position if no injury is the client. The nurse notes that after a series of cycles of “recovery” position. It has been found to be optimal to keep the airway open, and also will compressions and ventilations have been completed, reduce the risk of aspiration if the client has an emesis. the client still is unresponsive, but a pulse is present and breathing has returned. What intervention would the nurse perform to maintain an open airway?
| Eliminate all the other options. While a nasogastric tube might resolve the problem with aspiration from emesis, it will not help open the airway. In addition, keeping the client flat—even with the head of the bed elevated—will not open the airway, because the jaw and tongue will tend to fall back. Do not continue rescue breathing if spontaneous respirations are adequate. |
284 The nurse is performing basic life support on an infant Correct answer: 2 BLS guidelines indicate that when not confident that signs of circulation are present, if you who is under 1 year of age. The nurse thought the feel no pulse, or if you feel a pulse rate less than 60/minute with poor signs of perfusion, you brachial pulse was present, but is unsure. What action begin chest compressions. would the nurse take next?
| Waiting for one minute would lose time to restore oxygenation and circulation, and BLS guidelines direct you to not take more than 10 seconds to check for signs of circulation. Knowledge of CPR for infants would tell you that a carotid would not be a good place to find a pulse, and in infants, palpating the apical impulse does not assure that circulation is present. |
285 The nurse in the pediatric unit walks into a 5‐year‐old Correct answer: 1, 3 Since the child was eating, you must determine if foreign body airway occlusion (FBAO) has child’s room and notes the child is on the floor, occurred. This can be accomplished by the tongue/jaw lift and visualization of the mouth. unconscious and cyanotic. The lunch tray is near the Opening the airway and attempting rescue breathing would aid in identifying if FBAO is bed, with half of the food consumed. What present. Blind finger sweeps are not done. The nurse would not check a brachial pulse on a 5‐ interventions would the nurse perform? Select all that year‐old, and an external defibrillator is not the core issue when there is FBAO. apply.
| Look at the information given in the stem of the question. The child has just eaten, which would indicate that FBAO might have occurred. If so, recall knowledge of BLS guidelines for children indicating not to do a blind finger sweep. This could push the object further into the airway. For children, palpating a carotid pulse is recommended. |
286 While performing cardiopulmonary resuscitation Correct answer: 4 The most common cause of sudden cardiac arrest is an abnormal heart rhythm called (CPR) on an adult visitor in a shopping mall, the mall ventricular fibrillation. Therefore, delivering a shock via the AED can restore normal cardiac security guard arrives with an automatic external rhythm. An AED warrants use immediately when it becomes available. defibrillator (AED) device. What actions would the nurse at the scene take at this time?
| Recall knowledge of causes of cardiac arrest and the BLS guidelines to aid in answering this question. Early defibrillation is the key in sudden cardiac arrest, and waiting is not warranted, which would eliminate options 1 and 3. Rescue breathing is not done during the analysis and shock, because of the danger of shock to the rescuer. |
287 A school nurse is performing cardiopulmonary Correct answer: 1 The child is old enough to apply the adult guidelines, which are 1 1/2–2 inches for effective resuscitation (CPR) on a 9‐year‐old child. Rescue chest compressions. breathing has been initiated. The child has no pulse. The nurse would begin chest compressions using which of the following methods?
| Knowing the age parameters for the techniques in BLS will aid in answering this question. This child is old enough to use the adult guidelines. The other options are either incorrect in depth for compressions or used for smaller children and infants. |
‐ The middle and ring fingers at a depth of 1/2–1 inch ‐ The heel of one hand 1 1/2–2 inches | |
288 The nurse follows the instructions of the AED for Correct answer: 1 BLS guidelines for AED use is to perform three analyses and, if no shock is indicated and there three analyses, with no shock indicated. The adult is still no sign of circulation, perform CPR for one minute before checking circulation and client remains unconscious and pulseless, and is not cycling the AED to analyze the rhythm again. breathing. What would be the nurse’s next intervention?
| Knowledge of the AED will help to eliminate the incorrect options. Do not remove the AED pads, because analyzation of the rhythm is needed again. Also, correct procedure is to perform only three analyses, then resume CPR for one minute, so the third and the fourth choice are incorrect. |
289 A nurse dining at a restaurant is summoned to assist Correct answer: 1 An alternate position with the obese client is using the chest thrusts while the individual is in with a choking adult who is markedly obese. The a standing or sitting position. individual is conscious. While attempting to perform the Heimlich maneuver, the nurse cannot encircle the arms around the abdomen to be effective. Which option should the nurse choose to modify the technique?
| Don’t lose precious time by waiting until a person becomes unconscious to intervene, especially when alternate methods can be used. Asking the client to lie down is not in the recommended guidelines, and a finger sweep is used only when the client becomes unconscious. |
290 The nurse working in a food manufacturing plant is Correct answer: 2, 1, 3, Most electric shock injuries in adults occur at work, as is possible in this scenario. Removing summoned to help with a worker who has collapsed. 4 the electrical source that this client is on or near and providing scene safety prior to Upon arrival, the nurse finds an adult male lying on the approaching the victim are the first steps in this sequence. Then follow the BLS guidelines for floor near wires from a bottle‐packing machine. The EMS activation, CPR, and AED use. individual is not moving, and does not respond to his name being called. The plant noise is loud, and it is possible he does not hear his name. Order the sequence of steps the nurse would follow to assist in helping this individual. Click and drag the options below to move them up or down.
| In the stem of the question, identify the risk of electrical shock opposed by the client’s being near wires. Scene safety measures to prevent injury to the rescuer would direct you to select turning off the power before approaching the client to implement CPR. |
291 The nurse is monitoring clients in the dining room of a Correct answer: 2 Individuals with partial obstruction can still breathe and cough. They are to be encouraged to rehabilitation unit. An adult stroke client begins to continue this. FBAO interventions are to be used only with severe or complete airway cough after eating a piece of meat. What intervention obstruction. would the nurse use to help this client?
| Knowledge of BLS guidelines for FBAO will help in determining the answer. Eliminate the other options, because there is no indication that there is complete airway obstruction. |
292 The nurse has conducted client teaching with the Correct answer: 3 The prodromal period is the time between the initial symptoms and the presence of the full‐ mother of a 4‐year‐old child who has been exposed to blown disease. The rash would not be apparent during this time. All the other statements are chickenpox. In evaluating the effectiveness of the correct. instruction, the nurse determines that the mother needs additional information after the mother makes which statement?
| The core issue of the question is knowledge of client teaching points related to chickenpox, particularly related to the timing of symptoms. Use nursing knowledge and the process of elimination to make a selection. |
293 A mother overhears two nurses discussing the Correct answer: 1 The incubation period is the time between exposure and outbreak of the disease. It is often a incubation period for a measles outbreak. The mother period when the child can be contagious without others being aware of the possible exposure. asks the nurses why it is important to know the incubation period. The nurse’s reply would include which of the following statements about the incubation period?
| The core issue of the question is knowledge of the significance of the prodromal period in a communicable disease. Use nursing knowledge and the process of elimination to make a selection. |
294 A 9‐year‐old child is at the 98th percentile for weight Correct answer: 2 The NCHS growth charts use the 5th and 95th percentiles as criteria for determining those and at the 40th percentile for height. The school nurse children who fall outside the normal limits for growth. Children whose height and weight are determines that this child is: above the 95th percentile are considered overweight or large for stature. Prepubescent growth spurts are between ages 10 and 12 for girls and 12 and 14 for boys. This is not a normal proportion for height and weight for this 9‐year‐old.
| The critical words are "9‐year‐old child" and "98th percentile for weight and 40th percentile for height." Knowledge of the growth charts and normal growth is needed to answer the question correctly. |
295 A 2‐year‐old child in the hospital for a fractured Correct answer: 1 Caladryl will reduce itching and discomfort and therefore diminish scratching and skin femur breaks out with chickenpox. Which nursing breakdown. Acetylsalicylic acid should not be given to young children with a viral disease intervention will best prevent secondary skin because of the relationship to Reye syndrome. Immunoglobin will not decrease skin eruptions. infections? Nubaine is a narcotic analgesic.
| The core issue of the question is knowledge of various products used in the care of children and which one will reduce the likelihood of itching or pruritus with skin lesions. Use nursing knowledge and the process of elimination to make a selection. |
296 A child is being treated at home for chickenpox. The Correct answer: 1 Tepid baths allow heat to be removed from the body. Aspirins are avoided because of the risk home‐health nurse is visiting and notes an elevated of Reye syndrome. The child should wear only light clothing to allow heat to escape. Antibiotics temperature. To prevent a common complication of an are not usually ordered for this viral infection. elevated temperature, the nurse recommends which of the following?
| The core issue of the question is an effective measure to prevent febrile seizures as a complication of fever in a child. Use nursing knowledge and the process of elimination to make a selection. |
297 A child has been diagnosed with mumps, and the Correct answer: 4 Mumps is a viral infection and thus antibiotics will not be effective. The other statements are mother has been given instructions on caring for the true. Acetaminophen, fluids, and soft foods are helpful, and the mother should watch for child during the acute period. Which statement by the vomiting and headache. mother indicates a need for additional education?
| The core issue of the question is knowledge of supportive measures for a child with mumps. Use nursing knowledge and the process of elimination to make a selection. |
298 A 2‐year‐old child with rubeola (measles) is brought Correct answer: 3 The child has a stuffy nose, which can impair air exchange. Nursing care involves use of a cool‐ to the hospital with a rash covering the entire body, mist vaporizer and gentle suctioning of the nose. The rash does not cause skin impairment. A 2‐ photophobia, and stuffy nose that interferes with year‐old will not have a disturbed body image. Disturbed sleep pattern would have less priority breathing. The nurse utilizes which of the following than gas exchange if this problem developed. nursing diagnoses as a priority for care when administering care to this child?
| The core issue of the question is the ability to set appropriate priorities of care for a child with a communicable disease. Use nursing knowledge and the process of elimination to make a selection. |
299 A child is exposed to a playmate who contracted Correct answer: 2 The upper respiratory symptoms may be early prodromal symptoms of chickenpox. The chickenpox. Two days later, the child is admitted to the incubation period of chickenpox is 10 to 21 days. The other responses are either too short hospital for another problem, and the parents inform (option 1) or too long (options 3 and 4). the nurse of the exposure on admission. How long after the exposure should the child be watched for signs of upper respiratory illness?
| The core issue of the question is knowledge of the incubation period for chickenpox. Use nursing knowledge and the process of elimination to make a selection. |
300 The home‐health nurse sees a child with mumps. The Correct answer: 3 Cool fluids will help decrease the swelling of the glands around the mouth and neck. Acidic mother says that the child is not eating well and asks foods are too irritating and difficult to swallow. Warm, chopped foods may be difficult to for suggestions. The nurse most appropriately suggests swallow (option 1), and spices are also likely to be irritating (option 2). The child should be which of the following? given small, frequent meals with soft foods rather than a regular diet (option 4).
| The core issue of the question is knowledge of foods and beverages that will be helpful to the child with mumps. Use principles of diet therapy that utilize cool, soft, and nonirritating food items to make a selection. |
301 The mother of a 3‐year‐old child with measles calls Correct answer: 3 Soothing the skin with an oatmeal‐based substance will decrease the itching and redness. the nurse at the clinic and asks what she can do to help Overdressing the child will increase perspiration and thereby increase the itching. Although decrease the redness and itching. The nurse responds drinking adequate fluids is helpful, it does not directly affect the itching. that which of the following actions is likely to be helpful?
| The core issue of the question is an effective measure to treat itching caused by a communicable disease such as measles. Use nursing knowledge and the process of elimination to make a selection. |
302 The clinic nurse is working with a toddler who has Correct answer: 1 The route of transmission of roseola is unknown. It is not known to be transmitted by the been diagnosed with roseola (exanthema subitum) respiratory tract (option 2), contact with contaminated articles (option 3), or body secretions after being seen for fever and a skin rash. The nurse such as urine or stool (option 4). makes which response to the mother who asks how to reduce the risk of infecting other children at home?
| The core issue of the question is knowledge of transmission of roseola. The wording of the question tells you the correct answer is also a true statement. Use nursing knowledge and the process of elimination to make a selection. |
303 A college student was hospitalized following onset of Correct answer: 2 Pertussis is most infectious early in the course of the disease, so it is not necessary for the a severe case of pertussis. In preparing for discharge, client to self‐isolate following discharge from the hospital. Coughing bouts may still be the nurse would correct which client statement that triggered by irritants, so these should be avoided. Frequent handwashing and increased fluid indicates a misconception about postdischarge care? intake are generally helpful measures that should also be continued in the home setting.
| The core issue of the question is knowledge of care to a client recovering from pertussis. Note that the client is nearing discharge and is not in an acute state to choose the item that does not need to continue. The wording of the question tells you the correct answer is an incorrect client statement. Use nursing knowledge and the process of elimination to make a selection. |
304 A child who may have scarlet fever is being evaluated Correct answer: 3 Koplik's spots are seen with roseola, not scarlet fever. Reddened edematous pharynx, red in the urgent care clinic. The nurse concludes that the strawberry tongue, and rash in the axillae and groin are findings consistent with scarlet fever. client’s presentation is not consistent with scarlet fever after noting which of the following during assessment?
| The core issue of the question is the ability to discriminate between clinical findings associated with scarlet fever and roseola. The wording of the question tells you the correct answer is an incorrect client statement. Use nursing knowledge and the process of elimination to make a selection. |
305 The nurse is assessing a child in the outpatient clinic Correct answer: 4 Fifth disease is characterized by flulike symptoms such as fever, malaise, nausea, and who has fever, lethargy, nausea, and vomiting. The vomiting, and by the characteristic “slapped cheeks” appearance. This finding is not nurse notes that the child’s cheeks have the characteristic of chickenpox, measles, or diphtheria. appearance of being wind‐burned or slapped. The nurse suspects which of the following childhood communicable diseases?
| The core issue of the question is the ability to discriminate the classic sign of Fifth disease from other childhood communicable diseases. Use nursing knowledge and the process of elimination to make a selection. |
306 The spouse of a postal worker who contracted Correct answer: 4 Anthrax is caused by a bacterium and is therefore amenable to treatment with antibiotics. cutaneous anthrax asks the nurse whether this Antivirals and immune globulin play no role in treating this disease, and the statements in communicable disease can be treated. Which of the options 1 and 2 are incorrect because they indicate no treatment is available. following responses by the nurse is most appropriate?
| The core issue of the question is knowledge of available treatment methods for anthrax. Use nursing knowledge and the process of elimination to make a selection. |
307 The nurse is providing health teaching to a group of Correct answer: 6 The incubation period for infectious mononucleosis is up to 6 weeks (with a minimum of 4 high school students regarding infectious weeks). This has important implications for the nurse and the client, since the source of the mononucleosis. When discussing the incubation period exposure may be difficult to determine after several weeks. as part of disease transmission, the nurse explains that the incubation period for this infection is weeks. Write in a numerical answer. | The core issue of the question is knowledge of the incubation period for infectious mononucleosis. Specific knowledge is needed to answer this type of question. Note that the question asks for the number of weeks, which suggests that the number to be typed in is not excessively large. |
308 The child is receiving an intravenous antibiotic that Correct answer: 4 The nurse’s responsibility involves early recognition of side effects from a drug. Therefore, has a known side effect of ototoxicity. The nurse the nurse would monitor the child for symptoms of ototoxicity. Diluting the dose and slowing administering the dose should: the infusion would not diminish the total dose of drug and would not prevent ototoxicity. The nurse cannot decrease a dose independently. Reducing the dose will decrease the blood levels and may lead to bacterial resistance.
| Recognize that ototoxicity is damage to the ears and look for options that refer to ears and ear function. |
309 A child is being treated at home for chickenpox. The Correct answer: 1, 5 Tepid baths allow heat to be removed from the body. Aspirins are avoided because of the risk home‐health nurse is visiting and notes an elevated of Reye Syndrome. The child should have only light clothing to allow heat to escape. Antibiotics temperature. To prevent a common complication of an are not usually ordered for this viral infection. elevated temperature, the nurse recommends which of the following? Select all that apply.
| Knowledge of the nursing management of a child with fever will help to choose the correct answer. |
310 A child who enters the nursing clinic has a diagnosis Correct answer: 1 Immunoglobulin titers are low in children with SCID, with or without an infection. The low of rule out severe combined immunodeficiency disease titer levels are what prevent the child from fighting an infection. The other options do not (SCID). The child is being seen in the clinic because of a address this concept. possible infection. In evaluating the lab reports, the nurse would expect to find:
| The critical concept is the severe combined immunodeficiency. Select the option that contains the laboratory value that would be expected in this client. |
311 The nurse is working in a clinic that provides free Correct answer: 2 Epinephrine 1:1000 is the drug of choice for an acute anaphylaxis reaction. A child may have immunizations to clients with financial hardship. In the allergies yet unknown at the time of immunizations. Albuterol is a bronchodilator that opens morning before seeing any of the day’s clients, the the airway but epinephrine is the drug of choice during anaphylaxis. Toxoids and nurse checks that which of the following supplies is immunoglobulins are other classes of drugs that affect the immune system but they do not available should a client experience an anaphylactic treat anaphylaxis. allergic reaction to a vaccine?
| Knowledge of the emergency management of anaphylaxis will aid in choosing the correct answer. Learn to automatically pair anaphylaxis with epinephrine. |
‐ Immunoglobulin ‐ Toxoid | |
312 The child has been diagnosed with mumps. The home‐ Correct answer: 4 Children with mumps are uncomfortable but rarely very ill. Give non‐aspirin analgesics and health nurse has given the mother instructions on antipyretics to control fever and pain. Swallowing and chewing may be painful so give fluids caring for the child during the acute period. Which and soft foods. Be alert to signs of complications such as headache, stiff neck, vomiting, and statement by the mother indicates a need for photophobia which may indicate meningeal irritation. Antibiotics are not prescribed. additional education?
| Critical words are “indicates a need for additional teaching.” Look for an answer that is incorrect. Knowledge of the nursing management of the child with mumps will aid in choosing the correct answer. |
313 A 2‐year‐old child is seen in the pediatric clinic with Correct answer: 3 Koplik’s spots are unique lesions found in the mouth of the individual with rubeola. rubeola (measles). The mother asks how the doctor can be sure it is rubeola and not some other disease. The nurse explains that the characteristic lesion of rubeola is:
| The rash characteristics are not enough to distinguish rubeola from other diseases. Select the one unique feature that is seen in no other disease. |
314 A young infant is admitted to the pediatric unit with a Correct answer: 4 Altered temperature, jaundice, and respiratory distress are all symptoms of sepsis in infants. diagnosis of sepsis. The nurse is completing a nursing Respiratory function is the highest priority. assessment. The priority assessment for this infant would be which of the following?
| Recognize that all responses are correct for this child. Consider which diagnosis would have the highest priority. |
315 In caring for an adolescent with suspected narcotic Correct answer: 1, 2, 5 Typical symptoms of narcotic abuse include constricted pupils, euphoria, and respiratory abuse, the nurse would monitor the adolescent for depression. Options 3 and 4 do not apply. which of the following? Select all that apply.
| The symptoms that the nurse will assess for are the same that would be seen in the client receiving a narcotic for a therapeutic purpose. |
316 The nurse in the hospital would suspect severe Correct answer: 1 The first infection often seen in these children is oral candidiasis (thrush). That along with the combined immunodeficiency disorder (SCID) when low white blood cell count would a be a warning symptom. A 2‐year‐old is unlikely to have which child is admitted to the unit? survived this long undiagnosed.
| Two of the options refer to a newborn. Eliminate those options because maternal antibodies acquired intrauterinely will protect these infants. |
317 A 5‐year‐old child is brought into the clinic after Correct answer: 3 Maintaining an open airway is always the highest priority. With anaphylactic shock, the experiencing an insect sting. The child appears to be airway may constrict, mucous membranes swell, and air trapping occurs. going into anaphylactic shock. The nursing action with the highest priority is:
| Note the critical word “action” in the stem of the question. This suggests the correct answer is a nursing intervention rather than an assessment. Airway always has the highest priority. |
318 The mother of a newborn is concerned her infant has Correct answer: 1 Babies are born with nonspecific immunity. Active immunity and specific immune response been exposed to a communicable disease. She states are developed over time with exposure to an organism. Immunizations are inactivated the doctor says the baby is protected because of some substances or weakened organisms given to promote the development of immunity. kind of immunity, but is unsure of the type. The nurse would identify the type of immunity as:
| Consider which type of immunity a young infant would have. Immunizations can be eliminated because a newborn will not have had any. |
319 A 12‐year‐old boy is hospitalized and diagnosed with Correct answer: 2 The family will need to know how to protect themselves from the virus. Handwashing is the the recent development of human immunodeficiency first line of protection. However, family coping skills will best be enhanced by the nurse virus (HIV) infection secondary to factor transfusions demonstrating acceptance of the child. This along with child and family education will help the for hemophilia. The family of the child is very family deal with this disease. concerned about the risk this child presents to the rest of the family and questions whether the child should remain in the home. The nursing activity that will best promote family coping would be:
| Knowledge of the emotional support and care of the child with HIV will help to choose the correct answer. |
320 A newborn has health problems immediately after Correct answer: 4 TORCH is an acronym for toxoplasmosis; other, which includes hepatitis and syphilis; rubella; birth. The mother tells the nurse that the doctor cytomegalovirus; and herpes simplex. These infections are caused by bacteria, viruses, and suspected a TORCH infection, but she does not know other organisms. what causes this. The nurse would respond that a TORCH is:
| Since all the letters in TORCH are capitalized that should be a hint that this is an acronym. |
321 The school nurse is teaching teenagers about how the Correct answer: 3 Transmission is by blood or body fluid contact. It is not an inherited disorder. Equipment is human immunodeficiency virus (HIV) is spread. The not shared in the nursery, but the virus can be spread only if the contact involves blood or students state they know about blood transfusions, IV body fluid. drug use, and sexual contact, but question how babies can be born with HIV. The nurse explains that babies can receive the HIV virus:
| Since HIV is a blood borne pathogen, look for the option that would have blood exposure. |
‐ During delivery from maternal contact. ‐ In the nursery from shared equipment. | |
322 A child is to receive "allergy shots." The mother tells Correct answer: 4 Hyposensitization injections carry the risk of allergic reaction including anaphylaxis. They the office nurse that she is a nurse and asks why she should only be given in a controlled environment with emergency drugs and equipment on can’t give her child his shots at home because she was hand. trained to give insulin injections to the family pet. The office nurse should respond:
| The core concept in this question is maintaining a safe environment for the child. |
323 A child is exposed to a playmate that contracted Correct answer: 2 The upper respiratory symptoms may be early prodromal symptoms of chickenpox. The chickenpox. Two days later the child is admitted to the incubation period of chickenpox is 14 to 21 days. hospital for another problem. The nurse is informed of the exposure on admission. How long after the exposure should the child be watched for signs of upper respiratory illness?
| Recognize that upper respiratory symptoms relate to the onset of chickenpox, and consider the prodromal period. |
324 The nurse is providing care to a toddler who has Correct answer: 2 Option 1 is incorrect as gastric lavage would be performed before the administration of ingested an unknown amount of his grandfather's activated charcoal. The activated charcoal will aid in the absoption and removal of any medication which is described as "a white pill." The medication left after gastric lavage is completed. The term lavage indicates wash the stomach, physician has ordered the gastric lavage and removing the saline after administration. administration of activated charcoal. What action should the nurse take?
| Consider the purpose of the lavage and activated charcoal to deternine the correct order of administration. |
325 Parents report that their small child stiffens when Correct answer: 1 Although a thorough examination and assessment is necessary to diagnose autism, it can be being held and does not smile or make eye contact suspected based on the information provided. These symptoms are not normally associated with them. Based on this initial information, the nurse with the other disorders listed. suspects that the child may have which disorder?
| Recall that lack of interaction with others is a primary feature of autism. |
326 The nurse is providing information about reducing Correct answer: 3 Both live and silk flowers will have increased dust levels associated with them. The other exposure to antigens in a client who is allergic to dust. activities are appropriate. When the nurse visits the home, she evaluates the learning of the family. Which finding in the client’s home indicates a need for additional teaching? | Eliminate those options which would reduce dust in the environment leaving only the incorrect response. |
‐ Hardwood floors with attractive throw rugs decorate the family room ‐ The adult family members have switched to the nicotine patch as they attempt to stop smoking ‐ The room is decorated with hanging live plants and arrangements of silk flowers ‐ The family reports they take turns vacuuming the entire house each day | |
327 A teenager has been diagnosed with asthma, and Correct answer: 2 Cromolyn sodium is an aerosol taken daily to prevent an attack. All of the other answers are cromolyn sodium (Intal) has been ordered for this incorrect. child. Which statement by the child indicates a correct understanding of this drug?
| Options 1 and 4 discuss the drug relieving an immediate attack and can be eliminated. Knowledge of the drug will help you to choose from the remaining options. |
328 A client has an opportunistic respiratory infection. Correct answer: 3 An opportunistic infection is one in which an individual develops a disease from an organism Which of the following is most likely correct? that does not cause disease in healthy individuals. This occurs with compromised immunity.
| Note the use of the word compromised. Select the option that matches the definition of opportunistic infection. |
329 A client presents in the emergency department with Correct answer: 2 Antibiotics may affect the outcome of the culture. Fever will continue to be present until the fever of 102 degrees F, malaise, and a productive bacteria are eliminated, making obtaining a culture a priority. cough. Which of the following should be done first?
| This item requires priority setting. All of the options may be pertinent, but identification of the first step is important. |
330 The drug of choice to treat a "walking" or Correct answer: 2 The erythromycin products are the best for treating mycoplasmal pneumonia or walking mycoplasmal pneumonia is: pneumonia. Vermox is used for helminthic infections; Aralen hydrochloride is used for protozoal infections; and Chloromycetin is used for spirochetal infections.
| Select the option that identifies a drug commonly used for pneumonias. |
331 Which of the following refers to the ability of bacteria Correct answer: 2 A pathogen is any organism capable of causing disease. Pathogenicity refers to the ability of to produce pathologic changes or disease in the host? the organism to cause pathologic changes.
| Note the use of the word “pathologic” in the question. This will lead to selection of the correct response. |
332 Which of the following is true concerning human Correct answer: 1 The virus makes a DNA copy of its own RNA using the reverse transcriptase enzyme and the immunodeficiency virus (HIV)? DNA copy is inserted into the genetic material of the infected cell.
| Identify the response that addresses the pathophysiology of HIV. |
‐ HIV replication occurs extracellularly. ‐ DNA replication is similar to that of other viruses. | |
333 Which of the following viruses is most likely to be Correct answer: 1 Influenza virus is transmitted through respiratory droplets. Herpes virus is transmitted by acquired through casual contact with an infected direct contact and HIV through blood and body fluids. Cytomegalovirus is an opportunistic individual? infection.
| The key element in the question is the term ‘casual contact.’ This leads to the correct response of influenza. |
334 A female prostitute enters the clinic for treatment of Correct answer: 2 Epidemiological studies indicate chlamydia as the most prevalent sexually transmitted disease a sexually transmitted disease. Given that this disease in the United States. is the most prevalent in the United States, the nurse can anticipate that the woman has which of the following?
| This question requires application of factual knowledge about the disease chlamydia. |
335 Endotoxins differ from exotoxins in that exotoxins Correct answer: 3 Endotoxins are often not destroyed even by autoclaving. Options 1, 2, and 4 are descriptions have which of the following characteristics? of endotoxins.
| This is a question that requires application of facts about endotoxins and exotoxins. |
336 A client exhibiting symptoms of a rickettsia infection Correct answer: 3 Rickettsia are parasites of ticks, fleas, and lice. Influenza is an example of transmission by probably acquired it through: respiratory droplets, encephalitis is transmitted by mosquitos; lice and scabies are transmitted by direct contact.
| This is a question that requires application of knowledge about the transmission of rickettsia. |
337 Nurses should understand the chain of infection Correct answer: 2 Infection occurs in a predictable sequence requiring virulence, movement from a reservoir, because it refers to: and entry into a susceptible host.
| Note that the question stem is asking about the ‘chain of infection’ which most closely relates to option 2, referring to transmission of disease. |
338 An infection characterized by bacterial resistance that Correct answer: 1 The capsule contributes to the invasiveness of pathogenic bacteria. Encapsulated bacteria are develops may be linked to the fact that the bacterial protected from phagocytosis unless coated with anticapsular antibody. capsule:
| This item requires application of knowledge of bacterial resistance. Option 4 can be eliminated because of use of the absolute ‘always’. |
339 Which of the following client laboratory test results Correct answer: 4 Eosinophilia is present with allergies and infestation with parasites. Neutrophils are elevated would likely be elevated with nematode infestation? with acute infections and bacterial organisms. Options 2 and 3 are irrelevant.
| White blood cells would be elevated, eliminating options 2 and 3. |
340 A nurse researcher is interested in the epidemiology Correct answer: 4 Epidemiology is the study of how various states of health are distributed in the population. of HIV. This means that the researcher is concerned about which of the following?
| Select the option with the word ‘population.’ |
341 A young male college student came to the clinic after Correct answer: 3 Herpes is a virus and is spread through direct contact. An antifungal would not be useful; contracting genital herpes. Which of the following bedrest and temperature measurement are usually not necessary. interventions would be most appropriate?
| Because the priority with this condition is prevention of transmission select the option that would accomplish this. |
342 Which of the following drugs would be most effective Correct answer: 3 Acyclovir is the antiviral drug of choice for treating herpesvirus. Penicillin products are used in treating genital herpes? for a wide variety of bacterial infections. Rifadin is used for TB and Virazole is an antiviral agent.
| This item requires knowledge of the preferred treatment for herpes. Options 1 and 2 can be eliminated as they are not used to treat viral disease. |
343 A young adult male relates to the nurse that he has Correct answer: 2 Neutrophil counts are often decreased in viral infections and elevated in bacterial infections. recently experienced signs and symptoms of infection. Neutropenia can occur because of chemotherapy and immunosuppression. With recovery, his His neutrophil count is lower than normal. The nurse neutrophil count should be returning to normal. concludes that most likely he:
| This item requires application of factual knowledge that viral infection often lowers neutrophil count. |
344 A young girl presents with fever and abdominal Correct answer: 3 Abdominal distention is caused from infestation of worms. Blood in sputum often results distention. Her mother states that she has also from migration of worms through alveoli. Mycoplasma pneumonia has similar side effects as "coughed up blood" in recent days. Which of the bacterial pneumonia (cough, fatigue, rales, and temperature). Spirochetes cause fever, neck following is compatible with these symptoms? stiffness, and lymphadenopathy; rickettsial infections cause headaches, nausea, vomiting, and muscle aches.
| Select the response which best corresponds with the symptoms. |
‐ Infection with nematodes ‐ Infection with spirochetes | |
345 Which of the following is correct concerning prion Correct answer: 2 Prions are associated with degenerative encephalopathies. While similar to viruses, they lack disease? nucleic acid and lesions are usually limited to a single organ.
| This item is a knowledge question, requiring that the student recall a fact. |
346 A client has a WBC of 15,000, of which 60 percent are Correct answer: 3 With bacterial infection there is an increased need for neutrophils. When the percentage of segmented neutrophils and 3 percent are bands. An immature neutrophils (bands) increases at a greater rate than mature neutrophils (segs), it is antibiotic is prescribed. Three days later the WBC an indication that the infection is severe or prolonged. This is often referred to as a shift to the remains at 15,000; 62 percent segs and 10 percent left. bands. This most likely indicates:
| Note that the WBC remains the same, making options 1 and 3 incorrect while bands and segs are increased, making option 4 incorrect. |
347 Which of the following is incorrect concerning Lyme Correct answer: 1 Lyme disease is a spirochetal infection. Examples of rickettsial infections are Typhus and disease? Rocky Mountain Spotted Fever.
| Note the word ‘incorrect’ in the question stem is asking for identification of the only option that is not related to Lyme disease. |
348 Which of the following substances is useful in Correct answer: 3 Cytokines serve as mediators of inflammation, while leukocidin, adherins, and coagulase inhibiting viral and bacterial growth in the body? enhance bacterial resistance to body defenses.
| This item requires application of factual knowledge. |
349 One structural difference in the cell wall of fungi that Correct answer: 2 Most antifungal agents act by inhibiting biosynthesis of ergosterol. makes them susceptible to antifungal agents is that:
| Select the only response that speaks to the composition of the cell wall. |
350 Which of the following has been associated with Correct answer: 1 A surface peptide found in chlamydia is similar to one in heart myosin and may trigger T‐cells chlamydial infection? to attack both chlamydia and the heart.
| This item requires application of learned information about chlamydia. |
351 The drug of choice for systemic fungal infections is: Correct answer: 4 Fungizone and Mycostatin are both antifungal agents. Mycostatin is most commonly used for topical application, while Fungizone is used systemically.
| Select the antifungal agent that can be given intravenously. |
352 The drugs of choice for treating chlamydia include: Correct answer: 2 Chlamydia is a bacteria and responds to bacteriostatic agents that interfere with protein synthesis.
| Options 1 and 3 should be immediately eliminated, as they are not effective in treatment of bacterial infections such as chlamydia. Select the drug that is the drug of choice. |
353 Which of the following is generally associated with Correct answer: 4 Neuropathies are usually associated with spirochetal infections along with lymphadenopathy, spirochetal infections? fever, and stiff neck. Skin rash is associated with rickettsial infections; an unproductive cough and fever could be many infections including protozoal. Toxic shock is usually associated with staphylococcal infections.
| This item requires application of learned factual information. |
354 Pneumocystis carinii pneumonia is caused by: Correct answer: 3 Pneumocystis pneumonia is a protozoal infection that often affects immunocompromised clients with human immunodeficiency (HIV). It is characterized by a dry, unproductive cough and results from aggregation of parasites and cellular debris.
| Eliminate options 1, 2, and 4 as this is a protozoal infection. |
355 Which of the following is correct concerning Hepatitis Correct answer: 1 Administration of immune globulins can provide passive short‐term immunity to the disease if A? administered within 7 days of exposure. Hepatitis A is transmitted through food feces and is usually not chronic.
| Recognize that options 2, 3, and 4 can be eliminated as they describe hepatitis B. |
356 The Epstein‐Barr virus is most often associated with: Correct answer: 2 Epstein‐Barr virus is the causative agent for mononucleosis.
| The question is asking about a virus. Options 3 and 4 are bacterial and can be eliminated. |
357 Which of the following is correct concerning varicella Correct answer: 3 Varicella zoster results from reactivation of a latent virus in sensory cells of the dorsal root zoster? ganglion. Activation tends to follow the nerve path. | The key characteristic of varicella zoster is pain along a dermatome. |
‐ It is caused by the influenza virus. ‐ It is usually asymptomatic. ‐ Painful lesions appear to follow the path of a dermatome. ‐ Interferon stimulates viral replication. | |
358 Which of the following viral infections has been Correct answer: 4 Influenza has been associated with Guillian‐Barré syndrome, which causes progressive associated with Guillian‐Barré syndrome? paralysis.
| Eliminate options 1, 2, and 3 which have no known association with Guillian‐Barré. |
359 Which of the following is true of botulism? Correct answer: 2 The bacteria produces a neurotoxin that blocks release of acetylcholine at the neuromuscular junction.
| The key term in the correct response is ‘neurotoxin.’ The neurotoxin produces the characteristic symptom of stiff jaw. |
360 Which of the following is used to treat Klebsiella Correct answer: 1 Klebsiella is a Gram‐negative rod. Aminoglycosides are used effectively against Gram‐negative pneumoniae? bacteria by binding to ribosome and preventing protein synthesis.
| Eliminate option 3 as Flagyl is an anti‐fungal. Recall that penicillins and sulfonamides are not used to treat Klebsiella. |
361 Which of the following is true of Helicobacter pylori Correct answer: 2 The enzyme urease produced by the bacteria raises the pH of the stomach, allowing the bacteria? bacteria to survive. Urea in the stomach is converted to ammonia, which is cytotoxic to gastric mucosa.
| Note the term ‘erosion of gastric mucosa’ in option 2. Recall that H. Pylori is often associated with ulcers of the GI tract. |
362 Which of the following is associated with Correct answer: 4 Scarlet fever, rheumatic fever, and glomerulonephritis can all result from streptococcal streptococcal infection? bacteria. Tuberculosis is caused by M. tuberculosis; PID by Neisseria gonorrhoeae; and toxic shock by staphylococcus.
| Use process of elimination to eliminate those options not associated with streptococcal infection. |
363 Which of the following is true of purified protein Correct answer: 3 While the PPD skin test can detect previous exposure to the tuberculosis bacillus, it does not derivative (PPD) and tuberculosis? necessarily establish the presence of active infection.
| This requires application of knowledge that PPD is used to screen for TB exposure. Eliminate the options that do not address detection of exposure. |
364 One of the primary concerns with treatment for Correct answer: 1 Treatment for tuberculosis often requires months of antimicrobial therapy and compliance tuberculosis is: must be encouraged.
| Eliminate options 2 and 4 as they are not true. Select option 1 as the best option as compliance with long‐term treatment is often a concern. |
365 The tetracyclines are identical in their overall Correct answer: 4 Tetracyclines and chloramphenicol are identical in mechanism of action and organisms mechanism of action and are often used similarly to: against which they are effective.
| Select the option most like tetracyclines in action. |
366 The most serious disadvantage of clinical use of Correct answer: 4 Chloramphenicol is reserved for serious infection because it may cause bone marrow chloramphenicol (Chloromycetin) is the: suppression.
| Look for bone marrow suppression when side effects or disadvantages of chloramphenicol are requested. |
367 The mother of a 12‐year‐old who has been diagnosed Correct answer: 2 Mycoplasma pneumonia is an atypical form of pneumonia, occurs often in children, and is with mycoplasma pneumonia wants to know what transmitted by droplets. Signs and symptoms are similar to bacterial pneumonia and the illness she has. The best explanation would be that: virulence is no worse.
| Recall that ‘walking pneumonia’ is the common term for mycoplasma pneumonia. |
368 A middle‐aged woman presents with signs and Correct answer: 3 The proximity of the anus to the urethra in female clients increases the risk for infection from symptoms of urinary tract infection. The most likely bacteria normally found in the colon, such as E. coli. Prion disease is similar to viruses. causative agent is: Staphylococcus is responsible for many infections such as sepsis, cellulites, and toxic shock syndrome; Treponema causes spirochetal infections.
| Recall that the most common causative agent of UTI in females is E. coli because of the proximity of the urethra to the rectum, where E. coli is normally found. |
369 Helicobacter pylori is able to survive in the acidic Correct answer: 1 Urease breaks down urea in the stomach, producing ammonia that increases the pH to allow environment of the stomach because of the enzyme: survival of Helicobacter pylori.
| Select the option that would influence pH in the stomach. |
370 A client with an infection caused by amebiasis will Correct answer: 4 Amebic infection can be carried via the blood to other organs, with the liver as the most most likely have gastrointestinal symptoms. Another common site, causing liver abscess. site that could be affected is the:
| Recall that the liver is structurally close to the GI tract. |
371 Which of the following properties would allow Correct answer: 4 Both forms of hepatitis may result in jaundice, fever, and elevated liver enzymes, but the distinction between Hepatitis A and Hepatitis B incubation period for Hepatitis B is greater than that for Hepatitis A. infection?
| Use the process of elimination to eliminate options 1, 2, and 3 as they occur with both Hepatitis A and B. |
372 A woman with recurring gonorrhea or chlamydia Correct answer: 2 Both gonorrhea and chlamydia may be asymptomatic, with the bacteria invading should be concerned about which of the following? reproductive organs prior to detection.
| Consider that both of these are STDs and affect the organs of reproduction. |
373 A child with suspected toxoplasmosis is experiencing Correct answer: 3 Toxoplasmosis is spread through contact with cat feces. Ticks carry the threat of Lyme disease signs and symptoms of fatigue, fever, and or rickettsial infections. Protozoal infections can be found all over the world. lymphadenitis. Which of the following would be most important in obtaining a nursing history?
| Recall that toxoplasmosis is associated with contact with cat feces. Select the only option that refers to cats. |
374 Which of the following clients would most likely Correct answer: 3 M. avium‐intracellulare is a mycobacterial infection (an opportunistic infection) that has been acquire Mycobacterium avium‐intracellulare? identified in those who are HIV‐positive or have AIDS.
| Select the option that reflects the immunocompromised individual. |
375 A client has recently experienced fever, chills, Correct answer: 2 The convalescent stage occurs when the infection is contained and symptoms are diminished. headache, and myalgia from influenza. The symptoms The acute stage is when all symptoms are present; prodromal is the presence of initial have diminished; however, fatigue is still present. This symptoms; resolution is elimination of an organism. is an example of what stage of the infectious process?
| Use the definition of the term ‘convalescent’ (getting better) to identify it as the correct response. |
376 Mycoplasmal infections are usually resistant to Correct answer: 1 Mycoplasma have no cell wall membrane and therefore are not sensitive to penicillin, which antibiotics such as penicillin because: works by interfering with cell wall synthesis.
| This item requires knowledge of mycoplasma and penicillins. Eliminate options 2, 3, and 4 as being incorrect. |
377 Which of the following is correct concerning viral Correct answer: 2 The viral replication cycle can range from minutes to days. Some viruses remain latent for infections? long periods of time without replicating.
| Eliminate options 1, 3, and 4 as being untrue regarding virus. |
378 Which one of the following suggestions by the nurse Correct answer: 2 Zinc deficiency is associated with taste changes; therefore, supplementation may benefit a would be most helpful to a human immunodeficiency client experiencing altered taste perception. Drinking salty broth and fluids will not help with virus (HIV) positive client who has altered taste taste changes but may help restore electrolyte balance in clients experiencing diarrhea. Dairy perception? products, fish, and poultry are better food choices than meat when taste is altered. Substitution of plastic utensils for metal ones is suggested to decrease possibility of taste perception of “metal.”
| The core issue of the question is knowledge of measures to minimize taste alterations in a client with HIV infection. Use nursing knowledge and the process of elimination to make a selection. |
379 Which of the following suggestions would the nurse Correct answer: 3 Small, frequent meals help lessen nausea because they require less work of digestion and do give to a client with human immunodeficiency virus not overwhelm the client with food odors from a lengthy meal. High‐fat foods are more (HIV) infection to best alleviate nausea? difficult to digest and may distend the stomach. Lying down after eating can encourage reflux. Drinking liquids can give a sensation of fullness. High‐fat foods, reclining after meals, and drinking large quantities of liquid all increase the risk of nausea and vomiting.
| The core issue of the question is the ability to provide teaching to minimize nausea in a client with HIV. Use nursing knowledge and the process of elimination to make a selection. |
380 To enhance meeting the psychosocial needs of a Correct answer: 4 It is important to assess the psychosocial needs of a client on transmission‐based precautions client on transmission‐based precautions, the nurse and to intervene to provide sensory stimulation for the client. Isolation procedures can cause should place highest priority on which of the clients to become depressed and withdrawn and to sleep excessively. Although it is important following? to maintain isolation precautions as ordered, attention must be given to include the client’s psychosocial needs as part of the plan of care. Limiting contact time may be indicated for infection control, but it does not provide psychosocial support.
| The critical word in the question is psychosocial. With this word in mind, focus on the intervention that best meets nonphysical needs of the client. Use nursing knowledge and the process of elimination to make a selection. |
381 A client diagnosed with scleroderma is complaining of Correct answer: 2 Clients who have scleroderma usually have Raynaud’s phenomenon. Raynaud’s can be painful fingers that change colors (pale to red) when triggered by temperature changes, and prolonged water contact may cause activation. Use of washing dishes. Which suggestion by the nurse might gloves when washing dishes may prevent temperature changes yet still allow the client to help the client with this symptom? participate in ADLs. Hotter water may increase the risk of scalding and so is not suggested. Physical therapy and H<sub>2</sub> receptor blockers are indicated for treatment of esophageal problems associated with scleroderma.
| The core issue of the question is recognition of Raynaud’s syndrome and the ability to select an appropriate intervention for that problem. Use nursing knowledge and the process of elimination to make a selection. |
382 The white blood cell (WBC) count of a client with Correct answer: 4 All identified nursing diagnoses are of concern for a client with SLE. However, the results of systemic lupus erythematosus (SLE) shows a shift to the laboratory test demonstrate an increased risk for infection that is due to the disease the left. Which nursing diagnosis reflects the highest process and/or possible treatment measures such as steroids and immunosuppressive agents. priority for this client? A shift to the left in a WBC differential indicates an increased number of immature cells, suggesting infection.
| The core issue of the question is the ability to analyze WBC differential count data to determine risk of infection. Use nursing knowledge and the process of elimination to make a selection. |
383 A client is to start taking prednisone for the Correct answer: 2 Steroid therapy is usually done as part of a tapered‐dose treatment plan. It is important to treatment of rheumatoid arthritis (RA). Which client take this medication at the same time each day and to become aware of tapered‐dose effect. statement indicates that medication teaching was Steroids are usually taken with foods to minimize GI upset. Steroids cause fluid retention, and successful? therefore sodium intake may be restricted. Steroids also increase blood glucose, so insulin therapy dosages may have to be adjusted.
| The core issue of the question is knowledge of client teaching related to steroid therapy. Use nursing knowledge and the process of elimination to make a selection. |
384 The nurse assesses the client with rheumatoid Correct answer: 1 Swan‐neck deformity occurs at the proximal interphalangeal (PIP) joint and ulnar deviation arthritis for which of the following characteristic joint occurs as a result of joint destruction with disease progression. Heberden’s and Bouchard’s changes? nodes are commonly found in clients with osteoarthritis. Tophi (firm, moveable nodules) are associated with gout. Charcot’s joint is considered a neuropathic disorder that falls under the broader category of rheumatism. It is not specific to RA and is more likely to be seen as a complication in clients with diabetes.
| The core issue of the question is identification of signs and symptoms of RA. Use nursing knowledge and the process of elimination to make a selection. |
385 In establishing a plan of care to manage pain for a Correct answer: 3 Heat and cold applications can provide analgesia and relieve muscle spasms. The individual client with rheumatoid arthritis, what intervention client will have to determine whether heat, cold, or alternation of both is most effective. Pain would the nurse use to increase the client’s mobility? medication should be taken on a regular schedule if the client has chronic pain so that the pain threshold can be raised and pain relief maintained at a constant level. Exercising in the presence of pain may only further exacerbate pain. Flexing of muscle groups is not related to effective pain control.
| The core issue of the question is knowledge of measures that relieve the symptoms of RA. Use nursing knowledge and the process of elimination to make a selection. |
4.‐ Teach the client to flex muscle groups when pain is felt in an extremity. | |
386 Which of the following information will the nurse use Correct answer: 3 Methotrexate treatment takes several weeks to effect relief. Once relief is obtained, the dose when explaining therapeutic measures to a client is adjusted to achieve maximum response at the lowest dose. If the drug is discontinued, then taking methotrexate (Rheumatrex) for rheumatoid symptoms of the disease do return. arthritis?
| The core issue of the question is knowledge of management principles for RA. Use nursing knowledge and the process of elimination to make a selection. |
387 The nurse looks for results of which laboratory Correct answer: 2 CD<sub>4</sub> cells are indicative of a client’s HIV status. As the disease measurement that provides a reliable indicator of progresses, the T‐helper cells decrease in number and lose their ability to function effectively, lymphocyte status in a client with HIV infection? leading to an overaggressive immune response. B lymphocytes indicate the status of humoral immunity and are not directly associated with HIV infection. NK cells and T‐cytotoxic cells are not directly related to HIV infection and as such are not considered to be reliable indicators of HIV status.
| The core issue of the question is knowledge of which laboratory measure will provide information about the status of the immune system of a client with HIV. Use nursing knowledge and the process of elimination to make a selection. |
388 The nurse who is providing care to a group of clients Correct answer: 4 Transfusion and Goodpasture’s are examples of type II cytotoxic hypersensitivity reactions concludes that the client with which of the following and are involved with the activation of complement. Lupus is an example of a type III problems exhibits a type III immune‐ hypersensitivity reaction, which involves IgG and IgM with the activation of complement. complex–mediated hypersensitivity reaction?
| The core issue of the question is the ability to associate various types of hypersensitivity reactions with their etiologies. Use nursing knowledge and the process of elimination to make a selection. |
389 A male client who has acquired immunodeficiency Correct answer: 2 While Megace is used as a palliative treatment for clients with advanced cancers, this is not syndrome (AIDS) asks why oral progesterone (Megace) the rationale for its use with AIDS. In AIDS clients, it provides appetite enhancement. Side is being prescribed for treatment. What is the nurse’s effects of Megace can include nausea and constipation. best response?
| The core issue of the question is the purpose of oral progesterone in a client with AIDS. Use nursing knowledge about anorexia as a symptom of AIDS and the process of elimination to make a selection. |
390 The nurse would assess for which of the following Correct answer: 1 Hyponatremia is a common finding in clients with AIDS. The incidence of opportunistic electrolyte imbalances as a common finding in a client infections may contribute to this decrease in sodium. Hypernatremia, hyperkalemia, and with AIDS? hypocalcemia are not usually seen in clients who have AIDS.
| The core issue of the question is identification of an electrolyte disturbance that is more common to clients with AIDS. Use nursing knowledge and the process of elimination to make a selection. |
391 Which of the following assessments by the nurse Correct answer: 2 Prolonged morning stiffness is associated with RA. Occasional use of NSAIDs is not by itself a warrants further investigation to determine if the direct link to the development of RA. Complaints of pain with movement are more likely to be client has rheumatoid arthritis (RA)? associated with degenerative joint disease (osteoarthritis).
| The core issue of the question is the ability to identify symptoms that are possibly associated with RA. Use nursing knowledge and the process of elimination to make a selection. |
392 The nurse teaches a client that which of the following Correct answer: 1 Pregnancy can be associated with an exacerbation because of increased estrogen levels. factors might increase risk of developing an Hypotension, fever, and GI upset do not exacerbate SLE. exacerbation of systemic lupus erythematosus (SLE)?
| The core issue of the question is risk factors and triggers for SLE. Use nursing knowledge and the process of elimination to make a selection. |
393 A client will undergo scratch tests for allergies. In Correct answer: 3 A scratch test tests many allergens at once. It is of low sensitivity, but many allergens can be teaching the client about the planned tests, the nurse tested at once, and the results can be obtained in 30 minutes. should include which of the following information?
| The core issue of the question is identification of appropriate concepts to teach a client about scratch tests for allergies. Use nursing knowledge and the process of elimination to make a selection. |
394 The nurse would expect which of the following Correct answer: 4 Diseases with HLA associations have poorly understood etiologies, are usually chronic or findings in a client with an immunologic disorder subacute in nature, and have limited effect on reproductive capacity. associated with an HLA antigen?
| The core issue of the question is knowledge of diseases associated with the HLA antigen. Use nursing knowledge and the process of elimination to make a selection. |
395 A client presents with dyspnea, pruritis, and localized Correct answer: 3 The priority intervention is to maintain a patent airway in a potential anaphylactic reaction. swelling of the forearm after being stung by a bee. Therefore, the nurse should assess for swelling of the tongue and stridor, which could indicate What is the priority intervention? impending respiratory obstruction. The other interventions are supportive measures that can be used during an allergic response.
| Remember in emergency or near‐emergency situations to use the ABCs (airway, breathing, and circulation) to plan priorities of care. Use the process of elimination to make a selection. |
396 Medication instruction for the client with rheumatoid Correct answer: 1 Gold salts may cause anaphylaxis. Sulfasalazine may cause nausea and vomiting, but fluids arthritis (RA) should include which the following should be encouraged (option 2). Acetaminophen does not provide the same anti‐ teaching points? inflammatory effects as ASA and NSAIDs (option 3). Penicillamine cannot be used during pregnancy (option 4).
| The core issue of the question is knowledge of appropriate client teaching related to medications used to treat rheumatoid arthritis. Use nursing knowledge and the process of elimination to make a selection. |
397 The nurse writing a care plan determines that which Correct answer: 1 Skin manifestations are a common finding in clients with scleroderma and therefore require of the following is a priority nursing diagnosis early in preventative and supportive nursing care as the priority. As the disease progresses, the care of a client with scleroderma? dermatologic effects may lead to disturbances in body image. In addition, with disease progression, there may be an impact on respiratory and musculoskeletal function, leading to activity intolerance. Similarly, hopelessness can develop with new and worsening symptoms. Therefore, the nursing diagnoses in options 2, 3, and 4 are of lesser priority in the early phase of the disease process.
| The core issue of the question is knowledge that scleroderma is primarily a skin disorder in many cases and that therefore the primary nursing diagnosis needs to address loss of skin as a protective barrier. Use nursing knowledge and the process of elimination to make a selection. |
398 An infant is admitted to the pediatric unit with a Correct answer: 4 Altered temperature, jaundice, and respiratory distress are all symptoms of sepsis in infants. diagnosis of sepsis. The nurse is completing a nursing Respiratory function is the highest priority because without an adequate airway and breathing, assessment. The priority assessment for this infant the client cannot maintain life. would be
| Use the ABCs and the process of elimination to make a selection. Airway and breathing typically take priority in situations of high acuity, such as sepsis. |
399 The nurse is caring for a pediatric client with acquired Correct answer: 1 Body fluid‐contaminated liquids may contain the human immunodeficiency virus (HIV) and immunodeficiency syndrome (AIDS). Which activity by can be absorbed through the eye mucosa. The other activities do not expose the nurse to the nurse should be reported to the employee health blood and/or body fluids of the client and therefore pose no risk of contracting HIV. department as an exposure for the nurse?
| The core issue of the question is the ability to identify a breach in standard precautions. Use nursing knowledge about transmission of HIV via body fluids and the process of elimination to make a selection. |
400 The pediatric nurse would suspect severe combined Correct answer: 1 The first infection often seen in these children is oral candidiasis (thrush). That symptom, immunodeficiency disorder (SCID) when which of the along with the low WBC count, would be a warning symptom of SCID. A 2‐year‐old is unlikely following children is admitted to the hospital nursing to have survived this long undiagnosed. ELISA tests evaluate HIV infection, and a TORCH titer is unit? unrelated. A newborn is too young for symptoms to have manifested.
| The core issue of the question is the ability to identify signs and symptoms of SCID. Use nursing knowledge and the process of elimination to make a selection. |
401 A 5‐year‐old child is brought into the clinic after being Correct answer: 3 Maintaining an open airway is always the highest priority. With anaphylactic shock, the stung by an insect. The child appears to be going into airway may constrict, mucous membranes swell, and air trapping occurs. The second priority anaphylactic shock. Which of the following nursing would be airway access, followed by renal assessment, and finally site care. actions is of highest priority?
| Use the ABCs—airway, breathing, and circulation to answer questions related to anaphylaxis. Airway is always the first priority in life‐threatening situations. |
402 A 12‐year‐old boy is hospitalized and diagnosed with Correct answer: 2 The family has stated multiple concerns, and demonstrating acceptance of the child is the the recent development of human immunodeficiency best way to foster acceptance of the child and development of further coping skills. Prevention virus (HIV) infection secondary to factor transfusions of transmission, handwashing, and drug therapy are all important, but none of these for hemophilia. The family is very concerned about individually targets the global concerns of the family. their ability to manage his care, risk of infection to family members, and whether the child should remain in the home. Which action by the nurse will best promote family coping at this time?
| The core issue of the question is the best action of the nurse to model acceptance of the child and lead to enhanced coping skills by the family. Select the option that is the most global in nature because the family has multiple concerns, and use the process of elimination to make a selection. |
403 A client must undergo skin testing for allergies. The Correct answer: 3 The client needs to discontinue use of antihistamines for 72 hours (3 days) prior to allergy nurse determines during client history that the client testing to avoid false negative readings. takes an antihistamine to control symptoms. The nurse explains that the client must discontinue use of the antihistamine for days before the skin testing in order to avoid false negative results. Write in a numerical answer. | The core issue of the question is knowledge of the time frame that antihistamine drugs need to be withheld so as not to interfere with the results of allergy testing. Use specific nursing knowledge to determine the correct answer. |
404 A mother brings her child to the clinic complaining of Correct answer: 2 Koplik's spots are associated with measles (rubeola) and appear on the buccal mucosa two malaise and low‐grade temperature. In reviewing the days before and after the onset of the rash. child's medical history, the nurse notes the child is behind on immunizations. When the nurse assesses the mouth of this child, Koplik's spots, reddish spots, are seen on the buccal mucosa. The nurse suspects:
| Knowledge of the presenting signs and symptoms and clinical manifestations of measles will aid in choosing the correct answer. |
405 A child is being seen in ambulatory clinic for vague Correct answer: 4 An elevated basophil count is associated with a chronic infection, inflammatory reactions, or symptoms. A CBC with differential is drawn. The nurse stress. It is not associated specifically with allergy, viral infection, or bacterial infection. notes that the basophil count on the CBC is elevated. The nurse concludes that the problem is probably:
| Knowledge of the laboratory values and possible findings will help to choose the correct answer. |
406 A 4‐year‐old child is having scratch tests for allergies. Correct answer: 3 A scratch test tests many allergens at once. It is of low sensitivity, but many allergens can be In teaching the family about the planned tests, the tested at once and the results can be obtained in 30 minutes. nurse should include the information that:
| Note that the term “scratch” test should give some information necessary to respond to this question. |
4.‐ The scratch test involves drawing a small amount of blood from the client. | |
407 A 2‐year‐old child hospitalized for a fractured femur Correct answer: 1 Caladryl will reduce itching and discomfort and therefore diminish scratching and skin breaks out with chickenpox. The physician has written breakdown. Acetylsalicylic acid should not be given to young children with a viral disease the following orders: Which intervention will best because of the relationship to Reye's syndrome. Immunizing the sibling and isolation will have prevent secondary skin infections? no effect on skin eruptions.
| Determine which nursing activities will help the affected child, eliminating options which are not beneficial to the child. Then determine which activity will decrease scratching. |
408 A mother known to be infected with the human Correct answer: 1 The child will need to be tested at approximate three‐month intervals until the child is 18 immunodeficiency virus (HIV) gives birth to a healthy‐ months to 2 years. CD4+ counts are used to assess a young child's immune status and risk for appearing male infant. Which plan is best to follow up disease progressions. The p24 antigen test needs to be repeated if positive. The ELISA is used on the infant's HIV status? with children over 18 months.
| Be aware that tests for HIV are repeated over time. |
409 A toddler is being discharged from the hospital Correct answer: 4, 5 Carpet, bedding, fabrics, pets, dust, and cigarette smoking can cause allergic reactions. Option diagnosed with allergies. The child is on corticosteroids 1 can be eliminated as the use of sterile water is unnecessary. and prophylactic antibiotics. The nurse will discuss environmental control of the home and include which of the following suggestions: (Select all that apply.)
| Remember that anything that would hold dust should be removed from the child’s room. |
410 A young infant is diagnosed with severe combined Correct answer: 1 Even with aggressive treatment, prognosis is poor. Current developments in bone marrow immunodeficiency disorder (SCID). The nurse has transplantation are hopeful. Because of possible genetic involvement, parents may feel some taught the mother about the disease. The statement guilt. by the mother that indicates a lack of understanding is:
| Determine which statement is incorrect information about SCID. |
411 A child is being treated for human immunodeficiency Correct answer: 3, 4, 5 The child's immunizations should be kept up‐to‐date. Live vaccines should be avoided for the virus (HIV) infection. In planning health care for this child and family. The family will need information on how to protect themselves and how to child, the nurse would share information related to administer the prophylactic drugs as well as their side effects. The child can safely attend which of the following? Select all that apply. school with proper education of the school personnel.
| Consider all activities which will protect the child and others. |
5.‐ Handwashing technique for the entire family | |
412 A 13‐year‐old child is scheduled for a bone marrow Correct answer: 1 Bone marrow aspirations are usually performed under local anesthesia unless the child is too aspiration. The nurse has explained the procedure to small to cooperate to hold still. The other statements are correct and do not require further the patient and his mother. Which statement by the follow‐up or teaching. mother indicates a need for additional teaching?
| Eliminate all responses that indicate correct understanding of a bone marrow aspiration, then consider each of the options left. |
413 An infant born to a mother known to be infected with Correct answer: 1 Emotional support for families of HIV+ clients can be challenging. Families who have already human immunodeficiency virus (HIV) has also been dealt with the problems associated with the disease process are most likely to be receptive to diagnosed as HIV positive. While assessing the the discussion and able to offer emotional support. psychosocial support for the family, the nurse should ask:
| Knowledge of the need for psychosocial support for families with children who are diagnosed with chronic conditions will aid in choosing the correct answer. |
414 The nurse has explained allergy‐proofing the home to Correct answer: 4, 5 Cloth items hold in dust. Only essential items should be stored in the child’s bedroom, and the mother of a child with dust allergies. Which those should be in drawers or closets. Stuffed animals retain dust and should be removed from statement by the mother indicates a clear the bedroom. Cotton curtains would be preferred over blinds because cotton curtains can be understanding of appropriate allergy‐proofing? (Select washed frequently. Both the mattress and the bed should be enclosed in special plastic covers all that apply.) to eliminate a source of dust.
| Consider what objects would hold dust and eliminate them from the environment. |
415 A child is in the clinic for a prick test. Because of the Correct answer: 1 Prick tests determine allergens. Should the child have an allergy, epinephrine might be risk of anaphylaxis, the nurse has which of the needed to counteract anaphylaxis. Corticosteroids such as prednisone are helpful in minimizing following medications available for emergency allergic response, but would not be effective in the management of anaphylaxis. In addition, treatment? pretreatment with prednisone would make test results invalid. Naloxone reverses the effects of opioid analgesics, and cromolyn sodium is useful in managing asthma.
| Eliminate Naloxone immediately after associating it with narcotic overdose. The other three drugs are related to allergies, but the correct answer is one that will work quickly and have a systemic response rather than a local one. |
416 A mother brings a 3‐year‐old child to the clinic for a Correct answer: 3 Every time a child enters the healthcare system, the immunization status should be checked. well‐child checkup. The child has not been to the clinic Some children have uncertain history of immunization due to parental noncompliance or since 6 months of age. The nurse determines that special circumstances, such as being refugees. which of the following is the priority care for this child?
| The key word in this stem is the priority nursing action. While all these activities must be completed, the most important is to update immunizations. |
4.‐ Complete hearing screening. | |
417 The mother of a 1‐year‐old child says that breast‐ Correct answer: 1 Infants receive passive immunity, which lasts 3 to 4 months, through the placenta or feeding her infant is sufficient to provide immunity. breastmilk. Active immunity lasts long term and is acquired by exposure to disease or She does not want to sign the permit for immunizations. immunizations. What is the nurse's best approach in working with this client?
| Option 4 can be eliminated because the nurse will never give the immunizations without maternal permission. Asking about the diet will not affect the need for immunization, leaving only two choices to choose between. |
418 The nurse is caring for several children in a hospital Correct answer: 1 The immunocompromised child would be the one at greatest risk for acquiring an infectious unit where there has been a recent outbreak of organism. The other children would be at less risk for acquiring the gastrointestinal infection. bacterial diarrhea. None of these children were admitted for diarrhea, but the nurse is aware that they may be exposed. After assessing the client population on the unit, the nurse determines that the child most susceptible to developing diarrhea would be the:
| The ability to fight infection is related to the immune system. Select the child with a disease of the immune system. |
419 A child is admitted to the hospital with an allergic Correct answer: 4 Eosinophils are the type of white blood cell that is associated with allergic reactions. reaction. The physician orders a complete blood count Hemoglobin is present in red blood cells (RBCs), and RBCs carry oxygen to tissues. Leukocytes (CBC) with differential. The nurse would expect to see fight infection. an elevation in the level of:
| The RBCs and the hemoglobin level are not related to the immune system, so these can be eliminated immediately. Choose between the remaining two to select the type of WBC that is associated with allergies. |
420 An infant is being discharged from the infant and Correct answer: 1, 3, 5 TORCH is the acronym for a set of microbes that includes toxoplasmosis; other (including children’s unit with a positive TORCH titer. Parents syphilis and hepatitis); rubella; cytomegalovirus; and herpes simplex. If an infant has one of the should be informed that: (Select all that apply.) viruses, the virus could be shed for up to 1 year. The baby may be asymptomatic at birth, but the disease may show up later. The disease is congenital—present at birth but not genetic. Since the baby may shed the virus, which in turn would affect an embryo, a pregnant woman should avoid contact with the baby. The earlier in pregnancy the embryo is exposed, the greater the risk of fetal loss or damage.
| Recall what the acronym TORCH stands for in order to answer the question correctly. |
421 An infant with acquired immunodeficiency syndrome Correct answer: 2 The HIV virus is spread by contact with blood and body fluids. Clean gloves should be worn (AIDS) will be attending daycare. The daycare workers when changing the diapers as bare hands would expose the workers to body fluids. It is not are concerned about spreading the human necessary to store the infant’s items separately from those of others, since the virus is not immunodeficiency virus (HIV). The public health nurse transmitted on objects. It is also not necessary, and in fact is excessive, to wear isolation is explaining to the workers the precautions they gowns, and it is unnecessary to minimize contact when the infant has a fever. should take. The nurse would include in this discussion which of the following precautions that need to be taken?
| Recall that the virus responsible for AIDS is a bloodborne pathogen. The correct answer is the one that represents standard precautions, which are sufficient to prevent the acquisition of a bloodborne pathogen. |
422 A mother overhears two nurses discussing a measles Correct answer: 1 The incubation period is the time between exposure and outbreak of the disease. It is often a outbreak. The nurses are talking about the incubation period when the child can be contagious without others being aware of the possible exposure. period. The mother asks the nurses why it is important to know the incubation period for a childhood disease. The nurse would include which information about the incubation period of a disease in the reply?
| To answer this question correctly, it is necessary to understand the concept of the incubation period. |
423 An infant with numerous congenital defects and a Correct answer: 3 With the birth of a less‐than‐expected infant, the parents may have difficulty accepting the diagnosis of rule out TORCH syndrome is admitted child. In addition, the anticipated longer hospitalization and separation from the parents inhibit from the birth hospital directly to the pediatric bonding, which could lead to altered attachment. hospital. The father tells the pediatric nurse that he and his wife had planned a beautiful birth experience and can’t believe what’s happened. The nurse would formulate which of the following nursing diagnoses as a priority for this family at this time?
| Options 1 and 4 can be eliminated since there is no evidence of either in the stem of the question. Choose between options 2 and 3 by choosing the option that includes all of the clients in the question. |
424 A 14‐year‐old child is receiving intravenous antibiotics Correct answer: 3 One of the most common side effects of gentamycin is nephrotoxicity. The nurse can monitor for an infection. The physician has ordered gentamycin kidney function by monitoring intake and output. (Garamycin). Because of the side effects of this drug, the nurse would monitor:
| Gentamycin is a member of the aminoglycoside group of antibiotics, all of which are nephrotoxic and ototoxic. |
425 A 3‐year‐old child is admitted to the hospital to rule Correct answer: 3 White blood cells are one component of the general nonspecific immune response. They are out an infection. Which diagnostic test does the nurse among the first responders stimulated by a pathogenic organism. A white cell differential can anticipate being ordered that is likely to differentiate often determine if the illness is of bacterial, viral, or allergic origin. an infection from an allergic response?
| Recall that a WBC count can determine infections. The WBC with differential can also determine if an allergic reaction has occurred. |
426 A 2‐year‐old child has eczema that causes extreme Correct answer: 1 Because of the itching, the child will be scratching. Intense scratching can break the skin, and itching. Treatment has not been able to control the the child might develop a bacterial infection secondary to the skin trauma. Imbalanced rash. It has been determined that the primary allergen nutrition, more than body requirements, does not clearly state the problem with the food is wheat. An appropriate nursing diagnosis would be: allergies, nor does ineffective infant feeding behavior. There is no evidence of noncompliance, and infant feeding would not be a diagnosis for a 2‐year‐old.
| The diet is a problem for the child due to wheat allergy, but an appropriate diagnosis related to diet is risk for infection. The fact that treatment has not controlled the symptoms does not indicate noncompliance. |
427 A child’s mother tells the nurse that her child has Correct answer: 4 Oral polio virus vaccine contains a live virus, which could cause an infection in a child who is been on steroids for several months. Which of the immune‐depressed as a result of taking steroids. following vaccines is contraindicated?
| The word “live” in the option should be a clue to the right response. |
428 A child with severe combined immunodeficiency Correct answer: 2 Care of the immunocompromised child focuses on preventing infection. The nursing disorder (SCID) is being discharged from the hospital to implementations related to reaching this goal might include limiting contact with a large home. Client teaching is important to reach client number of people, but that would not be the goal of the nursing care plan. goals. The nursing care goal for the client before and after discharge would be that the child:
| Recognize that a child with an immunodeficiency will not be able to fight infections, so prevention is important. |
429 A child is being worked up for allergies. The mother Correct answer: 4 Allergies are confirmed by a RAST test. RAST is a radioallergosorbent test that detects IgE asks how the diagnosis will be made. The nurse antibodies that are part of the allergic response. Urticaria is itching and is symptomatic of explains that diagnosis of allergies is based on: allergies and other diseases, and an increase in eosinophils is diagnostic of allergies.
| There are several testing methods for allergies. Eliminate symptoms of the disease as that is not a diagnostic test. The learner should be aware that eosinophil levels would be elevated. IgG is a normal immunoglobulin found in the blood. |
430 An infant is born with microcephaly. Part of the Correct answer: 3 The acronym TORCH stands for toxoplasmosis, other (syphilis, hepatitis), rubella, infant’s assessment includes a TORCH test. In providing cytomegalovirus, and herpes simplex virus. It is a study of common viruses that cause client education, the nurse explains to the mother that significant fetal damage. the TORCH test will assess for:
| Recall the meaning of the acronym TORCH to answer this question correctly. |
431 A 2‐month‐old infant has been admitted with a Correct answer: 1 Neonates with sepsis may display either hypothermia or hyperthermia, but hypothermia is diagnosis of sepsis. The nurse would monitor the child more common. The other symptoms are not associated with sepsis. for evidence of:
| Recall that neonates are as likely to demonstrate hypothermia as hyperthermia. |
432 A 12‐year‐old child with positive human Correct answer: 4 Families need to know that casual contact cannot spread HIV. However, basic infection immunodeficiency virus (HIV) antibodies is going home control practices must be maintained to prevent exposure through body fluids. Growth and from the hospital. Which of the following would be the development milestones and immunization schedules are routine elements of teaching, and most important home‐going instructions? are therefore not as high of a priority for this client as infection control. Lab studies and results are ongoing and are therefore also of lesser priority.
| The spread of infection would be a concern for this child whether at home or at the hospital. |
433 A 4‐year‐old child has been exposed to chickenpox. Correct answer: 1 The prodromal period refers to the period of time between the initial symptoms and the After the nurse has provided information about presence of the full‐blown disease. The rash would not be apparent during this time. All the chickenpox, the nurse asks the mother to repeat the other statements are correct. information. The mother’s statement that indicates a need for additional information is:
| Understanding the meaning of the term “prodomal” will guide the learner to the right response. |
434 A child who contracts chicken pox at age 5 has Correct answer: 1 Active acquired immunity occurs when the body produces antibodies or develops immune developed which type of immunity? lymphocytes against specific antigens (chickenpox). Breastfeeding a child would offer passively acquired immunity; immune globulins offer passively acquired artificial immunity; immunizations offer actively acquired artificial immunity.
| Use the rule of opposites to answer this question. |
435 A person who is HIV‐positive starts to exhibit signs of Correct answer: 4 A client with AIDS will usually have a low CD4 count and a high viral load. What is desired is to AIDS. The indication that the client has seroconverted have a high CD4 count and a low viral load (which should normally be zero). The white blood would be partially diagnosed by which of the count will usually show neutropenia. following? | This question requires knowledge about viral loads and CD4 levels. |
‐ Low viral load ‐ High CD4 count ‐ High white blood count (WBC) ‐ High viral load | |
436 A sexually active teenager with flu‐like symptoms is Correct answer: 2 The ELISA test may be negative upon initial testing and positive at the time of seroconversion, given an ELISA test that returns negative. The physician which takes 6 to 12 weeks after infection. This time period when the antibodies are negative is informs her that another ELISA test will be conducted called the seroconversion window and virally infected individuals may have negative antibody in several weeks. The client wants to know why. The tests. best explanation is that:
| This question requires knowledge about the ELISA tests. |
437 A client experiences an anaphylactic reaction after Correct answer: 2 Type I hypersensitivity reactions are caused by widespread antigen‐antibody reactions such as taking an antibiotic for the first time. The results of this anaphylaxis. These responses are usually immediate and lead to an antigen‐antibody complex Type I hypersensitivity response are caused by: that causes the release of histamine. Option 4 is an explanation of what occurs with a blood transfusion reaction. Option 3 is an explanation of a Type IV delayed hypersensitivity. Option 1 is false.
| This question requires knowledge about hypersensitivity responses. |
438 A client who has recently been diagnosed with Correct answer: 1 Recognition of self as foreign is the definition of any autoimmune disease. Further diabetes mellitus (DM) Type 1 asks the nurse how she explanation may be needed to explain that the immune system usually recognizes self and developed this because no one in her family is a identifies what is foreign, targets foreign cells, and destroys them. diabetic. The nurse’s best response is, “DM is an autoimmune disease characterized by:”
| This question requires knowledge about diabetes. |
439 A mother of twins calls the office and speaks to the Correct answer: 3 You should have recognized this as serum sickness, a reaction a week after ingestion of a nurse concerning a rash that has developed on both drug. Serum sickness is a type III hypersensitivity reaction where formation of IgG or IgM children since taking an antibiotic prescribed 5 days antibody‐antigen complexes occur in the blood. ago. The nurse knows that this is most likely a:
| This question requires knowledge about hypersensitivity reactions. |
440 In working with clients with HIV, the nurse knows that Correct answer: 4 Symptoms of HIV infection are vague and nonspecific. Characteristic manifestations of HIV the illness is more difficult to manage once AIDS has disease resulting from opportunistic infections and neoplasm make treatment difficult. been diagnosed. Which of the following best Invasion may be from sexual contact as well as blood contact. HIV is not always predictable characterizes HIV disease? because the virus can lie dormant for many years. There are really no carrier states in HIV. 1.‐ Individuals who test positive are carriers and considered contagious. | This question requires knowledge about HIV/AIDS. |
‐ Clinical manifestations have a characteristic and predictable sequence. ‐ The HIV virus invades cells primarily via the bloodstream. ‐ Symptoms result from opportunistic pathology. | |
441 Which of the following individuals is at highest risk of Correct answer: 3 Only fluids containing blood or blood cells have been identified as a mode of transmission for contact with HIV? An individual who: HIV. Collecting blood, especially in a mobile unit (where the population is more diverse) is a risk for any healthcare worker. Appropriate gloving is essential. Counseling may require touch, which is not a form of transmission; perspiration has not been identified as a form of contact; and the ELISA test requires contact with saliva.
| This question requires knowledge about blood borne pathogens. |
442 A client is brought to the Emergency Department Correct answer: 1 Because laryngeal spasms and bronchial constriction can occur with anaphylaxis, assessing after taking a dose of penicillin. Which of the following the client's airway is top priority. The nurse should maintain and establish a patent airway first. diagnoses is the highest priority in this client who is Remember the ABCs (airway, breathing, and circulation), cardiac output would come next demonstrating anaphylaxis? followed by risk for injury and finally anxiety.
| Recall the ABCs (airway, breathing, and circulation). Airway is always a priority. |
443 In addition to a viral load of 25,000, which of the Correct answer: 3 A client with AIDS will have exacerbations and remissions with opportunistic infections, following would indicate that the medications being therefore symptoms may vary. With a diagnosis of AIDS, an ELISA test would remain positive taken by a client with AIDS are working? for antibodies. WBC of 1,700 shows neutropenia which does not indicate improvement. The CD4 cell count between 200 and 500 is in the "suppressed immune state" but certainly above the 200 mark that is indicative of severe depression of the immune system.
| Use the process of elimination to answer this question. |
444 A child with asthma caused by allergies would be Correct answer: 1 Eosinophils are usually elevated in an allergic response. The WBC in option 2 is barely above expected to have which of the following findings on a normal. The monocytes are normal in option 3 and the elevated neutrophils indicate an acute complete blood count (CBC) report? infection (option 4).
| This question requires knowledge about the CBC. |
445 The mother of a child with swollen lymph nodes is Correct answer: 2 The mother is already alarmed enough, and the nurse needs to be careful with wording of the extremely panic‐stricken that the swelling means response. Option 2 is correct and is not alarming so that the mother may be able to focus on a cancer. The nurse could calm the mother by stating different perspective besides cancer. that:
| Use the process of elimination to discover the correct answer. |
446 A client reports to the clinic complaining of itching Correct answer: 4 This type of contact dermatitis is commonly a delayed reaction and a type IV hypersensitivity. and weeping along the back of her legs. Upon This reaction is cell‐mediated rather than antibody‐mediated and delayed 24 to 48 hours. inspection, wheals are evident that appear to be poison ivy. After talking to the client, it is learned that she broke out a day after sitting on the car seat in shorts. She sat on the same seat as her husband, who had been working in a field of grass all day. This type of reaction is a:
| This question requires knowledge about hypersensitivity reactions. |
447 A client with A‐negative blood can receive which type Correct answer: 2 Remember the Rh must also match besides the type of blood (A in this case). Rh matching is of blood transfusion in order to avoid any allergic not just for mothers and infants to prevent erythroblastosis fetalis. reaction?
| Use the process of elimination to determine the correct answer. |
448 In assessing a client with a suspected latex allergy, the Correct answer: 3 Clients with a history of allergies to fruit such as bananas or kiwi tend to have latex allergies. nurse should ask which of the following? The degree of moistness of the skin might need to be assessed but will not determine a latex allergy. Although drug allergies should be asked, this information does not help in determining a latex allergy. Option 4 is also important information for an assessment, but the focus of the question for a latex allergy would be if there were any problems after the surgery similar to the one being exhibited now.
| Use the process of elimination to determine the correct answer. |
449 Which of the following symptoms would be expected Correct answer: 4 A barking cough, wheezing, and stridor are clinical manifestations of the bronchoconstriction in an anaphylactic reaction? and edema that accompanies anaphylaxis. The blood pressure is usually low (hypotension) and the pulse fast (tachycardia).
| This question requires knowledge about anaphylactic reactions. |
450 The pathophysiology behind the destructive power of Correct answer: 2 The T‐helper cells are the primary target for the parasite to infect in order to replicate. The AIDS is that HIV kills the: virus destroys the T‐cells and along with this destruction, memory cells can also be destroyed, hence opportunistic infections are more prevalent.
| This question requires knowledge about blood borne transmissions. |
451 Of the following people who is at increased risk of Correct answer: 2 The police officer and nurse on the telemetry unit should be using standard precautions acquiring HIV? including gloves anytime body secretions are encountered. Although either of these may encounter blood accidentally, the percentage is low. A school nurse should not be coming into contact with body secretions that would increase the risk factor. A sexually active teenager, especially if the act is unprotected, is at highest risk.
| This question requires knowledge about HIV. |
452 A client with recent HIV seroconversion and early Correct answer: 2 The stages of HIV are varied, but most clients begin with flu‐like symptoms that occur days to infectious disease asks the nurse what to expect in weeks after contracting the virus. Following this is a long asymptomatic period; however the terms of disease progression. The nurse tells the client virus is still present. It is unclear why or when a client moves from being asymptomatic to that although the disease can vary greatly among AIDS. individuals, the usual pattern of progression includes:
| This question requires knowledge about HIV. |
453 The second child (who is Rh+) of an Rh‐ mother may Correct answer: 4 To answer this question correctly, you must understand that transfusion reactions (in this develop problems because of: case from mother to child since the Rh was incompatible) is a type II hypersensitivity reaction. The maternal antibodies that were developed with a first child who may have been Rh+ are passed to the infant and cause hemolysis of fetal red blood cells (not white blood cells). The child may suffer from anemia (option 3) but this is not the primary cause of the problem.
| This question requires knowledge about Rh factor. |
454 The parents of a child who is in surgery having a Correct answer: 2 The spleen is vital in storing blood and in the breakdown of red blood cells, but it is not splenectomy ask the nurse how their child can live essential for life. The liver and bone marrow assume its function when it is removed, and most without a spleen. The nurse's best response is: clients do well even though it is removed.
| This question requires knowledge about splenectomy. |
455 A common clinical manifestation of a transfusion Correct answer: 2 Common manifestations are fever, chills, low back pain, hypotension, tachycardia, nausea, reaction (type II hypersensitivity reaction) is: and vomiting. Urticaria and red‐colored urine are often seen.
| This question requires knowledge about hypersensitivity reactions. |
456 In assessing the lung sounds of a client in anaphylaxis, Correct answer: 3 Edema and bronchoconstriction are the clinical manifestations involving the respiratory the nurse would expect to hear which of the following system in anaphylaxis and usually produce diminished lung sounds, wheezing and stridor sounds? (which does not require a stethoscope).
| This question requires knowledge about anaphylaxis. |
457 A positive tuberculosis (TB) skin test would be Correct answer: 2 TB skin tests are read 72 hours after administration and a true positive reading should show manifested in which of the following? redness and be raised (greater than 5 mm). Clients may react within several hours to 24 hours of receiving the injection and then show a negative finding at 72 hours. A TB skin reaction at 72 hours is a type IV delayed hypersensitivity reaction and can indicate exposure or active disease.
| This question requires knowledge about TB skin test. |
458 A client, who received a skin graft 2 months ago Correct answer: 1 Acute tissue rejection is common and usually occurs between 4 days and 3 months after because of extensive burns, reports to the clinic with transplant. The manifestations are caused by the inflammatory process. complaints of redness, swelling, fever, and tenderness over the graft site. This client is exhibiting:
| This question requires knowledge about acute and chronic reactions. |
459 A client receiving a unit of packed red blood cells Correct answer: 3 The key word in this stem is 'first.' All of the options are correct, and the nurse should (RBCs) begins to complain of chills, temperature is perform all of them, but in the proper sequence. The transfusion should be stopped because of 101.4 degrees F, pulse is 185, and blood pressure is the signs of a transfusion reaction. The physician then needs to be called at the same time the 80/50. The nurse should do which of the following vital signs and client are monitored every 5 minutes. Sending the bag to the laboratory is the first? last step. ‐ Call the physician ‐ Send the blood bag to the laboratory ‐ Stop the transfusion and flush the line ‐ Continue to record the VS and monitor the client every 5 minutes | This question requires knowledge about the first aid needed. |
460 A client with AIDS who is at high risk and having Correct answer: 1 When the viral load (number of circulating HIV particles per milliliter) is high and the CD4 multiple opportunistic diseases would probably have a count is low, the client is most at risk. This would explain why the opportunistic infections are low CD4 count and which of the following? recurring, the immune system is extremely compromised. A zero viral load is expected in normal individuals. A moderate or low viral load may be seen in clients who have received medication for AIDS.
| Recognize the inverse relationships in each option. |
461 The difficulty in assessing clients who are HIV‐positive Correct answer: 1 Although options 2, 3, and 4 are sometimes the case, the flu‐like symptoms are rather vague. after exposure, but who have a negative ELISA test, is Most individuals do not rush to a physician with flu‐like symptoms unless they are not getting that the symptoms are: any better. 1.‐ Flu‐like and vague. | Use the process of elimination to determine the correct answer. |
‐ Specific and similar to tuberculosis. ‐ Often ignored. ‐ Attributed to other illnesses. | |
462 The wife of a client diagnosed as HIV‐positive states Correct answer: 4 Sexual activity if one partner is positive for HIV can be resumed as long as protection is always she will never be able to have sexual intercourse again. used. Option 1 is inappropriate and option 2 is incorrect. Option 3 may need to occur but The nurse should respond with: seems to be an answer that avoids the client's concern at this time.
| This question requires knowledge about HIV states. |
463 Education in the community about HIV should consist Correct answer: 2 Consenting sexual partners should be tested to determine that each is HIV‐negative if of which of the following? unprotected sex is preferred. No known proof exists that saliva is a route for transmission. HIV1 is the most common form in the United States, HIV2 is in Africa, and AIDS is still a major threat to certain populations in the United States.
| This question requires knowledge about HIV. |
464 Which of the following is responsible for direct Correct answer: 2 Killer T cells bind with cell surface antigen or virus‐infected or foreign cells. Killer T cells antigen attack and destruction? destroy the antigen by combining with it and then either destroying its cell membrane or releasing cytotoxic substances into the cell.
| This question requires knowledge about direct antigen attacks. |
465 A nurse accidentally gets stuck with a needle from a Correct answer: 3 After exposure to a known antigen such as hepatitis, temporary immunity is recommended in known hepatitis B client. The protocol would be for her the form of immune globulins. If the nurse had received the hepatitis B vaccine (Heptavax), he to receive a hepatitis B immune globulin to offer: or she should have artificial active immunity. Remember, natural immunity comes in the form of antibodies from having the disease or from mother's who breastfeed.
| Use the rule of opposites to answer this question. |
466 The immune complexes in type III allergic reactions Correct answer: 3 An Arthus reaction is a type III hypersensitivity reaction that causes acute, localized edema cause a localized reaction of tissue necrosis. This is and tissue inflammation (usually of the skin). It usually occurs at the site of an injection of an called: antigen in a client previously sensitized.
| This question requires knowledge about Arthus reactions. |
467 An example of a type I hypersensitivity immune Correct answer: 1 Hay fever is an atopic type I reaction that is local instead of systemic. Transplant rejection is a response includes which of the following? type IV; transfusion reaction is a type II and serum sickness is a type III. 1.‐ Hay fever | Use the process of elimination to correctly answer this question. |
‐ Transplant rejection ‐ Transfusion reaction ‐ Serum sickness | |
468 The most common transplanted organ affected by Correct answer: 4 Graft‐versus‐host disease is most common with bone marrow transplants. When graft‐versus‐host disease (GvHD) is which of the immunocompetent graft cells recognize host tissue as foreign, a cell‐mediated immune following? response occurs.
| This question requires knowledge about GvHD. |
469 The reason the AIDS virus is so devastating to the Correct answer: 3 CD4 or T helper cells are those that play a key role in controlling the immune response by immune system is that it attacks: stimulating proliferation of other T cells, amplifying the cytotoxic activity of killer T cells, activating B cells to proliferate and differentiate, and interact directly with B cells to promote antibody production.
| This question requires knowledge about the AIDS virus. |
470 The "seroconversion window" of HIV infection refers Correct answer: 3 In category A of the CDC classification, individuals who have been infected may not to that time which: demonstrate antibodies on an ELISA test or Western blot. This time period when antibodies are negative, but infection has occurred, is called the "seroconversion window." The danger here is that the individual does not know he or she is HIV‐positive and may infect others.
| This question requires knowledge about the seroconversion in HIV. |
471 An individual who is HIV‐positive and who develops Correct answer: 3 AIDS dementia complex involves cognitive, behavioral, and motor deficits and is a common memory loss, difficulty concentrating, euphoria, and central nervous system complication of untreated HIV. Along with the above symptoms, lethargy is developing which of the following? apathy, confusion, hallucinations, personality changes, unsteady gait, leg tremors, impaired handwriting, and mental slowing will occur.
| This question requires knowledge about AIDS dementia. |
472 The nurse encourages a new mother to breastfeed Correct answer: 3 Antibodies that the mother has will be passed on to the infant. This form of immunity is her infant, even for a short time, because colostrums natural versus artificial. Remember the difference between passive (temporary immunity) and in breast milk will provide the infant with: active (long‐term). Words such as indefinite (option 1) and all (option 2) should be red flags that these are incorrect.
| This question requires knowledge about passive versus active immunities. |
473 A client with seasonal allergies has just recovered Correct answer: 1 Allergic rhinitis is a type I or IgE‐mediated hypersensitivity where an allergen interacts with from a severe case of rhinitis and an increased IgE that is bound to mast cells and basophils. A radio allergy sorbent test (RAST) will determine incidence of asthma attacks. The nurse would expect the presence of IgE. to see an increase in which of the following?
| This question requires knowledge about immunity. |
474 Initial evidence that should indicate to the nurse that Correct answer: 3 Any local reaction (type I hypersensitivity) to an injected allergen should place the nurse or a client may experience a systemic anaphylactic health care provider on guard for a possible anaphylactic reaction. The client should be closely reaction to an injected allergen is the development of: monitored. The itching and edema are common local reactions. If itching occurs all over, especially on the palms and scalp, a systemic effect is likely. If dyspnea occurs, a systemic anaphylactic reaction is occurring and precaution should be taken to manage the airway. A wheal and flare reaction usually doesn't occur for several hours or days and is a local reaction, sometimes expected.
| Use intuition to determine the initial response. |
475 A client develops severe angioedema involving her Correct answer: 1 Reactions such as these may be genetic and knowing whether other members of a family face, hands, and feet with burning and stinging of the have similar reactions is useful in determining a cause. The use of OTC medications and home lesions after consuming her 9:00 A.M. medications. A medications may be helpful, but if this reaction has not occurred before, it is less likely to be significant risk factor for allergies that the nurse should from those sources. Option 3 would not offer any assistance at this time. question the client about is:
| This question requires knowledge about family history of allergies. |
476 After being bitten by an unknown insect, a client Correct answer: 2 Airway is always first (ABCs) when determining priority in an emergency situation such as this. allergic to wasp stings is brought to a clinic by a All of the other options are accurate and should be implemented, but with the symptom of coworker. Upon arrival, the client is anxious and difficulty breathing, laryngeal edema is a priority concern. having difficulty breathing. The first action by the nurse is to:
| Remember the ABCs (airway, breathing, and circulation). Airway is a key priority. |
477 The nurse discusses the prevention and management Correct answer: 4 Although a change in occupation may be wise, the beekeeper can practice cautious steps and of allergic reactions with a beekeeper who has preventative measures to protect self. A Medic‐alert bracelet is highly suggestive and developed a hypersensitivity to bee stings. The nurse epinephrine (Epi‐Pen) should be with him always. Use of corticosteroids as a maintenance dose identifies a need for additional teaching when the is not recommended because of the vast majority of side effects. client states:
| Use the process of elimination to determine the correct answer. |
478 Over‐the‐counter (OTC) pseudoephedrine tablets and Correct answer: 2 Decongestant nasal sprays have a rebound effect, which causes congestion and swelling of nasal sprays are used by a client to control symptoms the mucous membranes with long‐term use. Although temporary relief may be obtained, of seasonal rhinitis. In teaching the client about the continued chronic use of the sprays may be needed due to this engorgement of the vessels and use of OTC allergy medications, the nurse advises the increased congestion. This client may need to consult an allergist or physician. This question client that: draws on your knowledge of pharmacology. As you study and you find a question such as this that you miss, go back and look up the classification of this drug and agents such as oxymetazoline (Afrin) or phenylephrine (Neo‐Synephrine) and reread about it.
| Use knowledge of allergy medications to answer this question. |
479 The client who received a bone marrow transplant for Correct answer: 1 This is an example of graft‐versus‐host disease (GvHD), which is a complication of bone treatment of leukemia develops a skin rash 10 days marrow transplants. When immunocompetent graft cells recognize host tissue as foreign, a after the transplant. The nurse recognizes that this cell‐mediated immune response is initiated. The skin, liver, and gastrointestinal tract are often reaction indicates that: targets.
| This question requires knowledge about leukemia |
480 A client who tested positive for HIV 3 years ago is Correct answer: 4 This client has a Category C2, which is an AIDS‐indicator condition (pneumonia) and a CD4 admitted to the hospital with Pneumocystis carinii count between 200 and 499. Category A: PGL is persistent generalized lymphadenopathy and pneumonia and a CD4 count of 200 would not be accompanied by the pneumonia. Category B has several conditions that may mm<sub>3</sub>. Based on diagnostic occur but Pneumocystis carinii pneumonia is not one of these. criteria established by the Centers for Disease Control and Prevention, the client is diagnosed as having:
| This question requires knowledge about HIV. |
481 A client receives a skin prick test for determination of Correct answer: 3 Wheals, erythema, and itching are common after a skin prick test, which is conducted by allergies. Besides the wheals and erythema present, placing a drop of a specific allergen to the skin and pricking the skin at the site of the drop. A another symptom that will most likely be exhibited by response should occur in 15 to 20 minutes. Dyspnea would indicate an anaphylactic reaction the client with a positive test would be: and usually hypotension occurs. A rash usually doesn't occur over the entire body.
| This question requires knowledge about allergy testing. |
482 Which of the following atypical findings would the Correct answer: 3 Mental status changes ranging from restlessness to confusion is one of the most frequent nurse look for in the older adult client who presents "atypical" signs of infection in older adults. Fever, erythema, edema, and leukocytosis may be with an infection? present in varying degrees; however, these presentations are considered typical responses. Coexisting chronic conditions along with the use of prescribed medications may cause typical responses to be minimized or absent altogether in the elderly client.
| Recall that changes in behavior are early signs of change in status. |
‐ Behavioral changes and confusion ‐ Leukocytosis | |
483 A client has an unexplained weight loss of more than Correct answer: 4 Any client who presents with unexplained weight loss and persistent nonspecific complaints 10 percent of ideal body weight (IBW) and voices of fatigue and nausea should be evaluated with regard to HIV status. Testing measures are not nonspecific complaints of fatigue and nausea over the always conclusive and it is not apparent from the client's statement exactly what specific tests last 6‐month period. The nurse should place the were administered. Low‐grade fever does not correlate directly with the presence of HIV. highest priority on further assessing the client when Vitamin supplements could be considered to be supportive and protective. A history of blood the client makes which of the following statements? transfusion may prove to warrant further assessment but it is not the highest priority at the present time. ‐ "I have had a low‐grade fever for the past week." ‐ "I had a blood transfusion several years ago after having surgery." ‐ "I have been taking vitamin supplements on a daily basis for the last 2 weeks." ‐ "I have been tested for HIV in the past, but the results were negative." | This question requires knowledge about the importance of HIV screening. |
484 While obtaining a review of systems the client Correct answer: 1 Type 1 hypersensitivity involves humorally mediated antigen‐antibody reactions. Food informs you that he is "highly allergic" to many food allergies and medications can provide a localized as well as systemic response. Clients who items and medications. You conclude that which have a history of multiple allergies usually have high IgE levels that are a characteristic hypersensitivity reaction would be responsible for this measure of this type of reaction. The other hypersensitivity reactions do not apply to this type of clinical presentation? characteristic presentation.
| This question requires knowledge about hypersensitivity reactions. |
485 A client who receives a positive antinuclear antibody Correct answer: 2 Antinuclear antibodies indicate the presence of an autoimmune disorder. They are not (ANA) test result with a titer level > 1:40 does not considered specific for systemic lupus, because many other autoimmune disorders have understand what the test result means and asks the significant numbers of these antibodies. This reported titer is suggestive of the presence of nurse for an explanation. Which of the following ANA antibodies, and therefore it is an abnormal response. responses to the client would be most appropriate in this situation?
| This question requires knowledge about ANA testing. |
486 Which one of the following measures would be Correct answer: 4 Clients with a past medical history of anaphylaxis should have epinephrine readily available beneficial in helping a client with a past history of for emergencies because it is the drug of choice for treatment. Tylenol and ASA will not anaphylaxis to develop a plan for handling possible mediate the chemical response to prevent anaphylaxis. Benadryl, although an antihistamine, allergic reactions? may not be effective enough to prevent a full‐blown anaphylactic response.
| This question requires knowledge about anaphylaxis. |
487 Hydroxychloroquine (Plaquenil) is prescribed for a Correct answer: 2 Plaquenil is an antimalarial agent used in the treatment of rheumatoid arthritis. This client for the treatment of rheumatoid arthritis. The medication can cause retinal toxicity, and therefore the client should be closely monitored for nurse would include which one of the following this possibility with specified visual exams. Gastric irritation, fluid retention, pulse elevations, measures as part of client teaching with regard to this and drowsiness are not routinely seen with this type of medication. medication? 1.‐ Take this medication on an empty stomach to minimize gastric irritation. | This question requires knowledge about medication side effects. |
‐ Have an initial baseline eye exam performed and adhere to follow‐up exam schedule to monitor for potential ocular changes. ‐ Monitor weight and vital signs as the medication can cause fluid retention and pulse elevations. ‐ Be aware that medication can cause drowsiness and do not take it if planning to drive a car. | |
488 The nurse has conducted discharge teaching for a Correct answer: 4 Anticholinesterase medications are aimed at symptom management. These medications client diagnosed with myasthenia gravis. The nurse should be taken prior to eating to help the client chew and swallow and to minimize gastric evaluates that the client understood the instructions upset. Taking this medication at night may not provide symptom relief and since absorption is given with regard to the administration of variable, the client may not be assured of receiving the correct dose. The medication does not anticholinesterase medication if the client takes the have to be taken with milk in order to minimize gastric upset. Taking the medication on a full medication: stomach (which would constitute after eating) would not allow for the primary effect of aiding with swallowing and chewing that is needed in clients who have this disease process.
| Recall that an empty stomach is often optimal to enhance medication absorption. |
489 The nurse would assess for which one of the following Correct answer: 1 Raynaud's phenomenon is one of the most common findings associated with systemic findings that is consistent with clinical manifestations sclerosis. Conjunctivitis, photophobia, and splenomegaly can all be seen in clients who of systemic sclerosis? experience the effects of systemic lupus erythematosus.
| This question requires knowledge about systemic sclerosis. |
490 Which one of the following statements indicates the Correct answer: 3 The client's understanding is demonstrated by acknowledging the fact that sun exposure client's understanding of measures used in the should be limited to times other than 10:00 A.M. to 3:00 P.M. (when the sun is at its highest treatment of systemic lupus erythematosus? intensity). Tanning bed exposure can be considered to be an ultraviolet light trigger and could exacerbate dermatologic presentations. Initial use of SPF 15 sunscreen (or higher value) is indicated, as is the reapplication of sunscreen during exposure periods. Clients should avoid exposure to potential infection.
| Use the process of elimination to answer this question. |
491 Regardless of the type of isolation precautions that a Correct answer: 2 Regardless of isolation precautions, the basic action by the nurse to prevent infection is hand client has been assigned, which of the following washing. All of the other options should also be followed but hand washing establishes the first actions by the nurse should be given the highest line of defense and is therefore of highest importance. priority in terms of infection control?
| Recall that hand washing is generally a high priority. |
492 An HIV‐positive client now presents with a Correct answer: 4 CDC case definition of AIDS for adults states that the two factors described in the question CD<sub>4</sub> count of &lt; 200/ul are diagnostic of progression to AIDS. Seroconversion and positive HIV status has already and invasive cervical cancer. How would the nurse occurred. The latent period is considered to be one in which the individual is asymptomatic. evaluate these findings in terms of current CDC definitions?
| This question requires knowledge about HIV clients. |
‐ The client is in the latent period of the disease process. ‐ The client has acquired immunodeficiency syndrome. | |
493 A client who has been diagnosed with an Correct answer: 3 A client diagnosed with an autoimmune disease is faced with a lifetime of chronic illness and autoimmune disorder questions the nurse as to what yet may not appear acutely ill because of the episodic nature of remissions and exacerbations. impact this may have on activities of daily living in the The nurse promotes a therapeutic relationship by allowing the client to ventilate feelings. It is years to come. The best explanation that you, as the inappropriate to minimize any changes that a client may experience that are unnoticeable to nurse, can give is: others as they may be quite unsettling to the individual. It is not the role of the nurse to speculate how a disease process will progress. Suggesting that the client use any "available remedy" may lead the client to potential harm or medical quackery.
| This question requires knowledge about therapeutic communication. |
494 Which of the following nursing diagnoses has the Correct answer: 2 Pain and pain control are the most important elements of care for a client who has highest priority for a client who has rheumatoid rheumatoid arthritis. Interventions aimed at pain management will allow the client to function arthritis? at a more optimal level. While the other diagnoses are important, pain management remains the critical factor.
| Recall that pain management is a high priority. |
495 A client who has been diagnosed with scleroderma is Correct answer: 4 Raynaud's phenomenon is a common presentation in clients who have scleroderma. It is complaining of pain in his fingertips and pallor characterized as a vasospastic disease of the periphery that causes color changes ranging from followed by blanching of the extremities and redness. pallor to reactive hyperemia. Joint swelling, effusion, and symmetric polyarthritis can be seen The nurse communicates in intershift report that the in other autoimmune processes such as systemic lupus erythematosus and rheumatoid client reports symptoms of which of the following arthritis. disorders?
| This question requires knowledge about scleroderma. |
496 A client who is HIV‐positive and is taking antiretroviral Correct answer: 2 One of the most critical problems with regard to antiretroviral therapy is the emergence of medications asks why he was told that a change in antiretroviral resistance as the HIV virus continues to mutate. Combination therapies have medication might be expected during the course of been proven to be more effective in treating disease progression. Antiretroviral therapies, in treatment. The best explanation to give the client is: proper dosage, do not cause specific organ toxicity although they can cause myelosuppression.
| This question requires knowledge about HIV and antiretroviral medications. |
497 A client receives a polio vaccine during a clinic visit. Correct answer: 2 Vaccines are administered to the client to promote the development of specific antibodies to The nurse explains that this will provide what type of afford protection. This is an example of active artificial immunity. Active natural immunity immunity to the client? implies the development of antibodies in response to a client who had an actual active infection. Passive natural immunity implies the maternal and or placental transfer of antibodies. Passive artificial immunity implies the specific injection of an immune serum.
| Use the rule of opposites to answer this question. |
498 A client who is diagnosed with myasthenia gravis Correct answer: 4 The client should be monitored for myasthenic crisis, which is often a result of missed or (MG) had not been compliant with his medication under medication. The other options (gastrointestinal symptoms, vertigo, and bradycardia) are regimen and has missed several doses of associated with cholinergic crisis. Cholinergic crisis is usually the result of overmedication. Both pyridostigmine (Mestinon). For which complication complications are viewed as acute in nature and may require airway assistance. The nurse would the nurse monitor? must be acutely aware of the potential for clients with MG to have these types of complications.
| Consider the respiratory depression in MG as a priority. |
499 A client with tuberculosis is being admitted to the Correct answer: 3 Airborne precautions should be instituted for all clients being admitted with a diagnosis of medical‐surgical unit. Which type of precautions tuberculosis. Specific CDC guidelines may also be instituted to prevent TB transmission in should the nurse institute to protect the client and healthcare facilities. Standard precautions should be maintained for all clients in the hospital staff from possible exposure? setting. Contact and droplet precautions do not apply to this disease process.
| This question requires knowledge about isolation procedures. |
500 You have been asked to perform a home assessment Correct answer: 3 Scattered area rugs are a potential safety hazard for an individual who has longstanding RA on a client who has longstanding rheumatoid arthritis. because of possible joint deformities and contractures that could increase risk of falls. All of Which one of the following findings should receive the the other assessment findings are considered to be supportive of this client with RA because highest priority for follow‐up teaching? they enhance mobility, safety, and medication compliance.
| Use the process of elimination to answer this question. |
501 The nurse is performing an abdominal examination Correct answer: 3 The spleen is not usually palpated in an individual with normal immune function. Splenic and is able to palpate the spleen. What information enlargement (splenomegaly) is associated with a deviation from normal and bears further does this alert the nurse to suspect? investigation. Deep palpation is not indicated when splenic congestion is noted as it may cause the spleen to rupture. Dehydration and allergic reaction are not consistent with enlargement of the spleen.
| This question requires knowledge about the physiological function of the spleen. |
502 A client is breastfeeding her infant and asks the nurse Correct answer: 4 While breastfeeding does convey passive acquired immunity to the infant, it by no means whether or not this method of feeding will protect the offers complete protection against any and all infectious processes. Immunizations with infant against infection. Based on the understanding of antigens (vaccines) will provide the infant with active artificial immunity and is more long immunity, how would the nurse answer this question? lasting. In addition, the infant can and will receive "booster" doses to maintain immunity status. The length of time or duration of breast‐feeding is not the sole determinant of an infant’s passive immunity. The richest source of immunoglobulins is actually provided to the infant during the transfer of colostrum, which is the precursor to actual breast milk.
| Use the process of elimination and use care when answering questions which require absolutes. |
503 The nurse working with a client who has an Correct answer: 4 The thymus gland is located in the superior mediastinum. In the child, the gland is usually autoimmune disease explains that which of the quite large. As the individual ages, the gland shrinks in size. Initially, the thymus gland is following occurs to the size of the thymus gland with responsible for T‐lymphocyte differentiation and maturation. The gland becomes a source of increasing age? connective tissue, lymphocytes, and fibers in the older client.
| This question requires knowledge about the thymus gland. |
504 The nurse conducting an in‐service presentation Correct answer: 2 The MPS helps to trigger or promote an immune response by capturing, processing, and about immune disorders to coworkers explains that presenting the antigen to the lymphocyte. The MPS contains monocytes and macrophages that which of the following is one of the primary actions of participate in forming a bound antigen complex and presenting it to circulating lymphocytes to the mononuclear phagocyte system (MPS)? elicit an immune response. While the MPS is a critical factor in the immune response, it does not complete the immune response but rather serves as a pathway for the response to start and progress. The MPS operates using the process of phagocytosis, whereby it engulfs the antigen.
| This question requires knowledge about the listed processes. |
505 The nurse looks for results of which of the following Correct answer: 2 CD<sub>4</sub> cells are indicative of a client's HIV status. As the disease laboratory measurements of lymphocytes to provide a progresses, the T‐helper cells decrease in number and lose their ability to function effectively reliable indicator of the immune response in a client leading to an overaggressive immune response. B‐lymphocytes indicate the status of humoral with HIV infection? immunity and are not directly associated with HIV infection. NK cells and T‐cytotoxic cells are not directly related to HIV infection and as such are not considered to be reliable indicators of HIV status.
| This question requires knowledge about HIV. |
506 The nurse is providing care to a group of clients. The Correct answer: 4 Transfusion and Goodpasture's are examples of Type II cytotoxic hypersensitivity reactions client with which of the following problems exhibits a and are involved with the activation of complement. Lupus is an example of a Type III Type III immune‐complex mediated hypersensitivity hypersensitivity reaction which involves IgG and IgM with the activation of complement. reaction?
| This question requires knowledge about immune responses. |
4.‐ Systemic lupus erythematosus | |
507 The client complains of loss of warmth in the foot Correct answer: 1 The assessment of the circulation or potential disruption of the circulation would be a priority after a fall from the bed. The assessment technique in assessment of this client. Palpation to assess disruption of sensorimotor or bone integrity the nurse should perform following inspection of the would follow. foot would be to:
| Remeber the ABC rule: airway, breathing, and circulation to select the highest priority for this client. |
508 A client presents to the clinic with a chief complaint Correct answer: 3 Clients with gout will usually have elevated serum uric acid levels. Laboratory findings as well of a swollen and painful great toe. The client states as physical assessment will confirm the diagnosis. The joint of the great toe is usually involved that the clien'ts brother has it, and has the same in initial attacks of acute gouty arthritis. There are many other factors that will affect the symptoms. The physician suspects gout. What specific results of hematocrit, serum calcium, and sodium levels. Erythrocyte sedimentation rate (ESR laboratory test would the nurse expect to be ordered or sed rate) and white blood cell (WBC) counts will also be elevated in cases of gout. for this client?
| This question requires knowledge about gout. |
509 A client with acquired immunodeficiency syndrome Correct answer: 3 With a diagnosis of neutropenia, the primary concern is to protect the client who is (AIDS) is being admitted to the hospital with a immunosuppressed from developing further infections. The immunosuppressed client should diagnosis of neutropenia. The nurse determines that not be exposed to potential infection in a semi‐private room (option 1). Use of Standard which of the following room assignments would be Precautions will prevent transmission of the virus (option 3). Contact precautions are most appropriate for this client? unnecessary (option 4).
| This question requires knowledge about neutropenia. |
510 A client with rheumatoid arthritis is seeking diet Correct answer: 4 Celery juice, honey, and fresh fruit are considered to be "non‐effective" dietary foods for modifications to ease symptoms of this disease. Which clients with arthritis. Salmon is high in omega‐3 fatty acids. Omega‐3 fatty acids have proven to of the following food items would be beneficial in be of benefit in clients with heart disease and rheumatoid arthritis by reducing inflammation. easing symptoms of rheumatoid arthritis?
| This question requires knowledge about the listed foods and rheumatoid arthritis symptoms. |
511 A client diagnosed with human immunodeficiency Correct answer: 3 Client identification of help from family support indicates that coping strategies have been virus (HIV) 2 years ago comes to the clinic for a instituted and have allowed the client to adapt to the disease process. Refusal to discuss other scheduled check‐up. Which of the following client matters does not reflect successful coping strategies or open communication. Scheduling behaviors would indicate that the client is coping well requests relates to personal preference and time management, not coping. with this disease process?
| Use the process of elimination to determine the correct answer to this question. |
4.‐ The client relates that reading no longer provides relaxation. | |
512 A 4‐year‐old child is receiving postoperative care for Correct answer: 1 There is great potential for alteration in bowel function (adynamic ileus) because of surgery surgical resection of a Wilms' tumor. In addition to and radiation to the abdominal area and the use of chemotherapeutic agents. This is an urinary functioning, one of the most important intrarenal tumor, so neurological status and bone pain are not related manifestations. Activity postoperative assessments is level would not be a specific assessment to make with this diagnosis.
| The core issue of the question is knowledge that Wilms' tumor affects the kidney, and therefore principles related to care following abdominal surgery apply to this client. Use nursing knowledge and the process of elimination to make a selection. |
513 A child with a brain tumor has shown symptoms of Correct answer: 2 Diabetes insipidus presents with symptoms of increased urinary output and very dilute urine. diabetes insipidus. A nursing assessment to monitor Urinary specific gravity will measure the concentration of the urine. Blood glucose and BUN are this condition would include unrelated to the issue of the question. ACTH levels are not routinely monitored in any client.
| The core issue of the question is knowledge of diabetes insipidus and methods to assess the status of this complication. Use nursing knowledge and the process of elimination to make a selection. |
514 The nurse determines that the client with Ewing’s Correct answer: 1 Bone marrow suppression occurs with radiation therapy, which can lead to risk of infection sarcoma understands instruction related to radiation when white blood cells are affected, bleeding when platelets are affected, and anemia when therapy when the client reports that side effects red blood cells are affected. Constipation and hemorrhagic cystitis occur after chemotherapy. include which of the following? If appetite is affected, it decreases rather than increases.
| The core issue of the question is knowledge of bone marrow suppression in a client receiving radiation therapy. Use basic nursing knowledge and the process of elimination to make a selection. |
515 A 6‐month‐old infant is being treated for Correct answer: 1 Because infant kidneys do not concentrate urine as well as the kidneys of adults, urine neuroblastoma. Because of the chemotherapy, the volume and specific gravity may not indicate fluid volume as accurately as will daily weight. infant feeds poorly and vomits frequently. The nurse Weight loss can be directly tied to fluid loss. Hemoglobin and hematocrit could rise and fall would use which of the following assessments to best because of hemodilution or hemoconcentration, depending on fluid status, but these levels determine the child’s fluid status? would be indirect indicators with large changes in fluid status and therefore not specific fluid balance measurements.
| The core issue of the question is the most reliable method of determining fluid balance in an infant that is not feeding well because of neuroblastoma. Use nursing knowledge of fluid balance measurement and the process of elimination to make a selection. |
516 A child is being treated for acute lymphocytic Correct answer: 3 In leukemia, the WBCs that are present are immature and incapable of fighting infection. leukemia (ALL). The laboratory report shows a white Increases or decreases in the number of WBCs can be related to the disease process and blood cell (WBC) count of treatment and not related to infection. The only value that indicates the child is infection‐free 7,000/mm<sup>3</sup>. The nursing care is the temperature. The use of proper handwashing technique is a measure or intervention plan lists risk for infection as a priority nursing used to meet a goal but is not a goal itself. diagnosis, and measures are being taken to reduce the child’s exposure to infection. The nurse determines that the plan has been successful when the
| The core issue of the question is knowledge of an indicator of infection in a client who is immunosuppressed from leukemia. Recall that temperature and WBC counts are frequently used as indicators of infection. Recall that in leukemia the WBCs are abnormal to choose the option related to temperature. |
‐ Child’s temperature remains within normal range. ‐ Parents demonstrate good handwashing technique. | |
517 A child with neuroblastoma will be started on total Correct answer: 1 Only regular insulin is administered in solutions administered by the IV route. Monitoring parenteral nutrition (TPN) because of cancer cachexia. blood glucose and I&O is appropriate. The child is usually anorexic but will be allowed to The nurse would question which of the following newly eat any food that appeals to him or her. written physician orders?
| The core issue of the question is knowledge of total parenteral nutrition as a means of providing nutritional support to a client with cancer. Use nursing knowledge about the uses of various preparations of insulin and the process of elimination to make a selection. |
518 A child has been diagnosed with a brain tumor, but Correct answer: 3 When a client is lying flat, the blood flow to the brain is greater, increasing the intracranial surgery cannot be scheduled for several days. The pressure. If the client sleeps in a semi‐Fowler’s position, less pressure will develop, which in mother asks what she can do to ease her child’s turn should ease headaches. Excess liquids and blowing the nose could aggravate headache. headaches. The nurse suggests that the mother: Discouraging bowel movements will reduce straining but is not a helpful measure from a gastrointestinal perspective.
| Recall principles of gravity to answer this question. When a client lies flat, blood can accumulate to a greater extent in the cranium, resulting in vasodilation, increased pressure, and worsening headache. Placing the client’s head in an elevated position allows gravity to drain blood to the heart and thereby keeps intracranial pressure rises to a minimum. |
519 A child is being treated with corticosteroids for acute Correct answer: 3 A person taking steroids may have increased blood pressure, increased appetite, and weight lymphocytic leukemia (ALL). On a follow‐up visit, the gain. Alopecia is related to chemotherapeutic agents that may be used to treat the leukemia. pediatric home health nurse assesses for side effects of steroid use, including:
| The core issue of the question is knowledge of adverse effects of combination agents, specifically steroids in this case, needed to treat cancer in a child. Use nursing knowledge and the process of elimination to make a selection. |
520 A client with squamous cell carcinoma of the lung Correct answer: 3 While all of the above are potential risks to clients with cancer depending on site, edema of comes to the emergency department reporting the face and arms results from obstruction of blood flow, which is indicative of superior vena shortness of breath and respiratory difficulty. On cava syndrome. Spinal cord compression would give rise to neurological symptoms. SIADH assessment, the nurse notes generalized cyanosis and would result in general fluid overload, and sepsis would be noted by signs of infection. edema of the face and arms. Based on this assessment, the nurse suspects the client is probably experiencing which of the following?
| The core issue of the question is knowledge of various oncological emergencies. Use nursing knowledge about which body systems are affected by each and then use the process of elimination to make a selection. |
521 The nurse reads in the medical record that a client’s Correct answer: 2 T2 indicates a measurable tumor, N0 indicates no regional node involvement, and M0 tumor is at stage T2, N0, M0. The nurse concludes that indicates no evidence of distant metastasis. Options 1, 3, and 4 are either partially or totally this staging indicates which of the following about the incorrect. client’s status?
| The core issue of the question is knowledge of staging for solid tumors. Recall that for an option to be correct, all of the parts of the option must be correct. Note the numeric zeros by the N and the M to choose the option that does not contain metastasis or lymph node involvement. |
522 A client with lung cancer is admitted to the oncology Correct answer: 2 Radiation is palliative treatment for spinal cord compression to reduce the tumor size and clinic to receive radiation therapy for treatment of relieve compression. Options 1, 3, and 4 are incorrect statements. spinal cord compression. The client’s spouse asks why radiation is being done. The nurse’s response would include that radiation therapy is used:
| The core issue of the question is the rationale for using radiation therapy in a client with spinal cord compression secondary to cancer. Recall that radiation therapy is often used as a supplement to shrink tumors to aid in making a selection. |
523 A client with esophageal cancer arrives in the Correct answer: 2 Oxygen and IV access are immediate interventions for the client with cardiac tamponade. emergency department with shortness of breath, Vasopressor agents will be administered to manage hypotension (option 1); a tachycardia, hypotension, and cyanosis. The physician pericardiocentesis is performed, not a thoracentesis (option 3); and radiation therapy is not determines the client is experiencing cardiac indicated for cardiac tamponade (option 4). tamponade. Which of the following interventions would the nurse expect to include in this client’s care?
| The stem of the question indicates that the client has an ineffective airway (shortness of breath and cyanosis). Look for the option that first addresses airway (oxygen) as the correct answer. |
524 The nurse is discussing risk factors associated with Correct answer: 2 Prostate cancer has surpassed lung cancer in order of occurrence; colorectal cancer is the cancer to a male client in the clinic. The client asks third‐most common cancer. Options 1, 3, and 4 are incorrect. which cancers have the highest incidence in men. In order of occurrence, the nurse would explain that the client has greatest risk for which of the following cancers based on gender?
| Specific knowledge of the risks associated with various cancers in men is needed to answer the question. Use nursing knowledge related to epidemiology of cancer and the process of elimination to make a selection. |
525 A new nurse on the unit is admitting a severely Correct answer: 3 Because of the immunosuppression, the client is at severe risk of infection. Precautionary leukopenic client who is receiving radiation therapy. measures such as a private room and protective isolation must be instituted to protect the The preceptor determines that the new nurse client from sources of infection. The client with pneumonia (option 1) poses a risk of infection, understands precautionary measures necessary for contact isolation (option 2) is not necessary, and option 4 does not provide the client with the this client when he or she admits this client to which of necessary isolation precautions. the following rooms?
| The core issue of the question is knowledge of room accommodations required by a client who needs neutropenic precautions. Recall that infection is the risk and use process of elimination to make a selection. |
526 After completing a health risk assessment on a client, Correct answer: 4 Smoking and drinking large quantities of alcohol daily increase the risk of oral and esophageal you determine health teaching and education is cancers. Options 1 and 2 are risk factors of development of other types of cancers. Option 3 is necessary because of an increased risk for laryngeal unrelated. cancer caused by which of the following risk factors? | The core issue of the question is a risk factor for laryngeal cancer. Note the word smoking in one of the options and associate it with the word laryngeal (referring to airway) to make a word connection between the stem and the correct option. |
‐ Past infection with Epstein‐Barr virus ‐ Past exposure to asbestos ‐ Smoking marijuana for recreational drug use ‐ Smoking cigarettes and consuming large quantities of alcohol daily | |
527 A client newly diagnosed with breast cancer is Correct answer: 3 The lymph node biopsy is performed to assess any metastasis from the primary site of cancer, scheduled for a lymph node biopsy and asks the nurse and a common metastatic site for breast cancer is regional lymph nodes. Options 1, 2, and 4 why it is necessary when a diagnosis of cancer has are incorrect statements. already been made. The nurse’s response is based on which of the following?
| The core issue of the question is knowledge that a biopsy procedure is used to diagnose a primary tumor or to evaluate lymph node involvement or metastasis. Use nursing knowledge and the process of elimination to make a selection. |
528 A 65‐year‐old postmenopausal client tells the nurse Correct answer: 2 The nurse should be concerned because painless bleeding not related to the menstrual cycle that she has recently experienced painless vaginal is often the only symptom of uterine cancer. Postmenopausal bleeding is not normal, with or bleeding. The nurse should: without pain. Anemia is not an immediate concern. Pain is often considered to be a late sign related to the diagnosis of cancer.
| The core issue of the question is the significance of painless vaginal bleeding in a client who is postmenopausal. Use nursing knowledge and the process of elimination to make a selection. |
529 A client is brought to the surgical unit after a Correct answer: 2 A very dark red output character following prostatectomy may indicate venous bleeding or suprapubic prostatectomy. He has a three‐way Foley inadequate dilution of the urine. The Foley catheter is at risk for occlusion. Increasing the catheter. The nurse notices a very dark red output via irrigation flow will prevent the formation of blood clots and occlusion of the catheter. If the the catheter. What is the appropriate nursing urine does not clear, then it would be appropriate to notify the physician. Although reviewing intervention? the latest hemoglobin and hematocrit may be appropriate, it is not the most pressing intervention the nurse must do following prostate surgery.
| The core issues of the question are interpreting the significance of dark red urine flow following prostatectomy and the ability to choose a corrective action. Interpret that the dark color is due to clots and then select the answer on the basis of which intervention will reduce clot formation. |
530 The nurse who is screening female clients for cancer Correct answer: 3 Ovarian cancer generally causes no warning signs or symptoms in the early stages, which is anticipates which of the following in relation to the why screening is important. Painful urination, pelvic pain radiating to the thighs, and low back early signs of ovarian cancer? pain are not associated with this health problem.
| The core issue of the question is knowledge of early signs of ovarian cancer. Use nursing knowledge and the process of elimination to make a selection. |
531 A client has stage II ovarian cancer documented as a Correct answer: 2 Option 2 describes stage II ovarian cancer. Option 1 describes stage I, option 3 describes stage diagnosis on the medical record. The nurse plans care III, and option 4 describes stage IV. based on which characteristic of this tumor at this stage?
| The core issue of the question is knowledge of the staging system for ovarian cancer. Use nursing knowledge and the process of elimination to make a selection. |
532 A client is scheduled for a radical mastectomy. When Correct answer: 2 Option 2 describes a radical mastectomy. Option 1 describes a modified radical mastectomy; reinforcing the surgeon’s explanation of the option 3 is a simple mastectomy; and option 4 is a lumpectomy. procedure, the nurse would include that the surgery involves which of the following?
| The core issue of the question is the ability to discriminate among various types of mastectomy procedures. Use nursing knowledge and the process of elimination to make a selection. |
533 A client returns to the medical unit following Correct answer: 1 Clients with three‐way Foley catheters usually complain of sensations of having to void transurethral resection of the prostate (TURP). The despite the presence of the catheter. This urge to void is caused by the pressure exerted by the client states to the nurse that he wants the three‐way balloon in the internal sphincter of the bladder and the wide diameter of the catheter that is Foley catheter to be removed because it is causing him used for the purpose of irrigation. Antispasmodics may be prescribed for the client with a to have bladder spasms. Which of the following is the three‐way irrigation catheter. A TURP involves the insertion of a resectoscope via the urethra. best response by the nurse? The complaint of having the urge to void is common with clients undergoing bladder irrigation. Local reactions to the catheter usually do not include bladder spasms.
| The core issue of the question is knowledge of the significance of bladder spasms following prostate surgery. Recall that spasms are not expected findings to help narrow the plausible options. Then use nursing knowledge and the process of elimination to make a selection. |
534 The client who underwent prostate surgery is Correct answer: 4 The healing period after prostate surgery is 4 to 8 weeks, and the client should avoid approaching the time of discharge from the hospital. strenuous activity during this period. Blood in the urine is fairly common after surgery. Which of the following instructions should the nurse Continued increased fluid intake will help the urine to remain dilute and reduce the risk of clot provide to this client as part of discharge teaching? formation. The client should not drive for 2 weeks, except for short rides.
| The core issue of the question is knowledge of postdischarge care to a client following prostate surgery. Use nursing knowledge and the process of elimination to make a selection. |
535 The nurse would write which of the following Correct answer: 4 The arm should be elevated above heart level following mastectomy to reduce the risk of interventions in the care plan of a client following edema after lymph node removal on the affected side. Warm, moist compresses could mastectomy for breast cancer? enhance edema formation, and IV lines should not be used on the affected side at any location (lab draws and injections and blood pressure readings should also be avoided). Gentle, simple range of motion exercises can be started immediately after surgery.
| The core issue of the question is knowledge that edema is a risk following mastectomy and of nursing measures that can reduce this risk. Use nursing knowledge and the process of elimination to make a selection. |
536 A client has a continuous bladder irrigation running Correct answer: 700 The total infused is 600 + 1500 = 2,100 mL. The total drained was 800 + 1050 + 950 = 2,800 after prostatectomy. During the shift, 600 mL of one mL. Subtract 2,100 from 2,800 to obtain 700 mL, the true urine output for the shift. bag of irrigant has infused and 1,500 mL of the next has also infused. Upon draining the urine bag three times during the shift, the nurse measures the volumes to be 800 mL, 1,050 mL, and 950 mL. The client’s true urine output is mL. Write in a numerical answer. | The principles for intake and output calculation are the same as for any other client. Tally first the intake, then the output, and subtract the difference to determine how much of the output is actually because of urinary drainage. Use knowledge of basic nursing procedures to calculate the answer. |
537 A child is admitted to the hospital with a diagnosis of Correct answer: 2 The low red blood cell count will limit the ability of the blood to carry enough oxygen to meet leukemia. Presenting lab values show low numbers of tissue needs, making risk for impaired gas exchange the correct diagnosis. There is no platelets and red blood cells. A very high white blood indication that the child is at risk for injury. The high WBC count does not indicate an infection cell (WBC) count is also noted. The nurse formulates is present but is an indication of the disease process. Since the WBCs are immature, they which of the following as an appropriate nursing would be unable to fight an infection appropriately. The deficiencies are not related to diagnosis? inadequate nutritional intake. The volume of blood is adequate; rather, it is the cell count that is abnormal.
| Option 3 is not related to blood values and can be eliminated. Option 4 is not a reflection of the lab values. Choose between options 1 and 2. Realize leukemia would cause the high white count and not infection. In addition, infection is a medical diagnosis, not a nursing diagnosis. |
538 A child with leukemia develops oral stomatitis Correct answer: 1 Stomatitis may cause the child to refuse fluids and foods. Hydration status would be an secondary to chemotherapy treatments. Nursing appropriate assessment to monitor the child's condition. Vitamin C intake would be important assessments related to this condition should focus on: in healing the mucous membranes but not as important as hydration. The condition of the teeth and handwashing techniques are not involved in stomatitis.
| Oral stomatitis is mouth ulcers which are very painful. The child will refuse liquids. The only other possible option is handwashing and that is not an assessment. |
539 A nurse is administering a chemotherapy drug to a Correct answer: 1 The chemotherapy agent poses a risk to all individuals including the child who was to have patient via a central line when the intravenous bag received the drug. Removal of individuals from the area reduces the risk of inadvertent slips and breaks open, spilling the chemotherapy agent exposure. Care is taken to avoid inhalation of the fumes, but the procedure would involve on the tile floor. The nurse should: activities to avoid aeration of the chemical not speed in cleanup. Disposable cleanup materials are included in a spill kit.
| Option 4 can be eliminated as all of the other options indicate concern over cleanup. Option 3 can be eliminated as that would expose the water system to the chemotherapy. |
540 The mother of a child receiving chemotherapy asks Correct answer: 1 Using multiple chemotherapeutic agents with different modes of action allows for the the nurse why they are giving the child more than one greatest amount of cell destruction. Using multiple drugs does not prevent renal damage, drug at a time. The mother states this is why her child reduce nausea, or allow for efficient use of nursing time. is so sick and it would be better to give the series one drug at a time. The nurse explains to the mother that using protocols of combination drugs:
| Knowledge of the rationale underlying chemotherapy induction will help to choose the correct answer. Recognize that options 2, 3, and 4 are not reasonable. |
541 The surgeon has instructed the nurse to discuss the Correct answer: 4 The access device illustrated is a tunneled central venous access device. The tunneled device care of the venous access device (shown) to the can last for years and once implanted, does not require puncturing the skin for access. parents of a child who will be receiving chemotherapy for at least two years. The nurse provides the parents information related to a:
| Recognize this is a tunneled catheter as the “tunnel” can be seen on the client’s skin. |
‐ Subcutaneous infusion port. ‐ Tunneled catheter. | |
542 A child with neoplastic disease is in terminal Correct answer: 3 There is no maximum dose of morphine. Increasing the dose in small increments is condition. The child is receiving a large dose of appropriate to control the pain. Addiction is not an issue as the child is terminal. Stopping the morphine by continuous infusion for pain control. infusion will put the child into withdrawal, which could be fatal. The physician is not misusing a After the mother and nurse both reported to the narcotic. physician that the child continues to be in severe pain, the physician has ordered a small increase in the morphine dosage. The nurse should:
| Recognize that because of tolerance, dosing of narcotics will need to be increased periodically. |
543 A 3‐year‐old girl is undergoing radiation therapy for a Correct answer: 1, 5 Because of the danger of radiation, the child will be alone in the therapy room. Staff or neoplasm. She states she is afraid of the large parents cannot stay with the child. A 3‐year‐old is not old enough to use mental imaging when machines in the radiation department. To calm the frightened. A favorite stuffed toy can provide comfort as well as the calming voice of the child during the procedure, the nurse could do which parent over the intercom system in the room. of the following? Select all that apply.
| Considering the child’s age, option 4 is inappropriate. In radiation therapy, nurses and parents should not be exposed to the radiation. |
544 In planning care for a 4‐year‐old with anemia Correct answer: 3 Assessing this child will give baseline data to plan and evaluate care. Activity intolerance will secondary to chemotherapy and radiation therapy, the be likely, so rest is important. This child is also too young to make choices about planning nurse would include: schedules and is likely to choose favorite foods that do not meet his nutritional needs. The caregiver should be educated in planning activities and making food choices that include soft, non‐spicy foods that are high in iron and protein.
| The core concept is anemia and nursing interventions. Think of energy conservation when a stem describes anemia. |
545 Appropriate interventions for a 2‐year‐old with Correct answer: 1 Using antiemetics regularly will help to manage nausea and vomiting. Foods that have strong nausea and vomiting related to chemotherapy would odors will increase nausea and vomiting. Only small amounts of fluids should be offered. include: During periods of illness, children often regress to a "safer" period and regressive behaviors should be allowed if they comfort the child.
| Knowledge of the administration of antiemetic drugs to lessen nausea from chemotherapy will aid in choosing the correct answer. Option 4 is unrelated to nausea. Options 2 and 3 are inappropriate activities in the care of nausea. |
546 Nursing considerations for hemorrhagic cystitis, Correct answer: 2, 5 One of the side effects of cyclophosphamide is hemorrhagic cystitis not anaphylaxis. which may occur with the use of cyclophosphamide Appropriate interventions include using Mesna to counteract the irritating nature of Cytoxan, (Cytoxan), include: (Select all that apply.) forcing fluids, and having the client empty the bladder frequently. | Consider which option will lessen cellular exposure to the chemical. |
‐ The use of antibiotics. ‐ Emptying the bladder frequently. ‐ Restricting fluids. ‐ Planning for anaphylaxis. ‐ Encouraging increased fluid intake. | |
547 A 6‐year‐old child is being admitted for surgical Correct answer: 2 Vomiting is a symptom of increased intracranial pressure. Bulging fontanels would not be removal of a brain tumor. The nurse anticipates that present in a school‐age child. Drainage from the ear or nose might indicate a basilar skull which of the following nursing assessment data will be fracture, not a brain tumor. Some brain tumors display the symptom of diabetes insipidus, not present during the preoperative period? diabetes mellitus, thus the symptom would be dilute urine rather than elevated blood glucose.
| Consider two items in answering the question: normal growth and development of the school‐age child, and typical symptoms of a brain tumor. |
548 A child is receiving chemotherapy to induce remission Correct answer: 2, 5 Nausea and vomiting, anorexia, mouth sores, constipation, and pain are early and common in acute leukemia. When considering common side side effects of chemotherapy. Bone marrow suppression reaches its peak 7 to 10 days after effects of chemotherapy, the nurse would write which induction. Sleep disturbance may be related but is not directly caused by chemotherapy. of the following as appropriate nursing diagnoses early Peripheral tissue perfusion is not related to the question. in the course of therapy? (Select all that apply.)
| The core concept is early side effects of chemotherapy. Recall that chemotherapy drugs kill rapidly growing and dividing cells to help select the options that pertain to rapidly growing cells that line the gastrointestinal tract. |
549 A client is to begin radiation therapy after the Correct answer: 3 Self‐care during external radiation therapy includes loose‐fitting clothes, gentle washing with removal of Wilms’ tumor. The parent statement that mild soap, avoiding sun exposure, and avoiding scratching and other irritation. Any lubricant indicates to the nurse a lack of understanding of must be water‐soluble, not oil‐based such as petrolatum jelly. related skin care would be “We will:
| The critical words in the question are “lack of understanding.” Eliminate those responses that would be appropriate skin care for a radiation patient. |
550 An adolescent receiving cyclophosphamide (Cytoxan) Correct answer: 4 Hematuria is an adverse effect of the commonly used cancer medication cyclophosphamide for acute lymphocytic leukemia (ALL) asks the nurse to (Cytoxan) and should be reported. Fluids are usually encouraged prior to administration, and come quickly to evaluate “blood in my urine.” The the bladder is emptied frequently to prevent hematuria. Measuring intake and output should most important action by the nurse would be to: be done routinely on all clients and is not specific to managing this complication.
| Options 2 and 3 are normal activities for all patients receiving chemotherapy. Determine the correct response from options 1 and 4 considering that hematuria is not a normal finding. |
551 A pediatric client who is known to have cancer is Correct answer: 3 A private room assignment is indicated for children with chemotherapy‐related neutropenia. being admitted for mild neutropenia and a severe oral Careful handwashing is also an essential element to reduce the risk of infection. Because the monilial infection. The nurse should assign the child to neutropenia is mild at this time, the client does not require neutropenic precautions and does which room? not require full protective isolation. However, neutropenic precautions could be instituted later if the client’s neutrophil count continues to decline.
| This oral infection is spread by direct contact, so the infection itself would not prevent the child from sharing a room. However, the neutropenia would require the client not to share a room. Note the critical word “mild” to determine that neither neutropenic precautions nor protective isolation are needed at this time. |
552 The nurse is assigned to the postoperative care of a Correct answer: 4 Nursing care must be supportive of body image adjustment. The child would be encouraged child with a below‐the‐knee amputation for osteogenic to sit in a chair and ambulate on crutches while waiting for the permanent prosthesis. The sarcoma. The nurse plans to include which of the stump dressing is a continuous ace bandage, which supports the stump shape in preparation following in nursing care of the child? for the prosthesis.
| To answer correctly, consider appropriate stump care and eliminate those options as incorrect, leaving only the psychological response. |
553 The nursing diagnosis for a child undergoing Correct answer: 2 The client’s goal should be stated in terms of behaviors of the child that demonstrate the chemotherapy for leukemia is “Imbalanced nutrition: problem is solved. Option 1 is a nursing action, not a goal. Absence of nausea does not less than body requirements related to nausea and guarantee adequate intake. Equal intake and output indicates fluid balance but does not anorexia.” The nurse would formulate which of the indicate adequate nutrition. Only the caloric intake adequately addresses the outcome needed following as an appropriate goal for this client? by this client.
| Consider which response best answers the problem of imbalanced nutrition. The correct option would likely be addressing caloric intake or maintaining/gaining weight. |
554 A child is to receive chemotherapy with a vesicant Correct answer: 2 A vesicant drug can cause significant tissue damage if the IV line infiltrates. By checking for drug by the intravenous (IV) route. The nurse can blood return throughout the administration, the nurse can stop the infusion at any time a ensure safe administration of this drug by doing which blood return does not occur. A positive pressure infusion pump, maintaining the infusion site of the following? below the level of the heart, or rapid drug delivery does not guarantee that the infusion does not extravasate.
| The core concept in this question is the vesicant property of the drug and safe administration. Eliminate options 1 and 4 because they are excessive or extreme. Choose option 2 over 3 because it directly addresses the issue of proper IV catheter placement in the vein. |
555 A child with leukemia has developed pancytopenia. Correct answer: 2, 4 Studies have shown that simply rinsing the mouth with water decreases the onset of The nurse would institute which measures designed to stomatitis in chemotherapy patients. Alcohol‐based mouthwash would be avoided as it is reduce stomatitis in this child during the course of drying to the oral mucous membranes. A stiff toothbrush may cause the gums to bleed. Should chemotherapy? (Select all that apply.) oral lesions be present, acidic foods and liquids will increase discomfort. Drinking through a straw and pain management will provide comfort for the child, as will using swabs for mouth care.
| Consider the pain of stomatitis to determine the appropriate activities. Choose the options that relieve discomfort or prevent irritation as the correct care measures. |
556 During rounds, the interdisciplinary team is discussing Correct answer: 4 The stages of grief and bereavement include denial, anger, bargaining, depression, and a child with leukemia who has just been diagnosed as acceptance. The anger expressed may often be displaced and directed toward persons who terminal. The nurses describe the mother’s behavior as have a role in the loss. Nurses and other healthcare personnel must be aware of this in order angry, claiming the nurses are not providing care for to help the family cope with the impending loss. her child. The team leader then focuses on which of the following, which is most likely the cause of the mother’s anger?
| Most of the options include information not provided in the stem. Only option 4 is complete with the stem information. |
557 An 18‐month‐old client is brought in for a well‐child Correct answer: 1, 3, 4 This is the usual presentation of Wilms’ tumor (nephroblastoma), and palpating the area may visit. The parent reports feeling a lump to the right of cause the tumor to spread. Since Wilms’ tumor is a cancer of the kidney, it is important to the “bellybutton” during bathing. Initial assessments assess growth and development; kidney function; and blood pressure, which may be elevated should include: (Select all that apply.) due to increased renin production. There is no evidence of abuse or rationale for performing a neuro check.
| Consider what conditions are common in the abdomen of toddlers. All normal assessments would be performed as well as assessments related to the possible condition. Knowledge of Wilms’ tumor and the contraindication for palpating the abdomen will also help to identify the correct answer. |
558 The parent of a child with neuroblastoma verbalizes Correct answer: 2 This tumor occurs in 1 in 10,000 live births. It arises out of embryonic neural crest cells and, regret at not coming in earlier for the child’s therefore, is usually found in the adrenals or retroperitoneal sympathetic chain. Symptoms are complaints. An appropriate response is: vague and depend on location.
| Look for a therapeutic response that addresses the parent’s comment. Eliminate the answers that are not therapeutic and only convey information. Knowledge of neuroblastoma and therapeutic communication will aid in choosing the correct answer. |
559 A 4‐year‐old is diagnosed with acute lymphocytic Correct answer: 4 Acute lymphocytic leukemia (ALL) is staged at diagnosis to determine treatment. The goal is leukemia (ALL). Following teaching about the testing remission, which is usually accomplished using chemotherapy. and therapy, the nurse evaluates the family’s understanding of the problem. The statement by the family that indicates appropriate knowledge would be: “Tests will:
| The core concepts to correlate are leukemia tumor staging. Knowledge of ALL and the use of tests to diagnose the disease will aid in choosing the correct answer. |
560 The school health nurse has seen a child several times Correct answer: 3 The most common reported symptoms of brain tumors in children are headache, especially with the same complaints. The school health nurse upon awakening, and vomiting that is unrelated to eating. Both are related to increased would suspect a brain tumor after noting the presence intracranial pressure. Irritability and ataxia may also be present; however, presenting of which of the following symptoms that is compatible symptoms are often vague. Fever is not a symptom of a brain tumor. Papilledema may be with this health problem? noted, but red reflex is not indicative of brain tumors. | Remember that the earliest symptoms of brain tumors in school‐age children are often due to the inability of the skull to expand and select symptoms accordingly. |
‐ Ataxia and irritability ‐ Papilledema and positive red reflex ‐ Early morning headache and vomiting ‐ Fever and seizures | |
561 In Chapter 12, Pretest, question 5 should read: "A 17‐ Correct answer: 2 Bone tumors usually occur in otherwise healthy children. Given the interruption of normalcy year‐old is being admitted for an amputation related and the developmental tasks of the adolescent, body image disturbance can occur when a limb to a bone tumor. The nurse is developing a nursing is lost. care plan and determines the most appropriate age‐ related diagnosis is:
| The critical words in the stem of the question are “age‐related.” Body image is a concern for all adolescents even without physical problems. Knowledge of the clinical management of a bone tumor will also aid in identifying the correct answer. |
562 A child has been treated with chemotherapy for Correct answer: 2 Neutropenia is a reduced white blood count, which increases the risk for infection. Only live cancer. The nurse anticipates that neutropenia is an vaccines are contraindicated in children who are immunocompromised. Contact sports would expected consequence and teaches the parents to: be a problem with thrombocytopenia and spicy foods would increase discomfort if an alteration in mucous membranes occurred.
| Knowledge of the side effects of chemotherapy and how to manage the resultant neutropenia aids in answering the question correctly. |
563 A child diagnosed with Ewing’s sarcoma is being Correct answer: 4, 5 Thrombocytopenia refers to a decrease in platelets. Preventing falls and bruises would be treated with chemotherapy. The results of a complete appropriate for an individual with platelet deficiencies. Fresh flowers may contain molds and blood count (CBC) indicate severe thrombocytopenia. fungus that can lead to infection and would be a concern for a child with neutropenia. Nursing interventions related to this finding would Providing foods high in iron would be appropriate to restore red blood cells. Limiting contact include: (Select all that apply.) with the child could affect his or her body image and self‐esteem. Contact is acceptable as long as the individual is not infectious.
| The learner will need to understand which blood cell is deficient in thrombocytopenia. |
564 The parents of a child with neutropenia secondary to Correct answer: 3 Healthy children are often a source of infectious organisms. Children in hospitals may carry a chemotherapy have been taught protective isolation number of infectious organisms. Hospitalized neutropenic children should be protected from behaviors. Nursing observations that indicate a need exposure to other children whenever possible. Toys from home would not carry a high risk. for further education is when the parents: Handwashing before contact with the child is the important intervention. Limiting physical contact with peers would decrease exposure to infectious organisms. Telephone contacts allow for the peer support the child needs.
| Knowledge of neutropenia and the care of the child will aid in choosing the answer that indicates a need for further teaching of the parents. Consider the activity that would have the highest exposure to organisms. |
565 Following diagnosis of Wilms’ tumor, the child Correct answer: 4 All of these assessments look at possible postoperative complications. Since the child is left undergoes removal of the affected kidney. In the with only one kidney, failure of that kidney due to inadequate blood flow, infection, or any postoperative period, priority nursing assessments other cause could be fatal. should focus on: | Although respiratory is often the response in prioritizing assessments, in this specific case, the learner should recognize the importance of the remaining kidney. |
‐ The incision. ‐ Lung sounds. ‐ Temperature. ‐ Kidney function. | |
566 A child will be undergoing chemotherapy. The nurse Correct answer: 2 Preparation helps individuals handle stressful situations. If the child had not been prepared discusses the issue of hair loss with the child and for hair loss, it could be more anxiety‐provoking for the child. Hair loss cannot be prevented. family before chemotherapy begins. Later the family asks the nurse why this information was given to the child at this time. The nurse’s response will include the information that:
| Knowledge of the affect of hair loss on the child and the need to prepare the child prior to this stressful event to facilitate coping will help to identify the correct answer. |
567 Which of the following assessment parameters in the Correct answer: 4 As the immature white blood cells crowd the marrow, the ability for the marrow to perform client with leukemia is most important? the proliferation of red blood cells and platelets is also inhibited leading to a potential for infection, occult blood, and hemorrhage. While the client may also experience constipation, nausea, vomiting, anxiety, or depression, the potential for hemorrhage is most important.
| This question requires knowledge of bleeding as a key complication. |
568 A client with hypercalcemia caused by malignant Correct answer: 3 Hypercalcemia produces a generalized slowing of functions through neuromuscular myeloma might exhibit which of the following? depression, i.e., constipation, increased urination, hyporeflexia, and confusion.
| This question requires knowledge of malignant melanoma. |
569 An important consideration when administering Correct answer: 1 Gallium nitrate can impair renal function as evidenced by elevated urea and creatinine levels. gallium nitrate for a client with multiple myeloma is to: Hypotension, extravasation, and hyperglycemia are not side effects of gallium nitrate.
| This question requires knowledge of renal clearance. |
570 A client with cancer presents with a calcium of 12.5 Correct answer: 3 Although all the interventions help to decrease serum calcium, ambulating the client is the mg/dL. She is alert and oriented with good urine action that will most likely encourage calcium to return to the bone. output. The most appropriate intervention to aid in decreasing the serum calcium concentration is to:
| This question requires knowledge of methods to decrease calcium. |
571 A client with suspected Hodgkin's disease wants to Correct answer: 2 A lymph node biopsy is the only definitive means of establishing the diagnosis of Hodgkin's know why a lymph node biopsy is necessary. The best disease. The presence of the Reed‐Sternberg cell is ascertained through this biopsy. Options 1, response by the nurse is that the biopsy is: 3, and 4 are not necessarily true.
| Recall that the biopsy is the definitive diagnostic tool. |
572 A client presents with acute myelogenous leukemia Correct answer: 1 Preventing contact with contagious visitors decreases the client's risk of infection. The use of (AML). Her white blood cell (WBC) count is 1,000/ aspirin or aspirin products as well as injections should be avoided in clients with mm<sub>3</sub>, hemoglobin is 8.0 g/dL, thrombocytopenia. The client's temperature should be monitored every 4 hours for signs and hematocrit is 20 percent, and platelet count is 80,000/ symptoms of infection, not necessarily the respirations. mm<sub>3</sub>. Which of the following interventions is appropriate?
| This question requires knowledge of neutropenic precautions. |
573 A client admitted with newly diagnosed sickle cell Correct answer: 3 Vasospasm creates the log jam, which impedes blood flow that leads to clots, infarction, and crisis asks the nurse why there is so much pain. The pain. The repeated sickling and unsickling causes the weakened cell membrane and hemolysis. best explanation is which of the following? A clot can form (option 2) but is usually not in the deep vessels, but in the microcirculation. Option 4 is incorrect because vasodilation does not occur.
| This question requires knowledge of sickle cell crisis. |
574 A client with hemophilia A asks the nurse whether the Correct answer: 3 Since hemophilia A is carried on the X‐chromosome, all of the female children will be carriers. disease can be passed on to his children. The nurse’s The disease will not affect a male child, unless he marries a woman who is also a carrier. best response would be:
| This question requires knowledge of the transmission of hemophilia A. |
575 The nurse doing health promotion in a client with Correct answer: 2 During decreased oxygen tension in the plasma, the hemoglobin S causes the red blood cells sickle cell disease teaches the client to avoid situations to elongate, become rigid, and assume a crescent, sickled shape causing the cells to clump that lead to sickle cell crisis, which are primarily together, obstruct capillary blood flow causing ischemia and possible tissue infarction. instances when there is an inadequate amount of:
| This question requires knowledge of impact of hypoxia on sickled cells. |
576 For a client with iron‐deficiency anemia, adequate Correct answer: 4 Adequate iron stores are required to allow the oxygen molecule to attach to the red blood iron is a crucial part of hemoglobin because: cell. Small hemoglobin molecules insufficient in iron and oxygen are released into the circulation resulting in the signs and symptoms of fatigue and shortness of breath.
| This question requires knowledge of the pathophysiology of anemia. |
577 When severe neutropenia is present, the primary Correct answer: 2 In severe neutropenia, there is a decrease of mature white blood cells, which significantly symptom of infection for the nurse to assess may be: decreases the inflammatory response. Therefore, fever may be the first sign of infection in these clients.
| This question requires knowledge of temperature as an early sign of infection. |
578 The presence of Auer rods in the cytoplasm is Correct answer: 2 Auer rods may be present in the cytoplasm of the myeloblasts in AML. A standard diagnostic primarily found in which type of leukemia? criterion for AML is that over 30 percent of hematopoietic cells must be myeloblasts.
| This question requires knowledge of the Auer rods. |
579 The nurse prepares the client with suspected Correct answer: 2 Gastric secretion analysis in the client with pernicious anemia reveals an absence of free pernicious anemia for gastric analysis. This disorder hydrochloric acid in a pH maintained at 3.5. would be confirmed by a subsequent laboratory report that indicates which of the following?
| This question requires knowledge of pernicious anemia. |
580 In a client with chronic myelogenous leukemia (CML), Correct answer: 1 Leukostasis occurs as the leukemic blast cells accumulate and invade the vessel walls, causing the nurse should monitor for high white blood cell rupture and bleeding. Patients with extremely high circulating blasts (WBC > counts caused by the complications associated with 50,000/mm<sub>3</sub>) are at increased risk for leukostasis. leukostasis. The most common and most lethal complication of leukostasis is:
| This question requires knowledge of leukemia. |
581 The nurse conducting health teaching for a client with Correct answer: 2 Tissue requires a certain degree of oxygenation to prevent feeling fatigued. When inadequate iron‐deficiency anemia explains that activity oxygenation is available due to the pathophysiology of the disease, a supply and demand intolerance is specifically related to: imbalance occurs. Iron‐deficiency anemia results in less iron available and less oxygen to adhere to the hemoglobin molecule.
| This question requires knowledge of the role of hypoxia with iron deficiency anemia. |
4.‐ Inadequate secondary defenses. | |
582 The nurse monitors a client with Hodgkin's disease for Correct answer: 4 Relentless proliferation of lymphocytes invade and compromise the function of various which of the following complications that could be organs, especially the bone marrow. Most clients with Hodgkin's disease exhibit signs of fatal? immune deficiency early in the disease. Immunosuppressive therapy makes the client even more susceptible to infection and hemorrhage because of a compromised bone marrow function.
| This question focuses on safety related to Hodgkin’s disease. |
583 Multiple myeloma is characterized by which of the Correct answer: 4 Leukocyte proliferation is characteristic of lymphomas. Multiple myeloma is a neoplastic following? proliferation of the plasma cells.
| This question requires knowledge of multiple myeloma. |
584 The nurse teaches a client that which of the following Correct answer: 4 Antacids coat the stomach and intestinal lining thereby inhibiting the absorption of iron medications will decrease absorption of an iron supplements. Vitamin C increases absorption. Birth control pills and aspirin products have no supplement if taken simultaneously? effect on absorption.
| Recall that antacids hamper the absorption of many medications by making the stomach alkaline. Note that this is a frequent NCLEX<sup>®</sup> question. |
585 Which of the following nursing diagnoses is most Correct answer: 2 The greatest risk affecting a client with hemophilia is the potential for hemorrhage. Although appropriate for the client with hemophilia? activity intolerance may also be a problem, in these clients it is caused by the injury potential, not a decrease in functioning hemoglobin. Option 1 is appropriate for a client with pernicious anemia and option 3 for a client with leukemia.
| Consider the disease and the risk when establishing priority nursing diagnoses. |
586 A client has just been diagnosed with Hodgkin's Correct answer: 3 After a lymphangiogram, veins of the lower extremities, dorsal skin of the feet, and urine may disease. Several hours after she returns to the room have a blue‐green discoloration from dye excretion for 2 to 5 days. The best response to the after having a lymphangiogram, she tells the nurse her client's question is one that provides accurate information as well as reassuring the client. urine is blue. The nurse's best response is:
| This question requires knowledge of Hodgkin’s disease. |
587 The nurse assesses for petechiae and ecchymosis as Correct answer: 4 Thrombocytopenia is a decrease in circulating platelets leading to a prolonged bleeding time the most common signs in a client diagnosed with and disruption of the primary homeostatic plug. While a Vitamin K deficiency can lead to a which of the following disorders? prolonged prothrombin time, the patient does not exhibit petechiae and ecchymosis. | Consider the condition most prone to bleeding. |
‐ Iron‐deficiency anemia ‐ Pernicious anemia ‐ Vitamin K deficiency ‐ Thrombocytopenia | |
588 A client is prescribed to take ferrous sulfate for iron‐ Correct answer: 1 Iron supplements are better absorbed if taken before meals; however, the side effect of deficiency anemia and is experiencing nausea with the nausea may be experienced if taken on an empty stomach. Taking with meals may hinder medications. The client should be instructed by the absorption, so orange juice or other foods containing Vitamin C may be taken with the nurse to: medicine to help with absorption.
| This question requires knowledge of ferrous sulfate. |
589 The nursing care plan for a client diagnosed with Correct answer: 3 ITP is an autoimmune disorder in which the body destroys platelets. In order to decrease the idiopathic thrombocytopenia purpura (ITP) takes into immune response, corticosteroids are usually administered. Platelet transfusions may be given account which of the following therapies for this in acute bleeding, however the body will actively destroy these as well. disorder?
| This question requires knowledge of ITP. |
590 The nurse providing health teaching to a client Correct answer: 1 Although COPD can be an underlying etiology for the formation of secondary polycythemia; it explains that the underlying cause of secondary is the chronic tissue hypoxia from the COPD that is the underlying cause of the condition. Not polycythemia is which of the following? all patients with COPD develop the condition.
| This question requires knowledge of compensatory mechanisms for hypoxia. |
591 A 67‐year‐old female client refuses to be screened for Correct answer: 2 Approximately 67% of all cancer occurs in people over age 65, necessitating early screening cancer, stating, "I am too old to get cancer and if I and detection. The incidence of cancer increases with age, making it a significant factor in the don't have it by now, I will never get it." Which of the development of cancer. following would be the basis of your response to her?
| This question requires knowledge of the cancer screening methods. |
592 A client just diagnosed with a benign neoplasm asks Correct answer: 1 Benign neoplasms are localized, encapsulated growths. They are not malignant, and they do you if he is going to die. On which of the following not metastasize. They are harmful only if they interfere with vital functions such as circulation. items of information will you base your response? Malignant neoplasms have a high mortality rate unless therapeutic interventions are performed. The client's question is a normal, expected response.
| This question requires knowledge of benign processes. |
593 A client receiving intravenous chemotherapy is Correct answer: 3 Administering antiemetics before chemotherapy helps reduce the severity of nausea. Waiting experiencing nausea. Which of the following would be until the client is experiencing nausea demonstrates lack of planning. Cool foods and liquids the best intervention to lessen the severity of nausea? are better tolerated and are less irritating than warm foods and liquids. Small, frequent meals are more easily tolerated and may reduce the incidence of nausea and vomiting.
| This question requires knowledge of basic care concepts. |
594 When teaching safety precautions to the client with Correct answer: 2 The client is a risk to others as long as the radiation implant is present. Therefore, certain an internal radiation implant, you would include which precautions to protect others must be taken. The client should have a private room, and of the following in explanations to the client? visitors should maintain a distance of 6 feet and limit visits to 10 to 30 minutes. The client may not need isolation for the entire period of hospitalization; rather just for the time the implant is in place.
| This question requires knowledge of the means to protect the client and others. |
595 A nurse is educating a client who will likely experience Correct answer: 1 Washing the hair daily will promote further hair loss. Hair washing should be limited to 2 to 3 alopecia (hair loss) as a result of the current times per week. Options 2, 3, and 4 are correct actions taken by the client. chemotherapy treatment. Further instructions are necessary when the client states which of the following?
| Use the process of elimination to determine the correct answer, in this case the incorrect option requiring further instruction. |
596 A client receiving chemotherapy is experiencing a low Correct answer: 3 The client with a low WBC count is at high risk for infection. The grandchild recently exposed white blood cell (WBC) count. The nurse should teach to varicella could be contagious at this point. The nephew with HIV, unless currently infected the client to avoid contact with which of the following with another communicable disease, does not pose a risk. There is no indication that the family members? husband has tuberculosis. The pregnant daughter does not pose a risk.
| Use the process of elimination to determine which poses the greatest risk. |
597 The nurse is counseling a 22‐year‐old female in the Correct answer: 1 The American Cancer Society recommends a breast examination by a healthcare provider health clinic. The nurse determines that she every 3 years for ages 20 to 39, then yearly from age 40 and older. Breast self‐examinations understands the teaching instructions for the early should be performed monthly. Mammograms are recommended yearly beginning at age 40. detection and screening of breast cancer when she makes which of the following statements?
| This question requires knowledge of the correct screening procedures. |
598 A client is to receive intravenous chemotherapy via a Correct answer: 2 Extravasation of the chemotherapeutic agent, especially if the agent is a vesicant, is a major peripherally inserted central catheter (PICC). The nurse complication of intravenous administration of chemotherapy. Never test vein patency with the should plan to take which of the following essential medication. Making the client comfortable is important, but assuring vein patency is the actions before beginning the administration? highest priority. There is no indication to administer acetominophen.
| This question requires knowledge of the function of platelets. |
599 A client with a low platelet count demonstrates Correct answer: 1 The client with a low platelet count (thrombocytopenia) is at risk for bleeding. Aspirin further understanding of instructions to avoid potential interferes with platelet functioning. Monitoring for fever (option 2) is necessary for low WBC complications by doing which of the following? count, and managing fatigue (option 3) is necessary for anemia. Flossing is contraindicated in the client with low platelet count (option 4).
| Recognize that this question asks about basic hygiene concepts. |
600 The nurse is evaluating the nutritional status of a Correct answer: 4 Damage to the mucous membranes, especially oral mucous membranes (stomatitis), leads to client who is receiving chemotherapy. On assessment, painful ulcerations of the mouth, interfering with the client's desire to eat. The mucous which finding could potentially affect the client's membranes and mouth may be dry (xerostomia) as a side effect of the chemotherapy. Pale nutritional intake? skin may be a sign of anemia, and ecchymosis may be indicative of a low platelet count.
| This question requires knowledge of the listed processes. |
601 A client undergoing radiation therapy has a severely Correct answer: 1 The immunosuppressed client is at high risk for infection. A private room, maintaining aseptic depressed white blood cell (WBC) count. A priority technique, and limiting visitors will reduce exposure and risk. Fresh fruits and vegetables may nursing intervention would include which of the harbor bacteria; serve cooked foods only. The client with a decreased platelet count should be following? counseled to avoid using razors.
| This question requires knowledge of the function of WBCs. |
602 The assessment nurse is working in a local clinic. Correct answer: 1 Unexplained, rapid weight loss may be the first symptom associated with cancer, and Based on the history provided by the clients, which immediate evaluation is required. Options 2, 3, and 4 are risk factors associated with cancer, one of the following requires an immediate referral for and education and screening are important to reduce the risk of cancer. screening and evaluation?
| Recognize that this question focuses on the significance of unintended weight loss. |
603 The nurse is counseling a client on risk factors Correct answer: 4 Options 1, 2, and 3 are noncontrollable or nonmodifiable risk factors. Diet is the only listed associated with cancer. For which of the following will risk factor that is controllable. Assisting the client to develop a diet plan low in fat and high in the nurse assist the client in developing a plan to fiber will help reduce the risk of some types of cancer. reduce the risk of cancer? 1.‐ Heredity | Use the process of elimination to identify modifiable risk factors. |
‐ Gender ‐ Age ‐ Diet | |
604 The nurse is making a home visit to a client receiving Correct answer: 3 Lotion, deodorant, and powders should not be applied to the radiation site during the external radiation therapy on an outpatient basis. treatment period to avoid further irritation to the skin. Options 1, 2, and 4 are correct actions. Further teaching is necessary when the nurse observes the client doing which of the following?
| Use the process of elimination to determine the correct answer. |
605 A hospitalized client with an internal radiation Correct answer: 2 Long‐handle forceps should be used to pick up the implant. Lead containers are necessary to implant calls the nurse to the room to report the prevent exposure to radiation. Direct handling of the implant causes exposure to radiation; no implant is dislodged and is lying in the bed. The nurse’s one should directly touch the implant. Gloves and biohazard bags do not offer protection from actions would include which of the following? radiation. Infection control personnel have no role in the disposal of the implant, which should be returned to the radiation therapy department after properly being placed in the lead container.
| This question requires knowledge of the handling of radiation implants. |
606 A client with leukemia is undergoing the "conditioning Correct answer: 4 The conditioning phase depresses bone marrow function, and infection is the major cause of phase" for a bone marrow transplant (BMT). The death for clients with leukemia. Options 1, 2, and 3 are appropriate diagnoses for clients priority nursing diagnosis for this client is which of the receiving chemotherapy and radiation, but the risk for infection is the highest priority during following? this phase.
| Recognize that this question asks about priorities related to infection, important with the neutropenic client. |
607 The nurse has counseled a male 52‐year‐old client Correct answer: 1 The American Cancer Society recommends a digital rectal examination and PSA yearly for about early detection and screening for prostate males beginning at age 50. Options 2 and 3 are only partly correct, and option 4 is incorrect. cancer. The nurse evaluates that the client has understood instructions when he states which of the following?
| This question requires knowledge of the screening tests for cancer. |
608 A client who had a mastectomy yesterday refuses to Correct answer: 2 Denial is a protective mechanism, and during this time, the client needs a supportive look at the incision. The nurse can best assist the client environment. Allowing the client to express feelings will enable an effective adaptation to this to cope with the disturbed body image by doing which change. Option 1 is not therapeutic. Wound care must be done in order to prevent of the following? complications (option 3), and the client is obviously not psychologically ready to participate in self‐care (option 4).
| Recall that allowing for client ventilation of feelings is an important strategy. |
4.‐ Have the client assist you with the dressing change. | |
609 In assessing a client receiving chemotherapy, which of Correct answer: 2 Options 1, 3, and 4 are common side effects of chemotherapy. Even though they do require the following would require further evaluation? intervention, ecchymotic areas may be a sign of decreased platelet count, making the risk of hemorrhage the priority.
| Use the process of elimination to differentiate common and uncommon side effects. |
610 A client receiving external radiation expresses Correct answer: 2 External radiation poses no risk of radiation exposure to contacts, even during intimate concern to the nurse about physical intimacy with physical contact. Clients are encouraged to maintain their usual activities, as long as they are spouse. When offering sexual counseling to the client tolerated (option 3). There is no increase in risk of infection to the client with cancer during and spouse, the nurse tells them which of the intimate physical contact unless that person has a current infection (then contact should be following about intimate physical contact? avoided until infection is treated).
| This question requires knowledge of the care of a client having radiation therapy. |
611 A client with acute leukemia is admitted for a bone Correct answer: 2 Bone marrow is usually harvested from the iliac crest (option 1), frozen, then stored until marrow transplant. The nurse concludes that the client treatment. The marrow is administered intravenously through a central line. Options 3 and 4 understands teaching based on which of the following are incorrect. statements?
| This question requires knowledge of the care of the client having a bone marrow transplant. |
612 The nurse is teaching a male client with cancer about Correct answer: 3 Even though anemia (option 1) and hemorrhage (option 2) also result from bone marrow potential complications associated with bone marrow suppression, immunosuppression leading to an inability to fight infection is the priority to suppression as a side effect of the treatment plan. The prevent complications potentially leading to death. Weight loss (option 4) may occur as a nurse determines that the client understands the risk result of anorexia and can be managed. of complications when he states that the most life‐ threatening complication is which of the following?
| Use the process of elimination to determine the greatest risk. |
613 A female client comes to the clinic for a cancer Correct answer: 1 For cancers in females, by order of occurrence, breast cancer ranks first, followed by lung and screening and preventive education. When educating colorectal cancers. Options 2, 3, and 4 are incorrect. the client, the nurse would include information about which of the following cancers found in females, in order of occurrence?
| This question requires knowledge of the most common cancers. |
614 A client receiving chemotherapy is experiencing mild Correct answer: 1 Stomatitis is inflammation of the oral mucosa, a common side effect of chemotherapy. stomatitis. Based on an understanding of this Management includes teaching client to use a soft toothbrush, rinse mouth with plain water or complication, the nurse will teach the client which of saline, and to avoid irritants such as mouthwashes, peroxide, and hot liquids (options 2, 3, and the following measures? 4).
| Use the process of elimination to outline mouth care. |
615 The nurse is caring for a client receiving Correct answer: 2 Profound malnutrition can result from loss of appetite related to nausea and vomiting, and chemotherapy who is experiencing severe nausea, the concurrent stress of the body fighting cancer. Options 1, 3, and 4 do not completely vomiting, and anorexia, and has not eaten in 2 days. address the issue of altered nutrition. Which of the following is the priority nursing diagnosis for this client?
| This question requires knowledge of the priorities associated with chemotherapy. |
616 The nurse is counseling a group of college students Correct answer: 3 Dietary habits that reduce the risk of cancer include consuming cruciferous vegetables such as about healthy lifestyle choices to reduce the risk of cauliflower, broccoli, and cabbage (option 3) and high‐fiber foods (option 4), avoiding nitrates cancer. The students demonstrate understanding of in prepared meats (option 1), and limiting intake of red meats. Pineapple and other tropical instruction related to nutritional practices when they fruits offer no special protection against cancer (option 2). identify that eating which of the following foods may reduce the risk of cancer?
| This question requires knowledge of the foods thought to play a role in cancer prevention. |
617 The nurse is caring for a client hospitalized to receive Correct answer: 2 The client receiving a bone marrow transplant must first undergo an immunosuppressive a bone marrow transplant. When establishing the plan phase before receiving donor marrow. This places the client at extreme high risk for infection. of care, the nurse determines that the client is at Options 1, 3, and 4 are potential complications but are not immediately life‐threatening. highest risk for which of the following?
| Use the process of elimination to determine the correct answer. |
618 An elderly male client undergoing treatment for Correct answer: 3 In the elderly and immunocompromised client, even a slight elevation of temperature may cancer is being cared for at home by the family. After indicate an infection and must be investigated and treated immediately. Options 1, 2, and 4 teaching potential complications associated with are appropriate actions to be taken by the family. chemotherapy and radiation, the nurse concludes the family requires further education when one of them makes which of the following statements?
| Use the process of elimination to determine the correct answer. |
619 The nurse working in the outpatient oncology clinic Correct answer: 2 A white coating on the tongue may indicate thrush (Candida). Infections should be identified determines that the client receiving radiation therapy and treated immediately to avoid complications. The client may experience a very dry mouth to the neck has understood the teaching instructions (xerostomia), but it is not a serious complication (option 1). Dental floss should be avoided if about follow‐up care when the client calls to report the client has thrombocytopenia secondary to bone marrow suppression (option 3). which of the following? Mouthwash should be avoided to reduce irritation to the mouth (option 4); however, options 3 and 4 do not relate to follow‐up care.
| Use the process of elimination to differentiate normal versus abnormal results. |
620 The nurse is conducting an in‐service to a group of Correct answer: 4 Superior vena cava syndrome is usually caused by the growth of a lung or mediastinal tumor, nurses about oncologic emergencies in clients with not by metastasis (option 1). The tumor obstructs the flow of blood to the right atrium, leading cancer. Using the diagram shown, the nurse would to facial and arm edema. Superior vena cava syndrome occurs as a late‐stage manifestation explain which of the following about the complication (option 3), and option 4 is incorrect. of superior vena cava syndrome?
| This question requires knowledge of superior vena cava syndrome. |
621 The nurse is preparing a care plan for a client with Correct answer: 2 Clients with polycythemia experience satiety and fullness resulting from hepatomegaly and polycythemia vera on ways to maintain nutrition. The splenomegaly. Frequent, small meals will help maintain adequate nutrition. Foods rich in iron nurse should include which of the following in the are not appropriate because there is an increase in erythrocytes in this condition. Spicy foods plan? will increase the gastrointestinal symptoms, which also include dyspepsia and increased gastric secretions.
| The core issue of the question is knowledge of an appropriate diet for a client with polycythemia. Use nursing knowledge and the process of elimination to make a selection. |
622 A client with thrombocytopenia presents to the Correct answer: 2 Clients with thrombocytopenia have decreased platelet counts below 150,000/uL. The usual primary care center. During assessment, the nurse presenting manifestation of this condition is the appearance of petechiae, purpura, and notices petechiae. The nurse interprets that which ecchymosis. The other laboratory values will not explain the petechiae or support the presence laboratory result best supports the presence of a of a clotting disorder. disorder of hemostasis?
| The core issue of the question is the laboratory test results that best indicate a disorder of abnormal clotting ability. Use nursing knowledge and the process of elimination to make a selection. |
623 A nurse is admitting a client with a diagnosis of Correct answer: 2 Clients with aplastic anemia usually experience pancytopenia (decreased erythrocytes, aplastic anemia. Which of the following is the best leukocytes, and platelets). The client with this type of hypoplastic anemia should therefore room for the nurse to assign this client? have a room where reverse isolation can be instituted. The client with aplastic anemia is susceptible to infection as well as hemorrhage. Respiratory isolation requiring negative airflow (option 2) is not necessary in the care of clients with aplastic anemia.
| The core issue of the question is knowledge of the effects of aplastic anemia on the immune system, which then requires special intervention to prevent infection. Use nursing knowledge and the process of elimination to make a selection. |
4.‐ A semiprivate room with a client whose diagnosis is thrombophlebitis. | |
624 The nurse is reviewing laboratory results of a client Correct answer: 4 In DIC, there is abnormal initiation and formation of blood clots. As clots are formed and then suspected of having disseminated intravascular begin to dissolve, more end products of fibrinogen and fibrin are also formed. These are called coagulopathy (DIC). The nurse looks to the results of fibrin degradation products or fibrin split products. Although the PT and PTT are prolonged and which test as the more specific marker for DIC? the platelet count is reduced in DIC, they could also be a result of other coagulation disturbances. Only the increase in FDP would occur because of the widespread accelerated clotting present in DIC.
| The core issue of the question is knowledge of trends in changes of laboratory data in DIC. Use nursing knowledge and the process of elimination to make a selection. |
625 The husband of a client with disseminated Correct answer: 3 Initially, there is an enhanced coagulation mechanism with resulting increase in fibrin and intravascular coagulopathy (DIC) approaches the nurse platelet deposition in arterioles and capillaries in DIC, resulting in thrombosis. Although it and expresses his concern that his wife might be remains controversial in DIC, the use of heparin is aimed at preventing the formation of getting the wrong medication after he was told that additional thrombotic clots that further complicate the bleeding disorder. the client was receiving heparin. What is the nurse’s best response?
| The core issue of the question is the possible role of heparin in the management of DIC. Use nursing knowledge and the process of elimination to make a selection. |
626 The nurse is administering oral care on a client with Correct answer: 3 Clients with DIC should be protected from injury that will result in bleeding. An oral swab is disseminated intravascular coagulopathy (DIC). Which least likely to cause tissue injury to the oral cavity during the performance of oral care. of the following is the most appropriate for this client? Mouthwashes containing alcohol should be avoided because they may cause discomfort and because they tend to dry the mucous membranes. Toothbrushes may be used only if they are soft‐bristled, but a swab or toothette is the best option.
| The core issue of the question is appropriate methods of providing mouth care to a client with stomatitis. Use nursing knowledge and the process of elimination to make a selection. |
627 A client with stomatitis and on neutropenic Correct answer: 3 Hydrogen peroxide is not a good choice of mouthwash solution in clients with stomatitis precautions is ordered to have mouthwashes every 2 because it tends to dry the oral mucosa and further aggravate the discomfort. The other three hours. Which of the following choices of mouthwash options are acceptable mouthwash solutions; diphenhydramine (Benadryl) or Maalox may also solutions should the nurse question if ordered by the be used. physician?
| The core issue of the question is a mouth care product that would be irritating to a client with stomatitis. Use nursing knowledge and the process of elimination to make a selection. |
628 A client with acute myelogenous leukemia (AML) is Correct answer: 2 Harvested bone marrow is infused into the recipient intravenously. The transplantation is scheduled for a bone marrow transplant (BMT). In usually preceded by chemotherapy and radiation therapy. During this period and up to when teaching the client’s family about BMT, which of the the client’s response to the transplantation has been successful, nursing interventions should following statements by the nurse is best? focus on prevention of infection.
| The core issue of the question is knowledge of bone marrow transplantation as a treatment method. Use nursing knowledge and the process of elimination to make a selection. |
‐ “The client will be brought to the radiology department to transplant the marrow.” ‐ “A large bore needle will be inserted into the client’s bone marrow where the donor marrow will be infused.” | |
629 A client has undergone a lymph node biopsy. The Correct answer: 1 Histological isolation of Reed‐Sternberg cells in lymph node biopsy examination is a diagnostic nurse anticipates that the report will reveal which of feature of Hodgkin’s lymphoma. Philadelphia chromosome is attributed to chronic the following if the client has Hodgkin’s lymphoma? myelogenous leukemia. Viruses are much smaller than can be visualized with cytology.
| The core issue of the question is knowledge of characteristic findings in the diagnosis of lymphoma. Use nursing knowledge and the process of elimination to make a selection. |
630 During physical examination, the nurse finds a Correct answer: 2 A nontender and moveable cervical node may suggest the presence of malignancy and even nontender, moveable cervical node on a client. The lymphoma. Palpable nodes do not confirm the diagnosis of a malignancy. Biopsy and nurse makes which interpretation of this finding? histological examination will aid in interpreting the significance of enlarged nodes.
| The core issue of the question is the ability to interpret assessment data related to lymph nodes. Use nursing knowledge and the process of elimination to make a selection. |
631 A client with thrombocytopenia has an order for Correct answer: 2 Clients with thrombocytopenia are at risk for altered cerebral perfusion from bleeding. Since neurological checks every hour. The nurse explains to a a neurologic assessment can assist in determining the presence of occult bleeding in the curious nursing assistant that the reason for frequent cerebrovascular system, it is a necessary nursing intervention to include in the care of these neurological assessment is which of the following? clients.
| The core issue of the question is knowledge that a low platelet increases risk of bleeding, which includes the risk of intracranial bleeding. Use this nursing knowledge and the process of elimination to make a selection. |
632 During assessment, the nurse notices a systolic Correct answer: 1 In anemia, there is a decrease in the viscosity of blood as a result of a decrease in the number murmur on a client with anemia. The nurse interprets of red blood cells. The increase in cardiac output and flow are compensatory mechanisms that this finding correlates with which of the because of the decrease in the quantity of hemoglobin in circulating blood. following?
| The core issue of the question is knowledge of how pathophysiology relates to assessment data in a client with anemia. Use nursing knowledge and the process of elimination to make a selection. |
633 A client with anemia has a nursing diagnosis of Correct answer: 1 Activity intolerance in clients with anemia results from the imbalance between oxygen activity intolerance. Which of the following nursing demand and supply. Activities should be planned to intersperse activity with periods of rest to interventions should the nurse implement? decrease hypoxemic episodes and to decrease tissue demand for oxygen. All the other options are appropriate interventions for a client with anemia, but they do not relate to the nursing diagnosis of activity intolerance.
| The core issue of the question is knowledge that anemia causes fatigue and that measures to prevent fatigue need to be incorporated in the plan of care. Use this knowledge and the process of elimination to make a selection. |
634 The nurse is teaching a client with hemophilia A about Correct answer: 2 Clients with hemophilia should be taught to participate in noncontact sports and to avoid any home management. Which of the following should the activities that increase the risk of tissue injury and bleeding. Clients with hemophilia should nurse include in the teaching plan? never use aspirin because of the risk of bleeding. Joint pain may be caused by hemarthrosis (bleeding in the joints), a situation in which the client should be taught to seek medical care immediately. Iron‐rich foods are not appropriate in clients with this condition unless there is an accompanying anemia.
| The core issue of the question is an appropriate element of client teaching with hemophilia. Use concepts related to prevention of bleeding and the process of elimination to make a selection. |
635 The nurse is obtaining a health history on a client who Correct answer: 2 Aplastic anemia may be congenital or acquired, but most cases do not have an identifiable is admitted with a diagnosis of “rule out aplastic etiology. It is known that aplastic anemia may follow exposure to chemicals (e.g., Benzene, anemia.” Considering the diagnosis, which of the DDT) or drugs (chloramphenicol, sulfonamides). It is therefore important that the nurse obtain following data is most important for the nurse to elicit exposure history on this client. during the interview?
| The core issue of the question is knowledge of the possible etiologies of aplastic anemia. Use knowledge about the possible causes of this disorder and the process of elimination to make a selection. |
636 The nurse is teaching family members about Correct answer: 4 A client with neutropenia has a compromised immune system and is predisposed to precautions to take in visiting a client who has infections. Fresh fruits and flowers in the client’s room are not allowed because they tend to neutropenia. Which of the following instructions would harbor bacteria. All the other options are reasonable instructions to be given to visitors as well not be included by the nurse in the discussion? as health care personnel who come in contact with the client.
| The core issue of the question is knowledge of the components of neutropenic precautions. The wording of the question tells you the correct answer is an incorrect statement. Use nursing knowledge and the process of elimination to make a selection. |
637 A client has a platelet count of Correct answer: 1 A platelet count below 20,000 indicates that the client is at risk for bleeding and necessitates 18,000/mm<sup>3</sup>. What the avoidance of activities and interventions that increase this risk. Nursing interventions such intervention must the nurse include in the plan of as the use of intramuscular injections, rectal temperatures, and shaving with a razor are care? activities that predispose the client to further injury. Reverse isolation is not appropriate for this client unless there is accompanying evidence of neutropenia.
| The core issue of the question is appropriate interpretation of a low platelet count and interpreting the appropriate intervention to protect the client from bleeding. Use nursing knowledge and the process of elimination to make a selection. |
638 A nurse is assisting a physician with a bone marrow Correct answer: 1 Application of direct pressure and pressure dressing should follow the withdrawal of the aspiration on a client with anemia. After the aspiration needle after a bone marrow aspiration. If the client has thrombocytopenia, pressure procedure, the nurse should take which of the should be applied on the site for at least 3 to 5 minutes or until hemostasis has been achieved. following actions? The other options are not appropriate following a bone marrow aspiration. Continued observation of the site should be made to assure that there is no bleeding.
| The core issue of the question is knowledge of specific care following bone marrow aspiration that will prevent complications of the procedure. Use nursing knowledge and the process of elimination to make a selection. |
639 The white blood cell (WBC) differential on a client Correct answer: 2 A shift to the left indicates an increase in immature neutrophils or bands. An increase in the indicates a shift to the left. The nurse makes which of number of bands indicates an increase in the production of granulocytes, which could be a the following accurate interpretations of this report? compensatory mechanism in response to infection.
| The core issue of the question is the ability to make an accurate interpretation of findings on a laboratory report of WBC count and morphology. Use nursing knowledge and the process of elimination to make a selection. |
640 A client with iron‐deficiency anemia is scheduled for a Correct answer: 3 The morphologic characteristics of RBCs in iron‐deficiency anemia is microcytic and complete blood count. The nurse anticipates that the hypochromic. Vitamin B<sub>12</sub> anemia produces a macrocytic and report will show which characteristics of the red blood normochromic morphology. Aplastic anemia, hemolysis, and acute blood loss will reveal RBCs cells (RBCs)? with normocytic and normochromic characteristics.
| The core issue of the question is the pathophysiological changes of RBCs in specific anemias. Use nursing knowledge and the process of elimination to make a selection. |
641 The nurse in the hematology clinic is reviewing Correct answer: 2 Reticulocytes are immature RBCs. An increase in the number of reticulocytes indicates the laboratory findings for a 2‐year‐old being treated for body is producing new RBCs. Iron intake does not indicate an improvement in anemia status, anemia. Which finding is the best indication that the and the child with anemia is not cyanotic but pale. An increase in activity is hard to measure treatment is successful? subjectively and would be a late finding.
| The core issue of the question is the ability to evaluate outcomes of care for a client with anemia. Use nursing knowledge and the process of elimination to make a selection. |
642 A pregnant woman tells the nurse that she has a Correct answer: 3 Sickle cell is inherited as an autosomal recessive disorder. Both parents must carry the family history of sickle cell anemia and is afraid her defective gene. The other statements are factually incorrect. baby will be born with the disease. The nurse would provide which information during a discussion with this client?
| The core issue of the question is the ability to teach a client about genetics as they relate to sickle cell disease. Use nursing knowledge and the process of elimination to make a selection. |
643 A young child who was admitted to the hospital with Correct answer: 1 Hemophilia is characterized by a deficiency in one or more clotting factors, while ITP is a a bleeding disorder has been diagnosed with idiopathic platelet disorder. Because the child with ITP is not deficient in clotting factors, this treatment thrombocytopenic purpura (ITP). The mother of the would not be beneficial. child says to the nurse, “I have a friend who has a son with hemophilia. When he bleeds, they give him a ‘factor,’ which they keep in their home refrigerator. Can we just give my child this factor?” Which of the following is the best response by the nurse?
| The core issue of the question is an understanding of the differences between hemophilia and bleeding disorders caused by platelet problems. Use nursing knowledge and the process of elimination to make a selection. |
644 The nurse has admitted a child newly diagnosed with Correct answer: 2 Clients with anemia will experience activity intolerance with even the simplest activities of anemia of unknown origin. Which of the following daily living. There is no vaso‐occlusion or abnormal platelet count with anemia. There may be nursing diagnoses is most appropriate? insufficient cardiac output, but it will not be related to platelet count. There is no information in the question to indicate that the anemia is secondary to poor diet.
| The core issue of the question is knowledge of typical pathophysiology and client assessments in anemia and using this information to identify the most important nursing diagnosis. Use nursing knowledge about anemia and the process of elimination to make a selection. |
645 The nurse is caring for a child with beta‐thalassemia Correct answer: 3 Frequent blood transfusion will lead to an overload of iron in the body. This iron is stored in who has received many blood transfusions. The nurse tissues and organs and is called hemosiderosis. Blood transfusions do not lower the white assesses for which of the following as a priority at this count or cause petechiae or hemoglobin in the bile. time?
| The core issue of the question is identification of a complication of chronic blood transfusion therapy. Note the critical word 'priority' in the question, which tells you the correct option is the condition of most importance at the current time. Use nursing knowledge of thalassemia and the process of elimination to make a selection. |
646 A client with Vitamin B<sub>12</sub> Correct answer: 2, 4, 5 Clients with nutritional anemias require dietary sources of folic acid, such as green, leafy deficiency needs to increase dietary intake of foods vegetables; fish; citrus fruits; yeast; dried beans; grains; nuts; and liver. Apples and carrots are that are good sources of this vitamin. The nurse not as rich in folic acid as the other food sources listed. recommends that the client increase intake of which of the following foods? Select all that apply.
| The core issue of the question is knowledge of foods that are rich in Vitamin B<sub>12</sub>. Use nursing knowledge and the process of elimination to make your selections. |
647 An 8‐year‐old is being admitted in vaso‐occlusive Correct answer: 3 A vaso‐occlusive crisis is a very painful experience and proactive assessment and pain control crisis. When creating the care plan, to which of the are imperative. Although oxygen will help in pain control by preventing more sickling, high following actions should the nurse give priority? concentrations are not needed. Acid‐base balance is not routinely disrupted in a vaso‐occlusive crisis. Factor VIII replacement therapy is utilized with hemophilia.
| First eliminate activities not related to sickle cell then determine priority of those remaining options. |
648 The nurse is completing discharge teaching for the Correct answer: 3 Bed rest without immobilizing and elevating the affected area is inappropriate to stop the parents of a child newly diagnosed with hemophilia B. bleeding. If coagulants are needed, they would be applied topically, not orally. Gentian violet Which measures should the nurse include when will have no effect upon the bleeding. Warm compresses will increase the blood flow, making discussing the control of minor bleeding episodes? it harder to stop the bleeding.
| Two of the responses include elevating the body part. That should be an indication that one of those responses is the correct answer. Knowledge of the care of bleeding episodes will help to eliminate the incorrect options. |
649 The elementary school nurse is called to the gym Correct answer: 2 As the child's safety is the first concern, walking to the office would not be safe at this time. when a child with a history of thalassemia complains of Sitting immediately will decrease the chance of falling. The urgent safety requirements take dizziness during physical education class. The priority precedence over physical assessment. The information given does not indicate the need for action of the nurse should be to: ammonia at this time to prevent fainting.
| Knowledge of the care of the child with thalassemia to prevent injury will aid in choosing the correct answer. Consider which activity provides the highest level of safe practice. |
650 The nurse in the pediatrician's office receives a call Correct answer: 2 A change in the stools to a black, tarry color is an expected side effect of the medication and from the mother of a child who was started on iron a sign that the medication is working properly. It is not a symptom of the anemia, a sign that supplements approximately two weeks ago. The the dose is high, or that the child is experiencing bleeding. mother is panicked because this morning her daughter's stools were a black, tarry color. The nursing response would be:
| The core concept in this stem is the addition of an oral iron preparation. Consider common side effects of this drug in making a selection. |
651 A child with sickle cell anemia is admitted to the Correct answer: 3 Children with sickle cell anemia develop sickling of the red cells when exposed to low oxygen hospital. The nurse anticipates that laboratory tension; this means that the cells become crescent‐shaped. Polycythemia is not a finding with evaluation of the client's red blood cells would reveal: sickle cell anemia (option 1). Hematopoiesis is the formation of new cells, which occurs at a rapid rate in children with sickle cell anemia due to the rapid destruction of RBCs; however, this process is not visible under the laboratory microscope. Children with sickle cell anemia have adequate iron stores so the cells are not pale in color (option 4).
| Compare each of the responses with what is known about sickle cell anemia. The fact that it is an anemia eliminates polycythemia. |
652 During a routine visit to the hematology clinic, the Correct answer: 3 All of the other activities hold a risk of bleeding, whether it is from physical contact or stress parents of a 10‐year‐old with hemophilia voice their on joints and muscles. Swimming is considered ideal for clients with hemophilia as it provides concerns as to their son's physical activity in relation to necessary activity with minimal risk for bleeding and injuries. the potential for injury and bleeding. Physical activities the nurse can suggest include:
| Consider which of the activities provides the least risk of physical contact. |
653 An 11‐month‐old girl who has iron‐deficiency anemia Correct answer: 2 Children with iron‐deficiency anemia are more susceptible to infection related to microcytosis is hospitalized for a respiratory infection. Her mother and limited bone marrow function. The information in the other options is incorrect and does voices confusion as to the connection between her not address the connection between the conditions of anemia and infection. daughter's anemia and her infection. The nurse would explain that children with iron‐deficiency anemia are:
| Option 4 can be eliminated as it does not relate to iron deficiency anemia. Then choose if there is a relationship between infections and anemia in a child with both conditions. |
4.‐ At risk for respiratory infections because of the inability to produce leukocytes. | |
654 A 16‐month‐old toddler is admitted to the hospital for Correct answer: 3 A child with hemoglobin and hematocrit levels this low would already have a heart that is severe anemia secondary to insufficient iron intake. under stress. A sudden increase in blood volume can cause congestive heart failure. All of The child's hemoglobin is 8 grams/dL and hematocrit is these assessments are appropriate, but pulse rate is the priority assessment. 23%. A blood transfusion is ordered. During the transfusion, the nurse’s priority in assessment would be:
| Monitoring vital signs and allergic reactions are common nursing activities during a blood transfusion. Recognize that the blood values listed are very low and consider which of the vital signs would take precedence in this situation. |
655 A 2‐year‐old has just been diagnosed with sickle cell Correct answer: 3 The child with sickle cell anemia does not need more iron supplements than the regular child. anemia. The nurse has explained the diagnosis to the The cause of the child's anemia is fragile red blood cells, which are broken down more rapidly family as well as provided information about the than the normal cell. Children with sickle cell anemia must guard against low oxygen tension in treatment plan. The nurse will anticipate the need for the air. For that reason, they should not fly in unpressurized planes. Because infections additional teaching when the mother makes which increase the basal metabolic rate (BMR) and oxygen requirements, infections often precipitate statement? a crisis. During a sickling crisis, the child will need hydration therapy and pain management to break the sickling cycle.
| Knowledge of the management of sickle cell disease will help to choose the correct answers. The wording of the question indicates the need for an option that would be inappropriate for a child with sickle cell anemia. |
656 The nurse is caring for a child in the ICU being treated Correct answer: 4 The PTT is used to monitor heparin therapy, as it is an indicator of the clot formation for disseminated intravascular coagulopathy (DIC). pathways. Bilirubin levels are elevated with liver disease or excessive RBC damage. A client Which of the following laboratory tests will take with DIC will likely need to have platelets and hemoglobin and hematocrit monitored, but they priority for the nurse when monitoring the efficacy of are not indicators of effectiveness of heparin therapy. the heparin therapy?
| Heparin therapy reduces blood clotting. Consider which lab results relate to blood clotting. |
657 A 2‐year‐old with hemophilia is being discharged, and Correct answer: 4 It is not possible for parents of a hemophiliac to prevent a bleeding episode, no matter how the nurse is completing discharge teaching with his careful they are. The nurse should reinforce this information along with methods for parents. Which of the following statements by the decreasing the chance of an injury that will lead to a bleeding episode. The other statements parents indicates they require further teaching all indicate an appropriate understanding of hemophilia. regarding hemophilia?
| Consider which statement would be inappropriate for a child with hemophilia. |
658 The parents of a child with sickle cell anemia are Correct answer: 2 Sickle cell anemia is an autosomal recessive condition. Therefore, if both parents have the asking for information about future pregnancies. trait, each pregnancy carries a 25% (1 in 4) risk that the child will have the disease. Neither parent has sickle cell anemia. The nurse would provide them with the information that any future pregnancies will have a:
| Since neither parent has the disease, they are both carriers, meaning that they each have only 1 gene with the disorder. Affected children must have both genes affected. There are four combinations of the parents’ genes. |
659 The nurse is working with the family of an 8‐month‐ Correct answer: 3 Many infants with nutritional anemia rely primarily on the milk/formula for dietary intake and old infant who has severe nutritional anemia. In refuse solid foods. When the milk/formula is limited, the child will be more willing to take solid providing dietary recommendations, the nurse should foods. Cow’s milk is a poor source of iron. Peanuts and unsweetened chocolates are sources of instruct the family to: iron but are not appropriate for this child’s diet.
| Nutritional anemia means a diet with inadequate iron. Milk is a poor source of iron. |
660 A child is being admitted to the unit with thalassemia Correct answer: 2 Blood transfusions are utilized in order to maintain normal hemoglobin (HGB) levels. There is major. In preparing client assignments, the charge an excess of iron secondary to repeated transfusions, and, thus, iron supplements will not be nurse wants to assign a nurse to this child who can: necessary. The other therapies are inappropriate for the child with thalassemia major.
| Because of fragile blood cells, the child will be anemic and require blood. Use this information to select the correct response. |
661 The nurse is caring for a child who is being treated for Correct answer: 3 Appropriate oxygenation is not possible when there is significant loss of blood volume. extensive bleeding in the Emergency Department. The Replacing the blood volume is critical to saving the child’s life, and it is imperative that source and extent of bleeding are being determined as replacement occurs prior to any of the listed nursing actions. the nurse is trying to control the bleeding. The nurse places highest priority on which of the following activities?
| Use Maslow’s hierarchy of needs to answer the question. The physiological intervention would be the first concern, as the child is actively bleeding. |
662 The nurse is working with the family of a toddler who Correct answer: 4 Folic acid potentiates the removal of iron from ferritin, which makes it further available for is being treated for iron‐deficiency anemia. In teaching heme production. The synthesis of albumin, blood proteins, fibrinogen, and hemoglobin is dietary considerations, the nurse will instruct the dependent upon the presence of proteins. None of the others are involved in building red family to add sources of iron and: blood cells (RBCs).
| Iron deficiency anemia refers to inadequate hemoglobin and RBCs. Look for nutritional additions that will help develop RBCs. |
663 The elementary school nurse is assessing and giving Correct answer: 2 The nurse would elevate the leg above the level of the heart to reduce bleeding. Aspirin or initial care to a client with hemophilia who has aspirin‐like products such as ibuprofen interfere with the clotting mechanisms. During active significant pain in his knee. The nurse suspects bleeds, the joint should be immobilized. Warm soaks would promote bleeding; ice packs hemarthrosis. As the nurse waits for his caregiver to should be used instead. arrive, the nurse would take which of the following actions?
| Since hemarthrosis is bleeding into the joints, look for strategies to reduce bleeding. |
664 The nurse has admitted a 2‐year‐old in vaso‐occlusive Correct answer: 1 Such positioning indicates the likelihood of abdominal pain. Nausea or constipation does not crisis. As the nurse starts the initial assessment, the generally cause a child to self‐position as described. Fear related to the hospitalization would child insists upon lying in bed, on her side, with her be common in a child this age. However, if this were the case, it is more likely the child would knees flexed to the abdomen. The nurse decides to seek refuge in the arms of one of her parents. further assess the child for the presence of which of the following?
| The core concept is preferred positioning and why a child chooses a particular position. |
665 The 10‐year‐old client in the Emergency Department Correct answer: 4 Such lab results indicate severe anemia. Fatigue results when the oxygen‐carrying capacity of has complete blood count (CBC) results that include RBCs is impaired and cellular hypoxia is present. Fatigue can be diminished and oxygen hemoglobin (Hgb) of 8 grams/dL and hematocrit (Hct) depletion limited when the client’s energy is conserved. There will be an increased oxygen of 24%. The nurse determines that, based on requirement and increased fatigue with increased mobility. Increasing general hydration laboratory results, which nursing action has the without transfusing RBCs will not positively affect the anemic state. Skin integrity is not a high highest priority? priority at this point. Although improving nutrition is appropriate, the response would not be immediate. The priority activity would be conserving energy and reducing cardiac stress.
| First recognize that these lab values are very low. Therefore, the child’s oxygen‐carrying ability is reduced. Select the option that relates to oxygenation. |
666 The nurse is caring for a child diagnosed with Correct answer: 3 Chelation therapy works to rid the body of excess iron storage that results from the frequent thalassemia major who is receiving her first chelation transfusions required to maintain adequate hemoglobin. Chelation will have no effect upon therapy. The nurse reinforces teaching about chelation hypoxia or bleeding. Sickling of RBCs does not occur with thalassemia. therapy with the parents by stating that it is done to:
| First determine the pathology of thalassemia as well as its treatment. Then determine which response relates to this knowledge. |
667 The nurse has completed some child and family Correct answer: 4 A child diagnosed with thalassemia who will receive multiple transfusions throughout life will education for a child diagnosed with thalassemia. The need chelation therapy for excessive iron stores. An iron supplement would be inappropriate medical plan of treatment includes blood transfusions in this child. when the anemia reaches a severe point. Which statement by the parents indicates a need for further education? 1.‐ “Because of the anemia, my child will need extra rest periods.” | Consider which statements are appropriate for a child with thalassemia and eliminate those. That will leave only the response that indicates the need for more education. |
‐ “My child inherited this disorder from both of us.” ‐ “We should be alert to periods when our child seems paler than usual.” ‐ “My child needs an iron supplement.” | |
668 The nursing assistant is setting up a hospital room Correct answer: 1 Rectal temperatures can traumatize the fragile rectal mucosa, leading to bleeding, and should preparing to admit a child with disseminated be avoided. The vital signs will need to be measured on a regular basis. An intravenous start kit intravascular coagulopathy (DIC). Which item would is appropriate as the child will need plasma and blood products. A bedpan will be needed if the the nurse remove from the set‐up? child is on bed rest. Urinary catheters are avoided if possible.
| This child is at risk for bleeding. Consider equipment that might trigger a hemorrhage and eliminate that from the environment. |
669 At a hemophilia camp, several children with injuries Correct answer: 3 All of the injuries require nursing care; however, the child with the head injury has a arrive at the clinic at the same time. When prioritizing potentially life‐threatening injury. care for the children, the child who requires the most immediate care from the nurse is the child with:
| Consider which injury has the greatest opportunity for serious injury. Knowledge of the care of medical emergencies and prioritizing care of injuries will aid in choosing the correct answer. |
670 A 14‐year‐old boy with sickle cell anemia is admitted Correct answer: 1 RBCs sickle under conditions where low oxygen concentrations exist; therefore, administering with severe pain in his abdomen and legs. He asks why oxygen will prevent additional sickling. The oxygen has no effect on the oxygen‐carrying the doctor ordered oxygen when he is not having any capacity of RBCs. It will not have an effect on development of respiratory complications. It will problems breathing. The nurse will be most accurate in not decrease the potential for infection. stating that the main therapeutic benefit of oxygen is to:
| Knowledge of the underlying rationale for the management of sickle cell disease will help to answer the question correctly. |
671 The nurse is administering a liquid iron preparation to Correct answer: 3 Iron preparations should be taken through a straw in order to prevent staining the teeth. a 3‐year‐old with iron deficiency anemia. It will be While it is best to give toddlers choices in the hospital setting, the other options are not most appropriate to: appropriate as iron is best absorbed on an empty stomach.
| While option 4 might be true, the stem describes a difficult situation for the family. Consider the difference the options are offering. |
672 The nurse is admitting a child newly diagnosed with Correct answer: 3 In an acute care setting such as a hospital and with a potentially life‐threatening disease such disseminated intravascular coagulopathy (DIC). as DIC, the family members may need help with coping with the stress they are feeling. This Although the physician has explained the plan of care stress often interferes with communication. A patient response by the nurse with repetition of to the family members, they continue to ask about information will allow the family to absorb the information. The other options are not helpful. each nursing activity. The nurse notes that the family seems unable to comprehend the answers. The nurse would most appropriately: 1.‐ Notify the doctor because the family seems to have a comprehension problem. | While option 4 is appropriate, the stem describes a difficult situation for the family. Option 3 responds to this difficult situation. |
‐ Ask the doctor to write down the information for the family. ‐ Recognize that the family is under stress and continue to answer their questions. ‐ Assume they are a family with English as a second language (ESL). | |
673 The nurse is administering factor VIII to a child with Correct answer: 2 Factor VIII concentrate is a blood product. Fluid volume overload is an unlikely concern, as hemophilia. The nurse should observe for which the factor will be given in a comparatively small volume of fluid. There is no greater a chance potential complication during the infusion? of emboli formation with administration of factor than with any other IV preparation. Concern as to contracting AIDS from administration of a blood product is a long‐term concern related to multiple administrations. It is not a concern during the actual administration of the factor.
| Since factor is a blood product, it carries many of the same potential complications as most other blood products. |
674 The clinic nurse has organized a class for several Correct answer: 1, 2, 5 There are 3 common problems seen in sickle cell anemia. First there is the anemia crisis. This parents of children newly diagnosed with sickle cell is a continuous problem for the sickle cell patient. Sequestration crisis occurs primarily in disease. The nurse explains that problems with the children under 6 and in older children and adults who have functioning spleens. The crisis is a disease can include: (Select all that apply.) pooling of the blood causing circulatory collapse. The third crisis is the vaso‐occlusive crisis.
| Consider the definition of the terms. That will eliminate two choices, polycythemia and hemochromatosis. Knowledge of the etiology and pathophysiology of sickle cell disease will help to aid in the final selection. |
675 Which of the following statements should be included Correct answer: 3 Anemia does occur easily in infancy, and infants have limited stores of iron. The first solid when teaching the parents of a 7‐month‐old infant food offered to infants is often cereal, which is an excellent source of iron. All infants do not about preventing anemia? require iron supplements; it is preferable that the iron comes from dietary intake.
| Knowledge of infant iron needs and nutrition will help you to choose the correct answer. Options 2 and 3 are opposites, indicating one is probably the right answer. |
676 A child with an alteration in platelet function has Correct answer: 4 Alterations in platelet function necessitate treating a break in the skin’s integrity as you would been receiving intravenous fluids for two days. The an arterial stick—apply pressure for 5 minutes or more. The goal of treatment is to apply nurse is discontinuing the peripheral IV. The nurse pressure long enough that the defective clotting mechanism will have time to form a clot. Steri‐ should: strips would not close the wound adequately, and restricting arm movement will not assist in the initial formation of a clot.
| Platelet dysfunction refers to clotting problems. Two options refer to measures to prevent bleeding; one of these is the correct response. Knowledge of the care of the client with decreased platelets and IV care will help to make a final selection. |
677 A client with anemia has a hemoglobin of 6.5 g/dL. Correct answer: 3 Cerebral tissue hypoxia is commonly associated with dizziness. The greatest potential risk to The client is experiencing symptoms of cerebral tissue the client with dizziness is injury, especially with changes in position. Planning for periods of hypoxia. Which of the following nursing interventions rest and consuming energy are important with someone with anemia because of his or her would be the most important in providing care? fatigue level, but most important is safety.
| Recall that safety, here prevention of falls, is a key priority. |
‐ Assisting in ambulation to the bathroom ‐ Checking temperature of water prior to bathing | |
678 The nurse observing manifestations of complications Correct answer: 1 Major complications of multiple myeloma include bone pain, hypercalcemia, renal failure, in a client with multiple myeloma concludes that they anemia, and impaired immune responses that are a result of bone marrow involvement and are caused by which of the following? the systemic effects of substances secreted by the malignant plasma cells.
| This question requires knowledge of the pathophysiology of myeloma, also notice, odd man out, the correct answer is longer. |
679 A client has a diagnosis of myelodysplastic syndrome. Correct answer: 2 Myelodysplastic syndromes often progress to acute myelogenous leukemia. They are often The nurse planning care keeps in mind that this refractory to treatment and are associated with a poor prognosis. They are not hereditary and condition: are often referred to as pre‐leukemia.
| This question requires knowledge of myelodysplastic syndrome. |
680 A 40‐year‐old client is referred to a hematologist with Correct answer: 4 Bone marrow biopsy and aspirate is the only definitive diagnosis of AML. The presence of a tentative diagnosis of acute myelogenous leukemia Auer rods is diagnostic for AML. The presence of leukemic cells in the spinal fluid is more (AML). The client's only complaint is fatigue. Which of common in acute lymphocytic leukemia (ALL). Uric acid and lactic dehydrogenase levels may the following diagnostic tests would the nurse expect be elevated in AML, but this is not diagnostic for the disease. to be ordered first?
| Recall that the biopsy procedure is usually definitive for a malignant process. |
681 Which of the following dietary recommendations Correct answer: 1 Option 1 contains foods high in protein, folic acid, iron, and Vitamin should the nurse make to increase the intake of B<sub>12</sub> that are needed for erythropoiesis. Options 2 and 4 contain lesser nutrients needed for erythropoiesis? amounts.
| This question requires knowledge of high‐iron foods. |
682 A client has an order for an iron preparation to be Correct answer: 2 IM administration is recommended over intravenous infusion because of the potential for given by the parenteral route. The nurse plans to give anaphylaxis. The gluteal muscle is the best route for administration since the muscle is large the medication by which of the following routes? and highly vascular. The Z‐track method is preferable to prevent tattooing of the skin and tissue necrosis caused by infiltration into the subcutaneous tissue.
| This question requires knowledge of the basics of parenteral medications. |
683 In the normal blood clotting cycle, the final formation Correct answer: 3 Platelet aggregation forms a platelet plug at the site of bleeding, but fibrin reinforces the of a clot will occur at which of the following times? platelet plug. The absence of clotting factors impairs the coagulation response and the capacity to form a stable clot.
| This question requires knowledge of the clotting cycle. |
684 The client is given radioactive Vitamin Correct answer: 3 Pernicious anemia is caused by the body's inability to absorb Vitamin B<sub>12</sub> in water for a Schilling B<sub>12</sub>. This is caused by a lack of intrinsic factor in the gastric juices. The test. The nurse instructs the client that the primary Schilling test helps diagnose pernicious anemia by determining the client's ability to absorb purpose of this test is to measure his body's ability to Vitamin B<sub>12</sub>. do which of the following?
| This question requires knowledge of pernicious anemia. |
685 A client with a history of sickle cell anemia begins to Correct answer: 1 Pain from sickle cell crisis is primarily related to obstructed capillary blood flow causing complain of pain. The nurse expects that the client is ischemia and possible tissue infarction. While dehydration often causes increased viscosity, the going into sickle cell crisis because of the pain, which primary cause of pain is vasoocclusion of the blood vessels from sickled red blood cells. signals which of the following?
| This question requires knowledge of the pathophysiology of sickle cell anemia. |
686 The nurse diligently assesses a leukemic client with Correct answer: 3 The client with neutropenia is unable to mount an inflammatory response. Fever is usually neutropenia for signs of infection, anticipating that the first sign of infection. Options 1, 2, and 4 are all true, but they explain why the neutropenic they will be absent or muted because: client is at greater risk for infection.
| This question requires knowledge of leukemia. |
687 A client with anemia due to chemotherapy has a Correct answer: 1 Cerebral tissue hypoxia is commonly associated with dizziness. Recognition of cerebral hemoglobin of 7.0 g/dL. Which of the following hypoxia is critical since the body will attempt to shunt oxygenated blood to vital organs. complaints would be indicative of tissue hypoxia related to anemia?
| This question requires knowledge of the sequelae of cerebral hypoxia. |
688 A client's medical record indicates that a client has a Correct answer: 3 Approximately 95 percent of clients with CML are Philadelphia chromosome‐positive. This positive Philadelphia chromosome. The nurse plans represents a translocation of the long arms of chromosomes 9 and 22. care for which of the following disorders?
| This question requires knowledge of the listed disorders. |
‐ Chronic myelogenous leukemia (CML) ‐ Chronic lymphocytic leukemia (CLL) | |
689 A nurse caring for a client who has experienced a Correct answer: 1 The risk for hemorrhage is of greatest risk since a large‐bore needle is used to perform the bone marrow biopsy and aspiration should assess for biopsy and aspiration. Many of these clients often have an altered clotting capability. While which of the following as the most serious the risk of infection is also a consideration, the procedure is performed under sterile complication? conditions and is less of a concern than hemorrhage.
| Recall that the greatest risk of many invasive procedures is bleeding. |
690 For the client diagnosed with iron‐deficiency anemia, Correct answer: 3 Organ meats such as liver are a good source of iron as well as green, leafy vegetables and egg the nurse should recommend an increased intake of yolks. Whole grain breads also contain iron, however not in as high a quantity as organ meats. which of the following foods?
| This question requires knowledge of high‐iron foods. |
691 The nurse would interpret that a client is most Correct answer: 3 Options 1, 2, and 4 relate to the white blood cells. A platelet count below 20,000 increases severely at risk for bleeding when which of the the client's risk for severe bleeding because of reduced platelets to assist in the clotting following is noted on laboratory test results? cascade to form a clot.
| This question requires knowledge of the function of platelets. |
692 The common feature of leukemia is which of the Correct answer: 2 Leukemia is a result of erratic production of white blood cells by the bone marrow, which following? replace normal marrow components. It can arise from both a lymphatic and a myelocytic etiology. White blood cells are often immature and incapable of performing their expected function(s).
| This question requires knowledge of leukemia. |
693 The nurse would teach a client with sickle cell trait Correct answer: 4 Sickle cell trait is generally a mild condition that produces few if any manifestations. These that he or she: clients are considered carriers of the disease and require genetic counseling to determine presence of the hemoglobin S. Certain stressors result in a sickle cell crisis.
| This question requires knowledge of sickle cell trait. |
694 A client with pancytopenia enters the clinic with Correct answer: 1 All of the medications in the first option can affect platelet aggregation and should be avoided excess ecchymosis. The client should be cautioned to in a client with bleeding tendencies. A thorough review of all medications taken at home avoid which of the following, since medications can should be done whenever clients are issued new medications. alter platelet function? 1.‐ Acetylsalicylic acid (aspirin), digitalis (Lanoxin), and quinidine sulfate (Quinidex) | Recognize that aspirin should be considered with caution on NCLEX<sup>®</sup> questions. |
‐ Milk of magnesia, heparin, and quinidine sulfate (Quinidex) ‐ Senna (Senokot), furosemide (Lasix), and phenytoin (Dilantin) ‐ Acetaminophen (Tylenol), sulfonamides, and penicillins | |
695 The nurse would explain to a client newly diagnosed Correct answer: 2 Hemophilia is a group of hereditary clotting factor disorders characterized by prolonged with hemophilia that it is a hereditary bleeding coagulation time that results in prolonged and sometimes excessive bleeding. It is an X‐linked disorder that: recessive characteristic transmitted by female carriers, displayed almost exclusively in males often resulting in spontaneous bleeding into the joints resulting in hemoarthrosis with joint deformity and potential disability. Option 3 is a specific form of hemophilia, von Willebrand's Disease. Option 4 is pernicious anemia.
| This question requires knowledge of hemophilia. |
696 A client enters the clinic with complaints of a sore Correct answer: 1 Assessment findings in pernicious anemia include a smooth, red, beefy tongue; altered mouth. Physical assessment reveals a beefy red sensations such as numbness or tingling in the extremities; and difficulty identifying one's tongue. These symptoms are most suggestive of which position in space, which may progress to difficulty with balance and spinal cord damage. of the following disorders?
| This question requires knowledge of the listed diagnoses. |
697 In preparation for discharge, which of the following Correct answer: 4 Palpitation is a significant change in the condition of the client and may be indicative of statements would indicate that a client does not have progressing anemia. If palpitations occur, the client should report the symptom to the a full understanding about her diagnosis of anemia? physician. Options 1, 2, and 3 are all positive responses to client teaching.
| This question requires knowledge of the function of hypoxia in leading to dysrhythmias. |
698 Pain in a client with multiple myeloma commonly Correct answer: 3 Lytic bone lesions are the most common cause of pain in multiple myeloma. Although the results from which of the following? marrow may be involved, this is not a common cause of pain. Neural infiltrations and intestinal obstructions are not common in multiple myeloma.
| This question requires knowledge of multiple myeloma. |
699 Which of the following characteristics is associated Correct answer: 2 Chronic leukemia progresses over a period of years rather than weeks. It occurs primarily with chronic leukemia? between ages of 50 and 70.
| Use the process of elimination to determine the answer most associated with chronic, rather than acute, leukemia. |
700 Sickle‐shaped hemoglobin in sickle cell anemia may Correct answer: 4 Hemoglobin S in sickle cell anemia causes the red blood cells to elongate, become rigid, and cause which of the following that leads to assume a crescent sickle shape causing the cells to clump together, obstruct capillary blood manifestations of the disease? flow in small vessels causing ischemia, decreased organ perfusion, and possible tissue infarction.
| This question requires knowledge of sickle cell disease. |
701 The nurse discusses hypercalcemia and diuretic use Correct answer: 2 Increased calcium excretion in the urine from the diuretics decreases calcium levels. All other with the client diagnosed with multiple myeloma. measures increase calcium. Which of the following mechanisms described by the nurse explains the depletion of calcium from the body?
| This question requires knowledge of the function of kidneys in excreting many body minerals and substances. |
702 A client asks the nurse why Vitamin Correct answer: 3 Vitamin B<sub>12</sub> deficiency anemia causes the production of abnormally B<sub>12</sub> is important for red blood large red blood cells. This deficiency causes the red blood cell to be irregular and oval, rather cell formation. The nurse responds with the knowledge than the biconcave shape of a normal red blood cell. This shape predisposes the cells to a that Vitamin B<sub>12</sub> deficiency shorter lifespan. In this type of anemia, there is an increase in the MCV (option 1) and a causes which of the following changes in the red blood decrease in the hemoglobin (option 2). Option 4 is characteristic of iron deficiency anemia. cell?
| This question requires knowledge of the pathophysiology of pernicious anemia. |
703 A nurse is discussing the role of hypoxia in red blood Correct answer: 2 Hypoxia stimulates the release of the hormone erythropoietin from the kidney and increases cell (RBC) production. Which of the following bone marrow production of RBCs. The hemoglobin does not increase in size with hypoxia. statements is accurate? Reticulocytes mature in 24 to 48 hours, and their maturation is not influenced by hypoxia.
| This question requires knowledge of the pathophysiology of hypoxia. |
704 A client with a hemolytic blood disorder presents to Correct answer: 1 Lysis of red blood cells cause retention of iron and other substances including bilirubin to the primary care center with jaundice. The nurse accumulate in plasma. The accumulation of bilirubin causes jaundice. Although hepatitis explains to the client that the jaundice is most likely infection may also be the reason for jaundice, the hemolytic anemia present most likely caused caused by which of the following? the jaundice to occur.
| This question requires knowledge of the pathophysiology associated with jaundice. |
705 A nurse is evaluating the response of a patient with Correct answer: 4 The reticulocyte (immature RBC) count is an indicator that new red blood cells are being anemia to therapy. Which of the following laboratory produced by the bone marrow. An increase in the reticulocyte count in an anemic client tests would the nurse look to that best reflects bone indicates that the bone marrow is responding to the decrease in RBCs. The hematocrit count marrow production of red blood cells? measures the percent of RBCs in the total blood volume. Hemoglobin is not directly linked to bone marrow activity. Serum ferritin levels reflect available iron stores.
| This question requires knowledge of bone marrow function. |
706 The nurse who is assessing a client with iron‐ Correct answer: 3 Iron‐deficiency anemia is manifested clinically by glossitis or inflammation of the tongue. deficiency anemia notes that the tongue is inflamed. After pallor, this is the second most frequent manifestation of this type of anemia. Cheilitis or The nurse documents this observation as: inflammation of the lips is another finding in this type of anemia. Achlorhydria, or the absence of free hydrochloric acid is a manifestation of a depressed parietal cell function and is associated with Vitamin B<sub>12</sub> deficiency anemia. Cheilosis is cracking of lips at the angles of the mouth.
| This question requires knowledge of the definitions for the listed terms. |
707 The nurse is teaching a client about measures to Correct answer: 2 An acidic environment (such as in the presence of Vitamin C) enhances the absorption of iron. increase the absorption of the prescribed oral iron Administering the medication with meals binds the iron with food and interferes with its preparation. Which of the following instructions would absorption. the nurse give to the client?
| This question requires knowledge of orange juice’s effect on iron absorption. |
708 Which of the following statements made by a client Correct answer: 1 The client on an oral iron preparation should be taught to expect stools to turn black because with iron‐deficiency anemia indicates the need for of the excessive iron that is eliminated. All the other choices should be included in the teaching further teaching? plan. The health care practitioner may change the iron preparation prescribed to the client if gastrointestinal symptoms become intolerable.
| Use the process of elimination to determine the correct answer. |
709 Which of the following food choices made by a client Correct answer: 4 Liver and muscle meats are excellent sources of iron. The other foods are also beneficial for with anemia best indicates that the teaching regarding the dietary management of anemia, but option 4 is specifically an excellent source of iron. selection of foods high in iron has been successful?
| This question requires knowledge of dietary sources of iron. |
710 A nurse is preparing to administer an intramuscular Correct answer: 1 When administering an iron preparation intramuscularly, it should be given deep in the (IM) dose of iron to a client with anemia. Which of the muscle. The site should be in the upper outer quadrant of the buttocks utilizing the Z tract following precautions should the nurse take? technique. No more than 2 mL of the solution should be administered and the length of the needle should be 2 to 3 inches. The area should not be massaged after the injection.
| Recognize that this question reinforces basic psychomotor skills. |
711 The nurse would assess a client who has undergone a Correct answer: 2 Resection of the distal ileum results in the impaired absorption of Vitamin small bowel resection of the ileum for development of B<sub>12</sub>. The other cause of Vitamin B<sub>12</sub> deficiency which type of anemia? is the loss of intrinsic factor‐secreting surfaces that are normally secreted by parietal cells.
| This question requires knowledge of pernicious anemia. |
712 A client has an order for a test to determine if Correct answer: 2 Schilling test involves the administration of radioactive Vitamin B<sub>12</sub>. pernicious anemia is present. For which of the Increased absorption of Vitamin B<sub>12</sub> when intrinsic factor is given following tests should the nurse schedule the client? parenterally is indicative of pernicious anemia.
| This question requires knowledge of the diagnostic tests for pernicious anemia. |
713 The nurse is assessing a group of clients and identifies Correct answer: 2 Individuals who are chronically undernourished including the elderly, alcoholics, substance which of the following as being at high risk for the abusers; and those with high metabolic requirements and on total parenteral nutrition are also development of folic acid deficiency anemia? at risk for folic acid deficiency anemia. Alcoholics are particularly at risk because alcohol interferes with folate metabolism.
| This question requires knowledge of risk factors. |
714 Which of the following questions during the data‐ Correct answer: 3 The differentiating symptom of Vitamin B<sub>12</sub> and folic acid deficiency gathering phase is important for the nurse to ask a anemia is the absence of neurologic symptoms such as numbness and altered proprioception client suspected of having a nutritional anemia? in folic acid deficiency anemia. The gastrointestinal symptoms of cheilosis, glossitis, and diarrhea are present in both forms of nutritional anemia although usually more severe in folic acid deficiency anemia.
| This question requires knowledge of key assessments. |
715 A couple seeks genetic counseling for sickle cell. Both Correct answer: 2 Sickle cell disease is an autosomal recessive genetic disorder where the individual is have sickle cell traits. The nurse understands that the homozygous for the abnormal hemoglobin. If both parents have sickle cell traits, there is a 25 chances of the couple's offspring developing sickle cell percent chance that each pregnancy will produce a child with the disease. disease with each pregnancy is: | This question requires knowledge of genetic transmission. |
‐ None of the offspring will develop sickle cell disease. ‐ Twenty‐five percent of their offspring will develop sickle cell disease. ‐ Fifty percent of their offspring will develop sickle cell disease. ‐ All their children will have sickle cell traits, but none will have the disease. | |
716 The nurse is preparing a teaching plan for a client Correct answer: 2 Clients with sickle cell disease have scarred spleen resulting in decreased ability to fight off with sickle cell disease about ways to prevent crisis infection. The individual with sickle cell disease must seek early treatment of infections. episodes. Which of the following should be Pneumonia is one of the most common infections affecting individuals with sickle cell disease. emphasized to prevent sickle cell crisis? Option 4 is inaccurate in that vigorous physical activity should be avoided.
| Use the process of elimination to determine the correct answer. |
717 Which of the following nursing diagnoses should Correct answer: 1 The client in sickle‐cell crisis will have pain related to ischemic tissue injury resulting from receive the highest priority in a client with sickle cell obstruction of blood flow. The other diagnoses, although important, are of lesser priority than crisis? the nursing diagnosis of pain.
| Use Maslow’s hierarchy of needs to reinforce the priority of comfort. |
718 The nurse is reviewing laboratory results of a client. Correct answer: 2 Clients with sickle cell disease express 80 to 90 percent of HbS. Clients with sickle cell trait Which of the following laboratory results indicate that usually express less than 40 percent of HbS. The hematocrit of clients with sickle cell disease is a client has sickle cell disease? usually decreased between 20 and 30 percent.
| This question requires knowledge of the listed values. |
719 Which of the following statements made by a client Correct answer: 1 Clients with sickle cell trait may also develop sickle cell crisis although their symptoms are with sickle cell trait indicates the need for further often milder since only about 30 percent of their hemoglobin is abnormal. The other options teaching? are rational lifestyle adjustments the client makes in order to deal with the disease.
| Use the process of elimination to determine the correct answer. |
720 Which of the following nursing observations indicate Correct answer: 1 An observation for the client in sickle cell crisis that indicates a positive outcome includes that a positive outcome for a client with sickle cell stable vital signs, an oral intake of 3,000 mL/day, and verbalization of pain control. Maintaining crisis has been met? an adequate intake is essential to maintain blood flow, decrease pain, and prevent renal damage.
| Use the process of elimination to determine the correct answer. Recall that appropriate urine output is 30 mL per hour. |
721 The nurse is preparing a teaching plan for a client Correct answer: 2 Clients with polycythemia experience satiety and fullness resulting from hepatomegaly and with polycythemia vera on ways to maintain nutrition. splenomegaly. Frequent small meal servings will help maintain adequate nutrition. Foods rich The nurse should include in the plan which of the in iron are not appropriate since there is an increase in erythrocytes in this condition. Spicy following? foods will increase the gastrointestinal symptoms, which also include dyspepsia and increased gastric secretions.
| Use the process of elimination to determine the correct answer. |
722 A client with thrombocytopenia presents to the Correct answer: 2 Clients with thrombocytopenia have decreased platelet counts below 150,000/uL. The usual primary care center. During assessment, the nurse presenting manifestation of this condition is the appearance of petechiae, purpura, and notices petechiae. The nurse anticipates that which of ecchymoses. The other laboratory values will not explain the petechiae or support the the following laboratory results would support the presence of a hemostatic disorder. presence of a hemostatic disorder?
| This question requires memorization of selected laboratory values. |
723 A nurse is admitting a client with a diagnosis of Correct answer: 2 Clients with aplastic anemia usually experience pancytopenia (decreased erythrocytes, aplastic anemia. Which of the following is the best leukocytes, and platelets). The client with this type of hypoplastic anemia should therefore room for the nurse to assign this client? have a room where reverse isolation can be instituted. The client with aplastic anemia is susceptible to infection as well as hemorrhage. Respiratory isolation requiring negative airflow (option 2) is not necessary in the care of clients with aplastic anemia.
| Recall that when a client is at risk for infection, answer with the option that provides the greatest amount of privacy and protection. |
724 The nurse evaluates the laboratory results of a client Correct answer: 4 In DIC, there is abnormal initiation and formation of blood clots. As clots are formed, more suspected of having DIC (disseminated intravascular end products of fibrinogen and fibrin are also formed. These are called fibrin degradation coagulopathy). Which of the following laboratory tests products or fibrin split products. Although the PT and PTT are prolonged and the platelet count is a more specific marker for diagnosing DIC? is reduced in DIC, they could also be a result of other coagulation disturbances.
| This question requires knowledge of the listed lab tests. |
725 The husband of a client with disseminated Correct answer: 3 Initially there is an enhanced coagulation mechanism with resulting increase in fibrin and intravascular coagulopathy (DIC) approaches the nurse platelet deposition in arterioles and capillaries in DIC. This results in thrombosis. Although it and expresses his concern that his wife might be remains controversial in DIC, the use of heparin is aimed at preventing the formation of further getting the wrong medication after he was told that thrombotic clots that further complicates the bleeding disorder. the client was receiving heparin. The nurse's best response is:
| This question reinforces sound teaching and communication principles. |
726 A client is brought to the emergency department Correct answer: 4 Heat stroke is a life‐threatening situation, and interventions to cool the body must be after being found with a body temperature of 106°F. accomplished quickly. Removing the clothing and cooling by evaporation is the most effective The client is unresponsive, hypotensive, and intervention to accomplish cooling quickly. A complete health assessment and documentation tachypneic. A medical diagnosis of heat stroke is made. are important but after the cooling process has begun. Core body temperatures will be utilized What would be the nurse's priority intervention in the to monitor effectiveness of treatment. care of this client?
| Recognize that bringing the client's temperature down is the priority and should be accomplished before completing the other options. |
727 A client is being weaned from a ventilator. Arterial Correct answer: 3 Evaluate the pH first to determine acidosis or alkalosis. Then evaluate blood gases drawn prior to extubation reveal: pH 7.32; PaCO<sub>2</sub> as the metabolic component. The client's pH &lt; 7.35 and PaO<sub>2</sub> 90 mmHg; PaCO<sub>2</sub> > 45mm Hg indicate a state of respiratory acidosis and PaCO<sub>2</sub> 56 mmHg; indicates that the client is not tolerating the weaning process. Metabolic alkalosis would be HCO<sub>3</sub><sup>‐</sup> indicated by a pH > 7.45 and a HCO<sub>3</sub><sup>‐</sup> > 26 mEq/L. The nurse calls the physician with these 26 mEq/L. Respiratory alkalosis would be seen in a client with a pH > 7.45 with a results because they indicate that the client is in a PCO<sub>2</sub> &lt; 35 mmHg. Metabolic acidosis would be indicated in a state of: client with a pH &lt; 7.35 with a HCO<sub>3</sub><sup>‐</sup> &lt; 21 mEq/L.
| This question requires knowledge of respiratory acidosis and ABGs. |
728 A client presents to the emergency department with Correct answer: 3 The primary assessment includes the assessment of airway, breathing, circulation, and a stab wound to the neck. During the primary disability. Although a decrease in neuromuscular function and loss of rectal tone would assessment of this client who sustained a traumatic indicate neurological damage, they would not be included in the primary assessment. Neck injury, the nurse would assess for which of the range of motion would not be included until cervical spines have been cleared. following?
| Differentiate the primary and secondary assessment. Select the distractor that is specifically part of the primary assessment. |
729 A client is scheduled for biopsy to rule out lymphoma. Correct answer: 1 Histological isolation of Reed‐Sternberg cells in lymph node biopsy examination is a diagnostic The nurse understands that a biopsy finding suggestive feature of Hodgkin's lymphoma. Philadelphia chromosome is attributed to chronic of a lymphoma is the presence of: myelogenous leukemia.
| This question requires knowledge of lymphoma. |
730 The nurse prepares a client for insertion of a Correct answer: 3 A pulmonary artery catheter will provide information about the function of the left ventricle pulmonary artery catheter. Preprocedural teaching for when the balloon is wedged. The pulmonary artery catheter does not directly determine the this client will include which of the following cardiac output and cardiac index. An arterial line is used to directly monitor the client's arterial statements? pressure.
| Eliminate options that are inconsistent with the direct actions of a pulmonary artery catheter. |
‐ "The catheter will provide information about your left ventricular function." ‐ "The catheter will provide information about your cardiac index." | |
731 In order to communicate effectively with a client who Correct answer: 4 The best method to improve communication with the client is to eliminate background noises has sensorineural hearing loss caused by presbycusis, that could interfere with hearing. The client should be approached from the front so as not to the nurse should do which of the following to improve frighten him or her. The nurse should use normal pronunciation of words, speak in normal communication with the client? tones, and refrain from shouting, which is demeaning and not helpful.
| The core issue of the question is the appropriate strategy for communicating with a client who is hearing impaired. Recall that clients rely on visual cues and can benefit from reduced background noise to aid in answering the question. |
732 A client has completed a full course of antibiotics for Correct answer: 4 Ear pain is the most common symptom of otitis media that motivates clients to seek health acute otitis media. The nurse conducting a follow‐up care; secondary or associated symptoms include fever, nausea and vomiting, dizziness, and assessment determines whether medication therapy hearing impairment. was effective by questioning the client about relief from which of the following most common presenting symptoms?
| The critical words in the question are most common, which tell you it is necessary to prioritize the options in terms of the frequency of their occurrence. Use nursing knowledge and the process of elimination to make this selection. |
733 A client has undergone myringotomy. The nurse Correct answer: 2 Myringotomy is a surgical procedure that perforates the tympanic membrane to allow working in an ambulatory surgery center would drainage from the middle ear. Postoperatively, the client should avoid getting water into the instruct the client to avoid which of the following ear canal, which could potentially enter the middle ear. The other activities are not risks to the activities while healing is occurring? client.
| The core issue of the question is identification of activities that could be harmful to the client while healing is occurring after surgery. Recall that it is necessary to avoid getting the surgical area wet to make the appropriate selection. |
734 A 68‐year‐old female client tells the ambulatory care Correct answer: 1 Presbycusis is the most common form of sensorineural hearing loss in older adults. Otalgia is nurse during a routine visit that she has recently an earache; otitis externa is infection in the external auditory canal and can occur in clients of noticed a decline in her ability to hear. The nurse any age. Meniere’s disease is an inner ear disorder that primarily affects middle‐aged adults. documents this information on the client’s health record, suspecting that this client most likely is exhibiting which of the following?
| The core issue of the question is the ability to identify age‐related changes in hearing in an older adult. Use nursing knowledge and the process of elimination to make a selection. |
735 After a client has undergone outpatient surgery for a Correct answer: 2 The client should avoid lying on the operative side following eye surgery in order to minimize right eye cataract removal, the nurse teaches the edema and intraocular pressure. Options 3 and 4 pose no risk to the client. Option 1 is not a client to avoid which of the following when the client problem given the information in the question. Some clients with severe visual impairment or gets home? other health problems may need assistance to move about in the environment.
| The core issue of the question is client teaching about safe and unsafe activities following cataract surgery. Recall that it is important to avoid positions in which gravity can lead to increased edema in order to make the correct selection. |
‐ Picking up objects that are at waist level ‐ Washing dishes in the sink | |
736 A client has hearing loss that is characterized by Correct answer: 1 When hearing loss is characterized by distortion of sounds, amplification of sound is of little distortion of sounds that are heard. The client help because it only increases the intensity of distorted sounds. The other options are questions the nurse about the benefits of obtaining a incorrect. hearing aid. The nurse would include in a response that a hearing aid will have which of the following effects for this client?
| The core issue of the question is the ability to correlate the types of hearing loss that can be improved with the use of a hearing aid. To do this, reflect on the types of hearing loss and the likely effect of a hearing aid for that condition. Use nursing knowledge and the process of elimination to make a selection. |
737 A client reports ongoing problems with vertigo. The Correct answer: 4 Vertigo, tinnitus, hearing loss, and a sense of fullness in the ear are classic symptoms of nurse should question the client about which of the Meniere’s disease. Nystagmus also occurs with acute attacks. Headache, double vision, and following accompanying manifestations to determine pain are not part of this clinical picture. Purulent drainage suggests infection. whether the client has developed Meniere’s disease?
| The core issue of the question is identification of signs and symptoms of Meniere’s disease. Recall that this is a disorder of the inner ear, thus making symptoms related to balance as well as hearing important to identify. Use nursing knowledge and the process of elimination to make a selection. |
738 The nurse prepares to initiate client teaching for Correct answer: 1 Antivertigo and antiemetic medications, such as meclizine, are used to control symptoms which of the following medications commonly used to associated with Meniere’s disease. Diuretics are used between acute attacks to reduce the treat a client diagnosed with Meniere’s disease? volume of endolymph and prevent attacks. Glucocorticoids (options 2), beta‐blockers (option 4), and analgesics (option 3) are not part of an effective treatment plan.
| The core issue of the question is the ability to anticipate medications that will be effective in relieving the symptoms associated with Meniere’s disease. To answer correctly, it is necessary to have a core body of knowledge related to pharmacology. Use nursing knowledge and the process of elimination to make a selection. |
739 A client with glaucoma has been prescribed Correct answer: 3 Pilocarpine is a miotic agent, which constricts the pupil and thereby stimulates the ciliary pilocarpine (Pilocar). The nurse explaining the use of muscles to pull on the trabecular meshwork surrounding the canal of Schlemm, which this medication would state that it is useful because it increases the flow of aqueous humor and decreases intraocular pressure. works by:
| The core issue of the question is the ability to anticipate medications that will be effective in relieving the symptoms associated with glaucoma. To answer correctly, it is necessary to have a core body of knowledge related to pharmacology. Use nursing knowledge and the process of elimination to make a selection. |
740 The initial nursing intervention for a client in the Correct answer: 4 The immediate priority for clients with chemical burns is flushing the affected eye with emergency department who suffered a chemical burn copious amounts of normal saline or water. Evaluation of visual acuity is an appropriate to the eyes is to: intervention after flushing. Analgesics, with the exception of topical anesthesia, are not indicated. Antibiotics may be administered after the initial actions have been taken.
| The critical word in the question is initial, which tells you that more than one or all options could be correct and that it is necessary to prioritize the most important or immediate action needed. Whenever there is an injury involving chemicals, the priority action is to remove the offending substance. |
4.‐ Irrigate the eyes with 0.9% saline solution or water. | |
741 The nurse is caring for a client who is in the recovery Correct answer: 2 Clients with retinal detachment frequently report flashing lights and loss of vision, commonly area following cataract surgery. The nurse would ask described as a veil or curtain being drawn across the eye. Retinal detachment is not associated the client about which of the following manifestations with increased lacrimation or tearing (option 1), eye pain (option 3), or change in ocular that would indicate onset of retinal detachment as a movements (option 4). postoperative complication?
| The core issue of the question is knowledge of complications of cataract surgery. Use nursing knowledge and the process of elimination to make a selection. |
742 A client who was diagnosed with chronic open‐angle Correct answer: 3 Medications that end in ‐olol are beta‐adrenergic blocking agents. When taken as ophthalmic glaucoma has been started on medication therapy with preparations, they can produce systemic effects such as bradycardia, hypotension, and timolol maleate (Timoptic). The nurse assesses for bronchospasm. Beta‐adrenergic blockers act as CNS depressants and may also be used to treat which of the following possible adverse systemic anxiety, but this does not relate to the issue of this question, which is glaucoma. responses to the drug?
| The core issue of the question is the ability to identify adverse effects of medication used to treat glaucoma. To answer correctly, it is necessary to have a core body of knowledge related to pharmacology. Use nursing knowledge and the process of elimination to make a selection. |
743 The daughter of an elderly client diagnosed with dry Correct answer: 1 Atrophic or dry macular degeneration results from atrophy and degeneration of the outer macular degeneration asks the nurse to explain this layer of the retina. In exudative or wet macular degeneration, blood leaks into the subretinal disorder. In formulating a response, the nurse would space and scar tissue gradually forms. The resulting loss of vision occurs rapidly and is more include information that this condition is characterized profound. Exudative macular degeneration accounts for 90% of all cases of legal blindness. by which of the following?
| The core issue of the question is the ability to discriminate correct information to be used in teaching clients and/or families about disease processes. Thus, to answer this question, it is necessary to understand the two types of macular degeneration and how they present in terms of symptoms. Use nursing knowledge and the process of elimination to make a selection. |
744 The nurse is evaluating the effectiveness of Correct answer: 1 Scleral buckling is correctly described in option 1. It is used in conjunction with laser preoperative teaching done for a client who needs to photocoagulation or cryothermy to achieve the best results. Option 2 defines pneumatic have repair of a detached retina. The nurse evaluates retinopexy. Options 3 and 4 are incorrect. that the client understands the procedure if the client indicates that scleral buckling involves
| The core issue of the question is evaluation of a client’s understanding of a surgical procedure. To select correctly, it is necessary to be able to identify how the surgery will be performed. Use nursing knowledge and the process of elimination to make a selection. |
745 The nurse would take which of the following actions Correct answer: 3 Prevention or reduction of intraocular pressure (that may accompany blunt trauma to the when the client first comes into the emergency eye) can be accomplished by the use of semi‐Fowler’s position and administration of a department with blunt trauma to the eye? carbonic anhydrase inhibitor, such as acetazolamide (Diamox). Semi‐Fowler’s position also reduces edema formation at the site of injury when compared to lying flat. Constriction of the pupil with miotics is not indicated. Blunt trauma does not cause loss of intraocular contents; and no foreign body is present. 1.‐ Irrigate the eye to remove foreign substances. | The core issue of the question is identification of a correct action in the treatment of eye trauma. Recall that injuries are characterized by formation of edema at the site, and therefore early actions for any injury may involve proper positioning of the client to reduce edema formation. |
‐ Administer miotics. ‐ Place the client in semi‐Fowler’s position. ‐ Prevent loss of intraocular contents. | |
746 Which of the following statements indicates that the Correct answer: 1 The client should avoid activities that raise intraocular pressure, such as bending over. The client has understood home care instructions following client should sleep on the nonoperative side. Activities involving the eyes are done at the cataract surgery? advice of the surgeon. Typically, an eye shield is used at night, and dark protective glasses are worn during the day.
| The core issue of the question is the ability to evaluate client understanding of postoperative instructions following cataract surgery. Evaluate each of the options in terms of the truth of the statement, since the question contains the critical word understood. |
747 The nurse is assessing a client’s hearing using the Correct answer: 4 To perform the Weber test, the nurse places a vibrating tuning fork on the midline vertex of Weber test. The nurse documents the client’s result as the client’s head. The sound should normally be heard equally in both ears. Sound that normal if the client reports which of the following after lateralizes to one side indicates either conductive hearing loss on that side or sensorineural placement of the vibrating tuning fork on the midline hearing loss on the opposite side. vertex of his head?
| The core issue of the question is the ability to correctly analyze results of physical assessment techniques. Use nursing knowledge and the process of elimination to make a selection. |
748 The nurse has an order to do an otic irrigation to the Correct answer: 4 The client should lie on the affected side following the irrigation to allow gravity to further left ear of an assigned client. The nurse implements assist in draining the ear canal. The irrigant should be directed along the wall of the external this procedure correctly by doing which of the canal, not the center (which could damage the tympanic membrane). Usually, 50 to 70 mL of following? solution are used, according to the size of the syringe used for the procedure. A single cotton ball is placed loosely into the external meatus to absorb any remaining irrigant after the procedure.
| The core issue of the question is the ability to correctly perform the nursing procedure of eye irrigation. Use nursing knowledge and the process of elimination to make a selection. |
749 Which of the following would be least useful for the Correct answer: 1 Warm compresses, not cold, should be used as part of the management of conjunctivitis. nurse to use as part of the collaborative management Warm compresses help relieve discomfort and reduce inflammation by increasing circulation of a client who has conjunctivitis? to the area. The other options contain items that are part of the standard collaborative management for conjunctivitis. Dark sunglasses are helpful in reducing photophobia.
| The critical words in the stem of the question are least useful, indicating that the correct answer is an option that is either incorrect or lowest priority. Use nursing knowledge about care of the client with conjunctivitis and the process of elimination to make a selection. |
750 The nurse who is administering an ophthalmic Correct answer: 2 The nurse should apply pressure to the inner canthus (nasolacrimal duct) during and for at medication to a client would do which of the following least 30 seconds following instillation, according to agency procedure. Doing so will help as correct procedure? prevent systemic absorption of the medication. The medication should be dropped into the lower conjunctival sac. The eye should not be rubbed after instillation of the medication. The nurse should wait from 1 to 5 minutes between drops, depending on the medication and manufacturer’s recommendations.
| The core issue of the question is the ability to administer eye medication correctly. Use nursing knowledge and the process of elimination to make a selection. |
‐ Rub the eye with a cotton ball after instillation. ‐ Wait 10 seconds between drops. | |
751 The nurse has administered a dose of antibiotic Correct answer: 1 It is appropriate to comfort the child following a painful procedure. Option 1 provides support intramuscularly to a 5‐year‐old client with tonsillitis. and comfort. By fulfilling the child’s request, the nurse allows the child to regain some control The child cries for a Band‐Aid over the injection site. over the situation. It is not appropriate to argue with the child. Which of the following is the best nursing action?
| The core issue of the question is the best response to a 5‐year‐old client who is responding to a painful procedure such as an injection. Eliminate options 2 and 3 because these communications do not meet the client’s immediate need for comfort following the injection, and option 4 is incorrect because the issue is a psychological/comfort issue, not a question of stopping bleeding. |
752 Which is the most appropriate nursing intervention Correct answer: 4 A febrile infant is at risk for fluid volume deficit resulting from larger‐than‐normal insensible when caring for an infant with acute otitis media and fluid losses and decreased fluid intake. It is contraindicated to sponge with cool water or add 102.7 degrees F. fever? blankets. Intake of solid food is less important than preventing dehydration. ‐ Provide sponging with cool water to reduce fever. ‐ Encourage the baby’s intake of solids to maintain adequate caloric intake. ‐ Swaddle the baby in layers of blankets to promote comfort and prevent chills. ‐ Offer fluids frequently to prevent dehydration. | The core issue of the question is an appropriate nursing intervention when a client has hyperthermia. Use nursing knowledge and the process of elimination to make a selection. |
753 Which of the following would be the most Correct answer: 3 A symptom of pharyngitis is sore throat and difficult swallowing, which could lead to the appropriate nursing diagnosis for a child with refusal to drink. Thus, risk for deficient fluid volume is an appropriate diagnosis. Option 2 pharyngitis? would apply when the client cannot clear secretions from the respiratory tract, which is not applicable to this question. Options 1 and 4 are not pertinent to this health problem.
| The core issue of the question is the ability to determine priority concerns for a client with pharyngitis by selecting a nursing diagnosis. Whenever the airway is involved, first think about the ABCs and then think about hydration/food intake as the next priority of physiological needs using Maslow’s hierarchy. |
754 The nurse recommends a humidified atmosphere for Correct answer: 4 Humidifying the air can prevent dry mucous membranes and recurrence of epistaxis. Other a child with recurrent epistaxis. When questioned by options do not correctly identify the benefit of humidity for a client with recurrent nosebleed. the parent, the nurse explains that which of the following is a benefit of humidity for the child?
| The core issue of the question is an understanding of the rationale for nursing actions for a client with recurrent epistaxis. Use nursing knowledge and the process of elimination to make a selection. |
755 A 9‐month‐old infant has been diagnosed with Correct answer: 2 Children of this age cannot understand the necessity of cooperating with medication conjunctivitis. An antibiotic ointment has been administration. Mummying the child reduces the risk of injury from the ointment tip and prescribed. In teaching the mother to administer this promotes adequate dosing. Applying ointment to the eyes of a sleeping child would increase drug, the nurse would recommend which of the the child’s fears. The ointment is instilled in the lower conjunctival sac, not on the lids. following?
| The core issue of the question is identification of correct procedure for administering an ophthalmic medication to a child. Use nursing knowledge of this basic procedure and the process of elimination to make a selection. |
756 The nurse would provide which of the following Correct answer: 2, 3 Typical instructions after fluorescein angiography include increased fluid intake to aid in dye instructions to the client after fluorescein excretion. The client should know that the dye causes temporary skin discoloration in the angiography? Select all that apply. injected area and temporary green discoloration of urine that resolves when dye is fully excreted. The client should avoid sunlight or other bright light sources for several days until pupil dilation returns to normal. Although the client should rest after the procedure, it is not necessary to lie down with eyes closed for 12 hours. Headache and blurred vision are not expected.
| The core issue of the question is knowledge of postprocedure instructions to a client following fluorescein dye eye examination. Use nursing knowledge and general concepts of procedures that utilize contrast dye to make your selections. |
757 The nurse is teaching a mother to administer Correct answer: 2 Pulling the pinna down and back straightens the auditory canal of an infant, permitting the eardrops to her infant. After teaching is complete, the instillation of eardrops. Pulling the pinna up and back is the proper method for straightening nurse will know the mother understands when the the canal of an adult client. The other options are incorrect. mother is observed administering ear drops by pulling the pinna of the ear:
| Although the stem of the question is quite long, the basic question is: “To open the ear canal of the infant, how do you move the pinna?” |
758 The nurse is assessing the ears of a 4‐year‐old client. Correct answer: 4 A normal tympanic membrane is pearly gray and mobile when a puff of air is applied to it Upon examination, the tympanic membrane is mobile using an attachment on an otoscope. A red, bulging non‐mobile tympanic membrane would be and is pearly gray in color. The nurse concludes: typical with otitis media, a common ear infection in young children.
| Knowledge of normal assessment findings is the key to answering this question normally. |
759 The school health nurse has seen three children who Correct answer: 3 The child is no longer considered contagious after completing 24 hours of antibiotic therapy. have symptoms compatible with bacterial Until 24 hours of antibiotic therapy, the child would be contagious. conjunctivitis (pink eye). The nurse calls for the parents to bring the children home and writes in a note that they can safely return to school:
| Option 2 does not really define a time that the student could return to school. Conjunctivitis is not a systemic disease. Therefore, eliminate options 2 and 4. The core issue of the question is the ability to transmit infection to others; use this concept to choose between options 1 and 3. |
760 The nurse counsels the parents of an infant with Correct answer: 3, 5 Exposure to secondhand smoke increases incidence of otitis media so this should be avoided chronic otitis media. Which of the following should the to reduce the risk of future episodes of otitis media. Preventing the infant from falling asleep nurse recommend to prevent future infections? Select with a pacifier will also help because saliva from sucking cannot accumulate and enter the all that apply. Eustachian tube. Infants who feed in the supine position have an increased risk of otitis media. Medications such as a nasal decongestant would have side effects and should be avoided unless specifically needed. Warm compresses will not prevent future infection.
| Consider which options will have an effect on the middle ear. Warm compresses cannot be applied to the middle ear so that option is incorrect. From this point, recall risk factors for otitis media to aid in choosing the correct options. |
‐ The parents should avoid exposing their infant to tobacco smoke. ‐ The parents should apply warm compresses to the ear daily. ‐ The parent should not allow the baby to fall asleep with a pacifier. | |
761 A 4‐year‐old has been diagnosed with amblyopia. The Correct answer: 2, 3 Although strabismus is associated with a positive family history in many cases, the mode of nurse who is providing the parents with information inheritance is unknown. The pathophysiology is misalignment of the eyes causing the brain to about this diagnosis should include which of the stop receiving the signal of the affected eye. Without treatment, including patching, corrective following items of information? Select all that apply. lenses, and muscular exercises, the damage will become permanent.
| Knowledge of amblyopia, its causes and treatment, will assist in correctly answering this straight forward question. |
762 A child who is otherwise healthy is brought to the Correct answer: 4 The child should be positioned where pressure to the nostrils can be applied and upright to emergency room with an episode of epistaxis. To stop avoid excessive amounts of blood swallowed. Hyperextending the head opens the airway and the episode of epistaxis, the nurse would do which of increases the risk of aspiration. Positioning the client in Trendelenburg position also increases the following? the risk for aspiration by allowing blood to accumulate in the nasopharynx.
| Three of the four options relate to position. Consider which position would be safe for the child with epistaxis. |
763 The nurse working in a pediatric outpatient clinic Correct answer: 3 Early identification and treatment of visual impairment can prevent significant vision loss in routinely performs assessments to detect visual children at risk. For this reason, screening should be started at birth. impairment beginning at what time?
| The critical words in the question are “beginning at.” This tells you the correct option is the one that indicates the initial start time for visual assessment. |
764 The nurse working in a pediatric clinic concludes that Correct answer: 2 Symptoms of decreased visual acuity are squinting to focus, excessive tearing of the eyes, and which assessment finding in a child indicates a risk for rubbing of the eye. visual impairment?
| Language would not be affected by diminished vision. To distinguish among the other options, recall signs of visual impairment at various ages. |
765 To prevent amblyopia, the nurse would implement Correct answer: 3 To encourage the child to use the weaker, deviating eye and in an attempt to strengthen the which of the following as part of therapeutic muscles of the affected eye, the unaffected eye is patched. management of a child with strabismus?
| Note the choices offered. One choice is patching the affected eye, another choice is patching the unaffected eye. More than likely, one of these choices is the right answer because they are opposites. |
766 The nurse is caring for a school age child with Correct answer: 1, 5 Strabismus (or cross‐eyes) affects the appearance and visual acuity of the child. This can strabismus. In planning the nursing care, the nurse affect parental relationships. It is not a painful disease and there is no risk for infection. The would identify which of the following as appropriate circulation to the eye is normal. nursing diagnoses? Select all that apply.
| Consider nursing diagnoses related to visual problems and physical appearance. |
767 A child is to receive eye ointment that has been Correct answer: The procedure for instilling eye ointment begins with washing hands and applying clean ordered to treat conjunctivitis. Indicate on the picture gloves. After ensuring the medication is at room temperature and removing any discharge shown where the nurse should place the ointment. from the eye, the lower lid is pulled down to make a sac and the ointment is applied there. The tip of the tube should never touch the eye surface, and the tip is held parallel to the eye so as to prevent injury if the child should move suddenly. | The core concept is safe administration of eye ointment. Recall that ointment needs to be administered in the lower conjunctival sac to follow correct administration procedure. |
768 The nurse is caring for a 6‐year‐old child who just Correct answer: 4 The nurse observes increased swallowing rather than decreased swallowing when there is returned to the day‐surgery recovery area following a bleeding following tonsillectomy. The child may also spit out red blood from the mouth at this tonsillectomy, adenoidectomy, and bilateral time. Tachycardia and hypotension are late signs of significant blood loss, and these would be myringotomy with insertion of tympanostomy tubes. consistent with active uncontrolled bleeding. The child would not exhibit hypertension or Which assessment data indicates to the nurse that the bradycardia. child is experiencing active, uncontrolled bleeding at the operative site?
| The choices here have multiple responses; consider each option individually. The first choice is either tachy‐ or bradycardia. Tachycardia is seen in early hemorrhage, eliminating option 2. The second choice is hyper‐ or hypotension. The most common option is hypotension, eliminating option 1. Choose option 4 over option 3, recalling that there is increased swallowing (early) or possible hemoptysis (late) when there is surgical bleeding. |
769 The nurse caring for a pediatric client following Correct answer: 1 Age and developmental level affect the pain response of a child. Infants are less able to tonsillectomy would keep in mind which of the communicate their feelings than an older child and usually demonstrate restlessness and following nursing considerations when planning care crying behaviors. Adolescents are able to describe their pain sensations. Children do not for this child? generally recover from painful procedures more quickly than adults (option 2). Children do not have higher pain thresholds than adults (option 4) and do require opioid analgesics (option 3).
| Consider the two core concepts in this question—response to pain and children as they differ from adults. Use knowledge of postoperative care and appropriate developmental considerations to choose the correct answer. |
770 The nurse is beginning an otoscopic examination of Correct answer: 4 Uncooperative pediatric clients may need to be gently restrained long enough to accomplish the ear of a 2‐year‐old child. The child cries, kicks, and the assessment or procedure that is necessary. Parents may be able to assist with this pulls away from the nurse. The nurse should take effectively. A 2‐year‐old will not listen to explanations (option 1) and is not likely to respond to which of the following actions? pleas for acting maturely (option 3). The exam should not be postponed until the next yearly exam (option 2).
| Critical words are “2‐year‐old” and “cries, kicks, and pulls away.” This child, at the age of 2, is too young to understand. Reason that the answer is an intervention that allows for the exam to proceed. |
771 During a day‐surgery hospitalization experience for Correct answer: 1 One of the greatest fears of preschoolers is fear of mutilation. Options 2 and 3 tonsillectomy for a 4‐year‐old child, the nurse (immobilization and premature death) are not developmentally appropriate concerns of a anticipates that the child will most likely be fearful of: preschooler. Unfamiliar caregivers (option 4) could be a concern for any child, but is less so than the fear of mutilation for a child of this age.
| Knowledge of normal stress reaction to hospitalization for the developmental stage is necessary to answer the question. Compare each response with the age of the child to determine which behavior is developmentally appropriate. |
772 The nurse is performing an assessment of a 14‐month‐ Correct answer: 1 The tympanic method is preferred. It is quick, accurate, and convenient. Oral temperature can old toddler admitted to the day surgery unit for be obtained on a cooperative child age 3 and older. A rectal temperature is obtained as a last bilateral myringotomy and placement of resort, when other methods are not possible. tympanostomy tubes. To take an accurate temperature, the nurse should use:
| Consider the age of the child and safety to eliminate the rectal and oral temperatures. Then consider the need for accuracy to eliminate the forehead strip. |
773 Which of the following care measures should the Correct answer: 1, 4, 5 Crusting of dried exudate is common with bacterial conjunctivitis. The parents will need to nurse include when teaching home‐care of a child who know how to administer the eye drops or ointment. Washing the hands frequently will reduce has bilateral bacterial conjunctivitis? (Select all that the spread of the infection, which is hand‐to‐eye and spreads easily to other children. The use apply.) of antihistamines and topical anesthetics is not indicated in the management of bacterial conjunctivitis.
| Critical words are “home‐care measures” and “bacterial conjunctivitis.” Knowledge of conjunctivitis as a contagious disease and management will help to answer the question correctly. Consider both medical and nursing interventions as necessary to treat this infection. |
774 The nurse should teach the parent of an infant Correct answer: 4 Increased fussiness and elevated temperature are expected symptoms of viral pharyngitis in diagnosed with viral nasopharyngitis to notify the infants. A cough may occur because of local irritation. Symptoms of ear infection can occur health care provider if which of the following occurs? because of secondary infection and should be reported to the health care provider.
| The core concept is that the illness is viral. Viral infections are usually treated symptomatically, but complications should always be noted. Knowledge of the complications of nasopharyngitis is then necessary to answer correctly. |
775 Decongestant nasal drops are prescribed for an infant Correct answer: 1 Eliminating contact or sharing of items with the infected person can reduce the potential with nasopharyngitis. The nurse should include which spread of infection to other family members. Medication should be used as specifically of the following in instructions given to the caregiver ordered (option 4). Medication should not be saved for use during future illness (option 2). The who will be administering the drops? dropper should not be inserted “as far as possible” due to risk of injury to the infant.
| Critical words are “nasal drops are prescribed for an infant.” Specific knowledge of the correct method to administer nasal drops will help to answer this question correctly. |
776 The nurse teaches the importance of finishing the full Correct answer: 4 Rheumatic fever can follow an infection of certain strains of group‐A beta‐hemolytic course of oral antibiotic therapy to the caregivers of a streptococci. Otitis media is an ear infection that can be caused by many organisms, but is not toddler who has streptococcal pharyngitis. The nurse the priority concern related to a strep infection. Diabetes insipidus and nephrotic syndrome explains that a potential complication of inadequately are pituitary and renal disorders, respectively, but are not related to sequelae of strep treated streptococcal infection is: infection.
| The core question is “what is a sequela of untreated streptococcus infection?” Knowledge of antibiotic resistance and complications from strep help to answer the question correctly. |
777 The physician orders amoxicillin (Amoxil) 500 mg IVPB Correct answer: 1 Amoxicillin is given only by the oral route. Because of this, the nurse cannot give the dose and q 8 hours for a pediatric client with tonsillitis. What is must question the order. There is no problem with the dosage or the frequency. the appropriate nursing action?
| Critical words are “amoxicillin” and “IVPB.” The question identifies an error in ordering amoxicillin. Focus on route, dose, and timing to determine the right answer. |
778 The nurse administers cefprozil (Cefzil) as ordered to Correct answer: 3 Candida infections are a common side effect of antibiotic therapy due to alteration of the a 22‐month‐old client with bacterial pharyngitis. The normal bacterial flora by the antibiotic agent. The white patches in the mouth do not nurse notes patches of white on the child’s oral represent allergic reaction, herpes simplex infection, or mumps. mucosa that cannot be removed. Which condition does the nurse suspect?
| Key words are “cefprozil” and “patches of white on the child’s oral mucosa that cannot be removed.” Knowledge of the side effects of antibiotic therapy is necessary to answer the question correctly. This question asks the learner to make the association between antibiotics and the development of thrush infection due to loss of normal flora. |
779 A pediatric client has been diagnosed with otitis Correct answer: 2 The nurse must emphasize the importance of completing the full course of antibiotic therapy, media. The nurse should place highest priority on even though symptoms may have resolved before the antibiotic is finished. teaching the parent:
| Key words are “diagnosed with otitis media” and “highest priority.” Although all choices are knowledge that should be discussed with the parents, how to administer the medication and completing the medication regimen must be done immediately. Although ear drops may be given, the antibiotics will be given systemically, making completing the regimen the highest priority. |
780 Nursing care of the child who is postoperative for a Correct answer: 2, 5 The nurse must observe the post‐tonsillectomy client for signs of excessive bleeding or tonsillectomy should include: (Select all that apply.) hemorrhage from the operative site. In the posterior pharynx, the bleeding can be concealed by the child swallowing the blood. Applying heat to the neck, warm liquids, or giving a straw would be contraindicated, as this could cause bleeding.
| Critical words are “nursing care of a child who is postoperative for a tonsillectomy.” Two choices mention temperatures—warm compresses on neck area and warm liquids—and one must be wrong. Since warmth promotes vasodilatation, that would make that one wrong. All correct activities relate to reducing the risk of hemorrhage. |
781 The nurse is caring for a child with a common cold Correct answer: 3 The common cold is a viral infection. It is self‐limiting, with symptoms lasting about 4 to 10 (nasopharyngitis). The primary goal of nursing care is days. Therefore, emphasis is on symptom management. Antibiotics are not indicated for a viral directed toward: infection. Nutrition and injury prevention are general concerns for a child, but do not relate to the question.
| Key words are “child with a common cold” and “primary goal of nursing care.” Although there is information about the child’s age in the question, nothing in the choices is differentiated by age. Therefore, that can be ignored. The key concept is the medical diagnosis and determining the purpose of nursing interventions. |
782 The nurse obtains a health history on a pediatric Correct answer: 3 Turning up the volume loudly is a behavioral indicator suggesting hearing impairment. The client. A sign alerting the nurse to possible hearing other options are behaviors that are not consistent with or indicative of hearing impairment. impairment in the child is:
| Critical words are “sign” and “possible hearing impairment.” Knowledge of hearing impairment and behavioral indicators helps to answer the question correctly. The only symptom that relates to hearing is turning volume up. |
783 The nurse is caring for a 1‐month‐old client who is Correct answer: 2 Development of parent–infant attachment is important in promoting developmental blind, secondary to retinopathy of prematurity. The progress. Parents are encouraged to talk, sing, and interact with their baby to learn about their nurse is teaching the parents about activities to infant’s response, and to provide appropriate stimulation at 1 month of age. The other options promote their infant’s development. Which of the are incorrect statements to the parents. following statements by the nurse is correct?
| Critical words are “1‐month‐old client who is blind” and “teaching the parents to promote development.” Use knowledge of normal interventions for parents of one‐month‐olds to promote normal development. Consider activities that may be used on any infant to stimulate development. Then identify those that do not require vision. |
784 The nurse is assessing a child with conjunctivitis (pink Correct answer: 4 Purulent exudate and crusting are characteristics of conjunctivitis. Conjunctivitis associated eye). Which of the following would the nurse most with foreign body can cause severe eye pain. Serous drainage and periorbital edema are not likely assess? associated with conjunctivitis.
| Critical words are “child with conjunctivitis” and “most likely assess.” Note that in this question, two choices describe discharge from the eye. That indicates that one of these choices is probably the right answer. |
785 The nurse teaches a child with conjunctivitis Correct answer: 4 The infected area should be cleansed with a disposable tissue after a single use. Handwashing measures to prevent the spread of infection. The nurse is important to prevent the spread of infection. Items that come in contact with the infected concludes that further teaching is needed when the eye are considered contaminated. child states the following:
| Critical words are “teaches a child with conjunctivitis measures to prevent the spread” and “concludes that further teaching is needed.” This means you need to identify an incorrect response from the child that would indicate he or she did not understand the teaching. Notice that two of the choices describe activities relating to wiping drainage from the eyes. Because the question addresses preventing the spread of infection, disposing of the tissue is the best choice. |
786 A 4‐month‐old infant has severe nasal congestion, Correct answer: 3 Saline nose drops will loosen secretions and crusting. The bulb syringe is necessary because nasal mucous drainage, and crusting in and around the infants cannot blow their own noses. The other options are incorrect nursing actions for this nares. What is the best way for the nurse to clear the purpose. infant’s nasal passages?
| Critical words are “infant has severe nasal congestion” and “best way to clear the nasal passages.” This question concerns a 4‐month‐old child. This would rule out option 4, as the child will not follow commands at this age. Of the 3 remaining choices, the only one that removes drainage is option 3. |
‐ Administer saline drops in the nose and suction with bulb syringe. ‐ Instruct the client to blow the nose and keep disposable tissues handy. | |
787 A client has just been diagnosed with closed‐angle Correct answer: 3 Narrow‐angle glaucoma develops abruptly and manifests with acute face and eye pain and is (narrow‐angle or acute angle‐closure) glaucoma. The a medical emergency. Halo vision, dull eye pain, and impaired night vision are symptoms nurse assesses the client for which of the following commonly associated with open‐angle glaucoma. most common presenting symptoms of this disorder?
| This question requires differentiation of open and closed angle glaucoma. |
788 The nurse notes a cloudy appearance to the lens of an Correct answer: 3 A cloudy‐appearing lens is symptomatic of cataract development. As the cataract matures, 80‐year‐old client's eye. Which of the following the red reflex is lost. A sense of a curtain falling over the visual field is associated with additional assessment findings would help confirm the detached retina. Eye pain and double vision are not associated with cataracts. diagnosis of cataracts?
| Recall that the opacities of cataracts decrease the red reflex. |
789 The priority nursing measure for the client with a Correct answer: 2 The foreign body should not be removed or manipulated. It should be immobilized if possible penetrating eye injury from a visible foreign body is to: and the eye covered to protect from further injury. A paper cup can be used in place of an eye patch. Patching both eyes is an appropriate intervention to prevent ocular movement but follows immobilization of the foreign body. Irrigation with water is an intervention for chemical burns to the eyes. Carbonic anhydrase inhibitors are used to decrease intraocular pressure following blunt trauma.
| This question requires the knowledge of first aid. |
790 A client is diagnosed with conductive hearing loss and Correct answer: 4 Conductive hearing loss results from changes that occur in the external or middle ear. Hearing asks how this occurred. The nurse should respond by aids, assistive listening devices (i.e., "pocket talkers"), and reconstructive surgeries can stating that conductive hearing loss: improve or correct hearing loss. Exposure to high levels of noise on an intermittent or constant basis damages the hair cells of the Organ of Corti, resulting in sensorineural hearing loss.
| This question requires knowledge of the differences between conductive and sensorineural hearing loss. |
791 A client with sensorineural hearing loss should be Correct answer: 4 Weber and Rinne tests are used to differentiate conductive hearing loss from sensorineural. assessed using which of the following? Tympanocentesis is the aspiration of fluid/pus from the middle ear to identify the causative organism of acute otitis media. Transillumination of the sinuses is a diagnostic tool used to assess for sinusitis. The diagnosis of Meniere's disease is confirmed by electronystagmography, a series of tests to evaluate vestibular‐ocular reflexes.
| This question requires the knowledge of sensorioneural hearing loss. |
4.‐ Weber and Rinne tests | |
792 The teaching plan for the parents of an infant with Correct answer: 2 A higher incidence of acute otitis media is noted in infants who are bottle‐fed in a horizontal acute otitis media should include which of the position and who live in homes with smokers. The full 10‐ to 12‐day course of antibiotic following? therapy must be administered. There is no relationship between the ingestion of fruit juices and acute otitis media.
| Use process of elimination to determine the correct answer. |
793 The nurse developing a teaching plan for a client with Correct answer: 2 Atrophic macular degeneration causes loss of central vision. Magnification devices and atrophic macular degeneration should include enhanced lighting help to promote safety. Peripheral vision remains intact. Although laser information concerning: photocoagulation is effective for exudative macular degeneration, there is no treatment for the atrophic form. Since macular degeneration is not an infectious process, antibiotic therapy is not indicated.
| This question requires knowledge of macular degeneration. |
794 Which of the following ophthalmic medications would Correct answer: 1 Pilocarpine (Pilocar) is a miotic and the most commonly prescribed drug for glaucoma. be indicated for the client with open‐angle glaucoma? Scopolamine (Hycoscine) and atropine are anticholinergics; epinephrine is an adrenergic agonist. All three are mydriatrics. The pupil dilation caused by mydriatrics is contraindicated in glaucoma.
| Recognize that three options are mydriatics; one is a miotic indicating the odd man out. |
795 A 60‐year‐old male presents to the clinic complaining Correct answer: 3 These symptoms, along with dysphagia, foul‐smelling breath, and pain when drinking hot or of hoarseness and a cough. His spouse states his voice acidic fluids, are common signs of laryngeal cancer. Chronic sinusitis can produce foul breath has changed in the last few months. The nurse and pain or burning in the throat. GERD and CAD may produce epigastric and/or chest pain, but interprets that the client's symptoms are consistent hoarseness and change of voice do not occur. with which of the following disorders?
| This question requires the knowledge of the symptoms of cancer. |
796 The priority postoperative nursing action following Correct answer: 3 All of the nursing actions listed are appropriate for the client following nasal packing for nasal packing for epistaxis is: epistaxis; however, the risk of aspiration is high, and monitoring respiratory function essential. Notice the question asks for the priority intervention.
| Remember the ABCs (airway, breathing, circulation). Airway is always a priority. |
797 A client reports sudden onset of continuous eye pain Correct answer: 1 Closed or narrow‐angle glaucoma has an abrupt onset and is characterized by severe pain of and impaired vision. Pupil dilation is noted. The nurse sudden onset. The pain usually lasts longer than 20 minutes with closed‐angle glaucoma. Eye concludes that this assessment data is consistent with pain that comes and goes quickly can be indicative of allergies. Open‐angle glaucoma occurs which of the following disorders? gradually with no initial manifestations. Pain is not associated with cataracts or retinal detachment.
| This question requires knowledge that open angle glaucoma is painless and closed‐angle is painful. |
798 A client with Meniere's disease would probably Correct answer: 2 Meniere's disease is associated with vertigo that may last for hours as well as fluctuating complain of which of the following? hearing loss, nausea, and vomiting. The disorder is unilateral, but because hearing is bilateral, the client often does not realize the extent of the hearing loss. Option 3 is indicative of swimmer's ear, and option 4 is indicative of acute otitis media.
| This question requires the knowledge of Meniere’s disease. |
799 A male client has just had a cataract operation Correct answer: 4 Without a lens, the eye cannot accommodate. Since it is difficult to judge distance and climb without a lens implant. In discharge teaching, the stairs when the eyes cannot accommodate, for safety reasons the client should have nurse will instruct the client's wife to: assistance when climbing stairs.
| This question requires knowledge of cataract surgery. |
800 An adult client presents to the Emergency Correct answer: 2 Retinal detachment is painless, but eventually floaters and visual loss will be manifested, Department after having a rock hit his eye while especially if hemorrhage has occurred. Subconjunctival hemorrhage is a manifestation of blunt weeding along a ditch near a busy highway. The event trauma to the eye. Halo vision is characteristic of glaucoma. occurred several hours earlier. The nurse assesses the eye and finds redness and weeping, but the client denies any pain. Which of the following early symptoms would help confirm retinal detachment?
| This question requires knowledge of the early symptoms of retinal detachment. |
801 A client is diagnosed with a cholesteatoma and asks Correct answer: 2 Cholesteatomas are benign, slow‐growing tumors of the middle ear that are filled with the nurse to explain what this is. The best explanation epithelial cell debris. Untreated cholesteatomas may enlarge to fill the middle ear, destroy the by the nurse would be, “Cholesteatoma is an:” ossicles, and cause profound hearing loss. Option 1 (endolymph) is indicative of Meniere's disease. Options 3 and 4 are distracters.
| Use the process of elimination to select the correct answer. |
802 Which of the following clients is at highest risk for Correct answer: 2 Age‐related macular degeneration is the leading cause of loss of vision in clients over 50 years macular degeneration? of age. Blunt trauma, exposure to toxins, and allergies are not known causes of macular degeneration.
| This question requires knowledge of the characteristics of aging. |
803 A client presents to the clinic with complaints of Correct answer: 3 Transillumination of the sinuses in a non‐invasive technique used to detect fluid in the sinusitis. The nurse anticipates that the most useful maxillary and frontal sinuses. The Weber test differentiates conductive hearing loss from techniques for diagnosis would be: sensorineural hearing loss. Fluorescein staining helps identify corneal abrasions and caloric testing is used to evaluate nystagmus in Meniere's disease.
| This question requires knowledge of the diagnosis of sinus disease. |
804 Which of the following is a priority nursing diagnosis Correct answer: 1 Since the amount of blood lost in a nosebleed can be frightening to clients, anxiety is a for a client with epistaxis? priority nursing diagnosis. Blood draining into the nasopharynx poses a risk of aspiration. Risk for infection and pain are appropriate nursing diagnoses related to nasal packing but are not the priorities. Impaired verbal communication is unlikely.
| Recall priority establishment based on Maslow’s Hierarchy of needs. |
805 Which of the following clients is at highest risk for Correct answer: 3 The two major risk factors for laryngeal cancer are prolonged smoking along with laryngeal cancer? A client who: concomitant use of alcohol. Although the majority of cases occur in men ages 50 to 75, advancing age does not significantly increase risk. Injury to the larynx and chronic sinusitis are not risk factors.
| This question requires knowledge of those factors that place the client at increased risk. |
806 Nursing interventions for a client with sensorineural Correct answer: 2 The client with sensorineural hearing loss experiences social isolation and depression and hearing loss include: may appear withdrawn. Amplification devices such as hearing aids are helpful for clients with conductive hearing loss but only amplify noxious sounds for the client with sensorineural hearing loss. Antibiotics are not helpful for sensorineural hearing loss, and tympanoplasty is used to correct damage to structures in the middle ear.
| This question requires knowledge of differentiating types of hearing loss. |
807 In order to improve communication with the client Correct answer: 4 The best method to improve communication with the client is to face him directly when having a diagnosis of sensorineural hearing loss, the speaking. Hearing‐impaired clients often consciously or unconsciously lip‐read to enhance nurse should instruct the client's family to: perception. The other options are ineffective and may frustrate or demean the client.
| This question requires selecting the answer which shows the most respect for the client. |
‐ Speak loudly to get the client's attention. ‐ Face the client directly when speaking. | |
808 The nurse would reinforce explanations about which Correct answer: 2 Leukoplakia are white, patchy, precancerous lesions; erythroplakia are red, velvety, of the following diagnostic test is recommended for precancerous patches. Both can be found on the laryngeal mucosa. Biopsies of both types of laryngeal cancer? lesions aid in diagnosing and staging laryngeal cancer. Gonioscopy and tonometry are tests used for glaucoma. Caloric testing is associated with Meniere's disease and central nervous system (CNS) disorders.
| Recognize that biopsies are the most conclusive diagnostic test listed. |
809 A child is noted to have a very short stature, non‐ Correct answer: 1 These are the key assessment features in Turner's syndrome. If the child is diagnosed early in pitting lymphedema of the hands and feet, webbed age, proper treatment with growth hormone can be offered to the family. neck, and low posterior hairline. The nurse will expect which of the following diagnoses?
| The question describes one of these genetic disorders. If guessing, eliminate the ones you know are incorrect. |
810 The nurse working in an ambulatory surgery center Correct answer: 2 Tympanostomy (ventilation) tubes allow air into the middle ear. While in place, it is important would instruct the parents of a pediatric client to to avoid getting water into the ear canal, which could potentially enter the middle ear. The prohibit their child from participating in which of the other activities are not risks to the pediatric client with tympanostomy tubes. following activities following insertion of tympanostomy tubes?
| This question uses the “odd man out” for the activities. |
811 A 75‐year‐old client reports to the nurse during the Correct answer: 3 Presbycusis is the most common form of sensorineural hearing loss in older adults. Meniere's admission process that she was recently diagnosed disease is an inner ear disorder that affects primarily middle‐aged adults. Otalgia is an earache; with age‐related hearing loss. The client is most likely otitis externa is infection in the external auditory canal and can occur in clients of any age. describing:
| This question requires knowledge of the normal changes of aging. |
812 After surgery for a cataract removal, the nurse Correct answer: 3 Bending over to pick up objects from the floor is contraindicated because it increases teaches the client about home care. Which of the intraocular pressure. Activities such as walking on level surfaces, lying on the nonoperative following activities would be contraindicated? side, and performing simple isometric exercises are not harmful.
| This question requires knowledge of the components that raise ocular pressure. |
813 A client with sensorineural hearing loss asks about Correct answer: 3 Amplification is of no help with sensorineural hearing loss and serves only to increase the whether a hearing aid would be beneficial. The nurse intensity of distorted sounds. The other options are incorrect. makes which of the following replies to this client?
| This question requires knowledge of conductive versus sensorineural hearing loss. |
814 A client diagnosed with Meniere's disease would Correct answer: 2 These are the classic symptoms of Meniere's disease. Nystagmus occurs with acute attacks. complain of vertigo and which of the following? Headache, double vision, pain, and purulent drainage are not reported.
| This question requires knowledge of Meniere’s disease. |
815 The nurse anticipates that which of the following Correct answer: 1 Anticholinergics and antiemetics are used to control symptoms associated with Meniere's treatment options would be included in the disease. Diuretics are used between acute attacks to reduce the volume of endolymph and management of a client diagnosed with Meniere's prevent attacks. Glucocorticoids, beta blockers, and analgesics are not commonly used. disease?
| This question requires knowledge of Meniere’s disease. |
816 The nurse explaining the use of medication therapy Correct answer: 3 Constricting the pupil stimulates the ciliary muscles to pull on the trabecular meshwork for a client diagnosed with glaucoma would state that surrounding the Canal of Schlemm. This increases the flow of aqueous humor and decreases miotics are useful because they work by: intraocular pressure.
| This question requires knowledge of the medications needed to treat glaucoma. |
817 The initial nursing intervention for a client in the Correct answer: 4 The immediate priority for clients with chemical burns is flushing the affected eye with emergency department who suffered a chemical burn copious amounts of normal saline or water. Evaluation of visual acuity is an appropriate to the eyes is to: intervention after flushing. Analgesics, with the exception of topical anesthesia, are not indicated. Antibiotics may be administered after the initial actions have been taken.
| This question requires knowledge of first aid. |
818 The nurse would question the client about which of Correct answer: 4 Clients with retinal detachment frequently report flashing lights and loss of vision commonly the following clinical manifestations that commonly described as a curtain being drawn across the eye. Retinal detachment is painless, does not occurs in retinal detachment resulting from cataract cause increased lacrimation (unless associated with trauma), and does not affect ocular extraction? movement.
| This question requires knowledge of retinal detachment. |
4.‐ Flashing lights and loss of part of the visual field | |
819 An elderly client is diagnosed with chronic open‐angle Correct answer: 1 Remember drugs that end in ‐olol are beta blockers. Beta blockers, when administered as glaucoma and has been prescribed timolol maleate ophthalmic preparations, can produce systemic effects such as bradycardia, hypotension, and (Timoptic). The nurse assesses for which of the bronchospasm. Beta blockers act as central nervous system (CNS) depressants and are used to following possible adverse systemic responses to the treat anxiety. drug?
| Note that a frequently asked topic on NCLEX<sup>®</sup> is that a heart rate (HR) is always assessed before giving a beta blocker and that the drug should be held if HR is less than 60/min. |
820 A client presents to the walk‐in clinic with fever, Correct answer: 2 Symptoms of acute sinusitis include facial pain, purulent nasal discharge, fever, and complaints of right facial pain, and copious yellow‐ headache. Transillumination is a diagnostic tool used to detect fluid in the maxillary or frontal green nasal discharge. There is no transillumination of sinuses. Fluid in the sinuses indicates infection. Transillumination is not used to diagnose the the right maxillary sinus. The nurse anticipates that the other conditions. most likely diagnosis is:
| This question requires knowledge of the diagnosis of sinus illness. |
821 Prior to a total laryngectomy for laryngeal cancer, the Correct answer: 2 Although all of the options are appropriate, providing the client with an opportunity to client appears withdrawn and depressed. He keeps the express feelings of anger or fear is the priority. Clients with laryngeal cancer requiring total curtain drawn, refuses visitors, and states he wants to laryngectomy need permission to grieve for their anticipated losses before mobilizing coping be left alone. Which of the following is the priority strategies to deal with the surgery and follow‐up care. nursing intervention?
| This question requires knowledge of the value of ventilating concerns. |
822 A priority nursing intervention for the infant with cleft Correct answer: 1 The infant with cleft lip is unable to create an adequate seal for sucking. The child is at risk for lip is which of the following? inadequate nutritional intake as well as aspiration.
| Consider Maslow’s hierarchy when prioritizing. |
823 The clinic nurse who is treating a client with anterior Correct answer: 3 The trauma resulting from nose picking is a common cause of anterior epistaxis because of epistaxis needs to assess for which of the following as damage to Kiesselbach's area, a highly vascular area in the anterior septum. Blood dyscrasias, an etiology for the episode? hypertension, and diabetes are causes of posterior epistaxis.
| This question requires knowledge of first aid. |
824 The nurse is providing preoperative teaching for a Correct answer: 3 Options 1 and 2 are incorrect. Option 4 is the definition of pneumatic retinopexy. Scleral client who has a detached retina. The nurse reinforces buckling as described in option 3 is used in conjunction with laser photocoagulation or that scleral buckling involves: cryothermy.
| This question requires knowledge of the treatment for detached retina. |
825 The priority intervention for the client with blunt Correct answer: 1 Blunt trauma does not cause loss of intraocular contents, and no foreign body is present. trauma to the eye is to: Constriction of the pupil with miotics is not indicated. Intraocular pressure may increase as a result of the trauma and is prevented by the use of carbonic anhydrase inhibitors.
| This question requires knowledge of measures to decrease edema. |
826 Which of the following statements indicates that the Correct answer: 3 Proper positioning is important after eye surgery to avoid complications. The client should client has understood the instructions to follow at avoid bending, straining, and strenuous activity in order to reduce intraocular pressure in the home after cataract surgery? affected eye.
| Use the process of elimination to find the correct answer. |
827 The client is diagnosed as having presbycusis. The Correct answer: 2 Presbycusis is a term to describe degenerative changes from aging and is associated with loss nurse explains to the client that this disorder is which of the hair cells in the Organ of Corti leading to sensorineural hearing loss. Air and bone of the following type of hearing disorder? conduction are terms applying to conductive hearing loss. The term "central" is not commonly used when referring to hearing loss.
| This question requires knowledge of hearing disorders. |
828 The nurse has provided discharge teaching for the Correct answer: 2 Low‐sodium diets and diuretics help reduce the volume of endolymph and prevent client with Meniere's disease. The nurse is able to recurrence. Salted cashews are the high‐sodium food in this list. evaluate the client's understanding of the teaching if the client states that which of the following foods should be avoided?
| This question requires knowledge of the dietary restrictions associated with Meniere’s disease. |
829 The clinic nurse should provide which of the following Correct answer: 1 Ninety percent of nosebleeds arise from the anterior portion of the nose known as as the initial treatment for epistaxis? Kiesselbach's area. Pinching the area for 5 to 10 minutes aids in hemostasis. Nasal packing and cauterization are subsequent treatments if bleeding doesn't subside. The application of warm compresses is contraindicated.
| This question requires knowledge of first aid. |
830 A client with laryngeal cancer has just been told that Correct answer: 3 Laryngeal cancer spreads by direct invasion into surrounding tissues and by metastasis. The the cancer has metastasized. The nurse suspects that most common site of metastasis is the lungs. Metastasis to other sites such as the brain, metastasis has occurred to which of the following breast, and uterus is rare. most common areas for this type of cancer?
| This question requires knowledge of a common origin of metastasis. |
831 The nurse prepares to carry out which of the Correct answer: 1 Intranasal steroids are commonly used to treat sinusitis to reduce inflammation. Nasal following orders for a client with sinusitis as part of oxygen by cannula (which dries the mucous membranes), the use of diuretics, and restriction standard medical management? of oral fluids are contraindicated.
| Recall that a function of steroids is to decrease swelling. |
832 Which of the following assessment findings would be Correct answer: 1 Open‐angle glaucoma is characterized by halo and blurred vision. The abrupt onset of severe noted in the client with open‐angle glaucoma? eye pain, a fixed, partially dilated pupil, and increases in intraocular pressure are indicative of closed‐angle glaucoma. The normal intraocular pressure ranges from 12 to 20 mmHg. Floaters in the visual field are found with detached retina.
| Recall that halo vision is a classic sign of glaucoma. |
833 The pediatric health nurse explains to parents that Correct answer: 3 A child's Eustachian tubes are shorter and straighter than those of an adult. The other acute otitis media is more common in infants and responses are incorrect. children than adults because a child's Eustachian tubes:
| This question requires knowledge of ear physiology. |
834 The nurse would carry out which of the following Correct answer: 2 The development of cataracts causes scattering of the light entering the eye, resulting in interventions for a client newly diagnosed with glare. Sunglasses will reduce glare. Night vision declines in clients with cataracts and would be cataracts? discouraged. Pilocarpine eye drops and carbonic anhydrase inhibitors are used to treat glaucoma.
| Consider the least invasive measure available. |
835 A client is admitted with a new diagnosis of retinal Correct answer: 4 The priority nursing intervention is directed toward maintaining contact of the retina with the detachment. The nurse should place the highest choroid and positioning the client so the area of detachment falls against the choroid. Both priority on which of the following interventions? eyes are patched to limit ocular movement. Retinal detachment is generally painless. Darkening the room is not necessary. | Consider positioning a basic strategy. |
‐ Administering analgesics as prescribed ‐ Covering the affected eye ‐ Darkening the room ‐ Positioning the client properly | |
836 A 70‐year‐old client comes to the outpatient clinic Correct answer: 2 Increasing difficulty with central vision and distortion of vision in one eye are common complaining of increasing difficulty with "close work" manifestations of macular degeneration. Peripheral vision is usually not impaired. The such as knitting. She indicates she does not have symptoms are not characteristic of glaucoma or cataracts. Subconjunctival hemorrhage occurs difficulty seeing objects on either side but does state with ocular trauma. that straight lines appear distorted or wavy. The nurse suspects which of the following disorders that is consistent with the client's reported symptoms?
| This question requires knowledge of eye disorders. |
837 A client who has undergone a visual acuity test has Correct answer: 1 A result of 20/120 means that this client can read at a distance of 20 feet what another results of 20/120 in the right eye. When explaining this individual with normal vision can read at a distance of 120 feet. This means that the client is finding to the client, which of the following statements nearsighted in that eye. The other responses are incorrect. would be most appropriate?
| This question requires knowledge of visual screening. |
838 A client being prepared for an ocular examination has Correct answer: 4 Cyclopentolate is a mydriatic and a cycloplegic medication that is used to dilate the pupil and an order for a topical eye medication. The nurse paralyze the ciliary muscles before an eye exam. Carbachol and latanoprost are miotics that prepares to administer which of the following constrict the pupil and are used to treat glaucoma. Glycerin is an osmotic diuretic used to treat medications? acute angle‐closure glaucoma.
| This question requires knowledge of the functions of myotics, mydriatics, and cycloplegics. |
839 A client has just been diagnosed with glaucoma. The Correct answer: 3 It is important to share with the client that lifelong medication therapy is needed to preserve nurse should place highest priority on teaching the vision. The statement in option 2 is correct also but is not as critical as option 3, since the client which of the following pieces of information? client has just been diagnosed. Options 1 and 4 are false statements.
| Use the process of elimination to choose the highest priority. |
840 The nurse notes a slight cloudy appearance to the Correct answer: 2 A cloudy‐appearing lens is characteristic of cataract development. Early symptoms of cataract lens of a 64‐year‐old client's eye. Which of the formation include blurred vision and a loss of ability to see colors. A sense of a curtain falling following symptoms should the nurse question the across the field of vision characterizes detached retina. Eye pain and double vision are not client about? symptoms associated with cataracts.
| This question requires knowledge of cataract development. |
‐ Slight but constant eye pain ‐ Double vision | |
841 A client admitted to the hospital has a notation on Correct answer: 1 A client who is legally blind has either visual acuity no better than 20/200 in the better eye the medical record that reads "legally blind." The nurse with optimal correction, or has a visual field of 20 degrees rather than 180 degrees. interprets that the client's best corrected vision in the better eye must be no better than which of the following? 1.‐ 20/200 2.‐ 20/120 3.‐ 20/360 4.‐ 20/100 | This question requires knowledge of the definition of legally blind. |
842 A client with a suspected impaction of cerumen has Correct answer: 4 It is essential to determine that the tympanic membrane is intact before completing an otic an order for an otic irrigation. The nurse should take irrigation. No more than 50 to 70 mL of solution should be drawn up at one time, and the fluid which of the following essential actions before should be at body temperature. The client may be positioned wherever it is comfortable, and beginning the irrigation? needs only a receptacle to hold the drainage, and a waterproof pad to protect clothing.
| Use the highest priority to prevent further injury. |
843 A client has been treated for acute otitis media. The Correct answer: 3 Ear pain is a primary or classic symptom associated with otitis media. Secondary nurse would evaluate whether the client obtained manifestations could include dizziness, vertigo, and diminished hearing in the affected ear. relief from which of the following primary symptoms associated with this disorder?
| Recall pain as a classic symptom of infection. |
844 The nurse working in an ambulatory surgery center Correct answer: 2 Following ear surgery, clients should avoid activities that could result in increased pressure in would plan to instruct the client that which of the the middle ear. These include blowing the nose, sneezing, coughing, or doing any activities that following activities is acceptable following ear surgery? involve holding the breath or bearing down. Talking is an acceptable activity.
| Use the process of elimination to find the correct answer. |
845 The nurse is performing an otic examination on a Correct answer: 1 Otosclerosis is characterized by Schwartz's sign, a tympanic membrane that is reddish or client with otosclerosis. Then nurse documents that pinkish‐orange because of increased vascularity. It would not be pearly white or pale (options the tympanic membrane is: 2 and 4), nor would it have a bruised appearance (option 3).
| This question requires knowledge of otosclerosis. |
846 The nurse has conducted discharge teaching for a Correct answer: 4 The client with Meniere's disease should limit intake of salty foods that could cause an client diagnosed with Meniere's disease. The nurse increase in endolymphatic fluid in the inner ear. The other foods listed pose no problem. evaluates that the client understood the instructions given if the client states to refrain from eating which of the following favorite foods?
| This question requires knowledge of the diet related to Meniere’s disease. |
847 A client comes to the ambulatory clinic seeking care Correct answer: 3 The nurse should evaluate the client's vision first to provide a baseline, and then treat the with a complaint of "getting something in my eye." injury. Irrigation is often used to remove foreign bodies from the eye, followed by application Which of the following actions should the nurse take of an eye patch. first?
| Always remember the need to assess first. |
848 A client is being admitted to the post‐anesthesia Correct answer: 2 Following eye surgery, the head of bed should be elevated 30 to 45 degrees and the client recovery area following lens removal and replacement should lie on back or unaffected side to reduce intraocular pressure. Small pillows may be used in the left eye for a cataract. The nurse places the at the sides of the head to immobilize the head when lying on the back. client into which of the following most appropriate positions?
| When looking at positioning questions, it is important to consider positioning on the unaffected side. |
849 A client who has developed impaired vision because Correct answer: 1 Glaucoma is characterized by a gradual loss of vision that is irreversible, because of the of previously undiagnosed glaucoma asks the nurse if effects of increased intraocular pressure on the optic neurons. Compliance with medication the lost vision will return. Which of the following therapy is important to preserve the current level of vision, although vision that is lost cannot replies by the nurse is most accurate? be regained.
| Use the process of elimination to select the correct answer. |
850 A client is admitted with a newly diagnosed detached Correct answer: 4 The client with a detached retina should have activity restricted with eyes patched to reduce retina. The nurse should place highest priority on doing eye movement and prevent worsening of the detachment. The client may be prepared for which of the following? surgery quickly, and thus may be placed on NPO status rather than clear liquids.
| Use the basic principle of decreasing stimuli as an intervention. |
851 The nurse who is planning care for a client who is Correct answer: 2 The nurse should orient the client to the room for safety, using both words and a physical legally blind should do which of the following as most walking tour for best effect. Options 2 and 4 are helpful, but do not ensure client safety. important to ensure the client's safety? Leaving doors partially closed (option 1) is hazardous because the client could inadvertently walk into the door during ambulation. Pathways should be free of obstacles.
| Recall that safety is always a priority. |
852 The nurse is performing the Rinne test on a client Correct answer: 4 The nurse places the base of the tuning fork on the client's mastoid bone to perform the with a suspected hearing impairment. The nurse places Rinne test. When the sound is no longer heard, it is quickly repositioned in front of the client's the base of the tuning fork in which of the following ear, and hearing is again assessed. The tuning fork may be placed at the top of the forehead or locations? the vertex of the skull in the midline to perform the Weber test. The bridge of the nose is not used as a reference point for assessing hearing.
| This question requires knowledge of screening assessment. |
853 The nurse is providing instructions to a client who has Correct answer: 3 The client should avoid the use of aerosol sprays, cosmetics, or other hair or facial products been diagnosed with hearing impairment and has just near the hearing aid. The aid should not get excessively wet. The hearing aid should be turned received a hearing aid. The nurse would include which off when not in use, and should be maintained on the lowest setting that is comfortable and of the following statements in discussion with the effective. client?
| Use process of elimination to discern the correct answer. |
854 A nurse is providing care to a client who just Correct answer: 2 A stapedectomy is a common surgical procedure used to treat the hearing loss that is underwent a stapedectomy. The nurse checks the associated with otosclerosis. It is not performed for the other conditions listed. client's medical record, noting that this client had which of the following diagnoses prior to surgery?
| This question requires knowledge of the care for a post‐operative client. |
855 A 72‐year‐old client reports to the nurse during a Correct answer: 3 Presbycusis is an age‐related decline in hearing. Otosclerosis is a familial disorder health history that the physician previously diagnosed characterized by hearing loss. Meniere's disease is a disorder of the inner ear that results in an age‐related loss of hearing. The nurse documents in vertigo. Otalgia is an earache. the medical record that the client reports which of the following disorders?
| This question requires knowledge of the definitions for the various disorders listed. |
856 The nurse would prioritize that which of the following Correct answer: 1 Meniere's disease is characterized by bouts of vertigo, which place the client at risk for falls nursing diagnoses has highest priority for a client and injury. The client may have manifestations of the other nursing diagnoses as well, but the experiencing an attack of Meniere's disease? highest priority is on preventing injury.
| Use safety principles to establish priorities. |
857 A client has a history of angle‐closure glaucoma. The Correct answer: 1 Angle‐closure glaucoma can manifest abruptly as acute onset of eye and facial pain. It is nurse would assess the client for which of the considered a medical emergency because it signals a rapid rise in intraocular pressure. Halo following symptoms to determine a recurrent episode vision and difficulty seeing at night are symptoms commonly associated with open‐angle of this health problem? glaucoma. Itching of the eyes is an unrelated item.
| This question requires knowledge of closed‐ and open‐angle glaucoma. |
858 The nurse is performing a routine eye assessment on Correct answer: 2 A Snellen eye chart, as shown in the photograph, is used to test distance vision. The client a client as shown in the accompanying photograph. reads aloud the smallest line of print that can be seen. Each line is coded to interpret the visual The nurse documents results of this test as an acuity for that line. Normal vision is 20/20. A Rosenbaum chart is used to test near vision; an indication of the client's: Ishihara chart is used to test color vision. The nurse performs peripheral vision testing by facing the client and bringing an object into both of the client's visual fields from the side.
| This question requires knowledge of screening procedures. |
859 A 73‐year‐old client has a clouding of the lens of the Correct answer: 1 A clouding of the lens occurs with cataract development. The red reflex becomes absent or is right eye. The clinic nurse would assess for which of lost as the cataract gets worse or "matures." Double‐vision and intermittent aching eye pain the following that supports a suspected finding of a do not occur. Option 3 describes findings with macular degeneration. cataract?
| This question requires knowledge of screening techniques. |
860 A client is brought to the emergency department Correct answer: 4 The foreign body should not be removed or manipulated. It should be kept immobilized if after a shard of glass penetrated the left eye in an possible with an item such as a plastic cup, which will not put pressure on the eye. Eye industrial accident. The glass is presently visible, patching is desirable (option 3), but a flat patch could cause further eye injury. Eye irrigation is immobile, and protruding from the eyeball. Which of done when the client suffers chemical burns to the eye (option 1). Assessment of vision (option the following is the priority nursing action on 2) while the glass is still imbedded could cause further harm by encouraging eye movement. admission?
| Choose the intervention which requires the least invasive measures. |
861 A client is suspected of having presbycusis. Which of Correct answer: 2 Presbycusis is characterized by sensorineural hearing loss. Weber and Rinne tests are used to the following tests would provide additional data to differentiate conductive from sensorineural hearing loss. Caloric testing evaluates ocular‐ confirm this diagnosis? vestibular reflexes. Tympanocentesis is the aspiration of fluid/pus from the middle ear to identify the causative organism of acute otitis media. CT scanning is not used.
| This question requires knowledge of hearing loss. |
862 The nurse should place highest priority on teaching a Correct answer: 4 Atrophic macular degeneration results in loss of central vision. Thus, the priority is to obtain client newly diagnosed with atrophic macular magnification devices, other aids, and provide enhanced lighting to promote safety. Antiviral degeneration about which of the following? medication is not a form of therapy. Surgical therapy is not an option for the atrophic (dry) form of macular degeneration. Peripheral vision loss rarely occurs with macular degeneration.
| Recall that safety is always a priority. |
863 The nurse questions a client with open‐angle Correct answer: 3 Open‐angle glaucoma is characterized by halo and blurred vision. The presence of floaters or glaucoma about the presence of which of the following the sensations of a curtain or veil over the visual field are found with detached retina. A symptoms? burning sensation in the eyes is not part of the clinical picture.
| Recall that halos are indicative of glaucoma. |
864 A client is admitted to the pre‐surgical area before Correct answer: 1 The priority nursing intervention is one that maintains contact of the retina with the choroid undergoing surgery to repair detached retina. The by positioning the client so the detached area falls against the choroid. It is unnecessary to admitting nurse would take which of the following darken the client's immediate environment. A preoperative medication may be ordered, but actions first? has lesser priority than maintaining proper position of the head to protect the eye. Both eyes, not just the affected eye, are patched to minimize eye movement.
| Use Maslow’s hierarchy to establish priorities. |
865 A 76‐year‐old woman visits the ambulatory clinic with Correct answer: 4 Visual difficulty caused by distortions and impairment of central vision is common with reports of having difficulty reading and doing macular degeneration. Peripheral vision in most cases is normal. The symptoms are not needlework because of visual distortions. The characteristic of glaucoma, cataracts, or detached retina. peripheral vision assessment by the nurse yields normal findings. The nurse suspects that this client is experiencing which of the following visual problems?
| This question requires knowledge of macular degeneration. |
866 Which of the following strategies by the nurse would Correct answer: 2 Communication with a hearing impaired client is enhanced by facing the client while speaking, be most useful in promoting communication with a because they often consciously or unconsciously lip‐read to better interpret the spoken word. client with presbycusis? The other options are inappropriate and ineffective.
| Use the process of elimination to determine the correct answer. |
867 A nurse is teaching a group of young adults about skin Correct answer: 1 Tanning and sun exposure can increase susceptibility to skin cancers. This is a potentially lesions. Which of the following would be inappropriate harmful activity and should not be included in client teaching. The other items are important to include in discussions with these clients? to discuss with clients who are trying to maintain healthy skin.
| The wording of the question tells you that the correct response is a false statement of fact. Use the process of elimination and nursing knowledge to make a selection. |
868 A client with psoriasis receives a prescription from Correct answer: 4 Methotrexate is used for severe and nonresponsive cases of psoriasis. It is not a first‐line the primary physician. The nurse concludes that the form of therapy. Options 1, 2, and 3 are first‐line treatments for psoriasis. client is not receiving first‐line therapy after noting that the prescription is written for which of the following?
| The core issue of the question is knowledge of the sequence of treatments for psoriasis. The wording of the question tells you that the correct response is also a true statement of fact. Use the process of elimination and nursing knowledge to make a selection. |
869 The nurse practitioner documents in a client record Correct answer: 1 Whiteheads are classified as closed comedones. Blackheads are open comedones. Options 3 that a client has closed comedones. The nurse explains and 4 are irrelevant. to the client that this means the lesions are what type of skin eruption?
| The core issue of the question is knowledge of various skin eruptions. The wording of the question tells you that the correct response is also a true statement of fact. Use the process of elimination and nursing knowledge to make a selection. |
870 The nurse evaluates that a client understands the Correct answer: 3 No medication is indicated for seborrheic keratosis (options 1, 2, and 3). These lesions may be therapeutic management of seborrheic keratosis if he treated with electrocautery or liquid nitrogen for removal. mentions which of the following?
| The core issue of the question is knowledge of treatments for seborrheic keratosis. The wording of the question tells you that the correct response is also a true statement of fact. Use the process of elimination and nursing knowledge to make a selection. |
871 A client with contact dermatitis asks the nurse how Correct answer: 1 Contact dermatitis is an inflammatory response following prior sensitization to an antigen he could have developed the condition. The nurse with production of a specific IgE antibody. Skin manifestations occur with subsequent includes in a response that contact dermatitis is exposures. The other options are false. caused by which of the following?
| The core issue of the question is the ability to correctly describe contact dermatitis. The wording of the question tells you the correct answer is also a true statement. Use the process of elimination and nursing knowledge to make a selection. |
4.‐ Side effect of oral medication | |
872 When explaining the disorder to a client with tinea Correct answer: 2 Fungal infections such as tinea corporis may be transmitted by direct contact with animals corporis, the nurse should include which of the and other persons. Therefore, it is contagious from person to person. It does require following about this skin disorder? treatment, is not malignant, and is not treatable by sunlight.
| The core issue of the question is knowledge of the characteristics of infection with tinea corporis. The wording of the question tells you the correct statement is the correct answer. Use the process of elimination and nursing knowledge to make a selection. |
873 A client asks the nurse about the meaning of the term Correct answer: 2 A full‐thickness burn involves all layers, including the epidermis and dermis, and may extend “full‐thickness burn.” The nurse should respond that into the subcutaneous tissue and fat. The other options indicate varying depths of burn injury. burns classified as full‐thickness involve tissue destruction down to which of the following levels?
| The core issue of the question is knowledge of the various depths of burn injury. The wording of the question tells you the correct statement is the correct answer. Use the process of elimination and nursing knowledge to make a selection. |
874 The client comes to the office for evaluation of a skin Correct answer: 1 The most important question for this office visit for evaluation of a skin rash would be to get rash. What question would be included in obtaining a information about the chief complaint. In this case, it would be to investigate additional history? information about the presenting rash. The other options are either unrelated or could be asked at a later time.
| The issue of the question is appropriate questions to ask when obtaining a nursing history about a skin disorder. The wording of the question tells you the correct statement is the correct answer. Use the process of elimination and knowledge of health assessment to make a selection. |
875 The nurse is assessing the client’s skin and wants to Correct answer: 2 When assessing petechiae, pressure applied to the site will not produce blanching of the skin. evaluate a site for petechiae. What technique can the For other lesions, blanching may occur. Options 1, 3, and 4 are false. nurse perform to help identify whether the site has petechiae?
| The issue of the question is knowledge of nursing assessment techniques for the skin. The wording of the question tells you the correct statement is the correct answer. Use the process of elimination and nursing knowledge to make a selection. |
876 A client has been diagnosed with eczema. Which of Correct answer: 1 Skin care for eczema should include keeping the skin well hydrated and avoiding harsh soaps the following statements made by the client indicates (option 2). This can be done by using mild bath soaps and applying emollients immediately an understanding of the management of eczema? after bathing (option 4). Option 3 is false.
| The core issue of the question is knowledge of appropriate care to the skin when the client has eczema. The wording of the question tells you the correct statement is the correct answer. Use the process of elimination and nursing knowledge to make a selection. |
877 The client diagnosed with psoriasis has been Correct answer: 4 Antihistamines are useful to help relieve itching. The other options do not explain the prescribed an antihistamine. The client asks the nurse rationale for the use of this type of medication with psoriasis. what this is used for because she does not have nasal allergies and congestion. What is the most appropriate response?
| An understanding of the nature of the condition and the client’s symptoms are needed to make the correct response. The wording of the question tells you the correct statement is the correct answer. Use the process of elimination and nursing knowledge to make a selection. |
878 Instructions for a client diagnosed with seborrheic Correct answer: 2 Coal tar shampoos are recommended for seborrheic dermatitis of the scalp. Over‐the‐ dermatitis would include which of the following? counter shampoos may not control symptoms. Seborrheic dermatitis cannot be cured. Symptoms can be controlled with proper treatment.
| The core issue of the question is knowledge of care and treatment for seborrheic dermatitis. The wording of the question tells you the correct statement is the correct answer. Use the process of elimination and nursing knowledge to make a selection. |
879 In teaching clients about measures to reduce the risk Correct answer: 2 The most common form of skin cancer is basal cell carcinoma, with approximately 400,000 of developing basal cell carcinoma, the nurse should new cases per year. Protecting the skin with sunscreen SPF 15 or higher, along with avoiding include which of the following? the sun during the peak hours of 10:00 a.m. to 2:00 p.m., is recommended to help prevent skin cancer.
| The core issue of the question is knowledge of behaviors that can reduce the risk of developing basal cell carcinoma. The wording of the question tells you the correct statement is the correct answer. Use the process of elimination and nursing knowledge to make a selection. |
880 The client with cellulitis is being discharged from the Correct answer: 3 Infection may be manifested by fever, chills, erythema, tenderness, and drainage at the site, hospital. Discharge instructions for the client should especially if it is cloudy or serous. The physician must be notified if these symptoms occur. include which of the following statements?
| The core issue of the question is the risk of infection and the need to notify the health care provider if signs of infection occur. The wording of the question tells you the correct statement is the correct answer. Use the process of elimination and nursing knowledge to make a selection. |
881 Which of the following is a priority nursing diagnosis Correct answer: 4 Clients with cellulitis experience pain at the local site. Controlling the pain is the priority for a client experiencing the skin infection cellulitis? nursing diagnosis for this client. Option 1 may not apply unless the client is in pain. Options 2 and 3 may or may not apply, but would have lower priority than the physiological need (option 4).
| Recall that pain relief is high priority for many clients and is included in the physiological needs on Maslow’s hierarchy. Use the process of elimination and nursing knowledge to make a selection, considering that physiological needs take priority over psychosocial needs in most cases. |
882 The client receives a prescription to treat a skin Correct answer: 3 Current treatments for psoriasis include coal tar shampoo and topical steroids. Folliculitis, infection affecting the scalp and neck. The medications cellulitis, and furuncles are bacterial infections of the skin and would be treated with prescribed are coal tar shampoo and topical steroids. antimicrobial therapy. The nurse concludes that which of the following is the probable diagnosis of this client? | The core issue of the question is knowledge of the uses of medication therapy for psoriasis. The wording of the question tells you the correct statement is the correct answer. Use the process of elimination and nursing knowledge to make a selection. |
‐ Folliculitis ‐ Cellulitis ‐ Psoriasis ‐ Furuncles | |
883 A client has just been diagnosed with herpes virus Correct answer: 1 The initial outbreak of herpes is the most uncomfortable or painful. Recurrent episodes of type 2. The nurse should share with the client which of herpes infection present with a prodrome of symptoms, such as tingling and burning. Herpes is the following pieces of information? a virus that may lie dormant for periods of time, and repeated episodes may occur during periods of stress.
| The core issue of the question is knowledge of the characteristics and presentation of this type of viral infection. The wording of the question tells you the correct statement is the correct answer. Recall that the first outbreak is the most severe to make a selection. |
884 A client presents for removal of a skin lesion after it is Correct answer: 4 To meet all four criteria for removal of a lesion, the lesion will be asymmetrical (A) with an determined that he meets all four criteria for removal irregular border (B), have color change or more than one color (C), along with an increased according to the ABCD rule. The nurse interprets this diameter (D). to mean which of the following?
| The core issue of the question is knowledge of criteria that determine the need to remove a skin lesion. The wording of the question tells you the correct statement is the correct answer. Use the process of elimination and nursing knowledge to make a selection. |
885 The nurse performing a skin examination of a client Correct answer: 2 Spider angiomas are red lesions with vessels radiating from the center. A venous star is a flat notes the client has vascular skin lesions that are flat, blue lesion with radiating linear veins. Petechiae appear as red “freckles” or dots. A port wine bright red in color, with tiny vessels that radiate out stain is a flat, irregular‐shaped lesion that does not have radiating vessels. from the center of the lesion. The nurse concludes that the lesions are probably which of the following?
| The core issue of the question is knowledge of various types of skin lesions. The wording of the question tells you the correct statement is the correct answer. Use the process of elimination and nursing knowledge to make a selection. |
886 A client presents on admission with pressure ulcers Correct answer: 4 Stage 4 ulcers result in full thickness skin loss with extensive damage to the muscle and bone. extending into the bone. The nurse documents this ulcer at stage . Write in a numerical answer. | The core issue of the question is knowledge of various stages of ulcer development. The wording of the question guides you to a decision. Use nursing knowledge to make a selection. |
887 A child was admitted to the emergency department Correct answer: 1 Coughing and wheezing may indicate that the child has inhaled smoke or toxic fumes. with a thermal burn to the right arm and leg. Which of Maintaining airway patency is the highest nursing priority in this situation. Skin color changes the following assessments requires immediate action? are expected. Thirst may be present but does not require immediate nursing action.
| The core issue of the question is the ability to determine that the client’s airway could be in jeopardy. Use the ABCs whenever a question deals with burn injury as a first method to determine priority setting. |
888 A school‐aged child develops eczema secondary to Correct answer: 2 Eczema is a chronic inflammatory skin disorder. School‐aged children are very aware of their food allergies. An appropriate nursing diagnosis for this own and others’ skin appearance. Children with eczema will feel different from other children, child would be which of the following? and this may affect their body image. Food allergies do not relate to decreased nutrition. Eczema does not affect the skin’s ability to maintain temperature, and it does not affect blood flow to the area.
| The core issue of the question is recognition of key concerns of a child with eczema. The wording of the question tells you the correct statement is the correct answer. Use the process of elimination and nursing knowledge to make a selection. |
889 An infant has a positive family history of allergies. To Correct answer: 4 Infants with eczema frequently have food sensitivities. Slow introduction of new foods allows reduce the risk of the infant developing eczema, the the parents to recognize food sensitivities and eliminate the offending item from the diet. The nurse teaches the family to mother is taught to avoid scratchy clothing such as wool. Childhood immunizations would be given as scheduled but do not reduce risk. Eczema is not an infectious disease. Avoiding infectious personnel is appropriate for all children but does not prevent the development of eczema.
| The core issue of the question is appropriate client teaching to reduce risk of developing eczema. Recall the risk factors and use the process of elimination to make a selection. |
890 The parents of an 18‐month‐old with eczema are Correct answer: 3 The nurse should encourage parents to identify and discuss their feelings and concerns. concerned that a secondary infection that has Changing the topic or giving false reassurance is inappropriate. Merely not blaming parents developed will permanently disfigure their child. How does not give them the opportunity to discuss what is important to them. can the nurse best support the parents’ feelings?
| The core issue of the question is the ability to use basic communication techniques in responding to the concerns of a parent. Choose the option that directly addresses the client’s or family’s issues and concerns. |
891 The child has just been admitted to the pediatric burn Correct answer: 3 Until a complete assessment and treatment plan are initiated, the child should be kept NPO. unit. Currently, the child is being evaluated for burns to A complication of major burns is paralytic ileus, so until that has been ruled out, oral fluids his chest and upper legs. He complains of thirst and should not be provided. asks for a drink. What is the most appropriate nursing action?
| The core issue of the question is the need to avoid fluid intake during the acute phase of burn injury when hemodynamics could be unstable. Use nursing knowledge to recall that fluid resuscitation needs to be done parenterally. |
892 Hospitalization of a child has resulted in disturbance Correct answer: 3 Identification of nursing diagnoses that apply to the specific problem(s) of the child and family of the dynamics of the family life. Which nursing is an essential step of the nursing process. Family‐centered care addresses the needs of the diagnosis would be most appropriate for the nurse to family members, including the child's siblings. The primary goals are to maintain the formulate? relationship with the child and siblings during the period of separation while hospitalized and avoid boredom and distress for the hospitalized child.
| Concepts of hospitalization and family dynamics are needed to answer this question correctly. |
893 The parent of a 6‐month‐old infant is concerned that Correct answer: 4 Fontanels are inspected and palpated for size, tenseness, and pulsation. The anterior fontanel the infant's anterior fontanel is still open. The nurse should be soft, flat, and pulsatile with the child in the sitting position. The anterior fontanel would explain to the parent that further evaluation is should be completely closed by age 12 to 18 months. If the fontanel is found to be open after needed if the anterior fontanel is still open after: 18 months, the child is referred for further evaluation.
| Critical words are "6‐month‐old" and "concern that the anterior fontanel is still open." Use knowledge of normal closure of anterior fontanel to choose the correct answer. |
894 The nurse determines that parents understood Correct answer: 4 Use of a mild soap such as Dove® or Tone® prevents the skin from excessive dryness in atopic instructions about the care of the child with atopic dermatitis. Hot water is drying to the skin so should be avoided. Fabric softeners and many dermatitis (eczema) after the parents state that the lotions contain perfumes that are irritating to the skin so should also be avoided. child should:
| Consider which activities would not be drying to the skin and which would not expose the skin to perfumes. |
895 A parent of a child with a full thickness burn asks why Correct answer: 2 Sulfamylon is a topical antibiotic that is used on burns to prevent bacteria from infecting the the nurse keeps spreading "that white cream" on the burn site. The other options are incorrect statements child's burns. The nurse explains that the cream is mafenide (Sulfamylon), which is being applied to the burned area because it is a:
| Knowledge of the actions for the medications used to treat burns will aid in choosing the correct answer. |
896 A child has been diagnosed with scabies. The nurse Correct answer: 1, 5 The saliva, ova, and feces of the scabies mite triggers an antigenic response that causes reinforces to the parents that, in addition to 5% intense pruritus. Pain is not present nor is scarring. Antibiotics would only be added to the permethrin lotion, appropriate medical therapy for regimen if the itching leads to scratching and breaks in the skin with development of a this child would include: (Select all that apply.) bacterial infection. Scabicides are used to kill the mites causing scabies.
| Consider the symptoms of scabies to determine the correct response. |
897 When assessing a teenager with atopic dermatitis Correct answer: 2 By the teenage years, eczema presents as large patches of thickened dried (lichenified) skin. (eczema), the nurse would expect to find what type of Areas of excoriation, crusts, and papules characterize eczema in infants and younger children. skin lesions? Bullae are not present in eczema.
| The core concept in this stem is the age of the child in association with the disease process. |
898 A child with cellulitis of the leg is being treated at Correct answer: 3 The cause of cellulitis is a bacterial infection, often preceded by trauma. Colds and flu illness home. Following patient teaching, which statement by are viral infections and are not related to cellulitis; thus further teaching is needed about the the mother indicates a need for additional education? cause. The child should complete all medication ordered and is not contagious so company is allowed. If further swelling occurs, it could indicate the infection is not responding to the antibiotics.
| The wording of the question indicates that the correct answer is an incorrect statement on the part of the parents. Eliminate responses that contain correct information. |
899 When telling parents how to apply topical steroids to Correct answer: 1 Topical steroids are readily absorbed through the skin; therefore, they should be applied treat eczema the nurse should explain that: sparingly over affected areas only. They are applied three to four times daily as ordered over clean dry skin.
| Recall that corticosteroids would not be applied to normal skin so that option can be eliminated. An antibiotic cream will be most effective on dry skin so that option can also be eliminated. |
900 The nurse is admitting several children who have skin Correct answer: 3 Eczema is also called allergic dermatitis. It is not contagious. Scabies is caused by the mite and conditions to the hospital unit during the work shift. is highly contagious. Pediculosis capitis is an infestation with lice and can spread. Impetigo is an When considering room assignments, the child who infection caused by staphylococci and streptococci and can also be spread on contact. does not pose a risk for spread of his or her disease is the child with:
| Determine the cause of each condition. Those that have an organism associated are usually contagious. |
901 The nurse is caring for several children with burn Correct answer: 3 Burns that are circumferential are always considered major because they can cause edema injuries. The nurse determines that it is most that restricts blood flow to an extremity. Therefore, it is important to check pedal pulses in this important to check the pedal pulses in a child with: child. Pedal pulses should always be assessed, but the nurse would be more alert to the possibility of impaired circulation in a child with a circumferential burn.
| Of the four options, all are very similar except the option that describes the circumferential burn. |
902 A 4‐year‐old child was just diagnosed with impetigo. Correct answer: 4 Handwashing is always the most important action that a nurse can take to prevent the spread What is the most important action the nurse should of infection. Merely applying ointment or covering the site does not address the spread of take to ensure that it does not spread? infection, nor does isolation of a child at home. The nurse would teach the family the importance of good handwashing.
| Understanding the means of transmission is important in correctly responding to this question. Knowledge of impetigo and the prevention of the spread of infections will aid in choosing handwashing as the first line of defense against the spread of illness. |
903 The nurse is providing home care instructions for a Correct answer: 2, 3, 4, Live nits can hatch up to 8 to 10 days later, so it is important to remove them from the family with a toddler diagnosed with lice. The nurse 5 environment. Soaking combs in a Lysol or anti‐lice shampoo mixture will kill lice or nits. Dry includes which of the following instructions in the cleaning is not necessary because home washing and drying on hot settings will be sufficient to teaching plan? (Select all that apply.) kill lice and nits. Use of commercial sprays is not recommended. Each member of the family should be assessed so those infested can be treated. Sharing of haircare material spreads lice and should be avoided.
| Knowledge of the spread of lice and the home care necessary to prevent reinfestation is necessary to choose the correct answer. Identify those options that are absolutely incorrect first. Then consider the remaining options. |
904 The Emergency Department (ED) nurse hears a radio Correct answer: 2 The anticipated appearance of partial thickness burns is bright red skin with blisters of varying transmission from an ambulance stating that a 10‐year‐ sizes. A superficial burn typically only has pink or red skin. A full thickness burn may be dark in old boy is en route who sustained partial thickness color, from deep red to black. burns to his right arm and abdomen after tossing gasoline on a fire. On admission to the ED, the nurse expects the appearance of the burn site to be:
| Organize the options from the least serious burn injury to the most serious. Since partial thickness falls in the middle of the least serious to most serious, this should allow the learner to select the right option. |
905 Permethrin 5% (Elimite) is prescribed for a 10‐year‐ Correct answer: 4 Permethrin is applied to cool dry skin after a bath, but only from the neck down. The child old child diagnosed with scabies. What instructions may dress after the lotion is applied. It should be washed off after 8 to 12 hours. A second should the nurse provide for the mother? application is often prescribed for 1 week later.
| Scabies primarily occur where skin is in contact with skin. Applying the medication to the head would be unnecessary. It is necessary to remember how long the medication must remain in contact with the skin. Since the scabies burrow into the skin, it would make sense that a longer contact time is needed for treatment. |
906 When assessing a child with a possible diagnosis of Correct answer: 1 A recent history of otitis media is often present in children with facial cellulitis. Sunburn facial cellulitis, the nurse will want to question the would present as more diffuse and widespread redness. An insect or animal bite can be a parent about a recent history of: cause of cellulitis, but in the case of cellulitis on the face the nurse would question a recent history of an ear infection first if a bite was not obvious. Dental caries are unrelated.
| Knowledge of cellulitis and the etiology and pathophysiology of cellulitis will aid in answering the question. |
907 In teaching a group of school‐age children, a nurse Correct answer: 2 Lice can only be passed by direct contact because lice do not fly. The usual mode of would explain that lice on a child can be most easily transmission is sharing of hats, combs, brushes, or hair ornaments. Being close to someone in spread by: a classroom, bus, or car does not presuppose direct contact with hair or nits that have been shed on hair.
| Select the option that allows for direct contact. The incorrect options do not allow for direct contact of the infected individual or contact with the infected individual’s belongings. |
908 The nurse is developing a care plan for a 10‐year‐old Correct answer: 3 Keeping the skin well hydrated will prevent the need to scratch dry skin that can lead to girl with eczema of the elbows, hands, and face. The excoriation and secondary infection. Eczema is not infectious, nor is it managed by dietary nurse would formulate which of the following as an restrictions. Pruritus, not pain, is associated with eczema. appropriate client goal for this child?
| Consider the common symptoms of the disease to determine typical client goals. Determine that the correct answer must address the needs of the skin based on disease pathophysiology. |
909 A 5‐year‐old boy was brought to the Emergency Correct answer: 2 Because he was in close proximity to the fire and tried to put it out, he is at risk of having Department after being burned trying to put out a fire inhaled smoke and therefore having a compromised airway. Other physiological signs will be of in his closet, where he was playing with matches. The next highest priority, such as pain. Infection would be a third priority since it would not happen priority nursing assessment for this child would be: immediately, and psychosocial concerns are addressed once physiological needs have been met.
| Recall that a patent airway is almost always the primary assessment. Assessing pain, psychosocial needs, or for infection occurs only after establishing airway patency. |
910 Intravenous (IV) morphine sulfate is ordered for a 13‐ Correct answer: 2 The predictable rate of absorption makes IV morphine useful in treating severe pain. As part year‐old girl hospitalized with major burns to 30% of of the physiological stress response, blood is shunted away from the gastrointestinal tract, her body. A licensed practical nurse (LPN) asks the making oral absorption rates less predictable. The IV route will not prevent ileus and may registered nurse (RN) why the morphine is given by the actually have greater side effects because of rapid onset of action. The half life of the drug is IV route when the child can talk and swallow. The RN not relevant to the question asked. should explain to the LPN that, when given by the IV route, morphine does which of the following?
| The core concept is the purpose for giving morphine by the IV route. Eliminate options 3 and 4 because they are false. Choose option 2 over 1 because it directly addressed the purpose of this route. |
911 The nurse is providing a teaching session for parents Correct answer: 4 Permethrin is the over‐the‐counter treatment of choice for head lice. Other choices are about over‐the‐counter treatment for head lice. Which topical agents, but they would not be used for lice. Option 1 would be used for infection, while of the following would the nurse mention as options 2 and 3 would be used to treat burns. appropriate for treating this problem?
| Note that three of the medications are antibacterial. The one that is different is the only medication listed for lice. |
912 When bathing a 3‐year‐old with eczema, the nurse Correct answer: 3, 5 Hot water can exacerbate symptoms of eczema and increase pruritus. Tepid water feels more tells the mother to have the bathwater: (Select all that comfortable than cool water. Strong or harsh soaps and perfumed products could be irritating apply.) to the skin and should not be used.
| Options 1 and 2 include the word “hot,” which would be wrong, leaving only options 3 and 4 to choose between. |
913 The nurse explains to the mother that a child who has Correct answer: 2 Impetigo remains contagious for 48 hours after antibiotics are begun. The presence or begun treatment for impetigo with a topical antibiotic absence of crusts does not address the issue of contagion. can return to daycare:
| With many infectious diseases, the patient is not considered contagious after 48 hours of antibiotics. |
914 When assessing a child’s hair and scalp, the nurse Correct answer: 3 The characteristic appearance of pediculosis capitis (lice) is nits that adhere to the hair shaft notices what looks like dandruff, but it does not flake about 1/4‐inch from the scalp. They cannot be easily brushed off as dandruff. Scabies, eczema, off easily. The nurse suspects the child has: and impetigo do not typically appear on the scalp and present as skin lesions elsewhere on the body.
| The critical words are "dandruff . . . does not flake off easily." |
915 A child has been admitted to the burn unit with a Correct answer: 4 The fluid shift that occurs in burns leads to edema, so the burned extremity should always be circumferential burn to the right leg. The nurse will elevated above the level of the heart. position the client:
| Options 2 and 4 are opposites. One of them is likely to be the correct answer. Use gravity as the method of making a final selection. |
916 A 3‐year‐old child is suspected of having eczema. The Correct answer: 1 Eczema in a young child tends to be characterized by dry, scaly crusts that are well nurse assesses for which of the following as a major circumscribed. Pruritus is always present. symptom of eczema?
| Eliminate any option that describes skin lesions that would not be dry and scaly. |
917 A child has been diagnosed with eczema. While taking Correct answer: 3 About 60% of children with eczema have a family history of asthma or other allergy. Scabies is the nursing history, the nurse will assess for a family caused by contact with a mite; impetigo and cellulitis are bacterial infections. history of:
| Since another name for eczema is atopic dermatitis, and the term atopy refers to allergies, the nurse would look for this family history. |
918 When assessing a child with facial cellulitis, the nurse Correct answer: 2 Sinusitis frequently precedes periorbital cellulitis. Facial cellulitis may be preceded by otitis will want to ask the parent about a recent history of: media. A dog bite could cause cellulitis anywhere. Sun exposure causes a thermal injury.
| The suffix “‐itis” refers to inflammation, which is often related to infection. Look for an option that suggests another infection in the general area. |
919 A child will be treated for cellulitis of the left leg. The Correct answer: 1 The only way to eliminate the infectious agent is to complete the prescribed course of nurse will include in the care plan the need for: antibiotics. Strict bed rest is not indicated, although the child initially may feel more comfortable resting with the extremity elevated. Fluid intake has no effect on the course of the infection, which is not contagious; therefore, visitors do not have to be limited.
| Any bacterial infectious disease requires completion of the antibiotic therapy. |
920 There have been several cases of lice in the Correct answer: 4 Lice is spread by sharing combs and hats. Close contact is required as the lice do not jump or elementary school. The school health nurse is fly. providing information about lice prevention at the PTA meeting. Correct information should include:
| Option 1 can be eliminated as healthy children are not treated. Lice is spread by contact, so options 3 and 4 are the options to choose between. |
921 The nurse is working with a teenager diagnosed with Correct answer: 3 A teenager can and should be part of the treatment plan. If itching is avoided to prevent eczema. In order to increase treatment compliance, excoriation and secondary infection, scarring is unlikely. Improvement is often slow, and the the nurse will explain: problem may persist into adulthood. Food avoidance will not change the course of the disease.
| The key to this question is to increase treatment compliance. Learning that scarring can be prevented will encourage compliance. |
922 The nurse is teaching self‐care to a client with Correct answer: 1 Emollients will ease the problem of dry skin that increases pruritus and causes the psoriasis to psoriasis. The nurse should encourage which of the be worse. Washing and drying the skin with rough linens or pressure may cause excoriation. following for his scaled lesion? Constant occlusion may increase the effects of the medication and increase the risk of infection.
| Recognize that the longest and correct answer mentions the scales found in psoriasis. |
923 The nurse teaches a client that the first step in self‐ Correct answer: 2 In order to plan the appropriate management of contact/irritant dermatitis, the cause of the management of contact/irritant dermatitis is to do inflammation should be identified. Removal of the cause may be all the treatment needed. which of the following? Antihistamines and hydrocortisone creams are treatment options. Skin testing may be helpful to determine the allergen if not evident in the history.
| Recall the logical first step; remove the cause. |
924 A mother asks how her 2nd‐grade child got head lice. Correct answer: 2 Lice are transmitted by direct contact with infested persons or by sharing hats, brushes, or The nurse responds by telling the mother that lice: combs of infected persons. Classrooms are excellent areas for close contact, and children often do not know when other classmates have lice. Options 1, 3, and 4 are incorrect. | Knowledge of the spread of head lice is needed for this question. |
‐ Only occurs in socioeconomically deprived people. ‐ Was probably spread by person‐to‐person contact in the classroom. ‐ Is an airborne infestation. ‐ Is due to improper washing of her hair. | |
925 The nurse conducting a health fair teaches attendees Correct answer: 1 The disease is ten times more common in fair‐skinned people who work indoors. This that which of the following groups of people are most population often experiences severe sunburns and blistering in childhood and tends to at risk for developing malignant melanoma? vacation in areas of intense sun exposure. Remember, episodic intense sun exposure is more damaging than constant exposure.
| In this question look for opposites in the responses and make sure both components of the question are correct. |
926 A client is admitted to the emergency department Correct answer: 4 There is no sensation of pain to light touch in full thickness burns because the pain and touch with 50 percent burns to the chest and arms. The skin receptors have been destroyed. There may not be pain with some partial thickness degree is white, dry, and there is no pain. The nurse assesses burns, but the appearance described is characteristic of full thickness. the type of burn the client has as which of the following?
| Remember full thickness burns are painless, except around the edges where partial thickness burns exist. |
927 A young boy is brought to the trauma unit with a Correct answer: 3 A burn involving the face, neck, or chest may cause airway closure because of the edema that chemical burn to the face. Priority assessment would occurs within hours. Remember the ABCs: airway, breathing, and circulation. Airway always include which of the following? comes first, even before pain. The nurse will also assess skin integrity (option 1), blood pressure and pulse (option 2), and pain (option 4), but these are not the highest priority assessments.
| Remember the ABCs (airway, breathing, circulation). Airway is a key priority in questions. |
928 A 10‐year‐old female client complains of dandruff. On Correct answer: 4 Pediculosis capitis is head lice, and nits are cemented to the hair shaft. They are most examination, the nurse notices the dandruff flakes commonly seen on hair on the back of the head near the nape of the neck. A papular don't brush off the hair, and there is a papular rash on excoriation may be present at the nape of the neck secondary to scratching. her neck. The nurse suspects which of the following disorders?
| This question requires knowledge of the appearance of head lice. |
929 The nurse is most concerned about a wasp sting for a Correct answer: 3 If the client previously had a reaction to a wasp sting, immediate treatment must be client who: administered. If a reaction is anticipated, do not complete the exam or wait for symptoms to develop, be proactive. Pain often causes the blood pressure to rise. The client who has never been stung should be monitored closely.
| Remember the risk in allergies is with second and subsequent exposures. |
930 A client who has been on two antibiotics complains of Correct answer: 2 Candidiasis (oral thrush) often develops as a result of the overgrowth of bacteria after a client burning on the tongue and doesn't want to eat. has been on an antibiotic. Inspection of the tongue reveals a white, milky plaque that does not come off with rubbing. The nurse suspects which condition?
| This question requires knowledge of secondary infections. |
931 The nurse would include which of the following pieces Correct answer: 1 Since a wart is a virus‐induced epidermal tumor, it may reappear at the original site or of information in health teaching for a client with another body area despite the fact that the original wart was removed. Immunity may develop warts? to further warts after 5 years.
| Use the process of elimination to select the correct and the longest answer. |
932 A 70‐year‐old female complains of burning and itching Correct answer: 2 Dermatomal pain, itching, or burning may be severe and often begins 4 to 5 days before for several days in her right abdominal area. She thinks eruption occurs. The trunk is affected in the majority of cases. An insect bite usually manifests she has been bitten by something because she can feel immediately, warts do not burn or itch, and scabies usually do not burn. Scabies form lines in small bumps at the site. The nurse suspects which of the folds of the skin. the following conditions based on this assessment data?
| Recall that herpes effects along nerve lines. |
933 A 23‐year‐old male presents with a pustular Correct answer: 3 Folliculitis is an inflammation of the hair follicle caused by infection, chemical irritants or inflammation of his neck. Which of the following would injury. It is most commonly caused by Staphylococcus aureus. Using a clean razor each time he the nurse use as an important management strategy? shaves will decrease the risk of reinfection.
| Use the principles of asepsis to answer this question. |
934 A client asks the nurse in the dermatologist's office Correct answer: 4 All three diagnoses are a bacterial infection of the skin arising from the hair follicle, where about what characteristics folliculitis, furunculosis, and bacteria can accumulate, grow, and cause a localized infection. Options 1 & 3 are carbunculosis all have in common. The nurse replies incorrect. that all three disorders are:
| Notice that bacterial infection is repeated in two options so look at those closely for the correct answer. |
935 A 2‐year‐old child has been sick with a cold and Correct answer: 1 Impetigo is an infection of the skin typically beginning with a vesicle or pustule. The lesion develops a honey‐colored lesion on her chin within the ruptures, leaving an open area that discharges a honey‐colored serous liquid that hardens into past 3 days. The nurse determines that this clinical a crust. Impetigo spreads quickly if not treated. picture is consistent with which of the following?
| This question requires knowledge of impetigo as a bacterial infection. |
936 The nurse would include which of the following in the Correct answer: 4 Psoriasis is a chronic disease with factors such as stress precipitating an exacerbation. A nursing management of the client with psoriasis? healthy lifestyle is recommended and includes a well‐balanced diet, frequent exercise, moderate alcohol intake, and avoidance of tobacco products. The disease cannot be transferred to another person, keeping the skin moist relieves the itching, and medications can be effective.
| Use the process of elimination to choose the correct answer. |
937 A client presents to the clinic with thick, white, flaky Correct answer: 1 Normally, the keratinocyte migrates to the outer layer of the skin in 14 days. Psoriatic skin skin. The nurse knows that these symptoms occur cells complete this journey in 4 to 7 days producing an abnormal keratin that forms thick, flaky when the cell cycle is shortened, such as occurs with scales at the surface of the skin. Options 2, 3 and 4 do not have white, flaky skin as a which of the following diseases? characteristic.
| Use the process of elimination to choose the correct answer. |
938 The nurse working at a community health fair in the Correct answer: 3 Melanomas tend to have asymmetry (A), border irregularity (B), color variegation (C), and booth for skin assessment should be teaching the diameter (D) greater than 6 mm. The ABCD rule can be applied to any skin condition, but ABCD rule as a definitive measurement for which malignant melanoma is the most severe and has changes in all 4 of the rules. diagnosis?
| Recall the ABCD rule for melanomas. |
939 A man suffers from burns to the arms and chest when Correct answer: 2 Restrictive jewelry and clothing are removed immediately from the burn victim to prevent a fire got out of control. The nurse removes jewelry circumferential constriction of the torso and extremities. Assessment of the fingers and from the affected burn site in order to do which of the interference with treatment may require removal of jewelry, but the primary reason is option following? 2.
| Recall knowledge of pressure areas. |
940 A 9‐year‐old child plays three baseball games on a Correct answer: 4 A superficial thickness burn, such as sunburn, involves only the epidermal layer of the skin. hot, humid summer day. The child is at high risk for The color ranges from pink to bright red and small painful blisters may form. dehydration and which of the following conditions? 1.‐ Skin cancer | Recall that sun exposure increases the risk of sunburn. |
‐ Full thickness burn ‐ Partial thickness burn ‐ Superficial thickness burn | |
941 When evaluating a client with a new skin lesion, it is Correct answer: 3 Tanning and sun exposure can increase susceptibility to skin cancer and not all individuals use most important to ask the client about which of the a sunscreen or consider tanning as having serious consequences. following?
| Select the client at highest risk. |
942 The nurse teaches the client with urticaria about Correct answer: 1 Moisturizing the skin helps decrease dryness that can aggravate pruritus. Soaps and hot water controlling the pruritus. Which of the following are also drying to the skin. Tepid water and a mild soap should be used and it is not necessary statements would the nurse include in discussion with to take a bath daily. Oral intake should be increased to bring extra moisture to the skin, and the client? only those perfumes/lotions with alcohol should be avoided.
| Recall that dry skin leads to itching, requiring lotion. |
943 A male client complains of having red lesions on the Correct answer: 2 Staphylococcus aureus is the most common organism causing folliculitis, furuncles, and face after shaving and wants to know what it is. The carbuncles. The red lesion noticeable after shaving is common in inflammation of the hair nurse identifies these as characteristic of: follicle.
| When given choices, be sure both answers are correct. |
944 In planning care for a female client with tinea capitis, Correct answer: 2 Hair loss occurring with tinea capitis is usually temporary but can be of extreme concern for a the nurse should explain that the client should expect female. The other responses are incorrect for this disorder. which of the following?
| Knowledge of tinea capitis is required. |
945 In teaching the client about her topical medication for Correct answer: 4 Symptoms may resolve quickly after a few days, but the full course of prescribed medication candidiasis, the nurse should stress which of the for antifungals (7 to 10 days) should be used to prevent recurrence. following?
| Remember to ensure that a full course of antibiotics is taken. |
946 The mother of a 5‐year‐old child with recurrent Tinea Correct answer: 1 The combination of moisture and the rubber boots contribute to fungal growth. Wearing pedis asks the nurse how the child got the condition. clean cotton socks daily and changing them frequently decreases the moist environment of the After talking with the mother about the child's habits, feet. The other two options should not be problematic. the nurse determines that which of the following would be the most likely cause?
| Recall that moisture increases risk of infection. |
947 A client goes to the dermatology clinic for the Correct answer: 4 Plantar warts occur at pressure parts on the soles of the feet, which prevent the wart from removal of a wart. The nurse documents which of the growing outward so they extend deeper and become painful. following most classic distinguishing features of a plantar wart?
| Recall that pain is a key symptom of plantar warts. |
948 The nurse conducting discharge teaching for a client Correct answer: 3 Increased pain, fever, drainage, or spread of blisters can indicate a secondary infection. The with herpes zoster should include which of the disease is contagious to people who have not had chickenpox. Secondary occurrences are rare. following in discussions with the client? Antiviral medications, antipruritics, and pain medications are usually prescribed.
| This question requires knowledge of the symptoms of secondary infections. |
949 A client is admitted with 25 percent total body Correct answer: 1 Fluid shifts from the intravascular compartment to the interstitial compartment due to surface area (TBSA) burned. The rationale for damage to the cells' permeability, causing a drop in blood pressure and edema. Option 2 does administering intravenous fluids initially is which of the occur in the beginning, but is not the reason for administering fluids. Notice the question asks following? about initially; options 3 and 4 would be appropriate rationales for decreasing fluid later on.
| Be sure both options are correct when choosing answers with more than one item mentioned. |
950 Which of the following clients would be most likely to Correct answer: 3 The major etiological factor in basal cell carcinoma is solar radiation. An outdoor construction develop basal cell carcinoma? worker is more prone to constant sun exposure and for long periods of time. Chemicals (options 1 and 4) and radiation (option 2) are not causes.
| Knowledge is needed of the causes of skin cancer. |
951 In teaching a client about sunscreens, the nurse Correct answer: 3 A waterproof or water‐resistant sunscreen with SPF 15 or more should be used before every advises using which of the following as the minimum exposure to the sun. level of protection?
| Note that this question refers to the minimum level of protection. |
‐ Lotion with SPF of 15 ‐ Oil with SPF of 12 | |
952 A client diagnosed with senile lentigo is concerned Correct answer: 1 Senile lentigo occurs on UV light‐exposed skin of older Caucasian adults and is benign. It is about skin cancer. The best response by the nurse commonly called "liver spots." Option 2 is premalignant lentigo; option 3 is squamous cell would be? carcinoma; and option 4 is commonly called benign lentigo.
| This question requires knowledge of senile lentigo. |
953 A mother asks the nurse for advice concerning a Correct answer: 3 Shampooing alone is not enough to remove the eggs; manual removal with a comb is recurring case of head lice in her child. Upon necessary. Also, NIX does not need to be repeated in 7 to 10 days, it is a one‐time treatment. assessment the nurse discovers the mother washed The stuffed animals and pillows must be washed but do not need to be discarded. the child's hair one time with NIX. Further instructions would be to:
| Use the process of elimination, noting that option 3 is a more inclusive answer than option 1. |
954 A client presents to the clinic with herpes zoster. It is Correct answer: 3 Herpes zoster is believed to result from reactivation of a varicella virus that has remained in most important for the nurse to ask about which of the sensory dorsal ganglia after a childhood infection of chickenpox. the following?
| This question requires knowledge of the relationship of varicella to herpes zoster. |
955 A 40‐year‐old male presents to the emergency Correct answer: 3 A client with previous reactions to insect bites may have a severe reaction to a large number department with 20 to 30 hornet stings after hitting a of stings by hornets. Options 1, 2, and 4 are characteristic of insect bites and should be nest while mowing the lawn. The wife states he is watched closely. Option 3 is extremely concerning and could mean an anaphylactic reaction allergic to bee stings. Which of the following has begun. symptoms warrants immediate attention?
| Remember the ABCs (airway, breathing, circulation). Airway is the priority. |
956 A client presents with a skin rash on her hands, Correct answer: 2 The lesions of scabies are characteristic: small red‐brown burrows sometimes covered with elbows, and axillary areas. On examination, the nurse vesicles. The collection of lesions appears as a rash. The other responses do not have these assesses raised burrows with thread‐like ridges classic characteristics. between the fingers, on the palms, antecubital spaces, and axillary areas. The client probably has which of the following disorders?
| This question requires knowledge of scabies. |
957 A client visits the dermatology clinic at 1:00 P.M. with Correct answer: 2 True urticaria lesions do not last longer than 24 hours. If a lesion lasts longer than that time, what appears to be urticaria lesions. Confirmation of other differential diagnoses must be investigated. the diagnosis would be made based on information that the lesions first started:
| This question requires knowledge of urticaria. |
958 Nursing management of a client with a superficial Correct answer: 4 Treatment of superficial thickness or first‐degree burns includes cleansing with a mild soap thickness burn includes which of the following? such as Phisohex, topical anesthetics as needed, and no dressings.
| Choose the least invasive option. |
959 A 45‐year‐old male asks the nurse to assess several Correct answer: 3 Seborrheic keratosis appears as brown "stuck‐on" spots over the trunk, may bleed when spots that have suddenly appeared. They are large, irritated by clothing or picking, are usually benign, and occur in the middle aged. smooth, velvety, and brown. The nurse determines that these are characteristic of which of the following conditions?
| This question requires knowledge of seborrheic keratosis. |
960 The client with a skin rash has been prescribed an Correct answer: 1 Although option 4 is true, option 1 is the appropriate rationale for use of an antihistamine for antihistamine and asks why it is needed. The nurse most skin rashes. Option 2 is not therapeutically stated and option 3 avoids the client’s responds by using which of the following as the best question. explanation?
| This question requires knowledge of the action of antihistamines. |
961 In the rehabilitation phase of care for a burn client, Correct answer: 3 The rehabilitative stage of burn injury is to return the client to the highest level of health the nurse would implement which of the following as a restoration, which includes physical therapy, occupational therapy, psychological, cultural and priority intervention? spiritual counseling if needed. By the time the client is ready for rehabilitation, the concerns for shock, electrolyte, and fluid imbalances should be lessened.
| Note that the word ‘rehabilitation’ in the question stem is key in answering this question. |
962 A client who presents with a burn to the anterior Correct answer: 4 Remember that according to the Rule of Nines, the anterior chest is 18 percent and both chest and both arms anterior and posterior is said to arms are 9 percent each, totaling 36 percent. have burned what percentage of the body using the Rule of Nines? 1.‐ 27 percent | This question requires knowledge of the rule of nines. |
‐ 45 percent ‐ 37 percent ‐ 36 percent | |
963 Client teaching concerning the causes of contact Correct answer: 3 Contact dermatitis is a type of dermatitis caused by a hypersensitivity response or chemical dermatitis would include which of the following? irritation.
| Note the key word ‘contact’ in the question stem. |
964 A mother brings her three children to the clinic with a Correct answer: 1 Tinea corporals are a fungal infection of the body called ringworm. The most common lesions rash on each of their faces. On assessment, the nurse are large, circular patches with raised, red borders of vesicles, papules, or pustules. notes the areas are circular patches with raised red borders. The nurse concludes that this is compatible with which of the following problems?
| This question requires knowledge of tinea. |
965 Discharge instructions for the client with cellulitis Correct answer: 4 Signs of infection may include fever, chills, erythema, tenderness, drainage, and malaise. A should include which of the following? healthcare provider should be notified.
| Remember the importance of assessment as a key intervention. |
966 The client has been prescribed to use tar shampoo for Correct answer: 3 Coal tar shampoo is a treatment option for psoriasis of the scalp. Folliculitis and cellulitis are a scalp infection. The nurse tells the client to return to bacterial infections requiring antibiotics. Pediculosis is head lice, which requires a shampoo the ambulatory clinic if this treatment is not effective such as Nix or Kwell. against the condition, which is probably caused by:
| This question requires knowledge of the treatment of psoriasis. |
967 Which of the following nursing diagnoses is of highest Correct answer: 2 Clients with herpes zoster have impaired skin integrity and pruritis with scratching along with priority for a client with herpes zoster? possible excoriation, which causes a high risk for secondary bacterial infection. Altered comfort would also be a diagnosis but is not one of the options.
| Note that in this question safety is a priority. |
968 When counseling clients regarding prevention of Correct answer: 3 Most burns that occur at home are caused by hot water or steam. Lowering the temperature common burns, the nurse should stress which of the setting of the hot water heater is a first‐line prevention measure, especially with children following? present. 1.‐ Stop smoking | This question requires knowledge of the common causes of burns. |
‐ Smoke detectors in the home ‐ Temperature setting of the water heater ‐ First aid measures | |
969 The client, a healthcare provider herself, presents Correct answer: 3 A contact dermatitis common to healthcare providers is latex glove allergies. All options could with a rash to her hands. Assessment of which of the be correct but the addition in the stem of the question about the client's field of work should following would be most helpful in differentiating the direct the learner to the correct option. Other common causes of contact dermatitis include cause of the rash? chemicals, soaps and detergents, but most agencies use milder forms.
| This question refers to the risk of the occupation. |
970 In addition to impaired skin integrity, which of the Correct answer: 3 By altering the skin integument, all three diagnoses place the client at risk for infection by following would be a priority nursing diagnosis for Staphylococcus, which is normally found on the skin. Psoriasis can also be triggered by a clients with disorders such as burns, psoriasis, and respiratory infection, particularly pharyngitis caused by Streptococcus. Pain is usually not a shingles? concern in psoriasis and will depend on the stage of a burn. Options 2 and 3 could be correct, but notice the stem asked for the priority diagnosis.
| This question requires knowledge that the skin is the first line of defense. |
971 During a teaching session about acne, a client asks Correct answer: 2 Dietary restrictions have not been found to be clinically relevant in the severity or cause of which foods should be avoided. The nurse's best reply acne. Stress should be placed however on healthy food preferences. is:
| This question requires knowledge that diet is not associated with acne. |
972 The nurse notes that a client has an elevated lesion Correct answer: 3 A bulla measures > 0.5 cm. A papule is solid; a vesicle measures &lt; 0.5 cm; and a that contains clear fluid and measures >1 cm in pustule contains purulent exudates. diameter. This finding is best documented by the nurse as which of the following?
| This question requires knowledge of the definition of the terms in the answer choices. |
973 The nurse alerts the primary care practitioner about a Correct answer: 1 The mole in option 1 meets the criteria of the "ABCD" rule: the size has increased in diameter mole. Which of these characteristics indicates the over two months, the mole has two colors, the center is black, and the border is irregular. need for intervention?
| The key to this question is rapid growth. |
974 A client with herpes simplex virus 1 makes the remark Correct answer: 2 Herpes simplex virus 1 may reappear in times of reactivation. The infection is described as a that she hopes she never gets another lesion on her lip vesicular lesion that occurs on the oral mucosa (lips, mouth), making option 3 incorrect. "like this one." What is the nurse's best response? Option 4 is false because herpes lesions are painful and because the description is incorrect.
| This question requires knowledge of herpes simplex virus. |
975 The nurse would include which of the following Correct answer: 3 The client with herpes zoster may experience impaired skin integrity and pruritis in which the priority interventions in the plan of care for a client client may frequently scratch the lesions, contributing to a secondary bacterial infection. Cool diagnosed with herpes zoster? environments should be maintained because heat and scratching will make the pruritis worse (option 4). Options 1 and 2 are irrelevant to the client's case.
| This question stresses the importance of assessing for further infection. |
976 The client telephones that she wants to come to the Correct answer: 3 The common wart, flat wart, and filiform wart are not painful, whereas the plantar wart is office for evaluation of a painful wart. The nurse often painful. anticipates that the client will present with which of the following cutaneous lesions that is commonly painful?
| This question requires knowledge that plantar warts are painful. |
977 The client presents with an increase in the number of Correct answer: 1 Vitiligo is a slowly progressive depigmentating condition of the skin caused by disappearance white patches across his chest and back. Multiple of melanocytes. Eczema is an inflammatory condition in which the skin appears erythemic, dry, creams and lotions were not helpful. The nurse and thickened. Psoriasis is a chronic inflammatory condition in which lesions appear whitish concludes that this client's clinical picture is consistent and scaly and commonly appear on the scalp, knees, and elbows. Contact dermatitis is an with which of the following conditions? eruption of the skin related to contact with an irritating substance or allergen.
| This question requires knowledge of vitiligo. |
978 When counseling clients regarding first‐line burn Correct answer: 1 Most burns occur at home caused by hot water or steam. All other aspects are important to prevention, the nurse should plan to include which of general prevention but temperature setting of the water is a first‐line prevention. the following items?
| This question requires knowledge of the common causes of burns. |
979 When caring for a client with a burn in the emergent Correct answer: 4 In the emergent stage, the nurse assesses the cause and extent of the burn and determines stage, which of the following has lowest priority as first aid measures that were used. Gender is not a factor in burn assessment. part of an accurate burn assessment? | Use the process of elimination to select the one correct answer. |
‐ Where it occurred ‐ Cause of the burn ‐ First‐aid treatment given ‐ Gender | |
980 The client presents with a pruritic rash. Questions Correct answer: 1 The location of the rash helps identify the possible offending antigen. Age, gender, and recent about which of the following would help differentiate travel are less helpful in identifying the etiology of the pruritic lesion. the cause?
| Use the process of elimination to select the one correct answer. |
981 In obtaining a health history on a client with psoriasis, Correct answer: 2 Psoriaris can often be brought on by a respiratory infection, particularly streptococcal which recent infection is significant? pharyngitis. The other responses are insignificant findings as they relate to psoriasis.
| This question requires knowledge that strep infections may precipitate psoriasis. |
982 A client presents with silvery plaques on both elbows Correct answer: 3 Psoriasis is characterized by the presence of silvery plaques, particularly on the extensor that are not itchy, but bleed when the scales are prominences, that bleed when scales are removed. The other disorders listed are not removed. The nurse concludes that the client most characterized in this way. likely has which of the following conditions?
| Use the process of elimination to select the one correct answer. |
983 A client presents to the primary care clinic Correct answer: 1 Even though all these problems may cause itching, a classical symptom of scabies is pruritus complaining of frequent scratching and itching of the with worsening at night. The mites tend to have increased movement at night, which accounts skin that is worse at night. The nurse should suspect for the worsening symptoms at that time. which of the following skin disorders?
| This question requires knowledge of scabies. |
984 The nurse determines that which of the following Correct answer: 3 Dietary restrictions were once believed to be necessary to decrease acne, but this has not reported by a client with acne would not contribute to been clinically relevant or supported in research. Stress and the use of moisturizers and oil‐ the severity of the acne? based cosmetics do seem to affect the severity of the disorder.
| Use the process of elimination to select the most feasible answer. |
985 The nurse who is counseling a family about treatment Correct answer: 2 Lindane (Kwell) can cause neurotoxicity in young children and nursing/pregnant women. This for scabies would tell the family to avoid which of the is not a concern with the other products listed. following products, based on knowledge that the family has young children and the woman is pregnant?
| This question requires knowledge of the adverse effects of the listed medications. |
986 Which of the following would not be included in the Correct answer: 3 Plastic shoes or sandals increase moisture collection in the feet. This should be avoided as it nurse's instructions to a client to prevent a recurrence increases the risk of recurrence. The other options describe helpful measures to prevent of tinea pedis? recurrence of tinea pedis.
| Look for incorrect answers and use the process of elimination to select the one correct answer. |
987 Which of the following clients that the nurse is Correct answer: 3 The consistent use of condoms helps protect from spreading herpes virus type 2 to other scheduled to see this morning at the ambulatory care partners. The other options do not represent circumstances that provide any protection clinic is the least likely to be infected with herpes virus against sexually transmitted diseases. type 2?
| This question requires knowledge that herpes is spread via sexual contact. |
988 The client asks the nurse if a lesion on her hand could Correct answer: 1 A wart is described as being a round, raised, firm lesion of the skin that may have ragged be a wart. The nurse would examine the area to borders. Warts do not contain fluid and generally have the color of normal flesh (options 3 and determine the presence of which of the following 4). Generally only plantar warts on the feet are associated with pain. characteristics?
| This question requires knowledge of the appearance of warts. |
989 The nurse would plan to include which of the Correct answer: 1 To improve folliculitis, the use of antibacterial soap daily along with good hand washing will following in the care of a client diagnosed with control and prevent spread of the infection. Isolation is not needed. The site should also be folliculitis? allowed to air dry and should not be covered with a bandage.
| Remember that good handwashing is often a feasible answer. |
990 The nurse should plan to include which of the Correct answer: 2 Good hygiene is recommended to help to prevent spreading the infection to other family following statements in client teaching for impetigo? members. Option 1 is false. Impetigo is contagious and antibiotic therapy is the recommended treatment (options 3 and 4).
| Beware of answer choices containing absolutes (never, only, etc.). |
991 The nurse conducting health promotion about Correct answer: 4 The epidermis protects the tissues from damage and prevents fluid loss of the body. The maintaining healthy skin in the community teaches dermis regulates body temperature (options 2 and 3). Option 1 is false. clients that the epidermis has which of the following functions?
| This question requires knowledge of the function of skin. |
992 A client visits the primary care clinic because of a Correct answer: 1 The fastest and most cost‐effective method to diagnose a fungal infection is using KOH rash. The nurse suspects the rash to be a fungal preparation to reveal more clearly the spores and hyphae of each fungus. infection. The nurse anticipates using which of the following tests as the most appropriate?
| This question requires knowledge of the medications for fungal infections. |
993 The nurse would document the presence of which of Correct answer: 2 A macule is a nonpalpable flat lesion. All the other lesions listed are elevated. If needed, refer the following in the medical record after noting a back to Table 10‐1 (Primary Skin Lesions) in the textbook, for detailed descriptions. lesion that is not raised?
| This question requires knowledge of these types of lesions. |
994 The nurse noting the presence of "satellite" lesions Correct answer: 1 Satellite lesions are maculopapular areas outside an area of original infection and are would suspect that the client has which of the characteristic of candidiasis. Satellite lesions are not characteristic of the other conditions following skin disorders? listed.
| This question requires knowledge of the listed skin disorders. |
995 The nurse should give which of the following nursing Correct answer: 1 Herpes zoster presents with vesicular lesions that could become infected if the skin is not diagnoses highest priority for an elderly client monitored carefully. This is the priority diagnosis for the elderly client. There could be a diagnosed with herpes zoster? possibility of injury and ineffective coping, however these are not the priority diagnoses. Risk for fluid volume deficit is irrelevant to the situation described.
| Recall that safety is a high priority according to Maslow. |
996 Which of the following would not be included in the Correct answer: 2 A systematic skin inspection should be done at least once a day with particular attention to care plan for a client with a pressure ulcer? the bony prominences. Weekly skin inspections are too infrequent to meet the needs of the client and evaluate how the ulcer is healing. The other interventions listed are appropriate to the care of a client with a pressure ulcer.
| This question calls for determination of the frequency of assessment. |
4.‐ Change client position at least every 2 hours | |
997 Which of the following rehabilitation measures would Correct answer: 2 Rehabilitation measures focus on the prevention of contractures and scars. The client is be done upon discharge of a client with partial‐ taught to continue ROM exercises to enhance mobility and to support the injured joints. thickness burns? Options 1, 3, and 4 should have been completed prior to the rehabilitative phase of burn management.
| Note the word ‘rehabilitation’ in the question stem. |
998 A client visits the primary care center because of Correct answer: 2 First‐line therapy consists of using topical retinoids or benzoyl peroxide. Antibiotics and acne. In anticipating the pharmacologic management accutane are used for moderate and severe cases. Corticosteroids are not to be used on the of this client, the nurse should anticipate which of the face because of absorption of the medication. following as a first line medication therapy?
| This question calls for the least risky medications to be used first. |
999 Which of the following lesions if found on a client Correct answer: 3 All other lesions are benign, but lentigo melana (pre‐melanoma) may develop into a true poses concern for the nurse because of the possibility melanoma over time. of progression to a melanoma over time?
| This question requires knowledge of the listed lesions. |
1000 Client education for repeated bee stings would not Correct answer: 2 Reexposure to a bee sting may precipitate a more severe reaction and require emergency include which of the following? care. It would be inappropriate to give the client false information that reactions will decrease. Options 1, 3, and 4 should be included in client teaching. ‐ First‐aid measures ‐ Assurance of decreased reactions with repeated exposure ‐ Use of insect repellants ‐ Method for removal of stinger | Note that this question requires use of the process of elimination to find the wrong answer. |
1001 Which electrolyte abnormalities would the nurse Correct answer: 1 Sodium levels decrease and potassium levels increase secondary to massive fluid shifts into expect to occur while working with a client who just the interstitium and release of potassium from cells that are destroyed. The other responses sustained partial‐ and full‐thickness burns? are incorrect. ‐ Decreased sodium and increased potassium ‐ Increased calcium and decreased potassium ‐ Decreased magnesium and increased sodium ‐ Increased sodium and decreased potassium | Associate high potassium levels with cell destruction and make sure both items in the option are correct. |
1002 The nurse provides teaching to a client after the Correct answer: 3 Dead skin and exudates often collect under the cast, and efforts to remove it should be done removal of a short leg cast. The nurse should include gradually. The client should be instructed to avoid any vigorous scrubbing of the skin to avoid which of the following in discussions with the client? breaks, which increase the risk for infection. The use of undiluted peroxide is too harsh for the skin. There is no reason why the leg cannot be touched after removal of the cast. ‐ Wash the skin with undiluted hydrogen peroxide. ‐ Vigorously scrub the legs to remove dead skin. ‐ Gently wash and lubricate the leg. ‐ Avoid touching the leg for 2 weeks. | The core issue of the question is the knowledge of skin care following cast removal. Use nursing knowledge and the process of elimination to make a selection. |
1003 Which of the following nursing diagnoses would be Correct answer: 3 Impaired physical mobility is the appropriate priority nursing diagnosis for a client with the priority for a client with Paget’s disease? Paget’s disease. The client needs to remain active to decrease the complications associated with immobility and to maintain the ability to perform self‐care activities. The other diagnoses, although appropriate, are not the priority in clients with Paget’s disease. ‐ Risk for noncompliance ‐ Disturbed sleep pattern ‐ Impaired physical mobility ‐ Disturbed body image | The core issue of the question is the knowledge of priorities for the client with Paget’s disease. Use nursing knowledge and the process of elimination to make a selection. |
1004 A client with a right arm cast for fractured humerus Correct answer: 1 This symptom suggests neurological injury caused by pressure on nerves and soft tissue states, “I haven’t been able to extend the fingers on because of swelling. Other symptoms of neurovascular compromise should be assessed and my right hand since this morning.” What action should reported to the physician. the nurse take next? ‐ Assess neurovascular status. ‐ Ask the client to massage the fingers. ‐ Encourage the client to take the prescribed analgesics as ordered. ‐ Elevate the right arm on a pillow to reduce edema. | The core issue of the question is the knowledge of priority assessments in a client with possible compartment syndrome. Use nursing knowledge and the process of elimination to make a selection. |
1005 A client with an open fracture is at risk for developing Correct answer: 2 Elevated temperature is a classic symptom seen with this osteomyelitis as a systemic osteomyelitis. Which of the following classic symptoms response to the invading organism. Pain, swelling, and tenderness may also accompany the would the nurse assess for to detect development of fever. Acute respiratory distress (option 3) is more suggestive of embolism but not infection. this complication? The extremity does not shorten. ‐ Low bone density ‐ Elevated temperature ‐ Acute respiratory distress ‐ Shortening of the affected extremity | The core issue of the question is the knowledge of manifestations of osteomyelitis. Use nursing knowledge and the process of elimination to make a selection. |
1006 An obese client with degenerative joint disease is Correct answer: 1 Aspirin therapy for this condition is continuous and is effective only after a therapeutic level is being managed pharmacologically with aspirin therapy. reached. It should not be taken intermittently (option 1). The other options are correct The nurse knows that additional client teaching is statements about self‐care measures when taking aspirin for degenerative joint disease. necessary when the client makes which of the following statements? ‐ “I take my aspirin only when I have extreme pain and stiffness.” ‐ “I use heat sometimes to help decrease my pain and joint stiffness.” ‐ “I frequently examine my stools for bleeding.” ‐ “I started an exercise program to lose weight.” | The core issue of the question is the knowledge of appropriate self‐management techniques for degenerative joint disease. Use nursing knowledge and the process of elimination to make a selection. |
1007 A client underwent a lumbar laminectomy today. Correct answer: 4 Immediately after surgery, the client will be inclined not to move because of pain and fear of Which nursing diagnosis has highest priority for this disturbing the operative site. Minimal scarring results from this surgery, so body image client? disturbance is not likely to be appropriate (option 1). The psychosocial diagnoses in options 2 and 3 have less priority than option 4 because option 4 is a physiological concern. ‐ Disturbed body image disturbance ‐ Social isolation ‐ Ineffective role performance ‐ Impaired physical mobility | The core issue of the question is the knowledge of priority nursing diagnoses following musculoskeletal surgery. Use nursing knowledge and the process of elimination to make a selection. |
1008 A client had a left above‐the‐knee amputation today. Correct answer: 1 Elevating the limb on a pillow facilitates venous return, decreases swelling, and promotes For the first 24 hours postoperatively, the nurse makes comfort. The stump dressing is usually a compression type to mold the stump and to decrease it a priority to do which of the following to properly the edema associated with inflammation, so option 2 is an inappropriate intervention. The manage the surgical site? other options are also inappropriate because option 3 increases risk of edema and option 4 is done as ordered. ‐ Elevate the residual limb on a pillow. ‐ Loosen the stump dressing every 4 hours. ‐ Maintain the residual limb in a dependent position. ‐ Change dressings as often as needed. | The core issue of the question is the knowledge of postoperative stump care and positioning. Use nursing knowledge and the process of elimination to make a selection. |
1009 A client with a femoral fracture is in Buck’s traction. Correct answer: 3 Traction, to be effective, must have an opposing force (countertraction). The aim in traction is While making rounds, the nurse notices that the to maintain a constant force to align the distal and proximal ends of a fractured bone. Options client’s foot is flush with the footboard of the bed. 1, 2, and 4 violate this principle of traction in the treatment of fractures. Centering the client in Based on the nurse’s knowledge of the principles of bed maintains the line of pull and ensures that countertraction is maintained. traction, an appropriate action is to do which of the following? ‐ Wedge a pillow between the footboard and the client’s foot. ‐ Praise the patient for maintaining countertraction. ‐ Center the client on the bed. ‐ Ask the client to pull up in bed while holding the weights. | The core issue of the question is the knowledge of proper use of traction. Use nursing knowledge and the process of elimination to make a selection. |
1010 A truck driver presents to the primary care provider Correct answer: 4 Prolonged sitting or standing aggravates back injury because of the additional stress placed with complaints of persistent back pain. The nurse on the structures supporting the back. Lifting objects close to the body, shifting positions explains that which client activity documented during frequently, and providing back support are appropriate actions to maintain good body the nursing history may contribute to further back mechanics. injury? ‐ Lifting objects close to the body ‐ Shifting positions often when sitting for prolonged periods ‐ Providing back support with a pillow when sitting ‐ Prolonged standing or sitting | The core issue of the question is the knowledge of risk factors and aggravating factors of low back pain. Use nursing knowledge and the process of elimination to make a selection. |
1011 A client underwent a lumbar laminectomy. Which of Correct answer: 3 The physician orders the client’s activity after a laminectomy. After a laminectomy procedure, the following activities would be best 4 hours a client should be assisted to logroll from side to side. The principle is to maintain the postoperatively? alignment of the vertebral column at all times. Clients with lumbar laminectomy should be kept flat or with head of bed slightly elevated to minimize stress on the suture line. Using the side‐rails to get out of bed causes shifting of the vertebral column. Sitting up in a chair or on the side of the bed is usually done the evening of the surgery or the first day following surgery, and it is for brief periods only. ‐ Sitting up in a chair to watch television ‐ Sitting at the side of the bed ‐ Lying in bed in good alignment with the head of bed flat ‐ Using the side‐rails for support to get out of bed | The core issue of the question is the knowledge of activity levels after surgery that will not cause harm to the surgical area following laminectomy. Use nursing knowledge and the process of elimination to make a selection. |
1012 The nurse provides teaching to a 50‐year‐old male Correct answer: 1 Smoking has been found to contribute to disc deterioration. Lack of exercise predisposes the Caucasian client with chronic low back pain. The client muscles of the back to strain. The extra weight of obese individuals imposes more strain on the weighs 200 pounds, works as a truck driver, sits for back and also interferes in maintaining good body mechanics in lifting. Occupations that prolonged periods, and seldom participates in exercise require prolonged sitting or standing predispose those individuals to exacerbation of back pain. activities. The client smokes one pack of cigarettes and Option 1 is the only answer that accurately reflects risk factors associated with chronic low drinks six cans of beer per day. What risk factors back pain for the client described in the question. should the nurse include in the discussion? ‐ Lack of exercise, obesity, sitting for long periods, smoking, sedentary occupation ‐ Degenerative disk disease, gender, race, smoking ‐ Degenerative disk disease, race, alcohol use, smoking, inactivity ‐ Age, obesity, lack of exercise, genetic factors | The core issue of the question is the knowledge of factors that aggravate low back pain. Use nursing knowledge and the process of elimination to make a selection. |
1013 The nurse is teaching a postmenopausal client about Correct answer: 2 A combination of calcium and Vitamin D is recommended for the prevention of osteoporosis. the use of calcium to prevent the effects of Vitamin D increases the intestinal absorption of calcium and mobilizes calcium and phosphorus osteoporosis. The client asks: “Why do I have to take into the bone. Vitamin D alone does not prevent osteoporosis (option 2). Whereas some Vitamin D with my calcium?” Which of the following is elderly might be deficient in Vitamin D, a postmenopausal state does not necessarily cause the the nurse’s best response? deficiency (option 3). There are other interventions for the prevention of osteoporosis, including lifestyle modifications (e.g., smoking cessation), which makes option 4 inaccurate. ‐ “Vitamin D prevents osteoporosis.” ‐ “Vitamin D increases intestinal absorption of calcium.” ‐ “You are most likely to be deficient in Vitamin D.” ‐ “Calcium and Vitamin D supplementation is the only way to prevent osteoporosis.” | The core issue of the question is the knowledge of risk factors for and prevention of osteoporosis. Use nursing knowledge and the process of elimination to make a selection. |
1014 The nurse is caring for a client with a week‐old cast. Correct answer: 3 A complication of cast application is skin breakdown underneath the cast. If this occurs, The client asks why the nurse palpates the casted area infection can set in and can cause the area over the breakdown to be warmer than other when doing the assessment. Which of the following is areas. A bad odor coming from the area may also be noted. Option 1 is inaccurate because the most appropriate response by the nurse? generally plaster casts dry in 48 hours or less and fiberglass casts in 30 minutes to 1 hour. If a cast is too tight, symptoms associated with neurovascular compromise will be noted, which include pain, paresthesia, pallor, diminished pulse distal to the cast, and paralysis (option 4). ‐ “I am making sure that the cast has dried.” ‐ “I am evaluating the strength of the cast.” ‐ “I am feeling for hot spots that might indicate infection.” ‐ “I am making sure that the cast is not too tight.” | The core issue of the question is the knowledge of various complications of casts. Use nursing knowledge and the process of elimination to make a selection. |
1015 A client is placed on continuous passive motion (CPM) Correct answer: 1 The client’s knee will externally rotate if there is insufficient space between the client’s hip machine postoperatively after a total knee and the machine. The knee should be upright, facing the ceiling, as the machine moves the leg replacement. The nurse observes that the client’s knee back and forth. is externally rotating during flexion. What should the nurse do next? ‐ Move the client up in bed or move the CPM machine down toward the foot of the bed ‐ Support the client’s knee with sandbags to prevent external rotation ‐ Assist the client to sit up in bed in a 45‐degree position ‐ Do nothing; the client’s knee is properly aligned | The core issue of the question is the knowledge of appropriate assessment and care of the client in CPM. Use nursing knowledge and the process of elimination to make a selection. |
1016 A client in skeletal traction for a right femur fracture Correct answer: 1 Pain and absent pulse in the affected extremity are urgent signs requiring immediate is complaining of pain in the affected limb. The nurse intervention. Impairment of circulation in the affected limb initiates various pathophysiologic assesses that the right foot is pale without a pulse. processes, including destruction of nerves and tissues. If this state is uninterrupted, loss of the What should the nurse do next? limb may occur. The nurse needs to ensure that the leg is not above heart level so no further damage occurs. The physician needs to be notified immediately so medical interventions can be instituted before irreversible tissue and nerve damage occurs. ‐ Ensure that the leg is not raised above heart level ‐ Administer analgesics as ordered ‐ Release the traction ‐ Document the observation and recheck the pulse in 5 minutes | The core issue of the question is the knowledge of adverse neurovascular changes to a client in a cast. Recall principles of gravity and blood flow to aid in answering the question. Use nursing knowledge and the process of elimination to make a selection. |
1017 A nurse receives a client from the emergency Correct answer: 1 It is essential to monitor the condition of the skin under traction, as well as bony department in Buck’s traction following a fracture of prominences, because these areas are at risk for breakdown due to continuous friction and the right femur. The nurse documents which of the pressure from the skin traction device. Option 2 is incorrect because Buck’s traction is a type of following as a priority in the client medical record? skintraction. Skeletal tractions use pins, wires, or tongs to aid in realignment. Option 3 is appropriate, but the most essential assessment to be documented for a client with skin traction is the condition of the skin underneath the straps. ‐ Status of skin underneath the traction and over bony prominences ‐ Type of pin, wire, or tongs used ‐ The effectiveness of pain medication given in the field ‐ Medications given in the emergency department | The critical word in the question is priority, which tells you that all or more than one options are correct and that the most essential one is the correct answer. Use nursing knowledge about skin traction and the process of elimination to make a selection. |
1018 The nurse planning for the care of a client admitted Correct answer: 2 Balanced suspension allows for ease with bedpan use and skin care without disturbing the with balanced suspension traction explains to the line of traction. In this type of traction, the client’s injured extremity is lifted off the bed and a family that an advantage of balanced suspension is straight pull is accomplished by the application of several forces and several weights. Skin which of the following? breakdown is not eliminated with this type of traction because any immobile client can be at risk. ‐ It eliminates the risk for skin breakdown. ‐ It allows the client to raise the buttocks off the bed for bedpan use and skin care. ‐ It is more effective in reducing hip contracture. ‐ It requires only one weight to maintain traction. | The core issue of the question is the knowledge of Buck’s traction as a skin traction and the need to assess the underlying skin. Use nursing knowledge and the process of elimination to make a selection. |
1019 A client is taking colchicine for gout. The client Correct answer: 2 Colchicine is used in treating the acute attack of gout. The symptoms described are signs of complains of weakness, abdominal pain, nausea, toxicity. The client should be instructed to stop the medication and be seen for follow‐up vomiting, and diarrhea for the past 2 days. The nurse treatment. The expected effect of colchicine is to diminish the joint pain associated with the interprets these complaints indicating which of the acute attack. following? ‐ Therapeutic effects of the medication ‐ Signs of toxicity ‐ Expected side effects ‐ An allergic response | The core issue of the question is the knowledge of actions and adverse effects of colchicines in the client with gout. Use nursing knowledge and the process of elimination to make a selection. |
1020 An 87‐year‐old client sustained a right hip fracture. Correct answer: 2 Age, site of the fracture, and blood supply to the affected area all affect the rate of bone The client asks the nurse about the length of time healing. Younger and healthy individuals prior to the injury will have faster bone healing than needed for the fracture to heal. The nurse’s response the elderly and those with chronic illnesses. Although physical therapy will assist in mobility, it includes consideration of which client factor that does not directly enhance bone healing. The weight of the client, unless accompanied by influences the rate of bone healing? malnutrition, does not have a direct bearing on bone healing. ‐ Frequency of physical therapy ‐ Age of the client ‐ Weight of the client | The core issue of the question is knowledge of possible threats to bone healing in an identified client. Use nursing knowledge and the process of elimination to make a selection. |
4.‐ Early ambulation | |
1021 A client is scheduled to have a closed reduction of a Correct answer: 3 In a closed reduction procedure, the physician applies traction and manipulates the bone until right ankle fracture. The nurse determines the client the broken ends are realigned. Open reduction is a realignment of bone with surgery (option understands the procedure when the client states that 2), and internal fixation devices are surgically inserted during an open reduction to immobilize the procedure involves which of the following? the fracture during the healing process (option 4). Endoscopy (option 1) is not a surgical modality for reducing fractures. ‐ Applying an endoscopic procedure to realign the bones ‐ Realigning the bone using surgery ‐ Correcting the bone alignment using manual manipulation ‐ Inserting pins, rods, or other implantable devices | The core issue of the question is the knowledge of various approaches to correct bone fracture. Use nursing knowledge and the process of elimination to make a selection. |
1022 A child is admitted to the hospital with a diagnosis of Correct answer: 1 The history of a child with osteomyelitis may include a recent upper respiratory infection osteomyelitis. Which of the following would the nurse (which may include an ear infection or sinus infection), skin infection, or blunt trauma to a likely find when gathering the nursing history? bone. Gastroenteritis would not be found in the recent history of this child that would lead to this illness. LCPD and CHD do not lead to osteomyelitis. ‐ History of an upper respiratory infection ‐ History of gastroenteritis ‐ History of Legg‐Calve‐Perthes disease ‐ History of congenital hip dysplasia | The core issue of the question is the knowledge of risk factors for osteomyelitis. Use nursing knowledge and the process of elimination to make a selection. |
1023 Two hours after a child had a cast applied for a Correct answer: 3 A very swollen hand despite application of ice and elevation is a grave concern, especially fractured radius, the nursing assessment reveals with the child complaining of numbness. Such swelling can lead to compartment syndrome, swelling in the hand, which is elevated higher than the which can lead to neurological damage. This is a medical emergency, and the physician should heart. Ice has been applied continuously. The child be called immediately. The nurse can then provide diversional activities while waiting for does not complain of pain but does complain of definitive orders. numbness and tingling. Which should the nurse do first? ‐ Medicate for pain. ‐ Elevate the injured extremity even higher. ‐ Call the physician. ‐ Provide the child with diversional activities. | The core issue of the question is recognition of a complication, compartment syndrome, that can lead to neurological damage. The correct answer is the one that provides for definitive treatment of the problem, which in this case is in the practice realm of the physician. |
1024 The pediatric nurse interprets that which of the Correct answer: 3 The infant who is carried with the hips abducted is at decreased risk for developing following infants is the least likely to be diagnosed with developmental dysplasia of the hip. Options 1, 2, and 4 are all factors that would possibly developmental dysplasia of the hip? increase the incidence of this defect. ‐ The infant with a family history of developmental dysplasia of the hip ‐ The infant who weighs over 10 pounds ‐ The infant carried on the mother’s hips ‐ The infant who had breech position while in the uterus | The core issue of the question is recognition of which situation allows the infant to keep the hips abducted. Evaluate each option according to this criteria to make a selection. |
1025 Which of the following interventions would be Correct answer: 3 Pain must be managed properly in the child after spinal fusion in order for the client to essential for the nurse to implement to promote a participate in respiratory exercises. Logrolling and repositioning, as well as coughing, deep‐ stable respiratory status in the adolescent who breathing, and use of incentive spirometry should be done every 2 hours around the clock with recently had a spinal fusion for scoliosis? this postoperative client. Providing adequate pain relief will enable the client to carry out these important activities. ‐ Logrolling and repositioning every 4 hours ‐ Coughing and deep‐breathing every 2 hours during the day ‐ Assessing pain status and ensuring adequate pain relief ‐ Encouraging use of incentive spirometry every 4 hours while awake | The core issue of the question is the ability to prioritize nursing activities. While the ABCs are quite important, the client cannot meet goals for the respiratory portion of ABCs unless pain relief is achieved. With this in mind, choose option 3 as the correct answer. |
1026 An 8‐year‐old child presents to the emergency Correct answer: 4 The symptoms described are symptoms of osteomyelitis. This disease can result from a department with complaints of his ankle hurting and penetrating wound, but it also may result from an infection elsewhere in the body that difficulty walking. The triage nurse notes the following traveled to the bone. Osteomyelitis may follow an upper respiratory infection, which is assessments: pain, redness, and swelling of the ankle. common in school‐aged children. The ankle has decreased mobility and range of motion. The child has a temperature of 100.8 degrees F and a heart rate of 140 beats per minute. The child does not recollect any injury to the ankle. Which of the following diagnoses would the triage nurse suspect? ‐ Legg‐Calve‐Perthes disease ‐ Slipped capital femoral epiphysis ‐ Fracture of the ankle ‐ Osteomyelitis | The issue of the question is the ability of the nurse to analyze assessment data and compare it to typical data of childhood musculoskeletal problems. Note that the temperature is elevated to help choose the option related to infection. |
1027 The nurse is preparing to help a client get up from a Correct answer: 4, 1, 3, The proper procedure is as follows:<BR /> chair using crutches. Place in order the steps that the 2, 6, 5 nurse outlines to the client to do this procedure correctly. Click and drag the options below to move them up or down. ‐ Place unaffected leg slightly under or at the edge of the chair. ‐ Grasp the arm of the chair using the hand on the unaffected side. ‐ Grasp the crutches by the horizontal hand bars using the hand on the affected side. ‐ Move forward to the edge of the chair. ‐ Assume a tripod position. ‐ Push down on the crutches and the chair armrest while raising the body out of the chair. | Visualize the procedure and think about principles of joint support and balance to complete the ordered steps. |
1028 The mother of a newborn is upset that her baby has Correct answer: 1, 5 The exact cause of clubfoot is unknown, though several possible etiologies exist. Abnormal congenital clubfoot. She asks the nurse what she did to intrauterine position may cause the deformity, along with neuromuscular or vascular cause her baby's deformity. Which of the following problems. A positive family history increases the chance of this deformity. answers is the most appropriate? Select all that apply. ‐ Abnormal uterine positioning could have caused this deformity ‐ A lack of good nutrition during pregnancy could have caused this defect ‐ Having the baby before the due date could have caused this problem ‐ There are no known etiologies of this defect ‐ Neuromuscular and vascular problems may have caused the problem | Knowledge of the etiology of clubfoot will help to determine the correct response. Consider which response, in addition to being accurate, would be most comforting for the mother. |
1029 Which of the following are appropriate nursing Correct answer: 1, 2, 4 The postoperative care of the child undergoing repair of clubfoot includes elevation, interventions to include in the initial postoperative application of ice, assessment for neurovascular status, bleeding and swelling, and pain. care of a child who has had surgery for clubfoot? Nasogastric intubation is usually not needed and warm blankets are not indicated. Select all that apply. ‐ Apply ice bags to the foot; keep the ankle and foot elevated on a pillow ‐ Check for drainage or bleeding; observe for swelling around the cast edges ‐ Administer pain medications routinely and maintain nasogastric intubation ‐ Perform neurovascular status checks every 2 hours and provide diversional activities ‐ Cover the surgical extremity with warm blankets | Knowledge of the postsurgical care of the infant with clubfoot will aid in choosing the correct answer. |
1030 Which of the following does the nurse expect to find Correct answer: 3 All symptoms listed are clinical manifestations of developmental dysplasia of the hip, during assessment of a 5‐year‐old client who has although the only one that would be found in a 5‐year‐old would be the telescoping of the developmental dysplasia of the hip (DDH)? femoral head into the pelvis. Other clinical signs in an older child would be lordosis, and a waddling gait with a marked limp. A positive Ortolani‐Barlow maneuver is found in the infant younger than 2 to 3 months of age. Limited abduction is the sign most often used for an infant older than three months, along with asymmetry of thigh and gluteal folds. ‐ Asymmetry of gluteal and thigh fat folds ‐ Positive Ortolani‐Barlow maneuver ‐ Telescoping of the femoral head into the pelvis ‐ Limited abduction of the affected hip | Knowledge of the assessment findings for a child with DDH will aid in choosing the correct answer. |
1031 A 14‐year‐old boy is diagnosed with slipped capital Correct answer: 2 The exact cause of SCFE is unknown. Predisposing factors include obesity, a growth spurt femoral epiphysis (SCFE). He asks the nurse what resulting in a tall and thin stature, and endocrine disorders such as hypothyroidism and caused this condition. Which of the following best hypogonadism. There may be a genetic predisposition to this disorder. answers his question? ‐ SCFE is a result of an injury to the hip ‐ SCFE may be caused by an endocrine disorder ‐ SCFE may be caused by an abnormality of the muscles ‐ SCFE is caused by abnormal intrauterine position | Knowledge of the possible etiology of SCFE will aid in choosing the correct answer. |
1032 An adolescent is wearing a cast following a spinal Correct answer: 1, 2, 3 All are appropriate interventions for the child who has undergone a spinal fusion, although fusion for scoliosis. The nurse would include which of only the first three are appropriate interventions directly aimed at the client experiencing an the following interventions to address the nursing altered body image. Teaching cast care is important, but would be appropriate under the diagnosis of disturbed body image related to wearing a nursing diagnosis of knowledge deficit. The nurse would assist with coping, but this does not cast after spinal fusion? Select all that apply. necessarily involve new hairstyle or clothes. ‐ Encourage independence in daily activities ‐ Encourage the adolescent to participate in community activities ‐ Provide contact with a peer who has undergone the same treatment ‐ Teach cast care as appropriate ‐ Suggest the client change hairstyle or buy new clothes as a coping mechanism | Knowledge of the interventions aimed at helping the adolescent in a cast with body image difficulties will help to choose the correct answers. |
1033 Which of the following instructions would be Correct answer: 2 Activity restrictions should be followed for six to eight months following a spinal fusion. Lying, appropriate for the nurse to include in the discharge standing, sitting, walking, normal stair climbing, and gentle swimming are generally allowed teaching of an adolescent following a spinal fusion? following spinal fusion. Bending and twisting at the waist is not recommended, along with lifting more than 10 pounds, household chores such as vacuuming, mowing the lawn, physical education classes, and any sports besides walking. ‐ No sitting for longer than 15 minutes ‐ The adolescent should not bend at the waist ‐ Walking is limited to only one half mile per day ‐ The adolescent should not climb stairs | Knowledge of the postoperative care of the child with spinal fusion and the relevant discharge instructions will aid in choosing the correct answer. |
1034 A 15‐year‐old adolescent with osteogenesis Correct answer: 3 Exercise such as swimming is allowed for clients with osteogenesis imperfecta and will help imperfecta (OI) who is hospitalized for a fractured improve muscle tone and prevent obesity. Bowling and wheelchair sports would not be femur says to the nurse, "I feel so unhealthy. I can't do allowed, as the weight involved with both could cause fractures of the upper extremities. any activities at school or any sports, and I love sports." Which of the following responses by the nurse would provide the most accurate information to this client? ‐ "It must be very hard not to be able to be involved in any sports; it's just too dangerous for you." ‐ "Have you thought about bowling? That is a sport that is allowed when you have this condition." | Knowledge of the normal developmental needs and activities permitted for the adolescent with osteogenesis imperfecta will aid in choosing the correct answer. |
‐ "Swimming is an activity that you can participate in and will improve overall muscle tone." ‐ "How about trying wheelchair sports? Maybe you would enjoy wheelchair basketball." | |
1035 Which of the following assessment findings would the Correct answer: 1 A child with DMD would have enlargement of muscles as a result of fatty tissue infiltration. A nurse expect to find in the school‐age child with school‐aged child with DMD is generally still ambulatory. Muscles at this age are weak, not Duchenne's muscular dystrophy? paralyzed. A weak cough reflex would occur as the disease progresses. ‐ Enlargement of muscles ‐ Bedridden ‐ Weak cough reflex ‐ Paralysis of lower muscles | Knowledge of the assessment findings for the school aged child with muscular dystrophy will aid in choosing the correct answer. |
1036 The nurse concludes that a child in Bryant’s traction is Correct answer: 4 Bryant's traction is used specifically for children under 3 years of age and weighing less than in correct position after noting which of the following? 35 pounds who have developmental hip dysplasia or fractured femur. This bilateral traction is applied to the child's legs, with the hips flexed at 90 degree angle, with knees extended and buttocks slightly off the bed. The other distracters describe Russell, Buck, and Dunlop traction. ‐ The lower leg is suspended in a padded sling ‐ Leg is in extended position without hip flexion ‐ The arm is kept flexed and is suspended horizontally ‐ Hips are flexed at a 90 degree angle, with buttocks off the mattress | Knowledge of Bryant’s traction will aid in choosing the correct answer. |
1037 A child with Legg‐Calve‐Perthes disease is undergoing Correct answer: 2 To promote healing of the affected hip in LCPD, the femoral head is contained in the hip non‐surgical treatment. Which of the following would socket until ossification is complete, which may take up to two years or more. This is indicate to the nurse that the parents understand such accomplished by keeping the hips abducted by continual use of Petrie casting, or Toronto and treatment? Scottish‐Rite braces. The child should be encouraged to attend school during this time. Untreated LCPD clients may develop osteoarthritis and hip dysfunction. The other answers are incorrect statements of fact. ‐ "My child will need to wear a brace while he is sleeping." ‐ "My child will need to wear a brace for two years or more." ‐ "My child will not be able to attend school until healing has occurred." ‐ "My child will develop hip dysfunction later in life." | Knowledge of the care of the child with LCPD will help to choose the correct answer. |
1038 Parents of an unborn infant have just learned that, Correct answer: 1 The initial treatment for clubfoot begins immediately or shortly after birth and consists of based on ultrasound, their infant has clubfoot. They weekly cast changes and manipulation. Surgery is completed only if nonsurgical intervention of ask the nurse how clubfoot is treated. Which of the serial casting is not effective. A Denis Browne splint may be used to maintain correction once it following treatments should the nurse discuss with the is achieved. Abduction devices are used for hip conditions. parents? ‐ Weekly cast changes with manipulation ‐ Probable surgery on the affected limb ‐ Abduction device to keep the hip in full abduction ‐ Use of a Denis Browne splint to achieve correction | Option 3 can be eliminated as it refers to the hip, not the foot. The other options are used in clubfoot, but the learner must choose the option that would be used immediately after birth. |
1039 An infant is placed in a Pavlik harness for Correct answer: 1, 2, 3 Diapers should be placed underneath the straps of a Pavlik harness; a t‐shirt should be worn developmental dysplasia of the hip. The nurse has under the straps of the harness. The harness should be worn for 23 hours a day. The child completed parent teaching, but the parents seem to quickly “catches up” once the device is no longer worn if developmental milestones are be overwhelmed by the condition and make several delayed because of the abduction device. Babies should never be lifted by their legs when statements indicating a lack of understanding. The changing diapers. Early treatment is usually successful without surgery. The treatment is not statements that indicate more teaching is needed are: painful. (Select all that apply.) ‐ “The straps of the harness should be placed next to the skin.” | Knowledge of the care of the child in a Pavlik harness will aid in choosing the correct answer. The wording of the question guides you to eliminate responses that are correct information. |
‐ “The harness should be worn for 6 hours a day.” ‐ “It will take a long time for my child to walk and crawl.” ‐ “I should not lift the baby by his legs when changing his diaper.” ‐ “Because my child’s defect was caught early, treatment will not usually require surgery.” | |
1040 A 4‐year‐old child with osteogenesis imperfecta (OI) is Correct answer: 3 Because of their very fragile bones, children with OI experience countless fractures, and the admitted to the hospital unit for an unrelated prevention of injury takes highest priority in this child’s care. Pain would be important if a condition. The nurse determines that which nursing fracture actually occurs, but the key is prevention of fractures, making risk for injury more diagnosis has the highest priority for this child? appropriate. Skin integrity impairment would also not be a concern unless a fracture actually occurred. ‐ Impaired skin integrity related to cast ‐ Pain related to fractures ‐ Risk for injury related to disease state ‐ Disturbed body image related to short stature | Option 4 can be eliminated as the child is 4 years old and body image is not a great concern. Of the three remaining, choose the option that would be a concern throughout the care of this child. |
1041 A child is admitted to the hospital unit with a Correct answer: 1 Swelling and redness of involved joints is a symptom found in juvenile arthritis, not LCP diagnosis of “rule out acute onset of Legg‐Calve‐ disease. Stiffness in the morning or after rest, an insidious limp after activities, and referred Perthes (LCP) disease.” The symptom that would not pain to the knee are all consistent with this diagnosis. be associated with LCP is: ‐ Swelling and redness of the involved joint(s). ‐ Stiffness in the morning or after rest. ‐ Insidious limp after activities. ‐ Referred pain to the knee. | Knowledge of the signs and symptoms of LCP disease will help to choose the correct answer. Eliminate symptoms normally seen in LCP. That leaves only the correct response. |
1042 A 12‐year‐old male is admitted to the adolescent unit Correct answer: 2 Once the diagnosis is made, the child should be non‐weight‐bearing on the affected hip, as with a diagnosis of slipped capital femoral epiphysis. weight‐bearing can increase the amount of slippage. Wheelchair use should be avoided, as this Which of the following activities should not be allowed also may increase the amount of slippage. by the nurse prior to surgical correction? ‐ Ambulation with crutches; avoid bearing weight on the affected leg ‐ Sitting in a wheelchair ‐ Moving on a stretcher ‐ Maintaining bed rest | Knowledge of the care of the client with slipped capital femoral epiphysis will help to answer the question correctly. After noting the critical word “not” in the question, select the option that places the affected joint at risk. |
1043 An adolescent diagnosed with idiopathic structural Correct answer: 1 Back pain is not identified as a symptom of idiopathic structural scoliosis. Skirts that hang scoliosis describes all of the following symptoms. unevenly, unequal shoulder height, and uneven waist level are all positive symptoms of this Which one would the nurse conclude is not associated disorder. with this diagnosis? ‐ Back pain ‐ Skirts that hang unevenly ‐ Unequal shoulder heights ‐ Uneven waist angles | Determine which options are symptoms of scoliosis. Eliminate these, leaving only the correct answer. |
1044 A 15‐year‐old who has a diagnosis of scoliosis is being Correct answer: 1 Adolescents are greatly concerned about their physical appearance as part of their growth seen in the outpatient clinic. The nurse is planning care and development. Unless there is a clear priority based on physiological need, attention to for this adolescent and develops the following nursing developmental concerns such as body image is important when caring for the adolescent diagnoses. Which nursing diagnosis should take highest client. priority? ‐ Disturbed body image related to treatment of scoliosis ‐ Diversional activity deficit related to treatment of scoliosis ‐ Anxiety related to outcome of treatment for scoliosis ‐ Fear related to treatment and unknown outcomes | Eliminate options 3 and 4 because they are so similar. Then, consider the developmental period of the child, which is key to determining the correct response. All adolescents worry about body image and being different. This child will appear different and may be encased in a brace or cast. |
1045 An adolescent is returning to the hospital unit after Correct answer: 2, 3, 5 There is some degree of paralytic ileus following a spinal fusion; therefore, nasogastric surgical spinal fusion for scoliosis. The nurse would intubation is required along with frequent assessment of return of bowel function. The pain include which of the following in the immediate experienced by this client is severe and requires intravenous medication, preferably with postoperative care of this client? (Select all that apply.) patient‐controlled analgesia (PCA). Logrolling must be done every 2 hours, once allowed, to prevent the accumulation of secretions in the lungs. Urinary retention is common, and an indwelling catheter is used if present rather than repeated straight catheterization. Monitoring the child’s respiratory status is crucial as is the use of an incentive spirometer. ‐ Oral analgesia for pain ‐ Logrolling every 2 hours ‐ Nasogastric intubation ‐ Straight catheterization every 4 hours ‐ Use of an incentive spirometer every two hours while awake | Look carefully at each option to make sure the option is totally correct. Eliminate those that are either incorrect or only partially correct. |
1046 A 3‐year‐old child is suspected of having Duchenne’s Correct answer: 3 The child with Duchenne’s muscular dystrophy (MD) has a history of meeting early muscular dystrophy. Which of the following developmental milestones. Symptoms usually begin at around 3 years of age and include assessment findings by the nurse would support this difficulty climbing stairs, running, and pedaling. Duchenne’s MD is also called diagnosis? pseudohypertrophic MD as the muscles appear enlarged. The appearance of the hips is normal. ‐ A history of delayed crawling ‐ Outward rotation of the hips ‐ Difficulty climbing stairs ‐ Wasted muscle appearance | Knowledge of Duchenne’s muscular dystrophy will aid in choosing the correct answer. Eliminate option 4 as it is the opposite of the findings of Duchenne’s MD. Also, children develop normally until there is onset of symptoms, so option 1 would be incorrect. |
1047 A child is admitted to the hospital with a diagnosis of Correct answer: 2 Serum laboratory studies in a child with osteomyelitis will reveal an increased WBC count, C‐ “rule out osteomyelitis.” Which of the following serum reactive protein, and sedimentation rate. The blood culture is usually positive. This disease laboratory values noted by the nurse supports this process does not affect the HCT or BUN. diagnosis? ‐ Decreased white blood cell (WBC) count ‐ Positive blood cultures ‐ Increased hematocrit (HCT) ‐ Increased BUN | Option 1 can be eliminated because with infections the WBC is elevated. Two of the other tests have no relation to infections. |
1048 A 6‐year‐old child has a cast applied for a fractured Correct answer: 3 The sensation of numbness or tingling is a sign of neurovascular impairment. Neurovascular radius. The nurse completes an orthopedic assessment impairment can lead to nerve ischemia and destruction, with possible permanent paralysis of on this child. Which of the following symptoms the extremity. Any symptom of neurovascular impairment, such as paresthesia, lack of pulses, requires immediate attention and should be reported edema that does not improve with elevation, pallor, and pain, needs immediate attention. to the physician? ‐ Capillary refill of 4 seconds in the affected hand ‐ Edema in the affected fingers that improves with elevation ‐ Child describing feeling of the affected hand being “asleep” ‐ Skin surrounding the cast is warm | Determine which finding is abnormal. All others are expected findings. |
1049 Which of the following nursing care measures takes Correct answer: 2 The child with skeletal traction has a pin that passes through the skin into the end of a long highest priority in caring for a child in skeletal traction? bone. This procedure provides an entrance for microorganisms. Frequent monitoring of the pin site, pin care according to institutional policy, and frequent monitoring for signs of infection take priority over the other nursing interventions listed. ‐ Assessing bowel sounds every shift ‐ Assessing temperature every 4 hours | The key concept is monitoring for complications of skeletal traction. |
‐ Providing adequate nutrition ‐ Providing age‐appropriate activities | |
1050 A nurse performs triage in a pediatric orthopedic Correct answer: 1 Slipped capital femoral epiphysis is a slipping of the femoral head that occurs most frequently clinic. Which of the following should the nurse before or during the rapid adolescent growth spurt. The onset of symptoms is gradual, and recognize as a symptom of slipped capital femoral symptoms include limp, holding the leg in external rotation to relieve pain, restricted and epiphysis? painful internal rotation, and knee and hip pain. ‐ Pain in the hip of a preadolescent child ‐ Acute onset of knee pain ‐ Presence of a limp in a school‐age child ‐ Painful external rotation of the affected leg | First consider the age of the child most frequently seen with this condition. This will rule out one of the responses. Option 4 can be eliminated as the symptoms are not associated with rotation. |
1051 Which of the following statements made by the Correct answer: 1 The therapeutic management of the child with osteomyelitis includes limiting weight‐bearing parent of a child being discharged with osteomyelitis on the affected part, immobilization, and administration of antibiotics. Antibiotic therapy may requires further teaching by the nurse? continue intravenously for 3 to 6 weeks, and orally for another 2 weeks depending on duration of symptoms, response to treatment, and sensitivity of the organism. Discharge teaching needs to include follow‐up antibiotic care at home, care of the IV site, and continuing antibiotic therapy even though it may seem as if all the symptoms are gone. Food sources such as calcium and protein should be provided for bone healing. ‐ “I can stop the antibiotics when I see that my child is afebrile for one week” ‐ “We will make sure that our child’s diet has plenty of calcium and protein.” ‐ “I will look at the intravenous site for signs of infection a couple of times a day.” ‐ “My child won’t take physical education at school until allowed by the doctor.” | Determine the right answer by eliminating any choice that is obviously correct information. |
1052 A 5‐month‐old infant is being assessed for Correct answer: 3, 5 All four of the signs are assessment tests for developmental dysplasia of the hip. Ortolani and developmental dysplasia of the hip. The nurse Barlow signs disappear after 2 to 3 months. Trendelenburg sign will be seen in the child who is concludes that positive signs and symptoms that able to stand. Allis sign, shortening of the affected limb on the affected side, is a reliable test at indicate this disorder include: (Select all that apply) 4 months of age. Asymmetric folds would be a positive sign at any age. The child is too young to walk, so a limp would not be observed. ‐ Ortolani sign. ‐ Barlow sign. ‐ Allis sign. ‐ Trendelenburg sign. ‐ Asymmetric thigh and gluteal folds. | The core concept is the age of the child at the time of diagnosis. Wrong answers can be eliminated based on age. |
1053 A newborn is being admitted to the newborn nursery. Correct answer: 3 Clubfoot is apparent at birth, with the affected foot fixed in an abnormal position. The The nurse would assess the infant for congenital affected foot is usually smaller, shorter, with an empty heel pad. The affected limb is usually defects. In addition to the abnormal position of the shorter and has some calf muscle atrophy. foot, the nurse would note which of the following if clubfoot is present? ‐ Affected foot is larger and longer. ‐ Affected limb is longer. ‐ There is calf muscle atrophy of the affected limb. ‐ Affected foot is cooler. | Eliminate option 4 first as clubfoot does not affect circulation. Basically options 1 and 2 are the same, so they can be eliminated. |
1054 A child is admitted with osteogenesis imperfecta (OI). Correct answer: 3 Children with this disorder have normal calcium and phosphorus and abnormal precollagen In reviewing laboratory findings, the nurse would type I. This prevents the formation of collagen, the major component of connective tissue. The expect to find abnormal levels of: precollagen remains relatively unstable and unable to undergo final transformation into collagen. | Three of the tests listed are common tests. One is uncommon. |
‐ Calcium. ‐ Phosphorus. ‐ Precollagen type I. ‐ Vitamin D. | |
1055 Which of the following statements made by a parent Correct answer: 4 Children with mild OI may be able to participate in sports, and many are able to participate in of a child with osteogenesis imperfecta (OI) needs swimming. There are no current medications that stop this disease process. There are a variety clarification by the nurse? of surgical procedures that may be done to help strengthen the bones; one is the insertion of intermedullary rods to provide for stability. The child with OI may participate in school, though care needs to be provided to protect this child from injury. ‐ “My child may be able to participate in sports.” ‐ “There are no medications available to help this disease process.” ‐ “Surgery may be needed to place rods in the bone for stability.” ‐ “My child will need to be home schooled to protect him from injury.” | The goal of treatment for all children is to promote growth and development. The one action that would limit growth and development would be home schooling. |
1056 The physician has written the following orders for a Correct answer: 4 Children with muscular dystrophy quickly suffer from complications of immobility. Therefore, child with Duchenne muscular dystrophy hospitalized when hospitalized, these children should have physical therapy, range‐of‐motion exercises, and for a respiratory infection. The nurse should question bed‐to‐chair activity as soon as possible. Children with respiratory infections are treated with the order for: vigorous antibiotic therapy, as well as postural drainage and cupping. ‐ Physical therapy. ‐ Antibiotic therapy. ‐ Passive range of motion exercises. ‐ Strict bed rest. | The core concept is Duchenne muscular dystrophy. It is important with these children that function be maintained, and bed rest will promote disability. |
1057 A 14‐year‐old adolescent has just been fitted for a Correct answer: 3 The Milwaukee brace is worn for scoliosis, when the degree of curve is greater than 20 but Milwaukee brace. Which of the following should the less than 40 degrees. It is worn for 23 hours a day. Exercises to increase pelvic tilt, for lateral nurse include in teaching about this brace? strengthening, and to correct lordosis should be done several times a day while in the brace. The brace should be worn over a T‐shirt to minimize skin irritation. The adolescent may experience muscle aches resulting from new alignment. ‐ The brace should be worn only when the adolescent is sleeping or in the recumbent position. ‐ The brace should be worn next to the skin. ‐ Exercises to increase pelvic tilt should be done several times per day while in the brace. ‐ The adolescent should experience no pain as a result of wearing this brace. | The goal of therapy is to prevent progression of the scoliosis. To be successful in answering this question, the learner must understand the treatment plan. |
1058 The nurse has completed instructions on health Correct answer: 3 Aerobic exercises such as swimming help the client to maintain maximum range of motion maintenance for a client diagnosed with osteoarthritis. (ROM) and mobility while minimizing strain on joints. Isotonic exercises such as tennis, jogging, The nurse verifies that the client understood the and volleyball place excessive strain on diseased joints. instructions if the client states that participation in which of the following sports would be beneficial? ‐ Tennis ‐ Jogging ‐ Swimming ‐ Volleyball | Choose the odd option of the four, noting that swimming is the only non‐weight bearing exercise on the list. |
1059 A health history and physical assessment on a client Correct answer: 4 Swan neck deformities of the hand are classic deformities associated with rheumatoid with rheumatoid arthritis (RA) may reveal which of the arthritis secondary to the presence of fibrous connective tissue within the joint space. Clients following assessment data? with RA do experience morning stiffness, but it can last from 30 minutes up to several hours. RA is characterized by symmetrical joint involvement, and Heberden's nodes are characteristic of osteoarthritis. ‐ Heberden's nodes ‐ Morning stiffness no longer than 30 minutes ‐ Asymmetric joint swelling ‐ Swan neck deformities | This question requires differentiation of osteoarthritis and rheumatoid arthritis. |
1060 Which of the following over‐the‐counter (OTC) agents Correct answer: 3 Aspirin interferes with the action of uricosuric drugs. Acetaminophen, naproxen, or ibuprofen should the client on uricosuric drugs be instructed to may be used effectively as an analgesic in the treatment of pain associated with acute gout, avoid? and they do not interfere with the action of uricosuric drugs. ‐ Acetaminophen (Tylenol) ‐ Ibuprofen (Motrin) ‐ Aspirin (ASA) ‐ Naproxen (Naprosyn) | Be cautious with choosing ASA as a medication choice due to the high number of side and adverse effects associated with it, especially in the presence of a chronic illness. |
1061 Which of the following nursing interventions is Correct answer: 1 Options 2, 3, and 4 are appropriate nursing interventions when caring for a client diagnosed contraindicated in the care of a client with acute with osteomyelitis. The application of heat can increase edema and pain in the affected area osteomyelitis? and spread bacteria through vasodilatation. ‐ Apply heat compresses to the affected area ‐ Immobilize the affected area ‐ Administer narcotic analgesics for pain ‐ Administer OTC analgesics for pain | Remember not to use heat with infection; it will increase circulation and the dissemination of the infection. |
1062 Which of the following lab data would be most Correct answer: 4 Serum alkaline phosphatase is elevated because of increased activity of bone cells. significant in the client with Paget's disease? Inflammation is in the bone and usually doesn't reveal an elevated serum WBC, ESR, or the presence of Staphylococcus. ‐ Elevated white blood count (WBC) ‐ Elevated erythrocyte sedimentation rate (ESR) ‐ Positive tissue biopsy for <i>Staphylococcus</i> ‐ Elevated serum alkaline phosphatase | This question requires knowledge of the diagnostics associated with the illness. |
1063 Which of the following individuals is at greatest risk Correct answer: 4 Osteosarcomas are most commonly seen in males during optimal growth years. Middle‐aged for developing an osteosarcoma? males (option 1), females age 50 to 60 (option 2), and females of childbearing age (option 3) are less likely to develop osteosarcoma. ‐ Male, age 42 ‐ Female, age 52 ‐ Female, age 20 ‐ Male, age 15 | Make sure when answering this question that the gender and age are both correct. |
1064 A drug history is important in a client with systemic Correct answer: 1 Although the etiology of SLE is unknown, certain environmental factors have been associated lupus erythematosus (SLE) because the disease may be with the onset of symptoms. The administration of procainamide (Procan SR) and hydralazine associated with use of which of the following drugs? (Apresoline) have been associated with SLE symptoms, which usually subside after the drug is discontinued. ‐ Procainamide (Procan SR) ‐ Acetylsalicylic acid (aspirin) ‐ Diazepam (Valium) ‐ Azathioprine (Imuran) | Recall that valium and aspirin are common medications and that Imuran is an immunosuppressant. Use the process of elimination to choose Procan. |
1065 To prevent occurrences of Raynaud's phenomenon, Correct answer: 1 Raynaud's disease is characterized by spasms of the blood vessels within the fingers of the what should the client diagnosed with systemic hands resulting in diminished circulation. Gloves protect the hands from cold temperatures Scleroderma be instructed to do? and provide warmth, which promotes blood flow to the affected areas. Raynaud's phenomenon is in the CREST syndrome, a type of scleroderma. ‐ Wear gloves ‐ Perform range‐of‐motion exercises daily ‐ Limit sodium intake ‐ Avoid warm temperature | Recall that vasoconstriction occurs in response to cold, which then exacerbates the client’s pain. |
1066 Which of the following occurs during the remodeling Correct answer: 3 During earlier stages of bone healing, overproduction of callus enlarges the bone and acts as phase of bone healing? a splint. Callus is eventually replaced with mature bone during the ossification phase of bone healing, and then the excess callus is resorbed during the remodeling phase to return the bone to its original shape. ‐ Callus formation occurs. ‐ Callus is replaced with mature bone. ‐ Osteoclasts resorb excess callus to return the bone to its original shape. ‐ Proliferation of osteoblast and fibroblasts occurs within the hematoma at the fracture site. | This question requires knowledge of the remodeling stage. |
1067 Which of the following statements applies to Correct answer: 1 Edema is expected immediately following a fracture, but because the fascia is non‐elastic, compartment syndrome? excessive swelling will lead to increased capillary pressure within the area resulting in nerve and muscle damage if left untreated. Damage is irreversible if the capillary pressure reaches 30 mmhg. A pulse may still be present during early stages of compartment syndrome. One factor that can differentiate pain associated with trauma from the fracture, and that from compartment syndrome, is the ineffectiveness of analgesics when compartment syndrome occurs. ‐ Increased pressure within the tissues results from excessive edema at the fracture site. ‐ Capillary pressures over 15 mmhg can result in permanent muscle and nerve damage. ‐ The presence of a peripheral pulse will rule out compartment syndrome. ‐ Pain associated with compartment syndrome will be relieved with use of analgesics. | With compartment syndrome, think edema. |
1068 To determine if a client is experiencing compartment Correct answer: 3 Although assessing for edema, pulses, and the presence of drainage is important in the care syndrome, which of the following is a priority area for of a client with a fracture, pain unrelieved by analgesics is the symptom most indicative of nursing assessment? compartment syndrome. ‐ Assessing for edema at the fracture site ‐ Palpation of a pulse at the fracture site ‐ Performing a pain assessment ‐ Assessing for the presence of drainage on the cast | Recall that pain is a key indicator with test questions; look at it carefully. |
1069 Beta blockers are given to clients with scleroderma to Correct answer: 4 When clients with scleroderma develop Raynaud's phenomenon, which is characterized by treat which of the following symptoms? vasospasms of the arteries and veins of the hands, beta blockers are the treatment of choice. Bradycardia is not specific to scleroderma. Clients may experience pericarditis, but this is not treated with beta blockers. ‐ Telangiectasis ‐ Pericarditis ‐ Bradycardia ‐ Raynaud's phenomenon | Recall that beta‐blockers have cardiovascular actions; Raynaud’s is a cardiovascular phenomenon. |
1070 Which of the following lab values is most significant Correct answer: 1 Hypercalcemia (option 1) can occur as a complication of Paget's disease secondary to when assessing complications associated with Paget's increased osteoclast activity. The other tests are not specific to Paget's disease although they disease? are all abnormal values. ‐ Calcium level of 15 mg/Dl | With questions referring to bone diseases, such as Paget’s, think calcium. |
‐ Positive RF factor. ‐ Blood urea nitrogen (BUN) of 140 mg/dl ‐ Eosinophil sedimentation rate (ESR) of 30 mm/hr | |
1071 Which of the following statements applies to Ewing's Correct answer: 2 Ewing's sarcoma is a primary bone tumor associated with rapid metastasis to the lung. It sarcoma? occurs most frequently in males during optimal growth periods. ‐ Occurs most frequently in men between the ages of 20 and 40 years of age ‐ Is a primary bone tumor characterized by rapid growth and lung metastasis ‐ Is a metatastic bone tumor that occurs secondary to colon cancer ‐ Usually originates in bone cartilage | Use the process of elimination to find the one correct answer. |
1072 The pathophysiology underlying gouty arthritis may Correct answer: 2 The pathophysiology of gouty arthritis is related to overproduction or decreased excretion of be attributed to: uric acid in the primary form. The other options are incorrect. ‐ Increased immune complexes within the joint cavity. ‐ An alteration in purine metabolism resulting in hyperuricemia. ‐ Excessive bone remodeling secondary to increased levels of phosphorus. ‐ The presence of fibrous adhesions within bony cartilage. | This question requires knowledge that Gout is related to uric acid build‐up. |
1073 A client is diagnosed with osteomyelitis involving the Correct answer: 2 Although all the items listed are important in the plan of care for the client diagnosed with foot. The highest priority during the implementation of osteomyelitis, maintaining aseptic technique and preventing the spread of infection is crucial nursing care is: to resolving the disease process. ‐ Maintaining adequate pain control. ‐ Implementing aseptic technique. ‐ Promoting adequate nutrition. ‐ Splinting the foot to prevent foot drop. | Maslow's hierarchy may identify option 1 as highest priority, but infection is the cause of the pain. Recall what causes the problem and deal with that first in a question like this one. |
1074 When counseling the parents of a child diagnosed Correct answer: 3 Symptoms of muscular dystrophy usually manifest themselves in the toddler years. The child with muscular dystrophy, which of the following has a waddling gait and experiences frequent falls. There is no cure for the disease and muscles statements most accurately describes the disease become progressively weak. Most children are wheelchair confined by the teen years. As the progression? disease progresses, heart and lung muscle are affected, resulting in cardiac and pulmonary failure. These complications frequently occur by the age of 20. ‐ "Prognosis is favorable with early detection." ‐ "With aggressive physical therapy and the use of a walker, your child will remain ambulatory through adulthood." ‐ "The muscles and the lungs may also become involved, and this can shorten your child's lifespan." ‐ "Muscle weakness is progressive and rapid, and your child will most likely be confined to a wheelchair by the age of 5." | This question requires knowledge of the prognosis of muscular dystrophy. |
1075 Which of the following statements best describes the Correct answer: 1 Articular cartilage is responsible for decreasing friction during joint movement and displacing underlying pathology of osteoarthritis (OA)? the force of the workload onto the subchondral bone. In OA, the composition of the articular cartilage is changed because of a malfunction in the production in proteoglycans. Consequently, the articular cartilage can no longer perform its original function. ‐ Changes in the composition of the articular cartilage contribute to increased friction during joint movement. ‐ Joint inflammation occurs secondary to the presence of immune complexes within the joint cavity. ‐ Excessive bone necrosis within the joint occurs secondary to increased osteoclastic activity. ‐ Bone damage occurs secondary to osteolysis and excessive bone remodeling. | This question requires knowledge that osteoarthritis is a degenerative disease. |
1076 In the early treatment of rheumatoid arthritis (RA), Correct answer: 4 DMARDs are now being used earlier in the treatment regime for RA because evidence which of the following drugs would the nurse expect to suggests that they may play a role in arresting the disease process. NSAIDs are used in be included in the client's drug regime? combination with this drug classification for pain management. Systemic corticosteroids are not used until NSAIDs are no longer effective because of the severe side effects associated with their use. ‐ Non‐steroidal antiinflammatory drugs (NSAIDs) ‐ Systemic corticosteroids ‐ Disease modifying anti‐rheumatoidal drugs (DMARDs) ‐ NSAIDs and DMARDs | Notice that option 4 is the most inclusive answer as it includes both options 1 and 3. |
1077 Which of the following statements best describes the Correct answer: 2 Osteoporosis is characterized by excessive bone resorption that exceeds the body's ability to pathophysiology underlying osteoporosis? The disease produce new bone. It is more prevalent in postmenopausal women with low levels of process is related to: estrogen. A decrease in the number and activity of osteoblasts and an increase in the number and activity of osteoclasts occurs. ‐ Increased amounts of estrogen in postmenopausal women. ‐ A decrease in osteoblasts and an increase in osteoclasts. ‐ Decrease in blood supply to the bone resulting in bony necrosis. ‐ Invasion of a pathogen leading to osteolysis of bone. | Use the process of elimination to find the one right answer. |
1078 After analyzing a urine report on a client with Correct answer: 2 Proteinuria in a client with SLE indicates renal involvement. The nurse should record I & systemic lupus erythematosus (SLE), the nurse O and analyze the results of additional labwork including blood urea nitrogen (BUN) and determines that the client has proteinuria. This finding creatinine (CR). would lead the nurse to place the highest priority on assessing: ‐ Blood pressure. ‐ Intake and output (I&O). ‐ Pulse. ‐ Temperature. | With proteinuria, think of diseases which may cause or be related to damage in the kidneys. This question asks about assessments which measure kidney function. |
1079 Which of the following classifications of scleroderma Correct answer: 1 Scleroderma is not drug‐induced. Systemic sclerosis may result in changes to the esophagus, is associated with a poor prognosis, secondary to intestines, lungs, heart, and kidneys. Depending on which organs are involved, the condition involvement of vital organs? may be life‐threatening. CREST syndrome and limited scleroderma are self‐limiting and associated with a good prognosis. ‐ Systemic sclerosis ‐ CREST syndrome ‐ Limited scleroderma ‐ Drug Induced scleroderma | Notice that the word ‘systemic’ in option 1 provides a hint for the answer. |
1080 Which of the following statements best describes the Correct answer: 4 Although the etiology of scleroderma is unknown, the disease process is related to pathophysiology related to scleroderma? overproduction of collagen leading to fibrosis and inflammation, which causes damage to the affected area. ‐ Excessive ossification and thickening of collagen tissue causes thickening of the skin. ‐ Overproduction of osteoblasts contributes to bone deformities. ‐ Overactivity of osteoclasts contributes to erosion of the bone. ‐ Overproduction of collagen leads to fibrosis and inflammation of affected areas. | This question requires knowledge of the pathophysiology of scleroderma. |
1081 Which of the following diagnostic tests is most Correct answer: 1 Serum ESRs and ANAs are elevated in scleroderma but are also indicative of other conditions. conclusive in the diagnosis of systemic lupus A skin biopsy reveals collagen thickening and confirms the diagnosis. The rheumatoid factor is erythematosus (SLE)? only significant for rheumatoid arthritis. ‐ Skin biopsy ‐ Eosinophil sedimentation rate (ESR) ‐ Anti‐nuclear antibodies (ANA) | For this question, look for the most invasive and most conclusive diagnostic test. |
4.‐ Rheumatoid factor | |
1082 Which of the following is the priority nursing Correct answer: 1 Immobilizing the fracture is the priority nursing intervention in the emergency management intervention for a client immediately following a of a client with a fracture. After the area is immobilized, the nurse should follow through with fracture? interventions outlined in options 2, 3, and 4. ‐ Immobilize the fracture ‐ Administer analgesics to control pain ‐ Apply ice to the fracture site ‐ Assess the radial pulse | This question uses a basic principle of first aid. |
1083 A client on bedrest for the past 48 hours secondary to Correct answer: 2 A fat emboli is a common complication following the fracture of a long bone. Symptoms of fat a fractured femur presents with tachycardia and a emboli include tachycardia, a petechial rash, and tachypnea. petechial rash. The nurse attributes these symptoms to a(n): ‐ Deep vein thrombosis (DVT). ‐ Fat Emboli. ‐ Hypovolemic shock. ‐ Allergic reaction to medication. | This question requires knowledge of the symptoms of fat emboli. |
1084 Compartment syndrome occurs as a result of Correct answer: 3 Compartment syndrome occurs as a result of an excessive pressure within the joint cavity obstruction in: which results in obstruction of both arterial and venous blood flow. Hence, the symptoms of decreased or absent pulse, pallor, and decreased capillary refill. ‐ Arterial circulation. ‐ Venous circulation. ‐ Arterial and venous circulation. ‐ The lymphatic system. | Notice that option 3 is the most comprehensive answer, containing both options 1 and 2. |
1085 Which of the following teaching tips should the nurse Correct answer: 3 An adequate intake of calcium, either in the diet or through supplements and regular include when providing health teaching to clients participation in weight‐bearing activities are the most effective way to prevent osteoporosis. regarding prevention of osteoporosis? Walking, jogging, and weight‐lifting are examples of weight bearing exercises; swimming is not. Estrogen replacement is effective in preventing osteoporosis in postmenopausal women. ‐ Swimming is an effective weight‐bearing activity. ‐ Estrogen replacement is important for preventing osteoporosis in premenopausal women. ‐ Maintaining calcium intake between 1,200 to 1,500 mg/day is important. ‐ All clients over 40 years of age should undergo bone density studies annually. | With prevention, think of the most basic means, in this case nutrition. |
1086 The first indication of bone loss in clients with Correct answer: 3 Although clients with osteoporosis are predisposed to pathological fractures, loss of height is osteoporosis is: usually one of the first indicators of osteoporosis. ‐ Crepitus with joint movement. ‐ Symmetrical joint deformities. ‐ Loss of height. ‐ Pathological fracture. | Notice the hint in the question stem with the words ‘first indication.’ Recall that loss of height is one of the indications of bone loss. |
1087 Which of the following responses from a client Correct answer: 3 Application of heat prior to exercising may help improve joint function. Jogging is not recently diagnosed with osteoarthritis (OA) indicates a recommended because it puts excessive stress on joints. Clients with OA should maintain their clear understanding of health maintenance teaching? weight to prevent excessive stress on joints. A firm mattress is recommended for support of the lumbar spine. ‐ "I have no dietary restrictions and can eat whatever I want." ‐ "I can resume jogging 1 mile a day once I start on medication." ‐ "Heat applications before exercising may help improve my joint function." | Use the process of elimination to determine the most realistic option for this client. |
4.‐ "I will get a softer mattress on my bed for extra support." | |
1088 A client is admitted to the emergency department Correct answer: 1 A client admitted to the emergency department and diagnosed with an acute episode of gout and diagnosed with acute gouty arthritis. Which of the will be in severe pain. Although a serum uric acid level should be obtained, pain management following is a priority nursing intervention? should be the first priority for the nurse. Clients prescribed uricosuric drugs for prevention of further gouty attacks should be instructed to increase fluids to prevent kidney stones associated with their use, however teaching should be conducted after the client is relieved of pain. ‐ Providing pain management ‐ Collecting intake and output (I&O) ‐ Straining urine for kidney stones ‐ Obtaining a serum uric acid level | Recall that pain is an early sign and an indicator for nursing intervention. |
1089 Which of the following clients is at risk for developing Correct answer: 3 Hematogenus osteomyelitis originates as a blood borne infection and occurs most commonly hematogenus osteomyelitis? in children under 10 years of age with a recent history of a throat, ear, or skin infection. Options 1, 2, and 4 are examples of direct entry osteomyelitis. ‐ 17‐year‐old client with a gunshot wound to the femur ‐ 78‐year‐old client diagnosed with a fractured hip ‐ 8‐year‐old client with otitis media ‐ 20‐year‐old client, five days status post‐appendectomy | Use the process of elimination to find the only option which indicates a hematogenic origin. |
1090 The osteoblastic scelerotic phase of Paget's disease is Correct answer: 3 Paget's disease is characterized by two phases. The osteoblastic phase is characterized by characterized by: slowing down of bone resorption and enlarging of bones. ‐ Excessive bone remodeling. ‐ Replacement of normal bone marrow with vascular, fibrous, connective tissue. ‐ Slowing down of bone resorption and enlargement of bones. ‐ An increase in the activity of osteoclasts causing erosion of bone. | This question requires knowledge of the progress of Paget’s disease. |
1091 Which of the following statements made by the Correct answer: 3 Muscular dystrophy is a genetic disorder of the recessive gene on the X‐chromosome (mother parents of a child diagnosed with muscular dystrophy to son). Option 1 would be true if all future pregnancies were males. (MD) verifies to the nurse that they understand teaching regarding the disease process? ‐ "Any child from future pregnancies is at risk for inheriting the disease." ‐ "The disease occurred because my child has a defective immune system." ‐ "The disease is genetically transmitted from mother to son." ‐ "The disease relates to a genetic disorder on the father's side." | This question requires knowledge of sex‐linked genetics. |
1092 A client diagnosed with a metastatic bone tumor asks Correct answer: 3 The most common sites for metastatic bone tumors are the ribs, spine, and pelvis. the nurse where the tumor is. The nurse knows the most likely place is in the: ‐ Tibia. ‐ Fibia. ‐ Spine. ‐ Skull. | This question requires knowledge of bone tumors. |
1093 Osteosarcomas originate in: Correct answer: 1 The tissue of origin associated with osteosarcomas is the metaphyseal of long bones. The formation of chrondrosarcomas originate in cartilage, and Ewing's sarcoma originate in the nerve tissue within the bone marrow. ‐ The metaphyseal of long bones. ‐ In the cartilage. | This question requires knowledge of osteosarcomas. |
‐ In nerve tissue within the bone marrow. ‐ The lung. | |
1094 A client has been diagnosed with a metastatic bone Correct answer: 3 Gently supporting limbs and bony structures during transfers and position changes is the most tumor. Which of the following interventions would be effective way to prevent pathological fractures associated with bone tumors. Option 1 might most effective in preventing a pathological fracture? cause limited range‐of‐motion (ROM); options 2 and 3 aren't applicable. ‐ Restricting activities to complete bedrest. ‐ Instructing the client on pivot transfers. ‐ Gently supporting limbs during position changes. ‐ Providing a calcium supplement. | For this question, use the most supportive measure which also increases client independence. |
1095 Which of the following clients is at greatest risk for Correct answer: 3 Although the etiology of SLE is unknown, hormonal imbalances associated with pregnancy are developing systemic lupus erythematosus (SLE)? thought to precipitate the onset of the disease. Women of childbearing years are at a greater risk. ‐ A male, 25 years of age ‐ An elderly female, 72 years of age ‐ A college female, 24 years of age ‐ A Caucasian female, 42 years of age | For this question, ensure both the gender and age range are correct. |
1096 A client with osteoarthritis (OA) asked the nurse Correct answer: 4 The joints most often affected in osteoarthritis are the weight‐bearing joints; hips, knees, which joints are most commonly effected? The best lumbar and cervical spine, and the phalangeal joints. answer is: ‐ Thoracic spine. ‐ Wrist. ‐ Elbow. ‐ Distal phalangeal joints. | Use common experience to guide you in this question. Recall that many people with arthritis are effected in their fingers. |
1097 Which of the following musculoskeletal disorders is Correct answer: 2 During chronic osteomyelitis infection spreads through the bone, bone cells become necrotic characterized by the formation of sequestra? and break off into segments called sequestra. ‐ Osteoarthritis ‐ Osteomyelitis ‐ Scleroderma ‐ Osteosarcoma | This question requires knowledge of sequestra. |
1098 Which of the following is a priority when providing Correct answer: 3 Although options 1, 2, and 4 are all important interventions in the health teaching of clients health teaching to a client with rheumatoid arthritis with rheumatoid arthritis, instructing the client on energy conservation techniques and pacing (RA)? Instruct the client: activities early in the teaching plan will help to provide immediate symptom control. Decreasing activity (option 2) may further limit range‐of‐motion. ‐ On weight reduction. ‐ To decrease activity to avoid joint pain. ‐ To pace activities to decrease joint stress. ‐ To contact the Arthritis Foundation for support services. | Notice the stem asks for the priority intervention. This also allows the client the greatest level of independence. |
1099 A 40‐year‐old athletic male client has been diagnosed Correct answer: 3 In adult males, the most prevalent contributing factor in the development of osteoarthritis is with osteoarthritis of the knee. The nurse will most history of joint trauma. An athletic male may have had trauma to the knee from a sport many likely attribute the etiology of the disease to the years earlier in high school. client's: ‐ Age. | Recall that a previous injury may be a site for arthritis. |
‐ Gender. ‐ Previous trauma. ‐ Current weight. | |
1100 Which of the following clinical manifestations is a Correct answer: 4 Tophi are hard movable nodules with irregular surfaces associated with chronic untreated primary indicator of chronic gouty arthritis? gout. Acute pain and hyperuricemia are not exclusive to chronic gouty arthritis. ‐ Acute pain ‐ Hyperuricemia ‐ Swan neck deformities ‐ Tophi on the helix of the ear | This question requires knowledge of chronic gouty arthritis. |
1101 The primary organism responsible for osteomyelitis Correct answer: 1 The most common causative agent in clients with osteomyelitis is Staphylococcus aureus. The is: other organisms could contribute but are not usually the primary organism; look for key words. ‐ <i>Staphylococcus aureus</i>. ‐ <i>Escherichia coli</i>. ‐ <i>Streptococcus</i>. ‐ <i>Pseudomonas</i>. | This question requires knowledge of osteomyelitis. |
1102 Which of the following clinical manifestations Correct answer: 3 Increased head size, headaches, and hearing loss indicate that Paget's disease has progressed indicates the involvement of the cranium in a client and involves the cranium. with Paget's disease? ‐ Ptosis ‐ Alterations in vision ‐ Enlarged head size ‐ Difficulty chewing | This question requires knowledge of Paget's disease, remembering that it is a bone disease. |
1103 Which of the following is usually one of the first Correct answer: 4 Symptoms of muscular dystrophy present around 2 to 3 years of age. Children usually present symptoms observed in children with muscular with a waddling gait, toe walking, and frequent falls. Kyphosis occurs with disease progression, dystrophy (MD)? and recurrent URIs occur with involvement of lung tissue. ‐ Leg bowing ‐ Recurrent URI's ‐ Kyphosis ‐ Toe walking and frequent falls | Notice that this question asks for the first or earliest signs of having MD. |
1104 Which of the following statements made by a client Correct answer: 1 The etiology of fibromyalgia is unknown, but it is believed that it may be precipitated by with fibromyalgia indicates to the nurse that the client stress. The condition may be acute or chronic, non‐steroidal antiinflammatory drugs (NSAIDs) has a clear understanding of the health teaching? will help to control joint and muscle pain associated with the condition but is not a cure. ‐ "I need to identify the stressors in my life and work on reducing them." ‐ "The drugs prescribed by the doctor will cure my condition within six months." ‐ "I will include high‐fiber foods in my diet." ‐ "My frequent headaches are unrelated to my condition." | This question reinforces the connection of stress with fibromyalgia. |
1105 The nurse analyzes the results of x‐rays done on a Correct answer: 4 Options 1 and 3 are characteristic of malignant tumors. Soft tissue sarcomas are not detected client with a benign bone tumor. Which of the on x‐rays; a computed tomography (CT) scan or magnetic resonance imagery (MRI) must be following results would the nurse expect to find? performed. ‐ Extension of tumor beyond the structure of the bone ‐ The presence of a soft tissue sarcoma ‐ Undefined tumor borders | Notice options 3 and 4 are opposites, meaning one of them is likely to be the correct answer. |
4.‐ Well‐defined tumor margins | |
1106 The pathophysiology of systemic lupus erythematosus Correct answer: 1 SLE is an autoimmune disease in the body, characterized by production of autoantibodies (SLE) is primarily related to: against DNA secondary to hyperactivity of B‐cells. ‐ The production of autoantibodies against DNA. ‐ A mutated gene. ‐ Overproduction of collagen. ‐ Chronic inflammation secondary to a virus. | This question requires knowledge of SLE and its causes. |
1107 Which of the following joint deformities is usually Correct answer: 3 Bouchard's nodes are located on the Proximal Interphalangeal (PIP) joints of clients with evident in the hand of a client diagnosed with osteoarthritis. Swan neck deformities, ulnar drift, and boutaniere deformities are osteoarthritis (OA)? characteristic of rheumatoid arthritis (RA). ‐ Swan neck deformities ‐ Boutaniere deformities ‐ Bouchard's nodes ‐ Ulnar drift | This question requires knowledge of the terminology and OA. Use the process of elimination to select the option associated with OA. |
1108 The primary care provider determines that a 55‐year‐ Correct answer: 3 Women of menopausal age are at risk for osteoporosis, and foods high in calcium should be old female client is experiencing menopause and is encouraged. All the foods in option 3 are high in calcium. Chicken and eggs are high in protein; also at risk for osteoporosis. What foods other than wheat and corn are high in carbohydrates. milk can the nurse suggest to this client to increase her calcium intake? ‐ Seafood, wheat, corn, green vegetables ‐ Chicken, green vegetables, sardines, broccoli ‐ Green vegetables, sardines, salmon with the bone, broccoli ‐ Eggs, cheese, sardines, fish | This question requires knowledge of nutrition. Select the option with the highest amount of calcium. |
1109 What risk factors identified by the nurse would put a Correct answer: 1 The factors presented in option 1 put the client at risk for osteoporosis. Smoking, alcohol client at risk for developing osteoporosis? intake, and dietary deficiency of calcium and Vitamin D are major factors in the development of osteoporosis. Deficient protein and carbohydrate intake, obesity, depression, and history of falls do not contribute to the development of osteoporosis. ‐ Menopause, stress, sedentary lifestyle, smoking, excessive alcohol intake, and diet deficient in calcium and Vitamin D ‐ Family history, age, history of falls, smoking, alcohol, and diet deficient in protein ‐ Diet deficient in protein and carbohydrates, smoking, excessive alcohol intake, stress, and sedentary lifestyle ‐ Inadequate sunlight exposure, obesity, depression, poor dietary intake of calcium, and excessive alcohol intake | Select the answer with the greatest number of risk factors. |
1110 Alendronate (Fosamax) is ordered for a client with Correct answer: 4 Fosamax is the drug that prevents bone resorption. Calcitonin (Micalcin) increases bone mass osteoporosis. Which information should the nurse and is dispensed as a nasal spray; raloxifene (Evista) is a selective receptor modulator. include in teaching the client about this drug? ‐ It is a selective estrogen receptor modulator. ‐ It increases bone mass. ‐ It may be obtained as a nasal spray. ‐ It prevents bone resorption and is taken orally. | This question requires knowledge of Fosamax. |
1111 The nurse is preparing a client who sustained a hip Correct answer: 1 The client with hip surgery should avoid all activities that will cause hip adduction, internal fracture for discharge. The nurse should teach the rotation, and flexion beyond 90 degrees. The focus of the teaching on clients with hip surgery client to avoid which of the following groups of is to avoid dislocation and the risk for further injury. activities to prevent dislocation of the hip? ‐ Crossing legs, bending at hips, and sitting on low toilet seats | Notice that this question asks for an incorrect answer. Use the process of elimination to find the one wrong answer. |
‐ Taking leisurely walks, low chair seats, and bending at hips ‐ Using reachers for applying shoes and socks, and sitting in chairs with arms ‐ All exercises, bedrest, and using raised toilet seats | |
1112 A client with a total hip replacement is concerned Correct answer: 1 Extremes of internal rotation, adduction, and 90‐degree flexion of the hip should be avoided 4 about dislocation of the prosthesis. What can the to 6 weeks after surgery to prevent dislocation. Although use of elevated seats prevents excess nurse say to reassure this client? flexion of the hip, it alone does not suffice in preventing dislocation. Bending activities (such as putting on shoes) place the client at risk for dislocation. Abduction pillows are used to prevent external rotation and must be used postoperatively. ‐ "Avoid activities that cause adduction of the hip to prevent dislocation." ‐ "Use of elevated toilet seats alone will prevent dislocation." ‐ "Perform bending exercises as often as able to prevent dislocation." ‐ "Remove the foam abduction pillow as soon as possible postoperatively." | This question asks about the basic care after hip replacement. Recognize that option 1 is the best answer, although several options are true. |
1113 A client has undergone a lumbar laminectomy and Correct answer: 3 Musculoskeletal injuries and subsequent treatment have the potential to cause has just returned to the nursing unit. It is essential for complications. Bleeding and swelling from the surgery may cause compression of nerves that the nurse to perform which of the following activities can lead to permanent neurological damage and paralysis. Frequent assessment of the during this period? neurovascular status of the client is essential following laminectomy. Neurovascular assessment includes assessing for pain, pulses, pallor, paresthesia, and paralysis. The physician usually orders ambulation. Vital signs are not done every 30 minutes unless the client is in the post‐anesthesia care unit. Although loss of bladder tone may indicate nerve damage, it may also be a residual effect of the anesthesia. Assessing ability to void becomes of prime importance if the client is due to void, usually 6 to 8 hours after last voiding. ‐ Early ambulation ‐ Vital signs checks every half‐hour ‐ Neurovascular checks ‐ Assessment of bladder function | Remember assessments are usually an essential action to be done first. |
1114 A client in traction slides down in the bed so that the Correct answer: 3 The pull of traction on the affected limb should never be disturbed to ensure healing and feet touch the foot of the bed. What should the nurse union of the bone in proper alignment. This intervention is an independent nursing activity and do to ensure that the pull of traction remains does not require a physician's order. A change in weight is not indicated. Elevating the client's uninterrupted? feet will not correct the situation. ‐ Release the weights, pull the client up in bed, and then reapply weights ‐ Ask the physician for a change in the amount of weight ordered ‐ Move the client up in bed without releasing the pull of traction on the extremity ‐ Elevate the client's feet on a pillow | This question asks for the traction to be uninterrupted. Note that option 3 is best. |
1115 The nurse is caring for a client with skeletal traction. Correct answer: 1 A major complication of skeletal traction is infection. The nurse must provide pin site care It is most important that the nurse monitor which of using aseptic technique to prevent infection. the following? ‐ The pin site for unusual redness, swelling, purulent drainage, and foul odor. ‐ The distance between the client's hip and the traction. ‐ The number of times the client exercises the affected limb. ‐ How the client is coping with immobilization. | Recognize that although the other options might be appropriate, option 1 is an essential nursing intervention. |
1116 A client in skeletal traction complains of unrelieved Correct answer: 4 Unrelieved pain, diminished pulses, pallor, paresthesias, and pain on passive motion are all pain at rest and paresthesia in the affected extremity. symptoms of compartment syndrome. This is a medical emergency because the pressure must The assessment by the nurse reveals diminished pulse, be relieved in the affected limb. Otherwise, the swelling in the closed compartment may lead pallor, and increased pain on passive motion. What to further permanent complications, such as loss of the limb. Options 2 and 3, although must the nurse do first? appropriate, are not the priority interventions in this case. The administration of oxygen is an inappropriate initial action in this situation. ‐ Administer oxygen ‐ Encourage deep‐breathing and coughing exercises ‐ Administer pain medication as ordered ‐ Notify the physician immediately | Notice that this situation calls for emergency care. The nurse has conducted the appropriate assessments and basic comfort measures and it is time to call the physician. |
1117 The nurse is caring for a client who had open Correct answer: 3 The elevated temperature, chills, malaise, and pain are all clinical manifestations of reduction and internal fixation (ORIF) of the right osteomyelitis. Symptoms of fat embolism include acute respiratory distress. Symptoms of femur 4 days ago. The client complains of intense pain, compartment syndrome include progressively worsening pain distal to the affected site swelling, tenderness and warmth at the site, chills, unrelieved by analgesics. Malunion of the bone will not cause an elevated temperature. malaise, and has a temperature of 102.2 degrees F (39 degrees C). This data indicates which of the following? ‐ Fat embolism ‐ Compartment syndrome ‐ Osteomyelitis ‐ Malunion of the bone | Recall that these are cardinal signs of infection. |
1118 The nurse prepares a client for an arthrogram with Correct answer: 2 An arthrogram involves injecting dye into a joint for diagnostic purposes. It is critical that the contrast dye. What priority nursing assessment should nurse evaluate the client for history of allergic reaction to contrast dye before the procedure be performed for this client? since this can lead to a life‐threatening response such as anaphylactic shock. The other options are not priority assessments or are irrelevant. ‐ History of claustrophobia ‐ History of allergic reaction to contrast dye ‐ Vital signs ‐ Presence of metallic implants such as a pacemaker or aneurysm clips | Recall that allergy assessments are integral prior to diagnostics. |
1119 A retired 66‐year‐old female client is being evaluated Correct answer: 1 Low bone mass, structural deterioration of bone tissue leading to bone fragility, and for osteoporosis as part of a yearly physical. The client increased susceptibility to fractures is seen with osteoporosis. The client also has risk factors tells the nurse that she is a smoker, watches television associated with osteoporosis: smoking, sedentary lifestyle, and being female and for most of the day, and has been hospitalized with postmenopausal. three different fractures within the last year. Based on the information given by the client, the nurse suspects which of the following? ‐ Low bone mass leading to increased bone fragility. ‐ Degeneration of the articular cartilage. ‐ Recurrent attacks of acute arthritis. ‐ Personality changes caused by the chronic nature of the illness. | This question requires knowledge of risk factors associated with osteoporosis. |
1120 Following laminectomy surgery, the nurse should turn Correct answer: 3 After laminectomy it is critical that proper body alignment is maintained to prevent and reposition the client by doing which of the postoperative complications such as neurological damage. Logrolling technique ensures that following? the client turns as a unit. All the other options put stress on the spine. ‐ Having the client use the side rails of the bed. ‐ Elevating the head of the bed 45 degrees, then turning the legs together towards the floor, bending at the waist. ‐ Logrolling the client as a unit, keeping the body in proper alignment. ‐ Turning the client's head and shoulders then hips. | Recognize that logrolling is a key intervention with spinal surgery. |
1121 The nurse receives a client with a hip spica cast that is Correct answer: 3 Handling a cast that is not completely dry with the fingertips creates indentations in the cast. not completely dry. When turning the client the nurse These indented areas are thinner and are prone to cracks when the cast is completely dry. A uses the palms and not the fingertips. The nurse wet cast should be handled with the flat part of the hands and exposed to air to assist in chooses this technique for which of the following drying. purposes? ‐ To speed‐dry the cast. ‐ To decrease pain from moving. ‐ To prevent damage to the cast. ‐ To prevent swelling. | Recall basic principles of cast care. |
1122 The nurse is assigned to a 70‐pound client in skin Correct answer: 3 Countertraction will prevent the client from sliding to the foot of the bed. This can be traction. The nurse plans care to maintain effective achieved with Trendelenburg position of the bed or raising the foot of the bed slightly if the countertraction by doing which of the following? client's body weight is not sufficient. The other options do not add to countertraction. ‐ Elevating the head of the bed ‐ Adding weights to the existing traction ‐ Placing the bed in Trendelenburg position ‐ Keeping the bed flat | This question assesses knowledge of traction and countertraction. |
1123 A client underwent hip replacement yesterday. Which Correct answer: 4 Clients with joint replacement require aggressive physical therapy postoperatively to regain nursing diagnosis is of highest priority to be included in range of motion in the joint caused by pain and swelling. The other nursing diagnoses are not a the client's plan of care? priority at this time. ‐ Self‐care deficit ‐ Chronic pain ‐ Disturbed body image ‐ Impaired physical mobility | Remember physiological needs should be met first, then physical mobility is important after this surgery. |
1124 The nurse observes that a female client has Correct answer: 2 A classic sign of scoliosis is asymmetrical dress or skirt tail/hem caused by unevenness of the asymmetry of the shoulder, hips, and the tail/hem of affected shoulder and hip. The lateral curvature resulting from the spinal deformity causes the her dress. The nurse suspects that the client may be asymmetry. The other options do not necessarily cause all the manifestations listed in the presenting with which of the following disorders? question. ‐ Congenital hip dislocation ‐ Scoliosis ‐ A fractured tibia ‐ Degenerative disc disease | Recall the classic signs of scoliosis. |
1125 The nurse is caring for a client in Russell's traction. Correct answer: 1 Weights help to keep the fractured extremity in proper alignment to facilitate healing and The nurse observes the client's son playing with the therefore should not be manipulated. Nursing interventions for clients on traction should weights attached to the traction. The nurse takes include ensuring that the weights hang freely at all times to maintain the line of pull. Traction immediate action for which of the following reasons? is not released to maintain a steady pull. ‐ Manipulation of the weights will affect healing of the client's fracture. ‐ Traction should only be released once a day. ‐ The spasms of the extremity might increase. ‐ The client's hip may dislocate. | Notice that all the other options are not as essential as option 1, which is correct. |
1126 The nurse encourages a 68‐year‐old client to discuss Correct answer: 2 Estrogen therapy decreases bone demineralization preventing progression of osteoporosis. It estrogen replacement therapy with the physician after also increases bone density in the spine and hip and therefore reduces the risk of fractures. explaining that estrogen has which of the following The other options do not appropriately describe the action of estrogen in the preventive and benefits? therapeutic management of osteoporosis. ‐ Enhances the storage of Vitamin D ‐ Helps prevent progression of osteoporosis ‐ Increases longevity in postmenopausal women ‐ Cures osteoporosis | This question requires knowledge of estrogen replacement therapy. |
1127 A client is ready for discharge from the hospital Correct answer: 1 A client who undergoes surgery to the hip must be careful to avoid flexing the joint to greater following hip surgery. The nurse would ensure that than 90 degrees postoperatively to prevent dislocating the hip. There is no portable Buck’s which of the following is available for the client at the traction, although traction may be used preoperatively to immobilize the limb. A soft cushion time of discharge? is not essential. The client may need to use a walker for assistance, but does not need crutches. ‐ Raised toilet seat ‐ Portable Buck’s traction ‐ Soft cushion to use on chairs ‐ Crutches | This requires knowledge of hip surgery and treatment. |
1128 A client presents to the Emergency Department with Correct answer: 2 Standard x‐rays will not provide the detail necessary to evaluate soft tissue or cartilage a shoulder injury sustained while playing ice hockey. damage; arthroscopy is used to examine the interior of a joint; a bone scan is used to diagnose The nurse teaches the client about which of the bone malignancies. following diagnostic tests that would best identify abnormalities of the cartilage and soft tissue surrounding the joint? ‐ Standard x‐ray ‐ Magnetic resonance imaging (MRI) ‐ Bone scan ‐ Arthroscopy | Recall that MRIs show all structures. |
1129 A client presents to the Emergency Department with Correct answer: 3 A fractured extremity will be shorter than the unaffected extremity because of contraction of multiple injuries caused by a motor vehicle accident. the muscle, swelling at the site, and misalignment of the bone fragments. Pain with movement The nurse suspects that the client may have a right and bruising are not caused solely by hip fracture, and thus they are not distinctive signs. fractured hip after noting which of the following distinctive signs? ‐ The client reports increased pain with movement of the limb. ‐ There is bruising over the right hip. ‐ The right leg is shorter than the left. ‐ The right leg is longer than the left. | Note that options 3 and 4 are opposites, therefore one may be correct. |
1130 The nurse is providing care for a young athlete who Correct answer: 2 Routine stretching and warm‐up exercises are essential before strenuous physical activities to presents with muscle strain of the back that occurred prepare the muscle to withstand the stress of the motion. The intake of supplemental during a tennis match. Client teaching about electrolytes (such as what is contained in Gatorade) and high‐protein drinks do not prevent preventing such injuries in the future should include strains from occurring. The use of a back brace impedes movement during an activity such as which of the following? tennis and is not the best strategy to preventing future muscle strain. ‐ Drinking 2 liters of Gatorade before every sports activity ‐ Routine stretching and warm‐up exercises before every sports activity ‐ Wearing a back support brace ‐ Drinking a high‐protein shake before activity | Recall basic principles of mobility. |
1131 The nurse provides care to an elderly client in Correct answer: 2 Russell's traction can partially immobilize the extremity to reduce spasms. It is important that Russell's skin traction prior to reduction of a left hip the nurse monitors the skin under the traction for breakdown, especially over bony fracture. Priority nursing assessment should include prominences and other pressure areas. Option 1 is incorrect because this is a type of skin observation of which of the following? traction, and therefore there is no insertion site. Assessment of the skin for dehydration does not necessarily have to be done under the skin traction; rather it can be done in other areas. ‐ The pin sites for infection ‐ The client's skin for breakdown ‐ The left leg for decreasing length ‐ The client's skin for dehydration | Recall that skin integrity is the body’s first line of defense. |
1132 A client presents to the clinic with Paget's disease. Correct answer: 1 Skeletal pain is a classic symptom of Paget's disease. The location of the pain depends on the The client's chief complaint is skeletal pain. The nurse bone affected. Arthritis may result from damage to joint cartilage, but Paget's disease does not interprets this symptom as which of the following? result from bone deformities or from poor calcium uptake. There is excessive bone resorption followed by bone formation which leads to weakened bone, pain, deformity, and pathologic fractures. ‐ A characteristic of the disease process ‐ An ominous sign that should be reported to the physician immediately ‐ Caused by bony deformities ‐ Caused by poor calcium uptake by the bones | This question requires knowledge of the process of Paget's disease. |
1133 The nurse teaches a client with osteoarthritis about Correct answer: 1 Joint pain with movement seen with osteoarthritis is aggravated by continual activity. A managing joint stiffness associated with the disease. planned rest period is a very important intervention for managing the discomfort. Clients with The nurse knows that the teaching objective has been osteoarthritis should maintain a regularly scheduled exercise program to maintain joint met when the client makes which of the following flexibility and mobility. The application of heat and cold on the affected joint is for temporary statements? pain relief. A high‐calorie intake does not address the management of joint stiffness. ‐ "I will balance activities with rest periods throughout the day." ‐ "I will increase my calorie intake to supplement my energy needs." ‐ "I will apply a heating pad to the affected site when I feel pain." ‐ "I will apply a cold pack to the affected site when I feel pain." | Recall that rest periods are often key to disease management. |
1134 The nurse assists a client with osteoporosis to plan a Correct answer: 1 The combination of foods in option 1 has the highest amount of calcium. Each food in this meal high in calcium. Which meal would be the best meal is high in calcium overall. choice for the client? ‐ Baked salmon with the bone, broccoli, 1 cup of fruit yogurt, 1 cup of skim milk ‐ Turkey sandwich with Swiss cheese and mayonnaise on wheat bread, 1 small peach, iced tea ‐ Egg sandwich on whole wheat bread, 1/2 cup cottage cheese, iced tea, 1 slice cheesecake ‐ Steamed chicken on brown rice, 1 cup skim milk, tossed salad, 1 slice yellow cake | Select the option with the highest amount of calcium. |
1135 The nurse provides teaching to a 35‐year‐old client Correct answer: 2 Strengthening the back muscle is a critical intervention to preventing injury. This goal can be who is a construction worker about managing accomplished by regular exercise. Teaching a client the principles of good body mechanics, symptoms associated with chronic low back pain. The maintenance of good posture, and the importance of adhering to a prescribed exercise routine nurse determines that the teaching objective was met are important to strengthen back and abdominal muscles. The goal of managing back pain is to when the client makes which of the following prevent its recurrence. The use of a back brace and sporadic exercise are not appropriate in statements? decreasing the episodes of back injury. ‐ "I will wear a brace at work." ‐ "I plan to start a regular exercise program." ‐ "I will not carry objects more than 10 pounds." ‐ "I will try to exercise whenever I can." | This question requires knowledge and management of chronic low back pain. |
1136 A client had an above‐the‐knee amputation yesterday Correct answer: 1 It is normal to continue to have sensation in the amputated limb site since nerve endings are because of advanced peripheral vascular disease. The still present. The client feels real pain, and interventions should be provided to relieve it. Fat client is complaining of pain and itching in the embolism (option 3) is usually a complication of bone fracture and may have a clinical amputated limb. The nurse should take which of the presentation of confusion. However, other signs accompany fat embolism. following actions? ‐ Administer the prescribed analgesic for pain and explain to the client that this sensation is typical. ‐ Explain to the client that the limb is no longer present and the sensation will go away. ‐ Notify the physician immediately since this could be a sign of fat embolism. ‐ Obtain a psychiatric assessment for the client who may be hallucinating. | Recall that pain needs to be managed from the client’s perspective. |
1137 The nurse assessing a client with osteoarthritis notes Correct answer: 3 Heberden's nodes are bony enlargements on the distal interphalangeal joints (DIP), and finger deformities on the proximal and distal Bouchard nodes are bony enlargements on the proximal interphalangeal joints (PIP). The figure interphalangeal joints. The nurse documents this shows the typical changes of the DIP and PIP. Ulnar deviation and Boutonniere and swan neck common finding as which of the following in the deformities are typically associated with rheumatoid arthritis. medical record? ‐ Interphalangeal drift and ulnar deviation ‐ Boutonniere deformity ‐ Heberden's and Bouchard nodes ‐ Swan neck deformity | This question requires differentiation of osteoarthritis and rheumatoid arthritis. |
1138 A client recently diagnosed with hypothyroidism Correct answer: 3 Clients with hypothyroidism need to take thyroid hormone replacement medication daily all demonstrates understanding of prescribed of their lives. After the client has reached normal serum T<sub>4</sub> levels, the levothyroxine (Synthroid) medication when she makes normal metabolic rate may help the client lose the weight gained during the hypothyroid state, which of the following statements? but this is not the purpose of the replacement medication. Usually, the medication should be taken on an empty stomach, 1 hour prior to a meal or 2 hours after a meal. ‐ “I should be able to become pregnant in a couple of months.” ‐ “This medication will help me lose all this excess weight.” ‐ “I should call the physician for nervousness, diarrhea, or increased pulse.” ‐ “This medication should be taken with food, preferably dairy products.” | The core issue of the question is knowledge of medications used to manage hypothyroidism. Use nursing knowledge and the process of elimination to make a selection. |
1139 The client is post‐transsphenoidal hypophysectomy. Correct answer: 3 Bending the knees and squatting is preferred to bending at the waist to reach the floor as a The client demonstrates understanding of education means of preventing rises in intracranial pressure (ICP) following pituitary surgery. Holding the when he states, “I know I need to be careful not to breath as well as leaning over will increase ICP. Clients should be taught to avoid holding the increase the pressure in my head by breath for any reason and to avoid leaning forward or bending at the waist to prevent an increase in intracranial pressure. To tie shoes, the client should sit on the couch or bed, bend the knee and place his or her foot on the couch or bed to reach the shoelaces; Alternatively, the client can sit on the floor to tie shoes or can avoid shoes that tie until there is no risk for increased ICP. ‐ Sitting in a soft chair and leaning over slowly to tie my shoes.” ‐ Holding my breath when I reach down to pick up something from the floor.” ‐ Bending my knees first before squatting down to reach something on the floor.” ‐ Holding my breath while I use mouthwash, then leaning my head down toward the sink to spit it out.” | The core issue of the question is knowledge of measures to prevent rises in intracranial pressure following pituitary surgery. Use nursing knowledge and the process of elimination to make a selection. |
1140 The client who is 80 hours post‐transphenoidal Correct answer: 2 The numbness of the upper lip and gum near the incision as well as a decreased sense of hypophysectomy reports numbness on the upper lip smell are normal and should resolve in 3 to 4 months. The movement of the small rugs and gum, a headache when reclining, and has a suggests an unsteady gait or foot drop; both this and the headache are signs of increased tendency to kick around small rugs in the room when intracranial pressure. In‐depth assessments of neuromuscular function and incision site are walking. The home health nurse should do which of the needed, and then the surgeon should be consulted immediately. The other responses are following? either excessive or insufficient. ‐ Inform the client that these are normal responses and will disappear over 2 to 3 weeks. ‐ Assess neuromuscular function and incisional area and then report all findings to the surgeon. | The core issue of the question is the ability to accurately interpret the significance of client findings after pituitary surgery and then determine the next action. Use nursing knowledge and the process of elimination to make a selection, recalling that further assessments are often indicated when encountering abnormal data. |
‐ Immediately arrange for the client to be transported to the hospital for treatment of increased intracranial pressure. ‐ Assess vital signs, fluid volume status, bowel function and nutrition status. | |
1141 The client with diabetes mellitus requests a Correct answer: 2 Headache, restlessness, anxiety, sweating, and increased pulse are signs of hypoglycemia. medication for headache soon after returning from an Resolution of symptoms should occur after the client drinks the juice. The other options either early morning x‐ray procedure. The nurse observes the delay treatment (options 1 and 3) or fail to recognize the real problem (option 4). client is upset about the headache, angry at missing breakfast, and has moist hands. The nurse should do which of the following as the priority action? ‐ Administer the medication for headache and arrange for a breakfast tray. ‐ Check the blood glucose level and be prepared to give 4 ounces of juice immediately. ‐ Acknowledge his dissatisfaction, offer to obtain a snack, and give the medication. ‐ Administer the headache medication and review the day’s lab test results. | The core issue of the question is recognition that the client is at risk for hypoglycemia and the corrective actions that need to be taken. Use nursing knowledge and the process of elimination to make a selection. |
1142 A 70‐year‐old client admitted a few hours ago with a Correct answer: 3 Increased preload caused by the intravenous infusion at 250 mL/hr may exceed the blood glucose level of 750 mg/dL is being treated for myocardium’s workload capacity, leading to signs of decreased cardiac output and congestive hyperosmolar hyperglycemic nonketotic coma (HHNK) heart failure. The other options focus on inappropriate information. with intravenous regular insulin at 10 units/hour, normal saline with 40 mEq of potassium per liter infusing at 250 mL/hr, and oxygen at 2 L/min. The client is oriented when stimulated, and FBG has dropped to 400 mg/dL. The client starts demanding to get out of bed and the nurse notes the skin feels cool and moist. The nurse should do which of the following? ‐ Interpret this as a sign of hypoglycemia and check his blood glucose. ‐ Recognize that client is feeling better and is seeking control of his situation. ‐ Auscultate breath sounds and assess oxygen saturation for signs of decreased cardiac output. ‐ Assess the client for bladder distention or signs of imbalanced body temperature. | The core issue of the question is recognition that rapid infusion of fluid in a 70‐year‐old client could lead to circulatory decompensation. Use nursing knowledge and the process of elimination to make a selection. |
1143 A client who underwent a colonoscopy after being Correct answer: 4 Decreased level of consciousness, weak hand grasp, and peripheral pulses with increased premedicated with midazolam (Versed), returns to the heart rate and decreased BP result from acidosis. These are signs of respiratory acidosis nursing unit. The client is given morphine sulfate IV secondary to hypoventilation from the midazolam. For this reason, option 4 is the appropriate push after reporting abdominal pain associated with diagnostic reasoning process. BP 140/80, pulse 78, RR 20. Twenty minutes later, the client is lethargic, has weak hand grasps, weak peripheral pulse of 88, BP 120/66, RR 14. The nurse makes which interpretation of these assessment findings? ‐ The client is resting with pain relieved. ‐ The client is now showing signs of dehydration because of the colon procedure preparation. ‐ The client is now fatigued because of anxiety, pain, and fear of outcome of the procedure. ‐ The client is experiencing impaired gas exchange because of hypoventilation. | The core issue of the question is accurate interpretation of a change in client status. A critical word in the stem of the question is midazolam. Recall the properties of this medication, and use nursing knowledge and the process of elimination to make a selection. |
1144 The client is scheduled for bilateral adrenalectomy Correct answer: 1 During the first 48 hours after adrenalectomy, clients are at risk for adrenal insufficiency and secondary to an adrenal cortex tumor. Which of the hypovolemic shock. The lack of cortisol production can cause fluid and electrolyte loss and following is the nurse’s highest priority for this client in hypoglycemia. Elevated cortisol does place the client at risk for delayed wound healing and the immediate postoperative period? infection, but adrenal insufficiency is more life threatening and more common in the first 2 days following surgery. ‐ Assess fluid and electrolyte balance, signs of hypoglycemia, and hypotension. | The core issue of the question is knowledge that clients are at risk for adrenal insufficiency following adrenalectomy and how to assess for its occurrence. Use nursing knowledge and the process of elimination to make a selection. |
‐ Assess for signs of hypoxia, cardiac arrhythmias, and peripheral edema. ‐ Monitor the incision integrity, peripheral pulses, and magnesium level. ‐ Assess for hyperthermia, bed mobility, pupil reaction and eye movement. | |
1145 A female client has been taking propylthiouracil (PTU) Correct answer: 1 The client’s complaints of lack of energy and weight gain are consistent with hypothyroidism, for 5 months to treat hyperthyroidism. After falling which is diagnosed with a serum T<sub>4</sub>. Considering the client’s and spraining her ankle, she is treated in the complaints of energy deficit, the recent fall causing the sprain, and information about the emergency department and is given crutch‐walking thyroid medication, the nurse is obligated to consult the physician for instructions. She states that she will never have T<sub>4</sub> evaluation to prevent further injury. Encouraging the client to rest enough energy to get around on crutches and is and investigating the need for a walking splint are appropriate actions but not the first priority. frustrated at the 10 pounds she gained this winter. The nurse’s first action should be to ‐ Document the client’s complaints and consult the physician to order a serum T4. ‐ Discharge the client to home and encourage her to have a TSH level drawn. ‐ Encourage the client to rest at home until the sprain is healed, then increase activity. ‐ Investigate the availability of a walking splint instead of using the crutches. | The core issue of the question is the ability to correlate client reports with the underlying diagnosis of hypothyroidism. Use nursing knowledge and the process of elimination to make a selection. |
1146 The client with diabetes mellitus (DM) is going home Correct answer: 2 Clients with either diabetic mellitus or other conditions that have arterial insufficiency as a following angioplasty. The nurse observes that the component of the disorder must constantly protect their feet from injury; assess the skin client walks to the restroom barefoot, although condition daily; prevent dry, cracked skin; and avoid crossing the legs in order to maintain slippers are in reach. The priority nursing diagnosis for tissue perfusion and prevent infection. These clients have delayed wound healing and poor this client is which of the following? sensation in their feet, increasing risk for injury and undetected injury with infection. ‐ Risk for injury related to potential for falls while walking barefoot ‐ Risk for infection related to impaired tissue perfusion and walking barefoot ‐ Deficient knowledge related to post angioplasty care ‐ Risk for impaired cerebral perfusion related to potential for hypoglycemia | The core issue of the question is interpretation of behaviors that pose risk for complications to the client with diabetes mellitus. Use nursing knowledge and the process of elimination to make a selection. |
1147 The client is 6 hours post‐thyroid surgery. The nursing Correct answer: 1 Usually, with thyroid surgery, there is minimal bleeding postoperatively. Blood on the gown assistant reports that the client is upset because there indicates excessive incisional bleeding. Breath sounds, including auscultating over the tracheal is blood on the client’s gown. Which of the following is area, and respiratory effort should be assessed first to determine if edema is present in the the priority action of the nurse? tissues, thus compromising the airway. After thoroughly assessing the client and reinforcing or changing the dressing per protocol, the nurse should inform the surgeon of the amount of bleeding and all other assessment data. Options 2 and 3 do not protect the client from possible harm. Option 4 ignores the client’s airway, a high priority following this surgery. ‐ Assess the client’s breath sounds and respiratory effort. ‐ State that it is normal to have some bleeding and ask the nurse aide to change the gown. ‐ Reassure the client that some bleeding is normal, and then assess the client’s level of pain. ‐ Reinforce the dressing, change the gown, and call the surgeon. | The core issue of the question is possible threat to the airway and breathing with excessive bleeding following thyroid surgery. Use nursing knowledge, the ABCs, and the process of elimination to make a selection. |
1148 A client who was admitted with hyperglycemic Correct answer: 3 HHNK is associated with hyperglycemic response to infection or other disease or illness, some hyperosmolar nonketotic coma (HHNK) asks how he medications, dehydration, stress‐induced hyperglycemia, or a combination of these factors. can prevent recurrence of this illness. The nurse would HHNK occurs in clients with type 2 diabetes mellitus, primarily the elderly, and thus insulin is instruct the client that which of the following are not part of the usual treatment plan (option 1). Option 2 is insufficient; 6 to 8 glasses of water helpful prevention measures? are recommended for general health. Option 4 does not demonstrate an understanding of prevention of HHNK. ‐ Use sliding‐scale insulin to cover periodic snack of candy. ‐ Maintain fluid balance by drinking 4 glasses of water daily. ‐ Detect and treat infection early, maintain hydration, and use stress‐management techniques. ‐ Consult primary care provider when fasting blood glucose is elevated. | The critical word in the stem of the question is prevent. With this in mind, look for the option that will reduce the likelihood of the client experiencing a recurrence. Use nursing knowledge and the process of elimination to make a selection. |
1149 The client who has a long history of type 1 diabetes Correct answer: 4 Diabetic ketoacidosis can occur in diabetic clients with infection and is characterized by mellitus is being treated for bronchitis and sinusitis. elevated blood glucose and ketonuria. Deep, rapid, unlabored respirations are called Kussmaul The nurse observes deep, rapid, unlabored respirations. Kussmaul respirations, fruity odor, and dry skin are signs of hyperglycemia. respirations, fruity odor on the client’s clothes, and dry Option 2 represents the opposite problem, not the hyperglycemia being displayed. Options 1 skin. Which of the following actions should the nurse and 3 do not address hyperglycemia and ketoacidosis, which is the issue of the question. take next? ‐ Assess breath sounds for additional signs of response to treatment of the infection. ‐ Assess blood glucose level for signs of hypoglycemia. ‐ Encourage the client to rest frequently and to drink 8 to 10 glasses of fluids daily. ‐ Assess blood glucose level for hyperglycemia and check urine for ketones. | The core issue of the question is recognition that a diabetic client with an infection is at risk for diabetic ketoacidosis and knowing how to assess for this complication. Use nursing knowledge and the process of elimination to make a selection. |
1150 A female client newly diagnosed with hypothyroidism Correct answer: 3 Hypothyroidism is associated with fatigue, weight gain, and decreased activity tolerance. indicates that she no longer wants to participate in There is not enough data to conclude decreased cardiac output or sleep alterations. Client evening social activities stating, “There is too much stated she is able to socialize during the day at work. walking, and I prefer to go to bed early. I see enough of my friends at work every day.” The nurse formulates which of the following as a priority nursing diagnosis for this client? ‐ Social isolation related to sleep rest needs as evidenced by desire to go to bed early ‐ Disturbed sleep pattern related to excessive work as evidenced by desire to go to bed early and avoid evening activities ‐ Fatigue related to reduced metabolic rate as evidenced by desire to avoid evening activities after work ‐ Decreased cardiac output related to weak myocardium as evidenced by desire to avoid walking | The core issue of the question is the etiology of the client’s symptoms and applying a nursing diagnostic label to the problem. Use nursing knowledge and the process of elimination to make a selection. |
1151 A recently retired client who lives alone is admitted Correct answer: 4 Myxedema is characterized by severely decreased cardiac output, fluid and electrolyte with myxedema coma. It is determined that imbalance, acidosis, decreased respiratory function, tongue edema, and hypothermia. Skin myxedema occurred after she stopped her thyroid breakdown is a significant risk that needs to be managed concurrently with promotion of medication because she could not afford to buy the oxygenation, but airway and circulation have highest priority. medication. Which of the following is the highest priority of the nurse in this client’s plan of care? ‐ Assist the client to chair every 4 hours to promote oxygenation and prevent skin breakdown. ‐ Prevent injury related to mental confusion and elevated BP. ‐ Prevent skin breakdown and promote nutrition with low‐fiber foods. ‐ Monitor for signs of decreased cardiac output and airway obstruction. | The core issue of the question is assigning a priority to client needs during myxedema. Recall that physiological needs take priority before psychosocial needs. Use nursing knowledge about the condition and the process of elimination to make a selection. |
1152 A client with hyperparathyroidism is admitted to the Correct answer: 4 Hyperparathyroidism causes hypercalcemia. Large doses of saline infusions concurrently with critical care unit with cardiac dysrhythmias, including Lasix will stimulate a decrease in serum calcium through renal excretion. In acute situations frequent premature atrial contractions, bursts of requiring rapid reduction, clients can be given IV calcitonin and phosphates. supraventricular tachycardia, and occasional premature ventricular contractions. The client asks why the cardiologist prescribed so much IV fluid and then furosemide (Lasix). The best explanation by the nurse is that these orders would ‐ Improve cardiac output. ‐ Eliminate metabolic wastes. ‐ Replace missing electrolytes. ‐ Promote excretion of calcium. | The core issue of the question is knowledge of methods used to manage hypercalcemia in hyperparathyroidism. Use nursing knowledge and the process of elimination to make a selection. |
1153 A client with hypoparathyroidism is to be discharged Correct answer: 2 Clients with hypoparathyroidism have low serum calcium levels, paresthesia, mood disorders, home after stabilization of fluid and electrolyte levels. muscle spasms, and hyperactive reflexes placing them at risk for falling. They must actively Which of the following critical concepts does the nurse seek to increase their intake of calcium and Vitamin D to maintain therapeutic serum levels in teach the client prior to discharge? addition to taking their prescribed medication. The other options do not address safety as the critically important need. ‐ Importance of keeping follow‐up appointments for lab and with primary health care provider ‐ Strategies to prevent falling and how to plan meals high in calcium ‐ Significant signs of hypoglycemia to monitor for and report ‐ Signs and symptoms of renal calculi and urinary tract infections to monitor for and report | The core issue of the question is health teaching that is appropriate for a client with hypoparathyroidism. Use nursing knowledge about safety measures and altered calcium levels and the process of elimination to make a selection. |
1154 A client recently diagnosed with syndrome of Correct answer: 2 Clients with SIADH are usually on a strict fluid restriction to correct water overload; inappropriate antidiuretic hormone (SIADH) is therefore, all fluids (including the enteral feeding and the flush solution) should be considered receiving a continuous enteral nutrition via an enteral when planning the fluid restriction. Clients are also encouraged to drink fluids high in sodium, feeding tube. Considering the impact of the disorder so clients being treated for SIADH should have their feeding tubes flushed with normal saline on fluid balance, the nurse does which of the following and not water. To prevent electrolyte loss, all of the residual that is aspirated from a feeding when working with the enteral feeding tube? tube should be returned to the client. ‐ Discard the 50 mL residual and replace it with 50 mL water. ‐ Flush the tube with 50 mL normal saline. ‐ Count the flush but not the feeding in planning the fluid limitation. ‐ Flush the tube with 50 mL water to maintain patency. | The core issue of the question is proper fluid use and management in a client with SIADH. Use nursing knowledge about fluid imbalance in this disorder and the process of elimination to make a selection. |
1155 A client with a history of Cushing’s syndrome is being Correct answer: 4 The BUN and sodium are elevated because of dehydration and deficient fluid volume, since admitted for acute management of multiple the creatinine is normal, thus supporting normal renal function. The potassium and chloride contusions and lacerations following a motor vehicle are at the higher end of the normal range, which also supports dehydration and fluid volume accident. Morning serum laboratory values are BUN 30 deficit. Clients with Cushing’s syndrome are at risk for infection because of an impaired mg/dL, creatinine 1.0 mg/dL, sodium 148 mEq/L, immune function related to an elevated cortisol level. potassium 4.8 mEq/L, chloride 108 mEq/L, and cortisol 29 mcg/dL. This client’s two high‐priority nursing diagnoses are ‐ Impaired urinary elimination and risk for fluid volume excess. ‐ Risk for injury and risk for disuse syndrome. ‐ Ineffective airway clearance and ineffective health maintenance. ‐ Risk for infection and deficient fluid volume. | The core issue of the question is the ability to determine priorities of care for a client with Cushing’s syndrome who experiences trauma. Use knowledge of pathophysiology and the process of elimination to make a selection. |
1156 A client underwent adrenal gland radiation therapy Correct answer: 1 Florinef and other adrenal replacement drugs cause sodium and fluid retention. Clients are at for benign tumors. The client is being treated with risk for excess sodium and fluid retention leading to fluid volume excess. Risk for infection fludrocortisone acetate (Florinef Acetate) for could apply but is not timely if the client has completed this course of therapy. Impaired gas mineralocorticoid and glucocorticoid replacement. The exchange may result from extensive fluid volume excess that can lead to ineffective breathing high‐priority nursing diagnosis for this client is pattern. The highest priority is the risk for fluid volume excess. ‐ Risk for excess fluid volume. ‐ Risk for infection related to radiation damage. ‐ Risk for constipation. ‐ Ineffective breathing pattern. | The core issue of the question is the ability to determine priority concerns for a client receiving mineralocorticoid and glucocorticoid therapy. Use nursing knowledge and the process of elimination to make a selection. |
1157 The client is being treated for Addison’s disease with Correct answer: 4 Glucocorticoid replacement medication can cause fluid and sodium retention, leading to glucocorticoid replacement medication. The nurse weight gain and fluid volume excess. These medications need to be increased during times of evaluates that the client understands medication stress and can impair the body’s ability to recover from an infection. Therefore, the physician therapy when the client makes which of the following must be consulted for weight gain or signs of a cold or infection. These medications should be statements? taken in the morning with food and will increase BP (thus are not safe for clients with hypertension), and the medication will not affect cardiac rhythm. ‐ “I should take this medication every evening at bedtime.” ‐ “My irregular pulse should convert to a regular rate and rhythm.” ‐ “This medication will help me control my increased blood pressure.” ‐ “I should call my doctor if I gain 2 pounds, feel weak, or have a cold.” | The core issue of the question is knowledge of adverse effects of drug therapy following client teaching. Use nursing knowledge and the process of elimination to make a selection. |
1158 An 8‐month‐old infant born outside the United States Correct answer: 1 A low‐phenylalanine diet reduces the amount of toxic metabolites in the body, thus reducing is brought to the endocrine clinic with symptoms of a or preventing additional damage. There is no indication of a need to admit the child to a long‐ musty body odor, seizures, and an eczema‐like rash. term care facility, and babies with PKU have normal life expectancy. No medications are The infant is tested for phenylketonuria (PKU) and the currently being used to treat PKU. diagnosis is positive. In planning nursing care for this infant, the nurse will anticipate: ‐ The need for dietary information about a low‐phenylalanine diet. ‐ Admission to a long‐term care setting for handicapped infants. ‐ Preparing the family for the child’s early demise. ‐ Providing instruction on medication management of PKU. | The core issue of the question is management of PKU in a newly diagnosed infant. Use nursing knowledge and the process of elimination to make a selection. |
1159 A 15‐year‐old weighing 250 pounds has started to Correct answer: 2 Some teens develop type 2 diabetes, especially those who are overweight. They might need experience increased thirst, increased appetite, and to take an oral hypoglycemic with or without accompanying insulin. Insulin is not used for frequent urination. When he is admitted to the those who won’t take oral medication. Sweets and complex carbohydrates still need to be hospital, he is given oral medication after being restricted. Option 1 does not offer the information that the child needs about the treatment diagnosed with diabetes mellitus. What information options. should the nurse give the teenager about medication therapy? ‐ “You might receive a pill now, but you’ll get insulin in the future if you don’t comply with diet and medication therapy.” ‐ “Overweight teenagers may develop type 2 diabetes, which can be treated with an oral medication. You may or may not need insulin in the future.” ‐ “Insulin is used when diabetics won’t take oral pills, so you can avoid these by taking your medication as ordered.” ‐ “Your diabetes is mild, so you don’t need to take medication for long. You will probably only need to restrict sweets.” | The core issue of the question is correct information about medication therapy for overweight adolescents with new onset diabetes. Use nursing knowledge and the process of elimination to make a selection. |
1160 A mother is quite concerned about her 7‐year‐old Correct answer: 2 The child should be seen by the physician because there might be secretion of sex hormones, daughter after noticing some breast development and and precocious puberty may affect linear growth. Although she may be teased in school by the the appearance of a small amount of pubic hair. The other children (option 3), the main reason for seeking treatment is health promotion. Options mother asks the nurse if this is a cause for concern. 1 and 4 are incorrect statements. What would be the best response by the nurse? ‐ “No. Some girls just develop earlier than boys.” ‐ “Yes. Your daughter may have precocious puberty. Let’s talk to the pediatrician because she may need referral to an endocrinologist.” ‐ “Yes. She probably doesn’t want the other children at school making fun of her.” ‐ “No. This early development may slow down when she reaches 9 years old.” | The core issue of the question is the priority need of a client with suspected precocious puberty. Use nursing knowledge and the process of elimination to make a selection. |
1161 The mother of a diabetic adolescent tells the nurse Correct answer: 1 Adolescents need to feel like part of their group, even if it means impairing their health. that her son likes to go out with his friends on Friday Displaying risk‐taking behaviors is not likely the primary motivation, but rather a secondary nights and eat burgers and french fries. The adolescent event. Option 3 is true but is not likely to be the motivating factor. There is no information to knows that he is exceeding the allowable carbohydrate support a self‐destructive wish (option 2). exchanges on the diabetic diet, but he does so anyway. The nurse discusses with the mother that teens sometimes take chances that place health at risk because: ‐ They want to be just like their peers. ‐ They have a self‐destruction wish. ‐ They often like french fries and can’t eat them at home. ‐ They want to show risk‐taking behavior. | The core issue of the question is knowledge of age‐specific concerns of adolescents with diabetes mellitus. Use nursing knowledge and the process of elimination to make a selection. |
1162 A 13‐year‐old girl is being evaluated for delayed Correct answer: 1 A karyotype is simply a study of the chromosomes. A blood sample may be used to provide puberty. The client says, “The doctor said he was going the cells for analysis. Options 2 and 3 are incorrect. Option 4 provides no information at all for to do a karyotype. Will that hurt?” Which of the the child and does not address the client’s concern. following is the best response by the nurse? ‐ “A karyotype is just a microscopic picture of your chromosomes.” ‐ “The karyotype test is an evaluation of your luteinizing hormone levels.” ‐ “The doctor has ordered an x‐ray of your hand to determine your bone age.” ‐ “You don’t need to worry about that because I will be with you.” | The core issue of the question is appropriate information about a karyotype test. Use nursing knowledge and the process of elimination to make a selection. |
1163 The nurse is assessing a client with a tentative Correct answer: 2, 3, 5 The client with hyperpituitarism will exhibit the following: tall stature if onset in childhood, diagnosis of hyperpituitarism. What assessment large hands and feet with prominent jawbone, joint changes consistent with arthritis, deep findings should the nurse observe for in this client? voice and possible dysphagia, hypertension, organomegaly, and skin changes leading to rough, Select all that apply. oily texture. The client would not have a soft voice or be short in stature. ‐ Short stature if onset is in childhood ‐ Large hands and feet with prominent jawbone ‐ Joint changes consistent with arthritis ‐ Soft, high‐pitched voice ‐ Hypertension | The core issue of the question is knowledge of assessment findings with hyperpituitarism. Recall the functions of the pituitary gland and then correlate the functions with the logical signs of excess to make the appropriate selections. |
1164 The nurse is preparing an 8‐year‐old child for a Correct answer: 1 Visual aids such as dolls, puppets, and outlines of the body can be used to illustrate the cause procedure. What is the most appropriate nursing and treatment of the child's illness. Use of such equipment provides information to the school‐ intervention considering the child's stage of growth age child to understand and cope with feelings about the procedure. Written pamphlets should and development? be given to the parents to review prior to the procedure. Children should be allowed to cry or verbalize feelings without guilt as long as they hold still. Parents should be given a choice to accompany their child during the procedure. ‐ Provide visual aids, such as dolls, puppets, and diagrams in the explanation ‐ Provide a written pamphlet for the child to review prior to the procedure ‐ Discourage any display of emotional outbursts ‐ Request that the parents wait outside while the nurse provides instructions to the child | Critical phrases are "preparing and 8‐year‐old child for a procedure" and "intervention." Knowledge of coping mechanisms appropriate for the age of the child to deal with illness is needed. |
1165 A school‐age child has a thyroidectomy performed for Correct answer: 1 A complication of a thyroidectomy is thyroid storm, which can be fatal. Other primary treatment of hyperthyroidism. In planning the concerns would be observing for hemorrhaging, respiratory obstruction, and laryngeal nerve postoperative care, the priority nursing activity would damage. These would be the priority nursing activities. be: ‐ Observing for signs of "thyroid storm." ‐ Beginning treatment with synthetic thyroid hormone. ‐ Reassuring the child that the scar will be barely noticeable. ‐ Teaching the child about the effects of hyperthyroidism. | The key concept is the priority nursing activity. A crisis or other critical event would be the priority. |
1166 After providing a lecture on puberty for 5th‐ and 6th‐ Correct answer: 1, 3, 2, Puberty is a process that brings about the development of secondary sexual characteristics, grade girls, the school nurse asks the group to place 4 which begin with the appearance of breast buds at 9 or 11 years followed by the growth of the secondary sexual characteristics in the order of pubic hair. Menarche follows approximately 1 year later. Following menarche, there is an their appearance during puberty. The nurse concludes abrupt deceleration of linear growth. the students learned the information presented if the students responded with which order to the characteristics listed? Click and drag the options below to move them up or down. ‐ Appearance of breast buds ‐ Occurance of the first menarche ‐ Appearance of pubic hair ‐ Growth slows | Critical words are "girls" and "ordering the signs of puberty." Knowledge of puberty is needed to answer the question correctly. |
1167 A pre‐adolescent girl is being followed in the Correct answer: 3 The child is expressing concern about her appearance as compared to others, making body endocrine clinic for precocious puberty. The child has image disturbance the best diagnosis. There is no evidence in the stem regarding social already developed secondary sexual characteristics isolation or personal identity disturbance. The cause of the precocious position would have and is taller than her classmates. She complains that been discussed earlier. because of her height she "stands out and everyone stares at her." The nurse would formulate which of the following as an appropriate nursing diagnosis for this child? ‐ Deficient knowledge related to the cause of precocious puberty ‐ Social isolation related to height ‐ Body image disturbance related to differences from classmates ‐ Disturbed personal identity related to height | The one option that directly relates to the child’s statement is body image disturbance. Knowledge of the body image changes in precocious puberty will aid in choosing the correct diagnosis for this child. |
1168 A 5‐year‐old known diabetic has been admitted with Correct answer: 3 The only form of insulin given IV is regular. Physicians often order ketoacidosis secondarily to an infection. Which one of D<sub>5</sub>1/2NS with insulin added providing the child the glucose to meet the physician's orders should the nurse question? the body's needs while providing the insulin in the same infusion. Antibiotics would be appropriate to treat the underlying infection. The blood glucose should be monitored on a regular basis. ‐ IV D51/2NS at 80 mL/hr ‐ Add 100,000 units aqueous penicillin to the IV every 6 hours ‐ Add 4 units NPH insulin to the IV for every 100 mLs IV fluid ‐ Monitor blood glucose levels every 4 hours and prn | Knowledge of the clinical therapy for ketoacidosis will aid in determining the correct answer. Recall that the only insulin given IV is regular. |
1169 A 14‐year‐old boy has just been diagnosed with type 1 Correct answer: 2 Lispro insulin peaks at one hour after administration. A food source should be available at the diabetes mellitus and has been taught to draw up and bedside to prevent the possibility of hypoglycemia shortly after administration. All of the other administer his own insulin. The nurse arrives at the choices are incorrect. bedside with the vials for the morning insulin dose: NPH 15 units and Lispro 8 units; before breakfast arrives. The client draws up and mixes the insulin in one U‐100 syringe, but the nurse instructs him not to inject it just yet for which of the following reasons? ‐ Adolescents should not administer insulin to themselves until they have practiced drawing up the medication at least 10 times. ‐ Lispro insulin is very fast‐acting insulin. The breakfast tray should be at the bedside before insulin administration. ‐ The child's mother should be present to witness the injection. ‐ These two forms of medication should never be mixed. | Consider the onset, peak, and duration of each time of insulin to determine the correct answer. |
1170 The nurse is meeting with a child recently diagnosed Correct answer: 3, 5 The exchange diet plan is suggested for clients with diabetes mellitus. Even young children with type I diabetes mellitus and his family to provide can learn to trade foods in the same exchange category to maintain control. All basic food diabetic diet counseling. What information should be groups should be included. Diet sodas are allowed. A high fiber diet is recommended for included in the discussion? Select all that apply. improved control of blood glucose. ‐ As long as the child consumes 1,200 calories a day, the food selection doesn't matter ‐ To stop eating snacks immediately; eat only three balanced meals a day ‐ Foods from all basic food groups are important, but don't overdo simple sugars and carbohydrates ‐ Sodas in any form must be avoided; the child should drink water and juices only ‐ A high fiber diet is recommended | Options 1 and 3 are opposites, so consider these options first as possible correct choices. |
1171 The nurse in the endocrine clinic is performing an Correct answer: 4, 5 Exophthalmos (bulging eyes) and an enlarged thyroid are evidence of hyperthyroidism. Other intake assessment on an adolescent. The adolescent symptoms would include weight loss, tremors, tachycardia, and elevated basal body demonstrates all of the following symptoms. The nurse temperature. Some children may display behavior problems and have sleeping difficulties. The would suspect hyperthyroidism based on the presence other symptoms are not associated with hyperthyroidism. of which of the following? Select all that apply. ‐ Acne ‐ Dilated pupils ‐ Asymmetrical facies ‐ Bulging eyes ‐ Enlarged thyroid | Knowledge of the signs and symptoms of hyperthyroidism will help to determine the correct answer. Eliminate those options that are known to be wrong. The remaining options should be considered individually as to whether the physiology of hyperthyroidism would cause the problem. |
1172 A woman who wants to get pregnant comes to the Correct answer: 2 Women with PKU should maintain good control prior to becoming pregnant. The fetus may clinic for counseling. Her health history includes the have complications if the mother's phenylalanine levels are high. She should also avoid diet information that she was diagnosed with drinks because of the aspartame, which is high in phenylalanine. PKU follows the autosomal phenylketonuria (PKU) as an infant and remained on a recessive inheritance, and her baby could be affected if the father is a carrier. low phenylalanine diet through the age of 10. The nurse will include in the counseling session the information that: ‐ Since she is over the age of 8, she doesn't have to worry about keeping her phenylalanine level low. ‐ She should be on a low phenylalanine diet for at least three months prior to becoming pregnant in order to prevent congenital defects in the fetus. ‐ Since her condition promotes excessive weight gain, she should stop drinking regular soda and drink diet drinks with aspartame instead. ‐ Since this is an autosomal recessive disorder, her infant will not be born with phenylketonuria. | No information is known about the father, so option 4 could not be correct. Options 1 and 2 are opposites, so consider these statements to determine the correct answer. |
1173 After completing family education for the parents of a Correct answer: 1 Symptoms of excessive fatigue may indicate inadequate medication. Symptoms of overdose recently diagnosed infant with hypothyroidism, the would include a rapid pulse rate, diarrhea, and weight loss. The other answers indicate correct nurse evaluates the effectiveness of the teaching. The understanding of the management of hypothyroidism. nurse will need to provide additional instructions if the parents state: ‐ "If my child seems excessively tired, I know he will probably need a decrease in his medication." ‐ "My child will need to take this medication for the rest of his life." ‐ "I'm so glad that he was diagnosed soon after birth so that he will not develop mental retardation." ‐ "His tablets can be crushed and mixed with a small amount of his baby cereal." | Since hypothyroidism results from insufficient thyroid hormones, the medication will supply the hormones. Insufficient dosage will result in hypothyroid symptoms, excessive dosage will cause hyperthyroid symptoms. Key words are “will need to provide additional instructions” which indicates that the parent’s response is incorrect. Therefore, choose the answer that indicates a misunderstanding on the part of the parents. |
1174 A 12‐year‐old boy was just diagnosed with Type 1 Correct answer: 2 Children with Type 1 diabetes mellitus must take insulin because they have a total absence of diabetes mellitus. As the nurse teaches him about secretion of insulin from their pancreas. Type 2 diabetes mellitus, which does not make the insulin injections, he asks why he can’t take the client dependent on insulin, may be associated with some insulin production so the client can diabetic pills that his aunt takes. What would be the take the oral antidiabetic agents. best response by the nurse? ‐ “You will be able to take the pills once you reach adult height.” ‐ “You have a different type of diabetes where the pill won’t work.” | The core concept in this question is the difference between type 1 and type 2 diabetes. |
‐ “We have to test you to see if you can take the diabetic pills.” ‐ “You might be able to switch between taking the pills and insulin.” | |
1175 An adolescent with diabetes has had several episodes Correct answer: 3 Checking the blood glucose at least twice a day prevents sustained levels of either high or low demonstrating lack of diabetic control. The nurse is glucose readings. The glycosolated hemoglobin measures long‐term control and is a very reviewing techniques for checking the control of important value. diabetes. The nurse states to the adolescent, “The best way to maintain control of your disease is to: ‐ Check your urine glucose three times a week.” ‐ Check the glycosolated hemoglobin every 3 months and then every 6 months when stable.” ‐ Check the blood glucose twice a day and the glycosolated hemoglobin every 3 months.” ‐ Not check anything as long as you feel well.” | The more frequently blood glucose is checked, the better the control of diabetes. Therefore, select the option that provides the most frequent check. |
1176 A mother attends the pediatric clinic with her 10‐year‐ Correct answer: 1 Long‐term effects of Type 1 DM include retinopathy, heart disease, renal failure, and old daughter who has diabetes mellitus (DM). After peripheral vascular disease. These complications can affect children and adults. The longer the completing the diabetic teaching, the nurse evaluates child lives with diabetes, the greater the likelihood of complications. Exercise increases the the mother’s knowledge. Which statement by the utilization of glucose, thus an afternoon snack would be very important. Milkshakes would be mother indicates a satisfactory understanding of concentrated carbohydrates that should be avoided. diabetes? ‐ “I worry about my daughter maintaining control since children with diabetes have more complications than adults do.” ‐ “My daughter should drink vanilla milkshakes to maintain a high caloric intake.” ‐ “Complications from diabetes could include cataracts and kidney stones.” ‐ “My child won’t need a mid‐afternoon snack since she takes a gym class in the afternoon.” | Knowing that diabetes is a problem with carbohydrate metabolism and that exercise affects this metabolism, options 2 and 4 can be eliminated. |
1177 Considering a child’s developmental level in diabetic Correct answer: 4, 5 The toddler needs to feel some control. Cleaning off his fingers with alcohol, with supervision, care is essential. The nurse should include which will allow some control. Another way to promote control would be for the toddler to choose information in teaching the parents of a recently food selections from options offered. It is inappropriate to allow the toddler to assist with diagnosed toddler with diabetes? Select all that apply. injections and it is unnecessary to test glucose every time the toddler goes out to play. ‐ Allow the toddler to assist with the daily insulin injections. ‐ Prepare meat, vegetables, and potatoes for each dinner. The toddler cannot be allowed many choices in food selection. ‐ Test the toddler’s blood glucose every time he goes outside to play. ‐ Allow the toddler to assist with cleaning off his fingers before blood glucose monitoring. ‐ Allow the toddler to choose food selections from options offered. | Consider the growth and development of the toddler to determine which activity can safely be assumed by a toddler. |
1178 A 2‐month‐old infant arrives at the pediatric clinic. Correct answer: 2, 5 Most babies with congenital hypothyroidism exhibit bradycardia, protruding tongue, and Upon assessment, the baby exhibits the following hypotonia. Open fontanels are normal for a 2‐month‐old infant. characteristics. Which characteristic does the nurse relate to a diagnosis of congenital hypothyroidism? (Select all that apply.) ‐ Open fontanels ‐ Protruding tongue ‐ Tachycardia ‐ Hypertonia ‐ Hypotonia | Open fontanels are expected in a 2‐month‐old infant, so that is not a symptom of hypothyroidism. Hypertonia and tachycardia would both be symptoms of hyperthyroidism. |
1179 A 10‐year‐old girl comes to the office of the school Correct answer: 1 Exercise makes the body more sensitive to insulin, thus metabolizing the glucose faster. While nurse after recess. This is the child’s first day back in hospitalized, the child was less active. Now that the child has returned to normal activity, it is school after hospitalization, where she was diagnosed possible that the insulin dose is too high or more glucose is required in the diet. The other with diabetes. The child reports she took the dose of options are inaccurate. insulin as instructed and that it was the same as she took while hospitalized. The nurse notices that she is nervous with hand tremors present. She is pale, sweaty, and complaining of sleepiness. The school nurse would suspect: ‐ Exercise‐induced hypoglycemia. ‐ Hyperglycemia caused by increased intake at lunch. ‐ Ketoacidosis caused by an infection. ‐ The child is avoiding returning to class. | First decide if the symptoms the child is displaying are hypo‐ or hyperglycemia. Knowledge of the effect of exercise on glucose metabolism will aid in choosing the correct answer. Since the symptoms are hypoglycemic, there is only one option appropriate. |
1180 After being diagnosed with Graves’ disease, a Correct answer: 3 Lethargy may indicate an overdose of the drug, causing the child to exhibit signs of teenager begins taking propylthiouracil (PTU) for hypothyroidism. The other signs indicate signs of hyperthyroidism. treatment of the disease. What symptom would indicate to the nurse that the dose may be too high? ‐ Weight loss ‐ Polyphagia ‐ Lethargy ‐ Difficulty with schoolwork | Graves’ disease is hyperthyroidism. Recall that the drug is used to suppress the thyroid. Oversuppression would be a symptom of too much drug. |
1181 A 13‐year‐old boy is being evaluated for delayed Correct answer: 1 An adolescent client with delayed puberty may need to talk about issues of low self‐esteem. If puberty. He has had an examination with a pediatric he has a constitutional delay, puberty will usually follow with time. Hormone therapy is not endocrinologist who states that the child has a given until after the age of 14. constitutional delay. An appropriate communication to the child by the nurse that reinforces the physician’s explanation of the diagnosis would be: ‐ “All of your hormone levels are normal, so no medication is needed at this time. If you want to talk about it, I would be happy to discuss it with you.” ‐ “I am worried about your stature. I think you should get another opinion.” ‐ “Your father’s stature doesn’t matter. We just look at your height.” ‐ “If you want testosterone shots, I will arrange for them to be given.” | Consider which response would be therapeutic to determine the correct answer. |
1182 A child demonstrated a sudden onset of Correct answer: 2 Propranalol, a beta‐adrenergic blocking agent, provides relief from adrenergic thyrotoxicosis. The nurse anticipates that, besides hyperresponsiveness. It is usually needed for 2 to 3 weeks along with antithyroid hormone antithyroid therapy, the child is likely also to receive therapy. which of the following types of drugs? ‐ Antacid ‐ Beta‐adrenergic blocker ‐ Muscle relaxant ‐ Cardiac glycoside | Consider which drug would promote symptoms opposite to excessive thyroid hormone. |
1183 Four newborns have blood drawn for the Guthrie test Correct answer: 4 The screening is done only after an adequate amount of protein has been ingested. Breast for phenylketonuria. The nurse would question the milk and formula meet the requirements. The testing is usually done at 48 hours of age. results of the baby: ‐ Whose test is performed at 48 hours of age. ‐ Who was breast‐fed for the 24 hours before the test. ‐ Who was fed glucose water followed by formula for 30 hours. | Knowing that 24 hours of formula/breast milk are required to provide adequate test results, eliminate any choice that would not provide this. |
4.‐ Who was tested immediately after birth. | |
1184 A mother of a 4‐month‐old tells the nurse that her Correct answer: 2, 3, 4 Congenital hypothyroidism in infants is diagnosed due to hypotonicity and hypoactivity. The child has been diagnosed with hypothyroidism. The infants are often described as a “good baby” because they rarely cry. Prolonged jaundice, mother asks the nurse what symptoms led to the constipation, and umbilical hernia are common findings in hypothyroidism. diagnosis. The nurse explains that which of the following symptoms are consistent with this diagnosis? (Select all that apply.) ‐ High‐pitched shrill cry ‐ Prolonged jaundice at birth ‐ Described as a “good baby” ‐ Constipation ‐ Tall for gestation age at birth | Think of the baby with hypothyroidism as lethargic and consider which symptoms might be seen in a lethargic baby. |
1185 An infant was born 24 hours ago. The nurse has been Correct answer: 2 Tests done 24 to 48 hours after delivery may be interpreted as high because of the rise in TSH instructed to collect blood by heel stick for neonatal that occurs immediately after birth. screening for congenital hypothyroidism before the baby is discharged. The nurse questions the order with the pediatrician because 24 to 48 hours after birth is not the optimal time to collect this specimen for what reason? ‐ At 24 hours, the T4 level will be extremely low. ‐ There is an immediate rise in the TSH after birth. ‐ The baby needs to digest formula before a blood sample can be taken. ‐ A thyroid scan should be done first. | The learner should be familiar with common screening blood tests. With that knowledge, options 3 and 4 can be eliminated. Then determine whether the test response would be high or low after birth. |
1186 The nurse is administering propylthiouracil (PTU) to a Correct answer: 3 Sore throat and enlarged cervical nodes are common side effects of the medication. A dosage 12‐year‐old recently diagnosed with Graves’ disease. reduction or withdrawal of the drug should be considered. The child has been receiving the drug 3 times a day for 3 weeks. She suddenly complains of a severe sore throat. What would be the appropriate nursing action? ‐ Continue to give the medication or she will continue to exhibit signs of Graves’ disease. ‐ Offer lozenges for the relief of the sore throat. ‐ Withhold the dose and report this to the physician since a sore throat is a common side effect. ‐ Question whether she is complaining to avoid going to the school room in the hospital. | Knowledge of the side effects of this drug is the core concept of this item. |
1187 A 10‐year‐old diabetic client tells the school nurse Correct answer: 2 If a child exhibits signs of hypoglycemia, a source of sugar like orange juice can elevate that he has some early signs of hypoglycemia. The glucose levels and prevent further signs of hypoglycemia. A 10‐year‐old must remember to nurse recommends to the child that the child: only take one serving and wait ten minutes for symptoms to be alleviated. ‐ Take an extra injection of regular insulin. ‐ Drink a glass of orange juice. ‐ Skip the next dose of insulin. ‐ Start exercising. | Since the child is showing signs of hypoglycemia, the nurse will recommend action to increase the blood glucose level. |
1188 The nurse is teaching a 15‐year‐old client about the Correct answer: 4 The peak action of NPH or Lente insulin is 6 to 12 hours after administration subcutaneously. different types of insulin. The client takes NPH insulin During peak times, the client may need a snack to offset potential hypoglycemia. at 8:00 a.m. The nurse interprets that the adolescent understands this type of insulin when the child states that the most likely time for an insulin reaction would be: ‐ While working out at 9:00 am. ‐ While taking a test at 10:00 am. ‐ While eating lunch at noon. ‐ While golfing after school at 3 pm. | Add 6 to 12 hours to 8 am. That computes to be 2 to 8 pm. Only one response falls during that time frame. |
1189 A teenage mother arrives at the clinic with her new Correct answer: 3 Since hypothyroidism is a lifelong condition, the levothyroxine will need to be taken baby who has recently been diagnosed with congenital indefinitely. It is important that the infant takes the medication in a small amount of food or hypothyroidism. When instructing the mother about liquid and not placed in the bottle since he/she may not receive the full dose if the entire administering levothyroxine medication, the nurse bottle is not consumed. would include the information that she should: ‐ Crush the medication and place it in a full bottle of formula or juice to disguise the taste. ‐ Administer the medication every third day. ‐ Give the crushed medication in a syringe or in the nipple mixed with a small amount of formula. ‐ Understand that the medication will not be needed after age 5. | Options 1 and 3 discuss how to administer the medication in relation to the amount of formula. One of these is probably the right response. |
1190 A new mother of an infant diagnosed with Correct answer: 1 In each pregnancy, there is a 25% chance of the child having the disease, a 50% chance that phenylketonuria (PKU) meets with the nurse who the child will be a carrier of the gene, and a 25% chance that the child will be unaffected. PKU informs her that PKU follows autosomal recessive affects both sexes equally. inheritance. The mother states that this is a relief since she now knows her next baby will not have the disease. What additional information does the mother need? ‐ With autosomal recessive inheritance, each baby has a 25 percent chance of having the disease. ‐ Only female babies will have PKU. ‐ The mother passes the gene only to male offspring. ‐ Since she already has one baby with the disease, the next one will probably be a carrier for the disease. | The key concept is autosomal recessive inheritance. |
1191 A 4‐month‐old infant has been diagnosed with Correct answer: 3 Decreased levels of tyrosine cause a deficiency of the pigment melanin, causing most children phenylketonuria (PKU). The child has eczema and with PKU to have blond hair, blue eyes, and fair skin that is prone to eczema. sensitivity to sunlight. The mother asks the nurse why her child’s skin is so sensitive. An appropriate explanation by the nurse would be: ‐ "Some children just have sensitive skin. There is no reason to be excessively concerned." ‐ “Your child will outgrow his sensitivity when he is 5 years old. Just use sunscreen for now.” ‐ “Your child has a deficiency in melanin because of decreased tyrosine. You will always have to take special care of his skin.” ‐ “The phenylketones in your baby’s blood concentrate the sun’s rays, making burning more likely. Children with PKU can never be in the sun.” | The learner must know common symptoms of PKU and be able to link the symptoms to the disease process. |
1192 The nurse was working with a group of parents of Correct answer: 3 Foods with low phenylalanine levels include vegetables, fruits, juices, and some cereals and children with phenylketonuria. The nurse has breads. The amount of protein in the diet is restricted based on phenylalanine blood levels. completed family teaching on the dietary restrictions. The parents are given sample menus to choose a meal for their child. Which menu choice indicates understanding of the dietary instructions? ‐ A hamburger and a diet soda sweetened with aspartame ‐ Steak and mashed potatoes with orange juice | Eliminate any meal choice that has a lot of protein, especially meat and dairy products. |
‐ A large bowl of dry cereal with strawberries and apple juice ‐ Milkshakes and grilled cheese sandwich | |
1193 Mothers in the waiting room of the endocrine clinic Correct answer: 1 Keeping the levels of phenylalanine at a low level in children with PKU and daily are discussing their children’s illnesses. The nurse administration of levothyroxine in children with congenital hypothyroidism will decrease the determines that the mothers of children with incidence of mental retardation by allowing normal brain growth. phenylketonuria (PKU) and congenital hypothyroidism recognize a common goal in the early treatment of their children when they state they are hoping to avoid: ‐ mental retardation. ‐ fever. ‐ obesity. ‐ protein foods. | Review the disease process of PKU and hypothyroidism. There is a special diet in PKU, but not in hypothyroidism. Hypothyroidism is treated with medication, but PKU is not. Both diseases may lead to mental retardation if left untreated. |
1194 The nurse is obtaining a health history on a 36‐year‐ Correct answer: 2 Hyperthyroidism is an excess of thyroid hormone (TH), which places the body in a old female who reports an increase in appetite, weight hypermetabolic state manifested by increases in appetite, body temperature, and oxygen loss, intolerance to heat, and nervousness. On physical consumption. Hypothyroidism manifestations are the opposite of those seen in assessment, the client is noted to have thin hair and hyperthyroidism. The manifestations of parathyroidism are related to disturbances in calcium moist skin. Based on this information, the nurse would levels. suspect which of the following? ‐ Hypothyroidism ‐ Hyperthyroidism ‐ Hypoparathyroidism ‐ Hyperparathyroidism | This question is answered best by using the process of elimination. First consider the organ function which is reflected in the symptoms, in this case metabolism. That leads consideration of the thyroid function. Then consider whether the question refers to hyper‐ or hypo‐ functioning in order to select the correct answer. |
1195 A client is returning from a subtotal thyroidectomy Correct answer: 1 Though fluid volume status, neurological status, and pain are all important assessments, the for the treatment of hyperthyroidism. The immediate immediate priority for postoperative thyroidectomy is airway management. Respiratory priority in assessing this client would include which of distress may result from hemorrhage, edema, laryngeal damage, or tetany. Assessment of the following? respiratory status should include rate, depth, rhythm, and effort. ‐ Assess for respiratory distress. ‐ Assess fluid volume status. ‐ Assess neurological status. ‐ Assess for pain. | This question reinforces the priority of a patent airway. Since the thyroid gland is located in the neck, next to the trachea and upper airway structures, post‐operative edema may lead to respiratory distress. |
1196 A client with hypothyroidism is taking levothyroxine Correct answer: 3 For best absorption, thyroid medications should be taken 1 hour before meals or 2 hours sodium (Synthroid), a thyroid replacement hormone. after meals. Lifelong treatment of hypothyroidism is necessary. Foods that inhibit thyroid Which of the following statements made by the client hormone (TH) synthesis, such as cabbage, spinach, and carrots, should not be consumed in would indicate additional teaching is required? excessive amounts. Thyroid medications should be taken in the morning to reduce the possibility of insomnia. ‐ "I know I will be on this medication for the rest of my life." ‐ "I don't eat excessive amounts of cabbage or spinach." ‐ "I take my Synthroid with food." ‐ "I take my Synthroid in the morning." | Questions which ask about client teaching often ask to recount knowledge of material. Recall that Synthroid is best absorbed on an empty stomach, similar to some other medications. |
1197 In providing care for a client being admitted for Correct answer: 2 Hypercalcemia is the primary complication of hyperparathyroidism, and the manifestations of hyperparathyroidism, the nurse anticipates the disorder are directly related to the effects of hypercalcemia. Administering large amounts implementing which of the following actions? of intravenous saline promotes renal excretion of calcium. Calcium gluconate would increase serum calcium levels, and tetany is a symptom of hypocalcemia. | Note that this client is already diagnosed with hyperparathyroid disease so the question asks about treatment. Option 2 is the best treatment choice listed. |
‐ Administering intravenous calcium gluconate ‐ Administering large amounts of intravenous saline ‐ Maintaining strict fluid restriction ‐ Monitoring for tetany | |
1198 The nurse evaluating a client receiving supplemental Correct answer: 3 The normal serum calcium level is 8.8 to 10 mg/dL. The therapeutic response of supplemental calcium treatment for hypoparathyroidism knows that calcium is demonstrated by normal calcium levels. the client has achieved therapeutic effects of the calcium supplement when which of the following serum calcium levels is obtained? ‐ 5.6 mg/dL ‐ 12.0 mg/dL ‐ 9.0 mg/dL ‐ 7.0 mg/dL | This question calls upon memorized normal ranges for calcium. Note that this is an element commonly asked about on NCLEX<sup>®</sup>. |
1199 A client with Cushing's syndrome is admitted with the Correct answer: 2 Cushing's syndrome is manifested by sodium retention, which leads to edema and symptoms of hypertension, fatigue, and edema. The hypertension. Fluid volume excess is the appropriate diagnosis. Treatment is aimed at priority nursing diagnosis for this client would be which restoring normal body fluid balance. Anxiety and knowledge deficit should be addressed of the following? following fluid volume excess. ‐ Fluid volume deficit ‐ Fluid volume excess ‐ Anxiety related to lack of knowledge ‐ Knowledge deficit | The symptom edema provides the hint for the issue of fluid volume excess. Recall that physiological needs take priority. |
1200 A client with Conn's syndrome (hyperaldosteronism) Correct answer: 4 Hypertension and hypokalemia are the most common signs and symptoms of who will not be treated surgically is receiving hyperaldosteronism. Surgical removal of the adrenal gland(s) is the treatment of choice; spironolactone (Aldactone). The nurse explains the however, if that is not possible, the client is treated with Aldactone, a potassium‐sparing purpose of this drug to the client as being which of the diuretic, to treat the hypertension and correct the hypokalemia. following? ‐ To reverse the hyperaldosteronism ‐ To decrease the serum potassium level ‐ To promote fluid retention ‐ To treat hypertension and hypokalemia | The question calls for knowledge of the disease and of medications to deal with side effects from over functioning of the organs, in this case the adrenals. |
1201 A client with Addison's disease is being discharged Correct answer: 3 Weight must be monitored daily; any increase indicates fluid retention and should be home and will be taking hydrocortisone (Cortisol). The reported immediately. Corticosteroids are immunosuppressants; therefore, careful monitoring client requires further instructions about this for infection is necessary. Additionally, an increase in the medication may be required for medication when which of the following statements is stressors such as infection. A Medic‐Alert bracelet is recommended to inform healthcare made? providers of Addison's disease and cortisol treatment. Safety measures are encouraged to prevent injuries. ‐ "I will monitor closely for any signs of infection." ‐ "I will wear a Medic‐Alert bracelet indicating disease and treatment." ‐ "I will report any rapid weight gain or fluid in my legs if it persists for over 1 week." ‐ "I will take safety measures at home to prevent injuries." | Recognize that questions asking for further instruction are looking for an incorrect answer, in other words something which is wrong requiring continued teaching. |
1202 The nurse is establishing a plan of care for a client Correct answer: 3 SIADH results in fluid retention and hyponatremia. Correction is aimed at restoring fluid and newly admitted with syndrome of inappropriate electrolyte balance. Anxiety and risk for injury should be addressed following fluid volume antidiuretic hormone secretion (SIADH). The priority excess. diagnosis for this client would be which of the following? | Recall that too much ADH (antidiuretic hormone) causes fluid retention leading to fluid volume excess. |
‐ Fluid volume deficit ‐ Anxiety related to disease process ‐ Fluid volume excess ‐ Risk for injury | |
1203 The nurse is discussing the treatment regimen for a Correct answer: 1 Type 1, or insulin‐dependent diabetes, requires lifelong replacement of insulin, because no client newly diagnosed with Type 1 diabetes mellitus. insulin is produced from the beta cells of the pancreas. Options 2, 3, and 4 are incorrect for During the discussion of insulin administration, the Type 1 diabetes. client asks, "Why can't I just take a pill like my friend does?" Which of the following statements indicates the client understands the nurse's explanation? ‐ "My body does not produce insulin, therefore I must receive the injections." ‐ "I will be on insulin for a short while, then I can take the pills." ‐ "The pills are not as effective as the insulin injections." ‐ "When my body starts making insulin again, I can stop taking the injections." | This question requires knowledge of Type 1 diabetes. Recognize that the other three options are not true for Type 1 diabetes. |
1204 A client with exophthalmos as a result of Graves' Correct answer: 3 Exophthalmos occurs as a result of accumulation of fat deposits and by‐products in the retro‐ disease has expressed a desire for the medications to orbital tissues. Even with treatment of Graves' disease, these changes are not reversible. The "hurry up and work so that my eyes will go down." The client should receive instructions on proper eye care. nurse's response to the client will be based on which of the following? ‐ Reversal of exophthalmos occurs after a therapeutic level of the antithyroid medication is achieved. ‐ Reversal of exophthalmos occurs after treatment with ophthalmic medications. ‐ Changes in the eyes as a result of Graves' disease are not reversible, even after treatment of the disease. ‐ Exophthalmos as a result of Graves' disease is only a temporary symptom, and should resolve spontaneously. | This question requires knowledge of the composition of the exopthalmos, being fatty build ups which may not resolve. |
1205 The nurse is providing care to a client with myxedema Correct answer: 3 Myxedema coma is a life‐threatening crisis manifested by hypothermia, hyponatremia, coma. Priority nursing care would include which of the hypoglycemia, lactic acidosis, cardiovascular collapse, and coma. Maintaining airway and following measures? circulation are the priority interventions. ‐ Decrease body temperature. ‐ Decrease heart rate. ‐ Maintain airway, fluid and electrolyte balance, and cardiovascular status. ‐ Decrease blood pressure. | Recall that airway and other physiological needs have high priority. |
1206 A client diagnosed with primary hyperparathyroidism Correct answer: 1 The treatment for primary hyperparathyroidism is a parathyroidectomy (surgical removal of demonstrates that she understands the teaching plan parathyroid glands). Options 2, 3, and 4 are incorrect treatments for primary when the client makes which of the following hyperparathyroidism. statements? ‐ "I know I must have surgery to remove my parathyroid gland." ‐ "I must take diuretics the rest of my life." ‐ "I must eat a diet low in potassium." ‐ "I must limit my daily fluid intake." | In this question look for a correct answer to evaluate the effectiveness of teaching and learning. |
1207 The priority nursing diagnosis for a client with Correct answer: 2 Risk for injury related to hypocalcemia is the priority diagnosis as injury may occur as a result hypoparathyroidism would be which of the following? of low calcium levels and tetany. The client is at risk for fluid volume deficit, not excess, and anxiety and knowledge deficit would not take priority over injury. ‐ Risk for fluid volume excess ‐ Risk for injury ‐ Anxiety related to lack of knowledge ‐ Knowledge deficit | Remember safety is a priority, as is prevention of injury. |
1208 A client with Cushing's syndrome is receiving Correct answer: 3 The therapeutic effects of mitotane are the results of direct suppression of activity of the mitotane (Lysodren), a cytotoxic antihormonal agent. adrenal cortex. Modrastane blocks the synthesis of glucocorticoids (option 1), octreotide When assessing the client's response to the suppresses ACTH (option 2), and radiation destroys the pituitary gland (option 4). medication, the nurse would expect therapeutic effects to be the result of which of the following? ‐ Blocking the utilization of glucocorticoids ‐ Suppression of adrenocorticotropic hormone (ACTH) ‐ Direct suppression of activity of the adrenal cortex ‐ Destruction of the pituitary gland | Recall that cytotoxic drugs cause cell death; death of the cells of the adrenal cortex will cause a decrease in function. |
1209 The health education nurse has provided Correct answer: 1 Since the client will have a bilateral adrenalectomy, lifetime corticosteroid replacement is preoperative teaching for a client with Conn's necessary. After the adrenalectomy, the client's aldosterone levels should return to normal; syndrome who is scheduled for a bilateral therefore, no dietary restrictions will be necessary. adrenalectomy. The client understands the teaching when which of the following statements is made? ‐ "I will need to be on lifetime replacement of glucocorticoids." ‐ "I will need to increase my salt intake." ‐ "I need to avoid salt the rest of my life." ‐ "I will need temporary replacements of glucocorticoids." | Recall that once an organ is removed, lifetime replacement is required to fill that function. |
1210 A client with a history of Addison's disease is Correct answer: 1 Hydrocortisone is given to replace cortisol in the client with adrenal insufficiency. Abrupt admitted to the unit with Addisonian crisis manifested withdrawal of the hormone can precipitate Addisonian crisis. Florinef is given to replace by severe hypotension and nonresponsiveness. Which mineralocorticoids. Hyponatremia is caused by aldosterone deficiency, which affects the renal of the following statements provided by the client's tubules ability to conserve sodium; therefore adding salt to the diet is recommended. Insulin‐ spouse would the nurse suspect precipitated the dependent diabetes is a complication of Addison's disease; however, there is no indication that crisis? diabetes precipitated the crisis. ‐ The client stopped taking the prescribed hydrocortisone several days ago. ‐ The client routinely adds salt to meals. ‐ The client is taking fludrocortisone (Florinef). ‐ The client is an insulin‐dependent diabetic. | In this question the medications provide replacement of organ function. Recognize that if the medications are stopped, symptoms of the disease recur. |
1211 The nurse administering vasopressin (Pitressin) to a Correct answer: 2 Because of a deficiency in antidiuretic hormone, diabetes insipidus results in massive diuresis client with diabetes insipidus anticipates implementing and dehydration. Vasopressin (antidiuretic hormone) is administered to promote fluid which of the following actions for this medication? retention and achieve fluid balance. Oral fluids are encouraged, and hypotonic fluids are administered. ‐ Maintaining fluid restriction ‐ Monitoring urine output ‐ Administering intravenous hypertonic fluids ‐ Maintaining NPO status | Recall that diabetes insipidus is a disease of not enough ADH, therefore there is an increased urine output. Assessing urine output is an important way to assess fluid status. |
1212 Priority nursing management of the client with Correct answer: 1 Hypertension with systolic blood pressures reaching up to 300 mmHg is possible with pheochromocytoma would include monitoring which pheochromocytoma, making this disorder a life‐threatening event. Monitoring blood pressure of the following? is a priority. Urine output and neurological status would follow blood pressure, and there is no indication to monitor glucose levels. Treatment of choice for this disorder is an adrenalectomy. ‐ Blood pressure ‐ Urine output ‐ Neurological status ‐ Serum glucose levels | Recognize that safety is a high priority in this problem. Significant hypertension must be treated. |
1213 The nurse knows that a client newly diagnosed with Correct answer: 4 The client should inform the healthcare provider of illness, and then should follow "sick‐day insulin‐dependent diabetes (Type 1) will require rules" as prescribed by healthcare provider, which include taking insulin as prescribed, or further teaching when which of the following increasing insulin as prescribed, consuming extra fluids, resting, and monitoring glucose every statements is made? 2 to 4 hours. Options 1, 2, and 3 are all correct responses by the client. ‐ "I will notify my healthcare provider if my glucose levels run higher or lower than the target range." ‐ "I will take my insulin as prescribed, and I will not miss a dose." ‐ "I will check my glucose level 30 minutes before I eat and at bedtime." ‐ “I will not take my insulin if I am sick and cannot eat.” | The process of elimination is helpful with the three options that are correct. Choose the incorrect answer. |
1214 While administering an iodine preparation Correct answer: 1 Iodine reduces the size and vascularity of the thyroid, reducing the risk of hemorrhage, which preoperatively to a client who is scheduled for a is a potential complication of thyroidectomy. Antithyroid medications, not iodine, are given to thyroidectomy to treat hyperthyroidism, the client reduce hormone comprehension levels. The treatment for cancer of the thyroid is a total asks the nurse to explain the purpose of the iodine. thyroidectomy. The best explanation is based on which of the following? ‐ Iodine decreases the vascularity and size of the thryoid gland, thereby reducing the risk of intraoperative and postoperative hemorrhage. ‐ Iodine reduces circulating hormone levels, thereby reducing the effects of elevated hormones. ‐ Iodine is recommended in the treatment of cancer of the thyroid. ‐ Iodine enlarges the thyroid gland and facilitates the surgeon's ability to locate the thyroid. | This question calls for knowledge of the relationship of iodine with thyroid function which may be transferred to the need for iodine treatment. |
1215 The nurse knows that a client with hyperthyroidism Correct answer: 2 Hyperthyroidism causes a hypermetabolic state, resulting in increased body temperature understands the discharge teaching instructions about causing the client to have heat intolerance, and sensitivity to noise and loud sounds. A cool, the management of hyperthyroidism when the client quiet environment is recommended. Clients with hyperthyroidism require an increased, not a repeats which of the following instructions? decreased, caloric consumption. ‐ "I will consume a low‐calorie diet." ‐ "I will keep the environment cool and quiet." ‐ "I will keep the environment warm." ‐ "I will maintain an environment with constant stimulation." | This question asks for correlation of the symptoms of hypothyroid with the environmental modifications which may accommodate to those. |
1216 Further assessment by the RN of postoperative Correct answer: 3 The thyroid gland is highly vascular, therefore there is a potential risk of postoperative hemorrhaging in the thyroidectomy client is required hemorrhage. The client should be thoroughly assessed for hemorrhage behind the dressing, as when the student nurse makes which of the following blood may drain and run back and under the client. Options 1, 2, and 4 are correct assessments statements? for hemorrhage. ‐ "Blood pressure and pulse are equal to baseline measurements." ‐ "The client denies complaints of dressing tightness." ‐ "The dressing is dry and intact; therefore, no signs of bleeding are present." ‐ "No signs of respiratory distress are noted." | This question requires use of the process of elimination to look for the incorrect option. |
1217 While performing an assessment on a client with Correct answer: 1 Muscle twitching when pressure is applied in taking a BP is called a positive Trousseau's sign, hypoparathyroidism, the nurse notes that the client is which indicates tetany in a client with hypoparathyroidism. experiencing muscle twitching when the blood pressure is taken. Based on this finding, the client is most likely experiencing which of the following imbalances? ‐ Hypocalcemia ‐ Hypercalcemia ‐ Hyperkalemia ‐ Hypokalemia | This question uses opposites; ensure that both options in the answer are correct while using the process of elimination. |
1218 Upon initial admission of a client diagnosed with Correct answer: 2 Metabolic acidosis is the alteration in acid‐base balance with DKA. This question draws on diabetic ketoacidosis (DKA), the nurse notices a fruity your knowledge of ABG values. The results show uncompensated metabolic acidosis because odor to the breath, Kussmaul's respirations, and the question asked about the initial admission. Partially compensated (option 1) or fully lethargy. The glucose level is 700 mg/dL, positive compensated (option 3) values would be expected later. Option 4 indicates respiratory ketones in the urine and the family member states acidosis. they have not been able to afford the insulin. Which of the following results would be expected on ABGs? ‐ pH 7.25; CO2 33 mmHg; HCO3‐ 22 mEq/L ‐ pH 7.25; CO2 36 mmHg; HCO3‐ 22 mEq/L ‐ pH 7.38; CO2 33mmHg; HCO3‐ 22 mEq/L ‐ pH 7.25; CO2 48mmHg; HCO3‐ 29 mEq/L | Reading of ABGs requires use of the process of elimination, assessing the pH, and then looking at the CO<sub>2</sub> and HCO<sub>3</sub><sup>‐ </sup> to determine the correct one for metabolic acidosis. |
1219 A client with hypothyroidism is given dietary Correct answer: 2 Constipation is a potential complication of hypothyroidism as a result of decreased gastric instructions. After the instructions, the nurse motility. Instructing client to consume at least 2,000 mL of fluid a day, unless contraindicated, determines that further instructions are needed when increase fiber intake, and maintain a well‐balanced diet will help promote bowel elimination. the client makes which of the following statements? Options 1, 3, and 4 are appropriate responses. ‐ "I will increase fiber intake in my diet." ‐ "I will limit my fluid intake to 1,000 mL a day." ‐ "I will eat a well balanced diet." ‐ "I will increase my fluid intake to 2,000 mL a day." | This question provides opposites; determine if fluid restrictions or forcing fluids is correct. |
1220 Which of the following laboratory values would Correct answer: 3 The normal values for T3 (triiodothyronine) are 80 to 200 ng/dL, and the normal values for T4 indicate a therapeutic effect of levothyroxine sodium (thyronine) are 5 to 12 & µg/dL. Both of these values are decreased in hypothyroidism. (Synthroid) for a client with hypothyroidism? With treatment of thyroid medications resulting in therapeutic effects, the thyroid levels should be normal. The other values are too low and do not indicate therapeutic effects have been achieved. ‐ T3 50 ng/dL, T4 2 µg/dL ‐ T3 50 ng/dL , T4 10 µg/dL ‐ T3 100 ng/dL, T4 7 µg/dL ‐ T3 100 ng/dL, T4 2 µg/dL | Recall knowledge of normal ranges of diagnostic tests. |
1221 In performing an assessment on a client on the fourth Correct answer: 2 The most common cause of hypoparathyroidism and the resulting hypocalcemia is damage to postoperative day following thyroidectomy, the nurse the parathyroid glands during a thyroidectomy. Hyperactive reflexes, tetany, positive notes hyperactive reflexes, tetany, and positive Chvostek's and Trousseau's signs are all manifestations of hypocalcemia. Chvostek's and Trousseau's sign. The client is experiencing which of the following disturbances? ‐ Hyperparathyroidism ‐ Hypoparathyroidism ‐ Hypothyroidism ‐ Hyperthyroidism | This question asks for understanding of the signs of low serum calcium levels and the role calcium plays with parathyroid function. |
1222 A client is recently admitted with signs and symptoms Correct answer: 1 Increased serum cortisol levels are diagnostic for Cushing's syndrome. Options 2, 3, and 4 are suggesting Cushing's syndrome. When evaluating the opposite of the expected abnormalities seen in Cushing's syndrome. laboratory results, which of the following would support the diagnosis of Cushing's syndrome? ‐ Increased serum cortisol levels ‐ Decreased serum sodium levels ‐ Increased serum potassium levels | Requires knowledge of the diagnostic values associated with Cushing’s Disease. |
4.‐ Decreased serum glucose level | |
1223 Which of the following would be a priority nursing Correct answer: 2 Hyperaldosteronism leads to sodium retention, which increases fluid volume and blood problem for a client with Conn's syndrome pressure. Hypertension and hypokalemia are the most common signs of this disorder. (hyperaldosteronism)? ‐ Fluid volume deficit ‐ Fluid volume excess ‐ Hyperkalemia ‐ Hyponatremia | Requires knowledge of the function of the organ in fluid balance, such that a decrease in function would lead to excess fluid. |
1224 The nurse is evaluating laboratory results on a client Correct answer: 4 Hyperaldosteronism leads to sodium retention (hypernatremia), potassium depletion admitted with complaints of hypertension, fatigue, and (hypokalemia), and, as a result, metabolic alkalosis. headaches. Based on these symptoms, Conn's syndrome (hyperaldosteronism) is suspected. Which of the following laboratory values would support the diagnosis of Conn's syndrome? ‐ Hyponatremia, hypokalemia, and metabolic acidosis ‐ Hypernatremia, hypokalemia, and metabolic acidosis ‐ Hyponatremia, hyperkalemia, and metabolic alkalosis ‐ Hypernatremia, hypokalemia, and metabolic alkalosis | Use the process of elimination to assist with this question in which all three items need to be correct for the option to be the correct choice. |
1225 When providing discharge instructions to a client with Correct answer: 1 To decrease incidence of gastric ulcers, cortisol replacements (prednisone) should be taken Addison's disease, which of the following should the with food or milk. Clients should weigh themselves daily and report changes, and increase fluid nurse include in the teaching? intake up to 3,000 ml a day unless contraindicated. Abruptly discontinuing cortisol replacements can result in Addisonian crisis. ‐ Take prescribed prednisone (Deltasone) with food or milk ‐ Weigh self weekly and report changes ‐ Stop taking prednisone if stomach upset occurs ‐ Limit fluid intake to 1,000 ml in 24 hours | Recall knowledge that prednisone increases the risk for gastrointestinal irritation and strategies to alleviate this. |
1226 A client with Addison's disease expresses concern Correct answer: 2 A deficiency in cortisol leads to fluid volume depletion and sodium depletion. Added salt is about adding extra salt to meals. The nurse should recommended to replace sodium loss. Options 1, 3, and 4 are incorrect. explain that the added salt is necessary for which of the following reasons? ‐ Excess production of aldosterone means sodium is lost in the urine, therefore additional salt is necessary for replacement. ‐ The lack of sufficient aldosterone means sodium is lost in the urine, therefore additional salt is necessary for replacement. ‐ The added salt will help prevent dehydration. ‐ The added salt will help prevent an Addisonian crisis. | Use the process of elimination to assist with this question. |
1227 The plan of care for a client newly admitted with a Correct answer: 3 SIADH results in fluid retention and hyponatremia. Intravenous hypertonic saline solution is diagnosis of syndrome of inappropriate antidiuretic administered in addition to diuretics. Maintaining oral fluid restriction is necessary to correct hormone secretion (SIADH) would include which of the fluid imbalance. following for fluid management? ‐ Administration of intravenous infusion of hypotonic saline ‐ Encourage an increase in oral fluids ‐ Maintain oral fluid restriction ‐ Administration of antidiuretic medications | Recall knowledge that too much ADH causes fluid retention to be led to the nursing intervention of fluid restriction. |
1228 A client with chronic syndrome of inappropriate Correct answer: 1 Chronic SIADH may be life‐threatening if a medical emergency arises and the client is unable antidiuretic hormone secretion (SIADH) indicates to inform healthcare providers. Chronic SIADH requires lifelong treatment. The client should understanding of discharge teaching by making which weigh daily and report any changes, and there is no indication to consume more than the of the following statements? normal requirements of fluids once a fluid balance has been obtained. ‐ "I will wear a Medic‐Alert bracelet at all times." ‐ "I will only be on this medication for a short time." ‐ "I will weigh myself every month and report any changes." ‐ "I will drink 3,000 ml of fluid a day." | Use the process of elimination to determine the correct answer which evaluates understanding of teaching. |
1229 In establishing a plan of care for a client admitted Correct answer: 1 Excretion of massive volumes of urine leads to fluid volume deficit, which is the priority with diabetes insipidus, the priority nursing diagnosis diagnosis. Care and treatment is aimed at restoring fluid and electrolyte balance. Risk for injury for this client would be which of the following? and knowledge deficit are important diagnoses and should follow fluid volume deficit. ‐ Fluid volume deficit ‐ Fluid volume excess ‐ Risk for injury ‐ Knowledge deficit | This question requires knowledge of the pathophysiology of diabetes insipidus. |
1230 The nurse admitting a client with the diagnosis of Correct answer: 2 Hypertension and tachycardia are the most common manifestations of this life‐threatening pheochromocytoma knows that expected signs and disorder. Careful monitoring of blood pressure is required as blood pressure elevation can symptoms of pheochromocytoma would include which reach dangerously high levels. of the following? ‐ Hypotension, bradycardia ‐ Hypertension, tachycardia ‐ Hypertension, bradycardia ‐ Hypotension, tachycardia | This question calls for looking at sets of opposites and using the process of elimination to determine when both items are correct. |
1231 A client with type II diabetes is admitted to the Correct answer: 2 Stressors such as illness or surgery increase blood glucose levels. Temporary requirements for hospital for pneumonia. During the hospitalization, exogenous insulin may be necessary to adequately control glucose levels. The client should be insulin is administered to control elevated glucose informed of this temporary need. Options 1 and 3 are incorrect, and option 4 does not levels. The client expresses concern that the diabetes recognize the client's need for information or address the psychosocial needs as evidenced by is "worse," and that insulin will be required the expression of concern. permanently. The best response to the client would be which of the following? ‐ "Because you have not been compliant with your treatment regimen, you must now take insulin injections." ‐ "Stressors such as illness increase blood glucose levels. You will require insulin temporarily until your glucose becomes stabilized again." ‐ "Persons with type II diabetes eventually progress to type I diabetes." ‐ "You should not worry about the insulin now, just focus on getting better." | Use the process of elimination to find the one correct answer. |
1232 A client with Type 1 diabetes mellitus requires further Correct answer: 2 Diabetic clients often learn how to compensate and even be noncompliant without affecting instructions when which of the following statements is their glucose levels excessively. A well‐balanced diet with three meals is usually required to made? maintain the glucose at the appropriate level, especially since insulin is probably given in the morning. Options 1, 3, and 4 are all correct. ‐ "I will bring some fruit with me when I go swimming." ‐ "I will eat less for breakfast since I'm going to a big party tonight with lots of food." ‐ "I will check my glucose level before my insulin injection since I've been vomiting." ‐ "I will monitor my glucose levels as instructed." | Recognize that questions which call for further instruction require looking for an incorrect answer. |
1233 When implementing a teaching plan for a client newly Correct answer: 1 Signs of Hypoglycemia include shakiness, coldness, sweating, nervousness, and palpitations. A diagnosed with Type 1 diabetes mellitus the nurse fast‐acting carbohydrate such as juice, crackers, or milk should be taken. If a glucometer is knows that the client has understood the instructions readily available, the glucose should be confirmed. Glucose levels should be monitored as when which of the following statements is made? instructed (option 3) and a glucose level of 100 indicates a therapeutic response to insulin (option 4). ‐ "If I feel shaky, cold, and sweaty, I will take my fast‐acting carbohydrate immediately." ‐ "If I feel shaky, cold, and sweaty, I will take extra insulin immediately." ‐ "I will check my glucose only if I feel like it is low." ‐ "I will not take my insulin if my glucose is less than 100." | Recognize the symptoms and how to manage hypoglycemia. |
1234 The nurse is educating a client with hyperthyroidism Correct answer: 4 Since antithyroid drugs inhibit thyroid hormone (TH) production, they do not affect the about tapazole (Methimazole). The instructions to the hormones already formed. Therapeutic effects may not be noticed for several weeks, possibly client would include which of the following? up to 12 weeks. The client should be informed of this and encouraged to continue medications as prescribed. Weight gain, not loss, may be a sign of hypothyroidism, which is a potential effect of treatment with antithyroid drugs. Side effects include rash, pruritis, and elevated temperature. ‐ Generally, there are no specific side effects of this medication. ‐ Stop taking the medication and notify healthcare provider if symptoms have not improved within 2 weeks. ‐ Monitor and report any weight loss. ‐ Therapeutic effects of the medication may not be noticed for several weeks. | Use the process of elimination to find the one correct answer. |
1235 A client who is post‐thyroidectomy shows evidence of Correct answer: 4 To decrease strain on the suture line, the client should support the head and neck with both understanding the preoperative teaching instructions hands behind the neck while moving in bed, coughing, or any other activity that could increase when the nurse observes the client demonstrating strain on sutures. The client should be encouraged to deep‐breathe and cough, and pain which of the following actions? medication will promote comfort. ‐ Maintains a supine position at all times ‐ Avoids coughing ‐ Refuses pain medications ‐ Supports head and neck with both hands while moving in bed | This question calls for using the process of elimination to find a correct answer. |
1236 A client diagnosed with hypothyroidism is admitted to Correct answer: 2 Hypotension, bradycardia, and dysrhythmias result from decreased cardiac output related to the unit. In planning care, the nurse's priority hypothyroidism. Options 1, 3, and 4 are all appropriate assessments for clients with assessment would be which of the following? hypothyroidism; however, they should follow the cardiovascular assessment. ‐ Muscle weakness, fatigue, and lethargy ‐ Blood pressure, heart rate, and rhythm ‐ Baseline weight and bowel elimination pattern ‐ Neurological status and skin integrity | In this question all four options are correct, so establish priority among the four to select the correct answer. |
1237 In providing care to a client on the first postoperative Correct answer: 4 Maintaining integrity of suture line is essential following a parathyroidectomy. Nursing care is day following a parathyroidectomy for the treatment essentially the same as for a thyroidectomy. The head should be supported with both hands of hyperparathyroidism, the priority nursing care for behind neck when moving, sitting up in bed, or coughing. Restricting fluids is contraindicated, this client would include which of the following as is calcium, since hypercalcemia is a complication of hyperparathyroidism. Antithyroid actions? medications are given to treat hyperthyroidism. ‐ Restricting intravenous and oral fluids ‐ Administering antithyroid medications ‐ Administering intravenous calcium ‐ Assuring proper support of head | Use the process of elimination to determine the one correct answer. |
1238 In planning care for a client with hypoparathyroidism, Correct answer: 1 The primary complication of hypoparathyroidism is hypocalcemia, which is a result of failure the nurse should assess for which of the following to release parathyroid hormone. Manifestations are directly related to decreased calcium potential complications? levels. Options 2, 3, and 4 are manifestations of hyperparathyroidism. ‐ Laryngeal spasm ‐ Hypercalcemia ‐ Hypohosphatemia ‐ Hypertension | Use the process of elimination to find the one correct answer. |
1239 The nurse is providing care to a client on the second Correct answer: 3 Adrenalectomy results in adrenal insufficiency, causing fluid imbalance (loss) manifested by postoperative day following a bilateral adrenalectomy. hypotension. The lack of mineralcorticoids will result in hyponatemia and hyperkalemia In planning care for this client, which of the following (options 1 and 2), and the lack of glucocorticoids will result in hyperglycemia (option 4). imbalances may occur as a result of adrenalectomy? ‐ Hypernatremia ‐ Hypokalemia ‐ Hypotension ‐ Hyperglycemia | This question asks the function of the adrenals. Recall that when there is a loss of function there will be manifestations of the illness. |
1240 A client is admitted with a diagnosis of Addisonian Correct answer: 1 Severe hypotension, circulatory collapse, shock, then coma are the complications of crisis. In planning the immediate care for this client, Addisonian crisis. Immediate intravenous replacement of glucocorticoids and fluids are the nurse should anticipate which of the following indicated to prevent death. Options 2, 3, and 4 are recommended treatments for Cushing's actions? syndrome, the opposite of Addison's disease. ‐ Administration of intravenous glucocorticoids and saline fluids ‐ Administration of mitotane (Lysodren) ‐ Preparation of client for adrenalectomy ‐ Administration of trilostane (Modrastane) | Use the process of elimination to find the one right answer and to rule out the opposites. |
1241 A 27‐year‐old male sustains a head injury as a result Correct answer: 1 Syndrome of inappropriate antidiuretic hormone secretion (SIADH) results in fluid retention of a fall from a roof. He began experiencing seizure and hyponatremia. Treatment is aimed at correcting fluid and electrolyte imbalance, which activity and fluid retention and was diagnosed with includes intravenous administration of hypertonic saline solution and oral fluid restriction. syndrome of inappropriate antidiuretic hormone Edema is usually not a complication because fluid is retained between the intracellular and secretion (SIADH). His plan of care should include extracellular spaces. Lifetime treatment of this disorder is not necessary for an acute which of the following? occurrence because the manifestations usually resolve within 3 days. ‐ Administering intravenous hypertonic saline solution ‐ Administering oral fluids up to 2,000 mL per day ‐ Educating the client about the need for lifetime replacement medications ‐ Preventing complications associated with edema | Use the process of elimination to find the one right answer in the treatment of SIADH. |
1242 Which of the following statements indicates that the Correct answer: 1 The primary side effect of insulin is hypoglycemia. The client should be aware of the signs and client performing insulin self‐administration symptoms, and should always have a source of sugar available. Options 2, 3, and 4 are understands the basic principles? incorrect and these responses would require further instruction. ‐ "I will monitor myself for low glucose levels and keep a source of sugar available." ‐ "I will not take my insulin if my glucose level is normal." ‐ "I will not take my insulin if I skip a meal." ‐ "I will take less insulin if I have an illness." | Use the process of elimination to find the one correct answer. |
1243 A client is admitted in diabetic ketoacidosis (DKA) and Correct answer: 2 The nurse should watch for hypoglycemia during the peak time of both the regular insulin and is given both regular and NPH insulin. After 2 days, the NPH, which differ. The peak for regular is 2 to 4 hours; NPH 8 to 12 hours. glucose levels are maintained at 200 to 300 mg/dL. NPH and regular insulin is administered every day at 7:30 A.M. The nurse knows to watch for a hypoglycemic reaction between: ‐ 9:20 A.M. to 11:30 A.M. ‐ 9:30 A.M. to 7:30 P.M. ‐ 3:30 P.M. to 7:30 P.M. ‐ 9:30 A.M. to 3:00 P.M. | Recall knowledge of the peaks of both insulins, and then find the true answer for both types of insulins. |
1244 A female client is being given 30 mCi sodium iodide‐ Correct answer: 2 Clients receiving doses of I‐131 that are greater than 30 mCi may not have visitors for 24 or 131 (Iodotope) to treat Graves' disease. Before giving more hours based on radiation dose. For dose of 30 mCi or less, visitors must remain several the client her first dose you should do which of the feet away from client and client may not hold/cuddle children or sleep in same room as following? another person for 8 days (to protect them from radiation exposure). Clients who are allergic to shellfish are also allergic to iodine but egg allergy is irrelevant (option 1). Options 3 and 4 are unrelated to this medication. ‐ Assess the client for hypersensitivity by asking if she is allergic to eggs. ‐ Instruct her that she must not sleep in the same room with another person for 8 days. ‐ Assess her temperature to use as a baseline to evaluate the medication effectiveness. ‐ Instruct the client not to drink the medication mixture with a straw in order to ensure she drinks the entire dose. | Knowledge is needed of the precautions associated with radioactive isotopes. |
1245 A client is 12 hours post‐partial thyroidectomy. During Correct answer: 3 The parathyroid glands, located near the thyroid gland, may have been injured or accidentally the postoperative phase the nurse asks the client removed, resulting in hypocalcemia. Hypocalcemia is life‐threatening; thus it is important to about any numbness or tingling of the face, mouth, or identify early signs. Numbness and/or tingling of the mouth, face, or extremities are early extremities for which of the following assessment symptoms of low serum calcium. Reduced thyroid hormone levels are expected results of purposes? surgery (option 1). Option 2 should refer to the pituitary gland. Option 4 is possible, but could be detected by hoarseness or weak voice. ‐ Early identification of low thyroid hormone ‐ Detection of thyroid‐induced hypoglycemia ‐ Early identification of hypocalcemia ‐ Detection of nerve damage related to surgery | This question requires knowledge of the function of proximity of the parathyroid and thyroid glands. |
1246 The client is diagnosed with an allergy to iodine. In Correct answer: 2 Iodine intake is needed for the thyroid gland to produce thyroid hormone. Insufficient iodine addition to client education about avoiding foods with intake leads to low thyroid hormone production and symptoms of hypothyroidism, which iodine, the client should also be taught to report which includes constipation, weight gain, and muscle stiffness, among others. The other options are of the following symptoms associated with endocrine incorrect. malfunction related to low iodine intake? ‐ Diarrhea, weight loss, blurred vision ‐ Constipation, weight gain, muscle stiffness ‐ Fatigue, dry skin, increased BP ‐ Anorexia, dyspnea, weight loss | This question requires knowledge of the function of iodine as it impacts thyroid function. |
1247 A client is 20 hours post‐colon resection with end‐to‐ Correct answer: 2 Clients with Addison disease should be assessed for signs of Addisonian crisis following a end anastomosis for ruptured diverticulum. You have stressful event such as surgery. Signs of Addisonian crisis include decreased urine output, read in the medical record that he has an 8‐year decreased blood pressure, dry skin, and altered level of consciousness. Options 1, 3, and 4 do history of Addison's disease. After noting new onset of not apply to the necessary priority assessments related to Addisonian crisis, although they are lethargy with the current assessment, you would do good general post operative assessments. which of the following next? | This question requires knowledge of the assessments specific to Addison’s Disease. |
‐ Review his patient‐controlled analgesia (PCA) record for dose history ‐ Assess him for decreased urine output and blood pressure (BP) ‐ Check pupils for direct and consensual reaction ‐ Obtain a pulse oximeter to check his oxygen saturation level | |
1248 A client has new onset type I diabetes mellitus (DM). Correct answer: 1 Research by the National Institute of Health and the American Diabetes Association He asks you why he needs to check his blood glucose demonstrates a strong correlation between chronic hyperglycemia and complications of level so frequently. You explain that frequent coverage retinopathy, nephropathy, and neuropathy. Thus, there is damage to the eyes, kidneys, and with insulin to keep his blood glucose level between 80 peripheral nerves, respectively. Lactic acidosis occurs with diabetic ketoacidosis (option 2). and 155 mg/dL is important for which of the following Option 3 is a false rationale for the client in the question. Insulin is needed to carry glucose reasons? across the cell membrane into the cell, not to be transported in the blood (option 4). ‐ Chronic elevated blood glucose levels damage cells and causes multiple organ damage. ‐ High glucose levels cause the body to use proteins for energy, causing lactic acidosis. ‐ Early identification of hypoglycemia before the onset of symptoms is easier to treat. ‐ Carbohydrates are constantly being converted to glucose and transported in the blood by insulin. | Recall knowledge of the long term complications of hyperglycemia. |
1249 You have been teaching the client with new onset of Correct answer: 4 In SIADH there is excess secretion of ADH that causes fluid retention, dilutes the plasma syndrome of inappropriate antidiuretic hormone causing suppression of aldosterone, and increases renal excretion of sodium. Water then (SIADH) about the disorder. Which of the following moves into the cells from the plasma and interstitial spaces causing cellular edema. The statements by the client best indicates that he treatment is fluid restriction and hypertonic saline infusion. Options 1 and 3 are the opposite correctly understands how to manage this disease? of standard treatment and are therefore incorrect. Option 2 is unrelated to this client. ‐ "I should limit my sodium intake to 2 grams daily." ‐ "I should report constipation or fatigue to the doctor." ‐ "I should drink at least 3,000cc or 10 glasses of water daily." ‐ "I should limit my fluid intake to approximately 800 cc or 4 glasses of water daily." | In this question, look closely at the opposites to make the correct selection. |
1250 The client is admitted with decreased level of Correct answer: 3 Diabetes insipidus (DI) can develop with head injury, tumors, and other conditions that cause consciousness secondary to a closed head injury increased intracranial pressure. Excessive urine output of 350 ml/hr or more is a classic early resulting from a fall while roller‐skating. Urine output symptom of DI. The specific gravity provides valuable information about renal function and is 500 ml from 6:00 A.M. to11:00 A.M., 1000 ml from response to ADH. Using critical inquiry to analyze the urine output, specific gravity and other 11:00 A.M. to 2:00 P.M. and 350 ml from 2:00 P.M. to characteristics of the urine, the nurse assesses for classic signs of DI that can occur following a 3:00 P.M. which of the following actions by the nurse is head injury. Options 1 and 4 are false. Option 2 would be insufficient fluid replacement. appropriate? ‐ Realize that this is normal urine output and continue to monitor the client. ‐ Encourage the client to drink 8 to 10 glasses of fluid daily. ‐ Check the urine specific gravity and report any abnormality as well as the urine output. ‐ Decrease the IV rate from 100 ml/hr to 25 ml/hr suspecting fluid excess. | This question requires knowledge of the relationship to lack of organ function. |
1251 The client with acromegaly secondary to excessive Correct answer: 4 Option 4 addresses the lifelong hormone replacement of thyroid, glucocorticoids, and growth hormone (GH) states: "I'll be glad to have this gonadotropin needed when the entire pituitary gland is removed. Options 1 and 3 are surgery; after the pituitary gland is removed I will be incorrect. Option 2 relates to the immediate postoperative time while the client's comments cured–then no more lab tests and pills!" Which of the relate to long‐term outcome. following statements should the nurse document to evaluate the client's understanding of preoperative teaching? ‐ Criteria met: Client correctly verbalized understanding of outcomes. ‐ Criteria not met: Client needs to know about routine post operative lab tests done on first postoperative day to evaluate response to surgery. ‐ Criteria not met: Client needs to know surgery will slow down the disease process but client will need regular blood tests and x‐rays for 1 year. | In this question, determine first if the goals are met or not met, and then determine the rationale for this decision. |
4.‐ Criteria not met: Client needs to know surgery will stop excess production of GH and probably other hormones, and thus will need daily replacement medications for life. | |
1252 The client is admitted with metabolic acidosis Correct answer: 2 DKA is associated with excessive urine output, dehydration, and hypokalemia, placing the secondary to diabetic ketoacidosis (DKA). client at risk for decreased cardiac output and cardiac dysrhythmias. Option 1 is false regarding Understanding metabolic acidosis, you should choose output and does not address the metabolic problem. Options 3 and 4 may apply to the client which of the following as the priority nursing but are not the priority needs, in addition, option 3 will resolve as the DKA is treated. diagnosis? ‐ Decreased urinary elimination related to reduced output and muscle function. ‐ Decreased cardiac output related to fluid and electrolyte imbalance. ‐ Ineffective breathing pattern related to hyperventilation. ‐ Anxiety related to fears of long‐term outcomes and discomfort. | This question asks to set sound priorities based on the life‐threatening nature of the complication. |
1253 An elderly female client with dry flaky skin and Correct answer: 4 Daily total baths remove the protective sebum from the skin, placing the client at risk for activity intolerance secondary to myxedema is altered skin integrity. Since the client's level of participation in the bath or other self‐care admitted to the progressive care unit to improve her activity is not presented, the other 3 options are inappropriate. In addition, options 2 and 3 are activity tolerance and gain independence in self‐care. not specific and measurable enough to meet criteria for an outcome statement. For hygiene care the nursing order is two total baths per week on Saturday and Wednesday with partial baths on the remaining days of the week. Which of the following would be the desired outcome of this intervention? ‐ Client is able to sleep through the night and stay awake most of the day ‐ Gradual increase in ambulation ability over the first month ‐ Increased energy by the end of the first week of paced rest and activity ‐ Intact elastic moist warm skin by the end of first week | This question requires going “back to the basics” associated with fundamental nursing knowledge. |
1254 The client is 8 hours post partial thyroidectomy for Correct answer: 3 Early signs of edema of the larynx leading to airway obstruction are tight‐fitting dressing, Graves' disease. What's the best documentation by the stridor, stertor, and weak or harsh voice. Numbness or tingling of the extremities, lips or nurse of evaluation outcome criteria for the nursing mouth are signs of hypocalcemia that can lead to respiratory distress due to tetany. The data diagnosis risk for Ineffective airway clearance? in the other options are important routine postoperative assessments, but they do not relate to the client's airway. ‐ Dressing is clean dry and intact, pain minimal and controlled, alert and oriented. ‐ Vital signs stable; client supports neck with hand during change of position. ‐ No tracheal stridor, speaks clearly, and denies numbness or tingling. ‐ Balanced intake and output, vital signs stable, and alert and oriented. | In this question, recall the ABCs (airway, breathing, circulation) and focus on airway, a very high priority with all clients. |
1255 Which of the following evaluation data would best Correct answer: 1 HHNK results from hyperglycemia, causing excessive loss of water and retention of glucose lead the nurse to conclude that the client with that leads to dehydration, hypernatremia and hypokalemia. Symptoms are dry, tenting skin, hyperglycemic hyperosmolar nonketotic coma (HHNK) dry mucous membranes, altered level of consciousness and hyperthermia. Ketones are not has demonstrated improvement during the first 24 present in HHNK; thus, monitoring for ketones is inappropriate (option 3). Options 2 and 4 do hours? not address the primary problems that occur with HHNK. ‐ Alert and oriented, balanced intake and output, moist mucous membranes ‐ Intake equals output, denies pain and shortness of breath ‐ Alert and oriented, blood and urine without ketones, no orthostatic BP ‐ Respirations easy and even, eats 50 to 75 percent of meals, vital signs stable | This question reinforces the importance of client behavior in assessing client illness and responses to treatment. |
1256 The nurse is caring for a client with type 1 diabetes Correct answer: 1 The signs of hypoglycemia include hunger, shakiness, sweating, pale cool skin, and irritability. mellitus. In developing a teaching plan, which of the These signs may be manifestations of impaired cerebral function from the hypoglycemia. The following signs and symptoms of hypoglycemia should other options are all signs of hyperglycemia. be included? ‐ Shakiness ‐ Increased thirst ‐ Fever ‐ Fruity breath | The correct answer is a symptom of hypoglycemia, the rest are indicative of hyperglycemia. |
1257 A client with diabetes is being tested for glycosylated Correct answer: 2 Glycosylated hemoglobin reflects the average blood glucose over the life of the RBC, usually 4 hemoglobin. In explaining the purpose of the months. This test is not a ratio of hemoglobin to glucose content (option 3) nor is it helpful in laboratory test the nurse explains that glycosylated diagnosing anemia (option 1). The time frame in option 4 is too long. hemoglobin is used for which of the following purposes? ‐ To check for anemia ‐ To determine the average blood glucose level for up to the previous 4 months ‐ To compare hemoglobin to glucose levels ‐ To calculate the amount of glucose in hemoglobin for the past 6 months | In this question, define glycosylated hemoglobin to then determine the answer. |
1258 A post‐surgical client is brought back to the nursing Correct answer: 4 The danger of hemorrhage is greatest during the first 24 hours following thyroid surgery. The unit following a thyroidectomy. Which of the following tendency is for blood to flow down at the sides and posteriorly if hemorrhage occurs in the methods should the nurse use to assess for bleeding? area of the neck. Inspecting the front of the dressings for signs of hemorrhage may not reveal bleeding (option 1). Changing dressings immediately after surgery is not appropriate (option 2). A drop in hemoglobin may be a clue to bleeding but is not the best initial assessment action (option 3). ‐ Inspect the front of the dressing for signs of hemorrhage. ‐ Change the dressing applied in the operating room. ‐ Check the latest hemoglobin to determine if there has been a drop in value. ‐ Palpate the back of the neck and shoulders for evidence of bleeding. | Consider the client position, the vascularity of the thyroid gland, and the need for in depth nursing assessments. |
1259 A diabetic client with the flu asks why he should drink Correct answer: 1 Starvation‐induced ketosis can be prevented by drinking juices that equal the prescribed juices, check his finger stick glucose every 4 hours and carbohydrate meal pattern. Fluids are needed to prevent dehydration and hyperosmolality, take insulin when he is not eating and is vomiting. which could result from large fluid losses from persistent vomiting. The liver breaks down fats Which of the following would be the best explanation to form glucose for energy and ketones, leading to DKA. The other options do not address the by the nurse? key issues of dehydration and hyperglycemia. ‐ He needs to prevent dehydration, excessive breakdown of fats for glucose, and monitor for hyperglycemia. ‐ He needs to check his blood glucose because vomiting could cause hypoglycemia and drinking fluids will prevent dehydration. ‐ His body uses protein for energy when he is sick, causing increased ketones and hypoglycemia. ‐ If he could substitute water for the juices to prevent dehydration, then he would not need to check his blood glucose levels so often. | This question requires the knowledge of the development of DKA. |
1260 The client with diabetic ketoacidosis (DKA) is given Correct answer: 3 Level of consciousness responds quickly to early changes in pH and restoration of fluid and intravenous normal saline infusion and regular insulin. electrolyte balance. Urine output decreases as hyperglycemia is resolved. The respiratory In addition to hourly blood glucose monitoring, what buffer system takes a few hours to respond to change in ph. Dehydration is usually so severe assessment data are early signs of clinical that several hours of rehydration are needed to reduce pulse (option 2) and resolve orthostatic improvement? BP (option 1). Option 4 is inappropriate because eating a full meal is not an early sign of improvement. ‐ Respiratory rate of 12 to 15 and normal BP in the standing position ‐ Temperature and pulse in normal range ‐ Improved level of consciousness and decreasing urine output ‐ Client eats a full meal and respiratory rate is normal | Note that this question highlights behavior changes and level of consciousness as early signs of condition changes. |
1261 The nurse is preparing to discharge a client newly Correct answer: 4 The candy bar and ice cream may have too much glucose and fat, potentially leading to diagnosed with diabetes mellitus. The client states, "I hyperglycemia. In addition the fat may delay glucose absorption. Immediate absorption of should eat a candy bar or cup of ice cream every time I glucose is needed in hypoglycemia. The client should also check the blood glucose within 15 feel shaky, hungry, or nauseated." Which of the minutes of taking glucose because of signs of hypoglycemia. following is the best response by the nurse? ‐ "Yes, a candy bar or cup of ice cream is needed to treat the hypoglycemia." ‐ "Yes, you should eat the snack, then have a meal as soon as possible." ‐ "No, you should quickly eat a meal; the candy will cause hyperglycemia." ‐ "No, these have too much sugar and fat, 5 Lifesavers candy or skim milk are better." | This question asks the nurse to recommend both a nutritionally sound snack and one that raises the blood sugar rapidly. |
1262 The client had a bilateral adrenalectomy for Cushing's Correct answer: 4 Usually the cortex of the adrenal gland (not the medulla as in option 1) increases secretion of syndrome. He is being sent home with a new cortisol to stimulate the immune system in response to an infection. Thus the replacement prescription for hydrocortisone. The best statement dose during illness may need to be adjusted once a client's adrenal glands are removed. indicating understanding of the drug and associated Hydrocortisone can irritate gastric mucosa and so clients should not take gastric irritants such risk is: as aspirin or nonsteroidal anti‐inflammatory drugs (NSAIDs). Dosage may be adjusted during illness. Options 2 and 3 do not address the risk of the drug, which is the issue of the question. ‐ "I am taking this drug to replace the hormones usually secreted by the adrenal medulla." ‐ "I should take this pill every morning before breakfast." ‐ "This pill may cause weight gain, so I should exercise more and eat less." ‐ "I should call the doctor if I think I am starting a cold, and I should not take aspirin." | Recognize that this question has a focus on the risk of medications. |
1263 An obese, elderly client is being given a high‐dose Correct answer: 1 The client is at risk for type 2 diabetes mellitus (DM). Polydipsia and polyuria are signs of steroid protocol as emergency treatment of a spinal hyperglycemia, a symptom of DM. Steroids may also increase carbohydrate metabolism, cord injury. The client's family has requested frequent leading to hyperglycemia in clients with insufficient insulin. Thus the nurse should assess the refills for his cup of chipped ice and his urine output is client's blood glucose. Since hyperglycemia places the client at risk for fluid volume deficit the 600 mL for the first 4 hours and 900 mL in the second 4 nurse should calculate the client's fluid balance. The nurse also needs to record the assessment hours. The family states that the client was often data and report it to the physician. The client is not at risk for hypervolemia (options 2 and 3). thirsty at home, even prior to the injury. The nurse Option 4 is not a priority. should take which of the following most appropriate actions? ‐ Obtain finger stick blood glucose and tabulate the client's 24 hour intake and output. ‐ Restrict the client's intake to prevent fluid volume excess and electrolyte imbalance. ‐ Obtain and monitor CBC, hemoglobin and hematocrit, and vital signs for hypervolemia. ‐ Evaluate the clients breathing pattern and understanding of current treatment plan. | Note that this client is on steroids and is obese, increasing the risk of secondary and Type 2 diabetes. |
1264 The client has undergone hypophysectomy using a Correct answer: 2 The presence of a halo effect indicates cerebrospinal fluid (CSF). Glucose present in the nasal transphenoidal approach. You change the mustache drainage also suggests that the drainage is CSF. A persistent headache indicates a CSF leak. The dressing, noting clear exudate with a pale yellow physician needs to be informed of these assessment findings and the client must be colored ring at the edge of the drainage on the maintained on bedrest to stop the leak. A spinal tap may be done to decrease CSF pressure. dressing. You should do which of the following next? Option 1 is incorrect because it does nothing for the client. Options 3 and 4 do not address the real problem, a probable CSF leak. ‐ Document this as serous drainage and continue to monitor the client. ‐ Assess for headache and check the glucose level in the drainage. ‐ Apply an ice pack to the nasal bridge and a large fluffy dressing. ‐ Lower the head of the bed to decrease the gravity pressure on the wound. | This question requires use of the mnemonic that halo secretions lead to CSF. |
1265 A client who has a history of Graves' disease Correct answer: 4 With exophthalmos, the eyelids may not cover and protect the cornea of the eye. Thus, eye accompanied by exophthalmos is arriving from protection from the sheets or preventing the hands from accidentally touching the eyes is surgery. Based on the observations as you note the needed while the client is in bed. With Graves' disease clients usually experience heat photo, what should you educate the nurse assistant to intolerance, thus less covering and a cool room are preferred (option 1). Hyperglycemia is not do? usually associated with Graves' disease. The head of the bed should be elevated 30&deg; to minimize eye pressure (option 3). ‐ Keep the client's room warm to promote comfort ‐ Obtain fingerstick blood glucose every 2 hours twice ‐ Keep the head of the bed flat for 4 hours ‐ Provide eye protection measures for the client | This question asks the nurse to define eye protrusion and the safe care with this symptom. |
1266 The client is admitted with all of the following orders Correct answer: 1 Fluid and electrolyte replacement is the highest priority. Hyperglycemia is treated with to treat diabetic ketoacidosis (DKA) with severe regular insulin rather than an oral agent (option 3). Concurrent administration of IV regular metabolic acidosis. Which order would the nurse insulin would also be done as a priority. The items in the other options can be done after determine to be the first priority in managing this definitive treatment for dehydration is done. client? ‐ Start IV fluid infusion for rehydration. ‐ Insert an indwelling urinary catheter. ‐ Give oral glucophage (Metformin). ‐ Initiate continuous pulse oximetry. | The treatment requires IV access for the treatment with hydration and insulin. |
1267 A client is diagnosed with hyperglycemic Correct answer: 4 Glucagon is given IM or SC for low blood glucose associated with unconsciousness; usually the hyperosmolar nonketotic coma (HHNK) after being blood glucose is less than 20 mg/dL. Hypoglycemia associated with a change in level of admitted with a blood glucose level of 720 mg/dL. The consciousness or seizure requires immediate interventions. Glucagon will not help urine admitting orders include: normal saline infusion, output or blood pressure, and is not administered routinely when glucose levels fall to 150 insulin infusion, tylenol PRN and glucagon PRN. When mg/dL. should the nurse prepare to give the glucagons? ‐ When the blood sugar reaches 150 mg/dL ‐ For urine output less than 60 mL/hr ‐ For symptomatic BP less than 100/60 mmHg ‐ For precipitous drop in blood glucose leading to unresponsiveness | Recall treatment given for low blood sugar. |
1268 The client is being started on methylprednisolone Correct answer: 2 Clients taking methylprednisolone, a glucocorticoid, should be monitored for signs of (Solu‐Medrol) following craniotomy for removal of a Cushing’s syndrome and hyperglycemia. Increased corticosteroid serum level can cause sodium tumor. Understanding the potential side effects for retention, increased BP, edema, hypokalemia, weakness, and ecchymosis. this class of medication, the nurse knows it is important to monitor for which of the following? ‐ Rapid scar formation of the incision ‐ Polydipsia, polyuria, increased blood pressure (BP) ‐ Numbness and tingling of fingers ‐ Orthostatic hypotension, increased pulse | This question asks the nurse to understand the connection of prednisone with hyperglycemia. |
1269 The nurse is teaching a client about long‐term use of Correct answer: 3 Long‐term corticosteroid therapy can cause Cushing's syndrome. To prevent the osteoporosis therapeutic (additional) corticosteroid medication. associated with Cushing's syndrome, clients should eat diet high in calcium. Extra Which of the following is the best statement that corticosteroids over the long term can cause weight gain and increased hair on the body. indicates client understanding of the concepts taught? These clients are at risk for gastrointestinal bleeding and should avoid taking aspirin. ‐ "It is normal to have some hair loss." ‐ "I should eat more to prevent excessive weight loss." ‐ "I should eat 4 to 6 servings of food high in calcium." | Use the process of elimination to find the one correct answer. |
4.‐ "I should take aspirin for flu or cold symptoms." | |
1270 The client is admitted with thyroid storm. Assessment Correct answer: 4 Tachycardia, hypertension, and tachypnea increase stroke volume and tissue demand for reveals: BP188/102, HR 132 regular, RR 28 full depth oxygen, leading to increased cardiac workload and possible heart failure. If fluid volume deficit and symmetrical, no urine output since admission to is present, then there is an additional risk for decreased cardiac output. There is insufficient the emergency department, alert, and anxious. Which data to determine fluid volume status. The tachypnea is a symptom of the increased metabolic of the following would be the high priority nursing rate. diagnosis for this client? ‐ Fluid volume deficit r/t decreased absorption as evidenced by no urine output since admission ‐ Anxiety r/t fear as evidenced by client’s appearance ‐ Ineffective breathing pattern r/t increased metabolism as evidenced by RR 28. ‐ Risk for decreased cardiac output r/t increased ventricular workload as evidenced by BP 188/102, HR 132, RR 28 | With this question consider the priority cardiac output plays in clients with hydration issues. |
1271 A client with diabetic ketoacidosis had repeat arterial Correct answer: 3 The pH indicates acidosis; the PCO<sub>2</sub> is low, indicating increased blood gases (ABGs) drawn 24 hours after initiation of a respiratory rate; and the low bicarbonate level is usually associated with metabolic acidosis. Regular Insulin intravenous infusion. The results are: The respiratory system is attempting to compensate for the excess metabolic acids but there pH 7. 30, PaCO<sub>2</sub> 29, continues to be an excess of them. The bicarbonate level is low because it is being depleted in PaO<sub>2</sub> 95, an attempt to buffer the metabolic acids. O<sub>2</sub> saturation 99%, HCO<sub>3</sub><sup>‐</sup> 20 mEq/L and Base excess ‐1. 2. The nurse would interpret the results to be which of the following imbalances? ‐ Respiratory acidosis ‐ Respiratory alkalosis ‐ Metabolic acidosis ‐ Metabolic alkalosis | Use the opposites to determine the pH, and then use the CO<sub>2</sub> and HCO<sub>3</sub><sup>‐</sup> to determine the state of metabolic acidosis. |
1272 The nurse is instructing a client with diabetes mellitus Correct answer: 2 Clients with diabetes mellitus are susceptible to injuries because of the decreased sensation (DM) regarding foot care. The nurse should include associated with the effects of chronic hyperglycemia, compounded by the diabetes‐induced which of the following? arteriosclerosis. The client should be taught to inspect the feet daily utilizing a mirror to facilitate inspection of hard to see areas. Cotton socks are preferred as they absorb moisture and allow the feet to dry. The use of prophylactic antibiotics is not appropriate, the moisture could lead to skin maceration and breakdown. ‐ Inspect feet once a week ‐ Allow 1/2 to 3/4‐inch toe room when choosing shoes. ‐ Wear nylon socks. ‐ Apply antibiotic ointment sparingly between the toes to prevent infection. | Use the process of elimination to find the one correct answer. |
1273 During a scheduled exam the client's glycosylated Correct answer: 1 Glycosylated hemoglobin is elevated due to long‐term hyperglycemia. Values greater than 8 hemoglobin was found to be 9 percent. The client has percent indicate consistently poor control of blood glucose and the need to assess the client's had diabetes mellitus for 3 years. The nurse should do dietary pattern for the past several months in relation to the treatment plan. The other which of the following? options do not apply. ‐ Explore the client's general dietary pattern for the past 4 months. ‐ Assess for signs of infection and client's intake for the past 24 hours. ‐ Review the client's understanding of diabetic foot care. ‐ Immediately give sliding scale insulin medication. | Recall knowledge of the interventions associated with poor control, indicated by this HgbA1c. |
1274 A client has a total gastrectomy. The nurse explains to Correct answer: 3 The loss of parietal cells that secrete intrinsic factor results in Vitamin the client the need for long‐term injections of which of B<sub>12</sub> (cyanocobalamin) deficiency postgastrectomy, because intrinsic the following vitamins? factor is needed for absorption of Vitamin B<sub>12</sub>. For this reason, clients require Vitamin B<sub>12</sub> injections for life. The other options identify other B‐complex vitamins. ‐ Thiamine ‐ Folic acid ‐ Cyanocobalamin ‐ Niacin | The core issue of the question is knowledge that gastric surgery results in loss of ability to produce intrinsic factor and subsequent Vitamin B<sub>12</sub> deficiency. Use nursing knowledge and the process of elimination to make a selection. |
1275 A client with diverticular disease undergoes a Correct answer: 3 Bowel perforation is a possible result of colonoscopy if the colonoscope accidentally pierces colonoscopy. When conducting an abdominal the bowel wall. Perforation could lead to symptoms of peritonitis, such as guarding and assessment, the nurse looks for which of the following rebound tenderness. The other options are incorrect, because diarrhea (option 1), nausea and as a sign of possible complication of the procedure? vomiting as signs of obstruction (option 2), and redness and warmth of abdominal skin (option 4) are not of concern. ‐ Diarrhea ‐ Nausea and vomiting ‐ Guarding and rebound tenderness ‐ Redness and warmth of the abdominal skin | The core issue of the question is assessment data that correlates with complications of colonoscopy, such as peritonitis. Use nursing knowledge and the process of elimination to make a selection. |
1276 The client who has ulcerative colitis is scheduled for Correct answer: 2 A client with an ileostomy has no control over bowel movements and must always wear a an ileostomy. When the client asks the nurse what to collection device. The drainage tends to be liquid but becomes pastelike with intake of specific expect related to bowel function and care after foods. surgery, what response should the nurse make? ‐ “You will be able to have some control over your bowel movements.” ‐ “The stoma will require that you wear a collection device all the time.” ‐ “After the stoma heals, you can irrigate your bowel so you will not have to wear a pouch.” ‐ “The drainage will gradually become semisolid and formed.” | The core issue of the question is knowledge of stool characteristics and associated stoma appliance needs following ileostomy. Use nursing knowledge and the process of elimination to make a selection. |
1277 The nurse is conducting dietary teaching with a client Correct answer: 3 Dumping syndrome, in which gastric contents rapidly enter the bowel, can occur following who has dumping syndrome. The nurse encourages the gastrectomy. Dietary fats and proteins are increased, and carbohydrates, especially simple client to avoid which of the foods that the client carbohydrates such as fruits, are reduced. This helps slow the GI transit time and reduce the GI usually enjoys? cramping, diarrhea, and vasomotor symptoms associated with dumping syndrome. ‐ Eggs ‐ Cheese ‐ Fruit ‐ Pork | The core issue of the question is knowledge of foods to avoid when the client has dumping syndrome. Use nursing knowledge and the process of elimination to make a selection. |
1278 A client is being evaluated for possible duodenal Correct answer: 1 The pain of a gastric ulcer is dull and aching, occurs after eating, and is not relieved by food as ulcer. The nurse assesses the client for which of the is the pain from duodenal ulcer. The pancreatic juices that are high in bicarbonate are released following manifestations that would support this with food intake and relieve duodenal ulcer pain when the client eats. Chronic aspirin use is diagnosis? irritating to the stomach (option 2). The manifestations in options 3 and 4 are unrelated. ‐ Epigastric pain relieved by food ‐ History of chronic aspirin use ‐ Distended abdomen ‐ Positive fluid wave | The core issue of the question is expected assessment findings in duodenal ulcer. Recall the effect of pancreatic juices on the duodenal ulcer surface and use the process of elimination to make a selection. |
1279 The client returning from a colonoscopy has been Correct answer: 1 Steatorrhea is often present in the client with Crohn’s disease. Diarrhea is also key feature, given a diagnosis of Crohn’s disease. The oncoming but unlike ulcerative colitis, the loose stool usually does not contain blood and is usually less shift nurse expects to note which of the following frequent in number of episodes. manifestations in the client? ‐ Steatorrhea ‐ Firm, rigid abdomen ‐ Constipation ‐ Enlarged hemorrhoids | The core issue of the question is identification of common symptoms of Crohn’s disease. Use nursing knowledge and the process of elimination to make a selection. |
1280 A client is scheduled for a fecal fat exam. In planning Correct answer: 4 It is suggested that adults consume at least 100 grams of fat per day for 3 days before the test client education, the nurse includes that which dietary and throughout specimen collection. The other responses provide incorrect information. modification is necessary before the test? ‐ Eat a fat‐free diet the day before the exam. ‐ Eat a high‐fat meal right before the exam. ‐ Eat a diet containing 35 grams of fat for 36 hours before the test. ‐ Eat at least 100 grams of fat for 3 days before and during the test. | The core issue of the question is the ability to provide correct information when teaching a client about proper preparation for fecal fat examination. Use nursing knowledge and the process of elimination to make a selection. |
1281 The client with diverticular disease is scheduled for a Correct answer: 1 Perforation of an obstructed diverticulum can cause abscess formation or generalized sigmoidoscopy. He suddenly complains of severe peritonitis. The manifestations of peritonitis are abdominal guarding and rigidity and pain. abdominal pain. On examination, the nurse notes a Sigmoidoscopy is contraindicated in cases of perforation. Because treatment of this rigid abdomen with guarding. What action should the complication is beyond the scope of independent nursing practice, the physician must be nurse take next? notified. ‐ Notify the physician. ‐ Place the client in a more comfortable position. ‐ Keep the client distracted until the procedure begins. ‐ Tell the client that the test will show what is causing his problem. | The core issue of the question is the ability to identify the occurrence of peritonitis as a complication of diverticular disease and determine the appropriate course of action. Use nursing knowledge and the process of elimination to make a selection. |
1282 The nurse is educating the client with Correct answer: 1 Lifestyle modifications can minimize symptoms of GERD. Anything that increases intra‐ gastroesophageal reflux disease (GERD) about ways to abdominal pressure should be avoided, such as lifting weights. Obesity also aggravates minimize symptoms. Which information in the client’s symptoms, but a body mass index of 23 is normal. Being a vegetarian does not increase risk, history should the nurse address as an indicator that and calcium carbonate tablets often aid in symptom relief. needs to be changed? ‐ Lifting weights for exercise ‐ Being a vegetarian ‐ Having a body mass index of 23 ‐ Taking calcium carbonate tablets | The core issue of the question is ability to identify risk factors that aggravate symptoms of GERD. Use nursing knowledge and the process of elimination to make a selection. |
1283 The client with a duodenal ulcer asks the nurse why Correct answer: 2 H. pylori infection is a major cause of peptic ulcers. Treatment includes eradicating H. pylori an antibiotic is part of the treatment regimen. Which with antibiotics. The other responses are incorrect. information should the nurse include in the response? ‐ Antibiotics decrease the likelihood of infection. ‐ Many doudenal ulcers are caused by the Helicobacter pylori organism. ‐ Antibiotics are used in an attempt to sterilize the stomach. ‐ Many people have Clostridium difficile, which can lead to ulcer formation. | The core issue of the question is knowledge of etiology of peptic ulcers, including duodenal ulcers. Use nursing knowledge and the process of elimination to make a selection. |
1284 The nurse should evaluate results of which of the Correct answer: 1 Many clotting factors are produced in the liver, including fibrinogen (factor I), prothrombin following laboratory tests for a client who has cirrhosis (factor II), factor V, serum prothrombin conversion accelerator (factor VII), factor IX, and factor in order to plan for safe care? X. The client’s ability to form these factors may be impaired with cirrhosis, putting the client at risk for bleeding. The prothrombin time will evaluate blood clotting ability; the others will not. | The critical word in the question is safe. With this in mind, the correct answer is one that could detect a complication of cirrhosis. Use nursing knowledge and the process of elimination to make a selection. |
‐ Prothrombin time ‐ Urinalysis ‐ Serum lipase ‐ Serum troponin | |
1285 The nurse is caring for a client with a history of Correct answer: 3 Manifestations of chronic pancreatitis include nausea, vomiting, weight loss, flatulence, alcoholism. Which of the following findings would constipation, and steatorrhea (fatty stools) that result from a decrease in pancreatic enzyme indicate that the client has possibly developed chronic secretion. Weight gain (option 1) is the opposite of what occurs with this disorder, while pancreatitis? options 2 and 4 are unrelated. ‐ Steady weight gain ‐ Flank pain on left side only ‐ Fatty stools ‐ Excessive hunger | The core issue of the question is the ability to identify assessment findings that are consistent with the development of chronic pancreatitis. Use nursing knowledge and the process of elimination to make a selection. |
1286 The nurse caring for a client with hemolytic jaundice Correct answer: 1 Hemolytic jaundice is caused by excessive breakdown of red blood cells, and the amount of anticipates which of the following findings on the bilirubin produced exceeds the ability of the liver to conjugate it, so there is an increase in laboratory results? indirect bilirubin. Unconjugated bilirubin is insoluble in water and is not found in the urine. ‐ Elevated serum indirect bilirubin ‐ Decreased serum protein ‐ Elevated urine bilirubin ‐ Decreased urine pH | The core issue of the question is knowledge of clinical indicators of hemolytic jaundice. Use nursing knowledge and the process of elimination to make a selection. |
1287 A client was admitted to the hospital with Correct answer: 4 Nausea and RUQ pain occur in cystic duct disease, but obstruction of the common bile duct cholelithiasis the previous day. Which of the following results in reflux of bile into the liver, which produces jaundice. Alkaline phosphatase increases new assessment findings indicates to the nurse that with biliary obstruction but cholesterol level does not increase. the stone has probably obstructed the common bile duct? ‐ Nausea ‐ Elevated cholesterol level ‐ Right upper quadrant (RUQ) pain ‐ Jaundice | The core issue of the question is knowledge of clinical indicators of common bile duct obstruction. Think about the pathophysiology of blocked bile drainage and use the process of elimination to make a selection. |
1288 The nurse caring for a client with uncomplicated Correct answer: 2 Obstructive biliary disease causes a significant elevation in alkaline phosphatase. Obstruction cholelithiasis anticipates that the client’s laboratory in the biliary tract causes an elevation in direct bilirubin, not indirect bilirubin (option 4). test results will show an elevation in which of the Options 1 and 3 are unrelated. following? ‐ Serum amylase ‐ Alkaline phosphatase ‐ Mean corpuscular hemoglobin concentration (MCHC) ‐ Indirect bilirubin | Use nursing knowledge and the process of elimination to make a selection. |
1289 In caring for the client 4 days post‐cholecystectomy, Correct answer: 3 The T‐tube may drain 500 mL in the first 24 hours and decreases steadily thereafter. If there is the nurse notices that the drainage from the T‐tube is excessive drainage, the nurse should further assess the drainage to be able to describe it 600 mL in 24 hours. Which is the appropriate action by accurately and notify the physician immediately. Option 1 would be contraindicated; options 2 the nurse? and 4 are of no help. ‐ Clamp the tube q 2 hours for 30 minutes ‐ Place the patient in a supine position ‐ Assess drainage characteristics and notify the physician ‐ Encourage an increased fluid intake | The core issue of the question is knowledge of appropriate nursing action following notation of excessive T‐tube drainage. Use nursing knowledge and the process of elimination to make a selection. |
1290 The post‐cholecystectomy client asks the nurse when Correct answer: 1 When T‐tube drainage subsides and stools return to a normal brown color, the tube can be the T‐tube will be removed. Which of the following clamped 1 to 2 hours before and after meals in preparation for tube removal. If the client responses by the nurse would be appropriate? tolerates clamping, the tube will then be removed. ‐ “When your stool returns to a normal brown color, the tube can be removed.” ‐ “The tube will be removed at the same time as your staples.” ‐ “When the tube stops draining, it will be removed.” ‐ “The tube is usually removed the day after surgery.” | The core issue of the question is the appropriate timeframe for use of a T‐tube following gallbladder surgery. Use nursing knowledge and the process of elimination to make a selection. |
1291 Which of the following assessments made by the Correct answer: 1 Obstruction to portal blood flow causes a rise in portal venous pressure resulting in nurse could indicate the development of portal splenomegaly, ascites, and dilation of collateral venous channels predominantly in the hypertension in a client with cirrhosis? paraumbilical and hemorrhoidal veins, the cardia of the stomach, and extending into the esophagus. Bleeding gums would indicate insufficient Vitamin K production in the liver. Muscle wasting commonly accompanies the poor nutritional intake commonly seen in clients with cirrhosis. Hypothermia is an unrelated finding. ‐ Hemorrhoids ‐ Bleeding gums ‐ Muscle wasting ‐ Hypothermia | The core issue of the question is knowledge of associated findings in a client with portal hypertension. Use knowledge of the pathophysiology of the condition and the process of elimination to make a selection. |
1292 The nurse is caring for a client who has ascites, and Correct answer: 3 Spironolactone (Aldactone) is used in clients with ascites that show no improvement with the health care provider prescribes spironolactone bedrest and fluid restriction. It inhibits sodium reabsorption in the distal tubule and promotes (Aldactone). The client asks why this drug is being potassium retention by inhibiting aldosterone. The other options do not address this rationale. used. Which is the best response by the nurse? ‐ “This drug will help increase the level of protein in your blood.” ‐ “The drug will cause an increase in the amount of the hormone aldosterone your body produces.” ‐ “This medication is a diuretic but does not make the kidneys excrete potassium.” ‐ “This will help you excrete larger amounts of ammonia.” | The core issue of the question is knowledge of medication effects in a client with ascites. Use nursing knowledge related to pharmacology and the process of elimination to make a selection. |
1293 When caring for a client who has cirrhosis, the nurse Correct answer: 4 Asterixis, also called liver flap, is the flapping tremor of the hands when the arms are notices flapping tremors of the wrist and fingers. How extended. Option 1 reflects hypocalcemia. Option 2 refers to spiderlike abdominal veins that should the nurse chart this finding? are also commonly found in clients with cirrhosis who have portal hypertension as a complication. Option 3 is a specific odor noted in liver failure. ‐ “Trousseau’s sign noted.” ‐ “Caput medusa noted.” ‐ “Fetor hepaticus noted.” ‐ “Asterixis noted.” | The core issue of the question is knowledge of typical assessment findings in a client with cirrhosis. Use nursing knowledge and the process of elimination to make a selection. |
1294 A mother arrives at the pediatric clinic with her 6‐ Correct answer: 3 It is a common finding that when the infant with an umbilical hernia cries, the hernia month‐old infant. While the nurse is assessing the protrudes. It is not going to rupture. The family is instructed not to apply tape, straps, or coins child, the mother points to the umbilicus and says: to the umbilicus to reduce the hernia. “What am I going to do about this? When he cries, it looks like it’s going to burst.” Which of the following is the best response by the nurse? ‐ “It’s best if you let him cry. Just let him do what he wants.” ‐ “It probably won’t rupture unless he gets excessively upset. I wouldn’t worry about it at this time.” ‐ “I know it looks frightening, but it really won’t burst.” ‐ “Put a binder around it, and that will keep it from bursting when he gets mad.” | The core issue of the question is knowledge of the consequences of umbilical hernia and knowledge of therapeutic communication techniques. Use this knowledge and the process of elimination to make a selection. |
1295 A 9‐year‐old male client with severe esophagitis is 12 Correct answer: 3 Pain management is a high priority following gastric surgery, and the nurse should use age‐ hours status/post‐Nissen fundoplication for appropriate tools to assess for pain, such as the Wong FACES rating scale. A gastrostomy tube gastroesophageal reflux. To implement appropriate or nasogastric tube placed during surgery is kept in place to maintain gastric decompression. nursing care, the nurse should do which of the The child is kept NPO until bowel function returns. The use of a pH probe to measure gastric following? acidity is not necessary. ‐ Encourage him to take small amounts of clear liquids every 4 hours. ‐ Administer NG or gastrostomy feedings every 4 hours. ‐ Ask him to choose a face on the Wong FACES pain rating scale. ‐ Insert a pH probe to monitor esophageal acidity. | The core issue of the question is knowledge of appropriate interventions in the first 24 hours following gastric surgery. Use knowledge that the gastric tube should not be manipulated or used for feeding to eliminate some options. Use nursing knowledge of routine postoperative care and the process of elimination to make a final selection. |
1296 A 10‐month‐old female infant with biliary atresia is Correct answer: 4 Kasai procedure is palliative, and prognosis is best if performed before 10 weeks of age. Its being discharged after a Kasai procedure. Which purpose is to achieve biliary drainage and avoid liver failure. A liver transplant is required in 80 statement, if made by the parents, indicates that to 90% of cases. teaching with regard to prognosis has been understood? ‐ “We are glad this problem was found so early; now everything will be fine.” ‐ “We will stop her liver medicine now that she is being discharged.” ‐ “We are happy to be able to stop that special formula and many of those vitamins.” ‐ “We know that even though surgery is over, she will likely need a liver transplant.” | The core issue of the question is knowledge of the typical success of surgery with Kasai procedure in an infant with biliary atresia. Use nursing knowledge and the process of elimination to make a selection. |
1297 Which of the following diagnostic assessment Correct answer: 1 Measuring urine specific gravity provides data about the concentration of urine and provides methods would the nurse expect to be ordered for a information regarding hydration. Urine specific gravity is elevated in dehydration and would be child with dehydration as a result of vomiting and decreased with high fluid intake. The other tests listed are not indicated in the care of the diarrhea? dehydrated client. ‐ Serum sodium and serum osmolality ‐ Stool for ova and parasites ‐ Upper‐gastrointestinal series ‐ Seventy‐two‐hour fecal fat collection | The core issue of the question is dehydration and thus the correct option is one that addresses fluid balance in the body in some way. Use nursing knowledge and the process of elimination to make a selection. |
1298 The nurse is caring for a child with a history of severe Correct answer: 3 In severe diarrhea, excess bicarbonate (base) is lost, which predisposes to metabolic acidosis. diarrhea. Which of the following notations in the There is also carbohydrate malabsorption and depletion of glycogen stores, resulting in fat medical record about acid‐base imbalance would the metabolism. Ketoacids are the by‐products of fat metabolism, which adds to the metabolic nurse expect to find? acidosis. It is not a respiratory problem. ‐ Respiratory acidosis ‐ Respiratory alkalosis ‐ Metabolic acidosis ‐ Metabolic alkalosis | The core issue of the question is the ability to correlate acid‐base imbalance with a diagnosis of diarrhea. Recall that bicarbonate is a base and that the respiratory system is not directly involved to make a selection. |
1299 A nurse who floats to the infant and toddlers nursing Correct answer: 2 ESSR is the abbreviation for the four key steps in feeding the infant or child with cleft lip or unit asks the pediatric nurse about the notation “ESSR” palate. These steps are to Enlarge nipple; Stimulate suck reflex; Swallow fluid; Rest after each on the care plan of a client. The nurse explains that swallow. It does not refer to treatment of gastroesophageal reflux, pyloric stenosis, or this documentation refers to Hirschsprung’s disease. ‐ the feeding method for children with gastroesophageal reflux. ‐ the feeding method for children with cleft lip or palate. ‐ the procedure for repair of pyloric stenosis. ‐ the procedure for repair of Hirschsprung’s disease. | The core issue of the question is knowledge of a feeding technique in cleft lip or palate that reduces the risk of aspiration. Use nursing knowledge and the process of elimination to make a selection. |
1300 A child with Hirschsprung’s disease is being Correct answer: 3 It is important that any signs of infection be reported at once. After Soave procedure, the discharged after Soave endorectal pull‐through colostomy is usually closed and normal bowel function is expected (options 1 and 4). No rectal procedure for colostomy closure. Which of the irrigations are necessary (option 2). following items should the nurse include in the discharge teaching plan? | The core issue of the question is knowledge of routine discharge teaching following an abdominal surgical procedure. Use nursing knowledge and the process of elimination to make a selection. |
‐ Stools may be infrequent and uncomfortable for the first few weeks. ‐ It will be necessary to perform weekly rectal irrigations for approximately 6 weeks. ‐ Report fever, increasing pain or discomfort, or redness of the incision to the surgeon. ‐ Stools will be fatty for a week or so and then gradually return to normal. | |
1301 The nurse is taking a history from the mother of a Correct answer: 1 Acute episodes of celiac disease are characterized by bulky, frothy stools, anorexia, and child being admitted with flare‐up of celiac disease. irritability. Pain does not occur in waves prior to mealtimes. What piece of information would the nurse expect the mother to report? ‐ Stools that are fatty ‐ An increased appetite with no weight gain ‐ Episodes of abdominal pain that are wavelike just before meals ‐ Soft, formed stools | The core issue of the question is knowledge of assessment findings in a client with celiac disease. Use nursing knowledge and the process of elimination to make a selection. |
1302 The mother of a child undergoing an emergency Correct answer: 2 Parents often react to a child’s illness with feelings of guilt for not recognizing the severity of appendectomy tells the nurse, “If I had brought him in the condition sooner. A response that provides emotional support and reduces parental yesterday when he complained of an upset stomach, anxiety encourages parents to feel confident in their abilities as caregiver. The other responses this wouldn’t have happened.” Which of the following ignore the parent’s feelings (option 1) or add to the parent’s guilt or stress (options 3 and 4). is the best response by the nurse? ‐ “It’s okay; you got him here just in time before it ruptured.” ‐ “It is often difficult to predict when a simple complaint will become more serious.” ‐ “Next time he seems sick, you should bring him in immediately.” ‐ “Sometimes parents can make a mistake without meaning to do so.” | The core issue of the question is the ability to formulate a therapeutic response to a parent who indicates distress about not seeking help earlier for an ill child. Use nursing knowledge of therapeutic communication skills and the process of elimination to make a selection. |
1303 The nurse is teaching home feeding guidelines to the Correct answer: 3 Finger foods are helpful in encouraging children with failure to thrive to increase food intake. mother of a child with nonorganic failure to thrive. The parent should also be taught to encourage increased food intake and to make mealtimes Essential information for the nurse to include would be regular, nonstressful, but structured family events. the importance of ‐ restricting eating except at mealtimes. ‐ allowing the child to eat alone to minimize distraction. ‐ allowing the child to snack on finger foods, such as Cheerios, french fries, and bananas. ‐ a relaxed mealtime with few limits on behavior. | The core issue of the question is the intervention that will help to increase food intake in a child with nonorganic failure to thrive. Use nursing knowledge and the process of elimination to make a selection. |
1304 The nurse is admitting a child with a diagnosis of “rule Correct answer: 1, 2, 4 Manifestations of appendicitis often include generalized abdominal pain progressively out appendicitis.” The nurse assesses this client for worsening and localizing in the right lower quadrant at McBurney’s point, nausea and which of the following manifestations? Select all that vomiting, fever, chills, anorexia, diarrhea or acute constipation, and elevated WBC count: apply. 15,000 to 20,000 cells/mm<sup>3</sup>. Fatty stools and indigestion are not part of the clinical picture. ‐ Generalized abdominal pain ‐ Pain localizing in right lower quadrant ‐ Fatty stools ‐ Elevated white blood cell count ‐ Indigestion | The core issue of the question is knowledge of manifestations that are consistent with appendicitis. Use knowledge that the affected area is the large intestine to eliminate indigestion (stomach area, too vague) and fatty stools (small intestine absorption problem). |
1305 Whenever the parents of a 10‐month‐old leave their Correct answer: 2 Infants and toddlers between the ages of 6 months and 30 months experience separation hospitalized child for short periods, the child begins to anxiety. There are three stages of separation anxiety. The child who demonstrates crying and cry and scream. The nurse explains that this behavior rejecting anyone other than the parent is in protest, the first stage of separation anxiety. This demonstrates that the child: behavior does not exhibit spoiling or any indication of discomfort. The second stage is depair. The child expresses hopelessness, appears quiet, and is withdrawn. The third stage is detachment. The child becomes interested in the environment, especially the cregivers. If the parents return, the child ignores them. ‐ Needs to remain with the parents at all times. ‐ Is experiencing separation anxiety. ‐ Is experiencing discomfort. ‐ Is extremely spoiled. | Core concepts are the age of the child and recent hospitalization. Knowledge of coping mechanisms of infants and separation anxiety reaction are needed to answer the question correctly. |
1306 A 9‐year‐old with severe esophagitis is 12 hours Correct answer: 3 A gastrostomy tube or nasogastric tube placed during surgery is kept in place to maintain status/post‐Nissen fundoplication for gastric decompression. The child is kept NPO until bowel function returns. Appropriate pain gastroesophageal reflux (GER). To implement management is an ethical nursing obligation; a pain rating scale recognizes the child's right to appropriate nursing care, the nurse should do which of be in control. the following? ‐ Encourage him to take small amounts of clear liquids every four hours ‐ Administer NG or gastrostomy feedings every four hours ‐ Ask him to rank his pain on a scale of zero to 10 when zero is no pain and 10 is the worst possible pain ‐ Insert a pH probe to monitor esophageal acidity | Options 1 and 2 focus on feeding. Recall that feedings cannot be restarted until bowel sounds have returned. |
1307 A mother asks the pediatric nurse about what she Correct answer: 2 Introduction of solid food is recommended at age 4 to 6 months, when the gastrointestinal should begin to feed her 6‐month‐old infant. The system has matured sufficiently to handle complex nutrients. The suck reflex and tongue‐ correct response is: thrust reflex diminish at 4 months of age. Rice cereal is the first solid food because it is a rich source of iron and rarely induces allergenci reactions. Fruits and vegetables, good sources of vitamins and fiber, are introduced after cereal, one at a time to determine allergic reactions. Egg whites are highly allergenic. ‐ Egg whites are the least allergenic food to be introduced to the baby's diet. ‐ Rice cereal is the first solid introduced that is least allergenic of the cereals. ‐ Formula is the only source of nutrition given for the first year. ‐ Fruits and vegetables are good sources of iron. | Critical words are "begin to feed" and "6‐month‐old." Knowledge of introduction of solid food is necessary to choose the correct answer. |
1308 A child has been admitted to the hospital with Correct answer: 1, 5 Urine specific gravity is a measurement of the concentration of urine and provides dehydration. Which of the following measures would information regarding hydration. Urine specific gravity is elevated in dehydration. Careful the nurse expect to be included in the plan of care? measurement of intake and output, level of consciousness, skin turgor and mucous membrane Select all that apply. moisture will also indicate the child’s status. Sending a stool for ova and parasites evaluation could be indicated if this was suspected as a cause of diarrhea, but the stem of the question does not state that the child has diarrhea. Upper GI series and stool evaluation for fecal fat would help to diagnose GI disorders. ‐ Urine specific gravity ‐ Stool ova and parasites ‐ Upper‐gastrointestinal (GI) series ‐ 72‐hour fecal fat collection ‐ Intake and output | One of the options is a test that a nurse will not perform so that one can be eliminated. Only one of the lab tests will give any information about the hydration status of the child. |
1309 The nurse is caring for a child with a history of severe Correct answer: 3 In severe diarrhea, excess bicarbonate is lost. There is also carbohydrate malabsorption and diarrhea. Which of the following acid‐base depletion of glycogen stores, resulting in fat metabolism. Ketoacids are the byproducts of fat abnormalities would the nurse assess for as a possible metabolism. For both of these reasons, the client can develop acidosis. The nature of the consequence of the diarrhea? problem is metabolic rather than respiratory. | Recall that loss of bicarbonate would cause acidosis and the condition is metabolic in origin rather than a respiratory problem. |
‐ Respiratory acidosis ‐ Respiratory alkalosis ‐ Metabolic acidosis ‐ Metabolic alkalosis | |
1310 The nurse is reviewing nursing notes and sees a Correct answer: 2 ESSR feeding technique for cleft lip or palate: Enlarge nipple; Stimulate suck reflex; Swallow notation of "ESSR" in the medical record of a child with fluid; Rest after each swallow. It has nothing to do with a suture maintenance tool, the surgical a cleft lip and palate. The nurse interprets that the procedure, or a method of positioning the infant. notation of "ESSR" is referring to: ‐ The suture maintenance tool. ‐ The feeding method. ‐ The procedure for repair. ‐ The positioning of the infant. | Knowledge of the clinical therapy for cleft lip and palate will aid in choosing the correct answer. Recall that feeding is a major concern for the child with cleft lip and palate. |
1311 A child with Hirschsprung disease is being discharged Correct answer: 3 It is important that any signs of infection be reported at once. After Soave procedure, the after Soave endorectal pull‐through procedure for colostomy is usually closed and normal bowel function is expected. colostomy closure. Which of these measures should the nurse include in the home care plan? ‐ Refer the parents to an enterostomal therapist for ostomy care ‐ Teach parents how to perform weekly rectal irrigations ‐ Teach parents signs and symptoms of infection ‐ Teach parents PCA pain‐control methods | Remember that the stem states for colostomy closure, even if the medical name of the procedure is not recalled. This should help to eliminate most of the options. |
1312 A child is brought to the Emergency Department with Correct answer: 1 Corrosive agents cause the signs and symptoms listed. Indications of aspirin overdose are excessive drooling, edema of lips and tongue, swollen nausea, vomiting, diaphoresis, and seizures. Hydrocarobons cause nausea, vomiting, cyanosis, mucous membranes, and is hypotensive and and altered sensorium, and acetaminophen casues nausea, vomiting, diaphoresis, and later, tachycardiac. Based on this initial assessment, the jaundice. nurse suspects that the child has ingested which of the following agents? ‐ Corrosive agent ‐ Aspirin ‐ Hydrocarbons ‐ Acetaminophen | Aspirin and acetaminophen can easily be eliminated as they would not cause the swelling of the mouth. It is then necessary to choose between the hydrocarbons and corrosive agent. |
1313 The mother of a child undergoing an emergency Correct answer: 2 Parents often react to a child's illness with feelings of guilt for not recognizing the severity of appendectomy tells the nurse "If I had brought him in the condition sooner. Emotional support and reduction of parental anxiety encourages parents yesterday when he complained of an upset stomach, to feel confident in their abilities as caregiver. this wouldn't have happened." The nurse's best response is: ‐ "It's okay; you got him here just in time before it ruptured." ‐ "It is often difficult to predict when a simple complaint will become more serious." ‐ "Next time he seems sick, you should bring him in immediately." ‐ "Sometimes parents can make a mistake without meaning to do so." | Consider which response will reduce parental feelings of guilt. |
1314 A child has been diagnosed with non‐organic failure Correct answer: 1, 4, 5 Non‐organic failure to thrive is not due to metabolic or organic problems or the absence of to thrive. In addition to poor weight gain, the nurse food availability. Children with this form of malnutrition often display other non‐specific would expect the child to exhibit which of the symptoms related to the emotional illness. following? Select all that apply. ‐ Erratic sleep patterns | Option 2 can be eliminated as it is not associated with non‐organic failure to thrive. All other responses are correct. |
‐ Diarrhea ‐ Developmental delays ‐ Irritability and being difficult to soothe ‐ Food refusal | |
1315 A child who underwent cleft palate repair has just Correct answer: 3 Elbow restraints are used to keep hands away from the mouth after cleft palate surgery. This returned from surgery with elbow restraints in place. precaution will be maintained at home until the palate is healed, usually 4 to 6 weeks. They are The parents question why their child must have the not used to protect the IV site, maintain NPO status, or maintain body alignment. restraints. The nurse would give which of the following as the best explanation to the parents? ‐ “This device is frequently used postoperatively to protect the IV site in small children.” ‐ “The restraints will help us maintain proper body alignment.” ‐ “Elbow restraints are used postoperatively to keep children’s hands away from the surgical site.” ‐ “The restraints help maintain the child’s NPO status.” | Consider what movements elbow restraints will allow the child to determine the right answer. |
1316 The nurse is caring for an infant vomiting secondary Correct answer: 2 In pyloric stenosis, bile is unable to enter the stomach from the duodenum because the to pyloric stenosis. The mother questions why the pylorus muscle is hypertrophied, which causes the obstruction. vomitus of this child appears different from that of her other children when they have the flu. The nurse would explain that the emesis of an infant with pyloric stenosis does not contain bile because: ‐ The GI system is still immature in newborns and infants. ‐ The obstruction is above the bile duct. ‐ The emesis is from passive regurgitation. ‐ The bile duct is obstructed. | Consider the site of the pylorus to determine the correct answer. |
1317 The nurse is teaching the parents of a child with celiac Correct answer: 2, 3, 4 Most children who remain on a gluten‐free diet remain healthy and free of symptoms and disease about the dietary restrictions. The nurse would complications. Gluten is a protein found in wheat, barley, rye, and oats. For this reason, explain that the most appropriate diet for their child is appropriate foods need to be free of these grains. a diet that is free of which of the following? (Select all that apply.) ‐ Rice ‐ Wheat ‐ Oats ‐ Barley ‐ Corn | Children with celiac disease can eat corn and rice. All other grains need to be eliminated from the diet. |
1318 A high school experiences an outbreak of hepatitis B. Correct answer: 4 HBV vaccine provides active immunity, and current recommendations include immunizations In teaching the high school students about hepatitis B, for all newborns, as well as for several high‐risk groups. Hepatitis B is spread by blood and the school nurse would explain: body fluids, including sexual contact, not the fecal‐oral route. The disease can exist in a carrier state. ‐ Hepatitis B cannot exist in a carrier state. ‐ Hepatitis B is primarily transmitted through the fecal‐oral route. ‐ Immunity to all types of hepatitis will occur after this current attack. ‐ Hepatitis B can be prevented by receiving the HBV vaccine. | The student must know which forms of hepatitis are blood‐borne and which are not. The only form of hepatitis for which there is a vaccine is HBV. |
1319 A 4‐month‐old infant is admitted to the nursing unit Correct answer: 1, 2, 5 The nurse would expect an increased desire to drink fluids and a higher specific gravity caused with moderate dehydration. Which of the following by the concentration of urine. The heart rate would be elevated, and the fontanels sunken. The symptoms does the nurse suspect led to the diagnosis degree of dehydration is based on the percent of weight loss, so a weight gain would not be of moderate dehydration in this child? (Select all that likely. Diminished urine output with elevated specific gravity is an expected normal finding in apply.) dehydration. Capillary refill is slowed, especially in children under 2 years of age. ‐ Elevated heart rate ‐ Urine specific gravity of 1.038 ‐ Weight gain ‐ Polyuria ‐ Slow capillary refill | Two of the options are age related and appropriate for the infant. Polyuria and weight gain would not be symptoms of dehydration. |
1320 While performing a newborn assessment, the nurse Correct answer: 1 Clinical findings will vary in infants born with congenital diaphragmatic hernias, but the first notes the infant is having difficulty breathing, with indications are of respiratory distress. Further assessment will reveal bowel sounds nasal flaring, cyanosis, retractions, and an absence of auscultated over the chest, cardiac sounds on the right of the chest, and a sunken abdomen breath sounds on the left side. The nurse auscultates with a barrel‐shaped chest. the apical pulse on the right side of the chest. The nurse notifies the physician immediately because of suspected: ‐ Diaphragmatic hernia. ‐ Pyloric stenosis. ‐ Cleft palate. ‐ Omphalocele. | Note that all findings indicate the absence of normal findings on the left side of the chest. |
1321 The nurse has taught dietary restrictions to a 7‐year‐ Correct answer: 4 Celiac disease is characterized by intolerance for gluten. Gluten is found in wheat, barley, rye, old child who has celiac disease. After teaching, the and oats. This includes bread, cake, doughnuts, cookies, and crackers, as well as processed child is allowed to choose a meal from the hospital foods that contain gluten as filler. menu. The nurse evaluates that teaching was effective when the child chooses which of the following? ‐ Beef and barley soup, rice cakes, and celery ‐ Ham and cheese sandwich with lettuce and tomato on rye toast ‐ Beef patty on a hamburger bun and home fries ‐ Baked chicken, green beans, and a slice of cornbread | Determine which menu does not contain any rye, wheat, barley, or oats. Alternatively, select the menu that contains one or more items that are rice or corn. |
1322 An infant returns from initial surgery for Correct answer: 2 The corrective surgery for Hirschsprung’s disease requires pulling the end of the normal Hirschsprung’s disease. All of the following are routine bowel through the muscular sleeve of the rectum. With this type of procedure, rectal postoperative nursing interventions. Because of the temperatures and any invasive procedure would be avoided to allow proper healing to occur. type of surgery this child had, the nurse would exclude which of them? ‐ Maintaining the child NPO until bowel sounds return ‐ Monitoring rectal temperature every 4 hours ‐ Reuniting the parents with the child as soon as possible ‐ Assessing the surgical site every 2 hours | The critical word in the question is “exclude.” With this in mind, choose the option that represents an incorrect or unacceptable nursing action. |
1323 A 3‐month‐old infant has gastroesophageal reflux Correct answer: 2 Infants with GER should be given small, frequent feedings. After a feeding the infant should be (GER) but is thriving without other complications. The placed in a prone position with the head of the bed elevated. A harness can be used to help mother wants to know what she can do differently to maintain this position. Infant seats should be avoided because of the increased intraabdominal decrease the reflux. Which intervention should the pressure this position creates. nurse suggest to minimize reflux? ‐ Discontinue breast‐feeding immediately. | Consider which intervention decreases pressure on the abdomen. |
‐ Increase frequency of feedings and keep them small. ‐ Place the baby in prone position with the head flat. ‐ Place the infant in a car seat after feeding. | |
1324 A 10‐year‐old boy has been admitted with a diagnosis Correct answer: 3 Signs and symptoms of a ruptured appendix include fever, sudden relief from abdominal pain, of “rule out appendicitis.” While the nurse is guarding, abdominal distention, rapid shallow breathing, pallor, chills, and irritability. conducting a routine assessment, the boy states, “It doesn’t hurt anymore.” The nurse suspects that: ‐ The boy is afraid of going to surgery. ‐ The boy is having difficulty expressing his pain adequately. ‐ The appendix has ruptured. ‐ This is a method the boy uses to receive attention. | Read the question carefully and eliminate each of the incorrect options because there is no data in the stem of the question to support them. As an alternative, recall pain pattern in appendicitis before and after rupture to choose accurately. |
1325 An 18‐month‐old child with a history of cleft lip and Correct answer: 3 During the immediate postoperative period, protecting the operative site is a priority in the palate has been admitted for palate surgery. The nurse nursing care of this child. A toothbrush should be a familiar object to an 18‐month‐old child. would provide which explanation about why a Deciduous (primary) teeth are still present at this age and are replaced by permanent toothbrush should not be used immediately after (secondary) teeth around 6 years of age. Oral care will be performed according to the surgery? physicians’ orders but usually consists of cleansing the area with sterile water. ‐ The toothbrush would be frightening to the child. ‐ The child no longer has deciduous teeth. ‐ The suture line could be interrupted. ‐ The child will be NPO. | The core concepts for this question are cleft palate surgery and postoperative care. Since the stem states why use of toothbrush care is avoided, the learner must connect this to postoperative care. |
1326 The nurse instructs the parents about postoperative Correct answer: 3 The goal after pyloromyotomy is to slowly increase the volume of feeding while preventing feeding following their infant’s pyloromyotomy. The vomiting. Bubbling is essential after feed. Rocking is avoided as this might increase vomiting. nurse evaluates that the parents understand the Antiemetics are not helpful as the vomiting is not associated with nausea. instructions when the parents state they will: ‐ Avoid bubbling the baby after feeding to prevent vomiting. ‐ Rock the baby to sleep after feeding to keep the infant calm. ‐ Slowly increase the volume offered according to the physician’s orders. ‐ Maintain the infant on antiemetics to prevent vomiting. | Recognize the problem with pyloric stenosis is not related to vomiting but due to a tight pyloric muscle that will be incised. |
1327 Immediately after the delivery of an infant with an Correct answer: 4 Omphaloceles are congenital malformations in which abdominal contents protrude through omphalocele, the nurse would take which of the the umbilical cord. The protrusion is covered by a translucent sac; immediately after birth, the following actions? sac requires priority attention. The sac is covered with sterile gauze soaked in normal saline solution to prevent drying and injury. ‐ Weigh the infant ‐ Insert an orogastric tube ‐ Call the blood bank for 2 units of blood ‐ Cover the sac with moistened sterile gauze | The stem of the question is seeking the first action of the nurse. Ordering blood is not a nursing function. The nurse would not insert an orogastric tube without a medical order. Therefore, choose the most important action between the other two options. |
1328 While gathering admission data on a 16‐month‐old Correct answer: 1, 3, 5 Infants with Hirschsprung’s disease usually display failure to thrive, poor weight gain, and child, the nurse notes all the following abnormal delayed growth. Vomiting is usually bile stained. The child will demonstrate alternating findings. Which finding is related to a diagnosis of constipation and diarrhea, but the stools are not bloody. Decreased urine output and Hirschsprung’s disease? (Select all that apply.) intermittent sharp pain are nonspecific symptoms that can be associated with many different diseases and disorders. ‐ Bile‐stained vomitus ‐ Decreased urine output ‐ Poor weight gain since birth | Consider symptoms of Hirschsprung’s disease without looking at the options. Then review the options to determine which options match those symptoms. |
‐ Intermittent sharp pain ‐ Alternating constipation and diarrhea | |
1329 A 6‐week‐old infant is brought into the pediatrician’s Correct answer: 4 Small, frequent feedings followed by placing the infant at a 30‐ to 45‐degree angle has been office with a history of frequent vomiting after shown to be beneficial in treating gastroesophageal reflux. Diluting the formula would not be feedings and failure to gain weight. The diagnosis of recommended because the infant needs the calories from the full‐strength formula. It may be gastroesophageal reflux is made and discharge recommended to thicken the formula with rice cereal. It is recommended to burp frequently; instructions are begun. While planning discharge to delay burping would only increase the occurrences of reflux. Gastroesophageal reflux is not teaching on feeding techniques with the parents, the related to milk intolerance so changing the formula would not help the child. nurse should include instructions to: ‐ Dilute the formula. ‐ Delay burping to prevent vomiting. ‐ Change from milk‐based formula to soy‐based formula. ‐ Position the infant at a 30‐ to 45‐degree angle after feedings. | Knowledge of the care of the infant with gastroesophageal reflux will aid in choosing the correct answer. Consider which activities will decrease vomiting. |
1330 A 14‐year‐old boy is brought into the Emergency Correct answer: 2 An ice bag may help relieve his pain. A rectal tube is contraindicated because it stimulates Department with a diagnosis of rule out appendicitis. bowel motility, which would increase the pain. A heating pad is contraindicated because it He is complaining of right lower quadrant pain. The increases the flow of blood to the appendix and may lead to rupture. An antispasmodic agent nurse’s most appropriate action to assist in managing would not be beneficial for the pain associated with appendicitis. Antispasmodic agents are his pain would be to: typically used to inhibit smooth muscle contractions. ‐ Insert a rectal tube. ‐ Apply an ice bag. ‐ Apply a heating pad. ‐ Administer an intravenous antispasmodic agent. | Knowledge of the care of the child with appendicitis will aid in choosing the correct answer. One choice is apply an ice bag, another choice is a heating pad. These are opposites, so there is an increased likelihood that one is right and the other is wrong. |
1331 The nurse has completed discharge teaching on the Correct answer: 1 Discharge planning focuses on educating the parents in maintaining a gluten‐free diet for the dietary regimen of a child with celiac disease. The child. Dietary modifications are lifelong and should not be discontinued when the child is nurse recognizes that client education has been symptom‐free. Symptoms will return if dietary restrictions are not maintained. successful when the mother states that the child must comply with the gluten‐free diet: ‐ Throughout life. ‐ Until the child has achieved all major developmental milestones. ‐ Only until all symptoms are resolved. ‐ Until the child has reached adolescence. | Because celiac disease is a type of intolerance, the child will not outgrow the intolerance and must continue the diet throughout life. |
1332 An appropriate nursing assessment of an infant Correct answer: 4 Measuring the abdominal girth frequently aids in early detection of necrotizing enterocolitis, suspected of having necrotizing enterocolitis would be: which, in turn, minimizes loss of bowel. Assessment of gastric pH is not done. Frequent assessment of the neurologic status is not specific to this disease. Rectal temperatures are contraindicated because of the increased risk of perforation. ‐ pH of the stomach contents. ‐ Neurological status every 2 hours. ‐ Rectal temperature every 2 hours. ‐ Abdominal girth every 4 hours. | Because the disease is a gastrointestinal disease, locate symptoms that relate to the GI system. |
1333 The nurse is developing a teaching plan for the Correct answer: 2 Hepatitis A is highly contagious and is transmitted primarily through the fecal‐oral route. The parents of an infant diagnosed with hepatitis A. Which virus is transmitted by direct person‐to‐person contact or through ingestion of contaminated of the following instructions would be included to food or water, especially shellfish growing in contaminated water. The remaining answers are reduce the risk for transmission of this disease? related to other infectious diseases. ‐ Disinfect all clothing and eating utensils on a daily basis. | Consider how the virus spreads to determine the correct answer. Options 3 and 4 can be eliminated since they include a separate host. |
‐ Tell family members to wash their hands frequently. ‐ Spray the yard to eliminate infected insects. ‐ Vacuum the carpets and upholstery to rid the house of the infectious host. | |
1334 Which of the following signs would the nurse Correct answer: 3 Mucous membranes typically appear dry when moderate dehydration is observed. Other recognize as an indication of moderate dehydration in typical findings associated with moderate dehydration include restlessness with periods of a preschooler? irritability (especially infants and young children), rapid pulse, poor skin turgor, delayed capillary refill, and decreased urine output. Both anterior and posterior fontanels are closed on a preschool‐age child. The skin is usually dry with decreased elasticity, not diaphoretic. Urine specific gravity increases with decreased urine output associated with dehydration. ‐ Sunken fontanel ‐ Diaphoresis ‐ Dry mucous membranes ‐ Decreased urine specific gravity | Option 1 is the only symptom that is age related and is not associated with a toddler. Two options are not associated with dehydration, leaving only one response as correct. |
1335 A client is being admitted to a hospital unit Correct answer: 1 Pain over McBurney's point, the point halfway between the umbilicus and the iliac crest, is complaining of severe pain in the lower abdomen and diagnostic for appendicitis. Assessment for rebound tenderness would also assist in the is lying on the bed with his knees flexed. Admission diagnosis. Options 2 and 3 are common with ulcers; option 4 may suggest ulcerative colitis or vital signs reveal an oral temperature of 101.2 degrees diverticulitis. F. Which of the following would confirm a diagnosis of appendicitis? ‐ The pain is localized at a position halfway between the umbilicus and the right iliac crest. ‐ The client describes the pain as occurring 2 hours after eating. ‐ The pain subsides after eating. ‐ The pain is in the left lower quadrant. | Look for an option describing right sided abdominal pain. |
1336 An elderly client presents with fever, leukocytosis, left Correct answer: 2 Fever indicates an infection, ruling out options 3 and 4. Appendicitis typically causes pain in lower quadrant pain, and diarrhea alternating with the umbilical area or right lower quadrant and is not usually accompanied by diarrhea. Fever constipation. The nurse concludes that these are and diarrhea accompany diverticulitis. frequently seen in clients with: ‐ Appendicitis. ‐ Diverticulitis. ‐ Peptic ulcer disease. ‐ Irritable bowel syndrome. | Select an ‘itis’ as this indicates infection. Appendix pain is right‐sided. |
1337 A client says to the nurse, "My doctor told me my Correct answer: 4 H. pylori causes release of toxins and enzymes that promote inflammation and ulceration. It is ulcer may have been caused by bacteria. I thought not spread from one person to another. Contributing factors are those that increase secretion ulcers were caused by diet and too much stress." of acid and pepsin. Which of the following responses by the nurse is the best? ‐ "If it was caused by bacteria, you would have a fever as a result of the inflammatory process." ‐ "We know that ulcers are communicable. They can be spread easily. Be careful you don't spread it to your children." ‐ "Diet and stress have nothing to do with developing an ulcer." ‐ "Even though the bacteria <i>Helicobacter pylori</i> causes inflammation, other factors may cause increased acid in the stomach." | Option 4 names the commonly associated bacteria. |
1338 In caring for a client with a hiatal hernia, which of the Correct answer: 1 Heavy lifting is one factor that leads to development of a hiatal hernia. Dietary factors involve following should be included in a teaching plan limiting fat intake or spicy foods, not restricting the client to soft foods. It is more prevalent in regarding causes? individuals who are middle‐aged or older. Fair‐skinned individuals are not prone to this condition. | Recall that heavy lifting is associated with hernia, even hiatal hernia. |
‐ To avoid heavy lifting ‐ A dietary plan based on soft foods ‐ Its prevalence in young adults ‐ Its prevalence in fair‐skinned individuals | |
1339 An elderly male client is worried about bright red Correct answer: 2 Red blood in the stool is more characteristic of left‐sided cancer of the colon. If blood occurs blood in his stool along with feeling tired and worn in the stool at all in right‐sided cancer of the colon or gastric ulcers, it will be black or tarry. out. The nurse determines that these symptoms are There is no blood in the stool of a client with gallbladder disease. Remember, bright red blood characteristic of: can also occur with hemorrhoids, but this choice was not available. ‐ Ascending (right‐sided) colon cancer. ‐ Descending (left‐sided) colon cancer. ‐ Gallbladder disease. ‐ Gastric ulcers. | Recall that the descending colon is nearer to the rectum, so the blood from this area would be bright red, or fresh. |
1340 A client states, "My doctor told me to quit taking Correct answer: 2 Aspirin is one of the nonsteroidal anti‐inflammatory drugs (NSAIDs). These drugs are aspirin since I've developed this ulcer. I have to take predisposing or contributing factors in the development of an ulcer, because of the effect on aspirin to keep my arthritis from hurting. I don't know prostaglandins. Many of the medications used for arthritis may also irritate an ulcer; therefore, what to do." Which response on the part of the nurse a physician should be consulted. is best? ‐ "Let's worry about treating your ulcer‐‐your arthritis will have to wait." ‐ "Aspirin is one of the medications that makes an ulcer worse; another medicine can be ordered by the doctor for your arthritis." ‐ "Go ahead and take the aspirin if it helps, but watch closely for bleeding." ‐ "The doctor knows what is best for you, and you should follow those instructions." | Select the response that allows the exploration of an alternative medication. |
1341 The nurse is caring for a female client during Correct answer: 4 These are all signs of perforation. If the client is going into shock, it is important to establish recuperation following development of a duodenal IV access before the veins collapse. The doctor will probably schedule emergency surgery. If a ulcer. The client suddenly experiences severe client has a possible perforation, she should be in low Fowler's position (option 1) to contain abdominal pain, increased heart rate, increased the secretions in the abdomen. Walking (option 2) is not recommended, and food allergies respiratory rate, and diaphoresis. On palpation, the (option 3) are not as likely to be the problem. abdomen is rigid; bowel sounds are faint and diminished. Which of the following nursing actions is appropriate? ‐ Immediately place her in high Fowler's position to facilitate breathing. ‐ Help her walk to the bathroom to get rid of any flatus. ‐ Check to see if she has food allergies and see if she ate anything to which she might be allergic. ‐ Establish IV access and call the doctor to report the assessment data. | Select the option which includes the reporting of a significant change in the client’s condition. |
1342 A female client complains of a burning, cramping pain Correct answer: 1 This description of pain is consistent with ulcer pain. The pain is epigastric and is worse when in the top part of the abdomen that becomes worse in the stomach is empty and is relieved by food. These symptoms are not common with the middle of the afternoon and sometimes awakens cholelithiasis. Ordinary indigestion does not present with this clinical scenario. her at night. She reports that eating something usually helps the pain go away but that the pain is now becoming more intense. Which of the following is the best conclusion for the nurse to draw? ‐ These symptoms are consistent with an ulcer. ‐ The client is probably developing cholelithiasis. ‐ The client probably has indigestion and needs to watch what she eats. ‐ A snack before bed should be recommended. | Associate pain relieved by food with ulcers. |
1343 Which of the following clients would be most at risk Correct answer: 2 One form of intestinal obstruction is paralysis, caused by decreased movement of the for an intestinal obstruction? intestinal contents by normal peristalsis. The client in option 1 is at high risk for Crohn's disease and ulcerative colitis. Option 3 enhances the risk of cancer of the colon and diverticular disease; option 4 is consistent with peritonitis. ‐ A Jewish client who smokes and consumes large amounts of caffeine ‐ An elderly client who is on bed rest because of postoperative abdominal surgery ‐ An individual eating a low‐fiber, high‐fat diet ‐ An adult diagnosed with cirrhosis of the liver | Recall that immobility is associated with impaired bowel motility. |
1344 A client is complaining of dyspepsia, frequent Correct answer: 4 Gastroesophageal reflux disease causes epigastric pain that is usually described as burning; it belching, and increased salivation. The nurse suspects is accompanied by belching with a sour taste, pain after eating, increased salivation, and which of the following? flatulence. The symptoms of a sliding hiatal hernia are similar to GERD, but not those of a rolling hernia. Symptoms of PUD are more pronounced and reflective of a full or empty stomach. Ulcerative colitis symptoms are related to pain and bowel movements. ‐ Peptic ulcer disease (PUD) ‐ Ulcerative colitis ‐ Rolling hiatal hernia ‐ Gastroesophageal reflux disease (GERD) | Frequent belching is the hint to identifying option 4 as correct. |
1345 Hepatic fat accumulation in a 55‐year‐old male is Correct answer: 4 A fatty liver is one of the main effects of alcohol consumption, known as Laennec's cirrhosis. usually a result of which type of cirrhosis? Other factors such as dietary intake of fat, body stores of fat, and hormonal status can also contribute to fatty liver. ‐ Biliary ‐ Metabolic ‐ Postnecrotic ‐ Laennec's | Recall that Laennec’s is alcohol related cirrhosis. |
1346 A concerned mother doesn't understand how her Correct answer: 2 Hepatitis A has an acute onset, and accounts for about 25 percent of hepatitis cases in the child acquired hepatitis A, when he was perfectly United States. The usual incubation period is 15 to 40 days. The disease is spread where there healthy up to a week ago. One characteristic of is fecal contamination of water supplies and from oral contamination (such as in day care). hepatitis A that may help her to understand is that hepatitis A has: ‐ An incubation period of 60 to 180 days. ‐ A fecal‐oral mode of transmission. ‐ A positive carrier state. ‐ A sexual mode of transmission. | Omit options 3 and 4 as descriptive of hepatitis B. |
1347 The physical assessment findings of spider angiomas, Correct answer: 3 Portal hypertension and liver cell failure contribute to the late manifestations of cirrhosis. palmar erythema, peripheral edema, ascites, and Cholelithiasis and cholecystitis will be accompanied by pain, food intolerances and/or change in mental status are consistent with which of vomiting. Pancreatitis presents with pain radiating to the back, mild cardiovascular changes, the following disorders? and hypocalcemia. ‐ Cholelithiasis ‐ Cholecystitis ‐ Cirrhosis ‐ Pancreatitis | Recall that change in mental status is associated with cirrhosis, but not the other options. |
1348 A 45‐year‐old female hospitalized with acute Correct answer: 3 The onset of action for meperidine is 10 to 15 minutes and the onset for morphine is 20 to 60 pancreatitis has orders for meperidine (Demerol) 50 minutes. Both drugs are equal in the potential for addiction. Demerol is less sedating than mg IM every 4 hours as needed for pain. Demerol has morphine. The most important difference is that the meperidine causes fewer spasms of the been ordered rather than morphine for this client sphincter of Oddi, which contributes to the goal of giving the pancreas a rest. because it: | Recognize that the sphincter of Oddi should be the hint, as this is the reason for morphine being contraindicated. |
‐ Has a faster onset of action than morphine. ‐ Is less addictive than morphine. ‐ Causes fewer spasms of the sphincter of Oddi. ‐ Has fewer cognitive side effects. | |
1349 A 65‐year‐old female with a history of hepatic Correct answer: 4 The client is at increased risk for a return of the encephalopathy because of the diagnosis of encephalopathy is hospitalized for pneumonia and pneumonia and dehydration. She has volume depletion and the potential for electrolyte dehydration. When she complains to the nurse about imbalance, both of which can contribute to the development of encephalopathy. Dietary the small portions of meat ordered by the dietitian, protein intake must be controlled (or eliminated) in order to minimize the ammonia levels in the best response would be: the blood stream. ‐ "Ask your doctor about it in the morning." ‐ "I will call and order larger portions for you." ‐ "The amount of meat on your tray is dictated by certain blood test results." ‐ "Your protein is being limited, but you can have more food from another group." | Select the option that gives the client an accurate explanation and an option for other foods. |
1350 The physical assessment of a 55‐year‐old female with Correct answer: 3 In the cirrhotic liver, fibrous tissue develops among the parenchymal cells preventing the end‐stage cirrhosis reveals a protuberant abdomen production of adequate plasma proteins. The consequence of low plasma proteins leads to a with bulging flanks and dullness to the dependent side decrease in colloid osmotic pressure and generalized edema. When combined with high portal while lying on the right. The appropriate terminology capillary pressures, large amounts of fluid and protein form in the abdominal cavity, which is for documentation of this assessment is: called ascites. Gravity causes the fluid to sink and gas‐filled loops of the bowel rise creating the shifting dullness and tympany during assessment. ‐ Fluid overload. ‐ Malnutrition. ‐ Ascites. ‐ Distention. | Recall that dullness on the dependent side indicated fluid or ascites. |
1351 Which of the following statements is true regarding Correct answer: 3 The cancer cells alter enzyme secretion and flow to the duodenum in addition to causing fat cancer of the pancreas? and protein malabsorption. These changes result in weight loss and nausea, which are common signs and symptoms of cancer of the pancreas regardless of location. ‐ Clients with pancreatic cancer have often had a long history of painful sitting. ‐ Clients with pancreatic cancer will describe recent onset of black tarry stools. ‐ Clients with pancreatic cancer will describe a slow onset of anorexia and weight loss. ‐ Clients with pancreatic cancer will have no symptoms to report. | Select the option that reflects a change in nutrient absorption. |
1352 When providing discharge teaching to the client with Correct answer: 1 When bile production is reduced, the body has reduced ability to absorb fat‐soluble vitamins. chronic cirrhosis, his wife asks the nurse to explain why Without adequate Vitamin K absorption, clotting factors II, VII, IX, and X are not produced in there is so much emphasis on bleeding precautions. sufficient amounts. Which of the following provides the most appropriate response? ‐ "The liver affected by cirrhosis is unable to produce clotting factors." ‐ "The low protein diet will result in reduced clotting factors." ‐ "The increased production of bile decreases clotting factors." ‐ "The required medications reduce clotting factors." | Recall that the liver plays an important role in clotting; the diseased liver cannot assist in clotting. |
1353 Which of the following statements is true regarding Correct answer: 3 The posticteric phase follows jaundice. Symptoms decrease and the serum enzymes begin to viral hepatitis infection? return to normal. Hepatitis B is transmitted by parenteral, sexual, or perinatal routes. Hepatitis A is transmitted by the fecal‐oral route. Hepatitis D has a rapid onset. ‐ Hepatitis B is transmitted by the fecal‐oral route. ‐ Hepatitis A is a sexually transmitted disease. | Recall that posticteric means after jaundice onset. |
‐ The posticteric phase follows jaundice and lasts several weeks. ‐ Hepatitis D has a slow onset. | |
1354 When explaining the rationale for the use of lactulose Correct answer: 2 Chronulac is a synthetic nonabsorbable disaccharide metabolized to organic acids by enteric (Chronulac) syrup to the client with chronic cirrhosis, bacteria and causes osmotic catharsis while reducing the growth of ammonia‐forming the nurse would use which of the following bacteria. Chronulac also lowers the pH of the colon, which converts ammonia to a statements? nonabsorbable form allowing expulsion through the laxative action of the drug. The dose required is 15 to 30 mL orally every 4 to 6 hours and may be titrated to a lower dose if diarrhea occurs. ‐ "Chronulac syrup reduces constipation, which is a frequent complaint with cirrhosis." ‐ "Chronulac syrup suppresses the metabolism of ammonia and aids in its elimination through feces." ‐ "Chronulac syrup helps to reverse cirrhosis of the liver." ‐ "Chronulac syrup can be taken intermittently to reduce side effects." | Option 2 mentions the metabolism of ammonia, which is the purpose for the use of Chronulac. |
1355 A client presents to the clinic with "bad pain" in the Correct answer: 3 Lying on the side with legs flexed, pain over McBurney's point, and rebound tenderness are middle of the abdomen, vomiting, and "not knowing characteristic symptoms of appendicitis. Vomiting frequently accompanies the pain. The client what is wrong." Palpation reveals rebound tenderness definitely should not have an enema if appendicitis is suspected. If surgery is needed for with increased pain halfway between the umbilicus appendicitis, the client needs to be NPO. and the top of the pelvis. The client seems to have less pain when lying on the left side and flexing the knees. What is the best conclusion for the nurse to draw? ‐ To make sure the client does not have an impaction, an enema should be given. ‐ Since the client is vomiting, the problem is probably gastroenteritis. ‐ The client should be checked for possible appendicitis. ‐ Since the client has been vomiting, nourishment may help. | Recall that pain described as mid‐abdominal with rebound is often related to appendicitis. |
1356 A client with Zollinger‐Ellison syndrome thinks she has Correct answer: 2 Zollinger‐Ellison syndrome is a condition usually caused by a gastrin‐secreting tumor of the a rare form of cancer. The nurse explains that this pancreas, stomach, or intestines that leads to the increased secretion of pepsin and syndrome is characterized by which of the following? hydrochloric acid. This often leads to peptic ulcer disease. Option 1 explains one of the pathologic reasons for peptic ulcer disease; Option 3 explains a volvulus obstruction, and another name for Crohn's disease is regional enteritis. ‐ A destruction of the mucus‐protecting cells of the stomach that could lead to an ulcer ‐ A condition that causes increased secretion of pepsin and hydrochloric acid ‐ A twisting of the bowel that leads to intestinal obstruction ‐ Crohn's disease, which is an inflammatory bowel disorder | Omit options 3 and 4 as they are describing other conditions. The key is the mention of hydrochloric acid. |
1357 A client who is exhibiting borborygmi, cramping pain, Correct answer: 1 Dumping syndrome is the rapid influx of stomach contents into the duodenum or jejunum vomiting, and diarrhea has a diagnosis of peptic ulcer causing increased peristalsis and dilation of the intestines. Although this occurs primarily after disease (PUD) with recent surgical treatment. The a gastrectomy, the condition can cause an ulcer. client is probably experiencing which of the following? ‐ Dumping syndrome ‐ Complications of the PUD ‐ Perforation of the stomach ‐ Peritonitis | The question mentions that there was surgical treatment of PUD, which should omit options 2, 3, and 4. |
1358 A client diagnosed with peptic ulcer disease wants to Correct answer: 3 The bacteria H. pylori has been discovered to be the leading cause of many ulcers and can be know why he is being given antibiotics. The nurse's treated with success by antibiotics. Options 1, 2, and 4 are unrealistic answers for the action of best answer would be: antibiotics. ‐ "Antibiotics help calm the stomach and decrease the symptoms." ‐ "Antibiotics decrease dumping syndrome, which can lead to PUD." | Option 3 mentions ‘H. pylori,’ the bacteria associated with ulcers. |
‐ "<i>H. pylori</i> is a bacterial cause for PUD and antibiotics will treat the cause." ‐ "The excess acid can be decreased when the stomach is sterile." | |
1359 Which of the following foods should be avoided in a Correct answer: 4 Caffeine stimulates the acid secretion and can interfere with the function of the lower client with peptic ulcer disease? esophageal sphincter. Chocolate contains caffeine and should be limited along with other drinks and foods with caffeine. Spicy or hot foods, smoking, and alcohol should also be avoided. ‐ Vegetables ‐ Meats ‐ Fruits ‐ Chocolate | Look for the caffeine containing options as it is thought to be a source of increased acidity. |
1360 The nurse explains to a family that the main Correct answer: 3 The bowel wall becomes congested, thickens, and sometimes develops fistulas, which can physiologic reason for weight loss in a client with become infected. This leads to malabsorption and deficiency in absorption of folic acid, Crohn's disease is which of the following? calcium, and Vitamin D. The anorexia can play a role in weight loss, but most clients eat and cannot explain why they have weight loss. ‐ The symptoms of anorexia prevent the client from eating. ‐ The inflammation of the disease decreases the appetite. ‐ The thickening and congestion of the bowel wall results in malabsorption. ‐ The "skip lesions" interfere with food passage through the bowel. | The correct option has the word ‘malabsorption’ in it. This is the cause of weight loss. |
1361 The nurse explains to a certified nursing assistant Correct answer: 1 Elderly clients often eat less food with less roughage and fiber and therefore do not obtain (CNA) who is also a nursing student that the reason the proper nutrients from their diet, which can aid in the development of the disease. Most elderly clients are more prone to diverticulitis is often chronic constipation, not diarrhea, is a cause. because of: ‐ Poor, deficient diet. ‐ Chronic diarrhea. ‐ Frequent laxative use. ‐ Sedentary lifestyle. | Omit options 2 and 3 as constipation is more commonly associated. |
1362 A client who has Crohn's disease and is noncompliant Correct answer: 2 Clients with Crohn's disease are at risk of developing cancer of the GI tract. A noncompliant should be cautioned about the risk for which of the client increases that risk and should be educated that Crohn's can be successfully kept under following? control. ‐ Perforation of the bowel ‐ Colorectal cancer ‐ PUD ‐ Ulcerative colitis | Eliminate options 3 and 4 as they are not associated with Crohn’s. |
1363 Prior to giving an analgesic for pain to a postoperative Correct answer: 3 A client with any GI disorder, especially a peptic ulcer, should never receive any aspirin client who has a history of peptic ulcer disease (PUD), product. Many pain medications contain aspirin and are combinations of an opioid analgesic the nurse should check to see that the agent does not and a non‐opioid analgesic such as aspirin. The nurse administering the pain medication should contain which of the following? know what ingredients are in it. Hydrocodone is a schedule III opioid analgesic in agents such as Lortab. ‐ An opioid product ‐ Acetaminophen (Tylenol) ‐ Acetylsalicylic acid (aspirin) ‐ Hydrocodone | Recall that aspirin is contraindicated with ulcers. |
1364 A client is admitted to the unit with a large, distended Correct answer: 2 Inserting an NG tube will decompress the bowel, which will relieve the vomiting and pain and bowel, acute tenderness upon palpation of the hopefully prevent the client from going into shock. This may be a measure to institute only abdomen, fever, rigidity, and absent bowel sounds. until surgery can be performed. All of the interventions are appropriate, but vomiting fecal After being on the unit, the client's level of matter can be dangerous (as well as unpleasant) because of the possibility of aspiration, consciousness decreases, and he begins to have especially with a decreasing level of consciousness. feculent vomit. The priority therapeutic intervention would be to: ‐ Reduce the fever through antipyretics. ‐ Insert an NG tube to wall suction and monitor the output. ‐ Administer pain medications to relax the client. ‐ Listen to bowel sounds. | The item mentions feculent emesis. The NG would prevent aspiration and help to protect the airway and lungs. |
1365 Which of the following clients is more likely to Correct answer: 4 Causes of pancreatitis include alcohol abuse of excessive intake of liquor or wine for 6 years develop pancreatitis? or more; high triglyceride levels, and hypercalcemia. Stones lodged in the pancreatic duct can cause obstruction and lead to inflammation of the pancreas. Options 1, 2, 3 are worded incorrectly. ‐ A 59‐year‐old male with a history of occasional alcohol use ‐ A client with renal problems and hypocalcemia ‐ A client recovering from a myocardial infarction with hypercholesterolemia ‐ A client with a stone lodged in the pancreatic duct | Obstruction of the duct allows the enzymes to act on the tissue of the pancreas causing inflammation. |
1366 Which of the following actions of pancreatic enzymes Correct answer: 2 When the pancreas is injured and/or has an impaired or disrupted function, the pancreatic can cause pancreatic damage? enzymes (phospholipaseA, lipase, and elastase) leak into the pancreatic tissue and initiate autodigestion. Options 3 & 4 can be causes of pancreatitis. Option 1 is incorrect to this situation. ‐ Utilization by the intestine ‐ Autodigestion of the pancreas ‐ Reflux into the pancreas ‐ Clogging of the pancreatic duct | The digestive action on the organ causes pain and inflammation. |
1367 Which of the following laboratory tests indicates a Correct answer: 1 In pancreatitis, the lipase, amylase, glucose and white blood count (WBC) are all elevated. The diagnosis of pancreatitis? calcium is low for 7 to 10 days and is a sign of severe pancreatitis. This question draws on your knowledge of laboratory results and what is normal and abnormal. If this question was problematic, review your normal lab values for each of these tests and as you study. ‐ Lipase 230 IU/L ‐ Calcium 6.0 mEq/L ‐ Blood glucose 65 mg/dL ‐ White blood cell count 5,000/mm3 | Recall that lipase is a pancreatic enzyme. |
1368 The client with pancreatitis may exhibit Cullen's sign Correct answer: 4 Bleeding is a complication of pancreatitis and is usually identified through a positive Turner's on physical examination. Which of the following data sign (flank bruising) or Cullen's sign (umbilical bruising). Options 1 and 3 are correct in best describes Cullen's sign? pancreatitis, but do not answer the question. Read the stem carefully when taking the test. Option 2 is incorrect; remember the pain may be relieved by flexing the left leg or by walking. ‐ Jaundiced sclera ‐ Pain that occurs with movement ‐ Bluish discoloration of the left flank area ‐ Bluish discoloration of the periumbilical area | Omit option 2 as it is not descriptive of pancreatic pain. |
1369 Which of the following findings would strongly Correct answer: 2 Although option 4 is correct, it is not a strong indicator of cirrhosis. Pruritus can occur for indicate the possibility of cirrhosis? many reasons. Options 1 and 3 are incorrect, fluid accumulation is usually in the form of ascites in the abdomen. Hepatomegaly is an enlarged liver, which is correct. The spleen may also be enlarged. ‐ Dry skin ‐ Hepatomegaly ‐ Peripheral edema ‐ Pruritus | Recall that hepatomegaly means enlarged liver, which is common in early cirrhosis. |
1370 A client with cirrhosis may have alterations in which Correct answer: 3 Clients with cirrhosis have used their clotting factors, and the liver is unable to provide of the following laboratory values? enough clotting factors. A prothrombin time is an indication of the time needed for blood to clot. If clotting factors aren't present, bleeding is more likely. ‐ Carbon dioxide level ‐ pH ‐ Prothrombin time (PT) ‐ White blood cell count (WBC) | Recall that the liver plays a role in clotting. |
1371 Which of the following clients is most likely to acquire Correct answer: 4 Although hepatitis is associated with cholestasis (option 2), the most likely candidate would hepatitis? be someone with a viral infection. A classic example is someone with varicella zoster. Options 1 and 3 are not related to hepatitis. Other causes include alcohol, toxins, and severe hepatocellular damage. ‐ A child with a bacterial infection ‐ A client with dysfunction of the biliary system ‐ A client with metastasis of liver cancer ‐ An adult with varicella zoster | Select the option that describes a viral infection. |
1372 In reviewing the possible causes of hepatitis A in a 22‐ Correct answer: 3 Hepatitis A is transmitted by fecal‐oral route. The virus is excreted in oropharyngeal year‐old male, which of the following would be the secretions (nose and throat) and transmitted by direct contact of person‐to‐person, or by fecal most likely factor? contamination of food or water. A worker at the pub could have hepatitis A and transfer it to the food that is being prepared. Options 1, 2, and 4 are classic of hepatitis B, C, and D. ‐ Contact with blood in his profession as a policeman ‐ Receiving a blood transfusion during surgery ‐ Eating shrimp at the local pub ‐ Admitting to being sexually active | Hepatitis A is associated with eating chilled contaminated foods. |
1373 A client is admitted to the unit with complaints of Correct answer: 2 The symptoms in preicteric hepatitis are vague and more flu‐like as described above. The malaise, nausea, vomiting, anorexia, and headaches. physician usually needs laboratory work to verify a diagnosis. In this case, the presence of the The lab work shows abnormal electrolytes and antigen HBsAG concludes that the client has an active form of the disease since hepatitis B elevated aspartate aminotransferase (AST), alanine surface antigen is present. aminotransferase (ALT), and alkaline phosphatase (ALP). Hepatitis B surface antigen (HbsAG) is also present. The nurse would assume the client has: ‐ Hepatitis A. ‐ Hepatitis B. ‐ Cirrhosis. ‐ Pancreatitis. | Realize that the question states that the client has the hepatitis B surface antigen. |
1374 A client is admitted with possible liver cancer. Which Correct answer: 3 Although an abdominal ultrasound, x‐ray, and CT scan are useful in the diagnosis of cancer of of the tests below would be the most confirming of the liver, the alpha‐fetoprotein serum markers are specific to detecting primary hepatocellular this diagnosis? carcinoma. ‐ Abdominal ultrasound (US) ‐ Abdominal flat plate X‐ray ‐ Alpha‐fetoprotein markers ‐ Computed tomography (CT) scan | Recognize that option 3 is the only option that is not a radiology study. |
1375 A client says to the nurse "I have this pain from my Correct answer: 3 Eating at bedtime may cause increased secretion of pepsin and gastric acid, which will cause ulcer. When it comes on at night, I have difficulty pain later when the stomach is empty. Sleeping pills should be the last resort, and stress can sleeping." Which is the best response for the nurse to aggravate the circumstance, but it would not be just at night. make? ‐ "There really is nothing that can be done‐‐that is typical of ulcer pain." ‐ "Are you worrying a lot?" ‐ "Try limiting the food you eat at bedtime." ‐ "The best thing to do is to take a sleeping pill." | Recognize that option 3 gives the client a valid, concrete suggestion. |
1376 A child with a confirmed diagnosis of appendicitis has Correct answer: 2 When the appendix ruptures, there is a decrease in pain because the appendix is no longer been scheduled for an emergency appendectomy. distended. The problem is worse, not better. There is no indication in the question that the Suddenly, the child states his pain is much less. The child has had a change in level of consciousness. best interpretation of this is that: ‐ He is tolerating the pain much better. ‐ There is a possibility the appendix has ruptured. ‐ His level of consciousness has decreased. ‐ Perhaps the problem has been resolved. | Recall that temporary relief of pain is common with rupture. |
1377 Which of the following describes the best practice in Correct answer: 2 A high‐fiber diet increases stool bulk and decreases intraluminal pressure, decreasing an attempt to control diverticulosis? development of diverticula. The other responses will not necessarily be effective or they are incorrect. ‐ Daily intake of Vitamins A, C, and E ‐ High intake of dietary fiber ‐ High intake of carbohydrates ‐ Increasing intake of fluids | Recall that fiber is essential with diverticulosis to prevent infection. |
1378 The nurse would include which of the following in a Correct answer: 2 Clients with rectal and intestinal polyps have a higher incidence of colon and rectal cancer. teaching plan for the prevention of colon cancer? Early diagnosis facilitates more effective treatment. Caloric and fat content should not be increased. ‐ Increasing the fat content of the diet ‐ Colonoscopy if the client has a history of rectal polyps ‐ Avoidance of strenuous exercise and lifting ‐ Increased caloric content of the diet through carbohydrates | Recall that polyps put the client at increased risk. |
1379 A client with Crohn's disease is having continuous Correct answer: 4 The inflammatory process is the pathology in the development of Crohn's disease. watery diarrhea. The nurse concludes that this Inflammation results in ulcers and fissures or fistulas as well as fibrosis. The other options are symptom is caused by: not related to Crohn's disease. ‐ Multiple tumor growths within the wall of the small intestine. ‐ Allergic manifestations as a result of lactose intolerance. ‐ Excessive intake of fat. ‐ Inflammatory process in the bowel with ulcer and fissure formation. | Recall that Crohn’s disease is an inflammatory bowel disorder. |
1380 A client is admitted with complaints of being tired, is Correct answer: 2 Presence of a mass demands immediate attention. The other symptoms are characteristic of anorexic, and has lost weight. He denies pain at the cancer of the liver. These symptoms could represent stomach cancer also. present time but states he "knows something is wrong." Assessment reveals a mass in the right upper quadrant that is tender on palpation. What conclusion should the nurse draw from these findings? ‐ He is probably tired due to malnutrition and anemia. ‐ Referral needs to be made regarding the presence of the mass. ‐ A mass frequently is found in patients with hepatitis. ‐ He is probably dehydrated with electrolyte imbalances. | Recognize that a mass requires further investigation. |
1381 In planning a health screening for cancer awareness, Correct answer: 1 Annual guaiac testing is recommended by the American Cancer Society as a means of the nurse would want to include which of the following detecting colon cancer. The other options are not. to prevent rectal cancer? ‐ Annual guaiac testing for occult fecal blood for people over age 50 ‐ Upper GI x‐rays annually ‐ Routine testing of blood cholesterol ‐ Stress test | Recall that occult blood testing is a common screening method. |
1382 A client with a history of peptic ulcer disease is taking Correct answer: 1 Ranitidine (Zantac) is an H2‐receptor antagonist; the action is to block the secretion of HCl by ranitidine (Zantac). He questions the action of this depressing the histamine receptors. It does not coat the lining. The object is not to increase drug. The best answer for the nurse to give is: gastric acid or make histamine receptors more sensitive. ‐ "It blocks the secretion of hydrochloric (HCl) acid in the stomach." ‐ "It coats the lining of the stomach." ‐ "The release of gastric acid is increased." ‐ "The histamine receptors become more sensitive and act to protect the stomach." | The word ‘blocks’ in relation to hydrochloric acid is the key to the correct response. |
1383 As part of preparation for discharge for a client who Correct answer: 3 These symptoms are characteristic of dumping syndrome and occur because of hypertonic has undergone a Billroth II surgical procedure for food entering the jejunum with no sphincter. The other options result in a different set of peptic ulcer disease, the nurse teaches the client about symptoms. the possibility of dizziness, paleness, sweating, and feeling the heartbeat. The nurse explains that these symptoms are an indication of: ‐ Recurrence of the ulcer. ‐ Anemia caused by blood loss during surgery. ‐ Dumping syndrome. ‐ Perforation. | Recall that ulcer surgery may result in dumping syndrome. |
1384 An elderly client has had several gastrointestinal Correct answer: 4 These studies require the client to take strong laxatives and enemas and to be NPO as diagnostic procedures, including endoscopy and upper preparation for the procedure. The client may become dehydrated. GI series. Following these procedures, the nurse should assess the client for: ‐ Level of consciousness. ‐ Level of pain. ‐ Hypotension. ‐ Hydration and nutrition level. | This option relates to the preparation that is common for all of these examinations. |
1385 An elderly client expresses concern about the Correct answer: 1 Increasing fiber provides bulk and keeps the stools soft and easy to expel. Fluid intake affects possibility of constipation, stating "I have not had a the consistency of the stool. An obstruction takes more than one day to form. bowel movement today at all, and I don't want to get an obstruction." Which response by the nurse is most helpful to the client? ‐ "It is better to control your bowel habits with increased fiber and increased fluid intake." ‐ "Oh, don't worry about that!" ‐ "You probably need to take a laxative." ‐ "That's a part of the aging process; it is to be expected." | The correct option identifies good health practices as the solution to constipation. |
1386 A client is admitted with a history of chronic Crohn's Correct answer: 4 Colon cancer is more likely to develop in clients who have had inflammatory bowel disease. It disease. The nurse plans care based on which of the is not infectious and there is no effective cure. Symptomatic control is possible. following ideas? ‐ If the client adheres to the therapeutic regimen, there is a high chance of cure. ‐ There is nothing that can be done to alleviate the symptoms of this disease. ‐ This is an infectious process; therefore, communicable disease precautions must be taken. ‐ There is an increased risk of developing colon cancer with this disease. | Omit option 1 as this is a chronic disease. Omit option 2 as there are helpful treatments. Omit option 3 as this is not a communicable disease. |
1387 A client visiting an outpatient clinic mentions that she Correct answer: 4 Caffeine increases acidity in the stomach and can affect the lower esophageal sphincter, has been having severe indigestion and burning in her which could account for the symptoms that are consistent with gastritis. chest. The nurse takes a history and learns that she does not smoke or consume alcohol. Another dietary consideration to ask about initially would be: ‐ Vitamin intake. ‐ Herbal products. ‐ Amount of meat eaten per day. ‐ Amount of caffeine. | Select the option that does contribute to increased acid production. |
1388 A female client hospitalized for a broken pelvis from a Correct answer: 3 Stresses to the body such as burns, trauma, and surgery can cause stress ulcers even in motor vehicle accident is being sent home on an H2‐ individuals who did not have an ulcer before the event. Option 2 is not supported by the antagonist and an antacid as part of her home scenario and options 1 and 4 are incorrect. medications. When the client questions why, the nurse explains that: ‐ The medications are a preventive measure only. ‐ She has GERD because of the other medications she is taking. ‐ The stress of the accident and injury caused a stress ulcer. ‐ She probably always had an ulcer and didn't know it. | Recall that stress can lead to increased gastric acidity. |
1389 A 7‐year‐old boy is admitted to a children's hospital Correct answer: 2 A pH probe test is done to determine both the number of drops in pH of the stomach and the because of frequent complaints of burning pain in the length of each of the drops. Even though the level did not remain low, 100 drops in 24 hours is middle of his chest and frequent regurgitation. A pH excessive. Dyspepsia is a symptom (option 2). The scenario does not support options 1 and 4. probe test is done and reveals over 100 drops in the pH to between 2.0 and 3.5 within a 24‐hour period; however, none of the decreases remained low for longer than 2 to 3 seconds. The child most likely has: ‐ Curling's ulcer. ‐ GERD. ‐ Dyspepsia. ‐ PUD. | Pain in the center of the chest and low pH are the key to selecting GERD as the correct response. |
1390 The mother of a 15‐year‐old girl notices that she has Correct answer: 1 Crohn's disease has a characteristic skip lesion on visualization of the intestinal wall. Option 2 lost weight, complains of stomach pains, doesn't want occurs with ulcerative colitis; options 3 and 4 are not suggestive of Crohn's disease. to eat, and begins having frequent diarrhea. She is tested for Crohn's disease. The nurse expects that sigmoidoscopy will reveal which of the following? ‐ Skip lesions ‐ Lieberkuhn's crypts ‐ Ulcerated cavities ‐ Polyps | Omit options 3 and 4 as not associated with inflammatory diseases. Crypts, as in option 2 would suggest ulcerative colitis. |
1391 The reason diverticular disease is more common in Correct answer: 4 Elderly people have a lack of adequate blood supply because of the aging process and often the elderly is because of: consume less of the nutrients necessary in the diet to maintain adequate peristalsis and normal bowel function. Options 1 and 2 can be general causes; option 3 does not apply. ‐ Obesity and high dietary fat content. ‐ More frequent problems with constipation. ‐ Difficulty evacuating all of the bowels because of poor sphincter control. ‐ Blood supply and diet. | Reduction of blood supply and diet changes would be associated with aging. |
1392 Of the following clients, the one who is at high risk for Correct answer: 3 Intestinal obstructions are mechanical (options 1, 2, 4) or paralytic, in which neurogenic or a functional paralytic intestinal obstruction is the one: muscular impairment hinders peristalsis. Early ambulation after surgery usually helps to prevent this. ‐ With a tumor of the colon. ‐ Who develops adhesions after a bowel resection. ‐ Who develops a paralytic ileus after abdominal surgery. ‐ With a twisted colon. | Make the association between paralytic ileus and surgery to identify option 4 as correct. |
1393 An example of appropriate teaching at a health fair in Correct answer: 1 Middle school and high school age students are high users of tobacco by smoking, dipping, a middle or high school would be to emphasize which and chewing. Teenagers do not feel anything can harm them; therefore, they think they will of the following? probably never have cancer. Options 2 and 3 are less likely to apply to their age and teenagers are constantly altering their weight and appetite. Option 4 is false; lesions should be reported. ‐ Tobacco in any form increases risk of oral cancer. ‐ A stool specimen can be used to determine colorectal cancer. ‐ Any change in appetite or sudden weight loss could signal stomach cancer. ‐ White or red patches on the mouth do not need to be reported immediately. | Select the response that reflects a risk factor in this age group. |
1394 An elderly man presents to the outpatient clinic Correct answer: 1 Although the client's symptoms could suggest option 4, they are highly suggestive of complaining of changes in bowel habits, increased colorectal cancer. Options 2 and 3 are incorrect. diarrhea, thin stools, and some rectal bleeding. The nurse would be most concerned about: ‐ Left‐sided colorectal cancer. ‐ Stomach cancer. ‐ Intestinal obstruction. ‐ Diverticulitis. | Changes in the girth of stool are suggestive of colorectal cancer. |
1395 The nurse caring for a client with acute pancreatitis Correct answer: 4 Biliary obstruction caused by a stone in the pancreatic duct is one cause of pancreatitis. This observes that the client’s skin has become slightly type of Pancreatitis may result in mild jaundice depending on the degree of obstruction. It is jaundiced. Which of the following is the best not an indication of a terminal stage. The decision to give oral feedings is based on degree of conclusion for the nurse to make regarding the pain and presence of bowel sounds or laboratory data, which are an indication of prognosis of this client? improvement of the client and moving from an acute to chronic stage. ‐ The client has been misdiagnosed. He probably has cirrhosis or hepatitis. ‐ This client is approaching the terminal stage of pancreatitis. ‐ This is an indication the pancreas is overworked and the client should not be allowed to eat. ‐ The client's pancreatitis has resulted from biliary obstruction. | Associate jaundice with obstruction to the flow of bile. |
1396 A client says to the nurse, "I had a hepatitis B Correct answer: 3 Hepatitis B vaccine provides protection against hepatitis B or possibly hepatitis D only. immunization. Now I know I won't have to worry about Hepatitis A may also be contracted from contaminated food, water or direct contact. contacting any hepatitis any more." Which is the best interpretation for the nurse to make? ‐ The client is correct in his interpretation. ‐ The immunization does not provide post‐exposure protection against any form of hepatitis. ‐ The client does not understand that he can still contract hepatitis A. ‐ Hepatitis B is not contracted from contaminated needles. | The immunization is for hepatitis B, not other strains of hepatitis. |
1397 Diffuse fibrosis and conversion of normal liver tissue Correct answer: 2 The process of cirrhosis involves fibrotic changes in the liver in which fibrous bands form into abnormal nodules with fibrous bands describes nodules, which gives the liver a cobblestone appearance. Liver failure is a secondary condition. the progression of which of the following hepatic The process in hepatitis is more necrosis, hyperplasia, and inflammation. Liver cancer is the disorders? development of tumor cells. ‐ Liver failure ‐ Cirrhosis ‐ Hepatitis A ‐ Liver cancer | Recall that fibrous liver tissue is descriptive of late stage cirrhosis. |
1398 Lab results for a client who has portal hypertension Correct answer: 1 In portal hypertension, decreased protein synthesis results in a decrease in albumin, which show a low level of serum albumin. Based on this causes edema and ascites. Hypoglycemia occurs as a result of increased insulin production. information, the nurse knows that he has a high Esophageal bleeding can occur in portal hypertension, which can result in hypovolemic shock, chance of developing which of the following? but they are not a direct result of decreased serum albumin. ‐ Ascites ‐ Hypoglycemia ‐ Esophageal bleeding ‐ Hypovolemic shock | Albumin holds fluid in the vascular system. Low albumin level results in fluid in the abdominal cavity, or ascites. |
1399 At a health fair for adults in the community, the nurse Correct answer: 1 The incidence of cancer of the pancreas is twice as high in smokers as nonsmokers. Other risk is asked by a client on means to prevent cancer of the factors are high‐fat diet and pancreatitis. Correlation has not been shown to obesity, fiber, or pancreas. The nurse would suggest which of the alcohol. following? ‐ Cessation of smoking ‐ Consuming a low‐fiber diet ‐ Reduction of weight ‐ Cessation of alcohol | Remember that smoking cessation is a good health promotion measure. |
1400 A client has a history of gallbladder disease and is Correct answer: 1 Bile reflux causes activation of pancreatic enzymes, which cause autodigestion of the admitted for a diagnostic work‐up to rule out pancreatic tissue. There is a definite relationship between these two conditions. Pancreatitis is pancreatitis. The nurse knows the relationship not always directly caused by alcohol intake. between these two diseases is: | Recall that biliary obstruction is often the cause of pancreatitis. |
‐ When a stone obstructs the common bile duct, a reflux of bile may cause breakdown of pancreatic tissue. ‐ The symptoms are very similar, and it is necessary to differentiate between the two diseases. ‐ There is no relationship between gallbladder disease and pancreatitis. ‐ Pancreatitis is directly related to alcohol intake, and this is intensified by gallbladder disease. | |
1401 A client is admitted with recurrent abdominal pain, Correct answer: 4 Replacement of pancreatic tissue by fibrous changes causes exocrine and endocrine changes steatorrhea, weight loss, and elevated serum amylase with loss of pancreatic enzymes for digestion and loss of function of islets of Langerhans, and lipase with a history of chronic alcohol abuse. A which secrete insulin, resulting in diabetes mellitus. As a chronic condition, there is very possible diagnosis is chronic pancreatitis. The nurse limited recovery. There is a direct correlation between alcohol abuse and chronic pancreatitis. knows that chronic pancreatitis: ‐ Has very limited correlation to alcohol intake. ‐ Is easier to treat than acute pancreatitis with quick recovery and limited repercussions. ‐ Is an infectious process that occurs following appendicitis or other infectious conditions. ‐ Is a progressive disease, in which pancreas tissue is replaced by fibrous connective tissue and malabsorption occurs along with diabetes mellitus. | The inclusion of diabetes mellitus in option 4 is the key to the correct response. |
1402 Decreased excretion of bilirubin would probably be Correct answer: 3 Obstruction of the common bile duct interferes with movement of the bile so that it cannot attributed to which of the following? be excreted. ‐ A blood transfusion reaction ‐ Hemolytic anemia ‐ An obstructed common bile duct ‐ An obstructed pancreatic duct | Associate jaundice with biliary obstruction. Jaundice is due to increased bilirubin. |
1403 In caring for a client with acute hepatitis B, the client Correct answer: 4 The client's ability to determine activities that would not cause excess fatigue allow for self‐ says, "I am so tired of this bed. I don't think I can stay direction and participation. Bedrest is encouraged and activities are progressed slowly; here any longer!" The best response of the nurse is: however, strict bedrest is not common. Planned rest periods are highly recommended. ‐ "You must stay on strict bedrest, with slow progression to normal activities, for the liver to heal" ‐ "I know it gets boring staying in bed so long, but you must." ‐ "Don't you want to get well?" ‐ "What activity do you think you can do without getting too tired?" | Select the open‐ended response that involves the client. |
1404 In caring for a client with liver failure, the nurse Correct answer: 4 Increased ammonia occurs because the liver is unable to convert ammonia to urea. Calcium is knows that the pathophysiology of the disease causes probably decreased because of bedrest. Serum creatinine is probably increased because of which of the following? impaired renal function; RBCs are probably decreased because of decreased production in the bone marrow. ‐ Decreased serum creatinine ‐ Increased red blood cells (RBCs) ‐ Increased calcium ‐ Increased ammonia | Remember that the liver is responsible for forming urea from ammonia. |
1405 A newly admitted client with cirrhosis of the liver has Correct answer: 3 Low albumin in the blood causes a decrease in plasma colloidal osmotic pressure, causing a distended abdomen and the umbilicus is protruding. fluid to escape into the extravascular compartment. The nurse knows the pathological basis for this is: ‐ Increased fluid intake resulting from excessive use of alcohol causing overhydration. ‐ Increased size of the liver results in abdominal distension. ‐ Hypoalbuminemia causes fluid to leave the vascular system and enter the peritoneal cavity. ‐ Shunting of the blood to the collateral circulation in the esophagus results in decreased blood volume and accumulation of fluid. | Recall that albumin holds fluid in the vascular system. |
1406 A client with hepatic encephalopathy would expect to Correct answer: 4 In hepatic encephalopathy, the level of ammonia is increased with high levels of protein in the have which of the following changes in the diet? intestine. Calories are needed to promote healing. Potassium levels are usually increased because of impaired kidney function, therefore the intake should not be increased. Sodium is restricted because of ascites. ‐ Increase sodium intake to draw fluid from the abdomen ‐ Restriction of calories to decrease energy used as a result of digestion ‐ Increase intake of potassium in order to promote cardiac activity ‐ Restriction of protein in order to decrease levels of ammonia | Recall that ammonia is nitrogenous. Nitrogen comes from protein. |
1407 A client with a diagnosis of cirrhosis of the liver and a Correct answer: 3 Portal hypertension develops as a result of development of fibrous bands, which develop history of alcohol abuse is admitted to the unit. The following necrosis and regeneration of lung tissue. The other conditions are due to other nurse knows that portal hypertension is a possible changes in the liver as well as bleeding. Esophageal bleeding occurs as a result of portal complication of this condition for which of the hypertension, not just the opposite. following reasons? ‐ Hyponatremia and hypoproteinemia ‐ Ecchymosis, edema, and jaundice ‐ Fibrotic tissue from cell destruction ‐ Development of esophageal varices | Omit option 4 as this is the result of portal hypertension. Fibrosis around the portal vessels cause increased pressure. |
1408 A male client comes to the ambulatory care center Correct answer: 4 Esophageal varices occur as a complication of portal hypertension and cirrhosis. It results in complaining of weakness and vomiting. He states he vomiting of blood. The angiomas are another indication of bleeding tendencies common with "has several drinks a day and has done this over the cirrhosis. past 10 years." The client has spider angiomas on his forearm and dried blood on his lips. What should the nurse suspect? ‐ Hepatitis A ‐ Cerebral disorder ‐ Pancreatitis ‐ Esophageal varices | Recognize that the scenario states that the client has dried blood on his lips. This leads to the selection of option 4, esophageal varices. |
1409 A client asks, "What conditions lead to the Correct answer: 4 Obese, middle‐aged or older women are more likely to develop cholelithiasis. It is also seen in development of gallstones? My mother had a bad time Native Americans. with them." Which response is the best for the nurse to make? ‐ "They occur more often in younger people." ‐ "They are limited to older malnourished men." ‐ "Gallstones are only seen in elderly Jewish people." ‐ "Overweight middle‐aged women are especially susceptible." | The common association of gallstones: Female, Fat, and Forty can assist in identification of the correct response. |
1410 In caring for a client recovering from hepatitis A, who Correct answer: 1 All of the other options contain fat. Fat generally is not appetizing to clients with hepatitis. If is no longer infectious and without any indication of there are no complications, it is better to give high‐calorie and high‐protein early in the hepatic encephalopathy, which of the following meals morning before developing nausea. would be most appropriate? ‐ Pancakes, poached eggs, orange juice, coffee (breakfast) ‐ Fried chicken, potatoes and gravy, green beans (noon) ‐ Enchiladas, tortillas, chips, salsa (evening) ‐ Salami sandwich, French fries, ketchup, coca cola (evening) | Look for the highest calorie, highest quality protein (eggs), and the lowest fat menu. |
1411 The doctor has ordered oral administration of Correct answer: 4 Increased amount of gastrointestinal bleeding results in the formation of increased amount of lactulose (Chronulac) for a client with esophageal ammonia because of intestinal bacteria metabolizing the blood cells. The lactulose creates an bleeding from esophageal varices. The nurse knows acid environment, which causes the ammonia to leave the circulatory system and to be that the reason for administration of this drug is to: expelled through the colon. ‐ Correct constipation. ‐ Stop bleeding from the varices. ‐ Act as a nutritional supplement. ‐ Promote excretion of ammonia. | Recall that Chronulac should be associated with removal of ammonia. |
1412 When admitting a client with a diagnosis of cirrhosis, Correct answer: 4 Medications such as acetaminophen (Tylenol) are highly metabolized by the liver and should the nurse assesses the medications ordered. She be avoided. Other such drugs are barbiturates and sedatives. Options 1 and 2 are ordered to should question the administration of which of the decrease the ammonia level, and option 3 may be ordered for pain. following? ‐ Lactulose (Chronulac) ‐ Neomycin (Mycifradin) ‐ Meperidine (Demerol) ‐ Acetaminophen (Tylenol) | Omit options 1 and 2 as these are commonly used to reduce ammonia. Demerol is the better option for pain. |
1413 A client with cirrhosis of the liver and esophageal Correct answer: 2 Pain usually does not accompany ruptured varices. The increased venous pressure and gastric varices suddenly begins vomiting copious amount of acid causes the rupture, which is usually followed by bleeding. Hypertension, melena, and high dark‐colored blood. The sign/symptom that is least ammonia levels are all expected. expected would be which of the following: ‐ Hypertension. ‐ Pain. ‐ Melena. ‐ High ammonia level. | Eliminate options 1, 3, and 4 as commonly associated with ruptured varices. |
1414 A client on the unit with hepatitis B suddenly Correct answer: 2 A condition developing 6 to 8 weeks after initial symptoms in a client with hepatitis is develops anorexia, vomiting, abdominal pain, fulminant hepatitis where there is necrosis and shrinking of the liver with possible liver progressive jaundice, lethargy, and disorientation. The damage. The symptoms are classic and the condition often leads to coma, possibly death. nurse knows that these indicate which of the following? ‐ Laennec's cirrhosis ‐ Fulminant hepatitis ‐ Portal hypertension ‐ Cancer of the liver | Omit option 1 as this is alcoholic cirrhosis, and option 3 as a complication of cirrhosis. Omit option 4 as cancer of the liver is a risk for later in life in a post‐hepatitis B client. |
1415 A client with a history of hiatal hernia states he has Correct answer: 1 Elevating the chest and head may reduce gastric reflux, which is causing the pain. The other trouble sleeping because the pain is worse at night. positions do not accomplish this. Position change is preferable to medication for sleep. Which response by the nurse is most appropriate? ‐ "Try sleeping with your upper body elevated." ‐ "What sleep medication do you take?" ‐ "Try laying flat or on your side." ‐ "Sleep with your feet elevated." | Recall the most common recommendation for clients with hiatal hernia. |
1416 A client is taking misoprostol (Cytotec) because of an Correct answer: 3 The action of this drug is to promote healing by promoting mucus and bicarbonate ulcer that developed while taking NSAIDs for arthritis. production. It promotes healing because it is a prostaglandin. NSAIDs decrease prostaglandins The client questions the action of the drug. Which is and promote ulcer formation. It does not affect the proton pump, esophageal sphincter the most appropriate explanation? pressure, or the speed of gastric emptying. ‐ This drug increases the speed of gastric emptying. ‐ It increases lower esophageal sphincter pressure. ‐ It promotes healing by promoting mucus production and bicarbonate secretions. ‐ It binds the enzyme that acts as a proton pump. | Protection of the gastric lining by increasing mucous production is a goal of ulcer treatment. |
1417 Which of the following symptoms would lead the Correct answer: 4 Peritonitis follows gastric perforation with spilling of stomach contents into the peritoneal nurse to suspect that a client has peritonitis? cavity. Increased white blood cell count, abdominal rigidity, and severe pain occur, accompanied by fever. Dysuria is not seen. Although tarry stools may be seen with gastric bleeding, it is not characteristic of peritonitis. ‐ Leukopenia ‐ Tarry stools ‐ Dysuria ‐ Abdominal rigidity | Rigid abdomen is a serious symptom and needs immediate intervention, just as peritonitis does. |
1418 A client with Crohn's disease has a low potassium Correct answer: 1 Potassium has a tendency to be irritating to the lining of the esophagus or stomach and may level from excessive diarrhea. Oral potassium chloride cause nausea and vomiting. Giving it with meals will decrease this tendency. Options 2 and 4 (K‐lor) is prescribed. The nurse intends to give this would be irritating because the client has an empty stomach. It is appropriate to give this drug drug: at the same time other medications are given. ‐ With food or after meals. ‐ 2 hours after meals. ‐ In conjunction with no other medications. ‐ Before breakfast and at bedtime. | The strong taste and tendency to cause stomach upset should lead to the selection of option 1. |
1419 As opposed to ulcerative colitis, Crohn's disease is Correct answer: 3 Crohn's disease is characterized by lesions anywhere in the gastrointestinal system. The characterized by: diarrhea is more liquid and harder to control. The excessive diarrhea frequently causes fluid and electrolyte imbalance. It is often accompanied by fistulas between the colon and other organs or other segments of the bowel. The fibrotic changes cause the colon to be inflexible and thick. ‐ Lesions that are limited to the lower colon and rectum. ‐ Diarrhea that is self‐limiting and easier to control. ‐ Fistulas and fibrotic changes that cause the bowel to become less flexible. ‐ Fewer problems with fluid and electrolyte imbalance. | Omit options 2 and 4 as diarrhea and fluid and electrolyte disturbances are common issues for the client with Crohn’s disease. Omit option 1 as Crohn’s lesions can occur anywhere in the GI tract. |
1420 While recovering from a burn, a client suddenly Correct answer: 1 Curling's ulcers, which occur after a major burn, are characterized by multiple superficial begins to vomit blood, but denies any pain. The nurse ulcers caused by ischemia from vasoconstriction. They are not caused by excessive gastric acid. knows this is characteristic of: They are painless and may or may not involve massive bleeding. They are not related to H. pylori. ‐ Multiple superficial ulcers that occur following a major trauma. ‐ Rupture of a blood vessel while coughing. ‐ Cancer of the stomach. ‐ Chronic gastritis caused by <i>H. pylori</i>. | Recall that stress ulcers are common post burn. |
1421 Using the diagram on common sites for peptic ulcer Correct answer: 2 An ulcer below the pyloric valve is a duodenal ulcer, and the pain is more common when the disease, a client with an ulcer below the pyloric valve stomach is empty; food helps stop the pain for awhile. Option 1 is common with gastric ulcers. would complain of: Options 3 and 4 are not applicable to PUD. ‐ Pain immediately after a meal. | Remember that duodenal ulcers are relieved by food. |
‐ Pain on an empty stomach. ‐ Pain all the time whether the stomach is full or empty. ‐ Pain that is worse when drinking milk or milk products. | |
1422 A client who had been admitted for shock develops Correct answer: 3 Severe stress conditions such as burns, hypoxia, and shock decrease mucus production, which symptoms of peptic ulcer disease several days later. leaves the mucosal cells unprotected from the high acid environment of the stomach. Option 1 The reason this occured is most likely: and 2 are causes of PUD but not as a secondary condition of shock. Option 4 indicates the pathophysiology of shock, not PUD. ‐ Excess acid production. ‐ Increased delivery of acid. ‐ Decreased mucus production. ‐ Decreased blood flow. | Recall that mucous protects the stomach lining from gastric acid. |
1423 In scheduling a b.i.d. dose of antacid for a client with Correct answer: 1 Antacids should be separated from other medications by at least 1 to 2 hours and after meals a hiatal hernia (9:00 A.M. and 9:00 P.M.), the nurse by at least 1 hour. Therefore, if medications are scheduled for 9:00 A.M. and 9:00 P.M., the knows to schedule antacids at: antacid could be given an hour after (10:00 A.M./P.M.). ‐ 10:00 A.M. and 10:00 P.M. ‐ 11:00 A.M. and 11:00 P.M. ‐ 7:00 A.M. and 7:00 P.M. ‐ 12:00 noon and 12:00 midnight | Select the option that would allow 1‐2 hours between meals and other medications and the antacid. |
1424 A client who has Crohn's disease complains of feeling Correct answer: 3 When diarrhea occurs for an extended time in a client with Crohn's disease, dehydration is a very tired, extremely thirsty, and has experienced complication. Signs and symptoms are excess thirst, fatigue, sunken eyeballs, and decreased excessive diarrhea the last few days. The client has skin turgor. Although the client may be experiencing malabsorption (option 1) and electrolyte sunken eyeballs and upon examination, poor skin imbalance (option 2), the scenario did not give symptoms consistent with these complications. turgor. The nurse should recommend immediate treatment for: ‐ Malabsorption syndrome. ‐ Electrolyte imbalance. ‐ Dehydration. ‐ Peritonitis. | Recognize that the scenario describes classic symptoms of dehydration. |
1425 A client being treated for chronic cholecystitis should Correct answer: 2 These foods are all high in fat and are usually not tolerated with a client with cholecystitis. be given which of the following instructions? Clients should continue to ambulate and be as active as usual. Protein does not necessarily have to be increased. ‐ Increase rest ‐ Avoid sausage, bacon, fried foods, and peanut butter ‐ Increase protein in diet ‐ Use anticholinergics as prescribed | Recall that high fat foods aggravate gallbladder pain. |
1426 Which of the following laboratory values will the Correct answer: 1 The elevated amylase and lipase are key lab tests for pancreatitis. The glucose is elevated nurse interpret as confirming a client's diagnosis of because of the role of the pancreas in controlling glucose values. The calcium is decreased pancreatitis? because the calcium is deposited in the fatty necrotic tissue of the pancreas. In this type of question, try to think of the rationale for the decrease or elevation, instead of memorizing. ‐ Elevated amylase, elevated lipase, elevated serum glucose and decreased serum calcium levels ‐ Elevated amylase, elevated lipase, decreased serum glucose, and decreased serum calcium levels ‐ Decreased amylase, decreased lipase, elevated serum glucose, and increased serum calcium levels ‐ Decreased amylase, decreased lipase, decreased serum glucose, and increased serum calcium levels. | Omit options 2 and 4 as serum glucose would be elevated in pancreatic dysfunction. Omit option 3 as pancreatic enzymes would be increased. |
1427 A client is admitted with cholelithiasis. The most Correct answer: 2 An ultrasound of the gallbladder will detect the presence of stones. A barium swallow, as well common test to order for diagnosis of this disease is as endoscopy, is for upper gastrointestinal disorders. A CT scan is not usually the first choice if which of the following? the stones are visible on the ultrasound. ‐ Abdominal computed tomography (CT) scans ‐ Ultrasound (US) of gallbladder ‐ Barium swallow ‐ Endoscopy | Select the option that is specific to the gallbladder. |
1428 A client with cirrhosis begins with a flapping tremor of Correct answer: 4 Hepatic encephalopathy is a complication of cirrhosis and is manifested by changes in the hands whenever the arms are extended. Her consciousness, mentation, and motor function. Asterixis (or liver flap) is the flapping tremor of orientation is decreased, she is having trouble the hands when extending the arms. concentrating, and appears anxious. The client is probably developing which of the following? ‐ Portal hypertension ‐ Esophageal varices ‐ Fulminant hepatitis ‐ Hepatic encephalopathy | Focus on the mental status changes. This will lead to the selection of option 4. |
1429 Which of the following measures should the nurse Correct answer: 1 The cause of bleeding in a client with esophageal varices is usually rupture, which is a medical focus on in the client with esophageal varices who is emergency. The hemorrhage that occurs is usually frank bleeding such as vomiting of copious scheduled to undergo sclerotherapy? amounts of dark‐colored blood. The nurse should be able to recognize signs of hemorrhage (tachycardia, hypotension, low platelets, and hematocrit and hemoglobin H & H). ‐ Recognizing hemorrhage ‐ Controlling blood pressure ‐ Encouraging nutritional intake ‐ Teaching the client about varices | Think of hemorrhage associated with esophageal varices. |
1430 In teaching a high school health class, the nurse Correct answer: 3 Alcoholism in high school age students is common, and this population usually feels should emphasize the possibility of which of these? invulnerable to illnesses such as cirrhosis. Although biliary cirrhosis may occur because of drug abuse, alcoholism is more prevalent in teenagers in the United States today. ‐ Biliary cirrhosis ‐ Cholecystitis ‐ Laennec's cirrhosis ‐ Cancer of the liver | Select the option that is a true risk for the population being addressed. |
1431 When admitting a client to the hospital with Correct answer: 3 The bilirubin will be elevated in cholelithiasis and cholecystitis. When the indirect bilirubin is suspected acute cholecystitis, which of the following elevated, liver damage is suspected. The elevated direct bilirubin indicates involvement of the would help the nurse to know if liver damage is biliary ducts. The amylase should be normal and the alkaline phosphatase confirms the present? diagnosis. ‐ Elevated alkaline phosphatase ‐ Elevated direct bilirubin ‐ Elevated indirect bilirubin ‐ Normal serum amylase | Associate indirect with secondary cause of liver damage. |
1432 When a client who has a liver disorder is having an Correct answer: 1 Bleeding is a primary complication of a liver biopsy or invasive procedures involving the liver invasive procedure, the nurse helps assure safety by because the liver disorder has more than likely altered the clotting factors. In order to prevent assessing the results of which of the following tests? a massive hemorrhage or complications, the coagulation studies should be assessed prior to the procedure. ‐ Prothrombin time (PT) and Partial thromboplastin time (PTT) | Recall that clotting is impaired with liver disease. |
‐ Liver enzyme levels ‐ Serum chemistries ‐ White blood cell count (WBC) | |
1433 When teaching preventive measures to a client who Correct answer: 2 High fat content in the diet as well as hyperlipidemia are risk factors for cholelithiasis. In has a strong family history for cholelithiasis, which of addition, this client has a family history, which is another risk factor. Obesity is certainly a the following guidelines are most important? concern, but the stem does not indicate that as a problem (don't read into the question). ‐ Eat a low‐protein diet ‐ Eat a low‐fat low‐cholesterol diet ‐ Limit exercise to 10 minutes a day ‐ Keep weight proportional to height | Associate high fat intake with gall stones. |
1434 Which of the following considerations is of the Correct answer: 4 In cirrhosis, the liver is usually not functioning properly and cannot metabolize medications as highest priority when preparing to administer a well as it normally would if healthy due to the scarring of the tissue. Certain medications are medication to a client with cirrhosis? metabolized primarily by the liver, while other medications are metabolized by other organs. Consideration should be made for each medicine ordered to avoid overburdening the liver. ‐ Frequency of the medication ‐ Purpose of the medication ‐ Necessity of the medication ‐ Metabolism of the medication | Remember that the liver plays a role in the metabolism of many common medication. |
1435 A client asks the nurse how she can live without her Correct answer: 1 The liver produces between 700 and 1,000 mL of bile a day. The gallbladder stores and gallbladder. In order to respond to this client, the concentrates bile and then releases it when stimulated, but is not an essential structure. nurse must have which understanding of the hepatobiliary system? ‐ The liver produces about 1,000 mL of bile per day. ‐ The gallbladder makes about 90 mL of bile per day. ‐ The liver concentrates bile more than 10 times. ‐ The gallbladder dilutes and releases bile. | Recall that the role of the gallbladder is to store and concentrate, not to produce bile. |
1436 The nurse reviews a client's laboratory tests and Correct answer: 3 Hyperbilirubinemia (total serum bilirubin greater than 2.5 mg/dL) manifests in jaundice, a notices that the total serum bilirubin is 2.5 mg/dL. The yellow discoloration of the body tissues. Ascites (option 1) may accompany liver disease in nurse should assess the client for which of these later stages, but there is no evidence in the question to indicate this. Options 2 and 4 are clinical manifestations? unrelated to the question as stated. ‐ Ascites ‐ Diarrhea ‐ Scleral icterus ‐ Hypertension | Associate bilirubin with jaundice, which is often first noted in the sclera. |
1437 The client is diagnosed with obstructive jaundice. The Correct answer: 2 Clay colored stools indicate that no bile is reaching the intestine and suggests obstructive nurse should ask the client about which of these jaundice. Options 1 and 3 are unrelated to the question. Option 4 could be present due to manifestations? cardiovascular disease or as an indirect consequence of portal hypertension with impaired venous return, but there is insufficient information in the question to support this option. ‐ Clear, pale urine ‐ Clay‐colored stools ‐ Lactose intolerance ‐ Ankle edema | Recall that clay‐colored stool and dark urine are associated with jaundice. |
1438 A client has jaundice. Which of the following comfort Correct answer: 3 Jaundice frequently causes pruritis. Comfort measures include keeping the air temperature measures would be appropriate for the nurse to cool (68 to 70 degrees F) and the humidity at 30 to 40 percent. Tepid baths (not hot) with implement? colloidal agents decrease itching (option 2). Use of an emollient lotion is also helpful, but anything drying should be avoided (option 4). Hot beverages (option 1) are of no benefit as a comfort measure for pruritus due to jaundice. ‐ Offer hot beverages frequently ‐ Encourage taking a hot bath or shower ‐ Keep the air temperature at approximately 68 to 70 degrees F ‐ Suggest the use of alcohol‐based skin lotion | Omit options 2 and 4 as both would increase the risk of drying of the skin. |
1439 The client is exposed to hepatitis A. When teaching Correct answer: 2 The incubation period for hepatitis A is 4 to 6 weeks in length with viral shedding highest 10 this client about infection control, the nurse explains to 14 days before the onset of symptoms and during the first week of symptoms. The other that the client is most infectious to others at which of options do not fall within this time frame. these times? ‐ 7 days after exposure ‐ 10 days before the onset of symptoms ‐ 2 months after exposure ‐ 14 days after symptoms begin | Select the only option that identifies a period of time before the symptoms develop. |
1440 The client with cirrhosis of the liver asks the nurse Correct answer: 1 The liver is responsible for the production of albumin, which in turn is responsible for why he has edema. The nurse would use which of the maintaining colloidal osmotic pressure. With less production of albumin, osmotic pressure following statements to explain how edema results decreases and edema develops. Options 2, 3, and 4 are false statements that do not explain from pathophysiologic changes in cirrhosis? the relationship between cirrhosis and edema. ‐ "The edema occurs because your liver produces fewer proteins that help draw fluid into the blood stream." ‐ "The high osmotic pressure of proteins in your blood pushes fluid into body tissues." ‐ "Because of the liver disease, the kidneys are able to filter less fluid, so the body cannot excrete it as urine very easily." ‐ "Your body is metabolizing sex hormones more quickly, leading to fluid retention." | Select the option that describes the relationship between the liver and proteins. |
1441 The client has just had a liver biopsy. Which of the Correct answer: 1 Complications of liver biopsy include hemorrhage or accidental penetration of biliary following nursing actions would be the priority after canniculi. The nurse should assess for signs of hemorrhage (increased pulse, decreased blood the biopsy? pressure) every 30 minutes for the first few hours and then hourly for 24 hours. The client should be monitored for fever every 4 hours and remain on bedrest for 24 hours. ‐ Monitor pulse and blood pressure every 30 minutes until stable and then hourly for up to 24 hours. ‐ Ambulate every 4 hours for the first day as long as client can tolerate this. ‐ Measure urine specific gravity every 8 hours for the next 48 hours. ‐ Maintain NPO status for 24 hours post‐biopsy. | Recall that bleeding is the largest concern post liver biopsy. Vital sign changes are the only way to detect this complication. |
1442 Lactulose (Cephulac) is ordered for the client with Correct answer: 2 Lactulose (Cephulac) is a disaccharide laxative used to decrease the absorption of ammonia in cirrhosis. Which of the following serum laboratory the intestines, thereby lowering the serum ammonia and resulting in improvement in hepatic tests should the nurse monitor to determine if the encephalopathy. drug is having the desired effect? ‐ Albumin ‐ Ammonia ‐ Sodium ‐ Lactate | Recall that Lactulose is used to assist in reduction of ammonia. |
1443 The client is admitted to the hospital for possible Correct answer: 4 Factors that increase the risk of gallstone formation include female gender, aging, use of oral cholelithiasis. While taking the history, the nurse notes contraceptives, pregnancy, rapid weight loss, high cholesterol level, and diseases of the ileum. that the client has which of the following risk factors for the development of gallstones? ‐ Black race ‐ History of hypertension ‐ Age of 37 years ‐ Use of oral contraceptives | Omit options 1 and 2 as having no relationship to the disease. |
1444 The client is diagnosed with chronic pancreatitis, and Correct answer: 1 Pancrelipase (Lipancreatin) aids in the digestion of starches and fats and should be taken with pancrelipase (Lipancreatin) is prescribed. Which of the meals. It should not be crushed since hydrochloric acid destroys the drug, and it should not be following instructions should the nurse give to this mixed with alkaline foods (milk, ice cream). client about the administration of this medication? ‐ "Take the drug with meals." ‐ "Take the drug with a large glass of milk." ‐ "Take the drug between meals." ‐ "Take the drug after it is crushed and mixed with ice cream." | Recall that the drug is used to replace the natural digestive enzymes from the pancreas. |
1445 Which of the following assessments is essential for Correct answer: 2 The posterior pharynx is anesthetized for easy passage of the endoscope into the esophagus. the nurse to make when caring for a client who has The return of the gag reflex indicates that normal function is returning and the client is able to just had an esophagogastroduodenoscopy (EGD)? swallow. ‐ Auscultate bowel sounds ‐ Check gag reflex ‐ Monitor salivary pH ‐ Measure abdominal girth | Any upper GI procedure using a scope requires the anesthesia of the gag reflex, which can lead to aspiration. |
1446 A client has a nasogastric (NG) tube in place for Correct answer: 3 Thick secretions and particulate matter may obstruct the tube, causing drainage to cease; the gastric decompression and complains of increasing client may experience nausea and vomiting. The tube should be gently flushed to ensure nausea. Which action should the nurse take first? patency and rule out obstruction as the cause of the client's symptoms. ‐ Advance the tube 2 cm ‐ Place client in a recumbent position ‐ Instill 20 mL of saline ‐ Obtain abdominal x‐ray to assess placement | Select the option that assesses patency of the tube. |
1447 A client with a subtotal gastrectomy is scheduled for Correct answer: 3 Dumping syndrome is the rapid dumping of food into the jejunum without proper mixing and discharge. Which of these instructions should the digestion. Interventions that help to minimize dumping syndrome are lying down after eating, nurse give the client to reduce the possibility of eating a diet high in fat and protein and low in carbohydrates, and no fluids with meals. dumping syndrome? ‐ "Be sure to eat foods high in complex carbohydrates." ‐ "It is helpful to take a walk after eating." ‐ "Avoid drinking fluids with your meal." ‐ "Don't lie down for at least 2 hours after eating." | Select the option that would slow the movement of food through the GI tract. |
1448 A 32‐year‐old client is admitted to the hospital with a Correct answer: 2 BMI is an estimation of total body fat in relation to height and weight. An optimal BMI is 20 to body mass index (BMI) of 25. The nurse interprets this 25, increasing to 24 to 27 in the elderly. to mean the client: ‐ Is undernourished. ‐ Has an optimal amount of body fat. | Omit options 1 and 4 as they reflect extremes. Omit option 3 as there is no information to support this. |
‐ Is 10 percent overweight. ‐ Is morbidly obese. | |
1449 The nurse teaches the client with gastroesophageal Correct answer: 1 The client with GERD is encouraged to eat smaller, more frequent, low‐fat meals and to avoid reflux disease (GERD) about ways to minimize lying down after eating. Clients are instructed to not eat for at least 2 hours before bedtime symptoms. Which of the following statements made by and avoid foods that decrease lower esophageal sphincter pressure such as anything the client indicates that more teaching is needed? containing caffeine (coffee, tea, cola, chocolate). ‐ "I will be sure to drink tea instead of coffee." ‐ "I will take a walk after I eat." ‐ "I will try to eat smaller meals more frequently." ‐ "I will sleep with the head of the bed elevated about 12 inches.” | Remember that tea contains caffeine. |
1450 The client with a gastric ulcer is admitted to the Correct answer: 1 Gastric ulcers are usually a result of a disruption of the protective mechanism of the gastric hospital. The nurse should assess the client for intake epithelium. Substances that reduce prostaglandin secretion in the gastric mucosa (aspirin, of which of these substances that increases the risk of NSAIDs, alcohol) are responsible for gastric ulcers. Although certain foods and fluids may developing a gastric ulcer? aggravate an existing ulcer, they do not cause them. ‐ Aspirin ‐ Spicy foods ‐ Acetaminophen (Tylenol) ‐ Coffee | Recall that aspirin is often associated with ulcer formation. |
1451 The client with gastroesophageal reflux disease Correct answer: 4 Famotidine (Pepcid) is a histamine‐2 receptor antagonist and reduces the secretion of gastric (GERD) is prescribed famotidine (Pepcid). In order to acid. This class of drugs does not have a direct effect on reflux, LES tone, or GI motility. provide effective teaching, the nurse must have which of these understandings about the action of the drug? ‐ The drug improves gastric motility. ‐ The drug coats the distal portion of the esophagus. ‐ The drug increases LES tone. ‐ The drug decreases the secretion of gastric acid. | Think of the pathophysiology of GERD, which is reflux of gastric acid into the esophagus. The drug is used to reduce acid. |
1452 The client is admitted to the hospital with ulcerative Correct answer: 1 Hemorrhage and bleeding is a common feature of ulcerative colitis, and over time this can colitis. The nurse should assess the client for which lead to significant loss of RBCs. The client should be assessed for possible anemia. complication of the disease? ‐ Anemia ‐ Steatorrhea ‐ Cholelithiasis ‐ Thrombocytopenia | Recall that bleeding is common with ulcerative colitis. |
1453 The nurse is developing a health promotion program Correct answer: 1 Diverticular disease is virtually unknown in cultures where highly refined foods are not for intestinal health. Which of the following pieces of available (e.g., Africa, Asia) and was unknown in the United States prior to 1900. The other information should the nurse include in the program? statements are false. ‐ The addition of dietary fiber can reduce the risk of diverticulosis. ‐ A diet high in fat increases the risk of developing Crohn's disease. ‐ Irritable bowel syndrome is caused by a deficiency in soluble fiber. ‐ Laxatives can improve motility and bowel health. | Recall that the addition of dietary fiber is generally considered a good health promotion measure. |
1454 A client is admitted to the hospital with a bowel Correct answer: 1 Early in a bowel obstruction, the bowel attempts to move the contents past the obstruction, obstruction. Which of these findings by the nurse and this is heard as high‐pitched tinkling bowel sounds. As the obstruction progresses, bowel would indicate that the obstruction is in the early sounds will diminish and may finally become absent. stages? ‐ High‐pitched, tinkling bowel sounds ‐ Low rumbling bowel sounds ‐ No bowel sounds auscultated ‐ Normal bowel sounds heard in all four quadrants | Omit options 2 and 4 as they are descriptive of normal. Omit option 3 as a late sign. |
1455 A client with cirrhosis is admitted to the hospital. Correct answer: 1 In cirrhosis, the liver becomes fibrotic, which obstructs the venous blood flow through the Which of the following assessments made by the nurse liver. This increases the vascular pressure in the portal system, and causes congestion in the would indicate the development of portal spleen and development of varicosities in the esophagus. Bleeding esophageal varices are a hypertension? complication of portal hypertension and result in vomiting of blood and possible hemorrhage and death. ‐ Hematemesis ‐ Asterixis ‐ Elevated blood pressure ‐ Confusion | Recall that ‘heme’ means blood. Portal hypertension causes leaking of the esophageal vessels. |
1456 The nurse should teach the client with liver disease to Correct answer: 4 Any medication that is metabolized by the liver should be avoided, such as acetaminophen, avoid which of these over‐the‐counter medications sedatives, and barbiturates. Ranitidine is a histamine<sub>2</sub> reception after discharge? antagonist, psyllium is a laxative, and ascorbic acid is Vitamin C. ‐ Ranitidine (Zantac) ‐ Psyllium (Metamucil) ‐ Ascorbic acid (Vitamin C) ‐ Acetaminophen (Tylenol) | Recall that Tylenol is metabolized by the liver and should be avoided. |
1457 The nurse is doing discharge teaching for a client who Correct answer: 3 A low‐sodium diet is recommended for clients that have cirrhosis and ascites. Potato chips has cirrhosis and ascites. Which of the following foods are high in sodium. Cookies and hard candy are high in sugar, while bread is high in complex used by the client as snacks should the nurse instruct carbohydrates. the client to avoid? ‐ Whole wheat bread ‐ Cookies ‐ Potato chips ‐ Hard candy | Recall that potato chips would rarely be a recommended snack. |
1458 The client who has liver disease asks the nurse why he Correct answer: 1 The liver synthesizes clotting factors I, II, VII, IX, and X as well as prothrombin and fibrinogen. bruises so easily. Which of the following information These substances are needed for adequate clotting, so their reduction leads to increased risk should the nurse include in the response? of bleeding. The other responses do not address this concern. ‐ "Your liver is unable to make the proteins that are needed to make clotting factors." ‐ "Your liver can no longer metabolize drugs and render them inactive." ‐ "Your liver is breaking down blood cells too rapidly." ‐ "Your liver can't store Vitamin C any longer." | Recall the liver’s role in clotting to select option 1 as correct. |
1459 A client is seen in the clinic for a routine physical Correct answer: 2 HBsAg is hepatitis surface antigen and is usually present before symptoms manifest. It examination and the laboratory test results indicate an indicates acute disease. The other options are incorrect conclusions regarding this test result. elevated HBsAg. In order to plan teaching for this client, the nurse interprets this lab result to mean: ‐ The client has immunity to hepatitis B. | Recognize that this is the antigen, therefore it reflects active disease. |
‐ The client has active hepatitis B. ‐ The client has resolving hepatitis B. ‐ The client has had the hepatitis B vaccine. | |
1460 The client who has esophageal varices is receiving a Correct answer: 1 Vasopressin causes vasoconstriction and may precipitate an acute anginal attack or vasopressin infusion. Which of these findings would myocardial infarction, especially in those with known cardiovascular disease. The other options indicate a complication of this therapy? are unrelated to the question. ‐ Chest pain ‐ Tinnitus ‐ Flushed skin ‐ Polyuria | Select the most serious vascular symptom. |
1461 The client who has cholelithiasis is scheduled for Correct answer: 1 After the extracorporeal shock wave lithotripsy, the nurse should monitor for biliary colic and extracorporeal shock wave lithotripsy. The nurse nausea. The colicky pain is caused by passage of stone fragments through the biliary tree into should tell the client about which of these symptoms the small intestine. Headache, diarrhea, and hiccoughs are unrelated manifestations. that may occur after this procedure? ‐ Colic‐type pain ‐ Headache ‐ Diarrhea ‐ Hiccups | Select the symptom that would be most like cholelithiasis symptoms. |
1462 The client who has acute cholecystitis tells the nurse, Correct answer: 3 With the advent of laparoscopic surgical technique, the only absolute contraindication for "I just want my gallbladder taken out now." Which of surgery is acute infection. The other options do not address this concern. the following is the best response by the nurse? ‐ "I don't blame you, but they want your pain under control first." ‐ "Would you like me to ask if your physician will schedule surgery today?" ‐ "The symptoms are distressing, but the surgeon must wait until your gallbladder is less infected." ‐ "They will try to dissolve the stones before they do the surgery.” | Select the option that acknowledges the clients concern while offering an accurate explanation. |
1463 The client is admitted to the hospital with acute Correct answer: 2 Pancreatitis is associated with alcoholism in men and gallstones in women. The disorders in pancreatitis. The nurse taking a history should question options 1 and 3 are not associated with increased risk of pancreatitis, while option 4 promotes the client about which of these risks for developing health. pancreatitis? ‐ Inflammatory bowel disease ‐ Alcoholism ‐ Diabetes mellitus ‐ High‐fiber diet | Associate acute pancreatitis with alcohol abuse. |
1464 The client with chronic pancreatitis is being Correct answer: 1 The client with chronic pancreatitis may require pancreatic enzyme supplements such as discharged. The nurse should anticipate teaching the pancrelipase (Lipancreatin). These will promote proper digestion of foods. The other client about which of these medications? medications do not address this need. ‐ Pancrelipase (Pancrease) ‐ Morphine sulfate ‐ Biotin ‐ Lactulose (Cephulac) | ‘Pancrease’ sounds like pancreas. Use this finding to select the correct response. |
1465 A client is to receive gavage feeding through an NG Correct answer: 2 Keeping the client in a high Fowler's position minimizes the risk of aspiration. The other tube. Which of the following nursing actions should be options do not address this priority issue of care. instituted to prevent complications? | Select the option that will help to prevent aspiration. |
‐ Flush with 20 mL of air ‐ Place client in high Fowler's position ‐ Advance tube 1 cm ‐ Plug the air vent during feeding | |
1466 A client is to have an intestinal tube placed to Correct answer: 3 Activity, including position changes and ambulation, stimulate intestinal peristalsis and assist decompress the bowel. Which of the following in the forward movement of the tube. explanations should the nurse give to the client about what to expect? ‐ "You will need to remain on bed rest until the tube is removed." ‐ "While the tube is in place, you will need to lie on your right side." ‐ "Walking in the hall will help move the tube forward." ‐ "Keeping the bed flat should make you more comfortable." | Recognize that the intestinal tube needs to advance in order to be effective. |
1467 The nurse is caring for a client with a Sengstaken‐ Correct answer: 4 Scissors should be kept at the bedside of all clients with an esophagogastric tube and the tube Blakemore tube. Which of the following actions should should be cut if the client experiences respiratory compromise. Maintaining the client's airway the nurse take first if the client suddenly experiences is the first priority of care. difficulty breathing? ‐ Elevate the head of the bed ‐ Apply oxygen with a nasal cannula ‐ Listen to the client's lungs ‐ Cut and remove the tube | Use the ABCs (airway, breathing, circulation) to select the best response. If the client is having difficulty breathing it is likely due to the balloon obstructing the airway. Removal of the tube is the best option. |
1468 The client returns to the nursing unit postoperatively Correct answer: 2 A healthy stoma is red to reddish‐pink, moist, and shiny. A stoma that appears dark red, after a colostomy. Which of the following assessments bluish, or black indicates ischemia or necrosis. This finding must be reported immediately would require immediate action by the nurse? because the viability of the tissue is at risk. Options 3 and 4 are of no concern immediately postop. ‐ Stoma is bright red. ‐ Stoma is bluish. ‐ Stoma is draining serous fluid. ‐ Stoma is draining no fluid. | Recognize that a bluish stoma indicates lack of blood flow. |
1469 A client who had a Billroth I procedure is beginning to Correct answer: 2 Symptoms of dumping syndrome can occur within 5 minutes to 3 hours after eating and eat solid foods. The nurse should assess the client for include nausea, vomiting, tachycardia, diaphoresis, abdominal pain, diarrhea, syncope, and the development of dumping syndrome. Which of the hyperactive bowel sounds. following assessments would be indicative of dumping syndrome? The presence of: ‐ Bradycardia. ‐ Diarrhea. ‐ Dyspnea. ‐ Coughing. | Recall that dumping syndrome causes diarrhea. |
1470 A client is admitted to the hospital in a malnourished Correct answer: 1 Undernutrition affects many systems, causing decreases in metabolic function and cell‐ state. The nurse understands the client is at a high risk mediated and humoral immunity, thereby increasing the susceptibility to infection. The other for which of the following conditions as a result of responses are incorrect. decreased nutrition? ‐ Infection ‐ Diarrhea ‐ Fever ‐ Tumor formation | Recall that poor nutrition reduces ability to fight infection. |
1471 The nurse is preparing a client with hiatal hernia for Correct answer: 4 Conservative treatment for hiatal hernia consists of lifestyle changes including remaining discharge. Which of the following statements made by upright after eating; avoiding straining, tight clothing, and vigorous exercise; and eating small, the client would indicate that teaching has been frequent, low‐fat meals. effective? ‐ "I will join the gym and get in shape by lifting weights." ‐ "I know I need to eat a high‐fat diet to slow down my digestion." ‐ "I will join a support group." ‐ "I will take a walk after dinner each night." | The most common instruction is for the client to remain upright after a meal. |
1472 The nurse should question the client with Correct answer: 2 Many common substances contribute to decreased LES pressure including fatty foods, gastroesophageal reflux disease (GERD) about the use caffeinated beverages, nicotine, beta‐adrenergic blocking agents, calcium channel blockers, of which of these medications that decreases LES nitrates, theophylline, peppermint, alcohol, high levels of estrogen and progesterone, and pressure? anticholinergic drugs. ‐ Antidepressants ‐ Calcium channel blockers ‐ Antiestrogen agents ‐ Alpha‐adrenergic blocking agents | Recall that calcium channel blockers cause muscular relaxation. |
1473 The client with irritable bowel syndrome (IBS) asks Correct answer: 3 There is no known cause of IBS, and diagnosis is made by excluding all the other diseases that the nurse what causes the disease. Which of the cause the symptoms. There is no inflammation of the bowel. Some factors exacerbate the following responses by the nurse would be most symptoms, including anxiety, fear, stress, depression, some foods and drugs, but these do not appropriate? cause the disease. ‐ "This is an inflammation of the bowel caused by eating too much roughage." ‐ "IBS is caused by a stressful lifestyle." ‐ "The cause of this condition is unknown." ‐ "There is thinning of the intestinal mucosa caused by ingestion of gluten." | Omit options 1 and 4 as there is no causative relationship between foods and IBS. |
1474 A client with Crohn's disease (regional enteritis) who Correct answer: 2 Sulfasalazine is a GI anti‐inflammatory medication that exerts its action by decreasing is taking sulfasalazine (Azulfidine) asks the nurse why prostaglandin production in the bowel. It does not have the other effects listed. this medication is necessary. Which information should the nurse include in the response? ‐ The drug decreases abdominal cramping by slowing peristalsis. ‐ The drug decreases prostaglandin production in the bowel so it decreases inflammation. ‐ The drug inhibits neurotransmission of pain impulses. ‐ The drug stimulates the release of endorphins so pain is relieved. | Recall that anti‐inflammatory medications often work by influencing prostaglandin production. |
1475 The nurse should evaluate results of which of the Correct answer: 1 Many clotting factors are produced in the liver including fibrinogen (factor I), prothrombin following laboratory tests for a client with cirrhosis in (factor II), factor V, serum prothrombin conversion accelerator (factor VII), factor IX, and factor order to plan for safe care? X. The prothrombin time will evaluate blood clotting ability while the others will not. ‐ Prothrombin time ‐ Urinalysis ‐ Serum lipase ‐ Troponin | The item asks about safety. Recall that bleeding is a safety concern for clients with cirrhosis and PT results would help to address this. |
1476 The nurse is caring for a client with a history of Correct answer: 3 Manifestations of chronic pancreatitis include nausea, vomiting, weight loss, flatulence, alcoholism. Which of the following findings would constipation, and steatorrhea that result from a decrease in pancreatic enzyme secretion. indicate that the client has possibly developed chronic Weight gain (option 1) is the opposite of what occurs with this disorder, while options 2 and 4 pancreatitis? are unrelated. ‐ Weight gain | The pain of pancreatitis is not in the flank. Weight loss is associated with pancreatitis. Hiccoughs are not related. Steatorrhea is due to the inability to breakdown fats. |
‐ Flank pain ‐ Steatorrhea ‐ Hiccoughs | |
1477 The nurse caring for a client with hemolytic jaundice Correct answer: 1 Hemolytic jaundice is caused by excessive breakdown of red blood cells and the amount of would expect which of these findings on the laboratory bilirubin produced exceeds the ability of the liver to conjugate it, so there is an increase in results? indirect bilirubin. Unconjugated bilirubin is insoluble in water and is not found in the urine. ‐ Elevated serum indirect Bilirubin ‐ Decreased serum protein ‐ Elevated urine Bilirubin ‐ Decreased urine pH | Recall that indirect means due to a secondary cause, in this case the inability of the liver to metabolize the excessive RBC breakdown. |
1478 The client has cholelithiasis. Which of the following Correct answer: 4 Nausea and RUQ pain occur in cystic duct disease, but obstruction of the common bile duct assessment findings indicates to the nurse that the results in reflux of bile into the liver, which produces jaundice. Alkaline phosphatase increases stone has probably obstructed the common bile duct? with biliary obstruction but not cholesterol. ‐ Nausea ‐ Hypercholesterolemia ‐ Right upper quadrant (RUQ) pain ‐ Jaundice | Recall that obstruction of bile flow causes jaundice. |
1479 The nurse caring for a client with uncomplicated Correct answer: 2 Obstructive biliary disease causes a significant elevation in alkaline phosphatase. Obstruction cholelithiasis should expect an elevation in which of in the biliary tract causes an elevation in direct bilirubin, not indirect bilirubin (option 4). these laboratory tests? Options 1 and 3 are unrelated. ‐ Serum amylase ‐ Alkaline phosphatase ‐ Mean corpuscular hemoglobin concentration (MCHC) ‐ Indirect Bilirubin | Omit options 1 and 3 as having no relationship to gall bladder disease. |
1480 In caring for the client 4 days post‐cholecystectomy, Correct answer: 3 The T‐tube may drain 500 mL in the first 24 hours and decreases steadily thereafter. If there is the nurse notices that the drainage from the T‐tube is excessive drainage, the physician should be notified immediately. Option 1 would be 600 mL in 24 hours. Which is the appropriate action by contraindicated while options 2 and 4 are of no help. the nurse? ‐ Clamp the tube q 2 hours for 30 minutes ‐ Place the client in a supine position ‐ Notify the physician ‐ Encourage an increased fluid intake | Omit options 2 and 4 as these actions would not influence drainage. |
1481 The post‐cholecystectomy client asks the nurse when Correct answer: 1 When T‐tube drainage subsides and stools return to a normal brown color, the tube can be the T‐tube will be removed. Which of the following clamped 1 to 2 hours before and after meals in preparation for tube removal. If the client responses by the nurse would be appropriate? tolerates clamping, the tube will then be removed. ‐ "When your stool returns to a normal brown color the tube can be removed." ‐ "The tube will be removed at the same time as your staples." ‐ "When the tube stops draining, it will be removed." ‐ "The tube is usually removed the day after surgery." | Omit option 2 as the removal of staples is not the criteria for removal of the t‐tube. Recognize that option 4 is incorrect as the first post operative day is too soon for tube removal. |
1482 Which of the following assessments made by the Correct answer: 1 Obstruction to portal blood flow causes a rise in portal venous pressure resulting in nurse could indicate the development of portal splenomegaly, ascites, and dilation of collateral venous channels predominantly, in the hypertension in a client with cirrhosis? paraumbilical and hemorrhoidal veins, the cardia of the stomach, and extending into the esophagus. ‐ Hemorrhoids ‐ Bleeding gums ‐ Muscle wasting ‐ Hypothermia | Look for the option that would reflect increased venous pressure. |
1483 The nurse is caring for a client who has ascites and Correct answer: 3 Spironolactone (Aldactone) is used in clients with ascites that show no improvement with the healthcare provider prescribes spironolactone bedrest and fluid restriction. It inhibits sodium reabsorption in the distal tubule and promotes (Aldactone). The client asks why this drug is being potassium retention by inhibiting aldosterone. used. Which is the best response by the nurse? ‐ "This will help increase the level of protein in your blood." ‐ "The drug will cause an increase in the amount of the hormone aldosterone your body produces." ‐ "This medication is a diuretic but does not make the kidneys excrete potassium." ‐ "This will help you excrete larger amounts of ammonia." | Recall that Aldactone is the most common potassium sparing diuretic. |
1484 When caring for a client that has cirrhosis, the nurse Correct answer: 4 Asterixis, also called liver flap, is the flapping tremor of the hands when the arms are notices flapping tremors of the wrist and fingers. How extended. should the nurse chart this finding? ‐ Trousseau's sign noted ‐ Caput medusa noted ‐ Fetor hepaticus noted ‐ Asterixis noted | Recall that asterixis is called liver flap. |
1485 A client has a total gastrectomy. The nurse should Correct answer: 2 The loss of parietal cells that secrete intrinsic factor results in Vitamin teach the client about long‐term treatment for which B<sub>12</sub> deficiency post‐gastrectomy. For this reason, clients require of these conditions? Vitamin B<sub>12</sub> injections for life. ‐ Vitamin K deficiency ‐ Vitamin B12 deficiency ‐ Vitamin A deficiency ‐ Vitamin C deficiency | Recall that parietal cells in the stomach are needed for B<sub>12</sub> absorption. |
1486 A client with suspected duodenal ulcer has an upper Correct answer: 1 A side effect of Gastrografin is diarrhea. It does not cause the other signs and symptoms GI series with meglumine diatrizoate (Gastrografin). listed. The nurse should inform the client about which of the following side effects of this contrast medium? ‐ Diarrhea ‐ Peritonitis ‐ Flushing ‐ Dysuria | Select the gastrointestinal symptom listed. |
1487 A client with diverticular disease undergoes a Correct answer: 3 Bowel perforation is a possible result of colonoscopy, if the colonoscope accidentally pierces colonoscopy. The nurse should assess the client for the bowel wall. The other options are incorrect. which of the following possible complications of the procedure? ‐ Diarrhea ‐ Obstruction ‐ Bowel perforation | Recall that perforation would always be a risk when an instrument is introduced into the bowel. |
4.‐ Infection | |
1488 A nasogastric (NG) tube is ordered to be inserted in a Correct answer: 1 Use of the high Fowler's position utilizes gravity to protect against aspiration and is the client with a possible bowel obstruction. In position of choice for NG tube insertion. Option 2 provides minimal protection against preparation for this procedure, the nurse places the aspiration, while options 3 and 4 provide none. client in which position? ‐ High Fowler's ‐ Head of the bed elevated 20 degrees ‐ Lying on right side ‐ Flat | Select the option that puts the client in the highest position. |
1489 After completing a gavage feeding using a bag and Correct answer: 3 The tube should be clamped to prevent air from entering the stomach; air causes cramping tubing for a client receiving an enteral formula, the and bloating. Next, the tube should be flushed with water (30 ‐ 60 mL). The client should nurse should take which of these actions first? remain in a high Fowler's position or an elevated side‐lying position for 30 to 60 minutes to reduce the risk of aspiration. ‐ Position the client in the left lateral position ‐ Instill 30 mL of air to clear the line ‐ Clamp the tube ‐ Flush the tube with water | Omit option 1 as this would increase the chance for aspiration. Omit option 2 as water should be used to clear or flush the line. |
1490 Which of the following nursing actions should be a Correct answer: 1 Intestinal tubes are used to treat bowel obstruction, a symptom of which is a fecal taste in priority for a client with an intestinal tube? the mouth. Frequent mouth care including hard candy, ice chips, and throat lozenges is essential to reduce the experience of fecal taste. The client is encouraged to move in bed and ambulate to assist in the advancement of the tube. ‐ Mouth care ‐ Vital signs ‐ Skin care ‐ Elevate side rails | Select the option that names a structure that is part of the GI tract. |
1491 The nurse is caring for a client who has severe Correct answer: 4 Excessive blood loss will result in the development of shock symptoms such as tachycardia, continuous bleeding from a self‐inflicted wrist cool, clammy skin, and changes in mental status, because hypovolemia leads to laceration. While applying direct pressure to the area vasoconstriction and shunting of blood to the central circulation. Applying ice to lower the with a dry, sterile dressing, the nurse's next action body temperature would not be appropriate since the body temperature is usually decreased would to be to do which of the following? with hypovolemia. Measures to decrease circulation to the affected extremity, such as elevation of that extremity to heart level would be appropriate, although elevating it further could lead to ischemia. A psychiatric evaluation would be appropriate after the client has become hemodynamically stable. ‐ Call for a psychiatric evaluation since this was a self‐inflicted injury ‐ Apply ice to lower the body temperature to slow circulation ‐ Lower the extremity to below heart level ‐ Assess for signs of shock | Consider the ABCs (airway, breathing, and circulation). After these have been addressed, additional interventions can be implemented safely. |
1492 The nurse should encourage the client with dumping Correct answer: 3 Dumping syndrome can occur following gastrectomy, in which gastric contents rapidly enter syndrome to avoid which of these foods? the bowel. Dietary fats and proteins are increased, and carbohydrates, especially simple carbohydrates such as fruits, are reduced. This helps slow the GI transit time and reduce the GI cramping, diarrhea, and vasomotor symptoms. ‐ Eggs ‐ Cheese ‐ Fruit ‐ Pork | Select the highest carbohydrate option as these foods are too easily digested. |
1493 A client is admitted to the hospital for morbid obesity Correct answer: 4 The individual is considered obese at 20 percent over ideal body weight and morbidly obese and asks what that means. In order to answer the when over 100 percent above the ideal body weight. client's question, the nurse should understand that morbid obesity is determined when the client is: ‐ 20 percent over ideal body weight. ‐ 40 percent over ideal body weight. ‐ 60 percent over ideal body weight. ‐ 100 percent over ideal body weight. | Select the option with the highest number as morbid obesity is considered severe. |
1494 The nurse would expect which of these assessment Correct answer: 1 The pain of a gastric ulcer is dull and aching and occurs after eating and is not relieved by findings in a client with duodenal ulcers? food as is the pain from duodenal ulcer. Chronic aspirin use is irritating to the stomach (option 2). The manifestations in options 3 and 4 are unrelated. ‐ Epigastric pain relieved by food ‐ History of chronic aspirin use ‐ Distended abdomen ‐ Positive fluid wave | Recall that pain relieved by food intake is associated with ulcers. |
1495 Which of the following statements made by a client Correct answer: 4 Many salt substitutes use potassium chloride. Potassium intake is carefully regulated in with chronic renal failure and who is on hemodialysis clients with renal failure, and the use of salt substitutes will worsen hyperkalemia. Increases in indicates the need for further teaching? weight (option 1) do need to be reported to the health care provider as a possible indication of fluid volume excess. The control of hypertension (option 2) is essential in the management of a client with renal failure. An AV fistula does need to be protected from injury that could be caused by constricting clothing, venipunctures, and other items (option 3). ‐ “I will report any increase in my weight of 5 pounds in a 2‐day period.” ‐ “I take my prescribed antihypertensive drugs daily.” ‐ “I am careful to take precautions in the arm with the AV fistula.” ‐ “I comply with salt restrictions in my diet by using salt substitutes.” | The core issue of the question is the ability to determine accurate statements about self‐ care of clients with renal failure. Specifically, clients need to restrict both sodium and potassium, and salt substitutes are high in potassium. Use nursing knowledge and the process of elimination to make a selection. |
1496 What type of renal failure would the nurse expect to Correct answer: 4 Nephrotoxic drugs, such as aminoglycoside antibiotics (tobramycin), can damage the see in a client who overdosed accidentally on nephrons and cause intrarenal (within the kidneys) failure. There is no condition called tobramycin (Nebcin)? extrarenal failure. ‐ Prerenal failure ‐ Postrenal failure ‐ Extrarenal failure ‐ Intrarenal failure | The core issue of the question is the ability to associate causes of renal failure with their categories in specific client situations. Use nursing knowledge and the process of elimination to make a selection. |
1497 A client with urinary tract infection (UTI) is prescribed Correct answer: 2 The drug makes the urine reddish orange in color, and the client should be advised that this phenazopyridine (Pyridium). Which of the following might stain the underwear and other clothing. The client should also be reassured that it instructions would the nurse give the client? should not be confused with blood in the urine. The use of Pyridium in UTI is controversial because it does not target the cause of the infection. However, it offers relief of UTI symptoms such as pain, frequency, and urgency (option 1). Taking the drug after meals minimizes GI symptoms associated with the use of this drug (option 3). Option 4 is incorrect because the indiscriminate use of a urinary analgesic can mask symptoms and delay initiation of treatment. ‐ “This drug will take care of the infection causing your symptoms.” ‐ “Your urine may turn reddish orange and may cause staining of your clothes.” ‐ “Take the drug before meals to minimize GI symptoms.” ‐ “Always keep this drug and use it at the first symptom of a UTI.” | The core issue of the question is knowledge of expected adverse effects of Pyridium. Use nursing knowledge and the process of elimination to make a selection. |
1498 A client with a urinary diversion device has the Correct answer: 3 Emptying the reservoir bag every 2 hours prevents overfilling and possible leakage of urine nursing diagnosis risk for impaired skin integrity. Which into the skin surface. The urine collection device should be changed as needed to maintain of the following interventions will the nurse use with integrity of the system. Self‐catheterization is not appropriate for this nursing diagnosis. this client? Monitoring for foul‐smelling urine and monitoring for signs of infection are more appropriate interventions for the diagnosis risk for infection. ‐ Change urine collection device every other day. ‐ Teach self‐catheterization technique. ‐ Empty the bag reservoir every 2 hours. ‐ Monitor for foul‐smelling urine. | The core issue of the question is knowledge of appropriate care for a client with a urinary diversion. Use nursing knowledge and the process of elimination to make a selection. |
1499 A client with renal calculi is advised to restrict calcium Correct answer: 3 Chocolate, smoked fish, milk products, beans, lentils, and dried fruits are high in calcium. In in his diet. The nurse determines that the client calcium phosphate and calcium oxalate calculi, dietary management includes an acid‐ash diet understands the restrictions when he states he will and limiting foods high in calcium and oxalate. avoid which of the following? ‐ Chicken, beef, and salmon ‐ Green vegetables, fruit, and legumes ‐ Chocolate, smoked fish, and low‐fat milk ‐ Eggs, meat, and poultry | The core issue of the question is knowledge of foods that are high in calcium. Use nursing knowledge and the process of elimination to make a selection. |
1500 In conducting client teaching with a client who will Correct answer: 4 Peritonitis is a grave complication of peritoneal dialysis, caused by bacteria that may enter undergo peritoneal dialysis at home, the nurse through the catheter or dialysate solution. Hypotension is a common complication of includes discussion of what common and significant hemodialysis but not peritoneal dialysis (option 2). Pulmonary embolism and dyspnea are not complication of peritoneal dialysis? common complications of peritoneal dialysis. ‐ Pulmonary embolism ‐ Hypotension ‐ Dyspnea ‐ Peritonitis | The core issue of the question is knowledge of the complications associated with peritoneal dialysis and their relative frequency. Use nursing knowledge and the process of elimination to make a selection. |
1501 The nurse is preparing to admit a client with urge Correct answer: 4 Urge incontinence is the unpredictable passage of urine soon after a strong urge to void is incontinence. In writing the nursing care plan, the felt. Option 1 describes total incontinence, option 2 describes stress incontinence, and option nurse writes interventions that target the client’s 3 describes urinary retention. The pathophysiology, contributing factors, therapeutic and nursing interventions for the different types of incontinence differ. ‐ involuntary loss of urine without warning or stimulus. ‐ loss of urine when coughing or sneezing. ‐ inability to empty bladder. ‐ inability to stop urine flow long enough to reach the toilet. | Use nursing knowledge and the process of elimination to make a selection. |
1502 A male client who presents to the emergency Correct answer: 3 The symptoms are typical of acute glomerulonephritis. Hematuria and proteinuria are caused department with coffee‐colored urine and edema by a damaged glomerular capillary membrane, which allows blood cells and proteins to escape states that he had a bad sore throat a few weeks ago. into the renal filtrate. A urinary tract infection usually manifests with signs of infection His blood pressure is elevated, and urinalysis shows including fever, malodorous urine, frequency, and urgency. Clients with urinary calculi usually blood and protein in the urine. The nurse interprets present with renal colic. Prostatitis, or inflammation of the prostate gland, also has presenting that the client’s clinical picture is consistent with which symptoms similar to a urinary tract infection. of the following? ‐ Urinary tract infection ‐ Urinary calculi ‐ Acute glomerulonephritis ‐ Acute prostatitis | The core issue of the question is the ability to identify signs and symptoms of glomerulonephritis and associate it with a common etiology. Use nursing knowledge and the process of elimination to make a selection. |
1503 A client in the intensive care unit develops prerenal Correct answer: 3 Prerenal failure is caused by factors such as hypovolemia and decreased cardiac output that failure following surgery. Which of the following affect renal blood flow and perfusion. Urethral obstruction (option 2) can cause postrenal causes should the nurse suspect? failure. Vascular disease and glomerulonephritis may be factors in the development of intrarenal failure. ‐ Vascular disease ‐ Urethral obstruction ‐ Hypovolemia ‐ Glomerulonephritis | The core issue of the question is the ability to identify causes of prerenal failure. Use nursing knowledge and the process of elimination to make a selection. |
1504 Which of the following discharge instructions would Correct answer: 2 To reduce the risk of nephrotoxicity, the client who receives aminoglycoside antibiotics the nurse give to a client who will receive should report signs of edema or hypertension and maintain a fluid intake of 2,000 to 2,500 mL aminoglycoside antibiotics at home? per day. ‐ Limit fluid intake to 1200 mL daily ‐ Report sudden weight gain or puffy eyes ‐ Edema is a normal side effect of the medication ‐ Elevated blood pressure is an expected effect of the medication | The core issue of the question is the ability to correctly institute client teaching with knowledge of nephrotoxicity as an adverse effect of aminoglycoside medications. Use nursing knowledge and the process of elimination to make a selection. |
1505 The nurse caring for a client undergoing a Correct answer: 4 Hypotension is the most common complication during hemodialysis and is related to several hemodialysis procedure places high priority on factors, including changes in serum osmolality and rapid removal of fluid from the evaluating the client frequently for what common intravascular compartment. Dialysis dementia is a progressive, long‐term complication. complication during the treatment? Infection and fever should be an ongoing assessment for a hemodialysis client. Hyperglycemia could occur because of the composition of the dialysate, but it is not of great concern unless the client has diabetes mellitus. ‐ Hyperglycemia ‐ Infection and fever ‐ Dialysis dementia ‐ Hypotension | The core issue of the question is the ability to identify important complications associated with hemodialysis. Use nursing knowledge and the process of elimination to make a selection. |
1506 The nurse is explaining the process of peritoneal Correct answer: 3 The peritoneum acts as a semipermeable membrane, allowing substances to move from an dialysis to a client who recently developed renal area of high concentration (the blood) to an area of lower concentration (the dialysate). failure. Which of the following statements would the Metabolic waste products and excess water can be eliminated through osmosis and diffusion nurse include in a discussion with the client? utilizing the peritoneum as the semipermeable membrane. ‐ “The solutes in the dialysate will enter the bloodstream through the peritoneum.” ‐ “The peritoneum is more permeable because of the presence of excess metabolites.” ‐ “The peritoneum acts as a semipermeable membrane through which wastes move by diffusion and osmosis.” ‐ “The metabolites will diffuse from the interstitial space to the bloodstream mainly through diffusion and ultrafiltration.” | The core issue of the question is the ability to relate accurately the key elements of peritoneal dialysis. Use nursing knowledge and the process of elimination to make a selection. |
1507 Which of the following laboratory data is the most Correct answer: 2 Creatinine is the metabolic end product of creatine phosphate and is excreted via the kidneys accurate indicator that a client with acute renal failure in relatively constant amounts. BUN, a measurement of the nitrogen portion of urea, is also has met the expected outcomes? excreted in urine and is a good indicator of renal function. However, conditions that increase protein catabolism also cause a rise in BUN levels. Therefore, the serum creatinine levels are more appropriate to evaluate in determining the return of renal function. Neutrophils and lymphocytes are not used to monitor the return of renal function. ‐ Decreasing blood urea nitrogen (BUN) levels ‐ Decreasing serum creatinine ‐ Decreasing neutrophil count ‐ Decreasing lymphocyte count | The critical words in the question are most accurate. This tells you that more than one response is technically correct, and you must prioritize to choose the option that best answers the question. Use nursing knowledge and the process of elimination to make a selection. |
1508 Which of the following statements made by a client Correct answer: 3 Adult polycystic kidney disease is an autosomal‐dominant disorder, and the client should be with polycystic kidney disease indicates that the advised to have family members screened for the disease. The management of clients with desired outcome has been met? polycystic kidney disease is mainly supportive. Eventually, clients with this disease require dialysis or transplantation. ‐ “I know these drugs will make the cysts disappear.” ‐ “The development of renal failure with this disease is very rare.” ‐ “I will have my family seek genetic counseling and screening.” ‐ “I sure am glad that hemodialysis will shrink the cysts.” | The core issue of the question is knowledge that this disorder has a genetic basis. Use nursing knowledge and the process of elimination to make a selection. |
1509 A client is scheduled for a partial nephrectomy. In Correct answer: 4 The upper abdominal incision site in clients with nephrectomy predisposes them to the teaching the client about postoperative care, the nurse development of respiratory complications, particularly atelectasis and pneumonia. The uses which rationale to explain why aggressive proximity of the incision to the muscles involved in breathing and coughing makes the client measures are needed to prevent atelectasis and breathe shallowly and avoid coughing because of the fear of pain. Adequate pain control is pneumonia? necessary in the care of this client. The other options are not accurate statements. ‐ Nephrectomy involves paralyzing the intercostal muscles. ‐ Intraoperative surgical contamination of the pulmonary structures is unavoidable. ‐ The client must be maintained in a flat position for 24 hours. ‐ The surgery involves an upper abdominal incision. | The core issue of the question is the ability to correlate location of incision with risks for postoperative complications following nephrectomy. Use nursing knowledge and the process of elimination to make a selection. |
1510 Which of the following statements made by a client Correct answer: 2 Clients with renal transplant need to be on long‐term immunosuppressive drugs. This who has received a renal transplant indicates that the predisposes them to infection. The client must verbalize factors that potentially expose him to desired outcome of the discharge teaching plan has infection. Dietary restrictions must be discussed with the physician and the dietician. The client been met? with renal transplant also needs to verbalize understanding of his medications to prevent rejection, including the use of immunosuppressants. However, he must adhere to the dose prescribed by the physician. The success of transplantation is not guaranteed. ‐ “I will double my prednisone dose if my urine output is less than 300 mL/day.” ‐ “I will need to avoid crowds and prevent infection.” ‐ “Now I can eat whatever I want as long as I watch how much salt I use.” ‐ “Since I have not yet rejected the transplant, I never have to worry about rejection anymore.” | The core issue of the question is the knowledge that clients who have had organ transplant are greatly at risk for infection because of drug therapy needed to prevent organ rejection. Use nursing knowledge and the process of elimination to make a selection. |
1511 Which of the following statements by a female client Correct answer: 2 Maintaining an intake of 8 to 10 glasses of fluid daily will help prevent UTI. Cotton underpants indicates that instruction in ways to prevent urinary are best, and nylon should be avoided because synthetic fibers dry and irritate the perineal tract infection (UTI) was understood? area. Irritation of the perineal area can promote the growth of bacteria. The client should not delay voiding when the urge is felt. Emptying the bladder every 2 to 4 hours while awake is recommended to prevent urinary stasis. ‐ “I should limit intake of water so I won’t need to urinate so often.” ‐ “I should drink 8 to 10 glasses of fluid per day.” ‐ “I should only wear nylon underpants.” ‐ “I should void every 6 hours while I am awake.” | The core issue of the question is knowledge of risk factors for UTIs that must be avoided by clients at risk. Use nursing knowledge and the process of elimination to make a selection. |
1512 A client with chronic renal failure asks the nurse why Correct answer: 3 Anemia is common in clients with renal failure. Among the factors causing the anemia are he is anemic. Which of the following responses by the decreased production of erythropoietin by the kidneys and shortened RBC life. Erythropoietin nurse is best? is involved in the stimulation of the bone marrow to produce RBCs. ‐ “The increased metabolic waste products in your body depress the bone marrow.” ‐ “We will need to review your dietary intake of iron‐rich foods.” ‐ “There is a decreased production by the kidneys of the hormone erythropoietin.” ‐ “It is most likely that you have hereditary traits for the development of anemia.” | The core issue of the question is the pathophysiology underlying renal failure and associated changes. Use nursing knowledge and the process of elimination to make a selection. |
1513 A client with end‐stage renal failure is to be admitted Correct answer: 3 Clients with potassium levels of 6.5 and greater are predisposed to develop cardiac to the hospital because of shortness of breath. The arrhythmias, muscle cramps, and gastrointestinal symptoms. The client should be admitted to serum potassium level is 7.0 mEq/L. What appropriate a nursing unit with telemetry or cardiac monitoring capabilities because of the risk of hospital unit should this client be admitted to? developing life‐threatening cardiac dysrhythmias. Typical ECG abnormalities associated with hyperkalemia are prolonged PR interval; wide QRS; tall, tented T‐wave; and ST segment depression. Major cardiac dysrhythmias common in clients with highly elevated potassium levels include heart block, ventricular standstill, and ventricular fibrillation. ‐ A semiprivate room in a medical surgical unit ‐ A private room in a medical surgical unit ‐ A nursing unit with continuous electrocardiographic monitoring ‐ A nursing unit for ventilator‐assisted clients | The core issue of the question is knowledge of the significance of a high serum potassium level and the appropriate placement of the client to detect possible complications. Use nursing knowledge and the process of elimination to make a selection. |
1514 A client with chronic renal failure has fluid volume Correct answer: 3 Clients with renal failure retain sodium, and any decrease in the serum level will most likely excess. The laboratory report indicates the sodium be caused by hemodilution from the excessive fluid retention. A sodium level of 112 mEq/L is level to be 120 mEq/L. The nurse interprets this as lower than normal. which of the following? ‐ An elevated sodium level that must be reported immediately to the physician ‐ An error in the laboratory analysis ‐ A possible hemodilution effect secondary to excessive water retention ‐ An expected electrolyte abnormality in clients with chronic renal failure | The core issue of the question is the ability to make an accurate interpretation of laboratory data in a client with renal failure. Use nursing knowledge and the process of elimination to make a selection. |
1515 A child has been admitted to the unit with nephrotic Correct answer: 2 Typical symptoms of nephrotic syndrome are clear, frothy urine that is diminished in volume. syndrome. In talking with the mother, she reports that AGN presents with smoky urine that is also diminished in volume. AGN is a postinfectious a cousin had acute glomerulonephritis (AGN) last year. disease with no genetic basis. Antibiotics are not used in nephrotic syndrome. Oliguria is The mother asks how these two diseases compare, as usually defined as 0.5 to 1.0 mL/kg/hr. they both affect the kidneys. The nurse’s response would include the information that ‐ both diseases produce smoky colored urine. ‐ both diseases cause greatly reduced urine output. ‐ both diseases have a genetic basis. ‐ treatment for both involves antibiotic therapy. | The core issue of the question is knowledge of the similarities and differences between nephrotic syndrome and glomerulonephritis. Use nursing knowledge and the process of elimination to make a selection. |
1516 A child is being treated for nephrotic syndrome. The Correct answer: 4 Nephrotic syndrome involves the loss of protein in the urine. Gamma globulins, which help nurse has told the mother that it is important to keep the body fight infections, are proteins. Skin that is not clean and dry is more prone to the child’s skin clean and dry. The mother asks why. breakdown, which could lead to infection. The child is oliguric and therefore does not urinate The nurse’s response is based on the knowledge that frequently. The only restrictions on the child’s intake are fluid and perhaps sodium. There is no electrolyte deficiency. ‐ the skin is fragile secondary to electrolyte deficiency. ‐ frequent urination may leave moisture on the skin that predisposes breakdown. ‐ dietary restrictions make fighting infection hard. ‐ the condition causes a reduction of gamma globulin in the body. | The core issue of the question is the ability to relate gamma globulin deficiency in nephrotic syndrome to situations that increase risk of infection, such as unclean or moist skin. Use nursing knowledge and the process of elimination to make a selection. |
1517 In a child with acute renal failure, the nurse would Correct answer: 2 Potatoes, tomatoes, and oranges have a high level of potassium content. The others have less help to prevent hyperkalemia by limiting which of the potassium in them. following foods in the child’s diet? ‐ Grains, cheese, and citrus fruits ‐ Potatoes, tomatoes, and oranges ‐ Cereals, processed sugars, and wheat ‐ Rice, leafy green vegetables, and carbonated beverages | The core issue of the question is knowledge of foods that are high in potassium to avoid in the client with renal failure. Use nursing knowledge and the process of elimination to make a selection. |
1518 A child has been admitted with acute Correct answer: 1 An elevated ASO titer indicates a recent streptococcal infection, which is a precursor to AGN. glomerulonephritis (AGN). All of the following tests are The elevated ESR indicates inflammation in the body and is associated with many diseases. positive for AGN. The nurse concludes that which Hematuria is simply blood in the urine, which has many possible causes. Creatinine laboratory test is most conclusive of this disease? concentrations reflect the functioning of the kidney. ‐ Elevated antistreptinolysin O (ASO) titers ‐ Elevated erythrocyte sedimentation rate (ESR) ‐ Presence of hematuria according to urinalysis ‐ Elevated creatinine concentrations | The critical words in the question are most indicative. This tells you that all options are correct, and you must select the response that uniquely identifies glomerulonephritis as the disorder. Use nursing knowledge and the process of elimination to make a selection. |
1519 The mother of a child at the renal clinic asks why a Correct answer: 1 Radiological evaluations done after a documented UTI in children reveal structural radiological evaluation is performed on all children abnormalities in 1% to 2% of girls and 10% of boys. Radiological tests cannot confirm bacterial who have had one documented UTI. The best colonies, determine the site of an old infection, or help predict whether infection will reoccur. explanation by the nurse will include the information that the x‐ray ‐ rules out structural abnormalities. ‐ confirms the absence of bacterial colonies after antimicrobial therapy. ‐ determines which kidney was infected. ‐ determines the probability of the infection recurring. | The core issue of the question is knowledge that UTIs are uncommon in children and could result from structural abnormalities that are yet undiagnosed. With this in mind, use the process of elimination to make a selection from the available options. |
1520 The nurse is caring for a client with poor urine output. Correct answer: 30 The minimal urine output by the kidneys per hour is 30 mL. It is prudent for the nurse to The nurse would report to the health care provider if report a drop below this amount if it persists for 2 hours or longer so that corrective treatment the client had a urine output less than milliliters can be undertaken. per hour for 2 consecutive hours. Write in a numerical answer. | The core issue of the question is knowledge of minimal hourly urine output based on normal kidney function. Use nursing knowledge to formulate an answer. |
1521 A 4‐year‐old child has been diagnosed with renal Correct answer: 2 Dietary intake is often inadequate in children with renal failure related to anorexia and failure. The nurse would ensure that the diet for this dietary restrictions. Calories and nutrition are needed to optimize growth and to prevent child would contain: growth retardation. Depending on the degree of renal failure, sodium, potassium and phosphorus may be restricted. Fluids are monitored closely for balance and may be restricted if oliguria is present. ‐ Foods high in potassium and sodium. ‐ Adequate calories to optimize growth. ‐ Foods high in calcium content to promote bone growth. ‐ Increased fluid intake to flush the urinary system. | Recognize that a child in renal failure will have problems excreting wastes. The only option that does not provide excessive volume or ingredients is option 2. |
1522 The priority concern for the nurse in assessing a child Correct answer: 1 The kidney normally excretes potassium. Hyperkalemia occurs with decreased kidney function with acute renal failure (ARF) should be to look for resulting in cardiac arrhythmias, which can be life‐threatening. which electrolyte imbalance? ‐ Hyperkalemia ‐ Hypernatremia ‐ Hypercalcemia ‐ Hypophosphatemia | Consider which of the electrolyte imbalances occur with renal failure. In renal failure, the normal imbalances are hyperkalemia, hyponatremia (due to excessive fluid retention), hypocalcemia, and hyperphosphatemia. |
1523 The nurse would formulate which of the following as Correct answer: 3, 5 Peritoneal dialysis is an invasive procedure that places the child at risk for infection. an appropriate nursing diagnosis for a child receiving Hypervolemia is secondary to poor kidney function and does not cause altered renal tissue peritoneal dialysis? Select all that apply. perfusion. The child is anorexic and the child is not at risk for fluid volume deficit. The child’s condition is chronic and routine health maintenance will need to be integrated with chronic disease management. ‐ Deficient fluid volume related to sodium and water retention ‐ Imbalanced nutrition, greater than body requirements related to increased hunger ‐ Risk for infection related to invasive procedures and diminished immune functioning | Consider typical symptoms with renal failure. There would not be fluid volume deficit and renal tissue perfusion would not be related to hypervolemia. That leaves two choices to choose between. Use knowledge of the disease to make a final selection. |
‐ Impaired renal tissue perfusion related to hypervolemia ‐ Ineffective health maintenance related to chronic condition | |
1524 A child is admitted to the nursing unit with acute Correct answer: 3 Dehydration results in hypovolemia, which can precipitate acute renal failure in infants and renal failure (ARF). When reviewing the nursing children. The other responses are incorrect because they don't directly impact renal perfusion. history, the nurse notes a history of all of the following diseases. The nurse concludes that which most likely precipitated the onset of ARF? ‐ Chickenpox ‐ Influenza ‐ Dehydration ‐ Hypervolemia | Consider which of the diseases directly relates to the kidneys. Also note that the options contain opposites which usually indicates one is the right answer. |
1525 A child has been admitted in renal failure. The nurse Correct answer: 3, 5 Azotemia and oliguria are characteristics associated with renal failure in children. The BUN would expect to find which of the following laboratory would be elevated. Renal failure is characterized by inadequate glomerular filtration. values? Select all that apply. ‐ Decreased BUN ‐ Adequate glomerular filtration ‐ Oliguria ‐ Polyuria ‐ Azotemia | Renal failure prevents the elimination of waste products from the body so the nurse would expect excesses in most lab values. |
1526 The nurse is planning care for a child who has been Correct answer: 3 Although there is fluid retention as a result of oliguria, this does not hamper the renal tissue diagnosed with nephritic syndrome. Which of the perfusion. The weight gain is a result of fluid retention not overeating. The child will be following would be the most appropriate nursing lethargic but not in acute pain. diagnosis for this child? ‐ Ineffective tissue perfusion (renal) related to fluid retention. ‐ Imbalanced nutrition, more than body requirements related to excessive weight gain. ‐ Risk for impaired skin integrity related to edema and lowered resistance to infection. ‐ Pain related to decreased kidney function | The core concept of nephrotic syndrome is protein loss leading to loss of osmotic pressure. Using this fact, eliminate the wrong options. |
1527 An infant has been admitted for treatment of Correct answer: 2 This condition is repaired surgically. Preoperative teaching can relieve parental anxiety hypospadias. The nurse would include which of the regarding body image disturbances. The other options are unrelated to care needed for the following in the plan for nursing management of the client with hypospadias. child and family? ‐ Parent education regarding steroid therapy. ‐ Addressing parental anxiety related to functioning and appearance of the penis. ‐ Home health teaching of proper straight catheterization techniques. ‐ Monitoring for signs and symptoms of nephrotic syndrome. | Recall the medical treatment for hypospadias to help eliminate the incorrect options. Knowledge of the care of the child and parents regarding anxiety and body image disturbances will also help in choosing the correct option. |
1528 Shortly after birth, the newborn was found to have Correct answer: 3 The prepuce or foreskin may be needed in the reconstruction of the penis. The mother can epispadias. Prior to delivery, the mother had signed sign permission for her son without needing the father’s permission as long as she is fully alert. permission for a circumcision. The obstetrician is The risk of infection is no greater for this child than for others. planning to perform the circumcision immediately after delivery. The nurse explains to the mother that the circumcision will not be done at this time because: ‐ The mother should not have signed consent before delivery. ‐ The father also needs to sign permission for surgery. ‐ The prepuce will be used for the surgical correction. | The proper response is likely to be specific to the congenital defect so this helps to narrow the options to 3 and 4. Knowledge of the care of the child who will need a surgical repair for epispadias will help to choose the correct answer. |
4.‐ The risk of infection is greater with a child with epispadias. | |
1529 A baby is born six weeks prematurely. On admission Correct answer: 2 Premature males are often born with undescended testicles. The testes normally descend to the nursery, the nurse is unable to locate any during the last few weeks of gestation or shortly after birth. This would not be a concern at testicles in the scrotum. The nurse should: this time. If surgery should be needed, it will be done prior to age 2. Undescended testicles do not affect urine formation. ‐ Immediately notify the physician as the child is at risk for renal failure. ‐ Note the findings in the child's record and take no further action at this time. ‐ Discuss with the father the need for surgical correction of cryptorchidism. ‐ Catheterize the child to determine if urine is present in the bladder. | Be aware that the testicles have nothing to do with urination so options 1 and 4 can be eliminated. Knowledge of cryptorchidism and the usual management will aid in choosing the correct answer. |
1530 The mother of an infant who underwent surgery to Correct answer: 1 A double‐diapering technique will help to protect a urinary stent following repair of repair hypospadias asks the nurse why the infant is hypospadias or epispadias. The inner diaper collects the infant's stool, while the outer one double‐diapered. The nurse would respond that this collects urine. method of diapering will help to: ‐ Protect the urinary stent that has been put in place. ‐ Adequately measure the urinary output. ‐ Provide for maximum absorption of urine. ‐ Provide optimal protection of perineal skin from infected urine. | Knowledge of the rationale for the double diapering technique will aid in choosing the correct answer. Options 2 and 3 are virtually the same, leaving only options 1 and 4 to choose between. |
1531 The nurse would place highest priority on which Correct answer: 3 Urinary tract infections are ascending in nature; an untreated UTI can lead to acute nursing activity in managing a young child diagnosed pyelonephritis with resulting kidney scarring and damage. Early diagnosis and prompt with urinary tract infection (UTI)? antimicrobial therapy will prevent or minimize permanent renal damage. ‐ Provide adequate nutrition to prevent dehydration. ‐ Prevent enuresis. ‐ Administer ordered antibiotics on schedule. ‐ Restrict fluids to provide kidney rest. | With any infectious disease, it is important that antibiotics be administered on schedule. |
1532 When reviewing a urinalysis report of a client with Correct answer: 3 Proteinuria (presence of protein in urine) is a prime manifestation of acute acute glomerulonephritis, the nurse expects to note glomerulonephritis. The other options are inconsistent with this diagnosis. which of the following? ‐ Decreased creatinine clearance ‐ Decreased specific gravity ‐ Proteinuria ‐ Decreased erythrocyte sedimentation rate (ESR) | Eliminate those tests that are blood exams. That leaves proteinuria and specific gravity. Both findings would be abnormal, but specific gravity would not be specific for glomerulonephritis. |
1533 While a child is receiving prednisone (Deltasone) for Correct answer: 1 Prednisone is a synthetic corticosteroid that depresses the immune response and increases treatment of nephrotic syndrome, the nurse susceptibility to infection. Steroids mask infection; therefore, the child must be assessed for determines that it is important to assess the child for: subtle signs and symptoms of illness. ‐ Infection. ‐ Urinary retention. ‐ Easy bruising. ‐ Hypoglycemia. | The core concept is side effects of the drug. |
1534 The nurse is admitting a 12‐year‐old girl to the Correct answer: 4 Specimens collected utilizing proper technique will minimize contamination of the urine hospital prior to surgery. The physician has ordered a sample ensuring accurate urinalysis results. It is unnecessary to force fluids prior to specimen urinalysis. In order to obtain accurate urinalysis data, collection. The specimen container is not cleansed, although the urinary meatus is. The the nurse should: specimen should be sent to the lab immediately after collection to prevent urine degradation. | Eliminate any response that would adversely affect the results, such as forcing fluids before collection (dilutes the urine) and cleansing the specimen container with Betadine. Recall that all specimens should be delivered to the lab as soon as possible—if the specimen needs to be cooled, it can be done in the lab. |
‐ Encourage fluids to 1000 mL prior to specimen collection. ‐ Cleanse the specimen container with povidone‐iodine (Betadine) prior to collecting the specimen. ‐ Allow the urine to cool to room temperature before taking it to the lab. ‐ Provide client/parent education for specimen collection before the specimen is obtained. | |
1535 The parents of a child diagnosed with upper urinary Correct answer: 3 With infectious or inflammatory processes of the upper urinary tract, the kidneys’ ability to tract infection (UTI) ask the nurse why the child needs filter and reabsorb salt and water is altered, resulting in edema. Weights can be an easy and a daily weight. In formulating a response, the nurse effective measure to determine fluid loads. includes that it is important because a daily weight will: ‐ Determine if the child’s caloric intake is adequate. ‐ Indicate the need for dietary restrictions of sodium and potassium. ‐ Keep track of possible loss or gain of fluid retained in body tissues. ‐ Track the amount of fluid ingested orally each day. | Two of the options deal with fluids. Determine if one of these is the right response. Then review the other options to ensure the right response. |
1536 A child has been diagnosed with acute renal failure Correct answer: 2 Gentamicin is an aminoglycoside antibiotic that is nephrotoxic. Nephrotoxic drugs should be secondary to an infectious organism. The nurse would avoided in a child with acute renal failure. The other options do not represent drug groups that question the medical order for: are particularly nephrotoxic. ‐ Aqueous penicillin. ‐ Gentamicin (Garamycin). ‐ Antihypertensives. ‐ Corticosteroids. | The core concept is which medication has side effects that would be detrimental to kidney function. |
1537 The newborn has been diagnosed with Correct answer: 4 HCG is given to induce the descent of testes if testes have not descended during the first year cryptorchidism. The physician has ordered human of life. The other reasons listed are incorrect rationales. chorionic gonadotropin (HCG) to be administered to the baby. The mother asks the nurse why the baby is receiving this drug. The nurse’s best explanation would be that the drug will: ‐ Maintain an adequate temperature around the testes. ‐ Prevent infections in the undescended testes. ‐ Prevent the development of cancer. ‐ Promote descent of the testes. | The medication is not an antibiotic or an antipyretic, so options 1 and 2 can be eliminated. Medications do not prevent cancer. This leaves only the correct response. |
1538 The nurse admits children with the following diseases Correct answer: 3, 5 Nephrotic syndrome is an inflammatory reaction in the kidneys. Urinary tract infections and to the unit. The nurse determines that the children obstructions are also associated with the development of acute renal failure. The other with which diseases are at risk for the development of diseases pose minimal risk of developing acute renal failure. acute renal failure (ARF)? (Select all that apply.) ‐ Leukemia ‐ Cryptorchidism ‐ Nephrotic syndrome ‐ Phenylketonuria ‐ Urinary tract infection | Eliminate those conditions that are not associated with kidney disease. |
1539 A child has recurrent nephrotic syndrome. The Correct answer: 4 The parents must understand the need for compliance with medical orders to promote the mother reports to the nurse that she is overwhelmed child’s health. Relaxation should be accomplished without harming the child. with the care of her child. After the nurse discusses options with the mother, which statement by the mother indicates continued coping difficulties? | Consider which response would be inappropriate for the child. |
‐ “I joined a support group like you suggested. I hope it does some good.” ‐ “I’m going to ask my mother‐in‐law to come on a regular basis to allow me an afternoon out.” ‐ “My husband has agreed to help me manage my son’s medication.” ‐ “We’re going to skip his dietary restrictions one day a week to allow us both some relaxation.” | |
1540 A child returning to the unit after an intravenous Correct answer: 4 The additional fluids will increase urinary output, causing greater urine volume and more pyelogram (IVP) has an order to drink extra fluids. frequent voiding, thus flushing the dye from the urinary system. The other options do not When the mother asks the purpose of these fluids, the describe the correct rationale for this intervention. nurse responds that increased fluid intake will: ‐ Overhydrate the child. ‐ Increase serum creatinine levels. ‐ Make up for fluid losses from NPO status before tests. ‐ Flush any remaining dye from the urinary tract. | Consider the testing methods to determine which is the correct response. Knowledge that the test uses a dye to visualize the kidney’s collection system and that the dye needs to be excreted will help to choose the correct answer. |
1541 A newborn is found to have exstrophy of the bladder. Correct answer: 2, 5 Epispadias and bilateral inguinal hernias are frequent anomalies associated with exstrophy of The nurse should evaluate the infant for: (Select all the bladder. The other conditions listed are not. that apply.) ‐ Hypospadias. ‐ Epispadias. ‐ Cryptorchidism. ‐ Acute tubular necrosis. ‐ Bilateral inguinal hernias. | Knowledge of commonly associated defects with exstrophy of the bladder will help to choose the correct answers. |
1542 A child has been admitted to the hospital with a Correct answer: 2 Edema is the major clinical symptom of nephrosis. The child may gain twice his or her normal diagnosis of “rule out nephrosis.” The nurse would weight in severe cases. assess the child for: ‐ Hematuria. ‐ Edema. ‐ Petechial rash. ‐ Dehydration. | Nephrosis is a urinary condition, so look first for the options related to urinary function. That would eliminate the rash, leaving hematuria, dehydration, and edema. Body fluid is involved in dehydration and edema, which are opposites. If the kidneys aren’t working effectively, there will be problems eliminating fluid. |
1543 The nurse is caring for a toddler who is not toilet‐ Correct answer: 3 Diapers are weighed on a gram scale before using them and after removal (1 g = 1 mL). The trained. The doctor has ordered intake and output weight of the dry diaper is then subtracted from the weight of the wet diaper to determine measurement. The nurse will most accurately measure urine output. the urine by: ‐ Estimating output as small, moderate, or large and recording on the child’s chart. ‐ Weighing each wet diaper and recording the weight of the diaper as the amount of urine output. ‐ Subtracting the weight of a dry diaper from a wet diaper and recording this amount. ‐ Determining urine output by the number of diaper changes in each 24‐hour period. | Notice that options 2 and 3 are very similar. Determine which of the two would provide the most accurate information. |
1544 The nurse is teaching the parents of a preschooler Correct answer: 1, 2, 4 Bubble baths are irritating to the meatus and increase the incidence of urinary tract information about urinary tract infections (UTIs) and infections. An acidic urine is desirable in preventing urinary tract infections, and the proper means of reducing their recurrence. Statements from way to wipe is front to back. the parents that indicate an understanding of ways to prevent UTIs include: (Select all that apply.) ‐ “I should try to get her to drink a lot of water and juices.” ‐ "I will buy her underwear made with cotton." ‐ “Soaking in a bubble bath will reduce meatal irritation.” ‐ “If I notice her starting to wet the bed again, I need to have her checked for another urinary tract infection.” | The core concept in this item is that it is a little girl with a urinary tract infection. Girls are more at risk for UTIs from ascending organisms due to the shorter urethra. |
5.‐ “I should avoid giving her cranberry juice as it has been shown to make the urine more acidic.” | |
1545 The nurse would include which of the following in the Correct answer: 2, 3, 4 Although children with acute glomerulonephritis may feel well, they are confined to bed until care of a child with acute glomerulonephritis? (Select hematuria resolves. This can lead to boredom, making it important for the nurse to provide all that apply.) activities that are fun for the child to help pass the time. ‐ Careful handling of edematous extremities ‐ Observing the child for evidence of hypertension ‐ Providing fun activities for the child on bed rest ‐ Monitoring the urine for hematuria ‐ Encouraging fluid intake | With glomerulonephritis, there is damage to the glomerular capillary causing the loss of red blood cells through the urine, decreased urine output, and hypertension. Consider any interventions related to these symptoms. |
1546 A urinalysis is ordered for a child with a throat culture Correct answer: 4 Urinalysis allows for early diagnosis and treatment of acute glomerulonephritis, which is a positive for group‐A beta‐hemolytic streptococcus serious complication that can follow group‐A beta‐hemolytic streptococcal infection. (strep throat). The mother asks why this test is being ordered. The nurse explains: ‐ The urinalysis will indicate whether an HIV infection is also present. ‐ Urinary tract infections are common with streptococcal infections and need to receive prompt treatment. ‐ Pyelonephritis is a potential complication of antibiotic therapy. ‐ Group‐A beta‐hemolytic streptococcus infections can be followed by the complication of acute glomerulonephritis. | Remember to associate strep infections with the common complications of rheumatic fever and glomerulonephritis. |
1547 An appropriate nursing diagnosis for a toddler with Correct answer: 4 The open bladder allows bacteria to enter the urinary system, and urinary tract infections are unrepaired exstrophy of the bladder would be: common. At this age, sexual dysfunction would not be an appropriate diagnosis. The unformed bladder does not hold urine, so urinary retention would not be an appropriate diagnosis. Disorganized behavior doesn’t apply. ‐ Disorganized infant behavior. ‐ Sexual dysfunction. ‐ Urinary retention. ‐ Risk for infection. | Exstrophy of the bladder is a congenital defect where the bladder does not have an anterior wall so cannot collect urine. With the absence of the abdominal skin, there is no prevention of infections. |
1548 A child has been admitted to the unit with acute Correct answer: 1 The ASO titer indicates a preceding infection with group A beta‐hemolytic streptococcus. The glomerulonephritis. The test that would confirm this urinalysis would show hematuria, but this alone would not be diagnostic of acute diagnosis is: glomerulonephritis. Blood cultures may be negative as the infection preceded the illness by 1 to 3 weeks. ‐ Antistreptolysin‐O (ASO) titer. ‐ Urinalysis. ‐ Blood cultures. ‐ White blood cell (WBC) count. | Knowing the cause of AGN, the learner will select the option that would test for the causative agent. |
1549 The doctor orders a clean‐catch urine specimen on an Correct answer: 1 Clean‐catch urine specimens are not reliable urine samples; therefore, catheterization is infant who is not toilet‐trained. The best means of necessary. The urine does need to be obtained at the time of voiding. collecting this urine would be to: ‐ Perform a straight catheterization. ‐ Apply a urine collection bag. ‐ Use diaper analysis. ‐ Perform Foley catheterization. | Determine whether the specimen should be sterile or clean, then select the option that would provide an uncontaminated specimen. |
1550 A 14‐year‐old is being treated for renal failure. The Correct answer: 3 With the inability to secrete urine, electrolytes will build up in the blood, including sodium nurse would ensure that the child follows a: and potassium. The child should be on a low‐sodium, low‐potassium diet with restricted fluids and proteins. ‐ High‐sodium diet. | In renal failure, the kidneys have difficulty excreting waste products. Therefore, the diet will reduce the amount of substances that are hard to clear. |
‐ High‐protein diet. ‐ Low‐sodium diet. ‐ Low‐fiber diet. | |
1551 A 25‐year‐old college student is diagnosed with an Correct answer: 2 Pyelonephritis is an upper urinary tract infection, involving the kidney tissue. Lower urinary upper urinary tract infection. Which of the following tract infections include urethritis, prostatitis, and cystitis. The most common upper urinary would be documented on the medical record? tract infection is pyelonephritis. ‐ Cystitis ‐ Pyelonephritis ‐ Urethritis ‐ Prostatitis | Omit options 1, 2, and 4 as being lower urinary structures. |
1552 The nurse would expect to see which pathogen on the Correct answer: 3 E. coli is the infective organism in over 90 percent of first‐time infections. The nurse should urine culture and sensitivity (C & S) of a client check that the organism is sensitive to the antibiotic or notify the healthcare professional. with a urinary tract infection? ‐ <i>Streptococcus</i> ‐ <i>Staphylococcus</i> ‐ <i>E. coli</i> ‐ <i>Klebsiella</i> | E. coli inhabits the bowel and due to the proximity with the GU tract is often the causative organism in UTI. |
1553 A urinary tract infection would be considered Correct answer: 4 Due to the anatomic structure of the male urethra and bacteriostatic effect of prostatic fluid, complicated in which of the following clients? all urinary tract infections in the male client should be considered complicated. ‐ Teenager who has recently become sexually active ‐ A child, age 2 ‐ An elderly, bedridden client ‐ A male client | Identify the male as the client in which a diagnosis of UTI is unusual. |
1554 The client with cystitis has a routine urinalysis (UA) Correct answer: 3 Urine may have a foul odor and appear cloudy because of mucus and excess white cells done. Pyuria is noted on the report, which means the present, which is common in cystitis. Casts and proteins are never normal in urine. urine has: ‐ Blood. ‐ Casts. ‐ Excess mucus and white blood cells. ‐ Protein. | Omit option 1 as the term for blood in the urine is hematuria. Casts and protein in the urine would be noted by their names. |
1555 When assessing the client with urinary calculi, an Correct answer: 2 The greatest risk factor for stone formation is a prior personal or family history of urinary important subjective finding would be: calculi. The other answers are important information to know but do not contribute greatly as risk factors. ‐ Allergies to sulfonamides. ‐ Father of client who has had urinary stones twice. ‐ Last urinary tract infection 2 months ago. ‐ Alcohol intake of two six‐packs of beer per day. | Recall that there is thought to be a genetic link to incidence of renal stones. |
1556 The presence of red blood cell casts is most likely Correct answer: 4 Red blood cell casts are not present in the normal urinalysis but are present in glomerular caused by which disorder? diseases. ‐ Urinary tract infection ‐ Pyelonephritis ‐ Renal failure ‐ Glomerulonephritis | Recognize that casts are abnormal and would not be present in infection or failure. |
1557 Which of the following is an iatrogenic cause of acute Correct answer: 3 Iatrogenic causes result from treatment from a physician or other care provider. Examples renal failure? include nephrotoxic medications, radiologic contrast dye, and shock after surgery. ‐ Alcohol ‐ Diet ‐ Nephrotoxic medications ‐ Exercise | Recall that the term ‘iatrogenic’ is often used to describe untoward medication effects. |
1558 Glomerular filtration rate is less than 30 percent of Correct answer: 3 In end stage renal failure, 90 percent or more of the nephrons are destroyed; glomerular normal in which of the following? filtration rate is &lt; 20 percent normal with increased creatinine and BUN. ‐ Urinary tract infection ‐ Kidney cancer ‐ Acute renal failure ‐ Polycystic kidney disease | Recall that GFR reduces in renal failure. |
1559 What laboratory test is a common measure of renal Correct answer: 2 The blood urea nitrogen is primarily used as an indicator of kidney function because most function? renal diseases interfere with its excretion and cause blood levels to rise. Creatinine is produced in relatively constant amounts, according to the amount of muscle mass and is excreted entirely by the kidneys making it a good indicator of renal function. ‐ Complete blood count ‐ Blood urea nitrogen/creatinine ‐ Glucose ‐ Alanini aminotransferase (ALT) | Associate creatinine with renal function. |
1560 In the second stage of chronic renal failure, what Correct answer: 4 In the second stage of chronic renal failure, renal insufficiency, there is at least 75 percent of percent of renal tissue is destroyed? functional renal parenchyma destroyed. 1.‐ 25% 2.‐ 30% 3.‐ 50% 4.‐ 75% | Recall that renal failure is insidious, so that by the time it is discovered a great deal of function is lost. Select the response that reflects the largest loss of function. |
1561 The nurse would question a client with balanitis about Correct answer: 2 Balanitis, or inflammation of the foreskin and prepuce, would cause edema and pain of the complaints of which of the following? penile glans, leading to dysuria. Option 1 is inappropriate for balanitis; a urethral discharge (option 3) may occur in gonorrhea; back pain (option 4) could indicate many diseases, but not balanitis. ‐ Vaginal discharge ‐ Pain with urination ‐ Spontaneous urethral discharge ‐ Back pain | Omit option 1 as this could not occur in a female. Use the process of elimination to work through the other options. |
1562 The nurse would assess the client experiencing Correct answer: 4 Prostatitis creates pain in the tissues surrounding the prostate gland. Option 1 indicates a prostatitis for which of the following symptoms? gonococcal infection; option 2 herpes virus; and option 3 syphilis (secondary stage). ‐ Spontaneous penile discharge, dysuria, and pain with ejaculation ‐ Painful blisters and crater‐like lesions, enlarged groin nodes, fever ‐ Brownish rash on palms, painful crater‐like lesions, malaise, and fever ‐ Rectal pain, pain with erection, low abdominal pain, and low back pain | Think of the location of the prostate and identify likely symptoms. |
1563 A client reports to the clinic with complaints that a Correct answer: 1 Secondary syphilis begins with the healing of the chancre, and ends when the rash disappears, sexual partner from last year has been diagnosed with which can take up to 6 months from time of infection. The latent stage of syphilis then starts, syphilis. The nurse would expect the client to have: which can last for years. VDRL and RPR would need to be positive for syphilis (option 2); option 3 could indicate TB or HIV; option 4 is signs and symptoms of nongonococcal infections in females. ‐ Had a painless sore that healed and a rash on the palms of his hands. ‐ Negative VDRL, negative rapid plasma reagin (RPR), and positive fluorescent treponemal antibody absorption (FTA‐ABS). ‐ Night sweats, cough, low‐grade fever, and elevated white count. ‐ Vaginal discharge, dysuria, and pain with orgasm. | Recall that rash on the palms is the symptom associated with syphilis. |
1564 The nurse concludes that teaching has been effective Correct answer: 3 Hypospadias repair is undertaken using the foreskin to create a channel through the penis to when the mother of an infant born with hypospadias the tip of the glans so that he will deposit his sperm near his partner's cervix. Although option says, "Our son will:” 1 may also be an appropriate answer, it is not the best answer to demonstrate effective teaching. Options 2 and 4 are incorrect. ‐ “Need surgical correction so that he looks like the other boys." ‐ “Require circumcision now to prevent complications later." ‐ “Have surgical correction so he will be fertile as an adult." ‐ “Likely have other reproductive tract anomalies we can't see." | Recall that fertility is the major concern with hypospadias. |
1565 Which medication would the nurse expect the client Correct answer: 4 DUB most commonly results from a progesterone deficiency that causes a fragile with dysfunctional uterine bleeding (DUB) be endometrium that fails to mature from proliferative stage to secretory. This causes irregular prescribed? menstrual bleeding. Treatment is aimed at correcting the cause, thus progesterone supplementation is prescribed. ‐ Testosterone ‐ Estrogen ‐ Steroids ‐ Progesterone | Recognize that options 1 and 4 do not relate to the condition and can be eliminated. |
1566 In preparing to discharge a client with gonococcal Correct answer: 1 Douching should be avoided in order to prevent bacteria present in the lower reproductive pelvic inflammatory disease (PID), the nurse would tract from being forced upwards into the uterus, potentially causing PID. intervene if the client made which statement? ‐ "I should douche after every episode of intercourse." ‐ "Using condoms will decrease the risk of this happening again.” ‐ "My boyfriend and I should be monogamous." ‐ "The sexual position I use won't prevent this infection." | Recall that douching is a practice that is usually discouraged. |
1567 The 23‐year‐old client has been diagnosed with Correct answer: 3 Chemotherapy and radiation used in the treatment of testicular cancer often cause a radically testicular cancer. Which of the following should be decreased sperm count. If the client desires children, he should consider sperm banking prior included in his teaching plan? to beginning treatment. ‐ Future fertility is not affected by treatment. ‐ Impotence often results from needed treatments. ‐ Sperm banking should be done prior to treatment. ‐ Sexual interest will increase as a result of treatment. | Focus on preservation of fertility. |
1568 The client with fibrocystic breast disease is most likely Correct answer: 4 Caffeine can precipitate or worsen fibrocystic breast disease. No other dietary factors have to report a diet high in which of the following? been identified. ‐ Bacon, sausage, ground meat ‐ Fresh fruits and grain cereal | Caffeine content of foods is a concern in fibrocystic disease. |
‐ Cheese and milk ‐ Coffee and cola | |
1569 A male client has been diagnosed with Chlamydia Correct answer: 1 Doxycycline (Vibra‐tabs) is a commonly utilized treatment for chlamydia infections, and like trachomatis infection. The plan of care should include all antibiotics must be taken until the medication is gone. Use of condoms with every sexual which of the following? encounter decreases the transmission of sexually transmitted diseases. Sexual contacts should be notified of the infection so that appropriate testing can be obtained. This is especially important with Chlamydia because it is so often asymptomatic in women, and early detection can prevent complications such as pelvic inflammatory disease. Testicular self‐exam is screening for testicular cancer, not diagnosing. ‐ Instructions to take all of the doxycycline (Vibra‐tabs) that was ordered. ‐ Encouragement to use condoms with most episodes of intercourse. ‐ Obtaining the names of sexual contacts if client desires. ‐ Teaching of testicular self‐exam (TSE) for diagnosis. | Omit options 2 and 3 as having information that is inconsistent with sound health practices. Completion of antimicrobial therapy is the focus of treatment. |
1570 The client has a diagnosis of primary dysmenorrhea. Correct answer: 3 Primary dysmenorrhea begins at menarche and is usually a lifelong condition. Options 1, 2, Which of the following would likely appear in her and 4 can occur with secondary dysmenorrhea or endometriosis. history? ‐ Heavy flow and clots for at least 3 months ‐ Irregular menses with breakthrough bleeding ‐ Painful periods since menarche ‐ No periods for the last 7 months | Recall that the prefix 'dys' indicates pain. |
1571 A urinalysis is ordered for a client with urinary calculi. Correct answer: 4 Hematuria, either gross or microscopic, is generally present in clients with urinary calculi. Which of the following is usually positive on the Leukocytes and protein may be common with other urinary disorders. urinalysis report? ‐ Leukocytes ‐ Nitrite ‐ Protein ‐ Blood | Remember that mechanical irritation of the calculi causes bleeding. |
1572 A 40‐year‐old male is at high risk for which of the Correct answer: 3 Adult polycystic kidney disease is an autosomal dominant disorder. In children, it is caused by following, if his dad also had the problem? an autosomal recessive trait. ‐ Glomerulonephritis ‐ Renal failure ‐ Polycystic kidney disease ‐ Urinary tract infection | Omit options 1, 2, and 3 as not being genetically linked. |
1573 The client has a urinalysis return showing a high white Correct answer: 1 Acute pyelonephritis is a bacterial infection of the kidney. Chronic pyelonephritis is associated blood count. Further tests pinpoint the origin in the with nonbacterial infections and noninfectious processes that may be metabolic, chemical or kidney. The client most likely has: immunological. ‐ Acute pyelonephritis. ‐ Renal failure. ‐ Chronic pyelonephritis. ‐ Calculi. | Associate an increased white cell count with an acute infectious process. |
1574 It is important to teach clients with chronic Correct answer: 1 Hypertension may develop as renal tissue is destroyed. pyelonephritis to monitor: ‐ Blood pressure. ‐ Temperature. | Recall that kidney function plays a key role in the control of blood pressure. |
‐ Diet. ‐ Stress level. | |
1575 Acute glomerulonephritis is usually caused by which Correct answer: 1 Infection of the pharynx or skin with group‐A beta Hemolytic‐streptococcus is the common pathogen? precipitating factor for acute glomerulonephritis. ‐ <i>Group‐A beta Hemolytic‐streptococcus</i> ‐ <i>Staphylococcus</i> ‐ <i>E. coli</i> ‐ <i>Proteus</i> | Associate glomerulonephritis with being preceded by strep throat. |
1576 Which of the following clients is at highest risk for a Correct answer: 1 Risk factors of urinary tract infections include female, older clients, urinary obstruction or urinary tract infection (UTI)? calculi, strictures, chronic disease, prostatic hypertrophy and prostatitis, diaphragm use, instrumentation and impaired immune system. Although children and teenagers can contract a UTI, incontinence and disease conditions in the elderly make them a higher risk population. ‐ Elderly ‐ Male adult ‐ Teenager ‐ Child | Recall that the elderly are generally at higher risk for most infections. |
1577 In rapidly progressive glomerulonephritis, crescent‐ Correct answer: 1 Glomerular cells proliferate along with macrophages to form crescent‐shaped lesions shaped lesions form and obliterate: obliterating Bowman's space resulting in a rapid decline in glomerular filtration rate (GFR), which leads to many of the complications. ‐ Bowman's space. ‐ Urinary bladder. ‐ Renal tubules. ‐ Loop of Henle. | Eliminate option 2 as not being a part of the kidney. Use the process of elimination to work through the other answers. |
1578 Sally is diagnosed with an uncomplicated urinary tract Correct answer: 2 Sulfonamides are considered to be the drug of choice for acute, recurrent, or chronic urinary infection. The first‐line therapy is: tract infections when there is no evidence of obstruction or bacteremia. ‐ Ciprofloxacin (Cipro). ‐ Trimethoprim‐sulfamethoxazole (Bactrim). ‐ Amoxicillin (Amoxil). ‐ Erythromycin (Erythrocin). | Look for the sulfa drug as the first line treatment of UTI. |
1579 Which vitamin can help to maintain acidic urine and Correct answer: 3 Vitamin C helps to maintain a pH of 5 or less thereby inhibiting bacterial growth. The other may help a client with recurrent urinary tract vitamins have no proven use in preventing urinary tract infections. infections? ‐ E ‐ B ‐ C ‐ D | Recall that Vitamin C is associated with acidic food like oranges. |
1580 Nursing management of the client with a urinary tract Correct answer: 3 Caffeine and alcohol can increase bladder spasms and mucosal irritation, thus increase the infection should include: signs and symptoms of a urinary tract infection (UTI). Fluids should be taken, and douches will not help a UTI. All antibiotics should be taken completely to prevent resistant strains of organisms. ‐ Taking medication until feeling better. ‐ Restricting fluids. ‐ Decreasing caffeine drinks and alcohol. | Eliminate options 1, 2, and 3 as they are contrary to the treatment plan for UTI of increasing fluid and taking prescription medications until the course of treatment is complete. Douching is rarely a recommended treatment. |
4.‐ Douching daily. | |
1581 When triaging in the clinic, which client should be Correct answer: 1 The primary genital herpes infection involves systemic viremia, and encephalitis is a possible seen first? The client with: complication. Headache and stiff neck may indicate encephalitis, and require further investigation. ‐ Genital herpes infection diagnosed yesterday, with a severe headache. ‐ Recurrent herpes infections for 3 years, with burning during urination. ‐ Chlamydia diagnosed yesterday, now with worsening pelvic pain. ‐ Secondary syphilis diagnosed last month, due for penicillin injection. | Select the option with a severe symptom such as a neurological symptom. |
1582 Which of the following statements should be Correct answer: 4 Breast cancer detection begins with monthly self‐breast exams. Mammograms should be presented in a breast cancer detection program for the performed yearly after age 40. Birth control pills do not increase nor decrease breast cancer community? risk, but the longer a woman is on estrogen replacement therapy the greater her risk for developing the disease. ‐ Mammograms should be started when women become age 50. ‐ Self‐breast exams should be performed weekly. ‐ Birth control pills may prevent breast cancer. ‐ Estrogen replacement may increase breast cancer risk. | Eliminate options 1, 2, and 3 as being inconsistent with current recommendations regarding breast cancer. |
1583 The client with benign prostatic hyperplasia has Correct answer: 1 Continuous bladder irrigation serves to flush out the blood that will be oozing from the raw undergone transurethral resection of the prostate edges of the TURP site before the blood can clot. Clots in the bladder would obstruct the urine (TURP) and is asking why he needs continuous bladder flow through the catheter. irrigation (CBI). The nurse's best response would be: ‐ "The irrigation prevents blood from clotting and blocking the catheter." ‐ "Your bladder needs to be kept full to promote healing after this surgery." ‐ "The urine would be very concentrated without the irrigation." ‐ "The saline running through the bladder helps keep you hydrated." | Select the response that addresses clotting. |
1584 Teaching for the client with endometriosis Correct answer: 4 Lupron is a synthetic analog of luteinizing hormone‐releasing hormone, and acts as an undergoing leuprolide (Lupron) therapy is effective estrogen antagonist, causing the endometriosis deposits to shrink in size, thus decreasing the when she states: pain and infertility associated with endometriosis. Hot flashes and night sweats are common side effects while on the medication, and resolve upon discontinuation of the medication. ‐ "I may have cold hands and feet while taking this medication." ‐ "It's possible that I'll be heat intolerant while taking these shots." ‐ "My voice may become higher during this therapy." ‐ "Hot flashes are likely while I am taking these shots." | Recall that hot flashes are associated with hormonal therapies. |
1585 Which client is at the highest risk for developing Correct answer: 3 Balanitis, inflammation of the foreskin, occurs due to poor hygiene, and occurs after the balanitis? foreskin becomes retractable (at about age 3). Options 2 and 4 are incorrect because of the circumcision. ‐ 1‐year‐old with intact foreskin ‐ Circumcised 40‐year‐old ‐ 12‐year‐old with intact foreskin ‐ Circumcised 6‐year‐old | Recall that balanitis only occurs in uncircumcised clients. |
1586 Which client is at lowest risk for developing breast Correct answer: 3 Early childbearing with breastfeeding for a total of 2 years or more decreases a woman's cancer? lifetime risk of developing breast cancer. BRCA1 or BRCA2 gene mutations increase risk. Hodgkin's disease treatment usually involves chest radiation, which increases breast cancer risk and breast cancer mortality. Aging is another factor: The older a woman becomes, the more likely she is to develop breast cancer. ‐ Client with BRCA1 gene mutation. ‐ Client who had Hodgkin's disease ‐ First child at age 18, breastfed for 2 years ‐ Smoker, age 74 | Eliminate the options that put an individual at higher risk, such as genetic link, prior cancer diagnosis, and increased age. |
1587 Female clients with Chlamydia trachomatis infections Correct answer: 4 Chlamydia, although often silent and asymptomatic, will eventually present symptoms will most likely present with which signs and including new occurrence of dyspareunia, dysmenorrhea, and low abdominal and pelvic pain, symptoms? with yellow or yellow‐green vaginal discharge. ‐ Painful perineal blisters and high fever of sudden onset ‐ Painless crater‐like lesion on the labia that lasts 6 weeks ‐ Rapidly progressing pruritic rash on labia and buttocks ‐ Yellow‐green vaginal discharge, dyspareunia, pelvic pain | Recall that chlamydia does not have lesions or rash. |
1588 The client with a new diagnosis of genital herpes Correct answer: 3 HSV1 does not survive more than a few minutes on inanimate objects, and although it is often simplex virus 1 (HSV1) wants to know how she a genital tract infection it does occur orally. Sexual contact is the most likely method of contracted the infection. The nurse's best answer is transmission, and persons with intact immune systems can easily be infected. based on which of the following? ‐ Inanimate objects can harbor HSV1 for several hours. ‐ HSV1 is found only in the genital tract and not orally. ‐ Sexual contact is the most common mode of transmission. ‐ Immune system suppression is needed to contract the infection. | Recall that HSV1 is known as a sexually transmitted disease. |
1589 The client with benign prostatic hyperplasia (BPH) Correct answer: 2 BPH clients may be asymptomatic until large alcohol intake, which relaxes the bladder may experience a sudden onset of urinary retention sphincter, making it impossible to empty the bladder. after doing which of the following? ‐ Drinking several cups of coffee in the morning ‐ Having a weekend of binge drinking ‐ Starting a multivitamin supplement ‐ Walking farther than he usually does | Eliminate options 3 and 4 as not having a relationship to bladder function. |
1590 The nurse would assess the client with multiple Correct answer: 1 Subserosal uterine myomas are located on the outer surface of the uterus and tend to cause subserosal uterine myomas for which of the following? fewer menstrual disorders than submucosal or intramural myomas. However, they do cause mechanical pressure on the pelvic contents from their size and weight, including bladder pressure that results in urinary frequency and urgency. ‐ Uterine enlargement, urinary frequency, and pelvic pressure ‐ Uterine enlargement, pain with urination, and vaginal discharge ‐ Uterine atrophy, heavy and painful menses, and decreased libido ‐ Uterine atrophy, pain with intercourse, and vaginal dryness | Recognize that uterine enlargement is a key symptom. |
1591 An 80‐year‐old female is brought to the office by her Correct answer: 3 Older clients may not exhibit the classic symptoms of UTI but present with nonspecific daughter with decreased appetite and confusion. The complaints such as nocturia, incontinence, confusion, behavior change, lethargy, anorexia, or daughter has noticed these complaints for the past 3 just not feeling right. Urinalysis would be a first‐line diagnostic test. days and wonders what could be the reason. The nurse knows that these complaints may be symptoms of: ‐ Dementia. ‐ Cerebral vascular accident (CVA). | Recall that confusion in an elderly client is often associated with UTI. |
‐ Urinary tract infections (UTI). ‐ Constipation. | |
1592 Mr. Smith is admitted with hemorrhage caused by a Correct answer: 2 Pre‐renal causes of acute renal failure include those affecting renal blood flow and perfusion. gastrointestinal bleed and begins to experience acute Hemorrhage, an extracellular fluid loss, can lead to renal ischemia due to decreased renal renal failure (ARF). Which category of ARF is caused by perfusion, decreased glomerular filtration rate and azotemia. a hemorrhage? ‐ Post‐renal ‐ Pre‐renal ‐ Intrarenal ‐ Inter‐renal | Recall that pre‐renal indicates a cause that comes before the kidney in terms of perfusion and blood flow. |
1593 Which of the clients below would most likely Correct answer: 3 The most common cause of urologic obstruction is urolithiasis, stones within the urinary experience a urinary obstruction? A client with: tract. The symptoms in option 3 are the typical signs and symptoms of stones. Option 1 is associated with bladder cancer, option 2 with UTI, and option 3 with glomerulonephritis. ‐ Painless hematuria. ‐ Complaints of burning, frequency, and difficulty in urination. ‐ Complaints of severe colicky pain, nausea, pallor, and clammy skin. ‐ Brown‐tinged urine, edema, hypertension, and fatigue. | Recall that colicky pain is common with stones which can obstruct the urinary tract. |
1594 A client has a routine physical and the urinalysis Correct answer: 1 Painless hematuria is the presenting sign in 75 percent of urinary tract tumors, along with returns with microscopic hematuria. Which other flank pain and an abdominal mass. Hematuria may be gross or microscopic. symptoms would likely be present in a client with a urinary tract tumor? ‐ Flank pain ‐ Burning on urination ‐ Infection ‐ Polyuria | Recognize that options 2, 3, and 4 are more common with infection and presence of bacteria in the urine. |
1595 A Caucasian male is more prone to develop which of Correct answer: 2 Males are more likely to develop nephrolithiasis than females. Option 1 would be more the following? common in females, option 3 in African‐Americans, and option 4 does not apply. ‐ Urinary tract infection ‐ Nephrolithiasis ‐ Acute renal failure ‐ Polycystic kidney disease | Without any other information, recall that males more commonly suffer from kidney stones. |
1596 A client experiencing urinary calculi asks the nurse Correct answer: 4 The majority of kidney stones are comprised of calcium oxalate or calcium phosphate. what makes a stone in the body. The nurse's best Sturvite stones (15 to 20 percent), uric acid (5 to 10 percent) and cystine stones are answer is that the majority of kidney stones consist of: uncommon. ‐ Uric acid. ‐ Cystine. ‐ Sturvite. ‐ Calcium. | Select the answer that reflects the most common stone component, calcium. |
1597 The client with a uric acid kidney stone requires which Correct answer: 1 A low‐purine diet is required for clients with uric acid stones. High‐purine foods such as type of diet? sardines and organ meats are eliminated. Moderate‐level purine foods such as red and white meats and some seafoods are limited. Proteins are restricted in renal failure. | Recall that purine metabolizes into uric acid |
‐ Low purine ‐ Low protein ‐ High protein ‐ High purine | |
1598 A client experiencing oliguria would probably have Correct answer: 2 Oliguria is a urine output of less than 400 mL/24 hrs. It may result in decreased glomerular which of the following urinary outputs in a 24‐hour filtration rate. Option 3 is of concern and should be monitored closely. period: ‐ 750 mL/24 hrs. ‐ 400 mL/24 hrs. ‐ 600 mL/24 hrs. ‐ 1,000 mL/24 hrs. | Recall that oliguria is defined as urine output of less than 400 mL/24 hours. |
1599 A disruption in the renin‐angiotensin system in the Correct answer: 4 The decreased glomerular filtration rate caused by the inflammation of the glomerular client with glomerulonephritis can cause: membrane causes activation of the renin angiotensin‐aldosterone system and can lead to hypertension. Hypertension can also be caused from fluid retention and disruption of the renin‐ angiotensin system, a key regulator of blood pressure. Option 1 is common with urinary tract infections, option 2 with kidney stones, and option 3 with polycycstic kidney disease. ‐ A temperature of 101 degrees F, positive urine culture. ‐ Severe colicky pain with nausea. ‐ Proteinuria, polyuria, and/or nocturia. ‐ Blood pressure of 190/98. | Recall that renin affects blood pressure. |
1600 A client enters the clinic complaining of cocoa‐ or Correct answer: 1 The urine of acute glomerulonephritis is often cocoa‐ or coffee‐colored. Hematuria is coffee‐colored urine. This would most likely indicate associated with the other disorders and may be gross or microscopic. which disorder? ‐ Glomerulonephritis ‐ Kidney stone ‐ Urinary tract infection ‐ Bladder cancer | Recall that coffee‐colored urine is associated with glomerulonephritis. |
1601 A client is taking tobramycin sulfate (Tobrex) for a Correct answer: 4 This question draws on your knowledge of pharmacology as well as acute renal failure. severe infection and could possibly experience which Tobramycin can be nephrotoxic to the kidneys and a blood urea nitrogen/creatinine should be of the following: monitored during administration, especially if high doses are given. Even in a client with normal, healthy kidneys, the nephrotoxic effects can occur. This question draws on your knowledge of pharmacology as well as ARF. ‐ Glomerulonephritis. ‐ Pyelonephritis. ‐ Polycystic kidney disease. ‐ Acute renal failure. | Omit option 3 as this disorder has a genetic disorder. Associate drug reactions with an acute response. |
1602 What is the classic triad of symptoms indicating renal Correct answer: 2 The classic triad of symptoms, gross: hematuria, flank pain, and a palpable abdominal mass tumors? occur in only about 10 percent of people with renal cell carcinoma. Painless hematuria is the most consistent symptom. ‐ Fever, weight loss, oliguria ‐ Gross hematuria, flank pain, a palpable abdominal mass ‐ Dysuria, pain, fever ‐ Fever, pain, dysuria | Eliminate options 1, 3, and 4 as they all focus on fever which is more common with inflammatory response than malignancy. |
1603 Which diagnostic test usually provides the first Correct answer: 4 Renal ultrasound often provides the first diagnostic evidence of a kidney tumor. It is evidence of a kidney tumor? particularly beneficial in differentiating cystic kidney disease from renal neoplasms. CT is used to provide information about the tumor. ‐ Intravenous pyelography (IVP) ‐ Computed tomography (CT) ‐ Kidney, ureter, bladder (KUB) ‐ Renal ultrasound | Eliminate options 1 and 3 as these are preliminary tests and will not provide specific enough information. |
1604 The treatment of choice for nonmetastatic tumors of Correct answer: 3 Radical nephrectomy is the treatment of choice for tumors of the kidney. The adrenal gland, the kidney is: perirenal fat, upper ureter, and fascia surrounding the kidney are removed. Radiation and chemotherapy are treatment options for metastatic kidney tumors. Dialysis is used for end‐ stage renal disease. ‐ Radiation. ‐ Chemotherapy. ‐ Radical nephrectomy. ‐ Dialysis. | Recall that removal of the tumor is the first line of treatment. |
1605 Benign prostatic hypertrophy (BPH) is the most Correct answer: 4 Obstructive causes of acute renal failure are classified as post renal. BPH is the most frequent common precipitating factor in which type of acute precipitating factor and a form of obstruction. Other causes may include renal and urinary renal failure? calculi and tumors. ‐ Pre‐renal ‐ Intrarenal ‐ Inter‐renal ‐ Post‐renal | Think of the prostate in terms of location, below the kidneys. |
1606 Clients in the maintenance phase of acute renal Correct answer: 1 Salt and water retention lead to edema and puts the client at risk for congestive heart failure failure are at risk for heart failure and pulmonary and pulmonary edema. The immune function is impaired, leading to infectious complications. edema caused by: Increased urine volume occurs at the end of the maintenance phase, diuretic period. Nephrotoxins are associated with the initiation phase of ischemia. ‐ Salt and water retention. ‐ Immune function. ‐ Increased urine volume. ‐ Nephrotoxins. | Inability of the kidney to remove fluids and wastes leads to the correct response. |
1607 The most common cause of chronic renal failure is: Correct answer: 4 Conditions causing chronic renal failure typically involve diffuse, bilateral disease of the kidneys leading to progressive destruction and scarring of the nephron. Diabetic nephropathy causes glomerulosclerosis and thickening of the glomerular basement membrane. ‐ Cystic kidney disease. ‐ Hypertension. ‐ Glomerulonephritis. ‐ Diabetic nephropathy. | Recall that diabetes is the leading reason for dialysis due to renal failure. |
1608 Which of the following would be expected in the Correct answer: 4 Cardiovascular disease is a common cause of death in clients with end‐stage renal disease uremic stage of end‐stage renal disease and to resulting from accelerated atherosclerosis. Hypertension, hyperlipidemia, and glucose contribute to death of the client? intolerance all contribute to the process. All other disorders may be present throughout the uremic stage but are less likely to cause death. ‐ Respiratory infection ‐ GI disturbance ‐ Neurologic complication ‐ Cardiovascular disease | Identify option 4 as the condition likely to cause death. |
1609 Which of the following would be the most critical Correct answer: 2 Weight is the most critical index of fluid status. Although options 1 and 3 suggest fluid index of fluid excess in a client with chronic renal problems, weight is used as a measure for how much fluid is retained. If over hydrated, the failure? hematocrit would be low. ‐ Intake greater than output ‐ Weight gain of 6 pounds ‐ Edema +1 ‐ Low hematocrit | Eliminate options 1 and 4 as expected in most renal failure clients. Weight is a more significant indicator of fluid balance than edema. |
1610 Which of the following serum creatinine levels is Correct answer: 3 Normal serum creatinine for an adult female is 0.5 to 1.1 mg/dL and 0.5 to 1.2 mg/dL for an considered high and is expected in a client with chronic adult male. Levels greater than 4.0 mg/dL indicate serious impairment of renal function. renal failure? Although options 2 and 4 are high, with chronic renal failure, levels greater than 4.0 should be expected. ‐ 0.8 mg/dL ‐ 1.5 mg/dL ‐ 4.5 mg/dL ‐ 3.0 mg/dL | Based on the question, select the highest value. |
1611 Which of the client phone calls to the urology clinic Correct answer: 2 Urinary retention may result when a client with benign prostatic hypertrophy ingests large should be returned first? amounts of alcohol or takes a medication with B‐sympathomimetic side effects. The bladder sphincter becomes relaxed and does not open, and the bladder is unable to generate enough force to get urine past the enlarged prostate gland. ‐ 28‐year‐old man, with burning upon urination, greenish‐yellow penile discharge ‐ 68‐year‐old man, complaining of inability to void since taking allergy medication yesterday ‐ 45‐year‐old man, with weak stream of urine, worsening over last 6 months ‐ 52‐year‐old man, with foul‐smelling dark‐colored urine for past 2 days | Recognize that inability to void for 24 hours is an emergent situation. |
1612 Which client should the home health nurse visit first? Correct answer: 3 A modified radical mastectomy requires Jackson‐Pratt drains, which would still be in place 6 days post‐operative, and is therefore at greater risk for infection than the other clients. In addition, this client faces significant psycho‐social issues related to the cancer diagnosis and removal of the breast, which will affect her body image. Physiologic and psycho‐social assessments should be performed. ‐ 79‐year‐old male, 2 weeks post‐transurethral resection of the prostate for prostate cancer ‐ 15‐year‐old pregnant female, 1‐week for post‐pelvic inflammatory disease treatment ‐ 37‐year‐old female, 6 days post‐modified radical mastectomy ‐ 23‐year‐old male, 4 days post‐circumcision for phimosis | Radical mastectomy is a major surgical procedure and in the first week post‐surgery the client would have significant care needs. |
1613 The client with secondary dysmenorrhea would be Correct answer: 4 Secondary dysmenorrhea develops after menses have become ovulatory and regular, most likely to have recently experienced: following menarche. Obstruction is the most common cause and can result from uterine fibroids or scarring of the uterine cavity. ‐ Normal, spontaneous, vaginal delivery of her third child. ‐ Severe viral illness with high fever, body aches, and diarrhea. ‐ Infertility requiring diagnostic laparoscopic surgery. ‐ Chlamydia trachomatis pelvic inflammatory disease. | Recall that the term secondary implies after a significant related illness. |
1614 To help the client with pedunculated uterine fibroids Correct answer: 3 Uterine fibroids or myomas are solid tissue tumors that are not precancerous. Pedunculated understand her diagnosis, the nurse describes them as: fibroids are on a stalk or stem and can extend either into the uterine cavity or outward into the pelvic cavity. ‐ Fluid‐filled sacs on the outside wall of the uterus. ‐ Precancerous spots on the inside of the uterus. ‐ Solid growths on a stem that attach to the uterus wall. | The word ‘pedunculated’ in the question should lead to the selection of option 3 that uses the word stem to describe the growths. |
4.‐ The same as what is shed each month with menstruation. | |
1615 The pregnant client with gonorrhea wants to know Correct answer: 3 Gonococcal opthalmia neonatorum is the eye infection in newborns caused by Neisseria why she needs to be treated now before the baby is gonorrhoeae. This infection can cause blindness within a few hours after birth if not treated born. The nurse explains that treatment is necessary to with antibiotic eye medication. avoid the fetus developing: ‐ Pneumonia that can cause death ‐ Seizures that can cause brain injury. ‐ Eye infection that can cause blindness. ‐ Heart failure that can create preterm labor. | Recall that transmission occurs by contact during the birth process. This leads to the selection of option 3. |
1616 Which statement indicates that the teaching for the Correct answer: 1 Anti‐viral medications like acyclovir (Zovirax) and valcyclovir (Valtrex) are used to treat client with genital herpes simplex virus 1 (HSV1) primary infections and recurrences and will shorten the duration of the outbreak. As infection has been effective? suppressive therapy, they help prevent recurrences. No cure exists for HSV1 infections; the virus will live on the nerve root until the next outbreak. ‐ "When I feel a recurrence starting, I'll begin taking my medication." ‐ "When I am finished with this medication, I'll be cured of the infection." ‐ "The medication will help me feel better but doesn't affect the infection." ‐ "I'm guaranteed I'll never have another infection if I take my medication." | Notice that the use of the word ‘recurrence’ in option 1 is a hint to the correct response. |
1617 The client with prostate cancer has had an abdominal‐ Correct answer: 1 Radiation treatments cause nausea and vomiting; fluid status should be assessed to perineal resection and is now undergoing radiation determine if the client is dehydrated. treatments. Which of the following is the most important action for the nurse to take? ‐ Pinch the skin on the back of the hand gently. ‐ Take the temperature and blood pressure. ‐ Check the urine for the presence of protein and glucose. ‐ Determine how the client is coping with cancer. | Eliminate option 3 as being unrelated to the condition described. Eliminate option 4 as physical problems will take priority over psychosocial. Radiation would more likely cause problems with hydration than temperature and blood pressure. |
1618 The client with phimosis will experience difficulty Correct answer: 3 Phimosis is a tight foreskin that is unable to be retracted by an age when retraction should with: take place. ‐ Replacing the retracted foreskin. ‐ Complete bladder emptying. ‐ Retracting the foreskin. ‐ Maintaining an erection. | Eliminate options 2 and 4 as unrelated to the condition. |
1619 The client is scheduled for a transurethral resection of Correct answer: 1 Benign prostatic hyperplasia (BPH) is seen in elderly men in all ethnic groups and races and is the prostate (TURP) to treat his benign prostatic thought to result from decreasing testosterone levels that begin in middle‐age. BPH is neither hypertrophy (BPH) and asks the nurse how his prostate cancerous nor precancerous. became enlarged. The best response is: ‐ "Prostate enlargement happens to most men as they age and their hormones change." ‐ "Your prostate has become cancerous, which is really quite a rare occurrence." ‐ "Because of your diet, your prostate gland has quit working, and became larger." ‐ "Your chronic constipation put excessive force on the prostate, and it enlarged." | Eliminate option 2 as the condition is benign. Options 3 and 4 are incorrect since diet and bowel activity are not contributory to the condition. |
1620 The client has had a benign breast cystectomy. The Correct answer: 2 Caffeine and smoking both increase the incidence of benign cysts of the breast. Breast cysts nurse knows that discharge teaching has been (fibrocystic breast disease) are neither a precursor to nor a risk factor for developing breast effective when the client states: cancer. The small incision will usually not affect lactation. | Select the option that identifies a positive behavior change to reduce risk. |
‐ "I'll need to wear an underwire bra from now on." ‐ "I should quit smoking and drinking coffee." ‐ "My risk for cancer is much higher after this cyst." ‐ "I won't be able to breast feed if I have children." | |
1621 The client has undergone a lumpectomy for breast Correct answer: 1 Small tumors that are localized are often treated with lumpectomy. Recurrence rates and cancer and asks, "Why didn't the doctor take off my survival rates are not improved in these cases with more radical surgery. whole breast?" The nurse's best response is: ‐ "Some cancers don't have better outcomes with mastectomy." ‐ "Every surgeon I know only does mastectomies. I don't know." ‐ "Your cancer had progressed so far that a mastectomy wouldn't help." ‐ "Your doctor would only do what's best. Everything will be just fine." | Eliminate options 2 and 4 as they are non‐therapeutic responses. Recognize that option 1 is the only true statement. |
1622 Which client is at greatest risk for developing Correct answer: 2 Cryptorchidism is the single greatest predictor of testicular cancer, even when the condition testicular cancer? is corrected in early childhood. Varicocele does not increase the risk of the disease, nor does a second‐degree relative with the disease. No activity has been associated with testicular cancer. ‐ Client who is a bicycle racer ‐ Client who has uncorrected cryptorchidism ‐ Client who has an uncle with the disease ‐ Client who underwent repair of varicocele | The word ‘uncorrected’ in option 2 helps in identification of that as the correct response. |
1623 Nursing management of the client with Neisseria Correct answer: 4 Condoms used consistently will decrease the transmission of sexually transmitted infections gonorrhoeae infection of the cervix includes: and protect sexual partners. ‐ Education on the use of birth control pills. ‐ Assessment of tampon or sanitary napkin use. ‐ Arranging a method of transportation to the hospital. ‐ Instructions on the correct use of condoms. | Recall that reduction in transmission is a major goal of care. |
1624 Which client with a sexually transmitted infection is Correct answer: 3 Latent syphilis usually has no symptoms. The latent phase begins when the rash of secondary most likely to have an asymptomatic infection? syphilis clears, and may last for decades without further symptoms. ‐ Female with cervical gonorrhea ‐ Male with urethral Chlamydia ‐ Female with latent syphilis ‐ Male with primary herpes simplex virus, type 1 | Note that the word ‘latent’ is the hint to identification of option 3 as correct. |
1625 Which statement, if made by the client with prostate Correct answer: 2 Giving away personal possessions is a sign of depression and suicidal ideation. Although the cancer, requires immediate intervention? diagnosis of cancer may result in depression, indications of suicidal tendencies must be addressed. Impotence after prostatectomy is common, and sometimes responds to oral or injectable medications. Chemotherapy often causes nausea, and medication to control the nausea should be used. Normal incisional healing involves some itching, and because the subcutaneous nerves are severed during surgery, numbness around the area may result. ‐ "I want the pill that will let me have sex again." ‐ "I've made out my will and given away my money." ‐ "I get nauseated for 2 days after each chemotherapy." ‐ "My incision is itchy, and the skin around it is numb." | Omit options 3 and 4 as being factual assessments of symptoms. Option 1 is eliminated based on the fact that it addresses a common outcome. |
1626 The nurse is planning a community presentation on Correct answer: 4 Nerve‐sparing surgical techniques can sometimes be utilized, but impotence and incontinence prostate cancer. The presentation should include: are still common side effects. First‐degree relative with the disease is a strong risk factor for developing prostate cancer. In elderly men the cancer is slow‐growing, but the younger the man is at the time of diagnosis the more aggressive the cancer is likely to be. ‐ Having a first‐degree relative with the disease does not increase the risk for a patient. ‐ Prostate cancers are slow‐growing and rarely progress beyond the gland in men of any age. ‐ New surgical techniques do not injure surrounding nerves, so incontinence never occurs. ‐ Impotence is a common side effect of abdominal or perineal surgical treatment. | In a community presentation the common concern of impotence should be addressed. |
1627 The 34‐year‐old woman client presents with regular, Correct answer: 2 Uterine fibroids or myomas will cause heavy menses with large clots. The presence of heavy menses with clots up to golf‐ball size. She has intramural or submucosal myomas can cause early pregnancy loss or infertility. Ultrasound had three first‐trimester spontaneous abortions this examination will detect the presence of myomas. year. The nurse would expect the physician to order which of the following? ‐ Magnetic resonance imaging (MRI) ‐ Ultrasound ‐ Blood type and Rh ‐ Diagnostic laparoscopy | Recall that ultrasound would be done before laparoscopy for diagnosis. |
1628 The client has given birth to a stillborn infant in which Correct answer: 3 Congenital syphilis can occur when a mother is in any stage of syphilis infection during the a diagnosis of congenital syphilis has been made. The pregnancy, including if she becomes infected during this pregnancy. All sexual partners should plan of care would include: be treated. Penicillin is the antibiotic used for treating syphilis. Because syphilis is blood‐borne, gowning and gloving when having contact with the dead infant's skin is all that would be required. Diagnostic work‐up may include lumbar puncture. ‐ Asking if the client is allergic to erythromycin. ‐ Utilizing droplet precautions when handling the body. ‐ Asking the client for the names of all sexual contacts. ‐ Preparing the client for a magnetic resonance imaging (MRI) scan. | Omit options 1, 2, and 4 as not related to the condition. |
1629 The client with endometriosis is most likely to make Correct answer: 2 Endometriosis causes infertility both in the presence of blockage of the fallopian tubes from which statement? endometrial implants as well as without blockages for unknown reasons. Pregnancy is often extremely difficult if not impossible unless medical or surgical intervention is initiated. ‐ "I've been alternating between diarrhea and constipation." ‐ "I haven't been able to get pregnant in 7 years of trying." ‐ "I get urinary tract infections about every other month." ‐ "I have green vaginal discharge and pain with intercourse." | Recall that endometriosis is a common cause of infertility. |
1630 Which of the following complaints is most likely to be Correct answer: 4 Herpes simplex virus (HSV) infections of the genital tract are exquisitely painful, start as herpes simplex virus 1 (HSV1)? blisters that become crater‐like lesions, and are often accompanied by enlarged groin nodes. ‐ Yellow penile discharge ‐ Painless crater‐like lesion ‐ Dysuria of sudden onset ‐ Painful blisters and craters | The description of the herpes lesions as painful is the key to identification of the correct response. |
1631 A client who lives in a heavily industrialized area has a Correct answer: 3 People living in heavily industrialized states experience higher rates of urinary tract cancers higher incidence of which renal/urinary disorder? than those living in agricultural states. People living in northern regions have a higher risk than those living in southern regions. | Associate industrial pollution with cancer risk. |
‐ Urinary tract infection ‐ Kidney stones ‐ Bladder carcinoma ‐ Renal failure | |
1632 If a urine specimen is needed for a client with signs Correct answer: 1 Midstream urine is considered less likely to be contaminated from the external genitalia. and symptoms of acute renal failure (ARF), the nurse Analysis for disorders as serious as ARF requires a good specimen if not a cath specimen. should instruct the client to collect a urine specimen: ‐ Midstream. ‐ At the beginning of urination. ‐ At the end of urination. ‐ First thing in the morning. | Recall that midstream collection is always preferable. |
1633 A urinalysis returns with positive proteins, positive Correct answer: 3 Cranberry juice helps the acidity of the urine to inhibit bacterial growth. The juice should not glucose, specific gravity of 1.010, and pH of 4.5. The account for the presence or absence of glucose or protein. The specific gravity is affected by nurse knows that cranberry juice can alter which part fluid balance. of the urinalysis? ‐ Protein ‐ Specific gravity ‐ pH ‐ Glucose | Recall that cranberry juice acidifies urine, thus altering pH. |
1634 Phenazopyridine (Pyridium) is sometimes ordered for Correct answer: 2 Phenazopyridine (Pyridium) is a urinary analgesic that stains the urine/semen orange. the client with a urinary tract infection. Which of the Antibiotics can be used (option 1); options 3 and 4 are incorrect. Fluids should always be following should be explained to a male client? encouraged. ‐ "This is an antibiotic that is commonly used." ‐ "This drug may discolor the urine and semen orange." ‐ "The drug will cure the urinary tract infection and takes the place of increasing fluids." ‐ "This drug is good, but very nephrotoxic." | Omit options 1, 3, and 4 as incorrect information. Recall that the drug is an analgesic. |
1635 The nurse is preparing a teaching plan for the client Correct answer: 3 An increase in fluid intake of 2,500 to 3,000 mL/day is a prevention measure for further with a urinary stone. Fluid intake is an important urolithiasis. A client with CHF, however, will probably not tolerate this amount of fluid without preventive measure and should be between 2,500‐ complications. 3,000 mL/day. Which of the following clients would have to decrease this measure even though it is recommended? A client with: ‐ Arthritis. ‐ Systemic lupus. ‐ Congestive heart failure (CHF). ‐ Diabetes. | Remember that fluid restriction is sometimes necessary in CHF. |
1636 Which of the following diets should be ordered for Correct answer: 1 Restricting dietary protein early in chronic renal failure may slow the disease progression and clients with chronic renal failure? also reduce nausea and vomiting due to anorexia associated with uremia. Protein intake of 0.6 g/kg body weight or approximately 40 g/day is usually adequate. Carbohydrates should be high to compensate for energy needs. ‐ Low protein, high carbohydrates ‐ High protein, high carbohydrates ‐ High protein, low carbohydrates ‐ Low protein, low carbohydrates | Associate low protein and calories, primarily from carbohydrates, as the preferred diet in renal failure. |
1637 The goal of treatment for the client with chronic renal Correct answer: 1 Early management of the client with chronic renal failure focuses on elimination factors that failure is to: may further the decrease of renal failure and measures to slow the progression of the disease to end‐stage renal disease. If conservative treatment fails, dialysis or transplantation is the treatment option. ‐ Maintain present renal function. ‐ Prepare the client for dialysis. ‐ Prepare for transplantation. ‐ Limit involvement and activity to decrease stress. | Recognize that option 1 identifies the most important goal, which is to preserve function as long as possible. |
1638 Because most urinary stones consist of calcium, Correct answer: 3 Limiting Vitamin D inhibits absorption of calcium from the GI tract. Acid‐ash foods promote which of the following should be reduced in a client acidity of the urine, whereas alkaline‐ash foods promote calcium stones. with stones? ‐ Low‐purine foods ‐ Bananas ‐ Vitamin D ‐ Acid‐ash foods | Recognize that milk and dairy products are high in calcium and often fortified with Vitamin D. |
1639 Which test is the best measure of renal function? Correct answer: 2 Creatinine is solely indicative of renal function and represents damage to a large number of nephrons. BUN can be affected by the amount of protein in the diet. Bilirubin indicates liver problems and electrolytes can be altered for many reasons. ‐ Creatinine ‐ Bilirubin ‐ Blood urea nitrogen (BUN) ‐ Electrolytes | Creatinine should always be considered as the best measure of renal function. |
1640 A common factor that predisposes adolescents and Correct answer: 4 Vesicoureteral reflux is a condition in which urine moves from the bladder back toward the children to developing pyelonephritis is: kidney. Diet, swimming, and circumcision should not cause an infection of the kidneys. ‐ Diet. ‐ Frequent swimming. ‐ Circumcision. ‐ Vesicoureteral reflux. | Eliminate options 1, 2, and 3 as not generally causes of infection. |
1641 When discharging a client from the hospital after a Correct answer: 4 The indwelling urinary catheter is left in place about 2 weeks after a TURP procedure. The transurethral resection of the prostate (TURP) or urine should progressively become clearer and less pink, and clots are to be reported to the benign prostatic hyperplasia (BPH), which of the physician immediately. Low abdominal pain of new onset can be a symptom of cystitis, and following is essential to teach the client? should be reported. Nonsteroidal anti‐inflammatory drugs are to be avoided because of the potential for increased bleeding. Adequate fluid intake is important to keep the catheter draining well, but caffeine and alcohol are both bladder irritants and may cause bladder spasm as well as dehydration. ‐ The indwelling catheter will be removed by the physician in about 2 days. ‐ The color of the urine may become red and contain small clots. ‐ Pain in the lower abdomen is to be expected; take aspirin or ibuprofen (Advil). ‐ Drink plenty of fluids, especially water, and avoid caffeine and alcohol. | Select the response that provides for sound basic advice in the post‐operative period. |
1642 Which client is at greatest risk for contracting Correct answer: 1 The highest incidence of syphilis infections is among black men in urban areas, particularly in syphilis? the southeastern United States. This client has two risk factors, because syphilis is spread through sexual contact as well as being blood borne. ‐ African‐American, urban‐dwelling intravenous drug‐user who does not use condoms | Notice that option 1 states lack of condom use, so this can be identified as the correct response. |
‐ Hemophiliac who has had multiple blood transfusions ‐ Caucasian suburban teen who has had 4 sexual partners ‐ Emergency department healthcare worker in rural setting | |
1643 The parent of a newborn with epispadias is asking Correct answer: 1 Epispadias is a rare defect that develops very early in fetal development. No known risk how this happened. The best answer would be: factors have been identified, and parents should be assured it wasn't caused by anything they did or didn't do. ‐ "The defect happens early in fetal development." ‐ "The alcohol you drank caused the defect." ‐ "Because you smoked, the penis did not form correctly." ‐ "You had a deficiency of folic acid that caused this." | Select the response that does not place blame on the parent. |
1644 The female client with Chlamydia trachomatis is at Correct answer: 2 Chlamydia trachomatis is the most common bacterial cause of pelvic inflammatory disease. risk for which possible complication? The bacteria ascend from the cervix into the uterus and fallopian tubes, where infection worsens. ‐ Diarrhea with dehydration ‐ Pelvic inflammatory disease ‐ Rash on the palms and feet ‐ Encephalitis | Select the response that makes sense in terms of progression of the infection to adjacent structures. |
1645 Which client is most likely to be diagnosed with Correct answer: 2 Testicular cancer occurs most often between the ages of 15 and 34, and presents with lump testicular cancer? or thickening of one testicle, pain in the testicle, and lower abdomen, lower back, or rectum. ‐ 25‐year‐old with sudden onset of testicular pain that started when he was lifting weights ‐ 18‐year‐old with unilateral testicular pain and low abdominal pain that is worsening ‐ 40‐year‐old with increasing rectal pain, lower back pain, and low‐grade temperature ‐ 50‐year‐old with nocturia, hesitant and weak urinary flow whose father had lung cancer | Select the response that describes pain not associated with strenuous activity. |
1646 The client has been diagnosed with neurosyphilis. The Correct answer: 4 Neurosyphilis can occur during any stage of syphilis but most commonly occurs during the nurse knows that teaching has been effective when the tertiary stage. Central nervous system involvement causing dementia, paralysis, gradual client states: blindness, and numbness characterizes neurosyphilis. Syphilis is blood borne and sexually transmitted, so all sexual contacts should be tested. Treatment is based on lumbar puncture results and estimated length of time of the syphilis infection. ‐ "I must have gotten infected when I ate at a Caribbean restaurant last winter." ‐ "My wife doesn't have to worry about being tested because she's postmenopausal." ‐ "I'll need to make sure that my grandson doesn't drink from the same cup that I use." ‐ "The treatment for this will be ongoing and based on what my lab results show. | Omit options 1, 2, and 3 as syphilis is sexually transmitted. |
1647 The client who may have dysfunctional uterine Correct answer: 4 Bleeding calendars are utilized to quantify the amount and frequency of bleeding. The client bleeding (DUB) is being instructed to complete a should document each day that she has bleeding, how much bleeding she has, the color of the bleeding calendar. The client should include: flow, and when she has clots (including the size of the clots.) All information must be obtained in order to make an accurate diagnosis. ‐ Days of bleeding and color of the flow. ‐ Amount of flow and temperature. ‐ Time bleeding started and clots. ‐ Amount of flow and color of blood. | Note that option 4 is more descriptive of the bleeding than the other options. |
1648 Teaching has been effective when the client Correct answer: 1 Endometriosis is small areas of growing endometrium in the pelvic and/or abdominal cavity, diagnosed with endometriosis describes the condition which increase in size during the secretory phase of the menstrual cycle. Because there is as: nowhere for the endometrium to be shed, scarring occurs. | Notice that the phrase ‘outside the uterus’ in option 1 is the key to identifying this as the correct option. |
‐ Collections of endometrium outside the uterus. ‐ Endometrium growing among the myometrium. ‐ Small, solid tumors within the uterine wall. ‐ Tiny pockets of blood throughout the pelvis. | |
1649 Which of the following would probably be ordered for Correct answer: 4 Primary dysmenorrhea results from the over‐production of prostaglandins by the the client suffering from primary dysmenorrhea? myometrium. Nonsteroidal anti‐inflammatory (NSAIDs) medications (like Naprosyn) have anti‐ prostaglandin activity and thus decrease the dysmenorrhea. ‐ Meperidine hydrochloride (Demerol) ‐ Propanolol (Inderal) ‐ Acetaminophen and codeine phosphate (Tylenol #3) ‐ Naproxen (Naprosyn) | Omit options 1 and 3 as narcotics are not generally necessary. Propanolol is a beta blocker and would not be useful. |
1650 The client with benign prostatic hyperplasia will be Correct answer: 4 Ibuprofen is a nonsteroidal anti‐inflammatory drug, and has anti‐platelet aggregation undergoing a transurethral resection of the prostate in properties. It must be discontinued 10 days prior to surgery to prevent excessive blood loss. 2 weeks. Which medication does the client need to discontinue prior to surgery? ‐ Phenytoin (Dilantin) ‐ Nystatin powder (Micostatin) ‐ Omeprazole (Prilosec) ‐ Ibuprofen (Motrin) | Look for medications that have an influence on bleeding. Recall that NSAIDs are discontinued due to bleeding. |
1651 The nurse has admitted a client with uremia. The Correct answer: 2 Uremia is a syndrome, or group of symptoms, associated with end‐stage renal disease. The nurse plans care for which of the following underlying normal function of the kidney is altered, resulting in various metabolic and systemic effects disorders? including fluid and electrolyte disturbances. Pyelonephritis (inflammation of the kidney and renal pelvis) and cystitis (inflammation of the urinary bladder) do not lead to uremia. Polycystic kidney disease is a hereditary disease characterized by kidney enlargement and cyst formation. ‐ Polycystic kidney disease ‐ End‐stage renal failure ‐ Pyelonephritis ‐ Cystitis | Recognize that options 3 and 4 are treatable and not associated with uremia. Polycystic kidney disease is also not a uremic condition. |
1652 A client receiving peritoneal dialysis (PD) has outflow Correct answer: 2 If outflow drainage is less than inflow, the nurse should change the client's position to shift that is less than the inflow for two consecutive abdominal fluid, and hopefully move the catheter into contact with the fluid in the abdomen. exchanges. Which of the following actions would be Although vital signs are monitored, the blood pressure is not a concern at this time (option 1). best for the nurse to take first? The catheter does not need to be irrigated (option 3). A direct nursing intervention is needed, while continuing to monitor is an assessment and does not correct the current problem (option 4). ‐ Check the client's blood pressure ‐ Change the client's position ‐ Irrigate the dialysis catheter ‐ Continue to monitor the third exchange | Select a simple non‐invasive strategy for a first attempt. |
1653 The nurse is planning to teach the client with acute Correct answer: 2 A client with glomerulonephritis should eat a diet that is high in calories but low in protein to glomerulonephritis about dietary restrictions. The inhibit protein catabolism, and allow the kidneys to rest by diet (since they have fewer nurse should include in the plan to make which of the nitrogenous wastes to clear). It is important to protect the kidneys while they are recovering following dietary changes? their function. The other responses are incorrect. ‐ Limit fluid intake to 500 mL per day ‐ Restrict protein intake by limiting meats and other high‐protein foods ‐ Increase intake of high‐fiber foods, such as bran cereal ‐ Increase intake of potassium‐rich foods such as bananas or cantaloupe | Recall that protein restriction is associated with kidney diseases. |
1654 A client develops a renal disorder after taking an Correct answer: 3 Acute renal failure is a condition that may be caused by nephrotoxic drugs such as antibiotic that has nephrotoxicity as an adverse effect. aminoglycoside antibiotics. Acute renal failure has a rapid onset and is potentially reversible. The nurse adds to the client's medical record a The condition usually responds to treatment if diagnosed early. Chronic renal failure develops standardized care plan for which of the following insidiously and requires dialysis or transplantation. disorders? ‐ Polycystic kidney disease ‐ Glomerulonephritis ‐ Acute renal failure ‐ Chronic renal failure | Eliminate options 1 and 2 as they are not caused by nephrotoxic drugs. The situation described is acute, not chronic. |
1655 A client with a chronic urinary tract infection is Correct answer: 3 Serum creatinine measures the amount of creatinine in the blood. Creatinine is the end scheduled for a number of laboratory tests. The nurse product of creatine phosphate, used in skeletal muscle contraction. Blood urea nitrogen (BUN), would review results of which of the following tests to another common laboratory test, measures the nitrogen portion of urea and helps detect best evaluate whether the kidneys are being adversely dehydration. These tests are often ordered together when assessing renal function. affected? ‐ Serum potassium ‐ Urinalysis ‐ Serum creatinine ‐ Urine culture | Look for the option that would best assess renal function, creatinine. |
1656 A female client with recurrent cystitis has been told Correct answer: 4 An acid‐ash diet lowers urine pH, which may reduce bacterial growth. An acid‐ash diet to follow an acid‐ash diet. The client demonstrates includes the following foods: meat, fish, shellfish, poultry, cheese, eggs, cranberries, prunes, understanding of diet instruction if she states to avoid plums, corn, lentils, grains, and foods high in chlorine, phosphorus, and sulfur. Foods to be which of the following foods? avoided include: milk and milk products; all vegetables except corn and lentils; all fruits except cranberries, plums, and prunes; and foods containing high amounts of sodium, potassium, calcium, and magnesium. ‐ Fish ‐ Corn ‐ Eggs ‐ Milk | Recall that dairy foods tend to raise pH. |
1657 The nurse is teaching the client to perform peritoneal Correct answer: 2 Peritonitis is the major complication of PD. The nurse should use strict aseptic technique and dialysis (PD). The nurse reviews in detail which of the should teach the client to use it whenever accessing the catheter. The client does not need following essential actions that will help to prevent the post‐void residuals (option 1). Heparin is added to dialysate as ordered, but it would be added major complication of peritoneal dialysis? to each bag, not to one bag per day randomly; the catheter site dressing is changed daily (options 3 and 4). ‐ Monitor the client's post‐void residuals ‐ Maintain strict aseptic technique during connection and disconnection ‐ Add heparin to the dialysate at least once per day ‐ Change catheter site dressing twice daily | The most common complication is peritonitis. Select the option that stresses asepsis. |
1658 The nurse would assess a client with kidney stones for Correct answer: 1 Renal colic is an acute, severe pain in the flank and upper abdominal quadrant on the affected which of the following to best determine whether the side, generally associated with renal calculi that obstruct a ureter. Clients experiencing renal client is developing renal colic? colic describe it as sudden in onset and may be accompanied by nausea, diaphoresis, and vomiting. ‐ Flank pain ‐ Difficult urination ‐ Absence of urine ‐ Headache | Recall that flank pain is the symptom associated with renal colic. |
1659 A client seen in the emergency department complains Correct answer: 2 Painful urination, frequency, and urgency are common signs of cystitis, or bladder infection. of painful urination, frequency, and urgency. Which of In addition, the urine may have a foul odor and appear cloudy. Bacteria, virus, parasites, or the following conditions would the nurse suspect? fungi may cause the condition, with GI tract bacteria being the most common cause. ‐ Renal calculi ‐ Cystitis ‐ Glomerulonephritis ‐ Polycystic kidney disease | Omit options 3 and 4 as the symptoms are inconsistent with these conditions. |
1660 Which of the following is the priority nursing Correct answer: 4 Pain is the most common sign of UTI and is usually the most distressing symptom for the diagnosis for a client with urinary tract infection (UTI)? client. The pain may be caused by inability to void or by bladder spasms. The client may have manifestations of the other nursing diagnoses as well, but pain is the highest priority. ‐ Anxiety ‐ Disturbed sleep pattern ‐ Disturbed body image ‐ Pain | Recall that pain is the most frequent complaint in UTI. |
1661 The nurse caring for a client with benign prostatic Correct answer: 3 Various relationships between BPH and diet, obesity, sexual activity, and racial origins have hyperplasia (BPH) explains that currently the cause of been explored; however, none of these provide insight into its etiology. this disorder is: ‐ Linked to sexual activity. ‐ Linked to diet. ‐ Unknown. ‐ Related to racial origins. | Options 1, 2, and 3 list specific causes. Note that option 4 is different and in this case correct. |
1662 A male client presents to the emergency room with Correct answer: 1 Priapism is considered a medical emergency, because continued erection may lead to tissue priapism, or sustained erection. The nurse understands fibrosis and impotence. Immediate treatment involves ice packs, not warm soaks. Options 2 that this client needs which of the following? and 4 do not apply. ‐ Immediate medical attention ‐ A relaxing environment so his erection will recede ‐ Warm soaks to the penis ‐ An evaluation for sexual dysfunction | Note that the situation is set in an emergency room; therefore immediate medical attention is a logical response. |
1663 The nurse is evaluating a client with erectile Correct answer: 1 Propranolol, a beta adrenergic blocker, and many other antihypertensive medications can dysfunction. Which of the following medications contribute to erectile dysfunction. Other examples include clonidine (Cata pres) and benazepril currently used by the client could be an underlying (Lotensin). The other medications listed in options 2, 3, and 4 aren't known to have this effect. cause? ‐ Propranolol (Inderal) ‐ Acetylsalicylic acid (aspirin) ‐ Penicillin ‐ Furosemide (Lasix) | Note that only option 1, the beta blocker, has neurovascular effects. |
1664 A 68‐year‐old female client presents to the Correct answer: 2 Because painless vaginal bleeding is often the only symptom of cervical or uterine cancer, this gynecology clinic with complaints of painless vaginal client should be tested for cancer. Options 1 and 4 are not probable given the client's age. bleeding. The nurse should be certain the client is Hormonal imbalances (option 3) may cause bleeding but are less urgent than the threat of tested for which of the following health problems? cancer. ‐ Ovarian cyst ‐ Cervical or uterine cancer ‐ Hormonal imbalances | Recognize that unusual bleeding is symptomatic of cancer and clients should be evaluated accordingly. |
4.‐ Endometriosis | |
1665 The nurse concludes that a client who undergoes Correct answer: 3 NPTR monitoring helps differentiate between psychogenic and organic causes of erectile nocturnal penile tumescence and rigidity (NPTR) dysfunction. The other options are not assessed using NPTR monitoring. monitoring is most likely being evaluated for which of the following disorders? ‐ Prostate cancer ‐ Infertility ‐ Erectile dysfunction ‐ Phimosis | Notice that the question uses the words ‘penile’ and ‘rigidity,’ leading to the correct response. |
1666 When examining a female client, the nurse observes Correct answer: 4 Third‐degree uterine prolapse is visible outside the body as the uterus inverts the vaginal tissue protruding from the vagina. The nurse checks canal. Rectocele is prolapse of the rectum. Cystocele is prolapse of the urethra. A vaginal the medical record for a documented history of which infection would not cause tissue protrusion from the vagina, although the vaginal tissues of the following disorders? would be reddened and/or edematous. ‐ Rectocele ‐ Cystocele ‐ Vaginal infection ‐ Uterine prolapse | Omit option 3 as the scenario does not indicate infection. The uterus is above the vagina and a prolapse would present as described. |
1667 A client has just had a Papanicolaou (Pap) test. The Correct answer: 3 The Pap smear test is used to screen women for cervical cancer, assess hormonal status, and nurse would write which of the following indications identify the presence of sexually transmitted diseases, such as HPV infection. Infertility and for the test on the laboratory requisition? AIDS are not diagnosed with the Pap test. Sterility is a male reproductive problem. ‐ Infertility ‐ Sterility ‐ Human papilloma virus (HPV) infection ‐ Acquired immunodeficiency syndrome (AIDS) | Recall that a Pap test is helpful in diagnosis of cervical cancer. Options 1, 2 and 4 are not associated with cervical cancer. |
1668 When evaluating a client for breast cancer, the nurse Correct answer: 4 Early menstruation, before the age of 12, is a risk factor for breast cancer. Use of foam recognizes that which of the following client‐related contraceptives is not a factor. Late menopause increases the risk for breast cancer, but not factors is a risk for developing this disease? early menopause. A first birth after the age of 30 is a risk factor, but first birth before age 20 is not. ‐ Use of foam contraceptives ‐ Early menopause, before age 45 ‐ First birth before age 20 ‐ Early menarche, before age 12 | Select the response that reflects that the client has had prolonged exposure to hormones, specifically estrogen and progesterone. |
1669 When teaching a female client to perform breast self‐ Correct answer: 2 Breast examinations should be done monthly, at the same time each month to aid in examination (BSE), the nurse should instruct her to remembering to do it regularly. A post‐menopausal woman would select the same date each perform the exam: month, while premenopausal women should do BSE at completion of the menstrual cycle. Breast examination during menstrual flow is not the best time, because of hormonal influences on the breasts. ‐ During menstrual flow. ‐ At the same time each month. ‐ At a random time each month. ‐ Every 2 months. | This is the best response as it describes the procedure being done on a consistent basis. |
1670 When caring for a client with syphilis, the nurse Correct answer: 2 Syphilis is transmitted from open lesions during any sexual contact: genital, oral‐genital, or instructs the client that syphilis may be transmitted by anal‐genital. Kissing, sharing eating utensils, and shaking hands do not transmit the disease. which of the following methods? ‐ Kissing ‐ Open lesions during any sexual contact ‐ Sharing eating utensils ‐ Shaking hands | Recall that syphilis is a sexually transmitted disease. |
1671 When caring for a client diagnosed with end‐stage Correct answer: 2 With end‐stage renal disease the kidneys have difficulty excreting protein and the build‐up of renal failure, which of the following diets should the toxins in the system causes systemic problems. Clients must usually restrict dietary protein nurse recommend? while increasing carbohydrate intake to meet energy needs and prevent tissue breakdown. Potassium and sodium are restricted in clients with end‐stage renal failure. Protein‐rich foods are also high in phosphorus, which is restricted to avoid osteodystrophy. Magnesium is not specifically restricted. ‐ Increased protein, decreased carbohydrates ‐ Restricted protein, increased carbohydrates ‐ Increased potassium and sodium ‐ Restricted phosphorus and magnesium | Recognize that a client in renal failure gets necessary calories from carbohydrates. |
1672 The client diagnosed with cystitis will be given a Correct answer: 1 The pain experienced with cystitis usually resolves as antibiotic therapy becomes effective. prescription for an antibiotic. The nurse explains to the However, clients may be treated for urinary tract pain with phenazopyridine, which is a urinary client that which of the following medications that is analgesic. Bethanechol chloride is a cholinergic agent used with neurogenic bladder or urinary combined with the antibiotic will reduce the symptom retention. Oxybutinin and propantheline bromide are antispasmodics used to treat bladder of dysuria? spasm. ‐ Phenazopyridine (Pyridium) ‐ Bethanechol chloride (Urecholine) ‐ Oxybutinin chloride (Ditropan) ‐ Propantheline bromide (Pro‐Banthine) | Recall that Pyridium is the only commonly used urinary analgesic. |
1673 The client has developed urolithiasis, and it is Correct answer: 3 Clients who have urinary stones of the uric‐acid type should avoid foods containing high determined that the client has uric acid stones. The amounts of purines, including the following: organ meats (liver, brain, heart, kidney, and nurse instructs the client to limit which of the sweetbreads), herring, sardines, anchovies, meat extracts, consommés, and gravies. Foods that following foods in the diet that was previously eaten are low in purines include all fruits, many vegetables, milk, cheese, eggs, refined cereals, sugars regularly? and sweets, coffee, tea, chocolate, and carbonated beverages. ‐ Oranges ‐ Cheese ‐ Liver ‐ Eggs | Associate organ meats with high purine content, and therefore contribute to excess uric acid. |
1674 In gathering data on an elderly male client the nurse Correct answer: 1 Benign prostatic hyperplasia (BPH) is a common cause of urinary retention when the enlarged suspects that the most likely cause of his urinary prostate gland obstructs urinary flow. The other answers may also cause retention, but are less retention is: common than BPH. ‐ Benign prostatic hyperplasia (BPH). ‐ Urinary tract infection. ‐ Voluntary urinary retention. ‐ Anticholinergic medications. | Notice that the question states that the client is elderly. BPH is common in elderly men. |
1675 A client complains of inability to inhibit urine flow Correct answer: 3 This type of incontinence is called urge incontinence, caused by a hypertonic or overactive long enough to reach the toilet. The nurse documents detrusor muscle that leads to increased pressure within the bladder. Stress incontinence is loss the presence of which type of urinary incontinence? of urine with abdominal pressure. Reflex incontinence refers to loss of urine at somewhat predictable intervals when a specific bladder volume is reached. Functional incontinence is an involuntary, unpredictable passage of urine. ‐ Stress ‐ Reflex ‐ Urge ‐ Functional | Notice that the word ‘urge’ helps to identify this as the correct response. When the urge to void occurs, urine flow tends to be immediate. |
1676 Which of the following nursing actions is most Correct answer: 1 Clients with excess fluid volume need to have restrictions in sodium intake because of the appropriate when caring for a client with a nursing relationship of water and sodium. Elevated serum sodium will cause water to be retained. The diagnosis of excess fluid volume? client should be instructed to avoid foods that are high in sodium such as cured meats, preserved foods, and canned goods. In addition, developing a schedule for oral intake and offering limited ice chips and frequent mouth care helps in the water restriction necessary for these clients. The other options are not appropriate interventions for the nurse to implement specifically for the nursing diagnosis of excess fluid volume. ‐ Teaching clients about sodium content of foods ‐ Administration of Vitamin D supplements ‐ Assessing and documenting client's energy level ‐ Observing for signs of hypocalcemia | Use the fact that sodium causes retention of water to select the correct answer. |
1677 Which of the following types of liquid should the Correct answer: 4 Cranberry juice reduces bacteria by acidifying urine and making it more difficult for bacteria nurse recommend for a client who has frequent to remain attached to the bladder wall. Citrus fruits should not be used because they make the urinary tract infections? urine alkaline. Drinks containing caffeine, including sodas, may irritate the bladder and worsen the urinary frequency. ‐ Soda drinks ‐ Caffeine drinks ‐ Citrus juices ‐ Cranberry juice | Recall common information to identify option 4 as correct. |
1678 A client has undergone creation of an ileal conduit. Correct answer: 4 Peristomal skin should be cleansed with each appliance change using a gentle soap and water, Which of the following instructions to the client about and then should be rinsed and dried thoroughly. The client should change the appliance early ostomy care would be appropriate to include in the in the morning, when urine production is slowest from lack of fluid intake during sleep. The teaching plan? opening of the appliance should be cut no larger than 3 mm greater than the opening of the stoma; an opening smaller than the stoma would prevent proper application. Fluids are encouraged to dilute the urine and decrease the odor. ‐ Cut the faceplate of the appliance so that the opening is slightly smaller than the stoma. ‐ Plan to do appliance changes just before bedtime. ‐ Limit fluids to minimize odor from urine breakdown to ammonia. ‐ Cleanse the skin around the stoma using gentle soap and water, rinse and dry well. | Recognize that option 4 describes good basic skin care, not necessarily specific to the ostomate. |
1679 The nurse is caring for a client with a history of renal Correct answer: 1 Nephrotoxicity can be caused by aminoglycoside antibiotics. This type of drug accumulates in disease. The nurse most closely monitors the client for tubular cells, eventually killing them. Options 2 and 3 are ototoxic, while option 4 is avoided in signs of nephrotoxicity if the client is ordered to renal disease. receive which of the following medications? ‐ Aminoglycoside antibiotics ‐ Aspirin‐containing drugs ‐ Loop diuretics | Associate this drug category with nephrotoxicity. |
4.‐ Potassium supplements | |
1680 A client underwent cystectomy for cancer of the Correct answer: 2 A Kock pouch is a continent internal ileal reservoir, eliminating the need for an external bladder and had a Kock pouch created for urinary pouch. The nurse needs to instruct the client about the technique for catheterizing the pouch diversion. The home care nurse would follow up with to empty the urine. Antibiotics are not required unless an infection is present and dietary the client about which of the following instructions for restrictions are unnecessary. self‐care? ‐ Application and care of external pouch ‐ Technique for catheterizing the Kock pouch ‐ Proper administration of prophylactic antibiotics ‐ Foods that must be restricted in the diet | Recognize that option 2 is the only option specific to Kock pouch. |
1681 A client asks the nurse what causes syphilis. The nurse Correct answer: 2 The spirochete Treponema pallidum causes syphilis. The other responses are incorrect. answers correctly that syphilis is caused by a: ‐ Bacterial infection. ‐ A spirochete. ‐ Fungal infection. ‐ Yeast infection. | Note that the three incorrect responses all contain the word ‘infection.’ |
1682 A client with syphilis exhibits flu‐like symptoms, a skin Correct answer: 2 The client's symptoms are consistent with secondary syphilis, which occurs 2 weeks to 6 rash on the palms of the hands, and hair loss. The months after the initial chancre disappears. Latent syphilis produces no symptoms, and tertiary nurse develops a plan of care based on which stage of syphilis is the final stage of the illness. Tertiary syphilis is characterized by the development of the disease? infiltrating tumors and involvement of the central nervous and cardiovascular systems. ‐ Primary syphilis ‐ Secondary syphilis ‐ Tertiary syphilis ‐ Latent syphilis | Omit option 4 based on the word ‘latent,’ implying no symptoms. Omit option 3 as in this stage symptoms are neurological. Primary infection is noted by only a chancre. |
1683 Which of the following nursing diagnoses is the top Correct answer: 1 Herpetic lesions are very painful, so the first priority is to provide comfort measures for the priority during a client's first outbreak of genital client. The other diagnoses do not address the client's most immediate concern. herpes? ‐ Pain ‐ Sexual dysfunction ‐ Anxiety ‐ Risk for infection | Recognize that prioritization is the key to correctly answering this question. The most immediate issue is pain. |
1684 The nurse is teaching a group of men about testicular Correct answer: 1 A painless, hard nodule is the classic presenting symptom of testicular cancer. Testicular self‐ cancer. Which of the following statements would the examination can help detect this sign. Testicular cancer is the most common cancer in men nurse include about this type of cancer? between the ages of 15 and 35, and is the third‐leading cause of cancer death in young men. ‐ It's usually painless, and therefore hard to detect. ‐ It causes severe pain in the early stages. ‐ Testicular self‐examination doesn't help detect it. ‐ It rarely affects young men. | Omit options 3 and 4 as incorrect. Options 1 and 2 are opposite, therefore one is likely correct. |
1685 The nurse working in an urgent care center would Correct answer: 3 Testicular torsion, or twisting of the testes and spermatic cord, is a potential emergency, consider it a surgical emergency if a client presented because compromised blood flow to the testicle may lead to ischemia and necrosis. The other with which of the following conditions? conditions usually don't require emergency intervention. | Note that options 1, 2, and 3 are similar in that they are all ‘cele’ conditions and generally not urgent. |
‐ Hydrocele ‐ Spermatocele ‐ Testicular torsion ‐ Varicocele | |
1686 A client is admitted for treatment of hydrocele. The Correct answer: 1 Hydrocele is a fluid‐filled mass within the scrotum. Option 2 describes spermatocele. Option 3 nurse understands this results from which of the describes varicocele. Option 4 describes testicular torsion. following? ‐ A fluid‐filled mass within the scrotum ‐ A mass containing dead spermatozoa ‐ Dilated veins within the spermatic cord ‐ Twisting of the testes and spermatic cord | Use the prefix ‘hydro’ in the question stem to identify the correct option. |
1687 The nurse anticipates that a client being evaluated for Correct answer: 3 Sildenafil is an oral medication used to treat erectile dysfunction in men. The other erectile dysfunction may receive a prescription for medications may worsen the client's condition. which of the following medications? ‐ Propranolol (Inderal) ‐ Diazepam (Valium) ‐ Sildenafil (Viagra) ‐ Progesterone | Omit options 1, 2, and 3 as not specific to the condition being treated. |
1688 The nurse is teaching a male client about the use of Correct answer: 4 Clients who take nitrates may experience severe hypotension when using sildenafil. Taking sildenafil (Viagra). Which of the following instructions the drug after a high‐fat meal will delay its onset. The drug should not be combined with other is correct? treatments for erectile dysfunction, and should not be taken more often than once daily. ‐ "Take the drug after a high‐fat meal to avoid GI upset." ‐ "You may combine the drug with your vacuum constriction device." ‐ "It's acceptable to use the drug several times a day." ‐ "Don't use the drug if you take nitrate medications, such as nitroglycerin." | Select the option that is a common concern with medications, combination with other drugs. |
1689 The nurse is teaching about sexually transmitted Correct answer: 2 Chlamydial infection may be present for months or years without producing symptoms in diseases. Which of the following is the greatest women. The disease may invade the uterus, resulting in devastating complications. It is caused concern with chlamydial infection that the nurse by Chlamydia trachomatis, a bacterium that behaves like a virus. Young women using oral should emphasize? contraceptives have the highest risk. ‐ It causes severe pain and burning with urination. ‐ There is a lack of symptoms until infection invades the uterus. ‐ It is caused by yeast infection that spreads easily. ‐ Older women are at highest risk in contracting the disease. | Recall that a lack of symptoms is common with this infection and so is key in identifying the correct response. |
1690 When teaching a male client about prostate cancer, Correct answer: 1 When diagnosed early and confined to the prostate gland, prostate cancer is curable and the the nurse explains that the survival rate for prostate 5‐year survival rate is 100 percent. Men under the age of 40 rarely have prostate cancer. cancer is: African‐American men have a higher incidence of prostate cancer and a higher mortality rate. ‐ Excellent when diagnosed early. ‐ Poor, no matter when diagnosed. ‐ Best for men under age 40. ‐ Best for African‐American men. | There is no indication of client age or race in the question so omit options 3 and 4. Omit option 2 as being incorrect information. Recall most cancers have a variable prognosis based on factors such as age and point of diagnosis. |
1691 The nurse plans for interventions for the nursing Correct answer: 4 Positioning the client in semi‐Fowler's position allows optimal lung expansion. Positioning the diagnosis "Ineffective breathing pattern" on a client client on the operative side helps to splint the incision and improves lung expansion. The who underwent a nephrectomy today. Which of the combination of these two positions provides the best positions to prevent respiratory following is the best intervention for this diagnosis? depression in a post‐nephrectomy client. ‐ Alternating prone and semi‐Fowler's position ‐ Positioning the client on the operative side ‐ Positioning the client on the non‐operative side ‐ Alternating semi‐Fowlers and side‐lying on the operative side | Select the response that includes more than one position. Recall that prone is generally not a useful client position. |
1692 The nurse is caring for a client admitted to the Correct answer: 2 Dehydration and immobility predispose the client to the formation of renal calculi. Prolonged hospital from a nursing home with suspected renal immobilization leads to loss of bone calcium and hypercalciuria, which predisposes an calculi. In reviewing the client's history, which of the individual to the development of calcium oxalate stones. Adequate hydration prevents urinary following conditions most likely contributed to the stasis and stone formation. Option 3 does not have a direct link to the development of renal disorder? calculi. While infection of the urinary system can lead to development of renal stones, it is not the most likely cause. ‐ Fever and malnutrition ‐ Dehydration and immobility ‐ Glycosuria and ketonuria ‐ Indwelling Foley catheter | Notice that the scenario indicates the client was in a nursing home. Select the option that reflects common problems with nursing home clients. |
1693 A client with renal failure has a creatinine level of 7 Correct answer: 2 A client with impaired renal function requires close monitoring of intake and output. The mg/dL. Which of the following nursing assessments is serum creatinine value of 7 (normal 0.8 to 1.2 mg/dL for males; 0.6 to 0.9 for females) provides most important to evaluate? evidence of an estimated decrease in the glomerular filtration rate. Although peripheral edema, weight increase, and skin changes may occur in renal impairment, assessment of intake and output is vital in monitoring fluid balance. ‐ Peripheral edema ‐ Intake and output ‐ Weight ‐ Skin turgor | Select the option that will best measure elimination. |
1694 Which of the following nursing actions is most Correct answer: 3 Forcing fluids helps prevent urinary retention and flushes bacteria from the bladder. Citrus appropriate for a client with a severe urinary tract juices along with caffeine and alcohol should be avoided because they cause bladder irritation. infection? The use of a heating pad and sitz baths may ease the discomfort associated with the infection but increasing the fluid intake is a more important action. ‐ Maintaining NPO status ‐ Encouraging citrus juices ‐ Forcing oral fluids ‐ Applying of heating pad | Recall that UTI is best treated by flushing the system with oral fluids. Only specific juices (i.e., cranberry) are indicated. |
1695 The nurse is caring for a client with incontinence. Correct answer: 3 Urinary incontinence is not a normal part of aging. The causes of urinary incontinence include Which of the following statements made by the client anything that may interfere with bladder or sphincter control. Option 1 refers to Kegel indicates a need for further teaching? exercises, which can contribute to regaining continence. Voiding schedules and prompted voiding help too in regaining continence. Application of pressure over the bladder area, also known as the Crede maneuver, helps in successful urination. ‐ "I do pelvic exercises five times each day." ‐ "I go to the bathroom to try to urinate every 2 hours." ‐ "I am trying to accept this incontinence as a normal part of aging." ‐ "I apply pressure over my bladder to help me urinate successfully." | Select the response that is incorrect. In this case option 3 reflects that the client does not understand that the condition can be controlled. |
1696 The nurse is collecting a 24‐hour‐urine specimen from Correct answer: 2 The first specimen contains urine that was in the bladder before the test began, so it should a client. After collecting the first specimen, the nurse be discarded. The test begins with the next voided specimen. should: ‐ Save it as part of the collection. ‐ Discard the specimen, and then begin collecting. ‐ Test the specimen, and then discard it. ‐ Collect 100 mL of the specimen, discard the rest. | Omit options 3 and 4 as they are inconsistent with the 24‐hour collection. Option 1 is incorrect as it would alter the timing of the collection. |
1697 Which of the following nursing diagnoses is of highest Correct answer: 1 Infection is a significant risk for CAPD clients, because organisms can enter the body through priority for a client receiving continuous ambulatory the peritoneal catheter and through the dialysate solutions. The other diagnoses are either peritoneal dialysis (CAPD)? inappropriate or have lower priority because the problems are less threatening. ‐ Risk for infection ‐ Risk for bleeding ‐ Altered body image ‐ Risk for fluid volume deficit | Associate peritonitis as the highest risk in CAPD. |
1698 A client who receives a kidney transplant will need to Correct answer: 4 Corticosteroids, such as prednisone, help control rejection of the new kidney. Rejection is a take medications for life. The nurse places highest common cause of graft loss in individuals with renal transplants. The other medications are not priority on client teaching for which of the following routinely ordered for the client. medications? ‐ Penicillin G ‐ Heparin ‐ Gamma globulin ‐ Prednisone | Recall that prednisone is the only anti‐inflammatory or anti‐rejection drug listed. |
1699 A client with chronic renal failure asks the nurse why Correct answer: 2 Erythropoietin, a hormone synthesized in the kidneys, stimulates the bone marrow to he has developed anemia. The most accurate response produce red blood cells. The production of this hormone is in response to low oxygen levels in by the nurse is: the kidney cells. When there is decrease in functioning renal mass, erythropoietin synthesis is also decreased. With deficient erythropoietin, anemia develops in the client with renal disease. ‐ "The increase in nitrogen wastes in your blood destroys your bone marrow." ‐ "A hormone in your kidneys that stimulates your bone marrow is lacking." ‐ "You have lost some blood through your urine." ‐ "The low protein diet that you are on causes the anemia." | Choose the option that best refers to erythropoietin and the kidneys' function in blood formation. |
1700 A client is scheduled for urinary diversion surgery. Correct answer: 3 The figure shows that a portion of the ileum is formed into a tubular pouch with the open end Based on this figure, nursing interventions will be brought to the surface of the skin and the ureters inserted into the pouch. An ileal conduit is planned for which type of urinary diversion? the most common urinary diversion. A colon conduit (option 1) is similar to the ileal conduit but utilizes a portion of the sigmoid colon rather than the small intestine. Option 2 (Indiana continent reservoir), describes a surgical diversion whereby the reservoir is formed from the colon and cecum. A Kock pouch (option 4) is similar to the ileal conduit but nipple valves are formed, which prevents leakage and reflux. ‐ Colon conduit ‐ Indiana continent urinary reservoir ‐ Ileal conduit ‐ Kock pouch | Select the most common urinary diversion. |
1701 When teaching a male client who is being tested for Correct answer: 2 The seminiferous tubules within the testes produce sperm, while Leydig's cells (interstitial fertility, the nurse explains that sperm and cells) within the testes manufacture testosterone. The other options are incorrect. testosterone are produced in the: ‐ Prostate gland. ‐ Testes. ‐ Seminal vesicles. ‐ Bulbourethral glands. | Recall that testosterone is a hormone manufactured in the testes, the only endocrine gland listed. |
1702 A client is preparing to undergo a prostatectomy. Correct answer: 1 Because the statement in option 1 is incorrect, the client needs more teaching. He will be Which statement indicates that he needs more able to have intercourse and will remain fertile without his prostate gland. Semen volume will teaching? decrease, because the prostate secretions make up one‐third of the volume. ‐ "I won't be able to have sex without my prostate gland." ‐ "The prostate gland isn't necessary in order to have intercourse." ‐ "I'll still be fertile without my prostate gland." ‐ "My semen volume will be less without the prostate gland." | Options 1 and 2 express opposite concepts. One of the items in the pair is likely correct. |
1703 In developing a teaching plan for a group of high Correct answer: 4 The vagina, ovaries, fallopian tubes, and uterus are parts of the internal organs of the female school students about the female internal reproductive system. The other organs listed are external. reproductive system, the nurse includes discussion of the: ‐ Labia majora. ‐ Labia minora. ‐ Clitoris. ‐ Vagina. | Recognize that option 4 is the only option that names an internal structure. |
1704 A client with symptoms of chlamydia needs to have a Correct answer: 3 The definitive diagnosis for chlamydia is tissue culture of the endocervix or the urethra. This is diagnostic test for the infection. Which of the following an expensive test and therefore a careful analysis of the history and physical assessment is the appropriate test that the nurse should prepare findings are relied upon. VDRL, RPR, and FTA‐ABS are diagnostic tests for syphilis. for? ‐ VDRL ‐ RPR ‐ Tissue culture ‐ FTA‐ABS | Omit options 1, 2, and 4 as being diagnostic for other STDs. |
1705 Which of the following questions is most appropriate Correct answer: 1 Option 1 is the most sensitive way to inquire about erectile function. Interview questions are for the nurse to ask a male client when assessing the less threatening if they are asked in a way that gives the client the option to report behaviors reproductive system? and symptoms. ‐ "Have you noticed any changes in your erections?" ‐ "Do you have difficulty achieving an erection?" ‐ "Can you maintain an erection?" ‐ "Has your partner complained about your erections?" | Select the option that is open and would most encourage the client to discuss sensitive issues. |
1706 When assessing a 75‐year‐old male client, the nurse Correct answer: 2 Benign prostatic hyperplasia (BPH) is the most common disorder of the aging male client. questions the client about symptoms of which of the Testicular cancer is the most common cancer in men between the ages of 15 and 35. Testicular following conditions that is common in older men? torsion occurs at any age and gonorrhea is highest in occurrence during the sexually active years. Among women, 15‐ to 19‐year‐olds and men 20‐ to 24‐years‐old have the highest rate. ‐ Testicular cancer ‐ Benign prostatic hyperplasia ‐ Testicular torsion ‐ Gonorrhea | Recognize that option 2 is the only condition that risk increases with age. The others are common in younger individuals. |
1707 The nurse is caring for a 68‐year‐old male diagnosed Correct answer: 4 The statements in the first three options correctly describe signs of BPH. Option 4 indicates with benign prostatic hyperplasia (BPH). Which of the the need for further teaching because the client should increase his fluid intake (unless following statements by the client indicates the need contraindicated) to prevent urinary tract infections and lessen dysuria. for further teaching? ‐ "The enlarged prostate gland causes me to get up three times every night to urinate." ‐ "The enlarged prostate gland may produce blood in my urine." ‐ "I can get urinary tract infections because of the enlarged prostate gland." ‐ "I should cut down on the fluids I drink so I won't have to urinate so often." | Recall that reducing fluid intake is rarely advised. |
1708 A client with benign prostatic hyperplasia (BPH) is Correct answer: 2 A retropubic prostatectomy is used to remove massive prostatic tissue. It involves having a scheduled tomorrow for surgery to resect prostatic low midline abdominal incision but the bladder is not incised. A suprapubic prostatectomy tissue. The physician described the surgery with the involves an abdominal incision but cuts through the bladder to access the anterior aspect of above diagram indicating an approach through an the prostate. TURP is a surgical approach that involves insertion of a resectoscope into the abdominal incision. What surgical approach will the urethra. In the perineal resection approach, the incision is made between the anus and the nurse plan for? scrotum. Perineal resection is used more commonly in cancer of the prostate. ‐ Transurethral resection of the prostate (TURP) ‐ Retropubic prostatectomy ‐ Suprapubic prostatectomy ‐ Perineal resection | Omit options 1 and 4 as they are inconsistent with the information in the scenario, in that they would not require an abdominal incision. |
1709 Which of the following instructions should the nurse Correct answer: 4 The healing period after prostate surgery is 4 to 8 weeks, and the client should avoid provide for a client returning home after prostate strenuous activity during this period. Blood in the urine is fairly common after surgery. The surgery? client should not drive for 2 weeks, except for short rides. ‐ "Reduce your fluid intake so you won't need to void as often." ‐ "Call the doctor immediately if you notice blood in your urine." ‐ "You may drive yourself home." ‐ "Avoid strenuous activity and heavy lifting for 4 to 8 weeks." | Identify the instruction that would be common in any post operative client. |
1710 A client tells the nurse he has been diagnosed with Correct answer: 4 With prostatodynia, the client experiences symptoms of prostatitis, but shows no signs of chronic, nonbacterial prostatitis (prostatodynia). The inflammation or infection. Positive cultures, chills and fever, and purulent secretions are nurse would expect to note which of the following symptoms of infection. findings? ‐ Positive urine cultures ‐ Chills and fever ‐ Purulent prostatic secretions ‐ No evidence of inflammation in the prostate | Recognize that options 1, 2, and 3 would generally occur together and be associated with infection. |
1711 Which of the following assessment findings in a 35‐ Correct answer: 1 A positive Kernig’s sign is common in intracranial hematomas, which is described in option 1. year‐old client with an intracranial hematoma should Option 2 is a negative Babinski; with a hematoma, the nurse should expect a positive Babinski concern the nurse? (dorsiflexion of the toes in an adult). Option 3 is common in many illnesses; option 4 is specific to Parkinson’s disease. ‐ Hamstring pain when the hip and knee are flexed and then extended ‐ Curling of the toes when the bottom of the foot is stroked in upward motion ‐ Muscle aches and cramping, especially at night ‐ Cogwheel and lead pipe rigidity | The core issue of the question is knowledge of associated findings with intracranial hematoma. Use nursing knowledge and the process of elimination to make a selection. |
1712 The nurse would prevent corneal abrasion in the Correct answer: 2 Corneal abrasion in the client with myasthenia gravis is caused by dryness of the cornea from client with myasthenia gravis by performing which of inability to close the eyelids and blink. It can be prevented by application of artificial tears the following nursing interventions? every 1 to 2 hours. The other options do not address this need. ‐ Doing a saline eye irrigation every shift ‐ Instilling artificial tears in the eyes every 1 to 2 hours ‐ Ensuring the client’s contact lenses are on while awake ‐ Providing sunglasses when client is outside | Use nursing knowledge and the process of elimination to make a selection. |
1713 The client with newly diagnosed Parkinson’s disease Correct answer: 1 The nurse should first encourage the client experiencing a loss to express his feelings. This states, “I just don’t think I can handle having answer acknowledges the client’s feelings, is open‐ended, and promotes further discussion. Parkinson’s disease.” What is the nurse’s best first Option 2 provides false reassurance. Options 3 and 4 do not address the client’s feelings as response? shared with the nurse. ‐ “You sound overwhelmed. Can you tell me more?” ‐ “I am sure you can. A lot of other people do!” ‐ “What do you think will be the hardest thing to handle?” ‐ “The entire health care team will help you manage the disease.” | The core issue of the question is a therapeutic communication. For communication questions, look first for the option that addresses the client’s feelings or concerns. |
1714 The nurse caring for the client with myasthenia gravis Correct answer: 3 When the muscles involved in chewing and swallowing as well as the diaphragm and would do which of the following as a priority to intercostal muscles are weak, the client may aspirate or experience poor gas exchange; both minimize the risk for complications of the disease? increase the risk for pneumonia. Options that protect the airway always have highest priority. The client is not at risk for hemorrhage (option 1) or pneumonia (option 2). Option 4 may be an element of routine care. ‐ Inspect for hemorrhage. ‐ Assess for pneumonia. ‐ Offer to cut the client's food as needed. ‐ Provide the client with a bedside commode. | The core issue of the question is the ability to determine a priority complication of myasthenia gravis and to then select the intervention that reduces it. Use nursing knowledge and the process of elimination to make a selection. |
1715 A client calls the telephone triage nurse to report Correct answer: 2 A stiff sore neck is a sign of meningeal irritation and possible meningitis. The nurse may fever, nausea, chills, and malaise. The nurse instructs further inquire if flexion of the neck causes pain and the hip and knee to flex (Brudzinski’s sign) the client to come immediately to the emergency and how high the fever is. The other symptoms are typical of influenza. room when he relates he also has which of the following? ‐ A bad headache ‐ A stiff sore neck ‐ A heart rate of 106 ‐ A roommate with the same symptoms | The core issue of the question is the ability to recognize clients at risk for or showing early signs of meningitis. Use nursing knowledge and the process of elimination to make a selection. |
1716 When assessing the client with meningitis, the nurse Correct answer: 2 The first signs of increased intracranial pressure are often subtle changes in level of looks for which of the following as a frequent first sign consciousness. Other changes (including rising systolic BP, irregular respiratory rate, and of increased intracranial pressure? bounding pulse) come later as intracranial pressure rises further. ‐ A rising systolic blood pressure ‐ Change in mood or attention level ‐ Irregular respiratory rate and depth ‐ A bounding radial pulse | The core issue of the question is the ability to discriminate early signs of rising intracranial pressure from later ones. Use nursing knowledge and the process of elimination to make a selection. |
1717 The nurse is instructing the client who has been in the Correct answer: 1 It is essential that the client recovering from bacterial meningitis take all of the prescribed hospital with bacterial meningitis and will be going antibiotic as directed. Failure to do so puts the client at risk for a relapse of symptoms and home soon. Which of the following will be of the contributes to development of bacterial resistance to antibiotics. Options 2, 3, and 4 are highest priority? important aspects of self‐care during recuperation but are not as essential as the completion of antimicrobial therapy. | The core issue of the question is the ability to prioritize completion of antibiotic therapy with bacterial meningitis as essential. Use nursing knowledge and the process of elimination to make a selection. |
‐ Take all of the antibiotics as directed until completely gone. ‐ Eat a high‐protein, high‐calorie diet ‐ Exercise daily, beginning with active ROM. ‐ Get at least 8 hours of sleep per night with frequent rest periods. | |
1718 Which of the following instructions would the nurse Correct answer: 4 Urinary retention in the client with multiple sclerosis is a sequela of impaired conduction of give to a client with multiple sclerosis who has urinary nerves innervating the bladder. Performing self‐catheterization will drain the bladder and help retention? prevent urinary tract infection. The client with multiple sclerosis will be encouraged to increase fluid intake to prevent constipation. Because urinary retention is incomplete emptying of the bladder, neither running water nor caffeinated beverages would be useful. ‐ “Run water whenever you experience difficulty initiating urination.” ‐ “Decrease your fluid intake to prevent urgency.” ‐ “Drink a caffeinated beverage to promote the ability to form urine.” ‐ “Catheterize your bladder according to the schedule we discussed.” | The core issue of the question is knowledge of appropriate methods to manage urinary retention in a client with multiple sclerosis. Use nursing knowledge and the process of elimination to make a selection. |
1719 The nurse advises the family of the client with Correct answer: 3 While options 1, 2, and 4 are all appropriate interventions for the client with Parkinson’s Parkinson’s disease that the best approach to helping disease, the essential approach to enhance and encourage self‐care abilities will be an the client maintain as much functional independence unhurried one that allows sufficient time for self‐expression and for the client to do as much as as possible will be to possible for himself or herself. ‐ Assist the client to take a warm bath every morning. ‐ Perform passive ROM three times a day. ‐ Display an unhurried manner that allows the client sufficient time to respond or act. ‐ Obtain assistive devices that will make activities of daily living (ADLs) easier. | The critical word in the question is approach, which implies a manner of behaving rather than a specific or single action. Use nursing knowledge and the process of elimination to make a selection. |
1720 The nurse concludes that more teaching may be Correct answer: 2 Fluid restriction may be needed in the period immediately following a stroke, but this is not necessary when visiting a client post‐CVA during the necessary after discharge to home. Keeping urine dilute will help prevent urinary tract first home visit because infection. A fluid intake of 2000 cc per day will also improve bowel elimination. ‐ The commode is observed to be at the bedside. ‐ A fluid restriction chart is on the refrigerator. ‐ Metamucil is on the kitchen counter. ‐ Hand weights are next to the couch. | The core issue of the question is knowledge of fluid needs in a client post‐stroke who has been discharged from the acute care setting. Use nursing knowledge of rehabilitation and the process of elimination to make a selection. |
1721 The office nurse should encourage a client on the Correct answer: 1 What the client describes is a classic ascending progression of Guillain‐Barré syndrome. The phone to go directly to the hospital emergency room muscular weakness may ascend to include the diaphragm. Total respiratory paralysis can based on which of the following statements? occur, requiring ventilatory support. The incorrect responses refer to chronic problems, not an acute one. ‐ “My legs are weak and now I’m having trouble getting a good breath.” ‐ “My shaky hand is no better than last visit. In fact, I think it’s getting worse” ‐ “The double vision went away when I put my eye patch on.” ‐ “My headache doesn’t seem any better even though I gave up coffee.” | Remember the ABCs and prioritize an answer that refers to a possible impaired airway. Use nursing knowledge and the process of elimination to make a selection. |
1722 A 76‐year‐old woman comes to the emergency room Correct answer: 3 The client is showing signs of rising intracranial pressure, and infusion of IV fluids leads to by ambulance because of a possible stroke. Vital signs hypervolemia and worsens the intracranial pressure. Following Maslow’s hierarchy, choose are pulse 90, blood pressure 150/100, respirations 20. physiological before psychological answers. A Dilantin level would not be relevant to CVA Thirty minutes later, vital signs are pulse 78, blood status. The nurse would want to avoid adding to the client’s volume status by offering fluids, pressure 170/90, respirations 24 and irregular. The and dehydration is not a concern at this time. nurse should take which action at this time? ‐ Ask the woman to describe how she’s feeling. ‐ Check the client’s phenytoin (Dilantin) level. | Use nursing knowledge and the process of elimination to make a selection. |
‐ Get an order to decrease the rate of IV fluids. ‐ Offer the client clear liquids to prevent dehydration. | |
1723 A client seen in the neighborhood clinic complains of Correct answer: 4 A more detailed assessment is important in collecting data to meet client needs. A picture of “eye problems” and noticed generalized weakness that multiple sclerosis may be unfolding. The nurse takes the time to be therapeutic without became markedly worse after visiting with a friend and providing false reassurance or limiting responses. Open‐ended, nonjudgmental responses are using the friend’s hot tub. The client gives considerably ideal. long, detailed answers during the history. The nurse’s best response is: ‐ “Was the weather the same each time you used the hot tub?” ‐ “You’ll feel better after getting this all off your mind.” ‐ “Please be brief in your answers so I can get you through this.” ‐ “Can you tell me more about the eye problems?” | The core issue of the question is selection of an appropriate communication that focuses on assessment. Use nursing knowledge and the process of elimination to make a selection. |
1724 An abnormal EEG indicates that a 2‐year‐old client Correct answer: 1 Also known as absence seizures, petit mal seizures may be no more observable than brief has epilepsy, but the parents indicate that they have staring instances. The mother should be instructed to note and report any change in the child’s never observed a seizure. The pediatric nurse behavior, no matter how small. concludes that the child may be experiencing seizures of the following type? ‐ Petit mal ‐ Myoclonic ‐ Jacksonian ‐ Grand mal | The core issue of the question is the ability to discriminate different types of seizures based on presentation (or lack of manifestations). Use nursing knowledge and the process of elimination to make a selection. |
1725 The nurse provides care for a 13‐year‐old who was Correct answer: 2 The nurse would want to assess the pin sites for redness, edema, and drainage and would placed in a halo brace within the last 24 hours because want to ensure that the vest fits snugly. Following the nursing process, an assessment answer of a spinal cord injury. Which of the following is the would precede an implementation answer (options 3 and 4). first priority of the nurse? ‐ Loosen any connections on the vest to assess the skin ‐ Assess the pin sites ‐ Ask how the client is able to reposition self in bed ‐ Encourage active range of motion to lower extremities | The core issue of the question is knowledge of appropriate care for a client who is in a halo vest. Use nursing knowledge and the process of elimination to make a selection. |
1726 The rehabilitation nurse is admitting a client following Correct answer: 4 Hemisection of the anterior and posterior portions of the spinal cord results in loss of spinal cord injury. The nurse concludes that the client position sense (proprioception) on the same side of the body as the trauma, below the level of has developed Brown‐Séquard syndrome after injury. Option 3 is seen in anterior cord syndrome; option 1 is incorrect. assessing which of the following in the client? ‐ Ipsilateral motor loss above the lesion ‐ Contralateral loss of proprioception ‐ Hyperanesthesia below the level of the lesion ‐ Ipsilateral motor loss below lesion | The core issue of the question is knowledge of characteristics of Brown‐Séquard syndrome following spinal cord injury. Use nursing knowledge and the process of elimination to make a selection. |
1727 While assessing airway and breathing, the client Correct answer: 4 The brain stem’s final effort to maintain cerebral perfusion is seen with an increased systolic presenting with increased intracranial pressure would blood pressure, bradycardia, and an irregular respiratory pattern know as Cushing’s response. most likely exhibit which of the following vital signs? ‐ BP 190/84, HR 150, and an irregular respiratory pattern ‐ BP 80/50, HR 50, and Kussmaul respirations ‐ BP 80/50, HR 150, and Cheyne‐Stokes respirations ‐ BP 190/84, HR 50, and an irregular respiratory pattern | The core issue of the question is the ability to recognize patterns of change in vital signs that reflect increasing intracranial pressure. Use nursing knowledge and the process of elimination to make a selection. |
1728 In providing for the safety of the client during a grand Correct answer: 3 The nurse’s priority is to protect the client from injury. To promote drainage, it is more mal seizure, the nurse performs which of the following effective to secure an airway by turning the client onto the side (option 1). Inserting a tongue interventions? blade can cause trauma (option 2); the tongue blade may move during the seizure and obstruct the airway. Oxygen should be available but does not have to be applied (option 4). ‐ Positions the client on his back ‐ Gently places a padded tongue blade between the teeth ‐ Protects the client from injury ‐ Applies oxygen immediately via mask | The core issue of the question is priority concerns for a client experiencing a seizure. Use Maslow’s hierarchy of needs, nursing knowledge, and the process of elimination to make a selection. |
1729 The community health nurse interprets that clients Correct answer: 3 Mosquitoes, the vectors that transport encephalitis, are found in large numbers in swampy who live in a swampy bayou area in the southern areas. Meningitis can be attributed to overcrowded conditions; Parkinson’s has an uncertain United States might be at risk of contracting which of etiology; and risk factors for multiple sclerosis include genetics and family history. the following? ‐ Meningitis ‐ Parkinson’s ‐ Encephalitis ‐ Multiple sclerosis | The core issue of the question is knowledge of risk factors for encephalitis. Use nursing knowledge and the process of elimination to make a selection. |
1730 The client recently diagnosed with Guillain‐Barré Correct answer: 2 Guillain‐Barré syndrome is an acute demyelinating disorder that less commonly may present syndrome is drooling and having difficulty swallowing with initial weakness in the cranial nerves that progresses downward. Impairment of cranial secretions. When the family asks why this occurs, the nerves IX and X will affect swallowing. nurse indicates that the cause is ‐ Obstructed blood flow to the midbrain. ‐ Demyelination of cranial nerves responsible for swallow and gag reflex. ‐ Enlargement of the parotid and salivary glands. ‐ Deficiency in the thiamine and pyridoxine in the central nervous system. | The core issue of the question is the ability to explain pathophysiology underlying signs and symptoms of Guillain‐Barré syndrome. Use nursing knowledge and the process of elimination to make a selection. |
1731 A 1‐year‐old child has been diagnosed with cerebral Correct answer: 4 At this age, a 1‐year‐old is beginning speech. This child will have trouble developing language palsy. The child has the spastic form that affects all because of the spasticity. Urinary incontinence occurs in all 1‐year‐old children, as does extremities. Which of the following nursing diagnoses feeding self‐care deficit. Thought processes are difficult to evaluate in a 1‐year‐old. would be appropriate for a child at this age? ‐ Urinary incontinence ‐ Feeding self‐care deficit ‐ Impaired thought processes ‐ Impaired verbal communication | The core issue of the question is the ability to determine appropriate nursing diagnoses for a client with cerebral palsy while taking into consideration growth and development. Use nursing knowledge and the process of elimination to make a selection. |
1732 The nurse observes a child starting to have a seizure. Correct answer: 2 Observation and documentation of seizure activity can provide valuable information to help After assessing the airway, which is the highest priority in diagnosis and treatment. Once a seizure is in process, it would be dangerous to attempt to of the nurse? insert an airway. Administration of medication would require a physician’s order. Actually restraining the extremities is more likely to inflict injury than prevent. ‐ Insert an artificial airway. ‐ Observe and record seizure activity. ‐ Administer diazepam (Valium). ‐ Restrain the extremities to protect the child from injury. | The core issue of the question is the ability to provide safe care to a client experiencing a seizure. Use nursing knowledge and the process of elimination to make a selection. |
1733 The nurse has taught the parents of a 6‐year‐old child Correct answer: 4 In most children, by age 6, the cranial suture lines have fused and the fontanelles are closed, with a ventriculoperitoneal (VP) shunt to monitor the so the first three symptoms would not be common. An altered level of consciousness would be child for shunt malfunction. The nurse determines the a symptom of shunt malfunction for the older child. parents understand the instructions if they state they will notify the physician if the child presents with: ‐ Bulging soft spot. ‐ Expanding head size. ‐ Sunset eyes. ‐ Altered level of consciousness. | The core issue of the question is knowledge of early signs of rising intracranial pressure, which is a sign of shunt malfunction. Use nursing knowledge and the process of elimination to make a selection. |
1734 A child is admitted with a head injury after being in a Correct answer: 2 Drainage of cerebrospinal fluid (a clear fluid) from the ear is a symptom of basilar skull motor vehicle accident. The nurse notes a clear fracture. Children with linear skull fractures are often asymptomatic. Subdural and epidural drainage from the left ear. The nurse would suspect: hematomas present with signs of increasing intracranial pressure. ‐ Linear skull fracture. ‐ Basilar skull fracture. ‐ Subdural hematoma. ‐ Epidural hematoma. | The core issue of the question is the ability to correctly interpret signs of head injury. Use nursing knowledge and the process of elimination to make a selection. |
1735 The nurse has formulated a nursing diagnosis of Correct answer: 3 While families may need education about seatbelts and sources of support, it is not the ineffective family processes related to hospitalization optimal time to implement such teaching at this point in the crisis. It is optimal to find out of a child with a potentially fatal condition for the what the family members' perceptions are of what is going on and what they feel their needs family of a child who sustained a brain injury during an are. The best way to determine this is to encourage them to ask questions and express their automobile accident. Which of the following feelings. Timelines for visitation are appropriate but of less priority than option 3. interventions would have the highest priority? ‐ Teach the family the importance of using seatbelts. ‐ Refer the family to support services in the community. ‐ Encourage family to ask questions and express feelings. ‐ Explain rules for visiting in the intensive care unit. | The core issue of the question is the ability to determine priorities for the family of a critically ill child. Select the option that will most closely address the family’s current issues and concerns. |
1736 A client arrives at the Emergency Department Correct answer: 1 In a grade 1 concussion, the client exhibits transient confusion with no loss of consciousness following head injury and is diagnosed with a and a duration of abnormal mental status for less than 15 minutes. Grades 2 and 3 concussion concussion. The client exhibits transient confusion with consist of more severe neurological symptoms, with increasing levels of loss of consciousness no loss of consciousness and a duration of abnormal and more significant abnormalities of mental status. mental status for less than 15 minutes. The nurse concludes that this client’s symptoms are compatible with a concussion of grade? Write in a numerical answer. | The core issue of the question is the ability to correctly interpret signs of head injury related to concussion. Use knowledge of the pathophysiology of concussion to determine an answer. |
1737 The Emergency Department nurse is educating a Correct answer: 1, 2, 4 Using warning stickers like Mr. Yuk to teach the child to avoid these items will help to keep parent on safety measures for a child who has been substances from being ingested. Using childproof caps will also inhibit the child from opening treated for accidental ingestion of acetaminophen medicine containers. An important aspect of teaching is to inform parents to contact the (Tylenol). The nurse concludes that the parent has Poison Control Center or 911 for instructions on the appropriateness of care following understood the teaching instructions when the parent ingestion of substances. Activated charcoal, magnesium citrate, and magnesium sulfate are not makes which statements? Select all that apply. used in the home setting for treatment of poisonings. ‐ “I will use warning stickers like Mr. Yuk on all medicine containers.” ‐ “I will buy products with childproof caps.” ‐ “I will keep magnesium citrate available.” ‐ “I will put the Poison Control Center phone number by every phone in the house.” ‐ “I will keep activated charcoal in the house and use it readily if needed.” | Knowledge of the ways to avoid childhood poisoning will help to choose the correct answers. |
1738 The family who has a child with a chronic health Correct answer: 2 All families deal with stresses, and the family with a child with a chronic health problem is no problem such as spina bifida experiences "chronic exception. Chronic sorrow is the emotional experience many families experience of grieving sorrow" throughout the child's life. The nurse can for the loss of the perfect child. This grief is intensified at times of developmental crisis and anticipate that this will be more prevalent when: each time in the child's development at traditional milestones such as "first steps" when the parent is reminded of what their child will not be able to do. ‐ The child is admitted to the hospital for a planned procedure. ‐ The child reaches the age of a "developmental milestone" that the child cannot attain. ‐ The child attains independence by attending school. ‐ A sibling is born without any health problems. | Knowledge of the response of the parents to developmental crisis from inability of the child to achieve traditional milestones will aid in determining the correct answers. |
1739 The nurse discusses the risk of aspiration with the Correct answer: 3 Toddlers chew well, but may have difficulty swallowing large pieces of food. Young children parents of an 18‐month‐old. The nurse recommends cannot discard pits (such as from cherries). Foods like peanuts and hard candies are easily the parents avoid giving their child: aspirated. ‐ Oranges, crackers, and applesauce. ‐ Apples, fruit juice, and raisins. ‐ Cherries, peanuts, and hard candy. ‐ Cheerios, toast, and bananas. | Considering the normal activities of a child of this age will lead to the right answer. |
1740 A newborn has been admitted to the unit with a Correct answer: 3, 5 Prior to surgical repair of the meningocele, leaking cerebrospinal fluid usually reduces the myelomeningocele. The nurse would include which of intracranial pressure. The priority concern preoperatively is maintaining the meningocele sac the following as priority elements of care during the and preventing infection. It is not a priority to measure head circumference daily, use semi‐ preoperative period? Select all that apply. Fowler’s position, or monitor for irritability and vomiting (signs of increased intracranial pressure). ‐ Measuring the head circumference on a daily basis ‐ Preventing increased intracranial pressure by laying the baby in semi‐Fowler's position ‐ Positioning the infant on his abdomen to protect the spinal defect ‐ Monitoring the child for signs of irritability and vomiting ‐ Covering the sac with a sterile saline dressing to protect its integrity. | Three of the options related to increased intracranial pressure. One option, the correct option, deals with the spinal defect. |
1741 The parents of an infant who has just had a Correct answer: 2 The prognosis for children receiving shunts depends on brain damage that has already ventriculoperitoneal (VP) shunt inserted for occurred. The shunt will need to be revised as the child grows. Usually an extended length of hydrocephalus are concerned about the infant's tubing is placed with ventriculoperitoneal shunts to allow for some growth but eventually a prognosis and ongoing care. The nurse should include revision is necessary. Most brain damage is not reversible. which of the following in discussions with the parents? ‐ The prognosis is excellent and the shunt is permanent ‐ The shunt will need to be revised as the child gets older ‐ During the first year of life, any brain damage that has occurred is reversible ‐ Hydrocephalus is usually self‐limiting by 2 years of age and the shunt will then be removed | Knowledge of the pathophysiology of hydrocephalus will eliminate options 3 and 4. While option 1 is basically correct, option 2 expands the knowledge in as much as the need for the shunt is permanent, the device itself will be replaced on an ongoing basis as the child grows. |
1742 The nurse is teaching a class on health Correct answer: 1 Research studies have shown a significant decrease in incidence of spina bifida in infants born promotion/disease prevention to women of to mothers who took folic acid supplements prior to pregnancy and during the first trimester. childbearing age. The nurse stresses that one action Spina bifida is not related to rubella or rubeola. No relationship has been seen between that has been shown to be effective in reducing the maternal age and the development of spina bifida, nor is there a genetic trait that can be incidence of spina bifida is: linked to spina bifida. ‐ Taking folic acid supplements or using fortified enriched grain products during pregnancy. ‐ Being immunized for rubella and rubeola. ‐ Avoiding pregnancy after the age of 45. ‐ Not having children with a man who also carries the spina bifida genetic trait. | Each of the options describe known causative factors associated with a variety of conditions. Recall that folic acid has been associated with neural tubes defects to make the correct selection. |
1743 A 7‐year‐old child has just been diagnosed with a Correct answer: 1, 5 Common side effects with antiepileptic medications include ataxia and rashes, which seizure disorder and the physician has prescribed disappear when dosage is adjusted. Some drugs such as phenobarbital can adversely affect carbamazepine (Tegretol) 500 mg/day. The nurse cognitive function, school performance, and behavior. Carbamazepine is considered relatively should teach the parents about which common side free of the sedative‐like side effects but does have the side effects of blurred vision, diplopia, effects of this medication? Select all that apply. drowsiness, vertigo, headache, and rarely a rash (Stevens‐Johnson syndrome). ‐ Dizziness and headache ‐ Hives and aching joints ‐ Diaphoresis and vomiting ‐ Blurred vision and papular skin rash ‐ Drowsiness and vertigo | This question requires specific knowledge about carbamazepine. Recall that many antiepileptic drugs have a side effect of drowsiness and dizziness. Eliminate hives because it would be an indication of an allergic reaction. |
1744 Following surgery for the insertion of a Correct answer: 4 A serious complication after the insertion of shunt would be infection, most likely meningitis. ventriculoperitoneal (VP) shunt for hydrocephalus, the It is not common to see decreased intracranial pressure, but too‐rapid decrease can result in a infant demonstrated irritability, high‐pitched cry, subdural hematoma. Symptoms of shunt malfunction would include all signs of increased elevated pulse rate, and temperature of 40 degrees C. intracranial pressure. Symptoms of infection such as meningitis in the young infant include (104 degrees F.). The nurse concludes that these fever, poor feeding, vomiting, marked irritability, restlessness, seizures, and a high‐pitched cry. symptoms are consistent with which postoperative complication? ‐ Shunt obstruction ‐ Increased intracranial pressure ‐ Decreased intracranial pressure ‐ Infection | With two options being decreased or increased intracranial pressure, these should be evaluated first for the right answer. However, neither fits the symptoms listed in the stem. The temperature elevation should have been a clue to point toward infection. |
1745 During a well‐child visit for an 8‐month‐old girl, her Correct answer: 4 The best answer is to do further assessments of the child's abilities. At eight months, most parents express concern that their older child was infants can sit without support; however a remarkable piece of history for this child is her already sitting alone at this age. The child was born six prematurity. Up until 2 years of age, it is important to remember to adjust for the weeks weeks premature but had no major difficulties during premature to have more realistic milestones for this individual child. Additional assessment of the neonatal period. The best response of the nurse to motor skills is important to determine developmental progress while accounting for the parents is: prematurity. Motor impairments associated with voluntary control are not usually apparent until after 2 to 4 months at the earliest so that motor dysfunction (and subsequent diagnosis of cerebral palsy) may not be confirmed until the second half of the first year. It is not unusual for the disorder to be overlooked in mildly affected infants until they exhibit a delay in some advanced motor skill such as walking. ‐ "Your observations are good. Your child is demonstrating a developmental delay and probably has cerebral palsy." ‐ "You shouldn't jump to conclusions. All children are individuals, and it is not fair to compare one child to another." ‐ "You have nothing to worry about. Your child's development is completely normal." ‐ "Can you tell me more about your child? Is she sitting alone and turning over?" | Responses which deny the parents’ concerns or tell them not to worry are usually not correct. In addition, for an option to be correct, every part of that option must be correct. |
1746 A 15‐year‐old wrestler who suffered a concussion Correct answer: 2 Since it may take up to a month for the brain to heal after a concussion and subsequent after being thrown on his head during a match was injuries can compound the original injury, the child should not engage in contact sports for a seen in the emergency room for assessment and month. Post‐concussion syndrome in adolescents includes headache, dizziness, irritability, and observation. After providing the parent with discharge impaired concentration. It can be helpful for teachers to understand any possible changes in instructions about post‐concussion syndrome, the behavior or school performance during this period. Vomiting should be reported and is a nurse determines the parents have adequate serious symptom of increasing intracranial pressure; but it is not treated with antiemetic. understanding of the information if they state to: While monitoring the child on a regular basis for 24 to 28 hours post injury is recommended, having him bend his head to his chest (Brudzinski's sign) would be a good indicator of meningitis but will not provide helpful information about complications of brain injury. ‐ Closely observe the child when he participates in a wrestling meet tomorrow. | Options 1, 3, and 4 contain false information. Since the nurse is evaluating the parental understanding of discharge information, these must be incorrect options. |
‐ Plan to speak with his teachers about the injury. ‐ Call the primary health care provider for an antiemetic prescription if he has any vomiting. ‐ Check him every four hours during the night and have him bend his head to his chest to check for pain. | |
1747 A 3‐month‐old infant has been admitted with a Correct answer: 3 While all other choices are important to monitor, the priority in assessing any critically ill diagnosis of encephalitis. The first nursing priority child follows the ABC rule—airway, breathing, and circulation. would be to assess: ‐ Pupillary reaction. ‐ Level of consciousness. ‐ Ability to maintain airway. ‐ Blood glucose level. | Utilize the ABCs: Airway is always the first physical priority. |
1748 The nurse places a young child scheduled for a lumbar Correct answer: 3 This position opens the intervertebral spaces and allows easier access to the spinal canal. The puncture in a side‐lying position with the head flexed position does not decrease pain or help to restrain the child. All lumbar punctures are done and knees drawn up to the chest. The mother asks why below L4 (the level of the spinal nerves), so injury to the spinal cord is always avoided. the child has to be positioned this way. The nurse explains the rationale for the positioning is that: ‐ Pain is decreased through this comfort measure. ‐ Injury to the spinal cord is prevented. ‐ Access to the spinal fluid is facilitated. ‐ Restraint is needed to prevent unnecessary movement. | Visualize the procedure and positioning. Compare each option to the information in the stem looking for an option that fits with the question. To choose correctly, recall that the spinal vertebrae need to be separated to allow easier access by the spinal needle. |
1749 An 18‐month‐old child is observed having a seizure. Correct answer: 4 It is important to never forcibly restrain a child during a seizure or insert a padded tongue The nurse notes that the child’s jaws are clamped. The blade; both are more likely to add trauma than prevent it. Oxygen via mask is of little benefit. priority nursing responsibility at this time would be: Overall, the child must be protected from injury from the environment. ‐ Start oxygen via mask. ‐ Insert padded tongue blade. ‐ Restrain child to prevent injury to soft tissue. ‐ Protect the child from harm from the environment. | Padded tongue blades and restraints are not used during a seizure, leaving two options. Although airway is always the priority response, providing oxygen through a mask will not maintain oxygenation because the child may not be breathing or may not have an open airway. Activities toward maintaining an open airway would be more important. That leaves protecting the child from the environment as the only viable option. |
1750 A 3‐year‐old child is admitted to the hospital unit with Correct answer: 1, 3, 4 Viral meningitis does not require antibiotics. Treatment is aimed at reducing the symptoms. a diagnosis of viral meningitis. The nurse should take The child should be allowed to assume a position of comfort; the room should be kept dim and which of the following actions in the care of this child? stimulation reduced. Seizures can occur, although the disease is usually self‐limiting. (Select all that apply.) Measuring the head circumference is of no benefit because the sutures are fused. ‐ Allow the child to assume a position of comfort. ‐ Keep the lights bright to monitor skin color. ‐ Administer acetaminophen for pain. ‐ Monitor the child for seizures. ‐ Administer antibiotics. | Viral infections do not require antibiotics. Consider the age of the child to determine if head measurement will provide any important data. Eliminate any options that would increase stimulation. |
1751 The nurse is providing client education for a family Correct answer: 3 This therapy involves an implanted pump that must be accessed through the skin to refill the whose child has cerebral palsy and is receiving pump. Parents are not taught to refill the pump. Baclofen does inhibit the neurotransmitter baclofen epidural therapy to control spasticity. Which GABA; however, this is not the essential data to be shared with the parents. Promising the of the following is most important for the nurse to parents that the child will be able to run with normal gait offers false hopes. The implanted include in the discussion? pump’s dosage cannot be changed without special equipment. ‐ The drug acts to inhibit the neurotransmitter GABA. | To determine the correct answer, first determine which responses are accurate and then prioritize the information that the parents will need. |
‐ The child should be able to run with normal gait after insertion of the pump. ‐ Parents must bring the child back to the clinic on a regular basis to have more medicine added to the pump. ‐ Parents can be taught to regulate the dosage on a sliding scale. | |
1752 A 10‐year‐old client presents with weakness in the Correct answer: 3 Guillain‐Barré syndrome is an ascending paralysis. While the child will have increasingly less legs and history of the flu. The medical diagnosis is muscle tone in the extremities, the hoarseness could indicate involvement in the muscles of Guillain‐Barré syndrome. It would be imperative for respiration. Serious concern is raised when the respiratory muscles are affected. Sometimes the nurse to inform the physician after observing mechanical ventilation is indicated. Tingling is a common sign of Guillain‐Barré and not related which of the following? to respiratory distress. ‐ Weak muscle tone in feet ‐ Weak muscle tone in legs ‐ Increasing hoarseness ‐ Tingling in the hands | Consider which option can have serious implications. Knowledge of Guillain‐Barré as an ascending paralysis would indicate that hoarseness would be an impending sign of difficulty. |
1753 The nurse is providing discharge instructions for a Correct answer: 3 Discharge instructions will include the necessity of waking the child to check neurological child who has suffered a head injury within the last status throughout the night. Vomiting could be a sign of increasing intracranial pressure and four hours. The nurse determines there is a need for should be reported. Narcotics are not given after a head injury. Amnesia for the events additional teaching when the mother states: surrounding the injury may be permanent. It is not a sign of increasing intracranial pressure. ‐ “I will call my doctor immediately if my child starts vomiting.” ‐ “I won’t give my child anything stronger than Tylenol for headache.” ‐ “My child should sleep for at least 8 hours without arousing after we get home.” ‐ “I recognize that continued amnesia about the injury is not uncommon.” | Consider care of the client with a head injury and determine which response is not in line with the normal care. |
1754 A 2‐year‐old child is admitted to the neurosurgical Correct answer: 4 No eye opening, no verbal response, and no motor response are the lowest criteria on the unit following a head injury. The nurse is using the scale. Confusion is a criterion applicable only for the older child and adult but is comparable to Glasgow Coma Scale to measure neurological “irritable and cries” for the infant (which is a 4 out of 5 on the verbal response subscale). “Eyes functioning. Which of the following assessment open only to pain” is the next to the lowest level on the eye‐opening category. findings indicates the lowest level of functioning for this child? ‐ Confusion ‐ Irritable and cries ‐ Eyes open only to pain ‐ No response to painful stimuli | Options 2 and 3 can be eliminated as these are normal findings. Consider options 1 and 4 and determine which response shows the least brain functioning. |
1755 Upon performing a physical assessment of a 7‐month‐ Correct answer: 3 The Moro or startle, tongue extrusion, and tonic neck reflexes are all neonatal reflexes that old child, the nurse notes the following findings. The should have disappeared by this child’s age. Lack of head lag indicates good motor nurse concludes that which finding is abnormal and development. A developmental delay or the presence of a neonatal reflex are some of the could suggest cerebral palsy? earliest clues to cerebral palsy. ‐ No head lag when pulled to a sitting position ‐ No Moro or startle reflex ‐ Positive tonic neck reflex ‐ Absence of tongue extrusion | Differentiate normal from abnormal findings in a 7‐month‐old infant. |
1756 A 4‐year‐old child is being evaluated for Correct answer: 4 All of the above are symptoms of increased ICP or hydrocephalus. Head enlargement and hydrocephalus. The nurse notes which of the following bulging fontanels would not be seen in the child after closure of the sutures (12 to 18 months). as an early sign of hydrocephalus in this child? Shrill, high‐pitched cry is a late‐stage symptom of children. Headache and vomiting on arising would be an early symptom in an older child. ‐ Bulging fontanels ‐ Rapid enlargement of the head ‐ Shrill, high‐pitched cry | The key concept here is the age of the child. At four years old, the sutures and fontanels have closed, eliminating two of the four options. |
4.‐ Early morning headache | |
1757 A child with a history of a seizure was admitted 2 Correct answer: 2 Brudzinski’s sign indicates meningeal irritation. As the head and neck are flexed toward the hours ago. The history reports fever, chills, and chest, the legs flex at both the hips and the knees in response. Brudzinski’s sign may be seen in vomiting for the past 24 hours. In report, the nurse is the other options because of the meningeal irritation. told that the child has a positive Brudzinski’s sign. The nurse knows that this is most likely caused by: ‐ Increased intracranial pressure. ‐ Meningeal irritation. ‐ Encephalitis. ‐ Intraventricular hemorrhage. | Consider how Brudzinski’s sign is tested. Flexing the neck is not likely to affect things going on in the skull, so the most likely response is 2. |
1758 A nurse is assessing a new admission. The 6‐month‐ Correct answer: 1 Increased intracranial pressure in infants is characterized by lethargy, irritability, bradycardia, old infant displays irritability, bulging fontanels, and tachycardia, apnea, bulging fontanels, setting‐sun eyes, vomiting, and hypertension. setting‐sun eyes. The nurse would suspect: Myelomeningocele refers to a neural tube defect, which is obvious on the back. Skull fractures indicate injury to the head and may be asymptomatic or may be accompanied by other pathology that could lead to increased intracranial pressure. Hypertension does not display symptoms of setting‐sun eyes. ‐ Increased intracranial pressure. ‐ Hypertension. ‐ Skull fracture. ‐ Myelomeningocele. | The bulging fontanels are a strong indication of increased intracranial pressure. The other options do not have this as a symptom. |
1759 An 8‐year‐old client with a ventriculoperitoneal shunt Correct answer: 3 The most common mechanisms for the development of hydrocephalus include decreased was admitted for shunt malfunction. He presents with reabsorption (communicating hydrocephalus) and obstruction to the flow of CSF symptoms of increased intracranial pressure. The (noncommunicating). Obstruction may result from congenital anomalies, inflammation, mechanism of the development of his symptoms is external blockage, and other causes. most probably related to: ‐ Increased flow of cerebrospinal fluid. ‐ Increased reabsorption of cerebrospinal fluid. ‐ Obstructed flow of cerebrospinal fluid. ‐ Decreased production of cerebrospinal fluid. | Knowledge of shunt function would indicate that a malfunctioning shunt would obstruct flow of CSF. |
1760 A child with a myelomeningocele is started on a Correct answer: 2 Most children with spina bifida cystica (myelomeningocele included) have the level of their bowel management plan. The child’s mother questions defect at a point that does affect the innervation to both the colon and anal sphincter. The why this is being done. The nurse’s response will be result is constipation and incontinence. Any lack of mobility increases the risk for constipation, based on the understanding that lack of: and all children need a pattern of regular bowel movements. ‐ Innervation to the colon predisposes the child to diarrhea. ‐ Innervation to the anal sphincter predisposes the child to being incontinent. ‐ Mobility increases the gastric‐colic reflex. ‐ Mobility decreases the need for regular bowel movements. | Determine if both a lack of mobility and innervation exist. Since they both exist in the child with this spinal defect, consider which would have the most effect on bowel function. Once it is determined that the major problem is lack of innervation, the learner must choose whether this is likely to cause diarrhea or incontinence. |
1761 A child has just been diagnosed with bacterial Correct answer: 3 Clients are considered contagious until the causative organism is determined and antibiotic meningitis. The parent asks the nurse how long the therapy has been initiated. Children are usually placed in respiratory or droplet isolation. child will be in isolation. The nurse’s reply will be based Twenty‐four hours of antibiotic therapy usually eliminates the necessity of isolation. on a protocol that isolation continues until: ‐ The organism is located. ‐ The antibiotics are initiated. ‐ The antibiotics have been administered for 24 hours. | Three of the four choices relate to antibiotics, so the correct response is likely to be one of them. Choose the time frame that is not immediate and not too lengthy. |
4.‐ Ten days of antibiotic therapy have been completed. | |
1762 The nurse observes a client with the neck and back Correct answer: 4 The child with meningitis will hyperextend the neck and head in an arching position referred arched and extremities severely extended. The mother to as opisthotonic. The child does this to relieve discomfort from the meningeal irritation. asks why the child is doing that. The nurse explains Decerebrate posturing is a symptom of dysfunction at the level of the midbrain and is that this posturing is called: characterized by rigid extension and pronation of arms and legs. Decorticate posturing is a symptom of a dysfunction of the cerebral cortex and is characterized by adduction of the arms at the shoulders, the arms flexed on the chest with hands in fists and wrists flexed, and lower extremities extended and adducted. Jacksonian seizure is a simple motor seizure characterized by clonic movements that begin in a foot, hand, or face and then spread to sometimes include the entire body. ‐ Decerebrate. ‐ Decorticate. ‐ Jacksonian seizure. ‐ Opisthotonos. | The learner must be able to distinguish between the positioning seen in neurological defects. |
1763 A child is being treated for increased intracranial Correct answer: 1, 2, 4 Turning the head to one side can occlude the flow of CSF, increasing the ICP. Oxygen can pressure (ICP). Appropriate actions to decrease serve as a vasodilator, decreasing the ICP. Keeping the head of the bed slightly elevated also intracranial pressure would include: (Select all that promotes flow of CSF. Diuretics are often part of the medical treatment to decrease ICP. apply.) Vigorous range of motion and forcing oral fluids would not be appropriate. ‐ Keeping head of bed at a 30‐degree angle. ‐ Providing supplemental oxygen. ‐ Turning head to one side. ‐ Administering IV osmotic diuretics as ordered. ‐ Promoting fluid intake. | Eliminate any activities that would increase intracranial pressure such as emotional upset, vigorous exercise, and increased fluid intake. |
1764 A 10‐year‐old boy receives a blow to his head with a Correct answer: 1 Epidural hematomas are characterized by arterial bleeding. Onset of symptoms occurs within hard baseball and is admitted to the hospital for minutes to hours. Other types of bleeding are often venous, which have a slower onset of observation. If the child were to develop an epidural symptoms. hematoma, the child would most like display symptoms: ‐ In the emergency room or soon after arriving on the unit. ‐ On the unit over the next few days. ‐ After discharge home. ‐ Over the next two months. | Recall that an epidural bleed is arterial, which would mean symptoms would appear quickly. |
1765 A 15‐year‐old client is seen in the emergency Correct answer: 3 Obtunded indicates a diminished level of consciousness with limited response to the department following a head injury from football. environment. The child will fall asleep unless given verbal or tactile stimulation. Stupor is a During the first few hours after admission, he sleeps diminished level of consciousness with response only to vigorous stimulation. Semicomatose is unless awakened, but he can be aroused easily and is when a child only responds to painful stimuli; lethargy is when a child sleeps if left undisturbed oriented. In charting assessment findings, the nurse and has sluggish speech and movement. would describe this level of consciousness as: ‐ Semicomatose. ‐ Lethargic. ‐ Obtunded. ‐ Stuporous. | Recognize that this child is not fully conscious. At the same time, he is not in a stupor or semicomatose. Then choose between lethargic and obtunded based on knowledge of levels of consciousness. |
1766 A young child has just been diagnosed with spastic Correct answer: 2 The most common form of cerebral palsy involves spasticity of muscles. Because of the cerebral palsy. The nurse is teaching the parents how excessive energy expended, these children often need more calories than other children their to meet the dietary needs of their child. The nurse age and size. Feeding difficulties are often a component of cerebral palsy, but whether a child would explain that children with cerebral palsy needs assistance with feedings is dependent upon the muscle groups affected. frequently have special dietary needs or feeding challenges because: ‐ The paralysis of their muscles decreases their caloric need. ‐ The spasticity of their muscles increases their caloric need. ‐ The hypotonic muscles make eating difficult. ‐ The child’s inactivity increases the risk of obesity. | The child with spasticity has hypertonic muscles, so option 3 can be eliminated. The spastic muscles use extra energy to stay in that hyperactive state. |
1767 The priority in preparing the room for a client with a Correct answer: 3 Although a ventilator is not required for injury below C3, the innervation of intercostal C7 level spinal cord injury is having: muscles is affected. Hemorrhage and cord swelling extends the level of injury, making it likely that this client will need a ventilator. ‐ The special kinetic bed. ‐ The halo brace device. ‐ A ventilator on stand‐by. ‐ A catheterization tray. | Recall that protecting respiratory function is the most important issue for the spinal cord injured client. |
1768 Upon return of the closed‐head injury client from CT Correct answer: 2 Keeping the head of the bed elevated to 30 degrees promotes venous drainage, which is scan, the head of the bed is maintained at 30 degrees important in decreasing ICP. Alignment of the head prevents obstruction of the jugular veins. and the client is positioned on his side with a towel roll Obstruction would impede venous drainage. placed vertically under the pillow. This unique positioning facilitates: ‐ Prevention of pulmonary embolism. ‐ Venous drainage from the brain. ‐ Airway management. ‐ Intracranial pressure (ICP) readings. | Recall that appropriate drainage is enhanced by gravity. Keeping the head of the bed elevated will promote drainage. |
1769 After regaining consciousness, a client reports a Correct answer: 1 Momentary loss of consciousness followed by a lucid period and rapid deterioration is a tremendous headache as he was taken from the site of classic picture resulting from a torn cerebral artery, producing an epidural bleed. a motorcycle crash by ambulance. The wife is unprepared when arriving at the hospital to find he had become comatose. The nurse explains the cause as which of the following? ‐ An expanding epidural hematoma ‐ A reticular activating system concussion ‐ A diffuse axonal injury ‐ An expanding pericardial hematoma | Recall that head injury would be most closely related to epidural hematoma development. |
1770 Following a grand mal seizure, the client is Correct answer: 4 The period after the clonic phase of a seizure is the postictal period. Typically, the client unconscious and unresponsive when the nurse tries to slowly regains consciousness, moving from a relaxed, quiet state to confusion or disorientation awaken the client. The nurse takes which of the on awakening. following actions? ‐ Calls a code ‐ Notifies the physician ‐ Reduces the Dilantin ‐ Allows gradual awakening | Recall that sleepiness following a seizure is expected. Select the option that takes this into account. |
1771 The nurse assesses the client's understanding of Correct answer: 1 Protective pads/diapers should be used only after all other treatment modes have been tried. discharge needs and goals after experiencing a Early dependency on incontinence products may decrease motivation to seek evaluation and cerebral vascular accident (CVA). Which of the treatment. following statements indicates further information and teaching will be necessary? ‐ "I'm getting a lifetime supply of adult diapers." ‐ "I worry about those scary transient ischemic attacks." ‐ "I've got to find a walking buddy." ‐ "I'm getting a rail installed in my tub." | Select the option that refers to a situation that does not address expected outcome of CVA. |
1772 The major focus for nursing care of the client with Correct answer: 3 Clients with meningitis will be less able to protect themselves from both internal and external meningitis will be to: injury. Providing cognitive stimulation and increasing cardiac output are contraindicated with meningitis. Enhancing coping skills may be a focus if the client has residual effects from meningitis but it is not a major focus. ‐ Enhance coping skills. ‐ Provide cognitive stimulation. ‐ Assess risk for injury and prevent complications. ‐ Increase cardiac output. | Omit options that would put added stress on the client, such as options 2 and 4. Focus of care is on physiological protection. |
1773 The client comes to the Emergency Department with Correct answer: 1 Pre‐syndrome to Guillain‐Barré syndrome is often a viral infection or immunization. Lower weakness that has been progressing upward in both extremity weakness or paralysis that progresses upward is classic in Guillain‐Barré. Fatigue is legs for a couple of days. The nurse, suspecting Guillain‐ not usually seen, nor are tremors or seizures. Barré syndrome, begins care by: ‐ Taking medical history, noting recent viral influenza. ‐ Giving the client orange juice for fatigue and low blood sugar. ‐ Instructing on tests for myasthenia gravis ‐ Evaluating for petit mal seizures. | Select the response that addresses the cause of Guillain‐Barré, which is viral infection. |
1774 The teaching plan for a client with myasthenia gravis Correct answer: 3 The client should know the signs of crisis and should report them immediately. There is often should include which of the following as a priority more fatigue and weakness later in the day than in the morning, so the client should plan instruction? important activities for early in the day. It may be easier to eat three small meals with snacks because chewing may cause fatigue. ‐ Exercise to increase peripheral circulation ‐ Plan important activities for late afternoon ‐ Identify signs of an action during crisis ‐ Eat three well‐balanced meals a day | Recall that the priority of care is to recognize and treat crisis. |
1775 The client with Parkinson's disease finds the resting Correct answer: 3 The resting or nonintentional tremor may be controlled with purposeful movement, such as tremor he is experiencing in his right hand very holding an object. Deep breathing, a warm bath, and diazepam will promote relaxation but are frustrating. The nurse advises him to: not specific interventions for the tremor. ‐ Practice deep breathing. ‐ Take a warm bath. ‐ Hold an object in that hand. ‐ Take diazepam (Valium) as needed. | Choose the option that addresses the non‐intentional nature of Parkinsonian tremor. |
1776 A client on the first day after abdominal surgery ranks Correct answer: 2 Always believe the client's report and ranking of pain. The client tolerated the last full dose of his pain as 9 on a scale of 0 to 10, 0 being no pain and medication so he should be given a full dose now. The nurse would reassess the client's pain 10 being the most pain possible. He is laughing and level within 30 minutes of administering pain medication depending on peak action time of the talking with visitors at this time. The client has defined drug. The nurse would not need to take vital signs unless indicated. a pain level of 5 as his comfort level goal. He has an order for analgesics every 1 to 2 hours. His last dose was the maximum ordered 2 hours ago. He had no untoward effects. The nurse should do which of the following? ‐ Record his pain level at 5 ‐ Administer the maximum dose of the analgesic ‐ Administer half the maximum dose of the analgesic ‐ Take his vital signs in 30 minutes | Omit options 1 and 4 as they do not address the client’s complaint of pain. Option 3 is not appropriate as the client’s self assessment of his pain level is high. |
1777 A young female with a diagnosis of multiple sclerosis Correct answer: 4 Stresses such as pregnancy can increase the chance of an exacerbation of MS. Signs of an (MS) has just discovered she is also pregnant. She and exacerbation are spasticity, weakness, or visual changes. Option 1 indicates Guillain‐Barré her husband have been trying to conceive for several syndrome; option 2 indicates increased intracranial pressure or hematoma; option 3 indicates years and are very excited. What client education meningitis. should be given to the client concerning her disease and pregnancy? ‐ Immediately report weakness that progresses upward in the extremities. ‐ Report a change in level of consciousness, severe headache, or slow pulse. ‐ Recognize that a sore/stiff neck and pain when the neck is flexed are critical signs to report. ‐ Immediately report spasticity, weakness, or visual changes. | Omit options 1, 2, and 3 as not indicative of MS exacerbation. |
1778 A client has seizure activity that is continuous in Correct answer: 2 When seizure activity becomes continuous and repetitive, respirations are affected and the nature. When the nurse leaves to obtain an oxygen set‐ progression of status epilepticus is life‐threatening. Nursing interventions address prevention up, the seizures resume. The client's coloring is getting of hypoxia, acidosis, hypoglycemia, hyperthermia, and exhaustion. worse. The nurse decides to enact standing orders to treat: ‐ Anticonvulsant syndrome. ‐ Status epilepticus. ‐ Brain herniation. ‐ Syphilitic posturing. | Recognize that the word “epilepticus” in option 2 is a hint. |
1779 A client has recently completed chemotherapy and Correct answer: 3 Most chemotherapeutic agents cause some degree of bone marrow suppression. This results has developed bone marrow suppression. Which in a decrease in leukocyte and erythrocyte counts. Calcium, phosphorus, and serum PSA levels laboratory report should the nurse monitor? are not specifically affected by bone marrow suppression. ‐ Calcium ‐ Phosphorus ‐ White blood cell (WBC) count ‐ Serum prostate‐specific antigen (PSA) | Identify what is produced by the bone marrow. Select the option that is consistent with this. |
1780 After a magnetic resonance imaging (MRI) to rule out Correct answer: 3 The spinal needle is inserted into the area below the spinal cord, eliminating the likelihood of an expanding brain lesion, the nurse prepares the paralysis. A misdirected needle may puncture a distended bladder. The client must maintain client for a lumbar puncture. Information for the client the knees to chest position until completion of the lumbar puncture. Because cerebrospinal would include: fluid (CSF) has been removed during the lumbar puncture, time must be allowed for production and replacement of the CSF. ‐ The risk of paralysis because the needle is inserted through the spinal cord. ‐ Maintaining a full bladder for better visualization. | Look for the option that addresses the most common complication of this procedure, headache. |
‐ Keeping his head flat to avoid a headache. ‐ Directions to straighten the legs slowly. | |
1781 The nurse at the community clinic assesses a client Correct answer: 4 Spinal cord injury at or above the level of T6 can experience an exaggerated sympathetic with complaints of a pounding headache. The client is response, seen only after recovery from spinal shock. If untreated, autonomic dysreflexia is known to have a T4 level spinal cord injury that potentially fatal as bradycardia and severe hypertension progress. occurred some time ago. The nurse should first assess for: ‐ Sinus infection. ‐ Spinal shock. ‐ Upper motor neuron deficit. ‐ Autonomic dysreflexia. | Select the response that is related to the injury, but can occur after an extended period of time. Sinus infection is not related to the injury. |
1782 Corneal abrasion in the client with myasthenia gravis Correct answer: 2 Corneal abrasion in the client with myasthenia gravis is caused by dryness of the cornea from can be prevented by which of the following? inability to close the eyelids and blink. It can be prevented by application of artificial tears every 1 to 2 hours. ‐ Saline soaks applied every shift ‐ Instilling artificial tears in the eyes every 1 to 2 hours ‐ Ensuring the client's contact lenses are on while awake ‐ Providing sunglasses when client is outside | Recognize that keeping the eye moistened by frequently administering artificial tears is the key to the correct response. |
1783 To reduce risks for meningitis, the nurse's best advice Correct answer: 2 Meningitis bacteria or viruses often gain entry into the cerebrospinal fluid secondary to an to an elderly client is: upper respiratory tract infection. Options 1, 3, and 4 are generally healthy practices for the elderly client but not specific health promotion for prevention of meningitis. ‐ Stay mentally active and engaged. ‐ Get pneumococcal pneumonia and influenza vaccinations. ‐ Drink at least 3,000 mL fluids per day. ‐ Exercise 15 to 30 minutes most days of the week. | Option 2 is the only one that addresses a specific method of preventing infection. |
1784 The nurse is providing care for a client with Guillain‐ Correct answer: 3 Plasmapheresis is performed to remove autoantibodies that attack the myelin sheaths of Barré syndrome who has plasmapheresis. Which other motor and sensory nerves in Guillain‐Barré and attack the acetylcholine receptors at the neurological condition is sometimes treated with neuromuscular junction in myasthenia gravis. The other diseases have not been identified with plasmapheresis? autoimmune disorder. ‐ Meningitis ‐ Parkinson's disease ‐ Myasthenia gravis ‐ Amyotrophic lateral sclerosis | Eliminate option 1 as it is an infectious process. |
1785 The nurse is caring for a client who is paralyzed and Correct answer: 4 PCV is used for those clients who are unable to initiate spontaneous inspiration. SIMV and requires mechanical ventilation. The client is CPAP are primarily weaning modalities. ACMV is used when the client has some inspiratory unresponsive and has no spontaneous ventilatory effort. effort at the present time. What type of ventilation should the nurse expect the physician to order? ‐ Synchronized intermittent mandatory ventilation (SIMV) ‐ Continuous positive airway pressure (CPAP) ‐ Assist‐control mode ventilation (ACMV) ‐ Pressure‐control ventilation (PCV) | Review the types of mechanical ventilation. Select the option that best represents the client who is unable to initiate a breath and trigger the ventilator. |
1786 The client's postoperative pain seems to be getting Correct answer: 4 The client's pain is affective as well as sensory. Grieving his wife's death is a normal response worse instead of better. When the nurse asks the that does not necessarily require psychiatric consult. Options 1 and 2 address the sensory, not client, "Why do you think it's getting worse?" the client the affective component of his pain. replies, "My wife died last month. It's all I can think about." The nurse must now consider: ‐ Calling the physician for an increased dosage of pain medication. ‐ Calling the physician for a sedative. ‐ Referring the client for a psychiatric consult. ‐ Developing interventions for grief and loss. | Recognize that the scenario refers to a recent loss. |
1787 When assessing the client with meningitis, the nurse Correct answer: 2 The first signs of increased intracranial pressure are often subtle changes in level of knows that the first sign of increased intracranial consciousness. Other changes (including rising systolic BP, irregular respiratory rate, and pressure is often: bounding pulse) come later as intracranial pressure rises more. ‐ A rising systolic blood pressure. ‐ Change in mood or attention level. ‐ Irregular respiratory rate and depth. ‐ A bounding radial pulse. | Recall that change in affect or mood should be associated with early symptoms of IICP. |
1788 The nurse is instructing the client who has been in the Correct answer: 1 It is essential that the client recovering from meningitis take all of the prescribed antibiotic as hospital with meningitis and will be going home soon. directed. Failure to do so puts the client at risk for a relapse of symptoms and contributes to Which of the following instructions will be of the development of bacterial resistance to antibiotics. Options 2, 3, and 4 are important aspects of highest priority? self‐care during recuperation but not as essential as the completion of antimicrobial therapy. ‐ Take all of the antibiotics as directed until completely gone. ‐ Eat a high‐protein, high‐calorie diet. ‐ Exercise daily beginning with active range‐of‐motion. ‐ Get at least eight hours of sleep per night with frequent rest periods. | Option 1 discusses the appropriate use of antimicrobials, which is key in preventing treating this infection. |
1789 When assessing the client with chronic pain, the Correct answer: 2 Chronic pain is multidimensional, often without an identifiable cause and not responsive to nurse acquires essential data for planning care when conventional treatment. By asking how/if the pain interferes with the client's daily activities, asking the client to quantify: the nurse will obtain information about the impact the pain has on the person's quality of life. ‐ The severity of the pain using a 1 to 10 scale. ‐ How the pain affects the client's daily life. ‐ What the client thinks is causing the pain. ‐ What the client does to relieve the pain. | Recognize that the question is asking about planning care. Reference to interruption of daily life and activities is a hint to the correct response. |
1790 The nurse teaches the client with multiple sclerosis Correct answer: 4 Urinary retention in the client with multiple sclerosis is a sequelae of impaired conduction of who has urinary retention to: nerves innervating the bladder. The client with multiple sclerosis will be encouraged to increase her fluid intake to prevent constipation. Urinary retention is incomplete emptying of the bladder. Neither running water nor caffeinated beverages would be useful. ‐ Run water when experiencing difficulty initiating urination. ‐ Decrease fluid intake to prevent urgency. ‐ Drink a caffeinated beverage to promote diuresis. ‐ Perform self‐intermittent catheterization. | Select the option that will directly assist the client in emptying the bladder. |
1791 While obtaining the health history from the elderly Correct answer: 4 The nurse interviewing the client will promote client independence, communication, and self‐ client with Parkinson's disease, the client's daughter esteem by talking directly to the client and patiently and carefully listening to him. continually answers all questions directed to the client. The nurse: | Select the response that directs the family member to allow the client to respond. |
‐ Accepts this as helpful because the client's voice is low, monotone, and difficult to understand. ‐ Stops the interview and resumes it later when the daughter is not there. ‐ Allows the daughter to complete the interview form. ‐ Respectfully tells the daughter, "I need to hear what your father has to say." | |
1792 The nurse advises the family of the client with Correct answer: 3 While options 1, 2, and 4 are all appropriate interventions for the client with Parkinson's Parkinson's disease that the best approach to helping disease, the essential approach to enhance and encourage self‐care abilities will be an the client maintain as much functional independence unhurried one that allows sufficient time for self‐expression and for the client to do as much as as possible will be to: possible for himself. ‐ Assist the client to take a warm bath every morning. ‐ Perform passive range‐of‐motion three times a day. ‐ Maintain an unhurried manner that allows the client sufficient time. ‐ Obtain assistive devices that will make activities of daily living easier. | The question is asking about functional independence. Select the answer that encourages the client to perform activities at his/her own pace. |
1793 The nurse receives report from the nurse caring for Correct answer: 2 A positive Babinski is an indicator of upper motor neuron disease of the pyramidal tract. The an elderly client following transfer to the unit with a physician must be contacted immediately when a client's reflex changes from a negative to a closed head injury. Which statement, if made by the positive Babinski as this reflects increased intracranial pressure. nurse, would indicate negligence? ‐ "The client was medicated with Tylenol for a headache an hour ago." ‐ "The client began to have a positive Babinski an hour ago." ‐ "The client had the head of the bed at 30 degrees the entire shift." ‐ "The client had a positive bulbocavernous reflex the entire shift." | Recall that a positive Babinski in an adult is always a grave sign and should be reported immediately. |
1794 The sister of a 76‐year‐old client with increasing Correct answer: 3 Increasing intracranial pressure is aggravated by hypercarbia and suctioning should not be intracranial pressure asks why the nurse uses the extra done for longer than 10 seconds. The other three options are not appropriate. oxygen when suctioning. Which of the following statements is most correct? ‐ "Your brother seems to pink‐up when we give him extra air." ‐ "The extra oxygen helps relieve the bradykinesia by decreasing the carbon dioxide." ‐ "The extra oxygen helps relieve the pressure in his brain by decreasing the carbon dioxide." ‐ "Your brother seems less congested when we give him extra air." | Omit options 1 and 4 as they refer to extra ”air” as opposed to extra oxygen. Omit option 2 as bradykinesia is not the reason for increasing oxygen. |
1795 During the insertion of a Swan‐Ganz catheter, the Correct answer: 3 The anatomical proximity of the apex of the lung and the subclavian vein increases the client complains of shortness of breath and possibility of the development of a pneumothorax caused by accidental puncture of the lung. assessment finds labored respirations, decreased The client was demonstrating classic signs of pneumothorax. Pulmonary embolism, myocardial breath sounds on the side of the insertion, and infarction, and anxiety do not cause asymmetrical chest movement. asymmetrical chest movement. The nurse should suspect: ‐ Pulmonary embolism. ‐ Myocardial infarction. ‐ Pneumothorax. ‐ Anxiety. | The principle being tested is that with any insertion of a central venous catheter there is a risk of collapsing the lung from a puncture during insertion. Select the option that is consistent with this complication. |
1796 Given her deficits, which of the following is an Correct answer: 1 Mechanical ventilation would not be necessary with a thoracic injury at T8. Options 2, 3, and unrealistic statement offered by a 16‐year‐old with a 4 are all applicable for a T8 injury. T8 spinal cord injury concerning an expected outcome? ‐ "I know this means being on a ventilator the rest of my life." ‐ "I know this means my legs won't work like before." ‐ "I know this means using a catheter for a while." ‐ "I know this means an adaptation to my car before I can drive again." | Option 1 is the only response that reflects a disability above the level of the injury. |
1797 The office nurse should encourage a client on the Correct answer: 1 What the client describes is a classic ascending progression of Guillain‐Barré syndrome. The phone to go directly to the Emergency Department muscular weakness may ascend to include the diaphragm. Total respiratory paralysis can based on which statement? occur, requiring ventilatory support. ‐ "My legs are weak, and now I'm having trouble getting a good breath." ‐ "My shaky hand is no better than last visit." ‐ "My diplopia changed when I put my eye patch on." ‐ "My headache doesn't seem any better even though I gave up coffee." | Note that there is a reference to difficulty breathing in option 1, which makes it the most urgent. |
1798 A 76‐year‐old woman comes to the Emergency Correct answer: 3 A Dilantin level would not be relevant to a stroke status. The nurse would want to avoid Department by ambulance because of a possible adding to the client's volume status or contributing to increasing intracranial pressure (IICP) stroke. Vital signs are pulse 90, blood pressure since a confirmed diagnosis has not been made. 150/100, and respirations 20. Thirty minutes later, vital signs are pulse 78, blood pressure 170/90, respirations 24 and irregular. The nurse should first: ‐ Ask the woman to describe how she's feeling. ‐ Check the client's phenytoin (Dilantin) level. ‐ Decrease the rate of intravenous (IV) fluids. ‐ Offer the client clear liquids to prevent dehydration. | Note that the change in vital signs, specifically blood pressure, indicate that fluid volume should be controlled. |
1799 A client seen in the neighborhood clinic complains of Correct answer: 4 A more detailed assessment is important in collecting data to meet client needs. The picture "eye problems" and generalized weakness that of multiple sclerosis may be unfolding. The nurse takes the time to be therapeutic, without became markedly worse after visiting with a friend and providing false reassurance or limiting responses. Open‐ended, nonjudgmental responses are frequently using the hot tub. The client is going into ideal. considerably long, detailed answers as you take the history. Your response is: ‐ "This is important information but there's just not enough staffing now." ‐ "You'll feel better after getting this all off your mind." ‐ "Please be brief in your answers so I can get you through this." ‐ "Tell me more about the eye problems." | Select the response that focuses the conversation, yet encourages the client to give information on the important symptom. |
1800 The nurse has assessed a client and suspect that the Correct answer: 4 Tracheal and mediastinal shifting will occur to the uninjured side because of increased client has developed a tension pneumothorax. Which intrathoracic pressure on the side of the injury (option 4). The client will exhibit hypotension of the following assessment findings would support caused by the decreased cardiac output (option 2), respiratory acidosis caused by hypoxemia this conclusion? (option 3), and tachypnea (option 1). Mediastinal shift is always a late sign and requires immediate treatment to relieve the buildup of trapped air to prevent death. ‐ Decreased tidal volume and normal respiratory rate ‐ Hypertension ‐ Respiratory alkalosis and hypoxemia ‐ Mediastinal shift toward uninjured side | This question requires an understanding of the pathophysiology of a tension pneumothorax. Apply this pathophysiology to each distractor to determine the correct response. |
1801 The nurse provides care for a 13‐year‐old in a halo Correct answer: 2 After assessing the pin sites for redness, edema, and drainage, a sterile applicator dipped in brace because of a spinal cord injury. Which of the hydrogen peroxide is used around each pin site. This may be followed by normal saline and a following is the first priority? topical antibiotic per hospital policy. ‐ Tighten any loose connections on the vest. ‐ Assess the pin sites. ‐ Turn the client every hour. ‐ Provide range of motion to extremities. | Recognize that limiting risk of infection is the highest priority. |
1802 The rehabilitation nurse discussing the client's Correct answer: 4 Hemisection of the anterior and posterior portions of the spinal cord result in loss of position transition to home may note which of the following sense (proprioception) on the same side of the body as the trauma, below the level of injury. characteristics in a client with Brown‐Séquard's Option 3 is seen in anterior cord syndrome; option 1 is incorrect. syndrome? ‐ Ipsilateral motor loss above the lesion ‐ Contralateral loss of proprioception ‐ Hyperaresthesia below the level of the lesion ‐ Ipsilateral motor loss below lesion | They key is identifying the response that refers to same side deficit, below the lesion. |
1803 While assessing airway and breathing, the client Correct answer: 4 The brain stem's final effort to maintain cerebral perfusion is seen with an increased systolic presenting with increasing intracranial pressure (IICP) blood pressure, bradycardia, and an irregular respiratory pattern know as Cushing's response. Cushing's triad presents with: ‐ BP 190/84, HR 150, and an irregular respiratory pattern. ‐ BP 80/50, HR 50, and Kussmaul respirations. ‐ BP 80/50, HR 150, and Cheyne‐Stokes respirations. ‐ BP 190/84, HR 50, and an irregular respiratory pattern. | Recall that wide pulse pressure combined with bradycardia is a hallmark of Cushing’s Triad. |
1804 In providing for the safety of the client during a grand Correct answer: 3 To promote drainage, it is more effective to secure an airway by turning the client on the mal seizure, the nurse performs which of the side. Inserting a tongue blade can cause trauma; the tongue blade may move during the following? seizure and obstruct the airway. Oxygen should be available but does not have to be applied. ‐ Positions the client on his back. ‐ Gently places a padded tongue blade between the teeth. ‐ Protects the client from injury with padded bedrails. ‐ Applies oxygen immediately per mask. | Eliminate any option that calls for direct contact with the client during a seizure. |
1805 The nurse has completed the health history for a new Correct answer: 1 Inspection is the first diagnostic technique utilized in a physical assessment . Percussion is client and is ready to begin a physical assessment. next followed by palpation and finally auscultation. What assessment technique will the nurse describe to the client that will be completed first? ‐ Inspection ‐ Percussion ‐ Palpation ‐ Auscultation | Review the best order for how to perform a physical assessment. |
1806 While caring for a client undergoing initial warming Correct answer: 3 During re‐warming, the client is at high risk for development of tissue ischemia, seizures, and for hypothermia, the most appropriate nursing cardiac arrhythmias. Infection, pain, and knowledge deficit about the plan of care and diagnosis would be: prognosis are lower priorities. ‐ Deficient knowledge. ‐ Risk of infection. ‐ Risk for injury. ‐ Pain. | During re‐warming, electrolytes leave the cell and enter the serum. Select the distractor that represents the greatest risk to the client’s life. |
1807 The nurse caring for the client with myasthenia gravis Correct answer: 2 When the muscles involved in chewing and swallowing as well as the diaphragm and knows that awareness of possible complications intercostal muscles are weak, the client may aspirate or experience poor gas exchange; both directs the care provided. Prioritizing, the nurse will increase the risk for pneumonia. first: ‐ Inspect for hemorrhage. ‐ Assess for pneumonia. ‐ Offer to cut the client's food as needed. ‐ Provide the client with a bedside commode. | Recognize that the respiratory complications should take priority. |
1808 The nurse knows that a major goal for nursing Correct answer: 4 Parkinson's disease is a progressive degenerative neurological disease. The goal of care is to management of the client with Parkinson's disease is: control symptoms so that the client can maintain as much independence and function as possible. The disease does not go into remission. Skin care and weight gain may be intermediate goals but are not the major goal. ‐ Skin care. ‐ Disease remission. ‐ Weight gain. ‐ Symptom management. | Option 4 acknowledges the progressive nature of this disease. |
1809 The nurse enters the room and finds the client Correct answer: 1 Vital signs (VS) should be watched for 30 minutes to an hour after a grand mal seizure. The posturing in bed and unconscious. The nurse should respiratory rate, pulse, and blood pressure may be decreased but should slowly return to assess which of the following during the postictal normal. An aura would precede the seizure. Electrolytes and remembrance of the event are phase? not critical during the postictal stage. ‐ Vital signs ‐ Aura ‐ Remembrance of the event ‐ Electrolytes | Assessment of vital functions is the priority post seizure. |
1810 Applying the gate control theory of pain, the nurse: Correct answer: 2 The gate control theory of pain postulates that large sensory fibers close the gates to pain in the dorsal form, blocking the transmission of small nociceptive fibers. Rhythmic breathing promotes relaxation, affecting the behavioral components of pain. Guided imagery affects the cognitive components of pain. ‐ Instructs the client to call for pain medication as soon as the pain begins. ‐ Gives the client a back massage. ‐ Teaches the client slow rhythmic breathing. ‐ Leads the client in guided imagery. | Recall that the gate control theory is associated with massage. |
1811 A newly admitted trauma victim is flown in by Correct answer: 1 Changes in level of consciousness, confusion, restlessness, lethargy, disorientation to time, helicopter after a fall from a second‐story window. The place, and then person are the most sensitive and earliest indicators of increased intracranial MRI shows an intracranial hematoma. Concerned pressure (IICP) produced by an expanding lesion. about expansion, the nurse will assess for: ‐ Level of consciousness. ‐ Pupil changes. ‐ Respiratory changes. ‐ Seizure activity. | The risk is for IICP. Option 1 identifies the early symptom of this change. |
1812 Which statement by the client with myasthenia gravis Correct answer: 3 Extremes of temperature may cause an exacerbation of myasthenia gravis. Alcohol and indicates a need for further instruction before quinine water may increase weakness. Medications should be taken on time to maintain blood discharge? levels and thus muscle strength. The client should avoid energy activities that will cause excessive fatigue. ‐ "I realize I need to be sure I take my medications at the scheduled times." ‐ "I won't be drinking anymore gin and tonics!" ‐ "I am looking forward to taking a really long, hot bubble bath when I get home." ‐ "I am not going to train for the triathlon this year." | Options 1, 2, and 4 reflect positive adaptation to the changes caused by the disease process. |
1813 The client with Guillain‐Barré syndrome is Correct answer: 4 The nurse needs to further assess the client's respiratory status by first auscultating the lungs, complaining of shortness of breath and seems checking tidal volume and oxygen saturation, and suctioning the nasopharynx if needed. confused. The nurse should: Confusion may be caused by cerebral hypoxia. ‐ Call for the code team. | Recognize that the assessment in option 4 matches the symptoms in the scenario. |
‐ Suction the client's oropharynx. ‐ Perform a mental status exam. ‐ Auscultate breath sounds. | |
1814 A client presents with circumferential burns to the Correct answer: 3 Electrical burns cause massive soft tissue and muscle injury from the inside out. chest and shortness of breath following an electrical Circumferential burns to the chest wall will decrease chest expansion and ventilation and will burn injury. The nurse identifies that the priority compromise breathing. An ineffective breathing pattern is evident as a result of this injury. nursing diagnosis for this injury would be: There is potential for further tissue damage, decreased cardiac output, and fluid volume deficit caused by hypoxia and edema formation for burn with third‐spacing of fluids. However, breathing and airway are priorities in this case. ‐ Deficient fluid volume. ‐ Risk for injury. ‐ Ineffective breathing pattern. ‐ Decreased cardiac output. | This question is testing knowledge of the mechanism of injury for an electrical burn and the implications for the client. Select the distractor that reflects the extent of injury and associated risk. |
1815 The nurse knows the client with a patient‐controlled Correct answer: 1 Only the client is allowed to administer the medication. The PCA pump has preset dose limits. analgesia (PCA) pump and his family understand Both of these measures prevent overdose. The client is instructed to push the delivery button instructions when they relate: when the pain begins. Persons using opioids for acute pain have a very low prevalence of addiction. Less total medication is needed with use of a PCA. ‐ The client alone is allowed to administer the medication. ‐ They should call the nurse when the pain begins. ‐ Pushing the control button too often may lead to an overdose. ‐ The client who uses a PCA is more likely to become addicted. | Recognize that option 1 is consistent with patient controlled. |
1816 To treat a client with autonomic dysreflexia, the Correct answer: 4 This position promotes venous drainage from the head and decreases venous return, nurse positions the client: reducing blood pressure. ‐ Prone, head to the side, arms on pillows. ‐ In a fetal position with a blood pressure cuff on. ‐ Leaning forward over the bedside table. ‐ By elevating the head of bed and removing support hose. | Identify the option that describes a position of comfort and that would promote drainage. |
1817 Which of the following nursing actions would be Correct answer: 4 Alcohol is a drying agent and should not be used when performing mouth care (lemon‐ contraindicated when performing mouth care with an glycerin products should also be avoided). Use a small toothbrush to make cleaning easier. unconscious client? Place the client on the right or left side and avoid the supine position to reduce the risk of aspiration. Toothettes can be used on the gums, tongue, and mucous membranes to reduce drying and subsequent breakdown. ‐ Give oral care using toothettes ‐ Brush the teeth with a small (child‐size) toothbrush ‐ Position the client to one side or the other ‐ Use an alcohol‐based product for better cleansing | Recall that alcohol is considered a drying agent and is always avoided with skin or oral care. |
1818 A nurse monitoring a client who has sustained a head Correct answer: 4 Vital signs changes are late indicators of rising intracranial pressure. Trends include an injury would determine that the intracranial pressure increase in temperature and blood pressure, and a decrease in pulse and respirations. The (ICP) is rising if which of the following vital sign trends level of consciousness would also deteriorate before these manifestations arise. is noted during the course of the work shift? ‐ Increased temperature, decreased pulse, increased respirations, decreased BP ‐ Decreased temperature, increased pulse, decreased respirations, increased BP ‐ Decreased temperature, increased pulse, increased respirations, decreased BP ‐ Increased temperature, decreased pulse, decreased respirations, increased BP | Look for the combined symptoms of bradycardia, increased temperature and increased blood pressure indicating IICP. |
1819 The client has been intubated and placed on a Correct answer: 2 Hyperventilation to achieve a PaCO<sub>2</sub> of 25 to 30 mm Hg causes mechanical ventilator to reduce intracranial pressure cerebral vasoconstriction that will lead to reduced intracranial blood volume and reduced ICP. (ICP) by decreasing the carbon dioxide level. Which of Option 1 is excessive; option 3 is normal, and option 4 indicates hypercarbia (excess carbon the following carbon dioxide values would indicate dioxide). that the optimal amount of hyperventilation has been achieved? ‐ PaCO2 18 mm Hg ‐ PaCO2 29 mm Hg ‐ PaCO2 38 mm Hg ‐ PaCO2 46 mm Hg | Omit options 3 and 4 as both are too high to achieve the goal. |
1820 A client who experienced a thrombotic stroke and has Correct answer: 2 Hemiparesis is a one‐sided weakness that often occurs following stroke. The client will have residual hemiparesis of the right side is undergoing maximum return of function and the least amount of frustration with relearning new tasks rehabilitation. The nurse caring for this client when objects are placed within easy reach on the unaffected side. This will also decrease the reinforces occupational therapy recommendations by risk of client injury because the client will not have to reach for objects needed for self‐care. placing items for personal hygiene: Unilateral neglect is not a problem when the client has right‐sided deficits, so objects do not need to be placed on the affected side. ‐ On the overbed table on the right side. ‐ On the overbed table on the left side. ‐ One foot away from the bed on the right side. ‐ One foot away from the bed on the left side. | Recognize the need to place the items within reach on the side with function. |
1821 A client with spinal cord injury is at risk for Correct answer: 3 Clients who have a spinal cord injury above the level of T7 are at risk for autonomic experiencing autonomic dysreflexia. The nurse would dysreflexia, an exaggerated autonomic response to a noxious stimulus. This complication can carefully monitor for which of the following be assessed by noting the presence of severe, throbbing headache, flushed face and neck, manifestations? bradycardia, and severe hypertension that is sudden in onset. Other signs to assess for are nausea, sweating, nasal stuffiness, and blurred vision. ‐ Tachycardia ‐ Hypotension ‐ Severe, throbbing headache ‐ Cyanosis of the head and neck | Identify the symptom that may be associated with hypertension that is the primary issue with autonomic dysreflexia. |
1822 A nurse is caring for a client who just experienced a Correct answer: 2 Documentation about seizure activity includes the time the seizure began, changes in pupil seizure. While doing follow‐up documentation, the size, eye deviation or nystagmus, body part(s) affected, utterance or sounds (epileptic cry), the nurse would include which of the following items in type of movements and progression, client condition during the seizure, and post‐ictal status. the nursing progress note? The other items listed are unnecessary. ‐ The amount of lighting in the room when the seizure began ‐ Utterance of sounds ‐ Amount of sleep the client had during the night prior to the seizure ‐ Food and fluid intake just before onset of the seizure | The item is asking about post seizure documentation. Identify the option that refers to post seizure function. |
1823 The nurse has implemented a teaching plan for the Correct answer: 2 Clients with Parkinson's disease have bradykinesia (slow movements that are hard to initiate), client with Parkinson's disease. The nurse evaluates which can be offset to some degree by rocking back and forth to initiate movement. Activities the teaching as effective if the client states to do which should be interspersed with rest periods throughout the day to minimize fatigue. Chairs should of the following to help combat manifestations of the be high and firm rather than soft and deep. Velcro fasteners and slide buckles will be of most disease? use to a client who is trying to maintain independence with dressing and grooming. ‐ Plan the most strenuous activities for the evening hours when bedtime is near ‐ Use a rocking motion to get up out of chairs ‐ Sit in a soft reclining chair to support joints while watching television | Eliminate options 1, 3, and 4 as being contraindicated in caring for Parkinson’s clients. |
4.‐ Choose clothing with several snaps and buttons to increase the benefits of physical therapy | |
1824 A client who is in Stage II of Alzheimer's disease has Correct answer: 1 Nurses caring for clients who have Alzheimer's disease should ensure that these clients are memory impairment. The nurse should plan to do wearing an identification bracelet so they do not become lost if they wander. It is unnecessary which of the following at the beginning of the to assess LOC hourly, and restraints are also not indicated. It is not essential that the client be upcoming work shift? placed in a quiet, calm environment; rather, they often prefer to be allowed to move about at will. ‐ Check to ensure that the client is wearing an ID badge. ‐ Place the client in a quiet, calm environment. ‐ Write a note on the cover of the chart asking for a prn order for restraints. ‐ Instruct ancillary caregivers to assess the client's level of consciousness hourly. | Recall that wandering is a concern for clients with Alzheimer’s. |
1825 A client newly diagnosed with trigeminal neuralgia Correct answer: 1 The pain of trigeminal neuralgia is triggered by stimulation of the sensory fibers of the asks the nurse to explain why it hurts so much when an trigeminal nerve. Examples of pressure‐related triggering events include shaving, episode occurs. The nurse would explain that the pain toothbrushing, washing the face, and eating or drinking. Examples of temperature‐related of trigeminal neuralgia is the result of which of the triggers include environmental changes and hot or cold food and drink. The other options following? listed do not initiate the pain of this disorder. ‐ Stimulation of the nerve by temperature or pressure ‐ Irritation due to cellular effects of hypoglycemia ‐ Release of epinephrine during the fight‐or‐flight response ‐ An immune system reaction to cold and influenza viruses | Recognize that the use of the word 'nerve' in option 1 is a helpful hint. |
1826 A client is scheduled for an electroencephalogram Correct answer: 2 Antidepressants, tranquilizers, and anticonvulsants are generally withheld for 24 to 48 hours (EEG) early in the morning. The nurse working the before an EEG. The client does not have to be NPO, but should avoid stimulants such as coffee, night shift prior to the procedure would write a note tea, cola, alcohol, and cigarettes. Pre‐procedure care for EEG involves teaching that there is no to do which of the following per protocol order in the discomfort, and shampooing the hair. early morning on the day of the test? ‐ Instruct the client to refrain from washing the hair ‐ Hold the daily dose of anticonvulsant ‐ Place the client on NPO status ‐ Reinforce client teaching that the test is only mildly uncomfortable | Because EEG looks at the electrical activity in the brain, alteration of the activity with anticonvulsants is contraindicated. |
1827 An unconscious client who is not receiving mechanical Correct answer: 1 Oral or gastrointestinal secretions can enter the client's airway and cause aspiration. The ventilation and who does have enteral feeding infusing onset of adventitious breath sounds indicates this risk clearly. The other options are incorrect has sudden onset of adventitious breath sounds. The because they do not relate to the client's airway. nurse would first gather additional data to determine the presence of which of the following nursing diagnoses? ‐ Risk for aspiration ‐ Risk for fluid volume deficit ‐ Risk for imbalanced nutrition: less than body requirements ‐ Altered thought processes | Identify airway complications as most important. |
1828 A client has undergone insertion of an intracranial Correct answer: 4 Normal ICP readings extend up to 10 mm Hg pressure (options 1, 2, and 3). Sustained pressure (ICP) monitoring device. The nurse would elevations above 15 mm Hg are of concern, as they are abnormally high. The client's become most concerned if the ICP readings measured neurological status is probably deteriorating as well. which of the following for a prolonged period of time? ‐ 3 mm Hg ‐ 7 mm Hg | In this case the incorrect options are rather close and so they should be eliminated. |
‐ 10 mm Hg ‐ 22 mm Hg | |
1829 The nurse is admitting a client from the emergency Correct answer: 2 As outlined in the options, the Glasgow Coma Scale is divided into three subsets. Each subset department following a fall that resulted in increased has a range of scores within it, and for the total scale the highest possible score is 15 while the intracranial pressure (ICP). The nurse interprets that lowest is 3. The higher the score, the more optimal should be the recovery. Scores in the "best the client's Glasgow Coma Scale score has improved eye opening response" category range from spontaneously (4), to speech (3), to pain (2), to no the most after making which of the following latest response (1). Scores in the "best motor response" category range from obeys verbal assessments? commands (6), localizes pain (5), flexion‐withdrawal (4), flexion‐abnormal (3), extension‐ abnormal (2), to no response (1). Scores in the "best verbal response" category range from oriented (5), conversation‐confused (4), speech‐inappropriate (3), sounds‐incomprehensible (2), to no response (1). ‐ Best eye opening response 5, best motor response 4, best verbal response 8 ‐ Best eye opening response 4, best motor response 6, best verbal response 5 ‐ Best eye opening response 6, best motor response 5, best verbal response 4 ‐ Best eye opening response 3, best motor response 8, best verbal response 6 | Options 1 and 4 must be eliminated as they exceed the maximum value for the scale. Option 2 reflects the most improvement. |
1830 The nurse planning care for a client who suffered a Correct answer: 2 A client who experienced a CVA may have involvement of the cranial nerve responsible for cerebrovascular accident (CVA) with residual dysphagia swallowing (XII), and generally undergoes a swallowing evaluation to determine whether a diet would write on the care plan to avoid doing which of can be taken. The client with some residual dysphagia may be started on a diet once the gag the following during meals? and swallow reflexes have returned. In this instance, liquids should be thickened to avoid aspiration. The other options represent helpful actions for the client with dysphagia. ‐ Feed the client slowly ‐ Give the client thin liquids ‐ Give foods with the consistency of oatmeal ‐ Place food on the unaffected side of the mouth | Recall that thin liquids are difficult to swallow. The other options assist with swallowing. |
1831 A client who experienced a spinal cord injury at the Correct answer: 3 Above the level of T6, clients with spinal cord injury are at risk for autonomic dysreflexia. It is level of T5 rings the call bell for assistance. Upon a life‐threatening syndrome triggered by a noxious stimulus below the level of the injury. This entering the room, the nurse finds the client to have a complication is characterized by severe, throbbing headache, flushing of the face and neck, flushed head and neck, complaining of severe bradycardia, and sudden severe hypertension. A client may also exhibit nasal stuffiness, headache, and being diaphoretic. The pulse is 47 and blurred vision, nausea and sweating. BP is 220/114 mm Hg. The nurse concludes that immediate treatment is needed for: ‐ Malignant hypertension. ‐ Pulmonary embolism. ‐ Autonomic dysreflexia. ‐ Spinal shock. | Recall that autonomic dysreflexia is always associated with severe hypertension and bradycardia. |
1832 A nurse is preparing to admit a client from the Correct answer: 1 It is highly controversial whether or not to use a bite stick when a client is experiencing emergency department who experienced seizure seizure activity. The greatest risk is that teeth could be damaged if it is inserted during a activity. The nurse would omit placing which of the seizure. The other pieces of equipment listed are useful in the care of the client and should be following pieces of equipment in this client's room? made ready at the bedside. ‐ Padded tongue blade ‐ IV equipment ‐ Oxygen and suction equipment ‐ Padded bedrails | Recall that putting anything in a client’s mouth during a seizure is contraindicated. |
1833 The home care nurse is doing an admission Correct answer: 2 The Parkinsonian gait is characterized by short, shuffling, accelerating steps. The head leans assessment on a client discharged from the hospital forward, the hips and knees flexed, and the client has difficulty starting (bradykinesia) and with a diagnosis of Parkinson's disease. When stopping. Options 1, 3, and 4 describe ataxic, dystrophic, and festinating gait, respectively. assessing the client's neurological status, the nurse would find the client's gait to be: ‐ Staggering and unsteady. ‐ Shuffling and propulsive. ‐ Waddling but broad‐based. ‐ Accelerating with walking on tips of toes. | Recall that shuffling is the term frequently used to describe the gait of a client with Parkinson’s disease. |
1834 A client with Alzheimer's disease begins to speak to Correct answer: 4 Since long‐term memory is retained for a longer period of time than short‐term memory, the nurse about life in the 1930s. Which of the clients with Alzheimer's disease will be able to recollect events from long ago. It is helpful to following actions by the nurse is most appropriate? allow clients to reminisce. The other options represent non‐therapeutic techniques for this client as described. ‐ Orient the client to time, place, and person. ‐ Distract the client by inviting him to watch television. ‐ Encourage the client to talk about recent events in the news. ‐ Listen to the client's anecdotes. | Select the option that best allows the client to discuss the events that he remembers. |
1835 The nurse reads in an admission note that the Correct answer: 3 The optic nerve, which governs vision, is cranial nerve II. For this client it would be most physical examination of a client revealed an helpful to clear the area of objects that may not be perceived by the client but that could lead impairment of cranial nerve II. The nurse instructs to falls. The actions described in the other options are unnecessary. ancillary caregivers to do which of the following when caring for this client? ‐ Whisper to the client ‐ Serve food at room temperature ‐ Clear the client's path of obstacles ‐ Test the temperature of any running water | Identify that cranial nerve II is the optic nerve, effecting vision. |
1836 The nurse is instructing the client with Bell's palsy on Correct answer: 4 Prednisone is often used to treat Bell's palsy. The drug is a steroid, which will reduce information regarding medications that might reduce inflammation and edema and thereby allow the return of normal circulation in the area of the nerve tissue edema. The nurse would explain the nerve. It can help preserve a significant amount of function, and is effective against pain, when actions and side effects of which of the following given early in the course of treatment. medications? ‐ Acetaminophen (Tylenol) ‐ Ibuprofen (Advil) ‐ Dexamethasone (Decadron) ‐ Prednisone (Deltasone) | Associate reduction of edema with steroids. |
1837 A client with a C4 fracture has been stabilized and Correct answer: 1 The client should move the entire torso to scan the visual field because the client cannot turn fitted for the device shown. Which of the following the head. The client should use straws to prevent spills with liquids. The client should avoid discharge instructions would be appropriate for the bending because the device has a high center of gravity, which could lead to falls. The device is nurse to share with the client? not removed at bedtime. ‐ Move the entire torso in order to be able to scan the visual field ‐ Avoid the use of straws until the device is removed ‐ Bend slowly to pick objects up from the floor ‐ Take the device off only at bedtime | Safety measures due to inability to turn the head are key in correctly answering this question. |
1838 A client who experienced an intracerebral bleed is Correct answer: 1 The zero level for ICP monitoring is 1 inch above the ear, which is at the height of the undergoing intracranial pressure (ICP) monitoring. The foramen of Munro. Each time an ICP reading is done, it should be done with the client's head in nurse would be sure to avoid doing which of the the same position. following while caring for this client? ‐ Level the transducer at the pinna of the ear ‐ Check all stopcocks and connections for leaks ‐ Utilize surgical aseptic technique when touching the system ‐ Monitor the insertion site for signs and symptoms of infection | Note the word “avoid” in the stem. Options 2, 3, and 4 are reflective of good technique when using invasive monitoring. |
1839 The nurse would conclude that a clear fluid leaking Correct answer: 4 Basilar skull fracture can lead to leakage of CSF from the ears or nose. CSF is noticeable in from the nose following basilar skull fracture is that the drainage will separate into bloody or yellow concentric rings on the dressing material, cerebrospinal fluid (CSF) after noting that the fluid: which is called Halo's sign. The fluid also will test positive for glucose. ‐ Has bright red blood in it and has a pH of 6. ‐ Is clear in appearance and tests negative for glucose. ‐ Has a foul odor and has a pH of 7. ‐ Separates into concentric rings and tests positive for glucose. | Associate CSF with glucose content. |
1840 A client who experienced a stroke now has a residual Correct answer: 3 Scanning the environment can help to overcome homonymous hemianopsia, loss of one half deficit of homonymous hemianopsia. The nurse of the visual field. The other items listed will not be of help to the client who has this type of explains that which of the following strategies will visual deficit. assist the client to compensate for this complication? ‐ Keep all objects in the impaired field of vision to strengthen eye muscles ‐ Wear a patch on the affected eye ‐ Scan the visual field by turning the head ‐ Wear sunglasses during the day and early evening | Note that the question asks about compensation. Scanning the visual field is a method of compensation. |
1841 The client newly admitted with spinal shock following Correct answer: 4 During spinal shock, there is loss of voluntary control of skeletal muscles, autonomic reflexes spinal cord injury would exhibit which of the following below the level of the injury. These lead to flaccid paralysis, loss of spinal reflex arcs, and manifestations during assessment? bowel and bladder retention. The other responses are either partially or totally incorrect. ‐ Spastic paralysis of the legs, bowel and bladder incontinence, hyperreflexia ‐ Spastic paralysis of the legs, bowel and bladder retention, hyperreflexia ‐ Flaccid paralysis of the legs, bowel and bladder incontinence, areflexia ‐ Flaccid paralysis of the legs, bowel and bladder retention, areflexia | Omit options 1 and 2 as they refer to spastic paralysis. Look for an option that combines flaccid paralysis and bowel and bladder retention. |
1842 A client develops sudden seizure activity. The client's Correct answer: 2 Generalized seizures are seizures without a focal point of onset and that are bilaterally entire body first becomes very rigid, followed by symmetric. There are seven subtypes, including tonic‐clonic, tonic, clonic, absence, atonic, alternating periods of muscle relaxation and myoclonic, and infantile spasms. The tonic‐clonic pattern is as described in the stem. Partial contraction occurring in all four extremities. The nurse seizures begin locally, and are divided into three subtypes, including simple partial seizures documents that the client is exhibiting: (without impaired LOC), complex partial seizures (with impaired LOC), and partial seizures secondarily generalized. ‐ Partial seizures secondarily generalized. ‐ Generalized tonic‐clonic seizures. ‐ Simple partial seizures. ‐ Complex partial seizures. | Recognize that the scenario is describing tonic‐clonic activity. |
1843 The nurse had been describing to a client the Correct answer: 4 Parkinson's disease is characterized by depletion of dopamine levels in the substantia nigra, physiological basis for symptoms in Parkinson's leading to the onset of symptoms of Parkinson's disease. Option 1 describes Guillain Barré disease. Which of the following explanations for syndrome. Option 2 is nonspecific. Option 3 describes myasthenia gravis. symptoms would be most accurate for the nurse to share? ‐ A viral infection triggers an autoimmune reaction in the nervous system. ‐ Peripheral nerve compression is responsible. ‐ Antibodies against acetylcholine receptors impair neuromuscular transmission. ‐ Dopamine levels decrease in the substantia nigra and basal ganglia. | Identify the option that refers to dopamine and basal ganglia as correct. |
1844 The family of a client with Alzheimer's disease asks Correct answer: 2 The plaque that characterizes Alzheimer's disease is a cluster of degenerating nerve about the pathologic changes that are occurring in the terminals, both dendritic and axonal, which contain amyloid protein. The other responses are brain. The nurse would explain that this disease is incorrect statements. caused by: ‐ Damage to the myelin sheath of neurons. ‐ Abnormal accumulation of proteins. ‐ Destruction of neurons. ‐ Increase in production of cerebrospinal fluid (CSF). | Eliminate options 1 and 4 as not being associated with this disease. Note the word “abnormal” in option 2 as a key to this being the correct response. |
1845 The nurse admitting a client with a history of Correct answer: 2 Trigeminal neuralgia is manifested by spasms of pain that begin suddenly and last anywhere trigeminal neuralgia (tic Douloureux) would question from seconds to minutes. Clients often describe the pain as stabbing or similar to an electric the client about which of the following manifestations? shock. It is accompanied by spasms of facial muscles, which cause closure of the eye and/or twitching of parts of the face or mouth. ‐ Facial droop accompanied by numbness and tingling ‐ Stabbing pain that occurs with twitching of part of the face ‐ Aching pain and ptosis of the eyelid ‐ Burning pain and intermittent facial paralysis | Note that pain and twitching as symptoms help to identify the correct response. |
1846 The nurse believes a client has slight one‐sided Correct answer: 1 This assessment may be done to detect small changes in muscle strength that might not weakness and decides to further test the client's otherwise be noted. Pronator drift occurs when a client cannot maintain the hands in a muscle strength. The nurse asks the client to hold the supinated position with the arms extended and eyes closed. Nystagmus is the presence of fine, arms up and supinated, as if holding a tray, and then involuntary eye movements. Hyperreflexia is an excessive reflex action. Ataxia is a disturbance asks the client to close the eyes. The client's right hand in gait. moves downward slightly and turns. The nurse documents and reports that the client has: ‐ Pronator drift. ‐ Nystagmus. ‐ Hyperreflexia. ‐ Ataxia. | Recall that the opposite of supinate is pronate. |
1847 The nurse has admitted a client to the emergency Correct answer: 2 A CK level above 150 with over 5% MB isoenzyme indicates myocardial damage from acute room with complaints of chest pain over the previous myocardial infarction. Elevated potassium is not indicative of myocardial infarction. Elevated 2 hours. There are no clear changes on the 12‐lead WBC is an indicator of many conditions, including MI. ECG. The nurse would expect which laboratory test to provide confirmation of a myocardial infarction (MI)? ‐ Potassium of 5.2 mEq/L ‐ Creatinine kinase (CK) of 545 with MB of 4% ‐ CK of 320 with MB of 12% ‐ WBC of 11,400/mm3 | The core issue of the question is the ability to correlate indicators of myocardial damage with a client situation. Evaluate each option carefully, and use nursing knowledge and the process of elimination to make a selection. |
1848 The nurse is preparing to discharge a client after Correct answer: 4 Nausea and anorexia are signs of digitalis toxicity. The other laboratory values would not CABG surgery. The client is taking several new explain the client’s symptoms and therefore are not priorities to assess before telephoning the medications, including digoxin (Lanoxin), metoprolol physician. (Lopressor), and furosemide (Lasix). The client complains of nausea and anorexia. The nurse is preparing to report this finding to the physician before discharging the client. Which laboratory result will the nurse check before calling the physician? ‐ Potassium level ‐ Sodium level ‐ PT/INR ‐ Digoxin level | The core issue of the question is the ability to correlate early signs of digoxin toxicity with a need to check digoxin level in a client with cardiac disease. Evaluate each option carefully, and use nursing knowledge and the process of elimination to make a selection. |
1849 The registered nurse has finished reviewing the 7:00 Correct answer: 1 A stable client with complex dressings is an appropriate assignment for an LPN because the a.m. shift report on a telemetry unit. Which of the task is appropriate for an LPN. Initial assessment (new admission from the ED), the assessment following clients would be the best for the RN to assign of a client before and after a complex procedure (PTCA), and discharge teaching are all to the licensed practical nurse? responsibilities of the professional registered nurse and may not be delegated to the LPN. ‐ A 7‐day postoperative CABG client with an infection in the sternal surgical incision, requiring dressings and irrigation ‐ A client who has just arrived on the unit from the emergency room for observation to rule out a myocardial infarction ‐ A client who has had successful valve replacement therapy and will be discharged this morning ‐ A client who is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) at 10:00 a.m. | Evaluate each option carefully, and use nursing knowledge and the process of elimination to make a selection. |
1850 The nurse is caring for a client with a history of Correct answer: 2 The client’s heart rate is bradycardic, and metoprolol, a beta‐blocker, decreases the heart hypertension. The client is being treated with rate. Neither the captopril nor the hydrochlorothiazide lowers the heart rate, and either may metoprolol (Lopressor), hydrochlorothiazide be safely administered to maintain control of the hypertension. When a dose of medication is (HydroDiuril), and captopril (Capoten). The client has a withheld, it is the responsibility of the nurse to notify the physician of the action and rationale. blood pressure of 120/80 mmHg and a pulse rate of 48. Which of the following is the best action by the nurse? ‐ Administer the metoprolol (Lopressor) and the hydrochlorothiazide (HydroDiuril), hold the captopril (Capoten), and notify the physician. ‐ Administer the captopril (Capoten) and the hydrochlorothiazide (HydroDiuril), hold the metoprolol (Lopressor), and notify the physician. ‐ Administer all the medications and notify the physician. ‐ Withhold all the medications and notify the physician. | The core issue of the question is determining which medication is responsible for the adverse effect on client status and acting accordingly. Evaluate each option carefully, and use nursing knowledge and the process of elimination to make a selection. |
1851 The nurse has finished reviewing the shift report on a Correct answer: 3 A client with endocarditis is at risk for thrombus formation, and chest pain and anxiety are cardiac unit. The nurse should plan to see which of the signs of pulmonary embolism (PE), which is a life‐threatening complication requiring following assigned clients first? immediate attention. Dyspnea is a chronic symptom with hypertrophic cardiomyopathy, which requires assessment; a temperature of 101 degrees F requires additional assessment, and a client who is ambulating for the first time will be assessed by the nurse. However, the client who needs to be assessed for PE is the most emergent. ‐ A client with hypertrophic cardiomyopathy who is reporting dyspnea ‐ A client who had a cardiac catheterization and will be ambulating for the first time ‐ A client receiving antibiotics for bacterial endocarditis who is reporting anxiety and chest pain ‐ A client who is recovering from coronary artery bypass grafting (CABG) surgery with a temperature of 101 degrees F | The key to determining the answer to priority‐setting questions is to evaluate which client is most unstable or has the greatest risk for developing a complication. Evaluate each option carefully using these methods, and use nursing knowledge and the process of elimination to make a selection. |
1852 The nurse is discharging a client to home with a new Correct answer: 4 A serious complication of atrial fibrillation is pulmonary embolism. Chest pain and hemoptysis diagnosis of atrial fibrillation. The nurse explains that are common symptoms of pulmonary embolism. Irregular pulse is expected with atrial which of the following is the most important symptom fibrillation. Fatigue may accompany atrial fibrillation in some individuals. Fever is not to report to the physician? associated with atrial fibrillation and is not necessarily included in discharge teaching. However, it could be a sign of illness that could increase the workload of the heart, and therefore it would be the second‐most important item to report if it occurred. ‐ Irregular pulse ‐ Fever ‐ Fatigue ‐ Hemoptysis | The core issue of the question is knowledge of signs and symptoms of complications to report to the physician in the presence of atrial fibrillation. Evaluate each option carefully, and use nursing knowledge and the process of elimination to make a selection. |
1853 The nurse is caring for a client with a history of renal Correct answer: 3 Renal failure is a common cause of hypocalcemia, and a value of 7.0 mg/dL is below the failure and a new myocardial infarction. The nurse who normal range of serum calcium. Options 1 and 2 are within the upper limits for potassium and is reviewing laboratory findings would call the doctor sodium, and option 4 is within the therapeutic range of digoxin. to report which of the following results? ‐ Potassium level of 5.0 mEq/L ‐ Sodium level of 145 mEq/L ‐ Calcium level of 7.0 mg/dL ‐ Digoxin/digitalis level of 0.8 ng/mL | The core issue of the question is knowledge of normal and abnormal values that are important to report in a client with an acute cardiac problem and a history of renal failure. The best strategy in questions such as these is to pick the value with the most abnormal number and/or one that relates to the underlying disorder(s). |
1854 The nurse is caring for a client who had a permanent Correct answer: 4 The client is not allowed to ambulate for 24 hours to prevent dislodging of the electrodes. pacemaker inserted because of a complete heart Normal sinus rhythm, heart rate of 80, and a BP of 120 over 80 do not reflect pacemaker block. The nurse determines that which of the function. Paced beats indicate that the pacemaker is functioning. following client outcomes indicates a successful procedure? ‐ Client ambulating in the hall within 4 hours of the procedure without dyspnea or chest pain ‐ Client’s ECG monitor demonstrates normal sinus rhythm ‐ Heart rate of 80 beats per minute, blood pressure 120 systolic, and 80 diastolic ‐ Client’s ECG monitor shows paced beats at the rate of 68 per minute | Evaluate each option carefully, and use nursing knowledge and the process of elimination to make a selection. |
1855 The nurse is caring for a client with a diagnosis of Correct answer: 1 Symptomatic aortic stenosis has a poor prognosis without surgery. Restricting activity limits aortic stenosis. The client reports episodes of angina myocardial oxygen consumption. Since the incidence of sudden death is high in this population, and passing out recently at home. The client has it is prudent to decrease the strain on the heart while awaiting surgery. surgery scheduled in 2 weeks. Which of the following would be the nurse’s best explanation about activity at this time? ‐ “It is best to avoid strenuous exercise, stairs, and lifting before your surgery.” ‐ “Take short walks three times daily to prepare for postoperative rehabilitation.” ‐ “There are no activity restrictions unless the angina reoccurs; then please call the office.” ‐ “Gradually increase activity before surgery to build stamina for the postoperative period.” | The core issue of the question is the level of activity that will minimize the client’s risk of complications or sudden death until surgery. Evaluate each option carefully, and use nursing knowledge and the process of elimination to make a selection. |
1856 The nurse is caring for a client who has just Correct answer: 3 The dye used in angiography is nephrotoxic, and a client should have adequate fluids after the undergone cardiac angiography. The catheter insertion procedure to eliminate the dye. The client should lie with the affected leg extended for 6 to 8 site is free from bleeding or signs of hematoma. The hours. Leg exercises are not recommended because exercise could disrupt the clot that formed vital signs and distal pulses remain in the client’s at the insertion site. Option 1 is incorrect because it gives false reassurance to a client who normal range. The intravenous fluids were could be at risk if fluids are not taken in. discontinued. The client is not hungry or thirsty and refuses any food or fluids, asking to be left alone to rest. Which of the following is the nurse’s best response? ‐ “You are recovering well from the procedure and resting is a good idea.” | The core issue of the question is knowledge of the correlation between lack of fluid intake and risk of kidney complications following angiography. Evaluate each option carefully, and use nursing knowledge and the process of elimination to make a selection. |
‐ “It is important for you to walk, so I will be back in 1 hour to walk with you.” ‐ “It is important to drink fluids after this procedure, to protect your kidney function. I will bring you a pitcher of water, and I encourage you to drink.” ‐ “You will need to do the leg exercises that you practiced before the procedure to keep good circulation to your legs. After your exercises, you can rest.” | |
1857 A client undergoes ligation of varicose veins. The Correct answer: 1 Compression stockings exert pressure on the veins of the lower extremities, promoting nurse includes in the plan of care which of the venous return back to the heart. Stockings are removed for at least an hour per day to allow following important interventions for the nursing for inspection and ensure blood flow through small, superficial vessels. Flexing the extremities diagnosis of ineffective tissue perfusion? does not aid tissue perfusion, although it maintains joint range of motion. However, after this surgery clients are taught to either stand or lie down and avoid flexing at the hip and knee. Numbness is a temporary or rarely permanent complication of surgery. Briskly scrubbing the extremities will not aid tissue perfusion. ‐ Teach client to remove compression stockings for at least 1 hour per day. ‐ Teach client to flex lower extremities four times a day. ‐ Teach client that numbness is common after vein ligation. ‐ Encourage client to briskly scrub lower extremities to improve circulation. | The core issue of the question is a measure that will improve tissue perfusion for a client following vein ligation. Using principles of blood flow, choose the option that will aid circulation. Evaluate each option carefully, and use nursing knowledge and the process of elimination to make a selection. |
1858 A client’s angiogram demonstrates the final stage of Correct answer: 1 The final stage of the atherosclerotic process is the development of atheromas, which are atherosclerosis. The nurse concludes that this client’s complex lesions consisting of lipids, fibrous tissue, collagen, calcium, cellular waste, and pathophysiology includes which of the following capillaries. The calcified lesions may rupture or ulcerate, stimulating thrombosis. The other elements? options are not consistent with the ultimate or final changes in the atherosclerotic process. ‐ The presence of atheromas ‐ Fatty deposits in the intima ‐ Lipoprotein accumulation in the intima ‐ Inflammation of the arterial wall | Note the critical words "final stage." Evaluate each option carefully, and use knowledge of pathophysiology and the process of elimination to make a selection. |
1859 When assessing a client with peripheral arterial Correct answer: 3 Leg pain (also called intermittent claudication) is a primary manifestation of peripheral disease, the nurse assesses the client for which of the arterial disease. Intermittent claudication is muscle pain caused by interruption in arterial flow, following signs and symptoms that would be resulting in tissue hypoxia. Peripheral edema and brownish discoloration to the skin on the leg consistent with tissue ischemia? would be consistent with venous disease, not arterial disease. Widened pulse pressure would be an unrelated finding. ‐ Peripheral edema ‐ Widened pulse pressure ‐ Leg pain while walking ‐ Brownish discoloration to the skin on the leg | The critical words in the question are peripheral arterial disease, which direct you to look for manifestations that are abnormal and that are consistent with arterial but not venous disease. Evaluate each option carefully, and use nursing knowledge and the process of elimination to make a selection. |
1860 In providing community education on prevention of Correct answer: 4 Nicotine in cigarettes promotes vasoconstriction. The three most significant risk factors for peripheral arterial disease, the nurse is careful to development of peripheral arterial disease are smoking, hyperlipidemia, and hypertension. The include which of the following as a major risk factor? presence of dysrhythmias, low‐protein intake, and exposure to cool weather are not risk factors for the disease, although cool weather could worsen the symptoms when disease is already present. ‐ Dysrhythmias ‐ Low‐protein intake ‐ Exposure to cool weather ‐ Cigarette smoking | Note the critical word “prevention” to focus on the option that contains information that will affect the likelihood of whether the client will develop peripheral arterial disease. Evaluate each option carefully, using nursing knowledge and the process of elimination to make a selection. |
1861 When teaching a client with an aneurysm what signs Correct answer: 4 Aneurysms vary by size and location. Signs of rupture depend on the location of the and symptoms may indicate impending rupture, the aneurysm. Dissection can occur anywhere but most often occurs in the ascending aorta where nurse considers which of the following? pressure is the highest. The medication the client is receiving is vague and is not directly related. The blood pressure relates to whether the aneurysm may rupture, not to the associated signs and symptoms. The age and gender of the client are unrelated to the size and symptoms of aneurysm rupture. ‐ Medication therapy the client is receiving ‐ Client’s usual blood pressure ‐ Age and gender of the client ‐ Size and location of the aneurysm | With the critical words “signs” and “symptoms” in mind, choose the option that most directly relates to the core issue of the question. Evaluate each option carefully, and choose option 4 as the only one that could affect the specific list of signs and symptoms that the nurse would teach related to aneurysm rupture. |
1862 An important outcome of care for a female client Correct answer: 2 An important outcome in care of the hypertensive client is the ability to identify and with hypertension has been met when the client is counteract personal risk factors that the client has the ability to change. Modifiable risk factors able to do which of the following? for hypertension include smoking, hypercholesterolemia, diabetes mellitus, sedentary lifestyle, obesity, stress, and alcohol use. Option 1 is not likely to be an issue. Option 3 may or may not be sufficient. Option 4 is contraindicated. ‐ Return to her usual activities of daily living ‐ Identify actions to counteract two of her modifiable risk factors ‐ Lower her blood pressure by 10% ‐ Discontinue lifestyle modifications | The core issue of the question is the ability to identify an indicator that is a positive effect of care for the hypertensive client. Evaluate each option carefully, and use nursing knowledge and the process of elimination to make a selection. |
1863 Which of the following suggestions should the nurse Correct answer: 1 The client should avoid long periods of standing or sitting to promote adequate blood flow. include when conducting health teaching for clients The legs and feet should be below heart level to increase peripheral circulation. Regular with arterial insufficiency? exercise enhances development of collateral circulation, increases vascular return, and is recommended for clients with either arterial or venous insufficiency. Moist heat is helpful for venous problems. ‐ Avoid long periods of sitting and standing. ‐ Keep the legs and feet in a raised position. ‐ Decrease ambulation to decrease pain. ‐ Apply moist heat twice a day. | A critical word in the stem of the question is “arterial,” which tells you that the correct answer is an option that is beneficial to the client with impaired circulation to the legs. Choose option 1 over the others because it is a generally helpful measure to increase circulation, while options 2 and 4 are helpful with venous problems. Option 3 does not help either arterial or venous circulatory problems. |
1864 A client with endocarditis develops sudden leg pain Correct answer: 2 The client is exhibiting symptoms of acute arterial occlusion. Without immediate with pallor, tingling, and a loss of peripheral pulses. intervention, ischemia and necrosis will result within hours. The nurse should first wrap the leg The nurse’s initial action should be to: to maintain warmth and protect it from further injury, and should then quickly notify the physician. The leg should not be elevated above heart level because doing so would worsen the tissue ischemia, and passive range of motion will also increase ischemia by increasing tissue demand for oxygen. ‐ Elevate the leg above the level of the heart. ‐ Wrap the leg in a loose blanket. ‐ Notify the physician about the findings. ‐ Perform passive ROM exercise to stimulate circulation. | The core issue of the question is recognizing the complication of acute arterial occlusion and then determining which action should be taken first. Choose an option that is client‐ focused rather than physician‐notification focused, if one is available. In this case, the nurse can protect the client from further injury with option 2. |
1865 In coordinating care for a client with venous stasis Correct answer: 4 The client with venous ulcers must keep the legs elevated above the level of the heart as ulcers, the nurse explains to unlicensed assistive much as possible. Elevation of the extremities enhances venous return and improves personnel that which of the following is the most circulation, providing oxygen and nutrients to the lower extremities. The client with a leg ulcer important intervention in ulcer healing? should avoid exercise to prevent further damage to tissues at risk. Option 1 may or may not be indicated. Asepsis is important, but no ulcer will heal unless the edema and stagnant tissue metabolites can be reduced through leg elevation. ‐ Surgical debridement ‐ Meticulous cleaning of the ulcers to prevent infection | The critical words in the stem of the question are “most important intervention,” indicating that more than one option, or all options, may be correct, but one is better than the others. Look at the question carefully and note that the nurse is talking to an ancillary caregiver. Consider that the correct option is one that is within the scope of practice of that caregiver in making a selection. |
‐ Performance of leg exercises to increase collateral circulation ‐ Elevation of the extremities to increase venous return | |
1866 Which of the following clients is most at risk for Correct answer: 3 A major risk factor for formation of thrombophlebitis is oral contraceptive use in women who developing a deep‐vein thrombosis? smoke. Being 1‐week postpartum does not place a client at risk since mobility is usually restored. Anticoagulant therapy is used to prevent development of thrombi. Laparoscopic surgical procedures are associated with more rapid recovery times with reduced immobility, keeping this client at lower risk than the client in option 3. ‐ A 30‐year‐old client who is 1 week postpartum ‐ A 63‐year‐old client post‐CVA on anticoagulant therapy ‐ A 40‐year‐old woman who smokes and uses oral contraceptives ‐ A 41‐year‐old female who underwent laparoscopic cholecystectomy | The critical words in the stem of the question are “most at risk,” telling you that the correct option is the one that contains the most severe or greatest number of risk factors for thrombophlebitis. With this in mind, evaluate each option and use the process of elimination to make a selection. |
1867 The nurse is caring for a 2‐month‐old child with Correct answer: 3 The open ductus arteriosus will allow a small amount of mixing of oxygenated and transposition of the great vessels. Which of these unoxygenated blood. Stress will increase the cardiac workload and therefore is a priority for interventions has highest priority? the nurse to avoid. Maintaining caloric intake and comfort are the next priorities using Maslow’s hierarchy. Documenting vital signs is a routine activity and not a priority when compared to actual care activities. ‐ Providing comfort for parents ‐ Maintaining proper caloric intake ‐ Reducing stressors for infant ‐ Documenting vital signs | Use Maslow’s hierarchy of needs to review each option and choose the one that most closely relates to the ABCs and thus cardiac workload. Use this knowledge and the process of elimination to make a selection. |
1868 During the acute phase of rheumatic fever, which of Correct answer: 2 The main complication of rheumatic fever is carditis. The nurse must assess for early signs of the following is a priority action of the nurse? bacterial endocarditis. The client should be encouraged to rest during the acute phase, and hydration needs may not be sufficiently met with sips of water. Narcotic analgesics may not be necessary, although NSAIDs are likely to be ordered. ‐ Encourage ambulation at least four times per day. ‐ Assess for early signs of endocarditis. ‐ Maintain hydration by encouraging sips of water. ‐ Manage pain with strong narcotic analgesics. | The core issue of the question is the ability to set priorities for a client with rheumatic fever. Omit option 1 because of the words 'at least,' knowing that rest is encouraged. Likewise, eliminate option 3 because of the word 'sips.' Choose option 2 over 4 knowing that NSAIDs are likely to be effective in managing pain and inflammation from rheumatic fever. |
1869 A 6‐year‐old child has been diagnosed with Correct answer: 1 Decreased circulation to lower extremities would contribute to muscle fatigue and pain in the coarctation of the aorta. Lately, he has been legs. Many of the children returning from recess will have increased respiratory rate secondary complaining when he comes in from recess. The health to play activities. Blurred vision and bruises are not related to coarctation. nurse should question the child about which of the following? ‐ Weakness and pain in legs ‐ Blurred vision ‐ Increased respiratory rate ‐ Bruises on shins | The core issue of the question is knowledge of signs of exercise intolerance in a 6‐year‐old client with a cyanotic heart defect. Use principles of gas exchange and knowledge of normal and abnormal findings after exercise to make a selection. |
1870 A toddler with Kawasaki’s disease is going home on Correct answer: 1 Salicylates prevent platelet agglutination. Gastrointestinal bleeding is often a side effect of salicylate (aspirin) therapy. Which is the priority aspirin therapy. It is not necessary to avoid other children. Tingling of extremities is not a teaching at the time of discharge? concern, although ringing in the ears could be a sign of salicylate toxicity. A low‐calorie diet is not indicated. ‐ Monitor the child for gastrointestinal bleeding. ‐ Avoid contact with other children. ‐ Report complaints of tingling extremities. ‐ Maintain a low‐calorie diet. | The core issue of the question is knowledge of adverse drug effects of salicylate therapy for the child with Kawasaki’s disease. Use this knowledge and the process of elimination to make a selection. |
1871 A toddler requires supplemental oxygen therapy for a Correct answer: 2 Allowing mobility is helpful to promote growth and development in the toddler. Strategies cyanotic heart defect. In planning for home care, the should be discussed to promote mobility while maintaining the supplemental oxygen. Options nurse would discuss which of the following with the 1 and 4 are unnecessary. Signs of oxygen toxicity are not the priority based on the information parents? in the question. ‐ The need to maintain the child on bedrest ‐ Means of promoting mobility while meeting the need for supplemental oxygen ‐ Symptoms of oxygen toxicity ‐ How to draw blood for blood gases | The core issue of the question is home care needs of a toddler receiving oxygen therapy. Use principles of needs related to normal growth and development to help select the correct option. |
1872 The nurse would assess for which of the following Correct answer: 1, 2, 4 The client would exhibit pain, pallor of the affected skin, diminished or absent radial pulse, manifestations in a client with suspected arterial parasthesias (altered local sensation), paralysis (weakness or inability to move extremity), and embolism to the left hand? Select all that apply. poikilothermia (cooler temperature). The client would not have a bounding radial pulse (opposite finding is true) or pitting edema, indicating a fluid volume excess or heart failure. ‐ Pain ‐ Pale skin ‐ Bounding radial pulse ‐ Parasthesias ‐ Pitting edema | The core issue of the question is knowledge of assessment findings in arterial embolism. Visualize a clot in the local circulation and use that image to determine the effect of the blockage on circulation to the affected area. |
1873 The nurse is caring for a child with Kawasaki’s disease. Correct answer: 3 Cardiac involvement is the most serious complication. The other signs and symptoms are The nurse determines that which assessment data diagnostic indicators of Kawasaki's disease. indicates the presence of the most serious complication of Kawasaki’s disease? ‐ Dermatitis of extremities ‐ Strawberry tongue, erythema of mouth ‐ Change in blood pressure, pulse, skin color ‐ Fever over five days, bilateral conjunctivitis | The critical words in the question are “most serious complication.” This indicates the need to know what the most serious complication is and also how it is manifested. All symptoms are present in Kawasaki’s Disease but the one with the most potential for damage is cardiac. |
1874 A 6‐year‐old is admitted with suspected acyanotic Correct answer: 1 Older children with acyanotic congenital heart disease may be asymptomatic, or manifest heart disease. After learning that the heart defect is a exercise intolerance, chest pain, arrhythmias, syncope, or sudden death. Option 2 is false, and congenital disorder, the parents ask the nurse how options 3 and 4 are both false and place inappropriate blame on the parents. they could have missed the problem all these years. The nurse's response should include the information that: ‐ Acyanotic heart disease may be asymptomatic. ‐ The child would only be cyanotic with great exertion. ‐ The parents should have recognized the symptoms associated with an acyanotic heart defect. ‐ The parents were probably ignoring the symptoms and hoping they would go away. | Responding correctly to this question requires consideration of the facts about acyanotic heart disease and reducing psychological stress. |
1875 The pediatric nurse is caring for two children with Correct answer: 2 Chronic hypoxemia in cyanotic heart disease leads to polycythemia, an above‐normal heart disease. The nurse concludes that which increase in the number of red cells in the blood. This change increases the amount of laboratory finding would be seen in the client with hemoglobin available to carry oxygen. The other answers do not differentiate between the cyanotic heart disease but not in the client with cyanotic and acyanotic forms of heart disease in the child. acyanotic heart disease? ‐ Elevated pO2 ‐ Elevated hemoglobin ‐ Decreased hematocrit ‐ Decreased pCO2 | The difference between acyanotic and cyanotic heart disease is that in cyanotic heart disease, the blood is partially unoxygenated. Consider how this will affect each of the option lab values over time. |
1876 The mother asks the purpose of aspirin therapy in a Correct answer: 1, 5 Aspirin is an antipyretic (option 5), an analgesic (option 1), and an anti‐inflammatory (option child with rheumatic fever. The nurse explains that the 1). It does not prevent complications, hasten recovery, or relate to the development of chorea. purpose is to do which of the following? Select all that apply. ‐ Provide comfort and reduce inflammation ‐ Prevent cardiac complications ‐ Hasten recovery ‐ Prevent the development of chorea ‐ Reduce fever | Consider the therapeutic actions of aspirin therapy and its use in rheumatic fever to aid in choosing the correct answers. |
1877 The parents of a toddler who has undergone a Correct answer: 1 Infective endocarditis is the most common complication of the cardiac surgery. Children may successful repair of a ventricular septal defect (VSD) need prophylactic antibiotic therapy for specific conditions as recommended by the American question why the child is being sent home on Heart Association. antibiotics when no infection is present. The nurse explains that this is prophylactic to prevent the complication of: ‐ Infective endocarditis. ‐ Pulmonary embolism. ‐ Cerebrovascular accident. ‐ Gastritis. | The core concept is prophylactic antibiotic use. Of the options listed, infective endocarditis is the primary bacterial condition. |
1878 In assessing children with congenital heart defects, Correct answer: 1, 3 Clubbing of the fingers and toes occurs in cyanotic heart defects, such as transposition of the the pediatric acute care nurse would expect to see great vessels. clubbing of the fingers and toes in the child diagnosed with: (Select all that apply.) ‐ Transposition of the great vessels. ‐ Atrial septal defect. ‐ Tetralogy of Fallot ‐ Patent ductus arteriosus. ‐ Coarctation of the aorta. | Any defect that bypasses the lungs will lead to these symptoms. Those defects which recycle through the lungs will not. |
1879 A 7‐year‐old client is diagnosed with rheumatic fever. Correct answer: 1 Rheumatic fever is an inflammatory response of collagen tissue after experiencing a The physician orders throat cultures of all family streptococcal infection. Some members of the family may be asymptomatic carriers. members. When questioned by the parents about the rationale for this order, the nurse explains that: ‐ "Family members can carry streptococcus and be asymptomatic." ‐ "The child must have infected others." ‐ "Rheumatic fever is familial." ‐ "Family members can carry the virus for rheumatic fever." | Knowledge that the agent involved in the pathophysiology is bacterial will eliminate option 4. Eliminate option 3 as vague and incorrect. Of the other options, option 1 is the best answer because option 2 is not necessarily true. |
1880 A 3‐month‐old was diagnosed with transposition of Correct answer: 3 At this stage of grieving, the mother needs someone to listen and validate that her feelings the great vessels. The mother cannot stop sobbing and are respected. Information will not be heard or remembered. tells the nurse she feels guilty about her child's condition. The nurse's best response is to: ‐ Agree that a teratogenic stressor could cause this. ‐ Disagree with her feelings of guilt. ‐ Use therapeutic listening and support. ‐ Talk about the newest technology available for cures. | Notice that the correct response utilizes communication terminology. This is often a clue to the right answer. |
1881 The nurse explains to parents of an infant with an Correct answer: In the child with an atrial septal defect, blood follows the normal pathway from right atrium atrial septal defect (ASD) that, in a healthy heart, the to right ventricle to left atrium. At that point, some of the blood will flow through the atrial blood pathway is right atrium to right ventricle to left septal defect back to the right atrium. atrium to left ventricle. In explaining the altered cardiac blood flow in ASD, the nurse points to what area on the picture shown to indicate the first chamber receiving blood via the abnormal pathway? Click on the correct area on the image. | An atrial septal defect is an acyanotic heart defect. All acyanotic heart defects have either no shunting or left to right shunting, so eliminate the left atrium and ventricle as the first chamber that received abnormal blood flow. Use the word “atrial” to narrow the choice to the right atrium. |
1882 A child has been diagnosed with tetralogy of Fallot Correct answer: 1 Prostaglandin E1 helps maintain a patent ductus arteriosus open and thereby allows for and is taking prostaglandin E1 (Alprostadil). The child is mixing of blood. If the ductus arteriosus closes, cyanosis will increase. The other options very cyanotic, weak, and has moist respirations. Which represent false statements. evaluation would indicate a therapeutic response to this drug? ‐ Cyanosis does not increase ‐ Blood pressure lowers ‐ Respirations increase ‐ Temperature drops | Consider the therapeutic effects of the drug to determine the correct answer. |
1883 The nurse is teaching a class at an outpatient cardiac Correct answer: The pressure is greatest in the left ventricle because that heart chamber must supply blood clinic held for parents of children with congenital throughout the body. The pressure in the other chambers is lower. cardiac defects. Before explaining the movement of blood through septal defects, the nurse tells the parents about pressure gradients in the normal heart. The nurse will indicate on the picture of the heart that the pressure is greatest in which chamber? | Recall that pressure gradients are higher in the ventricles than in the atria. Then recall that the left ventricle has the greatest muscle mass and must push blood throughout the body. |
1884 An infant who has a congenital heart defect comes Correct answer: 3 The hemoglobin molecule carries oxygen. The oxyhemoglobin gives the skin the pink color. In into the clinic with irritability, pallor, and increased the absence of oxyhemoglobin, the skin color darkens. cyanosis that began quickly over the last 30 minutes. As the nurse assesses the infant, the parent asks why the child’s color is bluish. The best response by the nurse is, “The baby’s skin color is: ‐ Caused by a left‐to‐right shunting of blood.” ‐ Associated with liver dysfunction secondary to congestive heart failure.” ‐ Related to hemoglobin level and oxygen saturation.” ‐ Due to poor iron levels in your child’s body.” | Recall that cyanosis is due to unoxygenated hemoglobin. Look at the responses to determine which responses would contribute to unoxygenated hemoglobin. |
1885 A 14‐year‐old child is admitted with a diagnosis of Correct answer: 4 Jones Criteria is a protocol to assist in identifying rheumatic fever. It consists of major “rule out rheumatic fever.” Based on Jones Criteria, symptoms, minor symptoms, and supporting evidence. Erythema, polyarthritis, and elevated the nurse assesses for: ASO titer are among the major and minor symptoms and supporting evidence. ‐ Polyarthritis and dental caries. ‐ Fever, headache, and low red blood cell count. ‐ Chorea, muscle weakness, and decreased erythrocyte sedimentation rate. ‐ Erythema, polyarthritis, and elevated antistreptolysin‐O (ASO) titer. | Recall that the Jones Criteria divides the symptoms of rheumatic fever into major manifestations and minor manifestations based on the frequency seen in the disease. Note that the correct option contains the phrase “strep‐,” which is often associated with the term “rheumatic fever.” |
1886 A toddler with Kawasaki’s disease is ordered to Correct answer: 2 Aspirin therapy is ordered 80 to 100 mg/kg/day until fever drops. Then aspirin is continued at receive aspirin therapy. The nurse anticipates that 10 mg/kg/day until platelet count drops. Aspirin is used as an anti‐pyretic and anti‐ medication therapy with aspirin will follow which agglutination drug. principle? ‐ High doses of aspirin will be given while fever is high. ‐ Length of aspirin therapy is related to child’s response. ‐ Aspirin dose will be increased after fever is gone. ‐ Aspirin dosage is unrelated to platelet count. | The test item requires specific knowledge about the effects of ASA on fever and platelets. |
1887 The nurse has taught the parents of a baby girl who Correct answer: 2 Furosemide (Lasix) is a diuretic given to the client with congestive heart failure to assist the has congestive heart failure (CHF) about drug therapy kidneys in reducing the fluid load in the body. An ineffective heartbeat tends to retain excess with digoxin (Lanoxin) and furosemide (Lasix). The body water. nurse concludes that the parents understand the information presented when one of the parents says, “The Lasix: ‐ Is given to the baby because she has a kidney defect.” ‐ Helps her heart by reducing the amount of water in her system.” ‐ Prevents the Lanoxin from becoming toxic.” ‐ Keeps the potassium levels in her body from getting too high.” | Recall that Lasix is a diuretic that increases urine output. Next determine which option describes increased urine output. |
1888 A 2‐year‐old boy is being discharged home and will Correct answer: 1 Although a child requiring surgery for tetralogy of Fallot may have a need for additional have palliative surgery for tetralogy of Fallot at a later services, such as supplemental oxygen at home, the child should be able to play and move date. The mother wants to know about how much about in the environment to meet both physiological and developmental needs. physical activity she can allow for the child. The nurse’s best answer is: ‐ “Allow him to regulate his activity.” ‐ “Keep him on complete bed rest.” ‐ “Limit his activities to a few hours per day.” ‐ “Keep him from crying.” | During the toddler years the child begins to explore the environment. Considering the activity level of a 2‐year‐old as well as the child’s need for growth and development, eliminate options 2 and 3 as unrealistic. Next eliminate option 4 as being difficult to accomplish and unnecessary. |
1889 After a pediatric client has a cardiac catheterization, Correct answer: 4 Direct pressure on the wound site helps to form a clot and reduce bleeding. Hemorrhage can which intervention would the nurse consider to be of be life‐threatening in the immediate postprocedure period. Food intake is a lesser concern highest priority during the immediate post‐procedure than maintaining hemostasis. Infection would not be apparent immediately following the period? procedure. Signs of congestive heart failure could relate to the original disease process but are not a priority at this time; physiological needs take current priority. ‐ Encourage intake of small amounts of fluid. ‐ Teach the parents signs of congestive heart failure. ‐ Monitor the site for signs of infection. ‐ Apply direct pressure to entry site for 15 minutes. | Options 3 and 4 are the best responses for interventions in the immediate postcatheterization period. Of those two, the highest priority would be preventing bleeding. |
1890 A 6‐month‐old infant is receiving digoxin (Lanoxin) Correct answer: 1, 2 Furosemide is a diuretic, so measurements that most directly illustrate output and water loss and furosemide (Lasix) for congestive heart failure. The would be evaluated. With this in mind, intake and output and daily weight would be key nurse who is evaluating the effectiveness of assessment parameters, as they typically and accurately reflect fluid balance. Hemoglobin level furosemide would monitor which of the following? measures the iron content of red blood cells. The pulse can be influenced by many variables. (Select all that apply.) Partial pressure of oxygen is measured via arterial blood gases and is unrelated to the question. ‐ Intake and output ‐ Daily weight ‐ Hemoglobin and hematocrit levels ‐ Pulse rate ‐ Partial pressure of oxygen | Recall that furosemide promotes urine output, which indicates that intake and output should be measured. In children, one of the best tools to evaluate fluid volume is daily weight. Eliminate the other options because they are not directly linked to fluid status. |
1891 A 2‐year‐old child has a known cardiac defect and is in Correct answer: 3 Signs of digoxin toxicity include bradycardia, cardiac dysrhythmias, nausea, vomiting, congestive heart failure. Which assessment finding anorexia, dizziness, headache, weakness, and fatigue. indicates to the nurse a toxic dose of digoxin? ‐ Tachycardia and dysrhythmia ‐ Headache and diarrhea ‐ Bradycardia and nausea and vomiting ‐ Tinnitus and nuchal rigidity | Knowledge of the toxic effects of digoxin is required to correctly answer this question. Recall that the purpose of digoxin is to slow and strengthen the heart so that it can contract more effectively. Reasoning that toxic effects of a drug are often related to excessive effect of its original purpose, select the option that exhibits a slow heart rate. |
1892 The home health nurse is monitoring the status of a Correct answer: 1 Because of activity intolerance and respiratory distress, the child may be unable to take in child with known cyanotic heart defect. In addition to enough nutrients to meet the body’s need for growth. The child is not at risk for seizures or monitoring cardiac function, the nurse monitors the pain because of this health problem. There is no information in the question to support the child’s other body systems for problems secondary to diagnosis of diversional activity deficit. the heart defect. Which of the following nursing diagnoses should the nurse write on the client care plan? ‐ Imbalanced nutrition, less than body requirements ‐ Risk for injury, seizures ‐ Pain ‐ Diversional activity deficit | Consider each nursing diagnosis as it would relate to the child with low oxygen levels secondary to a cyanotic heart defect. Eliminate option 4 as it is a psychosocial need, not a physiological one. Eliminate options 2 and 3 as unrelated. |
1893 An infant is admitted with an acyanotic heart defect. Correct answer: 2 Children with acyanotic heart defects may have a murmur without other symptoms. Dyspnea Which assessment finding should be discussed with the and tachycardia are early signs of pulmonary edema, which may lead to congestive heart physician? failure. ‐ Heart murmur ‐ Dyspnea ‐ Weight gain ‐ Eupnea | Eliminate all normal findings in a patient with acyanotic heart disease. Weight gain could be a positive growth sign or a sign of impending heart failure. Without additional information, that option is questionable. Dyspnea is a negative finding that should be reported. |
1894 The nurse is caring for an infant with a cyanotic heart Correct answer: 1, 4, 5 Pulmonary overload occurs prior to congestive heart failure. Crackles and frothy secretions defect. Symptoms that would indicate risk for are signs of moist respirations, a symptom of pulmonary overload. Fluid volume excess, congestive heart failure include: (Select all that apply.) secondary to ineffective cardiac function, leads to hepatomegaly and rapid weight gain. ‐ Respiratory crackles and frothy secretions. ‐ Increased blood pressure. ‐ Oxygen saturation increase. ‐ Hepatomegaly. ‐ Rapid weight gain. | The learner needs to remember that symptoms of congestive heart failure arise from impaired cardiac output, pulmonary venous congestion, and systemic venous congestion. |
1895 A child is admitted with a diagnosis of “rule out Correct answer: 1 ASO titers indicate history of streptococcal infection, which is a precursor to rheumatic fever. rheumatic fever.” All of the following symptoms are The other symptoms are not related to this diagnosis. The streptococcus may or may not be present in the child. Which finding supports the present at the time of diagnosis, so the blood culture could be negative or positive and the diagnosis of rheumatic fever? WBC count normal or elevated. ‐ Elevated antistreptolysin‐O (ASO) ‐ Elevated hematocrit ‐ Blood cultures negative ‐ White blood cell count within the normal range. | The ASO titer tests for antibodies produced by the body against an enzyme produced by the streptococcal organism, streptolysin O. If the organism has not been present recently, the test will be negative. |
1896 A child is admitted with possible coarctation of the Correct answer: 4 Blood pressure will be elevated in upper extremities and reduced in lower extremities with aorta. The admitting nurse reviews the medical orders presence of coarctation of aorta. The constriction of the aorta may be progressive. Vital sign for the child and should question which of the assessments provide data related to this progression and should be more frequent than once a following orders? day. ‐ Regular diet ‐ BP of upper and lower extremities q 4 hours ‐ Intake and output ‐ Vital signs on admission, then daily. | Vital signs include blood pressure. One order says on admission and once a day. The other order says blood pressure every 4 hours. These orders are in conflict so one must be wrong. |
1897 A child with tetralogy of Fallot becomes acutely ill Correct answer: 2 The knee‐chest position decreases venous return to the heart and thereby increases systemic with an increase in cyanosis, tachycardia, and vascular resistance, which leads to decreased cardiac output. tachypnea. To relieve the cardiac load, the nurse will: ‐ Place the child in Trendelenburg position. ‐ Place the child in knee‐chest position. ‐ Have oxygen equipment available. ‐ Have suction equipment available. | The key concept is to “relieve cardiac load.” Neither suction nor oxygen will modify cardiac load, so the correct response must have something to do with positioning. Which position will decrease the blood return to the heart? |
1898 A child with a cyanotic heart defect is being Correct answer: 3 Parents need to be prepared for emergencies. Crying for short periods is effective as deep discharged home to await surgical repair. In the breathing exercises. Increased intracranial pressure is not associated with cardiac failure. discharge teaching, the nurse instructs the parents: Monitoring growth and development would not be the primary concern. ‐ To prevent the child from crying at all. ‐ To observe the child for signs of increased intracranial pressure. ‐ In cardio‐pulmonary resuscitation. ‐ To identify growth and development milestones. | Eliminate those responses that do not relate to the heart. Then prioritize the responses that remain. |
1899 A child with rheumatic fever is admitted to the Correct answer: 2 Among the symptoms of rheumatic fever is migratory polyarthritis. The child will complain of nursing unit. The nurse’s most important intervention aching joints. At the time of diagnosis, the child is not infectious. CPR is not a priority at this is to: time because the child is hospitalized. ‐ Prevent spread of rheumatic fever. ‐ Provide comfort from arthralgia. ‐ Evaluate for nervous system complications. ‐ Teach parents about cardiopulmonary resuscitation (CPR). | Consider those responses that relate to rheumatic fever; eliminate options not related to rheumatic fever. Then prioritize the remaining responses, remembering that the stem asks for the most important intervention during hospitalization. |
1900 A child with Kawasaki’s disease is admitted to the Correct answer: 1 Aspirin is ordered as an antipyretic and anti‐clotting agent, while immunoglobulins decrease pediatric unit. Since promotion of comfort is an fever and inflammation. Reducing symptoms of the disease will increase client comfort. The appropriate nursing goal, the nurse: child’s lips are cracked, and soft foods and liquids are comforting. The child will be lethargic, and passive range of motion exercises are utilized to facilitate joint movement. ‐ Administers aspirin and immunoglobulins as ordered. ‐ Splints extremities to prevent contractures. ‐ Keeps child NPO for the first 24 hours. ‐ Encourages a vigorous exercise program. | Consider activities appropriate for the treatment of a child with this condition. Then consider the options that would promote comfort. |
1901 A pediatric client is discharged after an acute phase of Correct answer: 2 The child needs to take prescribed antibiotics indefinitely to prevent future infection and rheumatic fever. The priority discharge instruction possible endocarditis from streptococcal infection. Complete bed rest is not required in the given by the nurse is that the child: recovery period, but the child is maintained with limited activities. Complications of rheumatic fever are cardiac, not CNS. ‐ Is to resume regular activities. ‐ Needs to take antibiotics as ordered. | Options 1 and 3 are opposites but in this case, neither one is accurate. Option 4 is not related to the condition. Therefore, by elimination, the correct answer must be 2. |
‐ Needs to maintain complete bed rest. ‐ Will experience central nervous system (CNS) complications. | |
1902 The nurse is talking with the parents of an infant with Correct answer: The patent ductus is a fetal structure that lies between the aorta and pulmonary artery. In patent ductus arteriosus. The nurse uses the picture fetal life, the ductus allows blood to bypass the lungs. After birth, because of the change in shown to illustrate where the defect occurs. Indicate pressures, oxygenated blood will return to the lungs by the ductus. the spot representing patent ductus arteriosus. | The patent ductus arteriosus lies between the aorta and pulmonary artery. |
1903 The client complains of chest pain after mowing the Correct answer: 3 Angina pectoris is the term for chest pain related to myocardial ischemia (not enough oxygen lawn. This pain is most likely the result of which of the supply to the tissue for the demand). Any activity that increases the need for oxygen without following? an adequate available supply can cause angina. Pain from a pulmonary embolus would be abrupt in onset and not necessarily related to activity. ‐ Pericardial effusion of fluid ‐ Pulmonary edema ‐ Myocardial ischemia ‐ Pulmonary emboli | Associate the symptom of chest pain with lack of oxygen or ischemia. |
1904 The client who has peripheral edema during the day Correct answer: 2 Orthopnea is shortness of breath caused by the movement of fluid back into the vasculature states he wakes up in bed at night with difficulty when the client lies down. He may have beginning signs of congestive heart failure and should breathing. Which of the following is he most likely be checked. Sleep apnea may cause orthopnea but not edema; angina doesn't necessarily experiencing? cause edema either but should be accompanied by chest pain. ‐ Angina pectoris ‐ Orthopnea caused by recumbent position ‐ A sinus infection ‐ Sleep apnea | Recall the definition of orthopnea (difficulty breathing at night when lying flat) to select the correct response. |
1905 The client is experiencing shortness of breath, Correct answer: 2 Left ventricular failure causes pulmonary congestion and increased pressure in the lungs, productive cough, tachycardia, and orthopnea. The which leads to tachycardia. Remember Left and Lung—the two Ls go together; two of the nurse concludes that these are frequently noted as symptoms deal with respiratory symptoms and none of the other answers are related to a signs and symptoms of: diagnosis affecting the lungs. ‐ Hypertension (HTN). ‐ Left ventricular failure. ‐ Coronary artery disease (CAD). ‐ Peripheral vascular disease. | Eliminate options 1 and 4 because the symptoms described are not typical of these diagnoses. Angina would be more likely with CAD. |
1906 The client has S‐T segment depression on his 12‐lead Correct answer: 3 Depressed S‐T segments and inverted T waves represent myocardial ischemia. Injury usually electrocardiogram (ECG). The nurse determines that has an S‐T segment elevation. this would be indicative of: ‐ Necrosis. ‐ Injury. ‐ Ischemia. ‐ Nothing significant. | Look for an option of ischemia with S‐T depression and inversion. |
1907 The early stage of left ventricular failure would most Correct answer: 3 Left ventricular failure results in inability to empty the pulmonary vascular system leading to likely result in which of the following changes in the increased pulmonary pressures. client? ‐ Right ventricular failure ‐ Diminished left atrial pressures ‐ Higher pulmonary pressures | Recall that the blood entering the left side of the heart comes from the pulmonary system. Failure of the ventricle to pump efficiently would increase pulmonary pressure. |
4.‐ Low pulmonary pressure | |
1908 A client on a telemetry monitor has a heart rate of 54 Correct answer: 4 Bradycardia decreases the myocardium’s demand for oxygen by decreasing workload of the bpm. The nurse knows that this rate would probably heart. Heart rates less than 60 bpm are considered bradycardia. However, if the heart rate is not increase oxygen demand for the myocardium, but too low, blood supply is decreased and oxygen supply may be hindered. the rate is indicative of: ‐ Tachycardia. ‐ Ventricular hypertrophy. ‐ Hypertension. ‐ Bradycardia. | Use the definition of the term bradycardia to select the correct response. |
1909 The client demonstrates significant Q waves on the Correct answer: 4 Infarction (heart attack) is the term for tissue that has been deprived of oxygen until the cells electrocardiogram (ECG). The nurse should notify the have died. Immediate attention should be given to the client who has just had a myocardial physician because this is indicative of: infarction (MI), which is noted by Q waves on an ECG. ‐ Gangrene. ‐ Ischemia. ‐ Infection. ‐ Infarction. | Omit options 1 and 3 as they are not generally associated with ECG changes. Eliminate option 2 as ischemia is associates with S‐T changes. |
1910 The client in the Emergency Department was Correct answer: 1 Occlusion of a coronary artery blocks the blood flow and prevents oxygen from getting to the diagnosed with acute myocardial infarction (MI). He myocardium. Option 2 indicates ischemia; option 3 could be bradycardia or a block; option 4 asks the nurse to explain what this is. The nurse should could be hypertrophy. tell him that an MI usually results from which of the following? ‐ Obstruction of a coronary artery with death of tissue distal to the blockage ‐ Spasm of a coronary artery causing temporary decreased blood supply ‐ A slow heart rate leading to decreased blood supply to myocardium ‐ Dilation of the ventricular wall causing decreased blood supply | The scenario states that the client had an infarction. Recognize that only option 1 refers to tissue death or infarction. |
1911 The nurse teaching the client about behavioral Correct answer: 1 Hyperlipidemia (option 2), cigarette smoking (option 3), and lifestyle (option 4) can be changes, which can affect development of changed by modifying behaviors. These risk factors should be stressed and plans made for how atherosclerosis, should discuss which of the following to change them. as a nonmodifiable risk factor for atherosclerosis? ‐ Female over 55 years of age ‐ Hyperlipidemia ‐ Cigarette smoking ‐ Sedentary lifestyle and obesity | Identify the option that describes characteristics that cannot be changed. |
1912 The client is in the clinic for a follow‐up visit following Correct answer: 4 NTG can be taken as a preventive measure prior to activities that trigger angina. This is new onset of stable angina. The nurse should teach the especially helpful with sexual activity or work‐related activities that may need to be continued. client precipitating causes of angina such as exercise Modifying such activities may be necessary, but cardiac clients should not become restricted and stress. Which of the following should also be by their condition and lead sedentary lifestyles. taught as a way to handle these precipitating causes? ‐ Avoid these activities. ‐ Perform such activities anyway. ‐ Lead a sedentary lifestyle. ‐ Use a nitroglycerin (NTG) tablet before the activity. | The question asks for a method of handling the precipitating event. Option 4 is the only option that provides a way of preventing the angina associated with exercise and stress. |
1913 A client is at the local health clinic and the nurse takes Correct answer: 3 Systolic hypertension over 150 mmHg may occur after the use of over‐the‐counter (OTC) cold and records a systolic blood pressure of greater than remedies. A warning is placed on OTC medications, cautioning clients with hypertension to 160 mmHg. The nurse tells the client that it could be consult a physician first. Renal diseases contribute to hypertension, and salt causes fluid caused by: volume retention, which increases the blood pressure. Increases in the electrical activity of the heart will cause a variety of arrhythmias, not systolic hypertension (option 1). The failure of the elastic tissue is frequently seen in the skin of the elderly and side effects of antihypertensives would most likely cause systolic hypotension (option 2). Anaphylactic shock or an increased electrical activity of the heart would cause a state of systolic hypotension (option 4). ‐ An increase in the electrical activity, causing hypertrophy of the left ventricle. ‐ Failure of the elastic tissue or the side effects of hypertension medications. ‐ Use of over‐the‐counter medications, renal stenosis, or increased ingestion of salt. ‐ Anaphylactic shock or increased electrical activity of the heart causing hypertrophy of the heart muscle. | Recognize that the words “stenosis” and “increased ingestion of salt” are both associated with increased blood pressure. |
1914 The nurse should assess the client's pulse and blood Correct answer: 2 When administering propranolol (Inderal), the client's apical pulse and blood pressure must pressure as part of the administration of which of the be assessed. Propranolol is a beta blocker used to treat hypertension and tachycardia. The following drugs? drug should not be given if the apical pulse is below 60 beats per minute (bpm), if there has been a significant drop in the blood pressure, or if the systolic pressure is below 100 mm Hg. Side effects include bradycardia, congestive heart failure, pulmonary edema, hypotension and edema, depression, memory loss, insomnia, drowsiness, and dizziness. Clonidine (Catapres) is an alpha blocker prescribed to control mild to moderate hypertension. Side effects are drowsiness, nightmares, nervousness, depression, hypotension, and bradycardia. Sulfinpyrazone (Anturane) is a medication used to manage long‐term gout, while calcitonin (Calcimar) is used in the treatment of Paget's disease by decreasing the rate of bone destruction (option 1). Glucagon (GlucaGen) is a specific medication for the management of hypoglycemia when glucose is not appropriate (option 3). Hydroxyzine (Vistaril) is used in the treatment of anxiety, pruritus caused by allergies, psychiatric and emotional emergencies, nausea and vomiting (excluding the nausea and vomiting of pregnancy), as a preoperative and postoperative sedation, and as a prepartum and postpartum adjunct therapy (option 4). ‐ Sulfinpyrazone (Anturane) and calcitonin (Calcimar) ‐ Propranolol (Inderal) and clonidine (Catapres) ‐ Glucagon (GlucaGen) and pyridostigmine bromide (Regonol) ‐ Hydroxyzine (Vistaril) and prazosin hydrochloride (Minipress) | Select the option in which both medications require the monitoring. |
1915 The nurse should discuss which of the following as Correct answer: 4 Family history and age cannot be modified as risk factors in any form of hypertension. Current non‐modifiable risk factors influencing hypertension? research suggests there are several genes influencing the development of hypertension. Ethnicity is a non‐modifiable risk factor; however, stress can be modified if the interruption of the stressor is undertaken (option 1). Obesity and substance abuse are risk factors that may be managed through behavioral modification and support groups (option 2). Nutrition and occupation are both modifiable with assistance (option 3). ‐ Ethnicity and stress ‐ Obesity and substance abuse ‐ Nutrition and occupation ‐ Family history and age | Select the option in which both items in the pair are non‐modifiable. |
1916 In the process of a physical examination of an adult Correct answer: 2 Blood pressure readings from three different positions are helpful in ruling out the presence client with a possible diagnosis of hypertension, the of hypertension. The difference between each of these readings should be less than 5 mmHg. If nurse should gather data through the use of which the reading difference is higher, repeat readings should be within the follow‐up plan for this method? client. Options 1, 3, and 4 will not provide enough data to determine if a problem exists. ‐ Blood pressure from one arm only | Select the option that would provide the most data. Orthostatic readings are performed in the lying, sitting, and standing positions. |
‐ Orthostatic blood pressure with 2 minutes between each reading ‐ Blood pressure from both arms taken 5 minutes apart ‐ Cuff and doppler blood pressure in both arms | |
1917 Priority teaching for a client with Buerger's disease Correct answer: 4 Smoking is the primary etiological factor identified with clients diagnosed with Buerger's would include which of the following? disease. Emphasis should be placed on cessation of smoking, use of nicotine (Nicoderm) patches, and support groups. Option 1 is usually required with clients with Raynaud's disease, although clients with Buerger's should protect the extremities from cold injury as well. Clients with Buerger's disease should wear comfortable shoes that will not cause blisters or sores, but they do not necessarily have to be flat (option 2). Although pain is present, the use of opioids is usually not indicated (option 3). ‐ Wear gloves if the extremities are cold and painful. ‐ Avoid wearing flat‐heeled shoes. ‐ Report severe pain that may require analgesics. ‐ Cessation of smoking | Recall the association of smoking with Buerger’s disease to lead to selection of the correct option. |
1918 One of the largest concerns with the hypertensive Correct answer: 3 Frequently, clients perceive and become helpless when confronted with multiple lifestyle client is non‐adherence to the care regimen. changes. The healthcare team and the client need to determine the most significant lifestyle Noncompliance is most likely influenced by which of modification needed and begin to work with this one. The other modifications are started as the following factors? the client is able to incorporate them. The major focus is to establish and maintain a partnership with this client. Many times the therapeutic action of the medication will not cause the client to feel or perceive any difference in their well‐being (option 1); however, client education can help to enlighten a client about the need for lifelong therapy. Option 4 may or may not be true for some clients, and option 2 is not a plausible response by healthcare workers. ‐ Medications are not working as indicated by the client statement, "I don't feel any different." ‐ A health professional reportedly stating, "Take it easy and stop worrying about taking those medications." ‐ The many lifestyle changes needed in diet, exercise, and smoking patterns seem overwhelming. ‐ The client has a lack of support persons to assist the client with different therapies. | Note that the words “lifestyle changes” in option 3 help to identify it as the correct option. |
1919 Which of the following clients has the greatest risk of Correct answer: 2 Cardiac diseases such as congestive heart failure, myocardial infarction, and cardiomyopathy developing a thromboembolism? are conditions that coexist with thromboembolism. Each of these conditions creates the possibility of thrombus occurring because of ineffective emptying of the heart during its pumping action. Thromboembolism generally occurs in clients over the age of 40. Gender usually does not play a role in embolism; a male who is Jewish and over the age of 40 is more prone to Buerger's disease (option 3). Kidney disease has not been identified as a cause of emboli (option 4). ‐ A 20‐year‐old client ‐ A client with a cardiac disease ‐ A female client who is Jewish ‐ A client with known kidney disease | Recognize that only option 2 refers to a specific condition related to thromboembolism formation. |
1920 The nursing management for a client with Correct answer: 1 Part of the medical regime will include anticoagulant therapy. The rationale for this is to thrombophlebitis would include: prevent the development or extension of thrombi by inhibiting the synthesis of the clotting factors or through deactivation of the mechanism. The client's legs need to remain in an elevated position for comfort and to facilitate venous circulation to prevent the development of emboli and thrombi in the lower extremities (option 2). Low molecular weight heparin (LMWH) is usually used as a preventative agent in clients prone to thrombophlebitis, not as a treatment with a confirmed diagnosis (option 3). The treatment is usually to raise the foot of the bed 6 inches off the floor (Trendelenburg's position). The knee level needs to remain in this position 24 hours per day until the healthcare team considers the need for elevation of the legs no longer exists (option 4). The head of the bed may be elevated for activities such as eating and bathing. ‐ The use of anticoagulant therapy to inhibit the clotting factors. ‐ Keeping the client's legs in a position of comfort. ‐ Using low molecular weight heparin (LMWH) once a confirmed diagnosis exists. ‐ Elevating the head of the bed 6 inches on wooden blocks. | Omit options 2 and 4 as being vague and non‐specific. Omit option 3 as being a prophylactic measure, not a treatment. |
1921 An elderly gentleman enters the Emergency Correct answer: 2 The symptoms exhibited by the client are typical of an abdominal aortic aneurysm. The most Department with complaints of back pain and feeling significant sign is the audible pulse in the abdominal area. If hemorrhage were present, the fatigued. Upon examination, his blood pressure is abdomen would be tender and firm. There isn't enough information to determine if the 200/110, pulse is 120, and hematocrit and hemoglobin hypertension is secondary or essential (option 1). There is no evidence of congestive heart are both low. The nurse palpates the abdomen which failure (CHF) in the scenario (option 3). Signs of Buerger's disease involve the extremities is soft, non‐tender, and ausculates an abdominal pulse. (option 4). The most likely diagnosis is: ‐ Secondary hypertension. ‐ Aneurysm. ‐ Congestive heart failure (CHF). ‐ Buerger's disease. | The identification of an audible abdominal pulse should lead to the correct option. |
1922 When caring for a client with Raynaud's disease, Correct answer: 1 The major task of the healthcare team is to medicate the client with drugs that produce which of the following outcomes concerning smooth muscle relaxation, which will decrease the vasospasm and increase the arterial flow to medication regimen is of highest priority? the affected part. The drugs used are calcium antagonists. Frequently, the client will be medicated during the cool to cold months when vasoconstriction is a physiological response to the environmental temperature. Options 2 and 3 are a concern, but the highest priority is reducing spasms. If the medicines work, pain will be reduced and blood flow maintained (thus lesions prevented). Raynaud's disease does not usually cause major disabilities (option 4). A client may develop gangrene of the skin of the tips of the digits, but these are in the upper extremities (option 3). ‐ Relaxing smooth muscle to avoid vasospasms ‐ Controlling the pain once vasospasms occur ‐ Avoiding lesions on the feet ‐ Preventing major disabilities that may occur | Omit options 3 and 4 as this disease affects the hands and does not generally cause disability. Prevention of spasms is the priority of care. |
1923 The client on a telemetry unit exhibits regular ECG Correct answer: 1 Depolarization of the myocardium results in contraction (systole) and that produces the complexes of normal duration and a heart rate of 82 palpable pulse and the corresponding QRS complex on the electrocardiogram. bpm. The nurse assesses the client and notes that for each complex there is a corresponding palpable pulse. The nurse knows that for each pulse to be palpable what had to occur? ‐ Ventricular contraction ‐ Ventricular relaxation | Omit options 3 and 4 as having no pulse. Recall that contraction produces the pulse. |
‐ Fibrillation ‐ Cardiac standstill (asystole) | |
1924 The client arrives in the Emergency Department with Correct answer: 2 Stimulation of the SNS increases heart rate and respiratory rate. Remember "fight‐or‐flight" a heart rate of 130 bpm. The client appears anxious syndrome is a response by the SNS that increases heart rate. and is tachypneic. What part of the central nervous system is most likely responsible for this increased heart rate? ‐ Parasympathetic nervous system (PSNS) ‐ Sympathetic nervous system (SNS) ‐ Acetylcholine‐cholinesterase feedback ‐ Vagus nerve | Eliminate options 3 and 4 as they are not part of the central nervous system (CNS). Increased pulse and respiratory rate is a sympathetic response. |
1925 The client appears in the Emergency Department with Correct answer: 1 Right‐sided heart failure leads to backward venous congestion, resulting in jugular vein distended neck veins, a large, round abdomen, distention, portal hypertension, and abdominal venous congestion resulting in ascites. palpable liver edges, and peripheral edema. These Remember Right means Rest of the body, whereas Left means Lung in identifying where fluids signs are suggestive of which of the following? stagnate. ‐ Congestive heart failure (CHF) ‐ Acute liver dysfunction ‐ Chronic liver disease ‐ Restrictive lung disease | Focus on the distension of neck veins, which combined with the other symptoms is typical with CHF. |
1926 A client with chest pain is given nitroglycerin (NTG) Correct answer: 4 The client does need another NTG if the chest pain is still present; however, a BP should be 1/150 sublingual for complaint of angina pectoris. Prior assessed first. If the systolic is greater than 100, another NTG can be given. If the systolic is less to the NTG, his blood pressure was 110/78. After 5 than 100, the physician should be consulted. Morphine sulfate is often given in this case. minutes, he says the chest pain is better but not gone. The nurse should first: ‐ Give another NTG. ‐ Check the pulse rate. ‐ Give morphine sulfate instead of NTG. ‐ Check the blood pressure (BP). | Note that the BP is mentioned in the scenario, giving a clue for the need to assess the BP before NTG is administered. |
1927 A client with congestive heart failure has digoxin Correct answer: 4 The Lanoxin should be held for a pulse rate less than 60 bpm. Nurses cannot arbitrarily give (Lanoxin) ordered every day. Prior to giving the half of a dose without a physician's order. Unless specific parameters are given concerning medicine, the nurse checks the digoxin level that is pulse rate, most resources identify 60 as the reference pulse. therapeutic and auscultates an apical pulse. The apical pulse is 62 bpm for 1 minute. The nurse should: ‐ Hold the Lanoxin. ‐ Give half the dose now, wait an hour, and then give the other half. ‐ Call the physician. ‐ Give the Lanoxin as ordered. | The mention of a therapeutic level and a pulse in an acceptable range will help to identify option 4 as the correct response. |
1928 Which of the following clients is at high risk for Correct answer: 2 Family history is a nonmodifiable risk factor. Although diet and exercise should be developing coronary artery disease (CAD) that may not encouraged, this may not be sufficient to lower cholesterol and prevent CAD. be responsive to diet and exercise alone? A client who: ‐ Has diabetes. ‐ Has a strong family history of cardiovascular disease. ‐ Is overweight and 55 years old. ‐ Had a stroke at age 40. | Select the option that implies a genetic component. |
1929 The client presents to the Emergency Department Correct answer: 4 The inner layer of the heart is referred to as the endocardium. with substernal chest pain and is diagnosed with a subendocardial infarction. The client asks the nurse what that means. The nurse should tell him that the damage is: ‐ On the anterior wall of the left ventricle. ‐ On the posterior wall of the left ventricle. ‐ Involving the full thickness of the wall. ‐ Involving the inner layer of the heart. | Use the prefix “sub” as the clue to the correct answer. |
1930 The client is admitted to the coronary care unit with a Correct answer: 4 Left ventricular failure leads to pulmonary congestion. When the left side cannot pump the diagnosis of left‐sided heart failure. When listening to blood out adequately, congestion occurs in the lungs where the blood backs up from the left the lung sounds, the nurse hears crackles bilaterally. ventricle. The nurse anticipates this because left ventricular failure leads to: ‐ Increased coronary artery perfusion. ‐ Pulmonary emboli. ‐ Increased peripheral resistance. ‐ Pulmonary congestion. | Eliminate options 1 and 3 as not being associated with crackles in the lung fields. Pulmonary congestion is likely associated with left ventricular failure. |
1931 The client with a diagnosis of anterior myocardial Correct answer: 2 The ischemia that causes the MI can also cause the heart muscle to become irritable and infarction (MI) begins to show dysrhythmias on the irritated cells fire early, causing dysrhythmias. Although options 3 and 4 are true, nothing in monitor. Which of the following most likely the stem indicates that these are specific to this client. Acidosis is usually the shift with MI, if predisposes to dysrhythmia development with a one occurs. myocardial infarction? ‐ Respiratory alkalosis ‐ Tissue ischemia ‐ Hypokalemia ‐ Digitalis toxicity | Note that myocardial infarction is the only diagnosis mentioned in the stem. Tissue ischemia is associated with MI. |
1932 The client is being discharged from the hospital and Correct answer: 3 A low‐fat, low‐sodium diet aids in the reduction of cholesterol and/or triglycerides that could needs discharge teaching. Some important measures have caused the MI. A client who has had an MI should not participate in heavy exercise; a the nurse should teach the client to prevent moderate exercise program with daily walking would be sufficient. Anticoagulant therapy with reinfarction following a myocardial infarction (MI) aspirin, not thrombolytics, may be recommended, and clients with an MI should stop smoking would include: completely. ‐ Thrombolytic therapy. ‐ Heavy exercise such as high‐intensity aerobics. ‐ Low‐fat, low‐sodium diet. ‐ Reduction in cigarette smoking. | This is addressing discharge teaching which often focuses on positive life‐style changes. |
1933 In teaching a group of middle‐aged men concerned Correct answer: 1 The healthcare provider must be sure that the client is aware of the need to eat sufficient about hypertension, the nurse should emphasize which amounts of calcium, magnesium, and potassium. Foods high in magnesium are green, leafy of the following? vegetables; seafood; wheat bran; milk; legumes; bananas; oranges; grapefruit; and chocolate. Foods high in calcium are milk, cottage cheese, cheese, yogurt, rhubarb, broccoli, collard greens, spinach, tofu, canned sardines, and salmon. Potassium‐rich foods are fruits and fruit juices, vegetables and vegetable juices, meats, and milk products. These food products are best if they are fresh and not processed. The consumption of alcohol is limited to 1 ounce per day; however, with some anti‐hypertensive medications, the recommendation is the client not consume any alcohol (option 2). Jogging is a good activity in moderation, i.e., 1 mile per week (option 3). Herbal therapies containing licorice cannot be safely used by a hypertensive client. Licorice causes the blood pressure to rise (option 4). ‐ Adequate intake of dietary calcium, magnesium, and potassium ‐ Alcohol consumption should not exceed 5 ounces per day ‐ Jogging 3 miles per day ‐ Use of herbal therapy containing licorice | Select the option that teaches a positive lifestyle change that is reasonable for all members of the group. |
1934 Secondary hypertension (HTN) is an elevated blood Correct answer: 3 By definition, secondary hypertension has some underlying cause. Approximately 10 percent pressure caused by a number of underlying of all pregnant women develop this condition. The criteria are that the systolic blood pressure physiological processes. Which of the following rises 30 mmHg and the diastolic blood pressure rises 15 mmHg prior to the 20th week of statements about secondary HTN is correct? gestation. Diagnostic tests are conducted to confirm the diagnosis and rule out polycythemia, hyperaldosteronism, and pheochromocytoma. The systematic long‐term use of contraceptives containing estrogen may contribute to secondary hypertension (option 1). Coarctation of the aorta is rare; when it occurs, it interferes with the renal blood flow, which stimulates the renin‐ angiotension‐aldosterone system of the kidney (option 2). Endocrine disorders and hypertension are rare and involve the adrenal medullary system (option 4). ‐ A nonsystematic, short‐term use of contraceptives containing estrogen can cause HTN. ‐ Coarctation of the aorta has little to no relationship with the renin‐angiotension‐aldosterone system of the kidney. ‐ Hypertension in pregnancy is a frequent cause for maternal and fetal morbidity and mortality. ‐ Hypertension with an endocrine disorder accounts for a large population of clients. | Eliminate option 1 due to the qualifier “short‐term,” and option 4 as it refers to a “large population” which makes the statement untrue. Option 3 is the only true statement. |
1935 The pathophysiology of hypertension is related to Correct answer: 2 One of the factors that regulates blood pressure is the amount of fluid volume within the which of the following monitoring systems? body system. Excess concentration of sodium and water increases the blood pressure and the pressure in the kidney filtration, resulting in diuresis. The baroreceptors respond to the activity of the receptors as well as pressure and chemical composition within the vascular system. Arterial receptors are also involved (option 1). The endocrine system is usually not involved (option 3). Hypertension causes an increased production of sodium and water releasing hormone (option 4). ‐ Baroreceptors only ‐ Regulation of the amount of body fluid volume ‐ Endocrine system ‐ Underproduction of sodium‐retaining substances | Select the option that is clearly associated with hypertension, regulation of body fluids. |
1936 Laboratory tests are usually ordered to complete the Correct answer: 4 These laboratory studies would be the most helpful and give an estimate of the degree of assessment of the client with hypertension (HTN). vascular involvement as well as the degree of damage. An elevated cholesterol level would Which laboratory values are essential in the diagnosis? suggest HTN related to atherosclerosis. Creatinine is the most specific test of kidney function (a cause of HTN) and is not affected by foods as is the blood urea nitrogen (BUN). A hematocrit will be helpful in determining fluid problems, which could account for HTN also. Bone scan (option 1), glucose tolerance (option 2), and prothrombin time (option 3) are not essential tests for diagnosing HTN. | Select the option in which all items in the string would be included in the assessment of hypertension. |
‐ Serum sodium, serum potassium, and a bone density scan. ‐ Hemoglobin, hematocrit, and a glucose tolerance test. ‐ Stress test, prothrombin time, and urine analysis. ‐ Serum cholesterol, complete blood count, and serum creatinine. | |
1937 The nurse would identify which of the following Correct answer: 2 An overweight client on bed rest from a hip surgery is at higher risk because of the two risk clients to be at high risk for thrombophlebitis? factors (obesity and immobility). Even though the client will be ambulated and progressively increase weight‐bearing, the potential exists because of the immobility. HTN does not increase the risk, nor does smoking (option 1). Raynaud's is not a factor (option 3); option 4 is vague about the cardiac history and further information is needed. ‐ 25‐year‐old male who is a smoker with hypertension ‐ 67‐year‐old overweight female recovering from a hip replacement (1st day post‐op) ‐ 22‐year‐old female with a history of Raynaud's disease in the family ‐ 72‐year‐old male with a history of arthritis and bypass surgery | Recall that thrombophlebitis is a common postoperative complication, particularly with overweight clients and with joint surgery. |
1938 A male client is seen in the clinic complaining of pain Correct answer: 4 These are signs and symptoms of PVD; the diagnosis is supported by the pallor noted when when he tries to walk in order to exercise three times the feet are elevated for 30 minutes. The pulse is diminished because it is arterial occlusion a week. Upon examination, his feet are noted to be and not venous. Pain and itching are usually felt with varicose veins (option 1). dusky and purplish while dangling from the stretcher. Thrombophlebitis is associated with redness, warmth, and swelling of an extremity (option 2). The pedal pulse is palpable but diminished, and he Raynaud's is more involved with the digits of both the hands and feet (option 3). states his feet "tingle on occasion." The nurse has him lie supine on the stretcher with the foot of the stretcher elevated for about 30 minutes, after which his feet show pallor. The client is probably suffering from: ‐ Varicose veins. ‐ Thrombophlebitis. ‐ Raynaud's disease. ‐ Peripheral vascular disease (PVD). | Omit option 3 as Raynaud’s affects the fingers. The color and tingling are the symptoms that should lead to the correct response of PVD. |
1939 The client with intermittent claudication is at risk for Correct answer: 2 Whenever there is tissue breakdown associated with intermittent claudication, the client will activity intolerance and possible tissue breakdown. If be confined to bed in order to be able to meet the oxygen requirements for the damaged tissue breakdown occurs, the plan of care would tissues. Activity (options 1, 3, and 4) raises the amount of oxygen required to sustain both consist of: healthy and diseased tissues to a point where deficits will occur and healing will be stalled. At the time the client is to be ambulated, the shoe of choice is a supportive, comfortable shoe. ‐ Limited exercise. ‐ Bed rest. ‐ Range of motion exercises. ‐ Walking in comfortable light slippers. | Select the option that differs from the others, which all refer to some sort of exercise. |
1940 The most common cause of a thrombus is: Correct answer: 3 These are known as Virchow's triad and are the most commonly associated reasons for a blood clot. A thrombus usually involves the venous, not arterial, system (option 1). Situations that contribute to venous stasis are myocardial infarction and prolonged sitting; however, a stroke is not classified in this manner (option 2). Injury may or may not cause thrombi, while continued bed rest can contribute (option 4). ‐ Arterial stasis, hypocoagulability, and arterial wall injury. ‐ Myocardial infarction, stroke, and prolonged sitting. ‐ Venous stasis, hypercoagulability, and venous wall injury. ‐ Motor vehicle accident and prolonged bed rest. | Omit options 2 and 4 which list conditions that may increase risk, but not the common cause. All items in the string must be correct. <u>Hypo</u>coagulability would not contribute to thrombus formation. |
1941 Assessment of a client with possible thrombophlebitis Correct answer: 2 Pain felt in the calf while pulling up on the toes is abnormal and indicates a positive test. If the to the left leg and a deep vein thrombosis is done by client feels nothing or just feels like the calf muscle is stretching, it is considered negative pulling up on the toes while gently holding down on (option 3). A tourniquet test (options 1 and 4) is used to measure for varicose veins. the knee. The client complains of extreme pain in the calf. This should be documented as: ‐ Positive tourniquet test. ‐ Positive Homan's sign. ‐ Negative Homan's sign. ‐ Negative tourniquet test. | Eliminate options 1 and 4, while identifying the options with Homan’s sign as the assessment for thrombophlebitis. Recall that pain indicates a positive response. |
1942 Effective teaching for a client with Raynaud's disease Correct answer: 3 A client with Raynaud's disease needs to be taught to protect the digits from extreme cold by is evident in which of the following statements? “I using warm clothing, gloves, and socks. Use of gloves is essential any time the digits may be will:” cold (such as at night). Smoking should be stopped completely (option 1). Relaxation and stress management are essential (option 2). Diet is not associated with Raynaud's disease (option 4). ‐ "Decrease my smoking to 6 cigarettes per day." ‐ "Try to learn to relax, but I can't promise anything." ‐ "Wear gloves and socks to bed at night." ‐ "Try to eat a healthier diet." | Recognize that “gloves and socks” in option 3 lead to the correct answer as clients with Raynaud’s are taught to protect distal extremities. |
1943 The client admitted for an acute myocardial infarction Correct answer: 2 Decreased workload of the myocardium leads to decreased oxygen demand. Rest periods (MI) is getting ready for discharge. The client is anxious allow the demand to equal the supply. Although a slower heart rate can decrease workload to go home. He states, "I have so much work to do and oxygen demand, rest does not necessarily lower the heart rate. Option 3 is indicated for around the house." The nurse instructs the client on hypertension, and option 4 is indicated for congestive heart failure. the need for rest periods, especially if he begins to feel chest discomfort. The rationale for rest in the treatment of acute myocardial infarction is to: ‐ Decrease the heart rate. ‐ Reduce the workload of the heart. ‐ Decrease the peripheral vascular resistance. ‐ Improve the stroke volume. | Focus on the term “workload” to assist in identification of the correct response. This is a goal of care in the post MI client. |
1944 The client was admitted with right‐sided congestive Correct answer: 4 Marked rales, rhonchi, S<sub>3</sub> heart sounds, and frothy sputum heart failure and treated with diuretics, and his edema (frequently pink from being blood‐tinged) are classic pulmonary edema characteristics. cleared quickly on the second day. He was given a Corticosteroids are used in situations like this, but remember that a side effect is congestive round of steroids to help because he had no appetite heart failure. and was extremely fatigued. On day 3, he has a relatively normal head‐to‐toe assessment at 8:00 A.M. when the nurse makes rounds. Around 10:00 A.M., the nurse aide reports the client is having trouble breathing and his respirations are 42 and labored. The nurse assesses his condition and finds that he has marked rales and rhonchi; an S<sub>3</sub> heart sound; and frothy, pink sputum. The nurse suspects: ‐ Return of right‐sided heart failure. ‐ Development of mild left‐sided heart failure. ‐ Tamponade. ‐ Pulmonary edema. | Recall that frothy, pink sputum is associated with pulmonary edema. |
1945 The client presenting with angina pain in the Correct answer: 4 Angina pectoris is pain related to insufficient oxygen supply to meet the workload demands of Emergency Department states, "I thought I was having the heart. If the workload demand is decreased (as in rest), the pain goes away. Option 1 may a heart attack." Which response by the nurse would be correct but is not usually the case; option 2 is incorrect. In option 3, a CPK‐MB level provide the client with the most accurate information indicates the amount of muscle damage. about the difference between the pain of angina and that of myocardial infarction? ‐ "The pain associated with angina is much more intense than that of a heart attack." ‐ "The pain associated with a heart attack radiates up the jaw and that of angina radiates down the arm." ‐ "The intensity of pain with a heart attack indicates the amount of muscle damage." ‐ "The pain of angina is usually relieved by resting or lying down." | Look for methods of relieving the pain identified in the options. Pain relief with rest is key in differentiating MI from angina. |
1946 The echocardiogram report on a client states that the Correct answer: 1 Increased pressure needed to push the blood through the stenotic valve causes the left client has dilation and hypertrophy of the left atrium. ventricle to enlarge in order to become stronger and bigger to accommodate the increased The nurse knows these are the initial compensatory blood volume and the higher pressure needed. responses in: ‐ Mitral stenosis. ‐ Aortic stenosis. ‐ Tricuspid stenosis. ‐ Acute rheumatic fever. | Use knowledge of anatomy to note that the mitral valve is on the left side of the heart. |
1947 The client was admitted with a diagnosis of right Correct answer: 3 Rales and rhonchi are not characteristic of right heart failure (RHF). All the others are classic ventricular failure. If the client's condition were to signs and symptoms. If the client entered with RHF and develops left heart failure (LHF), worsen and go into biventricular failure, which of pulmonary complications would develop. these symptoms would the nurse expect to find? ‐ Decreased urine output ‐ Jugular neck vein distention ‐ Rales and rhonchi ‐ 3+ pitting edema in the legs | Recall that <u>left</u> heart failure leads to <u>lung</u> symptoms. |
1948 The client is being discharged after a two‐day hospital Correct answer: 4 Angina is the result of decreased supply of oxygen to meet the demands of increased stay following admission for new‐onset angina. An workload of the heart. Rest decreases the workload and therefore the oxygen supply is angiogram revealed a 90% blockage, which was sufficient. This client could have had an anterior wall myocardial infarct of the left ventricle successfully opened by percutaneous transluminal because of the location of the blockage in the picture. Since the left ventricle is the "power" of coronary angioplasty (PTCA). The client asks the nurse the heart, an adequate supply of oxygenated blood flow is needed at all times. why rest is important when the chest pain begins. The nurse should tell the client that: ‐ The coronary blood vessels dilate at rest. ‐ Venous return to the heart is increased in the seated or supine position. ‐ Coronary blood flow is improved because of an increase in blood pressure. ‐ The coronary circulation adequately meets the metabolic needs at rest. | Recall that lack of oxygen is the cause of pain. Select the response that addresses metabolic needs. |
1949 A compensatory mechanism for congestive heart Correct answer: 3 The law states that the more stretch of the muscles the better the contraction force until the failure in the initial phase that improves cardiac output muscle is stretched out and can no longer contract sufficiently to move the blood through the is: circulation. Initially, this improves cardiac output. Option 1 is helpful in hypotension; Option 2 explains contraction with each heartbeat; option 4 is the pathophysiology behind hypertension. ‐ The renin‐angiotensin‐aldosterone system. ‐ An action potential. ‐ The Frank‐Starling's law. | Eliminate options 1, 2, and 3 as not being directly related to CHF. |
4.‐ Increasing peripheral vascular resistance. | |
1950 In congestive heart failure (CHF), the goal is to Correct answer: 2 Afterload is the force or resistance that the left ventricle must pump against the impedance decrease workload, increase contractility, and to the flow of the blood. By decreasing afterload in CHF, a pump that is already inefficient has decrease afterload. Which of the following is the best to work less to be effective. definition of afterload? ‐ The volume of blood remaining in the left ventricle after systole ‐ The impedance to ejection of blood from the left ventricle ‐ The amount of force of ventricular contraction ‐ The measurement of left ventricular end‐diastolic pressure | Omit options 1 and 4 as they do not relate to afterload. Omit option 3 as it talks about force of contraction. |
1951 The client is being discharged from the hospital and Correct answer: 4 Congestive heart failure is the inability of the heart to pump adequate blood to meet the asks the nurse to explain to him what congestive heart oxygen and nutritional needs of the tissue. Think of CHF as a "pooped‐out" pump. failure (CHF) really is. The nurse's best response would be that CHF is: ‐ Circulatory congestion resulting from extracellular fluid volume excess. ‐ Inadequate myocardial function due to damage of the cardiac muscle. ‐ Circulatory congestion resulting from heart failure and its compensatory mechanisms. ‐ Cardiac output insufficient to supply the metabolic needs of the peripheral tissues caused by an inefficient pump. | Focus on the response that identifies “inefficient pump” as the cause of CHF. |
1952 A client is due to receive a calcium channel blocker Correct answer: 3 Both the beta blocker and the calcium channel blocker have the potential of lowering the BP and a beta blocker for angina. Vital signs are BP and pulse (sometimes significantly). Most textbooks still list 60 bpm as the baseline pulse. 100/68, pulse 52 bpm, respirations 20. Which of the Giving the medicine as usual could lower the vital signs even further. Even if vital signs are following is an appropriate action by the nurse? monitored, the drugs will be in the client's system and could result in harm. Holding the medicine until rounds is not usually an acceptable practice. Unless specific parameters are established on a unit, the nurse should cover herself with a written order for parameters. ‐ Give the medicine and check vital signs in 30 minutes. ‐ Hold the medicine until the physician makes rounds. ‐ Call the physician first. ‐ Give the medicine as usual. | Note the pulse rate below 60 bpm which in the case of cardiac drugs requires a call to the physician. |
1953 An understanding of the renin‐angiotension Correct answer: 1 Renin is released to conserve water, thus increasing the systemic blood pressure. Options 2, mechanism in hypertension is important because renin 3, and 4 are incorrect because the mechanism results in decreased renal flow, decreased blood is released to: pressure, and decreased tubular sodium concentration. ‐ Correct hypotension. ‐ Increase renal flow. ‐ Raise blood pressure. ‐ Increase tubular sodium concentration. | Recall that the renin‐angiotensin system produces vasoconstriction, thus correcting hypotension. |
1954 A thorough history concerning any blood pressure Correct answer: 3 Prior to surgery, the client should be questioned concerning any family history or prior problems before surgery is necessary in order to problems with hypertension (HTN) if anesthetics were used. Malignant HTN is a medical determine: emergency that can occur after administration of anesthetics. Although problems with hypotension (option 1) and the normal BP range (option 4) are important, anesthetics are usually associated with concern for malignant HTN. ‐ Potential problems with hypotension. ‐ Need for antihypertensives because of pain. ‐ Possibility of malignant hypertension. ‐ Client’s normal blood pressure (BP) range. | The question is addressing hypertension in a pre‐surgical situation. Focus on the possible complication of malignant HTN. |
1955 Early in the development of hypertension, there may Correct answer: 2 The disease of hypertension progresses slowly into the vessels, the heart, the kidney, and the be few, if any, pathological changes except brain. Essential hypertension is an elevated systemic arterial pressure (option 1). There is no intermittent elevations of the systemic blood pressure. known cause. Normotension is a client with a normal blood pressure (option 3). Secondary This is called: hypertension is an elevated blood pressure associated with several primary diseases (option 4). ‐ Essential hypertension. ‐ Labile hypertension. ‐ Normotension. ‐ Secondary hypertension. | Recognize that the word “intermittent” in the stem is a hint to the correct response of Labile hypertension. |
1956 Frequently, the client with chronic, untreated Correct answer: 1 As hypertension progresses untreated, the fundi of the eye will demonstrate changes. These hypertension will have an ophthalmoscopic include a) minimal vascular changes in the early stage; b) irregular appearance of arterioles; c) examination. The findings will be reported as: changes progressing to attenuation of retinal vessels with retinal hemorrhage; and d) attenuation of retinal vessels with disc swelling in the late stage. Microaneurysms are seen in clients with diabetes mellitus (option 2). No red reflex is seen in clients with a completely opaque lens (option 3). Cupping of the optic disc is seen in a client with glaucoma (option 4). ‐ Ocular changes in the fundi. ‐ Microaneurysms. ‐ No red reflex. ‐ Cupping of the optic disc. | The key word of “changes” in option 1 aids in identifying it as the correct response. |
1957 Renin converts angiotensin I to angiotensin II (a Correct answer: 4 ACE inhibitors block the conversion of angiotensin I to angiotensin II or inhibit the effect of potent vasoconstrictor) in order to increase the angiotensin II; therefore, the potent vasoconstrictor is not able to increase the blood pressure. systemic blood pressure. This explains the Sympatholytics and beta blockers block the sympathetic nervous system, which stimulates effectiveness of which group of antihypertensives? renin (options 1 and 2); diuretics affect the absorption of sodium and water (option 3). ‐ Beta blockers ‐ Sympatholytics ‐ Diuretics ‐ ACE inhibitors | Omit options 1, 2, and 3 as not influencing the renin‐angiotensin system. |
1958 An aggressive teaching plan is devised with the client Correct answer: 4 Teaching about the antihypertensive drug management will include informing the client about for the purpose of reducing the risk of untoward situations that might cause lightheadedness and fainting. These situations would be standing reactions of hypertension. The highest priority would motionless for a prolonged period of time, rising suddenly from a sitting position, or soaking in be to: a hot bath. All of the answers are correct. However, if the drugs are properly administered, compliance is maintained (options 1 and 2) and the BP could be monitored on a monthly basis (option 3). ‐ Prevent poor compliance. ‐ Identify unawareness of noncompliance. ‐ Actively monitor the blood pressure (BP). ‐ Manage medication therapy. | The phrase “untoward reaction” leads to the identification of the correct option, manage medication therapy. The other options would not reduce the risk of untoward reactions. |
1959 Collaborative care frequently includes modifications Correct answer: 4 MHR is determined by subtracting the client's age from 220. A target heart rate (THR) should in lifestyle for the hypertensive client. One area for be estimated based on the client's condition. However, the MHR is the upper limit the client modification is to increase the client's physical activity. can safely reach (if possible), but should not be exceeded. Options 1 and 3 are too low; Option A 49‐year‐old client should be taught to exercise three 2 is too high for an MHR. times a week for 20 to 30 minutes and not to exceed his or her maximum heart rate (MHR) of: ‐ 110 beats per minute. ‐ 250 beats per minute. ‐ 152 beats per minute. | The item asks for a maximum heart rate. Eliminate options 1 and 3 as too low for a maximum. Heart rate over 200 is not recommended, so eliminate option 2. |
4.‐ 171 beats per minute. | |
1960 A client with varicose veins needs to consider the Correct answer: 4 The client with varicose veins must be assessed for the presence of constipation. If this is possibility of risk reduction. What area would probably present, the client is encouraged to consume a high‐fiber diet. Constipation increases the intra‐ be overlooked by a client and should be stressed in a abdominal pressure, thus promoting venous stasis in the lower extremities. Options 1, 2, and 3 teaching plan? are more commonly considered because these are likely problematic to the client already. Clients should be taught to avoid standing or sitting in one spot for a prolonged time period. Frequently, the healthcare provider will suggest wearing support hose, elastic stockings, or wrapping the legs from toes to upper thigh with elastic bandage. Knee‐bending exercises are also suggested (option 1). Walking for the client with varicose veins is appropriate; however, the walking time should be about 1 mile per day, unless the client is already walking 3 miles (option 2). Encouraging the obese client to investigate a weight loss program is satisfactory; however, the key is to enroll and to become actively involved with the weight loss program (option 3). ‐ Avoid standing or sitting in the same spot for more than 5 minutes at a time. ‐ Walk at least 3 miles per day. ‐ Encourage the obese client to investigate weight loss. ‐ Encourage the client to consume a high‐fiber diet. | The question asks for the area that would be overlooked. Select the option not directly related to the risks for varicose veins. |
1961 Which nursing diagnosis is the primary focus in Correct answer: 1 The client with Raynaud's disease will have altered peripheral tissue perfusion to the fingers planning the care for a client with Raynaud's disease? and toes caused by spasms within the arterioles. This phenomenon may occur unilaterally or bilaterally as a result of a number of diseases, such as, collagen vascular diseases, pulmonary hypertension, and many others. Raynaud's disease does not usually impair physical mobility (option 2). Anxiety is not a common finding; however, it may be present because Raynaud's disease is considered a chronic illness (option 3). Skin integrity may be decreased because of a diminished level of oxygen to the peripheral vessels. When this occurs, skin breakdown might occur and the risk of infection would increase (option 4). ‐ Altered tissue perfusion: peripheral ‐ Impaired physical mobility ‐ Anxiety ‐ Risk for infection | Focus on the pathology of Raynaud’s, which is peripheral vasospasm. This will help to identify the correct response. |
1962 Which of the following nursing diagnoses is the Correct answer: 4 When assessing fluid volume, the nurse needs to include the amount of blood loss from the highest priority in a postoperative client after the client's system. Warning signs would be a decreasing blood pressure, restlessness, clammy repair of an abdominal aneurysm? skin, pallor, decreasing levels of consciousness, thirst, oliguria less than 30‐50 mL/hr, and an increasing abdominal girth. Any changes indicating hypovolemia need to be reported to the surgical team immediately. Although options 1, 2, and 3 may be appropriate, notice that the question asks for the highest priority. Ischemia of the bowel may occur when the mesenteric vessels have been clamped and an ischemic colitis may follow (option 1). Altered tissue perfusion has probably occurred during the surgery. It is essential that pulses in each of the extremities be determined for presence or absence and have the client report tingling or numbness anywhere in the body (option 2). Impaired gas exchange may occur because of the extent of the abdominal incision and the client's ability to cough and deep breathe (option 3). ‐ Potential for injury: ischemia of the bowel ‐ Altered tissue perfusion: peripheral ‐ Impaired gas exchange ‐ Fluid volume deficit | The question asks for the priority, usually indicating that all of the options are correct. Recall that the nature of the surgery would place option 4 at the highest priority due to blood and fluid loss. |
1963 Which of the following diagnosis is high priority for a Correct answer: 4 A client who is stable (without symptoms) and does not want to take medications or modify client who is stable with a medical diagnoses of his or her lifestyle is likely to be noncompliant. Certain treatments for CHF are life‐long in congestive heart failure (CHF), but is having trouble order to prevent major complications, such as keeping blood pressure under control, modifying their lifestyle? modifying salt intake, exercising, maintaining a proper weight, and taking prescribed medication. Emphasis should be placed on the need to continue care even though there are no symptoms present. ‐ Altered tissue perfusion: systemic ‐ Altered nutrition: more than body requirements ‐ Risk for injury ‐ Risk for decreased cardiac output | Focus on options 3 and 4 as they are stated as “risk for.” Recall that the priority for a client with CHF is the risk for decreased cardiac output. |
1964 The client comes to the clinic for a routine check‐up. Correct answer: 4 Hypertension is one of many potentially modifiable risk factors. All the other noted factors The nurse notes that the blood pressure (BP) is 180/96. are not modifiable by the client. Other modifiable risk factors are smoking, high cholesterol, The client denies any history of hypertension. The obesity, stress, and leading a sedentary lifestyle. nurse begins to educate the client on risk factors for coronary artery disease (CAD). The client is a 50‐year‐ old male with a strong family history of CAD. The nurse would include which of the following in his or her teaching about modifiable risk factors? ‐ Age ‐ Gender ‐ Family history ‐ Hypertension | Focus on the option that describes a factor that can be changed or controlled. |
1965 The client presents with a cholesterol level of 325 Correct answer: 1 Cholesterol is the substance carried by lipids that deposits along the arterial walls causing mg/dL. In teaching the client about risk factors for stiffening and narrowing of the vessel. These atherosclerotic plaques lead to coronary artery coronary artery disease (CAD), the nurse would best disease. The other answers are not applicable. describe cholesterol as: ‐ The substance that sticks to the inside of the blood vessels, decreasing blood flow ‐ The stuff that deposits in the veins and prevents absorption of nutrients. ‐ The food you eat that causes the blood vessels to get soft and pliable. ‐ The number one cause of heart failure. | The question is asking about the relationship of cholesterol to CAD. Select the option that best describes the disease process. Omit option 3 as food is not the only source of cholesterol. Omit option 2 as being physiologically untrue. |
1966 In evaluating the electrocardiogram (ECG) of the Correct answer: 2 Inverted T waves and a depressed S‐T segment are classic signs of ischemia. Elevated S‐T client in the Emergency Department, the nurse notes segment means damage. LVH would be noted by changes on a 12‐lead EKG. inverted T waves and S‐T segment depression, indicating which of the following? ‐ Left ventricular hypertrophy (LVH) ‐ Ischemia of the myocardium ‐ Atrial wall infarction ‐ Right ventricular infarction | Recall the association of S‐T depression with ischemia to choose the correct answer. |
1967 A client on the telemetry unit with a diagnosis of Correct answer: 1 Atrial fibrillation is accompanied by an irregular rhythm. The heart rate can be slow, within congestive heart failure and atrial fibrillation has an normal limits, or fast. The action of digoxin (Lanoxin) is to increase the force of contraction order for digoxin (Lanoxin). The client's pulse is 112 (positive inotropic) and decrease the heart rate (negative chronotropic). These actions will and irregular. The nurse should: help in both congestive heart failure and atrial fibrillation. There is no need to monitor the vital signs every 15 minutes while on a telemetry monitor and in this situation. ‐ Give the dose as ordered. ‐ Hold the dose and call the physician. ‐ Call the physician immediately. ‐ Give the dose and monitor vital signs every 15 minutes. | Omit options 2 and 3 as calling the physician is not indicated by the scenario. Omit option 4 as the client is already on a monitor. |
1968 The nurse teaching on the management of risk factors Correct answer: 4 Normal cholesterol is less than 200 mg/dL. All the other options are nonmodifiable but are in coronary artery disease would include which of the risk factors nevertheless. Emphasis should always be placed on modifiable risks. following as modifiable risk factors? ‐ Postmenopausal syndrome ‐ Gender ‐ Father died of acute myocardial infarction at age 63 ‐ Cholesterol level of 290 mg/dL | Identify the correct answer by selecting the only option that can be changed or controlled. |
1969 A client states that over the past several months he Correct answer: 1 Intermittent chest discomfort relieved by rest is most likely angina pectoris. The pain of a has begun experiencing some chest discomfort that myocardial infarction does not disappear until the damage has been done. Although the chest comes and goes. It usually stops when the client is pain can mimic gastrointestinal distress or other illnesses, a thorough exam of the client resting. The client asks the nurse if he is experiencing a should be made. heart attack. Which of the following is the nurse’s best response? ‐ "Pain related to a heart attack would not stop when you rest." ‐ "You could be having a heart attack but it is not doing any damage to the muscle." ‐ "The discomfort you describe is not related to your heart." ‐ "The discomfort you are experiencing is related to stomach gas production and will go away." | Make an association between angina and pain that is relieved by rest. Recall that heart attack pain is not relieved by rest. |
1970 The client's electrocardiogram (ECG) shows significant Correct answer: 2 A silent myocardial infarction can occur with no noticeable chest discomfort, and Q waves will Q waves in two contiguous leads. The nurse asks the appear on the EKG. client if he has ever had a heart attack. The client states he has never experienced any significant amount of chest pain. The best explanation for the Q waves would be that: ‐ The ECG results are wrong due to misplacement of electrodes. ‐ Sometimes a person can have a heart attack without any pain. ‐ Q waves have no relevance to the presence of a heart attack. ‐ If the client never experienced chest pain, then he never had a heart attack. | Focus on the nurse questioning the client regarding a history of a heart attack, in spite of the absence of chest pain. This leads to the selection of the correct response, option 2. |
1971 The client presents to the Emergency Department Correct answer: 3 Nitroglycerin is a vasodilator that dilates the coronary arteries and increases the blood flow with substernal crushing chest pain. The doctor orders to the myocardium, therefore relieving the pain. Morphine sulfate would be an example of nitroglycerin (NTG) sublingual to be given. The client option 2; options 1 and 4 are not related to angina. asks the nurse what the NTG is for. The best explanation is that NTG is a(n): ‐ Neuroblocking agent to reduce the pain. ‐ Opioid for pain relief. ‐ Vasodilator and works by providing more oxygenated blood flow to the heart. ‐ Antiarhythmic for the treatment of supraventricular tachyarhythmia. | Always associate pain with lack of oxygen to the tissues. Recall that NTG relieves pain by enhancing the delivery of oxygenated blood. |
1972 The nurse knows that in heart failure, decreased Correct answer: 1 Increased heart rate decreases diastolic filling time, compromises coronary artery perfusion, cardiac output leads to the onset of certain and increases myocardial oxygen demand; the resulting ischemia leads to decreased cardiac compensatory mechanisms. The effects of these output. The body's initial attempts are an effort to meet the supply and demand of the heart. compensatory mechanisms may be to: Compensatory mechanisms, however, begin to work negatively later on. ‐ Hasten the deterioration of cardiac function. ‐ Decrease heart rate and decrease cardiac output. ‐ Increase sensitivity to the sympathetic nervous system (SNS). ‐ Promote vasodilatation by increasing alpha‐receptor sensitivity. | Eliminate options 2 and 3 as not being consistent with the question. Option 1 is correct as adaptive or compensatory mechanisms will fail after extended use. |
1973 The client is admitted to the hospital with a diagnosis Correct answer: 4 Shortness of breath, dyspnea on exertion, and crackles are classic signs and symptoms of left‐ of left‐sided heart failure. How should the nurse sided heart failure. The fluid backs up into the lungs from the left side. Right‐sided heart failure differentiate left and right heart failure? The client leads to backflow of blood to the peripheral circulation causing edema in the extremities, would: jugular vein distention, and possible ascites. ‐ Demonstrate distended neck veins in left heart failure. ‐ Present with crackles in his lung fields with right heart failure. ‐ Have peripheral edema associated with left heart failure. ‐ Present with dyspnea and crackles bilaterally with left heart failure. | Use the association of LEFT = Lung for heart failure symptoms. |
1974 The client in the coronary care unit, status post‐ Correct answer: 2 Left heart failure produces increased pulmonary congestion and therefore elevated anterior myocardial infarction (MI), has been pulmonary artery pressures. A normal PA is 25/10 mmHg. Pink, frothy sputum and exaggerated diagnosed with heart failure. A pulmonary artery (PA) symptoms would be present for pulmonary edema to be diagnosed. Right‐sided heart failure catheter has been placed. The PA pressure is 30/15 includes signs of peripheral edema. mmHg and the client has mild crackles. The nurse knows from this reading that the client is experiencing: ‐ Right heart failure. ‐ Left heart failure. ‐ Both right and left failure. ‐ Pulmonary edema. | The key in the question is the presence of crackles, which would be associated with left failure. |
1975 The client returns to the clinic for a follow‐up visit Correct answer: 3 PND is a result of the fluid shift at night in the supine position, from the interstitial to the post hospitalization for heart failure. On his discharge intravascular compartment causing increased workload to the heart. Because of the increased papers, the term paroxysmal nocturnal dyspnea (PND) volume, pulmonary congestion occurs. The client awakes with severe dyspnea. was listed. The client asks the nurse to explain this. Which of the following is the best response? ‐ "PND is when you have to get up frequently at night to urinate." ‐ "PND is a term that doctors use to encourage clients into compliance with care instructions." ‐ "PND is a sudden onset of difficulty breathing during the night." ‐ “PND is the onset of a life‐threatening dysrhythmia, and you must call 911 immediately.” | Use the terminology in the question to identify the correct response; nocturnal means night, dyspnea means difficulty breathing. |
1976 The client presents to the Emergency Department Correct answer: 2 Elevated heart rates lead to decreased ventricular filling time and weaker pulse. Arrhythmias complaining of "palpitations." The nurse connects the such as atrial tachycardia may increase the heart rate to 180 to 200 bpm. Assess for signs of client to the monitor. The heart rate is 180 bpm and adequate cardiac output. blood pressure is 108/50. The nurse would expect his pulse to be: ‐ Full and bounding. ‐ Weak and thready. ‐ Weak and bounding. ‐ Full and thready. | Omit options 3 and 4 as being contradictory. Recall that a high pulse rate would generally result in a weak and thready pulse. |
1977 The client admitted to the coronary care unit with a Correct answer: 1 Frequent monitoring of vital signs and hemodynamic monitoring allows for early detection of diagnosis of heart failure asks why he must be changes in condition and early intervention. Clients with heart failure can rapidly deteriorate; awakened so often and why his blood pressure is being usually vital signs are the first indicator. taken so often. The nurse's best response would include which of the following statements? ‐ "Assessment of subtle changes in vital signs may lead to early interventions." ‐ "The doctor ordered frequent assessments." | Select the response that is client‐focused to answer this question correctly. |
‐ "Charting of frequent blood pressure is necessary for joint commission documentation." ‐ "The nurse manager is coming in early to do chart assessments and we need all the blanks filled in." | |
1978 The client in the coronary care unit with a diagnosis Correct answer: 2 Atrial dysrhythmias are frequently seen in heart failure. Atrial fibrillation is irregular, has no of heart failure states his chest feels "funny." The discernable P waves, and is often accompanied by a fast ventricular response. nurse assesses the client and monitor, noting an irregular rhythm with a rate of 110. All the QRS complexes look alike, but there are no discernable P waves and the rhythm is irregular. The client is most likely experiencing: ‐ Normal sinus rhythm with premature ventricular contractions. ‐ Atrial fibrillation. ‐ Accelerated junctional rhythm. ‐ Normal sinus rhythm with premature junctional contractions. | Eliminate options 1 and 4 as absence of P waves eliminates normal sinus rhythm as an option. |
1979 The client comes in for a follow‐up visit after Correct answer: 1 Sinus arrhythmia is a normal variant related to increased intrathorasic pressure (vagus discharge from the hospital with a diagnosis of acute stimulation) as seen with deep inspiration and expiration. It is a benign arrhythmia that myocardial infarction. The client explains that when he requires no treatment. walks, he sometimes notes that his pulse is slightly irregular. The nurse assesses his pulse and finds that it is slightly irregular. The monitor confirms a slightly irregular rhythm with no ectopic beats and all the characteristics of a normal sinus rhythm. The nurse explains this to the client as a: ‐ Normal variation that occurs in some people and is frequently associated with deep breathing. ‐ Very serious condition that must be addressed by the physician. ‐ Condition that must be treated with medication. ‐ Condition that reflects a decreased oxygen supply to the myocardium. | Focus on the statement in the scenario that defines the rhythm as a normal sinus rhythm. |
1980 The client presents to the Emergency Department Correct answer: 2 Athletic syndrome is common with very active individuals that have increased cardiac complaining of knee pain. The client was running a strength and force of contraction. The heart rate may be as low as the 30s in extremely race at his school and fell and twisted his knee. The athletic individuals, especially runners. If the client is asymptomatic, no treatment is necessary. client tells the nurse that he has been running track for 4 years. On assessment, his pulse is 52. The nurse's explanation for this sinus bradycardia is:
| Omit options 1 and 3. Recall that anxiety and pain would increase the heart rate. |
1981 The client is brought to the Emergency Department Correct answer: 3 Junctional rhythm is a regular rhythm originating in the AV junction with a rate of 40 to 60 by the emergency medical system with complaints of bpm, no discernable P wave or an inverted P wave before, during, or after the QRS complex. near syncopal episode. After placing the client on the The QRS complex is less than 0.12 seconds in duration. The cause of the arrhythmia should be monitor, the nurse notes a regular, slow rhythm‐‐a determined and treated or a pacemaker inserted. rate of 42 bpm. There are no discernable P waves and the QRS complexes are less than 0.12 seconds in duration. The nurse would interpret the rhythm as: ‐ Atrial fibrillation with slow ventricular response. ‐ Idioventricular rhythm. ‐ Junctional rhythm. | Eliminate options 1 and 4 as being inconsistent with the slow rate in the scenario. |
4.‐ Sinus bradycardia. | |
1982 The client's 12‐lead electrocardiogram was just Correct answer: 4 Second‐degree heart block Type II (also referred to as Classical) has two or more P waves per placed on the chart. The nurse looks it over and notes QRS complex and has a constant PR interval. The ventricular rate is usually bradycardic. that the atrial rate is 82 and the ventricular rate is 40. The PR interval is constant at 0.16 seconds, with two P waves for every QRS complex. With the above description, the nurse interprets the client's rhythm to be: ‐ Third‐degree heart block. ‐ Second‐degree heart block Type I. ‐ First‐degree heart block. ‐ Second‐degree heart block Type II. | Recognize that the difference in the atrial and ventricular rate helps to define this as a second‐degree block. |
1983 Persistent severe hypertension is a medical Correct answer: 1 When assessing a client with severe hypertension, the client may be demonstrating emergency. The nursing assessment should include: hypertensive encephalopathy. If this occurs, the client will have a change in the level of consciousness ranging from confusion to coma and possible seizures. The client experiencing severe hypertension may or may not demonstrate a headache (option 2). Unless pulmonary edema is present, the breath sounds will be clear bilaterally (option 3). Temperature is less critical than pulse (option 4). ‐ Level of consciousness. ‐ Presence of headache. ‐ Breath sounds. ‐ Temperature. | Select the option that is likely to occur and have serious consequences, in this case, altered level of consciousness. |
1984 The medical management of thrombophlebitis is Correct answer: 3 The PTT is used to monitor the level of heparin so that a therapeutic dose may be through the use of anticoagulant therapy. The nurse administered. GPT is a liver enzyme and will not be affected by heparin (option 1). The PT is will determine the effectiveness of heparin therapy by used to monitor Coumadin therapy (option 2). The FBS is used to monitor the blood glucose assessing which of the following? levels (option 4). ‐ Glutamate pyruvate transaminase (GPT) ‐ Prothrombin time (PT) ‐ Partial thromboplastin time (PTT) ‐ Fasting blood sugar (FBS) | Omit options 1 and 4 as not being associated with anticoagulant therapy. |
1985 Frequently, sodium consumption and substance Correct answer: 4 When reviewing the risk factors that are listed, both sodium consumption and the use of abuse are linked to hypertension. These factors are substances may be modified if the client desires to participate in a lifestyle change. classified as: Nonmodifiable risk factors are those that are not changeable, such as family history, gender, and ethnicity (option 1). Personal choice risk factors is not a commonly used phrase (option 2). Gender risk factors are a subgroup of the nonmodifiable risk factors (option 3). ‐ Nonmodifiable risk factors. ‐ Personal choice risk factors. ‐ Gender risk factors. ‐ Modifiable risk factors. | Recognize that both sodium consumption and substance abuse are controllable or able to be changed, therefore modifiable. |
1986 Raynaud's disease is a disease of the small arteries Correct answer: 2 Triggers in Raynaud's are cold, caffeine, smoking, and stress. Raynaud's disease has the and arterioles, which constrict in the presence of characteristic of the vessels that become vasospastic in nature, but inflammation does not stimuli. Which of the following is true? occur (option 1). Smoking is considered a trigger because of the nicotine contained in the tobacco, but claudication is not usually found in clients with Raynaud's disease (option 3). Smoking is the primary cause of Buerger's disease (option 4). Raynaud's is caused by genetics or autoimmune disorders. | Associate Raynaud’s with spasm of the digital vessels. Recall that symptoms should be associated with cold exposure. |
‐ Vasospasm occurs, causing inflammation of the veins. ‐ Stimuli include cold temperatures and caffeine. ‐ Smoking triggers an event and claudication of the leg occurs. ‐ Smoking is the primary cause. | |
1987 The primary nursing management of a medical client Correct answer: 3 The primary treatment of a client with thrombi is to monitor the anticoagulant therapy. The with thrombi includes which of the following? therapy will prevent the formation or extension of thrombi by inhibiting the clotting factors or by quickening their inactivation. Options 1, 2, and 4 are correct, but are not the primary treatment. Clients need an analgesic for their discomfort. Warm packs may also be used to promote comfort (option 1). The client's bed is to be elevated 6 inches at the foot of the bed. This forces (via gravity) the blood to return and not to remain stagnant (option 2). Pulmonary emboli may occur and lung sounds should be auscultated (option 3). ‐ Monitor the client for the degree of discomfort. ‐ Elevate the legs at least to a 45‐degree angle. ‐ Monitor the anticoagulant therapy. ‐ Assess lung sounds. | Focus on the aspect of therapy with the most risk associated, which is the anticoagulant therapy. |
1988 Community screening and self‐care are general public Correct answer: 1 Hypertension is a major public health concern in the areas of prevention and early detection health initiatives. Which one of the following is of the of new cases across the age continuum. Monitoring the existent hypertensive clients is a highest priority? challenge and the focus is on the prevention of further complications of the disease and to reduce the cardiovascular risks (option 2). The study of cardiovascular risks is a long‐term goal. The population awareness and early detection are important within each community (option 3). The study of isolated systolic hypertension is narrowly focused and could be addressed in other initiatives (option 4). ‐ Hypertension as a major concern of the general public ‐ Monitoring the existing hypertensive clients ‐ Studying cardiovascular risk factors ‐ Studying isolated systolic hypertension | Recognize that the question is asking about screening efforts, which are usually directed at the general public as in option 1. |
1989 Dietary management and client teaching for a Correct answer: 3 The diet of the client with hypertension needs to include the essential amounts of calcium hypertensive client include which of the following food found in milk for neuromuscular irritability, transmission of nerve impulses, skeletal muscle selections? contraction, and clotting. Magnesium in the form of oranges is needed as an important intracellular enzyme system. Also, neither of these foods is high in sodium. Processed foods are generally high in sodium and should be avoided by the hypertensive client (option 1). Carbonated beverages contain either high levels of sodium or potassium (option 2). Nuts are high in phosphorus and sodium. Phosphorus and calcium are in an inverse relationship to each other (option 4). ‐ Processed foods ‐ Carbonated beverages ‐ Milk and oranges ‐ Nuts | Eliminate foods known to be high sodium such as processed foods and nuts. Recognize that carbonated beverages have little or no nutritional value. |
1990 The elderly client with decreased total body water Correct answer: 1 Drug distribution is determined by the adequacy of the plasma volume, the extracellular fluid may react differently to antihypertensive drugs volume, and the serum protein levels. Many of the drugs are processed through the liver or because: the kidney. Any impairment of either organ will potentially cause a problem of overdose (option 2). With a decrease of the total body water, the peripheral resistance will be increased to provide the body with an auto‐transfusion (option 3). The elderly client has a slowing of the intestinal motility and absorption. This may adversely affect the therapeutic drug level (option 4). ‐ Drug distribution is changed by plasma volume, extracellular fluid volume, and serum protein levels. ‐ Liver and renal functions have little to no influence on the drug's distribution. | The item is asking about total body water. Select the only option that refers to drug distribution as related to fluid volume. |
‐ Decreased peripheral resistance occurs when body fluid decreases. ‐ Intestinal absorption of the antihypertensive drug is accelerated. | |
1991 The priority intervention in the plan of care for a Correct answer: 2 When the client has a diagnosis of fluid volume excess, monitoring all fluids is important. hypertensive client with excess fluid volume includes: Failure to monitor the client places him or her at risk for further complications, such as pulmonary edema and congestive heart failure. Options 1, 3, and 4 are correct but are not the highest priority. Teaching the client about the treatment plan is important but is not the highest priority (option 1). The client needs to know about a low‐sodium diet and appropriate food selection (option 3). Assessing the client for signs of dependent edema is important, but intake and output of all fluids is higher (option 4). ‐ Teaching the client the importance of following the treatment plan. ‐ Monitoring the intake and output of fluids carefully for each shift. ‐ Teaching the client about low‐sodium diets. ‐ Assessing the client for signs of dependent edema. | Assume all of the items to be correct, so select the priority. Recall that intake and output is the priority assessment as it can assist in the evaluation of the other options. |
1992 A characteristic of essential hypertension is: Correct answer: 4 The kidneys will not excrete water and sodium unless there is an adequate pressure gradient. The mean arterial pressure rises between 40 and 60 percent in essential hypertension (option 1). Blood flow resistance rises between two‐ and four‐fold in essential hypertension (option 2). The client with essential hypertension has a normal cardiac output (option 3). ‐ A 90 percent increase of the arterial pressure. ‐ The decrease in resistance of the blood flow through the kidneys. ‐ The rise in cardiac output. ‐ That the kidneys will not excrete water and sodium unless the arterial pressure is high. | Focus on the characteristic of essential hypertension as increased fluid volume and sodium. |
1993 Raynaud's disease is characterized by: Correct answer: 1 Raynaud's disease occurs predominately in young women between the ages of 20 and 40. Causes are usually unknown or genetic (option 2). Raynaud's disease is known as a progressive disease, which becomes worse over time (option 3). Intermittent claudication is not associated with Raynaud's disease (option 4). ‐ Onset between 20 and 40 years of age, predominately in women. ‐ A heavy smoking history. ‐ An intermittent course for the disease. ‐ Intermittent claudication. | Recall the association of this condition with females of childbearing years. |
1994 The nursing management of Raynaud's disease has as Correct answer: 3 The major therapeutic intervention that has the highest priority is to keep the client's hands its highest priority: and feet warm as well as free from injury. The hands and feet must be kept from exposure to cold temperature, which is a trigger stimulus. The client with Raynaud's disease does not have intermittent claudication (option 1). Opioids are usually not needed in Raynaud's (option 2). Stress management is considered important because anxiety may be a triggering stimuli (option 4). ‐ Providing rest during the periods of intermittent claudication. ‐ Providing opioid analgesics for pain. ‐ Keeping the client's hands and feet warm and injury‐free. ‐ Teaching the client stress management. | Look for a response that identifies cold as the trigger for symptoms. |
1995 Buerger's disease is characterized as: Correct answer: 1 Buerger's disease is a vascular disease of the small‐ and medium‐sized peripheral arteries that become inflamed, thrombotic, and spastic. This disease is primarily found in the legs and feet. The exact cause of Buerger's disease is unknown; however, it is possible that it is an autoimmune response. There is a high incidence of the disease in heavy smokers and it occurs in men under the age of 40 (option 2). Buerger's disease has an intermittent course characterized by exacerbations and remissions. Over time, the severity and duration of the attacks become more severe (option 3). The hands of the client are rarely affected (option 4). ‐ An occlusive vascular disease with an autoimmune response. ‐ Occurring in men over 65 years of age. ‐ Progressively worsening over time. ‐ Affecting only the hands. | Look for the word occlusive in the correct response to make a choice. |
1996 Nursing management of a client with Buerger's Correct answer: 4 When planning for the nursing management of a client with Buerger's disease, managing the disease has as its highest priority: altered peripheral tissue perfusion is primary. Because the arterial circulation is thrombosed, inflamed, and spastic, there is limited ability to carry oxygen and nutrients to the tissues and return with the waste products of metabolism. All options are correct but the stem asks for the highest priority. The risk of injury to the tissue may be due to tissue hypoxia. The client must be encouraged to completely stop smoking (option 1). The client will probably be placed on bed rest because of the impaired activity and immobility during the exacerbations of symptoms (option 2). Pain is caused by the intermittent claudication. This, in turn, is caused by the vasoconstriction and vasospasm of the arteries following inflammation of the arteries (option 3). ‐ Prevention of injury. ‐ Limiting activity. ‐ Pain management. ‐ Managing altered tissue perfusion. | Look for the most serious of the options, which is altered tissue perfusion. |
1997 A compensatory mechanism of the body in a client Correct answer: 4 As the muscle hypertrophies in order to contract forcefully enough to overcome the high with essential hypertension is the development of pressure and peripheral vascular resistance, this mechanism eventually requires more hypertrophy in order to increase the workload of the oxygenated blood to the heart. The increased workload will cause the heart to "tire out" and left ventricle. Over a long period, however, this congestive heart failure can occur. What was a compensatory mechanism of the heart increases the risk of which of the following? becomes a complication. The stiffened muscle cannot produce the necessary cardiac output and becomes congested. Options 1, 2, and 3 are not compensatory mechanisms. ‐ Pulmonary embolus ‐ Cardiac tamponade ‐ Myocardial infarction ‐ Congestive heart failure (CHF) | Hypertrophy of the left ventricle is discussed in the scenario. Recall that this is associated with CHF. |
1998 The first priority of care in the management of a Correct answer: 1 Anticoagulant therapy is started early to prevent the extension of the thrombus or the client with thrombophlebitis is: possible embolization of the thrombus. All options are correct but option 1 is the highest priority. Elevation of the client's legs is a comfort measure, and the elastic bandages will provide support to the extremity. The client's heel must be included in the wrap. These bandages are to be applied snuggly and rewrapped every 4 to 8 hours. They must be inspected frequently as they may become dislodged (option 2). The use of warm packs and an analgesic are appropriate but not as the first priority (option 3). The monitoring of the PTT or the INR will be done every 4 hours (option 4). ‐ Anticoagulant therapy with heparin or coumadin (Warfarin). ‐ Elevation of the client's legs, which are supported by elastic bandages from toes to groin. ‐ Using warm packs and a sedative. ‐ Monitoring effect of anticoagulant therapy every 36 hours by using the partial thromboplastin time (PTT) or the International Normalized Ratio (INR). | Associate thrombophlebitis with anticoagulant therapy. This is a priority over monitoring of the blood work. Monitoring the blood studies will aid in the medication management. |
1999 The first priority in assessing a client with Correct answer: 2 The nurse will assess the lower extremities for swelling. Frequently, measurement of the mid‐ thrombophlebitis is: calf is obtained every eight hours. Homan's sign is considered somewhat unreliable. It is reported that approximately 35 percent of clients with deep venous thrombosis will have a positive Homan's sign (option 1). The extremity may be reddened in the area of the thrombosis if a superficial vein is involved. The client may or may not report calf tenderness (option 3). A pulse is usually palpable or audible by doppler unless an arterial clot is present (option 4). ‐ Homan's sign because it is reliable. ‐ Inspection of the lower extremities for swelling. ‐ Color change and tenderness. ‐ Palpation of a pulse. | Recall that inspection is the first step in assessment. |
2000 Education for a client with varicose veins should Correct answer: 1 Teach the client not to sit for prolonged periods of time (more than 30 minutes) or stand include which one of the following? (more than 5 minutes) without changing positions. Instruct the client not to cross the legs when sitting and to elevate the legs if prolonged standing is needed. Medication is usually not recommended with varicose veins (option 2). Protection from cold is needed in Raynaud's and Buerger's diseases, not for varicose veins (option 3). The management of the client's pain may be of concern but should be controlled by over‐the‐counter medications and regulating activity. The pain is caused by the venous pooling of blood and the lack of nutrients and oxygen to the tissues. If the pain is worsening, the client's condition needs further assessment and possible modification of the treatment regimen (option 4). ‐ Activity tolerance ‐ Medication compliance ‐ Protecting extremities from cold ‐ Pain management | Recall that activity is a key element in treatment/control of varicose veins. Look for that word to help identify option 1 as the correct answer. |
2001 The pathophysiology of varicose veins is explained by Correct answer: 2 The major pathophysiological factor in the development of varicose veins is the prolonged which of the following? increased pressure within the venous structure. The process is compounded by the venous values becoming stretched and unable to close, creating a pooling of venous blood. Blood flow is compromised, and is moving slower in the venous system of the lower extremities (option 1). Varicose veins involve the venous, not arterial, system (option 3). The intra‐abdominal pressure is constant and compresses the venous system of the lower extremities (option 4). ‐ Chronic status of blood in the vessels ‐ Chronic increased intravenous pressure ‐ Increased arterial pressure ‐ Intermittent intra‐abdominal pressure on the veins | Recall that venous pressure is the key to identification of the correct option. |
2002 A nurse is able to distinguish venous insufficiency Correct answer: 4 The pulses with a venous insufficiency are normal or decreased; however, the pulses for an from arterial insufficiency by noting: arterial ulcer are diminished or absent. Warmth usually indicates inflammation and possible thrombophlebitis (option 1). The skin appearance is brown with a venous stasis, and cyanotic when placed in a dependent position (option 2). The level of pain the client is reporting is usually a mild, achy pain with venous insufficiency (option 3). ‐ Warmth to the calf. ‐ Red skin appearance. ‐ Severe pain. ‐ Pulses. | Look for a reference to pulses to help identify the correct response, as the quality of the peripheral pulse is a distinguishing factor in determining venous versus arterial disease. |
2003 The nurse is monitoring a client who recently has Correct answer: 2 When cardiac tamponade occurs, the restriction reduces stroke volume, cardiac output, and undergone pericardiocentesis. The nurse suspects blood pressure. The right atrium is restricted, causing JVD and increasing pressure during cardiac tamponade after observing which of the diastole. While the decreased stroke volume decreases the pressure during systole, the client following? compensates for decreased stroke volume and cardiac output by increasing heart rate. Because of decreased filling pressure, cardiac output drops, and blood pumped from the right heart is reduced. Lung sounds are usually clear; heart sounds become more distant and muffled because they are heard through the fluid collection in the pericardium. ‐ A rapid increase in blood pressure, and flushing ‐ Jugular vein distention (JVD) and narrowing pulse pressure ‐ Bradycardia and bilateral crackles ‐ Louder and harsher heart sounds | The identification of a narrowing of pulse pressure is the key to identifying option 2 as correct. |
2004 A 54‐year‐old male client recently was diagnosed with Correct answer: 2 Once a client is diagnosed with SBE, he is at risk for repeated episodes. Taking prophylactic subacute bacterial endocarditis (SBE). The nurse antibiotics prior to dental care is an important activity to prevent further infections. There is determines that the client understands the discharge no routine sodium restriction with SBE. Antibiotic treatment for SBE is given by the IV route for teaching when he does which of the following? the entire course. Although stopping smoking will decrease his risk factor for coronary artery disease, it does not affect the SBE. ‐ Asks for a referral to a dietician for a low‐sodium diet. ‐ Explains to his wife why he needs antibiotics before seeing the dentist. ‐ Asks when he can start to take his antibiotics in pill form. ‐ Explains his plans to quit smoking. | Recall that antibiotic prophylaxis is part of ongoing treatment, and should be included in teaching. |
2005 The nurse on a cardiac unit is caring for a client Correct answer: 3 Pulmonary edema in a client with heart failure is the accumulation of fluid in the alveoli admitted with an acute exacerbation of heart failure. characterized by increased rales; tachypnea; tachycardia; pink, frothy sputum; and decreased The nurse concludes that the client is developing SO<sub>2</sub> and PO<sub>2</sub>. The client presents with acute pulmonary edema after observing which change in the restlessness and anxiety. Urine output generally is decreased in heart failure clients; increased client? urinary output usually is caused by diuretic therapy. ‐ Bradycardia ‐ Increased urination ‐ Cough with pink, frothy sputum ‐ Increased sleepiness | Recall that pink, frothy sputum often is associated with pulmonary edema. |
2006 A client is scheduled for a cardiac angiography. In Correct answer: 1 The dye typically used for cardiac angiography is iodine‐based. The client with known allergy reviewing the client's record, what significant finding to seafood is at risk for anaphylaxis, and requires alternate media; atrial fibrillation and chronic needs to be reported to the physician before the renal failure are not contraindications to cardiac angiography; 5.0 mEq/L is a normal value for exam? potassium. ‐ The client reported an allergy to shrimp. ‐ The client's ECG shows atrial fibrillation. ‐ The potassium level is 5.0 mEq/L. ‐ The client has a history of chronic renal failure. | Recall that seafood allergy is associated with problems with angiography dye. Look for an option that reflects this. |
2007 The nurse is developing a plan for a client who is Correct answer: 3 Daily weight is the most sensitive indicator of changes in fluid status. It is more accurate for a going home with a new diagnosis of heart failure. The client at home than is urine output. A fluid restriction may be recommended for a client with nurse is teaching the client to monitor fluid status. The advanced heart failure, but it is not a method of monitoring fluid status. The client should best instruction is to teach the client to do which of never adjust the dose of her medications. the following? ‐ Restrict fluid intake to 800 mL per day. ‐ Increase the dose of diuretics if there is decreased urination. ‐ Record body weight every day before breakfast, and report a weight gain of 3 or more pounds in a week. ‐ Keep track of daily output, and call the doctor for if it is less than 1 L on any day. | Recall that the best monitoring of fluid status is weight. Identify the option that talks about accurate measurement of daily weights. |
2008 The nurse is caring for a client who has just had a Correct answer: 2 Bedrest is prescribed to allow the arterial puncture to seal and reduce the risk of bleeding. cardiac catheterization. The client insists on getting up Explaining the rationale to the client is the best way to facilitate the client's cooperation. to go to the bathroom to urinate immediately when he Although the factual information in the other options might be true, they do not assist the is brought back to his room. Which of the following client to understand the basis for care restrictions. would be the nurse's best response? ‐ "You can't walk yet. You might be too weak after the procedure, and may fall." ‐ "If you bend your leg, you will risk bleeding from the insertion site. It is an artery, and it could lead to complications." ‐ "If you get out of bed, you could have an arrhythmia from the catheterization. Your heart has to rest after this procedure." ‐ "The doctor has ordered that you stay on bedrest for the next six hours. It is important that you follow these orders." | Identify a reference to bleeding as the reason for bedrest. |
2009 A client is getting ready to go home after a Correct answer: 4 Metoprolol (Lopressor) is a beta blocker, and it slows heart rate; the main therapeutic effect myocardial infarction (MI). The client is asking after an MI is to reduce cardiac workload. It does not dilate the coronary arteries, and it questions about his medications, and wants to know actually decreases contractility (strength of the heartbeat). why metoprolol (Lopressor) was prescribed. The nurse's best response would be which of the following? ‐ "Your heart was beating too slowly, and Lopressor increases your heart rate." ‐ "Lopressor helps to increase the blood supply to the heart by dilating your coronary arteries." ‐ "This medication helps make your heart beat stronger to supply more blood to your body." ‐ "It slows your heart rate and decreases the amount of work the heart has to do, so it can heal." | Recall that the word ending “‐olol” helps to identify the medication as a beta blocker. Option 4 describes the action of a beta blocker. |
2010 A client is taking digoxin (Lanoxin) and furosemide Correct answer: 1 A prudent diet would be high in potassium because digoxin and furosemide both can deplete (Lasix) for heart failure. Which of the following would potassium. The diet needs to be low in sodium to prevent additional fluid overload with heart be the best menu choices for this client? failure. Chicken, potato, and cantaloupe are all potassium‐rich foods, and options 2, 3, and 4 are higher in sodium. ‐ Chicken with baked potato and cantaloupe ‐ Eggs and ham ‐ Grilled cheese sandwich and French fried potatoes ‐ Pizza with pepperoni | Omit options 2, 3, and 4 as being too high in sodium content. |
2011 A nurse is preparing to admit a client with restrictive Correct answer: 4 Although some clients might have fear, hopelessness, or knowledge deficit related to their cardiomyopathy to the hospital for the management disease progression, most clients with cardiomyopathy are likely to have decreased cardiac of worsening heart failure. Which of the following output and corresponding activity intolerance. More data would be needed to determine would be the most appropriate nursing diagnosis for whether the other nursing diagnoses apply. this client? ‐ Fear related to new onset of symptoms ‐ Hopelessness related to lack of cure and debilitating symptoms ‐ Knowledge Deficit related to medication regime ‐ Activity Intolerance related to decreased cardiac output | Identification of the option that would apply to all clients with this diagnosis will lead to selection of option 4 as correct. |
2012 The nurse is preparing to utilize an external Correct answer: 4 A client who is in ventricular fibrillation requires immediate defibrillation; a client with atrial pacemaker for a client with a dysrhythmia. The nurse fibrillation might require synchronized cardioversion; a client with ventricular tachycardia knows that this pacemaker often is necessary when a could require defibrillation. The client with second‐degree heart block is the client in this group client is in which of the following cardiac rhythms? most likely to need a pacemaker. ‐ Ventricular fibrillation ‐ Atrial fibrillation ‐ Ventricular tachycardia ‐ Second‐degree heart block | Recognize the need to omit all options that require the use of a defibrillator for either defibrillation or cardioversion; that would be options 1, 2, and 3. |
2013 A client with hypertension has a blood pressure of Correct answer: 4 Blood pressure should be consistently below 140/90. Lifestyle modification must be used in 170/96 after six months of intensive exercise and diet all hypertensive clients, with or without medication therapy. modifications. The nurse advises the client: ‐ To continue the current treatment plan, as his blood pressure is being adequately controlled. ‐ To discontinue the current treatment plan, as it has not been effective, and medications will be required. ‐ To increase his exercise twofold and continue dietary modifications to attempt to lower blood pressure further. ‐ That medication therapy likely will need to be started along with the exercise and diet program. | Look for the option that will continue the lifestyle modifications but add medications. |
2014 Evidence that the outcome of increased arterial blood Correct answer: 1 Pain of arterial occlusive disease is related to interrupted blood flow, which causes tissue supply to the extremity has been met in a client with hypoxia. An increase in blood supply, then, should reduce the client's ischemic pain. The other peripheral arterial disease includes: options list additional manifestations of peripheral arterial disease. ‐ Reduced muscle pain. ‐ Reduced sensation to touch. ‐ Increased rubor. ‐ Decreased hair on the extremity. | Carefully read the option, focusing on the qualifier paired with the symptom. Reduction of muscle pain is the only option that applies to increased blood supply. |
2015 In teaching a hypertensive client about the side Correct answer: 3 Beta adrenergic blocking agents, such as propranolol, cause a decrease in heart rate and effects of propranolol (Inderal), the nurse plans to decreased contractility, which can result in bradycardia or heart failure. Constipation is a side include which side effect of this medication therapy? effect of therapy with some of the calcium channel blockers, while hypokalemia increases risk of digitalis toxicity. ‐ Hypokalemia ‐ Constipation ‐ Heart failure ‐ Tachycardia | Recall that the word ending “‐olol” often is associated with beta‐blocking agents. Option 3 is reflective the decrease in contractility associated with the use of these drugs. |
2016 A client is at high risk for developing deep vein Correct answer: 4 The classic manifestations of a deep vein thrombosis are calf or groin pain, which might or thrombosis. For which of the following manifestations might not be associated with leg swelling. The other options describe symptoms of arterial does the nurse assess? disease. ‐ Absent pulse and pale extremity ‐ Ulcerated toes and rubor ‐ Cyanotic extremity and numbness ‐ Leg swelling and calf pain | Look for the option that includes pain, recalling that it often is associated with DVT. |
2017 A client on furosemide (Lasix) therapy demonstrates Correct answer: 4 Orange juice is an excellent source of potassium. Coffee will adversely elevate blood pressure. understanding of how to increase potassium in his diet Milk is high in sodium. Cranberry juice is not as high in potassium as is orange juice. when he states he will add which of the following beverages to his diet? ‐ Milk ‐ Cranberry juice ‐ Coffee ‐ Orange juice | Recall that oranges are high in potassium. |
2018 Which of the following findings in a client awaiting Correct answer: 1 The primary symptom of a dissecting aneurysm is sudden, severe pain. Abdominal dissections abdominal aortic aneurysm repair would you report commonly cause back pain. The other responses do not address this emergency. immediately to the physician? ‐ Severe back pain ‐ Swelling of the arms and face ‐ Increased blue areas of the feet ‐ Hoarseness or difficulty swallowing | The words “severe pain” in the distractor help to identify a reason to contact a physician. |
2019 Which of the following laboratory values is most Correct answer: 2 Heparin dose concentration and number of units per milliliter per hour are ordered to important for the nurse to assess to monitor maintain a therapeutic PTT. The other responses are incorrect. therapeutic levels of heparin therapy? ‐ Prothrombin time (PT) ‐ Partial thromboplastin time (PTT) ‐ Clotting time ‐ Bleeding time | Always associate heparin therapy with monitoring of PTT. |
2020 A client complains of pain and cramping after short Correct answer: 3 Intermittent claudication caused by muscle ischemia is a primary symptom of peripheral periods of walking, symptoms that stop when he rests. arterial disease. Pain occurs with activity but is relieved with rest. The other options are not The nurse concludes he is describing which of the associated with this disorder. following symptoms of peripheral arterial disease? ‐ Arterial–venous shunting ‐ Phlebitis ‐ Intermittent claudication ‐ Raynaud's phenomenon | The description of the pain in the question will help to identify option 3, intermittent claudication, as correct. |
2021 Which nursing activity would be important to add to Correct answer: 1 Clients with orthostatic hypotension are at risk for dizziness and syncope if they arise quickly. the plan of care for an older adult suspected of having Option 3 is a correct action, but does not relate directly to orthostatic hypotension. Blood orthostatic hypotension? pressure should also be taken while the client is sitting and standing (option 2). Option 4 is unrelated to the question. ‐ Teaching the client to get out of bed slowly ‐ Monitoring all blood pressure readings when the client is lying down ‐ Taking blood pressure readings in both arms ‐ Teaching the client about the use of sublingual nitroglycerin | Recall that controlling change of position is key for clients with orthostatic hypotension. |
2022 When educating the client with primary hypertension, Correct answer: 4 A common complication of hypertensive disease is target organ disease, including retinal the nurse instructs the client to: damage to the eye. The appearance of the retina can provide important information about the severity of the hypertensive process. ‐ Take anti‐hypertensive medications when blood pressure is elevated. ‐ Monitor blood pressure annually. ‐ Avoid foods with concentrated sugars. ‐ Have regular eye exams. | Omit options 1 and 2 as being inappropriate methods of treating and monitoring hypertension. |
2023 A client is being treated for new‐onset heart failure Correct answer: 2 A side effect of digoxin and furosemide is that they promote the excretion of potassium, and with a sodium‐controlled diet, digoxin (Lanoxin), and a U wave is a sign of hypokalemia. The other options are incorrect. furosemide (Lasix). The ECG monitor shows a new U wave. Based on this new finding, the nurse determines that it is important to check which of the following laboratory test results? ‐ Sodium ‐ Potassium ‐ Calcium ‐ Magnesium | Focus on the combination of two drugs that contributes to hypokalemia. |
2024 The nurse is caring for a client who has a central Correct answer: 1 The transducer must be at the same level as the right atrium to obtain an accurate venous pressure (CVP) monitor. The nurse prepares to measurement. It is the nurse's responsibility to level the CVP transducer to this point at regular measure the CVP by placing the client in which intervals according to policy and before each measurement. position? ‐ Supine, with the transducer at the level of the right atrium | Select the option that stresses the importance of aligning the transducer with the right atrium. |
‐ Sitting in the chair, with the transducer at the level of the left ventricle ‐ On the left side, with the head of the bed flat ‐ In any position, since it does not affect readings | |
2025 The nurse on a telemetry unit is caring for a client Correct answer: 2 Vitamin K is not associated with the incidence of PVCs. There is no evidence in the question who has infrequent premature ventricular contractions that this client has a potassium deficiency, or is at risk for one. It is recommended that clients (PVCs) noted on the continuous ECG monitor. In having PVCs eliminate caffeine and nicotine from their diets. preparing discharge instructions, which of the following statements is most appropriate to say to this client? ‐ “Make sure that you have several servings of green, leafy vegetables daily to keep up your intake of vitamin K." ‐ "Avoid caffeine and nicotine, because they can contribute to your irregular heartbeats." ‐ "Make sure that you have foods rich in potassium, because decreased potassium could be the cause of your irregular heartbeats." ‐ "There are no dietary recommendations for your irregular heart rhythm." | Recall that caffeine and nicotine are known to increase myocardial irritability. |
2026 The nurse is caring for a client with atrial fibrillation. Correct answer: 3 Atrial fibrillation is characterized by irregularly irregular QRS complexes and rhythm. There is The nurse is administering digoxin (Lanoxin), and is no underlying regular rhythm with atrial fibrillation. assessing the apical pulse. The nurse expects to hear which of the following types of rhythms? ‐ A very rapid, regular rhythm ‐ A regular rhythm with intermittent irregular beats ‐ A rhythm that is irregularly irregular ‐ A regular rhythm with intermittent pauses | Omit options 1, 2, and 4, as they describe a regular rhythm, which is not descriptive of atrial fibrillation. |
2027 The nurse in the emergency room is administering Correct answer: 1 Cerebrovascular accident (CVA) is a very serious complication of thrombolytic therapy. The tPA (Activase) for an acute myocardial infarction. In most important intervention to detect this complication is frequent assessment of neurological order to avoid a serious complication of this status. Testing for occult blood is important with these clients to detect GI or urinary tract treatment, the nurse plans to do which of the bleeding, a less serious complication. PTT monitoring does not detect a specific area of following? bleeding. Teaching a client to use a soft toothbrush is important to prevent bleeding gums, a minor complication of this therapy. ‐ Assess the client's neurological status frequently. ‐ Test stools, urine, and blood for occult blood. ‐ Monitor the client's PTT. ‐ Teach the client to use a soft toothbrush. | Select the option that would detect a serious bleed to answer correctly. |
2028 The homecare nurse is caring for a client with Correct answer: 4 Prognosis often is poor with advanced cardiomyopathy, and little can be done to increase the cardiomyopathy whose symptoms have become more client's activity level. The symptoms usually become worse as the disease progresses. severe over the last year. On the first visit, the client Irritability and withdrawal could be signs of feelings of inadequacy or despair. Validating the reports extreme fatigue and dyspnea with any activity. difficulty of the client's experience is an intervention to create an environment of acceptance The client is irritable and withdrawn. The best and empathy. response by the nurse is which of the following? ‐ "Let's see what we can do to increase your energy." ‐ "Have you tried resting frequently?" ‐ "Sometimes these symptoms improve with time." ‐ "It must be difficult to experience these changes." | Focus on the option that is open‐ended and allows expression of feelings on the part of the client. |
2029 The nurse is caring for a client with subacute bacterial Correct answer: 3 Sudden‐onset dyspnea, anxiety, and tachycardia are signs of pulmonary embolism, a serious endocarditis (SBE). In assessing for complications of complication of SBE. Chills and fever could be symptoms of SBE; bleeding gums and occult SBE, the nurse is alert for which symptom(s)? blood are not symptoms of a direct complication of SBE; the client with SBE usually has a normal WBC. ‐ Chills and fever ‐ Bleeding gums or occult blood in stools ‐ Sudden onset of dyspnea, anxiety, and tachycardia ‐ Increased white blood cell (WBC) count | The question is asking for a complication of SBE. Focus on the most severe set of symptoms that would be associated with SBE. |
2030 The homecare nurse is visiting a client who has heart Correct answer: 3 In a client with heart failure, a weight gain of 3–5 pounds over a week is a significant indicator failure. The client denies any changes in the way she of an increase in retained fluid. It is not appropriate to provide false reassurance to a client. feels. The nurse notes that the client has gained 3 The fluid increase indicates that the therapeutic regime is not adequate for this client. It is pounds in the last week, and the client is concerned important for the nurse to ascertain if the client has been taking her prescribed diuretics, and about the weight gain. Which of the following would to consult with the primary care provider before the client's fluid overload becomes excessive. be best for the nurse to say at this time? Diet alone is not adequate to treat this increase in fluids. ‐ "Let's go over your diet for the last week and see if we can plan menus for next week that are lower in fat." ‐ "I can't even tell that you gained the weight. Three pounds isn't really a problem." ‐ "Tell me what medications you took this week." ‐ "What did you eat differently this week?" | Look for a response that would indicate the nurse is assessing the use of diuretics. |
2031 The nurse is caring for a client who recently was Correct answer: 3 Pain usually is the first presenting sign of new or extended MI, which is a very serious admitted to the intermediate care unit with a complication for this client. Activity order for a client immediately post‐MI usually is bedrest or myocardial infarction (MI). The nurse is most commode privileges. Although an important client outcome is to be free from life‐threatening concerned about achieving which client outcome? dysrhythmias, clients frequently have benign dysrhythmias after an MI, and many are not in normal sinus rhythm. Maintaining a balanced intake and output is important, but not as critical as remaining pain‐free. ‐ The client will ambulate in the room without fatigue. ‐ The client will maintain a balanced intake and output. ‐ The client will be pain‐free. ‐ The client will have a normal sinus rhythm. | Identify the option that addresses the priority of post‐MI care, pain. |
2032 The nurse is caring for a client with continuous ECG Correct answer: 4 The rhythm shown in the figure is ventricular fibrillation. This is a cardiac emergency, and monitoring. The nurse observes that the client's immediate defibrillation is the recommended response. Administration of intravenous rhythm has changed to the rhythm shown. After lidocaine is recommended for ventricular tachycardia. Checking vital signs and calling the activating the emergency response system, the next physician are included once the emergency response system is activated. best action by the nurse is to: ‐ Call the physician and report the change in rhythm. ‐ Check the client's blood pressure. ‐ Administer intravenous lidocaine. ‐ Immediately defibrillate the client. | The scenario indicates that the client is in an emergent situation. Options 1 and 2 are not priorities of care at this time. Recognize that defibrillation is the only treatment. |
2033 The nurse places highest priority on implementing Correct answer: 4 Pulses are assessed frequently to ensure that adequate circulation is present and an occlusion which of the following measures on the surgical unit or leakage of the graft has not occurred. Pulses should be marked preoperatively so the nurse on the first postoperative day following surgical repair has a comparison point postoperatively. Pulses could be absent for the short‐term of an aneurysm? postoperatively due to vasospasm or hypothermia. ‐ Administer anticoagulant therapy. ‐ Position the legs in Trendelenburg position. ‐ Apply elastic stockings to both legs. ‐ Palpate peripheral pulses q2–4h. | Recall that assessment is the first step in the nursing process. Option 4 reflects an assessment. |
2034 A client with venous stasis ulcers is being treated with Correct answer: 1 Elevation of the extremities promotes venous return. Pulses are assessed to ensure adequate an Unna boot. Other interventions should include: circulation. Option 3 is unnecessary because the Unna boot is treating the ulcer and is changed every 1–2 weeks. ‐ Elevating legs and assessment of peripheral pulses. ‐ Keeping legs dependent for pain relief and improved circulation. ‐ Wet to dry dressings to ulcer b.i.d. ‐ Elevating legs and standing as much as possible. | Eliminate options 2 and 4, as dependency in the position of the leg is contraindicated. |
2035 In planning care for a client receiving warfarin sodium Correct answer: 4 Aspirin is an antiplatelet agent, and its properties will increase the risk of bleeding while the (Coumadin), the nurse instructs the client to: client is taking anticoagulant therapy. The medication does not place the client at risk for infection (option 1) or directly affect blood pressure (options 1 and 4). ‐ Monitor blood pressure weekly. ‐ Observe for signs and symptoms of infection. ‐ Get up slowly from the chair or bed. ‐ Avoid aspirin and aspirin‐containing products. | Recall the association of Coumadin with a contraindication of aspirin products. |
2036 For a client with deep vein thrombosis receiving Correct answer: 3 During heparin therapy, the therapeutic PTT equals 1.5–2.0 times the control value. The other heparin sodium, the nurse evaluates the partial options do not reflect this ratio. thromboplastin time (PTT) as therapeutic when the results are noted as: ‐ Control = 25 seconds, PTT = 20 seconds. ‐ Control = 20 seconds, PTT = 25 seconds. ‐ Control = 25 seconds, PTT = 50 seconds. ‐ Control = 30 seconds, PTT = 90 seconds. | Omit option 1, as the PTT should increase with therapy. Omit option 4, as this is a large variance. |
2037 A client reports burning and numbness of the hands. Correct answer: 3 In Raynaud's disease, vasospasm causes the digits to turn blue, then white. As the vasospasm After noting them to be bluish‐white, changing to very ends and circulation returns, the digits become very red and warm. The other disorders listed red, the nurse concludes that the findings likely do not have these manifestations. represent: ‐ Intermittent claudication. ‐ Carpal tunnel syndrome. ‐ Raynaud's disease. ‐ Arterial occlusion. | Recall that changes to hand color are often associated with Reynaud’s disease. |
2038 Evidence that the outcome of "restore tissue Correct answer: 4 A goal of venous ulcer care is for the client to experience no signs of inflammation or integrity" has been met in a client with a venous stasis infection. This is the goal that is directly related to tissue integrity. The other options are good ulcer includes: outcomes but do not relate directly to the question as stated. ‐ Absence of bleeding. ‐ No reports of pain. ‐ Increased activity tolerance. ‐ No signs of inflammation or infection. | The question is referring to a stasis ulcer. Focus on no infection as a result of restoration of tissue integrity or healing. |
2039 Which of these statements by a client receiving Correct answer: 1 Both butter and margarine have 4 grams of fat, making the client's statement incorrect and in dietary instruction for atherosclerosis would indicate a need of clarification. The responses in the other options are correct. need for further discussion? ‐ "Margarine has less fat than butter, so I will no longer use butter." ‐ "I will steam, bake, or broil my foods." ‐ "American cheese has 76 percent fat calories." ‐ "I will increase my consumption of fruits and vegetables." | Omit options 2, 3, and 4 as being true and generally recommended. Recognize option 1 as false. |
2040 The nurse would plan to instruct the client that which Correct answer: 2 Dry mouth is a common side effect of this centrally acting adrenergic blocker, which acts to of the following medications might require the use of reduce the flow of blood through the sympathetic nerves to the blood vessels and heart. Use sugarless chewing gum or hard candy to relieve the of sugarless chewing gum, hard candy, and frequent sips of water will help relieve this side side effect of dry mouth? effect. ‐ Nadolol (Corgard), a beta‐blocking agent ‐ Clonidine HCl (Catapres), a centrally acting sympatholytic agent ‐ Warfarin (Coumadin) ‐ Hydralazine HCl (Apresoline), a vasodilator | Omit option 3, as all other options have descriptors. Recall the association of dry mouth with the sympathetic nervous system. |
2041 Which of the following items is most important to Correct answer: 4 Smoking is a major etiological factor for development of Buerger's disease. Nicotine is a include in instructions given to a client with potent vasoconstrictor, and will exacerbate peripheral vascular disorders. The other options do thromboangiitis obliterans (Buerger's disease) to not address the issue of the question. prevent advancement of the disease? ‐ Checking blood pressure weekly ‐ Weighing self every morning and reporting gains of more than 3 pounds ‐ Not driving a vehicle at night ‐ Smoking cessation | Look for the most common risk factor for complications of this disease, smoking. |
2042 The nurse would plan to do which of the following as Correct answer: 3 Bedrest and immobility are risk factors for the development of deep vein thrombosis. Early the most effective measure to reduce the risk of ambulation assists venous return to the heart because of muscle movement against veins, and developing deep vein thrombosis? should be implemented as soon as possible in hospitalized clients. ‐ Active ROM ‐ Passive ROM ‐ Ambulation as soon as possible ‐ Repositioning every two hours | DVT is a common postoperative complication. Identify option 3 as the most common method of prevention. |
2043 A client is prescribed sublingual nitroglycerine for the Correct answer: 4 Nitroglycerine loses potency over time when exposed to light and heat. The tablets should be treatment of angina pectoris. What response from the kept cool, dry place, and in a dark container. Clients should get a new bottle every six months. client indicates that the client understands this Tablets should be taken five minutes apart; taking more that one tablet at a time can actually medication? decrease the effectiveness of the drug, and can cause severe hypotension. ‐ "Will the physician give me a year's supply of nitroglycerine tablets?" ‐ "I will carry my nitroglycerine tablets in the inside pocket of my jacket, so they are always close." ‐ "I usually take three of my nitroglycerine tablets at the same time. I find that they work better that way." ‐ "I have a small, labeled case for a few nitroglycerine tablets that I carry with me when I go out." | Select the option that indicates that the client has learned that nitroglycerine should be carried with her at all times and properly stored. |
2044 A client is being evaluated for a possible myocardial Correct answer: 2 ST elevations indicate immediate myocardial injury; ST depressions indicate myocardial infarction. The nurse performs a 12‐lead ECG for an ischemia; a Q wave forms several days after a myocardial infarction; a U wave is a sign of episode of new chest pain. The nurse will monitor for hypokalemia. which sign of acute myocardial injury? ‐ ST depressions ‐ ST elevations ‐ New Q wave ‐ New U wave | Omit options 3 and 4 as not reflective of the acute phase of myocardial injury. Recall that ST elevations reflect injury. |
2045 The nurse is caring for a client who underwent a Correct answer: 1 ST depressions are a sign of ischemia. The physician should be notified immediately of any percutaneous transluminal coronary angioplasty signs of ischemia after PTCA. This is the best first action, after which the nurse should continue (PTCA) four hours previously. The client has no change to assess the client for chest pain. Administration of nitroglycerine without an order is not an in the catheter site or vital signs since returning from appropriate nursing action. There is no sign of bleeding at the site; therefore, there is no the procedure. The nurse obtains a 12‐lead ECG, and indication to apply pressure. notes that the client has ST depressions. The client denies any chest pain. Which of the following is the next action that the nurse should take? ‐ Notify the physician. ‐ Continue to assess the client for chest pain. ‐ Administer nitroglycerine. ‐ Apply pressure to the catheter site. | The scenario describes a change that requires an action. Recognize that option 1 is the only appropriate action. |
2046 The nurse is caring for a client who is being Correct answer: 3 St. Jude Medical is a mechanical valve. Lifelong anticoagulation therapy is required with this discharged after valve replacement surgery. The client mechanical valve because there is a risk of thrombus formation. If a valve is replaced with a has a new St. Jude Medical valve, and the nurse is tissue valve, anticoagulation might be required during the immediate postoperative period, reviewing the instructions for the client's follow‐up but not necessarily lifelong anticoagulation. It is recommended to take antibiotics prior to care. The nurse determines that the client understands dental care. an important aspect of responsibility in the care of this valve when the client makes which of the following statements? ‐ "I will take Coumadin for two months, and get my blood drawn every week until I stop taking it." ‐ "I will remind the doctor to give me a prescription for anticoagulant medication every time I go to the dentist." ‐ "I will need to take anticoagulant medication for the rest of my life." ‐ "I won't take any anticoagulant medication or blood thinners because they could cause a problem with my new valve." | The question asks for an evaluation that the client has understood teaching. Select option 3 as the only correct statement. |
2047 The nurse is caring for a client on the third Correct answer: 2 Vigorous coughing is discouraged for post‐CABG clients because it can increase intrathoracic postoperative day after coronary artery bypass (CABG) pressure and cause instability in the sternal area. Incentive spirometry and deep breathing are surgery. Because an important nursing diagnosis for the preferred techniques for lung expansion with these clients. Premedication before post‐ CABG clients is Ineffective Breathing Pattern, ambulation will facilitate activity tolerance; auscultating the lungs will detect adventitious lung what is the best plan by the nurse? sounds resulting from the ineffective breathing pattern, but it is not an action to encourage effective breathing patterns. ‐ Ensure that the client performs deep breathing and vigorous coughing every hour. ‐ Ensure that the client uses the incentive spirometer every hour. ‐ Premedicate the client before ambulation. ‐ Auscultate the lungs once a shift. | Omit options 3 and 4, as they are not applicable to the nursing diagnosis in the scenario. Select option 2 as addressing the nursing diagnosis and being safe for the client situation. |
2048 The nurse is caring for a client with angina pectoris Correct answer: 4 A cholesterol level higher than 200 indicates elevated cholesterol; a ratio of HDL to total who was ruled out for a myocardial infarction. The cholesterol of less than 1:5 indicates increased cardiovascular risk; triglycerides higher than nurse reviews the client's laboratory results, and plans 190 indicate increased risk. (Exception: triglycerides higher than 190 without elevated to include dietary teaching after noting that the client's cholesterol do not indicate increased cardiac risk until they reach 250.) lipid profile shows which of the following sets of values? ‐ Cholesterol: 180; HDL: 40; triglycerides: 220 ‐ Cholesterol: 190; HDL: 40; triglycerides: 160 ‐ Cholesterol: 120; HDL: 25; triglycerides: 220 ‐ Cholesterol: 220; HDL: 40; triglycerides: 190 | Identify the only option with abnormal total cholesterol, option 4. |
2049 The nurse is caring for a client with new‐onset atrial Correct answer: 3 Synchronized cardioversion is most effective with new‐onset atrial fibrillation. Pacemakers fibrillation. The nurse anticipates that which of the are indicated for heart block, AICDs are used for ventricular dysrhythmias, and defibrillation is following is a possible treatment for this dysrhythmia indicated for ventricular fibrillation and pulseless ventricular tachycardia. when it first develops? ‐ External pacemaker application ‐ Insertion of automatic internal cardiac defibrillator (AICD) ‐ Synchronized cardioversion ‐ Defibrillation | Use process of elimination to omit options 2 and 4, as both refer to defibrillation, which is not appropriate. |
2050 The nurse is assessing a client the morning of a Correct answer: 4 The client should have a light meal with no caffeine before a cardiac stress test. Options 1, 2, scheduled cardiac stress test. The client reports that and 3 are incorrect because they do not follow this guideline. no breakfast was delivered this morning, and the client is hungry. Which of the following is the nurse's best action? ‐ Bring the client coffee and toast. ‐ Explain that a client should have no food the morning of a cardiac stress test. ‐ Call the nutrition department and get the client's regular full breakfast. ‐ Have the nursing assistant get the client cereal with milk and orange juice. | Select the response that reflects the needs of a client having a cardiac stress test that day. Recall that means a light meal with no caffeine. |
2051 A hospitalized client has continuous ECG monitoring, Correct answer: 3 The best first action is to assess the client's level of consciousness and assess if the ventricular and the monitor shows that the rhythm has changed tachycardia is perfusing the body (BP, pulse). With pulseless ventricular tachycardia, to ventricular tachycardia. Which of the following is immediate defibrillation is performed by an ACLS‐certified nurse. If the client has a good BP the first action that the nurse should take? and pulse, and is awake and alert, the nurse may administer lidocaine as prescribed or, in some cases, a precordial thump. ‐ Administer intravenous lidocaine according to emergency protocol. ‐ Obtain the defibrillator, and defibrillate the client. ‐ Quickly assess the client's level of consciousness, blood pressure, and pulse. ‐ Administer a precordial thump. | Recall that assessment is the first step of the nursing process. Option 3 is an assessment. |
2052 The physician has diagnosed a myocardial infarction Correct answer: 2 Anxiety and fear are common responses to a diagnosis of myocardial infarction, because of on the basis of ECG changes for a client in the the possibility of death. This prevents the client and family from absorbing the detailed Emergency Department. The nurse is assessing the explanations about the care being provided. Memory lapses are not a common symptom of client frequently, and notes that the client seems myocardial infarction, and there is not adequate information to determine that this memory forgetful, making the nurse repeat the explanations lapse is associated with Alzheimer's disease. Nurses in the Emergency Department are capable about the ECG and non‐invasive blood pressure of explaining procedures well to their clients. monitors. The nurse concludes that the client's response is most likely due to which of the following reasons? ‐ The client is showing signs of Alzheimer's disease. ‐ The client is showing signs of fear and anxiety. ‐ Nurses in the Emergency Department are too busy to properly explain the purpose of equipment. ‐ Memory lapses are common with clients experiencing myocardial infarctions. | Select an answer for which there are adequate data provided. Omit option 3 as not being client‐centered. There is no evidence that Alzheimer s disease is present. |
2053 The nurse is performing an assessment on a 50‐year‐ Correct answer: 3 Fifty percent of people over the age of 50 develop varicose veins, and a major risk factor is old male who is a cashier at a local store, and who standing for long periods of time at work. The other responses do not address this concern. often stands 6–8 hours at a time. The nurse should inspect the client for: ‐ Capillary dysfunction. ‐ Buerger's disease. ‐ Varicosities. ‐ Aneurysms. | Make the association between advancing age and standing for long periods to identify option 3 as correct. |
2054 The nurse is conducting a screening clinic for Correct answer: 4 Primary hypertension is more common in African‐Americans than in people of other ethnic hypertension in the community. For which of the backgrounds. For this reason, this client should be evaluated carefully. following clients should the nurse pay particular attention to blood pressure? ‐ Caucasian adult female ‐ Latino/Hispanic adult male ‐ Asian adult male ‐ African‐American adult male | Remember the association between hypertension and those of African‐American decent. |
2055 When assessing a client, the nurse determines the Correct answer: 3 Blanching of the nailbed for more than 3 seconds after release of pressure could indicate capillary refill time to be 7 seconds. The nurse reduced arterial capillary perfusion, which can be an indication of decreased cardiac output. determines the client might be experiencing: The other options are incorrect for the time frame indicated or do not apply. ‐ Normal signs of aging. ‐ Impending stroke. ‐ Decreased cardiac output. ‐ Hypokalemia. | Omit options 2 and 4, as neither can be diagnosed by measurement of capillary refill. |
2056 After the first dose of an antihypertensive agent, your Correct answer: 4 Elevating the legs increases venous return to the heart, and will assist in raising the blood client suddenly becomes hypotensive. The nurse pressure. A semi‐Fowler's position could lower the blood pressure even further. A side‐lying should position the client: position will have no beneficial effect, and the Trendelenburg position could impair respirations by causing upward pressure on the diaphragm by gravity. ‐ In a semi‐Fowler's position. ‐ In a side‐lying position. ‐ In Trendelenburg position. ‐ With her legs elevated 30 degrees. | Eliminate option 1, as it maintains the head above the heart. Option 2 would also be eliminated as not contributing to increasing perfusion of vital organs. |
2057 The nurse is planning to instruct a client on the side Correct answer: 2 Calcium channel blockers relax arterial smooth muscle, which lowers peripheral resistance effects of nifedipine (Procardia) for hypertension. through vasodilation. Dizziness is a common side effect due to orthostatic hypotension. Clients Which side effect should the nurse include? need to be taught to change position slowly to prevent falls. ‐ Hypokalemia ‐ Dizziness ‐ Bleeding ‐ Tachycardia | The drug is being used to treat hypertension. Select the option that is symptomatic of hypotension. |
2058 A client taking spironolactone (Aldactone) complains Correct answer: 3 Spironolactone is a potassium‐sparing diuretic. Hyperkalemia (potassium level higher than 5.5 of irregular heart rate, diarrhea, and stomach mEq/L) is a possible side effect. The other responses are incorrect. cramping. The client's potassium level is 7.1 mEq/L. The nurse concludes that the client is experiencing: ‐ Hyponatremia. ‐ Hypercalcemia. ‐ Hyperkalemia. ‐ Hypernatremia. | Recognize that the hyperkalemic value is presented. Omit the options for which there are no data. |
2059 The nurse explains to a client that the goal of Correct answer: 1 Anticoagulant therapy is used for deep vein thrombosis to prevent propagation of the clot, anticoagulant therapy in a client with a deep vein development of a new thrombus, and embolization. It does not dissolve the clot. It has no thrombosis is to: effect on infection, and does not allow for immediate ambulation. ‐ Prevent embolization. ‐ Dissolve the clot. | Eliminate options 3 and 4, as they do not directly address the clot. Omit option 2, as it is false. |
‐ Allow immediate ambulation. ‐ Prevent infection. | |
2060 The nurse needs to explore with a client her Correct answer: 3 Sclerotherapy, the injection of a sclerosing agent into a varicose vein followed by understanding of treatment options for varicose veins compression with a compression bandage for a period of time, is a common procedure for that were just described by the physician. Which varicose veins. treatment would the nurse plan to include in this discussion? ‐ Endarterectomy ‐ Venography ‐ Sclerotherapy ‐ Plethysmography | Use the suffixes in options 2 and 4 to eliminate these options. “‐graphy” is generally indicative of a study or diagnostic measure. “‐therapy” in option 3 helps to identify this as a treatment. |
2061 Which of the following medications is likely to be Correct answer: 3 Because of the risk for inflammation or a blood clot, low doses of aspirin are recommended administered on a daily basis to a client newly for all clients with peripheral vascular disease. Aspirin has antiplatelet activity; without platelet admitted to the clinical nursing unit who has a history aggregation, a clot cannot form. of peripheral arterial disease? ‐ Acetaminophen (Tylenol) ‐ Ibuprofen (Motrin) ‐ Aspirin ‐ Heparin | Look for a common medication used for its ability to limit clotting, like aspirin. |
2062 Which of the following statements would indicate a Correct answer: 4 Sensation in the feet can be diminished in clients with arterial occlusive disease. Teach the positive outcome for a client with chronic arterial client to check the bathwater with her hands to prevent the risk of a burn injury. The client occlusive disease? should stop and rest when pain is experienced (option 3). Options 1 and 2 are useful treatments for venous disease. ‐ "I will keep my feet elevated above the level of my heart when I sleep." ‐ "I will wear my compression stockings when awake." ‐ "I will keep walking even when I feel pain in my legs, to increase circulation." ‐ "I will check the temperature of my bathwater with my hands before getting into the water." | Select the option that indicates that the client understood the teaching. |
2063 The nurse teaching health maintenance strategies for Correct answer: 1 Clients with COPD are highly susceptible to respiratory infections such as influenza, so they the client with COPD should include which of the should be immunized yearly. Clients with COPD should undergo a progressive rehabilitation following? program to increase their activity tolerance. Fluid restriction is not needed with COPD unless there is fluid retention from another etiology. ‐ Yearly influenza immunizations ‐ Annual tuberculin skin test ‐ Limitation of physical activity ‐ Fluid restriction | The critical words in the stem of the question are health maintenance. This phrase indicates that you should focus on the option that prevents a health problem rather than diagnoses or treats it. |
2064 The nurse who is explaining the pathophysiology of Correct answer: 1 The impaired gas exchange occurring with COPD is caused by the loss of alveolar surface area COPD to a client includes the fact that alveolar available for gas exchange. Destruction of alveoli is not related to increased dead space air, destruction results in which of the following? pulmonary emboli, or chronic dilation of bronchioles. With COPD, there is progressive narrowing of bronchioles. ‐ Decreased surface area for gas exchange ‐ Increased dead space air ‐ Pulmonary emboli ‐ Chronic dilation of bronchioles | The core issue of the question is the nature of the pathophysiology of COPD. Use general nursing knowledge and the process of elimination to make a selection. |
2065 The nurse explains to a client and family that the Correct answer: 1 Symptoms of COPD typically appear in the fifth and sixth decades of life following chronic development of COPD in a young adult is likely caused abuse to pulmonary tissues from smoking or environmental pollutants. Onset of the by which of the following? physiological changes compatible with COPD is most often associated with a hereditary deficiency of alpha‐1‐antitrypsin, an enzyme that protects lung tissue against loss of elasticity. Onset of heavy smoking during childhood and heavy secondary smoke exposure during childhood are not typically associated with early onset of the physiological alterations of COPD. Use of smokeless tobacco during childhood is associated with development of oral cancer. ‐ Hereditary deficiency of alpha‐1‐antitrypsin ‐ Onset of smoking during childhood ‐ Heavy secondary smoke exposure during childhood ‐ Use of smokeless tobacco during childhood | The core issue of the question is sharing with a client and family the correct basis of the current health problem. Use nursing knowledge and the process of elimination to make a selection. |
2066 A client who develops acute respiratory distress Correct answer: 1 One of the primary alterations occurring with ARDS is the collapse of alveoli and therefore syndrome (ARDS) is exhibiting hypoxemia unresponsive loss of ventilation in those areas. Perfusion might be normal, but gas exchange is impaired due to oxygen therapy. In explaining the client’s condition to inadequate ventilation. Surfactant production decreases with ARDS, a factor that impairs to the family, the nurse would incorporate which of adequate gas exchange. Air does not become trapped in hyperinflated alveoli in ARDS; instead, the following concepts? alveoli collapse. ‐ Blood is shunted past alveoli with no ventilation. ‐ The individual has difficulty expelling air trapped in the alveoli. ‐ There is excess surfactant production by the alveoli. ‐ Thick secretions block the airways. | The core issues of the question are an understanding of disease process and how to select appropriate concepts for family teaching. Use nursing knowledge and the process of elimination to make a selection. |
2067 What intervention does the nurse identify as the Correct answer: 3 Coughing, deep breathing, and adequate hydration are essential for achieving effective airway priority for the client with a nursing diagnosis of clearance. Insertion of a tracheostomy is not a primary treatment to maintain airway ineffective airway clearance related to tumor mass? clearance. Elevating the head of the bed might help the client to cough more forcefully, but head elevation alone is not an effective maneuver. ‐ Provide supplemental oxygen. ‐ Keep the head of the bed elevated. ‐ Teach the client coughing and deep breathing, and maintain hydration. ‐ Prepare the client for the possible insertion of a tracheostomy tube. | The critical word in the stem of the question is priority, which tells you that more than one option could be correct, and you must choose the most important one. Use nursing knowledge and the process of elimination to make a selection. |
2068 When assisting with psychological issues for the client Correct answer: 1 The nurse should help the client and family to approach the diagnosis of lung cancer from a with lung cancer, which epidemiological factor should realistic perspective. Symptoms of lung cancer usually appear late in the course of the disease. the nurse keep in mind? Tumor growth does typically begin in a bronchus and progress upward, but this information has no relation to the client’s psychological adaptation to the disease. ‐ The five‐year survival rate for lung cancer is less than 15 percent. ‐ Symptoms usually occur early during lung cancer progression. ‐ Tumor growth usually begins in a bronchus, then migrates upward in the tissue. ‐ Risk of lung cancer is associated with length of exposure to cigarette smoking. | The core issue of the question is the knowledge of the interrelationship between prognosis and the communication approaches used by the nurse. Use nursing knowledge and the process of elimination to make a selection. |
2069 The nurse administers which of the following Correct answer: 3 Administration of anticoagulants (option 3) is an effective intervention to prevent pulmonary medications as a part of pharmacological treatment embolism. Thrombolytic drugs (option 1) may be used to dissolve a clot that is already formed. aimed at prevention of pulmonary embolism? Vitamin K (option 2) and protamine sulfate (option 4) facilitate clotting and counteract the effect of anticoagulants. ‐ Streptokinase ‐ AquaMEPHYTON (vitamin K) ‐ Enoxaparin (Lovenox) ‐ Protamine sulfate | The core issue of the question is knowledge of medication to reduce risk of pulmonary embolus. Use nursing knowledge and the process of elimination to make a selection. |
2070 In the client with respiratory distress, which finding is Correct answer: 4 Increased respiratory rate, tachycardia, and agitation are all early signs of respiratory distress. most compatible with a worsening clinical state? Cyanosis develops later in the progression of respiratory distress. ‐ Increased respiratory rate ‐ Tachycardia ‐ Agitation ‐ Cyanosis | The critical word in the stem of the question is worsening, which tells you that the symptom will be a late sign, not an early one. Cyanosis is always a late sign. Use nursing knowledge and the process of elimination to make a selection. |
2071 For the hospitalized client, which factor would the Correct answer: 3 Symptoms associated with pulmonary embolism typically have a sudden onset. The client nurse assess to be a symptom of pulmonary often feels panic because of the sudden dyspnea. Increase in heart rate and respiratory rate is embolism? abrupt, not slow. Cyanosis of the upper torso is associated with embolism of a central vein other than the pulmonary vasculature. Bilateral wheezing is more often associated with asthma than with pulmonary embolism. ‐ A slow increase in heart rate and respiratory rate ‐ Cyanosis of the upper torso ‐ Abrupt onset of dyspnea and apprehension ‐ Significant bilateral wheezing | The critical words in the stem of the question are symptom and pulmonary embolism. They tell you that the question is seeking an answer that is a correct assessment. Use nursing knowledge and the process of elimination to make a selection. |
2072 A client underwent a thoracentesis a few hours Correct answer: 2 The finding of crepitus at any time is associated with pneumothorax, and should be reported earlier. Which finding should the nurse report immediately to the physician. Oozing of blood from the thoracentesis puncture site is not immediately to the physician? uncommon, and does not require emergency intervention, as would crepitus. Diminished breath sounds on the affected side and fever might or might not be related to the thoracentesis. All of these findings should be noted and reported to the physician, but the finding of crepitus is clearly related to development of pneumothorax, and signals immediate need for intervention by the physician. ‐ Oozing of blood from the puncture site ‐ Crepitus ‐ Diminished breath sounds on the affected side ‐ Fever | The core issue of the question is the ability to recognize and prioritize complications that need to be reported to the health care provider. Use nursing knowledge and the process of elimination to make a selection. |
2073 The nurse who is assisting the client with obstructive Correct answer: 3 The primary physiological alterations occurring with COPD are alveolar air trapping and pulmonary disease to learn effective breathing alveolar hyperinflation, which lead to alveolar rupture and loss of area available for gas techniques would use which of the following exchange. Decreased surfactant production is associated with ARDS, and is not a primary statements to explain why dyspnea occurs? alteration of COPD. Lung compliance is decreased, but this is due to the alveolar air trapping and hyperinflation. ‐ “Decreased surfactant causes many of your alveoli to collapse.” ‐ “You have difficulty breathing in enough air.” ‐ “Your airways open wider on inspiration, and trap air on expiration.” ‐ “Your lung compliance is decreased.” | The core issues of the question are knowledge of the underlying changes associated with COPD and how to communicate that information effectively to a client or family. Use nursing knowledge and the process of elimination to make a selection. |
2074 A client is admitted to the hospital with a medical Correct answer: 2 Viral pneumonia is considered less serious for the client because symptoms are not as diagnosis of viral pneumonia. The nurse assesses for apparent compared with bacterial pneumonia. Viral pneumonia is associated with which of the following most frequent manifestations? nonproductive cough, low‐grade fever, normal white blood cell count, and normal or minimal chest x‐ray findings. Ghon's tubercles are seen on x‐ray in clients with tuberculosis. ‐ Presence of Ghon's tubercle on chest x‐ray ‐ Nonproductive cough ‐ Elevated white blood cell count ‐ High fever | The critical words in the stem are most frequent. With this in mind, you must compare options in terms of their frequency. Use nursing knowledge and the process of elimination to make a selection. |
2075 The nurse would question an order for ipratropium Correct answer: 1 Anticholinergics such as ipratropium are contraindicated in clients with angle‐closure bromide (Atrovent) ordered for a client with asthma if glaucoma because they can inhibit flow of aqueous humor and raise intraocular pressure. The the client had a concurrent history of which of the other options do not address this concern. following? ‐ Glaucoma ‐ Cushing’s syndrome ‐ Warfarin therapy ‐ Fluid retention | The core issue of the question is knowledge of contraindications to medication therapy. Use nursing knowledge and the process of elimination to make a selection. |
2076 The nurse teaches the client newly diagnosed with Correct answer: 2 Clients with mild and infrequent asthma symptoms are treated with regular daily asthma who has infrequent acute episodes that which administration of an anti‐inflammatory inhaler and a short‐acting beta‐agonist inhaler for quick medication is most effective for providing quick relief relief in acute episodes. Bronchodilators and corticosteroids as oral or inhaled medication are in acute episodes? used for clients with more severe and frequent episodes of asthma. ‐ Corticosteroid via metered‐dose inhaler as needed ‐ Beta‐agonist via metered‐dose inhaler ‐ Anti‐inflammatory via metered‐dose inhaler ‐ Daily use of a bronchodilator inhaler | The core issue of the question is knowledge of the rapid management of symptoms in a client with asthma. Use nursing knowledge and the process of elimination to make a selection. |
2077 The nurse caring for a client diagnosed with ARDS Correct answer: 3 A primary physiological alteration occurring with ARDS is shunting of blood around considers that, in this client, impaired gas exchange is nonventilated alveoli. Alveoli collapse in ARDS, and ventilation decreases. Blood perfusing to mostly likely related to which of the following? these areas cannot undergo adequate gas exchange. ‐ Air trapping in the alveoli ‐ Accumulation of exudative fluid into the alveoli ‐ Shunting of blood around nonventilated alveoli ‐ Excessive alpha‐1‐antitrypsin | The core issue of the question is knowledge of pathophysiology in the development of ARDS. Use nursing knowledge and the process of elimination to make a selection. |
2078 A child with laryngotracheobronchitis (LTB) is being Correct answer: 2 Epinephrine is a bronchodilator used to increase the diameter of the airways. The best treated in the Emergency Department. The nurse position is semi‐ to high‐Fowler s. Corticosteroids and antibiotics may be used, but will not would plan to do which of the following to ease ease respiratory distress immediately. respiratory distress? ‐ Turn the child onto his side. ‐ Administer racemic epinephrine. ‐ Administer corticosteroids. ‐ Administer intravenous antibiotics. | The core issue of the question is the expected plan of care for a client with laryngotracheobronchitis. Use nursing knowledge and the process of elimination to make a selection. |
2079 The parents of an infant with bronchiolitis ask the Correct answer: 1 RSV is the cause of bronchiolitis in most cases; RSV can live for several hours on nonporous nurse why their baby s room has a sign on the door surfaces, and can be transferred by the hands. that says “Contact Precautions,” and why the nurses all wear gowns and gloves when they hold him. What is the nurse s best response? ‐ “The virus that usually causes bronchiolitis can spread to other babies if extra precautions are not taken.” ‐ “Your baby is very ill, and we don’t want to have another baby catch what he has.” ‐ “It’s because your baby is in isolation.” ‐ “We always wear gowns when babies are coughing.” | The core issue of the question is the ability of the nurse to explain the rationale and use of isolation techniques. Use nursing knowledge and the process of elimination to make a selection. |
2080 Which of the following would be a priority nursing Correct answer: 2 Maintaining strict I & O will provide immediate notification of signs of dehydration; intervention for a child with bronchiolitis? children with bronchiolitis could already have a history of poor fluid intake when initially seen by medical personnel. Because of respiratory difficulty, the child should be kept quiet, with limited stimulation and visitors. If the child is tachypneic, oral fluids present a risk of aspiration. | The core issue of the question is knowledge that a client with bronchiolitis has a priority need for hydration. Use nursing knowledge and the process of elimination to make a selection. |
‐ Keep the child well stimulated. ‐ Maintain strict intake and output. ‐ Encourage visitors. ‐ Encourage oral fluids, if tachypneic. | |
2081 When taking the nursing history of a child with cystic Correct answer: 3 Meconium ileus in the newborn period is often the first indication of cystic fibrosis. The other fibrosis, what piece of information about the child’s options are unrelated to this question. newborn period would the nurse expect the mother to report? ‐ That the child required resuscitation in the delivery room ‐ That labor was longer than 24 hours ‐ That the child had a meconium ileus ‐ That labor was less than four hours | The core issue of the question is knowledge of the association between meconium ileus and cystic fibrosis in the neonate. Use nursing knowledge and the process of elimination to make a selection. |
2082 The nurse should counsel the parents of a child with Correct answer: 1 Bronchodilators open the airways and afford easier removal of secretions. Options 2 and 3 asthma that before performing postural drainage are unnecessary. Option 4 could be done after the procedure, if necessary. exercises, they should do which of the following? ‐ Administer her bronchodilator. ‐ Change her clothes. ‐ Administer her antibiotic. ‐ Suction her throat. | The core issue of the question is knowledge of the proper sequence of actions when a client undergoes chest physiotherapy. Use nursing knowledge and the process of elimination to make a selection. |
2083 If treatment for acute epiglottis is effective, the nurse Correct answer: 4 Clear breath sounds indicate effective airway clearance and decreased mucosal swelling and would expect to record that the child: obstruction. Tripod position is a clinical manifestation of a child in distress caused by epiglottitis. Pale lips and mucous membranes could indicate hypoxia. Tachypneic and dysphonic are symptoms of the disease. ‐ Has pale lips and mucous membranes. ‐ Maintains tripod position. ‐ Is tachypneic and dysphonic. ‐ Has clear, equal breath sounds. | The core issue of this question is correctly identifying when an appropriate outcome measure has been achieved. Use nursing knowledge and the process of elimination to make a selection. |
2084 The parents of a child with bronchopulmonary Correct answer: 5 Tracheostomy suctioning can be stressful to the child, and increases risk for hypoxia, dysplasia (BPD) are receiving home instructions on infection, and mucosal damage. Each pass of the suction catheter should be limited to no more tracheostomy care. With regard to suctioning, the than 5 seconds, and the child should be allowed to rest between passes with supplemental nurse should advise the parents that each suction pass oxygen, if needed. should take no longer than seconds. (Write in a numerical answer.) | The critical issue of this question is the appropriate length of time for suctioning without impairing the respiratory status of a child. Use nursing knowledge and the process of elimination to make a selection. |
2085 A toddler is being discharged after an emergency Correct answer: 3 Toddlers are naturally inquisitive, and explore things with their hands and mouths. It is admission for foreign body aspiration. The parents ask developmentally inappropriate to attempt to teach a toddler to stop normal hand‐to‐mouth the nurse what they can do to prevent another activity. Small objects and foods should be kept out of reach. accident. The nurse should advise the parents to: ‐ Watch her very carefully. ‐ Teach her not to eat nonfood items. ‐ Keep small objects and toys out of her reach. ‐ Avoid leaving her with teen babysitters. | The core issue of the question is the best method to provide a safe environment for a toddler. Use nursing knowledge and the process of elimination to make a selection. |
2086 The nurse wears gloves when assessing a child with Correct answer: 4 Handwashing is the most important infection‐control practice, and decreases the spread of respiratory syncytial virus (RSV). After removing the RSV and other organisms. Option 1 is unnecessary because gloves are discarded in the trash gloves, what should the nurse do next? basket. Options 2 and 3 are not timely. ‐ Discard the gloves in the laundry basket. ‐ Inspect the gloves for holes or fraying. ‐ Remind the parents to wear gloves. ‐ Wash hands. | The core issue of the question is basic principles of infection control using medical asepsis. Use nursing knowledge and the process of elimination to make a selection. |
2087 A 6‐year‐old child is hospitalized following an acute Correct answer: 2 Swimming is recommended for children with asthma because prolonged expiration under asthmatic episode. Which statement by the parents water is beneficial. Cromolyn sodium is used prophylactically to prevent exercise‐induced indicates that further teaching is needed? asthma, and immediate access to a rescue inhaler is also recommended. ‐ “Next time, we ll be sure he takes his cromolyn before soccer.” ‐ “After this episode, he will need to quit the swim team.” ‐ “We think this was an exercise‐induced asthma episode.” ‐ “We need to make sure he has his inhaler at all times.” | The core issue of the question is an understanding of the relationship of exercise to episodes of asthma. Use nursing knowledge and the process of elimination to make a selection. |
2088 The nurse would anticipate administering respiratory Correct answer: 1 Aerosol therapy such as a nebulizer is frequently used during hospitalization to administer medications to a child hospitalized with asthma by medications. An advantage is that this route delivers medication directly to the airways. which of the following most frequently used routes? ‐ Aerosol ‐ Intravenous ‐ Subcutaneous ‐ Oral | The core issue of the question is an understanding of medication routes used in children, specifically those with respiratory problems. Use nursing knowledge and the process of elimination to make a selection. |
2089 The nurse anticipates using postural drainage as a Correct answer: 3 Chest physiotherapy and postural drainage for children with cystic fibrosis help loosen treatment modality for which of the following pulmonary secretions and facilitate removal from airways. They are not used for epiglottitis conditions? and bronchopulmonary dysplasia because they can increase respiratory distress in those conditions. They will not remove the foreign body. ‐ Epiglottitis ‐ Foreign body aspiration ‐ Cystic fibrosis ‐ Bronchopulmonary dysplasia | The core issue of the question is the purpose of doing chest physiotherapy in a child with cystic fibrosis. Use nursing knowledge and the process of elimination to make a selection. |
2090 The nurse teaches a mother how to attach a spacer to Correct answer: 4 Steroids given via metered‐dose inhaler on oral mucosa increase the risk for yeast infection. A the metered‐dose inhaler for a young child, explaining spacer avoids the mucus membranes and works directly on the airways. that a spacer: ‐ Makes the device look less intimidating to a small child. ‐ Makes it unnecessary to shake the inhaler before administering the drug. ‐ Decreases the chances for undesired side effects of medication. ‐ Reduces the risk for oral yeast by depositing medication more deeply into the airways. | The core issue of the question is the rationale for using a spacer. Use nursing knowledge and the process of elimination to make a selection. |
2091 The nurse documents which of the following expected Correct answer: 2 Excess fluid in the alveoli is a manifestation of bacterial pneumonia. The sound produced by findings after auscultating the lungs of a child with fluid in the airways is crackles. Retractions are asymmetrical chest wall movements that are bacterial pneumonia? seen in any client having respiratory difficulty. Wheezes are often typical of pneumonia caused by RSV, or conditions where the air passages are narrowed, such as asthma. Apnea is a pause in respirations, which is under the control of the central nervous system. ‐ Wheezes ‐ Crackles | The core issue of the question is the type of adventitious breath sound that is expected in pneumonia. Eliminate apnea because the focus is respiratory, not the central nervous system. Eliminate retractions next because they are seen rather than heard. Choose crackles over wheezes, recalling that the infection process leads to fluid accumulation, not to bronchoconstriction. |
‐ Apnea ‐ Retractions | |
2092 An infant with respiratory syncytial virus (RSV) is Correct answer: 3 Ribavirin is an antiviral drug that causes crystallization of soft contact lenses, and is associated receiving ribavirin. While caring for this infant, the with conjunctivitis. The other options are satisfactory items in the care of this client. nurse should not: ‐ Plan to become pregnant for at least one year. ‐ Care for any other children. ‐ Wear contact lenses. ‐ Stay in the room with the door closed. | The core issue of the question is safe administration of ribavirin to a client. Use nursing knowledge and the process of elimination to make a selection. |
2093 An adolescent with asthma says she heard her doctor Correct answer: 1 A trigger for an asthma attack can be exercise, smoke, allergic irritants, or emotions. Each say smoking was her trigger. The adolescent asks the child's trigger is individualized, and identification can afford some degree of protection in nurse what that means. The nurse explains to the avoiding asthmatic episodes. The other options indicate incorrect statements. adolescent that a trigger is: ‐ A substance or condition that initiates an asthmatic episode. ‐ The term for narrowing of the airways during an asthmatic episode. ‐ Another way to describe asthma. ‐ The rapid breathing associated with an asthma attack. | Knowledge of the definition of trigger and its use in asthma management will aid in choosing the correct answer. |
2094 The pediatric nurse is observing a new nurse perform Correct answer: 2 CPT should be performed prior to meals. Waiting until after the child has eaten can lead to chest physiotherapy (CPT) on a child. Which vomiting. The child should wear a layer of clothing between the chest and the hands. A observation by the new nurse indicates the need for clapping or popping sound is expected. A variety of positions may be used during CPT. the first nurse to intervene? ‐ The child has on only a T‐shirt. ‐ The nurse delayed the treatment until the child had finished breakfast. ‐ The nurse s hand makes a popping sound when doing percussion. ‐ The child is positioned in various head‐down positions. | Critical words are “indicates the need for additional teaching,” which signal the need for an incorrect strategy. Knowledge of the correct way to administer CPT will aid in choosing the correct answer. |
2095 A child in respiratory distress requires intubation. The Correct answer: 2, 4, 5 The endotracheal tube is inserted through the nose or mouth to maintain a patent airway by nurse would explain the intubation to the parents by bypassing an upper airway obstruction, or to reduce respiratory distress. While the tube is in stating that the endotracheal tube: (Select all that place, the child will be unable to talk. The child might or might not require a tracheostomy, apply.) depending on how long the child is intubated. Intubation does not allow for more accurate blood gas sampling. ‐ Is a temporary measure until the physician can perform a tracheostomy. ‐ Helps keep the airway open so the child can breath easier. ‐ Allows the doctor to assess arterial blood gases more accurately. ‐ Will prevent the child from speaking while the tube is in place. ‐ May be placed through the child’s nose or mouth. | Consider all the information that parents would need to know about endotracheal intubation. |
2096 The father of a premature infant asks why oxygen Correct answer: 4 Bronchopulmonary dysplasia is an obstructive lung disease that occurs primarily when concentrations are not higher to help his son breathe premature infants are subject to prolonged mechanical ventilation and high levels of oxygen better. The nurse's best response explains the risk for therapy. Pneumonia results from bacterial or viral infections. development of which of the following? ‐ Cystic fibrosis ‐ Pneumonia ‐ Bronchiolitis ‐ Bronchopulmonary dysplasia | Differentiate the causative factor in each of the diseases listed in the options. Knowledge that the prolonged use of high levels of oxygen will result in BPD will aid in choosing the correct answer. |
2097 A child presents to the Emergency Department in Correct answer: 2 Epinephrine by the intravenous route is a rapid‐acting beta‐adrenergic agonist that relaxes acute respiratory distress caused by an asthmatic smooth muscles by opening airways for immediate relief of bronchospasm. Terbutaline is an episode. Which of the following drugs would the nurse adrenergic bronchodilator, but would take longer to act due to oral or subcutaneous plan to administer first according to a protocol order administration. Prednisone is a corticosteroid given to decrease inflammation and bronchial set? hyper‐reactivity. Cromolyn sodium may be used prophylactically to avoid exercise‐induced asthma, and is of little use once an episode occurs. ‐ Prednisone (Deltasone) ‐ Epinephrine (Adrenalin) ‐ Terbutaline (Brethaire) ‐ Cromolyn sodium (Intal) | Prioritizing the administration of drugs is a key concept. Consider which drugs would have an immediate effect, and which effects would be delayed. |
2098 A child recently was diagnosed with asthma. The Correct answer: 3 Sudden temperature change is a common asthma trigger, and snow skiing would expose the nurse and mother are discussing physical activities for child to cold air. Exercise is a trigger in some children, but activities with short bursts like the child. The nurse will recommend that the child gymnastics are not usually a problem. Swimming is actually beneficial because of the breathing avoid: of moistened air and prolonged expiration required under water. Restriction from playgrounds would interfere with normal socialization. ‐ Swimming. ‐ Gymnastics. ‐ Snow skiing. ‐ Playgrounds. | Consider all the ramifications of each activity to determine the correct activity to avoid. |
2099 The highest‐priority nursing intervention for a child Correct answer: 2 Pulmonary infections must be treated aggressively with CF patients to minimize the chance hospitalized with a bacterial respiratory infection and for colonization of resistant pathogens. Once colonized, children have a poorer survival rate. cystic fibrosis would be: The sweat chloride test is for diagnostic purposes only. Maintaining adequate hydration helps liquefy secretions. Pancreatic enzymes help the child absorb food substances, which is not the priority intervention. ‐ Administering pancreatic enzymes. ‐ Administering intravenous antibiotics. ‐ Recording vital signs every four hours. ‐ Arranging for sweat chloride testing. | All of the options except the fourth are appropriate. The stem asks for the priority intervention, which would be the option that addresses the root cause of the client s current problem, the bacterial respiratory infection. |
2100 A 6‐year‐old client with cystic fibrosis (CF) is preparing Correct answer: 4 Children with CF require pancreatic enzymes before each meal and snack to manage to eat breakfast. What is the most important data the malabsorption and steatorrhea. Enzyme dosage is individualized based on nutritional status nurse would want to obtain before the child eats? and stool consistency. It is also important that the child eat his prescribed high‐calorie, high‐ protein diet to support weight gain. The information in the other options are not necessary to know before the child eats. ‐ Whether the meal is exactly what he ordered ‐ If he plans to eat all of it ‐ When he ate last ‐ If he has taken his enzymes | Consider the nutritional problems of cystic fibrosis to determine the important assessment data. |
2101 A child was diagnosed with cystic fibrosis (CF) as an Correct answer: 4 Clubbing of the fingers is seen in pulmonary disease, and is associated with hypoxia and infant. The child shows you her hands, and asks why ischemia. In this instance, the clubbing occurs as a result of pulmonary changes due to cystic her fingers look like that. The nurse's best response fibrosis. would be: ‐ "You inherited them from your parents. Someone in your family probably has the same style of fingers." ‐ "It's a part of the cystic fibrosis syndrome, and is a recognizable symptom." ‐ "That's the way your fingers looked at birth." ‐ "The shape of your fingers is due to the hypoxia caused by your cystic fibrosis." | Options 2 and 4 address cystic fibrosis. Option 4 provides more complete information. |
2102 A child in the clinic has been seen with recurrent Correct answer: 3 Handwashing is the most important infection‐control practice. Isolation is unrealistic, and respiratory infections. The nurse providing anticipatory limits the child's socialization opportunities. Respiratory infections are generally spread by guidance in preventing future respiratory infections nasal pharyngeal secretions from infected persons. would recommend which of the following? ‐ Keeping the child away from other children ‐ Seeing the pediatrician weekly ‐ Maintaining strict handwashing ‐ Avoiding all animals | Options 1 and 4 are unrealistic, and would be impossible to maintain with a child. Seeing a pediatrician weekly will not prevent infection. |
2103 The mother of an infant diagnosed with bronchiolitis Correct answer: 3 At least one‐half of all cases of bronchiolitis are attributed to respiratory syncytial virus. The asks the nurse what causes this disease. The nurse’s majority of cases of bronchiolitis are not attributable to Klebsiella, mycoplasma pneumoniae, response would be based on the knowledge that the or haemophilus influenzae. majority of infections that cause bronchiolitis are a result of: ‐ Klebsiella infection. ‐ Mycoplasma pneumoniae. ‐ Respiratory syncytial virus (RSV). ‐ Haemophilus influenzae. | This question asks for basic information related to causation of bronchiolitis. Key words are “majority” and “bronchiolitis.” Use knowledge of the etiology of the disease to choose the correct answer. |
2104 A child is brought to the Emergency Department with Correct answer: 4 Any manipulation of the tongue or throat could stimulate the gag reflex and cause complete suspected epiglottitis. The nurse would avoid doing obstruction, so this is the action that should be avoided. The other actions are appropriate. which of the following for the child with epiglottitis, The child should be allowed to remain in a position of choice for ease of respiration. which distinguishes the care needed by this child from Emergency intubation equipment should be readily available before any examination of the the care needed by a child in the adjacent treatment throat is attempted. Parents should be encouraged to comfort the child. area who has laryngotracheobronchitis? ‐ Allowing the child to remain in the position of choice ‐ Placing intubation equipment at the bedside ‐ Encouraging the parents to comfort the child ‐ Examining the throat | The key concept is differentiating between epiglottitis and laryngotracheobronchitis. Because of the critical word “avoid,” choose the option that would represent unsafe care to the client, based on knowledge of pathophysiology of the infection. |
2105 An 18‐month‐old boy who was seen in the Emergency Correct answer: 3 The child s respiratory distress makes it difficult for him to lie down. The child will breathe Department with respiratory distress is admitted to more easily in a semi‐ to high‐Fowler s position. Rocking the child and holding the child in the the nursing unit with a diagnosis of pneumonia. arms does not specify an upright position, and therefore these are too vague to be useful Following the initial workup, the child is still short of suggestions. A sleeping pill is not indicated. breath, but is rubbing his eyes as if he is sleepy. The mother wants to lay the child down for his nap, but he refuses to lie down. The nurse would suggest which of the following as the most effective strategy to help the child rest? ‐ Rock the baby until he is asleep, and then lay him down. ‐ Hold him in her arms while he sleeps. ‐ Allow him to sleep in an upright position. ‐ Give him an over‐the‐counter sleeping pill. | The core concept is positioning for respiratory distress. Determine the correct answer by analyzing which choice best promotes oxygenation. |
2106 Which statement by an 8‐year‐old girl who has Correct answer: 1 Peak expiratory flow readings over time indicate the child s respiratory ability when she is asthma indicates that she understands the use of a well. Readings of 50 percent below “personal best” indicate an asthma episode is imminent. peak expiratory flow meter? The meter does not prevent an attack. ‐ “My peak flow meter can tell me if an asthma episode might be coming, even though I might still be feeling okay.” ‐ “When I do my peak flow, it works best if I do three breaths without pausing in between breaths.” ‐ “I always start with the meter reading about halfway up. That way, I don t waste any breath.” | Critical words are “understands” and “peak expiratory flow meter.” Knowledge of this device and how it helps to manage asthma helps to answer the question. |
4.‐ “If I use my peak flow meter every day, I will not have an asthma attack.” | |
2107 A child with cystic fibrosis is hospitalized for a Correct answer: 1 Frothy, foul‐smelling stools reflect malabsorption and indicate that pancreatic enzymes are respiratory infection. Which documentation in the not being consumed, or that dosages might need adjustment. Maintenance of weight and chart would indicate the need for counseling regarding consuming meals and snacks are positive nutrition goals for children with cystic fibrosis. nutrition and gastrointestinal complications? ‐ Frothy, foul‐smelling stools ‐ Weight unchanged from yesterday. ‐ Consumed 80% of breakfast. ‐ Eats three snacks every day. | Eliminate normal findings to determine which documentation indicates the need for nutrition intervention. |
2108 An adolescent was diagnosed with cystic fibrosis as an Correct answer: 4 The developmental task of adolescence is to set future goals, including marriage and family. infant. The nurse anticipates that the adolescent will Men with cystic fibrosis are usually sterile, and women can have decreased fertility as thick need additional teaching related to: cervical mucus interferes with mobility of sperm. The difference between sterility and impotence should also be addressed. The client does not need information about a sweat chloride test (diagnostic test for the disease) or weight reduction. There is no adverse effect of pancreatic enzymes on sex hormones. ‐ Obtaining a sweat chloride test. ‐ The effect of pancreatic enzymes on the sex hormones. ‐ Increased need for a weight‐reduction diet. ‐ Reproductive ability. | The key word is “adolescent.” Consider the changes that occur with adolescence to determine the needs at this time. |
2109 A 10‐month‐old child is being admitted with Correct answer: 1, 2, 3, Both the child and the parents will be anxious about the child s condition and the need for laryngotracheobronchitis in the middle of the night. 4 emergency admission to the hospital. Respiratory distress is an obvious sign of ineffective The child has a loud stridor and moderate respiratory breathing. The child will need extra fluids due to increased insensible fluid loss and inability to distress. In planning care for this child, the nurse will take fluids due to respiratory distress. The parents will want to know the cause of the disease, identify which of the following as appropriate nursing and interventions for future episodes. The outcome for this disease is usually positive, so diagnoses? Select all that apply. Anticipatory Grieving would not be appropriate. ‐ Fear/Anxiety ‐ Ineffective Breathing Pattern ‐ Risk for Deficient Fluid Volume ‐ Deficient Knowledge ‐ Anticipatory Grieving | Appropriate nursing diagnoses are based on the clinical picture of the disease. With this in mind, select nursing diagnoses that relate to breathing, effects of dyspnea on fluid and food intake, and the need for information about the disease. |
2110 A 9‐month‐old infant has been admitted to the Correct answer: 2, 4 RSV is very contagious, especially with infants and clients who are immunocompromised. pediatric unit with respiratory syncytial virus infection. Therefore, in clients with immunodeficiency, chemotherapy and aplastic anemia should be The nurse assigned to provide care to this infant will avoided. need to be assigned to care for other clients as well. The charge nurse should assign the nurse to which of the following children as an appropriate assignment? Select all that apply. ‐ A toddler with neuroblastoma undergoing chemotherapy ‐ A 10‐year‐old with a fractured femur in traction ‐ An infant with immunodeficiency ‐ A preschooler with impetigo ‐ A 2‐year‐old with aplastic anemia | The core concept is risk of transmission of infection from an infant with RSV. The correct choices would avoid infants and clients who are immunocompromised. |
2111 The nurse is teaching home tracheostomy care to the Correct answer: 2 Accumulating mucopurulent secretions might provide a medium for bacterial growth, and can parents of a toddler. What information would be obstruct the lumen of the tube. Suctioning is another risk for introduction of bacteria. Early essential for the nurse to include? recognition of signs of infection is important. The tube does not need to be changed every day (option 1), and cannot be removed (option 3). It is small objects, not large objects (option 4), that pose a risk to aspiration and would need to be avoided. ‐ The importance of changing the tracheostomy every day ‐ How to recognize signs of infection and obstruction ‐ How to remove the tracheostomy so the child can talk ‐ Teaching the child to keep large objects away from the tube | The key concept is the most essential information for home tracheostomy care. Recall that infection and obstruction are key concerns related to artificial airways. |
2112 A child with a respiratory infection is scheduled to Correct answer: 4 Children with cystic fibrosis have elevated chloride concentrations of sweat because of the have a sweat test. After the physician discusses the dysfunction of the exocrine glands. test with the child's mother, the mother approaches the nurse and asks the purpose of this diagnostic test. Which of the following responses by the nurse would best reinforce the physician s explanation? ‐ “This will determine if your child is dehydrated.” ‐ “This will assess whether your child’s sweat glands are functioning.” ‐ “This will help us to identify the infectious organism.” ‐ “This will diagnose whether the child has cystic fibrosis.” | The key word of this test item is “purpose.” |
2113 The mother of an infant who has had recurrent Correct answer: 4 Infants and young children have narrower airways, and shorter distance between structures; respiratory infections asks the nurse why infants are at accessory muscles generally used for breathing are immature. The respiratory rate of infants is increased risk for complications from respiratory faster than that of adults, and parents can be taught to assess the child for respiratory infections. The best response by the nurse explains problems. that with infants: ‐ The airway structures are larger, allowing for entry of a greater number of organisms. ‐ The respiratory rate is slower than in adults. ‐ Parents are unable to assess respiratory problems accurately. ‐ The airways are narrower and more easily obstructed. | Critical words are “why infants are at increased risk for complications from respiratory infections.” The core knowledge is the physiological differences between infants and older children. After eliminating options 1 and 2 as inaccurate, knowledge of infant anatomy will lead to the selection of option 4. |
2114 The mother of a neonate hospitalized with an upper Correct answer: 3 Newborns are unable to coordinate breathing and sucking simultaneously. They are nose‐ respiratory tract infection asks why her baby won’t breathers, and anything that interferes with nasal patency impairs feeding as well. The take her bottle. The nurse’s best answer would be: difficulty with sucking does not relate to hunger, or to selection of formula. ‐ “She’s probably not hungry.” ‐ “It s okay, because we re giving her intravenous fluids; therefore, she is not hungry.” ‐ “Newborns breathe through their noses. Congestion might be interfering with her ability to breathe and eat at the same time.” ‐ “She might need a different type of formula. We’ll call the physician to get a new order.” | Critical words are “neonate hospitalized with an upper respiratory tract infection” and “baby won t take her bottle.” The core concept is a neonate with an upper respiratory infection (URI) and refusal to suck. The knowledge that normal coordination of breathing is hampered by nasal congestion will help guide to the correct answer. |
2115 A 4‐year‐old female child presents to the Emergency Correct answer: 2, 3, 4, In epiglottitis, any manipulation of the throat can cause stimulation of the gag reflex. The Department with a sore throat, difficulty swallowing, 5 inflamed, edematous epiglottis could then completely obstruct the airway. All other and a suspected diagnosis of acute epiglottitis. Initial assessments should be made. assessment of the child should include: (Select all that apply.) ‐ Throat culture. ‐ Vital signs. ‐ Past medical history. ‐ Auscultation of chest. ‐ Observation of swallowing ability. | Critical words are “epiglottitis” and “initial assessment should include.” Knowledge of epiglottitis and its care and management is needed to determine which assessment should not be done. |
2116 The nurse is providing homecare instructions to the Correct answer: 3, 5 Children with cystic fibrosis require pancreatic enzymes with every meal and snack to counter parents of a child with cystic fibrosis. Which statement malabsorption and nutritional problems. They require well‐balanced diets with 120–150% of by the parents indicates that they do not understand RDA calories and 200% protein. Normal bowel movements indicate that enzyme dosage is the treatment regimen? Select all that apply. appropriate. It is important to avoid other children with infections, but physical activity is encouraged within the child’s capability. Chest percussion is a normal part of health maintenance for this child. ‐ “We will perform chest physiotherapy and postural drainage four times a day.” ‐ “We will keep her away from the church nursery if any of the children are coughing and have fever or runny noses.” ‐ “If her bowel movements are normal and her appetite is good, she does not need her pancreatic enzymes.” ‐ “The relay races and swimming at our Sunday school picnic next week will be good exercise for her.” ‐ “My child will not need any special dietary intake.” | Critical words are “child with cystic fibrosis” and “indicates the parents do not understand.” Eliminate all choices that would be appropriate for the parents to perform at home. This leaves the choices that illustrate a lack of understanding of the needed home care. |
2117 A 2‐year‐old child is being discharged after Correct answer: 3 Developmentally, small children practice increased hand‐to‐mouth activity and explore bronchoscopy for removal of a coin from his objects with their mouths. Any small toy or food can be ingested, and can potentially obstruct esophagus. The most important topic of discharge the airway. All of the other choices are correct, but 3 is most important. teaching would be the importance of: ‐ Reassuring the child that he is fine. ‐ Proper nutrition for the next few days. ‐ Restricting his access to small toys or objects. ‐ Administering acetaminophen for his sore throat. | Critical words are “removal of a coin” and “most important topic.” Knowledge of foreign body aspiration and teaching about prevention of future aspirations and removal of potential hazards are essential to prevent future problems. |
2118 A 15‐year‐old child with a history of cystic fibrosis is Correct answer: 4 Pulmonary pathogens are particularly detrimental to children with cystic fibrosis. Colonization admitted to the pediatric unit with assessment findings of the lungs with resistant organisms often leads to poor survival rates. Aggressive intravenous of crackles, increased cough, and greenish sputum. A administration of high‐dose antibiotics is always a priority. two‐week hospitalization is anticipated. Which nursing intervention holds the highest priority? ‐ Referral to Child Life Services for school lesson plans ‐ Arranging for liberal visitation from peers ‐ Taking a diet history ‐ Gaining intravenous access | Knowledge of cystic fibrosis and the illness management of the disease to prevent complications is essential to answer the question. The highest priority for the client will be related to respiratory function. Therefore, planning for IV access allows for rapid implementation of the medical plan of care. |
2119 A 7‐year‐old child is brought to the Emergency Correct answer: 2 A beta<sub>2</sub> agonist (short‐acting) is the drug of choice for acute therapy Department for an acute asthma attack. He is given via inhalation for emergency relief of acute bronchospasm; action is immediate, within wheezing, tachypneic, and diaphoretic, and looks 5–10 minutes. Use before an inhaled steroid. Methylprednisolone and prednisone are both frightened. The nurse should prepare to administer: corticosteroids to reduce the inflammatory process, but would not give immediate relief. Cromolyn sodium is a preventive medication. ‐ IV methylprednisolone. ‐ Albuterol. ‐ Oral prednisone. ‐ Cromolyn sodium. | The critical concept here is “acute” asthma attack. Knowledge of the medications used to treat asthma emergencies is necessary to answer the question correctly. Select the medication that would be utilized during an acute attack. |
2120 The nurse would select which of the following as an Correct answer: 4 The sudden onset of severe respiratory distress is frightening and very stressful for the family appropriate nursing diagnosis for the family of a and child. There is no prolonged hospital confinement. There is no permanent loss for which to toddler being treated for acute grieve, and growth and development are not likely to be affected. laryngotracheobronchitis? ‐ Anticipatory Grieving ‐ Impaired Growth and Development related to acute onset of illness ‐ Impaired Social Interaction related to confinement in hospital ‐ Fear/Anxiety related to dyspnea and noisy breathing | Critical words are “toddler” “laryngotracheobronchitis.” Consider the symptoms of acute laryngotracheobronchitis. Since the diagnosis is frightening but not fatal, and has no long‐ term sequelae, options 1 and 2 can be eliminated. |
2121 A child with bacterial pneumonia is crying, and says it Correct answer: 1 Splinting the affected side with a pillow or stuffed animal lessens the discomfort experienced hurts when he coughs. The nurse would teach the child with bacterial pneumonia. to: ‐ Hug his teddy bear when he coughs. ‐ Ask for pain medicine before he coughs. ‐ Take a sip of water before coughing. ‐ Try very hard not to cough. | The child is complaining of pain during coughing, so look for a choice that would reduce pain without suppressing the cough reflex. |
2122 An infant with chronic bronchopulmonary dysplasia Correct answer: 3 Home oxygen therapy and tracheostomy care require access to emergency equipment (BPD) and a tracheostomy is being discharged to home typically not available on a camping trip. Additionally, campfires are hazardous. All other oxygen therapy. Which statement by the mother choices indicate correct information. indicates that further teaching is needed before discharge? ‐ “I will call my pediatrician if she gets a fever or has more secretions than usual from her tracheostomy.” ‐ “I have a cute bib to loosely cover her tracheostomy when she eats and when we go outside in the wind.” ‐ “We are so glad the baby will get to go with us on our camping trip to Yellowstone National Park. We have been waiting for her to get well so we can go.” ‐ “We have already notified Alabama Power Company that our baby is coming home today.” | Critical words are “home oxygen therapy” and “statement indicates that further teaching is needed.” Because wording of the question guides you to select an incorrect statement, eliminate all responses that are appropriate for home care of a child with a tracheostomy who is receiving oxygen. |
2123 A client has chronic respiratory acidosis caused by Correct answer: 1 COPD clients have low oxygen and high carbon dioxide levels. Therefore, hypoxia is the main end‐stage chronic obstructive pulmonary disease stimulus for ventilation in persons with chronic hypercapnia. Increasing the level of oxygen (COPD). Oxygen is delivered at 1 L/min per nasal would decrease the stimulus to breathe. cannula. The nurse teaches the family that the reason for this precaution is to avoid respiratory depression, based on which of the following as the best explanation? ‐ COPD clients depend on a low oxygen level. ‐ COPD clients depend on a low carbon dioxide level. ‐ COPD clients tend to retain hydrogen ions if they are given high doses of oxygen. ‐ COPD clients thrive on a high oxygen level. | Select option 1 as the best explanation of the physiological phenomenon of hypoxic drive. Note that options 1 and 2 are essentially opposite. Generally, one item in a pair of opposites will be correct. |
2124 A client presents to the Emergency Department with Correct answer: 4 A combined low PO<sub>2</sub> and low Cal SO<sub>2</sub> acute respiratory distress and the following arterial represents hypoxia. The pH, PCO<sub>2</sub>, and blood gases (ABGs): pH 7.35; HCO<sub>3</sub><sup>‐</sup> are normal. ABGs will not necessarily be PCO<sub>2</sub> 40 mmHg; altered in TB or pleural effusion. Initially, in pneumonia, both the PO<sub>2</sub> PO<sub>2</sub> 63 mmHg; and PCO<sub>2</sub> are usually low because the hypoxia leads to HCO<sub>3</sub><sup>‐</sup> hyperventilation. 23; oxygen saturation (Cal SO<sub>2</sub>) 93%. Which of the following represents the best analysis of the etiology of these ABGs? ‐ Tuberculosis (TB) ‐ Pneumonia ‐ Pleural effusion ‐ Hypoxia | Blood gases are not diagnostic of disease states, but simply provide information, such as whether hypoxia is present. |
2125 When assessing a client with early impairment of Correct answer: 3 The cardinal signs of respiratory problems and hypoxia are restlessness, diaphoresis, oxygen perfusion, such as in pulmonary embolus, the tachycardia, and cool skin. Bradycardia might occur much later in the process, when the nurse would expect to find restlessness and which of condition is severe. Eupnea is normal respirations in rate and depth. the following symptoms? ‐ Warm, dry skin ‐ Bradycardia | Note that options 2 and 3 reflect opposite symptoms in terms of heart rate. One of the opposites is likely correct. Tachycardia is the early symptom. |
‐ Tachycardia ‐ Eupnea | |
2126 One day postoperative, the client complains of Correct answer: 2 The first three symptoms could be indicative of any of the conditions. The distinguishing dyspnea, respiratory rate (RR) is 35, slightly labored, symptom is the lack of breath sounds in the lower‐right base when a portion of the lung has and there are no breath sounds in the lower‐right collapsed. base. The nurse would suspect: ‐ Cor pulmonale. ‐ Atelectasis. ‐ Pulmonary embolus. ‐ Cardiac tamponade. | Select the option that is common in the postoperative period, atelectasis. |
2127 A client with an acute case of pneumonia has a dry, Correct answer: 1 The effects of the respiratory treatment should break up the congestion and cause hacking cough, elevated temperature, elevated white bronchodilation; thus the change in lung sounds and more productive cough effort. As the blood cell (WBC) count, decreased breath sounds, and pneumonia resolves, the lungs should begin to clear and the cough diminish. Notice that the pain upon deep inhalation or coughing. Which of the question asks about an acute case; be careful to note the situation in the stem. following would indicate positive results after a respiratory treatment of normal saline, acetylcysteine (Mucomyst), and metaproterenol (Alupent)? ‐ Crackles and cough productive of a moderate amount of sputum ‐ Absent breath sounds in bases and normal breath sounds in upper lobes ‐ Wheezing, nonproductive cough ‐ Diminished breath sounds with a small amount of productive sputum | The question is asking about positive results of a respiratory treatment, which would include coughing up sputum. |
2128 Which of the following needs immediate medical Correct answer: 3 Option 3 is indicative of a tension pneumothorax, which is considered a medical emergency. attention and emergency intervention? The client who: The respiration system is severely compromised, and venous return to the heart is also affected. The mediastinal shift is to the unaffected side. Option 1 contains symptoms of pleurisy, and option 2 lists symptoms of bronchitis; neither is an emergency. The client in option 4 should expect difficulty breathing after exercise when asthma is an existing condition, and could need immediate attention if the rescue inhaler is ineffective. ‐ Complains of sharp pain upon taking a deep breath, and excessive coughing. ‐ Exhibits yellow, productive sputum, low‐grade fever, and crackles. ‐ Has a shift of the trachea to the left, with no breath sounds on the right. ‐ Has asthma, and complains of inability to "catch her breath" after exercise. | No breath sounds is the key to identification of this as the correct answer. |
2129 A teenage client newly diagnosed with asthma is Correct answer: 2 A young person needs to know the triggers of asthma. Physical exercise in school and as a being discharged from the hospital after an episode of part of life will be everpresent, and prevention of an attack before exercise is essential at this status asthmaticus. Discharge teaching should include time in the client's life. Sports do not have to be limited in all asthmatic people. Living a which of the following? productive, normal life should be stressed. The client might have to use preventative medications before a sport of her choice. The fear associated with asthma is common, and might take a while to overcome. Instructions on identifying triggers and using the rescue inhalers need to be taught, and the fear will eventually subside. ‐ Incidence of status asthmaticus in children and teens ‐ The relationship of symptoms to a specific trigger, such as physical exercise ‐ Limitations in sports that will be imposed by the illness ‐ Specific instructions on staying calm during an attack | Prioritize methods of avoiding future attacks by identifying triggers. |
2130 A known cardiac client is experiencing angina at night Correct answer: 4 As the upper airflow obstruction occurs in sleep apnea, the CO<sub>2</sub> rises, only and excessive fatigue, and the spouse states that and cardiac arrhythmias and angina can occur because of the lack of oxygenated blood supply the client snores excessively. The physician orders a to the heart. Clients with sleep apnea do not get adequate amounts of REM sleep, and are sleep apnea study with and without oxygen. The often awakened frequently during the night in order to make breathing possible. rationale for considering a pulmonary source rather than a cardiac source as the cause of the angina at this time is: ‐ Sleep apnea is an obstruction of the lower airway, which impedes airflow. ‐ Clients with sleep apnea have adequate amounts of REM sleep, but snoring contributes to the decrease in oxygen levels. ‐ Sleep apnea causes an increase in muscle tone during REM sleep in order to make breathing possible. ‐ Excess periods of apnea during sleep and severe drops in oxygen levels can contribute to the angina, which is occurring only at night. | Recognize that options 4 is the only option that addresses the relationship to angina. |
2131 Which of the following symptoms is most Correct answer: 2 The most common sign of cancer of the lung is a persistent cough that changes. Other signs characteristic of a client with cancer of the lung? are dyspnea, bloody sputum, and long‐term pulmonary infection. Option 1 is common with chronic obstructive pulmonary disease (COPD); option 3 is common with asthma; and option 4 is common with tuberculosis. ‐ Exertional dyspnea ‐ Persistent, changing cough ‐ Air hunger; dyspnea ‐ Cough with night sweats | Recall that cough is considered a cardinal symptom of cancer. |
2132 A client is admitted to the unit after a traumatic Correct answer: 3 Adult respiratory distress syndrome is common after a trauma or shock situation. Clients will encounter with a bull in a pasture that speared his often become hypoxic and alkalotic with pulmonary edema. right chest wall. The client is admitted with a flail chest, and is treated accordingly. The nurse should be particularly observant to the sudden changes that might be evidence of which of the following? ‐ Hypercapnia ‐ Sepsis ‐ Adult respiratory distress syndrome ‐ Metabolic acidosis | The key is the reference to sudden changes, as ARDS often has a rapid onset. |
2133 A client was involved in a motor vehicle accident Correct answer: 3 A mediastinal shift, along with the other symptoms in the question, is indicative of a tension (MVA) in which a seat belt was not worn. The client is pneumothorax. Since the individual was involved in an MVA, assessment would be targeted at exhibiting crepitus and decreased breath sounds on acute traumatic injuries to the lungs, heart, or chest wall rather than the conditions indicated the left, complains of shortness of breath (SOB), and in the other options. Option 1 is common with pneumonia; values in option 2 are not alarming; has a respiratory rate of 34/min. Which of the and option 4 is typical of someone with chronic obstructive pulmonary disease (COPD). following assessment findings should concern the nurse the most? ‐ Temperature of 102°F and a productive cough ‐ Arterial blood gases (ABGs) with a PaO2 of 92 and PaCO2 of 40 mmHg ‐ Trachea deviating to the right ‐ Barrel‐chested appearance | Tracheal deviation is always emergent. |
2134 A nurse is teaching a client newly diagnosed with Correct answer: 2 Option 2 is the pathophysiology behind emphysema. Option 1 explains asthma, option 3 emphysema about the disease process. Which of the explains bronchitis, and option 4 explains cystic fibrosis. following statements best explains the problems associated with emphysema, and could be adapted for use in the nurse's discussion with the client? ‐ Hyperactivity of the medium‐sized bronchi caused by an inflammatory response leads to wheezing and tightness in the chest. | Use of the word “trapped” in option 2 is the key to identification of this option as correct |
‐ Larger‐than‐normal air spaces and loss of elastic recoil cause air to be trapped in the lung and collapse airways. ‐ Vasodilation, congestion, and mucosal edema cause a chronic cough and sputum production. ‐ Chloride is not being transported properly, producing excess absorption of water and sodium, and thick, viscous mucus. | |
2135 A sweat test, arterial blood gases (ABGs), and chest x‐ Correct answer: 4 Cystic fibrosis is diagnosed with a high chloride level (normal: less than 40 mmol/L) on the ray (CXR) are ordered for a child with symptoms sweat test, hypoxemia on the ABGs, and atelectasis or hyperinflation on the CXR. suggestive of cystic fibrosis (CF). Which of the following results would be consistent with this diagnosis? ‐ Chloride 32 mmol/L; PaO2 82 mmHg; and atelectasis in the lower lobe ‐ Chloride 37 mmol/L; PaO2 95 mmHg; and hypoinflation of the lungs ‐ Chloride 29 mmol/L; PaO2 90 mmHg; and white‐out of the lungs ‐ Chloride 64 mmol/L; PaO2 70 mmHg; and hyperinflation of the lungs | The sweat test would be significant if it showed high chloride levels. Select the highest level. |
2136 A middle‐aged man who suffered a large myocardial Correct answer: 3 Barotrauma (decreased cardiac output and damage to lung tissue) is a common complication infarction develops adult respiratory distress of PEEP. A drop in BP is associated with a decreased cardiac output. The sinus tachycardia syndrome (ARDS) as a complication. The client is could be a compensatory mechanism to raise the BP, or a response to the ARDS. Anxiety is to intubated and placed on positive end‐expiratory be expected with intubation, and a small rise in temperature might or might not indicate an pressure (PEEP). Which of the following is a finding of infectious process. concern while on the PEEP? ‐ Sinus tachycardia of 125 beats/min ‐ Anxiety ‐ Blood pressure (BP) of 88/52 ‐ Temperature 100.5°F | Omit options 1, 2, and 4 as common findings in the intubated client. |
2137 A client admitted to the medical nursing unit has Correct answer: 2. Exposure with a positive TB skin test usually requires six months of prophylactic treatment classic symptoms of tuberculosis (TB), and tests unless contraindicated. The TB skin test should not be repeated; the results will always be positive on the purified protein derivative (PPD) skin positive. A CXR is usually not required annually in the event of a positive skin test. test. Several months later, the nurse who cared for the client also tests positive on an annual TB skin test. The most likely course of treatment if the nurse's chest x‐ ray (CXR) is negative is to: ‐ Repeat a TB skin test in six months. ‐ Treat the nurse with an anti‐infective agent for six months. ‐ Monitor for signs and symptoms within the next year. ‐ Follow up in one year at the next annual physical with a CXR only. | Conversion of a skin test following a potential exposure requires treatment. |
2138 Clients with severe sleep apnea who are members of Correct answer: 2 The deprivation of oxygen during the night often leaves individuals tired during the day. Any a support group should be educated to plan frequent activity increases the need for oxygen, which is already limited in a client with this disorder. rest periods and activities around how well they feel in order to maximize energy because they might complain of which of the following during the day? ‐ Cardiac arrhythmias ‐ Fatigue ‐ Jaw pain ‐ Productive cough | The question refers to rest periods, which should lead to option 2. |
2139 A client who has a known history of cardiac problems Correct answer: 1 Pleuritic pain is typically sharp and stabbing. Pleural effusion (option 2) and atelectasis (option and is still smoking enters the clinic complaining of 3) can cause pain, but usually have other symptoms, like dyspnea and diminished or absent sudden onset of sharp, stabbing pain that intensifies breath sounds. Pleurisy is common in smokers. Tuberculosis (option 4) causes chest pain along with a deep breath. The pain is occurring on only one with other symptoms. side, and can be isolated upon general assessment. The nurse concludes that this description is most likely caused by: ‐ Pleurisy. ‐ Pleural effusion. ‐ Atelectasis. ‐ Tuberculosis. | Omit options 2, 3, and 4 as having other associated symptoms in addition to pain. |
2140 The nurse is delivering postmortem care to a client Correct answer: 4 If the blockage is large enough and blood flow is hindered to the lung, the tissue will die. This who died from a large pulmonary embolus (PE). The usually occurs when a large clot blocks the entire main pulmonary artery. Option 1 is rather nurse concludes that the client's death was most likely vague because blood flow is decreased to the heart, lung, brain, and other vital organs because caused by which of the following? of the blockage, but the amount of decrease can be variable. Option 2 is incorrect; dead space is increased with PE. Option 3 is correct in pulmonary embolism, but is not usually the cause of death. ‐ Decreased blood flow ‐ Decreased alveolar dead space ‐ Inefficiency of the heart insufficient to pump adequately ‐ Infarction of the lung tissue | Associate the term embolus with a subsequent infarct. |
2141 An elderly client recuperating from hip surgery will Correct answer: 3 Without any evidence of a blood clot or PE, LMWH is usually used for prevention purposes, most likely be placed on which of the following in especially since the client is elderly, and will be on bedrest for a period of time. Heparin and order to prevent a pulmonary embolism (PE)? Coumadin are used when a confirmed clot exists. Thrombolytics are used when a clot needs to be dissolved immediately. ‐ Tissue plasminogen activator (TPA) ‐ Warfarin (Coumadin) ‐ Low–molecular weight heparin (LMWH) ‐ Heparin | Select the option that would be used most often for clot prophylaxis. |
2142 A 50‐year‐old client with chronic obstructive Correct answer: 1 A sustained elevation in the resting mean pressure above 20 mmHg from a pulmonary artery pulmonary disease (COPD) who has smoked two packs is defined as pulmonary hypertension, which could be caused by the COPD. Rust‐colored of cigarettes a day is being cared for in the intensive sputum (option 2) is usually indicative of lung cancer; thick, viscous mucus (option 3) can be care unit for an acute exacerbation of the disease. significant in a number of disorders; and absent breath sounds (option 4) are indicative of Which of the following should alert the nurse to the many pulmonary disorders, but not of pulmonary hypertension. possibility of pulmonary hypertension? ‐ Pulmonary artery pressure of 30 mmHg ‐ Rust‐colored sputum ‐ Thick, viscous mucus ‐ Absent breath sounds | Option 1 gives information about pulmonary pressure. |
2143 A result of many chronic lung diseases is cor Correct answer: 2 Chronic lung disease causes hypertrophy of the right ventricle; eventually, the right ventricle pulmonale. The nurse would explain to a client that the fails, mainly because of the increased pressure within the pulmonary artery that results from pathophysiology behind this complication is that the the lung disease. Signs and symptoms of right‐sided heart failure will occur. effect of the lung disease: ‐ Increases the workload of the left ventricle. ‐ Increases the workload of the right ventricle. ‐ Dilates the pulmonary artery. ‐ Constricts the pulmonary artery. | Cor pulmonale is associated with right heart failure. |
2144 Which of the following clients should be watched Correct answer: 4 ARDS is a problem with impaired diffusion, whereas upper airway obstruction (option 1), rib carefully for respiratory failure caused by impaired gas fractures (option 2), and drug overdose (option 3) are problems with impaired ventilation. diffusion? ‐ A client who has meat lodged in the back of his throat, causing an upper airway obstruction ‐ A client who fell from a tall ladder and suffered several rib fractures ‐ A client who overdosed on morphine sulfate ‐ A client who is suddenly developing adult respiratory distress syndrome (ARDS). | Recall that diffusion is specific to ARDS. |
2145 The nurse is explaining to a nursing assistant why it is Correct answer: 2 With chronic hypoxia, the kidneys increase the production of red blood cells, leading to important to report any client complaints of calf pain. polycythemia and increased viscosity of the blood. The increased viscosity can lead to The explanation for this is that in the client with formation of blood clots. emphysema, the possibility of developing blood clots exists because: ‐ The client is often on bedrest, and clots are more likely to develop. ‐ Polycythemia results from chronic hypoxia. ‐ Pulmonary emboli are more likely when there is hypercapnia. ‐ The trapping of air associated with emphysema can cause an air embolus. | The term “chronic hypoxia” in option 2 should lead to the selection of this option, as emphysema is associated with chronic hypoxia. |
2146 Which of the following sets of symptoms best Correct answer: 2 The respiratory rate and heart rate are increased when a portion of the lung has collapsed; describes a client experiencing atelectasis? hypoxia occurs, and there usually are diminished or absent breath sounds over the affected area. ‐ Dyspnea; respiratory rate (RR) 12/min; heart rate (HR) 125; PaO2 of 70 mmHg; rales ‐ Dyspnea; RR 32/min; HR 125; PaO2 70 mmHg; diminished breath sounds over one lobe ‐ Shallow, labored respirations; RR 22/min; HR 78; PaO2 90 mmHg; diminished breath sounds ‐ Deep respirations; RR 32/min; HR 115; PaO2 98 mmHg; crackles scattered bilaterally | Increased respiratory rate combined with reduced PaO<sub>2</sub> and breath sounds are the combination to look for. |
2147 A client who is a long‐term smoker develops a cough Correct answer: 3 An antibiotic may be ordered if another respiratory infection, such as bronchitis, is present. A and severe pain with any chest movement, coughing, cough suppressant may be prescribed for nighttime only, but should not be ordered if a or deep breathing. Upon assessment, the pain is productive cough occurs. The relief of pain is of top priority in order to allow the client to rest localized on one side, and a diagnosis of pleurisy is and cough effectively, if necessary. made. The highest priority for treatment is which of the following? ‐ Antibiotics ‐ Cough suppressant ‐ Analgesics for pain ‐ Bedrest | Pain is the most prominent symptom that would require treatment. |
2148 A client has a chest tube inserted for a Correct answer: 4 A properly working system should have fluctuation in the water‐seal compartment that pneumothorax. The nurse assesses the drainage increases with inspiration and falls with expiration, and intermittent bubbling should be noted. system for adequacy. Which of the following signifies that the system is working correctly? ‐ There is no fluctuation in the water‐seal compartment. ‐ Constant bubbles are noted in the water‐seal without fluctuation. ‐ There are no bubbles noted in the water‐seal compartment. ‐ There is fluctuation in the water‐seal compartment coinciding with respirations. | Fluctuation with respiration is the key to functional chest drainage. |
2149 Theophylline (Theo‐dur) is ordered for a client with Correct answer: 3 The action of theophylline is bronchodilation, which should relax respiratory efforts. Eupnea emphysema for the main purpose of relaxing bronchial is normal respirations, which should be a direct result of bronchodilation. smooth muscle. Which of the following indicate(s) therapeutic effects of the drug? ‐ Decreased heart rate ‐ Thinner, clear‐to‐white secretions ‐ Eupnea respirations ‐ Increasing respiratory rate | Recall that eupnea means normal breathing, which is the goal of therapy. |
2150 A client visits the clinic with a diagnosis of Correct answer: 2 The trapping of air causes the typical barrel chest appearance and the pink color of the skin emphysema. Then nurse expects to note which of the (unless in the later stage of emphysema). The clubbing of the nails is related to the chronic following typical characteristics for a client with this hypoxia. diagnosis? ‐ Cyanosis, clubbing of the nails, and pigeon chest ‐ Barrel chest, pink color, and clubbing of the nails ‐ Barrel chest, cyanosis, and peripheral edema ‐ Thin body appearance and pigeon chest | Option 2 describes the typical clinical picture of this disease. |
2151 A client with chronic obstructive pulmonary disease Correct answer: 3 Side effects of the methylxanthines (related to caffeine) are headache, seizures, diarrhea, (COPD) is prescribed a methylxanthine muscle twitching, and anorexia. A normal theophylline level is between 10 and 20 g/mL; the (bronchodilator) to relieve the symptoms of dyspnea client should be closely monitored for toxicity, in which levels exceed the high end of the and reduce the respiratory effort. Which of the normal range. following should alert the nurse to notify the physician to have a theophylline level drawn? ‐ Increased appetite ‐ Constipation ‐ Hand tremors ‐ Bradycardia | Shaking is associated with caffeine effects, and is similar to increased theophylline level. |
2152 A female client with asthma is instructed to keep a Correct answer: 2 Although 210 (option 4) and 250 (option 1) are better than the reading during an asthmatic daily log of her peak flow meter readings during a attack, effective medication should return the client to a fairly normal value, if not close to normal day as well as prior to and after an asthma what the average reading is in a normal day. Ideally, 350 would be effective, but 300 is attack. If the peak flow meter reading averages 350 certainly an improvement, and is at least 80% of the client's potential. (350 x 0.80 = 280.) but drops to 200 during an asthma attack, the client should expect to see which of the following readings if the rescue inhaler is effective? 1.‐ 250 2.‐ 300 3.‐ 150 4.‐ 210 | The question is asking about effective treatment, so select the best reading. |
2153 In educating a group of clients with pulmonary Correct answer: 3 In conditions such as emphysema or asthma, where airways are constricted or airflow is disorders about the use of pursed‐lip breathing, the limited, pursed‐lip breathing keeps the airways open by maintaining positive pressure. nurse is asked how this technique helps them to breathe. The best response would be that pursed‐lip breathing: ‐ Improves lung expansion. ‐ Reduces anxiety that increases oxygen demand. ‐ Keeps airways open. ‐ Helps the client regain control of the attack. | The technique is used with clients with emphysema for whom the main problem is keeping airways open. |
2154 The nurse explains that during an acute attack of an Correct answer: 2 Decreasing anxiety which lessens oxygen demand as well as abdominal breathing to improve obstructive pulmonary disorder, such as chronic lung expansion assists the client to breathe more easily and to relieve some of the air hunger obstructive pulmonary disease (COPD) or asthma, that accompanies obstructive breathing disorders. abdominal breathing might be most effective because it: ‐ Keeps airways open. ‐ Improves lung expansion. ‐ Decreases the workload of the lungs. ‐ Decreases the pulmonary pressure. | Think of the abdomen as a place for lung expansion. |
2155 For a client with thick, tenacious secretions, which of Correct answer: 1 All of these answers are appropriate and correct for an individual who has respiratory the following actions by the nurse would be the most problems with productive sputum. The stem asks, however, which option is most effective effective? with thick secretions. Increasing fluid intake can be as effective as an expectorant or mucolytic. ‐ Encouraging fluid intake of 2,000 cc per day unless contraindicated ‐ Assisting the client to sit upright to promote chest expansion ‐ Monitoring pulse oximetry, which indicates airway obstruction ‐ Providing humidified oxygen to decrease its drying effects | Liquefy thick secretions with increased liquids. |
2156 A primary consideration by the nurse in preoperative Correct answer: 4 This measure assists the client in eliminating the anesthetic gases that can eventually lead to teaching for prevention of atelectasis would be to pneumonia. It also promotes lung expansion and rids the lungs of secretions that could be a educate the client about: medium for growth of microorganisms. ‐ Lung complications postsurgery. ‐ How difficult coughing might be. ‐ The use of analgesics before the pain becomes too severe. ‐ Turning, coughing, and deep breathing every two hours. | Recall this as a basic postoperative care strategy. |
2157 The nurse assesses for which of the following as a Correct answer: 2 The inflammatory process in the pleural cavity (which usually has a thin layer of serous fluid) unique manifestation in a client with pleurisy? can cause a friction rub when auscultating lung sounds. This symptom is unique to this health problem. ‐ Dull, pressure type of pain ‐ Pleural friction rub ‐ Generalized chest discomfort ‐ Productive cough | Note the phrase “unique manifestation” in the question stem, and see that it would describe option 2. |
2158 A client in the Emergency Department who suffered Correct answer: 3 A pneumothorax is the presence of air in the pleural cavity; a hemothorax is the presence of chest injury in a motor vehicle accident has overheard blood in the pleural cavity. The cause (e.g., knife wound, crushing injury, or other thoracic conversation during the course of rapid treatment. He trauma), signs and symptoms, and treatment are basically the same. asks the nurse about hemothorax and pneumothorax, which were discussed in his presence. The nurse explains that the difference between these two is the: ‐ Cause. ‐ Amount of collapsed lung. ‐ Presence of air versus blood in the pleural cavity. ‐ Difference in treatment options. | Use the word prefixes 'hemo‐', meaning blood, and 'pnumo‐', meaning air, to select the correct answer. |
2159 The nurse expects to administer which of the Correct answer: 1 Heparin (an anticoagulant) is the initial treatment for a confirmed PE to prevent the extension following as the most important initial or propagation of thrombi, and to inhibit the formation of new clots. Coumadin is usually pharmacological treatment for a cardiac client on started after the heparin has been infused for several days. LMWH is not the drug of choice for bedrest just diagnosed with a pulmonary embolism this client, and TPA is a thrombolytic drug that dissolves clots that are already formed. (PE)? ‐ Heparin ‐ Low–molecular weight heparin (LMWH) ‐ Warfarin (Coumadin) ‐ Tissue plasminogen activator (TPA) | Recall that heparin is used to treat PE. LMWH is used as prophylaxis. |
2160 For a client on a heparin drip for a diagnosis of Correct answer: 2 For a therapeutic effect of heparin, the PTT value should be 1.5–2 times the normal control pulmonary embolus, which of the following partial level. Options 1 and 3 show subtherapeutic levels, and option 4 shows an excessively high thromboplastin times (PTT) shows a therapeutic level. effect? ‐ PTT value of 20 sec, control of 14 ‐ PTT value of 29 sec, control of 14 ‐ PTT value of 13 sec, control of 14 ‐ PTT value of 42 sec, control of 14 | Remember 1.5–2 times control for PT and PTT values. |
2161 In planning care for a client, the nurse understands Correct answer: 3 The pulmonary vascular system has low pressure, high blood flow, and low resistance; that pulmonary hypertension is a more severe therefore, it takes more to raise the pressure within the pulmonary artery. This is not reflected condition than hypertension seen in a cardiac client in the systolic pressure as readily. because: ‐ An underlying condition could be masking the symptoms of pulmonary hypertension. ‐ The low resistance in the pulmonary vascular system makes the diagnosis more difficult to detect. ‐ The pulmonary artery pressure rises significantly before a systolic increase occurs. ‐ The pulmonary vasculature thins, and can rupture, in pulmonary hypertension. | Select the option that addresses both pulmonary and systemic pressure. |
2162 A client receiving mechanical ventilation after acute Correct answer: 1 Because of the action of a neuromuscular blocking agent, movement and communication are respiratory failure has been given a neuromuscular blocked, and this can be frightening to a family member. Option 3 is true, but is an blocking agent to suppress the ability to breathe and inappropriate answer for a concerned family member who probably will not understand what lessen the agitation caused by the ventilator. A family was said. Options 2 and 4 are unacceptable. member asks the nurse why the client does not move. The nurse's best response is: ‐ "The lack of movement and communication is temporary, and will return when the drug wears off." ‐ "The depression of the drug shouldn't be taken seriously, although the client appears to be comatose." ‐ "A neuromuscular blocking agent was given, and this drug blocks the action of acetylcholine at the nicotinic receptors of skeletal muscles." ‐ "Perhaps you should speak to the physician." | Select the response that gives a truthful response in understandable terms. |
2163 If a client demonstrates chest wall movement on Correct answer: 2 With flail chest, the classic chest wall movement is for the wall to collapse upon inspiration inspiration and expiration, the nurse should be because of the negative pressure exerted within the lung cavity. The positive pressure causes suspicious of: the chest wall to expand upon expiration. This does not happen with the other disorders listed. ‐ Pneumothorax. ‐ Flail chest. ‐ Hemothorax. ‐ Adult respiratory distress syndrome (ARDS). | Flail chest is the only disorder listed that has a peculiar chest movement as a symptom. |
2164 A client with extremely foul‐smelling, purulent Correct answer: 3 The smaller bronchi and bronchioles become dilated as a result of the infection in the sputum; wheezing; dyspnea; and weight loss is respiratory tract. As the dilation occurs, pockets form where infectious material is trapped and probably experiencing: allows abscesses to develop. The walls of the bronchi are weakened, and become necrotic, resulting in foul‐smelling sputum. ‐ Lobar pneumonia. ‐ Emphysema. ‐ Bronchiectasis. ‐ Asthma. | Recall that purulent sputum is characteristic of bronchiectasis. |
2165 A male client who has chronic obstructive pulmonary Correct answer: 3 In emphysema, air is trapped, and causes hyperinflation of the lung, thus causing the barrel disease (COPD) breathes better while sitting up on the chest. Although asthma and chronic bronchitis also can be a part of COPD, these diagnoses do side of the bed. His appearance is cachectic and barrel‐ not account for the appearance of the chest. chested. The nurse realizes that the barrel chest appearance is a result of: ‐ Chronic bronchitis. ‐ Asthma. ‐ Emphysema. ‐ Empyema. | Recall that barrel chest is associated with emphysema. |
2166 A client newly diagnosed with pneumonia has fine Correct answer: 4 In a newly diagnosed client, the consolidation can be so dense that the client is ineffective in rales, a nonproductive cough, dyspnea, fever, and pain removing the sputum, and lung sounds are quite diminished. Options 1 and 2 are correct, but upon inspiration. Regardless of the effort to cough, the are not necessarily going to help with coughing, which can be very painful. Movement will help client fatigues easily, and is not effective. A nursing the client, although planned rest periods are needed (option 3). intervention that will help the ineffective cough is to: ‐ Use a nonrebreather mask. ‐ Offer endotracheal suctioning. ‐ Encourage bedrest. ‐ Teach the client to splint the chest with a pillow. | Omit options 1 and 2, as they would not address the issue. Option 3 would increase congestion and ability to cough. |
2167 A client with an exacerbation of chronic obstructive Correct answer: 1 Respiratory failure in a COPD client is manifested by a drop in oxygen of 10–15 mmHg from pulmonary disease (COPD) is admitted to the unit for the previous level. Although the other ABGs are not adequate, the values must be compared treatment. The arterial blood gases (ABGs) upon with previous values for the COPD client who is already hypoxic and hypercapnic. admission are as follows: PaO<sub>2</sub> 49 mmHg; PaCO<sub>2</sub> 55 mmHg; and pH 7.35. Within hours, the client becomes restless, cyanotic, diaphoretic, tachypneic, and tachycardic. The nurse calls the physician, and repeat ABGs are ordered. Which set of ABGs would indicate respiratory failure? ‐ PaO2 39 mmHg; PaCO2 40 mmHg; pH 7.30 ‐ PaO2 47 mmHg; PaCO2 62 mmHg; pH 7.37 ‐ PaO2 50 mmHg; PaCO2 40 mmHg; pH 7.32 ‐ PaO2 39 mmHg; PaCO2 60 mmHg; pH 7.35 | The reduction in PaO<sub>2</sub> combined with the acidosis is the hint to the correct response. |
2168 Which of the following would be the priority Correct answer: 2 Pain management is a primary consideration in any end‐stage cancer. Although all of the assessment for a client with end‐stage lung cancer? other answers are important when caring for a client with lung cancer, palliative support is essential, and should include around‐the‐clock pain relief. This is not the appropriate time to be concerned about opioid addiction. ‐ Lung sounds ‐ Pain | Recall that with end‐stage disease, comfort is the priority. |
‐ Sputum color and consistency ‐ Any changes in respiratory function | |
2169 A client with chronic obstructive pulmonary disease Correct answer: 4 Oxygen is drying to the nasal passageway, and under the positive pressure of CPAP, a (COPD), sleep apnea, and cardiac problems has been nosebleed is likely to occur in individuals who are already prone to this. Applying a small placed on continuous positive airway pressure (CPAP) amount of antibiotic ointment in the nostril prone to bleeding before bedtime might help. at night at home to assist with the sleep apnea. He Cardiac conditions such as hypertension or arteriosclerosis, as well as medications such as complains of having a nosebleed after about a week of anticoagulant or antiplatelet drugs, can also cause nosebleeds. The stem, however, does not the home oxygen therapy. What is the nurse's best give enough information as to the type of cardiac problems that the client has; avoid reading explanation for this? into the question. ‐ The oxygen therapy is probably not the cause; other reasons should be investigated. ‐ The cardiac problems are more likely the cause of the nosebleed. ‐ The oxygen causes a vasodilating effect, which could enhance a nosebleed. ‐ The oxygen is drying to the nasal passage, and could be irritating the membranes. | Recognize that the word drying in option 4 is the key to the correct response. |
2170 Which of the following clients is at highest risk of Correct answer: 3 The etiology is not fully understood, but tall, young, thin‐chested men who smoke are more experiencing a spontaneous pneumothorax? prone to developing a spontaneous pneumothorax. Option 1 is more likely to be positive for tuberculosis (TB); option 2 might experience sleep apnea; and option 4 is more likely to experience pulmonary hypertension. ‐ A client who is homeless, HIV‐positive, and lives in an overcrowded alley ‐ A client who is obese, elderly, and a chronic smoker ‐ A tall, thin young man who smokes ‐ A 35‐year‐old woman who smokes and is overweight | Recall that spontaneous pneumothorax occurs in young, tall, thin males. |
2171 Asthma, COPD, cystic fibrosis, and bronchiectasis all Correct answer: 1 Because of the obstruction to airflow, bronchoconstriction is associated with all of these cause problems with obstruction to airflow out of the diagnoses, mostly because of damage to the lung or inflammation. The other three symptoms lung. The nurse expects which of the following are specific to one particular disorder. assessment findings to be present in these diagnoses? ‐ Wheezing ‐ Angina ‐ Orthopnea ‐ Anxiety | Recall that obstruction is associated with wheezing. |
2172 The nurse is teaching nutritional information to the Correct answer: 3 The excessive mucus production from cystic fibrosis blocks the ducts of the pancreas, which mother of a child with cystic fibrosis. As a basis for the prevents the digestive enzymes from being released. In the absence of these enzymes, discussion, the nurse would include that malnutrition digestion is impaired. and weight loss are caused by: ‐ Decreased appetite because of chloride loss. ‐ Suppressed appetite because of the increased work of breathing. ‐ Pancreatic failure and insufficient pancreatic enzymes to digest food. ‐ A downward push of the diaphragm, which makes eating more difficult. | Look for the answer choice (option 3) that mentions pancreatic failure. |
2173 A client underwent bronchoscopy using conscious Correct answer: 2 An intact gag reflex indicates that topical sedation has lost its effect, and that the client is able sedation. Which of the following outcomes is most to swallow, a major safety consideration prior to discharging the client from the health care important to meet prior to discharging the client? facility. The ability to swallow would precede consumption of oral intake. Knowing symptoms to report to the physician following discharge is important, but the physiological condition takes priority in this case. The client's ability to verbalize discharge instructions prior to discharge is not a good predictor of postdischarge memory; therefore, it is essential that written instructions be sent home with the client. Fever, if present, can take hours or days to resolve; the client might have been febrile at the onset of the procedure. ‐ The client verbalizes symptoms to report to the physician following discharge. ‐ The client has an intact gag reflex. ‐ The client is afebrile. ‐ The client is taking oral fluids. | Recall that presence of a gag reflex protects the airway, which is always a priority. |
2174 A client is admitted to the hospital with the medical Correct answer: 3 The medulla and pons are the areas of brain tissue that control breathing. Injury to these diagnosis of traumatic brain injury. From the tissues would produce alterations in the client's breathing rate and pattern. The other options assessment finding of slow, shallow respirations, the are incorrect. nurse concludes that which area of the brain is affected by the injury? ‐ Anterior pituitary ‐ Hypothalamus ‐ Medulla ‐ Cerebral cortex | Recall that the medulla controls vital functions. Omit options 1 and 2 as relating to endocrine functions. |
2175 In the client with right lung pneumonia, the nurse Correct answer: 4 With unilateral lung disease, the example to remember is "good lung down." Since ventilation should encourage which position to facilitate optimal and perfusion are gravity‐dependent, enhancing ventilation and perfusion to healthy lung oxygenation? tissue and alveoli will enhance oxygenation. Perfusion refers to the circulation of blood into the tissues and cells. Supine positioning would provide near‐equal ventilation and perfusion to both lungs. In the diseased lung, excess fluid and fibrosis inhibit gas exchange at the pulmonary capillary membrane, thereby diminishing oxygenation. ‐ Prone position ‐ Supine position, with head elevated 30 degrees ‐ Positioned with the right side dependent ‐ Positioned with the left side dependent | Recall that keeping the infected lung up promotes expansion. |
2176 The nurse is making a home visit to a 70‐year‐old Correct answer: 2 Increased anterior–posterior diameter of the chest, pursed‐lip breathing, and circumoral client with emphysema. Which assessment finding has cyanosis are chronic findings in clients with emphysema. They do not indicate acute changes in the most serious implication for this client's nursing the client's condition. Bilateral crackles throughout the lung fields indicate excessive care? pulmonary fluid, requiring acute intervention. The etiology of the fluid excess in the lungs needs to be explored in depth. ‐ Increased anterior–posterior diameter of the chest ‐ Bilateral crackles throughout the lung fields ‐ Pursed‐lip breathing ‐ Circumoral cyanosis | Recognize that option 2 is the only finding that is considered out of the ordinary in light of the diagnosis. |
2177 A postoperative client with emphysema is receiving Correct answer: 2 Carbon dioxide level is one of the primary stimuli for breathing in clients with chronic oxygen at 2 L/min via nasal cannula when he complains obstructive lung disease, who adjust to higher‐than‐normal carbon dioxide levels. Abrupt of feeling dyspneic. The client's wife asks the nurse to elevation of the oxygen level will depress the stimulus for breathing, and can even produce increase the oxygen intake to help him breathe more respiratory arrest. Administration of 100% oxygen to the client with COPD who is not receiving easily. Which response by the nurse is appropriate? mechanical ventilation is highly likely to lead to depressed breathing and respiratory arrest. The wife's presence might be providing comfort and support for the client. Psychological distress caused by her absence could worsen the dyspnea. Pain medication can depress breathing. ‐ Switch the oxygen to a 100% non‐rebreathing mask. ‐ Explain to the wife that high concentration of oxygen could depress breathing. ‐ Ask the wife to leave the room to let the client get some sleep. ‐ Administer pain medication. | Remember to always associate COPD with hypoxic drive. |
2178 For the client with bacterial pneumonia, the nurse Correct answer: 3 Productive cough is compatible with bacterial pneumonia, and differentiates it from viral expects the finding of: pneumonia. Excessive sputum is produced as pulmonary bacteria die. The white blood cell count is elevated in bacterial pneumonia compared with viral pneumonia. Chest x‐ray findings with bacterial pneumonia usually show consolidation, whereas the chest x‐ray is often normal with viral pneumonia. ‐ Normal white blood cell count. ‐ Atelectasis. ‐ Productive cough. ‐ Unremarkable chest x‐ray. | Recognize that option 3 describes an expected symptom of pneumonia. |
2179 The occupational health nurse teaches a group of Correct answer: 1 Many foreign particles inhaled from the environment are non‐biodegradable, and cause employees to follow all safety policies because chronic inflammation of lung tissue. The chronic inflammation leads to progressive scarring irreversible lung damage can result from occupational and fibrosis of lung tissue, thereby impairing the gas diffusion capabilities of the lungs. exposure to substances such as coal, asbestos, or glass, Antigen–antibody reactions are related to exposure to protein substances. due to: ‐ Chronic inflammation of lung tissue. ‐ Frequent antigen–antibody reaction to foreign substances. ‐ Chronic air trapping. ‐ Surfactant deficiency. | Recognize that the substances described are irritants, and cause inflammation. |
2180 In developing the care plan for a client with Correct answer: 2 Mycobacterium tuberculosis is transmitted via airborne droplets, so use of a properly fitted pulmonary mycobacterium tuberculosis, what primary particulate filter mask is indicated to prevent its spread. The other options do not represent precaution should be included? methods of preventing airborne droplet transmission. ‐ Contact skin precautions ‐ Use of special mask to avoid inhaling infected airborne droplets ‐ Avoidance of blood contamination ‐ Containment of draining wounds | Recall that TB is spread by droplet. A special mask as described in option 2 is the key to the correct response. |
2181 The family of a client with emphysema asks the nurse Correct answer: 4 Emphysema is a chronic disease with progressive destruction of alveoli and loss of alveolar about the disease process. The nurse explains that the area available for gas exchange. Paralysis of respiratory muscles, airway obstructions, and disorder results from a decreased oxygen supply due pleural effusion would diminish ventilatory capacity, which ultimately could lead to decreased to: oxygen supply. ‐ Paralysis of respiratory muscles. ‐ Infectious obstructions. ‐ Pleural effusion. ‐ Loss of surface area for gas exchange. | The reference to surface area for gas exchange describes the pathology of emphysema. |
2182 In the client with new rib fractures, which assessment Correct answer: 3 Clients with rib fractures should be assessed periodically for the possible complication of finding would best alert the nurse to the possible pneumothorax. Decreased or absent breath sounds are related to pneumothorax, which development of a pneumothorax? compresses functional lung tissue. Pink, frothy sputum is a possible (but unlikely) finding in clients with pneumothorax. Hoarseness is indicative of an airway obstruction or laryngeal nerve paralysis. Percussion sounds are hyperresonant in the area of a pneumothorax due to collection of air in the pleural space. ‐ Pink, frothy sputum ‐ Hoarseness ‐ Decreased breath sounds on the affected side ‐ Dullness to percussion on the unaffected side | Recognize that options 3 and 4 describe one‐sided changes. Option 3 would be an expected finding. |
2183 A client comes to the clinic with an acute asthma Correct answer: 2 Expiratory wheezing is a characteristic finding in acute asthma, due to airway constriction. episode. Which breath sound characteristic does the Crackles are indicative of excess pulmonary fluid, which is not a typical finding with acute nurse expect to find upon auscultation? asthma. Rhonchi are related to mucus obstruction of large airways, and are a common finding in chronic obstructive pulmonary disease processes. ‐ Bilateral crackles ‐ Wheezing ‐ Diminished breath sounds in the upper lobes ‐ Rhonchi | Recall that wheezing is most commonly associated with asthma. |
2184 Which of the following blood gas reports would the Correct answer: 4 During the later stages of COPD, arterial blood gas findings indicate low pH, elevated nurse expect in a client with progressive chronic pCO<sub>2</sub>, low pO<sub>2</sub>, and elevated obstructive pulmonary disease (COPD)? HCO<sub>3</sub><sup>‐</sup>, which indicate the body's attempt to compensate for chronically low pH. Option 1 is indicative of respiratory alkalosis; options 2 and 3 are variations of normal ABG results. ‐ pH 7.55; PaCO2 30 mmHg; PaO2 80 mmHg; HCO3‐ 24 mEq/L ‐ pH 7.40; PaCO2 40 mmHg; PaO2 94 mmHg; HCO3‐ 22 mEq/L ‐ pH 7. 38; PaCO2 45 mmHg; PaO2 88 mmHg; HCO3‐ 20 mEq/L ‐ pH 7.30; PaCO2 60 mmHg; PaO2 70 mmHg; HCO3‐ 30 mEq/L | Eliminate options 2 and 3, as they are relatively normal. Select option 4 based on the acidotic pH. |
2185 What is the priority item in discharge teaching for the Correct answer: 2 Cigarette smoking is the primary etiology of chronic bronchitis, so cessation is the priority for client with chronic bronchitis? the client. Teaching the client about potential side effects of any prescribed medications should be included in all discharge teaching. Avoidance of crowds to lower the risk of pulmonary infections is a recommendation that is more individualized and less common than the need for smoking cessation. Fluids are often increased. ‐ Fluid restriction ‐ Smoking cessation ‐ Avoidance of crowds ‐ Side effects of drug therapy | Recall that smoking cessation is encouraged in anyone, but especially respiratory clients. |
2186 A client has returned to the clinic 72 hours after a Correct answer: 3 An induration of 5–9 mm resulting from a tuberculin skin test is indicative of close contact tuberculin skin test with an induration of about 5–6 with an individual infected with mycobacterium tuberculosis. The client with this finding will be mm at the administration site. The client is visibly prescribed isoniazid for 6–12 months as prophylaxis against development of active TB. History upset, and states: "I can't believe I have TB!" Which of diabetes is not related to false positive tuberculin skin test. The nurse should demonstrate a statement by the nurse is appropriate? calm, supportive, and informing manner with this client. ‐ "You'll need to put on a mask and wear it whenever you are around other people." ‐ "The doctor will prescribe Isoniazid for you to take for the next 3 months." ‐ "This finding does not confirm TB; it might indicate a recent exposure to tuberculosis." ‐ "We'll need to do a chest x‐ray. This could be falsely positive because of your history of diabetes." | Recognize that option 3 is the only option in which all of the information presented is true. |
2187 What instruction is most important for the nurse to Correct answer: 3 For any client with a tracheostomy, maintenance of the airway is clearly the priority. Clients provide during discharge teaching of a client who are taught to perform routine tracheostomy care to prevent airway obstruction. Only those underwent a laryngectomy? clients discharged with a feeding tube will need instruction about operation of a feeding pump. Wound care and use of a Passy‐Muir valve for communication are important factors to include in discharge teaching, but the airway is the clear priority. ‐ Operation of feeding pump ‐ Use of a Passy‐Muir (speaking tracheostomy) valve ‐ Tracheostomy care ‐ Wound care | Use the ABCs (airway, breathing, circulation) to identify option 3 as the best response. |
2188 A postoperative client has a sudden onset of Correct answer: 3 With sudden onset of shortness of breath, the priority is for the nurse to maintain airway shortness of breath. What initial action by the nurse is patency and gas exchange. Positioning the client supine with a high degree of head elevation indicated? will assist with airway maintenance and ventilation. The nurse should then rapidly assess the client's heart and lung status before notifying the physician. ‐ Notify the physician. ‐ Assess oxygen saturation using pulse oximetry. ‐ Assist the client to a high Fowler's position. ‐ Auscultate the heart and lungs. | Recognize that all of the actions are correct but need to be performed in a logical order. Positioning to attempt to improve oxygenation is first priority. |
2189 A client has a right chest tube following a Correct answer: 1 Gravity helps maintain the water seal, thereby preventing backflow of air and fluid into the thoracotomy. When assisting the client to ambulate, chest. The chest tube should never be clamped, as this can cause pneumothorax. The chest what measure is appropriate to maintain the water tube should not be milked unless ordered by the physician for clients with visible clots in the seal? chest drainage tubing. Milking the chest tube creates suction within the tubing, and can cause pleural tissue damage. ‐ Keep the collection device below the level of the chest. ‐ Clamp the chest tube before assisting the client out of bed. ‐ Milk the chest tube when the client returns to bed, to assess patency. ‐ Connect the collection device to a portable suction machine. | Recognize that options 2, 3, and 4 are interventions that are not recommended. |
2190 A client is brought to the Emergency Department Correct answer: 3 Tension pneumothorax is a life‐threatening condition, so the nurse must recognize potential following a motor vehicle crash with a tree. Which indicators. Deviation of the trachea toward the unaffected side occurs due to increased finding is suggestive of a tension pneumothorax? pressure within the pleural cavity. Increasing pressure on the great vessels in the chest causes decreased cardiac output, which can be fatal. Hypotension and tachypnea occur with pneumothorax, but are also related to numerous other conditions. Unilateral wheezing is indicative of narrowing of the airways. ‐ Tachypnea ‐ Hypotension ‐ Tracheal deviation ‐ Unilateral wheezing | Recall that tracheal deviation is associated with tension pneumothorax. |
2191 What is the priority nursing diagnosis for the finding Correct answer: 3 Secondary polycythemia, or increased red blood cell count, develops as chronic obstructive of secondary polycythemia in a client with chronic pulmonary disease occurs, in response to chronic hypoxemia. Of the options above, impaired obstructive pulmonary disease? tissue perfusion related to chronic hypoxemia is the only factor related to development of secondary polycythemia. Risk for injury in these clients related to venous thrombi or use of oxygen might or might not be present. Impaired gas exchange also could be a factor; however, it is related to hypoxia. ‐ Risk for Injury related to venous thrombi ‐ Risk for Injury related to use of oxygen ‐ Impaired Tissue Perfusion related to chronic hypoxemia ‐ Impaired Gas Exchange related to factors other than hypoxia | Recall that polycythemia influences perfusion because of chronic hypoxia. |
2192 When auscultating breath sounds in the client with an Correct answer: 2 Wheezing is a common finding during an acute asthma episode; however, the wheezing is not acute asthma episode, the nurse uses which of the a consistent predictor of the severity of the attack. Airway obstruction might be so severe that following to guide interpretation of severity of the client is moving little or no air, and is experiencing severe respiratory distress. Breath findings? sounds are prolonged in expiration with asthma, but this factor does not alter the plan of care in any way. ‐ Severity of airway obstruction is associated with intensity of wheezing. ‐ Wheezing might be absent with severe airway obstruction. ‐ Unilateral wheezing indicates an origin for respiratory distress other than asthma. ‐ Breath sounds are prolonged on expiration. | Recall that in severe obstruction, there is no air passing, and therefore no wheezing. |
2193 What nursing intervention is most effective to Correct answer: 1 Frequent coughing and deep breathing is an easy maneuver for the postoperative client that prevent atelectasis in the postoperative client? has great benefit to optimize ventilation. Good pain management facilitates effective coughing and deep breathing. Getting the client out of bed, or administering oxygen or bronchodilators, are all appropriate interventions for preventing or treating atelectasis, but clearly the best option is to prevent its occurrence by simple maneuvers such as coughing and deep breathing. ‐ Frequent coughing and deep breathing ‐ Assisting the client out of bed ‐ Administration of bronchodilators ‐ Supplemental oxygen | Remember nursing basics of coughing and deep breathing to keep airways clear. |
2194 What blood gas alteration would the nurse expect to Correct answer: 2 Carbon dioxide is eliminated from the body as exhaled gas. The greater the rate of breathing, occur with persistent tachypnea? the greater the quantity of carbon dioxide eliminated. Normal CO<sub>2</sub> levels are 35–45 mmHg. Normal HCO<sub>3</sub><sup>‐</sup> levels are 22–26 mEq/L. With decreasing CO<sub>2</sub> levels, HCO<sub>3</sub><sup>‐</sup> should also fall to compensate. ‐ pCO2 48 mmHg ‐ pCO2 30 mmHg ‐ pO2 82 mmHg ‐ HCO3‐ 29 mEq/L | Recall that rapid breathing would reduce CO<sub>2</sub>. |
2195 What nursing intervention might improve Correct answer: 4 For the client with ARDS, placing the client in a prone position allows for expansion of the ventilation–perfusion matching in clients with acute posterior chest wall, which might be effective in enhancing oxygenation. Transfusing red blood respiratory distress syndrome (ARDS) who show no cells or albumin does not increase oxygenation in ARDS. Option 3 should have been performed improvement with increases in oxygen concentration as an initial measure. administered? ‐ Transfusion of packed red blood cells ‐ Infusion of albumin ‐ Positioning supine with head elevated 30–45 degrees ‐ Prone positioning | Recall that prone positioning is rarely performed, but is associated with ARDS treatment. |
2196 The nurse would expect to find a diminished Correct answer: 1 Carbon dioxide is eliminated from the body as exhaled gas. The faster the rate of breathing, pCO<sub>2</sub> level in a client who has the greater the quantity of carbon dioxide eliminated. physical assessment finding of: ‐ Hyperventilation. ‐ Hypoventilation. ‐ Prolonged expiration. ‐ Stridor. | Recall that rapid breathing results in low pCO<sub>2</sub>, from “blowing off” CO<sub>2</sub>. |
2197 While making rounds, the nurse observes a client Correct answer: 2 Oxygen administered by a Venturi mask can be regulated to deliver between 24 and 50 receiving oxygen through a Venturi mask. The nurse percent, which is a benefit for clients who require higher oxygen supplement without expects that the primary benefit of this method of mechanical ventilation. The Venturi mask does not prevent rebreathing of carbon dioxide, as oxygen supplementation is: does a non‐rebreather mask. Oxygen concentration of 100 percent would be administered to COPD clients only in rare circumstances via mechanical ventilation. ‐ The ability to prevent rebreathing of exhaled carbon dioxide. ‐ Oxygen concentration can be regulated. ‐ Constant humidity can be administered to liquefy pulmonary secretions. ‐ The ability to deliver up to 100 percent oxygen concentration for clients with COPD. | Eliminate option 4, as this is contraindicated in most circumstances. Eliminate option 1, as the device does allow rebreathing. |
2198 From the client's history, the nurse recognizes that Correct answer: 3 Cigarette smoking is the leading cause of lung cancer. Smokeless tobacco is more often which of the following is the most significant factor associated with oral cancer. Air pollution could also be a contributing factor to development of related to the development of bronchogenic lung cancer. History of asthma is not associated with greater risk of lung cancer. carcinoma? ‐ Asthma ‐ Smokeless tobacco ‐ Cigarette smoking ‐ Air pollution | Recall that smoking is the leading cause of lung cancer. |
2199 Following placement of a central venous line, which Correct answer: 3 Increased heart rate and/or respiratory rate within minutes to several hours following central of the following data should the nurse report venous line insertion are symptoms of a pneumothorax caused by puncture of the pleura. The immediately to the physician? client will require a chest x‐ray to determine if a pneumothorax is present. If the client does have a pneumothorax, placement of a chest tube is likely. Pain at central line insertion site, fever, and diminished breath sounds in lung bases will require intervention, but the etiology of these symptoms is not likely to be potentially life‐threatening, as is the development of a pneumothorax. ‐ Pain at the insertion site ‐ Fever ‐ Increased heart rate and/or respiratory rate ‐ Diminished breath sounds in lung bases | Use the ABCs (airway, breathing, and circulation) to identify changes in respiratory or cardiac function that should be reported. |
2200 The nurse recognizes that which of the following Correct answer: 1 Pulmonary embolism is the most common complication of hospitalized clients, and is due factors in the postoperative client poses the greatest primarily to immobility. Postoperative clients are at risk for immobility associated with risk for development of pulmonary embolism, and surgery. Infrequent coughing and deep breathing is associated with postoperative atelectasis. must be addressed in the client's care plan? Pulmonary embolism originates from deep veins in the extremities, not in superficial varicose veins. ‐ Immobility ‐ Infrequent coughing and deep breathing ‐ Varicose veins ‐ Lower‐extremity edema | The qualifier postoperative should lead to the selection of immobility, which is frequent in the postoperative period. |
2201 When planning care for the client admitted with Correct answer: 1 All of these nursing diagnoses are appropriate for the client with COPD; however, the primary exacerbation of chronic obstructive pulmonary disease alteration is related to impaired gas exchange. The alteration in gas exchange is the etiology of (COPD), the nurse identifies which nursing diagnosis as the other problems. the priority? ‐ Impaired Gas Exchange ‐ Activity Intolerance ‐ Risk for Infection related to impaired respiratory defenses ‐ Ineffective Breathing Pattern | Look for the diagnosis that is most descriptive of the pathology. |
2202 Nutritional recommendations for the client with Correct answer: 2 Clients with COPD are often underweight due to the fatigue associated with eating. chronic obstructive pulmonary disease (COPD) should Therefore, calorie‐dense foods will help them to ingest more calories with less effort for include which of the following? eating. Carbohydrate intake should be about 50 percent of total calories. Since carbohydrates metabolize to carbon dioxide and water, excessive carbohydrate intake could contribute to carbon dioxide retention. Small, frequent intakes of food should be encouraged. ‐ Weight‐reduction guidelines ‐ Identification of foods that are calorie‐dense ‐ Avoidance of between‐meal snacks ‐ More than 50 percent of intake as carbohydrates | Associate the increased respiratory effort of COPD with increased calorie need. |
2203 A client has been admitted for dehydration after Correct answer: 1 A prolonged fasting state can lead to dehydration. During fasting, the body reverts to cellular fasting for five days. For which of the following breakdown to maintain energy, and lactic and pyruvic acids build up in the body. This acid–base imbalances would the nurse assess this accumulation of acids leads to the development of metabolic acidosis. Options 2 and 4 are client? incorrect because alkalosis would not occur. Option 3 is incorrect because the primary disturbance is not respiratory. ‐ Metabolic acidosis ‐ Metabolic alkalosis ‐ Respiratory acidosis ‐ Respiratory alkalosis | Note the critical word fasting that indicates this is a metabolic rather than respiratory problem, which eliminates options 3 and 4. Choose option 1 over 2 because metabolic by‐ products are acidic in nature, not alkaline. |
2204 A client is admitted to the hospital after vomiting for Correct answer: 2 Vomiting leads to the loss of hydrochloric acid from gastric acids. Hydrogen ions must leave three days. Which of the following ABG results would the blood to replace this acidity in the stomach. Option 2 reflects metabolic alkalosis elevated the nurse expect? pH and HCO<sub>3</sub><sup>‐</sup>, and normal PaCO<sub>2</sub>. Option 1 is incorrect because it reflects respiratory acidosis with partial compensation decreased pH, and elevated PaCO<sub>2</sub> and HCO<sub>3</sub><sup>‐</sup>. Option 3 is incorrect because it reflects a mixed acid–base imbalance metabolic alkalosis with respiratory acidosis: normal pH, and elevated PaCO<sub>2</sub> and HCO<sub>3</sub><sup>‐ </sup>. Option 4 is incorrect because it reflects respiratory alkalosis increased pH, decreased PaCO<sub>2</sub>, and normal HCO<sub>3</sub><sup>‐</sup>. ‐ pH 7.30; PaCO2 50; HCO3‐ 27 ‐ pH 7.47; PaCO2 43; HCO3‐ 28 ‐ pH 7.34; PaCO2 50; HCO3‐ 28 ‐ pH 7.47; PaCO2 30; HCO3‐ 23 | Note the critical word vomiting, and recall that stomach contents are rich in acid. Loss of acid would raise the pH (eliminating option 1 and 3) and lead to increased free circulating HCO<sub>3</sub><sup>‐</sup>, eliminating option 4. |
2205 A client is admitted to the hospital with a diagnosis of Correct answer: 1 Clients with respiratory acidosis from ingestion of barbiturates would have slow and shallow respiratory acidosis secondary to overdose of respirations, leading to hypoventilation. Palpitations are a subjective complaint reported by barbiturates. Which of the following assessments the client; the nurse cannot directly assess this symptom. In addition, palpitations are would the nurse encounter? associated with respiratory alkalosis. Tetany symptoms and increased deep tendon reflexes are also associated with respiratory alkalosis. ‐ Slow, shallow respirations ‐ Tetany symptoms ‐ Increased deep tendon reflexes ‐ Palpitations | The wording of the question guides you to look for objective data, which eliminates option 4. Also recall that barbiturates are CNS depressants, while options 2 and 3 indicate CNS excitation. For this reason, eliminate options 2 and 3, which leaves option 1 as the correct option. |
2206 A client is admitted with a diagnosis of renal failure. Correct answer: 2 Clients with renal failure have difficulty synthesizing HCO<sub>3</sub><sup>‐ Which of the following ABG results would the nurse </sup> in the renal tubules secondary to the renal failure. These clients also retain expect to see with this client? K<sup> </sup>, and subsequently develop metabolic acidosis. Option 2 reflects uncompensated metabolic acidosis. Option 1 is incorrect because it reflects metabolic alkalosis increased pH and HCO<sub>3</sub><sup>‐</sup>, and normal PaCO<sub>2</sub>. Option 3 is incorrect because it reflects respiratory acidosis decreased pH, increased PaCO<sub>2</sub>, and normal HCO<sub>3</sub><sup>‐</sup>. Option 4 is incorrect because it reflects a mixed acid–base imbalance metabolic alkalosis with a respiratory acidosis: normal pH, and increased PaCO<sub>2</sub> and HCO<sub>3</sub><sup>‐ </sup>. ‐ pH 7.49; PaCO2 36; HCO3‐ 30 ‐ pH 7.30; PaCO2 35; HCO3‐ 18 ‐ pH 7.31; PaCO2 50; HCO3‐ 23 ‐ pH 7.43; PaCO2 48; HCO3‐ 30 | First, recognize renal failure as a metabolic condition in which there is an impaired ability to eliminate metabolic acids and wastes. With this in mind, eliminate options 1 and 4 because of an elevated pH and a normal pH, respectively. Then choose option 2 over 3 because the bicarbonate (indicating metabolic status) is lower in option 2. |
2207 A client is admitted to the hospital with atelectasis Correct answer: 4 A client with atelectasis has collapsed alveoli that retain CO<sub>2</sub>, which and complaints of chest pain. For which of the can lead to respiratory acidosis. The client most likely would have hypoventilation as a following acid–base imbalances would the nurse assess respiratory pattern, which would further contribute to the development of respiratory this client? acidosis. Options 1 and 3 are incorrect because the client would not be in an alkalotic state. Option 2 is incorrect because the primary disturbance is respiratory; clients with respiratory problems can report “chest pain.” Further information would be needed to rule out cardiac problems. ‐ Respiratory alkalosis ‐ Metabolic acidosis ‐ Metabolic alkalosis ‐ Respiratory acidosis | The critical word in the stem of the question is atelectasis. Recall that this term is associated with respiratory problems to eliminate options 2 and 3. Choose option 4 over option 1, recalling that CO<sub>2</sub> retention characterizes many respiratory conditions, leading to acidosis (since CO<sub>2</sub> acts as an acid in the body). |
2208 A client is admitted to the hospital with respiratory Correct answer: 3 Obesity can lead to chest wall abnormalities and hypoventilation. Respiratory acidosis results acidosis. Which of the following conditions most likely from hypoventilation. Option 1 is incorrect because prolonged diarrhea likely leads to the led to the development of this state? development of metabolic acidosis. Option 2 is incorrect because DKA leads to the development of metabolic acidosis. Option 4 is incorrect because diuretic administration leads to the development of metabolic alkalosis. ‐ Severe diarrhea for several days ‐ Diabetic ketoacidosis ‐ Obesity ‐ Diuretics | Note the term acidosis in both the stem of the question and in the correct option to help you choose option 2 correctly. Alternatively, eliminate options 1 and 4 because they are similar in that they both lead to fluid loss, and then eliminate option 3 as irrelevant. |
2209 Which of the following signs and symptoms indicates Correct answer: 2 Clients who have metabolic acidosis develop Kussmaul's breathing (rapid and deep that a client has metabolic acidosis? respirations). Weight gain and melena are not associated with the development of metabolic acidosis. Option 4 is incorrect because shallow breathing is associated with the development of metabolic alkalosis. ‐ Weight gain ‐ Rapid, deep respirations ‐ Melena ‐ Decreased respiratory rate and depth | The critical words in the stem of the question are metabolic acidosis. Recall that in metabolic abnormalities, the respiratory system helps to compensate; this will help to eliminate options 1 and 3. Choose option 2 over option 4 because it is the option that assists the body to “blow off” acid in the form of CO<sub>2</sub>. |
2210 Which of the following medications should the nurse Correct answer: 3 Alkalosis, especially respiratory alkalosis, makes the client more sensitive to the effects of review first for its potential interaction in a client digoxin; toxicity can develop even at therapeutic levels. A serum digoxin level should be admitted to the hospital with alkalosis? obtained, and the client evaluated for potential digoxin toxicity. Warfarin affects clotting factors. Metformin can cause the development of lactic acidosis. Ibuprofen can cause gastric irritation. ‐ Warfarin (Coumadin) ‐ Metformin (Glucophage) ‐ Digoxin (Lanoxin) ‐ Ibuprofen (Motrin) | Specific knowledge of medications that are affected by alkalosis is needed to answer this question. Use nursing knowledge and the process of elimination to make your selection. |
2211 A client is admitted to the hospital with complaints of Correct answer: 2 Acute pain usually leads to hyperventilation, which causes CO<sub>2</sub> to be sudden onset of severe abdominal pain. Which of the blown off, leading to an increased pH and decreased CO<sub>2</sub> level. If the following values in the arterial blood gas would the client has not compensated, the bicarbonate level will be normal. If the client is compensating, nurse expect to see? then the bicarbonate level will decrease in an attempt to restore the pH. Option 1 is incorrect because it reflects only a slight elevation of PaCO<sub>2</sub>; if the client were in severe pain, the level would likely be higher. Option 3 is incorrect because the pH is only slightly acidotic. Option 4 is incorrect because the oxygen saturation is within normal limits. ‐ PaCO2 48 ‐ HCO3‐ 18 ‐ pH 7.32 ‐ SaO2 90 | Visualize a picture of the client in pain. This person is most likely to have an increased respiratory rate, which blows off carbon dioxide (eliminating option 1) and decreases the bicarbonate level as a compensatory mechanism. This will help you to easily choose option 2 as correct. |
2212 A client is admitted to the hospital with an acid–base Correct answer: 3 The pH is low, indicating acidosis; the PaCO<sub>2</sub> is elevated, indicating a imbalance. ABG results are pH 7.33; respiratory basis; and the HCO<sub>3</sub><sup>‐</sup> is elevated, PaCO<sub>2</sub> 49; indicating that compensatory mechanisms are partially working. Option 1 is incorrect because HCO<sub>3</sub><sup>‐</sup> compensation is taking place due to increased HCO<sub>3</sub><sup>‐ 28. The nurse interprets these results as which of the </sup> level. Option 2 is incorrect because the client is not alkalotic. Option 4 is incorrect following? because the primary disturbance is respiratory. The change in the PaCO<sub>2</sub> level is greater than the change in the HCO<sub>3</sub><sup>‐</sup> level, which indicates a respiratory disturbance. ‐ Respiratory acidosis, uncompensated ‐ Metabolic alkalosis, uncompensated ‐ Respiratory acidosis, partially compensated ‐ Metabolic acidosis, partially compensated | First, eliminate option 2 because it is an alkalosis, and the client s pH of 7.33 indicates acidosis. Next, note that both the CO<sub>2</sub> and HCO<sub>3</sub><sup>‐</sup> levels are abnormal, indicating that the body is attempting to compensate (eliminating option 1). Choose option 3 over 4 because the elevated CO<sub>2</sub> “matches” a respiratory acidosis, and the HCO<sub>3</sub><sup>‐</sup> (an alkaline substance) is rising to try to compensate. |
2213 A client is admitted to the hospital with numerous Correct answer: 4 The pH is just below the high limit, and the HCO<sub>3</sub><sup>‐ complaints of muscle weakness and twitching. ABG </sup> is elevated, indicating a metabolic problem. The PaCO<sub>2</sub> is results are pH 7.44; PaCO<sub>2</sub> 49; elevated, indicating that compensation is taking place. Option 1 is incorrect because the client HCO<sub>3</sub><sup>‐</sup> is not acidotic. Option 2 is incorrect because the CO<sub>2</sub> would be 30. The nurse interprets these as which of the decreased rather than elevated. Option 3 is incorrect because the primary disturbance is following? metabolic, and the CO<sub>2</sub> is elevated rather than decreased. ‐ Metabolic acidosis, uncompensated ‐ Respiratory alkalosis, compensated ‐ Respiratory alkalosis, uncompensated ‐ Metabolic alkalosis, compensated | Note that the pH is within normal range, which indicates that the condition is compensated, thus eliminating options 1 and 3. Note that the high HCO<sub>3</sub><sup>‐</sup> is a metabolic indicator (not a respiratory one), and is consistent with a pH near the high end of normal, to help you choose option 4 over 2. |
2214 The nurse would suspect that a client who frequently Correct answer: 1 Excessive use of oral antacids can lead to metabolic alkalosis. Use of ibuprofen and Tylenol is uses which of the following is at risk for the not associated with the development of metabolic alkalosis. Overdoses of aspirin can be development of metabolic alkalosis? associated with the development of respiratory alkalosis, and eventually can lead to metabolic acidosis. ‐ Calcium carbonate (Tums) ‐ Ibuprofen (Motrin) ‐ Acetylsalicylic acid (aspirin) ‐ Acetaminophen (Tylenol) | Knowledge of medication side effects is needed to answer this question. First, eliminate options 2 and 4 because they are similar (non‐opioid analgesics). Then, eliminate option 3 because acid would not lead to alkalosis. Alternatively, recall that calcium carbonate is an antacid, which in excess could lead to metabolic alkalosis. |
2215 The nurse is admitting a client who has metabolic Correct answer: 4 Clinical manifestations of metabolic alkalosis are associated with the presence of tetany‐like alkalosis. The nurse plans to assess for signs and symptoms. Clients should be monitored for the presence of these symptoms because they symptoms of which of the following electrolyte usually correlate with low levels of calcium. Although it is important to assess all serum imbalances? electrolyte values to obtain a comprehensive picture, the presence of hypocalcemia can cause the client to have significant clinical symptoms. Early monitoring and prompt intervention can result in restoration of balance. ‐ Hypernatremia ‐ Hypochloremia ‐ Hypermagnesemia ‐ Hypocalcemia | Specific knowledge of the association between metabolic alkalosis and various electrolytes is needed to answer this question. Use nursing knowledge and the process of elimination to make your selection. |
2216 A client s blood gas results are pH 7.48; Correct answer: 3 The client’s pH is high, indicating alkalosis. The PaCO<sub>2</sub> is abnormal, PaCO<sub>2</sub> 30; indicating a respiratory basis. The HCO<sub>3</sub><sup>‐</sup> is HCO<sub>3</sub><sup>‐</sup> normal, indicating that compensation has not started. Option 1 is incorrect because the 23. How will the nurse interpret these results? HCO<sub>3</sub><sup>‐</sup> level would decrease with compensation. Options 2 and 4 are incorrect because the primary disturbance is respiratory, as indicated by the decrease in the CO<sub>2</sub> parameter. ‐ Respiratory alkalosis, compensated ‐ Metabolic alkalosis, uncompensated ‐ Respiratory alkalosis, uncompensated ‐ Metabolic alkalosis, compensated | Note that the pH is high, so the condition is not compensated, eliminating options 1 and 4. Choose option 3 over 2 because a low CO<sub>2</sub> correlates with a high pH, whereas an HCO<sub>3</sub><sup>‐</sup> at the lower end of the normal range does not correlate with a high pH. |
2217 The nurse determines that a client with a nasogastric Correct answer: 2 A client who has prolonged nasogastric suction is apt to have higher levels of bicarbonate tube on low suction for five days is at risk for because of hydrogen ion loss. Bicarbonate excess leads to a metabolic disturbance and the developing which acid–base imbalance? development of metabolic alkalosis. Options 1 and 3 are incorrect because the client will not experience acidosis. Option 4 is incorrect because the primary disturbance is caused by retained levels of bicarbonate in the body. ‐ Respiratory acidosis ‐ Metabolic alkalosis ‐ Metabolic acidosis ‐ Respiratory alkalosis | Eliminate options 1 and 4 first because impaction is a GI (metabolic) problem rather than a respiratory one. Choose option 2 over 3, recalling that pancreatic juices are rich in bicarbonate. A client who is impacted cannot eliminate bicarbonate in the stool, and thus it may be reabsorbed. |
2218 The following ABG results are on the client s chart: pH Correct answer: 3 The pH indicates alkalosis; HCO<sub>3</sub><sup>‐</sup> is high, 7.50; PaCO<sub>2</sub> 36; indicating a metabolic basis; and the PaCO<sub>2</sub> is normal, which indicates HCO<sub>3</sub><sup>‐</sup> that compensation has not taken place. Option 1 is incorrect because with compensation, the 30. How will the nurse interpret these blood gas PaCO<sub>2</sub> level would be increased. Options 2 and 4 are incorrect because reports? the primary disturbance is metabolic, as reflected by the increased bicarbonate level. | First, note that the pH is high, and so the imbalance cannot be compensated (eliminating option 2). Then note that HCO<sub>3</sub><sup>‐</sup> is the abnormally high value (not CO<sub>2</sub>), so the imbalance must be metabolic rather than respiratory (eliminating option 4). Choose option 3 over option 1 because the CO<sub>2</sub> (normally 35–45) has made no attempt to rise to compensate for the high HCO<sub>3</sub><sup>‐</sup>. |
‐ Metabolic alkalosis, partially compensated ‐ Respiratory alkalosis, compensated ‐ Metabolic alkalosis, uncompensated ‐ Respiratory alkalosis, uncompensated | |
2219 A client is admitted to the hospital. ABG results are Correct answer: 3 ABG results reflect elevated pH, indicating alkalosis, and normal pH 7.50; PaCO<sub>2</sub> 40; PaCO<sub>2</sub> and an increased HCO<sub>3</sub><sup>‐ HCO<sub>3</sub><sup>‐</sup> </sup>, indicating metabolic alkalosis. Vomiting is a common cause of this condition. The 29. Which of the following questions should the nurse presence of diarrhea is associated with metabolic acidosis. COPD and smoking are associated ask the client in order to help determine an etiology with respiratory acidosis. for this ABG result? ‐ “Have you had diarrhea lately?” ‐ “Do you have a history of COPD?” ‐ “How long have you had nausea and vomiting?” ‐ “Do you smoke?” | An ability to interpret ABGs and specific knowledge of manifestations of metabolic alkalosis are needed to answer this question. Use nursing knowledge and the process of elimination to make your selection. |
2220 A client s blood gas results are pH 7.36; Correct answer: 1 The pH is just within normal range, so the blood gas results are either normal or PaCO<sub>2</sub> 50; compensated. However, the PaCO<sub>2</sub> is high, indicating a respiratory HCO<sub>3</sub><sup>‐</sup> problem, and thus the ABGs cannot be normal. The HCO<sub>3</sub><sup>‐ 28. What do these results indicate to the nurse? </sup> is also high, which along with a normal pH indicates complete compensation. Options 2 and 3 are incorrect because the primary disturbance is respiratory, as reflected by the correlation between an elevated PaCO<sub>2</sub> and a pH toward the low end of normal. Option 4 is incorrect because the HCO<sub>3</sub><sup>‐ </sup> level would be normal if there were no compensation taking place. ‐ Respiratory acidosis, compensated ‐ Metabolic acidosis, compensated ‐ Metabolic acidosis, uncompensated ‐ Respiratory acidosis, uncompensated | Because the pH is within normal range, eliminate options 3 and 4. Choose option 1 over 2 because the pH is near the acidic end of the range and the high CO<sub>2</sub> correlates with acidosis, whereas the high HCO<sub>3</sub><sup>‐ </sup> would correlate with an alkalosis. |
2221 Which of the following statements by the client Correct answer: 2 Respiratory alkalosis is caused by hyperventilation. Stress and anxiety are two things that can indicates that discharge teaching for respiratory cause hyperventilation. It is important that clients who are prone to develop respiratory alkalosis is understood? alkalosis be aware of how to manage causative factors. Options 1 and 3 are incorrect because antacids and diuretics are associated with the development of metabolic alkalosis. Option 4 is incorrect because diarrhea is associated with the development of metabolic acidosis. ‐ “I will not take so many antacids anymore.” ‐ “I will take a stress management class.” ‐ “I will not take my Lasix without taking my potassium supplement.” ‐ “I will tell the doctor the next time I have diarrhea for so long.” | The critical word in the question is respiratory. Eliminate each of the incorrect options that would correlate better with a metabolic condition than with a respiratory one. Alternatively, consider that a common cause of respiratory alkalosis is hyperventilation, which is often caused by anxiety, and managed with stress management. |
2222 A client is admitted with severe diarrhea. ABGs are pH Correct answer: 1 The pH and HCO<sub>3</sub><sup>‐</sup> are decreased, indicating 7.33; PaCO<sub>2</sub> 42; metabolic acidosis. The PaCO<sub>2</sub> is normal, indicating that compensatory HCO<sub>3</sub><sup>‐</sup> mechanisms have not started working. Options 2 and 4 are incorrect because the primary 20. The nurse concludes this client has which of the disturbance is metabolic, as indicated by the low bicarbonate level. Option 3 is incorrect following? because with compensation, a decrease in PaCO<sub>2</sub> to restore balance would be expected. ‐ Metabolic acidosis, uncompensated ‐ Respiratory acidosis, compensated ‐ Metabolic acidosis, compensated ‐ Respiratory acidosis, uncompensated | First, correlate diarrhea with a metabolic problem to eliminate options 2 and 4. Then, note that the pH is not within normal limits to choose option 1 over option 3. |
2223 An elderly client is admitted with pneumonia and Correct answer: 2 As people age, respiratory function decreases, and the alveolar exchange surfaces become respiratory acidosis. The nurse is aware that less effective in controlling respiratory acidosis. Options 1, 3, and 4 are incorrect because respiratory compensatory mechanisms are not as likely changes consistent with aging reflect a decrease in respiratory function and gas exchange. to correct the acid–base balance due to: ‐ Increased pulmonary excretion of CO2 and increased alveolar exchange areas in the lungs. ‐ Decreased respiratory function and decreased alveolar exchange areas in the lungs. ‐ Increased pulmonary excretion of HCO3‐ and reduced alveolar exchange areas in the lungs. ‐ Increased pulmonary exchange of HCO3‐ and increased alveolar exchange areas in the lungs. | Critical words are pneumonia and respiratory acidosis. Recall the physiology of changes in the elderly to be directed to option 2. |
2224 A nurse is orienting a newly employed RN. Which of Correct answer: 1 The PaO<sub>2</sub> is not the only determinant used to assess oxygen the following statements by the new nurse indicates a saturation. Oxygen saturation reflects the total oxygen concentration that is carried on the lack of understanding about oxygen saturation? hemoglobin molecule. There is a relationship observed between the PaO<sub>2</sub> and SaO<sub>2</sub> indicating safe and dangerous levels as the PaO<sub>2</sub> level drops. Options 2, 3, and 4 are consistent with the concept of SaO<sub>2</sub>. ‐ “Oxygen saturation is only assessed by analyzing the PaO2.” ‐ “The SaO2 indicates how well the blood is oxygenated.” ‐ “The SaO2 reflects the amount of oxygen that is bound to a hemoglobin molecule.” ‐ “Oxygen saturation can be affected by acid–base balance.” | The critical words are lack of understanding. This is a negative‐response question, indicating that three of the options are correct statements. Recognize that options 2, 3, and 4 are true statement about oxygenation and eliminate them. |
2225 An elderly client admitted with a diagnosis of heart Correct answer: 3 Clients who take potassium‐wasting diuretics, such as Lasix, are at risk for developing failure has been taking furosemide (Lasix) for hypokalemia and metabolic alkalosis. Options 1 and 2 are incorrect because they reflect an treatment of heart failure. Serum potassium level is acidotic state. Option 1 is a respiratory acidosis and option 2 is a respiratory acidosis with 3.2 mEq/L. Which of the following ABG results would partial compensation. Option 4 is incorrect because the primary disturbance is a respiratory the nurse expect this client to manifest? alkalosis due to the increased PaCO<sub>2</sub> level. ‐ pH 7.20; PaCO2 50; HCO3‐ 22; PaO2 93 ‐ pH 7.30; PaCO2 48; HCO3‐ 36; PaO2 90 ‐ pH 7.49; PaCO2 36; HCO3‐ 30; PaO2 90 ‐ pH 7.50; PaCO2 49; HCO3‐ 18; PaO2 90 | Critical words are furosemide and potassium level of 3.2. Recognize the drug is a potassium‐wasting diuretic that contributes to metabolic alkalosis. Determine that options 1 and 2 reflect acidosis, and eliminate them. Option 4 is respiratory in nature, so eliminate it. |
2226 A nurse is caring for a client with pneumonia. Arterial Correct answer: 3 The pH is elevated, HCO<sub>3</sub><sup>‐</sup> is elevated, and blood gas (ABG) results are pH 7.49; PaCO<sub>2</sub> is low. This indicates that there is a mixed respiratory and PaCO<sub>2</sub> 32 mmHg; metabolic alkalosis. Clients with pneumonia are prone to develop respiratory alkalosis. Option HCO<sub>3</sub><sup>‐</sup> 1 is incorrect because the HCO<sub>3</sub><sup>‐</sup> level alone 28 mEq/L; PaO<sub>2</sub> 89 mmHg. would be decreased. Options 2 and 4 are incorrect because the ABG values do not reflect these This nurse analyzes these results as: conditions. ‐ Metabolic acidosis, uncompensated. ‐ Metabolic alkalosis, uncompensated. ‐ Mixed respiratory and metabolic alkalosis, compensated. ‐ Respiratory acidosis, uncompensated. | First, look at the pH to determine it indicates alkalosis. Then, note that carbon dioxide is low and bicarbonate is elevated, and recognize this reflects a mixed alkalosis. |
2227 The nurse expects which of the following arterial Correct answer: 2 Antacids contain a high proportion of HCO<sub>3</sub><sup>‐</sup>. blood gases (ABGs) in a client who has had excessive Overuse of these agents places clients at risk for developing metabolic alkalosis due to high use of antacids? concentrations of bicarbonate. Option 2 reflects metabolic alkalosis (pH alkalotic, HCO<sub>3</sub><sup>‐</sup> elevated, normal PaCO<sub>2</sub>). Option 1 reflects respiratory acidosis (pH acidotic, HCO<sub>3</sub><sup>‐</sup> normal, elevated PaCO<sub>2</sub>). Option 3 is incorrect because it reflects normal ABG values. Option 4 is incorrect because it reflects respiratory alkalosis (pH alkalotic, HCO<sub>3</sub><sup>‐</sup> normal, decreased PaCO<sub>2</sub>). ‐ pH 7.30; PaCO2 48 mmHg; HCO3‐ 23 mEq/L ‐ pH 7.48; PaCO2 41 mmHg; HCO3‐ 30 mEq/L ‐ pH 7.42; PaCO2 40 mmHg; HCO3‐ 23 mEq/L ‐ pH 7.48; PaCO2 30 mmHg; HCO3‐ 24 mEq/L | The critical word is antacids. Recognize that antacids contribute to metabolic alkalosis. Eliminate option 1, since the pH indicates acidosis, and option 3, since the pH is normal. Choose option 2, as the elevated bicarbonate level reflects a metabolic cause. |
2228 An elderly client with a history of not taking Correct answer: 1 A client with type 1 diabetes who doesn't take prescribed insulin is at risk for developing prescribed insulin is admitted to the hospital in an diabetic ketoacidosis, which leads to the formation of ketone bodies and the development of unresponsive state. Arterial blood gas (ABG) results are metabolic acidosis. Blood gas results indicate that no compensation is occurring, since the pH 7.30; PaCO<sub>2</sub> 40 mmHg; PaCO<sub>2</sub> is normal, pH is acidotic, and bicarbonate level is decreased. HCO<sub>3</sub><sup>‐</sup> Option 3 is incorrect because with compensation, a rise in PaCO<sub>2</sub> 15 mEq/L. The nurse analyzes that this client has: would be expected. Options 2 and 4 are incorrect because the ABG values are not consistent with a respiratory disturbance, as the PaCO<sub>2</sub> level is normal. The major disturbance rests with the HCO<sub>3</sub><sup>‐</sup> level, which indicates a metabolic disturbance. ‐ Metabolic acidosis, uncompensated. ‐ Respiratory acidosis, uncompensated. ‐ Metabolic acidosis, compensated. ‐ Respiratory acidosis, compensated. | First, determine that the pH reflects acidosis, and since CO<sub>2</sub> is within normal limits, recognize the bicarbonate is low, and supports the cause's being metabolic in nature. |
2229 A client is admitted with complaints of muscle Correct answer: 2 Clients with metabolic alkalosis are at risk for developing hypocalcemia. The client's twitching, and numbness and tingling around the symptoms are consistent with hypocalcemia. Options 1, 3, and 4 are not consistent with the mouth. Arterial blood gases (ABGs) are pH 7.49; client's presenting symptoms. PaCO<sub>2</sub> 38 mmHg; and HCO<sub>3</sub><sup>‐</sup> 29 mEq/L. The nurse concludes that this client should also be assessed for which of the following? ‐ Hypokalemia ‐ Hypocalcemia ‐ Hyponatremia ‐ Hypochloremia | Critical words aremuscle twitching and tingling around the mouth. Recognize that these are classic signs of low calcium accompanying alkalosis. |
2230 A client had gastrointestinal (GI) surgery, and has a Correct answer: 1 NG suction removes H<sup> </sup> ions from the stomach, and can lead to a nasogastric (NG) tube on low, intermittent suction. The client's developing metabolic alkalosis. Options 2 and 3 are incorrect because removal of GI nurse plans to assess the client for which of the drainage leads to acid loss and bicarbonate excess. Option 4 is incorrect because respiratory following acid–base imbalances? alkalosis is more likely to occur with hypoxic states, central nervous system disorders, drug use, or hyperdynamic states. ‐ Metabolic alkalosis ‐ Metabolic acidosis ‐ Respiratory acidosis ‐ Respiratory alkalosis | Critical words are gastrointestinal (GI) surgery and nasogastric (NG) tube. Recall that these both contribute to loss of body acids, predisposing the client to alkalosis. |
2231 The nurse carefully assesses a client with a new Correct answer: 2 Lower gastrointestinal (GI) tract fluid loss leads to a loss of ileostomy for development of which of the following HCO<sub>3</sub><sup>‐</sup>, resulting in the development of acid–base imbalances? metabolic acidosis. Options 3 and 4 are incorrect because a client with an ileostomy does not retain bicarbonate. Option 1 is incorrect because respiratory acidosis involves a primary disturbance in CO<sub>2</sub> levels. ‐ Respiratory acidosis ‐ Metabolic acidosis ‐ Metabolic alkalosis ‐ Respiratory alkalosis | The critical word is ileostomy. Recognize that intestinal fluids are alkaline, and that these are lost via the ileostomy, leading to metabolic acidosis. |
2232 When caring for a client with chronic obstructive Correct answer: 2 Due to long‐term lung disease, clients with COPD tend to develop respiratory acidosis pulmonary disease (COPD), the nurse anticipates which because they compensate and adjust to a higher level of CO<sub>2</sub>. The pH of the following ABG results? reflects acidemia,and there is an elevated PaCO<sub>2</sub> and normal HCO<sub>3</sub><sup>‐</sup>. Option 1 is incorrect because the pH is acidotic and there is a normal CO<sub>2</sub> and decreased HCO<sub>3</sub><sup>‐</sup>. Option 3 is incorrect because the pH is normal, but CO<sub>2</sub> is increased and there is a normal HCO<sub>3</sub><sup>‐</sup>. Option 4 is incorrect because the pH is alkalotic, and there are decreased CO<sub>2</sub> and normal HCO<sub>3</sub><sup>‐</sup>. ‐ pH 7.30; PaCO2 38; HCO3‐ 18 ‐ pH 7.32; PaCO2 48; HCO3‐ 23 ‐ pH 7.42; PaCO2 47; HCO3‐ 25 ‐ pH 7.55; PaCO2 30; HCO3‐ 22 | The critical term is COPD. Recall that CO<sub>2</sub> is retained with this condition, contributing to acidosis. Look for the pH to reflect acidosis and CO<sub>2</sub> to be elevated. |
2233 A client with COPD is admitted to the hospital with an Correct answer: 1 A pH of 7.30 indicates acidosis. A PaCO<sub>2</sub> of 51 indicates a respiratory exacerbation of the disease. Arterial blood gas (ABG) acidosis is occurring. Since the PaCO<sub>2</sub> is elevated with a normal results are pH 7.30; PaCO<sub>2</sub> 51; HCO<sub>3</sub><sup>‐</sup>, an uncompensated respiratory acidosis HCO<sub>3</sub><sup>‐</sup> is occurring. Options 2 and 4 are incorrect because the pH value does not indicate that 25. How would the nurse interpret these? alkalosis could be present. Option 3 is incorrect because the bicarbonate level is normal, indicating that compensation has not taken place. With compensation, you would expect an increase in the bicarbonate level. ‐ Respiratory acidosis, uncompensated ‐ Respiratory alkalosis, partially compensated ‐ Respiratory acidosis, compensated ‐ Metabolic acidosis, compensated | First, determine that the pH indicates acidosis, and then examine CO<sub>2</sub> to determine that the cause is respiratory. Since bicarbonate is normal, choose option 1. |
2234 A client admitted to the Emergency Department with Correct answer: 2 A client with a chest injury is likely to hypoventilate (have a shallow respiratory pattern) as a chest injuries following a motor vehicle accident result of pain due to associated trauma. It is unknown at this time whether there are any complains that it hurts to breathe. The client s internal injuries that could affect the client s oxygen saturation. This type of respiratory respiratory rate is 12 and very shallow. The nurse pattern is associated with respiratory acidosis. Options 1 and 4 reflect normal lab values. would anticipate which of the following results on Option 3 reflects metabolic alkalosis (increased pH and arterial blood gases (ABGs)? HCO<sub>3</sub><sup>‐</sup>, decreased pCO<sub>2</sub> and SaO<sub>2</sub>). ‐ pH 7.42; PaCO2 41 mmHg; HCO3‐ 23 mEq/L; SaO2 96% ‐ pH 7.31; PaCO2 49 mmHg; HCO3‐ 24 mEq/L; SaO2 87% ‐ pH 7.49; PaCO2 34 mmHg; HCO3‐ 30 mEq/L; SaO2 89% ‐ pH 7.38; PaCO2 38 mmHg; HCO3‐ 22 mEq/L; SaO2 90% | Before looking at the options, recognize that the client is at greatest risk for respiratory acidosis. Eliminate options 1 and 4, since pH is normal, and eliminate option 3, since pH reflects alkalosis. |
2235 What action should the nurse take initially to avoid Correct answer: 3 One of the first things a nurse should do when a client is hyperventilating is to give the client acid–base imbalance when a client becomes anxious a paper bag into which to breathe. This prevents the CO<sub>2</sub> level from and starts to hyperventilate? decreasing, and rebreathing the gas in the bag will also help to decrease the respiratory rate. Hyperventilation is associated with respiratory alkalosis. Although sedatives might be indicated to decrease anxiety and hyperventilation, the use of a paper bag might stop the breathing pattern response by redirecting the client s focus. Telling the client that he might pass out could make him change the breathing pattern, but it could also make it worse by increasing anxiety. Notifying the physician might be indicated to further assist in client treatment, but the initial response should be to interrupt the present breathing pattern of the client. ‐ Tell the client to stop breathing so fast because he could pass out. ‐ Give the client a sedative to decrease anxiety and stop hyperventilation. ‐ Give the client a paper bag into which to breathe. ‐ Notify the physician. | Critical words are “initially” and “hyperventilate.” Recognize that some of the options are partially correct, but choose option 3, since this offers an option readily available that can be tried before the other options might be needed. |
2236 The nurse would closely monitor a client with diabetic Correct answer: 1 DKA is associated with an increase in acid production. Diabetic clients with DKA are unable to ketoacidosis (DKA) for which of following primary metabolize glucose, and the liver responds with an increase in fatty acid metabolism. These acid–base imbalances? fatty acids are oxidized, leading to ketone body formation and increased acidity. Option 2 is incorrect because metabolic alkalosis is the opposite imbalance. Option 3 is unrelated, and option 4 would occur as a secondary compensatory mechanism for the client in DKA. ‐ Metabolic acidosis ‐ Metabolic alkalosis ‐ Respiratory acidosis ‐ Respiratory alkalosis | Note that ‐acidosis is part of the word ketoacidosis. Recall that diabetes is a metabolic disorder to choose option 1. |
2237 A 36‐year‐old female is admitted with vomiting and Correct answer: 3 The pH indicates alkalosis, and the HCO<sub>3</sub><sup>‐</sup> is dehydration after having the flu for three days. Arterial elevated, indicating a metabolic basis. The PaCO<sub>2</sub> is slightly elevated, blood gas (ABG) results are pH 7.46; indicating that compensation is occurring. Options 1 and 2 are incorrect because the client s PaCO<sub>2</sub> 50; pH reflects alkalosis. Option 4 is incorrect because compensation is occurring due to the HCO<sub>3</sub><sup>‐</sup> increased CO<sub>2</sub> level. 33; SaO<sub>2</sub> 95%. What do these values indicate to the nurse? ‐ Metabolic acidosis, uncompensated ‐ Respiratory acidosis, compensated ‐ Metabolic alkalosis, partially compensated ‐ Metabolic alkalosis, uncompensated | First, determine that the pH reflects slight alkalosis. Note the increased bicarbonate level reflects that the cause is metabolic, and since CO<sub>2</sub> is elevated, the pH is partially compensated. |
2238 A client in a full cardiac arrest is admitted to the Correct answer: 3 During a cardiac arrest, the client develops profound respiratory acidosis, and needs to be Emergency Department. Arterial blood gases (ABGs) ventilated, first with a bag‐valve‐mask device and then by mechanical means once intubation is indicate a respiratory acidosis. How does the nurse accomplished. Other interventions will be instituted during the course of the code, but the respond to correct this condition? nurse should always respond to any emergency situation with the ABCs (airway, breathing, and circulation). ‐ Administer NaHCO3 to correct the acidosis. ‐ Administer epinephrine to get a heart rate so the acidosis can be corrected. ‐ Ventilate client to “blow off” excess CO2. ‐ Start cardiac compressions. | Note that the client is in full cardiac arrest, necessitating initiation of ABCs airway, breathing, and circulation to direct you to option 3. |
2239 The nurse identifies which of the following clients to Correct answer: 1, 4 Loss of acidic contents via NG drainage can lead to alkalosis and intake of antacids, which are be at risk for developing metabolic alkalosis? Select all frequently alkaline substances. Diarrhea leads to a loss of alkalotic fluids, predisposing the that apply. client to acidosis. Salicylate toxicity results in acidosis. The client with asthmatic bronchitis retains carbon dioxide, leading to respiratory acidosis. | Recall conditions that contribute to a loss of acidic body fluids and gain of alkaline substances to direct you to options 1 and 4. |
‐ Has a nasogastric tube (NG) on continuous suction. ‐ Has had diarrhea for two days. ‐ Admitted with a salicylate toxicity. ‐ Takes antacids frequently for heartburn. ‐ Admitted with asthmatic bronchitis. | |
2240 The arterial blood gas (ABG) results of a 68‐year‐old Correct answer: 2 The slightly elevated pH (alkalosis), the low PaCO<sub>2</sub> (respiratory client admitted with pneumonia are pH 7.46; origin), and the low HCO<sub>3</sub><sup>‐</sup> indicate PaCO<sub>2</sub> 30; compensation is starting but is not yet fully complete, since the pH is still abnormal. In HCO<sub>3</sub><sup>‐</sup> addition, the SaO<sub>2</sub> level is decreased significantly, which is not 19; SaO<sub>2</sub> 72. The nurse consistent with aging alone. Option 1 is incorrect because the pH is alkalotic. Option 3 is interprets this as: incorrect because in an uncompensated respiratory alkalosis, the bicarbonate level would be normal. Option 4 is incorrect because the bicarbonate level is not elevated. ‐ Respiratory acidosis, uncompensated. ‐ Respiratory alkalosis, partially compensated. ‐ Respiratory alkalosis, uncompensated. ‐ Metabolic alkalosis, partially compensated. | First, determine that the pH is alkalotic. Then, recognize that the CO<sub>2</sub> is low to determine that the cause is respiratory. Choose option, 2 since the bicarbonate level reflects some compensation. |
2241 A 71‐year‐old client develops hypertension, Correct answer: 1 The pH is low (acidosis) and PaCO<sub>2</sub> high (respiratory origin). The tachycardia, and increased respirations two days after HCO<sub>3</sub><sup>‐</sup> is normal, indicating that compensation surgery. Arterial blood gas (ABG) results are pH 7.29; has not occurred. The client is experiencing hyperventilation, but blood gases reveal a PaCO<sub>2</sub> 52; respiratory acidosis, probably due to prior hypoventilation. Option 2 is incorrect because the HCO<sub>3</sub><sup>‐</sup> bicarbonate level has not increased in an attempt to restore balance. Options 3 and 4 are 24; SaO<sub>2</sub> 95%. The nurse incorrect because the bicarbonate levels are within normal limits and yet the interprets that these results indicate which of the PaCO<sub>2</sub> level is still elevated. following? ‐ Respiratory acidosis, uncompensated ‐ Respiratory acidosis, partially compensated ‐ Metabolic acidosis, uncompensated ‐ Metabolic acidosis, partially compensated | First, determine that the pH level indicates acidosis. Next, analyze the CO<sub>2</sub> to determine that the cause is respiratory. Choose option 1, since the pH is not normalized by the bicarbonate. |
2242 A 57‐year‐old client is admitted with a diagnosis of Correct answer: 3 The pH is normal (but is nearer to the acidotic end), while the PaCO<sub>2</sub> acute myocardial infarction. Arterial blood gas (ABG) is low (compensation has occurred) and the HCO<sub>3</sub><sup>‐ results are pH 7.36; PaCO<sub>2</sub> 29; </sup> is low (indicating metabolic origin). The oxygen saturation of 100% indicates the HCO<sub>3</sub><sup>‐</sup> blood is well oxygenated, making options 2 and 4 incorrect, because the client is not 20; SaO<sub>2</sub> 100%. The nurse hypoxemic. Since the pH is within normal limits, it is more likely that there are mixed interprets that this client is: acid–base disorders occurring that are compensating each other. Since the PaCO<sub>2</sub> and HCO<sub>3</sub><sup>‐</sup> are low, metabolic acidosis is occurring with a respiratory alkalosis. ‐ Well‐oxygenated, with uncompensated respiratory alkalosis. ‐ Hypoxemic, with compensated respiratory acidosis. ‐ Well‐oxygenated, with compensated metabolic acidosis. ‐ Hypoxemic, with compensated metabolic acidosis. | This question requires you to identify ABG results and quality of oxygenation. Since the oxygen level is 100%, eliminate options 2 and 4. Since pH is within normal limits, choose option 3. |
2243 Arterial blood gases on a client with pneumonia Correct answer: 3, 4 The respiratory acidosis in this client is secondary to retention of carbon dioxide. Coughing indicate the client is in respiratory acidosis. In order to and deep breathing will stimulate expectoration of secretions, allowing for improved gas best improve this acid–base imbalance, the nurse exchange. Option 1 is incorrect; fluids will help to liquefy secretions, and do not need to be implements which of the following nursing restricted to water. It would be helpful to ambulate the client (option 2), which will promote interventions? Select all that apply. lung expansion, but not as much as will option 3. Option 4 is correct; medicating the client frequently with narcotics might decrease respiratory drive, but a nonnarcotic medication might enable the client to breathe deeply. Option 5, magnesium, has no effect on acid–base. ‐ Restrict oral fluid intake to water only. ‐ Ambulate the client in hallways twice a shift. ‐ Encourage frequent cough and deep‐breathing exercises. ‐ Medicate with a nonopiate pain medication frequently for intercostal muscle pain. ‐ Give magnesium. | Recall that causes of respiratory acidosis are related to retention of carbon dioxide. Determine that option 1 provides measures to best promote improved gas exchange in the lungs. |
2244 A client receiving intravenous (IV) sodium bicarbonate Correct answer: 1 Symptoms of alkalosis include irritability, confusion, cyanosis, irregular pulse, slow for treatment of metabolic acidosis develops muscle respirations, and muscle twitching. These symptoms warrant discontinuing the medications twitching and an irregular pulse. Which actions should and notifying the primary health care provider, since the client might have received excessive be taken by the nurse initially? sodium bicarbonate. Option 2 is incorrect. Options 3 and 4 would be carried out after the physician has been notified. ‐ Stop the infusion and notify the physician. ‐ Reduce the infusion by one‐half of the ordered rate and observe client closely. ‐ Monitor heart rate, blood pressure, and mentation every 15 minutes. ‐ Check pulse oximetry and place the client on bedrest. | The critical word is initially, indicating all or some of the options are correct, but one takes first priority. Recognize that the client is experiencing metabolic alkalosis, and choose option 1 as having highest priority. |
2245 Which of the following arterial blood gases (ABGs) Correct answer: 2 Apnea and hypoventilation result in rising carbon dioxide levels, which lead to acidosis. The would the nurse expect to see when a client has apnea ABG would likely reflect respiratory acidosis without compensation. Option 1 is incorrect and develops acidosis? because it reflects a normal pH, a slight increase in PaCO<sub>2</sub>, and a normal HCO<sub>3</sub><sup>‐</sup> level. Option 3 is incorrect because it reflects normal values for all three parameters. Option 4 reflects an alkalotic state because the pH and HCO<sub>3</sub><sup>‐</sup> are elevated, and the PaCO<sub>2</sub> is decreased. ‐ pH 7.42; PaCO2 48 mmHg; HCO3‐ 25 mEq/L ‐ pH 7.29; PaCO2 62 mmHg, HCO3‐ 23 mEq/L ‐ pH 7.36 PaCO2 42 mmHg HCO3‐ 26 mEq/L ‐ pH 7.49; PaCO2 30 mmHg; HCO3‐ 35 mEq/L | Critical words are apnea and acidosis, indicating the cause will be respiratory in nature. Look for the ABG with a pH indicating acidosis to direct you to option 2. |
2246 The nurse concludes that which of the following Correct answer: 2 The kidneys respond more slowly to acid–base imbalances than do the lungs, but are more statements by a student nurse reflects correct effective in restoring acid–base balance to the extracellular fluid. The primary response to understanding about the body’s attempt to restore acidosis is with lung compensation. Option 1 is incorrect because the kidneys do not respond homeostasis during periods of acidosis? immediately to correct acid–base imbalances. Option 3 is incorrect because the kidneys utilize several mechanisms to restore acid–base balance, involving phosphate buffer salts, reabsorption of bicarbonate, and excretion of ammonia. The bicarbonate buffer system is a very strong buffer system in the body, and also helps to regulate the respiratory response to acid–base balance. Option 4 is incorrect because the kidneys help to restore acid–base balance by reabsorbing bicarbonate by ionizing carbonic acid. Ion exchange occurs between Na<sup> </sup> and H<sup> </sup>, which leads to formation of bicarbonate, which is then absorbed into the blood. ‐ “The kidneys start to work within seconds after an imbalance occurs, and are very effective in restoring the body to a correct acid–base balance.” ‐ “The kidneys might not start to function immediately, but are very effective as a buffer system to restore the acid–base balance.” ‐ “The kidneys are not as effective as the lungs in restoring the acid–base balance because the bicarbonate ion is not a good buffer.” ‐ “The kidneys are very slow to respond to any acid–base imbalance, but are very effective in ridding the body of carbonic acid.” | Note that some of the options are only partially correct to eliminate options 1 and 4. Recall the role of the kidney in maintaining acid–base balance to choose option 2. |
2247 Which of the following ABG results would the nurse Correct answer: 2 Diarrhea leads to loss of bicarbonate from the intestinal tract. This can cause metabolic expect to see when a client is admitted with diarrhea acidosis. With metabolic acidosis, the pH is low and the that has lasted for four days? HCO<sub>3</sub><sup>‐</sup> is also decreased. Option 1 is incorrect because the pH is alkalotic, the PaCO<sub>2</sub> is elevated, and the HCO<sub>3</sub><sup>‐</sup> is slightly elevated. These values reflect metabolic alkalosis. Option 3 is incorrect because the pH and PaCO<sub>2</sub> are within normal limits, and the HCO<sub>3</sub><sup>‐</sup> is slightly elevated. These values do not reflect a cause for concern at this point in time. Option 4 is incorrect because the pH is alkalotic, the PaCO<sub>2</sub> is normal, and the HCO<sub>3</sub><sup>‐</sup> is slightly elevated. These results reflect metabolic alkalosis. ‐ pH 7.50; PaCO2 60 mmHg; HCO3‐ 28 mEq/L ‐ pH 7.30; PaCO2 40 mmHg; HCO3‐ 18 mEq/L ‐ pH 7.40; PaCO2 < 38 mmHg; HCO3‐ 28 mEq/L ‐ pH 7.50; PaCO2 38 mmHg; HCO3‐ 32 mEq/L | The critical word is diarrhea. Recall that this leads to a loss of alkaline fluids, which will cause acidosis, to direct you to option 2. |
2248 The nurse has been caring for a client who has Correct answer: 2 Clients who are extremely anxious tend to hyperventilate and have a rapid, shallow become extremely anxious and agitated. When respiratory pattern. Cardiac rhythm and regulation are independent of respiratory function, assessing the client, the nurse would expect to find and the rate can vary depending on the client s medical condition and/or treatment. A rapid which of the following that could ultimately lead to an deep respiratory pattern is associated with further respiratory compromise. acid–base imbalance? ‐ Rapid, deep respiratory pattern ‐ Rapid, shallow respiratory pattern ‐ Rapid, irregular heart rate ‐ Slow, irregular heart rate | Critical words are anxious and agitated. Visualize this client in considering options. Eliminate options 3 and 4, since they are related to pulses and not breathing. Recall breathing patterns seen in anxious clients to choose option 2. |
2249 Which of the following pH values would the nurse Correct answer: 3 Anxious clients hyperventilate, which leads to alkalosis because of a depletion of carbon expect to see in an anxious client? dioxide. Options 1 and 2 reflect normal pH values. Option 4 reflects acidemia, and is associated with clients who hypoventilate. 1.‐ 7.45 2.‐ 7.38 3.‐ 7.50 4.‐ 7.20 | The critical word is anxious. Recall that anxiety will cause an increase in respiratory rate with loss of carbon dioxide, resulting in alkalosis. |
2250 The nurse anticipates which of the following Correct answer: 3 A client with metabolic acidosis will have an increase in respiratory rate and depth, in an responses in a client who develops metabolic acidosis? attempt to compensate for the acidosis. Increases in heart rate, temperature, and urinary output are all metabolic responses that are not directly associated with maintaining acid–base balance. Initial compensation with metabolic acidosis will be via the lungs. ‐ Heart rate will increase. ‐ Urinary output will increase. ‐ Respiratory rate will increase. ‐ Temperature will increase. | Recall that the respiratory system will try to compensate acidosis by blowing off carbon dioxide and water to direct you to option 3. |
2251 The nurse assesses a client with uncontrolled type 1 Correct answer: 4 Due to a lack of insulin, diabetic clients are more likely to use fats as an energy source. During diabetes mellitus for which of the following acid–base the metabolism of fats, free fatty acids are released, leading to accumulation of fatty acid imbalances? fragments and the development of diabetic ketoacidosis. Diabetic clients are likely to develop metabolic acidosis characterized by decreased pH and HCO<sub>3</sub><sup>‐</sup> levels. ‐ Metabolic alkalosis ‐ Respiratory alkalosis | Recognize that this condition leads to ketoacidosis with retention of carbonic acid to direct you to option 4. |
‐ Respiratory acidosis ‐ Metabolic acidosis | |
2252 The client with respiratory acidosis from COPD asks Correct answer: 2 The pulse oximeter measures the amount of oxygen in the blood, and is a good indication of the nurse why a continuous pulse oximeter is ordered. oxygenation status. It is not meant to replace needed ABG monitoring, but rather is used in Which of the following responses by the nurse conjunction with appropriate respiratory assessment to provide important information on a provides the best response? continuous basis. Pulse oximetry does not determine or reflect ventilatory effort, regardless of client positioning. ‐ “The pulse oximeter measures your CO2 level so ABGs only need to be drawn once a day.” ‐ “The pulse oximeter measures the oxygen saturation in your blood at any given time.” ‐ “The pulse oximeter is being used so we don’t ever have to draw ABGs on you while you are in the hospital.” ‐ “The machine is used to adequately assess your ventilatory effort while you are in bed.” | Critical words are COPD and pulse oximeter. Recall the function and purpose of the latter to choose option 2. |
2253 A 10‐month‐old infant is admitted to the emergency Correct answer: 2 The client’s history suggests fluid volume deficit and dehydration. Sunken eyes, altered department with a 102°F rectal temperature and a mental status and behavior, and dry, furrowed tongue are reliable signs of fluid volume deficit history of vomiting and diarrhea for the past 48 hours. in infants. Bulging fontanels, peripheral edema, and neck vein distention are seen with fluid For what signs and symptoms should the nurse look volume excess. related to this client s likely fluid imbalance? ‐ Bulging fontanels, tearless cry, and low urine output ‐ Sunken eyes, lethargy, and dry, furrowed tongue ‐ Weight loss, dilute urine, and peripheral edema ‐ Dry skin, thready pulse, and neck vein distention | The core issue of the question is the ability to correlate a clinical picture with risk for hypovolemia. Use nursing knowledge of signs of dehydration and the process of elimination to make a selection. |
2254 Which observation by the nurse is a reliable indicator Correct answer: 2 Venous congestion results from fluid volume excess, and causes full, bounding pulses, delayed that therapy for fluid volume excess is achieving the hand vein emptying, and S<sub>3</sub> heart sounds. Flat neck veins with the desired outcome? head of the bed elevated are an indicator of the absence of venous congestion. ‐ Full, bounding peripheral pulses ‐ Flat neck veins with the head of the bed elevated ‐ Hand vein emptying longer than 20 seconds ‐ S3 heart sound clearly audible on auscultation | The core issue of the question is knowledge of signs of fluid overload and normal findings. Use nursing knowledge and the process of elimination to make a selection. |
2255 The nurse concludes that which of the following is a Correct answer: 2 Ascites is a form of third space fluid. Therapy is aimed at moving third space fluid back into reliable sign that ascites are being effectively mobilized the circulation, where it can be eliminated by the kidneys. When this fluid is drawn back into in response to therapy? the vascular space (leading to a rise in BP and venous pressure), the kidneys increase the urine output to eliminate the excess fluid. Loss of fluid results in loss of weight. ‐ Weight gain of 1 pound in 24 hours ‐ Increase in urine output ‐ Drop in blood pressure ‐ Hand veins fill slowly | The core issues of the question are recognition of ascites as a third space fluid and knowledge of effective mobilization of that fluid. Recall that mobilized fluid must be eliminated via the kidneys to assist in making a selection. |
2256 Which of the following should be included in an Correct answer: 1 Those who exercise in hot climates need to continuously replace both fluid and electrolyte education program to prevent dehydration for a hiking losses. Sports drinks provide carbohydrates, water, and electrolytes. Drinking large amounts of club that is planning a 12‐mile hike in the summer? only water fails to replace electrolytes, which can lead to water intoxication. Salt tablets are no longer recommended, because too much salt has a hypertonic effect, causes diuresis, and can actually worsen fluid loss. ‐ Take water and commercial sports drinks to sip often along the way. ‐ Drink large amounts of water, at least 16 ounces every hour, while hiking. ‐ Take salt tablets every 3–4 hours, and drink plenty of water while in the heat. ‐ Stop every 4 hours along the way, and drink a few ounces of water while resting. | The core issue of the question is knowledge of measures to prevent fluid and electrolyte imbalance during exercise. Use nursing knowledge and the process of elimination to make a selection. |
2257 Which one of the following postoperative clients Correct answer: 3 A TURP procedure can place a client at risk for developing hyponatremia in the postoperative would be at risk for developing a sodium imbalance? period due to increased fluid irrigation used during and after surgery. Clients with a TURP procedure have a CBI (continuous bladder irrigation) as a routine part of their postoperative care. The other options do not place a client at risk for development of sodium imbalances, because they do not require lengthy fluid and dietary restrictions, or excessive fluid irrigation. ‐ A client who has just had a tonsillectomy ‐ A client who has a primary cesarean section for failure to progress in labor ‐ A client who has a transurethral resection of the prostate (TURP) ‐ A client who has a right knee arthroscopy | The core issue of the question is knowledge that procedures and surgeries requiring the use of water for irrigation can lead to dilutional hyponatremia. Use nursing knowledge and the process of elimination to make a selection. |
2258 The nurse is caring for a client experiencing Correct answer: 4 Hyponatremia can also be referred to as dilutional hyponatremia or water intoxication. Water hyponatremia. As part of the care, the nurse will restriction would be an important part of the treatment plan when caring for a client who has restrict which of the following items for this client? hyponatremia. The restriction of Gatorade (electrolyte‐rich solution), eggs, cheese products, and salt on the diet tray are not indicated, because the client is experiencing a sodium deficit. ‐ Sports drinks, such as Gatorade ‐ Eggs and cheese products ‐ Salt on the diet tray ‐ Water | The core issue of the question is effective treatment measures for hyponatremia. Use nursing knowledge and the process of elimination to make a selection. |
2259 The nurse is caring for a client experiencing Correct answer: 3 Clients with hypernatremia are thirsty, and need water replacement to balance their hypernatremia. The nurse concludes that it is increased sodium levels. Cough medication and lactulose can further increase sodium levels, important to administer which of the following to this and should not be administered unless there is sufficient clinical information to warrant their client? use. Three‐percent saline is a hypertonic solution that would also increase serum sodium levels, and should not be given to this client. ‐ Cough suppressant to treat symptomatic cough ‐ Three‐percent saline solution ‐ Water ‐ Lactulose (Chronulac) | The core issue of the question is knowledge of measures that effectively treat hypernatremia. Use nursing knowledge and the process of elimination to make a selection. |
2260 The community health nurse is assigned to a client Correct answer: 4 The frequent use of Alka‐Seltzer can cause an increase in serum sodium levels. It is important who recently was discharged from the hospital with during an initial assessment to obtain information about all medications (prescription and OTC) resolving hypernatremia. During the initial assessment that a client is taking. Options 1 and 2 are incorrect because they do not relate to potential interview, what information would be of critical sodium imbalance. They are helpful in determining the client s support system and mobility importance in determining a plan of care for this status. Option 3 suggests that the client might have diabetes, but this does not relate to client? increases in serum sodium levels. ‐ The client lives on the second floor of an apartment building that has an elevator. ‐ The client has a neighbor who picks up the mail each day and brings it to the apartment. ‐ The client performs self‐monitoring of blood glucose once a day. ‐ The client uses Alka‐Seltzer on a frequent basis for gastrointestinal complaints. | The core issue of the question is knowledge of factors that can lead to elevated serum sodium levels. Use nursing knowledge and the process of elimination to make a selection. |
2261 The nurse is caring for a client who has sustained Correct answer: 1 During periods of major trauma, potassium shifts from the ICF to the ECF because of cell second‐ and third‐degree burns over 30% of his body. death, leading to high serum levels of potassium. Hypokalemia is not seen in burn clients The nurse assesses for which of the following during the time of fluid shifting secondary to trauma. The client with burns is more likely to be electrolyte imbalances, which occurs as electrolyte hypovolemic and hypocalcemic at this point in time because there are fluid and electrolyte loss shifts from the intracellular fluid (ICF) to the caused by altered capillary integrity. extracellular fluid (ECF)? ‐ Hyperkalemia ‐ Hypokalemia ‐ Hypervolemia | The core issue of the question is knowledge that burn injury increases the risk of hyperkalemia. Use nursing knowledge and the process of elimination to make a selection. |
4.‐ Hypercalcemia | |
2262 The nurse concludes that a history of which of the Correct answer: 2 In clients with cirrhosis, increased amounts of aldosterone are secreted, which leads to following conditions places a client at risk for possible sodium retention and potassium excretion from the kidneys; these clients are likely to become hypokalemia? hypokalemic. Clients with COPD, malignant melanoma, and CRF are likely to develop hyperkalemia due to retention of acids. ‐ Chronic obstructive pulmonary disease (COPD) ‐ Cirrhosis ‐ Malignant melanoma ‐ Chronic renal failure (CRF) | The core issue of the question is the ability to discriminate predisposing factors for hypokalemia from factors for hyperkalemia. Use nursing knowledge and the process of elimination to make a selection. |
2263 Which of the following orders should the nurse Correct answer: 4 Potassium is never given as a bolus when it is administered intravenously. All of the other question regarding a client with severe hypokalemia? orders are within a safe and therapeutic range. KCl should never be given rapidly or by IV push, because serious arrhythmias or cardiac arrest can occur. ‐ Infuse 1,000 mL normal saline with 20 mEq potassium chloride IV over 8 hours. ‐ Give KCl 20 mEq PO daily after meals. ‐ Infuse 1,000 mL normal saline with 40 mEq KCl at 200 mL/hour. ‐ Give 20 mEq KCl/IV over 10 minutes. | The core issue of the question is knowledge of safe and unsafe methods of administering potassium as replacement therapy. Use nursing knowledge and the process of elimination to make a selection. |
2264 Which of the following treatment options does the Correct answer: 4 A serum potassium level of 3.5 mEq/L is at the low end of the normal range. With a low nurse anticipate will be appropriate for a client with a normal level, it is better to continue to monitor the client and offer foods that are good potassium level of 3.5 mEq/L? sources of potassium. In the absence of additional medical history, it is not advisable to use additional treatment options at this point in time. Therefore, options 1 and 3 would not be indicated: they would be included for a client who is hypokalemic. The use of salt substitutes would require more background information, because the client might have other conditions for which their use is not advisable. ‐ Administration of Kayexalate per rectum ‐ Use of salt substitutes in the diet ‐ Administration of oral KCl ‐ Continue to monitor and offer foods high in potassium. | The core issue of the question is knowledge of treatment measures depending on the severity of hypokalemia. First, recognize that this is a value at the low end of normal, and then select the mildest intervention of the choices provided. |
2265 Which one of the following assessments should be Correct answer: 3 A client who is at risk for developing hypocalcemia requires monitoring of serum albumin included in a plan of care for a client who is at risk for (provides information relative to physiologically available calcium) and magnesium levels. developing hypocalcemia? (Decreased magnesium levels are usually seen concurrently with low serum calcium levels.) The other options reflect assessments that would be included for a client who would be at risk to develop hypercalcemia. ‐ Monitor BUN and creatinine levels to determine renal dysfunction. ‐ Monitor the client for constipation. ‐ Monitor serum albumin and magnesium levels. ‐ Monitor for fluid volume excess related to intravenous saline therapy. | The core issue of the question is the ability to choose assessments to detect hypocalcemia. Use nursing knowledge and the process of elimination to make a selection. |
2266 A client with hypocalcemia is taking supplemental Correct answer: 3 Calcium is absorbed in the intestines only under the influence of vitamin D, which is activated vitamin D. The nurse explains the rationale for vitamin in the kidneys. Option 1 is incorrect because parathyroid hormone directly opposes calcitonin. D is that: Option 2 is incorrect because renal disease prevents activation of vitamin D, thereby reducing the body’s ability to absorb calcium. Option 4 is incorrect: there are other ways to obtain vitamin D in the body (such exposure to sunlight). ‐ It directly opposes calcitonin. ‐ It prevents renal disease in clients with hypocalcemia. ‐ Calcium is absorbed in the intestines only under the influence of activated vitamin D. ‐ The only way to obtain vitamin D is with oral supplementation. | The core issue of the question is knowledge of the purpose and effects of vitamin D in a client with hypocalcemia. Use nursing knowledge and the process of elimination to make a selection. |
2267 Which of the following medications reported by a Correct answer: 1 Anticonvulsants such as phenytoin (Dilantin) alter vitamin D metabolism and lead to client during a nursing history could be associated with hypocalcemia. Options 2 and 3 represent calcium sources, and the inclusion of these in a the development of hypocalcemia? treatment plan would lead to increased serum calcium levels. Option 4 is incorrect because thiazide diuretics can lead to calcium retention. ‐ Phenytoin (Dilantin) ‐ Calcium carbonate (TUMS) ‐ Calcitriol ‐ Hydrochlorothiazide (HydroDIURIL) | The core issue of the question is knowledge of medications that increase the risk of hypocalcemia. Use nursing knowledge and the process of elimination to make a selection. |
2268 The family of a client with hypercalcemia states that Correct answer: 1 Clinical manifestations of hypercalcemia include personality changes. All other options are the client is “not acting like himself.” The nurse focuses signs and symptoms of hypocalcemia. assessment on which of the following symptoms? ‐ Personality change ‐ Anxiety ‐ Convulsions ‐ Carpal spasms | The core issue of the question is knowledge of manifestations of hypercalcemia. Use nursing knowledge and the process of elimination to make a selection. |
2269 The nurse who is assessing the client for signs of Correct answer: 2 Clinical manifestations of hypocalcemia include a positive Trousseau’s sign, which is an hypocalcemia would conclude that this electrolyte ischemia‐induced carpopedal spasm. A positive Chvostek’s sign is associated with imbalance exists after noting which of the following? hypocalcemia, while hypoactive bowel sounds are a sign of hypercalcemia. Kernig’s sign is an indication of meningeal irritation. ‐ Negative Chvostek’s sign ‐ Positive Trousseau’s sign ‐ Positive Kernig’s sign ‐ Hypoactive bowel sounds | The core issue of the question is knowledge of manifestations of hypocalcemia. Use nursing knowledge and the process of elimination to make a selection. |
2270 The nurse would review a client’s electrolyte levels to Correct answer: 3 Addison’s disease, known also as adrenal insufficiency, can cause increased magnesium levels detect a possible increase in magnesium if the client resulting from volume depletion. Cushing’s syndrome is hyperfunction of the adrenal gland. had which of the following conditions? Diabetes could lead to low magnesium levels if osmotic diuresis is present from hyperglycemia. Splenomegaly is an unrelated finding. ‐ Cushing’s syndrome ‐ Diabetes ‐ Addison’s disease ‐ Splenomegaly | The core issue of the question is knowledge of risk factors for hypermagnesemia. Use nursing knowledge and the process of elimination to make a selection. |
2271 The nurse concludes that a client does not have an Correct answer: 3 SVT is seen with decreased magnesium levels, as are premature ventricular contractions and increased magnesium level based on which of the ventricular fibrillation. The other three options are findings with hypermagnesemia. following findings? ‐ Hypotension ‐ Bradycardia ‐ Supraventricular tachycardia (SVT) ‐ Flushing and sweating | The core issue of the question is the ability to discriminate signs of hyper‐ and hypomagnesemia. Use nursing knowledge and the process of elimination to make a selection. |
2272 A client with renal failure is experiencing Correct answer: 1 Either hemodialysis or peritoneal dialysis is used to remove excess magnesium in the client hypermagnesemia. The nurse explains that which of with renal failure. Diuretics will not be effective if the kidneys are not functional. Fluid the following treatments will decrease the magnesium restriction would be ineffective, and high‐volume IV fluid replacement would be level most effectively? contraindicated in renal failure. ‐ Dialysis | The core issue of the question is knowledge of effective therapies for increased magnesium levels. Note the critical words renal failure, which lead you to look for a treatment that does not involve functional kidneys. Use nursing knowledge and the process of elimination to make a selection. |
‐ Diuretics ‐ Fluid restriction ‐ High‐volume IV fluids | |
2273 The nurse reviews the laboratory test results for a Correct answer: 4 Decreased magnesium level (option 4) can occur in toxemia of pregnancy, pre‐eclampsia, and client with pre‐eclampsia, expecting to find which of eclampsia, causing convulsions (seizures). The other responses are incorrect because they are the following values? directed at sodium (options 1 and 2) or increased magnesium level (option 3). ‐ Sodium 148 mEq/L ‐ Sodium 125 mEq/L ‐ Magnesium 3.1 mEq/L ‐ Magnesium 1.2 mEq/L | The core issue of the question is knowledge of conditions that are consistent with decreased magnesium levels, and the ability to determine a reduced level. Use nursing knowledge and the process of elimination to make a selection. |
2274 A client was admitted to the hospital with a weight Correct answer: 2 Cushing s syndrome causes low potassium and magnesium levels and an increase in sodium gain of 30 pounds over the past month. Upon and chloride levels. The moon face and buffalo hump are also symptoms of excess assessment, the client was noted to have a moon face corticosteroids. Option 1 is incorrect because Addison s disease causes low sodium, and and a “buffalo hump.” On admission, lab results increased magnesium and potassium. Option 3 is incorrect because burn states cause indicated decreased serum potassium and magnesium, significant fluid and electrolyte disturbances (loss of sodium, chloride, and magnesium, with and elevated serum chloride and sodium levels. The alterations in potassium depending on the stage of burn), but the presence of a moon face and nurse interprets that which of the following disorders buffalo hump is characteristic of Cushing s syndrome. Option 4 is incorrect because SIADH is is consistent with these manifestations? associated with hyponatremia. ‐ Addison’s disease ‐ Cushing’s syndrome ‐ Burns ‐ Syndrome of inappropriate ADH (SIADH) | The core issue of the question is the ability to synthesize electrolyte results with a clinical picture in a client with Cushing’s syndrome. Use nursing knowledge and the process of elimination to make a selection. |
2275 A home health nurse is making a visit to an elderly Correct answer: 2 The home health nurse should be most concerned with the decreased chloride level because client who has a history of heart failure (CHF). The it can lead to complications such as dilutional hypochloremia. The client s history of CHF places client was prescribed diuretics twice a day and a low‐ the client in a higher risk category for fluid retention, electrolyte disturbances, and acid–base sodium diet. The nurse should be most concerned disorders. All of the other options reflect laboratory values that are within normal range, and about which of the following laboratory results? are reassuring. ‐ Na+ 145 mEq/L ‐ Cl‐ 90 mEq/L ‐ K+ 4.2 mEq/L ‐ HCO3‐ 27 mEq/L | The core issue of the question is the ability to determine abnormal electrolyte levels. Use nursing knowledge and the process of elimination to make a selection. |
2276 Which of the following findings in a client’s history Correct answer: 1 Poor nutritional intake, vomiting, diarrhea, and the overuse of antacid are related to would alert the nurse to assess for signs and symptoms alcoholism and alcohol abuse. These can lead to hypophosphatemia. During oliguria, the of hypophosphatemia? kidneys are unable to excrete phosphorus (option 2). Clients with prolonged (not short‐term) gastric suction are more likely to experience hypophosphatemia (option 3). Prolonged or continuous use of aluminum‐containing antacids (not occasional use) leads to hypophosphatemia (option 4). ‐ Withdrawal from alcohol ‐ The oliguric phase of acute tubular necrosis ‐ Short‐term gastric suction ‐ Occasional use of aluminum‐containing antacids | The core issue of the question is knowledge of risk factors for hypophosphatemia. Use nursing knowledge and the process of elimination to make a selection. |
2277 Which of the following concurrent electrolyte Correct answer: 3 Calcium and phosphorus have an inverse relationship in the body. For this reason, when imbalances should the nurse anticipate while assigned phosphorus levels are high, calcium levels are low (option 3). The other responses do not to the care of a client with hyperphosphatemia? address this relationship. ‐ Potassium 2.8 mEq/L ‐ Sodium 131 mEq/L ‐ Calcium 6.8 mEq/L ‐ Magnesium 3.4 mEq/L | The core issue of the question is knowledge that hypocalcemia accompanies hypermagnesemia. To answer the question correctly, you must also be able to recognize abnormal laboratory values. Use nursing knowledge and the process of elimination to make a selection. |
2278 The nurse would report to the charge nurse that an Correct answer: 5.1 Hyperkalemia exists when the serum potassium level rises above the upper limit of normal, assigned client has hyperkalemia after noting that the which is 5.1 mEq/L. serum potassium level drawn that morning was greater than mEq/L. | The core issue of the question is knowledge that hypocalcemia accompanies hypermagnesemia. To answer the question correctly, you must also be able to recognize abnormal laboratory values. Use nursing knowledge and the process of elimination to make a selection. |
2279 The nurse notices that an elderly nursing home Correct answer: 3 Mental status changes and concentrated urine are common signs of dehydration or FVD in resident has not been eating or drinking as much as the elderly. Tenting and dry, flaky skin are consistent changes seen with normal aging. Hand usual. Which assessment finding would best indicate veins that fill within 3–5 seconds and clear lungs sounds with unlabored breathing are normal the presence of fluid volume deficit (FVD)? findings. ‐ Clear lung fields with unlabored respirations ‐ Tenting and dry, flaky skin ‐ Increased drowsiness, mild confusion, and concentrated urine ‐ Hand veins that fill within 3–5 seconds of being lowered below the heart | Critical words are best and fluid volume deficit. Note that options 1 and 4 are normal findings, and eliminate them. Recognize that option 3 is the best indicator of fluid volume deficit to select this option. |
2280 A client who is three hours post‐tonsillectomy has Correct answer: 4 D<sub>5</sub>W has a hypotonic effect when infused intravenously, providing had minimal blood loss. The client has consumed 12 free water to cells after glucose is metabolized. Ice chips contain no solute, and also provide cups of ice chips to soothe throat discomfort, and has free water through the GI tract. This client has received an excess of free water without received 3 liters of D<sub>5</sub>W during electrolytes, and thus is at risk for hypotonic overhydration (water intoxication). The client is this time frame. The nurse recognizes the client is at not experiencing deficit or dehydration. risk for developing which fluid imbalance? ‐ Isotonic fluid volume deficit ‐ Hypertonic dehydration ‐ Isotonic fluid volume excess ‐ Hypotonic overhydration | Critical words are ice chips and D<sub>5</sub>W; recall that these are hypotonic fluids. Recognize that the client has consumed an excessive amount to choose option 4. |
2281 A 56‐year‐old client with a history of heart failure and Correct answer: 4 A history of heart failure increases the risk for fluid volume excess and pulmonary edema. The hypertension is hospitalized following abdominal priority is to detect signs of pulmonary edema by assessing for adventitious lung sounds surgery. Vital signs have been stable, and (auscultation for moist crackles). The other observations provide useful information, but are D<sub>5</sub>1/2NS is infusing at 80 not the priority. mL/hour. The client awakens in the middle of the night complaining of trouble breathing. Which assessment by the nurse should take priority at this time? ‐ Review intake and output record. ‐ Assess extremities for edema. ‐ Count apical heart rate. ‐ Auscultate lung fields. | Critical words are history of heart failure and trouble breathing. Recall the priority of ABCs, airway, breathing and circulation, to be directed to option 4. |
2282 The nurse is assessing the hydration status of a 50‐ Correct answer: 2 Postural hypotension, a drop in systolic BP greater than 10 mmHg after rising from lying to year‐old client with gastroenteritis. Which finding standing, is a sign of decreased circulating blood volume. Elevated temperature is associated would be most indicative of a fluid volume deficit with fluid volume deficit. Falling pulse oximetry readings indicate a problem with oxygen (FVD)? delivery from the lungs to the blood, which occurs with pulmonary edema, not fluid volume deficit. The presence of S3 heart sounds in an adult is indicative of venous congestion and fluid overload. ‐ Oral temperature 97.8°F ‐ 30 mmHg drop in systolic blood pressure (BP) when client stands ‐ Falling pulse oximetry values ranging from 90– 92% ‐ Presence of S3 heart sounds | The critical term is fluid volume deficit. Associate the drop in blood pressure to fluid loss in the blood vessels to be directed to option 2. |
2283 Which of the following interventions should the nurse Correct answer: 1, 2, 3, Ice chips are a source of fluid intake, and if taken in unlimited amounts, can easily contribute include when caring for a client on a fluid restriction? 5 to excess fluid intake. Fluids taken with medications must be included with measurements of Select all that apply. intake and output. Use of the other measures listed is indicated to maximize compliance with fluid restriction. ‐ Involve the client in dividing fluid allowances over the 24‐hour period. ‐ Use an infusion pump to control the infusion of any required intravenous fluids. ‐ Include ice chips in the client's oral intake measurement. ‐ Provide unlimited ice chips to help keep the client's mouth and lips moist. ‐ Do not include fluid taken with medications. | The critical term is fluid restriction. Note the word unlimited is opposite of restriction and recognize that all fluid intake must be measured to eliminate option 4. |
2284 A 45‐year‐old client is admitted with extreme thirst, Correct answer: 2 High serum glucose increases blood osmolality, causing water to be pulled from the cells into frequent urination, tenting skin, sunken eyes, and a the vessels. The excess fluid volume in the vessels is then excreted by the kidneys, resulting in dry, furrowed tongue. Because serum sodium is hypertonic dehydration of the cells and its associated symptoms. normal and serum glucose is elevated, the nurse determines the client is experiencing which fluid imbalance? ‐ Isotonic fluid volume deficit ‐ Hypertonic dehydration ‐ Isotonic fluid volume excess ‐ Hypotonic overhydration | Recognize that the symptoms reflect a fluid deficit, and that the elevated glucose indicates a hypertonic condition, and choose option 2. |
2285 A mother brings her 14‐month‐old to the Emergency Correct answer: 3 Assessing for low urine output (number of wet diapers) helps determine how severe the Department, concerned that the infant has been child's fluid losses are. Although an elevated temperature can affect fluid balance by increasing vomiting for two days and "isn't keeping much down." basal metabolic rate, it is not the most accurate determinant of fluid status at the present Which question should the nurse ask next to elicit the time. Dietary intake (including solids and fluid) are important in maintaining fluid balance, but most relevant information needed at this point? the greatest concern is to focus on urinary output as a measure of volume status. ‐ "What does your baby usually eat?" ‐ "How much does your baby normally drink?" ‐ "How many diaper changes have you done in the last 24 hours?" ‐ "Did you take the baby's temperature?" | Recognize the age of the client and associate urine production with hydration status to choose option 3. |
2286 The nurse identifies which of the following clients as Correct answer: 1 Infants and the elderly are the age groups at greatest risk for FVD, in part because they being at the greatest risk for developing fluid volume cannot compensate for fluid losses as easily as older children and younger adults do. The 2‐ deficit (FVD) and dehydration? month‐old is losing fluid from vomiting, and cannot compensate. Arthritis does not directly increase the risk for FVD. Adults usually handle fluid changes efficiently unless there are prolonged symptoms and/or underlying disease processes. ‐ A 2‐month‐old with vomiting ‐ A 30‐year‐old with pneumonia ‐ A 45‐year‐old with diarrhea ‐ A 70‐year‐old with arthritis | Associate infancy and fluid losses from vomiting with a fluid volume risk, and choose option 1. |
2287 A client with congestive heart failure (CHF) has come Correct answer: 3 Fluid gains cause acute weight gain, which should be explored with clients taking diuretics. to the clinic for a prescription refill for a diuretic. The Missing doses can lead to fluid gain, or the dosage might need to be adjusted if the heart client reports a 5‐pound weight gain in the past two failure is worsening. days, and that his shoes are tight. What response by the nurse is most appropriate? ‐ "Have you changed your eating habits lately?" ‐ "Five pounds isn't much. You can skip desserts and lose that." ‐ "Such a rapid gain is probably water weight. Have you missed any days taking your pill?" ‐ "Your clothes still look good on you. Everyone's weight fluctuates during a week." | Critical words are CHF, diuretic, and 5‐pound weight gain. Recognize that this weight gain reflects fluid retention to be directed to option 3. |
2288 The nurse determines that which of the following Correct answer: 1 Edema that is still present after lying down all night is more likely to be of cardiac origin. Local findings in a client most likely reflects edema related edema is caused by local obstruction or poor lymph flow (standing; sitting; lymph node to inadequate heart pumping action? removal). Dependent edema is more reflective of localized obstruction or valvular incompetence. ‐ Swollen feet and sacral area of an elderly client upon awakening in the morning ‐ Swelling of legs and feet in a 45‐year‐old client after a ten‐hour airplane flight ‐ Ankle swelling in 40‐year‐old waitress that resolves after sleeping all night ‐ Swelling in the arm of a client who has had axillary lymph nodes removed | Critical words are edema and inadequate heart pumping action. Recall physiology of the heart and gravity to associate backup of fluid to swollen feet, and note that the fluid is still present in the morning, to choose option 1. |
2289 A 78‐year‐old client is admitted with dehydration and Correct answer: 2 This client presented with deficient fluid volume because of dehydration. Older adults have urinary tract infection. After IV infusion of 750 mL NS, less cardiac and renal reserve to compensate for acute fluid imbalances, and thus are more the client begins to cough, and asks for the head of the susceptible to overcorrection when being treated for them. JVD, tachypnea, cough, and bed to be raised to ease breathing. The nurse assesses dyspnea indicate that this client has received too much IV fluid at too rapid a rate. Older adult jugular vein distention (JVD) and increased respiratory clients cannot tolerate rapid rehydration, due to decreased cardiac and renal function. rate. The nurse interprets that: ‐ The fluid volume deficit is worsening. ‐ Hypervolemia is developing. ‐ Hypotonic water intoxication is beginning. ‐ Ascites is causing respiratory compromise. | Note that the client is elderly, and has received too much fluid, indicating a fluid overload. Recall knowledge of fluid volume excess to eliminate option 1. Recognizing that the fluid is isotonic eliminates option 3. Option 4 can be eliminated, since no signs of ascites are mentioned. |
2290 The nurse is helping a client who recently was placed Correct answer: 1 Processed and canned foods (bologna, soup, tomato juice), sodas, and pickled foods are high on a low‐sodium diet to choose foods for lunch. The in sodium. Fresh foods (grilled chicken, fruit, vegetables) are lower in sodium. nurse recommends that which of the following lunch menus would be best for this client? ‐ Grilled chicken sandwich on white bread, apple, salad, and iced tea ‐ Bologna sandwich on wheat bread, canned fruit cocktail, salad, and a soda ‐ Ham and bean soup, fresh fruit salad, pickles, and a diet soda ‐ Cheeseburger, grapes, fresh pineapple, and tomato juice | Note the critical word best is used, indicating that one of the choices is better than the others. Recall knowledge of the sodium content of various foods to eliminate options 2 and 3. Option 4 contains tomato juice, high in sodium, making option 1 best choice. |
2291 A 28‐year‐old client is admitted with severe bleeding Correct answer: 1 Acute bleeding results in isotonic fluid loss, and can quickly lead to shock and vascular from a fractured femur. Which intravenous (IV) fluid collapse. The priority is to expand vascular volume and restore circulation using isotonic IV does the nurse anticipate as the most appropriate to fluid. Hypertonic (3% saline) and hypotonic (D<sub>5</sub>W, replace potential fluid losses? D<sub>5</sub>¼NS) solutions are not indicated. ‐ 0.9% sodium chloride (0.9% NaCl) ‐ 3% sodium chloride (3%NaCl) ‐ 5% dextrose in water (D5W) ‐ 5% dextrose in 0.225 sodium chloride (D5¼NS) | The critical words are most appropriate and fluid losses. Recognize that the client needs replacement of isotonic fluids to eliminate options 2, 3, and 4, since these are either hypertonic or hypotonic. |
2292 A 54‐year‐old client with liver failure due to cirrhosis Correct answer: 2 The failing liver does not make enough albumin to keep capillary oncotic pressure at normal comes to the clinic complaining of a swollen abdomen levels; thus excess fluid is lost from vessels into the peritoneum, causing ascites and vascular and dizziness upon standing. The client is pale, with fluid volume deficit. Orthostatic hypotension, weak peripheral pulses, and delayed hand vein weak radial pulses, delayed hand vein filling, and filling are all signs of low circulating fluid volume. distended abdomen. The nurse develops a care plan identifying which of the following nursing diagnoses? ‐ Excess Fluid Volume: Intravascular related to third space fluid shifts ‐ Deficient Fluid Volume: Intravascular related to third space fluid shifts ‐ Excess Fluid Volume: Extravascular related to hormonal disturbances ‐ Deficient Fluid Volume: Extravascular related to hormonal disturbances | Note that the client has cirrhosis, and that the symptoms reflect a deficit intravascularly and an excess extravascularly (the abdomen). Eliminate options 3 and 4, since the cause is not hormonal. Choose option 2, since symptoms support a deficient fluid volume: intravascular. |
2293 The nurse caring for the following group of clients Correct answer: 3 The 76‐year‐old client has more risk factors than do the other clients. This client is elderly, considers which client to be at greatest risk for losing fluids via the NG tube as well as being NPO, and is postoperative of major surgery. developing deficient fluid volume? Clients taking steroids usually retain sodium and water. Repair of an inguinal hernia is not a major surgery, and the client is likely to recover quickly and be able to resume fluid intake. Following a sigmoidoscopy, fluids will be resumed. ‐ A thin, 52‐year‐old female receiving steroid therapy for bronchitis ‐ A 60‐year‐old male who had a left inguinal herniorrhaphy 12 hours ago ‐ A 76‐year‐old male who has a nasogastric (NG) tube on intermittent suction following colon resection ‐ A 68‐year‐old female who is NPO for a flexible sigmoidoscopy procedure | Critical words are at greatest risk and deficient fluid volume. Recall knowledge of risk factors contributing to fluid deficits, and determine that option 3 has the greater number of them. |
2294 A 17‐year‐old client who sustained a head injury in a Correct answer: 2 5% dextrose in water (D<sub>5</sub>W) has a hypotonic effect when infused, motorcycle collision two days ago is responsive only to providing free water to cells, which would worsen this client s cerebral edema. The other fluids pain. Which intravenous (IV) fluid order would the listed are isotonic, and would remain primarily in the extracellular spaces. nurse question because it could increase the risk of complications? ‐ Ringer’s solution ‐ 5% dextrose in water (D5W) ‐ 0.9% sodium chloride (0.9% NaCl) ‐ Lactated Ringer’s solution | Note that the client has a head injury, and recognize the danger of hypotonic fluids that could contribute to cerebral edema. Also note that the question requires the nurse to question an order, indicating one option will be inappropriate and 3 are appropriate. Choose option 2 because it is a hypotonic fluid, and is therefore an incorrect solution to use. |
2295 The nurse is caring for a client admitted with Correct answer: 1, 2, 3 Hemoglobin and hematocrit can decrease or increase secondary to hemoconcentration or congestive heart failure (CHF). When assessing the hemodilution. ANP is a cardiac hormone released when atria are stretched by increased blood client’s risk for fluid imbalances, the nurse should volume, which would occur in CHF. Glucose and liver enzymes would not be affected by fluid check which of the following laboratory values? Select volume. all that apply. ‐ Hemoglobin (Hgb) ‐ Hematocrit (Hct) ‐ Atrial natriuretic peptide (ANP) ‐ Blood glucose ‐ Liver enzymes | Note that the client has CHF. Recall knowledge of fluid imbalances, and correlate lab studies associated with them. Eliminate options 4 and 5, since they are not affected by fluid volume. |
2296 A client with a nursing diagnosis of Excess Fluid Correct answer: 1 S<sub>3</sub> heart sounds and moist lung crackles are signs associated with Volume has been treated with diuretics and fluid fluid overload, not deficit. Since they are resolving, the client is returning to normal status, but restriction. Which of the following findings would has not yet reached complete balance. Option 2 indicates full resolution of fluid balance, and is indicate to the nurse that fluid volume balance has not therefore incorrect. Options 3 and 4 show resolving signs of fluid volume deficit and yet been achieved? dehydration, but the question is addressing excess fluid volume. ‐ S3 heart sound and moist lung crackles resolving ‐ Return to coherent conversation and appropriate behavior | Note the critical phrases Excess Fluid Volume and has not yet been achieved. Recall signs and symptoms of fluid excess, and eliminate option 2 because it indicates full resolution of these signs. Eliminate options 3 and 4 because they indicate resolution of deficient fluid volume, which is not the focus of the question. |
‐ Urine output increasing and specific gravity decreasing ‐ Skin tenting decreasing and conjunctiva of eyes moist | |
2297 During intershift report, the nurse is told that a client Correct answer: 1 Diabetes insipidus (DI) is a condition caused by insufficient production and/or release of ADH. who has suffered a stroke has also developed diabetes Inadequate ADH leads to increased excretion of dilute urine. Excessive production of ADH, insipidus. The nurse concludes this client is now at risk known as SIADH, leads to fluid retention and excess fluid volume. Changes in glucose levels and for which of the following? insulin production are associated with diabetes mellitus. ‐ Severe deficient fluid volume because of excess urine output ‐ Severe excess fluid volume because of inadequate urine output ‐ Hyperglycemia because of poor insulin production ‐ Hypoglycemia because of excess insulin production | The critical words are diabetes insipidus and at risk for. Eliminate options 3 and 4 because they relate to diabetes mellitus. Discriminate appropriately between DI and SIADH to choose correctly between options 1 and 2. |
2298 A father telephones the clinic nurse asking what he Correct answer: 2 Commercial oral rehydration fluids, such as Pedialyte or Rehydralyte, are balanced water, should do for his 3‐year‐old son, who developed fever, carbohydrate, and electrolyte solutions that replace both fluids and electrolytes lost in vomiting, and diarrhea today. Which of the following diarrhea. They also do not have a high osmolality, caffeine, or excess sodium, all of which can would be an appropriate recommendation by the worsen diarrhea and fluid loss. Replacing diarrhea losses with only water could lead to nurse? electrolyte imbalances. Fruit juice and sports drinks are too high in sugar, which can worsen diarrhea and fluid loss. Solid foods, including the BRAT diet, are not appropriate while the client is vomiting. ‐ “Have him drink as much water as you can get him to swallow.” ‐ “Give small sips of commercial oral rehydration fluids frequently.” ‐ “Provide frequent sips of fruit juice and commercial sports drinks.” ‐ “Have him eat only bananas, rice, applesauce, and toast (BRAT diet).” | Recall knowledge of age‐appropriate fluids. Determine that the symptoms reflect risk for fluid volume deficit to choose option 4. |
2299 The nurse determines that which of the following Correct answer: 1 Infants and the elderly don't compensate well for fluid losses. Clients with NG suction (loss of clients is at greatest risk for developing a fluid volume fluids and electrolyes in fairly proportional amounts) are at greater risk for fluid volume deficit. deficit? The elderly client with NG suction has both risk factors, while the child’s age is the only risk factor. The client taking glucocorticoids is predisposed to sodium and fluid retention rather than fluid loss. The 30‐year‐old jogger is a young adult in a moderate climate, which lowers the risk from exertion alone. ‐ A 76‐year‐old client who has a nasogastric (NG) tube on low suction following surgery for colon cancer ‐ A thin, 55‐year‐old client who smokes and takes glucocorticoids for chronic lung disease ‐ A 1‐year‐old child being treated in the clinic for a runny nose and ear infection ‐ A 30‐year‐old client jogging in 50‐degree weather | Recall concepts of fluid balance, and factors contributing to losses. Eliminate option 2, since fluid is gained with steroids, and options 3 and 4 because they have fewer risk factors than the correct option. |
2300 The nurse is assisting in a health fair at a senior Correct answer: 4 Items that are liquid at body temperature are also considered part of fluid intake, so ice pops, citizen center. Which of the following instructions gelatin, and ice cream can be considered part of overall fluid intake. The color of urine is only should the nurse include when giving the elderly client one indicator of hydration, and many elderly people take a diuretic, which would produce guidelines to remain hydrated in hot weather? more dilute urine, falsely reassuring the client. With aging, the thirst mechanism becomes less effective. Significant fluid can be lost before thirst is triggered, so the elderly should not rely solely on thirst to indicate when they need to drink fluids. ‐ “If your urine is clear yellow, you are drinking adequate fluids.” ‐ “Drink only water to keep yourself properly hydrated.” ‐ “Popsicles, gelatin, and ice cream provide fluid intake as well as liquids you drink.” ‐ “Use your thirst as a guide to the amount of fluid you should be drinking.” | Note the critical words elderly and remain hydrated. Recall knowledge of risk factors for dehydration in the elderly and of fluid intake to make a selection. |
2301 An adult client in the clinic complains of a cough, Correct answer: 3 The client has symptoms of fluid volume deficit (FVD) and hypovolemia. The presence of fever, nausea, and vomiting for three days. postural hypotension when rising from a lying position indicates the presence of significant Examination reveals dry tongue and oral mucosa, and hypovolemia. The other vital signs are important for general reasons, but do not directly concentrated urine. The client also reports feeling reflect circulating fluid volume. weak and dizzy. To best assess the client’s fluid status, the nurse checks which of the following assessment parameters? ‐ Temperature ‐ Respiratory rate and depth ‐ BP and pulse in lying and standing positions ‐ Pulse oximetry reading at rest | Recognize that the client has signs and symptoms of an FVD: intravascular, and recall clinical manifestations of such. Eliminate options 1 and 4 because they don t reflect intravascular fluid losses. Choose option 3 over 2, since it best supports the client complaints of weakness and dizziness. |
2302 The nurse evaluates the hydration status of a client Correct answer: 1, 4, 5 The neck veins are normally flat when the head of bed is elevated, due to gravity. Dyspnea who has been receiving intravenous (IV) fluids at 150 with exertion is often a sign of fluid in the alveoli. Pitting edema reflects fluid in the interstitial mL/hour. The nurse identifies that the client has excess spaces. Hand veins would remain full or empty slowly if excess fluid volume (EFV) is present. fluid volume after assessing which of the following? Peripheral pulses would be bounding with an EFV. Select all that apply. ‐ Neck veins are distended when the head of the bed is elevated 45 degrees. ‐ Hand veins are empty when the hand is raised above the heart. ‐ Peripheral pulses are rapid and weak. ‐ Client becomes short of breath when ambulating. ‐ Pitting edema is present over tibia. | Note the critical words hydration status and excess fluid volume. Choose those options that reflect a full vascular bed, which in this case are peripheral edema, venous engorgement, and excessive pulmonary fluid. |
2303 A client hospitalized for gastrointestinal (GI) bleeding Correct answer: 3 Normal saline (0.9% NaCl) is an isotonic fluid that prevents fluid shifts into or out of the GI has orders for nasogastric tube (NGT) placement, with tract. Option 1 (3% saline) is hypertonic, and could pull water from the GI tract, resulting in irrigations until the returns are clear. Which of the water loss. D<sub>5</sub>W and sterile water are hypotonic, and could be pulled following solutions should the nurse plan on using? into GI tissue, as well as wash electrolytes from the GI tract, resulting in water intoxication. ‐ 3% Sodium chloride (NaCl) ‐ 5% Dextrose in water (D5W) ‐ 0.9% Sodium chloride (NaCl) ‐ Sterile water | Recall the principles of osmosis and diffusion, and the differences among hypotonic, isotonic, and hypertonic fluids. Eliminate options 1, 2, and 4, since fluid shifts will occur with hypotonic and hypertonic solutions. |
2304 A 70‐year‐old hospitalized client with a past medical Correct answer: 4 A moist cough, dyspnea, and a falling pulse oximetry reading in a client with a history of heart history of hypertension and myocardial infarction is disease are signs of developing pulmonary edema secondary to excess fluid volume (EFV). The postoperative following stomach surgery. Vital signs first action should be to reduce IV fluid intake, to prevent more fluid from accumulating in the have been stable, and an IV of lungs; then further assessment can be done, emergency actions taken, and the physician D<sub>5</sub>HNS is infusing at 100 contacted. mL/hour. The client now complains of trouble breathing, and has a moist cough, and the pulse oximetry reading has fallen to 92%. What action should the nurse take first? ‐ Measure blood pressure and heart rate. ‐ Assess legs and arms for pitting edema. ‐ Telephone and notify the physician. ‐ Slow the intravenous rate to 10–20 mL/hour. | Note the critical word first, indicating one option has a priority action. Use knowledge of cardiovascular disease and EFV to choose option 4. |
2305 A 45‐year‐old client with excess fluid volume (EFV) Correct answer: 2 Option 2 provides accurate information in simple terms without unduly alarming the client. because of acute kidney dysfunction is placed on a Option 4 is technically correct, but is stated in an abrupt and alarming manner. Option 1 offers 1,000 mL fluid restriction per 24‐hour period. The no explanation to facilitate understanding. Option 3 assigns the client blame for the current client asks the nurse, “Why there is such a severe fluid condition without providing a clear explanation for the fluid restriction. restriction when I already have dry lips and mouth?” Which response by the nurse is best? ‐ “The doctor ordered the fluid restriction, so it is important to comply with those orders.” ‐ “Your kidneys cannot eliminate extra fluid right now, so intake must be limited to protect your heart and lungs from being overloaded with fluid.” ‐ “You probably drank too much fluid before you got sick, so you can’t compare your usual intake to your limitations now that your kidneys are not working.” ‐ “Too much fluid will cause your heart to fail and your lungs to fill with water, which could be fatal.” | Note the critical words best and response. Use knowledge of communication skills and regulation of fluid imbalances to choose option 2. |
2306 A 45‐year‐old female client is receiving a loop diuretic Correct answer: 1 An excess response to diuretic therapy results in an excess loss of water and electrolytes in for treatment of edema. The nurse determines the the urine, leaving the blood hemoconcentrated, and causes a high BUN (normally 8–22 mg/dL) client is experiencing an excessive response to the and HCT (normally approximately 38–45%). The water loss results in an acute weight loss. treatment when the client demonstrates: Weight gain indicates ineffective response to diuretic therapy. ‐ Blood urea nitrogen (BUN) 28 mg/dL; hematocrit (HCT) 45%; and an 8‐pound weight loss in 24 hours. ‐ BUN 21 mg/dL; HCT 29%; and an 8‐pound weight gain in 24 hours. ‐ BUN 16 mg/dL; HCT 31%; and an 8‐pound weight loss in 24 hours. ‐ BUN 25 mg/dL; HCT 33%; and an 8‐pound weight gain in 24 hours. | Note the critical words excessive response, indicating a greater‐than‐desired action is achieved. Use knowledge of diuretic action to eliminate options 2, 3, and 4. |
2307 A client is receiving an intravenous (IV) infusion of Correct answer: 4 G NS (0.225% sodium chloride) is a hypotonic solution that provides free water to the cells. 0.0225% sodium chloride at 50 mL/hour. In order to Cerebral cells are especially sensitive to fluid gains from hypotonic fluids. If infused too rapidly, detect complications of therapy, it is most important the cerebral cells will be the first to gain fluid too quickly, resulting in neurological changes. for the nurse to monitor: Monitoring the client for urine output, edema, and oral cavity dryness is important, but this reflects a response to IV therapy rather than detection of a complication. ‐ Urine output and concentration. ‐ Legs and arms for edema. ‐ Tongue and mouth for dryness. ‐ Mental status and orientation. | Note critical words complications of therapy and most important, indicating that one of the options is of highest priority. Recall knowledge of fluid shifts with hypotonic fluids to choose option 4. |
2308 When caring for an adult receiving an intravenous (IV) Correct answer: 1 Three percent (3%) saline is very hypertonic, and, if infused too rapidly, will increase serum infusion of 3% sodium chloride (NaCl), the nurse places sodium and osmolality, causing high volumes of water to be pulled into vessels from cells. This priority on monitoring which of the following to detect results in cellular dehydration and vascular volume overload. Serum sodium levels, complications of therapy? neurological status, and lung function should be closely monitored. Although daily weights are important, they do not provide information leading to early detection of complications of therapy. Vital signs, serum glucose levels, urine‐specific gravity, oxygen saturation, and peripheral edema provide later indications of complications of therapy. ‐ Neurological status, lung sounds, and serum sodium levels ‐ Heart rate, blood pressure, and daily weights ‐ Serum glucose levels and urine‐specific gravity ‐ Pulse oximetry and peripheral edema in the legs | Note critical words priority and detect. Recall physiology of fluids shifts from hypertonic solutions to choose option 1. |
2309 The nurse identifies which of the following Correct answer: 3 A TURP procedure can place a client at risk for developing hyponatremia in the postoperative postoperative clients to be at risk for developing a period due to increased fluid irrigation used during treatment. Clients with a TURP procedure sodium imbalance? have a continuous bladder irrigation (CBI) as a routine part of their postoperative care. The other options do not place a client at risk for the development of sodium imbalances, as they do not require lengthy fluid and dietary restrictions or excessive fluid irrigation. ‐ A client who has just had a tonsillectomy | The critical term is sodium imbalance. Note that the question does not specify hypo‐ or hypernatremia. Associate irrigation fluids post‐TURP with a sodium imbalance to choose option 3. |
‐ A client who has a primary cesarean section for failure to progress in labor ‐ A client who has a transurethral resection of the prostate (TURP) ‐ A client who has a right knee arthroscopy | |
2310 The nurse is caring for a client experiencing Correct answer: 4 Hyponatremia can also be referred to as dilutional hyponatremia or water intoxication. Water hyponatremia. As part of the care, the nurse will restriction would be an important part of the treatment plan when caring for a client who has restrict: hyponatremia. The restriction of Gatorade (electrolyte‐rich solution), eggs, cheese products, and salt on the diet tray are not indicated, because the client is experiencing a sodium deficit. ‐ Gatorade. ‐ Eggs and cheese products. ‐ Salt on the diet tray. ‐ Water. | The critical term is hyponatremia. Recall that water will further dilute the sodium, and choose option 4. |
2311 The nurse is caring for a client experiencing Correct answer: 3 Clients with hypernatremia are thirsty, and need water replacement to balance the increased hypernatremia. The nurse concludes that it is sodium levels. Cough medication and lactulose can further increase sodium levels, and should important to administer: not be administered unless there is sufficient clinical information to warrant their use. Three‐ percent saline is a hypertonic solution that would also increase serum sodium levels, and should not be given to this client. ‐ Cough suppressant to treat symptomatic cough. ‐ 3% saline solution. ‐ Water. ‐ Lactulose. | The critical term is hypernatremia. Associate the role of water in dilution of sodium to choose option 3. |
2312 The nurse provided teaching about dietary sodium Correct answer: 3 Pork contains high amounts of sodium. Clients with CHF are prone to hypervolemic modifications for a client with congestive heart failure hypernatremia, and should decrease their salt intake. The other options list foods containing (CHF). Which of the following menu selections relatively small amounts of sodium that could easily be incorporated into the client's diet. indicates that the client needs further education? ‐ Broiled chicken breast ‐ Salad ‐ Baked pork chop ‐ Toast with margarine | The question is a negative‐response item, indicating there are three correct responses reflecting the client's correct choice of foods. Recall foods high in sodium to choose option 3. |
2313 A client with a history of sodium imbalances presents Correct answer: 1, 2, 4 Osmotic pressure causes fluids to move in both directions simultaneously; it is not a to the clinic for a monthly checkup. Which of the parameter that is assessed. Skin turgor, intake and output, and blood pressure are physical following parameters should the nurse assess related assessment parameters the nurse would consider when assessing fluid‐and‐electrolyte balance to fluid and electrolyte balance? Select all that apply. in a client who has experienced prior sodium imbalances. Options 3 and 5 would not be necessary for a routine fluid‐and‐electrolyte assessment. The key concept is fluid and electrolyte balance. ‐ Blood pressure ‐ Intake and output ‐ Content of last meal ‐ Skin turgor ‐ Exercise tolerance | Recall measurements that are reflective of fluid balance to choose options 1, 2, and 4. |
2314 A client has severe hyponatremia secondary to Correct answer: 2 When hyponatremia is severe, hypertonic IV solutions may be used as part of the treatment syndrome of inappropriate antidiuretic hormone plan. Three‐percent saline is an example of a hypertonic solution. In SIADH, hypotonic and (SIADH). The nurse concludes that the appropriate IV isotonic solutions are not indicated, because urine output is minimal and water is retained solution for this client would be a(n): (options 1 and 3). Option 4 is also incorrect, because D<sub>5</sub>W is not an isotonic solution, but rather a hypotonic solution. It is important to know not only the correct type of solution indicated but also the types of solutions that fall under each category. ‐ Isotonic solution, such as normal saline (NS). ‐ Hypertonic solution, such as 3% saline. ‐ Hypotonic solution, such as D5W. ‐ Isotonic solution, such as D5W. | The key term is SIADH. Recall that this condition is characterized by hyponatremia and fluid volume excess to choose option 2. |
2315 The nurse is monitoring the daily weight of a client Correct answer: 2 Weight loss of more than 0.5 pounds in 24 hours is considered to be due to fluid loss. A with a sodium imbalance. The nurse interprets that weight loss of 0.25 pounds is not significant enough to be considered fluid loss. Although 1 fluid loss might be occurring when daily weight loss pound or 1 kilogram might indeed reflect a significant fluid loss, these are greater than the begins to exceed: minimum level that denotes fluid loss. ‐ 0.25 pounds. ‐ 0.5 pounds. ‐ 1 pound. ‐ 1 kilogram. | The question addresses the relationship of weight loss to fluid loss. Recall normal equivalency to be directed to option 2. |
2316 The nurse is providing care to a client experiencing Correct answer: 2 Hypotonic fluid volume excess (FVE) involves an increase in water volume without an increase hypotonic fluid volume excess. The nurse incorporates in sodium concentration; thus an increase in sodium intake is part of the treatment. Decreased which of the following dietary considerations in the sodium intake will result in an even lower sodium level, since hypotonic FVE is associated with menu for this client? low sodium. Fluids are restricted, and an intake of potassium‐rich foods is not related to the treatment of hypotonic FVE. ‐ Decreased sodium intake ‐ Increased sodium intake ‐ Increased fluid intake ‐ Intake of potassium‐rich foods | Critical terms are hypotonic fluid and FVE. Recall that this condition reflects water excess and sodium deficiency to be directed to option 2. |
2317 A client presents to the walk‐in clinic complaining of Correct answer: 2 The client's clinical presentation suggests that hyponatremia is occurring (tachycardia, nausea and vomiting for two days, and development of hypotension, and dry skin/membranes). Obtaining information relative to intake and output a mild headache this morning. Physical examination can help to identify potential/actual fluid losses and possibly identify the etiology of the reveals BP of 100/70; pulse rate of 92; respiratory rate sodium deficit. It will also give vital information relative to the hydration status of the of 20; and pale, dry skin. What other priority individual. While the other options should be addressed, they are not the priority at the information would help the nurse to evaluate this present time, unless there is an acute presentation. client relative to sodium balance? ‐ Pain characteristics related to the headache ‐ Intake and output over the last two days ‐ Whether the client is experiencing any other symptoms ‐ Whether the nausea continues throughout the day or is relieved after the client vomits | Analyze the options for all relevant parameters related to fluid and sodium imbalances. Recall the importance of intake and output to fluid imbalance to choose option 2. |
2318 A client's serum sodium level is 175 mEq/L. Which Correct answer: 4 It is vital to notify the physician of a laboratory value that is critical. A sodium level of 175 one of the following priority treatment measures mEq/L requires immediate medical attention and intervention. Option 1 is incorrect, as a should the nurse use to restore normal sodium hypertonic solution is not indicated in the treatment of hypernatremia. Option 2 is incorrect balance? because the TPN might be causing the client to experience hypernatremia as a source of salt excess/concentrated hypertonic solution. Option 3 might be indicated at a later date, but it is not a priority at the present time. Prompt recognition and treatment with appropriate fluids (free water, NS, or D<sub>5</sub>W depending on the client's volume status) should be instituted per protocol. Remember that cerebral cells are adaptive to different sodium levels, and that rapid correction can lead to further complications. ‐ Correct rapidly using a 3% saline solution to restore intravascular deficits. ‐ Continue to hang ordered TPN solution and wait for further physician orders based on the current serum value. ‐ Consult with a dietician to eliminate additional sodium in the diet. ‐ Notify the physician of the client's current sodium level and other serum and urine electrolyte levels that will help to identify the clinical picture. | Recognize that the abnormal level reflects hypernatremia. Eliminate options 1 and 2, since they provide additional sodium. Because the level is critically high, choose option 4. |
2319 When assessing a client with diabetes insipidus (DI), Correct answer: 2 DI is characterized by a decrease in ADH secretion, resulting in loss of fluids through polyuria; the nurse expects to find which of the following? polyuria in turn leads to increased thirst. Options 1, 3, and 4 are not characteristic of DI. ‐ Nausea and vomiting ‐ Polyuria and polydipsia ‐ Dysuria ‐ Confusion | Recall physiology of DI. If you have trouble recalling information, a clue might be the common word diabetes—although diabetes mellitus is different from diabetes insipidus, they share the common symptoms of polyuria and polydipsia. |
2320 A client receiving treatment for hypernatremia is Correct answer: 2 Too rapid a correction of hypernatremia can lead to changes in vascular tone, which can being monitored for signs and symptoms of affect vessels and cause increased fluid entry into the brain, thereby causing cerebral edema. complications of therapy. The nurse would assess this Option 1 reflects cellular dehydration, which is caused by hypernatremia. Options 3 and 4 are client for which of the following? not viewed as risks when treating hypernatremia. ‐ Cellular dehydration ‐ Cerebral edema ‐ Red blood cell (RBC) destruction ‐ Renal shutdown | Critical words are hypernatremia and complications. Note that the question addresses the complications of treatment. Recall that treatment involves fluid replacement, increasing risks of fluid shifts, to choose option 2. |
2321 A client is semiconscious and restless, and exhibits Correct answer: 4 This client has signs and symptoms of hypernatremia, and the serum sodium level would be tremors and muscle weakness. Physical examination greater than 145 mEq/L. Options 1 and 2 reflect decreased serum sodium levels, and are reveals a dry, swollen tongue, and body temperature considered to be hyponatremic. Option 3 reflects a normal serum sodium level. of 99.8°F. The nurse anticipates that the serum sodium value for this client is most likely to be which of the following? ‐ 120 mEq/L ‐ 132 mEq/L ‐ 142 mEq/L ‐ 155 mEq/L | Recognize that the symptoms in the question reflect hypernatremia. Systematically eliminate options lower than 145 mEq/L. |
2322 A client was brought to the hospital following a near‐ Correct answer: 1 Near drowning in salt water often results in hypernatremia due to the high sodium level in drowning experience in the Atlantic Ocean. In sea/salt water. Hyponatremia and disturbances in calcium levels are not seen in this clinical providing care to this client, the nurse plans to situation. carefully monitor for which of the following? ‐ Hypernatremia ‐ Hyponatremia ‐ Hypocalcemia ‐ Hypercalcemia | Critical words are near‐drowning and ocean, indicating ingestion of salt water. Recognize that this constitutes a sodium load, and choose option 1. |
2323 When caring for an adult client diagnosed with Correct answer: 1 In hyponatremia, water is already present in an excessive amount compared with the amount hyponatremia, the nurse plans to restrict which of the of sodium present. This can result in water intoxication or dilutional hyponatremia; therefore, following? water restriction is a cornerstone of therapy. The other electrolytes (sodium, potassium, and chloride) should not be restricted, but rather should be included in the treatment plan so as to prevent further electrolyte imbalances from occurring. ‐ Water ‐ Sodium ‐ Potassium ‐ Chloride | The critical word is restrict. Recall dangers related to further dilution of sodium to choose option 1. |
2324 For which of the following manifestations should the Correct answer: 4 Thirst is a primary indicator of sodium excess (hypernatremia), and should be assessed in a nurse assess when developing a plan of care for a plan of care for a client with hypernatremia. Muscle weakness is not reflective of client with hypernatremia? hypernatremia, but is more likely to be found with sodium deficit. Moist mucous membranes are not associated with sodium imbalances, and reflect a normal parameter. An elevated temperature would be expected with hypernatremia. ‐ Muscle weakness ‐ Moist mucous membranes ‐ Subnormal temperature ‐ Complaints of thirst | Critical words are manifestations and hypernatremia. Recall the primary compensatory mechanism for fluid balance to choose option 4. |
2325 The nurse is providing care to a client with syndrome Correct answer: 2 In SIADH, the antidiuretic hormone is present in excess amounts. This causes excessive water of inappropriate antidiuretic hormone (SIADH). The reabsorption. Water must be restricted, to avoid water intoxication. Giving additional fluids nurse explains to the unlicensed assistant that water would only serve to further increase fluid levels and increase sodium deficit. While it is intake should be: important to consider a client s preference in fluid selection, fluid restriction is the major priority. Administering fluids only via the intravenous route is not the preferred method. While fluid therapy can be given IV, it is important to allow the client to take PO fluids, even if only on a restricted basis. ‐ Encouraged. ‐ Restricted. ‐ Given according to the client’s preference. ‐ Given via intravenous fluids only. | The question addresses the relationship between water and SIADH. Note that options 1, 3, and 4 are similar in that all provide fluids in some form; therefore, these should be eliminated. |
2326 A client with a diagnosis of bipolar disorder has been Correct answer: 2 The client has exhibited behavior that could indicate a sodium‐and‐water imbalance, and is drinking copious amounts of water, and voiding actually exhibiting signs of hyponatremia. The nurse would check the electrolyte levels, frequently. The client is experiencing bounding pulse expecting to find a low sodium level. Monitoring the CBC for a platelet level is not indicated, as and confusion, and is reporting a headache. The nurse there is no correlation between sodium levels and platelet activity. The client s serum checks laboratory test results for which of the osmolality and urine‐specific gravity are expected to be low due to water intoxication. following? ‐ Low platelet count ‐ Low sodium level ‐ High serum osmolality ‐ High urine‐specific gravity | Recognize that the symptoms are reflective of a fluid volume excess and hyponatremia to choose option 2. |
2327 A client with a feeding tube has been experiencing Correct answer: 1 The client is exhibiting signs of hypernatremia and dehydration. The most appropriate nursing severe watery diarrhea. The client is lethargic, with intervention is to measure and record intake and output and daily weight. Administering salt decreased skin turgor, pulse rate of 110, and tablets would further contribute to the client s hypernatremic state. Restricting fluid intake hyperactive reflexes. The nurse would include which of and holding feedings could further contribute to the client s state of hypernatremia with fluid the following interventions on the client s plan of care? volume deficit (hypertonic dehydration), as the client already has extensive fluid loss due to diarrhea, elevated pulse rate, and decreased skin turgor. | Recognize that the symptoms reflect dehydration and hypernatremia. Eliminate options 3 and 4 because fluids need to be replaced. Eliminate option 2 because additional salt is not needed. |
‐ Monitor and record intake, output, and daily weights. ‐ Administer salt tablets, and monitor hypertonic parenteral solutions. ‐ Withhold tube feedings until diarrhea subsides. ‐ Avoid adding additional water before and after tube feedings. | |
2328 The nurse assigned to a client with hyponatremia Correct answer: 3 Fluid retention can result in hyponatremia through dilutional effect. Options 1 and 2 could would conclude that which of the following client lead to hypernatremia. Option 4 would lead to hypernatremia. factors probably contributed to this electrolyte imbalance? ‐ Osmotic diuretic therapy ‐ Fever ‐ Fluid retention ‐ Excessive hypertonic intravenous infusion | Analyze the options to identify the potential for sodium losses or dilution. Eliminate options 1 and 2, since more water than sodium is lost. Eliminate option 4, since sodium would be gained. |
2329 For which of the following serum electrolyte Correct answer: 3 The combination of high fever and severe dehydration leads to insensible water loss. This imbalances would the nurse assess in a client admitted indicates a loss of pure water, which does not contain electrolytes. Therefore, excessive with a high fever and severe dehydration? amounts of insensible water loss result in a hypertonic dehydration that leads to a state of hypernatremia and hyperchloremia. Calcium levels usually decrease in the presence of dehydration and fever. Phosphate levels usually increase in the presence of dehydration and fever. Potassium levels can usually remain normal in the serum, and are increased in the urine. ‐ Hypercalcemia and hypophosphatemia ‐ Hypokalemia and hyponatremia ‐ Hypernatremia and hyperchloremia ‐ Hypophosphatemia and hypocalcemia | Critical words are imbalances, high fever, and severe dehydration. Systematically eliminate options containing an imbalance not associated with water losses and dehydration. Recall that only water is lost with fever, combined with the dehydration, to choose option 3. |
2330 Which of the following clients would the nurse Correct answer: 1 The use of corticosteroids can lead to the development of hypernatremia because they cause identify as being at greatest risk to develop a sodium sodium to be retained and potassium to be excreted. The elderly client drinking eight glasses imbalance? of water each day is within a normal range of fluid intake, and is not at risk for developing sodium imbalances. The diabetic client whose blood glucose is within normal range is not at risk for developing sodium imbalances. The teenager who is using Gatorade as an oral replacement therapy to compensate for fluid and electrolyte loss during exercise is not at risk for developing sodium imbalances. ‐ An adult client taking corticosteroid therapy ‐ An elderly client who drinks eight 8‐ounce glasses of water each day ‐ A diabetic client who is under glycemic control ‐ A teenager who is drinking Gatorade during exercise workouts | The critical word greatest indicates that all or some of the options are correct, but one will have the greatest influence on creating the imbalance. Eliminate option 2, since this is not an abnormal amount of water to consume. Eliminate option 3, as it is not associated with sodium, and option 4, since the client is young and better able to accommodate an imbalance. |
2331 When caring for a 79‐year‐old client who has a Correct answer: 1 The thirst mechanism is decreased in the elderly, and would normally serve as a sodium level of 149 mEq/L, the nurse identifies that compensatory mechanism to provide water intake. Aldosterone production would be the client will be at increased risk to develop decreased in the presence of hypernatremia. Muscle mass can be reduced in the elderly, but dehydration because of which of the following factors? the decreased thirst poses a greater risk. ADH is still produced. ‐ A diminished thirst drive ‐ An increased level of aldosterone ‐ A decrease in muscle mass ‐ ADH, antidiuretic hormone, is no longer produced. | Critical items to note include an elderly client, hypernatremia, and risk for dehydration. Knowledge of compensatory mechanisms of fluid balance is required to answer this question. Eliminate options 2 and 4, since they are incorrect. Choose option 1 over 3, since this most affects fluid balance. |
2332 Which of the following interventions does the nurse Correct answer: 3 Clients with hypernatremia (normal sodium level is 135–145 mEq/L) should be assessed for complete when caring for a client admitted with a potential development of neurological complications, such as seizures. Malaise and nausea are sodium level of 152 mEq/L? symptoms of hyponatremia. Blankets are not needed, since temperature is often elevated with hypernatremia. Clients with hypernatremia have an increased need for fluids, not a decreased need. ‐ Provide extra blankets for warmth. ‐ Observe the client for nausea and malaise. ‐ Observe and prepare for possible seizures. ‐ Restrict fluids to 1,200 mL per day. | The core concept of the question is knowledge of interventions that are necessary when a client has hypernatremia. Recall that high sodium levels cause temperature elevations to eliminate option 1, and eliminate option 4, since fluids need to be encouraged. Remember that seizures are a risk with high sodium levels to choose correctly between options 2 and 3. |
2333 The nurse is teaching a client on a low‐sodium diet Correct answer: 1, 2, 3 Processed foods, seasonings, some baking products, and many over‐the‐counter cough, cold, how to read food labels and check for hidden sodium and flu remedies contain sodium. Clients need to be taught to look for products that list content. The nurse informs the client that sodium is sodium as an ingredient. contained in higher amounts in which of the following products? Select all that apply. ‐ Baking goods containing baking powder ‐ Seasonings using monosodium glutamate (MSG) ‐ Over‐the‐counter cold and cough preparations ‐ Canned fruits ‐ Salad oil | Recall knowledge of foods or products containing sodium. Eliminate option 4 because it would be high in sugar, and option 5 because it is oil, which typically does not have sodium added. |
2334 The nurse is caring for a client who is experiencing a Correct answer: 1 As sodium levels decrease, fluid shifts in the brain can lead to cerebral edema and seizures. steady decline in sodium level. The nurse places the Clients should be assessed for headaches, lethargy, decreased responsiveness, and seizures. highest priority on: Hyponatremia will also cause weakness and fatigue, and the client needs to conserve energy, but neurological status is of the highest priority. Oral and skin care would also not be of highest priority. ‐ Close monitoring of neurological status. ‐ Preventing weakness and fatigue. ‐ Spacing activities to conserve energy. ‐ Providing oral hygiene and skin care. | Critical words are highest priority, indicating that all options will be appropriate, but one is most important. Note the similarity between options 2 and 3 to eliminate them. Choose option 1, since neurological status is of higher priority than skin care. |
2335 When caring for a client with syndrome of Correct answer: 4 SIADH is caused by excessive production of ADH or an ADH‐like substance, resulting in inappropriate antidiuretic hormone (SIADH), the nurse decreased serum sodium and hypervolemia. Loop diuretics are given to promote diuresis. Oral plans to do which of the following to correct the fluid‐ fluids are restricted due to the hypervolemia. Dietary sodium is encouraged. Hypertonic or and‐electrolyte imbalance associated with this isotonic intravenous solutions are administered to provide needed sodium. disorder? ‐ Encourage the client to drink plenty of water. ‐ Restrict dietary salt intake. ‐ Monitor infusion of hypotonic saline infusions. ‐ Administrate ordered loop diuretics. | The concept is testing application of SIADH knowledge. Recall that the client experiences fluid retention and sodium losses to eliminate options 1, 2, and 3. |
2336 Lab chemistry results reveal that a client s serum Correct answer: 270; An estimate of serum osmolality is obtained by multiplying the sodium level by 2. The normal sodium is within normal range. Based on this finding, 290 range of sodium is 135–145. the nurse estimates the client s serum (plasma) osmolality to be between and mOsm/kg. | Recall normal serum sodium level, and multiply by 2. |
2337 A client with abnormal sodium loss is receiving a Correct answer: 1 Processed foods such as cheese are high in sodium content. Ham is high in sodium because it regular diet. To encourage foods high in sodium, the is cured as a preservative process. The addition of these types of foods will supply extra nurse would recommend which of the following foods sodium in the diet. The other options are lower in sodium content. for lunch? | The question requires recall of the sodium content of foods. Note that a food high in sodium is the correct answer. Choose option 1, since processed and preserved foods contain a lot of sodium. |
‐ An American cheese and ham sandwich ‐ Chicken salad on lettuce ‐ Tossed salad with vinegar dressing ‐ White fish and plain baked potato | |
2338 Which of the following interventions should the nurse Correct answer: 2 Hyponatremia is caused by an excess of water, which dilutes the amount of sodium present in anticipate implementing in a client who is experiencing the plasma. Clients who are experiencing dilutional hyponatremia are in fluid volume excess dilutional hyponatremia? (FVE). It is important to restrict additional fluids, as this can further increase the sodium deficit. In addition, the client already is in an FVE state, which can lead to development of further disturbances of fluid balance. Options 1and 4 are incorrect, as hypotonic fluids would further complicate the hyponatremia. Sodium usually does not need to be replaced in dilutional states. ‐ Administration of hypotonic intravenous solutions ‐ Restriction of additional oral fluids ‐ Increasing sodium intake in the diet ‐ Encouraging intake of tap water | The critical word is dilutional. Eliminate options 1 and 4, since additional water is not needed. Eliminate option 3, since additional sodium is not needed. |
2339 A client is given furosemide (Lasix) 80 mg IV push for Correct answer: 4 Furosemide (Lasix) is a loop diuretic that promotes potassium excretion. A weak pulse is seen treatment of heart failure. The nurse would be in clients with hypokalemia, and could be attributed to the effects of Lasix administration. It concerned if the client manifested which of the also could be due to excessive diuresis of sodium and water. Decreased neck vein distention following signs? and decreased adventitious breath sounds are suggestive of fluid volume reduction, and would be beneficial for a client with heart failure. A BP of 120/78 is within the normal range. ‐ Decreased neck vein distention ‐ Decreased adventitious breath sounds ‐ BP 120/78 ‐ Weak pulse | Recall that Lasix is a potassium‐wasting diuretic, and that a weak pulse is a sign of hypovolemia and hypokalemia, to choose option 4. |
2340 A client has been taking a corticosteroid for six Correct answer: 4 Hypokalemia can result from corticosteroid use. Hypokalemia causes cardiac problems that months. Which of the following electrocardiogram are manifested on an ECG as flattened T waves, depressed ST segments, and prominent U (ECG) findings would indicate to the nurse that the waves. Peaked T waves and prolonged, depressed ST segments are seen in clients with client is experiencing a serious side effect of this hyperkalemia. medication? ‐ Tall, peaked T waves and depressed ST segments ‐ Flattened T waves and flattened U waves ‐ Prolonged ST segment and U waves ‐ Flattened T waves and depressed ST segments | First, recall that corticosteroids contribute to sodium retention and potassium loss. Then, analyze each option for the EKG change associated with hypokalemia, and choose option 4. |
2341 A client is being treated for diabetic ketoacidosis Correct answer: 4 DKA leads to an increase in the loss of potassium due to diuresis, and insulin leads to (DKA) with large doses of regular insulin. The nurse potassium being shifted into intracellular fluid. Administration of insulin to a client with DKA should observe for which of the following electrolyte causes transcellular shifting that promotes potassium uptake back into the cell. This action can imbalances? result in hypokalemia. Low calcium is seen with alkalosis, not acidosis. Hyponatremia is usually seen in clients with DKA. ‐ Hyperkalemia ‐ Hypocalcemia ‐ Hypernatremia ‐ Hypokalemia | Recall the physiology of DKA, recognizing that potassium is lost in the urine. Also recall that potassium is needed to transport insulin into the cell, resulting in hypokalemia. |
2342 For which of the following complications related to Correct answer: 2 A client who is on long‐term diuretic therapy is more likely to suffer effects of potassium electrolyte imbalance should the nurse assess in a depletion. Tetany is associated with low levels of calcium (hypocalcemia), which can client who has been taking furosemide (Lasix) for two accompany hypokalemia. Nausea and vomiting are nonspecific complaints not directly years? associated with loop diuretic therapy. Diabetes is not related to Lasix administration, although the use of this loop diuretic can cause the client to become hyperglycemic. Respiratory depression is not associated with use of this medication. ‐ Tetany ‐ Respiratory depression ‐ Nausea and vomiting ‐ Diabetes | The core concept is the long‐term use of a potassium‐wasting diuretic. Recognize that long‐ term depletion of potassium can also result in loss of calcium to be directed to option 1. |
2343 A client with hypokalemia reports being constipated. Correct answer: 2 Hypokalemia causes decreased gastrointestinal motility that can lead to constipation. The nurse provides which of the following explanations Hypokalemia does not promote fluid loss in the gastrointestinal (GI) tract. The effect of to the client about this problem before implementing potassium in the GI tract is on the smooth muscle, with imbalances causing hyper‐ or treatment measures? hypomotility. ‐ "The level of potassium makes the stools very hard and difficult to expel." ‐ "Your potassium level makes your bowel less active, and might make you constipated." ‐ "The potassium pulls the fluid from the bowel, leading to constipation." ‐ "The low potassium level causes the bowel to stop acting, resulting in constipation." | Critical words are hypokalemia and constipated. Recall the effect of this imbalance on GI motility to be directed to option 2. |
2344 A client's potassium level is 3.0 mEq/L. The nurse Correct answer: 3 Large doses of penicillin, aminoglycosides, and glucocorticoids can lead to hypokalemia. ASA, suspects that which of the following medications might Tylenol, and antibiotics are not associated with hypokalemia. It is important for the nurse to be be contributing to this serum potassium level? aware of potential drug effects on serum electrolyte levels in order to effectively participate in the client's plan of care. ‐ Acetylsalicylic acid (aspirin, ASA) ‐ Acetaminophen (Tylenol) ‐ Gentamicin (Garamycin) ‐ Azithromycin (Zithromax) | Note that options 1 and 2 are both analgesics, and that options 3 and 4 are anti‐infectives. Recall that drugs in the latter category are often associated with electrolyte imbalances to narrow your options. Recognize that gentamicin is an aminoglycoside, a category associated with potassium loss. |
2345 A client in the coronary care unit (CCU) is receiving Correct answer: 4 A client receiving continuous IV therapy containing KCl could become hyperkalemic and 1,000 mL normal saline with 40 mEq potassium require immediate action. All of the incorrect choices reflect a hypokalemic state. While it is chloride (KCl) every eight hours for treatment of important to monitor response to treatment and to notify the physician, the priority hypokalemia. Which of the following assessment data information would be that the client has dyspnea and specific ECG changes that are suggestive would the nurse report to the physician? of hyperkalemia. ‐ Complaints of muscle weakness, and an ECG showing ST segment depression ‐ Nausea and vomiting, with U waves evident on the monitor ‐ Muscle twitching, and ECG showing a flattened T wave ‐ Dyspnea and tall, peaked T waves on the monitor | The core concept is to recognize that hypokalemia is being treated with replacement of intravenous KCl. Recognize that this electrolyte imbalance can be overcorrected with IV infusion of KCl. Recognize the EKG changes seen with hyperkalemia to choose option 4. |
2346 Which of the following should be included in the Correct answer: 3 KCl is never administered as an IM injection or as an IV push medication; that could cause nurse's plan when preparing to give a client potassium development of potentially lethal cardiac arrhythmias. KCl should be diluted in the correct chloride (KCl)? amount of IV solution, and administered via an infusion pump. Monitoring output is an expectation of any IV therapy. ‐ Use an appropriate‐size needle for IM injection. ‐ Administer the KCL undiluted through a continuous running IV. ‐ Use an infusion pump when administering KCl. ‐ Administer only into the dorsogluteal muscle. | Recall the importance of diluting IV KCl, and eliminate option 2. Recall that potassium is never given IM to eliminate options 1 and 4. |
2347 Which of the following interventions would be Correct answer: 1 The client with hypokalemia could develop muscle weakness and therefore require assistance appropriate for the client with hypokalemia who has a with ambulation. Monitoring the ECG for changes does not directly relate to injury potential nursing diagnosis of Risk for Injury related to skeletal related to general weakness. Medication and dietary interventions might be necessary to muscle weakness? restore normal serum levels, but do not directly relate to injury potential. ‐ Assist the client with ambulation. ‐ Monitor the client's ECG for conduction changes. ‐ Administer KCl 20 mEq by mouth daily as ordered. ‐ Encourage a diet intake high in fiber and fruit. | The question asks you to choose the interventions associated with a risk for injury related to muscle weakness. Associate safety with assistance, and choose option 1. |
2348 In explaining to a client the importance of potassium Correct answer: 2 Potassium (K<sup> </sup>) in the extracellular fluid (ECF) is responsible for to the body’s functioning, which statement should the conducting nerve impulses, which contribute to cardiac rate and rhythm. The amount of nurse make? potassium in the ECF is actually a very small amount, explaining why even minor changes can have a major impact on the body. While K<sup> </sup> is an important electrolyte in the body, it does not increase the metabolic rate of tissues in the body. K<sup> </sup> levels are not the regulators of salt and fluid retention. The body relies on a balanced level of electrolytes in the body, and K<sup> </sup> is just one element in the body's ability to maintain homeostasis. ‐ "Potassium is important because it makes the muscle tissue work faster so the heart can pump effectively." ‐ "Potassium is vital to support the muscles by making them contract more effectively, including the muscles of the heart." ‐ "It is vital that the body have enough potassium so that the kidneys can function effectively to prevent salt and fluid retention." ‐ "Muscles are dependent on large amounts of potassium in order to work effectively." | Read each option carefully, noting that not all options provide a thorough explanation. Recall that generally, potassium has neuromuscular, cardiac, and cellular functions. Recognize that option 2 discusses muscle and heart function. |
2349 Which of the following serum potassium levels would Correct answer: 1 A client who has diarrhea or nasogastric suctioning will be more likely to develop the nurse expect to see in a client in the Emergency hypokalemia. A serum potassium of 3.0 mEq/L is considered to be hypokalemic. A level of 3.6 Department with a three‐day history of diarrhea? mEq/L is just within the normal range, but one would expect a greater K<sup> </sup> loss, given the client s history of three days of diarrhea. A level of 4.1 mEq/L is within the normal range, and does not reflect K<sup> </sup> loss. A level of 5.8 mEq/L is suggestive of hyperkalemia. ‐ 3.0 mEq/L ‐ 3.6 mEq/L ‐ 4.1 mEq/L ‐ 5.8 mEq/L | Critical words are three‐day history of diarrhea. Review normal potassium levels, and recall that potassium is lost with diarrhea, to choose the lowest level. |
2350 The nurse is instructing a client diagnosed with Correct answer: 3 Salt substitutes have potassium chloride as their main compound, and individuals with high hyperkalemia about foods to avoid. Which of the potassium levels should not use salt substitutes. Bananas, tomatoes, and avocados are all following statements by the client indicates to the foods that are high in potassium, and should be limited in a client with hyperkalemia. Clients nurse a need for further instruction? should be aware of foods to avoid that are high in potassium if teaching has been successful. ‐ “I should avoid eating a lot of bananas.” ‐ “I guess I can’t eat all the tomatoes I want this summer.” ‐ “I can still use my salt substitute instead of real salt.” ‐ “No more avocado salads for me.” | Review foods high in potassium. Note that the question refers to the need for further instruction, and look for the one incorrect response. Recall content of salt substitutes to choose option 3. |
2351 A client is admitted to the hospital with a serum Correct answer: 4 A serum level of 2.8 mEq/L reflects hypokalemia, which often manifests as cardiac and potassium level of 2.8mEq/L. The nurse anticipates respiratory problems related to the ineffective smooth muscle contractions. Option 2 reflects assessment findings will include which of the normal findings. The symptoms listed in options 1 and 3 do not indicate severe hypokalemia. A following? serum potassium of 2.8 mEq/L in conjunction with irregular pulse and shallow respirations is a symptomatic presentation in this client, and suggests severe hypokalemia. It is important to look at the whole clinical picture and not just the serum level to determine the severity of an electrolyte imbalance. ‐ Elastic skin turgor, and vomiting a small amount of bile‐stained emesis | Recognize that the value is indicative of severe hypokalemia. Eliminate option 2, since findings are normal, and options 1 and 3, since they are not as severe as those in option 4. |
‐ Pink nail beds, and ECG showing a normal sinus rhythm with a rate of 76 ‐ Respiratory rate 16 with equal bilateral breath sounds, and two loose stools this morning ‐ Irregular pulse rate, and shallow respirations | |
2352 The nurse instructs a client receiving Correct answer: 1 HCTZ is a potassium‐wasting diuretic, and its use can lead to hypokalemia. Leg cramps and hydrochlorothiazide (HCTZ) to report which of the muscle weakness are two of the symptoms seen in a client with hypokalemia. Diarrhea, following symptoms to the health care provider? fatigue, nausea, and irritability are not usually seen with the use of this class of diuretics. ‐ Leg cramps and muscle weakness ‐ Muscle weakness and diarrhea ‐ Fatigue and irritability ‐ Nausea and irritability | Recall that this diuretic is potassium‐wasting to direct you to option 4. |
2353 Which of the following foods should the nurse Correct answer: 2 Spironolactone is a potassium‐sparing diuretic, and clients need to be aware of their intake of instruct the client who is taking spironolactone foods high in potassium. Cantaloupes are very high in potassium, and should be avoided. (Aldactone) to avoid? Bread, green beans, and squash are not considered to be good sources of potassium. These foods do not need to be restricted in the diet. ‐ Bread ‐ Cantaloupe ‐ Green beans ‐ Squash | This a reverse‐response question, where three options are permissible. Recall that aldactone is potassium‐sparing to choose the food item highest in potassium. |
2354 A postoperative client with a serum potassium level Correct answer: 10 The maximum routine rate of infusion for KCl is 5–10 mEq/hour. Clients who are moderately of 3.6 mEq/L is ordered to receive an IV with a hypokalemic may have potassium administered at a rate of 10–20 mEq/hour, but this client is potassium supplement (KCl) via a peripheral line. The not moderately hypokalemic. Concentrations of potassium in solution can range from 10 to 40 nurse checks to determine that the amount of KCl mEq/L, and are administered via a peripheral vein with an infusion pump. Higher ordered does not exceed the standard hourly concentrations of potassium can be administered via a central line in critically ill clients who replacement rate of mEq. are hemodynamically monitored. | The critical words are exceed and hourly replacement rate. Note that the question indicates a peripheral line to help you identify an amount that is not high. |
2355 The nurse concludes that a client has an Correct answer: 3 Lasix is a potassium‐wasting diuretic that can cause the client to become hypokalemic. This understanding of the side effects of furosemide (Lasix) can manifest as a weak, thready pulse and onset of orthostatic hypotension. Diarrhea is not and its relationship to potassium levels when the client usually seen as a side effect of this medication. Monitoring of one s pulse is not required for states: clients taking diuretic therapy, but is necessary for clients taking digoxin, or clients who have a pacemaker. Bananas are a good source of dietary potassium, and might be warranted for this client to maintain normal serum potassium levels. ‐ “I don’t need to take my pulse anymore when I take my Digoxin.” ‐ “I should call the doctor if I develop diarrhea.” ‐ “I should call my doctor if I feel myself becoming dizzy when I stand up.” ‐ “I don t need to eat bananas for breakfast any more, since I am taking this medication.” | The core concept of the question is the relationship of low potassium to the diuretic. Eliminate options 1 and 4, as these are still important actions to take. Eliminate option 1, since this is not a usual effect of Lasix. |
2356 The nurse provides which of the following Correct answer: 3 Aldactone is a potassium‐sparing diuretic, and the intake of potassium‐rich foods should be instructions to a client going home with a prescription discouraged. It is important that the client be aware of potassium‐retaining diuretics, since for spironolactone (Aldactone)? most clients associate diuretics with potassium loss. Diuretics should be taken with food to decrease GI upset. Diuretics should not be taken before going to bed, because their primary effect is diuresis. This time frame could cause the client to experience altered sleep patterns due to nocturia. Clients taking diuretics should be aware of their fluid intake, and monitor accordingly. ‐ “Be sure to take this medication on an empty stomach.” ‐ “Take this pill just before you go to bed.” ‐ “Cut back on your intake of those foods on your list that are high in potassium.” | Recall knowledge of diuretics to eliminate options 1, 2, and 4. |
4.‐ “You don’t have to watch your intake of fluid while you are taking this medicine.” | |
2357 The nurse identifies which of the following clients Correct answer: 2, 5 A client with metabolic alkalosis is at risk for developing hypokalemia due to the shift of admitted to the hospital as being at risk for developing potassium to the ICF from the ECF. Clients with NG tubes lose potassium from the stomach, hypokalemia? Select all that apply. and the NPO status limits their intake. Clients with acute renal failure are usually hyperkalemic due to a decreased ability to excrete potassium. Clients with ARDS are usually hyperkalemic due to compromised ventilation, resulting in metabolic acidosis. Metabolic acidosis is associated with hyperkalemia because potassium shifts from the ECF to the ICF as a result of increase in hydrogen ion concentration. ‐ A client whose blood gases indicate metabolic acidosis ‐ A client who had developed metabolic alkalosis ‐ A client with acute renal failure ‐ A client with adult respiratory distress syndrome (ARDS) ‐ The client with a nasogastric tube on low intermittent suction | Recall knowledge of conditions in which potassium is lost, or shifts into the cell, to choose options 2 and 5. |
2358 The nurse plans to administer which of the following Correct answer: 3 Sodium bicarbonate will temporarily alkalinize the plasma, causing the potassium to move intravenous (IV) treatments to a client for treatment of into the cells. NS is an isotonic solution, and therefore will not cause fluid or electrolyte hyperkalemia associated with severe acidosis? shifting. Calcium gluconate is given to blunt the effects on the myocardium; it does not decrease the serum K<sup> </sup> level. Insulin and dextrose are given to decrease K<sup> </sup> levels by increasing K<sup> </sup> uptake at the cellular level. ‐ Calcium gluconate, to make the potassium shift from the intracellular fluid (ICF) to the extracellular fluid (ECF) ‐ Insulin and dextrose, to make the client hypoglycemic ‐ Sodium bicarbonate, to make the client alkalotic so the potassium will shift into the ECF ‐ Normal saline (NS), to provide extra sodium so the potassium will move out of the ICF into the ECF | A critical word is acidosis. Recall that potassium is increased in acidosis to direct you to option 3, in which alkalosis is the goal of treatment. |
2359 Which of the following potassium levels would be of Correct answer: 4 Clients who take furosemide (Lasix) lose potassium, and are in danger of developing greatest concern to the nurse when seen in a client hypokalemia. The other choices reflect either a normal potassium level (options 2 or 3) or who is taking furosemide (Lasix)? elevated levels (option 1), which would not be consistent with the action of this loop diuretic. ‐ 5.4 mEq/L ‐ 4.3mEq/L ‐ 3.4 mEq/L ‐ 3.1 mEq/L | The critical word is greatest. Recall normal potassium levels and eliminate options 1 and 2, since one is elevated and one is normal. Choose option 4 over 3, since it is more abnormal. |
2360 Which of the following statements should the nurse Correct answer: 3 To prevent gastric irritation, oral potassium supplements should be taken with at least 4 include when teaching a client about oral potassium ounces of fluid, or with food. Oral potassium medication should not be crushed. The use of a supplementation? salt substitute is not recommended when taking potassium as a medication, because it might also contain potassium, leading to hyperkalemia. It is important for the client to have an understanding of potassium medications, potential side effects, and food–drug interactions. ‐ “When you take your potassium pill, if you can’t swallow it, you can crush it up and put it in orange juice.” ‐ “Potassium should only be taken in the morning on an empty stomach.” ‐ “Take your potassium tablet after you have eaten breakfast.” ‐ “You can continue to use salt substitute while you are taking your potassium supplement.” | Recall that potassium should not be crushed and is irritating to the stomach to eliminate options 1 and 3. Recall that salt substitutes contain potassium to eliminate option 4. Note that options 2 and 3 are opposites, indicating one could be true. |
2361 The nurse anticipates that which of the following Correct answer: 1 Clients in chronic renal failure have diminished or no excretion of potassium from the clients would be at greatest risk to develop kidneys, causing hyperkalemia. Clients with intestinal or nasogastric suction, diarrhea, and/or hyperkalemia? cirrhosis are more likely to be hypokalemic, due to potassium losses. ‐ The client with chronic renal failure | The critical word is hyperkalemia. Review ways in which potassium is lost from the body to eliminate options 3 and 4 and choose option 1. |
‐ The client just diagnosed with cirrhosis ‐ The client with intestinal and nasogastric suctioning ‐ The client who has had diarrhea for the last four days | |
2362 The nurse should place highest priority on which of Correct answer: 1 Clients with renal failure have impaired excretion of potassium, resulting in hyperkalemia. the following nursing interventions for a client with Hyperkalemia leads to cardiac conduction problems and possible fatal dysrhythmias. ECG renal failure who has a potassium level of 6.8 mEq/L? monitoring is indicated for this type of client. LOC, urinary output, and ABGs are important monitoring aspects for a client in renal failure, but hyperkalemia is potentially life‐threatening, and should be addressed first as the primary intervention. ‐ Obtain an electrocardiogram (ECG). ‐ Evaluate level of consciousness. ‐ Measure urinary output. ‐ Draw arterial blood gases. | The critical words are highest priority. Eliminate option 3, since the client is in renal failure. Remember ABCs airway, breathing, and circulation to choose option 1. |
2363 The nurse should include diet teaching regarding Correct answer: 1, 5 HCTZ and Lasix are diuretics that increase the excretion of potassium, so clients should be adding potassium‐rich foods if which of the following taught to increase the intake of potassium in their diet. All of the other medications are diuretics are ordered? Select all that apply. considered K‐sparing or combination diuretics, and, as such, dietary supplementation would not be indicated. ‐ Hydrochlorothiazide (HCTZ) ‐ Spironolactone (Aldactone) ‐ Maxizide (Triamterene with hydrochlorothiazide) ‐ Midamor (Amiloride) ‐ Furosemide (Lasix) | The question is testing knowledge of potassium‐wasting diuretics. Recall that thiazides decrease potassium to choose option 1. |
2364 The nurse anticipates using which of the following as Correct answer: 2 Kayexalate (cation exchange resin) is usually administered rectally, and binds potassium in the most effective route to administer sodium exchange for sodium in the gastrointestinal tract. It is then excreted through the stool. polystyrene sulfonate (Kayexalate) ordered for a client Although Kayexalate can be administered orally, it requires administration with an osmotic who has a serum potassium level of 6.0 mEq/L? agent to prevent constipation, and might not be tolerated as well. This drug is not given by the IV or subcutaneous routes. ‐ Intravenous ‐ Rectal ‐ Oral ‐ Subcutaneous | The critical words are most effective, indicating one answer is most correct or the best choice. Eliminate options 1 and 4, since the drug is not given by these routes. Recall that the drug works in the bowel to choose option 2. |
2365 When caring for a client who has a potassium level of Correct answer: 2 Hypokalemia can lead to alterations in smooth muscle functioning. Smooth muscle 2.8 mEq/L, the nurse should assess for which of the alterations in the gastrointestinal tract can lead to development of a paralytic ileus. following? Complications of hypokalemia are usually not associated with renal failure, diabetes, or a perforated bowel, as these conditions are more likely to lead to increased potassium levels. ‐ Perforated bowel ‐ Paralytic ileus ‐ Renal failure ‐ Diabetes mellitus | Recall the action of potassium on body systems and its action on the neuromuscular system to choose option 2. |
2366 The nurse determines that the intravenous (IV) Correct answer: 3 Calcium gluconate is given to antagonize the effects of the potassium on the conduction administration of calcium gluconate to a client with system of the heart. It is not given to promote potassium excretion (either in urine or stool). hyperkalemia has been effective when which of the The medication acts to blunt the effects of elevated potassium on the myocardium. following is seen on assessment? ‐ Urine output increases. ‐ Bowel movements are loose. ‐ Cardiac dysrhythmia is corrected. | The question requires recall of the use of calcium in treating hyperkalemia. Eliminate options 1, 2, and 4, since calcium is not given to eliminate potassium from the body. |
4.‐ Bowel sounds become less hyperactive. | |
2367 Which of the following statements by a client Correct answer: 2 Bran flakes are not a source of potassium in the diet. It is important for the client to indicates a need for further instruction regarding communicate to the physician if symptoms develop during the course of therapy. Bananas and treatment for hypokalemia? cantaloupe are excellent sources of dietary potassium. Taking potassium supplements on a full stomach will help to minimize gastric irritation, which is commonly associated with this medication. ‐ “I will eat more bananas and cantaloupes for breakfast.” ‐ “I will eat more bran flakes to increase my potassium level.” ‐ “I will take my potassium in the morning after breakfast so it doesn’t upset my stomach.” ‐ “I will tell my doctor if I start having any of the symptoms on the list you gave me.” | The question requires reverse thinking; three options are accurate statements and one is wrong. Note similarities in options 1 and 2, and note that bran is not a good source of potassium to choose that as the incorrect response. |
2368 Which of the following is the best response by the Correct answer: 3 Potassium works to maintain cardiac contractility and normal heart rate. Hypokalemia leads nurse to the 22‐year‐old daughter of a 46‐year‐old to the development of potential arrhythmias that can result in ischemia and death. While the client who was admitted with hypokalemia and is length of bedrest and actual potassium level could be associated with a complaint of dizziness, complaining of being dizzy upon standing? it is more likely that the dizziness is associated with orthostatic hypotension and inefficient heart‐pumping action due to hypokalemia. It is important for the client (and family) to understand that electrolyte imbalances can have significant complications that can affect the entire body. ‐ “Your mother has just stayed in bed too long, and when she stands up, she will get dizzy.” ‐ “The level of your mother’s potassium is making her dizzy.” ‐ “Your mother is probably dizzy because her heart is not pumping as effectively, making her blood pressure low.” ‐ “Your mother is dizzy because her nervous system isn t functioning correctly; once her potassium level goes up, she will improve.” | The question asks for best answer, indicating that all options might be completely or partially correct, but one is better. Eliminate option 1, since it does not relate to potassium. Eliminate option 3, since the client is 46 years old. Choose option 4 over 2, since it provides a more thorough explanation. |
2369 When assessing a client with hypocalcemia, the nurse Correct answer: 1 Due to a lack of adequate calcium for neuromuscular transmission, hypocalcemia produces should ask which of the following questions? neuromuscular irritability, which is first manifested by paresthesias, or a sensation of numbness and tingling circumorally (around the lips) and in the fingertips and toes. The other questions pertain to symptoms of hypercalcemia. ‐ “Do you have any tingling sensation in your fingers or toes?” ‐ “Have you been constipated lately?” ‐ “Do you have to urinate frequently?” ‐ “Are you having a lot of headaches?” | The critical word is hypocalcemia. Recall that there is insufficient calcium in this disorder, which allows for excessive nerve transmission, resulting in irritability. |
2370 After receiving an intershift report for the day shift at Correct answer: 4 Fosamax must be administered on an empty stomach with a full glass of water to ensure 07:00, the nurse is checking medications due to be proper absorption. The presence of food, juices, or other medications will interfere with administered during the shift. The nurse notes that adequate absorption. All of the other options would be inappropriate. alendronate (Fosamax) 70mg weekly is scheduled to be administered at 09:00 with the other daily medications. The nurse should take which of the following actions? ‐ Administer the Fosamax as ordered at 09:00, but be sure the client drinks at least 16 ounces of water. ‐ Adjust administration time of Fosamax to be given with breakfast. ‐ Withhold the dose of Fosamax, and reschedule it to be given at bedtime. ‐ Administer the Fosamax at 07:30, separating it by at least one hour from breakfast or the other medications. | Knowledge of bisphosphonate is required to answer this question. Recall that this class of medications must be administered before the client eats or drinks anything else to be directed to option 4. |
2371 A client presents with an elevated parathyroid Correct answer: 2 Primary hyperparathyroidism is the most common cause of hypercalcemia in the general hormone (PTH) level. The nurse suspects that the population. There is excessive secretion of PTH by one or more of the parathyroid glands. etiology of this PTH elevation is: Excess thyroid‐stimulating hormone (TSH), not PTH, is associated with a hypoactive thyroid gland. Metastasis rarely produces excessive PTH. Sarcoidosis is associated with unregulated conversion of activated vitamin D. ‐ A hypoactive thyroid gland. ‐ Primary hyperparathyroidism, most likely from an adenoma. | Critical words are PTH and etiology. Recall that PTH is secreted by the parathyroid glands and associate the word elevated with hyper‐ in option 2 to choose correctly. |
‐ Pulmonary cancer with metastasis. ‐ Sarcoidosis. | |
2372 A client who is hemorrhaging is receiving massive Correct answer: 3 Citrate binds with calcium, decreasing ionized calcium levels. Acidosis leads to decreased blood transfusions. The nurse notes a low serum binding of calcium, thereby increasing the calcium level. Options 1 and 4 are incorrect because ionized calcium level, and concludes that a probable blood transfusion therapy would not warrant the clinical usage of rapid infusion of crystalloids, cause for this calcium imbalance is: and hypomagnesemia is not a related consequence of blood therapy. ‐ Rapid infusion of crystalloids. ‐ Development of metabolic acidosis. ‐ The citrate used as an anticoagulant in preserved blood. ‐ That hypomagnesemia has occurred. | Critical words are massive blood transfusions and low serum calcium. Recognize that massive transfusions will most likely necessitate use of stored blood, which contains citrate, and choose option 3. |
2373 When a client with pancreatitis reports numbness Correct answer: 4 Pancreatitis causes hypocalcemia because byproducts released from the inflamed pancreas around the mouth and tingling in the hands and feet, chelate calcium. Numbness and tingling around the mouth and extremities are characteristics the nurse should make it a priority to assess the client of tetany from hypocalcemia. All of the other options do not relate to this finding. for which of the following? ‐ Hypercalcemia ‐ Hypokalemia ‐ Hypophosphatemia ‐ Hypocalcemia | Recognize that the symptoms in the question are not typical signs and symptoms of pancreatitis. Recall the physiology of this disease, and recognize that the symptoms reflect low serum calcium. |
2374 A client has a serum calcium level of 11.5 mg/dL, an Correct answer: 1 Due to the inverse relationship of calcium with phosphorus, one would expect low ionized calcium of 5.6 mg/dL, and a 24‐hour urine phosphorus when the calcium is elevated. In most cases, when there are elevated total serum calcium level greater than 400 mg/dL. The nurse calcium and ionized calcium levels, then hyperparathyroidism needs to be considered. In this expects that additional review of laboratory test case, the alkaline phosphatase and PTH would also be elevated. Potassium is often low in cases results will show which of the following associated of hypocalcemia. electrolyte levels? ‐ Phosphorus lower than 2.5 mg/dL ‐ Alkaline phosphatase of 40 units/L ‐ Parathyroid hormone (PTH) level of lower than 11 picograms/dL ‐ Potassium level of 3.2 mg/dL | Recognize that calcium levels are elevated, and recall that the relationship to phosphorus is inverse to calcium. Then determine which options identify abnormal levels to be directed to the low phosphorus. |
2375 Which of the following findings relative to calcium Correct answer: 2 A client in renal failure exhibits hypocalcemia in the presence of increased phosphate, would the nurse expect to see in a client in renal potassium, and creatinine levels. Option 1 is incorrect because due to the inverse relationship failure? between calcium and phosphorus, one would expect to see decreased calcium levels and increased phosphate levels in renal failure. Option 3 is incorrect, as potassium levels would be increased in renal failure. Option 4 is incorrect, as creatinine levels would be increased as renal function deteriorates. ‐ Increased calcium levels and decreased phosphate levels ‐ Increased calcium excretion and phosphate retention ‐ Decreased calcium and potassium ‐ Increased calcium and decreased creatinine levels | The critical term is renal failure. Recall that the kidneys are unable to excrete most of the electrolytes in this condition. Recall that vitamin D synthesis is altered, leading to low calcium. |
2376 The client has a dietary deficiency of calcium. The Correct answer: 3 In chronic hypocalcemia from dietary deficiencies, oral calcium and vitamin D supplements nurse prepares to administer a dose of which of the might be all that is needed. Calcitriol has a more rapid onset and more rapid clearance from following types of medications as ordered? the body, and is especially useful in renal failure. Option 1 is incorrect, as glucocorticoids increase absorption of calcium in the intestines as well as increase calcium excretion, worsening the hypocalcemia. Option 2 is incorrect because aluminum preparations should not be used, due to aluminum accumulation in the bone, resulting in osteomalacia. Option 4 is incorrect, since bisphosphonate therapy is used to treat hypercalcemia and osteoporosis. ‐ A glucocorticoid ‐ An aluminum‐containing antacid ‐ A calcitriol supplement ‐ A bisphosphonate | The critical term is dietary deficiency. Recall that vitamin D is needed for adequate absorption of calcium to be directed to option 3. |
2377 A client is recovering from a parathyroidectomy to Correct answer: 4 A common cause of hypocalcemia after parathyroidectomy is lack of blood supply to the treat primary hyperparathyroidism. To ensure that remaining parathyroid gland, with a resultant decreased PTH level. To prevent complications nursing diagnosis goals have been met, the nurse and to indicate that goals for this client have been met, the calcium and PTH levels must be monitors the level of serum ionized calcium and what closely monitored. The serum creatinine and magnesium are important laboratory levels to other serum laboratory test? monitor, but are not the priority. Option 3 is incorrect, as calcitriol is the activated form of vitamin D. ‐ Serum creatinine ‐ Serum magnesium ‐ Calcitriol ‐ The parathyroid hormone (PTH) level | Recall that the parathyroid glands secrete PTH, which regulates serum calcium and phosphorus levels, to be directed to option 4. |
2378 A client is admitted with an ionized calcium level of Correct answer: 1 Hypocalcemia becomes symptomatic when ionized calcium levels fall below normal, which 3.5 mg/dL. In anticipation of complications, the nurse this laboratory value indicates. The astute nurse is aware that seizures are signs of should do which of the following? hypocalcemia, and anticipates complications. All of the other options are pertinent to hypercalcemia. ‐ Institute seizure precautions. ‐ Prepare the client for dialysis. ‐ Initiate an intravenous infusion of normal saline. ‐ Perform an electrocardiogram to assess for shortening QT interval. | First, recognize that the level is indicative of hypocalcemia. Then, recall that this condition places the client at risk for seizures to be directed to option 1. |
2379 A client is admitted with chronic renal failure. The Correct answer: 4 Renal failure can result in hypocalcemia from diminished formation of calcitriol from renal nurse would use which of the following statements to cell damage, as well as from hyperphosphatemia. In renal disease, severe hypocalcemia can explain the need to monitor for hypocalcemia? occur from abnormal renal losses of calcium. Serum creatinine would be high due to nephron destruction in renal failure. Renal colic occurs from hypercalcemia. ‐ “Your kidneys do not eliminate as much calcium, so we need to check for signs of hypocalcemia.” ‐ “Your calcium level can decrease because it goes down when the creatinine in the bloodstream is high.” ‐ “Signs of hypocalcemia will appear before you experience pain from renal colic.” ‐ “Your kidneys are unable to produce calcitriol, which is needed to regulate calcium levels in the bloodstream.” | The critical term is chronic renal failure. Recall physiology of renal failure to direct you to option 4. |
2380 A client presents with a mildly elevated calcium level. Correct answer: 1 Thiazide diuretics can cause mild hypercalcemia because they have calcium‐retaining effects After completing a nursing history, the nurse identifies on the kidney. Increasing urinary output and eating a high‐protein diet would lead to which of the following as a contributing factor to the hypocalcemia. Bisphosphonates lower serum calcium levels by preventing bone resorption of abnormal calcium level? calcium. ‐ Use of a thiazide diuretic ‐ Recent reports of polyuria ‐ A high‐protein diet ‐ Ingesting a biphosphonate weekly | Systematically evaluate each option for factors that would promote intake or retention of calcium. Eliminate options 2 and 3, since they contribute to loss of calcium. Eliminate option 4, since this is given for treatment of hypercalcemia or osteoporosis. |
2381 A client with hypercalcemia is receiving digoxin Correct answer: 2 The client with hypercalcemia is more sensitive to the toxic effects of digoxin (Lanoxin). (Lanoxin). The nurse plans to incorporate which of the Frequent apical and radial pulse checks by the nurse will aid in detecting potential following in client assessments? complications. Options 1 and 4 are assessment priorities in hypocalcemia. Auscultation of bowel sounds is appropriate, but not of high priority with digitalis therapy. ‐ Checking for Trousseau’s sign ‐ Frequent pulse checks ‐ Auscultation of bowel sounds ‐ Inspection of skin for signs of bleeding | The core concept is that the client is on digoxin; recall the role of calcium in cardiac contractility and the action of digoxin to direct you to option 2. |
2382 A client returns to the unit following a thyroidectomy. Correct answer: 1 Hypocalcemia frequently results from accidental removal or destruction of parathyroid tissue The nurse plans to frequently assess for which of the or its blood supply during surgery. Clinical manifestations of tetany include laryngospasm following? postoperatively. The other options are assessment criteria representative of hypercalcemia. ‐ Signs of laryngospasm ‐ Polyuria ‐ Hypertension ‐ Hypoactive deep tendon reflexes | Recall that the parathyroid glands can be accidentally removed during surgery, resulting in hypocalcemia. Eliminate options 2, 3, and 4, since they are related to hypercalcemia. |
2383 When developing a plan of care for a client with Correct answer: 3 Tetany and seizures are clinical manifestations of hypocalcemia. The nurse must be aware of hypocalcemia, the nurse chooses which of the all potential risks to the client based on physiological factors of the presenting illness, and following as a high‐priority nursing diagnosis? must plan for the client s safety. The other nursing diagnoses are appropriate for hypercalcemia. ‐ Potential Complication: Electrolyte Excess ‐ Risk for Injury related to sensorium changes ‐ Risk for Injury related to tetany and seizures ‐ Deficient Fluid Volume | Critical words are hypocalcemia and high‐priority, so eliminate options 1 and 4, since they are associated with hypercalcemia. Choose option 3, since it is of highest priority. |
2384 The nurse notes that a client s serum calcium level is Correct answer: 4 Ionized calcium is approximately 40–50% of the total serum calcium. Ionized calcium is the 7.9 mg/dL. Since the client has no symptoms of portion of the serum calcium that is not bound to protein and is physiologically active and imbalance at this time, the nurse interprets that: clinically important. Hypocalcemia (normal is 9–11 mg/dL) that is due to reduced protein binding is asymptomatic. The question states that the total serum calcium is low; therefore, option 1 is incorrect. Ionized calcium levels can remain normal even when total calcium levels are low. Option 2 is incorrect, as hypocalcemia could be a result of hypomagnesemia, not hypermagnesemia. Option 3 is incorrect, as phosphorus and calcium are inversely proportional, so phosphorus would be high. ‐ This level reflects only the ionized calcium. ‐ The client’s magnesium is high, resulting in false levels of calcium. ‐ Phosphorus is low, resulting in low serum calcium levels. ‐ This does not reflect the ionized calcium that results in symptomatology. | The question requires correlation of a hypocalcemic lab value to its cause. Recall factors that influence serum calcium levels to direct you to option 4. |
2385 When caring for the client with signs of severe Correct answer: 2 Ten‐percent calcium gluconate is the treatment option for symptomatic severe hypocalcemia. hypocalcemia, the nurse anticipates administration of: All IV calcium preparations are administered slowly to prevent dysrhythmias and damage to veins. Normal saline and IV phosphorus are used to treat hypercalcemia. ‐ Isotonic normal saline as a rapid infusion. ‐ 10% calcium gluconate by slow IV push. ‐ Intravenous phosphorus over 6–8 hours. ‐ 10% calcium chloride by rapid IV push. | Critical words are severe hypocalcemia. Eliminate options 1 and 3, since they would be given to increase calcium. Eliminate option 4, recognizing that calcium should never be given rapidly. |
2386 A client who has a serum calcium level of 11.8 mg/dL Correct answer: 2 Calcium levels of 11–12 mg/dL indicate hypercalcemia. The mainstay of treatment of is receiving a 0.9% sodium chloride infusion. The nurse hypercalcemia (normal is 9–11 mg/dL) is to increase renal calcium excretion with extracellular determines that hydration has been effective when: volume expansion. Chvostek s sign indicates hypocalcemia, which would not be an overcorrection of treatment. Serum creatinine elevation indicates that renal function is diminished, and is therefore not an effective response to therapy. ‐ Chvostek’s sign is positive. ‐ Volume status has been restored. ‐ Calcium level is 11–12 mg/dL. ‐ Serum creatinine is elevated. | This question requires you to look for the absence of signs indicative of hypercalcemia. Recognize that option 1 could indicate that the calcium level has been brought down to normal level, or is reduced, to choose it. |
2387 The nurse caring for a client with a calcium imbalance Correct answer: 4 Although all systems are impacted by calcium imbalance, the major clinical manifestations of places highest priority on nursing interventions that calcium imbalance are due to either increased or decreased neuromuscular irritability. help to manage: ‐ Renal signs and symptoms. ‐ Cardiac changes. ‐ Hematologic disorders. ‐ Neuromuscular clinical manifestations. | Note that the question does not specify if calcium is decreased or elevated. Recall the major system affected by calcium to choose option 4. |
2388 The nurse determines that a client with a serum Correct answer: 4 The client with hypercalcemia (normal is 9–11 mg/dL) should increase fluid intake to 2–3 calcium level of 12 mg/dL understands client teaching liters a day. Hydration leads to increased calcium excretion, and prevents the development of when the client states: kidney stones. TUMS is a calcium carbonate supplement that can be used to increase calcium; the client in the question already has hypercalcemia, so this is not indicated. Phosphorus supplements can decrease calcium, but need to be taken more than once a day. Strict bedrest leads to increased calcium from osteoclastic activity. ‐ “If my stomach becomes upset, I can just take more TUMS.” ‐ “I’ll need to take my phosphorus supplements once a day.” ‐ “I’ll need to be on strict bedrest to help with this problem.” ‐ “I ll need to drink many more fluids than I have been, even up to 2–3 liters each day.” | Recall the treatment modalities for hypercalcemia to answer this question. Recognize that TUMS are a source of calcium, and that bedrest would increase bone reabsorption of calcium, to eliminate options 1 and 3. Choose option 4 as providing the most complete answer. |
2389 A client with hypocalcemia asks the nurse why Correct answer: 2 Calcium plays a unique role in the regulation of many enzymes and intracellular signaling. calcium is so important. The nurse makes which of the Although calcium does play an important role in acid–base balance, other electrolytes do this following statements to describe the function that is as well. Sodium and potassium are also needed for heart muscle contraction. Sodium is unique to calcium? primarily responsible for shifts in body water. ‐ “It helps to regulate acid–base balance.” ‐ “It activates enzymes that stimulate many chemical reactions.” ‐ “It stimulates the heart muscle so it will produce a contraction.” ‐ “It helps the body to maintain overall water balance.” | The critical word is unique. Note that all the options are functions of electrolytes, but only one is unique to calcium. |
2390 The results of a client s laboratory tests show Correct answer: 3 In hyperparathyroidism, the ionized calcium is almost always elevated. In elevated ionized calcium and parathyroid hormone hyperparathyroidism, the level of intact PTH is elevated, and is best interpreted in conjunction (PTH) levels. The nurse suspects that the cause is: with ionized calcium. PTH is suppressed in clients with most other causes of hypercalcemia, which makes the other options incorrect. ‐ Hypoparathyroidism. ‐ A malignancy. ‐ Hyperparathyroidism. ‐ Vitamin D deficiency. | Critical words are elevated and parathyroid. Eliminate options 1 and 4, since these would be seen with hypocalcemia, and eliminate option 2, since it would be related to hypercalcemia only. |
2391 A client develops hypocalcemia as a result of Correct answer: 1 Prolonged NGT suctioning leads to metabolic alkalosis. Changes in pH will alter the level of prolonged nasogastric (NG) tube suctioning. The nurse ionized calcium. Alkalosis increases calcium binding to albumin, leading to a decrease in concludes that the primary cause for hypocalcemia at ionized calcium. There might be fluid shifts from hypoalbuminemia, but this would not be due this time is: to NG tube suctioning. Hypomagnesemia can be a cause of hypocalcemia. Metabolic acidosis decreases calcium binding to albumin, leading to more ionized calcium. ‐ Metabolic alkalosis. ‐ Fluid shifts from hypoalbuminemia. ‐ Hypermagnesemia. ‐ Metabolic acidosis. | Recognize that NG suctioning removes acidic fluids, resulting in an alkalotic state. Recall that calcium salts are bound in alkalosis and that serum levels decrease to choose option 1. |
2392 A client has a diagnosis of ovarian cancer, and is Correct answer: 2 Many malignant tumors produce chemicals that are carried in the blood and cause release of undergoing chemotherapy. Because the client s calcium from the bones, most commonly in association with ovarian cancer, renal cell calcium level is now elevated, the nurse suspects carcinoma, and breast cancer, among others. Several antineoplastic medications cause which of the following? hypocalcemia; lack of dairy products and pancreatitis cause hypocalcemia. ‐ Antineoplastic medications are the cause for this elevation in calcium. ‐ The ovarian cancer has metastasized, causing the increase in calcium. ‐ The client is not eating enough dairy products, as a result of decreased appetite. ‐ The client is developing pancreatitis. | Recall the physiology of malignancy to stimulate release of calcium from the bones to direct you to option 2. |
2393 A client with hypocalcemia has been started on Correct answer: 2 Large doses of glucocorticoids decrease calcium absorption in the intestines, leading to a intravenous (IV) corticosteroids. Which of the further decrease in serum calcium levels. A positive Chvostek’s sign indicates hypocalcemia following findings would indicate to the nurse a further and hypomagnesemia. A positive Trousseau’s sign would be seen with hypocalcemia. Polyuria decrease in calcium level in the client? and muscle weakness are seen with hypercalcemia. ‐ Absence of Trousseau's sign ‐ Positive Chvostek’s sign ‐ Muscle weakness ‐ Frequent urination | Critical words are hypocalcemia and corticosteroids. Recall the signs and symptoms of hypocalcemia to direct you to option 2. |
2394 When assessing a client with hypercalcemia, the Correct answer: 3 Hypercalcemia causes decreased neuromuscular irritability, while hypocalcemia has clinical nurse concludes that which of the following findings in manifestations that indicate increased neuromuscular irritability. Options 1, 2, and 4 are all the neuromuscular examination is consistent with that signs of increased neuromuscular irritability, signs of hypocalcemia. electrolyte imbalance? ‐ Tetany ‐ A positive Trousseau’s sign ‐ Muscle weakness ‐ Hyperactive deep tendon reflexes | Recall that excessive calcium results in decreased transmission at the neuromuscular junction to direct you to option 3. |
2395 When caring for a client with hypercalcemia who is Correct answer: 2 The cardiac effects of hypercalcemia include shortened plateau phase of the action potential, on a cardiac monitor, the nurse checks the cardiac which causes shortening of the QT interval. Atrial fibrillation can develop, but heart block (with rhythm strip for which of the following typical prolonged PR interval) is more of a concern with hypercalcemia, due to delayed changes? atrioventricular conduction. Peaked T waves are associated with hyperkalemia. ‐ Development of atrial fibrillation ‐ Shortening of the QT interval ‐ Shortening of the PR interval ‐ Peaked T wave | This question requires knowledge of ECG interpretation and changes associated with electrolyte abnormalities. Recall ECG changes associated with high calcium levels to direct you to option 2. |
2396 A nurse prepares to administer calcium gluconate to Correct answer: 1 Hypoparathyroidism is characterized by hypocalcemia and hyperphosphatemia, and is often a client post‐thyroidectomy. The nurse explains to the associated with tetany. Hypoparathyroidism usually results from accidental removal of or licensed practical nurse (LPN) that this replacement damage to parathyroid glands during thyroidectomy. Because hypocalcemia can be severe, therapy is needed: prolonged parenteral administration of calcium might be necessary to avoid serious postoperative complications. Hypoparathyroidism results from a deficiency or absence of PTH; therefore, option 2 is incorrect. Immobility results in hypercalcemia, making option 3 incorrect. ‐ Because of accidental removal of the parathyroid gland. ‐ Because it is related to increased parathyroid hormone (PTH) release during surgery. ‐ To prevent complications from immobility postoperatively. ‐ Due to hypophosphatemia after this type of surgery. | The critical words are post‐thyroidectomy. Recall anatomy and function of the parathyroid gland to choose option 1. |
2397 A client presents with complaints of fatigue, Correct answer: 4 Symptoms of fatigue, headache, and increasing muscle weakness are clinical manifestations headache, and increasing muscle weakness, and has of hypercalcemia. Increased hydration is needed to reduce the serum concentration and aid in blood work drawn to evaluate the serum calcium level. elimination. All of the other options will worsen the client s symptoms and increase The nurse anticipates medical management for an hypercalcemia. Thiazide diuretics inhibit calcium excretion; vitamin D supplements will abnormal value to include which of the following? increase absorption of vitamin D in the intestine; and fluid restriction will cause hemoconcentration, leading to increased serum calcium. ‐ Thiazide diuretics ‐ Vitamin D supplements ‐ Fluid restriction ‐ Increased hydration | First determine that the symptoms reflect hypercalcemia. Eliminate options 1, 2, and 3, since these would all increase calcium levels even further. Alternatively, note that options 3 and 4 are opposites, which is a clue that one of them might be the correct choice. |
2398 The nurse evaluates that discharge teaching has been Correct answer: 2 Tingling or numbness around the mouth is called circumoral paresthesia, and is a sign of effective when the client with hypocalcemia states: impending tetany. A health care provider should be notified immediately. TUMS is a brand name for calcium carbonate, which can be used as a calcium supplement when calcium intake is inadequate. To prevent hypocalcemia, the client should increase the protein in the diet. Kidney stones are a sign of hypercalcemia. ‐ “I shouldn t take antacids, such as TUMS.” ‐ “I should notify my health care provider if I start to feel tingling or numbness around my mouth.” ‐ “I will need to cut down on the amount of protein I include in my diet each day.” ‐ “I will watch my urine for signs of kidney stones.” | Review nursing and medical interventions to increase calcium levels, and eliminate option 1, since TUMS are a source of calcium. Recall early warning signs of tetany to direct you to option 2. |
2399 The nurse correlates which of the following Correct answer: 3 Parathyroid hormone (PTH) is important in renal magnesium regulation, and conditions with increased renal wasting of magnesium, hypoparathyroidism is associated with renal wasting of magnesium. The other conditions listed and so plans to monitor the client for signs of do not have this effect. hypomagnesemia? ‐ Hypothyroidism ‐ Hypertension ‐ Hypoparathyroidism ‐ Hyperparathyroidism | This question requires specific knowledge of each diagnosis listed. Recall the role of PTH to magnesium to be directed to option 3. |
2400 When caring for a client with hypercalcemia, the Correct answer: 1 Calcium competes with magnesium in the loop of Henle; therefore, an elevated calcium level nurse would expect to see which of the following could decrease renal absorption of magnesium, causing hypomagnesemia. effects on the magnesium level? ‐ A decreased magnesium level ‐ A rise in magnesium level ‐ No change from baseline magnesium level ‐ A normal magnesium level | The question requires knowledge of the effect of calcium on magnesium. Recall the antagonistic relationship to be directed to option 1. |
2401 The nurse anticipates that a client receiving which of Correct answer: 2 Furosemide, a loop diuretic, increases urinary output and excretion, decreasing magnesium the following drugs is at risk for magnesium reabsorption. The following drugs promote magnesium loss: aminoglycosides, potassium‐ imbalance? wasting diuretics (such as furosemide), cortisone, amphoteracin B, and digoxin. Cimetidine (a histamine 2 receptor blocker), erythromycin (an antibiotic), and aspirin (an antipyretic, analgesic, and antiplatelet agent) do not have this effect. ‐ Cimetidine (Tagamet) ‐ Furosemide (Lasix) ‐ Erythromycin (E‐Mycin) ‐ Aspirin (generic) | Analyze each option for the drug's effect on magnesium. Recall that loop diuretics can cause magnesium loss to choose option 2. |
2402 A prenatal client is admitted for pre‐eclampsia. The Correct answer: 1 Low magnesium produces clinical manifestations such as seizures, tremors, spasticity, and nurse would include in client teaching that magnesium increased reflexes. Magnesium sulfate is the preferred agent for prevention and treatment of is a standard form of therapy to accomplish which of seizures in pre‐eclampsia and eclampsia due to its efficacy and low neonatal morbidity. The the following? other options are incorrect reasons for administering this drug. ‐ Control seizures. ‐ Maintain intrauterine homeostasis. ‐ Achieve optimal strength of contractions. ‐ Increase renal function. | The critical word is pre‐eclampsia. Recall that this disorder is associated with hypomagnesemia, placing the client at risk for seizures, to be directed to option 1. |
2403 The nurse assesses for which of the following Correct answer: 2, 4, 5 The ECG and actual magnesium level can provide information about the severity of the electrocardiogram (ECG) changes that can occur in a electrolyte imbalance. A prolonged QT interval might be evident on an ECG due to lengthening client whose laboratory test results reveal of the ST segment. The T wave might be flattened, while the QRS might have diminished hypomagnesemia? Select all that apply. voltage. The ST segment is not elevated. Changes in the ST segment and T wave can ultimately precipitate ventricular tachycardia, while a prolonged QT interval can precipitate heart block. ‐ ST segment elevation ‐ Prolonged QT interval ‐ Absent Q wave ‐ Flattened T wave ‐ Depressed ST segment | Specific knowledge of EKG and magnesium imbalances is needed to answer this question. Review this material if this question was difficult to answer. |
2404 The nurse would expect a client diagnosed with Correct answer: 4 An elevated serum magnesium level is usually due to renal insufficiency and the decreased hypermagnesemia to have which of the following ability of the kidneys to excrete magnesium. Diabetes and chronic alcoholism can lead to disorders listed in the medical record? hypomagnesemia. Hypertension is not part of the clinical picture. ‐ Chronic alcoholism ‐ Diabetes mellitus ‐ Hypertension ‐ Renal insufficiency | Recall conditions contributing to magnesium retention. Associate decreased renal excretion of electrolytes to hypermagnesemia, and choose option 4. |
2405 The nurse would assess for hypermagnesemia when Correct answer: 1 Magnesium sulfate is a cathartic used to stimulate peristalsis and increase elimination of magnesium sulfate is repeatedly used to control which stool. It is not used to treat vomiting, anorexia, or fever. of the following symptoms? ‐ Constipation ‐ Vomiting ‐ Anorexia ‐ Fever | The critical words are magnesium sulfate and repeatedly used. Recall that magnesium has laxative properties to be directed to option 1. |
2406 When caring for a client with hypomagnesemia, the Correct answer: 3, 5 Magnesium deficiency can contribute to decreased levels of calcium, potassium, and nurse should closely monitor levels of which other phosphates. For this reason, each of these electrolyte levels should be monitored. electrolyte? Select all that apply. ‐ Sodium ‐ Chloride ‐ Phosphate ‐ Bicarbonate ‐ Calcium | Recall the electrolytes associated with magnesium imbalances. Recognize that potassium and calcium are frequently decreased along with magnesium to choose option 3. |
2407 The nurse determines that a client with Correct answer: 1 Tapping on the facial nerve below the temple is the method of testing for Chvostek's sign. A hypomagnesemia has a positive Chvostek's sign after positive sign would be a twitch of the nose or lip. noting which of the following responses to stimulation? ‐ Twitch of the nose or lip ‐ Blink ‐ Lacrimation ‐ Pain | Recall how Chvostek's sign is checked. Associate the “ch” in Chvostek with the tapping of the “ch” in cheek. Recognize that options 2 and 3 relate to the eye (too high on the face), and eliminate them. Recall that this is a physical sign that is observed to choose option 1. |
2408 The nurse determines that treatment for Correct answer: 4 Effects of hypomagnesemia are mainly due to increased neuromuscular responses, and are hypomagnesemia has been most effective when the manifested by neuromuscular irritability, increased deep tendon reflexes, and signs of tetany. client demonstrates which of the following? Decreased or normal deep tendon reflex indicates that the treatment was effective. ‐ A slight improvement in muscle paralysis ‐ Paresthesias of the hands ‐ Numbness in the extremities ‐ Normal deep tendon reflexes | The critical word is effective. Recognize that three of the options are similar, and indicate neuromuscular irritability still exists, and eliminate them. Associate the word normal in option 4 with correction of the magnesium deficiency. |
2409 When caring for a client receiving intravenous (IV) Correct answer: 1 Excessive or too‐rapid infusion of magnesium sulfate can result in a rapid rise of serum replacement of magnesium sulfate, the nurse should magnesium, which can manifest itself as respiratory depression or decreased deep tendon plan to monitor the client for which of the following reflexes. Abdominal cramping can occur secondary to diarrhea with oral magnesium sulfate potential complications? supplementation. Respirations would decrease, not increase. Headaches would not be caused by high magnesium levels. ‐ Rebound hypermagnesemia ‐ Abdominal cramping ‐ Tachypnea ‐ Headaches | The critical words in the question are IV, magnesium sulfate, and complications. Recall the need to infuse magnesium slowly to prevent rapid increases in plasma levels to direct you to option 1. |
2410 The nurse doing health promotion with a group of Correct answer: 1 Magnesium binds calcium to tooth enamel, and thus helps to maintain the health of teeth. clients should explain that magnesium has which of the The other responses are incorrect statements. following important functions to maintain the health of teeth? ‐ Binds calcium to tooth enamel. ‐ Decreases risk of gum disease. ‐ Protects teeth from bacteria. ‐ Raises serum calcium levels. | Critical words are magnesium, functions, and teeth. Recall functions of magnesium to choose option 1. |
2411 The nurse would recommend to a client who has Correct answer: 2, 3, 5 Legumes, seafood, and whole grains are high in magnesium. The other options listed contain hypomagnesemia that the client increase intake of either low or trace amounts of magnesium. which of the following foods? Select all that apply. ‐ Rice ‐ Seafood | This question requires specific knowledge to make the correct choices. Recall food sources high in magnesium to choose options 2, 3, and 5. |
‐ Legumes ‐ Fresh fruit ‐ Whole grains | |
2412 The nurse anticipates that which of the following Correct answer: 2 Treatment for hypermagnesemia is to promote urinary excretion of magnesium to decrease treatments would be used for a client who has a serum levels, so a diuretic might be indicated. Laxatives and antacids often contain magnesium level of 2.5 mEq/L? magnesium, which could worsen the imbalance. Fluid restriction would be contraindicated, because it would prevent flushing of excess magnesium from the body. ‐ Magnesium oxide (MagOx) ‐ Furosemide (Lasix) ‐ Calcium carbonate (TUMS) ‐ Fluid restriction | First, determine that the magnesium level is elevated. Eliminate option 1, since it is a source of magnesium. Eliminate option 4, since it would inhibit magnesium excretion, and option 3, because it is not useful. |
2413 The nurse anticipates that which of the following Correct answer: 4 Renal failure interferes with excretion of electrolytes, including magnesium. All of the clients is at risk for hypermagnesemia? conditions listed in the incorrect options increase the risk of hypomagnesemia by interfering with magnesium absorption in the small intestine. ‐ An anorexic 16‐year‐old female ‐ A 57‐year‐old alcoholic male ‐ A 47‐year‐old female with a history of partial gastrectomy ‐ A 62‐year‐old male with chronic renal failure | Critical words are hypermagnesemia and risk. Eliminate options 1 and 2, since intake of magnesium is reduced in these conditions. Recall that magnesium is absorbed in the small intestine, and eliminate option 3. |
2414 The nurse explains to a new nurse orientee that a Correct answer: 2 The hyperglycemic diabetic client experiences osmotic diuresis and polyuria, which increase hyperglycemic diabetic client might experience low the risk of excess urinary excretion of magnesium, leading to lowered magnesium levels. The magnesium levels due to which of the following? other options are incorrect. ‐ Liver toxicity ‐ Osmotic diuresis ‐ Kidney failure ‐ Low serum osmolarity | Recognize that hyperglycemia produces a hyperosmotic state in the blood, leading to diuresis, to direct you to option 2. |
2415 The nurse would assess for which of the following Correct answer: 4 Oral administration of magnesium can cause diarrhea, which would further decrease common side effects when administering oral magnesium absorption. The other options are unrelated items. magnesium to a client? ‐ Decreased appetite ‐ Decreased urine output ‐ Increased thirst ‐ Diarrhea | The critical word is oral. Recall that magnesium is a common ingredient in laxatives to direct you to option 4. |
2416 The nurse would assess for signs of hypomagnesemia Correct answer: 4 Gentamicin is one medication whose use can lead to hypomagnesemia. All the conditions or in which of the following clients? circumstances listed in the other options increase serum magnesium levels by enhancing the absorption of magnesium by the small intestine or interfering with its excretion by the kidney. ‐ A client with a history of laxative abuse ‐ A client who is noncompliant with diuretic therapy ‐ A client who takes magnesium‐containing antacids ‐ A client who is taking gentamicin (Garamycin) | Eliminate options 1 and 4, since these conditions would contribute to an increase of magnesium. Eliminate option 2, since this would reduce the amount of magnesium lost in the urine. |
2417 A client is admitted with new‐onset renal failure. The Correct answer: 2 Neuromuscular symptoms such as depressed deep tendon reflexes are among the most nurse would observe for which most common clinical common clinical manifestations of hypermagnesemia. Decreased respirations, hypotension, manifestation of hypermagnesemia? and ventricular arrhythmias also can occur in some clients, but are not the most common signs. ‐ Palpitations ‐ Decreased deep tendon reflexes ‐ Decreased respirations ‐ Hypertension | Recall magnesium’s role in the regulation of acetylcholine at the neuromuscular junction to direct you to option 2. |
2418 After treating hypomagnesemia with IV fluids, a Correct answer: 2 The repeat serum magnesium level is very high. Calcium gluconate is an antagonist of client's repeat serum magnesium level is 4.0 mEq/L. magnesium, and is used intravenously to counteract toxicity. The nurse anticipates receiving an order for which of the following medications? ‐ Dextrose ‐ Calcium gluconate ‐ Potassium chloride ‐ Sodium chloride | Recognize that the magnesium level is dangerously elevated. Recall the need to antagonize the cardiac and muscular effects of excessive magnesium to choose option 2. |
2419 The nurse would expect a client to have a high serum Correct answer: 3 Many laxatives are magnesium‐based compounds. Overuse could result in increased level of magnesium after seeing which of the following absorption of magnesium and decreased kidney excretion. The other problems listed do not health problems listed in the medical history? elevate magnesium levels. ‐ Malabsorption ‐ Anemia ‐ Overuse of laxatives ‐ Alcoholism | The question requires you to correlate a high magnesium level to a cause. Eliminate options 1 and 3, since they would contribute to lowering magnesium. Recall the content of many laxatives to choose option 3. |
2420 The nurse should assess for which of the following Correct answer: 4 Deep tendon reflexes (DTRs) can be diminished or absent when magnesium levels are high classic manifestations in a client with a magnesium (normal is 1.4–2.1 mEq/L). This is because magnesium diminishes acetylcholine activity at the level of 2.5 mEq/L? myoneural junction, impairing impulse transmission. ‐ Diarrhea ‐ Hyperreflexia ‐ Hypertension ‐ Diminished deep tendon reflexes | The critical word is manifestations, and the concept is hypermagnesemia. Recall the role of magnesium in regulating neuromuscular conduction to direct you to option 4. |
2421 The nurse is educating the client who has a Correct answer: 3 Clients should be instructed to eat foods that are high in magnesium in order to raise blood magnesium level of 1.2 mEq/L. What information is levels to within the normal range. Read each option carefully, and analyze the need for most important for the nurse to include in discussions teaching to correct the magnesium imbalance. Recognize that option 3 will help to provide with the client? correction of the condition, and choose it. ‐ Avoid hazardous activities. ‐ Weekly laboratory evaluation ‐ Diet counseling ‐ Moderate alcohol consumption | Simply remember that food supplies the electrolytes needed by the body. Use this concept to focus on diet counseling as the correct option. |
2422 A client who takes a mild diuretic complains of leg Correct answer: 4 Magnesium deficiency often coexists with other electrolyte imbalances, especially decreased cramps. After determining that the client s potassium calcium and potassium. Leg cramps are a manifestation of hypomagnesemia. The calcium and level is normal, the nurse suspects that which of the phosphorus levels are elevated, and chloride would not be a causing leg cramps. following abnormal laboratory studies could be the underlying cause? ‐ Calcium level of 11.6 mg/dL ‐ Chloride level of 90 mg/dL ‐ Phosphorus level of 4.8 mg/dL | Determine if the electrolyte levels are elevated, normal, or decreased. Then recall that leg cramps can also be precipitated by low magnesium to direct you to option 4. |
4.‐ Magnesium level of 1.2 mEq/L | |
2423 A client with chronic renal failure has a magnesium Correct answer: 1, 4 A magnesium level of 2.8 is elevated (normal is 1.4–2.1 mEq/L), most likely as a result of level of 2.8 mEq/L. When reviewing the client’s dietary inadequate renal secretion secondary to the chronic renal failure. Foods high in magnesium history, the nurse identifies which of the following include whole grains; legumes; oranges; bananas; green, leafy vegetables; and chocolate. frequently eaten foods as a possible cause of this laboratory value? Select all that apply. ‐ Hot chocolate ‐ Apples ‐ Pork sausage ‐ Spinach salad ‐ Swiss cheese | First, recognize the magnesium level is elevated. Recall foods high in magnesium to choose options 1 and 4. |
2424 A client admitted with a history of alcoholism has a Correct answer: 4 Decreased magnesium levels also contribute to reductions in potassium, calcium, and magnesium level of 1.2 mEq/L. The nurse should also phosphate, since all are cations involved in cellular metabolisms. plan to check the results of serum laboratory studies for which of the following? ‐ Elevated potassium ‐ Elevated phosphorus ‐ Decreased sodium ‐ Decreased calcium | First, recognize that the magnesium level is decreased. Then, recall which electrolyte might be abnormal in the presence of low magnesium to direct you to option 4. |
2425 The nurse who is teaching a review of basic nutrition Correct answer: 2 Magnesium decreases the amount of acetylcholine activity, thereby causing muscle is discussing the effects of various electrolytes and relaxation. The other responses are incorrect. minerals in the body. In describing the action of magnesium, the nurse would explain that it diminishes acetylcholine and thus acts as a: ‐ Nerve stimulant. ‐ Muscle relaxant. ‐ Vitamin metabolizer. ‐ Stimulant for blood sugar. | This question requires you to translate the chemical action of magnesium to its physiological effect in the body. Recall the action of acetycholine on neuromuscular function to direct you to option 2. |
2426 Following bowel resection surgery, a client’s Correct answer: 1 Hyperactive reflexes are early signs of tetany; the low magnesium level (normal is 1.4–2.1 magnesium level is 1.0 mEq/L. Which of the following mEq/L) could lead to tetany and seizures, and should be reported to the physician. The other assessment findings should be reported to the symptoms can be related to electrolyte imbalances, but might also be secondary to the physician immediately? surgery, effects of anesthesia, and narcotic analgesics given for pain. ‐ Hyperactive reflexes ‐ Nausea ‐ Anorexia ‐ Abdominal pain | Recognize the critical level of the magnesium level. Recall that this imbalance can lead to seizures to direct you to option 1. |
2427 The nurse doing health promotion instructs the 28‐ Correct answer: 3 The RDA for magnesium is 310–320 mg for young adult women, and 400–420 mg for young year‐old male client to take in how many milligrams of adult men. Extra requirements beyond this amount are needed during pregnancy and magnesium to be within the recommended dietary lactation. allowance (RDA) for magnesium? ‐ 75 mg ‐ 200 mg ‐ 400 mg | Recall RDA requirements to answer this question. Beyond that, questions that require numbers for answers can tend to “bury” the number in the middle of the set, rather than as the first or last option, where it could be more obvious. |
4.‐ 650 mg | |
2428 When caring for a client with a magnesium level of Correct answer: 4 Sources of magnesium in the diet include green, leafy vegetables; nuts; legumes; whole 1.1 mEq/L secondary to malabsorption, the nurse grains; seafood; bananas; oranges; and chocolate. encourages the client to increase the intake of which of the following foods? ‐ Poultry ‐ Tomatoes ‐ Dairy products ‐ Nuts | Specific knowledge of the mineral content of various types of foods is needed to answer the question. Recall foods high in magnesium to choose option 4. |
2429 The nurse evaluates a client admitted to the hospital Correct answer: 3 Use of drugs such as chlorothiazide diuretics can lead to hypochloremia, a decrease in serum with a history of taking chlorothiazide (Diuril) as a chloride, because the client is losing chloride in the urine. Options 1 and 2 indicate increased diuretic for the past six months in an attempt to lose serum electrolyte levels that would not occur with the use of this class of diuretic drug. Option weight. Which of the following disturbances in 4 is incorrect because thiazide diuretics cause retention of calcium by increasing the action of laboratory values should the nurse assess as part of parathyroid hormone on the kidneys, and therefore hypercalcemia would be expected. the general nursing care plan? ‐ Hyperchloremia ‐ Hypermagnesemia ‐ Hypochloremia ‐ Hypocalcemia | The critical words are diuretic and six months. Recognize that the diuretic is a thiazide type. Recall that it causes sodium and chloride losses and calcium retention to be directed to option 4. |
2430 Preadmission laboratory work was drawn for a client Correct answer: 2 Bromides can cause a false elevation of chloride levels. The client's serum sodium level is at admitted to the hospital for surgery. The results the high end of normal range, and therefore, given the client's history, a repeat lab draw would indicated a chloride level of 120 mEq/L and sodium be indicated. All of the other options are not warranted, given the client's history of bromide level of 145 mEq/L. The client reported a history of ingestion. taking bromides for several days. The nurse should expect the client to receive which of the following laboratory assessment orders next? ‐ Reassess the sodium level. ‐ Reassess the chloride level. ‐ Draw a potassium level. ‐ Draw a magnesium level. | The critical word is bromide. Recognize that the chloride level is excessively high in relation to sodium to be directed to option 2. |
2431 A client treated for hypochloremia is being prepared Correct answer: 1 It is important for the client to know foods and other dietary items that are high in chloride, for discharge. The nurse determines that the discharge such as table salt. All of the other options are inappropriate actions because they will decrease instructions have been understood when the client serum chloride levels. makes which of the following statements? ‐ "I will increase salt in my diet." ‐ "I will increase my dose of diuretics." ‐ "I will reduce processed foods in my diet." ‐ "I will reduce foods such as lettuce, tomatoes, and celery in my diet." | The critical word is hypochloremia. Recall that sources of chloride include salt, dairy products, and processed foods to choose option 1. |
2432 A client was admitted to the hospital with a diagnosis Correct answer: 3 Hemodilution of body fluids can decrease the serum chloride level. Options 1 and 4 are of hypochloremia. The nurse interprets that which of incorrect because both increased adrenocortical hormones and seawater will increase serum the following would predispose the client to this chloride levels. Option 2 is incorrect because increased environmental temperature causes condition? perspiration and loss of fluids. ‐ Increased adrenocortical hormone ‐ Increased environmental temperature | The question asks for identification of risk factors contributing to losses of chloride. Analyze each option to determine that excess water will contribute to dilution of the chloride, and choose option 3. |
‐ Drinking excessive amounts of plain water ‐ Drinking excessive amounts of bottled sports drinks | |
2433 When caring for a client who has second‐ and third‐ Correct answer: 4 Chloride loss occurs with oozing at the burn surface. Option 1 is incorrect because sodium is degree burns, the nurse should monitor for fluid lost with body fluids, causing hyponatremia. Option 2 is incorrect because calcium is lost in the imbalances and which electrolyte imbalance? edematous fluid. Option 3 is incorrect because potassium leaves the cells as sodium shifts into the cells, causing hyperkalemia. ‐ Hypernatremia ‐ Hypocalcemia ‐ Hypokalemia ‐ Hypochloremia | Recall the fluids shifts and losses that occur with this level of burn. Recognize that chloride accompanies sodium losses to be directed to option 4. |
2434 For which of the following should the nurse monitor Correct answer: 1 Large doses or prolonged use of oral cortisone therapy increases serum chloride, and in a client with a long history of corticosteroid decreases potassium and magnesium levels. treatment? ‐ Increased serum chloride levels ‐ Increased serum magnesium levels ‐ Increased serum potassium levels ‐ Decreased serum sodium levels | The critical word is corticosteroid. Recall that this drug promotes sodium and potassium losses, and eliminate options 3 and 4. Recognize that chloride accompanies the sodium retention to choose option 1. |
2435 When examining a client admitted with complaints of Correct answer: 4 The nurse should be aware that the client is exhibiting symptoms of hyperchloremia due to a weakness and lethargy, the nurse notices that the fluid deficit. A hypotonic solution should be administered to increase the extracellular fluid client's respirations are deep and rapid. Upon further (ECF) and decrease the serum osmolality. All of the other options would not be indicated, assessment, it is documented that the client is because they are all high in saline and chloride, and could cause the client to develop further dehydrated from inadequate fluid intake for more than fluid and electrolyte complications. four days. The nurse should expect to administer which of the following as ordered? ‐ 3% saline solution ‐ Salt tablets ‐ Isotonic saline with 10% dextrose ‐ Hypotonic IV fluids | Read the question carefully, and recognize that the symptoms reflect metabolic acidosis and accompanying chloride retention. Note the similarity of sodium content in options 1 and 2, and eliminate them. Recognize the need for hydration, and choose option 4. |
2436 A client with a history of bulimia is admitted for Correct answer: 4 The client with bulimia often purges, or uses excessive laxatives, resulting in the loss of treatment of electrolyte imbalances. Recognizing the sodium, chloride, and potassium. Excessive water intake can lead to dilutional hyponatremia need to prevent further losses of sodium and chloride, and hypochloremia. All of the other foods and fluids would provide needed salt and chloride. the nurse instructs the client to limit the intake of: ‐ Milk and dairy products. ‐ Broths to two cups a day. ‐ Processed foods and snacks. ‐ Bottled or tap water. | The critical words are sodium, chloride, and limit. Note that options 1, 2, and 3 are all high in sodium, and would be encouraged to restore electrolyte balance, and eliminate them. |
2437 Intake of which of the following foods would indicate Correct answer: 2 Fruit has the lowest amount of chloride, and is an appropriate item for intake as part of a low‐ to the nurse that dietary instruction has been chloride diet. The other options are incorrect because they are all high in chloride. adequate for a client placed on a low‐chloride diet? ‐ Rye ‐ Fruit ‐ Seaweed ‐ Canned vegetables | The critical term is low‐chloride diet. Recognize that foods high in sodium also contain chloride, and eliminate options 1, 3, and 4. |
2438 A client returns to the clinic after being prescribed a Correct answer: 2 Compliance with the medication administration schedule will influence effectiveness of the 10‐day course of diuretics for fluid retention. After medication. Diuretics should reduce chloride levels if taken appropriately. Further data reviewing the lab data, the nurse notices that the collection is needed prior to intervention. Option 1 is incorrect, since merely drawing another chloride level of 106 mEq/L was higher than on the blood sample would provide no additional information at this point in time. There is no reason first visit. The nurse's initial action should be to: to suspect that there has been a laboratory error or that the initial result is inconclusive. Options 3 and 4 are also incorrect, because there is not enough information to warrant the change of diuretic therapy or referral to a specialist at this point in time. ‐ Draw another blood sample. ‐ Determine if the client took the medication as prescribed. ‐ Request that the physician order a different diuretic. ‐ Make an appointment for the client to be seen by a specialist. | First, recognize that the chloride level is on the high end of normal. Then, recognize that chloride is lost with diuretics, but the level does not correlate with the loss that would be expected, and choose option 2. |
2439 Laboratory test results indicate that the client has a Correct answer: 4 Weakness and lethargy occur with hyperchloremia (normal is 95–108 mEq/L). All of the other serum chloride level of 114 mEq/L. The nurse would options reflect manifestations that are associated with hypochloremia. assess the client for which of the following anticipated manifestations? ‐ Tremors and flaccid muscles ‐ Twitching and spastic reflexes ‐ Hyperreflexia and tremors ‐ Weakness and lethargy | The core issue of the question is that the client has hyperchloremia. Recognize the similarities in options 1, 2, and 3 to eliminate them. |
2440 Which of the following should be included as a Correct answer: 1 In metabolic alkalosis, bicarbonate ions are retained, and the kidneys respond by excreting priority intervention for a client diagnosed with chloride ions, which in turn causes reciprocal hypochloremia. Option 2 is incorrect because metabolic alkalosis associated with hypochloremia? deep, rapid respirations and stupor are symptoms of hyperchloremia. Options 3 and 4 are incorrect because serum chloride levels are decreased, and the restriction of salt and administration of diuretics will normally cause further chloride losses to occur, which could further compromise the client s status. ‐ Assess for muscle tremors and slow, deep respirations. ‐ Assess for rapid, deep respirations and stupor. ‐ Restrict salt in the diet. ‐ Administer diuretics. | Recall first that metabolic alkalosis leads to hypochloremia. Eliminate options 3 and 4, since they would cause further hyperchloremia. Recall signs of hypochloremia to choose option 1. |
2441 When a client is admitted with a chloride level of 80 Correct answer: 3 The client presents with hypochloremia, and most likely is experiencing other electrolyte mEq/L, the nurse anticipates administration of which deficiencies as well, most notably sodium and potassium. A solution with 0.45% saline with of the following intravenous solutions? added potassium would be an appropriate option, because this would correct all fluid and electrolyte imbalances. Option 2 would not be appropriate, because it does not address the issue of additional electrolyte deficiencies. Option 1 is incorrect because these fluids can further dilute the plasma and the serum chloride level. Option 4 is incorrect. Hypertonic saline is usually administered in cases of severe hyponatremia. ‐ 5% dextrose and water ‐ 0.9% sodium chloride ‐ 0.45% sodium chloride with 20 mEq of potassium ‐ 3% sodium chloride | First, recognize that the level is dangerously low, and recall that sodium and potassium losses occur with low chloride, and will need to be replaced. Option 3 provides both of these electrolytes. |
2442 Which of the following statements would the nurse Correct answer: 4 Dates and bananas are high in chloride, and therefore can be included in a dietary pattern to make during dietary teaching for a client who has a increase chloride levels. Option 1 is incorrect; foods containing rye should be included in the serum chloride level of 86 mEq/L? diet, because they are high in chloride. Option 2 is incorrect because diuretics can increase the excretion of chloride and thereby reduce serum chloride levels. In addition, the nurse cannot tell a client to alter prescribed medication therapy. Option 3, while increasing the amount of citrus fruit in the diet provides nutritional benefit, does not increase chloride levels. Citrus is high in potassium. ‐ “Avoid eating foods containing rye.” ‐ “Take your prescribed diuretic daily.” ‐ “Increase the amount of citrus fruit in your diet.” ‐ “Increase intake of dates and bananas in your diet.” | The core issue of the question is knowledge of foods that are naturally high in chloride. A critical word in the question is dietary, which helps to eliminate option 3. Recall foods high in chloride to choose option 4. |
2443 After checking the medical record of a client admitted Correct answer: 2 A serum value of 110 mEq/L reflects an elevated serum chloride level. Cushing s syndrome with shortness of breath and lethargy, the nurse noted causes retention of excess sodium and chloride, and potassium deficit. Option 1 is incorrect a chloride level of 110 mEq/L. Which of the following because Addison s disease is associated with decreased levels of sodium and chloride, and coexisting health problems would the nurse suspect? potassium excess. Option 3 is incorrect because elevated chloride levels are usually associated with metabolic acidosis. Option 4 is incorrect because SIADH is associated with chloride deficit. ‐ Addison’s disease ‐ Cushing’s syndrome ‐ Metabolic alkalosis ‐ Syndrome of inappropriate antidiuretic hormone (SIADH) | First, recognize that the level is elevated. Recall that hyperchloremia is seen with elevated sodium to direct you to option 2. |
2444 Which of the following nursing diagnoses would the Correct answer: 3 The stated value represents an elevated chloride level. Increased use of table salt will cause nurse most likely identify for a client with a serum an increase in both sodium and chloride levels. Option 1 is incorrect because the use of NG chloride level of 112 mEq/L? suctioning causes HCl acid to be lost, thereby decreasing the chloride level. Option 2 is incorrect because it is not a nursing diagnosis, and the client has hyperchloremia, not hypochloremia. Option 4 is incorrect because it is not a nursing diagnosis, and chloride excess is associated with metabolic acidosis, and is seen in clients who have acute renal failure. ‐ Ineffective Health Maintenance related to nasogastric suctioning ‐ Altered Electrolytes related to hypochloremia ‐ Imbalanced Nutrition: More than Body Requirements related to excess intake of foods rich in salt ‐ Impaired Renal Function (Chronic) related to acid–base imbalance of metabolic alkalosis | First, determine that the level is elevated. Eliminate options 1, 2, and 4, as they are associated with low chloride levels. |
2445 A client who is experiencing hypochloremia is Correct answer: 1 Chloride levels are typically drawn as part of general serum electrolytes, and do not require scheduled to have blood drawn for a chloride level. In the client to be NPO prior to the test; in addition, the client does not need to alter typical salt preparation for the blood work, the nurse instructs the intake. Caffeine and hormones will not interfere with test results. client to: ‐ Eat a typical diet with ordinary or typical salt intake. ‐ Restrict intake of caffeine‐containing beverages the day before blood is drawn. ‐ Fast for 8 hours before the blood is to be drawn. ‐ Stop taking any hormone medications for 24 hours. | Recognize that caffeine and hormones do not affect chloride levels. Recall that chloride is drawn with other electrolytes to choose option 1. |
2446 A client is admitted to the intensive care unit (ICU) Correct answer: 4 An admitting clinical diagnosis of metabolic alkalosis, hypokalemia, and hyponatremia is with metabolic alkalosis, hypokalemia, and usually associated with chloride deficit. It would be prudent to check serum chloride levels in hyponatremia. The nurse should look at the results of order to ascertain the client s baseline in the presence of multiple electrolyte deficiencies. The serum laboratory studies to detect which additional other test results do not reflect serum electrolytes, and therefore will not change in test that likely has an abnormal result? proportion to the electrolyte changes. ‐ Ammonia ‐ Uric acid | Recall that chloride goes in the same direction as sodium to help make the correct selection of which test on which to focus. |
‐ Creatinine ‐ Chloride | |
2447 Which of the following items in a client’s recent Correct answer: 1 The use of acetazolamide (Diamox) can lead to the development of hyperchloremic acidosis, history does the nurse identify as contributing to a because it increases chloride levels. All of the other options are incorrect, because they would state of hyperchloremic acidosis? lead to chloride deficiencies that would result in an alkalotic state. ‐ Administration of acetazolamide (Diamox) ‐ Administration of antacids ‐ Administration of thiazide diuretics ‐ Chronic laxative use | Recognize that options 2, 3, and 4 would contribute to loss of chloride, and eliminate them. |
2448 Which of the following changes in urine levels would Correct answer: 1, 2 Options 1 and 2 are correct. Low urine sodium and chloride indicates chloride retention in the be expected in a client with cardiac disease who is body, especially with overhydration or fluid excess. Option 3 is incorrect because it indicates experiencing pitting edema? Select all that apply. fluid deficit. Option 4 is incorrect because calcium is not altered by fluid retention due to cardiac disorders. Option 5 is incorrect, as phosphorus would not be affected. ‐ Decreased sodium ‐ Decreased chloride ‐ Increased phosphorus ‐ Decreased calcium ‐ Increased phosphorus | Critical words are cardiac and pitting edema. Recognize that sodium and chloride would be retained with edema and as a result renal losses of chloride and sodium would decrease to choose options 1 and 2. |
2449 A client is being discharged with a prescription for Correct answer: 1 Glucocorticoids cause retention of chloride and sodium, leading to fluid retention. All of the prednisone. Which statement would indicate the client other options, such as decreasing diuretic intake, eating more vegetables, and eating foods understands the side effects that affect the client’s such as spinach and celery (high in chloride content), will increase the serum chloride level. serum sodium and chloride levels? ‐ “I should limit my salt intake.” ‐ “I will not need to take my diuretic now.” ‐ “It will be important to eat more vegetables.” ‐ “I should increase my intake of spinach and celery, which I enjoy.” | The critical words are prednisone and side effects. Recall that this drug is a corticosteroid, and that this type of drug causes retention of sodium and chloride, to direct you to option 1. |
2450 Which of the following should be included in the plan Correct answer: 2 Increased use of sodium bicarbonate causes excretion of chloride or hypochloremia; of care for a client who received multiple ampules of therefore, it would be appropriate to have serum chloride levels monitored for potential sodium bicarbonate over several days? deficits. Option 1 is incorrect because D<sub>5</sub>W infusion is hypotonic, and will cause further fluid shifting and more potential electrolyte imbalances, given the high rate. This will decrease chloride levels if administered over a prolonged time. Option 4 is incorrect, because diuretics will decrease chloride levels. Option 3 is incorrect because a magnesium value will not give any additional information, and is therefore unnecessary. ‐ Administer dextrose 5% in water infusion at 125 mL/hour for five days. ‐ Closely monitor serum chloride level. ‐ Check serum magnesium level daily. ‐ Administer diuretics to prevent metabolic acidosis. | Critical words are multiple ampules and sodium bicarbonate. Recall that chloride losses occur with bicarbonate use or retention to choose option 2. |
2451 Which of the following laboratory test results would Correct answer: 1 When serum osmolality is higher than 295 mOsm/kg, there are more sodium and chloride the nurse expect to see in a client admitted with ions in proportion to water. Therefore, you would expect to see a higher serum chloride level. Cushing’s syndrome who has a serum osmolality of 298 In a client who has Cushing s syndrome, one would expect to see elevated serum chloride and mOsm/kg? sodium levels, elevated urinary chloride, and a decreased potassium level. All of the other options are inconsistent with the clinical presentation of Cushing s syndrome. ‐ Serum chloride level of 111 mEq/L | Critical words are Cushing's syndrome and osmolality of 298. Recognize that the osmolality is slightly high, indicating an increase of solutes in the serum, which are usually sodium and chloride. Recall normal lab values for electrolytes, and choose option 1, since this value is elevated. |
‐ Serum sodium level of 130 mEq/L ‐ Serum potassium level of 5 mEq/L ‐ Urine chloride level of 90 mEq/L | |
2452 Which of the following interventions should the nurse Correct answer: 3, 4 It is important for accurate results that the blood sample not be hemolyzed. A tourniquet can complete when preparing to draw a serum chloride cause turbulence in blood flow, and alter results by hemolyzing erythrocytes. If possible, blood level on a client? Select all that apply. should be drawn without the use of a tourniquet. Option 1 is incorrect because drawing blood from an implanted port used for chemotherapy is not recommended procedure. Option 2 is incorrect because the action of clenching and unclenching the fist can lead to hemolysis of RBCs and cause altered test results. The client does not need to be NPO prior to drawing any electrolyte sample. ‐ Draw the blood from an implanted port used for chemotherapy, if necessary. ‐ Do not ask the client to clench and unclench his hand prior to drawing the blood. ‐ Draw a 3–5 mL blood sample without a tourniquet, if possible. ‐ Ensure that the specimen is not hemolyzed. ‐ Ensure that the client has been NPO for at least six hours prior to drawing the blood sample. | Recall knowledge of the effect of hemolysis on blood samples to aid in making the correct selection(s). Recall that many routine labs, such as electrolytes, do not require NPO status. |
2453 Which one of the following clients does the nurse Correct answer: 3 In CHF, chloride is increased, and the administration of hypertonic saline could cause a lethal identify as being the least likely to benefit from the hypervolemia. In addition, mechanisms for excreting sodium, chloride, and water are administration of 3% saline solution for compromised in CHF, causing significant fluid and electrolyte alterations if such a therapy were hypochloremia? utilized. The clients in options 1 and 2 would benefit from administration of a hypertonic solution in a closely monitored situation. Option 4 is incorrect because a client diagnosed with alkalosis would benefit from administration of a hypertonic solution, since the client would most likely be experiencing chloride and sodium deficits. ‐ A client diagnosed with Addison s disease. ‐ A client who has been NPO for several days. ‐ A client diagnosed with congestive heart failure (CHF). ‐ A client experiencing metabolic alkalosis. | This question requires you analyze each option for the effect of additional sodium and ability to improve chloride level. Eliminate options 1, 2, and 4, since sodium could improve these conditions. |
2454 A client has developed weakness, lethargy, and Correct answer: 4 The clinical symptoms noted above (weakness, lethargy, and fatigue) are associated with fatigue because of a chloride imbalance. Which of the hyperchloremia. Option 1 is incorrect because the symptoms related to chloride deficiency can following statements to the client by the nurse is most be reversed with clinical treatment that restores serum chloride levels to normal. Option 2 is accurate? incorrect because there is no correlation between exercise and increase in serum chloride level. It is likely that increased exercise would lead to a chloride deficiency through sweat and perspiration losses. Option 3 is incorrect, because merely increasing salt intake will not automatically increase serum chloride levels. ‐ “Your symptoms are permanent, but you can learn to live with them.” ‐ “If you increase your exercise routine, your chloride level will return to normal.” ‐ “You will have to increase your salt intake in order to eliminate your symptoms.” ‐ “Your symptoms will disappear after your chloride level decreases to normal.” | Note that this question does not identify the type of chloride imbalance. Recognize that the symptoms reflect hyperchoremia to direct you to option 4. |
2455 The nurse should place highest priority on which of Correct answer: 1 With severe chloride and ECF losses, the blood pressure drops, potentially leading to shock, if the following interventions when caring for a client not corrected. The nurse should place the highest priority on monitoring the client to prevent admitted with symptoms related to a chloride level of development of potential complications and to maintain client safety. Although it might be 70 mEq/L and extracellular fluid (ECF) loss? necessary to assist the client to the bathroom, this is not the priority intervention. If there is sufficient ECF loss, the client would most likely be too weak to ambulate, and bedrest would be indicated. Option 3 is incorrect because starting IV therapy with a hypotonic solution could further exacerbate the client s clinical condition. Although it would be important to monitor the client s pulse, this again is not the priority intervention at this point in time. | The critical words are highest priority. Recognize that the chloride level is critically low and that fluid loss is also present to direct you to option 1. |
‐ Monitoring blood pressure for decrease in value ‐ Assisting client to the restroom to prevent injury ‐ Starting an IV with dextrose in water ‐ Monitoring pulse for pounding, slow rate | |
2456 Which of the following nursing diagnoses would be a Correct answer: 3 Neurological alteration related to chloride imbalance includes tremors and twitching of the priority for a client experiencing neuromuscular muscles with hypochloremia, or weakness and lethargy with hyperchloremia. These abnormalities related to a chloride imbalance? manifestations place the client at risk for injury. Options 1, 2, and 4 might be potential diagnoses, but more data would be needed to determine the priorities. ‐ Excess Fluid Volume ‐ Deficient Fluid Volume ‐ Risk for Injury ‐ Interrupted Thought Processes | The critical word in the question is neuromuscular. Eliminate options 1 and 2, since these are related to fluid imbalances, and eliminate option 4, since this might or might not be a related diagnosis. |
2457 An alert client is admitted with a diagnosis of Correct answer: 2 Documenting the history can assist in determining the cause of the elevated chloride level. hyperchloremia. The nurse should implement which of This should occur, if possible, prior to intervention. Option 1 is incorrect because isolation is the following as a priority intervention? not indicated for hyperchloremia. Option 3 is incorrect because ambulating independently without assessment is unsafe, since the client will probably have weakness and lethargy. Option 4 is incorrect because infusing saline is an unsafe intervention that would lead to increased chloride levels. ‐ Place the client on isolation precautions. ‐ Document the client’s history. ‐ Allow the client to ambulate ad lib unassisted. ‐ Start an IV of 0.9% sodium chloride infusion. | The critical words in the question are alert, hyperchloremia, and priority. Eliminate option 1, since it is not warranted. Eliminate option 3, since this would be unsafe until a full assessment was performed. And eliminate option 4, since the client does not need more sodium chloride. |
2458 A client with anorexia nervosa has been taught to Correct answer: 1, 2 Foods high in chloride include bananas and dates; green, leafy vegetables; seafood; poultry; increase intake of foods high in chloride. The nurse and dairy products. Canned soups tend to be higher in sodium, and chloride is combined with determines that teaching has been effective when the sodium as salt. client identifies which of the following foods as high in chloride? Select all that apply. ‐ Bananas ‐ Canned soups ‐ Apples ‐ Beef ‐ Pasta | Clients with anorexia nervosa usually have electrolyte deficiencies. Foods high in chloride are also generally foods high in sodium. |
2459 The nurse is teaching a class on osteoporosis to a Correct answer: 3, 5 Phosphorus is a critical mineral in the development of teeth and bones. It also plays a role in community group, and explains the role of calcium and acid–base balance (option 5), and it assists in regulating calcium levels (option 1). Phosphorus phosphorus. The nurse should include which of the is found in the cell membranes as phospholipids (option 2), and is essential in the metabolism following information? Select all that apply. of carbohydrates, fats, and proteins (option 4). ‐ Phosphate levels regulate potassium levels. ‐ Phosphate is found in the cell membrane as triglycerides. ‐ Phosphorus participates in the formation of teeth and bones. ‐ Phosphorus plays a minor role in the body's metabolism. ‐ Phosphorous also acts as an acid–base buffer. | Critical words are osteoporosis and phosphorus. Recall the functions and physiology of phosphate as they are involved in bone health to be directed to option 3. |
2460 The nurse understands that phosphorus levels might Correct answer: 1 The kidneys are responsible for 90% of phosphate excretion to maintain normal phosphate be abnormal in the client with which of the following balance. Impaired renal function usually results in decreased phosphorus excretion. The other conditions? options are incorrect. | Note that the question only indicates that level might be abnormal. Read each option, and analyze any correlation to phosphorus. Recall that phosphorus is reabsorbed and excreted via the kidneys to be directed to option 1. |
‐ Impaired renal function ‐ Hepatobiliary disease ‐ Asthma ‐ Abdominal ascites | |
2461 When reviewing lab results, the nurse notes a Correct answer: 4 Hypophosphatemia causes platelet destruction and dysfunction from lack of adenosine phosphorus level of 1.7 mg/dL, indicating triphosphate (ATP). Myocardial contractility is decreased, leading to shock (option 1); muscles hypophosphatemia. The nurse plans to assess the are weakened, leading to respiratory failure (option 2); and granulomatous activity is client for: depressed, leading to signs of infection (option 3). ‐ Tachycardia. ‐ Tachypnea. ‐ Elevated white blood cell count. ‐ Bruising. | Recognize that the phosphorus level indicates hypophosphatemia and that platelets are decreased to be directed to option 4. |
2462 A client has a phosphorus level of 5.3 mg/dL. The Correct answer: 1 The level reflects hyperphosphatemia, which has a reciprocal relationship with calcium. Since nurse plans to closely monitor the client for: the symptoms of hypocalcemia are often most prominent, the client should be assessed for signs of tetany. The other choices are associated with hypophosphatemia. ‐ Signs of tetany. ‐ Cardiac dysrhythmias. ‐ Elevated blood glucose. ‐ Gastrointestinal bleeding. | First, recognize that the phosphorus level reflects hyperphosphatemia. Recall that hypocalcemia occurs reciprocal to the elevated phosphorus to be directed to option 1. |
2463 The nurse notes that a client's serum phosphorus Correct answer: 3 Acute renal failure impairs the ability to excrete phosphorus normally, since the kidneys are level is 4.9 mEq/L. The nurse concludes that this is the major organs for excretion of phosphorus. The other options are incorrect. compatible with which of the following disorders in the client's recent history? ‐ Asthma ‐ Pituitary tumor ‐ Acute renal failure ‐ Peripheral vascular disease | First, determine that this is an elevated phosphorus level. Recall conditions associated with phosphorus excretion to be directed to option 3. |
2464 The nurse explains to a client with Correct answer: 2 Eggs are high in phosphorus content, along with dairy products, poultry, organ meats, red hyperphosphatemia that which of the following foods meat, legumes, and whole grains. For this reason, they should be limited in the diet when should be limited or avoided as a breakfast item? hyperphosphatemia is present. The other foods listed have less phosphorus content. ‐ Orange juice ‐ Eggs ‐ White bread toast ‐ Pancakes | Recall that foods high in phosphorus are proteins and dairy products. Recognize that option 2 is high in protein to choose it. |
2465 The nurse working on a surgical unit plans to monitor Correct answer: 2 A client who has had thyroidectomy might accidentally have had all or part of the parathyroid for hyperphosphatemia in a client who just underwent gland, which regulates calcium level, removed. If the client becomes hypocalcemic, then serum which procedure? phosphorus levels will rise. ‐ Tonsillectomy ‐ Thyroidectomy ‐ Total knee replacement ‐ Open reduction of a fracture | Analyze each option to determine if a risk for impaired phosphorus regulation exists. Recognize the risk for hypocalcemia with thyroidectomy, and recall this imbalance has a reciprocal or inverse relationship with phosphorus. |
2466 A client with anorexia, nausea, vomiting, and Correct answer: 1 A client who has had hypercalcemia is at risk for hypophosphatemia, since calcium and evidence of a pathological fracture has hypercalcemia. phosphorus have an inverse relationship in the body. The normal value is 2.5–4.5 mEq/L, Which of the following serum phosphorus levels would making option 1 the value that is below the normal range. the nurse anticipate finding on the serum laboratory report for this client? ‐ 1.9 mEq/L ‐ 2.8 mEq/L ‐ 3.9 mEq/L ‐ 5.0 mEq/L | Recognize the reciprocal relationship of phosphorus and calcium. Recall normal values of phosphorus, and choose option 1 because it is below normal. |
2467 For which of the following manifestations should the Correct answer: 2 Muscle spasms and tetany accompany hyperphosphatemia because of the corresponding nurse assess in a client with a history of chronic use of drop in serum calcium level. The other options listed are signs of hypophosphatemia. phosphorus‐containing laxatives? ‐ Profound muscle weakness ‐ Muscle spasms ‐ Malaise ‐ Muscle pain and tenderness | Recognize that chronic use of laxatives will lead to hyperphosphatemia and hypocalcemia. Recognize that muscle spasms correlate to these imbalances to choose option 2. |
2468 The nurse determines that which of the following Correct answer: 2 Rhabdomyolysis is the breakdown of striated muscle, which causes large amounts of clients is at greatest risk for developing phosphorus to enter the bloodstream. The other conditions listed place the client at risk for hyperphosphatemia? hypophosphatemia. ‐ A severely malnourished client undergoing refeeding ‐ A client with rhabdomyolysis ‐ A client with chronic antacid use ‐ A client with severe alcohol abuse | Analyze each option to determine risk for phosphorus retention or impaired regulation. Recall that phosphorus is intracellular, and released with muscle damage, to be directed to option 2. |
2469 The nurse utilizes which of the following concepts Correct answer: 2 Newborn levels of phosphorus are nearly twice those of an adult. Normal adult serum about phosphate levels in the newborn when phosphate levels in the adult range from 2.5 to 4.5 mg/dL, and newborn levels range from implementing client care? about 4.0 to 7.0 mg/dL (option 3). Phosphate levels vary throughout the day (option 1). Phosphorus is the second most abundant mineral in the body (option 4). ‐ Phosphate levels are consistent throughout the day. ‐ Phosphate levels in newborns are nearly twice the adult level. ‐ Normal serum phosphate levels range from 1.5 to 2.0 mg/dL. ‐ Phosphorus is the most abundant mineral in the body. | The critical word is newborn. Recognize that options 1, 3, and 4 are incorrect statements to eliminate them. |
2470 When caring for a client with a phosphorus level of Correct answer: 1 A decrease in phosphorus depletes available adenosine triphosphate (ATP) needed for cellular 1.8mg/dL, the nurse plans interventions to promote: energy production, which will be manifested in the client as fatigue and muscle weakness. Option 2 is incorrect; the kidneys try to reabsorb phosphorus in order to conserve it when levels are low. Option 3 is incorrect; bowel sounds and motility are already decreased with low phosphorus levels. Option 4 is incorrect; the rate and depth of breathing are already increased in response to hypoxemia experienced with hypophosphatemia. ‐ Conservation of energy. ‐ Increased renal perfusion. ‐ A decrease in peristalsis. ‐ Deep and rapid breathing. | Recall that the normal phosphorus level is 2.5–4.5 mg/dL. |
2471 A client experiencing hypophosphatemia has been Correct answer: 1, 5 Oxalate (in spinach and rhubarb) and phytates (found in bran and whole grains) can interfere started on sodium phosphate (Neutra‐Phos). The nurse with absorption of phosphate by binding with them in the intestines. Milk, orange juice, and instructs the client to avoid taking the medication with chicken do not pose this problem for absorption of phosphate. which of the following foods? Select all that apply. ‐ Whole grains ‐ Milk ‐ Orange juice ‐ Chicken ‐ Spinach | Calcium and phosphorus have an inverse relationship, and there is no harm from too much phosphorus in the diet. |
2472 The nurse would assess for signs and symptoms of Correct answer: 1 Severe vomiting and diarrhea deplete the body s many stores of electrolytes, including hypophosphatemia in the client who has which of the phosphorus. Prolonged use of aluminum‐ and magnesium‐containing antacids that bind to following predisposing clinical conditions? phosphorus (option 2) is a condition leading to hypophosphatemia. Balanced TPN solutions contain adequate levels of phosphorus (option 3). Vitamin D deficiencies lead to decreased intestinal absorption of phosphorus (option 4). ‐ Severe vomiting and diarrhea ‐ Occasional use of magnesium‐containing antacids ‐ Infusion of balanced total parenteral nutrition (TPN) solutions ‐ Vitamin D excess | Critical words are predisposing clinical conditions. Note the word severe in option 1, and recognize that phosphorus will be lost with vomiting and diarrhea. |
2473 When caring for a client with a serum phosphorus Correct answer: 2 Hypophosphatemia results in decreased ATP production, decreasing enzyme levels of 2,3‐ level of 1.9 mg/dL, the nurse should be alert to which DPG, which in turn keeps oxygen bound to hemoglobin and less available to the tissues. Clients of the following signs? with hypophosphatemia will experience hypoactive bowel sounds (option 1), muscle weakness (option 3), and paresthesias and anemia due to RBC fragility from low ATP levels (option 4). ‐ Hyperactive bowel sounds ‐ Dysrhythmias related to decreased oxygenation ‐ Increased muscle tone ‐ Polycythemia | Recall that phosphorus is needed for ATP production and oxygenation. Recognize that these deficiencies can contribute to irregular heart rhythms to direct you to option 2. |
2474 When caring for the client with hypophosphatemia, Correct answer: 3 Hypophosphatemia leads to a decline in 2,3‐DPG levels, reducing the release of oxygen to the the nurse should anticipate complaints of which of the tissues. Clients are more likely to have complaints of apprehension than euphoria (option 1). following? Decreased gastric motility leads to anorexia in the hypophosphatemic client (options 2 and 4). ‐ Euphoria ‐ Hunger ‐ Chest pain ‐ Thirst | Recognize the need for adequate phosphorus for oxygenation needs to direct you to option 3. |
2475 A client with chronic renal failure (CRF) has been Correct answer: 3 In order to maximize binding of the phosphate, phosphate binders should be given with the started on a phosphate binder for treatment of meal, or shortly after, for the medication to have contact with the phosphate in the food. hyperphosphatemia. To enhance effectiveness of the medication, the nurse plans to administer it: ‐ On an empty stomach. ‐ Thirty minutes before the meal. ‐ With meals. ‐ Two hours after a meal. | Note similarities in options 1 and 4 to eliminate them. Recognize the purpose and action of the medication to direct you to option 3. |
2476 A history of which of the following disorders in a Correct answer: 2 Chronic renal failure impairs the ability to excrete phosphorus normally, since the kidneys are client would lead the nurse to suspect a problem with the major organs for excretion of phosphorus. The other options are incorrect. phosphorus excretion? ‐ Bowel obstruction ‐ Chronic renal failure ‐ Chronic obstructive pulmonary disease ‐ Coronary artery disease | Recall that the kidneys are the major organ for excretion of electrolytes to direct you to option 2. |
2477 The nurse determines a client with a phosphorus level Correct answer: 3 Red meat is high in phosphorus content, as are dairy products, eggs, poultry, organ meats, of 4.9 mg/dL indicates an understanding of dietary legumes, and whole grains. For this reason, it should be limited in the diet when instructions when the client limits intake of which of hyperphosphatemia is present. The other foods listed have less phosphorus content. the following food items? ‐ Pork chops ‐ White rice ‐ Sirloin steak ‐ Green peas | Recall foods high in phosphorus to direct you to option 3. |
2478 The nurse determines that a client who chronically Correct answer: 1 Enemas can be high in phosphorus, putting the client at risk for hyperphosphatemia if they uses which of the following types of over‐the‐counter are frequently used. The other products listed do not have large amounts of phosphorus in products is at greatest risk for developing them. hyperphosphatemia? ‐ Enemas ‐ Cough preparations ‐ Cold preparations ‐ Bedtime sleeping aids | Analyze each option for phosphorus content, eliminating options 2, 3, and 4, since they are not high in phosphorus. |
2479 The physician orders a high‐phosphorus diet for the Correct answer: 2 Dairy products are naturally high in phosphorus. Although many food sources contain client with hypophosphatemia. You would expect to phosphorus, the greatest amounts are found in red and organ meats, fish, poultry, eggs, dairy see which of the following dietary items on the meal products, nuts, whole grains, and legumes. Carbonated soft drinks are also high in phosphorus, tray? although they are low in nutrient value. ‐ An apple ‐ Milk ‐ Lemonade ‐ White bread | The critical words are high‐phosphorus diet. Recall foods high in phosphorus to direct you to option 1. |
2480 When checking serum phosphorus levels on a Correct answer: 2 Children have higher phosphate levels than do adults because of their more rapid bone pediatric client with hypophosphatemia, the nurse development rate. Options 1, 3, and 4 are incorrect. Replacement therapy would result in an anticipates that: increase in phosphorus level. A venous, not arterial, sample is taken. Serum phosphate levels vary throughout the day. ‐ Levels will be highest in the early morning. ‐ Normal levels are slightly higher secondary to rapid skeletal growth. ‐ A decrease will be seen initially after starting replacement therapy. ‐ An arterial sample must be used to provide the most accurate level. | First, recognize that this is a pediatric client, and that pediatric phosphorus levels would normally be higher. Eliminate arterial sampling, as ABGs are the only common lab drawn arterially. After starting phosphorous replacement, the levels should rise. |
2481 When checking laboratory values on a client, the Correct answer: 2 A phosphate level of 1.7 mg/dL reflects hypophosphatemia. Since phosphorus is needed for nurse notes the phosphate level is 1.7 mg/dL. The formation of the red blood cell enzyme 2, 3‐DPG, deficiency states can lead to anemia, which nurse should also check laboratory values for evidence would be reflected by the low hemoglobin level. The other options are incorrect. Platelets also of which of the following? can be decreased. Calcium and phosphorus have a reciprocal relationship, and therefore calcium would be elevated. Magnesium would be decreased. ‐ An elevated platelet count | First, recognize that the phosphate level reflects hypophosphatemia. Recall the role of phosphorus in red blood cell production to direct you to option 2. |
‐ A decrease in hemoglobin level ‐ A decrease in calcium level ‐ An elevated magnesium level | |
2482 The nurse would assess for signs and symptoms of Correct answer: 2 Clients in diabetic ketoacidosis lose excessive amounts of phosphate in the urine. Clients with hypophosphatemia in the client who had which of the first‐degree burns do not experience severe fluid shifts that affect phosphorus levels (option following predisposing clinical conditions? 1). Hypomagnesemia can result in renal excretion of phosphorus (option 3). Decreased urine output results in less renal filtration of phosphorus (option 4). ‐ First‐degree burns ‐ Diabetic ketoacidosis ‐ Hypermagnesemia ‐ Oliguria | Critical words are hypophosphatemia and predisposing clinical conditions. Analyze each option, recalling that phosphorus is lost in the urine. Recognize that polyuria seen with acidosis will contribute to phosphorus loss to choose option 2. |
2483 The nurse would plan to include which of the Correct answer: 4, 5 Although phosphorus is found in a large number of food items, it is found in greatest following foods in the diet when providing discharge quantities in red and organ meats; fish; poultry; eggs; milk and milk products; legumes; whole teaching for a client with hypophosphatemia? Select grains; and nuts. The other options identify foods that have lesser amounts of phosphorus. all that apply. ‐ Green, leafy vegetables ‐ White bread ‐ Citrus fruits ‐ Eggs ‐ Liver | Recall foods high in phosphorus to choose options 4 and 5. |
2484 A client has just been started on total parenteral Correct answer: 3 TPN is a concentrated glucose‐and‐protein solution that utilizes phosphorus in metabolism of nutrition (TPN) for severe malnutrition. The nurse the nutrients and produces a shift of phosphorus into the cells, thus causing a serum determines that refeeding syndrome has occurred phosphorus deficit. Options 1, 2, and 4 are incorrect. These electrolytes also can be decreased after noting which of the following laboratory test in the refeeding syndrome. results? ‐ Magnesium 2 mg/dL ‐ Calcium 9.8 mg/dL ‐ Phosphorus 1.2 mg/dL ‐ Potassium 4.2 mEq/L | First, recall the purpose and content of TPN. Recall that electrolytes are utilized for enzyme reactions and metabolism, and recognize that the phosphorus level is low, to choose option 3. |
2485 Which of the following findings in a client’s history Correct answer: 1 Poor nutritional intake, vomiting, diarrhea, and overuse of antacids are related to alcoholism would alert the nurse to assess for signs and symptoms and alcohol abuse. These can lead to hypophosphatemia. During oliguria, the kidneys are of hypophosphatemia? unable to excrete phosphorus (option 2). Clients with prolonged (not short‐term) gastric suction are more likely to experience hypophosphatemia (option 3). Prolonged or continuous use of aluminum‐containing antacids (not occasional use) leads to hypophosphatemia (option 4). ‐ Withdrawal from alcohol ‐ The oliguric phase of acute tubular necrosis ‐ Short‐term gastric suction ‐ Occasional use of aluminum‐containing antacids | Recognize that some of the options have conditions that would contribute to a low phosphorus level, but identify option 1 as having the greatest risk. |
2486 Which of the following concurrent electrolyte Correct answer: 3 The client has hyperphosphatemia, since the normal phosphate level is 2.5–4.5 mg/dL. imbalances should the nurse anticipate while caring for Calcium and phosphorus have an inverse relationship in the body. For this reason, when a client with a phosphate level of 4.9 mg/dL? phosphorus levels are high, calcium levels are low. The other responses do not address this relationship. ‐ Hyperkalemia ‐ Hyponatremia ‐ Hypocalcemia | Recall the relationship between calcium and phosphorus to direct you to option 3. |
4.‐ Hypermagesemia | |
2487 A client has developed a serum phosphorus level of Correct answer: 2 In clients with hyperphosphatemia (normal is 2.5–4.5 mg/dL) from use of cytotoxic drugs, 5.0 mg/dL secondary to cytotoxic drug therapy. allopurinol (Zyloprim) may be ordered to decrease uric acid production, which prevents the Because of the hyperuricemia that also occurs with formation of uric acid calculi in the kidney and uric acid nephropathy. Aluminum hydroxide this therapy, the nurse anticipates administration of (Amphogel) is an antacid that would be useful in binding phosphates (option 1); acetazolamide which of the following medications? is a diuretic (option 3); and hydralazine (option 4) is an antihypertensive. ‐ Aluminum hydroxide (Amphogel) ‐ Allopurinol (Zyloprim) ‐ Acetazolamide (Diamox) ‐ Hydralazine (Apresoline) | Note that there are two conditions in the question hyperphosphatemia and hyperuricemia but the question addresses only treatment of the latter. Eliminate option 1, since this is used to treat hyperphosphatemia. Recall that allopurinol is used to reduce uric acid levels to choose option 2. |
2488 When providing discharge teaching for a client who Correct answer: 1 Food additives tend to be high in phosphates. For this reason, clients should be taught to read requires a diet high in phosphates, the nurse would food labels carefully. Vitamin D, not vitamin A, will enhance phosphorus absorption (option 2). include which of the following statements? Aluminum‐containing antacids decrease phosphorus absorption by binding to it (option 3). Soy‐ based foods are low in phosphorus (option 4). ‐ “High levels of phosphates are found in food additives.” ‐ “Increase your vitamin A intake to enhance phosphorus absorption.” ‐ “Aluminum‐based antacids increase phosphorus absorption.” ‐ “Soy and soy products are excellent sources of phosphorus.” | Key words are discharge teaching and diet high in phosphates. Recall knowledge of phosphorus sources to direct you to option 1. |
2489 The following neonates are admitted to the nursery. Correct answer: 3 Feeding a baby with a respiratory rate greater than 60 breaths/min orally increases the risk of The nurse should withhold the scheduled initial feeding aspiration. A heart rate of 118 is slightly below the normal range of 120–160 beats/min, but it on which newborn? is not a contraindication to feeding the infant. A hypothermic or SGA infant is at risk for hypoglycemia, and requires a consistent source of glucose. ‐ A neonate with a sustained heart rate of 118 beats/min ‐ A neonate with an axillary temperature of 97.5°F ‐ A neonate with a sustained respiratory rate of 68 breaths/min ‐ A neonate who is small for gestational age (SGA) | Simply recall that breathing and swallowing cannot be done at the same time. This will help you to select the infant with an elevated respiratory rate as the one who is at risk if given feedings orally. |
2490 The nurse hears the parents of a 26‐weeks'‐gestation Correct answer: 2 Families are often in a state of denial with the birth of a sick newborn. It is important for newborn tell family members, “We ll be ready to bring nurses to gently encourage the parents to be realistic. By agreeing with the parent s statement the baby home in a few weeks.” The most therapeutic (option 1), the nurse is prolonging the state of denial and making it more difficult for the response by the nurse is which of the following? parents to see the situation realistically. Some parents do benefit from professional counseling, but nurses still need to provide support when working with families. It is not important if the nursery is ready yet (option 4), and this distracts from the real issues this family is facing at this time. ‐ “I’m glad he’s doing so well.” ‐ “He probably won’t be ready to come home for a few months.” ‐ “A therapist could help you resolve your feelings of denial.” ‐ “Do you have the nursery ready yet?” | Use knowledge of therapeutic communication techniques to answer the question. The correct response is one that provides factual information about the infant’s status while respecting the parent’s potentially vulnerable status. |
2491 While observing parents interact with their high‐risk Correct answer: 2 The act of taping family pictures to the sides of the isolette promotes bonding and infant newborn, the nurse recognizes that teaching has been stimulation. Parents should wash their hands when they enter the unit, but do not need to effective if the parents do which of the following? wear gloves when in contact with their infant. Young children often harbor organisms that could be transmitted to vulnerable newborns, and should not have contact until the infant is moved out of the neonatal intensive care unit. ‐ Wear gloves every time they touch their baby. ‐ Put family pictures in the isolette. | The wording of the question tells you that the correct answer is an option that contains an appropriate action on the part of the parents. Use nursing knowledge and the process of elimination to make a selection. |
‐ Bring a 2‐year‐old sibling to visit. ‐ Turn off the cardiac monitor when at the newborn’s bedside. | |
2492 The nurse is developing a plan of care for an infant Correct answer: 3 A healthy respiratory rate for all newborns is 30–60 breaths/min. The other interventions are born at 28 weeks' gestation. A realistic goal for this not timely for a 28‐weeks'‐gestation infant at 1 week of age. infant is that within one week, the infant will: ‐ Drink from a bottle. ‐ Recognize the parents. ‐ Maintain her respiratory rate between 30 and 60 breaths/minute. ‐ Maintain her body temperature in a bassinet. | Specific knowledge of expected fetal development by gestational age is needed to answer this question. Use nursing knowledge and the process of elimination to make your selection. |
2493 The nurse is making patient assignments. Which baby Correct answer: 3 An LPN/LVN is qualified to perform certain procedures and care for stable patients (option 3). could be appropriately assigned to an LPN/LVN? An LPN/LVN is not qualified to admit a patient, administer blood, or make nursing decisions based on changes in a patient’s assessment. The infants identified in the other options require assessment and care by a registered nurse. ‐ An infant being admitted with hypoglycemia ‐ An infant scheduled to receive blood this shift ‐ A stable premature infant being fed every two hours ‐ An infant with rising bilirubin levels | Specific knowledge of scope of practice by RNs and LPNs/LVNs is needed to answer this question. Use this knowledge and the process of elimination to make your selection. |
2494 A newborn is receiving phototherapy for the Correct answer: 4 It is important to protect the infant s eyes from the bililight to prevent permanent damage. treatment of hyperbilirubinemia. The nurse evaluates The infant should be unclothed, to allow as much skin exposure to the bililight as possible. that teaching has been effective when the parents do Breastfeeding is not contraindicated with hyperbilirubinemia. Loose green stools are a side which of the following? effect of bilirubin excretion through the intestines. ‐ Cover the infant with a blanket while under the bililights. ‐ Stop breastfeeding because of the jaundice. ‐ Limit the infant’s formula intake due to loose green stools. ‐ Cover the infant s eyes before placing him under the bililight. | The core issue of the question is knowledge that the ultraviolet light used to treat jaundice can cause damage to the infant’s retinas. Specific knowledge of treatment of jaundice is needed to answer this question. Use nursing knowledge and the process of elimination to make your selection. |
2495 Which of the following would be most important to Correct answer: 1 Narcotics cross the placenta, and, if given close to delivery, can cause respiratory depression note as part of the initial assessment of a newborn’s in the newborn. The other three answers might warrant further investigation, but the priority history? at delivery is to establish and maintain an airway. ‐ Mother received meperidine (Demerol) 50 mg IV 20 minutes before delivery. ‐ Mother reports drinking a glass of wine with dinner each night. ‐ Mother’s age is 14. ‐ Mother’s blood type is O negative. | Note that critical words in the stem of the question are most important. This tells you that some or all of the options are correct, but you must select the priority option. Use nursing knowledge and the process of elimination to make your selection. |
2496 The parents of a preterm neonate ask why their baby Correct answer: 2 Preterm infants have minimal adipose tissue, so they lose heat more quickly through their gets cold so easily. The nurse explains that preterm skin. The skin is thin, with blood vessels near the surface, which increases the amount of heat neonates: lost through their skin. Because they are weak and neurologically immature, they aren t able to lie in a tight fetal position, allowing exposure of a greater percentage of the body to the air, which causes heat loss. In general, infants are not able to shiver to produce body heat when they are cold. ‐ Are able to shiver to produce body heat. ‐ Have minimal body fat to retain body heat. ‐ Have blood vessels that are deep under the skin surface. ‐ Lose heat faster because they lie in a fetal position. | The wording of the question tells you that the correct option must be a true statement. Use knowledge about the physical characteristics of premature infants and the process of elimination to make your selection. |
2497 While feeding an infant, the nurse notices white, Correct answer: 2 The primary sign of an oral yeast infection, or thrush, is the presence of white patches in the adherent patches on the infant s gums and buccal mouth that tend to bleed if they are touched. This is not a normal finding, and is unrelated to cavity. The nurse should take which of the following whether vitamin K was given at delivery, or maternal history of herpes simplex. actions? ‐ Document this normal finding. ‐ Further evaluate for yeast infection. ‐ Verify that vitamin K (AquaMEPHYTON) was given at delivery. ‐ Assess for maternal history of herpes simplex. | The core issue of the question is the significance of white patches in the infant’s mouth. Eliminate option 1 because this is not a normal finding. Eliminate option 3 because vitamin K aids in blood clotting. Herpes simplex (cold sores) would present as vesicles, not white patches. |
2498 Which of the following data would alert the nurse Correct answer: 4 Signs of dehydration in an infant include dry mucous membranes, sunken fontanel, and dry that the infant is experiencing dehydration? skin turgor. The other assessment data are expected findings in an infant. ‐ Urine‐specific gravity 1.006 ‐ Urine volume 2 mL/kg/hr ‐ Low serum sodium ‐ Sunken anterior fontanel | Specific knowledge of manifestations of dehydration is needed to answer this question. Use nursing knowledge and the process of elimination to make your selection. |
2499 A newborn male is admitted to the nursery 15 Correct answer: 4 The highest priority after delivery is to maintain and support respiratory function. This infant minutes after delivery. His skin is mottled, and mucous is demonstrating initial signs of respiratory deficiency. Once this is done, the nurse may check membranes are blue; he is active, and is wrapped in a the umbilical cord for bleeding, measure temperature, and, finally, check for visible blanket. The primary nursing assessment should be to deformities. assess which of the following? ‐ Umbilical cord for bleeding ‐ Infant’s temperature ‐ Visible deformities ‐ Patent airway | Follow the ABCs of resuscitation airway, breathing, and circulation to select the correct answer to this question. Airway and breathing are assessed before circulation (bleeding). |
2500 Which nursing intervention is appropriate in the care Correct answer: 1 Infants use additional oxygen and glucose when faced with cold stress. Infants with RDS are of an infant with respiratory distress syndrome (RDS)? already compromised, so it is important to keep environmental temperatures stable to minimize their oxygen and glucose requirements. A complete assessment could increase oxygenation requirements even further (option 2). Chest physiotherapy (option 3) might or might not be needed. There is no specific evidence in the question that meconium is present (option 4). ‐ Maintain a neutral thermal environment. ‐ Perform a complete gestational age assessment. ‐ Perform chest physiotherapy twice a day. ‐ Suction meconium from airway as needed. | Note that the core issue of the question is care of an infant with respiratory distress. First, eliminate option 2 because of the word complete. Choose option 1 over options 3 and 4 because there is no evidence in the question that these are needed. |
2501 A 26‐weeks'‐gestation neonate has received 80–100% Correct answer: 2 This infant has been receiving high levels of oxygen for several weeks, and is at risk for oxygen via mechanical ventilation for two weeks, and retinopathy of prematurity (ROP). All preterm infants who receive oxygen should have a has received several blood transfusions for anemia. thorough eye exam done by an ophthamologist prior to discharge. It is important to administer The nurse should plan for which of the following the minimum amount of oxygen to infants, to decrease the risk that this condition will interventions? develop. Oxygen should be weaned, and not withdrawn suddenly. Artificial surfactant may be administered within the first several days of life to decrease the risk of respiratory distress syndrome (RDS). ‐ Begin phototherapy. ‐ Schedule an eye exam by an ophthalmologist prior to discharge. ‐ Discontinue oxygen immediately. ‐ Administer surfactant via the endotracheal tube. | The core issue of the question is knowledge of the effects of long‐term oxygen therapy for a neonate. Use nursing knowledge and the process of elimination to make your selection. |
2502 The nurse is caring for an infant born to a mother Correct answer: 3 Hepatosplenomegaly (enlarged liver and spleen) can be an early sign of HIV infection in an who is HIV‐positive. Which sign in the newborn should infant. All other assessment data are within normal limits. be evaluated further? ‐ Absence of tears ‐ White bumps on nose ‐ Enlarged liver ‐ Fine, red rash over trunk | The core issue of the question is discriminating normal findings from abnormal findings in a newborn born to a mother who is HIV‐positive. Use nursing knowledge and the process of elimination to make your selection. |
2503 An infant of a diabetic mother (IDM) is admitted to Correct answer: 4 An infant of a diabetic mother is at risk for hypoglycemia, and should be monitored closely the nursery. Which of the following is the priority after delivery. All other interventions are important, but are not the highest priority. nursing intervention at this time? Therefore, these can be completed once the blood glucose level has been measured and treated, if necessary. ‐ Clean the cord with alcohol. ‐ Administer vitamin K (AquaMEPHYTON) intramuscularly. ‐ Complete a gestational age assessment. ‐ Assess the infant’s blood glucose level. | Note the critical word priority in the stem of the question. This tells you that multiple options are technically correct, but you must decide which has the greatest importance at this time. Note the connection between the word diabetic in the stem and the word glucose in the correct option to help you make a selection. |
2504 A father asks how the bilirubin lights make the Correct answer: 3 Phototherapy assists the body in converting unconjugated bilirubin to conjugated bilirubin, bilirubin level go down. The nurse’s best reply is which which is water‐soluble and easier for the body to eliminate. The other statements are not of the following? accurate explanations. ‐ “The lights prevent more bilirubin from being released into your baby’s body.” ‐ “Exposing the skin to the air helps get rid of the jaundice. The bililights really just keep the baby warm while this occurs.” ‐ “The bililights help convert the bilirubin to a form the baby can get rid of.” ‐ “The bililights release a substance in the body that attacks the bilirubin and destroys it.” | The core issue of the question is knowledge of how phototherapy assists in lowering the bilirubin levels of a jaundiced newborn. Use nursing knowledge and the process of elimination to make your selection. |
2505 The nurse assesses a newborn and obtains the Correct answer: 3 This infant has signs of Erb's paralysis. It is important to provide passive range of motion on following information: Left arm limp and extended; left the affected side to prevent muscle wasting. The infant should not be positioned on the hand internally rotated; positive grasp reflex affected side. Occasionally, a splint may be applied, but a cast is not indicated. bilaterally; no response on left side to Moro reflex. What is the most appropriate nursing intervention for this infant? ‐ Assess for congenital hip dysplasia. ‐ Turn infant to left side. ‐ Passive range of motion ‐ Prepare supplies for a cast application. | The core issue of this question is recognition of and appropriate intervention for an infant with Erb's paralysis. Use nursing knowledge and the process of elimination to make your selection. |
2506 A neonatal nurse is attending a high‐risk delivery, and Correct answer: 1 Narcotics cross the placenta, and can cause respiratory depression in a neonate when given is told that the mother received morphine sulfate IV 30 shortly before delivery. Naloxone (Narcan) is the drug of choice to reverse respiratory minutes ago. The nurse should be prepared to give depression in the neonate caused by narcotics. Insulin would be given for hyperglycemia. which of the following medications to the infant Double doses of vitamin K are not given. Magnesium sulfate is given to the mother to prevent immediately after delivery? eclampsia. ‐ Naloxone (Narcan) ‐ Regular insulin ‐ Double dose of vitamin K (AquaMEPHYTON) ‐ Magnesium sulfate | The core issue of the question is knowledge of adverse effects of morphine sulfate. Use nursing knowledge and the process of elimination to make your selection. The wording of the question tells you that there is only one correct option. |
2507 Which of the following infants is at greatest risk for Correct answer: 1 SGA infants often experience intrauterine growth restriction related to decreased blood flow the nursing diagnosis of High Risk for Infection? to the placenta, which increases their risk for infection. In comparison, the infants in the other options are at less risk for infection. | The wording of the question tells you the correct answer is the infant who is at greatest risk for infection. Knowledge of the relative risk for infection in each of the neonates listed is needed to answer this question. Use nursing knowledge and the process of elimination to make your selection. |
‐ 38 weeks' gestation, small for gestational age (SGA) ‐ 39 weeks' gestation, diagnosed with caput succedaneum ‐ 38 weeks' gestation, cesarean delivery for breech presentation ‐ 41 weeks' gestation, infant of a diabetic mother (IDM) | |
2508 An infant with fetal alcohol syndrome is about to be Correct answer: 3, 2, 4, Infants with fetal alcohol syndrome have an increased risk of feeding difficulties related to discharged home with foster parents. Place in order 1 hyperactivity. Nutrition is a key concern for this infant for proper growth and development. the priority of the nurse in teaching the following Infection prevention is the next concern, since this will help to maintain healthy physiological topics to the foster parents. Click and drag the options condition. The immunization schedule has third priority because it is also related to prevention below to move them up or down. of communicable diseases and infection. Finally, although toy safety is important, it is the fourth priority because newborns are not developed sufficiently to play with toys. ‐ Toy safety ‐ Infection prevention ‐ Feeding methods ‐ Immunizations | Use Maslow’s hierarchy of needs to guide priority setting. Physiological needs come first, followed by safety needs, then psychosocial needs. |
2509 A nurse is admitting a baby to the nursery 30 minutes Correct answer: 4 A maternal history of diabetes increases the risk of hypoglycemia in the newborn, and this after delivery. Which information from the mother's infant should be monitored closely. If the woman received meperidine (Demerol), most of the history should be of greatest concern? drug would be metabolized within three hours, and should not cause respiratory depression in the infant at delivery. A marginal placenta previa increases the mother's risk of bleeding during pregnancy, but should not cause significant complications in the newborn after delivery. Membranes ruptured greater than 24 hours prior to delivery increase the risk of infection for mother and infant. ‐ Received meperidine (Demerol) IV three hours prior to delivery. ‐ Marginal placenta previa ‐ Membranes ruptured 10 hours prior to delivery. ‐ Preexisting insulin‐dependent diabetes mellitus | Knowledge that the infant born to the diabetic mother is at risk for hypoglycemia will aid in determining the correct answer. Remember that the information of greatest concern is related to the greatest risk for the infant's safety. |
2510 A baby's mother is hepatitis B–positive. Which of the Correct answer: 1 Infants born to mothers who are hepatitis B–positive should receive a hepatitis B vaccine following interventions is most important when within 12 hours of birth to decrease their risk of acquiring the infection from maternal planning care for this newborn? exposure. It is appropriate to assess for HIV risk factors in all infants, not just those at risk for hepatitis B. An exchange transfusion and isolating the infant are not appropriate in this situation. ‐ Administer hepatitis B vaccine within 12 hours after delivery. ‐ Assess for HIV risk factors. ‐ Prepare for exchange transfusion. ‐ Isolate the newborn. | The key focus of the question is the risk of transmission of hepatitis B from mother to infant. The correct answer would be the option that contains a nursing action to reduce the risk of disease transmission for this infant. |
2511 The nurse is observing a graduate nurse administering Correct answer: 4 Gavage feedings should be administered over 5–10 minutes to decrease the risk of GI a gavage feeding to a newborn. The nurse must distress. All of the other options are correct when administering a gavage feeding. intervene if which of the following is observed? ‐ The gavage tube is measured from the tip of the ear to the sternum to the xiphoid process. ‐ The stomach contents are aspirated prior to administering the feeding. ‐ The infant is offered a pacifier during the feeding. ‐ The feeding is administered within 15 seconds. | Critical words are "[t]he nurse must intervene," which means that the graduate nurse is performing an incorrect step in the process. Therefore, you are looking for an incorrect method. Knowledge of how to administer a gavage feeding is necessary to choose the correct answer. |
2512 The nurse realizes that a neonate born at 34 weeks' Correct answer: 4, 5 Preterm infants lack adequate surfactant to keep their alveoli open during expiration. This can gestation might not have enough surfactant, so the lead to the development of respiratory distress syndrome (RDS), which would be evidenced by nurse should observe closely for: (Select all that apply.) signs of respiratory distress, including sternal retractions and tachypnea. Abdominal distention, jaundice, and jitteriness are not directly related to RDS. ‐ Abdominal distention. ‐ Jaundice. ‐ Jitteriness. ‐ Sternal retractions. ‐ Tachypnea. | The focus of the question is assessment findings in a premature infant with the potential for developing respiratory distress. Eliminate options 1, 2, and 3 because abdominal distention, jaundice, and jitteriness are not directly related to RDS. |
2513 A nurse observes that a preterm infant's urine output Correct answer: 2 Adequate hydration is evidenced by urine output of 1–3 mL/kg/hr and specific gravity is less than 1 mL/kg/hr with a specific gravity greater &lt;1.013. This newborn shows signs of dehydration. Metabolic acidosis and electrolyte than 1.020. The nurse determines that this indicates: imbalance would be determined by serum, not by urine analysis. ‐ Adequate hydration. ‐ Dehydration. ‐ Metabolic acidosis. ‐ Electrolyte imbalance. | Knowledge of specific gravity and adequate urinary output will aid in determining the correct answer. |
2514 Which neonate requires the closest observation by Correct answer: 2 Central cyanosis is always considered abnormal, and warrants further evaluation. All of the the nurse? other assessments are normal for an infant. ‐ The neonate with irregular respirations at 30–40 breaths/minute ‐ The neonate whose color became cyanotic during the first feeding ‐ The baby who startles at loud sounds ‐ The neonate with enlarged breast tissue | The key focus of the question is abnormal assessment findings in need of further investigation. Eliminate options 1, 3, and 4 because these assessment findings are normal for an infant. Knowledge of the ominous sign of central cyanosis and the need for close observation will also help to determine the correct answer. |
2515 The nurse can best promote parental bonding with a Correct answer: 1 Parents should be given a Polaroid picture of the infant before the baby is transported. Calling high‐risk newborn by doing which of the following? the unit to check on their baby might help bonding, but seeing the baby is more effective. Parents are typically allowed to visit as often and for as long as they want. It is important to be honest with parents, even if the prognosis is poor. ‐ Giving the parents a Polaroid picture of the baby prior to transport to the NICU ‐ Encouraging the parents to call the NICU daily ‐ Allowing parents to see the newborn for 15 minutes three times each day ‐ Not discussing how sick the infant is | Knowledge of care of the family and of promoting attachment with the high‐risk infant will aid in choosing the correct answer. |
2516 The nurse is observing a student practicing Correct answer: 4 Infants are obligate nose breathers. A gastric tube may be inserted to keep the stomach maintaining a patent airway on a newborn doll. The decompressed and allow for easier lung expansion. But if it is inserted nasally, it occludes one nurse must intervene if which of the following is nare, and might make respiratory effort more difficult. All other options are correct observed? interventions for maintaining a patent airway. ‐ Suctioning the mouth, then the nose ‐ Squeezing the bulb syringe before insertion into mouth ‐ Positioning the infant in a "sniffing" position ‐ Inserting a nasogastic tube | Critical words are "[t]he nurse must intervene if which of the following is observed." This means that you are looking for an incorrect action on the part of the student. Knowledge of the correct procedure to maintain a patent airway will be necessary to determine which of the answers gives an incorrect action. |
2517 A priority nursing intervention for a newborn Correct answer: 1 The newborn reacts to hypothermia by burning brown fat to produce body heat. This process experiencing hypothermia is: requires oxygen and glucose. When an infant experiences hypothermia, glucose and oxygen needs increase, and hypoglycemia can result. The infant might require oxygen administration, but the need should always be assessed first. Infants should be rewarmed slowly to prevent hypotension. Phototherapy is not indicated. ‐ Monitoring for hypoglycemia. ‐ Rapidly rewarming the newborn. ‐ Administering oxygen. ‐ Starting phototherapy. | The key focus of the question is nursing care to reduce the risk to the newborn from hypothermia; a risk related to hypothermia is hypoglycemia. Eliminate option 2 because infants should be rwarmed slowly to prevent hypotension. Eliminate option 3 because no data have been given to support this action at this time. Eliminate option 4 because phototherapy is not indicated in this situation. |
2518 The nurse is caring for a 30‐weeks'‐gestation infant at Correct answer: 2 Changes in the gastrointestinal assessment, including abdominal distention, occur with NEC. risk for necrotizing enterocolitis (NEC). The nurse The other choices should be reported to the health care provider, but are not related to NEC. should observe for which of the following? ‐ A decrease in respiratory rate ‐ Abdominal distention ‐ Discolored feet ‐ A bulging fontanelle | The key focus of the question is necrotizing enterocolitis, a digestive disorder. Eliminate options 1, 3, and 4 because these assessment findings should be reported to the health care provider, but are not related to NEC. |
2519 The parents of a 28‐weeks'‐gestation neonate ask the Correct answer: 2 Neonates generally aren't able to effectively coordinate sucking, swallowing, and breathing nurse, "Why does he have to be fed through a tube in until 34–36 weeks' gestation. If fed orally before that time, they are at greater risk of his mouth?" The nurse's best response is that: aspiration. Typically, they will be fed through a gavage tube until they are able to drink from a bottle or breastfeed. Intake can be accurately assessed with oral and gavage feedings. The stomach of a preterm infant can digest small amounts of formula or breast milk. Thrush is an oral yeast infection commonly caused during passage through the birth canal, and gavage feedings will not prevent it from occurring. ‐ "It allows us to accurately determine the baby's intake." ‐ "The baby's sucking, swallowing, and breathing are not coordinated yet." ‐ "The baby's stomach cannot digest formula at this time." ‐ "It helps to prevent thrush, an infection that could affect the baby's mouth." | The wording of the question indicates that the correct option is also a true statement. Knowledge of the preterm neonate's capabilities regarding nutritional intake will help to choose the correct answer. |
2520 Which nursing diagnosis should be the highest priority Correct answer: 1 Newborns compensate for hypothermia by metabolizing brown fat. This process requires of the nurse who is caring for a preterm newborn? glucose and oxygen. Preterm newborns are at risk for hypoglycemia and respiratory distress, so hypoglycemia can further increase their needs for oxygen and glucose, and can cause serious complications. The other diagnoses are appropriate, but not the highest priority. ‐ Ineffective Thermoregulation related to lack of subcutaneous fat ‐ Anticipatory Grieving related to loss of "perfect delivery" ‐ Imbalanced Nutrition: Less than Body Requirements related to immature digestive system ‐ Risk for Injury related to thin epidermis | Remember ABCs. The correct answer would be the option that contains a true statement that could negatively impact breathing and circulation. Cold stress can contribute to respiratory distress. |
2521 A nurse is caring for a 12‐hour‐old newborn. The Correct answer: 2 Jaundice in an infant less than 24 hours old is often caused by Rh or ABO incompatibility. A nurse notes a yellow tint to the baby's skin and sclera. direct Coombs' test determines the presence of maternal antibodies in the baby's blood. The What lab test should the nurse anticipate being other lab tests are not related to hyperbilirubinemia. ordered? ‐ Blood glucose ‐ Direct Coombs' ‐ Blood culture ‐ Arterial blood gas (ABG) | The focus of the question is jaundice. Eliminate options 1, 3, and 4 because they do not provide data related to this abnormal condition. |
2522 A newborn is admitted with a diagnosis of transient Correct answer: 2 Transient tachypnea of the newborn (TTN) is caused by delayed absorption of fetal lung fluid. tachypnea of the newborn (TTN). When planning Nursing care is focused on supporting oxygenation needs to allow the newborn's body to nursing care for this baby, the nurse's goal should be reabsorb the fluid. TTN causes tachypnea, so stimulating respirations is not appropriate. to: Inadequate surfactant is related to prematurity and respiratory distress syndrome. Meconium in the airway results in meconium aspiration syndrome, and is usually associated with fetal asphyxia. ‐ Promote adequate quantity of surfactant. ‐ Promote absorption of fetal lung fluid. ‐ Assist in the removal of meconium from the airway. ‐ Stimulate respirations. | Recall that transient tachypnea is associated with amniotic fluid in the newborn lungs. Eliminate options 1, 3, and 4 because they are not related to this problem. |
2523 The nurse is assigned to a baby receiving Correct answer: 3 Infants should be unclothed while receiving phototherapy, to increase the circulating blood phototherapy. Which assessment warrants further volume exposed to the phototherapy light. However, this increases the risk of temperature investigation by the nurse? instability, and infant temperatures should be monitored carefully. Any temperature below 97.6°F is considered hypothermia, and requires immediate attention. Loose green stools and a yellow tint to the skin are expected findings with hyperbilirubinemia. A fine, raised red rash might appear on the infant's skin as a side effect of the phototherapy, and does not require intervention. ‐ Loose green stools ‐ Yellow tint to the skin ‐ Temperature 97.2°F ‐ Fine, red rash on trunk | The focus of the question is an abnormal finding in the present treatment of jaundice. Eliminate options 1, 2, and 4 because they are normal findings in a newborn with jaundice being treated with phototherapy. |
2524 A mother is crying while sitting by the isolette of her Correct answer: 4 Reflection allows the client to verbalize her feelings. The nurse should not give the client false premature newborn, who was born at 25 weeks' hope. Clients often do not know why they feel the way they do, and it is not helpful to ask gestation. The most therapeutic communication by the them. Some clients might find comfort in a religious leader, but care should be taken not to nurse is: stereotype the client's religious beliefs. ‐ "It's important to try not to worry. Let's hope that everything will work out." ‐ "Can you tell me some specific things that have gotten you upset?" ‐ "Would you like me to call the hospital chaplain? This has helped many others." ‐ "This must be hard for you. Can you share with me what has you most concerned at this time?" | The key focus of the question is therapeutic communication. The correct answer would be the option that validates the client's feelings and invites further communication by the client. |
2525 A baby's mother is HIV‐positive. Which of the Correct answer: 2 Administering zidovudine (ZDV, formerly AZT) to the mother prenatally and intrapartally, and following interventions is most important for the nurse to the infant immediately after delivery, decreases the prenatal risk of transmission of HIV by to include when planning care for this newborn? 60–70%. Breastfeeding is contraindicated in an HIV‐positive mother because the virus can be passed through breast milk. Cuddling the infant is important, but not the highest priority in this situation. Decreasing environmental stimulation is not indicated. ‐ Encourage the mother to breastfeed. ‐ Administer zidovudine (ZDV) after delivery. ‐ Cuddle the baby as much as possible. ‐ Place the baby's crib in a quiet corner of the nursery. | The core focus of the question is reduction of HIV transmission from mother to infant. Eliminate option 1, as it would increase risk of transmission. Eliminate options 3 and 4, as they are not related to HIV transmission. |
2526 The nurse is preparing to initiate bottle feeding in a Correct answer: 4 Any sustained respiratory rate higher than 60 breaths/minute increases the risk of aspiration preterm infant. In which of the following situations in the infant. Oral feedings should be withheld on infants experiencing tachypnea to decrease would the nurse withhold the feeding and notify the the risk of aspiration. An apical heart rate of 120 is a normal finding. Although an infant health care provider? temperature of 97.2°F is considered hypothermia, it would not be a contraindication to oral feedings. Jaundice can be considered abnormal, but it alone would not be an indication to withhold an oral feeding. ‐ Apical heart rate 120 ‐ Axillary temperature 97.2°F ‐ Yellow tint to skin and sclera ‐ Respiratory rate 72 | The focus of the question is identification of abnormal findings that would contraindicate feeding. The correct answer would be the option that contains an abnormal finding related to a condition that could be exacerbated by feeding. |
2527 A newborn's mother has a history of prenatal narcotic Correct answer: 2, 5 Infants experiencing neonatal abstinence syndrome (NAS) often have an increased need for abuse. Which of the following nursing interventions non‐nutritive sucking, and offering a pacifier would help meet this need. The other three would be most appropriate for this infant? Select all answers are incorrect because they all involve increasing environmental stimulation. This is that apply. contraindicated in these infants because they are already hyperstimulated from the drug withdrawal process. Place the infant on the right side or in semi‐Fowler's position to avoid possible aspiration of vomitus or secretions. ‐ Hold and rock the infant as much as possible. ‐ Offer the infant a pacifier. ‐ Place a mobile on crib. ‐ Encourage family members to stroke and talk to the infant. ‐ Position the infant on the right side or in semi‐Fowler's position. | The focus of the question is a newborn experiencing abstinence syndrome, a condition associated with hyperstimulation. The correct answer(s) would be the option(s) that reduce stimulation and quiet the infant. |
2528 The nurse is caring for a preterm infant who is at risk Correct answer: 2 Increasing occipital frontal circumference (OFC) is an indication of increasing intracranial for an intraventricular hemorrhage (IVH). Which daily pressure, which could result from an intraventricular hemorrhage (IVH). It should be assessed assessment is most critical for this infant? in infants at risk for an IVH every 8–12 hours. Changes in blood pressure also might occur, but the changes might not be as noticeable, and can be caused by many other problems. Changes in Moro reflex are not an indication of an IVH. Intake and output are routine measurements that are not directly helpful in this situation. ‐ Blood pressure ‐ Occipital frontal circumference (OFC) ‐ Intake and output ‐ Moro reflex | The key focus of the question is intraventricular hemorrhage, frequently manifested by increasing fetal head circumference. Associate the word "intraventricular" in the stem with the assessment of the head in the correct option, recalling that soft fontanelles will lead to increasing head circumference in the presence of bleeding in the cranium. |
2529 The nurse is admitting a neonate two hours after Correct answer: 2, 5 Nasal flaring and retractions could be signs of respiratory distress, and require immediate delivery. About which assessment data should the intervention. The other assessment data are normal findings for a neonate at 2 hours of age. nurse be concerned? Select all that apply. ‐ Hands and feet blue. ‐ Nasal flaring ‐ Minimal response to verbal stimulation ‐ Apical heart rate 156 ‐ Retractions | Critical words are "neonate two hours after delivery" and "About which assessment data should the nurse be concerned". This indicates the need to look for an abnormal sign that indicates a problem. Only options 2 and 5 indicate abnormal findings. |
2530 Of the following nursing diagnoses for a high‐risk Correct answer: 3 Maintaining a patent airway is the highest priority when providing care for a newborn. A newborn, which requires the most immediate newborn's condition will deteriorate rapidly without a patent airway. intervention by the nurse? ‐ Acute Pain related to frequent heelsticks ‐ Imbalanced Nutrition: Less than Body Requirements related to limited oral intake ‐ Ineffective Airway Clearance related to pulmonary secretions ‐ Deficient Knowledge related to infant care needs | Remember ABCs. Maintaining an open airway would be the priority. |
2531 On admission to the nursery, it is noted that the Correct answer: 1 This newborn is at risk for sepsis caused by prolonged rupture of membranes and maternal mother's membranes were ruptured for 48 hours fever. A primary sign of sepsis in the newborn is temperature instability, particularly before delivery, and her temperature is 102°F. What hypothermia. An irregular respiratory pattern is normal. Jitteriness could be a sign of information from this newborn's assessment should hypoglycemia. Excessive bruising is often related to a difficult delivery with an increased risk of the nurse evaluate further? hyperbilirubinemia. ‐ Axillary temperature 97.2°F ‐ Irregular respiratory rate ‐ Jitteriness | The focus of the question is the risk for neonatal sepsis. The correct answer would be the option that contains abnormal assessment data related to infection in the newborn. Eliminate options 1, 3, and 4 because they are not related to sepsis. |
4.‐ Excessive bruising of presenting part | |
2532 The nurse would take which of the following actions Correct answer: 2 Neonatal abstinence syndrome, or drug withdrawal, causes hyperstimulation of the neonate's as part of nursing care of the baby experiencing nervous system. Nursing interventions should focus on decreasing environmental and sensory neonatal abstinence syndrome? stimulation during the withdrawal period. ‐ Place stuffed animals and mobiles in the crib to provide visual stimulation. ‐ Position the baby's crib in a quiet corner of the nursery. ‐ Avoid the use of pacifiers. ‐ Spend extra time holding and rocking the baby. | Recall that neonatal abstinence syndrome is accompanied by hyperstimulation of the central nervous system. The correct answer would be the option that contains a strategy to reduce stimulation. Eliminate options 1, 3, and 4, as they increase stimulation. |
2533 A mother was diagnosed with gonorrhea immediately Correct answer: 1 A newborn can become infected with gonorrhea as it passes through the birth canal. after delivery. When providing nursing care for her Gonorrhea can cause permanent blindness in the newborn, called ophthalmia neonatorum. All baby, an important goal of the nurse is to: babies' eyes are treated with an antibiotic prophylactically after birth. ‐ Prevent the development of ophthalmia neonatorum. ‐ Lubricate the eyes. ‐ Prevent the development of thrush. ‐ Teach the danger of breastfeeding with gonorrhea. | The focus of the question is providing safety for the newborn of a mother with a gonococcal infection. The correct answer would be the option that addresses preventing the spread of the infection from the mother to the infant. |
2534 A full‐term newborn weighed 10 pounds, 5 ounces at Correct answer: 2 Newborns experiencing macrosomia are more likely to experience birth injuries during birth. A priority nursing diagnosis for this baby is: delivery. Nursing care after delivery should focus on assessing for signs of birth injuries and intervening, if appropriate. ‐ Ineffective Thermoregulation related to lack of subcutaneous fat. ‐ Risk for Injury related to macrosomia. ‐ Impaired Gas Exchange related to lack of surfactant. ‐ Deficient Knowledge related to newborn care. | The core focus of the question is an abnormally large infant. The correct answer would be the option that addresses a risk for this newborn. |
2535 The nurse finds the mother of a 28‐weeks'‐gestation Correct answer: 3 Reflecting on what the client said offers her an opportunity to share her feelings. Avoid giving infant crying in her room. The mother states, "I just false reassurance or asking a client "why" they feel the way they do. know my baby is going to die." What is the most therapeutic response by the nurse? ‐ "I know this seems overly optimistic, but it is likely that everything will be fine." ‐ "Why do you think that?" ‐ "You seem very worried about what will happen to your baby." ‐ "My baby was born at 27 weeks, and he is fine now." | The key focus of the question is therapeutic communication. The correct answer would be the option that validates the client's feelings. |
2536 A nurse is admitting the infant of a diabetic mother Correct answer: 2 Infants of diabetic mothers are at risk for hypoglycemia after delivery. A primary sign of (IDM). At 1 hour of age, the nurse notices that the hypoglycemia is jitteriness. The newborn is not showing any signs of hypoxia, so oxygen would newborn is very jittery. Which action by the nurse is not be appropriate. Putting the newborn under a warmer or on a monitor would not harm the most appropriate? infant, but these are not the priority interventions at this time. ‐ Begin oxygen by nasal cannula. ‐ Assess the newborn's blood sugar. ‐ Place the newborn under a radiant warmer. ‐ Initiate use of a cardiac/apnea monitor. | Knowledge of the care of the newborn of a diabetic mother will aid in answering the question correctly. Recall that blood glucose is the primary test to assess diabetic control. |
2537 A newborn's temperature is 97.4°F. The priority Correct answer: 4 This newborn has a low temperature, and the nurse must intervene quickly to prevent nursing intervention is to: complications related to hypothermia. Wrapping the baby in warm blankets and covering the head will help prevent heat loss through conduction, convection, and radiation, and are the most important initial interventions. A baby can lose a large amount of heat from his head, so keeping it covered will help stabilize the temperature. ‐ Notify the physician or nurse practitioner immediately. ‐ Take the newborn to the nursery, and observe for two hours. ‐ Reassess the temperature in four hours. ‐ Wrap the newborn in two warm blankets, and place a cap on the head. | The focus of the question is an abnormal finding indicating cold stress. The correct answer would be an intervention to counteract this problem and safely warm the newborn. |
2538 A nurse is assessing a neonate born 12 hours ago, and Correct answer: 2 This newborn has signs of jaundice, which include a yellow tint to the sclera and skin. Jaundice notes a yellow tint to the sclera. The nurse should read is considered pathologic if it occurs in the first 24 hours of life, when it is most often caused by the medical record for what other assessment that is Rh or ABO incompatibility. It would be important to assess both the mother's and newborn's important to note at this time? blood type and Rh factor to determine if this could be causing the jaundice. A bilirubin level should also be obtained. ‐ Blood glucose ‐ Blood type and Rh factor of mother and newborn ‐ Most recent blood pressure ‐ Length of time prior to delivery that membranes ruptured | This question requires additional assessment of jaundice, an abnormal finding in a newborn at this age. The correct answer would be the option that contains information related to pathologic jaundice. |
2539 The nurse determines that the client who is at Correct answer: 2 A rapid labor and delivery can cause exhaustion of the uterine muscle and prevent greatest risk for postpartum hemorrhage is the one contraction of the uterus after delivery, which controls the amount of bleeding. The infants in who delivered which of the following infants? the other options either were not identified for length of labor (option 1) or were delivered after 9‐hour and 12‐hour labors (options 3 and 4). ‐ 5‐pound, 12‐ounce infant ‐ 6‐pound infant after a 2‐hour labor ‐ 7‐pound, 6‐ounce infant after a 9‐hour labor ‐ 8‐pound infant after a 12‐hour labor | First, eliminate options that are similar (options 3 and 4), because they identify infants of similar size who were delivered within reasonably similar time frames. Choose option 2 over 1 because of the very short duration of labor. |
2540 The nurse is preparing for beginning‐of‐shift rounds Correct answer: 2 A hematoma is a collection of blood in the pelvic tissue caused by damage to a vessel wall on assigned postpartum clients. After reviewing the without laceration of the tissue. A gestational diabetic client is more prone to have a large assignment, the nurse plans to assess for hematoma baby that could cause tissue trauma during delivery. She had to be delivered with forceps, formation in which of the following clients, who is at which is another high‐risk factor for developing a postpartum hematoma. Maternal age does greatest risk for this postpartum complication? not affect the development of a hematoma (options 1 and 4). The size of the newborn, rather than the number, determines risk for hematoma formation (option 3). ‐ A 17‐year‐old client who gave birth to a small‐for‐gestational‐age infant ‐ A 26‐year‐old client with gestational diabetes and forceps delivery of a large‐for‐gestational‐age infant ‐ A 35‐year‐old client having twins ‐ A 40‐year‐old client having her first infant | The core issue of the question is knowledge of fetal size at the time of delivery as a risk factor for hematoma formation. Eliminate option 1 first because of the infant s size; next, eliminate option 3 because twins are more likely to be small than large. Choose option 2 over 4 because option 4 addresses age rather than size. |
2541 The clinic nurse receives a telephone call from a Correct answer: 3 Late‐postpartum hemorrhage occurs anytime after the first 24 hours postdelivery. The causes seven‐day postpartum client who states she is having of early hemorrhage are uterine atony, DIC, hematomas, and lacerations. This leaves retained increased vaginal bleeding and asks if it is serious, and placental fragments as the cause for late‐postpartum hemorrhage. The retained fragments what could be causing it. The nurse suspects which of undergo necrosis, forming fibrin deposits. These deposits form polyps, which eventually detach the following, the most common cause of such late‐ from the myometrium, causing hemorrhage. postpartum hemorrhage? ‐ Uterine atony ‐ Disseminated intravascular coagulation (DIC) ‐ Retained placental fragments ‐ Laceration | Specific knowledge of how to discriminate etiology of early‐ and late‐postpartum hemorrhage is needed to answer this question. Use nursing knowledge and the process of elimination to make your selection. |
2542 The postpartum nurse would utilize which of the Correct answer: 3 Adequate fluid intake (up to 3,000 mL/day) prevents urinary stasis, dilutes urine, and flushes following therapeutic measures to help prevent a out waste products, all of which help to prevent UTI. Bedrest is of no value (option 1). The urinary tract infection (UTI) in an assigned client who client should attempt to void every few hours, rather than waiting to regain a sense of a full has just delivered an infant? bladder (option 2). While intake of juices is healthy (option 4), it is the large volume of fluid consumed that aids in flushing out wastes. ‐ Promote bedrest for 12 hours postdelivery. ‐ Discourage voiding until the bladder regains the sensation of being full. ‐ Force fluids to at least 3,000 mL per day. ‐ Encourage the intake of orange, grapefruit, or apple juice. | The core issue of the question is knowing how to decrease risk for UTIs. Recall that increased fluid intake and intake of foods and beverages that yield acidic urine (cranberry juice, ascorbic acid in high doses) can decrease the risk. With this in mind, eliminate each of the incorrect options easily. |
2543 A newly postpartum client is going into hypovolemic Correct answer: 4 Increasing the rate of IV fluids is an effective initial measure necessary to replace lost fluid shock as a result of uterine inversion. Which initial volume that occurs in uterine inversion caused by hemorrhage. Blood products might also be order should the nurse expect to implement to restore necessary, but generally take some time to obtain from the blood bank. Oxygen also would be fluid volume? given (option 1) to increase perfusion to tissues, but does not restore circulating volume. An oxytocic drug (option 2) will help to limit further bleeding, but will not restore circulating volume. Monitoring pulse is an assessment, and will not limit the condition (option 3); an intervention is needed in this situation. ‐ Administer oxygen at 3–4 L/min via nasal cannula. ‐ Administer an oxytocic drug via IV. ‐ Monitor heart rate every five minutes. ‐ Increase the IV infusion rate. | The core issue of the question is fluid volume replacement. Eliminate each of the incorrect options because they do not replace fluids, although they might be helpful in a specific way. |
2544 A client delivered by vaginal birth after cesarean Correct answer: 4 A common risk associated with VBAC is uterine rupture. Pain in the abdomen and between (VBAC). During postpartum recovery, she suddenly the scapulae can occur when the uterus ruptures, the hemorrhage is concealed, and blood complains of severe pain in the abdomen and between accumulates under the diaphragm. This is an emergency, and requires immediate medical her scapulae. She has a minimal amount of vaginal intervention, which is initiated by calling the physician. The client may be put in modified bleeding. The nurse s priority action should be to: Trendelenburg position to manage shock, not Trendelenburg (option 1); uterine atony is not the problem (option 2); and IV fluids would be increased, rather than maintained (option 3). ‐ Put the client in Trendelenburg position. ‐ Continue to assess for uterine atony. ‐ Maintain the rate of IV fluids. ‐ Notify the physician promptly. | Note the core issue of the question is recognition of internal hemorrhage due to uterine rupture. Eliminate each of the incorrect options because they fail to provide effective treatment for this medical emergency. |
2545 The nurse interprets that which client would be Correct answer: 3 The traditional definition of early postpartum hemorrhage after a vaginal birth is more than classified as having early postpartum hemorrhage? 500 mL in the first 24 hours. Given this, each of the other options is incorrect. ‐ A client who had a blood loss of 350 mL in the first 24 hours after delivery ‐ A client who had a blood loss of 1,000 mL in the first 48 hours after a cesarean delivery ‐ A client with a more than 500 mL blood loss in the first 24 hours postdelivery ‐ A client with a blood loss of 500 mL in the first 48 hours postdelivery | The core issue of the question is an understanding of criteria for postpartum hemorrhage. Use nursing knowledge and the process of elimination to make your selection. |
2546 To prevent early‐postpartum hemorrhage in the Correct answer: 2 Maintaining contraction of the uterus is important in controlling bleeding from the placental woman who just had a cesarean birth, the recovery site. Assessing the fundus every 15 minutes helps assure that this is taking place. Early nurse should implement which of the following detection of a boggy uterus can lead to actions that will prevent hemorrhage. While the other measures? assessments might be appropriate for the client, they will not help to detect early‐postpartum hemorrhage. ‐ Maintain an IV rate of 125 mL/hr. ‐ Assess the uterus for firmness every 15 minutes. ‐ Assess abdominal dressing for drainage. | Note that the critical word in the question is prevent. Use the process of elimination to make a selection. Note that none of the incorrect options address the root cause of postpartum hemorrhage. |
4.‐ Monitor urinary output. | |
2547 A client has been taking methylergonovine maleate Correct answer: 1 Late‐postpartum hemorrhage most frequently occurs due to retained placental tissue. (Methergine) for uterine subinvolution. It has not been Dilatation and curettage is the vaginal procedure of choice to remove retained tissue from the effective in controlling late‐postpartum hemorrhage. uterus. The other procedures are abdominal surgeries, and are not used to treat this condition. Which procedure does the clinic nurse anticipate will be ordered to correct the cause of this condition? ‐ Dilatation and curettage ‐ Laparotomy ‐ Hysterotomy ‐ Hysterectomy | Consider first that the client is bleeding, and determine the most likely cause, retained placental fragments. Then visualize each of the surgeries described, and use the process of elimination and nursing knowledge to choose the one that will effectively treat the condition. |
2548 The husband of a client who delivered four days ago Correct answer: 2 Before providing further instructions, explain that these are signs of postpartum blues, which calls the nurses station stating that his wife is happy is a normal process related to hormonal changes. Option 1 does not address the client s one minute and crying the next. He states, “She never concern. (In this case, the husband is the client.) Option 3 is excessive, and option 4 is was like this before the baby was born.” The nurse s unnecessary and excessive. initial response should be to: ‐ Tell him to ignore the mood swings, as they will go away. ‐ Reassure him that this is normal in the postpartum period because of hormonal changes. ‐ Advise him to contact a psychiatrist immediately; this is the first step in postpartum psychosis. ‐ Instruct the husband in signs and symptoms of postpartum psychiatric disorders. | The core issue of the question is recognition and appropriate instruction regarding mood changes in the postpartum period. Use nursing knowledge and the process of elimination to make your selection. |
2549 The postpartum nurse reviews the clinical Correct answer: 4 Uterine atony accounts for 80–90% of all early (within first 24 hours) hemorrhage. Infants assignment, and determines that the client at greatest weighing between 5 and 7 pounds would not overdistend the uterus (option 1). The client s risk for early‐postpartum hemorrhage is which of the age (option 2) also does not increase the incidence of postpartum hemorrhage. Endometritis following? (option 3) could cause late‐postpartum hemorrhage, not early hemorrhage. ‐ A client with an infant weighing 5 pounds, 7 ounces ‐ A client who is 17 years old ‐ A client with endometritis ‐ A client with uterine atony | First, recall the causes of early postpartum hemorrhage, which might help you to easily select the correct option. Alternatively, eliminate option 3 first because it is a different postpartum complication, then option 1 because the baby is small, and finally option 2 because it is irrelevant. |
2550 While performing a postpartum assessment, the Correct answer: 1 Excessive bleeding must be evaluated and managed immediately to prevent excessive loss of nurse notices the client’s lochia is very heavy. Which of blood and shock. Repositioning the client will do nothing. Waiting will only hurt the client. the following should be the nurse’s first response? Bleeding should be assessed immediately. ‐ Palpate and massage the uterus. ‐ Elevate the head of the bed to Fowler’s position. ‐ Reevaluate in 10 minutes to see if the problem has corrected itself. ‐ Place the client in modified Trendelenburg position. | The core issue of the question is knowledge of measures to reduce postpartum bleeding. With this in mind, eliminate option 3 first because it delays action. Choose option 1 over options 2 and 4 because positioning will not correct a boggy uterus. |
2551 The postpartum nurse would use which of the Correct answer: 2 Calf pain upon dorsiflexion of the foot indicates a positive Homans' sign, a sign of following interventions as most effective in detecting thrombophlebitis. If there is any question of thrombus formation, the legs, especially the the development of thrombophlebitis? calves, should not be massaged, because doing so could dislodge a potential clot. Petechiae are not a clinical sign of thrombophlebitis. ‐ Monitoring the client’s temperature ‐ Assessing for Homans' sign ‐ Asking the client if she has pain when the nurse massages her leg ‐ Assessing for petechiae on the lower extremities | Specific knowledge of assessment of thrombophlebitis is needed to answer this question. You can easily eliminate option 3, because legs should not be massaged, and option 4, because the problem is not evidenced by bleeding into skin tissue. Choose option 2 over option 1 because it is a more specific sign than elevated temperature. |
2552 The nurse expects that the client’s lochia and location Correct answer: 2 The fundus should be midline, two fingerbreadths below the umbilicus, with dark red lochia, of the uterine fundus on the second day after delivery which might contain small clots. This explains lochia rubra. Option 1 explains lochia alba, which would most likely be documented as which of the does not occur until about 10 days postpartum. Option 3 describes lochia serosa, which usually following? occurs between days 4 and 9 postpartum. Option 4 describes a complication of subinvolution. ‐ Yellowish‐white lochia with no clots, fundus three fingerbreadths below the umbilicus ‐ Dark red lochia with small clots, fundus midline and two fingerbreadths below the umbilicus ‐ Pinkish‐brown lochia with no clots, fundus midline and four fingerbreadths below the umbilicus ‐ A large amount of bright red lochia with large clots, fundus midline and at the umbilicus | Specific knowledge of changes in lochia during the postpartum period is needed to answer this question. Use nursing knowledge and the process of elimination to make your selection. |
2553 The clinic nurse working with women during the Correct answer: 3 Option 3 indicates that the mother is interacting with her infant and accepting responsibility postpartum period would interpret that which of the for self‐care and care of her infant. Options 1 and 2 indicate potential psychiatric problems following behaviors exhibited by a client is typical that require additional investigation. Option 4 requires investigation of why the mother is not during this time? eating well, which is important during the postpartum period. ‐ The mother experiences feelings of depression as she assumes responsibility for her new baby. ‐ The mother does not take care of herself, but attends well to her infant. ‐ The mother is receptive to learning about her baby, and demonstrates bonding. ‐ The mother does not sleep or eat well, but tries to take care of herself. | The core issue of the question is healthy adaptation to life with a new infant. Choose the option that indicates the greatest resemblance to healthy behavior and adaptive coping. |
2554 The nurse has been caring for a postpartum client Correct answer: 4 Applying a cold pack will minimize swelling, bleeding, and discomfort. Labial hematomas do diagnosed with a right labial hematoma. When not necessarily need to be drained (option 3); they will usually resolve on their own. A hot pack planning care, the nurse should explain to the client is incorrect because it will increase engorgement at the site via vasodilation (option 1). Witch that: hazel will not decrease the swelling in the area (option 2). ‐ A hot pack will be used to increase comfort and to decrease blood loss. ‐ Witch hazel pads will be applied to reduce discomfort. ‐ She needs to give informed consent for surgery to incise and drain the hematoma. ‐ A cold pack will help to decrease bleeding and reduce the swelling. | The core issue of the question is knowledge of heat and cold applications to aid in reabsorption of hematoma. Use basic nursing knowledge and the process of elimination to make your selection. |
2555 A postpartum patient develops thrombophlebitis in Correct answer: 3 Bedrest is recommended following a diagnosis of thrombophlebitis, to help prevent an her right calf, and is started on heparin therapy. Which embolus. Clients receiving heparin therapy should avoid aspirin and nonsteroidal anti‐ of the following interventions would be most inflammatory drugs because they will potentiate the action of heparin. Once the appropriate? thrombophlebitis resolves, the client should not experience any residual effects. ‐ Encourage the client to ambulate to reduce lower‐extremity swelling. ‐ Encourage the client to take salicylic acid (aspirin) for leg pain. ‐ Instruct the client to remain on bedrest to reduce the possibility of embolism. ‐ Inform the client that she will experience numbness in her leg for several months. | The core issue of the question is knowledge of measures to prevent complications of thrombophlebitis. Note that options 1 and 3 are opposites, which means that one of them likely is correct. Use knowledge that activity can cause thrombi to yield emboli to choose option 3 over 1. |
2556 A postpartum client receiving heparin asks whether Correct answer: 3 A woman can continue to breastfeed while on heparin. Heparin will not affect the she can continue to breastfeed. Which of the following breastfeeding, and requires no special precautions. Heparin does not pass to the breast milk. is the best advice for the nurse to give? ‐ She should stop breastfeeding immediately. ‐ She can continue to breastfeed, but must assess the baby daily for ecchymotic spots. ‐ Heparin will not affect the breastfeeding, and requires no special precautions. ‐ She should alternate breast‐ and bottle feeding. | Specific knowledge of acceptable medication to use while breastfeeding is needed to answer this question. Use nursing knowledge and the process of elimination to make your selection. |
2557 During a home visit, a postpartum client complains of Correct answer: 1 These symptoms are suggestive of mastitis, and require prompt attention by the client s a reddened, swollen, and tender breast 10 days after physician. It is not therapeutic to wait for the symptoms to resolve on their own. Breastfeeding delivery. Based on this finding, the nurse would advise does not have to be stopped if mastitis is present. the client that: ‐ These symptoms suggest an inflammatory or infectious process, and require immediate physician notification. ‐ She should mention it to her physician at her two‐week checkup, because it will be abnormal if it continues after two weeks. ‐ This is normal breast engorgement, and should subside within another week. ‐ She has to stop breastfeeding immediately until the swelling and redness resolve on their own. | The core issues of the question are recognition of mastitis and applying knowledge of appropriate intervention. Use nursing knowledge and the process of elimination to make your selection. |
2558 The postpartum nurse is caring for a client who Correct answer: 2 DIC is a disorder of widespread microvascular clotting that can result in bleeding once clotting developed disseminated intravascular coagulopathy factors are consumed. Vaginal bleeding can be excessive if a coagulation disorder is present. (DIC) following a placenta previa. The nursing priority Antibiotics will not affect a clotting disorder. DIC does not affect a client s reflexes. Homans' would be to: sign is associated with thrombophlebitis, not with DIC. ‐ Assess Homans' sign hourly. ‐ Frequently monitor her vaginal bleeding. ‐ Administer antibiotics. ‐ Monitor reflexes hourly. | The core issue of the question is knowledge that DIC can be evidenced by bleeding once clotting factors have been consumed. When answering questions about DIC, look first for an option that addresses bleeding. |
2559 The postpartum nurse is caring for a client with Correct answer: 1, 3, 4 Symptoms of pulmonary embolus include sudden onset of dyspnea, chest pain, anxiety, thrombophlebitis. The nurse monitors the client for diaphoresis, elevated pulse, and hypotension. Confusion can also occur because of decreased which of the following symptoms of complications? oxygenation to the brain resulting from loss of adequate gas exchange in the affected area of Select all that apply. the lung. The client would not experience chills or fever; these are more indicative of infection. ‐ Confusion ‐ Sudden high fever ‐ Dyspnea ‐ Diaphoresis ‐ Sudden onset of chills | Specific knowledge of manifestations of pulmonary embolism is needed to answer this question. Use nursing knowledge and the process of elimination to make your selection. |
2560 The nurse observes that a postpartal client who Correct answer: 3 Heavy bleeding is an abnormal postpartal finding. Early hemorrhage can be caused by uterine delivered three hours ago has saturated four peripads atony or by a lacerated cervix. Palpation of the uterine fundus can determine uterine atony. with bright red blood during the past hour. Her vital The client did not report excessive perineal pain or pressure, which would be caused by a signs are stable. The nurse assesses her bleeding to be: hematoma. Blood is retained in the tissue with a hematoma, and is not usually visible on the perineal pad. Subinvolution causes the majority of late‐postpartal hemorrhages occurring after the first 24 hours following delivery. ‐ A normal indication of subinvolution. ‐ Abnormal, requiring inspection for a hematoma. ‐ Abnormal, indicating the need to palpate the uterine fundus. ‐ Normal, requiring no further action by the nurse. | Recognize the assessment findings in the question as abnormal; the time period indicates early‐postpartal hemorrhage. Eliminate option 1 because subinvolution causes the majority of late‐postpartal hemorrhages occurring after the first 24 hours following delivery. Eliminate option 2 because blood is retained in the tissue with a hematoma, and is not usually visible on the perineal pad. Eliminate option 4 because this is not a normal finding. |
2561 A client has just been diagnosed with mastitis. The Correct answer: 1 The infant will not be affected by the infection in the mother's breast; it does not get into the nurse should place highest priority on teaching the breast milk. The client needs to empty her breasts frequently to prevent stasis of milk, which client which of the following? can cause further problems with the mastitis. Stopping the breastfeeding or binding the breasts would do nothing to help with the mastitis. ‐ Breastfeed frequently to prevent any stasis of milk. ‐ Nurse the infant only from the uninvolved breast. ‐ Stop breastfeeding totally to allow the infection to heal. ‐ Tightly bind the breasts with elastic bandages. | The focus of the question is client education to facilitate resolution of mastitis. The correct answer would be the action that facilitates breastfeeding and milk flow. |
2562 The nurse notices that a client who has just had her Correct answer: 2 The client is demonstrating symptoms of depression. Primiparas without support are at first baby is staying in her room, has had no visitors, higher risk for postpartum depression. Determining her lack of support systems will help to has not taken a shower since delivery, and keeps her assess her risk for depression and the need to develop an appropriate plan to deal with this back turned to the baby's bassinet when the baby is in concern. The client's vital signs and symptoms of pain will not assist the nurse in helping the the room. What further evaluation should the nurse client with symptoms of depression. make? ‐ Assess the client's vital signs. ‐ Look at the chart to see if the client had anyone with her during labor and what kind of support system she has. ‐ Check to see if the client listed a contact person in case of emergency. ‐ Assess the client for pain. | Recall that adequate support systems are a key factor to psychological adaptation. The correct answer would be the option that contains assessment of client support. |
2563 The nurse would place high priority on assessing Correct answer: 2 A client with gestational diabetes is more likely to have a large baby that could cause tissue which of the following postpartum clients who would trauma during delivery. The use of forceps during delivery is another risk factor for developing be most likely to develop a hematoma? a postpartal hematoma. The age factor does not affect the development of a hematoma nor does a small for gestational age infant. ‐ A 17‐year‐old who had a small‐for‐gestational‐age infant. ‐ A 26‐year‐old with gestational diabetes who required forceps to deliver her large‐for‐gestational‐age infant. ‐ A 35‐year‐old having twins. ‐ A 40‐year‐old having her first infant. | The key focus of the question is hematoma, a complication associated with trauma to maternal tissues at the time of delivery. The correct answer would be the option that presents the greatest potential for maternal tissue trauma at birth. |
2564 The nurse determines that the client with which of Correct answer: 3 Late‐postpartal hemorrhage occurs anytime after the first 24 hours postdelivery. The causes the following is at greatest risk for late‐postpartal of early postpartal hemorrhage include uterine atony, DIC, hematoma, and lacerations. hemorrhage? Retained placental fragments are the primary cause of late‐postpartal hemorrhage. The retained fragments undergo necrosis, forming fibrin deposits. These deposits form polyps, which eventually detach from the myometrium, causing hemorrhage. ‐ Uterine atony ‐ Disseminated intravascular coagulation (DIC) ‐ Retained placental fragments ‐ Hematomas and lacerations | Knowledge of the causes of late‐postpartal hemorrhage will be needed to answer this question. Focus on the critical word "late" in making a selection. |
2565 Twenty‐four hours after delivery, a postpartal client Correct answer: 4 The client is complaining of symptoms that might indicate a urinary tract infection. Cystitis is develops a temperature of 99.8°F, has been voiding not an uncommon infection after delivery. The low‐grade temperature, dysuria, and frequent small amounts frequently, and complains of pain upon voidings of small amounts are symptoms of cystitis. Several factors place women at risk for urination. The nurse would take which of the following postpartal urinary tract infections. These include bladder trauma, stasis of urine caused by actions? hypotonicity of the bladder, and catheterization during labor. Fifty percent of women who are catheterized during labor develop a urinary tract infection. The other answers do not address urinary tract infection. ‐ Notify the nursery that the client might have an infection, and separate the baby from the mother. ‐ Explain that some women have these symptoms. ‐ Suspect that the client needs to complain because of stress. ‐ Notify the physician of the symptoms. | Recognize these assessment findings as abnormal and indicative of urinary tract infection. The correct answer would be the option that promotes client safety. Reporting these findings so treatment can begin protects the client |
2566 A postpartal client complains of sweating, has a Correct answer: 4, 5 All of these symptoms are normal findings in the first 24 hours postpartum. The body is temperature of 99.6°F, and has voided over 2,000 mL beginning to return to the prepregnancy state. The nurse can explain to the client that these since delivery. Nursing actions would include which of are normal symptoms, and the reasons for the diaphoresis, frequent urination, and low‐grade the following? Select all that apply. temperature. Offering comfort measures such as a dry gown and linens will enhance the client's feeling of well‐being. ‐ Notify the physician; the client is showing symptoms of puerperal infection. ‐ Draw a blood culture and sensitivity. ‐ Isolate the client in a private room. ‐ Explain to the client that these are normal postpartal changes. | Recognize these assessment findings as normal in the postpartal woman. Eliminate options 1, 2, and 3 because they are actions based on abnormal findings not observed in this client. |
5.‐ Offer a fresh, dry gown and bed linens to enhance comfort. | |
2567 The nurse explains to a breastfeeding client that Correct answer: 4, 5 Cracked and bleeding nipples provide an entrance for bacteria. Therefore, frequently checking which of the following is generally helpful in the nipples for cracking will help to prevent mastitis, as will adequate instruction in proper preventing mastitis? Select all that apply. breastfeeding techniques prenatally. Routine antibiotics are not given to prevent mastitis. Clients can develop bacteria that are antibiotic‐resistant. Waiting too long between feedings and decreasing nursing time can lead to stasis of milk and clogged ducts, which contribute to the development of mastitis. ‐ Decreased nursing time, to prevent sore nipples ‐ Decreased frequency in nursing, so the infant will be hungrier at each feeding ‐ Prophylactic antibiotics for all nursing mothers ‐ Frequent assessment of the condition of the nipples, to prevent cracking and bleeding ‐ Prenatal instruction on proper breastfeeding techniques | The wording of the question tells you that the correct answer would be the option that contains a nursing action to prevent mastitis. Eliminate options 1, 2, and 3 because they do not help prevent mastitis. |
2568 Which of the following statements would the nurse Correct answer: 4 The client should take all the prescribed medication, and ask her physician about include in educating a client with mastitis? recommending an analgesic. The client should empty her breasts frequently, either through nursing the baby or through pumping her breasts. This will prevent stasis of the milk and further clogged ducts, which could cause further complications and development of an abscess. ‐ "You can stop the antibiotics when you feel better." ‐ "You should give the baby formula until you are better." ‐ "You can take any kind of over‐the‐counter analgesics, since medications do not go into breast milk." ‐ "Nurse your baby frequently to prevent stasis of milk and potential further complications." | Knowledge of the nursing care of the client with mastitis will aid in choosing the correct answer. The wording of the question tells you the correct answer is a true statement. |
2569 Which nursing measure would be appropriate for the Correct answer: 3 Leg exercises promote venous blood flow and prevent venous stasis while the client is still on nurse to implement to prevent thrombophlebitis in the bedrest. Options 1 and 2 increase the risk for thrombophlebitis, while option 4 might not be immediate recovery period following a cesarean birth? realistic. ‐ Place a rolled blanket underneath the client's knees. ‐ Limit fluid intake for the first 24 hours. ‐ Assist the client in performing leg exercises every two hours. ‐ Ambulate the client as soon as the anesthesia wears off. | The key focus of the question is prevention of thrombophlebitis; improving circulation prevents this complication. Eliminate options 1 and 2 because they increase the risk for thrombophlebitis, while option 4 might not be realistic. |
2570 Which of the following items of clothing worn by a Correct answer: 3 The postpartal woman is prone to develop superficial thrombophlebitis due to increased postpartal client could possibly promote a problem for amounts of clotting factors in the blood during the postpartal period, as well as an increased the woman? amount of platelets and increased adhesiveness. Any restrictive clothing on the legs should be avoided. ‐ Pantyhose ‐ Short athletic socks ‐ Knee‐highs ‐ Colored tights | Recognize that all options include statements about hosiery; the probable complication to be considered is thrombophlebitis. Eliminate option 1 because it prevents circulatory stasis. Eliminate options 2 and 4 because these items do not impede circulation. |
2571 Which of the following actions by a lactating client Correct answer: 4, 5 Preventing stasis of the milk and emptying the breast frequently will help prevent mastitis. would the nurse support to help the client prevent The other options will not. mastitis? Select all that apply. ‐ Apply vitamin E cream to soften the nipples. ‐ Wear a tight, supportive bra. ‐ When the client's nipples are sore, offer the infant a bottle. ‐ Encourage the client to breastfeed her infant frequently. ‐ Instruct the mother in breastfeeding shortly after birth, and review correct techniques often. | The question is worded in a positive manner, indicating that the correct options are items that will prevent mastitis. Use knowledge about the prevention of mastisis to choose the correct answer. |
2572 The home health nurse is making a home visit to a Correct answer: 3 The signs of a postpartal infection would include a temperature of greater than 100.4°F on postpartal client. The nurse would document and two successive days after the first 24 postpartal hours; tachycardia; foul‐smelling lochia; and report which of the following as a symptom of pain and tenderness of the abdomen. The pinkish lochia is normal, and the temperature might infection? indicate a cold or breast milk coming in. Bradycardia would be an unrelated finding. ‐ Pinkish lochia ‐ Bradycardia ‐ Abdominal tenderness ‐ Oral temperature of 99.2°F | The focus of the question is an infection, an abnormal finding in postpartum. Postpartal infections are usually located in the uterus. The correct answer would be the option that contains abnormal assessment data associated with uterine infection. |
2573 Which of the following nursing interventions would Correct answer: 3 A full bladder can cause uterine atony, and contribute to bleeding. If a client has have the greatest direct effect on reducing postpartum hemorrhaged, a Foley catheter might also be needed to allow accurate measurement of urine hemorrhage? output, which is an indicator for kidney function. Overly aggressive stimulation of the fundus could cause decreased uterine tone; this is detrimental, because overstimulation of the uterine muscle fibers can contribute to uterine atony. Avoid the Trendelenburg position because it has been reported to interfere with cardiac and respiratory function by increasing pressure on chemoreceptors and decreasing the area for lung expansion. A tocolytic agent relaxes the uterus; in this case, an oxytocic drug to contract the uterus would be indicated. ‐ Continuous fundal massage to decrease bleeding and facilitate uterine contraction ‐ Trendelenburg position to facilitate cardiac function ‐ Bladder catheterization to maintain uterine contraction ‐ Administration of a tocolytic drug | Eliminate option 1 because overstimulation can cause uterine relaxation, and option 4 because a tocolytic drug causes uterine relaxation; uterine relaxation would increase bleeding. Option 3 is incorrect because maternal position does not impact hemorrhage. |
2574 The nurse interprets that which factor in a client's Correct answer: 1 Factors contributing to postpartum endometritis include the introduction of pathogens with history places the woman at greatest risk for invasive procedures, prolonged labor, and prolonged rupture of membranes. The risk of postpartal endometritis? endometritis is greatest after a cesarean delivery, especially after a long labor and prolonged rupture of membranes. Options 2, 3, and 4 are not invasive, and do not increase the client's risk for infection. ‐ Cesarean delivery after 24 hours of labor and failure to progress ‐ Use of external fetal monitoring during labor ‐ Ruptured membranes for four hours prior to delivery ‐ Spontaneous vaginal delivery after eight hours of labor | The focus of the question is risk for uterine infection. Eliminate options 2, 3, and 4 because they include common, noninvasive actions or data that represent normal birth experiences. |
2575 After the delivery of a large‐for‐gestational‐age Correct answer: 1 Suspect lacerations if the client is bleeding and the fundus is firm. If the cause were uterine infant, the nurse notes a client has bright red blood atony, the fundus would not be firm. When there are fragments of the placenta or the continuously trickling from the vagina. Her fundus is membranes, the uterus will not contract effectively. firm and located in the midline. The nurse concludes that which of the following is the most likely cause of this bleeding? ‐ Lacerations ‐ Hematoma ‐ Uterine atony ‐ Retained fragments of conception | The critical concept in the question is continuous bleeding with a firm uterine fundus, a classic symptom of a laceration. Eliminate option 2 because bleeding would be concealed, option 3 because the uterine is not firm with atony, and option 4 because this finding is commonly associated with late‐postpartum hemorrhage. |
2576 A client is in the immediate postpartal period after Correct answer: 4 Of the options given, the only one that immediately affects the bleeding is uterine massage. It delivery of a 9‐pound, 14‐ounce baby. The client is a might be important to start an IV with oxytocin at a rapid rate, and to allow the client to empty gravida 6, para 5. The nurse has been checking the her bladder; however, the first action is to massage the uterus to stop or slow down the blood client every 15 minutes for the last 45 minutes. The flow. client has been stable with a firm fundus and moderate amount of lochia. As the nurse begins her final 15‐ minute assessment, she notices some new blood stains on the top sheet, and discovers the client lying in a pool of blood that covers the protective bedpad. The fundus is located above the umbilicus and is boggy. What would the nurse's first action be? ‐ Take the client's blood pressure. ‐ Put the client on a bedpan in case she needs to empty her bladder. ‐ Start an IV. ‐ Massage the uterus. | The focus of the question is hemorrhage in the presence of uterine relaxation. The correct answer would be the option that contains a nursing action to contract the uterus and prevent further hemorrhage. |
2577 A woman who delivered three weeks ago calls the Correct answer: 3 Mastitis most frequently occurs 2–4 weeks after delivery with initial flulike symptoms plus postpartum unit with breastfeeding questions. She breast tenderness and redness. The client might be describing symptoms of a breast infection. wants to know if it is all right to continue to breastfeed Sleep, lochia, and edema with visual disturbances are not associated with breast problems. while she has the flu. She states that she feels achy all over, has been having chills, and her temperature is 103°F. What question is important for the nurse to ask? ‐ "Have you been sleeping well?" ‐ "What does your lochia look like now?" ‐ "Do you have any reddened areas or tenderness on your breasts, or unusual breast discharge?" ‐ "Do you have any swelling in your legs or visual disturbances?" | The focus of the question is breastfeeding and the potential complication of mastitis. The correct answer would be the option that obtains further assessment data related to the breasts. |
2578 It is most important for the nurse to have which drug Correct answer: 3 Protamine sulfate is the drug used to combat bleeding problems related to heparin overdose. readily available when the client is being treated with Option 1 raises serum calcium levels. Option 2 is the antidote for warfarin. Option 4 is an iron heparin therapy for thrombophlebitis? supplement. ‐ Calcium gluconate ‐ AquaMEPHYTON ‐ Protamine sulfate ‐ Ferrous sulfate | The key focus of the question is anticoagulation related to heparin use. The correct answer would be the option that contains a drug with an action to combat bleeding. |
2579 The homecare nurse is caring for a postpartal client, Correct answer: 1, 2, 3 Postpartum psychosis usually becomes evident within three months of delivery. Delusions and suspects the development of a postpartum and hallucinations are common. The risk for suicide or infanticide is increased by the psychotic psychosis. Which of the following findings support the woman's distorted thoughts about herself and/or the baby. The psychotic woman would nurse's judgment? Select all that apply. typically display agitation, hyperactivity, and confusion. Adjustment reaction with depressed mood, commonly known as maternal or baby blues, occurs in 50–70% of women, and is characterized by feelings of fatigue, anxiety, or being overwhelmed by the new maternal role. A key feature is episodic tearfulness without reason that typically occurs within a few days of birth and resolves spontaneously on about the 10th postpartal day. ‐ The client has a history of a bipolar (manic‐depressive) disorder. ‐ The client reports voices telling her the baby is evil, and must die. ‐ The client can't remember details of the delivery or when the infant last ate. ‐ The woman is tearful without an identifiable reason. ‐ The woman is calm and seated during the home visit. | The question is worded as a positive statement. The correct answers would be the options that contain assessment findings for postpartal psychosis. |
2580 The client is a 36‐year‐old woman, gravida 6, para 6, Correct answer: 1 Women that are parity of 6 or higher (grandmultiparity) are at the greatest risk of uterine who delivered a baby girl at 38 weeks' gestation after atony due to repeated distention of uterine musculature during pregnancy. Labor leads to eight hours of labor. The baby weighed 7 pounds, 14 muscle stretching, diminished tone, and muscle relaxation. The client's age is not a factor in ounces. The client's vital signs are stable, and her uterine atony; the length of labor is not considered to be prolonged or precipitous; and the lochia is bright red and heavy, and contains various size of the baby is considered appropriate for gestational age, and is not considered to be clots. The largest clot is about half‐dollar size. The macrosomic. nurse would consider the client to be at high risk for uterine atony because of which of the following? ‐ Grandmultiparity ‐ Size of the baby ‐ Length of labor ‐ Client's age | The focus of the question is identification of risk for uterine atony. Eliminate options 2 and 4, as this client's infant is of normal size, and labor was of average duration. Option 3 should be eliminated because maternal age is not a risk factor for hemorrhage. |
2581 A client continues to pass large amounts of clots and Correct answer: 4 Cervidil is used to ripen the cervix before labor; terbutaline sulfate is a tocolytic, and could bright red lochia despite the nurse's attempt to cause further muscle relaxation; magnesium sulfate is used to decrease contractions or massage the fundus. Upon reexamination, the nurse prevent seizures; and Hemabate is a prostaglandin, used to manage uterine atony. Oxytocin finds that the client's uterine fundus remains boggy. remains the first‐line drug, the prostaglandins now are more commonly used as the second‐ The nursing actions and oxytocin (Pitocin) do not seem line drug, and carboprost (Prostin 15‐M or Hemabate) is the most commonly used uterotonin. to be helping to keep the fundus firm. What second As many as 68% of clients respond to a single carboprost injection, with 86% responding by the medication does the nurse anticipate the physician will second dose. order to manage uterine atony? ‐ Dinoprostone (Cervidil) ‐ Terbutaline sulfate (Brethine) ‐ Magnesium sulfate ‐ Carboprost (Prostin 15‐M or Hemabate) | The focus of the question is a second‐line agent to stimulate uterine contraction. Eliminate options 1, 2, and 3 because none of the drugs identified possess this action. |
2582 A new mother with mastitis is concerned about Correct answer: 3 The organisms are localized in breast tissue, and are not excreted in the breast milk. The breastfeeding while she has an active infection. The other answers are not correct. nurse should explain that: ‐ The infant is protected from infection by immunoglobulins in the breast milk. ‐ The infant is not susceptible to the organisms that cause mastitis. ‐ The organisms that cause mastitis are not passed in the milk. ‐ The organisms will be inactivated by gastric acid. | The wording of the question indicates that the correct option is a true statement. Knowledge of the care and pathophysiology of the woman with mastitis will aid in choosing correctly. |
2583 If the nurse suspects a uterine infection in the Correct answer: 2 An abnormal odor of the lochia indicates infection in the uterus. The vital signs might be postpartum client, the nurse should make which affected by an infection, but that is not definitive enough to suspect a uterine infection. A priority assessment? distended abdomen usually indicates a problem with gas, perhaps a paralytic ileus. Inspection of the episiotomy site would not provide information regarding a uterine infection. ‐ Pulse and blood pressure ‐ Odor of the lochia ‐ Episiotomy site ‐ The abdomen for distention | The critical words in the question are uterine infection. The correct answer would be the option that includes an assessment specific to uterine infection. Options 1, 3, and 4 should be eliminated because they are not specific assessments for uterine infection. |
2584 A postpartum client develops a temperature during Correct answer: 4 A temperature elevation greater than 100.4°F on two postpartum days not including the first her postpartum course. Which of the following 24 hours meets the criteria for infection. This criterion is the most common standard in the temperatures indicates the presence of postpartum United States. It is not abnormal for a postpartum client to run a low‐grade fever in the first 24 infection? hours. This can be caused by the body's reaction to labor, dehydration, or a reaction to epidural anesthesia. Postpartum nurses should assess other signs and symptoms of infection in addition to fever and WBCs when evaluating the possibility of infection in mothers who had epidural analgesia. | The focus of the question is assessment data that define puerperal morbidity. This definition includes a time element (after 24 hours) and a threshold for elevated temperature (greater than 100.4°F. Options 1, 2, and 3 should be eliminated because they do not meet the definition for postpartal infection. |
‐ 99.0°F 12 hours after delivery, decreasing after 18 hours ‐ 100.2°F 24 hours after delivery, decreasing on the second postpartum day ‐ 100.4°F 24 hours after delivery, remaining until the second postpartum day ‐ 100.6°F 48 hours after delivery, continuing into the third postpartum day | |
2585 For which of the following signs of thrombophlebitis Correct answer: 3 These are classic signs of thrombophlebitis that appear at the site of inflammation; the other should the nurse instruct the postpartal client to look signs listed are not. when at home after discharge from the hospital? ‐ Muscle soreness in her legs after exercise ‐ Varicose veins in her legs ‐ Local tenderness, heat, and swelling ‐ Bruising | The wording of the question indicates the correct option is a true statement. Knowledge of the signs and symptoms of thrombophlebitis will help to choose the correct answer. |
2586 Which instruction should the nurse include in the Correct answer: 4 An increase in lochia or a return to bright red bleeding after the lochia has changed to pink discharge teaching plan to assist the postpartal client indicates a complication. The other statements are not early signs of complications. to recognize early signs of complications? ‐ Expect to pass clots, which occasionally can be the size of a small orange. ‐ Report any decrease in the amount of brownish‐red lochia. ‐ Palpate the fundus daily to make sure it is soft. ‐ Notify your health care provider of any increase in the amount of lochia or a return to bright red bleeding. | The wording of the question indicates the correct option is a true statement. Knowledge of complications for the postpartal client will aid in choosing the correct answer. |
2587 A client delivered a 9‐pound, 10‐ounce infant assisted Correct answer: 4 Bleeding into the connective tissue beneath the vulvar skin can cause the formation of vulvar by forceps. When the nurse performs the second 15‐ hematomas, which develop as a result of injury to tissues with spontaneous as well as minute assessment, the client complains of increasing operative deliveries (use of forceps). One of the first signs of a hematoma might be complaint perineal pain and a lot of pressure. What action should of pressure, pain, or an inability to void. An ice pack to the perineum can be used to reduce the nurse take? swelling, but a hematoma is abnormal, and should be reported to the physician. The fundus should be assessed, but the client's complaints warrant perineal or vaginal assessment. ‐ Put an ice pack on the client's perineum, reassuring the client that this is normal. ‐ Call for assistance. ‐ Assess the fundus for firmness. ‐ Check the perineum for a hematoma. | The question presents abnormal assessment data that warrant further assessment. The correct answer would be the option that includes an action for the nurse to take to obtain additional assessment findings related to perineal pain and pressure. |
2588 On the client's third postpartum day, the nurse enters Correct answer: 3 Creating an environment where a client and her family can discuss emotional concerns is the room and finds the client crying. The client states essential. Sharing time with the new mother to discuss thoughts and feelings is important to that she doesn't know why she is crying, and that she clients. Responding with patronizing answers (options 1 and #4) does nothing to assist the can't stop. Which of the following is the most mother to talk about her thoughts and feelings, and could increase her sense of isolation and appropriate statement for the nurse to make? feelings of inadequacy and despair. ‐ "There is no need to cry, you have a healthy baby." ‐ "Are you dissatisfied with your care?" ‐ "Many new mothers have shared with us their same confusion of feelings. Would you like to talk about them?" ‐ "This happens to lots of mothers. You'll get over it." | The focus of the question is therapeutic communication. The correct answer would be the option that validates and explores the client's feelings. |
2589 Because postpartum depression occurs in 8–26% of Correct answer: 4, 5 Risk factors for postpartum depression include primiparity; ambivalence about maintaining postpartal women, the prenatal nurse assesses clients the pregnancy throughout the pregnancy; history of previous depression or bipolar illness; lack for risk factors for postpartum depression during the of a stable support system; lack of a stable relationship with parents or partner; poor body prenatal period. Which of the following clients would image; and lack of a supportive relationship with parents, especially her father as a child. the nurse consider to be at risk for postpartum Ambivalence regarding pregnancy is a normal response in the first and into the second depression? Select all that apply. trimester, but should be resolved by the third trimester. Postpartum blues occur in approximately 50–80% of postpartum women; the blues do not particularly indicate that a woman will develop postpartum depression. ‐ A client who is an unmarried primipara with family support ‐ A client who has previously had postpartum blues ‐ A client who is a primipara with documented ambivalence about her pregnancy in the first trimester ‐ A client who is a primipara with a history of depression and lack of a supportive relationship ‐ A client who is an unmarried primipara living on her own who was consistently ambivalent about maintaining the pregnancy | The focus of the question is risk factors for postpartum depression. Eliminate options 2 and 3, as they contain findings common in a normal pregnancy. Option 1 can be eliminated because the presence of support can reduce the risk of psychological complications. |
2590 The nurse caring for a high‐risk client in labor Correct answer: 2 Variability of fetal heart rate indicates fetal well‐being. Loss of variability or decreased observes the presence of variability of the fetal heart variability (less than 2–5 beats per minute) is associated with depression of the autonomic rate of 10–12 beats per minute as recorded by the nervous system that regulates heart rate. Hypoxia can cause loss of variability of the FHR, as internal fetal monitor. Which of the following can maternal sedation and fetal sleep, though the last two are less serious signs. The presence conditions does the nurse suspect? of variability is assessed by internal fetal monitoring, since there is less artifact that could be mistaken for variability of heart rate. ‐ Fetal hypoxia ‐ Fetal well‐being ‐ Umbilical cord compression ‐ Uteroplacental insufficiency | The core issue of the question is knowledge of the significance of variability in fetal heart rate. Recall that less or loss of variability might be a cause for concern, depending on the circumstances leading to it. Use nursing knowledge and the process of elimination to make your selection. |
2591 The nurse locates fetal heart tones in the upper‐right Correct answer: 3 Fetal heart tones are heard loudest over the fetal back. In breech presentation, this tends to quadrant. This finding should cause suspicion that the be above the umbilicus. Fetal heart tones are heard just below the midline of the umbilicus in fetus is in a(n): shoulder presentation or transverse lie. ‐ Occiput posterior position. ‐ Occiput transverse position. ‐ Breech presentation. ‐ Shoulder presentation. | Specific knowledge related to fetal position and associated location of fetal heart sounds is needed to answer the question. Use nursing knowledge and the process of elimination to make your selection. |
2592 A client s contractions have become less frequent and Correct answer: 1 The nurse should suspect CPD because of the lack of progress since the last exam. The less intense in the past hour. Vaginal examination physician might assess the maternal pelvis by CT, MRI, or other means, or could stimulate reveals 6‐cm dilatation and 0 station, indicating there contractions with oxytocin (Pitocin), opting for a trial of labor (TOL). Lack of progress could be has been no change since the last examination over caused by inadequate contractions, and a vaginal delivery could be possible, so it is too early to two hours ago. The nurse should take which of the anticipate cesarean delivery. Encouraging rest and continued observation will do nothing to following actions at this time? resolve the problem. ‐ Notify the physician of the last exam. ‐ Continue to observe over the next hour for further progress. ‐ Encourage the client to turn on her side and relax. ‐ Anticipate the need for cesarean delivery. | The core issues of the question are recognition of lack of progress in labor and the nurse s decision‐making ability once this is detected. Eliminate options 2 and 3 first, because they do nothing to help labor progress again, and choose option 1 over 4 because there is not enough information yet to indicate that cesarean delivery is needed. |
2593 A delivery of a client who has shoulder dystocia is Correct answer: 1 Flexing the thighs against the abdomen (McRoberts maneuver) increases the pelvic angle best accomplished using the McRoberts maneuver. from symphysis pubis to sacrum, and facilitates delivery by making the bony pelvis less The nurse should have the client perform this restrictive. maneuver by doing which of the following? ‐ Flexing the thighs against the abdomen | Specific knowledge of the McRoberts maneuver is needed to answer this question. Use nursing knowledge and the process of elimination to make your selection. |
‐ Placing her legs in stirrups ‐ Assuming a side‐lying position for delivery ‐ Sitting upright for delivery | |
2594 The nurse explains to a client with premature labor Correct answer: 3 Corticosteroids such as betamethasone have been shown to enhance fetal lung maturity and that betamethasone (Celestone) is administered for prevent respiratory distress. Betamethasone does not stop labor or cervical changes. A side which of the following purposes? effect is increased risk of infection. ‐ Stop uterine contractions. ‐ Prevent infection. ‐ Hasten fetal lung maturity. ‐ Prevent cervical dilatation. | Specific knowledge of the purpose of betamethasone late in pregnancy is needed to answer this question. Use nursing knowledge and the process of elimination to make your selection. |
2595 After teaching the client and her husband about Correct answer: 4 Signs of premature labor can include abdominal cramping and pressure, or persistent back premature labor, the nurse recognizes that the pain. The client should be instructed to empty her bladder, lie down on her side, and drink 3–4 intervention was effective when the client states: cups of water. If symptoms do not disappear within an hour, the health care provider should be notified. Unusual vaginal discharge should be reported sooner. Excessive fetal movement can sometimes indicate fetal distress, but is not a sign of premature labor. ‐ “I will call the office if I notice excessive fetal movement.” ‐ “I will come to the hospital if I have back pain.” ‐ “I will lie down and rest awhile if I notice watery vaginal discharge.” ‐ “I will call the office if I have abdominal cramps or pressure that does not go away after I drink three or four cups of liquid and rest for an hour.” | The wording of the question tells you that the correct answer is an option that contains a true statement. Eliminate option 3 because this symptom should not be ignored, and would not be relieved by rest. Eliminate option 1 because it does not have to do with labor, and eliminate option 2 because back pain might or might not indicate labor. Also, option 4 is very detailed and comprehensive, which is a clue that this is the correct choice. |
2596 The client is admitted in active labor with a breech Correct answer: 2 Fetal heart rate greater than 160 beats per minutes is considered fetal tachycardia, an early presentation. Which of the following signs would sign of distress. Meconium passage often occurs in breech presentation because of pressure indicate fetal distress? on the presenting part, and is not an indication of fetal distress in this situation. Mild variable decelerations and increased variability are not indications of fetal distress, and occur more frequently in breech presentations. ‐ Meconium‐stained amniotic fluid ‐ Fetal heart rate of 180 beats per minute ‐ Mild, variable decelerations ‐ Increased fetal heart rate variability | The core issue of this question is the ability to correlate knowledge of breech presentation with knowledge of fetal distress. Choose option 2 over the other options by recalling that the normal fetal heart rate (FHR) is 120–160 beats per minute. An FHR outside this range is generally a cause for concern regardless of the specific situation. |
2597 A nulliparous client has not made any progress in Correct answer: 4 Dilatation has stopped (arrested) after considerable progress. The cause could be hypotonic cervical dilatation or station since she was 7 cm and 0 uterine contractions, malposition, or cephalopelvic disproportion. The terms prolonged station over two hours ago. According to the labor (option 1) and protracted (option 2) mean that progress occurs at a very slow rate. Arrest of graph, or Friedman curve, this represents: descent (option 3) occurs when the station, rather than cervical dilatation, does not change. ‐ Prolonged deceleration phase. ‐ Protracted active phase. ‐ Arrest of descent. ‐ Secondary arrest of dilatation. | Note the critical phrases not made any progress and over two hours ago. Correlate these phrases with the word arrest to eliminate options 1 and 2. Choose option 4 over 3 because dilatation has not changed and because the word secondary implies that labor was active at one time, which is true in this case. |
2598 The nurse explains to a client that the presence of a Correct answer: 1 Bandl’s ring forms when labor is obstructed. The upper uterine segment continues to thicken Bandl s ring, which the client overheard from the while the lower segment thins and retracts. If left untreated, uterine rupture can occur. Bandl’s physician, will alter the client s plan of care because it ring necessitates cesarean section. is: ‐ A serious complication requiring cesarean section. ‐ A constriction ring that could prolong labor. ‐ The normal physiologic division between the upper and lower uterine segments. ‐ An abnormal depression in the lower uterine segment. | Specific knowledge of Bandl’s ring is needed to answer this question. Use nursing knowledge and the process of elimination to make your selection. |
2599 The client in labor tells the nurse that she overheard Correct answer: 3 Frequent contractions and increased uterine muscle tone impede the blood flow through the physician say she is having hypertonic uterine uterine arteries to the placenta. The incidence of umbilical cord compression is not increased, contractions. She is worried that this will harm the and hypertonic contractions are not necessarily associated with placental separation. While baby. The nurse explains that the contractions could maternal exhaustion and lactic acid accumulation can occur over time, they do not increase the risk of fetal distress because: immediately threaten fetal well‐being. ‐ Maternal exhaustion occurs, producing a buildup of lactic acids. ‐ Umbilical cord compression occurs, decreasing oxygen supply. ‐ Increased uterine tone and frequent contractions interfere with blood flow from mother to fetus through the uterine arteries. ‐ Placental separation can occur. | The core issue of the question is knowledge of how hypertonic uterine contractions affect the well‐being of the fetus. Eliminate options 1 and 4 as least likely to happen, then eliminate option 2 because the cord might or might not be compressed, depending on the position of the fetus. |
2600 After the initial care following amniotomy, the nurse Correct answer: 4 The risk of infection is increased after rupture of membranes. Therefore, the nurse should should include which of the following assessments assess for signs of infection, including fever, foul‐smelling amniotic fluid, and tenderness. Blood every two hours? pressure, pulse, and fetal movement are checked more often during active labor. Color and consistency of amniotic fluid are assessed immediately after rupture, and each time, the underpad is changed. ‐ Maternal blood pressure and pulse ‐ Fetal movement ‐ Color and consistency of amniotic fluid ‐ Oral temperature | Recognize that the term amniotomy (‐otomy means “cutting into”) refers to artificial rupture of the membranes. Correlate this with increased risk for infection as a complication to choose option 4 as an indicator of infection. |
2601 Which of the following conditions, if identified in the Correct answer: 4 Although not always preventable, uterine inversion can occur because of excessive traction pregnant client’s history, places her at increased risk on the umbilical cord during the third stage of labor with or without vigorous fundal massage for uterine inversion during the current labor and to remove the placenta, especially if the placenta is implanted in the fundus. The other options delivery? are not associated with inversion. ‐ Forceps delivery of the infant ‐ Fundal pressure during delivery of the head and body ‐ Precipitous birth of less than three hours' duration ‐ Traction on the umbilical cord and vigorous fundal massage in the third stage | Specific knowledge of the etiology and risks of uterine inversion is needed to answer this question. Use nursing knowledge and the process of elimination to make your selection. |
2602 Which of the following is the priority nursing goal in Correct answer: 1 While all of the answers are appropriate goals, establishing a trusting relationship with the helping a client during a complicated labor? client and her family is a priority. In an emergency situation, the nurse might have little time to ensure that the client knows what to expect, or to protect her privacy. It is not always possible to prevent fear and anxiety. A trusting relationship increases the likelihood of cooperation and compliance during a crisis. ‐ Establish a trusting relationship. ‐ Ensure that the client knows what to expect. ‐ Prevent invasion of privacy. ‐ Prevent fear and anxiety. | Note the critical word priority in the question, which tells you all options might be partially or totally correct, and you must choose the most important one. A client experiencing a complicated labor is likely to experience both fear and lack of knowledge. Choose option 1 over the others because a trusting relationship is the foundation for assisting the client through the labor process and reducing fear and lack of knowledge. |
2603 Late decelerations on the fetal monitor should cause Correct answer: 3 Uteroplacental insufficiency (UPI) is believed to be the cause of late decelerations. The the nurse to suspect which of the following insufficiency or decreased uteroplacental blood flow leads to fetal hypoxia. Several factors conditions? including maternal hypotension, anemia, vasoconstriction, uterine tetany, and dehydration can be primary causes of UPI. Head compression (option 1) causes early deceleration, and cord compression (option 2) causes variable deceleration. Option 4 is incorrect because it might not lead to UPI and eventual late deceleration. ‐ Head compression ‐ Cord compression ‐ Decreased uteroplacental blood flow | Specific knowledge of the significance of late decelerations is needed to answer this question. Use nursing knowledge and the process of elimination to make your selection. |
4.‐ Close uterine contractions | |
2604 A client asks what trial of labor means. Which of the Correct answer: 1 A trial of labor means that the client will be followed closely and given more time to show following is the best response by the nurse? progress before considering a cesarean. Options 2 and 3 make cesarean delivery seem inevitable, and can increase the client s anxiety. Option 4 is incorrect because the client will be allowed to continue laboring as long as some progress is made. ‐ “The doctor has decided to give you more time to make progress in labor before considering a cesarean delivery.” ‐ “You will be expected to make progress in the next hour, or a cesarean will be done.” ‐ “Even though your pelvis is small, sometimes it is possible to deliver your baby vaginally.” ‐ “A cesarean delivery will be done because you have had a trial of labor, and have not made much progress.” | Eliminate option 4 because it provides knowledge to the client in retrospect, while nursing information is given in a current and timely manner whenever possible. Eliminate option 3 because it does not directly answer the client s question. Choose option 1 over option 2 because of the time frame and because there is an undercurrent of threat in the wording of option 2. |
2605 The nurse should suspect cephalopelvic disproportion Correct answer: 4 Cephalopelvic disproportion (CPD) means that the fetal head is too large to pass through the after noting documentation of which of the following bony pelvis. Options 1 and 2 refer to a smaller‐than‐normal pelvis, but do not take into account for a laboring client? the fetal head size. Option 3 refers to shoulder dystocia. ‐ Pelvic outlet is less than 9 cm. ‐ Midpelvis is contracted. ‐ Fetal shoulders are too large to pass through the bony pelvis. ‐ Fetal head is too large to pass through the bony pelvis. | Specific knowledge of cephalopelvic disproportion is needed to answer this question. Use nursing knowledge and the process of elimination to make your selection. |
2606 The nurse explains to a pregnant client at 37 weeks' Correct answer: 1 The Bishop score, an assessment of the mother’s physical readiness for labor, takes into gestation that a Bishop score is being completed to account cervical dilatation, effacement, consistency, cervical position, and station before determine which of the following? contractions begin. The higher the score, the more likely a client can be successfully induced. ‐ The client’s readiness for labor ‐ The fetus’s readiness for labor ‐ Progress during induction ‐ Cervical changes in labor | Recall that a Bishop score focuses primarily on the mother rather, not on the fetus, which eliminates option 2. Choose option 1 over options 3 and 4 because the stem indicates that the client is not yet in labor. |
2607 Which of the following priority items should the nurse Correct answer: 3 Self‐image refers to how a client feels about herself. A positive self‐image enables a client to assess because of the potential impact on the laboring deal with labor and delivery realistically, even in the event of complications. Research has client’s psychological status? shown that self‐image impacts the laboring patient’s psyche. Other options have not been identified as having a significant impact during labor. ‐ Attitude about parenting ‐ Relationship with the client’s own mother ‐ Self‐image ‐ Beliefs about health | Note that the focus of the question is on the client in active labor. With this in mind, choose option 3 because it is the only option that specifically relates to the client's current status. |
2608 A client is experiencing contractions that occur every Correct answer: 2 Hypotonic uterine dysfunction occurs most often during the active phase. It is characterized 3–4 minutes, of 35‐second duration and mild intensity, by contractions that have become further apart, less intense, and of shorter duration. during the active phase of labor. After making this Contractions are typically 2–3 minutes apart, strong, and last 45–60 seconds in the active assessment, the nurse suspects which of the phase of labor. following? ‐ Hypertonic uterine dysfunction ‐ Hypotonic uterine dysfunction ‐ Normal uterine activity ‐ Progressive labor pattern | Note that the question contains the critical words mild intensity and active phase. Reasoning that active labor should be characterized by strong contractions, you would select option 2 because it contains the word hypotonic. Alternatively, eliminate options 3 and 4 because they are similar, and eliminate option 1 because the word hypertonic conveys the opposite of what the client in the question is experiencing. |
2609 In preparing the client in labor for vacuum extraction, Correct answer: 1 Suction applied over the occiput commonly causes edema and bruising of the scalp. Although it is important to teach her that the infant might it might appear to be a deformity of the fetal head, the edema disappears in 2–3 days. Suction initially have which of the following after delivery? is not applied to the face (options 2, 3, and 4). ‐ A large caput and bruising of the scalp ‐ Red marks on the face ‐ Edema of the face ‐ Swelling of the eyes | Note the critical word vacuum in the stem of the question, and eliminate each of the incorrect options because they refer to a part of the face, rather than to the occiput of the head. |
2610 While performing a vaginal examination, the nurse Correct answer: 1 A compound presentation involves two fetal parts. The fetal head and a hand are the most should suspect a compound presentation if what is common combination, although hand‐and‐foot presentation is also possible. Option 2 is palpated? incorrect unless a head is also presenting, since this could occur with shoulder presentation. Both feet presenting is called "double footling breech presentation." ‐ Presentation of two fetal parts ‐ Protrusion of the hand and arm through the cervix during labor ‐ A shoulder presentation ‐ Both feet protruding through the introitus | The core issue of the question is a compound presentation, two different fetal parts. Eliminate option 2 unless a head is also presenting, since this could occur with shoulder presentation. Eliminate option 3 because only one fetal part is presenting, the shoulder. Eliminate option 4 because both feet presenting is called "double footling breech presentation." |
2611 The nurse should encourage the pregnant client not Correct answer: 3 Molding of the fetal head does not occur during labor in the breech presentation. The fetal to push during vaginal delivery of a breech infant to body can pass through an incompletely dilated cervix, leaving the larger, firmer fetal head avoid which of the following: entrapped. The woman might feel a strong urge to push before complete dilatation due to pressure from the fetal body, increasing the risk of head entrapment. Options 1 and 2 are incorrect because prolapsed cord and fetal distress are risks inherent with breech delivery whether the woman pushes or not. Option 4 is incorrect, since cervical lacerations most often occur at the time of delivery from the application of forceps or manipulation of the fetus to deliver the after‐coming head. ‐ Prolapsed cord ‐ Fetal distress ‐ Fetal head entrapment ‐ Cervical lacerations | The core issue of the question is the risk from pushing during vaginal breech delivery. Eliminate options 1 and 2 because prolapsed cord and fetal distress are risks inherent with breech delivery whether the woman pushes or not. Eliminate Option 4 because cervical lacerations most often occur at the time of delivery from the application of forceps or manipulation of the fetus to deliver the after‐coming head, rather than from pushing. |
2612 The nurse encourages limiting the number of vaginal Correct answer: 3 Even with strict adherence to aseptic technique, the risk of infection increases with frequent examinations to minimize the client's risk of: vaginal examinations, especially if membranes are ruptured, or if labor is prolonged. Most authorities recommend keeping the number of vaginal examinations to a minimum for this reason, as well as for client comfort. Cervical lacerations, bleeding, and loss of control are incorrect. ‐ Cervical lacerations. ‐ Bleeding. ‐ Infection. ‐ Loss of control. | The focus of the question is identifying a risk from excessive vaginal examinations in labor; the greatest risk is infection. Options 1, 2, and 4 can be eliminated because they do not contribute to an increased risk of infection. |
2613 A term fetus with a face presentation is in a left Correct answer: 1 If the chin (mentum) of the fetus presents and remains in a posterior position, vaginal mentum posterior (LMP) position. The nurse delivery cannot occur. The inability of the fetus to flex and extend the head as it moves anticipates which of the following? through the mid‐pelvis causes an arrest of descent. A cesarean delivery is necessary. The other answers are incorrect. ‐ Cesarean delivery ‐ Vaginal delivery ‐ Prolonged labor ‐ Forceps‐assisted vaginal delivery | Recall the memory aid 'Every darn fool in Rotterdam eats rotten eggrolls everyday.' Eliminate options 2, 3, and 4 because normal flexion and then extension necessary for delivery are not possible in the LMP position. |
2614 The nurse is assigned to a pregnant client who is Correct answer: 2, 5 The uterus should be assessed for overdistention and an elevated resting tone due to having an amnioinfusion. In addition to fetal heart rate overinfusion of solution into the uterine cavity or trapping of infused solution behind a and contractions, the nurse monitors which of the presenting part. The elevation in uterine tone can lead to fetal distress. Maternal vital signs are following during the procedure? Select all that apply. also assessed, to determine physiological status. The other answers do not represent items that require assessment during this procedure. ‐ Fetal movement ‐ Uterine tone ‐ Maternal vital signs ‐ Labor progress ‐ Uterine overdistention | The key focus of the question is amnioinfusion, the infusion of fluid into the uterus. Eliminate options 1, 3, and 4, as they are not specifically related to assessment during amnioinfusion. |
2615 The nurse interprets that a pregnant client Correct answer: 4 External cephalic version involves abdominal manipulation to rotate the fetus from either a understands the purpose and the procedure of breech or shoulder presentation to vertex. Clients need to know that the attempt is not always external cephalic version when the client states: successful. Option 1 is not correct. Version involves turning the fetal body, not just the head. Staying in bed after a version is not necessary. The procedure will be stopped immediately if there is maternal or fetal distress. ‐ "My doctor will place a hand inside my uterus and pull the baby into a head down position." ‐ "My baby's head will be turned slightly to make the delivery easier." ‐ "After the baby is turned, I must remain in bed." ‐ "The procedure will be stopped if my baby shows signs of distress." | Knowledge of external cephalic version will aid in answering the question correctly. The question is worded as a positive statement. The correct answer would be the option that contains a true statement about a point of client education. |
2616 Which of the following interventions carried out by Correct answer: 2 Counterpressure over the sacral area during contractions is helpful in alleviating the lower the nurse would be most helpful for the client with back pain without the use of narcotics that can be transferred across the placenta to the fetus. lower back pain caused by occiput posterior position? Ice packs have not been shown to be helpful. Pelvic rocking has been helpful for back pain in the antepartum period, but patients in labor seem to benefit more from conscious relaxation during contractions (avoiding movement and tension). ‐ Administer small amounts of the ordered analgesic IV. ‐ Provide counterpressure over the sacral area with the palm of the hand. ‐ Provide an ice pack to place over the lower back. ‐ Teach the client how to do pelvic rocking. | Eliminate incorrect choices. Eliminate option 1, as IV analgesics are not always necessary. Eliminate option 3 because ice packs have not been shown to be helpful. Eliminate option 4 because pelvic rocking has been helpful for back pain in the antepartum period, but patients in labor seem to benefit more from conscious relaxation during contractions (avoiding movement and tension). |
2617 For the pregnant client whose fetus has a face Correct answer: 4 The spiral (fetal) electrode used for internal monitoring penetrates 2 mm into the presenting presentation, which of the following actions should the part. While this does not create a problem on the fetal scalp, the face should be avoided for nurse avoid? cosmetic reasons, and to avoid eye injury. None of the other actions would be harmful for a patient with face presentation. ‐ Performing Leopold's maneuver ‐ Ambulating the client to the bathroom ‐ Placing the client in a high semi‐Fowler's position ‐ Monitoring of internal fetal heart rate | The focus of the question is client safety with this abnormal fetal presentation. The correct answer would be the option that creates the greatest risk, and that therefore should be avoided. |
2618 A long loop of umbilical cord has prolapsed through Correct answer: 1 Covering the cord with warmed, saline‐soaked, sterile towels will prevent it from drying out the introitus. The nurse notes that it is still pulsating, and occluding blood flow until the delivery can be accomplished. The other answers do not and the fetal monitor indicates that the fetal heart protect the umbilical cord. rate (FHR) is between 110 and 120. In addition to contacting the physician immediately, what action should the nurse take? ‐ Cover the cord with a sterile, warm, saline‐soaked towel. ‐ Cover the cord with a dry, sterile towel. ‐ Continue to palpate for pulsations. ‐ Do nothing until the physician arrives. | The key focus of the question is promoting safety during this obstetric emergency. Eliminate options 2 and 3 because they can impede uteroplacental blood flow. Eliminate option 4 because this is an emergency situation that requires prompt and safe action. |
2619 A nurse is monitoring a client receiving intravenous Correct answer: 5, 4, 1, Uterine hyperactivity decreases the oxygen supply to the fetus. The priority of the nurse is to oxytocin (Pitocin) to induce labor, and identifies 3, 2 reduce uterine activity by stopping the oxytocin (Pitocin). The nurse then acts to increase fetal hypertonic uterine contractions. List in order of oxygenation by administering oxygen by face mask to the mother and repositioning the client priority the actions the nurse should take. Click and to the side, left side‐lying preferred, to improve uteroplacental blood flow. The nurse would drag the options below to move them up or down. then perform a vaginal examination to determine labor progress, and check for a prolapsed cord. The nurse would assess the blood pressure for hypotension or hypertension. ‐ Administer oxygen by face mask at 8–10 L/min. ‐ Check the client's blood pressure. ‐ Perform a vaginal examination. ‐ Reposition the client. ‐ Stop the oxytocin (Pitocin). | Recognizing that the client is experiencing hypertonic uterine contractions will assist in determining what the priority action would be to stop the oxytocin (Pitocin) that stimulates uterine contractions. Actions to increase fetal oxygenation would be next, followed by assessment of the client's labor status and blood pressure. |
2620 A multiparous client who has been in labor for almost Correct answer: 1 Nursing action should be directed toward preventing a rapid and uncontrolled delivery of the three hours suddenly announces that the baby is infant's head. Directing the client to pant prevents pushing. If time allows, the nurse may don coming. The nurse sees the infant crowning. Which of gloves, or obtain a towel or blanket, to support the fetal head. Delivery is imminent, so there the following interventions should the nurse do first? might not be time to obtain sterile gloves or to contact the physician. The client should not be left alone, so going to the nursing station to get the precipitous delivery tray is not an option. ‐ Ask the woman to pant while preparing to place gentle counterpressure on the infant's head as it is delivered. ‐ Quickly obtain sterile gloves and a towel. ‐ Retrieve the precipitous delivery tray from the nursing station. ‐ Telephone the physician using the bedside phone. | This question focuses on the imminent delivery of the infant in a safe manner. Eliminate options 3 and 4 because they decrease safety by leaving the client's bedside. Eliminate option 2 because the action is desirable but not required in an emergency. |
2621 The nurse determines that a client does not Correct answer: 4 Blood transfusions are not routinely given during cesarean sections. Although blood typing understand what to expect during cesarean delivery and screening are often ordered prior to surgery, it is seldom necessary for a client to receive a when the client states: (Select all that apply.) blood transfusion. IV lines are necessary for instillation of fluid, medications, and potential blood products during surgery. A Foley catheter is inserted to prevent bladder damage during surgery, and an antacid is administered to prevent aspiration of acidic gastric contents, thus reducing the risk of lung damage. The client's husband or primary support person is usually present at the birth except in extreme emergencies. ‐ "An indwelling (Foley) catheter will be inserted before surgery." ‐ "My husband can be present during birth." ‐ "I may be given an antacid before surgery." ‐ "I will receive a blood transfusion during surgery." ‐ "I will not need an IV, since I will have an epidural anesthesia." | The wording of the question indicates that the correct options are incorrect statements. Use knowledge of the care of the client undergoing a cesarean section to aid in determining the appropriate options. |
2622 The nurse concludes that deceleration of the fetal Correct answer: 1 The pattern described is a variable deceleration, which is associated with umbilical cord heart rate from 130 to 70 beats per minute with compression. During variable decelerations, the FHR drops below 90 beats a minute very contractions, followed by a rapid return to a normal quickly as fetal blood flow through the umbilical cord is interrupted. FHR returns rapidly to baseline rate, is most likely a client's response to: baseline as soon as the cord compression is relieved. FHR patterns associated with fetal head compression (early deceleration) and utero‐placental insufficiency (late deceleration) have a shallower appearance, since they do not drop as precipitously. Variable deceleration, unless severe (lasting longer than 60 seconds), does not indicate severe hypoxia. ‐ Umbilical cord compression. ‐ Fetal head compression. ‐ Severe fetal hypoxia. ‐ Utero‐placental insufficiency. | The key words in this question are deceleration and rapid return to baseline. Eliminate options 2, 3, and 4, as they are associated with decelerations that develop and resolve more slowly, mirroring the shape of contractions. |
2623 The nurse determines that fetal distress is occurring Correct answer: 3 Meconium passage prior to birth occurs in response to a stressful event for the fetus. after noting which of the following signs? Moderate bloody show often occurs late in labor. Pink‐tinged amniotic fluid occurs because of a small amount of blood, usually from the cervix. Accelerations of FHR are considered a normal response, and do not indicate fetal distress. ‐ Moderate amount of bloody show ‐ Pink‐tinged amniotic fluid ‐ Meconium‐stained amniotic fluid ‐ Acceleration of fetal heart rate with each contraction | Key words are "fetal distress," indicating that the focus of this question is abnormal assessment data. Eliminate options 1, 2, and 4, as they are common and normal findings during labor. |
2624 On performing Leopold's maneuver on a multiparous Correct answer: 3 Findings on palpation are consistent with shoulder presentation or transverse lie. Vaginal client in early labor, the nurse finds no fetal parts in delivery is not possible, so the nurse should anticipate cesarean section. Since the client is in the fundus or above the symphysis. The fetal head is labor, version is contraindicated. palpated in the right mid quadrant. The nurse notifies the admitting physician and anticipates: ‐ An external version. ‐ An internal version. ‐ A cesarean delivery. ‐ Prolonged labor. | The focus of this question is a client in labor with a transverse lie, a presentation that is incompatible with vaginal delivery. The correct answer would be the option that provides a safe alternative to vaginal delivery. |
2625 The nurse discovers a loop of the umbilical cord Correct answer: 4 Pressure on the cord must be relieved to save the life of the fetus. Applying upward manual protruding through the vagina when preparing to pressure to the presenting part and having the mother assume a knee–chest position are perform a vaginal examination. The most appropriate appropriate emergency actions, followed by starting oxygen and calling the physician. Options intervention is to: 2 and 3 do nothing to relieve cord occlusion. ‐ Call the physician immediately. ‐ Place a moist, clean towel over the cord to prevent drying. ‐ Immediately turn the client on her side, and listen to the fetal heart rate. ‐ Perform a vaginal examination, and apply upward digital pressure to the presenting part while having the mother assume a knee–chest position. | The focus of this question is maintaining the safety of the fetus. The correct option would contain an action to prevent cord compression and promote adequate oxygenation to the fetus. |
2626 The client has refused sedation ordered by the Correct answer: 1 Prolonged latent‐phase labor is associated with uncoordinated, hypertonic, and painful physician for hypertonic contractions and prolonged contractions that do little to dilate or efface the cervix. Maternal exhaustion and dehydration latent‐phase labor for fear that her labor will stop. The are concerns. Medical management is directed toward providing rest and hydration, and nurse can help by explaining: allowing time for contractions to become coordinated. Often, clients awaken from sedation in progressive labor. While option 2 is correct, this does little to explain the rationale for sedation. Option 3 is incorrect. There is very little risk to the fetus unless contractions are intense and &lt; 2 minutes apart. Option 4 is not correct, because it is too soon to anticipate the need for cesarean delivery. ‐ Sedation helps to provide needed rest, and allows time for the uterine contractions to become coordinated, so that labor is progressive. ‐ If the woman is experiencing true labor, contractions will not stop even with sedation. ‐ If contractions continue without cervical effacement and dilatation, the fetus is at risk for hypoxia. ‐ Sedation will stop contractions that are uncoordinated, and will provide more time to determine if a cesarean delivery is needed. | The wording of the question indicates that the correct option is a true statement. Knowledge of the care of the labor client with hypertonic labor will aid in answering the question. |
2627 The client is receiving intravenous magnesium sulfate Correct answer: 3 Early signs of magnesium toxicity that could lead to respiratory arrest are loss of patellar at 2 grams/hr to stop premature labor. The nurse reflexes and decreased respiratory rate (&lt; 12/min). Since magnesium is excreted from determines that the most important nursing the body through the renal system, hourly urine output should be assessed. Although blood assessments of this client include: pressure is a standard assessment for most antepartum clients, there is minimal blood pressure change, if any, associated with administration of magnesium sulfate. ‐ Intake and output, level of consciousness, and blood pressure. ‐ Blood pressure, pulse, and uterine activity. ‐ Deep tendon reflexes, hourly urine output, and respiratory rate. ‐ Intake and output, blood pressure, and reflexes. | The focus of the question is the action of magnesium sulfate. Recall that the drug is a central nervous system depressant, and remember the ABCs; the correct answer would be the option that includes assessment of airway, breathing, and circulation. |
2628 During augmentation of labor with intravenous Correct answer: 3 Although rupture of the uterus is rare, there is an increased risk for multiparas and clients oxytocin (Pitocin), a multiparous client becomes pale undergoing induction or augmentation of labor. Early signs include pain and a tearing and diaphoretic, and complains of severe lower sensation, signs of shock, and fetal distress. Blood loss is usually severe, but might not be abdominal pain with a tearing sensation. Fetal distress visible. Amniotic fluid embolus is frequently associated with cardiac and respiratory distress. is noted on the monitor. The nurse should suspect: Symptoms of precipitate labor and uterine prolapse do not include pallor, diaphoresis, or fetal distress. ‐ Precipitate labor. ‐ Amniotic fluid embolus. ‐ Rupture of the uterus. ‐ Uterine prolapse. | Critical words in this question are tearing sensation and oxytocin. A tearing sensation is the classic symptom of uterine rupture, a risk with oxytocin administration. Eliminate options 1, 2, and 4, as the symptom presented in the question would not be present with these conditions. |
2629 During vaginal examination, the nurse palpates the Correct answer: 4 In a brow presentation, the fetal forehead and the large, diamond‐shaped anterior fontanelle fetal head and a large, diamond‐shaped fontanelle. The are palpated during vaginal exam. In vertex presentation, the back of the fetal head (occiput) nurse documents that the fetal presentation is: and small, triangular fontanelle are palpated. In breech and shoulder presentations, fetal parts would feel soft and irregular. ‐ Face. ‐ Transverse. ‐ Vertex. ‐ Brow. | The critical words in this question are fetal head and diamond‐shaped fontanelle. Eliminate option 2, as the fetal head would not be palpable in a transverse lie. Eliminate options 1 and 4, as the anterior fontanelle would not be palpable with these presentations. The correct answer would be the presentation that permits palpation of the anterior fontanelle. |
2630 Following amniotomy, the nurse would implement Correct answer: 2, 3, 4 The risk of umbilical cord compression or prolapse increases when amniotic fluid is released. which of the following as important nursing actions? Listening to fetal heart tones after amniotomy will quickly detect the presence of cord Select all that apply. compression. Observing color and consistency of the fluid should be done next. Placing a clean underpad on the bed and repositioning the mother are important in providing comfort, but are not the first priority. Temperature should be monitored every 1–2 hours for signs of infection. ‐ Position the mother in lithotomy position for delivery. ‐ Place a clean underpad on the bed. ‐ Listen to fetal heart tones. ‐ Observe the color and consistency of the amniotic fluid. ‐ Take vital signs every four hours to monitor for infection. | Recall knowledge of the care of the client undergoing amniotomy, and the resulting complications, such as umbilical cord compression and infection. The correct answer will be the option that best promotes the safety of mother and fetus. Eliminate options that are important but not critical to safety. |
2631 The nurse can help a client with a fetus in the right Correct answer: 2 Gravity can help the fetus rotate to an anterior position for vaginal delivery. The positions in occiput posterior (ROP) position by avoiding which of options 1, 3, and 4 enlist the aid of gravity. Option 2 should be avoided because it will not help the following actions? the fetus to rotate. ‐ Positioning her on her left side ‐ Positioning her on her right side ‐ Helping her walk around the room ‐ Assisting her to a knee–chest position | This is a negative statement. The correct answer would be the option that includes an undesirable nursing action in this situation. This situation could be improved by the use of gravity to rotate the fetus. Look for the option that does not use gravity; option 2 fits this criterion. |
2632 A nulliparous client has not made any progress in Correct answer: 4 Dilatation has stopped (arrested) after considerable progress. Causes can include hypotonic cervical dilatation or station since she was 7 cm and 0 uterine contractions, malposition, or cephalopelvic disproportion. Options 1 and 2 are not station over two hours ago. The nurse interprets that correct, because prolonged and protracted mean that progress occurs at a very slow rate. according to the Friedman curve, this client is Arrest of descent (option 3) occurs when the station, rather than cervical dilatation, does not experiencing: change. ‐ Prolonged deceleration phase. ‐ Protracted active phase. ‐ Arrest of descent. ‐ Secondary arrest of dilatation. | The core focus in this question is progress to 7 cm dilatation followed by no change in two hours. Eliminate options 1 and 2 because prolonged and protracted mean that progress occurs at a very slow rate. Eliminate option 3 because it focuses on the station rather than on cervical dilatation. |
2633 A client's amniotic fluid is greenish‐tinged. The fetal Correct answer: 1 Meconium released by the fetus causes amniotic fluid to be greenish‐tinged. Although the presentation is vertex. Fetal heart rate (FHR) and presence of meconium is associated with fetal distress, there is no evidence of immediate uterine activity have remained within normal limits. At danger to the fetus during labor in this case. However, the infant is at risk for aspirating the time of delivery, the nurse should anticipate the meconium at the time of delivery. Steps to prevent aspiration include thorough suctioning of need for: the nasopharynx, including visualization of the vocal cords to remove meconium particles before the first breath. ‐ An infant laryngoscope and suction catheters. ‐ Forceps. ‐ A transport isolette. ‐ Emergency cesarean setup. | Recall the ABCs; meconium in the amniotic fluid can interfere with a clear airway and effective breathing. The correct answer will include an action to clear the airway prior to the newborn's first breath. |
2634 A client who is at 34 weeks' gestation has been having Correct answer: 4 Hydration has been shown to decrease premature labor contractions. Therefore, drinking contractions every 10 minutes. In addition to water or other noncaffeinated beverages is recommended. If contractions continue at 10 instructing her to lie down and rest while continuing to minutes apart or less for an hour with rest, the client should call her health care provider. time contractions, the nurse should also tell her to: ‐ Refrain from eating or drinking anything. ‐ Take slow, deep breaths with each contraction. ‐ Go to the hospital if contractions continue for more than an hour. ‐ Drink 3–4 cups of water. | Knowledge of the nursing care of the premature‐labor client will help to answer the question correctly. The wording of the question is positive, indicating that the correct option is a true statement of fact. |
2635 The client who has had a previous cesarean birth asks Correct answer: 2 A classical incision involves the upper uterine segment, and is more likely to separate or about vaginal birth after cesarean (VBAC). Which of rupture with subsequent uterine contractions. Induction is not a contraindication if managed the following factors from her history is a judiciously. The type of abdominal incision is not a concern, since it is not affected by uterine contraindication for VBAC? contractions. ‐ PThe pevious cesarean was for breech presentation. ‐ The client had a classic uterine incision. ‐ The abdominal incision was vertical rather than transverse. ‐ An induction of labor is planned for this delivery. | Focus on safety of the mother and infant with this question. The greatest risk during a VBAC is uterine rupture; potential for rupture is influenced by location of the previous uterine scar. Eliminate options 1, 2, and 4 because they do not address the prior uterine incision. |
2636 Which of the following statements by the nurse is Correct answer: 3 Promoting a positive feeling about how well she was able to cope with an emergency most therapeutic in talking with a client and her family cesarean delivery will have an influence on self‐image and the client's feelings about her ability following emergency cesarean birth? to handle future pregnancies and births. In addition, providing an opportunity for the client and her family to ask questions and to express feelings helps in dealing with any disappointment, anger, or guilt they might feel. Other options indicate that the birth was not normal, and can promote negative feelings about the infant or the experience. ‐ "I'm sorry that you couldn't have a normal delivery." ‐ "Your baby was really in danger. I think he is doing better now." ‐ "You did so well throughout the delivery. I'm sorry I didn't have more time to explain things." ‐ "I know you never expected this to happen. Maybe things will work out better next time." | This question focuses on therapeutic communication. The correct answer would be the option that best supports the client's feelings and behaviors. Eliminate options 1, 2, and 4, which are nontherapeutic responses. Only option 3 is therapeutic and promotes a positive feeling about her coping through the delivery. |
2637 The pregnant client is receiving oxytocin (Pitocin) to Correct answer: 2, 5 Oxytocin (Pitocin) stimulates uterine contractility; exceeding maximum doses or increasing induce labor. The nurse should monitor the client for doses too rapidly can result in uterine hyperstimulation. Blood pressure might initially which of the following adverse maternal effects? decrease, but after prolonged drug administration, it could rise to 30% above baseline. The Select all that apply. antidiuretic effect of oxytocin decreases water exchange in the kidney and reduces urinary output, leading to fluid overload rather than dehydration. Bradycardia and jaundice are possible adverse effects for the fetus rather, not for the mother. ‐ Bradycardia ‐ Decreased urine output | The focus of this question is adverse maternal effects of oxytocin (Pitocin). Recall that the action of the drug is to stimulate the smooth muscle of the uterus and blood vessels, and that the drug has an antidiuretic effect. An adverse effect can be an excess of a known drug action; therefore, options 2 and 5 would be correct actions. |
‐ Dehydration ‐ Jaundice ‐ Uterine hyperstimulation | |
2638 In addition to routine assessment and care, nursing Correct answer: 3 Terbutaline, a beta‐adrenergic agent, has many maternal and fetal side effects, including care of the client who is receiving terbutaline tachycardia, cardiac arrhythmias, and pulmonary edema. In addition to taking vital signs, the (Brethine) to prevent premature labor should include nurse should assess for pulmonary edema. The frequency of assessment of fetal heart tones assessing: and oral temperature depends on the intensity and length of the drug therapy, as well as surrounding circumstances. Deep tendon reflex assessment is not indicated. ‐ Oral temperature every two hours. ‐ Fetal heart tones every 30 minutes. ‐ Breath sounds every four hours. ‐ Deep tendon reflexes every four hours. | The focus of the question is the action of terbutaline (Brethine), a beta‐adrenergic agent. Recall that beta‐adrenergic drugs cause side effects related to cardiopulmonary function. Remember the ABCs; the correct answer would be the option that includes assessing maternal heart and lung function. |
2639 The nurse monitors a client during a vaginal delivery Correct answer: 1 With breech presentation, fetal parts do not completely fill the lower uterine segment, of a breech infant for which of the following as the allowing more opportunity for the umbilical cord to proceed through the cervix or become greatest risk? compressed by the fetus, especially following rupture of membranes. The incidence of the other options is no higher in breech than it is with vertex presentation. ‐ Umbilical cord prolapse ‐ Intracranial hemorrhage ‐ Meconium aspiration ‐ Fracture of the clavicle | Remember the ABCs related to safety of the infant at birth. The correct option would jeopardize the safety of the infant by interfering with normal oxygenation and circulation through the umbilical cord. |
2640 The client is a 37‐year‐old gravida 1 at 38 weeks' Correct answer: 4 Amniocentesis for genetic testing is usually done early in the second trimester. This test, on a gestation. She was diagnosed with diabetes at age 17, client who has diabetes, and is at 38 weeks' gestation, is probably being done to assess lung and is scheduled for an amniocentesis. The nurse maturity in anticipation of delivery. concludes that the procedure is probably being done to assess for the presence of which of the following? ‐ Neural tube defects ‐ Down syndrome ‐ Effects of TORCH syndrome ‐ Lung maturity | The critical words in the question are 38 weeks' gestation. Use knowledge of the timing of tests used to diagnose genetic defects to systematically eliminate the incorrect options. As an alternative, consider that lung maturity is a key concern as a pregnant client approaches the due date. |
2641 A client has been scheduled for an amniocentesis. Correct answer: 2 The test, completed on an outpatient basis, is done under guidance of ultrasound Which of the following actions should the nurse plan visualization. The test is done without anesthetic, or with a local anesthetic. The client is to take in the care of this client? positioned on her back with a wedge under her left hip to avoid hypotension from pressure of the uterus on the vena cava. ‐ Arrange for the client’s admission to the hospital. ‐ Arrange for access to an ultrasound machine for use during the procedure. ‐ Assist the woman in assuming a supine position. ‐ Arrange for administration of general anesthetic. | Use knowledge of the procedure to eliminate options 1 and 4. Choose option 2 over 3 because the procedure is guided by ultrasound, and option 3 does not address risk of pressure on the vena cava in the supine position. |
2642 The client is scheduled to have an amniocentesis for Correct answer: 3 The amount of lecithin increases as the fetal lungs mature. The ratio of lecithin to assessment of lung maturity. She seems upset, and sphingomyelin is used to assess lung maturity; changes in color (options 2 and 4) are not. says that she doesn t understand how this test could Option 1 is not a therapeutic response. tell if a baby s lungs are mature. What is the best response by the nurse? ‐ “There is no need for you to worry about that. Your doctor knows the procedure well.” | Recall that amniotic fluid is clear to eliminate options 2 and 4. Choose option 3 over 1 because option 1 is not a therapeutic response. |
‐ “The fluid changes color as the fetal lungs mature. We assess the color to determine the lung maturity.” ‐ “A chemical called lecithin is made by the fetal lungs. The amount of it increases as gestation continues. It flows out into the amniotic fluid, where we can measure it.” ‐ “The amount of bilirubin in the fluid increases as lung maturity increases. We measure the yellow color in the fluid to assess lung maturity.” | |
2643 The nurse would formulate which of the following as Correct answer: 3 Most women view invasive antenatal testing with anxiety because of the reason for the test, the highest‐priority nursing diagnosis for a client about the impending results, and concern about maternal and fetus complications. Because of the to undergo an amniocentesis? small amount of fluid removed, option 4 is unnecessary. Options 1 and 2 are completely incorrect. ‐ Imbalanced Nutrition: Less than Body Requirements related to NPO status ‐ Risk for Aspiration related to anesthesia ‐ Anxiety related to concern for fetal well‐being ‐ Risk for Deficient Fluid Volume related to removal of amniotic fluid | Use knowledge of the procedure to assist in eliminating incorrect options. Eliminate options 1 and 2 first, because there is no need for NPO status and there is no anesthesia. Choose option 3 over 2 (a valid concern, but a psychosocial issue rather than a physiological one) because the amount of fluid removed is very small. |
2644 The nurse assesses that which of the following Correct answer: 4 Contractions elicited during the test could cause increased bleeding if an abruption is present. findings would be a contraindication for conducting a Intrauterine growth restriction, diabetes mellitus, and post‐term pregnancy are all indications contraction stress test? for completing a contraction stress test. ‐ Intrauterine growth restriction ‐ Diabetes mellitus ‐ Pregnancy at 42 weeks' gestation ‐ Marginal abruptio placentae | Note the critical word contraindication in the stem of the question. This tells you that the correct answer is likely an item that could pose risk of harm to the fetus. From there, recall that abruptio placentae can lead to bleeding to help you choose correctly. |
2645 A primigravida is hospitalized at 32 weeks' gestation Correct answer: 1 The client has stated that she is worried, which creates anxiety. The information presented after a second hemorrhage from a complete placenta does not represent denial or immaturity. There are insufficient data to determine whether the previa. The client appears subdued and sad after the client s coping is effective at this time. physician informs her that she will remain in the hospital until delivery. She says that she is worried about her husband, who will be at home alone much of the time. The nurse interprets the client s response as which of the following? ‐ Anxiety ‐ Denial ‐ Immaturity ‐ Ineffective coping | Note that the client exhibits appropriate nonverbal behavior (subdued and sad), and is able to articulate a concern (worried about husband). Consider that all of these are expected reactions to choose anxiety over the other options. |
2646 The nurse reviews the client s chart for results of Correct answer: 4 Percutaneous umbilical blood sampling (PUBS) obtains an actual sample of fetal blood for which of the following diagnostic tests, which will best analysis. The other options provide information about fetal well‐being, but do not directly indicate a diagnosis of erythroblastosis fetalis? sample the fetal erythrocytes. ‐ Amniocentesis ‐ Biophysical profile ‐ Indirect Coombs’ test ‐ Percutaneous umbilical blood sampling | Note the word erythroblastosis in the question, and correlate that with erythrocytes or red blood cells. Eliminate options 1 and 2 first because they are not related to red blood cells. Then choose option 4 over 3 because it allows access to fetal cells, not to maternal cells. |
2647 The nurse caring for a client with a concealed Correct answer: 3 A concealed abruption could result in a Couvelaire uterus, which doesn t contract effectively abruptio placentae prepares to assess the client for after delivery, leading to uterine atony. The other complications could occur in any client. which complication as a priority after delivery? ‐ Retained placental fragments ‐ Urinary tract infection ‐ Uterine atony ‐ Vaginal hematoma | Specific knowledge of the risks of concealed abruptio placentae is needed to answer the question. Use nursing knowledge and the process of elimination to make your selection. |
2648 A pregnant client who has class II heart disease has Correct answer: 1 Prophylactic antibiotics are given during labor to prevent bacterial endocarditis. The other progressed throughout her pregnancy without medications might be needed based on additional assessment findings, or might not be complication, and is admitted to the labor and delivery needed at all for a client with class II heart disease. unit in active labor. The nurse anticipates administering which medication based on the client s history? ‐ An antibiotic ‐ An antihypertensive ‐ A cardiac glycoside ‐ A loop diuretic | The core issue of the question is knowledge of the significance of class II heart disease during labor. Use nursing knowledge and the process of elimination to make your selection. Consider that antihypertensives, cardiac glycosides, and diuretics are used to manage symptoms that are not present in the stem of the question. An antibiotic is the only drug listed that could prevent a new problem (infection). |
2649 A client with placenta previa reports that she has Correct answer: 3 The client is likely to lose some blood with a placenta previa. Increasing iron in her diet is a religious beliefs that prohibit receiving blood or blood positive response that does not interfere with her religious beliefs. Option 1 is not a true products. The nurse provides client teaching, and statement. Option 2 does not address the client’s need or right to care. evaluates that the teaching has been effective if the client states: ‐ “A judge will force me to accept a transfusion if I really need it.” ‐ “I might have to sign out of the hospital against medical advice (AMA).” ‐ “I will meet with the dietician to increase the amount of iron in my diet.” ‐ “There is little chance that I will bleed heavily during this pregnancy.” | The core issue of this question is culturally competent care to reduce risk of complications. Eliminate option 1 because of the word force, and eliminate option 2 because of against medical advice. Choose option 3 over 4 because the client cannot predict the risk of bleeding during pregnancy. |
2650 The nurse would assess the pregnant client with a Correct answer: 1 The client with multiple partners is at high risk for sexually transmitted diseases and history of multiple sexual partners for which ascending infection that can lead to blockage in the fallopian tubes. Ultimately, this process complication of pregnancy that is of greatest concern could lead to ectopic pregnancy. The other options do not address this particular in this situation? pathophysiological concern. ‐ Ectopic pregnancy ‐ Premature rupture of membranes ‐ Pregnancy‐induced hypertension ‐ Rh‐incompatibility | Note the critical words multiple sexual partners and greatest concern in the question. This tells you that the correct answer has a connection to risks associated with multiple sex partners. Use knowledge of complications of sexually transmitted infections to choose option 1 over the others. |
2651 The nurse anticipates that a pregnant client with a Correct answer: 3 The chance of transmission of HIV is less than 1% if the infant is delivered by cesarean prior to history of which of the following might benefit from a membrane rupture. Only the client with active herpes lesions should be delivered by cesarean scheduled cesarean birth to achieve an improved to prevent transmission of the virus during vaginal birth. outcome for the infant? ‐ Diabetes mellitus ‐ Herpes simplex type II ‐ Human immunodeficiency virus ‐ Systemic lupus erythematosus | The core issue of the question is knowledge of methods of transmitting infection from mother to newborn during the delivery process. Eliminate options 1 and 4 first because they do not address infection. Choose option 3 over 2 because there is greater risk of transmitting HIV during delivery, while only active herpes lesions transmit that virus. |
2652 Which of the following short‐term client outcomes Correct answer: 2 A short‐term outcome of maintained weight is appropriate while the client is being stabilized would be most appropriate for a client admitted to the in the hospital. An outcome is the result of nursing care. Options 1 and 3 are nursing hospital with hyperemesis gravidarum and the nursing interventions. Option 4 does not address the nursing diagnosis. diagnosis of Imbalanced Nutrition: Less than Body Requirements? ‐ Assess hourly intake and output. ‐ Maintain present weight. ‐ Provide favorite foods. ‐ Verbalize risks to the fetus. | The critical words in the question are client outcomes. With this in mind, eliminate options 1 and 3 because they are interventions. Choose option 1 over 4 because it directly correlates with nutrition, which is the focus of the nursing diagnosis. |
2653 A type 1 diabetic prenatal client asks the clinic nurse Correct answer: 2 Breastfeeding should be encouraged, because it benefits both the mother and her infant. It is whether she will be able to breastfeed her baby. not contraindicated for diabetic mothers (option 1), might or might not help prevent future Which response by the nurse is most accurate? pregnancy during lactation (option 3), and does not necessarily lead to loss of blood glucose control with careful management (option 4). ‐ “Breastfeeding is contraindicated for insulin‐dependent moms.” ‐ “Certainly, breastfeeding will be beneficial for both of you.” ‐ “I think this is a good idea because it also prevents pregnancy.” ‐ “You will have a lot of difficulty maintaining a stable blood sugar.” | Note the key words most accurate, which tell you that the correct answer is the one that is a true statement, while the others are false to a greater or lesser degree. Eliminate options 1 and 4 first because of the words contraindicated and a lot of difficulty, respectively. Then choose option 2 over 3 because option 3 might not be true, depending on individual circumstances. |
2654 A client is admitted with membranes that ruptured Correct answer: 2 The client with premature ruptured membranes is at risk for developing an infection, and four hours ago, and occasional mild contractions. The should have her vital signs, specifically temperature, monitored every two hours. The client term fetus looks healthy on external monitoring. may be on bedrest, not ambulating, following rupture of the membranes (option 1). Promoting Which of the following is the priority in the nursing rest (option 3) and providing clear liquids (option 4) are slightly lower priorities for this client. plan of care for this client? ‐ Encourage ambulation. ‐ Monitor vital signs. ‐ Promote rest. ‐ Provide clear liquids. | The core issue of the question is knowledge of infection as the key risk following rupture of the membranes. Eliminate options that do not address this risk. Only option 2 addresses vital signs, which includes monitoring temperature as one way of detecting infection. |
2655 A prenatal client at 14 weeks' gestation complains of Correct answer: 4 Ultrasound confirms the diagnosis of molar pregnancy that is indicated by the client’s continuous nausea and vomiting, and a severe symptoms. The client will have high hCG levels and low maternal serum alpha‐fetoprotein headache. The client has elevated blood pressure, and levels, but these are not conclusive for hydatidiform mole. Option 1 is inappropriate before the the fundal height is 21 centimeters. Which diagnostic third trimester because it evaluates the fetus. test does the nurse anticipate will be ordered to confirm a hydatidiform mole? ‐ Biophysical profile ‐ Human chorionic gonadotropin ‐ Maternal serum alpha‐fetoprotein ‐ Sonography | The core issue of the question is the best method to determine hydatidiform mole. Choose option 4 over all the others because it is the only one that provides for visualization of the reproductive structures, and that allows discrimination of true pregnancy from hydatidiform mole. |
2656 An HIV‐positive client in active labor with ruptured Correct answer: 4 The rate of transmission of HIV to the newborn is decreased from 17% to less than 7% if the membranes is being transported to the hospital via mother is given prophylactic zidovudine (Retrovir) orally during pregnancy and by IV during ambulance. The labor and delivery nurse anticipates labor. There are no indications presented in the question for any of the other medications priority administration of which medication to this listed, although an antibiotic could be administered if the mother acquired an infection client? secondary to ruptured membranes. ‐ Antibiotics ‐ Immune globulin ‐ Oxytocin (Pitocin) ‐ Zidovudine (Retrovir) | The core issue of the question is management of the HIV client in active labor with respect to preventing transmission of HIV to the newborn. With this in mind, eliminate options 2 and 3 first, as they do not prevent or treat infection. Choose option 4 over 1 because it is an antiviral rather than antibacterial. (Note also the ‐vir that indicates virus in the drug name Retrovir.) |
2657 A client who admits to crack cocaine use during her Correct answer: 1 Option 1 is a therapeutic response to the client’s concerns. The nurse should remain pregnancy asks the nurse not to inform the baby’s nonjudgmental when clients reveal information about substance abuse. Option 2 is father about the substance abuse. Which response by nontherapeutic because it does not explore the client’s concern. Option 3 is inaccurate, and the nurse is most appropriate? option 4 is judgmental. ‐ “You must be very worried about how he will react to that information.” ‐ “This is your pregnancy and your body, so I’ll keep your information private.” ‐ “Your baby will probably not survive, so there is no need for him to know.” ‐ “Have you considered that he deserves to know what you may have done to his baby?” | The core issue of the question is a therapeutic response to a concern shared by the client. Eliminate each of the incorrect options systematically because they do not invite further sharing of information between client and nurse. |
2658 A client experiencing profuse hemorrhage from Correct answer: 2 The left lateral position facilitates uteroplacental perfusion. Semi‐Fowler s position would placenta previa is being prepared for an emergency decrease maternal cerebral perfusion; Trendelenburg puts the weight of the gravid uterus cesarean birth. The client exhibits signs of against the maternal lungs; and knee‐chest is unlikely to be maintained by a client in shock. hypovolemia. The nurse makes it a priority to place the client into which of the following positions? ‐ Knee‐chest ‐ Left lateral ‐ Semi‐Fowler’s ‐ Trendelenburg | The core issue of the question is how to maintain uteroplacental perfusion for the client in shock. With this in mind, choose the position that turns the client to the left side and takes pressure of the gravid uterus off the great vessels in the abdomen. |
2659 Which of the following nursing diagnoses has the Correct answer: 2 The client with DIC is at risk for hemorrhage, which takes priority over the non–life‐ highest priority for a client with a missed abortion who threatening options 1 and 4. The client could experience bruising or other areas of local has developed disseminated intravascular bleeding from the disorder, but hypovolemia from hemorrhage takes priority over risk for coagulopathy (DIC)? injury (option 3). ‐ Anticipatory Grieving ‐ High Risk for Deficient Fluid Volume ‐ High Risk for Injury ‐ Spiritual Distress | The issue of the question is knowledge of complications of DIC, specifically hemorrhage and loss of circulating volume. With this in mind, focus on physiologically based nursing diagnoses, and eliminate options 1 and 4. Choose option 2 because it addresses a greater and more specific physiological risk. |
2660 A client with premature spontaneous rupture of Correct answer: 1 Glucocorticoids such as betamethasone are contraindicated for use in diabetic clients membranes (SROM) at 33 weeks' gestation is to be because they raise the blood glucose level even further. The other disorders are not given betamethasone (Celestone) to increase fetal lung contraindications for giving betamethasone. maturity. The nurse checks the client s record to ensure that the client does not have what disorder that would be a contraindication for this drug? ‐ Diabetes mellitus ‐ History of alcohol abuse ‐ Incompetent cervix ‐ Intrauterine growth restriction (IUGR) | The core issue of the question is knowledge of key side effects of betamethasone, which helps to select the client for whom it should not be used. Recall that the glucocorticoids often end in ‐sone to help you recognize the drug as a glucocorticoid. Recall next the risk of elevating blood glucose levels to choose option 1 over the others. |
2661 The nurse concludes that a client is at risk for Correct answer: 2 An increase of 30 mmHg systolic and 15 mmHg diastolic on two occasions is diagnostic for pregnancy‐induced hypertension (PIH) when the vital PIH. The blood pressures in each of the other options do not meet the criteria for increase in signs taken today show that the blood pressure has either the systolic or the diastolic blood pressure reading. increased during pregnancy from: ‐ 90/56 to 110/70. ‐ 100/60 to 130/76. ‐ 122/80 to 138/86. ‐ 134/80 to 140/88. | Specific knowledge of the criteria for PIH is needed to answer this question. Use nursing knowledge and the process of elimination to make your selection. As an alternative, choose option 2 because it has the greatest degree of change in both systolic and diastolic measurements. |
2662 A client who has experienced a spontaneous abortion Correct answer: 1 The majority of early abortions are related to abnormal chromosomes. The client might fear at 8 weeks asks the nurse why this happened. The that she has caused the loss, and should be provided with accurate information. The other nurse provides accurate information by stating that responses are not accurate. the most common cause of “miscarriage” is: ‐ Chromosome abnormalities. ‐ Environmental teratogens. ‐ Excessive activity. ‐ Substance abuse. | Specific knowledge of the etiologies of spontaneous abortion is needed to answer the question. Use nursing knowledge and the process of elimination to make your selection. |
2663 A client who received no prenatal care delivers a 9‐ Correct answer: 3 An LGA infant who demonstrates respiratory immaturity could have a diabetic mother. The pound, 4‐ounce baby boy who exhibits signs of infant produces his own insulin during pregnancy, and stores the excess glucose as fat to respiratory distress. The nurse obtains a blood sample compensate for high maternal glucose loads. However, after delivery, the infant is at high risk from the infant to assess for which of the following? for hypoglycemia because excess maternal glucose is now absent from the infant s circulation. ‐ Hemolysis ‐ Hyperbilirubinemia ‐ Hypoglycemia ‐ Sepsis | The core issues of the question are prenatal risks for LGA infants and the consequences after delivery. Use nursing knowledge and the process of elimination to make your selection. |
2664 The nurse explains to a client who had a cervical cone Correct answer: 2 Cervical trauma and scarring can result in cervical incompetence during pregnancy. The other biopsy several years ago that she is now at increased options are unrelated to cone biopsy. risk for which complication of pregnancy? ‐ Abdominal pregnancy ‐ Incompetent cervix ‐ Gestational trophoblastic disease ‐ Placenta previa | Note the critical word cervical in the stem of the question, and choose option 2 over the others because it also refers to the cervix. |
2665 A client with a complete placenta previa is Correct answer: 3 The priority diagnosis is related to maintaining circulation and oxygenation. The other options hospitalized on bedrest at 24 weeks' gestation. In are of lesser importance. preparing the plan of care, what nursing diagnosis takes priority for this client? ‐ Activity Intolerance related to enforced bedrest ‐ Imbalanced Nutrition: Greater than Body Requirements related to sedentary lifestyle ‐ Ineffective Tissue Perfusion related to placental location ‐ Anticipatory Grieving related to potential fetal loss | Remember the ABCs. The correct answer would be the option that contains a nursing diagnosis related to airway, breathing, or circulation. |
2666 A 20‐year‐old gravida 2, para 0 at 37 weeks' gestation Correct answer: 4 The MacDonald cerclage is a purse‐string suture that ties the cervix closed. The suture needs calls the nurse because she is experiencing to be removed before vaginal delivery is possible. Options 1 and 2 place the client at risk of contractions every 7–8 minutes. Her first pregnancy cervical injury. The cerclage is usually removed at 37 weeks to allow natural labor to begin. ended with a spontaneous abortion at 18 weeks, and the client had a MacDonald cerclage placed early in the current pregnancy. Which of the following instructions by the nurse are the most appropriate? ‐ "Try a warm bath and relaxation techniques to see if the contractions will go away." ‐ "You must wait until your contractions are every 5 minutes before going to the hospital." ‐ "You need to go to the hospital, so we can stop your premature labor this time." ‐ "You should go to the hospital to be evaluated and have the cerclage removed." | Knowledge of the need to remove the cerclage prior to delivery and labor for the 37‐ weeks client will help to identify the correct response and the correct answer. |
2667 A pregnant client comes to the hospital at 36 weeks Correct answer: 2 During pregnancy, only amniotic fluid will dry to a ferning pattern. Urine occasionally might reporting that her "water broke," but denies any be alkaline, and turn nitrazine paper blue, or old nitrazine paper might be unreliable. contractions. Which of the following assessment data Performing a vaginal exam places the client at unnecessary risk for an ascending infection, and provides the nurse with the most reliable indication of feeling for membranes is unreliable. A watery vaginal discharge is not necessarily amniotic premature rupture of membranes? fluid. ‐ A dried specimen shows a microscopic fern pattern. ‐ Fluid from the perineum turns nitrazine paper dark blue. ‐ No membranes are felt on a sterile vaginal exam. ‐ The client has a visible watery vaginal discharge. | The core issue of the question is the most objective data to document rupture of membranes. Eliminate option 2 because other fluids might result in this finding. Eliminate option 3 because it jeopardizes the safety of the client, and can result in inaccurate data. Eliminate option 4 because this finding is not conclusive for amniotic fluid. |
2668 During which of the following procedures should the Correct answer: 1 According to universal precautions, the caregiver should wear goggles when contamination nurse wear protective goggles in addition to gloves? from splashing is possible, as when the membranes are artificially ruptured. The other options place the nurse at risk for contamination from skin contact, necessitating the use of gloves. ‐ Changing a soaked disposable bed pad ‐ Performing an amniotomy ‐ Starting an intravenous line ‐ Washing dirty instruments | Recall that goggles are indicated to prevent contamination of the eyes. Eliminate options 1, 3, and 4 because they place the nurse at risk for contamination from skin contact, necessitating the use of gloves, not goggles. |
2669 When caring for a client with pre‐eclampsia, which of Correct answer: 4 The normal platelet value is 150,000–450,000/mm<sup>3</sup>. The pre‐ the following laboratory results should the nurse eclamptic client is at risk to develop the potentially fatal HELLP syndrome, with low platelets as report to the physician immediately? one of the defining factors. The other options are all within normal values for pregnancy. ‐ Creatinine 0.3 mg/dL ‐ Fasting blood glucose 65 mg/dL ‐ Hemoglobin 11 grams/dL ‐ Platelets 50,000/mm3 | The focus of the question is abnormal laboratory results in pre‐eclampsia. Eliminate options 1, 2, and 3 because they contain normal values for pregnancy. |
2670 When providing discharge information to an Rh‐ Correct answer: 2 Rh‐immune globulin, RhoGAM, must be administered within 72 hours of any event that negative mother, the nurse evaluates that the client presents a possibility for the mother to become sensitized to the Rh antigen. This includes has understood the teaching when she states: pregnancy with an Rh‐positive infant, which could be the case in a first‐trimester abortion (miscarriage), though the blood type is not usually obtained. If the father is also Rh‐negative, the fetus will be also, and no problems will occur with this pregnancy. The indirect Coombs' test is used to determine maternal Rh sensitization. While option 4 might be correct during this one reproductive event, precautions must be taken during future pregnancies. ‐ "I don't have to be concerned unless my husband is also Rh‐negative." ‐ "I must have Rh‐immune globulin if I ever have a miscarriage." ‐ "The direct Coombs' test will determine if I am sensitized to Rh‐positive blood." ‐ "Since my baby is also Rh‐negative, I don't need to worry about it." | Knowledge of the risks for the Rh‐sensitized pregnant woman will help to choose the correct answer. The question is worded as a positive statement. The correct answer would be the option that contains a true statement about a point of client education. |
2671 A client with severe pre‐eclampsia has a physician's Correct answer: 600 The mixed concentration of magnesium sulfate is 2 grams in 100 mL of fluid. The client should order that reads, "magnesium sulfate 4 grams loading receive 200 mL (4 grams) over 20 minutes, so the pump must be set to deliver 600 mL over 60 dose, then 2 grams/hour." The nurse mixes 20 grams minutes. of 10% magnesium sulfate in 1,000 mL of Ringer's lactate per agency protocol. Using a mini‐drip IV set, the nurse sets the IV pump to deliver the loading dose at mL/hour over 20 minutes. | Knowledge of the calculation needed to administer the required dose of medication will be essential to arrive at the correct answer. |
2672 A client who has experienced a complete Correct answer: 1 Feelings of anger are commonly experienced during the grieving process. The client who has spontaneous abortion expresses her anger at the had a spontaneous abortion is grieving the loss of her imagined child, and should receive physician and the nurses for not doing enough to save supportive care. her pregnancy. The nurse evaluates this behavior as: ‐ A common grief response. ‐ Displaced marital strife. ‐ Ineffective social skills. ‐ Maladaptive coping. | The focus of the question is a childbearing loss. The correct answer would be a common psychological experience after loss, grief. |
2673 Which of the following factors found in a prenatal Correct answer: 2 Previous endometriosis and pelvic inflammatory disease can cause scar tissue formation that client's history would place her at increased risk for could block the normal passage of a fertilized ovum through the fallopian tube. The other ectopic pregnancy? Select all that apply. options would not interfere with movement of the ovum. ‐ Android pelvis ‐ Endometriosis ‐ Late menarche ‐ Previous cesarean ‐ Pelvic inflammatory disease | The focus of the question is a causative factor for ectopic pregnancy. Eliminate options 1, 3, and 4 because they would not interfere with movement of the ovum in the fallopian tube, the common location for an ectopic pregnancy. |
2674 The nurse caring for a pre‐eclamptic client discovers Correct answer: 3 The nurse remains with the client to prevent injury during the seizure. Insertion of a tongue her on the bathroom floor having an eclamptic seizure. blade is not recommended, because of the risk of injury to both nurse and client. The client What are the nurse's priority actions? should be placed on her side, to avoid aspiration. ‐ Call the physician, and prepare for cesarean birth. ‐ Insert a tongue blade, to prevent biting the tongue. ‐ Remain with the client, and call for help. ‐ Turn the client to her back, and observe her movements. | Knowledge of the nursing interventions for the client who is seizing is necessary to answer the question correctly. This question focuses on the safety of the client. The correct answer would be the option that presents the first action to prevent injury. |
2675 A client at 10 weeks' gestation who has recently Correct answer: 1 The client has three risk factors of molar pregnancy: Japanese background, brownish, "prune emigrated from Japan comes to the prenatal clinic juice" vaginal bleeding, and the severe nausea and vomiting associated with excessive hCG because she is having some dark brown vaginal found in trophoblastic disease. The client has only one symptom of hyperemesis; placenta spotting, and is experiencing severe nausea and previa presents with bright red bleeding; and there is no information suggestive of psychosis. vomiting. The nurse interprets that these symptoms are compatible with which of the following conditions? ‐ Gestational trophoblastic disease ‐ Hyperemesis gravidarum ‐ Placenta previa ‐ Pregnancy‐induced psychosis | The core issue of this question is a cluster of symptoms. Eliminate options 2 and 3 because they are characterized by one main symptom. Eliminate option 4 because no psychological symptoms are presented. |
2676 A client who experienced an incompetent cervix with Correct answer: 1 The Shirodkar operation is closure of the cervix with suture material to prevent preterm a previous pregnancy has had a Shirodkar operation dilatation. When labor ensues, the suture must be cut so the fetus can pass through the birth done at 18 weeks in the current pregnancy. The client canal. Waiting for harder contractions will increase the likelihood of cervical damage from the calls the clinic at 37 weeks' gestation because she is suture. Option 3 does not address the client's risk, which is the priority. Clients who expect to having irregular contractions every 5–7 minutes. have several future pregnancies may be delivered by cesarean to avoid repeated cerclage, but Which response by the nurse is most appropriate? there is no necessity to this option. ‐ "You need to go to the hospital to have the cerclage removed before your baby is born." ‐ "You should wait, and come in when the contractions are closer and harder." ‐ "You sound like you are worried about this baby. It must be frightening for you." ‐ "You will need to have a cesarean birth with the Shirodkar cerclage in place." | Recall that the placement of a suture in cerclage places a barrier to safe delivery of an infant as the due date approaches. With this in mind, select the option that allows for labor to progress safely, or to begin safely, if the labor is false at this time. |
2677 A client who had no prenatal care presents to the Correct answer: 1 The risk for placental abruption is increased with cocaine abuse. The other factors make the labor and delivery unit with a moderate amount of client high risk for complications of pregnancy, but not particularly for abruption. vaginal bleeding and complaints of severe abdominal pain. Fundal height is 34 centimeters. Contractions are every 1.5 minutes, lasting 60 seconds, and strong, with increasing resting tone. The monitor shows consistent late decelerations. What information from the nursing assessment is most consistent with a risk for placental abruption? ‐ The client admits to using cocaine. ‐ The client has had no prenatal care. ‐ The client is HIV‐positive. ‐ The client is poor and uneducated. | Knowledge of the risks from cocaine abuse will aid in answering this question correctly. Eliminate the other answers, which are not factors that increase the risk for abruptio placentae. |
2678 A client is hospitalized on the antepartum unit with Correct answer: 4 The client with ruptured membranes prior to the beginning of labor is at increased risk for premature rupture of membranes at 37 weeks' ascending infection (chorioamnionitis). The client's temperature should be taken every 2–4 gestation. Which of the following routine physician hours, to identify early signs of sepsis. orders would the nurse question for this client? ‐ Bedrest with bathroom privileges ‐ Diet as tolerated ‐ External fetal monitor prn ‐ Vital signs every shift | The core focus of this question is planning care for a client with a complication. The correct answer would be the option that includes additional or more frequent assessment of the client's status. |
2679 The nurse would question an order for which of the Correct answer: 3 The infant of an HIV‐positive mother will test positive on an ELISA test for the human following laboratory tests, which is inappropriate to immunodeficieny virus because the maternal antibodies cross the placenta during pregnancy. test the current condition of a newborn of an HIV‐ This does not indicate that the newborn has HIV. The diagnosis using the ELISA test for the positive mother? baby is not made until around 15 months, when maternal antibodies are degraded and the infant forms antibodies to HIV if infected. The other tests give information about the infant's current condition. ‐ Bilirubin level ‐ Blood glucose level ‐ ELISA testing ‐ Hematocrit | The focus of this question is an immune disorder. The correct answer would be the option that includes a test designed to assess antigen–antibody responses. Knowledge of the care of the newborn exposed to HIV/AIDS and of the transmission of maternal antibodies to the newborn will aid in answering correctly. |
2680 A client with heart disease has been prescribed Correct answer: 2 Digoxin is a cardiac glycoside that increases cardiac output by increasing the strength of digoxin (Lanoxin) during her pregnancy. The nurse contraction of the myocardium and slowing the heart rate. A pulse rate lower than 60 is a evaluates that client teaching has been effective when serious adverse effect of the medication, and the dose should be held. The client needs the client states: adequate potassium for myocardial function. Antibiotics are not contraindicated with digoxin. The drug may be given with or without food. ‐ "I will avoid eating foods high in potassium while taking this medication." ‐ "I will check my pulse, and not take the medication if it is less than 60." ‐ "I will not take antibiotics at the same time as this medication." ‐ "I will take this medication with a full glass of water before breakfast." | A critical word in the question is "effective." This indicates the correct option is a true statement. Knowledge of the action of digoxin and its side effects will help to choose the correct answer. |
2681 A 34‐year‐old client comes to the Emergency Correct answer: 1, 5 The nurse should provide emotional support to all clients experiencing perinatal loss. Offering Department with cramping and vaginal bleeding. She the client an opportunity to talk with another health care professional or clergy for additional has missed two menstrual periods. Which of the help is also supportive. The other answers are insensitive, and option #4 might not be true. following statements by the nurse is most appropriate when the client is diagnosed with an incomplete abortion? Select all that apply. | Choose options that contain therapeutic communications. Only options 1 and 5 are therapeutic and offer support; the other answers can be eliminated, since they are not supportive measures. |
‐ "I am so sorry. This must be difficult for you." ‐ "The doctor will clean out your womb with a D and C." ‐ "Did you really want to be pregnant now?" ‐ "You'll still be able to have children after this is over." ‐ "Would you like to speak with a hospital chaplain or counselor?" | |
2682 A client with pre‐eclampsia is receiving magnesium Correct answer: 2 Magnesium sulfate is a CNS depressant used to prevent seizure activity in the pre‐eclamptic sulfate and oxytocin (Pitocin) IV to induce labor at 38 client. The other options might occur, but are not the intended effect of the drug. weeks. The nurse determines the magnesium sulfate has been effective after noting which of the following effects on the client? ‐ Lowered blood pressure ‐ Absence of seizures ‐ Onset of sedation ‐ Stools that are soft | Recall that the classification of magnesium sulfate is a CNS depressant, which will help you to recall that it will prevent seizures, the major risk of pre‐eclampsia. The other options are all similar and incorrect; they might occur when the drug is used, but are not the primary action of the drug. |
2683 The nurse anticipates that which of the following Correct answer: 1 A sinusoidal fetal heart rhythm is associated with fetal anemia, which could be associated complications of pregnancy would be most consistent with an abruption. The other complications would result in other signs of fetal distress, such as with development of a sinusoidal fetal heart rate tachycardia, loss of variability, and late decelerations. pattern during labor? ‐ Abruptio placentae ‐ Chorioamnionitis ‐ Pregnancy‐induced hypertension ‐ Prolapsed cord | Identify the option that is different from the rest. Blood loss from abruptio placentae can cause fetal anemia, which is associated with a sinusoidal fetal heart rhythm. The other options are similar because they can cause fetal distress but not fetal anemia, and are likely to be incorrect. |
2684 A client who admits to substance abuse during Correct answer: 4 Option 4 is the only answer that acknowledges the client's intent to cut down on substance pregnancy tells the nurse, "I know I am just a really abuse while seeking additional information about the client's self‐concept. Option 1 places the weak person, but I will try to cut down while I'm emphasis on the nurse, while options 2 and 3 are demeaning and negative. pregnant." Which response by the nurse would be most therapeutic? ‐ "I am concerned about you and your baby. What can I do to help you?" ‐ "I don't believe that you are weak at all. You just need to say no to drugs." ‐ "I have heard that before. You need to get serious now, or your baby will suffer." ‐ "That is a very positive plan. Could you tell me more about feeling like a weak person?" | Eliminate options 2 and 3, which are negative and nontherapeutic. Option 1 can be eliminated because it doesn't focus on the client and her needs to explain herself and her feelings. |
2685 A client with class II heart disease is being seen for Correct answer: 3, 5 Anemia increases the cardiac workload, and should be avoided by clients with heart disease. her first prenatal visit. Which of the following teaching The client should discuss medications with her caregiver, but she may be allowed to take points would the nurse stress for this client? Select all acetaminophen or a few other OTC medications. The client with class II cardiac disease is that apply. slightly compromised with ordinary activity levels, and would not tolerate exercise. There is a 2–4% chance that the baby will inherit a congenital defect. ‐ Avoid all over‐the‐counter (OTC) medications during pregnancy. ‐ Regular exercise will help increase cardiac capacity during pregnancy. ‐ It’s important to take prenatal vitamins and iron as prescribed. ‐ The client’s fetus will probably have a similar congenital heart defect. ‐ Adequate nutrition to prevent anemia and avoid excessive weight gain | Knowledge of the complications from heart disease during pregnancy will help to answer the question correctly. |
2686 A client with type 1 diabetes mellitus gives birth. The Correct answer: 1 The placenta produces human placental lactogen (hPL) and increased amounts of estrogen postpartum nurse monitors the blood glucose level and progesterone. These hormones interfere with maternal glucose metabolism, and require carefully, expecting that the client’s insulin increased insulin production or supplementation. As soon as the placenta is expelled, these requirements in the first 24 hours after delivery will: hormone levels fall dramatically, and the mother might require no insulin at all or a very reduced dose in the first 24 hours. ‐ Drop significantly. ‐ Gradually return to normal. ‐ Increase slightly. ‐ Stay the same as before delivery. | This question is time‐dependent, as noted by the words “insulin requirements in the first 24 hours after delivery.” Recall that this is a time of rapid and dramatic changes for the woman. Eliminate options that do not meet this criteria. |
2687 The nurse is especially interested in which of the Correct answer: 2 The glycosylated hemoglobin (H. A<sub>1c</sub>) test provides an indication of following lab tests, which provides the nurse with the what glucose levels have been over the last 4–8 weeks, because glucose attaches to the red best information about ongoing control of type 1 blood cells (RBC) and remains there for the residual life of the RBC. Increased blood glucose diabetes mellitus in a pregnant adolescent? levels will be reflected in an increased percentage of H. A<sub>1c</sub>. The other tests indicate current blood glucose levels only. ‐ Fasting blood glucose ‐ Glycosylated hemoglobin (H. A1c) ‐ Oral glucose tolerance test (OGTT) ‐ Post‐prandial test | The critical words in the question are “ongoing control.” This tells you that the correct option identifies a test measurement that does not reflect only current time. Knowledge of the laboratory assessment of long‐term glucose control will aid in answering the question correctly. |
2688 The nurse should be aware that pregnant women Correct answer: 3 Pregnancy presents an ideal time for nurses to reach out to substance‐abusing clients in a who practice substance abuse and present themselves caring way, since the client herself recognizes that she and her baby will benefit from prenatal for prenatal care: care. Option 1 is unrealistic, option 2 is punitive, and option 4 is judgmental. ‐ Are ready to kick their habit. ‐ Must be reported to the authorities. ‐ Recognize the need for caring interventions. ‐ Will lack appropriate parenting skills. | Options 1, 2, and 4 are punitive, and should be eliminated. Option 3 is the only one that indicates a therapeutic response to someone who recognizes the need for prenatal care even though she is abusing drugs. |
2689 Which of the following nursing actions would take Correct answer: 2 The client with a suspected ectopic pregnancy might be at risk for the development of priority when caring for the woman with a suspected hypovolemic shock. Assessment is the first step of the nursing process, and airway, breathing, ectopic pregnancy? and circulation are the priorities. Options 1 and 4 are possible later interventions, and option 3 is the surgeon s responsibility. ‐ Administering oxygen ‐ Monitoring vital signs ‐ Obtaining surgical consent ‐ Providing emotional support | The critical word in this question is “suspected.” The correct answer would be the option that provides further assessment of the client’s condition. |
2690 A client is being discharged from the hospital after Correct answer: 3 The client requires frequent monitoring to rule out development of malignancy after evacuation of a molar pregnancy. The nurse recognizes experiencing trophoblastic gestational disease. Weekly hCG measurements are done until that additional discharge teaching is required when the normal levels are recorded for three weeks. Option 2 is a possibility for this client. The client client states: should use contraception for at least one year during the follow‐up care (option 4), and expressions of sadness are appropriate for any pregnancy loss, even if no fetus developed (option 1). ‐ “I am so sad that I lost this baby.” ‐ “I may need to have chemotherapy after this.” ‐ “I will need to see the doctor yearly for follow‐up.” ‐ “I will use contraception for the next year.” | The wording of the question reflects a negative stem, and so the correct option will be an option that is false. Knowledge of the complications from hydatidiform mole and the required medical regime will aid in choosing the correct answer. |
2691 The charge nurse in the labor and delivery unit has Correct answer: 3 The registered nurse is responsible for client assessments (options 2 and 4), and for client become overwhelmed with admissions and births. For teaching (option 1). The intervention of helping the client to the bathroom is within the which client can the charge nurse best delegate the practice abilities of a CNA if the RN has determined that it is safe for this client to get out of needed care to a trusted certified nursing assistant bed. (CNA) who is currently going to school to become a nurse? ‐ A client in false labor who needs teaching about true versus false labor signs ‐ A client with PIH who needs to be evaluated for reflexes and clonus ‐ A primigravida in early labor who needs to be helped to the bathroom ‐ An obese laboring client who needs to have her fetal monitor adjusted | Recall that assessment and teaching should not be delegated to unlicensed personnel to eliminate incorrect options. |
2692 A client with a known placenta previa is admitted at Correct answer: 1 One mL of blood weighs approximately 1 gram. The other responses are incorrect. 30 weeks gestation with painless vaginal bleeding. The nurse weighs the client s peripads to monitor blood loss. After noting an increased weight of 50 grams, the nurse would document that this equals approximately mL blood loss. | The critical information needed to answer the question is that 1 mL is approximately equal to 1 gram. Learn this information now if this question was difficult. |
2693 A client with hyperemesis gravidarum would most Correct answer: 2 The client with hyperemesis gravidarum is anxious or even fearful about the effects of her likely benefit from nursing care designed to address condition on the fetus. The etiology of hyperemesis is unknown, but the incidence is increased which of the following nursing diagnoses? in conditions with increased hCG. There might be an emotional component, but there is no indication that this is an unwanted pregnancy. With appropriate treatment, the prognosis is favorable for the fetus. The client experiences excessive vomiting, and would have the diagnosis of Imbalanced Nutrition: Less than Body Requirements. ‐ Imbalanced Nutrition: More than Body Requirements related to pregnancy ‐ Anxiety related to effects of hyperemesis on fetal well‐being ‐ Anticipatory Grieving related to inevitable pregnancy loss ‐ Ineffective Coping related to unwanted pregnancy | The core focus in this question is the effects of hyperemesis, excessive vomiting, and deficient nutrition. Eliminate option 1, as it deals with overnutrition. Eliminate options 3 and 4, as there are no data to support them. |
2694 The initial laboratory results for a primigravida Correct answer: 1 The Rh‐negative client whose partner is Rh‐positive could carry an Rh‐positive fetus, and indicate a hemoglobin of 12 grams/dL, hematocrit of would be at risk for Rh‐sensitization, which could create risks for future pregnancies. This 36%, and a blood group and type of A, Rh‐negative. father of the baby needs to have his blood type assessed. The client is not anemic based on What would be the priority nursing action to promote these hemoglobin and hematocrit values, so options 2 and 4 are incorrect. There is no a healthy pregnancy for this client and her fetus? relationship between the lab values and the client s weight in this scenario (option 3). ‐ Determine the blood type of the father. ‐ Encourage the client to eat more dark green, leafy vegetables. ‐ Provide information on weight gain during pregnancy. ‐ Suggest an iron supplement in addition to prenatal vitamins. | Only option 1 indicates a need that is identified by the scenario. The other answers are not correct, given the normal hemoglobin and hematocrit. In addition, three options are similar (focusing on nutrition), and are therefore likely to be incorrect. The correct answer, option 1, is different. |
2695 The nurse has taught the client to perform deep‐ Correct answer: 3 Placing the hands directly on the incision during coughing will diminish the discomfort breathing and coughing exercises. The nurse associated with coughing. Each of the other options indicates correct procedure on the part of determines that the client needs more teaching when the client. the client is observed doing which of the following activities? ‐ Sitting upright before performing deep‐breathing and coughing exercises ‐ Taking deep breaths before attempting to cough ‐ Placing both hands vertically and lightly on either side of the incision ‐ Using a pillow for splinting during coughing | The words needs more teaching in the stem of the question tells you that the incorrect client statement is the correct option. Use knowledge of nursing fundamentals to make a selection. |
2696 A toddler is being prepared for a surgical procedure. Correct answer: 4 The child fears separation from her parents. The child has no previous experiences to This is the child’s first experience with surgery. The compare to this experience, so she will not anticipate pain. The child cannot anticipate any child’s mother expresses concern about the child’s changes in her body, and does not worry about communication. psychological adaptation to the surgery. While planning for postoperative care, the nurse recognizes that which of the following is likely to be the child’s greatest concern? ‐ Anticipated pain ‐ Body image changes ‐ Communication difficulties ‐ Separation from parents | The critical word greatest in the stem of the question provides a clue that more than one option could be partially true. Use knowledge of growth and development to make a selection, recalling that toddlers fear separation from their parents. |
2697 A female client is being prepared for surgery. When Correct answer: 4 Taping a wedding band in place is acceptable for the client who does not wish to remove it, the nurse asks the client to remove her wedding ring, unless there is danger the finger might swell during or after surgery. Option 1 assumes the ring the client refuses. Which of the following would be the is tight, and that the client wishes to remove it. Option 3 is a false statement, while option 2 most appropriate response by the nurse? creates unnecessary fear at a time when anxiety already is likely to be increased. ‐ Encourage the client to use soapy water to remove the ring, if it is tight. ‐ Explain that the hospital cannot be responsible for jewelry worn during surgery. ‐ Notify the surgeon’s office that the surgeon must see the client in the preoperative holding area. ‐ Tape the ring in place before the client is transported to the preoperative holding area. | Identify the core issue of the question, which is the method of safeguarding client property during surgery. Choose the option that meets the needs of the client and protects both the hospital and the client’s property. |
2698 The nurse is caring for clients in the preanesthesia Correct answer: 1 Option 1 is correct because with increased age, there is a greater likelihood that the kidneys room. The nurse notes that one client, who is an older start to degenerate. All the other options are incorrect: hunger does not necessarily cause adult, has an increased surgical risk based on which of hyperacidity, comprehension is not altered in all older adults, and cardiovascular problems do the following factors? not necessarily diminish pain sensations. ‐ Decreased kidney function leading to potential fluid and electrolyte imbalances ‐ Increased hunger sensations leading to postoperative complications from hyperacidity ‐ Inability to comprehend the seriousness of surgical interventions, leading to noncompliance ‐ Poor cardiovascular status leading to decreased pain sensation | For questions that ask you to choose one client over others, determine which client description indicates the worst client status or greatest risk for complications. In this case, note that fluid and electrolyte balance poses the greatest risk in the intraoperative period, which is the core issue of the question. |
2699 A client who takes numerous medications is being Correct answer: 3 Corticosteroids can lead to weight gain because of salt and water retention, and also can prepared for surgery. The nurse reviewing the client delay wound healing. An antidysrhythmic helps to regulate the cardiac rhythm (option 1). A medication list is most concerned about which sedative‐hypnotic can interfere with uptake of the anesthetics, but does not affect healing medication that increases surgical risk? (option 2). An oral hypoglycemic agent is used for diabetes, but the medication itself does not pose added risk to the client during surgery (option 4). ‐ An antidysrhythmic ‐ A sedative‐hypnotic ‐ A corticosteroid ‐ An oral hypoglycemic | To answer this question, recall the actions and adverse effects of each drug class listed. Use the process of elimination, focusing on the risk to the client during an actual surgical procedure, to make your selection. |
2700 The following clients are in the preanesthesia holding Correct answer: 4 Nephrectomy is a major type of surgery because the kidney is a major vital organ, loss of room. The nurse determines that the client undergoing blood is likely to be greater than with the other mentioned surgeries, and there is greater which procedure is having the most serious or major likelihood of complications. Options 1, 2, and 3 are all examples of minor surgery because they surgery? do not involve a high degree of risk. ‐ Tonsillectomy ‐ Biopsy of the breast ‐ Arthroscopy ‐ Nephrectomy | The core issue of the question is the degree of surgical risk associated with each procedure. Use the process of elimination, focusing on the nature of each surgical procedure and the seriousness of each one. |
2701 All of the following clients will be having surgery this Correct answer: 1 Dementia affects the person s understanding of the proposed surgery and ability to morning. The nurse concludes that which client is most cooperate with the perioperative care; it also affects the medications given. Cultural likely to be at higher surgical risk? differences should not pose a risk unless the client s beliefs are contrary to the proposed measures. Mild anxiety will not create a risk, and previous surgeries could be helpful for the client to draw on previous experiences. ‐ A client who has dementia ‐ A client who is culturally different than the medical personnel ‐ A client who has mild anxiety ‐ A client who has had previous surgeries | The core issue of the question is the degree of surgical risk associated with each client circumstance. Use the process of elimination, recalling that physiological issues take precedence over psychosocial ones, and that previous surgery might or might not be relevant to the current surgery. |
2702 The nurse is preparing a client for surgery. Prior to Correct answer: 1 Abrasions, pustules, or other skin conditions have to be assessed and documented because completing the skin preparation, the nurse assesses they can interfere with wound healing, or increase the risk of infection. Hair growth lack of it the surgical site for which of the following? or presence of lanugo or fine hair will not interfere with the skin preparation. Pulsation is not always visible or available to assess, depending upon the part of the body being operated on. ‐ Presence of pustules or abrasions ‐ Absence of hair growth ‐ Presence of lanugo ‐ Absence of pulsation | The core issue of the question is knowledge of integumentary risks to a surgical procedure. Use the process of elimination, focusing on skin breaks or alterations as the option that interferes with the protective function of the skin. |
2703 The nurse asks the client about previous surgeries. Correct answer: 4 Previous surgeries can reveal possible difficulties or problems with certain anesthetic agents, The client asks the nurse why this information is but do not necessarily interfere with absorption of anesthetics (option 1), hinder important. The nurse would explain that previous comprehension of instructions (option 2), or affect the central nervous system (option 3). surgeries can do which of the following? However, they can affect the physiological or psychological responses of the client to the planned surgery. ‐ Interfere with the absorption of anesthetic agents. ‐ Affect the ability of the client to comprehend the instructions prior to surgery. ‐ Affect the central nervous system. ‐ Alter the client s responses to surgery. | Focus on the issue of the question, which is the need to gather assessment data that could put the client at risk during the surgical procedure. With this concept in mind, eliminate each of the other options that are false statements. |
2704 A client who is scheduled for an outpatient surgical Correct answer: 1 Alcohol affects the central nervous system, and therefore the client s response to surgery and procedure arrives at the hospital. During the the anesthetic itself. Smoking, not alcohol (in small amounts), poses respiratory risks. Alcohol preoperative assessment, the nurse smells alcohol on effects cannot be reduced by the use of sedatives or hypnotics. Past and recent intake of the client’s breath. The nurse reports this finding to alcohol can impact responses, which can be either slowed down or escalated. the surgeon, prior to completing the preoperative assessment, after drawing which conclusion about the significance of this finding? ‐ Alcohol can affect the client’s response to anesthesia and surgery. ‐ Alcohol can increase the risk for respiratory complications. ‐ Use of sedatives and hypnotics prior to surgery can decrease the alcohol effects. ‐ Physiological and psychological responses are slowed down by recent alcohol intake. | The core issue of the question is knowledge that alcohol has an interactive effect with anesthesia and possibly other medications used during surgery. Focus on the option that safeguards the client’s physical status as the reason for notifying the surgeon. |
2705 The staff nurse is asking questions about the Correct answer: 4 The ability of the client to see and hear could affect the preoperative and postoperative preoperative client s vision and hearing. A family teaching methods used. Social resources and accident prevention rely not only on the client s member asks the nurse why these questions are vision and hearing (options 1 and 2), but also on family supports and the client s physical and important prior to surgery. What information should mental status. Unexpected needs is a very general term that can be applied not just to vision the nurse provide as the primary reason for seeking and hearing but also to any area of client functioning (option 3). this information? ‐ “This will help us determine the need for additional resources after discharge.” ‐ “This will help assess the risk of accidents in the home after surgery, which could affect the surgical outcome.” ‐ “This helps identify any unanticipated needs prior to beginning the surgery.” | Eliminate options 1 and 2 because the postdischarge time frame makes these less relevant to the current situation. Choose option 4 over option 3 because it is more specific, and applies to the client's situation. |
4.‐ “This will help us to individualize how we provide preoperative and postoperative teaching.” | |
2706 A client is admitted for surgery. During the Correct answer: 3 Anticoagulants inhibit clotting of the blood, putting the client at increased risk for bleeding preoperative assessment, the nurse learns the client is postoperatively. Delirium tremens needs to be monitored for clients who had problems with taking warfarin sodium (Coumadin). When planning alcohol use (option 1). Respiratory compromise might occur if clients take sedatives or postoperative care for this client, the nurse would hypnotics (option 2). If clients are taking diuretics or cardiovascular agents, fluid volume could include monitoring for which of the following? be a problem (option 4). ‐ Delirium tremens ‐ Respiratory depression ‐ Bleeding or oozing at the surgical wound ‐ Hypovolemia | The core issue of the question is knowledge that warfarin sodium is an anticoagulant, and that this medication increases risk of bleeding unless stopped for a sufficient amount of time before surgery (approximately 7 days, depending on client and surgery). With this in mind, eliminate options 1 and 2 first. Choose option 3 over 4 because there are other causes of hypovolemia besides bleeding, such as inadequate fluid replacement during surgery or the postoperative period. |
2707 While planning postoperative care for an obese client Correct answer: 1 Wound and cardiovascular complications are more common among clients who are obese. prior to surgery, the nurse would develop which The heart is stressed from its workload, and the added stress of surgery could place the client nursing diagnosis specific to the effect obesity has on at risk. The client has no risk for excess fluid volume (option 2), and decreasing fluid intake postsurgical recovery? could complicate wound healing. Pressure ulcers occur more frequently in emaciated clients than in obese ones (option 3). The obese client has no problem with thermoregulation (option 4). ‐ Risk for Ineffective Tissue Perfusion (Cardiopulmonary) ‐ Excess Fluid Volume ‐ Risk for Impaired Skin Integrity (Pressure Ulcers) ‐ Ineffective Thermoregulation | Recall that obesity leads to increased cardiovascular risks in general, and that it can also be a risk factor for poor wound healing after surgery. Eliminate options 2 and 4 first as being least related to the core issue of the question, and choose option 1 over 3 as the priority risk. |
2708 The postsurgical unit nurse is implementing measures Correct answer: 1 Antiembolic stockings facilitate venous return from the lower extremities. Smoking can to prevent thrombophlebitis. Which of the following is contribute to cardiovascular events, but cessation will not necessarily lessen the chance of the priority action by the nurse? thrombophlebitis in the immediate postsurgical period. Assessment of the leg will help with detection, but it will not prevent thrombophlebitis. Homans' sign is pain on dorsiflexion of the leg, and this is also a means of detection, not prevention. ‐ Apply ordered antiembolic stockings. ‐ Reinforce importance of smoking cessation. ‐ Assess the legs with each set of vital signs. ‐ Teach the client to report Homans' sign. | Focus on the critical word in the stem, prevent. Discriminate between those options that address assessment and those that address prevention. |
2709 A client has been admitted for surgery for resection Correct answer: 4 A surgical procedure that relieves symptoms of disease or pain but does not cure is described of nerve roots. The client, observing the written as palliative. The other options are incorrect explanations. comment that the surgery is palliative, asks what this means. The nurse would offer which of the following explanations? ‐ The surgery schedule is overbooked, so the client s surgery could be delayed. ‐ The surgeon is against performing the surgery. ‐ The exact surgical procedure has not been decided. ‐ The procedure will be done to relieve pain, but will not cure the problem. | Use the process of elimination, selecting the answer that is an accurate description of the meaning of the term palliative. |
2710 The physician progress note indicated a plan to let a Correct answer: 4 A wide scar occurs in tertiary intention because the edges are not approximated, and they client’s wound heal by tertiary intention. The nurse regenerate via granulation. Options 1 and 3 refer to secondary healing, while option 2 is determines that healing has occurred when which of characteristic of primary healing. the following is observed? ‐ The wound is smaller but irregular. ‐ Very little scarring has occurred. ‐ Tissue loss prevents the edges from approximating. ‐ A wide scar is present over the area of wound closure. | First, recall the definition of tertiary intention. Then, visualize the appearance of the wound to make your selection. |
2711 A postoperative client is observed to have moderate Correct answer: 4 Purulent drainage is made up of tissue debris, WBCs, and bacteria; it could be comprised of wound drainage that has a greenish tinge. The nurse different colors, depending upon the type of bacteria, and it is thick in consistency. It often should take which of the following actions next? indicates wound infection. The next action by the nurse would be to gather additional data that could indicate infection, such as elevated temperature and WBC count. The nurse would document the findings at some point, but this is not the priority action. There is no reason to assess for bleeding within the wound, or to measure pulse and BP. ‐ Document the expected findings. ‐ Check for bleeding at the base of the wound. ‐ Take the pulse and blood pressure, and compare with previous readings. ‐ Note the latest temperature and white blood cell (WBC) count. | The critical word in the stem of the question is next. This means that the correct option is the one that contains a critical‐thinking sequence based on the information presented. Correlate the word purulent with infection, and then choose the option that assesses for signs of infection. |
2712 A client experiences wound dehiscence when Correct answer: 3 Covering the wound with sterile, saline‐moistened gauze keeps the wound moist, and coughing. After assisting the client to a low Fowler’s protects it from infection. Option 1 is incorrect; in wound dehiscence, the layers of the wound position with legs slightly elevated, what is the next are disrupted, but there is no protrusion of vital organs. In addition, pushing back organs such best action? as the intestines is extremely dangerous because it could cause strangulation. A hydrocolloid dressing is not indicated (option 2), because its absorptive properties are not needed. Option 4 would be ineffective, and does not protect underlying tissue. ‐ Push the internal organs back into the abdominal opening. ‐ Cover the wound with a moist hydrocolloid dressing. ‐ Cover the wound with a sterile, saline‐moistened dressing. ‐ Use Steri‐Strips to hold the wound together. | The core issue of the question is nursing management of wound dehiscence. Recall that the priority sequence of actions is to remove the effects of gravity on the wound, and then to protect the wound. Eliminate options 1 and 4 as ineffective, and then choose correctly based on knowledge of various types of wound dressings. |
2713 A client is scheduled for surgery, and has been placed Correct answer: 2 By keeping the stomach empty during surgery, the risk of vomiting and aspiration is on NPO status. The client complains of thirst and decreased. The other options are unrelated to NPO status. hunger, and asks for breakfast. The nurse would explain that which of the following is the purpose of NPO status? ‐ To make anesthesia induction easier ‐ To avoid the risk of aspiration ‐ To prevent excessive bleeding ‐ To allow the wound to heal faster | Use knowledge of basic principles of preoperative care to make a selection. The wording of the question tells you that there is only one correct choice. |
2714 The nurse is teaching a client about wound care in Correct answer: 2, 3 Return demonstration is the best way to evaluate teaching of a procedure. Ideally, the preparation for discharge. How should the nurse teaching is done over a few days, and is then evaluated. Having the client explain the evaluate the effectiveness of homecare teaching on procedure is also appropriate, because it indicates that the client has the necessary knowledge wound care? Select all that apply. to perform the procedure. Giving a paper‐and‐pencil quiz and having the client critique a video would measure cognitive aspects of learning, but are not realistic. Asking the client detailed questions during the procedure is not helpful, because it detracts from learning. ‐ Give a paper‐and‐pencil quiz. ‐ Have the caregiver or client demonstrate the procedure. ‐ Have the client or caregiver explain the procedure. ‐ Have the client or caregiver critique a video on the procedure. ‐ Ask the client detailed questions while demonstrating the procedure. | Use fundamental principles of teaching and learning to answer the question, recalling that the best methods of evaluation involve knowledge and action on the part of the client, which can be determined by verbal explanation and return demonstration. |
2715 Which of the following activities would the nurse Correct answer: 1 Assessment in the preoperative phase includes anticipating any health problems that might carry out in the preoperative period for a client occur during and after surgery. Option 2 is applicable during the intraoperative phase, when scheduled for surgery? specific, specialized activities are carried out in the operating room. Option 3 is a very general activity that should occur continually. Prevention of complications (option 4) occurs in the postoperative stage. ‐ Identify potential or actual health problems. ‐ Perform specialized procedures to maintain safety. ‐ Assess the client's response to interventions. ‐ Intervene to prevent complications. | Recognize that the word “identify” in option 1 is a clue to the correct response. Nursing care during the preoperative period is aimed at identification of issues that might present problems that would result in complications for the operative client. |
2716 The nurse is caring for several clients in the pre‐ Correct answer: 3 Ablative surgery involves removal of diseased body parts. Option 1 is an example of anesthesia room. Of the following client situations, transplant surgery, option 2 is for a diagnostic purpose, and option 3 is for a palliative purpose. which merits ablative surgery? ‐ Replacing a hip that has degenerative disease ‐ Identifying if a tumor is malignant ‐ Removing a diseased part of the kidney ‐ Resecting a nerve root | Use the meaning of the word “ablate” to identify the correct response as one that would indicate removal of a part. |
2717 A client having surgery has a degree of risk associated Correct answer: 2 Risk is not associated with the place where surgery is performed; also, this is not a client‐ with the surgery. What client‐related factor is related factor. Risk is associated with poor nutritional status, so option 3 is incorrect. The responsible for a high degree of risk associated with higher the likelihood of complications, the greater the risk, making option 4 incorrect. When surgery? surgery is performed on vital organs, there is a greater likelihood for complications, and therefore the risk is higher. ‐ Type of institution where surgery is performed ‐ Involvement of vital organs ‐ Average nutritional status ‐ Little likelihood of complications | Focus on a client‐related factor that would raise surgical risk. |
2718 An infant who is having surgery has a higher risk than Correct answer: 2 The infant has immature vital organs that affect his ability to metabolize medications, such as does an adult. The nurse would conclude that which of the anesthetic, and the ability to resist infection. Infants do not suffer from declines in the following is a reason for the increased risk? functioning (option 1). Hypothermia is more likely to occur than hyperthermia, since the infant has an immature temperature regulation and large body surface area (option 3). The volume of blood in an infant is limited, and does not fluctuate (option 4). ‐ Decline in functioning ‐ Immaturity of vital organs ‐ Increased possibility of hyperthermia ‐ Volume of blood fluctuation | Recognize that the word immaturity in option 2 is key. |
2719 A preschool‐age child is facing surgery, and might Correct answer: 1 Option 1 is correct, since toddlers and preschool‐age children are fearful of painful events. have fears related to the surgery. The type of fear the The other options are incorrect; appearance is not a primary concern at this age, anticipating nurse would anticipate in this child would be which of an inability to do certain things is not a concern at this developmental level, and children at the following? this age are unaware of competency issues of medical personnel. ‐ Being awake during surgery, and experiencing pain ‐ Looking drastically different after surgery ‐ Not being able to do the things she used to do ‐ Medical personnel not knowing what they are doing | Look for the response that best corresponds to the developmental issues experienced by a preschool‐age child. |
2720 A client has just entered the postanesthesia care unit Correct answer: 1 Although all the options contain aspects that need assessment, the parameters in option 1 (PACU) from surgery. The postoperative client's are the most important to assess initially because they relate to physiological needs and are immediate needs include initial monitoring of which of more global indicators of overall functioning than are the other options. the following items? ‐ Vital signs, level of consciousness, and presence of pain ‐ Skin coloring, surgical incision, and limb movements ‐ Skin temperature, blood pressure, and mental status ‐ Temperature, emotional status, and social support | Select the option that addresses the most important thing to monitor, vital signs. |
2721 The nurse in the PACU is assessing a postoperative Correct answer: 1 The color of the skin, nails, and lips are indicators of tissue perfusion, and pallor and cyanosis client. Which of the following indicators suggest indicate alteration. Mobility, pain, and fluid loss are incorrect, as they are not signs of tissue alteration in tissue perfusion? perfusion. ‐ Pallor or cyanosis ‐ Difficulty with mobility ‐ Pain in the incision area ‐ Fluid loss | Recall that tissue perfusion would be noted only by change in color. |
2722 After surgery, the nurse encourages the client to Correct answer: 4 Turning side‐to‐side allows the lungs alternately to expand properly. Peristalsis increases with move from side to side at least once every two hours. movement even without the turning, and muscle weakness can be lessened with movement. The client questions this activity. The nurse explains Turning does not necessarily induce sleep. this intervention is to achieve which of the following? ‐ Lets peristalsis return at a faster rate ‐ Lessens muscle weakness ‐ Increases the client's ability to sleep ‐ Lets the lungs alternately achieve maximum expansion | Select the option that is of greatest concern in the postoperative client, which is respiratory function. |
2723 The nurse is assessing the client's surgical wound in Correct answer: 3 The first signs of healing are absence of bleeding and wound edges bound by fibrin in the clot. the postoperative period. Which finding indicates the Inflammation at the wound edges follows the first sign, and then, when the clot diminishes, first stage of healing? inflammation decreases, and collagen forms a scar. ‐ Inflammation in the wound edges ‐ Bleeding around the incision ‐ Clot binding the wound edges ‐ Collagen synthesis | Eliminate option 2 as not being indicative of healing, and option 4 as being a later stage than is described in the question stem. |
2724 The nursing team is creating a care plan for a Correct answer: 3 Absence of pain indicates that the client is comfortable. The other options indicate goals of postoperative client. The diagnosis is Pain. An either risk reduction or restoration of well‐being. appropriate client outcome for this client would be which of the following? ‐ Balanced fluid intake and output ‐ Seeks help as needed. ‐ Absence of nonverbal signs of pain ‐ Performs leg exercises as instructed. | Recognize that option 3 is the only outcome that directly addresses the diagnosis. |
2725 A client is being admitted to the hospital on the day Correct answer: 3 Option 1 is not the best question initially, as it focuses not on the client but on the doctor. before a scheduled surgery. Which of the following is Option 2 is not an appropriate initial question. Option 4 is challenging, and not appropriate as the most appropriate initial question to ask this an initial question. Option 3 is correct, as it will lead to the nurse's further exploration. preoperative client? ‐ "Has your doctor talked to you about the type of surgery you are having? What did the doctor say?" ‐ "What questions do you have about your surgery?" ‐ "What type of surgery are you having, and why are you having it done?" ‐ "What do you know about what will be done to you?" | Select the option that is open‐ended, and gives the client the opportunity to use his own words in explaining the procedure. |
2726 A presurgical client asks the nurse for more Correct answer: 2 Respiratory and circulatory depression is a disadvantage of general anesthetics because there information about the advantages of a general is a greater risk for complications, especially for clients with chronic illnesses. General anesthetic. The nurse's answer would correctly reflect anesthetic agents are rapidly excreted, and produce amnesia. General anesthetics produce what information? central nervous system depression, so clients do not feel the pain of surgery. ‐ The respiratory and circulatory functions are depressed. ‐ The client loses consciousness, and does not perceive pain. ‐ The anesthetic agent is not rapidly excreted, so the timing of the surgery can be adjusted. ‐ General anesthesia reduces the chance that the client suffers from amnesia. | The question asks for the advantage of general anesthesia. Option 2 is the only response that can be considered an advantage. |
2727 A benzodiazepine has been administered to a client Correct answer: 2 Benzodiazepines such as lorazepam and diazepam decrease anxiety and produce side effects preoperatively. After the drug has been administered, such as hypotension and sedation. Major tranquilizers such as chlorpromazine produce ‐ Anxiety ‐ Hypotension ‐ Hypocalcemia ‐ Extrapyramidal reactions | Preoperative medications are generally given to reduce anxiety, and, as a side effect, produce hypotension. |
2728 A preoperative client has elevated hemoglobin and Correct answer: 4 Increased hemoglobin and hematocrit might be a result of dehydration. Immune deficiency is hematocrit levels. What would the nurse suspect an indication of decreased white blood cell count (option 1), while an increase in electrolytes, regarding the significance of these increased values? such as potassium, sodium, or chloride, indicates kidney dysfunction (option 2). Malignancy may be suspected with increased platelet count. ‐ Immune deficiency ‐ Kidney dysfunction ‐ Malignancy ‐ Dehydration | Increased hemoglobin and hematocrit are often the result of hemoconcentration caused by dehydration. |
2729 The nurse has completed preoperative teaching to a Correct answer: 1 The anesthetic agent is injected into the subarachnoid space for spinal anesthesia, and into pregnant woman. During the discussion, the nurse the epidural space (which is outside the dura mater) in epidural anesthesia. Regional describes the different types of anesthesia available. anesthesia can include local or topical anesthesia or nerve blocks, and does not require clients Which statement by the client indicates understanding to have sedation, or produce amnesia. of regional anesthesia? ‐ In spinal anesthesia, the anesthetic agent is injected into the subarachnoid space. ‐ The anesthetic agent is injected into the dura mater of the spinal cord for epidural anesthesia. ‐ The client is sedated, and has some awareness of the event. ‐ Regional anesthesia produces analgesia and amnesia. | Eliminate options 3 and 4 as being descriptive of other forms of anesthesia. |
2730 The client arrives in the PACU in an unconscious state. Correct answer: 1 Option 1 is the correct answer, as in this position, gravity keeps the tongue forward, which In what position is the unconscious client placed in the prevents aspiration. A pillow elevates the head, semi‐prone position is unsafe in most cases, as immediate postanesthetic stage? it can interfere with breathing. ‐ Side‐lying, with the face slightly down ‐ Side‐lying, with a pillow under the client's head ‐ Semi‐prone, with the head tilted to the side ‐ Dorsal recumbent, with the head turned to the side | Select the option that provides the highest level of airway protection. |
2731 The client has been in the PACU unit for an hour. The Correct answer: 3 Excessive bloody drainage on dressings or the bedclothes, often underneath the client client is now groggy, but able to respond to voice (because of gravity), indicates hemorrhage. commands. While assessing the client, the nurse checks the bedclothes underneath the client. The nurse is assessing: ‐ Drainage from the tubes or drains. | The bedclothes underneath the client are often the site of blood collection from hemorrhage. |
‐ Fluid balance. ‐ Hemorrhage. ‐ Perspiration. | |
2732 A client is in the postoperative stage, and the Correct answer: 2 Option 2 is the correct answer, as the client has an inability to retain the information, and physician has ordered ambulation. The client has therefore has a deficiency in knowledge base. Self‐care Deficit is incorrect, as there is no shown difficulty understanding the necessity for early indication of inability to perform self‐care activities such as bathing and eating. Options 3 and 4 ambulation. An appropriate nursing diagnosis for this are definitely incorrect. client would be: ‐ Self‐care Deficit. ‐ Knowledge Deficit. ‐ Ineffective Coping. ‐ Risk for Injury. | Focus on the key phrase in the question, “[t]he client has shown difficulty understanding ...”, to select the correct answer. |
2733 The nurse is assessing the client on return to the Correct answer: 1 The drain allows for drainage of excessive fluid and purulent material that might have hospital unit from the PACU, and notes the presence of accumulated during the surgery. Healing is promoted, but not necessarily at a rapid rate, and a drain in the surgical wound. A family member not all drains have to be shortened or connected to suction. observes the drain, and asks why the tube was left in the wound. The nurse explains that drains: ‐ Allow drainage of excessive fluids such as blood, edema, or pus from the surgical site. ‐ Allow healing to occur at a very rapid rate. ‐ Have to be shortened to allow healing to occur from the inside out. ‐ Have to be connected to suction tubes. | Select the option that best addresses the purpose of a surgical drain, which is to remove fluids. |
2734 A client is being discharged following outpatient Correct answer: 2 Option 2 could indicate wound infection. All options except 2 indicate normal wound healing surgery. The nurse is providing the caregiver with or characteristics. instructions for wound care. The nurse would instruct the caregiver to report which of the following findings to the surgeon? ‐ Scar formation ‐ Increased redness or drainage ‐ No odor of the wound drainage ‐ No unusual color of the drainage | Omit options 1, 3, and 4 as being expected, and not necessary to report. |
2735 The nurse admitting a female client from the Correct answer: 2 With decreased oxygen saturation, more oxygen is needed, but the best choice is to stimulate postanesthesia care unit (PACU) gives the following the client who still has some anesthetic effects after surgery. The other options will not have report: BP 100/64; temperature 97; pulse 90; this beneficial effect. respirations 12; and O<sub>2</sub> saturation 88%. The skin is pale but warm to the touch; pulse is irregular but strong and equal bilaterally; respirations shallow without extra effort; drowsy, but responds to verbal command; IV is intact; Foley catheter has 250 mL new urine since the last hour; chest tube connected to three‐chamber collection device in place to low wall suction; nasal cannula in place with oxygen at 2 liters/min. The nurse should take which priority action based upon the assessment data? ‐ Ask the client if she is in pain ‐ Stimulate the client to breathe deeply and cough ‐ Increase the IV flow rate, to balance losses in urine and chest drainage | The nurse may presume that pain is the cause for decreased oxygen levels and increased pulse. But without the blood pressure and respiratory rate also increased, pain usually is not the problem. Increasing the IV fluids will not improve the oxygen problem. Increasing the oxygen flow rate might help, but if the client is not breathing deeply enough, or often enough, increasing the flow rate will not solve the problem. Stimulation of the client to breathe more and deeper will oxygenate the client better. |
4.‐ Increase the oxygen flow rate, to raise the O2 saturation level | |
2736 The nurse concludes that which postoperative activity Correct answer: 3 Preoperative teaching should be reinforced postoperatively. By asking to take the TED hose by the client would demonstrate a need for additional and SCDs off, the client indicates that he does not comprehend that the purpose is to teaching? maximize blood flow to the legs at all times, especially when lying in bed. ‐ Demonstrates how and when to use the incentive spirometer for ten repetitions several times per hour. ‐ Tells the staff to help turning every two hours when log rolling is ordered. ‐ Requests that the elastic hose and sequential compression devices (SCDs) be removed while sleeping at night. ‐ Tries to drink at least eight ounces of fluids every hour while awake. | The directions for the incentive spirometer, turning, and fluid status are correct. No additional teaching is needed for those topics. Only the desire for removal of the TED hose and SCDs needs additional instructions. |
2737 The client had abdominal surgery five weeks ago, and Correct answer: 1, 3, 4 The complication that could have been avoided was deep vein thrombosis (DVT). now is having leg pains. What activities could the nurse Repositioning every two hours, avoiding crossing one s legs, and wearing TED hose and SCDs all have performed when the client was hospitalized that will increase the blood flow to the legs and minimize venous status, which causes the clots to would have minimized this complication’s risk? Select form. all that apply. ‐ Turn the client every two hours. ‐ Increase the fluid intake to at least eight ounces per hour. ‐ Tell the client to avoid crossing the legs. ‐ Instruct the client to wear TED hose and SCDs while in bed. ‐ Massage the client’s legs. | Fluid intake can help with circulation to some extent, but if blood is allowed to become stagnant, or is restricted by positioning, fluids do not decrease the risk of clot formation. All other activities will minimize venous status and decrease the risk of DVT. |
2738 A 78‐year‐old client with chronic obstructive Correct answer: 2, 4 The symptoms are of possible dehiscence and evisceration. The nurse cannot report to the pulmonary disease (COPD) has had abdominal surgery, physician what has occurred without first assessing the problem. A sterile towel and sterile and suddenly feels something “let go” in the incision normal saline are used to maintain a moist environment until the client goes back to surgery. underneath the dressing when coughing. What are the Staying with the client is essential to calm him down and explain the circumstance. You should nurse’s immediate actions? Select all that apply. have a second nurse call the doctor to report the problem. ‐ Call the physician before checking the wound. ‐ Open the dressing, and view the problem. ‐ Apply pressure over the site, and have someone else call the physician. ‐ Use a sterile towel and sterile saline to keep the open incision moist. ‐ Sit the client upright in bed. | If you try to call the doctor before assessing the wound, you have no data to report. Applying pressure over the wound will not return the contents into the abdominal cavity if they have eviscerated. You can do harm by decreasing the blood flow from the pressure, causing tissue necrosis or tissue hypoxia if continuous pressure is applied. |
2739 What findings might indicate to the nurse that a client Correct answer: 1 The calf is the most common place for a deep vein thrombosis to develop. Although it is a has developed a deep vein thrombosis (DVT)? nonspecific finding, the classic symptom is pain on dorsiflexion. As the calf muscle compresses the thrombus, pain is triggered. Although the affected leg could be warm to the touch (option 3), the warmth would be in the affected calf area, not the thigh. Skin coolness (option 2) and decreased pulses below groin level would indicate a decreased arterial blood flow, not venous, and this rare occurrence would likely be associated with arterial thrombosis (a possible complication of catheter insertion at the femoral artery). A generalized fever, chills, and dyspnea (option 4) would indicate a systemic infection rather than a DVT. ‐ Pain in the calf on dorsiflexion ‐ Skin coolness of the entire limb, with decreased pulses starting at the groin ‐ Skin hot to the touch with a tenderness felt over the thigh ‐ Generalized fever of 101°F, chills, and dyspnea | Recall first the common location of DVTs, and recall that DVTs lead to a disturbance in venous blood flow. Use this knowledge to eliminate options 2 and 3, and eliminate option 4 because these are systemic symptoms rather than local ones. |
2740 The nurse plans to do which of the following as part Correct answer: 1, 2 A three‐way urinary catheter is used to irrigate the bladder after surgery most of the time. of the postoperative management of a client who will The common assessment factors will indicate the rate of flow, bleeding, and other possible be admitted from the postanesthesia care unit with a problems. A common problem with surgery on the bladder is bladder spasms that create pain three‐way urinary catheter? Select all that apply. with the cramping. The B & O suppository is the most common treatment to relax these spasms, since it is a belladonna‐and‐opioid combination drug. ‐ Assessment of color, amount, consistency, and content of urine ‐ Administration of belladonna‐and‐opium (B & O) suppository for bladder spasms ‐ Limit salt and oral fluids to prevent fluid overload. ‐ Increase the irrigation solution when the urine becomes clearer. ‐ Clamp the tube for 15 minutes out of each hour. | Limiting salt is not a good idea, since the sodium level can drop with frequent irrigations of the bladder, depending upon the solution that is chosen. Restricting oral fluids is not feasible, and should be discouraged; additional fluids will help to keep the urinary system flowing without complications. When the irrigating solution is adjusted, the following rules apply: a) Increase the rate when the urine is darker, to try to wash out any excess tissue or bleeding; b) Decrease the rate when the urine is becoming clearer, to further assess the status of the bladder. Increasing the flow when the urine is clear will only serve to wash out electrolytes and waste solution. |
2741 A client is one day postop for an abdominal hernia Correct answer: 2 Atelectasis is collapsed lung tissue from decreased depth of breathing. The sounds that would repair. Which of the following symptoms alerts the be heard over the collapsed tissue would be diminished or absent, depending upon the nurse that the client might be developing atelectasis? amount of tissue involved. Since most clients lie in bed on their backs, the collapsed tissue is usually bilaterally in the posterior lower lobes. ‐ Friction rub at fifth anterior intercostal space at the midclavicular line ‐ Diminished posterior breath sounds bilaterally ‐ Crackles in the upper lobes the of anterior chest ‐ Wheezing in the upper bronchi on expiration | A friction rub, as described in option 1, is present when two adjacent tissues are inflamed and rubbing against each other, such as when an infarcted myocardium rubs against the pericardial sac. Because of the location described, this must be a pericardial friction rub rather than a pleural friction rub. Crackles (option 3) are heard when fluid is present in the alveoli, but this would be expected in the lower lobes if they occurred because of atelectasis. Wheezing (option 4) is present when spasms reduce the air flow through the bronchi and bronchioles of the lung. |
2742 An elderly client has intravenous (IV) fluids infusing at Correct answer: 2 The elderly are more prone to congestive heart failure when their systems are overloaded 125 mL/hour. The client reports the following with fluids that cannot be adequately pumped. The symptoms in the question stem are symptoms: bubbling sputum, difficulty breathing classical symptoms of congestive heart failure. Reducing the IV flow rate will not do harm, and except in an upright position, and progressive will allow further assessment without increasing the strain on the heart. weakness. On inspection, the nurse finds increased jugular vein distention and blood‐tinged coloring in the sputum. What is the nurse’s first action? ‐ Raise the head of bed. ‐ Decrease the rate of IV fluids. ‐ Prepare for intubation and ventilation. ‐ Apply oxygen at 4 liters/minute. | Raising the head of the bed will help the dyspnea, but will not improve the cardiac functioning enough as a first step. But raising the HOB could be the second step. Decreasing the IV flow rate will decrease the workload of the heart. Intubation and ventilation might be possible, but not at this time, since the client is still breathing on her own. Increasing the flow rate of oxygen might help, but 4 liters per minute could cause decreased respiratory rate, since it is the CO<sub>2</sub> in the blood that stimulates respirations, and a high oxygen flow rate might reduce the CO<sub>2</sub> rate below the respiratory stimulation levels. |
2743 When teaching a client about home management Correct answer: 1, 2 Postoperative management of any eye surgery client includes avoiding activities that might following cataract removal with lens implant surgery, increase intraocular pressure. Straining at stool and lifting heavy objects both raise the the nurse should include which of the following in the intraocular pressure, and should be avoided. Stool softeners are used to present this straining. teaching plan? Select all that apply. ‐ Take a stool softener and/or laxative daily to prevent constipation. ‐ No lifting or bending over for at least six weeks. ‐ Shampoo the hair daily with mild soap. ‐ Stay on strict bedrest until you return to the doctor in three weeks. ‐ Wash the face and around the eyes three times daily. | Shampooing should be delayed, to avoid contamination of the surgical site with dirt or shampoo solutions. Strict bedrest is not recommended, and most clients are asked to sit up in recliners rather than lie flat in bed. Getting up and performing daily activities are not contraindicated, since they do not increase pressure in the eye. Safety issues with partial loss of vision from dressings, eye patches, or blurring should be included in the educational process to prevent injury from falls and other problems. |
2744 In a client who is one day postoperative following Correct answer: 3 Urinary output should be at least 30 milliliters per hour, and 150 milliliters per shift does not lumbar laminectomy, which finding would be of show adequate renal perfusion or functions. greatest concern to the nurse? ‐ Hemoglobin 10.5 grams/dL ‐ Blood urea nitrogen (BUN) 8 mg/dL; creatinine 1.2 mg/dL ‐ Urinary output of 150 mL for last shift ‐ Decreased bowel sounds in all four quadrants | Blood loss is expected in laminectomy surgery, and the hemoglobin of 10.5 is low, but within acceptable ranges. BUN also is at the upper edge of normal levels, and should be watched, but does not require urgent management. The first 24 hours postanesthesia, it is not unusual not to have bowel sounds in all four quadrants. Continued assessment would be necessary, but not urgent. Without adequate renal functions, the client could go into complete renal shutdown, and further assessment should be made immediately. |
2745 The nurse working in a busy surgical unit has four Correct answer: 4 The client who already has impaired respirations due to increased weight would be at postsurgical clients who are receiving patient‐ greatest risk for respiratory complications when receiving a narcotic that suppresses controlled analgesia (PCA) with fentanyl (Sublimaze). respirations. Snoring loudly reflects poor air exchange. Narcolepsy suggests that he is sleep‐ Which of the following clients does the nurse plan to deprived from respiratory obstruction at night. Close assessment should be given to this client. assess most frequently? ‐ A client with respirations of 14 per minute who is easily awakened by spoken command ‐ A client with COPD who has an oxygen saturation of 92% ‐ A 94‐year‐old female who has never been sick, but weighs only 45 Kg ‐ A male client weighing 150 kg who has noisy breathing and a history of narcolepsy | Respirations of 14 are within normal range, and as long as the client can be awakened by verbal stimuli, the client is not at risk for respiratory problems. The COPD client has good oxygen saturation, and is not in any immediate danger. The small, frail, elderly client could develop problems, but has been healthy all her life, and does not have any symptoms of problems at present. With her low weight and loss of subcutaneous tissue, she would need to be encouraged to breathe deeply to prevent problems, but she currently is not in any difficulty. |
2746 Which client with a nasogastric (NG) suctioning tube Correct answer: 4 Whenever the client states she is choking or having difficulty breathing, further assessment would be the nurse’s priority for client assessment? should be done immediately. The tubing could be coiled at the back of her throat, or swelling might have occurred to limit the air flow. ‐ A two‐day‐postoperative client who had an open cholecystectomy with 150 mL of greenish drainage in the collection bag ‐ A one‐day‐postoperative client who had a partial gastrectomy with 200 mL of sanguineous fluid in the collection bag ‐ A five‐day‐postoperative client with a repair of a gunshot wound that nicked the liver and spleen, who had 40 mL of thick yellowish green secretions in the surgical drain ‐ A client with a newly inserted NG tube who complains of “trouble breathing” from the tube | The color and amounts of solutions are correct for each situation based upon the surgical problem involved. Each is an expected assessment that is normal. Choking and dyspnea are never normal. |
2747 When staffing the surgical nursing unit, which of the Correct answer: 1 Delegation to UAP can include any activity that is within their role. Ambulating the client and following clients could the nurse delegate to an administering an enema are within this role. unlicensed assistive person (UAP)? ‐ A third‐day‐postoperative client who needs to be walked and have an enema this bedtime ‐ A new surgical client who has just complained of oozing from the mastectomy site ‐ A new amputee who is stable, but needs dressings reinforced ‐ A fourth‐day coronary artery bypass client who still has stable angina after surgery | Activities that require assessment, sterile procedures, and clients in unstable conditions are not assigned to UAP staff. These are roles of the professional nurse, and cannot be delegated. |
2748 Which PRN medication would the nurse anticipate Correct answer: 1 Drug management includes knowing what the counteragent is for common dangerous drugs. using when a client is suspected to have taken too Narcan is the acceptable antidote for narcotic overdose. many narcotics, and has a respiratory rate of approximately 8 breaths per minute? ‐ Naloxone (Narcan) ‐ Protamine sulfate (generic) ‐ Phytonadione (vitamin K) | Protamine sulfate is used to counteract heparin. Vitamin K is used to treat overdoses of Coumadin. Romazicon is used to treat overdoses of benzodiazepines. |
4.‐ Flumazenil (Romazicon) | |
2749 A client has a triple‐lumen catheter in place. There Correct answer: 1 Triple‐lumen catheters have three ports for openings at the tip, which is located just outside are orders for a unit of packed red blood cells (PRBCs) the right atrium of the heart. The distal port is located at the tip of the catheter, and is the and normal saline at 75 mL/hour IV, and the client largest gauge of the three. It is 16‐gauge in size, and is suitable for infusing colloids and blood needs an IV push pain medication at the same time. To products. The other two ports are 18‐gauge openings, and are used for blood draws or routine which port would the nurse connect the PRBCs for the IV crystalloid fluids. safest administration? ‐ Distal port ‐ Medial port ‐ Proximal port ‐ None; start a second IV site for the blood. | The other two ports (medial, proximal) are smaller openings, and could damage the blood cells when forced through them. A separate IV site is not necessary, since the medication can be given through the saline IV solution with an intravenous push of the medication. If the unused port is used for pain med administration, then the port must be re‐heparinized after the drug administration, to maintain patency between uses. Starting another site is also probably difficult, since the client would not have the central line unless other accesses were difficult or inadequate. |
2750 A client is about to undergo skin biopsy to determine Correct answer: 3 The area is anesthetized using a local anesthetic before skin biopsy, so the client should only if a skin lesion is malignant. The client asks how much feel discomfort while the anesthetic is administered. Analgesics are not given before the the biopsy will hurt. Which response by the nurse is procedure (option 1), and the procedure is not pain‐free (option 2). The client may take best? medication such as acetaminophen following the procedure (option 4), but this does not address the client’s question about pain during the procedure. ‐ “We will give you a pain pill in just a moment that will minimize any pain during the biopsy.” ‐ “Luckily, this type of procedure does not cause any pain for most people.” ‐ “You may feel some discomfort while the local anesthetic is injected, but this will numb the area for the actual biopsy.” ‐ “This procedure does cause some pain, but you can manage any soreness afterward with over‐the‐counter medications such as acetaminophen (Tylenol).” | The core issue of the question is pain during a skin biopsy procedure. Eliminate option 4 because it does not address the client’s concern. Use knowledge that local anesthesia is used during the procedure to make your selection. |
2751 The client is about to undergo a computerized Correct answer: 2 Because a contrast agent will be used for the test, it is most important for the nurse to ask tomography (CT) scan of the head with contrast. about an allergy to iodine or shellfish. While it is good to know if the client has had a similar Which of the following questions by the nurse is most test for anxiety reduction, it is not the priority. The client should not have anything to eat or important to ask while preparing the client for the drink for four hours prior to the test. It is generally helpful for the client to void before leaving test? the unit to avoid having to do so during the test, but this is also a lower‐priority item than assessing for allergy. ‐ “Have you ever had a procedure like this before?” ‐ “Do you have an allergy to iodine or shellfish?” ‐ “Would you like something to drink before you go to the Radiology Department?” ‐ “Have you voided in the bathroom in the last few hours?” | The core issue of the question is knowledge that a client who is allergic to iodine or shellfish is likely to have an allergic reaction to iodinated contrast media. Eliminate options 1 and 4 as least important, and then eliminate option 3 because fluids are not allowed prior to CT scans with contrast. |
2752 The client is scheduled for a magnetic resonance Correct answer: 4 Because the MRI scanner uses magnets, the client cannot wear any metal, and clients who imaging (MRI) study of the spine. The outpatient nurse have implanted metal might be ineligible for this study. The client does not need to withhold instructs the client that which of the following is an food or fluids before the test. The client does not need to remain in the department for important part of preprocedure care? additional observation after the test, and can drive herself home. ‐ “Do not eat or drink after midnight the day before the test.” ‐ “Plan to have someone drive you home after the test.” ‐ “Expect to stay in the MRI Department for an hour afterward for observation.” ‐ “Do not wear any metal, such as jewelry or hairclips.” | The core issue of the question is knowledge that metal cannot be worn in the vicinity of an MRI scanner because of the magnetic field. Use nursing knowledge about this test and the process of elimination to make a selection. |
2753 A client will undergo a radionuclide scan of the Correct answer: 2 The amount of residual radioactivity following radionuclide scanning is very small, and poses thyroid. A nursing assistant asks what needs to be no risk to visitors or staff. Using standard precautions in handling blood or body fluids is done to protect staff from any residual radiation sufficient for protection. It is unnecessary to stand six feet away from the client, use a private following the scan. Which of the following is an room, or place the client on contact precautions. appropriate response by the nurse? ‐ “All caregivers and visitors need to stand six feet away from the client for 24 hours. I need to put a sign above the bed.” ‐ “Using standard precautions for handling body fluids will be sufficient to protect staff.” ‐ “I have arranged for the client to be moved to a private room for 48 hours after the test.” ‐ “The client will need to be on contact precautions. I will have the unit secretary call the central processing department for a cart with gowns and gloves.” | The core issue of the question is knowledge that the amount of radioactivity following radionuclide imaging is very small. With this in mind, eliminate each of the incorrect options, which contain excessive and unnecessary steps for protection of staff. |
2754 A 17‐year‐old girl is brought to the Emergency Correct answer: 3 The most important question is to determine whether the client could be pregnant, since x‐ Department for x‐rays after twisting her ankle while rays are contraindicated during pregnancy, especially during the first trimester. The question playing basketball. Which of the following questions is second in importance would be whether the client is wearing any metal, but possible most important for the nurse to ask the client before pregnancy is a priority. It is helpful, but not of highest priority, to know if the client has had an sending her to the Radiology Department? x‐ray before, to alleviate concerns. Asking about fear of small or closed spaces would be important for MRI machines and possibly for CT scanning machines. ‐ “Do you experience claustrophobia when in small spaces?” ‐ “Are you wearing any necklaces or other metal objects?” ‐ “When was your last monthly period?” ‐ “Have you ever had an x‐ray before?” | The core issue of the question is knowledge that x‐rays are contraindicated during pregnancy. Note the critical words most important in the question, which tells you that more than one option could be correct, and you must prioritize your answer. Use general knowledge of x‐rays and the process of elimination to make a selection. |
2755 A female client is returning to the nursing unit Correct answer: 1 There is no special aftercare following pelvic ultrasound. For this reason, the nurse should following a pelvic ultrasound. The nurse plans to do make the client comfortable and ask if she needs anything before leaving the room. The client which of the following at this time for the client? does not need to drink fluids, should not have cramping pains, and does not need to wait an hour before eating. ‐ Make the client comfortable, and ask if she needs anything. ‐ Instruct the client to drink at least one quart of water over the next hour. ‐ Explain that analgesic medication is available to relieve the expected cramping pain. ‐ Tell the client that she will be able to eat in one hour. | The core issue of the question is knowledge that there is no special aftercare following ultrasound as a diagnostic test. Use nursing knowledge and the process of elimination to make a selection. |
2756 A client who underwent bronchoscopy four hours ago Correct answer: 4 Before offering food or fluids to a client following bronchoscopy, it is essential to ensure that is asking for something to drink to ease his sore throat. gag and swallow reflexes have returned. A local anesthetic is used to numb the throat to ease The nurse obtains some juice for the client after noting passage of the bronchoscope, and if protective reflexes have not returned, the client could which of the following assessment data? aspirate. The other client data are also normal, but would not indicate whether the client can safely swallow. ‐ Respiratory rate has ranged from 16 to 18. ‐ Breath sounds are clear bilaterally. ‐ The client has had no hemoptysis. ‐ Gag and swallow reflexes have returned. | The core issue of the question is knowledge that gag and swallow reflexes need to be present before offering clients food or beverages to prevent aspiration. Think of gag and swallow reflexes as a possible priority concern whenever a client has had a procedure ending in ‐oscopy. Otherwise, use nursing knowledge of this key principle and the process of elimination to make a selection. |
2757 A client underwent angiography of the left leg. Which Correct answer: 3 The assessment finding that should be of greatest concern to the nurse is the adverse change of the following data obtained during the current in the distal pulse on the leg that underwent angiography. Skin that is paler and cooler is also assessment is of greatest concern to the nurse? of concern, but the reason for these adverse changes is the reduced circulation to the leg, which is in turn caused by the decreased pulse. A bandage that has a small amount of old blood is expected, and is not of concern at this time. ‐ Skin paler on left foot than right. ‐ Skin temperature cooler on left foot than right. ‐ Left dorsalis pedis pulse audible by Doppler, previously 2 . ‐ BAND‐AID at femoral access site has trace amount of dark red blood. | The core issue of the question is the most serious adverse change in the neurovascular status of a client who underwent angiography. The critical words in the stem of the question are greatest concern, which indicates that more than one piece of data might be abnormal. Use nursing knowledge about adverse circulatory changes and the process of elimination to make a selection. |
2758 The client who will undergo a cardiac catheterization Correct answer: 4 The client is asked to lie still except for specific requests, such as to cough or deep‐breathe to says to the nurse: “I am nervous about having a cardiac aid in catheter movement, or to terminate cardiac dysrhythmias caused by irritation of the catheterization. Can you tell me what to expect during catheter. The procedure is done in a special cardiac catheterization room in the radiology this test?” Which of the following replies by the nurse department, not in the operating room. The lights in the room may be dimmed at times so is appropriate? catheter movement can be visualized on a fluoroscopy screen. The catheter insertion site is anesthetized with a local anesthetic, so the client should feel pressure but not pain. ‐ “The procedure will be done in the operating room to help ensure sterile conditions.” ‐ “The room will be brightly lit at all times.” ‐ “The insertion of the catheter in the femoral area will be one of the few painful moments of the procedure.” ‐ “The physician will ask you to lie still except to do specific things, such as cough or take a deep breath.” | The core issue of the question is knowledge of typical events during a cardiac catheterization. Knowledge of these factors helps alleviate client fears. Use nursing knowledge and the process of elimination to make a selection. |
2759 A client who is scheduled for a cardiac Correct answer: 1 There is no restriction of food or fluids prior to a cardiac (or any) echocardiogram. This test echocardiogram at 9 a.m. the following morning asks uses sound waves emitted from and reflected back to a transducer, and it is noninvasive. the nurse if he will be able to eat breakfast before the Options 2 through 4 are all variations of an incorrect response. test. Which of the following responses by the nurse is appropriate? ‐ “Yes, we can arrange for your breakfast tray to arrive a half hour early so that you have time to eat before the test.” ‐ “Yes, but you will need to get up at 5 o clock so that you will be without food or fluids for four hours before the test.” ‐ “Yes, but you can only drink clear liquids, such as ginger ale, black tea, or apple juice, and you cannot eat solid food until after the test.” ‐ “No, you cannot eat or drink before the test, but you can have a full breakfast after the test.” | The core issue of the question is knowledge of client preparation for echocardiography. Recall that this is a noninvasive test to eliminate option 4, and then use nursing knowledge and the process of elimination to make a selection. |
2760 A client has just received a Holter cardiac monitor to Correct answer: 3 The client should go about his usual daily activities and exercise pattern while wearing the wear for the next 24 hours. The nurse determines that monitor, and should record activities and any symptoms experienced in the diary. The client the client understands its use when the client makes does not need to make diary entries every 30 minutes, but as needed to provide an overview which of the following statements? of activity so that it can be correlated with any cardiac abnormalities on the time‐stamped electrocardiogram being recorded. The client should not take a bath or a shower while wearing the device, which has electrical circuitry. The client does not need to walk a total of three miles during the 24‐hour period. ‐ “I should write in the diary what I am doing every half‐hour.” ‐ “I should only take a bath, not a shower, for the next 24 hours.” ‐ “I can continue with my usual activity and exercise pattern while wearing the monitor.” ‐ “I need to try to walk a total of three miles over the next 24 hours while wearing the monitor.” | The core issue of the question is knowledge of proper use of a Holter monitor. The wording of the question tells you that only one option is a correct statement. Use nursing knowledge and the process of elimination to make a selection. |
2761 A client who underwent cystography 16 hours ago has Correct answer: 3 The client has 15 mL less than the expected minimum urine output of 240 mL in 8 hours. The a urinary output of 225 mL in the previous 8 hours. first steps by the nurse would be to assess the client s fluid intake and encourage the client to Which of the following actions should the nurse take drink increased fluids. Although it is not incorrect to measure specific gravity, the nurse could as a priority at this time? expect the value to be high if the urine output volume were low because of poor intake. Documenting the value is insufficient because further nursing action is warranted. The nurse should call the physician if the reduced output continues after increasing the client s fluid intake. ‐ Measure the specific gravity of the urine. ‐ Document the volume on the client’s flowsheet. ‐ Encourage the client to drink more fluids. ‐ Notify the physician. | The critical words in the question are at this time, which tell you that more than one option might be plausible, but there is a sequence of nursing actions appropriate to the situation. Recall that when urine output is low, an early measure is to offer increased fluids. Use this nursing knowledge and the process of elimination to make a selection. |
2762 The nurse has assigned a nursing assistant to a client Correct answer: 2 The nursing assistant should wash the client s hair to remove the paste or colloidon that was who just returned to the nursing unit at 0945 after used to secure the electrodes to the head for the diagnostic test. The client should be able to electroencephalography. Which of the following eat and drink, and can resume usual activity unless otherwise ordered. There is no dye used in directions should the nurse give the nursing assistant this diagnostic test. regarding care for the client? | Use nursing knowledge and the process of elimination to make a selection. |
‐ “Do not give any food or fluids until lunchtime.” ‐ “Wash the client’s hair at your earliest opportunity.” ‐ “Keep the client on bedrest for the remainder of the shift.” ‐ “Encourage the client to drink fluids to flush dye through the kidneys.” | |
2763 A client has just returned to the nursing unit following Correct answer: 1 Following myelogram with water‐based contrast, the head of the bed needs to be elevated to a myelogram, which was done to diagnose a herniated 60 degrees to reduce the risk of meningeal irritation from any residual contrast in the spinal intervertebral disk. The medical record indicates that a fluid. If an oil‐based contrast was used, the head of the bed would need to remain flat. The water‐based contrast medium was used during the other options indicate incorrect responses, because the head of the bed is too low to prevent test. The nurse should assist the client to which of the headache from meningeal irritation as a complication of the procedure. following positions in bed after transferring from the stretcher? ‐ Supine, with the head of the bed elevated 60 degrees ‐ Supine, with the head of the bed elevated 15 degrees ‐ Left side‐lying, with the head of the bed flat ‐ Any position of the client's choice, with the head of the bed elevated 30 degrees | The core issue of the question is knowledge of correct head position following myelogram using water‐based contrast. Use nursing knowledge and the process of elimination to make a selection. |
2764 A client has received discharge instructions after Correct answer: 3 The client should limit joint movement, including walking, for 2–3 days after arthroscopy. undergoing arthroscopy of the knee earlier in the day. Analgesics are often needed to manage pain, and the client should be instructed about what to The nurse concludes that the client understands self‐ use and how often to take it. The physician may order ice to control swelling, but not heat, care after discharge when the client makes which of which would aggravate swelling. Increased swelling and bleeding after discharge should be the following statements? reported, because these are abnormal findings, and could indicate a complication of the procedure. ‐ “I should not expect to need pain medication following this procedure.” ‐ “I should apply warm, moist heat to my knee to maintain comfort.” ‐ “I should limit my activities, including walking, for 2–3 days.” ‐ “I should expect increased swelling and perhaps some bleeding in the knee area after going home.” | The core issue of the question is knowledge of measures to prevent complications and aid healing after arthroscopy. Use nursing knowledge about care following arthroscopy and the process of elimination to make a selection. |
2765 A client with gastroesophageal reflux disease has just Correct answer: 1 Because the throat is anesthetized so the client can tolerate the endoscope, the client’s gag undergone esophagogastroscopy. Which of the and swallow reflexes are temporarily lost during any upper endoscopy procedure, such as following client data is the nurse’s highest priority for esophagogastroscopy. The nurse’s priority is to monitor for return of these protective airway continued monitoring? reflexes. While mildly elevated temperature and reports of heartburn and sore throat also bear continued monitoring, they are of lesser priority than concerns related to the client’s airway. ‐ Inability to swallow saliva ‐ Temperature of 99.4°F oral ‐ Client report of heartburn ‐ Client report of sore throat | Use the ABCs airway, breathing, and circulation to answer the question. Options that involve the airway are frequently the highest‐priority items. Use nursing knowledge and the process of elimination to make a selection. |
2766 The nurse has given instructions to a client who will Correct answer: 3 The client should not eat or drink anything for 8–12 hours before the test, so the client should have a barium swallow in three days. The nurse not eat or drink anything after midnight. Oral medications are usually withheld before the determines that the client understands how to procedure as well. properly prepare for the test after the client makes which of the following statements? ‐ “I should eat a low‐fat meal for the next two days, and then have clear liquids the day before the test.” ‐ “I should stop taking all medication except antacids the day before the test.” ‐ “I should not eat or drink anything after midnight on the day of the test.” ‐ “I should eat a high‐carbohydrate diet for the three days before the test.” | The core issue of the question is knowledge of dietary preparation before a barium swallow or upper GI series. Use ordinary logic to determine that the GI organs would be difficult to visualize if they contained food or fluid. Use nursing knowledge and the process of elimination to make a selection. |
2767 The nurse is providing instructions to a client who is Correct answer: 2 The diet may be resumed after colonoscopy, but the client usually tolerates it better if it is returning to home following colonoscopy. Which of resumed gradually. The client should not drive for about 24 hours, until all medications have the following statements would be appropriate for the fully worn off. It is normal to pass gas and feel bloated because of the carbon dioxide used to nurse to include? insufflate the colon to visualize the area. It is abnormal for bleeding to be present, and the client should notify the physician if it occurs. ‐ “You may drive in about six hours, after all the medication given during the procedure has fully worn off.” ‐ “It is alright to eat and drink, but it is helpful to resume the diet gradually.” ‐ “You should call the doctor if you feel distended, or begin passing gas.” ‐ “Bleeding from the rectum is expected after this procedure, but call the physician if it gets severe.” | The core issue of the question is knowledge of self‐care following colonoscopy. Use nursing knowledge and the process of elimination to make a selection. |
2768 The nurse would give which instruction regarding Correct answer: 2 The client should avoid using any skin products, such as lotions or deodorant, on the skin of preprocedure care to a woman who is scheduled for a the breast or underarm prior to mammogram. The client may eat and drink as usual. Although mammogram? the procedure might cause some women discomfort with compression of the breast, it is not necessary to premedicate with analgesics. There is no activity restriction following the test. ‐ “Drink liquids, but don’t eat breakfast on the morning of the mammogram.” ‐ “Do not use any deodorant or lotions on the chest or underarms before the mammogram.” ‐ “Take a mild analgesic such as acetaminophen (Tylenol) before coming to the clinic for the mammogram.” ‐ “Plan a light schedule for the day of the mammogram, so you can plan on getting some rest after the procedure.” | The core issue of the question is knowledge that skin products should be avoided to prevent possible skin damage prior to a radiographic procedure such as a mammogram. The wording of the question tells you that only one option is a correct statement. Use nursing knowledge and the process of elimination to make a selection. |
2769 The occupational health nurse has given an Correct answer: 2 A Mantoux test (or PPD test) to screen for tuberculosis should be read in 48–72 hours. If the intradermal injection of purified protein derivative test was planted on Monday, the result must be read in 2–3 days, which is Wednesday or (PPD) to a client to screen for tuberculosis. After Thursday. The other options are either partially (options 1 and 3) or completely incorrect noting that the current day is Monday, the nurse (option 4). instructs the client to return to have the result read on which of the following days? ‐ Tuesday or Wednesday ‐ Wednesday or Thursday ‐ Thursday or Friday ‐ Friday or the following Monday | The core issue of the question is knowledge of specific time frames for reading a PPD test. Remember that when there is more than one part to an option, the entire option must be correct for that option to be the correct answer. Use nursing knowledge and the process of elimination to make a selection. |
2770 A client will undergo basal gastric acid secretion Correct answer: 1, 3, 5 Selected drugs (antacids, steroids, cholinergics, and anticholinergics) and coffee and alcohol analysis. The client is taking the following types of should be restricted for at least 24 hours prior to test; note on the test request form if the medications. Which of the following types of drugs client has not complied with the restrictions. There is no reason to withhold a cardiac glycoside should the nurse withhold prior to the test? Select all or a diuretic, because these medications would not affect the test results. that apply. ‐ Anticholinergic ‐ Cardiac glycoside ‐ Antacid ‐ Diuretic ‐ Steroid | The core issue of the question is knowledge of drugs that could interfere with basal gastric acid testing and analysis. The wording of the question tells you that more than one option might be correct. Use nursing knowledge and the process of elimination. |
2771 A client has a blood urea nitrogen (BUN) of 68 mg/dL Correct answer: 4 Potassium is contraindicated in clients with renal dysfunctions. It cannot be filtered out if and a creatinine level of 6.0 mg/dL. The IV fluid is 5% there is decreased renal filtration. With increased damage in tissues, additional potassium is dextrose in 0.9% sodium chloride, with 40 mEq released, causing an even higher level of potassium that can be life‐threatening. potassium chloride (KCl) at 100 mL/hour. Which action would be most appropriate for the nurse to take? ‐ Encourage more protein in the diet. | Protein creates more potassium in the body, and the lab shows that the kidneys are not filtering as they should. Additional potassium from protein metabolism could cause death. Activities such as ambulation will not change the BUN or creatinine, since they reflect filtration of the renal system, and not the rate of circulation of the blood. Taking the vital signs every hour only gives you information about the circulatory status, and does not explain or improve the renal functions. Action needs to be taken immediately to discontinue the IV with the potassium to minimize the buildup of potassium to toxic levels that could be life‐threatening. |
‐ Ambulate the client more, to increase circulation. ‐ Take vital signs every hour. ‐ Question the use of potassium in the IV fluids. | |
2772 A client is suspected of having hyperkalemia. Which Correct answer: 1 Since potassium is an intracellular ion, higher levels will alter the electrical pattern of the EKG. symptom or sign would the nurse expect to find when The peaking of a T wave is an indication that potassium is too high. assessing the client? ‐ Peaking of T wave on the telemetry monitor ‐ The absence of bowel sounds, such as in an ileus ‐ Muscle cramping of the lower extremities ‐ Somnolence with early changes | Muscle weakness, flaccidity of muscles, diarrhea, abdominal cramping, and cerebral irritability/restlessness are present with hyperkalemia (higher‐than‐normal potassium levels). Therefore, bowel sounds would be hyperactive and not silent, such as with an ileus. Muscles are weak and flaccid, not in a cramping state. Cerebral functions are stimulated, and somnolence (sleeping, sluggishness) is not present. |
2773 When a client has arterial blood gases (ABGs) drawn Correct answer: 3 Packing the sample in ice will minimize the changes in gas levels during the transportation of from the radial artery, the nurse should be prepared to the specimen to the lab. perform which follow‐up action? ‐ Apply pressure to the site for up to one minute. ‐ Transfer the blood sample to a heparinized test tube. ‐ Pack the sample in ice for transporting to the laboratory. ‐ Obtain a second specimen after ten minutes, to compare results. | The site, since it is an artery, should be held for at least five minutes or more if the client is anticoagulated. The syringe is heparinized, and the blood is not transferred to a test tube. The needle on the syringe needs to be sealed to minimize changes in gas levels during transport. A second specimen is not necessary for blood gases. If the client is having blood cultures, many times the doctor will ask for a “blood culture times 2,” which implies a second specimen is requested. Since these are blood gases and not blood cultures, a second draw is not needed. (Note: Blood gases are drawn from arteries, and blood cultures are done from veins.) |
2774 Which laboratory test results would indicate that the Correct answer: 3 Prothrombin time is the test that measures the coagulation times related to Coumadin client is adequately anticoagulated on sodium warfarin management. The time that is preferred is 1½–2 times the time of normal clotting without (Coumadin) during the postoperative period, when the drug usage. Therefore, for a therapeutic level, the prothrombin time is expected to be physician is trying to prevent deep vein thrombosis between 20–30 seconds while on Coumadin. (DVT)? ‐ Partial prothrombin time (PTT) 25 seconds ‐ International normalized ratio (INR) 1 ‐ Prothrombin time (PT) 19 seconds ‐ Clot retraction test 75% in two hours | PTTs are done for heparin drug management, not for Coumadin. INR converts to a standardized formula the ratio between the client s PT value and the laboratory control value. INR levels are expected to be between 2 and 3 after 3–5 days of oral anticoagulation; therefore, 1 is too low. Clot retraction time has nothing to do with Coumadin therapy, and is used to evaluate platelet and fibrinolysis, such as in clients with DIC, snakebite, malaria, and adult respiratory distress syndrome. |
2775 Which diagnostic results would you expect to find in Correct answer: 1 A low T cell count (normal is 1,500–4,000/mm<sup>3</sup>) indicates that the T the client who has been newly diagnosed with lymphocytes have been damaged or destroyed by the AIDS virus, causing immune suppression. acquired immunodeficiency syndrome (AIDS)? CD4/CD8 ratios are altered with AIDS virus damage, causing the ratios to decrease significantly (normal is 1.0–3.5). This result is within normal range, and does not reflect a decreased T cell count. ‐ T cell count of 400 ‐ Negative enzyme‐linked immunosorbent assay (ELISA) ‐ Platelet count of 500,000/mm3 ‐ CD 4/CD 8 test of 1.5 | Negative ELISA means that there currently are no antibodies present in the blood, not that the virus is not present in the tissue. A negative ELISA test score can occur even if HIV is present, since some of the phases eliminate the antibodies temporarily after exposure. A high platelet count does not reflect AIDS; this occurs with a splenectomy or polycythemia vera, where excessive cells are present. |
2776 When a client’s guaiac test for occult blood in feces is Correct answer: 2 The blood of red meat can be identified with the guaiac test; therefore, it often is positive, the nurse should consider which of the recommended to avoid meat for several days prior to the exam, to minimize the risk that a following? false positive might occur. ‐ Iron preparations can give a false positive. ‐ Red meat can give a false positive. ‐ Occult blood is not a good screening test for cancer of the colon. ‐ A blue color on the results of the test indicates that no blood is present. | Iron products will not contribute to a false chemical response that might be interpreted as blood being present. Occult blood by guaiac testing is an excellent indicator for screening for colon cancer. Few other reasons cause a bleed, and therefore this gives an early warning for further assessment to possibly catch the cancer in an earlier stage. A blue coloring result on the test is a positive confirmation that blood is present. |
2777 When planning to administer blood products by Correct answer: 4 Type O has antibodies against both the A and B antigens (but not antigens on the RBCs). Type typing and crossmatching of blood, what should the AB has no antibodies against A or B, but does have A and B antigens on the RBC. Therefore, nurse recall in order to prevent ABO incompatibilities? type O blood antibodies would agglutinate the RBCs of type AB blood. ‐ Type A blood products can be given only to type B clients. ‐ Type B can be given to type O clients. ‐ Type O can only receive type AB blood products. ‐ Type AB cannot receive type O blood products. | Type A has A antigens on the RBC, and B antibodies in serum. Type B has B antigens on the RBC, and A antibodies. Type AB has A and B antigens on the RBC, and no antibodies. Type O has no antigens on the RBC, and both antibodies in serum. Type O, as the universal donor, can be given to all other blood types, because none of the principle antigens occur on the RBCs. Those with type AB are universal recipients, since AB contains no antibodies in the serum. |
2778 The nurse would anticipate that a client with a Correct answer: 2 Coombs’ test tells us that the maternal blood has exposed the fetus’s red blood cells to positive Coombs’ test would be likely to have which antibodies or globulin complexes that can cause agglutination of the RBCs. Agglutination of clinical condition? RBCs means that the red blood cell can be broken apart or hemolyzed by these foreign antibodies from the mother as they cross the placental barrier. ‐ Autoimmune thyroid condition ‐ Hemolytic diseases of the newborn ‐ Systemic lupus erythematosus (SLE) ‐ Thrush or another fungal infection | Coombs testing only evaluates the antibodies attached to the RBCs. The thyroid does not affect the RBC or immunity by antibodies. SLE is an autoimmune disease process that is tested by the sedimentation rate or C‐reactive protein analysis that reflects inflammation. Coombs test does not have anything to do with SLE. Thrush and fungal infections are not tested with Coombs either, and are best identified by Wet Mount using KOH preparations to show the budding yeast. |
2779 A client is admitted with Graves’ disease. Which Correct answer: 4 Graves’ disease is an overproduction of thyroid hormone, usually from an autoimmune attack testing results would the nurse expect to find when on the thyroid gland. The lab results would be an increase in the total thyroxine (T4) and a ‐ Increased parathormone levels, with calcium levels above normal ‐ Elevated somatotropin hormones, with decreased basal metabolic rate (BMR) ‐ Elevated adrenocorticotropic hormone (ACTH) level ‐ Elevated total thyroxine (T4), and decreased thyroid‐stimulating hormone (TSH) levels | Parathormone is secreted by the parathyroid, and does regulate calcium levels, but it does not relate to thyroid functioning or to Graves’ disease. Somatotropin is growth hormone |
2780 Which intervention would the nurse use to be most Correct answer: 4 Hospital‐acquired infections are spread by cross‐contamination between clients. Simple effective in preventing and managing hospital‐acquired handwashing and/or antiseptic foam use between clients will prevent the spread of both types infections often caused by staphylococci and gram‐ of bacteria. negative rods? ‐ Administer prophylactic antibiotics to surgical clients. ‐ Implement isolation techniques for all clients who have high fevers. ‐ Culture all open wounds. ‐ Wash hands or use antiseptic foam between all clients. | Prophylactic antibiotics can help minimize the risk of infection prior to surgery, but they do not prevent hospital‐acquired infections that occur from cross‐contamination after surgery. Isolation protocols are not necessary, increase expense for all clients who have fevers, and still would not be effective if prevention of crosscontamination were not maintained. Culturing all open wounds could identify possible sources of contaminants, but again would not prevent the spread if techniques were not performed to prevent the spread by crosscontamination. |
2781 When trying to obtain the best sputum specimen, Correct answer: 3 The first morning specimen is more concentrated, and is easier to analyze. Mouthwash which directions should the nurse include when contains antiseptic solution that would change the flora present in the specimen. Rinsing with teaching the client how to collect the specimen? water will remove secretions of the mouth without contamination by the mouthwash (option 1). Spitting only removes saliva, and does not require the depth of respiration and coughing that is needed to produce a specimen of lung secretions. Letting the secretions set for several hours could cross‐contaminate the specimen with bacteria in the air. Specimens should be taken to lab for analysis immediately. ‐ Gargle with mouthwash before getting the specimen, to remove oral bacteria. ‐ Spitting is just as effective as coughing, if it hurts to breathe deeply. ‐ Save your first morning specimen, since it is the most concentrated. ‐ Save all you can for several hours to get the correct amount that is needed. | Use knowledge of basic procedures for specimen gathering and handling, and the process of elimination, to make a selection. |
2782 If a wound is inflamed, and secretions are noted Correct answer: 3 Aspiration of a wound by sterile needle and syringe is preferred due to the lower likelihood of around a Penrose drain, what would be the best contamination from skin flora. Both the needle and syringe are sterile, and the surface area method for the nurse to obtain a specimen for that the needle touches is the least likely source for contamination from skin flora. culture? ‐ Swab the tip of the Penrose drain. ‐ Swab around the skin around the Penrose, but not the Penrose tip. ‐ Aspirate some secretions into a syringe with a small needle. ‐ Cut part of the dressing that has secretions on it, and send it to the lab. | Swabbing a wound or the Penrose tip would risk the cross‐contamination of skin flora on the sterile swab. Cutting the dressing will not yield the secretions needed, since they already are absorbed into the material. Swabbing is not recommended; however, a sterile swab can be inserted into the draining wound without touching the skin, to obtain a deep culture from a wound. |
2783 A urinary catheter is suspected as the source of a Correct answer: 2 To prevent cross‐contamination from any other source, a sterile container is used to collect possible infection in a client. How would the nurse plan the tip of the catheter that has been cut with sterile scissors. Sterile‐to‐sterile is always the to get a specimen from the catheter tip that was just rule to prevent contamination from other sources. removed from the client? ‐ Place the entire catheter in a sterile container. ‐ Cut the tip off with sterile scissors, dropping it into a sterile container. ‐ Cut the tip with your bandage scissors, and place in a clean container. ‐ Swab the tip, and place the swab in a sterile container. | The entire catheter is not needed, and additional flora might result from cross‐ contamination from the tubing or the bag, from poor technique. Only the tip is required for analysis. Clean equipment or containers do still contain bacteria, and false readings might be obtained from the scissors or the clean cup. Swabbing the tip might not get the bacteria, and the actual tip is needed to see what bacteria or contaminant is present. |
2784 The nurse would complete which of the following as a Correct answer: 4 Anxiety reduction is needed when the client is waiting for the outcome of tests, to assist her priority action for a client following a full‐body scan? in processing her feelings and exploring her options based upon the results of the test. ‐ Pain assessment, due to discomfort of the actual procedure ‐ Vital signs, to assess for possible bleeding ‐ Prophylactic anti‐emetic, due to radiation exposure causing nausea ‐ Therapeutic communication, to reduce possible anxiety caused by outcomes | The purpose of the test is to identify a possible problem, and the client's greatest fear is that the test will validate that something is wrong. Therefore, communication is the first priority in care of a post‐test client. Pain is a possibility, since the test does require the client to lie still for a while. But fear will intensify pain even more if not addressed first. Only minimal radiation exposure occurs during a scan, and not enough to cause any radiation sickness (nausea). Bleeding is not a possible outcome from the scan, since the procedure is not invasive. |
2785 After which exam would the nurse plan to follow a Correct answer: 1 When testing with a PET scan, the client is injected with a radionuclide that emits positrons, protocol to prevent possible exposure to radioisotopes which are special isotopes. The emissions are translated into color‐coded images. It is effective used during the diagnostic procedure? to evaluate stroke, epilepsy, migraine headaches, Parkinson’s disease, dementia, and schizophrenia. The isotopes are removed through renal excretions, and precautions are needed to prevent exposure risks. The other tests listed do not require isotopes for analysis of body tissue. Therefore, none of them require precautions after the testing related to isotope excretion from the body. ‐ Positron emission tomography (PET) scan ‐ Magnetic resonance imaging (MRI) ‐ Computed tomography (CT) scan ‐ Angiography | Use knowledge of the various types of diagnostic test and the process of elimination to make a selection. |
2786 When giving directions for a client who is about to Correct answer: 3 A full bladder is necessary to bounce the sound waves off to compare other tissues or undergo a pelvic sonogram, which statement should structures being assessed. If done during pregnancy, the fetus must be older than 26 weeks in the nurse include? order to not have the restriction for the full bladder, since the amniotic fluid would be used at that point. ‐ “Drink nothing for several hours prior to the exam.” ‐ “You will be given an enema to cleanse the bowel.” ‐ “Have a full bladder.” ‐ “Do not have any medications prior to the exam.” | Fluids are needed to fill the bladder, and are not withheld prior to testing. Bowel structures do not interfere with the assessment of structures, and an enema is not required. Medications do not impact on sound waves, and holding medications is not necessary for any reason. |
2787 What would the nurse calculate a client s pulse rate Correct answer: 3 One large square is 0.20 seconds in time. The formula is to divide 60 seconds by the number to be if there were four larger squares on the ECG of squares between beats multiplied by 0.2 seconds to equal the beats per minute.<BR /> graph paper between each of the QRS complexes? ‐ 55 beats per minute ‐ 65 beats per minute ‐ 75 beats per minute ‐ 85 beats per minute | Knowledge of timing on the ECG paper and recognizing the components of the individual heartbeat are necessary to calculate heart rates and the timing of various parts of the individual heartbeat. Recognizing the differences between the larger and smaller blocks is necessary to calculate rates per minute. One smaller block is 0.04 seconds; the larger block is 0.2 seconds of time. Formulas are necessary to show rates. Another formula would be to count the number of beats per 30 larger squares and multiply it by 10 to get a full minute s count. (Thirty larger squares are equal to six seconds of time.) |
2788 Which of the following nursing actions would be Correct answer: 3 The EEG measures electrical brain wave activities, and allowing the client to take a nap prior inappropriate for a client who is about to undergo an to the test will alter the outcome of the brain activities. electroencephalogram (EEG)? ‐ Make sure the hair is cleaned by a shampoo. ‐ Avoid caffeine products prior to the exam. ‐ Allow a nap prior to the exam. ‐ Withhold any tranquilizers or sedatives prior to the exam. | The hair needs to be clean, to allow the gel to give the best electrical conduction possible. Food is necessary to prevent changes from hypoglycemia, but stimulants are avoided. Sleeping will alter the EEG reading, and often the client is sleep‐deprived prior to the exam, to give a better reading or testing outcome. Medications that alter brain functions are also withheld for up to 48 hours prior to the exam, to prevent inaccurate readings due to drug changes. |
2789 Which of the following pulmonary function Correct answer: 4 With obstructive disorders, there is retention of CO<sub>2</sub> by constriction techniques would the nurse consider to be most at the alveolar levels. With pursed breathing techniques, the air is pressurized between the helpful for clients with obstructive pulmonary atmospheric pressure and the alveolar pressure by reducing the air flow on exhalation, thus disorders? allowing more CO<sub>2</sub> to be released into the atmospheric air. ‐ Incentive spirometry ‐ Turning, coughing, and deep breathing ‐ Oxygen flow rates above 4 liters per minute ‐ Pursed‐lip breathing exercises | An incentive spirometer measures air flow, and increases total lung capacities by allowing inhalation of more air. Clients with COPD or pulmonary obstructive disorders have vasoconstriction of the alveoli, and air will not pass through the constriction. Turning, coughing, and deep breathing will help normal tissue to prevent atelectasis, but diseased lung tissue will not respond to this simple technique. By raising the flow of oxygen to 4 liters per minute, you increase the availability of O<sub>2</sub>, but you decrease the CO<sub>2</sub> levels. The obstructive pulmonary clients need to have to have high levels of CO<sub>2</sub> to stimulate the medulla s respiratory center to initiate breathing. Without adequate blood levels of CO<sub>2</sub>, breathing will cease. |
2790 After a lung biopsy and thoracentesis, in which 500 Correct answer: 3 When removing the fluid or tissue from the lungs, the diaphragm might have been irritated, mL of purulent fluid was removed, what nursing causing the spasms of coughing episodes. If this cannot be minimized, more respiratory efforts assessment would indicate a need for emergency will deprive the client of the needed oxygen–carbon dioxide exchange that is necessary for life. intervention? ‐ Lip coloring that is pale, and capillary refills greater than three seconds ‐ Oxygen saturation that was moving from 87% to 92% ‐ Coughing spasms that cannot be slowed or controlled by the client ‐ Equal chest movement with less muscle effort noted. | Pallor and delayed capillary refills are common, due to poor oxygenation from a pleural effusion and/or thoracentesis. Improving oxygen saturations is a good outcome, and no emergency is anticipated, as they improve in the perfusion process. Equal chest movement means that both sides of the thoracic cavity are moving equally well, and without collapse or shifting of lung tissue. Answer options 2 and 4 are desired outcomes following a thoracentesis. |
2791 The nurse is providing care to a client who underwent Correct answer: 1 Diabetes insipidus is a complication for any client who has undergone removal of a pituitary removal of a pituitary tumor. Eighteen hours after tumor. Edema of the remaining pituitary gland can cause reduction in the release of surgery, the urine output is markedly increased, and antidiuretic hormone (ADH), resulting in the movement of water from the glomerulus into the the urine‐specific gravity is 1.002. The nurse expects to collecting tubules of the nephron. The client excretes large volumes of urine with a low specific note which of the following corresponding findings gravity. As water is removed from the vascular compartment, the serum sodium becomes when reviewing results of laboratory tests? concentrated. Thus, the lab result indicates hypernatremia. The serum potassium, osmolality, and hematocrit would not be low (options 2, 3, and 4). ‐ Serum sodium 148 mEq/L ‐ Serum potassium 3.4 mEq/L ‐ Serum osmolality 263 mOsm/L ‐ Hematocrit 29% | This question calls for specific knowledge of ADH and the alteration in ADH secretion that commonly occurs following surgery for removal of a pituitary tumor. Remember that ADH results in the movement of free water (that is, water without sodium) into the collecting tubules of the nephron, which results in large volumes of water being removed from the blood. The specific gravity (concentration) of the urine decreases. In addition, removal of water from the serum concentrates (and thereby elevates) the serum sodium. Recall also that hemoconcentration could also raise, not lower, other lab values. |
2792 The nurse would be most concerned about which of Correct answer: 4 Furosemide inhibits reabsorption of sodium, water, and potassium from the distal renal the following laboratory values obtained for a client tubules and the loop of Henle, leading to a diuresis. The most common electrolyte disturbance receiving furosemide (Lasix) therapy? associated with furosemide administration is hypokalemia. BUN and creatinine can be either elevated or lowered, depending on a client s individualized response to therapy. Similarly, the hematocrit could rise or fall, depending on the amount of fluid retained in the vascular compartment. ‐ Blood urea nitrogen 20 mg/dL ‐ Hematocrit 46% ‐ Creatinine 1.1 mg/dL ‐ Potassium 3.2 mEq/L | This question calls for specific knowledge of the action of furosemide, and knowledge that hypokalemia is a common side effect of furosemide therapy. Use nursing knowledge and the process of elimination to make a selection. |
2793 The nurse inserts a nasogastric tube, and it Correct answer: 2 Hypokalemia is an almost universal complication of loss of gastric hydrochloric acid. In this immediately drains 1,000 mL of fluid. Which of the scenario, loss of the hydrogen ions results in a metabolic alkalosis. In turn, compensation for following electrolyte assessments is of greatest this loss takes place in the nephron, where hydrogen ions are retained. The nephron is concern to the nurse at this time? obligated to excrete potassium, which could result in profound hypokalemia and require vigilant IV replacement. Other electrolytes might be affected, but not to the degree that potassium homeostasis is altered. ‐ Sodium ‐ Potassium ‐ Chloride ‐ CO2 content | This question calls for specific knowledge that loss of hydrochloric acid triggers the mechanism whereby the kidneys lose potassium. Use nursing knowledge and the process of elimination to make a selection. |
2794 A client who was just admitted to the nursing unit has Correct answer: 3 Elevated uric acid levels are commonly seen with gout, and this is the initial question to ask a uric acid level of 9.5 mg/dL. Which question would the client. Uric acid does not rise with gallbladder disease, and is not affected by green tea. the nurse ask initially? Although the client could experience renal stones from precipitation of uric acid crystals (causing flank pain), this is not the initial question to ask, since renal stones are a complication of gout. ‐ “Do you have a history of gallbladder disease?” ‐ “Do you drink large amounts of green tea?” ‐ “Do you have a history of gout?” ‐ “Have you been having any pains in the flank area?” | Note that the stem of the question has the critical word initially, which tells you that more than one option might be technically correct but one is best. Use nursing knowledge related to uric acid level and gout, and the process of elimination, to make a selection. |
2795 The nurse is caring for a client who received a renal Correct answer: 2 Serum creatinine is the best indicator of renal function. Decreases in serum creatinine often transplant 24 hours previously. Which of the following are dramatic following renal transplantation. Regular monitoring of serum creatinine levels is trends in lab studies indicates to the nurse that the imperative in assessing the function of the transplanted kidney. Hemoglobin levels can new kidney is functioning? increase postoperatively due to blood transfusions. Serum phosphate might decrease long‐ term as the kidney increases excretion of phosphates. However, this is not a reliable indicator of renal function. Serum sodium levels might fluctuate according to individual clients sodium–water balance. ‐ Hemoglobin 12%, increased from 11.8% ‐ Serum creatinine 1.6 mg/dL, decreased from 1.9 mg/dL ‐ Serum sodium 140 mEq/L, increased from 136 mEq/L ‐ Serum phosphate 4.4 mg/dL, decreased from 4.8 mg/dL | This question calls for the specific knowledge that creatinine is the best indicator of renal function. Use nursing knowledge and the process of elimination to make a selection. |
2796 The nurse is caring for a client who has just returned Correct answer: 3 The hematocrit is an indicator of the proportion occupied by the cells in a given volume of from the operating room. Blood loss was minimal, but blood. The hematocrit might decrease when cell volume of the blood is decreased because of the client was given large volumes of crystalloid fluid blood loss. In addition, the hematocrit might decrease when the liquid portion of the blood during the procedure. Which of the following volume increases, as would be the case when large volumes of intravenous fluid are laboratory test results suggests overhydration? administered. Hemoglobin would not be increased in this client situation, nor would sodium and calcium balance be altered. ‐ Sodium 147 mEq/L ‐ Hemoglobin 14% ‐ Hematocrit 33% ‐ Calcium level 8.8 mg/dL | This question calls for the specific knowledge that hematocrit can be reduced even if there is no blood loss. In this case, it is indicative of increased volume, most likely due to administration of intravenous fluids. Use nursing knowledge and the process of elimination to make a selection. |
2797 A client is being evaluated for possible appendicitis. Correct answer: 1 Neutrophils are responsible for destruction of bacterial invaders. In acute bacterial infections, Which of the following results of laboratory tests such as appendicitis, the percentage of neutrophils (especially immature bands) in the suggests most strongly to the nurse the presence an complete blood count will increase. This presence of an increased number of bands in the CBC acute bacterial infection? is known as a “shift to the left.” Lymphocytes are responsible for destruction of viruses. Erythrocytes and platelets are not affected by infections. ‐ Elevated neutrophils ‐ Elevated erythrocytes | This question calls for the specific knowledge that neutrophils are responsible for destruction of bacterial invaders, and will be elevated in acute bacterial infections. Use nursing knowledge and the process of elimination to make a selection. |
‐ Elevated lymphocytes ‐ Elevated platelets | |
2798 The nurse is assigned to the care of a client who has Correct answer: 4 Lymphocytes are responsible for the destruction of viruses. Thus, the presence of been admitted with meningitis. A spinal tap has been lymphocytes in the cerebrospinal fluid (CSF) suggests that the meningitis is viral in etiology, ‐ Platelets ‐ Neutrophils ‐ Red blood cells ‐ Lymphocytes | This question calls for the specific knowledge that lymphocytes are responsible for destruction of viruses. Use nursing knowledge and the process of elimination to make a |
2799 In caring for a female client who has a urinary tract Correct answer: 2 A positive leukocyte esterase suggests a urinary tract infection. Leukocytes (white blood cells) infection with more than 100,000 colonies of contain esterases that react with substances contained in urine. More than 100,000 colonies of Escherichia coli bacteria, which of the following would bacteria (per high‐powered field) are needed before the patient can be diagnosed with a UTI. the nurse expect to see on the client’s urinalysis Testing for the presence of leukocyte esterase may be done using a voided urine sample, which report? is simple compared with the need for a catheterized urine sample. Nitrites might be positive in this situation. White blood cells could be elevated. Potassium in the urine is unaffected, and rarely measured. ‐ Negative nitrites ‐ Positive leukocyte esterase ‐ Positive potassium ‐ Negative WBCs | This question calls for the specific knowledge that leukocyte esterase will be positive in a sample of urine infected with bacteria. Use nursing knowledge and the process of elimination to make a selection. |
2800 The nurse is reviewing the results of follow‐up Correct answer: 2 The goal for total serum cholesterol is to keep the value below 200 mg/dL. While options 1 laboratory studies on a client diagnosed with and 2 are within the normal range, the best outcome of therapy is the value that is the lower hyperlipidemia. Which of the following total of the two. cholesterol levels indicates to the nurse that the client has been compliant with diet and medication therapy? ‐ 198 mg/dL ‐ 174 mg/dL ‐ 269 mg/dL ‐ 214 mg/dL | The core issue of the question is knowledge of normal serum cholesterol levels. Use nursing knowledge and the process of elimination to make a selection. |
2801 A nurse notes the client’s albumin level is 2.4 Correct answer: 1 Albumin is a protein responsible for increasing osmotic pressure and maintaining grams/dL. The nurse should plan to assess the client intravascular fluid volume. Low albumin levels result in a decrease in intravascular colloid for which of the following at this time? osmotic pressure, which in turn allows fluid to move out of the blood vessel and into interstitial tissues. This condition will be assessed as fluid retention in the form of edema, crackles, and so on. Skin turgor will be elastic when fluid shifts into the interstitial spaces. Bowel sounds and mucous membranes would not be affected. ‐ Fluid retention ‐ Inelastic skin turgor ‐ Hypoactive bowel sounds ‐ Dry mucous membranes | Determine that this test result is an abnormally low albumin level. Recall that albumin is necessary for maintenance of fluid balance between body compartments. Systematically eliminate incorrect options. |
2802 A client is admitted with complaints of severe nausea Correct answer: 2 The loss of stomach acids creates an imbalance, leading to an excess of alkaline fluids in the and vomiting for several days. The nurse expects the body. The source of the loss is metabolic, not respiratory. client is at risk for experiencing which acid–base imbalance? ‐ Metabolic acidosis ‐ Metabolic alkalosis ‐ Respiratory acidosis ‐ Respiratory alkalosis | First, determine if the imbalance is metabolic or respiratory. Loss of GI fluids is a metabolic function, so options 3 and 4 can be eliminated. Next, determine if the imbalance is acid or base. Loss of body acids will lead to an excess of bicarbonate in the body. |
2803 Troponin levels are ordered on a client to confirm a Correct answer: 3 Troponin is a specific marker for cardiac injury. Elevations in serum levels usually begin 4–6 myocardial infarction. When should the nurse plan to hours after onset of symptoms, and peak in 12–24 hours. Drawing the blood in the first 2 hours have blood drawn for this test? would be too soon, and waiting longer than 24 hours would miss the times for peak levels. ‐ Within 1–2 hours of onset of chest pain ‐ Within the first 24 hours of onset of chest pain ‐ Between 6 and 24 hours of onset of chest pain ‐ Between 24 and 48 hours of onset of chest pain | The question calls for specific knowledge of troponin physiology. Recall the times for elevations following cardiac injury and choose the option closest. Choose option 3 over 2 because it is more specific. |
2804 The nurse would anticipate that a client with cirrhosis Correct answer: 1 In cirrhosis, the damaged liver is unable to properly metabolize amino acids and synthesize of the liver would have decreased levels of which of albumin, resulting in decreased serum concentrations. The damaged liver is unable to the following? completely break down bilirubin, and serum levels are elevated. Ammonia is normally converted to urea; serum levels are increased with liver damage. Prothrombin times are increased when the liver is unable to synthesize clotting factors. ‐ Albumin ‐ Bilirubin ‐ Ammonia ‐ Prothrombin time | This question tests knowledge of liver functions and cirrhosis. Recall the liver s function as related to each of the lab values, and systematically eliminate incorrect options. |
2805 The nurse checks the prothrombin time on a client Correct answer: 2 Prothrombin times should be 1.5–2 times the control when anticoagulation therapy is being with aortic valve replacement who is receiving sodium given, indicating the Coumadin is effective. The level is in the therapeutic range, and the next warfarin (Coumadin). The client’s level is 20 seconds; dose should be given as scheduled. Encouraging the client to eat foods high in vitamin K would control is 13 seconds. The nurse should take which of reduce effectiveness of the Coumadin. The client would be at risk for bleeding, not for deep the following actions? vein thrombosis, when prothrombin times are prolonged. ‐ Encourage the client to eat foods high in vitamin K. ‐ Administer the daily dose of Coumadin as ordered. ‐ Monitor the client closely for signs of a deep vein thrombosis. ‐ Withhold the next scheduled dose of Coumadin, and notify the prescriber. | First, determine if the level is abnormal. Recall that in order to be therapeutic, prothrombin times must be 1.5–2 times the control. Eliminate options 1 and 4 because they would be counterproductive to the purpose of the Coumadin therapy. Eliminate option 3 because the client is not at risk for this problem. |
2806 A client is being evaluated for hypothyroidism, and Correct answer: 2 In hypothyroidism, the thyroid gland does not produce thyroxine (T<sub>4</sub>), has had blood drawn to determine TSH and despite being stimulated by the pituitary gland (TSH, thyroid‐stimulating hormone) to do so. T<sub>4</sub> levels. Which of the Elevated TSH and T<sub>4</sub> levels are seen with secondary hyperthyroidism following would support the diagnosis? caused by excessive TSH production by the pituitary. A decreased TSH and elevated T<sub>4</sub> are seen with primary hyperthyroidism. Decreased TSH and T<sub>4</sub> levels are seen in hypothyroidism secondary to insufficient pituitary secretions. ‐ An elevated TSH and elevated T4 levels ‐ An elevated TSH and decreased T4 levels ‐ A decreased TSH and elevated T4 levels ‐ A decreased TSH and decreased T4 levels | The question requires knowledge of pituitary and thyroid hormone functions. Recall the negative feedback loop of the endocrine system. Eliminate options 1 and 4 because there is an increased T<sub>4</sub> level, which would not be seen with primary hypothyroidism. |
2807 A client is admitted with dehydration secondary to Correct answer: 3 Dehydration results in loss of fluids, causing a hemoconcentration of BUN, which is elevated. prolonged nausea and vomiting. Which of the Sodium would be elevated, not normal, with dehydration. The potassium level is normal, and following lab values would the nurse expect to see? would most likely be lower because of losses from the vomiting. The hematocrit would also be elevated secondary to hemoconcentration. ‐ Sodium 138 mEq/dL ‐ Potassium 4.2 mEq/dL ‐ BUN 30mg/dL ‐ Hematocrit 40% | The question requires analysis of fluid losses on common lab values. Recall that vomiting will result in loss of sodium, potassium, and water. Eliminate options 1 and 2 because they are normal, and you are looking for abnormal values. Eliminate option 4 because it is also normal, and would be elevated with fluid losses. |
2808 The nurse is establishing a plan of care for a client Correct answer: 1 Hemoglobin is the oxygen‐carrying component of red blood cells. When levels are decreased, who has a hemoglobin level of 7.6 grams/dL. Which of the client will be fatigued, and tire easily. Altered nutrition might be the cause of the low the following does the nurse identify as a priority hemoglobin, but it is not of highest priority, since intolerance to activity involves safety nursing diagnosis? concerns. Constipation and risk for deficient fluid volume would not be as high in priority. ‐ Activity Intolerance ‐ Constipation ‐ Risk for Deficient Fluid Volume ‐ Imbalanced Nutrition: Less than Body Requirements | The question asks to choose a priority, indicating that all options might be partially or totally correct. Eliminate options 2 and 3 because they are not as high a priority. Choose option 1 over 4 because it addresses a problem related to the function of hemoglobin. |
2809 The nurse should assess for Trousseau's sign in the Correct answer: 4 Hypocalcemia causes excitability of skeletal, cardiac, and smooth muscle tissues. Evidence of client with which of the following electrolyte this is seen in Trousseau's sign, a carpopedal spasm. Hypokalemia, hyponatremia, and abnormalities? hypochloremia would not cause this sign. ‐ Hypokalemia ‐ Hyponatremia ‐ Hypochloremia ‐ Hypocalcemia | Specific knowledge of Trousseau's sign is needed to answer this question. Recall that this is a carpopedal spasm seen with low calcium and magnesium levels. Eliminate options 1, 2, and 4 because they would lead to muscle weakness, not neuromuscular excitability. |
2810 The white blood cell (WBC) count of a client is 18,000 Correct answer: 4 Tissue injury can cause an increase in WBCs. The WBC count could decrease with rheumatoid cells/microliter. The nurse attributes this value to arthritis, alcoholism, and viral infections (options 1, 2, and 3). which of the following health problems of this client? ‐ Rheumatoid arthritis ‐ History of alcoholism ‐ Viral infection ‐ Wound dehiscence | First, determine that the value is abnormally high. Recall conditions that elevate the white count, such as bacterial infections, stress, and tissue injury. Evaluate each option to eliminate conditions in which the white count is decreased. Choose option 4 because wound dehiscence is a type of tissue injury. |
2811 The nurse would assess the client for fever and other Correct answer: The normal range for the white blood cell count is signs of infection if the client s white blood cell count 10,000|10000 5,000–10,000/mm<sup>3</sup>. For this reason, the nurse would be concerned was noted to be greater than about the risk of infection if the count exceeded 10,000. cells/mm<sup>3</sup> on the laboratory report. | The core issue of the question is knowledge of normal laboratory values. Use this knowledge to choose an answer. Since specific knowledge is needed to answer correctly, memorize this value if you found the question difficult. |
2812 A client has an albumin level of 1.8 grams/dL. The Correct answer: 1, 3, 4 Low albumin levels are commonly seen in diseases of the liver, since proper liver function is nurse recognizes that probable causes of this include: needed to synthesize albumin. Low levels also are seen in conditions in which adequate (Select all that apply.) protein is not ingested or absorbed. Albumin levels often appear elevated in dehydration. Albumin levels would not be affected by ketoacidosis or pericarditis. ‐ Malabsorption syndrome. ‐ Dehydration. ‐ Cirrhosis. | First, identify that the albumin level is low. Consider conditions in which protein is not synthesized or absorbed adequately. Systematically rule out the options that are not connected to albumin. |
‐ Liver failure. ‐ Diabetic ketoacidosis. | |
2813 A client has an admitting diagnosis of Rule out Correct answer: 4 Troponin levels greater than 2.2 ng/mL are diagnostic for an MI. Abnormal potassium levels myocardial infarction (MI). The nurse interprets that can contribute to cardiac arrhythmias, but are not diagnostic for an MI. An elevated which of the following abnormal findings would best triglyceride contributes to coronary artery disease, but also is not diagnostic for MI. Although support the diagnosis of MI? elevated creatinine kinase levels are used to support a diagnosis of MI, the fractionated portion of the enzyme, CK‐MB, is preferred, since it is specific to the heart muscle. ‐ Potassium 3.4 mEq/L ‐ Triglycerides 200mg/dL ‐ Creatinine kinase 45 mcg/dL ‐ Troponin 2.5 ng/mL | The question asks for the best answer, indicating that choice is most specific to the content. In case you are unable to remember the normal values for all tests listed, the question also indicates that all options are abnormal values. Recall knowledge of tests used to confirm a diagnosis of MI. Eliminate option 1, since it is associated with cardiac dysrhythmias. Eliminate option 2, since this is a risk factor. Choose option 4 over 3, since this is more specific to cardiac injury. |
2814 A client is admitted to the Emergency Department Correct answer: 1 Administration of an intramuscular injection could cause a false elevation of the isoenzyme with complaints of severe chest pain, and a myocardial levels secondary to muscle trauma. Catheterizing the client, administering oxygen, and infarction is suspected. Blood work for creatine inserting an intravenous catheter would not affect levels of the isoenzymes. phosphokinase (CK) isoenzymes is ordered. Prior to the blood being obtained, the nurse should avoid: ‐ Administering an intramuscular injection. ‐ Catheterizing the client. ‐ Giving oxygen to the client by nasal cannula. ‐ Inserting an intravenous catheter into the antecubital fossa. | The item is testing knowledge of factors that would influence or alter the level of CK isoenzymes. Recall that creatinine kinase is found in cardiac, skeletal, and smooth muscles. Eliminate options 2 and 3, since they would not affect muscle tissue. Choose option 1 over 4, since the injection goes directly into the muscle; insertion of an intravenous cannula has less effect on the smooth muscle of the vein. |
2815 The nurse checks the laboratory test results on a Correct answer: 1 Therapeutic levels of heparin therapy are measured by checking the activated partial client receiving heparin therapy. Which of the thromboplastin time (APTT), which should be 1.5–2.5 times the normal of 20–35 seconds. following values indicates the therapy needs to be Thirty‐four seconds would be within the normal value, but lower than the therapeutic level to adjusted? provide anticoagulation. Sixty seconds is within the therapeutic range. Prothrombin times are used to measure therapeutic levels of Coumadin therapy. ‐ APTT 34 seconds ‐ APTT 60 seconds ‐ Prothrombin time 15 seconds ‐ Prothrombin time 30 seconds | The item is testing knowledge of lab studies that measure effectiveness and safety of heparin therapy. Eliminate options 3 and 4, since this test does not measure heparin therapy. Choose option 1 over 2, since this level is too low to provide a therapeutic effect. |
2816 In assessing the laboratory findings for a client with Correct answer: 1 Calcium levels are low in clients with renal failure secondary to the kidneys inability to chronic renal failure (CRF), the nurse should be aware activate vitamin D, which is needed to absorb calcium. Levels of potassium, phosphorus, and that a decreased serum level of which electrolyte magnesium are elevated secondary to the kidneys inability to excrete excess amounts. should be expected? ‐ Calcium ‐ Potassium ‐ Phosphorus ‐ Magnesium | This question tests knowledge of the complications of chronic renal failure. Recall the normal functions of the kidney. Systematically eliminate options that are incorrect. |
2817 A client is being evaluated to confirm a diagnosis of Correct answer: 1 Antinuclear antibody is a screening test for collagen disorders, and is specific to SLE. Amylase systemic lupus erythematosus (SLE). The nurse would levels are elevated in pancreatitis. IgE is released in response to allergic and anaphylactic expect which of the following laboratory tests to be reactions. C‐reactive protein is present with acute bacterial inflammatory conditions. performed? ‐ Antinuclear antibody ‐ Serum amylase level | This question tests specific knowledge of SLE and related immunology lab tests. Recall that SLE is an autoimmune disease in which tissues and cells are destroyed. ANA detects antibodies that destroy cells and tissues. Eliminate option 2, since it is specific to the pancreas. Even though items 3 and 4 are also immunology tests, they can be eliminated, since they are not specific to antibodies. |
‐ Immunoglobulin IgE ‐ C‐reactive protein | |
2818 A client s laboratory report indicates that his Correct answer: 2 A potassium level of 2.8 is indicative of hypokalemia. Muscle weakness and fatigue frequently potassium level is 2.8 mEq/L. The nurse should assess are seen in hypokalemia. Hyperactive bowel sounds and diarrhea are seen in hyperkalemia. A the client for which of the following manifestations? positive Chvostek’s sign is seen with hypocalcemia and hypomagnesemia. Blurred vision is not associated with hypokalemia. ‐ Hyperactive bowel sounds ‐ Muscle weakness ‐ Presence of Chvostek’s sign ‐ Blurred vision | First, determine that the level of 2.8 is abnormally low. Recall signs and symptoms of hypokalemia. Systematically eliminate the options that are not related to functions of potassium, options 3 and 4. |
2819 A laboratory report on an assigned client indicates Correct answer: 1 Bilirubin levels above 2.0 mg frequently are evidenced by a yellow discoloring of the sclera the total bilirubin level is 2.2 mg/dL. When assessing and skin. Dark‐green stools are not associated with elevated bilirubin; clay‐colored stools are. the client, the nurse anticipates which of the following Peripheral edema and dry mucous membranes can be associated with causes of elevated physical assessment findings? bilirubin, but information about the cause of the abnormal level is not provided in the question. ‐ Jaundiced sclera ‐ Peripheral edema ‐ Dark‐green stools ‐ Dry mucous membranes | First, determine that this is an elevated bilirubin level. Recall the signs and symptoms seen with elevated levels. Systematically eliminate the incorrect options. |
2820 A client with type 2 diabetes mellitus has blood drawn Correct answer: 4 HGB measures the amount of glucose attached to a hemoglobin molecule. Measurements up for glycosylated hemoglobin (HGB). Which of the to 7.5% indicate good diabetic control. Measurements greater than 9% indicate poor control. following levels would indicate that the client has poor control of the diabetes? 1.‐ 4% 2.‐ 5% 3.‐ 7% 4.‐ 9% | The question tests specific knowledge of glycosylated hemoglobin. A critical word is poor, indicating the most abnormal level is the correct answer. Identify options 1, 2, and 3 as acceptable percentages. |
2821 The nurse is checking the laboratory tests on a client Correct answer: 1, 5 Pancreatitis produces an inflammation of the organ, which causes an elevation in the white with chronic pancreatitis. Which of following would blood cell count and the pancreatic enzymes (amylase, lipase, and trypsin). The blood glucose support this diagnosis? Select all that apply. would be elevated secondary to impaired insulin production from the pancreas. Triglycerides are not reflective of pancreatic function. ‐ Elevated triglycerides ‐ Elevated lipase ‐ Decreased blood sugar ‐ Decreased amylase ‐ Elevated white blood cell count | The question tests knowledge of the imbalances in body chemistry seen with pancreatitis. Recall the normal functions of the pancreas. Eliminate option 1, since it is not associated with pancreatic function. Eliminate the options that do not correlate with impaired pancreatic function. |
2822 A client is receiving allopurinol (Zyloprim) for Correct answer: 1 Allopurinol is a uricosuric drug that inhibits reabsorption of uric acid in the kidney, thereby treatment of gouty arthritis. Which of the following decreasing serum levels. The white blood cell count also might decrease as the inflammation is changes in laboratory values would indicate to the reduced, but this is not due to the action of allopurinol. (Colchicine, also given for gout, nurse that the medication is effective? reduces migration of leukocytes.) Elevated alkaline phosphatase levels are seen with bone metastasis and bone disease. An increase in neutrophil count might be seen with improvement of bacterial and viral infections, and leukemia. ‐ A decrease in uric acid ‐ A decrease in the white blood cell count ‐ An increase in alkaline phosphatase ‐ An increase in neutrophil count | The question tests specific knowledge of gout and the drug allopurinol. A key word is effective. Look for options containing the desired action of allopurinol. Eliminate options 3 and 4, since they do not pertain to gout. Choose option 1 over 2, since it is specific to the action of allopurinol. |
2823 A client has had blood drawn for carcinoembryonic Correct answer: 2 Chronic cigarette smoking can produce elevated CEA levels. Alcohol, a high‐fat diet, and antigen (CEA). The nurse recognizes that which of the aerobic exercise do not have an impact on the level. client’s daily habits could produce a falsely elevated level? ‐ Alcohol use ‐ Cigarette smoking ‐ High‐fat diet ‐ Aerobic exercise | The question requires specific knowledge of CEA levels. Systematically eliminate options you know will not affect the test. |
2824 The urinalysis report on a client indicates that the Correct answer: 1 Urine‐specific gravity is a measurement of the solute concentration and diluteness of the specific gravity is 1.035. The nurse can anticipate the urine. 1.035 is greater than the norm of 1.005–1.030, indicating the urine is concentrated with client will: a low water content and/or high solute content. It will be darker than normal, pale yellow urine is, and more concentrated. The urine might have a high specific gravity secondary to a urinary tract infection, but that cannot be determined by specific gravity. It would be malodorous secondary to certain medications or infections. It does correspond to frequency of urination. ‐ Have dark, concentrated urine. ‐ Have a urinary tract infection. ‐ Have malodorous urine. ‐ Need to urinate frequently. | Recognize that this is an abnormally high level. Analyze each option for a correlation with a high urine‐specific gravity. Options 2 and 3 can be eliminated, since they can occur with a high specific gravity but are not as specific as option 1. |
2825 A client is being evaluated for possible Correct answer: 1 Hyperparathyroidism is associated with hypercalcemia and hypophosphatemia. Normal hyperparathyroidism. The nurse interprets that which serum calcium levels are 8.5–10.5, and normal serum phosphorus levels are 1.7–2.6. Sodium is of the following laboratory values would support this not affected. diagnosis? ‐ Calcium 12.5 mEq/L ‐ Calcium 9 mEq/L ‐ Phosphorus 4.0 mEq/L ‐ Sodium 142 mEq/L | Note that all the options are electrolytes. Recall what imbalances are created with hyperparathyroidism. Options 2 and 4 are within normal limits, and can be eliminated easily. Choose option 1 over 4, since phosphorus levels are decreased with hyperparathyroidism. |
2826 A client is admitted with angina, and has a history of Correct answer: 3 The range of magnesium is narrow (1.7–2.6). Low levels of magnesium predispose the client coronary heart disease. Which of the following to premature ventricular contractions and dysrhythmias. The sodium is slightly low, but does laboratory values should the nurse report to the not present as great a danger, and also could be dilutional. The sodium and carbon dioxide primary care provider immediately? levels are within normal limits. ‐ Potassium 3.8 mEq/L ‐ Sodium 133 mEq/L ‐ Magnesium 1.2 mEq/L ‐ Carbon dioxide 26 mEq/L | Critical aspects of the question are the client s report of angina and history of coronary artery disease, and the word immediately, indicating there could be serious consequences if the values are ignored. Eliminate options 1 and 4, since the levels are within normal limits. Choose option 3 over 2, since the level is several points below normal, and magnesium has a very low therapeutic level. |
2827 A client has developed syndrome of inappropriate Correct answer: 2 Serum osmolarity is decreased in SIADH secondary to fluid retention. The serum sodium level antidiuretic hormone (SIADH).Which of the following will be decreased due to fluid retention and excess losses through kidney excretion. BUN laboratory findings would the nurse expect to find? would be low due to fluid retention. Potassium is not affected. ‐ Blood urea nitrogen (BUN) 35 mg/dL ‐ Serum osmolality 250 mOsm/kg ‐ Sodium level 148 mEq/L ‐ Potassium level 5.0 mEq/L | The question tests specific knowledge of SIADH. Recall that fluid is retained and sodium is lost via the kidneys, and the blood becomes hemodiluted. Option 4 can be eliminated, since it is not affected by SIADH. Eliminate option 3, since it is the high end of normal. Choose option 2 over 1, since it reflects the fluid retention and low sodium level. |
2828 The nurse is checking laboratory results on a client Correct answer: 1 Serum carbon dioxide reflects the precursor to bicarbonate levels in the body. It is combined who is receiving a carbonic anhydrase inhibitor for with another hydrogen and oxygen molecule to make bicarbonate. Elevated levels indicate treatment of uric acid stones. The nurse should check alkalosis, while decreased levels indicate acidosis. Osmolarity measures the percentage of which laboratory value to detect an adverse effect of solutes in the blood. Carbonic anhydrase inhibitors help to eradicate uric acid stones by this type of drug? producing alkaline urine, but the urine pH would not be the best indicator of serum acidity or alkalinity. Serum ammonia levels reflect liver functioning. ‐ Serum carbon dioxide ‐ Serum osmolarity ‐ Urine pH ‐ Serum ammonia | The question requires specific knowledge of acidosis and alkalosis. The question is direct; there is only one right answer. Eliminate options 2 and 4, since they are not connected to acid–base balance. Choose option 1 over 3, since the urine pH would not always correlate with serum pH. |
2829 A client is receiving a thiazide diuretic. Which of the Correct answer: 3 Thiazide diuretics can cause reabsorption of calcium, leading to hypercalcemia. The value of following laboratory findings would indicate that the 11 mEq/L is above the normal value of 8.5–10.5. Thiazides would cause loss of potassium and client is experiencing a side effect of the drug? sodium. The sodium level is low, but still within normal limits. The potassium is at a high normal level. Magnesium is within normal limits. ‐ Potassium 5.0 mEq/L ‐ Sodium 137 mEq/L ‐ Calcium 11.5 mEq/L ‐ Magnesium 3.0 mEq/L | Specific knowledge of thiazide diuretics is needed. The question directs you to look for a side effect, so an abnormal level would be expected. Eliminate options 1, 2, and 4, since they are within normal limits. |
2830 When checking a client’s prostate‐specific antigen Correct answer: 1, 3, 4, PSA levels are elevated with enlargement, inflammation, and cancer of the prostate, or when (PSA) level, the nurse considers that the serum level 5 the gland has been manipulated, as in a rectal examination. Levels are not elevated with other can be elevated in which of the following conditions? cancers or urinary tract infections. Select all that apply. ‐ Prostate cancer ‐ Sigmoid carcinoma ‐ Benign prostatic hypertrophy ‐ Prostatitis ‐ Recent rectal examination | The question calls for specific knowledge of the prostate gland and related disorders. Eliminate option 2, since it is not connected to prostate function. |
2831 The nurse is caring for a client receiving a heparin Correct answer: 1 Correct dosage calculation must be performed. First, calculate the units/mL contained in the infusion containing 25,000 units heparin in 250 mL 5% solution; then, calculate the desired amount using the standard formula:<BR /><BR /> dextrose in water. The activated partial thromboplastin time (APTT) is 48 seconds. Standing orders for the infusion indicate the infusion should be increased by 100 units per hour if the APTT is less than 50 seconds. The nurse should increase the infusion by mL/hour. | Use knowledge of basic pharmacological math calculations to solve the problem. |
2832 A client has a new order to receive vancomycin Correct answer: 2 Because vancomycin (Vancocin) can cause thrombophlebitis, this adverse effect is less likely (Vancocin) to treat a systemic infection. The nurse to occur with central IV administration than with a peripheral IV administration (option 1). anticipates the order would indicate which of the Dilution of the drug lessens irritation to the vein. Vancomycin is not absorbed in the GI tract, following routes for optimal administration? so the oral route is used only to treat Clostridium difficile associated with antibiotic‐induced pseudomembranous colitis (option 4). Intramuscular administration is contraindicated (option 3). ‐ Peripheral venous access ‐ Central venous access ‐ Intramuscular ‐ Oral | Focus on the critical word systemic in the stem of the question. Use this word and knowledge of safe administration of this drug to eliminate the incorrect options regarding best route. |
2833 Gentamicin (Garamycin) therapy is to be initiated. Correct answer: 3 Increased serum creatinine indicates renal dysfunction. Nephrotoxicity is a common adverse Which of the following laboratory test results would effect of aminoglycosides such as gentamicin. The urine creatinine clearance would be indicate to the nurse that the client is manifesting a decreased in renal impairment (option 1). Coagulation disturbances and hypokalemia are not common adverse effect? attributed to this class of antibiotic as a direct adverse reaction (options 2 and 4). ‐ Elevated urine creatinine clearance ‐ Increased prothrombin time (PT) ‐ Increased serum creatinine ‐ Hypokalemia | Note the critical words common adverse effect in the stem. Recall that aminoglycosides often adversely affect the kidneys to narrow the options to 1 and 3. Note that option 3 indicates renal impairment to select it over option 1. |
2834 The nurse teaches the client who is taking isoniazid Correct answer: 1 Peripheral neuritis is the most common side effect of isoniazid (INH). Adding vitamin (INH) and experiencing paresthesia as a common side B<sub>6</sub> (pyridoxine) to the client s intake is the therapy to correct this side effect to include what food in the diet? effect. The diet may be supplemented with vitamin B<sub>6</sub>. Foods highest in vitamin B<sub>6</sub> include beef, chicken, and pork, including beef liver and chicken liver. Other foods listed are not high in pyridoxine. Foods other than meats that could be included are raw avocados, baked potato with skin, raw banana, figs, and soybeans. ‐ Liver ‐ Peanuts ‐ Whole milk ‐ Raw apples | The core issue of the question is knowledge of what nutrient will reduce adverse drug effects of INH. Recall that vitamin B<sub>6</sub> will assist in this action, and then choose the food that is highest in this vitamin. |
2835 A client taking digoxin (Lanoxin) along with Correct answer: 1 Amphotericin‐induced hypokalemia might potentiate toxicity of digoxin because hypokalemia amphotericin B (Fungizone) could experience digitalis is a primary cause for digitalis toxicity. Amphotericin B is available for only intravenous and toxicity due to which of the following? topical routes. Antifungal agents and cardioglycosides do not compete for the same receptor sites. ‐ Hypokalemia ‐ Antifungal attaching to receptors before digoxin ‐ Increased plasma concentration of amphotericin B ‐ Increased gastrointestinal absorption of digoxin and amphotericin B | The core issue of the question is knowledge of drug interaction of digoxin and amphoteracin B. Use specific nursing knowledge and the process of elimination to make a selection. |
2836 A client is receiving levofloxacin (Levaquin) in addition Correct answer: 4 Eradication of the intestinal flora can occur during antibiotic therapy. Absorption of vitamin K to an oral anticoagulant. Which of the following from the intestines can be interrupted, and prolonged bleeding can result due to inadequate treatments would the nurse anticipate administering if serum level of prothrombin (hypothrombinemia). Vitamin K is essential to the synthesis of the client experiences an adverse drug effect as a prothrombin (factor II) by the liver. Appropriate therapy in this case is to administer result of this combination? phytonadione or menadiol sodium diphosphate (Synkayvite). Since intestinal absorption might not be optimal, the parenteral route is preferred. In addition, the nurse must assess for and protect against increased bleeding. ‐ Albumin ‐ Platelets ‐ Protamine sulfate ‐ Phytonadione (vitamin K) | The core issue of the question is knowledge of drug interaction between levofloxacin and oral anticoagulants. Recall that vitamin K reverses bleeding to help identify the drug that reverses the effect of oral anticoagulant drugs. |
2837 The nurse assesses a client taking doxycycline Correct answer: 3 ALT is specific for diagnosing and monitoring liver disease or impairment. Differential (Vibramycin) as being jaundiced and lethargic. What diagnosis of etiology of jaundice between hepatic dysfunction and hemolysis of red blood cells laboratory study would be most specific for the nurse is indicated by the bilirubin. AST can help to diagnose or monitor heart disease or disease of to assess? the liver. ‐ Bilirubin ‐ Alkaline phosphatase (ALP) ‐ Alanine aminotransferase (ALT or SGPT) ‐ Aspartate aminotransferase (AST or SGOT) | The core issue of the question is the laboratory test that will help evaluate the presence of jaundice as an adverse effect of doxycycline. Use specific nursing knowledge and the process of elimination to make a selection. |
2838 A client taking ampicillin (Omnipen) develops a Correct answer: 3 A minor rash is the most common side effect of the penicillins, and might be relatively macular rash on the chest. The nurse should draw insignificant. Its presence does not signify an allergic reaction, and does not prohibit future which of the following conclusions about this administration of penicillin. However, the nurse closely monitors for further hypersensitivity assessment finding? reaction because other clinical manifestations could develop, such as fever, urticaria, chills, erythema, Stevens‐Johnson syndrome, respiratory distress, and anaphylaxis. If itching occurs, an antihistamine such as diphenhydramine (Benadryl) may be prescribed. All available antimicrobials are capable of stimulating an exaggerated immune response, but not all clients experience allergy with antibiotic therapy. Stevens‐Johnson syndrome is a more serious aberration of the skin associated with antimicrobial adverse reactions; it resembles a second‐ degree burn in that necrolysis separates the epidermis from the dermis, causing blisters. ‐ This reaction is Stevens‐Johnson syndrome. ‐ A minor rash usually precipitates the development of more severe reactions. ‐ A minor rash requires notification of the prescriber, but might be well tolerated, and might fade with continued treatment. ‐ Hypersensitivity reactions requiring discontinuation of the antibiotic occur to some extent with all clients taking a penicillin agent. | The core issue of the question is the significance of a rash that develops in a client taking ampicillin. Use specific nursing knowledge and the process of elimination to make a selection. Recall that not all drug rashes indicate hypersensitivity to aid in choosing the correct option. |
2839 The nurse teaches the client who is started on Correct answer: 1 Improvement in clinical manifestations of the infection should be noted within 48–72 hours. erythromycin (Erythrocin) as treatment for pneumonia Otherwise, compliance with prescribed drug therapy should be assessed, and adjustment of to contact the health care provider for which of the drug, dose, and/or administration frequency might be needed. Anorexia, nausea, and following reasons? fluctuating febrile state can be common sequelae in systemic infections (options 3 and 4). The client s ability to take in fluids can temporarily sustain his nutritional status for a few days, particularly if dietary supplements are also included, which is appropriate for client education (option 2). ‐ Improvement of fever, cough, or respiratory effort is not observed in 48–72 hours. ‐ Client is taking fluids orally, but continues to refuse to eat after 24 hours. ‐ Client develops anorexia and nausea within 24 hours. ‐ Fever fluctuates. | The core issues of the question are knowledge of unsatisfactory progress after beginning erythromycin and indicators that need to be reported to the prescriber. Use specific nursing knowledge and the process of elimination to make a selection. |
2840 A child with otitis media is taking trimethoprim‐ Correct answer: 4 The volume of a household teaspoon can vary by 2–10 mL, so a calibrated device is necessary sulfamethoxazole (TMP‐SMZ) as a suspension. The for accurate dosing. The suspension is to be shaken to disperse the particles just prior to nurse provides what instruction to the mother? measurement. It is recommended that a glass of water be given with the medication, and that adequate urinary output be maintained (option 1). The medication is stable at room temperature, but the taste might be more palatable if cold (option 3). Food does not interfere with absorption of the medication, and could help to minimize gastrointestinal side effects (option 2). ‐ Do not allow the child to drink water immediately after taking the medication. ‐ The medication is to be taken on an empty stomach. ‐ The medication must be kept refrigerated. ‐ Use a calibrated measuring device. | The core issue of the question is the proper method of administration of trimethoprim‐ sulfamethoxazole to a child. Use specific nursing knowledge and the process of elimination to make a selection. |
2841 A client receiving an anti‐infective drug begins to Correct answer: 1 Epinephrine is the primary drug used when bronchoconstriction causes inadequate wheeze. The nurse anticipates initial administration of respiratory exchange, as in anaphylactic shock. Marked improvement in respiration occurs what drug? within a few minutes after subcutaneous administration of 0.1–0.5 mL of 1:1000 strength epinephrine. Corticosteroids may be given to minimize the inflammation and edema, but are not the initial agent given (option 2). Atropine might minimize secretions, but would not be given unless vagal‐induced bradycardia or asystole occurred; then atropine could be given as an IV bolus rapidly before, during, or after cardiopulmonary arrest (option 3). Dopamine HCL, a catecholamine (as is epinephrine), may be given to increase blood pressure if shock develops (option 4). ‐ Epinephrine HCL (Adrenalin Chloride) ‐ Methylprednisolone (Solu‐Medrol) | The core issue of the question is knowledge of drugs that are used to treat hypersensitivity or anaphylactic reactions. Use specific nursing knowledge and the process of elimination to make a selection. |
‐ Atropine sulfate (Atropine) ‐ Dopamine HCL (Intropin) | |
2842 The nurse would teach a client that alcohol taken in Correct answer: 1 A disulfiram‐like effect is associated with certain drugs, including metronidazole (Flagyl). conjunction with which of the following ordered Onset is usually within 15–30 minutes of ingestion of alcohol, but can occur up to 72 hours medications can cause a reaction causing flushing, after Flagyl has been discontinued. The reaction lasts approximately 20–30 minutes but can dizziness, pounding headache, sweating, abdominal remain up to 24 hours. cramps, nausea, irritability, and low blood pressure? ‐ Cefoxitan (Mefoxin) ‐ Metronidazole (Flagyl) ‐ Clindamycin (Cleocin) ‐ Ampicillin (Omnipen) | The core issue of the question is knowledge of which drugs can cause a disulfiram‐like reaction when used with alcohol. Use specific nursing knowledge and the process of elimination to make a selection. |
2843 The nurse assesses the client receiving cefotazime Correct answer: 2 Opportunistic infections or superinfections are manifested by these signs and symptoms. (Claforan), and notes three diarrhea stools in the past Common ones are vaginal and GI tract infections, including candidiasis and diarrhea. They 24 hours, rectal itching, glossitis, and fever. The nurse often result from broad‐spectrum antibiotic use that destroys bacteria in the normal flora, concludes these adverse effects probably indicate allowing the resistant pathogens to proliferate. Early recognition and intervention with which of the following? administration of sensitive anti‐infectives is important in controlling discomfort and the severity of the reaction. The other options represent incorrect conclusions about the data presented. ‐ Leukocytosis ‐ Opportunistic infection ‐ Bone marrow depression ‐ Drug failure against original infective organism | The core issue of the question is knowledge of adverse drug effects of cefotazime and their significance. Use specific nursing knowledge and the process of elimination to make a selection. |
2844 What teaching or intervention is appropriate for a Correct answer: 2 Yogurt and buttermilk products can decrease the diarrhea as well as add protein to the diet client taking an antibiotic that causes diarrhea to provide albumin for drug binding. Blood or mucus in the stool with increased number of secondary to elimination of normal intestinal flora? stools indicates the possibility of pseudomembranous colitis that should be reported to the health care provider. Antacids would interfere with the effectiveness of the antibiotic (option 4). The route of administration of antibiotics is not the cause of destruction of normal flora (option 3). Clients are not usually taught to test their stool for occult blood (option 1). ‐ Test stool for occult blood. ‐ Include yogurt or buttermilk products in the diet. ‐ Arrange for IV administration instead of oral route for the antibiotic. ‐ Take antacids with oral antibiotic to slow absorption of antibiotic, and to reduce the severity of the diarrhea. | The core issue of the question is knowledge of client teaching points related to antibiotic therapy that has diarrhea as a side effect. Use specific nursing knowledge and the process of elimination to make a selection. |
2845 A disulfiram‐like reaction occurs in a client taking Correct answer: 3 Disulfiram‐ or antabuse‐like reactions can occur when cephalosporins are taken with cefoperazone sodium (Cefobid). The nurse suspects ingestion of alcohol during and up to 72 hours after discontinuation of the cephalosporin. this reaction is a drug interaction resulting from the Caffeine and the other medications listed would not cause this reaction. client’s ingestion of which of the following substances within the last few hours? ‐ Caffeine in tea or coffee ‐ Sulfamethoxazole (Gantonol) for a chronic urinary tract infection ‐ Alcohol‐containing cough syrup ‐ Ampicillin (Omnipen), which has a cross‐sensitivity to cephalosporins | The core issue of the question is knowledge of the causes of disulfiram‐like drug reactions. Use specific nursing knowledge and the process of elimination to make a selection. |
2846 The nurse evaluates for an adverse reaction to Correct answer: 2 Vestibular ototoxicity as well as cochlear otoxicity can occur with administration of an tobramycin sulfate (Tobrex) by conducting what aminoglycoside such as tobramycin. A positive Romberg s test indicates vertigo or loss of assessment? balance, and can suggest a vestibular problem. Babinski s reflex present in the adult reflects a possible lesion in the corticospinal tract (option 4). Chvostek s sign is seen in tetany and hypocalcemia (option 3). One method of assessing peripheral circulation is to check the capillary refill (option 1). ‐ Capillary refill ‐ Romberg’s test ‐ Chvostek’s sign ‐ Babinski s reflex | The core issue of the question is knowledge of assessment techniques that will help determine whether ototoxicity is occurring in a client taking tobramycin. Use specific nursing knowledge and the process of elimination to make a selection. |
2847 What does the nurse teach an adult premenopausal Correct answer: 1 Griseofulvin does not cause increased bleeding unless the client is also on anticoagulant client receiving griseofulvin microsize (Grisfulvin V) for therapy (option 2). The agent also has no known effect on blood pressure, and known a systemic antifungal condition? interaction with calcium intake (options 3 and 4). However, griseofulvin can interfere with the effectiveness of estrogen‐containing oral contraceptives (option 1). ‐ If taking oral contraceptives, use an alternative form of contraception during and for one month after use of griseofulvin. ‐ Keep a record of the number of absorbent products used daily, to monitor for increased menstrual flow while taking griseofulvin. ‐ Check blood pressure daily during treatment if taking oral contraceptive and griseofulvin, as both can increase blood pressure. ‐ Avoid taking calcium supplements concurrently with griseofulvin. | The core issue of the question is knowledge of key teaching points regarding systemic griseofulvin. Use specific nursing knowledge and the process of elimination to make a selection. |
2848 Because of the mechanisms of action of tetracycline, Correct answer: 1 Bacteriostatic agents inhibit or retard bacterial growth and replication, but they do not kill the client needs to have which of the following in the entire bacteria. These agents depend on the host s defense mechanisms to complete order for the drug to be effective? elimination of the bacteria. Bactericidal agents actually kill and lyse the bacteria. Tetracyclines are bacteriostatic. Supplemental vitamin B<sub>6</sub> is indicated with isoniazid (INH) administration (option 3). Iron, as well as antacids, laxatives, food, and dairy products, should be separated one hour before or two hours after administration of a tetracycline (option 2). These substances interfere with the absorption of tetracyclines. Option 4 is unnecessary. ‐ A competent client immune system ‐ Concurrent administration of iron ‐ Supplemental pyridoxine HCL (vitamin B6) ‐ Weekly evaluation of the complete blood count | The core issue of the question is the mechanism of action of tetracycline, and how it leads to eradication of infection. Use specific nursing knowledge and the process of elimination to make a selection. |
2849 The nurse assesses for which lab result when a client Correct answer: 3 The prothrombin time (PT) and the international normalization ratio (INR) values are standard is receiving long‐term oral anticoagulation therapy and tests to monitor warfarin (Coumadin) levels. The beta‐lactam antibiotics can cause increased is also taking a beta‐lactam penicillin? PT and INR. The bleeding time (option 1) evaluates the integrity of the vascular and platelet factors associated with stagnated blood. Thrombin time (option 2) evaluates the fibrinogen‐to‐ fibrin conversion factor that can be used to gauge heparin effectiveness. However, the APPT (option 4) is currently used most often in regulating heparin therapy. ‐ Decreased bleeding time ‐ Increased thrombin time (TT) ‐ Increased prothrombin time (PT) ‐ Increased activated partial thromboplastin time (APPT) | The core issue of the question is the expected change in laboratory results for a client taking a beta‐lactam penicillin and an oral anticoagulant. Use specific nursing knowledge and the process of elimination to make a selection. |
2850 During a routine screening, a client has a positive Correct answer: 4 The PPD injection stimulates a local inflammatory response at the injection site in the client response to intradermal injection of purified protein who has been exposed to the tubercle bacillus in the past. The client develops a cellular derivative (PPD or Mantoux test). The nurse draws response to tubercle bacillus at 3–10 weeks after infection. A positive PPD result does not which of the following conclusions about this result? indicate that the client currently has active tuberculosis, or is in an infectious state (options 1 and 2). Follow‐up sputum tests for tubercle bacillus and/or chest films are done to clarify current status. ‐ The client is currently infectious. | The core issue of the question is the significance of PPD test results. Use specific nursing knowledge and the process of elimination to make a selection. |
‐ The client has active tuberculosis. ‐ The client has been exposed to the tubercle bacillus within the past 2weeks. ‐ The client has been infected with tuberculosis, and has developed a cellular (T cell) response to the tubercle bacillus. | |
2851 Appropriate teaching for a young adult female related Correct answer: 4 Antibiotics, especially aminopenicillins such as ampicillin, can decrease the effectiveness of to a new prescription for ampicillin (Omnipen) orally oral contraceptives. The other clinical manifestations are not related to penicillin therapy. would include which of the following? ‐ Observe for easy bruising. ‐ Observe for clinical extrapyramidal tract manifestations. ‐ Change positions slowly to avoid orthostatic hypotension. ‐ If applicable, use an alternative to oral contraceptives during and for one month after therapy. | The core issue of the question is client teaching that is needed for a client beginning drug therapy with ampicillin. Use specific nursing knowledge and the process of elimination to make a selection. |
2852 A female client is taking sargramostim (Leukine) Correct answer: 3 It is the responsibility of the nurse to address the client’s body image related to alopecia. following a bone marrow transplant. During an Option 1 does not apply. Option 2 is not a nursing diagnosis. Option 4 is a secondary diagnosis assessment, the client voices concern about her hair that could apply, but option 3 is more relevant to the side effect of the medication. falling out. Based on this assessment, which of the following would be the priority nursing diagnosis? ‐ Impaired Skin Integrity ‐ Alopecia ‐ Disturbed Body Image ‐ Anxiety | The core issue of the question is knowledge of how adverse drug effects of sargramostim can affect a client, necessitating formulation of a nursing diagnosis. Use specific nursing knowledge and the process of elimination to make a selection. |
2853 A client receiving aldesleukin (Proleukin) begins to Correct answer: 1 Potential flulike symptoms can occur with aldesleukin (Proleukin). For this reason, the nurse complain of a fever and pain. Which of the following is must provide for adequate fluid‐and‐electrolyte balance to prevent deficient fluid volume. the priority nursing diagnostic statement for this Options 2 and 4 have lesser priority because they are not side effects (although they are client? usually general priority items), and option 3 is the opposite of the actual problem. ‐ Risk for Deficient Fluid Volume related to flulike symptoms ‐ Ineffective Airway Clearance related to fever ‐ Excess Fluid Volume related to flulike symptoms ‐ Ineffective Airway Clearance related to increased pulmonary secretions | The core issue of the question is knowledge of how adverse drug effects of aldesleukin can affect a client, necessitating formulation of a nursing diagnosis. Use specific nursing knowledge and the process of elimination to make a selection. |
2854 Clients receiving oprelvekin (Neumega) should be Correct answer: 2 Oprelvekin (Neumega) can cause cardiopulmonary insufficiency with irregular heart rate and assessed frequently for signs and symptoms of which fluid retention. Thus, it is a nursing priority to assess the client frequently for signs and of the following? symptoms of congestive heart failure. The other options do not address this priority concern. ‐ Dehydration ‐ Congestive heart failure (CHF) ‐ Anxiety ‐ Hyperuricemia | The core issue of the question is knowledge of adverse drug effects of oprelvekin. Use specific nursing knowledge and the process of elimination to make a selection. |
2855 Based on the prescribed therapy of mycophenolate Correct answer: 3 Mycophenalate (CellCept) is administered orally 72 hours after transplant. The time frames (CellCept), the nurse can expect the renal transplant listed in each of the other options are incorrect. client to receive the first dose at which of the following times? ‐ In the postanesthesia recovery area ‐ Within one hour of admission to intensive care ‐ Seventy‐two hours following the transplant ‐ One week following the transplant | The core issue of the question is knowledge of time frames to begin drug therapy with mycophenolate following transplant. Use specific nursing knowledge and the process of elimination to make a selection. |
2856 A 28‐year‐old male client is admitted to the Correct answer: 2 It is recommended that every client have a tetanus vaccine every 10 years to prevent Emergency Department with a three‐inch laceration infection caused by tetanus. The primary opportunity for this assessment is following a over his left eye. The nurse should assess which of the laceration. Delayed wound healing is a possibility with corticosteroid therapy, but assessment following priority items related to the risk of infection of tetanus immunization status takes priority. Temperature and blood pressure measurement before beginning drug therapy to prevent infection? (options 1 and 3) do not address the risk of infection caused by trauma while the client is in the Emergency Department. ‐ The client’s temperature ‐ The date of the client’s last tetanus vaccine ‐ If the client’s blood pressure is decreased ‐ Whether the client is taking corticosteroid medication | The critical words in the question are laceration and Emergency Department. Recall that the skin is the first line of defense against infection to choose option 2. |
2857 A pit bull has bitten a 28‐year‐old woman. Upon Correct answer: 3 Antirabies serum equine 55 U/Kg IM can be applied to the animal bite wound. The medication admission to the Emergency Department, the nurse does not need to be administered parenterally (options 1, 2, and 4). will administer the prescribed antirabies serum (equine) into which of the following locations? ‐ Intravenously ‐ Intramuscularly into the right gluteal muscle ‐ Into the animal bite ‐ Z‐track into the anterolateral thigh | The core issue of the question is knowledge of how to administer antirabies serum. Use specific nursing knowledge and the process of elimination to make a selection. |
2858 In conducting client teaching about Beta 1b Correct answer: 4 Beta 1b (Betaseron) reduces the severity of acute exacerbations of multiple sclerosis. The (Betaseron), the nurse would explain that the goal of drug decreases the demyelination in brain tissue. The other responses do not accurately reflect the administration is which of the following? the action of this medication. ‐ Cure the client of multiple sclerosis. ‐ Prevent signs and symptoms of anaphylaxis. ‐ Destroy nerve tissue that is laden with plaque. ‐ Decrease the demyelination in the brain tissue. | The core issue of the question is knowledge of goals of drug therapy with interferon (Betaseron). Use specific nursing knowledge and the process of elimination to make a selection. |
2859 To decrease renal insufficiency side effects in clients Correct answer: 3 Adequate fluid intake greater than 2,000–3,000 mL per day allows for the kidneys to flush receiving cyclophosphamide (Sandimmune), the nurse renal toxins, and prevents renal insufficiency. Option 1 is a general measure to prevent should instruct the client to do which of the following? constipation. Option 2 would be a monitoring function, but would not prevent renal insufficiency. The nurse would not instruct the client to take additional medication that is not specifically part of the plan of care (option 4). ‐ Consume a diet high in fiber. ‐ Have his creatinine level assessed weekly. ‐ Drink 3,000 mL of fluid per day. ‐ Administer hydrochlorothiazide (HCTZ) with cyclophosphamide. | The core issue of the question is knowledge of measures to prevent the development of renal side effects with use of cyclophosphamide. Use specific nursing knowledge and the process of elimination to make a selection. |
2860 To assess a client s baseline prior to the Correct answer: 1 The most significant laboratory test to utilize prior to medication therapy with azathioprine is administration of azathioprine (Imuran), the nurse creatinine level, because renal and hepatic function should be assessed. Option 2 is irrelevant, should put highest priority on evaluating which of the while options 3 and 4 evaluate blood clotting and components of the blood, respectively. following laboratory test results? Other risks of azathioprine would be increased white cell count (infection) and decreased platelet count. ‐ Creatinine ‐ Uric acid ‐ PT and PTT ‐ Red blood cell count | The core issue of the question is knowledge of adverse drug effects of azathioprine and of which laboratory test to use as a baseline measure. Use specific nursing knowledge and the process of elimination to make a selection. |
2861 Azathioprine (Imuran) and allopurinol (Zyloprim) are Correct answer: 2 Azathioprine (Imuran) is administered to treat multiple sclerosis, and allopurinol (Zyloprim) is administered to a client diagnosed with multiple administered to treat symptoms of gout. When these two medications are administered sclerosis and gout. It is important for the nurse to together, the dose of azathioprine should be reduced. The uric acid level and client symptoms assess the results of which of the following laboratory should be assessed to determine the control of gout. tests in this client? ‐ Creatinine ‐ Uric acid ‐ Blood glucose ‐ Blood urea nitrogen (BUN) | The core issue of the question is knowledge of drug interactive effects of azathioprine and allopurinol. Use specific nursing knowledge and the process of elimination to make a selection. |
2862 A client is scheduled for diagnostic testing for Correct answer: 2 Edrophonium (Tensilon) is used for diagnostic purposes. Clients who receive an injection of myasthenia gravis. The nurse would prepare which of edrophonium and exhibit a temporary relief of symptoms are diagnosed with myasthenia the following medications necessary for this testing? gravis, which is characterized by a decrease in the concentration of acetylcholine in the neuromuscular junction. The medications listed in the other options are not used to diagnose myasthenia gravis. ‐ Ambenonium (Mytelase) ‐ Edrophonium (Tensilon) ‐ Neostigmine (Prostigmine) ‐ Physostigmine (Eserine) | The core issue of the question is knowledge of medications used for diagnosis of myasthenia gravis. Use specific nursing knowledge and the process of elimination to make a selection. |
2863 Which of the following points should be included in a Correct answer: 1 Medications used to treat symptoms of multiple sclerosis have been noted to increase teaching plan for a client receiving medications to pulmonary edema, leading to chest pain and shortness of breath. Option 2 could increase risk treat multiple sclerosis? of urinary tract infection. Option 3 is useful to avoid infection, but does not specifically relate to medication teaching. Option 4 could increase fatigue, if done to excess, and lead to exacerbation of symptoms. ‐ The signs and symptoms of pulmonary edema ‐ The restriction of fluids ‐ The requirement to remain restricted from crowds ‐ The requirement to exercise to enhance muscle strength | The core issue of the question is knowledge of essential teaching points for a client being treated with drug therapy for multiple sclerosis. Use specific nursing knowledge and the process of elimination to make a selection. |
2864 A client has been exposed to hepatitis A. Which of the Correct answer: 3 Immune serum globulin should not be administered to clients with a history of coagulation following client factors would be an indication for disorders. The other options do not represent contraindications to administration of this withholding administration of immune serum globulin medication. to the client? ‐ The client has received a hepatitis B vaccine. ‐ The client has recently fallen and suffered a hip fracture. ‐ The client has a history of a coagulation disorder. ‐ The client is scheduled for foreign travel. | The core issue of the question is knowledge of safe administration of serum immune globulin. Use specific nursing knowledge and the process of elimination to make a selection. |
2865 A client with Parkinson s disease is admitted to the Correct answer: 4 Physostigmine (Eserine) is an anticholinesterase agent that crosses the blood–brain barrier. It Emergency Department with lethargy, hypotension, is used as an agent to correct anticholinergic poisoning. The other medications listed do not and weakened gait. The nurse should be prepared to have this effect. administer which of the following medications? ‐ Carbidopa (Lodosyn) ‐ Levodopa (Dopar) ‐ Atropine (generic) ‐ Physostigmine (Eserine) | The core issue of the question is knowledge of drug therapy to reverse excessive effects of medications used to treat Parkinson’s disease. Use specific nursing knowledge and the process of elimination to make a selection. |
2866 To prevent toxicity during IV administration of Correct answer: 4 The intravenous administration of physostigmine (Eserine) should be no faster than 1 mg per physostigmine (Eserine), the nurse should administer minute, to prevent toxic adverse reactions. The other options do not relate to toxicity of the medication: physostigmine. | The core issue of the question is knowledge of safe administration technique for physostigmine. Use specific nursing knowledge and the process of elimination to make a selection. |
‐ Retrograde. ‐ Through a central line. ‐ Concurrently with Parlodel. ‐ No faster than 1 mg per minute. | |
2867 The client taking isoniazid (INH) reports paresthesia of Correct answer: 4 Administration of vitamin B<sub>6</sub> is recommended during therapy with the extremities. The nurse initially assesses the client isoniazid (INH), to reduce the incidence of peripheral neuritis, which could be associated with for which of the following? isoniazid. Monitoring motor reflexes would not be indicated (option 1). Paresthesia is not usually a clinical manifestation of hypercalcemia (option 2). Antacids interfere with absorption of INH when taken within 1–2 hours of the INH, but would not cause the symptoms reported by the client (option 3). ‐ Hyperactive motor reflex responses ‐ Other clinical manifestations of hypercalcemia ‐ Concurrent self‐administration of aluminum antacids ‐ Compliance with taking pyridoxine (vitamin B6) supplement | In order to answer this question, recall nursing interventions associated with the administration of this medication. If this was difficult, review the nursing interventions in the administration of the medication. |
2868 Rifampin (Rifadin) is being initiated prophylactically Correct answer: 3 Rifampin causes an orange‐red discoloration of body fluids, including urine. The client needs for a client who lives with a family member who has to be aware of this. The drug is being ordered prophylactically to prevent the development of Haemophilus influenzae meningitis. What client meningitis, not to treat it (option 1). Adverse effects are generally minor with rifampin (option teaching would be most appropriate? 2). Because the drug is metabolized by the liver, regular liver function tests should be monitored (option 4). Rifampin should be used with caution in the presence of elevated liver enzymes or hepatic dysfunction. ‐ Explain that rifampin is being prescribed to treat meningitis. ‐ Adverse effects might be severe, such as convulsions and coma. ‐ Protect undergarments, because with rifampin (Rifadin), urine will become orange‐red, and will stain. ‐ The client will need to keep follow‐up visits with her health care provider, but it will not be necessary to continue blood test monitoring. | In order to answer this question correctly, recall the side effects and client responses to listed medications. If this was difficult, review side effects and client responses to the medications. |
2869 A client with benign prostatic hyperplasia (BPH) is Correct answer: 1 Amantadine (Symmetrel) can cause anticholinergic effects, two of which are bladder receiving amantadine (Symmetrel) for influenza A. The relaxation and detrusor muscle contraction. Urinary retention could become more of a nurse includes in the care plan to monitor the client problem for a client with BPH on this medication. Hypermotility of the bowel and increased for which of the following side effects? lacrimation are cholinergic effects, not anticholinergic effects (options 2 and 3). Amantadine is not particularly nephrotoxic (option 4). ‐ Increased risk for urinary retention ‐ Hypermotility of bowel ‐ Increased lacrimation ‐ Nephrotoxicity | In order to answer this question correctly, recall the side effects and client responses to listed medications. If this was difficult, review side effects and client responses to the medications. |
2870 A client with herpes zoster infection (shingles) has Correct answer: 4 Agents for herpes virus as herpes zoster can be nephritic. Important interventions include started therapy with acyclovir (Zovirax). The nurse monitoring renal function and ensuring good hydration to decrease toxic effects. This drug is performs what important intervention during the not reported to be particularly hepatotoxic (option 1). Sexual intercourse is to be avoided if course of this treatment? the client is being treated with the acylovir for genital herpes (option 2). Insomnia is not a side effect of acyclovir (option 3). ‐ Monitors for jaundice and elevated liver enzymes. ‐ Teaches the client to avoid sexual intercourse during therapy. ‐ Administers the dose early in the day, as it could cause insomnia. ‐ Encourages fluid intake of 2,500–3,000 mL daily, since it is not contraindicated by other client conditions. | In order to select the correct answer to this question, recall that the medication is toxic to the kidneys. Knowing this, be directed to option 4. The other answers do not apply to nephrotoxicity. |
2871 The nurse determines that the client understands an Correct answer: 1 A full course of antibiotic therapy must be taken in order to decrease the risk of resistance to important principle of self‐administration of an oral the antibiotic, or reoccurrence of the infection. Missed doses should be taken as soon as they antibiotic when the client makes which of the are remembered, but the dose should not be doubled by taking two doses at the same time following statements? (option 2). Antibiotic doses are to be taken at regular intervals spaced throughout the 24 hours, without interrupting sleep when possible, in order to maintain effective therapeutic blood level of the antibiotic (option 3). Chewable tablets must be crushed or chewed, or the drug might not absorb adequately (option 4). ‐ "I will continue to take the antibiotic as it is ordered, even though I no longer have a cough with yellow sputum." ‐ "When I missed a dose of my antibiotic this morning, I made up for it by taking two doses when it was time to take the next dose." ‐ "I am careful to take the antibiotic every day at breakfast, lunch, and dinner." ‐ "Even though the doctor prescribed amoxicillin (Amoxil) chewable tablet, I have no problem swallowing it whole." | Note that the question stem asks for selection of the answer that indicates that the client understands correct administration of medication. Reviewing basic information about medications will lead to option 1 as the correct answer. |
2872 A client who has been on anti‐infective therapy for 10 Correct answer: 4 More than 4–6 watery stools per day and stools with blood are clinical manifestations of days has developed diarrhea, with 10 watery stools a pseudomembranous colitis. C. difficile is the causative microorganism for this superinfection. day. The nurse should anticipate an order for which of The client is at risk for developing metabolic acidosis due to increased loss of bowel contents the following? with loss of base (option 1). Antiperistaltic agents can promote retention of toxins, and should not be given (option 2). Antidiarrheal agents may be given for mild diarrhea, but not when toxins need to be eliminated (option 3). ‐ Monitor for clinical manifestations of metabolic alkalosis. ‐ Administer an anti‐peristaltic agent, such as dicyclomine HCl (Bentyl). ‐ Administer an antidiarrheal agent, such as kaolin and pectin (Kaopectolin). ‐ Collect a stool specimen for cytotoxin assay to detect <i>Clostridium difficile</i>. | The key information in the question stem is that the client has been on anti‐infective therapy for 10 days, and has now developed diarrhea with watery stools. The length of time should direct selection of the first intervention before any treatment can begin. This would lead to first collecting the stool specimen, as is indicated in option 4. |
2873 The client with pneumonia is being treated with Correct answer: 4 Specific indicators of improvement, such as the resolution of pulmonary infiltrates, improved amoxicillin (Amoxil). The nurse monitors for breath sounds, and normalization of pulse oximetry, are important outcomes to monitor in therapeutic effectiveness by noting which of the pneumonia. Systemic signs including fever, malaise, and leukocytosis are expected to following? demonstrate improvement within 48–72 hours of antibiotic therapy (option 1). Option 2 does not indicate therapeutic effectiveness, and option 3 is unrelated to the question. ‐ Normalization of fever beginning 96 hours after therapy starts ‐ No clinical manifestations of hypersensitivity ‐ Resolution of orthostatic hypotension ‐ Pulse oximetry of 98% | Picking up on the key system of respiratory in the question stem should assist in selecting the correct answer. Looking for an answer that addresses respiration will point to option 4. Eliminate option 3 since there is no indication of hypotension in the question stem. |
2874 A client receiving penicillin (PCN) for several days Correct answer: 1 The penicillins are structured with a sodium or potassium salt. When a high‐sodium‐content complains of weakness, numbness, tingling in the penicillin is administered, serum sodium can be elevated, which often results in hypokalemia. extremities, and nausea. The nurse palpates a weak This client is demonstrating clinical manifestations of hypokalemia. With the elevated sodium, pulse, and auscultates an irregular heart rate and the accompanying anion would most likely be chloride, resulting in hyperchloremia, and not decreased bowel sounds. The nurse further monitors hypochloremia. the client for specific signs of which of the following imbalances? ‐ Hypokalemia ‐ Hypochloremia ‐ Hypercalcemia ‐ Hypophosphatemia | In reviewing the question stem, the client is experiencing cardiovascular changes. Knowing that low potassium will lead to cardiovascular changes will lead to the answer of hypokalemia. |
2875 The prescriber has ordered cefdinir (Omnicef), a third‐ Correct answer: 4 A cross‐allergenicity with penicillin might exist. Cephalosporins cannot be assumed to be an generation cephalosporin, for a client with a absolutely safe alternative in penicillin‐allergic clients. If the cephalosporin is administered to staphylococcal infection. The nurse collaborates with this client, the nurse needs to administer it cautiously, observing for manifestations of the prescriber about which of the following data hypersensitivity, especially respiratory difficulty. Emergency equipment should be readily related to the client? accessible. BUN is within normal limits. It is expected that the granulocytosis would occur in response to a bacterial infection. To wait several hours for the results of the C & S could compromise the client's response to the treatment. If the C & S findings reveal that the bacteria are resistant to the prescribed antibiotic, the drug can be changed to one that will be effective against the organism. ‐ BUN 14 mg/dL ‐ Elevated granulocyte count ‐ Culture and sensitivity (C & S) results not yet available. ‐ History of type I hypersensitivity to penicillin | Using the process of elimination should eliminate option 1, as this is a normal result. Option 2 is an expected result with the disease process. Option 3 can be eliminated, since it does not apply to the question. This should lead to the only correct option. |
2876 A client's white blood cell count differential shows a Correct answer: 1 A "shift to the left" refers to an increase in neutrophils, and immature neutrophils called "shift to the left." The nurse recognizes that the client bands or stab cells. Production of these white blood cells is stimulated by an acute bacterial needs to be assessed for what type of infection? infection. Lymphocytes, T cells, and B cells are increased primarily in viral infections. Monocytes also fight bacterial infection by phagocytic action. Eosinophils and basophils are elevated in allergic reaction. ‐ Bacterial ‐ Acute viral ‐ Parasitic ‐ Retroviral | Having knowledge of the term “shift to the left” will lead to the only correct answer. The shift refers to an increase in neutrophils, with an increase indicating a bacterial infection. This answer is listed in option 1. |
2877 Prior to the administration of filgrastim (Neupogen), Correct answer: 4 Filgrastim (Neupogen) is contraindicated with a hypersensitivity to E. coli products. It is the client reports a history of hypersensitivity to E. coli important for the nurse to assess for any contraindications prior to the administration of this products. The nurse should take which of the following medication due to the risk of allergic reaction. Option 1 constitutes changing a medication actions? dosage, and is unsafe. Options 2 and 3 do not provide for client safety. ‐ Reduce the dosage of filgrastim by 5 micrograms. ‐ Assess the client for leukopenia and fever. ‐ Administer diphenhydramine (Benadryl) prior to administering filgrastim. ‐ Withhold the administration of filgrastim, and notify the physician. | Take into account the word hypersensitivity, and be alerted that the question is a safety question. Options 1, 2, and 3 do not consider safety for the client, and should be eliminated. The only correct answer that addresses safety is option 4. |
2878 A client is taking sargramostim (Leukine). The nurse is Correct answer: 3 Adult respiratory distress syndrome can develop due to the toxicity of colony‐stimulating especially careful to conduct a pulmonary assessment factors. The other options do not reflect concerns specific to this medication. to detect which of the following risks associated with this drug? ‐ Congestive heart failure (CHF) ‐ Respiratory alkalosis ‐ Adult respiratory distress syndrome (ARDS) ‐ Pulmonary embolism | Knowing the side effects of the medication will lead to the correct answer choice. If this was difficult, review the side effects of the medication. |
2879 A client with rheumatoid arthritis has developed a Correct answer: 1 Medications used to treat the symptoms of rheumatoid arthritis increase the client's fever. The nurse suspects that this might be related to susceptibility to infection. Fever accompanies infection, and requires further assessment. which of the following? Options 2 and 4 are incorrect because they do not reflect a concern related to this type of medication. Option 3 is incorrect because infection is harmful to the client, and needs to be treated. ‐ The effect of prescribed medications on immune response ‐ A stable effect unrelated to medication ‐ A known, expected reaction to medication that is not harmful ‐ The client's ability to adapt to the medication regime | Note in the question stem that the client has rheumatoid arthritis. Medications that are given for rheumatoid arthritis cause an increased susceptibility to infection. Knowing this information and using the process of elimination should lead to selection of option 1 as the correct answer. |
2880 Following the administration of immune serum Correct answer: 3 Immune serum globulin will irritate tissues, and the application of heat will reduce pain and globulin, the nurse should instruct the client to do discomfort. The other responses are unrelated to the issue of the question, which is local which of the following? discomfort at the injection site. ‐ Avoid exposure to children. ‐ Call the physician with signs of bleeding. ‐ Apply heat to the injection site. ‐ Repeat the dose within one week. | Recognize that the question is referring to the injection site. The only answer that addresses the injection site is option 3. The other options do not address the administration of a medication. |
2881 A client with a known seizure disorder is taking Correct answer: 1 Anticonvulsant medications administered concurrently with cyclosporine will cause decreased cyclosporine (Sandimmune) following a kidney therapeutic levels of the cyclosporine medication. For this reason, the cyclosporine dose will transplant. Based on this information, the nurse is need to be increased. The anticonvulsant dose needs to be given at standard dosage to aware that which of the following medication dosages maintain therapeutic blood levels. will need to be altered? ‐ The standard cyclosporine dose will need to be increased. ‐ The client's anticonvulsant dose will need to be increased. ‐ The standard cyclosporine dose will need to be decreased. ‐ The client's anticonvulsant dose will need to be decreased. | In order to answer this question, recall that anticonvulsants are maintained at a therapeutic level to maintain blood levels. They should not be changed unless there is a therapeutic need. This would eliminate options 2 and 4. If this was difficult, review the effects of anticonvulsants on immunologic medications. |
2882 A male client calls the physician's office complaining Correct answer: 3 The client and family should be instructed to assess for fluid retention and an irregular heart of shortness of breath and edema. He is currently rate. However, with the client complaining of shortness of breath and edema two days after taking hydrochlorothiazide (HCTZ) and digoxin chemotherapy and administration of oprelvekin (Neumega), the nurse should suspect that the (Lanoxin). Two days ago, he received chemotherapy, client is in cardiopulmonary insufficiency requiring medical attention. Options 1, 2, and 4 delay followed by oprelvekin (Neumega). Based on this necessary medical attention and place the client at further risk for complications. information, the nurse should take which of the following actions? ‐ Schedule him an appointment to be seen by the nurse practitioner. ‐ Instruct him to lie down with his head elevated 45 degrees. ‐ Instruct him to call 911 and be transported to the Emergency Department. ‐ Call the client's family to assess his heart rate. | This question is asking for selection of the option that would address the safety of the client. Option 3 is the only safe answer in consideration of the other options. The other options delay safe care, and should be eliminated. |
2883 A renal transplant recipient enjoys a grapefruit for Correct answer: 2 The only food interaction of significance with cyclosporine (Sandimmune) is grapefruit. This breakfast. He is taking cyclosporine (Sandimmune). The combination will result in an increased serum cyclosporine level. The other options are nurse should instruct him that ingestion of grapefruit completely false. would have which of the following effects? ‐ Cause an increase in edema and renal insufficiency. ‐ Increase the serum level of cyclosporine. ‐ Assist in relieving his constipation. ‐ Increase renal metabolism of cyclosporine. | The only correct statement is answer 2. In selecting the correct answer, recall the contraindications when taking the medication. |
2884 It is reported in the news that a restaurant worker at Correct answer: 4 Exposure to hepatitis A from a restaurant worker necessitates the administration of immune a local burger establishment has been diagnosed with serum globulin to prevent hepatitis A. The other options fail to address the client's need for hepatitis A. A patron of this establishment calls the protection against possible exposure. health department for advice. The nurse should provide which of the following instructions to the patron? ‐ Call the physician for guidance. ‐ Assess self for future development of jaundice. ‐ Come to the health department and have a hepatitis blood test. ‐ Come to the health department to receive immune serum globulin. | The question is asking for selection of the priority option that protects the patron. Recognize that options 1, 2, and 3 do not address protection of the client. The only option that addresses protection is option 4. |
2885 A young mother asks the obstetrics nurse why her Correct answer: 2 Childhood illnesses possess a high rate of mortality and morbidity. The use of immunizations baby needs to receive immunizations. Which of the assists in the promotion of health and prevention of illness. Immunizations are begun shortly following would be the best response by the nurse? after birth, and are required before a child can attend school. Option 3 is false. Options 1 and 4 are true, but do not address the reason immunizations need to be administered. ‐ "Immunizations are required by law." ‐ "Immunizations prevent illnesses that are associated with a high death rate." ‐ "Immunizations are safe, without side effects." ‐ "Immunizations are inexpensive, and can be provided free by the health department." | In selecting the best answer, eliminate options 1, 3, and 4, as these options do not address the client’s question. The best response is to explain to the client why the immunizations are given, as presented in option 2. |
2886 A client with myasthenia gravis presents in the Correct answer: 4 Atropine (an anticholinergic medication) should be administered to counteract the cholinergic Emergency Department with severe ataxia and reaction of the medications used to treat myasthenia gravis. The other options are incorrect tremors. The nurse should be ready to administer because they do not have anticholinergic activity. which of the following medications? ‐ Edrophonium (Tensilon) ‐ Ambenonium (Mytelase) ‐ Neostigmine (Prostigmine) ‐ Atropine (generic) | In selecting the best answer, identify which of the medications is classified as an anticholinergic. The only medication that has this classification is option 4. |
2887 While teaching the client about taking a new Correct answer: 1 Metronidazole (Flagyl) has several gastrointestinal side effects, including metallic or bitter prescription of oral metronidazole (Flagyl), the nurse taste. It can be taken with food, unless in the form of Flagyl ER, which should be taken one advises the client which of the following? hour before or two hours after meals. There is no evidence that Flagyl causes visual disturbances or urinary retention (options 2 and 3). Alcohol taken during drug therapy or within 48 hours after the drug is discontinued can induce a disulfiram‐like effect (option 4). ‐ To take with food to minimize the metallic or bitter taste ‐ That visual disturbances are a common side effect ‐ To monitor for urinary retention ‐ That alcohol should be avoided until the last dose is taken | Knowing the nursing interventions regarding client teaching will lead to the correct answer. If this was difficult, review nursing interventions regarding teaching to clients. |
2888 The nurse evaluates that the immunocompromised Correct answer: 3 A different gloved finger or a different finger cot should be used to apply acyclovir to each client best understands use of topical acyclovir lesion, not only to prevent spread on the client's own body, but also to prevent transmission to (Zovirax) for treating genital herpes when the client others. Caution needs to be taken as well not to contaminate the ointment in the container by makes which of the following statements? obtaining ointment with a contaminated finger cot/glove. Handwashing is important, but is not a barrier protection (option 1). Acyclovir is the drug of choice for primary herpes lesions in the immunosuppressed client, but it has not been proven that acyclovir benefits the immunocompetent client, although it could reduce viral shedding (option 2). Option 4 is a false statement. ‐ "I need to wash my hands for at least 10 seconds with a teaspoon of antibacterial soap before and after application of the drug." ‐ "My sister isn't immunocompromised, but she has genital herpes, and should use acyclovir too." ‐ "I need to use a different finger cot when getting ointment and applying the ointment to each sore, to prevent self‐inoculation in other areas." ‐ "Acyclovir has been around a long time. I know there have to be newer drugs that are better to treat my genital herpes." | The question stem is asking for selection of an answer that indicates the client understands the treatment procedure. Options 2 and 4 can be eliminated because they do not address treatment. Option 3 is the only correct answer because it addresses the caution needed in the application to a client in an immunocompromised state. |
2889 The nurse prepares to initiate therapy with acyclovir Correct answer: 3 The nurse assesses hydration status; intake and output; creatinine; BUN; creatinine clearance; (Zovirax) for a client with AIDS. What intervention is and other laboratory tests for renal dysfunction. The nurse also assesses for concurrent most appropriate for the nurse to perform? nephrotoxic agents being taken, since these drugs could increase the risk for nephrotoxicity developing with administration of acyclovir (Zovirax). The bilirubin differentiates jaundice caused by liver impairment from that caused by hemolysis (option 1). Bowel pattern and hypokalemia are not particular to acyclovir therapy (options 2 and 4). ‐ Assess bilirubin. | In order to select the correct answer, recall that the medication is toxic to the kidneys, and be directed to answer 3. The other answers do not apply to nephrotoxicity. |
‐ Assess for hypokalemia. ‐ Assess for other nephrotoxic drugs being taken. ‐ Assess the number of stools in the past 24 hours, and their consistency. | |
2890 The nurse anticipates that the client will be Correct answer: 1 Almost all clients receiving IV amphotericin B experience adverse reactions involving fever, premedicated with an antipyretic, an antihistamine, chills, piloerection, hypotension, tachycardia, malaise, myalgia, arthralgia, anorexia, nausea, and an antiemetic to decrease infusion‐related vomiting, and headache. The other agents listed do not cause this cluster of severe side reaction. Which of the following anti‐infectives is most effects. Meperidine (Demerol) may also be given to help manage the side effects. likely prescribed? ‐ Amphotericin B (Fungizone) ‐ Acyclovir (Zovirax) ‐ Cefazolin sodium (Ancef) ‐ Methicillin (Staphcillin) | Knowing the side effects and client responses will lead to the correct answer. The only option that has the side effects that require premedication is option 1. |
2891 Knowing that serum protein is needed to bind with Correct answer: 4 Complete proteins are higher‐quality proteins, and contain all nine essential amino acids in anti‐infectives in order to maintain therapeutic sufficient amounts to meet the body's needs. Sources of these proteins are of animal origin, response rate, the nurse recommends which of the such as eggs, milk, cheese, and meat. Gelatin, an animal product, is an exception, since it is an following desserts? incomplete protein. The pudding contains milk, but the egg custard contains the largest quantity of animal proteins such as eggs and milk. ‐ Sherbet ‐ Pudding ‐ Fruit gelatin ‐ Egg custard | Having knowledge of foods made with complete protein will assist in selecting the correct answer. If this was difficult, review foods that are composed of complete proteins. |
2892 The nurse assesses the client receiving gentamicin Correct answer: 2 The most significant adverse effects related to the aminoglycosides, of which gentamycin (Garamycin) for what two most specific toxicities? (Garamycin) is a member, are nephrotoxicity and ototoxicity. Risk for ototoxicity is increased in the presence of nephrotoxicity. ‐ Hepatotoxicity and neurotoxicity ‐ Nephrotoxicity and ototoxicity ‐ Leukocytosis and thrombocytopenia ‐ Pseudomembranous colitis and crystalluria | Knowing the side effects of the medication will lead to the correct answer choice. Realizing that nephrotoxicity is present with gentamycin will lead to the one answer with nephrotoxicity in the answer. If this was difficult, review the side effects of the medication. |
2893 The nurse assesses for what most significant side Correct answer: 1 The most common adverse effect of isoniazid (INH) is peripheral neuritis manifested as effect in a client with tuberculosis taking isoniazid paresthesia of the extremities. The items in the other options are not side effects of this (INH)? therapy. ‐ Paresthesia in limbs ‐ Hearing loss ‐ Visual acuity ‐ Crystalluria | Knowing the side effects of the medication will lead to the correct answer choice. This is the only correct answer, and can be selected with understanding of the side effects of the medication. If this was difficult, review the side effects of the medication. |
2894 During administration of vancomycin (Vancocin), the Correct answer: 3 "Red man syndrome" or "red neck syndrome" is flushing of the face, neck, and upper chest nurse recognizes which of the following clinical associated with too‐rapid IV administration of vancomycin (Vancocin). Hypotension with shock manifestations as a specific response to the drug being (not hypertension) also can result from the histamines released with too‐rapid infusion (option infused too rapidly? 1). Option 2 does not occur. Pseudomembranous colitis (option 4) is the result of a superinfection. ‐ Hypertension ‐ Projectile vomiting ‐ "Red neck syndrome" ‐ Pseudomembranous colitis | Knowing the side effects and client responses of the medication will lead to the correct answer choice. This is the only correct answer, and can be selected if the client responses of the medication are understood. If this was difficult, review the side effects of the medication. |
2895 Tetracycline has been ordered for a 2‐year‐old child. Correct answer: 2 Tetracycline should not be given to children under 8 years of age. The drug forms deposits in What intervention by the nurse is most appropriate? the bone and primary dentition in growing children that can cause underdevelopment of the child's bones and teeth, temporary stunting of the child's growth, and discoloration of the child's teeth. Discoloration of the teeth is not caused by direct contact of teeth with the medication, as can happen with iron preparations (option 1). Since the drug should not be administered to a child under 8 years of age, options 3 and 4 are less important, and therefore incorrect. ‐ Teach the child to drink liquid tetracycline, to avoid discoloration of the teeth. ‐ Collaborate with the prescriber about appropriateness of the order. ‐ Evaluate renal function prior to initiation of therapy. ‐ Administer with 6–8 ounces of water. | In order to select the correct answer, recall the contraindicated population for administration of the medication. Review the contraindications for the medication if this was difficult. |
2896 The nurse teaches a client taking a tetracycline or a Correct answer: 2 Photosensitivity is a side effect of these two classes of antibiotics. The client avoids sun sulfonamide to do which of the following? exposure and tanning beds. Milk and food interferes with effectiveness of the tetracyclines, so tetracyclines are taken on an empty stomach (option 3). These drugs are not associated with increased bleeding or orthostatic hypotension (options 1 and 4). ‐ Have regular evaluation of the prothrombin time (PT) and international rationalized ratio (INR). ‐ Wear long sleeves and long‐legged pants, hat, and sunglasses when in the sunlight. ‐ Take with milk or food, to minimize gastrointestinal disturbances. ‐ Change position slowly, to avoid orthostatic hypotension. | Knowing the side effects of the medication will lead to the correct answer choice. This is the only correct answer, and can be selected if the side effects of the medication are understood. If this was difficult, review the side effects of the medication. |
2897 The preceptor assigned to a new graduate nurse has Correct answer: 2 Shaking the vial of filgrastim (Neupogen) will result in destruction of the medication's protein. delegated him to administer filgrastim (Neupogen) to a Option 1 is unnecessary, and options 3 and 4 are not actions related to the administration of client with cancer. The preceptor directs the graduate this medication. nurse to take which of the following actions related to administration of this medication? ‐ Administer the medication with IV normal saline. ‐ Never shake the bottle, due to destruction of the protein. ‐ Assess the mobilization of stem cells. ‐ Administer before bone marrow transplant is done. | Note that the question is asking which action to take related to administrating the medication. Options 3 and 4 can be eliminated, since they do not address administration of the medication. The correct answer is option 2, since it considers safety as well as administration. |
2898 A client diagnosed with cancer who is receiving Correct answer: 2 The provision of good oral hygiene will reduce the chance of stomatitis, which is common in sargramostim (Leukine) should be instructed to do immunosuppressed clients with cancer, who are in need of this medication. There is no need which of the following? to receive vitamin B<sub>6</sub> concurrently (option 1). Alopecia and elevated blood glucose levels (options 3 and 4) are not related to sargramostim. ‐ Receive vitamin B6 concurrently. ‐ Use good oral hygiene. ‐ Expect alopecia. ‐ Assess blood glucose levels daily. | Note that the client has cancer, and is receiving chemotherapy. Since these clients are high‐ risk for stomatitis, try to prevent this complication of chemotherapy. This should lead to the option 2, which addresses prevention of stomatitis. |
2899 A client with rheumatoid arthritis develops type 1 Correct answer: 2 Monitoring strategies of care, particularly the ability to fill syringes and administer insulin, is a insulin‐dependent diabetes mellitus (IDDM). The nurse nursing priority. Rheumatoid arthritis might limit fine motor movements of the hands that are should make it a priority to make which of the needed for self‐administration of insulin, and this client might need further assistance from following client assessments? family or other caregivers. The assessments in the other options are also important, but the ability to manage medication therapy takes priority. ‐ Response to corticosteroids ‐ Ability to fill syringes and give injections ‐ Ability to exercise | The question is asking for the priority nursing intervention. There are two options listed that would be considered interventions: options 2 and 3. Using the process of elimination, option 2 is the priority, since it also covers safety concerns for the client. |
4.‐ Response to home environment | |
2900 A client who underwent a liver transplant asks the Correct answer: 3 Immunosuppressant agents reduce the client's ability to fight all infections, including nurse why it is necessary to do such frequent mouth inflammation and infection in the mouth (stomatitis). The client is at risk of developing care. The best response by the nurse would be to state infection from organisms normally found in controlled numbers in the oral cavity. The other that it helps prevent the development of which of the options do not relate to this particular effect of immunosuppressants. following client problems? ‐ Dysphagia ‐ Halitosis ‐ Stomatitis ‐ Dental caries | In reviewing the question, note that the client has had a liver transplant, and will need medication to prevent rejection. Recall that one of the side effects from the medications is stomatitis. Having stomatitis requires good oral hygiene. After thinking the question through in this manner, select option 3. |
2901 A client diagnosed with cancer is receiving Correct answer: 2 Sargramostim (Leukine) increases the production of granulocytes and macrophages. It also sargramostim (Leukine) prior to stem cell collection. mobilizes stem cells to allow for stem cell collection. The information contained in the other The client asks the reason for the medication. Which of options does not correctly describe the action of sargramostim. the following would be the best response to the client? ‐ The medication diminishes the number of immature stem cells. ‐ The medication assists in the mobilization of stem cells, allowing for collection. ‐ The medication blocks the body's inflammatory response to an antigen. ‐ The medication suppresses T cell production. | In order to select the correct answer, identify the purpose of the medication. If this was difficult, review the purpose of the medication. |
2902 Tacrolimus (Prograf) is being administered to a client Correct answer: 4 AST and ALT, which are liver enzymes, are important to monitor, since tacrolimus (Prograf) to prevent transplant rejection following organ and other immunosuppressants are hepatotoxic. The other responses do not relate as transplant. Which of the following laboratory studies is specifically to this adverse effect. it of great importance for the nurse to monitor? ‐ LDH and CPK ‐ Uric acid and bilirubin ‐ Alkaline phosphatase and albumin ‐ AST and ALT | Recognize that the medication is metabolized, and therefore toxic to the liver, to be directed to option 4, which features the only liver studies listed in the options. |
2903 During a well‐baby visit, the nurse notes that a child is Correct answer: 2 Hepatitis B is administered in three doses. The second dose follows one month after the first one year late for his third hepatitis B vaccine. What dose, and the third dose is given six months after the original dose. If too much time elapses should the nurse do to correct this? between doses, as in this case, the series might need to be restarted. Options 1 and 4 could result in incomplete or insufficient vaccination. The nurse does not set up immunization schedules independently (option 3). ‐ Give the vaccine now. ‐ Inform the parent that the series will need to be restarted, and consult with the physician. ‐ Inform the parent that the vaccine will need to be given now and in one month. ‐ Inform the parent that two vaccines are sufficient. | Use knowledge of correct administration of immunizations to select the correct answer. Eliminate options 1, 3, and 4, since these are incorrect actions by the nurse. |
2904 An infant girl is brought to the clinic for a well‐baby Correct answer: 1 For all clients, immunizations are contraindicated during a moderate‐to‐severe febrile illness. visit. She is scheduled to receive her second The nurse should withhold the vaccines, and have the mother bring the infant in to receive diphtheria, pertussis, and tetanus (DPT) and H‐flu them after the illness has subsided. The actions in the other responses are incorrect. vaccines, along with her oral poliovirus vaccine. While measuring the infant's weight, the nurse decides that the infant feels warm, and assesses her temperature, which is 101ºF. The nurse should take which of the following actions? ‐ Withhold the vaccines, and reschedule her visit for when she is not febrile. | Use knowledge of correct administration of immunizations to answer this question correctly. Review contraindications to immunization administration if this question was difficult. |
‐ Instruct the mother on vaccine administration, and have her give them tomorrow. ‐ Administer acetaminophen orally, and give the immunizations. ‐ Obtain titers on the needed immunizations, and withhold them until the results are obtained. | |
2905 A client who has multiple sclerosis and receives Correct answer: 4 Cyclophosphamide (Cytoxan) combined with digoxin (Lanoxin) can result in digoxin toxicity, so cyclophosphamide (Cytoxan) and digoxin (Lanoxin) the health care team must continually assess for signs and symptoms of toxicity. Nausea is an complains of nausea. The nurse would place highest early sign of digoxin toxicity, making option 4 the best action. Option 1 does not help the priority on which of the following actions? situation; options 2 and 3 treat the symptom, rather than the problem. ‐ Evaluate the cyclophosphamide level. ‐ Administer an oral antiemetic daily. ‐ Provide six small, frequent meals. ‐ Evaluate the digoxin level. | Note in the question stem that the client is complaining of nausea. This should lead to the answer related to digoxin, since the initial signs of digoxin toxicity are nausea and vomiting. The only correct answer to this question that relates to nausea is answer 4. |
2906 A client is receiving cyclosporine (Sandimmune). The Correct answer: 1 A side effect of cyclosporine (Sandimmune) is hirsutism, so the nurse should assess for signs nurse will need to assess the client for evidence of and symptoms that relate to the nursing diagnosis of Disturbed Body Image. Options 2 and 3 which of the following nursing diagnoses? do not apply to the client with the information given in the question. Option 4 is not a nursing diagnosis. ‐ Disturbed Body Image ‐ Pain ‐ Deficient Fluid Volume ‐ Altered neurological status | Knowing the side effects of the medication will lead to the correct answer choice. Recognize that the question is asking for selection of a nursing diagnosis. If this was difficult, review the side effects of the medication. |
2907 A client exposed to Mycobacterium tuberculosis Correct answer: 1 To prevent active tuberculosis after exposure, the client is initiated on a single‐agent regimen, starts on chemoprophylaxis. The nurse provides what usually isoniazid (INH). For newly diagnosed active disease (option 2), a combination of instruction to the client? antitubercular agents is used for at least the first several weeks: isoniazid (INH), rifampin (Rifadin), and pyrazinamide (Tebrazid). The combination therapy lessens the risk of drug resistance (option 3). Except for streptomycin, which is for IM use, the antitubercular agents are administered orally (option 4). ‐ "You will take a single drug as isoniazid (INH) by mouth every day for 6–12 months." ‐ "You will be on at least two drugs effective against the tubercle bacillus for 3 months." ‐ "You will be on combination therapy in order to prevent development of drug resistance." ‐ "You will need to learn to give yourself subcutaneous injections." | In order to select the correct option, recall the correct administration for the medication. If this was difficult, review administration of chemoprophylaxis to a client exposed to tuberculosis. |
2908 To minimize the pain related to intramuscular (IM) Correct answer: 3 Administration of very thick preparations of drugs, such as penicillin G with benzathine injection of 2 mL of penicillin G benzathine (Bicillin LA) (Bicillin LA), can be painful. To lessen the pain, intramuscular injection into a larger gluteal in the adult, the nurse will take which of the following muscle should be administered over 12–15 seconds, to separate the muscle fibers more actions? gradually. Cold compresses to the injection site would delay absorption of the drug (option 1). Aspiration for blood return with all IM injections is necessary for safety, since muscles contain larger blood vessels (option 4). Injection into the deltoid could also result in prolonged discomfort, resulting in limited motion of the upper extremities (option 2). Rotating sites, light massage, and warm compress to the site may also be employed to limit discomfort. ‐ Apply a cold compress to the site after injection. ‐ Divide the dose, and inject half into each deltoid. ‐ Administer the drug deep IM slowly into a large muscle such as the gluteus. ‐ Limit prolonging the time taken to administer the drug by not aspirating. | This question addresses the principles of safety in the administration of intramuscular (IM) injections. In order to answer this question, recall the principles of IM injections, as well as safety related to the injections. If this was difficult, review the basic principles of intramuscular administration. |
2909 The nurse suspects hepatotoxicity evolving in a dark‐ Correct answer: 4 Jaundice in the dark‐skinned client can best be observed by assessing the hard palate. skinned client who is on an antibiotic. In what area of Normally, fat may be deposited in the layer beneath the conjunctivae that can reflect as a the body should the nurse assess for jaundice? yellowish hue of the conjunctivae and the adjacent sclera in contrast to the dark periorbital skin. In these clients, palms and soles might appear jaundiced, but instead, calluses on the surface of their skin can make the skin appear yellow. ‐ Palms ‐ Sclera ‐ Conjunctivae ‐ Hard palate of the oral cavity | Note that the question is referring to liver toxicity, which would appear as jaundice. Recall that assessment involves looking in the client s mouth for skin discoloration. If this was difficult, review alterations to physical assessment. |
2910 The nurse assesses the results of a vancomycin Correct answer: 4 A serum specimen for peak level is drawn 15–30 minutes after IV administration, to test for (Vancocin) blood level drawn just prior to the next toxicity. Trough drug levels are drawn just prior to administration of the next IV dose, to scheduled intravenous (IV) dose. The nurse would measure whether satisfactory therapeutic levels are being maintained. If the peak is too high, collaborate with the prescriber if which of the toxicity can occur, and the dose needs to be reduced, and/or the frequency of administration following occurs? extended. If the trough is too low, then the dosage and/or frequency of administration need to be increased. ‐ There is a high serum level, indicating the peak level is too high. ‐ This test measures the highest therapeutic concentration, and it is low. ‐ Toxicity is evident, suggesting the drug's half‐life is too short with the frequency prescribed. ‐ The drug level is low, indicating the drug dosage and/or frequency should be increased to maintain therapeutic blood levels between doses. | In order to answer this question correctly, recall the definition and purposes of peak and trough levels of medications. If this was difficult, review the purposes of peak and trough levels. |
2911 The nurse observes cream‐colored or bluish‐white Correct answer: 1 Candidiasis may be treated with oral antifungal agents. The vaginal tablet used as a lozenge patches of exudates on the client's tongue and delivers a slow rate of dissolution over 15–30 minutes, which extends the length of contact pharyngeal mucosa. The nurse gently scrapes these with infected areas; the client is to swallow the saliva, but not to chew or swallow the troche plaques, and erythema appears. What intervention whole. The troche can be offered one‐half at a time, if needed. If the client wears dentures, does the nurse anticipate as being the most they are to be soaked overnight in oral suspension of the antifungal agent to destroy the therapeutic? fungus on the dentures and prevent reinfection (option 2). Rinsing the mouth frequently with warm sodium chloride solution may be palliative, not therapeutic or curative, but should not be performed when the antifungal agent is still in contact with the oral mucosa (option 3). The oral antifungal therapy must continue for 48 hours after signs and symptoms have been resolved in order to prevent relapse (option 4). ‐ Provide prescribed nystatin (Mycostatin) vaginal troche as a lozenge. ‐ If the client wears dentures, provide nystatin (Mycostatin) swish and swallow. ‐ Rinse the client's mouth every four hours with warm sodium chloride solution. ‐ Collaborate with the prescriber for oral antiprotozoan agent just until clinical manifestations are resolved. | Recognize that the description in the question stem is that of a fungus. After scraping the tongue fails to remove the plaques, the nurse should be alerted to the need to provide an antifungal medication. Use the process of elimination to be directed to option 1, which lists an antifungal as a source of treatment. |
2912 The nurse administering chloramphenicol Correct answer: 1 Both of these drugs can cause bone marrow depression, adversely affecting the immune (Chloromycetin) and methylprednisolone (Solu‐ system. The glucocorticosteroids also can mask clinical manifestations of infection. Observe for Medrol) concurrently for meningitis would assess for paleness; capillary refill greater than 3 seconds; sore throat; suprapubic pain or pressure; low which of the following? back pain; low‐grade fever; bruising; bleeding; petichiae; and fatigue. Serum levels of chloramphenicol (Chloromycetin) should be maintained in the range of 10–25 µg/mL. (More than 30 µg/mL increases risk for bone marrow depression.) Hypercalcemia is more likely than hypocalcemia to occur as an adverse effect of steroid therapy (option 3). Taste alterations and hallucinations are not particular adverse effects of these agents (options 2 and 4). ‐ Occult signs of infection ‐ Taste alteration affecting nutrition ‐ Chvostek's sign, indicating hypocalcemia ‐ Psychotropic effect, including hallucinations | Knowing the side effects of the medication will lead to the correct answer choice. If this was difficult, review the side effects of the medication. |
2913 The nurse who administers ketoconazole (Nizoral) for Correct answer: 1 Food will stimulate secretion of gastric enzymes, increasing the gastric acid environment, optimal gastrointestinal absorption will administer the which is needed for absorption of ketoconazole. Water will not stimulate gastric secretions drug with which of the following? (option 2). Antacids and H<sub>2</sub> histamine blockers should be avoided, or ketoconazole (Nizoral) should be given one hour before or two hours after these agents (options 3 and 4). ‐ Food ‐ Water ‐ Antacids ‐ An H2 histamine blocker | In the question stem, the priority words are gastrointestinal absorption. Since food stimulates gastric secretions, absorption will be increased. This is the only correct answer. Recognize that the other options will not assist with gastrointestinal absorption. |
2914 A client is to start on sulfamethoxazole (Gantanol) for Correct answer: 3 The nurse ensures the urine specimen for C & S is collected prior to the initial a urinary tract infection (UTI). What priority nursing administration of the urinary tract anti‐infective agent, so that the causative microorganism intervention precedes administration of the first dose? and the anti‐infectives to which the organism is sensitive can be identified. The results of the urine C & S will become available in several hours, but delaying anti‐infective therapy could cause the UTI to worsen (option 4). If the results of the test do not affirm the drug's efficacy, the nurse will collaborate with the prescriber. Checking the bilirubin would be appropriate only if attempting to differentiate the cause of existing jaundice as being hepatic impairment or hemolysis (option 1). The urine specimen should be a clean‐catch or catheterized specimen for more accurate results (option 4). Option 2 is not essential prior to initiating drug therapy. ‐ Check the bilirubin level. ‐ Have client empty her bladder. ‐ Ensure that a urine specimen for culture and sensitivity (C & S) has been obtained. ‐ Analyze results of a random voided urine specimen for culture and sensitivity. | The question is asking for selection of the priority intervention. To make certain that a client is being given the correct medication for the infection, a C & S must be performed before beginning the medication. The other options are incorrect when considering the priority intervention. |
2915 A client taking amoxicillin (Amoxil) experiences eight Correct answer: 3 The client is demonstrating classic clinical manifestations of pseudomembranous colitis. It is watery stools in the past eight hours, with abdominal important to identify whether this is a superinfection caused by C. difficile. Cisapride tenderness and cramping and fever. The nurse (Propulsid) is a GI stimulant, and would not be indicated as therapy for this condition (option anticipates performing what specific intervention 1). Hepatotoxicity and diet are not directly related to pseudomembranous colitis (options 2 related to these clinical manifestations? and 4). ‐ Administering cisapride (Propulsid) to stimulate GI motility to effectively remove toxins ‐ Analyzing liver enzymes for evidence of hepatotoxicity ‐ Collecting stool specimen for <i>Clostridium difficile</i> ‐ Teaching the client to reduce the fat in his diet | Knowing the classical symptoms of Clostridium difficile will lead to the only correct answer. The specific intervention relates to the symptoms of watery stools. Option 3 is the correct answer listing the collecting of stools to determine if the client has Clostridium difficile. |
2916 A client is receiving ciprofloxacin (Cipro). To intervene Correct answer: 3 Because ciprofloxacin can cause photosensitivity, clients are advised to use sunscreen, wear appropriately, the nurse utilizes which of the following protective clothing, and limit exposure to sunlight, especially since sunscreens might not information about this medication? protect the skin from this type of reaction. When Cipro first became available, it was believed it would be effective against MRSA, but resistance has developed (option 2). Cipro is processed through the liver and kidneys for elimination (option 1). Renal failure does extend the half‐life of each of the fluoroquinolones. Ciprofloxacin achieves serum levels that are effective against several systemic infections caused by gram‐negative bacilli (option 4). ‐ Ciprofloxacin is eliminated in the bile, so dosages do not need to be adjusted for clients with renal impairment. ‐ Ciprofloxacin is one of the few antibiotics demonstrating efficacy against methicillin‐resistant staphylococcus aureus (MRSA). ‐ Sunscreen or sunblock applications might not prevent sunburn in clients receiving ciprofloxacin. ‐ Ciprofloxacin is effective in treating urinary tract infections, but not systemic infections. | Knowing the side effects of the medication will lead to the correct answer choice. If this was difficult, review the side effects of the medication |
2917 Following the administration of an MMR vaccine, the Correct answer: 2 The nurse should assess for signs and symptoms of hypersensitivity reaction following the nurse should make a priority assessment for which of administration of all vaccines. Wheezing is a sign of hypersensitivity reaction, and warrants the following client manifestations? immediate further assessment and emergency action to prevent possible death. Local discomfort (option 1) may be expected, and is treated, if necessary, with acetaminophen. Anxiety and vomiting (options 3 and 4) are not associated with administration. ‐ Pain ‐ Wheezing ‐ Anxiety ‐ Vomiting | Note that the question stem asks for selection of a priority assessment. Immediately after administration of a medication, the priority assessment must relate to hypersensitivity. Hypersensitivity in a client is usually manifested with respiratory symptoms. This symptom is present in option 2, which is the correct answer. |
2918 Following a liver transplant, the nurse should instruct Correct answer: 4 Liver function includes the regulation of blood clotting. Thus, the client should be instructed the client to make it a priority to report which of the to report signs and symptoms of increased bleeding. Option 1 is a side effect of following signs and symptoms to the health care corticosteroids, but is not the priority from a physiological basis. Options 2 and 3 do not reflect provider? the vascularity of the liver and the associated risk of bleeding. ‐ Moon face ‐ Diminished pigmentation ‐ Dysphagia ‐ Bleeding | The question is asking for the priority physiological state that a client is experiencing. Also note that the client had a liver transplant. Since liver function involves blood clotting, bleeding as stated in option 4 would be the correct priority that the client should report. |
2919 A 3‐month‐old infant is diagnosed with leukemia. Correct answer: 3 Immunizations should be withheld during leukemia exacerbations, because the immune Which of the following does the nurse anticipate will system is compromised, and the client cannot manage an appropriate response to the be part of the plan of care for this infant? immunization. There is no need to place the client in isolation without added evidence of immunosuppression (option 1). Options 2 and 4 are irrelevant to the issue of the question. ‐ The baby will be placed in isolation. ‐ Leukemia is familial, and other children should be assessed. ‐ All immunizations will be withheld during exacerbations. ‐ The baby will be NPO during chemotherapy. | In planning the care and reviewing the possible answers for an infant diagnosed with leukemia, eliminate options 2 and 4, as they do not relate to what is stated in the question stem. Option 1 can also be eliminated, because there is no evidence in the question stem that the infant is immunosuppressed. This would allow selection of the correct option, 3. |
2920 Following the administration of a Correct answer: 1 An inspiratory stridor is indicative of a hypersensitivity reaction to the DPT immunization, and diphtheria/pertussis/tetanus (DPT) immunization, the epinephrine should be administered to counteract the symptoms of the allergic response. nurse notes that the infant has an inspiratory stridor. Options 2 and 3 are irrelevant, and option 4 places the infant at risk for injury or death. The nurse should take which of the following actions? ‐ Administer epinephrine as per protocol orders. ‐ Evaluate for pulmonary edema. ‐ Inspect for periorbital edema. ‐ Assess the baby again in 15 minutes. | Note that the question stem asks for selection of a priority action. Immediately after administration of a medication, the priority action must relate to hypersensitivity. Hypersensitivity in a client is usually manifested with respiratory symptoms, and the action is relief of the symptoms, which would lead to option 1. |
2921 A client who is taking cyclophosphamide is Correct answer: 1 Dysuria and bleeding are consistent with hemorrhagic cystitis, an adverse effect of complaining of dysuria and bleeding. The nurse draws cyclophosphamide. These data should be reported to the physician or nurse practitioner. The which of the following conclusions? other options represent incorrect conclusions from the manifestations listed. ‐ This is a side effect of cyclophosphamide. ‐ This is due to a medication interaction with ibuprofen. ‐ The client has an increased risk for renal calculi, which is causing the symptoms. ‐ The client is exhibiting signs and symptoms of renal failure. | Knowing the side effects of the medication will lead to the correct answer choice. If this was difficult, review the side effects of the medication. |
2922 A nursing student requires a rubella immunization Correct answer: 3 Women of childbearing age should not become pregnant for three months after receiving a prior to beginning a clinical rotation in a local health rubella immunization. The other options are incorrect statements regarding aftercare care facility. The health center nurse will need to following rubella immunization. instruct the student to do which of the following? ‐ Apply ice to the injection site. ‐ Have a titer drawn in three days. ‐ Avoid getting pregnant for at least three months. ‐ Delay beginning clinical for three weeks. | After administration of the immunization, teaching points should be given to the client. Knowing that rubella has the potential to be teratogenic to a fetus will lead to the correct answer, option 3. |
2923 A client with myasthenia gravis contracts poison ivy, Correct answer: 2 Prednisone is a corticosteroid medication. When corticosteroids are given with medications and is started on prednisone by mouth to decrease to treat myasthenia gravis, they decrease the effect of anticholinesterase medications. inflammation. The nurse will need to instruct the client Because of this, symptoms of the disease could reappear, including respiratory difficulty. The to do which of the following? other options do not address the interactive effects of these medications. In addition, the nurse does not instruct a client to change a dose of a medication (option 4). ‐ Eat small, frequent meals. ‐ Be aware of any respiratory difficulty, and notify the health care provider. ‐ Expect increased libido. ‐ Decrease her usual dose of neostigmine until after the prednisone is finished. | Knowing the pathophysiological disease process of myasthenia gravis and complications associated with it will assist in selecting the correct answer. If this was difficult, review the complications associated with myasthenia gravis. |
2924 When teaching a client about medication therapy for Correct answer: 3 Gold salts suppress the activity produced by prostaglandins that contributes to the rheumatoid arthritis, the nurse would incorporate destruction of joints. The statements in the other options do not reflect the action of this type which of the following points about gold salts in the of medication. discussion? ‐ They increase glycoproteins to stimulate neutrophil production. ‐ They increase sedimentation rate and reduce stiffness. ‐ They decrease prostaglandin activity that contributes to joint destruction. ‐ They decrease immunoglobulin to suppress arthritic symptoms. | In order to select the correct answer, recall the action and client responses to the medication, gold salts. If this was difficult, review the action of the medication. |
2925 To decrease the possibility of hepatotoxicity in a Correct answer: 4 Because of hepatotoxic effects of azathioprine and alcohol, the two substances should not be woman taking azathioprine (Imuran) to treat systemic administered together. Thus, the client should be instructed to avoid products containing lupus erythematosus, the nurse should instruct the alcohol. The client should not take acetaminophen, which is also toxic to the liver (option 1). client to do which of the following? Azathioprine should not be taken with grapefruit juice (option 2), which reduces the drug's effectiveness. Option 3 is a good general measure, but does not address the issue of hepatotoxicity. ‐ Take acetaminophen (Tylenol) for pain. ‐ Take azathioprine with grapefruit juice. ‐ Prevent exposure to infection. ‐ Avoid the use of alcohol. | The question stem mentions decreasing the possibility of hepatotoxicity. Considering that alcohol has a direct effect on the liver, this would be the correct answer choice. The other 3 options are incorrect, and should not be taught to the client. |
2926 When teaching the client measures to prevent a Correct answer: 4 The implementation of a high‐fiber diet will reduce the risk of constipation, a common side common side effect of filgrastim (Neupogen), the effect in clients taking filgrastim (Neupogen). Option 1 is hazardous because it could cause nurse should instruct the client to do which of the dependency in the client. Option 2 indicates an insufficient amount of fluids to maintain following? regular bowel function. Option 3 is irrelevant to the issue of the question. ‐ Take a laxative daily. ‐ Drink 1,000 mL per day. ‐ Eat a high‐protein diet. ‐ Eat a diet high in fiber. | Knowing the side effects of the medication will lead to the correct answer choice. If this was difficult, review the side effects of the medication. |
2927 The nurse instructs the client receiving chemotherapy Correct answer: 4 A client with thrombocytopenia should avoid activities that could result in injury and bleeding. to avoid what risk associated with thrombocytopenia? For this reason, the client should avoid trimming the nails with a nail clipper, and should use a nail file instead. Option 3 indicates the safe method for shaving; straight razors should be avoided, but electric razors are acceptable. Not all clients with thrombocytopenia also experience concurrent leukopenia. Options 1 and 2 should be avoided to minimize risk of infection, or when the client s white blood cell count is low. ‐ Being near individuals with upper respiratory infection ‐ Keeping fresh flowers and plants in the home ‐ Shaving with an electric razor ‐ Trimming nails with a nail clipper | The core issue of the question is safety measures for chemotherapy‐induced thrombocytopenia. Use nursing knowledge and the process of elimination to make a selection. |
2928 A newly registered nurse asks the nurse preceptor Correct answer: 3 Upon graduation, the registered nurse has attained adequate knowledge to manage standard what qualifications are needed in order to administer clinical problems. Before accepting an assignment to administer chemotherapy, the nurse chemotherapy agents. The nurse preceptor should should receive additional education on the management of treatment side effects, reply that a requirement is to: pharmacology, administration principles, and safe handling. Although a bachelor s degree and one year of clinical experience might be helpful, they are not required to safely administer chemotherapy. Certification in oncology nursing does not imply skill or knowledge of chemotherapy administration procedures. ‐ Hold a bachelor s degree in nursing. ‐ Be certified by an approved chemotherapy administration program. ‐ Be certified as an oncology nurse. ‐ Have at least one year of clinical experience after graduation. | The core issue of the question is prerequisite qualifications to administering chemotherapy. Make your selection based on knowledge that this is a specialized skill requiring additional certification. |
2929 During an intravenous (IV) push administration of Correct answer: 2 It is not uncommon to lose a blood return during IV administration of a vesicant. doxorubicin peripherally into client’s left forearm, the Repositioning the IV will only ensure infiltration due to manipulation. Restarting the IV gives no nurse becomes unable to obtain a blood return. The assurance that the blood return will not be lost again. Clients can experience extravasation client has no complaints of discomfort at the site, and without pain, but not without swelling. With no evidence of swelling or pain, it is safe to flush no swelling is noted. The nurse should take which of with 20 30 c mL of saline to ensure an extravasation has not occurred. the following actions? ‐ Remove the IV catheter, and restart it at another site. ‐ Flush the IV with saline, to ensure no extravasation has occurred. ‐ Reposition the needle, in hopes of obtaining a blood return. ‐ Since the client has no complaint of pain, continue the administration. | The core issue of the question is safe nursing practice relative to administration of IV medications that are chemotherapeutic agents. Choose the option that is safest in avoiding harm to the client if the line is infiltrated after losing a blood return. Eliminate options 3 and 4 first because they are potentially dangerous. Choose option 2 over 1 because option 1 might be unnecessary and excessive at this point. |
2930 The nurse should become concerned about which of Correct answer: 1 Prolonged diarrhea without adequate management will cause dehydration, nutritional the following risks to a client receiving chemotherapy malabsorption, and circulatory collapse. Option 2 can accompany diarrhea, but is not a who had prolonged diarrhea at home without resulting clinical problem. Options 3 and 4 do not result from untreated diarrhea. adequate management? ‐ Malnutrition ‐ Increased gastric motility ‐ Insidious weight gain and jaundice ‐ Renal failure | The core issue of the question is knowledge of complications of side effects from chemotherapeutic agents. Recall that nausea and vomiting deplete both fluid volume and nutrients. Make the selection that is consistent with one of these, which is option 1. |
2931 The nurse would apply which of the following clinical Correct answer: 1 Delayed nausea may occur 24–48 hours after chemotherapy administration, primarily due to labels to nausea and vomiting experienced by a client the ongoing effect that the metabolites exert on the CNS or GI tract. Despite effective 24 hours after chemotherapeutic drug administration antiemetic regimens, 93% of clients receiving cisplatin experience delayed nausea. Anticipatory with cisplatin (Platinol)? nausea occurs in approximately 25% of clients due to the classic conditioning response from prior therapy. Acute nausea occurs 1–2 hours after chemotherapy administration. 1.‐ Delayed nausea and vomiting | The critical words in the stem of the question are 24 hours after. From there, evaluate each option in terms of time frame. Eliminate options 2 and 3 because they are focused on the present, and eliminate option 4 because it is future‐oriented related to the chemotherapy administration. |
‐ Retching ‐ Acute nausea and vomiting ‐ Anticipatory nausea and vomiting | |
2932 The client is receiving chemotherapy with fluorouracil Correct answer: 4 Both 5‐FU and radiation therapy to the abdomen can cause diarrhea. Alopecia is uncommon (5‐FU) and concurrent radiation therapy to the with 5‐FU, and only occurs with irradiation to the skull. Some myelosuppression could result, abdomen for colon cancer. The client is at greatest risk but is not the greatest risk. Peripheral neuropathy is not related to either therapy. for developing which of the following adverse effects? ‐ Peripheral neuropathy ‐ Alopecia ‐ Thrombocytopenia ‐ Diarrhea | Note that the stem of the question contains the critical words greatest risk. This tells you that multiple options are correct, and that you must prioritize your answer. Choose the option that is a lower GI symptom, which is the area that both chemotherapy and radiation therapy will target. |
2933 The nurse would assess for pulmonary toxicity in a Correct answer: 4 Pulmonary toxicity is a dose‐ and age‐related toxic effect of bleomycin. Cardiotoxicity is a client receiving which of the following toxic effect of doxorubicin. Vincristine causes neurotoxicity. Cytoxan can cause hemorrhagic chemotherapeutic agents? cystitis. ‐ Doxorubicin (Adriamycin) ‐ Vincristine (Oncovin) ‐ Cyclophosphamide (Cytoxan) ‐ Bleomycin (Blenoxane) | The core issue of the question is knowledge of toxicity caused by bleomycin. If you associate the bl in bleomycin with the color blue for cyanosis, this might help you to recall that this drug causes pulmonary toxicity. |
2934 A client receiving cyclophosphamide (Cytoxan) as Correct answer: 2 Although painful urination, dysuria, suprapubic pain, and blood‐tinged urine can occur when a treatment for cancer experiences painful urination, client experiences a urinary tract infection, in the oncology client receiving Cytoxan or Ifex, the dysuria, suprapubic pain, and blood in the urine. The cause is usually chemically induced. A decreased platelet count might cause blood in the urine, nurse determines that these classic signs are but rarely causes the other symptoms. Renal dysfunction usually does not cause anuria. compatible with which of the following problems? ‐ Thrombocytopenia ‐ Hemorrhagic cystitis ‐ Renal dysfunction ‐ Urinary tract infection | The core issue of the question is knowledge of toxicity caused by cyclophosphamide. If you associate the cy in cyclophosphamide or Cytoxan with the beginning of the word cystitis, this might help you to recall that this drug can lead to hemorrhagic cystitis. |
2935 For what major risk factors influencing gonad toxicity Correct answer: 2 The likelihood that chemotherapy will affect a client s fertility depends in part on the client s would a nurse assess in a client who is receiving gender and age, and on the specific agent. Since chemotherapy affects rapidly dividing cells, chemotherapy drugs? men are more affected than women. Women over 30 are less likely to regain ovarian function, because they have fewer oocytes. ‐ Renal function, specific agents, and blood levels of chemotherapeutic drugs ‐ Gender, age, and specific agents ‐ Renal function, blood levels of drugs, and age ‐ Age, blood levels of drugs, and gender | The critical word in the stem of the question is gonad. From there, eliminate the options that refer to renal function (options 1 and 3). Choose option 2 over 4 because not all agents have the same degree of gonadal toxicity. |
2936 The nurse suspects that a client receiving Correct answer: 3 One of the most serious consequences of cancer is that the treatment intended to cure the chemotherapy with which of the following classes of client can contribute to the occurrence of a second malignancy. The alkylating agents, drugs is most likely to be at risk for developing a nitrosoureas, and procarbazine are the agents most likely to cause chemotherapy‐related second malignancy? malignancies. ‐ Antimetabolite ‐ Taxane ‐ Alkylating agent ‐ Vinca alkaloid | The core issue of the question is knowledge of chemotherapeutic agents that cause added risk for future malignancy. Specific knowledge of the drug classes is needed to answer the question. Use this knowledge and the process of elimination to make a selection. |
2937 The nurse caring for a client receiving chemotherapy Correct answer: 4 Educating clients to manage treatment side effects so that their treatment programs can incorporates which of the following practices into the remain on course is an essential function of nursing. Although the nurse should review routine for the day’s work shift? laboratory values before administering chemotherapy, it is the physician’s responsibility to make dose reductions. Only a pharmacist can dispense medications. It is inappropriate to influence the client’s decision making related to alternative treatment options. ‐ Determine if dosage reductions should be made based on the client’s laboratory values. ‐ Dispense the drugs that are part of the treatment regimen for the client. ‐ Encourage the client to consider alternative nonpharmaceutical treatment options. ‐ Educate the client about how to manage treatment side effects to maintain dose intensity. | The core issue of the question is knowledge of the nurse’s role related to chemotherapy that is prescribed for a client. Use general nursing knowledge and the process of elimination to make a selection. |
2938 Which of the following is the most appropriate Correct answer: 2 Since many chemotherapeutic agents can cause ototoxicity, continued administration could nursing diagnosis for a client who has experienced cause irreparable hearing loss. Clients can become anxious when their hearing is ototoxicity as a result of chemotherapy compromised. The hearing loss is not related to cerebral blood flow, and there is no pain administration? related with the condition. Hearing deficits are unrelated to skin integrity. ‐ Chronic Pain related to side effects of chemotherapy ‐ Anxiety related to potential or actual sensory loss secondary to chemotherapy ‐ Risk for Ineffective Tissue Perfusion related to decrease in cerebral blood flow ‐ Risk for Impaired Skin Integrity related to decreased cerebral blood flow | The core issue of the question is the ability to translate the label ototoxicity into a working nursing diagnosis that can be used to guide nursing care. Use general nursing knowledge and the process of elimination to make a selection. |
2939 A client who is 90 years old is exhibiting altered Correct answer: 4 The nurse should be specific when addressing a confused/disoriented client. In options 1 and mental status after chemotherapy with a neurotoxic 2, questions about the environment and the need to make choices might be too challenging, agent. Which of the following statements provides the and could decrease the client s self‐esteem. Option 3 provides irrelevant information. most appropriate reality orientation when the client first awakens in the morning? ‐ “Do you remember who I am, or what day it is? Would you like to write it down, so you can refer to it later?” ‐ “Did you sleep well? Which gown would you prefer to wear today, the pink or the blue?” ‐ “Today is Tuesday, and we will be having pancakes and sausage for breakfast.” ‐ “This is your second day in St. Elizabeth’s hospital. My name is Susan, and I will be your nurse for today.” | The core issue of the question is communication techniques that will be most effective in a client who has experienced confusion secondary to neurotoxicity. Use knowledge of general communication techniques and the process of elimination to make a selection. |
2940 In teaching the client receiving a continuous Correct answer: 4 The client should assess the oral cavity daily (not weekly) when receiving chemotherapy. A fluorouracil (5‐FU) infusion, the nurse should instruct low‐residue, semi‐soft diet does not prevent stomatitis, but might decrease diarrhea. White the client about the importance of an oral care patches on the mouth or tongue should be reported to the physician so that an antifungal protocol, including which of the following statements? agent (Nystatin) can be prescribed. The patches should not be manually removed, because doing so will cause bleeding of the mucous membranes. ‐ “Assess the inside of your mouth weekly.” ‐ “Remove white patches with your toothbrush, and apply a lanolin‐based jelly.” ‐ “Eat a low‐residue, semi‐soft diet to prevent stomatitis.” ‐ “Call your doctor if white patches appear on your tongue or mouth.” | The core issue of the question is knowledge of oral assessment protocols for a client receiving chemotherapy. Use knowledge of the signs and symptoms of stomatitis and fungal infection to choose option 4 over the others, which do not allow for appropriate recognition (option 1) or treatment (options 2 and 3). |
2941 The nurse is developing a plan of care for a client who Correct answer: 2 Client education is a nursing intervention, and does not require a physician s order. Although will receive chemotherapy with a neurotoxic agent. the nurse should assess client readiness, education related to chemotherapeutic agents should The nurse plans to implement client and family occur before the treatment is administered, rather than when the symptoms develop. If the education regarding these side effects at what client does not want to receive education, then the nurse should educate the caregiver. appropriate time? ‐ When the client requests it ‐ Before the treatment begins ‐ When the symptoms occur ‐ When the physician requests client education | The core issue of the question is appropriate timing of client and family teaching related to adverse effects of chemotherapy. Recall that a principle of client education is to conduct teaching about a problem beforehand whenever possible. This will easily help you to choose option 2 over the others. |
2942 Which of the following is an important intervention in Correct answer: 2 Broad‐spectrum antibiotics may be ordered for a client according to individual client a client receiving chemotherapy who has an absolute circumstances when the client is notably neutropenic, and at great risk of infection. A rectal granulocyte count (AGC) of less than temperature should not be performed on a neutropenic client. The neutropenic client should 500/mm<sup>3</sup>? avoid fresh fruits and vegetables. A daily bath will remove pathogens from the skin and decrease their potential for causing infection. ‐ Assess the client s rectal temperature every four hours. ‐ Administer broad‐spectrum antibiotics according to physician orders. ‐ Encourage intake of fresh fruits, to increase potassium level. ‐ Avoid bathing for two days, to reduce risk of skin irritation. | The core issues of the question are recognition that the client is neutropenic and selection of an appropriate action. Eliminate options 3 and 4 first because they increase the risk of infection. Then choose option 2 over 1 because it focuses on infection instead of possible bleeding as the risk. |
2943 Which of the following nursing interventions should Correct answer: 3 Avoiding fatty, spicy foods will often decrease nausea related to chemotherapy. Avoiding be the highest priority of the oncology nurse to nutrition before treatments should be discouraged, and has little to no benefit. Salty foods decrease nausea in a client receiving chemotherapy? might help, but potato chips are also high in fat. Antiemetics should be administered on a scheduled basis, not after vomiting has already occurred. ‐ Avoid oral nutrition 24 hours before chemotherapy administration. ‐ Encourage the client to eat salty snacks, such as potato chips. ‐ Encourage the client to avoid fatty or spicy foods. ‐ Administer an antiemetic each time vomiting is experienced. | The core issue of the question is knowledge of methods to reduce nausea and vomiting in a client receiving chemotherapy. Recall that fatty and spicy foods can aggravate nausea to help you make the appropriate selection. Note also that options 2 and 3 are opposite in terms of dietary fat, which is a clue that one of them might be the correct answer. |
2944 The nurse would explain to a client receiving which of Correct answer: 2 A common complaint of clients receiving nitrogen mustard, cisplatin, and cyclophosphamide the following chemotherapeutic agents that the drug is a metallic taste. Some clients become so sensitized to this taste that they become nauseated could cause a metallic taste during administration, and in anticipation of their administration. Sucking on peppermints during administration might lead to taste changes? help. None of the other drugs listed are known to cause this problem. ‐ Etoposide (VP‐16) ‐ Cyclophosphamide (Cytoxan) ‐ Doxorubicin (Adriamycin) ‐ Prednisone (Deltasone) | The core issue of this question is knowledge of chemotherapeutic agents that cause metallic taste as a side effect of therapy. Specific medication knowledge is needed to answer this question. Use the process of elimination to make a selection. You might be able to partially remember this by realizing that Cytoxan and tongue both have the letters to. |
2945 The nurse would assess the client receiving bleomycin Correct answer: 3 The cardinal sign of pulmonary toxicity is dyspnea, which can be present both on exertion and (Blenoxane) as treatment for cancer for which of the at rest. The client also might have generalized fatigue and respiratory acidosis, but these are following cardinal symptoms of pulmonary toxicity? not cardinal signs. A client does not have absence of breath sounds in upper lobes with pulmonary toxicity. ‐ Absent breath sounds in upper lobes ‐ Generalized fatigue ‐ Dyspnea on exertion and at rest ‐ Respiratory acidosis on arterial blood gases | The core issue of the question is recognition of manifestations of pulmonary toxicity in a client receiving chemotherapy for cancer. The critical word cardinal tells you that multiple options might be partially or totally correct, and you must prioritize your answer. Recall that a classic sign of respiratory distress or pulmonary toxicity is dyspnea to help you to prioritize this answer over the others. |
2946 The oncology nurse assesses a client receiving Correct answer: 1 Cardiomyopathy occurs in 40% of clients receiving anthracycline chemotherapy agents. While chemotherapy for what most well‐known and common other cardiac problems can occur, cardiomyopathy is by far the most common. chronic cardiac toxicity? ‐ Cardiomyopathy ‐ Asymptomatic bradycardia ‐ Hemorrhagic myocardial necrosis ‐ Coronary artery spasm | The critical words in the stem of the question are most ... common. This tells you that more than one option might be partially or totally correct, and that you must prioritize your answer. Use medication knowledge and the process of elimination to make a selection. |
2947 Neurological assessment is an important parameter Correct answer: 3 A decreased Achilles reflex is the earliest sign of neuropathy. Other assessment findings listed when administering plant (vinca) alkaloids. Which of are adverse medication effects that occur later in the trajectory of toxicity. the following assessed by the nurse indicates an early warning sign of pending impairment? ‐ Confusion ‐ Short‐term memory loss ‐ Depression of the Achilles reflex ‐ Decreased hand‐grasp strength | Recall knowledge of neuropathy signs and symptoms, and use the process of elimination to be led to the correct answer. |
2948 Which of the following items should be included in Correct answer: 3 Exercise strengthens cardiac muscle, increasing function. Dexrazoxane protects the cardiac the therapeutic management to prevent doxorubicin‐ muscle against the toxic effects of doxorubicin. The other options do not apply to this related congestive heart failure from cardiotoxicity in a situation. client who has cancer? ‐ Exercise and smoking cessation ‐ Smoking cessation and oxygen administration ‐ Exercise and administration of dexrazoxane (Zinecard), a cardioprotective antidote ‐ Oxygen administration and a low fat‐diet | In the question stem, there is no mention that the client needs smoking cessation; therefore, options 1 and 2 can be eliminated. Oxygen administration is not mentioned in the question either, and so option 4 can also be eliminated. |
2949 A client is receiving chemotherapy that has Correct answer: 2 With pursed‐lip breathing, back pressure is created to keep the airways open. This promotes pulmonary toxicity as an adverse effect. Which of the a more complete exhalation, and facilitates removal of secretions from the bronchial tree. The following breathing techniques is important to teach methods outlined in the other options do not achieve this effect. the client to improve the efficiency of breathing? ‐ Exhaling through the nose ‐ Exhaling through pursed lips ‐ Exhaling one half, and then inhaling ‐ Exhaling using accessory muscles | The only correct answer to this question is option 2. Recall knowledge that pursed‐lip breathing is the most effective in keeping the airways open. |
2950 The nurse assesses for chemotherapy‐induced Correct answer: 2 Pulmonary toxicity is a known adverse effect of bleomycin. The other responses are incorrect. pulmonary toxicity in a client receiving which of the It is helpful to think of "blue for bleomycin" to recall that it has adverse respiratory effects. following antineoplastic agents? ‐ Fluorouracil (5‐FU) ‐ Bleomycin (Blenoxane) ‐ Etoposide (Vepesid) ‐ 6‐mercaptopurine (Purinethol) | Recall the side effects of the antineoplastic agents listed. If this was difficult, review side effects of the medications. |
2951 A nurse is administering chemotherapy to a group of Correct answer: 2 Intact skin is the body's first defense against infection. Although altered mucous membranes clients. The nurse implements measures to reduce the are uncomfortable, and can affect the client's self‐image, they are not the most important risk of mucositis for which most important of the reasons. Occurrence of mucositis has no relationship to cancer recurrence. following reasons? ‐ To increase comfort ‐ To decrease infection ‐ To improve self‐image ‐ To reduce cancer recurrence | Note the word mucositis in the question. The suffix “‐itis” would indicate an inflammatory process. Recognize this to be directed to an answer that lists infection, which is option 2. |
2952 Which of the following clients is most likely to Correct answer: 1 A client's prior nausea history is indicative of her individual nausea threshold, and is predictive experience chemotherapy‐induced nausea? of how chemotherapy‐induced nausea will be handled. Women are at higher risk for developing chemotherapy‐induced nausea than are men. | In answering this question, be aware that a person s susceptibility to nausea is dependent on the past history. In looking at the answers, the one client who had the most significant nausea is option 1, which is the correct selection. The others should be eliminated, since they have less history of nausea than the priority option 1. |
‐ A mother of two who experienced severe morning sickness during both of her pregnancies ‐ A navy pilot who experienced motion sickness as a child ‐ A 38‐year‐old male who has alcoholism ‐ A young woman with no significant history of emesis | |
2953 Which of the following interventions should the nurse Correct answer: 3 Since most clients become septic from organisms on their skin and in their environment, plan to use for a client experiencing neutropenia? meticulous hygiene is the best way to prevent infection. An indwelling catheter is a source of infection, and should be used only if the client is immobile, and has a high risk for skin breakdown. Dressings should cover all open wounds to prevent contamination. Long‐term catheters should be flushed after use or Q 8 hours, to prevent clotting; however, this will not decrease the client's risk for infection. ‐ Insert an indwelling urinary catheter to maintain accurate intake and output. ‐ Leave all wounds open to the air, for better healing. ‐ Encourage daily hygiene, regular oral care, and perineal care after each stool. ‐ Flush all lumens of a long‐term catheter with heparinized saline every eight hours. | Remembering that interventions should be based on least invasive to most invasive will allow elimination of options 1 and 4. There is no mention of any wounds in the question stem, so option 2 can be eliminated as well. This would lead to the correct option, 3. |
2954 Which of the following interventions would be Correct answer: 3 Once stomatitis develops, meticulous oral hygiene must continue with a soft toothbrush or recommended for the client with the nursing diagnosis toothettes, fluoride‐containing toothpaste, and rinsing with a dilute baking soda solution. of Risk for Altered Oral Mucous Membranes related to Dilute hydrogen peroxide mouthwashes are not recommended, since they can dry the mouth side effects of fluorouracil (5‐FU)? and inhibit granulation tissue formation. Commercial mouthwashes are never recommended, since they usually contain alcohol, which is drying, and can burn irritated tissues. ‐ Schedule oral hygiene Q 2 hours with a soft toothbrush and non‐fluoride toothpaste. ‐ Rinse mouth Q 2 hours during the day and Q 4 hours at night with a baking‐soda‐and‐peroxide rinse. ‐ Schedule oral care Q 2–4 hours with a soft toothbrush, fluorinated toothpaste, and a baking soda with isotonic saline rinse. ‐ Continue oral hygiene BID with toothettes and baking soda, and rinse with commercial mouthwash to decrease mouth odor. | Since the client has stomatitis, it is important to use a soft toothbrush. Options 2 and 4 do not mention this, and should be eliminated. In considering options 1 and 3, option 1 lists nonfluoride toothpaste, and should be eliminated, since fluoride is important in dental health. This leads to the only correct answer, 3. |
2955 Which lifestyle changes should the nurse teach the Correct answer: 2 Increasing fiber in the diet increases bulk and gastric motility, thereby decreasing client in order to decrease the risk of developing constipation. Increasing activity and fluids is also helpful. The use of stool softeners should be constipation after receiving vincristine (Oncovin)? encouraged, but laxative usage should be kept to a minimum to prevent becoming laxative‐ dependent. ‐ Decrease physical activity. ‐ Add fiber to the diet. ‐ Increase laxative usage. ‐ Decrease fluid intake. | Adding fiber increases bulk, which decreases constipation. It is important to eliminate options 1 and 4, as these are not appropriate actions. Option 3 is discouraged as the first option in preventing constipation. |
2956 The nurse explains to a client that an important Correct answer: 2 In most cancers, single‐drug therapy has proven unsuccessful, and leads to major tumor drug advantage of combination chemotherapy over single‐ resistance. Combination chemotherapy has demonstrated long‐term remission, more effective drug regimens is that this will do which of the prevention of drug resistance, and tolerable treatment side effects. following? ‐ Reduce the potential for nausea and vomiting ‐ Reduce the potential for tumor resistance ‐ Spare the normal cells from severe toxicity ‐ Decrease the likelihood of drug‐induced gonadal sterility | The only correct answer to this question is option 2. If this was difficult, review the purpose and goals of combination chemotherapy. |
2957 Which of the following interventions represents the Correct answer: 2 Vesicant therapy will cause tissue irritation with eventual sloughing without the appropriate best nursing action should an extravasation of a antidote. Protocols should be in place to administer the antidote immediately after an vesicant occur? extravasation is observed, to neutralize the vesicant and minimize tissue trauma. The site should be observed for 3–4 weeks, but a plastic surgeon need be consulted only if tissue damage occurs (option 3). While the infusion must be stopped, the priority is not choosing a new site for administration (option 1). Emergency care is needed for anaphylaxis, not extravasation (option 4). ‐ The infusion of the drug should be stopped, and a new site chosen for administration. ‐ The site should be treated with the appropriate antidote, and observed for 3–4 weeks. ‐ A plastic surgeon should be consulted immediately. ‐ Emergency medical care, including corticosteroids and epinephrine, should be administered immediately. | Note that the question asks for selection of the best nursing action. With knowledge of potential tissue irritation, you should select an answer that addresses care of the skin. This would lead to option 2, which lists care of skin irritation. The other options do not initially address treatment for skin irritation. |
2958 The nurse is especially careful to assess for hematuria Correct answer: 1 Cystitis can occur in the bladder as a result of chemotherapy with cyclophosphamide or and dysuria when a client is receiving which of the ifosfamide. Nephrotoxicity can occur higher in the renal tubules as a result of therapy with following chemotherapeutic agents? cisplatin, methotrexate, streptozocin, and, more rarely, with mitomycin. ‐ Cyclophosphamide (Cytoxan) ‐ Doxorubicin (Adriamycin) ‐ Fluorouracil (5‐FU) ‐ Cytarabine (Ara‐C) | In order to answer this question correctly, recall the side effects and client responses to listed medications. If this was difficult, review side effects and client responses to the medications. |
2959 After noting altered gait, altered reflexes, and ileus in Correct answer: 2 The symptoms exhibited are most descriptive of neurotoxicity. Symptoms can arise as a result a client receiving chemotherapy, the nurse would of direct or indirect damage to the central nervous system, peripheral nervous system, cranial report to the oncologist that which of the following nerves, or any combination of the three. types of organ damage is occurring? ‐ Hepatic ‐ Neurologic ‐ Renal ‐ Gastrointestinal | In selecting the correct answer note in the question stem that there are two physiologic changes that are occurring that relate to neurology. This indicates the higher‐level system stated in option 2. |
2960 The nurse places highest priority on assessing for Correct answer: 3 Myelosuppression is the most common and lethal side effect of chemotherapy. Since which of the following most common and most lethal hematopoietic cells divide rapidly, they are most vulnerable to chemotherapy. Although side effects of chemotherapy? respiratory failure can be lethal, an increased respiratory rate does not indicate respiratory failure (option 1). Electrolyte imbalances and liver function study elevations can occur with greater or lesser severity, and are therefore not the most lethal (options 2 and 4). ‐ Increased respiratory rate ‐ Electrolyte imbalance ‐ Myelosuppression ‐ Elevated liver function studies | Knowing that a side effect of chemotherapy is the vulnerability of the cells to chemotherapy will lead to the correct option, 3. The other options are serious, but can be treated, and are not considered lethal. |
2961 Which of the following is the initial step that the Correct answer: 1 Clarifying information and dispelling the myths that surround cancer and cancer treatment nurse takes in client and family education regarding are the initial step in client and family education. Most institutions do not require a signed chemotherapy administration? informed consent to administer chemotherapy. Choosing the venous access device and the necessary safety equipment occurs after the initial education has been completed. ‐ Clarify information and dispel misconceptions. ‐ Obtain informed consent. ‐ Choose an appropriate venous access device. ‐ Demonstrate safe gloving and gowning. | Note that this question asks for selection of an initial step. Recognize that options 2, 3, and 4 are all interventions. Before implementing an intervention it is important to make certain that the client understands the process, and to teach any additional information that is required. This should lead to option 1. |
2962 A client asks the nurse to explain the term "cell Correct answer: 3 Drugs that are cell cycle–specific act preferentially on cells that are proliferating (dividing). cycle–specific," which was overheard when the health Cells in the G<sub>0</sub> phase or resting phase are dormant, and are out of the care team made rounds. The nurse replies that cell cycle. Cells that are differentiated are also out of the cell cycle. chemotherapy drugs that are cell cycle–specific act preferentially on cells that: ‐ Are well developed. ‐ Have entered a resting phase, and are not growing. ‐ Are actively getting ready to divide or are dividing. ‐ Are no longer alive. | Recall the definition of the term listed to be able to select the correct option. |
2963 When administering vesicant chemotherapy to a Correct answer: 1 The client should be instructed to notify the nurse of any burning or pain during client, the nurse should do which of the following? administration, so that the treatment can be stopped. Vesicant therapy should be administered in the large veins midway between the wrist and elbow. A blood return should be checked with every 1–2 mL of drug administered. Warm compresses should not be applied during administration, since a potential extravasation could be missed. ‐ Instruct the client to report any pain or burning experienced during the infusion. ‐ Infuse this type of medication in the large veins of the hands or wrist. ‐ Assess for a blood return after each 5–10 mL of chemotherapeutic drug administered. ‐ Apply a warm compress during the infusion to dilate the vein. | Note that the question asks for selection of the best nursing action. With knowledge of potential tissue irritation, select an answer that addresses any irritation to the skin during infusion. |
2964 The nurse assesses for cardiotoxicity most carefully in Correct answer: 2 Vincristine, doxorubicin, and nitrogen mustard are all vesicants. Doxorubicin has a dose‐ a client receiving which of the following limiting cardiotoxic effect. The major side effect of vincristine is peripheral neuropathy. The chemotherapeutic agents? major side effects of nitrogen mustard are severe nausea and vomiting, and thrombocytopenia. The major side effects of cisplatin are severe nausea and vomiting, and nephrotoxicity. ‐ Vincristine (Oncovin) ‐ Doxorubicin (Adriamycin) ‐ Nitrogen mustard (Mustargen) ‐ Cisplatin (Platinol) | In order to answer this question correctly, recall the side effects and client responses to listed medications. The only medication that has major side effects related to the cardiac system is option 2. If this was difficult, review side effects and client responses to the medications. |
2965 When administering chemotherapy, the nurse should Correct answer: 2 The incidence of drug interactions increases with the number of medications the client takes. be aware of which of the following drug interactions? Pretreatment and ongoing assessment are essential to detect potential interactions and avert or minimize an adverse outcome. Contrary to options 1 and 3, it is often necessary to administer chemotherapeutic agents concurrently or sequentially with other drugs. ‐ Cytotoxic chemotherapy drugs should never be given concurrently with another drug. ‐ Drug interactions can result in additive toxicity, decreased effectiveness, or altered activity of non‐chemotherapeutic medications. ‐ Chemotherapy should never be administered in sequence with another drug. ‐ The number of drugs a client is taking does not influence the incidence of drug interactions. | In order to answer this question correctly, recall the principles of safe administration of the medications. Note the similarities between options 1 3, and 4 . Knowing that some chemotherapeutic medications must be given concurrently will allow elimination of these options. |
2966 The nurse reinforcing health teaching with a client Correct answer: 4 Although a client's physical well‐being and response to previous treatments are important to explains that dose limitations of chemotherapy are know, toxicities of the drug commonly determine the maximum amount of the drug that can determined by which of the following client‐ or drug‐ be administered safely. The number of cancer cells in the body has little to do with the dose related factors? limitations of the medications. ‐ Physical status and medical history ‐ History of previous treatments ‐ Number of cancer cells in the body ‐ The toxicities of a particular drug | Note the word “limitations” in the question stem. In thinking about the word "limitation," consider toxicity when giving chemotherapeutic agents. Since chemotherapeutic agents are toxic, the only correct answer is option 4. |
2967 The nurse is administering nitrogen mustard Correct answer: 2 The question indicates that extravasation might be occurring. Prompt nursing action in (Mustargen), and notes swelling at the intravenous (IV) general will minimize tissue damage; therefore, nursing actions should be initially directed site. The nurse should first: toward the suspicious site. The drug administration should be stopped, since failure to do so will further disperse drug into the tissue. Clients can experience extravasation without pain, but not without swelling. Flushing the line with saline or dextrose is not advised, since there still might be vesicant drug remaining in the tubing. ‐ Continuing trying to aspirate for a blood return. ‐ Stop administration, and attempt to aspirate. ‐ Flush the line with saline. ‐ Obtain a new site for drug administration. | Note that the question asks for selection of the first nursing action. With knowledge of potential tissue irritation from chemotherapeutic agents, select an answer that addresses extravasation. This would lead to option 2. The other options are not the initial treatment. They are interventions that could be implemented after stopping the IV to assess the site. |
2968 During the nadir period, which of the following Correct answer: 2 Medications that inhibit platelet aggregation should be avoided. Aspirin, ibuprofen, and medications should be avoided? indomethacin are examples of some of these agents. Tylenol is the drug of choice for mild pain and fever. Benadryl is often used for sinus drainage or as an antihistamine, and Robitussin is used to manage cough. ‐ Acetaminophen (Tylenol) ‐ Ibuprofen (Motrin) ‐ Diphenhydramine (Benadryl) ‐ Guanefesin (Robitussin) | In order to answer this question, recall the definition of nadir. This can be termed the period of reconstruction. Any medications that inhibit platelet reconstruction should be avoided. The medication to be avoided is the one listed in option 2. The other options do not have an effect on platelet reconstruction. |
2969 The nurse would be most careful to assess for Correct answer: 1 Although many chemotherapy agents can cause stomatitis, the antimetabolites are stomatitis in a client receiving which of the following commonly known for causing this side effect. Fluorouracil is the only drug listed in this class. chemotherapeutic agents? Cisplatin is an alkylating agent; bleomycin is an antitumor antibiotic; and vincristine is a plant (vinca) alkaloid. ‐ Fluorouracil (5‐FU) ‐ Cisplatin (Platinol) ‐ Bleomycin (Blenoxane) ‐ Vincristine (Oncovin) | Knowing the classification of the medications should assist in selecting the correct answer. Antimetabolites are known to have the side effect of stomatitis. The other medications are not known for causing stomatitis, and can be eliminated. |
2970 A client experiences severe nausea for two weeks Correct answer: 3 A client at risk for nausea should not lie down for at least 30 minutes after meals, to avoid following her chemotherapy treatment. Which aspiration. The physician should be notified of excessive weight loss (option 1). Foods and statement indicates a need for further instruction on beverages are better tolerated when they are neither hot nor cold (option 2). Option 4 is a management of nausea? good client action if other measures fail. ‐ "I need to call my doctor if I lose more than 10 percent of my body weight." ‐ "I should try to eat bland, chilled foods, and drink liquids separate from my meals." ‐ "I need to lie down for an hour after each meal." ‐ "I should call the doctor if my nausea doesn't go away, to see if a different anti‐emetic could provide better relief." | This question is asking for an answer that indicates that the client does not understand the teaching for management of nausea. Option 3 is the only correct option, because it shows a lack of understanding, as lying down can lead to reflux, causing nausea. The other statement options indicate understanding. |
2971 The nurse would assess for functional constipation as Correct answer: 1 Neurotoxicity is a side effect of the vinca alkaloid classification, to which vincristine and a result of neurotoxicity when the treatment plan vinblastine belong. Fluorouracil, methotrexate, and doxorubicin often cause diarrhea. involves use of which of the following chemotherapy Gemcitabine and mitoxantrone commonly cause myelosuppression. agents? ‐ Vincristine (Oncovin) and vinblastine (Velban) ‐ Fluorouracil (5‐FU) and bleomycin (Blenoxane) ‐ Methotrexate (Folex) and doxorubicin (Adriamycin) ‐ Gemcitabine (Gemzar) and mitoxantrone (Novantrone) | Knowing that the side effects of a vinca alkaloid classification cause neurotoxic effects of constipation will lead to option 1. The other medications do cause this effect, and can be eliminated. If this was difficult, review the classifications of the medications. |
2972 The nurse is caring for a client receiving Correct answer: 3 Anthracyclines are known to cause cardiotoxicity by directly damaging the cardiac myocyte chemotherapy as part of cancer treatment. The nurse cells. Not all anti‐tumor antibiotics cause cardiomyopathy. Cardiotoxicity is not a common side looks for signs of cardiotoxicity due to direct damage effect of vinca alkaloids or alkylating agents. to cardiac myocyte cells in a client receiving drugs in which of the following classifications? ‐ Vinca (plant) alkaloids ‐ Alkylating agents ‐ Anthracyclines ‐ Antitumor antibiotics | In order to answer this question correctly, recall the side effects and client responses to listed medications. The only medication that has major side effects related to the cardiac system is the one in option 3. If this was difficult, review side effects and client responses to the medications. |
2973 The nurse provides anticipatory guidance about Correct answer: 2 The classification of chemotherapeutic agents that have the greatest effect on the gastric managing diarrhea for a client receiving chemotherapy mucosa is the antimetabolites. This can lead to diarrhea, which in turn can lead to fluid and drugs in which of the following classifications? electrolyte imbalances if not managed well. ‐ Vinca alkaloids ‐ Antimetabolites ‐ Hormonal agents ‐ Nitrosoureas | Knowing the side effect of constipation with the antimetabolites classification of chemotherapeutic agents will allow selection of option 2. The other medications do cause this effect, and can be eliminated. If this was difficult, review the classifications of the medications. |
2974 Which of the following is the most appropriate Correct answer: 1 An appropriate outcome is one that supports the client's functional ability in daily life. Clients outcome for a client with cardiotoxicity related to with cardiac toxicities might experience discomfort with cardiac ischemia (option 3), but can cancer treatment? expect that it will be controlled. Dyspnea and shortness of breath will occur (option 4), but should be controlled to allow the client to maintain normal daily activities. Option 3 is unrelated to the question, and might be unrealistic. ‐ Client will maintain activity levels that allow normal daily activities as identified by the client. ‐ Client will experience no pain. ‐ Client and caregiver will express relief about possible cancer cure. ‐ Client will experience no dyspnea during any activities. | Remember that in nursing, the goal is to assist clients to perform as many normal daily activities as possible. The only answer that addresses this goal is option 1. The other options should be eliminated. |
2975 The nurse would avoid using intravenous (IV) solution Correct answer: 3 When administering Paclitaxel, PVC bags and infusion sets should be avoided because of bags and infusion sets made from polyvinyl chloride leaching of DEPH (plasticizer). All other chemotherapy agents are safe to administer with (PVC) when administering which chemotherapy agent? conventional IV sets. ‐ Doxorubicin (Adriamycin) ‐ Vincristine (Oncovin) ‐ Paclitaxel (Taxol) ‐ Methotrexate (Folex) | In order to answer this question correctly, recall the methods of administration for the chemotherapeutic agents listed. If this was difficult, review the safe methods of administration of the medications. |
2976 The nurse instructs the client receiving chemotherapy Correct answer: 4 A client with thrombocytopenia should avoid activities that could result in injury and bleeding. that which of the following should be avoided to For this reason, the client should avoid trimming the nails with a nail clipper, and should use a reduce the risks associated with thrombocytopenia? nail file instead. Option 3 indicates the safe method for shaving; straight razors should be avoided, but electric razors are acceptable. Not all clients with thrombocytopenia also experience concurrent leukopenia. Options 1 and 2 should be avoided to minimize risk of infection, or when the client's white blood cell count is low. ‐ Being near individuals with upper respiratory infection ‐ Keeping fresh flowers and plants in the home ‐ Shaving with an electric razor ‐ Trimming nails with a nail clipper | The word “thrombocytopenia” in the question stem should alert to the condition of low platelets. A client with low platelets would be high‐risk for bleeding. The only option that addresses a high risk for bleeding is option 4. |
2977 A client being treated for glaucoma complains of Correct answer: 3 Clients experiencing photophobia are instructed to wear dark sunglasses and to avoid bright photophobia. The nurse’s teaching instructions include lights. Not enough information is provided to warrant discontinuing the medication. Eyes which of the following? should not be wiped with tissue immediately after instillation of drops, and no special glasses are required. ‐ Discontinue use of the medication. ‐ Wipe the eyes with tissue immediately after instillation of eye drops. ‐ Wear dark glasses when outside, or when around bright lights. ‐ Special glasses are necessary while being treated for glaucoma. | Focus on the word photophobia and use the process of elimination to choose the answer that shields the eyes from light. |
2978 Which of the following statements by the client Correct answer: 2 Difficulty in adjusting quickly to changes in illumination occurs as a result of miosis, an effect demonstrates an understanding of client education of pilocarpine. The client will experience more difficulty seeing at night (option 1). Driving is regarding pilocarpine (Isopto Carpine)? not contraindicated (option 4); however, nighttime driving might not be possible, because of the miosis. ‐ “I will see better at night.” ‐ “I may have trouble adjusting to darkness.” ‐ “I should not have any trouble adjusting to changes from light to dark.” ‐ “I will not use the medication if I plan to drive.” | Specific knowledge of the important teaching points related to pilocarpine is needed to answer the question. Use this knowledge and the process of elimination to make a selection. |
2979 The nurse is providing care to a client taking Correct answer: 4 The diuretic effects of methazolamide could lead to electrolyte disturbances of hypokalemia methazolamide (Neptazane), a carbonic anhydrase and hypernatremia. Options 1, 2, and 3 are either partially or totally incorrect. inhibitor for glaucoma. The plan of care includes monitoring for which of the following electrolyte imbalances? ‐ Hyperkalemia and hypernatremia ‐ Hypokalemia and hyponatremia ‐ Hyperkalemia and hyponatremia ‐ Hypokalemia and hypernatremia | The core issue of the question is knowledge of electrolyte disturbances for which the client is at risk during therapy with methozolamide. Recall that the medication has a diuretic effect, and reason that potassium might be lost while sodium is retained. Use this knowledge and the process of elimination to make a selection. |
2980 Which of the following statements by a client who Correct answer: 2 Improvement of the infection should be noticed within a few days of beginning the antibiotic has a prescription for otic chloramphenicol therapy. Superinfections are known to occur with this medication; therefore, seven days is too (Chloromycetin) indicates a need for further long to seek further evaluation and treatment. Options 1, 3, and 4 are correct actions by the instructions? client experiencing any ear infection or disorder. ‐ “I will inform my doctor of increased ear pain.” ‐ “I will inform my doctor if my ear infection has not improved within seven days.” ‐ “I will inform my doctor if I have an increase in drainage from my ear.” ‐ “I will inform my doctor if I experience any hearing disturbances.” | The wording of the question tells you that the correct answer is an inaccurate statement. Use the process of elimination, and select the option that represents incorrect information. |
2981 A client is receiving pilocarpine (Isopto Carpine) for Correct answer: 1 Symptoms of systemic absorption of pilocarpine include diaphoresis, diarrhea, bradycardia, the treatment of glaucoma. Which of the following and hypotension. Options 2, 3, and 4 are incorrect because they are opposites of actual signs symptoms experienced by the client does the nurse of systemic absorption. attribute to systemic absorption? ‐ Diaphoresis ‐ Constipation ‐ Tachycardia ‐ Hypertension | The core issue of the question is recognition of signs of systemic absorption of pilocarpine. Specific knowledge of systemic effects of this medication is needed to answer the question. Use this knowledge and the process of elimination to make a selection. |
2982 A client is receiving cyclopentolate and phenylphrin Correct answer: 2 Cyclomydril and other mydriatics are applied topically to produce mydriasis (dilated pupil) to (Cyclomydril) before an ocular examination. The nurse facilitate ocular examination. Options 1, 3, and 4 are incorrect because they drugs do not would explain the purpose of the medication as which constrict the pupil, provide anesthesia, or prevent infection, respectively. of the following? ‐ To constrict the pupil | The core issue of the question is knowledge of the intended effects of cyclomydril. Note that the name of the drug contains the letters myd, which is also the beginning of the word mydriasis (meaning to dilate the pupils). Using simple word association will sometimes assist in making the correct selection. |
‐ To dilate the pupil ‐ To provide anesthesia ‐ To provide a prophylactic antibiotic | |
2983 Which of the following symptoms described by a Correct answer: 1 Systemic side effects of ophthalmic atropine include tachycardia, confusion, dry mouth, client would lead the nurse to suspect a systemic side drowsiness, and slurred speech. Options 2 and 3 are opposites of known systemic side effects, effect of atropine ophthalmic solution? while option 4 (diaphoresis) is unrelated. ‐ Tachycardia ‐ Bradycardia ‐ Salivation ‐ Diaphoresis | The core issue of the question is knowledge of side/adverse effects of atropine. Recall that when used for cardiac reasons, the medication speeds up heart rate. With this in mind, eliminate each of the incorrect responses, and choose tachycardia as the correct answer. |
2984 Which of the following statements demonstrates the Correct answer: 1 Ophthalmic solution that has darkened or become cloudy should be discarded. Most solutions client’s understanding of proper administration of are clear (option 2). Swabs should not be used to apply medication (option 3), and the ophthalmic solutions? medications generally have a shelf life of three months (option 4). ‐ “I will not use any medication if it has turned brown.” ‐ “I will not use my medication if it is clear in color.” ‐ “I will use a cotton swab to apply my medication.” ‐ “I will not use any medication that is more than one month old.” | The core issue of the question is safe self‐administration of ophthalmic medications. Use nursing knowledge and the process of elimination to answer the question. |
2985 In teaching a client about side effects of medications, Correct answer: 1 Salicylates can cause tinnitus, vertigo, and hearing loss, if ingested in high doses. Vitamin C for which of the following over‐the‐counter (option 2), diphenhydramine (option 3), and vitamin A (option 4) do not present this concern. medications would the nurse discuss ototoxicity? ‐ Salicylates (aspirin) ‐ Vitamin C ‐ Diphenhydramine (Benadryl) ‐ Vitamin A | The core issue of the question is an understanding of the types of drugs that can cause ototoxicity. Use nursing knowledge and the process of elimination to make a selection. |
2986 During a follow‐up visit at the clinician’s office, a Correct answer: 4 Inserting objects, including medication droppers, into the ear canal can perforate the client states: “I insert the ear dropper deep into my ear tympanic membrane. Though the ear canal might be obstructed with cerumen (option 1), so the medication doesn’t run back out.” The nurse’s there are other reasons, such as inappropriate instillation technique, for the medication to not response and priority teaching to the client is based on flow into the ear canal (option 2). The client is instructed to lie on the unaffected side, not the which of the following? affected side (option 3), to allow flow of medication into the ear. ‐ The client’s ear canal is likely obstructed with cerumen. ‐ The client is using the appropriate technique for administering an otic solution. ‐ The client should lie on the same side as the affected ear for five minutes to allow medication to flow into the ear. ‐ The medication dropper or any other item should not be inserted into the ear canal. | The core issue of the question is an understanding of the procedure for safe self‐ administration of an otic medication. Use nursing knowledge and the process of elimination to make a selection. |
2987 Which of the following actions observed by the nurse Correct answer: 1 The recommended wait time between administrations of two ophthalmic solutions is five demonstrates appropriate technique by a client self‐ minutes. If an ophthalmic ointment is instilled, the waiting time is ten minutes between the administering an ophthalmic medication? ointment and the next medication. ‐ The client waits five minutes between instillation of two different ophthalmic solutions. ‐ The client administers ophthalmic ointment immediately after administering ophthalmic solution. ‐ The client administers the second ophthalmic solution immediately after administering the first ophthalmic solution. ‐ The client administers ophthalmic solution immediately after administering ophthalmic ointment. | The core issue of the question is an understanding of the procedure for safe self‐ administration of an ophthalmic medication. Use nursing knowledge and the process of elimination to make a selection. |
2988 The nurse is observing a client give a return Correct answer: 3 The eye is cleansed with sterile irrigating solution or sterile normal saline, to decrease risk of demonstration of the administration of eye drops. contamination. Options 1, 2, and 4 represent appropriate techniques demonstrated by the Which of the following actions taken by the client client. indicates a need for further teaching? ‐ The client pulls the lower lid of the eye down, forming a sac. ‐ The client instills the medication into the conjunctival sac. ‐ The client cleanses the eyelid with cotton balls moistened with warm tap water. ‐ The client cleanses the eye from inner canthus to outer canthus. | The wording of the question tells you that the correct option is an inappropriate action. Analyze each option to decide if it is a true or false statement, and make the selection that represents false information. |
2989 A client with open‐angle glaucoma is receiving timolol Correct answer: 3 Timolol is a beta‐adrenergic blocker that decreases the production of aqueous humor, (Timoptic) for treatment. When assessing the client’s thereby decreasing intraocular pressure. Sympathomimetics also decrease aqueous humor response to the medication, the nurse expects production. Prostaglandins increase the outflow of aqueous humor to decrease intraocular therapeutic effects to be the result of which of the pressure. following? ‐ A decrease in the outflow of aqueous humor ‐ An increase in the outflow of aqueous humor ‐ A decrease in aqueous humor production ‐ An increase in aqueous humor production | Note that the drug name ends in ‐olol, and reason that the medication is a beta‐blocking agent. With this in mind, recall the actions of beta‐blocker medications in the eye. Use nursing knowledge and the process of elimination to make a selection. |
2990 The nurse is providing information on safety Correct answer: 1 Carbachol causes miosis (pupil constriction), making quick changes in illumination difficult. measures to the family of an elderly client being Nighttime is particularly hazardous for the elderly client. The client and family are instructed treated with carbachol (Carboptic), an ophthalmic on methods such as lighting hallways and bathrooms at night, to reduce the potential for cholinesterase inhibitor. The safety measures injury. Mydriasis (option 2) is not a concern. Systemic side effects of carbachol include diarrhea implemented are related to which of the following? (option 3) and hypotension (option 4). ‐ The client will experience difficulty in making quick changes in illumination due to miosis. ‐ The client will experience difficulty in making quick changes in illumination due to mydriasis. ‐ The client will experience a side effect of constipation. ‐ The client will experience a side effect of hypertension. | Note that options 1 and 2 are opposites. When two options are opposite, consider the possibility that one of them is the correct answer. In this case, note that the client is elderly, and is not in a situation (such as an eye exam) when the pupils would be dilated. With this in mind, choose option 1 over 2. |
2991 The nurse is developing a plan of care for a client Correct answer: 2 Carbonic anhydrase inhibitors produce increased urinary elimination and subsequent receiving a carbonic anhydrase inhibitor for treatment increased excretion of potassium. Clients are monitored for fluid volume deficit (not excess, as of glaucoma. The nurse identifies that the client is at in option 1) and hypokalemia (options 3 and 4). Assess electrolytes; intake and output; daily risk for which of the following nursing diagnoses? weights; mucous membranes; and skin turgor. ‐ Excess Fluid Volume ‐ Deficient Fluid Volume ‐ Electrolyte Imbalance: Hyperkalemia ‐ Electrolyte Imbalance: Hypocalcemia | The core issue of the question is knowledge of what to monitor regarding side effects of carbonic anhydrase inhibitors. Use medication knowledge and the process of elimination to make a selection. Note also that options 1 and 2 are opposites, which suggests that one of them might be correct. |
2992 A client who just self‐administered the first dose of Correct answer: 2 Redness and swelling are signs of hypersensitivity to vidarabine. The medication should be vidarabine (Vira‐A) calls the clinic and reports eye discontinued, and the client should return to the clinic immediately for evaluation. Options 1, redness and swelling not present before treatment 2, and 4 are incorrect because they place the client at risk. began. The nurse instructs the client to take which of the following actions? ‐ No action is necessary, because these are normal signs and symptoms of the medication. ‐ Discontinue use of the medication, and return to clinic immediately for evaluation. ‐ If redness continues after three days, return to the clinic for evaluation. ‐ Discontinue use of the medication, and return to clinic at the next scheduled appointment. | Note that the question contains key information about adverse effects that began after the first dose of the medication. When symptoms suddenly appear, as in this question, consider the possibility of a hypersensitivity reaction, and choose an option accordingly. |
2993 Which of the following statements made by a client Correct answer: 4 Viroptic, used in the treatment of viral infections such as herpes, is administered for an being treated with ophthalmic trifluridine (Viroptic) additional 5–7 days after healing has occurred. Ophthalmic medications are stored in a cool, indicates an understanding of the medication dry place (option 3), and some are recommended for refrigeration (check label for instructions? instructions). Options 1 and 2 are incorrect because their time frames are too limited. ‐ “I will stop the medication once healing has occurred.” ‐ “I will administer the treatment for 7 days.” ‐ “I will store the medication in a warm place.” ‐ “I will continue the medication for 5–7 days after healing has occurred.” | The core issue of the question is knowledge of appropriate information about Viroptic as an ophthalmic medication. Use nursing knowledge and the process of elimination to make a selection. |
2994 The parent of a 2‐year‐old child exhibits correct Correct answer: 1 The child’s pinna is pulled down and back for administration of otic solutions. The pinna in the administration technique for otic solutions when doing adult is pulled up and back. Droppers should never be inserted into the ear canal, and the head which of the following in a return demonstration? is tilted toward the unaffected side. ‐ The parent pulls the child’s pinna down and back before administering the medication. ‐ The parent pulls the child’s pinna up and back before administering the medication. ‐ The parent places the dropper into the child’s ear canal before administering the medication. ‐ The parent tilts the head of the child towards the affected side before administering the medication. | One quick way to remember the direction for pulling the pinna is to associate the direction with the height of the person. Since an adult is taller, pull the pinna up and back, while for a child, who is shorter, pull the pinna down and back. |
2995 A client in the rural health clinic complains of Correct answer: 3 Acetazolamide, a carbonic anhydrase inhibitor, causes diuresis. The nurse should instruct the frequent urination during the night. Upon evaluation, client to take the medication early in the day, to avoid nocturia. Clients receiving the nurse suspects that which of the following actions acetazolamide are encouraged to consume at least 2,000 mL of fluid per day to avoid fluid by the client taking acetazolamide (Diamox) is likely volume depletion, and acetazolamide may be taken with juice or food to minimize the cause of the nocturia? gastrointestinal irritation. ‐ The client takes oral Diamox every morning. ‐ The client consumes 2,000 cc of fluid per day. ‐ The client takes oral Diamox before supper. ‐ The client takes oral Diamox with juice. | The core issue of the question is recognition of and client teaching to prevent nocturia, a side effect of carbonic anhydrase inhibitors. Use medication knowledge and general principles for timing the administration of diuretics to answer the question. |
2996 The nurse is orienting a newly hired nurse to the Correct answer: 2 Proparacaine is administered to prevent pain during procedures such as tonometry and outpatient ophthalmic clinic. The nurse concludes that removal of foreign bodies. The medication has a rapid onset, within 20 seconds, and duration the orientee understands instructions for of 15–20 minutes. Options 1, 3, and 4 are incorrect actions taken by the nurse because of the administering ophthalmic anesthetics for tonometry time frames identified. after observing which of the following actions? ‐ The orientee administers proparacaine hydrochloride (Ophthaine) 15 minutes before the scheduled tonometry. ‐ The orientee administers Ophthaine immediately before the scheduled tonometry. ‐ The orientee administers Ophthaine 5 minutes before the scheduled tonometry. ‐ The orientee administers Ophthaine after the tonometry is completed. | Note that the name of the drug ends in ‐caine to help remember that this drug has an anesthetic action. With this in mind, choose the option that best protects an eye that has no sensation, which in this case is the option that utilizes the medication just prior to the exam. |
2997 Which of the following is the priority in nursing Correct answer: 3 Assessment of allergies and reactions to medications is essential when administering a new management of the client prior to administering the medication. Hypersensitivity responses can occur with ophthalmic medications, and severe first dose of an ophthalmic medication? adverse reactions can occur with hypersensitivity to the medication, because it is systemically absorbed. Options 1, 2, and 4 are important to the nursing management of the client; however, avoiding reactions to the medication is the priority. ‐ Assessing the client's understanding of the purpose of the medication ‐ Assessing the client's eye and vision status ‐ Assessing the client's history of hypersensitivity to medications ‐ Assessing the client's understanding of the action of the medication | Knowing that one of the safety factors prior to administering any medication is assessing for any allergies or hypersensitivities will lead to the correct option. Recognize that while the other options are important, option 3 is the priority action. |
2998 Which of the following techniques performed by the Correct answer: 2 Correct technique for administration of ophthalmic medications includes pulling the lower client demonstrates an understanding of appropriate eyelid down and instilling the medication into the conjunctival sac. Options 1, 3, and 4 each administration of ophthalmic medications? contain information that is either partially or totally incorrect. ‐ Pulls the lower lid down, and instills the medication directly onto the eye. ‐ Pulls the lower lid down, and instills the medication into the conjunctival sac. ‐ Pulls the lower lid up, and instills the medication directly onto the eye. ‐ Pulls the lower lid up, and instills the medication into the conjunctival sac. | Use the process of elimination and knowledge of basic care in the instillation of eye medications to be led to option 2. Review the procedure for instillation of eye medication if this was difficult. |
2999 The external ear canal of a client with an ear infection Correct answer: 1 For an external ear canal obstructed with edema, a gauze wick is inserted past the edematous is obstructed with edema. Which of the following segment. The medication is then applied to the outside wick, allowing the medication to be techniques does the nurse instruct the client to use absorbed along the path of the wick. Option 2 delays treatment. Option 3 is unnecessary, and regarding medication administration? option 4 is a hazardous activity that could cause damage to the client's ear. ‐ Insert a gauze ear wick, and apply medication to wick. ‐ Wait until swelling subsides before instilling medication. ‐ Request a change in the route of medication. ‐ Insert the dropper past the edematous canal. | Note that the question stem asks for selection of a technique. The only techniques listed are option 1 and 4. Using the process of elimination, and considering safety, option 1 is the only correct answer. |
3000 A client with open‐angle glaucoma is being treated Correct answer: 3 Acetazolamide should not be mixed with alcohol or glycerin. To minimize gastrointestinal with oral acetazolamide (Diamox). Which of the distress, the client may take the medication with milk, or may crush it and mix it with juice. following statements made by the client indicates a Acetazolamide is taken in the morning to avoid nocturnal diuresis. need for further teaching? ‐ "I can take the medication with milk." ‐ "I should take the medication in the morning." ‐ "I can mix the medication with alcohol." ‐ "I can crush the tablet, and mix it in juice." | In order to answer this question correctly, recall the nursing interventions related to client safety. If this was difficult, review the nursing interventions related to the medication acetazolamide (Diamox). |
3001 A client being treated with dorzolamide (TRUSOPT) as Correct answer: 1 Carbonic anhydrase inhibitor agents such as dorzolamide decrease aqueous production by treatment for glaucoma asks for an explanation of how approximately one‐half of baseline, thereby lowering intraocular pressure. Dorzolamide does the medication will affect the disease. The nurse's not cause pupil constriction (option 2), increase aqueous humor production (option 3), or response includes which of the following? increase outflow of aqueous humor (option 4). ‐ The medication decreases production of aqueous humor. ‐ The medication causes pupil constriction. ‐ The medication increases the production of aqueous humor. ‐ The medication increases the outflow of aqueous humor. | Answer this question by recalling the pathophysiology of glaucoma. The question is not specific about the type of glaucoma, so remember a general understanding of the disease process. With this knowledge eliminate all the options except 1, which is the goal behind the treatment for clients with glaucoma. |
3002 A client is describing symptoms experienced since Correct answer: 3 Precipitation of an asthmatic attack is a systemic side effect of pilocarpine. Other side effects beginning pilocarpine (Isopto Carpine) for treatment of include salivation, hypotension, diarrhea, nausea, and vomiting. Dry mouth (option 1), glaucoma. The nurse concludes that which of the hypertension (option 2), and constipation (option 4) are opposites of known side effects. following symptoms indicates a side effect from systemic absorption? ‐ Dry mouth ‐ Hypertension ‐ Exacerbation of asthma ‐ Constipation | With knowledge of the side effects of the medication pilocarpine (Isopto Carpine), select option 3. This is the only correct answer, and can be selected with knowledge of the side effects of the medication. |
3003 The nurse concludes that an adult client understands Correct answer: 2 The adult client pulls the pinna up and back for administration of otic solutions. The pinna is proper otic medication administration after observing pulled down in the child (option 1). Droppers should never be inserted into the ear canal the client use which of the following techniques for (option 3), and the head should be tilted toward the unaffected side (option 4). administering an otic solution? ‐ The client pulls the pinna down and back before administering the medication. ‐ The client pulls the pinna up and back before administering the medication. ‐ The client places the dropper into the ear canal before administering the medication. ‐ The client tilts the head towards the affected side before administering the medication. | Note that the question stem asks for validation of a client s technique for instilling ear drops. Using the process of elimination and basic care knowledge of the instillation of ear drops will assist in selecting the correct answer. |
3004 The nurse determines that a client with newly Correct answer: 1 Ophthalmic beta‐blockers are administered to reduce intraocular pressure by decreasing diagnosed glaucoma understands the purpose for the production of aqueous humor. The medication must be continued as lifelong therapy to prescribed ophthalmic beta‐blocker when which of the maintain a stable intraocular pressure (option 2). Some glaucoma may be surgically treated following statements is made? (option 4). ‐ "The medication is given to reduce my intraocular pressure." ‐ "I can stop the medication once my intraocular pressure is normal." ‐ "The medication is given to increase my intraocular pressure." ‐ "This medication is the only treatment available for glaucoma." | Answer this question with knowledge of the pathophysiology of glaucoma. The question is not specific about the type of glaucoma, so recall a general understanding of the disease process. Use this knowledge to eliminate all the options except that 1, which is the goal behind the treatment for clients with glaucoma. Options 2 and 4 can be eliminated because they do not address what the question is asking. |
3005 As a nurse working in an outpatient surgical clinic, Correct answer: 1 Atropine, an anticholinergic agent, can precipitate acute glaucoma as a result of pupillary which of the following preoperative medications dilation; therefore, clients with pre‐existing glaucoma or a predisposition to acute glaucoma should be questioned for a client with a history of should not receive atropine. There are no contraindications for diphenhydramine, hydroxyzine, glaucoma? or promethazine in the client with glaucoma. ‐ Atropine (generic) ‐ Diphenhydramine (Benadryl) ‐ Hydroxyzine (Vistaril) ‐ Promethazine (Phenergan) | Understanding the pathophysiology with glaucoma will assist in selecting the correct answer. Also recall the medications that are contraindicated for a client who has been diagnosed with acute glaucoma. |
3006 A client who has begun taking brinzolamide (Azopt) Correct answer: 2 Carbonic anhydrase inhibitors such as brinzolamide can exacerbate the potential for renal indicates understanding of medication instructions calculi. Increasing fluid intake to two liters per day could reduce this risk. Diet when making which of the following statements? recommendations include increasing potassium and reducing sodium. ‐ "I will reduce my daily fluid intake." ‐ "I will consume two liters of fluid daily." ‐ "I will consume a diet high in sodium." ‐ "I will consume a diet low in potassium." | In order to select the correct answer to this question, recall the mechanism of excretion with the medication. Since it is excreted via the kidney, there is a higher incidence of side effects with the renal system. Teaching the client this side effect will encourage the client to consume more fluids, leading to the correct option, 2. |
3007 A client with type 1 diabetes mellitus is ingesting Correct answer: 2 If the client is monitored properly, the beta‐blocking agents will not mask symptoms of carteolol (Ocupress). Which of the following outcomes hypoglycemia, but might reduce the effect of some oral hypoglycemics (option 2). A serum is considered to have the most immediate significance, glucose level significantly lower than normal can place the client at great risk more rapidly and should be given first priority? than does elevated blood pressure. Many clients live for long periods with hypertension without immediate risks to their health (option 1). NSAIDs can reduce the antihypertensive effect of the drug (option 3). The diarrhea needs to be controlled because of the potential fluid and electrolyte loss, but is not the first priority (option 4). ‐ Blood pressure is within normal limits (WNL). ‐ Serum glucose is within normal limits (WNL). ‐ Headache is controlled with non‐steroidal anti‐inflammatory drugs (NSAIDs). ‐ Diarrhea is controlled with loperamide (Imodium). | Determine the relationship between Ocupress and the needs of a client with type 1 diabetes to select the correct answer. |
3008 A client indicates an understanding of instructions Correct answer: 2 Warming eardrops (if not contraindicated) makes administration of the medication more about self‐administration of the prescribed otic comfortable. Warming can be achieved by running the bottle under warm water, placing the solution when she makes which of the following bottle of medication in a cup of warm water (not cool, as in option 1), or by carrying in the statements? hand or pocket for 30 minutes (option 4). The medication should never be warmed in the microwave (option 3); serious injury to ear canal and tympanic membrane could occur. ‐ "I run the bottle of medication under cool running water before administering the medication." ‐ "I run the bottle of medication under warm running water before administering the medication." ‐ "I warm the bottle of medication in the microwave before administering the medication." ‐ "I warm the bottle of medication in my hand for five minutes before administering the medication." | Using the process of elimination, and knowledge of basic care in the instillation of eye medications, will lead you to option 2. Review the procedure for instillation of eye medication if this was difficult. |
3009 A client with a history of pulmonary disease is being Correct answer: 4 Clients with pulmonary disease are generally prescribed Betoptic for glaucoma because it is treated with betaxolol (Betoptic). After the nurse has Beta<sub>1</sub> selective (cardioselective). However, the client must still be provided instructions and information about the monitored for pulmonary side effects and respiratory difficulties that can occur with systemic medication, the client asks, "How can eye drops affect absorption. The explanation in options 1, 2, and 3 do not address this effect. my lungs?" The nurse's explanation includes which of the following? ‐ The medication does not have any effects on the pulmonary system. ‐ The client is only at risk if the prescribed ophthalmic medication is cardioselective (Beta1). ‐ The client is only at risk if the prescribed ophthalmic medication is given at the same time as the oral medications taken for pulmonary disease. ‐ If the ophthalmic medication is systemically absorbed, it can have the same systemic effects as other beta‐blocking agents. | Note that option 4 is the only one that addresses the client s question. The other choices do not address the client s question, and should be eliminated. |
3010 A client telephones the outpatient clinic and Correct answer: 1 The symptoms the client reports might indicate a ruptured tympanic membrane. The ear complains of severe ear pain that ceased suddenly. canal and tympanic membrane should always be evaluated before instilling otic medications, Now, the ear is draining. The client has otic antibiotics making options 2, 3, and 4 incorrect. remaining from a previous ear infection two months ago, and wants to know if it is safe to use the medication. The nurse's response is based on which of the following? ‐ The client should be referred to a health care provider, and should not use any medications until the ear is evaluated. ‐ Since the client was recently treated with otic antibiotics for an ear infection, the medication would be safe to use. ‐ The client should begin using the antibiotic, and seek evaluation if no improvement is seen within two days. ‐ The shelf life of otic medications is three months; therefore, the medication would be safe to use. | Using the process of elimination, and knowledge of basic care in the instillation of ear medications, will lead you to option 1. Knowledge that medication previously prescribed for a condition should not be used for another condition will lead to option 1. |
3011 The nurse evaluates that a client is demonstrating Correct answer: 2 Crust from eyes is cleansed using cotton balls, wiping from the inner canthus to the outer appropriate technique for using ophthalmic canthus. Swabs (options 3 and 4) should not be used, as damage to the eye could occur. Option medication when the client does which of the 1 represents incorrect technique. following? ‐ Cleanses crust from the eye by wiping from the outer canthus inward with a cotton ball. ‐ Cleanses crust from the eye by wiping from the inner canthus outward with a cotton ball. ‐ Cleanses crust from the eye by wiping from the outer canthus inward with a cotton swab. ‐ Cleanses crust from the eye by wiping from the inner canthus outward with a cotton swab. | Using the process of elimination, and knowledge of basic care in the instillation of eye medications, will lead to option 2. Review the procedure for instillation of eye medication if this was difficult. |
3012 A client prescribed gentamicin sulfate (Garamycin) for Correct answer: 2 Otic Garamycin is not approved for use in the United States. It is a safe and accepted practice an ear infection telephones the clinic, states that the for clinicians to prescribed ophthalmic Garamycin for otic use. The client should be informed of medication bottle indicates "for ophthalmic use," and this practice. Options 1 and 3 are incorrect because no error was made. Option 4 is incorrect refuses to use the medication. The nurse s response to because the client has not indicated inadequate knowledge of medication administration. the client is based on which of the following? ‐ An error is likely in the dispensing of the medication, since the clinician is treating an otic infection. ‐ It is an accepted and safe practice in the United States for clinicians to prescribe ophthalmic Garamycin for otic use. ‐ An error was likely committed by the clinician in prescribing the medication. ‐ The client requires further teaching on proper medication administration. | Note that option 2 is the only one that addresses the client s question. Options 1 and 3 are erroneous statements, and option 4 does not address the client s question, and should be eliminated. |
3013 A client with a history of cardiovascular disease is Correct answer: 1 Carteolol is a beta‐blocking agent with side effects of hypotension and bradycardia if admitted to the nursing unit with bradycardia and systemically absorbed. The other medications acetazolamide and dorzolamide, carbonic hypotension. The nurse suspects that these symptoms anhydrase inhibitors, and latanoprost, a prostaglandin do not affect heart rate and blood might be adverse effects of which medication recently pressure. started as therapy for glaucoma? ‐ Carteolol (Ocupress) ‐ Acetazolamide (Diamox) ‐ Dorzolamide (TRUSOPT) ‐ Latanoprost (Xalatan) | Knowing that carteolol (Ocupress) is classified as a beta‐blocker will assist in selecting the correct answer. This medication will affect the heart rate. The other medications do not affect the heart rate. |
3014 A client is receiving an ophthalmic anesthetic agent Correct answer: 4 The blink reflex is lost when ophthalmic anesthetic agents are used; therefore, the eye is at preoperatively for removal of sutures. Priority nursing risk for injury. Priority is given to protecting the cornea from irritants, debris, and rubbing. care includes which of the following? Generally, an eye patch is applied for protection. Since the medication is local, and the client is not anesthetized, the airway is not compromised (option 1), and the body temperature should remain at preprocedure reading (option 3). Clients are assessed for allergies or past hypersensitivity reactions (option 2) before the medication is administered. ‐ Measures to protect the airway ‐ Measures to reduce hypersensitivity ‐ Measures to control body temperature ‐ Measures to protect the eye | Note that the question stem includes the word “ophthalmic.” Recognize that the eye is being referred to in order to select the correct answer, 4, which lists eye in the answer statement. |
3015 A client with narrow‐angle glaucoma informs the Correct answer: 1 Atropine sulfate is commonly used preoperatively in outpatient procedures such as a nurse of an outpatient colonoscopy scheduled for later colonoscopy. The client needs to alert the staff about the diagnosis of glaucoma, since the use in the week. The client demonstrates understanding of of atropine is contraindicated in narrow‐angle glaucoma because it could precipitate acute subsequent teaching when which of the following glaucoma. statements are made? ‐ "I will inform my doctor and the nursing staff of my glaucoma and the medication I am taking." ‐ "I will stop taking my medication two days before the colonoscopy." ‐ "I will stop taking my medication one day before the colonoscopy." ‐ "My glaucoma is not a factor when having outpatient procedures done." | Recall knowledge of medications used during colonoscopies to assist in selecting the correct answer. Option 1 would be the best choice, since it is most important to inform the practitioner of any medical problems being treated, as well as the medications prescribed. This would be the priority response in this question. |
3016 Which action by the client indicates an understanding Correct answer: 1 Maintaining pressure on the lacrimal sac for 1–2 minutes is recommended for dipivefrin, to of instructions for administration of dipivefrin minimize systemic absorption of the medication. Eye drops are instilled into the conjunctival (Propine)? sac, never directly onto the eye. ‐ The client maintains pressure on the lacrimal sac for 1–2 minutes after instillation of medication. ‐ The client avoids lacrimal pressure after instillation of medication. ‐ The client instills medication directly onto the eye. ‐ The client maintains pressure on lacrimal sac for 30 seconds after instillation of medication. | Use the process of elimination and knowledge of basic care in the instillation of eye medications to select option 1. Review the procedure for instillation of eye medication if this was difficult. |
3017 While teaching a client about the proper Correct answer: 3 To promote absorption, the client should not blink for 30 seconds after the administration of administration of dipivefrin (Propine), the nurse would dipivefrin. Options 1, 2, and 4 are incorrect for the administration of dipivefrin. provide which of the following instructions? ‐ Gently squeeze eyes closed for 30 seconds immediately after instillation of medication. ‐ Close, but do not squeeze, the eyes immediately after instillation of medication. ‐ Do not blink for 30 seconds after instillation of medication. ‐ Close the eyes for one full minute after instillation of medication. | Use the process of elimination and knowledge of basic care in the instillation of eye medications to select option 3. Review the procedure for instillation of eye medication if this was difficult. |
3018 A client receiving hydroxyamphetamine (Paredrine) Correct answer: 4 Confusion and increased heart rate are signs of toxicity or adverse side effects of for open‐angle glaucoma demonstrates an hydroxyamphetamine. Stinging, headache, and brow ache are usual side effects of understanding of the medication's serious side effects hydroxyamphetamine. when informing the health care provider of which of the following symptoms? ‐ Stinging on instillation ‐ Occasional headache ‐ Occasional brow ache ‐ Confusion | In order to answer this question correctly, recall the toxic side effects of the medication. Option 2 and 3 can be eliminated, since there is only an “occasional” problem. Option 4 could indicate a central nervous system problem that could indicate toxicity. Review the high‐risk complications of the medication if this was difficult. |
3019 A client is scheduled for an ophthalmic examination. Correct answer: 3 Ophthalmic epinephrine is used to produce mydriasis for ocular examination. Dilation of pupil Before administering the prescribed epinephrine further constricts ocular fluid outflow, possibly causing an acute attack of glaucoma in a client solution, the nurse would assess for which of the with narrow‐angle glaucoma. Systemic absorption also causes hypertension and tachycardia. following conditions? Brow ache is a typical side effect of adrenergic agonists such as epinephrine (option 4). ‐ Hypotension ‐ Wide‐angle glaucoma ‐ Narrow‐angle glaucoma ‐ Brow ache | Recall the pathophysiology of glaucoma to answer this question. The question is not specific about the type of eye condition, but knowing that an epinephrine solution results in dilation will enable consideration of glaucoma and the complication associated with it. If this was difficult, review the general principles associated with an ophthalmic examination. |
3020 Which of the following statements by a client Correct answer: 1 Clients receiving ophthalmic corticosteroids have an increased risk of infection. Contact receiving ophthalmic corticosteroids indicates a need lenses should not be used during ophthalmic corticosteroid therapy. Options 2, 3, and 4 for further teaching? indicate an appropriate understanding of ophthalmic corticosteroid therapy. ‐ "I remove my contact lenses before instilling the medication, then put them back in after 30 minutes." ‐ "I am not wearing my contact lenses for the duration of the corticosteroid treatment." ‐ "I will take my medication for the length of time prescribed by my physician." ‐ "I will return to my physician to have my eyes examined after my treatment is completed." | Note two items to consider when selecting the correct option to this question: safety, and which of the statements indicates the client does not understand the teaching. Options 2, 3, and 4 indicate that the client understands safe care during eyedrop instillation. Option 1 should be the selection, since this indicates a lack of safe care and the client not understanding eye drop instillation. |
3021 Which of the following actions by the client indicates Correct answer: 1 Eyedrops are considered sterile. To reduce the chance of introducing organisms into the eye, an understanding of the proper administration the dropper should not touch the eye, eyelashes, or any other object. The dropper should not techniques for ophthalmic solutions? be rinsed with water (option 2). The eyes should not be squeezed tightly shut after instilling the medication (option 3). The medication is instilled into the conjunctival sac, not directly onto the eye (option 4). ‐ The client does not allow the tip of the dropper to touch the eye or any other object. ‐ The client rinses the eyedropper with water after every application. ‐ The client squeezes her eyes tightly shut after administration of solution. ‐ The client pulls the lower lid down, and drops the solution onto the eye. | Use the process of elimination and knowledge of basic care in the instillation of eye medications to select option 3. Review the procedure for instillation of eye medication if this was difficult. |
3022 A client complains of dizziness and nausea upon self‐ Correct answer: 1 The internal ear is sensitive to temperature extremes. Administration of cold medication into administration of ear drops. After discussing the the ear can cause dizziness and nausea. To avoid these conditions, the client should warm the client's usual medication administration procedure, medication to body temperature before administering the eardrops (option 2). The dizziness is the nurse determines that which of the following is unrelated to hypersensitivity (option 3) or speed of administration (option 4). likely the cause of these symptoms? ‐ The client does not warm the medication bottle before administering the medication. ‐ The client warms the medication bottle before administering the medication. ‐ The client is experiencing a hypersensitivity reaction to the medication. ‐ The client is administering the medication too quickly. | Use the process of elimination and knowledge of basic care in the instillation of ear medications to select option 1. Review the procedure for instillation of ear medication if this was difficult. |
3023 A client with open‐angle glaucoma is receiving Correct answer: 2 Latanoprost is a prostaglandin agonist that increases the outflow of aqueous humor to latanoprost (Xalatan) for treatment. When assessing decrease intraocular pressure (not decreasing outflow, as in option 1). Beta‐blockers, the client's response to the medication, the nurse adrenergics, and sympathomimetics decrease intraocular pressure by decreasing aqueous expects therapeutic effects to be the result of which of humor production (option 3 and 4). the following? ‐ A decrease in the outflow of aqueous humor ‐ An increase in the outflow of aqueous humor ‐ A decrease in aqueous humor production ‐ An increase in aqueous humor production | Recall the pathophysiology and usual treatment for glaucoma to correctly answer this question. Use this knowledge about glaucoma to be able to eliminate all the options except 2, which is the goal behind the treatment for clients with glaucoma. |
3024 A client receiving ophthalmic scopolamine Correct answer: 2 Dry mouth could be a sign of toxicity in the client receiving scopolamine hydrobromide. hydrobromide telephones the ophthalmic clinic to Tachycardia is also a sign of toxicity. For these symptoms, the client is instructed to withhold report a dry mouth. The nurse should instruct the the medication and seek immediate evaluation for toxicity. Options 1, 3, and 4 are incorrect client regarding which of the following? instructions that place the client at risk. ‐ Dry mouth is a normal side effect of scopolamine hydrobromide. ‐ Withhold the medication, and return to the clinic immediately. ‐ Increase oral fluid intake to 2,000 mL per day. ‐ Dry mouth is not a side effect or a sign of toxicity for scopolamine hydrobromide. | Recall the side effects and client responses to the medication. Recognize that that the other three options do not address the complication of toxicity. |
3025 Which of the following statements made by the client Correct answer: 2 Systemic absorption of beta‐blocking agents such as carteolol can lead to serious receiving ophthalmic carteolol (Ocupress) indicates the cardiovascular and pulmonary side effects. Nasolacrimal pressure is applied to prevent client understands the nurse's teaching about systemic absorption of ophthalmic medications. Options 1, 3, and 4 are incorrect techniques. medication self‐administration? ‐ "I will put pressure on the lacrimal duct to prevent the medication from running out of my eye." ‐ "I will put pressure on the lacrimal duct to prevent systemic absorption of the medication." ‐ "I will not put pressure on the lacrimal duct." ‐ "I will put pressure on the lacrimal duct only if the medication runs out of my eye." | Use the process of elimination and knowledge of basic care in the instillation of eye medications to select option 2. Review the procedure for instillation of eye medication if this was difficult. |
3026 A client being treated with dipivefrin (Propine) for Correct answer: 2 Dipivefrin lowers intraocular pressure by decreasing aqueous humor production and glaucoma asks for an explanation regarding how the increasing aqueous humor outflow. Options 1, 3, and 4 are either partially or totally incorrect. medication will affect the disease. The nurse's explanation includes that dipivefrin lowers intraocular pressure by which of the following actions? ‐ A decrease in aqueous humor production and a decrease in the outflow of aqueous humor ‐ A decrease in aqueous humor production and an increase in the outflow of aqueous humor ‐ A decrease in aqueous humor production ‐ An increase in aqueous humor product | To correctly answer this question, recall the pathophysiology and usual treatment for glaucoma. Use this knowledge about glaucoma to eliminate all the options except 2, which is the goal behind the treatment for clients with glaucoma. |
3027 The nurse explains to a client that a product Correct answer: 3 Alpha‐hydroxy acids are useful keratinolytics that help reduce the effects of photoaging. containing which of the following ingredients would be Propylene glycol is used to treat ichthyosis. Salicylic acid and resorcinol are keratinolytics that the most useful agent to treat photoaging of the skin? are used to treat a variety of other skin disorders. ‐ Propylene glycol ‐ Salicylic acid ‐ Alpha‐hydroxy acids ‐ Resorcinol | The core issue of the question is knowledge of products that assist the skin to appear younger and resist the aging effects of light. Use knowledge of these ordinary products and the process of elimination to make a selection. |
3028 The nurse would include which of the following pieces Correct answer: 4 Emollients contain petrolatum, oils, propylene glycol, or other substances, and make the skin of information when explaining the skin emollient soft and pliable by increasing hydration of the stratum corneum. They do not dry the skin Dermasil to a client? (option 2) or contain corticosteroids (option 3). Option 1 is not always necessary. ‐ It requires shaking before each use. ‐ It has a drying effect on the skin when the water evaporates. ‐ It includes a corticosteroid component. ‐ It is of use when skin is dry. | The core issue of the question is general knowledge of integumentary products that are emollients. Use knowledge of these ordinary products and the process of elimination to make a selection. |
3029 What instructions should the nurse give the client Correct answer: 4 Tretinoin is a retinoic acid derivative that needs to be applied once daily in a thin layer before who is receiving tretinoin (Retin‐A)? retiring. The area to be treated should be washed at least 30 minutes before applying. Increased intake of vitamin A, not vitamin C, needs to be avoided. ‐ Apply the preparation in the morning. ‐ Use gloves, and apply a thick layer four times a day. ‐ Avoid products containing vitamin C. ‐ Apply to dry skin 30 minutes after washing. | The core issue of the question is knowledge of proper use of tretinoin. Use medication knowledge and the process of elimination to make a selection. |
3030 The nurse anticipates that mafenide (Sulfamylon) Correct answer: 1 Mafenide is useful in treatment of partial‐ and full‐thickness burns to prevent septicemia would be ordered for use if it is known that a client’s caused by organisms such as Pseudomonas aeruginosa. Mafenide does not have a defined use burn is infected with which of the following with the other infectious organisms mentioned. organisms? ‐ Pseudomonas aeruginosa ‐ Tubercle bacillus ‐ Methicillin‐resistant Staphylococcus aureus ‐ Candida albicans | The core issue of the question is knowledge of the uses of mafenide in a client with burn injury. Use medication knowledge and the process of elimination to make a selection. |
3031 A female client who is using salicylic acid to treat Correct answer: 2 There is no cure for psoriasis. Psoriasis is notoriously chronic and recurrent. The cause is psoriasis asks how long she will have to use this drug. unknown. Each situation is individual, and the dermatologist who knows the client s situation Which of the following would be the best response by the longest is a good resource, but nevertheless, the best answer for most clients is that the the nurse? disease is recurrent, and therapy will need to be continued. ‐ “Response is rapid, and the drug will not be needed after three months of therapy.” ‐ “Drugs often do not produce prolonged remission, and maintenance therapy often is needed.” ‐ “Each situation is so individual that it is not possible to answer the question accurately.” ‐ “The dermatologist caring for you is the best resource for such a question.” | The core issue of the question is general knowledge about medications used to treat psoriasis. Use medication knowledge and the process of elimination to make a selection. |
3032 The nurse would recommend that a client with Correct answer: 2 A 1% lotion of selenium sulfide is used to relieve the itching and flaking of the scalp excessive dandruff use a medicated shampoo that associated with dandruff. A shampoo with lindane 1% (Kwell) would be used for pediculosis contains which of the following active ingredients? capitis. Corticosteroids can be used for many things, but dandruff is not one of them. Silver sulfadiazine is a cream used in the prevention and treatment of infection in partial‐ and full‐ thickness burns. ‐ Silver sulfadiazine ‐ Selenium sulfide ‐ Corticosteroid ‐ Lindane | The core issue of the question is general knowledge about medications used to treat dandruff. Use medication knowledge and the process of elimination to make a selection. |
3033 It is winter, and the client has extremely dry skin. Correct answer: 3 Dry skin can occur in otherwise healthy skin, and is usually worse in winter, when forced‐air Which type of preparation should the nurse heating reduces humidity inside many dwellings. Excessive washing with harsh soaps (such as recommend first? Dial) strips stratum corneum of its natural lipids, and exacerbates dry skin. No shake lotion is made specifically for management of dry skin. Itching can occur with dry skin, but before an antipruritic lotion is used, an emollient lotion or emollient should be tried. Emollient lotions are dilute dispersions of emulsified lipids in water. These provide smooth application and the most rapid hydration if applied to dry skin, but they do not provide a protective effect on the lipid barrier. Emollients (e.g., petrolatum) are occlusive agents that make the skin soft and pliable by increasing hydration of the stratum corneum. ‐ Regular use of soap, such as Dial ‐ Shake lotion ‐ Emollient or emollient‐containing lotion ‐ Antipruritic lotion | The core issue of the question is general knowledge about products used to treat dry skin. Use product knowledge and the process of elimination to make a selection. |
3034 Which of the following client disorders might require Correct answer: 1 Acyclovir is an antiviral agent that is useful in the treatment of herpes simplex viruses. The the use of acyclovir (Zovirax)? other conditions would require therapy with an anti‐infective, but not of the antiviral type. ‐ Herpes simplex viruses ‐ Chronic dermatitis ‐ Pseudofolliculitis ‐ Candidiasis | The core issue of the question is knowledge of the uses of acyclovir in a client with herpes infection. Use medication knowledge and the process of elimination to make a selection. Remember that an antiviral medication often contains vir somewhere in its name. |
3035 A child has scraped his finger on a sharp spot on a Correct answer: 1 Bacitracin is a topical antibiotic that is bactericidal against Gram‐positive cocci and bacilli, shower door edge. The mother would like to use a including staphylococci and streptococci. These organisms might cause infection in a skin topical antibiotic to prevent infection. Which agent wound. Malathion (option 2) is an antiparasitic agent for pediculosis. Ketoconazole (option 3) would the pediatric telephone consultation nurse is an antifungal agent. Mafenide (option 4) is an agent used for burns. recommend? ‐ Bacitracin (Baciguent Topical) ‐ Malathion (Ovide Lotion) ‐ Ketoconazole (Nizoral) ‐ Mafenide (Sulfamylon) | The core issue of the question is knowledge of the types of medications used for various skin conditions. Use medication knowledge and the process of elimination to make a selection. Remember that cuts or open wounds often heal effectively when topical antibiotics are used to prevent infection at the site. |
3036 The elderly client is being treated for a pressure ulcer. Correct answer: 4 Ulcers with necrotic material should be debrided, either by sharp debridement (e.g., using a The nurse would anticipate use of which of the scalpel) or chemical debridement (e.g., wound cleanser, such as an enzyme). An example of following types of agents to topically debride this such a preparation is collagenase (Santyl), which is inactivated by metal salts, ulcer? hexachlorophene, or acidic solutions. Hydrocolloid dressings can be helpful with uninfected wounds with fibrinous bases. Topical antibiotics will not help remove necrotic material. Allylamines are selected for fungal infections. ‐ Hydrocolloid dressing ‐ Antibiotic‐impregnated gauze packing ‐ Allylamine ‐ Enzyme | The core issue of the question is the type of topical agent to use when debridement is needed. Use medication knowledge and the process of elimination to make a selection. Enzymes often end in ase, which makes them easy to recognize on sight. |
3037 The nurse is preparing to do tracheostomy care, and Correct answer: 2 Hydrogen peroxide is an oxidizing antiseptic that can be used to clean wounds or notes that the client s tracheostomy has encrusted tracheostomy tubes. Options 1 and 3 as cleaning agents do not have the bubbling action of debris around the tube. The nurse should dilute which hydrogen peroxide. Mafenide is an antimicrobial used to treat burn injury. of the following antiseptic solutions to half strength to most effectively clean the skin around the tracheostomy? ‐ Iodine | The core issue of the question is knowledge of the type of skin cleansing agent used for tracheostomy. Use knowledge of these agents and the process of elimination to make a selection. |
‐ Hydrogen peroxide ‐ Chlorhexidine ‐ Isopropyl alcohol | |
3038 The physician’s order sheet calls for topical Correct answer: 4 Proteolytic enzymes such as Elase ointment can be used to chemically debride tissue. These application of the proteolytic enzyme Elase. The nurse areas commonly include venous stasis ulcers, burn wounds, and pressure ulcers. The areas carries out this order by applying this product to which listed in the other options are not appropriate for treatment with proteolytic enzymes. of the following areas on the client? ‐ External ear canal ‐ Rectal area ‐ Dry skin on feet ‐ Sacral pressure ulcer | The core issue of the question is knowledge of the debriding agents appropriate for use at various skin sites. Use knowledge of these agents and the process of elimination to make a selection. |
3039 The nurse explains to a client who seeks treatment Correct answer: 3 A keratinolytic agent such as salicyclic acid is used to treat warts. Keratinolytics are also used for a wart that which of the following types of to treat corns, calluses, and other keratin‐containing skin lesions. Astringents cause topical products will be effective in removing this growth? vasoconstriction. Antiseptics inhibit bacterial growth. Proteolytic enzymes are used to debride tissue. ‐ Astringent ‐ Antiseptic ‐ Keratinolytic ‐ Proteolytic | The core issue of the question is what type of medication is effective in treating warts. Begin to answer by reasoning that treatment of a wart includes breaking it down for removal. Next note the suffix ‐lytic in the correct option, which means “to break down.” |
3040 The nurse would be most careful when using a topical Correct answer: 3 Children have an increased risk of systemic toxicity from topically applied drugs because of drug for a client in which of the following age groups, the greater ratio of surface area to weight. The other responses are incorrect because they because of increased risk of toxicity? have similar body surface area–to‐weight ratios. ‐ Middle‐aged adult ‐ Older adult ‐ Child ‐ Adolescent | The core issue of this question is the age group that is at greatest risk because of its skin characteristics when topical drugs are used. Recall that the greater the area involved, the greater the risk of absorption and toxic effects. Finally, recall that infants and children have a greater skin surface–to‐weight ratio than an adult of any age. |
3041 Which of the following types of dermatological Correct answer: 1 Acne can be successfully treated with drying agents. Steroids would be of no benefit for this products would the nurse recommend as having the problem. Emollients and lubricants are moisturizers that might worsen the condition. most benefit for a client with acne? ‐ Drying agent ‐ Steroid ‐ Emollient ‐ Lubricant | The core issue of the question is what type of medication is effective in treating acne. Since this condition is characterized by inflammation and drainage, consider that an agent that has a drying effect would be opposite to the characteristics of the condition, and would help reduce symptoms. |
3042 The nurse would evaluate for which of the following Correct answer: 4 Corticosteroids such as hydrocortisone are anti‐inflammatory drugs. They do not exert effects in a client who has been using hydrocortisone antimicrobial action, and, in fact, they can increase risk of infection by suppressing the 1% cream (Ala‐Cort) as a topical agent? inflammatory response. Corticosteroids are not moisturizing or drying agents. ‐ Moisturizing ‐ Drying ‐ Antimicrobial ‐ Anti‐inflammatory | The core issue of the question is knowledge of the intended effects of corticosteroids as anti‐inflammatory agents. Use this information and the process of elimination to make a selection. |
3043 A client with psoriasis needs to apply a lubricating Correct answer: 1 Psoriatic plaques need to be lubricated so that they are easier to loosen and remove. lotion to a psoriatic placque. The nurse plans to teach Emollients and lubricants are fatty or oily substances that can be used for this purpose because the client to use which of the following types of they keep skin soft, and prevent water evaporation. The other products listed are harsher, and substances? some might have a drying effect. ‐ Emollient ‐ Antiseptic ‐ Alcohol ‐ Astringent | Note the word lubricating in the stem of the question. This tells you that regardless of the client s health problem, the agent is one that has a moisturizing effect on the skin. Use the process of elimination and knowledge of the categories of skin products to make a selection. |
3044 The nurse prepares to apply which ordered type of Correct answer: 2 Silver sulfadiazine is a metallic type of antiseptic that is widely used on burns. The silver in the antiseptic to a client with a burn wound once the area solution is toxic to bacteria, and prevents them from reproducing. The agents in options 3 and has been cleansed with sterile saline? 4 would not be beneficial. Option 1 is a fictitious solution. ‐ Copper‐containing ‐ Silver‐containing ‐ Biguanide ‐ Acetic acid | The core issue of the question is the type of agent that would be effective in preventing microbial growth in a client with a burn injury. Use knowledge of topical antimicrobial agents and the process of elimination to make a selection. |
3045 The nurse anticipates that a wound infection that is Correct answer: 4 A chlorine preparation such as Dakin s solution is used for infected wounds when other resistant to treatment with several antiseptics will treatments are ineffective. They are useful because they also dissolve necrotic materials and most likely respond to treatment with which of the blood clots; however, a disadvantage is that they delay blood clotting, which later could following antiseptics? interfere with wound healing. Options 1, 2, and 3 are not helpful in treating infections resistant to several antiseptics. ‐ Hydrogen peroxide ‐ Phenol derivative ‐ Isopropyl alcohol ‐ Dakin’s solution | The core issue of the question is knowledge of antiseptics that are useful in treating problems involving the skin. Use this knowledge and the process of elimination to make a selection. |
3046 The nurse is choosing a protective wound dressing for Correct answer: 1 Tegaderm is a protective dressing that is permeable to oxygen. The other products listed do a client. Which of the following products should be not have this advantage. DuoDERM and Tegasorb are absorbent products that exclude bacteria used when selecting a dressing that is permeable to and adhere to the site. Replicare excludes bacteria. oxygen? ‐ Tegaderm ‐ DuoDERM ‐ Replicare ‐ Tegasorb | The core issue of the question is the type of dressing that is permeable to oxygen. Use the process of elimination and knowledge of wound care products to make a selection. |
3047 The nurse is working with a client newly diagnosed Correct answer: 1 Psoriasis is a common, chronically recurring skin disease with scaly patches of varying size with psoriasis. The client asks the nurse about this most commonly seen on elbows, knees, and scalp. Pityriasis rosea is a common skin disorder disorder. Which of the following responses by the generally localized to the chest and trunk of young adults, and characterized by erythematous nurse is best? discrete lesions (option 2). Option 3 is a vague description unrelated to psoriasis. Contact dermatitis (option 4) develops after exposure to an irritant or allergen. ‐ "It is a chronic skin disorder characterized by whitish, scaling patches." ‐ "It is a disorder with reddish‐colored lesions of the chest and trunk that usually do not recur." ‐ "It is a skin disease characterized by redness, tenderness, and edema." ‐ "It is a contact dermatitis that can involve any part of body." | In selecting the best option for this question, it is important to be as complete as possible with responses to the client. Option 1 is the only correct answer; the other options could be eliminated because they are not complete. For example, option 3 lists the word disease, which is not the case with a skin disorder. |
3048 A child has been diagnosed as having impetigo. The Correct answer: 2 Mupirocin is a topical antimicrobial agent effective against impetigo caused by nurse anticipates that which topical agent will be Staphylococcus aureus, beta‐hemolytic streptococci, and Streptococcus pyogenes. prescribed? Ketoconazole is an antifungal agent; capsaicin is a topical agent that has been useful in certain painful syndromes; and acyclovir is an antiviral agent. ‐ Ketoconazole (Nizoral) | Knowing the causative agent for the diagnosis will assist in selecting the correct answer. Recall the classification of the medications in determining which is the best option. If this was difficult, review the diagnosis and usual method of treatment. |
‐ Mupirocin (Bactroban) ‐ Capsaicin (Capsin) ‐ Acyclovir (Zovirax) ointment | |
3049 The nurse should teach a client to use which one of Correct answer: 3 Synthetic detergent bars are milder on the skin. Dove is classified as synthetic detergent bar. the following for a skin disorder in which the use of Dial and Safeguard are deodorant soaps of a harsher nature. Ivory is classified as a true soap. mild soap is needed? ‐ Dial ‐ Safeguard ‐ Dove ‐ Ivory | Using the process of elimination will lead to the correct answer. The question lists the word “mild,” so the choice would be the soap that would be least abrasive to the skin. |
3050 The nurse conducting a community health teaching Correct answer: 4 The effectiveness of a sunscreen when compared to no use of sunscreen is usually indicated session explains that sunscreen with an SPF of 6 means by its sun protection factor (SPF) (e.g., 6, 15, 30). Option 1 is a false interpretation. Sunscreens that the product has which of the following also can be classified as water‐resistant (option 2) or waterproof (option 3), but the SPF characteristics? number does not indicate this information. ‐ Provides protection from sun's rays for six hours. ‐ Is water‐resistant, but not waterproof. ‐ Is waterproof for six immersions in the water. ‐ Provides six times the sun exposure protection as use of no sunscreen. | Recall knowledge that SPF is an abbreviation for "sun protection factor" to allow selection of the correct option, 4. |
3051 The nurse anticipates that which of the following Correct answer: 2 Lindane has long been considered an appropriate treatment for pediculosis (lice). Terbinafine agents would be used to treat pediculosis infestation is an antifungal agent for tinea infections. Collagenase is an enzyme used as a debriding in an adult client? preparation. Chlorhexidine is a skin and wound cleanser. ‐ Chlorhexidine (Hibiclens) ‐ Lindane (Kwell) ‐ Collagenase (Santyl) ‐ Terbinafine (Lamisal) | In order to select the correct answer, recall that the usual treatment for pediculosis is with lindane. Use this knowledge to select the correct option. |
3052 An adult client has scabies on the trunk. Permethrin Correct answer: 1 Permethrin is the preferred treatment for scabies at the present time. A variety of treatment (Elimite Cream) is prescribed. What instructions should protocols are suggested, but the greatest success is reported when product is left on for at be given to the client? least 8 hours. If the treatment is repeated, it is repeated at 7 days, not 6 hours (option 3). Household articles in direct contact with the client need to be thoroughly washed or disinfected, or both, but the human is the host for this parasite (option 4). Kwell can be used for pediculosis or scabies, but two similar agents would not be used together (option 2). ‐ "Apply the agent from the neck down. Leave on for 8–14 hours before washing it off." ‐ "Use this product with an agent such as lindane (Kwell)." ‐ "Apply the agent to the affected area; repeat application in 6 hours." ‐ "Treat the clothing rather than the body." | Use the process of elimination and knowledge of the usual treatment for scabies to lead you to option 1. It is important not to confuse scabies with pediculosis, as several of the options relate to treatment of pediculosis. Review treatment of scabies if this was difficult. |
3053 The nurse explains to a client with acne that which of Correct answer: 2 Benzoyl peroxide has bactericidal activity against Propionibacterium acnes. It is available in the following products is one of the most effective over‐the‐counter and prescription formulations, including bar soaps, washes, gels, and lotions, topical agents for use in treating this condition? in a variety of concentrations. Mafenide (option 1) is a preparation used in burn therapy. Chlorhexidine (option 3) is a skin and wound cleanser; it may be used for preoperative preparation of the skin. Cryotherapy (option 4) is a treatment used for some warts. ‐ Mafenide (Sulfamylon) ‐ Benzoyl peroxide ‐ Chlorhexidine (Hibiclens) ‐ Cryotherapy | Recall knowledge of the correct treatment for acne to lead to the correct option. The question is not asking about anything other than the best choice of medication. This can be determined with knowledge of the usual treatment for acne. |
3054 The nurse would provide instructions about how to Correct answer: 4 Isotretinoin is available in capsule form. The other products are also used for acne, but are take which oral agent that can be used in treatment of topical preparations. acne? ‐ Adapalene (Differin) ‐ Tretinoin (Retin‐A) ‐ Clindamycin (Cleocin T) ‐ Isotretinoin (Accutane) | Recall knowledge of the usual method of administration to assist in selecting the correct option. Since option 4 is the only oral medication, and the question states the word "oral" in the stem, this would be the correct answer. The other options are all incorrect. If this was difficult, review methods of administration of the medications. |
3055 Silver sulfadiazine (Silvadene) is used to prevent and Correct answer: 2 Silver sulfadiazine reacts with DNA and releases sulfadiazine. The silver replaces the hydrogen treat sepsis in burns. The Burn Unit nurse explains to bonding between strands of DNA, and prevents replication of the bacteria. It does not facilitate an orientee that an important point about its skin cell replication, and it is not of small molecular size. It is not classified as an antifibrinolytic mechanism of action is its: agent. ‐ Facilitation of skin cell replication. ‐ Replacement of hydrogen bonding between DNA strands. ‐ Antifibrinolytic property. ‐ Small molecular size. | In order to correctly answer this question, recall the mechanism of action of the medication. If this was difficult, review the medication s action, along with the classification. |
3056 A client is to receive medication to treat external Correct answer: 1 Salicylic acid preparations are useful for the removal of common warts. Povidone‐iodine warts. The nurse would prepare instructions related to (option 2) is used to prepare or cleanse skin preoperatively; masoprocol (option 3) is indicated which of the following medications? for actinic keratosis; and crotamiton (option 4) is an antiparasitic drug. ‐ Salicylic acid (Duofilm) ‐ Povidone‐iodine (Betadine) ‐ Masoprocol (Actinex) ‐ Crotamiton (Eurax) | Having knowledge of the correct treatment for external warts will lead to the correct option. The question is not asking about anything other than the best choice of medication. This can be determined with knowledge of the usual treatment for external warts. |
3057 The nurse would apply a closed soak to a client's skin Correct answer: 4 Closed soaks lead to heat retention, and are not used for a cooling effect. They are typically to achieve which of the following benefits? applied for 1–2 hours at a time, 2–3 times a day. They are not impermeable to air. ‐ Cooling effect ‐ Impermeability to air ‐ Ability to change it once every three days ‐ Heat retention | In determining the best answer for this question, think of the vasoconstriction. In a closed area there is heat conservation, which would lead to the only correct option, 3. |
3058 The nurse recommends the use of a topical cream to Correct answer: 1 A cream is an emulsion of oil in water; an ointment is considered to be a water‐in‐oil product. a client who needs which of the following ingredients Lotions are suspensions of powder in water or a liquid emulsion of thin consistency. A cream in a skin product? might or might not contain an antimicrobial agent, and it is not a drying agent. ‐ Emulsifying agent ‐ Ointment ‐ A drying agent ‐ Lotion | The question is asking for selection of a skin product. Option 3 can be eliminated because the question is not referring to the need to dry the skin. Options 2 and 4 are too broad for the client. This would leave correct option 1. |
3059 The nurse teaches the client that which of the Correct answer: 3 Iodine preparations stain skin and clothing. Benzalkonium, hexachlorophene, and hydrogen following skin cleansers is likely to stain the skin peroxide do not cause staining. and/or clothing? ‐ Benzalkonium (Zephiran) ‐ Hexachlorophene (Phisohex) ‐ Povidone‐iodine (Betadine) | Note the word iodine in option 3. Knowing that iodine stains the skin and clothing would allow selection of this option. |
4.‐ Hydrogen peroxide | |
3060 The nurse would plan to use DuoDERM for a client Correct answer: 4 DuoDERM is indicated for ulcers with moderate drainage, but which are uninfected. Agents with which of the following skin conditions? like Iodosorb might be used for ulcers with necrotic material (option 3), and Hydrasorb with ulcers with heavy drainage (option 2). Antimicrobials may be used to treat infected wounds. ‐ An infected wound ‐ An ulcer with heavy drainage ‐ An ulcer with moderate amounts of necrotic material ‐ An uninfected venous stasis ulcer | Knowledge that DuoDerm can only be used for wounds that are not infected will allow selection of option 4. All the other options allude to infections, and therefore can be eliminated. |
3061 A client with acne is prescribed oral minocycline. The Correct answer: 2 Minocycline can lead to development of a lupus‐like syndrome, and also can cause nurse would explain to the client that a disadvantage pigmentation changes. Minocycline does not suppress sebum production (option 1), lead to (or disadvantages) of this preparation is/are which of spontaneous abortions (option 4) or have low/lack of treatment efficacy (option 3). the following? ‐ Suppression of sebum production ‐ Lupus‐like syndrome, and pigmentation changes ‐ Lack of treatment efficacy ‐ Occurrence of spontaneous abortions | In order to select the correct answer, recall the side effects of the medication minocycline. If this was difficult, review the side effects of the medication. |
3062 The nurse who is using a very high–potency topical Correct answer: 2 Potent topical steroid therapy should be tapered within 2 weeks. Very high–potency topical corticosteroid would generally plan to use it: corticosteroids can induce atrophy, telangiectasis, and striae as early as 2–3 weeks following daily application. High‐potency topical corticosteroids and use of occlusion could induce hypothalamic‐pituitary‐adrenal (HPA) axis suppression and adverse reactions typically associated with chronic oral therapy. Dosing of topical corticosteroids more frequently than 2–3 times daily neither is indicated nor has proven benefit. ‐ For any type of skin disorder. ‐ For no longer than 2 weeks. ‐ Under an appropriate dressing. ‐ At least four times a day for best effect. | Note the words “very high–potency” in the question stem. Using the process of elimination should lead to an option that indicates short‐term use, as in answer 2. |
3063 The client has moderate acne. After assessment, a Correct answer: 1 Adverse reactions of acne preparations can include erythema; burning or stinging; excessive topical preparation of benzoyl peroxide is dryness; and increased susceptibility to sunburn. Directions include using a thin application recommended. The nurse will advise the client not to twice a day. Excessive use would be more likely to result in evidence of adverse reaction than overuse the product because it could result in which of would use as per product directions. Adverse reactions do not include extreme pruritus (option the following problems? 2), non‐healing lesions (option 3), or localized infection (option 4). ‐ Excessive dryness ‐ Extreme pruritus ‐ Lack of healing of lesions ‐ Localized infection | Note the word “peroxide” in the stem of the question. Realizing that peroxide is drying will lead, by the process of elimination, you to option 1. None of the other options mention drying, and they can therefore be eliminated. |
3064 An 18‐year‐old female client has severe acne. There Correct answer: 3 Accutane is an oral preparation that is a known teratogen; strict adherence to avoidance of has been no improvement from the use of various pregnancy is mandatory. Accutane is contraindicated with pregnancy because of the preparations, and isotretinoin (Accutane) is being occurrence of spontaneous abortions, as well as major abnormalities in the fetus at birth, such prescribed. The nurse evaluates that the client as hydrocephalus. Elevated triglyceride levels might occur, but changes in hormone functioning understood medication instructions if the client stated (option 4) are not anticipated. The medication should be applied thinly (option 1), and sun to do which of the following? exposure provides no added benefit (option 2). ‐ Apply a thick layer of isotretinoin twice a day. ‐ Increase exposure to the sun for added benefit. | Knowing that isotretinoin (Accutane) that has terotogenic effects, as well as that the client is an 18‐year‐old female, should assist in selecting the correct option, 3. The other options are incorrect, since they do not address the teratogenic effects of the medication. |
‐ Have a pregnancy test prior to beginning therapy, and use contraception. ‐ Have blood drawn for hormonal studies monthly for the first six months. | |
3065 A client who experienced a burn injury is being Correct answer: 3 Mafenide acetate is a water‐soluble cream that is used to treat burn injuries. It can cause a treated with topical mafenide acetate (Sulfamylon). stinging or burning sensation after it is applied, and this is considered to be normal. Options 1 The client reports a stinging and burning sensation and 2 are inappropriate actions, while option 4 will not prevent stinging of the medication. when the medication is applied. The nurse determines that it would be appropriate to do which of the following? ‐ Withhold the medication, and notify the physician. ‐ Wash off that dose of the medication. ‐ Explain that this is a normal sensation. ‐ Chill the preparation before using it next. | Being aware of the clinical manifestations of the medication will assist in selecting the correct answer. If this was difficult, review the clinical manifestations, as well as nursing interventions, of the medication. |
3066 A client has developed a bacterial infection in skin Correct answer: 4 The two most common organisms causing infection are Staphylococcus aureus and damaged by thermal trauma. The nurse anticipates Streptococcus pyogenes. Herpes simplex and herpes zoster are members of the herpes virus that wound culture will reveal the presence of one or family. Dermatophytes cause fungal infections of the skin, such as tinea capitis and tinea pedis. both of which two most common causative agents? Haemophilus aegyptius causes pinkeye. Haemophilus influenzae can cause meningitis, pneumonia, and serious throat and ear infections. ‐ <i>Haemophilus influenzae</i> and <i>Haemophilus aegyptius</i> ‐ Herpes simplex and herpes zoster ‐ Tinea capitis and tinea pedis ‐ <i>Staphylococcus aureus</i> and <i>Streptococcus pyogenes</i> | Using the process of elimination, option 4 can be the only correct answer. Options 2 and 3 would not be a causative agent in a thermal trauma, so eliminate them. Option 1 relates to a respiratory diagnosis, and can therefore be eliminated. |
3067 The nurse would include which of the following pieces Correct answer: 4 Emollients contain petrolatum, oils, propylene glycol, or other substances, and make the skin of information when explaining a skin emollient to a soft and pliable by increasing hydration of the stratum corneum. It does not dry the skin client? (option 2) or contain corticosteroids (option 3), and does not always require shaking before use (option 1). ‐ It requires shaking before each use. ‐ It has a drying effect on the skin when the water evaporates. ‐ It includes a corticosteroid component. ‐ It is of use when skin is dry. | Note that the question stem asks for an explanation of a skin emollient. The word emollient indicates a measure that would make the skin soft. Since emollients contain an oil base, the skin should be dry to begin with, unlike with a water base product, so that it can be absorbed better into the skin. If this was difficult, review the definition of an emollient. |
3068 The nurse explains to a client that the aluminum Correct answer: 1 Burow's solution is an astringent that coagulates bacterial and serum protein. It is classified as acetate solution (Burow's solution) ordered for a skin a soothing solution for the relief of inflammation associated with some skin problems. It is condition is which type of preparation? useful for conditions with vesicles where there is oozing, as might occur with poison ivy or allergic reactions. It is not an emollient (option 2), a detergent (option 3), or a balm (option 4). ‐ Soothing astringent ‐ Emollient ‐ Detergent ‐ Balm | In order to answer this question, recall the classification of the medication. If this was difficult, review the classification and purpose of aluminum acetate solution (Burow’s solution). |
3069 The nurse would assess a client for which of the Correct answer: 3 Side effects associated with the use of topical corticosteroids include acneiform eruptions, following side effects associated with topical allergic contact dermatitis, skin atrophy, burning sensation, dryness (option 2), itching, corticosteroid use? irritation, hypopigmentation (option 1), alopecia, and hypothalamic‐pituitary‐adrenocortical (HPA) axis suppression. Topical corticosteroids do not stain the skin (option 4). ‐ Hyperpigmentation ‐ Oiliness ‐ Burning sensation | In order to answer this question correctly, recall the common side effects of a topical corticosteroid. Options 1 and 4 are similar in that there is a skin color change, and therefore, they can be eliminated. Use knowledge of the side effects to be led to the correct option. |
4.‐ Staining of skin | |
3070 The client is experiencing severe itching with a skin Correct answer: 3 Hydroxyzine hydrochloride is an antihistamine that is a competitive inhibitor of the disorder. Which of the following drugs, if ordered, H<sub>1</sub> receptor. It is used to treat various reactions that are mediated by would the nurse administer as an appropriate oral histamine. It will decrease the pruritus produced by the release of histamine. Cimetidine is an preparation to decrease the itching? H<sub>2</sub> histamine antagonist, and these agents are not effective against hypersensitivity reactions. Lorazepam is a short‐acting benzodiazepine that is indicated for anxiety. Bupivacaine is a local anesthetic for nerve blocks. ‐ Cimetidine (Tagamet) ‐ Lorazepam (Ativan) ‐ Hydroxyzine (Atarax) ‐ Bupivacaine (Sensorcaine) | Knowing the action of the medications will lead to the correct answer, option 3. The other options are not used for complaints of itching. If this was difficult, review the purposes of the medication to assist in selecting the correct option. |
3071 The client has sustained both partial‐ and full‐ Correct answer: 3 Mafenide is a carbonic anhydrase inhibitor that rarely causes metabolic acidosis. In that thickness burns. Mafenide (Sulfamylon) is being used situation, the body would try to compensate to maintain a balanced pH. Hyperventilation or as part of treatment. While evaluating for potential labored respirations, and difficulty in breathing, would be evidence of the body's attempt to adverse reactions of this drug, the nurse will observe compensate. Mafenide would not cause diarrhea (option 1), hypertension (option 2), or the client for which of the following? abdominal pain (option 4). ‐ Diarrhea ‐ Hypertension ‐ Rapid breathing ‐ Abdominal pain | In order to answer this question correctly, recall the side effects of the medication. Knowledge that the medication does not cause gastrointestinal disturbances will allow elimination of options 1 and 4. Use knowledge of the side effects to select the correct option. |
3072 The client with partial‐thickness burns is being Correct answer: 4 Wound infection is a potential complication with burns. Microorganisms proliferate rapidly in managed as an outpatient. As part of client burn wounds. Monitoring arterial blood gases, and intake and output, is essential for the assessment, the nurse will do which of the following? hospitalized client with more severe burns, but these are not key assessments for clients being managed on an outpatient basis. The nurse removes any topical agents at the beginning of the dressing change, to allow for adequate wound assessment. ‐ Remove any topical treatment after making an assessment. ‐ Monitor arterial blood gases at periodic intervals. ‐ Evaluate fluid intake and output as a measure of hydration. ‐ Assess burn areas for evidence of infection and superinfection. | Note that the question stem asks for assessment of the burn. The only option that directly addresses assessment is option 4. Be certain to read carefully the question, and answer according to the nursing process requested. |
3073 The nurse is aware that in addition to anti‐ Correct answer: 2 Topical corticosteroids have vasoconstrictive action as well as anti‐inflammatory effects. They inflammatory effects, a mechanism of action of topical do not have fibrinolytic, emollient, or proteolytic effects. corticosteroids would be which of the following? ‐ Fibrinolytic ‐ Vasoconstriction ‐ Emollient ‐ Proteolytic | Recall knowledge of the mechanism of action of corticosteroids to be led to the only correct option, 2. If this was difficult, review the mechanism of action. |
3074 In planning care for a client receiving a topical Correct answer: 2 Medications that have ointment bases have enhanced penetration of skin lesions when used corticosteroid, which of the following vehicles would as topical preparations. The other options have less penetrating action. be most effective in enhancing the penetration of this medication? ‐ Gel ‐ Ointment ‐ Cream | Use the process of elimination and consider the words “enhancing penetration” to select option 2. Ointments have the highest level of absorption in the skin. |
4.‐ Lotion | |
3075 When evaluating the effectiveness of topical Correct answer: 2 The treatment of many skin disorders could take several weeks. A realistic timetable should preparations in treating a skin disorder, it is important be presented to clients. Drying soaps should not be used. It is unnecessary to use gloves for all for the nurse to utilize an understanding of which of preparations. Nonadherance to the prescribed regimen is sometimes a problem in managing the following? skin conditions. ‐ Washing the skin with drying soaps before application should be part of regimen. ‐ Skin lesions are often very slow to improve. ‐ Gloves should be used for application of all preparations. ‐ Nonadherance to the prescribed regimen is rarely a problem. | Note that the question stem asks for evaluation of the effectiveness of the treatment. The only answer that addresses evaluation of the nursing process is option 2. Options 1 and 3 are interventions in the nursing process. Option 4 does not address the question being asked. |
3076 A client has a diagnosis of psoriasis. The nurse Correct answer: 3 Anthralin is an antipsoriatic agent available as either a cream or ointment for the treatment anticipates that the client's medication history will of psoriasis. Hexachlorophene is a topical antiseptic that is incorporated into soaps, most likely reveal use of which of the following topical detergents, and other vehicles for topical use. Chlorhexidine is a skin and wound cleanser. agents as treatment for this condition? Capsaicin is a topical agent that has been useful in certain painful disorders. ‐ Hexachlorophene (Phisohex) ‐ Chlorhexidine (Hibiclens) ‐ Anthralin (Antra‐Derm; Drithocreme) ‐ Capsaicin (Capsin) | Recall that option 3 is the medication of choice for psoriasis to allow for elimination of the other options. If this was difficult, review the usual treatment for psoriasis. |
3077 A young child who has been taking growth hormone Correct answer: 2 Adverse/side effects during the first 2–3 months of treatment with growth hormone include (Somatropin) for one month is complaining of flank hypercalciuria, with resultant renal calculi. The client is not at increased risk for acute pain, colic, and GI symptoms. The nurse concludes that glomerulonephritis, bowel obstruction, or duodenal ulcer (options 1, 3, and 4). this client is at increased risk for which adverse effects that is more likely to occur during the first few months of treatment? ‐ Acute glomerulonephritis ‐ Renal calculi ‐ Bowel obstruction ‐ Duodenal ulcer | Note the key words in the question are first few months. This tells you that the adverse effect occurs soon after medication therapy begins. Use medication knowledge and the process of elimination to make a selection. |
3078 A client with coronary artery disease and Correct answer: 1 Clients with coronary artery insufficiency and hypertensive cardiovascular disease who take hypertension was recently diagnosed with diabetes ADH are at increased risk for developing fluid overload and edema. Option 2 is the opposite of insipidus. The nurse concludes that treatment with what would occur. Options 3 and 4 are not related to this client’s situation. antidiuretic hormone (ADH) is contraindicated for this client for which of the following reasons? ‐ Fluid overload and elevated BP could occur. ‐ Volume depletion and decreased blood pressure could occur. ‐ Overstimulation and agitation could occur. ‐ Hypercalciuria and renal calculi could occur. | Note that options 1 and 2 are opposite, which could be a clue that one of them is correct. Recall that ADH causes fluid retention to link this information with the associated risks for a client with cardiac disease. |
3079 A client with cardiovascular disease has been recently Correct answer: 2 Clients with known cardiovascular disease who are prescribed thyroid hormone replacement diagnosed with hypothyroidism, and levothyroxine therapy can develop chest pain that could lead to myocardial infarction. For this reason, it is (Levoxyl) has been prescribed. Which of the following the most important manifestation for the client to report. The other manifestations, if they signs and symptoms related to this medication is most occurred in this client, would have a lesser priority. important for the client to report to the physician? ‐ Increased urine output ‐ Chest pain | The critical words in the stem of the question are most important, which tell you that more than one answer might be correct, and that you must prioritize your answer. Use the ABCs (airway, breathing, and circulation) to select the answer most important to a client with cardiac disease (which affects circulation). |
‐ Increase in appetite ‐ Loose stools | |
3080 A client with a history of cardiac disease is exhibiting Correct answer: 3 Clients with severe symptoms of hypothyroidism and a history of cardiac disease must be severe symptoms of hypothyroidism, and is started on started on the lowest dose possible of hormone therapy and have the dose gradually medication therapy with levothyroxine (Synthroid). increased, in order to prevent onset of severe hypertension, heart failure, and myocardial The nurse anticipates that which of the following infarction (MI). The other options could put the client at risk for chest pain and subsequent MI. principles will be followed for initiation of drug therapy? ‐ The client will be started with the highest dose possible, and the dose will then be titrated according to the client’s response. ‐ The client will be started with the highest dose possible, and will be given a beta blocker to prevent any incidences of tachycardia. ‐ The client will be started with as low a dose as possible, and the dose will gradually be increased over a period of weeks. ‐ The client will receive a fixed dose calculated according to the client’s weight; this dose will not be adjusted unless necessary. | The core issue of the question is knowledge of the principles of beginning a medication that stimulates metabolism in a client with heart disease. Use knowledge of pathophysiology to select the option that causes the least stress on the heart during initiation of therapy. |
3081 A client with acute adrenal insufficiency (adrenal Correct answer: 3 Clients with acute adrenal insufficiency will complain of musculoskeletal symptoms of crisis) is admitted to the hospital. The nurse monitors weakness and fatigue; GI complaints of anorexia, nausea and vomiting, and weight loss; for resolution of which of the following manifestations integumentary symptoms of vitiligo and hyperpigmentation; and cardiovascular symptoms to determine that drug therapy with cortisone related to anemia, hypotension, hyponatremia, hyperkalemia, and hypercalcemia. The (Cortone) has been effective? manifestations in options 1, 2, and 4 are opposite those seen with adrenal insufficiency, and are therefore incorrect. ‐ Hyperexcitability and restlessness ‐ Increased appetite and weight gain ‐ Vitiligo and hyperpigmentation ‐ Hypertension and hypernatremia | The wording of the question tells you that the core issue is knowledge of signs and symptoms of adrenal insufficiency that should respond to drug therapy. Use nursing knowledge and the process of elimination to make a selection. |
3082 The nurse is assessing the laboratory data of a client Correct answer: 1 Clients with Cushing’s syndrome or hypercortisolism have elevated levels of cortisol, low diagnosed with Cushing’s syndrome. The nurse would ACTH levels, increased blood glucose levels, elevated white blood cell counts, elevated expect to note which of the following laboratory lymphocyte counts, increased sodium levels, decreased serum calcium levels, and decreased values prior to initiation of drug therapy? serum potassium levels. Drug therapy will reduce serum cortisol levels when given as directed. The laboratory trends noted in options 2, 3, and 4 are opposite what would be expected in Cushing’s syndrome. ‐ Elevated plasma cortisol level ‐ Decreased blood glucose level ‐ Decreased white blood cell count ‐ Decreased sodium level | The core issue of the question is knowledge of laboratory values that are expected to change once drug therapy is initiated for Cushing’s syndrome. Use nursing knowledge and the process of elimination to make a selection. |
3083 The nurse is caring for a client who has just been Correct answer: 4 Graves’ disease is caused by elevated levels of thyroid hormone. Clients experience diagnosed with Graves’ disease. Client education needs tachycardia, nervousness, insomnia, increased heat production, and weight loss. Medication to include which of the following? therapy with an agent such as propylthiouracil will help control the disorder. Option 1 is irrelevant, while option 2 is indicated for hypothyroidism. A client with this disorder needs a high‐calorie diet, not a low‐calorie one (option 3). ‐ Atropine‐like medication ‐ Thyroid hormone replacement therapy ‐ A low‐calorie diet ‐ Propylthiouracil (PTU) | The core issue of the question is the type of medication therapy that will be effective in treating hyperthyroidism or Graves’ disease. Use nursing knowledge and the process of elimination to make a selection. |
3084 A client with Graves’ disease related to Correct answer: 4 Cardiac problems related to Graves’ disease and hyperthyroidism include increased systolic hyperthyroidism has been taking medication therapy blood pressure, a widened pulse pressure, tachycardia, and other dysrhythmias. Appropriate as prescribed. Which of the following findings noted on control of the disorder with medication therapy would prevent these manifestations from cardiac assessment indicates to the nurse that the occurring. client has not had a sufficient response to medication therapy? | The core issue of the question is knowledge of which symptoms should resolve once medication therapy for Graves disease has begun. Recall that Graves disease represents a hypermetabolic state, and then eliminate each option that does not correlate with excessive metabolic activity. |
‐ Decreased systolic blood pressure ‐ Narrow pulse pressure ‐ Bradycardia ‐ Tachycardia | |
3085 The nurse is caring for a client who recently was Correct answer: 2 Management of hypoparathyroidism is aimed at correcting hypocalcemia, vitamin D diagnosed with hypoparathyroidism. To determine the deficiency, and hypomagnesemia. Options 1 and 4 are incorrect because they are the opposite effectiveness of medication therapy with calcitrol of effective treatment of hypoparathyroidism, while option 3 is an unrelated finding. (Rocaltrol), the nurse assesses laboratory findings to see whether which of the following has occurred? ‐ Hypercalcemia is resolving. ‐ Hypocalcemia is resolving. ‐ Hypermagnesemia is resolving. ‐ Vitamin D levels are decreasing. | The core issue of the question is knowledge of abnormal laboratory values that should resolve with effective medication therapy for hypoparathyroidism. Use knowledge of medication actions to eliminate each of the incorrect options. Options 1 and 2 are opposite, which is a clue that one of them is likely to be the correct answer. |
3086 A client with type 2 diabetes mellitus has been Correct answer: 1 Actos is a thiazolidinedione type of oral antidiabetic agent; its action enhances insulin action prescribed pioglitazone (Actos). Which one of the and promotes glucose utilization in peripheral tissues. This drug improves sensitivity to insulin following tests does the nurse anticipate will be done in muscle and fat tissue, and inhibits glucogenesis. Because of the potential for liver damage, before drug therapy is initiated with this medication? clients taking drugs in this class must have liver function studies done before therapy is begun, and periodically thereafter. ‐ Liver function tests ‐ Thyroid function tests ‐ Respiratory function tests ‐ Pituitary function tests | The core issue of this question is knowledge of the adverse effects of thiazolidinedione antidiabetic agents. Recall as a general strategy that many drug classes have adverse effects on the liver. Use medication knowledge and the process of elimination to make a selection. |
3087 A client newly diagnosed with adrenal insufficiency is Correct answer: 2 Adrenocortical replacement therapy medications are divided into mineralocorticoids and to begin therapy with fludrocortisone (Florinef). The glucocorticoids. Mineralcorticoids such as fludrocortisone increase resorption of sodium by nurse explains to the client in simple terms that this increasing hydrogen and potassium excretion in the distal tubule. Glucocorticoids decrease medication will do which of the following? inflammation by suppressing leukocyte migration and modifying the body’s immune response. The statements in the remaining options do not reflect these actions. ‐ Decrease resorption of sodium by decreasing hydrogen and potassium excretion in the distal tubule ‐ Increase resorption of sodium by increasing hydrogen and potassium excretion in the distal tubule ‐ Decrease inflammation by suppressing migration of leukocytes and modifying the body’s immune response to many stimuli ‐ Increase inflammation by stimulating the production of leukocytes and enhancing the body’s immune response to many stimuli | Specific medication knowledge about the effects of mineralocorticoid drug therapy is needed to answer this question. Use medication knowledge and the process of elimination to make a selection. |
3088 A homebound client with type 2 diabetes mellitus Correct answer: 4 If anorexia, nausea, or vomiting is present, sick‐day diabetic management care requires calls the nurse to report nausea and flulike symptoms clients to check their blood glucose level every 4–6 hours. Clients should not eliminate or for two days. What advice should the nurse give the adjust their doses of insulin or oral hypoglycemics. They also should drink 8–12 ounces of sugar‐ client? free liquids as tolerated every hour, to prevent dehydration. Meals should be eaten at regular times, and clients should consume foods and liquids that are more easily tolerated. To prevent diabetic ketoacidosis, this client must regularly check urine ketone levels if the blood glucose level is higher than 240 mg/dL. ‐ “Be sure to check your blood glucose level in the morning on a daily basis.” ‐ “Only take half of your regular dose of insulin and oral hypoglycemic agent.” ‐ “Limit fluid intake, and eat only when you feel hungry.” ‐ “Test your urine for ketones if your blood glucose is higher than 240 mg/dL.” | The core issue of the question is knowledge of how to manage medication therapy during illness. With this in mind, choose the option that does not decrease the drug dose (since blood glucose rises during illness), and that provides for safe and effective treatment (calling the physician when the level is excessive). |
3089 A client was just diagnosed with hypothyroidism. The Correct answer: 2 Thyroid hormones increase the effects of anticoagulants. Assessment of PT or INR will client also takes sodium warfarin (Coumadin). Before determine if the anticoagulant dosage must be decreased. The nurse also assesses the client giving any thyroid replacement hormone, the nurse for evidence of bruising or bleeding. A CBC could detect anemia caused by bleeding as a checks the results of what laboratory value? complication of excessive warfarin therapy. APTT measures the effectiveness of heparin. Coumadin levels are not drawn. ‐ Complete blood count (CBC) ‐ Prothrombin time (PT) or international normalized ratio (INR) ‐ Activated partial thromboplastin time (APTT) ‐ Warfarin (Coumadin) level | The core issue of the question is understanding of interactive effects of thyroid hormones and anticoagulants such as warfarin. Use knowledge of both medications and associated laboratory values to make a selection. |
3090 A client who has osteoporosis has been receiving Correct answer: 3 Hypercalcemia, hypomagnesemia, and digitalis toxicity could result when calcium calcium supplements on a long‐term basis. The supplements interact with digoxin. Clients must be instructed to take these two drugs at physician has ordered the client to start taking digoxin separate times of the day. Also, antacids must not be taken with digoxin. Hyperkalemia is not a (Lanoxin). For what type of drug interaction would the concern with calcium supplementation. homecare nurse assess during future visits? ‐ Hypocalcemia ‐ Hyperkalemia ‐ Digoxin toxicity ‐ Hypermagnesemia | The core issue of the question is knowledge of the effects of calcium supplements in a client who also takes digoxin. Use knowledge of medication interactions and the process of elimination to make a selection. |
3091 The nurse who is working in a women’s health clinic Correct answer: 4 Primary osteoporosis most often occurs in postmenopausal women who are thin and lean‐ has several clients to see during the day. Which of built. It is more prevalent in Caucasian and Asian women. these clients does the nurse anticipate will need medication teaching for calcium supplementation to treat primary osteoporosis? ‐ A premenopausal client ‐ An overweight client ‐ An African‐American client ‐ A Caucasian client | The core issue of the question is knowledge of the clients at risk for osteoporosis and amenable to therapy with calcium supplementation. Use general nursing knowledge and the process of elimination to make a selection. |
3092 A client with osteoporosis has been prescribed Correct answer: 2 Progesterone frequently is given along with estrogen as part of HRT to minimize the hormone replacement therapy (HRT) in addition to occurrence of endometrial or breast cancer. The other options do not relate to this calcium supplements. The nurse teaches the client that medication. progesterone is given along with estrogen in this therapy to decrease occurrence of what condition? ‐ Vaginitis ‐ Endometrial or breast cancer ‐ Benign breast tumors ‐ Ovarian cysts | The core issue of the question is knowledge of the adverse effects of HRT given in addition to calcium supplementation for prevention or treatment of osteoporosis. Use knowledge of adverse drug effects and the process of elimination to make a selection. |
3093 A client newly diagnosed with diabetes mellitus has Correct answer: 1 If diabetes is well controlled, blood glucose levels are not affected by mild consumption of begun taking insulin. The client asks the nurse about alcohol. Male clients taking insulin may ingest two alcoholic beverages daily, and female clients alcohol consumption. What should the nurse tell the may ingest one alcoholic beverage with, or in addition to, the regular meal plan. Because of client? the risk of alcohol‐induced hypoglycemia, diabetic clients must ingest alcohol only with or shortly after meals. In all cases, the client should confer with the prescribing physician and dietitian to determine whether alcohol may be utilized as part of the overall caloric intake. ‐ “Moderate‐to‐high alcohol consumption without food can cause your blood glucose level to go down too low.” ‐ “Moderate‐to‐high alcohol consumption without food can cause your blood glucose level to rise too high.” ‐ “Consumption of alcohol has no effect on your blood glucose, as long as you don t eat while drinking.” ‐ “As long as you only drink beer and wine, and not hard liquor, there should be no effect from the alcohol.” | The core issue of the question is knowledge of how alcohol can affect blood glucose levels in a client taking insulin. Use knowledge of interactive effects of medications and alcohol to make a selection. |
3094 The nurse is instructing the newly diagnosed diabetic Correct answer: 3 The following statements are commonly used to teach clients how to combine insulins in one client how to mix regular insulin and NPH insulin. What syringe: Gently roll the bottle of intermediate insulin to mix, because vigorous shaking creates should the nurse tell the client? bubbles, leading to an inaccurate dose. Air must be injected into each bottle before withdrawing. Withdrawing the shorter‐acting insulin first prevents the longer‐acting insulin from mixing in the bottle with the shorter‐acting insulin. ‐ Shake the bottle of intermediate insulin before withdrawing the amount. ‐ Withdraw the longer‐acting insulin first. ‐ Withdraw the shorter‐acting insulin first. ‐ Never inject air into the bottles before withdrawing. | The core issue of the question is proper technique for drawing up mixed insulins. Choose the option that does not contaminate the shorter‐acting insulin with the longer‐acting one, which would necessitate discarding the contaminated vial. |
3095 Metformin (Glucophage) has been prescribed for a Correct answer: 4 Metformin is given to clients with stable type 2 diabetes mellitus to inhibit glucose production client newly diagnosed with type 2 diabetes mellitus. by the liver and increase sensitivity of peripheral tissue to insulin. The other three options The nurse evaluates that the client understood contain factually incorrect statements. medication teaching when the client states that this medication does which of the following? ‐ Decreases sensitivity of peripheral tissue to insulin. ‐ Stimulates glucose production in the liver. ‐ Treats unstable type 2 diabetes mellitus. ‐ Decreases production of glucose by the liver. | The core issue of the question is knowledge of the actions of metformin on reducing blood glucose. Use medication knowledge and the process of elimination to make a selection. |
3096 The physician has prescribed vitamin D for a client. Correct answer: 2 Vitamin D regulates calcium and phosphorus levels by increasing blood levels, increasing The client asks the nurse what the medication is for. intestinal absorption and mobilization from bone, and reducing renal excretion of both Which of the following is the best response by the elements. The statements in the other options are the opposites of the actions of vitamin D. nurse? ‐ “Vitamin D decreases intestinal absorption of calcium and phosphorus, and decreases their mobilization from bone.” ‐ “Vitamin D helps regulate calcium and phosphorus balance.” ‐ “Vitamin D helps the kidneys rid the body of excess calcium and phosphorus.” ‐ “Vitamin D decreases blood levels of calcium and phosphorus.” | The core issue of the question is knowledge of the effects of vitamin D. Use medication knowledge and the process of elimination to make a selection. |
3097 A mother comes to the clinic with her 5‐year‐old son. Correct answer: 3 Growth hormone is approved for use in children only to treat a documented lack of growth She is concerned that he is not growing fast enough, hormone. It is available as a parenteral medication only, to be given IM or SC (option 2). Only and asks the nurse if he can receive growth hormone long bones are affected (option 3). Option 4 is incorrect because this response implies that this (GH). Which of the following would be the best treatment is appropriate despite the lack of additional diagnostic evidence needed for this response by the nurse? therapy. ‐ "Growth hormone will only affect your child's short bones." ‐ "Can your son swallow pills easily?" ‐ "Growth hormone is only given to children if there is a documented lack of growth hormone." ‐ "How tall do you want him to be?" | Options 2 and 4 can be eliminated, since these do not answer the mother s question. Option 1 is a false statement, so it can also be eliminated. This process leaves option 3 as the correct answer. |
3098 A client has been receiving high doses of Correct answer: 2 Abrupt cessation of long‐term steroid therapy can cause acute adrenal insufficiency, which glucocorticoids for several weeks. The client asks the could lead to death. Options 1 and 4 are incorrect statements. Central nervous system nurse when he can stop taking the medication. The symptoms such as confusion and psychosis are adverse effects of steroids such as prednisone nurse's response incorporates which of the following (option 3). information? ‐ Even at high doses, adverse reactions are unlikely if the medication is abruptly withdrawn. ‐ If steroid medication is withdrawn suddenly, a client could die of acute adrenal insufficiency. ‐ The client could experience severe psychological symptoms when the medication is withdrawn. ‐ Tapering of the medication requires daily assessment of serum chemistries. | Recall knowledge of the pathophysiological process of glucocorticoids. Option 2 is the only correct pathophysiological process of the classification. If this was difficult, review the action of glucocorticoids. |
3099 A client recently diagnosed with diabetes insipidus is Correct answer: 1 Desmopressin is not given by the intramuscular route. This medication may be given by the to receive desmopressin (DDAVP). The client expresses intravenous, subcutaneous, or intranasal routes (options 2, 3, and 4) in the treatment of concern about possible inability to properly self‐ diabetes insipidus. administer the medication. In responding to the client, the nurse conveys that this medication is not given by which of the following routes? ‐ Intramuscular ‐ Intravenous ‐ Intranasal ‐ Subcutaneous | This question requires knowledge of the correct administration methods of the medication. If unsure of the correct option for this medication, review administration of the medication in a medication book. |
3100 A client with Addison's disease is taking Correct answer: 1 Fludrocortisone is a mineralocorticoid used to treat Addison's disease. High doses of fludrocortisone (Florinef) for replacement therapy. In fludrocortisone can result in excess retention of salt and water, and depletion of potassium. evaluating the effects of drug therapy, the nurse Options 2 and 3 contain incorrect statements. In the treatment of Addison's disease, anticipates that which of the following could occur fludrocortisone is commonly used in combination with a glucocorticoid (option 4). when high doses of this drug are given? ‐ Excess sodium and water are retained, and potassium is depleted. ‐ Sodium and water are depleted, and potassium is retained. ‐ Hypotension and hypokalemia could develop. ‐ This could lead to toxic effects when given with any glucocorticoid. | In order to select the correct answer to this question, recall the effects of the medication. If this was difficult to answer, review the effects of the medication on the disease process. |
3101 A client newly diagnosed with hypothyroidism is Correct answer: 4 After the start of therapy, peak levels of the drug should not be expected for many weeks to placed on levothyroxine sodium (Synthroid). The client months. Thus, increased energy levels cannot be expected within a few days (option 2). The asks when his lack of energy will improve. The nurse's drug works best when taken before breakfast on an empty stomach (option 3). Lack of energy response includes which of the following? is a common symptom with hypothyroidism (option 1). ‐ Lack of energy is probably caused by depression, not hypothyroidism. ‐ Dramatic improvement in energy levels can be experienced, usually in 1–2 days. ‐ The drug works best when taken after a full meal. ‐ Optimum effectiveness of the drug might not occur for several weeks. | Note in the question stem that the nurse is being asked by the client when the energy level will increase. Options 1 and 3 should be eliminated, since they do not address the question the client is asking. This leaves options 2 and 4 as choices. Since the medication is long‐term therapy, immediate results cannot be expected, which would eliminate option 2. |
3102 A client with hypothyroidism is prescribed liotrix Correct answer: 2 Symptoms of adverse effects and thyrotoxicosis of liotrix (Thyrolar) include tachycardia, (Thyrolar). The nurse teaches the client which of the angina, tremor, nervousness, insomnia, hyperthermia, heat tolerance, and sweating. Options following signs and symptoms of thyrotoxicosis prior 1, 3, and 4 represent manifestations that are opposite those of thyrotoxicosis, which are also to discharge? manifestations of hypothyroidism. ‐ Bradycardia and hypothermia ‐ Tachycardia and hyperthermia ‐ Unusual lethargy, and inability to keep awake ‐ Complaints of chills and dry skin | In order to select the correct answer, recall the definition of thyrotoxicosis. The only sign or symptom of hyperthyroidism is option 2. The other options are of hypothyroidism, and can be eliminated. |
3103 A client with Graves' disease who has been taking Correct answer: 3 Agranulocytosis is the most serious toxic effect of this drug, and it can make the client propylthiouracil (PTU) for six weeks complains of a predisposed to a variety of infections. Although rare, this adverse effect can occur within the sore throat and fever. The nurse concludes that this first few months of treatment. Options 1 and 2 are incorrect conclusions; although option 4 is complaint could be an early sign of which of the possible, the manifestations reported are general signs of infection that might or might not be following? consistent with influenza. ‐ Hyperthyroidism ‐ Hyperpituitarism ‐ Agranulocytosis ‐ Haemophilus influenzae | Using the process of elimination, omit option 4 because Haemophilus influenzae is not a complaint, but a diagnosis. Option 1 can be eliminated because hyperthyroidism is another name for Graves disease. Option 2 does not relate to the thyroid, so it can also be eliminated. This would lead to the correct choice, 3. |
3104 A client with Paget's disease is prescribed calcitonin Correct answer: 1 Calcitonin rapidly lowers blood calcium levels by reducing mobilization of calcium from bone, (Calcimar). The nurse tells the client that the purpose decreasing intestinal resorption, and promoting urinary excretion of calcium. Options 2 and 3 of this drug is to do which of the following? are effects that are opposite to the ones caused by calcitonin, while option 4 is incorrect because of the word "gradual." ‐ Decrease mobilization of calcium from the bone ‐ Increase intestinal absorption of calcium ‐ Promote urinary retention of calcium ‐ Provide gradual lowering of blood calcium levels | Knowing the pathophysiology of Paget s disease will lead to the only correct answer, 1. If this was difficult, review the pathophysiology of Paget s disease. |
3105 A nurse is caring for a client who is receiving insulin. Correct answer: 3 Hunger; nausea; pale, cool skin; and sweating are signs of a hypoglycemic reaction. Fruity For which of the following signs of hypoglycemic breath (option 1) can accompany ketoacidosis. Flushing of the face (option 2) can accompany reaction should the nurse observe the client? hyperglycemia. Dry, flaky skin (option 4) is unrelated to hypoglycemia. ‐ Fruity breath ‐ Flushing of the face ‐ Hunger ‐ Dry, flaky skin | Knowing the signs and symptoms of hypoglycemia will lead to the correct answer, which is option 3. If this was difficulty, be sure to be able to distinguish between hypoglycemia and hyperglycemia signs and symptoms. |
3106 The nurse is evaluating the client's knowledge of Correct answer: 4 The initial action by the client is to take some form of oral glucose in order to raise the blood treatment if an insulin reaction occurs. Which of the glucose level. Option 1 would delay appropriate self‐treatment. Options 2 and 3 would cause following actions is most appropriate for the client to further harm to the client. understand? ‐ Notify the doctor. ‐ Inject a dose of regular insulin. ‐ Lie down and wait for the reaction to disappear. ‐ Take an oral form of glucose. | Note in the question stem that the nurse is to select an action for the client to be able to understand. While the client could notify the physician, this would delay recovery. The first choice for the client to implement is option 4. |
3107 A child is about to begin taking growth hormone. Correct answer: 1 The expected growth rate with growth hormone therapy is 3–5 inches in the first year. Height Which of the following teaching points should the and weight are measured monthly (option 2). Growth hormone is discontinued when optimum nurse stress to the parent? adult height is attained, when fusion of epiphyseal plates has occurred, or when there is no response to growth hormone (option 3). Growth hormone is related to growth of long bones, not fat deposition (option 4). ‐ "Your child's expected growth rate is 3–5 inches during the first year of treatment." ‐ "You need to measure your child's height and weight daily." ‐ "Growth hormone therapy, once started, must be taken until the child reaches the age of 21." ‐ "The amount of subcutaneous fat your child has will increase during the treatment period." | The question stem stresses points to explain to the parents. Use the process of elimination. If this was difficult, review the expected results of growth hormone administration to a child. |
3108 The nurse is instructing the client about insulin Correct answer: 3 Jogging increases insulin requirements, and absorption can be increased if the drug is injected administration. Which of the following pieces of client into the thigh. This lifestyle factor of the client requires special instruction. Options 1 and 4 are information alerts the nurse that special instruction unrelated to teaching about insulin administration. Option 2 guides the nurse to include the regarding insulin is necessary? spouse in teaching, but it does not indicate the need for special instruction regarding insulin. ‐ Client lives in an apartment with spouse. ‐ Client wishes to teach her spouse how to administer insulin. ‐ Client jogs 3–4 miles every other day. ‐ Client takes a nap in the afternoon. | Using the process of elimination, rule out options 1 and 4 because they do not relate to teaching that is necessary. Option 2 does not require any special instruction but more involvement of the family. This leaves the correct option, 3. |
3109 A client with a history of alcoholism was just Correct answer: 2 Tolbutamide interacting with alcohol can lead to a disulfiram‐like reaction, causing complaints diagnosed with type 2 diabetes mellitus and placed on of headache and flushing of the skin. This is an important teaching point for the client who has tolbutamide (Orinase). The nurse explains that which a history of alcoholism, even if he currently is not drinking. The reactions listed in the of the following reactions could occur if the client remaining options do not occur as a result of co‐ingestion with alcohol. drinks alcohol while taking this medication? ‐ Decreased diuresis ‐ Disulfiram‐like reaction ‐ Anaphylaxis ‐ Increased tolerance to the medication | In order to answer this question, recall the contraindications with the use of the medication. If this was difficult, review the contraindications with the use of tolbutamide (Orinase). |
3110 A child is placed on somatrem (Protropin). The Correct answer: 4 Resistance to growth hormone eventually develops, and the rate of growth begins to slow parents ask the nurse if the child will keep growing down with increasing age. Efficacy of the drug is usually lost by the age of 20–24 years (options after the drug has been discontinued. The nurse 2 and 3). The medication is quite effective in children (option 1), as long as there is a utilizes which of the following points about this demonstrated deficiency in growth hormone. medication in a response? ‐ The drug is not effective until the client has reached teenage years. ‐ The client must take the drug for a lifetime. ‐ The client can expect to grow well into his fourth or fifth decade. ‐ Efficacy of therapy declines as the client grows older. | Knowing that the efficacy of the medication declines with age will lead to the only correct option. |
3111 A client is taking metyrapone (Metopirone), and Correct answer: 2 In the presence of adrenal insufficiency, metyrapone can cause an adrenal crisis by stopping experiences an adrenal crisis. Which of the following the synthesis of cortisol. Options 1 and 4 are the opposite of what is occurring with the client. most likely predisposed the client to this occurrence? Option 3 is an unrelated finding. ‐ Cortisol synthesis has increased. ‐ The client has adrenal insufficiency. ‐ The client has type 1 diabetes mellitus. ‐ The client has no adrenal insufficiency. | Note in the question stem that the client is experiencing an adrenal crisis. Options 1, 2, and 4 can be eliminated because they are the direct opposite of the scenario in the question. Option 2 is the only option that addresses adrenal insufficiency. |
3112 A client is scheduled to have a bilateral Correct answer: 1 Hydrocortisone succinate may be given IV or IM, and is the preferred drug for replacement adrenalectomy. Which of the following drugs does the therapy in all forms of adrenocortical insufficiency. ACTH is mostly used for diagnostic testing nurse expect to administer in the postoperative (option 3). Dexamethasone is used for nonendocrine disorders (option 2), and ketoconazole period? (option 4) is used to suppress the synthesis of adrenal steroids. ‐ Hydrocortisone succinate ‐ Dexamethasone ‐ Adrenocorticotropic hormone (ACTH) ‐ Ketoconazole | Knowing the usual mode of treatment after an adrenalectomy will lead to the only correct answer to this question. If this was difficult, review the usual treatment after an adrenalectomy. |
3113 A client who was recently started on drug therapy Correct answer: 4 Desmopressin is a drug used to treat diabetes insipidus. The manifestations listed are all signs with desmopressin (DDAVP) complains of a headache, of water intoxication, which could occur as an excessive effect of the medication. Options 1 lethargy, and drowsiness. The nurse concludes that and 2 are unrelated to this medication, while option 3 is associated with diabetes insipidus, the which of the following might be responsible for this underlying condition for which this drug would be ordered. reaction? ‐ Streptococcal infection ‐ Excessive ingestion of calcium ‐ Dehydration ‐ Fluid overload | Using the process of elimination will lead to the correct answer. Options 1 and 2 do not relate to the disease process. Knowing that the clinical manifestations are signs of water intoxication will lead you to select option 4. |
3114 A client with hyperthyroidism is being prepared for Correct answer: 1 Propranolol is a beta‐adrenergic blocker, and is used to treat sympathetic nervous system surgery, and propranolol (Inderal) is prescribed. The symptoms related to hyperthyroidism, such as tachycardia, cardiac dysrhythmias, and mental nurse explains to the client that this drug is being given agitation. The manifestations identified in the other options would not be adequately treated to control which symptom? with this medication. ‐ Tachycardia ‐ Hypotension ‐ Dyspnea ‐ Drowsiness | Knowing the classification of the medication will lead to the only correct answer, option 1. If this was difficult, review the purposes of the medication. |
3115 A client who is taking digoxin (Lanoxin) is to receive a Correct answer: 2 Parenteral calcium can cause severe bradycardia in clients taking digoxin. Option 1 is the dose of intravenous calcium. For which of the opposite effect of what could occur. Hypertension is not an expected effect (option 4); following drug interactions must the nurse be hypotension could occur as a result of severe bradycardia, but this is a secondary effect prepared? (option 3). ‐ Severe tachycardia ‐ Severe bradycardia ‐ Severe hypotension ‐ Severe hypertension | Knowing that calcium can result in changes in heart rate will assist to eliminate options 3 and 4. When determining whether the answer is option 1 or 2, review the effects of digoxin (Lanoxin). |
3116 A client with hypocalcemia needs to increase his Correct answer: 4 Vitamin D regulates calcium and phosphorus metabolism, and increases blood levels of both calcium absorption. The nurse explains to the client elements. The vitamins in the other options do not have this beneficial effect. that which of the following vitamins will be most beneficial to the client? ‐ Vitamin A ‐ Vitamin C ‐ Vitamin B12 ‐ Vitamin D | In order to select the correct answer, recall that calcium is best absorbed with vitamin D. If this was difficult, review vitamins and their absorption. |
3117 A child diagnosed with deficiency of growth hormone Correct answer: 2 Children with growth hormone deficiency are smaller than peers, and frequently experience who needs replacement drug therapy comes to the problems with self‐esteem and body image. Option 1 would be the opposite problem of what clinic for treatment. Which of the following nursing the client is experiencing. The nursing diagnoses in options 3 and 4 are unrelated to the client diagnoses would be most appropriate for this client? in this question. ‐ Imbalanced Nutrition: More than Body Requirements ‐ Disturbed Body Image ‐ Diversional Activity Deficit ‐ Decreased Cardiac Output | Note in the question stem that the client is a child receiving growth hormone. Options 1, 3, and 4 do not address the concerns with a child who needs growth hormone. |
3118 A client with diabetes insipidus who has been taking Correct answer: 1 Signs of overdosage of desmopressin, an antidiuretic hormone, include blood pressure and desmopressin (DDAVP) intranasally comes to the clinic pulse elevation; mental status changes; and water and sodium retention. Because the for a regularly scheduled appointment. The nurse medication therapy needs to be interrupted, the nurse should notify the physician. Option 2 assesses the client's mental status and notes some would place the client at risk because of lack of timely treatment. Options 3 and 4 would not disorientation and behavioral changes. Significant address the current complication. pedal edema is also present. What should be the nurse's next action(s)? ‐ Check vital signs, and notify the physician. ‐ Have the client return in the morning for reevaluation. ‐ Instruct the client to limit salt intake for a few days. ‐ Suggest that the client change the route of administration to subcutaneous injections. | Note that the question asks for selection of the next action or intervention. Safety should also be taken into account in selecting the next intervention. Option 2 would not be safe. Options 3 and 4 do not address what the question is asking for next. Recognize that option 1 would be the next action that is appropriate as well as safe. |
3119 The nurse is caring for a client who has just been Correct answer: 4 Graves' disease is caused by elevated levels of thyroid hormone. Clients experience diagnosed with Graves' disease. Client education needs tachycardia, nervousness, insomnia, increased heat production, and weight loss. Medication to include which of the following? therapy with an agent such as propylthiouracil will help control the disorder. Option 1 is irrelevant, while option 2 is indicated for hypothyroidism. A client with this disorder needs a high‐calorie diet, not a low‐calorie one (option 3). ‐ Atropine‐like medication ‐ Thyroid hormone replacement therapy ‐ A low‐calorie diet ‐ Propylthiouracil (PTU) | Knowing the usual treatment modality will lead you to option 4. The other options are not correct education statements for the disease process. If this was difficult, review the treatment modalities for Graves disease. |
3120 The physician has prescribed vitamin D for a client. Correct answer: 2 Vitamin D regulates calcium and phosphorus levels by increasing blood levels, increasing The client asks the nurse what the medication is for. intestinal absorption and mobilization from bone, and reducing renal excretion of both Which of the following is the best response by the elements. The statements in the other options are the opposites of the actions of vitamin D. nurse? ‐ "Vitamin D decreases intestinal absorption of calcium and phosphorus, and decreases their mobilization from bone." ‐ "Vitamin D helps regulate calcium and phosphorus balance." ‐ "Vitamin D helps the kidneys rid the body of excess calcium and phosphorus." ‐ "Vitamin D decreases blood levels of calcium and phosphorus." | In order to correctly answer this question, recall the actions of calcium. The only correct option is option 2. If this was difficult, review vitamin D action. |
3121 The nurse is caring for a client with Paget's disease. Correct answer: 1 Drug therapy for Paget's disease focuses on decreasing calcium release by decreasing activity The nurse should include in the teaching plan for the of osteoclasts, thereby decreasing bone resorption. The other options indicate effects that are client that pharmacological therapy for treating this opposite those that are intended with drug therapy. disease is aimed at which of the following results? ‐ Decreasing bone resorption ‐ Increasing calcium release ‐ Increasing bone resorption ‐ Increasing activity of osteoclasts | In order to correctly answer this question, recall the goals of pharmacological therapy for a client with Paget s disease. |
3122 Glipizide (Glucotrol XL) has been prescribed for a Correct answer: 3 Glipizide is given to type 2 diabetic clients; it is used as an adjunct to diet therapy and client with diabetes mellitus. The nurse plans to teach exercise, but does not replace insulin for clients who need it (option 1). It increases the release the client that this medication is being used for which of insulin from pancreatic islet cells (option 4). Its use is contraindicated during pregnancy and of the following purposes? lactation (option 2). ‐ To take the place of insulin injections ‐ To treat clients with diabetes who are pregnant ‐ To treat type 2 diabetes mellitus ‐ To decrease release of insulin from pancreatic islet cells | In order to answer this question, recall the purpose of glipizide (Glucotrol XL). If this was difficult, review the purpose of the medication in a medication handbook. |
3123 Metformin (Glucophage) has been prescribed for a Correct answer: 4 Metformin is given to clients with stable, type 2 diabetes mellitus to inhibit glucose client newly diagnosed with type 2 diabetes mellitus. production by the liver and increase sensitivity of peripheral tissue to insulin. The other three The nurse evaluates that the client understood options are not actions of metformin. medication teaching when the client states that this medication does which of the following? ‐ Decreases sensitivity of peripheral tissue to insulin. ‐ Stimulates glucose production in the liver. ‐ Treats unstable type 2 diabetes mellitus. ‐ Decreases production of glucose by the liver. | In order to answer this question, recall the purpose of metformin (Glucophage). If this was difficult, review the purpose of the medication in a medication handbook. |
3124 The nurse is providing discharge education to a client Correct answer: 2 Early signs of hypoglycemia and lactic acidosis include hyperventilation, myalgia, malaise, and newly diagnosed with type 2 diabetes mellitus. The unusual somnolence. The client should learn to recognize these signs in order to check blood nurse tells the client that early signs of hypoglycemia glucose levels and take corrective action. and lactic acidosis can include which of the following? ‐ Bradycardia ‐ Hyperventilation ‐ Agitation ‐ Hypertension | In order to answer this question, recall knowledge of hypoglycemic reactions that a client will experience. Having knowledge of hyperglycemic and hypoglycemic reactions will allow selection of the correct answer. |
3125 A client is being evaluated for control of type 2 Correct answer: 4 Glycosylated hemoglobin concentrations are representative of a client's average blood diabetes mellitus with exercise, diet, and oral glucose levels over the previuos 2–3 months, not in recent hours or days (option 1). It does not medication therapy. A glycosylated hemoglobin test is diagnose anemia or kidney damage (options 2 and 3). ordered. The client asks the nurse what that test is for. Which of the following is the best response by the nurse? ‐ "Results of this test reveal your blood glucose over the last 24 hours." ‐ "Results of this test can indicate whether you are anemic." ‐ "Results of this test will show if you have any kidney damage." ‐ "Results of this test show your average blood glucose over the last several weeks." | In order to answer this question, recall the definition and purpose of this lab test. |
3126 A 60‐year‐old client has been prescribed rabeprazole Correct answer: 3 Omeprazole, pantoprazole, and rabeprazole must be swallowed whole. Lansoprazole and (Aciphex) for symptoms of gastroesophageal reflux esomeprazole capsules may be opened and sprinkled on applesauce or dissolved in 40 mL of disease (GERD). He has trouble swallowing pills. What juice. alternate medication could be used for this client? ‐ Omeprazole (Prilosec) ‐ Pantoprazole (Protonix) ‐ Lansoprazole (Prevacid) ‐ There is no substitute for Aciphex. | The core issue of the question is knowledge of the formulations of various proton pump inhibitors. Use medication knowledge and the process of elimination to make a selection. |
3127 A nurse is teaching a female client newly diagnosed Correct answer: 4 Ciprofloxacin is not recommended for Helicobacter pylori infection during pregnancy. The with Helicobacter pylori infection. The nurse expects other medications can be used after consulting with the physician. that which of the following medications will not be used after learning the client is pregnant? ‐ Metronidazole (Flagyl) ‐ Amoxicillin (Amoxil) ‐ Clarithromycin (Biaxin) ‐ Ciprofloxacin (Cipro) | The core issue of the question is knowledge of what medications are safe for use in pregnancy for a client with Helicobacter pylori infection. Use medication knowledge and the process of elimination to make a selection. |
3128 A client is taking bismuth for diarrhea. For which of Correct answer: 1 Bismuth‐containing preparations, such as Pepto‐Bismol, can cause all the listed side effects, the following side effects unique to this medication but transient darkening of the tongue and stool is a side effect specific to bismuth. would a nurse monitor? ‐ Darkening of the tongue ‐ Dyspepsia ‐ Abdominal pain ‐ Diarrhea | The critical word in the stem of this question is unique. This means that the answer is a side effect that does not occur with other drugs that the client is receiving. Use specific medication knowledge and the process of elimination to make a selection. |
3129 A client’s breath urease test is positive for Correct answer: 3 The highest rate of eradication of Helicobacter pylori infection is achieved by using a proton Helicobacter pylori organisms. The nurse anticipates pump inhibitor and two antibiotics (usually clarithromycin and amoxicillin or metronidazole). that which of the following medications will be The combinations of medications in options 1, 2, and 4 do not provide for this level of ordered to eradicate this infection most effectively? effectiveness. ‐ Antacids and amoxicillin ‐ Omeprazole, ranitidine, and amoxicillin ‐ Combination of proton pump inhibitor, amoxicillin, and clarithromycin ‐ Clarithromycin and bismuth salicylate | The core issue of the question is knowledge of what medications are commonly used in treating Helicobacter pylori infection. Use medication knowledge and the process of elimination to make a selection. |
3130 The nurse would interpret that which of the following Correct answer: 1 Promethazine is usually given 25 mg every 4–6 hours prn. Dosing may start at 12.5 mg every medications is ordered at a safe and effective dosage 4–6 hours prn depending on client status; however, 25 mg is the usual dose. Normal doses of range for an adult client who is experiencing nausea the other medications are as follows: prochlorperazine 5–10 mg t.i.d.–q.i.d.; metoclopramide and vomiting? 10 mg 30 minutes AC and HS; and trimethobenzamide hydrochloride 250 mg t.i.d.–q.i.d. prn. ‐ Promethazine (Phenergan) 25 mg every 4–6 hours prn ‐ Prochlorperazine (Compazine) 200 mg every 6 hours ‐ Metoclopramide (Reglan) 30 mg ac and HS ‐ Trimethobenzamide hydrochloride (Tigan) 20 mg t.i.d. prn | The core issue of the question is knowledge of the dosing schedule for various antiemetics. Use medication knowledge and the process of elimination to make a selection. |
3131 A client is receiving omeprazole (Prilosec) for Correct answer: 3 Omeprazole can cause an increase in liver enzyme levels (AST, ALT, alkaline phosphatase, and esophageal reflux. The nurse makes it a priority to bilirubin), leading to adverse reactions of liver necrosis and hepatic failure. For this reason, the monitor the results of which of the following nurse should monitor these lab values as they become available. Monitoring of BUN, uric acid, laboratory studies? and WBC count have a lesser priority; they are monitored only as indicated based on an individual client s identified health need. ‐ Blood urea nitrogen (BUN) ‐ Uric acid ‐ Liver enzymes ‐ White blood cell (WBC) count | The core issue of the question is knowledge of the laboratory values that could be affected by administration of omeprazole. With this group of medications, it is necessary to remember the liver. Use medication knowledge and the process of elimination to make a selection. |
3132 When caring for a client with onset of severe nausea, Correct answer: 2 All the medications listed are antiemetic agents, but transdermal scopolamine has the fastest the nurse telephones the health care provider for an onset of action. For this reason, it is most effective in providing relief from nausea for a order for which emetic that has the fastest onset of prolonged period of time. action? ‐ Oral promethazine (Phenergan) ‐ Scopolamine transdermal (Transderm‐Scop) ‐ Oral metoclopramide (Reglan) ‐ Haloperidol (Haldol) | The core issue of the question is knowledge of onset of action of various antiemetics. Recall that transdermal systems begin to absorb into the skin immediately after application, while oral doses take various amounts of time to absorb through the GI tract. Use medication knowledge and the process of elimination to make a selection. |
3133 A client has been diagnosed with severe erosive Correct answer: 2 Because of their antisecretory effect, proton pump inhibitors such as omeprazole are the esophagitis. The nurse developing a medication drugs of choice for moderate‐to‐severe erosive esophagitis. The course of therapy is usually 4‐ teaching plan would be sure to include information 8 weeks. The other medications might be helpful for certain clients; however, proton pump about which of the following most appropriate inhibitors are the medication classification of choice. medications to treat the disorder? ‐ Sucralfate (Carafate) ‐ Omeprazole (Prilosec) ‐ Nizatidine (Axid) ‐ Amoxicillin (Amoxil) | The core issue of the question is knowledge of the various GI medications that are useful in treating digestive system health problems. Recall that disorders that end in ‐itis involve inflammation, so the correct answer is one that reduces inflammation either by its own action or by inhibiting other irritants, such as gastric acid. Use medication knowledge of omeprazole as a proton pump inhibitor to make a selection. |
3134 A client has been advised to take an antacid to Correct answer: 1 Antacids should be chewed well and followed with four ounces of water for optimal effect. neutralize gastric acid, and thereby decrease the pain They should be taken regularly after meals, but the client should allow at least two hours of gastric irritation. What antacid‐related between taking the antacid and any other oral medication. Antacids should not be taken for administration issues should be discussed with the longer than two weeks without further evaluation. They can be taken before gastric upset client? occurs for better symptom control. ‐ To chew tablets and follow with four ounces of water ‐ To take the dose of antacid within two hours of any other prescribed medication ‐ To take the antacids on a regular basis for up to six weeks ‐ To take antacids after the onset of episodes of gastric irritation | The core issue of the question is knowledge of medication administration procedures for antacids. Recall that antacids are more effective when given with fluid to help disperse medication in the stomach. Use medication knowledge and the process of elimination to make a selection. |
3135 A client who has a history of glaucoma is diagnosed Correct answer: 1 Clients with glaucoma should not take anticholinergic agents such as dicyclomine, because with a gastrointestinal disorder. The nurse would the medication affects pupillary dilatation, and therefore indirectly affects the outflow of consult with the physician after noting a medication aqueous humor. The other medications listed do not pose this problem to the client. order for which of the following medications that should be used very cautiously, if at all, for this client? ‐ Dicyclomine (Bentyl) ‐ Omeprazole (Prilosec) ‐ Metoclopramide (Reglan) ‐ Magnesium hydroxide (Milk of Magnesia) | The core issue of the question is knowledge of medications that are contraindicated with glaucoma. Specific medication knowledge is needed to answer the question. Use medication knowledge and the process of elimination to make a selection. |
3136 A client who needs to take a histamine Correct answer: 4 Cimetidine decreases metabolism of beta blockers, phenytoin, procainamide, quinidine, H<sub>2</sub> antagonist also has a benzodiazepines, metronidazole, tricyclic antidepressants, and warfarin, leading to increased history of several health problems. The nurse explains risk of drug toxicity. Ranitidine, famotidine, and nizatidine are histamine blockers that are to this client that which histamine antagonist should newer than cimetidine, and have fewer side effects. be avoided because it has the greatest number of drug interactions? ‐ Famotidine (Pepcid) ‐ Ranitidine (Zantac) ‐ Nizatidine (Axid) ‐ Cimetidine (Tagamet) | The core issue of the question is knowledge of histamine antagonists that are highest in side or adverse effects. Specific medication knowledge is needed to answer the question. Use medication knowledge and the process of elimination to make a selection. |
3137 A client newly diagnosed with a gastric ulcer has been Correct answer: 2 Sucralfate forms an adhesive barrier on the surface of the gastric mucosa, protecting it from prescribed sucralfate (Carafate). The nurse explains gastric acid. It does not reduce spasms, relieve nausea or vomiting, or act as an anticholinergic. that this medication will have which of the following beneficial effects for the client? ‐ It will reduce GI spasms. ‐ It will protect the eroded ulcer surface from stomach acid. ‐ It will help relieve nausea and vomiting. ‐ It will act as an anticholinergic. | The core issue of the question is knowledge of the mechanism of action of sucralfate (Carafate). Specific medication knowledge is needed to answer the question. Use this knowledge and the process of elimination to make a selection. |
3138 A client with chronic pancreatitis has been prescribed Correct answer: 3 Pancrease, a pancreatic enzyme replacement, increases digestion of starches and fats, and pancrelipase (Pancrease). The nurse who is teaching thereby decreases the incidence of steatorrhea (fatty, frothy, foul‐smelling stools). Each of the the client about this medication would include that other options is only partially correct. pancrelipase increases digestion of what foods? ‐ Proteins and starches ‐ Proteins and fats ‐ Starches and fats ‐ Vitamins and starches | The core issue of the question is knowledge of the mechanism of action of pancrease. Specific medication knowledge is needed to answer the question. Use this knowledge and the process of elimination to make a selection. |
3139 A female client reports having diarrhea for the past Correct answer: 4 Associated symptoms of fever, abdominal pain, and dehydration might suggest pathological 24 hours. She took loperamide (Imodium) all day diarrhea. The health care provider should be contacted for further evaluation. The other yesterday per dosage instructions without relief. actions listed do not provide for the current physiological needs of the client. Today, she has a temperature of 102ºF, excessive thirst, and severe abdominal cramping. What is the highest‐priority action for the nurse at this time? ‐ Obtain a further history of digestive disorders. ‐ Discuss dietary factors that might be causing the diarrhea. ‐ Suggest acetaminophen (Tylenol) for fever and pain. ‐ Notify the health care provider. | The stem of the question contains the critical words highest‐priority. This tells you that more than one of the options could be partially or totally correct. Use general nursing knowledge about diarrhea associated with fever, and the process of elimination, to make a selection. |
3140 A parent of a 2‐year‐old child asks the nurse why Correct answer: 2 Bismuth subsalicylate contains small amounts of naturally occurring lead, but Reye's bismuth subsalicylate (Pepto‐Bismol) should not be syndrome is a theorized complication of salicylate use in young children. Taste and darkening used for diarrhea in children under 3 years old. The of the tongue are not the issue being addressed in this question. nurse should include which of the following rationales in a response? ‐ It has an offensive taste that children do not like. ‐ It could lead to development of Reye's syndrome because of its salicylate content. ‐ It has a higher‐than‐recommended lead content. ‐ It can cause darkening of the tongue, which is frightening for children of that age. | Note the critical word salicylate in the stem of the question. Immediately associate this word with aspirin, which is contraindicated for use in children because of the risk of developing Reye's syndrome. |
3141 The nurse is giving follow‐up instructions to a client Correct answer: 1 Methylcellulose is a bulk‐forming cellulose that absorbs intestinal fluids. This action helps with irritable bowel syndrome (IBS). The nurse prevent constipation and reduce or eliminate diarrhea. Bisacodyl and docusate sodium are provides information about which medication that laxatives, while dicyclomine is an antispasmodic. would be beneficial to treat both the diarrhea and constipation associated with IBS? ‐ Methylcellulose (Citrucel) ‐ Docusate sodium (Colace) ‐ Dicyclomine (Bentyl) ‐ Bisacodyl (Dulcolax) | The core issue of the question is knowledge of a medication that relieves both constipation and diarrhea. With this in mind, you need to select a medication that regulates the bowel. Use medication knowledge and the process of elimination to make a selection. |
3142 A 26‐year‐old female client comes to the clinic for an Correct answer: 4 A serious adverse effect of misoprostol (Cytotec) is that a pregnant woman who takes the annual health examination. She has been taking medication could experience a miscarriage. Misoprostol should be discontinued at least one misoprostol (Cytotec) for several years following a month before pregnancy occurs. Options 1 and 2 have lower priority, and option 3 might not gastric ulcer. She is getting married next month. What be necessary for this client. is the priority nursing intervention for this client? ‐ Discuss whether to continue taking her oral contraceptive. ‐ Discuss family planning. ‐ Ask the client about the need for sexually transmitted disease (STD) counseling. ‐ Explain the risks of using misoprostol during pregnancy. | The core issue of the question is associated risks of taking misoprostol during pregnancy. Eliminate options 1 and 3 first because they do not relate to misoprostol. Then choose option 4 over option 2 because it is more specific to the medication. |
3143 An 82‐year‐old female who has had compensated Correct answer: 1 Bisacodyl is a stimulant laxative that can cause fluid and electrolyte imbalance. This can have congestive heart failure for years comes to the additive effects, because the diuretic use would also contribute to this finding. For this reason, ambulatory care center for a quarterly routine health the nurse should assess the use of the laxative. The other options suggest items that would not examination. At this time, she reports increased help determine the cause of the client s current symptoms. fatigue, weakness, and dizziness, although physical examination findings are normal. Laboratory results include a normal CBC; sodium 123 mEq/L; and potassium 3.5 mEq/L. Her medications include Lasix 20 mg daily; K‐Dur 10 mEq daily; Lanoxin 0.125 mg daily; and prn bisacodyl (Dulcolax) suppository. What information would be helpful to evaluate the cause of the client s hyponatremia? ‐ How frequently the client uses the bisacodyl suppository ‐ Whether the client has skipped digoxin doses in the last week ‐ Whether the client has taken excess doses of K‐Dur ‐ How frequently the client eats salty foods in restaurants | Note that the question contains the critical word hyponatremia. With this in mind, evaluate each option in terms of its relevance to the low sodium value. Eliminate each of the incorrect options, because they would not cause the electrolyte imbalance stated in the question. |
3144 The nurse would recommend which type of laxative Correct answer: 1 Bulk‐forming laxatives, such as methylcellulose, absorb intestinal fluid, increasing stool as the best choice for a client with constipation and a volume, stimulating peristalsis, and decreasing straining on defecation. This type of laxative is history of coronary artery disease and congestive heart the best choice for a client with a history of heart disease complicated by heart failure. The failure? laxatives in the other options are more likely to cause straining at stool for the client, and therefore are less helpful for the client s overall status. ‐ A bulk‐forming laxative ‐ A saline laxative ‐ A stimulant laxative ‐ PRN enemas | The critical words in the stem of the question are best choice. This tells you that more than one option might be partially or totally correct, but one option is best. Keeping in mind that the client has heart disease, use the process of elimination to choose the bulk‐forming laxative as least likely to cause strain on the heart. |
3145 The client comes to the office to get a refill of a Correct answer: 2 Dicyclomine HCl is an antispasmodic drug. Peripheral side effects include hot, flushed, dry prescription for dicyclomine hydrochloride (Bentyl). skin; hyperthermia; and intolerance to high temperatures manifested by dizziness. The client She tells the nurse she is leaving the next day for a should be advised to drink extra fluids (nonalcoholic) if exposed to high temperatures to vacation to Florida. What education should the nurse reduce this occurrence. provide this client? ‐ “You do not need to be so concerned about taking the medication on vacation, because you probably won t be able to watch your diet very well anyway.” ‐ “This medication may make you more sensitive to high temperatures, which could lead to dizziness.” ‐ “You probably should discontinue the medication until you return home, because alcohol can increase the drug s effects on the central nervous system.” ‐ “While you are away, you should take antacids with this medication to decrease any symptoms of GERD.” | The core issue of the question is adverse effects of dicyclomine. A clue in the question is the reference to Florida, which suggests that option 2 (high temperature) is the correct option. |
3146 A mother rushes her 2‐year‐old child to the urgent Correct answer: 2 Activated charcoal absorbs ipecac syrup, thus decreasing its effect by inhibiting absorption care clinic. She has given the child two doses of ipecac from the GI tract into the general circulation. While calling the poison control center is syrup following ingestion of a bottle of children's important, it is not the highest‐priority action to ensure the safety of the client. Option 3 is aspirin. It has been over 40 minutes, and the child has incorrect, and option 4 could result in harm to the client. still not vomited. What should the nurse do first? ‐ Call the poison control center. ‐ Give activated charcoal. ‐ Offer milk or carbonated soda. ‐ Wait for physician to assess the client. | When selecting the correct answer to the question, note that the question stem asks for selection of the priority option. Calling the poison control center first would delay treatment, and would not be the first choice. Giving the child activated charcoal is the first choice to slow absorption of the ipecac, and then calling the poison control center would be the next. |
3147 The nurse is caring for a client with gastroesophageal Correct answer: 1 Metoclopramide is a GI stimulant, increasing motility of the GI tract and shortening gastric reflux disease (GERD) who is taking metoclopramide emptying time. The other options do not represent actions of this medication. (Reglan). The nurse determines that the client understands the purpose of the medication when the client verbalizes that the medication has which of the following actions? ‐ Increases GI motility. ‐ Decreases GI motility. ‐ Combats diarrhea. ‐ Kills <i>H. pylori</i> organisms. | In order to correctly select the answer to this question, recall knowledge of the purpose of the medication. If this was difficult, review the purpose of the medication. |
3148 A client is taking dicyclomine (Antispas) for irritable Correct answer: 4 Dicyclomine is a cholinergic‐blocking agent that decreases hypermotility and spasms of the GI bowel disorder. The nurse explains to the client that tract. The dose should be taken before a meal to be effective when needed. which of the following represents the optimal dosing for dicyclomine? ‐ Take after meals. ‐ Take with meals. ‐ Take only as needed. ‐ Take 30–60 minutes before meals and bedtime. | In order to answer the question correctly, review the method of administration. If this was difficult, review the methods of administration in a medication handbook. |
3149 A male client has been diagnosed with acute diarrhea. Correct answer: 2 Pepto‐Bismol (bismuth salicylate), is contraindicated in clients who are allergic to aspirin or He is allergic to aspirin (ASA), and takes no salicylates. The other medications can be given to the client safely. medications. Which antidiarrheal medication should not be given to this client? ‐ Kaopectate ‐ Pepto‐Bismol ‐ Lomotil ‐ Imodium | Knowing the compositions of the medications will lead to the correct answer. Realizing that salicylate refers to aspirin, as is listed in the question stem, will lead to the only correct answer that contains aspirin, option 2. |
3150 An ambulatory care nurse is working with a client Correct answer: 4 Metamucil is a bulk‐forming laxative that could aggravate diarrhea. Kaopectate (option 2) is who has come to the clinic because of diarrhea. The an antidiarrheal agent that is commonly used to manage this health problem, which is usually nurse determines that the client needs instruction self‐limiting. The client should contact the health care provider again if diarrhea persists about management of this health problem when the (option 3), because diarrhea lasting more than two days requires attention. Dairy products are client states to do which of the following? a food source that can aggravate diarrhea (option 1). ‐ Avoid dairy products. ‐ Take Kaopectate as directed. ‐ Contact health care provider if symptoms not resolved in two days. ‐ Use a bulk‐forming agent, such as Metamucil. | Note that the question stem asks for selection of the option that would establish that the client needs further teaching. Note that the words “bulk‐forming” are present in option 4. This would lead you to suspect that diarrhea would be aggravated, with more stool produced, if a “bulk‐forming” agent were consumed. The other answers all indicate that the client understands management of the illness. |
3151 Because discoloration of client's stool to dark green Correct answer: 4 To prevent unnecessary anxiety, the nurse should tell the client to expect the stool change or black is a side effect of oral ferrous sulfate, the (option 4). Since this is a harmless side effect, no change in initial process in needed (option 1). nurse performs which of the following: Taking the iron with food can reduce GI side effects such as nausea/vomiting, but will not prevent the dark stools. Ingestion of food with iron will decrease absorption (option 2). Administering the drug on an empty stomach can increase absorption, but will not prevent the change in stool color (option 3). ‐ Consult with the prescriber about ordering the drug IM rather than oral. ‐ Administer the drug with food to avoid this side effect. ‐ Administer the drug on an empty stomach to avoid this side effect. ‐ Inform the client to expect a change in stool color. | Recall that ferrous sulfate therapy causes black, tarry stools; a harmless side effect. |
3152 A 3‐year‐old client weighing 33 pounds is to receive Correct answer: 7.5 Use the following formula to calculate: <BR /> liquid Advil (ibuprofen) 150 mg PO q6 hours prn for temperature above 101 degrees F. The nurse should administer mL to the client from a bottle labeled 100 mg/5 mL. Fill in the numeric answer below. | Use the X equation to determine the correct amount. |
3153 An older adult client ingesting glyburide (Micronase) Correct answer: 2 Because of the drug’s action (hypoglycemic), duration (24 hours) and the half‐life (10 hours), 1.25 mg PO daily makes which of the following the client could be at significant risk if the dose is doubled (option 2). The common dosage is statements that would cause the home health nurse to once daily before or with breakfast (option 1). Ingestion of alcohol with the drug can result in a schedule another home appointment for the following disulfiram reaction or excessive sympathomimetic reaction (option 3). HBA1c provides day? information regarding the glucose level over a 4 month period (option 4). ‐ "I take the tablet with breakfast every day." ‐ "If I forget the dose on one day, I will take two tablets the next day." ‐ "I will avoid drinking alcohol while taking this drug." ‐ "I will keep appointments to have my HBA1c checked every 4 months." | Determine the client’s health maintenance ability based on the content of the statements to select the correct answer. |
3154 After receiving digoxin (Lanoxin) 0.125 po daily for 5 Correct answer: 4 The base for the antidote is made from sheep's blood so the nurse should monitor for an days, the client exhibited signs and symptoms of major allergic reaction (option 4). Response in adults occurs within 15‐60 minutes (option 1). side effects associated with the drug. The nurse Hypokalemia is more likely to occur (option 2). The client should be monitored for at least 2‐3 administers the antidote and does which of the weeks (option 3). following? ‐ Monitor serum digoxin at least 12 hrs after administration of antidote ‐ Monitor for hyperkalemia ‐ Inform prescriber improved cardiac rate occurred 2 hours after administration ‐ Monitor for allergic reaction | Recall that the antidote (Digibind) is made from sheep's blood and may cause allergic reaction. |
3155 When the nurse is administering medication to a Correct answer: 2 Because the identification bracelet is tangible and attached to the client, it is the most hospitalized client, which of the following is the most appropriate method for determining client identity prior to administering medication. The accurate way to assure that the right client gets the bracelet contains the client’s name as well as the medical record number. Within the last few medication? years, it has become acceptable to ask an oriented client to state his or her name and date of birth. The nurse must have tangible information to match the client’s response (option 2). Hospitalized or ill clients are often anxious, medicated, or confused and could respond incorrectly to this question (option 1). A nurse administering medications may be unaware that the UAPs/NAs may have changed room and bed assignments. Therefore, there is a very high risk of incorrect identification (option 3). Because the same diagnosis with the same medication may be appropriate for more than one client, matching the medication to the diagnosis or need will place the client at risk (option 4). ‐ Ask the client, "Are you (<i>name</i>)?" ‐ Check the client's identification band ‐ Check the client's room number and bed assignment ‐ Match the medication with the client’s diagnosis | Select the option that offers the best method for communication of the information. |
3156 The client received isophane (NPH) insulin 30 units SC Correct answer: 3 4 to 12 hours is the peak time period for NPH (option 3). 2 to 3 hours is the peak time period at 7:30 A.M. What time is the nurse most likely to for Regular insulin (option 1). 4 to 7 hours is the peak time period for Semilente (option 2). 8 to observe signs or symptoms of hypoglycemia? 12 hours is the peak time period for Lente (option 4). ‐ 9:30 am to 10:30 am ‐ 11:30 am to 2:30 pm ‐ 11:30 am to 7:30 pm ‐ 3:30 pm to 7:30 pm | Associate this drug with an intermediate range. |
3157 The client asks the nurse, "Can you give me the Correct answer: 3 Heparin will be destroyed by the gastric juices if taken orally (option 3). Because it will be not heparin dose in a pill or liquid form instead of these be absorbed intact, it is not produced in an oral form (option 1). Option 2 is not the reason injections?" The most appropriate nursing response Heparin is not administered orally. Option 4 is an incomplete response. While the drug includes: company does not produce in tablet form, this is not the reason it is not administered orally (option 4). ‐ "The oral route could be used if I call the physician first." ‐ "When taken orally Heparin may cause ulcerations.” ‐ "Gastric juices will destroy Heparin if taken orally." ‐ "The drug company does not produce Heparin in an oral form." | Recall the correct administration of Heparin and why it is given in this way. |
3158 The client taking diltiazem hydrochloride (Cardizem) Correct answer: 4 Grapefruit juice changes the metabolism of the calcium channel blocker drugs and leads to an 30 mg PO qid is experiencing symptoms of toxicity. increase in blood levels of the drug resulting serious signs and symptoms such as dysrhythmia, Which of the following assessments should be the angina, heart block, bradycardia, and hypotension (option 4). Assessment of respiratory nurse's highest priority? pattern may be important because of the toxicity, but does not address the primary problem directly (option 2). Assessment should focus on the cause. There is no direct relationship between altered body temperature and toxic levels of this drug (option 1). Weight gain is an adverse effect of this drug. The highest priority is insisting the client ingest this drug safely. Identification of the cause of the toxicity takes the highest priority (option 3). ‐ Client's body temperature, looking for elevation ‐ Rate, depth and regularity of the client's respirations ‐ Client's daily weight, looking for weight loss ‐ If client has ingested grapefruit juice with meals | Apply knowledge of the primary cause of toxicity in calcium channel blockers. |
3159 A client who is taking several prescribed oral Correct answer: 1, 3 Drug interactions, drug side effects, drug actions, and drug absorption should be examined medications for the treatment of congestive heart before ingesting multiple prescriptions (option 1). Reaching the goals of the drug therapy failure tells the nurse, "I usually take all of my would indicate that this approach is appropriate (option 3). Option 2 is a correct statement, medication with my breakfast." The nurse's best but is not comprehensive. The time is only one of the elements of concern (option 4). The response includes which of the following? Select all nurse needs to be sure there are no significant risks (option 5). that apply. ‐ "It might be good idea to examine each drug to determine the best times and conditions to ingest.” ‐ "That depends on what you eat at breakfast." ‐ “Are you reaching the goals of the drug therapy?” ‐ "What time do you usually have breakfast?" ‐ "That's a great idea." | Select options providing the most effective approach to the drug therapy. |
3160 While talking with a client, the nurse finds that the Correct answer: 3 If the client were unaware of the risks of bleeding and ease of tissue damage, appropriate client is unaware of the side effects of warfarin protective mechanisms would not be in place so injury is most likely to occur (option 3). There (Coumadin). Which of the following nursing diagnoses is no evidence of an oxygen deficit (option 1) nor evidence of reduced self‐management best describes the client’s current status? (option 2). There is no evidence that the client is at risk for infection (option 4). ‐ Ineffective gas exchange ‐ Reduced self‐management ‐ Risk for injury ‐ Risk for infection | Lack of knowledge places client at risk for injury. |
3161 The medication administration record shows that the Correct answer: 4 This is an example of two different drugs in the same sub‐category with very similar names. client is to receive lisinopril (Zestril) 10 mg PO at 9:00 The question of which drug should be administered to the client is answered by checking the A.M. On hand are tablets labeled fosinopril (Monopril) original physician order and giving that drug (option 4). These actions violate matching the 20 mg. Which action by the nurse ensures that the drug with the MAR (options 1 & option 2). This action violates using the appropriate right drug and the right dose are administered? sources to validate the accuracy of a transposed order (option 3). ‐ Give one tablet of Monopril from the drug supply ‐ Given one‐half tablet of Monopril from the drug supply ‐ Ask the client if the 20 mg tablet looks familiar ‐ Read the original physician order to verify the drug order | Apply principles of drug administration to select the correct answer. |
3162 A nurse educator is conducting a seminar for clients Correct answer: 3 Vitamin K is the antidote for the actions of Coumadin; any food (such as broccoli or cabbage) ingesting warfarin (Coumadin). The nurse instructs the or drug that contains vitamin K reduces the effects of the drug (option 3). Yellow vegetables clients to make which of the following dietary have no overlapping characteristics with Coumadin (option 1). Coffee and tea have no known adjustments? overlapping characteristics with the drug (option 2). Vitamin C may increase the risk of bleeding. The nurse would not want to enhance the effects of Coumadin (option 4). ‐ Reduce intake of yellow vegetables ‐ Reduce intake of coffee and tea ‐ Reduce intake of foods like broccoli and cabbage ‐ Increase intake of citrus fruits to enhance effect of the drug | Recall that some vegetables have a polar relationship with the drug. |
3163 Which of the following data indicates that the client Correct answer: 1, 2, 3, When microbes become established in body tissues, an inflammatory process develops which with cellulitis who is receiving an antiobiotic has been 4 required a significant increase in the metabolism. An increased metabolism results in an achieved satisfactory response to the medication? elevated body temperature. A continued elevation in body temperature indicates the microbes Select all that apply. continue to overcome the body defenses. The prescribed antibiotic needs to be re‐evaluated (option 2). When the offending agent is established and growing fluid drains into the area to reduce the irritation caused by the toxins. Decrease swelling would indicate the antibiotic has successfully reduced the number of microbes (option 1). Pain at the site is related to increased pressure on nerve ending. Reduction in the level of pain is indicative of decreased inflammation (option 3). When microorganisms are multiplying the WBC increase in number and migrate to the site. A reduced serum WBC would indicate the antibiotic is effective resulting in a reduced number of microorganism (option 4). Enlarged regional lymph nodes are common signs/symptoms of the disease (option 5). ‐ Swelling of the right arm is reduced ‐ Body temperature is 101 degrees F ‐ Client reports less pain in right arm ‐ White blood cell count has decreased ‐ Regional lymph nodes are enlarged | Apply knowledge of the inflammatory process to select the correct answer. |
3164 The nurse is planning to instruct a Hispanic American Correct answer: 1 Because a client of Hispanic heritage often lives in the community with an extended family, client about the drug regimen prescribed for newly the nurse should include the family members in the educational process (i. e., privacy rights diagnosed hypertension. When developing the plan, have been addressed). Since men are typically decision makers, the nurse should attempt to the nursing actions should be based on which of the include the male in this client’s life in the teaching sessions. The nurse must be sensitive to the following most relevant cultural information? client's wishes regarding privacy when doing health teaching. Because this cultural group cherishes its language, teaching materials in the native language will be appreciated (option 1). Whether or not this culture values education in all forms does not have a direct relationship to teaching the client about the medication (option 2). This culture prefers more personalized approach to health care (option 3). Disliking the use of medication to treat disease is aligned more with the practice of Christian Scientist (option 4). ‐ The client lives in an extended family setting in which men are the decision makers ‐ The client values education in all forms | Apply knowledge of this culture with this scenario to select the correct answer. |
‐ The client prefers using written materials as a way of learning ‐ The client dislikes using medication to treat health problems | |
3165 The nurse is administering tetracycline hydrochloride Correct answer: 3 The drug tetracycline is absorbed best when given to the client on an empty stomach with a (Tetracyn) 500 mg PO QID to a client with gonorrhea. glass of water (option 3). Food (option 1), dairy products (option 2), iron, and antacids Which of the following nursing actions best matches decrease the absorption of this drug (option 4). the client’s needs? ‐ Administer drug with meals ‐ Give drug with a full glass of milk to prevent gastric irritation ‐ Give drug on an empty stomach with a full glass of water ‐ Give drug with a glass of orange juice or other source of vitamin C | Remember that oral administration of this drug increases the risk of decreased absorption. |
3166 While still in the recovery room, a client with a large Correct answer: 2 The normal dosage range for morphine administered IV is 2.5‐15 mg q4 hours. Since the nurse abdominal wound requested a second injection of cannot alter the order, the health care provider needs to be contacted (option 2). Abdominal morphine sulfate (MS) 3 mg IV 2 hours after the first pain on the same day of surgery is usually very severe. Since the level of pain appears to be injection. If the order reads “MS 4‐10 mg IV q 3‐4 hours appropriate for the surgical procedure, assessing the wound to aid in determining the prn pain,” the nurse should perform which of the appropriateness of the pain response is illogical (option 1). Assessing the respiratory status following? needs to occur after it is determined an injection will be administered (option 3). Since the client has a large abdominal wound, the general anesthesia along with administration of analgesics will result in drowsiness for the next 24 hours. It will not aid in resolving the problem of the imbalance between the dosage level and the pain response (option 4). ‐ Assess the surgical wound ‐ Contact the prescriber ‐ Assess the respiratory status ‐ Assess the level of consciousness (LOC) | MS is a potent narcotic. If dosage and pain intensity are not matched, then adjustment is needed. Note that current order is less than maximum allowed. |
3167 The mother of the pediatric client asks the nurse, Correct answer: 2 This response answers the questions and provides safe instructions. Changing from brand "What is the difference between Advil and ibuprofen? I name drugs to generic drugs should be done by the health care provider (option 1). This is an can buy ibuprofen at a cheaper price, but the inaccurate statement. Advil, and enteric coated tablet, is a brand name of ibuprofen. Not all instructions from the clinic say to use Children's Advil ibuprofen is enteric coated (option 2). The drugs are the same. Ibuprofen is the generic name. Liquid." The nurse’s best response includes: Option 3 does not answer the question. It is inappropriate to make a referral when the nurse is capable of meeting the need (option 4). ‐ "Similarities do exist, but follow the instructions for now.” ‐ "There is no difference between Advil and ibuprofen." ‐ "Advil and ibuprofen are two different drugs with similar effects." ‐ "You need to talk to the person that prescribed the drug.” | Select the option that is most accurate and places the client at the least amount of risk. |
3168 A client is taking bismuth for diarrhea. For which side Correct answer: 1 Bismuth‐containing preparations, such as Pepto‐Bismol, can cause transient darkening of the effect unique to this medication would a nurse tongue and stool as a side effect. monitor? ‐ Darkening of the tongue ‐ Dyspepsia ‐ Abdominal pain ‐ Diarrhea | In order to answer this question correctly, recall the side effects of bismuth. The only correct answer for this question is option 1. The other options are all incorrect. If this was difficult, review the side effects to bismuth. |
3169 After observing the client taking phenelzine sulfate Correct answer: 4 The foods are high in tyramine, a chemical that can result in a hypertensive crisis if ingested (Nardil), eating a lunch of yogurt, sliced bananas, and while taking MAOIs such as phenelzine (option 4). The central nervous system side effects chocolate milk, the nurse should perform which of the involve mental alterations such confusion and anxiety rather than physical changes such as following? temperature elevation (option 1). Respiratory depression is more likely to occur (option 2). Diabetes mellitus is not associated with the drug (option 3). ‐ Monitor client's body temperature for elevation above normal ‐ Observe client for dyspnea ‐ Test a urine specimen for glucose and ketones ‐ Monitor client for elevated blood pressure | Associate negative reactions between MAOIs and foods containing tyramine. |
3170 After a prescriber writes a medication order for a Correct answer: 2 The nurse has a legal and ethical responsibility to assure that the client receives the correct client, the nurse determines that the dose is above the dosage. Since dosages may sometimes be outside recommended ranges, contacting the usual dosage range. The nurse should perform which prescriber for clarification is appropriate. A nurse initiate a medication order after assuring the of the following “rights” associated with medication administration have been met (option 2). When the problem is resolved, both the prescriber and the nurse administering the drug will be in agreement. This will not occur if the nurse talks with a second nurse (option 1). Appropriate initiation of the drug administration process includes considering if the “right” dosage is prescribed. The prescriber’s qualifications are not the central focus (option 3). Documentation of concerns should be entered in organizational records rather than the client’s record (option 4). ‐ Ask another nurse about the dosage order ‐ Contact the prescriber about the dosage ‐ Recognize that the prescriber is qualified to write drug orders ‐ Document the concern in the client's record | Seek the resource that is able to resolve the problem. |
3171 Because an over‐the‐counter (OTC) iron preparation Correct answer: 3 Pregnancy Category A is assigned to drugs that have not shown to have adverse effects on is categorized as Pregnancy Category A, the nurse fetal development. It is safe to ingest the drug during pregnancy (option 3). Option 1 is teaches a pregnant client which of the following most incorrect information. Clients should report to physician all OTC drugs ingested, but this important information? response does not correlate with the pregnancy categories (option 2). option 4 is a side effect of the tetracyclines. ‐ Should ingest the medication during pregnancy ‐ Immediately report to the physician that she has taken the drug while pregnant ‐ Safe to ingest this medication during pregnancy ‐ May be staining of the baby's first teeth from this medication | Apply knowledge of Pregnancy categories associated with drug therapy to select the correct answer. |
3172 The client taking theophylline (TheoDur) 16 mg/kg PO Correct answer: 2 Since the drug has a narrow therapeutic range, toxicity can develop quickly. The normal for asthma has a serum theophylline level of 22 therapeutic dose level is 10‐20 mcg/mL. Hence, the signs and symptoms are indicative of mcg/mL. Because the client is experiencing nausea, toxicity. The nurse should suspend the order until the prescriber is contacted (option 2). vomiting, and headache the nurse should perform Procuring and administering antiemetic would reduce the signs/symptoms but would not which of the following actions? resolve the problem (option 1). The lab test validates that toxicity exists (option 3). The nurse should suspend the order until the dosage can be changed. The drug’s duration is 4‐8 hours. Holding it for 24 hours would create the opposite problem (option 4). ‐ Seek an order for an antiemetic ‐ Temporarily suspend the order and notify the prescriber ‐ Ask if the client if mucous obtained during respiratory therapy was expectorated ‐ Stop ordered doses of TheoDur for 24 hours | Recall that this drug has a profound effect on the GI tract and cardiac function. Toxicity is likely to have an effect on the 2 systems. |
3173 A client with advanced liver disease is being treated with antibiotics for a respiratory infection. The nurse should assess the client for which of the following?
‐ High risk for allergy to drugs
‐ Teratogenic effects of antibiotics
‐ Symptoms of drug toxicity
‐ Drug dependence
3174 Which of the following physical changes commonly associated with aging are most likely to require a reduction in medication dosage in an elderly client? Select all that apply.
Correct answer: 3 The liver is the organ chiefly responsible for detoxification of drugs. Active drug may accumulate to toxic levels in clients with impaired liver function (option 3). Every client receiving drugs, especially antibiotics, should be assessed for drug allergy (option 1). The question does not state that the client is pregnant so teratogenic effects are not of concern in this situation. Signs/symptoms of tetragenic effects are too vague and too complex to be assessed during a general assessment (option 2). Antibiotics do not cause drug dependence to develop (option 4).
Correct answer: 1, 2 Since elderly clients experience a decreased rate of drug excretion, reduction of dosage would be appropriate (option 1). The decreased total body fluid proportion that accompanies physical aging increases the concentration of water‐soluble drugs and requires lower dosing in older adults (option 2). Decreased efficiency in drug distribution would not correlate with a need to lower the dosage (option 3). Elderly clients experience a decreased rate of drug metabolism (option 4). Most older adults tend to lose weight as they age (option 5).
Recall that most drugs are transformed by the liver then excreted by the kidneys.
Select the options that would place the client at greatest risk and that correlate closest to the information in the question stem.
‐ Increased rate of drug retention
‐ Decreased total body fluid proportionate to body mass
‐ Decreased efficiency in drug distribution
‐ Decreased rate of drug metabolism by the liver
‐ Significant weight gain
3175 A health care provider prescribed a prochlorperazine Correct answer: 3 The nurse should consult with the pharmacist before contacting the prescriber (option 3). Remember to presume the drug is not evenly distributed throughout the medium.
(Compazine) 12.5 mg suppository for a client with severe nausea. The nurse has on hand a 25 mg suppository. The next step for the nurse includes which of the following?
Drug companies do not guarantee that the medication is equally distributed throughout the medium (option 1). The dosage is not stable across routes. The nurse may not change prescriptions (option 2). After the dosage problem is resolved, the rectal vault should be cleared adequately to guarantee maximum absorption (option 4).
‐ Cut the suppository in half and insert the rounded edge
‐ Administer the drug orally
‐ Contact the prescriber, if unable to locate the dosage
‐ Clear the rectal vault of the contents before administering half of the suppository
3176
A client is taking nalidixic acid (NegGram) for treatment of a urinary problem. The nurse explains to the client that the medication is best described as which of the following?
‐ An antispasmodic
‐ A uricosuric
‐ An anti‐infective
‐ An analgesic
Correct answer: 3 Nalidixic acid is bactericidal, and inhibits microbial synthesis of DNA. The spectrum includes most Gram‐negative organisms except Pseudomonas. This medication does not belong to the antispasmodic, antigout, or analgesic families.
The core issue of the question is knowledge of basic information about nalidixic acid and its uses. Use the process of elimination and nursing knowledge to make a selection.
3177 The client with congestive heart failure (CHF) is eating Correct answer: 2 a 1‐gram‐sodium diet, and will be having a potassium‐ sparing diuretic added to the medication regimen. The nurse prepares to conduct teaching about which medication that is likely to be prescribed? ‐ Hydrochlorothiazide (HCTZ) ‐ Spironolactone (Aldactone) ‐ Furosemide (Lasix) ‐ Atenolol (Tenormin) | Spironolactone is a potassium‐sparing diuretic that promotes sodium excretion while conserving potassium. Options 1 and 3 are diuretics, but not potassium‐sparing diuretics. Option 4 is not a diuretic; it is an antihypertensive of the beta‐blocker type. | The core issue of the question is knowledge of drugs that are potassium‐sparing diuretics. Use the process of elimination and nursing knowledge to make a selection. |
3178 The home health care nurse is visiting an elderly Correct answer: 4 client who is taking furosemide (Lasix) twice daily. Which of the following statements made by the client indicates the need for further teaching? ‐ “I will take my medication in the morning and early evening.” ‐ “I will change my position slowly, so that I don t fall.” ‐ “I will notify my physician if my ankles swell.” ‐ “I will drink coffee and tea whenever I wish to get enough fluid.” | Tea and coffee are poor choices for hydration. They are mild diuretics, and can cause severe dehydration if used concurrently with diuretics. Taking medication at the same time each day improves compliance. In addition, morning and early evening are the best times to take Lasix, so as not to interrupt sleep. Notifying the physician when edema is noticed is important, and should be emphasized by the nurse. | The critical words in the stem of the question are need for further teaching. This tells you that the correct answer is an incorrect statement on the part of the client. Use the process of elimination and knowledge of diuretic therapy to narrow the selection to the one that utilizes additional diuretic substances. |
3179 A client is receiving dopamine (Intropin) therapy at 10 Correct answer: 3 mcg/kg/minute. The nurse assesses the client for evidence of which nursing diagnosis, for which the client is at risk? ‐ Excess Fluid Volume ‐ Increased Cardiac Output ‐ Impaired Tissue Perfusion ‐ Disturbed Body Image | The client receiving dopamine therapy should be assessed for impaired tissue perfusion related to peripheral vasoconstriction. There is not enough information in the question to determine if option 1 is appropriate. Option 2 is not a nursing diagnosis, although decreased cardiac output is one. Option 4 does not relate to the question as stated. | The core issue of the question is knowledge that higher doses of dopamine can lead to selective vasoconstriction, which in turn can reduce perfusion to peripheral tissues. Use the process of elimination and knowledge of dose‐related drug side effects to make a selection. |
3180 The nurse is reviewing the medication administration Correct answer: 1 record for a client newly admitted to the nursing unit for congestive heart failure. The client is receiving hydrochlorothiazide (HydroDiuril). Which of the following would concern the nurse in relation to administration of this medication? ‐ Hypokalemia, hyperglycemia, and sulfa allergy ‐ Hyperkalemia, hypoglycemia, and penicillin allergy ‐ Hypouricemia and hyperglycemia ‐ Hyponatremia and hypocalcemia | Thiazide diuretics are sulfa‐based medications; therefore, a client with a sulfa allergy is at risk for an allergic reaction. The side effects of hydrochlorothiazide are hypokalemia, hyperglycemia, hyperuricemia, and hypercalcemia. Options 2, 3, and 4 are either partially or totally incorrect. | Remember that in order for an option to be correct, all of the parts of the option must be correct. Options to which this strategy applies will include the word and. Recall that diuretics generally can cause hypokalemia or hyperkalemia as adverse effects. Since only options 1 and 2 address these conditions, eliminate options 3 and 4. Recall that sulfa rather than penicillin is of concern to choose option 1 over option 2. |
3181 The nurse is planning to administer furosemide (Lasix) Correct answer: 3 40 mg by the IV push route. The nurse uses which of the following techniques in administering this medication? ‐ Pushes the medication steadily over 1 minute. ‐ Gives the medication slowly diluted in 50 mL of NS. ‐ Injects the medication over 2–3 minutes. ‐ Dilutes the medication with sterile water, and injects over 5 minutes. | Furosemide should be given at a rate of 20 mg/minute or less. Rapid injection of furosemide can cause hearing loss as a result of ototoxicity. It does not need to be further diluted before injection (options 2 and 4). | Eliminate option 4 because it is not typical to dilute IV push medications in sterile water. Eliminate option 2 because it is an IV push medication, and a volume of 50 mL is usually given as an IV piggyback. Choose option 3 over option 1 because of the size of the dose and knowledge of adverse effects. |
3182 A client is being prescribed oxybutynin (Ditropan) for Correct answer: 1 a neurogenic bladder. The nurse determines that the client is possibly experiencing toxic effects of this medication after noting which of the following? | Excessive dosing of oxybutynin produces nervousness, hallucinations, restlessness, tachycardia, confusion, flushed or red face, and signs of respiratory depression. Options 2, 3, and 4 are opposite effects of what would be expected in this case. | Note that when two options are opposite, one of them likely is correct. Use this strategy to eliminate options 3 and 4 first. Use the process of elimination and medication knowledge to choose option 1 over 2. | |
‐ Restlessness ‐ Drowsiness ‐ Pallor ‐ Bradycardia | |||
3183 The nurse is admitting a client with a hypertensive emergency and a history of renal insufficiency. The nurse ensures that which of the following diuretics is readily available for use if ordered? ‐ Furosemide (Lasix) ‐ Hydrochlorothiazide (HCTZ) ‐ Chlorthalidone (Hygroton) ‐ Spironolactone (Aldactone) | Correct answer: 1 | Furosemide is a loop diuretic. The antihypertensive action involves renal and peripheral vasodilation, a temporary increase in glomerular filtration rate (GFR), and decreased peripheral vascular resistance. For this reason, it is the drug of choice for clients with low GFR as a result of renal insufficiency. Hydrochlorothiazide, chlorthalidone, and spironolactone are not associated with use in clients with low GFR. | Specific knowledge of the benefits of furosemide as a loop diuretic and as the diuretic of choice with renal insufficiency is needed to answer this question. Take time to learn about this common medication if you had difficulty with this question. |
3184 A client being discharged from the hospital is beginning medication therapy with bumetanide (Bumex). The nurse instructs the client to contact the prescriber if which of the following contraindications for use develops while using this medication? | Correct answer: 2 | Anuria is the absence of urine formation, and is a contraindication for using this medication. Diuretics such as bumetanide are used to increase the amount of urine excreted in clients with CHF (option 2), pulmonary edema (option 3), and hypertension (option 4). | The core issue of the question is knowledge of expected effects and adverse effects of loop diuretics such as bumetanide. Knowing that diuretics help to relieve the symptoms in options 1, 3, and 4 will help you to eliminate each of them. |
‐ Increase in peripheral edema ‐ Absence of urine output ‐ Shortness of breath ‐ Increase in blood pressure | |||
3185 The nurse notes while taking an admission history that a client is taking acetazolamide (Diamox). The nurse next questions the client about a history of which of the following medical conditions? ‐ Hypertensive crisis ‐ Congestive heart failure (CHF) ‐ Open‐angle glaucoma ‐ Peripheral vascular disease | Correct answer: 3 | Acetazolamide is a carbonic anhydrase inhibitor. Inhibition of carbonic anhydrase decreases the rate of formation of aqueous humor, and thereby reduces intraocular pressure. Acetazolamide may be used for treatment of edema caused by CHF, but it is not a first‐line therapy. This medication does not have a therapeutic effect on hypertensive crisis or peripheral vascular disease. | The critical word in the stem of the question is next, which tells you that more than one follow‐up question might be appropriate, but you must select the most important one. Eliminate options 1 and 4 first because they are not targeted by this type of therapy. Choose option 3 over 2 because of the frequency of its use for open‐angle glaucoma. |
3186 A client is taking cyclosporine (Neoral) for a kidney transplant. The nurse is reviewing the list of current medications. The nurse would be concerned after noting that the client is presently taking which of the following medications? ‐ Prednisone (Deltasone) ‐ Phenytoin (Dilantin) ‐ Diltiazem (Cardizem) | Correct answer: 2 | Some medications, such as phenytoin, rifampin, and phenobarbital, are known to reduce the level of cyclosporine in the body. Therefore, the cyclosporine level should be monitored regularly while the client is taking these medications. Occasionally, dosage adjustment is required. | The core issue of the question is knowledge of drug interactions. Specific knowledge is needed to answer this question. Use the process of elimination, and take time to review this important drug if this question was difficult. |
4.‐ Acetylsalicylic acid (Aspirin) | |||
3187 A client who has been taking bethanechol chloride (Urecholine) for three days begins to complain of abdominal pain and difficulty breathing. After assigning another staff member to remain with the client, the nurse checks to see that which medication is available on the nursing unit? ‐ Phytonadione (AquaMEPHYTON) ‐ Atropine sulfate (generic) ‐ Oxybutynin (Ditropan) ‐ Epinephrine (Adrenalin) | Correct answer: 2 | The client is exhibiting signs of cholinergic toxicity, and atropine is the antidote. Phytonadione or vitamin K (option 1) is the antidote to warfarin (Coumadin). Oxybutinin is indicated for use as a urinary antispasmodic. Epinephrine is used to treat severe hypersensitivity reactions (anaphylaxis). | Use the process of elimination, focusing on the critical words abdominal pain and difficulty breathing. After determining that the client is experiencing adverse or toxic effects of the medication, choose the option that is an anticholinergic drug, which will treat the cholinergic symptoms. |
3188 A client who requires diuretic therapy has a creatinine clearance less than 30mL/min. The nurse checks the physician order sheet, expecting to find an order for which of the following types of medication? | Correct answer: 4 | Loop diuretics have the disadvantage of requiring more frequent dosing, but are advantageous in clients with creatinine clearance less than 30mL/min. The other types of diuretics (osmotic in option 1, potassium‐sparing in option 2, and thiazide in option 3) are not as useful when the client has a decreased creatinine clearance level. | The core issue of the question is knowledge that loop diuretics are the most beneficial type of diuretic for clients with low creatinine clearance levels. Specific knowledge of this drug category and the ability to recognize drugs from each diuretic class are needed to answer this question. |
‐ Mannitol (Osmitrol) ‐ Spironolactone (Aldactone) ‐ Chlorothiazide (Diuril) ‐ Furosemide (Lasix) | |||
3189 The nurse practitioner has prescribed oxybutynin (Ditropan) for a 65‐year‐old female with urinary frequency and urgency. The nurse teaching the client about the side effects of this medication should explain that which of the following manifestations is associated with this medication? | Correct answer: 4 | Oxybutynin (Ditropan) is an antispasmodic medication used to restore normal voiding patterns in clients with spasms of smooth muscle of the urinary bladder. It produces anticholinergic side effects such as dry mouth, constipation, urinary hesitancy, and decreased gastroenteritis motility. Periodic interruptions in therapy are recommended to assess continued need for this medication. | Use the process of elimination. The core issue of this question is knowledge of side and adverse effects of this medication. Choose the option that indicates an anticholinergic effect, such as dry mouth. |
‐ Dizziness ‐ Increased bruising ‐ Diarrhea ‐ Dry mouth | |||
3190 Phenazopyridine (Pyridium) is prescribed to a client with dysuria. The nurse explains that the client should expect which of the following urine characteristics while taking phenazopyridine? ‐ Decrease in volume ‐ Odor that is foul ‐ Increase in volume ‐ Color that is orange or red | Correct answer: 4 | Phenazopyridine is a urinary analgesic with a local anesthetic effect on the urinary tract mucosa. This medication relieves pain during urinary tract infection. It causes the urine to have an orange‐to‐red color. It has no effect on volume of urine. Foul odor to the urine can be caused by urinary tract infection. | The core issue of the question is knowledge of the effects of phenazopyridine on the urine. A critical word in the stem of the question is dysuria, which reminds you that the medication is a urinary analgesic, and as the only drug of its type, it causes orange‐to‐red discoloration in body fluids, including urine. |
3191 A client in shock has a blood pressure (BP) that continues to drop despite IV fluids. Intravenous dopamine is ordered at 8 mcg/kg/minute. The anxious client asks the nurse how the medication will help him get better. Which is the best response by the nurse? | Correct answer: 2 | Dopamine acts on the alpha‐ and beta‐ adrenergic receptors, resulting in vasoconstriction; increased systemic BP; and increased force and rate of myocardial contraction. Option 1 is a false statement. Option 3 is the opposite of dopamine s effect. Option 4 is true in low doses (2–5 mcg/kg/minute), but the focus of dopamine for the client in shock who is not responding to fluids is to achieve vasoconstriction. | The core issue of the question is knowledge of the use of dopamine for the client in shock. Recall that it can be used to achieve increased urine output in early shock, and to cause vasoconstriction and increased BP in later shock, to make the correct selection. |
‐ “Dopamine will interfere with poor electrical conduction in your heart.” | |||
‐ “It will cause blood vessel walls to tighten, to help increase your overall blood pressure.” ‐ “It will make your heart contract less forcefully and thus decrease the amount of work it has to do.” ‐ “It will increase your urine output through its effect on the kidneys.” | |||
3192 A client arrives in the Emergency Department after complaining of unrelieved edema in her legs. The client has been taking spironolactone (Aldactone) at home. The nurse shares which of the following data with the physician that indicates a need to withhold the medication? ‐ Blood glucose level of 170 ‐ Blood pressure of 110/70 ‐ Sodium level of 146 mEq/L ‐ Potassium of 5.9 mEq/L | Correct answer: 4 | Aldactone is a potassium‐sparing diuretic that increases sodium excretion and decreases potassium secretion in the distal convoluted tubule. Potassium levels higher than 5.5 mEq/L are contraindicated with spironolactone, due to increased risk of hyperkalemia. The elevated blood glucose in option 1 is not a priority issue related to this medication. The elevated sodium level could be alleviated by the medication, and thus it is not a reason to withhold the dose. The blood pressure is normal, and does not warrant withholding a dose. | The core issue of the question is the need to monitor potassium levels in a client taking potassium‐sparing diuretics. Use knowledge of expected effects of diuretics to eliminate options 1 and 2, and choose option 4 over 3 because the medication is a potassium‐sparing diuretic, and the risk of hyperkalemia is great. |
3193 The nurse is preparing to administer a first dose of cyclosporine (Sandimmune) by the IV route. Which of the following priority items should the nurse make available at the bedside during administration of this medication? | Correct answer: 1 | Epinephrine and oxygen should be available at the bedside because of the risk of anaphylaxis during administration. An oral airway and suction machine are not the priority items, although maintaining an airway would be necessary if the client actually did go into anaphylaxis. Since an oral airway and portable suction machine are usually part of the contents of a code cart, the full cart would not also be necessary. | The core issue of the question is knowledge that anaphylaxis is possible with administration of cyclosporine. Note that the question contains the critical words priority items. Realize that more than one option might be partially or totally correct, and that you need to prioritize the first and therefore most important item you would need. Recall that epinephrine is used to treat anaphylaxis to make this selection. |
‐ Epinephrine ‐ Oral airway ‐ A code cart ‐ A suction catheter | |||
3194 The client beginning medication therapy with sulfisoxazole (Gantrisin) needs instructions for its use. Which of the following items would the nurse include in client teaching about the medication? ‐ Call the prescriber if the urine turns dark brown. ‐ Maintain a high fluid intake. ‐ Restrict salt intake. ‐ Decrease the dosage when symptoms are improving. | Correct answer: 2 | Each dose of this medication should be administered with a full glass of water, and the client should be encouraged to maintain a high fluid intake. The client should not discontinue or decrease the dosage without consulting with physician. Sulfisoxazole does not discolor urine brown (although nitrofurantoin does), and it is not harmful (option 1). It is not necessary to restrict salt intake (option 3), and the dose should not be decreased even if symptoms improve (option 4). | Specific drug knowledge is needed to answer the question; however, recalling that fluid intake should be increased with urinary infections should help to eliminate the other incorrect options. |
3195 The nurse has an order to administer a first dose of epoetin (Epogen) to a client with chronic renal failure. The nurse would make note of which of the following laboratory test results to establish a baseline? Select all that apply. ‐ Hemoglobin of 9% ‐ Hematocrit of 26% ‐ White blood cell count 3,000/mm3 ‐ Creatinine 3.2 mEq/L ‐ Blood urea nitrogen 56 mg/dL | Correct answer: 1, 2 | Epoetin is given to stimulate red blood cell production in the client with chronic renal failure. For this reason, the nurse should look at the hemoglobin and hematocrit as baseline measurements. A white blood cell stimulant such as filgrastim (Neupogen) would be given to raise white blood cell counts (option 3). Epoetin alfa will not treat creatinine or BUN levels (options 4 and 5); the client would be receiving dialysis to control these values. | Use the process of elimination and knowledge of drug therapy. Recall that dialysis is needed to treat renal failure, and thus options 4 and 5 can be eliminated first. Recall that clients in renal failure are anemic because of impaired ability to produce erythropoietin to eliminate the white blood cell count. |
3196 | The following medication orders were discovered in a Correct answer: 4 client’s chart. The nurse should note and implement all of the orders except which of the following? ‐ Digoxin (Lanoxin) 0.25 mg PO daily ‐ Zolpidem (Ambien) 10 mg PO at bedtime PRN ‐ Furosemide (Lasix) oral solution 40 mg PO daily ‐ Acetaminophen (Tylenol) 2 tablets PO q4 hours PRN for headache | The Tylenol order contains all of the pertinent information except the dosage. The prescriber needs to be contacted (option 4). The Digoxin order contains the drug, dosage, route, time interval (option 1). Because all of the components are present, the Ambien order can be implemented (option 2). The Lasix order includes all of the specific information: drug, form, dosage, route, and time period (option 3). | Recall that the sequence of noting medication orders includes a complete order along with appropriate components for the specific client. |
3197 A client receiving nadolol (Corgard) for hypertension Correct answer: 1 Feeling dizzy when moving from lying or sitting to standing position is referred to as tells the nurse, "I get dizzy when I stand up." Which of orthostatic hypotension and is a common side effect of the beta blocker drugs such as nadolol. the following is the nurse's most appropriate The client should be instructed to change positions slowly. Signs and symptoms should response? diminish after a few weeks of treatment (option 1). Dizziness is not a sign of toxicity, but is related to the body’s adjustment to reduced decreased cardiac output and reduced central circulating volume (option 2). Dizziness can be a sign or symptom of hypertension. Since the client is ingesting an antihypertensive drug, postural hypotension related to decreased central circulating volume should be suspected (option 4). ‐ "This is an expected side effect of the drug, and you should use caution and move slowly when standing up." ‐ "You may be experiencing a toxic effect of the drug, and I will notify the physician." ‐ "Dizziness is not related to the drug, but I will need to ask you a few more questions." ‐ "Episodes of dizziness when moving are common symptoms of elevated blood pressure." | Recall that the primary concept is safety. Select the option providing the greatest safety. | ||
3198 | A health care provider prescribes 1000 mL D5W Correct answer: 166 0.09% NSS/ 6 hours. The flow rate for this infusion is mL per hour. | The rate for administration is calculated by: <BR /> | Perform the appropriate conversions, use the X equation, and calculate the number of mL per hour |
3199 | Meperidine HCL (Demerol) 100 mg tablet PO is Correct answer: 1 prescribed for a first‐day postoperative client with an abdominal wound. The best nursing action includes which of the following? ‐ Procure an order for a change to the parenteral route ‐ Administer the drug with food ‐ Place the tablet in a capsule ‐ Encourage coughing and deep breathing two hours after ingestion | Because IM or IV is a more efficient route the drug is likely be more effective more rapidly (option 1). Food will delay absorption (option 2). The capsule may prevent the delay caused by food, but the oral route is not the most appropriate route for this client (option 3). Peak time period is one hour (option 4). | Associate the route with the magnitude of the client’s needs. |
3200 | While administering Insulin (NPH, Isophane) Correct answer: 3 subcutaneously, the client asks the nurse, "When should I expect my blood sugar to be at the lowest level?” The nurse's best response includes: ‐ 2 to 3 hours. ‐ Appropriately 60 minutes. ‐ 4 to 12 hours. ‐ 8 to 12 hours. | Since insulin can lower blood glucose to a life‐threatening level, it is imperative that client be aware of the pharmacokinetics of insulin. The client should expect the glucose level to be at the lowest level in 4 to 12 hours – NPH insulin (option 3). A 2 to 3 hour peak is more appropriate for regular insulin (option 1). A 4 to 12 hour peak is more appropriate for insulin aspart (Novolog) (option 2). An 8 to 12 hour peak is more appropriate for Lente insulin (option 4). | Apply knowledge of the pharmacokinetics associated with NPH insulin to select the correct answer. |
3201 The nurse is giving general information about antihypertensive medications to a young female client with a history of hypertension. The nurse includes that pregnant or lactating women should avoid using which of the following types of antihypertensives? | Correct answer: 3 | Because ACE inhibitors can cause fetal harm or death, they should be discontinued as soon as pregnancy is detected. The effect on breastfeeding infants is unknown. The effect of other medications is unknown during pregnancy. | There is only one correct answer to this question. In order to select the correct answer, review the complications of each medication. |
‐ Vasodilators ‐ Diuretics ‐ Angiotensin‐converting enzyme (ACE) inhibitors ‐ Calcium channel blockers | |||
3202 The home health care nurse is visiting an elderly client who is taking a prescribed calcium channel blocker. In conducting dietary teaching, the nurse instructs the client that what food is contraindicated to take with a calcium channel blocker? | Correct answer: 2 | Calcium channel blockers should be administered with a high‐fat meal; grapefruit should be avoided before and after dosing, due to altered effects. The foods listed in the other options will not have a dose‐altering effect. | There is only one correct answer to this question. In order to select the correct option, review the nursing interventions related to teaching aspects for a client when taking calcium channel blockers. |
‐ Oranges ‐ Grapefruit ‐ Bananas ‐ Grapes | |||
3203 The nurse provides discharge instructions to the client taking an antihypertensive medication. The nurse should include in the teaching plan to notify the health care provider that a hypertensive crisis exists if the diastolic blood pressure (BP) is higher than which of the following? | Correct answer: 3 | In hypertensive urgencies, clients present with a systolic BP higher than 240 mmHg and diastolic BP higher than 120 mmHg. In hypertensive emergencies, the client's diastolic BP is higher than 130mmHg. | Having knowledge of the normal standards of care will lead to the correct option. If this was difficult, review the parameters for notification to the practitioner when taking antihypertensives. |
‐ 100 mmHg ‐ 120 mmHg ‐ 130 mmHg ‐ 140 mmHg | |||
3204 The nurse provides instructions to the client prescribed a diuretic. The nurse informs the client that which diuretic causes a persistent gynecomastia? | Correct answer: 3 | Spironolactone is a potassium‐sparing diuretic used to treat hypertension. Gynecomastia is one of its adverse reactions. Adverse reactions usually disappear after the drug is discontinued; however, gynecomastia can persist after discontinuation of spironolactone. | There is only one correct answer to this question. Having knowledge of the adverse reactions to the medication will lead to the correct answer. If this was difficult, review the side effects of the medications. |
‐ Hydrochlorothiazide (HCTZ) ‐ Furosemide (Lasix) ‐ Spironolactone (Aldactone) ‐ Indapamide (Lozol) | |||
3205 A client was just prescribed hydrochlorothiazide (HCTZ) for hypertension. The client asks the nurse how this medication works in the body. The nurse explains that thiazide diuretics increase urinary excretion of sodium and water by affecting which part of the kidney? ‐ Loop of Henle ‐ Cortical diluting tubule ‐ Collecting ducts ‐ Glomerulus | Correct answer: 2 | Thiazide diuretics increase urinary excretion of sodium and water by inhibiting sodium reabsorption in the cortical diluting tubule of the nephron, thus relieving edema. The loop diuretics inhibit electrolyte reabsorption in the thick, ascending loop of Henle, thereby promoting the excretion of sodium, water, and potassium. Potassium‐sparing diuretics directly increase sodium excretion and decrease potassium secretion in the distal convoluted tubule. | Having knowledge of pathophysiological processes of diuretics will assist in selecting the correct answer. If this was difficult, review the glomerular filtration system, and its functioning with diuretics. |
3206 The nurse taking care of a client with benign prostatic Correct answer: 3 Alpha‐adrenergic blockers are used for peripheral vascular disorders, hypertension, and BPH. hyperplasia (BPH) explains to the client that what Options 1, 2, and 4 are incorrect. category of antihypertensive drug can also be prescribed for BPH? ‐ Beta blocker ‐ Calcium channel blocker ‐ Alpha‐adrenergic blocker ‐ Vasodilator | There is only one correct answer to this question. While all the listed options are classifications of antihypertensive options, review the purposes of each classification in order to select the correct option. |
3207 The nurse would monitor the client receiving which Correct answer: 4 Verapamil and diltiazem, of all the calcium channel blockers, have the greatest effect on the type of antihypertensive drug because it slows the AV AV node to slow the heart rate. Additional drug effects are slowing of the ventricular rate in node, and thus decreases the heart rate? atrial fibrillation or flutter, and conversion of supraventricular tachycardia (SVT) to a normal sinus rhythm (NSR). ‐ Angiotensin‐converting enzyme (ACE) inhibitor ‐ Beta blocker ‐ Alpha blocker ‐ Calcium channel blocker | Knowing that one of the actions of calcium channel blockers slows the heart rate will assist in selecting option 4. If this was difficult, review the effects of each listed classification. |
3208 An elderly client is given a prescription for celecoxib Correct answer: 1 Rationale: Older clients often take other prescribed drugs, herbs, or other alternative (Celebrex) for pain and stiffness of osteoarthritis of the remedies, and client maybe ingesting an over‐the‐counter (OTC) remedy for arthritis. Because hips and back. The nurse should perform which of the there is a potentially high risk for drug‐drug or drug‐herb interaction, getting a thorough following first? picture of the client's current drug regimen is the first step in planning for client education when a new drug is ordered (option 1). Providing written materials is appropriate as a supplement after the nurse has taught the client about the medication (option 2). Because of cognitive changes, the client may need a strategy to help maintaining the drug schedule, but should not be the first action. First action is based on the potential risk to the client (option 3). Teaching about the drug is very relevant to the management of the client’s health needs, but assessing the risk to the client should occur before implementation (option 4). ‐ Do a thorough medication assessment to see what other drugs the client is taking ‐ Provide the client with a printed pamphlet describing the new drug ‐ Inform the client where a medication organizer can be purchased ‐ Give the client a short, simple verbal explanation about the drug and its side effects | Elderly is the key term. Correlate knowledge associated with elderly clients and drug therapy and recall that assessment is the first step in managing client needs. |
3209 The nurse would assess a client receiving a Correct answer: 1 Nonselective beta blockers are associated with adverse events of hyperglycemia and nonselective beta blocker for development of which of hyperlipidemia. These changes might be temporary, but the client should be monitored for the following complications related to drug therapy? occurrence. Decreased liver enzymes and increased BUN are not directly related to non‐ selective beta blockers. ‐ Hyperglycemia and hyperlipidemia ‐ Decreased liver enzymes ‐ Hypoglycemia ‐ Increased BUN | Having knowledge of the adverse reactions of a nonselective beta blocker will lead to the correct answer. If this was difficult, review the complications of the medication type. |
3210 The nurse monitors a client receiving a Correct answer: 1 Sympathomimetics act predominantly by direct stimulation of alpha‐adrenergic receptors, sympathomimetic agent for which of the following which constrict blood vessels and increase their resistance. This in turn results in increased expected effects? total peripheral resistance, and increased systolic and diastolic BP. ‐ Increased blood pressure (BP) ‐ Decreased BP ‐ Increased heart rate | Having an understanding of the purpose of a sympathomimetic agent will lead to the only correct answer. If this was difficult, review the purpose of a sympathomimetic agent. |
4.‐ Decreased heart rate | |
3211 The client has been taking norethindrone (Micronor) Correct answer: 2 Norethindrone (Micronor) contains only progestin, and no estrogen. Because estrogen can oral contraceptive pills. Which of the following items is decrease lactation, progestin‐only pills are commonly used by lactating women. The other most likely to be found in her health history? options do not address the issue of contraception during lactation. ‐ Superficial phlebitis ‐ Current breastfeeding ‐ Dysmenorrhea ‐ Menarche at age 18 | Use the process of elimination, and know that contraceptives containing estrogen are contraindicated in. If this was difficult, review medication classifications contraindicated with women who are breastfeeding. |
3212 The client is taking Ortho‐Prefest Correct answer: 2 Breast tenderness, abdominal bloating, and monthly bleeding are common side effects of (estradiol/norgestimate) for hormone replacement hormone replacement therapy. Severe leg pain in either the calf or the thigh could indicate therapy. Which statement indicates that the client deep vein thrombophlebitis, and requires physician assessment. needs further education? ‐ "My breasts may be tender at times." ‐ "I can expect to get severe pain in my calf." ‐ "I might have abdominal bloating." ‐ “Menstrual‐like bleeding might start.” | Using the process of elimination, select option 2, as this is the only option that would alert to a high risk complication. The other options are expected side effects of the medication. |
3213 Which of the following medication orders should the Correct answer: 1 Methylergonovine (Methergine) is only administered postpartum to control or prevent nurse question? excessive uterine bleeding. It is not used during pregnancy. The other options represent appropriate orders that the nurse does not need to question. ‐ Methylergonovine (Methergine) 0.2 mg PO for a pregnant client ‐ Oxytocin (Pitocin) 20 units in 1 liter D5W for postpartum hemorrhage ‐ Methylergonovine (Methergine) 2.5 mg PO for postpartum hemorrhage ‐ Oxytocin (Pitocin) 10 units IM after placental delivery | Using the process of elimination and knowing that methergine is given only postpartum will lead to option 1. If this was difficult, review the purpose of methergine. |
3214 The client is a vegan, and has been prescribed Correct answer: 4 Premarin (conjugated estrogens, equine) is derived from the urine of female horses, and Premarin. She asks if the medication has any animal therefore is animal‐based. Premarin might be rejected as a hormone replacement therapy products in it. The nurse's best answer would be: product by women who follow strict vegetarian guidelines. The statements in options 1 and 3 are factually incorrect, while option 2 does not address the client's concern. ‐ "Premarin is synthetic, and not derived from any animal products." ‐ "Your physician knows your concerns, and has written an appropriate prescription." ‐ "Premarin is a combination of synthetic and animal‐derived estrogens." ‐ "Premarin is made from a substance that is collected from live horses." | Using the process of elimination to rule out all the answers other than option 4. This is the only option that addresses the client s concerns. |
3215 The client with infertility is on a medication regimen Correct answer: 4 Ovarian hyperstimulation can result after fertility drugs are utilized. Women are instructed to of menotropin (Pergonal) and human chorionic rest, and to avoid heavy lifting or activities that could cause their abdomens to be bumped, gonadotropin (Chorex). Her ultrasound examination because of the risk of rupture of the ovary. Intercourse is prohibited to prevent a multifetal detects ovarian hyperstimulation. What information pregnancy and ovarian rupture. does the client need? ‐ "Have intercourse today and again tomorrow." ‐ "You may continue to play soccer every day." ‐ "Take your temperature each morning at the same time." ‐ "Limit your activity to resting, and avoid heavy lifting." | Recognize that the question is referring to hyperstimulation. With this in mind, options 1 and 2 can be eliminated, since any activity can cause rupture of the stimulated ovary. Option 3 does not address hyperstimulation of the ovary, and can be eliminated. |
3216 The client has been using an illegally obtained Correct answer: 1 Anabolic steroids promote protein buildup. They are similar to testosterone, but with less anabolic steroid, nandrolone. He asks, "What's the big androgenic activity. The other statements are incorrect. deal? My body makes steroids naturally." Which of the following is the nurse’s best response? ‐ "The steroids your body makes are glucocorticoids. The anabolic steroids you've been using are synthetic, and are similar to testosterone." ‐ "The drugs you have been using will counteract the effect of the naturally occurring steroids your body makes, possibly making you ill." ‐ "The steroids from your adrenal glands make your body create more proteins. The drugs you've been using cause the proteins in your cells to break down." ‐ "You are correct. The anabolic steroids you have been using are virtually indistinguishable from those that your body creates." | Having an understanding of the purpose of anabolic steroids will lead to the only correct answer. If this was difficult, review the purpose of anabolic steroids. |
3217 The client with primary amenorrhea has been started Correct answer: 4 Different forms of estrogen are administered IM, transdermal, or PO. Ethinyl estradiol is on ethinyl estradiol (Estinyl) 0.05 mg PO t.i.d. for 14 administered orally in many combination oral contraceptive pills, and IM in the product named days, followed by 14 days of the same plus progestin. Lunelle. The nurse concludes that the teaching plan has been effective when the client states: ‐ "This medication is taken by mouth because estrogen can't be given any other way." ‐ "Estrogens are more effective when taken by mouth than when given by injection." ‐ "I have to take this in pill form because there is no skin patch–type estrogen preparation." ‐ "Different estrogens are administered in different ways. Mine is taken as a pill by mouth." | Note that the question is asking for selection of the answer that indicates effective teaching. Options 1, 2, and 3 are all incorrect statements. Option 4 encompasses all aspects of administration of estrogen, while the other options are not complete. This should lead you to the correct answer. |
3218 The client with amenorrhea has been started on 10 Correct answer: 1 Medroxyprogesterone acetate (Provera) taken for 10 days facilitates thickened endometrial days of oral medroxyprogesterone acetate (Provera). growth, and when the medication is ended, a menstrual cycle–like bleeding episode will occur. Medication instruction should include which of the It does not immediately induce menstrual bleeding (option 2), rule out pregnancy (option 3), or following points? maintain a state of amenorrhea (option 4). ‐ The client should have menstrual‐like bleeding after the medication has been completed. ‐ Progestins prevent endometrial growth, and will quickly induce menstrual bleeding. ‐ Administration of this medication will rule out a possible pregnancy. ‐ Amenorrhea will continue if this medication is taken as directed. | Having an understanding of the purpose of a medication will assist in selecting the correct answer. Note in the question stem that the client has amenorrhea. Use this knowledge to be directed toward an answer that discusses producing a menstrual‐like bleeding. This is present in option 1. |
3219 A female client has come to the clinic to be started on Correct answer: 4 Medroxyprogesterone acetate (Depo‐Provera) is given IM every 85–90 days. Amenorrhea medroxyprogesterone acetate (Depo‐Provera) during usually develops after the second or third injection (option 4), while breakthrough bleeding is her mense. Which of the following statements would common during the first 3–6 months (option 2). Contraindications include inability to receive the nurse include in medication teaching? the injections on time and desire to become pregnant within a year (option 3). ‐ "The IM injections of medroxyprogesterone acetate (Depo‐Provera) must be received every 90–100 days." ‐ "Your menstrual periods will not change on medroxyprogesterone acetate (Depo‐Provera)." ‐ "Women with migraine headaches should not take medroxyprogesterone acetate (Depo‐Provera)." ‐ "After taking medroxyprogesterone acetate (Depo‐Provera) for several months, amenorrhea may develop." | In selecting the correct answer to this question, it is important to understand the side effects and client responses to the medication. It is also important to know who is contraindicated for taking this medication. With this knowledge select the only correct answer, option 4. |
3220 The female client with infertility will be starting Correct answer: 1 Menotropin (Pergonal) is given IM (not IV, as in option 2) for 9–12 days to mature ovarian menotropin (Pergonal) this cycle. Which statement will follicles. The rate of multifetal pregnancy is about 20 percent of pregnancies (option 3). Several the nurse include in a teaching plan for menotropin cycles of fertility medications are often needed to achieve pregnancy (option 4). (Pergonal) use? ‐ Ovarian hyperstimulation could result. ‐ The medication is given IV. ‐ Multifetal pregnancies very rarely occur. ‐ The first cycle will result in pregnancy. | Note that the question stem is referring to infertility. The question is also asking for the use of the medication. The only question that refers to the teaching plan and use is option 1. If this was difficult, review menotropin (Pergonal). |
3221 The physician has written an order for sildenafil Correct answer: 1 Dosing of all medication is started small and increased if needed, to minimize the risks of side (Viagra). The client asks about the dosage of this effects. Viagra should be taken approximately one hour prior to sexual activity. Option 3 is medication. Which of the following items is included in incorrect because Viagra comes at three different doses: 25, 50, and 100 mg. Option 2 is the nurse's response? incorrect because the smallest dose is utilized, while option 4 is incorrect because the client does not titrate the dose at will. ‐ The smallest possible dose to achieve erection is utilized. ‐ The dose is started high and worked down until erection is not achieved. ‐ Almost every man uses 50 mg, so that is what the doctor prescribes. ‐ Higher doses create longer erections, so it is up to the client which dose is ordered. | While the question is referring to dosage, and all the answer choices refer to dosage, the method to choosing the correct answer relies on knowledge of the medication. The only correct option is 1. |
3222 The nurse is preparing the pregnant client to have her Correct answer: 3 Oxytocin (Pitocin) used for labor induction augments the endogenous oxytocin. It is labor augmented with oxytocin (Pitocin). Further administered as a dilute solution of 10 or 20 units in 1 liter IV fluid via infusion pump, with a teaching is needed when the client states, "This goal of increasing the frequency and intensity of contractions. Options 1, 2, and 4 are correct medication will:” statements, indicating that the client understands these aspects of medication administration. ‐ “Work with the hormones that my body is producing that make contractions.” ‐ “Cause my uterus to contract harder and more often.” ‐ “Create one long continuous contraction until the baby is born.” ‐ “Be given through my IV a little bit at the time.” | The question is asking for identification of understanding of the medication by the client. Having knowledge of the purpose of contractions should lead to the correct answer. Knowing that there should be a rest between contractions will enable selection of option 3, which can have negative effects for the fetus. The other options are all correct statements about oxytocin (Pitocin). |
3223 The client with preterm labor is being administered Correct answer: 1 Magnesium sulfate, when given parenterally, acts as a central nervous system (CNS) magnesium sulfate (generic) intravenously. Which of depressant and a depressant of smooth, skeletal, and cardiac muscle function. The side effects the following client manifestations is an expected of this medication when taken IV are drowsiness, flushing, heaviness in the limbs, and effect of this medication? decreased deep tendon reflexes. Option 2 is incorrect because a decreased respiratory rate is a sign of magnesium toxicity. Option 3 is incorrect because these are signs of CNS excitability. Option 4 is incorrect as well because this is the side effect of magnesium sulfate when taken orally. ‐ Decreased deep tendon reflexes ‐ Decreased respiratory rate ‐ Nervousness and tremors ‐ Nausea and diarrhea | Knowing that magnesium sulfate is a CNS depressant will lead to the correct answer. The only option that is a physiologic response to a CNS depressant is option 1. |
3224 The nurse is teaching a client about clomiphene Correct answer: 1 Clomiphene (Clomid) stimulates the production of lutein hormone (LH) and follicle‐ (Clomid). The nurse explains to the client that this stimulating hormone (FSH), and therefore increases ovulation in women with anovulatory medication is indicated for treatment of which of the infertility. Clomiphene is not used to treat hypogonadism (option 2) or postpartum following health problems? hemorrhage (option 3), or as hormone replacement therapy (option 4). ‐ Infertility ‐ Hypogonadism ‐ Postpartum hemorrhage ‐ Hormone replacement therapy | In order to select the correct answer, recall knowledge of the purpose of the medication clomiphene (Clomid). If this was difficult, review the purpose of the medication. |
3225 The client taking Ortho Tri‐Cyclen combination oral Correct answer: 1 When two pills are missed, the client should "catch‐up" by taking two pills per day for two contraceptives calls the clinic reporting that she has days and then one pill until finishing the pill pack. This will keep her cycle controlled, and will forgotten her pills for the last two days. Which of the minimize the chance of mid‐cycle bleeding. However, the client could ovulate when missing following suggestions would the nurse provide to the two or more pills. Thus a backup method such as condoms should be utilized for the rest of the client? cycle. ‐ "Take two pills today and tomorrow, and use a backup method for the rest of the cycle." ‐ "Take two pills today, and then one each day until the pill pack is finished." ‐ "Take one pill each day until all the pills are gone, and use a backup method for the rest of the cycle." ‐ "Stop taking the pills, and use condoms until the next mense, then restart a new pill pack." | Knowing the “catch‐up” protocol will lead to the correct answer. Options 1 and 2 should be reviewed as correct answers, but option 1 is the most correct, since it states that the client should use a backup method. |
3226 For which of the following clients would the nurse Correct answer: 1 Ritodrine (Yutopar) is a beta‐adrenergic medication utilized for tocolysis in the treatment of expect the physician to prescribe ritodrine (Yutopar)? preterm labor. It stimulates beta<sub>2</sub> receptors in uterine smooth muscle, reducing intensity and frequency of uterine contractions, and lengthening gestation period. Options 2 and 4 are incorrect because the clients do not require medication with a tocolytic effect. Option 3 is incorrect because ritodrine is not used for postpartum hemorrhage. ‐ A client at 27 weeks' gestation with regular uterine contractions ‐ A client at 41 weeks' gestation with irregular uterine contractions ‐ A client who delivered at 40 weeks' gestation who is having postpartum hemorrhage ‐ A client at 38 weeks' gestation with hypertension and seizures | In order to select the correct answer, recall knowledge of the purpose of the medication. The sole purpose of the medication is in the treatment of preterm labor. Since preterm labor is defined as before 38 weeks’ gestation, the only correct answer is option 1. |
3227 The hypertensive client is experiencing a postpartum Correct answer: 3 Oxytocin (Pitocin) is used to control postpartum hemorrhage and promotion of postpartum hemorrhage. Which medication would the nurse uterine involution. It causes the least increase in blood pressure of all of these oxytocic expect the certified nurse‐midwife to prescribe? medications, and therefore, considering the history of the client, would be used first in this case. ‐ Ergonovine (Ergotrate) ‐ Methylergonovine (Methergine) ‐ Oxytocin (Pitocin) ‐ Carboprost tromethamine (Hemabate) | Note in the question stem that the client is hypertensive, as well as suffering from postpartum hemorrhage. All the options are given in the treatment of postpartum hemorrhage, but it is imperative that the correct answer choice consider any side effect of increased blood pressure. The medication that has the least increase on blood pressure is option 3. |
3228 The client with infertility will be starting menotropin Correct answer: 1 Human chorionic gonadotropin (Chorex) serves to release the matured ovum from the (Humegon) and human chorionic gonadotropin follicle, which has matured by the action of the menotropin or Humegon (option 2). Chorex (Chorex) injections this cycle. During instruction does not limit the number of ova released (option 3) or prepare the uterine lining for the regarding medication administration, the client asks fertilized egg (option 4). why she needs to have the Chorex, and not just the menotropin (Humegon). The nurse's response would include that Chorex: ‐ Facilitates release of the mature follicle from the ovary. ‐ Matures the follicle, so an ovum is ready to be released. ‐ Prevents more than one or two ova from being released. ‐ Prepares the lining of the uterus for the fertilized egg. | In order to select the correct answer, recall knowledge of the purpose of the medication. The sole purpose of the medication is to release the matured ovum from the follicle. This is the only correct answer. If this was difficult, review the purpose of the medication. |
3229 A 16‐year‐old male client has been prescribed Correct answer: 4 Testosterone is responsible for development of male sex organs and the secondary sex testosterone cypionate (Andonate) to treat characteristics, and facilitates growth of bone and muscle. In cases of hypogonadism, too little hypogonadism. He asks, "Why do I need these testosterone is naturally produced, and supplementation might be required. The responses in hormones anyway?" Which of the following would be options 1 and 3 do not identify the purpose of this medication for a 16‐year‐old. The response the best response by the nurse? in option 2 is incomplete, and does not address the client's learning need. ‐ "Testosterone is necessary to prevent your muscles from atrophying." ‐ "This medication is a form of testosterone. Your doctor can best explain it to you." ‐ "Testosterone prevents your body from becoming feminine‐looking." ‐ "This medication will replace the testosterone that your body is not producing." | In order to select the correct answer, recall knowledge of the purpose of the medication. Options 1 and 3 can be eliminated, as they do not address the question the client is asking. Option 2 can be eliminated, since it does not address any learning for the client. This would leave correct answer 4. |
3230 The client has been prescribed danocrine (Danazol) Correct answer: 1 Danocrine (Danazol) is an androgen used in the treatment of endometriosis. It is taken orally for treatment of endometriosis. The nurse determines b.i.d. for several months. Option 2 is incorrect because the medication is given for 3–6 months; that the instruction on taking this medication has been therapy may be extended to 9 months, if necessary. It is important to know that the regimen successful when the client states: cannot be repeated. Danazol is only given orally (options 3 and 4). ‐ "This medication is taken by mouth twice daily." ‐ "I'll need to take this medication for the rest of my life." ‐ "I'll be giving myself injections weekly with this medication." | In order to answer this question, you will need to know the nursing interventions required when teaching the client about the medication. The only correct option with this question is option 1. If this was difficult, review nursing interventions. |
4.‐ "This medication is worn as a patch on my abdomen." | |
3231 The client asks why her oral contraceptive, Desogen, Correct answer: 2 Progestins thicken cervical mucus to prevent sperm penetration, while estrogen contains both desogestrel and ethinyl estradiol. Which administration prevents the luteinizing hormone (LH) surge that stimulates ova maturation. of the following would be the nurse s best response? Option 1 is incorrect because additional estrogen is not needed. Option 3 is incorrect because taking estrogens alone would not prevent pregnancy. Option 4 is incorrect because the contraceptive is made as a combination product, without the option of taking them separately. ‐ "Desogestrel is a weak estrogen‐and‐progestin combination that requires additional estrogen to work." ‐ "Together, the hormones prevent the ovum from maturing, and the sperm from penetrating through the cervical mucus." ‐ "Estrogens alone would prevent pregnancy, but progestins are added so that spotting doesn't occur." ‐ "Taking each hormone separately would prevent most pregnancies, but the combination is more effective." | Note in the question stem that the medication is described as an oral contraceptive. Knowing the purpose of an oral contraceptive will lead you to the correct answer, 2. If this was difficult, review the action of oral contraceptives. |
3232 The nurse preparing to conduct medication teaching Correct answer: 3 Sildenafil is a medication used for erectile dysfunction among the male population. It is would question an order for sildenafil (Viagra) when contraindicated if the client has had MI, cerebrovascular accident (CVA), or life‐threatening the client has which of the following conditions? dysrhythmia in the past six months, or if the client has hypotension, hypertension, unstable angina, or CHF. ‐ History of type II diabetes and peripheral vascular disease ‐ Myocardial infarction (MI) four years ago ‐ Congestive heart failure (CHF) ‐ Benign prostatic hyperplasia | In order to select the correct answer, recall knowledge of the contraindications for the medication sildenafil (Viagra). If this was difficult, review the contraindications for the medication. |
3233 The client is to begin clomiphene (Clomid) for Correct answer: 3 Clomiphene (Clomid) induces ovulation through stimulation of luteinizing hormone (LH) and treatment of infertility. The nurse concludes that the follicular‐stimulating hormone (FSH). It is taken orally in 50 mg dosage for five days each client needs additional teaching on this medication month, beginning on day 5 of the menstrual cycle. Options 1, 2, and 4 are incorrect because when she states: they are factually correct, which means the client understands medication teaching. ‐ "This medication will help make me ovulate." ‐ "I'll take this medicine orally for five days this month." ‐ "I'll be giving myself shots five days out of the month." ‐ "If this medication doesn't work, there are others to try." | Note that the question stem asks for selection of the answer that indicates that the client does not understand the purpose of the medication. In order to select the answer, recall the purpose and method of administration of the medication clomiphene (Clomid). The only answer that indicates the client does not understand administration is option 3. If this was difficult, review the purpose and dosing of the medication. |
3234 Which client is most likely to have testosterone Correct answer: 4 Androderm will replace the testosterone that should be produced by the testes. This therapy transdermal (Androderm) prescribed for his condition? is utilized when the testes have been removed, to maintain libido, sexual functioning, and secondary male characteristics. The clients in options 1, 2, and 3 do not require additional testosterone. ‐ A 45‐year‐old with status post–bilateral vasectomy ‐ A 17‐year‐old with status post–cryptorchidism repair ‐ A 23‐year‐old with status post–varicocele repair ‐ A 32‐year‐old with status post–bilateral orchiectomy | Note in the question stem that the medication being addressed is a testosterone. The only disease process listed that could require testosterone is option 4. The post‐surgical procedure involves removal of the testes, which produce testosterone. The other options do not require testosterone replacement. |
3235 The client is being prepared to have labor induced Correct answer: 3 Oxytocin (Pitocin) is administered by diluting 10 or 20 units in 1 L of IV fluid, and with oxytocin (Pitocin). Medication teaching has been administering small amounts (not large, as in option 4) via infusion pump. The synthetic effective when the client states: oxytocin supplements the endogenous oxytocin, and uterine contractions result. The medication is not given by mouth (option 1) or IM (option 2). ‐ "I'll take this medication by mouth to make my uterus contract." ‐ "This medication will be given to me as an IM injection." ‐ "Pitocin is a synthetic version of a hormone my body produces naturally." ‐ "A large dose of this medication will be given to me in my IV line." | The question is asking for selection of the answer that would indicate that teaching is successful. Knowing that the medication is only given IV will assist to eliminate options 1 and 2. Option 4 can also be eliminated, since it is not given as a large dose. Using the process of elimination will lead you to the correct option, 3. |
3236 For which of the following clients would the nurse Correct answer: 4 Ergonovine (Ergotrate) causes uterine contractions, and is indicated for use only in anticipate the physician ordering ergonovine normotensive postpartum women. This medication causes an increase in blood pressure, so (Ergotrate)? option 1 is incorrect. The clients described in options 2 and 3 are not presenting any signs and symptoms of bleeding, so using this medication would be futile. ‐ A client with untreated chronic hypertension ‐ A breastfeeding mother whose baby was delivered by forceps ‐ A bottle‐feeding mother who is a carrier for hepatitis C ‐ A normotensive mother with postpartum hemorrhage | In order to answer this question, recall the classification of the medication. Knowing the classification will lead to the only correct answer, 4. If this was difficult, review the purpose of the medication. |
3237 A female client taking Demulen, a combination oral Correct answer: 1 The symptoms of possible complications of combination oral contraceptives form the contraceptive pill, calls with sudden onset of blurred acronym ACHES: Abdominal pain; Chest pain; Headache; Eye problems; and Severe leg pain vision. The nurse's best response would be to ask her (calf or thigh). The complications indicated by these symptoms are: Abdominal pain–liver to: tumor formation; Chest pain, Headache, and Eye problems‐embolus; Severe leg pain‐ thrombophlebitis. Sudden onset of blurred vision could indicate blood clot formation and subsequent pressure on the optic nerves. ‐ Come in to see the physician now. ‐ Make an appointment to see the physician tomorrow. ‐ See an ophthalmologist as soon as possible. ‐ Have her call back after taking a nap. | In order to answer this question, recall knowledge of the complications associated with taking oral contraceptives. Since a sudden onset of blurred vision is a complication, it requires immediate attention, which is stated in option 1. The other options do not address this as a complication, and should be eliminated. If this was difficult, review complications of oral contraceptive pills. |
3238 The client in preterm labor has just received 2.5 mg Correct answer: 4 Terbutaline sulfate (Brethine) is a smooth muscle relaxant, and therefore used to treat both terbutaline sulfate (Brethine) SC. Which statement bronchospasm and premature labor. A beta‐adrenergic, the medication causes side effects of would the client be most likely to make? increased heart rate with a sensation of the heart beating harder, palpitations, muscle tremors, and nervousness. The symptoms in options 1, 2, and 3 are opposites of those caused by terbutaline. ‐ "My heart seems to be beating really slowly." ‐ "My arms and legs feel so heavy and thick." ‐ "This medication makes me feel so sleepy." ‐ "My hands are so shaky, I can't write." | In order to select the correct answer, recall knowledge of the side effects of terbutaline sulfate (Brethine). The only correct answer is option 4. The other options are the opposites of side effects of the medication. If this was difficult, review the side effects of the medication. |
3239 For which of the following clients would the nurse Correct answer: 2 Testosterone preparations are contraindicated with pre‐existing liver disease. Acne (option question an order for testosterone enanthate 1), melanoma (option 3), and testicular cancer (option 4) are not contraindications for use of (Delatestryl)? this medication. ‐ A 16‐year‐old with moderate acne ‐ A 32‐year‐old with liver failure ‐ A 66‐year‐old with melanoma ‐ A 25‐year‐old with testicular cancer | Knowing system metabolism for the medication will lead to the correct answer. It is also important to know the contraindications for the medication. The only correct answer is option 2. If this was difficult, review the contraindications as well as system metabolism for the medication. |
3240 The client is to receive dinoprostone (Prepidil) for Correct answer: 3 Prepidil is a form of prostaglandin E2, and is used for cervical ripening. The gel is inserted cervical ripening prior to induction of labor. For the around the cervix, through either a speculum or sterile vaginal exam. Positioning the client on administration of this medication, the client should be her back, with knees up and apart, will facilitate administration of the gel. placed in which of the following positions? ‐ On her left side ‐ On her right side ‐ On her back, with knees bent and apart ‐ On her hands and knees | Note in the question stem that the medication is for cervical ripening. Option 3 is the correct answer, since the medication is inserted at the cervix via speculum. |
3241 A client who is receiving phenytoin (Dilantin) to Correct answer: 3 Clients with seizure disorders rarely are able to stop taking the anticonvulsants. The last control seizures indicates an understanding of option is incorrect because of the word never. The first two options are incorrect statements. medication by making which of the following Extra doses are not taken related to stress, and there is no way to know at this time whether statements? medication therapy could be terminated near the one‐year mark. ‐ “I need to take more of my Dilantin when I am having a stressful day.” ‐ “I will be able to stop taking this medicine in about a year.” ‐ “I will probably need to take this medicine all my life.” ‐ “I will never have another seizure if I take this medicine.” | The wording of the question tells you that the correct answer is also a true statement. Use the process of elimination and medication knowledge to make a selection. |
3242 A client with a history of seizures is admitted with a Correct answer: 1 Phenytoin (Dilantin) is an anticonvulsant most effective in controlling tonic‐clonic seizures. partial occlusion of the left common carotid artery. Data collection before planning nursing care for a client with a seizure disorder should always The client has taken phenytoin (Dilantin) for 10 years. include a history of seizure incidence. Option 4 might be a prodromal phase in some clients, When planning care for this client, it is most important but a history of incidence is more important data. Removal of dentures might be indicated that the nurse does which of the following? during a seizure, but not at this time. Placing an airway or restraining a patient during a seizure could cause harm. ‐ Obtains a history of seizure incidence. ‐ Places an airway, suction, and restraints at the bedside. ‐ Asks the client to remove any dentures. ‐ Observes the client for increased restlessness and agitation. | The words most important in the stem of the question tell you that more than one or perhaps all options might be correct and that you must choose the best option. Use medication knowledge as well as knowledge of how to manage a client during a seizure to eliminate any of the incorrect options. |
3243 A client with a history of seizures is scheduled for an Correct answer: 3 The therapeutic blood levels of the anticonvulsant need to be maintained. The nurse should arteriogram at 10:00 a.m., and is to have nothing by question the physician about alternate routes of administration. Omission of a dose is not mouth before the test. The client is scheduled to prudent, nor is changing the route without a physician order. receive phenytoin (Dilantin) at 9:00 a.m. The nurse should take which of the following actions? ‐ Omit the 9:00 a.m. dose. ‐ Give the same dosage of the drug rectally. ‐ Ask the physician if the drug can be given IV. ‐ Administer the drug with 30 mL of water at 9:00 a.m. | The core issue of the question is how to maintain the client in a seizure‐free state while NPO. Analyze each of the options to determine the method that will best protect the client from seizure activity. |
3244 The nurse is assessing a client with Parkinson’s Correct answer: 1 Destruction of the neurons of the basal ganglia in Parkinson s disease results in decreased disease to determine effectiveness of medication muscle tone. This gives the face a masklike appearance, and causes a monotone speech therapy. The nurse would determine that the pattern that can be interpreted as flat. If medication therapy was ineffective, the client would medication is not working optimally if the client is still exhibit symptoms of the disorder, such as flattened affect. The other options do not apply demonstrating which of the following characteristics? to this disease. ‐ A flattened affect ‐ Tonic‐clonic seizures ‐ Decreased intelligence ‐ Changes in pain tolerance | The core issue of the question is the symptom that should be abolished by medication therapy. Use medication knowledge and the process of elimination to make a selection. |
3245 The client with Parkinson’s disease asks the nurse, Correct answer: 3 Levodopa is the precursor of dopamine. It is converted to dopamine in the brain cells until “How will levodopa treat this disease?” The nurse needed as a neurotransmitter. Improved neural myelination, acetylcholine production, and would incorporate into a response that levodopa does regeneration of injured cells cannot be attributed to levodopa. which of the following? ‐ Improves myelination of neurons. ‐ Increases acetylcholine production. ‐ Replaces dopamine in the brain cells. ‐ Causes regeneration of injured thalamic cells. | The wording of the question tells you that the correct option is also a true statement. Use medication knowledge and the process of elimination to make a selection. |
3246 A female client taking medications for seizures has Correct answer: 3 Barbiturates decrease the body's response to warfarin (Coumadin). As a result, there is less been placed on warfarin (Coumadin) for suppression of prothrombin; when inhibition caused by barbiturates disappears, hemorrhage thrombophlebitis. After the weekly prothrombin time, could result. Withdrawal symptoms are not a priority concern if the client just takes the the client contacts the office to see if there will be a barbiturate for sleep (option 1). Absence of sleep is not likely to result in seizure activity dosage change. The client also mentions that she is out (option 2). Control of seizure activity is not dependent on combined use of phenytoin and the of her barbiturate sleeping pill. She states that she will barbiturate sleep aid (option 4). wait until her next appointment to get a refill. The nurse instructs her to come for the refill immediately for which of the following most important reason? ‐ She otherwise could develop withdrawal symptoms. ‐ Absence of sleep could precipitate seizures. ‐ Discontinuance of the drug can affect the prothrombin level. ‐ Control of seizures is dependent on the combined action of phenytoin (Dilantin) and the sleeping medication. | The words most important in the stem of the question tell you that more than one or perhaps all options might be partially or totally correct, and that you must choose the most important option. The core issue of the question is knowledge of the interactive effects of barbiturates and warfarin. |
3247 A client is brought to the Emergency Department in Correct answer: 2 Diazepam is a benzodiazepene tranquilizer and an anticonvulsant used to relax smooth the midst of a persistent tonic‐clonic seizure. muscles during seizures. Diazepam does not slow cardiac contractions (option 1), dilate Diazepam (Valium) is administered intravenously. The tracheobronchial structures (option 3), or provide amnesia of seizure activity (option 4). nurse anticipates that the effects of diazepam will be to decrease central neuronal activity and: ‐ Sslow cardiac contractions. ‐ Relax peripheral muscles. ‐ Dilate the tracheobronchial structures. ‐ Provide amnesia of the seizure episode. | The wording of the question tells you that the correct option is also a true effect of the medication. Use medication knowledge and the process of elimination to make a selection. |
3248 The nurse would assess for which of the following as Correct answer: 4 Morphine is a CNS depressant. Its major adverse effect is respiratory depression. It can also symptoms of morphine overdose in a client receiving lead to lethargy, pupillary constriction, and depressed reflexes. Morphine does not slow the patient‐controlled analgesia? pulse rate (option 1), although it could lower blood pressure. It does not cause restlessness (option 2) or profuse sweating (option 3). ‐ Slow pulse; slow respirations; sedation ‐ Slow respirations; dilated pupils; restlessness ‐ Profuse sweating; pinpoint pupils; deep sleep ‐ Slow respirations; constricted pupils; sedation | The wording of the question tells you that the correct option is also a true effect of the medication. Use medication knowledge and the process of elimination to make a selection. |
3249 Levodopa is prescribed for a client with Parkinson’s Correct answer: 4 Levodopa is the precursor of dopamine. It reduces sympathetic outflow by limiting disease. Which of the following would the nurse vasoconstriction, which can result in orthostatic hypotension. The medication should be include in the teaching plan for the client about administered with food to minimize gastric irritation (option 1). It is not monitored by weekly levodopa? laboratory tests (option 2), nor does it cause initial euphoria followed by depression (option 3). ‐ It is poorly absorbed if given with meals. ‐ It must be monitored by weekly laboratory tests. ‐ It causes an initial euphoria, followed by depression. ‐ It can cause a side effect of orthostatic hypotension. | The wording of the question tells you that the correct option is also a true statement that would be included in client teaching. Use medication knowledge and the process of elimination to make a selection. |
3250 When caring for the client who is receiving phenytoin Correct answer: 1 Gingival hyperplasia is an adverse effect of long‐term phenytoin (Dilantin) therapy. (Dilantin), the nurse emphasizes meticulous oral Maintaining therapeutic blood levels and meticulous oral hygiene, including regular check‐ups hygiene to the client, stating that phenytoin has which with a dentist, can decrease the incidence of hyperplasia. It does not alkalinize oral secretions of the following effects on oral tissue? (option 2), destroy tooth enamel (option 3), or increase plaque and bacterial growth at gum lines (option 4). ‐ It causes hyperplasia of the gums. ‐ It increases alkalinity of the oral secretions. ‐ It irritates gingival tissue, and destroys tooth enamel. | The wording of the question tells you that the correct option is also a true statement that would be included in client teaching. Use medication knowledge and the process of elimination to make a selection. |
4.‐ It increases plaque and bacterial growth at the gum lines. | |
3251 The physician prescribes phenobarbital sodium Correct answer: 1 Phenobarbital depresses the CNS, particularly the motor cortex, producing side effects such (Luminal) for a client who has had a tonic‐clonic as lethargy, loss of appetite, depression, and vertigo. The other side effects listed for seizure. The nurse concludes that the client phenobarbital do not include anal itching or dizziness upon standing (option 2), diarrhea or understands the side effects of phenobarbital when upper body rash (option 3), or decreased tolerance to common foods or constipation (option the client states, “I should call the doctor if I develop:" 4). ‐ "Loss of appetite, or persistent fatigue.” ‐ "Dizziness when I stand up, or anal itching.” ‐ "Diarrhea, or a rash on the upper part of my body.” ‐ "Decreased tolerance to common foods, or constipation.” | Use medication knowledge and the process of elimination to make a selection. |
3252 The nurse administering methylphenidate (Ritalin) is Correct answer: 2 Fever is not a side effect of methylphenidate. Insomnia (option 1), rash (option 3), and monitoring the client for symptoms associated with palpitations (option 4) are possible side effects of methylphenidate. this medication. Which of the following is not a manifestation for which the nurse would assess? ‐ Insomnia ‐ Fever ‐ Rash ‐ Palpitations | Note that the stem of the question contains the word not, which indicates that the correct option is not an actual manifestation of the drug. Use knowledge of side/adverse medication effects to make a selection. |
3253 The physician prescribes phenytoin (Dilantin) for a Correct answer: 3 The primary action is to reduce voltage, frequency, and spread of electrical discharges within client to control tonic‐clonic seizures. The nurse the motor cortex, resulting in inhibition of seizure activity. The drug does not act directly on explains in simple terms to the client that the expected muscles (option 1), prevent CNS depression (option 2), or change permeability of cell effect of the drug is to do which of the following? membranes (option 4). ‐ Produce an antispasmodic action on the muscles. ‐ Prevent depression of the central nervous system. ‐ Control nerve impulses originating in the motor cortex. ‐ Alter the permeability of the cell membrane to potassium. | Use medication knowledge and the process of elimination to make a selection. |
3254 The nurse is providing information to a client taking Correct answer: 3 OTC medications with alcohol (another CNS depressant) should be avoided unless specifically benztropine (Cogentin), an anticholinergic given for directed by the provider. The other statements would indicate understanding of the Parkinson’s disease. Which of the following statements medication teaching. made by the client would indicate that more instruction is needed regarding this medication? ‐ “I may crush the tablets to make them easier to take.” ‐ “I should avoid driving until I know how this medication will affect me.” ‐ “I can take OTC cough or cold pills that have alcohol in them.” ‐ “I should never discontinue the medication abruptly.” | Note that the question contains the words more instruction, which indicates that the correct answer option contains incorrect information. Use medication knowledge and the process of elimination to make a selection. |
3255 The nurse is providing discharge instructions to a Correct answer: 2 The Alzheimer s client and family will need much support. Medication therapy will delay client with Alzheimer’s disease and his family after progression of symptoms, but will not effect a cure. The primary concern is for the safety of completing medication teaching. Because medication the client, so constant supervision is necessary. The other options are incorrect approaches. therapy will not reverse symptoms that have developed, which of the following should be included in this discussion? ‐ Keep the client in her own home, regardless of circumstances. ‐ Provide supervision to protect the client from becoming injured, humiliated, or lost. | The wording of the question tells you that the correct answer is an option that is a priority teaching measure. To make your selection, recall the nature of the disorder, and that medication therapy will not reverse symptoms. |
‐ Attend a 12‐step program with a homecare agency. ‐ Resist using adaptive‐assistive equipment. | |
3256 Which of the following would be the most important Correct answer: 4 The disturbance in thought processes is the primary nursing diagnosis. Effective medication nursing diagnosis for the client newly diagnosed with therapy will reduce the progression of symptoms of the dementia. A disturbance in sleep Alzheimer’s disease who is just beginning medication pattern (option 3) could become important later, but initially, the thought process is most therapy? significant. Altered fluid and electrolytes (option 1) is not a nursing diagnosis, while pain (option 2) is not applicable, given the information in the question. ‐ Altered Fluid and Electrolytes ‐ Pain ‐ Disturbed Sleep Pattern ‐ Disturbed Thought Processes | Note the key words most important in the stem of the question, which tells you that you need to prioritize your answer. Use knowledge of the key effects of medication therapy and the process of elimination to make a selection. |
3257 The nurse would include which of the following items Correct answer: 1 Tacrine (Cognex) increases the available acetylcholine in the brain; therefore, the in an assessment of the client with Alzheimer’s disease parasympathetic system is stimulated. Blood pressure, mental status, and GI status would be who is receiving tacrine (Cognex)? affected. Hemoglobin, red and white blood cell count, liver function, electrocyte balance, and edema in legs do not relate to this medication. ‐ Blood pressure (BP), mental status, and gastrointestinal (GI) status ‐ Hemoglobin (Hgb), white blood cells (WBCs), and liver function tests ‐ Hgb, red blood cells (RBCs), and mental status ‐ BP, electrolytes, and edema in legs | The wording of the question tells you that the correct option is also a true statement that would be included in client teaching. Use medication knowledge and the process of elimination to make a selection. |
3258 The client has migraine headaches. The provider has Correct answer: 4 Tagamet can increase the levels of Elavil in the blood, causing seizures, tachycardia, prescribed amitriptyline hydrochloride (Elavil) as hypertension, or toxicity. Acetaminophen (option 1), aspirin (option 2), and NSAIDs (option 3) prophylaxis for the headaches. What over‐the‐counter do not have that effect. (OTC) medication might intensify the actions of Elavil, meriting a warning from the nurse? ‐ Acetaminophen (Tylenol) ‐ Aspirin (ASA) ‐ Nonsteroidal anti‐inflammatory drugs (NSAIDs) ‐ Cimetidine (Tagamet HB) | Options that are similar are not likely to be correct. All of the incorrect options relate to analgesia, and so must be eliminated. |
3259 When administering anticholinergic medications for Correct answer: 3 Dry mouth, constipation, and urinary retention or hesitancy are all possible side effects of Parkinson’s disease, the nurse would be least anticholinergic medications. Fever is not a side effect of anticholinergic medications. concerned with assessing the client for which of the following? ‐ Dry mouth ‐ Constipation ‐ Fever ‐ Urinary retention or hesitancy | The key words in the stem of the question are least concerned. This tells you that the correct answer is an option that is not characteristic of this medication. Use medication knowledge and the process of elimination to make a selection. |
3260 The client receiving phenytoin (Dilantin) asks the Correct answer: 4 Phenytoin inhibits folic acid absorption, and potentiates effects of folic acid antagonists. Folic nurse why the doctor has prescribed folic acid with this acid is helpful in correcting some anemias that can result from phenytoin administration. The medication. The nurse s response would be based on other options are incorrect statements. which of the following? ‐ It improves absorption of iron from foods. ‐ Its content in common foods is inadequate. ‐ It prevents the neuropathy caused by phenytoin. ‐ Its absorption from foods is inhibited by phenytoin. | Use knowledge of the key side effects of medication therapy and the process of elimination to make a selection. |
3261 The client has been diagnosed with narcolepsy. The Correct answer: 3 Methylphenidate is a central nervous system stimulant. It increases the release of provider is considering prescribing methylphenidate norepinephrine and dopamine in cerebral cortex to the reticular activating system. Ritalin is (Ritalin). The nurse notes that the client has a history contraindicated in clients with glaucoma. Congestive heart failure, diabetes mellitus, and of which of the following prior medical conditions that hyperthyroidism do not represent contraindications to the use of methylphenidate. would disqualify the client from using this medication? ‐ Congestive heart failure (CHF) ‐ Diabetes mellitus ‐ Glaucoma ‐ Hyperthyroidism | In order to select the correct answer to this question, recall knowledge of the contraindications for the medication. If this was difficult, review Ritalin and the contraindications for the medication. |
3262 The client has just been diagnosed with a seizure Correct answer: 2 Medication must be taken to maintain therapeutic blood levels, even if there is no seizure disorder. The medication regimen has controlled the activity. The urine might turn pink or brown, but that is not the most important item to teach. seizures for several days. Prior to discharge, the nurse Options 1 and 4 are incorrect. After six months with no seizures, a client can often drive again. should place highest priority on sharing which of the following information with the client? ‐ Seizure disorders will often eventually stop on their own. ‐ Adherence to medication therapy is essential to avoid recurrence of seizures. ‐ Urine will turn pink or brown from the medication. ‐ The client can never drive a vehicle again. | Note that the question asks for selection of the highest‐priority teaching option. The highest priority in teaching about medication is to adhere to the medication protocol, which will lead you to option 2. |
3263 The client with a history of cluster headaches should Correct answer: 4 The client needs to give the medication the opportunity to work without aggravating the be taught which of the following information regarding headache. Ergotamine should be given orally 1–2 mg, followed by 1–2 mg every 30 minutes use of ergotamine tartrate (Gynergen)? until the headache abates or until the maximum dose of 6 mg/24 hours (option 1). It is unnecessary to drink large amounts of fluids (option 2), and increased warmth and energy are not associated with this medication (option 3). ‐ "Take the medication every 4 hours." ‐ "Take the medication with plenty of water." ‐ "You will feel energetic and warm after taking the medication." ‐ "Lie down in a darkened room after taking the medication." | In looking at the stem, note that the client has cluster headaches. Knowing that a quiet, darkened room will help clients with pain relief from cluster headaches will lead to the correct answer, 4. Understanding the disease process and the usual medical regimen will assist in selecting the correct answer. |
3264 The client is experiencing spasticity related to a spinal Correct answer: 2 Dantrolene is a central‐acting skeletal muscle relaxant. This medication may be used to cord injury. The nurse anticipates that which of the control spasticity after spinal cord injury. Dexamethasone is a corticosteroid used to decrease following medications is most likely going to be added swelling, especially cerebral edema. Dichlorphenamide is a carbonic anhydrase inhibitor used to the client's medication list? to treat glaucoma by decreasing production of aqueous humor, thereby lowering intraocular pressure. Dobutamine is a medication used to treat hypotension by increasing cardiac output. ‐ Dexamethasone (Decadron) ‐ Dantrolene (Dantrium) ‐ Dichlorphenamide (Daranide) ‐ Dobutamine (Dobutrex) | In order to select the correct option for this question, first know the classification of each of the medications. Option 2 is the only medication that will work as a muscle relaxant. If this was difficult, review the classification of the medications. |
3265 Which of the following are priority assessments by Correct answer: 1 Because opioid analgesics relieve pain, the nurse needs to assess the client's pain intensity the nurse when administering opioid analgesics to a before and 30 minutes after administering a dose. The respiratory rate and level of client? consciousness need to be assessed because respiratory depression and sedation are two adverse effects of this drug class. The items in the each of the other options are only partially correct. Urine output, liver function studies, seizure activity, electrolytes, and blood glucose are not ongoing assessments directly related to opioid administration. ‐ Pain intensity, respiratory rate, and level of consciousness | Note that the question asks for selection of a priority assessment. In considering the nursing process, consider the fifth vital sign (pain) as part of the priority assessment. Also see in the stem that the question is referring to an analgesic, which would again refer to pain. Knowing that opioids reduce respiratory rate will lead to option 1 as your choice. While pain is listed in two other options, they do not identify respiration as a priority. |
‐ Liver function studies, urine output, and pain intensity ‐ Seizure activity, mental status, and respiratory status ‐ Electrolytes, blood glucose, and pain intensity | |
3266 The nurse is teaching a client about anti‐inflammatory Correct answer: 2 Clients might take more aspirin, acetaminophen, and NSAIDs than prescribed by their medications. Client education regarding taking aspirin, providers if they are not aware that many OTC medications are combined with these acetaminophen, or non‐steroidal anti‐inflammatory medications. The other answers are cautions for a variety of other types of medications. drugs (NSAIDs) should include which of the following cautions? ‐ Radial pulse and temperature should be taken prior to medication administration. ‐ Consult a health care provider before taking over‐the‐counter (OTC) medications, since many are combinations that can include more of the prescribed medication than is safe. ‐ Cholesterol levels must be measured prior to treatment with medication. ‐ Do not discontinue use of medication abruptly; discontinuation must be tapered over a week. | Part of any teaching plan is to caution people to consult with their practitioner prior to taking over‐the‐counter medications when they take prescribed medications. This is stated in option 2, and would be the priority choice. The other options are incorrect, as these instructions are usually given with a variety of prescribed medications. |
3267 The nurse is caring for a hospitalized client with Correct answer: 3 The client should be assessed for seizure activity, changes in mental status, and respiratory diagnosis of seizure disorder. The client has an order status as highest priority. Assessing kidney function (BUN and creatinine) and urine output is for phenytoin (Dilantin). The nurse makes it a priority not the priority nursing consideration when the client is taking anticonvulsants. The to assess which of the following parameters? assessments in the other options are pertinent for a variety of other types of medications. ‐ Respiratory rate, and level of consciousness ‐ BUN, creatinine, and urine output ‐ Seizure activity, mental status, and respiratory status ‐ Electrolytes, serum osmolality, and leg edema | Note that the question asks for selection of a priority assessment. Knowing that the medication is prescribed for seizure activity will lead to option 3, which is the priority assessment. The other options do not list seizure activity in the answers, so they can be eliminated as your priority assessment. |
3268 The client is prescribed carbamazepine (Tegretol) for Correct answer: 4 Tegretol is contraindicated within 14 days of taking MAOIs, to help prevent a fatal reaction. a seizure disorder. The nurse cautions the client to The other drug classes listed do not have this interactive effect with carbamazepine. NSAIDs avoid taking which of the following types of are used to treat inflammation and pain, while opioid analgesics and skeletal muscle relaxants medications that could cause a fatal reaction with this are drug classes that exert an effect on the central nervous system. medication? ‐ Nonsteroidal anti‐inflammatory drugs (NSAIDs) ‐ Opioid analgesics ‐ Skeletal muscle relaxants ‐ Monoamine oxidase inhibitors (MAOIs) | In order to select the correct answer to this question, recall knowledge of the contraindications for the medication. There is only one correct option for this question. If this was difficult, review Tegretol and the contraindications for the medication. |
3269 A client with a seizure disorder has been started on Correct answer: 2 The seizure threshold is decreased when anorexiants or amphetamines are used concurrently medication therapy. The nurse should emphasize that with anticonvulsants, due to changes in the brain chemicals caused by the anorexiants and which of the following types of medications should not amphetamines. The medications listed in options 1 and 3 do not change the seizure threshold. be taken concurrently with anticonvulsants, as they The medications listed in option 4 may be used to treat seizures, which could raise the seizure might lower the seizure threshold? threshold. ‐ Aspirin, acetaminophen, and nonsteroidal anti‐inflammatory drugs (NSAIDs) ‐ Anorexiants and amphetamines ‐ Anticholinergics and dopamine agonists ‐ Hydantoins and benzodiazepines | In order to select the correct answer to this question, recall the contraindications for the medication. There is only one correct option for this question. If this was difficult, review anticonvulsants, as well as which combinations of medications should not be taken with anticonvulsants. |
3270 The client with a spinal cord injury is taking Correct answer: 3 Dantrolene is a skeletal muscle relaxant. Hepatotoxicity is an adverse reaction for dantrolene, dantrolene (Dantrium) for spasticity. The nurse should which can be manifested by abdominal pain, jaundiced sclera, or clay‐colored stools. The items instruct the client to notify the physician immediately in the other options do not address this adverse effect. if which of the following adverse effects of the medication occurs? ‐ Twitching, diarrhea, or rash | Having knowledge of the side effects of dantrolene (Dantrium) will assist in selecting the correct answer. Knowing that hepatotoxicity is a side effect of the medication should lead to an answer that considers the gastrointestinal (GI) system. The only answer that considers the GI system is option 3. |
‐ Change in blood or urine glucose levels ‐ Abdominal pain, jaundiced sclera, or clay‐colored stools ‐ Urine changing to pink or brown, or gingival hyperplasia | |
3271 The client is newly diagnosed with Parkinson's Correct answer: 4 The client needs to understand that high‐protein foods must be avoided so that the disease. The medication that has been prescribed is medication can be absorbed properly. Side effects do not include cushingoid symptoms (option levodopa (Dopar). The nurse should place a high 1) or oral ulcerations (option 3). There is no need to avoid vaccinations (option 2). priority on teaching which of the following information prior to discharge? ‐ Side effects include cushiongoid symptoms such as moon face and weight gain. ‐ There is a need to avoid vaccinations. ‐ Report any ulcerations or sores in the mouth to a health care provider immediately. ‐ Avoid high‐protein foods, since they interfere with absorption of the medication. | The question is asking for selection of the priority intervention in a teaching plan. A priority intervention with teaching about medication administration is to teach what might interfere with the absorption of the medication. Effectiveness of the medication is important. Option 4 lists the priority need of absorption and effectiveness. |
3272 Which of the following statements made by the client Correct answer: 3 Medication must be taken to maintain therapeutic blood levels, even with no seizure activity. indicates to the nurse an understanding of client If the client understands that adherence is important, he is more likely to be compliant with teaching regarding anticonvulsant therapy? the medication regimen. The client does not need to lie down after a dose (option 1), or have cholesterol levels checked (option 2). Anticonvulsant therapy is prescribed for long‐term or lifelong use (option 4). ‐ "After taking the medication, I should lie down." ‐ "I must be sure to have my cholesterol levels checked regularly." ‐ "It is essential for me to continue to take this medication to avoid recurrence of seizures." ‐ "Seizures will often stop without intervention, so I may not need this medication for long." | Understanding that anticonvulsants must be taken regularly will lead to the only correct answer, option 3. If this was difficult, review the teaching points for anticonvulsants. |
3273 Which of the following statements by the client with Correct answer: 1 If the client understands the importance of the finding the triggering factors, she will be more migraine headaches would indicate to the nurse that willing to be involved in decreasing the triggers, including lifestyle changes that might be she has understood client teaching regarding migraine necessary. The client should continue to exercise for general health and stress management medication? (option 2). Medication might not be needed every four hours (option 3), and driving is permitted (option 4). ‐ "I will be keeping a diary of my headaches, so that I can see if there is a pattern." ‐ "I will be able to stop my exercise program, since it has not helped my headaches." ‐ "I will take my headache medication every four hours." ‐ "I will never be able to drive again, due to my headaches." | Understanding the need to find the triggering mechanisms for migraines headaches will assist in selecting the only correct option, 1. If this was difficult, review the teaching points for a client who is taking migraine medication. |
3274 The client has been diagnosed with attention deficit Correct answer: 4 A history of Tourette's syndrome is a contraindication for Ritalin. There are other medications hyperactivity disorder (ADHD), and the provider is that could be used for treatment of ADHD, such as pemoline (Cylert) or dextroamphetamine considering prescribing methylphenidate (Ritalin). (Dexedrine). The medications listed in the other options are not contraindications for Which of the following past medical histories would be methylphenidate. a contraindication for Ritalin? ‐ A history of chickenpox ‐ A history of diabetes ‐ A history of seizures ‐ A history of Tourette's syndrome | In order to select the correct answer to this question, recall the contraindications for the medication. If this was difficult, review Ritalin and the contraindications for the medication. |
3275 A female client is being medicated with a central Correct answer: 3 The dose of an antihypertensive medication usually needs to be adjusted when a CNS nervous system (CNS) stimulant. The nurse should stimulant is added to a client's medication regimen. The other options are incorrect because place highest priority on educating the client regarding NSAIDs, skeletal muscle relaxants, and opioids are less affected by CNS stimulants than are adverse drug interactions with which type of antihypertensives. medication she is presently taking? ‐ Nonsteroidal anti‐inflammatory drug (NSAID) | To select the correct answer to this question, recall knowledge of which medication will have adverse drug interactions when taken with a CNS stimulant. If this was difficult, review general considerations for clients taking a CNS stimulant. |
‐ Skeletal muscle relaxant ‐ Antihypertensive ‐ Opioid analgesic | |
3276 A client has begun taking an anticholinergic Correct answer: 2 Anticholinergic medications cause decreased stimulation in the GI and urinary tract systems, medication. The nurse plans to carefully assess which leading to urinary and bowel problems such as urinary retention, hesitancy, and constipation. of the following client parameters? Other side effects of the anticholinergic medications are dry mouth and constipation. The items in options 1, 3, and 4 do not represent particular concerns when administering an anticholinergic medication. ‐ Pain intensity, respiratory rate, and level of consciousness ‐ Urinary retention, hesitancy, and constipation ‐ Seizure activity, mental status, and respiratory status ‐ Electrolytes, blood glucose levels, and leg edema | Knowing the systems involved when taking an anticholinergic will lead to the correct answer. The systems involved are the GI and urinary. The only answer that lists side effects related to these systems is option 2. The other options do not state answers related to these two systems, and can be eliminated. |
3277 The nurse is transcribing medication orders for a Correct answer: 2 Potentially fatal interactions occur between selegiline and opioids, especially meperidine client taking selegiline (Eldepryl). The nurse makes it a (Demerol). Therefore, nurses should be aware of all medications that a client routinely takes priority to telephone the prescriber after noting an when selegiline is ordered concurrently. The other classifications might have interactions, but order for which of the following types of medications? none are potentially fatal. ‐ Monoamine oxidase inhibitor (MAOI) ‐ Opioid analgesic ‐ Skeletal muscle relaxant ‐ Anticholinergic | In order to select the correct answer to this question, recall knowledge of the contraindications for the medication. There is only one correct option for this question. If this was difficult, review selegiline (Eldepryl) and the contraindications for the medication. |
3278 A client has been given a prescription for a Correct answer: 4 The medications used to treat disorders of either the neurological or musculoskeletal system medication affecting the musculoskeletal system. are complex, and require the client to understand how they work. When the client is informed, Which of the following points would the nurse include he is more likely to take the medication correctly. Options 1 and 2 might not apply, and option as significant when teaching the client about this 3 is of lesser importance than is option 4. medication? ‐ To decrease risk factors by eating a low‐fat diet, increasing exercise, and ceasing smoking ‐ The use of sunscreen, vitamins, and hats ‐ The history of the disease for which he is being medicated ‐ Name, dose, schedule, side effects, and possible adverse effects of the medication | The question is asking for selection of significant data. In teaching clients about their medication, the most significant information that should be taught to clients is that identified in option 4. |
3279 A client with a seizure disorder is being medicated Correct answer: 1 Phenytoin binds with the protein in the tube feedings, which decreases the medication with IV phenytoin (Dilantin). The physician changes the absorption into the blood. The tube feedings might need to be shut off for 30 minutes to an mode of administration to feeding tube. Of which of hour before and after the dose. The other answers are incorrect statements. the following points does the nurse need to be aware so that the client's blood level of phenytoin does not decrease? ‐ The tube feeding should be stopped 30–60 minutes before and after administration of the medication, to allow for proper absorption. ‐ The suspension of phenytoin is specially designed to be absorbed with tube feedings. ‐ The dose of IV phenytoin must be increased when given by the feeding tube. ‐ No specific requirements are needed to ensure the drug level stays steady. | Knowing the rate of absorption will lead to the correct answer. If this was difficult, review nursing interventions related to administration of medications by feeding tube. |
3280 The client has a back injury. The provider orders Correct answer: 1 The effects of muscle relaxants are intensified when taken in combination with other central cyclobenzaprine (Flexeril) for the muscle spasms. What nervous system (CNS) depressants, such as alcohol or cough preparations. The client should significant educational point does the nurse need to consult with the provider before taking other medications. Cholesterol levels do not need to share with the client? be checked (option 2). Apical pulse measurement is unnecessary (option 3), and it is antibiotics, not cyclobenzaprine, that must be finished even if symptoms improve (option 4). | In order to select the correct answer to this question, recall knowledge of the contraindications of other medication. If this was difficult, review the use of muscle relaxants with CNS depressants. |
‐ "Do not take this medication with alcohol or cough preparations, and do not drive during its use." ‐ "It is important for you to have your cholesterol levels checked regularly." ‐ "An apical pulse must be taken prior to taking this medication." ‐ "The medication must be finished, even if symptoms improve or cease." | |
3281 For which of the following symptoms would the nurse Correct answer: 4 Tonic‐clonic seizures are the most common generalized seizures. Periods of inattention and assess in a client with the most common generalized daydreaming characterize an absence seizure. Sudden loss of muscle tone and falling seizure disorder? characterize an atomic seizure. Repetitive small muscle group activity characterizes a partial seizure. ‐ Periods of inattention and daydreaming ‐ Sudden loss of muscle tone, and falling ‐ Repetitive small muscle group activity ‐ Tonic and clonic activity of the extremities | Knowing that generalized seizures are termed tonic‐clonic seizures will lead to the only correct option, 4. The other answers are not components of generalized seizures, and can be eliminated. If this was difficult, review seizure types and their classifications. |
3282 After a client has experienced a seizure, what is the Correct answer: 2 After the seizure, the client will be postictal, which is a deep sleeping state. He could aspirate most appropriate position in which the nurse should secretions unless side‐lying to promote drainage from the upper airway. Positioning the client place the client? on his back (option 1) increases the risk of aspiration. Positioning the client on his abdomen (option 3) or upright in a chair (option 4) is unrealistic, given the client's postictal state. ‐ On his back, with his head raised 15 degrees ‐ On his side ‐ On his abdomen ‐ Upright in a chair | Using the process of elimination and considering safety for clients who are high‐risk for aspiration after a seizure will lead to the correct answer. The only correct answer that would address a safe position is option 2. The other options would not be safe interventions for the client. |
3283 A client is experiencing seizure activity. The nurse Correct answer: 3 Phenytoin is a first‐line anticonvulsant medication that is used to control seizure activity. should prepare to administer which of the following Selegilene (option 1) is used to treat Parkinson's disease. Diclofenac (option 2) is an NSAID, medications according to protocol? while sumatriptan (option 4) is used to treat headaches. ‐ Selegilene (Eldepryl) ‐ Diclofenac sodium (Voltaren) ‐ Phenytoin (Dilantin) ‐ Sumatriptan (Imitrex) | Knowing the classification of the medications will lead to the correct answer. In the treatment of seizures, it is important to administer an anticonvulsant. The only anticonvulsant listed in the choices is option 3. If this was difficult, review medications that might be prescribed for seizure disorders. |
3284 Which of the following should be the highest priority Correct answer: 1 The client must understand that medication information is a priority item. Option 2 is a false of the education plan for a client being treated for a statement. Effective medication dosing should control seizure activity (option 4). Teaching that generalized seizure disorder? urine might turn pink or brown may be included if appropriate, but is not the highest priority and global response. ‐ Medication information, and to take medication even if there is no seizure activity ‐ Physical dependency might result from extended use of medications. ‐ Urine might turn pink or brown, but this is not harmful. ‐ Therapeutic effects of medications might not be seen for 2–3 weeks. | The question is asking for selection of significant data. In teaching clients about their medication, the most significant information that should be taught to clients is option 1. |
3285 Education considerations for clients with migraines Correct answer: 3 The ability to avoid the headache triggers is important for the client, and therefore must be must include which of the following? included in teaching. The urine does not change color (option 1). Effective therapy should not take 1–2 years (option 2). Gingival hyperplasia is a concern with phenytoin (option 4), which is used to control seizure activity. ‐ Urine might turn pink or brown. ‐ Therapeutic effects might not be seen for 1–2 years. ‐ Identification of triggers for headaches, and how to decrease them ‐ Proper brushing of teeth with soft toothbrush, and flossing, to prevent gingival hyperplasia | Understanding the need to find the triggering mechanisms for migraines headaches will assist in selecting the correct answer. Option 1 is the only correct answer to the question. If this was difficult, review the teaching points to a client who is taking migraine medication. |
3286 The nurse explains to a client recently diagnosed with Correct answer: 3 Dopamine is the neurotransmitter that is lacking in Parkinson's disease (PD). The other Parkinson's disease that most of the medications used neurotransmitters are not as integral in PD. to treat the disorder improve the availability of what substance in the brain? ‐ Acetylcholine ‐ Serotonin ‐ Dopamine ‐ Glutamic acid | Knowing the pathophysiology with Parkinson’s disease will lead to the correct answer. If this was difficult, review Parkinson’s disease. |
3287 The nurse observing a client with Parkinson's disease Correct answer: 2 Clients with PD have difficulty initiating movement, so arising from a chair is difficult without (PD) would conclude that which of the following assistance. The tremors of PD are resting tremors, not intentional. Medication therapy is manifestations is or are most likely to be seen? targeted at controlling tremors. The other options do not reflect manifestations of this disorder. ‐ Regular fine motor tremors of both hands that persist with intentional activity ‐ Difficulty in arising from a chair and beginning to walk without assistance ‐ Follows objects around the room with her eyes, and often smiles to herself when left alone in room. ‐ Weakness of right leg, becoming more noticeable after a warm bath or shower | Knowing the clinical manifestations of Parkinson’s disease will assist in selecting the correct answer. The only correct manifestation of Parkinson’s disease is option 2. If this was difficult, review clinical manifestations of Parkinson’s disease. |
3288 A client had surgery for a herniated disk two days Correct answer: 2 The client must have pain control with oral medications and have begun an exercise program ago. The medications ordered include IV/IM morphine prior to discharge. Option 1 is completely incorrect, while options 3 and 4 are partially sulfate (Morphine), an oral pain pill, and oral muscle incorrect. relaxant, cyclobenzaprine (Flexeril). What are the nursing goals of care so the client can be discharged tomorrow? ‐ Pain control achieved with IV medication only, and client maintains bedrest. ‐ Pain control achieved with oral medications, and an exercise program is begun. ‐ Pain control achieved with combination of IV/IM and oral medications, and an exercise program is begun. ‐ Pain control achieved with oral medications, and client maintains bedrest. | Note that the question states that the client has an IV/IM medication ordered, but also an oral medication. This should allow for consideration that the client’s pain control should eventually be with an oral medication. Knowing this, select option 2. |
3289 Which of the following nursing diagnoses has highest Correct answer: 2 The most important nursing diagnosis for the client at this time is related to inadequate priority for a client newly diagnosed with tonic‐clonic knowledge of medication management. Ineffective sexuality patterns and impaired thought seizure disorder beginning medication therapy? processes may be addressed later as needed, and pain related to headache is not applicable. ‐ Ineffective Sexuality Patterns ‐ Deficient Knowledge ‐ Pain related to headache ‐ Impaired Thought Processes | The question is asking for selection of the highest‐priority answer. When a client is beginning a new medication, the highest priority is usually knowledge deficiency. The client will need to be taught the significant information about the medication and its side effects. |
3290 Which of the following nursing diagnoses has highest Correct answer: 3 The primary issue for migraine headache sufferers is pain relief, which is amenable to priority for a client newly diagnosed with migraine treatment with medication therapy. Disturbed sleep pattern may be addressed later, while headaches? ineffective sexuality patterns and impaired thought processes are not applicable. ‐ Ineffective Sexuality Patterns ‐ Disturbed Sleep Pattern ‐ Pain related to headache ‐ Impaired Thought Processes | The question is asking for selection of the highest‐priority answer. When a client has a diagnosis of migraine headaches, pain is usually the priority. Option 3 is the correct priority diagnosis with this question. |
3291 A client has an order to begin an IV nitroglycerin Correct answer: 2 Intravenous nitroglycerin (NTG) must be prepared only in glass bottles, and infused via the (Nitrostat) drip. The nurse prepares this medication by manufacturer‐provided tubing. The polyvinyl chloride in regular tubing will adsorb (leech out) mixing the medication: the nitroglycerin. NTG is stable in a glass bottle for 24 hours, and does not require laminar flow ventilation. | The core issue of the question is knowledge that nitroglycerin adsorbs into plastic, making it necessary to use a glass bottle and special IV tubing from the manufacturer. Use nursing knowledge related to pharmacology and the process of elimination to make a selection. |
‐ In a solution that is covered by a plastic bag. ‐ In a solution that is in a glass bottle. ‐ Every 2 hours, because it is unstable. ‐ Under a laminar flow hood. | |
3292 A client with angina pectoris received nitroglycerin Correct answer: 2 Headache is a common side effect (not adverse reaction) related to the vasodilation tablets sublingually for chest pain. The client dislikes properties of nitroglycerin. The incidence of headache decreases over time as the client the medication because it causes headache. The nurse develops tolerance to the medication. The client should be encouraged to continue its use as makes which of the following interpretations about the needed, and to take acetaminophen or aspirin for headache, according to the preference of client’s statement? the physician. ‐ This is a common but unhealthy response to the medication. ‐ This is a common response that will diminish as tolerance to the medication develops. ‐ This is a response caused by cerebral hypoxia induced by the medication. ‐ This is an adverse reaction that must be reported to the physician immediately. | The core issue of the question is knowledge of common adverse effects of nitroglycerin therapy. Use nursing knowledge related to pharmacology and the process of elimination to make a selection. |
3293 A client who has just been diagnosed with Correct answer: 2 Adverse effects of beta‐adrenergic blockers such as propranolol include their potential to hypertension also smokes, and has diabetes mellitus. cause bronchospasm and to mask hypoglycemia attacks. Therefore, the clients who are at risk The nurse would question an order for which of the for these conditions should not utilize beta blockers as antihypertensive medications. Calcium following antihypertensive medications? channel blockers, alpha blockers, and diuretics do not directly affect these conditions. ‐ Diltiazem (Cardizem) ‐ Propranolol (Inderal) ‐ Prazosin (Minipress) ‐ Furosemide (Lasix) | The core issue of the question is knowledge of contraindications for beta‐adrenergic blockers, such as propranolol. Use nursing knowledge related to pharmacology and the process of elimination to make a selection. |
3294 Diltiazem (Cardizem) is prescribed for a client with Correct answer: 3 Diltiazem (Cardizem) is a calcium channel blocker. It is usually administered before meals and chronic, stable angina. The clinic nurse determines that at bedtime to increase the absorption of medication. Postural hypotension can occur, so the the client needs additional medication information if client must be instructed to rise slowly to avoid dizziness and falling. The medication can cause the client makes which of the following statements? a decrease in mental alertness until the body adjusts and the proper dosage is established. The client should notify the physician if she develops shortness of breath, irregular heartbeat, pronounced dizziness, nausea, or constipation. ‐ “I will call the physician if shortness of breath occurs.” ‐ “I will rise slowly when getting out of bed in the morning.” ‐ “I will take medications after meals.” ‐ “I will avoid activities requiring mental alertness until my body adjusts to the medication.” | The wording of the question tells you that the correct answer is an incorrect statement. Recall information about calcium channel blockers and use the process of elimination to make a selection. |
3295 The nurse has given medication instructions to the Correct answer: 2 Nicardipine (Cardene) is a calcium channel blocker. Weight gain and edema are potential client receiving nicardipine (Cardene) for angina. The signs of heart failure, and must be reported to the physician. The client taking this medication nurse would reinforce the teaching if the client makes should keep track of angina episodes, and report any increase in the episodes or change in the which of the following statements? pattern. The client may take a missed dose of medication if not too close to the next dose; otherwise, the dose should be omitted. The client should be taught to check his pulse, note the rate, and report if the heart rate is lower than 50 beats per minute. ‐ “I will keep track of angina episodes, and report them if they increase.” ‐ “I will ignore edema or weight gain as an expected side effect of the medication.” ‐ “I will report a pulse rate of fewer than 50 beats per minute.” ‐ “I will take any missed dose as soon as remembered, unless it is almost time for the next dose.” | The core issue of the question is knowledge of teaching points regarding calcium channel blockers, such as nicardipine. The wording of the question tells you that the correct answer is an incorrect statement. Use nursing knowledge related to pharmacology and the process of elimination to make a selection. |
3296 A client with hypertension has been given a Correct answer: 1 Cough and loss of taste are common side effects of angiotensin‐converting enzyme (ACE) prescription to treat the disorder. The nurse would inhibitors such as lisinopril. They disappear with discontinuation of the medication. The explain that cough and loss of taste are side effects if medications listed in the other options do not produce cough or change taste perception. which of the following antihypertensive agents is prescribed? ‐ Lisinopril (Prinivil) ‐ Propranolol (Inderal) ‐ Diltiazem (Cardizem) ‐ Furosemide (Lasix) | The core issue of the question is knowledge that ACE inhibitors lead to cough and loss of taste perception. From there, you must be able to identify which drug is an ACE inhibitor. Recall that these drugs end in ‐pril to help make a selection. |
3297 The physician prescribes losartan (Cozaar) for a client Correct answer: 4 Losartan is an angiotensin II antagonist that inhibits the conversion of angiotensin I to with hypertension. The nurse carrying out the order angiotensin II. Because angiotensin II is a powerful vasoconstrictor, this inhibition results in explains to the client that this medication promotes vasodilation and normalizing blood pressure. The client should be assessed for dizziness, vasodilation by: cough, and diarrhea while taking this medication. ‐ Preventing calcium from going into the cells. ‐ Promoting epinephrine and norepinephrine. ‐ Promoting release of aldosterone. ‐ Inhibiting conversion of a substance that would cause vasoconstriction. | The core issue of the question is knowledge of the mechanism of action of angiotensin‐ receptor blockers. To reach the correct answer, it is necessary to recognize that the drug is in this class. Use nursing knowledge related to pharmacology and the process of elimination to make a selection. |
3298 The client with hypertension states that he monitors Correct answer: 2 Lack of adherence to pharmacologic treatment strategies prevents the client from his blood pressure daily. His medications include establishing good control of the disease, and ultimately places him at risk for developing long‐ verapamil (Calan SR) 240 mg daily and term complications of hypertension. Noncompliance with the therapeutic program is a hydrochlorothiazide (HCTZ) 12.5 mg daily. He states significant problem in people with hypertension. The client should not skip doses of that if his BP reading is lower than 140 systolic, he medications without consulting the physician. skips his dose for the day. What would be the most appropriate response by the nurse? ‐ “As long as the systolic is lower than 140, it is OK to skip the dose.” ‐ “You should not skip doses unless instructed by the ordering physician.” ‐ “Maybe you won’t even need your BP medications in a few more months.” ‐ “Your doctor may want to stop the HCTZ and have you take only the Calan.” | The core issue of the question is knowledge that antihypertensive medications need to be taken as scheduled without missing or skipping doses. Use nursing knowledge related to pharmacology and the process of elimination to make a selection. |
3299 Adenosine (Adenocard) is to be administered to a Correct answer: 3 Adenosine (Adenocard) is an antidysrhythmic used in the treatment of paroxysmal client in the Emergency Department. Before preparing supraventricular tachycardia (SVT). Cardiac performance must be assessed before and the medication, the nurse ensures that which of the throughout treatment by cardiac monitoring. An endotracheal tube may be used if an following priority pieces of equipment is operational? emergency necessitates mechanical ventilation, but the tube itself is a rather isolated item. An IV pump might be needed, but is not a priority, because this medication is administered rapidly by IV push. A pulse oximetry machine might be helpful in assessing oxygenation, but is not a priority item. ‐ A pulse oximetry machine ‐ An IV infusion pump ‐ A cardiac monitor ‐ An endotracheal tube | The core issue of the question is the most important piece of equipment needed to monitor a client receiving adenosine. Recall that this drug is an antidysrhythmic to help choose the cardiac monitor as the appropriate answer. |
3300 The home health nurse would be most concerned Correct answer: 2 Anorexia, nausea, and yellow vision are signs of digoxin toxicity. Other signs include other that a client is developing digoxin toxicity after noting visual disturbances, vomiting, and diarrhea. The clusters of other symptoms listed does not fit which of the following during a routine visit? the profile of digoxin toxicity. ‐ Palpitations, elevated blood pressure, and shortness of breath ‐ Anorexia, nausea, and reports of yellow vision ‐ Chest pain, fatigue, and decreased blood pressure ‐ Taste alterations, dry mouth, and constipation | The core issue of the question is knowledge of early signs of digoxin toxicity. Recall that early signs are usually more subtle than are later signs. Use nursing knowledge related to pharmacology and the process of elimination to make a selection. |
3301 A client with myocardial infarction is experiencing Correct answer: 4 Lidocaine is a class I antidysrhythmic used to treat ventricular dysrhythmias. Other new, multiform, premature ventricular contractions medications that might be ordered include procainamide, amiodarone, or magnesium sulfate. (PVCs). The nurse checks the medication cart to ensure The other medications would not be used as a primary treatment of ventricular dysrhythmias that which of the following medications is available for because they are a cardiac glycoside (option 1), a beta blocker (option 2), and a calcium immediate use? channel blocker (option 3), respectively. ‐ Digoxin (Lanoxin) ‐ Metoprolol (Lopressor) ‐ Verapamil (Isoptin) ‐ Lidocaine (Xylocaine) | The core issue of the question is knowledge of first‐line treatment for PVCs. Use nursing knowledge related to pharmacology and the process of elimination to make a selection. |
3302 The nurse is preparing to administer amiodarone Correct answer: 3 Amiodarone is a class III antiarrhythmic used to treat life‐threatening ventricular (Cordarone) IV. The nurse should assure that which of dysrhythmias that do not respond to first‐line drugs (like lidocaine). The client should have the following is in use at this time? continuous EKG monitoring, and the medication should be infused through an IV pump. Oxygen therapy might be needed, but is unrelated to this medication. Options 2 and 4 are not critical during administration of this medication, although they are generally useful adjuncts. ‐ Oxygen therapy ‐ Noninvasive blood pressure monitoring ‐ Continuous cardiac monitoring ‐ Oxygen saturation monitoring | The core issue of the question is knowledge of what parameter needs to be monitored carefully during amiodarone therapy. Eliminate options 1 and 4 (oxygen and oxygen saturation monitor) because they are similar. Recall that the drug is an antidysrhythmic agent to make the final selection. |
3303 Which medication does the nurse anticipate will be Correct answer: 3 Heparin is the drug of choice in pregnancy. Low‐molecular‐weight heparins, of which used for a pregnant client who requires enoxaparin is an example, are not recommended for use during pregnancy (options 1 and 4). anticoagulation therapy? Epoetin alfa (Procrit) is a colony‐stimulating growth factor, and is not used for anticoagulation (option 2). ‐ Low‐molecular‐weight heparin (LMWH) ‐ Epoetin (Procrit) ‐ Heparin (Liquaemin) ‐ Enoxaparin (Lovenox) | The core issue of the question is knowledge of the anticoagulant that is safe to use during pregnancy. Use nursing knowledge related to pharmacology and the process of elimination to make a selection. |
3304 The nurse would include in a teaching plan that a Correct answer: 3 Clients who have atrial fibrillation are at risk to develop emboli. Therapy with Coumadin is client taking warfarin (Coumadin) for atrial fibrillation considered to be ongoing in nature, in order to prevent such an occurrence. The other time will need to remain on drug therapy for what period of frames are too short to achieve a preventative goal. In addition, the likelihood of emboli time? formation does not significantly diminish unless the client is anticoagulated on a long‐term basis. ‐ 6 months ‐ 2–3 months ‐ Indefinite, or long‐term ‐ 1 year | The core issue of the question is knowledge that treatment for prevention of blood clot formation from atrial fibrillation is indefinite. Use nursing knowledge related to pharmacology and the process of elimination to make a selection. |
3305 A client is placed on ticlopidine (Ticlid) following a Correct answer: 1 A client taking ticlopidine should be monitored for potential blood dyscrasias that can occur stroke. What follow‐up blood work is indicated in with this drug. Monthly PT and INR levels are not indicated as follow‐up for this medication, managing the client? but are used in conjunction with Coumadin therapy (option 2). ABGs are not indicated in the management of clients who are taking ticlopidine (option 3) There are no reported electrolyte imbalances with the use of this medication (option 4). ‐ Frequent CBC monitoring to evaluate for blood dyscrasias ‐ Monthly PT and INR levels to evaluate for clotting problems ‐ ABGs to evaluate respiratory status ‐ Serum chemistries to monitor for potential electrolyte imbalances | The core issue of the question is knowledge of adverse effects of ticlopidine that can be detected using laboratory monitoring. Use nursing knowledge related to pharmacology and the process of elimination to make a selection. |
3306 A client is undergoing percutaneous transluminal Correct answer: 2 ReoPro is often given IV following this type of procedure, to help prevent possible reocclusion coronary angioplasty (PTCA), and requires an of the coronary artery that has been treated. It can be administered in conjunction with weight‐ antiplatelet agent. The nurse prepares to administer based heparin therapy, but heparin is an anticoagulant agent (option 1). Plavix and ASA are which drug for this type of client immediately examples of antiplatelet agents that are given orally, and are not utilized in this particular following the procedure? acute‐care setting (options 3 and 4). However, ASA can be given later as follow‐up to the procedure, to prevent possible complications related to vessel occlusion. ‐ Heparin (Liquaemin) ‐ Abciximab (ReoPro) ‐ Clopidrogrel bisulfate (Plavix) ‐ Aspirin (ASA) | The core issue of the question is knowledge of drugs that have antiplatelet properties and that can be used IV following interventional cardiology procedures such as PTCA. Use nursing knowledge related to pharmacology and the process of elimination to make a selection. |
3307 A client is receiving thrombolytic therapy. The nurse Correct answer: 3 Clients taking thrombolytic therapy should be monitored closely for the possibility of monitors the client for what potential problem? hemorrhage, as therapy increases the risk of bleeding. Monitoring includes evaluating the skin for bruising and gums, and venipuncture sites for bleeding, and testing stool and urine for occult or obvious blood. Headache, fever, and bone pain are not directly related to thrombolytic therapy (options 1, 2, and 4). ‐ Headache ‐ Fever ‐ Hematuria ‐ Bone pain | The core issue of the question is knowledge that thrombolytics can lead to bleeding. With this in mind, recall the various ways that bleeding can manifest in a client taking drugs that interfere with clotting. Use nursing knowledge related to pharmacology and the process of elimination to make a selection. |
3308 The nurse would assess a client who is receiving Correct answer: 4 The use of thrombolytic agents can cause cardiac irritation and lead to development of thrombolytic therapy for which of the following? dysrhythmias that can be life‐threatening. The nurse must be aware of the serious likelihood that treatment can cause further cardiac compromise. Dry mouth, decreased urine output, and decreased clotting times (options 1, 2, and 3) are not seen with thrombolytic therapy. ‐ Dry mouth ‐ Decreased urine output ‐ Decreased clotting times ‐ Cardiac dysrhythmias | The core issue of the question is knowledge that thrombolytic drugs can cause reperfusion dysrhythmias as a result of clot lysis. Use nursing knowledge related to pharmacology and the process of elimination to make a selection. |
3309 For which of the following would a nurse monitor in a Correct answer: 1 Folic acid (in large doses) can cause the urine to become discolored and turn to a darker‐ client taking folic acid (Folvite)? yellow color. Dark‐green or black stools are more commonly associated with iron therapy (option 2). Temperature elevations and changes in pulse rate are not associated with folic acid (options 3 and 4). ‐ Dark‐yellow urine ‐ Dark‐green or black stools ‐ Temperature elevations ‐ Increased pulse rate | The core issue of the question is knowledge of expected side effects of folic acid. Recall that B complex vitamins can turn the urine a darker yellow as an aid to answering the question. Use nursing knowledge related to pharmacology and the process of elimination to make a selection. |
3310 Which of the following measures should the nurse Correct answer: 3 Liquid iron preparations can cause staining of teeth. It is important for the nurse to be aware utilize when administering ferrous sulfate (Feosol) of proper administration methods, which include drinking the mixture through a straw. Mixing elixir? medication with milk and carbonated beverages will decrease its absorption (options 1 and 4). The medication is usually taken with food to minimize GI upset (option 2). ‐ Mix the medication with milk to decrease GI effects. ‐ Administer oral medication without food. ‐ Administer the medication through a straw. ‐ Mix the medication with carbonated beverages to minimize gastric upset. | The core issue of the question is knowing that liquid iron stains the teeth. With this in mind, select the option that prevents the liquid from being absorbed through tooth enamel. Keeping other administration principles in mind helps you to eliminate the incorrect options. |
3311 A client has an order to receive 5,000 units of heparin Correct answer: 0.5 To calculate the dose, divide the desired dose (5,000) by the dose on hand (10,000 units) and subcutaneously. Available is a vial labeled "Heparin multiply that by the quantity (1 mL). The result is 0.5 mL. 10,000 units per mL." The nurse should administer mL of heparin solution. | The core issue of the question is the ability to calculate a drug dose. If necessary, memorize this basic formula for use in solving many medication questions. |
3312 A client has been diagnosed with iron deficiency Correct answer: 4 Vitamin C helps to enhance the absorption of iron in the diet, and is an easy step in diet anemia (IDA), and wants to know what foods would management towards improving iron levels in the body. A strict vegetarian diet focuses on non‐ help to maintain adequate iron levels in the body. heme sources of iron that are not as readily absorbable as heme sources (option 1). Eating ice Which of the following items regarding diet cubes is an example of pica, which is ingestion of a non‐food substance (option 2). Nonfood information would be beneficial for the nurse to items will not help to maintain iron, or prevent iron deficiency, and in certain cases can include in a teaching plan for achieving the goal of actually lead to deficiency states. Tea contains tannic acid, and cereals contain phytates and increased iron levels? fibers, all of which lead to decreased iron absorption in the diet (option 3). ‐ Maintain a strict vegetarian diet. ‐ Eat ice cubes that are present in beverages. ‐ Increase tea and cereal in the diet. ‐ Use adequate sources of vitamin C in the diet. | Note that the question is referring to maintaining iron levels, which should lead to thinking about how iron can best be absorbed. Knowledge of the need to consume vitamin C with iron will lead you to the only correct option, 4. |
3313 A client is taking anti‐platelet medication for several Correct answer: 4 Inspection of the client's skin is necessary to verify if there are additional areas of bruising or weeks, and presents with a noticeable bruise on the discoloration of which the client might not be aware. It is important to review current findings arm. What information should the nurse assess first in and compare them with baseline findings, as this might provide data to support a potential order to determine if this skin manifestation is related response to drug therapy. Asking the client if the bruising is related to a particular incident is to drug therapy? important (option 1); however, it does not rule out the possibility that drug therapy has made the individual more susceptible to bruising or bleeding tendencies. If the client has not taken the medication as ordered, it would be unlikely that the bruise would be a consequence of drug therapy (option 2). It is important for the client to continue to self‐monitor during drug therapy, but that choice by itself does not answer the question (option 3). ‐ Whether the bruising is a result of a specific injury, and therefore not caused by drug therapy ‐ Whether the client has taken the medication for the last several days ‐ Whether the client self‐monitors for skin manifestations ‐ Whether the client has bruising and discoloration on other areas of the body | The question is asking about assessment, the first part of the nursing process. Inspection of the client s body for other bruising and discolorations should be the first part of care. The other options are all subjective data, and can be gathered as a unit after inspecting the client s body. |
3314 In order to verify iron stores in the body, for which Correct answer: 1 Ferritin levels reflect the visceral stores of iron in the body. Transferrin levels reflect how iron priority laboratory test result would the nurse look in a is transported in the body (option 2). Hemoglobin and hematocrit refer to concentration and client's medical record? proportion measures of red blood cells (RBCs). While they provide information relative to blood count, they are not specific to body iron store values (option 3). A CBC will provide information relative to blood concentration of all three cell lines (red, white, and platelets) but again, it is not specific to body iron store values (option 4). ‐ Ferritin level ‐ Transferrin level ‐ Hemoglobin and hematocrit ‐ Complete blood count (CBC) | Having knowledge of specific laboratory tests will assist in selecting the correct answer. The only correct answer for this question is option 1, since it directly will reflect iron stores in the body. If this was difficult, specifically review laboratory tests and their purposes. |
3315 A client is being treated with alteplase (Activase) in Correct answer: 2 Activase is used in the emergency setting post‐stroke and –myocardial infarction (MI) in order the Emergency Department following a to dissolve clots and increase perfusion. A client receiving this medication is at risk to develop cerebrovascular accident (CVA or stroke). What is the significant cardiac dysrhythmias, and therefore should be placed on a cardiac monitor during priority nursing intervention related to the care of a treatment. While vital signs (including blood pressure and temperature) are important, they client receiving this drug therapy? are not the priority intervention (options 1 and 4). The monitoring of urinary output is not a priority unless there are underlying conditions regarding volume management (option 3). | Knowledge of the medication and side effects will lead to the correct answer. Since this medication has the primary side effect of dysrhythmias, the nurse would need to assess the client closely through cardiac monitoring. If this was difficult, review the side effects of the medication. |
‐ Perform vital signs every 15 minutes until the client's blood pressure is stabilized. ‐ Place the client on a cardiac monitor, and observe for potential dysrhythmias, as this medication can have cardiac effects. ‐ Insert a urinary catheter, and maintain accurate hourly output measures. ‐ Monitor the client for hypothermia, as this is a common side effect of this medication. | |
3316 A client is taking epoetin alfa (Epogen) for treatment Correct answer: 3 The target range for hematocrit with epoetin alfa therapy is 30–36%. A client who is taking of anemia related to chronic renal disease. What Epogen must be monitored closely, to prevent adverse side effects that can occur because of clinical finding reveals to the nurse that this either a rapid increase or high‐level hematocrit. Rapid or increased hematocrit levels can cause medication is working effectively? the client to develop seizures and hypertension (option 2). Bone pain and fever are seen in response to administration, and are not indicators of effective drug management (options 1 and 4). ‐ The client is not experiencing any related bone pain when the medication is being administered. ‐ The client's hemoglobin and hematocrit levels are rising rapidly based on the latest two daily blood draws. ‐ The client's hematocrit is in the established target range at 33%. ‐ The client is afebrile. | Recall knowledge of client responses to the medication to be led to option 3. If this was difficult, review the acceptable client responses to the medication. |
3317 A client who has elevated cholesterol levels has been Correct answer: 2 Facial flushing is an expected side effect of niacin, caused by its vasodilator properties. While prescribed nicotinic acid (Niacin). What information dosages are often adjusted, it is usually for the purpose of managing side effects related to would the nurse provide to this client? gastrointestinal complaints, and not based on lab values (option 1). Additional dietary sources of niacin are not required to enhance the effect of niacin supplements (option 3). Clients should not take niacin and lovastatin concurrently, as this can lead to the development of myopathy (option 4). ‐ Niacin treatment is highly individualized, and there might be dose adjustments based on lab values. ‐ Expect facial flushing, as this is a common expected effect of this medication. ‐ Dietary sources of niacin are necessary to ensure that the medication works effectively. ‐ Niacin can be taken concurrently with lovastatin (Mevacor) in order to maximize the therapeutic effect. | The question is asking for selection of side effects of the medication. The only option that refers to side effects is option 2. Knowledge of the side effects of the medication will lead to the correct answer. The other options are all interventions, and can be eliminated, since the question is referring to side effects. |
3318 A client with von Willebrand's disease is taking Correct answer: 1 DDAVP and cryoprecipitate are considered effective treatments for clients with von desmopressin (DDAVP) and cryoprecipitate as part of Willebrand's disease because they contain specific clotting factors (vW and VIII). They are the treatment regimen. The nurse would explain that considered a form of replacement therapy, but do not stimulate production of blood factors medication therapy will provide what pharmacologic (option 4). While DDAVP is an antidiuretic, it also has other pharmacological actions in the benefit to this client? body; specifically, it stimulates the body to release vW factor (option 2). These medications do not have to be given concurrently in order to potentiate their effects (option 3). Clients can receive them independently, based on physician preference. ‐ These medications will help to restore and release deficient clotting factors (vW and VIII) that occur in this disease process. ‐ DDAVP is given for its antidiuretic effect to promote fluid management. ‐ Cryoprecipitate and DDAVP must be given concurrently in order to potentiate their therapeutic effect. ‐ These medications will stimulate the client's own production of specific blood factors. | Having knowledge of the disease process and usual mode of treatment will lead to the correct answer. If this was difficult, review the disease process and medication regimen. |
3319 The nurse reviewing a client's laboratory test results Correct answer: 4 Hemostasis is the ability of the body to prevent bleeding and hemorrhage using platelets in would conclude that which of the following would the coagulation process. Thrombocytopenia (a reduced level of platelets in the body) can affect the client's ability to maintain hemostasis? profoundly affect the body's ability to react to a vascular insult. Neutropenia (a reduced neutrophil count affecting WBCs) can profoundly affect the body's ability to react to an immune response (option 3). Low ferritin levels and elevated triglyceride levels do not directly affect a body's ability to maintain hemostasis (options 1 and 2). ‐ Low ferritin level ‐ Elevated triglyceride level ‐ Neutropenia ‐ Thrombocytopenia | Understanding the definition of hemostasis will lead to the correct answer. The only correct option is 4, since thrombocytopenia refers to platelets, which in turn relate specifically to the ability to prevent bleeding. The other options do not refer to hemostasis, and can therefore be eliminated. |
3320 A client is being discharged on warfarin (Coumadin) Correct answer: 2 Clients who have valve replacement surgery require lifelong anticoagulation therapy. following heart valve replacement surgery. What Therefore, they must be instructed as to the possible risks for bleeding, and must modify their information would the nurse give to the client to environment and activities of daily living accordingly. Follow‐up lab testing is required, but is provide safe and effective care during the course of not usually limited to a weekly basis (option 1). Coumadin therapy is usually taken as an therapy? evening dose (option 3). Clients are instructed not to double up doses, and to take the medication specifically as ordered, to assure safe and therapeutic effects (option 4). ‐ Follow‐up lab testing is required on a weekly basis in order to monitor client response. ‐ Be alert to the possibility of bleeding tendencies caused by this drug therapy, and use electric razors and soft toothbrushes. ‐ Take medication upon arising in the morning on an empty stomach to maximize absorption. ‐ Since the therapy is based on achieving a therapeutic blood level, if a dose is missed, double up the next dose. | The question refers to the teaching required for a client who is taking anticoagulant therapy. Since all the answer choices are examples of teaching, the method of selecting the correct option will depend on knowledge of the medication. Recall understanding of the teaching required for clients taking the medication to select the correct option. |
3321 The nurse has just received an order to start Correct answer: 3 Heparin administration requires the use of an infusion pump in order to maintain an accurate intravenous heparin (Liquaemin) therapy on a client level of medication. While vitamin K is important in the coagulation cascade, it is not required admitted for deep vein thrombosis (DVT). What to be readily available when heparin is being infused. Protamine sulfate is a heparin antagonist, nursing intervention would the nurse employ in order and should be used when reversal is indicated (option 1). The client does not have to be NPO to implement this order? during this type of therapy (option 2). If using weight‐based therapy, it is important to weigh the client at the same time with the same scale each day to verify accuracy (option 4). ‐ Vitamin K should be readily available as long as the client remains on heparin therapy. ‐ The client should remain NPO as long as the medication is infusing. ‐ An infusion pump should be utilized for the administration of heparin. ‐ The client should be weighed twice a day in order to evaluate for potential fluid overload. | Note that this question refers to safety as the main issue. Select the most important intervention, option 3, as there must be accurate administration of the medication, and thus safety. |
3322 A client is being discharged with a diagnosis of angina. Correct answer: 2 Teach the client that the activity in which he is engaged might be causing the chest pain. The nurse is teaching the client about the use of Instruct the client in the exact method of taking NTG to avoid dizziness. The teaching about the nitroglycerine (NTG) tablets at home. What client frequency of the medication must be accurate and specific to prevent overdose, as could teaching is needed related to this medication? happen in option 4. Option 1 is incorrect because NTG becomes unstable when exposed to heat, light, and moisture. Option 3 is incorrect because the client shouldn't drive, for safety reasons. ‐ "Keep NTG tablets in your pants pocket next to your body to keep them handy at all times. Take two NTG tablets with a glass of water, and then go back to your activities." ‐ "Stop your activities and sit down near a telephone if possible, and place one NTG under your tongue. Take no more than three tablets, one every five minutes. If the pain is unrelieved after a total of three NTG tablets, seek help." ‐ "Stop your activities, take two NTG tablets, and drive immediately to your doctor's office." ‐ "Continue your activities slowly. Take three NTG tablets every five minutes until your chest pain is gone." | The question is referring to safe and effective administration of the medication. The options are all interventions, so in order to select the correct answer, recall knowledge of the correct administration of the medication. |
3323 The client states, "I always put my nitroglycerin (NTG) Correct answer: 3 Nitroglycerine patches and ointments must be rotated daily to a hairless area to reduce skin patch in the same place, so I do not forget to take it irritation. Options 2 and 4 are incorrect statements, while option 1 is only partially correct. off." The nurse s best response would be: ‐ "This is good, but it is very important to take the patch off each night." ‐ "Sometimes the patch should be placed over hairy areas to vary the absorption." ‐ "You should rotate the NTG patch to a different hairless area each day." ‐ "It does not matter if you leave your patch on when you put the next one on. The medication is all gone." | The question is referring to safe and effective administration of the medication. The options are all interventions, so in order to select the correct answer to the question, recall knowledge of the correct administration of the medication. |
3324 A client is hospitalized for heart failure, and is Correct answer: 2 It is important to monitor the apical‐radial pulse for a full minute before the administration of receiving digoxin (Lanoxin) IV push. The nurse should digoxin. Record and report significant changes from the client's own baseline data. Without withhold the drug and notify physician if the client's: solid data regarding the client's baseline, it is prudent to report a heart rate lower than 60, since bradycardia could indicate drug toxicity. Depression, respiratory rate, and blood pressure are unrelated to this medication. ‐ History reveals depression. ‐ Pulse is 53 beats per minute. | The question is referring to client responses. Option 1 can be eliminated, since it refers to history, and not responses. The priority intervention with the medication is to take an apical pulse before administration, so option 2 is correct in referring to the client response. Having knowledge of when to hold the medication will assist in selecting this answer. |
‐ Respiratory rate falls below 18. ‐ Blood pressure is 148/90. | |
3325 A physician orders a nitroglycerine (NTG) drip to be Correct answer: 3 The blood pressure and heart rate must be monitored closely during titration to prevent titrated. The nurse carrying out the order would hypotension and tachycardia. Shortness of breath is important, but not directly related to NTG monitor which of the following parameters? infusion. Respirations, urine output, and headache do not determine the titration rate. Headache frequently occurs, and is treated commonly with acetaminophen or another mild analgesic. ‐ Shortness of breath and level of consciousness ‐ Respirations and urine output ‐ Blood pressure and pulse rate ‐ Headache and blood pressure | Side effects of the medication are hypotension and tachycardia. Having this knowledge base will lead to option 3 as the correct answer choice. If this was difficult, review the side effects for the medication. |
3326 A client is receiving metoprolol (Lopressor) for Correct answer: 1 Metoprolol is a beta blocking agent that blocks the effects of both β<sub>1</sub> hypertension. The nurse should ask the client about a and β<sub>2</sub> receptors, leading to a reduction in systemic vascular history of which of the following conditions? resistance. This effect also can lead to bronchospasm (from bronchoconstriction secondary to β<sub>2</sub> blockade), and therefore metoprolol would be contraindicated in clients with bronchospastic illness. The drug has no effect on seizure activity or on myasthenia gravis, a neuromuscular disorder. ‐ Bronchospasm ‐ Seizure ‐ Hypertension ‐ Myasthenia gravis | Knowledge of any respiratory complications would be required prior to administering this medication. This is the only correct answer, since the other options are not significant in the administration of the medication. If this was difficult, review the medication s purpose and outcome effects. |
3327 A nurse assesses a client for side effects of verapamil Correct answer: 4 Verapamil is a calcium channel blocker used to treat angina. Constipation is a frequent (Calan SR). Which client manifestation would the nurse complaint of clients taking the sustained‐release form of verapamil. Many elderly clients have anticipate as a side effect of this medication? difficulty with this, and the nurse must anticipate the need for teaching about increasing fiber and fluid intake. Hypotension is an adverse reaction to verapamil. Skin rash is unrelated to the medication. ‐ Hypertension ‐ Angina ‐ Skin rash ‐ Constipation | Recall uses and side effects of this medication. If this was difficult, review the side effects of the medication. |
3328 The client is receiving a lidocaine infusion at a rate of Correct answer: 1 Early indications of toxicity to lidocaine include various central nervous system (CNS) 2 mg per minute via infusion pump. The nurse should complications. These can include slurred speech, dizziness, confusion, and paresthesias. If they discontinue the infusion and notify the physician are ignored, the client can develop seizures that are often difficult to stop, and death could immediately when the client does which of the ensue. Sinus tachycardia is unrelated to lidocaine. Concerns about the myocardial infarction following? are normal, and should be addressed. Leg cramps are unrelated to lidocaine use. ‐ Demonstrates slurred speech. ‐ Demonstrates a sinus tachycardia of 102. ‐ States he is concerned about his "heart attack." ‐ Reports leg cramps. | Having knowledge of toxicity of this medication on the central nervous system (CNS) will lead to the correct answer. Since the CNS is the system that is mostly affected with this medication, the only correct option is 1. The other options can be eliminated with knowledge of the primary side effects with the CNS. |
3329 The nurse anticipates a positive inotropic effect after Correct answer: 2 Digoxin is classified as a positive inotropic drug. It increases contractility (inotropy) of heart, administering which of the following medications? whereas propranolol (a beta blocker) and verapamil (a calcium channel blocker) are negative inotropic medications. Atropine has a neutral effect on contractility. ‐ Atropine sulfate ‐ Digoxin (Lanoxin) | Knowledge that an inotropic heart drug affects the force with which the heart muscle contracts will lead to the correct answer. The medication that fits this definition is option 2. The other medications do not fit with the definition of an inotropic heart drug, and can therefore be eliminated. |
‐ Propranolol (Inderal) ‐ Verapamil (Calan) | |
3330 A client asks the nurse to explain why she is receiving Correct answer: 3 Lidocaine IV is used to treat ventricular dysrhythmias (premature ventricular contractions, lidocaine (Xylocaine) in her IV when her dentist injects ventricular tachycardia, and ventricular fibrillation), particularly in clients with a myocardial it into her gums to numb the teeth before a filling. The infarction. It is a class 1‐A antiarrhythmic. The drug causes no anesthetic effect unless the best response by the nurse is: client receives an overdose that is evidenced by a central nervous system deficit (paresthesias, confusion, and slurred speech). Lidocaine can cause drowsiness, but is not used for relaxation (option 2). It is not a diuretic (option 4). ‐ "The medication is more effective intravenously, and you will feel no pain anywhere." ‐ "As an IV medication, it will help you relax and rest, so your heart can heal." ‐ "When given IV, this medication reduces the irritability of the cells in your heart, and helps reduce dysrhythmias." ‐ "The medication will increase your urine output, so that you will be less likely to suffer from heart failure." | The question is asking for the nurse to tell the client why she is receiving the medication. Option 3 is the only answer that would directly answer the client s question. Knowledge of the classification and purpose of the medication will also assist in selecting the correct answer. |
3331 The nurse provides discharge instructions to a client Correct answer: 2 The side effects of amiodarone take several weeks or longer to manifest themselves. about the use of amiodarone (Cordarone). Which of Sometimes they persist for up to four months, and because photosensitivity is a continuing the following statements by the client indicates an concern, the client should avoid tanning. The pulse should be monitored, and if it remains understanding of discharge teaching about this above 100, the physician should be notified. If a dose is missed, the client should call the medication? physician before taking any more medication. ‐ "As soon as the physician says I can stop taking this medication, I will be able to enjoy the sun again." ‐ "The side effects of this medication may not begin to show up for several weeks or even months after I start taking it." ‐ "If my pulse drops below 100 beats per minute, I should call the physician right away." ‐ "If I miss a dose of medication, I should take it as soon as I remember it." | It is important to understand the onset and duration of the medication in order to teach the client side effects and responses to the medication. Option 2 is the only correct option, and can be selected when the duration of the medication is understood. This knowledge will allow elimination of option 1. Recall client responses relative to tachycardia with the medication. If a client misses a dose, it is important that he follow up up with his primary practitioner, and not just take a second dose, thereby eliminating option 4. |
3332 A client is taking lovastatin (Mevacor) for treatment Correct answer: 4 Mevacor belongs to a group of drugs classified as statins. They work by inhibiting cholesterol of high cholesterol levels. In conducting medication synthesis in the liver. Bile‐acid resins and fibric acid derivatives also work to decrease teaching, the nurse explains that this medication works cholesterol levels, but they work at different sites (options 1 and 3). Bile‐acid resins work in the because it: gastrointestinal tract, and bind bile salts in the intestine. Fibric acid derivatives work on lipoproteins and triglycerides to reduce cholesterol. Mevacor is not a hormone (option 2). ‐ Is a bile‐acid resin. ‐ Is a hormone. ‐ Consists of a fibric acid derivative. ‐ Inhibits cholesterol synthesis. | Knowledge of the medication will assist in answering this question, as will looking at the ending of the medication. Knowing that a statin works by inhibiting cholesterol synthesis will lead you to the correct answer. Use this knowledge to eliminate the other options. |
3333 A client diagnosed with pernicious anemia is told that Correct answer: 3 It is important for the nurse to understand that both intrinsic and extrinsic factors are vitamin B<sub>12</sub> injections are necessary for the absorption of vitamin B<sub>12</sub>. If the client lacks intrinsic required. The client doesn't like "shots," and wants to factor (has pernicious anemia), the medication must be administered via the IM or deep SC know why the medication can't be taken orally. How route. The PO route of administration will not solve the problem if intrinsic factor is absent would the nurse respond? (option 1). Lifelong administration of vitamin B<sub>12</sub> is required for clients with this type of therapy (option 2). Injection therapy starts out on a more frequent dosing schedule. Therefore, it is incorrect to tell the client that injections will be given only once a month (option 4). In addition, this response minimizes the client's concerns, and is therefore not therapeutic. ‐ Initially, the medication must be given by injection, but it then can be switched over to the oral route once serum levels are maintained. ‐ The medication is only available as an injection, but the length of therapy is only a few months in duration. ‐ The medication cannot be given orally because this type of anemia causes a lack of intrinsic factor that is necessary for the absorption of vitamin B12. ‐ The medication can be given once a month by injection, and therefore shouldn't be too uncomfortable. | Knowledge of medication administration facts will lead to the correct answer. Since taking the medication is a lifelong process, option 2 can be eliminated. Option 4 can be eliminated, as it does not answer the client s question. Option 1 is incorrect, which will lead to the only correct answer, option 3, which does address the client s question. |
3334 A client is receiving intravenous (IV) thrombolytic Correct answer: 2 When administering IV thrombolytic medication, the IV site should be changed to the therapy, and complains of pain and redness at the opposite extremity if the client complains of pain or redness at the infusion site. These insertion site. Which nursing actions are most symptoms can indicate thrombophlebitis, and should be taken seriously and acted on appropriate? immediately. Continuing to monitor the IV site without appropriate intervention is not considered safe practice (options 1 and 4). Decreasing the rate of solution might be an option based on documented protocol, but the fact that the client complains of pain and redness takes immediate priority (option 3). ‐ Continue to monitor the IV site q 15 minutes, and check for infiltration or phlebitis. ‐ Restart infusion in the opposite extremity. Further dilute medication per protocol to prevent thrombophlebitis. ‐ Decrease the rate of infusion, monitor IV site q 15 minutes, and continue to assess the client for complaints of pain. ‐ Reposition the client's extremity, and continue to monitor the IV site. | Options 1, 3, and 4 do not address the safety issue to which the question refers. The only safe option is to restart the medication, since the IV site is red, which can indicate thrombophlebitis. Reassessing and repositioning the site will not safely care for the pain the client is experiencing. |
3335 The nurse would monitor the results of which of the Correct answer: 1 The reticulocyte count is an indication of the number of immature RBCs found circulating in following laboratory tests to determine whether a the body. An increased reticulocyte count indicates that the bone marrow is functioning, and client is responding to ferrous sulfate therapy? that RBC production has been stimulated. INR, PT, and APTT (options 2, 3, and 4) all refer to coagulation studies that are useful in managing anticoagulation therapy or clients who have coagulation disorders. ‐ Reticulocyte count ‐ International normalized ratio (INR) ‐ Prothrombin time (PT) ‐ Activated partial thromboplastin time (APTT) | Having knowledge of the purpose of the lab studies will assist in selecting the correct answer. If this was difficult, review the purposes of the listed lab studies. |
3336 A client is taking folic acid (Folvite) for treatment of Correct answer: 4 Oral contraceptives taken concurrently with folic acid will diminish the effectiveness of the folic acid anemia. Which one of the following would folic acid. The nurse should be alert to potential drug interactions, educate the client, and the nurse recognize as causing a potential drug notify the physician of potential interactions. Vitamin E, tetracycline, and allopurinol (options interaction for this type of therapy? 1, 2, and 3) all affect the administration of iron. ‐ Vitamin E ‐ Tetracycline ‐ Allopurinol ‐ Oral contraceptives | Knowledge of the contraindications of folic acid with other medications will assist in selecting the correct answer. If this was difficult, review the contraindications of other medications with folic acid. |
3337 A client being treated with heparin therapy is deemed Correct answer: 3 Because heparin is metabolized quickly in the body, it is important to know both the amount to have an overdose. The nurse takes which of the of drug that was given and the elapsed time frame. The dose of protamine sulfate will be following priority actions? calculated based on individual need. While it is true that the maximum dose of protamine is 50 mg over a 10‐minute period, that might not be the dosage required, since the pertinent information relative to heparin is not stated (option 1). APTT levels would be monitored, but are not the priority action at this time (option 2). Vitamin K should not be given with protamine sulfate, as it is the antagonist to Coumadin (option 4). ‐ Administer 50 mg of protamine sulfate over a 10‐minute period. ‐ Monitor the client's APTT levels prior to and following administration of protamine. ‐ Determine the amount of heparin that was given and the time frame that has elapsed since its administration. ‐ Administer protamine sulfate concurrently with vitamin K to increase its therapeutic effect. | The question is a safe, effective care, and the nursing process must be used in answering this question. Since the first step in the nursing process is assessment, select the option that is an assessment answer. Recognize that options 1, 2, and 4 are all interventions, and could be considered after the initial assessment. |
3338 A surgical client has suddenly begun to bleed Correct answer: 2 Hemostatics such as aminocaproic acid are used to control excessive bleeding. They can be excessively while in the operating room. The nurse applied topically to stop a local hemorrhage, or they can be administered parenterally to stop anticipates that an order will be given for which of the a systemic hemorrhage. Thrombolytics are used to dissolve existing clots (option 1). following medications? Antiplatelet agents are used to prevent platelet aggregation, and anticoagulants act on the coagulation cascade to prevent clot formation (options 3 and 4). It is important for the nurse to have a basic understanding of each of the drug groupings so that appropriate therapy can be properly monitored. ‐ Alteplase (Activase) ‐ Aminocaproic acid (Amicar) ‐ Dipyridamole (Persantine) ‐ Heparin (Liquaemin) | Understanding of the classification of the listed medications is needed to answer this question. If this was difficult, review the medications, and be familiar with medication classifications. |
3339 A client who has been diagnosed with anemia reports Correct answer: 4 If the client still complains of symptoms of anemia, it is possible that treatment with folic acid that symptoms have not improved since treatment might not be the primary problem. Folic acid and vitamin B<sub>12</sub> work with folic acid was started. What additional together to aid the growth of RBCs. Obtaining and comparing APTT results will not assessments would the nurse want to make to demonstrate whether the drug treatment is effective, as this test looks at the intrinsic determine the effectiveness of drug therapy? coagulation pathway. While it is true that alcohol has a major effect on folic acid levels and intake, there are many other medications that can affect folic acid levels. This response, while of concern, does not indicate that the drug therapy is effective. A review of dietary sources might be indicated, but if the client were taking drug therapy, then the amount of folic acid in the diet would not indicate whether the drug therapy was effective. ‐ Obtain current APTT, and compare with the client's previous APTT to see if the treatment is effective. ‐ Review dietary sources of folic acid with the client to verify if the treatment is effective. ‐ Verify that the client is not taking alcohol to see if the treatment is effective. ‐ Refer the client to the physician for possible deficiencies of other B vitamins, as folic acid and B12 deficiencies often occur together. | Note that the question stem asks for further assessment. Options 1, 2, and 3 are all considered interventions, and can therefore be eliminated. The only assessment answer is option 4, which would be to refer to a physician for further assessment to determine if there are other conditions causing the problem. |
3340 A client taking long‐term warfarin (Coumadin) Correct answer: 3 It is very important for the client to be aware of foods that are high in vitamin K while on therapy following cardiac valve replacement surgery Coumadin therapy. Green, leafy vegetables are very high in vitamin K, and if the client is eating comes in to the office for a follow‐up visit. Upon a large amount of these during the week, this might affect the action of Coumadin. While milk conducting a diet survey, which one of the following is a good source of vitamin K, the amount that the client is taking is not enough to cause client's dietary patterns would be of concern to the concern with regard to Coumadin interaction (option 1). The amount of wine and wax beans is nurse? not clinically significant to affect Coumadin interaction (options 2 and 4). ‐ The client is drinking a glass of milk at bedtime once a week. ‐ The client is eating yellow wax beans as a vegetable twice a week. ‐ The client has a salad for lunch on weekdays. ‐ The client has a drink of wine once a week with an evening meal. | It is important to know that eating foods high in vitamin K is contraindicated with clients who are taking coumadin. Recall knowledge of foods high in vitamin K. If this was difficult, review the client teaching needs for a client taking coumadin. |
3341 A client is receiving heparin therapy, and the Correct answer: 4 The APTT level should be 1.5–2.5 times the control value to reach a therapeutic range. A activated partial thromboplastin time (APTT) is being control value is always run with the test to make sure that the results are referenced. Higher monitored. For what level does the nurse look as a APTT levels are not considered to be therapeutic, and might require that the medication be therapeutic level? stopped until APTT levels fall back into a safe and therapeutic range. ‐ APTT level of 3 times the control value ‐ APTT level consistent with the control value ‐ APTT level of 3.5 times the control value ‐ APTT level of 1.5–2.5 times the control value | Knowledge of the normal lab results will assist in selecting the correct answer. If this was difficult, review normal lab results of the APTT test. |
3342 The nurse is caring for a client with chronic angina Correct answer: 4 Sotalol is a beta‐adrenergic blocking agent. Side effects include bradycardia, difficulty pectoris. The client is receiving sotalol (Betapace) 80 breathing, wheezing, bronchospasm, GI disturbances, anxiety, nervousness, weakness, mood mg PO daily. Which client manifestation would the changes, depression, and loss of libido. The symptoms listed in options 1, 2, and 3 do not nurse conclude is a side effect of this medication? occur. ‐ Difficulty swallowing ‐ Diaphoresis ‐ Dry mouth ‐ Bradycardia | Note that the question stem asks for selection of a side effect of the medication. While all of the listed options would be considered side effects, the only side effect listed for this medication is option 4. If this was difficult, review the side effects of the medication. |
3343 The nurse is caring for a client with a history of mild Correct answer: 3 Calcium channel blocker agents such as diltiazem (Cardizem) are used cautiously in clients congestive heart failure (CHF) who is receiving with aortic stenosis, bradycardia, CHF, acute myocardial infarction, and hypotension. The nurse diltiazem (Cardizem) for hypertension. The nurse would assess for signs that indicate worsening of these underlying conditions. Bradycardia and would assess the client for which of the following? peripheral edema signal adverse effects of this class of medication, and require follow‐up if they occur. ‐ Tachycardia and rebound hypertension ‐ Wheezing and shortness of breath ‐ Bradycardia and peripheral edema ‐ Chest pain and tachycardia | Knowing that the medication is a calcium channel blocker should assist in selecting the correct answer. Knowing that the client is being treated for CHF also should also assist in selecting the answer. Realize that tachycardia is not a side effect to assist in eliminating options 1 and 4. Two of the side effects of the medication are edema and bradycardia. |
3344 The nurse has just administered a dose of hydralazine Correct answer: 3 Hydralazine (Apresoline) is a powerful vasodilator that exerts its action on the smooth muscle (Apresoline) intravenously to a client. After the initial walls of arterioles. After a parenteral dose, blood pressure is checked every 15 minutes until dose, which of the following measurements is the stable, and then every hour. Although options 1, 2, and 4 are components of assessment, they priority assessment? are not directly related to the action of the medication. ‐ Cardiac rhythm ‐ Oxygen saturation ‐ Blood pressure ‐ Respiratory rate | Knowing the classification of the medication as a drug to reduce blood pressure will assist in selecting the correct answer. Since the medication has an effect on the blood pressure, the correct answer is option 3. |
3345 The nurse has begun a continuous infusion of Correct answer: 4 Nitroglycerin is an antianginal of the nitrate type that causes vasodilation of coronary and nitroglycerin (Nitrostat) intravenously. Which of the other arteries. It would be expected to cause a decrease in PCWP and CVP. The heart rate following indicates to the nurse that the client is could also decrease with overall improvement in cardiac output. A decrease in BP from 130/80 experiencing an adverse reaction? to 90/64 is excessive, and warrants further assessment by the nurse to determine whether perfusion to major organs is adequate. ‐ Pulmonary capillary wedge pressure (PCWP) falling from 13 to 11 mm Hg ‐ Central venous pressure (CVP) falling from 10 to 7 mm Hg ‐ Heart rate (HR) falling from 96 to 78 ‐ Blood pressure (BP) falling from 130/80 to 90/64 | Use the process of elimination, and realize that options 1 and 2 are expected outcomes of the medication, to assist in selecting the correct answer. A decrease in heart rate (option 3) is expected, but the drop in BP is excessive. This would lead to the correct option, 4. |
3346 The nurse is caring for a client with chronic stable Correct answer: 2 Amlodipine (Norvasc) is a calcium channel blocker. Adverse or toxic reactions from over angina receiving amlodipine (Norvasc). In developing a dosage could produce excessive peripheral vasodilation, and marked hypotension with reflex medication teaching plan, the nurse should include tachycardia. Frequent side effects include peripheral edema, headache, and flushing. Some which of the following findings as an adverse reaction sustained‐release forms of calcium channel blockers (such as Calan SR) could lead to to this medication? constipation, a milder side effect than the others. ‐ Hypertension ‐ Hypotension ‐ Constipation ‐ Diarrhea | Use the process of elimination and recall understanding of the purpose of the medication to be assisted in selecting the correct answer. Since hypotension (option 2) is a side effect of the calcium channel blocker, option 1 can be eliminated. The other options are not side effects of the medication. If this was difficult, review general characteristics of calcium channel blockers. |
3347 A female client tells the nurse, "Since I have been Correct answer: 2 Atenolol is a beta‐adrenergic blocker that causes a decreased heart rate, blood pressure, and taking that medicine, I feel so tired." She is being cardiac output. Fatigue is the most common side effect. If fatigue becomes severe enough, it treated with atenolol (Tenormin) for hypertension. The could interfere with the client's activity level. Activity intolerance is the state in which an client's statement is reflective of which nursing individual has insufficient energy to complete activities of daily living. There is no evidence that diagnosis? the client has ineffective cerebral perfusion, ineffective health maintenance, or self‐care deficit. ‐ Risk for Activity Intolerance ‐ Cardiac Output, Decreased ‐ Health Maintenance, Altered ‐ Self‐care Deficit | The question is asking for selection of a physiologic nursing diagnosis. Knowing this can eliminate options 3 and 4. Option 1 can also be eliminated, since there is nothing in the question referring to a risk for insufficient energy to carry out activities, which is the definition of activity intolerance. The only correct option is 2. |
3348 The nurse is scheduled to administer a dose of digoxin Correct answer: 4 The normal reference range for potassium for an adult is 3.5–5.1 mEq/L. Hypokalemia can (Lanoxin) to an adult client with atrial fibrillation. The make the client more susceptible to digitalis toxicity. The nurse monitors the results of client has a potassium level of 4.6 mEq/L. The nurse electrolytes for the potassium level. If the potassium level is low, the dose is withheld, and the interprets that the: physician is notified. This client's result is in the normal range, so the dose should be administered. ‐ Dose should be omitted only for that day. ‐ Client needs a dose of potassium before receiving the digoxin. ‐ Dose should be withheld, and the physician notified. ‐ Dose should be administered as ordered. | Knowing the therapeutic level for digoxin will lead to the correct answer. Use this knowledge and the process of elimination to lead you to the only correct answer, 4. |
3349 The nurse is planning to care for a client with Correct answer: 3 Lasix depletes potassium stores, and a client taking digoxin and furosemide needs to maintain congestive heart failure being treated with digoxin normal potassium levels and moderate salt intake. Hypokalemia makes the client more (Lanoxin) and furosemide (Lasix). Which is the susceptible to digitalis toxicity. Option 3 is the best choice because all three foods are high in following dinners would be the best choice from the potassium and low in sodium. daily menu? ‐ Beef vegetable soup, macaroni and cheese, and a dinner roll ‐ Beef ravioli, spinach soufflé, and Italian bread ‐ Baked whitefish, mashed potatoes, and carrot‐raisin salad ‐ Roasted chicken breast, brown rice, and stewed tomatoes | Recall knowledge that potassium is depleted with clients who are taking Lasix to assist in selecting the correct option. Option 3 food choices are the highest in potassium, and are therefore the best option. If this was difficult, review foods high in potassium. |
3350 The physician has prescribed propranolol (Inderal) for Correct answer: 2 The medication has side effects that could be disturbing to the client. These include a client with frequent premature ventricular hypotension, insomnia, lethargy, bronchospasm, mood changes, and decreased libido. The contractions (PVCs). The nurse collects material to client should be alert to these so that he can notify the physician or another health care conduct an education session with the client. Which of provider. It is not the nurse's role to describe alternatives to the currently ordered medication the following should the nurse plan to include in the (option 1). It is unnecessary to teach about effects at the cellular level (option 3) unless the teaching session? client has interest in this. It is also unnecessary to teach the client about various dysrhythmias (option 4), because this is not pertinent. ‐ A description of other effective medications ‐ Information about side effects and adverse reactions ‐ Material about the cellular effect of the medication ‐ Data regarding various dysrhythmias | When a nurse is teaching a client about side effects of medications, it is important that the teaching is at a level that the client will understand. The most important part of the teaching process with medications is to make sure the client understands the side effects and adverse reactions of the medication. |
3351 Chemical cardioversion is prescribed for a client in Correct answer: 1 Quinidine (Quinidex) is a Class I‐A antiarrhythmic that is very effective as a chemical atrial fibrillation. The nurse prepares which of the cardioversion agent. Verapamil is a calcium channel blocker generally used to control heart following medications specifically for chemical rate. Nifedipine is a calcium channel blocker used as a vasodilator. Bretylium is generally used cardioversion? for control of ventricular arrhythmias. ‐ Quinidine (Quinidex) ‐ Verapamil (Calan) ‐ Nifedipine (Procardia) ‐ Bretylium (Bretylol) | Use the process of elimination to select the correct answer. Options 2, 3, and 4 can all be eliminated, as they are not medications used in chemical cardioversion. The medication used in chemical cardioversion is an antiarrhythmic, and this will lead to option 1. |
3352 A client taking cholestyramine (Questran) to lower Correct answer: 3 Clients who are taking cholestyramine (which is a bile resin) should be monitored for fat‐ lipid levels should be monitored for possible deficiency soluble vitamin deficiencies (vitamins A, D, E, and K), as the gastrointestinal side effects of the of which vitamin(s)? medication can lead to reduced absorption. Niacin, folic acid, and vitamin B<sub>12</sub> (options 1, 2, and 4) are all examples of B complex vitamins that are water‐soluble. ‐ Niacin ‐ Folic acid ‐ Vitamins A and D ‐ Vitamin B12 | Using the process of elimination and knowledge that a deficiency of fat‐soluble vitamins occurs with medications that lower lipid levels to select the correct answer. Options 1, 2, and 4 are all water‐soluble, and can therefore be eliminated. |
3353 A client who is taking warfarin (Coumadin) therapy Correct answer: 3 Clients who are taking Coumadin should be alerted to the potential for drug interactions comes to the office for a follow‐up visit, and states when they are on long‐term anticoagulation therapy. Aspirin can potentiate the effect of that he has taken propoxyphene with aspirin (Darvon Coumadin, and interfere with the ability to maintain a therapeutic level. The use of Darvon, Compound 65) for aches and pains related to an old although previously prescribed, is not in the best interest of the client at this time due to back injury. How should the ambulatory care nurse Coumadin therapy. Telling the client to keep taking Darvon would lead to drug interactions respond to this information? (option 2). While a further assessment of the client's back pain might be necessary (option 1), it is not the primary action that the nurse should be addressing at this time. Option 4 is a false statement, because the two drugs together could enhance bleeding. ‐ Ask the client how long his back been hurting him, and assess the need for a referral for pain management. ‐ Tell the client that it is important to prevent the pain cycle from starting, and that the client can continue to take Darvon as ordered by the physician. ‐ Advise the client that Darvon contains aspirin, which can interfere with Coumadin therapy. Consult the physician for an alternate form of pain‐relief therapy. ‐ Instruct the client that continued use of Darvon on a daily basis would help to relieve back pain, but would require an increase in the dose of Coumadin. | Part of the nursing assessment is determining what medication the client is current taking. Once determined that the client is taking Coumadin and Darvon together, the nurse should be alerted to the fact that the client needs further teaching regarding the risk of decreasing the effectiveness of coumadin when taking aspirin. The best answer is option 3, since once the nurse assesses for medication usage, he can continue with the nursing process and develop a plan of care. |
3354 A postoperative client who has an order for 5,000 Correct answer: 4 Low‐dose heparin therapy is indicated in many postoperative clients to prevent the units of heparin SC for three doses wants to know why development of thromboembolic episodes. It is not used in every postoperative situation this drug is being ordered. What information would (option 1), but it is usually used for clients who have orthopedic surgery, or are anticipated to the nurse provide to the client to answer the question? be immobilized for a time following surgery. Short‐term therapy is not given to maintain adequate blood clotting levels (option 2), but merely to intervene as a preventative measure. The statement that heparin is given SC into the abdomen and is not usually painful is factual, but is not the reason the medication is given to the client (option 3). ‐ Heparin is used as a common medication in all postoperative situations. ‐ It is essential to have heparin during the postoperative period in order to maintain adequate blood clotting levels. ‐ The injections will be given in the abdomen, and are not usually associated with discomfort. ‐ Heparin is being used postoperatively to prevent blood clots from forming as a result of surgery or decreased mobility. | Using the process of elimination will lead to the correct answer. Option 1 should be eliminated because of the word “all.” This is a false statement. Option 2 should also be eliminated because of the word “essential,” which is also a false statement. Option 3 should be eliminated because it does not address what the client is asking. |
3355 A client who is receiving heparin protocol has an Correct answer: 3 The effectiveness of a heparin protocol is monitored by trending APTT results to achieve a activated partial thromboplastin time (APTT) level of therapeutic level. An APTT of 140 is above the therapeutic level of anticoagulation, and 140 seconds (control time is 36 seconds). What is the therefore the infusion should be stopped per protocol, and resumed at a decreased dose in 1 priority action that the nurse should institute? hour's time, with a repeat APTT ordered in 2‐3 hours per protocol. The dose should not be increased, as this would cause serious consequences to the client. Stopping the medication for a total 6 hours would undermine the anticoagulation control that the physician is trying to achieve. Ordering another APTT and continuing to run the infusion could also cause serious consequences to the client. ‐ Increase the heparin dose, as the APTT level is not therapeutic. Obtain a repeat APTT in 6 hours. ‐ Stop the heparin therapy for 6 hours. Then restart the therapy at the same unit dose, and obtain a repeat APTT in 6 hours. ‐ Stop the heparin therapy for 1 hour. Decrease the rate of infusion per protocol, and restart the medication in one hour. Obtain a repeat APTT 2–3 hours from the restart of the infusion. ‐ Obtain an additional APTT in 1 hour, and continue to monitor the client. | Having knowledge of the normal lab results will assist in selecting the correct answer. If this was difficult, review normal lab results of the APTT test. |
3356 A client receiving warfarin (Coumadin) therapy has a Correct answer: 2 With an INR level that high, and no incidence of bleeding, administration of vitamin K and very high INR (above 6), and shows no signs of withholding of Coumadin doses are usually indicated. Protamine sulfate is the antagonist to bleeding. What actions would the nurse employ to heparin administration, and is not indicated in this situation. Merely withholding the Coumadin protect the client from having a bleeding episode? dose is not appropriate, since the INR level is too high. The amount of vitamin K in the diet is not an immediate concern at this point, as the INR level is too high. ‐ Give the client protamine sulfate as ordered to normalize INR levels. ‐ Give the client vitamin K as ordered to normalize INR levels, and withhold the next Coumadin dose. ‐ Hold the next two Coumadin doses, and obtain an INR level the next day. ‐ Increase the amount of vitamin K in the diet, and continue to assess the client for potential bleeding. | Having knowledge of the normal lab results will assist in selecting the correct answer. If this was difficult, review normal lab results of the INR test. |
3357 A client has been diagnosed with folic acid anemia. Correct answer: 2 Folic acid helps to reduce hemocysteine levels, and is therefore important for cardiovascular Which of the following additional assessments should health. Decreased levels of folic acid and other B vitamins (B<sub>12</sub> and the nurse make after learning of this diagnosis? B<sub>6</sub>) can lead to increased levels of homocysteine, which are associated with increased risk of cardiovascular disease (option 1). Method of cooking/preparation can affect the bioavailability of vitamins, but is not usually the main cause of folic acid anemia (option 3). Folic acid anemia is not related to the development of diabetes (option 4). ‐ Other B‐vitamin deficiencies, and therefore increased homocysteine levels that are cardioprotective ‐ Cardiovascular health, because folic acid helps to decrease homocysteine levels ‐ Adequacy of folic acid sources in the diet, and method of cooking/preparation, as this might have caused the clinical deficiency ‐ The concurrent diagnosis of diabetes mellitus | Knowledge of the aspects of folic acid deficiency will assist with selecting the correct answer. If this was difficult, review the effects of folic acid deficiency on the cardiovascular system. |
3358 A client has been prescribed lovastatin (Mevacor) to Correct answer: 4 Often, clients who have multiple risk factors for developing hyperlipidemia must use a treat hyperlipidemia, since diet therapy and weight combination therapy of drugs and diet to achieve results. Diet management, weight control, reduction have not been successful in lowering and the use of drug therapy work together in supporting and maintaining lipid levels. There is cholesterol levels. The client does not understand why also a genetic component to hyperlipidemia that needs to be addressed by the client. Clients medication is necessary, because the client has only who are compliant with diet therapy often have to use drug therapy because of this genetic been watching what he eats for three months. How predisposition to produce more cholesterol. Drug therapy will not by itself eliminate the need would the nurse respond to questions about the use of for watching fat intake. Effective drug therapy is not only seen with documented weight loss. drug therapy as it relates to dietary management? The chemical actions of the drug depend on compliance to the medication schedule. Lovastatin (Mevacor) does not reduce triglyceride levels. Different antilipidemia agents work on various lipoproteins and triglycerides. ‐ Drug therapy should eliminate the need for watching the diet, and therefore the addition of the medication would be beneficial. ‐ Drug therapy is only effective when there is documented weight loss. ‐ Drug therapy will reduce both cholesterol and triglyceride levels, if taken properly. ‐ Combination therapy (drugs and diet) often helps clients meet their treatment goals to reduce cholesterol levels. | Understanding the treatment protocol in reducing cholesterol levels will lead to the correct answer. Option 1, 2 and 3 can be eliminated because they are false statements. The only option that is addressing the client’s question is option 4. |
3359 The nurse should review the results of which of the Correct answer: 2 When using a lipid‐lowering agent, the standard of care is that liver enzymes be routinely following to evaluate a client's response to a lipid‐ evaluated both before and during the course of therapy. These medications can cause lowering agent? abnormal results in liver function tests that can lead to serious consequences if the client is not properly monitored. CBC, clotting studies, and Doppler studies are not indicated for the management of this drug therapy. ‐ CBC with differential ‐ Liver function tests ‐ Clotting studies ‐ Doppler studies | Knowing the purpose of the laboratory tests will lead to the correct answer. Lipid‐lowering agents can have an effect on liver function tests, which would lead you to option 2. |
3360 A client is admitted for deep vein thrombosis (DVT) of Correct answer: 3 Heparin is the drug of choice for clients who have presenting symptoms of DVT, due to its the lower left extremity. Which one of the following rapid onset of action. Lovenox is an example of a low‐molecular‐weight heparin (LMWH), low‐ medications should the nurse expect to be used to dose therapy that is used as a prophylactic measure to prevent thromboembolism (option 2). treat this condition? Coumadin is an oral anticoagulant that has a slower onset of action, and is therefore not appropriate as first‐line therapy for a client with a DVT (option 1). Persantine is an antiplatelet medication that works on decreasing platelet aggregation. It works to prevent arterial thrombosis (option 4). ‐ Warfarin (Coumadin) ‐ Enoxaparin (Lovenox) ‐ Heparin (Liquaemin) ‐ Dipyridamole (Persantine) | Note that the client is being seen for the first time for a DVT. This should lead to selection of the first medication of choice in resolving a DVT, option 3: heparin. The other options are not used as the initial medication, and should be eliminated. |
3361 Which of the following statements indicates to the Correct answer: 3 With initial therapy, it is recommended that iron preparations be taken with meals to prevent nurse that a client understands the administration of GI upset. As therapy is tolerated, the medication can be given between meals to maximize iron therapy? absorption. Antacids and antibiotics when taken together, with iron, decrease its absorption (options 1 and 4). Oral iron salts differ in their amount of elemental iron; therefore, iron preparations should not be used interchangeably (option 2). ‐ "I will take an antacid when I take my iron pill, to decrease the GI effects of the drug." ‐ "It makes no difference which iron pill I take because all iron is alike." ‐ "I will take my iron medication initially with meals, to prevent GI upset." ‐ "I will take my iron medication when I take my antibiotic." | The question is asking for selection of the answer that indicates the client understands how to take the medication initially. In reviewing the choices, the one answer that addresses initial medication consumption is option 3. |
3362 In assessing a hospitalized client 1 hour after Correct answer: 2 Apresoline is a vasodilator, and if the client becomes dehydrated, hypotension will result. In receiving hydralazine (Apresoline) 20 mg PO, the nurse other words, during dehydration, both preload and afterload are reduced, causing the "tank" notes that the BP is 68/42. The client has been taking to get larger with less volume. The normal dose of hydralazine is 5–25 mg PO. Serum this medication for several years at home without potassium is high, but unrelated to Apresoline. The increased heart rate is a reflexive response difficulty. Which of the following factors most likely to the low cardiac output, to compensate with decreased preload and afterload. contributed to this episode of hypotension? ‐ The dose is excessive for this medication. ‐ Total intake for the previous 24 hours is 1,000 mL. ‐ Serum potassium is 5.8 mEq/L. ‐ Heart rate is 145 beats per minute. | Knowledge of side effects and nursing interventions when taking Apresoline will lead to the correct answer. Option 2 is a client response that relates to the side effects. If this was difficult, review the medication Apresoline, the side effects of the medication, and client responses related to interventions. |
3363 The client is receiving a loading dose of lidocaine Correct answer: 1 Lidocaine is given via IV push in doses of 1–1.5 mg/kg. The initial loading dose (bolus) is (Xylocaine) 100 mg IV for treatment of ventricular intended to achieve adequate blood levels to suppress ventricular dysrhythmias, and is tachycardia. The nurse prepares to take which action followed by an infusion of 1–4 mg/min via infusion pump. The initial bolus lasts approximately next? 10 minutes, so the infusion must not be delayed. The dose may be repeated one time under certain conditions, but the total dose should not exceed 3mg/kg. Oral therapy and pacemaker insertion are not indicated at this time. ‐ Start a continuous IV infusion at 1–4 mg/minute. ‐ Repeat the dose every 10 minutes for one hour or PRN. ‐ Begin oral procainamide (Pronestyl) therapy. ‐ Prepare for pacemaker insertion to override the dysrhythmia. | Note that the question stem is asking for selection of the next nursing intervention after the initial bolus. The next intervention is to begin an IV drip, so the correct option is 1. If this was difficult, review the nursing interventions for the medication. |
3364 A client has been admitted to the hospital with chest Correct answer: 3 The standard protocol is to administer up to three doses of NTG five minutes apart as long as pain. The client's symptom has not been relieved after the vital signs remain stable. After three doses, the physician should be called if pain is one dose of nitroglycerine (NTG) sublingually. Upon unrelieved. An electrocardiogram (ECG) may be ordered, but not an EEG (to measure brain monitoring the vital signs (VS), the nurse notices that waves). Using NTG paste, a longer‐acting form of the medication, is not appropriate at this they are stable. Which of the following indicates the time. appropriate action for nurse to take next? ‐ Notify the physician. ‐ Obtain an electroencephalogram (EEG). ‐ Give another dose of nitroglycerine. ‐ Add a dose of nitroglycerine paste. | Note that the question asks for selection of the next action. Knowing that the dose of NTG can be repeated will lead to the correct option, 3, as this is the appropriate action. |
3365 After three defibrillation attempts, the client Correct answer: 3 Lidocaine is the primary medication used to treat ventricular dysrhythmias. Lidocaine continues to be in a pulseless ventricular tachycardia. suppresses automaticity in the HIS‐Purkinje system by elevating electrical stimulation A lidocaine bolus of 100 mg IV is administered. The threshold of the ventricle during diastole, thus decreasing ventricular irritability. Ventricular nurse would expect to see which of the following as a fibrillation (option 1) is a worsening dysrhythmia. Slowing the heart rate (option 2) without therapeutic response to lidocaine? converting the rhythm to an atrial or sinus rhythm is not therapeutic. An increase in level of consciousness (option 4) would only occur once the ventricular rhythm is terminated. ‐ Conversion from a ventricular tachycardia to a ventricular fibrillation ‐ Slowing of heart rate to 80 beats per minute ‐ A reduction in ventricular irritability ‐ An increase in the level of consciousness | Knowledge of the purpose of lidocaine will assist in selecting the correct answer. Pay particular attention to the question that is being asked. Option 3 is the only correct response to the administration of lidocaine during ventricular tachycardia. |
3366 A client is being discharged after treatment for left‐ Correct answer: 1 The client's diet should be high in potassium to avoid hypokalemia. Hydrochlorothiazide is a sided heart failure. The nurse is teaching the client potassium‐depleting diuretic. If the client develops hypokalemia, she would be at a greater risk about the purpose, adverse effects, and dose of for developing digitalis toxicity. The client should measure the pulse before taking the cardiac digoxin (Lanoxin) and hydrochlorothiazide glycoside (digoxin). For the best therapeutic effect, the medications should be taken at the (HydroDIURIL). Which statement by the client indicates same time each day, preferably in the morning (so client will not have nocturia from the to the nurse that further discharge teaching is needed? diuretic). A combined therapeutic effect increases the urinary output via the positive inotropic effect of digoxin and the diuretic effect of hydrochlorothiazide. ‐ "I should decrease my intake of foods high in potassium, such as bananas." ‐ "I should take my radial pulse before taking this medication." ‐ "This medication can cause an increase in my urinary output." ‐ "This medication should be taken in the morning rather that in the evening." | The question is asking for selection of a statement by the client that indicates that she does not understand interventions taught during a teaching session. Since one of the side effects of the medication is hypokalemia, the goal with the medications would be to prevent this. Clients are encouraged to eat foods high in potassium, leading to option 1 as the answer that would indicate more teaching is required. If this was difficult, review the medication and teaching needs for clients. |
3367 A client is being discharged after recovery from an Correct answer: 1 Because of the vasodilating effects of nitrates, headache is a common side effect. Medical acute anterior myocardial infarction (MI) with attention is not necessary unless the headaches increase in frequency or severity. All three recurrent angina. The nurse is teaching the client the medications are nitrates, and will increase coronary artery blood flow by dilating the coronary following medications: diltiazem (Cardizem SR) 90 mg arteries and collateral blood vessels, which results in increasing blood flow to the heart. The PO twice daily; isosorbide dinitate (Isordil) 10 mg PO medications are used to prevent the frequency, intensity, and duration of anginal attacks. All three times daily; and nitroglycerine (Nitrostat) 0.4 mg should be stored in a cool, dry place. sublingually as needed. Which statement by the client would indicate that further discharge teaching is needed? ‐ "I should notify my health care provider if I experience headaches with any of these medications." ‐ "All three of these medications will increase blood flow to my heart." ‐ "All three of these medications will help to decrease the intensity of my chest pain.'" ‐ "I will store these medications in a cool, dry place." | The question is asking for selection of the option indicating that the client needs further teaching. Knowing the classification of all the medications will allow elimination of options 2 and 3, as these are accurate. Option 4 is correct information as stated by the client. Headaches are common, but do not require the client to contact the physician. Since this statement indicates the client is unclear when to call the physician, further clarification would be required. If this was difficult, review the medications. |
3368 Adenosine (Adenocard) is to be administered to a Correct answer: 3 Adenosine (Adenocard) is an antidysrhythmic used in the treatment of paroxysmal client in the Emergency Department. Before the supraventricular tachycardia (SVT). Cardiac performance must be assessed before and preparation of the medication, the nurse's priority throughout treatment by cardiac monitoring. An endotracheal tube may be used if an should be to ensure that which of the following emergency arises necessitating mechanical ventilation, but the tube itself is a rather isolated equipment is operational? item. An IV pump might be needed, but is not a priority because this medication is administered rapidly by IV push. A pulse oximetry machine might be helpful in assessing oxygenation, but is not a priority item. ‐ A pulse oximetry machine ‐ An IV infusion pump ‐ A cardiac monitor ‐ An endotracheal tube | Having knowledge of the purpose of the medication will aid in selecting the correct answer. The question is asking for selection of priority equipment. Since the medication is used for SVT, the correct priority choice should relate to cardiac, which will lead you to option 3. |
3369 The nurse is conducting teaching with a client who Correct answer: 4 Prinzmetal's angina results from spasm of the coronary vessels. Calcium channel blockers are recently was diagnosed with Prinzmetal's (variant) the medication prescribed for this condition. The risk factors are unknown, and Prinzmetal's angina. The nurse would evaluate the session as being angina is relatively unresponsive to nitrates. Beta blockers can worsen the spasm. Diet therapy successful if the client stated that this form of angina: is not indicated. ‐ Has the same risk factors as stable and unstable angina. ‐ Responds readily to a low‐sodium diet. ‐ Is most effectively managed by beta blocker medications. ‐ Is treated with calcium channel blocking medications. | Knowing the pathophysiology and treatment protocol of variant angina will lead to the correct answer. The only correct answer is option 4. If this was difficult, review the pathophysiology and usual treatment protocol for the medication. |
3370 The community health nurse visits a client at home. Correct answer: 1 Amiodarone (Cordarone) is a class III antiarrhythmic medication, and will probably not Amiodarone (Cordarone) has been prescribed for the demonstrate therapeutic effects for 1–3 weeks. This medication can cause fatigue, cough, and client. The nurse teaches the client about the pleuritic pain. The client must wear dark glasses and avoid exposure to the sunlight. The medication. Which of the following statements by the medication is given with food to avoid gastroenteritis distress. client indicates that further teaching is necessary? ‐ "I will notify my doctor if I don't feel better in a couple of days." ‐ "I'll report any tiredness, coughing, or chest pain to my doctor." ‐ "I'll be careful to use dark glasses, and to avoid skin exposure to the sun." ‐ "I'll take this medication with food." | In order to select the correct answer, recall knowledge of the client responses to the medication. It is also important to note in the question the need to pick the answer in which the client needs further teaching. If this was difficult, review the medication and the therapeutic effects of the medication. |
3371 The client is in ventricular tachycardia. The nurse is to Correct answer: 2 D<sub>5</sub>W is compatible with lidocaine, and should remain available to give an IV bolus of lidocaine (Xylocaine) immediately. flush the medication into the client as soon as the IV push bolus is completed. The nurse might Currently, an IV solution of 5% dextrose not have enough time to start another IV line. In addition, this is an emergency situation, and (D<sub>5</sub>W) is infusing. What is the another IV site is not necessary for the IV lidocaine. most appropriate action to take during administering of the lidocaine? ‐ Stop the IV, flush the IV line, and then give the lidocaine IV push. ‐ Pinch the IV tubing above the injection port, and give the lidocaine directly into the IV line. ‐ Start another IV site. ‐ Check for incompatibility of lidocaine with other IV medications. | The question is asking for selection of an action in administering the medication. The correct option is number 2, as this answer addresses the direct administration of the medication. |
3372 A client is beginning medication therapy with Correct answer: 1 A client taking a diuretic such as furosemide should self‐administer the medication in the furosemide (Lasix) once daily. The nurse should morning to allow for diuresis throughout the day. This will help to prevent nocturia, which instruct the client to take the medication at which of could cause disruption to the client's nightly sleep pattern. The time frame in option 2 is not as the following optimal times? early as in option 1, while options 3 and 4 clearly increase the risk of nocturia. ‐ 8:00 A.M. ‐ 12 noon ‐ 6:00 P.M. | By understanding that Lasix is a diuretic, and that diuresis will occur, the earlier time is the best option. The goal with Lasix is to prevent nocturia. By selecting an early time option, this can be prevented. |
4.‐ At bedtime | |
3373 The nurse is assessing the blood pressure (BP) of a Correct answer: 2 The National Institutes of Health (NIH) Committee has defined hypertension as a systolic client diagnosed with primary hypertension. The nurse pressure of 140 or higher and diastolic of 90 or higher when two or more blood pressure explains to the client that the basis for the diagnosis of measurements are averaged on 2 or more subsequent visits. Options 1, 3, and 4 are incorrect. hypertension should be established by: ‐ Five readings one month apart. ‐ At least three readings with average blood pressure of 140/90. ‐ One reading of blood pressure greater than 140/90. ‐ Three blood pressure readings taken on the same day in different positions. | The process of elimination and knowledge of the NIH guidelines will enable selection of the correct answer. Option 2 is the only correct option that correlates with the guidelines. |
3374 The physician prescribes losartan (Cozaar) for a client Correct answer: 4 Losartan is an angiotensin II antagonist that inhibits the conversion of angiotensin I to with hypertension. The nurse carrying out the order angiotensin II, resulting in vasodilation and normalizing blood pressure. The client should be teaches the client that this medication promotes assessed for dizziness, cough, and diarrhea while taking this medication. vasodilation by: ‐ Inhibiting calcium influx. ‐ Promoting catecholamines. ‐ Promoting release of aldosterone. ‐ Inhibiting conversion of angiotensin I to angiotensin II. | Understanding of the purpose of the medication will enable selection the correct answer. If this was difficult, review the classification of the medication. |
3375 After beginning an antihypertensive medication, the Correct answer: 2 Dry, persistent, tickling, nonproductive cough is a common side effect of angiotensin‐ client returns for a follow‐up visit and complains of a converting enzyme (ACE) inhibitors. dry, nonproductive cough. The nurse knows that this side effect is mostly caused by which type of antihypertensive medication? ‐ Beta blocker ‐ Angiotensin‐converting enzyme (ACE) inhibitor ‐ Calcium channel blocker ‐ Diuretic | Knowing the side effects of the medications will lead to the correct answer. If this was difficult, review side effects of the medication. |
3376 The nurse is teaching a newly diagnosed client with Correct answer: 4 Beta blockers inhibit cardiac beta 1 receptors, but also can affect beta 2 receptors in hypertension about her medications. The client has a bronchial and vascular smooth muscle, causing bronchoconstriction. Therefore, the client with history of chronic obstructive pulmonary disease COPD should avoid taking beta blockers. Options 1, 2, and 3 are incorrect. (COPD). The nurse informs the client that she should avoid which antihypertensive medication? ‐ Angiotensin‐converting enzyme (ACE) inhibitors ‐ Calcium channel blockers ‐ Diuretics ‐ Beta blockers | General knowledge of the pathophysiology of COPD and usual treatment should assist in selecting the correct option. If this was difficult, review COPD and the usual treatment regimen. |
3377 A 45‐year‐old female comes to the clinic with Correct answer: 2 Indipamide (Lozol) is a thiazide diuretic. Its hypertensive effect might be due to direct complaints of leg cramps. She has hypertension, and arteriolar vasodilation and decreased total peripheral resistance. Lozol can cause hypokalemia. has been taking indipamide (Lozol) 2.5 mg daily. Her Signs and symptoms of hypokalemia include muscle weakness and leg cramps. Electrolytes, blood pressure is 126/70 upon arrival. After particularly potassium, need to be evaluated. The other options are irrelevant. completion of assessment, the nurse plans to: ‐ Stop the indipamide (Lozol). ‐ Evaluate the electrolytes. ‐ Switch to furosemide (Lasix). | Note that the question states that the client is complaining of leg cramps. Notice that the client is taking a diuretic. After looking at these two characteristics, select option 2, as diuretics can cause a decrease in potassium, leading to leading to leg cramps. The other options do not apply, and can be eliminated. |
4.‐ Give her a nonsteroidal anti‐inflammatory drug (NSAID). | |
3378 A hypertensive male client presents to the clinic with Correct answer: 1 Thiazide diuretics decrease the effect of antigout medication by increasing hypersensitivity to complaints of a red, painful toe. In addition to treating allopurinol. Hyperuricemia is a side effect of thiazide diuretics. Option 3 is not the best answer, the client for gout, the nurse concludes that this could because while clients might experience pain and a burning sensation in the lower extremities, be due to: as well as signs of infection, with a diabetic neuropathy, there is no mention of diabetes history in the above question. ‐ A thiazide diuretic. ‐ Obesity. ‐ Diabetes. ‐ Alcohol intake. | Consider both the gout and the hypertension. If this was difficult, review the medications for contraindications. |
3379 The nurse practitioner has prescribed oxybutynin Correct answer: 4 Oxybutynin (Ditropan) is an antispasmodic medication used for urinary tract problems. It (Ditropan) for a 65‐year‐old female with urinary produces anticholinergic side effects such as dry mouth, constipation, urinary hesitancy, and frequency and urgency. The nurse teaching the client decreased gastroenteritis motility. Periodic interruptions in therapy are recommended to about the side effects of this medication should assess continued need for this medication. explain that which of the following manifestations is/are associated with this medication? ‐ Dizziness ‐ Increased bruising ‐ Diarrhea ‐ Dry mouth and increased thirst | Recall the side effects of the medication. If this was difficult, review the side effects of the medication. Understand that the medication produces anticholinergic side effects, and select option 4. |
3380 A 25‐year‐old female presents to the office with Correct answer: 2 Urinalysis and urine dipstick should be performed to assess for the presence of blood cells complaints of burning, frequency, and urgency. The and bacteria in the urine. Infection should be established before instituting pharmacologic most appropriate intervention taken by the nurse is: therapy. Clients with urinary problems should be encouraged to increase fluid intake, but it is not the most important intervention at this time. ‐ To increase fluid. ‐ Dipstick urine for leukocytes. ‐ To order phenazopyridine (Pyridium). ‐ To start antibiotic therapy. | Selection in this question needs to be based on the nursing process, of which assessment is the first step. The other three choices are interventions, and cannot be considered until the assessment is completed. |
3381 A 45‐year‐old man has been prescribed finasteride Correct answer: 2 Proscar is an androgen inhibitor used to treat benign prostatic hyperplasia (BPH). Pregnant (Proscar) for his enlarged prostate. The nurse plans to women and women of childbearing age should not be exposed to semen fluid of a male taking include which of the following points in the teaching finasteride (Proscar). Proscar is teratogenic, and can produce fetal abnormalities. Options 1, 3, session? and 4 are incorrect. ‐ Abstain from sex. ‐ Use contraceptives. ‐ Increase fluid intake. ‐ Take for only three days. | Knowing the side effects of the medication will lead to the correct answer, option 2. |
3382 A client is prescribed verapamil (Isoptin) to manage Correct answer: 2 Verapamil is a calcium channel blocker that decreases blood pressure and heart rate. Option his hypertension. The nurse should instruct the client 1 is incomplete. Calcium channel blockers have no effect on urinary output (option 3). Option 4 that verapamil will have which of the following effects is an opposite effect to this medication. on the body? ‐ Lower blood pressure ‐ Lower blood pressure and heart rate ‐ Increase urinary output ‐ Increase heart rate | Recalling the side effects of the medication will lead to the correct answer. If this was difficult, review the medication and side effects. |
3383 Phenazopyridine (Pyridium) is prescribed to a client Correct answer: 4 Phenazopyridine is a urinary analgesic with a local anesthetic effect on the urinary tract with dysuria. The client asks the nurse about the side mucosa. This medication relieves pain during urinary tract infection. It causes the urine to have effects of this medication. The nurse should inform the an orange/red color. It has no effect on volume of urine. Foul odor to the urine might be client to expect which of the following urine caused by urinary tract infection. characteristics? ‐ Decreased volume ‐ Foul in odor ‐ Increased volume ‐ Orange/red in color | Knowing the side effects of the medication will lead to the only correct answer, option 4. If this was difficult, review the side effects of the medication. |
3384 A client's blood pressure (BP) continues to drop Correct answer: 2 Dopamine acts on the alpha/beta‐adrenergic receptors, resulting in vasoconstriction, despite IV fluids. Intravenous dopamine is ordered. The increasing systemic BP, and increasing force and rate of myocardial contraction. Options 1, 3, client asks the nurse about the possible benefits of this and 4 are incorrect. medication. The nurse responds to the client based on the understanding that dopamine treats shock by: ‐ Blocking AV node conduction. ‐ Causing vasoconstriction, and increasing systemic BP. ‐ Decreasing the rate of myocardial contraction. ‐ Promoting diuresis. | Knowing the purposes of the medication will lead to the only correct answer, option 2. The other options are not purposes of the medication. If this was difficult, review the purpose of the medication. |
3385 The client being seen in an ambulatory clinic has Correct answer: 1 Emphasis should be placed on the client's adherence to the plan of treatment to avoid serious hypertension. During assessment, the client mentions consequences of noncompliance. The complications of high blood pressure include stroke, that she will stop taking her antihypertensive cardiac failure, and chronic renal failure. medications as soon as her blood pressure is under control. In developing a medication teaching plan, the nurse includes which of the following instructions? ‐ "In order to maintain control of your blood pressure, the medication must be continued indefinitely." ‐ "Only the physician can answer this question." ‐ “The medication will probably be stopped after your blood pressure is normal.” ‐ "The medication will be decreased in time." | Knowing that antihypertensives should be taken consistently will lead to the correct answer. Note that the question is asking for development of a teaching plan, and only option 1 incorporates teaching. |
3386 The home health nurse instructs the client about use Correct answer: 3 Some clients will experience an increased blood pressure with OTC cold preparations such as of an antihypertensive medication. The client plans to pseudoephedrine, due to vasoconstriction. Therefore, they should avoid taking these take an over‐the‐counter (OTC) medication for his medications with an antihypertensive. Options 1, 2, and 4 are incorrect. cold. The nurse should instruct the client to avoid which of the following OTC products while taking an antihypertensive? ‐ Acetaminophen ‐ Aspirin ‐ Pseudoephedrine ‐ Steroid cream | Knowing the classification of an antihypertensive and the effects of the options will lead to the correct answer. If this was difficult, review the general considerations of an antihypertensive medication. |
3387 A client with congestive heart failure is taking digoxin Correct answer: 4 Risk of hypokalemia is worsened by the concurrent use of a potassium‐wasting diuretic (Lasix) (Lanoxin) and furosemide (Lasix). A new diagnosis of and a beta‐agonist (albuterol) medication. Furthermore, the risk of cardiac glycoside toxicity is acute bronchitis is made, and albuterol (Proventil) via worse in the presence of hypokalemia. Hyperkalemia (option 1), hypernatremia (option 2), and inhalation is started. The nurse concludes that this hypocalcemia (option 3) are not concerns with this drug regimen. client is at risk for which of the following complications? ‐ Hyperkalemia ‐ Hypernatremia | The core issue of this question is the effects of taking a potassium‐losing diuretic with other cardiac or respiratory medications, which helps you to focus on hypokalemia. Note also that options 1 and 4 are opposite, so there is a greater chance that one of these is the correct answer. |
‐ Hypocalcemia ‐ Hypokalemia | |
3388 A client with asthma has started to take a beta‐ Correct answer: 2 Concurrent use of an MAOI and a beta‐agonist can lead to hypertensive crisis. The beta‐ adrenergic agent. The client also takes a monoamine agonist could lead to tachycardia (option 3), but since no specific agent is listed, the nurse oxidase inhibitor (MAOI). The nurse assesses the client should consider the potential interaction of the MAOI and the beta‐agonist first. Hypotension for which of the following complications? (option 1) and bradycardia (option 4) are not of concern with this combination of medications. ‐ Hypotension ‐ Hypertension ‐ Tachycardia ‐ Bradycardia | The core issue of the question is interactive effects of beta‐agonists and MAOIs. Use the process of elimination, and recall that an agonist type of drug enhances the action of a system, in this case the beta‐adrenergic system. Then recall that these effects include increased pulse and blood pressure. Note also that two of these options are opposites, making it more likely that one of them is the correct answer. |
3389 A diabetic client admitted to the Emergency Correct answer: 1 Epinephrine is a beta‐adrenergic agent used to dilate bronchial airways. It can cause an Department with acute bronchospasm is given increased blood glucose level, which is especially an issue for a client with diabetes mellitus. epinephrine (Bronkaid). The nurse should assess the Diabetic clients should be instructed to monitor blood glucose levels because an adjustment in client for which side effect of this medication? maintenance doses of hypoglycemic agents could be indicated. Option 2, 3, and 4 are unrelated to effects of the medication on diabetic clients. ‐ Blood glucose level 156 mg/dL ‐ Blood glucose level 77 mg/dL ‐ Potassium level 5.4 mEq/L ‐ Potassium level 3.1 mEq/L | The core issue of the question is knowledge that beta‐adrenergic medications stimulate the sympathetic nervous system, and that one of the end effects of the stimulation is increased blood glucose. Correlate this knowledge with the client in the question, who has diabetes, to make a correct selection relative to hyperglycemia. |
3390 The nurse is teaching a client with chronic obstructive Correct answer: 2 The client should wait at least one minute between inhalations. Dosages should be taken pulmonary disease (COPD) how to administer multiple exactly as prescribed (option 1). The OTC products should not be added without consulting the medications by inhalation. Which statement by the physician (option 3). Inhaler equipment should be rinsed and dried daily to keep it clean client indicates an understanding of the instruction? (option 4). ‐ “If my symptoms get worse, I can double my dosage.” ‐ “I will wait at least one minute between use of my different inhalers.” ‐ “I can take any of the over‐the‐counter medications I need for my symptoms.” ‐ “I cannot rinse my inhaler equipment, because it is not supposed to get wet.” | The core issue of the question is correct administration procedure for inhaled medications. The wording of the question tells you the correct answer is an option phrased as a true statement. |
3391 A client complains that a newly prescribed beta‐ Correct answer: 1 Nervousness and tremors might be experienced when medication is newly administered, but adrenergic agent is causing nervousness and tremors. they frequently decrease over time. Clients should not terminate medication use without Which statement by the nurse is effective? consulting the prescriber (option 2). Caffeine would exacerbate the problem (option 3). The symptoms are likely related to the medication, and not to the disease process (option 4). ‐ “Sometimes, those symptoms occur when first taking the medication but decrease over time.” ‐ “Stop taking the medicine, because those symptoms will only get worse.” ‐ “Drinking coffee or tea will help decrease the symptoms.” ‐ “Those symptoms indicate a worsening disease process, and should be reported to the physician.” | Eliminate option 2 because this is not advice a nurse would give, and choose option 1 over 3 and 4 because it is the true statement. |
3392 The nurse is teaching the client about home Correct answer: 4 Taking the medication with food can decrease GI symptoms. Sustained‐release forms should administration of theophylline (Theo‐Dur). Which not be crushed or chewed, because doing so irritates the gastric mucosa and changes the statement by the nurse is reflective of appropriate absorption of the medication (option 1). Medications should be taken as prescribed, without teaching? omissions or doubled doses (option 2). Medications should be taken at all times, not just when symptomatic (option 3). Prophylaxis, not acute treatment, is the goal. 1.‐ “Sustained‐release forms can be crushed, so they are easier to swallow.” | The core issues of the question are general medication knowledge and instructions for use of theophylline. Eliminate options 1 and 2 first because they are not consistent with general principles of self‐administration. Choose option 4 over 3 because the medication is not for p.r.n. use. |
‐ “If a dose is omitted, take a double dose the next time.” ‐ “Only take the medication when acute symptoms occur.” ‐ “Take the medication with food if gastrointestinal symptoms occur.” | |
3393 A client who takes theophylline (Theo‐Dur) complains Correct answer: 1 Restlessness is a sign of theophylline toxicity, but often is a first indicator of hypoxia. The first of restlessness. Which is the most appropriate action and best action is to assess for hypoxia. After ruling it out, the other actions should be taken: for the nurse to take first? assessing for other signs and symptoms of toxicity, obtaining an order for the blood level, and explaining toxicity to the client. ‐ Assess the client for hypoxia. ‐ Explain that this is a toxic reaction, and call the physician. ‐ Assess the client for other signs and symptoms of theophylline toxicity. ‐ Call the physician to obtain an order for a theophylline level. | The question contains the word first, which indicates that more than one option might be technically correct, but one is best. Choose option 1 over options 2, 3, and 4 because all the incorrect options refer to the theme of toxicity. If options are very similar, none of them can be correct. |
3394 The client asks the nurse why the physician ordered Correct answer: 2 Beclovent is an inhaled corticosteroid that is thought to decrease inflammation and dilate the beclomethasone (Beclovent) for his chronic airway. The exact mechanism of action is unknown. Beclovent, like any other corticosteroid, obstructive pulmonary disease (COPD). Which does suppress the immune response, but this is not the rationale for administration of the statement by the nurse is most appropriate? medication (option 3). Inhaled corticosteroids are thought to increase responsiveness of bronchial smooth muscle to beta‐agonist drugs (option 4). ‐ “Beclovent prevents airway dilation.” ‐ “Beclovent decreases inflammation, and makes it easier to breathe.” ‐ “Beclovent suppresses the immune response.” ‐ “Beclovent decreases responsiveness to medications that dilate the airway.” | Use medication knowledge and the process of elimination to make a selection. |
3395 The nurse is teaching a client about cromolyn (Intal). Correct answer: 2 Cromolyn is a nonsteroidal agent that stabilizes mast cells so bronchoconstrictive and Which of the following statements should the nurse inflammatory substances are not released when stimulated with an allergen. It is used to treat make about the mechanism of action of this inflammation of the airway. It does not cause bronchoconstriction (option 4), and is not a medication? bronchodilator (option 1) or expectorant (option 3). ‐ “Cromolyn relaxes bronchial smooth muscle, to assist with bronchodilation.” ‐ “Cromolyn limits inflammation, and therefore bronchoconstriction, with exposure to an allergen.” ‐ “Cromolyn helps to liquefy secretions to promote expectoration.” ‐ “Cromolyn promotes bronchoconstriction of overly dilated airways.” | Use medication knowledge and the process of elimination to make a selection. |
3396 The nurse is assessing the client who takes cromolyn Correct answer: 4 Side effects of cromolyn include dry mouth, irritated throat, cough, unpleasant taste, and (Intal). Which symptom indicates to the nurse that the headaches. Side effects do not include vomiting (option 1) or tachycardia (option 3). Moist client is experiencing a potential side effect? mucous membranes (option 2) are a normal finding. ‐ Vomiting ‐ Moist mucous membranes ‐ Tachycardia ‐ Headache | Specific medication knowledge is needed to answer this question. Use the process of elimination to make a selection. |
3397 A client beginning medication therapy with Correct answer: 1 Leukotrienes are released when a client is exposed to an allergen. Leukotrienes cause montelukast (Singulair) asks the nurse how the inflammation, bronchoconstriction, and mucus production. Leukotriene modifiers such as medication is helping his symptoms. Which is the best montelukast block the action of leukotrienes, and therefore decrease mucous secretion and response? reduce inflammation, preventing bronchoconstriction. ‐ “Singulair decreases inflammation and mucus secretion.” ‐ “Singulair increases mucus secretion and bronchodilation.” ‐ “Singulair prevents smooth muscle contraction by nervous system stimulation.” ‐ “Singulair increases the inflammatory response and mucus secretion.” | Specific medication knowledge is needed to answer this question. Use the process of elimination to make a selection. |
3398 The client asks the nurse about self‐care related to Correct answer: 2 Liver function tests should be monitored with leukotriene modifiers because of the potential newly ordered zafirlukast (Accolate). The nurse for liver dysfunction with this type of medication. Renal studies are unnecessary (option 1) in responds by telling the client that: relation to this medication. Fluid intake should be increased (option 3), unless contraindicated by another condition, in order to thin secretions and assist in their mobilization. The medication should be taken one hour before or two hours after meals (option 4). ‐ Renal function tests should be monitored. ‐ Liver function tests should be monitored. ‐ Fluid intake should be decreased. ‐ The medication should be taken with meals. | Recall that metabolism and excretion of many drugs occur in either the hepatic or renal systems. This provides a clue that either option 1 or 2 is correct. Choose option 2 over option 1 by associating the letter l in leukotrienes with the letter l for liver. |
3399 A client asks the nurse if there is a benefit to taking Correct answer: 3 Second‐generation antihistamines cause less sedation than do first‐generation medications, second‐generation antihistamines instead of first‐ so the client experiences less drowsiness. They are selective for peripheral H1 histamine generation antihistamines. The nurse replies that receptors, and do not cross the blood–brain barrier. Nausea (option 1), anxiety (option 2), and second‐generation drugs cause less: euphoria (option 4) are unrelated as comparison points between first‐ and second‐generation antihistamines. ‐ Nausea. ‐ Anxiety. ‐ Drowsiness. ‐ Euphoria. | Recall that second‐generation drugs generally have some type of improvement over first‐ generation drugs. In this case, since antihistamines often cause drowsiness, it is easy to reason that this side effect would be decreased in second‐generation medications in this category. |
3400 A client asks the nurse about drug interactions with Correct answer: 1 The effects of first‐generation antihistamines are increased with alcohol, tricyclic diphenhydramine (Benadryl). The nurse informs the antidepressants, antianxiety agents, antipsychotic agents, opioid analgesics, sedative client that which of the following will increase the hypnotics, and monoamine oxidase inhibitors. Nicotine (option 2), caffeine (option 3), and CNS effects of Benadryl? stimulants (option 4) would not have an additive effect. ‐ Alcohol ‐ Nicotine ‐ Caffeine ‐ Central nervous system stimulants | Recall first that first‐generation antihistamines cause drowsiness, and look for an option that would have an additive effect. Since alcohol is a CNS depressant, it is the correct choice for this question; the others represent agents that stimulate the CNS. |
3401 The nurse is teaching the client proper technique for Correct answer: 2 The proper application of nasal spray decongestants is with the client sitting and squeezing administration of nasal sprays. Which explanation the bottle once, holding a finger over the other nostril, and inhaling. Administering more than should the nurse use in order to provide accurate one squeeze application (options 1 and 4) would increase the dose. The applicator should be information? rinsed after each use to prevent contamination (option 3). ‐ “Lie down and instill the nasal spray, squeezing the bottle twice for each application.” ‐ “Sit and squeeze the nasal spray once as you inhale while holding your finger over the other nostril.” ‐ “Be careful not to rinse the tip of the spray bottle after use, or you will contaminate the medication.” ‐ “Lean your head back and administer two applications to each nostril for each dose, to be sure some of the medication is instilled.” | A key word in the question is accurate. The core issue of the question is the instruction that is a true statement. Use the process of elimination and knowledge of basic medication administration procedures to make a selection. |
3402 The nurse is developing a teaching plan for a client Correct answer: 3 Avoidance of eating or drinking for 30 minutes after medication administration allows the using nasal decongestant. The nurse should include medication time to work. Nasal spray decongestants should not be taken for more than three which of the following instructions in the teaching days, because they can cause rebound congestion (option 1). Fluid intake should be increased plan? to 2–3 L/day, not decreased, to liquefy secretions (option 2). Smoking should be avoided because it increases secretions, and decreases ciliary action (option 4). ‐ “Be sure to stay on the medication for at least seven days.” ‐ “Decrease fluid intake to 16 ounces/day to decrease nasal secretions.” ‐ “Avoid eating or drinking for 30 minutes after medication administration.” ‐ “Smoking decreases secretions, and increases ciliary action.” | The wording of the question tells you the correct answer is also a true statement. Eliminate options 2 and 4 first as least likely to be true. Choose option 3 over option 1, knowing the side effects of decongestants. |
3403 The nurse is preparing to teach the client important Correct answer: 1 It is important to teach clients side effects of medications. The side effects of expectorants information related to self‐administration of include nausea, vomiting, gastric irritation, and rash. If a cough lasts longer than a week guaifenesin (Robitussin). Which of the following should (option 2), it should be reported to the physician. The client should avoid eating or drinking for be included in the teaching plan? 30 minutes after medication administration to allow the medication to work (option 3). The medication should be taken as directed, and doses should not be doubled (option 4). ‐ Side effects include nausea, vomiting, and rash. ‐ Report a cough to the physician if it lasts longer than two weeks. ‐ Take the medication with meals. ‐ If the medication is not effective, double the dose. | Use the process of elimination and general medication knowledge to answer the question. Eliminate option 2 because the time frame is excessive, and option 4 because it is not standard medication teaching. Choose option 1 over option 3 because it is a true statement, and because option 3 could hinder medication absorption. |
3404 The nurse is assessing a client for side effects of an Correct answer: 4 All of the symptoms listed are potential side effects of opioid antitussives. The most opioid antitussive. Of the following, which is the most significant side effect is respiratory depression, evidenced by a respiratory rate of 10, when significant side effect assessed? normal is 12–20 breaths/minute. ‐ Dry, cracked lips ‐ Complaints of blurred vision ‐ Inability to stay awake ‐ Respirations of 10/min | The key words most significant tell you that more than one option might be technically correct, and that you must select the most important option. Use the ABCs (airway, breathing, and circulation) to make your selection. |
3405 Which of the following statements by a client taking a Correct answer: 4 Unused medication should be discarded after four days, not seven. Avoidance of smoking is mucolytic agent indicates a need for further teaching? necessary because smoking increases secretions and decreases ciliary action (option 2). Increasing fluids assists with thinning secretions (option 1). Rinsing the mouth after administration decreases oropharyngeal irritation (option 3). ‐ “I will drink at least 2–3 liters of fluid each day.” ‐ “I will avoid smoking.” ‐ “I will rinse my mouth after I take my medicine.” ‐ “I can keep the medicine for a week before discarding what I do not use.” | The phrase further teaching tells you the correct answer is an incorrect or false statement. Eliminate option 1 first because this is an important principle to follow, and then option 3 because this is a general medication administration principle. Choose option 4 over 2 because smoking cessation is always recommended. |
3406 The nurse has an order to administer 50% oxygen to a Correct answer: 4 The Venturi mask has a dial to set the percentage of oxygen, and can administer 50% oxygen. client with pulmonary edema. The nurse would select The nonrebreather mask (option 2) administers 60–100% oxygen. The partial rebreather mask which of the following oxygen administration systems (option 3) administers 70–90% oxygen. The nasal cannula (option 1) can administer up to 6 that allows that percentage of oxygen to be delivered? L/min, which is approximately 44% oxygen. ‐ Nasal cannula ‐ Nonrebreather mask ‐ Partial rebreather mask ‐ Venturi mask | Specific knowledge of the various concepts related to oxygen therapy is needed to answer this question. Use the process of elimination to make a selection, and remember that Venturi masks deliver precise oxygen concentrations. |
3407 The nurse who administers albuterol (Proventil) to a Correct answer: 1 The symptoms of an acute asthma attack are related to constriction of the airway. The client with symptoms of an acute asthma attack medication is a beta‐adrenergic agent administered to dilate the airway. Option 2 is a side anticipates which of the following intended effects? effect of the medication, but is not the intended effect. Options 3 and 4 are incorrect because bradycardia and bronchoconstriction are the opposites of the expected side effect and intended effect, respectively. ‐ Dilation of the airway ‐ Elevation of the heart rate ‐ Constriction of the airway ‐ Slowing of the heart rate | Note that this question asks for identification of the intended effects. This refers to client response. Option 1 is the correct answer, as this is the intended response. Understanding the differences between side effects and client responses will lead to choosing the correct answer. |
3408 The nurse should question an order for epinephrine Correct answer: 2 Adrenergic agents are contraindicated for clients with cardiovascular disease because of the (Primatene) in the treatment of acute bronchitis when potential to increase myocardial oxygen demand. Epinephrine would raise the heart rate and the client has which of the following diseases? blood pressure, but could decrease oxygenation of the myocardium for the client with cardiovascular disease. Asthma (option 1), hypotension (option 3), and bradycardia (option 4) are not contraindications for use of epinephrine (Primatene). ‐ Asthma ‐ Coronary artery disease ‐ Hypotension ‐ Bradycardia | Recall knowledge of the disease process coronary artery disease to choose the correct answer. Using the process of elimination and knowledge of the pathophysiology of the disease process, the only correct option is number 2. |
3409 Which item should the nurse plan to omit from the Correct answer: 4 Caffeine in coffee or tea can have an additive effect with theophylline, and therefore coffee meal tray of the client being treated with theophylline should be eliminated from the meal tray. Peas (option 1), beans (option 2), and milk (option 3) (Theo‐Dur)? are not problematic because they do not contain caffeine. ‐ Peas ‐ Beans ‐ Milk ‐ Coffee | Recall knowledge of the side effect of theophylline, vasodilation, to be led to the correct answer. By eliminating caffeine from the client s food tray, the additional additive effect of caffeine can be avoided. |
3410 The nurse is assessing a client with chronic Correct answer: 3 A potential side effect of an inhaled corticosteroid is oral fungal infection. It would be obstructive pulmonary disease (COPD) who is being therapeutic to have a decrease in audible wheezes (option 1). Inhaled corticosteroids can treated with beclomethasone dipropionate (Beclovent) cause dry mouth (option 2), and with less respiratory effort from effective therapy, the nurse via oral inhaler. Which client manifestation would the should anticipate a decreased respiratory rate (option 4). nurse conclude is a side effect of this medication? ‐ Moist mucous membranes ‐ Decrease in the audible wheezes ‐ Oral fungal infection ‐ Decreased respiratory rate | Note that the question is asking for identification of the side effects of the medication. Use the process of elimination to rule out all choices except option 3. If this was difficult, review side effects of inhaled corticosteroids. |
3411 A client on the inpatient unit is having an acute Correct answer: 2 Bitolterol is an adrenergic bronchodilator that is effective to provide bronchodilation in an asthma attack. Which of the medications from the acute asthma attack. Aminophylline (option 1) is a xanthine, triamcinolone (option 3) is an medication sheet would the nurse administer? inhaled corticosteroid, and cromolyn (option 4) is an inhaled nonsteroidal. All three of these agents can be used with asthma; however, they are not effective during an acute attack. ‐ Aminophylline (Truphylline) ‐ Bitolterol (Tornalate) ‐ Triamcinolone acetonide (Azmacort) ‐ Cromolyn (Intal) | The question is asking for selection of the correct answer for a client who is having an acute attack. Considering this, realize that in selecting the medication, the response should be immediate bronchodilation. While all medications are effective in the treatment of asthma, the key concept is acute treatment. |
3412 The nurse is evaluating the effectiveness of client Correct answer: 2 Zafirlukast is a leukotriene modifier. This is a newer class of medication for the prophylaxis teaching about home medication administration. and chronic treatment of asthma. Because they are not to be used during an acute attack, this Which statement by the client indicates that more response indicates that the client needs more teaching. Fluid intake should increase to liquefy teaching is needed related to zafirlukast (Accolate)? secretions and assist the client with expectoration. This medication should be taken one hour before meals or two hours after meals. It does take a few weeks of medication administration for the client to begin to see positive results. ‐ "I will take the drug a few weeks before I expect to notice an improvement in my symptoms." ‐ "I will use this medication when I have the symptoms of an acute asthma attack." ‐ "I will increase my fluid intake while I am taking this medication." ‐ "I will plan to take my medicine one hour before meals." | Note that the question is asking for selection of the response indicating that the client needs more teaching. Use knowledge about the medication and the process of elimination to select the correct option. Zafirlukast is contraindicated in an acute asthma attack. If the client is stating she will use the medication during an acute attack, this would indicate that further teaching is required. |
3413 Which statement would the nurse include when Correct answer: 4 Claritin should be taken on an empty stomach, to increase absorption. It is a second‐ giving a client instructions about loratadine (Claritin)? generation antihistamine, and does not cause drowsiness as the first‐generation medications do (option 1). It has a rapid onset of action (option 2), and is not effective in an acute asthma attack (option 3). ‐ "This medication will make you drowsy." ‐ "It will take this medication a few hours to take effect." ‐ "This medication will help in an acute asthma attack." ‐ "Be sure to take this medication on an empty stomach." | Recall knowledge of the medication loratadine (Claritin) to select the correct answer. Option 4 is the only correct answer, since it should be taken on an empty stomach to increase the absorption rate and thus effectiveness. If this was difficult, review nursing interventions for the medication of loratadine (Claritin). |
3414 In which circumstance should the nurse inform the Correct answer: 2 Cardiovascular side effects are possible with the administration of decongestants. If the client client to stop taking oral phenylephrine (Neo‐ develops these symptoms, the medication should be discontinued, and the physician notified. Synephrine)? Oral agents should be used for long‐term therapy (option 1). Rebound congestion (option 4) is more likely with nasal spray decongestants. Often, decongestants cause a dry mouth (option 3), but the client should use hard, sugarless candy rather than discontinue the medication. ‐ After three days of continuous use ‐ If the client develops hypertension or tachycardia ‐ If the client develops a dry, irritated oral cavity ‐ If the client develops rebound congestion | Note that the question is asking for selection of a circumstance requiring a client response, indicating that the client should stop taking the medication. Use the process of elimination and knowledge of the side effects of oral decongestants to select option 2. This medication can increase blood pressure and heart rate. If this was difficult, review side effects of oral decongestants. |
3415 The nurse correctly teaches the client about which Correct answer: 1 Guaifenesin is an expectorant. Potential side effects are nausea, vomiting, gastric irritation, potential side effect of guaifenesin (Robitussin)? rash, dizziness, and headache. It does not cause hypertension (option 2), hypotension (option 3), or urinary retention (option 4). ‐ Gastric irritation ‐ Hypertension ‐ Hypotension ‐ Urinary retention | Use the process of elimination and knowledge of the side effects for guaifenesin (Robitussin) to select option 1. The other choices are not side effects, and can be eliminated. If this was difficult, review the side effects of guaifenesin (Robitussin). |
3416 The nurse is caring for a client with acute bronchitis Correct answer: 3 A non‐rebreather mask should have flaps on the sides that are open during expiration and who is using a non‐rebreather mask. The nurse notices closed on inspiration. The idea is for the client to breathe in oxygen, and not the expired that the flaps on the sides of the mask are off. Which carbon dioxide. If the flaps are missing, the client needs a new mask. The nurse should not action is appropriate? change the oxygen order (option 2), and it is unnecessary to call the physician (option 4). ‐ Allow the client to continue to use this mask, as it appears to be functional. ‐ Change the client to a nasal cannula. ‐ Replace the non‐rebreather mask with a new one. ‐ Call the physician. | In selecting the correct response to this question, recall knowledge of the function of a non‐rebreather mask. If this was difficult, review the correct functioning and purpose of a non‐rebreather mask. |
3417 A 6‐year‐old child with asthma is being treated with Correct answer: 1 Potential side effects of this medication are stimulation of the central nervous system (CNS) metaproterenol (Alupent). The mother informs the and cardiovascular (CV) system. Metaproterenol is a beta 2 stimulant, and these effects are nurse that she has been using the medication more not as likely, but with increased doses, they could occur, especially in a 6‐year‐old child. frequently lately because the child's symptoms have Lethargy and bradycardia (option 2), decreased blood pressure (option 3), and fatigue (option worsened. For what potential side effects should the 4) are not consistent with either CNS or CV stimulation. nurse monitor the client? ‐ Nervousness and tachycardia ‐ Lethargy and bradycardia ‐ Decreased blood pressure and dizziness ‐ Increased blood pressure and fatigue | Recall knowledge of the medication metaproterenol (Alupent) to select the correct answer in option 1, as administering increased doses to a child can cause stimulation of the CNS and CV systems. If this was difficult, review the medication side effects. |
3418 The nurse is teaching a client about salmeterol Correct answer: 4 Use of salmeterol is prophylactic, not for an acute attack. Salmeterol is predominately a beta (Serevent), which is to be used at home. Which 2 stimulant, and therefore does not frequently cause tachycardia (option 3). It takes 20 statement indicates that the client has understood the minutes for onset of action, and is used for prophylaxis, not treatment of acute attack (option teaching? 2). It is dosed every 12 hours because of a 12‐hour duration of action (option 1). ‐ "I will use this medication every 6 hours." ‐ "I will take a dose of this medicine when I notice I am wheezing." ‐ "I know this medicine commonly causes increased heart rate." ‐ "This medicine is to keep me from having an attack, not to stop one that has started." | Knowledge of the purpose of the medication salmeterol (Serevent) will lead you to the correct answer. This medication is for prophylactic use, and the only answer choice that refers to prophylaxis is option 4. If this was difficult, review the administration interventions for the medication. |
3419 A client takes oxtriphylline (Choledyl) for chronic Correct answer: 3 Oxtriphylline is a xanthine brochodilator, and the mechanism of action is to increase the obstructive pulmonary disease (COPD). Which amount of cyclic adenosine monophosphate (cAMP), which leads to bronchial dilation due to explanation by the nurse correctly teaches the client relaxation of smooth muscle. Xanthines can increase heart rate and force of myocardial the rationale for taking this medication? contraction, but that is not the rationale for the administration of the medication. ‐ "The medicine increases your heart rate to help with blood flow." ‐ "The medicine helps your heart beat stronger and get more blood to the lungs." ‐ "The medicine is used to dilate your airways, and make it easier for you to breathe." ‐ "The medicine thins the secretions in your lungs, and makes it easier for you to cough." | Note that the question asks for an explanation of the rationale for taking the medication relative to chronic obstructive pulmonary disease (COPD). Understand the disease process and the purpose of the medication to be directed to the correct answer. The only correct choice is option 3, as this is the desired effect for a client with COPD. |
3420 A client is to be started on theophylline (Theo‐Dur). Correct answer: 3 Theophylline is contraindicated in clients with hyperthyroidism, as the disease can be The nurse should plan to consult the physician about exacerbated. It is also contraindicated in clients with tachydysrhythmias. Options 2 and 4 result changing the order if the client has which of the in low heart rates, and are therefore incorrect. following conditions? ‐ Hypothyroidism ‐ Bradycardia ‐ Hyperthyroidism ‐ Sick sinus syndrome | Use the process of elimination and knowledge of the medication to select the correct answer. The only correct answer is option 3, as this medication is contraindicated in clients with hyperthyroidism. |
3421 A client is admitted to the hospital with an Correct answer: 4 When both an inhaled and a systemic corticosteroid are used, a decrease in the dose of one exacerbation of chronic obstructive pulmonary disease or the other medication might be appropriate, due to the additive effect of local and systemic (COPD). Triamcinolone acetomide (Azmacort) is one of corticosteroids. Options 1 and 2 are incorrect because they indicate increased doses, while the home medications. Dexamethasone (Decadron) is option 3 is incorrect because the symptoms should decrease, rather than increase. added intravenously in the hospital. The nurse should anticipate which of the following because of interaction of these two medications? ‐ An increase in the Azmacort ‐ A higher dose of Decadron ‐ An increase in the symptoms with administration of the two drugs ‐ A smaller dose of Azmacort and/or Decadron | When administering two corticosteroids to a client, smaller doses of the two medications can be anticipated. |
3422 The nurse should question an order for fluticasone Correct answer: 1 Administration of corticosteroids such as fluticasone suppresses the immune system, and the aerosol (Flovent) when a client has which of the administration of these drugs is contraindicated in clients with suppressed immune systems (as following conditions? in AIDS). Fluticasone might be helpful with asthma (option 2) and COPD (option 4). It is not contraindicated with CAD (option 3), although it should be used cautiously because of possible fluid retention. ‐ Acquired immunodeficiency syndrome (AIDS) ‐ Asthma ‐ Coronary artery disease (CAD) ‐ Chronic obstructive pulmonary disease (COPD) | Knowledge of the side effects of immunosuppression with corticosteroids, as well as knowledge of the pathophysiologic process of AIDS, will lead to the correct answer. Since AIDS clients have a suppressed immune response, further suppression would result when a corticosteroid is administered. This is the only correct answer. |
3423 Which statement by the client indicates that teaching Correct answer: 3 Nedocromil should be used as ordered, even if no symptoms are noted. This medication is has been effective about the administration of used for the prophylaxis of asthma, not during an acute attack (option 1). It is possible that a nedocromil (Tilade)? decreased (not increased, as in option 2) amount of bronchodilator and/or inhaled corticosteroid might be needed after starting this medication, but this is not certain. It can take three weeks of daily dosing prior to seeing therapeutic effects (option 4). ‐ "I will take this medication only during an acute attack." ‐ "I may have to increase my dose of beclomethasone (Beclovent) after I start taking this medication." ‐ "I will take this medication daily, regardless of whether I experience symptoms." ‐ "I should see therapeutic effects of this medication as soon as I begin taking it." | Having knowledge of the purpose of the medication nedocromil (Tilade) will lead to the correct answer. This medication is for prophylactic use. The only option that refers to prophylaxis is option 3. If this was difficult, review the administration interventions for the medication. |
3424 A nurse is doing an admission history on a client who Correct answer: 3 Zileuton is a leukotriene modifier that blocks production of leukotriene, and thereby reduces takes zileuton (Zyflo). Which manifestation noted inflammation. The side effects of zileuton include headaches, dyspepsia, nausea, dizziness, and during the initial assessment would the nurse conclude insomnia. They do not include lethargy (option 1), constipation (option 2), or diarrhea (option is most likely a side effect of the medication? 4), although zafirlukast, another leukotriene modifier, can cause nausea and diarrhea. ‐ Lethargy ‐ Constipation ‐ Headaches ‐ Diarrhea | Use the process of elimination and knowledge of zileuton (Zyflo) to select the only correct answer in this question, option 3. If this was difficult, review side effects of the medication zileuton (Zyflo). |
3425 An 80‐year‐old client who complaines of nausea is Correct answer: 4 Promethazine is a traditional antihistamine that causes drowsiness because it works centrally being given promethazine (Phenergan) 12.5 mg as well as peripherally. It can cause central nervous system depression or stimulation. The intravenously. Which safety measure should the nurse client should be kept in bed, with the side rails up, until the effects of the drug wear off, to institute? promote client safety. The effects are heightened by the client's age. The actions in options 1, 2, and 3 provide a lower margin of safety for the client. ‐ Provide the client with no‐skid slippers for ambulation. ‐ Show the client the emergency cord in the bathroom, and give instructions for use. ‐ Put a chair next to the client's bed to make it easier for her to get herself out of bed. ‐ Keep the client in bed, with the side rails up. | Note that the question asks for identification of safety. Options 2, 3, and 4 provide a limited amount of safety, while option 1 provides the highest level. Eliminate the lower safety level options to be led to the higher safety level stated in option 1. |
3426 The nurse informs the client that oxymetazoline Correct answer: 2 Afrin is a topical decongestant and an adrenergic agent that promotes nasal decongestion by (Afrin) should not be utilized if the client has which of vasoconstriction. Adrenergic decongestants are contraindicated for the client with the following conditions? hypertension and coronary artery disease. Contraindications do not include hypotension (option 1), hypothyroidism (option 3), or emphysema (option 4). ‐ Hypotension ‐ Hypertension ‐ Hypothyroidism ‐ Emphysema | Having knowledge of the side effects of oxymetazoline (Afrin) and the modality of the treatment will lead to selection of the correct answer. Vasoconstriction leads to hypertension, which is listed in option 2. If this was difficult, review the side effects of the medication oxymetazoline (Afrin). |
3427 A client presents to the Emergency Department with Correct answer: 2 Epinephrine is a beta‐adrenergic agent that that has beta 1 adrenergic action, causing inspiratory and expiratory wheezes, and intercostal increased heart rate and increased force of myocardial contraction. The results of retractions. A diagnosis of acute bronchospasm subcutaneous epinephrine should be seen in five minutes. The effects can last up to four hours. secondary to acute bronchitis is made. Epinephrine The other options are incorrect. (Bronkaid) is ordered to be given subcutaneously. The nurse would anticipate seeing the intended effect of the medication in: ‐ One minute. ‐ Five minutes. ‐ Ten minutes. | Recall knowledge of the onset of the medication Epinephrine (Bronkaid). The only correct answer is option 2. If this was difficult, review the medication and its onset. |
4.‐ Fifteen minutes. | |
3428 An order for which beta agonist should be questioned Correct answer: 3 Terbutaline, pirbuterol, and metaproterenol are all beta 2 stimulants. Isoproterenol because it is contraindicated for a client with a history stimulates beta 1 and beta 2 receptors, and therefore should not be used with clients with of atrial fibrillation? tachydysrhythmias. ‐ Terbutaline (Brethine) ‐ Pirbuterol (Maxair) ‐ Isoproterenol (Isuprel) ‐ Metaproterenol (Alupent) | In order to answer this question, recall knowledge of beta 1 and beta 2 stimulants and their effects on the heart. Use the process of elimination, and exclude those medications of the same category, to be led to the correct choice. |
3429 A 70‐year‐old client with chronic obstructive Correct answer: 3 With increased age, there is an increased sensitivity to xanthines. Also, there are other pulmonary disease (COPD) is taking theophylline (Theo‐ disease processes that could lead to this elevated value. The dose of theophylline should be Dur). A blood level is drawn, and the result is 25 decreased to get the blood level to the 10–20 mg/dL range. Theophylline doses should be mg/dL. What explanation by the nurse helps the client based on lean body weight, to prevent entering the medication into the adipose tissue. understand this lab result? ‐ "Your dose of theophylline needs to be increased." ‐ "Your blood level is low because the dose was based on your total body weight instead of on your lean body weight." ‐ "The lab value could be high because of your age. We may have to decrease the dosage of your medication." ‐ "I am sure that lab value is incorrect. Theophylline levels are never that high." | Knowledge of a normal therapeutic level of theophylline will lead to the correct answer. Since the question refers to a result of 25 mg/dl, which is high therapeutically, the only correct option is 3. If this was difficult, review the therapeutic lab values for theophylline. |
3430 The nurse is assessing a 30‐year‐old client with a prior Correct answer: 2 Theophylline is a xanthine that causes bronchial dilation due to smooth muscle relaxation. history of smoking who takes theophylline (Theo‐Dur) Increased levels of theophylline occur with liver disease and congestive heart failure. Option 3 for chronic obstructive pulmonary disease. Additional is incorrect because the client is young, and therefore the age is insignificant. The smoking diagnoses include liver disease and congestive heart history (option 1) is not an issue; in fact, smokers metabolize theophylline more quickly, and failure. The client is experiencing tremors, dizziness, might need increased doses. There are no data about the client's weight (option 4) in the stem. tachycardia, and nausea. The nurse explains to the client that these symptoms could be the result of: ‐ A history of smoking cigarettes. ‐ Liver disease. ‐ The client's age. ‐ The client's weight. | Pay close attention to the assessment data in the stem to eliminate wrong answers and be led to option 3. |
3431 For which complication of administration of inhaled Correct answer: 2 The child receiving inhaled corticosteroids should be assessed for impaired bone growth. corticosteroids should the nurse assess a 4‐year‐old Bone growth should be monitored closely, especially in children between 4 and 10 years of child with asthma? age. Improved respiratory function is an expected outcome of treatment (option 1). Decreased urinary output (option 3) and increased immune response (option 4) do not apply. ‐ Improved respiratory function ‐ Impaired bone growth ‐ Decreased urinary output ‐ Increased immune response | Note that the question asks for selection of the complication; with the knowledge of the side effects of delayed growth and development with children with this medication use, the correct choice 2 can be selected. If this was difficult, review corticosteroid responses in the pediatric population. |
3432 The nurse is preparing a teaching plan for the client Correct answer: 3 Inhaled corticosteroids do predispose clients to osteoporosis. The mouth should be rinsed taking flunisolide (Aero‐Bid‐M). Which of the following after the medication is administered to decrease the likelihood of oropharyngeal candidiasis items should be included? (option 1). Clients should avoid allergens (option 2). The medication should be taken prophylactically, not with an acute attack (option 4). ‐ Avoid rinsing mouth after use of the inhaler. ‐ Exposure to allergens will assist with the healing process. ‐ Inhaled corticosteroids predispose the client to osteoporosis. ‐ Only take the medication when experiencing activity intolerance and/or awakening with symptoms of asthma. | With a strong knowledge base of nursing interventions related to the intake of corticosteroids, the correct answer can be selected. Use the process of elimination to be directed to option 3. If this was difficult, review the general nursing interventions in the long‐term use of corticosteroids. |
3433 The nurse is teaching a client the proper technique Correct answer: 4 The nurse should teach the client proper administration technique for inhaled medications. for administration of oral inhalers. Which statement by The canister should be shaken (option 1), and the cap removed. The client should sit or stand the client indicates the teaching has been effective? for maximal lung inflation (option 2). The client should coordinate pressing the canister to release the medication and inhalation to get the medication into the lungs. The client should hold her breath for 10 seconds. One to three minutes should elapse between inhalations or prior to administration of another medication (option 3). ‐ "I will be sure I do not shake the canister prior to administration of the medication." ‐ "I will lie on my bed when I take my inhaler." ‐ "I will wait 10 minutes between inhalations of medication." ‐ "I will sit upright and practice coordinating pressing the canister as I inhale." | Recall general knowledge of the use of oral inhalers to be led to the correct answer, option 4. If this was difficult, review the teaching protocol for the client who has been prescribed an oral inhalator. |
3434 The nurse is teaching the client about a newly Correct answer: 3 It is not advised to take two antihistamines concurrently, as they can have additive effects. prescribed antihistamine, loratadine (Claritin). The Loratadine is a second‐generation antihistamine, and is not as likely to cause drowsiness nurse would include which of the following points? (option 1). Loratadine, unlike other antihistamines, should be taken on an empty stomach to increase absorption (option 2). Prolonged exposure to sunlight (option 4) can cause sunburn, especially while on antihistamines. ‐ "This medication causes profound drowsiness." ‐ "This medication should be taken with meals." ‐ "Do not take another antihistamine at the same time as Claritin." ‐ "Prolonged exposure to sunlight is not a problem while on this medication." | General knowledge of the use of antihistamines will allow selection of the correct option, 3. If this was difficult, review the teaching protocol for the client who has been prescribed an antihistamine. |
3435 The client asks the nurse about the difference Correct answer: 4 Dimetane‐DC is an opioid antitussive that contains codeine, affecting the cough center between dextromethorphan (Robitussin DM) and directly and suppressing the central nervous system. Dextromethorphan is a nonopioid Dimetane‐DC. The nurse's response should be: antitussive that suppresses the cough reflex directly by affecting the cough center. ‐ "Dextromethorphan contains a narcotic." ‐ "Dimetane‐DC is non‐narcotic." ‐ "Dextromethorphan is an opioid antitussive that contains codeine." ‐ "Dimetane‐DC is an opioid antitussive that contains codeine." | Recall the difference between the letters DM and DC after a medication. DC would indicate that codeine is in the medication. Use of this knowledge will lead to the only correct option, 4. DM after a medication name does not refer to a narcotic in the medication. This will allow you to eliminate the other three options. |
3436 A client is admitted through the Emergency Correct answer: 4 Clients with COPD usually have a lower oxygen tension in the blood than do clients who do Department with an acute exacerbation of chronic not have chronic lung disease. In fact, because COPD clients usually have high carbon dioxide obstructive pulmonary disease (COPD). The nurse levels, their drive to breathe is from the low oxygen tension instead of the high carbon dioxide starts oxygen at a rate of 2 liters/minute with a pulse level. Starting oxygen at higher than 2 liters/min could cause hypoventilation, because it could oximeter (SO<sub>2</sub>) reading of 89% diminish the drive to breathe. SO<sub>2</sub> values of 87–90% are usually 15 minutes after the oxygen is started. The correct satisfactory for clients with COPD. interpretation of this action is:
| Knowledge of the usual treatment modalities for a client with COPD will lead to the correct answer. With this knowledge and the process of elimination, select the only correct option, 4. If this was difficult, review the pathophysiology of COPD and treatment modalities. |
3437 The client is reporting vague dread; she is pacing and Correct answer: 2 This client is suffering from anxiety. The correct answer is an anxiolytic. Option 1 is a hyperventilating. Her jaw is clenched, and she is sedative–hypnotic, which would not be prescribed. The client is not suffering from psychosis or wringing her hands. The nurse concludes that this hallucinations, so option 3 is inappropriate. Option 4 is inappropriate for the signs and client is in need of which of the following types of symptoms described. medications? | This question requires you to interpret the client s symptoms as being representative of anxiety, and to choose the drug category that is effective against it. Focus on the client manifestations to eliminate each of the incorrect options. |
‐ A barbiturate ‐ An anxiolytic ‐ An antipsychotic ‐ A CNS stimulant | |
3438 The client is taking zolpidem (Ambien). What would Correct answer: 3 Zolpidem (Ambien) is a sedative–hypnotic medication used to treat insomnia. Therefore, be a priority nursing diagnosis for this client? Disturbed Sleep Pattern is the appropriate priority nursing diagnosis. There is not enough information in the question to determine whether Self‐care Deficit, Risk for Violence, or Deficient Fluid Volume would be pertinent for the client. ‐ Self‐care Deficit ‐ Risk for Violence ‐ Disturbed Sleep Pattern ‐ Deficient Fluid Volume | First, recall that zolpidem is a sedative–hypnotic medication. Next, consider its use as a bedtime sleep aid to make the appropriate selection. |
3439 The nurse determines that the client understands the Correct answer: 2 The medication normally works within 30 minutes to one hour after administration, making effects of flurazepam (Dalmane) ordered at a dose of option 2 correct. Option 1 is incorrect because the client should not be watching stimulating 30 mg by which of the following client statements? shows on television before trying to fall asleep. Option 3 is incorrect because the medication will not work instantly. Option 4 is incorrect because the client should not take a sedative and then stay active for 30 minutes to one hour after taking medication. ‐ “After I take my medication at bedtime, I should be able to watch the boxing match or late night TV show, then go to bed and sleep.” ‐ “Once I take my medicine, I should be able to go to bed and read, and I will fall asleep within one hour.” ‐ “I will take my medicine, go to bed, and go to sleep.” ‐ “I will take my medicine, make my lunch for tomorrow, take my shower, get my clothes ready for work tomorrow, and then go to bed.” | The word understands in the stem of the question tells you the correct answer is also a true statement. Recall that the medication is used to enhance sleep, and utilize principles of good sleep hygiene to eliminate each of the incorrect options. |
3440 The nurse conducting medication teaching with a Correct answer: 2 In order to safely monitor clozapine, a weekly blood test is mandatory. If the client does not client explains that a safe, effective dose of clozapine have the hematologic exam, the medication is not given for the following week. This is to (Clozaril) is established by weekly: monitor for agranulocytosis, the drug s major adverse effect. A full physical exam (option 1) and urinalysis (option 3) are unnecessary. Follow‐up visits (option 3) are done periodically, but might not be needed weekly with the physician. ‐ Physical exam by a psychiatrist. ‐ Hematological monitoring. ‐ Follow‐up visits with a physician. ‐ Urinalysis. | The core issue of the question is knowledge of possible adverse effects of clozapine. Recall that the drug can cause bone marrow depression and agranulocytosis to choose the correct monitoring technique. |
3441 A client is taking sertraline (Zoloft). The nurse explains Correct answer: 2 Sertraline is an antidepressant of the SSRI type. These agents work within 1–4 weeks. Option to the client that how much time will pass before the 1 is an insufficient amount of time, while options 3 and 4 are excessive, as well as similar. onset of the medication occurs? ‐ 5–7 days ‐ 1–4 weeks ‐ 4–6 weeks ‐ 4–8 weeks | Specific knowledge of the time frame in which SSRIs exert an effect is needed to answer this question. Use medication knowledge and the process of elimination to make a selection. |
3442 The visiting nurse is evaluating for client safety. The Correct answer: 4 With an MAOI, such as phenelzine, the client must eliminate foods that contain tyramine. client is taking phenelzine (Nardil). A priority of the Intake of tyramine‐containing foods could lead to severe hypertension and other nurse’s teaching includes which of the following? complications. All of the other considerations are not major teaching considerations for MAOIs. ‐ Limiting daily intake of salt ‐ Encouraging a fluid intake of at least 2,000 mL ‐ Encouraging the client to have scheduled blood tests on time ‐ Eliminating foods containing tyramine | The core issue of the question is knowledge that phenelzine is an MAOI. From there, recall that foods high in tyramine need to be avoided to make the correct selection. |
3443 The client is diaphoretic, is disoriented, has a Correct answer: 1 These symptoms are the commonly seen symptoms of withdrawal from alcohol or other CNS temperature of 100°F, has insomnia, and is depressants. Option 2 is incorrect because there would usually not be complaints of complaining of feeling anxious and unable to sit still. disorientation or insomnia with flulike symptoms. Individuals do not usually have withdrawal The nurse suspects this client might: symptoms from antipsychotic medications (option 3), nor are these the signs of lithium carbonate discontinuation (option 4). ‐ Be withdrawing from alcohol or CNS depressants. ‐ Be demonstrating flu symptoms. ‐ Be withdrawing from an antipsychotic medication. ‐ Have abruptly discontinued lithium carbonate. | Clients withdrawing from a substance are likely to experience the opposite effects of the original drug. With this in mind, review the client s symptoms, and note that they represent excitation of the CNS. With this in mind, you can deduce that the original substance was some type of CNS depressant, leading you to option 1. |
3444 Immediately after taking alprazolam (Xanax) the Correct answer: 3 In the correct response, the nurse acknowledges the client s feelings, and asks the client to client says, “I know I shouldn’t feel this guilty, but I discuss his feelings and thoughts. In options 1, 2, and 4, the nurse is not acknowledging the don’t want to take medicine that makes me feel this client s feelings or thoughts. An open and trusting nurse–client relationship helps support the way.” What would be the most appropriate response client in decisions related to medication therapy. by the nurse? ‐ “Are you worried about what people will say because you are taking this medicine?” ‐ “Once the medication begins to work, you’ll feel differently about taking it.” ‐ “Can we talk about how you’re feeling about taking Xanax?” ‐ “It will be better for your long‐term mental health if you don’t worry about what other people think.” | The correct answer to the question is one that is the most therapeutic response by the nurse. Use knowledge of communication techniques and the process of elimination to make a selection. |
3445 The client is taking carbamazepine (Tegretol) for Correct answer: 2 The most serious side effect of carbamazepine is agranulocytosis (low WBC count). treatment of mania. The client is instructed to come to Neuroleptic malignant syndrome is not common with carbamazepine, nor is there a need for the laboratory weekly for monitoring of which of the weekly monitoring for low platelet count (option 3) or anemia (option 4) while taking following? carbamazepine. ‐ Neuroleptic malignant syndrome ‐ Agranulocytosis ‐ Thrombocytopenia ‐ Anemia | The core issue of the question is that an adverse effect of carbamazepine is agranulocytosis. With this in mind, eliminate each of the incorrect responses that do not address this concern. |
3446 A client with schizophrenia has been taking Correct answer: 3 Akathisia is an inability to sit. This is the most common extrapyramidal side effect of haloperidol (Haldol) for three weeks with good effect. haloperidol. The side effects in option 1 would include dry mouth, urinary hesitance, Today, he comes to group, but is complaining that he constipation, mydriasis, tachycardia, and diminished lacrimation. Option 2, gustatory feels like his legs are on fire. He is moving hallucination, is tasting something that is not present, while option 4 is a painful twisting and continuously, and states, “I can t sit here anymore.” turning of the head and neck. The nurse documents and reports that the client is experiencing which of the following medication side effects? ‐ Anticholinergic effects ‐ Gustatory hallucinations ‐ Akathisia ‐ Oculogyric crisis | The core issue of the question is correct identification of side effects of haloperidol. First, eliminate options 2 and 4, because gustatory refers to taste and oculo‐ refers to eyes. Choose option 3 over option 1 because the word akathisia is consistent with the client s presentation, while the word anticholinergic is not. |
3447 The nurse concludes the client understands the Correct answer: 3 Trazadone is an atypical antidepressant that is used more for insomnia than for depression. desired effects and major side effects of trazodone Abuse potential is minimal, so option 4 is incorrect. Option 1, for safety reasons, is not a good (Desyrel) when he makes which of the following practice when taking trazodone as a sleep aid, and option 2 is incorrect because taking more statements? fluids will not increase the effectiveness of the medication. ‐ “I know I will be able to get up and go downstairs to the bathroom during the night as long as I leave a nightlight on.” ‐ “I am drinking more fluids now that I am taking this medication, so it will work the way it is supposed to.” | First, recall that trazodone is often used as a sleep aid. With this in mind, eliminate each of the incorrect responses because they are not consistent with knowledge of its use for this purpose. |
‐ “This medicine should help me sleep without my having to worry about becoming addicted to it, and if I have a problem with priapism, I will notify my doctor immediately.” ‐ “I will feel more energetic after three or four weeks of taking this medication, and I understand I must take it only as prescribed so that I will not become addicted to it.” | |
3448 The client is hospitalized because of a suicide attempt Correct answer: 3 The client needs to make an agreement with the nurse to remain safe, or to report to the while in a manic phase. The client has now been taking nurse if not feeling safe. Option 4 does not keep the client safe for 24 hours, only during meals. chlordiazepoxide (Librium) for two days. Which of the The agreement in option 1 is too vague, and does not give specific responsibility to the nurse following is the most important safety measure for the or the client. The promise in option 2 is also vague, and does not make the client accountable nurse to implement with this client? to the health care professionals. ‐ Frequently remind the client to remain visible to the nurses at all times. ‐ Elicit the client s promise to tell someone if she is feeling suicidal. ‐ Make a contract for safety. ‐ Enforce the client’s promise to eat all meals in the dining room. | Note that the question contains a key phrase: most important safety measure. This tells you that more than one option might be partially or totally correct, and that you must prioritize. Keep in mind that medication therapy alone is not sufficient in treating this client. Choose option 3 over the others because it is the most inclusive of the client s safety needs. |
3449 If an overdose of benzodiazepines is suspected, the Correct answer: 4 Flumazenil is the only drug available that acts as an antagonist to the benzodiazepines. nurse obtains which of the following medications to Options 1 and 2 are benzodiazepines themselves, while option 3 is a selective serotonin reverse that drug’s effects as ordered? reuptake inhibitor (SSRI) type of antidepressant. ‐ Diazepam (Valium) ‐ Triazolam (Halcion) ‐ Fluvoxamine (Luvox) ‐ Flumazenil (Romazicon) | Specific knowledge of the antidote to benzodiazepines is needed to answer this question. It might help to remember that the antidote to benzodiazepines is a generic drug name that contains the letters ze, and is not a benzodiazepene itself. |
3450 The nurse is making a plan of care for a client who is Correct answer: 3 Dry mouth occurs from the anticholinergic effects seen with fluphenazine. Options 1 and 2 prescribed fluphenazine (Prolixin) 1 mg daily at are incorrect because orthostatic hypotension is not a major side effect of fluphenazine. bedtime. The nurse will include which of the following Confusion (option 4) is not a side effect of this agent. to monitor for side effects of the medication? ‐ Frequently remind the client to move slowly when getting out of bed or rising from a chair. ‐ Assess for dizziness or lightheadedness frequently during the day. ‐ Make sugarless hard candy, gum, and water available during the day. ‐ Monitor frequently for confusion. | First, eliminate options 1 and 2, because they are similar in referring to orthostatic hypotension. Choose option 3 over option 4 because option 3 addresses anticholinergic effects of the drug, which are of concern. |
3451 The client expresses an increase in appetite, a desire Correct answer: 1 Option 1 is the correct response to the situation. Option 2 is incorrect because imipramine is to participate in group today, and a request to have very slow to become effective 2–6 weeks, not 5 days and as the client begins to “feel better,” it her mother come to visit later in the week. The client is not appropriate to make major changes, especially after a suicide attempt. Options 3 and 4 has been in the inpatient locked unit on suicide are not true, but gradual change and monitoring for changes in mood and behavior are still precautions for 5 days, and is taking imipramine very critical for this client. (Tofranil). The nurse does not make major changes to the nursing care plan at this time for which of the following reasons? ‐ It is not safe after only 5 days to address too many changes at once. It is better to make gradual changes once the medication is more effective. ‐ Imipramine (Tofranil) is beginning to make the client feel less suicidal. ‐ After a suicide attempt, the likelihood of another attempt is rare, so it is better to let the client make adjustments, and then the nurse can change the care plan. ‐ The client is less likely to attempt suicide again if there is no change in the care plan or expectations of her. | To answer this question correctly, recall that antidepressants generally take more than 5 days for full effect. With this in mind, realize that the client is still a safety risk, and choose the option that keeps the client safest while medication therapy is progressing. |
3452 The client is receiving thioridazine (Mellaril) 100 mg Correct answer: 1 With thioridazine, the anticholinergic side effects of dry mouth, constipation, urinary t.i.d. Today, he comes to the clinic with the chief retention, and blurred vision are usually severe. Dry mouth is not associated with complaint of feeling like his mouth is “always dry.” The extrapyramidal side effects (option 2) or neuroleptic malignant syndrome (option 4). There is nurse concludes this side effect is related to which of usually a weight gain, not a weight loss, as a side effect of thioridazine (option 3). the following? ‐ High anticholinergic effects of thioridazine ‐ Extrapyramidal side effects (EPSE) ‐ Weight loss effect of the medication ‐ Neuroleptic malignant syndrome (NMS) side effect | Specific knowledge of the intended effects and side effects of this medication is needed to answer the question. Use the process of elimination to make your selection. |
3453 A client asks the nurse if it is true that marijuana is Correct answer: 1 Marijuana has been used for individuals with AIDS to increase their appetite. Marijuana does not just a street drug but has legitimate uses, as he not increase organization and motivation (option 2), reduce stress (option 3), or have read in a magazine article. The nurse replies that antibacterial properties (option 4). marijuana does have therapeutic uses, such as the ability to: ‐ Stimulate appetite. ‐ Stimulate clients to become more organized and motivated. ‐ Help clients to reduce stress. ‐ Act as an antibacterial agent. | The core issue of the question is legitimate uses for marijuana. To aid in making the correct selection, keep in mind that an effect of the drug is to stimulate appetite. |
3454 The nursing diagnosis is “Anxiety related to recent Correct answer: 3 Although options 1, 2, and 4 are all appropriate nursing interventions, the need for physical attack and robbery in apartment, evidenced by safety is the primary nursing priority for the client at this time. The others can be addressed episodes of immobilizing apprehension.” A short‐term once physical safety is established. anxiolytic has been prescribed. What is the primary nursing priority for this client? ‐ Help client learn alternative responses to the anxiety. ‐ Promote involvement of family/client in group or community support activities. ‐ Provide for physical safety. ‐ Assist with desensitization to phobic place (apartment). | Note that the drug prescribed is an anxiolytic. Next, relate the cause of the anxiety to the need for the medication. From there, choose option 3 over the others because it targets the best concern of the client and is congruent with the need for the medication. |
3455 The client is admitted to the inpatient unit with a Correct answer: 4 Risperidone has very few side effects; they include orthostatic hypotension (option 4) and diagnosis of paranoid schizophrenia. He is prescribed insomnia, agitation, headache, anxiety, and rhinitis. Options 1, 2, and 3 are incorrect risperidone (Risperdal). After five days of treatment, conclusions about the causes of the client’s dizziness. the client reports feeling dizzy. The nurse explains to the client that this is associated with: ‐ The desired effect of sedation. ‐ The side effect of loss of appetite. ‐ The anticholinergic side effects prominent with this agent. ‐ The side effect of orthostatic hypotension. | The core issue of this question is recognition of dizziness as a sign of orthostatic hypotension. With this concept in mind, eliminate each of the other options, because they do not relate to this concern. |
3456 Which of the following is the highest priority for the Correct answer: 3 The principle of remaining abstinent is one of the three most important goals of treatment client after withdrawing from alcohol and beginning for alcoholism. It is also critical when taking disulfiram, in order to avoid adverse effects from use of disulfiram (Antabuse)? the interaction of the medication and alcohol. The other two goals of treatment are amelioration of concurrent psychiatric conditions and long‐term prevention of relapse. Options 1, 2, and 4 are important components, but without option 3, the others could not occur, and they do not directly correlate with disulfiram therapy. ‐ Social reintegration ‐ Learning about the disease process ‐ Remaining abstinent ‐ Remaining in the rehabilitation unit | The core issue of the question is the interactive effect of disulfiram and alcohol. With this in mind, eliminate each of the incorrect options because they do not address this critical concern. |
3457 The psychiatrist is prescribing chlorpromazine Correct answer: 2 Because the client is hospitalized and is receiving an IM dose of Thorazine, the primary (Thorazine) 50 mg IM as an initial dose for a client concern should be to monitor for a decrease in the psychosis. Blood pressure and pulse should hospitalized with psychosis. Your initial concern is to be monitored as a general measure for initial treatment with Thorazine, whether IM or PO. monitor: Ability to walk and to eat lunch are not significant to the issue of initial concern. ‐ Blood pressure and pulse. ‐ A decrease in psychotic symptoms. ‐ The client's ability to walk. ‐ The client's ability to eat lunch. | Note the key word “initial,” and focus on the diagnosis of psychosis. Recall strong knowledge base of disease process of psychosis and usual mode of treatment to select the correct answer. Using the process of elimination, omit choices 1, 3, and 4, as they are not the most important initial concerns on which to focus. If this question was difficult, review the usual treatment medication protocol for psychosis. |
3458 The home care nurse is visiting a client discharged Correct answer: 3 The only correct option is slurred speech and drowsiness. Olanzapine is a relatively new drug yesterday from an inpatient unit. The client is taking approved for schizophrenia and other psychotic disorders. This agent is generally well olanzapine (Zyprexa) 10 mg daily. The client states that tolerated, and appears devoid of serious adverse effects. he needs more medication, because what he was given yesterday is all gone. He was given a 10‐day supply upon discharge. The nurse would then assess for which of the following signs? ‐ Headache and psychosis ‐ Lightheadedness and diarrhea ‐ Slurred speech and drowsiness ‐ Diarrhea and vomiting | Recall strong knowledge of schizophrenia and usual treatment to select the correct answer. If this was difficult, review the usual treatment medication protocol for schizophrenia. |
3459 A female client reports during an initial interview that Correct answer: 1 The only correct answer is option 1. Trazodone is an atypical antidepressant used more often she has been prescribed to take trazodone (Desyrel). for insomnia than for depression. It is not used for panic attacks or anxiety. The nurse questions her about a history of which of the following problems? ‐ Insomnia ‐ Panic attacks ‐ Mania ‐ Anxiety | Use the process of elimination and knowledge of the treatment of insomnia to assist in elimination of choices 2, 3, and 4, and to be led to the correct answer. If this was difficult, review insomnia medication treatment modalities. |
3460 A client is discharged taking a monoamine oxidase Correct answer: 3 The most important person to instruct is the client (not a family member, as indicated in inhibitor (MAOI). Which of the following are most option 4). With MAOIs, it is important to give the client not only oral but also complete written important client teaching objectives? instructions concerning medication administration, food interactions, etc. It is good to instruct the client how to notify the appropriate health care professional, but it is not a major objective to teach the family how to contact an appropriate health care professional. ‐ Give the client written and oral instructions on how to take daily doses of the medication. ‐ Instruct family members how to notify the appropriate health care professional after discharge. ‐ Give client written and oral instructions about medication administration, side effects, adverse effects, and food interactions. ‐ Instruct the client's family about the administration of medication. | Note the key words “most important.” Options 2 and 4 can be eliminated, as only the family is included in the answer, and not the client. Option 3 is the most complete answer because it includes all the components of teaching medications, while option 1 only includes administration instructions. If this was difficult, review teaching components with medication administration. |
3461 Keeping in mind that few benzodiazepines are safe Correct answer: 4 Diazepam and chlordiazepoxide are contraindicated for use with elderly clients (options 1 and for use by the elderly, the nurse would anticipate that 2), while trazadone is an atypical antidepressant, not a benzodiazepine. Lorazepam is the only which of the following would be the most effective for appropriate benzodiazepine listed that is good for use by elderly clients. use by a 74‐year‐old client? ‐ Diazepam (Valium) | Note that the question is asking about medication safety in the elderly. Understanding the individualized physiologic adaptations of the elderly and medication prescription safety will lead to the correct answer. If this was difficult, review safe medication use and the elderly. |
‐ Chlordiazepoxide (Librium) ‐ Trazadone (Desyrel) ‐ Lorazepam (Ativan) | |
3462 The client with a bipolar disorder is being discharged Correct answer: 3 The primary reason for re‐hospitalization is that a client with bipolar disorder stops taking today on lithium. Which of the following would be the medication (option 3). There will always be other problems in families and in life (options 1 most likely reason the client will be readmitted to the and 4), but these do not necessarily bring the client back to the hospital. If the client decides to inpatient unit? lose weight, this in itself does not indicate that the client will need to be hospitalized. ‐ There will be a crisis in the client's family. ‐ The client will begin a diet regime to lose weight. ‐ The client will stop taking lithium as prescribed. ‐ The client's spouse will become seriously ill. | Note that the reason the client is placed on lithium is to control the bipolar disorder. By using the process of elimination, omit answers that relate to problems in a client s life requiring adaptation (choices 1 and 4) without hospitalization. A person losing weight can be eliminated, since it is not life‐threatening. If this was difficult, review bipolar disorders and medication treatment modalities. |
3463 The nurse is working in the Emergency Department Correct answer: 4 The nurse should ask if the client is taking disulfiram (option 4) because this medication when a client is brought in vomiting profusely and causes the adverse reactions described in the question when alcohol is also ingested. Option 1 smelling of alcohol. The client keeps repeating, "It's the is not highest priority, because the smell of alcohol indicates that the time of the last intake medicine that's doing it; if I live through this, I'll never was relatively recent. Options 2 and 3 are not the first questions that the client should be drink again." Based on what the client is saying, you asked in this situation because they do not relate to the issue of vomiting and drug begin your assessment by first asking the client: interactions. ‐ "When was the last time you drank alcohol?" ‐ "Are you taking antihypertensive medications?" ‐ "Have you eaten today?" ‐ "Are you taking Antabuse?" | Note the word “first” in the question stem. Recall knowledge of the side effect vomiting of the medication disulfiram (Antabuse) to eliminate the other choices. The first part of the assessment is to determine if the client is taking medication that results in the symptoms. If this was difficult, remember assessment is always the first step in the nursing process, and care begins with assessing the client first, whether subjectively or objectively. |
3464 The client states, "Before I came to the hospital this Correct answer: 4 The nurse should refer the client back to the physician for clarification rather than try to time, I used to take Tofranil for my depression. The second‐guess the physician's thoughts or speak for the physician. Option 1 is not appropriate doctor said he thought it was time for me to change to because there is no basis for the statement. Option 2 is only one aspect of the difference a newer medicine, but I can't remember what he said between a tricyclic antidepressant and a selective serotonin reuptake inhibitor, and it does not about why this Zoloft would be better for me." The address the client's concern. Option 3 is accusatory, and therefore inappropriate. nurse's best response to this client would be which of the following? ‐ "Maybe the physician didn't think the Tofranil was working anymore." ‐ "I know there are fewer side effects with Zoloft than with Tofranil." ‐ "Did you always take the Tofranil as prescribed?" ‐ "Would you like me to get the physician so you can talk with him about this?" | Note that the question is asking for the “best” response. The question is asking why the physician changed the medication, and the only answer that would address this is option 4. Since the client would like to know why the medication was changed by the physician, the best answer is for the client to speak to the physician. If this was difficult, review depression and medication treatment modalities. |
3465 The client is visiting the clinic today after taking Correct answer: 3 Option 3 is correct. Clients taking fluoxetine usually demonstrate weight loss. The client needs fluoxetine (Prozac) 20 mg PO daily in the morning for to weigh himself daily and adjust nutritional intake as necessary. The client will need to three weeks. He is complaining of weight loss of 10 increase his caloric intake (option 2), not his fluid intake. The client does not necessarily need a pounds in the last two weeks, but states he has not change in medication (option 1). Option 4 is incorrect; it will take 3–4 weeks for the effect of changed his diet at all. The nurse would draw which of the medication to be seen. the following conclusions from this assessment data? ‐ The client will need to have a change in medication. ‐ The nurse will need to instruct the client on how to increase his daily fluid intake. ‐ This is a normal effect for clients taking fluoxetine. ‐ The physician needs to decrease the dosage of the medication. | Recall knowledge of the side effect weight loss with the medication fluoxetine (Prozac) to select the correct answer, option 3. The other options are not appropriate, as they do not address the client's concern of weight loss. If this was difficult, review the side effects of the medication. |
3466 A client is experiencing recurrent hiccups. The nurse Correct answer: 3 Chlorpromazine (Thorazine) is not only the oldest of the antipsychotic medications; it can also telephones the physician, anticipating an order for be used for relief of intractable hiccups. Risperidone (option 1), molindone (option 2), and which of the following phenothiazines that is also used thioridazine (option 4) do not have this effect. as an antipsychotic agent? ‐ Risperidone (Risperdal) ‐ Molindone (Moban) ‐ Chlorpromazine (Thorazine) ‐ Thioridazine (Mellaril) | Recall knowledge of treatment of hiccups and the use of the medication chlorpromazine (Thorazine) to be led to the correct answer. None of the other medications are used for the treatment of hiccups. |
3467 The client is taking haloperidol (Haldol) 2 mg t.i.d. The Correct answer: 2 Haloperidol is a high‐potency antipsychotic. Option 1 is not a classification of antipsychotics. nurse plans to assess the client frequently for dystonia, Options 3 and 4 are valid classifications of antipsychotics, but they do not describe haloperidol. parkinsonism, and akathisia as adverse effects of this: ‐ Relative‐potency antipsychotic. ‐ High‐potency antipsychotic. ‐ Medium‐potency antipsychotic. ‐ Low‐potency antipsychotic. | Use the process of elimination and understanding of the classification of haloperidol (Haldol) to select the correct answer. If this was difficult, review the classification of the medication listed. |
3468 A client taking bupropion (Wellbutrin) 100 mg twice Correct answer: 3 Dizziness, drowsiness, headache, and insomnia are some of the common CNS adverse effects daily for two weeks is returning to the clinic. As part of of bupropion. Decreased appetite (option 1) is not a concern. Option 2 is incorrect because it the nursing evaluation, you ask the client which of the asks about depression, while bupropion is used to treat anxiety. Option 4 indicates that the following questions regarding adverse effects of the client has had hallucinations, which are not associated with bupropion. medication? ‐ "Have you experienced a decrease in appetite?" ‐ "Have you experienced a change from your depressed mood?" ‐ "Have you had any episodes of dizziness, drowsiness, headache, or insomnia?" ‐ "Are you still hearing voices?" | Recall understanding of which medical diagnosis bupropion (Wellbutrin) is used for treatment to select the correct answer. The other choices do not address the side effects of this medication. If this was difficult, review the treatment modalities for anxiety as well as the side effects of bupropion (Wellbutrin). |
3469 A client with major depression is on suicide Correct answer: 3 The nurse should observe the same safety standards of medication administration as with all precautions since being admitted two days ago. While clients. Crushing a medication and placing it in applesauce is not necessary for a client on formulating the care plan, the nurse includes which of suicide precautions unless there is a problem with swallowing or taking tablets or capsules the following interventions pertaining to safe (option 1). Option 2 is incorrect because it is not the responsibility of the nursing assistant to medication administration? remain with a client taking medications. As with all clients, staying with the client for five minutes (option 4) is not necessary for safe medication administration. ‐ Always crush the medication and put it in applesauce. ‐ Ask the nursing assistant to watch the client drink all of the water given with the medication. ‐ Observe the same safety precautions of medication administration as for all clients. ‐ Remain with the client at least five minutes after medication administration. | Recall understanding of the principles of safe medication administration to select the correct answer. The question is asking for a general answer pertaining to safe medication administration. Option 3 is the only choice that is a generalization related to safe medication administration. The other three options are specific to certain client types. |
3470 The client taking lithium carbonate (Eskalith) is having Correct answer: 4 The symptoms listed are those of lithium toxicity, and are seen when the serum level is 2–3 a difficult time walking, and is confused, agitated, and mEq/L. The other options indicate lesser serum concentrations that would not produce these complaining of blurred vision. The nurse checks the manifestations. lithium level drawn earlier in the day, expecting the level to be within which of the following ranges? ‐ 0.5–0.8 mEq/L ‐ 1.2–1.5 mEq/L ‐ 1.5–1.8 mEq/L ‐ 2.0–3.0 mEq/L | Recall knowledge of normal and toxic lithium levels to be led to the correct choice. There is only one choice that is correct and with knowledge of the laboratory value the correct answer can be selected. |
3471 The client is taking an antidepressant medication. She Correct answer: 2 In option 2, the client is demonstrating progress in returning to usual living. She is working a arrives at the clinic for a 6‐week follow‐up visit. The reasonable amount of the day, sleeping regularly, and making plans with others. In option 1, nurse evaluates the medication as being effective if the the client is sleeping too many hours each day. She is reporting very little activity outside of client: sleeping. She remains withdrawn, and demonstrates no change in mood or activities. Option 3 indicates that the client is overworking, sleeping only 6 hours each night, and still reporting feelings of depression. Option 4 alone shows no signs of change. ‐ Reports going back to work 2 hours a day and sleeping 12 hours each night and 3 hours after coming home from her office job. ‐ Is talking about vacation plans for the following month, reports sleeping 9 hours each night, working a full‐time job, and feeling less tired and anxious than she was two weeks ago. ‐ Reports working a full‐time job and being able to work at least 3 or 4 hours a week overtime, sleeping 6 hours each night, and only feeling depressed after working 10 hoursa day. ‐ Is complaining of weight gain, but obtains 3 extra hours of sleep per night. | Use the process of elimination to select the correct answer. The only correct choice is option 2, since this choice demonstrates progress toward positive activities of daily living. The other options can be eliminated, since they do not reflect effective adaptation. |
3472 A nurse has admitted a client who is undergoing Correct answer: 2 Clients undergoing withdrawal from heroin exhibit craving, lacrimation, rhinorrhea, yawning, withdrawal from heroin. The nurse expects the client and diaphoresis. Option 1 is incorrect because irritability and insomnia are seen with to exhibit which of the following during the initial withdrawal from marijuana. The manifestations listed in options 3 and 4 pertain to withdrawal phase of withdrawal? from alcohol. ‐ Irritability and insomnia ‐ Drug craving, lacrimation, rhinorrhea, yawning, and diaphoresis ‐ Tremors, agitation, anxiety, and diaphoresis ‐ Hallucinations, delusions, and increases in blood pressure and pulse | Use the process of elimination to omit incorrect choices. By having knowledge of the side effects of heroin withdrawal, option 2 can be selected as the correct answer. Options 1, 3, and 4 can be eliminated, since they are not withdrawal symptoms of heroin. |
3473 An adult client has been taking alprazolam (Xanax) 2 Correct answer: 3 Option 1 is true for the symptoms of dry mouth, but is not the priority response because it mg for generalized anxiety for the last two weeks. does not fully address the information provided by the client. Option 2 is incorrect. The client Today, he is in the clinic, and states, "I can't believe is describing expected side effects of the medication ordered to decrease anxiety, so the how dry my mouth is since I have been taking this dosage should not be changed. Option 3 is the priority because of the need for safety when stuff. And sometimes I get so dizzy and lightheaded, using a benzodiazepine, given the common side effects the client described. Option 4 will serve but otherwise it works great. I don't feel all anxious no benefit to treat or help with the described side effects. anymore." The priority response by the nurse will be which of the following? ‐ "You can use gum or hard candy or sugarless gum to relieve some of those symptoms." ‐ "You will need to have the dosage of your medication lowered today so that you will not experience the side effects you are describing." ‐ "You feel dizzy and lightheaded, which is a side effect of the medication. Don't participate in activities that require you to be alert or operate heavy equipment, which could be a safety hazard, until you no longer have these side effects or are not taking the medication anymore." ‐ "You will need to take this medication with food from now on." | Note that the question is asking for the priority response. Remember Maslow s hierarchy of needs, and answer this in consideration of safety and security, which are of high priority in the hierarchy. While option 1 does address a nursing intervention related to relief of dry mouth it is not a priority. Option 3 is the priority response, since the client is asking the nurse to validate if dizziness and lightheadedness are acceptable. This answer will respond to his question, which is the priority. |
3474 A client is beginning treatment with an Correct answer: 3 TCAs account for 70 percent of all deaths from intentional drug overdose. SSRIs are not antidepressant medication. The nurse will include usually fatal if overdose is taken. MAOIs can be fatal if the client experiences a hypertensive appropriate teaching strategies and precautions in the crisis, but MAOIs are not usually that widely prescribed because of their numerous side effects, care plan, knowing that there is a high risk for especially with tyramine‐rich foods and drug–drug interactions. Anxiolytics are not a class of successful suicide with medications in which of the antidepressants. following antidepressant classes? | Use the process of elimination and knowledge of classifications of antidepressant medications to select the correct answer. In choosing this answer, it is important to know general categorizations of antidepressants. |
‐ Selective serotonin reuptake inhibitors (SSRIs) ‐ Monoamine oxidase inhibitors (MAOIs) ‐ Tricyclic antidepressants (TCAs) ‐ Anxiolytics | |
3475 A 46‐year‐old client newly diagnosed with Correct answer: 1 It is essential to teach both the client and his mother about the medication and why schizophrenia is being discharged to home in five days. compliance is very important. Option 2 is incorrect because it places responsibility for eating The client lives in a two‐bedroom apartment with his and taking medications on the mother, not on the client, which is inappropriate. Option 3 also elderly mother, who is frail but self‐sufficient. The is incorrect because it is the client's responsibility to take prescribed medications. Family nursing care plan must include which of the following members should know about the medications and be able to support the client and remind the to promote compliance with medication client of the benefits of taking the prescribed medication, but it is ultimately the client's administration? responsibility. Option 4 is inappropriate because there is no guarantee for the client that he will remain symptom‐free indefinitely. ‐ Teaching the client and his mother about the prescribed medication and why compliance is so important to the client's ongoing recovery process ‐ Teaching the client's mother the importance of regular meals so the client can take his medication after breakfast ‐ Instructing the mother to be sure that the client is taking his medication daily as prescribed ‐ Teaching the client about his medication regime and how taking his medication as prescribed will help him remain symptom‐free indefinitely | This question asks for means for the client to be compliant with taking medication. While it is important that the client understand the way to take the medication, it is also important to involve a significant other for support. The only option that addresses the client and a significant other is option 1. Options 2 and 3 place the responsibility on the mother and not the client, while option 4 gives the client false assurance that he will be symptom‐free. |
3476 An adult client is in the clinic today for a follow‐up Correct answer: 2 Option 1 is a piece of subjective data only, and should not be the sole information for the two‐week visit. Diazepam (Valium) 10 mg was nurses' evaluation of the effects of the anxiolytic medication. Option 2 is more objective, and prescribed during the client's last visit. In order to uses previous data and present facts to evaluate the client's condition. Option 3 is false; there evaluate that there are positive effects from the should be a change observed with an anxiolytic after two weeks; and option 4 does not medication, the nurse would: address the primary effect desired for use of anxiolytics (decrease of the anxiety). ‐ Hear the client saying that she is feeling much calmer now. ‐ See a change from the very anxious person documented at the last visit to a calmer and more focused person at present. ‐ Notice nothing; there are probably no observable changes in the client's behavior after only two weeks. ‐ Hear the client describe her increased appetite and how much more she is able to do since taking the medication. | When evaluating the effects of medication, it is important to assess using subjective and objective data, but to place a higher emphasis on the objective data. |
3477 The client will be discharged to home tomorrow on Correct answer: 3 Option 3 is correct because it acknowledges the client's feelings and addresses his concerns an antidepressant medication that will be taken once while still allowing him to make decisions for his present and future. Options 1 and 2 disregard daily in the morning. He asks: "Do I have to take and negate the client's feelings. Option 4 acknowledges his concern but takes away his decision‐ medicine every day? How will I be able to sleep when I making options by having someone else (the nurse) make a plan for his daily activities, rather go home? Do you think I'll be able to work, too, even than have him participate and make decisions for himself with help. though I have been in the hospital this long?" The nurse's best response is: ‐ "The best approach is to take it one step at a time, so that everything will work out." ‐ "I understand you're worried, but you and your wife will decide tomorrow when you get home." ‐ "You seem to be worried about when you get home and how you will function. Would you like to sit and discuss a plan for your daily activities?" ‐ "I'll do my best to set up a plan for discharge that you can take home with you and refer to later." | The question is asking for the best response. Option 3 is the only choice that acknowledges that the client has specific concerns related to becoming more independent and about reentry into society. Options 1 and 2 do not acknowledge that the client has concerns. Option 4 does not allow the client to move into society, but rather makes the nurse the person on whom he must depend. |
3478 The nurse is making a plan of care for a client who is Correct answer: 3 Dry mouth occurs from the anticholinergic effects seen with fluphenazine. Options 1 and 2 prescribed fluphenazine (Prolixin) 1 mg daily at are incorrect because orthostatic hypotension is not a major side effect of fluphenazine. bedtime. The nurse will do which of the following to Confusion (option 4) is not a side effect of this agent. monitor for side effects of the medication? ‐ Remind him frequently to rise slowly when getting out of bed or from a chair. ‐ Assess for dizziness or lightheadedness frequently during the day. ‐ Make sugarless hard candy, gum, and water available during the day. ‐ Monitor for confusion frequently. | Recall knowledge of the side effects and client responses of fluphenazine (Prolixin) to select the correct answer. The only correct answer is option 3. |
3479 The school nurse is assessing a muscular 17‐year‐old Correct answer: 2 The symptoms of hair loss, the student's age, and edema indicate that this is not a stage of female who is coming to the high school health service puberty. The symptoms are not indicated in abuse of barbiturates or marijuana use. By the for complaints of edema, voice changes, and hair loss. process of elimination, the correct answer is option 2. In order to answer this correctly, you Your primary analysis based on the subjective and need to have noted the muscular build of the student and to know the signs and symptoms of objective data is that the student: illegal steroid use. ‐ Is going through a stage of puberty. ‐ Might be using steroids. ‐ Might be abusing barbiturates. ‐ Is using marijuana regularly. | Note that the question is asking for selection of the primary analysis of data. Recall knowledge of times of pubescence onset for females to eliminate option 1. Options 3 and 4 would not produce the physiologic changes mentioned in the question. The only correct answer is option 2, as the question stem lists symptoms of illegal steroid use. |
3480 The nurse is preparing a client for discharge who will Correct answer: 4 Option 4 is correct because the client is honest, has an understanding of how to take the be taking lithium carbonate. Which of the following medication and what the side effects are, and knows that the side effect will subside statements indicates that the client is feeling eventually. Options 1 and 2 indicate that the client is feeling forced to take the medication but comfortable with being discharged on an antimanic has no desire or understanding of the benefits of the daily routine and dosages. Option 3 medication? indicates that the client has memorized the actions but does not understand the benefits or side effects of the medications. ‐ "I don't want to take the medicine you will give me, but you said I have to." ‐ "I know that if I take my lithium every day, I won't have to come to the hospital again." ‐ "I have a hard time taking this medicine, and I don't like the shaking, but I will take it every day with meals, and have my blood tests done, and come back to the clinic next month for my checkup like you said." ‐ "Even though I don't like taking medicine, I will take the lithium daily with my meals and have my blood tests on the dates I marked on my calendar. I should be able to do my normal things every day, and in a couple of weeks I won't feel shaky anymore." | The question is asking for the option that demonstrates that the client is comfortable with the plan of care of the medication prescription. The only correct option is 4, as this addresses the client s understanding of the medication and the need to be compliant with the interventions needed for the plan of care. |
3481 After taking chlordiazepoxide (Librium) 50 mg in the Correct answer: 3 Option 3 is correct because it addresses the client's concern and addresses his issue. Option 1 detoxification unit, the client states: "I'm not sure I denies the client's feelings and does not address his concern. Option 2 is disrespectful, and should be taking this stuff. I'm already addicted to again does not acknowledge the client's feelings or concerns. Option 4 is incorrect because it is alcohol, and I don't want to be addicted to this stuff, disrespectful, denies the client's feelings, and does not address the client's issue. too." Which of the following would be the nurse's best response? ‐ "You will not become addicted to chlordiazepoxide, because you are only using it to help you avoid the side effects of withdrawing from alcohol and any other drugs you have taken." ‐ "You do not have to worry about that. We won't let that happen to you while you are here in the detoxification unit. The dosages are prescribed as part of protocol orders, and therefore they are safe for just about everyone." | When answering this question, it is imperative that the client s concerns are acknowledged. Option 3 is the only answer that acknowledges the feelings of the client. When answering questions in which a client has concerns, select the answer in which the feelings of the client are acknowledged. |
‐ "You seem to be worried about the addiction potential of chlordiazepoxide. This medication helps you avoid the effects of alcohol withdrawal. It is given in predetermined doses so you won't become more ill but will be safe and eventually drug‐free. That is why you are being monitored medically until you are safely withdrawn from the alcohol and the chlordiazepoxide." ‐ "The physician has ordered the right doses of the medication so that you won't become addicted. This should enable you to relax and not be concerned about this any longer." | |
3482 A client is admitted to the locked unit because of Correct answer: 3 There is a high potential risk for NMS with the use of haloperidol. Monitoring for tardive frequent auditory hallucinations. Voices are telling the dyskinesia is not indicated this early in treatment. There is no reason to monitor for intake and client to harm himself. The client is being given output (option 2). Option 4 is unnecessary, although the nurse monitors mood, behavior, and haloperidol IM. The nurse will include in the plan of orientation during therapy. care which of the following primary interventions to provide a safe environment for the client? ‐ Monitor for tardive dyskinesia (TD). ‐ Monitor intake and output every two hours. ‐ Monitor for neuroleptic malignant syndrome (NMS). ‐ Assess alertness every 15 minutes. | Use the process of elimination and knowledge of side effects of haloperidol to select the correct answer. Option 3 is the only correct answer. If this was difficult, review the side effects of haloperidol. |
3483 The nurse explains to the family of a client Correct answer: 4 It is part of standard nursing practice to evaluate the effectiveness of medications that are hospitalized for schizophrenia that the effects of administered. Option 1 is inaccurate because antipsychotic medications are not addictive. antipsychotic medication will need to be evaluated Options 2 and 3 have nothing to do with the effects of an antipsychotic medication. primarily to: ‐ Prevent the client from becoming addicted to the medication. ‐ Continually encourage the client to increase his self‐care capability. ‐ Keep the client from isolating. ‐ Assess for effectiveness of the medication. | The question is asking for utilization of the last step of the nursing process, which is evaluation. Use the process of elimination to select the only correct answer, option 4, as it evaluates the effectiveness of the medication, which is what the question is asking. If this was difficult, be sure to note what part of the nursing process the question is asking about and to select an appropriate answer that is congruent with the step of the nursing process. |
3484 The nurse would assess which of the following as the Correct answer: 3 Measuring the blood alcohol level (option 3) is the most accurate test to indicate intoxication most accurate measure of the client's level of level. Testing urine for alcohol level (option 1) is not an accurate measure for alcohol. Testing intoxication? MCV and GGT (options 2 and 4) will indicate if the individual has been using alcohol chronically. ‐ A urine test for alcohol ‐ Mean cell volume (MCV) ‐ A blood alcohol level ‐ Gamma‐glutamyl transpeptidase (GGT) | Note that the question is asking for selection of the most accurate level of intoxication. Option 3 would be the correct choice, as this is the most accurate level of evaluation of current intoxication. If this was difficult, be certain to pay close attention to the words listed as most, first, or highest priority, and select the option that is most conclusive. |
3485 The nurse determines that the client understands the Correct answer: 2 The medication normally works within ½–1 hour after administration, making option 2 effects of flurazepam (Dalmane) ordered at a dose of correct. Option 1 is incorrect because the client should not be watching stimulating shows on 30 mg by which of the following client statements? TV before trying to fall asleep. Option 3 is incorrect because the medication will not work instantly. Option 4 is incorrect because the client should not take a sedative and then stay active for ½–1 hour after taking medication. ‐ "After I take my medication at bedtime, I should be able to watch the boxing match or late‐night TV show, then go to bed and sleep." | Use the process of elimination and knowledge of client responses to flurazepam (Dalmane) to select the correct answer. Option 2 is the only correct answer, as it addresses client responses. The other options do not address client responses but more actions after the medication is taken. If this was difficult, review the medication and responses to the medication. |
‐ "Once I take my medicine, I should be able to go to bed and read, and I will fall asleep within one hour." ‐ "I will take my medicine, go to bed, and go to sleep." ‐ "I will take my medicine, make my lunch for tomorrow, take my shower, and get my clothes ready for work tomorrow, and then go to bed." | |
3486 The visiting nurse is evaluating for client safety. The Correct answer: 3 With an MAO inhibitor such as phenelzine, the client needs to eliminate foods that contain client is taking phenelzine (Nardil). A priority part of tyramine. Intake of tyramine‐containing foods could lead to severe hypertension and other the nurse's teaching component includes which of the complications. All of the other considerations are not major teaching considerations for MAO following? inhibitors. ‐ Limiting daily intake of salt ‐ Encouraging a fluid intake of at least 2,000 mL ‐ Eliminating foods containing tyramine ‐ Encouraging the client to have scheduled blood tests on time | All the options should be included in a teaching plan, but the only option that addresses safety with this medication is option 3. If this was difficult, review the side effects of the medication. |
3487 The nurse should anticipate that which of the Correct answer: 1 Methergine provides long‐sustained contraction of the uterus. It is commonly used to treat following would be included in the therapeutic plan of late postpartum hemorrhage (subinvolution). Oxytocin (option 2) and prostaglandin are more care for a postpartum client with subinvolution? frequently used to treat early postpartum hemorrhage caused by uterine atony. When blood products are used (option 4), they are generally ordered for early postpartum hemorrhage. Increased fluid intake (option 3) is a general, helpful measure for any client who has lost body fluid volume, but it is not a specific therapy. ‐ Oral methylergonovine maleate (Methergine) ‐ Oxytocin (Pitocin) IV infusion for eight hours ‐ Oral fluids to 3,000 mL per day ‐ Blood replacement | Specific knowledge of ergonovine maleate (Methergine) is needed to answer this question. Use medication knowledge and the process of elimination to make your selection. |
3488 In which postpartum client would the nurse conclude Correct answer: 3 Methergine has a side effect of raising the blood pressure. A woman with hypertension or that methylergonovine maleate (Methergine) be pregnancy‐induced hypertension would not be a good candidate for use of Methergine. An contraindicated? alternative would be necessary. The client in option 1 has a normal blood pressure, which is not a contraindication. A pulse of 60 (option 2) or respiratory rate of 12 (option 4) are not contraindications to use of Methergine. ‐ A client with a blood pressure of 120/60 ‐ A client with a heart rate of 60 ‐ A client with a blood pressure of 140/100 ‐ A client with a respiratory rate of 12 | Specific knowledge of ergonovine maleate (Methergine) is needed to answer this question. Use nursing knowledge and the process of elimination to make your selection. |
3489 A postpartum client has an epidural catheter in place Correct answer: 4 Naloxone is the antidote to the opioid analgesics that are used with epidural analgesia. If following delivery of an infant via cesarean section. respiratory depression occurs, this medication needs to be readily available for use. The nurse determines that which of the following Meperidine is an opioid analgesic, but is not used for epidural analgesia. Betamethasone is a medications is a priority to have on hand for use if glucocorticoid used to enhance fetal lung maturity before premature delivery. Carboprost is an needed? abortifacient. ‐ Meperidine hydrochloride (Demerol) ‐ Betamethasone (Celestone) ‐ Carboprost (Hemabate) ‐ Naloxone (Narcan) | The core issue of the question is a priority medication to have on hand during epidural analgesia. Use the process of elimination to select the antidote needed for respiratory depression, a priority adverse effect of epidural analgesia. |
3490 The nurse is monitoring a client in labor who is Correct answer: 1 Contractions lasting longer than 90 seconds indicate uterine hyperstimulation, which is a receiving oxytocin (Pitocin) as a continuous infusion to reason to stop the oxytocin infusion. The increase in blood pressure is not of concern. Early augment labor. Which of the following observations of decelerations of fetal heart rate do not indicate fetal distress; rather, they are a reassuring the client would indicate to the nurse that the infusion sign. Squeezing the eyes shut during contractions could have variable meanings, including needs to be stopped? coping with the contraction, and needs to be correlated with other client data for proper interpretation. ‐ Contractions lasting 120 seconds | The core issues of the question are knowledge of adverse effects of oxytocin and how to recognize them in the woman in labor. Use the process of elimination and knowledge of adverse drug effects and uterine hyperstimulation to make a selection. |
‐ Maternal blood pressure increase from 124/82 to 130/86 ‐ Early fetal heart rate decelerations on the fetal monitor ‐ The mother squeezing her eyes shut during each contraction | |
3491 The nurse is evaluating the status of a pregnant client Correct answer: 4 The danger of pre‐eclampsia is that it can progress to eclampsia, characterized by seizure receiving magnesium sulfate. The nurse concludes that activity. Magnesium sulfate is given to prevent seizures. It is not given to stabilize BP, although the medication is having the intended effect if which of it can cause a transient decline in BP. It is not given to regulate the magnesium level or uterine the following is noted? contractions. ‐ BP has stabilized at 128/76. ‐ Serum magnesium level reaches 2.2 mEq/L. ‐ Contractions are steady at a frequency of every four minutes. ‐ There is an absence of seizure activity. | The core issue of the question is the action of magnesium sulfate in a client with pre‐ eclampsia. Use drug knowledge and the process of elimination to make a selection. |
3492 The nurse notes that the client is Rh‐negative and her Correct answer: 3 An indirect Coombs' test assesses for the presence of Rh antibodies in the maternal blood. baby is Rh‐positive. Which maternal laboratory result Direct Coombs' test and bilirubin tests are conducted on the newborn. Hemoglobin is not a would be important to interpret next in determining if determinant for the administration of RhoGAM. the client is a candidate for RhoGAM? ‐ Hemoglobin level ‐ Direct Coombs' test ‐ Indirect Coombs' test ‐ Bilirubin level | The core issue of the question is the laboratory indicator that signals the need for administration of RhoGAM. Specific knowledge of this drug is needed to answer this question. Use the process of elimination. |
3493 In addition to routine assessment and care, nursing Correct answer: 3 Terbutaline, a beta‐adrenergic agent, has many maternal and fetal side effects, including care of the client who is receiving terbutaline tachycardia, cardiac arryhthmias, and pulmonary edema. In addition to taking routine vital (Brethine) to prevent premature labor should include signs, the nurse should assess for pulmonary edema. The frequency of assessment of fetal assessing which of the following as an indicator of heart tones and oral temperature depends on the intensity and length of the drug therapy, as adverse drug effects? well as surrounding circumstances. Deep‐tendon reflex assessment is not indicated. ‐ Oral temperature every two hours ‐ Fetal heart tones every 30 minutes ‐ Breath sounds every four hours ‐ Deep tendon reflexes every four hours | Use the process of elimination. The core issue of the question is knowledge that terbutaline is a beta‐adrenergic drug that can lead to adverse effects, including pulmonary edema. Use the ABCs to help focus on breathing and respiratory assessment. |
3494 A client in premature labor is scheduled to receive a Correct answer: 3 Corticosteroids such as betamethasone have been shown to enhance fetal lung maturity and dose of betamethasone (Celestone). In teaching the prevent respiratory distress. Betamethasone does not stop labor or cervical changes. A side client about this medication, the nurse would explain effect is increased risk of infection. that the purpose of the medication is to do which of the following? ‐ Stop uterine contractions. ‐ Prevent infection. ‐ Hasten fetal lung maturity. ‐ Prevent cervical dilatation. | Specific medication knowledge is needed to answer the question. Recall that a drug ending in ‐sone is likely to be a steroid, and this hastens lung maturity in the fetus at risk for premature delivery. |
3495 The nurse is preparing to administer an intramuscular Correct answer: 2 The best explanation is the one that explains the use of phytonadione. The medication is injection of phytonadione (AquaMEPHYTON) to a given to supply vitamin K, which the newborn cannot produce in the early days of life because healthy newborn. Which of the following is the best of lack of the intestinal flora needed to synthesize it. Although phytonadione does treat explanation for the nurse to give the neonate’s hemorrhagic disease of the newborn, its use in the healthy infant is prophylactic. The mother? medication is not water‐soluble, nor is it a multivitamin. ‐ “This medication will treat hemorrhagic disease of the newborn.” | Note the critical word best in the stem of the question, which tells you that more than one or all answers might be factually correct. Note also the critical word healthy, which eliminates option 1. Eliminate options 3 and 4 because they contain inaccurate information. |
‐ “This medication supplies vitamin K, which the newborn cannot produce in the first 5–8 days of life.” ‐ “This medication is a multivitamin that has many effects, including helping to produce prothrombin in the blood.” ‐ “This medication is also known as vitamin K, and it is a water‐soluble vitamin that is deficient in newborns.” | |
3496 The nurse caring for a newborn 30 minutes after birth Correct answer: 2 The nurse would give the ophthalmic dose by applying a 0.5–1 cm ribbon of ointment into would do which of the following when preparing to each lower conjunctival sac. The dose can be delayed up to an hour after birth, but not two give a prescribed dose of ophthalmic erythromycin? hours. The eyes are not cleansed or irrigated after the dose, and a new tube is used for each newborn. ‐ Withhold the dose for two hours to allow for parent–infant bonding. ‐ Administer the dose into each lower conjunctival sac. ‐ Irrigate the eyes after the dose to flush out microorganisms. ‐ Use a tube of ointment from a previous birth that has only been open two hours. | Use the process of elimination, keeping in mind principles of aseptic technique and standard procedure for administration of eye medications. |
3497 A female client comes for her 24‐week prenatal visit. Correct answer: 4 German measles is also termed rubella. Pregnant women are tested at their first prenatal The nurse midwife tells her, “Your blood tests reveal visit for immunity to rubella. If the client is found to be nonimmune, immunization will be that you do not show immunity to the German given after delivery, before discharge. measles.” Which notation will the nurse include in the plan of care for the client? “Client will need: ‐ "Rh‐immune globulin at the next visit.” ‐ "Rh‐immune globulin within two days of delivery.” ‐ "Rubella vaccine at the next visit.” ‐ "Rubella vaccine after delivery on the day of discharge.” | Look for key differences in the answers. Here we have rubella and Rh isoimmunization, both of which are tested during pregnancy. Rh isoimmunization is prevented by giving RhoGAM at 28 weeks and again after delivery if the baby is found to be Rh‐positive, Coombs'‐negative. Rubella vaccine is not given during pregnancy. |
3498 A client who is breastfeeding her newborn is to be Correct answer: 1 The rubella vaccine is prepared with a live virus; therefore, it is not appropriate to administer discharged from the postpartum unit. She has been during pregnancy. Clients are counseled to avoid pregnancy for three months after found to have no immunity to rubella, and has orders immunization. to receive rubella vaccine on the day of discharge. What is the most important instruction for the nurse to include in the discharge plan? ‐ Practice contraception and avoid conception for at least 2–3 months. ‐ Discontinue breastfeeding to prevent the infant from becoming infected with the rubella virus. ‐ Avoid contact with women who are pregnant or who suspect they might be pregnant. ‐ Have the infant screened for active rubella virus at the 2‐month checkup. | Knowledge of immunizations is critical to planning care for clients. Rubella vaccine is a live‐ virus vaccine, and therefore pregnancy should be avoided while immunity is formed. |
3499 A primigravida with blood type A‐negative is at 28 Correct answer: 1 This client statement indicates that she does not understand the fundamental indications for weeks gestation. Today, her physician has ordered a treatment of this potential blood incompatibility. If an Rh‐negative client is carrying an Rh‐ RhoGAM injection. Which statement by the client positive infant, the potential for mixing of fetal blood into the maternal system could occur at demonstrates that more teaching is needed related to midpregnancy and again at delivery of the placenta. If the infant is found to be Rh‐positive, the this therapy? client will be given RhoGAM within 72 hours of delivery to block any antigen–antibody formation. ‐ “I’m getting this shot so that my baby won’t develop antibodies against my blood, right?” ‐ “I understand that if my baby is Rh‐positive, I ll be getting another one of these injections.” ‐ “This shot will prevent me from becoming sensitized to Rh‐positive blood.” ‐ “This shot should help to protect me in future pregnancies if this baby is Rh‐positive, like my husband.” | Mapping out the case management of a client with Rh‐negative blood is helpful in choosing potential interventions throughout pregnancy. |
3500 Aerosol therapy is an important part of the therapy Correct answer: 3 Aerosol medications are delivered via a liquid mist, which delivers medication to the lower for a pregnant woman with an exacerbation of asthma. respiratory tract. Postural drainage would be done if indicated. The droplets need to be small, Which of the following factors is most important for not large. Drugs are always administered during pregnancy after evaluating both the benefit to the nurse to consider in delivering aerosol medication? the mother and the risks to the fetus. ‐ It is used instead of postural drainage. ‐ The particles of moisture produced must be large enough to dilate the bronchioles. ‐ The aerosol delivers medication to the lower respiratory tract. ‐ Unlike with many pulmonary diseases, medications administered through aerosol therapy are contraindicated in pregnancy. | Remember the underlying principle of respiratory care entailing postural drainage, mist oxygen that delivers medication to the lower respiratory tract, and oral medications to decrease viscous secretions. The pregnant client actually breathes in more volume than the nonpregnant client. The nurse would be wise to monitor the fetal effects of the medications given to the mother; in this case, beta‐adrenergic agents cause fetal tachycardia. |
3501 The nurse explains to a new nurse orientee that Correct answer: 3 The neonate intestinal tract is sterile at birth. Colonization of bacteria in the gut necessary for phytonadione (AquaMEPHYTON) needs to be vitamin K synthesis takes approximately a week to occur. The other options listed contain administered to the neonate for which of the following incorrect rationales. reasons? ‐ It prevents gonorrhea, and it is a state law. ‐ It inhibits the production of prothrombin by the liver. ‐ The neonate lacks the intestinal flora for vitamin K production. ‐ The neonate cannot synthesize phytonadione. | Vitamin K is critical to normal clotting; careful attention to the subtle differences in the available answers will support better scores. |
3502 A pregnant client is receiving magnesium sulfate. The Correct answer: 2 Magnesium sulfate is a CNS depressant; therefore, disappearance of the patellar or knee‐jerk nurse evaluates which of the following as a sign of reflex would indicate serious CNS depression. The other options do not indicate adverse excessive blood levels of the drug? effects of the medication. ‐ Development of seizures ‐ Disappearance of the knee‐jerk reflex ‐ Increase in respiratory rate ‐ Increase in blood pressure | Remember your CNS assessments and that the patellar reflex is a specific indicator of CNS integrity. In a client receiving magnesium sulfate, you would expect the patellar reflex to be diminished but not absent. |
3503 After receiving magnesium sulfate, a client develops Correct answer: 4 The antidote for magnesium sulfate is calcium gluconate. The other drugs listed are not. signs of toxicity. The nurse should be prepared to administer which of the following? ‐ Oxygen ‐ Epinephrine ‐ Potassium chloride ‐ Calcium gluconate | Calcium gluconate is an antidote for excessive magnesium sulfate, and safe practice indicates that this drug should be available at the bedside. |
3504 Before administering IV magnesium sulfate therapy to Correct answer: 3 Excretion of magnesium sulfate is primarily accomplished through the renal system. Critical a client with pregnancy‐induced hypertension, the assessments prior to administration of the drug would be focused on the body's ability to nurse would assess which of the following parameters excrete the medication and the status of the CNS. Both assessments should be within normal that have highest priority? limits, or the prescribing health care provider should be notified. ‐ Urinary glucose, acetone, and specific gravity ‐ Temperature, blood pressure, and respirations ‐ Urinary output, respirations, and patellar reflexes ‐ Level of consciousness, funduscopic appearance, and knee reflex | The key to correctly answering this question is to focus on indications for stopping the drug; if these signs are present prior to administration, they must be reported to the prescriber. |
3505 During the administration of magnesium sulfate to Correct answer: 2 Magnesium sulfate is an anticonvulsant medication given to pregnant women with pre‐ the client with pre‐eclampsia, the nurse would observe eclampsia to diminish the risk of convulsions. The drug is a CNS depressant and therefore acts for which of the following toxic effects of the drug? to reduce central nervous system activity. CNS activity should not be absent. ‐ Dry, pale skin | Remember that CNS depressants should diminish reflex activity, not stop it altogether, or the client will cease respiratory and cardiac function. |
‐ Hyporeflexia ‐ Agitation ‐ Increased respirations | |
3506 A client in active labor is to have an epidural block. Correct answer: 4 Epidural medications cause vasodilatation, which can lead to hypotension. This is the primary While this is being administered, which of the risk factor the nurse needs to monitor after placement. Other considerations can be following the nursing actions takes priority? considered once the client's ABCs are stable. ‐ Checking the uterine contractions for an increase in strength ‐ Positioning the mother flat in bed to avoid postspinal headache ‐ Telling the mother she will feel the need to void more frequently ‐ Monitoring the maternal blood pressure for possible hypotension | Remember that many local anesthetics cause vasodilatation. |
3507 While a client is receiving magnesium sulfate for Correct answer: 3, 4, 5 The most critical incident that could occur in a client receiving magnesium sulfate is toxic CNS severe pre‐eclampsia, the nurse would carry out which depression, which could affect respiratory and cardiac function. Therefore, the antidote should of the following appropriate nursing interventions? be available at the bedside. The nurse should assess for patellar reflexes to detect excessive Select all that apply. dosing. It is also important to keep the room quiet. It is not necessary to prepare for precipitous birth (option 2) or severely limit fluid intake (option 1). ‐ Limit fluid intake to 1000 mL/24 hours. ‐ Prepare for the possibility of a precipitate delivery. ‐ Restrict visitors and keep the room darkened and quiet. ‐ Obtain calcium gluconate for use as an antagonist if necessary. ‐ Assess for patellar reflexes. | The critical word in the stem of the question is appropriate, which tells you that the correct options are also correct interventions. Use knowledge of magnesium sulfate and the process of elimination to make a selection. |
3508 After consulting with the health care provider, the Correct answer: 1 Very common substances to be avoided during pregnancy include aspirin, caffeine, cough and nurse explains to a woman who has just found out she cold products, stimulants (such as diet pills), and nicotine, but acetaminophen generally is safe is pregnant that which of the following common drugs and effective for occasional use. may be taken if needed during pregnancy? ‐ Cough and cold products ‐ Diet pills ‐ Acetaminophen (Tylenol) ‐ Aspirin | Specific knowledge of the adverse effects of various drugs on the developing fetus is needed to answer the question. Take time to review this material if the question was difficult. |
3509 Which statement by the nurse to a group of pregnant Correct answer: 4 Almost all forms of drugs in the maternal circulation can be readily transferred to the women who plan to breastfeed best reflects the need colostrum and breast milk. For this reason, women should use drugs only if necessary during for cautious medication use during lactation? lactation. The statements contained in the other options are not true. ‐ "Almost half of mothers probably should not breastfeed, because there are many interactions between drugs and foods." ‐ "Because a single dose of almost any drug is not of much concern, breastfeeding is a preferred method of feeding the newborn." ‐ "As long as the pregnant woman delivers at term, the infant's liver is well developed, and so the mother can take several commonly used medications." ‐ "Most drugs that enter the mother's bloodstream can be readily transferred to the breast milk." | Use basic principles of drug distribution to make your selection. |
3510 The neonatal nurse assigned to work with a newborn Correct answer: 3 The neonate has as immature renal system, and cannot metabolize medications effectively. interprets that which infant‐related factor adversely This places the neonate at risk from the viewpoint of pharmacokinetics (absorption, affects the neonate with respect to pharmacokinetics? distribution, biotransformation, and excretion). The neonate might not have hyperactive bowel sounds; the musculoskeletal system is not necessarily weak; and thermoregulatory issues can affect temperature regulation, but would not directly affect pharmacokinetics, making option 3 the best answer. ‐ Hyperactive bowel sounds ‐ Weak musculoskeletal system ‐ Immature kidney function | Use knowledge of fetal and newborn growth and development to make a selection. Recall that most drugs are affected by the liver and kidneys to help guide your selection. |
4.‐ Insufficiently developed thermoregulation | |
3511 A woman who is lactating needs to take a medication. Correct answer: 1 If a breastfeeding mother must take medication, it is suggested that the dose be timed The nurse explains that the drug effects on the infant immediately after breastfeeding to maximize the time span before the next feeding. This will can be minimized by taking the drug at which of the allow for the greatest amount of the drug to be metabolized and excreted. The other time following times? frames listed provide less time for clearance from the maternal bloodstream, and therefore can cross into the breast milk more readily. ‐ Immediately after breastfeeding ‐ Immediately before breastfeeding ‐ One hour before breastfeeding ‐ Two hours after breastfeeding | Use basic principles of pharmacokinetics and knowledge of growth and development to help guide your selection. |
3512 While caring for a client receiving total parenteral Correct answer: 1 TPN contains a 20–60% glucose solution, which often causes hyperglycemia and is routinely nutrition (TPN), nursing responsibilities will include regulated by giving regular insulin. The solution should be clear and homogenous without which of the following? layering or cracking. TPN solutions are infused at a steady rate. An alternative solution would be used to adjust fluids for urine output, NG losses, etc. Injection caps are changed per institution protocol, usually every 72 hours. More frequent changes increase risk for bacterial contamination. ‐ Covering elevated blood glucose levels with a sliding scale of regular insulin ‐ Inspecting solution to ensure "layering" of contents is present ‐ Adjusting rate of solution to client's output every shift ‐ Changing injection caps on the intravenous tubing every shift | The question asks for nursing responsibilities and the wording of the question indicates the correct option is also a true statement. Recall TPN solutions contain high concentrations of glucose. Systematically eliminate incorrect options, choosing option 1, which addresses the high glucose content. |
3513 Clients suffering from profound malnutrition may Correct answer: 1 Magnesium, potassium, and phosphate levels may drop because magnesium (needed for ATP experience the refeeding syndrome when first synthesis) and phosphorus (a component of ATP) are utilized rapidly as the TPN solution is initiating total parenteral nutrition (TPN). To metabolized, and potassium is taken up intracellularly in energy metabolism. Blood sugars are determine if this occurs, the nurse must do which of checked frequently but are not related to the refeeding syndrome. Bowel sounds and level of the following? consciousness would be part of a routine assessment but do not reflect refeeding syndrome. ‐ Monitor potassium, phosphorus, and magnesium levels closely. ‐ Check blood glucose levels every 6 hours. ‐ Assess client for hyperactive bowel sounds. ‐ Assess client's level of consciousness every shift. | The question requires specific knowledge of the refeeding syndrome. Eliminate option 4 because it is unrelated to the other 3 options. Eliminate option 3 because TPN is often given to rest the bowel. Choose option 1 over 2 because it is more specific and blood sugars are specifically connected to hyperglycemia. |
3514 Which of the following conditions leads the nurse to Correct answer: 3 TPN solutions contain hypertonic glucose (20–70%), which would cause severe irritation and conclude that a client's total parenteral nutrition (TPN) phlebitis to a peripheral vein. Central veins are much larger, and the solution becomes diluted solution needs to be administered through a central quickly. A rate of 150–200 would provide excessive fluid volume and calories. The infusion is of venous catheter? a high caloric content, but this fact does not explain why it must be given centrally. Peripheral sites do require more frequent changes, but frequency of changes does not influence the decision to use a central vein. ‐ The client will be receiving fluids at a rate of 150–200 mL/hr. ‐ The client will be receiving an infusion with a high caloric content. ‐ The end concentration of dextrose in the solution will be 25%. ‐ The use of a peripheral vein would require more frequent site changes. | Recall the effect of osmolarity on blood vessels. Eliminate option 1 because it is an excessively high flow rate. Options 2 and 4 are correct statements but can be eliminated because they are not as specific. Option 3 gives a justification. |
3515 A client recovering from multiple trauma is started on Correct answer: 1 TPN provides a readily available source of carbohydrates, fats, and proteins in order to total parenteral nutrition (TPN) therapy. The nurse restore or maintain positive nitrogen balance. Recovery from multiple trauma utilizes protein determines that which of the following is a major goal and fat stores, leading to a negative nitrogen balance. TPN provides some hydration and helps of this therapy? to maintain urine output, but the primary purpose is to spare the body's own energy stores. Trace minerals are added to TPN solutions but are not the primary reason TPN solutions are used. | A key word in the question is major, indicating some or all of the options may be correct, but one is considered more important. Recognize the major purpose of TPN is to provide calories and nutrition. Choose option 1 because it is more global and pertains to the nutritional needs. |
‐ Prevent a negative nitrogen balance in the client. ‐ Maintain a high urine output. ‐ Provide adequate hydration. ‐ Ensure client receives needed trace minerals. | |
3516 A 46‐year‐old male client has had a central venous Correct answer: 1 Inspiration into a deflated lung produces sharp chest pain as resistance to airflow is met and catheter inserted in the subclavian vein recently so is a sign of a pneumothorax. Oxygenation would decrease as ventilation capacity is decreased, that he can be started on total parenteral nutrition but this effect could be attributed to many factors and is not the best indicator of a (TPN) therapy. Which of the following assessment pneumothorax. A rapid pulse is also not a specific indicator of pneumothorax. A red and findings best indicates the client may have a swollen insertion site is a sign of irritation or infection. pneumothorax? ‐ Client complains of sharp chest pain. ‐ Pulse oximetry is 90% on room air. ‐ Catheter insertion site is red and swollen. ‐ Radial pulse is rapid. | Note the question asks for the best answer, indicating one option is a better choice. Omit options 2 and 4 because they could be symptomatic of many respiratory and cardiovascular problems. Omit option 3 because it is the least related to a respiratory problem. |
3517 A 34‐year‐old female client recovering from severe Correct answer: 3 A 2‐pound weekly gain is the ideal weight gain when TPN is given to restore nutritional weight loss secondary to Crohn's disease is being balance and improve weight. It demonstrates the treatment is effective. Maintenance of discharged and has received instructions on home weight would be a goal if weight gain were not desired. Weight gains of 1 pound or less per parenteral nutrition. The nurse instructs the client to week are less than desirable. weigh herself weekly, suggesting the desired goal of therapy is: ‐ To maintain current weight. ‐ A weight gain of 0.5 pound per week. ‐ A weight gain of 2 pounds per week. ‐ A monthly weight gain of 4 pounds. | Key words in the question are weekly and desired goal. Also note the client is receiving the TPN to improve weight. Eliminate option 1 because a weight gain is desired. Eliminate option 4 because it is monthly; a weekly goal is desired. Choose option 3 over 2 because it gives an easily measurable weight (as some scales do measure half pounds). |
3518 Total parenteral nutrition (TPN) is being started on a Correct answer: 2 A baseline weight is needed to provide a foundation for clinical therapy and to assess client with malabsorption syndrome. Prior to starting response to treatment. The calculation of nutrients is done by a dietitian. It is not necessary to the infusion, nursing responsibilities will include which have a baseline EKG. Client should be assessed for allergies to eggs. of the following? ‐ Calculating the nutrients needed for an individualized formula ‐ Obtaining a baseline weight ‐ Ensuring an EKG is performed on client prior to starting infusion ‐ Checking for allergies to wheat | Recall the nurse's role in hanging TPN and the content of the solution. Eliminate option 1 because it is not the nurse's responsibility. Eliminate option 3 as unnecessary and option 4 as incorrect. |
3519 Prior to hanging a total parenteral nutrition (TPN) Correct answer: 1, 3, 5 In addition to the base solution, TPN contains electrolytes, minerals, and multivitamins. solution, the nurse checks the content of the solution. Regular insulin may be added, but NPH cannot. If diuretics are needed because of underlying Which of the following ingredients would the nurse client condition, it would not be added to the TPN solution. expect to be included? Select all that apply. ‐ Trace minerals ‐ NPH insulin ‐ Electrolytes ‐ Diuretic ‐ Multivitamin | Specific knowledge of the content of TPN is needed. Systematically eliminate ingredients that you recognize would not be appropriate. |
3520 A client is receiving an infusion of TPN at 83 mL/hr. Correct answer: 91 If TPN infusion is interrupted, the nurse should not play "catch up," but TPN can be safely The infusion is stopped for 4 hours while client is off restarted at up to 10% of the baseline rate with an appropriate order to help replace nutrients the nursing unit. When the client returns, the standing missed. order indicates the infusion should be restarted at a rate of 10% greater than the baseline rate. The infusion should be run at mL/hour. Write in a numerical answer. | Correctly calculate by multiplying the baseline rate of 83 by 10%. The exact calculation of 91.3 is rounded to the nearest tenth, making the correct answer 91 mL.<BR /> |
3521 The nurse is careful to ensure that when a client's Correct answer: 4 TPN should be gradually discontinued over a 24–48 hour period to allow for adjustment in total parenteral nutrition (TPN) infusion is metabolic function and prevent a sudden drop in blood glucose. Refeeding syndrome occurs discontinued, it is done gradually. The client questions when TPN is first initiated. Hypovolemia and hyponatremia are not as significant a risk as why gradual tapering is necessary. The nurse responds hypoglycemia. that this measure will prevent which of the following? ‐ Refeeding syndrome ‐ Hypovolemia ‐ Hyponatremia ‐ Rebound hypoglycemia | The question indicates the action should be done gradually, implying that abrupt withdrawal would have consequences. Consider each option in terms of what would occur if the solution were stopped suddenly. Eliminate option 1 because refeeding syndrome occurs at the beginning of TPN therapy. |
3522 The nurse is preparing to hang the next scheduled bag Correct answer: 2 It is recommended that TPN be brought to room temperature before infusing to prevent of total parenteral nutrition (TPN) solution. Prior to client discomfort and lowering of body temperature. It is not necessary to irrigate the IV line hanging the bag, the nurse does which of the with heparin or saline. Bags should be changed using aseptic technique, but sterile gloves are following? not needed. ‐ Irrigates the intravenous port with Heparin ‐ Removes solution from refrigerator 1 hour prior to hanging it ‐ Infuses 100 mL of normal saline to clear the intravenous line ‐ Has sterile gloves available to use when changing bags of solution | Knowledge of nursing responsibilities related to TPN is necessary. Although protocols differ among institutions, the options are general and apply to basic principles. Eliminate option 4 because sterile technique is not used when changing IV bags. |
3523 A subclavian catheter has been inserted in a client Correct answer: 2 Confirmation of correct catheter placement is essential before TPN is started to assure who will be receiving total parenteral nutrition (TPN). infusion will enter the superior vena cava. Confirming client is afebrile and obtaining a baseline Before beginning the infusion, it is most important for weight are also important, but not of highest priorty. Intake and output should be monitored the nurse to do which of the following? once TPN is started. ‐ Obtain a baseline weight. ‐ Confirm x‐ray report of correct catheter placement. ‐ Determine client is afebrile. ‐ Check intake and output for the past 24 hours. | The core concept in the question is identifying the action that must be taken before therapy can be started, and the key word is most, indicating all or some of the options are important, but one has a higher priority. Analyze each option and choose option 2 because it is most critical. |
3524 A client is receiving a continuous total parenteral Correct answer: 1 The client is at greater risk for hyperglycemia because he or she is both receiving TPN and nutrition (TPN) solution and is also on a regular diet taking in additional calories on a regular diet. Assessing urine output, offering a nutritional while recovering from a multiple trauma. Which of the supplement, and encouraging high‐protein foods are all appropriate, but not of highest following nursing actions is of most importance when priority. caring for this client? ‐ Monitor blood glucose levels closely. ‐ Assess urine output. ‐ Encourage intake of high‐protein foods. ‐ Offer nutritional supplements at bedtime. | Recall TPN solutions contain a high caloric content and, combined with another source of calories, will increase risk of hyperglycemia for client. The key word in the stem is most, since all of the options are correct. |
3525 A client admitted with malnutrition has received total Correct answer: 3 Prealbumin levels are the best indicators of protein stores and nitrogen balance, reflecting parenteral nutrition (TPN) for 2 weeks. To best the client's nutritional status. Checking blood glucose levels assesses for hypoglycemia and evaluate the effectiveness of the treatment, the nurse hyperglycemia. Assessment of weight gain is indicated but is not the best indicator of should do which of the following? nutritional status because fluid retention may influence the weight gain. Skin turgor is a measure of hydration status. ‐ Monitor recent blood glucose levels. ‐ Check for recent weight gain. ‐ Check prealbumin levels. ‐ Evaluate skin turgor. | The question asks that you evaluate effectiveness of treatment. A key word is best, indicating that some or all options are partially correct. Eliminate options 1 and 4 because they don't measure an outcome of treatment. Choose option 3 over 2 because it is a more specific measurement. |
3526 The nurse is assisting a student nurse in the Correct answer: 1 Aseptic technique is used when changing solution bags. Sterile gloves are not needed and preparation of a continuous infusion of total would be contaminated as soon as the outside of the bag is touched. TPN requires use of a parenteral nutrition (TPN) solution. The nurse special micron filter. Solutions that are layered or cracked should not be used. The primary recognizes that which action by the student is provider must order the content of TPN. unnecessary? ‐ Dons sterile gloves when connecting tubing to the solution bag ‐ Attaches tubing that contains a micron filter to the solution bag ‐ Checks solution for evidence of layering and cracking ‐ Verifies orders are current for TPN | The word unnecessary is significant and indicates that three of the options are important or required for the task. Analyze each option for appropriateness to TPN therapy. |
3527 The client has been receiving total parenteral Correct answer: 2 The client's body has adjusted to higher blood glucose levels as a result of receiving TPN with nutrition (TPN) for several days. The central venous high dextrose concentrations. Abruptly stopping TPN can result in hypoglycemia. The other access device became dislodged and the nurse notes answers are incorrect. that the client's IV has not been running for several hours. The nurse would monitor the client for which of the following complications related to the stopped infusion? ‐ Hypocalcemia ‐ Hypoglycemia ‐ Sepsis ‐ Hyperkalemia | Select the response that would best correspond to abrupt withdrawal of the major component of TPN, which is glucose. |
3528 A nurse has obtained a unit of packed red blood cells Correct answer: 1 Vital signs are taken immediately prior to beginning the transfusion. Because most blood (PRBCs) from the blood bank. She and another nurse transfusion reactions occur within 15 minutes of starting infusion, it is of great importance to have confirmed that it is the correct blood for the establish the pre‐infusion baseline immediately prior to beginning the transfusion. Skin color, patient. Immediately prior to starting the blood hemoglobin levels, and renal function would be important considerations; however, it would transfusion, the nurse should assess which of the not be essential that such assessments take place immediately prior to the start of the following? transfusion. ‐ Vital signs ‐ Skin color ‐ Hemoglobin level ‐ Creatinine clearance | The question focuses on the action that should be taken immediately prior to beginning the transfusion. |
3529 A nurse is preparing to administer a unit of packed Correct answer: 4 Normal saline is the solution of choice when used as an adjunct to a transfusion. Ringer's red blood cells (PRBCs). When obtaining the necessary lactate and dextrose solutions are contraindicated due to the potential for clotting and supplies, the nurse would obtain which of the hemolysis. following IV solutions to hang with the unit of blood? ‐ Ringer's lactate ‐ 5% dextrose in 0.9% sodium chloride ‐ 5% dextrose in 0.45% sodium chloride ‐ 0.9% sodium chloride | The focus of the question is compatibility of blood with intravenous solutions. Use nursing knowledge and the process of elimination to make a selection. |
3530 A nurse returns to evaluate a client who has been Correct answer: 3 Circulatory overload is a complication associated with rapid transfusion administration. receiving a blood transfusion for the past 30 minutes. Symptoms include bounding pulse, dyspnea, and crackles in the lungs. Crackles in the lungs The client is observed to be dyspneic. Upon would not be associated with an immune response, hypovolemia, or polycythemia vera. assessment, the nurse auscultates the presence of crackles in the lung bases and an apical heart rate of 110 beats per minute. The nurse suspects that the client is experiencing which of the following complications associated with blood transfusions? ‐ Immune response to transfusion ‐ Hypovolemia ‐ Fluid overload ‐ Polycythemia vera | The core issue of the question is the ability to recognize signs of circulatory overload. Use nursing knowledge and the process of elimination to make a selection. |
3531 A nurse determines that a client receiving a unit of Correct answer: 3 The nurse is to stop the transfusion immediately and keep the IV line open with normal packed red blood cells (PRBCs) is experiencing a saline. The nurse would then notify the physician. A white blood cell count or a saline bolus transfusion reaction. The nurse promptly stops the would be ordered by the physician; however, these actions would not be independently blood transfusion and next does which of the initiated by the nurse without contacting the physician first. following? ‐ Contact the physician. ‐ Obtain a white blood cell count. ‐ Run normal saline at keep vein open (KVO) rate. ‐ Infuse a normal saline bolus. | The core issue of the question is the ability to take proper action when a transfusion reaction is suspected. Use nursing knowledge and the process of elimination to make a selection. |
3532 A client arrives at the emergency department Correct answer: 1 A transfusion of FFP is indicated for clients who are actively bleeding with a prothrombin time following a gunshot wound. The client is actively greater than 1½<BR /> bleeding and has been taking warfarin (Coumadin) therapy. His prothrombin time is twice the desired amount. The nurse expects the physician will order a transfusion with which of the following blood products? ‐ Fresh frozen plasma ‐ Random donor platelets ‐ Red blood cells ‐ Crystalloids | The core issue of the question is the ability to anticipate the need for fresh frozen plasma. Use nursing knowledge and the process of elimination to make a selection. |
3533 An adult female client has a hemoglobin level of 9.2 Correct answer: 4 Iron deficiency anemia can result from blood loss and is common in menstruating women. grams/dL. A nurse interprets that this is most likely Leukemia is reflected in the white blood cell count. Amenorrhea, the absence of menstruation, related to which of the following conditions? is unlikely to cause of iron deficiency anemia. Vitamin B<sub>12</sub> deficiency anemia is often associated with dietary deficiency, such as experienced by vegetarians or those who avoid dairy products. ‐ Leukemia ‐ Amenorrhea ‐ Vitamin B12 deficiency anemia ‐ Iron deficiency anemia | The core issue of the question is the ability to anticipate the needs of a client with iron deficiency anemia. Use nursing knowledge and the process of elimination to make a selection. |
3534 A nurse has received an order to transfuse a client Correct answer: 3 An in‐line filter is required for the administration of blood. Tubing with a microdrip, an air with one unit of PRBCs. In preparation for the infusion, vent, and tinting that protects the blood from light would not be indicated for blood the nurse selects the appropriate tubing for blood administration. administration. The nurse is aware that the tubing is manufactured with which of the following? | The core issue of the question is knowledge that an in‐line filter is required for blood transfusion. Use nursing knowledge and the process of elimination to make a selection. |
‐ A macrodrip chamber ‐ An air vent ‐ An in‐line filter ‐ Tinting that protects blood from exposure to light | |
3535 A postoperative client is to receive a transfusion of Correct answer: 3 A transfusion of platelets is indicated for the client with active bleeding. A transfusion with platelets because of a critically low platelet count. The PRBCs would result in increased hemoglobin and hematocrit levels. Platelet administration is client requests information on the benefits of the not associated with the prevention of deep vein thrombosis. The administration of platelets is transfusion. In response to the request, the nurse's not associated with the return of the prothrombin time to normal. answer should include which of the following? ‐ Improvement of hemoglobin and hematocrit ‐ Prevention of deep vein thrombosis ‐ Decrease in bleeding from surgical site ‐ Return of prothrombin time to expected range | The core issue is knowledge of platelet transfusion therapy. Recall that platelets are critical for proper blood clotting to make a selection. |
3536 The nurse has received an order to transfuse two Correct answer: 175 If a 350 mL unit of packed red blood cells is to infuse over 2 hours, the rate will be 175 mL per units of PRBCs to a client for more than 2 hours apiece. hour. The nurse notes after obtaining the first unit that it contains 350 mL. The nurse would administer the infusion at an hourly rate of mL/hour. Write in a numerical answer. | Use knowledge of pharmacological math to calculate the drip rate. |
3537 A nurse has received a report on a client being Correct answer: 1, 3 Key features of anemia include coolness to touch, intolerance to cold, tachycardia, admitted with anemia who requires a blood orthostatic hypotension, and headaches. Hypertension, bounding pulses, and diaphoresis are transfusion. The nurse will anticipate which of the not associated with anemia. following assessment findings? Select all that apply. ‐ Tachycardia ‐ Hypertension ‐ Headache ‐ Diaphoresis ‐ Bounding peripheral pulses | The core issue of the question is the ability to anticipate the needs of a client with moderately severe anemia. Use nursing knowledge and the process of elimination to make a selection. |
3538 A client is scheduled for elective surgery in 4 weeks. Correct answer: 4 An autologous transfusion involves the collection of the client's blood prior to the anticipated When the nurse in the surgeon's office initiates need, thus compatibility is not problematic and the potential for contamination is eliminated. preoperative education, the client expresses concern It would not be appropriate for the nurse to predict blood loss as a result of a surgical regarding the potential need for a blood transfusion. procedure. Further, stressing the safety of blood transfusions may elicit a false sense of The nurse's best response is: comfort for the client. While the family may be able to donate blood, this would not be as potentially beneficial to the client as an autologous blood transfusion. Not all relatives share the same blood type. ‐ "It is unlikely that you will lose that much blood during the surgery." ‐ "Blood transfusions are safer now than in the past." ‐ "Your family may be able to donate blood for you." ‐ "You may want to consider an autologous blood transfusion." | The core issue of the question is knowledge of various types of transfusions. Use nursing knowledge and the process of elimination to make a selection. |
3539 A nurse is caring for an immunocompromised client Correct answer: 4 The normal white blood cell count is between 5,000 and with cancer. A nurse would consider implementing 10,000/mm<sup>3</sup>. The nurse should consider implementing neutropenic neutropenic precautions when the client's white blood precautions when the white blood cell count is at or below cell count is: 2,000/mm<sup>3</sup>. ‐ 10,500/mm3 ‐ 7,650/mm3 | The core issue of the question is knowledge of white blood cell counts. Use nursing knowledge and the process of elimination to make a selection. |
‐ 6,000/mm3 ‐ 2,000/mm3 | |
3540 A client has experienced an adverse reaction shortly Correct answer: 2 When a transfusion reaction has occurred, the nurse must return any remaining blood to the after a blood transfusion is initiated. The nurse blood bank. If a reaction had not occurred, the nurse would dispose of the blood in an documents the event according to hospital policy and appropriate biohazard bag. It would not be appropriate for the nurse to send the blood to the does which of the following with the remainder of the laboratory or infection control department. blood that has not been transfused? ‐ Discards the blood in the appropriate biohazard bag ‐ Returns the blood to the blood bank ‐ Sends the blood to the chemistry laboratory for analysis ‐ Sends the blood to the infection control department | The core issue of the question is knowledge of critical actions to take when a transfusion reaction occurs. Use nursing knowledge and the process of elimination to make a selection. |
3541 A client with a low hemoglobin and hematocrit is to Correct answer: 1 Because the client is febrile, the nurse must notify the health care provider. The health care receive a unit of packed red blood cells (RBCs). Prior to provider will determine if the client can tolerate the transfusion or if additional therapeutic initiating the transfusion, the nurse determines that intervention is warranted, which may include the administration of acetaminophen (Tylenol) or the client’s temperature is 100.8 degrees F orally. The an antihistamine. most appropriate action for the nurse to take is which of the following? ‐ Delay hanging the blood and notify the physician. ‐ Begin the transfusion as prescribed. ‐ Administer 650mg of acetaminophen (Tylenol) and begin the transfusion. ‐ Administer an antihistamine and begin the transfusion. | The core issue of the question is knowledge of critical actions to take when a client requiring a blood transfusion has an elevated temperature. Use nursing knowledge and the process of elimination to make a selection. |
3542 A client presents to the emergency department Correct answer: 4 Albumin is used as a plasma expander and is used in the treatment of hypovolemic shock. following a motorcycle accident. The client is in Packed RBCs are indicated in the treatment of anemia. Platelets are indicated in the treatment hypovolemic shock. The health care provider has of thrombocytopenia. Cryoprecipitate is administered to treat von Willebrand’s disease and ordered plasma expansion. The nurse anticipates that fibrinogen levels below 100 mg/dL. the client will be transfused with which of the following blood products? ‐ Packed red blood cells ‐ Cryoprecipitate ‐ Platelets ‐ Albumin | The core issue of the question is knowledge of the uses of various blood products. Use nursing knowledge and the process of elimination to make a selection. |
3543 A client has received a granulocyte transfusion. The Correct answer: 3 Granulocyte transfusions are administered to neutropenic clients with infections for white nurse will assess which of the following labs to blood cell replacement. Therefore, the white blood cell count would indicate the success of the determine if the client has benefited from the treatment. The hemoglobin, hematocrit, erythrocytes, and platelet counts would not be transfusion? appropriate for evaluating this therapy. ‐ Hemoglobin and hematocrit ‐ Erythrocytes ‐ White blood cells ‐ Platelets | The core issue of the question is knowledge of appropriate outcomes of blood component therapy. Use nursing knowledge and the process of elimination to make a selection. |
3544 A client has experienced an adverse reaction to a Correct answer: 1 Diphenhydramine (Benadryl) is administered for the treatment of anaphylaxis. Benadryl blood transfusion. The client is found to have a pruritic competes with the H<sub>1</sub> receptors on effector cells, thus blocking the rash and urticaria. The nurse anticipates that which of effects of histamine. Tylenol and hydrocortisone would provide symptomatic relief from signs the following medications will be ordered for the and symptoms of a transfusion reaction. Aspirin would not be indicated for treatment of a client? transfusion reaction. ‐ Diphenhydramine (Benadryl) | The core issue of the question is knowledge of appropriate treatments for transfusion reactions. Use nursing knowledge and the process of elimination to make a selection. |
‐ Acetaminophen (Tylenol) ‐ Hydrocortisone cream ‐ Acetylsalicylic acid (Aspirin) | |
3545 The nurse recognizes albumin therapy would be Correct answer: 2 A client who has heart failure should not receive albumin therapy due to potential side effects contraindicated for which of the following clients? of circulatory failure and fluid overload that may further exacerbate the client’s cardiac status. All of the other options reflect clinical conditions whereby albumin therapy might be indicated and of benefit in the clinical setting. ‐ A client in hypovolemic shock ‐ A client with a history of congestive heart failure (CHF) ‐ A client who has hypoalbuminemia ‐ An infant with hemolytic disease of the newborn | Recall that albumin is a colloid and will increase blood volume. Recognize it is useful in the treatment of conditions in options 1, 3, and 4 and eliminate them. |
3546 A client has received 10 units of stored blood Correct answer: 2 Citric acid in the transfused blood binds with calcium; the multiple transfusions would put the following massive blood loss. The nurse plans to check client at risk for hypocalcemia. Hemolysis of cells occurs with stored blood causing the release for which of the following electrolyte imbalances? of intracellular potassium, leading to hyperkalemia. Options 3 and 4 would not be expected. ‐ Hypokalemia ‐ Hypocalcemia ‐ Hyperphosphatemia ‐ Hypernatremia | The critical words are 10 units of stored blood and electrolyte imbalance. Recognize there is an association between the transfusions and the imbalance. Recall the action of citrate used in stored blood to be directed to option 2. |
3547 A client being treated for fluid volume deficit (FVD) is Correct answer: 3 The client’s weight gain indicates retention of volume but the symptoms of extracellular fluid gaining weight as expected but remains orthostatic volume deficit (tachycardia, orthostatic, and dry mucous membranes) indicate that the fluid is and tachycardic with dry mucous membranes. The moving into a third space. Options 1 and 2 are incorrect because the presence of JVD and an nurse should assess the client for: S<sub>3</sub> heart sound would indicate fluid volume overload, and the client clearly has an extracellular fluid volume deficit. Option 4 is incorrect because the presence of elastic skin turgor indicates adequate hydration. ‐ Jugular venous distention (JVD). ‐ A third heart sound. ‐ Third spacing of body fluids. ‐ Elastic skin turgor. | Recognize the symptoms of hypotension and tachycardia indicate vascular volume is still depleted. Options 1 and 2 reflect vascular fluid excess and eliminate them. Associate the weight gain with third space fluids and choose option 3. |
3548 The nurse is reviewing the intravenous (IV) therapy Correct answer: 3, 5 A client with SIADH needs fluids with solutes. Individuals with liver disease are unable to orders for assigned clients. Which of the following IV metabolize the lactate in lactated Ringer's solution. All of the other options are incorrect orders should the nurse question? Select all that apply. because they are appropriate solutions for the indicated clients. D<sub>5</sub>W is hypotonic and provides free water for the cells of the dehydrated client. NS is isotonic and is used to replace ECF volume loss from any cause, in this case NG suction. NS is also indicated for post‐op fluid management in order to avoid significant hyponatremia from the administration of hypotonic fluid. ‐ D5W for the dehydrated client ‐ 0.9 % NaCl (NS) replacement of losses from nasogastric (NG) suction ‐ Lactated Ringer’s for the client with liver disease ‐ 0.9 % NaCl for the new postoperative client ‐ D5W for a client with syndrome of inappropriate antidiuretic hormone (SIADH) | Read each option and analyze appropriateness of the solution to the condition. Recall the liver metabolism needed for lactated ringers to choose option 3. Recall that D<sub>5</sub>W does not replace electrolytes to choose option 5. |
3549 A client presents with a blood glucose level of 620 Correct answer: 1 Significantly increased blood glucose causes osmotic diuresis with resultant fluid volume mg/dL. The nurse would expect which other abnormal deficit (FVD). Option 2 is incorrect as a decrease in CO<sub>2</sub> content laboratory values in this client? consistent with metabolic acidosis would be expected; the client is clearly experiencing diabetic acidosis with a blood glucose of 620 mg/dL. Option 3 is incorrect because FVD means an increased solute concentration in the blood or increased serum osmolality. Option 4 is incorrect because the serum potassium is generally increased in clients with FVD, even though total body potassium may be low. ‐ Increased blood urea nitrogen (BUN) ‐ Increased CO2 content ‐ Decreased serum osmolality ‐ Decreased serum potassium | The critical term is glucose of 620mg/dL. Recognize that the level is extremely elevated and would increase serum osmolarity and promote diuresis. Recognize the FVD that exists to choose option 1. |
3550 A client has received 4 units of packed red blood cells Correct answer: 4 The client receiving four units of packed RBCs for severe anemia will have an increased blood (RBCs) for severe anemia. Which of the following volume, which in turn increases blood pressure and decreases the heart rate. The heart will assessment findings would the nurse expect to see? not have to work as hard to try and oxygenate body tissues and tissue perfusion will increase. Likewise the lungs will not have to work as hard to oxygenate the blood, as greater oxygen exchange will occur at the pulmonary capillary level with more RBCs available. ‐ Increased heart rate ‐ Decreased blood pressure ‐ Decreased tissue perfusion ‐ Decreased respiratory rate | Recall that the heart rate and respirations will increase to compensate for the anemia. Recognize 4 units of packed RBCs should help to restore blood volume and compensatory mechanisms will resolve and be directed to option 4. |
3551 A client with an isotonic fluid volume deficit is being Correct answer: 4 Treatment with normal saline should expand the extracellular fluid (ECF) volume, because it is appropriately treated with normal saline solution. an isotonic fluid like the ECF. Expansion of this volume in turn will increase blood pressure, Which of the following changes would the nurse decrease heart rate, increase body weight (not decrease it), and increase urine output, expect to see in this client? because there is improved renal perfusion. Urine specific gravity should decrease, not increase, because urine will be less concentrated. ‐ A decrease in urine output ‐ An increase in urine specific gravity ‐ A decrease in body weight ‐ A decrease in heart rate | The critical term is isotonic normal saline. Recognize this fluid is used to restore ECF fluid and will not cause fluid shifts. Recognize correction of the vascular volume will eliminate the need for a compensatory increase in heart rate. |
3552 A client with congestive heart failure (CHF) who is Correct answer: 3 It is imperative that the nurse report an increase in adventitious lung sounds, because the being treated with diuretics for a fluid volume excess client's CHF could be worsening and pulmonary edema may develop. Airway, ventilation, and does not seem to be responding adequately to oxygenation are always the first priority. All of the other options should also be reported to treatment. Which of the following clinical findings is the physician because they all support inadequate treatment for a fluid volume overload, but most important for the nurse to report to the they are not the priority assessment for reporting. physician? ‐ Increase in blood pressure ‐ Increase in peripheral edema ‐ Increase in adventitious breath sounds ‐ Increase in body weight | Recall the priority of ABCs (airway, breathing, and circulation) to be directed to option 3. |
3553 After receiving 100mL of RBCs, a client develops Correct answer: 3 The symptoms indicate a hemolytic reaction, usually as a result of ABO incompatibility. lumbar pain, nausea and complains of burning at the Clumping of RBCs can block capillaries and reduce blood flow to vital organs, necessitating insertion site. After quickly assessing the client, the immediate discontinuation of the infusion. The IV line should be kept patent with normal saline nurse's next action should be which of the following? to allow for emergency access as needed. The other options would not be appropriate. ‐ Slow the infusion to half the rate at which it was infusing. ‐ Notify the physician and have another nurse monitor the client. ‐ Discontinue the infusion of RBCs and maintain the IV with normal saline solution. | Recognize the client has received approximately half of the infusion when symptoms started. Associate the symptoms of pain with blockage to organs. Recall the effect of hemolytic reactions to be directed to option 3. |
4.‐ Decrease the infusion rate and reassess client in 10 minutes. | |
3554 A client receiving a transfusion of PRBCs suddenly Correct answer: 1 The client is experiencing a severe allergic/anaphylactic reaction. The nurse should first stop sounds hoarse, begins wheezing, is diaphoretic and the infusion of any more blood. Next, the nurse should maintain the client’s airway, administer short of breath, and reports palpitations. Blood oxygen, and infuse normal saline solution through a clean IV tubing (i.e., one not contaminated pressure is 76/52. What is the priority nursing action? with blood) to maintain the intravascular volume and prevent vascular collapse. Hospital protocol may include the administration of epinephrine and steroids. It is always critical to follow current standards of care and hospital protocols during transfusion therapy. ‐ Stop the transfusion. ‐ Rapidly infuse the normal saline solution to maintain intravascular volume. ‐ Administer epinephrine and steroids. ‐ Maintain the client's airway and notify the physician. | The critical word is priority, indicating all or some of the options are correct and may be done almost simultaneously, but one takes highest precedence. Recognize the client's symptoms represent an anaphylactic response to direct you to option 1. |
3555 Which of the following actions should the nurse take Correct answer: 2, 5 A client receiving granulocytes is expected to experience fever and chills due to high potential when a client is receiving a granulocyte transfusion? for development of allergic reactions. Option 1 is incorrect because granulocytes should be Select all that apply. administered slowly as in option 5, and the client should be premedicated with antihistamines, steroids, and an antipyretic. Option 3 is incorrect because a microaggregate filter would trap the granulocytes and nullify the transfusion. Option 4 is incorrect because, although lymphocytes are present in the transfusion, they are granulocytes and the neutrophil count is the appropriate laboratory value to trend. ‐ Administer the granulocytes rapidly. ‐ Premedicate with an antihistamine, a steroid, and an antipyretic. ‐ Attach a microaggregate filter to the IV tubing. ‐ Check lymphocyte count following the transfusion. ‐ Administer the granulocytes slowly. | The critical word is granulocyte. Recall the increased risk for reactions with this type of transfusion to direct you to options 2 and 5. |
3556 Which of the following laboratory tests should the Correct answer: 2 A client with CHF has a compromised cardiac pump and therefore already has an increased nurse monitor closely in an elderly client with risk for fluid volume excess or overload. Albumin is a hypertonic colloid solution that can cause congestive heart failure (CHF) who is receiving IV circulatory overload. This represents a double risk, then, for a client with CHF. The hematocrit albumin? would decrease as the plasma volume increases (hemodilution). All of the other options are incorrect as the platelet count, PT, and serum bilirubin will be unaffected by albumin administration. ‐ Platelet count ‐ Hematocrit ‐ Serum bilirubin ‐ Prothrombin time (PT) | Critical words are elderly, CHF, and albumin. Recall the effect of albumin on fluid balance and underlying pathophysiology of CHF to direct you to option 2. |
3557 The nurse is conducting a class for oncology clients Correct answer: 2 Clients may develop HLA antibodies in response to previous transfusions of blood that are not who frequently receive blood products. The nurse leukodepleted. Since platelets carry class 1 HLA antigens, the HLA antibodies will quickly explains that if a client becomes alloimmunized, the destroy them. Therefore, attempting to match the donor’s platelet antigens with the most effective way to increase the platelet count recipient’s and then transfusing these platelets should increase the platelet count. All of the would be to: other options are incorrect because they will not reverse alloimmunization. ‐ Transfuse single‐donor platelet units. ‐ Transfuse HLA‐matched donor platelets. ‐ Use a WBC filter to minimize infusion of white blood cells. ‐ Premedicate the client with diphenhydramine (Benadryl) and acetaminophen (Tylenol). | The critical word is alloimmunized. Recall the physiology of this process to direct you to option 2. |
3558 A physician has ordered dextran for a client while Correct answer: 1 Dextran is a glucose solution that is not extracted from human plasma and therefore presents waiting for the results of the type and cross‐match. no risk of transmission of viruses. Option 2 is incorrect because dextran has a higher risk for The nurse anticipates that an advantage of using anaphylaxis as compared to hetastarch and albumin. Options 3 and 4 are incorrect because dextran for this client is that it: dextran promotes dehydration of tissues due to its hyperosmolar effect and does affect clotting factors. ‐ Contains no risk of transfusion‐related illnesses. ‐ Has a decreased risk for anaphylaxis as compared to hetastarch or albumin. ‐ Promotes hydration of tissues. ‐ Has no effect on clotting factors. | Note that dextran is being given in lieu of blood products to provide some clues to its advantages. Recall the properties of dextran to eliminate options 2, 3, and 4. |
3559 Which of the following interventions should the nurse Correct answer: 4 Hespan can dilute clotting factors and therefore create transient changes in PT, PTT, and include in developing a plan of care for a client clotting times. Option 1 is incorrect, because Hespan will not interfere with blood typing and receiving hetastarch (Hespan)? cross‐matching. Option 2 is incorrect because Hespan expands the plasma volume and thus can cause hypervolemia. Option 3 is incorrect; urine output will be increased because Hespan causes osmotic diuresis. ‐ Draw specimen for type and cross‐match prior to beginning Hespan infusion. ‐ Monitor client for signs of hypovolemia. ‐ Expect decreased urine output as body begins conserving plasma volume. ‐ Monitor for transient changes in PT, PTT, and clotting times. | Review purpose of using Hespan to expand intravascular fluid volume. Recall Hespan's effect on clotting factors to choose option 4. |
3560 A client will receive 2 units of packed RBCs. The nurse Correct answer: 3 The nurse's highest priority is client safety; therefore, it is imperative that the client know places highest priority on teaching the client which of what to report to the nurse should a reaction occur, i.e., chilling, fever, itching, shortness of the following? breath, back pain. All of the other options should be explained to the client to promote understanding and comfort, but are not the highest priority. ‐ The rationale for the transfusion ‐ Overview of the procedure so the client will know what to expect ‐ Signs and symptoms to report to the nurse if they should occur ‐ Frequency with which vital signs will be taken so as not to alarm the client | The critical word is highest priority, indicating all or some of the options are correct, but one takes more precedence. Choose option 3 since this reflects safety. |
3561 A client scheduled to receive 4 units of packed RBCs Correct answer: 3 Option 3 describes a mild nonhemolytic febrile reaction, which is the most common reaction with premedication therapy wants to know what effect and one that may be minimized through premedication. Option 1 is incorrect because hives premedication will have on reducing chances of a are a common occurrence, but airway swelling is not and will probably not be managed by transfusion reaction. The best response by the nurse to premedication alone. Option 2 is incorrect because it gives false reassurance and is the client's concern would be: nontherapeutic. Option 4 is incorrect because it suggests a possible hemolytic reaction that is uncommon and will not be minimized by premedication. ‐ "Hives and airway swelling may occur due to an allergic reaction but will be prevented by the medications." ‐ "You have no need to worry because your doctor has ordered medications to prevent a reaction." ‐ "Chilling and fever caused by previous exposure to blood or blood products may occur but these are minimized by the medications." ‐ "The premedication will prevent incompatible blood reactions that could result in shortness of breath and kidney problems." | Recall the purpose for giving premedication before packed RBCs to direct you to option 3. |
3562 A trauma victim admitted to the emergency Correct answer: 3, 5 A client who is hemorrhaging and in shock requires immediate restoration of oxygen‐carrying department is hemorrhaging, in shock, and has lost a capacity. With no time available for cross‐matching, universal donor blood (type O, Rh‐ significant percentage of blood volume. Since there is negative) is administered. Option 1 is incorrect because type AB, Rh‐positive blood can only be no time to perform a cross‐match, which of the given to type AB, Rh‐positive recipients. Option 2 is incorrect because albumin has no oxygen‐ following actions should the nurse take immediately? carrying capacity, which is essential for a trauma client. In addition, it would remain in the Select all that apply. intravascular space and would not assist in restoring blood volume and maintaining adequate circulation. Option 4 is incorrect because platelets may be administered if needed, but they are not oxygen‐carrying cells, which is the first priority. Option 5 is correct. Establishing an intravenous site should be done prior to transfusing blood products. ‐ Transfuse type AB, Rh‐positive blood. ‐ Transfuse albumin to expand the remaining plasma volume. | Recognize the need for the client to receive a blood replacement secondary to the type of fluid losses to choose the option that establishes IV access. Recall Type O is a universal donor to choose option 3. |
‐ Transfuse type O, Rh‐negative blood. ‐ Transfuse platelets to restore adequate clotting ability. ‐ Establish an intravenous line. | |
3563 A client with pretransfusion hemoglobin and Correct answer: 3 Each unit of PRBCs should raise the hemoglobin by l gram and hematocrit by 3%. Option 3 is hematocrit values of 9 grams and 27%, respectively, the only option illustrating the expected increase. The nurse should be aware of expected received two units of packed red blood cells (PRBCs) responses to therapy in order to validate that treatment has been effective. on the evening shift. The nurse determines the transfusions were effective when repeat laboratory tests indicate which of the following results? ‐ 11 grams, 33% ‐ 12 grams, 36% ‐ 13 grams, 30% ‐ 15 grams, 39% | Recall the expected changes that would be effected by a transfusion of PRBCs and multiply that by 2. |
3564 In addition to monitoring for bleeding, which of the Correct answer: 1, 5 Coumadin depresses the synthesis of vitamin K dependent clotting factors in the liver, following interventions should the nurse include in a resulting in a prolonged PT/INR (extrinsic coagulation pathway). FFP contains the needed plan of care for a client who has accidentally taken too clotting factors and will reverse the PT/INR. The PT/INR needs to be adjusted to the much warfarin (Coumadin)? (Select all that apply.) therapeutic range for client’s underlying condition. Option 2 is incorrect because the aPTT/PTT measures the intrinsic coagulation pathway. Options 3 and 4 are incorrect because neither albumin nor platelets will restore clotting factors. ‐ Check prothrombin time (PT) or International Normalized Ratio (INR). ‐ Check partial thromboplastin time (PTT) or activated PTT (aPTT). ‐ Prepare to administer albumin. ‐ Prepare to administer platelets. ‐ Prepare to administer fresh frozen plasma. | Recall the role of Coumadin in the clotting cascade to direct you to option 1 and 5. |
3565 A female client with type B, Rh‐negative blood has Correct answer: 2 A client with type B blood can only receive type B (client/recipient has no anti‐B antibodies) been exposed to Rh‐positive blood in the past. The and type O (contains no antigens for recipient to react to). Since the client is Rh‐negative and nurse will evaluate that instruction regarding blood has been previously exposed to Rh‐positive blood, the client may have antibodies to Rh‐ compatibility has been effective when the client positive blood. Therefore only Rh‐negative blood should be administered. Option 1 is incorrect verbalizes it is safe to receive which of the following because the client cannot receive type O positive blood due to the identified negative Rh types of blood? factor. Options 3 and 4 are incorrect because they each contain at least one incompatible blood type component (type A antigens and type O positive blood). ‐ Type B positive and type O positive blood. ‐ Type B negative and type O negative blood ‐ Type AB negative and type O negative blood ‐ Type A positive and type O positive blood | Recognize the risk for Rh incompatibility existing in the client to direct you to option 2. |
3566 A client in need of a blood transfusion is concerned Correct answer: 3 Option 3 is accurate and realistic and may help the client with decision making. Option 1 is about the possibility of disease transmission. Which of not accurate and offers false reassurance. Option 2 is incorrect because it involves giving the following statements by the nurse may help to "medical" advice, is nontherapeutic, and may increase client anxiety due to questioning of alleviate some anxiety for the client? treatment plan. Option 4 is incorrect because it may delay treatment and there is no evidence that designated donor blood is safer. ‐ "All blood products are absolutely safe after testing, and there is no need to worry." ‐ "If you do not want the transfusion, do not sign the consent. Perhaps the physician can give you some iron pills." ‐ "More sophisticated screening tests have made the blood supply safer, and the risk of infection, while it exists, is very low." ‐ "Have a family member or friend donate blood for you because this will guarantee its safety." | Critical words are alleviate anxiety and disease transmission. Eliminate option 1 since it is inaccurate and provides false reassurance. Eliminate option 2 since it does not answer the client's question. And eliminate option 4 since it is not totally accurate. |
3567 Which of the following blood products does the nurse Correct answer: 3 FFP is derived from one unit of whole blood and contains the clotting factors that the client anticipate the physician will order for a client needs plus fibrinogen. Option 1 is incorrect because even though whole blood contains some diagnosed with hemophilia? clotting factors, it is deficient in others and is indicated for significant acute blood loss (which is not the client's problem). Option 2 is incorrect because improved oxygen‐carrying capacity (rendered by the infusion of PRBCs) is something the client does not need. Hemophilia is a clotting disorder that requires clotting factor replacement. Option 4 is incorrect, because albumin contains no clotting factors. ‐ Whole blood ‐ Packed red blood cells (PRBCs) ‐ Fresh frozen plasma (FFP) ‐ Albumin | The critical word is hemophilia. Recall the deficiency of clotting factors associated with this illness to choose option 3. |
3568 A client received a severe burn in a house fire. On the Correct answer: 4 Protein is responsible for a significant portion of the osmotic pressure found in the blood second day of hospitalization, the physician orders the vessels and maintains fluid within the vessels. In burn injuries, protein is lost allowing fluid to client to receive albumin. Which of the following does escape into the tissues. Albumin is used to replace the lost proteins and pull fluids from the the nurse cite while explaining the rationale for interstitial space back into the vascular system. It does not contain clotting factors (option 1), albumin administration? red blood cells (option 3), nor is there enough fluid volume to consider it as part of primary fluid resuscitation (option 2). ‐ Improves the level of clotting factors and prevent bleeding ‐ Provides fluid resuscitation to prevent dehydration ‐ Replaces the lost red blood cells and reduce the anemia ‐ Provides proteins to increase the osmotic pressure in the blood | In severe burns, third spacing of fluids is the issue that replacement of plasma proteins such as albumin would be used to address. |
3569 A client is to receive his first dose of epoetin Correct answer: 3 Uncontrolled hypertension is a contraindication for the administration of epoetin because the (Epogen). Which of the following client assessment increase in hematocrit increases blood viscosity and peripheral vascular resistance. This will findings would be a contraindication to the nurse lead to a further increase in blood pressure. A hemoglobin level lower than 10 mg/dL would administering the medication? not be a contraindication, as the use of epoetin is associated with an increase in the hemoglobin and hematocrit levels. While an elevated blood glucose level is significant, it is not a contraindication for the use of epoetin. Similarly, a heart rate of 58 beats per minute would not impact the client’s ability to tolerate epoetin therapy. ‐ A hemoglobin level of 10 grams/dL ‐ A blood glucose level of 280 mg/dL ‐ A blood pressure of 180/100 ‐ A heart rate of 58 beats per minute | To accurately answer the question, the learner must understand the indication for using epoetin. Based upon this knowledge, select responses can be eliminated. An understanding of the physiological response of the medication also is necessary, as is evident in this scenario. |
3570 A client is to begin weight‐based intravenous heparin Correct answer: 6 The key to answering the question on weight‐based heparin is to identify the infusion rate, therapy for treatment of a deep vein thrombosis. The which is 6 units per kilogram per hour. Thus, to accurately obtain the information, the weight client's weight is 220 pounds. The client is to receive an must be converted from pounds to kilograms. There are 2.2 pounds per kilogram. To convert infusion of 6 units per kilogram per hour. The this amount into milliliters, it is necessary to identify how many units are in each milliliter of intravenous heparin on hand contains 100 units per available solution. milliliter. The client will receive mL of heparin per hour. Write in a numerical answer. | The client's weight in kilograms equals 100. The client is to receive 6 units per kilogram, which equals 600 units per hour. The amount of heparin on hand is 100 units of heparin per 1 mL. Thus, the client should receive 6 mL per hour. |
3571 The nurse has completed a type and crossmatch on Correct answer: 1, 2, 3, A client who has type AB blood is known as a universal recipient, and therefore can be the client she will be transfusing. The client is 4 transfused with any of the identified blood types (A, B, AB, or O). There is no type ABO. identified as having type AB blood. The nurse would be able to safely transfuse with which of the following blood types? Select all that apply. ‐ AB ‐ A | To answer the question accurately, the student must understand the principles of blood typing. Select blood types are able to receive all blood types, while others are able to donate to all blood types. |
‐ B ‐ O ‐ ABO | |
3572 A client is admitted to the medical/surgical unit with Correct answer: 2 Alcoholics are at risk for folic acid deficiency because alcohol suppresses the metabolism of liver cirrhosis related to chronic alcohol use. The client folate, from which folic acid is formed. Iron deficiency anemia often is associated with blood also is found to have a low hemoglobin level, as well as loss, increased energy demands, gastrointestinal malabsorption, and dietary deficiencies. a diminished number of circulating red blood cells. The Hemolytic anemia is associated with increased red blood cell destruction as the result of nurse suspects that the client's anemia is cause by trauma, infection, and autoimmune reactions. Vitamin B<sub>12</sub> deficiency which of the following? is associated with dietary deficiencies, malabsorption from intestinal tract, or a deficiency of intrinsic factor (Lemone and Burke, 2000). ‐ Iron deficiency anemia ‐ Folic acid deficiency anemia ‐ Hemolytic anemia ‐ Vitamin B12–deficiency anemia | Knowledge of the anemia associated with chronic alcohol use is needed to correctly identify the answer. Further, by using a process of elimination, incorrect answers can be eliminated. |
3573 A client with von Willebrand's disease presents to the Correct answer: 1 Cryoprecipitate, a product derived from plasma, contains von Willebrand's clotting factor. hospital with prolonged bleeding following a dental Packed red blood cells, granulocytes, and platelets do not contain von Willebrand's clotting procedure. The nurse is aware that the client might factor (Ignatavicius and Workman, 2002). need to be transfused with which of the following products? ‐ Cryoprecipitate ‐ PRBCs ‐ Granulocytes ‐ Platelets | Knowledge of von Willebrand's disease is needed to answer this question, as well as knowledge of the contents of each of the identified blood products. By identifying the connection between the deficit in the disease process and the supplement in the blood product, the learner can establish the relationship. |
3574 A client has been receiving intravenous heparin for Correct answer: 4 The onset of action for warfarin is slow; therefore, heparin usually is given during the first few treatment of a deep vein thrombosis. The client is to days of treatment. Therefore, the diagnosis of a deep vein thrombosis does not necessarily begin warfarin (Coumadin) therapy today. When the indicate that the client will require dual therapy. The heparin and warfarin will be administered nurse attempts to administer the warfarin, the client concurrently until the warfarin becomes effective, not necessarily until the client is discharged states "I am not taking two blood thinners. I could from the hospital. The nurse would not need to clarify the order unless a contraindication, bleed to death." What would be the most appropriate such as a previous reaction to the therapy, were identified. response from the nurse? ‐ "Both warfarin and heparin are necessary when you have a deep vein thrombosis." ‐ "I will call the physician to clarify this order." ‐ "You will only take both while you are in the hospital." ‐ "The warfarin will not become effective for several days." | The question asks for the most appropriate response. Thus, more than one response might be correct; however, one is most appropriate. To answer the question accurately, the learner must understand the pharmacotherapeutics for both of the medications. |
3575 A client with leukemia presents with dyspnea and Correct answer: 4 The purpose of the d‐dimer is to detect the presence of DIC in a client. The prothrombin time, prolonged bleeding. The client is suspected to have activated partial thromboplastin time, and white blood cell count are not specific for the disseminated intravascular coagulation (DIC). Which of diagnosis of disseminated intravascular coagulation. the following lab tests does the nurse plan to obtain to confirm the suspected diagnosis? ‐ Prothrombin time ‐ Activated partial thromboplastin time ‐ White blood cell count ‐ D‐dimer test | The key to answering the question is the client’s suspected diagnosis of DIC. The question asks for the test that would confirm the diagnosis. The process of elimination can be utilized to reach the answer. |
3576 A nurse is caring for a client with disseminated Correct answer: 3 DIC is characterized by abnormal clot formation. The widespread clotting consumes all of the intravascular coagulation (DIC). Which of the following circulating clotting factors and platelets. This is followed by excessive bleeding while blood actions by the nurse would be most appropriate? vessels are blocked by clots, leading to decreased blood flow to major organs. The nurse would not assess the client's blood pressure with an automatic cuff, obtain labs via peripheral venipuncture, or encourage the client to ambulate, due to the risk for hemorrhage. ‐ Assess blood pressure using an automatic cuff. ‐ Obtain all lab specimens via peripheral venipuncture. ‐ Assess the skin for hematomas and signs of tissue ischemia. ‐ Encourage client to ambulate at least 50 feet with assistance. | The question asks which of the actions would be most appropriate. Utilizing understanding the pathophysiology of DIC, identify the risk factors associated with the disease process. By the process of elimination, the correct answer can be determined. |
3577 A client recently was diagnosed with pernicious Correct answer: 2 Pernicious anemia is caused by the body’s failure to absorb vitamin anemia. The nurse anticipates that the client will be B<sub>12</sub>. Therefore, folic acid, iron, and albumin would not be indicated in treated with which of the following? the treatment of pernicious anemia. ‐ Folic acid ‐ Vitamin B12 ‐ Iron ‐ Albumin | To answer the question accurately, it is necessary to understand the pathophysiology of pernicious anemia. By identifying the deficiency in this type of anemia, one can anticipate the treatment. |
3578 A nurse is preparing to initiate a blood transfusion. Correct answer: 3 A 19‐gauge needle is the smallest size intravenous catheter that should be used for a blood The client does not have venous access. When transfusion. Large‐bore catheters allow cells to flow more easily, without occluding the lumen obtaining venous access, what is the smallest size of the catheter. A 20‐gauge or 22‐gauge catheter, both smaller than 19 gauges, is not intravenous catheter the nurse should use? preferable, due to the potential for occlusion. A 16‐gauge catheter is larger than a 19‐gauge but the question asks for the smallest size that can be used. ‐ 20‐gauge needle ‐ 22‐gauge needle ‐ 19‐gauge needle ‐ 16‐gauge needle | The knowledge of intravenous catheter gauges is essential to correctly answer the question. Recall that the larger the number, the smaller the diameter of the catheter. Note the critical words smallest size to focus your attention on the correct option. If you did not know the answer to the question, realize that in this type of question it may be possible that the correct answer is a number in the middle of the set provided. |
3579 A nurse is about to begin a blood transfusion of Correct answer: 3 The expiration date would be checked prior to administering the transfusion. The ABO type, packed red blood cells (PRBCs). The nurse inspects the Rh type, and requisition slip would not indicate the freshness of the product. quality of the transfusion to ensure that it does not show signs of deterioration. Which of the following would the nurse assess prior to initiating the transfusion to support the freshness of the product? ‐ ABO type ‐ Rh type ‐ Expiration date ‐ Requisition slip | To answer the question accurately, it is necessary for the learner to understand the significance of the blood type, Rh type, expiration date, and requisition slip. This would allow the elimination of select answers. The key is which of the identifiers would support the freshness of the product. |
3580 A client needs to have a type and crossmatch Correct answer: 1 Blood group antigens are present on the membrane of the red blood cell, and form the basis completed prior to administering a transfusion. The for the ABO blood categorization. The type and crossmatch do not evaluate the presence of nurse is aware that the blood type of the client antibodies on the red blood cell membrane or in the blood plasma. Antigens found in the represents which of the following? blood plasma are also not evaluated in the type and crossmatch. ‐ An antigen found on the red blood cell membrane ‐ An antibody found on the red blood cell membrane ‐ An antigen found circulating in the blood plasma ‐ An antibody found circulating in the blood plasma | Based upon the potential responses, it is evident that the blood type is either an antibody or antigen, and is located either on the red blood cell membrane or in the blood plasma. Based upon these options, the process of elimination will be useful. |
3581 A client with a critically low hemoglobin and Correct answer: 4 The nurse must respect the client's beliefs, and avoid cultural imposition. The physician hematocrit will require a blood transfusion to prevent should be made aware so that the client’s treatment plan can be reevaluated. It would not be shock. However, when the nurse approaches the client appropriate for the nurse to inform the client of the likelihood of death associated with with these findings, the client responds, "My religion declining a treatment. While the health care institution might require the client to sign an does not permit me to have a blood transfusion." against medical advise form, it would not be the most therapeutic response for the nurse. By Which of the following responses from the nurse suggesting that the client consider having a family member donate blood, the nurse is would be most appropriate? imposing personal beliefs on the client. ‐ "You will die without it, so please reconsider." ‐ "You will need to sign an AMA (against medical advice) form." ‐ "Perhaps your family could donate the blood." ‐ "I respect your wishes and will notify the physician of your beliefs." | The question asks which of the responses is most appropriate. Therefore, one or more of the responses might be correct. It is necessary to have an understanding of the ethical, legal, and cultural considerations for the client receiving a transfusion. However, given the available information, the most appropriate response would be selected. |
3582 A client with leukemia is receiving chemotherapy. The Correct answer: 2 Recall that neutrophils are granulocytes. The medication that would increase the neutrophil client is immunosuppressed, with a low absolute count is G‐CSF (granulocyte colony‐stimulating factor). Zidovudine is an antiviral medication neutrophil count. The nurse anticipates that which of and would be useful if the client had a viral infection. Raloxifene is a selective estrogen the following medications would be used in the receptor modulator that is used to reduce bone resorption in post‐menopausal women with or treatment of the client? at risk for osteoporosis. Toremifene is an antiestrogen similar to tamoxifen (Nolvadex) that is used to treat metastatic breast cancer in post‐menopausal women. ‐ Zidovudine (AZT) ‐ G‐CSF (Neupogen) ‐ Raloxifene (Evista) ‐ Toremifene (Fareston) | To answer the question correctly, it is necessary to have an understanding of the classification of each of the medications. This knowledge will allow the learner to eliminate the incorrect answers. |
3583 A client presents to the emergency department (ED) Correct answer: 1 Thrombocytopenia is characterized by a platelet count lower than with numerous ecchymotic areas on his arms, legs, and 50,000/mm<sup>3</sup>, and often presents as purple spots on the client’s skin. chest. The client's platelet count level is Polycythemia vera is characterized by an increase in hemoglobin and hematocrit levels. 45,000/mm<sup>3</sup>. The nurse Leukopenia is characterized by a low white blood cell count. Leukemia is associated with an suspects the client has which of the following overproduction of white blood cells. conditions? ‐ Thrombocytopenia ‐ Polycythemia vera ‐ Leukopenia ‐ Leukemia | The key information presented in the scenario includes ecchymotic areas and the low platelet count. By understanding the clinical presentation of all possible answers, the learner can eliminate those that do not fit with the findings presented in the question. |
3584 A client presents to the ED with chest pain and Correct answer: 2 Thrombolytics are used to treat acute thromboembolic disorders in an acute care setting. shortness of breath. The physician believes that the These agents dissolve clots via the endogenous fibrinolytic system. While anticoagulants and client is experiencing a myocardial infarction due to antiplatelets might be appropriate for the client at risk for myocardial infarction, the client thrombosis. The nurse anticipates administering which experiencing an acute myocardial infarction would be a candidate for thrombolytic therapy. of the following immediately? Beta blockers are used to prevent myocardial infarction, and are not associated with treatment of acute thrombolytic events. ‐ Anticoagulant ‐ Thrombolytic ‐ Beta blocker ‐ Antiplatelet | The question asks which of the agents will be administered immediately. While one or more of the medications might be appropriate therapy for the client with a myocardial infarction, the correct answer will be administered immediately. |
3585 A client scheduled to receive a transfusion of red Correct answer: 3 Washed RBCs are transfused when hyperactivity reactions are likely, or for those with a blood cells has a history of numerous transfusion history of reactions. Clients with a previous history of transfusion reaction are not necessarily reactions. Which of the following statements is most excluded from receiving a transfusion. While type O blood is considered the universal donor, accurate? the client still can experience an adverse reaction. While artificial blood might be available, it is not the first line of transfusion therapy for the client with a known history of transfusion reactions. ‐ "You will not be able to have a transfusion." ‐ "You will be able to receive type O blood." ‐ "You will receive washed red cells." ‐ "You will receive artificial blood." | The key to this question is to determine which of the answers is most accurate. This suggests that one or more responses may be applicable. Therefore, the learner must select the most accurate of all responses. |
3586 A client has a continuously running peripheral Correct answer: 4 Before making a decision about how to infuse the antibiotic, the nurse should check infusion. The physician orders an antibiotic as a compatibility of the antibiotic with the continuous IV solution. If the drug and the infusion piggyback infusion four times per day. In order to were compatible, they would be run at the same time. If the drug and infusion were administer the antibiotic, the nurse should do which of incompatible, the nurse would stop the infusion during the period of antibiotic administration the following? and flush the line carefully before and after the antibiotic. It is often inadvisable to start a second IV site unless absolutely necessary. The other answers are incorrect. ‐ Start a new IV access to administer the antibiotic so that there will not be compatibility issues. ‐ Start a new IV access to eliminate the problem of too much volume for one site. ‐ Increase the flow rate of the continuous infusion to facilitate the administration of the antibiotic. ‐ Check to see if the antibiotic is compatible with the continuous infusion. | The core issue of the question is the knowledge that it is critical to check for compatibilities when infusing IV solutions through the same line. Use this knowledge and the process of elimination to make a selection. |
3587 The family of a home infusion client calls the home Correct answer: 3 Alarms sound on electronic infusion devices when the infusion is complete, there is an health nurse one night to report that the electronic occlusion, air is in the line, the battery is low, or the cassette is improperly loaded. The other infusion pump is alarming. The nurse anticipates that answers are incorrect reasons for an alarm. the infusion pump alarm could be caused by which of the following? ‐ The client's pulse and blood pressure are falling. ‐ The client is experiencing a reaction to the medication. ‐ The infusion is complete or there is an occlusion. ‐ There is an incompatibility with the medications. | The core issue of this question is the ability to interpret the significance of an alarm on an infusion pump. Use knowledge of pump function in general and the process of elimination to make a selection. |
3588 The home health nurse is monitoring a client who Correct answer: 1 All catheters should be flushed with syringes with barrels of 10 mL or larger. The smaller the performs self‐care of a central line. The nurse observes barrel size, the greater the pressure that comes from the tip. Smaller syringes could damage the client doing all of the following activities. Which the catheter. All other activities are done correctly. activity indicates the need for further education? ‐ Flushing the central line with a 3 mL syringe ‐ Cleaning the needleless injection cap with alcohol before accessing ‐ Using sterile gloves to change the central line dressing ‐ Wearing a mask while changing the central line dressing | The wording of the question tells you the correct option is an incorrect statement. Use knowledge of IV catheter flush protocols and the process of elimination to make a selection. |
3589 The client has a tunneled Groshong catheter for Correct answer: 3 Groshong catheters have a three‐way pressure‐sensitive valve that restricts air from entering intermittent medication administration. After the venous system and prevents backflow of blood; therefore, the catheter should not be administering the medication, the nurse prepares to clamped and the client does not need to perform the Valsalva maneuver. The catheter is do which of the following? designed so that only saline is used to flush. The other answers are incorrect actions for catheter maintenance. ‐ Clamp the catheter. ‐ Flush the catheter with saline, then heparin. ‐ Flush the catheter with saline. ‐ Ask the client to perform Valsalva's maneuver when the medication IV tubing is disconnected. | The core issue of the question is knowledge of proper management and care of Groshong catheters. Use this knowledge and the process of elimination to make a selection. |
3590 The client has a percutaneous jugular central venous Correct answer: 1 Although it is not necessary to flush peripheral capped access devices with heparinized line that is capped and used for intermittent infusions. normal saline (100 or 10 units per 1 mL of normal saline), central venous access devices that After administering the medication, the best method are not Groshong catheters are flushed per agency protocols with heparinized normal saline. to maintain patency is to do which of the following? When medications are administered, the access device is first flushed with normal saline, then with heparinized normal saline. Heparin is incompatible with many medications, and for this reason, normal saline is used prior to the administration of heparinized saline that maintains patency of the catheter. The other answers are incorrect procedure. ‐ Flush the line first with 3–5 mL of normal saline, then with 1–3 mL of heparinized normal saline. ‐ Flush the line with 3–5 mL of normal saline. ‐ Flush the line with 3–5 mL of heparinized normal saline. ‐ Flush the line first with 3–5 mL of heparin, then with 1–3 mL of normal saline. | The core issue of the question is knowledge of proper management and care of central venous catheters. Use this knowledge and the process of elimination to make a selection. |
3591 The nurse is caring for a client with a Hickman central Correct answer: 4 One of the complications of IV therapy is air embolism, which is the introduction of air into line. While changing the central line dressing, the the vein. Air embolism can be prevented by using luer lock devices on all attachments. The nurse notes that the injection cap (e.g., heplock other responses are unrelated to this connection. adapter) is of the slip lock variety instead of a luer lock device. The nurse recognizes that this adapter puts the client at risk for which of the following complications? ‐ Sepsis ‐ Occlusion ‐ Phlebitis ‐ Air embolism | The core issue of the question is the ability of the nurse to detect situations that could lead to complications of IV therapy. Use knowledge of these risks to aid in making a selection. |
3592 The client is to receive vancomycin (Vancocin), an Correct answer: 3 The device that provides the most accurate infusion rate is the electronic infusion pump. The intravenous medication. To prevent adverse reactions other devices are less accurate and less controllable. from rapid infusion, the nurse would plan to administer this drug using which of the following methods? ‐ Gravity ‐ With a regulator ‐ Electronic infusion pump ‐ Elastomeric pump | The core issue of the question is the best method to prevent speed‐related adverse reactions from a drug infused intravenously. Use knowledge of IV infusion devices and the process of elimination to make a selection. |
3593 The physician is going to order a hypotonic Correct answer: 4 0.45% sodium chloride (one‐half normal saline) is a hypotonic solution that draws fluid from intravenous solution for a client with cellular the vascular compartment into the cells. Normal saline and lactated Ringer’s are isotonic dehydration. The nurse would expect which of the solutions, while 5% dextrose in normal saline is a hypertonic solution until the glucose is following fluids to be administered? metabolized, then it is isotonic. ‐ 0.9% normal saline ‐ 5% dextrose in normal saline ‐ Lactated Ringer's solution ‐ 0.45% sodium chloride | The core issue of the question is knowledge of the tonicity of various intravenous solutions. Use this knowledge and the process of elimination to make a selection. |
3594 The nurse is caring for several clients with central Correct answer: 1 The Groshong catheter is designed with a three‐way pressure‐sensitive valve that restricts air venous catheters. While changing the tubing on the from entering the venous system and prevents backflow of blood. The other options do not central lines, the nurse would not need to instruct the have this protection. client to perform Valsalva's maneuver when the client has which of the following catheters? ‐ Groshong ‐ Single‐lumen | The core issue of the question is knowledge of various central venous catheters and which one poses the least risk of air embolism requiring Valsalva's maneuver. Use this knowledge and the process of elimination to make a selection. |
‐ Percutaneous ‐ Accessed subcutaneous venous port | |
3595 The client is receiving 5% dextrose in 0.45% normal Correct answer: 3 0.9% sodium chloride (normal saline) is the only solution that can be administered with blood saline. The physician has ordered the client receive one or blood products. Other solutions may cause the blood cells to clump or cause clotting. The unit of packed cells. Prior to hanging the blood, the other options are incorrect. nurse will prime the blood tubing with which of the following solutions? ‐ 5% dextrose ‐ Lactated Ringer's ‐ 0.9% sodium chloride ‐ 5% dextrose in 0.45% sodium chloride | The core issue of the question is the knowledge that only normal saline is compatible with any blood product. Use this knowledge and the process of elimination to make a selection. |
3596 While assessing a client’s intravenous (IV) line, the Correct answer: 1 Infiltration is leakage of fluids into the surrounding tissues, resulting in edema around the nurse notes that the area is swollen, cool, pale, and insertion site, blanching, and coolness of skin around the site. The other options would not causes the client discomfort. The nurse documents have these manifestations. which of the following complications of IV therapy? ‐ Infiltration ‐ Phlebitis ‐ Infection ‐ Air embolism | The core issue of the question is the ability to accurately interpret an IV complication. Use knowledge of various IV complications and the process of elimination to make a selection. |
3597 The client is receiving 5% dextrose and 0.45% sodium Correct answer: 2 Continuing the infusion at that site would only increase the phlebitis. The IV is discontinued chloride intravenously and is complaining of pain at and restarted at a new site. Applying a warm compress to an area of phlebitis dilates the the IV site. The nurse assesses the site and notes vessel, improving circulation, and reduces the resistance to blood flow from within the vein erythema and edema. Which of the following would be reducing the pain. The other options are incorrect. the appropriate nursing action? ‐ Slow the infusion rate. ‐ Discontinue the IV and apply a warm compress to the IV site. ‐ Apply antibiotic ointment to the IV site. ‐ Gently pull back the IV access device to reposition within the vein. | The core issue of the question is the ability to accurately interpret an IV complication. Use knowledge of various IV complications and the process of elimination to make a selection. |
3598 The nurse is starting a new peripheral intravenous Correct answer: 2 Tourniquets are made of latex. A blood pressure cuff can be used as an alternative method of (IV) line in a client. The client reports a latex allergy. vein distention. A new tourniquet may not resolve the latex issue. The other responses do not The nurse has a typical IV start kit. Because of the latex address the latex issue. allergy, the nurse should take which of the following actions? ‐ Utilize a new tourniquet for this client. ‐ Utilize a blood pressure cuff to distend the vein. ‐ Avoid putting povidone iodine on the skin. ‐ Suggest an alternative therapy to a peripheral intravenous line. | The core issue of the question is providing for safety of the client who has a latex allergy. Use this knowledge and the process of elimination to make a selection. |
3599 The nurse is inserting an intravenous (IV) line into a Correct answer: 2 The nurse would refrain from advancing the catheter if mild resistance is noted. The other client. After piercing the skin and entering the vein, the data are normal. The IV should be inserted bevel side up. The client should not experience nurse would refrain from advancing the catheter if pain, and a backflow is normal on insertion, indicating that the vein has been pierced. which of the following were noted? ‐ Blood backflow into the IV catheter ‐ Mild resistance with advancement | The core issue of the question is knowledge of normal IV insertion procedure. Use this knowledge and the process of elimination to make a selection. |
‐ No reports of client discomfort ‐ The IV catheter was inserted bevel side up. | |
3600 The nurse is inserting a peripheral intravenous (IV) Correct answer: 5, 3, 1, The first step is to gather equipment. The nurse then selects a vein and cleanses the site. The line. Place the following steps in order to perform this 2, 4 nurse applies a tourniquet and inserts the catheter. Finally, the nurse attaches the primed procedure correctly. Click and drag the options below tubing and regulates the drip rate. Additional steps are to release the tourniquet, continue to to move them up or down. assess the site, apply a dressing, and document the procedure. ‐ Apply tourniquet. ‐ Insert catheter at 5–15 degree angle through skin. ‐ Select vein. ‐ Attach tubing primed with IV solution. ‐ Gather equipment. | Use this knowledge and the process of elimination to make a selection. |
3601 A client with dry skin and mucous membranes is Correct answer: 4 The client is manifesting signs and symptoms of dehydration. Since the serum remains weak, has orthostatic blood pressure changes, and has isotonic, this is isotonic dehydration or hypovolemia. Appropriate treatment is with an isotonic decreased urine output. The client's serum osmolality, fluid to replace fluid volume. Options 1 and 2 are incorrect because they are hypotonic however, is normal. Which of the following IV fluids solutions and would cause fluid shifting leading to cellular edema (i.e., client's cells are normal would the nurse anticipate being prescribed for this size and free water is not needed for cells). Option 3 is incorrect because the solution is client? hypertonic and will cause further fluid shifting leading to cellular dehydration. ‐ 5% dextrose in water ‐ one‐half normal saline ‐ 10% dextrose in water ‐ Normal saline | Critical words are normal osmolality, indicating the fluid replacement will need to maintain the normal osmolality. Recognize the need to restore fluid balance with use of an isotonic solution to direct you to option 4. |
3602 Which of the following outcomes would the nurse Correct answer: 4 25% albumin is a hypertonic colloid solution that will expand the plasma volume. This anticipate after infusion of 25% albumin to a client in increase in plasma volume should increase blood pressure, which in turn will decrease the hypovolemic shock? strain on the heart and thereby decrease heart rate. The increase in volume will not lower temperature or decrease peripheral perfusion; rather, it will have the opposite effect. ‐ Increase in heart rate ‐ Decrease in temperature ‐ Decrease in peripheral perfusion ‐ Increase in blood pressure | Recognize albumin is a plasma expander to direct you to option 4. |
3603 A client with gastrointestinal (GI) bleeding suddenly Correct answer: 2 Normal saline solution is an isotonic solution that will replace lost vascular volume and develops diaphoresis with a rapid and thready pulse, promote perfusion. All of the other options are incorrect because they are either hypotonic or and the nurse finds it difficult to hear a blood pressure. act as hypotonic solutions in the bloodstream, providing free water that moves into the Which of the following IV fluids does the nurse interstitial space and cells. Administration of these fluids can cause further fluid shifting, which anticipate the physician will order stat? will not help to replace lost volume or promote perfusion. In addition, when blood is available, it can be hung with the normal saline. Dextrose will cause lysis of red blood cells. ‐ Dextrose in water (D5W) ‐ 0.9% sodium chloride (normal saline) ‐ 0.45% sodium chloride (normal saline) ‐ Dextrose 5% in 0.45% sodium chloride (D5 HNS) | Recognize the need for replacement with a isotonic fluid to direct you to option 2. |
3604 The nurse is caring for a client who is experiencing Correct answer: 1 Albumin is given to facilitate remobilization of third space fluids. In the case of ascites it severe abdominal ascites secondary to cirrhosis. The would pull fluid from the abdomen into the intravascular space, resulting in a decrease in nurse determines an infusion of albumin has been abdominal girth. Option 2 is incorrect; the increase in intravascular fluid would lead to an effective when assessment findings indicate which of increase in blood pressure. The pulse may increase in compensation to the increased blood the following? volume, but this does not reflect effectiveness of the albumin treatment. A decrease in weight would most likely be seen as the reabsorbed abdominal fluid is excreted by the kidneys. ‐ Decrease in abdominal girth ‐ Decrease in blood pressure ‐ Increase in pulse ‐ Increase in weight | Critical words are ascites and albumin. Recall the physiology of ascites and recognize the purpose of the albumin in treatment of ascites to direct you to option 1. |
3605 Which of the following changes in laboratory values Correct answer: 2 The client's plasma is hypertonic (i.e., very concentrated) to begin with and thus serum would the nurse anticipate after administering isotonic osmolality, BUN, and hematocrit would be elevated from hemoconcentration. Once isotonic intravenous fluids to a client experiencing hypertonic fluids are administered, the plasma concentration should decrease and all three laboratory dehydration? test results should show a corresponding decrease. Option 1 is incorrect because one would expect to see an improvement upon administration of isotonic fluids and BUN and serum osmolality remain increased. Option 3 is incorrect because these findings would be consistent in a client who has not been treated for hypertonic dehydration. Option 4 is incorrect because one would expect to see a decrease in hematocrit with the administration of isotonic fluid therapy. ‐ Increased serum osmolality, increased blood urea nitrogen (BUN), and decreased hematocrit (HCT) ‐ Decreased serum osmolality, decreased BUN, and decreased HCT ‐ Increased serum osmolality, increased BUN, and increased HCT ‐ Decreased serum osmolality, decreased BUN, and increased HCT | Critical words are isotonic fluids and hypertonic dehydration. Recall the effect of isotonic fluids on serum osmolarity to choose option 2. |
3606 A client with a history of congestive heart failure Correct answer: 3 Abrupt changes in weight are an important clue to changes in fluid status. Unusual losses, (CHF) has been carefully rehydrated with normal e.g., fever or diarrhea, are significant; they need to be reported and may help the client (0.9%) saline solution for isotonic dehydration related prevent a fluid volume deficit (FVD) in the future, especially since the client is taking a diuretic. to overzealous diuresis. Which of the following Option 1 is incorrect because increasing salt and fluids may put the client at significant risk for statements by the client indicates that the nurse's fluid volume excess (FVE) considering the history of CHF. Options 2 and 4 may put the client at discharge teaching has been effective? risk for FVE or FVD, respectively. ‐ "I will increase my salt intake and double up on my fluid intake." ‐ "I will take my diuretic pill every other day." ‐ "I will weigh myself daily and notify the physician if I develop a fever or diarrhea." ‐ "I will drink only one glass of water a day so I can eventually stop taking my pill." | Critical words are CHF and isotonic dehydration. Eliminate options 1, 2, and 4 since they reflect unsafe behaviors. |
3607 The physician is going to order a hypotonic Correct answer: 4 0.45% NS is a hypotonic solution that draws fluid from the vascular compartment into the intravenous solution for a client with cellular cells. The other answers are incorrect. dehydration. The nurse would expect which of the following fluids to be administered? ‐ 0.9% normal saline ‐ 5% dextrose in normal saline ‐ Lactated Ringer's ‐ 0.45% sodium chloride | 0.45% sodium chloride is referred to as half normal. Normal saline is normal or isotonic. Half normal would be hypotonic. |
3608 Several clients are being admitted to the hospital unit Correct answer: 3 The client with the airborne infection can spread this infection simply by breathing and at one time. There is only one private room available. requires isolation in a private room. The client with the abdominal wound (option 2) would not Which client has the highest priority for being be as likely to spread this organism when the wound is dressed. The clients in options 1 and 4 admitted to this private room? have no medical need for a private room. ‐ Cient admitted for elective surgery that requested a private room prior to admission | The critical term is highest priority. Recall CDC precaution guidelines to enable you to make safe room assignments. |
‐ Client with a large infected abdominal wound ‐ Cient who has a communicable respiratory infection ‐ Client under the age of 12 | |
3609 The client is receiving 5% dextrose in 0.45 normal Correct answer: 3 0.9 sodium chloride (normal saline) is the only solution that can be administered with blood saline. The physician has ordered the client receive one or blood products. Other solutions may cause the blood cells to clump or cause clotting. The unit of packed cells. Prior to hanging the blood, the other options are incorrect. nurse will prime the blood tubing with which of the following solutions? ‐ 5% dextrose ‐ Lactated Ringer's ‐ 0.9% sodium chloride ‐ 5% dextrose in 0.45% sodium chloride | Blood is only hung and flushed with normal saline. |
3610 A client is placed on a patient‐controlled analgesia Correct answer: 2 Respiratory compromise is rare with opioid administration yet feared by many healthcare (PCA) pump with an opioid medication following total workers (option 4). Sedation precedes a fall in respiratory rate and/or depth and, therefore, hip replacement surgery. After the client has should be noted and recorded. It may not be feasible to allow the surgical client to rest administered a bolus of the prescribed medication, the uninterrupted for a several‐hour period (option 1). The infusion pump continuously records the nurse should do which of the following as highest amount of medication infused (option 3). priority? ‐ Allow client to rest uninterrupted for several hours ‐ Assess the client's level of sedation ‐ Record amount of medication the client received ‐ Monitor the client for respiratory arrest | The critical words are highest priority. Recall information about common side effects of patient‐controlled analgesia to assist in assuring client safety during its use. |
3611 The client is receiving 5% dextrose and 0.45% sodium Correct answer: 2 Continuing the infusion at that site would only increase the phlebitis. The IV is discontinued chloride intravenously and is complaining of pain at and restarted at a new site. Applying a warm compress to an area of phlebitis dilates the the IV site. The nurse assesses the site and notes vessel, improving circulation, and reduces the resistance to blood flow from within the vein erythema and edema. Recognizing these as signs of reducing the pain. The other options are incorrect. phlebitis, which of the following would be the appropriate nursing actions? ‐ Slow the infusion rate. ‐ Discontinue the IV and apply a warm compress to the IV site. ‐ Apply antibiotic ointment to the IV site. ‐ Gently pull back the IV access device to reposition within the vein. | Discontinuing the IV is usually the best option when site problems are described. |
3612 The nurse is assessing several clients with different Correct answer: 1 A contusion is a crushing of the tissues; there is no break in the skin. Therefore this wound is types of injuries. The nurse would conclude that the less likely to become infected. A septic wound is one that has been invaded by pathogenic client who is least likely to develop a wound infection microorganisms (option 3). Purulent exudate also is an indicator of infection (option 4). A would be the client with which of the following? wound healing by second intention is a wound in which there is extensive injury and the edges of the wound are not well approximated. Because of this factor, this type of wound has a risk of infection. ‐ A contusion ‐ A wound healing by second intention ‐ A septic wound ‐ A wound with purulent exudate | The critical words in the question are least likely. This tells you that the correct option is one that has the data that is the nearest to normal of the options presented. Use nursing knowledge and the process of elimination to make a selection. |
3613 A client has a continuously running peripheral Correct answer: 4 Before making a decision about how to infuse the antibiotic, the nurse should check infusion. The physician orders the addition of a compatibility of the antibiotic with the continuous IV solution. If the drug and the infusion antibiotic as a piggyback infusion four times per day. In were compatible, they would be run at the same time. If the drug and infusion were order to administer the antibiotic, the nurse should do incompatible, the nurse would stop the infusion during the period of antibiotic administration which of the following? and flush the line carefully before and after the antibiotic. It is always inadvisable to start a second IV site unless absolutely necessary. The other answers are incorrect. ‐ Start a new IV access to administer the antibiotic so that there will not be compatibility issues. ‐ Start a new IV access to eliminate the problem of too much volume for one site. ‐ Increase the flow rate of the continuous infusion to facilitate the administration of the antibiotic. ‐ Check to see if the antibiotic is compatible with the continuous infusion. | Omit options 1 and 2 as they call for an unnecessary stick. Omit option 3 as the flow rate is not addressed in the item and this does not answer the question. |
3614 When learning of the diagnosis of deep vein Correct answer: 2 To gain a client's trust, respect must be conveyed even if there is disagreement with the belief thrombosis, a client states that "if it is God's will, I will expressed. Introductions and further assessment are important but ineffective if respect is not get better." Which of the following would be the conveyed. Notifying the physician does not have priority at this time. highest priority intervention in order to provide culturally competent care? ‐ Notify the physician immediately ‐ Convey respect for the client's belief ‐ Further assess the client's knowledge of the disease ‐ Introduce yourself with your title | Awareness of nursing interventions to promote spiritual health will assist in selecting the option that aids in establishing a positive relationship with the client. Recall that religion may provide a framework for a client’s health beliefs. |
3615 A 4‐month‐old client has an order for Correct answer: 40 Use the following formula to calculate the rate of IV solutions:<BR /> D<sub>5</sub> half NS IV to run at a rate of 40 mL/hr. While the unlicensed assistive person (UAP) is obtaining an IV infusion pump, the nurse sets the drip rate at drops/minute, using a Soluset with microdrip tubing that has a drop factor of 60 gtts/mL.<BR /> | Use knowledge of basic IV calculation to set up the question. Calculate the problem carefully and double check your answer for accuracy. |
3616 A 3½‐month‐old infant has an order for Correct answer: 0.45 The problem can be set up using the following formula:<BR /> acetaminophen (Tylenol) suspension 45 mg po q4h prn. The product label lists a concentration of 500mg/5mL. After determining that the dosage is safe, the nurse should administer mL. Write the numerical answer. | Use knowledge of basic dosage calculation to set up the question. Calculate the problem carefully and double check your answer for accuracy. |
3617 A 4‐year‐old client's medication order reads, Correct answer: 2 First calculate the daily dose of the medication by dividing the number of mg (1380) by the cefotaxime (Claforan) 1380 mg IV every 8 hours. The client's weight in kg (13.8) to yield a single dose of 100 mg/kg. Because there are three doses client weighs 13.8 kg. Which of the following nursing ordered during a 24‐hour period, multiply 100 by 3 to yield 300 mg/kg/day. Since the dose actions is appropriate if the safe dosage range for a range is 100 to 200 mg/kg/day, the nurse should question the order for the excessively high child from 1 month to 12 years of age is listed as dose as a safe nursing action. 100–200 mg/kg/day given in divided doses? ‐ Give the dose as scheduled and document it appropriately. ‐ Question the order for the excessively high dose. ‐ Administer the slightly high dose but give it at half the recommended rate. ‐ Withhold the dose and question the prescriber, since it is below the recommended range. | Use knowledge of basic pediatric dosage calculation to set up the question. Calculate the problem carefully and double check your answer for accuracy. Remember that any dose that falls outside the safe dosage range needs to be questioned. |
3618 A 6‐year‐old client who weighs 18 kg is scheduled to Correct answer: 1 First calculate the total daily dose by dividing 240 mg by 18 kg to yield a single dose of 14.44 receive a dose of vancomycin (Vancocin) 240 mg IV mg/kg. Multiply the single dose by 4 doses (every 6 hours) to yield a daily total dose of 57.76 ordered every 6 hours. The safe dose range for a child mg/kg/day. Since this exceeds the safe total daily dose of 40 mg/kg/day, the nurse should is listed as 40mg/kg/day divided every 6 hours. What is question the order. the best nursing action? ‐ Question the dosage of the order. ‐ Question the frequency of the order. ‐ Administer the dose, being sure to use an infusion pump. ‐ Give the dose over at least 60–90 minutes to avoid adverse effects. | Use knowledge of basic pediatric dosage calculation to set up the question. Calculate the problem carefully and double check your answer for accuracy. Remember that any dose that falls outside the safe dosage range needs to be questioned. |
3619 A 5‐year‐old client has an order for baclofen (Lioresal) Correct answer: 4 The dose can be administered as ordered. The order for half of a 10 mg tab means that the half of 10 mg tab po three times per day. The safe dose child is receiving 5 mg per dose. If there are three doses per day, then the total daily dose is 15 range for a 2–7‐year‐old child is 10–15 mg/day in mg, which is within the safe dosage range. divided doses. Which of the following nursing actions is most appropriate? ‐ Question the total daily dose ordered. ‐ Question the single dose ordered. ‐ Refuse to give the dose because the child’s weight is not factored into the dose. ‐ Administer the dose as ordered. | Use knowledge of basic pediatric dosage calculation to set up the question. Calculate the problem carefully and double check your answer for accuracy. Recall that any dose that falls within the safe dosage range may be administered. |
3620 A 3‐year‐old client has an order for 120 mg Correct answer: 6 Convert 2.6 grams to 2600 mg. Since a single dose is only 120 mg, the client could acetaminophen (Tylenol) every 4–6 hours prn for pain. theoretically receive this dose 21 times (2600 divided by 120 = 21.66) within a 24‐hour period The maximum total dose is 2.6 grams/day for a child of without exceeding the top of the dosage range. However, since the medication is ordered only 2–3 years. The nurse could legally administer the every 4–6 hours, the nurse can legally administer the medication only six times maximum medication to this child times during a 24‐hour (every 4 hours). period. Write the numerical answer. | Use knowledge of basic math calculations to determine your answer. If the drug can be given no more frequently than every 4 hours, it cannot exceed six doses, since 24 divided by 4 is 6. |
3621 The client has an order for cefotaxime (Claforan) 1180 Correct answer: 12.4 The following formula illustrates one way to set up the problem:<BR /> mg IV q6h. The reconstituted medication vial is labeled as having a concentration of 95 mg/mL. The nurse should draw up mL of solution to add to the bag of IV solution that will be used for the intermittent infusion. Write the numerical answer, rounding to the nearest tenth. | Use knowledge of basic dosage calculation procedures to set up the question. Calculate the problem carefully and double check your answer for accuracy. |
3622 The 6‐year‐old client has an order for fexofenadine Correct answer: 60 One half of a 60 mg tablet is 30 mg. Because the dose is ordered twice a day, the total daily (Allegra) half of a 60 mg tab po twice daily. The nurse dose is 30 multiplied by 2, or 60 mg. calculates the child’s total daily dose as mg. Write a numerical answer, rounding to the nearest tenth. | Use knowledge of basic math calculation to set up the problem. Calculate carefully and double check your answer for accuracy. |
3623 The nurse is reviewing insulin administration Correct answer: 4 Correct administration technique is to use a 90‐degree angle (insulin syringes have a short, techniques with a 13‐year‐old client with uncontrolled half‐inch needle), avoiding aspiration before injection (e.g., to avoid tissue complications over diabetes. The nurse evaluates that the client is using time), and avoiding massaging the area after injection, which would enhance quicker proper procedure after noting that the client does absorption of the dose. which of the following during self‐injection? ‐ Aspirates before injection but does not massage the site following injection ‐ Uses a 45‐degree injection angle and aspirates before injection ‐ Uses a 90‐degree angle and massages the site following injection | The core issue of the question is knowledge of subcutaneous injection techniques. Use the process of elimination and nursing knowledge to answer the question. To help eliminate incorrect answers, recall that insulin and heparin should not be massaged and that a 90‐ degree angle is used for injection. |
4.‐ Uses a 90‐degree injection angle and does not massage the site following injection | |
3624 A 15‐year‐old client admitted with dehydration has an Correct answer: 83 Since the infusion device delivers fluid in drops/min, the nurse must calculate the number at order for a bolus infusion of normal saline (NS) 500 mL which to set the machine. The formula to use is:<BR /><BR /> IV for 1 hour. An infusion device is available that counts the number of drops per minute delivered. The IV tubing has a drop factor of 10 drops/mL. If the bolus is to infuse on time, the nurse should set the drip rate to drops per minute. Write the numerical answer, rounding to the nearest whole number. | Use knowledge of basic IV calculation procedures to set up the question. Calculate the problem carefully and double check your answer for accuracy. |
3625 A 6‐year‐old postoperative client has a medication Correct answer: 100 First convert the client's weight to kg by dividing 44 by 2.2 to yield a weight of 20 kg. Then order for cefazolin (Ancef) 500 mg IV every 6 hours. calculate the daily dose of the medication by dividing the number of mg (500) by the client's The client weighs 44 pounds. The safe dose range of weight in kg (20) to yield a single dose of 25 mg/kg. Because there are four doses (every 6 cefazolin for a child is 25–100 mg/kg/day in three to hours) ordered during a 24‐hour period, multiply 25 by 4 to yield a total daily dose of 100 four divided doses. The total daily dose that this client mg/kg/day. will receive is mg/kg/day. Write the numerical answer as a whole number. | Use knowledge of basic dosage calculation to set up the question. Calculate the problem carefully and double‐check your answer for accuracy. |
3626 A child who sustained a head injury has an order for Correct answer: 66.7 Since the infusion pump delivers fluid in mL/hour, the nurse needs to calculate the equivalent mannitol (Osmitrol) 20 grams. Available is a bag of 20% hourly rate when infusing the 100 mL over 90 minutes. The problem can be set up to cancel solution that contains 20 grams mannitol in 100 mL out the labels and end up with mL/hour:<BR /> volume. The medication may be administered over 30–90 minutes. If the nurse wishes to infuse the medication over 90 minutes, the infusion pump should be set at mL/hour if the pediatric infusion pump can be set to include tenths of a milliliter. Write in a numerical answer, rounding to the nearest tenth. | Use knowledge of basic math calculation to set up the question. Read the question carefully, noting that the time needs to convert from minutes to hours in order to have the correct labeling. Calculate the problem carefully and double check your answer for accuracy. |
3627 A client has a medication order for ceftazidime Correct answer: 30 First convert the child’s weight to kg by dividing 55 by 2.2 to yield a weight of 25 kg. Then (Fortaz) 250 mg IV every 8 hours. The client weighs 55 calculate the daily dose of the medication by dividing the mg (250) by the client's weight in kg pounds. The safe dose range of ceftazidime for a child (25) to yield a single dose of 10 mg/kg. Because there are three doses (every 8 hours) ordered is 30–50 mg/kg/day in three divided doses. The total during a 24‐hour period, multiply 10 by 3 to yield a total daily dose of 30 mg/kg/day. daily dose ordered for this client is mg/kg/day. Write in a numerical answer, rounding to the nearest whole number. | Use knowledge of basic pediatric dosage calculation to set up the question. Calculate the problem carefully and double check your answer for accuracy. |
3628 A child has an order to receive an NS bolus 400 mL IV. Correct answer: 267 Since the infusion pump delivers fluid in mL/hour, the nurse must calculate the equivalent If the nurse wishes to infuse this volume for 90 hourly rate when infusing the 400 mL over 90 minutes. The problem can be set up as follows to minutes, the infusion pump should be set at cancel out the labels and end up with mL/hour:<BR /> mL/hour. Write a numerical answer, rounding to the nearest whole number. | Use knowledge of basic math calculation to set up the question. Read the question carefully, noting that the time needs to convert from minutes to hours in order to have the correct labeling. Calculate the problem carefully and double check your answer for accuracy. |
3629 The nurse is about to administer a dose of Correct answer: 12.5 The problem can be set up using ratio and proportion as follows:<BR /> acetaminophen (Tylenol) 200 mg via the NG tube to a child. Available is a suspension with a concentration of 80 mg per 5 mL. The nurse should administer mL to give the dose. Write a numerical answer, rounding to the nearest tenth. | Use knowledge of basic pediatric dosage calculation to set up the question. Calculate the problem carefully and double check your answer for accuracy. |
3630 A pediatric client has been diagnosed with Correct answer: 4 Eye drops are placed in the lower conjunctival sac to prevent damage to the cornea and to conjunctivitis. The nurse is to administer eye drops facilitate coating the eye with the medication. The other answers are incorrect. four times a day. The nurse should administer the medication by gently dropping the medication onto which of the following areas? ‐ Center of the cornea ‐ Sclera by the inner canthus ‐ Sclera by the outer canthus ‐ Lower conjunctival sac | Option 4 describes the area of the eye that will allow the medication to remain in contact with the infected area. |
3631 A mother is to be taught to administer ear drops to Correct answer: 4 Pulling the ear pinna down and back straightens the ear canal allowing the drops to enter the her 4‐month‐old infant. The important concept in ear. The other choices are not the most important concepts in the teaching. teaching would be to do which of the following? ‐ Wear gloves when administering the ear drops. ‐ Not contaminate the bottle by touching the nozzle to the ear. ‐ Turn the baby on its back after administration to avoid the risk of SIDS. ‐ Pull the pinna gently downward and backward. | Option 4 has the most direct relationship to the actual teaching needed to accomplish the task. |
3632 The nurse is administering an intradermal tuberculin Correct answer: 1 For an intradermal injection, the needle enters the skin at a 10‐ to 15‐degree angle and the skin test to a client. The client comments that this medication forms a bleb under the epidermis. The other angles would permit the medication "shot" is different than other shots in the past. The to be deposited too deeply into either subcutaneous or muscle tissue, depending on needle nurse explains that because the medication goes into length and size of client. the dermal tissue, the angle for intradermal injections is: ‐ 10–15 degrees. ‐ 30–40 degrees. ‐ 45 degrees. ‐ 90 degrees. | The core issue is depth of penetration of medication utilizing correct needle angle. Choose the option that has the smallest angle, which will keep the injection from going too deeply. |
3633 The nurse is preparing to administer a less viscous Correct answer: 4 Several factors indicate the size and length of the needle to be used: the muscle, the type of (i.e., watery) intramuscular injection into the deltoid solution, the amount of adipose tissue covering the muscle, and the age of the client. A smaller muscle of a 160‐pound male. What is the preferred needle such as a 23‐ to 25‐gauge needle that is 1 inch long is commonly used for the deltoid needle size for the medication, muscle, and weight of muscle. More viscous solutions require a larger gauge (e.g., 20 gauge). The other answers are the client? less appropriate because of incorrect needle length or gauge. ‐ 1.5 inch, 20 gauge ‐ 1 inch, 20 gauge ‐ 1.5 inch, 25 gauge ‐ 1 inch, 25 gauge | The critical concepts in the question are that the deltoid muscle allows the use of a shorter needle and a watery solution allows the use of a smaller gauge needle. Use the process of elimination to choose the option that combines these concepts. |
3634 A nurse giving an intramuscular injection places the Correct answer: 2 The ventrogluteal site is in the gluteus medius muscle with the greater trochanter, the heel of the hand on the client's greater trochanter, anterior superior iliac spine, and the iliac crest as the landmarks. The vastus lateralis and the with the fingers pointing toward the client's head. The rectus femoris are located on the thigh, and the dorsogluteal is located on the buttocks, nurse places the index finger on the client's anterior making the other options incorrect. superior iliac spine, while the middle finger is stretched dorsally, palpating the iliac crest. After giving the injection in the triangle formed, the nurse documents the injection as being given in which intramuscular injection site? ‐ Vastus lateralis ‐ Ventrogluteal ‐ Dorsogluteal ‐ Rectus femoris | Use the process of elimination. Basic knowledge of injection sites and landmarks is necessary to answer this question. Choose the option that matches the description given in the question. |
3635 The nurse feels a client is at risk for skin breakdown Correct answer: 3 This is a risk diagnosis, and diagnostic statement has two parts: the human response because the client has only had clear liquids for the (impaired skin integrity) and the related/risk factor (malnutrition). Options 1 and 2 do not have last 10 days (and essentially no protein intake). The related factors that are under the control of the nurse (i.e., type of diet ordered). The diagnosis nurse would formulate which diagnostic statement to in option 4 does not specify the type of impairment (greater than or less than body best reflect this problem? requirements) and is therefore incomplete. It also does not provide direction for development of goals and interventions. ‐ Risk for malnutrition related to clear liquid diet ‐ Impaired skin integrity related to no protein intake ‐ Risk for impaired skin integrity related to malnutrition ‐ Impaired nutrition related to current illness | The critical phrase is at risk for skin breakdown. Use knowledge that nursing diagnoses are developed to address client responses that are amenable to nursing intervention to eliminate options 1 and 2. Note that the diagnosis in option 4 is incomplete to choose option 3. |
3636 A client is postoperative with an IV in place. The client Correct answer: 3 The essential parts of a drug that must be present in order to implement the order are name is taking a soft diet and, when asked, rates the pain as of the drug, date and time the order was written, dosage, route, frequency, and signature of 6 on a 1–10 scale. The following order is noted in the the person writing the order. Nurses may not independently administer a medication without client’s chart: morphine sulfate 6–8 mg q 4 hr prn for all of the essential parts or determine a route based upon the client’s condition. Administering pain. Considering the client's pain level and noting that Tylenol without a medical order constitutes practicing medicine without a license. In no route was ordered, the nurse should do which of hospitalized clients, an order must be present for any medication to be given. the following? ‐ Administer the dose intramuscularly (IM) because the client is on a soft diet and this is a safe IM dose. ‐ Recognizing this to be a safe IV dose, administer the dose IV until clarification is received from the physician. ‐ Withhold the dose and contact the physician for clarification of the order. ‐ Withhold the dose until a route is ordered by the physician, but administer Tylenol from stock supplies since these are available over the counter. | The core issue of the question is knowledge that medication cannot be given with an incomplete order. Eliminate options 1 and 2 because they do not specify a route in the original order, and eliminate option 4 because it gives a medication without an order. |
3637 The physician asks the nurse to take a telephone Correct answer: 2 A nurse can take a telephone order from a physician. When the nurse documents the order, order for acetaminophen (Tylenol) 500 mg by mouth q "telephone order" and the physician's name must be written on the order and the physician 4 hr prn for a temperature elevation higher than 100° must cosign it, usually within 24 hours. The other answers are incorrect. Option 1 is a false F. How should the nurse respond? statement, option 3 fails to note that it is a telephone order, and option 4 is unnecessary. ‐ Explain to the physician that nurses are not permitted to write orders. ‐ Record the order with "telephone order" from physician and the nurse's signature, and remind the physician to cosign it within the next 24 hours. ‐ Record the order and sign the physician's name first, followed by the nurse's signature. ‐ Ask the physician to restate the telephone order with another nurse witnessing and record the order with both the witness and the nurse's name. | The core issue of the question is knowledge of how to properly record a telephone order. The wording of the question tells you that only one option is correct. Use the process of elimination and basic nursing knowledge to make a selection. |
3638 The nurse is administering a medication to a client Correct answer: 1 Blood levels of two metabolically produced substances, urea and creatinine, are routinely with a history of renal impairment. The medication is used to evaluate renal function. Both are normally eliminated by the kidneys and are measured known to be excreted through the kidneys. To monitor as serum BUN and creatinine. The color and odor of the urine are general observations (option the client for adverse reactions, the nurse would 2). Sugar and acetone in urine are found in diabetes mellitus with ketoacidosis (option 3). monitor which of the following? Serum hemoglobin (option 4) is a measure of the RBC count but does not reflect kidney function. ‐ Serum blood urea nitrogen (BUN) and creatinine ‐ Color and odor of the urine ‐ Urine sugar and acetone levels ‐ Serum hemoglobin | The core issue of the question is knowledge of what to assess to determine kidney function as an indicator of clearance of medications. Use the process of elimination and basic nursing knowledge to make a selection. |
3639 A client has a continuously running peripheral Correct answer: 4 Before making a decision about how to infuse the antibiotic, the nurse should check intravenous (IV) infusion. The physician orders the compatibility of the antibiotic with the continuous IV solution. If the drug and the infusion addition of an antibiotic as a piggyback infusion 4 times were compatible, they would run together through the same line. If the drug and infusion were a day. In order to administer the antibiotic safely, the incompatible, the nurse would stop the infusion during the period of antibiotic administration nurse should do which of the following? and flush the line carefully before and after the antibiotic. It is always inadvisable to start a second IV site unless absolutely necessary. Increasing the IV flow rate constitutes changing a medical order, and does not address the issue of compatibility. ‐ Start a new IV access to administer the antibiotic so that there will not be compatibility issues. ‐ Start a new IV access to eliminate the problem of too much volume for one site. ‐ Increase the flow rate of the continuous infusion to facilitate the administration of the antibiotic. ‐ Check to see if the antibiotic is compatible with the continuous infusion. | The core issue of the question is the need to check compatibility of medications and IV solutions as a beginning point to decision‐making. Eliminate each of the incorrect options because they do not begin with compatibility checks (options 1 and 2) or are incorrect nursing actions (option 3). |
3640 The nurse is preparing to administer an oral Correct answer: 3 The correct action should be to withhold the medication and call the physician. Nurses cannot medication to a client. Upon entering the client's independently change the route of a medication. Oral medications should not be administered room, the nurse finds that the client's condition has to clients who are vomiting, which could interfere with the ability to absorb the medication changed and the client is now vomiting, has diarrhea, and possibly initiate further vomiting. The nurse should not just omit the dose without is confused, and has a fever. What should the nurse do notifying the physician of the client's change in condition. next? ‐ Administer the medication IM. ‐ Wait 2 hours and give the medication if vomiting subsides. ‐ Withhold the medication and call the physician. ‐ Omit this dose of medication. | Use the process of elimination and general measures for administering medications safely to make a selection. The wording of the question tells you that there is only one correct answer. |
3641 A nurse has prepared an IM injection for a Correct answer: 1 The nurse who prepares the medication must be the nurse to give the medication. It would preoperative client. Suddenly, another client becomes be prudent for the second nurse to assist the second client so that the first nurse may continue entangled in an IV tubing and yells for help. The nurse medication administration. Option 2 is incorrect. Option 3 is acceptable but requires rushes to assist. The surgery orderly is waiting for the destruction of the original medication, which is an added expense. Option 4 is appropriate but preoperative client, so the nurse asks a second nurse does not resolve the issue of the preoperative client. to give the injection to the preoperative client. Which of the following is the best response by the second nurse? ‐ Help the second client so the nurse can give the preoperative client the injection. ‐ Give the client the preoperative medication. ‐ Prepare a new syringe for the preoperative client. ‐ Explain to the nurse that no other nurse can administer the already prepared medication. | Use the process of elimination. The core issue of the question is the principle that nurses may not administer medications prepared by another nurse. The wording of the questions tells you there is only one correct answer. |
3642 The client is in the bathroom. When the nurse enters Correct answer: 4 Medications should not be left at the bedside, with certain exceptions that are ordered in the room to give medications, the client asks the nurse advance (e.g., nitroglycerin and cough syrup). The other answers are not prudent nursing to leave the pills on the bedside table. What is the best actions because they either fail to ensure that the medication is taken (option 1), waste the nursing action? nurse's time (option 2), or invade the client's privacy unnecessarily (option 3). ‐ Leave the medication on the bedside table. ‐ Wait in the room until the client comes out of the bathroom. ‐ Go into the bathroom and give the client the pills. ‐ Tell the client you will return in a little while with the medication. | Use the process of elimination. There is one correct answer utilizing basic principles of medication administration. |
3643 The client has an order for dexamethasone Correct answer: 1.5 Use the following formula to solve the problem:<BR /> (Decadron) 6 mg IV push stat. Available is a vial of dexamethasone with a concentration of 4 mg/mL. The nurse draws mL into the syringe to administer the dose. Write a numerical answer. | Use knowledge of basic pharmacological math to set up the question. Carefully review your work and double‐check placement of decimals for accuracy. |
3644 The client has an order for cefotaxime (Claforan) 1 Correct answer: 10.5 One gram is equal to 1000 mg. Use the following formula as one way to set up the gram IV q6h. The reconstituted vial in the client's problem:<BR /> medication drawer is labeled with a concentration of 95 mg/mL. For the intermittent infusion milliliters of solution should be added to the IV bag. Write a numerical answer. | Use knowledge of basic pharmacological math to set up the question. Carefully review your work and double‐check placement of decimals for accuracy. |
3645 The client has an order for glyburide (DiaBeta) 1.25 Correct answer: 0.5 The following is one way to set up the calculation:<BR /> mg before breakfast and dinner. Available are 2.5 mg tablets. The nurse should plan to administer tablets. Write in a numerical answer. | Use knowledge of basic pharmacological math procedures to set up the question. Check your work carefully and double check placement of decimals for accuracy. |
3646 The client has an order for lorazepam (Ativan) 0.5 mg Correct answer: 0.25 The following is one way to set up the calculation:<BR /> IV q6h PRN for agitation. Available is a vial containing 2mg/mL. The nurse should draw up mL of solution for injection. Write in a numerical answer. | Use knowledge of basic pharmacological math procedures to set up the question. Carefully review your work and double‐check placement of decimals for accuracy. |
3647 A client has a temperature of 101.2° F. There is an Correct answer: 2 The following is one way to set up the calculation:<BR /> order for acetaminophen (Tylenol) 650 mg PO for fever, and 325 mg tablets are available. The nurse should give tablets. Write a numerical answer. | Use knowledge of basic pharmacological math procedures to set up the question. Check your work carefully. |
3648 A client has an order for cefazolin (Ancef) 2 grams Correct answer: 20 Since the dose is 2 grams and each vial contains 1 gram, the nurse needs to use two vials. The IVPB. Available are vials filled with powder containing 1 nurse then adds 10 mL of sterile water to each vial of powder based on the direction to "add gram of cefazolin. The instructions state to "dilute 10 mL of sterile water per 1 gram of medication." Once both vials are reconstituted, the each 1 gram with 10 mL of sterile water." After concentration of each solution is 1 gram/10 mL. The nurse then must draw up the contents of reconstituting the medication, total milliliters of both vials, making the total volume 20 mL. solution should be drawn up to prepare the dose. Write in a numerical answer. | Use knowledge of basic pharmacological math procedures to set up the question. Check your work carefully. |
3649 A client has an order for a dose of digoxin (Lanoxin) Correct answer: 2 The following is one way to set up the calculation:<BR /> 0.25 mg IV push. Available is a vial containing 0.125 mg/mL. The nurse should draw up mL to administer the dose. Write a numerical answer. | Use knowledge of basic pharmacological math to set up the question. Carefully review your work and double‐check placement of decimals for accuracy. |
3650 The client has an order to receive methylprednisolone Correct answer: 3 The following is one way to set up the calculation:<BR /> (SoluMedrol) 120 mg IVPB q6h. Available is a solution containing 40 mg/mL. mL of medication should be added to the IV piggyback solution. Write a numerical answer. | Use knowledge of basic pharmacological math procedures to set up the question. Check your work carefully for accuracy. |
3651 The client has an order to receive 40 mg prednisone Correct answer: 4 The following is one way to set up the calculation:<BR /> (Deltasone) by mouth daily. Available are 10 mg tablets. The nurse should prepare to give tablets. Write a numerical answer. | Use knowledge of basic pharmacological math to set up the question. Check your work carefully for accuracy. |
3652 The client is a known diabetic. The nurse administers Correct answer: 3 Under the law, if a medication order is written incorrectly, the nurse who administers the 20 units NPH insulin IV stat per the physician's order. incorrect order is responsible for the error. This includes both the right medication and the Subsequent to the client receiving the insulin dose, the right dose (two of the six "rights" of medication administration). The other responses are client had an anaphylactoid reaction and died as a incorrect. result of receiving the NPH insulin via IV rather than subcutaneous, the only appropriate route. What liability is involved in this case? ‐ The nurse is not legally liable because the medication was administered as ordered by the physician. ‐ Only the physician is liable because the physician wrote the order. ‐ The nurse is legally liable for the medications administered even though the order was written incorrectly. ‐ The nurse is not legally liable because the nurse gave the correct medication, regardless of the route. | Only option 3 acknowledges that the nurse is responsible for his or her own actions regardless of the incorrect route in the physician’s order. |
3653 While the nurse is administering a client's dose of Correct answer: 1 The thin layer of epithelium and the vast network of capillaries under the tongue enhance nitroglycerin sublingual, the client asks why it is sublingual absorption. This medication dissolves rapidly and is absorbed immediately. The administered sublingually rather than orally. Which of other responses are incorrect. the following is the best response by the nurse? ‐ "It is absorbed more rapidly sublingually than when swallowed." ‐ "It is absorbed more rapidly when swallowed than sublingually." ‐ "The absorptions are the same so it really doesn't matter." ‐ "Sublingual provides a sustained release of the medication." | Note that options 1 and 2 are opposites. When opposites are offered, one of the opposites is usually correct. Option 1 gives the correct information about the drug. |
3654 The nurse is to administer 25 mg of promethazine Correct answer: 4 For an adult with well‐developed muscle mass, the preferred intramuscular (IM) injection site (Phenergan) IM to a 150‐pound client. The nurse for medications requiring a large muscle mass is the ventrogluteal. The vastus lateralis is the knows that this medication should be given into a deep preferred IM injection site for children under 7 months of age. The other responses are large muscle mass. The preferred site of injection for incorrect. this client would be which of the following? ‐ Deltoid ‐ Dorsogluteal ‐ Vastus lateralis | Use the process of elimination to narrow options. Dorsogluteal is not recommended for anyone. Vastus lateralis is recommended for injection in children who are very young and cannot yet walk. Ventrogluteal is larger and better developed in most adults than the deltoid. |
4.‐ Ventrolgluteal | |
3655 To administer 1 mL of a flu vaccine intramuscularly Correct answer: 2 For a well‐developed adult, a 5/8–1‐inch needle is the appropriate size for an IM deltoid (IM) to an obese adult in the deltoid area the nurse injection. Because this is an obese client, the longer needle is appropriate to ensure it reaches would use what size needle? the muscle. The other responses are incorrect. ‐ 5/8 inch ‐ 1 inch ‐ 1½ inch ‐ 2 inch | The range for an average size adult is 5/8–1 inch. For deltoid injection in an obese client, select the larger. |
3656 The nurse is preparing an IM injection of hydroxyzine Correct answer: 4 Z‐track technique prevents "tracking" and is used for administering medications that are (Vistaril) that is especially irritating to subcutaneous especially irritating to subcutaneous tissue. With z‐track, the skin is pulled approximately 1 tissue. To prevent "tracking" of the medication and inch laterally away from the injection site, the medication is injected, the needle withdrawn irritation to the tissues, it is best to take which of the and the tissue released. The other answers are incorrect. following actions? ‐ Use a small‐gauge needle ‐ Administer at a 45‐degree angle ‐ Apply ice to the injection site ‐ Use the z‐track technique | Note the use and emphasis on “tracking.” Prevention of tracking is accomplished by z‐track method. |
3657 The client is to receive vancomycin (Vancocin), an Correct answer: 3 The device that provides the most accurate infusion rate is the electronic infusion pump. The intravenous medication. Too rapid administration of other devices are less accurate. vancomycin is associated with life‐threatening adverse reactions. The nurse would plan to administer this drug using which of the following methods? ‐ Gravity ‐ Regulator ‐ Electronic infusion pump ‐ Elastomeric pump | The scenario stresses that rapid infusion can be life‐threatening, so select the option that provides the most control over the rate of infusion. |
3658 The nurse is to administer 10 grains of aspirin, which Correct answer: 2 In the apothecary system, 1 grain equals 60–65 mg. 10 grains equal 600–650 mg. Therefore, 2 comes 325 mg per tablet. The nurse would give tablets would be needed at 325 mg each to reach the needed dose. tablets to administer 10 grains? Write a numerical answer. | Use knowledge of apothecary system and simple calculation. |
3659 While administering an intramuscular (IM) injection Correct answer: 4 If blood returns while aspirating during an IM injection, the nurse should discard and prepare of meperidine (Demerol), the nurse aspirates and finds a new injection. Blood indicates that the needle has entered a blood vessel, and medication blood in the syringe prior to injecting the medication. injected directly into the bloodstream may be dangerous. Which of the following actions by the nurse would be appropriate? ‐ Continue to administer the medication because it is compatible with blood and would not present a harmful effect. ‐ Continue to administer the medication because the needle has hit a capillary and would not be an intravenous administration. ‐ Withdraw the needle, cleanse the needle and the new injection site with alcohol, and administer the medication. ‐ Withdraw the needle, discard the medication, and begin again with the medication administration. | Note that only one of the options directs the nurse to discard the medication. This is the correct option. |
3660 The nurse has instructed the client in using a metered‐ Correct answer: 2 Clients should be instructed to hold inhaler 2 inches away from mouth, hold the breath for 10 dose inhaler. The nurse determines that the client seconds, slowly exhale through pursed lips, and wait 2 minutes between puffs. The other understands the instructions when the client is options are incorrect. observed doing which of the following? ‐ Administering the two puffs in rapid order between breaths ‐ Holding the inhaler 2 inches away from the mouth ‐ Not shaking the canister before puffs ‐ Exhaling immediately after administering the puff | Use process of elimination to omit options 1and 4 because medication will not remain in contact with the respiratory tree in the desired dose with either option. Omit option 3 as shaking is recommended. |
3661 A client is receiving a continuous PEG tube feeding. Correct answer: 3 When medications are administered enterally and cannot be administered with tube The physician has ordered phenytoin (Dilantin) to be feedings, it is best to stop the tube feedings for at least 30 minutes prior to and after the administered through the PEG tube. The nurse notes administration of the medication. A time period of thirty minutes allows for the tube feeding that the medication cannot be administered with tube to clear the GI tract and therefore not mix with the medication. The other answers are feedings. Which of the following would be the best incorrect. intervention? ‐ Contact the physician for an order to administer the Dilantin by another route ‐ Contact the physician to change the type of tube feeding to one that is compatible. ‐ Stop the tube feeding for at least 30 minutes before and after the administration of the Dilantin. ‐ Stop the tube feeding, flush the feeding tube with water, administer the Dilantin, flush the tube feeding again with water and continue the tube feeding. | Note that options 1 and 2 pass responsibility to the physician and do not make good sense in regard to this drug. |
3662 A client is refusing to take her daily anti‐hypertensive Correct answer: 3 A client has the right to refuse a medication regardless how important it may be to their medication. The nurse has explained to the client why health. Withholding the medication because of client refusal does not require an incident the medication is important and the client verbalizes report, but it should be documented and reported to the physician. The other answers are understanding but still refuses. Which of the following incorrect. is the best nursing action? ‐ Administer the medication because it is important for the client. ‐ Inform the client that the medication needs to be taken until the nurse gets an order to discontinue it. ‐ Withhold the medication and report it to the physician. ‐ Withhold the medication and complete an incident report. | Select the option which best allows for client autonomy. |
3663 Which of the following findings would be of greatest Correct answer: 4 Options 1, 2, & 3 are expected findings and should not be considered cause for concern. concern to the nurse taking a client’s pulse? A pulse deficit, with an apical rate greater than the peripheral pulse rate may be a sign of significant vascular disease or cardiac dysfunction and should be reported immediately. ‐ Mild tachycardia in a febrile client ‐ Mild bradycardia in a young, otherwise healthy sleeping male ‐ 18‐month‐old with a heart rate of 120/minute ‐ Pulse deficit with an apical rate of 88 and a peripheral pulse of 72 | The critical words in the question are greatest concern. Recall the significance of common variations in pulse rates and volumes to enable you to recognize significant changes and take appropriate action. |
3664 The nurse is preparing to administer a less viscous Correct answer: 4 Several factors indicate the size and length of the needle to be used: the muscle, the type of (i.e., watery) IM injection into the deltoid muscle of a solution, the amount of adipose tissue covering the muscle, and the age of the client. A smaller 160‐pound male. What would be the preferred size needle such as an inch‐long, #23–25 gauge needle is commonly used for the deltoid muscle. needle for the medication, muscle, and size of the More viscous solutions require a larger gauge (e.g., #20 gauge). The other answers are client? incorrect. ‐ 1½‐inch, #20 gauge ‐ 1‐inch, #20 gauge ‐ 1½‐inch, #25 gauge ‐ 1‐inch, #25 gauge | Select the combination of shortest length and smallest gauge. |
3665 A nurse is observed giving an intramuscular injection. Correct answer: 2 The vastus lateralis and the rectus femoris are located on the thigh. The dorsogluteal is The nurse places the heel of the hand on the client's located on the buttocks. The ventrogluteal site is in the gluteus medius muscle with the greater greater trochanter, with the fingers pointing toward trochanter, the anterior superior iliac spine, and the iliac crest as the landmarks. The other the client's head. With the nurse's index finger on the answers are incorrect. client's anterior superior iliac spine, the middle finger is stretched dorsally, palpating the iliac crest. The index finger, the third finger, and the iliac crest form a triangle land marking which intramuscular injection site? ‐ Vastus lateralis ‐ Ventrogluteal ‐ Dorsogluteal ‐ Rectus femoris | Eliminate options 1 and 3 based on location in the thigh. Dorsal (dorsogluteal) means back. The area described is ventral. |
3666 A client is postoperative with an IV in place. The client Correct answer: 3 The essential parts of a drug that must be present in order to implement the order are: name is taking a soft diet and, when asked, rates the pain as of the drug, date and time the order was written, dosage, route, frequency, and signature of a 9 on a 1–10 scale. The following order is noted in the the person writing the order. Nurses may not administer a medication without all of the client's chart: Demerol 50 to 75 mg q 4 hr prn for pain. essential parts, or determine a route based upon the client's condition. Administering Tylenol Considering the client's pain level and noting that no without a medical order is practicing medicine without an order. route was ordered for the Demerol, the nurse should do which of the following? ‐ Administer the Demerol IM since the client is on a soft diet and the nurse recognizes this to be a safe IM dose. ‐ Recognizing this to be a safe IV dose, administer the Demerol IV until clarification is received from the physician. ‐ Withhold the Demerol until a route is ordered from the physician. ‐ Withhold the Demerol until you get a route ordered from the physician; administer Tylenol from stock supplies since these are available over the counter. | Option 3 is the only option which recognizes that the order described is missing a component. That medication cannot be administered until the order is complete. Over‐the‐ counter medication (option 4) requires an order in this situation. |
3667 While making rounds with the nurse, the physician Correct answer: 2 A nurse can take a verbal order from a physician. When the nurse transcribes the order, asks the nurse to write an order for Tylenol 500 mg q 4 "verbal order" is recorded with the order and the physician must co‐sign the order usually hr prn for a temperature elevation >100. What within 24 hours. The other answers are incorrect. should be the nurse's response? ‐ Explain to the physician that nurses are not permitted to write orders. ‐ Record the order with "verbal order" written with the nurse's signature and remind the physician to co sign it within the next 24 hours. ‐ Record the order and sign the physician's name first, followed by the nurse's signature. ‐ Ask the physician to restate the verbal with another nurse witnessing and record the order with both the witness and the nurse's name. | Select the option that returns the responsibility to the physician. |
3668 The nurse is administering a medication to a client Correct answer: 1 Blood levels of two metabolically produced substances, urea and creatinine, are routinely with a history of renal impairment. The medication is used to evaluate renal function. Both are normally eliminated by the kidneys and are measured known to be excreted through the kidneys. To monitor as serum BUN and creatinine. The other answers are incorrect. the client for adverse reactions, the nurse would monitor which of the following? ‐ Serum BUN and creatinine ‐ Color and odor of the urine ‐ Urine sugar and acetone levels ‐ Serum hemoglobin | Select the option which addresses renal function, rather than appearance of urine or evaluation of urine characteristics. |
3669 Which of the following assessment data would Correct answer: 4 The client doesn't need prior experience to gain the benefits of imagery. The client reporting prohibit the use of imagery with a client? a 6 on a 0–10 scale will benefit from the imagery session. Closing the eyes aids in establishing a state of internal awareness but is not necessary for an imagery session. The client could gaze at a fixed point 1–2 feet away instead of closing his or her eyes. When the client begins to trust the process, his or her eyes will get heavy and close. In clients with a history of organic brain syndrome or psychosis, deep relaxation may exacerbate symptoms of psychosis. Other relaxation methods should be instituted. ‐ No previous history of using imagery techniques ‐ States anxiety level of 6 on a 0–10 scale ‐ Client feels reluctant to close eyes for the imagery session ‐ Client has a history of psychosis | To answer this question, the nurse needs to know what clients will benefit from imagery and what the contraindication is for this technique. |
3670 The nurse has determined that music therapy may be Correct answer: 3, 4, 5 Music without words is recommended so that the client does not concentrate on the words. appropriate for use with a client. Which of the Music therapy needs to be at least 20 minutes in length to be effective. Music selections following should the nurse consider when choosing the should be based on the type of music the client perceives as relaxing. The nurse should music? Select all that apply. encourage the client to let the body respond to the music in any way it wishes, such as humming, relaxing muscles, or clapping. Analyzing the music will take away the focus from relaxing to thinking about the music. Any distracting thoughts should simply be let go, and the client should be instructed to concentrate on the music. ‐ Choose only music with words. ‐ Choose music that is 5–7 minutes in duration. ‐ Allow the client to choose music of his or her choice. ‐ Instruct the client to listen to the music and let the music take him or her wherever the music wants to go. ‐ Ask the client not to analyze the music. | The answer to this question reflects the critical elements when using music therapy with a client. |
3671 The nurse is using meditation with a client to help Correct answer: 2 The client needs to be involved in deciding which type of meditation to learn. The client’s him decrease his pain. Which of the following factors is condition or schedule may prohibit the use of this holistic therapy. Meditation can be used in important to consider when using this type of therapy? any facility and is not restricted to outpatient settings. Anyone can learn how to meditate. ‐ The type of meditation is best determined by the nurse or other health care provider. ‐ Consideration of the client's condition, schedule, and personal preference is necessary when choosing a type of meditation. ‐ The type of meditation used is based on whether it is taught in an inpatient or outpatient setting. ‐ A certified meditation professional should be the one teaching the client how to perform meditation. | This question requires that you know when it is appropriate for the nurse to utilize meditation. |
3672 The client asks the nurse how humor therapy affects Correct answer: 2, 3 Sympathetic nervous system is stimulated with humor therapy, leading to an increase in heart the client physiologically. The nurse responds that rate, respiratory rate, blood pressure, and oxygen saturation. The arousal state is followed by a laughter has which effect(s)? Select all that apply. relaxation state in which vital signs return to or below pre‐laughter baseline. Research suggests that humor therapy increases IgA levels in the saliva, which helps prevent upper respiratory infections. Laughter decreasesstress hormones such as cortisol. Laughter increases T lymphocyte cells, thereby increasing the immune response. Temperature is not affected. ‐ Decreases heart rate and oxygen saturation ‐ Increases salivary immunoglobulin A (S‐IgA) ‐ Produces an antagonist response to stress hormones ‐ Decreases the immune response by decreasing T‐lymphocytes ‐ Increases temperature set poin in the brain | An understanding of the pathophysiological effects of humor on the body is needed in order to answer this question correctly. |
3673 The nurse decides to teach a client with hypertension Correct answer: 3 The client needs to be in a comfortable position for relaxation to occur. Electromyogram the progressive relaxation response. Which sensors are applied to the forehead when using biofeedback to assess the physiological instructions should the nurse give to the client when response to relaxation technique. The progressive relaxation response requires the client to using this relaxation method? contract and relax muscles to gain a deeper state of relaxation. Repeating a phrase or word silently helps the client turn off other thoughts and focus on a neutral, monotonous stimulus. ‐ Sit in an upright position with legs crossed. ‐ Place sensors on the forehead to monitor physiological activity. ‐ Contract and then relax all your muscles sequentially from head to feet. ‐ Repeat a word or phrase forcefully with your breathing. | Knowledge of the process involved in performing progressive relaxation is needed to answer this question. |
3674 The nurse teaches the client about massage therapy. Correct answer: 4 Massage stimulates circulation, thereby improving blood flow and preventing the formation Which statement by the client demonstrates a correct of blood clots as well as decreasing muscle tension. Massage also stimulates the lymphatic understanding of the benefits of massage? system, enhancing lymphatic drainage. Massage causes the release of lactic acid that has accumulated during exercise. ‐ "Massage increases blood clot formation." ‐ "Massage inhibits lymphatic drainage." ‐ "Massage causes an accumulation of lactic acid as a result of the exercise." ‐ "Massage stimulates circulation while causing relaxation." | An understanding of the pathophysiological effects of massage on the body is needed to answer this question. |
3675 You have been invited to talk to the Woman's Guild in Correct answer: 3 Essential oils are distilled from flowers, roots, bark, leaves, wood, resins, citrus rinds, and your community about the cautions of aromatherapy. more; the quality of essential oils varies. Many oils should be kept out of the sunlight and heat. Which of the following would be correctly presented Essential oils can be toxic and produce an allergic reaction in some individuals. Some essential to the audience? oils are unsafe during pregnancy, so it is critical to contact the primary care provider prior to trying aromatherapy to determine which oils are safe and which are toxic. ‐ Aromatic oils are produced by a standard‐quality formula. ‐ The oils can be stored in any type of container. ‐ The skin should always be tested for allergies by applying a small amount of oil to the area before treatment. ‐ Oils should not be used during pregnancy. | The core issue of the question is that essential oils can cause an allergic reaction in the client. |
3676 Your class project is to prepare a speech on the Correct answer: 2 Humor decreases the social distance between people, putting them at ease. Humor reduces functions of humor in nursing situations for your peers. the presenter's anxiety and gains the audience's attention, which facilitates learning. Humor Following the presentation, you know the participants helps individuals act out impulses in a safe, nonthreatening environment, thus releasing anger understood your message when they respond that and aggression. Humor diminishes anxiety and fear, reducing tension and enabling the client to humor: confront and deal with the situation. ‐ increases the social distance between people and assists in putting them at ease. ‐ facilitates learning. ‐ holds in anger and aggression. ‐ aggravates coping mechanisms. | An understanding of the benefits of humor therapy is needed to answer the question correctly. |
3677 In evaluating the effectiveness of guided imagery for Correct answer: 4 The first statement indicates that the imagery session increases the client's anxiety level. The a client with preoperative anxiety, which data indicates second statement indicates that the client did not focus well during the session, which that this therapy is successful? prevents total relaxation. The third statement indicates the therapy was unsuccessful because guided imagery needs to be practiced daily to obtain the desired effect. The fourth statement indicates that the client's anxiety is decreased, which is the overall outcome of guided imagery therapy. ‐ "I hope that I don't have dreams like that tonight." ‐ "I couldn’t concentrate very much with all I have to do today." ‐ "I'll practice what I learned next week." ‐ "I feel less anxious about the upcoming surgery." | Understanding that the purpose of imagery is to help the client relax will help you choose the correct answer. |
3678 The nurse is using progressive relaxation in a client Correct answer: 3 It is not necessary to assess muscle strength prior to the relaxation therapy. It is not who is under a lot of stress. What nursing actions must necessary to assess for the use of sedatives because this therapy will cause relaxation. It is be instituted prior to the start of the session to protect essential to have the body supported as the muscles begin to relax. The client could obtain the client's safety? injury if he or she falls as muscle tension dissolves. It is not pertinent to know the client's allergies before performing progressive relaxation. ‐ Assess the client's muscle strength. ‐ Check to make sure the client is not on any sedatives. ‐ Remember to position the body so it is totally supported to prevent falls. ‐ Assess for any allergies. | The core issue of the question is the knowledge that a client can become so relaxed during the progressive relaxation session that falling is a risk if his or her body is not supported. |
3679 The nurse taught the client's wife how to perform a Correct answer: 4 The skin being massaged needs to be exposed. Massaging the back requires long strokes back massage on the client. Which observation by the along the spine with small, circular strokes peripherally. Warmed lotion helps enhance nurse indicates that the spouse understands how to relaxation. Massages should last 3–5 minutes and be given in an unhurried manner. give a back massage? ‐ Client is in his pajamas lying in bed. ‐ The spouse is rubbing his back with large, circular motions. ‐ The spouse is using cold lotion when performing the massage. ‐ The spouse massages the client's back for 3–5 minutes. | Knowing the steps in giving a back massage will help you answer this question. |
3680 The nurse taught the client about meditation. Which Correct answer: 4 Meditation involves focusing on the present moment and not on the future. Although statement by the client demonstrates a correct meditation was viewed as a religious practice, religious conviction is not required for understanding? meditation. Many types of meditation exist, and the techniques differ. All types of meditation involve relaxation and focused attention. ‐ "Meditation is a technique used to quiet the mind and focus on the future." ‐ "Meditation involves a religious conviction." ‐ "There is only one way to meditate." ‐ "Meditation involves both relaxation and focus of attention." | In order to answer this question correctly, you need to know the definition of meditation, the types of meditation, and how it is utilized. |
3681 The nurse is performing an imagery session with a Correct answer: 2 You would give the instructions in option 1 to a client who wants to meditate. Imagery group of clients. What instruction should the nurse involves visualization to assist in healing. An image often used in imagery is the healing of an ill give the clients? area of the body. Other images that can be used include destroying certain foreign substances (e.g., cancer cells) or connecting with a higher level of consciousness. The instructions in option 3 are appropriate for progressive relaxation exercises. Listening to music is not essential for the use of imagery. ‐ "Try to concentrate on your breathing, letting go of all your stress." ‐ "Imagine that your body is healing itself, and it is using all its energy to attain this goal." ‐ "Contract the muscles of your arm and then relax." ‐ "Listen to some music of your choice and let the music take you away." | To answer this question, the nurse must know the difference between imagery and other therapies like meditation, progressive relaxation, and music therapy. |
3682 A client is using aromatherapy to treat stress. Which Correct answer: 1 Dermatitis or eczema is a common allergic reaction to topical aromatherapy. Aromatherapy assessment data indicates an allergic reaction in a will not affect skin turgor. Aromatherapy will not change the pigmentation of the skin involved. client who has received an aromatherapy session? Edema is not a side effect of aromatherapy. ‐ Presence of a new rash ‐ Increased skin turgor ‐ Decreased pigmenation ‐ Edema peripherally | The question requires that the nurse know what to look for when a client has an allergic reaction to essential oils. |
3683 The preoperative waiting area has soft instrumental Correct answer: 2 Music therapy causes a hypometabolic state that stimulates the parasympathetic system and music playing in the background. The client asks the causes a relaxation response. Music therapy also helps reduce the stress and anxiety of the nurse, "Why are they playing this type of music instead preoperative client. Music therapy stimulates the right hemisphere of the brain where of tuning into a radio station?" The nurse explains that creativity resides. A radio station or soft intrumental music can be used to cover up the normal the purpose of using music therapy in the preoperative noises found in the hospital setting. client is that it: ‐ produces a hypermetabolic state. ‐ helps reduce physiological stress, pain, anxiety, and isolation. ‐ enhances the functions of the left hemisphere of the brain. ‐ covers up the normal noises found in the hospital setting. | Knowledge of the physiological effects of music is needed to answer this question correctly. |
3684 The client tells the nurse that when he walks, he Correct answer: 3 All of the symptoms described suggest intermittent claudication. Ginkgo is the only herb develops a pain in his right leg. He describes the pain effective for this condition because its anticoagulant properties will enhance blood flow to the as cramping or burning in his muscles that subsides extremities. All the other options are herbs that will not be effective with this painful condition with rest. Based on these symptoms, the nurse of the calf caused by reduced peripheral circulation. supports the use of which of the following herbs? ‐ Feverfew ‐ Garlic ‐ Ginkgo ‐ Ginseng | The core issue of the question is the effect of gingko in reducing blood coagulation. Use this knowledge and the process of elimination to determine the correct option. |
3685 A client is taking chlorpromazine (Thorazine). Based Correct answer: 3 Chlorpromazine (Thorazine), a phenothiazine, is metabolized in the liver. Milk thistle, the liver on metabolism of this prescribed medication, the herb, is known to reduce risk of hepatotoxicity caused by phenothiazines. The other options do nurse supports the concomitant use of which of the not have this beneficial effect. following herbs? ‐ Valerian root ‐ Ginger ‐ Milk thistle ‐ Hawthorn | The core issue of this question is recognition that milk thistle has a beneficial effect on the liver. Use this knowledge and the process of elimination to determine the correct option. |
3686 Which of the following therapeutic changes in Correct answer: 3 Garlic is used most widely to reduce total serum cholesterol and triglyceride levels. Option 1 laboratory values would the nurse anticipate in the is incorrect because garlic would reduce, not increase, platelet aggregation, thus leading to client taking garlic? bleeding tendencies. Although garlic has been shown to boost immunity, it has not demonstrated effects on the white blood cell count, making option 2 incorrect. Option 4 is incorrect because there is no known relationship between garlic and serum glucose levels. ‐ Increased platelet aggregation ‐ Increased white blood cell count ‐ Decreased serum cholesterol levels ‐ Decreased serum glucose levels | The core issue of the question is the use of garlic as an aid in reducing cholesterol and triglycerides levels. Use this knowledge and the process of elimination to determine the correct option. |
3687 The female client tells the nurse that she is planning a Correct answer: 4 The use of any herb should be discussed with the health care provider, particularly in pregnancy soon. In providing client education related pregnancy and lactation. Most herbs are contraindicated at this time, regardless of the form to the use of herbs during pregnancy, which of the and even when taken as directed or in lower doses. (Although some sources recommend following statements by the nurse is most ginger for morning sickness, other sources claim safety during pregnancy is unknown. Black appropriate? cohosh has been known to promote labor and should be avoided until birth is imminent.) ‐ "Most herbs are safe when taken as directed." ‐ "Only herbs in the topical form are safe." ‐ "Certain herbs are safe and effective when taken in lower doses." ‐ "You should discuss the use of any herbs with your health care provider." | The core issue of the question is that many herbs have unknown or adverse effects on the developing fetus and are therefore used cautiously or avoided during pregnancy. Use this knowledge and the process of elimination to determine the correct option. |
3688 The client presents to the health care clinic with an Correct answer: 1 Echinacea is effective when used topically to promote wound healing. It is also used internally abrasion to the left knee from a fall. After cleaning the to boost the immune system, particularly in the prevention and adjunct treatment of colds and abrasion, the nurse might support the use of which influenza. The other options do not have this beneficial effect. client‐chosen herb as adjunct therapy to treat the abrasion? ‐ Echinacea ‐ Ginger ‐ Valerian root ‐ Feverfew | The core issue of the question is the use of echinacea in wound healing and immune system enhancement. Note the correlation between these properties and the skin injury of the client. Use this knowledge and the process of elimination to determine the correct option. |
3689 The client scheduled for arthroscopic knee surgery Correct answer: 1 Ginger is known to inhibit thromboxane production. The inhibition of this prostaglandin has been taking ginger for relief of arthritic pain reduces platelet aggregation, increasing the risk of bleeding in the postoperative client. Option preoperatively at home. The client asks the nurse 2 is incorrect because ginger would be effective in this situation but is unsafe. Option 3 is about the use of ginger after surgery for continued incorrect; although it is a true statement, it addresses dosing but not safety when used relief of pain and also as a relief of postoperative postoperatively. There is no data to support ginger as potentiating the effects of opioid nausea. In providing client education, the nurse medications (option 4). explains that ginger: ‐ cannot be used safely postoperatively. ‐ would not be effective in this situation. ‐ may be repeated every 4 hours as needed. ‐ may potentiate the effects of opioid medications. | The core issue of the question is the risk of bleeding associated with the use of ginger. Note the association of that property of this herb and the word postoperative in the stem of the question. Use this knowledge and the process of elimination to determine the correct option. |
3690 In planning care for the client who is taking hawthorn, Correct answer: 2 The nurse should monitor blood pressure in the client taking hawthorn, which is known to the nurse includes which of the following decrease peripheral vascular resistance, thus decreasing blood pressure. There is no evidence interventions? that hawthorn has an affect on any of the other options. ‐ Monitor blood glucose levels ‐ Monitor blood pressure ‐ Monitor white blood cell count ‐ Monitor temperature | The core issue of the question is the effect of hawthorn on hemodynamics, such as lowering blood pressure and decreasing vascular resistance. Use this knowledge and the process of elimination to determine the correct option. |
3691 The client tells the nurse that a neighbor Correct answer: 2 One of the principle active ingredients of bilberry is pectin, a soluble fiber that decreases recommends the use of bilberry in treating simple diarrhea. The other options do not contain soluble pectin, and therefore they would be of no diarrhea. The nurse supports the client's use of bilberry use in controlling simple diarrhea. based on which of the following? ‐ Anthocynanosides in the berry decrease peristalsis. ‐ The berry contains pectin, which acts as a soluble fiber. ‐ Bilberry acts to counteract antimicrobial suppression of normal intestinal flora. ‐ Action of the berry works to decrease bacterial or viral causes of diarrhea. | The core issue of this question is recognition that bilberry contains pectin and that pectin is used to control diarrhea. Use this knowledge and the process of elimination to determine the correct option. |
3692 The nurse instructs the client taking Saint John's wort Correct answer: 4 The psychotherapeutic effects of Saint John's wort are not well understood. The herb is that which of the following foods preferred by the thought to work by inhibition of serotonin reuptake, but it may have a slight inhibition of client may be safely consumed while taking this herb? monoamine oxidase (MAO). It is therefore important for the nurse to instruct the client that it is safe to eat ice cream while taking Saint John's wort. The other options are incorrect because they contain tyramine, which, when consumed with MAO inhibition, may lead to severe hypertension. ‐ Chocolate ‐ Aged cheeses ‐ Beer ‐ Vanilla ice cream | The core issue of the question is the risk of interactive effects of foods containing tyramine with the MAO inhibitor effect of Saint John's wort. Use this knowledge and the process of elimination to determine the correct option. |
3693 Which of the following clients would benefit from the Correct answer: 3, 5 The client with coronary artery disease or peripheral vascular disease would benefit most therapeutic effects of garlic? Select all that apply. from use of garlic because of its ability to lower cholesterol and triglyceride levels. Garlic is not helpful in treating low blood pressure or liver disease (options 1 and 2). Because it inhibits platelet aggregation, the use of garlic by clients with a bleeding disorder could be hazardous (option 4). ‐ The client with decreased blood pressure ‐ The client with liver disease ‐ The client with coronary artery disease ‐ The client with a bleeding disorder ‐ The client with peripheral vascular disease | The core issue of the question is the use of garlic as an aid in reducing cholesterol and triglycerides as serum lipids. Use this knowledge and the process of elimination to determine the correct option. |
3694 The client returns from a vacation after a 5‐hour car Correct answer: 1 Ginger is most effective when started several days before traveling. A dose should be ride stating that the ginger taken to treat motion administered 30 minutes before the trip and may be repeated every 4 hours as needed. sickness was ineffective. The ginger was taken in Options 2 and 3 are incorrect as motion sickness from any type of travel, including seasickness, capsule form after riding inside the car for an hour. may be treated effectively with ginger. Option 4 is incorrect as the form of ginger is not The nurse explains that the ginger was most likely relevant to its effectiveness. ineffective for which of the following reasons? ‐ The herb is most effective to prevent motion sickness when started several days before traveling. ‐ Ginger is not recommended to prevent car sickness. ‐ Ginger is only effective to prevent motion sickness from air travel. ‐ The candied ginger form of the herb is recommended in this situation. | Select the response that reflects the optimal method of treating motion sickness which is to medicate before the travel begins, rather than focusing on the herb. |
3695 The client taking black cohosh should be cautioned by Correct answer: 4 Black cohosh should be avoided with concomitant use of antihypertensive medications as an the nurse to avoid which of the following medications? adverse effect of the herb is hypotension. The other options are incorrect although the client should discuss the use of any herbal medications with the health care provider. ‐ Warfarin (Coumadin) ‐ Acetaminophen (Tylenol) ‐ Fluoxetine (Prozac) ‐ Metoprolol (Lopressor) | Eliminate medications that would likely not have a life threatening interaction, such as Tylenol and Prozac. |
3696 The client reports use of echinacea for the past 2 Correct answer: 1 The client should be instructed about long‐term use of the herb. Echinacea, as with any other years to ward off colds and influenza. Based on herb, is not meant for long‐term use. Although most commonly used to boost the immune knowledge related to safe and effective use of system and ward off colds and influenza, echinacea may lead to hepatotoxicity when taken for echinacea, the nurse plans to instruct the client about more than 8 weeks; prolonged use may cause suppression of the immune system. Therefore, which of the following? option 4 is incorrect as the client does not demonstrate accurate knowledge related to the use of echinacea. Although correct dosage is important, it is not relevant in this client since the problem lies in the length of therapy, making option 2 incorrect. Option 3 is incorrect as there is no evidence that use of antihypertensive medications are contraindicated while using the herb, although all medications should be discussed with the health care provider. ‐ The effects of long‐term use of the herb ‐ Echinacea should be taken in the morning in tea form. ‐ The client should avoid concomitant use of acetaminophen (Tylenol). ‐ The client is already demonstrating accurate knowledge about use of the herb. | Note that the scenario stresses the client has been taking the herb for 2 years. Select the response that focuses on the length of use. |
3697 The client taking ginkgo should be monitored by the Correct answer: 4 Ginkgo inhibits platelet aggregation and adhesion thus the client should be monitored nurse for which of the following adverse effects? bruising and bleeding. The other options are incorrect. ‐ Decreased blood glucose levels ‐ Infection | Select the response that corresponds to the most frequent issue with this herb which is decreased platelet count. |
‐ Hepatotoxicity ‐ Bruising and bleeding | |
3698 The nurse includes which of the following Correct answer: 3 The nurse should monitor the client for headache and mild, temporary stomach upset, assessments in planning care for the client taking common adverse effects of valerian root. With large doses, the client may experience severe valerian root? headache, nausea, morning headache and blurred vision. Option 1 is incorrect as the herb is not known to have any effect on the immune system. Option 2 is incorrect as valerian root is known to have similar action to benzodiazepines, without addiction. Option 4 is incorrect as the use of the herb has no know effect on blood pressures. ‐ Immune system suppression ‐ Addiction ‐ Headache and mild, temporary upset stomach ‐ Hypertension | Note that only option 3 gives a combination of two assessments which is often a clue to the correct response. |
3699 The client taking garlic demonstrates the need for Correct answer: 3 Garlic decreases cholesterol by decreasing, not increasing, low‐density lipoproteins. It also further teaching when he states that garlic: decreases triglycerides and increases high‐density lipoproteins. The other options are correct and do not require further teaching: garlic should be chewed or crushed when taken in the raw form (clove) to effectively convert to the active ingredient allicin (option 1); garlic, as with all other phytomedicines, should be used cautiously with other phytomedicines (option 2); garlic may reduce the risk of stroke by its actions in reducing cholesterol and inhibiting platelet aggregation. ‐ Should be chewed if the fresh bulb is used. ‐ Should be used cautiously with other phytomedicines. ‐ Is known to increase low‐density lipoproteins. ‐ May reduce the risk of stroke. | Increasing low‐density lipoproteins is not a desired effect, therefore would require additional teaching. |
3700 The nurse evaluates the effectiveness of therapy with Correct answer: 2 The most common use of bilberry is the relief of simple diarrhea. Other known uses are the bilberry by monitoring for which of the following prevention and treatment of eye disorders, such as diabetic retinopathy, night blindness, outcomes? macular degeneration, glaucoma, and cataracts. It is also used in the treatment of diabetes mellitus, as an antioxidant and the possible treatment of varicose veins and hemorrhoids. The other options are incorrect. ‐ Decreased urinary frequency, nocturia and dysuria ‐ Relief of diarrhea ‐ Relief of night sweats and hot flashes ‐ Reduction of symptoms of cold/influenza | In this question note that all of the options, except the correct response, have multiple conditions in the string. |
3701 The client with hepatitis is taking milk thistle. The Correct answer: 2 Milk thistle, commonly referred to as the liver herb, is used as adjunct therapy in the nurse instructs the client to do which of the following treatment of liver inflammation related to cirrhosis, hepatitis and fatty infiltrates related to regarding its use? the use of alcohol and other toxins. The client should use water‐based extract and avoid the alcohol‐based extract. Option 1 is incorrect as there is no reason to discontinue the herb at this time. Option 3 is incorrect as milk thistle is not soluble in water and should not be used in tea form. Although rare, loose stools and diarrhea are the common adverse effects of the herb, not nausea and vomiting, making option 4 incorrect. ‐ Discontinue the milk thistle immediately. ‐ Use the water‐based extract of the herb. ‐ Administer the milk thistle in tea form. ‐ Report common adverse effects of nausea and vomiting. | Note the word water in the correct response. This is a key to the correct option as other bases used for the herb, such as alcohol, would be contraindicated. |
3702 The nurse cautions the client taking black cohosh to Correct answer: 4 The client taking black cohosh should avoid concomitant use of antihypertensives, such as avoid which of the following medications? captopril (Capoten), an ACE inhibitor. The other options are incorrect, although use of all medications should be discussed with the health care provider. ‐ Acetaminophen (Tylenol) ‐ Lorazepam (Ativan) ‐ Over‐the‐counter (OTC) cold and flu preparations ‐ Captopril (Capoten) | Select the response that would enhance the expected effect of the herb, in this case hypotension. |
3703 Which of the following assessments would the nurse Correct answer: 3 American ginseng is not known to have any effect on liver function. The other options are be least likely to monitor in the client taking American assessments that the nurse would be expected to monitor: Korean (American) ginseng ginseng? improves glycosylated hemoglobin (HbA1c) (option 1); it improves serum cholesterol and triglyceride levels (option 2); and it increases blood pressure with low doses and decreases blood pressure with higher doses (option 4). ‐ Glycosylated hemoglobin ‐ Serum cholesterol and triglyceride levels ‐ Liver function studies ‐ Blood pressure | Knowledge that ginseng is often used as a preventative treatment in cardiac health can be helpful in eliminating options 2 and 4. |
3704 The client asks the nurse about a magazine Correct answer: 1 The focus of the education should be on the client's ability to assess the reliability of the advertisement related to the use of ginger for the information source. Although all of the other options are also correct, option 1 is a global treatment of arthritis. The nurse focuses client response and takes into consideration all of the other options. education on which of the following? ‐ The client's ability to accurately assess the reliability of information sources ‐ The author of the article ‐ The type of magazine in which the advertisement was found ‐ The client's level of education | Reliability is the key word and is helpful in selecting the correct response. |
3705 A female client taking feverfew for the prevention of Correct answer: 1 Feverfew has not been proven safe for use in pregnancy and lactation. It is important for the migraine headaches reports to the nurse that she client to discontinue use of the feverfew immediately until the pregnancy has been verified. thinks she may be pregnant. Based on knowledge of Client education should also include that those who may possibly become pregnant should feverfew, what would be the nurse's priority action? avoid the use of any herbs. Therefore, first the client should be instructed to discontinue use of the feverfew and then have a pregnancy test performed. Option 3 is incorrect because the client would need to se the health care provider only if she is pregnant. Option 4 is incorrect because the dosage of the feverfew is not relevant. ‐ Instruct the client to discontinue use of the feverfew herb. ‐ Instruct the client to have a pregnancy test performed. ‐ Arrange for the client to see her health care provider. ‐ Instruct the client to reduce the dosage of the feverfew. | Select the option which describes the safest option for the fetus, which is to discontinue the herb. |
3706 A male client taking valerian root as a sleep aid Correct answer: 2 The active ingredient, valepotriate, might be carcinogenic and should be removed from the demonstrates safe administration of the herb when he form of the herb. Option 1 is incorrect as lorazepam (Ativan) and valerian root exhibit similar states that the herb: actions and may not be taken together safely. Option 3 is incorrect as the herb has not been proven safe in children, regardless of age. Option 4 is incorrect as the form of the herb is irrelevant to its effectiveness. ‐ May be taken safely with lorazepam (Ativan) in small doses. ‐ Should have the active ingredient valepotriate removed from the extract. ‐ May be used safely in children over the age of 5. ‐ Is not effective in the capsule form. | Omit option 1 as the herb and this drug work in the same manner. Omit option 3 as this herbal remedy which acts like a benzodiazepine would not be recommended for use in children. |
3707 A client taking saw palmetto to treat symptoms of Correct answer: 4 Saw palmetto taken in doses greater than the recommended 160 mg standardized liposterolic benign prostatic hyperplasia (BPH) complains of acid BID can produce diarrhea. This side effect is not related to the form of the extract or the diarrhea. Based on knowledge of this herb, the nurse client's age (options 3 and 4). Allergy to ragweed is not related to the use of saw palmetto concludes that the diarrhea is most likely related to (option 2). which of the following? ‐ The form of the herb extract ‐ Client history of allergy ‐ The age of the client ‐ The dose of the herb | Select the option that would most likely be related to any adverse effect, which is dosage. |
3708 A 50‐year‐old female client presents to the health Correct answer: 2 One of the major uses of black cohosh is in the treatment of postmenopausal symptoms, clinic with complaints of hot flashes and night sweats. which include hot flashes and night sweats. Black cohosh is also used to promote labor in After determining that the symptoms are not related pregnancy, to reduce blood pressure and cholesterol levels and is used in the treatment of to any underlying disease process, the nurse supports poisonous snake bites. The other options identify incorrect herbs for treatment of the client use of which of the following phytomedicines? symptoms listed. ‐ Echinacea ‐ Black cohosh ‐ Bilberry ‐ Valerian root | Use elimination to omit options that name herbs more commonly used for other conditions. For example, echinacea is used to treat colds; bilberry is used to prevent eye disorders; and valerian root is used like benzodiazepines. |
3709 The client is taking garlic on a daily basis. Which of Correct answer: 1 The effectiveness of garlic is based on scientific evidence and clinical trials. Garlic has the the following statements demonstrates the client's ability to affect bleeding times and should not be taken with other herbs that have the same understanding of its use? action, making option 2 incorrect. Option 3 is incorrect because garlic may be taken in enteric‐ coated tablets of garlic powder, which is effective in reducing bad breath although this form may not be as potent as raw garlic. Option 4 is incorrect because garlic should not be used with OTC medications such as ASA (Aspirin) or ibuprofen (Motrin) that may also affect bleeding times. ‐ "The effectiveness of garlic is based on scientific research." ‐ "Garlic may be used safely with ginger." ‐ "There are no remedies for the bad breath caused by the garlic." ‐ "I can take garlic safely with over‐the‐counter medications." | Omit options 3 and 4 as being either too general (4) or stated as an absolute (3). |
3710 Which of the following statements made by the nurse Correct answer: 3 Hawthorn should be avoided with concomitant use of prescription antihypertensive is most appropriate when providing client education medications, such as captopril (Capoten), which is an ACE inhibitor. Hawthorn is similar in regarding the use of hawthorn? action to the ACE inhibitors and works to reduce blood pressure by blocking the conversion of Angiotensin I to Angiotensin II, which is a potent vasoconstrictor. Option 1 is incorrect because hawthorn is only effective in the treatment of chronic stable angina. As with any phytotherapy, use should be restricted to chronic, self‐limiting conditions and not for acute episodes. Option 2 is incorrect as hawthorn has a negative chronotropic effect to decrease heart rate. Option 4 is incorrect as verapamil (Calan) is a calcium channel blocker and works to decrease blood pressure by blocking the influx of calcium ions across the cardiac and arterial muscle cell membrane. ‐ "You may use hawthorn for acute episodes of chest pain or angina." ‐ "Hawthorn will not affect your heart rate." ‐ "You should not take hawthorn while taking captopril (Capoten)." ‐ "Hawthorn is known to produce the same effects as verapamil (Calan).” | Omit option 1 as herbal remedies would not generally be recommended for acute cardiac episodes. Select the option that best corresponds with the action of the drug which is the blocking of vasoconstriction. |
3711 A client has been taking nutrition bars containing Correct answer: 3 Korean ginseng should not be used in combination with coffee, tea or colas. Option 1 is Korean ginseng for the past 2 weeks to increase incorrect as there is no evidence that the herb affects the ability to drive a car or operate concentration and stamina. Based on knowledge of the machinery (i.e., there are no known CNS effects). Option 2 is incorrect as the form of the herb herb, the nurse instructs the client to do which of the is not related the adverse effects. Option 4 is incorrect as there are specific precautions with following? the use of Korean ginseng; for example, a ginseng‐free period is recommended, usually 2–3 weeks on and 1–2 weeks off. ‐ Avoid operating machinery or driving a car while taking the nutrition bar. ‐ Avoid this form of the herb, which is known to increase adverse effects. ‐ Avoid use of the nutrition bar with coffee, tea, or cola. ‐ Continue use of the nutrition bar daily as desired. | Focus on the material in the question that describes the reason for the use of the herb. Substances containing caffeine are identified in option 3, which would not combine well with an herb being used to increase stamina. |
3712 A client taking Saint John's wort in capsule form to Correct answer: 3 Saint John's wort may take several weeks before the effects are evident. (All phytomedicines treat mild depression for the past week complains of it are slower to work than prescribed medications.) The form of the herb is not related to its ineffectiveness. Which of the following statements effectiveness, making option 1 incorrect. Saint John's wort in capsule form should be taken made by the nurse is most appropriate? three times per day, making option 2 incorrect. Option 4 is incorrect as Saint John's wort is appropriate for the treatment of mild to moderate depression. ‐ "You may need to switch to another form of the herb." ‐ "You should take the herb at night." ‐ "It may take several weeks for the therapy to be effective." ‐ "Saint John's wort may not be effective for your type of depression." | The question mentions a specific time frame. Select the answer that addresses the time frame. |
3713 In evaluating the effectiveness of saw palmetto for Correct answer: 2 There is conflicting evidence that saw palmetto will actually reduce the size of the prostate. the treatment of benign prostatic hyperplasia (BPH), Clinical evidence supports the use of the herb to reduce symptoms of residual volume (option the nurse would be least likely to focus on which of the 1), urinary frequency (option 3) and dysuria (option 4), common symptoms of the disorder. following assessments? ‐ Residual volume ‐ Size of the prostate ‐ Urinary frequency ‐ Dysuria | Select the response that most directly relates to the use of the herb. The other options could have multiple causes. |
3714 Which of the following statements made by the client Correct answer: 1 Saw palmetto should be avoided in tea form as it is insoluble in water. The other options are who is taking saw palmetto indicates a need for true statements and therefore do not require further teaching. further teaching? ‐ "I will take saw palmetto in the morning as a tea." ‐ "I will take the herb with meals or food." ‐ "Large amounts of the herb may cause diarrhea." ‐ "It may take as long as 6–8 weeks before effects of the therapy may be noticed." | Focus on the response that relates to self‐administration of the herb as this is frequently an area that requires reinforcement of teaching. |
3715 Use of hawthorn to treat hypertension is similar in Correct answer: 2 Hawthorn is similar in action to ACE inhibitors. They prevent the conversion of angiotensin I action to which of the following medications? to angiotensin II, a potent vasoconstrictor. The other answers are incorrect. Furosemide (Lasix) is a loop diuretic (option 1); hydralazine (Apresoline) is a direct‐acting peripheral vasodilator (option 3); amlodipine (Norvasc) is a calcium channel blocker (option 4). ‐ Furosemide (Lasix) ‐ Capoten (Captopril) ‐ Hydralazine (Apresoline) ‐ Amlodipine (Norvasc) | Recall that hawthorn acts by preventing vasoconstriction. Eliminate the options that do not act in this manner. |
3716 A client using phytomedicines is able to demonstrate Correct answer: 3 Many herbs may be used for different reasons. The dosage of some herbs depends on its safe and effective use when the client makes which of specific use. Option 1 is incorrect as acute and sudden illness should not be treated with the following statements? phytotherapy. Option 2 is incorrect as the FDA does not evaluate phytomedicines for the treatment, cure or prevention of disease, but how they affect the structure and function of the human body. Although not regulated in the United States by the FDA, most are regulated by the Dietary Supplement and Health Education Act of 1994 as dietary supplements. Option 4 is incorrect as many side effects and adverse reactions may occur with improper dosing and the words natural or all‐natural can be misleading. ‐ "Phytomedicines may be used effectively for sudden and acute illness." ‐ "The FDA regulates the medicinal use of herbs only when taken as directed." ‐ "It is important to know the use of each particular herb in order to determine the appropriate dose." ‐ "Large doses of phytomedicines are safe since they are natural substances." | Eliminate option 2 as an untrue statement. Options 1 and 4 are stated as absolutes, and are not true. |
3717 A client taking ginkgo biloba complains of itchy skin. Correct answer: 1 Unprocessed ginkgo leaves should be avoided as they contain ginkgolic acids, which are Which of the following statements made by the nurse potent allergens related to the substance uroshiol, which is the chemical responsible for the is most appropriate? itch in poison ivy. Option 2 is incorrect because the symptoms will continue with further use of the unprocessed leaves. Option 3 is incorrect as photosensitivity is not related to the use of ginkgo in any form. Option 4 is incorrect as relief of symptoms can be obtained from discontinuing use but will only reoccur if use of the unprocessed leaves is resumed. ‐ "Tell me what form of ginkgo you have been using." ‐ "This reaction is common and should disappear in a few days." ‐ "It is important to avoid the sun while taking gingko." ‐ "Discontinue use of the ginkgo until the symptoms disappear." | Select the response which asks for more information from the client regarding the therapy. |
3718 The client taking Saint John's wort should be Correct answer: 2 One of the side effects of Saint John's wort is photosensitivity requiring the client to avoid instructed to avoid which of the following activities? direct exposure to sunlight, especially if fair‐skinned. The other options are incorrect and not relevant. ‐ Bowling ‐ Sunbathing ‐ Yoga ‐ Weightlifting | Note that sun exposure is often problematic for clients when medications are in use. |
3719 The client asks the nurse about the purpose of taking Correct answer: 4 Valerian root is used as a sedative, to reduce anxiety, treat insomnia, and relieve muscle valerian root. Which of the following uses would be spasms. It is also used as adjunct therapy for the withdrawal of benzodiazepines, as it has least appropriate? similar action to this class of medications without the addiction or dependence. Valerian root has not been known to affect blood pressure, making option 4 incorrect. ‐ Relief of insomnia ‐ Relief of muscle spasms ‐ Reduction of anxiety ‐ Treatment of hypertension | Note that options 1, 2, and 4 are all common uses of benzodiazepines. Valerian root and benzodiazepines are similar in their actions. |
3720 The nurse supports use of bilberry for which of the Correct answer: 4 There are no known contraindications for the use of bilberry in conjunction with estrogen, following clients? although clients should always inform the health care provider when planning to utilize phytomedications. Bilberry may interfere with iron absorption when taken internally, making option 1 incorrect. Option 2 is incorrect as bilberry may increase coagulation time and should be avoided with the use of anticoagulants such as warfarin (Coumadin). Since vitamin E can antagonize vitamin K, it plays a peripheral role in blood clotting and should be avoided with concomitant use of bilberry, making option 3 incorrect. ‐ The client taking iron pills for the treatment of anemia | Omit options 1, 2, and 3 since these drugs are known to have interactions with this herb. |
‐ The client taking warfarin (Coumadin) for the treatment of thrombophlebitis ‐ The client taking vitamin E to improve the immune system ‐ The client taking estrogen for the treatment of premenstrual syndrome | |
3721 The nurse instructs the client taking valerian root to Correct answer: 4 Alprazolam (Xanax) is a short‐ to intermediate‐acting benzodiazepine. Concomitant use of this avoid the use of which of the following medications? drug with valerian root should be avoided since their actions are similar and the herb may potentiate the action of the alprazolam. The other options are incorrect. ‐ ASA (aspirin) ‐ Codeine ‐ Clonidine (Catapres) ‐ Alprazolam (Xanax) | Valerian root is known for acting similarly to benzodiazepines. Xanax is the only benzodiazepine option. |
3722 The nurse suggests that a client diagnosed with Correct answer: 4 Increased intraocular pressure is symptomatic of glaucoma. Bilberry is useful in the treatment increased intraocular pressure might benefit from of this and other eye disorders, such as diabetic retinopathy, night blindness, macular which of the following phytomedicines? degeneration, and cataracts. The other options are incorrect. ‐ Black cohosh ‐ Valerian root ‐ Saw palmetto ‐ Bilberry | Omit the herbs known for other common uses. Select Bilberry as the herb often used to prevent eye disorders. |
3723 The nurse would recommend ginger to treat which of Correct answer: 1 The most common use of ginger is the relief of nausea and vomiting. It is also useful in the the following complaints by the client? treatment of motion sickness and as an anti‐inflammatory in osteoarthritis and rheumatoid arthritis. The other options are incorrect. ‐ Nausea and vomiting ‐ Varicose veins ‐ Cold and flu symptoms ‐ Fatigue | Omit option 2 as being a condition that is generally not self‐treated. Select the option most closely related with the use of this herb. |
3724 When assessing the appropriateness of humor Correct answer: 1 It is most important to determine what the client sees as humorous. Humor is individualistic; therapy for a client, the nurse must first: what is funny for one client might not be funny to another client. Laughing when you might not think something is humorous does not help you be genuine with the client. When using humor therapy, jokes related to the client's religion, culture, or gender should be avoided. These jokes can make the client feel inferior, which will not enhance the client's healing. ‐ Observe the type of humor that the client creates. ‐ See the client laugh in response to a cartoon most clients find funny. ‐ Laugh at the same things the client does. ‐ Use jokes based on the client's culture as an icebreaker. | To answer this question correctly, the nurse needs to know when it is appropriate to use humor therapy. |
3725 The nurse has taught the client with nausea how to Correct answer: 1 If essential oil gets into the eyes, it must be flushed out immediately with milk or a carrier oil, use aromatherapy to alleviate the symptoms. Which rather than water, since the oils are not dissolvable in water. There are some contraindications statement by the client indicates that he has for some types of essential oils, so the nurse needs to consult the list of contraindications in demonstrated correct understanding of the training manual. The choice to use aromatherapy is best decided by a professional in the aromatherapy? field. Nurses should not administer essential oils orally, since this is not covered by the nurse's scope of practice. Also, some essential oils can be poisonous if given incorrectly, and should be administered orally by a trained professional in this field. Oils need to be stored in a dark, covered bottle and kept away from light and heat. ‐ "If I get the essential oil in my eyes, I need to flush them out with either milk or a carrier oil." ‐ "I can share my treatment with anyone else, since I now know how to use aromatherapy." ‐ "I can take it orally, if needed." | To answer this question correctly, the nurse needs to know how to administer and store oil, and what to do when it accidentally gets in one's eyes. |
4.‐ "I need to store my oil in any container as long as it is away from the light." | |
3726 A client is using music therapy to treat pain. To Correct answer: 4 It is unrealistic to expect the client to practice this technique every hour, and it takes 20 achieve the therapeutic outcome of being pain‐free, minutes to have an effective music therapy session. Music therapy needs to be practiced more the client should practice music therapy: often than once a day. Every other day does not provide frequent‐enough practice to elicit the relaxation response. A minimum of 20‐minute sessions, twice a day is needed to obtain the therapeutic response of music therapy. ‐ Five minutes every hour. ‐ Once a day for 45 minutes. ‐ Every other day for 10 minutes. ‐ Twenty minutes, twice a day. | The nurse needs to know how long and often the client should practice music therapy to answer this question correctly. |
3727 A tense and anxious client is a good candidate for the Correct answer: 1, 2, 3 The setting for the imagery needs to be quiet, and the client needs to be in a comfortable use of imagery. After discussing this therapy with her, position for the relaxation and imagery session to take place. Relaxation exercises are used in the nurse would do which of the following to support the beginning of the imagery session to assist the client to deep relaxation. Allowing the client the client's use of imagery? Select all that apply. to create her own images allows the client's subconscious to select images with which the client is ready to deal, and to block those with which the client is unwilling or unready to deal at this time. The nurse does not need to know the specifics of the client’s images, or interpret the meaning, but should encourage the client to explore what these images mean to her. ‐ Select a quiet, comfortable setting for the session. ‐ Use relaxation exercises to assist the client to relax prior to the imagery session. ‐ Allow the client to create her own images. ‐ Obtain specific information about the client's images during a session. ‐ Help the client interpret the meaning of her symbols and images. | The correct answers reflect what the nurse can do to facilitate the imagery session. For example, a quiet setting, using relaxation exercises, and allowing the client to create her own images are essential for a successful therapy. |
3728 While performing a massage on a client, the nurse Correct answer: 4 The nurse cannot assess the gastrointestinal system during the massage, since that would can concurrently assess which body system? involve listening to bowel sounds and percussing the abdomen. The nurse cannot assess the musculoskeletal system during the massage, since it would involve the palpation, range of joint motion, and strength of all the joints. During a massage, the muscles are compressed to enhance relaxation, and the joints are not mobilized or tested. The nurse cannot assess the peripheral vascular system during the massage, because this would involve assessing pulses of the extremity. The nurse can assess the skin color, temperature, and hair distribution, and observe for any lesions, while performing the massage. ‐ Gastrointestinal ‐ Musculoskeletal ‐ Peripheral vascular ‐ Integumentary | To answer this question correctly, the nurse needs to know what assessments can be done while giving a massage. |
3729 The nurse is using progressive relaxation with a client Correct answer: 2 Blood pressure will decrease in the relaxation state with because the body is in a state of who has chronic back pain. The nurse evaluates the lowered metabolic need. The respiratory rate will decrease, which is one of the first signs that therapy as being effective when observing a(n): the client is entering the relaxation state. The heart rate also will decrease when the client is in the relaxed state. Oxygen saturation will increase in a relaxed state, due to decreased oxygen consumption by the tissues. ‐ Increase in blood pressure. ‐ Decreased respiratory rate. ‐ Increase in heart rate. ‐ Decrease in oxygen saturation. | Knowing that progressive relaxation will stimulate the parasympathetic system and how this will affect the vital signs is necessary to answer this question correctly. |
3730 The nurse teaches the client that there are three Correct answer: 1 The three requisites to relaxation are correct posture, a quiet environment, and a mind at requisites for using relaxation. The client would be rest. A lying position, music, or an hour of time is not necessary for meditation. Moving the using these requisites when the client is: body through postures while focusing on a thought is yoga. Assessing energy changes when the hand is passed over a portion of the body is an energetic therapy, such as healing touch or therapeutic touch. ‐ Sitting in a chair with good posture, with the room quiet and the mind at rest. ‐ Lying on a couch, listening to soft music for 1 hour. ‐ Concentrating on a thought and moving the body in various postures. ‐ Assessing the energy with the palms of the hand over an area of the body. | The nurse needs to know what is required in perform relaxation exercises in order to answer this question correctly. |
3731 The primary purpose of humor therapy for a client in Correct answer: 1 Humor therapy stimulates the release of endorphins, which will reduce the perception of pain is to: painful impulses. Laughter does cause an increase in sympathetic response initially, which is then reversed in the relaxation stage. Both of these responses affect the perception of the pain. The client's level of conscious will increase with the sympathetic response, but this is not the primary purpose of using humor therapy. Increasing the blood supply to the brain with sympathetic stimulation does not decrease the perception of the pain. ‐ Stimulate the production of endorphins. ‐ Elicit the response of the sympathetic nervous system. ‐ Increase the client's level of consciousness. ‐ Improve blood supply to the brain. | An understanding of the pathophysiological effects of humor and laughter is needed to answer this question. |
3732 Which of the following findings would the nurse Correct answer: 1 During music therapy, the parasympathetic system will be stimulated, causing vasodilation to observe in a client who is successfully using music the skin, thereby increasing skin temperature. An increased respiratory rate would indicate a therapy? sympathetic response. An increased heart rate also would indicate a sympathetic response. An increased blood pressure also would indicate a sympathetic response. ‐ Increased peripheral temperature ‐ Increased respiratory rate ‐ Increased heart rate ‐ Increased blood pressure | An understanding of the pathophysiological effects of music therapy on the body is essential to answer this question correctly. |
3733 The nurse discusses ways for the preoperative client Correct answer: 4 Allowing the client to create his own images allows the subconscious to select images with to enhance healing, and the client decides to learn which the client is ready to deal, and block those with which the client is unwilling or unready imagery. When conducting an imagery session, the to deal at this time. Imagery will cause a decrease in respiratory rate, due to parasympathetic nurse needs to keep in mind that: stimulation. The nurse does not need to know the specifics of the client’s images, or interpret the meaning, but should encourage the client to explore what these images mean to him. There is no way to predict what will surface in the client's imagination, as every experience is different. ‐ It can be dangerous to allow a client to create his images. ‐ Imagery generally increases the client's respiratory rate. ‐ It is necessary to obtain specifics about the client's images during a session. ‐ No one can predict what images will occur in the client's imagination. | Knowing how to perform an imagery session and the effects of imagery on the body is necessary to answer this question. |
3734 Nurses assist in performing relaxation, biofeedback, Correct answer: 1 All three of these therapies involve deep breathing while learning how to relax the body. and imagery techniques with a client. These techniques Meditation also involves deep breathing and relaxation, but therapeutic touch involves share which of the following processes? assessing and correcting energy field imbalances in a manner that is different from relaxation, biofeedback, and imagery techniques. The body is not engaged in physical activity or touched with biofeedback, imagery, or relaxation therapies. Physical resting is common to these therapies, but reflexology involves applying pressure to the foot in certain areas to obtain a desired response. ‐ Physical resting and rhythmic breathing ‐ Therapeutic touch and meditation | An understanding of relaxation, imagery, and biofeedback is needed to determine what elements are in common. |
‐ Physical activity and therapeutic touch ‐ Physical resting and reflexology | |
3735 The client is using meditation to relieve stress. Which Correct answer: 1 The client needs a distraction‐free environment, to facilitate relaxation. The client should be statement by the client indicates an accurate sitting cross‐legged on the floor or be upright in a straight‐backed chair with the spine upright understanding of meditation? for meditation. Lying down will increase the chance that the client will fall asleep. Meditations need to be 10–20 minutes in length to obtain the desired effect. The client should be instructed to focus on her breathing or a mental image. When distracting thoughts enter the mind, she should let them drift back out by not focusing on them. ‐ "I try to meditate when I wake up, since everyone at home is still asleep." ‐ "I lie down in bed when I meditate." ‐ "I perform the meditation for at least five minutes at a time." ‐ "I find that it gives me time to think about my life and what I want in life." | Knowledge of the steps to perform meditation is needed to determine if the client has demonstrated correct knowledge on the topic. |
3736 The nurse is instructing the client how to use the Correct answer: 1, 2 Essential oils can be inhaled by placing them in a humidifier or vaporizer. Adding essential oils essential oils in aromatherapy. Which statements by to the bath will cause inhalation as the oil rises with the steam of the water. Essential oils the client indicate an understanding of how essential should not be placed directly on the skin without the use of carrier oil (e.g., almond oil). oils can be administered? Select all that apply. Placing the essential oil directly on the skin can cause irritation. Nurses should not administer essential oils orally, since this is not covered by the nurse's scope of practice. Also, some essential oils can be poisonous if given incorrectly, and should be administered orally by a trained professional in this field. ‐ "I can inhale the oils by putting a few drops in my humidifier." ‐ "I can add a few drops in my bath to help me relax." ‐ "I can rub the essential oils over achy areas of my body." ‐ "I can add the oils to a cup of hot water, and drink it with lemon." ‐ "I can heat the drops of oil, and sprinkle them on my skin." | Knowledge of how essential oils are administered is necessary to answer this question. |
3737 A client is using imagery to treat cancer. An outcome Correct answer: 1, 2, 4 The outcome for imagery is to give the client a sense of peace with a sense of purpose and for this healing intervention would include which of meaning of one's life. Remission or cure is not the outcome of imagery. Imagery is a useful the following? Select all that apply. technique to decrease the client’s perception of pain. ‐ A sense of peace and integration ‐ A deeper understanding of the meaning of life's events ‐ A total remission of the disease process ‐ Relief of pain ‐ Lengthened survival rate | An understanding that the outcome of imagery is relaxation, peace, and relief of pain, and not necessarily the cure of the illness, is needed to answer this question. |
3738 When using humor therapy with a client, the nurse Correct answer: 3 The nurse needs to establish a professional relationship with the client initially; so humorous should do which of the following? interventions are inappropriate at this time. Humor therapy should come naturally, and not be forced, as would be the case if the nurse were using many jokes and props trying to make the client laugh. The nurse needs to meet the physical and emotional needs of the client before initiating humor therapy. If humor is used when the client's needs are not met, the nurse will be insensitive. What one person thinks is humorous might not be something the other person feels is humorous. ‐ Use a humorous intervention within the first 20 minutes of meeting a client to establish the connection of shared laughter. ‐ Keep trying a different joke or prop until the nurse gets a laugh. ‐ Use humorous interventions after the nurse attended to the physical or emotional pain that the client might be experiencing. ‐ Try different jokes. If the client does not respond with observable laughter, he is unable to appreciate the humor the nurse shared. | Knowledge of how to implement humor therapy is needed to answer this question correctly. |
3739 The nurse is participating in a therapeutic touch Correct answer: 4 When assessing the client's energy fields, the nurse is noting changes in temperature and session with a client. The nurse evaluates that it would density; when there are none, it indicates a normal response. The end of the therapeutic touch be appropriate to stop the session when which of the session occurs when the practitioner assesses the whole body and tries to balance the areas following occurs? where the imbalances have been felt. This indicates that the client is relaxed, and the nurse still can provide therapy with the client sleeping. There is no minimal or maximal time requirement for a session. It is recommended to stop a therapeutic touch session when the imbalance in the energy field is resolved. ‐ There is no noticeable difference in temperature or density of energy fields. ‐ The client's muscles relax and the client falls asleep. ‐ The session has lasted the maximum time of one hour. ‐ The practitioner perceives that the imbalance have been resolved. | Knowledge of how to administer a therapeutic touch session and when to stop the session is needed to answer this question. |
3740 The nurse is caring for a client who is using Correct answer: 4 Massage is a CAM therapy. Use of relaxation tapes is also a CAM technique. Seeking the complementary and alternative medicine (CAM) assistance of an acupuncturist is also a CAM therapy. Having surgical repair of the foot is using therapies for treatment of foot pain. Which statement medical therapy and not CAM therapy. CAM therapies are holistic therapies that the client by the client does not reflect accurate use of CAM uses alongside the conventional medical management of the illness. therapies? ‐ "I go see my massage therapist to enhance my range of motion." ‐ "I try to listen to my relaxation tapes to decrease the pain intensity." ‐ "I go see the acupuncturist to decrease the pain in my foot." ‐ "I plan to have surgery on my foot next month." | An understanding of what therapies are involved in CAM is needed to answer this question correctly. |
3741 The relative health and well‐being of the nurse in Correct answer: 4 Nurses need to work as a team to receive the support they need to meet the needs of all the relation to helping clients constitutes a vital force in clients. Working through breaks will lead to exhaustion, and is not making the needs of the the healing process. A method that would be helpful to nurse a priority. By caring for the nurse's needs, she will be better equipped to care for the nurses in fostering their own health is: needs of the clients. Setting unrealistic goals will lead to frustration when they cannot be accomplished. It is best to start out with small, achievable goals to build confidence, and then increase the difficulty of the goals to obtain the ultimate outcome. Self‐care of the nurse is essential, and needs to be the top priority for the nurse to be able to care for her client’s holistic needs. ‐ Trying to do things independently, so as to not bother the other nurses. ‐ Working through breaks to meet the needs of the clients. ‐ Setting unrealistic goals. ‐ Reflecting on their own beliefs and values, and making self‐care a priority. | The nurse would need to know that an essential component to care for others holistically is for the nurse to care for herself first. |
3742 A client has returned to the nursing unit following a Correct answer: 1 The status of the client's airway and breathing is of highest concern. Once the nurse has tracheostomy. The nurse would place highest priority assessed the airway and breathing, then the amount of oxygen and dressing status can be on assessing which of the following? assessed. Finally, the time lapse since any analgesic medication can be determined. ‐ Respiratory rate and breath sounds ‐ Amount of oxygen ordered to be delivered ‐ How long ago client received any pain medication ‐ Status of tracheostomy dressing | Remember the ABC's: airway, breathing, and circulation. In questions asking for a priority action, all options may be correct, and you need to select the option that is most important or timely. Remembering the sequence of airway, breathing, and circulation may help with questions that relate to respiratory or circulatory disorders or procedures. |
3743 The nurse is providing care to a client who had a Correct answer: 3 The priority action of the nurse restores a patent airway. With this in mind, the nurse spreads tracheostomy performed 2 weeks ago. The client the retention sutures to reopen the stomal area. The nurse then quickly calls aloud for help so coughs the tube out of the trachea. Which of the assistance will arrive to aid in tube reinsertion. The nurse is not likely to suction the area at this following actions should the nurse take first? time, and the nurse would reinsert a new tracheostomy tube if allowed by agency policy, since the tube has been in place for more than 72 hours. ‐ Call aloud for help. | Remember the ABC's: airway, breathing, and circulation. The correct answer is one that directly affects the client's airway, which is opening the stoma. The other options are incorrect because they either are not the first action (options 1 and 4) or may not be done at all (option 2). |
‐ Suction the stoma to remove residual secretions. ‐ Grasp and spread the retention sutures to open the stoma. ‐ Attempt to reinsert a new tracheostomy tube. | |
3744 The client has just had emergency intubation for Correct answer: 2 The first action by the nurse is to assess for bilateral breath sounds as an initial indication of respiratory distress. Immediately after endotracheal correct tube placement. The nurse would next secure the tube and then call for chest x‐ray to tube insertion, which of the following actions by the confirm tube placement. Once the client's airway and breathing have been attended to, then nurse is most appropriate? the nurse can assure the client about alternative communication means. ‐ Tape the tube securely in place. ‐ Assess for bilateral breath sounds. ‐ Call for a chest x‐ray to determine placement. ‐ Assure the client that alternative communication means will be provided. | Remember the ABC's: airway, breathing, and circulation. The correct answer is one that directly affects the client's airway, which is assessing for bilateral breath sounds. Because the question asks for the priority action of the nurse, the other actions must be systematically eliminated. |
3745 Which of the following respiratory assessment Correct answer: 4 A harsh or crowing sound with inspiration indicates stridor, which is consistent with airway findings is of greatest concern to the nurse following narrowing and edema following endotracheal tube removal. This is of greatest concern endotracheal tube extubation? because it could lead to upper respiratory obstruction. The nurse needs to notify the physician. The other options are of less concern, since clients may be expected to have secretions or some rhonchi immediately after tube removal. An increase in respiratory rate from 16–20 bears watching for trends but is still with normal limits. ‐ Increased respiratory rate from 16–20 ‐ Scattered bilateral rhonchi ‐ Expectoration of whitish yellow secretions ‐ A harsh or crowing sound with inspiration | Note the critical words of greatest concern. This tells you that the correct option is the finding that is most abnormal. Use the process of elimination and knowledge of normal and abnormal physical assessment data to make a selection. |
3746 A client with a closed chest drainage system tries to Correct answer: 1 The priority action of the nurse is to submerge the tube in sterile water or saline to get out of bed alone and disconnects the chest tube reestablish the underwater seal. This will prevent the client from sucking air through the chest from the drainage system, which falls on the floor. tube into the pleural space during inspiration, thereby causing pneumothorax. After this initial Which of the following actions should the nurse take action, the nurse would assess the client's respiratory status, set up a new system, and then first upon entering the client's room? check the client's full vital signs before reporting incident to the physician. ‐ Submerge the tube in sterile water or saline. ‐ Set up and attach a new closed chest drainage system. ‐ Assess the client's respiratory status. ‐ Check the client's pulse and blood pressure. | Note the critical word first in the question. This tells you that more than one option may be technically correct but one is better than the others based on the client’s status or the needs of the situation. Recall that an underwater seal is critical to chest tube functioning to select the correct option. |
3747 Following chest tube insertion, the nurse notes Correct answer: 1 The nurse should document this normal finding and continue to monitor. Fluid addition or gentle, continuous bubbling in the suction control removal is based on fluid level, not on bubbling action of suction. The nurse should not turn up chamber of the closed chest drainage system. Which suction because the gentle bubbling indicates proper function, and increased suction could of the following actions should the nurse plan to take cause more rapid evaporation of water from chamber. at this time? ‐ Document and continue to monitor the bubbling. ‐ Add water to the suction control chamber. ‐ Remove water from the suction control chamber. ‐ Turn up the suction on the wall suction unit. | The wording of the question tells you that there is a single correct answer. Recall that gentle bubbling is normal to guide your answer. Use nursing knowledge about closed chest drainage systems and the process of elimination to make a selection. |
3748 During routine chest tube assessment, the nurse Correct answer: 2 Continuous bubbling in the water seal chamber most often indicates a leak or loose notes the presence of continuous bubbling in the connection in the system, and air is being sucked continuously into the closed chest drainage water seal chamber of the closed chest drainage system. If the client experienced a new large pneumothorax, there could be rapid bubbling, but system. The nurse suspects that which of the following this is not the most likely explanation. Turning up the suction on the wall unit would increase has most likely occurred? the bubbling in the suction control chamber, not the water seal chamber. Taping the connections too tightly is not a concern. ‐ The client has developed a sudden new pneumothorax. ‐ There is an air leak in the system. ‐ The wall suction unit has been set to intermediate or high level instead of low suction. ‐ The connections have been taped too tightly. | The core issue of the question is the significance of finding continuous bubbling in the water seal chamber. Use the process of elimination and knowledge of closed chest drainage systems to make a selection. |
3749 The client is scheduled for removal of a chest tube at Correct answer: 2 The client should be premedicated approximately 30 minutes prior to chest tube removal if 09:00. At approximately 08:30, the nurse should take the client has an analgesic order and the medication can be given at this time. It is the which of the following actions? physician’s responsibility to determine the results of the daily chest x‐ray. Obtaining equipment for removal and explaining the procedure to the client can be done earlier or later than the timeframe indicated. ‐ Call the radiology department for a telephone report of the morning chest x‐ray findings. ‐ Premedicate the client with an analgesic if it is ordered and can be given at this time. ‐ Ensure that a suture‐removal set and dressing materials are available. ‐ Explain to the client the upcoming removal procedure. | The core issue of the question is what action is timely 30 minutes before chest tube removal. Analyze each option to determine whether each needs to occur at that time. Recall that analgesics are usually given about 30 minutes prior to a painful procedure to select the correct option. |
3750 The nurse has received a telephone order to irrigate a Correct answer: 2 The maximum amount of fluid that should be used to irrigate a nephrostomy tube is 5 mL. nephrostomy tube after notifying the physician that it The nurse should also use strict aseptic technique to prevent infection of the renal pelvis as a has stopped draining. The nurse plans to use no more result of the procedure. than how many milliliters to carry out this procedure safely? ‐ 2 mL ‐ 5 mL ‐ 10 mL ‐ 20 mL | The core issue of the question is knowledge of appropriate volumes of fluid that should be used to irrigate tubes such as a nephrostomy tube. Eliminate the smallest and largest numbers as being least plausible. Choose 5 mL over 10 mL after visualizing the amount in the syringe and estimating the size of the renal pelvis. Memorize this number if the question was difficult. |
3751 The nurse should take which of the following actions Correct answer: 3 The nurse should ensure that the tubing is free of kinks or other obstructions to urine flow. when caring for a client with a nephrostomy tube? The tube is irrigated according to physician order only. The tube should never be clamped. Taping the drainage bag to the bedrail is dangerous because it could cause traction when the client moves in bed and become dislodged. ‐ Irrigate the tube every hour regardless of drainage. ‐ Keep a clamp at the bedside. ‐ Ensure the tubing is free of kinks. ‐ Tape the drainage bag to the bedrail. | Use general principles of tube management to answer the question. Eliminate option 4 first as being hazardous. Eliminate option 1 next as being excessive. Choose option 3 over 2 knowing that the tubing should be kept free of kinks and that these tubes should not be clamped. |
3752 A nurse is assigned to a client with a nasogastric tube Correct answer: 1 Gastric pH is acidic and readings should be 4 or less if the tube is placed properly in the and is checking gastric pH to verify correct tube stomach. The other options indicate placement in the intestine or higher up in the esophagus, placement. The nurse determines that the tube is since normal body pH is 7.35 to 7.45. properly positioned after obtaining which of the following pH readings? 1.‐ 4 2.‐ 6 3.‐ 7 4.‐ 8 | The core issue of the question is knowledge of pH readings that are consistent with placement of a nasogastric tube in the stomach. Use specific nursing knowledge and the process of elimination to make a selection. |
3753 The nurse would use which of the following Correct answer: 4 The nurse correctly measures the distance from tip of nose to earlobe and then to the xiphoid landmarks to correctly measure a client prior to process and marks the tube at this length prior to insertion. The other options identify one or nasogastric tube insertion? more incorrect landmarks. ‐ Tip of nose, mandible, and sternal notch ‐ Tip of nose, mandible, and xiphoid process ‐ Tip of nose, earlobe, and sternal notch ‐ Tip of nose, earlobe, and xiphoid process | The core issue of the question is knowledge of how to properly measure a client for nasogastric tube insertion. Use specific nursing knowledge and the process of elimination to make a selection. |
3754 A client with a partial bowel obstruction will have a Correct answer: 4 In order for the tube to migrate to the area of intestinal blockage, the tube must pass through nasoenteric tube placed by the physician later in the the pyloric sphincter of the stomach. Recall that this tube has a weighted tip and thus gravity day. The nurse explains to the client that which of the will affect its movement, as will peristalsis. Positioning the client with head elevated and on following positions will be utilized following tube the right side will utilize gravity to help the tube migrate into the intestines. The other placement so it will migrate to the intended area? responses will lead to less effective tube movement. ‐ Flat and on the left side ‐ Flat and on the right side ‐ Head of bed elevated and on the left side ‐ Head of bed elevated and on the right side | The core issue of the question is knowledge of proper client position following nasoenteric tube placement. Visualize tube movement using laws of gravity to aid in making a selection. Gravity should be a prime consideration as a possible influence whenever answering questions related to tube placement. |
3755 The nurse enters the room of a client who underwent Correct answer: 3 Nasoenteric tubes are not taped in place until they have migrated to proper position and insertion of a nasoenteric tube for partial bowel been confirmed by x‐ray. The nurse should note the assessment finding on the medical record. obstruction the previous evening. The nurse notes that The nurse does not need to call the physician, and it is unnecessary to immediately determine the tube is not taped at the nose. Which of the the x‐rays that are scheduled. It is completely unnecessary to notify the physician at this time. following actions is most appropriate at this time? ‐ Call the physician immediately. ‐ Tape the tube in place. ‐ Note the finding on the client's flowsheet. ‐ Call the radiology department to see if an abdominal x‐ray has been done. | The core issue of the question is knowledge that nasoenteric tubes are not taped until they have reached final position. Use specific nursing knowledge and the process of elimination to answer this question. |
3756 The nurse is about to receive an intershift report on a Correct answer: 2 A Sengstaken‐Blakemore tube is inserted to control bleeding from esophageal varices, which client who has a Sengstaken‐Blakemore tube in place. is the primary health problem of concern with use of this tube. The underlying health problem The nurse expects that the client has which of the that causes the bleeding is portal hypertension, which is a complication of cirrhosis of the liver. following health problems as the primary reason for Abdominal ascites may also accompany cirrhosis. tube placement? ‐ Cirrhosis of the liver ‐ Esophageal varices ‐ Portal hypertension ‐ Abdominal ascites | The core issue of the question is knowledge of the rationale for placement of a Sengstaken‐ Blakemore tube. Use knowledge of pathophysiology and the process of elimination to make a selection. |
3757 The nurse has just assisted with insertion of a Correct answer: 3 Scissors needs to be kept at the bedside of a client who has a Sengstaken‐Blakemore tube. If Sengstaken‐Blakemore tube. Before leaving the client's the tube becomes dislodged and the client cannot breathe, the nurse cuts the tube to allow room, the nurse ensures that which of the following the balloons to deflate and restore a patent airway. A suction machine and oxygen are equipment is at the bedside in case of tube generally helpful airway adjuncts, but they do not apply to this situation. A laryngoscope is dislodgement? used to insert an endotracheal tube but it does not apply to this question. ‐ Suction machine ‐ Oxygen mask ‐ Scissors ‐ Laryngoscope | The core issue of the question is knowledge that tube dislodgement can block the airway and that scissors are needed for rapid balloon deflation if this occurs. Use nursing knowledge and the process of elimination to make a selection. |
3758 The nurse working in the emergency department Correct answer: 3 An Ewald tube is a large‐bore tube used to evacuate stomach contents rapidly following learns that a client will be arriving who took an poisoning or overdose. Minnesota and Sengstaken‐Blakemore tubes are used for clients with overdose of acetaminophen (Tylenol) a short while bleeding esophageal varices. A Miller‐Abbot tube is a nasoenteric tube used to decompress the ago. The nurse should anticipate that which of the bowel with small bowel obstruction. following tubes will be used to evacuate the client's stomach upon arrival? ‐ Minnesota ‐ Sengstaken‐Blakemore ‐ Ewald ‐ Miller‐Abbott | The core issue of the question is knowledge of the use of various types of drainage tubes. Use nursing knowledge and the process of elimination to make a selection. |
3759 A client who took an overdose of a prescribed Correct answer: 1 The risk of aspiration with gastric lavage is of concern to the nurse. For this reason, medication was treated with gastric lavage. The nurse assessment of respiratory status, including respiratory rate and breath sounds, is of great assesses the client carefully for which of the following concern. Other vital signs are also important as a measure of general condition but are not as a priority to detect possible complications of focused on detection of complications of this procedure. Urine output is of general concern, treatment? but peripheral edema is not a priority. ‐ Respiratory status and breath sounds ‐ Heart rate and blood pressure ‐ Skin color and body temperature ‐ Urine output and peripheral edema | The core issue of the question is knowledge that gastric lavage can lead to aspiration as a complication. Use nursing knowledge and the process of elimination to make a selection. |
3760 The nurse has emptied a Jackson Pratt wound‐ Correct answer: 2 The nurse should squeeze the collecting chamber to reestablish negative pressure and suction drainage device and needs to reestablish suction to the to the device. The nurse then wipes the port with alcohol before closing to reduce the risk of tube. Which of the following actions should the nurse infection. The tubing should always be free of kinks to prevent obstruction. take to accomplish this objective? ‐ Ensure the tubing has no kinks. ‐ Squeeze the collection chamber. ‐ Wipe the port with alcohol. ‐ Close the cap on the device. | The core issue of the question is which action by the nurse will reestablish suction to a Jackson Pratt wound‐drainage device. Use nursing knowledge and the process of elimination to make a selection. |
3761 The nurse has received report on a client who Correct answer: 3 A Penrose drain allows free flow of abdominal drainage out of the abdominal cavity and onto underwent pelvic exenteration the previous day and thick layers of gauze dressings that are placed around the drain. It is used when moderate to has a Penrose drain placed in the lower abdomen. The large amounts of drainage are expected, as with extensive abdominal surgeries. The nurse nurse should take which of the following actions in the should assess the skin for irritation and breakdown from contact with abdominal skin if care of this wound drain? dressing changes are not done on time or if an insufficient number of gauze dressings are used around drain. The drain may be advanced over days for gradual removal. The surgeon does not need to be notified of moderate amounts of drainage because it is expected. ‐ Ensure that the drain always stays in the original position placed by surgeon. ‐ Place only a few gauze dressings around the tube to allow for easier assessment. ‐ Assess the abdominal skin for irritation or breakdown with dressing changes. ‐ Notify the physician for moderate amount of drainage. | The core issue of the question is knowledge that this type of drain can cause skin irritation by nature of the volume of drainage. Use nursing knowledge and the process of elimination to make a selection. |
3762 The nurse has an order to insert a nasogastric tube Correct answer: 2, 3, 1, The client's head of bed is raised first because airway and breathing are the priority. Next the into the stomach of an assigned client. Place in order 4, 5 tube is measured for accurate length of insertion. The tube is then advanced past the the steps that the nurse would follow to complete the nasopharynx. The client is then asked to take sips to help with tube advancement into the procedure. Click and drag the options below to move stomach. Finally, the tube is taped once placement is assured. them up or down. ‐ Place distal end of tube at tip of nose and measure to earlobe and then to xiphoid process to determine distance for tube insertion ‐ Insert tube into naris and advance upward and backward until resistance met; rotate catheter gently and advance into nasopharynx ‐ Sit client upright (high Fowler's position) | The core issue of the question is knowledge of the insertion procedure for a nasogastric tube. Use nursing knowledge to sequence the steps that the nurse needs to take. Visualize the procedure to aid in answering the question. |
‐ Ask client to take sips of water if able while tube advanced gently into stomach ‐ Tape tube in place | |
3763 A client has had a tracheostomy tube in place for Correct answer: 3 Catheters should be inserted only during one suctioning period to minimize the risk of three days. The client has learned how to assist in total contamination from allowing the catheter to lie out of the sterile packet, which would allow tracheostomy care as needed. Which statement would bacteria to grow between suctioning periods. indicate a need for additional teaching? ‐ The client says, "I can suction no more than 10 seconds each time before removing the catheter." ‐ The client says, "I can reuse the catheter for oral secretions after the tracheostomy suctioning, if needed." ‐ The client says, "I will reuse the catheters several times before discarding them, to save money." ‐ The client says, "I let my significant other assist by holding the mirror, while I clean underneath the flat part (flange) of the tracheostomy." | The so‐called 10‐second rule for suctioning allows for maximum suctioning without a loss of oxygen to the client. When moving from a sterile tracheostomy opening to the oral cavity, it is acceptable to move from sterile to clean surfaces. It is not acceptable to move from oral to tracheostomy opening, as the mouth contains bacteria that could cross‐ contaminate the sterile tracheostomy environment. Allowing the significant other to participate in the process in this non‐threatening manner encourages participation in the task despite minimal knowledge. In addition, the significant other can support the client's self‐esteem and independence in the process by the accomplishment of the task as needed. |
3764 A client is to receive a soap suds enema. Which Correct answer: 4 Deep breaths will relax the abdominal muscles and allow additional fluids to enter the colon directions would be included to assist in a successful while under less abdominal pressure. outcome? The client should: ‐ Hold the enema for at least 3 hours to get the best results. ‐ Bear down with the abdominal muscles when cramping, to decrease abdominal pressure. ‐ Sit on the toilet to decrease the risk of falls when hurrying to the toilet. ‐ Take deep breaths when feeling the urge to go until all of the solution is given. | Three hours is too long to hold a soap suds enema. Up to 1 hour is more than sufficient for the soap suds and water to stimulate peristalsis of the bowel. Most clients cannot hold it that long. Instantaneous results from an enema are more likely and realistic. Bearing down with the abdominal muscles will increase abdominal pressure, not decreasing the cramping but increasing peristalsis. An upright position is not the preferred position for the fluid to be instilled for an enema, since the fluid would have to go against gravity as it travels up the colon. The left side‐lying (Sims') position is preferred for the solution to flow downward into the rectum and descending colon with gravity. Sitting on the toilet will not give the maximum benefit of the enema itself. For safety purposes, a bedpan or bedside commode would be safer than trying to run across the room to the toilet. Instilling the maximum amount of solution will allow the most productive evacuation. The urge to void can be delayed by clamping the solution temporarily or slowing down the solution flow rate until the feeling passes temporarily to be able to complete the enema instillation. |
3765 When a rectal tube is used to collect continuous Correct answer: 2 Increasing girth shows a backup or buildup of contents or air in the abdominal area without watery diarrhea, which assessment would indicate an adequate movement within the gastrointestinal system to remove stool. If the source of the urgent need that should be addressed by the nurse? problem is not identified, additional complications will develop as stool stagnates or goes backwards in the GI tract. The most common problem of loss of peristalsis is an ileus. ‐ Increasing bowel sounds ‐ Increasing girth of the abdomen ‐ Decreasing bowel sounds ‐ Increased volume of stool contents | Bowel sounds will indicate the speed of peristalsis and rate of elimination.<BR /> |
3766 The nurse assesses the functioning of a client's Salem Correct answer: 3 sump nasogastric suction following abdominal surgery. Which indicates a problem exists with the suctioning? ‐ A pH of 3.0 on the aspirated gastric contents when tested ‐ Suction regulator set at 100 mmHg intermittent suction ‐ Suction tubing connected to the air vent tube ‐ Gastric secretions that are yellow/green in color | The air vent opening should remain open, to allow air to decompress the stomach, and suction is connected to the larger, primary opening of the double‐lumen tube. An anti‐reflex valve might be covering the air vent, but it does allow air to enter. Decompressing the stomach is achieved when some air enters the stomach through the air vent to prevent the pull of stomach mucosa into the hole of the larger lumen to which the suction is connected. | Normal pH of stomach contents is strongly acid (0–4). If the tube passed into the intestines, the secretions will yield a pH of 6–8. Accidental placement of the tube in the pulmonary tree would yield a 6–7 pH range. Suction for nasogastric tubing is to be in the low range of 30–40 mm Hg for continuous suction or high, intermittent suction up to 120 mm Hg. Normal gastric secretions are yellow–greenish to tan or off‐white. Duodenal samples can be deep yellow. Pulmonary secretions are clear to light yellow. The color of secretions is not a reliable indicator of location of the tube. Connecting the suction tubing to the air vent tubing will pull secretions from the stomach through the smaller tubing canal, and probably clog the tubing. If the air vent is clogged, the risk of damage to the mucosa is increased, and fewer secretions will be removed from the stomach in the long run. Only air should be pushed through the air vent tubing, to maintain the integrity of the system. |
3767 Which of the following would indicate a serious Correct answer: 2 complication from excessive suctioning of an endotracheal tube that requires immediate nursing intervention? | Bradycardia occurs when the vagus nerve has been stimulated during the suctioning process. Vagal stimulation will trigger a decreased heart rate, and can lead to cardiac arrest if the heart rate drops too low. The nurse should stop the suctioning until vagal stimulation is stopped and the client is stable. Tachycardia is expected in response to suctioning due to stimulation, as the heart rate increases to compensate for the decreased oxygen levels caused by suctioning. Pallor and slight cyanosis could be expected to occur as oxygen is removed along with the respiratory secretions. However, if severe cyanosis occurred, it would mean that too much oxygen has been removed and, if present, would be of great concern. | Note that all of the incorrect responses indicate a temporary decrease in oxygen when suctioning. Recall that bradycardia indicates a vagal stimulation response that could cause cardiac arrest to choose this as the correct answer. |
‐ Tachycardia ‐ Bradycardia ‐ Pallor ‐ Slight cyanosis | ||
3768 When evaluating a new graduate nurse, which Correct answer: 2 statement indicates a need for additional training when performing nasotracheal suctioning? The new graduate that says she will: ‐ Wait 2–3 minutes before suctioning again. ‐ Hyperventilate the lungs prior to suctioning. ‐ Hyperoxygenate before and after suctioning. ‐ Rotate the suction catheter only on the way out when suctioning. | Hyperventilation is giving too much volume of air into the lungs, and is not recommended, due to the risk of rupture of lung tissue. Other responses are appropriate actions that are recommended to minimize the loss of oxygen when suctioning the client. | Maintaining maximum oxygenation should always be the focus when suctioning the client who has a compromised respiratory function. Hyperventilation means to overextend the lung tissue. This is not recommended in an already‐compromised client, since this can rupture alveoli and decrease the surface areas available for oxygen exchange. Waiting will allow the client to regain any lost oxygen between suctioning episodes. Hyperoxygenating is beneficial to minimize oxygen loss during suctioning, since extra oxygen will be available by flushing the client with 100% oxygen for 1–2 minutes prior to the suctioning process. Rotating the catheter only on the way out when suctioning will remove only secretions and prevent pulling tissue into the catheter tip. Rotating the catheter when entering the endotracheal tube is of no benefit, since the suction is only on during the withdrawal of the catheter. |
3769 When a client is dealing with the stress of managing a Correct answer: 4 Stress of a life change such as having a permanent suprapubic catheter must be addressed permanent suprapubic catheter, the nurse should: like any other loss with which a client must deal while hospitalized. By exploring feelings and coping strategies that are present, the nurse will be able to work on strategies using familiar coping strategies that have been successful for the client. Also, if the strategies have not worked in the past to reduce stress, then new strategies can be introduced to the client as options to deal with this new stressor once the feelings have been clarified with the client. ‐ Tell the client all of the facts, to make sure home care will be done correctly. ‐ Give an anti‐anxiety med that is ordered. ‐ Reassure the client that many people live with these and have no problems. ‐ Identify coping skills, and explore the client’s feelings. | Answer option 1 dealt only with giving facts or knowledge related to the catheter, and does not explore how the client feels about the tube. Option 2 dismisses the client's feelings by giving medication to cover up or prevent the exploration of the feelings with which the client should be dealing during the stressful process. Option 3 is generalizing the issue and then giving false reassurance that everything will be OK. The nurse can not give that reassurance, because anything could happen. Only answer 4 addresses the actual feelings and strategies to cope with the stress itself. |
3770 Following a chest trauma three days ago, a chest tube Correct answer: 4 The chest tube in the second intercostals space is used to remove free air in the chest cavity. has been in place at the right second intercostals space Therefore, the chest wall should move equally bilaterally by the third day, when the air is of the anterior chest wall. The nurse would expect removed. which assessment? ‐ Absence of breath sounds in upper‐right chest area ‐ Secretions in the tubing to be serous ‐ Continuous bubbling when the collection device is connected to low wall suction ‐ Bilateral equal movement of the anterior chest wall | The chest tube is inserted to keep the lung inflated by removing free air from the chest cavity. Lung sounds should be present. There should be no secretions from the tubing, since it only removes air. Bubbling on a continuous basis indicates an air leak somewhere in the system, and requires immediate intervention. Bilateral chest movement should be equal, to show that both sides are fully expanding, since the lungs would be inflated by the third day. |
3771 A client has a new chest tube located at the base of Correct answer: 2 Crepitus would indicate an air leak into the subcutaneous tissues. This is a common side thoracic cavity. Which activity is expected during effect that requires further assessment to make sure no further leaks are occurring. None of nursing care? The nurse should: the other actions are normally done for a chest tube drain located at the base of the thoracic cavity, which is designed to drain secretions from the chest cavity. ‐ Teach the client to clamp the tube when getting up to walk. ‐ Palpate the chest wall for crepitus near the insertion site. ‐ Change the dressing daily, to decrease infection. ‐ Empty the drainage chamber at the end of each shift. | Clamping the tube is not recommended unless there is an air leak or break in the closed system. If the tube is clamped and the client inhales, the lung tissue might collapse again from the lack of negative pressure that is to be maintained by the water seal system. Dressing changes are not done daily, since the sealed system needs to be maintained, and risk of tube displacement would increase with manipulation of the dressing. Dressings are reinforced or retaped but not changed without medical supervision. Drainage chambers are meant to be measured and not emptied. To empty the chamber, a break in the closed system would be necessary, and air could possibly enter the system as the client inhales (while it is open), causing further tissue to collapse. Crepitus is painless air bubbles under the skin that can occur within 1½ inches around the chest tube, and can easily be palpated with the fingers. If it extends further than this distance, additional leaks should be located. Options 1, 2, and 4 are never appropriate. |
3772 When a drainage tube is located at the site of a Correct answer: 1, 2 Edema develops, pushing both internally and externally when it forms. Edema pushes on radical neck dissection, and edema is noted, what whatever structures are near it (airway, gag point, vocal cords). Pressure can occlude any of should the nurse do? Select all that apply. the areas that are vital to air flow, speech, or gagging. Rechecking the equipment will eliminate the possible cause of the loss of suction from no negative pressure. With no negative pressure to remove secretions, edema will stay in the tissues, create an obstruction, or damage vital tissue. ‐ Assess the airway, gag reflex, and the ability to talk. ‐ Check for negative pressure, to make sure suction is present in the drainage tube. ‐ Wait 2 hours to see if the edema increases in size or location. | Swelling often indicates that the drain is occluded or the suction has been lost. A leak in the tubing or displacement of the tube should also be assessed. Waiting for the edema to change can be life‐threatening if it cuts off the airway or ruptures the incision, causing bleeding. Opening up a suture for release of pressure on an incision is a medical management, and should not be a decision of the professional nurse. Opening the incision still does not guarantee an open airway. An airway must be maintained at all times for maximum O<sub>2</sub>/CO<sub>2</sub> exchange for life to continue. |
‐ Release the suture before it ruptures the incision. ‐ Check quickly for edema of the feet and sacrum. | |
3773 The doctor removed 500 mL of solution by a Correct answer: 2 Coughing would indicate irritation or increased stimulation of the diaphragm. When the fluids thoracentesis. Following the procedure, which are removed, all of the other symptoms are expected as signs of improved ventilation and the assessment would require immediate notification of removal of the pleural effusion. the doctor? ‐ Increased lung sounds in the area where the pleural effusion was located ‐ Increased coughing after the procedure ‐ Decreased crackles noted at the base of the lungs ‐ Decreased cyanosis and perioral pallor | Once fluids have been drained from the thoracic cavity, the lungs are free to expand to allow air flow for normal lung sounds, which in turn increases oxygen intake and gas exchange. Skin coloring should be increasingly less cyanotic or pale. Crackles indicate fluid present in the lung bases, and once the fluid is removed, a decrease of crackles should be noted upon auscultation. An increased frequency in coughing indicates increased irritability of the diaphragm. |
3774 A new postoperative client has hourly hemodynamic Correct answer: 2 A gradual decline in urinary output shows lessening pressures through the kidney and assessments. Which would indicate that an imbalance potential cardiovascular collapse. When urinary output is below 30 mL/hour on a consistent is present, and needs urgent care? basis, either the circulating volume is decreasing or the kidneys are not perfusing. Either of these requires immediate medical attention. ‐ CVP pressures: 8, 11, 10, 9 mm of Hg ‐ Urinary output: 40 mL, 30 mL, 20 mL, 20 mL ‐ Chest tube drainage: 60 mL, 45 mL, 50 mL, 20 mL ‐ Pulses: 94, 100, 98, 92 beats per minute | Central venous pressure (CVP) reflects hydration status of the body, and can vary slightly based upon position of the tubing and several other factors. The CVP readings are fairly stable or consistent, and do not represent a trend upward or downward. Chest tube drainage is not excessive, and can vary with the position of the client. Unless the chest tube drainage is excessive, or there is a major change in coloring to frank bleeding, the drainage is not in need of urgent care. The listed pulses, although slightly fast, do not represent a trend or change that is serious at present. The declining urinary output, however, reflects an immediate need for medical management or further assessments by professionals. |
3775 Which symptom would indicate excessive electrolytes Correct answer: 1 Option 1's symptoms are those of potassium lost during excessive washing out of gastric have been removed from a client with a nasogastric secretions, causing hypokalemia. Option 2's symptoms are those of hyperkalemia. Option 3's tube who has been eating large amounts of ice? symptoms are those of hypocalcemia. Option 4's symptoms are those of hypercalcemia. Note that pathological fractures occur as the body pulls calcium from the bones to maintain the high blood levels. ‐ EKG changes: U waves, flat T; anorexia, muscle weakness, ileus ‐ EKG changes: peaked T wave, prolonged QRS; muscle cramps, diarrhea ‐ Tetany, numbness of fingers/toes, twitching of nose or lips ‐ Pathological fractures, bradycardia, slowed reflexes | This question requires specific knowledge of electrolyte imbalances, their cause, and their manifestations. Take time to review this information if the question was difficult. |
3776 A client had a total hip replacement with the insertion Correct answer: 2 By the second day, the drainage fluid should have slowed down considerably. A volume of 500 of a Hemovac suction drain for drainage during the mL is almost two units of blood, and if the drainage is still sanguineous on the second day, the postoperative period. When assessing the drainage, nurse should suspect that a problem is present. Frank bleeding should have stopped soon after which statement would require immediate surgery, and secretions gradually should become more serosanguineous in nature within a few intervention by the nurse? hours post‐op. ‐ In the first hour postoperative, 250 mL of sanguineous fluid was drained. ‐ During a four‐hour period on the second day, 500 mL of sanguineous fluid was noted. ‐ On the third day post‐op, less than 30 mL/hour of serous fluid was noted. ‐ A 3‐inch circle of sanguineous fluid was noted on the 4‐by‐4 dressing after the client was up walking after the drain was removed on the third day. | Options 1 and 3 are normal, expected progression of drainage from a hip replacement. Option 4 reflects increased muscle action that is also common during increased muscle activity, creating an increased drainage at the site where the tube has been removed. Only the amount and color of drainage in option 2 reflect a cause for continued action by the nurse. |
3777 A client has a left arteriovenous (AV) graft in the Correct answer: 4 Normal capillary refill is less than 3 seconds; 5 seconds represents a delay in circulation. The forearm. Which nursing assessment would indicate a graft should have no negative impact on the circulation to the hand. Additional assessment need for additional interventions by the nurse? needs to be performed by the nurse. | Recall that the thrill and bruit indicate that there is adequate circulation through the graft, and these should be present at all times. The visibility of the graft on the forearm depends upon the amount of musculature and subcutaneous fat that are present in the client. |
‐ The thrill is present upon palpation of the graft. ‐ A bruit is noted upon auscultation. ‐ The graft is visible on the forearm. ‐ The capillary refill of the left hand is 5 seconds. | |
3778 When using vacuum‐assisted closure (VAC) for a Correct answer: 3 The wound must be open enough to place the foam dressing onto the site before the sealed wound, which finding would require additional dressing can be applied to minimize the damage to the site with the VAC suction. modification by the nurse to prevent complications? ‐ VAC suction dressing is changed every two hours. ‐ More than one inch of intact periwound tissue is available to get a tight seal. ‐ The wound is closed enough to seal the dressing without foam placement. ‐ Irrigation with normal saline is done during each dressing change. | The dressing is to be changed every two hours to maximize the effectiveness of secretion removal, and to minimize possible damage to the wound site. Only 2 cm of intact skin is required, and one inch exceeds that guideline. Irrigating the wound with normal saline is necessary to remove excessive exudates and to maintain moisture of wound for the dressing to be effective. Within a 24‐hour period, the suction can be held for only 2 hours per day to be effective. |
3779 When inserting an 18‐gauge French urinary catheter Correct answer: 2 If the catheter is well lubricated, the obstruction is based upon the collapsing of tissue near into a male client, the nurse met resistance when the the base of the penis. By lifting and using a 90‐degree angle for the shaft, the pathway is catheter was inserted less than one‐half of the opened. A smaller size is not the issue if the tissue is collapsed at the base; no matter what size distance required. What actions would be most the catheter is, it will not pass (option 1). A stylet does increase the rigidity of the catheter beneficial to complete the insertion of the catheter (option 3), but is not a nursing procedure. Only a trained doctor should use the stylet, since into the bladder? damage can occur with its use. Placing the shaft of the penis parallel to the body (option 4) will not open up the passageway for the catheter to pass. ‐ Removing that catheter and getting a smaller size ‐ Lifting the shaft of the penis to a 90‐degree angle to the abdomen ‐ Getting a stylette and using it to insert the urinary catheter ‐ Pulling the penile shaft to a parallel position with the body | Recall that by lifting and stretching out the shaft of the penis, the meatus is opened more directly, and curling up of the urinary catheter is less likely to occur. |
3780 A urinary catheter has been in place for several days, Correct answer: 2 The urinary system should remain a closed‐seal system to minimize the risk of cross‐ and the doctor has ordered a urine culture and contamination. The port hole is designed for puncturing for specimens. Using only the area sensitivity to be done. Which action by the nurse designed to be punctured (which will reseal when the needle is removed) is the only safe way would be appropriate? to collect the specimen without cross‐contamination to the specimen or the catheter's drainage system. ‐ Get urine from the bag after wiping the drain tip with alcohol. ‐ Wipe the port hole with alcohol, and aspirate the urine with a sterile needle and syringe. ‐ Wipe the connection between the catheter and drainage tubing with alcohol, and open the connection at the catheter to collect the urine. ‐ Puncture the catheter near the meatus after wiping with alcohol, to aspirate the urine. | Prior to collection of urine, the tubing often must be clamped temporarily to maintain some urine in the bladder, rather than draining it all into the bag as soon as it is produced. After clamping, the only way to collect by a sterile procedure is through the port hole. Through breaking the seal between the tubing and the catheter itself, or using the drain tip in the bag, cross‐contamination can occur to the specimen and/or to the system. By puncturing the catheter, you create a hole in the catheter that will not reseal, and the urine can leak out and bacteria can enter. |
3781 When assessing for placement of a nasogastric tube, Correct answer: 2 Gastric pH should be between 0–4 pH. The color of the gastric content should be which approach by the nurse would be most reliable yellow/green or tan, but this is a less reliable indicator of location. for confirmation of correct placement? ‐ Abdominal assessment with air pushed through the tubing | All nasogastric tubes are to be checked by radiological assessment, to be absolutely sure they are in the correct place. However, other assessments are helpful prior to the final assessment by x‐ray. Abdominal assessment by air is fairly reliable, but is not as reliable as pH confirmation. The absence of gagging does not mean that the placement is correct, only that the gag reflex is suppressed. In an unconscious or sedated client, the gag or cough reflex might be damaged or non‐functioning; therefore, it should not be the basis for your decision that the tube is in the correct location. Sticking the tube into a glass of water while looking for bubbles can create a risk for aspiration of fluids from the cup, if the tube is in the lung and the client inhales. |
‐ Aspiration of secretions for confirmation of color and pH ‐ Placing the tip of the tubing into a glass of water to observe for bubbling ‐ An absence of gagging or coughing by the client | |
3782 When a small‐bore feeding tube is in place for Correct answer: 3 The feeding should not hang for more than 4 hours, if continuous. However, for intermittent intermittent feedings every 6 hours, which nursing feedings, if a bag is used, the bag should be changed every day to minimize the risk of bacterial action is most appropriate? growth in the tubing. Most intermittent feedings are hand‐poured into a syringe. ‐ Placement should be checked each day. ‐ Retention checks should be done at least once a day. ‐ Bag tubing should be changed out each day. ‐ A minimum of 100 cc of water should be used before and after each feeding. | Placement should be checked before each feeding. Retention checks are to be done prior to each feeding, to assess peristalsis. For water, 30–60 mL is the usual amount used before and after feedings to flush the tubing and maintain hydration. |
3783 While completing a nursing assessment, the client Correct answer: 3 Age above 65 is a risk factor for cataracts. Double vision, increased intraocular pressure, and states he is 70 years old, has a history of blurry vision are signs of glaucoma. staphylococcus infections, increased intraocular pressure, and blurry vision. The nurse concludes that which item reported by the client is a risk factor for the development of cataracts? ‐ History of staphylococcus infections ‐ Increased intraocular pressure ‐ 70 years old ‐ Long complaint of blurry vision | The core issue of the question is knowledge of factors that increase client risk for conditions affecting sensory perception. Use the process of elimination and nursing knowledge to make a selection. |
3784 A 92‐year‐old client is in the hospital. The client is Correct answer: 3 Hearing loss, especially of upper‐range tones, is common in the elderly. Speaking to the client very hard of hearing, and the nurse needs to do the slowly and in a lower‐pitched voice while facing the client is the best means of communication. admission interview. Which of the following should the Options 1 and 4 are not helpful, and option 2 is unnecessary. nurse do when assessing the client? ‐ Obtain a cotton swab to clean cerumen in the client's ear before beginning the interview. ‐ Speak louder in the client's better ear after determining which has better hearing. ‐ Lower the pitch of the voice and face the client during the interview. ‐ Put new batteries in the hearing aid to ensure proper functioning. | The core issue of this question is the optimal choice for communicating with a client who is hearing impaired. Eliminate options 1 and 4 first as least helpful or unnecessary measures. Eliminate option 2 because it may not allow the client to see the nurse’s face, which assists in determining words when a client is hard of hearing. |
3785 A 72‐year‐old client has been in the ICU for the past 2 Correct answer: 3 Providing the client with a clock and calendar helps the client to be oriented to time and date. days. Which intervention would be the most These would be meaningful stimuli for the client and decrease the chance for sensory appropriate in decreasing the risk for sensory deprivation. It may not be realistic in an ICU to remove equipment from the room. Explaining deprivation? all procedures and routines would increase the risk of overload. Giving the client prolonged rest periods would only increase the risk for deprivation. ‐ Remove equipment from the room. ‐ Explain all procedures and routines to the client upon admission. ‐ Provide a clock and calendar in the client's room. ‐ Provide the client with prolonged rest periods. | The core issue of the question is nursing actions that can prevent the client from experiencing sensory deprivation. Use knowledge of basic nursing measures to help a client stay oriented to time, place, and person make a selection. |
3786 A client has a sprained ankle, and the nurse must Correct answer: 1 To prevent vascular impairment, proper application of elastic bandages is required. Wrapping apply an elastic bandage to provide support to the distal to proximal is compatible with the flow of venous return. Wrapping the bandage evenly ankle. Which of the following actions should the nurse while stretching it ensures that there will be even tension applied to the extremity. Wrapping it take during this procedure? loosely will not secure the bandage in place. Excessive pressure would cause circulation to be compromised. ‐ Wrap the bandage while stretching it from distal extremity to proximal. ‐ Apply the bandage loosely around the extremity. ‐ Apply heavy pressure with each turn of the bandage. | The core issue of the question is knowledge of basic wound‐care procedures. Use nursing knowledge of these procedures and concepts related to blood flow to make your selection. |
4.‐ Start at the upper end of the extremity and work toward the distal end. | |
3787 All of the following clients appear in the emergency Correct answer: 4 A closed fracture has no break in the skin. A cat bite, a laceration, and a stab wound all impair room during one shift. The nurse would clarify with the skin integrity, which could lead to infection. physician the reason for an antibiotic order for a client with which of the following injuries? ‐ Cat bite to the hand of an elderly client ‐ Laceration from broken glass in a 6‐year‐old client ‐ Stab wound in a 37‐year‐old client ‐ Closed‐fractured ankle in a 40‐year‐old soccer player | The core issue of the question is appropriate use of antibiotic therapy. Restate this question in the following way: "Which client is not at risk for infection?" Use the process of elimination and nursing knowledge to make the selection that poses little risk of infection. |
3788 A client is on complete bed rest and is at risk for Correct answer: 2 Disuse syndrome is a result of prolonged immobility. Stating "the client remains free of disuse syndrome. Which of the following client goals is contractures" describes in active terms the desired outcome for the client. The last two appropriate? options describe nursing activities to meet the stated client goal. The nurse has no control over option 1. ‐ The client has shorter periods of immobility. ‐ The client remains free of contractures in lower extremities. ‐ The nurse turns the client every 2 hours. ‐ The nurse performs passive range of motion to lower extremities every 4 hours. | Recall that goal statements are indicators of what the nurse wants to happen as a result of care. With this general principle in mind, eliminate each of the incorrect responses because they are focused on the nurse or are beyond the nurse’s control. |
3789 This is the first hospitalization for an adult client who, Correct answer: 4 The client is in a new environment. Changes in environment bring about uncertainty, and the after being admitted 3 days ago, is now having trouble client may be unable to sleep or may sleep less well than at home. Although the client is sleeping. The nurse also notes some confusion during confused, there is no other data presented that could be the cause, making disturbed sleep waking hours. Which of the following would be the pattern a more appropriate selection than disturbed sensory perception. In addition, disturbed most appropriate nursing diagnosis for this client? sensory perception relates to one of the five senses. Ineffective health maintenance and ineffective individual coping are more global and not applicable to this client's situation. ‐ Ineffective health maintenance ‐ Ineffective individual coping ‐ Disturbed sensory perception ‐ Disturbed sleep pattern | The core issue of the question is the ability to draw correct conclusions about client assessment data and translate it to a nursing diagnosis. In this case, the original problem is sleeping, and the correct answer is one that focuses on this problem. |
3790 An 80‐year‐old client has been admitted to the Correct answer: 2 Weight‐bearing exercise is the best approach to preventing disuse syndrome. Disuse nursing unit with Parkinson’s disease. Which of the syndrome occurs because the stresses of weight bearing are absent and the bone releases following activities would be most appropriate in calcium. The other options list general nursing interventions that are not specific to weight‐ preventing disuse syndrome? bearing. ‐ Providing for the nutritional needs of the client ‐ Promoting weight‐bearing exercises ‐ Encouraging 8 glasses of fluid in 24 hours ‐ Turning and positioning every 2 hours | The core issues of the question are the cause of disuse syndrome and nursing approaches that will minimize it. Use concepts of basic nursing care to answer the question. |
3791 A client has a pressure ulcer on the left hip. The Correct answer: 4 Options 1 and 2 indicate nursing activities aimed at promoting healing. Option 3 refers to nursing staff has written a nursing diagnosis of other areas of the body. Option 4 refers to the wound itself and is the best indication of the Impaired skin integrity with a client goal of "skin heals wound’s current status. by 6/12." Prior to June 12, the nurse evaluates progress on reaching this goal. Which statement is the best notation of progress toward the goal? ‐ Turning every 2 hours and avoiding lying on left side ‐ Wet to moist dressing changed every 4 hours ‐ No additional areas of breakdown noted | The core issue of the question is the type of documentation that best described progress toward wound healing. Questions such as these seek an answer that reflects an outcome rather than activities. |
4.‐ Ulcer less reddened and granulation tissue noted on edges | |
3792 In assessing a client who has been immobilized Correct answer: 2 After immobilization, unexercised muscles will atrophy. The muscles would not be flexible or because of illness, the nurse would most likely hardened. Hypertrophy is the opposite of atrophy. document the client’s muscles as which of the following? ‐ Hypertrophied ‐ Atrophied ‐ Flexible ‐ Hardened | This question requires application of basic nursing knowledge to a client situation. Select the term that is a common finding in clients who are immobilized. |
3793 A female client can move her right arm and leg but Correct answer: 2 Passive range of motion is most appropriate because the client is unable to move that side of has hemiplegia on the left. The nurse instructs the the body on her own. The other exercises require resistance on the part of the muscles on the nursing assistant to do which of the following exercises left side, and the client is unable to do that. on the client’s left side during care? ‐ Active range of motion ‐ Passive range of motion ‐ Isotonic ‐ Isometric | The critical words in the question are unable to move. This indicates that the client has hemiplegia and is unable to actively participate in exercising the joints. The wording of the question tells you that there is only one correct answer. |
3794 A client has weakness of the lower extremities and Correct answer: 3 The weight of the body should be borne on the arms, not the axillae. When clients allow the uses crutches for mobility. The nurse concludes the axillae to bear the weight of the body, they are at risk of developing crutch palsy, a nerve client needs further information about using crutches damage. The other options represent correct information about use of crutches, and therefore when the client does which of the following? no further information is needed on those points. ‐ Uses the swing‐to gait ‐ Uses axillary crutches ‐ Bears weight on the armpits ‐ Has new rubber tips on the crutches | The core issue of the question is proper use of crutches. Keep in mind that improper use can lead to nerve injury, and select the option that puts the client at risk. |
3795 A male client suffered numerous types of wounds Correct answer: 1 Primary intention healing occurs when the wound edges are well approximated; wounds that when he lost control of his motorcycle and was thrown heal by secondary intention have edges that cannot be approximated. Scarring is greater for onto the pavement. The client asks the nurse which wounds that heal by secondary intention and those that become infected. The location of a wounds will scar more. The nurse's reply will be based wound has little to do with scarring. on analysis that which of the following wounds would generally be least likely to scar? ‐ A wound that heals by primary intention ‐ A wound that heals by secondary intention ‐ A wound that becomes infected ‐ A wound to an extremity | The core issue of this question is knowledge of physiological wound healing. Use nursing knowledge and the process of elimination to make a selection. |
3796 A postoperative client tells the nurse that he Correct answer: 2 Activities that are likely to lead to dehiscence include vomiting and coughing because they developed dehiscence after his last surgery and wants increase intraabdominal pressure. In addition, clients who are obese and those with poor to make sure it doesn't happen this time. In attempting nutrition are candidates for dehiscence. Since the client is already postoperative, encouraging to prevent dehiscence from occurring, the nurse's weight loss at this time would not affect risk for dehiscence. interventions would be aimed at doing which of the following? ‐ Helping the client lose weight ‐ Preventing vomiting ‐ Administering antibiotics | The core issue of the question is knowledge of risk factors for dehiscence. Recall that dehiscence is most likely to occur when there is some type of stress on the incision line. Consider that vomiting puts sudden tension on the suture line to select it as the option that is most likely to be harmful to the client. |
4.‐ Keeping the wound dry | |
3797 An elderly postoperative client has an abdominal Correct answer: 1 Vascular changes, such as atherosclerosis and atrophy of capillaries, impair blood flow to the wound. Weeks after the surgery, the wound is still wound. The other statements are false. Older adults are not necessarily overweight, although healing. The client asks the clinic nurse why the wound weight gain does tend to occur with increasing age. Decreased activity levels with aging does is healing so slowly. The nurse would explain that not diminish local blood supply to a healing wound. Keloid formation is an abnormal type of which of the following is one factor that negatively healing of a wound. affects healing in the elderly? ‐ Vascular changes decrease the blood flow to the wound. ‐ Most elderly clients are overweight. ‐ Decreased activity levels prevent blood from reaching the area. ‐ Keloid formation prevents healing. | The core issue of the question is age‐related changes that have a negative impact on wound healing. Use nursing knowledge and the process of elimination to make a selection. |
3798 A young adult is admitted to the hospital for Correct answer: 3 Protein and vitamin C are necessary for building and maintaining tissues. A deficiency of gallbladder surgery. The client is also diagnosed as vitamin C would prolong wound healing. The other options have nothing to do with vitamin C. having a vitamin C deficiency. The nurse places high priority on assessing this client for which development postoperatively? ‐ Unusual muscle weakness ‐ Mental confusion ‐ Delayed wound healing ‐ Ataxia upon ambulating | The core issue of this question is the role of vitamin C in wound healing. Use nursing knowledge and the process of elimination to make a selection. |
3799 The nurse is assisting a client with a mobility problem Correct answer: 2 The client has bilateral weakness of the lower extremities, and the proper assistive device is in determining the appropriate assistance device. The one that will provide bilateral support. In this case, a walker provides the most support. client has no paralysis of the lower extremities, but the Additionally, a four‐wheeled walker does not require the client to lift the walker as steps are legs are very weak. Upper‐body strength is also taken. reduced. The nurse would suggest which device for this client? ‐ Cane ‐ Four‐wheeled walker ‐ Canadian or elbow extension crutch ‐ Lofstrand crutch | The core issue of the question is the assistive device that will provide the safest support to the client. The critical word legs in the stem of the question guides you to look for an option that provides bilateral support. |
3800 The nurse is evaluating a client using a cane. Which Correct answer: 1 To provide maximum support and appropriate body alignment while walking, the cane is held assessment made by the nurse would indicate that the in the hand on the stronger side. The tip of the cane should have rubber to prevent slipping. client is using the cane appropriately? ‐ Client holds the cane with the hand on the stronger side. ‐ Client holds the cane with the hand on the affected side. ‐ Client moves the cane and the affected leg together. ‐ The cane tip is made of aluminum to prevent slippage. | The core issue of the question is the proper use of a cane as an assistive aid. Use the process of elimination and basic nursing knowledge to make a selection. |
3801 A client is at risk for the developing a pressure ulcer Correct answer: 4 Unless the skin loss is extensive, the skin will continue to absorb vitamin D and prevent the and is placed on a repositioning regimen. The client loss of heat from the body. Tactile stimulation can still occur with a wound. However, a loss of does not like to lie on his side and complains about the skin integrity places the client at risk for bacterial invasion and subsequent infection. need to turn. To enhance compliance, the nurse uses which of the following most effective explanations? ‐ "Turning will help you to maintain normal sensation in all skin areas under pressure." ‐ "Excess pressure interferes with skin absorption of vitamin D." | The core issue of the question is knowledge of the functions of the skin and how pressure ulcers interfere with normal skin function. Use the process of elimination and basic nursing knowledge to make a selection. |
‐ "Staying in one position prevents proper heat loss from that area of the body." ‐ "Changing position prevents tissue breakdown that could ultimately become infected." | |
3802 The nurse is changing the dressing of a client who is 4 Correct answer: 4 Evisceration occurs when internal viscera protrude from an incision that is dehiscing. In this days postoperative with an abdominal wound. The situation, the nurse notes changes in wound appearance such as increased serosanguineous nurse has changed this dressing daily since surgery. drainage, edges lacking approximation, and the protruding viscera. Today, the nurse notes increased serosanguineous drainage, wound edges not approximated, and puffy tissue protruding through the wound. The nurse concludes which of the following conditions exists? ‐ Hemorrhage ‐ Normal healing by primary intention ‐ Normal healing by secondary intention ‐ Evisceration | The core issue of this question is the ability to draw accurate conclusions about the status of a surgical wound. Use the process of elimination and basic nursing knowledge to make a selection. |
3803 The nurse needs to conduct an admission interview Correct answer: 1, 4, 5 The nurse should position herself or himself within the client's line of vision to enable the with a 74‐year‐old client who is hearing impaired. client to read lips during the conversation. It is good to decrease background noises that Which of the following should the nurse do to enhance interfere with the client’s ability to hear the nurse. It is also helpful to speak at a moderate the client's ability to hear? Select all that apply. rate and use the same voice tone throughout each sentence, not dropping the tone at the end of a sentence. The lighting should not be dimmed because doing so would interfere with the client’s ability to read lips. Words should not be overarticulated; exaggerated, unnatural movement of the lips can distort words for the client who relies on lip reading to compensate for hearing loss. ‐ Position self to be within the client's line of vision. ‐ Dim the lights in the room. ‐ Overarticulate words. ‐ Turn down the television in the room. ‐ Talk at a moderate rate and with the same tone for all words. | The core issue of the question is effective communication strategies with a client whose hearing is impaired. Remember that correct answers to questions such as these focus on enhancing the client's vision during communication and are moderate in overall approach (i.e., not excessive or insufficient). |
3804 The school health nurse is interested in promoting Correct answer: 2 Option 1 is a factor related to the adult; option 3 is related to school‐age children, and option safety in the school population. In planning safety 4 is related to the elderly. education for this age group and parents, the nurse would recognize that which of the following is a developmental risk factor for adolescents? ‐ Substance abuse as a means of dealing with stress. ‐ Feelings of immortality related to the perception of being invulnerable to risks that affect others. ‐ Sports‐related injuries that are usually related to not obeying rules and/or intense competition. ‐ Polypharmacy, which results in mixing of multiple medications. | Select the option that identifies a characteristic common in adolescents, in this case, feelings of immortality. |
3805 The nurse is caring for a young child who has mitt Correct answer: 1 It is important that circulation is checked regularly. Typically the restraints are removed, one restraints. Which of the following priority actions at a time, every 2 hours to evaluate skin condition and circulation. Although options 3 and 4 needs to be done regularly to ensure that the child's are correct, they are not the best response as they do not have to be checked as regularly as needs are met? the circulation and skin condition. Option 2 applies to an elbow restraint. ‐ Check adequacy of circulation and skin condition ‐ Check that the tongue blades in pockets are intact and ends covered or padded ‐ Ensure that the straps are tied to non‐movable parts of the crib ‐ Check that the call bell is pinned to the child's gown | Look for a response that addresses a basic rule of restraint use, in this case, checking skin and circulation. |
3806 The nurse assesses the respiratory functioning of an Correct answer: 2 Options 1, 3, and 4 are all age‐related changes and do not suggest alterations. Orthopnea or elderly client. Which of the following symptoms would difficulty breathing when not in a sitting or upright position is suggestive of airway obstruction be considered unrelated to the client's age? or respiratory or cardiac disease. ‐ Increased rate and depth of respirations while walking quickly ‐ Difficulty breathing when lying in bed ‐ Coughing that is not as effective in clearing passages ‐ Frequent upper respiratory infections | The word difficulty in option 2 should lead you to the determination that this is not an age‐ related change, but an abnormal symptom. |
3807 A middle‐aged client complains to the nurse that Correct answer: 2 Middle‐aged adults have a decrease in deep sleep, stage IV NREM. Option 1 is an expected sleep patterns are different than when the client was pattern in older adults; option 3 is expected in young adults, and option 4 is expected in younger. Which of the following suggests a normal neonates. developmental pattern? ‐ Client sleeps about 6 hours per night with about 20–25 percent of REM sleep and a marked decrease in Stage IV NREM sleep. ‐ Client sleeps 6–8 hours per night with about 20 percent REM sleep and the amount of Stage IV NREM sleep. decreases. ‐ Client sleeps erratically because of work schedules with about 30 percent of REM sleep and no marked decrease in Stage IV NREM sleep. ‐ Client has light sleep with equal amounts of REM sleep and NREM sleep. | Select the option that describes the sleep change most closely matched with the middle‐ aged group, gradual reduction in quality sleep. |
3808 A client's hemoglobin level is 14 g/dL. Which of the Correct answer: 2 The laboratory value given is within normal limits (12–16.5 g/dL). All the other statements are following interpretations of the laboratory value is inaccurate. most accurate? ‐ Client has a low value and is malnourished ‐ Client has a normal laboratory value and has no nutritional risk ‐ Client has a low to normal value indicative of a nutritional risk ‐ Client has an elevated value indicative of polycythemia | Select the only option that lists the value as normal. The others indicate some level of abnormality. |
3809 The client is undergoing surgery for the formation of Correct answer: 3 The ileum, which is a part of the small bowel, is used to form a pouch where the ureters are an ileal conduit. Which of the following statements by implanted. Option 1 is incorrect because stool does not drain. Option 2 refers to a cutaneous the client best indicates an understanding of the ureterostomy. Option 4 is incorrect because the ileum is not part of the big intestines. surgery? ‐ "The hole in my abdomen will drain stool and urine." ‐ "There will be two small openings that drain urine out." ‐ "Part of my small bowel will be used as a pouch where the urine can drain out." ‐ "The urine will drain into a pouch made up by attaching the ureters to a part of my big bowel." | Select the option that uses the words small bowel and urine as the correct option. |
3810 The nurse is working with a client suffering from Correct answer: 3 Anxiety or anger increases peristalsis leading to subsequent diarrhea. All the other options diarrhea. In teaching ways to reduce diarrhea, the lead to the development of constipation. nurse would encourage the client to avoid which of the following that contribute most to the development of diarrhea? ‐ Excessive intake of cheese and eggs ‐ Habitually ignoring the urge to defecate ‐ Anxiety or anger ‐ Lack of exercise | Eliminate the options that are known causes of constipation: 1, 2, and 4. |
3811 A client is scheduled to have a divided colostomy. Correct answer: 1 In a divided colostomy, the opening from the digestive or proximal end produces fecal wastes While doing client teaching, the nurse will explain that while the other stoma, often called the mucous fistula, produces only mucus. after healing, the client can expect to have stool drain from which of the following? ‐ The proximal stoma ‐ The distal stoma | Eliminate options 3 and 4 as being incorrect. Select the option from the remaining pair that makes sense from a physiological stand point. |
‐ Both stomas ‐ Neither stoma, as this is a urinary diversion | |
3812 Parents of a group of toddlers are participating in a Correct answer: 1 A toddler is mobile and naturally curious and experiments with things in the environment; safety education class to prevent accidents. Which of therefore, the parents need to know that supervision will be necessary. Toddlers' reflexes are the following aspects need to be included in the health not necessarily slow, and reading is not a concern. Social and personality development is a teaching session? good topic for health teaching but is not the main concern in regards to safety. ‐ The child's physical capacities and curiosity ‐ The child's slow reflexes ‐ The child's difficulty in reading ‐ The child's social and personality development | Select the option that would relate to accidents most often encountered with toddlers, which are usually due to their ability to move about and curiosity. |
3813 A nurse on the unit observes that the night shift nurse Correct answer: 2 One of the purposes of restraints should be to prevent interruption of therapy such as the use has placed restraints on all of the following clients. In of dressings. Restraints should not be used for the convenience of the staff (option 1), nor which of the following situations would the use of should they be used because a client is weak or distraught (option 3). The client in option 4 has restraints be appropriate? no need for restraints. ‐ A hyperactive child ‐ A child scratching the incision site postoperatively ‐ A postoperative client who is alert but still weak ‐ A client who is severely anxious about test results | Look for the circumstance in which lack of restraints would affect recovery or care. |
3814 An elderly client on bed rest for a few days has been Correct answer: 2 Because the client has been incontinent, the possibility of skin bacteria reacting with the urea incontinent. The client is now complaining of pruritus in the urine can lead to ammonia dermatitis. Erythema (option 1) is reddening of the skin; and excessively dry skin, particularly in the area of the contact dermatitis (option 3) is a possibility if a client is allergic to soaps or other substances; lower back. To which of the following skin problems is and petechiae (option 4) are tiny pinpoints of bleeding in the skin. this client most susceptible? ‐ Erythema ‐ Ammonia dermatitis ‐ Contact dermatitis ‐ Petechiae | The use of the word ammonia in option 1 is a clue to the correct answer as urine has a high ammonia content. |
3815 A client has been instructed on the use of an Correct answer: 3 The proper sequence for using a spirometer is to exhale completely, place the mouthpiece, incentive spirometer. The nurse evaluates that the inhale, remove the mouthpiece, hold breath, and exhale. A Fowler's or sitting position best client understood the instructions if the client allows full chest expansion. Slower breaths are better and deeper than fast ones. Client should performs which of the following actions? remove the mouthpiece, exhale through pursed lips, and not exhale into the spirometer. ‐ Maintains a supine position while using the spirometer ‐ Inhales rapidly, exhales into the spirometer to reach the indicator, and waits 10 seconds before repeating the process ‐ Exhales completely, places mouth around mouthpiece before inhaling slowly to reach the indicator, removes mouthpiece, holds breath, and exhales slowly ‐ Purses lips tightly around mouthpiece, inhales slowly and deeply, and exhales slowly into the spirometer until spirometer reaches indicator mark | Because the incentive spirometer is used to increase respiratory capacity select the option that in which inhalation and the measurement indicator are paired. |
3816 A client complains of tickling in the throat and a Correct answer: 4 The client did not vomit blood (i.e., hematemesis), has no manifestations of being able to bubbling sensation in the chest, and then coughs up breathe only when in a sitting position (i.e., orthopnea), and has no indrawing chest movement bright red, frothy blood mixed with sputum. The nurse between the ribs (i.e., intercostal retraction). The client has the symptoms associated with documents that the client is experiencing which of the hemoptysis: bubbling sensation in the chest, tickling in the throat, and coughing up blood with following? the sputum. ‐ Hematemesis ‐ Orthopnea ‐ Intercostal retraction ‐ Hemoptysis | Narrow down the options by considering the two with heme or blood as part of the response. Further eliminate option 1 because hematemesis means vomiting blood. |
3817 A client is being discharged with oxygen therapy via a Correct answer: 3 Electrical equipment in good condition (with no frayed wires) is acceptable for use in the cannula. Which of the following instructions should the vicinity of oxygen. Petroleum products and most oils have the potential for being flammable nurse give to the client and family? when used on the body, which is a contraindication for their use. Cotton clothing limits static. ‐ Use battery‐operated equipment instead of electrical equipment. ‐ Use petroleum jelly for the nares to prevent chafing. ‐ Use cotton clothing to avoid static electricity. ‐ Use oil to protect the facial skin. | Eliminate options referring to the use of petroleum or oil productions which are contraindicated in use with oxygen. |
3818 A client is complaining of inability to sleep through Correct answer: 1 Pain can often interfere with sleep. Options 2, 3, and 4 do not negatively affect or interfere the night since admission three days ago. Which of the with sleep. Absence of unfamiliar stimuli (option 2) can assist with sleep; dealing with stress by following factors is most likely to negatively affect the talking about the day's events (option 3) promotes relaxation and eventually sleep; moderate client's sleep patterns? fatigue (option 4) may lead to a restful sleep. ‐ Presence of pain ‐ Absence of unfamiliar stimuli ‐ Ability to talk about day's events ‐ Moderate fatigue | Eliminate choices that are known to enhance sleep like options 2, 3, and 4. Pain can interfere with ability to sleep. |
3819 An elderly bedridden client complains of being Correct answer: 4 To promote bowel function, instruct clients to drink plenty of liquids, including fruit juices constipated but can not understand why. What such as apple and prune. In addition, foods that are high in fiber and roughage should be instruction should be given by the nurse? encouraged to avoid constipation secondary to immobility. ‐ Decrease fluid intake ‐ Encourage bland and low‐residue foods ‐ Avoid beverages with caffeine ‐ Drink hot liquids and fruit juices | Eliminate options 1, 2, and 3 as being contrary to promotion of normal bowel activity. |
3820 A client complains of occasional urinary incontinence. Correct answer: 2 When a premature urge to void occurs, focused breathing exercises may assist the client to The nurse has worked with the client with regard to overcome the sense of urgency. The intervals between voiding should eventually lengthen, bladder training. The nurse would evaluate the client rather than voiding every hour or more often when an urge is felt. Protector pads should be has achieved the expected outcome when the client is worn continuously for leakage. Adult diapers are used only as a last resort. able to which of the following? ‐ Void every time there is an urge ‐ Practice deep, slow breathing until the urge to void diminishes ‐ Use adult diapers continuously ‐ Use protector pads only when going out | Notice that option 2 addresses the issue of training the bladder, whereas the others address incontinence. |
3821 A client is taking a full fluid diet following gastric Correct answer: 2 A full liquid diet allows such items as puddings, creamed soups, sherbet, strained cereals, and surgery. The nurse evaluates the health teaching to be all items that are liquid at room temperature. Options 1, 3, and 4 would not be appropriate. successful when the family brings in which of the following for the client to eat? ‐ Pureed fruits ‐ Custard ‐ Soft cake ‐ Chopped vegetables | Omit options 3 and 4 as incorrect as they are not liquid. Omit option 1 because fruit is a solid at room temperature and eating the pureed form is not allowed on a full fluid diet. |
3822 The family member of an elderly client objects that Correct answer: 3 The client needs to be supervised and monitored and placed in a room that is more restraints are being used to prevent the client from accessible. Assessment is needed to determine causes of wandering. Stimulation is not wandering to other clients' rooms, especially in the necessary for a client who is a wanderer. Anti‐anxiety medications may cause more agitation, evening. Which of the following alternatives to the use and locking other clients' rooms will not prevent the client from wandering. of restraints should the nurse consider? ‐ Provide visual and auditory stimuli. ‐ Use anti‐anxiety medications as prescribed. ‐ Assign client to a room near the nurse's station. ‐ Lock the other clients' rooms. | Choose the option that provides for client safety while best protecting the rights and safety of others. |
3823 A client is hospitalized for the first time. Which of the Correct answer: 1 The environment must be clutter‐free; therefore, unnecessary pieces of equipment or following actions ensures the safety of the client? furniture should be out of the way. Lights on and side rails up are not mandatory at all times. It is unnecessary to keep equipment out of view. ‐ Keep unnecessary furniture out of the way. ‐ Keep lights on all the time. ‐ Keep side rails up at all times. ‐ Keep all equipment out of view. | Omit options 2 and 4 as unrealistic. Option 3 is a threat to safety. |
3824 A client who is unconscious needs frequent mouth Correct answer: 2 In the side‐lying position, fluid is more likely to flow readily out of the mouth or pool in the care. While performing mouth care, in what position side of the mouth where it can easily be suctioned. Fowler's position and Trendelenburg should the nurse place the client? positions are not appropriate since the unconscious client does not have the control to stay up in those positions. The supine position is unsafe as the client may aspirate the fluids. ‐ Fowler's position ‐ Side‐lying position ‐ Supine position ‐ Trendelenburg position | Omit the options which would put the client at risk for aspiration by having the client positioned on the back or sitting. |
3825 The nurse is providing health teaching to the client Correct answer: 3 Stress and long‐term alcohol use increase the blood pressure. Physical exercise increases about lifestyle factors that affect oxygenation. Which respirations and cardiac rate, increasing the supply of oxygen to the body. Nicotine increases of the following explanations is most accurate? blood pressure and vasoconstriction which prevents oxygen from reaching the different parts of the body. ‐ Epinephrine and norepinephrine released under stress decrease blood pressure and cardiac rate. ‐ Long‐term use of alcohol stabilizes blood pressure and cardiac functioning. ‐ Nicotine increases heart rate, blood pressure, and peripheral resistance, and produces vasoconstriction that decreases oxygenation to tissues. ‐ Physical exercise decreases the depth of respirations and cardiac rate and eventually lowers the need for oxygen by the tissues. | Options 3 and 4 speak specifically about tissue oxygenation, but only option 3 gives correct information. |
3826 A nurse is performing oropharyngeal suctioning on an Correct answer: 3 Gentle rotation ensures that all surfaces are reached and prevents trauma to any one area unconscious client. Which of the following actions is caused by prolonged suctioning. In oropharyngeal suctioning, the catheter should be advanced safe? to 10–15 cm; 20 cm is the distance for tracheal suctioning (option 1). Fifteen minutes of suctioning (option 2) and applying suction while inserting the catheter (options 1 and 4) can cause trauma to the mucous membranes. ‐ Insert the catheter approximately 20 cm while applying suction. ‐ Allow 20–30‐second intervals between each suction, and limit suctioning to a total of 15 minutes. ‐ Gently rotate the catheter while applying suction. ‐ Apply suction for 5 seconds while inserting the catheter and continue for another 5 seconds before withdrawing. | Look for time periods and measurements that do not make sense, as in options 1, 2, and 4. |
3827 A client with chest tubes is admitted to the nursing Correct answer: 4 Although all of the actions are appropriate, the highest priority on admission is to anticipate unit. The nurse should place the highest priority during any emergency that may occur if problems with the chest tubes occur, such as disconnection admission on doing which of the following? or accidental removal. | The question asks for prioritization. Select the option that provides for emergency equipment to be made available. |
‐ Plan to measure client's vital signs, respiratory and cardiovascular status regularly ‐ Explain the importance of deep‐breathing and coughing regularly ‐ Report if drainage exceeds 100 mL/h ‐ Place rubber‐tipped clamps, sterile water, and a sterile occlusive dressing materials near the client | |
3828 While doing a physical assessment on a client, the Correct answer: 1 Soft, flaccid muscles are signs of inadequate nutritional status. Muscles should be firm and nurse suspects that the client has poor nutritional well developed. All of the other options are signs of adequate nutritional status. status. Which of the following would confirm the nurse's observations? ‐ Flaccid, soft muscles ‐ Firm, smooth pink nails ‐ Moist buccal cavity mucous membranes ‐ Erect posture | Eliminate options 1, 2, and 3 as these findings are associated with overall good health and nutrition. |
3829 The nurse evaluates the results of laboratory tests Correct answer: 4 Options 1 to 3 are all normal levels; option 4 is indicative of potassium depletion that occurs completed on a client. Which of the following values in severe cases of malnutrition. indicate an abnormality related to nutritional status? ‐ Blood urea nitrogen (BUN) 15 mg/dL ‐ Urinary creatinine 800 mg/24 h in an adult female ‐ Albumin 5 g/dL ‐ Serum potassium 2.0 mEq/L | Identify the only abnormal laboratory value. |
3830 To avoid complications associated with urinary Correct answer: 1 Symptoms and ways of preventing an infection are crucial for a client to understand. elimination, the nurse teaches the client to perform Performance of perineal care independently and disposal of urinary output are not appropriate certain actions. Which of the following indicates that outcomes. Tub baths are to be avoided, especially in females, as they may increase the the expected outcome is achieved? possibility of developing lower tract infections. ‐ Identifies symptoms of and measures to prevent urinary tract infection ‐ Able to perform perineal care by self ‐ Maintains proper disposal of urinary output ‐ Takes regular tub baths and appropriate personal hygiene measures | The question asks for identification of an outcome and option 1 reflects an outcome which addresses prevention of complication. |
3831 A client with a colostomy is asking the nurse about Correct answer: 2 The foods that thicken stools are in option 2. Option 1 foods increase stool odor; option 3 and the types of foods that may loosen stool and cause 4 foods loosen stools. leakage into the pouch. Which of the following foods should the client be told to include in the diet to prevent this problem? ‐ Asparagus, beans, eggs, fish, onions ‐ Applesauce, bananas, rice, tapioca, yogurt ‐ Fried foods, spicy foods, raw fruits and vegetables ‐ Carbonated drinks, fruit juices, greasy and pureed foods | Select the option that contains food that is used to increase the thickness of stool such as pectin in bananas and apples. |
3832 An adolescent client is competing in a long‐distance Correct answer: 2 The diet before competition should be high in complex carbohydrates and low in fat and running event. The nurse is teaching the client about protein. Option 2 reflects the best selection to meet this dietary balance. All of the other eating for competition. The nurse explains that which options are high in fat and/or protein and would not be beneficial in terms of supporting of the following is an appropriate meal before the athletic performance. competition? ‐ Sausages, eggs, biscuits, and gravy ‐ Pancakes with fresh strawberries, orange juice, wheat toast, and fresh melon slices ‐ Yogurt, milk fortified with dry skim milk powder, and a protein bar ‐ Cheese omelet, hash brown potatoes, bacon, and coffee | The core issue of the question is knowledge that complex carbohydrates are beneficial before lengthy exercise. Use nutrition knowledge and the process of elimination to make a selection. |
3833 The nurse has completed a comprehensive health Correct answer: 2 One characteristic of Hispanic diets is the high‐fat preparation method used in cooking. assessment of a Hispanic client. Some cultural food Suggesting a new preparation method for a familiar food item would best help the client to practices place the client at risk for cardiovascular begin changing cooking habits. Option 1 is incorrect: Complex carbohydrates should not be disease. Which suggestion by the nurse is appropriate eliminated because they are components of a healthy diet. Option 3 is incorrect: The Hispanic for this client? client would probably be unwilling to relinquish beans and nuts in the diet because these are considered staple food products. Option 4 is incorrect because stewing is considered a high‐fat method of cooking because the fat from the meat does not drain off. ‐ "Try to stop eating so many complex carbohydrates." ‐ "Try to bake some foods instead of frying them." ‐ "Lean meats should replace the beans and nuts in your diet." ‐ "Do not stop stewing meat and vegetables together; it is a healthy cooking method." | The core issue of the question is knowledge of methods of reducing fat in the diet. Use nutrition knowledge and the process of elimination to make a selection. |
3834 Which of the following dietary recommendations Correct answer: 4 Egg yolks are high in cholesterol and should be limited to two or three per week. Dietary should the nurse include in the discharge instructions fiber, fish, and soybean products have been shown to lower blood lipids. Dietary fiber is of a client diagnosed with coronary artery disease? necessary in the body to promote regulation of elimination patterns and to help lower blood lipids. Soybean products are a source of phytoestrogens and have been shown to be cardioprotective. Tuna is an excellent source of omega‐3 fatty acids, which are helpful in protecting cardiac function and decreasing clot formation. ‐ Limit intake of whole grains. ‐ Limit intake of tuna. ‐ Limit intake of soybean products. ‐ Limit intake of egg yolks. | The core issue of the question is knowledge of the components of a low‐fat diet and that this is the diet required by clients with heart disease. Use nutrition knowledge and the process of elimination to make a selection. |
3835 The nurse is planning discharge teaching for the client Correct answer: 2 Foods that decrease lower esophageal sphincter (LES) pressure should be avoided to reduce with gastroesophageal reflux disease (GERD). What reflux symptoms; these include caffeine, alcohol, and chocolate. Clients should also avoid dietary modification should be included? eating large meals, drinking fluids with meals, and eating at bedtime; they should remain upright for 1–2 hours after eating. ‐ Eat three meals and a bedtime snack. ‐ Avoid intake of caffeine and alcoholic beverages. ‐ Drink 12–16 ounces of water with each meal. ‐ Lie down for 15–20 minutes after eating. | The core issue of the question is knowledge of foods that lower LES pressure and increase risk of reflux in GERD. Use nutrition knowledge and the process of elimination to make a selection. |
3836 The nurse interprets that which of the following client Correct answer: 3 A 2‐gram sodium‐restricted diet requires use of no salt in cooking, no salt added at the table, behaviors reflects compliance with a 2‐gram sodium‐ avoiding high‐sodium foods, and limiting milk to two cups per day. Option 1 is incorrect—no restricted diet? salt can be added in this restricted diet. Options 2 and 4 are incorrect. One cup of milk per day and the use of salt‐free butter are requirements of a 1‐gram sodium restricted diet. ‐ Using only the two packets of salt found on the meal tray ‐ Limiting milk to one cup per day ‐ Avoiding use of salt in cooking ‐ Using salt‐free butter with meals | The core issue of the question is knowledge of the various degrees of sodium restriction in the diet. Use nutrition knowledge and the process of elimination to make a selection. |
3837 The nurse determines that a hypertensive client Correct answer: 2 The DASH diet increases daily servings of vegetables and fruits, and recommends low‐fat dairy understands the DASH diet (Dietary Approaches to foods and reduced intake of saturated fats and cholesterol. Option 1 reflects increased fats; Stop Hypertension) when the client chooses which option 3 represents increased fat, cholesterol, and sugar; option 4 reflects increased sodium items from a sample menu used in dietary teaching? content. ‐ Caesar salad, bread sticks, frozen yogurt ‐ Grilled chicken sandwich, strawberries, and lettuce salad | The core issue of the question is knowledge that hypertensive clients should lose weight if necessary and restrict dietary intake of sodium. Use nutrition knowledge and the process of elimination to make a selection. |
‐ Grilled cheese sandwich, canned pineapple, brownie ‐ Chicken and vegetable stir‐fry, rice, egg roll | |
3838 A client who is recovering from partial‐ and full‐ Correct answer: 1 The client with burns needs increased amounts of protein and vitamins C and D until the thickness burns has been advanced to a general diet. wounds are completely healed. Option 1 reflects high‐protein sources, an antioxidant source, Which foods should the nurse encourage the client to and fortified milk that includes vitamin D and calcium. The other options do not reflect the eat most often? necessary protein, vitamins, and mineral sources needed for the care of clients recovering from burns. ‐ Meats, citrus fruits, milk ‐ Vegetables, cheese, pasta ‐ Milkshakes, salads, soups ‐ Breads, cereals, yogurt | The core issue of the question is knowledge that increased protein and vitamins are needed for wound healing. Use nutrition knowledge about food sources of protein and vitamins and the process of elimination to make a selection. |
3839 Which of the following client comments indicates to Correct answer: 3 Simple sugars and carbohydrates, including honey and jelly, increase the osmolality of the the nurse that more teaching is needed for the client gastric contents and enhance movement of food out of the stomach. Therefore, these should experiencing dumping syndrome after gastric surgery? be avoided by the client at risk for dumping syndrome. Six small meals per day, not taking fluids with meals, and lying down for 30–60 minutes after meals will help reduce the risk of dumping syndrome. ‐ "I should eat six small meals per day." ‐ "I should not drink fluids with my meals." ‐ "I should use honey or jelly instead of butter." ‐ "I should lie down for 30–60 minutes after eating." | The stem of the question has a negative wording, which tells you that the correct answer is an incorrect statement. Recall that sugars and concentrated carbohydrates should be avoided to help choose option 3 as the statement that is incorrect. |
3840 Which of the following dietary teaching statements Correct answer: 3 Increased dietary protein can lead to increased uric acid formation, which in turn lowers would the nurse make to a client who has renal urinary pH and causes precipitation of uric acid stones. Clients should not exceed protein calculi? intake of 100 grams per day and should monitor purine content of foods. Option 1 is incorrect because factors other than dietary intake can cause stone formation, specifically alterations in urinary pH and the presence of metabolic disease. Option 2 is incorrect because there is no clinical evidence to suggest that decreasing calcium intake will prevent the formation of renal calculi; rather, research is showing that a high‐calcium diet offers protection against stone formation. Even though most renal calculi are composed of calcium oxalate, it is the oxalate component that appears to cause the formation of stones. Option 4 is incorrect because increasing intake of complex carbohydrates is recommended to prevent renal calculi formation. ‐ "The presence of renal calculi is directly correlated to dietary intake." ‐ "Decreasing calcium intake will prevent the formation of renal calculi." ‐ "An increase in dietary protein can increase the likelihood of renal calculi." ‐ "Reducing dietary intake of complex carbohydrates decreases formation of renal calculi." | The core issue of the question is knowledge that protein sources can lead to uric acid formation and subsequent stone formation. Use nutrition knowledge and the process of elimination to make a selection. |
3841 A client with chronic obstructive pulmonary disease Correct answer: 3 Clients with COPD who overeat, in addition to consuming excess carbohydrates, have (COPD), who has been consuming more than 3,000 increasing difficulty with breathing because of excessive CO<sub>2</sub> levels calories/day to gain weight, now reports increased that place additional stress on the lungs. The client should eat a proper diet and correct breathing difficulty. The client states, "I thought that if percentages of macronutrients to maintain adequate weight. In addition, chronic COPD is I gained weight by eating more, I would feel better." associated with PEM (protein‐energy malnutrition), infection, and unintentional weight loss. How would the nurse respond to the client's concern? Option 1 is incorrect since increased calories alone can lead to increased work of breathing. The percentage of fat in the diet may also pose a problem if the client is experiencing contributory disease or malabsorption. Option 2 is incorrect because merely providing medication therapy to stimulate weight gain does not address the problem of the obvious excess of calories that the client is consuming or that the client is experiencing difficulty breathing. Option 4 is incorrect because an increase in high‐quality proteins will not help to correct the clinical symptoms. | The core issue of the question is knowledge that excessive carbohydrate intake results in excess carbon dioxide production, which can be harmful to the client with COPD. Use nutrition knowledge and the process of elimination to make a selection. |
‐ "The increase in calories is not as important as an increase in the fat percentage in the diet." ‐ "It is not necessary to increase caloric intake because medication therapy can be given to help with desired weight gain." ‐ "An increase in both calories and carbohydrates can lead to increased respiratory effort and clinical symptoms that you are having." ‐ "An increase in high‐quality proteins will help correct the respiratory symptoms." | |
3842 Which snack selection would be most appropriate for Correct answer: 4 A client who has stomatitis will have pain upon ingestion of food caused by the inflammatory the nurse to make for a client with cancer who has process. Cool foods are often tolerated better than hot foods, as are soft, creamy products. stomatitis? Option 1 is incorrect because peanut butter is a thick, dense food that may irritate the mouth by sticking on mucous membranes and requiring more effort to swallow. Option 2 is incorrect because pretzels are high in salt, which may cause further irritation to the oral cavity. Option 3 is incorrect because tomatoes are high in ascorbic acid; even though they are in the form of a soup, they may cause irritation. ‐ Peanut butter sandwich ‐ Soft pretzels with salt ‐ Tomato soup ‐ Yogurt | The core issue of the question is knowledge that clients with stomatitis need foods that are soft, nonirritating, and not hot. Use nutrition knowledge and the process of elimination to make a selection. |
3843 A client who is lactose intolerant is recovering from a Correct answer: 4 A client who is lactose intolerant has a difficulty handling milk and dairy products because of surgical procedure. What impact does the nurse deficient lactase enzyme. Full liquid diets are based on milk and dairy products. If a client is expect this to have on progression of diet as tolerated? known to be lactose intolerant, the diet will have to be adjusted to reflect lactose‐reduced or lactose‐free products in order to prevent GI irritation. Option 1 is incorrect because it does not reflect the added clinical condition of lactose intolerance but merely refers to progression of diet. Option 2 is incorrect because lactose intolerance does have an impact on diet patterns. Option 3 is incorrect because diet progression does not rely merely on the return of a bowel movement pattern. ‐ The client will be able to progress from a clear to full liquid diet easily once bowel sounds and gag reflex return. ‐ There is no impact with regard to diet progression because of lactose intolerance. ‐ The client's diet can be progressed following a bowel movement indicating return of bowel activity. ‐ The client's full liquid diet may have to be altered because this diet contains milk products. | The core issue of the question is knowledge of concepts related to lactose intolerance. Use nutrition knowledge and the process of elimination to make a selection. |
3844 A client is placed on enteral feedings via nasogastric Correct answer: 4 A client who is receiving enteral feedings via nasogastric tube can be at risk for dehydration tube to meet nutritional goals. Which of the following caused by inadequate fluid intake. It is therefore important to irrigate the tube with water as assessments should be included in a plan of care in ordered (before and after feedings or medication administration) and include these irrigations order to maintain fluid balance? in the client’s total I&O measurements. Option 1 is incorrect because although inspection of the skin surrounding the tube is necessary, it does not relate specifically to fluid balance. Option 2 is incorrect because clients are often weighed daily. Option 3 is incorrect because feeding tubes are not flushed only once a day. ‐ Assess the skin area around the tube site. ‐ Weigh the client every other day. ‐ Maintain strict I&O and flush the tube once a day to ensure patency. ‐ Irrigate the tube with water as ordered and include this fluid in total I&O. | The core issue of the question is knowledge that a client receiving enteral feedings is at risk for dehydration if there are no sources of free water provided. Use nutrition knowledge and the process of elimination to make a selection. |
3845 Which of the following points would the nurse make Correct answer: 3 A client with a significant cardiac history on a fat‐restricted diet should not use additional fat when doing dietary teaching with a client placed on a during the cooking or preparation process. Option 1 is incorrect because a client with a fat‐restricted diet because of significant cardiac significant cardiac history will require some form of fat control or restriction as part of a history? dietary pattern for the rest of his or her life. Option 2 is incorrect because fat is a necessary nutrient for the body. To deprive a client of all fat sources can lead to a clinical deficiency of essential fatty acids that can cause further problems for the client. Option 4 is incorrect because ice cream is considered a high‐fat product. The client could have low‐fat ice cream, yogurt, or sherbet to satisfy dietary needs. ‐ "This diet will be used temporarily to reduce saturated fat intake and cholesterol levels." ‐ "All forms of fat should be restricted because of your significant cardiac history." ‐ "No additional fat should be utilized when cooking or preparing foods." ‐ "Ice cream can be included in the diet, although fat from butter and meat is excluded." | Use nutrition knowledge and the process of elimination to make a selection. |
3846 A client's mother wants to know why she should have Correct answer: 3 Allergy I and II diets are used in sequence to identify and eliminate potential food allergens. her daughter follow an allergy I and II diet. How would Option 1 is incorrect. Even though this diet pattern is used over a short time period, this the nurse reply to this mother's concern? response does not address why it is necessary to follow the diet pattern. Option 2 is incorrect because it provides false and inaccurate information. Option 4 is incorrect because referral to an immunologist for allergy testing is not a required accompaniment to this dietary pattern. Referral to an immunologist for allergy testing may eventually be indicated if the client is found to have a multiple allergy profile. ‐ "This is a short‐term therapy diet, and it will be over before you know it." ‐ "This diet needs to be followed until your daughter grows out of her allergy phase." ‐ "This diet sequence helps to both identify and eliminate potential allergens, making future diet selection choices easier." ‐ "Allergy testing usually accompanies this type of diet pattern, and you should see an immunologist." | The core issue of the question is knowledge of the purposes of allergy I and II diets. Use nutrition knowledge and the process of elimination to make a selection. |
3847 Which of the following items should the nurse Correct answer: 4 Foods that contain gluten (wheat, oats, rye, and barley) are restricted for a client with celiac encourage in the diet of a client diagnosed with celiac disease because of an inability to handle gluten protein. All of the other choices reflect items disease? that cannot be used in a gluten‐restricted diet. ‐ Oatmeal ‐ Whole wheat toast ‐ Beef barley soup ‐ Cornflakes | The core issue of the question is knowledge that a foods containing wheat, rye, oats, and barley are restricted in celiac disease. Use nutrition knowledge about foods containing these grains and the process of elimination to make a selection. |
3848 Which of the following foods would the nurse suggest Correct answer: 3 A client taking MAO inhibitors has to avoid foods that are high in tyramine because it can lead as an item from the lunch menu for a client taking a to significant complications resulting in hypertensive crisis. Cottage cheese is an unfermented monoamine oxidase (MAO) inhibitor? cheese that can be used in the diet. All of the other options reflect foods that are high in tyramine. Aged cheeses are not allowed on the diet. ‐ Smoked fish ‐ Bologna sandwich ‐ Cottage cheese ‐ Salad with bleu cheese dressing | The core issue of the question is knowledge that clients taking MAOIs require a low‐ tyramine diet. Use nutrition knowledge of low‐tyramine foods and the process of elimination to make a selection. |
3849 How would the nurse best respond to a client's Correct answer: 3 The perception of being in a state of "always dieting" can be problematic in terms of statement: "I am always dieting, but I never seem to compliance and goal attainment because it can be viewed either as a restriction or as a form of be losing weight?" punishment. Option 1 is not true: wanting to lose weight is not the only factor to consider; many other variables affect weight loss. While it is important to find out the type of the diet the client is on (or has been on), this knowledge doesn’t address the main concern of the client regarding “always dieting” and yo‐yo effect (weight cycling). ‐ "Weight loss is only maintained if you really want to lose the weight." | The core issue of the question is identification of a client’s need for assistance with weight control. Use nutrition knowledge and the process of elimination to make a selection. |
‐ "Dieting is a way of life, and compliance is required to maintain weight loss." ‐ "By saying you are always dieting, it sounds like you need some assistance in attaining your weight‐loss goals." ‐ "I need to know which type of the diet you are on because it may not be effective." | |
3850 The nurse would encourage the client wishing to Correct answer: 2 Diets that are rich in fruits and vegetables have been proven to be effective in decreasing the reduce risk of cancer to maintain adequate intake of risk of developing cancer because these foods contain phytochemicals. None of the other food which foods? groupings have been shown to decrease the risk of cancer. ‐ Meat and dairy products ‐ Fruits and vegetables ‐ Rice and beans ‐ Milk and cheese | The core issue of the question is knowledge of foods that contain protective chemicals against cancer development. Use nutrition knowledge and the process of elimination to make a selection. |
3851 An athletic client states that he is thinking of using Correct answer: 4 When an athletic client is considering utilizing any ergonomic aid or supplement, trainers carbohydrate (CHO) loading to increase his and/or nutritional specialists can monitor the client closely to establish a client baseline, performance. How should the nurse respond to this provide education, and prevent potential complications related to therapy. Option 1 is client? incorrect because a nurse should not suggest an alternative ergonomic aid. The client needs a proper referral to an expert in the field. Option 2 is incorrect because it does not address the priority need—to make the referral. Although it is important to note what type of exercise the client practices, it is still more important to refer the client to the proper specialist who can assist in supervising an athletic treatment regimen. ‐ Suggest the use of alternative ergonomic aids such as creatine or creatinine because they provide better results. ‐ Discuss foods that are high in CHOs to assist the client in meeting his desired goal. ‐ Ask the client what type of sport activity he is doing to see if this method would help. ‐ Refer the client to a sports/nutritional specialist or trainer so that he can be properly supervised. | The core issue of the question is appropriate anticipatory guidance to a client seeking to use nontraditional methods of nutrition for supplemental use. Use knowledge that this client requires special monitoring and the process of elimination to make a selection. |
3852 The nurse would consult with the physician about Correct answer: 2 A clear liquid diet is recommended for short‐term use (1–2 days). Therefore, the maximum is either advancing the diet or instituting parenteral 2 days. It can be used both before and after surgery or diagnostic procedures, during acute nutrition if the client has been on a clear liquid diet for stages of illness, or as an initial diet after a significant period of GI inactivity or bowel rest. the maximum days? Write a numerical answer. | The core issue of the question is the length of time a clear liquid diet is appropriate. Use knowledge of clear liquid diet as a therapeutic diet to make a selection. |
3853 The nurse concludes that the client education about Correct answer: 2 A client is considered to be obese when his or her weight is greater than or equal to 20 nutritional status has been effective when the client percent over ideal body weight and the calculated BMI is greater than or equal to 30. The states: "Because I weigh 20 percent more than is ideal above statement by the client implies that there is understanding of this classification. Option and my body mass index (BMI) is greater than 30, I am 1 is incorrect because a BMI between 25 and 30 is categorized as "overweight." Option 3 is considered: incorrect as the findings relate to clinical obesity and not merely overnutrition. Option 4 is incorrect because the client is not underweight as defined by the information presented. ‐ Overweight." ‐ Obese." ‐ To have overnutrition." ‐ Underweight." | Note that the question identifies the client is over ideal weight to eliminate option 4. Eliminate option 3 since this is not a term used in nutrition. Recall the parameters of BMI to direct you to option 1. |
3854 What method would be most appropriate for the Correct answer: 4 Visualization of serving sizes is an easy tool that can be used to teach clients how to nurse to use when teaching an adolescent client who is determine accurate serving sizes without the use of formal measurement tools. It allows for a interested in learning how to measure serving‐size common reference between known objects and serving size and offers visual reinforcement. portions? Option 1 is incorrect as it would not be appropriate to ask the client to take measuring cups with her to school. Option 2 is incorrect because it has nothing to do with determining serving size. Option 3 is incorrect because reading the food label will provide information relative to a serving size for the item, but may not help to identify the concept of what a serving size is to the adolescent client. ‐ Have the client bring a set of measuring cups with her to school ‐ Have the client eat only half of what is on her plate during all meals ‐ Have the client read the food labels on packages ‐ Use visualization of serving sizes to illustrate the concept | The critical words are most appropriate and adolescent, recognizing that teaching needs to be geared to this age group. Eliminate option 1 since it is not practical. Eliminate option 2 since it does not answer the question and eliminate option 3 since this would not provide a measuring tool. |
3855 When participating in a local health fair the nurse Correct answer: 2 Lycopene is a phytochemical with powerful antioxidant activity found in tomato products and explains the risk of prostate cancer can be reduced by has been associated with a decrease in risk of prostate cancer. Options 2, 3, and 4 are not adopting which of the following nutritional habits? associated with reduction of prostate cancer. ‐ Increasing intake of tomato products ‐ Limiting intake of concentrated sweets ‐ Eating large amounts whole grains ‐ Decreasing consumption of carbonated beverages | The critical words are risk and prostate cancer. Recall the role of lycopene in risk reduction to direct you to option 1. |
3856 The client has a low total lymphocyte count (TLC). Correct answer: 2 The total number of lymphocytes will decrease when protein deficiency occurs. Options 1 and Which of the following does the nurse conclude to be 3 are incorrect because they will not directly affect the TLC. A bacterial infection will usually the most likely cause? stimulate white blood cell production. ‐ Rapid weight gain ‐ Protein deficiency ‐ Bacterial infection ‐ Inadequate iron intake | The critical words are low lymphocyte count and cause. Recall what factors are needed for lymphocyte production. Eliminate option 1 as it would not contribute to lymphocyte production and eliminate option 3 since this would result in an increased count. Recall that iron plays a role in hemoglobin to eliminate option 4. |
3857 Which statement made by a client indicates the Correct answer: 3 All meat products come from one particular group whose name contains the word meat. All nurse's teaching about MyPyramid has been effective? of the other choices are incorrect because hot dogs (beef, turkey, pork, or soy) belong to the "Hot dogs belong to the: meat group. ‐ Fruit group." ‐ Bread, cereal, rice, and pasta group." ‐ Meat, poultry, fish, dry beans, eggs, and nuts group." ‐ Fats, oils, and sweets group." | Note the question seeks to determine if teaching has been effective, so only one choice will be correct. Recall knowledge of food groups and content of hot dogs to direct you to option 3. |
3858 The nurse is assisting a client who is a Correct answer: 3 Pescovegetarians eat fish to supplement a vegetarian diet. The other options would not be pescovegetarian in menu selection. An appropriate used by type of vegetarian. protein choice for the nurse to suggest the would be: ‐ Turkey. ‐ Eggs. ‐ Fish. ‐ Pork. | The critical words are pescovegetarian and protein. Recognize pesco means fish to direct you to option 3. |
3859 The nurse is preparing teaching materials for a local Correct answer: 1 Soluble fiber from psyllium seed husk or whole oats is connected to decreasing the risk of health fair. The nurse includes the health claim that coronary heart disease and is one of the health claims allowed on food products by the Food consumption of psyllium seed husk or whole oats may and Drug Administration (FDA). Option 2 is incorrect as low folic acid levels are associated with reduce the risk of which of the following? neural tube defects. Option 3 is incorrect because decreased intake of fats (less than or equal to 30 percent) and increased consumption of fruits and vegetables correlate with reduced cancer risk. Option 4 is incorrect since calcium intake correlates with a decreased risk of osteoporosis. ‐ Coronary heart disease ‐ Neural tube defects ‐ Cancer ‐ Osteoporosis | The critical words are psyllium, oats, and reduced risk. Make the connection between the fiber of psyllium and oats to lower cholesterol levels to direct you to option 1. |
3860 When teaching a client about the concept of nutrient Correct answer: 4 Nutrient density refers to the amount of calories (in carbohydrates, proteins, and/or fats), density, the nurse explains it is the: vitamins, and minerals in a given quantity of food. Option 1 is incorrect as it relates to caloric value. Options 2 and 3 are incorrect because the quality or quantity of vitamins and minerals in a food is only one part of the calculated nutrient density. ‐ Amount of total calories in a specific food. ‐ Quality of the vitamins and minerals in a food. ‐ Quantity of the vitamins and minerals in a food. ‐ Calories, minerals, and vitamins in a quantity of food. | Note the word nutrient in the question to eliminate option 1, since it only includes calories. Also note the term includes density and eliminate option 2 since it only includes the quality of food. Choose option 4 because this provides a more inclusive definition. |
3861 A client has been involved in a nutritional research Correct answer: 1 Reliability is the accuracy or consistency of a study, often measured by the ability to replicate study that has been performed three times and the the study and obtain the same results. All of the other options are incorrect because they same findings have been obtained. The nurse relate to validity issues, which determine whether the study accurately reflects what it concludes this study has a good measure of: purports. ‐ Reliability. ‐ Statistical value. ‐ Validity. ‐ Worth. | Note that the study is repeated three times obtaining the same results and recall knowledge of research to direct you to option 1. |
3862 The nurse has instructed a client on the ingredients of Correct answer: 2 Ingredients are listed in order by descending weight. The information identified in each of the food labels. Which client statement indicates the other options is incorrect. nutritional teaching has been effective? "The ingredients of a food: ‐ Are listed in alphabetical order." ‐ Get listed in descending order by weight." ‐ Have proteins listed first, then carbohydrates, then fats." ‐ Are presented in the order of their importance for human nutrition." | The critical terms are food labels, ingredients, and effective teaching. Since food labels contain a lot of information, look for the one correct answer specific to ingredients. |
3863 What consistent statement in the Dietary Guidelines Correct answer: 2 The 2005 Dietary Guidelines apply the principles of scientific evidence in promoting health for Americans 2005 should the nurse include in and reducing risk of chronic disease through diet and physical activity. Option 2 is correct teaching the client to stay healthy? because it includes the two key components found in more than one guideline topics. Option 1 is incorrect because guidelines recommend a total fat intake of 20–35 percent and less than 300 mg of cholesterol per day. Options 3 and 4 are incorrect because under the topic "Food Groups to Encourage" milk is mentioned but only sufficient amounts while staying within energy needs. ‐ Restrict almost all fat and cholesterol. ‐ Balance the intake of food with physical activity. ‐ Include higher amounts of milk and meats. ‐ Increase portions to ensure adequate amounts of nutrients. | Note the critical word in the stem of the question consistent option 2 is the only choice mentioned more than once. |
3864 A client has received teaching of basic nutritional Correct answer: 1 Alcohol provides calories but is not an essential nutrient. All of the other choices reflect principles. The nurse determines the client needs statements that are consistent with basic nutritional knowledge. additional teaching when he states: ‐ "Alcohol is the chemical basis of one of the essential nutrients." ‐ "Protein and carbohydrates are examples of macronutrients." ‐ "Water is necessary for human life." ‐ "Calcium is a micronutrient." | Note the question asks to identify the need for further teaching, indicating a false response question. Thus, you need to look for an option that indicates an incorrect statement. Identify options 2, 3, and 4 as being correct statements, leading to option 1 as the answer to the question. |
3865 The nutrition consult done on a client indicates the Correct answer: 3 A BMI of less than 18.5 is classified as underweight. The most important nursing diagnosis is body mass index (BMI) is 17. Based on this information Imbalanced nutrition: less than body requirements because the client’s intake is not sufficient the nurse identifies which of the following nursing to maintain a normal BMI. A low BMI places client as risk for respiratory diseases, TB, digestive diagnoses as being most appropriate? diseases, and some cancers, but does not create risk for dehydration (option 4). The client could also be at risk for impaired growth, depending on age and specific nutritional deficits existing, but this information is not provided. The client could also have a knowledge deficit, but this is also not evident from the question, so would not be the most appropriate diagnosis. ‐ Impaired growth ‐ Deficient knowledge: nutrition ‐ Imbalanced nutrition: less than body requirements. ‐ Risk for injury: dehydration | Critical phrase is most appropriate, indicating some or all of the options may be indicated, but one is more correct. Eliminate options 1 and 2 since insufficient information is given in question to support their choice. Recall knowledge of BMI norms to choose option 3. |
3866 Which of the following data choices would the nurse Correct answer: 1 Height and weight are physical parameters that are considered to be anthropometric utilize as anthropometric measurements in measurements. Options 2 and 3 are incorrect because they represent laboratory/diagnostic determining a client's nutritional status? test results. Option 4 is incorrect because a 24‐hour dietary recall is part of a documented history. ‐ Height and weight ‐ Hemoglobin and albumin ‐ Total lymphocyte count (TLC) ‐ 24‐hour dietary recall | The critical words are anthropometric measurement. Recall knowledge of them to eliminate options 2 and 3, since they are laboratory measurements. Eliminate option 4 because it is not a measurement. |
3867 The nurse teaching a client about food product Correct answer: 1 The terms "light" or "lite" can only be used if the product has greater than or equal to one‐ labeling explains that a label that reads "Light Salad third fewer calories or greater than or equal to 50 percent less fat than a comparable regular Dressing" contains: product. Option 2 is incorrect because it refers to sodium levels, and the term "light" is related to specific caloric levels and/or fat. Option 3 is incorrect because it refers to an increased protein level. Option 4 is incorrect because the caloric decrease stated is much higher than the identified level. ‐ 50 percent less fat than comparable regular product. ‐ 35 percent less sodium than comparable regular product. ‐ 20 percent more protein than comparable regular product. ‐ At least 50 percent fewer calories than a comparable regular product. | Note that the question describes a food as "light," which refers to the fat content. Eliminate options 2 and 3 since they refer to sodium and protein content. Choose option 1 over 4 as it specifically addresses fat content. Recall knowledge of food labeling requirements. |
3868 The nurse caring for a client with a low basal Correct answer: 2 A low BMR occurs when calories are being burned at a slower than normal rate; therefore, metabolic rate (BMR) recognizes the client would be weight gain may occur. Option 1 is incorrect because a low BMR would correlate with most likely to experience which of the following increased weight gain due to possible endocrine disturbances. Options 3 and 4 are incorrect nutritional problems? because they reflect poor nutritional status, fatigue, and decreased oxygen‐carrying capacity, which can occur because a variety of other metabolic factors, not only nutrition. ‐ Undernutrition ‐ Obesity ‐ Low serum albumin ‐ Low hemoglobin | Critical words are most likely, indicating there is a tendency for it to occur. Eliminate options 3 and 4 because they do not reflect metabolism. Choose option 2 since weight gain correlates with a slowed metabolism. |
3869 The nurse is instructing a client on how to maintain a Correct answer: 3 A food diary involves recording intake of foods and beverages over a specific period of time food diary. The nurse explains the diary should include: and also includes emotions and rationales for eating. It can be used to help clients identify unhealthy patterns, and it can also be used for weight loss and bulimia/anorexia. Option describes a dietary intake record, which does not include emotions and reasons. Option 2 describes a 24‐hour recall. Option 4 might or might not be part of a food diary. ‐ Every type of food and beverage consumed in the past week. ‐ Exact amounts of foods and beverages consumed in the past 24 hours. ‐ Exact amounts of food consumed along with feelings and reasons for eating. ‐ When and where food is consumed during the last week. | Note the word diary is part of the plan, indicating more than just listing of food items will be involved. Eliminate options 1 and 2 since they just include food quantities. Eliminate option 4 because it is very general and less specific than option 3. |
3870 The nurse is instructing a client who wants to begin Correct answer: 1, 2, 3 Soy, beans, and nuts are part of the protein group and would be appropriate for a vegetarian. following a vegetarian diet about foods that provide Vegetarians do not eat animals that must be killed prior to consumption; most vegetarians protein. The nurse explains that which of the following (other than vegans) will consume eggs, legumes, and dairy products. choices would be appropriate for this client? Select all that apply. ‐ Soy ‐ Beans ‐ Nuts ‐ Turkey ‐ Wheat germ | Notice that the client is vegetarian; eliminate option 4 since it is of animal origin. Recall knowledge of protein‐containing foods. Eliminate option 5 since it is a grain. |
3871 The nurse reviewing the laboratory test results on an Correct answer: 3 Transferrin levels provide information relative to iron stores and visceral protein. Option 1 is assigned client that indicate a decreased transferrin incorrect because transferrin does not specifically relate to a low dietary intake level. Option 2 level. The nurse interprets that this finding would be is incorrect because transferrin levels do not relate to blood loss through hemorrhage, they associated with which of the following in the client? relate to body stores. Option 4 is incorrect because transferrin levels are not affected by bacterial infections. ‐ Low dietary iron intake ‐ Recent episode of blood loss ‐ Malnutrition, especially lack of protein ‐ Recent bacterial infection | The question requires knowledge of transferring. A key word is decreased level. Recall transferrin reflects stored iron to eliminate option 1. Eliminate options 2 and 4 since transferring is not related to blood loss or infection. |
3872 The nurse is writing a care plan for a client at risk for Correct answer: 2 Promoting healthy nutritional practices incorporates both the categories of undernutrition a nutritional deficit. An appropriate goal would be: and overnutrition. The correct option provides a goal that is global and relevant to nutrition. Option 1 and 4 are incorrect because they reflect an intervention, not a goal. Option 3 is incorrect because weight maintenance would only be an appropriate goal if the client is underweight and there is insufficient information to determine this. ‐ Client will wear prescribed oxygen at 2 liters/minute. ‐ Client will verbalize two healthy nutritional practices. ‐ Client will maintain current weight. ‐ Client will monitor weight twice daily at the same times each day. | Question requires identifying a goal that is realistic and relevant. Eliminate options 1 and 4 since they are nursing intervention, not goals. Eliminate option 3 since the question did not identify a weight problem. |
3873 An elderly client asks the nurse, "What’s all this stuff Correct answer: 1 A Daily Recommended Intake (DRI) is a nutritional guideline that goes beyond the RDAs. It about DRIs that I keep hearing?" Which of the includes Tolerable Upper Limits and Adequate Intake amounts and is established by the following statements by the nurse provides the best government to provide a more comprehensive approach to nutrition. Option 2 is incorrect explanation? because DRIs do not merely relate to caloric intake. Option 3 is incorrect because DRIs are not based solely on weight variables but reflect a recommended intake of nutrient factors. Option 4 is incorrect because even though the physician is knowledgeable, any one healthcare provider does not have complete knowledge of nutritional therapies. A collaborative approach is necessary to provide information to the client. | Note the critical word best, indicating some options may be partially correct. Eliminate option 4 because it does not offer an explanation to the client. Eliminate options 2 and 3 since they do not completely address DRIs. |
‐ "They are updated nutritional guidelines that the government developed." ‐ "The DRIs are guidelines for how many calories you need in a day." ‐ "They refer to guidelines for weight loss for persons who are 25% overweight." ‐ "Don’t worry, your doctor will tell you what you need to know about nutrition." | |
3874 The nurse is assisting the client in menu planning Correct answer: 2 MyPyramid recommends three servings a day from milk, cheese, and dairy products. One using MyPyramid as a standard. The nurse encourages serving is equal to 8 ounces of milk or 2 ounces of cheese. Option 1 does is equal to one the client to choose which of the following items on serving, but not a day’s supply. Option 3 is an insufficient amount. Option 4 is also insufficient, the menu to obtain an adequate daily intake of milk and eggs are not part of the protein category. and dairy products? ‐ 8 ounces of skim or whole milk ‐ 8 ounces of milk and 2 ounces of cheese ‐ One‐half cup of yogurt ‐ One‐half cup of yogurt and one egg | Note that question asks for adequate daily intake, not just a single serving size. Options 1 and 3 are similar and can be eliminated. Eliminate option 4 since eggs are not part of the milk and dairy group. |
3875 A 34‐year‐old diabetic client who is receiving insulin Correct answer: 2 The use of an exchange list is recommended by the American Dietetic Association for use by therapy is not making healthy dietary choices to diabetic clients for meal planning. Option 1 is incorrect: Even though the MyPyramid is control blood glucose. The nurse would use which of developed by the USDA to illustrate healthy diet choices, the use of an exchange system is the following as the most appropriate aid when geared specifically to equivalent carbohydrate contents that are critical for a diabetic client. reviewing diet planning with the client? Options 3 and 4 are incorrect because they are not diet planning guides but rather examples of tools that can be used to evaluate nutritional status. ‐ MyPyramid ‐ Exchange list ‐ Food diary ‐ 24‐hour recall | Note the question asks for a method or guide to diet planning. Eliminate options 3 and 4 since they involve record keeping of a diet, but do not involve planning. Recall knowledge of diabetic diets to choose exchange lists. |
3876 The nurse is demonstrating to a client how to read Correct answer: 4 Sugars are a carbohydrate (CHO), and each gram of CHO or sugar contains 4 kcal. Multiply 3 food labels. Using the label below, the nurse calculates grams 3 4 = 12 calories. the food item derives calories from sugars contained in the product? Write a numerical answer. | Identify how many grams of sugar are listed on the label. Be sure to select just sugar, not total CHOs. Use key at bottom of label to multiply and arrive at calories/Gm. |
3877 During a client teaching session, which of the Correct answer: 4 A hot dog bun is found in the bread, cereal, rice, and pasta group. Option 1 is incorrect. following foods would the nurse identify as belonging Peanuts are found in the meat, poultry, and fish group because they are considered to be to the bread, cereal, rice, and pasta group of legumes. Options 2 and 3 are incorrect because coconut is in the vegetable group; navy beans MyPyramid? are in the meat, poultry, and dried beans group. ‐ Peanuts ‐ Coconut ‐ Navy beans ‐ Hot dog bun | Recall knowledge of the food groups to eliminate options 1, 2, and 3, which are protein and vegetable groups. |
3878 The nurse is involved with a nutritional research Correct answer: 1 Epidemiologic nutritional research studies nutritional factors that influence the cause, project that involves quantifying calcium intake and frequency, and distribution of disease, injury, or other health‐related events in a defined osteoporosis rates of occurrence in elderly adults. The human population. Option 2 is incorrect because laboratory research is used to test scientific nurse concludes that this is which of the following hypothesis in a controlled setting. Option 3 is incorrect because the use of human studies types of studies? research involves manipulation of variables affecting nutrient intake. The stated example above relates to an intake study that is attempting to correlate rates of disease occurrence. Option 4 is incorrect because qualitative research looks at the quality of a given variable. The nutritional research study proposed does not provide enough information relative to type and amount of calcium intake, so one cannot categorize this research as either qualitative or quantitative. ‐ Epidemiologic research ‐ Laboratory research ‐ Human studies research ‐ Qualitative research | Note the critical word quantifying and that a specific population, the elderly, is being studied. Recall knowledge of types of research to choose option 1. |
3879 The nurse has taught a client to read nutrition labels. Correct answer: 2 Health claims on food products are regulated by the FDA, are trustworthy, and are based on Which of the following statements by the client scientific evidence. The food products making the claims must meet specific rigid criteria. indicates to the nurse that the teaching has been Options 1 and 3 are incorrect because FDA regulations are strictly enforced, and companies effective? must comply with federal guidelines or risk penalty. Option 4 is incorrect because food product labels are regulated by the FDA and not by individual states. ‐ "Those nutrition labels are misleading. Companies can put whatever they want on the labels." ‐ "When a label says a food product helps reduce the risk of cancer, you can believe it." ‐ "Food label health claims are exaggerated and based on eating abnormally large amounts." ‐ "The health claims on food product labels are individually determined by each state." | The question is asking to assess effectiveness of teaching. Recall specific knowledge of labeling standards and laws to choose option 2. |
3880 A nurse conducting a nutrition class tells the class Correct answer: 2 Calories or kilocalories are the most commonly used measurement of a food product’s that the energy contained in a specific amount of a energy. Grams and pounds reflect weight measurements. Joules represent electrical energy. food product is measured in: ‐ Joules. ‐ Calories. ‐ Grams. ‐ Pounds. | Critical words are energy and measurement. Recognize that options 1, 3, and 4 are measures of weight and quantity and thus they can be eliminated. |
3881 The school nurse is assigned to collect Correct answer: 3, 4 Height, weight, and skin fold thickness are common anthropometric data (i.e., measurement anthropometric data from preschool children of body parts) obtained by the nurse, as well as the body mass index. Options 1 and 2 are regarding nutrition. From which of the following incorrect: CBC (and hemoglobin, which is a test included in the CBC) reflect laboratory methods can the nurse choose to collect this type of parameters. Option 5 is incorrect because albumin is a type of serum protein and is another data? Select all that apply. laboratory measurement. ‐ Complete blood count (CBC) ‐ Hemoglobin ‐ Body mass index (BMI) ‐ Triceps skin folds ‐ Albumin | Critical words are anthropometric data and measurement. Eliminate option 2 since it does not involve an actual measurement. Note also that Options 1, 2, and 3 are distracters relating to diagnostic studies and not anthropometric data. |
3882 When assessing a client's nutritional status, the nurse Correct answer: 4 The Body Mass Index (BMI) is calculated by taking the weight in kilograms and dividing by the uses the client's Body Mass Index (BMI) to determine: height in meters squared. It assesses weight compared to height, or fatness. Option 1 is incorrect because these are merely descriptive terms that relate to body frame variables and overall distribution of weight. Option 2 is incorrect because the metabolic rate of an individual relates to basal metabolic rate (BMR). Option 3 is incorrect, because BMI does not detect hypercholesterolemia. Elevated cholesterol levels can be found in individuals with differing BMI values because both genetic and metabolic factors influence its development. ‐ Apple‐ versus pear‐shaped body type. ‐ Metabolic rate of the individual. ‐ Hypercholesterolemia. ‐ Relative fatness or weight to height. | The focus of the question is the purpose or applicability of BMI. Recall BMI involves measurement of height and weight. Eliminate options 2 and 3 since they are refer to metabolism and blood chemistries. Eliminate option 1 since it is a shape, not related to height and weight. |
3883 When planning nutritional requirements to promote Correct answer: 3 A positive nitrogen balance implies that a client is in a growth state whereby extra high a positive nitrogen balance in a client the nurse should biologic value protein sources are needed for growth of tissue. Option 1 is incorrect because include which of the following? additional protein, not CHO, is needed to restore nitrogen balance. While CHO sources are the primary source of energy, periods of positive nitrogen balance require additional protein as the necessary nutrient. Even though a decrease in the amount of saturated fat in the diet is advisable, the issue of nitrogen balance addresses protein. Option 4 is incorrect because although milk is a good source of protein, three servings is the usual recommendation in the diet and this will not meet the needs of a client who is in positive nitrogen balance. ‐ Increased carbohydrates (CHOs) in the diet to provide energy ‐ Decreased intake of saturated fats in the diet ‐ Increased intake of high biologic value protein foods ‐ Three servings of milk products in the daily diet | Recall that a positive nitrogen balance is achieved through protein to direct you to option 3. |
3884 The nurse identifies which of the following clients Correct answer: 4 A client who is in the hospital due to a GI infection is at risk to develop protein deficiencies if may be at risk for protein deficiency? GI symptoms such as diarrhea and intestinal inflammation exist. Option 1 is incorrect because the combination of milk and cereal represents a complementary protein and will support needed protein requirements. Option 2 is incorrect because soy burgers are an example of a complete protein source. Option 3 is incorrect as a client who is in renal failure is more likely to have problems related to excess protein due to an inability of the kidneys to handle an increased solute load. ‐ A young child who eats milk and cereal each day for breakfast ‐ A college student who eats soy burgers for lunch ‐ A client who is in renal failure ‐ A client who has been hospitalized for a gastrointestinal (GI) infection | Analyze each option for indication of protein deficiency or potential to contribute to same to choose option 4. |
3885 The nurse is teaching a group of clients with cardiac Correct answer: 3 The highest concentration of omega‐3 fatty acids is found in cooking oils, margarine, fatty fish disease about the health benefits of omega‐3 fatty (e.g., cod, tuna, salmon, shrimp, and mackerel), and flaxseed oil. The other options are not acids. The nurse suggests increasing consumption of good sources of omega‐3 fatty acids. which of the following? ‐ Chicken ‐ Butter ‐ Tuna ‐ Peanuts | Critical words are omega‐3 fatty acids. Recall that many fish contain this type of fat to choose option 1. |
3886 Which of the following findings does the nurse Correct answer: 1 Increased amounts of fiber in the diet (in excess of dietary recommendations or increased too attribute to the client's excess fiber intake in the diet? rapidly) can lead to GI presentations that include diarrhea, flatulence, and generalized discomfort. Option 1 is incorrect as increased use of insoluble fiber can decrease the absorption of certain minerals. Option 3 is incorrect because excess fiber will increase GI motility leading to diarrhea. Option 4 is incorrect because fiber helps to bind cholesterol in the body for elimination. ‐ Diarrhea and abdominal bloating ‐ Elevated calcium and magnesium levels ‐ Decreased motility of the gastrointestinal (GI) tract ‐ Increased serum cholesterol levels | The critical word is excessive. Recall the action of fiber in the GI tract to direct you to option 1. |
3887 What dietary instruction should the nurse give a Correct answer: 2 The client needs to increase water intake while increasing fiber intake to prevent client who is seeking to add more fiber to the daily constipation. It is recommended to have 3–5 servings of vegetables and 2–4 servings of fruit diet? daily, making option 1 incorrect. Option 3 is incorrect as many foods are high in fiber. Option 4 is incorrect because vegetables provide a good source of insoluble fiber while grains and broccoli tend to provide soluble fiber. ‐ Limit fruits and vegetables to twice a day. ‐ Increase water intake to accompany fiber intake. ‐ Use fiber supplements to increase dietary fiber because few foods are high in fiber. ‐ Limit the number of salads in the diet. | Note that the client is increasing fiber to eliminate options 2 and 4, since they limit intake of foods with fiber. Choose option 1 as appropriate advice to give regarding fiber. |
3888 What physiological response should the nurse expect Correct answer: 3 A high‐CHO meal will lead to an increase in circulating insulin levels as part of the glycemic in a client who consumes a high‐carbohydrate (CHO) response. Option 1 is incorrect because insulin production will increase in response to a high diet over a prolonged period of time? CHO meal. Option 2 is incorrect as a decrease in insulin sensitivity and an increase in insulin resistance would be expected in a client who has been consuming a high CHO diet for a prolonged period of time. Option 4 is incorrect because some form of dyslipidemia would be expected in a client who has been consuming a high CHO diet for a prolonged period of time. ‐ A decrease in the amount of circulating insulin ‐ An increase in insulin sensitivity ‐ An increased glycemic response ‐ A stable lipid profile | Critical terms are high CHO diet and prolonged time. Recall the effect of CHO on insulin, glucose, and fats to eliminate options 1, 2, and 4. |
3889 The nurse has instructed a client on food choices to Correct answer: 2 Option 2 represents the best source of complex CHOs because it includes whole grains and increase the amount of complex carbohydrates (CHOs) fruit. Option 1 is incorrect as instant rice and canned green peas are examples of food items in the diet Which menu selection made by the client that have been processed or refined. Option 3 is incorrect because scrambled eggs with ham indicates the teaching was effective? and sausage represent a meal that is high in protein and saturated fats. Option 4 is incorrect because fried potatoes are high in fat content and fruit juice is high in simple sugars. ‐ Grilled chicken, instant rice, and canned green peas ‐ Grilled chicken sandwich on whole wheat bread with an apple ‐ Scrambled eggs with ham and sausage ‐ Fried potatoes and fruit beverage | Analyze each option for complex CHO content. Eliminate options 3 and 4 since they contain more fats and proteins than CHO. Choose option 2 over 1 since it is less processed and refined. |
3890 Which of the following statements, if made to the Correct answer: 2 The incorporation of tuna in the diet reflects a food that is high in omega‐3 fatty acids, which nurse, reflects that a client with coronary artery is beneficial in reducing cardiovascular risks. Option 1 is incorrect because the amount of fiber disease (CAD) has been compliant with dietary specified is far below the recommended daily dietary intake. Option 3 is incorrect because the teaching to decrease fat intake? use of butter and partially hydrogenated cooking oils increases both the amounts of saturated fat and trans‐fatty acids in the diet. Option 4 is incorrect because the use of fried food products contributes to an increase in fat intake. ‐ "I have been limiting my fiber intake to 10 grams per day and drinking more fluids." ‐ "I eat tuna once a week." | Critical words are CAD and fat intake. Eliminate options 3 and 4 since they contain high fat food items. Eliminate option 1 since fiber should be increased with CAD. |
‐ "I use butter and partially hydrogenated cooking oils." ‐ "I eat chicken nuggets a few times a week." | |
3891 What information should the nurse give to a client Correct answer: 3 Food and Drug Administration (FDA) regulations require that foods containing olestra have a who is using artificial fats in the diet to replace natural warning label stating that abdominal cramping and loose stools can occur from the use of this sources of fat? artificial fat product. Option 1 is incorrect because artificial fat products cannot be substituted for low fat products. Low fat describes the content of a food item as having 3 grams or less of fat per serving. Option 2 is incorrect because there are different types of artificial fats derived from different chemical sources (carbohydrates and proteins). Option 4 is incorrect because the use of artificial fats in the diet can lead to decreased absorption of nutrients because most artificial fats are not absorbed well from the GI tract. ‐ "Artificial fats can be substituted for foods that are low in fat in the diet because they are chemically similar." ‐ "All artificial fat products are chemically similar." ‐ "Products that contain olestra can cause a client to experience gastrointestinal (GI) symptoms." ‐ "The intake of artificial fats leads to increased absorption of nutrients." | The question requires a comparison of artificial fats with natural fats. Recall that artificial fats are not well absorbed in the GI tract to choose option 3. |
3892 Which of the following food items should the nurse Correct answer: 3 Natural grain products usually contain little fat, and a half a bagel has a very low fat content. suggest to a client who is seeking to lower his fat The other choices reflect foods that have a high fat content and represent saturated (cheese intake? and coconut) and monounsaturated (almonds) types of fat. ‐ Natural cheddar cheese ‐ Coconut ‐ Half a bagel ‐ Almonds | Note the question does not address a certain type of fat and analyze each option for overall fat content, choosing option 3 as lowest. |
3893 The nurse is providing dietary counseling to a client Correct answer: 1 Omega‐3 fatty acids have been shown to reduce risk factors associated with heart disease. with coronary artery disease (CAD). The nurse They are found in fatty fish, fish and flaxseed oils, and cooking oils. encourages intake of foods high in omega‐3 fatty acids, such as those found in which of the following? ‐ Fish oils ‐ Whole grains ‐ Grapefruit ‐ Poultry | The question requires recall of knowledge of foods high in omega‐3 fatty acids. Since fatty acids are the product of fat breakdown, eliminate options 2 and 3 since they do not contain or have very little fat. Eliminate poultry (option 4) since it contains saturated fat in the skin. |
3894 Laboratory results indicate a client has elevated Correct answer: 3 Clinical evidence has supported that elevated homocysteine levels correlate with increased homocysteine levels. The nurse explains to the client risk for the development of atherosclerotic heart disease and deficiencies of certain B complex that this can contribute to which of the following? vitamins. Option 1 is incorrect—homocysteine is an amino acid that is produced by the breakdown of the amino acid methionine. Option 2 is incorrect because elevated homocysteine levels are associated with vitamin B deficiencies. Option 4 is incorrect because homocysteine metabolism is not related to lipid absorption. ‐ Decreased utilization of essential amino acids ‐ Increased metabolic production of B vitamins ‐ Increased risk of atherosclerotic disease ‐ Decreased absorption of lipids | A critical word is increased. Recall homocysteine is associated with cardiovascular disease to choose option 2. |
3895 The nurse explains to a client who is following a low‐ Correct answer: 4 Clients with deficient protein intake are at risk for immune dysfunction and fatigue. High protein diet that the following consequences could protein intake may put clients at risk of coronary heart disease, not low protein. Steatorrhea is possibly occur? usually associated with altered fat metabolism. Pyelonephritis is an infection and is not caused by low protein diets. ‐ Increased risk of coronary artery disease | Critical words are low protein diet. Eliminate option 1 because it is related to high protein intake. Option 2 is associated with fat metabolism. Recall protein is needed for adequate cellular metabolism to choose option 4. |
‐ Frequent episodes of steatorrhea ‐ Development of pyelonephritis ‐ Impaired immune function | |
3896 The nurse has conducted dietary teaching with a Correct answer: 4 Clients with heart disease benefit from foods that are low in fat and, if hypertensive, low in client who has heart disease. In evaluating the salt. Baked fish without added sources of fat represent the best choice on the sample menu. effectiveness of the session, the nurse concludes that The turkey would be a good choice if it did not have a cream sauce, which is high in fat. Beef is the best outcome is obtained when the client selects high in fat because it is an animal product and contains more fat than poultry. The baked which of the following food items from a sample chicken would be a better choice if the skin were removed, because skin is high in fat also. restaurant menu? ‐ Turkey casserole in a cream sauce ‐ Barbecued beef ribs ‐ Baked chicken breast with skin ‐ Baked fish coated in bread crumbs | Note animal foods provide richest sources of fat, so the beef can be eliminated first followed by the poultry. This leaves fish as the best choice, especially since there are no added sauces or coatings that contain fat. |
3897 The nurse would include which strategy as most Correct answer: 1 Trans‐fatty acids are found in processed hydrogenated foods. The other options address appropriate in the care plan of a client who needs to reduction of cholesterol and saturated fats in the diet, but do not address trans‐fatty acids limit intake of trans‐fatty acids? specifically. Some foods high in cholesterol and fat, although they should be reduced, may not be high in trans‐fatty acids. ‐ Teach client to read nutrition labels checking for hydrogenated fats. ‐ Have client select low‐cholesterol foods from a dietary plan. ‐ Assist client to choose non‐dairy foods when filling out the menu. ‐ Ask client to name three foods high in saturated fats. | A critical concept in the question is trans fatty acids. Options 2 and 4 can be eliminated since they address cholesterol and saturated fats. Recall hydrogenated fats are a common source of trans fatty acids to choose option 1. |
3898 Which of the following consequences would the Correct answer: 1 A state of prolonged CHO deficiency can lead to protein breakdown that results in formation nurse anticipate in a client who has had prolonged of ketone bodies and altered acid‐base balance (metabolic acidosis). Options 2 and 3 are carbohydrate (CHO) deficiency? incorrect because they are associated with protein deficiency and lipid deficiency, respectively. Option 4 is incorrect because these are associated with an increased amount of CHOs in the diet. ‐ Ketosis and metabolic acidosis ‐ Anemia and edema ‐ Skin lesions and weight loss ‐ Dental caries and obesity | Critical words are prolonged deficiency and CHOs. Eliminate option 4 as it is associated with excessive CHO intake. Recognize options 2 and 3 are associated with protein and fats to eliminate them. |
3899 The nurse has instructed a client on complementary Correct answer: 2 Pinto beans and rice are examples of the use of complementary protein because this proteins. Which diet selection by the client illustrates combines two different food items to yield a complete protein source. All of the other options that the client has understood the material presented? do not combine to make a complete protein source. A complete protein source provides all of the essential amino acids and is of high biologic quality and value. ‐ Eggs and bacon ‐ Pinto beans and rice ‐ Fish and chips ‐ Hamburger and fries | Recall knowledge of combining plant proteins to attain a complete protein. Eliminate options 1, 3, and 4 since they include meat proteins. |
3900 Which of the following dietary methods could the Correct answer: 3 High intake of sugars (CHOs) is associated with dental caries and progression of dental nurse best utilize in a plan of care for a client to disease. By limiting the intake of soft drinks in the diet, one is reducing the daily CHO content. minimize the risk of dental caries? Hard candies are mainly composed of sugar and will contribute to dental disease, because they increase the sugar medium in the oral cavity (option 1). Even air‐popped popcorn can easily become lodged between the teeth, leading to food's remaining in the oral cavity and bacterial progression (option 2). Option 4 is incorrect because rinsing of the mouth after eating candy will not effectively remove the extra sugar that the candy provided. Brushing and flossing the teeth would prove to be a better option because this would remove food remnants. ‐ Use hard candies to prevent dryness of the oral cavity. ‐ Eat air‐popped popcorn when eating a snack food. ‐ Limit intake of soft drinks to one or two a day. ‐ Rinse mouth after eating candy or anything sweet. | Note the critical word best, indicating one option is a better choice. Consider the residual effect of candy, soda and popcorn residue on teeth to eliminate options 1, 2, and 4. |
3901 Which of the following signs should the nurse check Correct answer: 3 Olestra blocks absorption of fat in the diet, sometimes causing abdominal cramping and loose for in a client who admits to eating a lot of snack foods stools. It is not associated with the symptoms in options 1, 2, and 4. containing Olestra? ‐ Numbness in fingers ‐ Headaches ‐ Abdominal cramping ‐ Dizziness | Recall knowledge of the function of Olestra to block fat. Note options 1, 2, and 4 all are similar in relating to the neurovascular status. Blockage of fat would occur in the intestines, providing a clue to the abdominal cramping. |
3902 A client needs to follow a low‐fat diet. Which of the Correct answer: 1, 2, 3 The degree of unsaturation is in the firmness of fats at room temperature. The following products would the nurse instruct the client polyunsaturated vegetable oils are liquid; therefore the more saturated animal fats are solid. to avoid using when cooking? Select all that apply. Options 1 and 2 are solid and should be avoided. Option 3 should also be avoided because even though coconut oil is not polyunsaturated. ‐ Solid margarine ‐ Shortening ‐ Coconut oil ‐ Corn oil ‐ Canola oil | The critical word avoid in the question stem tells you that the correct answer(s) will be items that are incorrect to use when trying to lower fat content in the diet. |
3903 Which information should the nurse provide to a Correct answer: 1 CHOs are the primary energy source used to maintain the body and a minimum level of CHOs client who is planning to begin a low‐carbohydrate (50–100 grams/day) is needed in order to avoid protein breakdown. Option 2 is incorrect (CHO) diet to lose weight? because there are other methods (besides lowering CHO intake) to establish sustained weight loss. Option 3 is incorrect. A balanced intake of all three macronutrients is needed in order to maximize function, prevent breakdown of constituent products, and maintain energy. Option 4 is incorrect because an increase in dietary fiber will not compensate for a decrease in total CHOs. Although dietary fiber provides health benefits related to elimination and cholesterol levels, an increase in fiber above current recommendations (20–35 grams/day) may cause an increase in GI symptoms and lead to constipation. ‐ A minimum level (50–100 grams/day) of CHOs is needed in the body in order to prevent protein breakdown. ‐ Lowering of CHOs is the only way to effect sustained weight loss. ‐ A decrease of CHOs in the diet will not affect other nutrient proportions in the body. ‐ The client should increase dietary fiber level to compensate for decreased CHOs. | Critical words are low CHO and lose weight. Recognize there are many ways to approach weight reduction and eliminate option 2. Eliminate options 3 and 4 since they are incorrect statements. |
3904 The nurse has instructed a vegetarian client regarding Correct answer: 4 The use of complementary proteins in a diet pattern refers to the combining of different plant the use of complementary proteins in the diet. Which proteins in a day to form a complete protein that is of high biologic value. Vegetarians should of the following statements by the client indicates that receive instruction on this method in order to maintain required essential amino acid client teaching has been adequate? requirements in the body and prevent clinical deficiencies that could arise due to their choice of vegetarianism. Option 1 is incorrect because gelatin is an animal protein of low biologic value and would not be included in a vegetarian diet. Option 2 is incorrect because the idea of complementary proteins is to combine food choices and not merely to increase the amount of complete protein sources. Option 3 is incorrect because an increase in fruits will not provide complete protein. ‐ "I will eat gelatin for dessert." ‐ "I will eat more complete protein food sources." ‐ "I will increase my intake of fruits and eat a wide variety of them." ‐ "I will eat different plant food products together to provide complementary proteins." | Note that the critical word in the question is complementary and this word is repeated in option 4. Recall knowledge of complete versus complementary proteins to eliminate options 1 and 2. Eliminate option 3 because fruits are not adequate protein sources. |
3905 A client asks the nurse, "How can I best reduce Correct answer: 3 It is recommended that cholesterol intake be limited to 300 mg/day. No more than 10 cholesterol in my diet?" Which of the following is the percent of fats should be saturated. Checking labels is advisable but does not provide the client nurse's best response? with specific guidelines. Eggs can be eaten but should be limited to 2–3/week. ‐ "No more than 30 percent of your diet should come from saturated fats." ‐ "Check the labels on foods to identify cholesterol content." ‐ "Limit intake of cholesterol to 300 mg/day." ‐ "Do not eat any eggs or products containing eggs." | The question addresses reduction of cholesterol. Eliminate option 2 since it does not answer the client's question. Eliminate options 1 and 4 because they are incorrect. |
3906 When assessing a client's nutritional status, the nurse Correct answer: 4 Nitrogen balance refers to the concept of a balanced protein state in the body to support concludes that which of the following conditions is metabolism. A client who is in positive nitrogen balance is taking more nitrogen in and most likely to affect the action of protein in the body? excreting less nitrogen in order to meet metabolic needs (growth state with increased demands). Options 1 and 2 are incorrect because they represent normal range findings for sodium and potassium levels in the body. It is important to note that protein function does depend on the interaction of acid/base and serum electrolytes in order to function effectively, and the nurse must be alert to look at pertinent laboratory findings. A slight state of fluid overload (option 3) is less significant than a state of positive protein balance, which correlates directly with the question. ‐ Serum potassium level of 4.0 mEq/L ‐ Serum sodium level of 145 mEq/L ‐ A state of slight fluid overload ‐ A state of positive nitrogen balance | Note that options 1 and 2 are normal lab values and can be eliminated. Recall nitrogen is the core molecule of protein to choose option 4. |
3907 The nurse is teaching a client ways to reduce total fat Correct answer: 4 Vegetables, fruits, and grains in the diet are low in fat and are rich in nutrients and intake in the diet. The nurse instructs the client to phytochemicals. Option 1 is incorrect because trans‐fatty acids are associated with increased increase intake of which of the following to achieve cardiovascular risks. Option 2 is incorrect because the use of fish oil supplements can interfere this result? with bleeding times, diabetic state, immune status, and wound healing. A balanced level of omega‐3 and omega‐6 fatty acids is recommended in the diet using natural sources. Option 3 is incorrect because the process of hydrogenation increases the amount of trans‐fatty acid and would not be a prudent choice. ‐ Trans‐fatty acids ‐ Omega‐3 fatty acids via fish oil supplements ‐ Hydrogenated food products ‐ Vegetables, fruits, and grains | Note question addresses reduction of fats. Eliminate options 1 and 3 because they suggest increasing fats. Eliminate option 2 since it does not address fat intake. |
3908 When caring for a client with a diet history of high Correct answer: 1 Increased intake of animal protein may be associated with cardiac disease because animal animal protein intake, the nurse interprets that the food protein sources are also high in saturated fat content. Options 2 and 3 reflect clinical client is at risk for developing which of the following? conditions in which there are protein losses due to either intake or cell breakdown. Diabetes (option 4) is associated with excessive caloric intake or an autoimmune origin. ‐ Marasmus ‐ Diarrhea ‐ Cardiac disease ‐ Diabetes | Critical words are history of high animal protein intake and increased risk. Eliminate options 1 and 2 since they are associated with protein losses or deficits. Recall correlation of animal protein sources with fat to choose option 3. |
3909 A client has received teaching about the function of Correct answer: 2 Lipids are not a primary energy source but rather serve as an energy reserve in the body. lipids in the body. The nurse determines further CHOs are the primary energy source of the body. Options 1, 3, and 4 are incorrect as they all information is required when the client states that represent functions of lipids in the body (e.g., part of cell membranes, support of internal fats: organs, and insulation). ‐ Are an integral part of cell membranes. ‐ Act as the primary source of energy in the body. ‐ Support and cushion internal organs. ‐ Maintain temperature by providing insulation. | This question requires identifying one incorrect answer, as 3 options are correct. Recall options 1, 3, and 4 are normal functions of fat and eliminate them. |
3910 Which of the following artificial sweeteners would Correct answer: 2 A client with PKU has a genetic condition that prevents the utilization and conversion of the the nurse recommend for a client who has amino acid phenylalanine, leading to increased levels with toxic clinical manifestations. The phenylketonuria (PKU)? product Sweet ’n’ Low contains saccharin as the sweetening agent, which will not cause problems for the PKU client. All of the other options are incorrect, because both Equal and Nutrasweet (options 1 and 3) contain aspartame (option 4) as their active ingredient. Aspartame contains aspartic acid, a methyl group, and phenylalanine. Intake of these products can be dangerous for a client who has a clinical diagnosis of PKU; warning labels are found on packages of these food products denoting this fact. ‐ Equal™ ‐ Sweet ‘n’ Low™ ‐ Nutrasweet™ ‐ Aspartame | The question requires specific recall of PKU and the content of artificial sweeteners. If you had difficulty answering the question, review this content. |
3911 A food diary indicates that a client is taking in an Correct answer: 315 Each gram of fat supplies 9 kcal. Multiply the 9 kcal by 35 (the number of daily grams of fat in average of 35 grams of fat per day. The nurse the diet) to obtain a result of 315 kcal. (9 3 35 = 315) calculates that the client is obtaining kilocalories from fat in the daily diet. Write in a numerical answer. | The core issue of the question is knowledge that each gram of fat contains 9 kilocalories. Take time to become familiar with these basic nutritional facts if this question was difficult. |
3912 The nurse is preparing to teach a group of 16‐year‐ Correct answer: 2 Essential nutrients are needed by the body in their original form, as the body cannot olds in a health class about essential nutrients. Which synthesize them from other materials in the body. Option 1 is incorrect because an essential of the following statements would the nurse use to nutrient does not provide all the necessary energy requirements for the body. Option 3 is best describe the concept of an essential nutrient? incorrect since essential nutrients differ in their amounts of fat, protein, and carbohydrates. Option 4 is incorrect because this statement describes a nonessential nutrient. ‐ "An essential nutrient provides all the necessary energy requirements for the body." ‐ "Nutrients that are essential are supplied to the body in their active form, as the body cannot synthesize them from other sources." ‐ "An essential nutrient provides the same amount of fat, protein, and carbohydrates." ‐ "An essential nutrient can be synthesized in the body from precursor forms." | Note the word best, indicating all or some options may be correct, but one provides a more thorough answer. Options 2 and contain similar concepts, but recall essential nutrients cannot be synthesized to choose option 2. |
3913 Which of the following statements would indicate to Correct answer: 3 Most healthy clients are able to meet their vitamin requirements through dietary intake. the nurse that client teaching regarding vitamins has Option 1 is incorrect as vegetables are usually very good sources of vitamins. Option 2 is been successful? incorrect because even though a banana has vitamin activity (A, C, K, and folate), the client is taking this to replace potassium losses incurred with the use of a diuretic. Option 4 is incorrect since vitamin needs are usually able to be met from food substances along with proper diet. ‐ "I need to eat small amounts of vegetables because they are not good vitamin sources." ‐ "I will eat a banana each day after taking my water pill." ‐ "As long as I eat a well‐balanced diet, I should be able to meet my vitamin requirements." ‐ "I will have to take vitamin supplements to meet my vitamin requirements." | The critical word is vitamin. Eliminate option 1 since it is incorrect and eliminate option 2 since it relates primarily to potassium replacement. Recall that food intake should be the first choice for intake of nutrients to direct you to option 3. |
3914 A client complains of oral discomfort. When the Correct answer: 2 B complex vitamin deficiencies can often present with clinical presentations affecting the physical examination reveals cheilosis and glossitis, the mouth and tongue resulting in cheilosis (inflammation of mucous membranes in the mouth nurse should instruct the client to increase intake of and lip) and glossitis (inflammation of the tongue). The other options are not associated with which of the following? this presentation. ‐ Fat‐soluble vitamins ‐ B complex vitamins ‐ Sodium and potassium ‐ Vitamin A | Critical words are cheilosis and glossitis. Note that the question asks for an increased intake of something, indicating a deficiency exists. Recall knowledge of these conditions to direct you to option 2. |
3915 A client has just been diagnosed with night blindness. Correct answer: 1 Night blindness is often the first indicator that a clinical deficiency of vitamin A exists in the The nurse should place the highest priority on body. Correction with vitamin A at the time of early clinical diagnosis will correct the clinical reinforcing with the client with which of the following condition. Option 2 is incorrect because this condition is not permanent if nutrient deficiency is pieces of information? detected and treatment is started. Option 3 is incorrect as this does not require long‐term hospitalization. Option 4 is incorrect because this condition is not caused by an allergic reaction and therapeutic treatment is needed to correct this problem. ‐ "This is only a temporary condition that can be reversed with effective medical treatment of vitamin A." ‐ "This condition will be permanent so a referral is needed for occupational therapy to assist you with living with this type of deficit." ‐ "Long‐term hospitalization may be needed for this condition." ‐ "This condition usually resolves spontaneously and is often a result of an allergic reaction." | Critical words are night blindness and highest priority. Recall that this condition is related to vitamin A deficiency to direct you to option 1. |
3916 When caring for homebound clients the home health Correct answer: 1 A homebound client may be more at risk to develop a vitamin D deficiency because sunlight nurse recognizes the need to assess for deficiency of plays a part in the activation of vitamin D in the body. The other options are not related to which of the following vitamins? being indoors on a consistent basis. ‐ D ‐ A ‐ C ‐ E | Recognize the clients are homebound and therefore unable to go outside. Recall the need of sunshine for Vitamin D synthesis to choose option 1. |
3917 Because a client being treated for potassium Correct answer: 1 A client who does not respond appropriately to potassium therapy often has coexisting deficiency is not responding to treatment, the nurse calcium and magnesium deficiencies as well. It is important to assess for each of these three should assess for which of the following additional electrolytes in order to correct the disturbance. Option 2 is incorrect because the client may nutrient deficiencies? be experiencing a higher level of phosphorus due to the inverse relationship that exists between it and calcium. Options 3 and 4 are incorrect as neither is related to potassium deficiency. ‐ Calcium and magnesium ‐ Phosphorus and vitamin D ‐ Chromium and selenium ‐ Vitamins C and E | Critical words are potassium deficiency and additional nutrient deficiencies. Recall the role of other electrolytes in cellular metabolism and neuromuscular transmission to be directed to option 1. |
3918 In order to promote the absorption of calcium, the Correct answer: 3 Absorption of calcium in the diet can be promoted by acidic foods. All of the other options nurse encourages a client taking calcium supplements would lead to a state of decreased absorption of calcium. The fiber in beans, oxalates in to take the pills with: spinach, and protein in beef would reduce the absorption of the calcium. ‐ Beans. ‐ Spinach. ‐ Beef. ‐ Orange juice. | The critical words are promotes absorption and calcium. Recognize that the foods that block or inhibit calcium are the first 3 options and eliminate them. |
3919 A client has been instructed on foods that interfere Correct answer: 4 Several dietary factors can reduce the absorption of iron in the body, including tannins found with the absorption of iron in the diet. The nurse in coffee or tea. All of the other options will lead to increased absorption of iron in the diet. determines the teaching was effective when the client states he will avoid taking the pills with: ‐ Grape juice. ‐ Poultry. ‐ Cheese. ‐ Coffee or tea. | This is a negative response question indicating there are three correct responses and one incorrect. Recall factors which interfere with absorption of iron to be directed to option 4. |
3920 A premenopausal client is concerned about Correct answer: 4 A pre‐menopausal client should take 1,500 milligrams of calcium per day as a standard developing osteoporosis in the future. What dietary recommendation. Dietary sources are recommended rather than calcium supplements suggestions could the nurse give to help prevent this because they differ in their absorption due to bioavailability. Option 1 is incorrect because an occurrence? increase in protein levels can lead to a decrease in absorption of calcium. Option 2 is incorrect as additional fluids will not help to increase calcium levels. Option 3 is incorrect because supplementation is not advised as a primary dietary treatment and can lead to the development of other potential imbalances. ‐ "Increase the amount of dietary protein to strengthen existing bones." ‐ "Increase fluid intake to maintain hydration." ‐ "Take Tums™ as an additional source of calcium in the diet." ‐ "Increase the amount of high calcium foods to obtain a daily intake of 1,500 milligrams per day." | Critical words are premenopausal, osteoporosis, and dietary suggestions. Recognize the factors affecting calcium absorption to eliminate option 1. Eliminate option 2 since this will not affect calcium and option 3 since the question specifically asks for dietary suggestions. |
3921 Because a client has recognized that large doses of Correct answer: 1 High zinc levels in the body can cause development of a copper deficiency. The other choices zinc aid in wound healing, the nurse should plan to are not affected by high levels of zinc. assess for signs of which of the following deficiencies? ‐ Copper ‐ Fluoride ‐ Chromium ‐ Sodium | Critical words are zinc and signs of deficiency. Note that all options contain other minerals and recall knowledge of these. Recognize factors affecting absorption of these minerals to be directed to option 1. |
3922 A client who works in a mine presents to the Correct answer: 2 Occupational exposure to the manganese can result from dust inhalation and can have Emergency Department with neurological problems. profound neurological effects. The other options would not be applicable to this client. The nurse suspects which mineral imbalance could be a likely cause for this presentation? ‐ Fluoride ingestion ‐ Inhalation of manganese dust ‐ Excess copper inhalation ‐ Sodium deficiency due to dehydration | Critical words are mine and neurological problems. Note that options 2 and 3 contain the word inhalation, which correlates to confinement in a mind. Recall knowledge of manganese sources to be directed to option 2. |
3923 A client informs the nurse he takes 3 grams of vitamin Correct answer: 2 Increased intake of vitamin C can increase risk for stone formation. The daily recommended C a day to prevent "catching a cold." Which of the dose is 90 mg per day. The increased vitamin C intake would not impact the other options. following client conditions would be of concern to the nurse? ‐ An iron deficiency anemia ‐ A history of kidney stones ‐ Occasional anginal episodes ‐ A history of cholecystitis | Knowledge of normal requirements is necessary. Recognize 3 grams is excessive and, being water soluble, the vitamin will be excreted via the kidneys to direct you to option 2. |
3924 The nurse would encourage which of the following Correct answer: 1, 3, 5 Good food sources of thiamine include wheat germ, lean pork, beef, liver, and whole and foods to the client with a deficiency in thiamine? enriched grains, seeds, nuts, and a few vegetables. Select all that apply. ‐ Sunflower and sesame seeds ‐ Citrus fruits ‐ Lean pork, beef, and liver ‐ Strawberries ‐ Peanuts | Refer to the similar options of 4 and 2, including fruits. In this case the similar options are incorrect and should be eliminated. |
3925 A client who abuses alcohol presents with significant Correct answer: 2 Clients who abuse alcohol are prone to develop thiamin deficiency because ethanol affects mental status changes and loss of balance. Which the intestinal absorption of thiamin. Wernicke‐Korsakoff syndrome is associated with a state of vitamin deficiency does the nurse suspect as the encephalopathy that is seen in clients with alcoholism and presents with mental status possible cause of this presentation? changes, psychosis, and coma. Option 1 is incorrect because vitamin C deficiency is associated with scurvy. Option 3 is incorrect because riboflavin deficiency is associated with ariboflavinosis. Option 4 is incorrect because niacin deficiency is associated with pellagra. ‐ Vitamin C ‐ Thiamin ‐ Riboflavin ‐ Niacin | Critical items in the question are alcohol and neuronal symptoms. Recall knowledge of vitamin absorption and alcohol intake to choose option 2. |
3926 The nurse determines that dietary teaching has been Correct answer: 4 Processed foods have the highest sodium content. Chocolate pudding is the only option that effective when a client states that which of the reflects a processed food item. Meat and milk are animal products and as such have following food items has the highest sodium content? physiological saline. Fresh fruit is lowest in sodium. ‐ Milk ‐ Fresh fruit ‐ Meats ‐ Chocolate pudding | Recall sodium is found in processed foods and many snack foods to direct you to option 4. |
3927 The nurse is teaching a client with type 2 diabetes Correct answer: 1 Chromium is helpful in maintaining glucose homeostasis by enhancing the activity of the mellitus about blood glucose control. The nurse would hormone insulin. The other options are sources of vitamins and not minerals. include in the discussion that it is important to take adequate amounts of which of the following in the diet or in supplements? ‐ Chromium ‐ Biotin ‐ Niacin ‐ Sodium | Identify the unique option 1 and associate it with the core issue (mineral) in the stem of question. |
3928 The clinic nurse is completing a history and physical Correct answer: 2 Iodine is predominately found in the thyroid gland, which secretes thyroid hormones that examination on a client who has a history of thyroid affect the body’s metabolic rate. The other options are not associated with thyroid problems. problems. The nurse assesses this client for signs of Other minerals that might be affected include sodium, potassium, iron, and calcium, which potential mineral imbalance? depending on the underlying presentation. ‐ Magnesium ‐ Iodine ‐ Zinc ‐ Selenium | Recall normal thyroid function requires iodine to produce the hormone thyroxine to choose option 2. |
3929 During a routine history and physical examination, the Correct answer: 2 Clients who exhibit behaviors of eating nonfood items such as ice, clay, and dirt are likely to client reports the desire to eat large amounts of ice have iron deficiency. This odd symptom presentation is often the first indicator that there may (two 8‐ounce cups) during the day. This nurse assesses be a potential problem. Option 1 is incorrect because a client who is dehydrated would be the client for other manifestations of which of the more apt to drink fluids than ice chips. Option 3 is incorrect because there is nothing to following possible underlying clinical conditions? indicate that the client is suffering from a protein deficiency. Option 4 is incorrect because the client is not ingesting sufficient fluid to dilute the serum sodium level. ‐ Water deficiency due to dehydration ‐ Iron deficiency associated with pica ‐ Malnutrition due to protein deficiency ‐ Sodium deficiency due to ingestion of ice | Critical phrases desire to eat, indicating a craving and also possible, indicating there is not an absolute cause and effect. Eliminate option 4 since the sodium deficiency would be caused by the excessive water intake and not produce a craving for it. Eliminate option 3 as ice is not a source of protein. Recall pica is food craving for nonfood items to choose option 2. |
3930 The nurse who is teaching a prenatal class about the Correct answer: 4 Folic acid deficiencies have been proven to cause neural tube defects in the developing fetus. need for vitamin supplements includes that deficiency Option 1 is incorrect because high levels of folic acid can prevent identification of vitamin of folic acid can lead to which of the following? B<sub>12</sub> deficiency. Option 2 is incorrect because high homocysteine levels are associated with folic acid and other B vitamin deficiencies. Option 3 is incorrect because folic acid deficiency results in a macrocytic anemia. ‐ Masking of vitamin B12 deficiency ‐ Decreased homocysteine levels ‐ Microcyctic anemia ‐ Neural tube defects | Recall functions of folic acid in the body to choose option 4. |
3931 When conducting discharge teaching for a client who Correct answer: 2 Pernicious anemia is due to a clinical deficiency of intrinsic factor that prevents the is at risk for pernicious anemia because of absorption of vitamin B<sub>12</sub> in the body. This commonly occurs following gastrectomy, the nurse reinforces that the client will gastrectomy. Thus, for treatment to be effective, vitamin B<sub>12</sub> must be require which of the following for preventive administered via injection for the rest of the client’s life. Options 1 and 3 are incorrect because treatment? niacin is unrelated to pernicious anemia, and iron will not correct pernicious anemia. Option 4 is incorrect because riboflavin is not related to the issue of pernicious anemia and riboflavin is administered orally. ‐ Niacin supplementation for lifetime ‐ Vitamin B12 injections for lifetime ‐ A single dose injection of ferrous sulfate to correct the condition ‐ Riboflavin injections monthly for at least a year | Refer to the core issue in the question of the client with pernicious anemia. Pernicious anemia is associated with the intrinsic factor as well as vitamin B<sub>12</sub>itself. |
3932 A client taking folate supplements reports to the Correct answer: 3 This is a normal finding with folate. Increasing water intake might dilute the urine and make it nurse her urine is very dark yellow and she is quite less yellow, but this response does not provide reassurance this is a normal reaction. Reducing concerned that. Which response by the nurse is amount of folate may not reduce the color. It does not need to be reported. appropriate? ‐ "You probably need to drink more water." ‐ "You probably need to reduce the amount of folate you are taking." ‐ "Folate can cause your urine to be a deep yellow color." | Eliminate option 1 since the question relates to the intake of folate. Eliminate option 4 since it is not a serious threat. Knowledge of normal folate action directs you to option 3. |
4.‐ "You should report this finding to your physician." | |
3933 The nurse encourages a client with macrocytic Correct answer: 2 Vitamin B<sub>12</sub> deficiency can result in the development of a macrocytic nutritional anemia to increase intake of which of the nutritional anemia because it is necessary for red blood cell production in the body. Option 1 is following micronutrients? incorrect because: A deficiency of calcium leads to bone demineralization. Option 3 is incorrect because iron deficiency results in a nutritional anemia that is microcytic. Option 4 is incorrect since vitamin B<sub>1</sub> (thiamin) clinical deficiency results in beriberi. ‐ Calcium ‐ Vitamin B12 ‐ Iron ‐ Vitamin B1 | Recall knowledge of macrocytic anemia to answer to direct you to option 2. |
3934 The nurse tells the mother of a newborn infant who Correct answer: 1 Infants receive an injection of vitamin K to protect them against the development of received an injection of phytonadione hemorrhagic disease of the newborn. Infants are born with a sterile gut and are therefore (AquaMEPHYTON) in the delivery room that this unable to synthesize vitamin K in the small intestines. A single injection of vitamin K helps to injection is the same as vitamin K, which will prevent introduce enough of the vitamin so that the infant is afforded protection. All of the other development of which clinical condition? options are incorrect because this drug has no clinical impact on these clinical conditions. ‐ Hemorrhagic disease of the newborn ‐ Hepatitis B ‐ Skin infections in the newborn ‐ Dehydration | Recognize that AquaMEPHYTON is vitamin K, which plays a role in the clotting process to direct you to option 1. |
3935 While obtaining a stool specimen for a guaiac test, Correct answer: 3 Clients who take more than 1 gram of vitamin C daily may have a false negative result on the nurse discovers that the client has been taking stool guaiac testing. It is important for the nurse to understand that the test results will be large doses of vitamin C for the past several days. The inconclusive and should be repeated in a few days once the client has stopped taking the nurse considers which of the following information additional vitamin C. Option 1 is incorrect because there is a relationship between the testing when deciding what action to take? chemical reaction. Option 4 is incorrect because the results are not valid and not open to interpretation due to drug interactions. ‐ There will be no effect on the test results. ‐ The test may show in a false positive result. ‐ The test may show in a false negative result. ‐ The test results will be open to interpretation. | The question asks what effect the vitamin C will have, implying an effect will occur, so eliminate option 1. Eliminate option 4 as being too vague. Recall knowledge of vitamin C to choose option 2. |
3936 A child presents with bowed legs and a pigeon breast Correct answer: 2 A clinical deficiency of vitamin D during childhood can result in structural deformities that on physical examination. The nurse suspects these result in a clinical diagnosis of rickets. The other options will not cause this type of structural deformities to be caused by a deficiency of which of deformity. the following nutrients? ‐ Vitamin A ‐ Vitamin D ‐ Folic acid ‐ Phosphorus | Critical words are bowed legs and pigeon chest, indicating a bone malformation. Recall knowledge of bone development to choose option 2. |
3937 The nurse concludes that a client has an adequate Correct answer: 1 Baked potato and broccoli are high in potassium. All of the other options reflect food sources understanding of potassium‐rich foods when the client that are lower in potassium. makes which of the following selections from a luncheon menu? ‐ Baked potato topped with broccoli and cheese ‐ Grilled cheese sandwich and pretzels ‐ Pasta salad and roll ‐ A bagel with cream cheese and dill pickle | Option 1 includes two sources of potassium and therefore a more comprehensive answer. |
3938 Which nutrient deficiencies might the nurse expect to Correct answer: 1 Whole grain products can contain large amounts of phytic acid (phytates), which can limit the see in the client who reports eating a large number of absorption of several nutrients: calcium, zinc, iron, and magnesium. Options 2 and 3 are whole grain products in the diet? incorrect because phytic acid is composed of inorganic phosphate compounds. Option 4 is incorrect because phytic acid does not affect either sodium or chloride levels. ‐ Calcium, zinc, iron, and magnesium ‐ Calcium and phosphorus ‐ Calcium, vitamin D, and phosphorus ‐ Sodium and chloride | Critical words are nutrient deficiencies and grain products. Recall specific information on phytates to choose option 1. |
3939 A client diagnosed with anemia who is being treated Correct answer: 3 Anemic clients who do not respond to iron replacement therapy and present with symptoms with iron replacement therapy is not responding to associated with neuropathy are likely to be suffering from an underlying vitamin clinical treatment and reports tingling and paresthesias B<sub>12</sub> deficiency. Option 1 is incorrect because, even if the client were of the extremities. The nurse questions the client to not being compliant, these types of symptoms would be due to an associated clinical determine if the client: deficiency. Option 2 is unrelated to any information presented in the question. Option 4 is incorrect because the use of vitamin C supplements would cause symptoms of iron overload since it enhances the absorption of iron. ‐ Is compliant with iron replacement therapy. ‐ Has an underlying medical condition of diabetes that is complicating the course of treatment. ‐ May also have a vitamin B12 deficiency that may account for presentation of neuropathy symptoms. ‐ May be taking vitamin C supplements that may account for presentation of neuropathy symptoms. | Recognize the symptoms are indicative of peripheral neuropathy to direct you option 3. |
3940 Which of the following symptoms, if seen in a client Correct answer: 2 Peptic ulcer disease can be aggravated by niacin, and the clients' complaints of heartburn are who takes large doses of over‐the‐counter niacin to indicative of GI irritation. Flushing is a side effect and although uncomfortable, it would not be treat high cholesterol, would be of most concern to as serious as gastric irritation. Dryness of the mouth is not life threatening. Diarrhea would be the nurse? a symptom of niacin deficiency. ‐ Warmth and flushing of the skin ‐ Heartburn and abdominal fullness ‐ Dryness of the mouth ‐ Occasional diarrhea | The critical words in the stem of the question are of most concern. This tells you that more than one option may be correct and that you must choose the most important option. Recall niacin causes GI irritation to direct you to option 2. |
3941 The nurse is assessing the dietary intake of a client Correct answer: 1 Avidin is a protein found in raw eggs that binds with biotin and decreases absorption of this with a biotin deficiency. The nurse identifies that the vitamin. Options 2 and 3 represent foods that are high in biotin; option 4 is high in vitamin C. frequent intake of which of the following foods may have contributed to the deficiency? ‐ Raw eggs ‐ Liver ‐ Dark green vegetables ‐ Citrus fruits | Critical words are frequent intake and biotin deficiency. If specific recall of biotin is poor, recognize raw eggs are not advised to choose option 1. |
3942 The nurse is instructing a client who has been started Correct answer: 2 Heme iron is considered to be the most absorbable form of iron in the body. In order to on iron supplements. In order to increase absorption maximize absorption of iron, meat, fish, poultry, and ascorbic acid (vitamin C) can be used. of the iron, the nurse suggests the client take them Milk would interfere with absorption of the iron, some green leafy vegetables contain oxalate, with which of the following? which also interferes with absorption. Water would not increase absorption. ‐ Milk ‐ Orange juice ‐ Green leafy vegetables ‐ A full glass of water | Critical words in the question are increased absorption. Recall iron absorption is increased by ascorbic acid to choose option 2. |
3943 When caring for a client experiencing catabolism, the Correct answer: 3 The catabolism of fats provides the most energy (460 molecules of Adenosine triphosphate) nurse encourages intake of which nutrient to generate because they are the most concentrated energy source (9 kilocalories per gram). Option 1 is the most energy? incorrect because vitamins do not yield energy although they function as coenzymes in metabolic processes. Options 2 and 4 are incorrect as both proteins and carbohydrates provide 4 kilocalories per gram. ‐ Vitamins ‐ Proteins ‐ Fats ‐ Carbohydrates | Critical words are catabolism, nutrients, and energy. Recall the kilocalorie per gram yield to be directed to option 3. |
3944 The nurse suspects a client with a history of alcohol Correct answer: 3 Vitamin B deficiency can be manifested as peripheral neuropathy, usually experienced as abuse has a vitamin B deficiency when the client numbness, tingling, and pain in the extremities. Options 1 and 4 can be related to several reports which of the following? factors. Option 2 is frequently seen in clients with gastritis or gastroesophageal reflux disease, secondary to excessive alcohol intake. ‐ Frequent headaches ‐ Epigastric burning ‐ Numbness in the fingers ‐ Constipation | Critical concepts are alcohol abuse and vitamin B deficiency. Recall the symptoms of Vitamin B deficiency to eliminate options 1 and 4. Recognize option 2 may be secondary to the alcohol use, but not to a vitamin deficiency and eliminate it also. |
3945 A client has received dietary teaching on the nutrient Correct answer: 2 Alcohol contains 7 kilocalories/gram and provides energy from these calories, but is content of various foods and beverages. The nurse considered a non‐nutrient because it is not needed by the body. Option 1 is incorrect because determines the teaching has been effective when the alcohol provides calories but is not high in protein. Option 3 is incorrect as it is not a client states that a glass of wine is: concentrated fat source. And option 4 is incorrect because alcohol provides energy but not protein. ‐ High in protein and calories. ‐ Considered a non‐nutrient food. ‐ A source of concentrated fat calories. ‐ A good source of energy and protein. | Critical words are nutrient content and wine. Recall the make‐up of wine to eliminate options 1, 3, and 4, since they are only partially correct. |
3946 The nurse provides which of the following suggestions Correct answer: 1 Foods known to decrease the lower esophageal sphincter (LES) allowing reflux of gastric acid for dietary modifications to reduce symptoms in a include chocolate, alcohol, coffee, tea, spearmint, and peppermint. Options 1 and 4 are client with gastroesophageal reflux disorder (GERD): incorrect because fruit juices and high fiber foods do not decrease the LES. Option 3 is incorrect as dairy products would not need to be increased. ‐ "Avoid eating chocolate and peppermint." ‐ "Restrict your intake of fruit juices." ‐ "Increase your intake of dairy products." ‐ "Eat high‐fiber foods in moderation." | Critical terms are dietary modifications and GERD. Recall the physiology of GERD to be directed to option 1. |
3947 A client receiving large amounts of antibiotics has Correct answer: 3 Prebiotics are supplements that stimulate bacterial growth, often in the colon, which has been started on prebiotics. When the client asks what been destroyed by antibiotic therapy. Probiotics are given to boost the immune system. this is for the nurse explains, “It will: Because they help to restore normal bacterial flora, they may prevent diarrhea, but this is not how they work. They do not destroy bacteria. ‐ Help to boost your immune system." ‐ Prevent the antibiotic from causing diarrhea." ‐ Help to restore normal bacterial in your body." ‐ Destroy bacteria that are not killed by the antibiotic." | Critical words are antibiotics and prebiotics. Note the similarity in endings of both words, but differences in the prefix and eliminate option 4. Recall the function of prebiotics to be directed to option 3. |
3948 When caring for a client with hyperthyroidism, the Correct answer: 2 Due to the increased rate of metabolism associated with hyperthyroidism, additional calories nurse will consult with a dietitian to consider the are needed to meet increased energy needs. Protein may be increased, but overall calories are client's need for: needed for energy. Vitamin supplements and iron are not necessary provided dietary intake is adequate. ‐ Increased protein. ‐ Increased energy. ‐ Vitamin supplements. ‐ Iron supplements. | Recall that the thyroid gland regulates cellular metabolism to be directed to option 2. |
3949 The nurse identifies which of the following clients to Correct answer: 2 Fever increases basal metabolic rate (BMR) approximately 7 percent for each one degree rise have an increased metabolism and plans for additional in temperature. Option 1 is incorrect as metabolism is reduced in hypothyroidism. Option 3 is caloric intake? The client: incorrect because although the energy needs of the post‐op client are needed for wound repair, activity is reduced and client is NPO the first day. Option 4 is incorrect since metabolism decreases with age and fat cells require less energy than lean tissue. ‐ Just diagnosed with hypothyroidism. ‐ With a fever of 102° F. ‐ Who is one day post‐op colon resection. ‐ Who is elderly and obese. | Critical words are increased metabolism and additional caloric intake. Read each option and systematically eliminate options 1, 3, and 4 since metabolism is reduced. |
3950 The nurse anticipates alterations in weight secondary Correct answer: 1 Hyperthyroidism causes an increase in the production of thyroxine, which in turn increases to altered hormone levels in the client with which of metabolism and utilization of energy, often leading to weight loss. Osteoporosis does not the following conditions? produce a change in hormone levels and cause weight changes. Weight loss may be associated with options 3 and 4 secondary to anorexia and vomiting, but not due to hormone imbalances. The gall bladder stores and secretes bile for digestion and the pancreas secretes digestive hormones. In severe cases of pancreatitis, the production of the hormone insulin may be affected as well. ‐ Hyperthyroidism ‐ Osteoporosis ‐ Cholecystitis ‐ Pancreatitis | Critical words are weight and altered hormones. Read each option and recognize that the thyroid gland secretes hormones related to metabolism to choose option 1. |
3951 The nurse is discussing dietary modifications with a Correct answer: 2 Foods known to produce gas, such as carbonated beverages, vegetables, milk products, client experiencing irritable bowel syndrome (IBS) and caffeine, and high fat and fat substitutes, can cause symptoms of IBS. A high protein diet is not offers which of the following suggestions? known to contribute to IBS. Fiber in the diet would not be contraindicated. Cholesterol is avoided with coronary heart disease. ‐ "Eat a diet high in protein." ‐ "Limit your intake of products containing caffeine." ‐ "Consume a low‐fiber diet." ‐ "Avoid eating foods high in cholesterol." | Critical words are dietary modifications and IBS. Recall foods that increase gas production and are irritating to the gastrointestinal tract should be restricted or avoided to be directed to option 2. |
3952 The nurse concludes that which of the following Correct answer: 3 Ketone production in the body can be seen in response to dehydration, starvation, low conditions most likely contributed to the formation of carbohydrate states, and metabolic conditions such as diabetes. Option 1 is incorrect because ketones in an assigned client? the presence of ketones reflects an acidic medium because ketones are composed of keto acids. Option 2 is incorrect as adequate carbohydrates prevent the formation of ketone bodies. Option 4 is incorrect because increased fluid intake decreases the likelihood of ketone production in the body. ‐ Metabolic alkalosis ‐ Adequate carbohydrates in the diet ‐ Dehydration ‐ Increased fluid intake | Recall conditions that lead to the break down of fatty acids for energy production to be directed to option 3. |
3953 The nurse would explain to a client who underwent Correct answer: 4 Meals that are high in carbohydrates, such as the meal in option 4, promote rapid gastric gastric resection that which of the following meals is emptying. The other options are associated with increased transit time because they contain most likely to cause rapid emptying of the stomach? sources of protein or fat, and meals of these types remain in the stomach for a longer time. ‐ Broiled steak and green beans ‐ Fried chicken and creamed potatoes ‐ Baked fish and fresh carrots ‐ Pasta with broccoli and garlic bread sticks | Recall gastric resection reduces size of stomach and review physiology of food metabolism. Note CHO will increase osmotic load, which will promote peristalsis, to choose option 4. |
3954 The nurse is caring for a client at risk for short bowel Correct answer: 3 The increased surface area of the microvilli on the brush border of the small intestine favors syndrome. The nurse would choose which of the the process of absorption by increasing the surface contact area. Option 1 is incorrect since following statements to explain the role of the small there is specialization in the GI tract that allows for specific nutrient release in order to intestine in absorption of nutrients? maximize absorption. Option 2 is incorrect because the small intestine has an alkaline environment. Option 4 is incorrect because dietary fiber consists of undigested material that usually enters the large intestine for bacterial degradation and elimination as feces. ‐ "Nutrients are delivered to the small intestine in a rapid manner to facilitate absorption." ‐ "The acidic environment of the small intestine enhances digestive enzyme function." ‐ "Increased surface area of the microvilli on the lining of the intestine favors absorption of nutrients." ‐ "The small intestine is able to facilitate the absorption of dietary fibers." | Note the nurse is explaining the function of the small intestine in relation to its absorption function and needs to explain it in lay terms. Eliminate options 2 and 4 as incorrect; option 1 does not provide a clear explanation. |
3955 The nurse identifies the client who has which of the Correct answer: 4 Gastric surgical resection can cause an alteration in the absorption of nutrients due to altered following to be most at risk for malabsorption of surface area, thereby delaying entry of food from the stomach to the intestines (i.e., nutrients? decreasing absorption and digestion). Option 1 is incorrect because hypoactive bowel sounds might or might not affect absorption. Option 2 would affect fluid reabsorption in the large intestine, but most nutrients would have been absorbed before entering the large intestine. Option 3 may affect elimination patterns but does not affect the absorption of nutrients. ‐ Hypoactive bowel sounds ‐ Colon resection ‐ Rectal polyps ‐ Gastric surgical resection | Eliminate options 1 and 3 since these conditions would not affect nutrient absorption. Note option 4 involves the gastric area to direct you to it. |
3956 The nurse instructs the client who develops heartburn Correct answer: 3 Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure, leading to reflux as a result of gastroesophageal reflux disease (GERD) and clinical symptoms of GERD. All of the other foods do not affect LES pressure. to avoid which of the following foods? ‐ Lettuce ‐ Eggs ‐ Chocolate ‐ Butterscotch | The concept of the question is identification of foods that will complicate GERD. Recall the physiology of this to choose option 3. |
3957 Which of the following food items should the nurse Correct answer: 3 Antibiotic therapy can lead to destruction of normal intestinal flora that is used to synthesize recommend to facilitate intestinal synthesis of vitamin vitamin K. Yogurt contains bacteria that help to promote intestinal synthesis. The other options K for a client receiving antibiotic therapy? do not contain necessary bacteria. ‐ Eggs ‐ Wheat germ ‐ Yogurt ‐ Fish | Critical words are intestinal synthesis of vitamin K and antibiotic therapy. Remember that yogurt is a probiotic. |
3958 Which of the following foods should the nurse Correct answer: 2 Celiac disease is a malabsorption disorder affecting the small intestine in which there is a remove from the lunch tray of a client diagnosed with problem with the ingestion of gluten, a protein normally found in grain products such as celiac disease? wheat, rye, oats, or barley. The other options reflect substances that do not contain gluten and should not pose problems for a client with this disorder. ‐ Butter ‐ Beef barley soup ‐ Fresh yellow squash ‐ Coffee | Recall knowledge of celiac disease and foods containing gluten to direct you to option 2. |
3959 When caring for a client with a history of alcoholism, Correct answer: 1 Because of deficient nutritional intake, the client with alcoholism frequently has deficiencies the nurse checks laboratory values, anticipating of many nutrients. Electrolytes that are particularly affected are magnesium and phosphorus, deficiencies of which of the following micronutrients? since they are utilized in maintaining energy production and numerous enzyme reactions. ‐ Magnesium and phosphorus ‐ Sodium and potassium ‐ Magnesium and chloride ‐ Calcium and potassium | Key words are alcoholism, lab values, and deficiencies. Note all options have two answers and both must be correct for the option to be correct. Recall nutritional intake deficiencies associated with alcohol intake to direct you to option 1. |
3960 The nurse anticipates that which of the following Correct answer: 2 Clients who are in shock are likely to form lactic acid as the body reverts to anaerobic metabolic processes will most likely to occur in a client metabolism in order to maintain homeostasis. Options 1 and 2 are incorrect because these recently admitted in hypovolemic shock? represent metabolic processes that require oxygen (aerobic metabolism). Option 4 is incorrect because transamination involves the exchange of amine groups in amino acids and reflects an anabolic process. ‐ Gluconeogenesis ‐ Anaerobic metabolism ‐ Glycogenesis ‐ Transamination | Critical words are metabolic processes and hypovolemic shock. Recall concepts of shock and energy requirements to direct you to option 2. |
3961 A nurse teaching a group of 13‐year‐old students Correct answer: 2 Vitamins function as coenzymes in many of the metabolic processes in the body to facilitate about the role of vitamins in the metabolism of energy release. Options 1 and 3 are incorrect since by themselves vitamins do not provide nutrients would make which of the following energy or supply additional calories. Option 4 is incorrect—vitamins should not be consumed statements? in large quantities because they can reach toxic levels (fat‐soluble vitamins). ‐ "Vitamins are needed because they provide additional energy sources." ‐ "Vitamins are needed because they participate as enzymes in metabolic processes." ‐ "Vitamins are needed to supply additional calories." ‐ "Vitamins are needed in large quantities in order to prevent oxidation of vital nutrients." | Eliminate options 1 and 3 since both are similar concepts. Eliminate option 4 since this practice would be dangerous with certain vitamins. |
3962 A client who has a history of alcoholism is receiving Correct answer: 1 Clients with alcoholism are usually deficient in thiamine, which is needed for carbohydrate intravenous therapy with 5% dextrose in 0.45% sodium metabolism. Administration of glucose solutions can precipitate symptoms of Wernicke's chloride and a regular diet. When the client refuses the encephalopathy, characterized by disorientation, memory difficulties, diplopia, ataxia, and ordered thiamine supplement, the nurse should nystagmus. The other symptoms may be experienced for other reasons in the alcoholic client, monitor for which potential complication? but option 1 is most indicative of the thiamine deficiency. ‐ Confusion and ataxia ‐ Abdominal cramps and diarrhea ‐ Headaches and nausea ‐ Numbness and tingling in the extremitites. | Critical words are alcoholism and thiamine. Recall the role of thiamine in CHO metabolism, and recognize the client is receiving a dextrose solution to associate the symptoms of option 1 to Wernicke's encephalopathy. |
3963 The client with Crohn's disease is not following Correct answer: 1, 2, 3 Crohn's disease can occur at any location in the GI tract, and the most common clinical dietary recommendations. The nurse would expect to manifestations are diarrhea, abdominal pain, weight loss, and fatigue. The disease is not assess which of the following clinical manifestations in characterized by constipation or uremia. The amount of bulk or fiber in the diet is reduced this client? Select all that apply. during acute episodes to control the diarrhea. ‐ Diarrhea ‐ Abdominal pain ‐ Weight loss ‐ Uremia ‐ Constipation | Refer to similarities of indicators associated with the GI tract. Uremia is associated with renal disease and so cannot be a correct option. Constipation is opposite of the clinical findings in Crohn's disease and can thus be eliminated also. |
3964 The nurse would make which of the following Correct answer: 2 The inclusion of dietary fibers helps to add fecal weight (soluble) and bulking (insoluble), statements in explaining how dietary fiber aids in the which assists with elimination patterns. Option 1 is incorrect because fiber does not provide a processes of digestion, transport, and absorption? coating effect to the gastric lining. Option 3 is incorrect because dietary fiber can affect digestion of nutrients, especially when consumed in large amounts. Option 4 is incorrect because there is no evidence to support the practice of taking mineral oil with dietary fiber to facilitate digestion, transport, and absorption. ‐ "Fiber helps to coat the gastric lining of the stomach in order to decrease the acidic environment." ‐ "Soluble fiber adds weight to feces, and insoluble fiber acts as a bulking agent to assist in the elimination process." ‐ "A large amount of fiber in the diet has no effect on the digestion of nutrients." ‐ "Dietary fiber must be taken with mineral oil to be effective in facilitating nutrient digestion, transport, and absorption." | Note that each option contains the word fiber, so read each option carefully and systematically eliminate options 1, 3, and 4 as incorrect. Choose option 2 because it is comprehensive for processes of digestion. |
3965 Which of the following clients is at greatest risk for Correct answer: 4 A client with TMJ disorder is at risk for developing swallowing problems due to pain developing a digestive problem related to the oral experienced from incorrect jaw alignment. Option 1 is incorrect because this client would have cavity? problems related to the esophagus. Option 2 is incorrect because "fast food" ingestion does not cause digestive problems. Option 3 is incorrect because a client with wisdom teeth removal may have initial discomfort and swallowing problems, but they usually resolve as healing occurs. Clients with TMJ disorder are likely to have acute exacerbations that can become problematic, affecting dietary intake and leading to a significant complication such as weight loss. ‐ A 48‐year‐old male client with a history of gastric reflux ‐ An 18‐year‐old college student eating "fast food" for lunch ‐ A 20‐year‐old client who has past medical history of wisdom teeth removal ‐ A 50‐year‐old client with a history of temporomandibular joint (TMJ) disorder | Refer to options 3 and 4, which have similarities and association to the oral cavity. Choose option 4 because it is more comprehensive. |
3966 The nurse is performing a gastrointestinal assessment Correct answer: 1 Steatorrhea (bulky, foul‐smelling stool) is a common finding related to malabsorption of fats. on a client. Which of the following clinical findings Option 2 is incorrect because gastric emptying time would be decreased as nutrients pass would the nurse associate with malabsorption of fat? more quickly because they cannot be absorbed. Option 3 is incorrect because diarrhea and steatorrhea are more common findings. Option 4 is a nonspecific finding that is independent of fat malabsorption and may be related to other factors such as anemia and decreased oxygenation states. ‐ Steatorrhea ‐ Increased gastric emptying ‐ Constipation ‐ Pallor | The core concept is malabsorption of fat. Recall physiology of bile action on stool to direct you to option 1. If you had difficulty with the question, note similarity in ending of word steatorrhea and diarrhea. |
3967 What client statement would indicate that dietary Correct answer: 2 Eating late at night can lead to development of GI symptoms as increased presence of food in teaching has been effective in a client with the stomach leads to an increase in acid secretion. If the client lies down with a full stomach, it gastroesophageal reflux disease (GERD) regarding further causes gastric distention and aggravation of clinical symptoms. Option 1 is incorrect dietary practices to facilitate digestion? because use of a daily antacid can cause alterations in digestion, transport, and absorption of nutrients that can further increase GI discomfort. Option 3 is incorrect because there is nothing to indicate that this client has a problem with swallowing or dentition. Option 4 is incorrect because water and fiber are necessary in the diet to facilitate adequate elimination patterns. ‐ "I will continue to use antacids on a daily basis." ‐ "I will limit late‐night snacking to prevent GI symptoms." ‐ "I will cut up my food into very small pieces to make it easier to chew." ‐ "I will limit the amount of fluid and fiber in my diet." | Associate the client action (lying down) with definition of GERD (backflow of acidic gastric juices). |
3968 The nurse anticipates that which of the following Correct answer: 4 Catabolism refers to processes involving the release of energy in order to restore body clients admitted to the nursing unit is in the most dynamics and is seen in clients undergoing acute periods of starvation and/or traumatic injury. severe catabolic pattern of metabolism? The client in option 4 has the most severe triggering condition for catabolism. The client in option 1 would undergo catabolism, but this is a short‐term event compared to option 4. The clients in options 2 and 3 are in an anabolic pattern of metabolism representing growth states and new tissue development. ‐ A 12‐year‐old with acute appendicitis ‐ A 22‐year‐old pregnant client with slight painless vaginal bleeding ‐ A client who is 5 days postoperative for femoropopliteal bypass ‐ A client who was admitted 3 days ago with multiple trauma | Option 4 is more comprehensive than the other options offered. |
3969 The nurse expects that a client experiencing which Correct answer: 2 Lactic acidosis is associated with anaerobic metabolism All of the other options represent metabolic process will develop lactic acidasis? metabolic processes during which oxygen is required. ‐ Glycolysis ‐ Anaerobic metabolism ‐ Gluconeogenesis ‐ Oxidative phosphorylation | The core issue of the question is knowledge of the nature of lactic acidosis as a bodily process. Analyze each option in terms of its use of oxygen. |
3970 A client with a history of lactose intolerance confides Correct answer: 1 Lactose intolerant individuals usually lack the enzyme lactase, necessary to break down milk to the nurse she consumed a large amount of ice sugars. Lack of the enzyme causes abdominal cramps, diarrhea, and gas formation. The other cream at a social event. The nurse can expect the symptoms would not be caused by lack of lactase. client to experience: ‐ Bloating and diarrhea ‐ Constipation for 2–3 days ‐ Foul smelling, bulky stools ‐ A headache | Recall function of lactase to break down milk sugars and inability of this will result in formation of gas. Systematically eliminate options 1 and 3 as not due to abdominal gas formation. Eliminate option 2 since it is associated with lack of bile and pancreatic enzymes. |
3971 A client's urine tests positive for presence of kettle Correct answer: 4 Ketone bodies are formed in response to the incomplete breakdown of fatty acids, when bodies. The nurse concludes that this test result lipids are used as an alternate energy source in response to low ingestion of CHOs, high indicates which of the following? protein or high fat intake, or fasting states. The presence of ketone bodies is associated with acidotic states. ‐ Excessive intake of simple sugars in diet ‐ Decreased lipids in the diet ‐ An alkaloid condition in the body ‐ Inadequate carbohydrate intake in the diet | Recall ketone bodies are formed from fatty acid breakdown and recall conditions when body does this to direct you to option 4. |
3972 The nurse would explain to a client with celiac disease Correct answer: 3 Celiac disease is due to inability to digest gluten sources, such as found in wheat, rye, oats, that which foods are best to avoid to reduce flares of and barley products. All other options have an unrelated source of gluten. the disease? ‐ Wheat, corn, and rice ‐ Barley, soybeans, and corn ‐ Wheat, barley, and rye ‐ Rice, oats, wheat | Refer to the sources of gluten in option 3. |
3973 A client continues to be an avid runner during her Correct answer: 3 Dizziness is a sign of overexertion and as such should alert the client to alter her present pregnancy. The nurse realizes that which of the exercise regimen. Option 1 is incorrect because decreased, not increased, fetal movement is following symptoms indicates the client needs to alter sign of overexertion due to decreased oxygen supply. Option 2 is incorrect as headache may the intensity of her exercise routine? occur for many other reasons and is not necessarily correlated with overexertion. Option 4 is incorrect because diaphoresis is a normal response to exercise. ‐ Increased fetal movement ‐ Headache ‐ Dizziness ‐ Increased diaphoresis | Key concepts are pregnancy and exercise intolerance. Recall the normal response to exercise to be directed to option 3 as being a danger sign. |
3974 A 23‐year‐old postpartum client is breastfeeding. The Correct answer: 2 Protein needs increase by 20 grams during lactation, and therefore protein‐rich foods should nurse has completed teaching about dietary changes be consumed. Option 1 is incorrect because caloric needs only increase by 500 calories during and is evaluating teaching effectiveness. Which of the lactation, and a 750 calorie increase would result in weight gain. Option 3 is incorrect as it is following statements by the client indicates the unwise to decrease calories during the pregnancy period because the mother's nutritional teaching was effective? stores will be depleted. Option 4 is incorrect because if a diet is adequate in calcium, then supplementation is not needed; the requirement is the same for similar‐aged lactating and non‐ lactating women. ‐ "I need to increase my caloric intake by about 750 calories per day." ‐ "I need to increase my consumption of protein‐rich foods such as legumes." ‐ "Now is the time to decrease my calories so I can lose my pregnancy weight." ‐ "My calcium consumption must increase to be able to produce the milk." | Key words are breastfeeding and dietary teaching. Eliminate options 3 and 4 as incorrect information. Eliminate option 1 since this is too high. |
3975 A client has chosen to formula feed her infant. The Correct answer: 1 Formula must be prepared according to manufacturer's directions to ensure that adequate nurse realizes that which of the following statements nutrients are received. All of the other options reflect adequate client teaching. by the client indicates further teaching is needed? ‐ "I can make the dry powder formula last longer by adding more water." ‐ "I can expect my baby to eat about six to eight times per day." ‐ "My baby will still be getting adequate nutrition with the formula." ‐ "I need know hunger cues to prevent overfeeding. Formula‐fed infants tend to gain weight faster." | The key concept is formula feeding. This question is a negative response type indicating that three options are correct and the incorrect response is the correct answer. Recall knowledge of formula feeding to choose option 1. |
3976 A full‐term infant is being formula fed. At the one‐ Correct answer: 1 Most infants feed 6–8 times per day and consume 2–4 ounces per feeding. This infant does week checkup, the infant's mother reports to the not seem to be feeding often enough. A likely explanation is a sleepy infant who is not being nurse that the infant consumes 10 ounces per day in roused frequently enough for eating. Options 2 and 3 are incorrect because the intake pattern about four feedings. Which of the following is not acceptable. Option 4 is incorrect as it presumes that there is a more serious problem statements by the nurse is most appropriate? than is reflected by the information provided. ‐ "Your infant is consuming less than I would expect at this age. Do you wake the baby for feedings?" ‐ "Your infant seems to be feeding well. Do you have any concerns?" ‐ "Your infant is consuming more than I would expect at this age. Let's weigh your infant to determine weight gain." ‐ "I think your infant may have a metabolism problem. We need to run some tests." | Note that the question requires analysis of the amount of formula necessary for a week‐ old infant. Recall the amount recommended at this age to be directed to option 1. |
3977 The nurse has completed health histories on several Correct answer: 1 A young pregnant adolescent is at highest risk because this age is associated with rapid pregnant clients. Which of the following clients is at growth and increased nutritional demands that are further exacerbated by pregnancy. The highest risk for nutritional alterations and requires clients in the other options have concerns but they are not as immediate. The 27‐year‐old will immediate nutritional teaching? have to be assessed for signs of continued altered eating habits, but the choice reflects a past history. The 37‐year‐old is at risk because of age versus nutrition and the fact that this is her first pregnancy. The 23‐year‐old will have to be monitored because she is already overweight prior to the demands of pregnancy. ‐ A 13‐year‐old living with parents ‐ A 27‐year‐old with a past history of bulimia nervosa in college ‐ A 37‐year‐old in her first pregnancy ‐ A 23‐year‐old who was 10 pounds overweight before pregnancy | Read each option carefully and analyze the risk factors for adequate nutritional intake. Recognize the high risk of an adolescent to be directed to option 1. |
3978 A pregnant client has undergone a glucose tolerance Correct answer: 3 Values that meet or exceed two or more of the designated glucose parameters are test. The results are 105 milligrams per deciliter ‐ considered diagnostic for GDM. This client exceeds parameters in all four levels (i.e., greater fasting, 200‐1 hour, 175‐2 hours, and 160‐3 hours. How than or equal to 95, greater than or equal to 80, greater than or equal to 155, greater than or would the nurse interpret the meaning of these equal to 140). The other options are incorrect because they do not indicate the client has GDM results? and there is nothing to indicate that the test results are not valid. ‐ Glucose levels are within normal limits; therefore, the client does not have gestational diabetes mellitus (GDM). ‐ Glucose levels indicate that the client is hypoglycemic and dietary alterations should be instituted. ‐ Glucose levels indicate GDM and treatment should be initiated. ‐ Glucose levels are inconclusive and the test needs to be repeated. | Recall the norms of glucose tolerance testing in pregnancy to be directed to option 3. |
3979 A client has pregnancy‐induced hypertension and is Correct answer: 3 Protein increases are recommended due to losses in urine, and sodium intake is reduced considered pre‐eclamptic. The nurse has discussed slightly due to potential edema formation. Options 2 and 4 are incorrect because fluids should dietary modifications and wishes to evaluate teaching. not be restricted in pregnancy due to a risk of dehydration. Option 1 is incorrect as proteins Which of the statements by the client indicates should never be restricted because of losses in urine, and a proportional increase in teaching was effective? carbohydrates may result in increased weight. ‐ "I need to decrease protein to 10 percent of my diet and increase carbohydrates by 20 percent." ‐ "I must restrict fluids to one liter per day and limit sodium to three grams." ‐ "I should increase protein to 1.5 grams per kilogram per day and limit sodium intake to 6 grams per day or less." ‐ "I need to restrict fluids to one liter per day and increase protein to 1.5 grams per kilogram per day." | Critical words are pre‐eclamptic and dietary modifications. Recall the need to alter protein and sodium both with this condition to be directed to option 3. |
3980 A pregnant client has a seizure disorder. The nurse Correct answer: 4 Some anticonvulsants interfere with vitamin D production, increasing the risk of deficiency. realizes which of the following changes will most likely Therefore, supplementation may be indicated. Option 1 is incorrect as changing drugs is not need to be made in the client's medication and dietary usually wise if the disorder is well‐controlled. Option 2 is incorrect because even though folate supplement regime as a result of drug interactions? has been known to alter anticonvulsant uptake, the risk of neural tube defects outweighs this difficulty so supplementation is still indicated. Option 3 is incorrect since women may experience increases in seizure activity during the pregnancy so decreasing anticonvulsant doses would not be appropriate. ‐ Change current anticonvulsant drug(s) ‐ Eliminate folate supplementation ‐ Decrease anticonvulsant doses ‐ Add vitamin D supplementation | Critical terms are seizure disorder, pregnancy, and medication interactions. Eliminate options 1 and 3 since it would be unwise to alter the seizure medication at this time. Recall the role of vitamin K in anticonvulsant therapy to choose option 4. |
3981 When assessing an infant diagnosed with failure to Correct answer: 5 Weight below the 5th percentile for height is diagnostic for FTT. thrive (FTT), the nurse would expect to find the infant's weight is below the th percentile for age and gender. Write a numerical answer. | Recall the parameters for FTT. |
3982 The nurse is teaching a mother about feeding her Correct answer: 1 Young children should not be given hard, round foods that do not dissolve easily, such as hot toddler. Which of the following statements by the dogs, because the risk of choking is too high. All of the other options contain foods that are mother indicates further teaching is required? appropriate or prepared in such a way to make them appropriate and do not pose safety risks. ‐ "She just loves hot dogs. She can hold them in her fingers to eat them." ‐ "I need to cook her vegetables and cut them into small pieces." ‐ "Graham crackers and milk would be a nice snack." ‐ "Cheese puffs would be a better choice than popcorn at this stage." | The critical word is toddler. Note that the question is a negative response item indicating three options are correct information, and one is the incorrect information nurse is evaluating. |
3983 A moderately overweight client who is 4 weeks Correct answer: 4 Weight reduction is never indicated during pregnancy. Moderate weight gains of 15–25 pregnant is at the first prenatal visit. The nurse should pounds are recommended for overweight clients. Option 1 is incorrect since an in increase in give highest priority to which of the following calories in the first trimester is not indicated, whereas in the second trimester and third, nutritional information during teaching? caloric needs are increased by 300. Option 2 is incorrect because weight reduction is not indicated during pregnancy. Option 3 is incorrect because all pregnant women are expected to receive supplements (prenatal vitamins) to ensure adequate folic acid is obtained, regardless of dietary intake. ‐ "Add an additional 300 calories to your daily diet now to ensure adequate nutrients are available to support your developing fetus." ‐ "You will need to follow a weight reduction diet, no lower than 1200 calories and adequate in essential nutrients." ‐ "As long as your diet is well balanced in all nutrients, a vitamin/mineral supplement will not be required." ‐ "You must eat a nutritionally sound diet. Pregnancy is not the time to lose weight." | Critical words are overweight, 4 weeks pregnant, and highest priority. Recall concepts of nutritional needs in the first trimester of pregnancy to choose option 4. |
3984 A 2‐day postpartum client informs the nurse, Correct answer: 3 Colostrum is produced before milk until about 4 days postpartum. It is yellow, rich in “Something is wrong with my milk; it is yellow.” Which nutrients, and should be consumed by the baby. Option 1 is incorrect because there is nothing of the following statements by the nurse is most to suggest that the client has a breast infection (temperature or breast soreness). Option 2 is appropriate? incorrect because dehydration may be associated with letdown of milk, not color. Option 4 is incorrect. Foods can alter a milk's taste, but not color. ‐ "You probably have a breast infection and will need to stop breastfeeding." ‐ "You are most likely dehydrated. Increase your consumption of caffeine‐free fluids so the milk will not be so thick." ‐ "The yellow fluid is normal and is called colostrum, a precursor to milk. It is full of nutrients and wonderful for the baby to drink." ‐ "What have you been eating? Some foods can discolor the milk." | Note that the client is only 2 days postpartum. Recall colostrum is secreted in the first few days to direct you to option 3. |
3985 The nurse has completed teaching the client about Correct answer: 4 Single‐grain infant cereals are recommended first because they are easily digestible and have introducing solid foods to an infant. The nurse added iron content. Option 3 is incorrect because yogurt is a milk product, and introduction determines teaching has been effective when the should be delayed until 12 months because of the risk of milk allergy. Options 1 and 2 are mother identifies the first solid food she will introduce incorrect because fruits and vegetables are usually given following the introduction of cereals. is: ‐ Pureed canned squash ‐ Pureed apples ‐ Yogurt ‐ Infant rice cereal | Recall need to begin solid food introduction with a cereal to choose option 4. |
3986 When caring for a pregnant client with congenital Correct answer: 2 Caffeine may increase heart rate that is already stressed due to pregnancy. Sodium may heart disease, the nurse plans for which alterations in cause fluid retention. Both may need to be restricted. The other answers are incorrect because the client's diet during pregnancy? calories, fat, and protein are not usually decreased due to the risk of nutrient deficiencies. ‐ Reduced calories and reduced fat ‐ Caffeine and sodium restrictions ‐ Decreased protein and increased complex carbohydrates ‐ Fluid restriction and reduced calories | Theoretical words heart disease. Recall the significance of caffeine and sodium on cardiac function to direct you to option 2. |
3987 An adult female client has been treated for iron Correct answer: 2 A sign of anemia is pale conjunctiva. If resolved, the conjunctiva should be pinker. The other deficiency anemia. To evaluate the effectiveness of the symptoms are not specific to iron deficiency and are usually associated with other vitamin or treatment, the nurse would assess for resolution of mineral deficiencies. which of the following symptoms? ‐ Dermatitis ‐ Pale conjunctiva ‐ Bleeding gums ‐ Hair pigment changes | Critical words are iron deficiency and effectiveness. Recall symptoms of anemia to direct you to option 2. |
3988 An infant with congenital hypothyroidism is placed on Correct answer: 3 At the beginning of therapy, it is essential that parents understand its importance. Other thyroid replacement therapy. Which of the following information is less of a priority. The other options contain information about administration, information is the most essential information for the assessing effectiveness, and side effects, which can be explained later. nurse to include in discharge teaching with the parents? ‐ The supplement may be mixed with formula. ‐ Notify the physician if the infant continues to be excessively sleepy. ‐ This replacement must be taken for the child's entire life to ensure normal growth and development. ‐ Notify the physician if the child becomes excessively irritable and diaphoretic. | Critical words are most essential, indicating some or all of the options are correct, but one is much more important. Note the condition is congenital, indicating it will be life long to direct you to option 3. |
3989 The nurse interprets that a premature infant is at Correct answer: 3 Vitamin E is a fat‐soluble vitamin, and the infant is at greatest risk of deficiencies due to greatest risk for inadequate intake of which of the impaired fat absorption. The other nutrients are also at risk for deficiency but usually because following vitamins because of alterations in fat of inadequate stores. All of the other options represent water‐soluble vitamins. absorption? ‐ B complex ‐ Vitamin C ‐ Vitamin E ‐ Folic acid | The core issue of the question is the ability to discriminate between fat‐soluble and water‐ soluble vitamins. Note correlation of altered fat absorption in question to the only option that is a fat‐soluble vitamin. |
3990 An adult client being started on sodium warfarin Correct answer: 1 A client receiving anticoagulant therapy should not take additional supplementation of (Coumadin) had previously been taking over‐the‐ vitamin K, either through dietary intake or supplemental therapies, because vitamin K counter vitamin K supplements. The nurse teaches the antagonizes sodium warfarin (Coumadin). Option 2 is not advised because increased dietary client to do which of the following at this time? intake can also influence this drug, resulting in altered clotting times. Option 3 is incorrect for the reasons stated above. While it is important to discuss any supplemental therapy with the healthcare provider (option 4), the time delay would place the client at risk for complications related to anticoagulant therapy. ‐ Discontinue taking the supplements. ‐ Increase the intake of dietary sources of vitamin K so no additional supplementation will be needed. ‐ Take vitamin K supplements every other day while on anticoagulant therapy. ‐ Discuss this issue with the healthcare provider at the next scheduled appointment. | The core issue of the question is an interaction between oral anticoagulant therapy and vitamin K. Recall a correlation of vitamin K to clotting to direct you to option 1. |
3991 A regular diet has been resumed for a client following Correct answer: 2 Nutrient stores exhausted during major trauma include protein, B complex vitamins, zinc, and a major traumatic injury. The nurse selects from the vitamins A and C. Option 2 is rich in all these nutrients. All of the other options reflect a lack of diet menu which of the following meals that would be specific nutrients needed to replenish stores. most appropriate for the client? ‐ Vegetable lasagna, bibb lettuce with dressing, white roll, and a slice of pound cake ‐ Chicken breast, brown rice, broccoli, and fresh orange slices ‐ Fried codfish fillet, macaroni and cheese, peas, and flavored gelatin ‐ Roast beef, mashed potatoes, corn, and ice cream | Critical words are major traumatic injury and replenish nutrients. Recall significance of protein and vitamins for wound healing to direct you to option 2. |
3992 The nurse has completed a comprehensive health Correct answer: 2 The most likely explanation is the death of the spouse. All of the other choices reflect factors history on an 80‐year‐old recently widowed client who that would have been present previously; the client had no problems until the spouse died. lost 15 pounds in 2 months. The nurse anticipates Depression and loneliness have been documented as major causes of nutrient alterations in which of the following is the most likely explanation? the elderly. ‐ Reliance on fixed income ‐ Depression and sense of loss over spouse's death ‐ Use of limited funds for medications ‐ Limited opportunities for social eating | Critical words are recently widowed. Recognize all options contain factors contributing to poor dietary habits of the elderly, but option 2 has a connection to the loss of spouse. |
3993 As prophylaxis against neural tube defects (NTD), the Correct answer: 0.4 Due to strong correlation between NTD and folic acid deficiency, a 0.4 mg/day supplement is nurse should recommend that a client planning to recommended for client considering pregnancy. Note that a dose of 0.6 mg/day is conceive for the first time should take in recommended for pregnant women; 4 mg/day is recommended for short‐term dosing for milligrams of folic acid daily. Write a numerical women with past history of pregnancy with NTD. answer. | Note the question addresses the recommended dose for someone trying to conceive, which may be different than for someone already pregnant. Recall specific knowledge of folate requirements to type in the correct response. |
3994 A new breastfeeding client is having difficulty with Correct answer: 2 A poorly positioned infant can cause trauma to the nipple. Although nipples can become sore nipples. The nurse assesses the client for which of infected, this is not the most common cause; breasts should be cleansed after feeding; letting the following since it is the most probable cause of this breast milk dry on nipples has been an effective treatment for sore nipples due to high fat problem? content and anti‐infective substances in breast milk. ‐ Infection of the nipples ‐ Infant is poorly positioned ‐ Not cleansing breasts after feeding ‐ Allowing breast milk to dry on nipples | A critical word in the question is most, indicating all or some of the options may be correct, but one choice is the best. Eliminate option 1 since this is not frequently seen. Eliminate options 3 and 4 since they are also not a likely cause. |
3995 A pregnant client is at the first prenatal visit. The Correct answer: 2 According to BMI criteria, the client would be considered overweight and advised to maintain nurse determines the client’s body mass index (BMI) is weight gain between 15–25 pounds. A less than 15‐pound gain is the restriction for obese 27.5. The nurse identifies the recommended weight clients; weight gains of 25 pounds or greater are for clients of normal weight or who are gain for this client is: underweight. ‐ Less than or equal to 15 pounds. ‐ 15–25 pounds. ‐ 25–35 pounds. ‐ 28–40 pounds. | Critical words are prenatal and BMI of 27.5. Recognize this BMI is high to direct you to option 2. |
3996 An elderly client states that fruits in any form cause Correct answer: 1 Dark, leafy vegetables such as spinach are an alternative source of vitamin C. Corn is a good diarrhea. Which of the following foods would the source of fiber but not vitamin C; sweet potatoes are rich in vitamin A; celery provides water nurse suggest to be the most appropriate alternative and fiber. to ensure the client receives adequate vitamin C? ‐ Spinach ‐ Corn ‐ Sweet potatoes ‐ Celery | Key words are most appropriate, alternative, and vitamin C. Note all options are vegetables and recall those with a high vitamin C content to choose option 1. |
3997 A new postpartum client has been told that her infant Correct answer: 3 PKU is a genetic disorder that reflects a problem with the metabolism of phenyalanine (amino has phenylketonuria (PKU). Which of the following acid). A special diet should be followed that restricts/limits the intake of this amino acid in instructions should the nurse provide to the mother to order to avoid potential metabolic complications. The other options do not acknowledge that ensure adequate nutritional management for this this inborn error of metabolism has lifelong consequences. newborn? ‐ "Feed the baby a wide variety of foods when she starts eating solid foods." ‐ "A special PKU diet will be necessary during the first year." ‐ "Your baby must follow a diet that restricts the amount of phenylalanine." | A critical phrase is adequate nutritional management. Recall knowledge of PKU and need for lifelong therapy to direct you to option 3. |
4.‐ "Your baby will grow out of this and can be managed using standard nutritional support." | |
3998 The nurse is teaching a client how to introduce solids Correct answer: 4 Foods should be introduced singly to identify possible allergies. Combination foods, such as to an infant. Which of the following statements by the those that would be served to the family, are not advised due to difficulty identifying allergies, client indicates that the client has correct and some table foods may have high‐sodium substances not tolerated well by an infant. Cereal understanding? should not be placed in bottle because it deprives the infant of an opportunity to develop chewing muscles. Formula should not be stopped all at once; it should be gradually weaned as the amount of solids increases to prevent weight and nutrient loss. ‐ "I can puree whatever the family is eating each night and offer it to my baby." ‐ "I can stop the formula now that solids are being given." ‐ "I can add cereal to my infant's bottle several times each day until he is starts to eat finger foods." ‐ "I’ll introduce one pureed food at a time and keep feeding it for several days before trying a new one." | Read each option carefully and systematically eliminate options 1, 2, and 3 since they do not answer the question or give incorrect advice. |
3999 The nurse is caring for a client who suffered major Correct answer: 1 Vitamin C promotes collagen formation and hence wound healing. Vitamins trauma in an auto accident and has been having B<sub>1</sub> and B<sub>12</sub> are involved primarily with the difficulty healing wounds. The nurse encourages the neurological system; vitamin K is involved with the blood coagulation cascade. client to increase foods high in which of the following vitamins? ‐ Vitamin C ‐ Vitamin B1 ‐ Vitamin B12 ‐ Vitamin K | The core concept is difficulty with wound healing. Recall that ascorbic acid aids in tissue repair to choose option 1. |
4000 A pregnant client with a glycosylated hemoglobin Correct answer: 4 Glycosylated hemoglobin (HbA<sub>1c</sub>) levels are indicators of longer term (HbA<sub>1c</sub>) level of 12% asks the glucose control (past 4–8 weeks); 12% indicates poor control, not good control. To determine nurse what this level indicates. The nurse explains: cause and best treatment, a comprehensive evaluation of diet and so on would be indicated. One value of 12% would not necessitate insulin administration. ‐ "You have been consuming inadequate calories and carbohydrates." ‐ "You have been maintaining your glucose levels well during past 24 hours." ‐ "You must be started on insulin; your glucose levels are out of control." ‐ "You have had poor glucose control during the last 4–8 weeks.” | The core concept of the question addresses interpretation of glycosylated hemoglobin levels, with this being a high level. Systematically eliminate incorrect options 1 and 2. Note option 3 may be correct but cannot be told to client with absolute certainty and choose option 4. |
4001 An elderly client complains of difficulty swallowing Correct answer: 4 Decreased saliva makes it difficult to moisten the food bolus so that it can be swallowed. foods such as bread. The nurse plans to assess for Periodontal disease and jaw deterioration affect chewing. Decreased peristalsis affects passage which of the following normal age‐related of bolus once in esophagus. physiological changes as the most likely explanation for the problem? ‐ Jaw bone deterioration ‐ Decreased peristalsis ‐ Periodontal disease ‐ Decreased saliva | Critical words are elderly, and difficulty swallowing. Eliminate option 2 since it does not involve chewing and swallowing. Recall physiological changes of aging to choose option 4. |
4002 The nurse has instructed a client with constipation Correct answer: 3 Kidney beans are legumes and contain 5.6 g of insoluble fiber per half cup. The other foods ways in which to increase fiber in the diet. Which of are not fiber rich. the following food selections by the client indicates teaching has been successful? ‐ White bread ‐ Pureed spinach ‐ Kidney beans | Recall knowledge of fiber content of foods. Eliminate options 1 and 4 as incorrect. Note spinach is creamed to eliminate it as well. |
4.‐ Spaghetti | |
4003 A client recently diagnosed with type 1 diabetes Correct answer: 4 The American Diabetes Association Exchange Lists divide food into similar content (milk, mellitus is learning to use the American Diabetes vegetables, fruit, starch/bread, meat, and fat). Each food within a list is similar in calories, Association Exchange Lists. The nurse concludes that protein, fat, and carbohydrates if eaten in a certain size portion. Foods may be exchanged the teaching has been effective if the client chooses within the same list. Rice and bread are starches, egg is meat, tomato is vegetable, and orange which of the following as an appropriate exchange for is fruit. white rice? ‐ Egg ‐ Tomato ‐ Orange ‐ Bread | The core concept of the question is identification of diabetic exchange equivalents. Recognize white rice is a starch to be directed to option 4. |
4004 The nurse is setting up the breakfast tray for a client Correct answer: 3 Foods that reduce lower esophageal sphincter (LES) pressure will increase reflux symptoms. with gastroesophageal reflux disease (GERD) and These include coffee, fatty foods, alcohol, and chocolate. All the other items can be given to notices one food item the client should not eat. The the client. nurse should remove the: ‐ Poached egg. ‐ Dry toast. ‐ Coffee with cream. ‐ Skim milk. | Recall dietary recommendations for GERD to reduce reflux of gastric acid. Recognize foods which decrease the lower esophageal sphincter tone should be avoided to choose option 3. |
4005 The nurse is admitting a client with thermal burns to Correct answer: 3 Clients should remain NPO upon admission to the clinical setting with a major burn. Initial both arms and the anterior trunk. When the client asks fluid replacement is started via the parenteral route. NPO status is maintained because burn for a drink of water the most appropriate response for injuries may cause internal damage to body structures and aspiration can occur. Options 1, 2, the nurse is? and 4 are incorrect because fluids and food via the mouth would be restricted at this time. ‐ "I'll get you a drink as soon as I'm finished establishing an intravenous line." ‐ "I can only give you juice to drink, not water." ‐ "I'm sorry, you cannot have anything to drink right now. Let me moisten your mouth instead." ‐ "Would you also like me to order you a meal tray?" | Note that the client has burns to the anterior trunk, necessitating the need to determine swallowing ability prior to allowing client to drink. |
4006 Which of the following would be an appropriate Correct answer: 1 Abuse of laxatives and diuretics is a frequent "purging" behavior for bulimic clients. Options 2 intervention for the nurse to include in the plan of care and 3 pertain to anorexia nervosa clients. In regard to option 4, food should never be used as a for a client with a clinical diagnosis of bulimia? reward. ‐ Assess for laxative and diuretic possession ‐ Supervise mealtimes to ensure eating ‐ Observe for ritualistic eating patterns ‐ Reward non‐purging behavior with a favorite snack | Recall behaviors associated with bulimia to be directed to option 1. |
4007 A client with congestive heart failure (CHF) has been Correct answer: 2 In a 2‐gram sodium diet, foods high in sodium content should be eliminated. It is not enough advised to follow a low‐sodium diet. Which statement to stop adding salt or to go only by taste; clients should also be taught to read food labels for by the client indicates to the nurse that diet teaching hidden sodium content. Added salt while cooking is allowed in a 4‐gram sodium diet, not a 2‐ has been effective? gram sodium diet. ‐ "If I stop adding table salt, I shouldn't have any problems." ‐ "I need to avoid eating processed foods and canned meats and vegetables." ‐ "I can still use a small amount of table salt in cooking." ‐ "I only have to worry about salty‐tasting foods like potato chips." | Critical words are CHF and low sodium. Eliminate options 1, 3, and 4 since they indicate false assumptions and are too general. |
4008 Which breakfast choice indicates to the nurse that Correct answer: 3 The American Heart Association recommends a diet with reduced saturated fats and the client with coronary artery disease (CAD) requires cholesterol for clients with coronary artery disease. Canned peaches are high in concentrated further diet instruction? sugars, which increase triglyceride levels. Egg yolks are high in cholesterol and whole milk is high in saturated fats. The other options reflect appropriate food selections that are low in saturated fat and cholesterol content. ‐ Orange juice, shredded wheat, skim milk, and toast with jelly ‐ Grapefruit juice, oatmeal, 1% milk, and bagel with jelly ‐ Canned peaches, egg omelet, whole milk, and fruit yogurt ‐ Applesauce, bagel with margarine, egg‐white omelet, and skim milk | The core concept of the question is CAD. Note this is a negative response question indicating that three of the choices are correct. Recall the diet should be restricted in fats and cholesterol to choose option 3. |
4009 Which nutritional measures should the nurse suggest Correct answer: 3 A client with GERD should limit (or possibly eliminate) the intake of coffee because this can to a client with gastroesophageal reflux disease (GERD) relax lower esophageal sphincter (LES) pressure and lead to symptoms. The other options to minimize the risk of symptoms? would not be warranted because all would contribute to the development of symptoms: large meals, spicy foods (e.g., extra garlic), and peppermint (which would relax LES pressure). ‐ Eat three large meals a day with no snacks ‐ Use a lot of garlic to season food rather than salt ‐ Limit intake of coffee drinks to two or fewer cups a day ‐ Use peppermint candies to take away the bitter taste in the mouth | Recall factors which will reduce the lower esophageal sphincter tone and eliminate options 3 and 4. Eliminate option 1 since large meals will increase upward pressure and contribute to reflux. |
4010 The nurse is caring for the client who is recovering Correct answer: 2 The eggs provide 24 grams of protein and the whole milk adds calories. The other options are from partial thickness burns. Which of the following lower in protein and calories. A client recovering from burns requires a high‐protein, high‐ breakfast choices indicates the client's understanding calorie diet. Option 1 does not reflect an adequate protein source. Option 3 reflects an of the recommended diet? increased carbohydrate source and bacon is considered a fat, not protein. Option 4 does not reflect a high‐protein, high‐calorie meal but rather a low‐calorie meal selection with greater carbohydrate content. ‐ Two slices of toast with butter, orange juice, and skim milk ‐ Two poached eggs, hash brown potatoes, and whole milk ‐ Three pancakes with syrup, two slices of bacon, and apple juice ‐ One cup of oatmeal with skim milk, half of one grapefruit, and coffee | Recall that clients with burns need additional protein and calories to be directed to option 2. |
4011 Which approach should the nurse use to develop a Correct answer: 4 Consistency and gentle firmness allow the client to learn that the nurse will follow through trusting relationship with the client who has an eating and do what is promised. Option 1 is not therapeutic; it may actually push the client away by disorder? making too many demands at too rapid a pace. Trust must be established slowly and respectfully. Option 2 allows the client to use manipulative behavior, and option 3 does not develop trust; it is directing/ordering behavior. ‐ Set strict limits that are detailed and numerous ‐ Encourage use of "testing" behaviors ‐ Tell the client how to behave ‐ Utilize consistency and gentle firmness | Recall that psychosocial and communication skills are needed to establish relationships and recall the need for limits and routine for clients with eating disorder to choose option 4. |
4012 A nurse is discussing the home maintenance regimen Correct answer: 1 Regular exercise can help to normalize bowel function. Cigarette smoking and gum chewing with a client who has irritable bowel syndrome (IBS). increase swallowed air; fresh vegetables are gas‐producing. Which of the following statements indicates client understanding? ‐ "I'll take a walk after dinner each evening." ‐ "I'll have a cigarette after meals to relax." ‐ "I'll chew gum between meals to curb my appetite." ‐ "I'll eat more fresh vegetables and fruits." | Recall factors which contribute to increased symptoms in IBS and eliminate options 2, 3, and 4. |
4013 A client with anorexia nervosa has a nursing diagnosis Correct answer: 3 One issue for clients with anorexia nervosa is an altered view of their body appearance (i.e., of disturbed body image. The nurse identifies which of visualizing themselves as being fat even when they are emaciated). Option 1 involves a the following as an appropriate outcome? knowledge deficit; option 2 involves possible resolution of family dynamic issues; option 4 involves psychological adaptation. ‐ Verbalizes knowledge of maintenance diet. ‐ Demonstrates assertiveness with family. ‐ Verbalizes body size accurately. ‐ Demonstrates control of obsessive behaviors. | Note similarity in option 3 of body size to body image in question to choose this option. |
4014 The nurse encourages increased intake of which of Correct answer: 1 Clients with burns are hypermetabolic and require increased protein levels in order to the following foods to best assist a client who has maintain a positive nitrogen balance. Vegetables (option 2 and fruits (option 3) are low in major burns to maintain a positive nitrogen balance? protein, although the nuts in option 3 are reasonable sources of protein. Dairy products and shellfish contain protein but are not as good sources as the foods in option 1. ‐ Meats and legumes ‐ Vegetables and clear liquids ‐ Fruits and nuts ‐ Dairy products and shellfish | Eliminate option 2 first as the lowest protein source. Discriminate among the other three options by selecting the option that has two protein sources listed rather than one. |
4015 A client has begun therapy with captopril (Capoten) Correct answer: 1, 4, 5 Captopril is an ACE inhibitor that leads to an elevation of serum potassium levels. Foods high for hypertension. Which of the following foods should in potassium such as oranges and bananas should be avoided. Other foods to avoid are the nurse caution the client to avoid? Select all that potatoes and beans, and vegetables such as broccoll and carrots. apply. ‐ Oranges and bananas ‐ Cheese and yogurt ‐ Milk and milk products ‐ Potato and beans ‐ Broccoli and carrots | Refer to knowledge of mineral potassium vital to cardiac function to associate with options offered. |
4016 As part of the teaching plan for a client with type 1 Correct answer: 4 Active exercise increases insulin sensitivity, thus lowering blood glucose levels. Additional diabetes mellitus, the nurse should include that carbohydrates may be needed to balance the usual insulin dose. All of the other options will carbohydrate needs can increase under which of the increase blood glucose levels. following circumstances? ‐ The client has an infection. ‐ The client has an emotional upset. ‐ The client eats a large meal. ‐ The client engages vigorous exercise. | Critical words are Type 1 diabetic, indicating client is insulin dependent. Systematically analyze each option for the effect on blood sugar and choose option since exercise will lower blood sugar. |
4017 Which of the following dietary measures should the Correct answer: 3 Small meals prevent overdistention and rapid emptying of stomach, thus helping to prevent nurse include when planning for the nutritional needs dumping syndrome. A low‐residue diet is not necessary for this client because this diet plan is of a client who has had a subtotal gastrectomy? usually used as a transition diet from liquids to solid foods to allow the colon to rest. A fluid intake below 1000 mL/day is too low and could cause the client to become dehydrated. Instead, the client should drink liquids between meals. A high‐carbohydrate diet is not recommended because concentrated sweets pass rapidly out of stomach and will intensify symptoms of dumping syndrome. A high‐protein diet is needed for tissue repair. ‐ Low‐residue, bland diet ‐ Fluid intake below 1000 mL/day ‐ Six small meals per day ‐ Low‐protein, high‐carbohydrate diet | Critical words in the question are nutritional intake and subtotal gastrectomy. Note correlation of small meals to reduced size of stomach to direct you to option 3. |
4018 The mother of a 16‐year‐old client calls to express Correct answer: 3 One form of bulimia is the "nonpurging" type. Clients with this type of bulimia use fasting and concern about the teen's obsession with dieting and excessive exercise to compensate for food binges. Many clients with bulimia will appear in a exercising. The teen appears healthy and has not lost normal weight range and perform their eating behaviors in secret. Option 1 is incorrect since any weight. What might the nurse suspect? anorexia presents with documented weight loss. Options 2 and 4 could be possibilities, but there is no evidence to support depression or use of drugs at the present time given the information provided. ‐ Anorexia ‐ Depression ‐ Bulimia ‐ Drug abuse | Note the connection between obsession with dieting but lack of weight loss to direct you to option 3. |
4019 What would the nurse prepare to do for the client Correct answer: 2 The client with burns often develops paralytic ileus within a few hours, thus a nasogastric who is 6 hours post‐burn and has absent bowel sounds tube should be used for stomach decompression. When bowel sounds return, feeding can and abdominal distention? begin, either via feeding tube or orally. ‐ Insert a feeding tube for nutrition. ‐ Insert a nasogastric tube to low intermittent suction. ‐ Withhold oral intake, except for water. ‐ Start a diet of clear liquids only. | Recognize the symptoms are indicative of a paralytic ileus. Eliminate options 1, 3, and 4 since oral intake could cause complications. |
4020 The nurse is reviewing the results of a lipid profile, Correct answer: 1 High HDL levels are associated with reduced risk for coronary artery disease (CAD) and are including high‐density lipoproteins (HDLs), low‐density thought to be cardioprotective. Decreased LDL and VLDL levels are associated with reduced lipoproteins (LDLs), and very low‐density lipoproteins risk for CAD. Increased levels of LDL and VLDL are associated with increased risk for CAD as are (VLDLs), for a client who is following a low‐fat diet. The low HDL levels. nurse concludes that the client has the desired pattern of results if the laboratory values show: ‐ High HDL, low LDL, low VLDL. ‐ Low HDL, high LDL, high VLDL. ‐ Low HDL, low LDL, low VLDL. ‐ High HDL, high LDL, high VLDL. | Systematically review each option and eliminate all incorrect ones. If you had difficulty with this question, review lipid metabolism and coronary heart disease. |
4021 A nurse is caring for a client who has burns over 50 Correct answer: 108 A nutritional goal for a client with burns is to maintain weight within 10 percent of the pre‐ percent of the body. The client's pre‐burn weight is burn weight. 120 pounds. When developing the plan of care, the nurse sets a goal that client's weight will not drop below pounds. Write a numerical answer. | Calculate 10 percent of 120 pounds by multiplying 120 by 0.10 to yield 12 pounds; subtract 12 pounds from 120 to yield a weight of 108 pounds. |
4022 Which of the following foods will the nurse include in Correct answer: 4 Clients with hypoparathyroidism require calcium replacement. These foods are high in the diet plan for a client with hypoparathyroidism? calcium. Option 1 reflects foods that are high in potassium; option 2 reflects foods that are high in sodium; option 3 reflects foods that are high in starches. ‐ Bananas, spinach, sweet potatoes ‐ Bacon, rice, canned tuna ‐ Bran cereal, lima beans, corn ‐ Cheese, yogurt, legumes | Refer to the physiological function of the parathyroid gland and the regulation of blood calcium. |
4023 A client newly diagnosed with anorexia nervosa Correct answer: 2 It is important in the early stages of treatment that a staff member sits with the client during refuses to eat. Which of the following interventions by mealtimes to offer encouragement and help calm fears of eating. The other options are not the nurse would be most appropriate? appropriate at this time. Having the client’s mother come during meals may affect the client’s coping status, while leaving the client alone may cause the client to refuse to eat. Obtaining an order for a feeding tube is not warranted at this time, since there is no clinical information to support an alternate feeding approach. ‐ Have the client's mother come to the nursing unit during meals. ‐ Sit with the client and offer gentle encouragement. ‐ Leave the client alone to eat in privacy. ‐ Obtain an order to place a feeding tube. | It is significant to note the client is newly diagnosed. Eliminate option 4 since this would be a last‐resort measure. Recognize the emotional and psychological nature of the disorder to direct you to option 3. |
4024 When planning for the nutritional needs of a client Correct answer: 2 Total kilocalories are based on the hypermetabolism response, which is proportional to the with partial‐ and full‐thickness burns, the nurse size of the wound or total body surface area burned. Weight does figure into the formula, but calculates the total kilocalories needs in relation to not height; cause and location do not affect total kilocalorie needs. which of the following? ‐ Preburn height and weight ‐ Extent of the burn ‐ Cause of the burn ‐ Location of the burn | The core concept of the question is nutritional needs and total kilocalories in a client with major burn injury. Note the connection between the types of burns, partial and full thickness, to direct you to extent in option 2. |
4025 A client with a colostomy has been experiencing Correct answer: 3 Increased intake of salad and fresh fruits and vegetables can lead to increased flatus increased flatus for the past 3 days. Which client formation in a client with a colostomy. Eating pasta, cereal, and milk and increasing fluids are information provided during assessment would lead not associated with increased gas formation. It is important for both the nurse and client to the nurse to suspect an etiology for this occurrence? recognize foods that can be gas‐forming and limit their inclusion in the diet. ‐ The client has been eating pasta for the past 3 days. ‐ The client has been eating cereal and milk for breakfast each morning. ‐ The client has been eating at a salad bar for lunch for the past 3 days. ‐ The client has been drinking more fluids for the past 3 days. | The question requires you to identify which food pattern would most contribute to gas formation. Many vegetables are in this category, allowing you choose option 3. |
4026 The nurse is assisting a client who has a newly Correct answer: 2, 3, 5 Sodium and potassium are lost via an ileostomy, and these foods are high in potassium (e.g., created ileostomy with menu selection. In order to oranges and potatoes) and high in sodium (e.g., tomato juice). Asparagus is not high in either offset the potential electrolyte losses from the and can cause an odor. Chicken breast is a healthy choice, but not to offset the electrolyte ileostomy, the nurse suggests the following foods? losses. Select all that apply. ‐ Asparagus ‐ Potatoes ‐ An orange ‐ Chicken breast ‐ Tomato juice | The question requires you to determine what electrolytes are lost. Recall drainage from an ileostomy is in the ileum and the body has not had time to reabsorb all the water and electrolytes. |
4027 The nurse is counseling a 14‐year‐old diabetic client Correct answer: 1 Type 1 diabetics should monitor blood glucose levels before, during, and after routine about diet and insulin. The client has soccer practice exercise. If levels before exercise are above 100 mg/dL, no additional food is needed. Exercise every day after school. Because the blood glucose will lower blood glucose, so additional insulin is not needed. Adjustment of CHO intake prior to records indicate daily levels are between 120 and 140 practice is not indicated as client's blood glucose level is above 100 mg/dL. mg/dL before practice, the nurse provides which instruction to the client? ‐ No additional food is needed before practice. ‐ Decrease carbohydrate (CHO) intake by 15 grams before practice. ‐ Increase CHO intake by 15 grams before practice. ‐ Increase regular insulin injection by 2 units. | Recall knowledge of normal blood glucose levels and correlate effect of exercise on Insulin utilization. Eliminate option 3 since levels are already elevated. Recall exercise will help to reduce blood sugar to choose option 1. |
4028 The nurse has reviewed the American Diabetes Correct answer: 2 The American Diabetes Association Exchange Lists group foods according to composition Association Exchange Lists with a diabetic client. The (similar calories, fat, protein, carbohydrate). One serving can be exchanged for another within nurse concludes that instruction effective when the the same list. Milk and yogurt are on the milk list. Peanut butter is on the fat list, while ground client chooses which of the following food pairs as an beef is on the meat list. Carrots and eggplant are on the vegetable list, while grapefruit is on equivalent allowable exchange? the fruit list. Bagels are on the starch/bread list. ‐ 1 tablespoon peanut butter = 1 ounce ground beef ‐ half of a cup of milk = 1 cup yogurt ‐ half of a cup of carrots = half of a grapefruit ‐ half of a bagel = half of a cup eggplant | Systematically review each option and eliminate options 3 and 4 since they contain foods from different groups. Eliminate option 1 since peanut butter is a fat and ground beef is a protein. |
4029 A client newly diagnosed with irritable bowel Correct answer: 4 Emotional stress, psychological factors, and food intolerances have been identified as factors syndrome asks the nurse how future attacks can be that can precipitate irritable bowel syndrome. Carbonated beverages (including seltzer) prevented. What is the nurse's best response? increase intestinal gas; laxatives can perpetuate constipation and should be avoided; fiber and bulk help to regulate bowel movements and should be increased. ‐ Include seltzer water with each meal. ‐ Use a stimulant laxative once a day. ‐ Reduce the amount of fiber in the diet. ‐ Identify and reduce emotional stressors. | Critical words are irritable bowel and prevented. Eliminate option 2 since daily laxative use promotes dependency and would not be recommended. Recall the emotional aspect of the disorder to direct you to option 4. |
4030 In order to reduce the development of dumping Correct answer: 3 To minimize the risk of a client's developing dumping syndrome, the client should take several syndrome in a post‐gastric resection client, the nurse small meals throughout the day rather than large meals, which would cause increased stomach encourages the client to: distention. Fluids should be taken either before or after meals to minimize the possibility of developing nausea. The diet should be low in simple sugars, moderate in fat, and higher in complex CHOs and protein. The addition of milk with every meal can cause possible abdominal bloating. ‐ Increase fluid intake with meals to decrease nausea. ‐ Provide a diet that is low in complex carbohydrates and high in fat and protein. ‐ Eat several small meals throughout the day. ‐ Have milk with every meal to coat the stomach lining. | Note all options are related to dietary intake. Recall the stomach size has been greatly reduced to direct you to option 3. |
4031 A client is diagnosed with hypercholesterolemia. The Correct answer: 2, 4 Liver is an organ meat and is therefore high in cholesterol. Egg yolks are also high in nurse would instruct the client to limit intake of which cholesterol. Chicken and yogurt are low in cholesterol, while carrots are a plant product and of the following favorite foods in the client's diet? do not contain cholesterol. Select all that apply. ‐ Yogurt ‐ Liver ‐ Chicken ‐ Eggs ‐ Carrots | Critical words are hypercholesteremia and limiting of food. Recall cholesterol and saturated fats contribute to the disease to choose option 2. |
4032 The nurse has just admitted a client who has bulimia Correct answer: 1 The most important objective is to normalize food intake with close supervision to control and has been abusing laxatives and diet pills. The nurse purging (e.g., vomiting, laxatives, diuretics). The other options are secondary to stabilizing places highest priority on which of the following goals nutritional status. of care? ‐ Promote adequate nutrition and retention of food. ‐ Promote the acceptance of self and body. ‐ Promote the development of insight into the behaviors. ‐ Promote the development of realistic dieting expectations. | Critical words are highest priority and goal, indicating one goal is more important overall. Eliminate option 4, since the focus is not on dieting at this time. Note similarities in the psychological nature of options 2 and 3 and choose option 1, since it identifies a physiological need. |
4033 The nurse reviewing the dietary assessment of an HIV‐ Correct answer: 4 A client who is HIV‐positive (regardless of sex) is likely to lose weight due to repeated cycles positive female notes the client has been skipping of wasting and malnutrition. The client, who might be unable to merely increase caloric intake, meals and progressively losing weight. What dietary should be instructed in dietary techniques that maximize quality of intake. Option 1 is incorrect interventions would be best for the nurse to suggest to because even though a food diary would provide pertinent information, the response allows promote weight gain? for a delay in treatment that could result in further weight loss for the client. The priority is to intervene early on to prevent the onset of wasting. Option 2 is incorrect as it provides the client with a false belief that fluid retention changes associated with the menstrual cycle may have an impact on nutritional status. Option 3 is incorrect because even though increased salt in the diet can lead to fluid retention and weight, it does not address the underlying issue of nutritional balance. ‐ Have the client keep a food diary recording food preferences and usual dietary pattern. ‐ Tell the client that her weight may fluctuate in response to her menstrual cycle so there is no need to worry for now. ‐ Tell the client that additional salt in the diet will help to increase weight. ‐ Tell the client that the use of nutrient‐dense food and fortified protein shakes will help promote weight gain. | Key concepts are weight loss and HIV. Recognize the malnutrition that occurs with HIV to be directed to option 4. |
4034 A client is admitted to the hospital with a primary Correct answer: 4 Sjögren's syndrome is an autoimmune disease that destroys exocrine glands in the body, and diagnosis of hip fracture and a secondary diagnosis of leads to a generalized "dryness" of body systems. The restriction of fluids is a concern because Sjögren's syndrome. Which one of the following orders the use of fluids helps to keep the oral cavity moist. There is no information to suggest that the would be of most concern to the nurse with regard to client has a need for fluid restriction due to other disease processes so this order should be the nutritional status of the client? clarified. All of the other options are reasonable for this client. ‐ NPO after midnight for surgery with a 7:30 a.m. case ‐ Intravenous of Lactated Ringer's at 125 milliliters per hour ‐ Maintain diet as tolerated ‐ Restrict oral fluids to 1000 milliliters per day | Of importance is the diagnosis of Sjögrens syndrome. Recall the tendency for dryness and xerostomia to be directed to option 4, since this would be contraindicated. |
4035 The nurse should provide which of the following Correct answer: 1 Due to the anorexia and fatigue frequently experienced by clients with SLE and the need to nutritional suggestions for a client with systemic lupus maintain adequate nutrient intake, small frequent meals are usually tolerated better than erythematosus (SLE)? large meals. Option 2 is incorrect because the diet should include all nutrients, not just fats and protein. Options 3 and 4 are incorrect as citrus and spicy foods do not necessarily need to be avoided, unless they induce nausea in the client. ‐ Eat small, but frequent meals throughout the day. ‐ Eat foods high in fat and protein. ‐ Avoid intake of spicy and highly seasoned foods. ‐ Limit intake of citric fruits and juices. | Recall the chronic nature of the illness. Identify that option 1 is sound advice to give any client to increase caloric intake and reduce nausea. |
4036 A client recovering from Guillain‐Barré syndrome is Correct answer: 2 A client who is recovering from Guillain‐Barré syndrome will need a diet that promotes admitted to the rehabilitation unit. Which of the positive nitrogen balance in order to counteract the effects of long periods of immobility on following methods does the nurse anticipate using to the body. Option 1 is incorrect as there is no evidence to support that the client is experiencing provide nutritional support for the client during this malabsorption at this time. Option 3 is incorrect because there is no clinical reason to limit time? fresh fruit. Even though the client may experience difficulty in chewing and swallowing, this is usually in the acute phase of the disease process. Option 4 is incorrect as there is nothing to suggest that the client is experiencing problems in this area or is at risk for aspiration. ‐ Use of a gastrostomy tube for feedings due to high incidence of malabsorption ‐ Maintenance of oral intake with adequate calories to maintain positive nitrogen balance ‐ Limit of fresh fruit in the diet ‐ Use of thickened liquids to prevent aspiration | Note that the client is being admitted to a rehabilitation unit and recovering from an illness, indicating a need to restore mobility and health. |
4037 Which of the following client statements regarding Correct answer: 1 Although some raw foods could be a source of contamination to the client with HIV who is HIV/AIDS would require further clarification from the immunocompromised, it would not be necessary to avoid all uncooked foods, such as fruits nurse? and vegetables. The nurse should clarify this statement by the client in order to provide accurate information. All of the other client statements reflect information that is appropriate for the management of client with HIV/AIDS. ‐ "I should avoid eating any raw or uncooked foods." ‐ "Blood tests will tell me if I have a nutritional anemia." ‐ "Maintaining adequate fluid and fiber intake will help me." ‐ "If I feel sick to my stomach, I should not drink liquids." | Recall the problems clients with HIV might have with nausea, anemia, and constipation to recognize that options 2, 3, and 4 are correct. |
4038 When developing a plan of care for a client with Correct answer: 3 Malnutrition is seen as a consequence of the HIV/AIDS virus because the disease process has HIV/AIDS, the nurse recognizes the following a progressive effect on client's nutritional status. Option 1 is incorrect because even clients statement is true concerning the nutritional status of who are asymptomatic may already have nutrient deficiencies and could be experiencing this disorder? "subclinical" signs of malnutrition. Option 2 is incorrect as wasting syndrome occurs early in the disease process; current clinical research states that the maintenance and preservation of nutritional status is a priority in the clinical management of this condition. Option 4 is incorrect because clients can experience vitamin and mineral deficiencies early on during the disease process. ‐ Clients who are asymptomatic have adequate nutritional stores of nutrients. ‐ The HIV wasting syndrome is seen in the latter stages of the disease process. ‐ Malnutrition is seen as a consequence of the immune disease. ‐ Vitamin and mineral deficiencies occur in the latter stages of the disease process. | Recall the course of the illness to eliminate options 1, 2, and 4 as incorrect. |
4039 A client is receiving radiation to the head and neck Correct answer: 4 Dry mouth can be a common complaint of clients undergoing radiation therapy. Using sugar‐ area for treatment of cancer. What interventions free candies or gum will help to stimulate the flow of saliva and ease the discomfort that the would the nurse use to help the client's complaint of a client is experiencing. Eating meals prior to radiation therapy may lead to increased nausea dry mouth? because the client would be lying down following eating the meal. It has no effect on complaints of a dry mouth. Eating larger portions of food will not help to ease complaints of a dry mouth. Furthermore, the client may not be able to increase the size of meals due to side effects experienced as a result of radiation therapy. The use of mouthwash can further cause the mouth to be dry and intensify the client's symptoms. ‐ Have the client eat prior to radiation therapy. ‐ Encourage the client to eat larger portions of food. ‐ Advise the client to use mouthwash. ‐ Suggest use of sugar‐free candies. | Note that the client is complaining of a dry mouth and eliminate options 1 and 2 since they would not help with dryness. Recall mouthwashes often contain alcohol which is drying and eliminate option 3. |
4040 A client has been referred for dietary teaching Correct answer: 4 Nutritional goals for a client with hepatitis are aimed at providing a diet that is high in calories regarding the management of hepatitis. The nurse (3,000–4,000 kilocalories) and high in quality protein (1.5–2.0 grams per kilogram). The diet should base development of nutritional goals on which should also be adequate in carbohydrates to spare protein and fat, provide concentrated of the following information? calories, and improve the taste of food. Option 1 is incorrect because the nutritional management of hepatitis is the same for all types. Option 2 is incorrect as there is no clinical indication to place the client on tube feedings given the information provided. If the gut works, then the usual clinical model is to use it. Option 3 is incorrect because dietary fat should not be limited unless the client is experiencing problems with malabsorption (steatorrhea) and there is no evidence to support this. ‐ Type of hepatitis the client has, as this will affect treatment ‐ Need for tube feedings to allow liver to rest and regenerate ‐ Dietary fats should be limited ‐ Diet should be high in calories and protein | Recall the need for liver regeneration and increased nutritional support to choose option 4. |
4041 Because the albumin level of a client with cirrhosis is Correct answer: 1 An albumin level of 2.5 milligrams per deciliter indicates decreased protein stores and 2.5 milligrams per deciliter, the nurse encourages the decreased albumin synthesis by the diseased liver. In cases of hepatic encephalopathy protein client to increase the intake of: will be limited, but there is not evidence of this. Although dairy products do provide some protein, beef and chicken would provide the best source of protein. Fruits and grains would not provide protein. ‐ Beef and chicken. ‐ Oranges and strawberries. ‐ Cheese and yogurt. ‐ Cereals and whole grain breads. | Recognize that the albumin level is decreased and recall the need for increased protein with cirrhosis to be directed to option 1. |
4042 When caring for a client with chronic obstructive Correct answer: 2 COPD places a client at risk to develop malnutrition due to reduction in muscle mass and fat pulmonary disease (COPD), the nurse develops a reserves. Option 1 is incorrect because COPD clients are more likely to suffer from respiratory nutritional plan of care to include which of the infections due to altered immune response (e.g., decreased cell‐mediated immunity, altered following concepts? immunoglobulin production, and impaired cellular resistance). Options 3 and 4 are incorrect because COPD clients usually present with weight loss and are hypermetabolic (i.e., require additional calories due to increased energy requirements as a result of increased work of breathing). ‐ The client has an adequate immune response. ‐ Clients with COPD are at increased risk of suffering from malnutrition. ‐ The client is likely to experience weight gain due to fluid retention. ‐ Decreased energy requirements often lead to weight gain. | Recall that clients with COPD have increased needs for calories and protein to be directed to option 2. |
4043 A 28‐year‐old client who is admitted to the unit with a Correct answer: 2 A client with MS is prone to developing both bowel and bladder dysfunction as a result of this relapse of multiple sclerosis (MS) is experiencing progressive degenerative neurological disease. Increasing fluids and roughage in the diet will constipation. The client asks what other methods help to facilitate evacuation by improving stool consistency. Option 1 is incorrect because the besides using laxatives can be used to prevent or treat client needs increased fluids. Option 3 is incorrect because increasing ROM exercises provides this condition. How should the nurse respond to the for joint motion but does not necessarily exercise the abdominal muscles, which could client's concern? influence peristalsis. Option 4 is incorrect because there is not enough clinical information provided to make this assessment. The nurse would have to assess further for elimination pattern and the date of the client's most recent bowel movement. ‐ Tell the client to reduce fluid intake. ‐ Have the client increase roughage in the diet. ‐ Have the client increase range of motion (ROM) exercises to stimulate peristalsis. ‐ Call the physician regarding an order for an enema. | Note that the question addresses the need to treat constipation without laxatives to eliminate option 4. Option 3 will not have a direct effect on bowel elimination and can be eliminated. Option 1 will aggravate constipation and needs to be eliminated as well. |
4044 A client covering from a spinal cord injury (SCI) has Correct answer: 1 Even though a client has had an SCI, the use of a diet high in protein, carbohydrates, and fiber been referred for nutritional counseling due to weight is necessary to prevent both the catabolic process that occurs following SCI and potential loss. The client states, "If I eat too much, the weight problems with bowel function. Option 2 is incorrect because it reflects the belief that weight will just stay on and I will become fat." How would the loss is an easy goal to achieve. Option 3 is incorrect because it assumes that merely getting nurse best respond to this statement? foods that the client likes will correct the problem. Option 4 is incorrect because excess nutrient stores will not merely help to preserve skin integrity but are needed for overall support of the client's metabolism and immune response. ‐ "It is important to continue to eat a diet high in protein, carbohydrates, and fiber to maintain optimal body function." ‐ "I know that you are concerned about weight gain, but you can always diet later on." ‐ "Let me know what your food preferences are and I will get you additional portions of whatever you like." ‐ "It is important to have extra nutrient stores in order to preserve skin integrity." | Eliminate options that do not address the client's concern (2 and 3). Choose option 1 over 4 since it provides a broader, more inclusive answer. |
4045 A client being treated for gout is being evaluated for Correct answer: 1 Scrambled eggs, white toast, and coffee are all foods that are low in purine content. A client compliance with diet therapy. Which of the following who is being treated for gout should restrict dietary purine sources because they can lead to meal selections would indicate that the client has an exacerbation of the disease process. All of the other choices reflect dietary selections that adhered to the diet plan? range from moderate to high purine content. If dietary education is successful, then the client would avoid/limit these food selections. ‐ Scrambled eggs, white toast, and coffee ‐ Seafood casserole, wheat roll, and soda ‐ Pizza with anchovies and soda ‐ Braised liver, lentils, green peas, and tea | Recognize that gout is affected by purine metabolism and systematically eliminate foods containing purines. |
4046 A client is to undergo bone marrow transplantation Correct answer: 3 A client undergoing a BMT will probably be fed by TPN in the post‐transplant period due to (BMT) for treatment of leukemia and is receiving pre‐ potential complications affecting the mouth, esophagus, and intestines, leading to diarrhea procedure teaching about nutrition. Which of the and malabsorption. Option 1 is incorrect. Supplemental enteral feedings would not help following postoperative nutritional support options because the client's GI tract has been affected by chemotherapy and other medical does the nurse anticipate will be utilized? treatments. In addition, merely supplementing the client will not provide sufficient calories and nutrients. Option 2 is incorrect because oral intake is usually not available due to side effects from high dose chemotherapy regimens that lead to anorexia, taste perception, nausea, vomiting, and inflammation of mucous membranes. Initiation of oral feedings will not prevent gastroparesis. Option 4 is incorrect because there is nothing to suggest that a PEG tube would be indicated. The goal with BMT clients is to return to a "normal" route‐feeding regimen as soon as possible once clinical effects of immunosuppression have been resolved. ‐ Supplementation with enteral feedings to prevent catabolism ‐ Oral feedings as soon as possible following BMT to prevent gastroparesis ‐ Total parenteral nutrition (TPN) for a period of months to maintain nutritional balance ‐ Insertion of a PEG tube following the BMT to maintain nutritional balance | Recognize the need for prolonged nutritional therapy and to bypass the enteral system following a transplant to direct you to option 3. |
4047 A 42‐year‐old male client with AIDS is admitted with Correct answer: 3 A client complaining that he has "difficulty eating and swallowing just about anything" may dehydration. The client states he has "difficulty eating have a fungal infection of the mouth and/or esophagus. A clinical diagnosis of AIDS suggests and swallowing just about anything." The client has that the client is at high risk for developing an opportunistic infection. Option 1 is incorrect. lost 10 pounds over a 3‐week period. What does the Even if the client may not be able to shop because of fatigue or other factors, it doesn’t nurse identify as the most likely etiology for the directly explain the client’s statement. Option 2 is incorrect because the client's complaint client’s chief complaint? addresses the issue of swallowing, not anorexia. Option 4 is incorrect—there is nothing to suggest that the client has not been compliant with the medication regimen. The presence of opportunistic disease can occur even in the presence of medication therapy due to underlying immunosuppression. ‐ The client has been too weak to shop for food. ‐ The client's medication profile is causing him to develop anorexia. ‐ The client could be developing an opportunistic infection. ‐ The client has not been compliant with medication regimen. | Critical words are difficulty eating and swallowing. Eliminate options 1 and 4 since they do not address the problem directly. Eliminate option 2 because anorexia is not the problem. |
4048 A 60‐year‐old male client who has had chronic Correct answer: 4 A client with COPD is often hypermetabolic from the disease process and requires increased obstructive pulmonary disease (COPD) for 15 years is calories, proteins, vitamins, and minerals in order to maintain desired weight and meet experiencing weight loss despite insisting that he has additional energy demands. Option 1 is incorrect: Caloric intake is not adequate, and been "eating a well‐balanced diet." The diet history increasing fat percentage above 30% is not prudent. Option 2 is incorrect: Increasing indicates the client has been consuming an adequate carbohydrates in the diet can lead to increased respiratory workload due to excess acid caloric intake of approximately 2,500 kilocalories per production. Option 3 is incorrect because increasing activity level will not help to prevent day composed of 15% protein, 70% carbohydrates weight loss. In addition, the client may not be able to increase activity level due to effects of (CHOs), and 15% fat. What recommendations would COPD. the nurse make regarding the client's weight status? | Recall the need for a high‐protein, high‐caloric diet with COPD. Eliminate options 1 and 2 since fats and CHO should not be increased. Eliminate option 3 since this could cause further weight loss. |
‐ Maintain calories and increase percentage of fat to 35% in the diet to promote weight gain. ‐ Decrease the amount of fat in the diet and increase complex CHOs. ‐ Increase activity level as caloric intake and percentages of nutrients are adequate to sustain weight status. ‐ Increase calories, protein, fat, vitamins, and minerals in order to prevent further weight loss. | |
4049 When assessing a client with scleroderma, the nurse Correct answer: 3 A client with scleroderma often suffers from increased acid secretion and esophageal reflux. identifies that which of the following conditions This could pose a significant nutritional problem. Option 1 is incorrect. Anorexia is not associated with this disease could present a nutritional commonly associated with this disease process. Option 2 is incorrect because alternating problem? periods of constipation and diarrhea are usually seen in a client who is experiencing irritable bowel syndrome (IBS). Option 4 is incorrect. Skin becomes hardened during this disease process and skin turgor is not increased. ‐ Diarrhea and anorexia ‐ Alternating constipation and diarrhea ‐ Reports of frequent heartburn ‐ Increased skin turgor | Recall that clients with scleroderma experience esophageal reflux to direct you to option 3, since clients with reflux often report heartburn. |
4050 Which of the following statements about cancer Correct answer: 3 Cancer cachexia is a syndrome that occurs in clients with cancer (malignancy) that leads to a cachexia would the nurse use in response to a cancer loss of muscle, fat, and body weight. It is thought to occur due to tumor‐induced changes that client questioning weight loss and wasting? cause profound effects on metabolism, nutrient losses, and anorexia. A cycle of wasting is established because alterations in nutrient requirements and intake lead to high cell turnover in body organs, affecting the GI tract and bone marrow. Alterations in digestion occur along with decreased immune response. Option 1 is incorrect because in simple starvation the body adapts to a lower metabolic rate. A client with cancer cachexia does not have an adaptive metabolic rate. The metabolic rate can be normal, decreased, or increased. Option 2 is incorrect because cancer cachexia occurs in the presence of both chemotherapy and radiation. Option 4 is incorrect—cancer cachexia can be seen in clients who have adequate caloric intake because it is not calorie dependent. ‐ "It is no different than simple starvation because the metabolic rate declines in response to tumor growth." ‐ "Cancer cachexia occurs as a result of chemotherapy but not radiation therapy." ‐ "Cancer cachexia occurs as a result of tumor‐induced changes." ‐ "It is usually seen in clients who have limited caloric intake." | First eliminate option as too general. Recall cancer cachexia is associated with tumors to direct you to option 3. |
4051 A 48‐year‐old male client who is HIV‐positive is being Correct answer: 2 A client who is receiving isoniazid (INH) as a prophylaxis for tuberculosis is at highest risk for treated prophylactically with isoniazid (INH). The nurse deficiencies of vitamins, specifically vitamin B<sub>6</sub> (because the drug acts concludes that this client is at highest risk for which of as a vitamin antagonist) and vitamin B<sub>12</sub> (interferes with absorption). the following nutritional problems? All of the other choices do not occur as a result of the action of this medication. ‐ Frequent bouts of diarrhea ‐ Deficiency of B vitamins ‐ Development of dental caries ‐ Excessive flatus formation | Recall significance of INH to intake of vitamin B<sub>6</sub> to prevent peripheral neuropathies. This will direct you to option 2. |
4052 A 52‐year‐old male client being treated for cancer is Correct answer: 2 Megesterol acetate (Megace) is oral progesterone that is used for both male and female use of a "female hormone," megesterol acetate clients to boost appetite and promote weight gain. It is important that all clients receive (Megace), as part of the treatment regimen. He is accurate information about prescribed medications and are aware of the indication for the afraid that it will alter his appearance. The nurse drug, potential side effects, and expected response to treatment. The nurse should respond to should respond to the client's concern of altered body the client's concern initially with factual information because the client does not seem to image by first explaining: understand the effect of the medication. Options 1 and 4 are incorrect because they do not address the client's concern and might further increase his anxiety about body image changes. Option 3 is incorrect because even though the client has the right to refuse any treatment, the response does not attempt to communicate pertinent factual information. | Recall the use of Megace in cancer and malnourished clients to direct you to option 2. |
‐ "The physical changes are only temporary." ‐ "This medication is used for its ability to stimulate appetite." ‐ "Your concern is realistic and you should not take the medication if you feel this way." ‐ "The medication will be used for a short time and any effects will be self‐limiting." | |
4053 Which one of the following actions by the nurse Correct answer: 1 Food should be cooked to reduce bacteria, which the immunosuppressed client cannot fight would be most appropriate related to diet selection effectively. Option 3 is incorrect, while options 2 and 4 are not relevant to the question as for an immunosuppressed client? stated. ‐ Provide any food enjoyed by the client as long as it is thoroughly cooked (i.e., well done). ‐ Limit fluids to prevent edema due to decreased protein stores. ‐ Encourage fresh foods and vegetable produce, which are essential to maintain adequate nutrition. ‐ Cut foods into small pieces to facilitate chewing. | The critical word is immunosuppressed. Recall the client is a risk for infection to direct you to option 1. |
4054 A 47‐year‐old male client with renal disease does not Correct answer: 3 Even though protein restriction is the mainstay of therapy for clients with impaired renal understand why the nurse is instructing him to include function, high biologic value proteins are favored due to their high content of essential amino high biologic value protein in the diet, since he has acids. Option 1 is incorrect because high biologic value proteins help to minimize urea always been told to restrict protein. What explanation production by allowing synthesis of nonessential amino acids from essential amino acids. should the nurse give to the client? Option 2 is incorrect: Protein restriction is needed because the kidneys’ ability to excrete nitrogenous end products is impaired in clients with renal disease. Option 4 is incorrect: Even though it is true the high biologic value proteins are necessary, they are not reserved only for clients on dialysis. ‐ High biologic value proteins help to increase urea excretion. ‐ Increased protein is needed to prevent catabolism, regardless of the stage of renal disease. ‐ High biologic value proteins contain essential amino acids that are necessary to maintain nutritional balance. ‐ High biologic value proteins are needed during times of stress to maximize metabolic efforts only in clients on dialysis therapy. | The critical words are high biologic value. Eliminate options 1 and 2 as incorrect information. Note the restriction of only in option 4 and eliminate it. |
4055 When assessing a client with a history of kidney Correct answer: 3 Vitamin C in megadoses can increase the risk for oxalate stone formation. It would be stones, the nurse notes the client is taking daily important to determine the amount of vitamin C that the client is taking in relation to the vitamin C supplements. What dietary counseling potential effects of stone formation. Option 1 is incorrect: Even though vitamin C has should the nurse provide to this client? antioxidant effects, the potential for stone formation outweighs the benefit of taking large doses of vitamin C. While it is important to increase fluids to prevent urinary stasis, option 2 is incorrect because the statement does not specifically address the issue of vitamin C supplements. Option 4 is incorrect since animal protein should be decreased in order to minimize potential stone formation. ‐ The client should increase daily intake of vitamin C for its antioxidant effects. ‐ Fluid intake should be monitored to prevent stone formation. ‐ Limit intake of supplemental vitamin C, which can exacerbate stone formation if taken in high doses. ‐ Stop taking vitamin C because it is only beneficial for common cold symptoms. | Identify the relationship between kidney stones and vitamin C to direct you to option 3. |
4056 What interventions should the nurse plan for in a Correct answer: 4 Elemental zinc taken with food or milk will help correct alterations in taste (i.e., dysgeusia). client admitted to the oncology unit for chemotherapy Option 1 is incorrect because this intervention is used to treat anticipatory nausea. While it is who is experiencing dysgeusia? important to assess a client for signs of dehydration (option 2), it is more important to correct altered taste sensation to enable the client to increase intake. Option 3 is incorrect because highly seasoned foods can cause nausea and irritation. ‐ Premedicate the client with an antiemetic. ‐ Observe the client for signs of dehydration. ‐ Use highly seasoned foods to stimulate taste buds. ‐ Obtain an order for zinc and give with food or milk to treat the symptom. | Recall meaning of the word dysgeusia. If you have difficulty with the question, recognize options 1 and 2 are applicable for many conditions and option 3 would not be recommended for a client receiving chemotherapy. |
4057 Which dietary instruction is most appropriate for the Correct answer: 3 Small frequent meals provide for adequate intake with reduced fatigue and SOB. Simple client with chronic obstructive pulmonary disease carbohydrates do provide quick energy, but a mixture of nutrients reduces carbon dioxide (COPD) experiencing fatigue and shortness of breath production and maintains respiratory function. Fat consumption can lead to hyperlipidemia during mealtime? and should only provide approximately 30 percent of total calories. Most individuals have more energy in the morning than evening. ‐ Include simple carbohydrates (CHO) for quick energy. ‐ Eat fatty foods to increase calorie intake. ‐ Eat frequent small meals to decrease energy use. ‐ Eat the largest meal before bedtime. | Refer to most appropriate in the stem of question and option 3 that makes reference to mealtime and decrease of energy needs. |
4058 A client presenting with ascites secondary to liver Correct answer: 4 A client experiencing ascites due to liver failure has decreased protein levels (albumin) that failure is being evaluated for fluid balance. The nurse lead to third spacing of fluids. The calculation of dry weight (i.e., total weight minus the weight would best assess fluid status using which of the of ascites) is critical to determining fluid status and medical management of the client. Option following? 1 is incorrect because it does not address the issue of ascites specifically but rather looks at a strict volume measurement. Option 2 is incorrect because one would expect abnormal liver function tests but this information is again not specific to fluid status but rather to the status of liver function. Option 3 is incorrect: Even though serum protein levels would be expected to be low, the caloric intake level would not help to define fluid status. ‐ Intake and output measurement ‐ Liver function test results ‐ Caloric intake and serum protein levels ‐ Dry weight calculation | Core concept is liver failure and ascites. Recall the fluid shifts that occur to direct you to option 4. |
4059 A client who has cirrhosis of the liver is now Correct answer: 2 A client being treated for hepatic encephalopathy has increased ammonia levels and is likely diagnosed with hepatic encephalopathy. The dietitian to be experiencing mental status changes and fluid retention (ascites). It is important for the has been consulted to evaluate this client for dietitian to note that the client's mental status precludes normal intake and nutrition support appropriate nutritional therapy. What priority may be indicated. Option 1 is incorrect. Although a weight and caloric baseline would be information should the nurse provide to the dietician important for the dietician to review, the current nutritional goal would be to decrease factors to help formulate nutritional goals for the client? that could lead to fluid retention and increased ammonia levels. Option 3 is less important than understanding the mental status as a basis for formulating nutritional goals. Although it is nice to know that the client has been compliant with medical treatment thus far, option 4 is incorrect because it does not specifically address the establishment of nutritional goals. ‐ Client's usual weight and caloric intake pattern prior to admission ‐ Client's reduced intake secondary to decreased mental status ‐ Client has a preference for snack foods and sodas ‐ Client has been compliant with medical treatment during this hospitalization | Core concepts are encephalopathy and nutritional support. Eliminate options 1, 3, and 4 since they do not address current eating pattern or intake. |
4060 The nurse is teaching the wife of a client who has a Correct answer: 4 The neutropenic client is immunocompromised and susceptible to bacterial contamination neutrophil count of 500/mm<sup>3</sup> from food. Cross contamination is avoided by using separate cutting boards. Vegetables may about dietary precautions that should be instituted. be eaten raw as long as they are thoroughly washed. It is not necessary to boil liquids, and Which of the following instructions should the nurse seeds and nuts may be eaten. include? ‐ Avoid eating any raw vegetables. ‐ Boil all liquids before serving them. ‐ Do not let him eat any seeds or nuts. ‐ Use a separate cutting board for beef and poultry. | Critical words are neutropenic precautions. Review new guidelines and recognize client is immunosuppressed to direct you to option 4. |
4061 The spouse of a client with Parkinson’s wants to know Correct answer: 1 A client with Parkinson's is at risk for aspiration. The statement by the client's wife indicates how to best assist her husband during feeding as he is that the client is experiencing an increase in clinical symptoms such as drooling and impaired having "increasing problems with drooling and swallowing. The use of thickened liquids and proper positioning can minimize the risk of swallowing." What instruction should the nurse aspiration and help the client's wife to feel comfortable and knowledgeable regarding feeding provide to the family member? concerns. The spouse should also notify the physician because an adjustment in medications may be needed. Option 2 is incorrect. There is not enough information to state that the client should be switched to enteral feedings at this time. Option 3 is incorrect because merely increasing fluids in a client experiencing increased drooling and difficulty swallowing could further increase the risk of aspiration. Option 4 is incorrect. Merely using a straw will not help to correct the underlying problems and could possibly increase the risk of aspiration due to inability to manage fluids. ‐ "Use thickened liquids along with upright positioning during feeding." ‐ "It might be time to switch to enteral feedings if you are afraid that your husband may choke." ‐ "Increase the amount of fluids he receives to decrease saliva formation and improve swallowing." ‐ "Use a straw during feedings to facilitate swallowing." | The problem with swallowing indicates a safety concern. Eliminate options 2, 3, and 4 since they do not offer appropriate suggestions to reduce risk of aspiration. |
4062 Which of the following foods enjoyed by a client with Correct answer: 1, 2, 3 Organ meats, such as liver, kidney, brain, and sweet breads are high in purines. Considered as gout would the nurse encourage the client to continue moderately high would be meats, seafood, and dried beans. The other choices are not high in to include in the diet? Select all that apply. purines. ‐ Beets ‐ Milk ‐ Eggs ‐ Sweetbreads ‐ Sardines | The core issue of the question is knowledge of foods that need to be avoided with gout because they are high in purines. With this in mind, choose the foods that are not high in purines. |
4063 Which of the following items should the nurse include Correct answer: 4 Foods containing gluten (e.g., wheat, oats, rye, and barley) are restricted for a client with in the diet of a client diagnosed with celiac disease? celiac disease, due to the client's inability to handle gluten protein. All of the other choices reflect items that cannot be used in a gluten‐restricted diet. ‐ Oatmeal ‐ Whole wheat toast ‐ Beef barley soup ‐ Cornflakes | Recall that clients with celiac disease cannot metabolize gluten to be directed to option 4. |
4064 Which of the following food selections would the Correct answer: 3 A client taking MAO inhibitors has to avoid foods that are high in tyramine because this can nurse include in the diet of a client taking monoamine lead to significant complications, resulting in hypertensive crisis. Cottage cheese represents an oxidase (MAO) inhibitors? unfermented cheese that can be used in the diet. All of the other options reflect foods that are high in tyramine. Aged cheeses are not allowed on the diet. ‐ Smoked fish ‐ Bologna sandwich ‐ Cottage cheese ‐ Salad with bleu cheese dressing | Recall the need to eliminate foods high in tyramine when taking MAO inhibitors. Recall foods in this category are often smoked, aged, or fermented to help you eliminate options 1, 2, and 4. |
4065 The nurse places highest priority on which Correct answer: 2 It is critical to verify tube placement prior to administration of any enteral feeding regimen to intervention when preparing to administer an enteral prevent the risk of aspiration. All of the other options are important but they are not the feeding? highest priority at the present time. ‐ Checking gastric residual ‐ Verifyimng tube placement ‐ Monitoring glucose levels ‐ Verifying intake and output | Key word is enteral. Recall the importance of preventing instillation of the feeding into the lungs to be directed to option 2. |
4066 A client who is severely malnourished because of Correct answer: 4 A severely malnourished client with a nonfunctional gut is unable to meet nutritional goals nonfunctional gut requires nutritional support. The through enteral feeding. This client needs to meet nutritional goals through total parenteral nurse recognizes which of the following methods nutrition (TPN) via a central line placement. Option 1 is incorrect because this client will not be would assist the client in meeting nutritional goals? able to tolerate cyclic feedings due to existing clinical state. Options 2 and 3 are incorrect because both enteral tube feedings and PPN will not be able to supply enough calories and nutritional support for this type of client. ‐ Cyclic feeding of total parenteral nutrition (TPN) via central line placement ‐ Continuous enteral feeding via tube placement ‐ Nutritional support through partial parenteral nutrition (PPN) ‐ TPN via central line placement | Key concept is severe malnutrition. Note the gut is not functioning and eliminate option 2. Recall that TPN provides the most concentrated source of nutrition to be directed to option 4. |
4067 What factors should the nurse include in the dietary Correct answer: 3 A client with gestational diabetes encounters increased metabolic needs from the pregnancy plan for a client with gestational diabetes? that result in an increased hormonal response and insulin sensitivity. Incorporating snacks in the diet plan will help to maintain a constant glucose supply and prevent potential imbalances. Option 1 is incorrect because a decrease in CHO sources is recommended for a client who has gestational diabetes in order to prevent excessive glycemic response. Option 2 is incorrect as an increase in calories is warranted, but this amount is too excessive and may further contribute to health problems and weight gain. Option 4 is incorrect because increasing CHO intake at one meal will lead to an overactive glycemic response. ‐ Increase the amount of carbohydrate (CHO) sources to maintain insulin response. ‐ Increase caloric intake to the normal value to meet growing metabolic needs of the maternal fetal unit. ‐ Incorporate snacks to maintain glucose balance because of increased metabolic needs. ‐ Have the majority of CHO intake during the breakfast meal to act as a significant fuel source for the rest of the day. | Key term is gestational diabetes. Recognize the need for glucose control while providing for increased metabolic demands on the mother to be directed to option 3. |
4068 What measures can be taken by the nurse to prevent Correct answer: 2 TPN solutions should be administered via an infusion pump so that fluid rate and volume can fluid volume excess (FVE) from developing in a client be controlled. This will prevent the risk of developing FVE as a result of inadequate rate who is receiving total parenteral nutrition (TPN)? regulation, leading to increased potential volume. All of the other options reflect acceptable nursing actions in regards to TPN therapy, but these will not affect the nursing diagnosis of FVE. ‐ Monitor client's blood glucose level during infusion of TPN ‐ Use infusion pump to administer TPN fluids ‐ Change TPN solution every 24 hours ‐ Monitor catheter insertion site during therapy | Key terms are FVE and TPN. Note that all the options are related to responsibilities of TPN infusion, but only option 2 involves regulation of fluid volume. |
4069 Which of the following diagnostic tests should the Correct answer: 4 Serum transferrin levels indicate visceral protein stores in the body. Albumin and prealbumin nurse check to monitor the protein status of a client levels also serve to indicate protein status. Option 1 is incorrect because BUN levels can be receiving nutritional support therapy? affected by a multitude of factors ranging from dehydration to renal status. Option 2 is incorrect as CBC with differential indicates hematology status. While it may reflect anemia, it is not considered a protein status indicator. Option 3 is incorrect because it would give information about to elimination and renal status. While it may reflect protein spilled in the urine, it is not considered a protein status indicator. ‐ BUN ‐ CBC with differential ‐ Urinalysis ‐ Serum transferrin | Key term is protein status. Review the purpose of each laboratory test provided in the choices, choosing option 4 since it is most specific to protein stores. |
4070 The nurse teaches a client with lactose intolerance to Correct answer: 1, 4 Casein and whey are often used as additives and stabilizers in processed foods. The client check food labels for which additives, since they may with lactose intolerance may have difficulty digesting these additives since they are milk cause gas and bloating? Select all that apply. products. Sodium phosphate is a preservative. Lecithin is an emulsifier. Maltodextrin is a sugar. ‐ Casein ‐ Sodium phosphate ‐ Lecithin ‐ Whey ‐ Maltodextrin | Key term is lactose intolerance, indicating the client has difficulty digesting milk products. Recognize casein and whey as by products of milk. |
4071 A client with a history of gout is concerned about Correct answer: 4 It is important to acknowledge the client's concerns about lifestyle changes. The offer of maintaining a purine‐restricted diet for the rest of his assisting the client in designing a diet plan with the required restriction but yet focusing on life. How should the nurse best respond to the client's palatability will increase client compliance. Option 1 is incorrect because this statement does concern? not take into account client preferences or stated client concerns. Option 2 is incorrect as this statement does not acknowledge the fact that this is a necessary diet for the client to prevent clinical symptoms. Option 3 is incorrect because this statement is not therapeutic and is viewed as being a punitive choice. ‐ Suggest that the client learn to eat pizza without anchovies. ‐ Have the client provide a listing of food preferences and suggest that he continue to eat what he likes, but in smaller quantities. ‐ Suggest to the client that this is for his own good to prevent further gouty attacks. ‐ Assist the client in designing a diet plan that minimizes purine ingestion but yet is palatable. | Key words are purine‐restricted diet and best. Recall foods high in purines and note the psychological aspect of the question. |
4072 An elderly client is admitted to the hospital with Correct answer: 1 This client presents in a depressed state with mild dehydration and recent weight loss. Enteral dehydration, weight loss of 15 pounds within the last feedings via an NG tube would help support the client in meeting nutritional goals. Option 2 is month, and in a depressive state. Which of the not correct because the client's clinical status does not indicate the need for TPN following nutritional support methods will the nurse administration at this time. Option 3 is not correct as surgical placement of a feeding tube is an anticipate being initiated for this client? invasive procedure that is not clinically indicated given the client information. Option 4 is incorrect because merely encouraging fluids, although high in protein, will not provide sufficient calories to maintain nutritional goals. Also, the client is admitted in a depressed state and, as shown by the recent history of weight loss, has not maintained adequate oral intake. ‐ Nasogastric (NG) enteral feeding ‐ Total parenteral nutrition (TPN) ‐ Percutaneous endoscopic gastronomy (PEG) tube insertion with enteral feeding ‐ Encouraged intake of high protein liquid supplements | Note that the client is dehydrated, depressed, and with significant weight loss. Recognize this indicates a need to restore fluids and nutritional balance to be directed to option 1. |
4073 A client with an acute exacerbation of Crohn’s disease Correct answer: 2 Clients should have a transition period from TPN to oral feedings. The GI tract will need time is having oral intake resumed after having been NPO to adjust, and the client may experience some GI upset, so TPN is not stopped abruptly. and receiving total parenteral nutrition (TPN) for 3 Restriction to ice chips would not be necessary; diet can be resumed starting with fluids or as weeks. The nurse plans to do which of the following in tolerated. The client may not eat sufficient calories during the day, so rate of TPN is usually order to ease transition of feeding methods? tapered, rather than only infusing it at nighttime. ‐ Allow client to have only ice chips for the first 2 days. ‐ Gradually begin oral feedings as parenteral solution is decreased. ‐ Infuse the TPN solution during the nighttime only when client is sleeping. ‐ Begin oral feedings of soft foods and stop TPN infusion. | The core concept of the question is transitioning from TPN to oral intake. Recall the bowel has not been metabolizing food for 3 weeks while client was NPO. Recognize the need to ease the transition and associate the word gradually in option 2 to this process. |
4074 Which of the following should the nurse include in a Correct answer: 2 TPN solutions should be changed every 24 hours in order to prevent bacterial overgrowth due plan of care for a client receiving total parenteral to hypertonicity of the solution. Option 1 is incorrect because medication therapy can continue nutrition (TPN)? during TPN therapy. Option 3 is incorrect since flushing is not required for TPN administration. Option 4 is incorrect because the initiation of TPN does not require a client to remain on bed rest during therapy. However, other clinical conditions of the client may affect mobility issues and warrant the client's being on bed rest. ‐ Withhold oral medications while the TPN is infusing. ‐ Change TPN solution every 24 hours. ‐ Flush the TPN line with water prior to initiating nutritional support. ‐ Keep client on complete bedrest during TPN therapy. | Review principles related to administration of TPN and recognize the actions in options 1, 3, and 4 are not necessary. Recall any intravenous solution should be changed after 24 hours to choose option 2. |
4075 Which of the following should the nurse plan to do in Correct answer: 1 TPN solutions are hypertonic, hyperosmolar solutions that lead to an increased glycemic load. order to maintain normal glucose levels in a client In response to this hyperglycemia, often a sliding scale insulin (with regular insulin) is used to receiving total parenteral nutrition (TPN) therapy? restore, prevent, or control the effects of the hyperglycemia. Options 2 and 3 are incorrect because the TPN rate is individualized to the client and should not be adjusted unless directed by the physician because of changes in the client’s clinical conditions. Option 4 is incorrect because only regular insulin is used as an additive in TPN solutions. ‐ Monitor blood glucose every 4–6 hours depending on the client's acuity and follow regular insulin sliding scale. ‐ Decrease rate of TPN solution to maintain euglycemic levels. ‐ Increase the rate of TPN solution to maintain euglycemic levels. ‐ Use NPH insulin as an additive in TPN solutions to help maintain euglycemic levels. | Note options 2 and 3 are opposite and require a physician’s order to eliminate them. Recognize regular insulin is the only insulin that can be given intravenously and eliminate option 4. Recall the high glucose content of TPN to direct you to option 1. |
4076 The nurse anticipates which type of enteral feeding Correct answer: 3 Elemental formulas represent predigested formulations of macronutrients that are beneficial formula will be selected for a client who has problems to clients with severe digestive or absorption problems. Option 1 is incorrect: Modular with severe digestion or absorption of nutrients? formulas are not nutritionally complete because they provide only one nutrient source. Options 2 and 4 represent intact protein sources that are not suitable for a client with digestive or absorptive problems. ‐ Modular ‐ Polymeric ‐ Elemental ‐ Ensure | Critical words are severe digestive problems and absorption. Recall content of the various formulas in the options, noting the client has severe problems and option 1 contains only 1 nutrient source. If you had difficulty with this question, review content of the various nutritional formulas. |
4077 A client with a history of food allergies asks how to Correct answer: 3 Avoidance and restriction of food items known to cause allergies is the most effective way to decrease the likelihood of allergic potential. What prevent the development of potential food allergies. Option 1 is incorrect—even small response by the nurse would be best? amounts of “allergic” food items can trigger a response (sensitizing—challenging dose). Option 2 is incorrect—increasing fluids does not affect allergy development. Option 4 is incorrect because the use of antihistamine medication may alleviate symptoms of allergic responses but should not be used as a prophylactic measure in assisting dietary selection. ‐ "Eat only small amounts of a food if it has allergic potential." ‐ "Increase the fluid content of the diet to minimize risk of food allergies." ‐ "Avoid food items identified as potential allergens." ‐ "Take antihistamines to prevent allergic reactions and eat what you like." | The core concept is avoidance of food allergens. Eliminate options 1 and 4 since they are unsafe advice. Recognize option 2 is not true to eliminate it. |
4078 A client is placed on a low‐residue diet. The nurse Correct answer: 4 Milk and milk products are limited in low‐residue diets. All of the other diet selections can be evaluates that the client understood dietary used for this type of diet and indicate client understanding. instructions given if the client states that she will refrain from eating which of the following favorite food items? ‐ Orange juice ‐ Baked potatoes | A critical term is low‐residue. Recall knowledge of residue and systematically eliminate options 1, 2, and 3. |
‐ Toasted white bread ‐ Milk | |
4079 The nurse considers which of the following factors to Correct answer: 3 Presence of bowel sounds accompanied by passage of flatus indicates gastric motility and be necessary in order to allow progression of the diet return of "normal" GI functioning. Option 1 is incorrect because postoperative clients are in a postoperative client? progressed in diet to assist in the restoration of ”normal” bowel activity. A bowel movement is not the initiating factor for diet progression. Option 2 is incorrect because abdominal distention might indicate a potential problem affecting GI motility. Option 4 is incorrect since a client's hunger is not the deciding factor in diet progression. ‐ Passage of a bowel movement ‐ Increased flatus production and slight abdominal distention ‐ Presence of bowel sounds and passage of flatus. ‐ Client reports feelings of hunger | Critical words are progression of diet and postoperative. Recall peristalsis is temporarily stopped secondary to anesthesia. Determine safety to begin feeding is present with return of peristalsis, indicated by passage of flatus and bowel sounds to direct you to option 3. |
4080 The nurse suggests which of the following diet Correct answer: 4 A full liquid diet contains all food items found on a clear liquid diet plus dairy products and selections for a client placed on a full liquid diet? prepared liquid formulas. Options 1 and 2 represent selections that are only found on a clear liquid diet. Option 3 represents a selection found on a low‐residue diet. ‐ Beef bouillon, cranberry juice, and tea ‐ Decaffeinated tea, gelatin, and ice pops ‐ Poached egg, coffee, and orange juice ‐ Plain yogurt and apple juice | The core concept in the question is a full liquid diet. Eliminate options 1 and 2 since they reflect clear liquids. Eliminate option 3 since it contains a solid food. |
4081 Which of the following should the nurse include as a Correct answer: 4 Transition (or progressive) diets are used on a short‐term basis to help the client move primary focus in the teaching plan for a client placed toward resumption of a regular diet pattern. A transition diet can progress rapidly from one on a transition diet? meal to the next if the client tolerates the feedings. Option 1 is incorrect because a transition diet is not given on a long‐term basis. Even though option 2 includes meal planning and diet selection techniques, this is not the primary focus in establishing a plan of care for this client in this short‐term therapy. Option 3 is important, but again, it is not the primary focus for this short‐term therapy. ‐ The diet will be used on a long‐term basis. ‐ The focus of the diet is on meal planning and diet selection technique. ‐ The client should understand the types of food items that are restricted on this diet. ‐ This diet plan will be a temporary dietary measure. | The critical words are primary focus and transitional diet. Note the similarity in the word transition in the question with the word temporary in option 4. |
4082 The nurse should include which of the following in a Correct answer: 2 Most clients with lactose intolerance can tolerate H cup milk at one time, and it provides a plan of care for a client who is mildly lactose calcium source. Option 1 is incorrect because the elimination of all dairy products can lead to intolerant? significant clinical deficiencies of other nutrients and may not be necessary. Option 3 is incorrect because drinking milk on an empty stomach can exacerbate clinical symptoms. Drinking milk with a meal may benefit the client because other foods (especially fat) may decrease transit time and allow for increased lactase activity. Option 4 is incorrect because although individual tolerance should be acknowledged, spreading out the use of known dairy products will usually exacerbate clinical symptoms. ‐ Remove all dairy products from the diet. ‐ Consume only an H cup of dairy products at one time. ‐ Drink small amounts of milk on an empty stomach. ‐ Spread out selection of dairy products throughout the day. | The critical words we lactose intolerant. Recognize the information in options 3 and 4 would not be recommended to eliminate them. Recall small amounts may be tolerated to choose option 2. |
4083 When caring for an elderly client who has difficulty Correct answer: 4 A mechanical soft diet can be used as part of a long‐term treatment plan because it includes chewing, the nurse identifies which of the following most foods found on a regular diet, except the texture is modified to assist clients who have diets to be most appropriate to use as a long‐term chewing problems. All of the other options reflect diets that should not be used on a long‐term treatment measure? basis. Clear and full liquid diets are not nutritionally complete and are missing calories, protein, vitamins, and electrolytes. In order to meet nutritional goals, a full liquid diet would require additional source supplementation. Option 3 is incorrect because a long‐term high‐protein diet can place additional renal demands on the individual client because of imposed solute loads. ‐ A low‐residue diet ‐ A full liquid diet ‐ A high‐protein diet ‐ A mechanical soft diet | Critical words in the question are long‐term and difficulty chewing. Recognize option 2 would not provide sufficient nutrients for long term and eliminate it. A low‐residue diet (option 1) helps reduce diarrhea but is not appropriate for the client who has difficulty with chewing. Long‐term high protein intake could also be harmful so eliminate option 3 as well. |
4084 A client who receives intermittent enteral feedings Correct answer: 2 It is important to check residuals prior to intermittent feedings (and every 4 hours for has a feeding ordered during the shift. Which of the continuous feedings) in order to evaluate if the client is able to process the feeding. Option 1 is following interventions would the nurse perform prior incorrect: Going to the bathroom prior to a feeding will not affect the feeding status, and the to starting the next feeding? client may also not be able to physically comply with this request. Option 3 is incorrect: Placing the client in this position is not warranted and can cause potential problems relative to impaired feeding or potential aspiration. Although monitoring of the client's intake and output for the last 24 hours is important, it is not as critical as checking for a residual at this point in time. ‐ Have the client go to the bathroom in preparation for the enteral feeding. ‐ Check the residual before beginning the feeding and note the amount. ‐ Place the client in a lateral recumbent position to facilitate the feeding. ‐ Tally the client's intake and output for the past 24 hours. | A critical word is prior. Eliminate option 1 since it does not pertain to the feeding. Recognize option 3 would be dangerous to eliminate it. Note the similarity in the word prior in the question with the word before in option 2 to direct you to the correct answer. |
4085 Which of the following nutritional interventions Correct answer: 3 The use of thickening agents is recommended for clients who have had CVA and have residual would be of most assistance to a client who has deficits that affect swallowing. The thickening agents are added to maximize texture, facilitate recently suffered a cerebrovascular accident (CVA)? the swallowing process, and minimize potential aspiration risks. Option 1 is incorrect because bite‐sized portions of foods may increase the risk of aspiration if they are swallowed and occlude the airway. The diet should be soft. Option 2 is incorrect. Merely placing the client on a full liquid diet gives no indication that the client is being assessed for potential aspiration or neurological deficits. Option 4 is incorrect because clients who are post‐CVA often encounter this type of problem; therefore, they should be properly monitored and assessed. ‐ Have the client eat bite‐sized portions of foods to facilitate digestion. ‐ Place the client on a full liquid diet. ‐ Use thickening agents to minimize the risk of aspiration and monitor the client closely during all feedings. ‐ Allow the client to eat alone as post‐CVA clients are often self‐conscious about their residual deficits. | Focus on the critical words assistance, suggesting client should not be left alone, and CVA to consider a risk for aspiration. |
4086 The nurse would expect which of the following Correct answer: 1, 3 TPN is indicated for disease states such as trauma/stress, surgical interventions, and/or assigned clients to be candidates for total parenteral related pathology of GI tract or oncological conditions. TPN is more appropriate for long‐term nutrition (TPN)? Select all that apply. nutritional support. All other options are clinical indications for enteral nutrition. ‐ A client suffering from severe trauma who is in a hypermetabolic state ‐ A client undergoing a cholecystectomy ‐ A client with short bowel syndrome ‐ A client undergoing radiation treatment for lung cancer ‐ A client recovering from a cerebrovascular accident (CVA) | Focus on knowledge of indications for TPN, especially the long‐term indicator. |
4087 A client given a clear‐liquid diet tray prior to Correct answer: 4 It is important to follow test diet instructions prior to diagnostic testing to ensure reliability diagnostic testing states, "I'm not eating this and want and consistency of test results. Conveying the indication for the use of a clear liquid tray will some real food." Which of the following would be the help the client to understand the treatment plan and foster compliance. Although option 1 best response by the nurse? might represent an accurate statement, it will not help the client with to deal with the present situation. Option 2 does not provide an adequate explanation to the client. Although option 3 is technically true, this response may serve to alienate the client as the nurse is not being sensitive to the client's needs. ‐ "I am sure that you will have a regular diet after the test, so please just try some of this for now." ‐ "Would like me to get you some other type of broth or juice?" ‐ "This is the diet that has been ordered for you. It is the only diet you can have right now." ‐ "I understand this is not your usual diet, but it is needed to help the test establish a diagnosis." | The critical word is best, indicating some options are correct, but one answers the question more thoroughly. Eliminate option 1 since it may offer false reassurance. Eliminate options 2 and 3 since they do offer the best explanation and do not adequately answer the client's question. |
4088 The nurse determines that which of the following Correct answer: 1 Increased fluid needs are indicated for a client who has burn injuries due to release of plasma assigned clients has an increased need for fluid intake? fluids through tissue destruction. All of the other options reflect clinical conditions that require a decrease in fluid needs. ‐ A client who has burn injuries ‐ A client in cardiac failure ‐ A client receiving blood transfusions ‐ A client in the oliguric phase of renal failure | Systematically evaluate each condition, recognizing fluid is retained in the conditions in options 2 and 4 and eliminate them. Recall the extensive fluid losses and shifts that occur in burn injuries to direct you to option 1. |
4089 The nurse has conducted discharge teaching for a Correct answer: 4 A clinical diagnosis of gout is associated with high uric acid levels in the body. Uric acid client diagnosed with gout. The nurse evaluates the represents the end product of purine catabolism in the body; therefore, foods that are high in client understood the instructions if the client states purines should be avoided. Anchovies are high in purine. All of the other options represent diet he will refrain from eating which of the following selections that are low in purine. favorite foods? ‐ Steak ‐ Poultry ‐ Dairy products ‐ Anchovies | The critical word is gout. Recall physiology of this metabolic disorder and need to restrict foods high in purines to choose option 4. |
4090 A client receiving total parenteral nutrition (TPN) via Correct answer: 24 The bag of TPN solution is changed every 24 hours. By reducing the number of times the TPN central venous catheter asks the nurse why the bag is tubing needs to be connected and disconnected from the central venous catheter, the risk of not changed as often as the IV bag of another client in infection is reduced, especially since high glucose levels in TPN can lead to bacterial growth. the room, who has IV solution ordered at a rate of 150 mL/hr. The nurse responds that the TPN bag is routinely changed every hours. Write in a numerical answer. | This question requires knowledge of factual information. Consider the common procedure for TPN bag changes to formulate a response. |
4091 Which one of the following diets would the nurse Correct answer: 3 A client being treated for dyslipidemia has an abnormal lipid profile that is high in cholesterol recommend for a client being treated for and triglycerides. The client needs a diet low in saturated fats with an increase in dyslipidemia? monounsaturated fats, small amounts of PUFA, and restricted sodium and hydrogenated food products. Option 1 is incorrect because high intake of PUFAs will cause a further increase in lipid levels. Option 2 is incorrect because protein‐controlled diets are usually indicated for clients who have renal disease. Option 4 is incorrect because monounsaturated fats should be increased, not decreased. ‐ High polyunsaturated fat diet ‐ Protein‐controlled diet with mild sodium restriction ‐ Low saturated fat diet ‐ Decreased monounsaturated fat diet | A critical word is dyslipidemia. Recall saturated fats contribute to lipid formation to eliminate options 1, 2, and 4. |
4092 The nurse uses which of the following rationales in Correct answer: 2 MAO inhibitor drug therapy can be complicated by excess intake of foods are high in tyramine deciding to perform a dietary assessment on a client (i.e., an intermediate product of amino acid metabolism), such as chocolate and cheese. These who is taking monoamine oxidase (MAO) inhibitors? can alter drug action, resulting in hypertensive crisis. Although all of the other options are also important, they are not the priority consideration when assessing a client on MAO therapy. ‐ It is important to determine food preferences since this may interfere with intake of nutrients. ‐ Certain foods, such as cheese or chocolate, can affect drug action, leading to serious complications. ‐ It is important to recognize potential food‐drug allergies because this may cause serious health problems. ‐ It is an expected assessment that is needed for any client. | Critical words are rationales and MAO inhibitors. Note option 1 does not address the medication to eliminate it. Eliminate option 3 since allergies are not the problem, and eliminate option 4 because it is too general. |
4093 Which of the following strategies should the nurse Correct answer: 2 Visualization of portion sizes is an extremely important strategy whereby the client is shown share with a client who wishes to avoid becoming graphic representations of what constitutes a serving size. Most often clients do not realize overweight? they are eating too large a portion, since traditional and "fast food" restaurants provide large servings. Option 1 is incorrect because following a low fiber diet may contribute to the development of weight gain because there is little satiety value in the diet. Options 3 and 4 are incorrect because an increase in other nutrients can lead to fat conversion during the metabolic process if intake exceeds the body's individual needs. ‐ Maintain a low‐fiber diet. ‐ Use visualization of portion sizes to control intake. ‐ Limit fat and increase the other nutrients such as protein and carbohydrates. ‐ Increase the amount of carbohydrates in the overall diet. | Note that options 3 and 4 increase intake of an item, which is counterproductive to the goal and eliminate them. Eliminate option 1 since it would also not contribute to weight loss. |
4094 The nurse plans to monitor a client with malnutrition Correct answer: 2 Malnutrition leads to severe metabolic and physiological consequences, resulting in the for which of the following consequences? inability to maintain adequate temperature regulation. A client with malnutrition is most likely to be found hypothermic upon physical examination. Option 1 is incorrect because hypoglycemia is more likely to occur with malnutrition. Option 3 is incorrect as a decrease in metabolic rate is usually seen with malnutrition. Option 4 is incorrect because immune function is depressed due to loss of protein stores in malnutrition. ‐ Hyperglycemia ‐ Hypothermia ‐ Increased metabolic rate ‐ Increased immune function | Key words are malnutrition and consequences. Note that most of the options involve an increased or elevated condition which would be the opposite of what would occur with lack of nutrient intake. |
4095 What advice can the nurse give to a client concerned Correct answer: 4 A comprehensive effort leads to the most effective long‐term management in regard to with weight control to help avoid the occurrence of weight control and will help to prevent the occurrence of weight cycling. Diet alone is not the weight cycling? answer to maintaining weight loss and avoiding the pitfall of weight cycling. If there are no other lifestyle modifications, then it is more likely that the client will regain or even surpass the initial starting weight. Although an increase in fluids is usually a beneficial choice in most diet plans (unless the client has fluid restriction issues related to disease processes), the addition of fluid will not help to prevent the occurrence of weight cycling. An altered meal pattern intake consisting of shakes/supplements for one meal may not translate to a balanced eating pattern. Again, if the client is not utilizing realistic goals and interventions, then resuming a "regular" diet pattern may lead to weight cycling. ‐ "Follow your dietary plan exactly as ordered and do not make any adjustments." ‐ "Increase the amount of fluids in your diet to maintain hydration." ‐ "Use nutritional shakes/supplements in the place of one meal each day." ‐ "Incorporate dietary reduction measures and physical activity into your weight loss program." | Key phrase is weight cycling. Note that option 4 is the only one to include exercise and recall the necessity of incorporating this into any weight loss maintenance to choose it. |
4096 When a client asks why central obesity is considered Correct answer: 1 The presence of central obesity (intra‐abdominal fat/truncal obesity) is associated with an to be a health risk factor; which of the following replies increased cardiac risk (hypertension and stroke) and diabetes. The accumulation of intra‐ by the nurse would be best? abdominal fat leads to increased cholesterol levels because the liver converts them directly into low density lipoproteins (LDL), a known risk factor for several disease processes. Option 2 is not clinically correlated as clients with cancer may present with cachexia or could be underweight. Option 3 is incorrect because an increase in central obesity is associated with an apple profile and it does not affect bone demineralization. Option 4 is incorrect since central obesity is usually seen in clients who smoke or drink alcohol, and it does not relate to vitamin deficiency. ‐ "Intra‐abdominal fat is associated with dyslipidemias, which increase risk of cardiovascular disease and diabetes." ‐ "Central obesity is associated with the development of cancer at several sites in the body." ‐ "Central obesity is associated with a pear‐like profile and this leads to bone demineralization over time." ‐ "Central obesity is seen in people who do not smoke or drink alcohol, but who tend to have vitamin deficiencies." | Key words are central obesity and risk factor. Recall that central obesity is also referred to as an apple shape and eliminate option 3. Recall correlation to heart disease to choose option 1. |
4097 A client informs the nurse he is trying to incorporate Correct answer: 4 Indoles are found in vegetables such as broccoli, cauliflower, and cabbage and offer more phytochemicals in his diet. Which of the protection against carcinogen development. All the other choices are phytochemicals; soymilk following menu choices made by the client indicate a and green tea provide isoflavones; carrots are high in carotenoids. choice of indoles? ‐ One cup of soy milk ‐ One‐half cup of carrots ‐ One cup of green tea ‐ One‐half cup of broccoli | Key word is indoles. Note that all the options are phytochemicals. Specific knowledge of indoles is necessary. |
4098 A mother is concerned that her daughter is going to Correct answer: 4 It is essential to address the parent's concern as being important and to include the daughter become obese as she is 5 feet tall and weighs 120 (client) in the plan of care. A comprehensive nutritional assessment is needed to support both pounds. The nurse should respond to the mother by of the family members. It is important to intervene, not merely react. Options 1 and 2 are saying: incorrect because they are not based on nutritional evidence. Option 3 reflects an alarmist attitude that could worsen the situation. ‐ "Children often grow out of their 'fat' stage, so there is little need to worry at this time." ‐ "It is too early to tell what your daughter's weight will be as an adult, so increase physical activity to prevent further weight gain." ‐ "This is indeed a serious concern and your daughter should probably be tested for diabetes." ‐ "A nutritional history should be done to assess typical intake pattern, physical activity level, and discuss body image concerns." | Recognize that height and weight may indicate an overweight condition, but more information is needed to direct you to option 4. |
4099 When taking a diet history the client admits to eating Correct answer: 2 Garlic can inhibit platelet function and ultimately affect coagulation ability during and after several cloves of garlic daily for its cardioprotective surgery. Nonsteroidal anti‐inflammatory drugs and aspirin, but not acetaminophen, can effect. Which of the following client situations would potentiate the action of garlic. The other conditions would not be affected by garlic be of most concern to the nurse? The client who: consumption. ‐ Is on strict bedrest. ‐ Is scheduled to have surgery. ‐ Has a history of migraine headaches. ‐ Takes acetaminophen for arthritic pain. | Key word is garlic. Analyze each option for impact or interaction of garlic intake, recalling the action this herb/food has on clotting ability and choose option 2. |
4100 Physical screening reveals a male client who is 6 feet Correct answer: 3 A client who is 6 feet tall with an average size frame should weigh roughly 178 pounds (106 tall and weighs 199 pounds. What information does for the first five feet with 6 pounds for every inch above). Taking into account body frame, this provide to the nurse in relation to a normal weight there could be a weight range from 168–188 pounds (small to large) that would be considered pattern? normal. Option 1 is incorrect because clearly the client is overweight with a calculated BMI of 27. Option 2 is incorrect as the client would not be considered to be obese but rather overweight. Option 4 is incorrect because the client clearly does not need additional calories in the diet. ‐ The client's weight is appropriate for his height and therefore no further action is needed. ‐ Given the client's height, his weight is not appropriate and the client should be treated for obesity. | Determine if the height and weight represent a normal, underweight, or overweight condition. |
‐ It is important to also note the client's body frame, as this will impact evaluation of normal weight pattern. ‐ The client is underweight and needs additional calories in the diet. | |
4101 A client is planning to use a diuretic to lose extra body Correct answer: 1 It is important that a client receives accurate information about reported weight loss weight. The nurse explains that diuretics: medication. Although diuretics promote fluid loss and are used in the clinical management of disease states (such as congestive heart failure and pulmonary edema), they do not promote fat loss and are therefore not an effective weight loss measure. Option 2 is incorrect because even though a prescription is required for the medication, it is not an effective weight loss treatment. Option 3 is incorrect as diuretics do have a therapeutic effect on fluid loss in the clinical setting in the management of disease states. Option 4 is incorrect because diuretics are not prescribed as an adjunct therapy for weight loss but may be used as an adjunct in the treatment of hypertension to promote fluid loss. ‐ Work to promote fluid loss, which is not the same as promoting fat loss. ‐ Require a prescription and long‐term therapy can be effective as a weight loss measure. ‐ Are used in the treatment of disease and have no therapeutic benefit on fluid loss. ‐ Should only be used as an adjunct to other weight loss programs. | Key words are diuretics and weight loss. Note some of the options are partially correct, but do not address the concern of using diuretics for weight loss and be directed to option 1. |
4102 The nurse has defined a goal of a weight gain of 2 Correct answer: 2 In order to affect a two‐pound weight gain, a client would need an extra 7,000 kilocalories per pounds in 1 week for an underweight client and week, which would correlate to 1,000 kilocalories per day. Option 1 is incorrect because it identifies an appropriate nursing intervention to be: does not give a specific amount of foods or calories. Option 3 is incorrect because 3,500 kilocalories per week would also lead to an increase of one pound. Option 4 is incorrect since a nutritional supplement may not provide the additional 1,000 calories per day needed. ‐ Incorporate more high fat and high carbohydrate foods into the diet. ‐ Increase caloric intake by 1,000 kilocalories per day for the week. ‐ Increase the caloric intake by 3,500 kilocalories per week. ‐ Have the client consume one high calorie nutritional supplement daily. | Key words are weight gain of 2 pounds per week. Note options 1 and 4 do not provide specific amounts. Recall the number of calories needed to gain one pound is 3,500 and choose option 2. |
4103 The nurse evaluates that a client understands the Correct answer: 3 A recommended weight loss pattern for the obese client is 0.5 to 1 pound per week. Option 3 need for a healthy weight loss pattern by indicating an offers the best possibility of maintaining weight loss. All of the other options are incorrect intention to lose: because too great a loss may predispose the client to weight cycling or loss of lean body mass. ‐ 10 pounds in one month. ‐ 5 pounds in one week. ‐ 1 pound in one week. ‐ 3 pounds in one week. | Critical words are healthy weight loss. Recognize that only 0.5 to 1 pound per week is the recommended healthy guideline to direct you to option 3. |
4104 Which of the following statements would the nurse Correct answer: 1 VLCD diets are used in the clinical treatment of obesity under close medical supervision. The use to best describe a very low kilocalorie diet (VLCD) diet is low in calories, high in quality protein, and has a minimum of carbohydrates in order to to a client? spare protein and prevent ketosis. ‐ "This diet is low in calories and high in protein and must used under close medical supervision." ‐ "This is a long‐term treatment measure that will assist obese people who can't lose weight." ‐ "The VLCD consists of solid food items that are pureed to facilitate digestion and absorption." ‐ "A VLCD contains very little protein." | The critical word is best, indicating all or some options may be correct, but one answers the question more thoroughly, as is the case in option 1. |
4105 A 40‐year‐old female client with a family history of Correct answer: 2, 5 Carotenoids are phytochemicals that have been found to decrease risk of CAD and are found coronary heart disease (CAD) expresses interest in in green, orange, red, and yellow fruits and vegetables. Option 1 is high in indoles. Options 3 modifying her diet to include foods to reduce and 4 are high in isoflavones. associated risk factors. The nurse suggests she increase intake of foods high in carotenoids by including which of the following? Select all that apply. ‐ Cauliflower and cabbage ‐ Strawberries and oranges ‐ Black and green tea ‐ Soy products ‐ Green peppers and squash | This question requires identification of foods high in carotenoids. If you have difficulty remembering this specific information, the word carotenoid is similar to the word carrots, which are orange in color and would help direct you to options 2 and 5. |
4106 When explaining to a group of adolescents why Correct answer: 4 Creatine has been demonstrated to improve the body's response in an exercise pattern creatine is being suggested as beneficial for athletic consisting of repetitive short‐term activities. Option 1 is incorrect: Creatine is supposed to performance, the nurse would explain that creatine: promote anabolism, not catabolism. Option 2 is incorrect because creatine has not been proven effective for long‐term exercise patterns. Option 3 is incorrect because creatine does not decrease lean body mass. ‐ Is an efficient fuel source in the body that promotes catabolic effects. ‐ Is effective for long‐term endurance performance. ‐ Decreases lean body mass and increases muscle strength. ‐ Assists the body in repetitive short‐term activity that requires energy bursts. | The critical phrase is beneficial for athletic performance. Eliminate option 1 since a catabolic effect would be a negative consequence. Recall use of creatine to muscle physiology to choose option 4. |
4107 A client states that he is considering using herbal Correct answer: 3 It is important to inform the healthcare provider at the start of herbal therapy, because this therapy as a natural source to aid in dietary health. can prevent problems from potential drug interactions, verify indication for therapy, and What suggestion should the nurse give to the client to acknowledge client’s concerns over common complaints. Option 1 is incorrect since it is critical assist with this decision? for the client to read all labels in order to be an informed consumer. Even though there are standard products, herbal therapy ingredients can vary in different types of formulations. With option 2, no prescription is required, but herbal therapy can cause a financial burden to the client. Option 4 is incorrect since herbal therapy can cause side effects. ‐ "Herbal therapy treatments reflect standard doses so all similar products will provide the same biologic effect." ‐ "Herbal therapy requires a prescription and may be an expensive treatment modality." ‐ "It is important to inform your healthcare practitioner about your choice to start herbal therapy." ‐ "Herbal therapy is a natural form of treatment with very few side effects." | Read each option, systematically eliminating those with incorrect information regarding herbal supplements. Recall importance of potential for interactions with herbal and OTC products to direct you to option 3. |
4108 The diet history of client receiving anticoagulants Correct answer: 4 Garlic is a food/herbal product that has long been recognized for its health benefits. It lowers indicates the client eats a lot of garlic. The nurse plans cholesterol/triglycerides, improves immune function, and decreases blood pressure. But garlic to include which of the following information when can inhibit platelet aggregation and therefore prevents blood clot formation. A client who is teaching the client about possible drug/food taking anticoagulation therapy should be advised of potential interactions with excessive interactions? amounts of garlic in the diet. Option 1 is incorrect since there is an increased risk of bleeding. Option 2 is incorrect because garlic does indeed affect blood coagulation. Even though garlic does help to support immune function (option 3), this fact does not directly relate to anticoagulation therapy. ‐ Garlic can enhance the coagulation process and accelerate clot formation. ‐ Garlic has no effect on blood coagulation. ‐ Garlic helps to support immune function but does not affect coagulation. ‐ Bleeding can occur because garlic inhibits platelet aggregation. | Critical words are garlic and anticoagulants. Recall garlic's effect on clotting function to direct you to option 4. |
4109 The nurse encourages eating foods high in which of Correct answer: 2, 5 Isoflavones and phytoestrogens are deemed beneficial in protecting female clients from the following phytochemicals as a possible preventive developing osteoporosis due to their estrogen‐like enhanced effects. Option 1 is incorrect: measure for a female client concerned about Phenolic acids are effective against cancers because they act as pro‐oxidants. Option 3 is developing osteoporosis? Select all that apply. incorrect as indoles make estrogen less effective. Option 4 is incorrect because carotenoids are considered to be in the classification of phenolic acids and help to decrease cancer risks. ‐ Phenolic acids ‐ Isoflavones ‐ Indoles ‐ Carotenoids ‐ Phytoestrogens | Critical words are phytochemicals and osteoporosis. Recall isoflavones and estrogen have a beneficial effect on bones to direct you to options 2 and 5. |
4110 Which of the following does the nurse discuss with Correct answer: 3 It is important the client demonstrate an understanding of the basics of the treatment the client — who is 5 feet 6 inches tall and weighs 250 program, focusing on a multifaceted approach of intake, physical activity, and weight control. pounds — as a realistic goal to start a weight loss Each one of these is an interrelated variable that affects the client's ability to achieve and program? maintain weight control. Option 1 is incorrect because this may not be prudent; physical activity is usually increased. Option 2 is incorrect since it is not wise to utilize this feeding pattern because it may contribute to weight gain. Option 4 is incorrect: The total calories may be somewhat low, but the percentage of calories from fat is too high to effect substantial weight loss. ‐ Maintain present physical activity level and decrease caloric intake. ‐ Eat only when hungry. ‐ Demonstrate understanding of caloric intake, weight control, and physical activity. ‐ Maintain an intake of 1,000 calories or less with 30 percent of calories from fat. | Recognize the need to reduce caloric intake as well as increase activity level to eliminate option 1. Eliminate option 2 since it does not provide specific suggestions, and eliminate option 4 since this caloric restriction is unsafe. |
4111 Which of the following instructions should the nurse Correct answer: 2 Anesthesiologists recommend that all herbal and botanical preparations be stopped 2–3 give to a client who takes numerous herbal weeks prior to scheduled surgery in order to minimize possible interactions between supplements and is being scheduled for an outpatient anesthesia induction and blood pressure response. Options 1 and 3 are incorrect for the surgical procedure? reason just stated. Even though it might be good to discuss herbal therapies with a dietitian (option 4), it is more important to acknowledge that herbal therapies should be stopped prior to scheduled surgeries to minimize anesthesia risks. ‐ "Take your supplements as usual until the morning of the surgical procedure." ‐ "Stop herbal and botanical products at least 2–3 weeks prior to the day of surgery." ‐ "Maintain usual doses of herbal products and stop a day before surgery." ‐ "Consult with the dietician prior to surgery about effects of herbal therapies." | The core concept is preparation for outpatient surgery. Recall many drugs and herbs may take several days to be eliminated from the body to direct you to option 2. |
4112 The nurse instructs the underweight client to Correct answer: 500 An extra 3,500 kilocalories per week is needed for a 1‐pound weight gain (500 kilocalories per consume an extra kilocalories per day for a 1‐ day). Weight gain strategies revolve around consuming foods that provide many kilocalories in pound weight gain per week. Write a numerical small volume along with building muscle. answer. | Focus on critical information of 3,500 kilocalorie equaling 1 pound of fat. |
4113 A 53‐year‐old male comes to the clinic for a routine Correct answer: 3 Obesity is defined by BMI of 30 or above with no co‐morbid conditions. It is calculated by physical examination. During the intake screening, the utilizing a chart‐nomogram that plots height and weight. This client’s BMI is 35, indicating nurse notes the client's weight is 216 pounds and obesity. The other responses represent inaccurate interpretations of the client's BMI. height is 66 inches. The body mass index (BMI) is calculated at 35. The nurse interprets that the client's weight: ‐ Is within normal limits, so a weight reduction diet is unnecessary. ‐ Is lower than normal, so education about nutrient dense foods is needed. ‐ Indicates obesity, so weight reduction and exercise are needed. ‐ Indicates an overweight status, so dietary modification and exercise is needed. | Note the question indicates that client has a high weight and is not very tall. This is a clue that options 1 and 3 are incorrect. Recall the categories for BMI to choose between options 3 and 4. |
4114 When evaluating a client for malnutrition, the nurse Correct answer: 1 Objective anthropometric measurements such as triceps skin fold and mid‐arm circumference utilizes which of the following to provide information (MAC), along with weight, are usually used to diagnose malnutrition. While all of the other about the client's nutritional status? choices represent tests that may provide useful information, they also may be affected by variables other than malnutrition. ‐ Triceps skin fold measurement ‐ Fasting blood glucose level ‐ Hemoglobin A1c level ‐ Serum lipid profile results | Critical words are malnutrition, evaluation, and nutritional status. Note options 2 and 3 measure glucose levels only to eliminate them. Recognize option 4 is used to measure coronary artery disease risk and eliminate it. |
4115 A client states that he has been told ketchup is a Correct answer: 2 Ketchup contains lycopene, which is a phytochemical that has health benefits. Option 1 does beneficial food and asks how can this be true. What not address the concern about health benefits. Option 3 is incorrect because even though would be the nurse's best response to answer the ketchup contains a large amount of sodium, this is not a health benefit and even can be viewed client’s concern? as a "hidden" source of sodium in the diet if used in excess. Option 4 is incorrect since ketchup is not a source of fiber in the diet. ‐ "Ketchup is considered to be a food enhancer and intensifies taste perception." ‐ "Ketchup contains lycopene, which has been shown to be effective against heart disease and prostate cancer." ‐ "Ketchup contains sodium, which provides health benefits." ‐ "Ketchup provides a fiber source in the diet that protects against cancer." | The critical word is beneficial. Recognize what health and nutritional benefits are provided by lycopene in ketchup to direct you to option 2. |
4116 The nurse interprets that which of the following Correct answer: 2 A waist‐to‐hip ratio of greater than 1.0 in a male client indicates an increased risk to develop clients is at increased risk to develop obesity? obesity. This indicates a larger amount of abdominal fat and correlates with an apple body shape. Option 1 is incorrect because a decrease in visceral fat stores in the abdomen would improve a client’s health status. Option 3 is incorrect since a 19 BMI is associated with being underweight. Option 4 is incorrect because a male client who is 6 feet tall and 162 pounds has a BMI of 22, which is considered within normal range. ‐ A client with decreased visceral fat stores in the abdomen ‐ A waist‐to‐hip ratio of greater than 1.0 in a male client ‐ A BMI of 19 in a female client ‐ A male client who is 6 feet tall and weighs 162 pounds | The critical words are increased risk and obesity. Recall norms of BMI and waist‐to‐hip ratio to choose option 2. |
4117 A client has heard information about functional foods Correct answer: 3 Using vegetables as a main ingredient will help to increase the amount of functional foods and asks how he can include them in his diet. Which of that have phytochemical activity. Option 1 is incorrect: Even though milk is a good source of the following suggestions should the nurse provide? vitamin D and calcium, it will not by itself increase the amount of functional foods in the diet. While limiting the amount of refined food products is beneficial (option 2), this does not increase the amount of functional foods in the diet. Option 3 is incorrect: Seasoning to taste may be important with regard to sodium level; however, it does not specifically relate to functional foods. ‐ Increase milk in the diet. ‐ Limit refined food products in the diet. ‐ Use vegetables as main‐dish ingredients. ‐ Season food to taste with salt. | Specific knowledge of functional foods is required to answer this question. If you cannot recall this material, note the question addresses what food should be included. Eliminate option 2, since the food is eliminated and option 4, since salt is not a food, but a seasoning and electrolyte. |
4118 The nurse would make which of the following Correct answer: 3 Leptin is a protein hormone that is secreted by adipose tissue; it is called the obesity gene. responses when questioned by a client about the Leptin increases the total fat mass in obese clients. Option 1 is incorrect because the presence leptin's role in the body? of leptin usually decreases food intake in individuals of normal weight. Option 2 is incorrect because it does not affect the regulation of steroid hormones but does have some effect on insulin release. ‐ "It increases food intake in clients of normal weight, thereby promoting obesity." ‐ "It assists in the regulation of steroid hormones." ‐ "It increases the total fat mass of people who are obese." ‐ "It decreases the total fat mass in the body of those who are obese." | Specific knowledge of leptin is necessary to answer this question correctly. |
4119 The nurse is assessing a client who is taking orlistat Correct answer: 2 A side effect of orlistat, a lipase inhibitor that aids in weight loss, is rectal incontinence, (Xenical) for weight reduction. The nurse suspects and/or oily stools that are associated with urgency. The fact that the client is presenting with incorrect use of the drug when the client reports which complaints of this symptom suggests he or she is not following the treatment regimen and is of the following? eating high‐fat meals. Options 3 and 4 reflect compliance with the treatment regimen. Increasing fluid intake does not affect compliance. Systematically eliminate options 1, 3, and 4 since the behaviors are correct. ‐ Increasing fluid intake to 8–10 glasses/day ‐ Urgent bowel movements since starting the medication ‐ Taking fat‐soluble vitamin supplements 2 hours after the medication ‐ Taking the medication with meals and following a low‐fat diet | Note the question asks for an indication that the drug is taken incorrectly, therefore indicating three of the options will have correct information regarding use of orlistat. |
4120 When performing a nutritional assessment on a Correct answer: 4 A BMI of less than 18.5 is considered to represent a client who is underweight and possibly at female client, which of the following data would risk for malnutrition. Option 1 is incorrect because a BMI of 22 is considered within normal indicate to the nurse the client is underweight? range. Option 2 is incorrect because being above IBW is not consistent with being underweight. Option 3 is incorrect because a waist/hip ratio of less than 0.8 in a female client represents a normal finding. It is important for the nurse to be aware of objective anthropometric measurements (both normal and abnormal values) so that the data can be interpreted adequately. ‐ A body mass index (BMI) of 22 ‐ Being 0.5% above ideal body weight (IBW) ‐ A waist/hip ratio of less than 0.8 ‐ A BMI of 18. | The critical word is underweight. Eliminate option 2 since it reflects an overweight status. Recall knowledge of BMI to choose option 4. |
4121 The nurse determines which one of the following Correct answer: 3 Pharmacotherapy for obesity is indicated when a client has been unable to achieve weight clients should consider pharmacotherapy for the loss of 1 pound/week after 6 months of therapy while following suggested lifestyle changes. treatment of obesity? Option 1 is incorrect: This is not a quick process decision. Option 2 is incorrect because the client has already demonstrated a reasonable weight loss pattern. Option 4 is incorrect because pharmacotherapy is not indicated for an adolescent client. ‐ A 20‐year‐old college student who wants to lose weight quickly ‐ A 32‐year‐old male who has lost 20 pounds during the past 6 months. ‐ A 28‐year‐old female who has been trying unsuccessfully to lose weight for 6 months following changes in lifestyle and exercise. ‐ A 12‐year‐old adolescent female who is tired of being overweight and does not have a social network of supportive friends. | Critical words are pharmacotherapy and obesity. Read each stem and determine history of weight loss attempts and risk factors. Eliminate option 1 since this reflects an unhealthy choice. Eliminate option 2 since the client has already lost weight. Choose option 3 since the client has had unsuccessful attempts with other modalities. |
4122 A client with renal insufficiency expresses interest in Correct answer: 2 A client with renal insufficiency should not start a low CHO diet—this implies that protein and starting a low‐carbohydrate (CHO) diet. The nurse fat levels will be increased, resulting in an increased renal solute load. Option 1 is discourages the client from doing so, recognizing it incorrect—30 grams of CHO is not enough to spare protein, thereby making fat the primary could have which of the following implications? energy source and leading to the development of ketosis, which will further compromise the client's clinical status. Option 3 is incorrect—osteoporosis is not associated with being on a low CHO diet but rather is due to multifactorial losses involved with calcium. Option 4 is incorrect because a client with renal insufficiency is unable to handle protein. While high biological value sources are warranted, the protein intake must be monitored cautiously to prevent further metabolic imbalances. ‐ As long as the client eats a minimum of 30 grams of CHO/day, there should be no problem. ‐ The client's clinical condition is a contraindication to starting a low CHO diet. ‐ Calcium supplements should be utilized to prevent the development of osteoporosis while on a low CHO diet. ‐ As long as the client eats foods that are high biologic protein sources, there will be no problems with following a low CHO diet. | The critical words are renal insufficiency and low CHO diet. Recall nutritional needs related to decreased renal function in regards to restriction of protein and need for CHO as a caloric source. |
4123 The nurse develops which goal as most realistic for a Correct answer: 3 A client diagnosed with Pickwickian syndrome is typically clinically obese and has client who is being referred for dietary counseling and hypoventilation symptoms. A realistic goal is to establish a weight loss plan because it will help has been diagnosed with Pickwickian syndrome? to improve breathing, relieve respiratory symptoms, and decrease the workload placed on both the heart and lungs. Option 1 is incorrect because maintaining the client's current weight will not help to improve clinical symptoms. Option 2 is incorrect as increasing caloric intake will further contribute to weight gain and affect respiratory status. Although the use of increased fluids may be helpful to thin secretions, the client with Pickwickian syndrome does not present with thick secretions, but rather has disturbances with sleep apnea. ‐ Maintain current body weight. ‐ Increase caloric intake by 2,000 calories. ‐ Follow prescribed weight loss plan. ‐ Increase fluids to thin secretions and maintain respiratory effort. | Critical words are Pickwickian syndrome and most realistic. Recall aspects of this syndrome to be directed to option 3. |
4124 A client who has received a kidney transplant is being Correct answer: 2 Azathioprine (Imuran) can cause a client to develop esophageal lesions; therefore, a soft diet treated with azathioprine (Imuran) post‐transplant as would be an appropriate choice if the client had noted side effects from the medication. part of the immunosuppressive regimen. When the Option 1 is incorrect because vomiting and diarrhea are also commonly seen side effects from client experiences drug side effects the nurse this medication and would only serve to increase symptoms. Option 3 is incorrect as fresh fruit encourages which dietary change? would not be an appropriate choice due to high bacteria content. Option 4 is incorrect because orange juice might be irritating to a client who had esophageal erosions and/or not be tolerated if a client was experiencing vomiting. ‐ Increased fluids ‐ Soft diet ‐ Fresh fruits ‐ Orange juice | Critical words are Imuran and side effects. Recall the side effect on the esophagus to be directed to option 2. |
4125 When caring for a client who has experienced major Correct answer: 2 A client who has experienced major trauma is under severe stress and experiences a trauma, the nurse develops a plan of care to decreased release of insulin, leading to a hyperglycemic response. The other options are incorporate the client's anticipated decrease in: incorrect because caloric needs, aldosterone, and ADH would all be increased during periods of severe stress. ‐ Kilocalorie needs. ‐ Release of insulin. ‐ Aldosterone secretion. ‐ Antidiuretic hormone (ADH) secretion. | The critical terms are major trauma and decrease. Recall that the physiology of trauma will necessitate an increase of calories and compensatory mechanisms will kick in to compensate for fluid losses to eliminate options 1, 3, and 4. |
4126 Which of the following laboratory results should the Correct answer: 2 A client at risk for re‐feeding syndrome is likely to experience decreases in serum potassium, nurse monitor for in a client at risk for re‐feeding magnesium, and phosphorus. All of the other choices reflect options that are not seen with re‐ syndrome? feeding syndrome, such as hyperkalemia, hypernatremia, and hypercalcemia. ‐ Hyperkalemia and hyponatremia ‐ Hypokalemia and hypophosphatemia ‐ Hypernatremia and hyperkalemia ‐ Hypokalemia and hypercalcemia | Note that all options have two parts and both parts must be correct. Recall that re‐feeding syndrome involves a drop in electrolyte levels, allowing elimination of options 1, 3, and 4. |
4127 An elderly client comes in for a routine visit to the Correct answer: 3 The elderly client who has been given a prescription for antibiotics and plans to take them clinic for renewal of prescriptions. The nurse identifies following meals is more likely to be at risk for diet/medication interactions because absorption the client might be at risk for diet/medication of the antibiotic may be reduced due to food intake. All of the other options do not pose interactions because the client: significant risk for diet/medication interactions. ‐ Takes a daily multivitamin supplement each in addition to prescribed medications. ‐ Drinks two cups of coffee each day. ‐ Has been given a prescription for antibiotics and plans to take them following meals. ‐ Is taking three different types of blood pressure medication. | Recall that the bioavailability of medications is affected by the presence of food and gastric pH to be directed to option 3. |
4128 A 45‐year‐old female who is 5 feet 4 inches tall and Correct answer: 2 A client who has undergone severe stress will have increased energy needs. Using the Harris‐ weighs 180 pounds has undergone severe trauma. In Benedict equation to estimate basal energy expenditure (BEE) requires the client's actual determining the client's energy needs the nurse places weight and height. Depending on the nature of the stress, additional calories will be estimated highest priority on: ranging from 20–100 percent. Option 1 is incorrect because the client's IBW is not sufficient to base calculations on and will lead to a false starting point. Option 3 is incorrect as a 20 percent increase is not appropriate for a client who has undergone severe trauma; a much higher percentage would be required to meet the client's energy needs. Option 4 is incorrect because even though albumin levels are needed, they are not part of the client's energy calculation. ‐ Estimating caloric intake based on ideal body weight (IBW). ‐ Recording actual body weight. ‐ Increasing caloric intake by 20 percent above calculated rate. ‐ Checking serum albumin levels. | Critical words are severe trauma and energy needs. Recall the need for additional calories for tissue repair and the need to be calculated on weight. |
4129 When caring for a client with acute respiratory failure Correct answer: 4 A client on mechanical ventilation as a result of acute respiratory failure is already who is placed on mechanical ventilation, the nurse experiencing fatigue and exhaustion from the work of breathing. The use of nutrient‐dense anticipates the use of which nutritional measure to pulmonary formulas to support the client is advised at this time because they provide fewer provide the client with the most effective nutritional carbohydrates and a greater fat content to minimize the production of carbon dioxide support? (CO<sub>2</sub>). Option 1 is incorrect because high carbohydrates lead to an increase in CO<sub>2</sub> production correlating with acidosis. Option 2 is incorrect as parenteral fluids are not being given to loosen secretions; parenteral fluids are used to correct fluid and acid‐base imbalances. Option 3 is incorrect because increased kilocalories above client needs could lead to overfeeding that could further increase CO<sub>2</sub> levels. ‐ Use of high carbohydrate solutions to meet nutrient needs ‐ Increased fluids through the parenteral route to loosen secretions ‐ Increased kilocalories to meet energy and protein needs ‐ Use of nutrient‐dense pulmonary formulas to support client | Critical words are acute respiratory failure and mechanical ventilation. Note options 1, 2, and 3 are less specific to the needs of the client with a respiratory condition and eliminate them. |
4130 A client recently started on sodium warfarin Correct answer: 4 The dosage of Coumadin is regulated by the client's prothrombin time (PT). Excessive intake (Coumadin) has received teaching on drug‐food of foods rich in vitamin K, such as spinach, could prolong the PT. A consistent daily intake interactions. When the client informs the nurse he should not affect the PT, whereas a fluctuating amount eaten each day would impact the loves to eat spinach salads, the nurse should make clotting time. It is not necessary to totally omit foods with vitamin K and the other factors which response? would not affect the clotting. ‐ "Unfortunately you will not be able to eat them while taking Coumadin." ‐ "Be sure you eat the salads at least 12 hours before or after taking the Coumadin." ‐ "It is okay to eat them as long as you use an oil‐based dressing." ‐ "As long as you eat a consistent amount of foods containing vitamin K each day it is OK." | Critical words are Coumadin and spinach salads. Recall that spinach is high in vitamin K and recognize the effect it has on blood clotting to be directed to option 4. |
4131 When caring for a client with sickle cell crisis, which Correct answer: 4 The sickled shape of the red blood cell (RBC) can lead to occluded circulation and impaired dietary measures should the nurse emphasize? RBC production. Adequate hydration is essential to improve blood flow, reduce pain, and prevent renal damage. There are no specific restrictions or recommendations in regards to protein, sodium, or frequency of meals. ‐ High‐protein supplements ‐ Limited intake of sodium‐rich foods ‐ Six small meals eaten throughout the day ‐ High fluid intake | The critical concept is sickle cell crisis. Recall the shape of the RBC in this condition and the impact it has on the circulatory system to be directed to option 4. |
4132 A client taking sodium warfarin (Coumadin) for the Correct answer: 3 A client who is taking an anticoagulant should not be drinking excessive amounts of alcohol. past several months following valve replacement The fact that the client has been consistently drinking two glasses of wine is a concern since comes into the clinic for a check‐up. Which of the alcohol can enhance the effects of the medication. This information bears further review by following findings by the nurse would trigger concern the nurse with communication to the healthcare provider. All of the other options do not regarding compliance with medication therapy? indicate any concern regarding compliance with medication therapy. ‐ The client has been following a well‐balanced diet for the past two months. ‐ The client has been going out to eat at a restaurant once a week. ‐ The client has been drinking two glasses of wine each night. ‐ The client has a salad with his evening meal twice a week. | The critical word is Coumadin. Recall the purpose and food and drug interactions of this drug to be directed to option 3. |
4133 A client taking warfarin (Coumadin) has had difficulty Correct answer: 1 Mayonnaise and salad oils are high in vitamin K, which will prolong the anticoagulation effects regulating prothrombin times. Which of the following of warfarin. CHOs and fruit juice are not high in vitamin K. Option 2 does not directly affect questions should the nurse ask to identify dietary coagulation. factors that could influence the drug levels? ‐ "Do you use a lot of mayonnaise and salad oils?" ‐ "How many times a day do you eat?" ‐ "Do you eat a diet high in carbohydrates (CHOs)?" ‐ "Are you drinking a lot of fruit juices?" | Critical words are warfarin and dietary factors. Recall type of drug warfarin is and recognize dietary factors that would impact this drug. Eliminate option 2 since it would affect coagulation. Recall foods with vitamin K content to direct you to option 1. |
4134 A 68‐year‐old male client who has longstanding Correct answer: 4 A client who has frequent hospitalizations due to chronic disease is likely to exhibit signs of diabetes with resultant complications has been sadness, depression, and loss of control regarding the disease process. The nurse should allow hospitalized with recurring frequency over the years the client to vent his feelings in the hopes of sharing concerns and offering emotional support. and is extremely upset over this most current Option 1 is incorrect, although it is important to ascertain a client's food preference, the admission. The client does not want to eat and information provided states that the client is repeatedly pushing away the food tray at several repeatedly pushes away the food tray at each meal. meals. Option 2 is incorrect because this client behavior presents as a continued pattern and How should the nurse best respond to the client's not an isolated incident. Therefore, the nurse should do more than try again with the next actions? meal to get the client to eat. Option 3 is incorrect because although it might be important to consult with the dietitian regarding food selections, this option does not address the immediate problem of the client pushing away the food trays. ‐ Tell the client that you can get him something else that would be more to his liking. ‐ Take the tray away and try again with the next meal to get the client to eat. ‐ Consult with the dietitian to improve client compliance. ‐ Ask the client to share with you why he doesn’t feel like eating. | Note the nature of the question is psychosocial. Review options for the one which best addresses clients refusal to eat to choose option 4. |
4135 The nurse is caring for a 32‐year‐old female client Correct answer: 4 The first priority with any trauma client is to establish baseline information by assessing skin with multiple traumas. The nurse identifies which of turgor, vital signs, and review of pertinent diagnostic tests in order to stabilize the client and the following as a priority intervention for nutritional determine the extent of injuries. Looking at the client's physical and diagnostic presentations support? will help to determine the client’s fluid balance and pertinent stressors. Option 1 is incorrect—even if the client is hungry, the existing trauma condition may preclude any feeding attempts at this time. Although it is important to establish IV access for a trauma client, the nurse cannot increase the rate without a physician's order, therefore option 2 is incorrect. More importantly, increasing the IV rate will not help to maintain nutritional status but rather will help to restore fluid balance. Option 3 is incorrect because the client's underlying trauma may require surgical intervention and therefore the client should be kept NPO until the exact extent of injuries is known. ‐ Determine if the client is hungry and what her favorite foods are. ‐ Provide IV access and increase fluid rate to maintain nutritional status. ‐ Offer sips of water and ice chips as tolerated. ‐ Assess skin turgor, vital signs, and diagnostic test results before seeking a diet order. | Critical words are multiple trauma and priority. Recognize need to obtain baseline data to determine specific needs of clients to direct you to option 4. |
4136 When caring for a client diagnosed with multiple Correct answer: 2 A client who is diagnosed with MODS in an ICU setting is critically ill. Determination of overall organ dysfunction syndrome (MODS), the nurse would health status is usually reviewed using the APACHE scoring, which provides relative utilize which of the following parameters to determine information regarding risk of mortality. APACHE scoring looks at acute physiological indicators, overall nutritional status? age, and presence of chronic health conditions to evaluate a client’s response and prognosis. Option 1 is incorrect—plasma osmolality does not serve as an indicator for acute physiology scoring. Option 3 is incorrect—these choices only reveal information about the client’s age and possibly chronic respiratory health problems. Option 4 is incorrect because a CBC with differential does not provide comprehensive information about the client’s overall health status. ‐ Plasma osmolality and presence of chronic disease process ‐ Age of client, presence of chronic health conditions, and physiologic parameters ‐ Rectal temperature and respiratory rate ‐ CBC with differential, electrolyte panel, and liver function tests | The core concept is MODS. Eliminate options 1, 3, and 4 since they focus on one type of parameter, which would be insufficient to identify nutritional needs. |
4137 A 42‐year‐old male client says, "I am an alcoholic. I Correct answer: 2 It is important to provide a client with the most comprehensive information available to heard that drinking is good for you in terms of answer questions and clarify concerns. The consumption pattern (i.e., type and amount) of preventing heart disease, so why should I stop?" What alcohol has been shown to be a risk factor in many disease processes—this should be clearly is the best response of the nurse to the client's stated to the client. Option 1 is incorrect because even though moderate alcohol consumption statement? has been documented to provide some cardiovascular benefits, the last portion of the statement indicates bias relative to the client’s alcoholism. Option 3 is incorrect because it does not address the client’s concern at this time. Option 4 is incorrect because it implies that the nurse does not believe the client's statement that he is an alcoholic. It is important for the nurse to respond to the question asked before delving further into confirming a diagnosis of alcoholism. ‐ "Alcohol is only beneficial if used in moderate amounts; so this fact does not apply to your situation." ‐ "Alcohol is a risk factor in many disease processes and the type and amount of alcohol consumed do have significant health consequences." ‐ "Are you interested in seeing a counselor for help with alcohol dependency?" ‐ "Will you complete a CAGE questionnaire so we can accurately determine if you really are an alcoholic?" | Note the psychological nature of the question as well as need to clarify misinformation. Eliminate the assumption made by Option 1. And eliminate options 3 and 4 as they do not address the client's question. |
4138 The nurse determines which of the following clients Correct answer: 4 A 48‐year‐old female client with the contributory diseases of hypertension (HTN) and would be at the greatest risk for nutritional problems? diabetes is at a greater risk for nutritional problems than any of the other clients. HTN and diabetes both have dramatic effects on vascular status and lipid physiology. Option 1 is incorrect because there is no information to suggest that the client has any underlying health problems. In option 2, even though the client is obese, this represents only a single‐risk factor for nutritional status. Similarly, the client in option 3 has only a single‐risk factor, that of asthma. ‐ A 42‐year‐old male admitted with a fracture of the femur as a result of a fall ‐ A 36‐year‐old obese female client admitted for pyelonephritis ‐ A 20‐year‐old female client admitted with exacerbation of asthma ‐ A 48‐year‐old female client who has a history of hypertension (HTN) and diabetes admitted for abdominal pain | Read each option, identifying risk factors that would contribute to nutritional problems. Eliminate options 1 and 3 since each contains only one risk factor. Choose option 4 since this client has two chronic conditions. |
4139 The nurse determines that a client taking sodium Correct answer: 4 A client taking warfarin should be aware of pertinent medication facts prior to initiation of warfarin (Coumadin) is being compliant with treatment therapy to avoid possible interactions and to maintain an adequate anticoagulation response. if the client: The client should eat a well‐balanced diet and consume a constant amount of vitamin K that can interfere with the action of the medication. Green, leafy vegetables are high in vitamin K. Option 1 is incorrect—the client should not double the dose because this can lead to severe consequences and altered coagulation. Option 2 is incorrect because a client taking warfarin should not take other medications unless the physician prescribes them. Option 3 is incorrect— even though it is important for the client to take the medication at the same time every day, it is also critical that the client be aware of the dosage. This information should be related as part of the client's pertinent medical history and can influence medical treatment by other healthcare providers. ‐ Doubles the dose when he misses a pill. ‐ Is taking OTC cold medication in addition to warfarin therapy. ‐ Takes the pill at the same time every day but is not aware of the dosage. ‐ Maintains a balanced diet and eats a constant amount of green, leafy vegetables. | Critical words are complications and warfarin. Recall this drug is an anticoagulant that requires maintenance of consistent blood levels and eliminate options 1 and 2 since they would alter steady blood levels. Choose option 4 since it addresses the most significant dietary information regarding warfarin. |
4140 When caring for a client who has had a liver Correct answer: 3 Early tube feeding leads to fewer complications than parenteral feedings in the acute post‐ transplant, the nurse would consider which of the transplant period and is the preferred method if the client has a functioning GI tract. In options following when planning for the clients' post‐ 1 and 2, there is increased protein catabolism in the acute post‐transplant period as well as an transplant nutritional needs? increase in the amount of urinary nitrogen. Option 4 is incorrect because the presence of end‐ stage liver disease is associated with a decrease in the amounts of branched chain amino acids, leading to an alteration in aromatic amino acids. This can further contribute to the presentation of hepatic encephalopathy. ‐ There is a decrease in protein catabolism. ‐ Urinary nitrogen losses stabilize in the acute post‐transplant period. ‐ Early tube feeding is favored over parenteral feeding. ‐ Branched chain amino acids are found in adequate amounts in the post‐transplant period. | The critical words are post‐transplant needs and liver. Recall protein needs in catabolic and acute stress conditions to eliminate options 1 and 2. Eliminate option 4 since these acids are decreased in the post‐operative state. If you had difficulty with this question, review content on the post‐transplant client. |
4141 The nurse will include dietary teaching on what Correct answer: 1 Adequate amounts of micronutrients (e.g., vitamins A and C, calcium, and zinc) will help micronutrient to help support the client's immune support immune function and restore healing in the trauma client. function and restore healing? ‐ Vitamin C ‐ Vitamin D ‐ Niacin ‐ Magnesium | The core issue of the question is knowledge of which micronutrients play a key role in immune function and healing. Use this information and the process of elimination to make a selection. |
4142 The nurse plans to monitor for which of the following Correct answer: 4 Refeeding syndrome can occur in the critically ill client in response to feeding attempts consequences of refeeding syndrome in a critically ill whereby glucose and electrolytes (phosphorus, potassium, and magnesium) rapidly enter into client receiving total parenteral nutrition (TPN)? body cells. These electrolytes are involved in enzyme reactions and ATP physiology that is part of metabolizing the TPN. In option 1, serum phosphorus levels are decreased dramatically in response to increased glucose needs. In options 2 and 3, hyperglycemia is present along with increased insulin resistance. ‐ Increase in serum phosphorus and sodium levels ‐ Hypoglycemia ‐ Decreased fasting blood sugar levels ‐ Decreased serum potassium, magnesium, and phosphorus levels | Recall that refeeding syndrome occurs secondary to utilization of electrolytes involved in energy metabolic pathways to direct you to option 4. |
4143 A client is admitted to the hospital with a painful Correct answer: 2 The client is usually kept NPO in order to minimize secretion of digestive enzymes that can attack of pancreatitis. The nurse anticipates that which contribute to the condition, and the client in acute pain is unlikely to want to eat until the pain of the following changes will impact nutritional status is adequately controlled. IV therapy may be instituted to maintain hydration levels, and the during treatment of this acute episode? client may also require administration of total parenteral nutrition (TPN) if the case is severe. The client with a mild case may receive enteral nutrition for support. The client will not have altered taste perception, and gastroparesis is not part of the clinical picture. The client should not lose more than 10 percent of body weight if enteral or parenteral nutritional support is adequate. ‐ Altered taste perception due to increased pain ‐ Inability to eat due to increased pain ‐ Potential for gastroparesis to develop due to disease process ‐ Weight loss of greater than 10 percent during management of the acute phase | Critical words are acute, pancreatitis, and pain. Recall impact of severe pain on appetite and need to be NPO until acute inflammatory stage is over to direct you to option 2. |
4144 A client with anemia of chronic disease (ACD) is Correct answer: 3 To make valid recommendations to meet nutritional goals with regard to ACD, it is vital to referred for nutritional counseling regarding dietary evaluate the client’s present dietary pattern for nutritional adequacy. This helps to establish a intake. Which of the following methods would be the nutritional baseline and determine food preferences and other related factors that influence most helpful for the nurse to implement in order to the client’s intake pattern. Option 1 is incorrect—even though medication therapy is aimed at meet nutritional goals? increasing RBC production, it does not specifically address nutritional adequacy in terms of maintaining nutritional stores. Option 2 is incorrect—merely increasing caloric intake without regard to adequacy or balance may place the client at an increased risk of nutritional imbalance. Consuming an adequate diet with all essential nutrients is as important as increasing caloric intake in clients with chronic disease processes. Although it is important to instruct the client about good sources of iron, this option is limited, since it will not provide the most comprehensive approach in dietary evaluation. ‐ Have the client continue to take Epogen/Procrit as prescribed because that will help to maintain adequate nutritional stores. ‐ Have the client consume more calories in order to meet increased nutritional demands. ‐ Evaluate client's dietary pattern for nutritional adequacy. ‐ Instruct the client on adequate sources of iron in the diet. | The critical words are most helpful. Recognize importance of assessing baseline data in a client. Eliminate option 2 since it does not address the anemia or nutritional status. Eliminate options 1 and 4 since they are specific to only one aspect of the problem. |
4145 An unlicensed caregiver asks the critical care nurse Correct answer: 2 Critically ill clients on ventilator support must be provided nutritional support in order to why it is so important to assess the nutritional status maintain nutritional adequacy, prevent depletion of nutrient stores, and respond to increasing of a critically ill client on ventilator support, who has hypermetabolic demands of illness and therapies. Clients receiving medications such as just been started on enteral nutritional support. Which dopamine and narcotics (opiates) are at risk to develop delayed gastric emptying, which can of the following items would the nurse consider when lead to further problems. In addition, changes in acid‐base and fluid/electrolyte balance can formulating a response? lead to decreased gastric emptying. ‐ Parenteral feeding is associated with a decreased rate of sepsis and mortality. ‐ Gastric emptying can be decreased in response to medication and acid‐base and fluid/electrolyte imbalances. ‐ The use of enteral feeding methods is associated with a decrease in liver function. ‐ Enteral feedings lead to a decrease in mucosal blood flow. | Option 1 is a factually incorrect statement. Options 3 and 4 are incorrect because enteral feeding is associated with a stimulation of blood flow in the gut and improved mucosal integrity and liver function. |
4146 The nurse would place highest priority on assessing Correct answer: 3 The use of hypertonic enteral nutrition can lead to bowel necrosis and therefore should not which of the following critically ill clients for be used for a critically ill client. All of the other choices would not lead to feeding complications associated with enteral feedings? complications in the critically ill client. Elemental formulas require minimal digestion and are readily absorbed. The use of full‐strength formula feedings in small volumes with appropriate monitoring according to individual tolerance is an accepted practice. A client should be hemodynamically stable prior to the initiation of enteral feeding. ‐ A client who is receiving an elemental formula ‐ A client receiving full‐strength formula feeding in small volumes ‐ A client receiving hypertonic enteral nutrition solutions ‐ A client who is hemodynamically stable | Read each option and determine if a risk factor is present. Note the word stable in option 4 and eliminate it. Recall knowledge of osmolarity and physiology to choose option 3. |
4147 The nurse should plan to monitor which of the Correct answer: 3 A client who is critically ill on a ventilator and receiving parenteral nutrition should have daily following indicators as the most reliable method of weight measured as a reliable indicator of nutritional status. Serum albumin levels are not assessing the nutritional status of a critically client on a reliable indicators of effectiveness of nutritional therapy, although prealbumin levels reflect mechanical ventilator who is receiving nutritional nutritional status over the last few days. Intake and output are excellent measures of fluid support via parenteral therapy? volume status, but not overall nutritional status. Skin turgor is a measure of fluid volume, but can be affected by other factors, such as age, and is not a reliable indicator of overall nutritional status. ‐ Serum albumin levels ‐ Intake and output ‐ Daily weight ‐ Skin turgor | Focus on the critical words most reliable. Eliminate vague options first, such as option 4. Eliminate next the two options that reflect fluid volume status only. |
4148 A client with a longstanding history of diabetes, Correct answer: 2 A client with a multiple disease profile is at great risk both medically and nutritionally because hypertension, and heart failure has been referred for of multiple organ system problems that could alter metabolism and absorption of nutrients. dietary counseling. Which of the following should the Since the client is likely to have a multiple medication profile, it would be prudent to obtain a nurse do initially? listing of all medication (both prescription and OTC) in order to evaluate potential drug–drug and drug–food interactions. Option 1 is incorrect because a 3‐day food diary will only provide information relative to intake. Option 3 is incorrect—vital signs will not enable the nurse to calculate a BMI, since height and weight are needed. Even though it is important to ask if the client is satisfied with current management of disease processes, option 4 is stated as a closed‐ ended question, which will provide no further information, and the client may not be able to provide an accurate assessment of his or her own treatment. ‐ Have the client provide a 3‐day food diary at the next scheduled appointment. ‐ Obtain a list of all medications currently taken, both prescription and OTC. ‐ Obtain vital signs (e.g., blood pressure, pulse, and respirations) in order to calculate BMI. ‐ Ask if the client is satisfied with ease of maintaining current therapies. | Note that the client has history of three different chronic conditions. Recall that multiple food and drug interactions that are possible. Eliminate option 3 since the BMI is not calculated with those parameters. Options 1 and 4 can be eliminated as they may provide some valuable information after baseline information is gathered. |
4149 The nurse would instruct the client taking sodium Correct answer: 3 A client on Coumadin (sodium warfarin) needs to avoid foods that are high in vitamin K, which warfarin (Coumadin) for a deep vein thrombosis (DVT) acts as an antidote to the drug. Foods high in vitamin K include green leafy vegetables (options of the left leg that it is acceptable to continue eating 1 and 2), and tomatoes (option 4), as well as wheat grains and liver. Corn is not high in vitamin which of the following foods that the client prefers? K. ‐ Broccoli ‐ Spinach ‐ Corn ‐ Tomatoes | Recall that green leafy vegetables are high in vitamin K to eliminate the first two options. It is then necessary to understand that tomatoes are a rich source of vitamin K to choose correctly between this option and the one containing corn. |
4150 When caring for a client who has undergone a liver Correct answer: 3 Increased weight gain can be attributed to fluid retention due to medical treatment therapies transplant, the nurse should consider which factor post‐transplant and as such does not reflect accurate information about nutritional status. In when assessing the nutritional status of the client? option 1, the use of immunosuppressant drugs can lead to increased nutrient needs due to side effects (e.g., nausea, vomiting, mouth lesions, and diarrhea). Option 2 is incorrect because the client's pre‐transplant nutritional baseline status has a very profound impact on post‐ transplant nutritional status. The organ is being replaced, not the vascular system, and clients with liver failure often have longstanding nutritional deficits as a result of altered liver metabolism. In option 4, a post‐transplant client still has to follow dietary restrictions due to existing medical treatment regimens and is followed closely by a dietitian. ‐ Use of immunosuppressant drugs, which decreases nutrient needs ‐ Nutritional status pre‐transplant, which has little influence on post‐transplant nutrition. ‐ Increased weight, which directly correlates with adequate nutrition. ‐ Awareness that no dietary restrictions are needed post‐transplant. | Read each option, checking for accuracy of content and relevance to the question. |
4151 Which of the following nutritional complications Correct answer: 2 A client with a longstanding history of congestive heart failure is likely to develop chronic would the nurse assess for in a client with longstanding protein energy malnutrition resulting in cardiac cachexia. Option 1 is incorrect because clients congestive heart failure (CHF)? with chronic CHF often have weight loss with superimposed edema that goes unnoticed, thereby masking poor nutritional status. Options 3 and 4 are incorrect because clients with chronic CHF have decreased activity tolerance and airway clearance due to disease pathology. ‐ Weight gain due to fluid retention ‐ Cardiac cachexia ‐ An increase in activity tolerance. ‐ Increased airway clearance | Critical words are nutritional complications. Eliminate options 3 and 4 since they are complications related to airway and oxygenation. Note the word cachexia to direct you to option 2. |
4152 Which of the following would be most helpful for the Correct answer: 4 Discussing dietary meal planning activities with an obese client who has multisystem nurse to do when planning for the nutritional disorders would be the most helpful in terms of prospective therapeutic management. This management of an obese client with multisystem option would allow the client to provide information relative to meal planning and disorders? demonstrate both application and compliance with medical/nursing treatments. Option 1 is incorrect because there is no indication that the client requires intervention by a psychiatrist. This option reflects a judgment by the nurse with no other defining information to suggest that the client is having a psychological problem. Option 2 is incorrect because there is no information to suggest that the client needs or is ready to accept medical treatment for obesity. Although it is important to ascertain that the client is being compliant with medication therapy, option 3 does not answer the question with regard to the nutritional management of the client. ‐ Refer to a psychiatrist for counseling. ‐ Refer to a physician who specializes in weight disorders. ‐ Make sure that the client continues to take all medications ordered to treat disease processes. ‐ Discuss dietary meal planning activities with client. | Note that the question addresses the nutritional needs of an obese client. First, eliminate option 3 since neither of the topics is addressed. Eliminate option 1 since there is no mention of a mental health problem. Eliminate option 2 once this defers the problem and does not involve the nurse. |
4153 While the nurse is discussing a client's likely death Correct answer: 3 Peripheral circulation decreases and shifts to the vital organs. The vascular system collapses, with family members, one of the adult children causing decreasing pulse and blood pressure. The gag reflex is lost, and mucus accumulates in inquires, "We plan on taking turns being here for now, the back of the throat. Respirations decrease in rate, and the rhythm is irregular. Muscle but we all want to be here at the time of death. Is rigidity typically occurs after death. Vision is blurred. A lucid moment is not a pattern in death. there any way we can tell when that time is close?" It is difficult to pinpoint the exact time when death will occur, but the imminence of clinical Which of the following is the nurse’s best response? death can be detected. ‐ "Often, people become lucid for about 15 minutes during the last hour before death. Watch for your [family member] to become more alert, with clearer eyes, and to look around, focus on faces, and clear his [or her] throat. Call the others in at that time." ‐ "I wish I could tell you that there was a way to know. It could be minutes from now or another three days. One just never knows." ‐ "The arms and legs become more bluish in color and are cool to touch. Breathing will become irregular and shallow and will change speed. Call me if you hear mucus in the throat. The pulse and blood pressure will decrease." ‐ "You can expect the muscles to become rigid, with staring eyes and mouth closed. The head is pulled back with neck rigidity. Don't be alarmed when you hear a death rattle in the throat." | Note the issue of the question, which is knowledge of impending signs of death. The words best response in the question tell you it is a true statement and will be a priority in client care. Options 1 and 4 are inaccurate. Choose option 3 because option 2 does not provide information about the characteristics of impending death. |
4154 A 90‐year‐old client expresses a wish to die at home Correct answer: 1 Hospice specializes in end‐of‐life care. A rabbi is an important person during the end of life, after being told that an esophageal stricture prevents but there is not an immediate need to make this call. An attorney or medical examiner is not swallowing. The client refuses a feeding tube. The necessary at this time. family fully supports this decision. Which of the following would be most appropriate for the nurse to call? ‐ Hospice care ‐ The rabbi ‐ An attorney | The key issue is that the client wishes to die at home. Option 1, hospice care, can be provided in the home at all times. The other options (the attorney or medical examiner) do not address the client's issue, which is 24‐hour care in the home at the end of life. |
4.‐ The medical examiner's office | |
4155 The nurse is providing postmortem care for a client. Correct answer: 1, 4 The body is to be handled with dignity at all times. Even though humor can alleviate stress, it Which of the following interventions would be is not appropriate at this time. Once the body is cleaned, all external tubes and drains are appropriate prior to allowing the family to visit? Select removed, the linen is freshened, the sheet is pulled to cover the client’s shoulders. While all that apply. gloves should be worn during postmortem care, sterility is not an issue. State laws and policies differ regarding the nurse's ability to declare death. Even if a physician is required to declare death, the time of death cannot be verified exactly and is not required prior to the family being allowed to view the client after death. ‐ Prepare the body to look as clean and natural as possible. ‐ Keep the sheet over the client's face until the family is comfortably seated in the room. ‐ Wear sterile gloves to pack the anal canal with gauze. ‐ Remove the external tubes and drains. ‐ Call the physician to verify the time of death before taking the body to the morgue. | Use the process of elimination to identify the options that contain inaccurate information. While some of the information is correct in options 3 and 5, there are elements that make those responses incorrect. For example sterile gloves are not necessary, although clean gloves are worn. The family can visit before the physician is called. |
4156 A dying client's spouse is afraid to leave the client's Correct answer: 2 The signs and symptoms listed indicate death will occur soon and the spouse is fearful to room to get a meal in the cafeteria for fear the client leave the room at this time. Obtaining a meal for the client's spouse while she remains at the will die while she is gone. There are no other family bedside and supporting her during the client's imminent death demonstrate knowledge of the members or visitors present. The client is dying process in addition to compassion and concern for the client and spouse. nonresponsive, his pulse is irregular and bradycardic, and he has Cheyne‐Stokes respirations. Which of the following represents the best course of action for the nurse? ‐ Encourage the client's spouse to take a break and go to the cafeteria and eat. The client is nonresponsive and won't know she is gone. ‐ Make arrangements for the client's spouse to receive a meal in the client's room. ‐ Tell the client's spouse she will be called if there are any changes and ask a nurse aide to sit with the client while the wife is gone to the cafeteria. ‐ Do not interfere with the spouse's decision. | The key issue is the signs and symptoms of imminent death of the client and the spouse’s desire to be with him when he dies. Options 1 and 3 would increase the spouse’s anxiety if she were notified while she was absent. Option 4 is correct but does not include the support from the nurse exemplified in option 2. |
4157 The family of a client diagnosed with terminal cancer Correct answer: 4 Hospice care is provided to those clients who have 6 months or less to live. Hospice nurses has been informed that he is not expected to live more are skilled in pain and symptom management as well as in emotional support to the dying than 2 months. Which of the following statements clients and their families. Hospice care does not terminate once families learn to provide care made by the family indicates to the nurse that the (option 1), and a client in need of hospice services cannot be expected to resume self‐care family understands the client's prognosis? (option 3). ‐ "Hospice nurses are going to help care for him at home until he gets better." ‐ "Hospice nurses are going to help care for him until we learn how to provide the care." ‐ "Hospice nurses are going to help care for him until he can take care of himself." ‐ "Hospice nurses are going to help care for him to make him more comfortable." | The core issue of the question is knowledge of the purpose and goals of hospice care. The other options indicate that the family expects improvement in the client’s condition, which is not realistic. |
4158 A client's spouse is upset and crying because her Correct answer: 3 This client situation acknowledges that while the lack of nutrition and fluids will produce husband is no longer taking liquids. She understands ketones and cause somnolence to decrease the client's anxiety and promote overall comfort, fluids can delay his death but is most concerned that the wife is more concerned about how dehydration might feel to her husband. Beneficence he will become dehydrated and feel uncomfortable. promotes doing good for the client, the focus of a quality death. Veracity and fairness are not The nurse will formulate an answer addressing which considerations in this situation. ethical principle? ‐ Justice ‐ Beneficence ‐ Nonmaleficence ‐ Veracity | The focus of this question is the ability to apply the ethical principles to end‐of‐life care. Eliminate options 1, 2, and 4 because they do not represent the principle of doing good. |
4159 The nurse anticipates that which of the following Correct answer: 3 People cope better when they accept what their life had to offer, have learned to cope with clients newly diagnosed with a terminal illness is least personal losses, have the time and ability to recover emotionally between multiple deaths, likely to have difficulty facing his or her mortality? believe that death is a part of living, and have religious beliefs. Option 3 indicates the individual has planned for the future and believes that death is part of living. The client in option 1 is incorrect because this client has lost three people over a brief period of time (6 months). The client in option 2 is incorrect because he shows dependence, having never moved out of the home of his parents, who are both healthy. The client in option 4 is incorrect because individuals with religious beliefs are found to cope better. ‐ A 71‐year‐old female whose grandson, sister, and best friend died over the past 6 months ‐ A 59‐year‐old male who never married, is an only child, and whose parents are both healthy ‐ A 70‐year‐old male who has planned his funeral and enjoys riding his motorcycle at high speeds in rural areas ‐ A 68‐year‐old female who is an atheist | The focus of this question is knowledge of how older adults cope with a diagnosis of a life‐ threatening illness. Using the criteria outlined in the rationale, use the process of elimination to make the correct choice. |
4160 A client with terminal lung cancer is receiving total Correct answer: 2 Clients go through multiple stages and tasks when they are dying. During bargaining, they brain radiation therapy to control the tremors in hands "negotiate" to meet a life goal. The other stages are not consistent with the client's statement. due to multiple metastatic lesions. As the nurse assists Denial would be refusal to accept the diagnosis of terminal cancer. Anger and depression are him back to his wheelchair, he comments "I'm hoping natural reactions to anticipated loss. Acceptance is shown when the client has come to terms this treatment will let me see my first tomato on the with the diagnosis and anticipated death. Fourth of July." According to Kubler‐Ross, this statement is an example of which stage of death and dying? ‐ Denial ‐ Bargaining ‐ Anger ‐ Depression ‐ Acceptance | This question focuses on Kubler‐Ross's five stages of death and dying. The client statements on options 3 and 4 do not include reflections of anger or depression. Denial statements would show refusal to accept the diagnosis or pushing away the reality from consciousness. Option 5 indicates the client has accepted the need for treatment but has not accepted the reality of the extent of his disease. |
4161 The Registered Nurse would intervene after hearing a Correct answer: 4 Option 4 does not treat the client with respect and sensitivity and therefore is an example of Licensed Practical Nurse (LPN) make which of the maleficence. Option 1 provides a rationale for a therapy that may be uncomfortable. Options 2 following statements regarding a client with severe and 3 advocate for the client. arthritis who is also newly diagnosed with a rapidly growing colorectal cancer? ‐ "Even though it hurts a bit, your arthritic joints will become less stiff with gentle exercise." ‐ "If we give more pain medication, will it stop his breathing?" ‐ "He has a living will that says he does not want to be resuscitated." ‐ "You have on a diaper so it's OK if you do not make it to the bathroom." | The critical word in the stem of the question is intervene, making the correct option the one that is physically or emotionally harmful. Option 4 can cause anxiety and distress to the client and is therefore the statement that potentially causes harm. Eliminate option 1 because it merely questions the rationale behind an intervention and option 2 because it tries to safeguard the client. Eliminate option 3 because it is a communication about client desires. |
4162 Based on Rando's process of bereavement, place in Correct answer: 1, 5, 3, Rando’s process of bereavement is to (1) recognize the loss and death, (2) react to experience order the following statements indicating the steps of 4, 2 and express the separation and pain, (3) reminisce, (4) relinquish old attachments, (5) readjust the process as experienced by a client regarding his and adapt to the new role while maintaining memories and form a new identity, and (6) father's death. Click and drag the options below to reinvest. move them up or down. ‐ "This is the second anniversary of my father's death." ‐ "My father was an alcoholic, so every Christmas I make certain that local AA groups have coffee and chocolates to help the members through the holidays." ‐ "It was so much fun to rummage through the antique stores together." ‐ "It's too difficult to be around his stepfamily, so I visit friends on vacation." ‐ "The homestead has run down since his death. It was hard to drive past and see the lack of care in his vegetable garden." | Remember the Six R's of Rando: recognize, react, reminisce, relinquish, readjust, and reinvest. They all begin with re and then the letters CAMLAI. A helpful memory aid could be Chocolate Always Makes Lads Act Icky. |
4163 A 46‐year‐old female client with a history of head and Correct answer: 1 The definition for the ethical principle of justice is "fairness." Option 2 reflects anger on the neck cancer was recently told she has multiple part of the family, while option 3 reflects anger on the part of the client. Option 4 metastatic sites in her lung. The nurse is discussing the demonstrates a concern that the client will suffer an injustice by enduring unnecessary tests. situation with the client and her sister. Which statement during the conversation reflects the ethical principle of justice? ‐ "The staff will do everything possible to make your sister comfortable while she is in hospice." ‐ "She told the doctor she did not want to lose her hair. It is not right that he coerced her into taking that experimental chemotherapy. Now she is bald and dying." ‐ "Why did I have to get this terrible disease? I just want my life back." ‐ "We have made special arrangements for her care at home. Now the doctor says she has to have more tests to see if there is cancer in her liver. Why? We know she's dying." | Option 1 is the only statement indicating fairness in client care. Option 2 is coercion, and 4 is an ethical dilemma. Option 3 is an example of the stages of the grief process. |
4164 A 22‐year‐old hospitalized client with a recent Correct answer: 4 Anger is a common element to all the theories of grief and stages of dying. It is important to diagnosis of acquired immunodeficiency syndrome acknowledge the client's anger, help him or her identify the source of the anger, and offer (AIDS) says to the nurse, "The food on this breakfast choices or control when possible. It is important to be nonconfrontational (option 2), not to tray is terrible. Why can't you people do even simple take the anger personally (option 1), and not to ignore the client's issue (option 3). things well?" What is the nurse's best response? ‐ "I know you are angry, but I cannot let you make me the object of your anger. I will send up the dietitian." ‐ "This is not about breakfast. Tell me what you are really angry about." ‐ "I understand you are angry. I'll shut the door and let you cool off." ‐ "I hear a lot of anger in your voice that is quite normal and healthy. Do you want a new breakfast or do you want something else?" | Eliminate option 1 because it indicates the nurse is taking the statement personally and assuming what the client needs. Option 2 also makes an assumption but does address the anger. The anger is also addressed in the third option but does not encourage the client to share the source of the anger. For these reasons, options 2 and 3 should be eliminated also. The last option addresses the normalcy of the anger in this situation and encourages the client to engage in further conversation with the nurse. |
4165 While talking to adult children of a dying male client, Correct answer: 4 Open communication with concrete evidence of emotional attachments assists in coping at the nurse finds them tearful, with ambivalent feelings the end of life. Option 4 provides concrete assurance in the presence of the loved ones. toward the client. The client often expresses beliefs of Relaxation tapes help with stress reduction but do not help with resolution of problems a wasted life. The children say that their father often experienced by the family. Staffing needs do not permit a nurse to be with one client showed love but followed it with criticism, anger, continually, and families require privacy as well. Assurance that the past no longer matters is damaging accusations, and emotional abuse. The nurse an assurance lacking concrete properties. would suggest which of the following interventions that is most likely to be helpful at this time? ‐ Listen to relaxation tapes before visiting each other. If negative feelings arise, listen to the tapes together. ‐ Have a nurse present in the room at all times when a family member visits the client so that the nurse can intervene with conflict resolution if problems arise. ‐ Assure the client and children that the past no longer matters; the only time that matters is the present and the future. Encourage the children to spend more time with their father. ‐ Make a videotape of each adult child telling a story of a time when their father showed love, while the client tells of a special love for each child. Plan a time for them to watch it together. | Use the process of elimination and address the client in the question. In this case, both the client and the adult children are the affected clients, so the correct option is one that benefits all of them. |
4166 A client questions the nurse about the difference Correct answer: 1 A living will is written by the client and includes desires for use of different types of treatment between a living will and power of attorney. The in case of a life‐threatening illness. A durable power of attorney is a legal document nurse's best response is which of the following? designating an individual to make legal decisions if the client is unable to make choices independently. | The core issue of the question is knowledge of a living will. The wording of the question indicates that the correct answer is a true statement. Systematically eliminate options 2, 3, and 4 because they are incorrect statements. |
‐ "The living will allows the client to indicate specific medical treatments to be omitted in the event of terminal illness, while durable power of attorney legally appoints another to make those decisions on the behalf of the client." ‐ "A lawyer carries out a living will, while a designated family member or friend carries out advanced directives." ‐ "In a living will, the client specifies medical treatments to be carried out should he or she be incapable of making decisions. Durable power of attorney allows the client to include both treatments to be carried out and treatments to be omitted in the event of terminal illness." ‐ "The living will indicates when a client wishes life support to be discontinued, while durable power of attorney gives that power to another in the event of terminal illness." | |
4167 The nurse working with a terminally ill client wishes Correct answer: 3 The nurse needs to consider the client's wishes while also acting within the law. Euthanasia to support the client's decisions concerning end‐of‐life constitutes illegal nursing practice in the United States at this time. To act ethically, the nurse care. To do this appropriately, the nurse should do should provide care to clients according to need, regardless of belief systems. Clients who are plan to which of the following? diagnosed with terminal illness may or may not be ready for do‐not‐resuscitate orders, depending on anticipated life expectancy, quality of current life, and psychosocial variables. ‐ Be comfortable in assisting the client with euthanasia when requested to do so. ‐ Ask another nurse to provide care if the client has a belief system that differs from the nurse's belief system. ‐ Respect the client's wishes about death to the extent possible by law. ‐ Encourage the client to request a do‐not‐resuscitate order because the client has been diagnosed with a terminal illness. | Eliminate option 1 because it is illegal. Nurses need to provide unbiased care to all clients, regardless of conflicts with belief systems, so option 2 is also incorrect. Option 4 is incorrect because it may or may not reflect the client's preference at this time. |
4168 The terminally ill client asks the nurse for information Correct answer: 4 The focus of hospice is improving the quality of life and preserving dignity for the client in about hospice care. The nurse would best respond by death. Hospice care may be provided by nurses, volunteers, or other members of the health stating: care team in a variety of settings. It is available to any client who has a terminal illness with a life expectancy of 6 months or less. ‐ "Hospice care is home nursing care provided to terminal cancer clients." ‐ "The client qualifies for hospice care at the time of diagnosis with a terminal illness." ‐ "The main focus of hospice is to educate the client concerning treatment options and alternatives." ‐ "Hospice regards dying as a normal part of life and provides support for a dignified and peaceful death." | Eliminate options 1, 2, and 3 because they represent incorrect definitions of hospice and do not accurately reflect the care provided. In addition, option 1 is insensitive. |
4169 The nurse concludes that which of the following Correct answer: 2 Grief resolution requires letting go of the past and looking forward to the future. The client would not be considered a sign of grief resolution in needs to be able to put the loss in perspective and engage fully and effectively in daily life as the bereaved client whose husband died a year ago? an independent person. In option 2, the client has not let go of the past because decisions are made in the present only through memories of preferences of the deceased. Options 1, 3, and 4 all indicate healthy grief resolution. ‐ Becoming future‐oriented when discussing details of everyday life ‐ Considering the opinions of the deceased prior to making decisions about everyday life ‐ Experiencing occasional waves of grief triggered by pictures or events ‐ Sharing stories of good times that the client and her husband shared over the years | The critical word in the question is not, which tells you the correct option is a statement that indicates inadequate coping with the loss or unresolved grief. |
4170 Which of the following nursing interventions would Correct answer: 1 Hope instillation is often an effective intervention in dealing with anticipatory grieving. Option be most appropriate for the nurse to include in the 3 deals with the symptom and not the actual problem. Options 2 and 4 are not appropriate care plan of a client with a nursing diagnosis of because there is no evidence in the stem of the question to support their need. anticipatory grieving? ‐ Hope instillation ‐ Forgiveness facilitation | The key words in the stem of the question are anticipatory grieving. Use the process of elimination to select the option that focuses on anticipated loss. Choose option 1 because of the word hope in the option, which relates to the word grieving in the question. |
‐ Medication management ‐ Hypnotherapy | |
4171 A client is dying, is in excruciating pain, and refuses Correct answer: 3 The Hindu and Buddhist religions require that believers are alert and mindful as they leave anything for relief that alters his sensorium. The nurse the life on earth and transcend to their next life. This requirement is not found in Islam or checks the psychosocial data part of the client's Catholicism. medical record, expecting that which of the following religions is most likely practiced by the client? ‐ Islam ‐ Judaism ‐ Buddhism ‐ Catholicism | Use the process of elimination. Only the religion identified in option 3 requires a state of being mindful and alert as their faithful transcend from life into death. |
4172 Which of the following indicates to the nurse that a Correct answer: 4 Knowledge of response to pain offers accurate and careful assessment of pain with earlier noncommunicative client's pain is not well‐managed? and more complete pain relief. It should include physical and emotional behaviors. ‐ Crackles in the lung ‐ Hyperactive bowel sounds ‐ Unwillingness to eat without assistance ‐ Constant restlessness and leg movement | Options 1 and 2 are due to inactivity from uncontrolled pain. Requesting assistance to eat is not an indication of pain, so option 3 is not a correct response. |
4173 A nurse who seeks to uphold the Patient Self‐ Correct answer: 1 The Patient Self‐Determination Act became federal law in 1990. This law states that clients Determination Act would do which of the following? have a right to participate in their own care. In addition, healthcare facilities are required to inform clients of the right to accept or refuse medical care. The other options are not provisions within the law. ‐ Inform clients of their right to be part of the healthcare decision process. ‐ Provide clients with a community case manager to manage their living wills. ‐ Allow clients the opportunity to choose between voluntary and involuntary treatment. ‐ Inform clients of their right to sue and to be compensated if a facility does not provide a mechanism for self‐determination. | Look for a specific answer to a specific question about this law. Recall situations seen in clinical that are examples of actions that are consistent with the provisions of this law. |
4174 In order to most effectively support a client through Correct answer: 3 Option 3 is correct. For nurses to be able to talk openly about death and dying, they must the death and dying process, a nurse should do which have some level of comfort with death, dying, and the experience of loss. It is important that of the following? they have addressed their own personal losses and done the necessary grieving. If this is not satisfactorily done, losses at work will trigger grief reactions. This may render the nurse less able to be available to assist the client, it may emotionally. Not being able to develop a healthy attitude about death and dying may also prevent the nurse from being able to communicate effectively with clients. Clients should be encouraged to talk about their feelings, both positive and negative. Although the process of life is important, clients should be given permission to talk about their own deaths and deaths of their loved ones. Options 1 and 2 are incorrect as they would actively prevent the client from talking about death. Option 4 would place an unreasonable responsibility on the nurse. Not only is the nurse not responsible for preventing or facilitating the clients from these feelings, the nurse will recognize that experiencing feelings of helplessness and depression are normal during the process of normal grieving. ‐ Encourage clients to focus on being positive ‐ Place a greater importance on the process of life, rather than a focus on death ‐ Have a healthy attitude about death and dying ‐ Have the ability to keep clients from becoming depressed and helpless | This is not a difficult question. Don't make it unnecessarily hard. In order to best support the client through anything difficult, the nurse has to be comfortable with the process. This is no different. If the nurse is comfortable with loss and dying. Then he/she will be able to make the client feel more comfortable also. |
4175 A nurse working in a hospice program understands Correct answer: 1 Option 1 is correct. Cultures have rules for grieving which delineate the appropriate that client cultural rituals and practices provide expression of feelings and determines patterns of appropriate behavior. Option 2 is incorrect individuals experiencing grief with: as it may be a consequence of cultural influence on the individual. Option 3 is incorrect because it will not assist a client in dealing with feelings of anger. Option 4 is incorrect as it may or may not be a tenet dictated by cultural beliefs. ‐ Assistance in stabilizing and coping when they are feeling confused and chaotic. ‐ Opportunity to identify more closely with their cultural heritage. ‐ Opportunity to oppose ethnic structures in order to displace feelings of anger. ‐ Assistance in establishing boundaries between themselves and the dying person. | Think about cultural rituals engaged in during a time of grieving. What psychologic purposes were served by the rituals? |
4176 A client whose newborn baby died at birth six weeks Correct answer: 3 Option 3 is correct. Normal grief is the total response to the emotional experience related to ago tells the nurse that she has been having trouble loss or death. Clients experience grief at different levels of intensity and for different periods sleeping and eating. She also reports having difficulty of time. Option 1 is incorrect as inhibited grief is a suppressed response to loss, which may be concentrating at work and does not experience any expressed by somatic complaints, such as physical symptoms around the anniversary of a loss pleasure from painting canvases like she once did. The or during holidays. Option 2 is incorrect because disenfranchised grief is a response to a loss in nurse concludes these statements as indicative of: which the bereaved is not regarded as having the right to grieve or is unable to acknowledge the loss to other persons. The loss is one which is not publicly sanctioned or acknowledged. As a result, the griever does not receive the needed support and validation for their pain. Examples might be abortion, miscarriage, or death of loved one from AIDS. Option 4 is incorrect as delayed grief is a postponed response in which the bereaved person may have a reaction at the time of the loss, but it is not sufficient in proportion to the loss. However, a loss at a later time may trigger a reaction that is out of proportion to the significance of the current loss. ‐ Inhibited grief. ‐ Disenfranchised grief. ‐ Normal grief. ‐ Delayed grief. | Recall basic definitions of different types of grief. Look carefully at the descriptors of the client’s behaviors. |
4177 The nurse working with a bereaved family utilizes Correct answer: 4 Option 4 is correct. Grief is a pervasive, individualized, and dynamic process that may result in which of the following concepts about grief work? physical, emotional, or spiritual distress because of loss or death of a loved one or cherished Grief is primarily a: object. Options 1, 2, and 3 are incorrect. Although each of these options are partially correct, option 4 provides the most comprehensive information about the conceptual framework the nurse utilizes with a bereaved family doing grief work. ‐ Physiological response following a loss or death. ‐ Psychological response following a loss or death. ‐ Spiritual response following a loss or death. ‐ Dynamic process of physiological, psychological, and spiritual responses to a loss or death. | Notice that three of the options give partially correct information that is included in the more comprehensive option. Choose the most comprehensive answer. |
4178 A 52‐year‐old client suffers a massive myocardial Correct answer: 1 Option 1 is correct. In adults between ages 45–65, the aging process can create an emotional infarction and cannot return to usual activities because reaction known as a grieving response. The loss of peak physical functioning, a change in health of the large amount of damage to the heart. The nurse status, attempts to change to "healthier" habits, and adjustment to a new body image are all actively assists this client who is most likely losses and may engender a grief reaction. Options 2, 3, and 4 are incorrect as they are not part experiencing: of this developmental stage. ‐ The grieving response. ‐ Life goal disappointment. ‐ Acceptance of failures. ‐ Mistrust of care givers. | Look for the combination of factors: age of the client and recent changes in physical health. |
4179 A terminally ill client with a grave prognosis will soon Correct answer: 3 Option 3 is correct. Anticipatory grief is anxiety and sorrow experienced prior to an expected be removed from life support. The nurse caring for the loss or death. The family members of a chronically or terminally ill client may anticipate the client notes that the family is beginning to distance loss of a loved one before her or his death because of the prognosis or severity of the person’s themselves from the client. The nurse concludes the illness. The family is beginning to "pull away" or distance themselves from the grief and sorrow family is experiencing: of the expected death of the client. Option 1 is incorrect as dysfunctional grief is unresolved that does not lead to a successful conclusion. Option 2 is incorrect because disenfranchised grief is a response to a loss or death in which the individual is not regarded as having the right to grieve or is unable to acknowledge the loss to other persons. Option 3 is incorrect as inhibited grief is a suppressed response, which may be expressed in other ways, such as somatic complaints (e.g., having physically symptoms on the anniversary of a loss or during holidays). ‐ Dysfunctional grief. ‐ Disenfranchised grief. ‐ Anticipatory grief. ‐ Inhibited grief. | Recognize that individuals often believe that anticipatory grieving will ease the pain of their loss once the death occurs. In actuality, the knowing, preparing for and, anticipating the dying of a loved one does not necessarily make the actual death any easier for the bereaved. |
4180 A client states, "I don’t know what I'm going to do to Correct answer: 4 Option 4 is correct. Reflecting the communication of the client will enable them to have a manage my family now that my husband has died." feeling of being heard. The goal in assisting a client in grieving can be achieved by the nurse What would be the nurse's best response to this who actively listens and encourages the client to discuss personal feelings. Options 1 and 2 are statement? incorrect as these options provide false reassurance and do not allow the client to discuss feelings of loss. Option 3 is incorrect because while it may be appropriate at some time, at this juncture the client needs someone to listen and provide support. ‐ "Everything will be all right. You will be able to survive without him. You'll see." ‐ "I know in time you will be able to get over your husband's death. Time heals all wounds." ‐ "I think you should contact your minister for advice. You need spiritual guidance now." ‐ "What I hear you saying is that you are feeling overwhelmed now." | Avoid selecting an option that contains platitudes. Recognize that reflecting the client’s feelings back to the client will facilitate further expression of feeling, which is very important when the individual is grieving. Remember listening is what is most important at this time. Not making assumptions or giving advice. |
4181 A nurse conducting health promotion classes in the Correct answer: 4 Option 4 is correct. Adolescents fantasize that death can be defied and may act out defiance community would teach parents that which age group through reckless behaviors. Option 1 is incorrect as toddlers do not have an understanding of is most likely to take unnecessary risks because they death. Option 2 is incorrect because preschool children believe death is reversible. Option 3 is believe they are invincible to death? incorrect as school‐aged children express a fear of death. ‐ Toddler ‐ Preschool ‐ School‐age ‐ Adolescent | Recall important concepts of developmental theorists, as well as behaviors of adolescents you known or have known. |
4182 A client has a terminal illness and is unable to eat. The Correct answer: 3 Option 3 is correct. Voluntary passive euthanasia occurs when treatment is intentionally client's advance directive clearly states a wish not to withheld by voluntary consent of the individual who is dying. Option 1 is incorrect as voluntary be fed by external feedings or with IV fluid active euthanasia occurs when the person being euthanized has agreed and volunteered for replacement. The nurse interprets this wish to be: death. Option 2 is incorrect because involuntary active euthanasia occurs when the person being euthanized has not agreed or volunteered for death. Option 4 is incorrect as involuntary passive euthanasia occurs when treatment is intentionally withheld without voluntary consent from the person who is dying. ‐ Voluntary active euthanasia. ‐ Involuntary active euthanasia. ‐ Voluntary passive euthanasia. ‐ Involuntary passive euthanasia. | Eliminate the two options containing involuntary. If the client has made advanced directive statements, from a legal perspective, these were made voluntarily. Then note that the client is asking for withholding of treatment, not administering of a treatment to hasten death |
4183 With a child newly diagnosed with leukemia, which Correct answer: 3 The child and family will be overwhelmed with such a life‐threatening illness; anticipating the nursing care measure would the nurse identify as a loss of a child would be a priority for the family. Options 1, 2, and 4 suggest pertinent teaching priority for the child and family? interventions, but during the initial period following learning of the diagnosis, the first need of the family is to react emotionally and begin to adjust to the losses implied by the diagnosis. ‐ Comfort measures ‐ Distraction activities ‐ Anticipatory grieving ‐ Bereavement counseling | Imagine yourself in the situation of this family. Would not your emotional level be very high? |
4184 The nurse is to counsel a mother who recently placed Correct answer: 4 Self‐awareness is a key component of any nurse/client experience. The nurse must be able to her newborn baby up for adoption. Before beginning examine personal feelings, actions, and reactions in order to better assist the client in fully the counseling, it is important for the nurse to deal expressing his or her own feelings and thoughts. A firm understanding and acceptance of self with personal feelings about adoption, grief, and loss. allows the nurse to acknowledge a client’s differences and uniqueness. In order to be This self‐awareness would: empathetic to the client, the nurse must be aware of his or her own feelings. Options 1, 2, and 3 do not focus on self‐awareness. ‐ Prevent the nurse from being personally affected by the client's choice in adoption. ‐ Prevent the nurse from sharing any personal feelings with the client. ‐ Assist the nurse to avoid discussing unpleasant feelings with the client. ‐ Assist the nurse to help the client express grief fully. | Look at what the question is asking, which is, In what way can self‐awareness benefit the nurse? |
4185 During a counseling session, a 21‐year‐old client with Correct answer: 1 Schizophrenia most often occurs in young adults who are in the prime of life and attempting schizophrenia verbalizes feelings of sadness and anger to achieve a normal adulthood. The individual experiences many losses, and the nurse should about being unable to keep a job or continue attending assist the client through the grieving process. The situation does not indicate that the client is college. The nurse should formulate which of the experiencing significant anxiety (option 2). This situation does not indicate that that the client following as the most applicable nursing diagnosis: is experiencing impaired coping or that hopelessness is present (option 3). Sadness and hopelessness are different emotions. The client’s grieving is not dysfunctional (option 4), as the client is actively grieving a recent loss. ‐ Grief related to perceived inability to achieve developmental milestones ‐ Anxiety related to fear of unknown and fear of failure ‐ Ineffective coping related to feelings of hopelessness and anger ‐ Dysfunctional grief related to unrealistic expectations of abilities and lack of achievement | Consider this client's reaction to be normal. |
4186 The community health nurse arrives at a home for a Correct answer: 2 Even though great emotional pain is felt after a loss, it is necessary for the grieving person to routine monthly visit. The client, who is crying, invites talk about memories of the lost person. This process begins early in the grief experience. the nurse in and says, "My mother’s funeral was Options 1 and 3 would actively prevent the reminiscing that is necessary in early. Additionally, yesterday. I'm so sad." What is the most appropriate option 3 would also change the focus from the grieving person's feelings to a more impersonal action by the nurse at this time? and clinical topic. In option 4, while it is true that people with a high level of ambivalence about the lost person may have difficulty resolving grief, this sort of exploration is inappropriate at this time. The client needs to express initial feelings of loss before moving on to other grieving tasks, which include reviewing the relationship. ‐ Encourage the client to think about something other than the mother's death. ‐ Allow the client to talk about personal memories of the mother. ‐ Ask the client to describe what led to the mother’s death. ‐ Explore the nature of the client's relationship with the mother. | Notice that the loss has occurred very recently. |
4187 A client reports that since her husband's death 4 Correct answer: 2 Somatic complaints may be experienced around the date of a loss. This is called an years ago, she has experienced migraine headaches anniversary grief response and is not a dysfunctional grief experience if the physical symptoms and severe nausea each year around the date of the occur only around the specific date of the loss and the individual has otherwise returned to a husband's death. The nurse suspects the client is full life. Individuals who have been together for many years often have these experiences for experiencing which of the following? many years. Delayed grief (option 1) is a postponed response in which the bereaved person may not grieve sufficiently at the time of the loss but instead has a disproportionate reaction to a later loss, which can be much more minor than the original loss. Disenfranchised grief (option 3) is a response to a loss, which the individual is not regarded as having the right to grieve, or is unable to acknowledge the loss to other persons. Unresolved grief (option 4) is a response that is prolonged or extended in length and severity of response. ‐ Delayed grief. ‐ Anniversary grief experience. ‐ Disenfranchised grief. ‐ Unresolved grief. | Notice the time period since the spouse's death. |
4188 The nurse works in a crisis clinic. A client arrives in a Correct answer: 3 Disenfranchised grief is a response to a loss or death in which the individual is not regarded as very agitated state saying, "My life partner of 15 years having the right to grieve or is unable to acknowledge the loss to other persons. Delayed grief has died of cancer and the family will not allow me to (option 1) is a postponed response in which the bereaved person may have a reaction at the attend the funeral. They never accepted our time of the loss, but it is not sufficient to the loss. However, a later loss may trigger a reaction relationship." The nurse plans to facilitate the grieving that is out of proportion to the meaning of the current loss. Inhibited grief (option 2) is a process in this client because circumstances place the suppressed response to loss that may be expressed by somatic complaints, such as physical client at risk for which type of grief? symptoms around the anniversary of a loss or during holidays. Unresolved grief (option 4) is a response that is prolonged or extended in length and severity of response. ‐ Delayed ‐ Inhibited ‐ Disenfranchised ‐ Unresolved | Recognize the extent of this client's aloneness and the absence of a support system. |
4189 The nurse informs a 20‐year‐old client that both Correct answer: 4 Although the stages of grief should be used with caution in labeling expected behaviors and parents and two older siblings were killed in an feelings, many clients will experience the five stages of grief as denial or shock, anger, automobile accident. The client screams "No! No!" bargaining, depression, and acceptance. Although the stages of grief should be used with while covering the ears and crying. Which of the caution in labeling expected behaviors and feelings, many clients will experience the five stages following types of behavior is the nurse likely to of grief as denial or shock, anger, bargaining, depression, and acceptance. observe next? ‐ Denial ‐ Depression ‐ Bargaining ‐ Anger | Recall commonly identified steps in the grief response. Think of grieving persons you have known. |
4190 When questioned by a client about what an advance Correct answer: 1 Advance directive is a general term that refers to a client's written instructions about future directive or living will is, the nurse should respond that medical care in the event that the client becomes unable to speak or is incapacitated. Specific this type of document indicates: instructions about what medical treatment the client chooses to omit or refuse (e.g., ventilator support) in the event that the client is unable to make those decisions is also included. Advance directives do not specify particular practitioners or family members preferred for providing end of life care (options 2 and 3). When an advance directive document is created, the individual makes the decisions about future treatment to be administered or withheld (option 4). Advance directives are not the same as designating another person to make medical decisions for the individual; this is a specific legal process known as healthcare proxy or medical power of attorney. ‐ What treatment should be provided or omitted if the client becomes incapacitated. ‐ Which practitioners should be allowed to provide end‐of‐life care. | Recall situations in the clinical area in which advance directives have been utilized. |
‐ Details about preferred caregivers for end‐of‐life care. ‐ Which family members are to be responsible for making end‐of‐life decision. | |
4191 The grandfather of a 3‐year‐old client died 2 days ago. Correct answer: 3 Preschool children believe death is reversible. They do not have a developed sense of death, Based on an understanding of normal growth and and they are unable to understand the permanent impact of death and dying. Children development, the nurse anticipates hearing the young between 5–9 years of age believe wishes or unrelated actions can be responsible for death client make a comment such as: (option 1). Preschool children do not have a developed sense of death, and are unable to understand the permanent impact of death and dying. The responses in options 2 and 4 indicate the child is aware the death is permanent. ‐ "Grandfather would not have died if I had wished a little harder." ‐ “Grandfather will be waiting for me when I die." ‐ "Grandfather will be back to take me to the ballgame next week." ‐ "Grandfather is gone, and now I have to be strong and not cry." | Review concepts of major theorists, such as Piaget. |
4192 The client with lung cancer is expected to die within 3 Correct answer: 2 This client needs to be assisted to move through the final developmental landmarks and tasks months. The nurse determines that a priority in at the end of life, which include closure and completion in relations with family and friends. working with this client is to assist the client to do This will also assist the family to engage in anticipatory grieving. Option 1 would actively which of the following? prevent the client from moving through the final developmental landmarks and end‐of‐life tasks. Relief of pain is of highest priority when the client is terminal (option 3). The nurse should be aware of the fact that there are means of using narcotic analgesics without causing clouding of consciousness. At end of life, the dying person should be allowed to be as independent as possible in order to preserve self‐esteem (option 4). ‐ Avoid discussing the future or making future plans, as the future is uncertain. ‐ Discuss feelings of impending death and acknowledge the inevitable outcome. ‐ Verbalize need to avoid taking narcotic analgesics since they can cause clouded thinking. ‐ Allow caregivers to provide as much care as possible to reduce stress and to preserve energy. | Recognize that providing appropriate end‐of‐life care is an important nursing role. |
4193 A client underwent a gastric banding surgical Correct answer: 1, 2 A perceived loss is experienced by one person but cannot be verified by others (e.g., loss of procedure as treatment for morbid obesity. Following self‐esteem or body image). An actual loss can be identified by others and can arise in a 140‐pound weight loss, the client's body mass index response to a significant change in a person’s appearance, body, or life circumstances, such as (BMI) is now 24.8. The client states, "I'm too fat. I weight loss after surgery. An anticipatory loss (option 3) is experienced before the loss actually always have been." The nurse concludes that this client occurs (e.g., terminal illness). A permanent loss (option 4) is an irreversible deprivation (e.g., has a disturbed body image related to which type(s) of paralysis). A painful loss (option 5) is a generalized term that does not have universal meaning. psychological loss? Select all that apply. ‐ Actual ‐ Perceived ‐ Anticipatory ‐ Permanent ‐ Painful | Recognize that this client will experience both positive and negative psychological effects from having had the surgery. Look beyond the obvious and evaluate each option in terms of its relevance to the client in the situation. |
4194 Before counseling parents who have recently lost a Correct answer: 1 The capacity for self‐awareness allows the nurse to reflect and make choices. Nurses who child to death, it is important for the nurse to have understand their own feelings and beliefs will be able to be therapeutic when clients need to already dealt with personal feelings about death, grief, address issues which are disturbing and difficult. The death of a child will personally affect the and loss in children. Having this self‐awareness is nurse, and it is critical for the nurse to share these feelings with others, including the parents important because it: (option 2). The nurse must be available both physically and emotionally for the parents in discussing unpleasant and difficult feelings (options 3 and 4). ‐ Assists the nurse to help the parents express their grief fully. ‐ Prevents the nurse from being personally affected by the loss. ‐ Prevents the nurse from sharing any personal feelings with the parents. ‐ Assists the nurse to avoid discussing unpleasant feelings with the parents. | Review concepts of grieving. Recognize that the nurse, too, can grieve. |
4195 A young woman arrives at a routine medical visit, Correct answer: 1 Although the loss of a child can be devastating, the ability of a parent to reintegrate appears depressed, and tells the nurse she is having involvement in usual activities is important to successfully resolving grief and loss. The client's difficulty dealing with the death of her infant son. The behavior indicates that she has not moved past the initial stage of grief in which preoccupation nurse learns the infant died 30 months ago in an with feelings of loss and intense emotional pain are prevalent. Options 1, 3, and 4 are more automobile accident. The initial nursing diagnosis is average responses to the death of a child. dysfunctional grieving. Which statement by the client would support this diagnosis? ‐ "When my children play in playgrounds, it makes me angry that my son will never be able to play like other children." ‐ "I spend most of every day crying in my son's room because he's not there any more." ‐ "I watch other toddlers in the neighborhood play, and I wish my son was still alive." ‐ "I think of my son and I am sad that my new baby will never be able to know his brother." | Review concepts or grief and mourning. Note that the child has been dead for 2½ years. |
4196 The client whose spouse died 4 months ago is Correct answer: 1 The client is showing denial, which is the earliest reaction to loss. This first stage of grieving is admitted for inpatient psychiatric care. The client has normally short‐lived, and the grieving person moves on to other grief responses, like anger. been unable to work since the spouse's death and has The total time for acute grieving is very individualized, but feelings of numbness, emptiness, lost 20 pounds. The client cries frequently and says, and active denial of the death 4 months later indicates that this client's mourning is not "No, I won’t believe it. It's not true." The client further progressing normally. Disenfranchised grief (option 2) is not present because there is nothing describes feeling "numb" and "empty." The admitting in the situation (e.g., a clandestine relationship) that would prevent the client from expressing medical diagnosis is major depression. The nurse grief. The client is grieving the actual loss of the spouse, not another situation, as would occur identifies which of the following as the priority in distorted grief (option 3). This client’s reaction is not consistent with the normal pattern of problem? grieving (option 4). ‐ Dysfunctional grief ‐ Disenfranchised grief ‐ Distorted grief ‐ Normal grief | Notice the time frame given in the question. Compare this with theories of grief and mourning. |
4197 A family who has gathered around their dying Correct answer: 3 Spiritual and cultural beliefs and practices greatly influence both a person's and family's grandmother's bed refuses to allow a feeding tube to reaction to death and subsequent behavior. Options 1, 2, and 3 may also be correct, but the be removed and to stop feeding her, even after the common organizing underpinnings to each of these options are cultural and spiritual beliefs. healthcare team has stated that nothing else could be done to help her recover. The nurse concludes that the family's resistance to removing the feeding tube is most likely based on which factor? ‐ Their refusal to accept the finality of death ‐ Their need to try every possible solution ‐ Their spiritual and cultural beliefs ‐ Their distrust of the healthcare system | When one or more options appear to be partially or completely correct, look for an answer that is more comprehensive and can include the other answers. |
4198 A father who recently lost his eldest son to cancer Correct answer: 1 Male or masculine expression of loss or death is commonly limited and less overt. Intense refuses to share his feelings in a support group and has feelings are usually experienced privately with a general reluctance to discuss these with not shown any tears related to the loss. What is the others. Option 2 would not be indicated at this time because the father is probably not nurse's most appropriate interpretation of this experiencing dysfunctional grief. There is not enough data in options 3 or 4 to support these behavior? options. ‐ A common expression of how men grieve loss and death. ‐ Dysfunctional expression of grief and the client should be referred to counseling. ‐ A common expression of denial and refusal to accept death or loss. ‐ The father's attempt to be strong for the rest of the family. | Recall information about grief styles of males versus females in American society since there is a lack of other cultural reference in the question. |
4199 A 4‐year‐old says, “If I can make a big enough wish, Correct answer: 2 Preschool children (ages 3–5) do not understand the finality of death, but instead may see it my daddy will not be dead any more.” The nurse as separation. They engage in magical thinking and truly believe in the power of wishes. concludes that the child is: Magical thinking is most common in preschool aged children (option 1). The child is not experiencing delusions or making up a story to avoid feelings (options 3 and 4). ‐ Expressing magical thinking common to much older children. ‐ Voicing thoughts that are normal for children this age. ‐ Delusional and should be evaluated by a psychiatrist. ‐ Making up the story in order to avoid feeling sad and scared. | Pay attention to the age of the child. Review theories about cognitive development in children. |
4200 A terminally ill 78‐year‐old female client tells the Correct answer: 2 With mutual pretense, the client, family, and/or healthcare providers know that the prognosis nurse she does not want her adult children to know is terminal but agree not to talk about it and make an effort not to raise the subject. In closed she is dying. Later that day when the adult children awareness (option 1), the client and family are unaware of impending loss or death. There is visit, they tell the nurse that they know their mother is no mutual concern (option 3). In open awareness (option 4), the client and involved individuals dying but will not talk about this front of her. The know about the impending loss or death and feel comfortable discussing it, even though it may nurse mentions in intershift report that this family's be difficult. situation is one of: ‐ Closed awareness. ‐ Mutual pretense. ‐ Mutual concern. ‐ Open awareness. | Notice that both the client and the family are making a decision independently of each other that they think is in the best interests of all. Select the option that is comprehensive of all people in the question. |
4201 A frail 79‐year‐old female calls the home health nurse Correct answer: 4 As the care receiver becomes more chronically ill and the caregiving burden becomes more and says, "I am a failure, and I can no longer care demanding, a great strain can be placed on the caregiver's emotional and physical health. adequately for my husband who has Alzheimer's There is not enough data to suggest ineffective coping, dysfunctional grief, or social isolation disease." She has been his primary caregiver for more (options 1, 2, and 3). than 5 years. Now he has become despondent, is unable to ambulate, and is difficult to manage. The nurse determines that which nursing diagnosis is most appropriate? ‐ Ineffective coping related to chronic illness ‐ Social isolation of family unit related to altered state of health ‐ Dysfunctional grief related to not accepting personal limitations ‐ Caregiver role strain related to overwhelming caregiving tasks and expectations | Imagine yourself in this spouse's situation. Can you feel the frustration, fatigue and strain? |
4202 The nurse is counseling a client who has lost the Correct answer: 3 A major outcome of grief counseling is to assist the client in sharing his or her loss and to spouse through death. Which of the following is an accept support from others. It is critical for the spouse to share the feelings of loss and grief appropriate outcome criterion? The client will: with others. A vital part of normal grieving is expressing feelings of loss and grief in a supportive interpersonal environment, particularly with those who are most significant in the grieving person’s life (options 1 and 4). It is too early to memorialize the spouse; the client must grieve the loss of client first (option 2). ‐ Stop expressing feelings about the spouse's death. ‐ Plan a memorial tribute for the spouse. ‐ Attend grief support groups. ‐ Avoid sharing loss with significant others. | Recall basic grief processes. Consider the normal need of the grieving person to talk about personal loss. Recognize the mutuality of loss in supportive personal relationships. |
4203 A 34‐year‐old unconscious client with severe brain Correct answer: 2 The purpose of having a health care proxy is to allow that person the right to make health damage due to a ruptured aneurysm has a surrogate care decisions on the client's behalf when needed. To uphold the rights of the client at this caregiver who has decided to stop all treatment and time, when the client can no longer convey his or her own wishes, the health care providers allow the individual to die. The surrogate caregiver is need to respect the authorized surrogate's right to make the decision to refuse or stop also the client's health care proxy. The nurse's best treatment. response would be: ‐ "Are you certain you want to give up hope?" | The core issue is the right of the authorized surrogate. Option 1 is an inappropriate response. Option 3 is offering a rationale for what could occur, but is not a supportive answer for the surrogate. If the nurse knows the decision maker is an authorized surrogate, as noted in the stem, it is an inappropriate response. |
‐ "I know this is a difficult decision to make about your loved one, but you have the right to make that decision." ‐ "Stopping all treatment could make the client very dehydrated and uncomfortable." ‐ "How do I know you have the right to make that treatment‐related decision?" | |
4204 A 28‐year‐old woman is dying with breast cancer. She Correct answer: 3 The goal of palliative care is to assess and treat the symptoms the dying client is experiencing. has metastatic disease to her bones and liver. She is to If treating the cause can alleviate the symptom, it is appropriate. Treating the disease is not receive palliative care. Which of the following would appropriate. the nurse expect to be included in the plan of care? ‐ Chemotherapy to treat the breast cancer ‐ No treatments ‐ Radiation therapy to her right arm to treat the bone pain from metastasis ‐ Hydration and tube feeding only | The focus is on the definition of palliative care and application to client care. Only Option 3 is an intervention to decrease the pain. |
4205 A client with a diagnosis of leukemia has excruciating Correct answer: 1 It is "ethically justified" to offer pain medication without fear of causing further respiratory pain. It has been two hours since the previous IV depression to a terminally ill client. medication for pain, and so it is ordered prn. The client's vital signs are temperature 98.8° F, pulse 68, and respirations 6. The nurse's best response would be to: ‐ Medicate the client for pain. ‐ Wait to medicate until the respirations are greater than 8. ‐ Call the physician for another stat order for pain medication. ‐ Offer a back rub to provide an alternative intervention to medication. | Only option 1 provides immediate pain relief for the terminally ill client. |
4206 A non‐responsive client with signs of imminent death Correct answer: 4 Relaxation techniques and minimizing stimulation will decrease the level of delirium and the has facial grimacing, frequent moaning, and restless agitation associated with it. legs. The nurse concludes that these are probably: ‐ Attempts to communicate to individuals in the room. ‐ Reflex responses to environmental stimuli. ‐ Additional signs of impending death. ‐ Signs of intractable pain. | Knowledge of the signs and symptoms of imminent death are key to this question. Options 1, 2, and 3 are incorrect. Option 4 identifies pain as a rationale for these unusual signs as death approaches. |
4207 The family of a dying client is distressed due to the Correct answer: 3 Minimizing environmental stimulation will help to reduce the sensory input that can delirium without drowsiness that the client continues aggravate delirium. Delirium without drowsiness is an acute state of disorientation, and to experience while going through the dying process. frequently is associated with agitation. It has an underlying metabolic cause, and should not be What information would be helpful for the nurse to confused with the chronic condition of dementia (option 4). Option 2 has faulty logic. Giving provide to this family? fluids could help to reduce the dehydration that can aggravate delirium, and aspiration might be not as critical a concern for the client who is in the process of dying (option 2). Talking to the client should not be done for the purpose of raising the level of awareness, but rather to comfort the client and to say goodbye (option 1). ‐ The family should talk to the client frequently to raise the level of awareness. ‐ Minimizing food and fluid given to the client will lessen the likelihood of aspiration. ‐ General environmental stimulation of the client should be reduced . ‐ This would be expected behavior if the client also has a history of dementia. | Identify the interventions that are factually correct and focus on options to decrease or eliminate the delirium. Use this knowledge and the process of elimination to make a selection. |
4208 A client with a terminal illness is experiencing Correct answer: 1 General muscle wasting and lack of nutrition are seen with most terminal illnesses. They are cachexia. The spouse is very upset, and notes that caused by a combination of multiple factors, including metabolic changes, depression, "there has never been a problem with my husband's treatments for disease or symptoms, or even the symptoms associated with the disease, such appetite." Which response from the nurse would be as pain. helpful? ‐ "Cachexia can be caused by multiple factors, such as depression and GI disruptions." ‐ "The most likely reason for this loss of weight is decreased food intake." ‐ "I can understand you are upset, but that will not solve the problem. We need to focus on your husband." ‐ "Would you like for tube feeding to be started, to assure adequate nutritional intake?" | The focus of this question is knowledge of cachexia and support to the spouse in the form of education. Options 2 and 4 are incorrect because more than decreased food intake is responsible for cachexia. Option 3 minimizes the concerns of the spouse. |
4209 A home health nurse is making a visit to a client who Correct answer: 3 Fecal impaction causes a diarrhea that has rapid onset. Diarrhea caused by anal incontinence is terminally ill and whose condition is deteriorating. A (option 2) often occurs twice a day, and the stool caused by malabsorption (option 1) would be family member reports to the nurse that his terminally foul‐smelling, fatty and pale. Diarrhea caused by food poisoning (option 4) would occur hours ill father experienced rapid‐onset diarrhea after eating after ingestion of food, typically accompanied by severe nausea and vomiting. breakfast. The nurse explains this was most likely due to: ‐ Malabsorption. ‐ Anal incontinence. ‐ Fecal impaction. ‐ Food poisoning. | Review the assessment information for diarrhea that occurs in clients who are near the end of life. The incorrect options do not provide sufficient or correct explanations. Use nursing knowledge and the process of elimination to make a selection. |
4210 Assessment of the right hip of a terminally ill client Correct answer: 1 An emollient lotion will lubricate and moisturize the skin in order to maintain tissue integrity. shows it has started to break down due to decreasing Alcohol is a drying agent, while hydrogen peroxide and warm towels are not indicated, and circulation. The nurse determines that massage with could cause harm. which of the following would be helpful to prevent further injury to the tissue? ‐ Emollient lotion ‐ Lubricant with alcohol ‐ Hydrogen peroxide ‐ Warm towel | The focus is maintaining tissue integrity. Only option 1 can accomplish this. Option 2 is drying, and option 3 can cause cellular damage as a result of its turbulent effect. Option 4 is rough and dry, which could cause further injury to sensitive tissue. |
4211 The family of a dying client is hesitant to stop IV fluids Correct answer: 2 Dehydration causes a variety of physiological changes, inducing somnolence in the dying because they are concerned it will cause suffering for client. The statements in the other options are not stated correctly, and do not help the their dying father. It would be helpful for the nurse to client’s family to understand the role of fluid therapy in the terminally ill. explain which of the following to the family? ‐ Their father cannot live without water, so he will not suffer for long. ‐ Dehydration increases ketone production, causing sleepiness, euphoria, and a decrease in pain. ‐ A lack of water will prevent the client from having loose stools immediately after death. ‐ Stopping fluids will alleviate edema and hearth failure. | Only option 2 provides comfort to a dying client. The other options are incorrect. |
4212 The family of a client dying from congestive heart Correct answer: 1, 2, 5 Families need to be taught that lack of fluids can promote comfort in the dying client with failure is concerned about making certain their mother decreased secretions, minimize fluid accumulation in the peripheral tissues, and stimulate is comfortable as she goes through the process of endorphin production. Lack of fluids, however, would contribute to the client's sense of dry dying. Which of the following statements indicate to mouth. the nurse that the family understands that lack of fluid and nutrition can promote comfort as a client dies? Select all that apply. ‐ "There will be less nausea and vomiting, since the GI secretions will be decreased." ‐ "Natural analgesia from the body's endorphin production will help with pain control." ‐ "A dry mouth will not be a problem, even without fluid." ‐ "Coughing and mucus production will continue, even after the fluids are discontinued." | Options 1, 2, and 5 promote comfort in the dying client as a result of fluid limitation. Options 3 and 4 are incorrect. |
5.‐ "Swelling and edema might decrease once we stop giving fluids." | |
4213 Which statement would the nurse use when Correct answer: 1 Knowledge that energy surges are indicative of the nearness of death can allow the nurse to explaining to a family the physical symptoms typically communicate with family members who wish to be with the client when they die. The seen in clients approaching death? explanations in the other options are incorrect. ‐ Energy surges indicate altered metabolism at the end of life. ‐ Restlessness at the end of life is due to lack of control of intractable pain. ‐ Clients frequently become irritable and agitated at the end of life. ‐ Activity and vigor change at least two weeks prior to death. | Identify the correct physical symptoms in the dying client. Options 2, 3, and 4 are incorrect. |
4214 The teenage daughter of a woman with a terminal Correct answer: 1 Role changes can cause altered family dynamics and social change. They do not necessarily illness begins to have difficulty with grades and no relate to lack of discipline, sibling rivalry, or resolution of disputes with friends. longer spends time with her friends. She is the eldest of six children. The father spends a lot of time between work and caring for his wife. The nurse concludes that the teenage daughter could be experiencing difficulty with which of the following? ‐ Role change ‐ Lack of discipline ‐ Sibling rivalry ‐ Resolving disputes with friends | Option 2 would result in more time with friends. Option 3 would result in acting out, negative behaviors, or "perfect child" behavior. While Option 4 is a possibility, with a dying parent, Option 1 is the more likely answer. |
4215 When speaking with a child who has a terminal Correct answer: 1 Being able to determine behaviors that indicate the terminally ill child no is longer interested illness, which behavior indicates to the nurse that the in talking is important when developing trust between client and nurse. child no longer is interested in talking about end‐of‐life issues? ‐ Changing the subject ‐ Drawing pictures with lots of black figures ‐ Asking questions about heaven ‐ Putting a puzzle together while chatting | Option 2 is a strategy to identify depression. Option 3 and 4 indicate the child is open and interested in talking. Only option 1 shows a cue signifying the end of discussion. |
4216 The nurse is speaking with the parents of a dying child Correct answer: 2 Siblings often feel left out as the parents focus on the dying child. The correct statement is about how the two siblings are coping as the parents one that illustrates emotional distance between the siblings and either the dying child or the focus on the child that is ill. The parents share some parents. conversations they have had with the children that afternoon. Which statement indicates there is a potential problem with the children feeling left out of their parents' lives? ‐ "When will we get to go to the hospital?" ‐ "I made your bed and walked the dog while you were gone." ‐ "I'm tired of going to the hospital instead of playing with my friends." ‐ "Could we take a friend when we go to the hospital?" | Option 1 and 4 indicate the child still is actively interested in seeing his dying sibling. Option 3 suggests the child would like a return of normalcy to life. Only option 2 shows the perfect child behavior indicative of stress in the well child. |
4217 The nurse teaches a family that memory framing can Correct answer: 3 Life review assists the living to understand and remember the meaningful events of the dying be an important activity as a loved one nears the end family member. Option 1 only includes remembering, while the option 3 (the correct option) of life. The nurse explains to the family that a key incorporates the importance of the memory to the dying individual, and is therefore of greater benefit of this intervention is that it will assist them to: overall benefit. Option 2 might be interesting, but is not important in this setting. Option 4 is inappropriate. ‐ Reminisce as they wait for the death of their family member. ‐ Recall the capers performed by the grown children when they were teenagers. | Note that the critical word in the question is key. This tells you that more than one option may be partially or totally correct, and that you must choose between competing options. Eliminate option 4 first as inappropriate. Eliminate options 1 and 2 because they are similar in essence, and must therefore be incorrect. |
‐ Identify the important memories held by the dying family member. ‐ Discuss memory loss of the member who is dying. | |
4218 Nurses who continuously care for clients at the end of Correct answer: 4 Expression of grief in "safe" and supportive situations helps the nurse acknowledge and life need to have formal support mechanisms to express the sadness and mourning experienced while caring for multiple and continuing client express their grief. Which statement indicates a nurse deaths. has been able to effectively deal with grief? ‐ "I read the obituary of our client who died yesterday." ‐ "The family brought a gift basket to the office to express their thankfulness for our care. That makes it all worth it." ‐ "My vacation is only one week away." ‐ "The weekly clinical debriefings are tough when we have a lot of deaths." | Only option 4 indicates a situation where nurses discuss the death of clients. Option 3 is important, but allows the nurse to "get away" from the clinical setting. Option 2 identifies how family expressions of gratitude make the nurse feel appreciated, but does not address debriefing of feelings. Option 1 only acknowledges a death. |
4219 Which statement indicates the nurse who works with Correct answer: 2 Bereavement overload and dysfunctional grieving can cause a nurse to experience death terminally ill clients might be experiencing death anxiety. anxiety? ‐ "I have three clients who are close to death and require lots of emotional support." ‐ "It is all I can do to deal with their physical needs." ‐ "It was tough, but I felt complimented to be at the bedside at the time of death." ‐ "We were afraid the eldest son was not going to get there in time to make the decision before the client died." | Option 2 indicates a nurse who is focusing only on the physical needs of the client and avoiding emotion‐laden issues. Options 1, 3, and 4 are statements of a nurse who is still focusing on the emotional needs of the dying. |
4220 Nurses working with dying clients might need to Correct answer: 4, 2, 3, Recognizing the five stages of adaptation is important for nurses working with dying clients move through the five stages of adaptation. Place 5, 1 and their families. these stages in the order of their occurrence by clicking and dragging the options below to move them up or down. ‐ Deep compassion ‐ Emotional survival ‐ Depression ‐ Intellectualization ‐ Emotional arrival | Think “ISDAD” adapting? It is an acronym for Intellectualization, Emotional Survival, Depression, Emotional Arrival, and Deep Compassion. |
4221 An organ transplant nurse is meeting with various Correct answer: 3 Only option 3 includes a religion or culture that is restricted in the donation of an individual's cultural and religious groups to discuss organ donation. organs. Individuals with the religious backgrounds in Options 1, 2, and 4 are able to donate if The nurse is aware that members of which group are they desire. Nurses need to be aware of the diverse cultural religious practices and beliefs. restricted from donating their organs? ‐ Hindu ‐ Islam ‐ Native American ‐ Christianity | To answer this question correctly, it is necessary to know specific cultural information as it relates to organ donation. Use this knowledge and the process of elimination to make a selection. |
4222 An Islamic client has died, and the nurse has entered Correct answer: 4 Nurses need to be aware of the diverse religious practices and beliefs and the implications for the room where the family is present. The nurse needs the end of life. to be aware of which of the following? ‐ Public grieving is accepted. ‐ The client and family believe in reincarnation. ‐ They will actively mourn, and would appreciate nursing intervention. ‐ Grief counseling might be intrusive. | Only option 4 is characteristic of Islam. The other options are incorrect. |
4223 When conducting an admission evaluation or an Correct answer: 2 Clients need to have communicated to them that they are in control of their own behaviors assessment of the client within the unit for the and that "acting out" will result in consequences. Reassuring the client that the staff will make potential for violent or aggressive behavior, it is sure nothing happens (option 1) takes away responsibility from the client. Just explaining that important for the nurse to: violence is unacceptable and not explaining to the client that he or she is in control (option 3) is nontherapeutic. Acting out is usually not allowed (option 4) because of safety of client and others. ‐ Reassure the client that everything will be all right, and the staff will make sure nothing untoward happens. ‐ Reinforce that the client is solely responsible for his or her own actions and will experience the consequences of acting out. ‐ Explain that violence is not acceptable, and the staff will not allow the client to act out. ‐ Reassure the client that limited acting out will be allowed but only in a controlled setting. | The core issue of the question is effective communication with a client at risk for acting out. Use the process of elimination and choose the option that provides accurate information to the client and holds the client accountable for his or her actions. |
4224 When responding to clients who display the potential Correct answer: 4 Preventing a client from free mobility is the most restrictive technique. Meeting in a quiet for violence, the nurse would use which of the room (option 1) is the least restrictive and most therapeutic. Chemical restraint (option 2) and following as the most restrictive intervention? escorting a client (option 3) are restrictive but less so than full four‐point restraint. ‐ Meeting in a quiet room to reduce stimulation ‐ Administering a PRN medication to reduce anxiety ‐ Providing physical interventions, such as two‐person escort out of a program area ‐ Using restraints, such as a four‐point restraint | Note the critical word most in the stem of the question. This tells you that you must order the interventions presented from least restrictive to most restrictive to enable you to choose correctly. |
4225 Which of the following is the most important Correct answer: 1 Once a client has escalated beyond least restrictive interventions, the nurse should plan for intervention by the nurse when a client does not the next step. Bargaining (option 2) with a client is counterproductive and positively reinforces respond to less restrictive interventions and is rapidly behavior. Offering a PRN medication (option 3) to reduce anxiety would occur after escalating toward violence? negotiation for least restrictive interventions is complete. Asking a client to take a time out (option 4) is a least restrictive intervention to which the client is not responding. ‐ Cease negotiation with client and implement plan of intervention to control client and provide safety. ‐ Bargain with client to determine what can be done to prevent assaultive behavior. ‐ Offer a PRN medication to reduce anxiety. ‐ Ask client to move to a less stimulating, private area and spend some time alone. | The wording of the question tells you that more than one option may be partially or totally correct and that you must prioritize your answer. Choose the option that best protects the safety of all people in the environment, including other clients and staff. |
4226 After a staff member has been involved in a Correct answer: 2 Debriefing allows the staff an opportunity to ventilate feelings and to calm down (option 1). It particularly violent episode with a client, debriefing should always occur, and all staff should be encouraged to participate (option 3). Debriefing should: following a violent episode should occur as soon as possible after the client and others are safe (option 4). ‐ Occur after the staff has had the opportunity to calm. ‐ Take place immediately to facilitate processing of feelings. ‐ Not occur until the staff requests such intervention. ‐ Be done after a 3‐day time‐off period. | The core issue of the question is the need for staff to process personal feelings after an episode of violence occurs with a client. Use the process of elimination and knowledge that staff can be traumatized by these events to choose the correct option. |
4227 Which one of the following situations experienced by Correct answer: 2 A situational crisis is one that occurs from external life events. An event involving normal a client would the nurse document as a situational stages of development (option 1) is a maturation crisis. A natural disaster (option 3) and an crisis? armed conflict (option 4) are examples of community crises. ‐ Being in the middle of menopause ‐ Recently being involved in an automobile accident ‐ Being a survivor of a flood following a hurricane ‐ Recently returning home from military duty after an armed conflict | Use the process of elimination. The core issue of the question is the ability to differentiate among various types of crises and to document them appropriately. |
4228 Which of the following coping behaviors does the Correct answer: 3 When a person is threatened and perceives himself or herself to be vulnerable to a situation, nurse expect to note in a client who encounters a coping behaviors are self‐protective. Coping behaviors may be ineffective to provide strength situation in which there is a significant psychological (option 1). Coping during a crisis is oriented toward the immediate here‐and‐now, not mastery threat and great personal vulnerability? (option 2). Coping behaviors may or may not be immobilized (option 4). ‐ Finding inner strength to get through the crisis ‐ Being more oriented toward mastery ‐ Acting in a more self‐protective manner ‐ Being totally immobilized | The core issue of the question is the expected response of a client to a threatening situation. Use knowledge of coping skills and the process of elimination to find the correct answer. |
4229 A nurse is planning an intervention for a client in crisis Correct answer: 2 Assisting the client in identifying coping patterns and then supporting them is essential to who witnessed a violent crime. Which of the following managing a crisis. Identifying the client's maladaptive coping mechanisms (option 1) may be is a key component of crisis intervention that the nurse beneficial after identifying the client’s strengths. Assisting the client to forget (option 3) is not should plan to utilize at this time? a therapeutic intervention for crisis management. Teaching a client to handle future crises (option 4) is more appropriate once the current crisis has abated. ‐ Identify the client's maladaptive coping mechanisms. ‐ Identify and support the client's coping patterns. ‐ Assist the client in forgetting the crisis situation. ‐ Teach the client to handle future crises. | The critical words in the question are at this time. This tells you that more than one option may be correct, but one of them is more timely than the others. Use nursing knowledge and the process of elimination to make a selection. |
4230 The nurse developing a care plan for a client using Correct answer: 1 Providing support and guidance are the primary objectives of crisis management. The client's crisis management principles would base interventions anxiety (option 2) may be needed in order for him or her to be energized to cope with the on which of the following primary tasks of crisis crisis; the goal is to achieve a manageable level of anxiety. Providing encouragement (option 3) management? and fostering independence (option 4) are important and may occur during crisis intervention, but they are not the primary task of crisis management. ‐ Provide support. ‐ Relieve anxiety. ‐ Provide encouragement. ‐ Foster independence. | The critical word in the question is primary. This tells you that more than one option may be correct, but one of them is more important than the others. Use nursing knowledge and the process of elimination to make a selection. |
4231 An adult client is having difficulty coping with a new Correct answer: 3 Short‐acting antianxiety agents are most useful in helping a client to achieve an effective diagnosis of colon cancer. The nurse telephones the reduction in level of anxiety. Antipsychotics (option 1) should be avoided. Antidepressants physician for an order for medication therapy to assist (option 3) require some time to achieve therapeutic levels and are not useful in a crisis the client in coping with this crisis situation. The nurse situation. Mood stabilizers (option 4) are not indicated. anticipates an order for which of the following types of medication? ‐ Haloperidol (Haldol) ‐ Amitriptyline (Elavi) ‐ Lorazepam (Ativan) ‐ Valproic acid (Depakote) | The critical words in the question are crisis situation, which tell you that the correct answer is a medication that will have a rapid onset of action and be effective in treating the client’s reaction to the diagnosis of colon cancer. Use nursing knowledge and the process of elimination to make a selection. |
4232 The nurse working with the family of a client with Correct answer: 3 Medications will help decrease the frequency and intensity of suicidal thoughts. Medication suicidal ideations is asked if the medication the client may treat the underlying cause of the suicidal ideation but does not necessarily reduce the risk is taking will prevent suicide. Which of the following for completing suicide. Medication does not prevent suicide; in fact, many times when clients would be the best response by the nurse? regain their energy from medications, they are at an increased risk for completing suicide (options 1 and 2). A client may not be currently suicidal, but medications do not assure that they will not be suicidal in the future (option 4). ‐ "Clients who take their medication as prescribed are at decreased risk for suicide." ‐ "Medication helps to treat an underlying mood disorder associated with suicidal thinking and therefore prevents suicide." | The critical word in the question is best. This tells you that more than one option may be partially correct, but one of them is better than the others. Use nursing knowledge and the process of elimination to make a selection. |
‐ "Medication helps decrease the frequency and intensity of suicidal thoughts." ‐ "The client has said that she would never try to hurt herself again. There is no need to worry." | |
4233 A suicidal client with low self‐esteem seems less Correct answer: 4 A client who is just regaining his or her energy should be encouraged to do simple tasks, lethargic today and agrees to participate in an which will also promote the client's self‐esteem. Suicidal clients are most at danger when they occupational therapy program. To help make the are feeling better and regaining their energy. Introducing the client to wood carving (option 1) session successful, the nurse should do which of the and making a belt from rope (option 3) place the client at risk for self‐harm. The nurse should following? encourage the client participate in the occupational therapy for self‐expression (option 2). ‐ Introduce the client to wood carving; show him how to safely use the carving and burning tools. ‐ Stay away from the client in occupational therapy so that he is free to express himself. ‐ Teach the client to macrame a plant hanger from jute rope and encourage him to work on it later in his room. ‐ Structure his activity to help him complete one simple task, such as painting a picture. | The core issue of the question is a safe activity for a client who is suicidal. The correct answer is the option that does not pose risk to the client or provide the client with the means to engage in self‐harm. |
4234 A client has recently been admitted for depression Correct answer: 4 Suicidal clients are at most risk when they begin to demonstrate improvement and have the and suicidal ideations with a plan to hang himself. The energy to carry out suicide. A mute client who is not willing to share with others (option 1) is at nurse assesses the client most carefully for risk for risk for suicide but may be placed on constant observation. Being afraid to go home (option 2) attempting suicide when: may be a positive sign that the client is aware of the danger he may pose to himself. Vacation is a stressful time, and being left alone (option 3) would place the client at risk; however, it is well documented that clients are at greatest risk when showing signs of improvement. ‐ He is mute and unlikely to tell anyone. ‐ He is ready to go home and afraid of leaving the hospital. ‐ His family goes on vacation. ‐ He begins to demonstrate clinical improvement. | The core issue of the question is recognition that the risk of suicide increases when a client begins to feel better, since the client now may have the energy to carry out a suicide attempt. Use the process of elimination and this knowledge to make a selection. The wording of the question tells you that only one answer is correct. |
4235 Which of the following individuals is at greatest risk Correct answer: 2 The group at highest risk for successfully completing suicide attempts are European‐American for suicide? males over the age of 50 (white, male, older adult). The clients in options 1, 3, and 4 are not in high‐risk groups. ‐ A 65‐year‐old African‐American male ‐ A 70‐year‐old European‐American male ‐ A 30‐year‐old Hispanic‐American female ‐ A 16‐year‐old African‐American female | The core issue of the question is knowledge of high‐risk groups for suicide. The wording of the question tells you only one answer is correct. Use nursing knowledge and the process of elimination to make a selection. |
4236 A client states that voices are telling him to hang Correct answer: 4 Voices telling a client to hurt himself or others are called command hallucinations. There is himself. The nurse documents that the client is at risk not enough data to support hopelessness (option 1), emotional pain (option 2), or delusions of for suicide on the basis of which of the following? grandeur (option 3). ‐ An intractable sense of hopelessness ‐ Intolerable emotional pain ‐ Delusions of grandeur ‐ Command hallucinations | The core issue of the question is correct interpretation of a client's symptoms. The wording of the question tells you only one answer is correct. Use nursing knowledge and the process of elimination to make a selection. |
4237 Which statement made by a client would indicate the Correct answer: 1 The client is communicating that he or she may not be around for the nurse to worry about. highest risk for suicide? Creating a solution (option 2), expressing hope for the future and making plans (options 3), and decreasing frequency of voices (option 4) indicate that the client is experiencing a reduction in the risk for suicide. ‐ "I know you've been worried about me. You won't have to worry too much longer." ‐ "I think I've found a solution to my problem. I'm going to check it out with my doctor." ‐ "I'm looking forward to the holiday season and the kids coming home from school. They will be a good distraction." ‐ "Over the past week I have been hearing the voices that tell me to hurt myself less often." | The critical words in the stem of the question is highest risk. This tells you that more than one option may indicate risk, but one is stronger than the others. Use nursing knowledge and the process of elimination to make a selection. |
4238 A client who became violent on the psychiatric unit Correct answer: 3 Releasing restraints at least every 2 hours is a standard of care to prevent physical harm. had restraints applied at 10:00. The nurse makes a Every 15 minutes (option 1) or hour (option 2) may be too often, and every 4 hours (option 4) note to release the restraint at no later than which of is too long and may cause the client injury. In addition to the intervention described, the the following times? client's circulation should be checked every 30 minutes. Ensuring the client's safety and well‐ being are a priority. 1.‐ 10:15 2.‐ 11:00 3.‐ 12:00 4.‐ 14:00 | The core issue of the question is knowledge of safe care to a client who is in restraints. Use the process of elimination and nursing knowledge to make a selection, recalling that 30‐ minute circulation checks and 2‐hour release times are standards of care. |
4239 A female client has been admitted to the psychiatric Correct answer: 2 Safety of the client is always a priority for clients who have recently attempted suicide. unit after spending 24 hours in the intensive care unit. Options 1, 3, and 4 are all appropriate goals after safety has been assured. Before the client's admission, she overdosed on 12 sertraline (Zoloft) tablets. Of the following nursing goals, which would be a priority on admission? ‐ Assuring the client that someone is concerned about her ‐ Protecting the client until she can protect herself ‐ Teaching the client how to solve problems ‐ Discussing the meaning of death | The critical word in the stem of the question is priority. This tells you that more than one or all options may be correct actions for the client, but one is more important than the others. To aid in making a selection, recall that safety needs are high priority for clients following a suicide attempt. |
4240 When interviewing a potentially violent or aggressive Correct answer: 1 The nurse should ensure that the interview be conducted in a quiet environment. Interruption client, which of the following environmental factors is should be kept to a minimum (option 2), but may not be possible to prevent. Intimidation of most important for the nurse to consider? the client (options 3 and 4) is inappropriate. ‐ The interview should take place in a calm and quiet area to reduce stimuli. ‐ Care should be taken to make sure that other staff do not interrupt. ‐ Restraint devices should be in full view of the client to reinforce consequences for violent behavior. ‐ The client should be told that violent behavior will not be tolerated. | The critical words in the stem of the question are most important. This is a clue that more than one option may be partially or totally correct, but one is more important than the others. Use nursing knowledge and the process of elimination to make a selection. |
4241 A new nurse orientee asks why a client admitted to Correct answer: 1 Decreasing sensory input may decrease the anxiety or anger and help the client regain the psychiatric unit has been placed in seclusion. The control. Seclusion should never be used for staffing ratios (option 2). Communication with nurse who is precepting the orientee explains that others (option 3) is part of milieu therapy. Seclusion takes away the client's responsibility which of the following is a benefit of seclusion? temporarily (option 4). ‐ The reduced sensory input allows the client to regain control. ‐ The unit can be managed with fewer staff. ‐ Clients are encouraged to communicate with others. ‐ Clients are forced to be responsible for themselves. | The core issue of the question is the benefit of seclusion as a therapy for a potentially violent client. Use nursing knowledge and the process of elimination to make a selection. |
4242 A 19‐year‐old female client recently admitted after Correct answer: 4 Option 4 provides the client with information that the nurse is concerned about her, which attempting suicide becomes very dejected and states may ease her emotional pain. Telling the client, "Of course people care" (option 1) is false that life is not meaningful and no one really cares what reassurance. Telling the client not to talk about sad things (option 2) invalidates and ignores happens to her. The nurse's best response would be the client’s feelings. Option 3 may be seeking clarification but may also cause the client to feel which of the following? she has to defend her position. ‐ "Of course people care. Your parents stayed with you in the ICU." ‐ "Let's not talk about sad things. Why don't we go for a walk?" ‐ "Can you write down a list of who does not care for you?" ‐ "I care about you, and I am concerned that you feel so down." | The core issue of the question is a therapeutic communication technique to use with a client who attempted suicide and is experiencing emotional pain. Use knowledge of therapeutic communication techniques and the process of elimination to make a selection. |
4243 The nurse has been working with a teenage female Correct answer: 1, 3, 4 The client demonstrates effective coping by being able to discuss the incident without client who was in crisis after she was assaulted and excessive distress and formulating a realistic plan to prevent recurrence, which will reduce robbed late one night when leaving a local mall at anxiety (parking closer to buildings and enrolling in self‐defense classes). If the client states she closing time. Which of the following outcomes will never shop at the mall again, or will go shopping only when accompanied, this shows indicates to the nurse that the client has achieved the unresolved anxiety and a nonadaptive approach that is likely to interfere with her lifestyle. expected outcomes of treatment? Select all that apply. ‐ The client can talk about the incident without excessive distress. ‐ The client states she will never shop at the mall again. ‐ The client states a plan to choose parking spaces that are close to building entrances when possible. ‐ The client is enrolling in a local self‐defense class for women. ‐ The client states she will go shopping only when she has someone available to accompany her. | The core issue of the question is knowledge of adaptive responses to crisis or near‐crisis situations. Choose the options that demonstrate adequate coping, which are ones that are neither insufficient nor extreme in tone. |
4244 A client recently admitted to an in‐patient psychiatric Correct answer: 1, 2, 3, Options 1, 2, 3, and 4 are correct. Psychomotor retardation is a pervasive phenomenon unit demonstrates extreme psychomotor retardation. 4 involving slowing of all bodily and psychologic processes. Clients with psychomotor retardation Unless prompted, the client sits and stares at the floor not only move, think and act slowly; they also experience slowing of involuntary internal for prolonged periods of time. The nurse considers processes and are therefore at risk for a wide variety of physical and emotional complications. that this client is at risk for which problems? Select all Option 1 is correct as visceral functioning is highly impacted by the state of depression. This that apply. leads to hypomobility and hyposecretion of the gastrointestinal tract. Constipation, fecal impactions and even bowel obstruction are possible. Other factors contributing to constipation are decreased physical activity, medication side effects and food and or fluid deficiency. Additionally, the client may not be responsive to normal sensations to evacuate the bowel. Option 2 is correct because the client with severe psychomotor retardation will have insufficient energy to initiate drinking and ask for fluids. Additionally, the client will tire easily and may not be able to drink even one full container of liquid. Option 3 is correct as the client’s psychomotor retardation will be accompanied by fatigue and anergy, which will contribute to activity intolerance. Option 4 is correct because this client is remaining immobile and maintaining the same position for prolonged periods of time. This increases the risk of pressure related skin problems, which can be intensified by fluid and or nutritional deficits accompanying extreme psychomotor retardation. Additionally, the client’s responsiveness to painful stimuli can be diminished. Option 5 is incorrect as the client is not at risk for impaired individual coping. Instead, this is an actual problem of the client. ‐ Constipation ‐ Deficient fluid volume ‐ Activity intolerance ‐ Impaired skin integrity ‐ Ineffective coping | Develop a mental picture of this client sitting before you. Notice that four of the options are physiologic. |
4245 A client has recently been admitted for severe major Correct answer: 4 Option 4 is correct. Suicidal clients who are depressed are at highest risk for suicide when depression and a plan to cause self‐harm using a gun. they begin to demonstrate improvement and have sufficient energy to carry out a suicidal act. The nurse considers that while in the hospital, this Thus for a time, treatment and improvement, instead of decreasing the suicidal risk, actually client will be at highest risk for attempting suicide increases it. Option 1 is incorrect because in the severely depressed client, mutism is when: considered to be a manifestation of psychomotor retardation. In addition to slowing visceral and motor responses, psychomotor retardation also affects cognitive processes that would be needed for formulating and acting on a suicidal plan. Option 2 is incorrect as interestingly, non‐ responsiveness to medication may not increase the client's risk for suicide while in the hospital. If the client is showing severe psychomotor retardation, medication non‐ responsiveness would lead to continuance of severe depressive symptoms that would make the client unable to form or act on a plan for suicide. Option 3 is incorrect because before the medication is begun, or before it becomes effective, the client’s risk for suicide remains stable. As stated in Options 1 and 2, the severely depressed client typically does not have the cognitive or the physical capacity to formulate or carry out a suicidal plan. ‐ Mute and uncommunicative. ‐ Unresponsive to medication. ‐ Medication is first being initiated. ‐ The level of depression decreases. | Remember that the nurse should be particularly vigilant when a depressed client's mood and energy level begin to improve. |
4246 When the nurse is interviewing a potentially violent Correct answer: 3 Option 3 is correct. The nurse should ensure that the interview be conducted in a non‐public, or aggressive client, which of the following quiet area in order to reduce stimuli. A potentially aggressive client is hypervigilant, environmental factors is most important? The distractible, and over reactive. At the same time, the nurse needs to be aware of own safety as interview should be: well. Option 1 is incorrect because the potentially violent person is likely to perceive an extended hand, or the touch associated with it, as a threatening gesture and/or act of aggression. Touch of any type should be avoided or used very cautiously with aggression prone clients. Option 2 is incorrect as large public areas of a unit are designed for use by groups of clients and staff. In such a setting, people come and go freely, and these kinds of interruptions and distractions are likely to further agitate the client. Option 4 is incorrect because this client, who is hyperresponsive and suspicious of the motives of others, is likely to interpret this as a statement of threat. ‐ Initiated with a firm handshake. ‐ Conducted in a large public area of the unit. ‐ Conducted in a calm quiet area. ‐ Preceded by informing the client that violent behavior will not be tolerated. | Remember that agitated and potentially violent persons are hyperresponsive to the environment and will respond aggressively to events that others would not notice or would not consider bothersome. |
4247 The client is suicidal. A nursing diagnosis is Correct answer: 4 Option 4 is correct. Having clients verbalize feelings of anger and hopelessness that have led "Ineffective coping related to feelings of anger and to their being suicidal is an initial step in helping clients learn how to cope more effectively. hopelessness." Which expected short‐term outcome is One cannot cope if one does not know exactly what the adaptive challenges are. Option 1 is the most appropriate? The client will cope more incorrect as denying feelings of hopelessness and anger is not therapeutic. Indeed, the nursing effectively as evidenced by: diagnosis indicates that this client’s impaired coping was attributable to underlying feelings of anger and hopelessness. These feelings must be acknowledged and dealt with directly if this client is to experience improved coping and reduced potential for suicide. Option 2 is incorrect because it is stated in an immeasurable way. How does one measure happy behavior? How can it be recognized? Also, the nurse should keep in mind that absence of anger does require that one be happy. Option 3 is incorrect as voicing no complaints does not necessarily mean that anger and hopelessness are absent. Various meanings for this behavior are possible. For instance, the individual could be suppressing verbal expression of strong negative feelings. The client could be displaying anger passive‐aggressively, or be knowledgeable about the hospitalization process and be aware that voicing complaints will delay the date of discharge. ‐ Denying feelings of hopelessness and anger. | Recall that nursing outcomes are ultimately directed toward modification or elimination of the identified problem. |
‐ Demonstrating happy behavior. ‐ Voicing no complaints. ‐ Verbalizing feelings of anger and hopelessness. | |
4248 When the client is at high risk for suicide, which Correct answer: 2 Option 2 is correct. When the client is at risk for suicide, the highest priority of the nurse is to action is of highest priority to the nurse? provide security and safety measures for the client. This will involve different levels of special interventions and precautions, beginning with constant visual observation of the client and confinement in a safe physical environment. As the client improves, less intense and or less frequent observations of the client are necessary. Option 1 is incorrect because while medications may be expected to be effective in reducing the client’s level of suicidality, the most important priority of the nurse is to provide a safe physical and psychological environment. Option 3 is incorrect as the nurse should encourage direct and open discussion of the client's suicidal thoughts and feelings. Contrary to popular opinion, talking about suicide does not increase the risk of suicide. Instead, if discussed in a caring and nonjudgmental manner, talking about the suicidal urges may diminish the likelihood of the person's acting on them. Additionally, in order for the nurse to know the level of potential lethality in the client’s situation, direct and frank discussion between the nurse and the client must occur. Option 4 is incorrect because social isolation is a risk factor for suicide. The more socially isolated a person is, the more likely it is that they will act on suicidal urges. ‐ Administer medications to make the client less suicidal. ‐ Monitor the client's location and behavior constantly. ‐ Change the subject whenever the client mentions suicide. ‐ Allow client time alone to reflect on feelings. | Recall that safety and security, along with basic physiologic needs, are always of highest priority. |
4249 The client is being discharged after a suicidal crisis. Correct answer: 2 Option 2 is correct. Alcohol use is highly correlated with suicide attempts, both in dependent When giving the client discharge instructions, what and non‐dependent drinkers. The alcohol does not cause the suicidal act, but since alcohol is a should the nurse emphasize? CNS depressant, use of it impairs thinking and judgment. Option 1 is incorrect as the nurse should anticipate that the client will function best if able to re‐connect to a former social support system. This is one of the principles of crisis intervention. Option 3 is incorrect because eating a nutritious diet is important for all persons, not just for those who have been suicidal. Option 4 is incorrect as unless the client has agoraphobia or for some other reason is uncomfortable around crowds, this is not a relevant intervention for the post‐suicidal client. ‐ Developing a new set of friends ‐ Avoiding alcohol use ‐ Eating a nutritious diet ‐ Avoiding crowds | Recall the prevalence of alcohol being used as a self medication when people are stressed or distressed. |
4250 While taking a comprehensive history, the nurse Correct answer: 3 Option 3 correct. It assumes that the client was abused. However, not all clients who are wants to assess the client's potential for violence or violent or aggressive have been sexually or physically abused. Asking the question as if the aggression. Which question would be least client were sexually or physically abused may cause them to become aggressive. If the nurse appropriate? wants to know whether the client was a childhood victim of abuse, a better way of asking the question would be, "Have you ever been sexually or physically abused?" Options 1, 2, and 4 are incorrect as all of these options are appropriate questions to ask a potentially violent or aggressive client. They should be asked calmly and matter‐of‐factly. ‐ "What is the closest you have come to being violent?" ‐ "Have you ever been arrested for violent behavior?" ‐ "Were you violent when you were abused as a child?" ‐ "Do you worry about being violent?" | Notice that the stem of this question is asking not for the best answer, but for an answer that identifies the least effective approach. Thus the correct option is the most incorrect question by the nurse. |
4251 Referring to a client who made an unsuccessful Correct answer: 4, 5 Options 4 and 5 are correct. While each of the statements carry some weight as a risk factor attempt at suicide, a staff member says, "It wasn't a for suicide, two are particularly significant: overdose of tricyclic antidepressant and plan to real attempt. She just wanted attention." To assist the drive car into a tree. Tricyclic antidepressants, more than many other antidepressants and staff member understand the potential lethality in this antipsychotics, are very dangerous when taken in overdose, as they can cause significant client's situation, on which client‐related factor should cardiac dysrhythmias. Planning to drive a car into a tree (assuming that trees exist in the the nurse's response focus? Select all that apply. immediate environment) constitutes having a potentially lethal plan with available and proximate means for suicide, a potentially lethal combination of factors. ‐ Last child left for college one month ago ‐ Divorced for 10 years ‐ Increased stress at work ‐ Overdose of tricyclic antidepressant yesterday ‐ Suicidal plan for driving car into a tree | Look for current factors that are "red flags" indicating a serious situation. |
4252 The day after a suicide attempt, a client is in tears and Correct answer: 3 Option 3 is correct. The client is still verbalizing hopelessness and worthlessness. The client is tells the nurse, "I'm a failure at everything, and now, still at risk for suicide. Option 1 is incorrect as the client is showing no signs of remorse. The I've even failed at killing myself." What interpretation client is at risk to attempt again because of feelings of worthlessness and personal failure. of this statement by the nurse would be best? Option 2 is incorrect because the client is not verbalizing guilt or thankfulness to be alive. The client is verbalizing feelings of worthlessness and personal failure and remains at risk for suicide. Option 4 is incorrect as the client is not verbalizing ambivalence. The client’s statement should be interpreted as an indication that the client is likely to attempt suicide again. ‐ The client is remorseful over the failed suicide attempt and unlikely to try again. ‐ The client feels guilty over the suicide attempt and is happy to be alive. ‐ The client verbalizes hopelessness and the potential for another attempt is great. ‐ The client is ambivalent about whether to live or die. | Consider carefully what the client has said. Notice its negative character. Eliminate any option that has a positive character. |
4253 When teaching staff members how to deal with Correct answer: 4 Option 4 is correct. Violent and aggressive behavior is a learned response that can be potentially violent and aggressive client behaviors, changed. Option 1 is incorrect because many times, strict, rigid rules cause clients to "act out" what will be important for the nurse to emphasize? in anger and aggression. Option 2 is incorrect as it is appropriate and expected for nursing staff to share their fears, anxieties, and concerns with their peers. Option 3 is incorrect because when demands for performance and/or participation are made, the likelihood of violence increases. ‐ Violent/aggressive behavior is best managed by strict behavioral controls, rigid unit rules, and medication. ‐ Nursing staff should not discuss with peers their feelings of fear and anxiety. ‐ Violent/aggressive behavior will decline when performance and participation are allowed. ‐ Clients can understand the reasons for their behavior and change their response patterns. | Recognize that staff members need practical, helpful information, rather than lengthy more scientific explanations. |
4254 The client presents in a crisis center saying, "They Correct answer: 3 This question is asking for the nurse to recognize that availability of social support, one of the didn’t warn me. After 20 years, and they just walk in balancing factors that determine whether one will enter into a crisis state, is absent. Balancing and say I no longer have a job." The client's personal factors include how the person perceives the event, past experience in coping, available coping counselor is ill and unavailable, and the immediate mechanisms, and availability of people who can be supportive. There is no indication that the family is away and unreachable by telephone. The client is misperceiving the event (option 1). Option 2 indicates a normal or expected response nurse interprets that the most significant reason this to an unexpected loss. While the nurse will observe the present state of confusion and shock in client is in crisis is that the client: assessing the client, this factor does not address why the client is in a crisis state at this time. Going to the crisis clinic for assistance (option 4) indicates that the client is making a serious attempt at coping. The client is feeling overwhelmed and does not have access to the normal support system. ‐ Is misperceiving the event. ‐ Feels confusion and shock about the event. ‐ Is unable to process the event with the usual support network. ‐ Is not making sufficient attempts to cope with the event. | Recall theory about balancing factors in crisis situations. Determine which of the balancing factors is/are absent. |
4255 An unlicensed mental health worker asks the nurse to Correct answer: 2 Crisis intervention assists a client in resolving an immediate problem that the client perceives explain how crisis intervention works. Which of the as overwhelming. Issues from early life experiences and the client’s personality (option 1) are following is the most appropriate response of the not dealt with during crisis intervention. Crisis intervention focuses on the immediate situation nurse? "Crisis intervention helps the client to: and presenting problem. Other issues, such as personality and early life experiences are dealt with in other therapy modalities and would not be addressed until the presenting crisis is resolved. In early crisis intervention, rather than teaching the client to develop new coping techniques (option 3), the client is encouraged to use previously successful coping skills. The emphasis of crisis intervention is on strengths and coping skills of the individual, not on personal limitations (option 4). ‐ Uncover unconscious processes and early life experiences." ‐ Find a solution to an immediate and overwhelming problem." ‐ Use new ways of coping with an unexpected major problem." ‐ Become aware of personal limitations that led to the crisis state." | To select the correct response, translate more complex theoretical concepts into easily understood language. |
4256 The client in a crisis state is having difficulty asking for Correct answer: 1 It is natural for clients in crisis to feel isolated and withdrawn. Clients frequently need help help from significant others. The nurse explains to communicating with others directly, especially if they place a high value on independence. Role caregivers that it is important to role model asking for modeling by the nurse helps the client to learn this skill. Option 2 (e.g., being resistant to help because clients in crisis are overwhelmed and: verbal suggestions) is in opposition to a common characteristic of the client in crisis, which is openness to suggestions. Option 3 (e.g., being hesitant) is also in opposition to a common characteristic of the client in crisis: readiness to depend on others for assistance with decision making. Most clients in crisis are not guarded (option 4); instead, they give free and direct expression to their feelings of anxiety. Severe and panic levels of anxiety are common to crisis states. ‐ Uncertain about how to communicate personal needs. ‐ Resistant to verbal suggestions about how problems can be approached. ‐ Hesitant to depend on others for assistance with problem resolution. ‐ Guarded and protective about talking about anxiety and other feelings. | Realize the client has experienced a crisis. Analyze each option and put yourself in the client’s position. Select the option that characterizes how you would expect to ask in a crisis situation. |
4257 A client seeks help in a crisis clinic after several family Correct answer: 3 The focus of crisis intervention is on the present, not the past. Particular attention is given to members were involved in a serious automobile allowing ventilation of current feelings, helping the client with coping mechanisms, and accident. The client speaks in a loud, disorganized identifying social supports. The focus of the nurse should be on the client, not the family manner with frequent changes of subject. Which (option 1). The nurse should keep the client focused and provide direction to avoid nursing approach is most likely to be effective? fragmentation of the client’s efforts. Sending the client to a chapel (option 2) is not appropriate. The client's behavior and the circumstances require that the nurse respond directly to the client. The client needs to ventilate feelings in order to begin to feel less anxious. Nonpharmacological strategies should be attempted prior to pharmacological strategies (option 4). ‐ Encourage the client to identify family members involved in the accident. ‐ Assist the client locate the chapel or another quiet area. ‐ Help the client to identify the problem and possible ways to manage it. ‐ Arrange for one‐time anxiolytic medication for the client. | Apply the principles of presence and support. Also reflect back on the behaviors you observed in a client who was in a crisis state. Consider commonly used crisis intervention techniques and eliminate options that are not in included among such techniques. |
4258 A client whose life partner recently died from Correct answer: 1 The nurse should recognize that ideas of self‐harm are very common in situations of this type. complications of AIDS has received lab results While some clients will not introduce thoughts of self‐harm, they will usually talk about suicidal indicating conversion to HIV‐positive status. The thoughts when asked. The nurse should ask if the client has a plan and the means for suicide. attending physician's office referred the client to the Safety is the priority, and suicidal clients should not be left alone. Altered thought process crisis unit because the client "shut down" emotionally (option 2), availability of social support (option 3), and ability to afford medication (option 4) after receiving the lab results. In the initial assessment are important assessment areas after the client’s safety has been ensured. interview, the nurse's priority is to determine if the client has: ‐ Ideas of self‐harm. | Recognize that this client has just heard news that many people would consider a death sentence. In such situations, suicide as a means of remaining in control is not uncommon. |
‐ Altered thought processes. ‐ An available social support network. ‐ Financial means to obtain anti‐AIDS medications. | |
4259 A young adult client frequently engages in high‐risk Correct answer: 2 The nurse should recognize that the all behaviors cited in the stem of the question could behaviors, including driving at high speed, drinking result in loss of life. They are therefore considered indicators of indirect self destructive excessively, and engaging in high‐risk sexual behaviors. behavior. There is no indication of a loss that would have precipitated grieving (option 1). It is most important for the nurse assessing this client While it is true that the client is young and is making unwise choices, there is no indication that to recognize that there is a high probability that: the client's development has been arrested (option 3). Disregard for the life and needs of others is seen in persons with antisocial personality disorders, but there is no indication in the stem that the client is disregarding or abusing the life of others (option 4). ‐ Unhealthy grieving is occurring. ‐ Unconscious thoughts of suicide are present. ‐ Arrested maturation is impairing judgment. ‐ Antisocial personality traits are causing disregard for life. | Look for an option that recognizes the intensity and dangerousness of the client's behaviors. |
4260 The client is hospitalized following an unsuccessful Correct answer: 2 Providing safety and preventing violence on an inpatient unit involves one‐to‐one supervision suicidal attempt by drug overdose. When offered a no‐ for the client as warranted, based on an assessment of current lethality level. This client did harm contract by the nurse, the client says, "I don't not make a commitment to the no‐harm contract, so the nurse should consider that the risk think I can agree to that." Which nursing intervention for self‐harm is still present. (The nurse should be aware of the suicide protocol in the agency is most appropriate? of employment. In some situations, this client might be placed on a different level of suicidal precautions.) Checks every 15 minutes (option 1), whether during both day and night or only during waking hours may not be adequate to ensure client safety. The situation does not suggest an urgent, high‐lethality situation that would call for the nurse to remain at arm's length from the client at all times (option 3). Constant visual observation only during waking hours (option 4) may not be adequate to ensure client safety. ‐ Visual observation of the client every 15 minutes, during both day and night ‐ Constant visual observation of the client, including when in the bathroom ‐ Constant visual observation of the client, remaining at arm’s length at all times ‐ Constant visual observation at all times during waking hours | Notice the client's hesitance and indefiniteness in not contracting. Recognize that as an indicator of continuing suicidal risk. |
4261 Five days ago, a client was admitted to the hospital Correct answer: 3 When a client has been suicidal, it is essential that discharge preparations include a plan for with major depression and suicidal ideations. The safety including social support contacts that can be used after discharge. This is particularly so client is now preparing for discharge. Which client if the client has acted on suicidal urges, rather than just having had suicidal impulses. Option 1 statement made to the nurse demonstrates that an does not clarify what the client's sleep pattern has been. Additionally, the nurse should important outcome/evaluation measure has been remember that disturbed sleep could indicate continuing depressed mood. Options 2 and 4 met? "When I go home: suggest that the client is feeling more energetic and optimistic, which are of course signs of progress. They are, however, not as urgently important as having a post‐discharge safety plan. ‐ I'll finally be able to get some sleep." ‐ I’ll be able to take care of my plants again." ‐ I have a list of people that I can call if I need to." ‐ I’ll cook for myself." | Remember that a danger period for suicide among depressed clients is the point at which they begin to improve and have more energy. |
4262 When working with a depressed client who has Correct answer: 1 Option 1 is correct. Nurses help reduce the client's feelings of being overwhelmed by helping suicidal ideation, the nurse anticipates that the client the client to prioritize concerns and problems. Supporting the client to put off problem‐solving may be overwhelmed by personal problems. With this is not advisable (option 2). Working on problem‐solving within a group setting is one of many in mind, the nurse should take which action to best ways to solve problems (option 3). Being directive and setting the priorities for the client assist the client to cope more effectively? should be avoided (option 4). ‐ Encourage the client to make a list of problems from most urgent to least urgent. | Note that the client is feeling overwhelmed by personal problems. Isn't it reasonable to think that if these problems can be managed, the client will no longer feel suicidal? |
‐ Support the client's decision to put off problem solving until outpatient therapy has begun. ‐ Encourage the client to work on problems only in group therapy. ‐ Take a directive approach and advise the client how to prioritize personal problems. | |
4263 The client has suicidal ideations with a vague plan for Correct answer: 2, 4 Warning signs of suicide generally exist but they may not be recognized until after a suicidal suicide. When teaching the family how to care for the attempt or suicidal death (option 2). Since almost all suicidal persons are ambivalent about person at home, what should the nurse emphasize? dying, they either consciously or unconsciously communicate their intent to others hoping Select all that apply. (consciously or unconsciously) to be rescued from their own impulses. The nurse should recognize that the risk for future attempts always increases once a person has made an unsuccessful attempt (option 4). This means that the nurse should always inquire about past suicidal behaviors and attempts, including those that occurred in the distant past. Suicide is a very individual act that does not necessarily reflect negative relationships in the family (option 1). Option 3 reflects a commonly held myth about suicide. Sometimes the person does not talk about suicide because he or she has made a specific plan and has the means to carry it out. Not talking about suicide can be a warning sign, and the nurse and family members need to know this. Family members are not responsible for preventing future suicidal attempts (option 5). They should be encouraged to create safe interpersonal and physical environments, but in spite of their best efforts, they may not be able to prevent their family member from ultimate self‐destruction. Telling the family members this will lead to an increased sense of guilt if their family member successfully suicides at a later time. ‐ Suicide occurring within the family environment indicates family dysfunction. ‐ Warning signs, even if indirect, generally are present before a suicidal attempt. ‐ When the client no longer talks about suicide, the risk of suicide has decreased. ‐ Following a failed suicidal attempt, the risk for future attempts is increased. ‐ Family members are responsible for preventing future suicidal attempts. | Look for myths and facts about suicide. Recognize the importance of teaching facts before dispelling myths. |
4264 A client presents in the mental health clinic saying, "I Correct answer: 3 Option 3 is correct. A situational crisis is one that is often unexpected and unavoidable and didn’t expect it. They just told me this morning that I causes an acute state of emotional disequilibrium. The stressful event threatens a person's don't have a job any more. I can't think straight. I feel physical, emotional, and/or social integrity. The person feels anxious, overwhelmed, and like I’m going crazy." The nurse documents that the confused. This experience is accompanied by a sense of disorganization and an inability to client is experiencing which type of crisis? make effective decisions. An adventitious crisis (option 1) occurs following a major catastrophic event, such as earthquake, hurricane, or war. This type of crisis represents one in which others experiencing the same or comparable event would react similarly. This question describes a unique, personal situation and a response that cannot be generalized to a larger population of individuals. A maturational crisis (option 2) occurs as part of the person’s normal development and maturation. Such crises are predictable and can be expected to occur as individuals age and progress through life events, changes, and stages, such as adolescence and older adulthood. A cultural crisis (option 4) is a response that occurs while a person is adapting to a new culture or returning to a previous culture after having assimilated into another. There is no indication that this client is in a culturally challenging situation. ‐ Adventitious ‐ Maturational ‐ Situational ‐ Cultural | Recall types of crisis responses. Notice that the precipitant event was unexpected and the event applies only to this client. |
4265 The client is in a crisis state. At the beginning of the initial assessment interview, what should the nurse assist the client to identify? Select all that apply. ‐ Current feelings ‐ The realistic nature of the event ‐ Others who might be affected by the event ‐ An immediate action plan ‐ Past emotional traumas | Correct answer: 1, 2 | Options 1 and 2 are correct. It is helpful for the client to identify and ventilate personal feelings being experienced. This relieves anxiety, allows the client to feel validated, and prepares the nurse and client to progress to other steps in crisis resolution. The client's perception of the situation should occur very early in crisis intervention. The nurse must have a clear idea of what the problem represents to the client and also be able to identify the current reality the crisis presents for the client. Then action plans can be developed. The focus of crisis intervention is on the individual who is experiencing the crisis response, not on others (option 3). The goal is to assist the person in crisis to reestablish equilibrium by using previously effective coping techniques. It is premature to develop an action plan at this time (option 4). Complete assessment and analysis of the problem must occur before proceeding to develop an action plan. Past emotional traumas (option 5) are not explored in crisis intervention. Intervention should focus on the current problem and facilitating the client’s coping in order that a return to pre‐crisis baseline may be accomplished. If past emotional traumas become apparent during a crisis, referral for counseling at a later time would be appropriate. | Remember that crisis intervention focuses on a current problem and the "here and now." |
4266 A client with suicidal ideation and a specific lethal plan for self‐harm was admitted to the hospital. The client's spouse died recently after a very brief illness. The client states, "There's no reason to go on living. My best friend is gone, and I’m all alone now. We did everything together. Now I have no one to turn to or do things with." Which nursing diagnoses are appropriate? Select all that apply. ‐ Helplessness related to suicidal attempt ‐ Decisional conflict related to loneliness ‐ Risk for suicide related to hopelessness ‐ Social isolation related to the loss of support system ‐ Acute grief caused from risk for suicide | Correct answer: 3, 4 | Options 3 and 4 are correct. The client's statement directly indicates feelings of hopelessness, as well as more indirect expressions of risk for suicide. The spouse’s death has left the client without adequate interpersonal support to cope with and adjust to a significant loss. The client is experiencing a situational crisis. In order to cope effectively in a crisis situation, individuals must identify and be able to rely on others in their world to support them emotionally both during and after the crisis. While the client is lonely, there is no indication that the client is helpless (option 1). Additionally, the question does not indicate there was an actual suicide attempt. Note also that as the diagnosis is written it says that the suicidal attempt caused helplessness, which is illogical. The client's statement in option 2 does not suggest difficulty with decision making, although this can be one of the manifestations of a crisis state. The nursing diagnosis in option 5 does not follow the "problem related to etiologic factor" format. Notice also that the two parts of the nursing diagnosis are reversed. | Look carefully at what the client is saying. The client directly expresses feelings of being alone and isolated. Additionally, there is an indirect message that could indicate suicidal intent. Make sure that the etiologic factor in the nursing diagnosis is shown in the stem of the question. |
4267 A client seeks assistance at a crisis center. The client Correct answer: 4 Option 4 is correct. The client is feeling overwhelmed by feelings associated with the crisis describes being intensely anxious and sleepless since precipitant. Before advancing to other interventions, including exploring habitual coping styles assisting with cleanup activities at a school where a and assisting the client with problem solving, the nurse needs to allow the client to freely student fatally shot a classmate. To assist the client to express emotions being experienced. There is no evidence to suggest that the client would cope more effectively, what should be the first benefit from a visit from clergy (option 1). This may be an effective intervention later, but at intervention of the nurse? this point it is not appropriate. The nurse should not make assumptions about this client’s religious or spiritual needs. More complete assessment data is needed. Option 2 is incorrect because the nurse's first intervention should be to help the client cope with the precipitant and actual event. Emphasis is on perception of presenting event, past experience in coping, available coping mechanisms, and availability of social supports. The client is in a state of emotional crisis that is considered a normal response to the event. Unless the crisis response intensifies and the client develops severe psychologic or physiologic symptoms, the crisis situation should be treatable in a nonhospital setting (option 3). ‐ Arrange for a member of the clergy to visit the client. ‐ Advise the client to avoid going near the school for at least 6 weeks. ‐ Send the client to the emergency department for further evaluation. ‐ Allow ventilation of feelings. | Note that this client was exposed to an overwhelming stressor and that symptoms began after exposure to the stressor. Consider how you would feel if you had been involved in this situation. Like most other crisis responses, the client's response to this intense situation is understandable. |
4268 When the nurse is working with a client in crisis, Correct answer: 2 Option 2 is correct. The nurse must remain focused on the immediate problem. Crisis which nursing action is most important? intervention is viewed as a "here‐and‐now" type of therapy. The only history that is relevant at this juncture is the recent history of events that led up to the crisis (option 1). Obtaining a complete past history at this time would impede the nurse's efforts toward assisting in the effective resolution of client's crisis state and would not be appropriate. Early life experiences are not examined in crisis intervention (option 3). The goal is to reestablish equilibrium and return the individual to the pre‐crisis level of functioning. Examination of early life experiences occurs in more traditional insight‐oriented psychotherapy. In crisis intervention, the nurse and the client enter into a relationship where action plans are developed jointly (option 4). However, it is appropriate for the nurse to be more directive than in other types of interventions. ‐ Obtaining complete assessment of the client's past history ‐ Remaining focused on the client's immediate problem ‐ Determining the relationship of early life experiences and the crisis state ‐ Developing an action plan for the client. | Review steps in crisis intervention. Think also about what makes sense. If the client is currently feeling overwhelmed, doesn’t it seem reasonable for the nurse to focus on now, not then? |
4269 For the third time within a month, a client with Correct answer: 2 Option 2 is correct. The risk of suicide is not reduced because a person makes frequent borderline personality disorder took a handful of pills, attempts or threats of suicide. Instead, the risk for successful suicide is greater once a single called 911, and was admitted to the emergency attempt has been carried out. Persons who make verbal threats or attempts are conveying department. The nurse overhears an unlicensed staff their desperateness and need for assistance in controlling their own impulses for self‐harm. member say, "Here she comes again. If she was serious Clients with certain personality disorders, including borderline personality disorder, are about committing suicide, she’d have done it by now." actually at higher risk for suicide (option 1). These individuals are easily overwhelmed and tend The nurse determines there is a need to teach the staff to react dramatically to events that others would find more tolerable. The nurse is obligated to member which of the following? provide protection to the client in a suicidal crisis (option 3). In every suicidal situation, the nurse must objectively explore the nature, frequency, and specificity of the suicidal thoughts. Talking about this, and determining whether a plan and a means for suicide are present, is a standard part of nursing intervention with the suicidal client. Talking about suicide does not increase the risk for suicide, which is a commonly held myth among nonprofessionals. There is not enough information to know whether the client will be admitted to an inpatient unit (option 4). If a sufficient action plan is developed that will provide for the client’s safety outside the hospital, it is possible that the client can be discharged from the emergency department. | Notice that the client has made three suicidal attempts within one month's time. Even if you didn't know that the client had borderline personality disorder, focus on the probability that that the client must have a certain sense of desperation to aid in making a selection. |
‐ Clients with personality disorders rarely kill themselves. |
‐ Each suicidal attempt should be taken seriously. ‐ Exploration of suicidal ideas and intent should be avoided. ‐ The nurse should prepare the client for direct inpatient admission. | |
4270 A client has been treated in the surgical intensive care Correct answer: 1, 3, 4 Options 1, 3, and 4 are correct. A priority goal for the client, once safety has been assured, is unit after sustaining a self‐inflicted gunshot wound. to explore life events leading to the decision to die (option 1). This can be followed by The client is now admitted to a psychiatric unit. The reviewing current feelings and determining whether the client still has active suicidal urges. If nurse schedules time to meet with the client on a one‐ so, the client must be adequately protected while in the inpatient psychiatric setting. When to‐one basis with the goals that the client will: (select determining potential lethality in a situation with a suicidal client, it is useful to know whether all that apply) the person has made previous attempts (option 3). If so, this increases the potential lethality of the situation. One of the most effective ways of providing for safety of the suicidal client is to have the client agree (or contract) with the nurse to notify a staff member if the urge to act on suicidal ideas occurs (option 4). If the client cannot agree to this, or if the client is very ambivalent or hesitant about agreeing, the nurse should recognize that the risk for self‐injury remains very high. It is the nurse's responsibility to initiate contact with the client and to determine whether the risk for suicide is still present (option 2). Do not assume that the client will be able to initiate interaction with the nurse. In fact, the client may resist such contact, and this behavior could suggest continuing suicidal potential. The priority should be on continually assessing client's suicidality and keeping the client safe in the present environment (option 5). While discharge planning is important, it is premature at this time. ‐ Explore current life events that led to the suicide attempt. ‐ Initiate contact with the nurse spontaneously. ‐ Discuss past suicidal ideations and behavior. ‐ Enter into a contract for safety with the nurse. ‐ Identify post‐discharge living arrangements. | Recall principles of lethality assessment. The SAD Persons scale would be useful. |
4271 A client who admits to having frequent suicidal Correct answer: 3 The nurse should look beyond the words that the client uses and determine what the ideations is admitted to the psychiatric inpatient unit. underlying meaning is (option 3). Improvement in mood and energy often occurs just before During the assessment interview, the client says, "I the suicidal person carries out a suicidal act. Once a suicidal plan has been made, it is as if the really don't need to be here. I'm very much at peace individual feels relieved of a great burden. While the client's words may suggest that the risk of with myself now." The nurse should interpret that the suicide is lessened, the hidden or indirectly expressed message is different (option 1). The client probably: nurse should recognize that this client may be describing a feeling of relief often experienced by a suicidal client after making a plan to end his or her life. The client may need to be put on heightened suicide precautions (option 2). The nurse should realize the client’s verbalizations indicate an actual plan to end life may have been made and could be carried out after discharge. Improvement in affect and energy is often observed in suicidal clients right after a suicide plan is made and right before the suicidal client carries it out (option 4). ‐ Has resolved suicidal feelings and is no longer at risk for self‐harm. ‐ Is ready to be discharged from the inpatient setting. ‐ Continues to be at significant risk for suicide. ‐ Has concluded that the risk for self‐harm is no longer present. | Notice the words at peace. Does it seem likely that someone so recently admitted to a psychiatric‐mental health unit would feel peaceful? Recognize this as a "red flag" statement. |
4272 The nurse determines that which nursing diagnosis Correct answer: 1 Option 1 is correct. The first priority in caring for the client with suicidal ideation and intent is would be the priority for a client with suicidal ideations maintaining safety. Options 2 (ineffective individual coping), 3 (hopelessness), and 4 (defensive and intent? coping) are incorrect. All other issues, including major psychological ones, are secondary to safety. Ineffective individual coping, hopelessness, and defensive coping would be appropriate nursing diagnoses only after safety has been assured. ‐ Risk for violence, self‐directed ‐ Ineffective coping | Don't try to make this question harder than it is. You already know that preservation of life is always a priority for the nurse. The fact that this is a psychiatric‐mental health client doesn't change that. |
‐ Hopelessness ‐ Defensive coping | |
4273 A suicidal client is placed on one‐to‐one observation. Correct answer: 1 Acknowledging the client's feelings of frustration and reaffirming the need for safety is the When the nurse accompanies the client to the priority. The nurse should remain calm and matter‐of‐fact in this situation while tolerating the bathroom, the client loudly shouts, "I'm sick of being client's verbal outburst and allowing for expression of feelings. The nurse's response should followed around and treated like a child who can’t be include validation of client's feelings and information about the intent of the one‐to‐one trusted." What would be the best response by the observation, which is to keep the client safe (option 2). During one‐to‐one observation, the nurse? nurse must remain at arm's length from the client at all times, including during toileting activities (option 3). The response in option 4 lacks compassion and is demeaning. While it suggests some awareness of safety considerations and procedure, it fails to express concern for this client's safety. ‐ "I understand that you do not like this, but I must be able to see you at all times to make sure you are safe." ‐ "You don’t have to be so loud. I do trust you, but I can't change the rules for you." ‐ "Since this is upsetting to you, leave the door open and I’ll wait outside it for you." ‐ "Being angry and uncooperative won't change anything. I can’t leave a suicidal client alone." | Keep in mind the need to be compassionate and calm while providing for the client's safety. Recognize that what the client is feeling and saying is common and very understandable in situations involving one‐to‐one care. |
4274 A client is transitioning to a less intensive level of Correct answer: 4 The problem with thoughts of using is keeping them a secret. When keeping things secret, the outpatient treatment for addiction. The client client is not telling the whole truth and is manipulating something. Engaging in secrets is statement that most reflects risk for relapse includes: reminiscent of using behaviors and can trigger using behaviors. It is natural to feel sad (option 2), hungry, or tired (option 3), and to have thoughts of using (option 1). ‐ Dreaming about gambling or engaging in compulsive sex. ‐ Not feeling happy. ‐ Feeling hungry or tired. ‐ Keeping thoughts of using a secret. | Use the process of elimination and nursing knowledge to answer the question. The wording of the question tells you that one answer is better than the others because it contains the key word best. |
4275 What statement made by the mother of a recovering Correct answer: 1 Checking on the compliance of a family member is an example of codependent behavior. The compulsive Internet user would indicate the need for nurse would focus the teaching on helping the mother detach from her son and his recovery more teaching? program and focus on her own well‐being. Options 3 and 4 would indicate that she is trying to identify and deal with her feelings. Option 2 is an obvious healthy behavior. ‐ "My son is not going to enough 12‐step meetings, he doesn't do his daily readings, and I don't think he is taking this seriously enough." ‐ "My daughter and I are going to go to Al‐Anon for the first time because we realize we have been affected by my son's addiction." ‐ "I need to sign up for a meditation class for me because I get too preoccupied with what my son is or is not doing." ‐ "I still have a lot of anger about the relationship problems that occurred between my son and me as a result of his addiction." | The wording of the question tells you that only one answer is correct. Use knowledge of codependency to differentiate the problematic behavior from the other expected behaviors. |
4276 The nurse observes a family visit on the unit and Correct answer: 1 There are three communication rules learned in families in which addiction is present: don’t recognizes that the family is suffering with effects of talk, don’t trust, don't feel. While these experiences cause anger, anxiety, or maladaptive addiction and codependence. What long‐lasting coping, they can also contribute to the development of shame, depression, and low self‐ interpersonal problems might the nurse expect family esteem. Without family healing, these problems can create much pain and suffering for all members to manifest? involved. ‐ Lowered self‐esteem ‐ Impatience ‐ Frustration tolerance ‐ Being argumentative | The core issue of the question is underlying consequences to families when addiction is present. Use nursing knowledge and the process of elimination to make a selection. |
4277 A mother brings her daughter into the Emergency Correct answer: 3 The client most likely has used one of the "club drugs" or "rave drugs," these substances most Department. She was at a party and danced for the last often are a cross between a stimulant and a hallucinogen. Such drugs are used at dance parties few hours. Now she is sweating and does not look well. and along with black lighting or strobe lights create a surreal experience. The stimulant effect The nursing assessment reveals temperature of 103° F, of the drug causes users to grind their teeth. To avoid this, teens often use pacifiers to suck on. grinding the teeth, rapid weight loss. What should the The combination of drug, dancing, and dehydration lead to dangerous body temperature nurse be most concerned about? increases, which must be addressed immediately. This client may also have an eating disorder, but that would not be the nurse's primary concern (option 2). Options 1 and 4 are incorrect. ‐ Poor nutrition from excessive alcohol consumption ‐ Possible eating disorder ‐ Dehydration and electrolyte imbalance ‐ Flu with accompanying high fever | Note the stem of the question contains the critical words most concerned. This tells you that more than one option may be partially correct and that you must prioritize an answer. Correlate elevated body temperature and weight loss with fluid balance to choose option 3 as correct. |
4278 The nurse is completing an admission for a client with Correct answer: 4 While most individuals believe that drugs of abuse enhance their sexual experience, the alcohol dependence. During the admission process, the opposite is mostly true. The four types of sexual problems that commonly occur as the result client acknowledges occasional sexual performance of chemical use are: anxiety about one's sexual performance; decrease or absence of sexual problems. Then he says, "It’s nothing a little alcohol arousal; difficulties in reaching orgasm; and decrease or absence of pleasure in and/or can't fix." The nurse provides education about the intensity of orgasm. effect of alcohol on sexual functioning by sharing that regular alcohol use causes which of the following? ‐ Increased desire and performance ability ‐ Headaches and the "too tired syndrome" ‐ Hyperarousal and premature ejaculation for men and anorgasmia for women ‐ Decreased desire and ability to perform | The core issue of the question is the relationship between chronic substance abuse and sexual performance. Use the process of elimination and nursing knowledge to answer the question. The wording of the question tells you that only one option is correct. |
4279 A physician just wrote an order for a client to take Correct answer: 3 Naltrexone is an excellent medication to treat alcohol or opiate dependence. It helps to naltrexone (ReVia). What would be the greatest prevent cravings and triggers to use, and it blocks the euphoric response if alcohol or opioids concern of the nurse while getting ready to administer are ingested (option 1). The nurse should always evaluate the client’s current knowledge level this medication? and provide education as needed (option 2). However, if the client is not completely detoxified from opiates, the use of naltrexone can precipitate withdrawal (option 3). Persons should be opiate‐free for 7–10 days before starting this medication. ‐ The medication blocks the euphoric feeling from narcotics and alcohol. ‐ Whether the physician provided good medication teaching. ‐ The medication can precipitate withdrawal if the client is not completely detoxified. ‐ The client will not be able to experience pleasurable sensations. | Note the key words greatest concern in the question. This tells you that more than one option could be partially correct and that you must prioritize an answer. Use nursing knowledge related to this medication to choose the option in which the client is at greatest risk. |
4280 You are conducting a daily nursing assessment on a Correct answer: 1 Recovering clients may tend to underestimate how difficult it will be to stay sober if they visit client with gambling and alcohol addictions who is in with friends who are still using or frequent old "hangout" places where they used to engage in the outpatient addiction program. As she checks in addictive behaviors. In early recovery, clients are encouraged to detach from people, places, with you, she makes which of the following statements and things associated with their addiction. As the person gains sobriety and recovery, he or she that reflects a need for more teaching? may be able to re‐engage, on a limited basis, with certain activities, such as being with friends who drink or celebrating an occasion at a bar. Options 2, 3, and 4 demonstrate positive coping measures and good management of potential triggers. ‐ "I am going to have a night out with some friends at an area night club." ‐ "I felt like drinking, so I cleaned the house instead." ‐ "It is hard for me to make phone calls if I feel like using, but I did it last night." ‐ "I told my brother that I couldn't help him as much as I have in the past." | The wording of the question tells you that the correct option is a statement that contains either a false statement or one that indicates the client is at risk. Choose option 1 over the others because it puts the client in an area where temptation is likely. |
4281 After completing a family session about addiction, a Correct answer: 2 Addiction affects the entire family system: communication roles and boundaries. Some woman approaches the nurse and shares that as a problems that individual family members experience are low self‐esteem, guilt, shame, mother, she will always have to bear the suffering of insecurity, and preoccupation with the chemically dependent family member. Families need having a chemically dependent daughter who could treatment to facilitate their own healing. If they get involved in a treatment facility–operated relapse at any time. What would be important family program, a spiritually centered family recovery program, or any of the family 12‐step information to share about family recovery from programs, active healing can take place whether the addict is using or not. Options 1 and 3 are addiction? incorrect. If the family is not engaged in its own treatment, it may not make any difference how many meetings the addicted member attends (option 4). ‐ Family recovery can begin when the addictive behavior ceases. ‐ Family recovery can begin even if active use continues. ‐ Family recovery will fail if the recovering addict relapses. ‐ Family recovery will be enhanced if the recovering addict attends several Alcoholics Anonymous meetings. | The core issue of the question is the family dynamics and impact on the family of a substance‐using family member. Use nursing knowledge and the process of elimination to make a selection. The wording of the question indicates that only one answer is correct. |
4282 A married client with marijuana dependence has Correct answer: 3 The client is spending a great deal of time on the Internet, which seems to be interfering with difficulty keeping her house clean because she spends not only her parental relationships but also her relationship with her husband as well. If the a lot of time playing an entertaining game on the client does not stop using marijuana and start practicing recovery, and if her Internet problems Internet. She also says that she waits until everyone are not addressed, they are unlikely to "go away on their own" and her family problems may goes to bed to start writing messages with sexual get worse (options 1, 2, and 4). content online with another man. What are the nurse's concerns? ‐ The Internet will cause her to break her marriage vows. ‐ Her children won't bring any friends home because the house is messy. ‐ She seems preoccupied with the Internet and is using poor judgment. ‐ She is depressed and finds her marriage unfulfilling. | Use the process of elimination and critical thinking skills to answer the question. The correct answer is one that is most comprehensive of all aspects of the problem described and does not place judgment on the client. |
4283 The nurse is educating parents about the purpose of Correct answer: 2 Environment and peer pressure play very strong roles in the development of addiction. Most laws that prohibit nicotine advertising on billboards smokers (90 percent) are addicted to nicotine by age 20. Although only 28 percent of the U.S. within 1,000 feet of children in academic and social population smokes, the vast majority of new smokers are under age 18. The Federal Drug areas. In response to a question from the group, she Administration (FDA) is trying to reduce smoking among children and teens by regulating shares that the law was designed to do which of the tobacco advertisements near schools and youth centers. The rationale is that by restricting following? tobacco advertising to youths, the desire to smoke will be reduced. It is good for the public to be educated about the hazards of smoking, including second‐hand smoke. This law does not specifically address option 1 and 3. Option 4 is part of the tobacco industry response to the proposed FDA regulation. ‐ Educate the general public about the hazards of smoking cigarettes. ‐ Diminish the environmental risk to teens. ‐ Diminish the effects of second‐hand smoke. ‐ Limit the free speech of children. | Use the process of elimination to answer the question. The correct answer is the one that reduces the exposure of children and teens to advertising about tobacco in locations that they tend to frequent, thereby diminishing the pressure to use. |
4284 A new mother who bottle‐feeds her infant comes in Correct answer: 3 Antidepressants regulate dysfunction in the neurotransmitter system, which results in mood for her 6‐week postpartum visit and talks about how equilibrium. Alcohol is a depressant that causes dysfunction in the neurotransmitter system, depressed she is feeling. The health care provider which can cause depression and/or anxiety. Use of alcohol or other mood‐altering drugs while prescribes an antidepressant for her. As the nurse taking antidepressants is contraindicated. delivering medication education, you assess the client's alcohol‐use patterns, and she shares with you that she has 1–2 drinks once or twice a week. You inform the client that she should not drink alcohol or use drugs in this situation because: ‐ It will cause nausea and vomiting. ‐ It will increase the effectiveness of the antidepressant. ‐ It will decrease the effectiveness of the antidepressant. | The core issue of the question is the interaction of a prescribed antidepressant with alcohol use. Recall that alcohol is a CNS depressant, which has an opposite effect of antidepressants. Use the process of elimination and general knowledge of drug interactions to make a selection. |
4.‐ It will cause increased blood pressure. | |
4285 A cocaine‐dependent client in recovery shares with Correct answer: 1 Persons can experience tolerance or tolerance‐like symptoms in response to taking certain the nurse that she has been using an OTC medication OTC medications. OTC sleep medications or psychoactive sleep medications are meant for to help her get to sleep each night for the past 3 short‐term use, no longer than 1 week consecutively (options 2 and 3). The FDA does not weeks. She gets defensive when the nurse raises regulate herbal products, and it is difficult to know what dose to recommend or how the concerns, stating emphatically that it is not addictive. product might interact with the client. Sleep difficulties are often a problem for people in early How does the nurse respond to the client? recovery. Providing education on sleep hygiene and validating experiences proves helpful in addressing this problem (option 4). ‐ Validate how difficult it is to have a tough time sleeping and explain that nonaddictive medication can be abused if taken in larger doses or more frequency than recommended. ‐ Acknowledge to the client that because the medication cannot be abused, it is not addictive. State there is a general concern that it could become a problem. ‐ Confront her firmly and persistently because she is increasing the risk for developing addiction if she uses this medication too frequently. ‐ Suggest she take some natural herbal sleep medication such as valerian or melatonin because they cannot cause any activation of the brain reward system. | Use the process of elimination and nursing knowledge to answer the question. Eliminate incorrect options because of the presence of "red flag" words cannot in options 2 and 4 and firmly and persistently in option 3. |
4286 As the nurse asks about sexuality during a nursing Correct answer: 4 The client acknowledges her problem and has tried to stop on her own; this puts her in the assessment, the client acknowledges that she has action stage. She is actively trying to change. The correct action of the nurse, then, is to assist. sexual problems. She shares that she has a Option 1 demonstrates precontemplation; option 2, contemplation; and option 3, masturbation compulsion and is trying to stop on her determination and preparation. own but can't. She says she needs to know what she can do to stop. Based on her stage of change, the nurse should use which approach to care? ‐ Help her to see that she has a serious problem. ‐ Encourage her that she will feel better if she stops the compulsive sexual behavior. ‐ Identify a date for her to stop her compulsive sexual behavior. ‐ Review strategies to assist her to stop the compulsive sexual behavior. | The critical words in the question are stage of change. This tells you that the correct answer is the one in which the action of the nurse matches the stage of change represented by the client statements. Use the process of elimination and nursing knowledge to make a selection. |
4287 The mental health nurse reminds clients who are Correct answer: 3 Alcohol and benzodiazepines are both depressants. Persons often use two drugs within the learning about cross‐addiction that there is a same class to enhance their effects. The capacity of other psychoactive substances within the synergistic or addictive effect from using various kinds same class of drugs to enhance the effect of the primary drug is called cross‐tolerance. Options of chemicals together. The nurse uses which of the 1 and 4 are examples of combining a stimulant with a depressant, while option 2 has only a following as examples of combinations of chemicals stimulant. that create this additive effect? ‐ Drinking beer and smoking cigarettes ‐ Drinking coffee and eating donuts ‐ Drinking wine and taking a benzodiazepine ‐ Drinking wine and coffee | The core issue of the question is knowledge that cross‐addiction occurs between drugs in the same class. Use the process of elimination and knowledge of the categories of the chemicals in the options to make a selection. |
4288 A male client is saying he is "wired," feels like he is on Correct answer: 3 Tactile disturbances are a symptom of alcohol dependence, and if the client reports stopping "pins and needles," and is irritable. He says he stopped alcohol use abruptly, he or she may be starting to experience withdrawal symptoms. However, using alcohol abruptly. What is the nurse's next the client may also have used and stopped other substances abruptly as well. The nurse must intervention in caring for this client? assess for other substances used. Multiple drug use is the rule more than the exception. Waiting (option 1) places the client at risk, and stimulants are not indicated (option 4). ‐ Wait to see if any other symptoms occur in the next few hours and then report them to the physician. ‐ Assess the time of his last drink and begin assessing signs and symptoms of alcohol withdrawal. ‐ Assess the client for all current substance‐use patterns, including time of last usage, and begin to assess for withdrawal. ‐ Ask the physician to write an order for a stimulant medication to help prevent delirium tremens. | The wording indicates that the core issue of the question is possible withdrawal. Use the process of elimination for options 1 and 4. Choose option 3 over option 2 because it is more comprehensive and includes option 2 within it. |
4289 The nurse has coordinated a health fair for the church Correct answer: 3 It takes the average person 1 hour to metabolize 1 ounce of alcohol or a 4‐ounce glass of parish with four other nurses. The first nurse speaks wine. If three to five glasses of wine are consumed within an hour, the average person about safe driving and includes that coordination and becomes intoxicated. Options 1 and 2 are insufficient, while option 4 is greatly excessive. mental alertness are affected at a blood alcohol level of 0.04, even though many states have a legal limit of intoxication of 0.08 (formerly 0.10). When asked how many drinks per hour the average person needs to reach 0.08 intoxication level, the nurse would make which of the following replies? ‐ A 4‐ounce glass of wine if the individual has eaten recently ‐ A 1–4‐ounce glass of wine on an empty stomach ‐ Three to five 4‐ounce glasses of wine, depending on how recently food was consumed ‐ Seven to eight 4‐ounce glasses of wine, depending on how recently food was consumed | Use the process of elimination to answer the question. Eliminate options 1 and 2 first because they contain small amounts of alcohol and because they tend to be more rigid amounts. Recognizing that the question has the key words average person, choose option 3 over option 4 because it is more moderate and because it allows for individual variation, which options 1 and 2 do not. |
4290 A nurse working in the addictions unit is stopped in Correct answer: 2 Impaired control is the defining symptom that moves someone’s use or abuse category to the the cafeteria by a coworker who states she is upset dependence category. The symptom of "use despite negative consequences" fits in both the about something the nurse told to a client. The client abuse and dependence category (option 1). Withdrawal (option 3) and/or tolerance (option 4) understands that the nurse said, "If your drinking has may or may not be present for someone who has dependence. created any problems for you, then you have addiction." The nurse clarifies that the statement was, "If you have the hallmark symptom of drinking, you have addiction." The nurse goes on to share which of the following as the hallmark? ‐ Use despite negative consequences ‐ Impaired control of use ‐ Withdrawal ‐ Tolerance | The core issue of the question is knowledge of hallmarks of alcohol abuse. Use the process of elimination and nursing knowledge to make a selection. |
4291 An orthopedic client who broke his ankle while Correct answer: 4 The behavior of drinking and driving fits in the abuse category as "recurrent substance use in drinking at a party is wondering if his drinking is hazardous situations." Option 1 is incorrect. Option 2 demonstrates the category of "okay." He says he has never been arrested for driving dependence. Option 3, "black out," is a symptom of intoxication. intoxicated, nor has he experienced any health or relationship problems. He called in sick to work one time and drove intoxicated several times. Family information validates his self‐report. The nurse concludes the client has an alcohol abuse problem on the basis of which of the following characteristics of this syndrome? ‐ Drinking more than two drinks per occasion ‐ The inability to stop drinking despite negative consequences ‐ Drinking that causes an individual to pass out or experience a blackout ‐ Drinking too much and too often with using poor judgment, and having negative consequences | Use the process of elimination to make a selection, matching the client statements in the question with the conclusions in the correct option. The wording of the question tells you that only one option contains a correct statement. |
4292 The school nurse at the local high school is teaching a Correct answer: 2 Any substance, legal or illegal, that activates the pleasure center in the brain has the potential drug prevention class to teens, who don't believe to cause dependence. Nicotine takes only 10 seconds to reach the brain. Nicotine causes both cigarettes should be labeled a drug. The nurse explains physical and psychological dependence. that when dealing with addiction, the word "drug" means which of the following? ‐ An illegal substance that activates the pleasure center ‐ A substance that activates the pleasure center in the brain ‐ A chemical that produces a pharmacological action when ingested | Use the process of elimination and basic knowledge of addiction to make a selection. The wording of the question tells you that only one option contains a correct statement. |
4.‐ Any kind of pill that is broken down in the stomach by digestive action | |
4293 A female student nurse visiting an outpatient Correct answer: 3 Methadone maintenance therapy seems to be an effective treatment regimen for a select addiction program is reviewing nursing care plans. She population. Clients with heroin and/or other opiate addictions receiving oral methadone do notices that there is one client with opiate addiction not receive the euphoria associated with their drug of choice (option 1). The person on who takes methadone and will not be tapering off the methadone maintenance who works a recovery program and is abstinent of all other mood‐ medication. The student nurse asks the preceptor‐for‐ altering substances is in good recovery (option 2 and 4). the‐day about this. The preceptor responds that clients with an opioid addiction who are on methadone maintenance: ‐ Are at high risk for using opiates. ‐ Are not really in recovery because they are still using a drug. ‐ Do fairly well in recovery as long as they are not using other drugs. ‐ Are exempt from having to participate in a 12‐step program. | Use the process of elimination and basic knowledge of addiction to make a selection. The wording of the question tells you that only one option contains a correct statement. |
4294 The nurse is conducting an education session about Correct answer: 1, 2, 4 Options 1, 2, and 4 are correct. DSM IV‐TR specifies that substance dependency can be alcoholism. Which of the following statements should diagnosed if the behaviors of the client over the past 12‐month period are consistent with the nurse include when explaining the concept of three or more of seven specific criteria. This option describes one of the criteria. Option 3 is alcohol dependences? "Alcohol dependence involves incorrect as this option is not included among the DSM IV‐TR criteria. These criteria recognize (select all that apply): that alcohol dependency can follow many different patterns, including episodic drinking to excess. The only time frame mentioned in the criteria is one year, and this is because persistent patterns of use are necessary to establish the diagnosis of alcohol dependency. Option 5 is incorrect because this option is not included among the DSM IV‐TR criteria. Also, confabulation is not considered one of the characteristic defense mechanisms of the alcohol dependent individual. These are denial, rationalization and projection. ‐ Continuing to drink despite critical alcohol related problems." ‐ Drinking larger amounts or over a longer time than was intended." ‐ Drinking to the point of drunkenness at least once per week." ‐ Experiencing a diminished effect with continued use of the same amount of alcohol." ‐ Using confabulation as a defense mechanism." | Review DSM IV‐TR criteria for substance dependency. |
4295 A client is dually diagnosed with alcohol dependency Correct answer: 3 Option 3 is correct. For the client who is dually diagnosed with alcohol dependency and and depression. The client says, "I think that once my another psychiatric‐mental health problem, he or she must receive treatment for both depression is managed, I won’t drink anymore." What illnesses in order to have the optimal chance of recovering. Treatment of only one of the is the most appropriate response by the nurse? disorder is incomplete and can lead to relapse. Options 1, 2, and 4 are incorrect because "Experts in the field generally agree that: treatment of only one of the disorders is incomplete and can lead to relapse. ‐ Decisions regarding sequencing of treatments should be made on an individual basis." ‐ Treatment for depression should occur before treatment for alcohol dependency." ‐ Treatment for both alcoholism and depression should occur at the same time." ‐ Alcohol related treatment should occur before treatment for depression." | Remember that persons with psychiatric disorders are at risk for substance dependency if both co‐morbidities are not treated. Individuals often will use alcohol and drugs for purposes of self medicating their untreated psychiatric illnesses. |
4296 The substance dependent client is in the rehabilitative Correct answer: 1, 2, 4 Options 1, 2, and 4 are correct. The substance dependent client must recognize that relapse is stage of treatment. When teaching the client relapse common among substance abusers. Clients need to be taught how to prevent relapse so that prevention skills, what should the nurse emphasize? they can gain confidence and the expectation of being able to cope without using a substance. Select all that apply. It can be useful for the client to learn to apply the HALT mnemonic, which teaches avoidance of situations that are known to promote relapse. These include being: Hungry, Angry, Lonely, and Tired. Other relapse prevention skills include involvement in an active recovery program, often a 12 step program that considers recovery to be a life‐long process that is best accomplished with the support of peers with the same addiction. Option 3 is incorrect as treatment programs emphasize the need to be open and honest about having urges to return to use of the substance. Suppressing feelings is considered to be an addictive behavior. Option 5 is incorrect because the recent social network of the client is most likely to be that of a group of substance users. Relapse prevention skills include developing a new social network of persons who will support efforts toward sobriety. ‐ Preventing fatigue ‐ Maintaining physical health ‐ Suppressing thoughts of returning to substance use ‐ Reducing amount of solitary unstructured time ‐ Reconnected with the recent social network | Recall information about usual behaviors and defense mechanisms associated with substance use. Recognize the importance of giving the client specific guidance that will assist with learning more effective coping skills. |
4297 Which of the following comments by a substance Correct answer: 1, 3, 4, Options 1, 3, 4, and 5 are correct. Substance dependence clients should be taught to have dependent client should cause the nurse to conclude 5 structure and routine in their lives, as well as to avoid boredom and loneliness. Option 3 that the client is vulnerable for relapse? Select all that suggests that the client feels overly confident, which can be lead to unwise behaviors that test apply. the recovery. Option 4 indicates dissatisfaction and impatience with others and can lead the client to feel justified in returning to the "solace" of using a substance. Option 5 indicates that the client is putting self into a situation of high risk to return to alcohol use. Also, the client is showing complacency rather than cautiousness. Option 2 is incorrect as this statement indicates that the client has an awareness of a high‐risk situation that could lead to relapse. After developing the awareness, the client can then make a conscious decision as to how to cope with the situation without using a substance. ‐ "I like being able to have a lot of free time." ‐ "Going to a football game makes me want to use again." ‐ "I've been sober for 2 years. I've got this problem under control." ‐ "No one else seems to work as hard as I do." ‐ "It's easy. I can go to a club and just drink soft drinks." | Look for options that clearly indicate that the client is in a situation of risk. Notice that only one option shows insight. However, that is not what is being asked for in this question. |
4298 Clients newly diagnosed with an addictive disorder Correct answer: 4 Option 4 is correct. Most substance use treatment programs encourage the client to often have difficulty dealing with the threat of loss of acknowledge that they are unable to maintain sobriety of their own accord. Accepting the independence. Which type of statement made to the need for help and asking for it are fundamental to the recovery process. Most 12‐step nurse would indicate that the client is successfully programs teach the concepts of powerlessness, surrender acceptance, and asking for help as working on these issues? The client is: primary to recovery from the disease. Options 1, 2, and 3 are incorrect as dealing with existential issues such as "who am I," feelings of loss, and anger are important parts of the recovery process, but this question is specifically asking for a response regarding independence issues. ‐ Asking, "What is the meaning of life?" ‐ Dealing with feelings of loss. ‐ Expressing anger. ‐ Asking for help. | Notice that this question is specifically dealing with issues surrounding independence. Disregard all other issues when looking at the options. |
4299 The client has a compulsive gambling addiction. The Correct answer: 2 Option 2 is correct. In the contemplation stage of change the client is becoming aware of a nurse has assessed the client as being in the problem but has not yet become motivated to change. Option 1 is incorrect as this reflects the contemplation stage of change. Based on this preparation‐determination stage of change in which the client is getting ready for a change assessment, the nurse anticipates that the client is and developing a plan to seek help. Option 3 is incorrect because stopping the gambling dealing with which issue? behavior is the action stage of change. Option 4 is incorrect as continuing the behavior of the action stage of change occurs in the maintenance stage of change, which, optimally, is a lifelong pattern. ‐ Completing the evaluation of the gambling problem and making plans to go to treatment ‐ Discussing the good and bad aspects regarding gambling ‐ Stopping gambling and beginning to take a longer route home to avoid the casino ‐ Taking action to assure staying away from gambling permanently. | Review definitions and basic information about stages of change. | |
4300 A 30‐year‐old female client is admitted to a program Correct answer: 4 for clients diagnosed with alcohol dependency and depression. Before administering any ordered medications to this client, it is most important for the nurse to verify that the client's record includes which of the following? | Option 4 is correct. When clients are of child‐bearing age, it is essential that evaluation for pregnancy occurs before active psychopharmacologic interventions are begun. This is so that substances known to be dangerous to unborn children (which includes many antidepressants) will not be given to the client. If the client is pregnant, prenatal exposure to alcohol has already occurred and the client is already at risk for delivering a child with one or more alcohol‐related birth defects, including fetal alcohol syndrome. Of all substances commonly abused or abused, alcohol carries the greatest risk for unborn babies. Option 1 is incorrect because while it is true that vitamin administration is an important part of treating both pregnant women and alcohol dependent persons, this is not as important a priority as is protecting a developing fetus from further exposure to dangerous chemicals. Option 2 is incorrect as this information is useful to assess the client's overall health, but this test only assumes urgent importance if the client has significant health problems or is to begin a drug that is known to cause hematologic changes. Option 3 is incorrect because recording of height and weight does provide baseline data for further treatment of the pregnant and/or alcohol dependent client. However, many medications can be safely begun without this data. | Notice the age and sex of the client. Most questions do not provide this information, so the fact that this appears in this question makes it very important. |
‐ Medical orders for vitamins ‐ Complete blood count (CBC) findings ‐ Recording of height and weight ‐ Pregnancy test results | ||
4301 A substance dependent client is attempting to Correct answer: 4 maintain sobriety. The nurse is teaching the client the technique of cognitive restructuring. What statement by the client indicates to the nurse that the client is making progress? | Option 4 is correct When the client is addicted, common elements in cognitive restructuring include making a commitment to choosing sobriety; not engaging in distorted thinking like blaming others and increasing the sense of perceived control. Option 1 is incorrect as this response indicates that the client is projecting blame and rationalizing the drinking behavior by blaming outside circumstances. When the client is addicted, common elements in cognitive restructuring include making a commitment to choosing sobriety; not engaging in distorted thinking like blaming others and increasing the sense of perceived control. Option 2 is incorrect because this statement indicates that the client is continuing to blame others. Additionally, it exhibits self pity and high expectations of the behavior of others, both of which indicate relapse vulnerability. The client who makes this statement is maintaining, not changing, personal cognition. Option 3 is incorrect as this statement indicates that the client is feeling overly‐confident and grandiose, both of which indicate relapse vulnerability. The client who makes this statement is maintaining, not changing, personal cognition. | Look for an option that indicates a change in the client's usual defensive and cognitive pattern. |
‐ "If I didn't have so many problems in my life, I wouldn't drink." ‐ "My family hasn't yet realized that I'm doing this for them." ‐ "I know how to work this program. I'm too smart to fail again." | ||
4.‐ "Addiction has brought a lot of hard lessons and many insights into my house. While it's not easy to abstain from drinking, the 12 steps have made me wiser and they help me make better choices. If I'm going to depend on anything again, it's going to a higher power." | |
4302 The nurse determines that which nursing diagnosis Correct answer: 4 Option 4 is correct. The definition for spiritual distress is disruption in the life principle that would be appropriate for a client who is in the anger pervades a person’s entire being and that integrates and transcends one’s biological and stage of grieving the loss of his or her addiction? psychosocial nature. The lifestyle change that is necessary to recover pervades a person's entire being and it helps explains why someone would be angry about having to make such a great change. Option 1 is incorrect as Ineffective denial is a disavowing of the meaning of something. This diagnosis is not reflected in the client’s current status. Option 2 is incorrect because Ineffective management of therapeutic regime suggests that one is not managing the recovery process well. This diagnosis is not reflected in the client's current status. Option 3 is incorrect as Knowledge deficit suggests a lack of knowledge about the disease. This diagnosis is not reflected in the client's current status. ‐ Ineffective denial ‐ Deficient knowledge ‐ Ineffective therapeutic regime management ‐ Spiritual distress | Recall that spirituality and religion are separate phenomena. Apply the broader concept of spirituality to this question. |
4303 Recovering substance‐dependent clients are Correct answer: 3 Option 3 is correct. If clients call someone when feeling depressed they are demonstrating completing a short question‐answer test after a coping they have learned how to use support. Reaching out to others for sobriety support and skills lecture the nurse delivered. What statement interpersonal support is key to maintaining recovery from depression and addiction. Option 1 indicates that a client is learning how to use a sober is incorrect as in recovery programs that utilize a sponsor, the sponsor's role is to provide support network? social and personal support, not financial support. Option 2 is incorrect because this statement indicates that the client has not accepted the importance of social support in a recovery program. Individual who try to "go it alone" are at high risk for relapse. Option 4 is incorrect as this statement indicates an awareness of areas of commonality between the client and others, but it does not indicate that the client knows how to utilize the social network. ‐ "My sponsor will loan me money if I need it." ‐ "I feel grateful that I have been able to stop using on my own." ‐ "If I start feeling depressed, I should let someone know." ‐ "I’ve learned that I'm not different from all the others in treatment." | Notice that the question is asking for a specific indicator regarding use of a sober social network. |
4304 The nurse instructs the client about addiction. The Correct answer: 2, 3, 4 Alcoholism was officially listed as a disease in 1956, and Jellinek’s identification of the four nurse determines that the client understands the phases of disease progression in 1960 reinforced the disease concept (option 2). Addiction information given when the client makes which includes behavioral habits and emotional attachment, but it is seen first as a medical disease statement(s)? Select all that apply. (options 3 and 4). Although alcoholism has been recognized as a disease for approximately 50 years, many members of the general public continue to view addiction as a moral weakness (option 1). Addiction experts do not consider that addiction can be cured (option 5). Instead, they consider it a chronic medical disease that can be managed. ‐ "Addiction is a moral problem." ‐ "Addiction is a medical illness." ‐ "Addiction is a behavioral habit." ‐ "Addiction is an emotional attachment." ‐ "Addiction is difficult to cure." | Remember that treatment approaches for alcoholism include both biomedical and biosocial models. |
4305 A client says, "I have a very small drink every morning Correct answer: 3 Taking a drink in the morning to steady one's nerves is a sign of physical dependence and is to calm my nerves and stop my hands from trembling." done to avoid withdrawal symptoms. Tremors are one of the the 10 symptoms of alcohol The nurse concludes that this client is describing which withdrawal listed in the Clinical Institute Withdrawal Assessment of alcohol symptoms. People of the following? with anxiety may have tremors, but the tremors would occur throughout the day (option 1). Tolerance is not indicated because the client does not describe needing to have a larger drink in order to prevent symptoms (option 2). This client has clearly progressed from alcohol abuse to alcohol dependency (option 4). ‐ An anxiety disorder ‐ Tolerance ‐ Withdrawal ‐ Alcohol abuse | Think about people you know and consider to be normal drinkers. Have you ever seen them engage in an early morning drink of alcohol? If your answer is affirmative, then recognize that this person is probably not a normal drinker. |
4306 The emergency department client is admitted Correct answer: 4 At a blood level of 0.35%, the non‐physically dependent, nontolerant drinker would be following a blow to the head sustained in a motor confused, ataxic, and either semi‐comatose or comatose. Death is expected when the BAL vehicle accident. The blood alcohol level (BAL) is 0.35% reaches approximately 0.50%. The situation suggests that this client has been drinking regularly and the client is walking without stumbling and talking over a long period of time and is now experiencing tolerance to alcohol (needing an increasing rationally about the accident. What alcoholic amount of alcohol to bring about the desired effect). Tolerance can only develop once the phenomenon should the nurse recognize? person is physically dependent on alcohol (option 2). This client is not acutely intoxicated, even though the BAL exceeds the normal level for intoxication (0.08–0.10%). This client's body now accepts unusually high concentrations of alcohol (tolerance) and has adapted to the presence of the alcohol (physical dependence) (option 4). There is no evidence of withdrawal symptoms (option 1), such as anxiety, tremulousness, and marked elevations in vital signs. No information is given that would allow recognition of psychological dependence (option 3), which can come very early in the drinking history and precede physical dependence and tolerance. ‐ Alcohol withdrawal syndrome ‐ Intolerance ‐ Psychological dependence ‐ Alcohol dependency | Review statistics about blood alcohol levels (BAL) and effects on behavior. Take note of the client's absence of usual behaviors associated with a BAL of 0.35%. |
4307 A client with a long history of relapsing from cocaine Correct answer: 4 Cravings appear to be the result of pleasurable memories engendered from the psycho‐ dependence states that in spite of having a desire to activating effect of engaging in addictive behaviors. Substances of abuse alter the brain's be sober, thoughts of reusing cocaine continue to reward system by artificially boosting dopamine effects, which keeps the pleasure circuit firing. occur. The nurse decides to educate the client about In option 1, it is true that environment and role models influence use patterns but this is not the role the brain reward system (BRS) plays in part of the BRS phenomenon. In option 2, it is true that people employ addictive behaviors to addiction. The nurse considers that the teaching has self‐medicate stress and pressure experienced, but this is not part of the BRS phenomenon. been effective if the client says, "The BRS: Option 3 indicates that the BRS is a positive phenomenon that assists with drug abstinence. Instead, the BRS is a negative phenomenon that assists with maintaining or returning to the substance use pattern. ‐ Reinforces the value of having positive role models. ‐ Offers a means of mediating job stress and pressure." ‐ Reduces physiologic and psychological cravings." ‐ Facilitates cravings and triggers for reusing." | Think of the BRS as a hungry animal that is very difficult to satiate. |
4308 A client asks the nurse to provide information about Correct answer: 3 Medically supervised withdrawal from benzodiazepines generally involves gradual downward the detoxification process and withdrawal from a titration of doses of the drug commonly used (option 3). Rapid or abrupt discontinuation of a benzodiazepine. The nurse should inform the client benzodiazepine is physiologically dangerous and can lead to death (options 1 and 2) Option 4 is that the process will involve which of the following? incorrect because most antipsychotics lower the seizure threshold and are therefore not appropriate for clients in active benzodiazepine withdrawal because they would increase the risk of seizure activity. ‐ Rapid reduction in amount and frequency of the drug normally used. | Compare protocols for alcohol withdrawal and benzodiazepine withdrawal. Identify areas of commonality and reasons for same. |
‐ Abrupt discontinuation of the drug commonly used. ‐ Gradual downward reduction in dosage of the drug commonly used. ‐ Planned, progressive addition of an anti‐psychotic drug. | |
4309 When the nurse is caring for clients experiencing Correct answer: 4 Alcohol withdrawal delirium (delirium tremens, or DTs) is a physiologically dangerous process delirium tremens, what is the most important nursing with potentially fatal consequences. Various medical approaches are used to treat it, and the intervention? nurse's care must fit into the protocol of the particular agency. Priority is assigned to the client's physical needs during this major withdrawal phenomenon. Beginning education about the disease (option 1) and encouraging development of a relapse prevention plans (option 2) are not appropriate at this time because the client is in physiologic peril. These options can be appropriate after the withdrawal period has ended. Administering anticraving medications (option 3) is not the highest current priority, as the client is actively withdrawing from alcohol and can be at risk physiologically. ‐ Present psycho‐education on the dangers of drug and alcohol use. ‐ Encourage the client to develop a relapse prevention plan. ‐ Administer anti‐craving medications. ‐ Provide withdrawal care based on unit protocol. | Remember that alcohol withdrawal delirium is considered a medical emergency and can lead to death if not properly treated. |
4310 A client detoxifying from alcohol requires medications Correct answer: 4 The nurse should recognize possible signs of autonomic hyperactivity that is a part of alcohol to treat the withdrawal. The nurse observes coarse withdrawal delirium. If the vital signs (also a part of autonomic hyperactivity) are elevated, the hand tremors and diaphoresis. How should the nurse client will require a prn dose of the cross‐tolerant drug that is being used as part of the first react to this observation? The nurse should: withdrawal protocol. Because the client is in active withdrawal, this is not the time to teach the client (option 1). The priority is on maintaining physiologic functioning and environmental safety. Thiamine and folic acid may be ordered for the client who is withdrawing from alcohol, but they are used to treat complications of alcoholism, not to manage the acute symptoms of withdrawal (option 2). This can only be done with a drug that is cross‐tolerant with alcohol. Option 3 is inappropriate, as it would not provide current data. The nurse should be able to recognize and respond to the clinical signs of increasing intensity of withdrawal symptoms. ‐ Explain the concepts of withdrawal to the client. ‐ Administer ordered thiamine and folic acid. ‐ Determine the most recent blood alcohol level. ‐ Assess vital signs. | Review the concepts of physical dependency, autonomic hyperactivity, and cross‐ tolerance |
4311 A nurse is teaching a group of community health Correct answer: 3 Naltrexone (ReVia) is a narcotic antagonist that is useful for treating alcohol‐dependent colleagues about the use of naltrexone (ReVia) in persons with high levels of craving and somatic symptoms. It works by blocking opiate treating alcoholism. The nurse interprets that the receptors and reducing or eliminating the alcohol craving. Naltrexone does not prevent teaching was effective if the colleagues state that withdrawal symptoms (option 1). Since it is a narcotic antagonist, and narcotics and alcohol naltrexone (ReVia) is used to do which of the are both CNS depressants, it is possible that naltrexone (ReVia) could precipitate withdrawal following? symptoms in an individual who has had recent intake of alcohol. Naltrexone (ReVia) is not expected to prevent or reduce alcoholic blackouts (option 2) or to directly manage anxiety (option 4). ‐ Prevent withdrawal symptoms. ‐ Reduce number of blackouts. ‐ Reduce craving for alcohol. ‐ Manage heightened anxiety. | Review the concept of cross‐tolerance. Determine how it might relate to naltrexone being used to treat alcoholism. |
4312 Adolescent alcoholic clients often relapse into Correct answer: 2 The quality of an adolescent's recovery environment can be helpful or hurtful to someone drinking because they feel pressured by their peers. attempting to maintain sobriety. Friends or acquaintances may encourage a recovering person Which skill training should the nurse plan for these to use. The recovering adolescent may want to refuse, but may not know how. Behavioral clients in order to assist them in relapse prevention? rehearsal, saying "no thanks" to an offer to engage in addictive behavior, can increase a recovering person's confidence. Vocational skills (option 1) will not help the adolescent to refuse a drink. Problem‐solving skills (option 3) and communication skills (option 4) may be useful but not as helpful as skills directly related to refusing to drink. ‐ Critical thinking skills ‐ Drinking refusal skills ‐ Problem‐solving skills ‐ Communication skills | Consider the tremendous impact that peer pressure has on adolescents. |
4313 A client is admitted to a medical unit for treatment of Correct answer: 4 The definition of decisional conflict is uncertainty about a course of action to be taken when chest pain. A family member reports a client history of choice among competing actions involve risk, loss, or challenge to personal life values. In chemical abuse. The client is ambivalent about the option 1, dysfunctional family processes: alcoholism may apply, but it is more appropriate for recommendation for treatment made by an addiction the family than the individual. Ineffective management of therapeutic regimen (option 2) consulting team. An appropriate nursing diagnosis for implies that the client has already made a commitment to recovery. Since the client probably the client would be: abuses or is dependent on alcohol, risk for injury (option 3) may be present. However, what is shown in the stem of the question is behavior that indicates decisional conflict. ‐ Dysfunctional family processes: alcoholism. ‐ Ineffective therapeutic regimen management. ‐ Risk for injury. ‐ Decisional conflict. | Look carefully at the information that is given in the stem. Do not assume that risk for injury, which is often a correct response, is correct in this instance. |
4314 A nurse is teaching a group of clients about addiction. Correct answer: 1 The key symptom of addiction is impaired control, or the inability to control, or regulate, One client says he can stop drinking whenever he one's addictive behavior. In addition to loss of control, the addicted person is not able to view wants. The nurse concludes that this client does not the addictive behaviors realistically (option 4) and frequently uses the defense mechanisms of yet understand that addiction is a disease in which denial, rationalization, and projection. While persons with addiction do not change their individuals lose ability to: behavior because of negative consequences suffered (option 2), it is not that they do not recognize the consequences. Rather, they continue the addictive behavior in spite of consequences experienced. Acting sober when intoxicated (option 3) is an addictive behavior. ‐ Control addictive and impulsive behaviors. ‐ Recognize that addictive behavior is harmful to themselves and others. ‐ Act sober even if they are not. ‐ Think logically about their addictive behaviors. | You might find it easier to answer this question if you reword it for yourself and then look for the things that are true about addiction. |
4315 As part of assessment activities to determine if the Correct answer: 3 The G in the CAGE mnemonic represents <u>guilt</u>. Not gulping drinks, as in client is alcohol dependent, the nurse needs to Option 1, indicates the C: <u>cutting</u> down or reducing alcohol. Option 2 conduct a CAGE assessment with the client. Which represents the A, being <u>annoyed</u> at what others say about the drinking. question asked by the nurse would not be consistent Option 4 represents the E, having an early morning drink to open the <u>eyes</u> with the structure of CAGE? "Have you ever: and calm the nerves. ‐ Felt that you needed to cut down on your drinking?" ‐ Been annoyed by comments made about your drinking?" ‐ Found yourself gulping drinks before going out?" ‐ Had a morning 'eye‐opener' to calm your nerves?" | Notice the words is not consistent in the stem of this question. This tells you that the correct answer is an incorrect item in the options. Analyze each option and select the one that is not part of that set of questions. |
4316 After orienting the client to the addiction treatment Correct answer: 4 Option 2 presents reality to the client in a matter‐of‐fact, informative way and creates an unit, the nurse suggests that the client invite his 13‐ opportunity for the nurse to help the client see that the parent–child relationship has no doubt year‐old son to the family sessions. The client been impacted by the addiction. Option 1 uses a judgmental and demeaning term a drunk, questions why the son needs to participate, because although the information it is conveying is accurate. Option 3 offers approval or praise and he has not seen his father drunk. What is the best allows the client to feel like a protective and good parent, instead of a parent whose behavior response by the nurse? has impacted negatively on the son. Option 4 removes the personal focus that is necessary to help the addicted parent recognize the impact of the addiction on the son. ‐ "Your son probably knows that you are a drunk." ‐ "Your son has probably seen changes in you when you were drinking." ‐ "It's good that you have concern for your underage son." ‐ "Thirteen‐year‐olds are old enough to start learning about the effects of alcohol." | Choose the answer that is most accurate, informative, and respectful of the client. |
4317 The nurse conducts an inservice session about Correct answer: 2 The most significant risk factors that lead nurses to abuse drugs and become drug dependent impaired nursing practice. The nurse evaluates that the are: (1) exposure to substances, (2) knowledge about specific effects of certain drugs, and (3) teaching was effective when one of the nurses says belief that knowledge about drugs will allow them to use drugs and alcohol safely. Some that the most influential risk for impaired nursing nurses have grown up in a dysfunctional family (option 1), but this does not put them at more practice is which of the following? risk than those in the general public who have similar backgrounds. Most nurses know that healthcare providers and professionals are at a high risk for drug dependency, but they deny that this could happen to them, as they feel protected by their knowledge about drugs (options 2 and 3). Some nurses may have problems with codependence (option 4), but this does not put them at more risk than those in the general public who have similar problems. ‐ Having grown up in a dysfunctional family ‐ Feeling that their knowledge about drugs protects them from drug dependency ‐ Thinking that professionals are not at high risk for substance dependency ‐ Having a tendency to involve self in co‐dependent professional and personal relationship | Identify what is different about the environment and knowledge levels of nurses and non‐ nurses. This will help guide you to the correct option. |
4318 A male client comes to day treatment surrounded by Correct answer: 1 It would not be unusual for a client who has severe addiction to come to day treatment an intense odor of alcohol. The client staggers when intoxicated and deny it. Denial would cause a client to insist he or she is not intoxicated or walking but insists that that he has not consumed any doesn't have a problem with alcoholism despite concrete evidence of the problem. alcohol. The nurse concludes that this behavior Rationalization (option 2) is a frequently used defense mechanism of the alcoholic individual, constitutes which of the following? but if it were being used, the client would offer an explanation for the odor of alcohol (such as "I spilled a bottle of cologne as I was getting dressed." Transference is the unconscious process of displacing feelings for significant people in the past onto the nurse in the present relationship (option 3). Countertransference (option 4) is the nurse’s emotional reaction to clients based on feelings for significant people in the nurse's past. ‐ Denial ‐ Rationalization ‐ Transference ‐ Countertransference | Recall the common trio of defense mechanisms used by substance dependent individuals. Look for a behavioral example of one of them. |
4319 A female alcohol‐dependent client who has Correct answer: 4 Option 4 indicates one of the areas of the CAGE questionnaire that deals with expressed cardiomyopathy tells the nurse that she is certain that concern from others about client’s drinking. Options 1, 2, and 3 would support the client's her family and friends are against her. The client goes belief that others are against her or have no right to be concerned about her. Specifically, each on to say, "They stay on my back about my drinking option would support either the client's denial, projection, or rationalization. and say I could die from it." What would be the best response by the nurse? ‐ "Anyone saying this to you must have a problem with his or her own drinking." ‐ "Although their intentions are good, they have no right to judge another person’s drinking." ‐ "Do you think they may be jealous that you can drink more than they can?" ‐ "Perhaps they have noticed that your drinking creates consequences for you." | Look for areas of commonalty between options. Look for the one that is different. In this case, it is the most matter‐of‐fact and least opinionated statement. |
4320 A client who is recovering from alcoholism presents in Correct answer: 3 This client will likely be dually diagnosed with alcoholism and depression. The nurse should the psychiatric unit and tells the admitting nurse she is recognize that current standards of addiction practice call for the substance use disorder and very depressed and has a hard time staying sober. The the psychiatric disorder to be treated simultaneously. Options 1, 2, and 4 do not recognize that nurse concludes that the most likely treatment in instances of dual diagnosis; current standards of addiction practice call for the substance use approach for this client will be one that involves disorder and the psychiatric disorder to be treated simultaneously. treating the client's: ‐ Depression before the sobriety issue. ‐ Sobriety issue before the depression. ‐ Sobriety issue and depression at the same time. ‐ Depression after the sobriety issue has been resolved. | Notice that this client has two problems, one of which (alcoholism) is considered a long‐ term problem that can be managed but never fully recovered from. |
4321 As part of the clinical experience, a student nurse is Correct answer: 2 AA teaches that a client with alcoholism can never safely return to social drinking and that required to attend an Alcoholics Anonymous (AA) total abstinence is the only course in treating the addiction. When sobriety has been achieved, meeting and write a report about what was learned. people don't "graduate" (option 1); they stay and help others achieve sobriety. Acceptance and What information would the student include in the Higher Power (options 3 and 4) are active concepts in AA, but practicing these principles does report about the 12‐step program? not remove urges to drink and does not guarantee sobriety. ‐ Once an individual learns how to be sober, he or she can graduate from attending meetings. ‐ Once an individual has achieved sobriety, he or she continues to be at risk for relapse into drinking. ‐ Acceptance of being an alcoholic will prevent urges to drink, since it represents giving up one's denial. ‐ A "Higher Power" will protect individuals if they feel like using. | Recall that alcoholism is considered a chronic disease that is characterized by remissions and exacerbations. |
4322 The nurse working in the maternal care area is Correct answer: 3 Alcohol use during pregnancy causes dysmorphic prenatal and postnatal difficulties and reinforcing physician health teaching about the risks of central nervous system dysfunction. These problems range from subtle cognitive‐behavioral substance use during pregnancy. When questioned by impairments to fetal alcohol syndrome, both of which predispose the infant to later academic the client, the nurse should reply, "The drugs that are and behavioral problems, as well as mental illness. Since alcohol is so widely used, many most likely to lead to significant physical, cognitive, people do not recognize its dangers, as they either do not consider it a drug or think that it is a and developmental problems for any infant would be: safe drug. Options 1, 2, and 4 indicate substances that can cause significant health problems for the infant, but these problems are not as pervasive as those associated with the mother's using alcohol during pregnancy. ‐ Benzodiazepines." ‐ Hallucinogens." ‐ Alcohol." ‐ Cocaine." | Think about the nature of the drugs listed and their potential effects to make a selection. Do not be misled by the fact that alcohol is a drug that can be obtained legally without a prescription |
4323 Having requested it as part of a comprehensive Correct answer: 1 The adverse reaction of disulfiram (Antabuse) will occur if the person taking this drug ingests, treatment program, the client is to receive disulfiram inhales, or absorbs alcohol, even in very small doses (such as inhaling vapors from paints or (Antabuse). Which statement should the nurse include woodstains, or oral ingestion in products such as mouthwash). These reactions include when teaching the client about this drug? throbbing headache, tachycardia, diaphoresis, and respiratory distress. Death can occur. This drug is not used often, but the nurse should know about its uses and dangers. While eating improperly cooked seafood (option 2) might lead to gastric distress and/or liver problems, uncooked seafood does not precipitate a disulfiram reaction. Disulfiram does not reduce the craving for alcohol (option 3), but opioid antagonists, such as naltrexone (ReVia) do. Disulfiram works on the classical principle of conditioned avoidance. If the individual drinks alcohol while taking disulfiram, intensely unpleasant and dangerous physical reactions can occur. The effect of disulfiram (Antabuse) when combined with alcohol is not intoxication (option 4). Instead, the individual experiences intensely unpleasant and dangerous physical reactions. ‐ "Inhaling fumes from paints and wood stains may cause a disulfiram reaction." ‐ "Eating inadequately cooked seafood may lead to disulfiram (Antabuse) resistance." | Recall the principles of operant conditioning and integrate that with your knowledge of the expected drug effect. |
‐ "Taking disulfiram will reduce your physical craving for alcohol." ‐ "If you consume alcohol while taking disulfiram, rapid intoxication will occur." | |
4324 A nurse has been told that a client's anxiety is at the Correct answer: 1 Subjective complaints of panic level of anxiety include choking or smothering sensation, panic level. The nurse would assess the client for which dizziness, chest pain or pressure, and fear of loss of control and death. Feelings of stomach of the following? "butterflies" are seen in the fight‐or‐flight response. Feelings of fatigue and inability to remain awake may be seen in the exhaustion stage of the general adaptation syndrome. Obsessive thoughts and compulsive behaviors are common in obsessive‐compulsive disorder. ‐ Dizziness, palpitations, and nausea ‐ Feelings of "butterflies" in the stomach ‐ Feelings of fatigue and inability to remain awake ‐ Obsessive thoughts and compulsive behavior | The core issue of the question is an ability to identify signs of panic in a client with anxiety. Use nursing knowledge and the process of elimination to make a selection. |
4325 The nurse concludes that a client has agoraphobia Correct answer: 3 Agoraphobia involves fear of being away from home and being alone in public places. Specific after the client states a fear of which of the following? phobia involves unrealistic fear of a particular object or situation. Social phobia is excessive fear of embarrassment and humiliation in public settings. Fear of loss of control is common in most phobias. ‐ Spiders ‐ Being embarrassed in public ‐ Leaving the home ‐ Losing control | The core issue of the question is an ability to identify signs of agoraphobia in a client. Use nursing knowledge and the process of elimination to make a selection. |
4326 A nurse asks a client, "Have you ever felt a sudden, Correct answer: 3 The onset of a panic attack is sudden, and the client may not be aware of the source of the intense fear for no apparent reason?" When the client anxiety. Agoraphobia is fear of being incapacitated by being trapped in an unbearable situation responds affirmatively, the nurse would assess the from which there is no escape. Obsessive‐compulsive disorder is characterized by obsessive client for other symptoms compatible with which of thoughts and compulsive behaviors. Posttraumatic stress disorder is associated with exposure the following? to an extremely traumatic, menacing event. ‐ Agoraphobia ‐ Obsessive‐compulsive disorder ‐ Panic disorder ‐ Posttraumatic stress disorder | The core issue of the question is an ability to identify signs of panic disorder. Use nursing knowledge and the process of elimination to make a selection. |
4327 A client has just been told that another operation Correct answer: 2 Because coping resources are depleted, the client can no longer deal with stressors. Stage of needs to be performed to correct a physical health alarm is characterized by the fight‐or‐flight response, and increased alertness is focused on the problem. The client begins to cry and says, "I just can't immediate task or threat. Stage of resistance occurs when the body mobilizes resources to take it anymore. Everything has gone wrong. I can't combat stress. even think straight anymore." The nurse interprets that the client is in which stage of anxiety? ‐ Alarm ‐ Exhaustion ‐ Fight‐or‐flight ‐ Resistance | The core issue of the question is an ability to differentiate stages of anxiety based on client presentation. Use nursing knowledge and the process of elimination to make a selection. |
4328 A nurse working with an extremely anxious client Correct answer: 1 Anxiety in a client may be empathetically experienced by the nurse. It is imperative that the reports feeling short of breath, tense, restless, nurse recognize these symptoms. There is not enough data to support the client being angry. apprehensive, and nervous. The nurse would most Even a nurse with high self‐esteem is receptive to experiencing anxiety empathetically. appropriately draw which conclusion? ‐ The client's anxious feelings have been transmitted to the nurse. | The core issue of the question is the ability to determine the effect that an anxious client can have on the nurse. Use nursing knowledge and the process of elimination to make a selection. |
‐ The client is probably becoming angry. ‐ The client should be reassigned to a different nurse. ‐ The nurse probably has a self‐esteem disorder. | |
4329 A client is going to begin electroconvulsive therapy Correct answer: 1 The client always needs to be treated with dignity and respect. There is no reason to bring the (ECT). The nurse knows that ECT is usually prescribed client to the treatment suite on a stretcher (option 2), nor does the client usually need to have for individuals who have major depression. The nurse a procedure explained many times by the physician or the nurse (option 3). The client with prepares a teaching plan keeping in mind that clients major depression can receive ECT (option 4) if medication therapy is not effective. with major depression: ‐ Need to be treated with respect and dignity. ‐ Need to be brought to the treatment suite on a stretcher. ‐ Should have the procedure explained to them many times because they cannot understand or retain the information. ‐ Should not receive ECT. | The core issue of the question is the right of every client to be treated in a respectful manner. Use nursing knowledge and the process of elimination to make a selection. |
4330 The visiting nurse is at the home of a 52‐year‐old Correct answer: 2 The only possible correct answer is option 2. Hypomania is a mood of elation (option 1), while postoperative client. During his presurgical physical cyclothymia (option 3) is a disorder of at least 2 years’ duration with episodes of hypomania, assessment, the client was diagnosed with type 2 and dysthymia (option 4) is a depressive disorder of at least 2 years’ duration. diabetes mellitus. At that time, he also related that he was not sleeping well and had a decreased appetite. He reported that he lost his job of 34 years 3 weeks before the preoperative physical exam and was very angry. The nurse then asks the client additional questions to elicit data about possible: ‐ Hypomania. ‐ Unipolar depression. ‐ Cyclothymia. ‐ Dysthymia. | The core issue of the question is an ability to identify clients at risk for various forms of depression. Use nursing knowledge and the process of elimination to make a selection. |
4331 Which would be the safest living environment for a Correct answer: 4 The client would be safest in a closed‐door seclusion room (option 4) or in a locked unit (not client who inflicted harm on a family member earlier in an option here). The client would not have the continuous monitored care if he were in a the day? respite home (option 1). He would have less safety or care in the home of a relative in another state (option 2). In an open‐door seclusion room (option 3), the client could leave the area and harm others if there were distractions to the staff on the unit. ‐ In a local respite home ‐ With a family member in another state ‐ In an open‐door seclusion room ‐ In a closed‐door seclusion room | The core issue of the question is placement of a client who has harmed another. Use nursing knowledge and the process of elimination to make a selection. Keep in mind that the safety of the client and others around him or her is the first priority. |
4332 Part of a discharge plan for a client on a psychiatric Correct answer: 3 Options 1, 2, and 4 may be correct intervention terms, but option 3 is the most correct inpatient unit includes walking for half an hour 3 days terminology for the nursing intervention described to prevent increased anxiety and stress. per week to maintain cardiovascular health and decrease stress levels. The nurse includes this in the care plan as what type of nursing intervention? ‐ Active ‐ Performance ‐ Preventive ‐ Physical | The core issue of the question is the ability to determine various types of nursing interventions needed by a hospitalized client with a mental health problem. Use nursing knowledge and the process of elimination to make a selection. |
4333 A client has a diagnosis of bipolar disorder. The nurse Correct answer: 4 The client who demonstrates a calm, focused exchange of information and self‐care is evaluating the client in a home environment after information would demonstrate control of the disorder, which is expected following discharge discharge from an inpatient unit 2 weeks ago. The from an inpatient setting. The client in a manic state would present with the option 1 or 2 nurse assesses the client for which of the following behaviors, while the client with depression would present as option 3 indicates. expected behaviors? ‐ Euphoric and talkative presentation with nurse ‐ Gregarious interactions with significant others ‐ Quiet and evasive presentation ‐ Calm, focused exchange of self‐care information with nurse | The core issue of the question is appropriate behavior exhibited by a client with bipolar disorder after treatment. Use nursing knowledge and the process of elimination to make a selection. |
4334 A 21‐year‐old male college student has become Correct answer: 2 Voicing doubt about the delusions is the most therapeutic intervention. The client will increasingly suspicious of his professor and fellow continue to voice a delusion even though the evidence would suggest otherwise (option 1). A classmates. He has accused the professor of conspiring paranoid client cannot use logic to dispel delusions (option 3). Option 4 challenges the client's with two other classmates to get him expelled from belief instead of voicing doubt. Providing evidence will not usually sway a paranoid client. school. The client is admitted to a psychiatric unit after telephoning and threatening to kill the professor and his classmates. The client tells the nurse, "They are all out to get me expelled. I think they are even trying to kill me. I have to stop them." What would be the most appropriate response by the nurse? ‐ "What makes you think they are out to get you expelled or to kill you?" ‐ "I find it hard to believe that your professor and classmates are out to get you expelled or to kill you." ‐ "It's not right to kill others even if they are out to get you expelled or want to kill you." ‐ "Your professor and classmates are not out to get you expelled or to kill you. Let's look at the facts." | The core issue of the question is appropriate therapeutic communication techniques to use with a client who is paranoid. Use nursing knowledge and the process of elimination to make a selection. |
4335 A client with schizophrenia is exhibiting delusions, Correct answer: 1 Minimal self‐care is a behavioral negative symptom of schizophrenia. A delusion is a cognitive hallucinations, minimal self‐care, and hyperactive positive symptom (option 2); hallucination is a perceptual positive symptom (option 3); and behavior. Which of the following would the nurse inappropriate affect (option 4) is an affective positive symptom. document as a negative symptom of schizophrenia? ‐ Minimal self‐care ‐ Delusions ‐ Hallucinations ‐ Inappropriate affect | The core issue of the question is an ability to discriminate between positive and negative signs of schizophrenia. Use nursing knowledge and the process of elimination to make a selection. |
4336 A client hears voices telling him that he is a terrible Correct answer: 2 Client safety is a priority. Hearing voices (hallucination) is a sensory‐perceptual alteration, but person who would be better off dead. Which of the safety is a priority (option 3). There is not enough data to support the nursing diagnoses of following would be a priority nursing diagnosis? impaired verbal communication (option 1) or impaired social interaction (option 4). ‐ Impaired verbal communication ‐ Risk for violence, self‐directed ‐ Impaired sensory‐perception ‐ Impaired social interaction | The core issue of the question is an ability to set priorities for a client who experiences auditory hallucinations. Look for the option that puts client safety first. Use nursing knowledge and the process of elimination to make a selection. |
4337 A client living in an assisted living facility is taking Correct answer: 3 Neuroleptic malignant syndrome (NMS) is a potentially fatal extrapyramidal symptom. conventional antipsychotic medications. One evening Symptoms of NMS develop suddenly and include muscle rigidity, respiratory problems, and the nurse notices that the client is experiencing muscle hyperpyrexia. Dystonia (option 1) and akathisia (option 2) are both extrapyramidal symptoms rigidity, confusion, delirium, and has a temperature of that are usually not fatal (option 1). Tardive dyskinesia symptoms include frowning, blinking, 104° F. The nurse interprets these as symptoms of: grimacing, puckering, blowing, smacking, licking, chewing, tongue protrusion, and spastic facial distortions, which can be socially disfiguring (option 4). | The core issue of the question is an ability to identify signs of adverse medication effects in a client being treated for psychosis. Use nursing knowledge and the process of elimination to make a selection. |
‐ Dystonia. ‐ Akathisia. ‐ Neuroleptic malignant syndrome. ‐ Tardive dyskinesia. | |
4338 A client states that he is able to receive radio waves Correct answer: 4 A delusion is a false belief that cannot be changed by logical reasoning or evidence. A from aliens because they placed a computer chip in his hallucination is the occurrence of a sight, sound, touch, smell, or taste without any external brain. The nurse would document this behavior as stimulus to the corresponding sensory organ; it is real to the client (option 1). The client is not which of the following in the medical record? exhibiting reality orientation (option 2). An illusion is a sensory misperception of environmental stimuli (option 3). ‐ A hallucination ‐ Reality‐oriented ‐ An illusion ‐ A delusion | The core issue of the question is an ability to correctly identify the types of thought patterns expressed in a client's communications. Use nursing knowledge and the process of elimination to make a selection. |
4339 The most appropriate outcome of care for a male Correct answer: 2 The client who gains coping skills reduces anxiety to a level at which dissociation is unlikely to client who has experienced a dissociative fugue is that occur. The client does not remember what occurred during the fugue state, nor does he the client will do which of the following? experience depersonalization. ‐ Remember what occurred during his fugue state ‐ Gain additional coping skills to deal with his current problems ‐ Report no feelings of being detached from his body ‐ State three positive aspects about himself | The core issue of the question is an appropriate outcome of care for a client who was in a dissociative fugue state. Use nursing knowledge and the process of elimination to make a selection, recalling that anxiety is usually the cause of the state, and therefore the answer points to an item that reduces anxiety. |
4340 A client with dissociate identity disorder (DID) who Correct answer: 3 Self‐mutilation, not uncommon with DID clients, is identified in the assessment. The client has just been admitted with several fresh burns on her remains at risk for injuring herself, producing tissue damage that provides tension relief. There ankles and wrists is refusing to attend group therapy. is no intent to kill; however, the client will need to learn less damaging ways to obtain relief. What is the priority nursing diagnosis? ‐ Self‐care deficit ‐ Impaired sensory perception ‐ Risk for self‐mutilation ‐ Noncompliance | The core issue of the question is a priority nursing diagnosis. Questions such as these are frequently focused on safety. Use nursing knowledge and the process of elimination to make a selection. |
4341 A client reports depersonalization experiences that Correct answer: 1 This response demonstrates empathy and encourages the client to elaborate further about have been frightening to him. Which of the following is his experience. Options 2 and 3 dismiss the affective component or miss the point of the the most therapeutic response by the nurse? client's statement. Option 4 is helpful in making connections between events but is not the best response to the client’s original comment. ‐ "It must be very scary for you. Tell me more about how they occur." ‐ "Don't worry, you will always come back together." ‐ "Being in the hospital must be very frightening." ‐ "Let's focus on the stresses in your life." | The core issue of the question is a therapeutic response to a client who is experiencing depersonalizing events. Use nursing knowledge of therapeutic communication skills and use the process of elimination to make a selection. |
4342 Which of the following behaviors would indicate that Correct answer: 3 The goal of care is to eliminate or reduce dissociative experiences, which can be care for a client who dissociates has been effective? accomplished in part by anxiety‐produced stress management techniques. ‐ Client reports dissociative episodes to the nurse ‐ Client seeks out social relationships ‐ Client demonstrates three stress management techniques ‐ Client is free from injury | The core issue of the question is the ability to determine an appropriate outcome of care for a client who dissociates. Recall that anxiety plays a role in dissociation and choose the option that reduces anxiety. |
4343 A client with amnesia is hospitalized. What might the Correct answer: 4 Amnesia is precipitated by stress related to trauma or conflict. The amnesia occurs abruptly nurse expect to find during the initial assessment? and there is no attempt to cover the memory loss. Confabulation, gradual loss of memory, and disheveled appearance are common in clients experiencing dementia. ‐ Confabulation of historical information ‐ Gradual loss of memory over months ‐ Disheveled appearance ‐ History of severe stress | The core issue of the question is knowledge of expected assessment findings in a client with amnesia. Use nursing knowledge and the process of elimination to make a selection. |
4344 The nurse would look for which of the following Correct answer: 3 A client with OCD, a Cluster C disorder, appears anxious or fearful. Individuals with a Cluster A characteristics in the behavior of a client diagnosed disorder appear odd or eccentric; those with a Cluster B disorder appear dramatic or erratic. with obsessive‐compulsive disorder (OCD)? The category of rigid/critical does not reflect a diagnostic cluster. ‐ Dramatic/erratic ‐ Odd/eccentric ‐ Anxious/fearful ‐ Rigid/critical | The core issue of the question is knowledge of expected behaviors that would be exhibited by a client with OCD. Recall that a client with this type of diagnosis is very ritualistic and therefore rigid. Use nursing knowledge and the process of elimination to make a selection. |
4345 The nurse places highest priority on which of the Correct answer: 3 In caring for clients diagnosed with antisocial personality disorder, it is important to maintain following nursing interventions when caring for a client a structured and consistent environment to decrease their attempts to control the situation diagnosed with antisocial personality disorder? through manipulation. It is unlikely that they will develop insight as the causes of problems in living are externalized. They are frequently quite sociable and take advantage of others for personal profit. Suicidal ideation is not associated with this disorder. ‐ Supporting the development of insight ‐ Encouraging socialization ‐ Maintaining consistent limits ‐ Monitoring for suicidal ideation | The core issue of the question is an ability to set priorities for a client who has an antisocial personality disorder. Use nursing knowledge and the process of elimination to make a selection. |
4346 The nurse looks for which of the following Correct answer: 2 Individuals diagnosed with personality disorders display either functional impairment or characteristics in a client diagnosed with a personality subjective distress. Frequently these problems in living are reflected in impaired interpersonal disorder? relationships. Flexibility and adaptability to stress (option 1) are incongruent with a diagnosis of a personality disorder. The presence of a physical disorder (option 3) has no relation to the diagnosis of a personality disorder. These individuals may or may not desire interpersonal relationships (option 4). ‐ Flexibility and adaptability to stress ‐ A tendency to evoke some form of interpersonal conflict ‐ A concomitant physical disorder ‐ A desire for interpersonal relationships | The core issue of the question is knowledge of expected assessment findings regarding behavior style in a client with a personality disorder. Note that the type of disorder is not specified, so the answer is a global or general pattern. Use nursing knowledge and the process of elimination to make a selection. |
4347 Which of the following beliefs by the nurse as a Correct answer: 1 Individuals diagnosed with antisocial personality disorder frequently try to play one staff member of the interdisciplinary team is most member against the other in order to control their environment. It is imperative that staff important to remember when developing a care plan present a unified, consistent, and structured approach to care to prevent this. Options 2, 3, for a client diagnosed with antisocial personality and 4 are incorrect because they would result in lack of team unity and an unstructured disorder? approach to care. ‐ Everyone involved in the client's care must agree with the diagnosis, goals, and plan. ‐ The team leader must determine the diagnosis and treatment plan to insure accuracy. ‐ The involvement of all team members in developing a nursing care plan is not necessary. ‐ An unstructured treatment approach is usually beneficial. | The core issue of the question is core beliefs about the value and roles of the interdisciplinary team. Use nursing knowledge and the process of elimination to make a selection. |
4348 The nurse is assessing a client with obsessive‐ Correct answer: 1 Individuals diagnosed with obsessive‐compulsive personality disorder become overly involved compulsive personality disorder. Most of the client's in details such as rules and regulations related to a need to be perfect. As a result, they fail to cognitive content will be centered around which of the see the big picture. Their relationships with others and participation in leisure activities are following? less important to them than is their devotion to work and productivity. ‐ The importance of rules and regulations ‐ Global approaches to problem solving ‐ Relationships with others ‐ Preferred leisure activities | The core issue of the question is knowledge of expected behavior styles in a client with OCD. Use nursing knowledge and the process of elimination to make a selection. |
4349 A client continues to have pain despite negative Correct answer: 1 The continuance of pain is related to reinforcement of the symptoms, such as the caring neurological findings. The nurse concludes that such responses of others, which give the client benefits that otherwise might not occur. There is no pain is likely to continue because of which of the organic basis for the pain. High endorphin levels are associated with feelings of euphoria. following? ‐ Secondary gain ‐ High endorphin levels ‐ Structural changes of tissue ‐ Derealization | The core issue of the question is knowledge of possible explanations of causation of pain in a client with no physical basis for pain. Use nursing knowledge and the process of elimination to make a selection. |
4350 A client with a conversion disorder has been eagerly Correct answer: 4 The client with a conversion disorder is characteristically indifferent to the symptoms (la belle preparing for his marriage. On the morning of the indifference) rather than being depressed, anxious, or blunted in affect. wedding, he is unable to move his legs. What would the nurse expect to find in the mental status examination? ‐ Mood: depressed ‐ Mood: anxious ‐ Mood: blunted ‐ Mood: la belle indifference | The core issue of the question is knowledge of expected assessment findings related to mood in a client with a conversion disorder. Use nursing knowledge and the process of elimination to make a selection. |
4351 A female client with hypochondriasis discloses that Correct answer: 3 Exploration of the client's decision is nonjudgmental and affirms the client's personal power. she may decide to leave the psychiatric facility without This reponse also helps the client understand connections in her own decision‐making process. completing her course of treatment and seek exploratory surgery. The nurse's best response is which of the following? ‐ "If you decide to leave now, you will be committed against your will." ‐ "You should not go until your doctor releases you. She knows what you need." ‐ "Tell me more about your decision." ‐ "Your surgery will just prove useless. Please stay." | The core issue of the question is a therapeutic communication to a client with hypochondriasis. Use nursing knowledge of therapeutic communication skills and the process of elimination to make a selection. |
4352 A client who has had many different physical illnesses Correct answer: 3 Data indicates that the client perceives a lack of control over her situation. There is in the past few years is no longer employed, rarely insufficient data to select any of the other nursing diagnoses. does housework or shopping, and states that she "just can’t seem to do anything." Which of the following is a priority nursing diagnosis? ‐ Impaired home maintenance management ‐ Fatigue ‐ Powerlessness ‐ Body image disturbance | The core issue of the question is the ability to form an appropriate nursing diagnosis based on client assessment data. Use nursing knowledge and the process of elimination to make a selection. |
4353 The nurse evaluates that the plan of care for a client Correct answer: 1 When stressors and anxiety are decreased, there remains no need for conversion symptoms, who suddenly lost her hearing (diagnosed as a and normal function resumes. conversion disorder) was effective if the client: ‐ Resumed normal hearing. ‐ Began learning sign language. ‐ Was fitted for a hearing aid. ‐ Agreed to have a stapedectomy. | The core issue of the question is knowledge of appropriate outcomes of care for a client with a conversion disorder. Use nursing knowledge and the process of elimination to make a selection. |
4354 Which of the following approaches would be best for Correct answer: 2 Verbal communication should be clear, concise, and unhurried. Shouting may be interpreted the nurse who is communicating with the cognitively as anger; therefore, a pleasant, calm, supportive tone of voice should be used. The use of sign impaired client? language or mostly nonverbal gestures would be frustrating to the client who may not understand what is being said. ‐ Loud and precise ‐ Simple and direct ‐ As nonverbal as possible ‐ Sign language | The core issue of the question is a therapeutic communication to a client with a cognitive impairment. Use nursing knowledge of therapeutic communication skills and the process of elimination to make a selection. |
4355 Which of the following evaluation criteria should the Correct answer: 4 The most important area of concern identified by both family and staff is the safety of clients nurse give first priority to when planning the care of a with dementia. The risk for injury is always present in clients with dementia, and as the disease client with dementia? progresses, the need for a safe and secure environment increases. The other options are appropriate for dementia but are not the first priority. ‐ Preventing further deterioration ‐ Finding suitable nursing home placement ‐ Supporting family caregivers ‐ Preventing injury | The core issue of the question is the ability to determine the appropriate priority of care for a client who has dementia. Focus on safety as an early priority whenever a client has a neurological impairment. Use nursing knowledge and the process of elimination to make a selection. |
4356 A client with suspected Alzheimer's disease is Correct answer: 4 Alzheimer's disease is diagnosed by ruling out causes for the client's symptoms. The only undergoing diagnostic workup. When the family asks definitive method of diagnosis is postmortem examination of brain tissue. the nurse the reasons for the "tests," the nurse responds that the diagnosis of Alzheimer's disease is usually based on which of the following? ‐ Abnormal laboratory findings ‐ A definitive CT scan ‐ Physiological findings ‐ Ruling out other causes for symptoms | The core issue of the question is methods of diagnosis for Alzheimer's disease. Use nursing knowledge and the process of elimination to make a selection. |
4357 The nurse writing a care plan for a client with Correct answer: 2 Dementia is a progressive disease that causes the individual to lose the ability to perform dementia would include that the overall goal for tasks that were once familiar and routine. Self‐care deficits involving many functional abilities nursing care is which of the following? occur to varying degrees. The most effective and respectful goals are those that allow the client to carry out as much self‐care as possible. Option 2 is the most global goal that encompasses meeting needs for food, water, dressing, bathing, and so on. ‐ Reorient the client to reality. ‐ Keep the loss of capacity for self‐care to a minimum. ‐ Assist the client with tasks of daily living. ‐ Maintain adequate hydration and nutrition. | The core issue of the question is the ability to set goals of care for a client with Alzheimer’s disease. Use nursing knowledge and the process of elimination to make a selection. |
4358 Which of the following nursing interventions would Correct answer: 1 Cognitive function will be supported by participation in meaningful activities that the client support optimal memory function for a client with enjoys. Stimulating activities will also promote self‐esteem and encourage the client to attain dementia? the highest level of cognitive function possible. Options 2, 3, and 4 could lead to frustration and more confusion. ‐ Develop stimulating and meaningful therapeutic activities. ‐ Remind the client of forgotten events. ‐ Orient the client to reality. ‐ Restrain the client when agitated. | The core issue of the question is planning for a client with dementia that supports remaining memory function. Use nursing knowledge and the process of elimination to make a selection. |
4359 The nurse would conclude that a client with Correct answer: 2, 3 Positive symptoms of schizophrenia are those behaviors that a client would not usually schizophrenia is exhibiting positive symptoms of the exhibit in everyday life, including delusion of being a king (option 2) or echolalia (option 3). disorder after noting that the client does which of the Negative symptoms of schizophrenia are those that reflect the absence of what is normally following? Select all that apply. seen in a person's behavior. These would include anergy (option 1), flat affect (option 4), and social withdrawal (option 5). ‐ Exhibits lack of energy ‐ States he is a king ‐ Repeats words the nurse says ‐ Has a flat affect ‐ Withdraws from other people | The core issue of the question is the ability to discriminate between positive and negative symptoms of schizophrenia. Use nursing knowledge of these manifestations and the process of elimination to make a selection. |
4360 The nurse is establishing outcomes for a client who is Correct answer: 2 Option 2 is correct. This option is measurable, and the others are not. Statements of client depressed. The outcomes will be entered into the outcomes should be written in specific measurable terms so that any nurse could determine nursing care plan and used by all members of the outcome achievement or lack of achievement. This option indicates that a specific numerical treatment team. The best stated outcome is the client comparison can be made. Options 1, 3, and 4 are incorrect. Each of them indicates the nurse's will: intention to bring about a change in the client's status, but not one of them is measurable. How does one measure "more" or "increase" without a standard of comparison? ‐ Feel less depressed. ‐ Decrease score on depression scale by one half. ‐ Develop more insight into his problems. ‐ Increase amount of time spent with other clients. | Recall basic elements of a well‐written outcome statement, including its measurability. |
4361 The client is a 5‐year‐old whose pet cat has died Correct answer: 4 Option 4 is correct. At age 5, children do not understand the finality of death, but rather within the past two days. Which of the following consider it a temporary state. Options 1 and 2 are incorrect as these responses would be those statements about this is the nurse most likely to hear? of older children. Option 3 is incorrect because 5‐year‐olds do not understand the irrevocability of death. ‐ "I don't want to die. My cat did." ‐ "The boogie man took my cat away." ‐ "I won't ever see my cat again. She's dead." ‐ "She'll be back tomorrow. She's dead today." | Recall basic facts about children's concepts of death at different ages. |
4362 A parent of a 14‐year‐old client has asked the nurse Correct answer: 3 Option 3 is correct. Erickson's theory places emphasis on peers and the culture and to explain the client's current difficulty mastering usual environment. Emphasis is given to attempts of the adolescent to incorporate beliefs and values psychosocial tasks. If the nurse bases a response on of the culture. Option 1 is incorrect as adolescents struggle and strive to become independent the theories of Erickson, the nurse should say, of the family. Option 2 is incorrect because Erickson's theory places emphasis on peers and the "Erickson believed that: culture and environment, with the family being a sociocultural unit in the environment. Option 4 is incorrect as the adolescent is in Erickson's stage of identity versus role confusion. ‐ Adolescents are overwhelmed at the prospect of becoming independent of the family." ‐ The family is the most important influence on the adolescent's development." ‐ Modern culture makes identity crisis the most challenging developmental task to resolve." ‐ Mastery of doubts preoccupies the adolescent and leads to resistant behavior within the family." | Notice the age of the client and relate that to Erickson's theory. |
4363 When the nurse informs an adolescent client that a Correct answer: 2 Option 2 is correct. Displacement is the transfer of emotional reactions from one object or scheduled parental visit will not occur, the client person to another object or person. Like other defense mechanisms of the ego, displacement throws a cup at the nurse. In order to best respond to is an unconsciously determined behavior that attempts to reduce anxiety. Reaction formation this behavior, the nurse should conclude that the client is a mechanism that causes a person to act exactly opposite to the way they feel. Projection is is displaying which of the following? a process in which blame is attached to others or the environment. Denial is an attempt to screen or ignore unacceptable realities by refusing to acknowledge them ‐ Reaction formation ‐ Displacement ‐ Projection ‐ Denial | Recall definitions of defense mechanisms of the ego and reasons why they are employed. |
4364 A 7‐year‐old recently admitted to a hospital states, Correct answer: 3 Option 3 is correct. It is average and expected for a 7‐year‐old to be anxious and fearful when "I’m not afraid of this place; I'm not afraid of admitted to a hospital. One of the ways that the client can reduce the anxiety is to use anything." Which defense mechanism of the ego does unconsciously motivated defense mechanisms of the ego. Reaction formation is a mechanism the nurse recognize? that causes a person to act exactly opposite to the way they feel. Regression is resorting to an earlier, more comfortable level of function. Repression is the unconscious mechanism by which threatening thoughts, feelings, and desires are kept from becoming conscious. Rationalization is the justification of certain behaviors by faulty logic and ascription of motives that are socially acceptable. ‐ Regression ‐ Repression ‐ Reaction formation ‐ Rationalization | Recall definitions of defense mechanisms of the ego and reasons why they are employed. |
4365 The client is a child with attention‐deficit Correct answer: 3 Option 3 is correct. A client who is receiving Ritalin is at risk for delayed growth and hyperactivity disorder (ADHD) who is receiving development. This is one of the most adverse effects that may occur if Ritalin (or most other methylphenidate (Ritalin). The nurse teaches the stimulants) is administered to children over a long period of time. The child should be weighed parents to carefully monitor which of the following in 2–3 times per week and weight loss should be reported promptly to the doctor or other the child? prescribing health care team member. Dental care, although important for child health, is nonspecific to therapy. Drying of membranes is a bothersome, but manageable side effect. Like other children, children taking Ritalin have specific physiologic needs for milk. However, there is no reason to decrease or increase milk intake in client's taking Ritalin. Instead, intake of caffeine should be restricted. ‐ Dental health ‐ Oral mucous membranes ‐ Height and weight ‐ Milk consumption | Review important side effects of stimulants. Consider which of these are most relevant when the client is a child. |
4366 Because of academic failure, a 10‐year‐old is to Correct answer: 3 Option 3 is correct. According to Erikson's stages of development, a 10‐year‐old is repeat a grade in school. When counseling the parents experiencing industry versus inferiority. Shame (option 1), guilt (option 2), and role confusion of this child, the school nurse who ascribes to (option 4) occur at other developmental levels. Erickson's theories will advise the parents to be alert for indications of which of the following? ‐ Shame ‐ Guilt ‐ Inferiority ‐ Role confusion | Review Erickson's developmental tasks by age group and apply the concepts to the age of this child. |
4367 A 14‐year‐old client is to be admitted to a psychiatric Correct answer: 4 Option 4 is correct. Children and adolescents with bipolar disorders are often misdiagnosed in‐patient unit for treatment of bipolar disorder. When as having conduct disorder or ADHD, which are part of the spectrum disorders of childhood. assisting staff to understand behaviors that are likely The adolescent client with bipolar disorder is likely to experience multiple and extreme mood to be seen in this client, what should the nurse swings in the course of a day. The adolescent client with bipolar disorder does have inflated emphasize? self esteem, but this is not as evident as it in the adult with Bipolar disorder. Instead, the adolescent client is much more likely to be irritable and socially aggressive and to experience multiple mood swings in the course of the day. The adolescent client with bipolar disorder does tend to manage money poorly, but this is not as evident as in the adult with Bipolar disorder. Instead, the adolescent client is much more likely to be irritable and socially aggressive and to experience multiple mood swings in the course of the day. ‐ Prolonged periods of extreme mood ‐ Inflated self‐esteem ‐ Poor management of spending money ‐ Inattention and distractibility | Recognize the similarities and differences between behaviors associated with the various spectrum disorders of children and adolescents. Compare these to the clinical presentations of mania in adults. |
4368 While conducting a mental status examination with Correct answer: 2 Option 2 is correct. This child is demonstrating inability to think abstractly. Rather than being an 8‐year‐old girl, the nurse asks the client to explain alarmed by this, the nurse should recognize it as normal growth and development. Eight‐year‐ the meaning of the expression "Don't cry over spilled olds cannot be expected to think abstractly. In Piaget's theory, abstract thinking develops milk." The child looks puzzled and shrugs her during the formal operational phase (12 years to adult). Children between 7–12 are in Piaget's shoulders. The nurse using Piaget's theory will view the concrete operational phase and cannot think abstractly, although they can pretend. Option 1 is child's response as suggestive of which of the incorrect because while Piaget’s theory does focus on cognitive styles, and this option contains following? the term "cognition," Piaget's theory does not address impaired cognition. Impaired cognition is abnormal. Piaget's theory deals with normal growth and development. Option 3 is incorrect as this client is not able to think abstractly. In Piaget's theory, ability to reason abstractly is a function of formal operational thinking that begins at approximately 12 years of age and extends into adulthood. Option 4 is incorrect because Piaget's theory does not use the term "illogical thought processes." To describe any period of normal growth and development. ‐ Impaired cognition ‐ Concrete operational thinking ‐ Formal operational thinking ‐ Immature thought processes | Notice the age of the child. Apply that to the basic concepts of Piaget's theory. |
4369 The parents of a 10‐year‐old take the child to the Correct answer: 2 Option 2 is correct. Children at 10 years of age are egocentric and concerned with mental health clinic. The nurse establishes rapport and themselves. Focusing on behavioral symptoms could lead to an adversarial relationship. credibility with the child by asking the child about Children often are uncomfortable talking about friends and family until they get to know a which of the following? person better. Most children are unconcerned about past medical problems; they are focused on the "here and now." ‐ Behavioral symptoms ‐ Hobbies and interests ‐ Relationships with friends and family members. ‐ Medical problems in the past. | Think of known 10‐year‐olds. How did they respond to adults? |
4370 The nurse is caring for a 4‐year‐old. To elicit Correct answer: 2 In Piaget's concept of preoperational thinking the child can use symbols to represent objects information about the child's feelings, the nurse offers and has the ability to pretend. The child does not think logically. Sullivan describes dynamisms the child a series of pictures showing facial expressions (option 1) as habits that highlight personality traits. Freud’s theory regarding defense and asks the child to point to the picture that shows mechanisms of the ego (option 3) is that they are unconsciously motivated ways of dealing the child's own feelings. The nurse bases these actions with anxiety. According to Erickson's theory (option 4), these developmental tasks are on which developmental concept? appropriate to middle childhood (i.e., 6–11 years). ‐ Sullivan's concept of dynamism | Note the age of the child. Recall the main age related concepts of the different theorists. |
‐ Piaget's concept of preoperational thinking ‐ Freud's concept of mechanisms of the ego ‐ Erickson's concept of industry versus inferiority | |
4371 The nurse is providing community education about Correct answer: 4 Children with autistic disorders are highly indifferent to shows of affection by anyone and do autism to a group of parents. The nurse concludes that not relate well with others. Autistic children's play is generally ritualistic and repetitive, rather teaching has been effective if the parents describe than creative and imaginative (option 1) and involves inanimate objects rather than people. which of the following as common behavioral signs of Rather than having early speech development many autistic children have delayed autism? development of language and mental retardation (option 2). Children with autistic disorders are not overly affectionate (option 4). They instead are remote and uninvolved emotionally, usually resisting shows of affection by the parents. ‐ Highly creative, imaginative play ‐ Early development of language ‐ Overly affectionate behavior toward parents ‐ Indifference to being held or hugged. | Recall the basic characteristics of autism, particularly the ones that relate to their social skills, interest in others, and ability to connect with others. |
4372 Which of the following is the highest priority Correct answer: 2 The primary focus of treating anxiety disorders in children is to decrease fear and anxiety. The intervention for the nurse who is working with a child most useful techniques for reducing phobia and the anxiety and fear associated with them are with a phobia? desensitization, reciprocal inhibition, and cognitive restructuring. These techniques can be used with any age group. Having the child face his or her fear (option 1) is often unrealistic because of the developmental level of the child. Children are easily overwhelmed when forced to face fears directly. The primary focus of treating anxiety disorders in children is to decrease fear and anxiety. Decreasing the fear, not protecting from fear, is the aim of treatment (option 3). Allowing the child to express his or her fears may be useful (option 4) but does not necessarily lead to decreased anxiety or fears. ‐ Have the child face his or her fear ‐ Decrease fear and anxiety ‐ Protect the child from fears ‐ Allow the child to express fears | Consider the primary affect associated with phobias. Look for an option that would minimize that affect. |
4373 The nurse is conducting a community education Correct answer: 1, 3, 4, The correct ranking is: 1. Accidents; 2. AIDS; 3. Homicides; 4. Suicide. For people 15–24 years session about preventing deaths in adolescents. Place 2 of age, suicide is the third leading cause of deaths, behind accidents and homicide. More in order from most frequent to least frequent the American teenagers and young adults die from suicide each year than from heart disease, causes of preventable adolescent deaths that the cancer, AIDS, birth defects, stroke, pneumonia, influenza, and chronic lung disease combined. nurse needs to include in the presentation. Click and Because of their lack of maturation and the developmental issues they face, many adolescents drag the options below to move them up or down. have a fatalistic perspective of the future and view suicide as the only option to manage their pain or problems. ‐ Accidents ‐ AIDS ‐ Homicide ‐ Suicide | Rank in the order of frequency, beginning with 1 as the most frequent. Specific knowledge is needed to answer the question. |
4374 The nurse is teaching a group of young adolescents Correct answer: 2 about eating disorders. The nurse would consider the sessions effective if the participants state that anorexia nervosa is best defined as an eating disorder that occurs: ‐ Only in young girls who are depressed. ‐ Mainly in young girls who perceive themselves to be grossly overweight. ‐ Primarily in young girls who live in chaotic families. ‐ In young boys and girls alike. | Anorexia nervosa occurs more often in young girls who perceive themselves to be grossly overweight. Anorexia nervosa and other eating disorders are considered to be manifestations of underlying psychological issues, such as control, power, and denied sexuality. If untreated or inadequately treated, complications of anorexia nervosa can lead to death. Anorexia occurs most often in young girls, but increasing numbers of boys and adult women and men are affected as well (option 1). Depression often coexists with anorexia, and antidepressants are often given to the client who is anorexic. Anorexia nervosa occurs more often in girls whose families are perfectionistic and rigid (option 3). If they develop an eating disorder, girls whose families are more chaotic and impulsive tend to have bulimia nervosa. Anorexia nervosa is not seen exclusively in young boys and girls (option 4). Increasing numbers of adult males and females are developing this problem. | Disregard any options that are exclusive and include or infer the word only. |
4375 The nurse is conducting an in‐service education Correct answer: 2 session about the relationship between anxiety and bulimia nervosa. The nurse best describes the relationship by saying, "When the client has bulimia nervosa, an increase in the anxiety level will generally result in: | Binging (excessive overeating) and purging (intentionally ridding one's body of food ingested) are characteristics of bulimia nervosa. These behaviors represent unhealthy attempts to cope and increase in frequency as anxiety increases. At the beginning of a bingeing episode, the client loses all self‐control and ingests enormous quantities of food in a short period of time. The purging activity temporarily—and falsely—restores the sense of control. Rigid control of what one eats is characteristic of anorexia nervosa (option 1). The person with bulimia actually loses all self‐control when beginning a bingeing episode and subsequently ingests enormous quantities of food. When the client has bulimia nervosa, overeating does occur, but it is followed by purging, which is used as a relief behavior (option 3). Overeating in the absence of purging is not considered to be a typical behavior associated with bulimia nervosa. Since the client with an eating disorder is using food‐related behaviors as an unhealthy means of coping with stress, the client is also likely to use other unhealthy coping methods, such as excessive alcohol intake (option 4). However, bulimia nervosa is characterized by both bingeing and purging involving food, not alcoholic beverages. | Mentally compare and contrast usual signs and symptoms of the eating disorders. Select the answer that is most specific to bulimia nervosa. |
‐ Rigidly controlling what he or she eats." ‐ Binging and purging." ‐ Overeating." ‐ Consuming alcohol." | ||
4376 When assessing an adolescent client for depression, it Correct answer: 2 is most important for the nurse to recognize that depression in adolescents is often: ‐ Similar in presentation to depression in adult clients. ‐ Masked by aggressive behaviors. ‐ Situational and not as serious as depression in adults. ‐ An indication of family dysfunction | Depression in adolescents is often masked by aggressive and/or behavioral problems. Symptoms are usually different from adults in that adolescents often exhibit intense mood swings, academic difficulties, antisocial behavior, and hypersomnia. While the DSM‐IV‐TR criteria for depression are the same for adults, children, and adolescents, the clinical presentation may be different in the different age groups (option 1). Depression in adolescents is often masked by aggressive and/or behavioral problems, including intense mood swings, academic difficulties, antisocial behavior, and hypersomnia. Depression in adolescents can have the same consequences as in adults and should be treated seriously (option 3). Family dysfunction may or may not be present when the adolescent client is depressed (option 4). As with adults who are depressed, there is evidence that depression in adolescence is highly associated with psychobiologic changes, especially in neuroendocrine functioning. | Consider normal or expected adolescent behavior. Ask yourself what relationship exists between this developmental level and the way in which the adolescent experiences depression. |
4377 The school nurse is conducting an assessment to Correct answer: 1, 2, 3, Option 1 indicates that the client is experiencing amenorrhea. DSM‐IV‐TR criteria for anorexia determine if a client has anorexia nervosa. Which 4 nervosa include the absence of at least three menstrual cycles when there is not another statement(s) by the client will most suggest that the medical reason for this, including pregnancy. Option 2 indicates that the client has disturbed client may indeed have anorexia nervosa? Select all body image and an unrealistic perception of own body appearance. A client suffering from that apply. anorexia nervosa has a weight loss of 15 percent or greater of normal body weight because of self‐imposed dietary restrictions and/or excessive exercise regimes. Even when dangerously underweight and in physiologic peril, the anorexic client will continue to believe that more weight should be lost. Option 3 indicates a serious interest in food, but not in eating it. Persons with anorexia are indeed often preoccupied with food, but they refuse to allow it into their bodies. It is not uncommon for them to prepare food for others but not to partake of it. Option 4 indicates a severe revulsion to food, which is common to persons who have anorexia nervosa. It does not suggest that the client will self‐stimulate nausea, as would the bulimic individual. Option 5 is not a correct statement. In addition to denying the reality of their extreme thinness, clients with anorexia deny that they have an eating problem. ‐ "I don't have periods any more. I'm glad." ‐ “People say I'm skinny, but I'm fat and repulsive." ‐ "I want to be a chef and cook for other people." ‐ "The idea of eating makes me nauseated." ‐ "I know that I have a problem with eating." | Consider DSM‐IV‐TR criteria for anorexia nervosa. Apply them to the client's statements. |
4378 In order to be admitted to an inpatient treatment Correct answer: 120 Set this up as a ratio and proportion problem. <BR /> program, clients with anorexia nervosa must meet the admission criterion of having experienced at least a 30 percent weight loss over the past 6 months. The client currently weighs 84 pounds. The nurse calculates that 6 months ago, this client weighed at least pounds. Write in a numerical answer. | Review basic information about ratio and proportion. No equivalencies are necessary for this calculation, which is based on basic mathematical and algebraic principles. |
4379 The adolescent client is depressed. The client's Correct answer: 2 It is important for the nurse to answer this question in an accurate and factual way that the ordered medication is fluoxetine (Prozac). Which of adolescent can understand. The nurse should know that fluoxetine (Prozac) is classified as a the following is the best response by the nurse when selective serotonin reuptake inhibitor (SSRI) and that it is one of the antidepressants fully the client says, "What will this medicine do inside my approved for treating children and adolescents. In option 1, the nurse is not responding to brain?" what the client has asked. This is a non‐answer answer, and the adolescent is likely to feel demeaned and belittled by it, feeling that the nurse is treating the client like a child. Unlike tricyclic antidepressants, it is not associated with changes in norepinephrine levels (option 3) and is not known to have a direct effect on blood glucose and dopamine levels (option 4). ‐ "It will help you feel less depressed." ‐ "It will regulate a neurotransmitter called serotonin." ‐ "It will raise your level of the brain hormone norepinephrine." ‐ "It will balance blood glucose and dopamine levels." | Review basic information about neurotransmitters and antidepressants. |
4380 The nurse is evaluating the progress of an adolescent Correct answer: 2 It is important for the client with an eating disorder to be able to connect emotion to the bulimic client who is being treated as an outpatient. relief‐seeking behavior: bulimia, anorexia, or binging without purging. Completing such a diary Which behavior would indicate that the client is in an honest manner will assist the client to recognize that the eating behavior is an unhealthy making positive progress? The client: attempt to deal with uncomfortable feelings. Individuals with eating disorders are often preoccupied with food and its nutritional content, although they do not eat normally. The client's remaining focus of attention in this area does not suggest that therapeutic progress is being made (option 1). Persons with bulimia generally isolate themselves from others before, during, and after eating. They eat in secret, ingest unusually large quantities of food while alone, and purge themselves as soon as possible after the meal (options 3 and 4). One of the means of discouraging purging is to have the individual remain in the presence of others for at least an hour after eating. Also, the client is an adolescent and should continue to function as a member of the family, even if family discord is present (which is often the case in families with bulimic members). ‐ Asks the nurse many details about the nutritional content of foods. ‐ Shows the nurse a completed food and emotion diary. ‐ Reports enjoying spending time alone after meals. ‐ Describes eating at times other than when the family members eat. | Recall that underlying psychological problems and emotions exist in clients with eating disorders. |
4381 A 13‐year‐old child is brought to the clinic with a Correct answer: 2 Option 2 is correct. Conduct problems are considered manifestations of acting‐out behaviors. history of conduct disorder. The nursing history reveals Inconsistent limit setting with very harsh discipline is often characteristic of families with several facts about the family. Which one is most likely children suffering from conduct disorders. Imposing high expectations on the child may cause to have contributed to the child's conduct problems? the child to be anxious, but this parental behavior is not generally thought to be directly The parents: related to conduct disorders (option 1). Being excessively involved in the child's life (option 3) may indeed make the child anxious, but it is not directly related to conduct disorders. Conduct disorders occur in one‐child and multichild families (option 4). ‐ Have very high expectations of the child. ‐ Employ harsh discipline and inconsistent limit setting. ‐ Are excessively involved in the everyday life of the child. ‐ Have no other children. | Look carefully at the options. Notice that limit setting is the only one that deals with behaviors, or conduct. |
4382 The parent of a child with attention‐deficit Correct answer: 4 The child with ADHD has difficulty concentrating and maintaining a focus. Behavior that is hyperactivity disorder (ADHD) tells the nurse that the seen as resistant may actually result from the child's not having properly understood what has child does not follow instructions well. Which strategy been said. If the child repeats what was heard, the parent will be able to know if the intended should the nurse recommend to the parent? message was actually received. If not, the message can be sent again in simple, concrete language. It is also helpful for the parent to know that giving only one instruction at a time is likely to be more effective than giving a complex set of instructions at the same time.<BR /> ‐ "Teach your child to be less aggressive and more assertive." ‐ "Consider developing a predictable daily routine." ‐ "It could be helpful to assign time out if instructions aren't followed." ‐ "Try having your child repeat what was said before starting the task." | Look exactly at the parent's statement. The child doesn’t follow instructions. Ask yourself if any of the other options show a relationship to that behavior. |
4383 Which primary interventions should the nurse plan Correct answer: 1 Option 1 is correct. Behavior modification is an effective strategy with children and for when a child has conduct disorder and is impulsive adolescents. The child is told exactly what behaviors are expected, what is not acceptable, and and aggressive? the consequences for specific undesirable behaviors These strategies use limit setting and require consistency for correct implementation. Open communication is effective, but a flexible approach to acceptable behavior may be confusing to the child (option 2). Open expression of feelings and assertiveness training (options 3 and 4) are useful techniques; however, they are more effective within a controlled environment and will not necessarily address impulsive and aggressive behavior. ‐ Limit setting and consistency | Notice that the client has conduct disorder and that specific problematic behaviors are cited. Then select the option that is most directly related to changing behavior. |
‐ Open communication and a flexible approach ‐ Open expression of feelings ‐ Assertiveness training | |
4384 The school nurse is teaching parents of 6‐ and 7‐year‐ Correct answer: 3 Separation anxiety disorder may develop at any age, although it is most common in children, old students about anxiety disorders in early school‐ with the peak onset between 7 and 9 years old. When it does occur, the child generally has aged children. Which disorder should the nurse performance and attendance difficulties in school. Obsessive‐compulsive disorder (option 1) is emphasize in the discussion? not common in children, although obsessive compulsive personality traits may be present in children this age. While the incidence of depression in children is increasing (option 2), it is not as common a problem in this age group as is separation anxiety. Posttraumatic stress disorder (option 4) can occur in persons of any age, but it is not as common as separation anxiety. As with adults, PTSD in children occurs following some intensely emotionally painful event, which is not an average occurrence for children. However, separation anxiety is considered more common. ‐ Obsessive‐compulsive disorder (OCD) ‐ Depression ‐ Separation anxiety disorder ‐ Posttraumatic stress disorder (PTSD) | Recall statistics about normal growth and development and mental health disorders in children. |
4385 When planning the care of a 6‐year‐child with Correct answer: 3 Behavior modification is quite effective with young children and adolescents. The child is told oppositional defiant disorder, the psychiatric nurse what is expected, what is not acceptable, and what the consequences will be for undesirable should include which of the following? behavior. The child is rewarded for changes in behavior. Reminiscence therapy (option 1) is indicated for clients who have memory deficits. It is often used with the geriatric population, particularly individuals with dementia. Emotive therapy (option 2) is more effective in older children. The young child with oppositional defiant behavior is often very emotive, but in an inappropriate way. While cognitive reframing (option 4) can be used with young children, the first approach should be to modify the behavior. Once the child is behaving more acceptably, other interventions such as cognitive reframing can be used. ‐ Reminiscence therapy ‐ Emotive therapy ‐ Behavior modification ‐ Cognitive reframing | Notice that this child's problem is related to conduct, or inappropriate behaviors. Choose the option that is expected to have the most immediate effect on modifying behavior. |
4386 A 3‐year‐old client has been diagnosed with attention‐ Correct answer: 3 Option 3 is correct. Central nervous system stimulants such as methylphenidate (Ritalin) and deficit/hyperactivity disorder (ADHD). The child's amphetamine and dextroamphetamine (Adderal) are the most frequently used medications for parents report that a friend told them that the child ADHD. These medications increase the ability to focus attention by blocking out irrelevant will likely receive "lots of drugs." The nurse should thoughts and impulses. Antidepressants (options 1 and 2) are not typically prescribed for the reply that the child will most likely be given a drug such treatment of ADHD. When they are used for depression, venlafaxine (Effexor) and fluoxetine as: (Prozac) seem to be the most effective. Haloperidol (Haldol) in option 4 is an antipsychotic drug that is useful in treating children and adolescents with Tourette's syndrome. It is not commonly prescribed for clients with ADHD. When it is, the nurse must be particularly observant for the occurrence of extrapyramidal side effects (EPS). ‐ Amitriptyline (Elavil). ‐ Paroxetine (Paxil). ‐ Amphetamine and dextroamphetamine (Adderal). ‐ Haloperidol (Haldol). | Consider the classifications of each drug. Recall that children often have paradoxical responses to drugs. Think about recent controversies in the public media about giving stimulant drugs to children. |
4387 The nurse employs play therapy with a small group of Correct answer: 1 Play therapy is especially useful for children under 12 because their developmental level 6‐year‐old clients. The primary expected outcome is makes them less able to verbalize thoughts and feelings. Learning to talk openly about for the clients to do which of the following? themselves (option 2), learning how to give and receive feedback (option 3), and learning problem‐solving skills (option 4) are not the intended goals of play therapy. Options 2, 3, and 4 require more structured group and individual activities than 6‐year‐olds are able to master. Play therapy provides an opportunity for children to express their feelings through play, without the need for advanced verbal or social skill sets. ‐ Act out feelings in a constructive manner. ‐ Learn to talk openly about themselves. ‐ Learn how to give and receive feedback. ‐ Learn problem‐solving skills. | Recall developmentally appropriate behaviors of 6‐year‐old children. Think perhaps about 6‐year‐old children you have known or worked with in clinical settings. |
4388 The parent of a child recently diagnosed with Correct answer: 3, 4 Options 3 and 4 are correct. Recall that children with ODD are disruptive, argumentative, oppositional defiant disorder (ODD) asks the nurse to hostile, and irritable. These children also have social problems with peers and adults and have explain what behaviors are associated with the impaired academic functioning. Stealing (option 2), along with cruelty (option 1) and arson condition. Which information should the nurse include (option 5), are included in the antisocial behaviors seen in children with CD. On the other hand, in an answer. Select all that apply. children with ODD are primarily disruptive, argumentative, hostile, and irritable. ‐ Cruelty ‐ Stealing ‐ Argumentativeness ‐ Irritability ‐ Arson | Recall behaviors associated with ODD. Look for behaviors that are oppositional, but not dangerous or antisocial. |
4389 The school nurse is planning a community education Correct answer: 3 Childhood disorders that appear to be genetically transmitted include enuresis, autism, program about childhood mental health problems that mental retardation, some language disorders, Tourette's syndrome, and attention‐deficit appear to be genetically transmitted. While conducting hyperactivity disorder (ADHD). Of these, autism is the more pervasive disorder. Anxiety (option the program, the nurse will emphasize information 1), sleepwalking (option 2), and oppositional defiance disorder (option 4) do not appear to be about which problem? genetically transmitted. ‐ Anxiety states ‐ Sleepwalking ‐ Enuresis ‐ Oppositional defiance disorder (ODD) | Notice that autism is a more pervasive problem than the other three options. Recall statistics about childhood mental health disorders to make a selection. |
4390 The client being seen in the out‐patient clinic has Correct answer: 3 Option 3 is correct. This will allow for collection of base‐line data that can be used for been taking olanzapine (Zyprexa) for one month and developing a weight control/loss program. Option 1 is incorrect as weighing daily can be has experienced a 12‐pound weight gain during that discouraging, as within the course of a week, several normal fluctuations in weight might time. When the client expresses an interest in occur. Additionally, reporting to the clinic daily (if the client has not already been doing so) is preventing further weight gain, the first action of the unnecessary and would add to both expense and stress levels of the client. Options 2 and 4 are nurse should make which recommendation to the also incorrect. It is premature to enroll in a formal weight management program or see a client? nutritionist at this time. The nurse should assist the client to establish baseline data before seeing other professionals. ‐ Report to the clinic for daily weights ‐ Enroll in a weight management program ‐ Keep a careful record of all food intake for one week ‐ Make an appointment with a nutritionist | Choose an option that allows for more data collection before a specific plan of action is developed. |
4391 The client diagnosed with bipolar I disorder is in an Correct answer: 2 Option 2 is correct. Redirecting the client in a calm, firm, non‐defensive manner is the most inpatient locked unit. The client begins to yell loudly at appropriate action to begin de‐escalation. This client will be distractible but irritable, so it is another client who is also sitting in the dayroom. In important that the nurse’s approach is one of quiet, matter‐of‐fact calmness. Options 1, 2, and order to provide a safe environment for both clients, 3 are incorrect. Turning on the television is not an appropriate approach because it is not likely the nurse should take which action? to distract the client. The nurse should personally gain the client's attention and attempt to verbally redirect the client. If the client with bipolar disorder is in a locked unit, prn orders should already be in place. At this time, the client's behavior requires the nurse's personal attention and intervention, not medication. In fact, if medication is given before other less restrictive interventions are used, it is illegal. Medication is considered a form of chemical restraint.<BR /> ‐ Turn on the television in the dayroom to distract the client. ‐ Redirect the client in a calm, firm, non‐defensive manner. ‐ Call the physician for a prn medication order for the client who is escalating. ‐ Escort the client to the seclusion room. | Recall that persons with elevated mood are distractible, as well as irritable and hostile. |
4392 The community mental health client says, "I'm afraid Correct answer: 2 Option 2 is correct. The nurse should recognize that this client is describing feelings which something is wrong with me. I don't have any appetite. could result in suicide. Even though the client has not directly described feeling self I don't get much sleep and some days I don't want to destructive, the nurse should recognize that there is a strong likelihood that these feelings are be alive." What is the most important first assessment present but unacknowledged. The nurse should directly and kindly inquire whether such by the nurse? thoughts are present and provide safety measures as appropriate to the client’s response. Having a suicidal plan and the means to carry out the plan increase the potential lethality of any situation with a client in suicidal crisis. Option 1 is incorrect because while the client is describing disturbance in physiologic functioning that is consistent with the mood state of depression, the nurse should know that assessing for self destructive intent is of higher priority than assessing basic physical needs. Option 3 is incorrect as completing the Beck's Depression Scale is not an urgent priority. Information gained from the test will contribute to planning appropriate care, but the test can be delayed. The priority action of the nurse should be to determine if the client is suicidal. Option 4 is incorrect because putting the client in a quiet room is contra indicated because the client needs to be in the staff's eyesight until suicidal ideation is confirmed or eliminated. Additionally, the client has begun to express feelings of depression and appears ready to discuss it. The nurse must be responsive to the client's emotional state. ‐ Ask the client specific questions about appetite and sleep patterns ‐ Establish the client's level of suicidality ‐ Complete a Beck's Depression Scale with the client ‐ Place the client in a quiet room | Choose an option that would be most protective for the client. Remember that discussing suicide will not increase the likelihood of a person acting on suicidal impulses, nor will it create suicidal impulses in the non‐suicidal person. |
4393 The client who takes fluoxetine (Prozac) 20 mg each Correct answer: 2 Option 2 is correct. Helping the client to avoid large amounts of caffeine could help improve morning complains of daytime fatigue and being able his sleep. Side effects of caffeine, particularly large doses or doses taken after noon, include to sleep only five hours per night. Describing feeling insomnia, irritability and anxiety. Option 1 is incorrect as Fluoxetine (Prozac) should not be less depressed than previously, the client reports given at bedtime because it impairs sleep. Option 3 is incorrect because decreasing the feeling bored and anxious after work, even after amount of time with friends (unless the time spent is unreasonably long) would not be drinking coffee or colas during in the evening while therapeutic for the client, since the client is being treated for depression. Withdrawal from socializing with friends. What recommendation should social contacts is one of the symptoms of depression, so if the client is experiencing the nurse make to the client? satisfaction from being with friends, this indicates improvement. Option 4 is incorrect as for most people, napping late in the day interferes with successful nighttime sleeping. Avoiding this is a part of good sleep hygiene for all persons. ‐ Begin taking fluoxetine at bedtime ‐ Limit caffeine amount and restrict to morning hours ‐ Return home earlier from social activities with friends ‐ Begin taking a short nap before meeting friends | Notice that the evening drinks of the client contain caffeine and correlate that with the limitation of caffeine in option 2. |
4394 The client has been taking lithium carbonate (Lithium) Correct answer: 4 Option 4 is correct. This client is within the therapeutic blood level for clients newly begin on 300 mg by mouth for six days. The serum lithium level Lithium (0.8 mg/% to 1.4 mg/%) and is displaying two of the commonly expected side effects of is 1.10 mg/%. In addition to noticing minor Lithium.<BR /> tremulousness in the client's hands, the nurse also observes the client drinking water frequently. What conclusion should the nurse reach? The client is:
| Recall therapeutic blood levels of Lithium, both during the initiation and maintenance phases of therapy. |
4395 The client is being discharged after a suicide attempt. Correct answer: 3 Option 3 is correct. The family needs the nurse to listen and support them. Reinforcing signs Discharge plans include medications and participation and symptoms of relapse will help the family members decrease their anxiety, knowing they in a day treatment program, as well as returning to live have a clear role in the recovery and ongoing care of the client without being totally with family members. When the family members tell responsible for the client. In option 1, the family needs to express their concerns, not be asked the nurse that they are concerned about the client's to identify what will make them feel better. Option 2 does not address the family concerns and safety, what is the most appropriate response by the attempts to give them false reassurance. Option 4 is an unreasonable recommendation that nurse? would place undue pressure on the family. The family and the client should be assisted to formulate safety plans that will allow all to carry out usual responsibilities. ‐ Listen to the family and ask them how the nurse can make them feel less concerned. ‐ Reassure the family that the day hospital program will provide the client with emergency telephone numbers. ‐ Allow the family to voice concerns and teach them the indications of possible relapse. ‐ Recommend developing a planned schedule so that a family member is always with the client. | Recognize that both survivors of suicidal attempts and their family members should be provided assistance and support. Remember also that once a person has made a suicide attempt, they are statistically at increased risk for suicide at all points in the future. |
4396 The nurse is preparing to take a client to the Correct answer: 3 Option 3 is correct. The client should be NPO before the procedure in order to be given electroconvulsive therapy (ECT) treatment suite. The anesthesia for the procedure. In option 1, the client, not the spouse, should sign the consent nurse must ensure that which pre‐treatment process is form. The client should be wearing loose‐fitting clothing that would not restrict movements of completed before the treatment can be administered? breathing (option 2). In option 4, the client should be NPO before the procedure in order to be given anesthesia. ‐ The client's spouse has signed the consent form. ‐ The client is wearing snug‐fitting clothing. ‐ The client is NPO. ‐ The client has been given a light meal before the procedure. | Recall the similarity between the pre‐surgical and pre‐ECT procedures. |
4397 The nurse is assigned to the care of a client who has Correct answer: 2 Option 2 is correct. For clients with dysthymia, major concerns are chronic dissatisfaction and dysthymic disorder. What is the most important social isolation. Additionally, they may have changes in appetite, although this is not as nursing intervention that the nurse should include in common as it is in persons with major depression. Option 1 is incorrect because it would the client's plan of care? encourage or perpetuate continuance of social withdrawal. The client will feel tired and may resist being more active, but increased physical activity can help to combat feelings of depression and any accompanying feelings of anxiety.<BR /> ‐ Provide at least 2 hours of quiet time every morning for the client. ‐ Encourage the client to eat in the main dining room with other clients. ‐ Teach the client about the expected effects of second generation antispychotics. ‐ Observe the client carefully for indications of "spacing out" into another personality. | Recall usual behaviors, particularly psychosocial ones, associated with dysthymic disorder. |
4398 The in‐patient client has bipolar I mood disorder and Correct answer: 3 Option 3 is correct. The client's level of risk for self‐harm is a major concern. While the mood is in a manic state. Which of the following is most is elevated, the client may injure self from restless hyperactivity or poor judgment. important for the nurse to consider when planning Additionally, the client may experience unpredictable mood swings and act on accompanying care to address the client's safety needs? The client suicidal urges. Options 1, 2, and 4 each describe a common client presentation in states of may: elevated affect. However, none of them are as important in regard to safety as is the likelihood of rapid mood swings. ‐ Experience increased stimulation while in the presence of others. ‐ Express frequent verbal hostility and harsh sarcasm while mood is elevated. ‐ React impulsively to self‐destructive feelings during a mood shift. ‐ Exhibit hypersexuality and socially inappropriate behavior. | Remember that bipolar disorders are characterized by unpredictable and cyclic changes in mood, with resultant changes in behavior. |
4399 The nurse is conducting an educational group on an Correct answer: 1 Option 1 is correct. This is a respectful response of the nurse. It shows that the nurse inpatient psychiatric unit. One client has not spoken recognizes that during this initial phase of the group process, the client may be (1) being during the group. What would be the most effective observant in order to decide whether he/she feels safe in the group or (2) remaining silent therapeutic response of the nurse? because of feelings of inadequacy.<BR /> ‐ Allow the client to remain present but non‐participative. ‐ Explain to the client that everyone in the group needs to participate. ‐ Ask the rest of the group members how they feel about this member not sharing. ‐ Stop the group and ask the client to leave. | Note that this client is a new member of the group. Imagine how you would feel in this situation. |
4400 The inpatient mental health client is being treated for Correct answer: 1, 3 The nurse should recognize that this client is experiencing psychomotor retardation, which, in major depression. The client moves very slowly, speaks addition to slowing voluntary motor activities, will also slow other bodily processes. The very little, and is extremely inactive physically, walking anticholinergic effects of the client’s medication will decrease motility of the GI tract, only to the bathroom and back. The client takes an specifically the stomach and bowel. The nurse should remember that the client's low level of antidepressant that causes anticholinergic side effects. physical activity increases the risk for constipation. If the client's constipation is not managed The nurse should conclude that this client is at adequately, other serious problems of fecal impaction and bowel obstruction may occur. There particular risk for developing which of the following? is nothing to indicate that the client is at high risk for vomiting (option 2), although the other Select all that apply. GI symptoms noted in option 1 and 3 are likely. Option 4. The nurse should recognize that this client not at risk for diarrhea (option 4), but is actually at high risk for constipation. Most experts consider weight gain (a common side effect of antipsychotics) to be an anticholinergic side effect (option 5). ‐ Digestive difficulties ‐ Vomiting ‐ Constipation ‐ Diarrhea ‐ Weight loss | Recall physiologic manifestations of depression and anticholinergic side effects. |
4401 The 26‐year‐old female hospitalized client is being Correct answer: 1 The client is demonstrating a pattern of behavior that should be investigated. The nurse treated for major depression. The client participated should take the time to assess the client’s feelings, thoughts, and actions. The client may just actively in group therapy during the hour before be tired and have a need to rest, but the nurse needs to be sure that the client is safe and not lunchtime. When it is time for lunch, the client tells the upset. The nurse should not make assumptions about what the client is feeling (option 2). nurse, “I’m not going. I’m going to my room.” The Before ascribing a meaning to the client’s behavior, the nurse should first talk to the client to nurse’s best response would be to: determine what feelings she is experiencing. Additionally, the nurse is using a closed‐ended question that can be answered with a “yes” or “no.” This is not the correct therapeutic technique to use when interviewing a client. The response in option 3 does acknowledge the client’s change in attitude but does not indicate that the nurse has any concern for the client. The response in option 4 changes the focus from the client to food in addition to prematurely and inappropriately presuming to understand the meaning of the client’s behavior. ‐ Ask the client to sit for a few minutes to discuss this. ‐ Ask the client if she is angry. | Notice that the client has not expressed any reasons for wanting to return to own room. This indicates a need for more information. |
‐ Tell the client that there is a unit schedule that must be followed by everyone. ‐ Ask the client if there is a problem with the food. | |
4402 The nurse is conducting discharge teaching for a client Correct answer: 2 Salami is a cured meat and must be avoided by clients taking tranylcypromine, a monoamine taking tranylcypromine (Parnate). The nurse oxidase inhibitor (MAOI). Foods rich in tyramine or tryptophan, such as cured foods, may determines that the client understands the induce a hypertensive episode in clients taking MAOI medication. Other foods to be avoided instructions given if the client says, "While I take this include those that have been aged, pickled, fermented, or smoked. Clients taking monoamine medicine, I should not eat: oxidase inhibitors (MAOIs) can eat potatoes (option 1), baked chicken option 3), and cottage cheese in reasonable amounts (option 4). ‐ Potatoes." ‐ Salami." ‐ Baked chicken." ‐ Cottage cheese." | Notice that salami is the only food listed that is prepared for a long‐term shelf‐life. |
4403 A client is admitted to a secure psychiatric inpatient Correct answer: 3 Providing safety for the nurse and the client is the primary concern immediately after unit for the treatment of bipolar I disorder. The nurse admission when the client is in a manic state. This is because the client is likely to be labile, begins the intake assessment but the client stands up hostile, and uncooperative. The information given in this question suggests that the client's and begins to walk around the room and shouts, "You elevated and angry mood poses potential safety hazards for the client and the nurse. While can’t do this to me! Do you know who I am? I want out obtaining the intake assessment data is important (option 1), this activity can be delayed until of here!!" The best action of the nurse at this time safety issues have been addressed. When the client demonstrates an elevated angry mood, it focuses on: poses a potential safety risk for the client and the nurse. It is this risk that requires the nurse’s immediate focus, not nutritional imbalance (option 2), even though this is often a nursing diagnosis for a client in a manic episode. There is nothing in the question that indicates that the client’s behavior is so extreme that medications must be given (option 4). The nurse should remember that prn neuroleptic medication is considered to be a chemical form of restraint. Other less restrictive measures, such as environmental manipulation, must always be used before the nurse administers prn medication. ‐ Obtaining the assessment information from the client. ‐ Providing the client with adequate food and fluids to maintain homeostasis. ‐ Providing client and self with a safe environment. ‐ Administering the prescribed prn neuroleptic medication to prevent escalation of behavior. | Notice the aggression of the client and recognize its possible danger to client and others. |
4404 The nurse observed that earlier in the afternoon a Correct answer: 2 It acknowledges independent and positive actions by the client. Information is reported in a depressed client visited the coffee shop and sat at a matter‐of‐fact manner to the client, and no evaluative words are used. While option 1 is table with two other clients. What is the best feedback probably intended to convey encouragement, it is very much overstated. Depressed clients do the nurse can give to the client? not accept praise easily. The appropriate feedback for the nurse to provide is a matter‐of‐fact observation that does not include evaluative terms like "wonderful." Options 3 and 4 use of the technique of exploring. The question that is being asked concerns feedback. Feedback involves the giving of information to the client, rather than getting information from the client. Questions are not asked when feedback is given. ‐ "You are doing such a wonderful job interacting with the other clients." ‐ "I saw that you sat with others in the coffee shop this afternoon." ‐ "How are you feeling after your visit to the coffee shop with other clients today?" ‐ "Do you plan to go to the coffee shop again tomorrow?" | Notice that the question is asking about feedback and that the client is depressed. Integrate your knowledge of each as you make your choice. |
4405 The hospitalized client is in a manic phase of bipolar I Correct answer: 1, 3, 4 Providing nursing care to clients with elevated mood (mania) can be particularly challenging disorder. When developing the nursing care plan for for the nurse. The client will generally be excited, physically hyperactive, labile, and this client, the nurse should anticipate that in social unpredictable. Clients in manic states tend to be exhibit behaviors that are controlling, interactions, this client's behavior is very likely to be: competitive, irritable, aggressive, and domineering in social situations. They are often socially (select all that apply) intrusive and inappropriate. When their demands are not met, they can easily become aggressive in ways that are dangerous to self or others. Because of this, the nurse should always consider the person in a manic state to be at risk for injury to self or others especially. Persons experiencing manic states will resist being alone and act as if they feel compelled to interact with others at all times (option 2). Persons in a manic state have unrealistically elevated self‐esteem, often feeling that they are the brightest, the wisest, or the most knowledgeable person in the world (option 5). They will therefore not hesitate to make decisions, but the decisions are made impulsively and without regard for consequences. ‐ Unpredictable. ‐ Isolative. ‐ Demanding. ‐ Competitive. ‐ Indecisive. | Develop a mental image of the client with elevated mood. As you read an option, "see" the client. Will he or she be likely to carry out this behavior? |
4406 The nurse observes that a client is pacing in the Correct answer: 3 Psychomotor agitation is recognized when a person’s behavior involves increased physical hallway, talking rapidly, and gesturing dramatically. activity, restless, and/or aggression. The behavioral manifestations will be accompanied by The nurse concludes that the client is beginning to strong affects, such as anxiety, and speeding of physiologic processes. When psychomotor demonstrate what kind of behavior? agitation is present, the client and others are at risk for injury. Psychomotor retardation (option 1) is a term that refers to slowing of physical activities and bodily processes. It is the opposite of what is described in this situation. Anxiety is a feeling, not a behavior (option 2). This question calls for the nurse to identify a behavior. The behavior of the client may be indeed be related to anxiety, but there are other possible reasons for the behavior. Depression is a mood state, not a behavior (option 4). The behavior of the client may be indeed be related to depressed mood, but there are other possible reasons for the behavior. ‐ Psychomotor retardation ‐ Anxiety ‐ Psychomotor agitation ‐ Depression | Look for a behavior, not an emotion. |
4407 A client states, "I just want to sleep all the time. I am Correct answer: 1 The client is describing symptoms that are consistent with those of a mood disorder, probably overweight again. I will go to work and do my grocery dysthymic disorder. The client's life is not well‐managed, nor does the client experience shopping, but that's all. My life's a mess." The nurse pleasure. There is nothing in the client's statement to indicate an immediate risk for violence should conclude that which nursing diagnosis is most (option 2). The client is dispirited and dissatisfied, but does not indicate that this is relevant? overwhelming enough to cause self‐destructive ideas or urges. The client's statement does not suggest inability to tolerate physical activity (option 3), but rather fatigue and disinterest. Activity intolerance is much more intense and specific than fatigue. Nothing in the client's statement suggests that acute anxiety is present (option 4). Anxiety is a common human emotion, but in order for it to be a nursing diagnosis, there should be clear evidence that the anxiety level is elevated beyond normal. ‐ Ineffective coping ‐ Risk for violence: self‐directed ‐ Activity intolerance ‐ Anxiety | Ask yourself if this client is managing life very well. |
4408 The client who has a diagnosis of bipolar I disorder has a new order for carbamazepine (Tegretol). Before beginning to administer the medication, the nurse checks to see that which laboratory results are in the client’s record? ‐ Blood glucose ‐ Liver function studies ‐ Bleeding and clotting time ‐ Thyroid profile | Correct answer: 2 | The nurse should know that carbamazepine (Tegretol) frequently causes changes in liver enzymes. These changes can result in dangerous or fatal problems for the client. Therefore, baseline laboratory results must be available before the first dose of the drug is administered. Subsequent results are then compared to this set of baseline data as the prescriber makes decisions about future doses. Changes in blood glucose (option 1) are not commonly associated with carbamazepine. Instead, there is a strong relationship to blood glucose changes and certain second generation antipsychotics, such as olanzepine (Zyprexa). While it is true that bleeding problems can be associated with carbamazepine (option 3), baseline bleed/clotting times are not required before the drug is administered. If the client were being given lithium (option 4), baseline information about thyroid functioning would be required. | Read the question carefully and draw on knowledge of pharmacology and common adverse drug effects. |
4409 A client in an inpatient unit is awake at 1 a.m. and tells the nurse, "I can't sleep because of the light in the hall and the noise from the kitchen. I need to have another sleeping pill." The most appropriate nursing intervention is to: ‐ Administer a prn sedative. ‐ Move the client to a quieter room. ‐ Close the door to the client's room. ‐ Allow the client to watch television for 1 hour. | Correct answer: 3 | The client has indicated that environmental noise and activity are preventing sleep. The nurse should first attempt to minimize environmental stimuli. Simply closing the client's door is a noninvasive, nonstimulating strategy that may work, assuming that it will not pose a safety hazard for the client. Before administering a prn sedative (option 1), the nurse should attempt other nonpharmacological options. It is not necessary to move the client (option 2) when closing the door can produce a noninvasive strategy. However, the door should not be closed if this would pose a risk for the client's safety. Turning on the television (option 4) will increase the amount of noise in the environment and could further stimulate the client and/or others. | Pay attention to the client's words. They define the exact nature of the problem. |
4410 The client is scheduled for electroconvulsive therapy Correct answer: 2, 5 The client receiving a series of ECTs can be expected to have "patchy" memories of events (ECT). When teaching the client about what to expect occurring during the days or weeks of the treatment period (option 2). This may or may not in the post‐ECT period, which statement(s) should the resolve as time passes. While modifications in the ECT procedure have increased the level of nurse make? Select all that apply. safety for the client, amnesia and possibly temporary confusion still remain as side effects of the procedure (option 5). The client is likely to have amnesia for recent events, especially for events that occurred just before the treatment was administered (option 1), so the client will not remember that the treatment has been administered. The memory loss that may occur as a side effect to ECT is not selective. Both positive and negative life events may be forgotten (option 3). Memory deficits are common in the client receiving ECT. When they do occur, the client and significant others generally feel alarmed. However, the nurse should recognize this as an expected and nonurgent side effect (option 4). ‐ "You should expect that you will be able to remember recent events more clearly than you did before you started receiving ECT." ‐ "It may hard for you to remember everything that happens during the days and weeks you receive ECT." ‐ "It is common for persons who receive ECT to lose all painful memories of early life." ‐ "If you notice that you are having changes in your memory, let a staff member know immediately." ‐ "Even though modifications have been made in ECT over the years, you may have some disorientation briefly upon awakening from the procedure." | Recall information about expected side effects of ECT. Present this information to the client in a simple and nonalarming style. | ||
4411 The client has bipolar I disorder. Lithium carbonate Correct answer: 1 The nurse should recognize that the client is experiencing side effects that are normal at this (Lithium) 300 mg 4 times daily has been prescribed. time. That information should be conveyed to the client, as well as information about what to After 3 days of lithium therapy, the client says, "What's expect in the future. It is important that the client continue to take the medication as wrong? My hands are shaking a little." The best prescribed. Serum lithium levels should be monitored frequently in order to determine response of the nurse is: therapeutic blood levels and prevent lithium toxicity. Minor hand tremors do not indicate lithium toxicity, but they can interfere with writing and other motor skills. Helping the client understand that the tremors can subside or disappear after 1 or 2 weeks is reassuring. Option 2 fails to give the client important information about side effects of Lithium. It also fails to respond to the client’s concern that something is wrong. Fine hand tremors are expected side effects at this time in the client's treatment (option 3). However, the presence of coarse tremors, coupled with such symptoms are gait changes, would suggest possible toxicity, which would require a totally different response from the nurse. In option 4, the nurse is probably trying to be reassuring but the client will likely feel demeaned. This response also deprives the client of the opportunity to receive important teaching. ‐ "Minor hand trembling often happens for a few days after lithium is started. It usually stops in 1–2 weeks." ‐ "There's no reason to worry about that. We won't, unless it lasts longer than a couple of weeks." ‐ "Just in case your blood level is too high, I am not going to give you your next dose of Lithium." ‐ "I wouldn't worry about it if I were you. It's a small tremor that doesn’t interfere with your functioning." | Recall normal and expected side effects of Lithium. Choose a response that gives that information to the client in simple terms. | ||
4412 | The client is being admitted to the inpatient Correct answer: 1, 4 psychiatric unit with a diagnosis of major depression. During the initial nursing assessment, the nurse anticipates that the client will acknowledge which of the following? Select all that apply. | The nurse should understand that in order for a client to be diagnosed with major depression, DSM‐IV‐TR specifies that symptoms consistent with at least 5 of 9 criteria must have been present for at least 2 weeks. Suicidal ideations and plans are included in one criterion (option 1). The nurse should keep in mind that the presence of suicidal ideations alone would not support the diagnosis of major depression. Another criterion for major depression involves markedly diminished interest or pleasure in all, or almost all, activities (option 4). Option 2 is incorrect because major depressive symptoms represent a more recent change in functioning, not a single episode within 2 years. While persons with major depression often have changes in weight and appetite (option 3), the relevant DSM‐ IV‐TR criterion for major depression does not involve a 3‐day period. It also allows for either increases or decreases in appetite to have occurred. Hallucinations (option 5) may occur in psychotic levels of major depression, but they are not part of the diagnostic criteria in DSM‐IV‐TR. | Compare and contrast usual presenting symptoms and DSM‐IV‐TR criteria for dysthymia and major depression. |
‐ Suicidal thoughts or plans of suicide over at least the past 2 weeks ‐ History of one depressive episode within the past 2 years ‐ Loss of appetite for approximately 3 days ‐ Loss of interest in previously enjoyed activities ‐ Presence of hallucinations for at least 3 days | |||
4413 | An client hospitalized with bipolar disorder is in a Correct answer: 3 state of mania. The client, who was admitted on a formal voluntary status, demands immediate discharge from the facility. The nurse will first: | The manic client has poor judgment and is impulsive and at risk for injury. The nurse should attend to the safety needs of this client before taking other actions. It is possible that the client will not be able to contract for safety. (At this point the first part of the contract would be for the client to remain in the hospital.) If the client could not do this, the nurse's next action is to explain the terms of the client’s admission status. Because the client is being treated on a formal voluntary basis, the nurse cannot comply with the client’s demand to be discharged. It is not appropriate to involve the police (option 1). While informing the spouse might be an appropriate later action, at this time the nurse should focus attention on the client. It is appropriate for the nurse to report the client's request to the nursing supervisor, but the first response to the client's request should be made to the client (option 4). Meeting the client's safety needs is of higher priority than informing the supervisor. | Ask yourself if it would be a good idea for this client to be able to leave the hospital at will. Consider the obligation of the nurse to provide safety for all clients. Recall relevant facts about types of psychiatric admissions. |
‐ Notify the police of the client's intention. ‐ Inform the client's spouse of the request of the client. | |||
‐ Offer the client a contract for safety. ‐ Notify the supervisor on the nursing unit. | ||
4414 The nurse needs to teach a client about newly Correct answer: 1, 5 The nurse should know that one of the common side effects of sertraline (Zoloft) is insomnia. prescribed sertraline (Zoloft). Which information is Therefore, most clients are given sertraline (Zoloft) early in the day. Sexual side effects to essential to include in the teaching? Select all that sertraline (Zoloft) and other SSRIs are common. One way to decrease the likelihood of apply. noncompliance is to inform the client that prompt reporting of such side effects can lead to corrective treatment measures. It is important for the nurse to know that diarrhea is a much more common side effect to sertraline (Zoloft) than is constipation (option 2). It is vital for the nurse to know that all persons taking sertraline (Zoloft) or other SSRIs should be taught to recognize early symptoms of possible central serotonin syndrome (option 3). Such symptoms include sudden onset fever, sweating, and extrapyramidal side effects (EPS). The development of central serotonin syndrome is a rare medical emergency, but the client will need intensive medical treatment because the mortality rate is very high. The nurse should teach the client that while some reduction in symptoms may occur in a relatively short period of time, it may be several weeks before full therapeutic effects are realized (option 4). Without this knowledge, clients often become discouraged and think that the medication is ineffective. | Translate the statements of the nurse into medical terminology and then determine if each option is related to a known side effect of sertraline (Zoloft). . | |
‐ Sertraline is most often taken as a morning dose. ‐ Constipation is a common side effect of sertraline. ‐ Fever and flulike symptoms are bothersome but not dangerous side effects of sertraline. ‐ Clients taking sertraline will usually recognize improvement within one week. ‐ It is possible that sexual side effects will occur. | ||
4415 A client who had coronary bypass surgery 6 days ago Correct answer: 3 reports having no appetite and feeling very sad. The client further complains of having difficulty falling asleep. The nurse concludes that it is likely that this client is experiencing: ‐ Disturbed body image. ‐ Activity intolerance. ‐ Depressed mood. ‐ Delayed surgical recovery. | The clinical presentation of depressed mood is similar to that of medically diagnosed depression. There is a high incidence of depressed mood and depression among hospitalized clients. Usually the more severe the illness, the more pronounced the symptoms. Clinical depression in the recovery period is relatively common among cardiovascular surgical clients. There is nothing in the client’s complaint that suggests body image concerns (option 1), although most postsurgical clients have this concern to some degree. The statements of this client instead suggest that the client is experiencing depressed mood, which is similar to the medical diagnosis of depression. Nothing the client has said indicates that the client is intolerant of activity (option 2). Feeling tired is a much more moderate problem than being intolerant of activity. There is no data in the stem of this question to suggest that the client’s recovery is delayed (option 4). | Look carefully at the client's words. Think about clinical signs of depression. Remember that depression is a medical diagnosis, not a nursing diagnosis. |
4416 The client diagnosed with dysthymia asks the nurse to Correct answer: 4 explain what the diagnosis means. When responding to the client, the nurse should state that before dysthymia can be diagnosed, depressed mood needs to be present for at least: ‐ 2 weeks. ‐ 4 weeks. ‐ 1 year. ‐ 2 years. | According to DSM‐IV‐TR, dysthymic disorder cannot be fully diagnosed until the depressed mood has been present for at least 2 years. Additional criteria are specified to diagnose dysthymic disorder, and once the depressed mood criterion has been met, only some of the other criteria must be met. This is in contrast to the DSM‐IV‐TR criteria for diagnosing major depression. In this case, at least 5 of 9 criteria must be met. | Review DSM‐IV‐TR criteria for dysthymia and major depression. |
4417 The hospitalized client is in the acute stage of mania. Correct answer: 4 Which of the following is an appropriate goal for the nurse and the client to work toward? The client will: ‐ Spend at least 30 minutes per hour watching TV in the activity room. ‐ Participate actively in the psychodrama group each day. ‐ Lead other clients in group physical exercises each morning. ‐ Maintain distance of 2–3 feet at all times when interacting with others. | The client in the manic state is generally intrusive and insensitive to the needs of others and does not recognize boundaries, whether psychologic or physical. The client also tends to have an intense preoccupation with sexual urges and frequently touches others or positions self in socially inappropriate ways. The nurse must encourage the client to set and maintain boundaries while interacting with others. The person in a manic state is unlikely to be able to conform to the schedule in option 1 or to sustain attention for this period of time. Additionally, the client is likely to find the activity room more stimulating than a quieter area of the unit. Individuals experiencing manic affect tend toward overreaction and overdramatization in any situation, so participating in a such a group would likely increase the client's manic hyperactivity and dramatization (option 2). While physical exercising will allow the client to sublimate some of the excessive energy that is felt (option 3), the client is likely to be domineering, overbearing, and highly competitive in groups. Further, it is likely that the client's level of mania will increase because of the extra stimulation. | Develop a mental picture of how the person with elevated affect is likely to act. "See" this client before you, and the correct answer will be obvious. |
4418 The family members of a client in an acute state of Correct answer: 1 mania relate that the client has not slept for 4 nights. They further report that the client climbed up and down the stairs of a nearby sports stadium for at least 6 hours without stopping. The client now has blisters on the feet and is perspiring profusely. When planning care for this client, the nurse should give priority to which of the following problems? | The nurse must first attend to safety and physiologic needs necessary to sustain life. Considering the prior level of physical activity of the client and that the client is currently perspiring profusely, the nurse should recognize that this client could easily enter into a state of fluid and/or electrolyte imbalance. This at‐risk problem will take priority over actual problems that do not involve basic physical needs or safety. Impaired skin integrity (option 3) is incorrect. The nurse should recognize that while this is an actual physical problem, it does not pose the same level of risk that the risk for injury and fluid deficit pose for this client. Like the psychological needs, this problem can be addressed after basic physiologic and safety needs are addressed. Ineffective coping and impaired adjustment (options 2 and 4) are not priority problems at this time. They are psychologic problems that can be addressed after basic physiologic and safety needs are addressed. | Develop a mental picture of this client. Notice the perspiration and connect it with the family’s report of extreme hyperactivity. Recall basic facts about fluid and electrolyte balance to choose correctly. |
‐ Risk for deficient fluid volume ‐ Ineffective coping ‐ Impaired skin integrity ‐ Impaired adjustment | ||
4419 The nurse assesses that a client in a state of elevated Correct answer: 2 affect is at risk for self harm. The nurse then places high priority on including which of the following in the plan of care? ‐ A room that is observable from the nurses' station ‐ Constant supervision of the client ‐ Administration of all medications intramuscularly rather than orally ‐ A quiet, nonstimulating private room for the client | Clients in a manic state are vulnerable to injure self or others, either through restless hyperactivity and poor judgment or through actions during unpredictable mood swings. Continuous and close nursing supervision of these clients to ensure safety is imperative, regardless of the type of room to which they are assigned. A quiet room near the nurse's station might be advisable for the client with elevated affect (option 1), but this will not substitute for constant immediate supervision of the client. Medications (option 3) should be given orally if possible, since the manic client is likely to overreact to any physical contact, either interpreting it as a physical assault or ascribing a sexual intent to it. Being in a quiet nonstimulating private room (option 4) is advisable for this client, but it is not as urgent as close personal supervision by the nurse. | Recall behaviors common to the client with elevated mood. Recognize that the nurse’s priority is always to provide for the safety of individual clients, as well as groups of clients. |
4420 Two years after getting mugged in a parking lot, the Correct answer: 2 Option 2 is correct. Post‐traumatic stress disorder is associated with a traumatic event. client verbalizes a fear of parking lots and complains of Symptoms such as nightmares and flashbacks are commonly associated with this disorder. recurring "bad dreams" about them. The nurse should Option 1 is incorrect as generalized anxiety disorder is associated with having a great deal of assess this behavior as a possible indicator of which difficulty controlling unrealistic, excessive anxiety associated with common daily experiences. problem? Option 3 is incorrect because social phobias present as fears of social occasions, and the phobic individual avoids many or most social situations because of dread of being embarrassed or humiliated. Phobic persons recognize that their behavior is irrational. Option 4 is incorrect because dysthymic disorder is a long lasting problem of the individual that involves lowered mood and a variety of other experiences that have lasted over at least a two year period. Sleep pattern disturbances are common, but nightmares of a specific event are not. ‐ Generalized anxiety disorder ‐ Post‐traumatic stress disorder ‐ Social phobia ‐ Dysthymic disorder | Notice the specific nature of the client's fears and sleep experiences. Recognize that post‐ traumatic stress disorder (PTSD) and the conditions mentioned in the other options are medical, not nursing diagnoses. |
4421 Which question would be most appropriate for the Correct answer: 3 Option 3 is correct. Generalized anxiety disorder is characterized by chronic, unrealistic, and nurse to ask when assessing a client for signs of excessive anxiety concerning a number of different stressors. Option 1 is incorrect as generalized anxiety disorder? agoraphobia involves anxiety and fear of places or situations, such as crowds. Option 3 is incorrect because panic attacks are characterized by sudden anxiety that may not be identifiable. Option 4 is incorrect as post‐traumatic stress disorder is characterized by "flashbacks" and/or nightmares about a traumatic event. ‐ "Are you more anxious at home or in a crowd?" ‐ "Do you experience sudden, intense fear for no reason?" ‐ "Do you find yourself worrying frequently about a number of different things?" ‐ "Have you ever had a 'flashback' or a nightmare about a traumatic event?" | Recall the basic definition of generalized anxiety disorder. Look for a response that fits with that definition. |
4422 During the initial assessment of a client, the nurse Correct answer: 3 Option 3 is correct. The client's behavior reflects a healthy response necessary for survival. asks if the client is afraid of anything. The client states, Option 1 is incorrect as a phobic reaction is an excessive and unrealistic fear of a particular "Since my hip surgery, I have been afraid to climb up object or situation. Option 2 is incorrect because chronic anxiety is low‐level anxiety occurring on my roof." The nurse should assess this response as: over an extended period of time. Option 4 is incorrect as in acute anxiety states, whether mild, moderate, or severe, the individual experiences specific physiologic symptoms and a feeling of uneasy dread and gloom. ‐ A phobic reaction. ‐ Chronic anxiety. ‐ Normal anxiety. ‐ Acute anxiety. | Note the realistic character of the client's statement. Do you think it would be a good idea for a person who has had a hip replacement to climb on a roof? |
4423 A client with obsessive‐compulsive disorder (OCD) Correct answer: 3 Option 3 is correct. This client describes dissatisfaction with both ascribed and assumed roles. ritualistically washes the hands numerous times per Option 1 is incorrect as the client does not describe having too many roles, but rather being day. The client reports feeling of inadequate and unable to perform the roles satisfactorily. Option 2 is incorrect because the client's description makes statements such as, "I can't do my job at work does not include anything about thought processes. However, if the client had described anymore, and I am not even a good parent or family thought patterns, it is not likely that they would have been described as irrational. Instead the member anymore." What would be the most client probably would have described them as repetitive, persistent and illogical. Option 4 is appropriate nursing diagnosis for this client? incorrect as the client's statement does not describe family relationship patterns, but rather the client's dissatisfaction with carrying out own roles in the family. ‐ Role overload ‐ Ineffective thought processes ‐ Ineffective role performance ‐ Impaired family relationships | Notice carefully what the client has said and the fact that the client feels ineffective. |
4424 The chronically anxious client says, "I'm so stupid. I Correct answer: 4 Option 4 is correct. The client is experiencing a repetitive irrational thought. Cognitive always fail at everything. I think about it all the time." restructuring focuses on teaching people to change their maladaptive beliefs, self‐statements Which intervention technique is appropriate for the and imageries that contribute to their having an anxiety disorder. Option 1 is incorrect because nurse to employ? what the client has said indicates repetitive thinking, not impaired coping with stress. Of course, impaired coping can be an outgrowth of pre‐occupation with negative thoughts, but the client's description is very specific: thoughts are bothersome. Option 2 is incorrect as security enhancement is indicated when a client’s level of anxiety is high enough for the client or others to fear that the client's behavior will become out of control. No indication of potential danger or lack of control is present in the client's statement. Option 3 is incorrect because calming techniques are useful for managing the physiologic dimensions of acute or chronic anxiety. These include such things as muscle relaxation and deep breathing. This client has described a cognitive, not a physiologic symptom of anxiety. ‐ Coping enhancement ‐ Security enhancement ‐ Calming techniques ‐ Cognitive restructuring | Notice that the client is bothered by a persistent thought, or cognition. A technique directed toward that experience is therefore most appropriate. |
4425 When the client is experiencing severe anxiety, the Correct answer: 3 Option 3 is correct. Severe anxiety must be reduced to a tolerable level before any other nurse should recognize that the short‐term priority goals can be achieved. Option 1 is incorrect as the presence and support of the nurse is intervention relates to: appropriate in almost all instances involving client care. However, in situations where the client's anxiety is severe, the nurse should go beyond being supportive and work actively to decrease the client's anxiety in order to prevent untoward consequences for the client or others.<BR /> ‐ Providing emotional support. ‐ Identifying the cause of the anxiety. ‐ Reducing the level of anxiety. ‐ Teaching coping skills. | Remember that the higher the level of anxiety, the less well the individual functions in all spheres, including learning and analytic processing. |
4426 While talking generally with a client about holiday Correct answer: 3 Option 3 is correct. The nurse should be aware that this is a general discussion, not a customs, the nurse notes that the client appears to be therapeutic interview. Therefore, when the client's anxiety seems to increase, the nurse can becoming uncomfortable and anxious. What action relieve the anxiety by altering the focus of the discussion. Option 1 is incorrect because asking should the nurse take? the client for more details in this social situation will probably increase the client's anxiety level. Exploring possible causes of the client’s anxiety at this time would be probing, a non‐ therapeutic response. Option 2 is incorrect as guided imagery is used to help the client focus away from anxiety‐producing stimuli and onto a positive image that feels safe. This would be inappropriate to use in a more general type of interaction with a client. Option 4 is incorrect because if the nurse physically leaves the conversation, the client can be left feeling rejected. The anxious client needs the presence of a supportive person, in this case, the nurse. ‐ Focus on the client's anxiety and ask what is causing it. ‐ Encourage the client to try to relax by using guided imagery. ‐ Refocus the conversation on another topic. ‐ Stop the conversation and leave the client alone. | Notice that this is not a therapeutic interview but a social interaction. |
4427 A client who has been experiencing panic attacks asks Correct answer: 3 Option 3 is correct. Symptoms associated with a number of medical conditions are very why the physician has ordered several laboratory tests. similar to the symptoms associated with panic attacks. When a medical condition is present, it The nurse’s answer to this question should be based should be identified and treated. Among conditions that may cause secondary anxiety are on the understanding that: hyperthyroidism, Cushing's syndrome, hyperventilation, hypoxia and anemia. Options 1 and 2 are incorrect as commonly used laboratory tests will not differentiate between types of anxiety, nor will they be identifying causes of panic attacks. They can measure some of the physiologic occurrences associated with anxiety and panic attacks.<BR /> ‐ Laboratory tests can differentiate between true anxiety and the anxiety associated with depression. ‐ Laboratory tests can determine the specific cause of the panic attacks. ‐ Physiologic symptoms associated with panic disorders often mimic medical disorders. ‐ Symptoms of panic disorders are usually related to hypochondriasis. | Recall the extent and distribution of physiologic occurrences during a panic attack. Compare and contrast these with symptoms of medical problems, such as hyperthyroidism. | |
4428 An anxious client begins to yell and interrupt other Correct answer: 4 clients. The client's speech is rapid and pressured. In addition to speaking softly to the client, what other action should the nurse take? | Option 4 is correct. If the nurse speaks softly to the client, this will serve as positive role modeling for the client. Additionally, if environmental stimuli are reduced, the client is likely to be able to moderate behavior, including beginning to speak more slowly and softly. This in turn could reduce stress related emotions and their physiologic consequences, which could reduce the client’s level of social aggression. Option 1 is incorrect because calming deep breaths could be used at a later time. Then initial response of the nurse should be something that is simple and direct and does not require concentration. Option 2 is incorrect as the focus of the nurse's response should be on the socially aggressive client, not on others. Option 3 is incorrect because if the nurse pointed this out to the client at this time, it is very likely that the client's emotions and the situation would escalate. Discussing causes of an individual's behavior should not occur in a group setting, unless it is a therapeutic group. | Remember that anger is an outgrowth of anxiety, which is easily "transmitted" from one person to another. If the nurse is calm and quiet, this is likely to have a calming effect on the client. |
‐ Ask the client to take deep calming breaths. ‐ Instruct the other clients to ignore this client's behavior. ‐ Point out to the client that the behavior is a sign of anxiety. ‐ Reduce the level of environmental stimuli. | ||
4429 When evaluating the effectiveness of nursing care Correct answer: 2 plans used for anxious clients, it is important for the clients to understand that: ‐ Defense mechanisms should not be used. ‐ Some anxiety can be helpful. ‐ They should strive to never experience anxiety. ‐ They should try to avoid the fight or flight response. | Option 2 is correct. Anxiety can be a healthy protective response to an actual threat. When at normal levels, it motivates and increases the individual's level of awareness and involvement in the environment. Option 1 is incorrect as defense mechanisms are unconscious psychological responses designed to diminish or delay anxiety. Used by all persons, some are considered healthy or adaptive, and others are considered to be maladaptive. The nurse should assist the client to learn to use healthy defense mechanisms. Option 3 is incorrect because it is unrealistic to strive toward experiencing no anxiety. Anxiety is a common part of the human experience. When at normal levels, it motivates and increases the individual’s level of awareness and involvement in the environment. Option 4 is incorrect as it is impossible for the human being to avoid the "fight or flight" response. It is a normal reaction to the person encountering a stressor and is part of the stress response. | Look here for the option that will be most useful to the client when again functioning without the direct support of the nurse. |
4430 Before a newly admitted anxious client begins Correct answer: 4 treatment with benzodiazepines, it is most important for the nurse to assess the client's: | Combined use of benzodiazepines and other central nervous system depressants can lead to death from respiratory failure. If the alcohol has been ingested shortly before admission (which is not at all uncommon for a client experiencing anxiety), giving a benzodiazepine could put the client at risk. Social support, coping mechanisms, and motivation for treatment (options 1, 2, and 3) are all important factors to document during the assessment. However, the client's immediate risk for safety is the priority at this point and must be assessed first. The other data can be compiled when the formal assessment is completed at a later time. | Recognize that benzodiazepines are central nervous system (CNS) depressants. Identify potential dangers that can be associated with them. |
‐ Level of motivation for treatment. ‐ Situational and social support. ‐ Stressors and use of coping mechanisms. ‐ Recent use of alcohol or other depressants. | ||
4431 A physician has just told a client that surgery will be Correct answer: 1 required to treat a health problem. After the physician leaves, the client reports feeling angry, tense, and shaky. The nurse notes that the client's palms are sweaty and the pupils are dilated. The nurse interprets this to mean that the client is experiencing symptoms consistent with which level of the general adaptation syndrome (GAS)? | The symptoms displayed by the client reflect an increased alertness and heightened level of arousal focused on an immediate concern or perceived threat. This is also referred to as "fight or flight" and occurs during the alarm stage of the general adaptation syndrome. Exhaustion and resistance (options 2 and 4) consist of more severe symptoms (both physical and psychological) experienced in the general adaptation syndrome. They occur in the second and third stages respectively of GAS. General anxiety (option 3) is characterized by significant difficulty controlling unrealistic, excessive anxiety associated with common daily experiences. This type of anxiety is more generalized, or free floating, and does not necessarily have a specific focus. | Recall theoretical information about the GAS. Look carefully at the client's presenting behaviors to guide your selection. |
‐ Alarm ‐ Exhaustion ‐ Generalized anxiety ‐ Resistance | ||
4432 The nursing assessment indicates that a client is Correct answer: 2 experiencing a panic attack. The client is unable to understand directions and is preoccupied with thoughts of danger. Which of the following would be the most appropriate nursing diagnosis? ‐ Ineffective health maintenance ‐ Impaired thought processes ‐ Risk for noncompliance ‐ Impaired communication | Impaired thought processes related to understanding directions and/or obsessive thoughts is an appropriate nursing diagnosis for clients with severe or panic‐level anxiety. This is an important nursing diagnosis because the altered thought processes that occur at this level of anxiety are usually accompanied with overwhelming emotions and disorganization. These factors often result in a regression to more primitive behaviors putting the client at risk for injury. Ineffective health maintenance (option 1) does not reflect the current cognitive state of the client. Option 3 is an at‐risk problem, and this client's current emotional state and risk for danger will take preference over any risk diagnosis. Impaired communication (option 4) does not reflect the current cognitive state of the client. | Remember that safety is always a priority concern. Of the choices available, altered thought processes addresses impaired cognition that occurs with acute panic, creating risks for injury to self or others. |
4433 The nurse would formulate which goal as most Correct answer: 2 appropriate for a client who has been diagnosed as having generalized anxiety disorder (GAD)? ‐ The client will describe dissociative experiences. ‐ The client will display the ability to cope with mild anxiety. ‐ The client will relive the traumatic event. ‐ The client will verbalize a sense of control over ritualistic behaviors. | Clients with generalized anxiety disorder should be able to demonstrate effective coping with mild anxiety. Clients with generalized anxiety disorder do not generally have dissociative experiences or perform ritualistic behaviors (options 1 and 4). Dissociation and compulsive behaviors occur with more severe levels of anxiety. Neither of these symptoms are in the diagnostic criteria for GAD. Anxiety related to traumatic events is associated with posttraumatic stress disorder (option 3). | Recall how GAD presents. Recognize that the behaviors in the other options are more dramatic than is generally true when a person has generalized anxiety disorder. |
4434 A client who is receiving an anxiolytic medication is Correct answer: 2 Anxiolytic medications alleviate or reduce symptoms of anxiety so the client can learn to reluctant to participate in group therapy and states, identify stressors and effective coping mechanisms. Anxiolytics allow the client to benefit from "The pills I am taking will take care of my stress. I don't individual and group therapy. Anxiolytics cannot change the source of the anxiety. While the need to talk about my problems." The nurse should statement in option 1 is true, it does not provide the information that the client needs at this explain that: time. Option 3 is an inaccurate statement. Anxiolytics are not curative. Persons with anxiety disorders need to change their coping behaviors. They cannot rely on drugs to address the underlying source of the anxiety. It is during group therapy that effective coping mechanisms can be introduced and practiced. The statement in option 4 is inaccurate. The chemical effect of the anxiolytics can be realized whether the client is in group or not; however, the combination of anxiolytic and group therapy is considered to be more effective than either alone. ‐ Many anxiolytics are habituating. ‐ Medications relieve symptoms, but do not change the source of the anxiety. ‐ The client will need to attend group therapy only until the medication becomes effective. ‐ The medications will not work unless the client participates in group therapy. | Don't be misled by option 1, which contains an accurate statement but does not answer the question asked. |
4435 A client states, "I am always late for everything Correct answer: 1 Ritualistic behaviors are related to heightened anxiety. The compulsive behaviors increase in because I can't leave my room without checking every intensity and/or frequency as the anxiety level escalates. The nurse should allow the client to drawer and door to make sure they are locked. If I complete the ritual in as reasonable and timely a manner as possible. Interrupting or stopping don't do that, I get so worried that I have to go back. I the ritual will increase anxiety, which in turn will increase the client's need to engage in the can't seem to stop my behavior." The nurse should ritual. Exploring childhood experiences (option 2) cannot be expected to bring about take which action at this time? reductions in anxiety or ritualistic behavior. Clients who display compulsive behaviors need support and encouragement to manage their daily lives by modifying the environment and allowing time for the behaviors. Assigning solitude (option 3) cannot be expected to decrease the client’s need for the ritual. What causes the client to have a need to perform the ritual is not from the actual environment. Hence, remaining in the room will not necessarily decrease the urge to recheck and recheck compulsively. The nurse should recognize that the client's motivations for the rechecking arise from within the psyche and are not related to environmental events (option 4). While keeping others out of the room may spare the client from feelings of embarrassment, it will not necessarily decrease the compulsive behavior. ‐ Allow the client adequate time to carry out the rituals. ‐ Explore childhood experiences that may have led to the behavior. ‐ Encourage the client to remain in the room until the urge to recheck has decreased. ‐ Remind the client that the staff will not allow others to enter the room. | Look beyond the rechecking behavior to what is thought to be underlying, or causing, it. |
4436 The client is experiencing a panic attack. Which of the Correct answer: 3, 4 At panic‐level anxiety, the individual will not be able to process complex ideas (option 3). following actions by the nurse would be appropriate? Using short simple sentences will provide the best way to communicate information, Select all that apply. directions, and support. Additionally, the nurse's highest priority is to reduce the client's anxiety to a more tolerable level. Anxiety is "contagious" in interpersonal situations. If the nurse conveys anxiety to the client, the client's anxiety will escalate further. Speaking calmly and projecting an image of competence may have a calming effect on the client (option 4). The nurse should avoid communicating loudly and firmly (option 1). Speaking to the client in this manner would most likely further increase the client's fearfulness, anxiety, and agitation. The client in panic level of anxiety has an urgent need for physical activity. Attempts to prevent or restrict the activity (option 2) will result in increased agitation. The physical hyperactivity should be allowed, but in a protected and nonstimulating environment in which the nurse is physically present and attending to the client’s safety needs. Clients in panic‐level anxiety are not able to learn (option 5), because they cannot concentrate and have a very narrow self‐ focus. Learning best takes place when anxiety is at a mild or moderate level. Cognitive restructuring is appropriate for clients with chronic, lower level anxiety. ‐ Speak loudly and firmly. ‐ Restrict the client’s physical activity. ‐ Use short simple sentences. ‐ Remain calm and serene. ‐ Teach cognitive restructuring skills. | Develop a mental picture of this client, who is feeling out of control and intensely anxious and fearful. Look for options that will address these feelings and reduce the anxiety while at the same time providing safety. |
4437 A client has obsessive‐compulsive disorder (OCD). Correct answer: 1 Loss of control is a major concern for clients who have OCD. Goals related to control of Which of the following statements made by the client unwanted thoughts and behaviors are appropriate for these clients. Clients with OCD are to the nurse would be the best indicator of aware that their compulsive behaviors are not normal (option 2). Knowing this does not improvement? mediate or change their ability to manage or control the unwanted thoughts and behaviors. This statement only reflects the client's awareness of his disorder; it does not indicate control over the behaviors and thoughts. The compulsive behaviors are utilized to reduce anxiety, not to reward self for good behavior (option 3). The statement in option 4 does not indicate control over behavior. ‐ "I have more control over my thoughts and behaviors." ‐ "I know that my thoughts and behaviors are not normal." ‐ "I only do my ritual to reward myself when I have been good." ‐ "My friends don't know about my disorder." | Recall that clients with OCD report being unable to resist urges and stop unwanted thoughts. |
4438 The client is taking triazolam (Halcion) to reduce Correct answer: 4 Hypnotic and anxiolytic agents should be taken for as short a period of time as possible. anxiety related symptoms. Which client statement Physical dependence on these drugs can develop in a very short period of time. Additionally, indicates that the nurse should provide more anxious clients should be assisted to improve their coping mechanisms without relying on teaching? medication. The statement in option 1 shows awareness of correct drug information. Triazolam (Halcion) has both anxiolytic and sedative effects. Its primary use is as a nighttime sedative. The statement in option 2 shows awareness of correct drug information. Since clients can become physically dependent on benzodiazepines in a very short period of time, abrupt discontinuation can precipitate a withdrawal response. The statement in option 3 shows awareness of correct drug information: Driving or operating heavy machinery are not recommended when clients take benzodiazepines or other drugs that have sedating effects. ‐ "The doctor wants me to take this drug at bedtime because it will help me sleep better." ‐ "I should not abruptly stop taking this medication." ‐ "I might not be able to drive while I am taking this medication." ‐ "I will probably have to take this medication for the rest of my life." | Apply what you know about benzodiazepines in general. Remember that these are one of the most popular "street drugs." |
4439 A client with generalized anxiety disorder states, "I Correct answer: 3 Suppression of feelings requires energy and will lead to increased anxiety. Clients need to talk now know the best thing for me to do is just to try to about their feelings. The client’s statement in option 1 does not suggest insight, which is the forget my worries." How should the nurse evaluate development of understanding of one's motivations. It suggests that instead of addressing and this statement? managing worries, the client will use avoidant behaviors. Generalized anxiety is characterized by worrying. The client will not be able to independently reduce this behavior and improve coping (option 2). However, if the client is taught the technique of cognitive restructuring, this might help to reduce the worrying behaviors. The nurse/client relationship should be maintained because the client continues to require guidance and support (option 4) ‐ The client is developing insight. ‐ The client's coping skills are improving. ‐ The client needs to be encouraged to verbalize feelings. ‐ The nurse/client relationship should be terminated. | Compare and contrast symptoms of acute anxiety and generalized anxiety. |
4440 During client assessment, the nurse finds that the Correct answer: 3 The client's complaints indicate the "fight‐or‐flight" response that occurs at the severe level client is trembling and restless, blood pressure and of anxiety. Mild anxiety (option 1) is associated with the tension of everyday life; the person is pulse are elevated, and the client reports dry mouth, alert, the perceptual field is increased, and learning is facilitated. In moderate anxiety (option shortness of breath, inability to relax, loss of appetite, 2), the perceptual field is narrowed, and low‐level sympathetic arousal occurs. Panic anxiety and an upset stomach. The nurse should conclude that (option 4) is associated with dread and terror, and physiological arousal interferes with motor this client is experiencing which level of anxiety? activities. ‐ Mild ‐ Moderate ‐ Severe ‐ Panic | Develop a mental picture of the client. Recall facts about behaviors associated with different levels of anxiety. Rule out options 1 and 4 immediately, as mild anxiety is normal and panic‐level anxiety results in greatly disorganized and frightened behavior. |
4441 During an assessment interview the client tells the Correct answer: 3 Obsessive‐compulsive (OC) behaviors represent attempts to relieve anxiety and decrease fear nurse, "I can't stop worrying about my makeup. I can't or guilt through controlling and ritualizing activities. People with obsessions and compulsions go anywhere nor do anything unless my makeup is engage in a kind of magical thinking and believe that something terrible will happen if they do fresh and perfect. I wash my face and put on fresh not act on their compulsion. If deprived of opportunity and adequate time to carry out a makeup at least once and sometimes twice an hour." ritualistic compulsion, the person's anxiety will escalate significantly, resulting in an increased The nurse's priority should be to adjust the client's need to carry out the compulsive behavior. It is best to schedule a therapeutic activity just plan of care so that the client will be: after the client has completed a ritual. The client with OC symptoms is likely to have been socially isolated prior to admission and should be encouraged to participate in therapeutic and social activities on the unit (option 1). Instead of a diary connecting feelings experienced if unable to carry out the ritual, it would be more useful for the client to understand the relationship of feelings to the initiation of the ritual (option 3). The client should be allowed to use personal products (option 4), but this is not as important as allowing the client extra time to prepare for unit activities. ‐ Required to spend daytime hours out of own room. ‐ Given advance notice of approaching time for all group therapy sessions. ‐ Asked to keep a diary of feelings experienced if unable to groom self at will. ‐ Allowed to use own cosmetics and grooming products. | Notice how much time the client's rituals are requiring. Recall that carrying out a ritual temporarily reduces anxiety. |
4442 When assessing an apparently anxious client, the Correct answer: 4 Because of shame or difficulty organizing thoughts, clients might be reluctant to talk about nurse ensures that questions related to the client's anxiety. Questions should be specific, direct, and individualized to the client. Option 1 is anxiety are: incorrect because when a client is experiencing anxiety, abstract thinking is impaired. Options 2 and 3 are incorrect because the nurse should ask direct questions about the client's anxiety. ‐ Abstract and nonthreatening. ‐ Avoided until the anxiety disappears. ‐ Avoided until the client brings up the subject. ‐ Specific and direct. | Recall behaviors associated with anxiety. Remember that an individual loses ability to process information as the level of anxiety escalates. |
4443 The nurse is working with a client who is anxious. Correct answer: 4 Safety needs have a higher priority than psychosocial needs, even when they are intense. Which nursing diagnosis has the highest priority at this Options 1, 2, and 3 are applicable nursing diagnoses for anxious clients, but safety has the time? highest priority. ‐ Defensive coping ‐ Ineffective denial ‐ Risk for loneliness ‐ Risk for self‐directed violence | Notice that three of the options indicate psychological needs. Recall Maslow's theory of human motivation to select the most basic need of the choices available. |
4444 The nurse has taught an anxious client a relaxation Correct answer: 2 The goal of teaching calming techniques such as relaxation therapy is to assist the client to technique. The nurse would evaluate the effect of the learn to experience anxiety without feeling threatened and overwhelmed. Relaxation therapy instruction on which client goal? "The client will: (option 1) does not assist a client to confront sources of anxiety, but rather to reduce the level of intensity of the anxiety. Keeping a journal (option 3) is a self‐monitoring technique but is not used to measure the outcome of relaxation. The goal is not to suppress anxious feelings (option 4) but to make them more manageable. ‐ Confront the source of the anxiety." ‐ Experience anxiety without feeling overwhelmed." ‐ Keep a journal of times anxiety is experienced." ‐ Suppress anxious feelings." | Think about times that you have used a relaxation technique. For what purpose did you decide to use it? |
4445 The nurse has established the following long‐term Correct answer: 2 Option 2 is correct. Long‐term goals for moderate anxiety should focus on assisting the client goal: "The client will learn new ways of coping with to understand the causes of anxiety and learn new coping strategies. Mild anxiety (option 1) anxiety." For which level of anxiety is this goal most does not require nursing intervention. Clients at high (severe or panic) levels of anxiety appropriate? (options 3 and 4) have very narrowed attention and cannot focus on learning. ‐ Mild ‐ Moderate ‐ Severe ‐ Panic | Recall cognitive characteristics at different levels of anxiety. |
4446 Which of the following would be the best nursing Correct answer: 1 To promote safety, the nurse should stay with extremely anxious clients. It is important that action for a client who is having a panic attack? the nurse remains calm and serene, use simple communication, and convey an attitude of calm authoritative competence. During a panic attack a client is unable to focus on teaching (option 2). The priority of the nurse is to provide safety, as clients at panic level anxiety are frantic and extremely disordered cognitively. Their judgment is impaired, they feel frantic, and they are therefore at high risk for injury if left alone (option 3). The client at panic level anxiety tends to be very overactive and restless. Assisting the client to engage in a simple repetitive task like deep breathing can be useful. Exploring possible sources of anxiety is appropriate when intervening in lower levels of anxiety (option 4). ‐ Remain with the client. ‐ Teach the client to recognize signs of a panic attack. ‐ Instruct the client to remain alone until the symptoms subside. ‐ Ask the client to describe what was happening before the anxiety began. | Recall that at the panic level of anxiety, people are frantic and unable to make sound decisions. |
4447 A client asks why a beta blocker medication has been Correct answer: 4 Beta blockers are effective in reducing cardiovascular symptoms (increased pulse and blood prescribed for anxiety. When answering this question, pressure, possible palpitations) associated with anxiety because they target the beta‐ the nurse should explain that this medication class is adrenergic receptors in the sympathetic nervous system (fight‐or‐flight response). Options 1, 2, effective for treatment of which symptoms associated and 3 are not cardiovascular symptoms and reflect symptoms that beta blockers will not with anxiety? relieve. ‐ Cognitive dissonance and confusion | Recall that beta blockers have their primary effects on cardiovascular functioning. Look for a cardiovascular‐related answer in the options. |
‐ Depression and suicidal ideations ‐ Insomnia and nightmares ‐ Palpitations and rapid heart rate | |
4448 A client who has refused to take the regular Correct answer: 4 Abrupt withdrawal from a benzodiazepine may lead to symptoms associated with prescribed dose of clonazepam (Klonopin) reports hyperarousal. Benzodiazepine use can quickly lead to physical dependency. Although the irritability, insomnia, tremors, and sweating. The nurse client's symptoms could be related to anxiety (option 1), the nurse notes that these symptoms concludes that the client is most likely, experiencing began after the client refused a benzodiazepine. Benzodiazepine use can quickly lead to symptoms associated with which of the following? physical dependency. Manipulation (option 2) is a purposeful behavior aimed at getting one's needs met at the expense of someone else. No data is given to suggest manipulation on the part of the client. Signs of benzodiazepine overdose (option 3) include severe drowsiness, ataxia, and impaired coordination. ‐ Anxiety ‐ Manipulation ‐ Overdose ‐ Withdrawal | Note the relationship of the onset of symptoms to the time of the client's having refused the medication. |
4449 The nurse is caring for a client with posttraumatic Correct answer: 2 People with PTSD often avoid interactions and develop an isolated lifestyle that prevents stress disorder (PTSD). Which statement by the client them from working and socializing with others. Clients are likely to feel victimized by the would indicate the most improvement? traumatic event (option 1). Options 3 and 4 reflect symptoms of PTSD, indicating the client is not yet showing improvement. ‐ "I am responsible for what happened to me." ‐ "I enjoy being back at work with my friends." ‐ "I like to stay awake all night." ‐ "I can’t relax. I stay alert all the time." | Recall behaviors common to persons experiencing PTSD. Notice that this question is asking for an indication of improvement. |
4450 The nurse is caring for a client with a somatoform Correct answer: 2 Option 2 is correct. Somatoform disorders are anxiety related disorders in which the disorder. Which of the following nursing interventions individual has physical symptoms for which there is no underlying physical basis. The five is most likely to be beneficial to this client? somatization disorders include somatization, conversion, pain disorder, hypochondriasis, and body dysmorphic disorder. These clients are obsessively interested in bodily processes and diseases and unconsciously use physical symptoms to attempt to reduce conflict and anxiety. They generally have great fears of abandonment and loss of love but are unable to express their feelings directly. Interventions that assist with anxiety reduction are therapeutic for these clients, who tend to develop more and more symptoms as their level of anxiety increases. Options 1, 3, and 4 are all incorrect because each of them would provide secondary gain and increase the likelihood of the client’s continuing to express physical symptoms instead of expressing needs and feelings more directly. ‐ Encourage seeking temporary relief from usual responsibilities ‐ Reinforce coping behaviors such as physical activity and relaxation techniques ‐ Support client's expression of physical discomfort ‐ Monitor client responses to prn medication with sympathetic attitude | Remember that somatoform disorders are classified as anxiety related disorders. Avoid choosing an option that would increase secondary gain. |
4451 When the nurse is caring for a client who was Correct answer: 2 Option 2 is correct. Conversion disorders, like other somatoform disorders, result when hospitalized for treatment of a conversion disorder, a individuals cannot express their needs (often to be loved) and feelings (often fear of primary goal is that the client will: abandonment) directly. They learn to have physical symptoms (loss of a bodily function in the case of conversion) to manage their anxiety. If the client can learn to express needs verbally, the need for using physical symptoms to avoid acknowledging conflict or anxiety will be minimized. Option 1 is incorrect as the client is not imagining the presence of the symptoms. The symptoms are real, but there is no objective physical reason for them. A more appropriate goal would be for the client to connect the physical symptoms to emotions being felt. Option 3 is incorrect because participating in adjunctive therapies like art and music therapy will be beneficial to the client and help reduce anxiety, but these therapies are not nearly as important as therapies which aim toward helping the person develop some level of insight into the meanings of the conversion symptoms. Option 4 would encourage dependency on the nurse, which would be a form of secondary gain. The client should be encouraged and guided toward being as independent as possible. ‐ State that physical symptoms are imagined. ‐ Verbally express conflicts and needs. ‐ Participate in art and music therapy. ‐ Have all physical needs met by staff. | Recall the underlying causes of conversion symptoms. Recognize that extreme measures are taken to reduce anxiety. |
4452 When conducting a teaching session with a client who Correct answer: 3 Option 3 is correct. Since the client is experiencing physical symptoms that do not have an has a somatization disorder, the nurse should focus on objective physical basis, it is vital for the client to begin to view the physical symptoms which of the following? differently. The nurse should work toward assisting the client to see that the symptoms are related to life circumstances, interpersonal relationships and unmet needs of the individual. Teaching about the relationship between mind‐body reactions and stress is one way of doing this. Options 1, 2, and 4 are inappropriate because, in varying ways, each of them focuses on the physical symptom without connecting the physical and psychological spheres of the individual's functioning. They would reinforce the client's erroneous assumption that a physiologic disorder is present. ‐ Drug interactions and side effects ‐ Physical sensations that may be experienced during sigmoidoscopy and other tests ‐ Mind‐body interaction in daily life and stressful situations ‐ Treatment approaches for physical symptoms | Recall that clients with somatization disorder are unaware of the relationship between their emotional experiences and their physical symptoms. |
4453 A client diagnosed with a conversion disorder reports Correct answer: 3 Option 3 is correct. Conversion disorder, which is the most common of the somatoform inability to see but rarely bumps into objects when disorders, is characterized by deficits in voluntary motor or sensory function. The dysfunction walking unassisted. What underlying factor should the does not correspond with current scientific understanding of the nervous system, nor does the nurse recognize in this situation? The client: dysfunction present in usual ways, such as stumbling into things when blind from organic causes. Conversion blindness is not the result of a physical change in structure or function; rather, it is an unconscious attempt to avoid conflict and anxiety. The client's expression of symptoms is a reflection of the client's particular way of understanding blindness. Option 1 is incorrect as there is no evidence that other senses are heightened when conversion symptoms such as blindness are present. Option 2 is incorrect because the term "faking" indicates conscious awareness and deliberateness. When these are present, the individual is malingering. Option 4 is incorrect as the client has unconscious awareness of environmental hazards. On the conscious level, the client is blind. ‐ Has highly developed other senses to compensate for blindness. ‐ Is faking blindness in order to obtain sympathy from family members. ‐ Is experiencing blindness in order to avoid some conflict or role. ‐ Has conscious awareness of environmental hazards | Recognize that this question is asking for identification of the psychodynamics of conversion symptoms. Also, avoid choosing an option that includes a judgmental term like "faking it." |
4454 | A client with body dysmorphic disorder is to be Correct answer: 3 discharged from a surgical unit following an elective face‐lift procedure to correct what the client calls "elephant‐like texture and wrinkles." What should the nurse include in the discharge teaching plan? | Option 3 is correct. Body dysmorphic disorder is a psychological disorder that requires mental health treatment. Clients usually have a normal appearance but are preoccupied with imagined defective body parts, often of the face, skin, genitalia, thighs, hips and hair. Thoughts about this body part become obsessional, and the client engages in compulsive behaviors such as mirror checking, camouflaging, and other "corrective" measures. Because of the intense preoccupation and embarrassment about the imagined defect, the client is apt to be socially isolated and seeks medical treatment for relief. Option 1 focuses on the skin, not the underlying psychological issues. This focus will reinforce the client's idea that the skin requires "fixing." Of course the nurse should teach the client about ways to maintain the integrity of the surgical wound, etc., but this should be done matter‐of‐factly without undue emphasis. Option 2 is incorrect as the client is already prone to solitary activities because of fear of others seeing the "defect." The nurse should encourage resuming social contact with others, but it is very likely that the client will have difficulty doing this. Option 4 suggests that the skin near the hairline has not been "fixed." The client is now likely to see this as confirmation of a continuing "defect." | Select an option that addresses underlying causes of the client’s symptoms, not the symptoms themselves. |
‐ Encourage use of skin softeners as soon as medically possible. ‐ Promote solitary activities to avoid embarrassment over appearance. ‐ Encourage continuing with mental health treatment. ‐ Suggest that wrinkles near the hairline can easily be removed later. | |||
4455 A client with body dysmorphic disorder is admitted Correct answer: 4 Option 4 is correct. In any nursing care situation, safety and maintenance of life always take for severe depression with suicidal ideation. The client precedence over psychologic issues, even when these issues are intense and lead to other spends hours per day staring into the mirror looking problems, such as depression. The client's statement indicates that a nurse has engaged the for "large skin pores." Which client statement would client in a no‐self‐harm contract, which is an appropriate intervention with a suicidal client. In indicate that the priority goal of the nursing care plan options 1 and 3 the client indicates a continued focus on the appearance of the face. Reactions has been achieved? to or preoccupations with facial appearance are psychological experiences of the individual and are therefore secondary in importance to physiologic and safety needs. Option 2 indicates that the client is not utilizing therapeutic supports to assist with resisting urges for self harm. Either the nurse has failed to offer the client a no‐self‐harm contract, or the client agreed to the contract but did not comply with its stipulations when feeling suicidal. | Notice that the client has two major problems. Decide which one is most important to address. Recall the basic relationship between physiologic and psychologic needs. | ||
‐ "I realize that my face can never be perfect, and I’ll just have to settle for what I am." ‐ "I had feelings of hurting myself yesterday, but I kept quiet and held myself back." ‐ "I’ve stopped looking in the mirror, but I can feel that my face is not right." ‐ "I'm not thinking of hurting myself now, but if I start feeling that way again, I will call the nurse." | |||
4456 | A client has been evaluated for complaints of Correct answer: 2 stomach pain, which the client believes to be caused from cancer. The client is very preoccupied with the pain experience. After hearing that gastroscopy results were negative for disease, the nurse notes the client's speech becomes loud and pressured. The client complains of chest pain and "wild heart beat." The client's blood pressure is 138/88, and the pulse is 124.<BR /> | Option 2 is correct. This client is showing typical physiologic manifestations of anxiety at this time. If this client has somatoform disorder, as the symptoms should suggest to the nurse, the anxiety was probably precipitated by receiving news of the negative gastroscopy findings. Somatization symptoms arise from underlying anxiety and exist for the purpose of reducing the anxiety and allowing the person to avoid the causes of the anxiety. For this reason, rather than relieving anxiety, hearing new of negative physical findings would increase the client’s anxiety. Option 1 is incorrect because although the client is experiencing pain, the priority diagnosis is the current presentation of anxiety, which is also the cause underlying the pain. Option 3 is incorrect as there is no indication of hopelessness in the situation described. Option 4 is incorrect because there is no indication of disturbed body image in the situation described, although clients experiencing chronic pain of any sort are subject to having body image changes. | Recognize that since this client uses somatic symptoms to express feelings, receiving news that there is no somatic problem will likely be perceived as unwelcome. |
‐ Pain ‐ Anxiety ‐ Hopelessness ‐ Disturbed body image | |||
4457 When the client has a pain disorder, which of the Correct answer: 2 following client characteristics should the nurse anticipate? | Option 2 is correct. One of the most frequent reasons for people to seek medical attention is pain. When testing rules out any organic basis for pain and significant impairment in functioning exists because of the pain, pain disorder may exist. When it does, the client usually focuses on the pain and is controlled by it, thus being relieved of awareness of underlying anxiety. Pain disorder, like other somatoform disorders, is classified as an anxiety disorder. Option 1 is incorrect because clients with somatoform pain are at very high risk for excessive use of narcotic or sedative medications. This is especially true if there are co‐morbid conditions like depression and personality disorders. Option 3 is incorrect as persons with pain disorder generally have a significant disability and are unable to perform ascribed or assumed roles. Option 4 is incorrect because when somatoform pain disorder exists, there is no structural damage at the site of the pain, and no organic reasons can be established for the pain. | Recall the basic psychodynamic elements of a pain disorder. If the person were aware of the interplay of anxiety and pain, would there be a reduction in the level of pain? |
‐ A preference to handle pain without medication ‐ A lack of understanding of the relationship between pain and stress ‐ Ability to perform role expectations in spite of the pain ‐ Structural damage at the site of pain | ||
4458 The client has many physical complaints for which no Correct answer: 1 organic basis has been established. A priority nursing diagnosis for this client will be which of the following? ‐ Ineffective coping ‐ Hopelessness ‐ Impaired verbal communication ‐ Pain | Option 1 is correct. When an individual has many somatic complaints that do not have an identifiable origin in physiologic functioning, it is appropriate to consider possible causative factors from the person's psychologic functioning. Generally it is thought that such people are expressing anxiety and problems in living through their somatic complaints. The person, however, is consciously unaware of contributing stressors and stress and is therefore unable to use other means to cope with anxiety. Option 2 is incorrect as hopelessness may develop in the person with chronic somatoform symptoms, but it is not generally recognized as a basic part of somatoform disorder. If it does occur, it is secondary to the continuing and unrelieved physical symptom, which itself is secondary to anxiety. Option 3 is incorrect because clients with somatoform disorder do have impaired ability to communicate. Organs involved in the communication process are intact and functioning. The unconscious mind interferes with their communication style, and they express their messages symbolically and non‐verbally through the particular physical symptom they have. Option 4 is incorrect as pain is a possible manifestation of somatoform disorder, but it is not a universal experience in all clients in this diagnostic group. | Recall basic psychodynamic considerations in psychophysiological and somatoform disorders. |
4459 When caring for a client with chronic pain disorder, Correct answer: 1 which of the following interventions should the nurse utilize? ‐ A program of physical exercise ‐ Music therapy ‐ Patient‐controlled analgesia pump | Option 1 is correct. Physical exercise, within the client's ability level, reduces muscle tension and pain. Additionally, exercise creates a feeling of greater self‐efficacy. Option 2 is the second‐ best response. Music therapy could result in reduced anxiety, which would be therapeutic for this client. However, an activity that would result in relaxation of muscles would be expected to be more beneficial for this client. Option 3 is incorrect as persons with chronic pain problems are at high risk for abuse or dependency on narcotics and sedatives. Non‐chemical means of pain control are preferable for these clients. Option 4 is incorrect because individuals with chronic pain should continue to be as active as possible. Placing the client on bed rest will prevent additional psychologic and physiologic problems. | Look for an option that approaches the underlying cause of pain, rather than the pain itself. |
4.‐ Complete bed rest | ||
4460 Which of the following is the most appropriate Correct answer: 1 nursing diagnosis for a client with pain disorder who is homebound and unable to work for the past 5 years? ‐ Impaired role performance ‐ Anxiety ‐ High risk for injury ‐ Disturbed sensory perception | Option 1 is correct. Chronic pain interferes with social and occupational functioning, prompting further stress and anxiety. The diagnoses in options 2, 3, and 4 do not address the long‐term homebound status and unemployment of the client. | Note the duration of symptoms and the limitations imposed by them. |
4461 A client who developed a glove anesthesia of the right Correct answer: 2 (dominant) hand was unable to play in a piano competition yesterday. The nurse will recognize that the consequence of the symptom, not having to perform, is best described as: ‐ Phobia. ‐ Primary gain. ‐ Carpal tunnel dysmorphia. ‐ Somatic delusion. | Option 2 is correct. This response describes unconscious avoidance of responsibilities or conflicts (competing in the recital) as a primary gain. The client's anxiety is reduced, and the client does not have to take personal responsibility for not playing; rather, the client can "blame" symptoms. Glove anesthesia does not have an organic basis and follows a pattern that is neither anatomically or neurologically possible. The client's symptom does not indicate unnatural fear of an actual object or situation, which is what occurs when a person has a phobia (option 1). Carpal tunnel dysmorphia is an organically caused problem and follows specific nerve tracks (option 3). Somatic delusions are fixed, false thoughts about the body that are sometimes present in persons with certain types of psychoses. This client is not psychotic. Conversion responses are considered to be a type of anxiety disorder (option 4). | Think about nerve distribution patterns in the hand. Ask yourself if it is neurologically possible for a person to experience anesthesia of the "glove" pattern. |
4462 The client who has body dysmorphic disorder says to Correct answer: 4 the nurse, "I can't get rid of the idea that my ears are weird‐looking." Which of the following is the most appropriate outcome criterion? The client will: ‐ Consider plastic surgery to reshape the ears. ‐ List three benefits of having unusual ears. ‐ Understand how body image is affected by maturation. ‐ Explore possible explanations for dissatisfaction with body image. | Option 4 is correct because it suggests that the client examine this interrelationship of personal emotion and body image. Additionally, it sets the stage for other interventions to deal with preoccupation with imagined physical defects. These include cognitive‐behavioral approaches such as (1) identifying and challenging distorted perceptions of the client and/or (2) interrupting self‐critical thoughts. A crucial early intervention is to help the person to identify and express feelings. Option 1, along with Option 2, would support the client’s preoccupation with appearance of the ears and would likely increase the client’s level of anxiety and dissatisfaction. Option 3 suggests that the client consider theory, but the theory mentioned is maturation. The option does not suggest that the client should examine the interrelationship of personal emotion and body image. | Notice that options 1 and 2 focus on the ears, with which the client is already preoccupied. Eliminate these choices very quickly and then decide between the remaining two options. |
4463 A female client with a 15‐year history of somatization Correct answer: 2 disorder is to be discharged from the first psychiatric hospitalization. Which client statement indicates that nursing care has been effective? | Option 2 is correct because it indicates accurate awareness of mind–body interaction and shows that the client no longer persists in (1) identifying illness as physical in origin and (2) feeling that medication is necessary to control the symptoms. Both of these are characteristic of somatization disorder. Option 1 indicates that the client still sees symptoms as something to medicate. Option 3 suggests that the client is receiving secondary gain from the family. A sign of progress would be a statement indicating recognition of secondary gain and its part in the chronicity of the symptoms. Option 4 indicates that the client is still focused on the idea of having an undiagnosed, untreatable problem. | Look for a positive change in behavior. Eliminate any options that indicate a static condition. |
‐ "I need to make sure that all of my medications are sent home with me." ‐ "I see now that when I get stressed, my <i>body</i> speaks for me." ‐ "My family is so good to me when I am sick like this." ‐ "There are so many illnesses that you nurses simply do not know about." | ||
4464 A client treated for hypochondriasis has an upsetting Correct answer: 4 phone conversation with her husband and subsequently requests an analgesic. The client states, "My head is killing me. I know there is a tumor in there somewhere, or it wouldn't hurt like this." The nurse's best response is: | Option 4 is correct. The nurse should provide physical care for the client in a matter‐of‐fact manner and, at the same time, should help the client note how symptoms increase at the time of stress and can be a way of coping with stress. The statement in Option 1 is confrontive and interpretative and will likely cause the client to feel frustrated and angry, which can increase the intensity of the headache. Option 2 would focus further attention the physical aspects of the client’s functioning without helping the client to move toward developing an awareness of the interrelationship between pain and emotions. It also suggests that the nurse requires physician guidance before intervening. The nurse should know that it is appropriate to provide physical care in a matter‐of‐fact manner, while at the same time helping the client to understand how symptoms increase in a time of stress and can be a way of coping with stress. Option 3 is a critical statement that will likely cause the client to feel frustrated and angry, which can increase the intensity of the headache. | Think about the nature of the pain and what underlies it. Ask yourself if symptomatic measures to relieve the pain will prevent future pain. |
‐ "You have no brain tumor. It is just your anger toward your husband." ‐ "I’ll get your vital signs and then call your doctor if they are abnormal." ‐ "You must try not to rely on the pain pills so much since they are addictive." ‐ "I’ll get your medication and then let's talk about what just happened." | ||
4465 While taking the nursing history, a client with body Correct answer: 2 dysmorphic disorder says, "After three surgeries, my jaw line still isn't right. Plus, it took five surgeries before my nose was finally fixed." The most appropriate nursing diagnosis is: ‐ Health‐seeking behaviors. ‐ Disturbed body image. ‐ Disturbed personal identity. ‐ Risk for self‐mutilation. | Option 2 is correct. This client is preoccupied with the appearance of the body, not the health of the body. Body dysmorphic disorder is characterized by preoccupation with imagined defects, usually on the face or head, that prompt the client to seek medical treatment. In option 1 the client's behavior does not suggest health‐seeking behavior, but rather relief from feelings that the body is defective. In option 3 this client's history and statements show a preoccupation with the appearance of the body, not with personal identity. In option 4, although great dissatisfaction with the appearance of the body is expressed, there is nothing in the client's statement to suggest immediate threat for self‐mutilation. | Look for the obvious. Don't try to make this question more difficult than it is. |
4466 Which of the following does the nurse expect to Correct answer: 3 assess during the nursing history of a client with pain disorder? | The correct option is Option 3 because the pain of somatization disorder often begins after trauma or injury. The client with pain disorder continues to express discomfort even after medication is given, does not respond well to medication, and exhibits no insight into the role of stress on pain perception. Individuals with pain disorder generally do not show a good response to analgesics and are at high risk for substance abuse and dependency (option 1). In pain disorder, the client is not indifferent to the pain. Instead the client is consumed by the pain experience (option 2). Indifference to pain is most associated with pain of the conversion type. Clients with pain disorder see pain as something that is imposed on them (option 4). | Recognize that this client's pain is not somatically caused. Consider possible psychological purposes of pain. |
‐ Good responses to past pharmacological treatment ‐ Indifference to the discomfort of pain ‐ Pain does not respond well to medication ‐ Insight into relationship between stress and pain | ||
4467 | A client is assessed as having bilateral stocking Correct answer: 1 paralysis with inability to walk. The most important nursing care approach will be to assist the client to: | Option 1 is correct. Focusing on the effects of the symptoms may help the client understand the relationship between symptoms and stressors and would help to identify secondary gains the client might be experiencing. Conversion symptoms are thought to represent unconscious attempts to solve a stressful dilemma or set of circumstances. The person "gets" two things from having the symptom: primary gain (i.e., avoiding a stressful or conflicted activity) and secondary gain (e.g., support from others because of having the conversion symptom). Options 2, 3, and 4 option will not assist the client to understand the relationship between symptoms and life circumstances. | Consider what effect not being able to walk would have on a person's life. Could it bring psychologic relief? Might others "come to the rescue?" |
‐ Explore how personal life is affected by being unable to walk. ‐ List the side effects of prescribed medication ‐ Be referred for outpatient physical therapy ‐ Demonstrate crutch‐walking techniques. | |||
4468 | A client says to the nurse, "I know you think this is in Correct answer: 3 my head, but my pelvic pain is real. I have a serious malignancy and am going to die." The nurse is aware that the physician just told the client that despite very extensive diagnostic testing, no abnormalities have been found. The nurse's best response is: | Option 3 is correct. It shows that when the nurse shows empathy by verbalizing the implied feeling of the client, an opportunity is created for the client. Specifically, the client can now express feelings and begin to connect these feelings to anxiety‐producing situations and the symptoms being experienced. Option 1 leaves the client feeling that a misdiagnosis has occurred. It will not assist the client to verbalize feelings, nor will it assist the client to learn to express self in nonsomatic ways. Option 2 focuses totally on the physical aspect of the client’s functioning and makes no effort to assist the client to recognize the interrelationship of emotions and the symptoms. Option 4 shows a lack of concern for the client and can lead to feelings of rejection, which can increase the client’s anxiety and therefore the preoccupation with own physical health. | Look for a response that could help the client connect anxiety with preoccupations about health. |
‐ "I guess it could be true. Sometimes doctors miss a diagnosis." ‐ "I realize that you do have pain and hurt a lot." ‐ "It must be hard for you to accept the testing results." ‐ "How about resting now and asking your doctor more about it later?" | |||
4469 | A client with a somatization disorder has been Correct answer: 4 attending group therapy. Which client statement suggests to the nurse that the therapy has been effective? | Option 4 is correct. This response shows that the client has profited from the opportunity to talk and gain support from others, both of which free up energy associated with unexpressed emotions. Unexpressed emotions and the energy associated with them play a significant role in the development of nonsomatically caused pain. The Option 1 statement gives no indication that the group therapy has been effective. Instead, the client is still focused on the perceived pain. Option 2's statement suggests that the client does not recognize commonalities between other clients and self. Instead, the client is still focused on the perceived pain. Option 3 suggests that the client has not participated fully in group therapy and cannot therefore be expected to have received full benefit from the therapy. | Look for the most insightful comment of the client. Eliminate any that show lack of change. |
‐ "I think I'd better get some pain pills. My back hurts from sitting in group." ‐ "The other people in the group have <i>mental</i> problems!" ‐ "I haven't said much, but I get a lot out of listening." ‐ "I feel better physically just from getting a chance to talk." |
4470 An older client with chronic low back pain receives Correct answer: 2 Secondary gains are unintentionally sought benefits that result from an illness, such as cooking and cleaning help from her extended family. support that otherwise might not be available. These benefits serve to reinforce illness The mental health nurse anticipates that this client behavior. The family's response (cooking and cleaning for the client) can be viewed as a benefits from which of the following in this situation? secondary gain for the client. Primary gains (option 1) are symbolic resolutions of unconscious conflict that decrease anxiety and keep the conflict from awareness. Attention‐seeking behaviors (option 3) are not indicated in the question. Attention‐seeking behavior directly calls attention of others to the individual who has experienced lack of satisfaction of either conscious or unconscious needs. Malingering (option 4) is motivated by deliberate conscious decisions of the individual. The individual offers a complaint, but has no actual dysfunction or symptom. Malingering is used to achieve secondary gain, but in this question, the client has actual back pain. ‐ Primary gain ‐ Secondary gain ‐ Attention‐seeking ‐ Malingering | Consider how the responses of the family members might impact on the client's symptoms. Think also, "Would I be likely to work to give up a symptom if my family took over my cooking and cleaning?" |
4471 The spouse of a woman diagnosed with somatization Correct answer: 3 This response offers empathy and information about the spouse's illness. Family members disorder tells the nurse that he "is running out of must understand the mechanism of somatization disorder and have their own needs patience with her" and feels that "she has all those addressed. The chronic nature of the physical complaints is very frustrating and disruptive of many health problems on purpose." The best response family functioning. The nurse must be responsive to this. Option 1 suggests an approach that by the nurse is: would be confrontational and therefore likely to increase relationship difficulties between the spouses. Option 2 fails to offer empathy to the spouse. In fact, it could make the spouse feel defensive. In essence it says, "You aren't attentive enough." While the statement in option 4 is perhaps factual, it does not offer empathy to the spouse. The nurse should be ever mindful that the chronic nature of the client's physical complaints is very frustrating and disruptive of family functioning. ‐ "Have you tried asking her? I think she'd tell you the truth." ‐ "Your wife is trying to gain your attention." ‐ "She doesn't have the problem on purpose. However, this is probably difficult for both of you." ‐ "She has some significant emotional problems that she cannot admit." | Notice that only one of the responses addresses the spouse's feelings in any way. |
4472 The client has chronic pain disorder. Which statement Correct answer: 1 Option 1 indicates beginning development of insight, which is a desired outcome for nursing by the client indicates to the nurse that the plan of intervention. Understanding the relationship between physical symptoms and stress helps the care has been successful? client to gain control of outcomes. Physical activity and limited use of pain medications (option 2) are indicated when the client has pain disorder. The client tends to allow the pain to dominate all spheres of functioning. Relaxation techniques (option 3) are most effective when practiced on a regular, not episodic basis, although they can be employed when pain levels are just beginning to rise. Clients with chronic pain disorders are at high risk for dependency on drugs, whether prescribed or nonprescribed (option 4). These clients should be taught nonpharmacologic methods of pain relief. ‐ "I realize that my pain can be influenced by stress." ‐ "I should avoid most physical activity." ‐ "Relaxation techniques only help when I am anxious about my pain." ‐ "I should keep myself pain‐free by increasing my pain medication as I need it." | Notice that the question is asking for an indication of progress on the part of the client. Use this as a benchmark against which to evaluate each option. |
4473 The client has a conversion disorder manifested by Correct answer: 4 When individuals have a conversion disorder, symptoms assist the client to avoid anxiety stocking and glove anesthesia. Which nursing diagnosis about unconscious conflicts. Effective means of coping would reduce the need to use physical is most appropriate for the nurse to write on the symptoms to express needs. Persons with conversion symptoms do not generally suffer injury client's plan of care? as a result of the conversion symptoms (option 1), and they do not have altered thought processes such as delusions (option 2). Their presenting symptom is physiologic, not cognitive or psychologic. The client with conversion symptoms is not normally at significant risk for suicide (option 3). The conversion symptom is protecting the individual from awareness of some underlying affect or situation. Many persons with conversion symptoms show a curious kind of bland emotional response to their symptoms. ‐ Risk for impaired tissue integrity ‐ Disrupted thought processes ‐ Risk for suicide ‐ Ineffective individual coping | Look at all options carefully. Think about what would have to happen in order for a person to express a psychologic conflict in a somatic manner. |
4474 What would the nurse expect the client who has a Correct answer: 4 Somatization disorder is characterized by chronic, multiple vague physical symptoms in somatization disorder to reveal in the nursing history? multiple body systems that impair role performance. The disorder usually begins before age 30 (option 1), and symptoms are a major source of concern throughout the client's life. The client reports significant distress and usually seeks out multiple providers for healthcare. Clients with somatization disorder do not generally have dissociative experiences (option 2) or ignore their symptoms (option 3). Instead, they focus obsessively on their body. When one somatic complaint is managed, another emerges. ‐ Abrupt onset of physical symptoms at menopause ‐ Episodes of personality dissociation ‐ Ignoring physical symptoms until role performance was altered ‐ Numerous physical symptoms in many organ systems | Remember that clients with somatization disorder are expressing psychologic distress through bodily symptoms and that the course of their illness is chronic and relapsing. |
4475 When caring for a client with hypochondriasis, the Correct answer: 3 Discharge criteria for clients with somatoform disorders, which are associated with anxiety, nurse should take which action? include understanding the relationships between symptoms and anxiety‐provoking events. The nurse should focus on assisting the client to understand this relationship. When the client has hypochondriasis, it is important to avoid focusing on the client's past and associated physical conditions or complaints (option 1). These actions would likely increase the client's anxiety and increase the preoccupation with symptoms. The client with hypochondriasis usually has a number of care providers in succession, going from one to another in a search for a cure, so encouraging a second opinion may suggest the presence of a serious problem, thus increasing the client's anxiety and further intensifying symptoms (option 2). When the client has a somatoform disorder, family members must learn not to reinforce physical symptoms or illness behavior of the client (option 4). ‐ Explore the details and history of the client's early life and illnesses. ‐ Encourage the client to seek second opinions about the symptoms experienced. ‐ Assist the client to identify relationships between life events and physical symptoms. ‐ Have the spouse encourage the client to talk more about the symptoms. | Recall principles of behavior therapy and remember that the attention of others can serve as a powerful social reinforcer. This will help eliminate some of the distracters in the question. |
4476 The nurse would anticipate that health assessment of Correct answer: 3 Clients with a conversion disorder have no physiological basis for the symptoms. Options 1, 2, a client with a conversion disorder is likely to reveal and 4 have physiological bases. Recall that conversion symptoms represent deficits in which of the following? voluntary motor or sensory functioning for which there are no objective explanations or findings. ‐ Elevated serum calcium levels ‐ Sensory loss along affected nerve tracks ‐ No significant physical or laboratory findings ‐ Motor loss to body parts along the nerve tracks | Notice that only option 3 does not relate to current scientific understanding of the nervous system or functioning of the body. |
4477 For a client with a somatoform disorder, the nurse Correct answer: 1, 2 Persons with somatoform disorders experience ineffective role performance because the plans to write which nursing diagnoses in the client's illness interferes with the usual responsibilities in life. These persons are controlled by their plan of care? Select all that apply. somatic symptoms and experiences, and significant others suffer greatly because of the preoccupations of the individual with somatoform disorder. Persons with somatoform disorders experience ineffective coping because they use their bodies to express emotional conflicts or needs (option 2), rather than expressing those needs more directly. Unless specific individual data is available that suggests risk for violence or impaired oxygenation, these NANDA problems are not an average part of somatoform disorder. Health‐seeking behaviors (option 5) is one of the nursing diagnoses that deals with healthy, adaptive efforts. The client with somatoform disorder cannot be expected to display behaviors that are consistent with this nursing diagnosis, because illness is a way of life with these clients. Their "doctor shopping" is not done in an effort to find wellness, but rather to confirm illness. ‐ Ineffective role performance ‐ Impaired coping ‐ Risk for violence, self‐directed ‐ Impaired oxygenation ‐ Health‐seeking behaviors | Recall that the client with somatoform disorder faces an ever‐changing array of physical symptoms that suggest a physical disorder. Do you think that this person could fully meet role expectations, such as those of being a parent? |
4478 A hospitalized client diagnosed with a somatization Correct answer: 1 The nurse should be aware that the client with somatization disorder is indeed experiencing disorder asks for prn medication for stomach pain. The pain, although physical diagnostic results may be negative. The client’s pain should be relieved nurse's best response is to: in a matter‐of‐fact manner. Prompt reduction of pain is the priority. Confronting the client with the negative physical findings (option 2) will likely increase the client's anxiety level and therefore the level of pain. Once the client’s pain is reduced, then the client can be taught relaxation techniques, like deep breathing (option 3). Teaching should not be attempted when the client is experiencing pain. The nurse should respond matter‐of‐factly to the client's request for medication and give the medication as ordered (option 4). Unnecessary delays will increase the client's anxiety and therefore the pain level. ‐ Matter‐of‐factly assess the pain and administer prn medication. ‐ Inform the client of negative gastroscopy findings. ‐ Teach the client to take slow, deep breaths. ‐ Delay fulfilling request for medication to see if the pain subsides first. | Remember that the pain experience is real, even though an organic cause for the pain cannot be established. Avoid being critical and judgmental of the client. |
4479 A client treated for hypochondriasis would Correct answer: 3 The statement in option 3 indicates some basic level of understanding about the meaning of demonstrate understanding of the disorder by which hypochondriacal concerns. Education for a client with hypochondriasis is effective if the client statement to the nurse? is aware that the symptoms present no real danger. Giving up the preoccupation with the serious nature of the symptoms is a gradual process of cognitive restructuring. Option 1 suggests that the client believes that the illness is too serious to be identified. Option 2 indicates that the client feels ill and misunderstood by the family. Option 4 suggests that the client is searching for reasons to explain symptoms being experienced. ‐ "I realize that tests and lab results cannot pick up on the seriousness of my illness." ‐ "Once my family realizes how severely ill I am, they will be more understanding." ‐ "I know that I don't have a serious illness, even though I still worry about the symptoms." ‐ "I realize that exposure to toxins can cause significant organ damage." | Identify the most positive client behavior. Recall that successful cognitive restructuring occurs in gradual steps. |
4480 | When the nurse is caring for a client with depersonalization, it is most important that the plan of care include which of the following? | Correct answer: 3 | Option 3 is correct. Depersonalization, which is probably underdiagnosed, is often not responsive to therapy or medications. Characterized by persistent feelings of being detached from one's body and feeling as if in a dream, depersonalization disorder is thought to relate to emotional abuse in childhood. Their primary symptom, which results from the defense mechanism of dissociation, is the feeling of being detached or living outside their own bodies. Option 1 is incorrect because while in a depersonalized state, individuals are oriented and in contact with reality. They know they are not living in a dream, even though the world seems dream‐like to them. Option 2 is incorrect as clients who are depersonalized can communicate well verbally. Option 4 is incorrect because self mutilative behavior is not associated with depersonalization disorder. Rather it is more common in persons experiencing dissociative identity disorder. In these persons, one or more of "alters" can be hostile and destructive toward the primary personality, which is seen as the occupier of "the body." | Remember that although both involve the defense mechanism of dissociation, states of depersonalization are different from dissociative identity disorders. |
‐ Frequent reorientation to time and date ‐ Assistance with expressing self verbally ‐ Teaching about the importance of long term treatment ‐ Protection from self mutilation. | ||||
4481 A client with a depersonalization disorder reports, "I Correct answer: 4 am beginning to feel weird again, like this is all unreal." What is the nurse's best action? ‐ Monitor the client's vital signs and report them to the physician. ‐ Suggest that the client lie down with eyes closed. ‐ Guide the client in taking slow, deep breaths. ‐ Ask the client to focus on the nurse's voice and look directly at the nurse. | Option 4 is correct. This intervention is called grounding the client. Grounding involves having the client focus on real, concrete things that can be seen or heard and redirects the client's attention from the depersonalization experience. This in turn interrupts the anxiety response. Option 1 is incorrect because when the client is depersonalizing, the nurse should remain with the client and use the grounding technique to interrupt the depersonalization process. Option 2 is incorrect as the client who is depersonalizing should be helped to focus on something that is happening outside of the self in the external world. If the client were left alone with closed eyes, this could accelerate the depersonalization response. Option 3 is incorrect because it is the second best response. The nurse's intent in this intervention is probably to reduce anxiety, but taking deep breaths calls for an internal focus. The client who is depersonalizing should be assist to develop an external focus. | Recognize the need to assist the client to develop an external focus. | ||
4482 | A client has been attending a support group for | Correct answer: 3 | Option 3 is correct. Support groups held for survivors of natural disasters are a form of crisis | Consider what psychologic support is in any situation, and then apply that concept to this client’s situation. |
people in a community whose homes were destroyed | intervention. They are intended to help the survivor create meaning of the event, obtain | |||
by a hurricane. Which statement by the client indicates | emotional and material support and reinforce positive coping efforts.<BR /> | |||
that the goals of attending a support group have been | ||||
met? | ||||
‐ "I'm feeling fine, but trouble never does bother me." | ||||
2.‐ "I know that other people lost a lot, but that was nothing compared to me." | ||||
3.‐ "I've learned a lot about how to handle things. The other folks are really helpful." | ||||
4.‐ "I think that complaining about an act of nature just wastes my time." | ||||
4483 The nurse assesses a client with dissociative identity Correct answer: 1 Option 1 is correct. Clients with DID often describe the experience of amnesia for events disorder (DID) for memory loss that is: when another personality is dominant, as "lost time." Option 2 is incorrect because when DID is present, the principal personality may or may not be aware of the presence of other personalities, or "alters." Option 2 is incorrect because the amnesia of the client with DID is not restricted to non‐awareness of alter personalities. Indeed memories of large parts of the client's life experiences may be lost. Option 3 is incorrect as the amnesia associated with DID may take any form: localized, selective, generalized or continuous. When situations of specific abuse have overwhelmed the individual and led to development of DID, the primary personality does not have memory of the specific events. Some "alters" may have this memory. Option 4 is incorrect because when DID is present, if the primary personality experiences amnesia, these memories remain submerged and outside of the individual’s awareness. ‐ Characterized by episodes of "lost time." ‐ Restricted to forgetting that there are other alters. ‐ Continuous, from the time of abuse. ‐ Characterized by forgetting to do things, but remembering later. | Recall the unconscious purposes served by dissociative responses. Recognize that memory loss can be extensive. |
4484 A client's best friend was killed in an automobile crash Correct answer: 1 Option 1 is correct. Verbalization about the event and gradually facing its reality in a safe that injured the client. The nurse determines that environment will decrease anxiety so that the experience may be reconstructed and which of the following would be an appropriate short‐ remembered. Option 2 is incorrect as the client’s current amnesia is probably a protective term goal for this client who does not recall the mechanism intended to reduce the client’s anxiety and/or guilt. As memories begin to filter accident? back into consciousness, the client should not work to prevent the recall from occurring. Option 3 is incorrect because day three is too early to expect the client to have a plan for safer driving. At this point the client is still amnesic of the event and cannot be expected to develop a strategy for future driving. Option 4 is incorrect as this is not a short term outcome, which is what the question is asking for. ‐ Talk to people from the accident scene and read accounts of the crash by week 1. ‐ Avoid efforts to remember the accident until week 4. ‐ Establish a plan for safer driving by day 3. ‐ Establish a suitable memorial for the friend by week 4. | Recognize the protective purpose served by this client's amnesia. |
4485 The spouse of a client who tends to dissociate under Correct answer: 4 Option 4 is correct. It suggests a method for external "grounding" of the client. While not stress says, "What can I do to prevent or help with merely being around other people prevents the individual from dissociating, any person who is this?" What would be the best response by the nurse? near can implement this technique when the client appears to begin dissociating. Grounding helps help to give the client a focus on external reality and decrease anxiety being experienced. A reduction in the anxiety level can then avert the dissociation in process. Option 1 is incorrect as merely being around other people does not help prevent dissociation. A more active approach must be used to bring about that end. Option 2 is incorrect because it implies that dissociation is a willful act of the individual. This is inaccurate, as dissociation is called into play by the unconscious mind of the individual. Option 3 is incorrect as it is dismissive and somewhat critical of the spouse's concern. ‐ "You need to get your spouse out around more people and prevent isolation." ‐ "If you will ignore this, your spouse will eventually stop this behavior." ‐ "I would suggest that you leave this up to your spouse's doctor." ‐ "When you notice anxiety, use your spouse's name and try to direct your spouse's attention to you." | Remember that when people are "spacing out," as in dissociation, focusing on a realistic something or someone can help to interrupt the dissociation. |
4486 The partner of a client who has several alters Correct answer: 2 Option 2 is correct. All family members are affected by dissociative identity disorder (DID). (personalities) is puzzled about why the couple's Children must also find ways to understand and deal with what is occurring to a parent, rather children are included in family therapy. What is the than denying what is obvious or proceeding on incorrect assumptions that are not challenged best explanation by the nurse? by accurate information. Options 1, 3, and 4 are incorrect because they each fail to recognize that all family members, including children, are affected by DID in the family unit. ‐ "There is probably a mistake in the referral; your partner is the one who has the problem." ‐ "Children need to have their experiences confirmed, and to learn to deal with the different personalities." ‐ "You and your partner should be seen, but it could be traumatizing to the children." ‐ "It would be best to ask the children if they would like to participate, and bring them if they want." | Figuratively put yourself in the position of the children of this family. Identify how you think you would feel. |
4487 A client was in a dissociative fugue for 4 weeks, Correct answer: 3 Option 3 is correct. Dissociative fugues, which last for varying periods of time, are during which time the client worked at a temporary characterized by wandering or moving away from one's familiar place with an amnesia for the job in another city and seemed normal to others. The complete past, including self. The person often assumes a new identity for the duration of the fugue state ended spontaneously, and the client is now fugue. Fugues are most often precipitated by sub‐acute, chronic stress, so prevention of future admitted in a state of heightened anxiety saying, "They episodes of fugues involves examining life circumstances and issues of the client before the told me I wandered away. I must be going crazy." The fugue started. In a very real way, a fugue state is a psychologic escape from a life circumstance nurse interprets that initial efforts of the entire or intense feeling that the individual feels unable to handle. Option 1 is incorrect as it is treatment team should be directed toward assisting impossible to plan for prevention of future fugue responses without knowing what might have the client to do which of the following? precipitated this one. Option 2 is incorrect because spending more time in solitary activities is not expected to benefit this client. People live in a world involving others, and withdrawing from others in a time of stress is a mechanism that has already caused difficulties for this client. Option 4 is incorrect as recalling events that occurred during the fugue (many clients never are able to do so) is not as valuable as recalling events that happened before the fugue. This is important because fugues generally follow an overwhelming environmental or psychological stressor. ‐ Plan for ways to avoid entering another fugue state. ‐ Spend more time in solitary activities. ‐ Examine life circumstances prior to the fugue. ‐ Recall events that occurred during the fugue. | Recall the basic unconscious purposes served by a fugue state. Recognize that if the pre‐ existing stress is not relieved, the client is at risk for further fugue states. |
4488 The nurse concludes that client education about Correct answer: 3 Option 3 is correct. It indicates that the client is beginning to make connections between dissociation has been effective if the dissociative client stress, anxiety, and dissociation. This will enable the client to modify stressors or personal makes which statement? response to them thus preventing the dissociative process. Options 1, 2, and 4 are incorrect. Each of them shows a lack of insight into the connection between stress, anxiety and dissociation, as well as a continuing tendency to engage in behaviors that are likely to bring about dissociation. ‐ "When I want to get out of a situation, I choose to space out." ‐ "When I have to cope with problems, I imagine I am somewhere else." ‐ "When I'm under stress, I have a tendency to dissociate." ‐ "When I think about my life, I pretend I am someone else." | Recall the basic unconscious purposes served by a fugue state. Recognize that development of insight and reduction of stress will reduce the likelihood of further dissociative occurrences. |
4489 A member of the staff asks the nurse to explain what Correct answer: 2 Option 2 is correct. Although all of the options are dissociative responses, only localized the treatment team meant when they said that a client amnesia is the inability to recall events in a circumscribed time period. Options 1, 3, and 4 are had localized amnesia. The nurse would say, "An examples of various dissociative states, but they do not show amnesia that is limited to a example is: specific or circumscribed period. ‐ Wandering about one's own neighborhood and using a new name." ‐ Forgetting about what happened during a personal assault." ‐ Being unaware of having several personalities." ‐ Feeling separated from one's own body and in a dream‐like state." | If the exact meaning of the term cannot be recalled, contrast it to the term generalized, and the answer to the question will be obvious. |
4490 The nurse is conducting a client teaching session Correct answer: 4 Dissociative disorders result from using the defense mechanism of dissociation. This about dissociative disorders. Which client statement dissociation prevents anxiety about traumatic events or stressors from entering conscious indicates to the nurse that the client understands awareness. Dissociation is not consciously employed and does not involve a gradual loss of important concepts about the disorder? memory (option 1). The process of changing alters generally occurs very quickly. Regressive behaviors (option 2) are common in dissociative states, but dissociation is intended to reduce anxiety, not avoid adult responsibilities. Use of hallucinogens can result in dissociation in persons who are prone to "trance states" or spacing out, but when this occurs, current use of the drug is most likely to have occurred (option 3). ‐ "People with dissociative disorder usually have gradual loss of memory for names and phone numbers." ‐ "Dissociative disorders serve as a means of avoiding adult responsibilities." ‐ "Dissociative disorders are caused from past use of hallucinogens." ‐ "People develop dissociative disorders to protect themselves from extreme anxiety." | Look for an accurate and simply stated option. |
4491 The nurse determines that which of the following is a Correct answer: 1 Dissociation occurs when anxiety is high; thus, a calm, safe, and supportive environment is priority nursing intervention for a person recently essential to decrease emotional arousal. Increasing sensory stimulation (option 2) will increase admitted to an inpatient unit with a dissociative psychological arousal and can lead to increased dissociation. Working through past trauma disorder? (option 3) is not an immediate priority. Even if a history of trauma is a causative factor, anxiety must be reduced to a level compatible with verbal exploration. Social skills (option 4) may or may not be problematic when the client is dissociating. This is dependent on the alter that emerges and its "function" within the group of personalities. ‐ Creation of a calm, safe environment ‐ Increasing sensory stimulation ‐ Working through past trauma ‐ Promoting social skills | Remember that dissociation occurs because of—and during—states of high emotional arousal and anxiety. Look for an option that would be likely to decrease anxiety. |
4492 The nurse assessing a client with dissociative identity Correct answer: 1 Clients with DID often have particular physical problems including headache, irritable bowel disorder (DID) is most likely to note which of the syndrome, and asthma. Elated mood (option 2) could be a co‐morbid condition associated with following? one more of the alters. However, it is not a universal symptom of dissociative identity disorder (DID). Memory is discontinuous in states of DID (option 3). Each personality has a memory of its own. Stocking or glove anesthesia are not characteristic of DID (option 4). ‐ History of headaches ‐ Elated mood ‐ Intact memory for recent and remote events ‐ Stocking anesthesia | Look for an answer that will be true in the vast majority of persons with DID. |
4493 A client with dissociative identity disorder (DID) is Correct answer: 2 The overdose of alcohol and benzodiazepines is particularly lethal, which demonstrates that admitted after an overdose of alcohol and the client is potentially harmful to self. The presenting personality may not be depressed or benzodiazepines, claiming that another alter "did it." may not have enough power to prevent the alter that is self‐destructive from acting out again, The nurse formulates which of the following as the so substantial risk remains. Physical safety is a priority over all other options (1, 3, and 4), priority nursing diagnosis? including psychological needs, even when they are intense. ‐ Posttrauma response ‐ Risk for self‐directed violence ‐ Disturbed personal identity ‐ Anxiety | Notice that only one diagnosis is not a psychological one and remember that safety and physical needs always take precedence over psychological or sociologic needs. |
4494 A client is brought to the emergency room after a Correct answer: 2 The client needs to have critical physical needs met, including physical comfort, as the first brutal physical assault. Although oriented and priority. Creating a sense of safety after an assault is essential as anxiety may fluctuate. The coherent, the client cannot remember the assault or nursing interventions in options 1, 3, and 4 are relevant, but not a priority and can be deferred events surrounding it. The priority intervention by the to a later time. nurse is to provide: ‐ Frequent reality orientation. ‐ Physical comfort and safety. ‐ Thoughtful questioning for the police report. ‐ Referral to a community support group. | Consider the nature of what has happened to this client. Recognize that unexpressed terror is probably present. |
4495 A client with dissociative identity disorder (DID) Correct answer: 3 The change in the client's voice indicates a change to a child alter. Reasons for this change suddenly begins to speak with a child's vocabulary and include regression, resistance, needing sustenance, wanting to be understood, or other voice. The nurse should interpret this as: possibilities that are connected to severe underlying anxiety. Persons with DID do not dissociate in order to gain attention (option 1). Dissociation is an unconscious mechanism used to reduce overwhelming anxiety. Depersonalization (option 2) involves a person's feeling disengaged and removed from one's surroundings, as if viewing things in a dream state. The person remains aware of personal identity during the time of depersonalization. Dissociation is not shown in this situation. Malingering (option 4) is a consciously motivated behavior in which the individual behaves as if ill or feigns an emotion. Malingering is not shown in this situation. ‐ An attempt to gain attention. ‐ A state of depersonalization. ‐ Changing to a child alter. ‐ Malingering. | Remember that states of dissociation develop as a protective response to reduce awareness of anxiety and stressors causing it. |
4496 A client with dissociative identity disorder (DID) Correct answer: 3 Changing alters often occurs with increases in anxiety. Asking the client to explain more will suddenly has a change in voice quality and sentence help the nurse understand what is happening on a system level, and why the child alter was structure. What is the most therapeutic response by emergent. Option 1 would increase the client's anxiety level. Option 2 would not help the the nurse? client become aware of feelings that preceded the dissociation. It is somewhat critical and represents a sort of private musing of the nurse that should not be verbalized to the child alter. Option 4 would also increase the client's anxiety level. ‐ "You must be feeling very needy." ‐ "I wonder why you're not acting your age." ‐ "Can you tell me what is happening?" ‐ "This behavior keeps you from working on your problems." | Identify the option that is most likely to keep the client focused on the reality of the present situation. |
4497 A client is diagnosed with depersonalization disorder. Correct answer: 2 Feeling detached, as if in a dream, is characteristic of depersonalization disorder. Multiple Which of the following is the nurse most likely to find personalities or alters (option 1) are not part of depersonalization disorder. Indifference to the in the assessment? symptoms (la belle indifference) and amnesia (option 3) are usually related to conversion disorder. In depersonalization, the client remembers the event and usually is distressed by the experience (option 4). ‐ Two or more personalities ‐ Feelings like "being in a dream" ‐ Indifference to the symptoms ‐ Amnesia about the event | Compare and contrast primary presenting symptoms of the different dissociative responses. |
4498 The nurse formulates which priority nursing diagnosis Correct answer: 3 Amnesia is a result of being unable to cope with high levels of anxiety. While heightened for a client experiencing amnesia associated with high anxiety can be associated with this diagnosis, there is no indication that the diagnoses in levels of anxiety? options 1, 2, or 4 are present at this time. However, it is universally true that when amnesia results from increased anxiety, the individual is coping ineffectively. | Look for an option that will be universally true. Remember that amnesia and other dissociative responses result for unhealthy or ineffective attempts at coping. |
‐ Confusion ‐ Powerlessness ‐ Ineffective coping ‐ Disturbed sensory perception | |
4499 A client reports episodic depersonalization Correct answer: 1 Reducing anxiety through the use of stress management techniques will prevent experiences to the nurse. Which of the following is an depersonalization that is a reaction to high levels of anxiety. There is no data to support appropriate goal of care? suicidal thoughts or multiple identities (option 2) or multiple identities (option 3). Improving self‐concept is helpful (option 4), but is not a priority when anxiety leads to dissociation. ‐ The client will describe three stress management techniques by day 2. ‐ The client will report no suicidal thoughts by week 1. ‐ The client will create a chart of all personalities by week 1. ‐ The client will state five personal strengths by day 2. | Remember that depersonalization is considered to be an anxiety disorder. |
4500 The client, although oriented to person, place, and Correct answer: 2 This client is showing localized amnesia. The client's memory loss began a few hours after a time, cannot remember being extracted from a disturbing event. Further, the client is unable to recall all memories of the event, and the burning automobile the day before. What term should memory loss is confined to this particular sphere of the individual’s functioning. Suppression the nurse use when documenting the client’s inability (option 1) is a consciously motivated response of an individual to a stressful event. When to remember events surrounding the accident? suppression is used, the individual is fully aware of what is taking place and refuses to acknowledge it. This client does not evidence this type of awareness. Confabulation (option 3) is the replacement of gaps in memory with imaginary information. This client is not showing this behavior. Continuous amnesia (option 4) is that type of memory loss in which the individual forgets successive events as they occur. This type of amnesia includes loss of memory of present events and affects orientation. ‐ Suppression ‐ Localized amnesia ‐ Confabulation ‐ Continuous amnesia | Notice that this client has just experienced an intensely stressful event. Doesn't it make sense that the psyche would try to protect the individual by blocking out memory of the event? |
4501 The nurse would select which of the following as the Correct answer: 1 A fugue state is a result of dissociation, a defense against overwhelming anxiety. It is often most appropriate nursing diagnosis for a client precipitated by subacute chronic stress and/or a major stressful event. This condition is rare experiencing a fugue state? and can last for varying periods of time. During the fugue state the person often behaves in ways that are inconsistent with normal personality and values. Without further data, it is impossible to determine that the stress and anxiety are related either to family difficulties, self‐ esteem, or relocation (options 2, 3, and 4). ‐ Anxiety ‐ Disturbed self‐esteem ‐ Interrupted family processes ‐ Relocation stress syndrome | Consider the concept of unconscious motivators of behavior. Notice also that no information is given about the client’s family, living circumstances, or self‐esteem. |
4502 The nurse assessing the client in a fugue state would Correct answer: 3 Fugue states usually begin abruptly after a major stressor such as war or natural disaster, and look for which of the following? end abruptly. The client experiencing a fugue state may or may not have a history of childhood trauma or depression (option 1). During the fugue state the person either appears totally normal to others or appears dazed and confused. Depression (option 2), if it occurs, is likely to precede or follow the fugue state. If the stressor is severe enough, the client can enter a fugue state without ever having had other dissociative responses (option 4). ‐ A history of childhood trauma ‐ Coexisting depression ‐ Exposure to a major stressor | Recall various types of dissociative responses. Identify the common underlying factor in each of them. Apply that knowledge to this situation. |
4.‐ Dissociative episodes | |
4503 A windstorm severely damaged a client’s farm. The Correct answer: 4 At this time the client needs an opportunity to work through the disaster event, acknowledge client recalls very little about the storm and repeatedly its reality, and reduce anxiety. This will best occur in a disaster survivor support group in which says, “I can’t believe the farm is destroyed.” When the other survivors of disaster and the client will talk about the reality of the loss. If this does not nurse is providing care, which of the following goals happen, the client is at risk for experiencing a crisis response. Feelings of depression (option 1) should take priority? By day 2 the client will: and anger (option 2), while a part of coping with loss, may occur later than 2 days after an event and will take more than a few days to resolve. It is too early to consider whether job retraining is necessary (option 3) or whether funds are available for rebuilding. ‐ Report decreased depression. ‐ Express anger about his loss. ‐ Apply for job retraining. ‐ Attend a support group for disaster survivors. | Apply theoretical information about crisis responses and balancing factors to select the correct answer. |
4504 A nursing assistant (NA) asks for advice about talking Correct answer: 1 Trust is the basis of a therapeutic relationship, and the client should proceed at a self‐ with a client recently diagnosed with dissociative determined rate, particularly if the subject is painful. Self‐pacing avoids flooding the client with identity disorder (DID). When the NA asks, “Should I severe anxiety. This self‐disclosure should be accepted nonjudgmentally by all persons with talk about her childhood abuse?” the nurse’s best whom the client has contact. Option 2 would result in flooding the client with anxiety, which is response is: not recommended. Additionally, the nurse should recognize that a nursing assistant is not properly prepared for this sort of intervention. Option 3 could interfere with trust and the client’s readiness to disclose. Option 4 is non‐accepting and demeaning to the client. ‐ “If she brings up the abuse, listen to her and be supportive.” ‐ “You will need to really push her to get it all out.” ‐ “Ask her to discuss this only with her therapist.” ‐ “Remind her that sometimes adults exaggerate their childhood experiences.” | Notice to whom the nurse is responding. Consider the level of complexity necessary for intervening in dissociative states. |
4505 The client is experiencing dissociative amnesia. The Correct answer: 2 Hypnosis may be effective to access memories and, if present, other personalities that result nurse has taught the client about therapeutic methods from dissociation. Option 1 is incorrect because ECT does not enhance recovery of memories. for memory retrieval. The nurse determines that the Instead, it can interfere with recall and memory, particularly of recent events. While teaching has been effective when the client says: overwhelming anxiety is associated with dissociative identity disorders, normal relaxation techniques (option 3) do not enhance memory retrieval. While overwhelming anxiety (option 4) is associated with dissociative identity disorders, antianxiety medications are symptomatic measures to reduce anxiety and are not directly associated with retrieval of memories. ‐ “Even if it does uncover hidden memories, I don’t want to have electroconvulsive therapy (ECT).” ‐ “I’m a little uneasy about being hypnotized, but it does help release memories.” ‐ “If I use relaxation techniques properly, my memories will come back quickly.” ‐ “Anxiety causes this memory problem, and antianxiety agents will greatly reduce it.” | Consider that dissociative states result from the unconscious mental activities designed to reduce anxiety. Look for the treatment that is most expected to access the unconscious mind. |
4506 The nurse determines that client education to Correct answer: 2 Objects or surroundings can be used to reorient the client by promoting concentration and an manage dissociative episodes is effective if the client external focus. Internal focusing only augments dissociation (option 4). Taking an antianxiety states, “Once I start to dissociate, I should:" medication at the time of dissociation (option 1) will not be an effective deterrent, since the dissociation has already begun. It is also unlikely that the person can actually take the medicine, because dissociation will already be interrupting integrated functioning. Beginning a relaxation technique at the time of dissociation (option 3) will not be an effective deterrent, since the dissociation has already begun. It is also unlikely that the person can focus on the relaxation technique because integrated functioning has already been interrupted by the dissociation. ‐ "Immediately take my antianxiety medication.” ‐ "Focus on what I can see and hear externally.” | Think about the psychological purposes served by dissociation. Look for an option that would promote a more realistic coping response. |
‐ "Begin my relaxation technique.” ‐ "Focus on my internal feelings.” | |
4507 The client who has dissociative identity disorder (DID) Correct answer: 4 Option 4 is correct because it is a supportive response. Many clients with DID have lack of is now 20 minutes late for cognitive therapy group. The awareness of events because another personality was present when these events were client says, “I was never told to go to that group.” discussed. Thus, the host personality has no knowledge of them. Although the client eventually What is the nurse’s best response? must be accountable for all actions of the personalities to the greatest extent possible, this may not initially be under the client’s control. The style of option 2 could be construed as somewhat condescending. The information is true, but there is no attempt to be supportive of this individual client. The nurse should not look upon the client’s lateness as resistance (option 3). Many other causative possibilities exist, including emergence of an alter personality that emerged and controlled the individual’s behavior. Also, this response is somewhat accusatory. ‐ “You can’t get out of group that easily.” ‐ “People with dissociative identity disorder forget quite a bit.” ‐ “Have you thought about just why you might be resisting treatment?” ‐ “It is possible that you were not aware of group time.” | Recall basic knowledge of clients with DID: Multiple personalities exist in the same person. Use this information to evaluate each option. |
4508 The spouse of a client who is experiencing a fugue Correct answer: 1 The client who has experienced a fugue is generally unable to remember events occurring state asks the nurse if the spouse will be able to during the fugue state (option 1), despite encouragement (option 2). During fugue states, remember what happened during the time of the clients are generally reclusive and quiet, so their behavior rarely attracts attention. Amnesia fugue. What is the nurse’s best response? for the events occurring during the fugue state can be predicted (option 3). The client does not have the ability to alternate personal identity with the partial identity assumed during the fugue state (option 4). ‐ “Your spouse will probably have no memory for events during the fugue.” ‐ “Your spouse will be able to tell you—if you can gently encourage talking.” ‐ “It is not possible to predict whether your spouse will remember the fugue state.” ‐ “Avoid mentioning it, or your spouse may start alternating old and new identities.” | Recall basic facts about fugue states and the unconscious purposes that they serve. |
4509 The client has dissociative identity disorder (DID). Correct answer: 2 Changing from one alter to another is manifested in a variety of ways including blinking, facial When the client is changing from one alter to another, changes, and changes in voice and train of thought. Orthostatic hypotension (option 1), which of the following would the nurse expect to dystonic reactions (option 3), or pallor (option 4) are not usually associated with changing from observe? one alter to another. ‐ Orthostatic hypotension ‐ Blinking or rolling of the eyes ‐ Dystonic reactions ‐ Pallor | Consider that among multiple personalities, the common means of communicating with the external world is through both verbal and nonverbal means. Choose option 2 over option 3 as a nonverbal behavior because option 3 can occur as an adverse effect of some medications. |
4510 When planning nursing care for a client diagnosed Correct answer: 2, 3, 4 Options 2, 3, and 4 are correct. Option 2 is correct because dichotomous thinking is one of with a borderline personality disorder, the nurse the prevalent cognitive disturbances of individuals with borderline personality disorder. This anticipates that this individual will display: (Select all type of thinking results in the person seeing the world in extremes—all good or all bad, totally that apply.) perfect or totally horrible, etc. This type of thinking permeates their interpersonal relationships and their views of themselves, which can involve rapidly shifting roles ranging from victim to victimizer, dominant individual to submissive individual, etc. Option 3 is correct because clients with borderline personality disorder are intense and unstable affectively. They have difficulty tolerating anxiety and moderating feelings. An emotion that would be of low grade intensity in others rapidly escalates to the level of a catastrophe for the client with borderline personality disorder. Option 4 is correct because due to intense shifts in emotion and frantic attempts to avoid abandonment, persons with borderline personality disorders often attempt to manipulate others to meet their needs. Depending on the emotion they are feeling, the manipulation can be aimed toward any number of purposes, ranging from having dependency needs met to suffering humiliation or injury. Option 1 is incorrect as persons with borderline personality disorder have intense needs to be loved and cared for. This leads them to seek relationships with others in intense, often desperate seeming, manners. The relationships are typically conflicted and short‐lived, but the individual with borderline personality disorder continues to seek the company of the others in the vain hope that the perfect friend or lover will be found. Option 5 is incorrect because clients with borderline personality disorder tend to be impulsive, unpredictable, and manipulative. ‐ Social withdrawal. ‐ Dichotomous thinking. ‐ Emotional liability. ‐ Manipulative behavior. ‐ Behavioral rigidity. | Recall the desperate and volatile nature of the behavior of persons with borderline personality disorder. |
4511 In planning care for a client diagnosed with paranoid Correct answer: 4 Individuals with paranoid personality disorder interpret the motives of others as malevolent; personality disorder, the nurse incorporates the thus, they perceive the world as threatening rather than boring, exciting, or interesting. Their understanding that this individual perceives the world distrust and suspiciousness of others is reflected in DSM‐IV diagnostic criteria for paranoid as: personality disorder and must be considered in the planning and delivery of care. Additionally, they tend to be secretive, guarded, and aloof. Option 1 is incorrect as the paranoid individual is hyper alert to all environmental stimuli, often ascribing a harmful intent to neutral people and situations. Options 2 and 3 are incorrect because instead of finding the world exciting or interesting, the individual with paranoid personality disorder sees it as hostile and dangerous. ‐ Boring. ‐ Exciting. ‐ Interesting. ‐ Threatening. | Recall basic descriptors of persons with paranoid personalities. Imagine how uncomfortable they must be. |
4512 The mental health nurse has noticed the client’s Correct answer: 3 Limit setting provides a structured environment rather than an unstructured environment. tendency to control interpersonal relationships This decreases the client’s opportunities to manipulate and is a small step in disrupting a through the use of manipulation. Which nursing maladaptive communication pattern. Option 1 is incorrect as justifying rather than stating approach will be most important in a plan of care for rules and regulations may be perceived by the client as a sign of discomfort or defensiveness this client? on the part of the nurse and may result in increased efforts at manipulation. Options 2 and 4 are incorrect because they would allow the client a wide range of opportunities to manipulate other clients or staff in an effort to have their needs met. ‐ Justify rules and regulations ‐ Be flexible about rules and regulations ‐ Set reasonable and necessary limits on behavior | Recall the importance of anticipating the need to set limits when the client has an established pattern of manipulating. Choose an option that is mater‐of‐fact and non‐ judgmental. |
4.‐ Allow the client to make decisions | |
4513 A newly admitted client reports feelings of boredom Correct answer: 3 Persons with borderline personality disorder do not manage anxiety well and are unable to and emptiness as well as intense feelings of anger tolerate and moderate strong feelings. Their interpersonal relationships are intense and toward a former roommate who “left me all alone.” unpredictable, as they have intense needs for acceptance and love, as well as unrealistic The client has numerous horizontal scars on both expectations of others. They are frequently self‐mutilative and can become actively suicidal, as forearms. The nurse would expect that the client’s Axis well as psychotic. It is estimated that 15‐25% of the population of psychiatric clients have 2 diagnosis would include: borderline personality disorder. Option 1 is incorrect because while histrionic and borderline personalities are both part of Cluster B disorders in DSM IV‐TR, individuals with histrionic personalities are most characterized by behaviors designed to seek stimulation and excitement in life. These individuals are often the center of attention and use attention seeking and/or seductive behaviors in order to seek attention and approval from others. Option 2 is incorrect as suicidal ideation is not an Axis 2 diagnosis. Axis 2 diagnoses either refer to personality disorders or mental retardation. Option 4 is incorrect because a motivational syndrome is associated with certain other long standing mental health problems, such as chronic schizophrenia. ‐ Histrionic personality disorder. ‐ Suicidal ideation. ‐ Borderline personality disorder. ‐ A motivational syndrome. | Compare and contrast characteristic behaviors associated with the two personality disorders shown in the options. Disregard the other two options, as they do not indicate types of personality disorders. |
4514 A male client was admitted with a diagnosis of Correct answer: 3 Responding to the client in a business‐like, non‐punitive fashion decreases the tendency of antisocial personality disorder. He comes to the the client to try to engage in a power struggle with the nurse. Justifications are not offered, nurses’ station at 11 P.M. asking to use the phone to but rather facts are presented simply and directly. Options 1and 4 are incorrect as they would call his estranged wife. The posted unit policy is that allow the client to gain control of the situation through manipulation. Both options would phone calls are not allowed after 10 P.M. Which of the reinforce the client’s tendency to see himself as special and deserving of unique following responses by the nurse is therapeutic? considerations. Option 4 suggests that the nurse and the client will engage in a cooperative act of secrecy. Option 2 is condemning of the client. The nurse should respond calmly and matter‐ of‐factly when refusing the client’s request for special privileges. ‐ “You may go ahead and use the phone; I know this situation is hard for you.” ‐ “You know better than to try to break the rules, I’m surprised at you.” ‐ “It is 11 P.M.; phone privileges ended at 10:00 P.M.” ‐ “You can call but don’t tell other clients I let you break the rule.” | Choose an option that applies the principles of limit setting. Recall facts about manipulative and demanding behaviors among persons diagnosed with antisocial personality disorders. |
4515 The nurse is conducting a staff education session Correct answer: 4 Personality disorders are typified by pervasive, inflexible, and enduring patterns of behavior regarding personality disorders. When describing that lead to distress or impaired functioning in all areas of the client’s life, beginning with personality disorders, the most accurate description adolescence. Major characteristics include inflexible and maladaptive responses to stress, the nurse can offer the staff is that, “In general, people disability in loving and working, and ability to evoke interpersonal conflict and/or “get under with personality disorders:” the skin” of others. These clients, however, generally lack to ability to recognize that their behavior contributes greatly to their unsatisfactory interpersonal relationships and their problems in living. Option 1 is incorrect as only some clients with personality disorders show intensely ritualistic behaviors. They are most likely to be those with obsessive‐compulsive personality disorder. Option 2 is incorrect because while it is true that individuals with personality disorders are often dually diagnosed with other psychiatric problems, there is not a specific correlation with chronic pain disorder. Option 3 is incorrect as people with personality disorders are not psychotic. Therefore, their thinking, while disturbed, will not be autistic and they will not experience delusions. Some clients with personality disorders develop psychotic symptoms, but when this occurs, the client is dually diagnosed, and the personality disorder is the Axis 2 diagnosis. ‐ “Engage in highly ritualistic and repetitive patterns of behavior.” ‐ “Have a tendency to develop chronic pain disorders.” | Look for an option that will be universally true among persons with all types of personality disorders. Recall the meaning of the term “ego‐syntonic.” |
‐ “Experience delusional thinking of a grandiose or omnipotent nature.” ‐ “Consider relationship problems to result from causes external to them.” | |
4516 In planning care for a client with an Axis II personality Correct answer: 1 Clients who are diagnosed with a personality disorder most frequently perceive their disorder, it is important for the nurse to remember personality patterns as egosyntonic or a natural part of themselves rather than as egodystonic, that the client will differ from clients with Axis I or foreign and distressing to the self. Option 2 is incorrect because this is one reason it is disorders in that clients with personality disorders: difficult to motivate individuals with personality disorders to try to change their maladaptive behavioral patterns. Individuals with personality disorders display problems in living rather than clinical symptoms. Option 3 is incorrect as clients who are diagnosed with a personality disorder most frequently perceive their personality patterns as ego‐syntonic or a natural part of themselves rather than as egodystonic, or foreign and distressing to the self. Option 4 is incorrect because due to their dissatisfactions and problems in living, clients with personality disorders are strongly predisposed to abuse of substances. ‐ Tend to experience symptoms as egosyntonic. ‐ Usually display clinical symptoms. ‐ Tend to experience symptoms as egodystonic. ‐ Seldom experience addictive behaviors. | Recall basic facts about psychological purposes served by personality disorders. |
4517 A client has been diagnosed with a dependent Correct answer: 4 It is difficult for individuals diagnosed with dependent personality disorder to make decisions personality disorder. How is the client likely to respond on their own; rather, they try to get others to make decisions for them. This characteristic is to the nurse who suggests that the client self‐ reflected in DSM‐IV diagnostic criteria. Options 1 and 3 are incorrect as they indicate that the administer morning care? client can readily make independent decisions Option 2 is incorrect because clients with dependent personality disorder are not likely to make critical remarks about others. Instead, they will go out of their way to agree with others to avoid rejection. ‐ “I’ll think I’ll wear my new pants.” ‐ “I think you should wear more makeup.” ‐ “I think this outfit looks good on me.” ‐ “What do you think I should wear?” | Develop a mental picture of the individual with dependent personality disorder. Can you “see” this individual making an independent decision about even a minor matter? |
4518 A client is diagnosed with paranoid personality Correct answer: 3 To the person with paranoid personality, the world is a hostile place in which people are not disorder. Although observing others very carefully, the to be trusted. Ever on the alert for misdeeds, this individual prefers solitude and emotional client tends to remain isolated from groups of people. distance from others. When this is not possible, the person tends to react with harsh criticism What implication for care should the nurse recognize? or anger directed toward others. For these reasons, the client can be least anxious and The client is likely to function best if: function best if allowed to have a private room. Option 1 is incorrect as persons with paranoid personalities have a strong fear of losing power and control to others, the client would be likely to view this sort of therapy with suspicion and disdain. Option 2 is incorrect because due to intense self‐preoccupation and suspiciousness, the person with paranoid personality disorder is not sensitive to the needs of others. Because of this and the fact that the client holds emotions until tight control (except for episodic hostile outbursts), this client is not a good candidate to lead a client group,<BR /> ‐ Active in one to one guided imagery therapy. ‐ Asked to serve as a peer group leader. ‐ Assigned to a private room. ‐ Introduced to all clients. | Recall paranoid clients seen in the clinical area. Think about which of the options would be most acceptable to that client. |
4519 The nurse and other members of the care team are Correct answer: 1 Individuals diagnosed with paranoid personality disorder frequently are critical or discussing how to care for a client with paranoid argumentative to maintain a safe distance between themselves and others related to their personality disorder. Which of the following is likely to inability to trust others. This, coupled with their aloofness, makes it difficult for others to feel be voiced by a nurse on the team? comfortable with them. Option 2 is incorrect as people who are considered shy are likely to have schizoid personality disorder. They are considered to be “loners” who have restricted ranges of feelings. Staff would also probably find it frustrating to work with these clients. Option 3 is incorrect because persons with paranoid personality disorder are not likely to dependent. They would fear being overpowered psychologically by the other person. Indecisive, clinging behavior is more likely to be seen in persons with dependent personality disorders. Staff would also probably find it frustrating to work with these clients. Option 4 is incorrect as checking and re‐checking behaviors are associated with compulsive personality disorder, not paranoid personality disorder. ‐ “I’m so frustrated with all of that criticism.” ‐ “I find it hard to work with such a shy person.” ‐ “It’s hard for me to be around such dependency.” ‐ “All that checking and re‐checking behavior is annoying to me.” | Notice that this question is asking about responses of the health care team to the behavior of the client. Most questions are focused on the client. |
4520 The client with a personality disorder says, “There is Correct answer: 2 Clients diagnosed with personality disorders view their personality patterns as natural, or no need for me to be treated. I’ve always acted this egosyntonic. They think their behavior is normal, and it is neither painful nor uncomfortable to way. It’s normal for me.” What term should the nurse them. For this reason, they rarely seek treatment. This view is directly opposite that of use when describing this statement in documentation? egodystonia, in which the individual is greatly distressed by behaviors and symptoms. Narcissistic responses (option 1) involve a grandiose sense of entitlement and focus on the self. Schizotypal individuals demonstrate eccentricities in behavior and avoidant responses (option 3). Avoidant behaviors involve social inhibition and feelings of inadequacy (option 4). ‐ Narcissistic ‐ Egosyntonic ‐ Schizotypal ‐ Avoidant | Remember that personality disorders are fixed, lifelong patterns of behavior. |
4521 The nursing diagnosis is “Risk for self‐mutilation Correct answer: 1 Verbalizing rather than suppressing one’s fear of abandonment is the first step in recognizing related to feelings of abandonment associated with its effect on the self and on interpersonal relationships. A fear of abandonment often drives ending of a close relationship.” Which nursing significant others away as it may be reflected in extremes of emotion, extremes of idealization, outcome would indicate that the client has improved? or devaluation of the other. It can be associated with impulsivity and a heightened risk of self‐ The client: mutilation. Expressing rage reflects emotional volatility and may be associated with a heightened risk of self‐mutilation (option 2). Vowing never to get involved in another relationship (option 3) reveals lack of insight into the desire and need for a close relationship and the related fear of abandonment. Suppressing one’s fear of abandonment (option 4) is not therapeutic. Verbalizing this fear can help with the development of insight about the self and interpersonal relationships. ‐ Verbalizes fear of abandonment in a realistic way. ‐ Vows never to get involved in a relationship again. ‐ Expresses rage over feelings of abandonment. ‐ Suppresses feelings of abandonment. | Identify common major problems of the person with borderline personality disorder. Look for an outcome that is then opposite of one of these problems. |
4522 The client has antisocial personality disorder and Correct answer: 2 In returning the focus of the conversation to the client, the nurse intervenes in the attempts persists in asking for the address and other personal at manipulation. The manner in which the nurse does this is professional and business‐like information about the nurse. The client states, “I just without appearing uncomfortable. The responses in options 3 and 4 make the nurse seem want to get to know you better. You’re the only one I uncomfortable. Sensing this, the client will feel in control of the interaction and use even more can really talk to.” What is the most effective response manipulative behaviors. Option 1 is defensive and shows the client that the manipulative by the nurse? attempt has “gotten under your skin.” This will encourage the client to continue with other manipulative efforts. | Remember that attempts at manipulation are aimed at allowing the manipulating individual to remain in control of the situation. |
‐ “You’re getting too involved with me. Maybe another nurse would be more appropriate for you.” ‐ “Let’s talk about my purpose in working with you and your feelings about it.” ‐ “Why are you focusing on me all the time?” ‐ “Stop trying to avoid talking about yourself and your problems.” | |
4523 A client arrives for her mental health appointment Correct answer: 3 The client’s pattern of attention‐seeking behavior reflects DSM‐IV‐TR diagnostic criteria for wearing a cocktail dress and theatrical makeup. She histrionic personality disorder. Dramatic attention‐seeking behaviors (option 1) are not as announces dramatically and flirtatiously that she needs common in borderline personality disorders as are those in which the individual is unstable to be seen immediately because she is experiencing and impulsive because of fears of abandonment. Dramatic and theatrical attention‐seeking overwhelming psychological distress. The nurse should behaviors are not characteristic of narcissistic personality disorders (option 2). Narcissistic recognize behaviors suggestive of which Axis II individuals show a sense of entitlement and lack of empathy for others. Dramatic attention‐ diagnosis? seeking is not a common behavior associated with antisocial personality disorders (option 4). Instead, even though they may be superficially charming and sociable, they have utter disregard and consideration for the rights of others and often violate the rights of others if it is to their own personal advantage. ‐ Borderline personality disorder ‐ Narcissistic personality disorder ‐ Histrionic personality disorder ‐ Antisocial personality disorder | Recall which type of personality disorder is most likely to be referred to by others as a “drama queen.” |
4524 A client diagnosed with antisocial personality disorder Correct answer: 4 Individuals diagnosed with antisocial personality disorder frequently attempt to play one staff tells Nurse A, “You’re a much better nurse than Nurse member against another. This behavior is referred to as splitting. Their goal in doing this is to B said you were.” The client then tells Nurse B, “Nurse manipulate others or control their environment. Individuals diagnosed with antisocial A is upset with you for some reason.” To Nurse C, the personality disorder have no regard for others and lack the capacity to empathize. Their client states, “I think you’re great, but Nurse A said she behavior is not driven by attempts to gain acceptance or attention or create guilt (options 1, 2, saw you make three mistakes this morning.” The nurse and 3). Rather, it is to gain control by manipulation. should conclude that these behaviors are intended to: ‐ Gain acceptance. ‐ Gain attention. ‐ Create guilt in the staff. ‐ Manipulate the staff. | Recall that persons with antisocial personality disorder lack positive regard or empathy. |
4525 The client with antisocial personality disorder has Correct answer: 1, 2, 3, Individuals diagnosed with antisocial personality disorder rarely take responsibility for their reportedly abused the spouse. During a nurse–client 5 behavior. Statements of this nature are likely to be insincere. They feel their behavior is interview, the client makes all of the following justified and typically blame others in an irritable fashion for their socially unacceptable comments. The nurse concludes that which of these actions. In addition, they feel that their physical aggression toward another is not only comments are likely to be insincere? Select all that justifiable but even deserved by the other person (option 4). They are not remorseful, and it apply. would be very unlikely that they would apologize. They characteristically assign blame to others. ‐ “I’ve done a stupid thing, but I’ve learned my lesson.” ‐ “I’m feeling awful about the way I’ve hurt my wife.” ‐ “I have a quick temper, but I can usually keep it under control.” ‐ “I hit her because she nags at me.” ‐ “If I was a little too forceful, I do apologize.” | Remember that the person with antisocial personality disorder does not experience guilt, shame, or remorse. Note the word “insincere” in the question. |
4526 The client with borderline personality tells the nurse, Correct answer: 4 Individuals diagnosed with borderline personality disorder frequently display a tendency to “You are so much smarter than the other nurses. dichotomous thinking or splitting. They perceive the self and others as all good or all bad. The You’re an ideal nurse.” The nurse should interpret this client may be seeking secondary gain from the nurse (option 1), but the manipulative behavior behavior as an example of: itself is not a manifestation of secondary gain. Acting‐out behavior (option 2) involves displacing anxiety from one situation to another in the form of some observable response like crying or being violent. Passive aggression (option 3) involves behaviors that appear passive on the surface but are actually motivated by unconscious anger. Examples are being obtuse, arriving late, and making “mistakes.” ‐ Secondary gain. ‐ Acting out. ‐ Passive aggression. ‐ Dichotomous thinking. | Recognize that clients with borderline personality disorders have an intense fear of abandonment. |
4527 The client’s behavior is characterized by repeated Correct answer: 4 Being encouraged to acknowledge attempts at manipulation is a small, but important step in attempts at manipulation of others. Which of the recognizing maladaptive communication patterns and their effect on relationships. Spending following is the most important short‐term goal for the more time alone (option 1) cannot be expected to lead to a decrease in manipulative behavior. nurse to establish? The client will: The manipulative person should be taught ways to have social interactions without manipulating and taking advantage of others. The manipulative person will have a great deal of difficulty sustaining lasting relationships (option 2). Working toward a change in this area would be a long‐term goal. Exploring childhood experiences (option 3) is not a short‐term goal. ‐ Spend more time alone. ‐ Sustain lasting relationships. ‐ Explore childhood experiences. ‐ Acknowledge own behavior. | Recall relevant steps in change theory and apply to this situation. |
4528 When the nurse is evaluating the progress of the Correct answer: 3 Change is reflected in action and behavior. Even if stated clearly and with apparent client whose interpersonal relationships are based on conviction, plans, promises, and words do not reflect actual behavioral change. Statements of manipulation, which statement by the client indicates plans and promises (options 1, 2, and 4) indicate intentions. In order to evaluate actual change, that progress has been made? behavior must be observed. ‐ “I plan to stop taking advantage of other people.” ‐ “I’ve promised myself that I will be kind to others.” ‐ “I did not try to take advantage of anyone today.” ‐ “I can be more kind if I make an effort to do so.” | Look for an indication of actual change in behavior. |
4529 The Axis II diagnosis of a client is schizoid personality. Correct answer: 2 DSM‐IV‐TR criteria for schizoid personality disorders indicate that such individuals are aloof Which approach should the nurse plan to use when and remote when interacting with others, as they have no desire for close relationships. The interacting with this client? nurse should accept this behavior pattern with calmness. To the schizoid client, helpful and nurturing (option 1), light and playful (option 3), and warm and friendly (option 4) approaches might seem like the nurse is attempting to be interpersonally close. This feeling would make the client uncomfortable and could be experienced as overwhelming. ‐ Helpful and nurturing ‐ Matter‐of‐fact and calm ‐ Light and playful ‐ Warm and friendly | Place yourself in the framework of the client’s thinking. Imagine how you would respond to each approach. |
4530 The nurse is responsible for providing care to a group Correct answer: 4 To meet DSM‐IV‐TR diagnostic criteria for a personality disorder, behavioral patterns must be of clients with various personality disorders. The nurse pervasive and maladaptive, resulting in functional impairment or subjective distress. The other should anticipate that a characteristic common to each behavioral patterns (options 1, 2, and 3) are associated with some but not all personality client will be: disorders. ‐ An ability to charm and manipulate people. | Look for the answer that is most comprehensive. It must be true of persons with personality disorders in general. |
‐ A desire for interpersonal relationships. ‐ A diminished need for approval. ‐ A disruption in some aspect of his or her life. | |
4531 A client has been diagnosed with borderline Correct answer: 2 The priority of care is always client safety. Intervening to minimize a client’s risk of self‐harm personality disorder. The client is impulsive, shows maintains a safe environment. The nursing diagnoses of anxiety (option 1) and ineffective labile affect, displays frequent angry outbursts, and has coping (option 4) are of secondary importance to the maintenance of the client’s safety. difficulty tolerating angry feelings without self‐injury. Although the client is impulsive and exhibits angry outbursts, more assessment data would be The nurse selects which of the following as the priority needed to determine if the client is at risk for violence directed toward others (option 3). nursing diagnosis for this client: ‐ Anxiety. ‐ Risk for self‐mutilation. ‐ Risk for violence toward others. ‐ Ineffective coping. | Consider Maslow’s hierarchy of needs or any other system of prioritization with which you are familiar. Recognize that basic physiologic and safety needs take precedence over all other needs. |
4532 The client has borderline personality disorder and Correct answer: 2 Growing up in a multigenerational enmeshed family system and failure to engages in dichotomous thinking. When considering separate/individuate the self are associated with the development of borderline personality possible etiologies for this type of thinking, the nurse disorder. Conflict in the area of separation/individuation can result in splitting or dichotomous should give particular attention to a client history of: thinking—perceiving the self and others as all good or all bad. Although each of the other etiologic factors in options 1, 3, and 4 are associated with the development of personality disorders in general, none of them are associated with the development of dichotomous thinking. ‐ Gender stereotyping. ‐ Family enmeshment. ‐ Perfectionistic standards. ‐ Physiological underarousal. | Look for the answer that applies specifically to the person with borderline personality disorder, not to persons with other personality disorders. Some questions may require the opposite type of thinking. |
4533 A client recently released from prison for Correct answer: 3 All four options indicate Cluster B disorders, as defined in DSM‐IV‐TR diagnostic criteria. embezzlement has a history of becoming defensive However, the disregard for others, lack of guilt and remorse, and involvement in illegal actions and angry when criticized and blaming others for are specific behaviors associated with antisocial personality disorder. The client’s behaviors do personal problems. The client has expressed no not indicate narcissism (option 1) because there is no indication of grandiosity or need for remorse or emotion about the actions that resulted in admiration. Histrionic qualities (option 2) are absent because there is a lack of emotion rather the prison term, but instead says that the than heightened emotionality. There is no indication of borderline personality (option 4) embezzlement was justifiable because the employer because the client is not showing a pattern of instability in interpersonal relationships, self‐ “did not treat me fairly.” The nurse concludes these image, and affect. behaviors are consistent with which of the following mental health problems? ‐ Narcissistic personality disorder ‐ Histrionic personality disorder ‐ Antisocial personality disorder ‐ Borderline personality disorder | Recall the principal characteristics of each of the Cluster B disorders in DSM IV‐TR. Focus on the client’s absence of remorse and guilt. |
4534 The mental health nurse is reviewing a 35‐year‐old Correct answer: 3 According to DSM‐IV‐TR criteria for avoidant personality disorder, the individual will show a client’s history before conducting an interview. The pattern of social inhibition, feelings of inadequacy, and avoidance of interpersonal contact and client’s history indicates fear of criticism and rejection new situations related to fear of rejection and embarrassment. Avoidant personality disorder from others, having few friends, and withholding is a Cluster B disorders, while schizotypal (option 1), paranoid (option 2), and schizoid information about thoughts and feelings in anticipation personality disorders (option 4) are Cluster A disorders in DSM‐IV‐TR. of rejection by others. Based on the data, the nurse suspects that the client may have which personality disorder? | The wording of the question indicates that you should not look for generalities. Look instead for something specific about each of the different personality disorders. |
‐ Schizotypal ‐ Paranoid ‐ Avoidant ‐ Schizoid | |
4535 The nurse caring for a client with antisocial Correct answer: 3 Individuals diagnosed with antisocial personality disorder display decreased impulse control, personality disorder would place highest priority on can be irritable and aggressive, and lack remorse for their actions. Recognizing the potential which nursing diagnosis? risk for violence and maintaining client safety is the first priority of nursing care. Clients with antisocial personality disorder do not have personal identity disturbance (option 1), which is an anxiety disorder. Clients with antisocial personality disorder do not show excessive fearfulness (option 2), which is a characteristic of Cluster C disorders in DSM‐IV‐TR. Instead of being socially isolated, the client with antisocial personality disorder often has a wide range of social contacts and activities, although they occur at a superficial level without regard for the feelings of the other persons (option 4). ‐ Disturbed personal identity ‐ Fear ‐ Risk for violence directed at others ‐ Social isolation | Recall characteristic behaviors of persons with antisocial personality disorder. Remember that they feel no concern or regard for others. |
4536 The nurse and the treatment team are establishing a Correct answer: 2 Since individuals diagnosed with schizoid personality disorder have no desire for plan of care for an in‐patient client who has an Axis I interpersonal relationships and are indifferent to the opinions of others, individual rather than diagnosis of major depression and an Axis II diagnosis group therapy would be the treatment of choice. If this client were placed in group therapy of schizoid personality disorder. The nurse works with (options 1 and 3), it is unlikely that the client could tolerate the interpersonal closeness of the the treatment team in planning to involve this client in group. A support group might be useful to the client after discharge (option 4), but the client which of the following? might find the interpersonal closeness threatening. ‐ Group psychotherapy ‐ Individual psychotherapy ‐ Family therapy ‐ Participation in a support group | Notice that only one therapy involves individual treatment. Recall presenting symptoms associated with schizoid personality disorders. Look carefully at the attitude of the schizoid individual to other people, especially groups. |
4537 The client with narcissistic personality disorder Correct answer: 4 A sense of entitlement, or believing that one is so special that others should defer to his or arrives late to group therapy. Without apologizing, the her needs, is included among in the DSM‐IV‐TR diagnostic criteria for narcissistic personality client interrupts another client and says, “Well, I’m disorder. Additionally, these clients lack empathy and have very disturbed interpersonal here. The group can start now.” The nurse interprets relationships due to their arrogance and selfish focus on self. Splitting (option 1), or this behavior as which of the following? dichotomous thinking, is associated with borderline personality disorders and involves seeing the world, the self, and others in extremes: all good or all bad; totally perfect or totally awful, etc. Hypersensitivity (option 2) especially when combined with suspiciousness (option 3) is more associated with paranoid personality disorder. ‐ Splitting ‐ Hypersensitivity ‐ Suspiciousness ‐ Entitlement | Look carefully at the client’s behavior. Notice the self‐centeredness of the client and the lack of apology to others. |
4538 Which intervention strategy should the nurse Correct answer: 1 Because the behavioral patterns of individuals diagnosed with antisocial personality reflect a routinely include in the nursing care plan for a client tendency to test and manipulate others, it is important to establish the parameters of with antisocial personality disorder? acceptable behavior upon admission through limit setting. The interventions ins options 2, 3, and 4 result in an unstructured environment with no consistent limits on behavior. This would increase rather than decrease an individual’s tendency to test and try to manipulate others in the environment. ‐ Establish clear and enforceable limits | Recall the major characteristics of persons with antisocial personality disorder, particularly the fact that they easily manipulate and take advantage of others with no hesitation or remorse. |
‐ Vary unit rules based on client demands ‐ Vary unit rules based on staff needs ‐ Let the client have a voice in when unit rules should apply | |
4539 Which of the following interventions would be Correct answer: 1, 2, 3 Individuals with obsessive‐compulsive personality disorder tend to become aggressive and appropriate for the nurse to implement when caring argumentative when someone is stressing the importance of routine, rules, and regulations. for the client with obsessive‐compulsive personality Learning to communicate more assertively (option 1) would be useful for these individuals. disorder (OCD)? Select all that apply. Obsessions and compulsions are attempts to control anxiety; therefore anxiety management (option 3) would be useful. Because persons with obsessive‐compulsive personalities need perfection and control, they usually have trouble making decisions, which can negatively affect their occupational functioning. Learning that decisions do not always have to be perfect and that they can be changed may be a first small step toward improvement (option 2). Twelve‐ step programs (option 4) are appropriate for treating individuals with addictive disorders. Distraction techniques (option 5) are not likely to be effective with persons with obsessive‐ compulsive symptoms. Their attention is riveted to the obsessions and accompanying compulsions. ‐ Assertiveness training ‐ Decision‐making skills ‐ Anxiety management ‐ A twelve‐step program ‐ Distraction techniques | Consider how restricted and anxious the world of the obsessive‐compulsive person is. Look for approaches that will help them to function better in their interactions with others. |
4540 The in‐patient client is being treated for Correct answer: 4 Tangential speech occurs when the topic of conversation is changed to an entirely different schizophrenia. While the nurse and client are talking topic. A permanent detour follows. It is considered a disturbance in associative thinking. There about the client’s childhood, the client changes the may be a logical progression but causes a permanent detour from the original focus. Option 1 topic and begins talking about volunteering at a shelter is incorrect as circumstantial speech pattern includes many unnecessary and insignificant for the homeless. The client does not return to the details before arriving at the main point. Option 2 is incorrect because a word salad is an topic of childhood. The nurse should document the incoherent mixture of words or phrases. Option 3 is incorrect as loose association is a vague, client’s speech pattern as: unfocused, illogical flow or stream of thought. ‐ Circumstantiality. ‐ Word salad. ‐ Loose association. ‐ Tangentiality. | Recall definitions for each of the options given. Notice that the client does not return to the original topic of conversation. |
4541 The nurse reads a note in the client’s record Correct answer: 4 Hypervigilance is a state of readiness with the expectation that something is about to happen. indicating that the client is demonstrating Generally the expectation is that a negative event will occur. Option 1 is incorrect as hypervigilance. When assessing this client, it will be hypervigilance and aggression are different phenomena. Hypervigilance can be thought of as most important for the nurse to observe the client for hyperalert and hyperwatchful behavior. Aggression is forceful, often harmful, behavior aimed behaviors that do which of the following? at another person or object. Hypervigilant individuals may or may not progress to being aggressive. Option 2 is incorrect because persons who are attending to internal stimuli will not be focused on the environment, but rather on their own experience. They will generally appear distracted and minimally aware of the environment. Option 3 is incorrect as hypervigilance is associated with heightened anxiety. ‐ Have a hostile and aggressive character ‐ Lead others to think that the client is attending to internal stimuli ‐ Protect the client from experiencing high levels of anxiety ‐ Involve attentive and expectant observance of the environment | Recall a time when you have been eagerly awaiting an event. Did you have a certain level of positive hypervigilance? |
4542 An in‐patient client on the psychiatric unit is being Correct answer: 1 Delusions are false, fixed beliefs that cannot be changed by logical reasoning or evidence. treated for paranoid schizophrenia. As the nurse These beliefs arise from an incorrect appraisal of external reality. They are firmly maintained approaches the client says, “You’re with the FBI; I can even in the face of clear evidence to the contrary. Option 2 is incorrect as a hallucination is the tell by the way you are walking.” The nurse should occurrence of a sight, sound, touch, smell, or taste without any external stimulus to the recognize this as a/an: corresponding sensory organ; they are real only to the person experiencing it. Option 3 is incorrect because an idea of<BR /> ‐ Delusion. ‐ Hallucination. ‐ Idea of Reference. ‐ Loose association. | Notice that this is a cognitive experience. The client thinks something that is not accurate. |
4543 A principle in communicating with a paranoid client is Correct answer: 3 The principle of communicating with a client who is paranoid is to express doubt about for the nurse to: paranoid content and not to attempt to convince him or her through arguing. Option 1 is incorrect as paranoid clients can not comprehend or accept logic. Option 2 is incorrect because providing an anxiety‐free environment may decrease a client’s paranoid episodes but will not necessarily assist the nurse in communicating with the client. Option 4 is incorrect as encouraging ventilation of anger must be done in a controlled environment because paranoid clients may react to false beliefs by placing themselves or others in harm’s way. ‐ Use logic and be persistent. ‐ Provide an anxiety‐free environment. ‐ Express doubt and do not argue. ‐ Encourage ventilation of anger. | Remember that the client is not thinking logically. Attempts to dispel the delusion through logic will not be effective. Indeed, they may lead the client to defend the delusion. |
4544 An appropriate activity for the nurse to recommend Correct answer: 4 Daily walks will allow the client to work off energy and possibly decrease agitation and anger. for a client who is extremely agitated and angry is: Option 1 is incorrect as volleyball would allow the client to dissipate his energy but may allow or encourage aggressive, competitive behavior toward others. Options 2 and 3 are incorrect because scrabble, bingo, and other board games do not allow a client to work off pent‐up energy. Additionally, each of them requires concentration, which will be difficult for a client in a heightened state of emotionality. ‐ Volleyball. ‐ Scrabble. ‐ Bingo. ‐ Daily walks. | Notice that two of the options involve concentration. Choose the option that involves large motor activity that is not likely to further stimulate the client. |
4545 When talking with a client, which client statement Correct answer: 2 The client is describing a tactile hallucination. Hallucinations are false sensory experiences should lead the nurse to conclude that the client is that can occur in any of the special sensory functioning areas: olfactory, gustatory, tactile, experiencing a hallucination? visual, or auditory. There is no external stimulus to the corresponding sensory organ; but the experience is perceived as real by the individual having the hallucination. Option 1 is incorrect as believing falsely that everyone is talking about the client is an example of a delusion. Option 3 is incorrect because mistaking stimuli such as shadows is an illusory experience. Illusions are increased in states of heightened anxiety. Option 4 is incorrect as delusions are false thoughts without a basis in reality. ‐ “I know that everybody is talking about me.” ‐ “I can feel something crawling inside my body.” ‐ “The shadows in the room at night scare me. I always mistake them for someone.” ‐ “The FBI is out to get me and my family because I did such a bad thing.” | Look carefully at the statements of the client. Remember that although auditory and visual hallucinations are generally more common, hallucinations can involve any of the special sensory functioning. |
4546 | The nurse is planning care for a client recently admitted with paranoid ideation. It would be counterproductive for the nurse to plan to do which of the following? | Correct answer: 2 | Arguing or attempting to disprove a client’s delusional or suspicious thoughts will be ineffective and can lead to increased mistrust. The nurse should respond to the underlying feelings rather than the illogical nature of the delusion. Option 1 is incorrect as a consistent program schedule will cut down on the number of surprises for the client and help develop trust in the staff. Option 3 is incorrect because orienting the client to the unit and introducing him to the staff will enable the client to start developing therapeutic relationships. Option 4 is incorrect as communicating clear expectations will prevent the client from being confused. | Recognize that this question is asking for identification of an approach that is not likely to be therapeutic for this client. |
‐ Ensure that a consistent program schedule be followed ‐ Confront and challenge inaccuracies in the client’s ideation ‐ Orient the client to the unit and introduce other staff ‐ Establish clearly defined expectations of the client | ||||
4547 | A client with schizophrenia is admitted to the psychiatric unit. As the nurse approaches the client with medication, the client refuses it and accuses the nurse of “trying to poison me.” The nurse’s best response would be to say, “I understand that you don’t feel comfortable taking this medicine, but:” | Correct answer: 4 | After making an empathetic comment (shown in the stem of this question), the nurse matter‐ of‐factly informs the client of the nature of the substance and its general purpose. Clients have a right to know the names and purposes of all medicines ordered for them. The nurse avoids arguing that the medicine is not poison and does not try to force the client to take the medication. Following this statement, the nurse should offer the medication to the client again. The client has the right to refuse the medication. Only if the client’s behavior is clearly dangerous (and a specific physician’s order is in place) can the nurse give the medication without the client’s consent. Option 1 is incorrect as this option would not persuade the client to take the medication. The client has stated a firm, but delusional, opinion that the medicine is poison. The nurse should also recognize that the client’s delusion probably relates to anxiety and lack of trust in the reliability and competence of staff. If this is the case, an attempted reassuring remark from the nurse will most certainly be rejected by the client. Option 2 is incorrect because this option implies punishment. Legally, this can be considered an assault of the client. If the nurse then gives the medication forcefully, this would be considered client battery. Option 3 is incorrect as the nurse and client have not yet established a relationship of trust, so this statement is rather inane on the part of the nurse. Additionally, the nurse should not be apologetic or defensive with the client. | Choose an answer that is simple and informative, as well as within the legal parameters for medication administration. |
‐ “It is not poison, so you can go ahead and take it.” ‐ “If you won’t take this, I will give you an injection.” ‐ “I’d really like for you to take it. I’m sorry you think that it is poison.” ‐ “This medicine is expected to calm you down. It is called <i>(medicine name)</i>.” | ||||
4548 | A client with the diagnosis of schizophrenia has improved and is playing a card game with peers. The group begins laughing at a joke told to them. The client jumps up and shouts, “You are all making fun of me.” What term should the nurse use when documenting this incident in the client’s record? ‐ Hallucination ‐ Delusion ‐ Idea of Reference ‐ Loose association | Correct answer: 3 | Ideas of reference or misinterpretation occurs when the client believes that an incident has a personal reference to one’s self when, in fact, it is not at all related. Option 1 is incorrect as a hallucination is the occurrence of a sight, sound, touch, smell, or taste without any external stimulus to the corresponding sensory organ; they are real to the person. Option 2 is incorrect because delusions are false beliefs that cannot be changed by logical reasoning or evidence. Option 4 is incorrect as loose association is a vague, unfocused, illogical flow or stream of thought. | Notice that the client is in an interpersonal situation that could feel threatening and increase the client’s anxiety level. |
4549 The nurse is conducting an initial assessment Correct answer: 3 When a client first mentions hallucinations, it is imperative for the nurse to assess for the interview with a newly admitted client whose possible presence of command hallucinations, or hallucinations that give the client an diagnosis is paranoid schizophrenia. When the client instruction. If command hallucinations are present, the risk of physical danger for the client or says, “The voices are talking with me right now. They others is great Note also that the nurse does not refer to the “voice” as a voice, because this won’t go away,” what is the most necessary response could lead the client to believe that the “voice” is indeed an actual voice. Option 1 is incorrect of the nurse? as this response could be appropriate later, once the nurse has established the content and nature of the hallucinatory experience. At this point, the client is newly admitted, and the nurse must assess for command hallucinations. If the client feels commanded to harm self or others the nurse must implement appropriate safety measures. Option 2 is incorrect because the nurse should know that the client who is hallucinating perceives the experience as being real. What is important is for the nurse to assess for the possible presence of command hallucinations. Option 4 is incorrect as it is inappropriate to try to educate the person at this point. More assessment data is needed so that appropriate interventions can be planned. Specifically, the nurse must assess for the presence of command hallucinations. ‐ “I don’t hear the same sounds that you are hearing.” ‐ “Does what you’re hearing seem real to you?” ‐ “Are you receiving a message from what you are hearing?” ‐ “What you’re hearing aren’t really voices of people. They’re thoughts in your head.” | Note that this client is newly admitted and that this is the initial assessment interview. |
4550 While talking with a female client diagnosed with Correct answer: 3 This client is most likely experiencing a visual hallucination. First, it is important for nurses to schizophrenia, the nurse notices the client look away know the content of the hallucination so they can assist the client to process the experience from the nurse and stare at the wall while making and prevent any aggressive behavior. After this intervention is completed, then the client facial grimaces. What is the most appropriate should be oriented back to reality. Ending the conversation (option 1) would not promote trust intervention by the nurse? with the client or allow the nurse to assess content of the hallucination. Trihexyphenidyl (option 2) will not prevent hallucinations. The nurse should not redirect the conversation (option 4) until the nurse has evaluated for hallucinations. ‐ End the conversation because the client is not listening ‐ Administer the ordered prn trihexyphenidyl (Artane) ‐ Ask the client if she sees something on the wall ‐ Redirect the conversation to a neutral topic | Recognize that this client is responding to internal stimuli. |
4551 A client taking antipsychotic medications for Correct answer: 1 Akathisia is an extrapyramidal side effect of antipsychotic medications that may manifest as treatment of schizophrenia reports feeling nervous. subjective and objective restlessness and increased motor movement. Akinesia (option 2) is The nurse notices that the client is pacing the long also an extrapyramidal side effect, but it is not shown in this client’s behavior. Akinesia is hallway and is unable to remain still, even when in decreased activity or motor movement. Dystonia (option 3) is also an extrapyramidal side conversation with other clients. What term should the effect, but it is not shown in this client’s behavior. Dystonia presents as sudden and often nurse use to document this occurrence? painful contractions of muscles, especially of the head and neck. Tardive dyskinesia (option 4) is also an extrapyramidal side effect, but it is not shown in this client’s behavior. Tardive dyskinesia presents as involuntary muscle movements, strange tics, and repetitive motor movements in persons who have taken antipsychotics for a long period of time. The situation gives no past history of the client. ‐ Akathisia ‐ Akinesia ‐ Dystonia ‐ Tardive dyskinesia | Define each term for yourself and then look back at the client behaviors described in the stem of the question. |
4552 The client who has schizoaffective disorder takes both Correct answer: 3 The nurse should know that the client has the right to have information about medications haloperidol (Haldol) and valproic acid (Depakote). being taken. This information should be accurate and given in manner that the client is likely to When the client asks the nurse to explain what this be able to understand. The nurse’s answer should be based on the understanding that particular combination of drugs is expected to do, haloperidol (Haldol) is a traditional antipsychotic and that valproic acid (Depakote) is a what would be the best response by the nurse? traditional anticonvulsant that is also used for the non‐traditional purpose of mood stabilization. Option 1 contains inaccurate information about expected drug effects. Option 2 is a nonspecific response and does not provide the client with the requested information, and Option 4 is an inaccurate statement because this sort of combination is not old—FDA approval for administering certain anticonvulsants (including valproic acid) was not approved until the early 2000s. ‐ “Haloperidol (Haldol) makes your moods calmer and valproic acid prevents tight muscles.” ‐ “This combination is good for people who have problems like yours.” ‐ “Haloperidol improves your thinking, and valproic acid stabilizes your moods.” ‐ “This is an old combination of drugs that helps people to keep thinking and feelings in balance.” | Look carefully at each option for factual correctness. This will require that you know relevant information about these two drugs. |
4553 A client admitted to an inpatient unit has a diagnosis Correct answer: 1 Paranoid schizophrenic clients are very suspicious and potentially dangerous. It is best to of paranoid‐type schizophrenia. The new mental avoid any physical contact, as well as any symbolic or actual invasion of the client’s personal health care worker on this unit approaches the nurse space because the client may feel threatened. Offering a back rub (option 2), shaking hands and asks about the best way to work with this client. (option 3), and placing a hand on the client (option 4) involve physical contact. It is unlikely How should the nurse respond? that the client could tolerate this without becoming aggressive. ‐ “When possible, remain at arm’s length from this client.” ‐ “This client is anxious. Offer back rubs at bedtime.” ‐ “Offer this client a hand‐shake before beginning conversation.” ‐ “To get the client’s attention, place your hand gently on the arm or hand.” | Recall a paranoid client you have seen in the clinical area. How do you think this client would react to each of these actions? |
4554 The client has schizophrenia, residual type. A nursing Correct answer: 3 Residual‐type schizophrenia manifests with socially withdrawn behavior, an inappropriate care plan should give priority to which nursing affect, and an absence of prominent psychotic symptoms. The most likely and common nursing diagnosis? diagnosis would be Social isolation. Impaired verbal communication (option 1), Self‐care deficit (option 2), and Anxiety (option 4) are less likely to be seen in a client with residual schizophrenia than is social isolation. ‐ Impaired verbal communication ‐ Self‐care deficit ‐ Social isolation ‐ Anxiety | Recall prominent behaviors associated with residual schizophrenia. Then consider which nursing diagnosis would encompass these behaviors. |
4555 The nurse observes that the client with paranoid Correct answer: 2,4 This client is actively responding to internal stimuli and could easily react aggressively to schizophrenia appears very preoccupied. The client is others, especially if experiencing command hallucinations or if responding to actual or pacing back and forth in the hall, periodically looking perceived intrusions of others into the client’s own personal space. The described behaviors do to the side, clenching the fist, and saying, “I told you to not suggest that this client is disoriented (option 1). Instead the nurse should recognize go away.” At this time, the nurse should plan to do indications that the client is experiencing hallucinations. The client is likely to respond which of the following? Select all that apply. aggressively to moving hand gestures (option 3), which will be perceived as a physical threat. If the nurse offered the kind of verbal statement to the client as in option 5, it is highly unlikely that the client would feel reassured. Indeed, this action might provoke further suspiciousness, as the client’s hyperalertness and mistrust will lead to misinterpretation of environmental events. ‐ Offer frequent orienting stimuli ‐ Reduce proximity to others ‐ Substitute non‐verbal hand gestures for words ‐ Avoid touching the client during conversation. ‐ Reassure the client of the safety of the environment. | Recall that when during periods of active hallucinations, clients are more responsive to internal stimuli than to external stimuli. This can put the client and others at risk for injury. |
4556 The nurse is to complete an AIMS assessment of the Correct answer: 3 client. When explaining this test to the client, the nurse should say, “This test will help us to learn if you are beginning to have:" ‐ "Weak muscles.” ‐ "Shaking hands and feet.” ‐ 'Uncontrollable motions in the body.” ‐ "Slowed body movement.” | The AIMS (abnormal involuntary movement scale) is used to screen for signs of tardive dyskinesia, which is a possible side effect associated with long‐term use of an antipsychotic, particularly of the traditional type. It is characterized by involuntary, repetitive, and often bizarre movements of the mouth, face, trunk, and extremities. It is considered irreversible, so early recognition is imperative. The AIMS test does not include assessments for muscle weakness (option 1), which would indicate acute EPS (extrapyramidal side effects) rather than tardive dyskinesia. The AIMS test excludes regular repetitive rhythmic tremors (option 2). These are indications of acute EPS (extrapyramidal side effects), not chronic tardive dyskinesia. The AIMS test does not measure slowed body movements (option 4), which would indicate acute EPS (extrapyramidal side effects), not chronic tardive dyskinesia. | Mentally review the major differences between tardive dyskinesia and acute EPS. |
4557 A client reports having blurred vision that began after Correct answer: 2 Blurred vision is an anticholinergic symptom/side effect that usually resolves in a few weeks. beginning drug therapy with a traditional If there is no improvement with time, then the doctor should be notified. It is too early to antipsychotic. What would be the best response by the schedule an appointment (option 1), as the client can be expected to accommodate to this side nurse? effects within a matter of days. However, if the client also complains of pain in the eye, the physician should be notified immediately, as the client may be experiencing glaucoma as a result of the pupillary dilation that caused the blurred vision. There is no indication of pain with the blurring of vision, so the nurse does not have to respond urgently (option 3). Permanent blurred vision is unusual (option 4). The client can be expected to accommodate to this side effect within a matter of days. ‐ “You need to schedule an appointment with your eye doctor to get a new prescription for your eyeglasses.” ‐ “Blurred vision is a temporary side effect of your medication that usually resolves within a few weeks.” ‐ “You need to stop taking your antipsychotic medication and notify your doctor immediately.” ‐ “Blurred vision is a permanent condition as a result of your medication.” | Compare and contrast effects of anticholinergic drugs with anticholinergic side effects. | |
4558 A client is planning to be discharged from the Correct answer: 4 hospital. It is the nurse’s responsibility to educate this client regarding prescribed medications. This client is taking clozapine (Clozaril). The nurse makes it a priority to teach the client to notify the physician immediately if there are: | Agranulocytosis is the most dangerous common side effect of clozapine and can lead to death if not detected and treated early. In addition to the requirement that weekly analysis of WBCs must be completed before clozapine can be reordered, it is important that the client, family, and nursing staff understand that changes in the WBC could occur during the time period between two laboratory testings. Therefore, reporting any observations of suspected infection is an urgent priority. Feeling more energy and interest (option 1) probably indicates a decrease in the intensity of negative symptoms of schizophrenia, and notification of the physician can be delayed. Sensitivity to ultraviolet rays (option 2) is a potential side effect of clozapine that is generally more bothersome than dangerous. Interference with a normal sleep pattern (option 3) is a problem that should be reported to the physician, but urgent reporting is not necessary. | Note the word priority in the question. Look for the most potentially dangerous side effect. |
‐ Feelings of increased energy and interest in the environment. ‐ Unusual reactions to exposures to the sun. ‐ Interferences with the normal sleep pattern. ‐ Indications of any sort of infection. | ||
4559 A client with chronic schizophrenia has been receiving Correct answer: 2, 4 Improvement in motivation and volition and ability to experience pleasure indicate a an atypical antipsychotic for 3 months. The nurse reduction in negative symptoms. While option 1 indicates improvement, the improvement is in concludes that the client is experiencing a reduction in the positive symptoms of schizophrenia: auditory hallucinations. Options 3 and 5 indicate negative symptoms of schizophrenia if a family improvement in the positive symptoms of schizophrenia: delusions. member says which of the following? Select all that apply. ‐ “We walked together for 15 minutes, and I could see no evidence he was ‘hearing voices’.” ‐ “For the past week, he has gotten up, dressed, and taken a walk early each morning.” ‐ “It’s been more than a month since he said that he is a Martian prince.” ‐ “We went to a musical concert, and he smiled and applauded the musicians. ‐ “I’ve noticed that his thoughts are better organized.” | Review differences between positive and negative symptoms of schizophrenia. Recall that both have a negative or unhealthy character. |
4560 A client diagnosed with schizophrenia, paranoid type, Correct answer: 4 Safety is always the highest priority when caring for any client. This is particularly true when is admitted to an acute‐care psychiatric hospital unit. the client has paranoid schizophrenia. These clients are extremely suspicious and distrusting of Which nursing diagnosis should be given highest the environment and feel that others have harmful intent toward them. They maintain an alert priority in the initial nursing care plan? and watchful hypervigilance and are at high risk for aggression and/or violence. Interrupted thought processes (option 1), social isolation (option 2), and impaired verbal communication (option 3) are appropriate for the client’s care plan but are not given highest priority, as they are not as important as safety. ‐ Interrupted thought processes ‐ Social isolation ‐ Impaired verbal communication ‐ Risk for violence directed at self or at others | Recognize that in any nursing situation, highest priority is always assigned to providing safety and maintaining basic physiologic functioning. |
4561 The client diagnosed with schizophrenia says, Correct answer: 2 The client is experiencing a delusion and indeed believes that the nursing staff members are “Everyone here is part of the secret police and wants secret police. Understandably, the client will be distrusting, suspicious, and frightened of all to torture me,” and refuses to be weighed by a actions of the staff. The nurse should show awareness of the feelings of the client (“That must member of the nursing staff. What is the most be a frightening thought.”) and present reality about the role of the nursing staff. (“We are appropriate response by the nurse? nurses who work at this hospital.”) Option 1 demeans the client and fails to allow the client to know the staff’s role. Option 3 attempts to respond to the client’s feeling and present reality, but it does not tell the patient about the role of the staff. Option 4 attempts to be reassuring, but it fails to give reality‐based information that might assist the client to feel more comfortable with the staff. It also could suggest to the client that torture will occur, but not at this location. | Look for an answer that both shows understanding of the client’s feeling and presents reality as perceived by the nurse. |
‐ “That is a strange idea. We aren’t secret police persons.” ‐ “That must be a frightening thought. We are nurses who work at this hospital.” ‐ “Being suspicious isn’t easy, is it? You won’t be tortured here.” ‐ “There is no need to be frightened. We will keep you safe from torture.” | |
4562 A male client is taking a second‐generation Correct answer: 2, 3, 5 Options 2, 3, and 5 are correct because diminished pleasure (option 2), blunted affect (option antipsychotic drug. The client’s spouse tells the nurse 3), and difficulty making decisions (option 5) all represent a loss or lack of normal skills and that she read that the drug is effective to treat functioning of the individual, which is the definition of negative symptoms of schizophrenia. negative symptoms of schizophrenia and asks the First‐generation antipsychotic drugs typically do not improve these symptoms, but second‐ nurse to explain what these are. What should the generation antipsychotic drugs do. Positive symptoms of schizophrenia, such as abnormal nurse include in a response to the spouse? Select all thoughts (option 1) and hallucinations (option 4) are symptoms that, if present, clearly and that apply. certainly indicate the presence of psychosis. | Define, then compare and contrast positive and negative symptoms of schizophrenia. Recognize that both groups of symptoms are undesirable, so the term negative can be confusing, unless you recall that it is the absence of what the typical person would have or experience. Think carefully about this, as the terms themselves can lead to confusion unless you have a clear definition in mind. |
‐ Abnormal thoughts ‐ Diminished pleasure ‐ Blunted affect ‐ Hallucinations ‐ Difficulty making decisions |
4563 The nurse is assessing a client who recently began Correct answer: 3 This client is exhibiting signs and symptoms of possible neuroleptic‐induced malignant taking a typical antipsychotic medication. The client syndrome (NMS), a potentially lethal side effect of antipsychotic medications requiring says, “All of a sudden I can’t breathe right.” The nurse immediate medical care. The care cannot be delayed, as the NMS may progress rapidly and observes generalized body rigidity and diaphoresis. The lead to client death. The client is not simply experiencing extrapyramidal effects (EPS), which body temperature is 103 degrees F, 39 degrees C, and would indicate the need for a prn anticholinergic (option 1). While orthostatic hypotension the pulse is 130. What should the nurse do next? (option 2) may occur as a side effect to many antipsychotic medications, making this the priority intervention at this time would ignore the possibility that NMS is present. Suspected NMS should be considered an immediate medical emergency. Failing to recognize the urgency of the situation and arranging for a physician’s visit later in the day (option 4) could put the client at grave risk for negative consequences, possibly including death. | Pay attention to the particular combination of symptoms that the client is manifesting. Look at them as a group, not individually. Recognize that in any nursing situation, highest priority is always assigned to providing safety and maintaining basic physiologic functioning. |
‐ Administer the ordered prn anticholinergic medication ‐ Assess the client for indications of orthostatic hypotension ‐ Begin preparing the client for immediate transfer to an emergency department ‐ Arrange for an additional physician’s visit later in the day | |
4564 While the nurse is meeting with the family of a client Correct answer: 2 The precise cause of schizophrenia is unknown. The general consensus is that schizophrenia with schizophrenia, a family member asks the nurse to results from the interaction between a variety of biologic and psychosocial factors that have explain what causes this disorder. What is the nurses’ been correlated with schizophrenia. Research has correlated genetic factors with best response? schizophrenia, but more research is needed (option 1). Poor parenting skills (option 3) and early‐age trauma (option 4) have not been documented as exact causes of schizophrenia. ‐ “Research indicates that schizophrenia is caused by a genetic predisposition.” ‐ “The exact cause of schizophrenia is unclear at this time.” ‐ “It is likely that poor parenting skills cause schizophrenia to occur.” ‐ “It is clear that early‐age psychological traumas cause schizophrenia.” | Look for the answer that will fit in any situation. Remember that in spite of extensive research and sophisticated diagnostics, no single cause for schizophrenia has yet been established. |
4565 The nurse is working with a severely withdrawn Correct answer: 1 This option recognizes that the client is not likely to initiate interpersonal or social activity client. Which of the following should the nurse independently. It is also a measurable goal that is reasonable to achieve in a short time. Clients formulate as an appropriate short‐term goal? The need to meet short‐term goals during hospitalization to promote a sense of accomplishment, client will: which may increase their self‐esteem. Leading a unit community group by the time of discharge (option 2) is a possible long‐term goal; however, this could be an unrealistic goal for the time of discharge. Option 3 is not written in measurable terms, even though it specifies a short time frame for accomplishment. It fails to indicate how the nurse can know that a client is “more comfortable.” Option 4 is not written in measurable terms, even though it specifies a short time frame for accomplishment. It fails to indicate how the nurse can know that a client “enjoys participating.” | Look for an outcome that is stated so specifically that it could be measured by any nurse at the end of the specified time frame. |
‐ Attend one group meeting accompanied by a staff member within 3 days. ‐ Voluntarily lead the unit community meeting by the time of discharge from the hospital. ‐ Be more comfortable in group situations by 3 days. ‐ Enjoy participating in group therapy by the time of discharge. |
4566 The client has catatonic schizophrenia and Correct answer: 1, 2, 4 Option 1—Catatonic schizophrenia is characterized by two phases: nonresponsive demonstrates rigidity, waxy flexibility, and extreme hypoactivity and unpredictable hyperactivity and aggression that may be dangerous to self or psychomotor retardation. The nurse anticipates that others. The nurse must always anticipate that the aggressive stage may occur. Option this client is at risk for which of the following? Select 2—Constipation is possible because of the psychomotor retardation and relative immobility of all that apply. the client. This client will likely be receiving antipsychotic medications, most of which have anticholinergic side effects, including constipation. Unless the staff assists the client and allows extra time for meals, the likelihood of nutritional deficiency (option 4) is increased because of the client’s psychomotor retardation and inability to verbally report any feelings of hunger. Option 3—The client is actually experiencing impaired individual coping, as expressed through the presenting behaviors. Option 5—Many clients who have had catatonic episodes are able to recall details and events occurring during a period of stupor. ‐ Aggressive outbursts ‐ Constipation ‐ Ineffective coping ‐ Nutritional deficiency ‐ Memory deficit | Form a mental picture of this client. Apply concepts of basic physiology and theoretical knowledge about manifestations of catatonic schizophrenia. |
4567 A client diagnosed with schizophrenia says, “I want to Correct answer: 3 Clang associations are association disturbances in which schizophrenic clients rhyme words in go home to tome in a dome.” When documenting, the a sentence that seems nonsensical to the listener. Echopraxia (option 1) is meaningless nurse will refer to this as: imitation of motions made by others. Echolalia (option 2) is involuntary parrot‐like repetition of words spoken by others. Associative looseness (option 4) does not involve rhyming, but rather lack of integration or logical connection between thoughts. ‐ Echopraxia. ‐ Echolalia. ‐ Clang associations. ‐ Associative looseness. | Notice that the client is speaking in a rhyming fashion. If you don’t remember the meaning of each of the terms, look at the root elements in the other terms. |
4568 The client is to begin taking olanzepine (Zyprexa). The Correct answer: 3 Increase in body weight and body mass index (BMI) can occur very quickly when clients take nurse makes it a priority to assess which of the olanzepine (Zyprexa). Baseline data about these should be obtained before the client begins to following before administering the first dose? take this drug. Determining the client’s sleep pattern (option 1) is not an urgent consideration, although the nurse should recognize that daytime somnolence might be an early side effect of the olanzepine (Zyprexa). Food and fluid preferences (option 2) are important considerations when the nurse teaches the client about usual side effects, but this can be done later. While some clients do have digestive disturbances (option 4) while taking olanzepine (Zyprexa), this is not nearly as common as the side effect of rapid weight gain. ‐ Usual sleep pattern ‐ Food and fluid preferences ‐ Body weight ‐ History of indigestion | Think about the most common and untoward side effects associated with second‐ generation antipsychotics. These include hyperglycemia, weight gain, and new‐onset Type 2 diabetes. Recall that unwelcome weight gain frequently contributes to non‐compliance. |
4569 A client diagnosed with schizophrenia tells the nurse Correct answer: 3 Thought insertion is a thought disorder of schizophrenia defined as the client believing that that another client is “creating negative thoughts in others are putting thoughts in his or her mind against the client’s will. Thought broadcasting me against my will.” The nurse documents that the (option 1) is the belief by a client that he or she can broadcast his or her thoughts to others. client is exhibiting which of the following features of Thought blocking (option 2) occurs when a client’s thoughts stop in midstream. Thought schizophrenia? control (option 4) is the belief that others can control one’s thoughts against his or her will. ‐ Thought broadcasting ‐ Thought blocking ‐ Thought insertion ‐ Thought control | Review basic definitions of cognitive distortions common in persons with schizophrenia. |
4570 A client with dementia is having difficulty recalling Correct answer: 3 Persons with dementia may exhibit confabulation, in which they fill in a memory gap with a activities from the day before and says, “I went to the detailed fantasy that they believe. This process allows preservation of self esteem. Option 1 is USO yesterday and danced with a cute soldier before incorrect as perseveration consists of repetitive behaviors such as lip licking, finger tapping, he was shipped overseas to fight the Germans.” The pacing, or echolalia. Option 2 is incorrect because agnosia is an inability to recognize familiar nurse interprets this statement as: situations, people, or stimuli. Option 4 is incorrect as hyperorality is the need to taste, chew, and examine any object small enough to be placed in the mouth. ‐ Perseveration. ‐ Agnosia. ‐ Confabulation. ‐ Hyperorality. | Recall definitions of each term given in the options. Recognize that the client’s statement is based on an unconscious attempt to preserve self esteem |
4571 An extremely agitated client with multiple drainage Correct answer: 4 If the delirious client is very agitated or restless, physical restraints may be necessary to keep tubes and an intravenous (IV) line is restrained in bed tubes and lines intact and functioning. The restraint should be used only if absolutely necessary with wrist and ankle cuffs. A family member expresses and the disoriented client should never be restrained and left alone. Clients who are restrained concern and asks for an explanation. What is the best can be expected to resist the restraints. Family members are likely to be alarmed and fearful initial response by the nurse? about the safety of their family member. The nurse’s response to the family should be sensitive to that. Option 1 is incorrect as the nurse should not have to wait for the physician to explain the purposes of the restraints. At the time that the family expresses concern, the nurse should give compassionate and accurate information to the family. Option 2 is incorrect because this option begins in an appropriate way by attempting to show empathy. The second part of the statement, however, is inaccurate. Delirious clients who are restrained, like other restrained individuals, are generally aware of and resistive to the restraints. Option 3 is incorrect as this option begins by trying to respond to the feelings of the family, but it ends with a poor attempt at reassurance, which will not comfort the family at all. ‐ “The physician has ordered the restraints and will explain the reason to you later if you would like to wait.” ‐ “I know this is upsetting to you, but you shouldn’t worry because your loved one is too confused to notice the restraints.” ‐ “I’m sure this is very frightening for you, but you will just have to trust us to give the best care and treatment possible.” ‐ “The restraints are a temporary safety precaution and will be removed as soon as possible when the agitation lessens.” | Think of the position of this family. Remember that restraints should only be used as a means of assuring safety after all other measures have failed. |
4572 The nurse is establishing client outcomes for a client Correct answer: 3 Clients in stage 3 of Alzheimer’s disease experience severe impairments usually requiring with stage 3 dementia of the Alzheimer’s type. Which total dependent care. The client is often incontinent and mobility is severely impaired. As the of the following outcomes is most appropriate? The disease progresses a more realistic goal for these clients is that the client will remain clean and client will: dry. Option 1 is incorrect as the client in stage 1 dementia might be able to meet this outcome with assistance. However, in state 2, behavior deteriorates markedly and the client begins needing assistance with ADLs. When Stage 3 is reached, total care becomes necessary. Option 2 is incorrect because in Stage 3 dementia, the client is confused and easily overwhelmed by unfamiliar situations and persons. He/she may become unable to identify even very familiar persons, such as a spouse. The client is also prone to wandering, so attending therapeutic outings would present a safety issue for the client. Option 4 is incorrect as the client in Stage 3 dementia easily becomes agitated and even violent. They have poor impulse control and are prone to behavioral outbursts. Nurses and other staff members should make every effort to manage these situations and to keep anxiety at a manageable level, but maintenance of physiologic, functioning is the priority. ‐ Shave, shower, and dress self by 9:00 A.M. every day. ‐ Interact with others in group activities and therapeutic outings. ‐ Maintain skin integrity despite incontinence or prolonged pressure. ‐ Maintain minimal anxiety level in response to difficult situations. | Recall that dementia is a progressive, condition of declining functioning. Review content regarding staging of dementia of the Alzheimer’s type (DAT). |
4573 The client with dementia is confused and frequently Correct answer: 3, 4 The client may not have the ability to read posted signs or the verbal ability to ask for help. wanders. In order to ensure the client’s safety, which An appropriate nursing intervention is one that will directly assist with orientation thereby of the following nursing interventions should the nurse reducing confusion that may indirectly lead to wandering that can compromise the client’s employ? Select all that apply. safety. Wandering may be an attempt to avoid stress and tension in the environment. Sensor devices can provide a warning if the confused client wanders through an outside door. Within a safe environment wandering can be beneficial, as it promotes exercise and stimulates oxygenation and circulation. Option 1 is incorrect as wandering behaviors usually begin in Stage 3 dementia. At that point, the client will not be able to remember information such as addresses and phone numbers. Option 2 is incorrect because by the time dementia has progressed sufficiently to cause wandering, the client will have lost the cognitive skills for reading and understanding a map. Option 5 is incorrect as due to significant cognitive impairment, the client will not be able to verbalize an explanation of reasons for wandering. ‐ Orient the client to the address of his or her home or nursing facility ‐ Provide a map of the surrounding community to the client ‐ Post pictures of the client with arrows pointing to the client’s room ‐ Explore the feasibility of installing sensor devices on unit doors ‐ Ask the client to explain reasons for wandering behavior | Notice that the client is in Stage 3, or advanced, dementia. Eliminate any option that involves complex cognition. Focus on the client’s need for safety. |
4574 Because they work, the family of a client with stage 1 Correct answer: 2 Families of clients in the early stages of DAT may need assistance in providing 24‐hour care dementia of the Alzheimer’s type (DAT) cannot provide for clients. If families are not available during the day, adult daycare centers are available in care during the daytime. Which of the following some communities. Options 1 and 3 are incorrect as skilled nursing facilities and options should the nurse help them explore? hospitalization are options usually reserved for clients with more advanced stages of DAT. Option 4 is incorrect because the laws providing for involuntary treatment of clients in hospital settings require that the client’s behavior be clearly and immediately dangerous to self or others and gravely disabled. The client in Stage 1 dementia would not meet these criteria. ‐ Skilled nursing facility ‐ Adult daycare center ‐ Short‐term hospitalization ‐ Psychiatric commitment | Notice that the client is in the early stages of dementia and is expected to be able to function with assistance in the home and community environments. |
4575 A client with chronic alcoholism had elective surgery Correct answer: 3 Withdrawal delirium symptoms develop after reduction or termination of sustained, high‐ three days ago. When the client begins perspiring dose use of certain substances such as alcohol. Due to forced abstinence during heavily and is disoriented, the nurse should be hospitalization, clients with chronic alcoholism may experience withdrawal symptoms two to concerned that the client may be exhibiting: three days following their admission. Alcohol withdrawal delirium is considered a medical emergency and can result in death even if treated. When the nurse knows that the client has an established history of alcohol use, the nurse should be alert for earlier signs of alcohol withdrawal such as hyperalertness, subjective distress described as “shaking inside” and heightened anxiety. These are among the many manifestations of alcohol withdrawal that the nurse should report promptly to the physician. If alcohol withdrawal is properly treated, the client is not expected to progress to the more dangerous situation of alcohol withdrawal delirium. Alcohol withdrawal symptoms may begin as early as a few hours after the last intake of alcohol cessation or reduction of intake of alcohol and can progress to alcohol withdrawal delirium, which will usually peak 48‐72 hours later. Options 1, 2, and 4 are incorrect as these conditions are usually associated with a sustained long‐term pattern of heavy drinking of alcohol. ‐ Alcohol‐induced persisting dementia. ‐ Alcoholic seizure disorder. ‐ Alcohol‐withdrawal delirium. ‐ Alcohol intoxication delirium. | Notice that three of the options are associated with long‐term use of alcohol. This client has been recently hospitalized and access to alcohol will have been restricted. |
4576 | The client is experiencing alcohol‐withdrawal delirium. What is the highest priority action by the nurse? ‐ Reality orientation ‐ Restraint application ‐ Referral to Alcoholics Anonymous ‐ Replacement of fluids and electrolytes | Correct answer: 4 | When intervening in delirium, highest priority is given to nursing interventions that will maintain life. Fluid and electrolyte loss caused by nausea and vomiting can be a life‐ threatening condition during alcohol withdrawal requiring replacement by intravenous therapy. Alcohol withdrawal delirium is considered a medical emergency and can result in death even if treated.<BR /> | Recognize the gravity of this client’s situation. Understand that the client could die as a result of alcohol withdrawal delirium. |
4577 A 79‐year‐old client is receiving haloperidol (Haldol) Correct answer: 1 on a regular and a prn basis. The nurse should recognize the vital importance of assessing this client frequently for indications of which of the following? ‐ Tardive dyskinesia ‐ Fecal impaction ‐ Pseudoparkinsonian side effects ‐ Sedation | Elderly clients have slower metabolism and elimination of drugs causing an increased susceptibility to side effects. Haloperidol is a first generation, high potency antipsychotic that frequently causes extrapyramidal side effects (EPS), either of an acute or a chronic nature. In younger clients, EPS are more likely to be acute, but elderly clients may be more at risk for tardive dyskinesia (TD), which is generally irreversible. Option 2 is incorrect as constipation is a common side effect of antipsychotic drugs. Unmanaged constipation can lead to fecal impactions, especially in the elderly. However, these are considered preventable or treatable problems, while tardive dyskinesia is irreversible. Option 3 is incorrect because pseudoparkinsonian side effects are one of the extrapyramidal side effects associated with antipsychotics, especially traditional ones like haloperidol. They are generally reversible and treatable. While not as likely as tardive dyskinesia in the older client, acute extrapyramidal side effects (EPS) can occur. Option 4 is incorrect as one of the more potent of the first generation antipsychotics, haloperidol is not likely to cause sedation as a side effect. | Notice the words “vitally important” in the stem. Look for the most untoward side effect that could create the most negative consequences for the client. | ||
4578 | The client has acute delirium associated with overdose of a non‐prescribed drug. Toward which of the following client outcomes should the nurse initially address care? The client will: | Correct answer: 3 | Initially, the delirious client is dazed and, drowsy with disturbed perceptions and difficulty sustaining attention. Further, the client is expected to experience alternating periods of disorientation, confusion and lucidity. These symptoms place the client at risk for injury, so an absence of them indicates that the client’s safety is less threatened. Options 1, 2, and 4 are incorrect as these outcomes could be appropriate at a later time after the client has been stabilized physically. Drug overdose and delirium place the client at significant medical and physical risk, and the priority at this time is to preserve physiologic functioning and reduce risk for injury. | Notice that this question asks for a short term outcome. Recall that this client is at significant medical risk and is expected to be disoriented and confused. |
‐ Verbalize dependence on drugs. ‐ Demonstrate adaptive coping strategies for dealing with stress. ‐ Demonstrate orientation to person, place, and time during lucid periods. ‐ Explore reasons for addictive behaviors. | ||||
4579 The client has early stage dementia. The nurse is Correct answer: 2 This statement addresses the client by name and gives a simple statement indicating why the returning to the client’s room after leaving to get extra nurse is at the client’s bedside. This is important because when the client has dementia, sheets for the bed. What should the nurse say to the addressing the person by name can help the client to focus on the speaker and retain personal client upon reentering the room? identity. The nurse should also speak in a low, warm respectful voice and identify self to the client by name. Option 1 is incorrect as this statement addresses the client by name, but it asks the client to make a decision (a difficult task for a person with dementia) and uses an unusual term (“your sleeping accessories), which the client may have difficulty understanding. Option 3 is incorrect because this option inappropriately tests the client’s memory and fails to give the client information about the purpose of the nurse being at the bedside. Option 4 is incorrect as this option addresses the client by name, but fails to be simple, direct and informative. ‐ “Hi, (<i>name</i>). Where would you like me to put your sleeping accessories?” ‐ “Hello, (<i>name</i>). I have come back with clean sheets for your bed.” ‐ “Do you remember that I said I’d be back? Well, here I am.” ‐ “I’ll bet you’d like some clean sheets, wouldn’t you, (<i>name</i>)?” | Remember that the client with dementia will have amnesia for recent events, difficulty processing complex ideas or words and problems with orientation. |
4580 The client with dementia of the Alzheimer’s type says Correct answer: 4 This response uses a method of reality orientation that increases self‐worth and personal to the nurse, “I have a date tonight for the Valentine’s dignity. It also allows client reminiscence, which is useful to persons with dementia as their dance.” What is the most appropriate response by the remote memories are more intact than recent ones. In option 1, the nurse is attempting to nurse? present reality, but in a non‐therapeutic manner. The statement is made in a demeaning and belittling manner. The nurse should present reality and provide orienting stimuli in a manner that preserves the client’s self esteem. In option 2, the response of the nurse promotes further disorganization in thinking and orientation in this client with dementia. The client’s statement in option 3 indicates disorientation and disorganized thinking that is very common in persons with dementia. There is nothing to suggest that this behavior requires a prn medication (such as aggression toward others) is present. ‐ “You’re confused again. There isn’t a dance tonight and this isn’t Valentine’s Day.” ‐ “I didn’t think your spouse was still living. Who is your date with?” ‐ “I think you need some more medication. I’ll be right back with your shot.” ‐ “Today is January 11th. Tell me about some of the other dances you’ve been to.” | Look for an option that presents reality and provides orienting stimuli in a manner that preserves the client’s self‐esteem. |
4581 The nurse is teaching a family caregiver how to help a Correct answer: 3 Clients with early dementia should be allowed to provide their own ADLs as independently as client with early dementia complete activities of daily possible for as long as possible. They will need extra time to perform tasks. It is premature to living (ADLs). Which information should be included in provide ADLs to the client with early dementia (option 1). This will likely be necessary at a later the teaching? stage of the illness. Having the client develop a written schedule for ADLs (option 2) may be overwhelming to the client and increase confusion and uncooperativeness. Giving the client an ultimatum about the time in which ADLs must be completed (option 4) may be overwhelming and therefore increase confusion and/or uncooperativeness. ‐ Perform ADLs for the client ‐ Have the client plan a schedule for ADLs ‐ Give the client ample time to perform the ADLs as independently as possible ‐ Tell the client that the ADLs must be finished by 9:00 a.m | Recognize the interdependent relationship between self‐esteem and independent functioning. |
4582 When working with a client who has dementia, the Correct answer: 4 Client safety and security are nursing priorities for clients with the disorientation, confusion, primary intervention by the nurse is to ensure that the and memory deficits seen in dementia. Option 1 is stated illogically. Dietary choices will not client: stimulate appetite. Additionally, recall that clients with dementia should not be expected to make choices, as this can overwhelm them. Client safety and security are nursing priorities for clients with dementia rather than social isolation (option 2) or low self‐esteem or anxiety (option 3). ‐ Is offered dietary choices to stimulate appetite. ‐ Meets other clients with dementia to prevent social isolation. | Recall Maslow’s hierarchy of needs or some other system that you know to be useful to assist with prioritizing. |
‐ Discusses feelings of fear and loss to prevent low self‐esteem and anxiety. ‐ Remains in a safe and secure environment to prevent injury. | |
4583 Accompanied by a friend, an emergency department Correct answer: 1 The highest priority is given to nursing interventions that will maintain life; therefore, basic client arrives by ambulance. The client is shouting physiological needs must be addressed initially with baseline vital signs. Checking the level of incoherently and fighting against restraints. The friend orientation (option 2) is important but does not provide any new information to the nurse. reports that the client “went crazy” about an hour Nutrition and fluid balance (option 3) may be maintained by IV therapy once vital signs are after taking a pill bought earlier in the day. Which of evaluated and a physician’s order is obtained. Sedative medications (option 4) may complicate the following actions should the nurse take first? an attempt to identify the original cause of the client’s symptoms. ‐ Take vital signs ‐ Check orientation ‐ Start intravenous (IV) fluids ‐ Administer sedative medication | Recall Maslow’s hierarchy of needs or some other system that you know to be useful to assist with prioritizing. |
4584 A delirious client was recently released from wrist Correct answer: 3 The client is experiencing tactile hallucinations. The most appropriate response is option 3, and ankle restraints. Suddenly, the client begins to which orients the client to the reality of being sick and reassures the client of safety. By making beat the sheets and yell, “Get those bugs away from statements that essentially agree that the bugs exist (options 1, 2, and 4), the nurse is me! They’re all over! Get them!” The best initial communicating that the hallucinated objects are real. This could make the client feel even response by the nurse is: more frightened. ‐ “What kind of bugs are on you?” ‐ “Those are just little bugs, they won’t hurt you.” ‐ “You’re seeing bugs because you are sick, but I don’t see any bugs on you.” ‐ “Just hold very still and the bugs will crawl away.” | Recognize the client’s fear and the attendant need for safety. |
4585 The nurse would formulate which of the following as Correct answer: 4 Most cognitive impairments seen in delirium are physiological in origin; therefore, the the most appropriate nursing diagnosis for a client identified problem and all its effects should be reflected in a complete nursing diagnosis. with a medical diagnosis of delirium caused by a Options 1, 2, and 3 are more reflective of the psychosocial processes associated with systemic infection? dementia. ‐ Disturbed self‐esteem and independent functioning ‐ Risk for caregiver role strain related to lack of respite and financial resources ‐ Confusion related to changing family roles and financial strain ‐ Interrupted thought processes related to elevated temperature | Remember that delirium results from biochemical and physical causes. |
4586 The client has a medical diagnosis of dementia. The Correct answer: 3 Catastrophic reaction is the human response of overreacting to minor stresses that often nurse observes that when anyone speaks loudly or occurs in demented clients. Pseudodementia (a medical diagnosis) is a reversible disorder that harshly to the client, the client cries out, retreats to mimics dementia (option 1). Pseudodelirium (a medical diagnosis) is characterized by bed, shivers, and covers the head. When documenting symptoms of delirium without any identifiable organic cause (option 2). Clients with dementia and giving intershift report, the nurse should refer to rather than delirium also often experience extreme agitation at the end of the day (option 4), the client’s behavior as: probably as a result of tiredness and fewer orienting stimuli such as planned activities and contact with people. This human response of restless and agitated behavior worsens at night and is commonly referred to as sundown syndrome. ‐ Pseudodementia. ‐ Pseudodelirium. ‐ Catastrophic reaction. ‐ Sundown syndrome. | Remember that the nurse diagnoses and reports human responses. The nurse does not establish medical diagnoses. |
4587 A client with dementia has been admitted to a Correct answer: 1 Recent memory loss is a common problem found in dementia; therefore, the client may be nursing home. Which of the following nursing actions frustrated when constantly confronted with evidence of failing memory. Pictures of family will help the client maintain optimal cognitive members can encourage a discussion of remote memories that will help the client feel less function? anxious while promoting a sense of pleasure from discussing past experiences. Options 2, 3, and 4 rely on recall of recent memories rather than remote memories and can cause increased anxiety and confusion. ‐ Discuss pictures of children and grandchildren with the client ‐ Play word games and do crossword puzzles with the client ‐ Watch the evening news on the television with the client ‐ Provide the client with a list of tasks to perform each day | Think of elders you have known. Identify areas of their lives that they enjoy discussing. |
4588 The nurse wishes to improve the hydration status of Correct answer: 2 When working with a confused client, the most effective nursing action is simple, direct, and the confused client. Which action should the nurse unambiguous. This option assigns responsibility to the nurse and specifies the frequency of the take? nursing intervention. The nurse should vary the type of fluid offered and limit the number of choices for the client to make, since making choices can be confusing to the client. The nurse should not assume that the client will drink water placed at the bedside (option 1). The nurse should actively offer the water to the client at regular planned intervals. Option 3 does not show a planned sequence for offering fluids. The term frequently does not have universal meaning. Further, no one person has responsibility to offer the fluids. Option 4 is incorrect because it removes the responsibility from the nurse to the family. It also does not specify a time period for offering the fluids. The family’s presence may be helpful to both the nurse and the client but the responsibility for increasing hydration should remain with the nurse. ‐ Place a pitcher of water at the bedside ‐ Offer fruit juice, soft drinks, or water every two hours while awake ‐ Instruct all staff members to stop by and offer fluids frequently ‐ Instruct a family member to sit with the client and offer fluids frequently | Remember that even when clients are not confused, the best communication is simple, direct, and specific. |
4589 A client who scores 11 out of 30 on the Mini‐Mental Correct answer: 3 A Mini‐Mental State Examination score of less than 20 usually indicates the presence of State Examination asks the nurse what this score might dementia or delirium and requires further investigation. When responding verbally to the mean. The nurse’s response will convey the client, it is important that the nurse use simple words, rather than medical terms. The Mini‐ information that this score suggests a high likelihood Mental State Examination does not measure education, bipolar disorder, or self‐esteem of: (options 1, 2, or 4). These components are investigated in a Mental Status Examination. ‐ Educational deficiencies. ‐ Bipolar disease. ‐ Brain dysfunction or disease. ‐ Low self‐esteem. | Compare and contrast the components of the Mental Status Examination and the Mini‐ Mental Status Examination. |
4590 The client is experiencing delirium in the post‐ Correct answer: 2 In every instance, physiologic and safety needs take precedence over psychological needs. operative period. Of the following nursing measures, Therefore, of the options given, assuring adequate hydration is the highest priority. If which one will have highest priority to the nurse? hydration is not maintained, the delirium will intensify, and the client will become at risk for various physiologic complications, ultimately even death. Anxiety and fear (option 1) are common experiences when the client is delirious. When present, they complicate management of delirium. However, these are psychological experiences and have lesser priority than basic physiologic or safety needs, such as hydration. Turning and repositioning the postoperative client (option 3) is very important to prevent future problems, but this physical measure is not a basic requirement for maintaining life. Maintaining adequate hydration is critical to continuation of life and therefore takes priority. The client who is delirious is generally disoriented, and the nurse should make frequent attempts to reorient the client (option 4). However, providing basic safety and maintaining basic physiologic needs are always of highest priority. | Ask yourself the question, “What’s the worst thing that could happen to this client?” The answer is, of course, “The client could die.” Use this common‐sense approach to answer this question. |
‐ Reducing anxiety ‐ Maintaining adequate hydration ‐ Turning and repositioning every two hours ‐ Offering frequent reorienting statements | |
4591 A client being cared for at home has dementia. Family Correct answer: 3 This question describes a symptom called hyperorality, which is common in stage 2 of members report that during the bath, the client tried Alzheimer’s disease. Clients experiencing this symptom have a need to place objects in the to chew on a bar of soap. The home health nurse mouth so they can taste or chew them. They cannot discriminate between hazardous and documents this behavior as which of the following? nonhazardous items. Hyperactivity (option 1) is a behavior characterized by decreased attention span, increased impulsivity, and emotional liability. Hyperetamorphosis (option 2) is the need to compulsively touch and examine every object in the environment. Hyperphagia (option 4) occurs when the individual eats, or ingests, excessive amounts of food. ‐ Hyperactivity ‐ Hyperetamorphosis ‐ Hyperorality ‐ Hyperphagia | Recall knowledge of the meanings of root elements in medical terminology to help make a selection. |
4592 A client is admitted for treatment of alcohol‐ Correct answer: 4, 5 Because the physical consequences of alcohol withdrawal can be lethal, they therefore take withdrawal delirium. It will be of high priority for the precedence over any psychological considerations. The client in a delirious state associated nurse to address which of the following when writing with alcohol withdrawal typically varies between hyperalertness and underreactivity to the the client’s care plan? Select all that apply. environment (option 1). Such fluctuations are unpredictable and can occur very rapidly. Presenting signs and symptoms of delirium caused by withdrawal from alcohol also include hyperactive behaviors such as restlessness and irritability (option 4). When coupled with unpredictable changes in level of awareness and impaired judgment, these symptoms place the client at risk for injury. Clients in active withdrawal, including withdrawal from alcohol, are at high risk for having seizures (option 5). One reason for using benzodiazepines as the cross‐ tolerant agents for medically supervised withdrawal is that most of them have anticonvulsant effects. The nurse should recognize that the physical consequences of alcohol withdrawal can be lethal and therefore take precedence over any psychological considerations, including self‐ esteem enhancement (option 2) or coping (option 3). ‐ Fluctuating level of awareness ‐ Self‐esteem enhancement ‐ Impaired individual coping ‐ Restlessness and irritability ‐ Potential for seizures | Recall that delirium occurs because of disruptions in physiologic processes. The correct options will then be easy to determine. |
4593 A client in stage 2 of dementia of the Alzheimer’s type Correct answer: 4 Wandering behavior poses a potential risk for injury or trauma because clients experiencing often wanders and becomes lost or confused. Which dementia get lost easily and are unable to retrace their steps back home. Although the nursing nursing diagnosis should the nurse select to address diagnoses in options 1, 2, and 3 apply, maintaining the safety of these clients is of utmost this behavior? importance. ‐ Confusion related to impaired cognition ‐ Anxiety related to fear of cognitive deficits ‐ Impaired verbal communication related to anxiety ‐ Risk for injury related to impaired judgment and cognitive deficits | Look beyond the presenting behaviors of wandering and confusion and identify the risks associated with the behaviors. |
4594 The client has dementia of the Alzheimer’s type (DAT) Correct answer: 2 It is most important for the nurse to recognize that this spouse, like others providing care to and is being cared for by the spouse in the home. What persons with DAT, is at high risk for caregiver role‐strain. Having to provide constant care to a self‐care activity will be most important for the nurse person with declining cognitive and physical capacity can exhaust and overwhelm the to recommend to the spouse? caregiver. The nurse should not assume that the spouse’s spiritual belief system (option 1) includes worship in a church. The nurse should assess the spouse’s belief system before making any recommendation for spiritual support. Reminiscence therapy (option 3) is more likely to be useful to the client in early stages of dementia. While it may be useful to the spouse as part of anticipatory grieving, it is most important recognize the high risk for caregiver role‐strain. While a predictable daily routine (option 4) is generally helpful to the spouse, it is most necessary for the client. ‐ Regular attendance at church services ‐ Periodic times of respite from caregiving ‐ Participation in reminiscence therapy ‐ Establishment of a predictable daily schedule | Notice to whom the nurse is giving care in this question to select the correct answer. |
4595 Which of the following would the nurse formulate as Correct answer: 1 Clients experiencing acute episodes of delirium will have periods of lucidity and will regain full an appropriate nursing outcome for a 68‐year‐old orientation when the underlying cause of the delirium is identified and treated. Suicidal female client experiencing an acute episode of ideation (option 2) may be seen with dementia but not usually associated with delirium. When delirium? The client will: the client is delirious, injury is more likely to be the result of impulsive, non‐intentional acts. Low self‐esteem (option 3) and tactile agnosia (option 4) are commonly seen with dementia but not usually associated with delirium. ‐ Have decreased confusion as evidenced by orientation to person, place, and time. ‐ Remain free from self‐directed violence as evidenced by agreement to a no‐suicide contract. ‐ Verbalize increased feelings of self‐esteem as evidenced by statements acknowledging ability to perform certain tasks independently. ‐ Have intact tactile senses as evidenced by ability to recognize familiar objects placed in her hand. | Compare and contrast usual presenting behaviors associated with delirium and dementia to determine the correct option. |
4596 The nurse would take which action that is most likely Correct answer: 4 When the nurse is attempting to increase the level of orientation of the client with dementia, to be effective in improving the orientation level of a nonverbal stimuli may be more effective than verbal stimuli. It is important that the 74‐year‐old male client with dementia? decorations be traditional, as the client is more likely to have intact remote memory that allows for recognition of objects from the distant past. The nurse should not assume that the client with dementia has a hearing deficit (option 1); what is present is a cognitive deficit. When telling the client the day of month and time, it will be more important for the nurse to speak simply and to repeat reorienting stimuli frequently. Except in emergency situations where client safety is compromised, the nurse should avoid giving the client with dementia untruthful or nonrealistic information (option 2). Instead of reorienting the client, the news station (option 3) would likely increase the client’s disorientation because the client would not be able to process the events in a normal cognitive manner. Additionally, the constant stimulation would probably be overtaxing to the client. ‐ Speak directly into the client’s ear when telling him the day of the month and time ‐ Assure the client that his deceased spouse is expected home later in the day ‐ Keep the client’s television tuned to a 24‐hour news station during the daytime hours ‐ Put traditional seasonal decorations within the client’s view | Recognize that sometimes a simple solution and a simple answer stand out from all the rest. This is one example of that notion. |
4597 The client with dementia is receiving the following Correct answer: 4 Donepezil (Aricept) is a cholinesterase inhibitor that appears to slow down cognitive medications. An unlicensed assistant who is enrolled in deterioration in individuals with mild to moderate dementia. When the activity of nursing school asks the nurse, “Which medication may cholinesterase is inhibited, the amount of acetylcholine in the synapse is increased. Options 1, lead to recovery of some mental functioning by 2, and 3 all indicate medications that may be prescribed for clients with dementia, but none of increasing acetylcholine in the nerve synapse?” The these medications is known to directly bring about improved cognitive function. nurse responds, “The medicine that does that is: ‐ Fluoxetine (Prozac).” | Identify the classification and general uses of each medicine the client is receiving. |
‐ Trazodone (Desyrel).” ‐ Haloperidol (Haldol).” ‐ Donepezil (Aricept).” | |
4598 A depressed older client with short‐term memory loss Correct answer: 3 Short‐term memory loss is a sign of depression in the older adult that can be caused by a is receiving paroxetine (Paxil). A family member says, “I deficit of serotonin in the brain. Paroxetine (Paxil) blocks the reuptake of serotonin resulting in don’t remember the reason this medicine might help.” elevated levels of serotonin in the brain. Also, the nurse should keep the communication as The nurse’s best response would be, “It will increase:” simple as possible because the listeners may not know or understand human anatomy or commonly used medical expressions. Options 1, 2, and 4 convey inaccurate information about the effects of paroxetine (Paxil). ‐ "Circulation to the brain.” ‐ "Acetylcholine levels in the brain.” ‐ "Serotonin levels in the brain.” ‐ "Oxygen levels in the brain.” | Recall classification systems of antidepressants. Identify the drug class for paroxetine (Paxil). The name of the class will give you the answer to this question. |
4599 A female client is a parent with stage 2 dementia of Correct answer: 4 Spending nonstressful time with the client helps diminish feelings of resentment, isolation, the Alzheimer’s type. At‐home care is being provided and alienation in the caregiver. Since remote memories are less diminished than recent by her daughter. Which statement by the caregiver memories, there is also the possibility that it will also increase the client’s self‐esteem by indicates to the nurse that the caregiver understands allowing reminiscence of past pleasurable life events. Because safety of the client is an urgent personal coping strategies that are most likely to be consideration, close supervision of the client should be provided at all times. However, if one useful? caregiver remains with the client 24 hours a day, that person is at high risk for developing caregiver role‐strain with feelings of resentment, isolation, and alienation (option 1). Regular periods of respite are necessary to help prevent this occurrence in caregivers. While assistance to personal hygiene and establishing a routine are important when providing care to the person with dementia (option 2), there is no prescribed time that personal hygiene should occur. Because safety of the client is an urgent consideration, close supervision of the client should be provided at all times. However, regular periods of respite are necessary for caregivers (option 3). ‐ “I need to stay with my mother 24 hours a day.” ‐ “I need to bathe my mother every day before breakfast.” ‐ “I need to postpone my vacation for a few more years.” ‐ “I need to spend time with my mother doing something we both enjoy.” | Notice that this question is focused on the caregiver, not the client. |
4600 A client diagnosed with a terminal illness states, Correct answer: 3 Use of empathy in option 3 communicates understanding to the client and allows him or her “What’s left for me? I feel hopeless.” The nurse to explore inner feelings of hopelessness. Options 1, 2, and 4 ignore and discount the client’s determines that which of the following would be the feelings. These responses would not encourage the client to further explore his or her feelings best response? with the nurse. ‐ “Come on, it’s not hopeless.” ‐ “Don’t be so depressed.” ‐ “It must be difficult feeling as though there is no hope.” ‐ “I don’t understand why you have to feel so bad.” | For questions involving nurse–client communication, choose the answer that is the most open‐ended in promoting further communication and sharing of client’s feelings. |
4601 The nurse observes that a client hospitalized with Correct answer: 4 The actions in option 4 indicate the client is attempting to cope with the situation in some newly diagnosed heart disease is frequently crying and way. Option 1 is incorrect because these actions may not be appropriate. Options 2 and 3 are staying in the room. These actions should be noted incorrect in terms of the demonstrated behaviors. during assessment by the nurse as identification of what behaviors? ‐ Inappropriate ‐ Psychiatric ‐ Psychotic ‐ Coping | Consider that the client has just learned about diagnosis of a chronic illness. Reason that the client may engage in any number of behaviors, such as crying, to cope with the initial diagnosis. |
4602 The nurse would plan to include which of the Correct answer: 1 Laboratory test results are part of biological assessment because they may provide insight following in a biological assessment of a client? into the occurrence of psychological symptoms. Options 2 and 3 do not relate to biological assessment, but to emotional and social assessments. Option 4 is not part of the assessment process, but rather is a prediction about the outcome of an illness. ‐ Laboratory test results ‐ Feelings of anxiety about illness ‐ Spiritual needs during illness ‐ Prognosis | The critical word in the stem of the question is biololgical. With this in mind, select the option that deals most directly with physiological needs or parameters. |
4603 A client with a terminal illness states, “If I could only Correct answer: 3 Bargaining is the stage in which the client attempts to bargain for more time. Denial (option live until I can walk my daughter down the aisle at her 1) indicates the stage in which the client denies that he or she is terminally ill. Seeking (option wedding, I will donate all of my money to research.” 2) reflects the stage in which a client seeks more answers and cures. Resolution (option 4) is The nurse reports that the client is in which phase of the stage in which the client has come to terms with the illness. the grief process? ‐ Denial ‐ Seeking ‐ Bargaining ‐ Resolution | The core issue of the question is ability to analyze a stage of grief by interpreting client comments. Use nursing knowledge and the process of elimination to make a selection. |
4604 A client diagnosed with a medical illness states, “I Correct answer: 1 Option 1 reflects the client’s statement in that the client’s normal eating pattern has been don’t enjoy my food anymore.” The nurse notes during disturbed in some way. Options 2 and 3 reflect a more severe, true eating disorder diagnosis. the assessment phase that this statement indicates Option 4 relates to a different psychiatric illness comprised of other behaviors. what kind of nutritional pattern?
| The core issue of the question is the ability to associate medical illness with the appropriate alteration in eating pattern. Use the process of elimination and nursing knowledge to make a selection. |
4605 As part of the admission process, the nurse is Correct answer: 3 Option 3 relates to social assessment and should be considered in terms of how a client might conducting a social assessment of a client. The nurse respond to the illness based on cultural background. Options 1, 2, and 4 relate to biological should ask which of the following questions at this assessment. time?
| The core issue of the question is knowledge of the components of a social assessment. Use the process of elimination and focus on the option that takes into account the social habits or expectations of a client. |
4606 A client who has a diagnosis of a chronic illness Correct answer: 2 It is typical of clients with a chronic illness to become tired and feel as though they can’t states, “I’m so tired. I can’t keep on like this every continue on in this way. Option 1 is incorrect because atypical is the opposite of typical. day.” The nurse interprets that the feeling the client is Options 3 and 4 are incorrect labels. expressing can be described as which of the following?
| The core issue of the question is the nurse’s ability to draw accurate conclusions about client statements in terms of coping with chronic illness. Use nursing knowledge and the process of elimination to make a selection. |
4607 The client hospitalized for five days with a medical Correct answer: 1 Hospitalized clients often feel that things are out of their control and their frustration rises. illness says loudly, “Bring me my pain pills now!” The Although the behavior may not be appropriate if it is disruptive, the nurse should first nurse concludes initially that the client’s behavior is a: recognize that it is a common response. There is not enough data to support options 2, 3, or 4.
| The core issue of the question is the recognition that clients who are hospitalized may feel out of control and may express this feeling in ways that are not socially acceptable. Note the critical word initially, which indicates that more than one option may be partially correct but that one conclusion is more appropriate to draw first. Use nursing knowledge and the process of elimination to make a selection. |
4608 The nurse notices that a client admitted with Correct answer: 4 These symptoms are indicative of possible depression (option 4) and require further obstructive pulmonary disease has poor eye contact assessment. The observed behaviors do not indicate hopefulness (option 1), anxiety (option 2), and has not been eating well. The nurse then looks for or an eating disorder (option 3). additional data that are consistent with which of the following?
| The core issue of the question is the ability to recognize signs of depression in a client. Use nursing knowledge and the process of elimination to make a selection. |
4609 In order to determine susceptibility to additional Correct answer: 2 Recent illnesses should be considered when conducting a biological assessment to determine health problems in a client with medical illness, the impact of these illnesses on current illness. Past medicines are not a primary concern related nurse should ask about which of the following in the to biological assessment (option 1). Spiritual needs (option 3) and cultural background (option biological assessment? 4) are a part of social assessment.
| The core issue of the question is the ability to determine what elements to include in a biological assessment of a client. Use nursing knowledge and the process of elimination to make a selection. |
4610 A client with a recent onset of multiple sclerosis is Correct answer: 1 Acceptance (option 1) indicates that the client is accepting limitations imposed by the illness observed taking part in giving self care. The nurse and is attempting to help self as much as possible. A client would not be helping self if the interprets this behavior to be consistent with which of stage was denial because there would be no awareness of need in the denial stage (option 2). the following stages of adaptation? Compensation (option 3) and indulgence (option 4) are not stages related to helping the self in medical illness.
| The core issue of the question is the ability to determine the client’s stage of adaptation to a chronic illness. Use nursing knowledge and the process of elimination to make a selection. |
4611 A client who underwent surgery for removal of a Correct answer: 2 Physical illnesses can create psychiatric symptoms. Options 1 and 3 conclude that the origin bowel tumor is exhibiting new onset of psychiatric of the client’s symptoms are psychiatric in nature, and this conclusion is premature. Option 4 symptoms. The nurse determines that the client may or may not be appropriate for this client. should first have a thorough:
| The core issue of the question is recognition that psychiatric symptoms may have a medical basis in a hospitalized client. Note the critical word first, which indicates that one action should be taken before some others. |
4612 The nurse is assessing coping behaviors as part of the Correct answer: 2 Although occupation (option 1), number of siblings (option 3), and income (option 4) may be psychological assessment and wishes to address of interest when considering lifestyle, substance abuse is of primary interest as a maladaptive lifestyle factors that can contribute to depression. The coping strategy and is also associated with depression. nurse would ask the client about which of the following as a priority item?
| Note the critical word depression in the question. Review each option and choose the one that correlates best with depression, which in this case is substance abuse. |
4613 In a client newly diagnosed with amyotrophic lateral Correct answer: 1 Denial (option 1) is most accurate because denial is a typical stage of grief related to loss. sclerosis, an illness that leads to progressive loss of Options 2, 3, and 4 are isolated events that could possibly occur but would be based on ability to perform activities of daily living, the nurse individual client characteristics rather than anticipated general patterns of response. should anticipate that the client may react to the diagnosis using which of the following strategies in an attempt to cope?
| Note that the correct answer is one that is a more comprehensive and global option, while the other options contain specific items of behavior. This makes the correct option different from the others, and also recall that a global option is often correct. |
4614 The nurse observes a client and family interaction. Correct answer: 2 Communication patterns within the family should be assessed for flexibility and support. Observed behaviors include anger, rigidity, and lack of Option 1, recent life‐changing events, relates to something occurring recently. Option 3, support for one another. The nurse should consider lifestyle patterns, refers to an overall way of living, and option 4, community resources, refers this interaction as an assessment of which of the to support outside of the family. following family characteristics?
| The core issue of the question is the nurse’s ability to observe family behavior and interpret it correctly. Note the critical word interaction in the stem of the question and the word communication in the correct response. |
4615 A client with a medical illness tells the nurse that Correct answer: 4 Option 4 encourages the nurse to broaden the definition of spirituality and what this might going to church is not a priority. Based on this mean to clients. Option 1 implies that communication should be closed, option 2 is not a information, the nurse should do which of the correct assumption under the circumstances, and option 3 is inappropriate. following?
| The core issue of the question is the ability of the nurse to assess the spiritual needs of a client. Use nursing knowledge and the process of elimination to choose the option that asks a follow‐up question during the interview process. |
4616 A client who was paralyzed from severe injuries Correct answer: 1 Option 1 refers to difficulty with adjustment to the current situation. Although options 2 and sustained during an automobile accident continually 3 might be occurring, it is not evident by the scenario described. Option 4 does not apply in attempts to do activities beyond capabilities. The most this situation either. appropriate nursing diagnosis for this client would be which of the following?
| The core issue of the question is the ability of the nurse to critically analyze data and select the appropriate nursing diagnosis label. Use nursing knowledge and the process of elimination to make a selection. |
4617 A client tells the nurse that acupuncture helps ease Correct answer: 3 Tere is nothing wrong with complementary medicine, and it can be very helpful in coping with the pain of a terminal illness. The nurse should do illness. Furthermore, it supports the client’s right to autonomy and self‐determination. There is which of the following? no rationale for option 1, option 2 is inaccurate, and option 4 is a false assumption.
| The core issue of the question is the appropriate response to a client’s choices about managing symptoms of chronic or terminal illness. The correct answer is the one that provides the greatest support to the client. |
4618 A client with inflammatory bowel disease has Correct answer: 4 Option 4 relates to assisting the client with ways to effectively cope with stress, which may exacerbations when job responsibilities become heavy limit exacerbations of the disease. Options 1 and 3 are not healthy ways to cope with stress. or there are family conflicts at home. The nurse Option 2 is not indicated by the information provided. determines that this client would benefit from instruction that focuses on which of the following?
| The core issue of the question is the ability to recognize the association between client stressors and exacerbation of the disease. Eliminate options 1 and 3 first as inappropriate, then choose option 4 over 2 because there is a clear association between client stressors in the stem and the words stress reduction in the correct option. |
4619 A client with chronic obstructive pulmonary disease Correct answer: 3 A client’s appropriate behavior should be acknowledged and reinforced. Option 1 is incorrect (COPD) has given up smoking and spaces out activities because the client is already living with the disease process and an attempt to avoid drawing over the course of the day. The nurse should respond attention to it is not reasonable. Option 2 is incorrect because the client’s adjustment is not by doing which of the following? maladaptive. Option 4 is incorrect because it patronizes the client.
| Use principles of communication to answer the question. The core issue of the question is recognition that the client has made an adaptation to medical illness and that this adaptation should be positively reinforced with the client. |
4620 A client newly diagnosed with inflammatory bowel Correct answer: 2 The exact role of psychologic factors in inflammatory bowel disease is unclear, but stressful disease asks the nurse if the symptoms can be related life events, such as separations, failures, and disappointments seem to interact with to “what I do and who I am.” The best response of the autoimmune factors and infections to bring about symptoms. There was a time that much nurse should incorporate information about the emphasis was given to compulsive personality traits as a causative factor, but recent research relationship of inflammatory bowel disease and: suggests that dependent personality traits and problems in living may be more significant. Option 1 is incorrect as inflammatory bowel disease is not thought to be caused from dietary indiscretions. Although when inflammatory lesions are present, the physical or chemical properties of certain foods may be further irritating to the bowel. Option 3 is incorrect because impatience and competitiveness are sometimes seen in persons with inflammatory bowel disease, but recent research suggests that dependent personality traits and problems in living may be more significant. Option 4 is incorrect as projection of emotions is not present in inflammatory bowel disease. It is possible, though that the client is using the defense mechanisms of interjection and/or conversion.
| Look for an option that would be most helpful to the client and would come from a recent theory base. |
4621 The nurse plans care for a group of clients, Correct answer: 1 Pessimism is a trait that that can create an increased likelihood of medical illness. It indicates understanding that there is a greater likelihood of the deficiencies or the absence of self‐efficacy, hardiness, resilience, and resourcefulness, all of medical illness occurrences in clients who exhibit which are considered to be positive traits that will lead to improved health and coping. behaviors that are: Pessimism is a trait that diminishes an individual’s capacity for self healing. Option 2 is incorrect as the capacity for self healing has a positive impact on outcome of illness. Option 3 is incorrect because humor can have a positive impact on the outcomes of illness. It can enhance the therapeutic effect of a variety of treatments from the traditional medical model. Option 4 is incorrect as energetic actions are useful in promoting relaxation, fitness, and improved coping. Pessimism leads to apathy, uninvolvement, and diminished energy.
| Even if you haven’t read anything about this, you should be able to recognize the answer. Think of pessimistic people you have known. Were they healthy? |
4622 A client who has experienced a recent heart attack Correct answer: 4 Option 4 indicates that the client is attempting to cope or deal with the situation by making makes a change in work schedule in order to make life style changes. Option 1 is incorrect as the statement indicates that the client is coping with work less stressful. The nurse concludes that the client anxiety, but that the anxiety level is escalating. Options 2 and 3 are incorrect because these is demonstrating what kind of behavior? behaviors are not demonstrated in the scenario. However, the client’s changing of pre‐existing behaviors could lead to reduced anxiety and anger, as well as increased hopefulness.
| Notice that the client is accommodating to having had the physical illness, a major stressor. |
4623 A client recently injured in a severe automobile Correct answer: 3 The client described stressful circumstances that existed prior to the accident. Options 1, 2, accident states, “All I remember is that before the and 4 are incorrect because as this situation is described, there is no data to support these accident I was upset about a situation at work.” What options. conclusion about the meaning of the client’s statement should the nurse reach? The client is describing:
| Look for an answer that is fully supportable by the data given. |
4624 A client who has just received a terminal illness Correct answer: 1 Option 1 indicates that the client is feeling overwhelmed by the enormity of the diagnosis and diagnosis states, “I want to kill myself now.” The nurse does not know how to manage this clear and obvious threat. As in other crisis responses, the recognizes that the client is experiencing which of the client is expected to be able to reestablish equilibrium, but during the crisis the priority of the following? nurse is to provide safety and assist with coping responses. Option 2 is incorrect as dissociative coping responses occur when the individual is facing an intensely stressful situation and parts of the personality split apart from other segments of the personality, which may lead to experiences as depersonalization, dissociative amnesia or multiple personalities. Option 3 is incorrect because when individuals are self‐destructive, their level of anxiety is very high and can be the precipitant that causes them to carry out a self‐destructive act. However, nothing in the situation directly describes anxiety. Option 4 is incorrect as nothing in the situation describes dependent personality traits, which are characterized by feeling helpless and having difficulty making everyday decisions.
| Notice that the client has recently been informed of having a terminal condition. At this time, the client may want to have some control over the timing and type of death to be experienced. However, the obligation of the nurse is to protect the client and support life. |
4625 A hospitalized client states, “I just want to sleep all of Correct answer: 4 Option 4 is correct. Sleep disruptions can take a number of forms, including hypersomnolence the time.” The nurse recognizes that this sleep pattern and impaired sleep efficiency. Options 1 and 2 are incorrect because in order to reach the is most clearly indicative of which of the following? conclusion that the client has physical or emotional problems, the nurse would require more data. Option 3 is incorrect as this is a nonsensical answer. Don’t give it a second glance.
| Use this question to help you focus on what is obvious in a situation, but expect to see much more challenging questions on the NCLEX<sup>®</sup> examination. |
4626 The nurse anticipates that a client’s ability to adapt to Correct answer: 1, 5 Support systems can provide emotional sustenance that can help reduce stress, diminish a significant medical illness is most influenced by the feelings of isolation, and positively influence the ability to cope and adapt. Self efficacy is the presence or absence of which of the following? Select belief that personal abilities and efforts affect the events in our lives. Having a sense of control all that apply. allows an individual to believe that personal behavior can make a difference. Accordingly, this client is most likely to take action and cope more effectively. Option 2 is incorrect as a specific anatomical understanding is not necessary imperative for the person to adapt to the diagnosis. Options 3 and 4 are incorrect because while these options might contribute to the response, options 1 and 5 clearly have an impact on a person’s ability to cope with situations
| Look carefully at the stem of the question to understand fully what it is asking. Paraphrase the question if that would help to understand it better. |
4627 The nurse observes restlessness, increased heart rate, Correct answer: 2 The symptoms are indicative of a possible anxiety related response. Other indicators could be and diaphoresis in a client with asthma. All other vital tremulous voice, jerky body movements, and dilated pupils. Options 1 and 4 are incorrect as it signs are within normal limits. The nurse’s next step is premature to take such definitive action without collecting more data. Option 3 is incorrect should be to do which of the following? because further assessment is needed, and the client’s safety needs should be attended, but a basic assessment of anxiety level is more appropriate at this time.
| Remember to collect as much data as possible before deciding on a course of action. |
4628 A client with chronic hypertension has recently been Correct answer: 3 Hypertension has a strong psychophysiologic component and is highly correlated with having difficulty with blood pressure readings being increased stress levels. Options 1, 2, and 4 are incorrect as these options address higher than usual. The priority intervention by the psychodynamic factors which may have an impact on emotions which affects biochemical nurse is to explore: functioning such as blood pressure. However, there is a stronger and more direct link between hypertension and poorly managed stress.
| Apply basic concepts of stress adaptation and psychophysiologic disorders. |
4629 The client is newly diagnosed with HIV/AIDS. When Correct answer: 2 Most clients diagnosed with HIV/AIDS experience anxiety disorders at some time during the caring for this client, the nurse keeps in mind that the course of their illness. Confirmation of the diagnosis can be catastrophic for the individual and primary psychosocial factor influencing the occurrence will elicit a cascade of emotional and social reactions including feelings of isolation and of psychological symptoms in this client is likely to be: stigmatization. These feelings are usually heightened as there is the sense of anxiety about how people will respond to the person and the new diagnosis. Option 1, 3, and 4 are incorrect because although they may be concerns of the client they are not usually the ones of primary concern at the time immediately following diagnosis.
| Put yourself in the psychologic position of this client; probably young, previously healthy, and now faced with a bleak diagnosis and future. |
4630 A client who recently had a leg amputation following Correct answer: 1 The client understands the disruption of the accident and that feeling down might be a car accident is now ready for discharge. The nurse expected, but the client is able to differentiate between mild and more severe depressive has been talking with the client about signs and symptoms, such as anhedonia and having trouble sleeping and eating. The client does not symptoms of depression. The nurse concludes that the understand that depression may be experienced somatically (options 2 and 3). The client does client best understands how depression might be not recognize that being inactive and remaining in bed (option 4) could be a symptom of exhibited if the client says: depression, nor does the client recognize that physical inactivity may increase the intensity of depression.
| Remember that depression has both psychologic and physiologic components. |
4631 A client diagnosed with ulcerative colitis is preparing Correct answer: 2 The client has verbalized that there is a relationship between the disease and stress and is for discharge from the hospital. The nurse concludes learning how deal with the stress. Options 1 and 3 indicate no understanding of the that the client understands the relationship between relationship between stress and gastrointestinal symptoms being experienced. Option 4 the disease and stress after hearing which statement indicates blaming, rather than awareness of the relationship between stress and made by the client? gastrointestinal symptoms.
| Look for an option that indicates a change in the client’s attitude. |
4632 The client, who has acquired immunodeficiency Correct answer: 4 Option 4 is correct because it indicates interest and concern about the client and facilitates syndrome (AIDS) has a nursing diagnosis of disturbed open communication. Options 1, 2, and 3 indicate that the nurse wants distance from the self‐esteem. When caring for this client, which of the client. following approaches will be most important for the nurse to use?
| Apply common sense to answer this question. If the client has low self‐esteem, could options 1, 2, and 3 be expected to elevate the client’s self‐esteem? |
4633 The nurse is developing a stress management seminar Correct answer: 3 Option 3 is correct because it indicates knowledge related to how personality types impact on for clients recently discharged from a cardiac care unit. cardiac illness. Options 1 and 2 do not have anything to do with understanding stress and Which of the following concepts should be included in cardiac disease. Option 4 is not a beneficial way to decrease tension. the seminar?
| Notice that option 3 includes the word cardiac. Since the stem of the question does also, this is a clue that suggests that this option is correct. |
4.‐ Use of confrontation as a beneficial way to decrease tension | |
4634 When the client has a chronic medical illness that Correct answer: 1 Persons with debilitating illness are at high risk for suicide. When suicidal ideation is present, results in severe disability, it will be most important for the nurse should gather other assessment data, including whether there is a specific plan for the nurse to assess for which of the following? suicide and a means for carrying out the suicidal act. The areas in options 2, 3, and 4 should be assessed, but they do not have priority over determining if a suicide plan has been developed and level of lethality. These last two factors would represent the most severe and dangerous response to physical illness and disability.
| Consider that psychological debilitation associated with chronic physical debilitation. Is it not reasonable to think that the two could lead to self‐destructiveness? |
4635 The nurse is aware that a client’s pain has both Correct answer: 2 Option 2 describes the normal response that a person engages in when threatened in any physiological and psychological components. The nurse way, such as with pain. Options 3 and 4 are inappropriate responses of coping with pain. bases pain management strategies on the Option 1 is not an option related to psychological nature of pain. understanding that the psychological component of pain comes from the need to:
| Notice that options 3 and 4 are stated in judgmental language. Eliminate them without further consideration. |
4636 The client has a medical illness that is causing a Correct answer: 4 Option 4 indicates that the client is a part of his or her own care and supports significant loss of independence. Which of the interdependence. Option 1 does not promote feelings of independence. Option 2 could lead to following is the most important intervention by the client isolation, while option 3 would place undue pressure on the client to feel that he or she nurse? should be doing things by him‐ or herself.
| Imagine yourself in this situation. Would you want tot give up your independence? |
4637 Before devising an initial plan of care for a client with Correct answer: 1, 2, 3 If the client is not receiving adequate sleep or nutrition, heightened symptoms of illness and a chronic medical illness, the nurse should assess the psychological distress will occur. Sleep and nutrition are basic physiologic needs (option 1 and client’s: (Select all that apply.) 2). If the client’s anxiety level is significantly elevated, the client will not be able to focus on important information about the plan of care. Additionally, heightened anxiety will create physiologic stress responses that can intensify prior existing medical illness and complicate recovery (option 3). The nurse does not typically assess financial status of clients, as this is responsibility of the social worker (option 4). Talking about aftercare plans is not appropriate when the nurse is establishing an initial plan of care (option 5). This discussion should take place later.
| Notice that this is an initial assessment and make it as inclusive as possible. Information from this assessment will form the database from which care is planned. |
4638 The nurse is conducting family therapy with a family Correct answer: 3 Option 3 conveys the information that the ill person and the family all share responsibility for in which one member has a progressively debilitating decision making. It further suggests that each person, including the client, should have an illness. Which comment by the nurse is most likely to awareness of his or her capacities and limitations and ask for assistance as necessary. Option 1 facilitate the family’s use of the healthy coping conveys useful information, but the information relates to preventing caregiver role strain, mechanism known as productive interdependence? rather than promoting interdependence. Option 2 conveys useful information and indicates that the family should be a team, but it does not suggest a specific route to productive interdependence for the family. Option 4 suggests restricting the client’s independence and removing the client from the family team.
| Look for the option that best indicates involvement of all family members as part of a team. |
4639 A client with a medical illness diagnosis is found to be Correct answer: 4 The existence of co‐morbidities is more prevalent in individuals in lower socioeconomic at a lower socioeconomic level of income. The nurse levels. Research indicates that a lower socioeconomic level does lead to a higher number of anticipates that this client is more likely to experience illnesses in these clients. No research indicates a specific correlation between socioeconomic an increase in which of the following? level and increased grief (option 1), increased pain (option 2), or use of defense mechanisms (options 3).
| Remember that extrinsic factors are significant role in the prevalence of diseases in certain populations. Extrinsic factors include economics and health practices. |
4640 The client was involved in a severe automobile Correct answer: 3, 4 Since the client has experienced both injury and surgery to the body, changes in body image accident and had emergency surgery two days ago. At should be anticipated (option 3). Having experienced an accident, this client is now in a this time, the nurse should anticipate the need to situation (acute illness and hospitalization) that is expected to limit the client’s personal assist the client to adapt to change or loss in which of autonomy (option 4). There is inadequate information to suggest that changes in verbal the following? Select all that apply. communication ability (option 1), cognitive patterns (option 2), or family relationships (option 5) may occur.
| Look for what is expected to be universally true of clients in this type of situation. |
4641 The nurse is assigned to a client who is hospitalized Correct answer: 2 The client shows a personal commitment to health and health‐seeking behaviors and a following a motor vehicle accident. The nurse willingness to participate actively in the treatment plan. This reflects a strong internal locus of determines that the client has a strong internal locus control. The other options reflect an external locus of control. In option 1, the client is blaming of control after hearing the client make which of the others. In options 3 and 4, the client expects that efforts of others will restore wellness. following statements?
| Identify the one statement that indicates that the client feels capable of having some control in the outcome of his or her own situation. |
4642 The client has been diagnosed with a cardiovascular Correct answer: 3 Many people with cardiovascular disease show Type A personality behaviors, consisting of disease. When the nurse is teaching the client about anger, hostility, a sense of urgency, becoming easily frustrated, and having workaholic‐type disease management techniques, the nurse should behaviors. These characteristics may play a significant part in the etiology of cardiovascular emphasize strategies for reducing which of the problems, and when present, they can complicate treatment and recovery. Option 1 is following? incorrect, because it is more common for people with Type A personalities and/or cardiovascular disease to be controlling of others. Option 3 is incorrect, because the nature of social encounters, rather than the frequency is more significant in determining the individual’s behavior. Option 4 is incorrect because feelings of urgency and frustration will not necessarily decline when the person is alone.
| Recall information about the interaction of stress, personality types, and physical illnesses to correctly answer this question. |
4643 The client has the diagnosis of acquired Correct answer: 3 The behaviors described in this situation are characteristic of clients with dementia, which is a immunodeficiency syndrome (AIDS). The nurse possible late consequence of AIDS. The nurse should understand that the occurrence of observes that the client is demonstrating changes in symptoms indicates progression of the AIDS illness and that care should be planned behavior that include memory difficulties, declining accordingly. Option 1 is incorrect because an individual can live with dementia for some time attention to personal hygiene, and frequent before death occurs, either from AIDS or another cause. Option 2 is incorrect because the manifestations of angry and hostile behaviors. The situation describes behaviors that are characteristic of the chronic progressive decline that is nurse assists the client’s family and friends to seen in persons with dementia. Option 4 is incorrect because the particular pattern of understand this as an indication of which of the behaviors that is described are not particularly associated with the side effect profile of drugs following? used to control AIDS.
| Review usual progression patterns of AIDS. Recognize that the client and significant others have a right to know what is happening. |
4644 The client has been diagnosed with a life‐changing Correct answer: 1 Anger is included in the stages of mourning, as clients grieve for what has been lost. Although medical illness. When planning care for this client, the clients may experience multiple emotional feelings in response to the diagnosis of a life‐ nurse should give priority to assessing for which of the changing medical illness, anger is one of the most common ones because of the sudden and following? often dramatic change in lifestyle. Anorexia (option 2) and apathy (option 3) might occur but are not considered stages of grief and mourning. Euphoria (option 4) is not a common manifestation of grieving, but if it is seen, it is probable that the loss precipitated a period of elevated affect associated with bipolar disorder.
| Recognize that the client is facing a situation that will require great adaptation to loss. Recall normal steps in grief and mourning. |
4645 The client is an adolescent who has gained Correct answer: 4 Since a developmental task of adolescence is dealing with one’s emerging social and sexual considerable weight as a side effect of steroid therapy urges and needs, the appearance of the body assumes great importance. When the body is for a chronic medical illness. Considering the client’s unattractive to the self and/or others (as in situations of debilitating medical illness or developmental level, in which of the following areas is significant changes in body weight), issues surrounding sexuality and identity are common. It is the client most likely to need assistance from the common for adolescents to have relationship difficulties with parents (option 1), but this is nurse? considered a normal part of adolescence. In this client’s situation, present (option 3) and future (option 4) educational plans and activities are not as likely to be directly impacted as is sexuality.
| Recall theories of adolescent development and your own adolescence. Imagine yourself in this client’s situation. |
| |
4646 The client has been diagnosed with an acute medical Correct answer: 1, 2, 4 This client is at risk for developing a crisis response (options 1 and 2). If balancing factors illness. The nurse determines that the client’s initial (social support and using familiar coping techniques) are present, a crisis will not be as likely to response to the illness will be most influenced by occur. If the individual can cope using socially appropriate rituals (option 4), a crisis response which of the following? Select all that apply. will not be as likely to occur. Persons of all socioeconomic and educational levels can be overwhelmed with life situations and develop a crisis response (option 3). No one is exempt from the possibility of developing a crisis response. The client’s response to a situation is not always parallel with the severity of the actual problem (option 5). Instead, it is parallel with the client’s perception of the problem.
| Identify those things that would be useful to any person in a crisis state. Remember that in certain circumstances, all persons are vulnerable to having a crisis response. |
4647 Because the client has frequent episodes of parotitis Correct answer: 2 Eating disorders are a manifestation of problems in living and difficulty dealing with emotions and lesions of the oral mucous membranes, the school and stress. Eating disorders are not about eating per se, but rather about making unhealthy nurse suspects that the client may have bulimia attempts to control emotions and manage stress. The nurse should avoid focusing on food and nervosa. As part of the assessment process, it will be food‐related topics with this client (option 1). If this client has bulimia, food is being used to most important for the nurse to ask the client about express underlying issues and conflicts. Clients with eating disorders do not typically have which of the following? declines in academic performance (option 2). In fact, many of them are compulsive over‐ achievers who may be seen as model students. Clients with bulimia may not lose weight and may even be at or near ideal body weight (option 4).
| Recognize that eating patterns are not necessarily related to biologic anorexia or hunger. Recall that food and eating can convey symbolic messages. |
4648 The nurse refers the family of a terminally ill client to Correct answer: 1, 3 It is likely that increased social connectivity (option 1) would result in increased social a grief support group. The nurse explains that such support, since the other persons in the group would also be dealing with grief issues. The work groups provide members opportunity for which of the of grieving is best accomplished in a compassionate and supportive emotional environment. following? Select all that apply. Grief support groups are aimed at helping a person to recognize, express, and cope with strong emotions (option 3), not eliminate them (option 2). It is normal for a grieving person to feel intense emotions. Feelings of loss are normal in grief responses (option 4). Grief groups acknowledge this and support healthy expression of these feelings, which must be fully expressed and dealt with so the person can progress healthily through all stages of grieving. Grief counseling does not focus on the deceased (option 5), but rather on the survivor and the survivor’s coping.
| Notice that two options indicate positive results, and the remaining ones suggest eliminating or minimizing feelings that are expected and normal in the grieving situation. |
4649 The client diagnosed with a chronic medical illness Correct answer: 1 Option 1, adaptive, indicates that the client is able to mobilize internal/external resources to arranged for a wheelchair ramp to be built for easier cope with the chronic illness and its effects. Maladaptive (option 2) relates to a response that access to the home. The nurse interprets that this is negative in nature. This client’s response will reduce the stress response, not increase it client is coping in a way that is: (option 3). This client’s response shows realism and adaptation to the stress being experienced, not hopelessness (option 4).
| Notice that three of the responses are negative in character. That should suggest to you that the one that is different is likely to be the correct answer. |
4650 While conducting an initial assessment of an infant, a Correct answer: 2 The action that demonstrates cultural sensitivity is the one that inquires about the home health nurse notices that he is wearing a soiled significance of the braided necklace while taking into account issues of client safety (in this piece of braided yarn around his neck. Which action by case risk of strangulation). Option 1 addresses risk of infection but not safety, while options 3 the nurse is most appropriate? and 4 fail to demonstrate any cultural sensitivity.
| Use the process of elimination and basic principles of culturally sensitive communication to make a selection. Eliminate options 3 and 4 as least respectful, and choose the correct option because it addresses the priority need of safety. |
4651 A Native American client who has a low‐grade fever Correct answer: 3 The nurse should continue to monitor the client’s status because the fever is low grade and tells the nurse on the reservation that he will only use considering that treatment consistent with the client’s beliefs will probably be the most a sweat lodge to treat his illness. Which approach by successful. The other options fail to show cultural sensitivity in respecting the client’s culturally the nurse would be most therapeutic? based beliefs about health.
| Use basic principles of therapeutic communication, client autonomy, and cultural sensitivity to make a selection. The critical words in the stem are low‐grade fever, which tells you that the situation is not life‐threatening or even an emergency. Avoid option 2 because it does not keep the responsibility with the nurse and option 4 because this action would violate a client’s right to self‐determination. |
4652 A male nurse needs to check the vital signs and Correct answer: 4 The response that shows cultural sensitivity is one that respects the personal boundaries for oxygen saturation level of a female client from a the client and asks permission to engage in care activities. There is no need for family or a different culture. As he approaches, the client moves female nurse to assist in these noninvasive procedures at this time without assessing first what to the other side of the bed and draws up the blanket. the client’s issues may be. The nurse should also not ignore the nonverbal communication What is the best nursing action? being sent by the client; this would not be therapeutic.
| Use basic principles of therapeutic communication, client autonomy, and cultural sensitivity to make a selection. First note that the nature of the nursing care activities involved indicate that this is not a situation that requires assistance from family or other nurses. Choose an option that focuses directly on the client. |
4653 A nurse is caring for two clients who have had Correct answer: 3 Pain is an experience that is more likely to be culturally influenced for clients. Hispanic or abdominal surgery. One client is of Hispanic heritage, Latino clients are more likely to externalize their pain, while Asian clients and some European who writhes in pain and moans when touched. The American clients tend to show few external signs. The best interpretation is one that does not other is an Asian client, who appears calm and rarely judge the level of the client’s pain without direct assessment (options 1 and 2) and that does complains of pain or discomfort. The nurse not label the client unfairly (option 4). appropriately draws which conclusion from these observations?
| Use principles of therapeutic, helping relationships and cultural sensitivity to evaluate each option. Keep in mind that the correct option will also be the one that is most respectful of the client. |
4654 A hospice nurse in a small Appalachian community is Correct answer: 2 Cultural practices near the time of death are important for clients and their families. The caring for a client at home who is an active member of nurse should respect the client and family wishes, since medical care is ineffective at this point his church. As death nears, the minister and several in time (option 4). Options 1 and 3 do not fully respect the needs of the client and those who members of the congregation come together in the are important in his life. home for a “death watch.” Which action by the nurse is most therapeutic?
| Recall that practices related to birth and death are highly culturally influenced. With this in mind, select the option that provides the greatest respect for the client and significant people in his life. |
4655 A home health nurse is assigned to an Asian American Correct answer: 1 The nurse should notify the health care provider of the client’s practices and should continue client who refuses to take the blood pressure to monitor the client to promote safe management of his health problem. It is unnecessary to medication prescribed by his physician. The client is ask for a nurse of the same culture to be assigned. The nurse would not indicate that the using acupuncture treatments and does not believe in medication would not work because of health beliefs. It would be punitive to discharge the taking pills. How can the nurse best help this client? client from services because of culturally based health practices.
| Eliminate option 4 because it implies punishment of the client. Eliminate option 2 because the nurse is abandoning the client. Choose option 1 over option 3 because option 3 is a false statement. |
4656 The nurse is checking the dietary trays that have been Correct answer: 3 The Jewish religion prohibits the ingestion of meat and dairy products during the same meal. delivered to the nursing unit. A client of Orthodox The nurse should ask that the entire meal tray be replaced by the dietary department. It is Jewish faith has received a tray containing a chicken unnecessary to remove the tea (option 1) or the chicken alone (option 2). Option 4 will not dinner with vegetables, tea, and a carton of 2% milk. resolve the dietary issue. What action by the nurse is best?
| The core issue of this question is that milk and meat products cannot be consumed during the same meal for Orthodox clients of the Jewish faith. Use the process of elimination and this knowledge to make a selection. |
4657 An Asian American client will be undergoing a cardiac Correct answer: 4 The client may be trying to demonstrate interpersonal harmony, which reflects a culturally echogram in a week. While the nurse is explaining the based value. There is insufficient evidence to support any of the other interpretations listed. procedure, the client repeatedly nods the head and smiles at the nurse. What conclusion about this behavior would be most appropriate for the nurse to draw?
| Use the process of elimination and knowledge of Asian American cultural values to make a selection. Choose correctly by recalling that peace and harmony are highly valued by Asian American people. As an alternative strategy, eliminate each of the incorrect options by noting a lack of data in the stem that would be consistent with those statements. |
4658 The nurse is caring for a Chinese client who Correct answer: 2 Yin and yang provide for balance in the body according to this theory. Because yin foods are subscribes to the yin and yang theory of treating cold and yang foods are hot, the client needs to eat cold foods for a hot illness and hot foods illness. The client tells the nurse she has a “hot” illness. for a cold illness. Options 3 and 4 are incorrect because the two types of foods are not mixed The nurse explains to the oncoming shift that the client in treating illness. will likely wish to consume which of the following in the diet to treat the illness?
| The core issue of the question is knowledge of the yin and yang theory in Chinese culture. Interpret the concept of balance as meaning “opposites” when choosing descriptions of foods in relation to the description of the illness. |
| |
4659 A nurse is working with a group of postpartum Correct answer: 4 Because American women tend to be more autonomous and have fewer relatives who assist women. Using culturally based practices as a guide, in the postpartum period, American women are more at risk for postpartum depression. Many which of the following clients is at greatest risk for non‐Western cultures will have family involvement in the care of the mother and infant for up postpartum depression? to 50 days after delivery. This prolonged support helps to prevent the new mother from feeling overwhelmed with new responsibilities or feeling abandoned.
| Use the process of elimination and knowledge of the social roles and support of various cultural groups to make a selection. Recall that American society generally tends to value autonomy and independence, which affects the nature of relationships in the postpartum period. |
4660 The nurse is caring for a Native American woman who Correct answer: 3 Following birth, the umbilical cord may be buried near a place or an object that symbolizes has given birth. The nurse anticipates that the couple the parents’ hope for the child’s future. For this reason, the parents of the newborn are likely will make which request regarding the umbilical cord? to request to take it home. The other options do not represent the cultural beliefs of Native Americans regarding the significance of the umbilical cord after birth.
| Use the process of elimination and knowledge of the cultural practices surrounding childbirth to make a selection. If needed, take time to review key cultural practices of Native American clients. |
4661 The nurse has taken a position in an ambulatory clinic Correct answer: 1, 4, 5 In the Latino culture, herbal medicines are just as important as Western medicines in treating in a Hispanic neighborhood. The nurse would use illness. Mourners would not be hired by a family to demonstrate grief after a death (that knowledge of which of the following practices to practice could occur in Korean culture). Staring at a child could cause the “evil eye” because of provide culturally sensitive care to this population? their inexperienced and vulnerable spirits. Depending on the specific illness, either hot or cold Select all that apply. foods would be used in treatment. Males may be the typical decision makers regarding health care. The client may want a caregiver of the same gender to enhance privacy.
| The wording of the question tells you that the correct options will also be correct statements about the Latino American culture. Use the process of elimination and nursing knowledge related to culture to make a selection. |
4662 A nurse is preparing to discharge a native American Correct answer: 1 Many Native Americans have been taught to live in the present and not be concerned with client who has been prescribed warfarin (Coumadin) the future. Because they tend to be present‐oriented, they might not adhere to laboratory with weekly prothrombin time monitoring. Which of monitoring and follow‐up appointments for medication therapy. While it would also be the following considerations should be the highest important for the nurse to explore the individual’s financial resources and dietary intake priority for the nurse to explore prior to discharging practices, these factors would not be as critical as evaluating whether the client would adhere the client? to follow‐up appointments. Because warfarin requires ongoing monitoring to prevent excessive bleeding, the highest priority would be for the nurse to verify that laboratory follow‐ up appointments would occur. If the client is unable or unwilling to adhere to the monitoring schedule, the nurse should contact the physician for alternative anticoagulant therapy.
| The question asks for the highest‐priority nursing action. Thus, the question does not exclude each incorrect response, but rather identifies one as being most important. While cost and dietary intake are important factors to consider, it is essential for the nurse to identify the client’s intentions for ongoing monitoring. By not engaging in such monitoring, the client risks hemorrhage or some other life‐threatening outcome. After establishing the intention for follow‐up care, the nurse can explore the other questions. |
4663 A nurse is providing discharge instructions to a Correct answer: 4 Chinese‐Americans can be erroneously perceived as being extremely shy or withdrawn. Chinese American client. As the nurse reviews the Chinese‐Americans might view tasks associated with increased eye contact as impolite and medications with the client, the nurse notices that the offensive. The nurse should provide explanations when performing tasks, while understanding client is looking away. Which of the following nursing that Chinese‐Americans might feel uncomfortable with face‐to‐face arrangements. actions would be most appropriate?
| By understanding the communication patterns of Chinese‐Americans, the nurse can identify the client’s response as being appropriate for the client, rather than as an indication of disinterest or misunderstanding. Thus, the learner can identify the correct response by eliminating incorrect responses. |
4664 A Latino client has been late for office appointments Correct answer: 4 Collaborating with the client and family to reinforce the importance of keeping the scheduled on several occasions. In fact, the client has arrived appointment offers the most realistic intervention for promoting timely arrival for more than two hours late for a scheduled appointments. Unless the lateness is associated with forgetfulness (and this information is not appointment. Which of the following strategies might in the question), it is unlikely that providing a client with a reminder call or an appointment be most effective in scheduling future appointments? card will facilitate timely arrival. Providing the client with a block of time in which to arrive might be convenient for the client; however, it is unlikely that the health care provider’s schedule can accommodate such flexibility.
| Because there is no specific data in the question that indicates the source or cause of the tardiness, select the option that is broadest in nature. Collaborating with the with client and family may help the nurse to determine an underlying problem while addressing the issue of tardiness. |
4665 The nurse has accepted a nursing position in an urban Correct answer: 2 When providing culturally competent care, it is essential as a first step for the nurse to be facility that serves clients of many different cultures. aware of personal biases. While appreciation of, sensitivity toward, and acceptance of diverse Which of the following is a prerequisite for the nurse, cultures is desired, these will not be accomplished until the nurse first considers his or her own who wishes to provide culturally competent care? biases..
| The key to answering the question correctly is identifying the quality that is essential first step to providing culturally competent care. |
4666 A client has a new order for a medication that should Correct answer: 2 Involving the client in the establishment of dosage times is an appropriate nursing be taken at the same time every day. Because the intervention. By initiating the client’s desired administration schedule during hospitalization, meaning of time varies from one culture to another, the client will be able to maintain the same schedule upon discharge. While the client can alter which of the following strategies would best promote the medication schedule following discharge, the nurse should attempt to integrate the the effectiveness of the medication regimen? desired time parameters during the inpatient stay as well.
| The key to correctly answering the question is to determine the most appropriate response. By identifying the intervention that offers the greatest benefit to the client, rather than to the nurse or health care organization, the learner can identify the best selection. |
4667 A nurse is assigned to provide care to a Chinese Correct answer: 3 By collaborating with the client and family, the nurse can best identify the expectations of client. Because the nurse is not familiar with Chinese nursing services. While performing a literature search and consulting with an individual of culture, which of the following actions would be most Chinese heritage may be helpful, such interventions might not promote the timely meeting of appropriate? the client’s needs. Recommending the reassignment of the client to another nurse is not necessary, particularly for the nurse who is interested in learning more about the client’s unique cultural background. Further, it is essential for the nurse to understand that as much diversity exists within cultural groups as exists between cultural groups.
| An understanding of culturally competent nursing practice is essential for correctly answering the question. |
4668 A Chinese client with cancer is likely to prefer Correct answer: 1, 4 Cancer is a disease associated with excessive yin forces. Diseases with yin forces are treated consuming which of the following food items? Select with foods with yang qualities. Yin is associated with cold, while yang is associated with all that apply. warmth. Yang foods, such as fried foods and spicy foods, are associated with warmth, whereas green vegetables and cold foods are associated with cold.
| An understanding of the concept of yin and yang is necessary for the learner to correctly answer the question. |
4669 A family of Asian descent has refused to allow Correct answer: 1 Select Asian cultures believe in reincarnation. According to these cultural beliefs, an autopsy physicians to perform an autopsy on their deceased cannot be performed, as it is necessary to keep the body intact for its next life. While many family member. Which of the following rationales cultures associate health status as being a gift from God, this premise is not necessarily might the nurse offer other health care providers as associated with declining an autopsy. The risk of disfigurement and the potential for disease insight into their decision? release are not associated with Asian cultures.
| Consider some of the commonalities in Asian cultures, and then answer the question using the process of elimination. |
4670 A Latino client presents to the Emergency Correct answer: 2 Empacho is a culture‐bound syndrome associated with Latino culture which occurs when food Department with a complaint of severe abdominal forms into a ball and clings to the stomach or intestines, resulting in pain or cramping. Hysteria pain and cramping. The client’s family expresses is a Greek culture–bound syndrome associated with the belief that the uterus has left the concern that food has stuck to the client’s intestines. pelvis for another part of the body. Mal ojo, or the evil eye, is a Latino culture–bound Which of the following culture‐bound syndromes syndrome believed to be caused by an individual excessively admiring a child. Bulimia is a would be consistent with the presenting symptoms? white culture–bound syndrome associated with overeating followed by vomiting.
| An understanding of specific culture‐bound syndromes is necessary for correctly answering the question. |
4671 A nurse is bathing an African‐American child. As the Correct answer: 4 When bathing a client, it is essential for the nurse to remember that the washcloth removes nurse examines the washcloth, she notices a brownish‐ some of the outermost skin layer. Sloughed skin will appear on the washcloth, with the color black discoloration to the previously white cloth. depending on the ethnic group of the client being bathed. Therefore, such findings do not Which of the following actions would be most prudent suggest improper bathing technique, neglect, infection, or incontinence. for the nurse to implement? | An understanding of transcultural skin care is necessary for correctly answering this question. By identifying this as an expected finding, the learner can eliminate the remaining answers. |
| |
4672 A postpartum client adheres to the hot/cold theory of Correct answer: 2, 3 Pregnancy is considered a hot state, with the delivery of an infant resulting in a loss of heat. disease causation. Which of the following Thus, the postpartum phase focuses on the restoration of warmth. Cold packs and sitz baths interventions would be appropriate for the are likely to be avoided. Heat packs and warming blankets are more appropriate for the postpartum client? Select all that apply. restoration of warmth in this client population.
| An understanding of the hot/cold theory is necessary for the learner to answer this question correctly. By correctly identifying the postpartum phase as being a cold state, the learner can identify all correct responses. |
4673 A Mexican‐American infant presents to the Correct answer: 3 Fallen fontanel, a Mexican‐American culture–bound syndrome, is associated with options 1, Emergency Department with caida de la mollera, or 2, and 4, but is not associated with slow removal of the nipple after feeding. Rather, it is fallen fontanel. Which of the following would not be associated with abrupt removal of the nipple during feeding. identified as a potential cause of this condition?
| An understanding of culture‐bound syndromes, including the etiology of the condition, is essential for answering this question correctly. |
4674 An African‐American client is diagnosed with glucose‐ Correct answer: 1 Following exposure to salicylates or other potentially injurious agent, the plasma membranes 6‐phosphate dehydrogenase (G6PD) deficiency. The of erythrocytes become damaged, leading to hemolytic anemia. Chronic renal failure would client presents with pallor, dark urine, and back pain not be a clinical manifestation of G6PD deficiency. Hemophilia A is caused by a deficiency of following the ingestion of aspirin. For which of factor VII. Thalassemias are inherited autosomal recessive disorders that lead to an impaired following does the nurse assess, as the most common rate of synthesizing of the alpha or beta chains of adult hemoglobin. clinical manifestation of G6PD?
| An understanding of the pathophysiology of G6PD is necessary to accurately answer the question. The answer can be identified through the process of elimination. |
4675 The parent of a child presents to the pediatrician’s Correct answer: 4 Susto is thought to be the result of a frightening experience or event that leads to the office with a chief concern that the child has temporary loss of the spirit from one’s body. Susto is thought to be associated with childhood experienced a loss of spirit from the body. When asked epilepsy. Brujos or brujas (witches) are not associated with the presenting symptoms. Mal ojo, to describe the event, the client describes recurrent the evil eye, is thought to be the result of someone excessively admiring a child. Caida de la episodes where the child experiences involuntary mollera, fallen fontanel, does not present with the identified symptoms. shaking of the body. Which of the following folk‐ related diseases is the client most likely experiencing?
| Use the process of elimination and knowledge of cultural beliefs to identify the correct response. |
4676 An Asian client is scheduled for surgery. The client is Correct answer: 4 Because succinylcholine is a muscle relaxant, the absence of the enzyme that inactivates the to receive succinylcholine, a muscle relaxant used medication can lead to an exaggerated or prolonged response to the medication. Therefore, during surgery. The nurse is aware that clients of Asian monitoring the client for prolonged muscle paralysis would be a priority for the nurse. While descent are at greater risk for having a deficiency of an allergic reaction is possible, it is not associated with Asian clients. Because the response pseudocholinesterase, the enzyme that inactivates might exceed the desired effect, it is not likely that the medication will fail to induce muscle succinylcholine. When administering this medication to relaxation. Seizure‐like activity also is not associated with Asian clients’ receiving the the Asian client, the nurse will focus monitoring on medication. which of the following?
| The process of elimination is essential for the correct answering of the question. |
4677 The wound care nurse who examines surgical wounds Correct answer: 2 Keloids are more common in African‐Americans than in other racial groups. Presenting as anticipates identifying keloids, or ropelike scars, in ropelike scars, keloids represent an exaggeration of the healing process. which of the following cultural groups?
| An understanding of cultural characteristics is essential for correctly answering the question. The process of elimination leads the learner to the correct response. |
4678 An Islamic client is hospitalized for minor elective Correct answer: 1 During the 28‐day period of Ramadan, Islamic adults refrain from food and drink from dawn surgery during Ramadan. The nurse anticipates that until sunset. Regardless of their content, meals are not accepted during the daylight. Total the client might desire which of the following parenteral nutrition would not be indicated for all clients who are fasting. While the physician interventions? should be made aware that oral medications may not be taken until night hours, it would not be correct to identify the client as having no oral intake.
| An understanding of Islamic culture, including Ramadan, is necessary for the correct answering of the question. |
4679 The nurse is aware that cultural differences in Correct answer: 1 Hypertensive African‐American clients tend to respond best to single‐agent therapy rather response to medications exist. Which of the following than combination therapy. Beta blockers and ACE inhibitors tend to be less effective, while would not be characteristic of hypertensive African‐ calcium antagonists and alpha blockers are considered to be the most optimal agents. It has American clients? been suggested that thiazide diuretics place the African‐American client at risk for signs and symptoms of depression.
| An understanding of the cultural considerations in pharmacology is necessary for correctly answering the question. The process of elimination is useful in determining the “incorrect” answer. |
4680 A dark‐skinned client is noted to have patches of Correct answer: 1 Vitiligo is a condition in which melanocytes become nonfunctional. The skin presents with white, unpigmented skin. The nurse concludes that unpigmented patches. The other options do not reflect correct information. which of the following variations in skin is likely present?
| An understanding of biocultural variations in skin is necessary for the learner to answer the question correctly. |
4681 A nurse is reviewing postoperative instructions with a Correct answer: 3 Smiling and nodding one’s head does not necessarily indicate that the Chinese‐American Chinese‐American client. The client is smiling and client is agreeing with the nurse’s statements. This form of nonverbal communication is nodding her head. The nurse is aware that this culturally acceptable behavior. nonverbal communication might suggest which of the following?
| An understanding of Chinese culture is necessary for correctly answering the question. |
4682 A female nurse informs her colleagues that she “isn’t Correct answer: 1 Ethnocentrism is the belief that one’s traditions or culture is superior to that of another familiar with cultural minorities.” The staff nurse who cultural group. Identifying another cultural group as a minority has been suggested as an overhears this nurse’s statement concludes that the ethnocentric statement in itself. Cultural imposition is the process of imposing one’s cultural nurse is exhibiting which of the following? beliefs on another individual. Acculturation is the process of integrating into the mainstream culture. Culture‐universal nursing care refers to commonly shared values and lifestyles that are similarly held among cultures.
| An understanding of the terminology is essential for correctly answering the question. |
4683 Which of the following cultural characteristics are Correct answer: 1, 2, 4 Mexican‐American culture is associated with placing a high value on extended family typically associated with Mexican‐American culture? relationships. In addition, Mexican‐American culture is associated with being patriarchal Select all that apply. (machismo), as well as having respect for authority. Mexican‐American culture does not value independence and autonomy. Rather, interdependence is valued.
| An understanding of Mexican‐American culture is necessary for correctly answering the question. |
4684 An Asian client presents to the Emergency Correct answer: 4 Cupping occurs when a vacuum is created inside a cup by igniting cotton soaked in alcohol Department with a report of recurrent body aches. sitting within the cup. When the flame is extinguished, the cup is placed onto the skin at the Upon assessment, the nurse identifies numerous painful site. The cup remains in place until the suction is released. The symmetrical burns circular, flat, ecchymotic burns. The burns appear to be would not be associated with abuse or cigarette burns. Coining occurs when the edge of a coin approximately two inches in diameter, and are is rubbed over a painful area. symmetrical. What is the likely cause of the condition?
| An understanding of Southeast Asian folk healing processes is necessary for correctly identifying the best response. |
4685 The international nurse who has recently begun Correct answer: 1 Anorexia nervosa is associated with Western culture, where food is prevalent. Trance practice in the United States would conclude that dissociation, susto, and the evil eye are not associated with Western culture. which of the following culture‐bound syndromes is associated with Western societies?
| An understanding of culture‐bound syndromes and their origins is essential for the correct answering of the question. |
4686 A Chinese‐American client is menstruating, a Correct answer: 1, 2, 3 Beef, eggs, and fried food are considered warm foods, and, as such, would be a treatment for condition considered to be yin (cold). The nurse yin (cold) conditions. Honey and broccoli are considered cold foods, and would not be anticipates that which of the following foods would be consumed with a cold condition. eaten by the client who is striving to promote balance? Select all that apply.
| An understanding of yin/yang principles, including the foods categorized in each group, is essential for the correct answering of the question. |
4687 When teaching an in‐service on culturally competent Correct answer: 2, 3, 4 Anglo‐American culture values materialism (such as money), youth, and beauty. Competition care, the nurse would explain that which of the is valued over harmony. Independence is valued over interdependence. following cultural values are associated with Anglo‐ American culture? Select all that apply.
| An understanding of Anglo‐American culture is necessary for correctly identifying the best responses. |
4688 A postoperative Chinese‐American client has not Correct answer: 3 Chinese‐American clients might elect to be stoic in pain management, and might not readily requested pain medication. Which of the following accept pain medication. However, it is necessary for the nurse to continue to monitor the pain statements made by the nurse would offer the most status of the client, as well as offer pain medication as needed. Biological differences or the appropriate nursing intervention? potential for dependency would not be factors in the assessment or treatment of pain. By waiting for the client to ring for pain medication, the nurse might miss valuable information on the client’s pain status.
| An understanding of cultural variances in pain reporting and communication with health care providers is essential for the learner to identify the correct response. |
4689 The nurse would place highest priority on assessing Correct answer: 1 Kawasaki disease is observed primarily in children of Japanese descent. The other cultural for Kawasaki disease, also known as lymph node groups identified are incorrect. syndrome, with a client from which of the following cultural groups?
| Knowledge of Kawasaki disease is essential for the correct answering of the question. |
4690 The nurse doing community education about the Correct answer: 3 The dominant value orientation of the United States promotes independence and hard work. effects of lifestyle on health would identify which Youth and beauty also are valued, as well as planning for a more productive, fulfilling future. quality as best describing the dominant value orientation of the United States?
| An understanding of the dominant value orientation of the United States is essential for identifying the correct response. |
4691 While realizing that all clients are unique, the nurse Correct answer: 1, 2, 4 African‐American culture typically values extended family, religion, and interdependence. would tend to associate which of the following cultural Long‐term goals and seclusion are not typically associated with African‐American culture. values with the African‐American culture? Select all that apply.
| An understanding of African‐American culture is necessary for the learner to identify the accurate responses. |
4692 The nurse has explained a therapeutic diet to a client. Correct answer: 2 It is important for the nurse to listen to the feedback given by the client to ensure the To ensure learning occurred, the nurse should do message sent was the message received. Repetition is important in the teaching process but which of the following? does not evaluate clients’ understanding (option 1). Options 3 and 4 are unnecessary as part of evaluation.
| The core issue of the question is determining the client response to teaching. In evaluation questions such as these, the correct option is likely to be one that focuses directly on the client. |
4693 A nurse is trying to establish whether a client who Correct answer: 2 To evaluate an unresponsive client’s ability to communicate, it is best for the nurse to ask appears unconscious can communicate. Which of the questions that will elicit a single act or response by the client. Option 1 is not appropriate for following would be the best approach for the nurse to the client’s condition. Options 3 and 4 may be noted during neurological assessment but do use? not relate to communication.
| In communication questions such as these, the correct option is one that is client‐focused and relates directly to communication. With this in mind, eliminate options 3 and 4 immediately, and choose option 2 over 1 because of its simplicity. |
4694 A client who is legally blind has been admitted to the Correct answer: 3 A client who is blind does not have the benefit of nonverbal cues to facilitate communication cardiac unit. Which of the following actions by the and understanding of the environment. It is important for the nurse to explain physical nurse would be best to promote adjustment to the surroundings and noises because the client cannot determine these without the added benefit environment? of sight. Options 1 and 4 are approaches that a nurse should use with a client who is hearing impaired. Placing a sign on the client’s door encroaches on confidentiality.
| In communication questions with a client who has loss of vision, the correct option is one that supplements vision impairment with verbal communication. Note the critical word best in the stem of the question, which indicates more than one response may be partially or totally correct. |
4695 The home care nurse has asked the client to Correct answer: 4 A return demonstration specifically identifies the client’s ability to perform a skill. The client’s demonstrate self‐injection technique. In doing so, the skill level may provide incidental information related to options 1, 2, and 4, but they are not nurse is primarily attempting to determine which of the primary reasons for asking the client to demonstrate a skill. the following?
| Recall that to evaluate learning of a skill, which is in the psychomotor domain, the best option is the one that utilizes return demonstration. In this way, the nurse can verify that the client can perform the skill and also has an opportunity to provide additional feedback. |
4696 Which of the following would be the most Correct answer: 1 Confrontation should not be used as a therapeutic communication technique unless trust has appropriate time for the use of confrontation as a been established in the nurse–client relationship. Because confrontation can be uncomfortable therapeutic technique in communication with an for the client, it is important for the nurse and client to have a trusting relationship as a assigned client? foundation. The other options represent situations in which the nurse might like to use confrontation but that are not appropriate for this communication technique.
| Note the critical words most appropriate in the stem of the question. This tells you that more than one option will be plausible and that you must choose one over the others based on what is most therapeutic for the client. |
4697 Which of the following teaching strategies should the Correct answer: 3 Client contracting provides adolescents with the ability to be involved in their care. nurse choose as being most likely to be effective when Adolescents should be involved in planning and decision making regarding their need for providing health instruction to an adolescent client? information about their own health issues. Lecture, viewing a video, and role‐play would not provide opportunity for feedback.
| In teaching and learning questions in which communication is key, choose the option that provides for two‐way communication between the client and nurse. Note the critical words most likely to be effective in the stem of the question, which tells you that more than one option is plausible and that you must choose based on knowledge of communication theory. |
4698 A nurse is evaluating a client’s ability to change the Correct answer: 2 Praising the client for steps performed correctly provides positive reinforcement. In addition, surgical dressing before discharge. During the explaining the client’s mistakes reinforces the correct way to perform the procedure. For the demonstration, the nurse notices the client has not nurse to redo the dressing decreases the client’s confidence. Praising the client without performed the procedure correctly. The most correcting the mistakes gives feedback that the procedure was done correctly. Having the appropriate action of the nurse would be to do which client repeat the procedure and stating it was done correctly without further guidance does of the following? not reinforce or assist learning.
| Note the critical words most appropriate in the stem of the question. This tells you that more than one option is plausible and that you must choose based on knowledge of communication theory. |
4699 When beginning to present information about heart Correct answer: 1 When presenting information to a client, it is important that the nurse find out what the disease to a client newly diagnosed with heart disease, client already knows, and then build on existing knowledge. It is not necessary to consult with which of the following is most important for the nurse a physician. It may be helpful to have family members present, but it is not the priority at the to do first? time of initial teaching. It is important when teaching to begin with basic concepts and progress to the complex after determining current client knowledge.
| Focus on the critical word first in the stem of the question. This tells you that more than one option may be correct and that a time sequence is involved. Recalling that assessment is the first step of the nursing process, choose an option that assesses the client’s current level of knowledge before beginning instruction. |
4700 During the nursing assessment of an elderly female Correct answer: 4 Restating the information in different ways may assist the elderly client in understanding. client, the nurse enhances communication by doing Increasing speech volume and gesturing (option 1) only further confuses the client. Older which of the following? adults do better with a slower paced interview with frequent breaks to decrease exhaustion (option 2). Relying on the family (option 3) is not respectful of the older adult’s autonomy.
| The core issue of the question is how to communicate most effectively with an elderly client. The correct option is the one that focuses on the client, incorporates age‐related needs, and does not incorporate ageism into the response. |
4701 The nurse would use which of the following Correct answer: 3 The communication technique of reflection (option 3) occurs when the nurse directs feelings statements when trying to encourage a client to and questions back to the client to encourage elaboration. The nurse uses the technique of express her feelings and allow the nurse to genuinely focusing (option 1) by asking questions to help the client focus on a specific area of concern. In respond to those feelings? summarizing (option 2), the nurse highlights important points of the conversation. The nurse uses restating (option 4) by repeating back to clients the main points or content of the conversation.
| The core issue of the question is knowledge of the various types of therapeutic techniques, specifically one that utilizes reflection as a means of encouraging continued communication. Use this knowledge and the process of elimination to make a selection. |
4702 Which of the following is the best approach for a Correct answer: 4 Empathy is the ability of the nurse to see the client’s perception of the world. Challenging nurse to use to encourage a client to express feelings clients (option 1) forces them to defend themselves from what appears to be an attack by the and to develop increased awareness about what those nurse. False reassurance (option 2) is another way of telling clients how to feel and ignoring feelings are? their distress. Advising (option 3) occurs when the nurse tells clients what to do, preventing them from exploring problems and using the problem‐solving process to find solutions.
| The core issue of the question is knowledge of the purpose and use of therapeutic communication techniques. Use this knowledge and the process of elimination to make a selection. |
4703 While talking with a client, the client tells the nurse, Correct answer: 3 Transference is the unconscious process of displaying feelings for significant people in the “You are just like my mother; you don’t trust me or like client’s past onto the nurse in the present relationship. Countertransference (option 2) is the me. You and she wish I were dead.” The nurse nurse’s emotional reaction to clients based on feelings for significant people in the nurse’s interprets this statement as indicating which of the past. Psychosis (option 1) is a state in which a client is unable to comprehend reality and has following processes? difficulty relating to others. Projection (option 4) is a defense mechanism in which blame for unacceptable desires, thoughts, shortcomings, and mistakes is attached to others in the environment.
| The core issue of the question is knowledge of various processes that can occur during therapeutic communication. Eliminate options 1 (a disorder) and 4 (a defense mechanism) first. Choose option 3 over 2 because it is the client who has made the transference, not the nurse. |
4704 The nurse is preparing to explain an upcoming Correct answer: 2 Taking into account the age and ethnicity of the client, it is helpful to speak slowly and procedure to a 72‐year‐old, English‐speaking Latino provide short and simple explanations. Speaking quickly does not help the client understand client. The nurse determines that the best way to the information presented. Eye contact is acceptable. There is no need for an interpreter verbally communicate with this client is to: based on the information in the question.
| Note that some options have more than one part to them. In such questions, all parts must be correct for the option to be correct. Eliminate option 3 based on information in the stem. Eliminate options 1 and 4 because they are opposite of information in the correct option. |
4705 The nurse observes a client who is fidgeting, wringing Correct answer: 1 The core issue of the question is the communication by the nurse that is most likely to elicit the hands, and has body tenseness and a wrinkled further data from the client. With this in mind, option 1 provides a broad opening for the brow. What is the best way for the nurse to interpret client. Option 2 places a judgment on the client’s behavior. Option 3 begins by acknowledging these nonverbal cues? the client’s feelings, but then risks putting the client in a defensive position by asking, “Is something bothering you?” Option 4 also places the client on the defense.
| The core issue of the question is how to apply general principles of therapeutic communication. In this question, the correct option is the one that is nonjudgmental, uses therapeutic communication techniques, and avoids communication blocks. |
| |
4706 A nurse floating to the nursing unit learns during Correct answer: 2 The nurse is more likely to exhibit therapeutic verbal and nonverbal communication by being intershift report that a client suffered disfiguring aware of the extent of the client’s disfiguring injuries. This will reduce the likelihood of surprise injuries in an accident a week ago. What is the best that can be seen in nonverbal behavior. The remaining options are also items that the nurse way for the nurse to prepare for the first encounter will do, but they are general to all clients and not particular to the client in the question. with this client?
| The critical phrases in the stem of the question are best way and first encounter. The phrase best way indicates that more than one option is a true statement and more than one option may compete for priority. The phrase first encounter assists you to focus on the real core issue of the question, which relates to communication. |
4707 The nurse enters a client’s room to obtain an Correct answer: 1 The client may have a need for increased personal space, which may account for withdrawing admission history, moves the chair to the top of the to the other side of the bed. However, cultural considerations cannot be ruled out by the bed by the client’s head, and sits down to better hear information in this stem. With this in mind, the correct action by the nurse is to validate the the client. The client draws back and moves to the reason for the client’s behavior. This is what option 1 represents, an attempt to determine opposite side of the bed. What is the best response by whether increased need for personal space is the reason for the behavior. Option 2 punishes the nurse? the client for the behavior by leaving the client alone. Option 3 is inappropriate because it does not acknowledge an unspoken need by the client. Option 4 would further invade personal space and is inappropriate until further data is gathered.
| The core issue of the question is how to respond to a client’s nonverbal behavior in a therapeutic manner. Choose the answer that validates the original data or impression, which is option 1. Eliminate options 2 and 3 because they are nontherapeutic and option 4 because it could worsen the situation. |
4708 The nurse, who has a heavy work assignment for the Correct answer: 1 The nurse has two competing priorities: the need to accomplish work on a busy shift and the day due to high client census, sees that a client is need to address the psychosocial needs of a client in distress. Option 1 takes into crying. Which of the following would be the best way consideration both of these factors. Option 2 creates psychological as well as physical distance for the nurse to convey a willingness to be with the between the nurse and the client because the question is asked from the doorway. Option 3 client for support? ignores the other workload of the nurse. Option 4 puts the client’s feelings on hold.
| The core issue of the question is the most therapeutic response to a client in distress. Note that the question also contains the critical words best way, which implies that the options will have greater or lesser degrees of correctness and that you must choose between them. Use the process of elimination and choose the option that takes into account all of the relevant information in the stem of the question. |
4709 A client asks about a new diagnostic test with which Correct answer: 1 Option 1 demonstrates honesty and openness between the client and the nurse. It also the nurse is unfamiliar. What is the best nursing addresses the client’s need for information. Options 2, 3, and 4 are incorrect because they put response? the client’s information needs on hold and do not represent a candid response by the nurse. The correct answer to communication questions is the one that best acknowledges the client and utilizes therapeutic communication techniques.
| Eliminate options 2 and 3 because they are similar in that they put the client’s request on hold and divert the responsibility to someone else. Eliminate option 4 because it is not a totally candid response. Choose option 1 because it is the only one that incorporates all the information in the stem of the question with regard to the nurse’s level of knowledge and the client’s need to know. |
4710 A client can understand only minimal English, and no Correct answer: 3 Because the client does not speak English, the nurse must utilize nonverbal communication. interpreter is available. What alternative measures can With this in mind, option 3 is the one that takes this need into account. Options 1 and 4 are the nurse use to enhance communication? helpful when the nurse is working with a client who is hearing impaired. Option 2 would be useful for the aphasic client who has use of the dominant hand, such as after a CVA.
| The core issue of the question is the best method for communicating with a client when there is a language barrier. Eliminate options 3 and 4 because they are similar with respect to the spoken word. Eliminate option 2 because it also relies on words that may not be in the client’s vocabulary. |
4711 A client has been on the nursing unit for a few weeks Correct answer: 1, 2, 5 The correct answers to communication questions are those that utilize therapeutic because of complications after surgery, including the communication techniques and avoid communication blocks. Options 1, 2, and 5 utilize these need for extensive wound care. During the last techniques, while options 3 and 4 use the communication blocks of false reassurance (option dressing change before discharge to home with home 3), challenging the client (option 4). Another block would be putting the client’s feelings on health services, the client becomes angry with the hold. nurse and says, “You don’t have to be so careful. I’m being sent home anyway!” Which of the following responses by the nurse would be therapeutic? Select all that apply.
| Analyze each statement in terms of being a communication enhancer or blocker. Choose the ones that incorporate therapeutic communication techniques without having any components of communication blocks. |
4712 A nurse enters the room of a female client and asks Correct answer: 4 Asking the client to describe feelings seeks additional information and indicates to the client her how she is doing. The client states, "I'm a little that the nurse is attentive. Asking "why" questions may force the client to defend himself or nervous this morning." The nurse's best reply would be herself by indicating there must be a reason for these feelings. Stating the client looks nervous which of the following? may be interpreted as nonsupportive. Providing a backrub does not allow the client to express feelings.
| Note that the correct response allows the client to explain her feelings and is open‐ended. |
4713 A client tells the nurse that her husband is an Correct answer: 4 Asking what the client has done before focuses him or her on solving own problems and helps alcoholic and hasn't worked for the last 3 months. The the nurse assess the client's coping mechanisms. The other options, although empathetic, may nurse's best response would be which of the block the communication process. following?
| Recognize that the correct option is open‐ended and allows the client to explore feelings. |
4714 During the introductory phase of communication with Correct answer: 3 During the introductory phase of communication the nurse and client identify goals and a client, the nurse becomes acquainted with the client objectives. Nurses should not offer advice when establishing a therapeutic relationship with a and does which of the following? client. Preparing for a client interview is the pre‐interview phase of communication.
| Look for a logical sequencing of events. The scenario asks for activity during the introductory phase when goals and objectives are developed. |
4715 A nurse has demonstrated wound care for a client Correct answer: 3 Clients are more likely to successfully complete a new procedure if they can actively using a mannequin. To promote client teaching, which demonstrate the procedure immediately after instructions have been given with the nurse of the following would be the best nursing action? present the first several times. A video and written literature do not allow for active participation; however, they can be used as supplementary learning aids.
| This is a psychomotor (skill learning) scenario, so supervised practice is the most appropriate. |
4716 Which of the following methods would be most Correct answer: 4 Learning is more likely to take place when the client's perceived needs are met. The nursing effective for an ambulatory care nurse to use when assessment identifies areas for client teaching and the client's ability to learn. The amount of trying to determine the priority health‐related learning time needed to implement a teaching plan is not associated with establishing priorities. needs of a client?
| Recognize that the correct option involves the client. |
4717 An acute care nurse has to discharge to home a client Correct answer: 2 Description of the client's self‐care abilities provides data to the referral nurse about who needs services from a home health nurse. What information needed to continue the client's care. Vital sign information is only one parameter discharge information is most important for the acute and does not provide enough information about the client's overall status. Medication last care nurse to give to the referral agency nurse? administered does not identify all of the medications the client is currently taking. The surgical report does not have direct relevance to the client's home care needs.
| Recognize that the correct option best describes what the home care nurse will be most concerned with in planning care. |
4718 An insurance company has requested a copy of the Correct answer: 4 All information in the client's record is confidential and access to the record is restricted client's chart from the doctor's office in order to unless the client has given permission for release. The other responses do not directly compensate the physician for the medical care advocate for the client's right to confidentiality. received by the client. Which of the following is the most appropriate nursing action by the office nurse?
| Follow the principles of confidentiality. Recall that the client must consent to release of information. |
4719 Which of the following statements heard by a nurse Correct answer: 1 A client who has not urinated following catheter removal would require nursing intervention, during intershift report provides the most useful specifically an assessment of the client's abdominal distention, reviewing intake and output information related to priority setting for the records, and possibly calling the physician for an order to do a straight catheterization. The upcoming shift? second priority would be the client who has incisional pain; however, since the client is 3 days postoperative, this is not as urgent a problem as option 1. The information contained in options 2 and 4 pose no threats to the health status of those clients.
| Identify the option that requires action on the part of the nurse. |
4720 The quality assurance nurse reads several nurses Correct answer: 3 The quality assurance nurse's best action is to report the findings to the Nursing Staff notes from different records that refer to clients' Development Department to improve the standards of nursing documentation in the facility. moods. Examples of these notes are: "The client is in good spirits today;" "The client feels depressed today"; and "The client is withdrawn today." Based on the quality assurance nurse's finding, which of the following would be the best action to take?
| Follow the chain of command in reporting issues, and address the learning needs of the nurses in terms of documentation. |
4721 Before going off duty, a nurse is reviewing the notes Correct answer: 3 Recording the time of the entry, the time of the assessment, and the missing data is an written for a client. The nurse discovers that there has acceptable documentation practice. Inserting information in the client record is not an been an omission of important assessment findings. appropriate documentation action. Clients' records should not be recopied. Verbally reporting Which of the following nursing actions is most the omission solely is not acceptable. appropriate at this time?
| Recognize that the correct option allows for addition of the missing data without disrupting the integrity of the original documentation. |
4722 A nurse observes a client pacing the halls, and it Correct answer: 2 The nurse should validate his or her perceptions with the client to ensure the correct appears as if the client has been crying. The most interpretation of the client's nonverbal behavior. Option 3 is inaccurate. The nurse should not appropriate nursing action is which of the following? make false assumptions (option 1) and should not ignore the client's behavior (option 4).
| Select the option that acknowledges the client’s emotions and is open‐ended. |
4723 Which of the following would be the best approach Correct answer: 3 Exploring the client's feelings indicates that the client's feelings are important to the nurse. for the nurse to use when a client conveys anxiety Providing reassurance to the client may dismiss the client's feelings as unimportant. Providing prior to surgery? information to a client at this time is inappropriate because it may not be assimilated because of anxiety. Relating a personal experience focuses the attention on the nurse, rather than the client.
| Select the option that addresses the emotion of the client’s communication. |
4724 A nurse is preparing to complete an admission Correct answer: 3 For a client who is hearing impaired, speaking slowly in a low‐pitched voice and facing the assessment on a client that is partially hearing client will promote understanding of the message sent. Option 4 will not provide enough impaired. The best approach would be to do which of information to effectively care for the client. Options 1 and 2 may be appropriate if the client the following? cannot hear at all.
| Notice that the scenario states that the client is “partially” hearing impaired. Select the option that adapts to the level of the client function. |
4725 A client states, "I am so sick, I know I am going to Correct answer: 4 Documentation needs to be accurate and complete and should not express the opinions or die." Which of the following would be the best way for judgment of the nurse. The other options are unclear, judgmental and/or represent the nurse's the nurse to document this data? interpretation of data.
| It is best to document the exact quote. Recognize that the other responses are the nurse’s assessment. |
4726 A client needs to learn how to take the pulse before Correct answer: 3 Before a client is able to learn a new skill he or she must be able to perform the skill. In this taking prescribed heart medication. Before beginning case if the client doesn't have the dexterity to palpate a pulse or ability to see a clock's second‐ the client teaching, the nurse needs to evaluate which hand, the client will need assistance with the skill. Options 1 and 2 are unnecessary for the of the following about the client? nurse to assess prior to implementing the teaching plan. Motivation to learn is also important, but the nurse must first evaluate the client's ability to perform the skill.
| Consider what ability is needed to take a pulse. Recall that this is an action, or a psychomotor skill. |
4727 The nurse assigned to care for a postoperative client Correct answer: 1 Prior to delegating any client care responsibilities the nurse must assess the client to assure has asked an unlicensed nursing assistant to help the that the delegation is appropriate to their care. Options 2, 3, & 4 would not constitute an client ambulate in the hall. Before delegating this task, assessment of the client’s current status. the nurse must do which of the following?
| The critical word is delegating. Recall principles of appropriate delegation in nursing practice to select the care measures that can be safely delegated. |
4728 Which of the following behaviors by a client indicates Correct answer: 1 Learning in the cognitive domain involves the acquisition and use of knowledge mentally or to the nurse that learning in the cognitive domain has intellectually. Option 3 involves learning in the affective domain, which involves changing taken place? feelings and values toward a positive health behavior. Options 2 and 4 involve learning in the psychomotor domain.
| Note the use of the word “explaining “in the correct answer. Explaining requires that the client have knowledge and can share it. |
4729 A nurse who has been called in to work due to Correct answer: 3 The Kardex should supply the information to provide nursing care to the clients assigned. The unusually high client census has missed the intershift other options are not good indicators of client care needs. report. While waiting to get report from another nurse, where can the nurse look to find the most concise and accurate information related to the client care assignment?
| Note the words “concise” and “accurate” in the question and identify the option that would meet both of these criteria. |
4730 What type of information communicated in the end‐ Correct answer: 1 Physical assessment data and client response to care are pieces of information that are most of‐shift report has highest priority in order to provide important in ensuring that client's health care needs are being met. The other options are care to clients? useful to a nurse assuming care of a client, but are more limited in the scope of information they provide (options 3 and 4) or are not as relevant to the client's status in real time (option 2).
| The question is asking for the highest priority to communicate. Select the response that includes the most important data in providing nursing care. |
4731 Charting by exception is used by a hospital for Correct answer: 4 Charting by exception is a form of documentation where notations are made if there was an documentation. Using this format, how would the exception to the rule. All other options are normal and are therefore not necessary to include nurse document routine care morning care? in documentation using this format.
| Recognize that the three incorrect options state the same information. |
4732 The nurse would ask a client to perform the self Correct answer: 4 When teaching a skill to a client the means of evaluation is observing the client perform the injection technique following the nurse's skill to determine if the teaching/learning goal has been reached. This action represents the demonstration during what phase of the nursing evaluation phase of the nursing process. process?
| Note the word “perform” which implies that the nurse is evaluating. |
4733 A nurse planning learning activities for a client would Correct answer: 4 Return demonstrating is an activity that actively involves the client and increases learner choose what activity to increase learner retention? retention. The other options involve visual (options 1 and 2) and auditory (option 3) learning, but do not engage the client as fully as when the client participates.
| Select the response that includes active participation on the part of the client to increase retention. |
4734 A nurse preparing a teaching plan for a diabetic client Correct answer: 3 The client is more likely to accept a plan consistent with the client's value system. If not, the assesses the client's health beliefs, cultural values, and plan may be more difficult for a client to accept, and the nurse may need to modify it later motivation for which specific purpose? based on the assessment data.
| Select the response that most closely responds to the question. The question addresses the plan as does the response. |
| |
4735 A client who verbalizes an understanding of the anger Correct answer: 3 Learning in the affective domain involves emotions, feelings, and attitudes. Learning in the she felt following the diagnosis of cancer demonstrates cognitive domain (option 2) involves processing information by listening or reading facts. which of the following items related to learning? Learning in the psychomotor domain (option 3) involves learning by doing. Option 4 is a prior condition needed for the most effective learning to take place.
| The scenario is discussing the client’s feelings. Select the option that addresses learning on a feeling level. |
4736 A client's nonverbal communication consistently Correct answer: 3 The client will be less anxious about intimate space being invaded if the client knows the indicates discomfort when a person stands too close. reason why and how it relates to health care. Ignoring the client's discomfort sends the Which of the following is the best approach for the message that the client's feelings are not important. Acknowledging the client's discomfort nurse to use when performing a physical assessment may be beneficial but is not the best option. Deferring the assessment is not appropriate on this client? nursing practice.
| Select the response that not only acknowledges the client’s issue but involves the client by explaining the process. |
4737 A nurse providing teaching on weight reduction Correct answer: 1 Providing positive reinforcement is likely to increase the client's continued use of positive compliments the client on exercising daily. This action health behaviors. Option 2 is vaguer than option 1. Options 3 and 4 do not promote the client's will promote the teaching plan by providing the client healthy behavior. with which of the following?
| Select the option that most closely responds to what the question asks. |
4738 When interpreting a client's message it is important Correct answer: 3 Nonverbal behavior should be consistent with verbal communication to ensure the message for the nurse to assess which of the following? sent is the message received. The other options are not components of the communication process.
| Note that the scenario is referring to the client’s message. The option that discusses communication most closely responds to the item. |
4739 The nurse has been called to "float" to another Correct answer: 2 Documentation is the means to communicate clients healthcare needs to all members of the department to take the place of a nurse who is going healthcare team and is the most important to ensure continuity of care. Reporting to another home. To ensure continuity of care prior to floating, nurse (including list of activities still to be done) also needs to be done. Telling clients he/she is the nurse should: leaving is appropriate, but it is not the most important item to ensure continuity of care. Not all clients may require side rails.
| Select the option that would provide the most information to the next care provider. |
4740 The elderly client expresses difficulty sleeping Correct answer: 2 Assessment of religious practices that the client would find comforting should be because her spirit is disturbed because of sin in her accomplished first in order to assist the client with spiritual distress. Option 1 would be done if life. The nurse should select which of the following as indicated as an answer to option 2. Option 3 may or may not be appropriate; there is the priority intervention? insufficient data in the stem of the question to support it. Option 4 may be needed if other options are unsuccessful.
| Recall common nursing interventions to promote spiritual health and use the process of elimination to select actions that aid in identifying and helping the client meet their spiritual needs. |
4741 A nurse concludes it is acceptable to use Correct answer: 3 Abbreviations used in documentation need to be consistent with facility policies for abbreviations in a chart when which of the following documentation. The client's record is a permanent document that must be consistent with conditions exist? professional and legal standards, which include agency/facility policy.
| Recall that policy dictates the use of abbreviations. |
4742 A nurse is teaching a class about aging at a senior Correct answer: 4 Options 1, 2, and 3 are true statements. Each physiologic system of a person ages at a citizen center. The nurse would know that a client different rate. needed further instruction if he or she made which of the following statements?
| The key phrase needs further teaching tells you to look for an incorrect choice. |
4743 The nurse assesses that a 75‐year‐old client has Correct answer: 3 Lentigines (brown age or liver spots) represent normal aging of the skin. Prebycusis also lentigines and presbycusis. When planning care for this occurs in normal aging. These changes do not require medical attention or interventions for client, the nurse should do which of the following? vision or temperature.
| When answering questions, look for all parts of the answer to be correct. |
4744 The nurse prepares to teach a class about normal Correct answer: 3 A normal body temperature of an older adult person may range from 96.5 degrees to 99 aging changes to a group of nursing assistants. The degrees F (35.9 degrees –37.3 degrees C). Therefore, a temperature of 98.6 degrees F (37 nurse should select which of the following techniques degrees C) may signify a fever in an older person. Incontinence is not a normal age‐related as most appropriate? change. Not all older adults have altered mobility needs, and those who do are more likely to use a cane or walker than crutches (which are used for injury). Use of blood glucose devices is generic or related to a diagnosis of diabetes and is not specifically related to normal aging changes.
| Eliminate choices that do not correlate to all parts of the question as well as those choices that have incorrect information. |
4745 A nurse evaluates that the care plan related to Correct answer: 4 With normal aging, there is loss of cartilage and joint fluid. Overall wear and tear does occur. normal physiologic changes has been effective for a 70‐ Sebaceous glands are less active, and older adults sweat less. There is a decreased need for year‐old client if he says: sleep, with shorter REM and non‐REM sleep cycles. Social support may decrease with deaths and fewer resources but does not relate to the question of physiologic needs.
| Read all choices and using nursing knowledge eliminate incorrect ones. |
4746 After conducting a physical assessment, the nurse Correct answer: 3 With normal aging changes, there is a decrease in vision, hearing, touch, smell, and taste. would conclude that a 75‐year‐old client’s ability to These changes can lead to falls, inability to leave a situation when called to do so, inability to maintain personal safety would be most adversely distinguish temperature with resulting burns, inability to smell smoke in a fire, and inability to affected by declining function in which of the following taste contaminated food. These changes can have a major impact on the safety needs of an systems? older adult.
| When answering questions related to development and aging, distinguish between normal development, which affects all, and illness, which affects some. |
4747 A 75‐year‐old woman with a pathological fracture of Correct answer: 4 Osteoporosis, a decrease in bone density, makes the older adult more prone to pathological the arm asks, “How did I get a broken bone?” The fractures. Decreased mobility, osteoarthritis, and scoliosis do not cause pathological fractures. nurse most appropriately responds by saying that Scoliosis is a curvature of the spine, usually diagnosed in adolescents. which of the following is the most probable reason for the fracture?
| Correlate the best reason with the choice. |
4748 Which nursing intervention would be most Correct answer: 1 Because of loss of skin receptors, the older adult has an increased threshold to pain, touch, appropriate to meet safety needs when caring for an and temperature. When feeding or bathing, remember that the older adult may be unable to older adult with sensory changes? distinguish hot or cold or to determine the intensity of heat. The older adult may feel less pain than younger adults and complain of only pressure or a minor sensation. The older adult, however, is the only one who can identify if they have pain or not. An older client’s sensory perception is less acute than that of younger adults, so when giving a massage, less pressure is needed. Everyone, and especially the older adult, needs touch.
| Imagine giving the stated care to assist in choosing the correct answer. |
4749 The nurse explains to children of aging parents that it Correct answer: 3 Promoting independence is a basic nursing principle. Older adults thrive on independence, is important to remember that most older adults: even with limitations. Older adults make their own decisions and do not appreciate others making decisions for them. Although some older adults cherish a family role, this is not necessarily the wish of every older adult. Remaining active is important for older adults; unnecessary protection from injury is inappropriate.
| Recognize that usually, the word all denotes an incorrect choice. |
4750 After teaching a driving safety education program for Correct answer: 4 Driving at night requires caution because accommodation of the eye to light is impaired and the older adult, a nurse should recognize which of the peripheral vision is diminished. Keeping the inside of the car warm at all times is not a following as evidence of a favorable response by an significant issue when driving during the day or in warm climates. Reflexes are slowed for older older adult when driving? adults; thus, caution in driving should be emphasized for this group.
| The phrase favorable response. cues you to look for the desired outcome. |
4751 A nurse teaches an older adult client about misuse of Correct answer: 4 Taking medications on time and, if a dose is missed, taking the next one on time indicates medications. Which of these observations would proper self‐administration. Misuse of medications by older adults include combining indicate that the teaching was effective? prescribed and over‐the‐counter medications; having prescriptions from different physicians and failing to tell each doctor what has previously been prescribed; and taking someone else’s medications.
| The phrase "would indicate that the teaching was effective," means the choices will have three incorrect outcomes and one desired outcome, which will be the correct choice. |
4752 Which of these instructions, if included in the care Correct answer: 4 Interrupting the flow of urine assists the external urethra to contract and strengthens pelvic plan for an older adult who has “leaking urine,” would floor muscles. Other actions involve assessment activities. be most effective in strengthening pelvic muscles?
| Distinguish choices related to actions, assessment, implementation, and correlate to answers. |
4753 A nurse has selected a transparent film dressing for a Correct answer: 4 Transparent film dressings on a clean, noninfected wound can be left in place for days, until stage 2 pressure ulcer. The nurse will change the the seal is broken, exudate leaks out, or the edges roll up. Older adults are at risk for skin dressing breakdown. A nurse needs knowledge of what dressings are chosen and when they are changed.
| Consider the choices; when there are similarities, some choices can be eliminated. |
4754 Which clinical manifestation would be significant Correct answer: 1 Ecchymoses are not the result of aging. when assessing the skin of an 85‐year‐old client?
| The phrase would be significant indicates abnormality, so that is the choice you are looking for. |
4755 An older adult client is admitted to an extended care Correct answer: 3 Prealbumin is a sensitive indicator of changes in nutritional protein status. Serum albumin can facility for follow‐up care of a total hip replacement. provide data about visceral protein stores but has a relatively long half‐life and may not The nurse assesses a BMI of 20, lackluster hair, and accurately reflect recent protein losses. Prealbumin can also alert the nurse to clients at risk pallor. Which laboratory assessments will the nurse for pressure ulcer development. review to obtain the most sensitive information about the client’s current nutritional status?
| Apply knowledge from other areas to choose the correct answer. |
4756 On admission, a 78‐year‐old client states he uses Correct answer: 3 The gastrointestinal system is the system that most older adult clients have complaints about, laxatives three times a week for constipation. The yet it remains the healthiest system over time with proper diet and care. Prolonged use of nurse would respond: laxatives can lead to dependence on them for stimulation of defecation and can actually lead to uncontrollable defecation.
| Choosing the correct response requires use of nursing knowledge, not reliance on myths. |
4757 The care plan for a client who has severe Correct answer: 2 Severe osteoporosis causes bone density loss, which can result in pathologic fractures when osteoporosis should include which intervention to the client is moved. A lift sheet can reduce the risk. The other choices do not address this prevent injury? safety issue.
| Narrow your choices to the question asked. |
4758 Which of these assessment findings in an older adult Correct answer: 3 Posture changes shift the center of gravity in an older adult client and put the client at risk for client should alert the nurse to an increased risk of falls. The other conditions increase the risk of injury if a fall occurs but not the risk of falling. falls?
| Read the question carefully and use similarities in the question stem and the answer to make a selection. |
4759 The nurse is irrigating the ears of an older adult man Correct answer: 1 Motion receptors can be stimulated with instillation of large amounts of fluid. Nausea or with a cerumen impaction. The nurse would stop the vomiting would be stimulated. Relief will occur if the irrigation procedure is stopped. procedure if
| The correct choice is the only answer that does not involve the ear or irrigation procedure directly. |
4760 An older adult client is receiving the third unit of Correct answer: 3 Older adult patients are at risk for developing fluid overload during fluid therapy, especially packed red blood cells in the last 8 hours. One hour when receiving multiple units of PRBCs. The infusion rate should be slowed to as low as into the third transfusion, the nurse observes the possible to prevent worsening of the problem. Then assess the vital signs. patient’s distended neck veins. What is the next action the nurse would take?
| Visualize care to determine first, second, third, and fourth action order. |
| |
4761 A nurse is assessing an older adult client who is at risk Correct answer: 2 Assessing cyanosis on older adult clients can be difficult, especially if they have darker skin. for shock. The nurse will effectively assess for cyanosis Fingernails and toenails can have ridges, fungal infections, and yellowing. The oral mucous on the membranes are the site where cyanosis and pallor are most obvious.
| Answering this question requires use of critical thinking. Information given in reference to anemia and fluid volume teaches use of mucous membranes for assessment. Focus on the word cyanosis in the stem of the question, and recall age‐related changes to aid in selecting an answer. |
4762 A licensed practical nurse (LPN) reports that there is Correct answer: 3 The elderly lose tissue elasticity in the hand, so accurate assessment about turgor and tenting on the back of an 85‐year‐old client’s hand. hydration cannot occur in this area. Better areas for assessment include the skin of the What is the next action that the registered nurse (RN) forehead, chest, and abdomen. The other actions are unnecessary (options 1 and 2) or not yet should take? timely (option 4).
| Understanding of normal developmental changes and abnormalities related to alterations in health is critical to care of the elderly. Assessment of turgor on the client’s chest will reveal abnormalities related to hydration status versus tenting of the hand, which is a normal aging change. |
4763 A nurse would assess for fluid‐and‐electrolyte Correct answer: 3 Laxatives can alter fluid‐and‐electrolyte balance. Dry skin is normal with aging. Occasional imbalance if an 80‐year‐old client made which dribbling of urine is not a normal finding, but is not likely to cause a fluid‐and‐electrolyte statement? imbalance. Drinking adequate fluids, as in option 4, will aid in maintaining normal fluid balance.
| Nurses detect and predict abnormalities. Chronic use of laxatives can cause excessive fluid and electrolyte changes. Dry skin can be a normal age‐related change. Dribbling urine is a problem, but will not alter fluid and electrolytes. |
4764 A postmenopausal woman asks the nurse what she Correct answer: 4 Daily weight‐bearing activities reduce reabsorption of calcium from the bones. The other can do to reduce her risk for osteoporosis. The nurse choices do not affect bone structure. would suggest:
| Although any of the choices could contribute to health, a weight‐bearing exercise is the only intervention that can reduce osteoporosis. A student could prepare a table that correlated preventative health behaviors to specific disease outcomes as an effective learning tool. |
4765 An elderly client with sensory deficits is scheduled for Correct answer: 3 Extra time is needed for teaching and reinforcement of content when an elderly client has surgery. The nurse would: sensory deficits, especially visual and hearing deficits. The other care activities described would be carried out as needed by any client.
| Recall normal principles of aging, and then apply them to specific health care interventions. |
4766 The nurse empties 100 mL of sanguineous drainage Correct answer: 1 A Hemovac drain removes fluid from the wound through closed suction. The drain must be from a Hemovac drain in the elderly client’s hip after a compressed and closed to create suction as it slowly re‐expands. No treatment change is total hip replacement. What other actions regarding needed specifically because the client is elderly. the drain should the nurse take?
| Understanding the effect of being elderly on basic surgical wound care is important. Wound healing might differ because of age, but a Hemovac or other drain will require similar care no matter what the age. The other choices are inappropriate. |
4767 A 90‐year‐old client stepped on a nail, and has a deep Correct answer: 1 Tetanus strains do not usually change from year to year. As humans age, there is a decline in puncture wound. The nurse is preparing to administer natural antibodies, a decreased response to antigens, and a reduction in antibody response a tetanus toxoid vaccination, and the client states, “I time. The vaccination will act as a booster to the one administered five years ago. don’t need a shot. I had one five years ago.” What is the best response by the nurse?
| Communication is critical in health care. When situations arise where a response is required, the nurse listens, clarifies, and gives information so that safe, effective care is given to the client. Options 2 and 4 provide incorrect information that would promote fear within the client. The registered nurse does not “pass the buck,” but rather clarifies and provides appropriate information to the client, so choice 3 is not correct. |
4768 A 65‐year‐old woman states that she is afraid to visit Correct answer: 3 Herpes zoster, or shingles, is an infection that is seen in later life from residual virus retained her grandson, who has chickenpox, because she does in the dorsal root ganglia of sensory nerves after a client has had varicella or chickenpox. not want to get shingles. The nurse would respond: Usually, shingles occurs whenever the client is immunocompromised. The elderly easily can become immunocompromised. Shingles is not transmitted from a person with chickenpox.
| Nurses entering the work force today need to understand common disease transmission. Shingles is a painful disease that predominantly affects the elderly population. Elimination of incorrect answers reveals the only correct choice. |
4769 An elderly client had a hip replacement 24 hours ago. Correct answer: 4 The client is the only one who can tell you if he is in pain. Confusion and being asleep do not How should the nurse conclude that the client does mean that the client is not in pain, or that he shouldn’t receive pain medications. Being not need pain medication? medicated three hours earlier does not mean he is pain‐free, or that he shouldn’t receive pain medication.
| Understanding the concept of pain as a subjective experience of which the client must communicate the true experience to you is critical to nursing practice. This principle crosses all ages. Ageism can prevent choosing the correct answer. |
4770 A 90‐year‐old client is brought to the Emergency Correct answer: 2 Elderly clients do not present with typical manifestations of infection. Confusion or behavioral Department (ED) and diagnosed with bacterial changes from hypoxia might be the first signs of pneumonia in the elderly. Sputum rarely is pneumonia. Which clinical manifestation would the seen unless a sample is obtained through suctioning, as coughing is diminished in the elderly. admitting nurse on the medical unit expect to find? Tenting of the back of the hand is normal aging, and does not indicate dehydration.
| This is a principle of aging that nurses apply in the health care setting. Remembering a case study about an elderly client with pneumonia might enhance retention of content and correct application in testing and clinical situations. |
4771 When assessing an elderly client’s respiratory status, Correct answer: 3 A diminished inflammatory response and muscle age cause the clinical manifestations of what information does a nurse remember about fever and cough to be absent in elderly clients with pneumonia. Atypical presentations are the pneumonia in the elderly? norm.
| The wording of the question calls for specific knowledge of the older adult with a respiratory infection. Use general principles of age‐related changes as the key to selecting the correct option. |
4772 Which of the following would be the best approach Correct answer: 4 Elderly clients might have presbycusis, and might not hear sounds like “sw,” “th,” or “m” well. for a nurse to use to verify understanding of Validation confirms appropriate understanding. Speaking to elderly clients with presbycusis in instructions about how to take oral Nystatin given to a low‐pitched tone also assists hearing. an older adult client with presbycusis?
| Some test questions require to a student to demonstrate understanding of multiple layers of content. In this question, you must define presbycusis, apply principles of normal aging, and know how to administer Nystatin. |
4773 When teaching a daughter of an older adult client Correct answer: 3 Maintenance of independence in all clients is a foundation of nursing practice. Strategies about behavior that should be encouraged, which within the environment and adaptive devices can help the elderly maintain their independence information should the nurse give the daughter? if disorders occur.
| Differentiating between ageism and promotion of independence within boundaries of safe practice helps to reveal the answer to this question. |
4774 The nurse would plan to teach a client who will be Correct answer: 4 Gastrointestinal absorption of digoxin is uneven. Many medications interfere with absorption. starting drug therapy with digoxin (Lanoxin) to do Digoxin should not be taken if the pulse rate is below 60 beats per minute. Aspirin may be which of the following? taken with digoxin; however, aspirin should not be combined with anticoagulants.
| These principles apply to all clients receiving digoxin. Knowledge of common medications, nursing implications, adverse effects, and common dosages is critical to successful NCLEX results and clinical practice. |
4775 A 70‐year‐old client will be started on medication Correct answer: 3 Most over‐the‐counter cold remedies contain sympathomimetic medications within the therapy for hypertension. The nurse will plan to teach preparation, which will increase blood pressure. the client which of the following?
| When choosing the answer, read all of your choices to assess which is the most correct or best choice. This is critical thinking at its best. |
4776 A nurse teaches an elderly client about signs and Correct answer: 3 Falls can be one of the first signs of infection in the elderly, and should be investigated to rule symptoms of infection. Which of these statements out infection, as well as cardiac, neurological, or musculoskeletal disorders. A temperature of would indicate that the teaching was effective? 36.5 degrees Celsius is normal in an elderly person. If other signs/symptoms of infection exist, and temperature is normal, this should still be investigated, as the elderly might not present with elevated temperature. Ingestion of aspirin every two hours or 8,000 mg of vitamin C is not safe.
| Falls have many etiologies or reasons for occurring. They might have cardiac, neurologic, or musculoskeletal etiologies, but in the elderly, they also could be a sign of infection. This is important in clinical assessment, as well as when answering exam questions. |
| |
4777 The nurse concludes that a 67‐year‐old client is Correct answer: 1 Integrity (instead of despair) is being demonstrated in the statement in option 1. According to exhibiting normal growth and development according Erickson, adults who do not achieve the tasks of middle adulthood will focus on themselves, to Erickson’s theory of development after the client becoming overly concerned about their own needs. Peck expands on this theory too. makes which statement?
| When reviewing the answer options, look for words such as every, only, or everyone; these are usually incorrect choices. |
4778 An 80‐year‐old client reports pain in the chest, Correct answer: 4 These are physiologic symptoms of aging heart muscles and potential cardiac disease. No shortness of breath, swelling of the feet, and rapid chest pain is acceptable. Chest pain should always be a 0 out of 10 on a pain rating scale. heartbeat. The health care team intervenes. Which outcome statement for the plan of care would a nurse write?
| Understanding of basic medical–surgical concepts is important to all developmental levels and age groups. Application of some concepts will be the same in any age group. |
4779 An elderly client is experiencing patterns of Correct answer: 2 More data are needed. Nurses collect information and don’t “pass the buck,” as choice 4 forgetfulness, and asks the nurse if he has Alzheimer’s allows. Nurses do not diagnose disease but rather the human responses to disease. Clients disease. The best response by the nurse would be: with Alzheimer’s disease experience patterns of forgetfulness and progressive confusion, and cannot perform daily activities. A client would do more than forget where she placed the keys, such as not know what keys are for.
| Decreased cognitive ability and memory loss are emotional topics. Assessment is critical before information can be given, so that accurate and appropriate information is provided when emotional topics are discussed. |
4780 An elderly client is hospitalized for treatment of an Correct answer: 3 Elderly clients often are confused by new surroundings, and require orientation to units. Not infection. When planning for the care of this client, the all infections require isolation, and not all elderly clients are incontinent or malnourished. nurse will: These are individualized responses to disease, not general rules of aging.
| This is a common occurrence, and does not mean that cognitive disorders are present. Both nurses and assistants provide daily orientation to the environment and planned activities. The other choices do not correspond to all clients, so 3 is the best choice. |
4781 Older adults are predisposed to fluid imbalances for Correct answer: 1, 2, 3, Options 1–4 are correct. Options 1, 2, and 4 correspond to fluid intake. Answer 3 corresponds which of the following reasons? Select all that apply. 4 to fluid volume changes related to sodium and osmosis of fluid from higher to lower concentrations. Option 5 (that older adults dislike water) is not necessarily true.
| These types of questions represent the thinking and work a nurse will do in the clinical. Answer these questions correctly by “picturing” the statement when reading the choices. Visualizing the theory or actions helps to determine if it is correct or not. |
4782 The clinic nurse predicts that which of the following Correct answer: 1 Both REM and non‐REM sleep are critical to physiological and psychological rest. Five to seven clients will have an older physiologic age? hours per night is recommended. The other behaviors are healthy behaviors.
| It is important to read the stem carefully, and then the choices. The stem is asking for why someone ages faster. Options 2–4 describe activities that slow aging, leaving choice 1 as the reason why people might have an older physiologic age. |
4783 A nurse who wishes to assess a client’s overall muscle Correct answer: 2 Hand grip strength correlates with strength of other muscles, and therefore is a good strength quickly and effectively will best do this by indicator of overall strength. The other assessments require additional time or do not assessing the client’s: correlate well with overall muscle strength.
| Within the stem are the words “quickly and effectively,” leaving option 2 as the most appropriate answer. |
4784 A nurse is instructing a client about cataract Correct answer: 1, 2, 4 Ultraviolet light, injury, and viral infections increase the incidence of cataract development. prevention. The nurse will instruct the client that The nurse recommends the use of sunglasses, eye protection, and safety throughout the life which of the following increase the incidence of span. Vitamin A and eyestrain do not increase the risk of cataract development. cataract development? Select all that apply.
| It is important to learn more than one response when studying risk factors for diseases and disorders. |
4785 An elderly client has fallen twice while getting up to Correct answer: 3 This is the only appropriate choice. Aging eyes require additional light and time to adapt to go to the bathroom at night. The nurse implements light to see effectively. Use of the call bell will provide assistance so that falls are prevented. which of the following to decrease the risk of further Four side rails are considered a form of restraint, as is chemical sedation. client falls?
| Choices 1, 2, and 4 are inappropriate nursing actions. |
4786 A nurse has taught a group of senior citizens about Correct answer: 1 Older adults need increased fiber, calcium, and vitamins C and A. They also need to decrease age‐related nutritional needs. The nurse knows the the number of calories taken in. Margarine contains trans‐fatty acids, which have been linked teaching was effective if a client states: to heart disease and cancer. Canned foods and prepared package foods contain large amounts of sodium, which could adversely affect the cardiovascular, fluid‐balance, and elimination systems.
| It is important to read all of the components of each option. When picking the correct option, all the components of that option must be correct. |
4787 An elderly female client has a history of Correct answer: 4 Most elderly clients have a slower rate of drug metabolism and excretion, resulting in more arteriosclerosis, hypertension, emphysema, and frequent drug toxicities at normal and higher doses. Many prescribed medications are effective arthritis. Her medications include digoxin (Lanoxin), at lower dosage levels. furosemide (Lasix), and aspirin. The nurse would expect that the client’s medication needs would include:
| This requires knowledge of physiology and application in the elderly. The names of the medicines could be changed. |
4788 A nurse develops a plan of care for an elderly client Correct answer: 3 Assessment is the first step in planning care with the client. Assessment will guide how blood who has been diagnosed with type 2 diabetes mellitus. glucose monitoring will be done, and by whom. Independence should be fostered; dependence What would the nurse write as the first step of the will have a negative effect. plan?
| Utilize fundamental principles of nursing process combined with knowledge about the process of teaching and learning, which requires assessment to be done before other actions are implemented. |
4789 A nurse is doing preoperative teaching for an older Correct answer: 3 Following cataract surgery, the client should not do anything that will increase intraocular client who will have cataract surgery on his right eye. pressure. Bending at the waist will increase the pressure; sleeping on the opposite side of The nurse concludes the client needs further teaching surgery and non‐vigorous care of nasal congestion will not. The physician should be notified of if he says: increased pain and fever, as intervention might be required.
| Reading all the answers and using the process of elimination can guide you to the “correct” answer, which is the wrong care when “needs further teaching” is in the stem of the question. |
4790 An older adult client with osteoarthritis is scheduled Correct answer: 3 Appropriate use of our health care system allows needs to be met. Many clients might for discharge. The client says: “I don’t know if I will be require direct care, or reinforcement of learning and application, in the home environment. able to remember all that you have told me. I live Keeping clients in the hospital when home care is available is not an appropriate use of alone, and am not sure what pills to take or when to resources; neither is asking the pharmacist to call the client at home to take medicine. Asking do the treatments.” What is the next action the nurse daughters, sons, or significant others to rearrange their lives might not be the first choice if would take? home care is available and chosen by the client.
| Application of development and knowledge of the health care system can help you to pick the best answer. |
4791 A nurse is conducting a health screening fair for Correct answer: 1 Risk factors for osteoporosis include being female; being amenorrheal with a BMI under 24; osteoporosis. The nurse determines that which of the being postmenopausal; being older; a diet low in calcium and vitamin D; excessive alcohol following clients is at greatest risk of developing intake; being sedentary; smoking cigarettes; being obese or too thin; and using meds such as osteoporosis? steroids, anticonvulsants, or loop diuretics on a long‐term basis.
| Understanding and application of risk factors will help to identify the client with the most risk factors. When choosing an answer, all choices within the answer must be correct. |
4792 The nurse selects which of the following as the most Correct answer: 2 With iron‐deficiency anemia, it is important to select dietary items that are high in iron to appropriate dietary menu items for a client with iron‐ counteract the deficit. Red meat tends to be high in iron, as do some green, leafy vegetables. deficiency anemia? Although options 1 and 4 contain salad greens (and therefore are green, leafy vegetables), the other components of these meals are not as high in iron. Lasagna and carrots (option 3) are not as high in iron as the other choices.
| The critical words most appropriate indicate that more than one option may contain iron, but you must pick the total meal selection that is best. Recall that iron is found in red blood cells to help focus on a dietary item such as red meat. Recall that green vegetables are also helpful to confirm your selection. Thus, option 2 is the only option that contains two good sources of dietary iron. |
4793 When discharging a client on oral anticoagulant Correct answer: 1 The oral anticoagulant drug is sodium warfarin (Coumadin), and its action can be limited by therapy, the nurse would include further teaching for excessive intake of foods containing vitamin K. Since green, leafy vegetables are high in vitamin the client who has a lifestyle that includes which of the K, the nurse needs to counsel this client about the possible antagonistic effect of these foods following? with the medication. Walking, rural living, and spending time alone pose no particular risk to the client.
| The core issue of the question is oral anticoagulant therapy. With this in mind, review each option for an item that will have either an antagonistic or additive medication effect. Choose option 1 because it could lead to antagonistic effect. |
4794 The chronic renal failure client states, “I don’t eat red Correct answer: 4 The client in renal failure needs balanced nutrition, and fish is often acceptable to clients who meat.” After further discussion with the client about do not eat red meat. Option 3 is less appropriate because crackers are not nutrient‐dense what foods are acceptable, the nurse would foods. Options 1 and 2 contain high amounts of sodium or potassium, which are not helpful to recommend which of the following meal choices to the the client in renal failure. client?
| Focus on the two core issues in the question: the client is in renal failure, and the meal choice must be acceptable to the client who does not eat red meat. Eliminate meal choices that contain meat and/or high amounts of salt and potassium, which must be limited because of renal failure. |
4795 The nurse is most concerned with providing further Correct answer: 4 The client who has diabetes needs to have regular meals that are evenly spaced throughout teaching for the client with diabetes who does which the day and may need to supplement meals with snacks. Eating six meals per day is excessive of the following? and could lead to inadequate glucose control. Options 1 and 2 pose no risk as long as they are in the client’s meal pattern. Option 3 is acceptable as long as the client ensures that the fruit is packed in water instead of syrup.
| Use principles of general dietary planning and calorie control to answer the question. Remember not to “read in” information into the question or the options, especially option 3. |
4796 The nurse explains to a client who has had all molars Correct answer: 2 By the third postoperative day, the suture lines from the teeth extraction should be beginning removed that he will likely be allowed which of the to heal, and the client should be able to manage soft foods. With this in mind, option 2 following foods added to the diet by the third provides the client with carbohydrates and a protein source for healing in a soft form. Options postoperative day? 1 and 3 contain items (bacon and cereal, respectively) that could be scratchy and irritate the suture lines. Option 4 would be appropriate the day after surgery while the suture lines are still new.
| Keep in mind principles of healing and principles of nutrition needed for healing to make a selection. The correct option is the one that combines appropriate nutrients and a soft form that can be tolerated by the client. |
4797 When the nurse assesses the intake of a vegetarian Correct answer: 4 Problems with vision may be attributed to vitamin deficiency, especially vitamin A. This client’s health and dietary patterns, which finding does finding could adversely affect the client’s health status and requires follow‐up by the nurse. the nurse conclude is most likely to negatively affect Options 1 and 2 will not adversely affect health status. Option 3 has a lesser chance of health status? adversely affecting health status, since it is a familial risk and not a personally identified problem.
| Use knowledge of components of a balanced diet to eliminate options 1 and 2. Choose option 4 over 3 because actual problems take priority over potential problems. |
4798 Which of the following clients is most at risk for skin Correct answer: 1 The older adult client has more years of living to increase risk of skin cancer from exposure to cancer? the sun. In addition, the farmer wears a cap, but no mention is made of protectant sunscreens or long‐sleeved shirts and pants. The clients in options 2, 3, and 4 have lesser risk because there are physical barriers to the sun identified in each option: sunscreen, umbrella, and ski outfit.
| First recall that exposure to ultraviolet light is a risk for skin cancer. Use the process of elimination while considering which option provides the least sufficient barrier to exposure to ultraviolet light to make your selection. |
4799 During a health fair at a public recreational park, the Correct answer: 2 Ultraviolet light exposure greatly increases risk of skin cancer, both basal cell and melanoma nurse providing cancer health risk information answers types. While direct sunshine contains ultraviolet light, the amount is decreased in indirect light. several questions for clients who use ultraviolet light The use of suncreen can reduce the risk of cancer but not “prevent” it. Option 4 is a global tanning salons. Which piece of information is most statement that may or may not be true depending on the disinfectant methods used. important to include?
| The core issue of the question is which option provides the most accurate and important information about ultraviolet light exposure. Eliminate options 3 and 4 first because they are not necessarily correct all of the time, and choose option 2 over option 1 because option 1 is false. |
4800 When giving postoperative care to a 30‐year‐old male Correct answer: 2 The priority for this client is to learn and begin to perform testicular self‐exam on a monthly client, the nurse discusses cancer risks. The client basis. Option 1 is insufficient in timeframe, and a physician does not need to perform the states, “I have never heard of testicular exams.” The screening. Options 3 and 4 are positive but general measures and do not target the immediate nurse should include which of the following priority need of the client for information related to detecting testicular cancer. interventions in the plan of care?
| Use the process of elimination and knowledge of cancer risk to make a selection. Note that the question and both options 1 and 2 refer to testicular examination, which gives a clue that one of them may be correct. Choose option 2 over 1 for frequency and accuracy of the statement. |
4801 When a client comes into the emergency department Correct answer: 2 Two common and key factors that increase risk of constipation are a diet that is low in fiber (ED) with complaints of constipation and abdominal and fluids and inadequate exercise to stimulate bowel motility, which could lead to impaction pain, which of the following would be the most and abdominal pain. Option 1 is partially correct; diverticulitis is something to assess for but is common risk factors to assess for? not as frequently an etiology as inadequate exercise and low‐fiber diet. In addition, diverticulosis does not give rise to signs and symptoms. Upon diagnostic workup, the client’s symptoms could be attributed to diverticulitis, but this is not as frequently found as constipation as an etiology. Options 3 and 4 are general assessments that are either irrelevant to the client’s complaint (option 3) or too vague to be correct for this question (option 4).
| Note the critical words most significant in the stem of the question. This tells you that more than one option is likely to be correct and that you must choose the best option, which in this case is the most frequent cause. |
| |
4802 When teaching a 30‐year‐old male about testicular Correct answer: 4 It is not normal to have one testicle that does not remain descended into the scrotal sac. The exams, the nurse recognizes more education is needed client needs to see a primary care provider for this health problem. Each of the other when he states: statements related to testicular self‐exam (TSE) are true.
| The critical words in the stem of the question are more education is needed, which tells you that the correct answer is an incorrect statement. Use the process of elimination and knowledge of TSE. |
4803 The ambulatory care nurse working with adolescent Correct answer: 4 Testicular cancer is most likely to affect late adolescent and young adult males. An and young adult male clients determines that the undescended testicle is one risk for testicular cancer. The client who wears protective gear is client most at risk for testicular cancer is which of the not at increased risk, nor is the client who swims. A familial history of colon cancer does not following? increase specific risk of testicular cancer because colon cancer occurs at a different site.
| Use the process of elimination, focusing on the core issue of the question, which is risk factors for testicular cancer. |
4804 The nurse is participating in a health promotion fair. Correct answer: 2 Each client should exercise at least 3 days per week for a minimum of 30 minutes in order for When discussing aerobic exercise, the nurse should exercise to be effective. Fast walking is a good form of aerobic exercise. If one cannot speak include which of the following points? when exercising, it is too strenuous and should be decreased in speed or amount.
| The core issue of the question is characteristics of effective aerobic exercise. Use the process of elimination and remember “3‐30,” which is the frequency in days and the minutes per session, to rule out some distracters. Choose walking as an extremely effective exercise as the correct answer. |
4805 A postmenopausal client is just learning to do breast Correct answer: 3 The client needs to perform BSE once per month, on the same day each month. The client is self‐examination (BSE). To aid in remembering to encouraged to associate performing BSE with another monthly activity, such as paying bills, or perform the procedure, at which of the following times to do it on the same calendar date each month (such as the first). The other statements should the nurse recommend that the client perform represent incorrect timeframes. BSE?
| Use the process of elimination and note that the core issue of the question is frequency and timing of BSE. Because the client is postmenopausal, look for the monthly option that is not associated with menses (as none are in this question). |
4806 A school nurse has finished conducting a teaching Correct answer: 3 BSE should be performed once per month, 1 week after beginning menstruation. At this time, session with high school girls about breast self‐ the breasts are least likely to be tender and/or swollen from the effects of hormones. At examination (BSE). The nurse concludes that the ovulation and menstruation, hormonal changes are likely to interfere with accurate palpation information was learned correctly when one of the of breast tissue. Performing the exam on the first of the month is recommended for girls states to do the exam at which of the following postmenopausal women who do not need to be concerned with changes in hormone levels times? associated with the timing of the menstrual cycle.
| The core issue of the question is knowledge that accurate BSE results depend on the exam being done without the interference of hormonal factors that could alter the results or make the BSE difficult to perform. With this in mind, each of the incorrect options can be eliminated using the influence of hormones as a guide. |
4807 An older adult female client has osteoporosis. In Correct answer: 4 Although all of the exercises listed are aerobic and therefore beneficial, the older adult client counseling the client about the best form of exercise, with osteoporosis needs to select an exercise that has a weight‐bearing component and yet the nurse would recommend which of the following? does not stress the joints. Such an activity will help to retain calcium in bone and reduce the rate of bone loss to osteoporosis. Walking is an aerobic exercise that does not stress the joints of the legs. Swimming and stationary cycling are not weight‐bearing exercises. Jogging could harm the knee and ankle joints and is not a preferred method of exercise for this client.
| The core issue of the question is the type of exercise that is appropriate for a client with osteoporosis and who is an older adult. With this in mind, eliminate swimming and stationary cycling as nonweight‐bearing, and eliminate jogging as increasing stress on joints in the leg. |
4808 The nurse working in a prenatal clinic concludes that Correct answer: 2 Sickle cell disease has an onset in childhood. This makes it the priority for genetic counseling. genetic counseling would be most important for the The other disorders listed (coronary heart disease, type II diabetes, and hypertension) are client who has a family history of which of the adult‐onset problems and therefore have lower priority. following disorders?
| Note that the stem of the question contains the critical words "most important." This means that all of the options may represent conditions for which some genetic counseling may be useful, but you must select the option that has highest priority. Use age at onset as a means of making your selection. |
4809 A 20‐year‐old female sees the health care provider Correct answer: 1, 3, 5 A body mass index (BMI) measurement is done at age 20 and at each health visit. Serum for her first adult physical examination. The nurse cholesterol levels are started at age 20 and are recommended every 5 years. Blood glucose anticipates that which of the following screening screening is recommended to begin at age 45 unless there is evidence of higher risk for measures will be done at this visit as a baseline for diabetes. Colorectal screening begins at age 50 and is done every 1 to 10 years depending on further reference? Select all that apply. method used. Clinical breast exam is done starting at age 20 and may be done every 3 years or more frequently depending on risk. Mammography is done yearly starting at age 40.
| Specific knowledge of frequency of recommended health screenings is needed to answer the question. Use the process of elimination, and review this content area if needed. |
4810 A 4‐year‐old client is coming to the health care Correct answer: 1, 2, 5 Blood pressure and vision screening are started at age 3 and continue with each visit. Hearing provider’s office for a well‐child visit. Which of the screening begins at age 4. Lead screening would only be done on an as‐needed basis for a 4‐ following routine screenings does the nurse plan? year‐old. Hemoglobin and hematocrit are done at 12 months and as needed (which may be Select all that apply. annually for females during adolescence). Urinalysis is done at age 5, in adolescence, and otherwise only as indicated.
| Specific knowledge of frequency of recommended health screenings is needed to answer the question. Use the process of elimination, and review this content area if needed. |
4811 Which of the following symptoms that are important Correct answer: 1, 2, 3, Painless swelling of scrotum, dull pain in scrotum, nodules between testes and cord, and to report would the nurse include in teaching about 4 dragging sensation in scrotum are signs of testicular cancer. A reddened rash or feeling of manifestations of testicular cancer? Select all that wetness in the scrotum are not applicable to this diagnosis but should be followed up for apply. general health reasons.
| Specific knowledge of manifestations of testicular cancer is needed to answer the question. Use the process of elimination and review this content area if needed. |
| |
4812 When teaching a group of adults about health Correct answer: 1, 3 Genetic screening can identify markers for several types of cancer. One method of reminding promotion practices, the nurse would include which of men to perform self‐checks for cancer is for them to mark on a calendar to do a monthly check the following? Select all that apply. for changes. Self‐exams as well as medical tests and exams uncover tumors. After a total mastectomy, women do not need mammograms. Colonoscopy is generally recommended once a client reaches age 50.
| Begin by eliminating option 4 as unnecessary and option 5 as a false statement because the timeframe is too early. Next look suspiciously at the phrase “most tumors” to eliminate option 2. Words such as “most” or “all” in options make them incorrect in many cases. This leaves options 1 and 3 as correct. |
4813 During a health fair at a public recreational park, the Correct answer: 1 Tanning from ultraviolet light, even in new tanning beds, is not safer than tanning from sun nurse provides cancer health risk information to a rays. The statements in the other options are true. Skin damage is more likely to occur when a group of individuals who indicate that they frequent client is in direct sunlight. Sunscreens are recommended in tanning beds, and proper cleaning ultraviolet sun tanning salons. Which statement by one of tanning beds will help prevent the spread of infection. of the attendees would lead the nurse to provide additional information?
| Think about what ultraviolet light means. It is powerful and damages skin whether it comes from the sun or from technology such as tanning beds. |
4814 The nurse is most concerned with providing further Correct answer: 4 A client with diabetes should follow the prescribed dietary plan, which usually includes three teaching for the diabetic client who states that he: meals and one or more prescribed snacks. This meal plan will help to maintain a blood glucose level within normal limits (with the addition of exercise and perhaps oral antidiabetic medication or insulin). Eating six meals per day is likely to lead to excessive calorie intake and hyperglycemia. Drinking orange juice (option 1) and eating an apple and cheese before bedtime (option 2) are acceptable and require no follow‐up by the nurse. Buying canned fruit (option 3) should trigger the nurse to question whether it is packed in water, juice, or syrup, but this is the second concern after questioning about the number of meals eaten.
| The critical words in the question are “most concerned.” This means that more than one option may be partially or totally correct and that you must prioritize your answer. Eliminate the alternatives that are within the ADA diet exchanges, such as options 1 and 2. Choose option 4 over option 3 because it poses a greater risk to maintaining euglycemia. |
4815 The ambulatory surgery nurse is providing discharge Correct answer: 4 Because the client has had all molars removed and the designated timeframe is the third teaching to a client who has had all molars removed. postoperative day, the client should be able to eat a mechanical soft diet, which includes The nurse explains that the client should be able to eat gelatin and applesauce. A soft diet that requires no chewing will be necessary until molars are which of the following foods on the third post‐ replaced, and it is especially necessary to use caution until the gumlines have healed. Foods operative day? that require more chewing or are rougher in nature, such as toast, bacon, fresh fruit, and cold cereal, should be avoided until further healing has occurred.
| Think about where all molars are and the textures of the foods in the options. Toast, bacon, cold cereal, and eggs all require chewing and would be difficult for the client to manage on the third postoperative day. Recall that gelatin and applesauce are included in a mechanical soft diet and would not increase the need for chewing or cause pain in the surgical area. |
4816 The client with chronic renal failure stated on Correct answer: 4 A client who is a vegetarian of the vegan type does not eat meat, milk, or egg products. The admission to the hospital, “I am a vegan type of most appropriate diet, therefore, is the green salad and walnuts, which contains only vegetarian.” What foods would the nurse consider vegetables and nuts. Option 2 contains meat (sausage), while option 3 contains milk. Option 1 most appropriate when filling out the client’s dietary contains canned vegetables and noodles, which may be acceptable in the diet but are also high menu? in sodium. Thus, the fresh salad would be a better choice.
| The critical words in the question are “most appropriate,” which indicate that more than one option is possibly correct but that one is better than the others. Use knowledge of the vegan diet and the fact that processed foods are often high in sodium to make a selection. |
4817 Which of the following should the nurse review in a Correct answer: 1, 2, 4 Discharge teaching for clients with diabetes mellitus should include a review of diet and discharge teaching plan for a client with Type 1 nutrition information (option 1), exercise (option 2), and the need for follow‐up medical diabetes mellitus who was admitted with a blood appointments (option 4). The client with type 1 diabetes will need to take insulin rather than glucose level of 562 mg/dL? Select all that apply. oral agents (option 3) and may be near normal weight or possibly underweight based on disease pathophysiology (option 5).
| Whenever discharge‐teaching diabetic clients, consider the lifestyle and habits necessary for compliance, and ensure that follow‐up care is clearly outlined. |
4818 The clinic nurse anticipates that genetic screening and Correct answer: 1, 2, 3 Cancer, particularly breast and skin cancer, may be linked to DNA tissue type. Clotting follow‐up counseling will most likely be provided for disorders such as Factor VIII hemophilia are genetically linked. While pregnancy for women clients who have which of the following? Select all that past age 35 or in other at‐risk situations warrants genetic screening, all routine pregnancies do apply. not. Hypertension is a prevalent health problem but does not warrant genetic screening and counseling.
| The core issue of the question is knowledge of conditions that are genetically transmitted and that might affect a client’s decision about whether to reproduce. Analyze each option in terms of reproduction to make selections. |
4819 The nurse would teach a male client over age 50 that Correct answer: 2 Males and females over age 50 should have a baseline colonoscopy, but not annually. If at risk which health screenings should be done annually? for osteoporosis, or if symptoms present, a bone density test can be done for a baseline, but it is not indicated as a routine annual exam. A prostate screening is recommended annually because of the incidence of prostate enlargement or cancer. Testicular self‐exams are performed monthly, not annually, although testicular cancer has higher frequency in late teens and in young adult males.
| The core issue of the question is knowledge of the timetables for various health screenings. Use the process of elimination to make a selection, and review these recommendations if needed. |
4820 The nurse should instruct a 75‐year‐old female client Correct answer: 1, 2, 4 Bone or joint pain can be serious for the 75‐year‐old who suffers from osteoarthritis or to seek follow‐up evaluation from a primary care osteoporosis, as fractures can occur spontaneously. Nodes can indicate infection or cancer. provider for which of the following observed or Loneliness after loss of a spouse is normal, but may need the attention of a physician or reported findings? Select all that apply. practitioner if it affects daily living habits (i.e., eating, sleeping, socialization), as depression in the elderly can lead to further physical problems. Dark pigments on forearms are likely normal for this client, as part of the skin changes that occur with aging. Slight fatigue at the end of the day is also expected.
| Use knowledge of normal age‐related changes and knowledge of what manifestations indicate potential health problems to make selection(s). |
| |
4821 The nurse would place highest priority on teaching Correct answer: 2, 4 Comments that indicate increased risk of behaviors associated with risk (unprotected sex in healthy behaviors to the adolescent who makes which option 2 and risk of drug experimentation in option 4) require follow‐up teaching by the nurse. of the following statements? Select all that apply. Comments that indicate decreased health risks to adolescents, such as those made in option 3 (regarding sex) and option 5 (regarding alcohol), do not pose concerns to the nurse. Neither does the comment in option 1 regarding learning to drive a truck.
| Use the process of elimination to discard options indicating typical adolescent comments that may not be significant, which are options 1, 3, and 5. Options 2 and 4 clearly show an attitude that “nothing can harm me” and need to be addressed by the nurse. |
4822 During a routine annual exam for a 6‐year‐old, the Correct answer: 2 The blood testing for screening is likely a complete blood cell count, which identifies the pediatric nurse explains to the mother that blood is normal cells. Screening is not done to detect all types of hepatitis (option 1), underlying drawn on the child to screen for which of the infection (option 3), and diabetes (option 4). These would be tested for according to specific following? risk.
| Note the critical words “routine annual exam.” All of the incorrect options indicate disease screening or diagnostic measures, while the correct answer more likely relates to normal growth and development. |
4823 The ambulatory pediatric nurse explains to the Correct answer: 1, 2, 3, A routine health screening for a child who is four years old would include routine assessment mother of a 4‐year‐old that a routine health screening 4 of growth and development and would screen for developmental delays, such as with the would include which of the following? Select all that Denver II screening exam. It may also include a routine urinalysis, but cranial nerve testing is apply. unnecessary.
| The critical word in the question is “routine.” Consider that an incorrect option would be more likely to be one that is excessively in‐depth or one that is done to detect specific disorders. |
4824 A 55‐year‐old African‐American female client Correct answer: 1 The most important assessment data needed next is what else the client may be taking, as a presents with a heart rate of 124 and blood pressure combination of herbs can cause cardiac dysrhythmias, and she may have mixed prescription of 130/80 mm Hg. She reports palpitations and medicines with herbs. The family history is important, but not as urgent to explore further. shortness of breath. During the health history, the Venous blood would be deoxygenated; the oxygen saturation is an intervention, and the nurse notes that the client takes multivitamins and fish question is focused on assessment data. oil. What should the nurse explore during the assessment?
| The critical words in the question are “fish oil.” This should indicate to assess for other dietary or herbal supplements that could pose health risks if taken in excess or in combination with some medications. |
4825 A client with cancer is hospitalized for radiation Correct answer: 1, 5 Yoga, acupuncture, and chiropractic practices are not used in hospital settings, since therapy and pain management. The client asks the physicians usually direct the orders for treatments. The client with cancer who has pain may nurse about the use of mind‐body therapies to aid in benefit from progressive relaxation, guided imagery, and hypnosis, but any treatment that may pain management. Which of the following would be stimulate cells, create nausea, or increase vital signs is usually contraindicated during cancer appropriate for the nurse to suggest? Select all that treatments. apply.
| Focus on the issue, pain management, and the setting, which is a hospital. With these two concepts in mind, select options that are noninvasive, would not stimulate the client, and are within the scope of practice of the nurse to suggest and assist with. |
4826 During chemotherapy as follow‐up treatment to Correct answer: 3 Meditation is a complementary therapy that is noninvasive and does not require an order. surgery for breast cancer, the nurse anticipates that Also, it will not interfere with other physiologically based treatments such as chemotherapy, the client wishing to use complementary therapy and it will not exacerbate symptoms such as nausea. would best benefit from which of the following?
| Consider what will relax and not stimulate the person with cancer. Smells of aromatherapy will likely create nausea. The naturopathy or herbal treatments may block some effects of chemotherapeutic agents. Meditation or prayer is usually widely appreciated, regardless of religious preferences. |
4827 The nurse would share with a support group for Correct answer: 2, 4 Music and hypnosis can assist with decreasing awareness of unwanted side effects, and may clients with cancer that what type of mind‐body promote healing and circulation. Aromatherapy will likely stimulate nausea and is therefore therapy is allowable during radiation therapy and not recommended. While light massage could relax a client, therapeutic massage will stimulate chemotherapy? Select all that apply. lymph flow, which may increase cancer cell proliferation. Acupressure also is generally not used, in keeping with the principles that apply to therapeutic massage.
| Use the process of elimination to discard options that are invasive or could conflict with other ongoing therapies. Choose therapies that are noninvasive and within the scope of the nurse. |
4828 What statement made by a client indicates to the Correct answer: 3, 4 Genetic screening involves obtaining blood samples of parents and children to analyze genetic nurse an understanding of genetic screening? Select all makeup. Counseling is provided at a follow‐up appointment. It is unnecessary to record intake that apply. or take prescribed medications. The client does not need to keep a diary during the week that the screening is conducted.
| Use the process of elimination and principles of genetics to make a selection. |
4829 While palpating the sternal aspect of the client’s Correct answer: 2 Subcutaneous emphysema or crepitus is caused by pneumothorax. This condition consists of thorax, the nurse discovers a sensation that feels like air introduced into the tissue from another condition, such as pneumothorax. Pneumocystis rubbing hairs between the fingers. Upon auscultation, pneumonia is an opportunistic infection often experienced by individuals who are HIV‐positive; an additional finding is a sound similar to a crackling, hemothorax refers to blood in the chest, and hemodilution is associated with fluid overload of popping noise. The probable cause of this finding is the vascular system. which of the following?
| The core issue of the question is identification of subcutaneous emphysema and the ability to correlate this finding with common causes. Rely on knowledge of abnormal physical assessment findings and associated pathophysiological conditions to eliminate the incorrect options. |
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4830 After assessing the client’s pupils with a penlight for Correct answer: 2 The correct abbreviation for pupils that are equal, round, and responsive to light and reaction, roundness, symmetry, and accommodation, accommodation is PERRLA. The other options represent incorrect abbreviations. It is important the nurse can document normal findings as which of for nurses to document using agency‐approved abbreviations to avoid misinterpretations and the following? to enhance communication among caregivers.
| Use knowledge of physical assessment techniques of the eye to answer the question. Recall that the first observation is whether pupils are equal (symmetry), which will help you to choose the option that has an E near the beginning of the abbreviation. |
4831 The nurse would use which of the following tests to Correct answer: 4 The Romberg test is done when the nurse asks the client to stand with eyes closed and feet evaluate a client’s motor ability and function as part of together. There should be minimal swaying for up to 20 seconds. A positive Babinski test in a neurological assessment? adults indicates upper motor neuron disease of the pyramidal tract. The Glasgow coma scale assesses the client’s level of consciousness. The abdominal reflex, if absent, may indicate a disease of the upper and lower motor neurons.
| The core issue of the question is basic knowledge of physical examination techniques. Use this knowledge and the process of elimination to make a selection. |
4832 The nurse notes unexpectedly during a routine Correct answer: 3 A weak, thready pulse is one that is difficult to palpate and easily diminished by slight screening examination that the client has a thready pressure. A 2+ pulse indicates one that is easily palpable and normal. A forceful pulse and a pulse. In what other way could this finding be pulsation felt with pressure from the index finger may be labeled as “full” or “bounding.” documented?
| The core issue of this question is knowledge of how to document an abnormal finding in a clear and objective manner. First eliminate option 1, which is a normal finding. Use the process of elimination to select the option that most clearly matches the data in the question. |
4833 To assess the intensity of a client’s pain during a Correct answer: 2 The nurse seeks to identify the intensity of the pain by asking the client to rate the pain on a health history, the nurse could ask the client to do scale of 1 to 10 with 1 indicating a slight nagging pain and 10 indicating an excruciating pain. which of the following? Some of the other components of the assessment would include the location (option 1), duration (option 4), and methods that the client has used to control the pain (also called alleviating factors, option 3).
| The key word in the question is intensity. Correlate this word with degree or strength of the pain to choose option 2 as the answer. |
4834 The nurse performs the Rinne test during a physical Correct answer: 4 The Rinne test involves the examiner using a tuning fork to compare air conduction to bone examination. This test will provide information that conduction related to transmission of sound. Mobility, thought processes, and swallowing are may contribute to which of the following nursing not assessed with this examination. diagnoses?
| The core issue of this question is the ability to correlate the Rinne test with the ear, and then to choose the nursing diagnosis that affects either hearing or balance (functions of the ear). Use the process of elimination to make your selection. |
4835 The nurse would plan to do which of the following as Correct answer: 1 As the nurse performs the health assessment and focuses on various systems, time can be a high priority during a routine health assessment? spent educating the client about achieving and maintaining wellness. The nurse should have a professional, caring approach and avoid in‐depth focus on pathology. The focus of routine examinations is not to explore client–family relationships.
| Note the key term high priority in the question. This means that some or all of the other options may be partially or totally correct, and you must choose the most important item. Note also the key word routine, which implies the client is healthy. With this in mind, the highest priority is to maintain and promote health and wellness. |
4836 When documenting the findings of the health history, Correct answer: 2 The information extrapolated from the health history should be documented in the client’s the nurse should do which of the following? medical record in a timely manner. If the nurse does not write the information down, the data could be forgotten or omitted from the record. The nurse should not wait until the client has left the area to document information unless there is an emergency. Standard abbreviations should be used in the chart. Asking the client to review the documentation is not required.
| The wording of the question tells you the correct answer is a true statement. Use the process of elimination, recalling that prompt documentation helps prevent omissions and errors at a later time. |
4837 The nurse plans to do which of the following using the Correct answer: 1 Inspection of a client can offer many clues about the overall state of health and can include all skill of inspection during a health assessment? data gathered through the senses. The nurse should compare each side of the body for symmetry prior to inspecting the next system (option 2). Equipment such as a tongue blade, otoscope, or tape measure can be used during inspection but does not necessarily need to be prepared ahead of time (option 3). The time required depends on the client’s condition and the nurse’s skill level (option 4).
| The core issue of the question is the skill of inspection. Choose the option that reflects principles of visual assessment. Eliminate options 3 and 4 because of the words all and significant amount of time. Choose option 1 over 2 using knowledge of physical assessment techniques. |
4838 The nurse would document which of the following Correct answer: 1 Percussion is a method of touching and tapping that the nurse uses to assess areas of density. pieces of information obtained using the skill of The notes of percussion differ in various regions of the body. The thorax and abdomen are percussion? usually assessed. Percussion can detect numbness, pain, or abnormal masses.
| Recall that percussion involves tapping to detect tissue density that correlates with major organs and masses. With this in mind, eliminate options 3 and 4 because they refer to the legs. Choose option 1 over option 2 because option 2 is obtained using vision, not touch. |
4839 A client tells the nurse during the health history, “I Correct answer: 3 The nurse is employing the communication technique of clarifying in order to fully understand feel jumpy all over since using my new respiratory the client’s subjective complaint. After understanding the client’s perception of this side effect, inhaler.” Which of the following questions would be the other questions would be appropriate. most appropriate for the nurse to ask next?
| The core issue of this question is appropriate use of therapeutic communication techniques. Note the word next in the question that tells you that all of the questions may be asked, but one is more important to determine first. With this in mind, choose the option that seeks to find out more about the client’s symptom. The other questions can then follow. |
4840 When asking a client newly admitted to the hospital Correct answer: 4 The client may have restrictions based on a medical condition (e.g., low‐sodium for heart about dietary history, which of the following questions disease), food allergies (e.g., shellfish), or religious convictions (e.g., abstaining from pork if would be most important? Jewish or Muslim). The nurse must note these restrictions and communicate with the nursing and dietary staff in order to avoid a potentially harmful occurrence. The other questions are pertinent for a dietary history but would not lead to a physiologic alteration if changed while hospitalized.
| Note the key words in the question are dietary history and most important. These tell you that the answer is the option that has a high priority, although some or all of the questions may be asked of the client. Select the option that impacts the diet the client will receive in the hospital. The others could be asked based on need or as the basis for later dietary teaching. |
4841 Which of the following statements made during a Correct answer: 4 How a client spends income, even on an unhealthy habit, is not necessary for the nurse to client interview represents a value judgment by the know in order to provide effective care. Option 1 would be considered appropriate in an initial nurse? interview as a means for the nurse to provide acknowledgment and positive reinforcement for a lifestyle change that resulted in a potentially improved health status. Options 2 and 3 would be common questions used to inquire about a client’s behavior.
| The core issue of the question is communication techniques that force the nurse’s values on the client and thus reduce the likelihood of open communication between client and nurse. Imagine you are the client and choose the option that is most likely to have an adverse effect on your willingness to communicate with the nurse. |
4842 An elderly client has experienced Wernicke’s aphasia Correct answer: 1 Wernicke’s aphasia is the inability to understand verbal or written words. Impairment is following a cerebral vascular accident (CVA). The nurse located in the posterior speech cortex in the temporal and parietal lobes. Based on the would expect the client to have difficulty with which of information provided, the client should be able to speak, spell, and eat with this type of the following activities? neurological deficit.
| Specific knowledge of the types of aphasia is needed to answer this question. Use nursing knowledge and the process of elimination to make a selection. |
4843 Which of the following is the most important data for Correct answer: 4 Major diseases such as diabetes, hypertension, arteriosclerosis, and cancer often have a the nurse to obtain regarding the family history of a genetic disposition and put the client at greater risk for developing them. The number and ages client? of siblings is a component of the family history, as well as inquiring about the client’s support network. Vaccines and immunizations would be covered in the section known as past history.
| Note the words most important in the stem of the question. This tells you that some or all of the options are data that you might wish to obtain but that you must prioritize to choose the option that represents the most essential piece of data. First eliminate option 2 because it does not relate to the family. Choose option 4 over options 1 and 3 because it has the greatest potential impact on physiological health status. |
4844 When assessing a preschool‐age child’s mouth, how Correct answer: 3 Children get the first of 20 deciduous teeth between the ages of 6 months and 5 years. many deciduous teeth should the nurse expect to find? Permanent teeth begin to erupt about the age of 6 as deciduous teeth fall out. All 32 permanent teeth are usually erupted in late adolescence.
| Specific knowledge of physical growth and development is needed to answer this question. Use nursing knowledge and the process of elimination to make a selection. |
4845 Which area is it important for the nurse to assess in Correct answer: 3 The single most important measure of brain growth in infants is head circumference, so it an infant that does not need to be assessed in an older should be measured at every assessment. toddler?
| The core issue of the question is determining an assessment that discriminates between infants and older toddlers. Use specific knowledge of infant and toddler physical growth and development and the process of elimination to make a selection. Recall that in infants the anterior and posterior fontanels close at specific times. Then recall that while one or both fontanels are open, head circumference could increase beyond normal growth if there is a problem with cerebrospinal fluid production. Once closed (as with toddlers), this data is not useful for this purpose. |
4846 When assessing a child for strabismus, the nurse Correct answer: 2 The cover‐uncover test assesses coordination of eye muscle movement. In strabismus, one should select which of the following eye tests? muscle is weaker and the eye wanders rather than focusing forward. Undetected and untreated strabismus can lead to amblyopia.
| The core issue of the question is assessment of strabismus. Use specific knowledge of physical assessment procedures and the process of elimination to make a selection. |
4847 When taking the history of a 7‐year‐old, what Correct answer: 1 By the time a child is 7 years old, the nurse can appropriately ask questions of the child. A 7‐ question might the nurse ask the child that would help year‐old would not be expected to have problems with night vision or glare and should know detect vision problems? colors. Problems in school could be a sign of vision problems and warrants a thorough visual assessment.
| Note the key words in the question are vision problems. Recall that children are more likely to have myopia (nearsightedness) than problems with night vision or glare. With this in mind, eliminate options 2 and 3. For the same reason, choose option 1 over option 4, which could be negatively affected by the child’s reduced ability to read a blackboard or other materials in the classroom. |
4848 When assessing the heart sounds of a 10‐year‐old, Correct answer: 3 An irregular heart rate that increases with inspiration and decreases with expiration is a sinus the nurse notices that the rate varies with inspiration arrhythmia, which is common in children. It requires no action on the part of the nurse. and expiration. The nurse determines that which of the Further evaluation is not necessary (options 1 and 4), and an assessment of caffeine (such as in following actions is most appropriate? carbonated beverages) is not indicated.
| Note that a core issue of the question is the age of the child, which is 10 years. With this in mind, correlate the heart sounds described with normal growth and development findings. After determining that this is a normal finding, eliminate each of the incorrect options. |
4849 When preparing to assess the vital signs of an infant, Correct answer: 2 Vital signs in an infant are best taken when the infant is quiet early in the exam. Counting the nurse should make a decision to use which respirations by observing the abdomen is least intrusive, followed by the heart rate and sequence? temperature.
| Note that the client in the question is an infant. Recall that vital signs may be affected by activity such as crying. With this in mind, select the order or sequence that creates minimal disturbance for the infant. |
4850 Which of the following would be of concern to the Correct answer: 3 A 6‐month‐old should be able to babble as well as localize sounds by turning head toward nurse when assessing the hearing of a 6‐month‐old? sounds. Failure to turn toward sound is an indication that further hearing assessment is necessary. The Moro reflex should not be present in a 6‐month‐old, and an infant that young would not be forming words yet.
| Note the key word concern in the question. This tells you the correct answer is an option that contains a questionable or abnormal finding. Use knowledge of growth and development and physical assessment techniques (option 4) to make a selection. |
4851 To assess the tympanic membranes of a 4‐year‐old, Correct answer: 1 The auditory canal of children over age 3 is like that of adults, narrower and more curved; the nurse should pull the pinna in which direction? therefore, the pinna should be gently pulled up and back.
| Use specific knowledge of anatomy of the child and knowledge of physical assessment techniques to systematically eliminate each of the incorrect options. |
4852 When assessing a 1‐month‐old infant, the nurse finds Correct answer: 1 The normal head circumference of a full‐term infant is 32 to 38 cm, about 2 cm greater than a head circumference of 32 cm and a chest the chest circumference. In the toddler, both measures are about equal; after the age of 2, the circumference of 30 cm. The nurse should draw which chest circumference exceeds that of the head. conclusion about this data?
| Use specific knowledge of growth and development of the infant to systematically eliminate each of the incorrect options. Recall that the measurements “cross over” at about age 2 when the head becomes smaller in circumference than the chest. |
4853 When assessing a 6‐week‐old infant, the nurse should Correct answer: 4 The Moro reflex is also known as the startle reflex, and it may cause the infant to cry. For this plan on assessing the Moro reflex at what point in the reason, it should be performed at the end of the exam. examination?
| Use basic knowledge of infant responses and specific knowledge of the Moro reflex to systematically eliminate each of the incorrect responses. |
4854 A 4‐month‐old infant is brought to the well‐child clinic Correct answer: 1 The grasp reflex usually disappears from the hands and feet by 3 months of age. This is an for a well‐baby visit. While assessing the infant, the abnormal finding that should be reported to the physician. The other options do not correctly nurse notes that the baby has a positive grasp reflex in interpret the significance of this finding. the hands and the feet. The nurse should do which of the following?
| Two of the options are positive findings, two negative. First decide whether this finding is normal or abnormal. Then choose between the two options to determine best answer. Since the two options suggesting normal findings are similar, they must both be eliminated. |
4855 A 4‐year‐old scores two failures on the Denver II. The Correct answer: 3 The Denver II is a screening test, not a diagnostic test; therefore children who score a failure nurse should draw which of the following conclusions should be retested. The child is considered at‐risk until other diagnostic indicators can based on this test result? determine a specific problem.
| Knowledge of the Denver II and the interpretation or scoring of the screening test will help to choose the correct answer. Eliminate the answers that give additional information that is not in the question such as speech problems. |
4856 The nurse is examining a 4‐year‐old child and notes Correct answer: 3 While difficult to assess directly in infants and young children, visual acuity does not approach visual acuity of less than 20/20. The nurse concludes that of adults until school age or about six years. that this finding is:
| Determine whether this finding is a normal or abnormal finding to reduce the options to consider. |
4857 The nurse is assessing an 18‐month‐old child and Correct answer: 1 The major reason for low hemoglobin and hematocrit in infants and children is deficiency of notes decreased hemoglobin and hematocrit levels. In iron intake in the diet. Iron‐fortified rice cereal is the first solid food recommended for infants analyzing the possible cause, the nurse concludes that beginning about four months of age as fetal iron stores are depleted. Children need iron daily which of the following would be the most likely cause in their diets. Hemodilution and blood loss are uncommon causes of low hemoglobin and of this anemia? hematocrit in children.
| The primary concept in this question is the most common cause of anemia in children. |
4858 A 2‐year‐old child is brought to the clinic for a well Correct answer: 4 The easiest way for a nurse to observe a child's gait is to unobtrusively observe the child child visit. While assessing the child, the nurse move about the examining room. If that is not possible, the nurse can ask the child to walk evaluates the child’s gait by: across the room at the conclusion of the physical assessment. Barlow's maneuver is performed to assess for congenital hip dislocation in infants. Stretching is not part of the assessment and parent report is part of the history.
| Eliminate choices that do not involve the child walking (options 1 and 2). Of the two remaining choices, determine which is the best to evaluate a child’s gait. |
4859 A 7‐year‐old is brought to the clinic because the Correct answer: 1 Tonsils enlarge throughout childhood and gradually begin to shrink with puberty. Exudate mother has noted large “lumps” on the child’s throat. should not be present on tonsils. The nurse assesses the child and determines that the lumps are tonsilar material. The child denies a sore throat and there is no tonsilar exudate. The nurse would tell the mother:
| Determine whether this is a normal or abnormal finding. Since this is a normal finding, there is only one option that states this is normal. |
4860 The nurse is completing an assessment of a child in Correct answer: 1, 2, 5 The history deals with subjective data, that which is reported by parents, for example. Option the clinic. Which of the following should be 3 is vague and should not be included as stated. Option 4 would be obtained by physical exam. documented in the child's health history? Select all that apply.
| The core concept is the term “nursing history.” To answer the question, it is necessary to differentiate history from physical findings. |
4861 The nurse is assessing a 4‐year‐old child being Correct answer: 3 Objective data is that which the nurse obtains through physical assessment or diagnostic admitted to the hospital. The nurse notes all of the studies. The presence of a scar is objective data. Other selections listed are part of the health following findings. The nurse documents which of the history and therefore are subjective data. following as objective data in the admission assessment?
| Differentiate the terms subjective from objective to determine the correct response. |
4862 When observing an 18‐month‐old child, the nurse Correct answer: 1 The typical toddler has lordosis and a protruding belly. The head still appears somewhat large notes a rounded belly, sway back, bowlegs, and slightly in proportion to the rest of the body. Because these are normal findings, there is no need to be large head. The nurse draws which of the following concerned about developmental delays, malnutrition, or neurological problems. conclusions from this data?
| The main concept here is the normal appearance of an 18‐month‐old infant. Since the symptoms are grouped together, they will be all normal or all abnormal. Focus in on the appearance features that are familiar. |
4863 The nurse is working in a well‐child clinic and has Correct answer: 4 Inspection, or observation, is always done before proceeding with other techniques of been assigned to assess five children ages: 2 months, 3 physical assessment. It is the least intrusive method of assessment. years, 5 years, 8 years, and 13 years. Regardless of the child's age, which assessment technique will the nurse always use first?
| The stem of the question indicates that all the techniques will be used. Recall that assessment will be easier if the child cooperates with the examiner. Therefore, consider which technique would be least intrusive to use first. |
4864 When using the otoscope to examine the ears of a 2‐ Correct answer: The ear canal in infants and young children is shorter, wider, and more horizontally year‐old child, the nurse should pull the pinna in which positioned than in older children. To adequately examine the tympanic membrane in young direction? Select an arrow in the picture shown. children, the pinna must be pulled back and down. | Critical words are “using the otoscope” and “to examine a 2‐year‐old.” Knowledge of the normal anatomy and physiology of the ear canal is necessary to answer the question correctly. |
4865 To assess the height of an 18‐month‐old child who is Correct answer: 3 Children younger than 2 or 3 should be measured lying down, preferably on a horizontal brought to the clinic for routine examination, the measuring board, to get an accurate assessment of height. A tape measure would be used to nurse should: measure head circumference. An arm‐span measure is not an appropriate estimation of adult height.
| Critical words are “height” and “18‐month‐old.” Use knowledge of assessment of children of different ages to determine the correct answer. The age of the child will determine the correct measurement style. |
4866 At what age would the pediatric nurse change the Correct answer: 4 The school‐age years are the first time a child is able to reliably cooperate with the examiner sequence of the examination of a child from that of and not squirm, talk, or otherwise interrupt the exam. In younger children, it is essential to chest and thorax first to head‐to‐toe? begin with the chest and thorax because the child needs to be quiet and at rest.
| Critical words are “sequence of the examination” and “head‐to‐toe.” Knowledge of the assessment of the child at different ages and developmental stages is needed to answer the question correctly. The core concept is the ability of the child to cooperate during an examination. |
4867 A mother of a pediatric client who is considering Correct answer: 3 The nursing process is used to identify and solve problems and to plan client care. A nursing going to nursing school asks the pediatric nurse how diagnosis is a statement of an actual or potential problem that can be resolved or changed by the nurse plans the child’s care. The nurse’s best nursing interventions. It involves the use of common labels established by NANDA. Nursing response would be that the nursing framework used is: diagnoses are based on data collected by the nurse but are not related to disease etiology or judgments of the overall health status of a client.
| Key words are “asks how the nurse plans the child’s care.” Knowledge of the nursing process is necessary to answer the question correctly. |
4868 The pediatric nurse should plan to include screening Correct answer: 3 Strabismus is detected with the cover‐uncover test that can first be reliably administered to for strabismus and amblyopia into the physical children over the age of 2. It is important to detect the problem early to prevent amblyopia. By assessment of which children? school age, vision loss would have occurred.
| Critical words are “screening” and “strabismus and amblyopia.” Knowledge of the assessment of the child at different ages and developmental stages is necessary to answer the question correctly. |
4869 The nurse who is examining an infant would Correct answer: 3 A positive Babinski in infants is a fanning of the toes when a stimulus is applied to the foot document a positive Babinski reflex after noting which along the lateral edge and across the ball. The response is normal and disappears by about age of the following? 2.
| The core concept being tested is normal reflexes in infants. Use nursing knowledge of growth and development to answer the question. |
4870 The nurse is performing a Denver developmental Correct answer: 2, 3, 4, The Denver Developmental Screening Test II evaluates 4 areas: Personal/Social, Fine screening test on a child. The child’s mother asks what 5 motor/adaptive, Language, and Gross motor. The Denver II does not include assessment of the nurse will be checking. The nurse’s best response physical maturity. would include: (Select all that apply.)
| Specific knowledge about the components of the Denver II screening exam is needed to answer the question. Use concepts related to knowledge of child development and screening tests to answer the question. |
4871 The pediatric nurse would perform abdominal Correct answer: 3, 5 Indirect percussion can be used to evaluate borders and sizes of abdominal organs and percussion to assess which of the following? (Select all masses. Percussion produces sounds of varying loudness and pitch, and these sound help to that apply.) identify the density of organs and tissues. The nurse assesses the liver with palpation and percussion, but not for placement. Inflammation is assessed with inspection, and tenderness is assessed with palpation.
| The core issue of the question is the ability to differentiate between palpation, auscultation, and percussion assessments. Use knowledge of physical assessment skills to determine the correct answer. |
4872 When assessing a 4‐year‐old child with a persistent Correct answer: 2 Infants and young children use the diaphragm and abdominal muscles for respiration, so the cough, the nurse would assess respirations by nurse would watch the rise and fall of the abdomen to count respirations. Use of accessory or observing which muscle group? intercostal muscles may be observed in respiratory distress.
| The core concept being tested is the normal respiratory function of a child of this age. Key words are “4‐year‐old with a persistent cough” and “muscle group.” Use knowledge of physical assessment and respiratory assessment to make a selection. |
4873 The nurse is assessing a newborn while the mother Correct answer: 3 The posterior fontanel closes by 3 months of age. The anterior fontanel closes by 18 months. watches. While assessing the fontanel, the nurse explains that the posterior fontanel will close by the time the infant reaches the age of months. Write in a numerical answer. | The core concept is normal growth and development of the head. Specific knowledge is needed to answer the question. |
4874 A 7‐month‐old infant has all of the following abilities. Correct answer: 4, 1, 3, An infant of 7 months just begins to transfer objects from one hand to the other. Pulling feet Place the skills in the order of appearance from 2 to mouth begins at about 4 months, smiling at self begins at about 5 months, and rolling over earliest to most recently acquired skills. Click and drag begins at about 6 months of age. the options below to move them up or down.
| Key concept is normal growth and development and order of skill development. |
4875 The school health nurse is scheduled to do routine Correct answer: 1 The Snellen eye chart measures visual acuity by assessing from a set distance how well a child vision testing with a group of students. The nurse can see. An ophthalmoscope looks at the internal parts of the eye, the cover‐uncover test would assess each child’s visual acuity using: measures eye muscle coordination, and the Weber test measures hearing.
| Critical words are “vision testing” and “acuity.” Use knowledge of health screening for visual acuity to answer the question correctly. |
4876 Children are usually brought to the clinic for health Correct answer: 3 By age 7, most children are able to clearly, and in chronological order, describe symptoms. care by a parent. Beginning at what age is it Their vocabulary is extensive enough to have words to describe what they are feeling, time of appropriate for the nurse to question the child about onset, changes from the norm, and so on. presenting symptoms?
| Key words are “beginning at what age” and “question the child about presenting symptoms.” Knowledge of the core concepts of growth and development and communication skills of children will help to answer this question. |
4877 When recording the health history of a child, what Correct answer: 3 It is important for the nurse to know the immunization record and status for any child. If a information that is uniquely pertinent to children is child is not up to date with immunizations it is up to the nurse to plan with the family a important for the nurse to obtain? schedule to get necessary immunizations. Hospitalizations, coping mechanisms, and accidents are important for the nurse, but immunizations are uniquely important for pediatric clients.
| Critical words are “recording the health history” and “uniquely pertinent to children.” Core knowledge of the importance of up‐to‐date immunizations for children is necessary to answer the question. |
4878 While taking the family history of a child, the mother Correct answer: Females are indicated by circles and males by squares. The child is indicated so the individual states that her brother had been diagnosed with will be one generation up on the mother’s side. The mother is indicated as number 30. diabetes mellitus. Mark the affected individual on the Therefore, the uncle of the child is number 28. genogram shown. | Start with the client and go up one generation. |
4879 When plotting a child’s height and weight on a growth Correct answer: 1 The normal range for most children falls somewhere between the 10th and 90th percentile. grid, which range represents the normal percentile The other ranges do not accommodate as many variations in height and weight that are range for children? considered normal.
| Critical words are “growth grid” and “normal percentile range for children.” Knowledge of the appropriate growth measurements is necessary to answer the question correctly. |
4880 When assessing a child who complains of abdominal Correct answer: 3 Save the painful area for last to avoid abdominal guarding and to gain the child’s trust. Always pain, what is the most appropriate nursing action? tell the child before touching a tender area. Light palpation, not deep palpation, would be used when assessing a painful or tender area.
| Critical phrases are “when assessing a child” and “complains of abdominal pain.” Knowledge of conducting a physical assessment of the child is needed to answer the question correctly. |
4881 When sharing the purpose of the Denver Correct answer: 2 The Denver II is used to screen children for possible developmental delays in the areas of Development Screening Test (Denver II) with parents gross‐motor skills, language, fine‐motor skills, and personal‐social development. The Denver II of an 18‐month‐old, the nurse should explain that: does not measure intelligence, cognitive difficulties, or speech difficulties.
| Critical words are “Denver II” and “the purpose.” Knowledge of developmental tests and their purpose is necessary to answer the question. |
4882 What order should the nurse utilize when performing Correct answer: 2, 1, 4, Auscultation is always easiest in a sleeping or quiet baby. Checking the eyes is considered a physical assessment on a sleeping 8‐month‐old baby? 3 invasive and should be saved for the end of the examination. Examination should proceed in an Click and drag the options below to move them up or orderly fashion from head to foot. down.
| This question asks for ordering the procedure. The core concept is cooperation from the baby. |
4883 When preparing to examine a preschool child, the Correct answer: 2, 5 The preschooler may be somewhat anxious, so the nurse should give feedback and nurse should: (Select all that apply.) reassurance about what will be done. Younger children often prefer to sit on the parent’s lap to be examined. Children do not need detailed explanations nor do they need to be told to act older than they are. Most children at this age are willing to remove clothing.
| Critical words are “to examine a preschool child.” Use knowledge of physical assessment of the preschooler. |
4884 The nurse obtaining a nursing history can enhance Correct answer: 3 Open‐ended questions encourage the client to speak freely and to elaborate and clarify data collection by utilizing the communication answers as needed. Restrictive questions that only require a “yes” or “no” answers do not technique contained in which of the following encourage free exchange of information nor does frequent rephrasing of the client’s answer. questions? Leading questions tend to elicit the answer that the nurse anticipated.
| Note which question would warrant the most descriptive response. |
4885 A nurse who is revising the nursing plan’s goals and Correct answer: 4 Validation of the effectiveness of the interventions to achieve the client specific goals interventions would require which of the following? encompasses input from the health care team members and knowledge of hospital standards of care. Medical assessment and written orders are components of the client care but not the focus of the nursing plan of care.
| When questioned about components of the nursing process, look for the response which has the most encompassing information. |
4886 The nurse assesses for hyperkalemia in a client with Correct answer: 1 Renal failure results in the inability of the kidneys to excrete potassium and that leads to which of the following problems? hyperkalemia. Nausea, vomiting and excessive laxative use, and loop diuretic will cause hypokalemia.
| Evaluate which choice results in the body’s inability to rid potassium versus losing an excess amount. |
4887 Baseline arterial blood gases are drawn on a healthy Correct answer: 3 Arterial blood gas findings of PO<sub>2</sub> 90 mmHg (80 to 100 mmHg normal) adult scheduled for surgery. The nurse expects the and pH 7.40 (7.35 to 7.45 normal) would be within the normal range for an adult. All the other findings to be which of the following? choices are abnormal findings.
| The client is described as a healthy adult, therefore look for normal findings. |
4888 In assessing the laboratory findings for a client the Correct answer: 2 A low serum potassium level enhances the action of digitalis and predisposes the client nurse should be aware that a decrease in the serum receiving digitalis to develop toxicity. The other lab values do not contribute to digitalis level of which laboratory value might cause digitalis toxicity. toxicity?
| Make the connection among which electrolyte affects cardiac contractility. |
4889 The nurse is preparing the client for an ultrasound of Correct answer: 1 The client will be required to have an empty stomach for the procedure to allow visualization the gallbladder. Which of the following statements of the gallbladder and adjacent structures to accurately rule out tumors, structural would be the most important to prepare the client for abnormalities, or the presence of stones. Since the lower GI tract is not visualized during this the test? procedure, there is no need for the bowel to be empty. Also, ultrasound does not require the use of radioactive isotopes to be used.
| Associate the anatomical site of the upper GI tract with the test prep required. |
| |
4890 A client has recently returned to the unit following a Correct answer: 3 The administration of a local anesthetic is possible during the procedure to decrease the gag bronchoscopy and is requesting a glass of water. The reflex and increase comfort. The nurse should check for the return of the gag reflex to prevent nurse’s first consideration in fulfilling the request the potential for aspiration. The position of the side rails, availability of the call light, and the would be which of the following? ability to ambulate without assistance are safety concerns but not related to the specific client request.
| Recall the ABCs principle to guide choices pertaining to safety (Airway, Breathing, and Circulation). |
4891 A client is experiencing shortness of breath after Correct answer: 4 An oxygen saturation of less than 80% with observable signs of shortness of breath indicates oxygen that was being delivered by nasal cannula was respiratory distress, which requires immediate intervention. A full respiratory assessment decreased to 2 L/min. Pulse oximetry reveals an should be performed and the physician advised of the findings immediately. Symptomatic oxygen saturation reading of 71%. Which of the respiratory distress should not be ignored. The repositioning of the client and the receiving of a following would be the most appropriate immediate physician’s order to increase the oxygen being delivered would be helpful. The client should be nursing action? continually monitored but 15 L/min flow rate of oxygen may be excessive.
| Look for the most complete set of interventions keeping client safety as a priority. |
4892 Which of the following steps of the nursing process Correct answer: 3 Diagnosing is a specific step of the nursing process that utilizes the information collected would the nurse use when determining specific client during the client specific database collection. Client teaching is a nursing intervention. Team needs based on the admission history database? collaboration is important in the intervention and evaluation phases of the nursing process. The utilization of a previously developed clinical pathway includes components of all steps of the nursing process.
| Nursing diagnoses are developed based on client needs, following a care history taken by the nurse. |
4893 The nurse is implementing a plan of care. Which of Correct answer: 2 Assisting the client to use the incentive spirometer is actively operationalizes the client’s plan the following actions would the nurse take in this of care to maintain optimal oxygenation status. Auscultation of the carotid bruits would be a phase of the nursing process? part of the assessment process from which a care need may be identified. Prioritization of care issues is part of the planning stage of the nursing process from which nursing interventions are determined. Consultation with other care providers is used in evaluating the effectiveness of the planning of care and gathering of information for possible revision.
| Determine which response requires the nurse to provide a direct‐care action for the client. |
4894 A client has been admitted to your unit this afternoon Correct answer: 4 Discharge planning should begin on admission to the unit and should be an ongoing process. for dehydration. The discharge planning for this client As a rule, clients are not ready to discuss discharge plans on the day of admission; however, should begin: planning for appropriate follow‐up and coordination of care cannot always be achieved the morning of discharge. | Regardless of the age, gender, or medical problem of the client, discharge planning begins with admission. |
| |
4895 The evaluation process of a nursing plan of care Correct answer: 3 The evaluation step of the client’s plan of care includes the assessment of their would include which of the following? accomplishments toward a previously identified desired outcome. The desired outcome would have been the result of the gathering of the client’s health history, identifying of a nursing diagnosis, goal formation, and implementing the assigned plan of care such as ambulation.
| Note which response would be evaluating progress towards a defined goal or outcome. |
4896 You would anticipate that a client with liver failure Correct answer: 2 In liver failure, an excess of serum ammonia results from the liver’s inability to convert would have an elevated serum blood level of which of ammonia to urea for excretion. Because of the liver’s inability to perform its normal functions, the following? glucose, albumin, and the client's platelet count will be decreased rather than increased.
| Recall the expected physiologic changes associated with hepatic system failure to choose the right answer. |
4897 Which of the following should be removed from the Correct answer: 3 MRI testing involves the use of a magnetic field and radiofrequency waves. Any object that client in preparation for a magnetic resonance imaging contains metal of any kind will be attracted to the magnetic field, which will affect the (MRI) procedure? diagnostic ability of the test and can potentially harm the client. Foam, plastic, and the urinary catheter are not attracted to the magnetic field.
| Connect the word ‘magnetic’ with any response associated with metal, which would be contraindicated. |
4898 Which of the following isoenzymes of lactic Correct answer: 1 LDH<sup>1</sup> and LDH<sup>2</sup> are the primary isoenzymes dehydrogenase (LDH) would the nurse expect to be for cardiac muscle and are utilized to diagnose an acute MI. LDH<sup>3</sup> is elevated in a client with a diagnosis of acute the primary pulmonary isoenzyme and LDH<sup>4</sup> and myocardial infarction (MI)? LDH<sup>5</sup> are indicators of hepatic dysfunction.
| Recall which isoenzymes are associated with which body system. |
4899 Which of the following would indicate that the client Correct answer: 3 Normal ABG pH is 7.35‐7.45 and a normal bicarbonate level is 24‐28 mEq/L. A low pH would is in metabolic acidosis? indicate a client is in an acidotic state and the low bicarbonate would indicate a metabolic cause for the acidosis. The pCO<sub>2</sub> level is an indicator of the respiratory component of the client’s acid‐base balance.
| Remember if the problem is respiratory‐generated, the pH and HCO<sub>3</sub><sup>‐</sup> will go in opposite directions. If metabolic, both will increase or decrease together. |
4900 A client has been diagnosed with renal failure. What Correct answer: 3 Creatinine levels are more sensitive and specific for renal disease. Although the BUN level is serum laboratory value would be the nurse’s best used to assess renal function, it can be affected by diet and fluid status. The potassium level indicator of the renal function? can be affected by many factors as well. Specific gravity is not a blood test, but rather is performed on the urine itself.
| Be sure to read all responses and look for the best (most indicative) of kidney function, as all could be potentially altered. |
4901 A client is scheduled for a colonoscopy and asks what Correct answer: 1 A colonoscopy is the insertion of a flexible tube into the lower GI tract for evaluation and will be determined from the test. The nurse’s response treatment of conditions of the bowel. An evaluation of the esophagus and stomach would is that a colonoscopy would: require an approach from the upper GI tract such as an esophagogastroduodenoscopy (EGD). The presence of blood in the abdominal cavity would require an abdominal ultrasound or other x‐ray procedure.
| Recall the knowledge of what comprises the lower GI tract. |
4902 A client is admitted with a diagnosis of diabetic Correct answer: 4 DKA produces an excess release of hydrogen ions into the serum that cannot be buffered by ketoacidosis (DKA). The nurse expects the ABGs to the already depleted bicarbonate level due to an osmotic diuresis that occurs. Therefore the reflect which of the following? client is in metabolic acidosis. There is no essential respiratory cause for this metabolic condition and the results will not be within normal limits due to the pathophysiology of the disease process.
| Recall that diabetes is a metabolic‐based condition and decide if the imbalance would be related to an excess of bicarbonate (hydrogen) or carbonic acid. |
4903 A client presents to the Emergency Department with Correct answer: 2 The first nursing assessment technique utilized to gather data is inspection of the area. a complaint of left arm pain following a fall. The first Palpation of any of the area would be attempted after the inspection. Obtaining the client physical examination technique the nurse utilizes history is not a component of the physical examination. would be:
| Most areas of physical assessment for the healthy or ill adult involve inspection first, followed by additional components. |
4904 When taking a health history, the nurse should focus Correct answer: 2 A nurse must focus on using good communication skills, which will enhance the interview. In on which of the following? addition, the ability to interpret nonverbal communication is paramount in achieving the goals of history taking. The history should be done at a comfortable pace and should not be rushed. The nurse must document carefully, but it is subjective data, not objective, that is recorded using the client's own words. The client can have family in the room if they do not distract the client or nurse in the interview; in many instances family members are helpful in the process.
| Taking a ‘global’ approach to answer the question will provide the best overall response, the focus should be client‐based, rather than on the family, or the time element. |
4905 Before palpating the abdomen during an assessment, Correct answer: 2 Before palpating the abdomen, the nurse should first listen to all four quadrants for bowel the nurse should do which of the following? sounds. Palpating and percussing the abdomen first can alter bowel sounds, making the assessment less reliable. It is unnecessary to use sterile gloves unless there is an open wound or lesion. The client should be in a supine position if tolerated by the medical condition.
| Recall the sequence in performing a physical examination of the abdomen to choose the correct answer. |
4906 The nurse would attempt to gather which of the Correct answer: 1 The nurse seeks to obtain data from the client using a holistic approach. The nurse focuses on following information while obtaining a health history physical, psychosocial, and spiritual concerns. Information regarding a client's personal from a client? finances should not be alluded to in the interview. Reactions to past hospitalizations and goals for future healthcare are encompassed in the psychosocial aspect of the history.
| Look for the response which is most global in nature, encompassing major concepts of a history. |
4907 The nurse would document which of the following in Correct answer: 2 Subjective data are only apparent to the person affected and can be described or verified only the medical record as objective data obtained during by that person. Itching, pain, and feelings of worry are examples. In addition, the client's client assessment? sensations, feelings, values, beliefs, and attitudes are regarded as subjective. Objective data are detectable by an observer or can be measured against accepted standards. They can be seen, heard, felt, or smelled during physical examination.
| Connect the term ‘objective’ with ‘observable’ by the nurse. |
4908 The nurse should do which of the following in order Correct answer: 1 A comfortable environment puts the client at ease and increases the likelihood that the nurse to increase the likelihood of obtaining quality data will be able to obtain necessary data. The family may be able to provide additional data when doing a complete physical assessment? through the assessment process (option 3). As the nurse proceeds with the more intimate components of the assessment, the family may be asked to leave. Inform the client immediately prior to assessing each system (rather than before the examination) what is entailed to facilitate understanding (option 2). Using lay terms for medical equipment (e.g., blood pressure cuff versus sphygmomanometer) is appropriate (option 4).
| Choose the response which would result in obtaining the most thorough assessment. |
4909 The nurse would use which of the following methods Correct answer: 1 Auscultation uses the sense of hearing to identify sounds that are normal and abnormal of examination to assess for the presence of a bruit in during the assessment. A bruit is an abnormal sound of the venous/arterial system that is only the abdomen? detectable by listening with a stethoscope.
| Recall the definition of a bruit to choose the correct answer. |
4910 The nurse examines the ocular motility of a client Correct answer: 3 Evaluation of ocular motility provides information about the extraocular muscles, the orbit, who recently experienced a cerebrovascular accident. cranial nerves III, IV, and VI, their brain stem connections, and the cerebral cortex. Follow‐up documentation would describe the function of which of the following cranial nerves?
| Consider using the mnemonic: “On Old Olympus's Towering Top A Finn And German Viewed Some Hops" to facilitate memory of the cranial nerves. |
4911 Which of the following statements made by the client Correct answer: 4 The Romberg test is performed to test motor function. The client is asked to stand with feet indicates an understanding of how the nurse performs together, arms resting at the sides and then to close the eyes. The nurse watches for the the Romberg test? presence of swaying, which is considered normal if it is only slight. However, if the client cannot maintain foot stance, it is documented as a positive Romberg's sign.
| Recall the standard neurological system physical assessment criteria. |
4912 A client who is alert and responsive was admitted Correct answer: 2 Using the principles of the ABCs (Airway, Breathing, and Circulation), an alteration in directly from the physician's office with a diagnosis of respiration is always a primary concern. A disturbance in normal ventilation is occurring rule‐out acute myocardial infarction. Of the following secondary to the medical diagnosis of myocardial infarction. The blood pressure remains in alterations found on the initial assessment, which is of acceptable range, and the temperature elevation is likely related to the overall inflammatory greatest concern to the nurse? response of the body. Infrequent abnormalities of cardiac rhythm are common and should be of concern when appearing regularly or with longer duration.
| Follow the principles of the ABCs (Airway, Breathing, and Circulation) as the approach for this type of question. |
4913 A normal thyroid assessment would be documented Correct answer: 2 The thyroid should be midline, smooth, and free of nodules. The parathyroid glands are too by the nurse as which of the following? small to be manually palpated. Any other assessment finding is considered an abnormality.
| Recall the normal findings from physical assessment. |
4914 Prior to taking the health history the nurse should Correct answer: 1 In order to gain as much insight and information from the client as possible, the nurse should first do which of the following? establish a level of trust or rapport with the client. The client will be best able to relax and answer questions if he or she is asked in a non‐threatening manner. Offering the client food and drink is not appropriate. The nurse should not ask the client about health insurance or finances, as other personnel determine this. The client does not need to wear an examining gown to answer questions.
| Look for the option that would provide comfort, resulting in the best intended outcome. |
4915 The nurse would use which of the following skills first Correct answer: 4 During inspection, the nurse scrutinizes and evaluates by sight any clues of pathology that when examining the abdomen of a client? may be present. By first performing the other assessment techniques (percussion, palpation, and auscultation), the nurse could alter the findings.
| Recall that inspection will generally be the first step in physical assessment of any system. |
4916 The nurse would conduct a health history on a newly Correct answer: 4 The health history is an important tool that assists the healthcare team to learn about the admitted client primarily to accomplish which of the client's overall state of health using data from the past and present. After the health history is following? complete, the healthcare team can assist the client to identify ways to improve the lifestyle. The health care team should display concern for the client during all phases of care.
| Reword the question to say ‘what is the primary purpose of a health history’ to choose the most conclusive answer. |
4917 As the client describes the chief complaint, the nurse Correct answer: 1 The chief complaint offers the nurse an indication of what the problem is and how health care should do which of the following? should proceed. The nurse can continue to probe during the interview to identify contributing factors to the client's chief complaint. The client's statements must be documented using their own phrases and terminology.
| Recall the principles of history taking/interviewing a client to choose the correct answer. |
4918 The nurse selects which of the following pieces of Correct answer: 2 The cremasteric reflex is tested in men only. The nurse uses a cotton‐tipped applicator or equipment to test for a cremasteric reflex? other smooth object to stimulate the inner thigh. The normal reaction is contraction of the cremaster muscle and elevation of the testicle on the side stimulated.
| Recall the normal body reflexes and how to elicit; most require percussion hammer, with the exception of this particular one. |
4919 The nurse should place the client into which of the Correct answer: 1 To assess for jugular venous distention (which indicates fluid volume overload), the client following positions in order to assess jugular venous should be lying supine with the head elevated to 30 degrees. The nurse assesses the highest distention? point of distention of the internal jugular vein in centimeters in relation to the sternal angle, the point at which the clavicles meet. The other positions listed would not aid in this physical assessment technique.
| Recall components of physical assessment in relation to fluid balances. |
4920 Which of the following nursing diagnoses would most Correct answer: 4 During physical assessment, the nurse inspects the client's legs for hair distribution. The most likely be associated with the absence of hair on a 70‐ common reason for shiny skin and a complete absence of hair is poor circulation related to year‐old male client's legs? peripheral vascular disease (PVD). The other nursing diagnoses should not affect hair distribution.
| Of the choices listed, look for the item that would affect hair growth on a male’s legs; it is the only option available. |
| |
4921 The nurse is preparing to palpate the abdomen as a Correct answer: 1 If the nurse begins with deep palpation and there are sensitive areas, the client may be too part of the physical examination. Which of the uncomfortable for light palpation, which is important to allow detection of masses, distention, following steps is appropriate? and the position of the abdominal organs. Deep palpation involves depressing the abdominal wall approximately 4 to 6 cm. Palpation should be completed despite absence of bowel sounds. The nurse uses the distal palmar surface and fingers of the hands for this examination.
| Recall the steps in physical assessment of the abdomen: inspect, auscultate, palpate, and percuss. |
4922 In which of the following positions would it be best to Correct answer: 3 The Bartholin glands are part of the female anatomy located on the posterior aspect of the place the client so the nurse can inspect and palpate vaginal orifice. Therefore, if the medical condition allows, having the client in a lithotomy the Bartholin glands? position (on her back, knees flexed, legs apart with feet supported on a surface or in stirrups) will provide the best opportunity for examination. The other responses are incorrect.
| Remember the function of the Bartholin glands to answer this question; a female‐only situation. |
4923 To adequately inspect the external ear canal of an Correct answer: 2 In order to facilitate visualization of the ear canal and tympanic membrane, the pinna should adult client, the nurse should do which of the following be pulled up and back for an adult client. If earrings are attached to the lobe, there should not prior to inserting the otoscope? be a safety issue; however, they may be removed if they are large in size or are causing the client discomfort during the examination. The nurse should not remove cerumen with an applicator because of the risk of pushing it further into the canal or rupturing the tympanic membrane. Generally, the ear and eye physical assessment are performed with the client sitting upright.
| Choose the strategy which both facilitates the best assessment, while promoting client safety and comfort. |
4924 The nurse conducting a physical examination of the Correct answer: 1 To inspect a client means that the nurse is scrutinizing and evaluating by sight any clues of heart and lungs would use inspection just prior to pathology that may be present. The order of physical assessment of the heart and lungs is which of the following assessment techniques? inspection, palpation, percussion, and finally auscultation.
| Recall that inspection will generally be the first step of physical assessment for most systems. |
4925 By maintaining a closed record, the nurse assures the Correct answer: 1 Clients must be assured the right of privacy because they disclose sensitive and personal client of which of the following? information. Beneficence promotes the health professional to do good for the client. Disclosure of information is restricted to authorized personnel only. Anonymity is not possible for permanent, legal healthcare records because the client's name, social security number and other identifying data must be included.
| Associate the words privacy and closed when choosing a response. |
| |
4926 During an interview, the client makes a comment that Correct answer: 3 Assessing a client's answers for truthfulness can be a difficult task for the nurse. To do so, the leads the nurse to suspect that the client's answers are nurse can ask very clear and pointed questions regarding the illness. Subjective facts can be not truthful. To assess the reliability of the client, the compared with objective findings to determine the validity of the statements. nurse could do which of the following?
| Look for the response which would provide more information/data compared to the others. |
4927 When addressing a client about a sensitive issue, the Correct answer: 4 It is not easy to ask clients about sensitive items, but the answers may impact the health and nurse's best approach is to do which of the following? the findings of the assessment. Therefore the nurse must ask these questions with sensitivity, which can be conveyed with a calm yet direct manner.
| Look at the strengths of each response from a ‘positive’ approach in dealing with the client. |
4928 To alleviate a client's anxiety during the health history Correct answer: 3 A non‐threatening and nonjudgmental attitude is most likely to put the client at ease. It is and assessment, the nurse could do which of the normal for a client to feel some anxiety during the interview; however, panic is not expected. following? The nurse should not rush the interview since it will heighten the client's anxiety level. Music may or may not be a helpful distraction.
| Choose the response which elicits the most caring behavior by the nurse. |
4929 The family history can provide the healthcare team Correct answer: 1 The family history can offer certain clues about hereditary diseases, such as hypertension, with important information. While taking the health coronary artery disease, diabetes, and breast cancer. The other options would not directly history it is important to ask about which of the affect the client's health status. following items?
| Look for the response which could directly affect the client’s own health. |
4930 Which of the following is important component of the Correct answer: 1 The nurse should approach the initial physical assessment holistically and it serves as the physical examination in relation to the nursing process baseline of the client's functional ability. The nursing diagnoses and evaluation of client goals is? would require more in‐depth contact with the client.
| Remember that beginning with a baseline of information provides a foundation for data collection and change. |
4931 The nurse is preparing to inspect the turbinates of a Correct answer: 3 Inspection of the mucosa of the nares for color, moisture, presence of polyps, exudate, and client. What piece of equipment would the nurse inflammation is performed with the aid of the nasal speculum. The otoscope can be used as a select that is necessary for this part of the light source (as can a penlight). assessment? | Recall the meaning of the anatomical term of ‘turbinate’ to know which piece of equipment is necessary. |
| |
4932 The nurse is auscultating the chest of a thin, elderly Correct answer: 3 The bell is placed lightly in contact with the skin to hear low‐pitched sounds, such as murmurs client. Which technique is most appropriate for the and bruits. The diaphragm detects sounds of higher pitch. The length of the stethoscope tubing nurse while evaluating the quality of a murmur? is standard; a Doppler is not necessary.
| Recall that heart murmurs require using the stethoscope bell. |
4933 The nurse auscultating a client's carotid artery hears a Correct answer: 3 Under normal circumstances, no sound should be heard while auscultating the carotid artery. "whooshing" sound through the stethoscope. The The presence of a sound is termed a bruit, and it indicates turbulent flow, often caused by nurse concludes that this sound indicates a positive atherosclerosis and subsequent narrowing of the blood vessel. finding of a:
| Recall the abnormal findings when conducting a physical assessment of the vessels to choose the correct answer. |
4934 A newly adopted 8‐year‐old child is brought to the Correct answer: 3 A history of an allergic reaction to baker’s yeast would be a contraindication to receiving this pediatric immunization clinic to begin the hepatitis B series of immunizations. Aminoglycoside antibiotics, mold, and egg yolks do not pose any risk immunization series. Before providing the to the client for allergy to the vaccine. immunization, the nurse inquires about any known history of allergy to which of the following?
| Specific knowledge of contraindications to hepatitis B vaccine is needed to answer this question. Use the process of elimination, and review this content area if needed. |
4935 A mother brings her infant into the immunization Correct answer: 3 It is normal for the solution in the vial to appear cloudy. The nurse should gently shake the clinic for the final hepatitis B vaccine. After picking up vaccine and then draw it up for administration. It is unnecessary to discard it or to notify the the vial of vaccine to draw up the dose, the nurse manufacturer. Warming the solution will not affect the cloudiness. notes that it is cloudy. Which of the following actions should the nurse take?
| Specific knowledge of the nursing considerations for hepatitis B vaccine is needed to answer this question. Use the process of elimination, and review this content area if needed. |
4936 The nurse who is preparing to draw up a dose of Correct answer: 2 The vial should be discarded according to agency policy. Administering the vaccine does not vaccine notices that a vial of DTaP vaccine on the protect the safety of the client, and it is unnecessary to report this particular incident to the countertop does not have a date recorded for when it state Board of Public Health. was opened. Which of the following actions should the nurse take?
| The core issue of this question is safe handling of vaccinations. Use principles of general medication preparation to make a selection. |
| |
4937 A parent brings a 3‐year‐old child to the immunization Correct answer: 1 The dose should be delayed for 1 month following any type of immunosuppressive therapy, clinic for a DTaP vaccine. During the interview, the such as prednisone. The other actions do not protect the client or uphold safe administration mother indicates the child is just finishing a tapered procedures for immunizations. dose of prednisone for a chronic respiratory problem. Which of the following actions should the nurse take?
| Use the process of elimination. Recall that immunizations affect the immune system and that steroids such as prednisone suppress the immune system to make the correct selection. |
4938 A child is brought to the pediatric ambulatory clinic Correct answer: 3 The immunizations should be administered as scheduled. They would be withheld for clients with a runny nose and a low‐grade fever. He is who are immunosuppressed or have moderate to severe febrile illnesses. The presence of a scheduled to receive the MMR (measles, mumps, and runny nose and low‐grade fever is not a contraindication according to the literature. rubella) and DTaP (diphtheria, pertussis, and tetanus toxoid) vaccines. What should the nurse do at this time?
| The core issue of the question is contraindications to administering scheduled immunizations. Use the process of elimination, and take time to review these immunizations if needed. |
4939 A pediatric client is scheduled to receive a dose of Correct answer: 3 A contraindication to MMR vaccine is a history of allergic reaction to neomycin or gelatin. MMR (measles, mumps, rubella) vaccine. The nurse Minor illnesses and history of local reaction to a previous dose are not contraindications. would question the order to give the dose at this time Weight loss is irrelevant to the question. if which of the following was noted during the short history obtained on intake?
| The core issue of the question is knowledge of contraindications to MMR vaccine. Use the process of elimination to make a selection, keeping in mind that both neomycin and gelatin are reasons to withhold the dose. |
4940 The mother of a child who has been exposed to Correct answer: 1 The nurse would inquire about the nature of the exposure and the client’s immune status. chicken pox calls the pediatric clinic for advice. The Chicken pox can be fatal in immunocompromised children, such as those who are undergoing triage nurse who answers the telephone would inquire steroid therapy, chemotherapy, and those who have other illnesses. If warranted, the varicella about which of the following before responding to the zoster immune globulin can be given up to 4 days after exposure to those with no history of mother’s request for information? chicken pox or prior exposure. Exposure to rubella (a different disease), height and weight of the child, and the person to whom the child was exposed are irrelevant as priority items in protecting the health of the child.
| The core issue of the question is knowledge of indications for use of varicella zoster immune globulin. Use the process of elimination and general concepts of immunity to answer the question. |
4941 A 9‐year‐old client is brought to the pediatrician’s Correct answer: 1 Contraindications to varicella virus vaccine include allergy to neomycin or gelatin, office for a varicella virus vaccine. Before preparing the immunosupression, or administration of immune serum globulin or blood products in the last dose of the vaccine, the nurse asks the mother 3 to 11 months. A history of spleen removal and allergies to penicillin or milk are irrelevant to whether the child has: safe use of this vaccine. | The core issue of the question is knowledge of contraindications for use of varicella vaccine. Use the process of elimination and general concepts of immunity to answer the question. |
| |
4942 A child stepped on a rusty nail and is brought to the Correct answer: 2 When there is accidental exposure and inadequate vaccination, passive immunity with emergency department. If the child was not tetanus immune globulin is indicated for immediate protection from the bacterial spores in the adequately immunized against tetanus according to nail. Options 1 and 4 provide active immunity and option 3 (broad‐spectrum antibiotic) is the immunization schedule, what would the inadequate. emergency department nurse anticipate will be ordered to treat this child?
| The core issue of the question is the ability to discriminate situations requiring active immunity and those requiring passive immunity. Use the process of elimination, and take time to review this information if needed. |
4943 A 2‐month‐old client is seen in the pediatric clinic for Correct answer: 1, 2, 3 The IPV, DTaP, Hib, and PCV vaccines are all scheduled to be given at 2 months of age. The a well‐baby checkup. The nurse anticipates that which MMR is given at 12 to 15 months, and again at 4 to 6 years. The varicella zoster vaccine is given of the following routine immunizations will be at 12 to 18 months. administered at this time? Select all that apply.
| The core issue of the question is knowledge of routine immunization schedules for a 2‐ month‐old infant. Use general knowledge of immunization schedules and the process of elimination to make your selections. |
4944 A nurse is preparing to draw up a dose of Correct answer: 3 The solution used for Hib vaccine is clear and colorless. MMR and varicella vaccines are a Haemophilus influenzae type B (Hib) vaccine for a clear yellow in color. No vaccines are pale pink or brown, although some are cloudy. pediatric client. The nurse knows that the vial is acceptable to use after noting which of the following expected coloration of the fluid in the vial?
| The core issue of this question is the ability to determine safe appearance of vaccines before administration. Use nursing knowledge and the process of elimination to make a selection. |
4945 The pediatric clinic nurse has just administered a dose Correct answer: 2 The parents should be taught to expect pain and redness at the site as possible local of Haemophilus influenzae type B (Hib) vaccine to a reactions. Fever, irritability, and decreased appetite are common side effects of the child. The nurse explains to the parents that they can heptavalent pneumococcal conjugate vaccine (PCV). expect which of the following local reactions following the injection?
| Use the process of elimination. One strategy to determine local reaction is to evaluate the options in terms of how confined they are to the site of injection. The incorrect responses are systemic in nature. |
4946 The nurse has an order to give an infant a dose of Correct answer: 2 Before administering a dose of IPV, the nurse should assess for allergy to neomycin, inactivated poliovirus vaccine (IPV). The nurse would streptomycin, or polymixin B. The solution should be kept in the refrigerator and should be do which of the following prior to administering the clear and colorless. The dose is administered by the subcutaneous route. medication to ensure the dose is safe and effective?
| The core issue of this question is the ability to administer IPV safely. Use nursing knowledge and the process of elimination to make a selection. |
4947 The neonatal nurse is providing anticipatory guidance Correct answer: 3 The first dose of IPV is given at 2 months, with subsequent doses at 4 months, 12 to 18 to the mother of a newborn infant. When discussing months, and 4 to 6 years, for a total of four doses. The other options do not match the immunization schedules, the nurse explains that the acceptable timeline for administration of this vaccine. first dose of inactivated poliovirus vaccine (IPV) is given at what age?
| The core issue of this question is the ability to administer IPV safely according to its recommended schedule. Use nursing knowledge and the process of elimination to make a selection. |
4948 The nurse has conducted client teaching with the Correct answer: 4 Although mild to moderate fever, drowsiness, and decreased appetite are some of the side parents of a client who received a dose of heptavalent effects of PCV, the most important one to report to the health care provider is rash with hives. pneumococcal conjugate vaccine (PCV). The nurse This likely indicates an allergic reaction, which could progress to anaphylaxis if left untreated. evaluates that the parents understand the information presented if they state that which of the following symptoms is most important to report promptly to the health care provider?
| The core issue of this question is the highest priority teaching regarding PCV. The critical words in the stem of the question are most important and promptly, which tells you that more than one or all options may be technically correct. Use nursing knowledge, the ABCs, and the process of elimination to make a selection. |
4949 The public health nurse is administering inactivated Correct answer: 1 High‐risk populations are found in specific states, all of which are west of the Mississippi hepatitis A (Hep A) vaccine to clients at risk. The nurse River. Native American and Native Alaskan clients are the cultural populations at highest risk. determines that, according to statistics regarding incidence, a client from which of the following cultural groups should have highest priority to receive the vaccine?
| The core issue of this question is the client population at highest risk for developing hepatitis A. Use general knowledge regarding this vaccine to make a selection. You can also use knowledge that hepatitis A is contagious and that Native Americans tend to live in groups to help you choose this option over the others. |
4950 A child with cardiac disease has been recommended Correct answer: 4 The influenza vaccine is administered annually in the autumn, especially during October, to receive the yearly influenza vaccine. The nurse November, and into December. The other months do not correlate with administration times would schedule the child to receive the vaccine at the that would prevent development of influenza during the winter months. routine visit scheduled in which of the following months?
| The core issue of the question is the timing of the annual dosage of influenza vaccine. Use knowledge of the epidemiology of the disease to choose the month prior to when flu season occurs. |
4951 A 6‐year‐old child with asplenia is receiving the Correct answer: 3 Meningococcal vaccine is indicated for children older than 2 years with asplenia. The vaccine meningococcal vaccine. The nurse explains to the duration is 5 years if the client is older than 4 years at the time of immunization. If the client is child’s mother that the vaccine should be effective for younger than 4 at the time of initial immunization, it should be repeated after 1 year. how many years? 1.‐ 1 2.‐ 2 3.‐ 5 4.‐ 10 | Specific knowledge related to the meningococcal vaccine is needed to answer the question. Take time to review this material if needed, and use the process of elimination in making a selection. |
4952 A nurse working in an immunization clinic ensures at Correct answer: 2 Epinephrine is the priority medication to have on hand if a client should experience the beginning of each workday that which of the hypersensitivity reaction/anaphylaxis following a dose of an immunization. Lidocaine is given following priority medications is available and within for cardiac dysrhythmias, while acetaminophen and ibuprofen are peripheral CNS analgesics. the expiration date?
| The core issue of the question is knowledge that anaphylaxis is a potentially life‐ threatening consequence of immunization. Use the process of elimination, choosing the answer that is an emergency drug associated with reducing allergic response. |
4953 The mother of a pediatric client does not have a Correct answer: 4 Initially, the nurse would be prudent to choose deficient knowledge. After explaining to the record of the child’s immunizations. Which of the mother the rationale for and importance of maintaining vaccination records, other nursing following initial nursing diagnoses would the nurse diagnoses such as noncompliance may apply. The other nursing diagnoses listed are choose? inappropriate in this instance.
| Use general nursing knowledge to make a selection after focusing on the critical word initially in the stem. In this case, the correct option gives the mother the benefit of the doubt about the reason for lack of immunization schedule maintenance. |
4954 The pediatric nurse is seeing a 2‐month‐old infant in Correct answer: 2, 4, 5 Diphtheria, Tetanus and acellular pertussis (DTaP), Haemophilus influenzae type b (Hib), the outpatient clinic for routine immunizations. The inactivated polio vaccine (IPV), and the pneumococcal conjugate vaccine (PCV) are the routine nurse should select which of the following immunizations scheduled for the 2‐month well‐child visit. The MMR is given first at 12 to 15 immunization teaching sheets to give to the mother months, and the varicella can be given at or anytime after 12 months. prior to preparing the immunizations appropriate for this visit? Select all that apply.
| The core issue of the question is knowledge of vaccinations that are due at a 2‐month well‐ child visit. Use the process of elimination, recalling that MMR and varicella cannot be given before 12 months of age. |
4955 The nurse observes on the chart of a 9‐year‐old girl Correct answer: 1 Some children might have missed earlier doses due to illness or missed health care visits. that she has not had some of the routine Children at any age can be started on the immunization schedule. Immunizations would not be immunizations. The nurse would plan to do which of repeated in this case. Having the child go to the lab to draw titers for all of the immunizations the following at this time? would be inappropriate. All children need to be immunized.
| Consider the purpose of immunizations and possible consequences of missed doses. From there, choose the option that limits the child’s risk of contracting a communicable disease that could be prevented by resuming the immunization schedule. |
4956 A 16‐year‐old seeks treatment in an urgent care clinic Correct answer: 4 A tetanus‐diphtheria booster is recommended every 10 years. This situation does not warrant for an accidental puncture wound in the foot from a an MMR booster. The immunization history and/or a titer need to be done before tent stake, sustained while on a camping trip. What administration of this immunization. would be the appropriate action for the nurse to take?
| To answer this question correctly, it is necessary to have an understanding of the immunization schedule. Other than that, recall that 10 is an easy number to remember, and associate it with tetanus boosters. |
4957 The nurse at the pediatrician’s office is giving Correct answer: 4 Common side effects of vaccines include redness, soreness at the injection site, and fever. information over the telephone to the mother of a 5‐ These are NOT symptoms of anaphylaxis or an allergic reaction. The nurse should reassure the year‐old. The mother states that her son received a mother but offer a route to share future concerns if they arise. vaccine two days prior, and now the area is reddened and painful, and the child has a temperature of 100 degrees F. What should the nurse tell the mother?
| Differentiate between serious and expected side effects of vaccinations, and use the process of elimination to make a selection. As a secondary strategy, imagine that you are the caregiver; what reply would be most reassuring to you? |
4958 The pediatric clinic nurse explains to a parent that the Correct answer: 2 The first dose of the MMR is recommended at 12–15 months of age. The other immunizations child should receive the first dose of which vaccine at may be started earlier in life, according to the current immunization schedules. 12–15 months of age?
| To answer this question correctly, it is necessary to have an understanding of the immunization schedule. Again, you might need to memorize this time frame to be able to answer this type of question correctly. |
4959 The nurse is preparing to update a child’s diphtheria, Correct answer: 3 Because of the high fever (which could lead to seizures in very young children), the nurse pertussis, and tetanus (DPT) immunization. The mother needs to consult with the health care provider. The reaction might need to be assessed casually mentions that the child developed a fever of further, and the provider needs to determine how to proceed with the immunization schedule 104 degrees F after receiving his last DPT to protect the child from adverse effects. immunization. What action should the nurse take at this time?
| To answer this question correctly, it is necessary to have an understanding of adverse effects of immunizations, and of how to differentiate local or mild reactions from more serious ones. Use this knowledge and the process of elimination to make a selection. |
4960 What should the nurse tell a mother whose child is Correct answer: 1, 4 A mild fever is an expected side effect of immunizations, and can be treated safely and receiving the immunizations required at 1 year of age? effectively with acetaminophen (Tylenol). The immunizations are not given together (option 2), Select all that apply. the physician does not need to be called unless the fever is high (option 3), and a rash is of concern because it could indicate hypersensitivity, and needs to be addressed rather than treated at home (option 5).
| Differentiate between mild and severe adverse reactions to immunizations, and use the process of elimination to make the correct selections. |
4961 What advice can the nurse give a mother who is Correct answer: 1 A laboratory test called a titer can be used to detect whether the child has an adequate level concerned that her child does not have adequate of circulating antibodies against the varicella virus responsible for chickenpox. The statements immunity to chickenpox? in the other options are incorrect.
| Recall basic concepts related to how immunizations work, and use the process of elimination to make a selection. |
4962 What should the nurse tell a mother who is fearful of Correct answer: 1 The response in option 1 is honest, and provides full information to the mother. It is true that the dangers of vaccines and does not want her child to vaccines have some adverse effects, but the benefits in terms of disease prevention do receive immunizations? outweigh the risks. The statements in the other options either are falsely worded or do not provide the mother with adequate information.
| Recall basic concepts about immunizations, and select the response that addresses both the good points and possible bad points of immunizations. |
4963 A 17‐year‐old is planning to attend college after high Correct answer: 3 Immunizations are considered to be a prevention strategy during infant, toddler, and school‐ school graduation. The school nurse informs the age years. Most parents do not follow through with the elective boosters or vaccines, since student that a health care visit needs to be scheduled they are not required. The student will be exposed to many new people, and might be in a prior to the start of college. When the student asks different living environment, so there are immunizations to protect her. If the student has any why, the nurse should explain that it is for what health problems, or needs birth control or nutrition education, this would have been primary purpose? determined in questioning by the school nurse.
| Recall that people who live in crowded circumstances (such as college dorms) or are frequently in large groups (such as classrooms) are more likely to contract and spread communicable diseases. Use this knowledge to make a selection from the list of options. |
4964 A recently adopted 5‐year‐old Russian orphan has Correct answer: 1 Children younger than 10 years of age who are internationally adopted are not required to presented to the pediatrician’s office. The parents do have proof of immunizations prior to entry into the United States. Adoptive parents are not have reliable information regarding immunization responsible for immunization decisions. Titers can be drawn to assess immunity status. status. To evaluate the child’s needs, the nurse should: Immunizations should be initiated as soon as possible, to reduce the risk of contracting and spreading infectious diseases.
| Use general knowledge of the principles of vaccinations and legal rights to make a selection. |
4965 The father of a child who is about to receive routine Correct answer: 2 Vaccine risks and benefits always should be discussed with parents for informed decision vaccinations states, “I’ve heard my child can become making. Misconceptions are common. An informed consent form always should be autistic when given a measles shot. I don’t think this is documented. The nurse should not give personal opinions. Objective information is vital to the a good idea.” Which of the following would be the best decision‐making process. reply by the nurse?
| Keep in mind principles of client rights in making a selection for questions such as these. |
4966 The mother of a 15‐month‐old is anxious about the Correct answer: 1, 2, 3, The nurse should provide the current Vaccine Information Statement (VIS) to parents for each immunizations her child is about to receive. The nurse 5 vaccine the child will receive, as required by the National Vaccine Injury Act of 1986 and 1993. should provide information to the parents about Aspirin is contraindicated due to the risk of Reye’s syndrome. Immunizations should not be immunizations, including: (Select all that apply.) delayed if the child is healthy.
| Recall general information about immunizations, and use this information to recognize the common teaching points. Recall also that aspirin is contraindicated in children to prevent the risk of Reye’s syndrome to eliminate option 4 from your possible answer choices. |
4967 A 4‐year‐old is faced with the administration of a Correct answer: 3 Age‐appropriate choices and forms of distraction are needed to promote coping strategies vaccine booster shot. The nurse’s best approach will when performing painful procedures. EMLA cream must be applied at least one hour before be to: injections to be effective. Due to anxiety, needle size should not be discussed with the child. “Sticking” the child without warning will create a fearful situation.
| Consider the age of the child, and select the strategy that allows the client an age‐ appropriate choice in the process but that still accomplishes the goal of timely immunization. |
4968 The nurse has an order to give a 2‐year‐old girl who Correct answer: 1 When reconstituting vaccines, it is important to use the solution provided, and to follow the has cerebral palsy her measles, mumps, and rubella manufacturer’s directions. The pharmacist, pediatric nurse, and pediatrician are less reliable (MMR) vaccine after surgery for a hamstring release. sources because it is possible that they might be incorrect in their advice. The nurse is not familiar with the administration of this vaccine. To confirm proper administration of the vaccine, the nurse should consult which of the following resources?
| Use general principles of pharmacology to answer this question. This question is actually testing a simple principle. |
4969 The nurse teaches parents that which of the following Correct answer: 3 Immunizations may be given if the child has a mild illness, with or without fever. Anaphylaxis would constitute an absolute contraindication for a is a life‐threatening reaction to an allergen or antigen, and can occur again if the patient is repeat dose of a pediatric immunization? exposed to the offending allergen or antigen. Redness and soreness are common reactions, not contraindications, to immunizations. One month is too long a time period for febrile convulsions to be related to vaccine administration.
| Use the process of elimination, and associate the word “contraindication” in the question with the word “anaphylactic” in the correct option. |
4970 A 6‐year‐old child is to receive regularly scheduled Correct answer: 3 The child’s temperature will help the nurse decide if the child has a mild illness or a severe immunizations. The parent states the child is not one. Postponing the immunization might result in a missed opportunity if the parent does not feeling well, and asks the nurse to defer the keep the appointment. Missing school is not a contraindication for immunizations. The nurse immunizations until next week. The nurse’s best action should ask about previous reactions to immunizations, but this is not related to withholding act this time is to: the immunization because the child is not feeling well.
| Recall that vaccinations should be given on schedule unless there is a very good reason to defer them. In this instance, select the option that actually verifies that the child might have symptoms of an illness that could require deferment of the vaccine until a later time. |
4.‐ Give the parent an immunization appointment for next week. | |
4971 The nurse is discussing the risks and benefits of Correct answer: 4 The risk of encephalopathy from complications of measles and varicella is much greater than vaccines with a family, and must secure a signed, the risk of encephalopathy from being immunized. Wheals and urticaria are local, non‐life‐ informed consent for the children to be immunized. threatening allergic reactions that can occur within minutes of any immunization. A mild fever The nurse emphasizes that which of the following is a common reaction 24–48 hours after administration of the diphtheria, tetanus toxoid, and reactions to vaccines is very rare? acellular pertussis (DTaP) vaccine. A rash can occur 7–10 days after the administration of measles, mumps, and rubella (MMR) vaccine.
| Use knowledge of vaccines and their possible adverse effects, and the process of elimination, to make a selection. Take time to review local systemic reactions, if needed. |
4972 A 10‐year‐old child has just received his first Correct answer: 1 This child’s reaction describes angioedema, laryngeal edema, and respiratory distress, immunization of influenza vaccine. His lips begin to indicating impending anaphylactic shock. All other answer choices are possible reactions to swell, and he states, “It feels like my throat is closing immunizations, but are non‐life‐threatening. shut and my chest is tight when I breathe.” The nurse recognizes these signs as:
| Remember that the ABCs (airway, breathing, and circulation) are of high priority. When a child has a problem with his airway following vaccination, always consider that the child might be having an anaphylactic reaction. |
4973 The nurse prepares the second diphtheria, tetanus Correct answer: 4 Haemophilus influenzae type B (HIB) vaccine is given at 2, 4, 6, and 12–15 months of age (four toxoid, and acellular pertussis (DTaP) vaccine and a doses). None of the other vaccines can be given to a 4‐month‐old infant. Influenza (TIV) vaccine second inactivated polio vaccine (IPV) vaccine for an may be given yearly to infants between 6 months and 3 years of age. Measles, mumps, and infant who is 4 months old. Provided a separate rubella (MMR) vaccine is given at 12–15 months and 4–6 years of age (two doses). Varicella injection site is used for all injections, the nurse also (Var) is given at 12–18 months or anytime up to 12 years (one dose), and to children 13 years may give which immunization during this well‐child and older (two doses, 4–8 weeks apart). visit?
| Use specific knowledge of immunization schedules to make your selection. If this question was difficult, take time to review the schedule. |
4974 A parent reports that a 5‐year‐old child, who has had Correct answer: 4 Fifth disease manifests first with a flulike illness, followed by a red “slapped‐cheek” sign. Then all recommended immunizations, had a mild fever one a lacy maculopapular erythematous rash spreads symmetrically from the trunk to the week ago, and now has bright red cheeks and a lacy extremities, sparing the soles and palms. Varicella (chickenpox) and rubella (German measles) red rash on the trunk and arms. The nurse recognizes are unlikely if the child had all recommended immunizations. The rash of rubella is a pink that this child might have: maculopapular rash that begins on the face and progresses downward to the trunk and extremities. Roseola typically occurs in infants, and begins abruptly with a high fever, followed by a pale, pink rash starting on the trunk and spreading to the face, neck, and extremities.
| Use knowledge of various signs and symptoms of viral illnesses to make a selection. Recall that the bright red cheeks are a hallmark of fifth disease. |
4975 The charge nurse is developing plans to reduce the Correct answer: 2 Age‐specific care is care that most closely meets the needs of the hospitalized child at any stress of a hospitalized, chronically ill 8‐year‐old child. age. Although visitation of peers is important, open visitation is usually recommended only for Coping for this child will be improved if the nurse family members. Mutual decision making is beneficial for the child and family. Depending on arranges for the child to the status of the child’s illness and resources available, tutoring may be recommended.
| Use the process of elimination. Critical words in the stem are 8‐year‐old, which leads you to look for an option that matches the needs of a child of this age group. |
4976 A mother brings her 15‐month‐old son to the clinic. Correct answer: 3 Children crawl or pull their body along the floor by their arms by 8 to 10 months. This is a During the a nursing assessment, the mother makes growth and developmental milestone during infancy. For a 15‐month‐old child, the inability to the following comments. Which comment merits crawl is an abnormal finding, and it should be referred to the pediatrician for follow‐up. It is a further investigation? normal response for the infant to cry when left with others. Infants often become attached to security items, such as a blanket. Toddlers begin to display food preferences.
| Use the process of elimination and knowledge of growth and development to answer the question. The correct answer is the option that indicates that the child is not meeting developmental milestones. |
4977 An inexperienced mother is playing with her 8‐month‐ Correct answer: 1 Objects that can be grasped and banged together, such as blocks, are most appropriate for an old in the playroom. The nurse has taught the mother 8‐month‐old child. Such play with blocks develops manipulation skills. Pleasure is experienced about toys that are developmentally appropriate for from the feel and sounds of these activities. A wagon or large‐piece puzzle may be used by the child. The nurse will conclude that teaching has preschoolers and toddlers; rattles are recommended for infants (1 to 6 months). been successful when the mother selects which type of toy?
| Use the process of elimination and knowledge of growth and development to answer the question. The correct answer is the one that matches the physical development level of the child with the skills ability needed to use the toy. |
4978 The nurse is caring for a 7‐year‐old child scheduled Correct answer: 3 The use of dolls may decrease a child’s anxiety and fear if the nurse uses such aids to explain for surgery in the morning. While conducting what is expected. Brochures and videotapes are useful with explanations to adolescents. A visit preoperative teaching, the nurse would choose which from the surgeon is informative primarily with the parents. of the following visual aids to enhance the child’s learning about the perioperative experience?
| Use the process of elimination and knowledge of growth and development to answer the question. The core issue of the question is the most effective method of teaching to use with a school‐aged child. |
4979 A mother has brought her 4‐year‐old child for Denver Correct answer: 4 There are many reasons why a child would be uncooperative, including fatigue, illness, and II testing for routine assessment of social and physical fear. In order to get accurate results, the test should be rescheduled for another day, and the abilities. The child refuses to complete the testing. child should not be forced to undergo testing that day. The child’s behavior does not indicate What should the nurse do? developmental delay, and there is no evidence at this time that the child needs a specialist.
| Use the process of elimination and knowledge of growth and development to answer the question. Keeping in mind that the 4‐year‐old may be trying to assert independence and control, each of the incorrect options may be eliminated as less than optimal responses by the nurse. |
4980 The parents of a 16‐month‐old ask when they should Correct answer: 1 Children must have the physical and developmental capabilities to begin toilet training. They begin toilet training. Which of the following should be should be able to stand and walk well, pull pants up and down, recognize the urge to urinate or included in a response by the nurse? defecate, and be able to wait until they reach the potty chair.
| Use the process of elimination and knowledge of growth and development to answer the question. The core issue of the question is physical and mental readiness for toilet training. The wording of the question tells you that one answer is better than each of the others. |
4981 The grandparents of a 2 1 /2‐year‐old ask what would Correct answer: 1 Imitative behaviors teach the toddler new skills. Toddlers enjoy such toys as a play telephone. be an appropriate toy to buy their grandson. Which of Manipulation of toys develops both gross and fine motor abilities in this period. Paint‐by‐ the following should the nurse recommend? number sets and complex puzzles are recommended for school‐aged children. Musical mobiles are appropriate for infants.
| Use the process of elimination and knowledge of growth and development to answer the question. The core issue of the question is knowledge of appropriate play items for a toddler. |
4982 The nurse working in a pediatric nursing unit of a Correct answer: 2 Play is not recommended at bedtime. A quiet and calm environment will promote sleep. Play hospital utilizes the concept that therapeutic play is a very effective teaching intervention. It is often used before surgery and diagnostic tests to helps a child during illness. At which of the following enhance understanding of these events. Play is therapeutic to help the child express feelings times would the nurse avoid the use of therapeutic during stressful times. play?
| Use the process of elimination and knowledge of growth and development to answer the question. The core issue of the question is that therapeutic play must be used at appropriate times and in appropriate ways to be effective. |
4983 The nurse discusses the risk of aspiration with the Correct answer: 3 Toddlers chew well but may have difficulty swallowing large pieces of food. Young children parents of an 18‐month‐old. The nurse recommends cannot discard pits (such as from cherries). Firm foods such as peanuts and hard candies are the parents avoid giving their child which of the easily aspirated, while softer ones, such as cereal or raisins, are better tolerated. following food items to minimize this risk?
| Use the process of elimination and knowledge of growth and development to answer the question. The core issue of the question is knowledge of the physical abilities of the child to swallow foods at various ages. |
4984 The pediatric nurse is a guest speaker for general Correct answer: 1 Nutrition is the greatest influence on growth and development because diet supplies the health teaching in a prenatal class. In discussing factors nutrients needed to sustain physiological needs and for bodily growth, which then influences that promote positive growth and development, the overall development. Other factors such an income and exposure to secondary smoke nurse stresses that the most important factor is indirectly affect health, while ethnic background has significant influence on culturally based habits but not necessarily on biological growth and development.
| Use the process of elimination and knowledge of growth and development to answer the question. The core issue of the question is knowledge of priority factors affecting overall growth and development. |
4985 The nurse working in a sexually transmitted infection Correct answer: 3 Adolescents often think no harm can come to them, which places them at high risk for injury (STI) clinic of the city health department gives a tour to or disease from dangerous behaviors. The adolescent’s immune system is well developed. a group of student nurses. A student notes that the Urinary tract infections do not cause sexually transmitted infections. Not all adolescents lack clinic population consists largely of teenagers. The parental supervision. nurse explains to the group that adolescents are at a greater risk for contracting STIs because of which of the following factors?
| Use the process of elimination and knowledge of growth and development to answer the question. The core issue of the question is characteristics of adolescent growth and development. |
4986 The nurse working in a sexually transmitted infection Correct answer: 1 Nurses are credible sources of information, support, and encouragement that can help (STI) clinic uses communication skills to assess clients adolescents cope with challenges. To develop trust, honest and accurate information must be and to provide health education. When developing given to the client. The adolescent should be given the choice to have his or her parents rapport with a new adolescent client, it is important present because of the nature of the health problem, but treatment for STIs can be given for the nurse to do which of the following? without parental consent. The client should not smoke during discussions with the nurse for general health reasons.
| Use the process of elimination and knowledge of growth and development to answer the question. The core issue of the question is knowledge that honest communication builds trust in a therapeutic relationship, regardless of the client’s age. A concept that also applies is knowledge related to issues of informed consent for an adolescent. |
4987 The Denver Developmental Screening Test has shown Correct answer: 3 The infant at 6 months should have head control and is working on sitting without support. a 6‐month‐old infant is delayed in gross motor Pulling the child to a sitting position allows the neck muscles to support the head. Propping the development. Activities by the nurse aimed at helping child in a sitting position helps to develop self‐righting behaviors. It is too early to worry about the child attain appropriate developmental levels standing. Talking to the child promotes language development. Handling a rattle is fine‐motor would include which of the following? behavior.
| Use the process of elimination and knowledge of growth and development to answer the question. The core issue of the question is the abilities of a 6‐month‐old infant. |
4988 A child is delayed in language skills. Which of the Correct answer: 3 The best nursing diagnosis is the one that directly relates to the lack of language skills. With following would be the most appropriate nursing this data, there is no evidence of hearing disability (option 4). There is insufficient data in the diagnosis for this child? question to determine whether social isolation or parenting behaviors play a role in the language delay (options 1 and 2). Because a nursing diagnosis describes health promotion and health patterns that nurses can manage, the diagnosis of impaired verbal communication also gives the best guidance for appropriate nursing interventions.
| Use the process of elimination and knowledge of growth and development to answer the question. Note the linkage between language in the stem of the question and verbal communication in the correct answer. |
4989 The nurse needs to obtain a height on a 3‐year‐old Correct answer: 2 It is recommended that the child’s height be measured with a stadiometer. The correct child as a part of routine health screening. To obtain an procedure is to have the child remove his or her shoes and stand erect facing the examiner, accurate measurement, the child at this age should do holding the head erect. Shoulders, buttocks, and heels should touch the back of the wall. which of the following?
| Use the process of elimination and knowledge of growth and development to answer the question. The correct answer is the one that incorporates proper technique based on the developmental level of the child. |
| |
4990 The nurse admitting four children to the hospital unit Correct answer: 2 The 13‐month‐old will suffer from toddler hospitalization reaction, which is primarily related learns that none of the parents will be staying with the to separation from the parents. The 2‐month‐old has not recognized object permanence and children. The nurse would be most concerned with will not suffer from the hospitalization as long as his or her needs are met in a consistent adjustment to hospitalization and separation from fashion. The 8‐year‐old and the 14‐year‐old are accustomed to separation from parents and parents in the infant or child of which age? working with new adults.
| Use the process of elimination and knowledge of growth and development to answer the question. The core issue of the question is recognition of the client that is most at risk for separation anxiety from parents during hospitalization. |
4991 A toddler is admitted for severe anemia, which is Correct answer: 1 Excessive milk consumption should be discouraged, especially more than 1 liter/day (32 oz), found to be dietary in nature. To increase iron in the since it is a poor source of iron. Fat‐soluble vitamins will not increase absorption or utilization diet as a means of promoting healthy growth and of iron. Although grains and legumes are good sources of nutrients, they are not especially development, the nurse recommends to the parents high in iron. Foods high in protein should be encouraged, and especially food proteins of that they: animal origin and organ meats, such as liver.
| Use the process of elimination and knowledge of nutrition, growth, and development to answer the question. The correct answer is the one that would either decrease the intake of iron‐poor foods or increase the intake of iron‐rich foods. |
4992 The mother of a neonate states she is concerned Correct answer: 4 Object permanence is the knowledge that an object or person continues to exist when not about her relationship with the infant. She states the seen, heard, or felt. The baby will not attach to a single person, even the mother, until he or baby goes to anyone and doesn’t seem to care if she is she is aware of the mother’s existence. Options 1, 2, and 3 do not address this phenomenon. present or not. The nurse explains that prior to developing a dependence on the mother, the infant must develop which of the following?
| Use the process of elimination and knowledge of growth and development to answer the question. The core issue of the question is knowledge that a young infant has not developed an awareness of object permanence. |
4993 The nurse discusses swimming pool safety with the Correct answer: 2 Flotation devices are not a substitute for supervision by an adult. Young children should never parents of 4‐year‐old twins. Which statement identifies be left unattended in a swimming pool. Options 1, 3, and 4 all describe appropriate parental that more instruction is needed? behaviors to support safety in the area of swimming pools.
| Use the process of elimination and knowledge of growth and development to answer the question. The critical words need further instruction guide you to choose the option that represents a safety hazard to 4‐year‐olds using a pool. |
4994 The nurse prepares to transport a sedated 3‐year‐old Correct answer: 3 Toddlers should be transported in a high‐top crib with siderails up to ensure safety. The from the pediatric unit to the endoscopy department. sedated toddler is at risk for falls. A wagon, wheelchair, or gurney will not eliminate the risk of Taking into consideration the child’s developmental fall injury to a sedated toddler. stage and safety, how should he or she be transported to the area?
| Use the process of elimination and knowledge of growth and development to answer the question. The correct option is one that prevents the child from slipping out of the transport device while under sedation. |
| |
4995 A 50‐year‐old female comes to the clinic with Correct answer: 2 These are classic symptoms of menopause. The first approach to management is complaints of fatigue, breast tenderness, change in sex implementing lifestyle changes, including following dietary and exercise plans. Reducing drive, constipation, and abdominal bloating. Which of caffeine, salt, and sugar helps to reduce stimulation and water retention. With increased the following concepts would the nurse include in a activity, more calories are burned, raising levels of endorphins for feelings of well‐being and teaching plan for management of this condition? improving the glucose tolerance curve. Smaller meals are helpful so the client feels satisfied without overeating. This is not a psychiatric issue but a physiological adaptation to changing hormone levels; drugs for sedation or hypnotics are not necessary. Asking the family to talk about the problem could help, but exercise is necessary to help overcome other symptoms. Resting too much only frustrates the client by leading to additional weight gain and/or decreased feelings of self‐worth.
| Identify the age of the client and common problems associated with menopause. Then, use nursing knowledge and the process of elimination to choose the interventions that will be most helpful and that are within the scope of practice and teaching by the nurse. |
4996 When assessing middle‐adult clients in the Correct answer: 3 Women in the middle‐adult range often have a decreased intake of iron products, in addition community, what common disorder seen more in to a gradual loss of red blood cells from menstruation. Therefore, at this age anemia is more women than men would the nurse try to prevent common in women than men. After women reach menopause, the statistics change, and levels through health promotion programs? of coronary artery disease and hyperlipidemia increase to match those of men at this age. Osteoarthritis is not a gender‐based disorder but rather one of wear and tear on joints caused by lifestyle.
| Read the question carefully to determine the core issue, which is a problem that occurs in greater frequency in women than men during middle‐adult years. Use knowledge of various health problems and the process of elimination to make a selection. |
4997 When planning a menu for the older adult client, the Correct answer: 4 Older clients develop a slower metabolic rate and often decrease their activity at the same nurse should limit which of the following types of time. By reducing intake of refined carbohydrates, the calorie count meets the needs of the foods? body. In addition, the other options are recommended to minimize complications of atherosclerosis and constipation.
| Low‐fat dairy is recommended for minimization of arteriosclerosis and atherosclerosis, which have serious consequences when combined with the aging process. Whole grain is recommended to increase gut motility and prevent the constipation and bloating that comes with decreased peristalsis from loss of muscle mass as one ages. Alternate proteins, such as white meat or soy, are recommended rather than red meat, which contains high fat and cholesterol components. |
4998 When discussing health promotion with young Correct answer: 3 Younger adults as a group are at risk for improper eating habits and, if exercise is inadequate, working adults, the nurse should focus prevention this could lead to obesity. Obesity increases the risk of diseases such as atherosclerosis, measures on which of the following disorders? hypertension, and heart disease. Hypoglycemia (option 2) is not a common disorder among young adults. Cancer (option 4) occurs with greater frequency with increasing age, as does heart disease (option 1).
| The core issue of the question is identification of health risks that are more likely to occur in young adults. Use nursing knowledge and the process of elimination to make a selection. |
4.‐ Cancer | |
4999 When planning a health promotion program for Correct answer: 3 With economical changes in society and possible financial and childcare issues, there is an adults who have grown children, what topic would the increased incidence of children (and grandchildren) who are returning home to live with their nurse choose that addresses a current trend in family parents (or grandparents). For some, this may be the result of financial struggles and divorces units that could affect developmental tasks for these or broken relationships. In addition, the cost of long‐term care has forced many adults to be adults? the primary caregivers for their own aging parents. The trend is that the “sandwich” generation is now caring for both ends of the spectrum in addition to trying to subsist in a slowing economy.
| The critical words in the question are “a current trend.” To help make a selection, focus on this concept and on how the trend could cause adverse consequences in the older adult. |
5000 While working in the yard, a 76‐year‐old man Correct answer: 1 The client is experiencing symptoms of heat exhaustion. The first action is to remove the suddenly experienced diaphoresis, fatigue, and client from the heat (the outdoors). Moving the client to a cooler environment and letting him headache. What should be the priority in management rest with a single cool cloth behind his neck will allow the body to return to normal of this condition? temperature without any major complications. Excessively low temperatures or too many fluids can do more harm than good by lowering the body temperature too quickly, causing a circulatory collapse. With the current symptoms, the client’s reaction to heat does not include complete heat stroke or heat cramps. This is not necessarily a major medical emergency that demonstrates a need to call EMS or 911.
| The core issue of the question is which action by the nurse is needed to return the client to a state of homeostasis. Recall that older adults do not adjust as easily to temperature changes. Choose the option that, without being excessive or inadequate, restores the client to normal balance. |
5001 When trying to teach the older adult about the Correct answer: 2 Constipation in the older adult results from decreased fiber intake and decreased activity, management of constipation, the nurse explains that which are compounded by a decreased peristalsis from declining basal metabolic rate. which of the following is usually the actual cause of Although roughage might be an issue (option 1), the actual problem is the decreased acidity this problem? and digestive juices, along with the slowed peristalsis that causes the food to move more slowly through the intestines. Decreased muscle mass and decreased strength of the abdominal muscles also reduce the effectiveness of stool evacuation. Refined starches can exacerbate constipation, but do not directly cause bloating (option 3). Salt and sugar do not delay digestive juices; rather, digestive juices are slowed as part of normal aging (option 4).
| The core issues of the question are knowledge of the age‐related changes in the digestive tract, and client teaching to avoid constipation as an age‐related health problem. Read the question carefully, and use the process of elimination to make a selection. |
5002 A client taking sodium warfarin (Coumadin) at home Correct answer: 2 Anticoagulant therapy with Coumadin needs to be assessed in relation to dietary habits as for anticoagulant therapy has a prothrombin time (PT) well as understanding of medical administration. If the drug is taken as directed, the only other result of 15 seconds. The laboratory control normal is influencer is the dietary changes that impact the Coumadin. Green, leafy vegetables and liver 11–16 seconds. In light of this test result, which of the both contain vitamin K, and, when eaten too much, will decrease the effectiveness of following statements by the client demonstrates a Coumadin as an anticoagulant. Therefore, these foods change the effectiveness of Coumadin, need for additional teaching for health promotion? and modify the lab results. The statements in options 1 and 3 reflect practices that enhance client safety.
| For adequate management of any drug, the client must understand all of the influencing factors that would alter the drug s effectiveness. The client knew that the amount of liver in the diet should be left unchanged, but not that green, leafy vegetables also contained vitamin K, which modified the Coumadin dosage. Safety issues with sharps were clear, as was the significance of the time of day that the med was taken. Therefore, only the other dietary information needed to be clarified. |
5003 A family member reports that the client does not Correct answer: 2 The nurse s primary roles are to protect the client and maintain dignity within a safe hear well, and will not acknowledge the hearing loss. environment. By first speaking with the client to determine her perception of the problem, the This situation is becoming problematic and increasingly nurse can plan care around the client s problem. Talking to the family or telling the client what emotional for both the client and the family. What to do without addressing the client s feelings takes away client independence. Speaking very might the nurse suggest to deal with this problem? loudly and writing messages are not helpful in approaching the problem long‐term, and often these suggestions will further increase the client s anxiety. The client also might perceive hearing loss as a personal failure in the process of growing old.
| Consider that the loss of any sense puts the client s self‐esteem and self‐worth at risk. By not admitting that a hearing issue is present, the client might be able to maintain dignity. To determine whether this is occurring, begin with assessment the first step in the nursing process and validate the client s concerns about the hearing loss. |
5004 When trying to talk to an older adult client who has Correct answer: 4 When hearing loss is present, the best method of communicating with the client is to face the hearing loss, the nurse should do which of the client, get his attention, and speak in a deeper tone at a regular speed. The older adult loses following? the higher pitch tones first; therefore, yelling and raising your voice only changes the tone without clarifying the words. Talking loudly directly into the ear does not allow the client to see the speaker s facial expressions or nonverbal cues. Exaggerated speech and slow enunciation of words also will not assist the client with his understanding. Pointing or using a communication board is not helpful in maintaining the adult client s dignity.
| Choose the option that promotes the client s hearing, but that also tries to maintain normal communication. |
5005 An elderly client is reporting constipation. What Correct answer: 3 Constipation can come in many forms. One of the most common perceptions in the elderly is information does the nurse need first to determine the perception that they are constipated because they don t have a stool every day. Therefore, whether the problem is real or perceptual in nature? asking about perceptions will clarify whether this is an actual or perceived problem for the client.
| When first asking what the client expects, there is no confusion about what both parties are talking about. Once the understanding is achieved, the nurse can explore whether food, activity, or another issue might be the cause. A thorough assessment can identify the problem and provide the nurse with the information needed to plan the means of improving the situation. |
5006 When obtaining a health history from an older adult Correct answer: 3 Increasing isolation from others is not a healthy adaptation, although it is common when one male client, which of the following symptoms would spouse dies that the other needs to adjust to leisure time spent as an individual rather than as the nurse consider abnormal? part of a couple. Bladder and sphincter weakness are normal with the aging process. Decreased tolerance of spicy foods also results from decreased acidity and motility of the digestive processes, which are common in the aging process. Circulatory instability can occur when getting up too quickly, since the vasoconstriction process of the legs can be slower as one ages. Also, dehydration can lead to a feeling of slight dizziness when moving about.
| Recall the expected changes that occur in the various age brackets, and use the process of elimination to make a selection based on this knowledge. |
5007 When trying to assess for elder abuse, which of the Correct answer: 1 When trying to get all of the information possible, an open‐ended question could be following questions by the nurse would elicit the most answered in a variety of ways. By first restricting the focus of the conversation, the nurse is accurate information? trying to determine what daily activities are present in the client’s life. Withholding of food, pleasure, and activities can be identified/eliminated as problems when gathering the background data on care provided for the client.
| If asked, “Are you falling down?,” the client can easily answer, “Yes,” and then avoid sharing information that is difficult to speak about. Also, it is presumed in this answer option that the client s vision is impaired, which it might not be. This presumption is stereotyping, or an ageism myth. Asking only about weekends and fun would limit information about the events during the week that could clarify the abuse. Direct confrontation by asking about abuse is aggressive, and allows a yes/no response rather than an explanation of the situation. |
5008 Which common neurological change that occurs in Correct answer: 1 Vision and hearing commonly deteriorate as part of the normal aging process. Although the “healthy” elderly would the nurse expect to note options 2, 3, and 4 represent changes that take place in the neurological system, none of the when performing a client assessment? causes are directly related to the aging process. A disease process would change the others. Nerve damage can occur with diabetes or decreased blood flow from atherosclerosis. Dysuria and incontinence are related to relaxed muscle tone or sphincter damage. Peripheral neuropathy is a disease process that changes the sensations and motor function, such as diabetes mellitus.
| When assessing the neurological progress of a “healthy” elderly person, recall the normal changes that take place during the aging process. Recognize that only vision and hearing decline are applicable from the options listed. |
5009 What would be the nurse s focus when conducting Correct answer: 4 A healthy 30‐year‐old has the greatest risks related to lifestyle behaviors, such as multiple health‐promotion activities for healthy adults in their sexual partners, “on‐the‐edge” lifestyle (thrill seeking), haphazard dietary intake, speeding, and thirties, based on knowledge of the highest risks during not sleeping enough. Cancers of the breast, uterus, lung, or prostate are not the greatest risks this period of life? for a 30‐year‐old; rather, these are of greater concern for the older adult. Bone density testing for osteoporosis is often not recommended for the female in her thirties. Most women will test for this near menopause.
| Focus on the age of the client, and use knowledge of age‐related changes, risks for disease, and growth and development to make a selection. |
5010 What health promotion technique would be most Correct answer: 4 When the nurse provides neutral information, the middle‐aged adult can learn of risks effective for the nurse to use when working with without feeling personally attacked. A referral also allows the client to choose the timing of middle‐aged adults who demonstrate excessive the follow‐through. One cannot refer all clients who drink to detoxification units. Not all accept alcohol intake? their own diagnosis and are ready to begin the needed rehabilitation process. Limiting your counseling to only those clients who admit abuse will cause you to miss the high proportion of the population that is ETOH‐dependent. By avoiding talking to the client and going to the family/significant others first, you do not address the issue directly with the client.
| Choose the option that provides information and resources, but allows the client to be independent enough to choose her own options. |
5011 A 65‐year‐old female is admitted to the hospital with Correct answer: 2 Muscle mass and strength decline with age, and demineralization of the bones can occur due a broken hip from a pathological fracture. The client to hormonal changes and dietary losses. Demineralization of the bones allows them to be says, “I didn’t even know my hip was broken.” The easily fractured. Spinal curve changes also reflect the collapsing of bone in the spine, leading to nurse explains that fractures occur because of: kyphosis and shortened stature. Arthritis and inflammation of the joints do not lead to fractures, since an overgrowth of scar tissue occurs. Some bone‐on‐bone changes can occur, but generally, hip fractures do not fall into this category.
| Recall that osteoporosis occurs postmenopause, and pathological fractures can occur easily without much stress on the bone. When teaching the client about the cause of the fractures, explain that the demineralization of the bone occurs from hormone losses and lack of weight‐bearing activities. |
5012 The nurse should encourage the children of aging Correct answer: 2 Taking control over aspects of an adult s life when it is unnecessary does not respect or parents to adopt which strategy when working with recognize the client s value or worth. Alternatively, to allow clients to do whatever they want parents who have been less able to care for to do might not be safe, and could lead to harm, despite saving some self‐esteem. Financial themselves? issues are the most worrisome issues that must be dealt with, and taking them over also removes the independence of the client. A plan of care needs to be clarified when the adult has clear thought processes, and can delegate or make an Advanced Directive.
| Recall that allowing independence as long as possible gives dignity and self‐worth to clients. |
5013 The nurse should include which of the following Correct answer: 2 Nighttime vision is impaired in the “old‐old” adult years. Of the options presented, this is the important suggestions when discussing driving safety only one that allows dignity and safety within some guidelines. Warming up the interior of the with the “old‐old” adult? car is nice, but does not make the client a safer driver. Driving the speed that matches the flow of traffic might be dangerous, since in most areas, the flow is well above the restricted guidelines. In addition, reaction time is decreased among people in this age group, and staying with the flow might not give them time to react safely. Using the hearing aid is helpful, but vision is a greater risk than hearing. Yearly eye exams and appropriate treatment would be of greater benefit, so the client can more clearly see what is on the road.
| Note that this is an educational class for this age group. Recall that a key point related to safety would be that day vision is much better than night vision. |
5014 The nurse anticipates that there is likely to be an Correct answer: 4 Polypharmacy is using multiple doctors and multiple pharmacies to get the health care increased risk for major medical complications in the needed, often from a variety of specialists. Although taking over‐the‐counter medications on older adult client based on which common problem? one s own in combination with prescription meds can lead to problems, polypharmacy is a greater issue. Sharing medications could be an issue for some adults who want to assist others by providing medications that helped in their own cases. Financial issues could come into play, but this is also a less‐dangerous issue than is polypharmacy. Taking medications as ordered will not increase the risk of complications; it should reduce that risk.
| Recall that with polypharmacy, different prescribers might not be aware of what other prescribers have ordered. Recall that some drugs might interact with others, or that there is the possibility the client could be taking the same drug in different forms. Recall that overdosing and interactions become more common in these situations. |
5015 A 6‐hour‐old infant passes an unformed, black, tarlike Correct answer: 1 Meconium stools are tarry, black, or dark green, and are usually passed within 8–24 hours of stool. The nurse should conclude that this is a: birth (option 1). It is unusual to pass meconium at birth, unless there has been hypoxia or trauma (option 2). Transitional stools are thinner in consistency, with a brown‐to‐green appearance, and consist of part meconium and part fecal material. They are expected a few days later, after food has been digested (options 3 and 4).
| The core issues of the question are recognition and identification of meconium stool. The wording of the question indicates that only one option is correct. Use nursing knowledge to make a selection. |
5016 Following delivery, the nurse would first assess which Correct answer: 4 To begin life, the infant must make the adaptations to establish respirations and circulation. of the following two newborn body systems that must These two changes are crucial to life. All other body systems become established over a longer undergo the most rapid changes to support period of time (options 1, 2, 3). extrauterine life?
| A key word in the question is first, which indicates more than one option might be partially or totally correct. The question requires you to set priorities for assessment. Use nursing knowledge and the ABCs to make your selection. |
5017 A newborn s father expresses concern that his baby Correct answer: 1 The newborn s body grows in a head‐to‐toe fashion; therefore, uncoordinated movements of does not have good control of his hands and arms. The the hands and arms are expected, rather than abnormal (option 2). Mild hypertonia might be nurse would explain which of the following concepts in noted (option 3), and muscle tone should be symmetric (option 4). Diminished tone or response to the client, using wording that the client asymmetric movement could indicate neurological dysfunction. can understand?
| The core issue of the question is discriminating between normal and abnormal motor movements of a newborn. Use knowledge of growth and development to make your selection. |
5018 When caring for a newborn, the nurse must be alert Correct answer: 2 When an infant is stressed by cold, oxygen consumption increases, and the increased for what potential sign of cold stress? respiratory rate is a response to the need of oxygen. Additional signs of cold stress are increased activity level and crying (option 1), and hypoglycemia as glucose stores are depleted (option 3). Newborns are unable to shiver as a means to increase heat production (option 4).
| This question is eliciting knowledge of manifestations of cold stress. Make a connection between increased metabolic need (oxygen) from shivering and increased supply of oxygen (increased respiratory rate) to make a correct choice. |
5019 Which of the following physical assessment findings Correct answer: 3 Plantar creases are part of the physical maturity rating on the gestational age assessment. would be recorded as part of a newborn’s gestational Options 1, 2, and 4 may be observed but are not part of the gestational age assessment. age assessment?
| The key words in the stem of the question are gestational age. Eliminate options 1 and 2, which should be typical findings for all infants. From this point, use the process of elimination and nursing knowledge to choose option 3 over 4. |
5020 When planning client instruction on breastfeeding, Correct answer: 1 Prolactin and oxytocin, two hormones necessary for breast milk production and letdown, are the nurse includes that the amount of breast milk the released from the stimulus of the newborn suckling. The mammary gland of each breast is mother produces is directly related to which of the composed of 15–20 lobes (where milk is produced and travels to the nipple) arranged around following? the nipple. Breast size is related to adipose tissue (option 2). Neither newborn weight (option 3) nor nipple erectility is directly related to breast milk production (option 4).
| The wording of this question is straightforward and direct. Use nursing knowledge and the process of elimination to make a selection. |
5021 A healthy newborn was born at term. The first‐time Correct answer: 4 The full‐term infant exhibits greater‐than‐90‐degree flexion of the extremities, and clenched parents are very anxious. The mother asks why the fists. Stimulation will not relax the muscle tone (option 1). Placing the infant in a supine baby s hands are clenched, and why the baby s knees position will not decrease the flexed position (option 2), and parental anxiety does not cause and elbows are bent. The nurse s response should the flexed position (option 3). include an explanation that:
| The core issue of the question is a communication that includes a rationale for musculoskeletal status of the newborn. Use knowledge of growth and development, and the process of elimination, to answer the question. |
5022 Which of the following actions by a breastfeeding Correct answer: 2 The newborn should be brought to the breast, not the breast to the newborn; therefore, the mother indicates the need for further instruction? mother would need further demonstration and teaching to correct this ineffective action. Options 1, 3, and 4 are correct actions for successful breastfeeding.
| Note the key words further instruction. This tells you that the correct answer has incorrect information in it. Evaluate the truth of each option presented, and select as the correct answer the option that contains false information. |
5023 A mother is anxious about her newborn. She asks the Correct answer: 4 The cry of the newborn is tearless because the lacrimal ducts are not usually functioning until nurse why there are no tears when her baby is crying. the second month of life. Lacrimal ducts are naturally patent, and not punctured (option 1). The nurse s response incorporates the understanding Neither silver nitrate nor antibiotics will reduce tear formation (option 2). Exposure to rubella that: is not known to cause stenosis of the lacrimal duct (option 3).
| The core issue of this question is physical growth and development of the newborn. Eliminate option 1 first as obviously incorrect. Use knowledge of growth and development to choose option 4 over options 2 and 3, which are incorrect statements. |
5024 The nurse observes that when the newborn is supine Correct answer: 1 The tonic neck reflex, or fencing position, refers to the position the newborn assumes when and the head is turned to one side, the extremities supine with the head turned to one side. The extremities on that side will extend, and the straighten to that side while the opposite extremities extremities on the opposite side will flex. The Moro reflex occurs when the newborn is startled flex. The nurse documents this as: and responds by abducting and extending arms, with fingers fanning out and the arms forming a “C” (option 2). The cremasteric reflex refers to retraction of the testes when chilled, or when the inner thigh is stroked (option 3). Babinski's reflex refers to the flaring of the toes when the sole of the foot is stroked upward (option 4).
| The core issue of this question is knowledge of the normal reflexes of a newborn. Use knowledge of growth and development, and the process of elimination, to make a selection. |
5025 The nurse anticipates that a newborn male, estimated Correct answer: 2 A full‐term male infant will have both testes in his scrotum, with rugae present. Good muscle to be 39 weeks’ gestation, would exhibit which of the tone results in a more flexed posture when at rest (option 1) and inability to move his elbow following characteristics? past midline (option 4). Only a moderate amount of lanugo is present, usually on the shoulders and back (option 3).
| The core issue of this question is knowledge of physical findings of an infant according to gestational age. First note that the infant is 39 weeks, which is a term infant. Eliminate option 3 because of the word “abundant.” Then use knowledge of physical growth and development of the newborn to eliminate each of the other incorrect options. |
5026 If a newborn does not pass meconium during the first Correct answer: 4 The first meconium stool should be passed within the first 24 hours after birth; if not, the 36 hours of life, which of the following is the most abdominal girth should be measured to evaluate distention and the possibility of obstruction. appropriate action by the nurse? The presence of anal fissures will not prevent the passage of a meconium stool (option 1). Notifying the physician will not provide more information (option 2). Increasing the amount of feedings will not provide more information, and if there is an obstruction, will complicate that problem (option 3).
| Note the key words not and first 36 hours. This tells you that there is a problem with the infant s gastrointestinal status. From there, make a selection that gathers more assessment data. Eliminate option 1 as obviously incorrect. Eliminate option 3 because increased feedings would not be given if a problem were suspected. Choose option 4 over 2 because a physician is called when there is a composite set of data, not one assessment item. |
5027 During a physical assessment, the nurse palpates the Correct answer: 2 The hard and soft palates are examined to feel for any openings, or clefts. The frenulum is a newborn’s hard and soft palate with a gloved index ridge of tissue found under the tongue and usually does not affect sucking (option 1). A thrush finger. The mother of the infant asks the nurse to infection is usually visible as white patches adhering to the mucous membranes and does not explain what is being done to the infant. The nurse need to be felt (option 3). Saliva is normally scant and can be observed (option 4). replies that this assessment is done to detect which of the following possible problems?
| The question seeks to detect knowledge of the underlying rationales for newborn assessment. Use knowledge of physical assessment to eliminate incorrect options to make a final selection, noting the correlation between the words “palate” in both the stem of the question and the correct option. |
5028 A new mother asks the nurse, “Why are my baby’s Correct answer: 1 Acrocyanosis is a bluish discoloration of the hands and feet and may be present in the first hands and feet blue?” The nurse explains that this a few hours after birth, but resolves as circulation improves. Erythema appears as a rash on common and temporary condition known as which of newborns, usually after 24–48 hours of life (option 2). Harlequin color results as a vasomotor the following? disturbance, lasting 1–20 seconds, which is transient in nature and not of clinical consequence (option 3). Vernix caseosa is a cheeselike substance that protected the newborn s skin while in utero (option 4).
| Note the key words new mother in the stem of the question to determine that the infant is a newborn. From there, use the process of elimination and knowledge of newborn physical assessment findings to make a selection. |
5029 A new mother overhears a nurse mention “first Correct answer: 2 The first period of reactivity lasts up to 30–60 minutes after birth. The newborn is alert, and it period of reactivity” and asks the nurse for an is a good time for the newborn to interact with parents. The second period of reactivity begins explanation of the term. Which of the following when the newborn awakens from a deep sleep (option 1). The amount of respiratory mucus statements would be best to include in a response? may still be noted during this period (option 2). Mothers may sleep and recover during the newborn s sleep state (option 3).
| Note the key words first and reactivity in the stem of the question. This leads you to interpret that this will be the first time the infant is quite alert, which could then lead you to select the option that maximizes interaction between mother and infant after birth. |
4.‐ “The period ends when the amount of respiratory mucus has decreased.” | |
5030 The nurse would suggest which of the following to the Correct answer: 3 Physiologic jaundice is best treated by more frequent feedings to increase stooling and the mother of a breastfeeding newborn as the best excretion of bilirubin. Switching to formula undermines the mother s feeling of her ability to treatment for physiologic jaundice? provide nutrition for the newborn and may result in too‐early weaning (option 1). Supplemental water may lead the infant to take less breast milk, delay the breast milk supply, and cause the bilirubin level to increase (option 2). Withholding food from the newborn will provide inadequate nutrition and cause bilirubin levels to increase (option 4).
| The core issue of the question is what interventions a new mother can use to decrease physiologic jaundice. Eliminate options 1 and 4 first because they are extreme options (the words permanently in option 1 and nothing in option 4). Choose option 3 over 1 because it reduces jaundice. Choose option 3 over option 2 because it the provides nutrition, not just hydration, for the newborn infant. |
5031 In providing guidelines to follow when using Correct answer: 1 The top of the can and can opener should be washed with soap and water to remove concentrated formula for bottle feeding, the nurse microorganisms. The concentrate is mixed with an equal amount of water (option 2). Forcing should instruct new parents to do which of the an infant to finish a bottle after he seems satisfied may cause regurgitation and lead to infant following? obesity (option 3). Warming the bottle in the microwave can cause “hot spots” and burn the infant’s mouth (option 4).
| The core issue of the question is proper methods and techniques for bottle‐feeding an infant. Note the words to instruct, which tells you that the correct option is also a true statement. Use the process of elimination and nursing knowledge to make a final selection. |
5032 A new mother who is breastfeeding her infant asks Correct answer: 2 Breastfed infants will have 6–10 small, loose yellow stools per day during the first few the nurse, “What kind of stools will my baby have, and months. Options 1 and 3 are incorrect in number and consistency of stool, and option 4 is how many will there be during the next month?” incorrect with regard to color. Meconium may have a greenish color to it, but it is not a Which of the following would be the best response by permanent color. the nurse? “Your baby should have:"
| The core issue of the question is normal bowel elimination patterns for a newborn infant who is breastfeeding. A simple way to remember this is to remember that they are yellow, liquid, and frequent. Eliminate options 1 and 3 first because they are formed, and eliminate option 4 next because meconium stools do not last for a month. |
5033 Which behavior by the postpartum client would Correct answer: 3 Breastfeeding the infant every 2–3 hours or on demand will stimulate hormone production indicate that the nurse s breastfeeding teaching has which will, in turn, stimulate breast milk production and the letdown reflex. Breastfeeding been effective? every 4 hours may result in a decreased or delayed milk production (option 1). Allowing the infant to breastfeed only 3–5 minutes does not allow enough time for the milk ejection reflex to occur and may not allow for the letdown of the hindmilk, which contains a higher fat content (option 3). Supplementing with glucose water may cause nipple confusion in the infant and will decrease the infant s demand for breast milk, thereby decreasing supply (option 4).
| Note the key word effective in the question, which indicates that the correct response is also a true statement. Read each option and eliminate the incorrect ones because they are false statements. Use knowledge of breastfeeding methods and techniques to guide your response. |
5034 The nurse’s admission assessment of a 3‐hour‐old Correct answer: 2 The expected response for the sucking reflex is that the newborn will suck the object placed newborn reveals all of the following findings. Which in his mouth, not lick it. Option 1 is the expected response for the grasp reflex. Option 3 is the finding indicates a need for further assessment? expected response for the trunk incurvation (Gallant) reflex. Option 4 is the expected response for the rooting reflex. | The key words further assessment indicate that the correct answer is an option that contains abnormal or questionable data. The core issue is knowledge of newborn physical assessment data. Use the process of elimination and nursing knowledge to make your selection. |
| |
5035 The nurse observes a newborn in respiratory distress Correct answer: 3 Clearing the airway is best done by suctioning the airway. Slapping on the back may cause because of excessive oropharyngeal mucus. The first aspiration (option 1). Starting CPR and calling the code team are not necessary (options 2 and action by the nurse is to: 4) at this time.
| Remember ABCs. The correct action would be the option that contains a true statement about maintaining a clear airway. |
5036 During a physical exam of a newborn with Correct answer: 4, 5 Abduction is limited in the affected leg. The nurse would also find asymmetrical gluteal folds developmental hip dysplasia, which of the following and an absent femoral pulse when the affected leg is abducted. assessment findings would the nurse expect to obtain? Select all that apply.
| The key focus of the question is abnormal assessment findings associated with hip dysplasia. Eliminate options 1, 2, and 3 because they are not associated with this disorder. |
5037 The nurse would expect to note which of the Correct answer: 4 Initial responses are triggered by physical, sensory, and chemical factors. The chemical factors following findings during the initial respiratory include a decreased oxygen level, increased carbon dioxide level, and a decrease in the pH as a adaptation period of a newborn? result of the transitory asphyxia that occurs during delivery. Oxygen is not increased in the blood (option 1). Rapid respirations and nasal flaring indicate a poor adaptation (option 2). The newborn's respiratory rate is not hyperresponsive to stimuli (option 3).
| The key focus of the question is normal respiratory adaptation after birth. Eliminate option 1 because oxygen is not increased in the blood. Eliminate option 2 because rapid respirations and nasal flaring indicate a poor adaptation. Eliminate option 3 because the newborn's respiratory rate is not hyperresponsive to stimuli. |
5038 A newborn undergoing phototherapy for jaundice Correct answer: 3 Infants undergoing phototherapy will need additional fluids to compensate for the increased experiences increased urine output and loose stools. fluid loss through the skin and loose stools. Decreasing the time in phototherapy needs a The nurse should take which of the following actions? physician's order (option 1). Losing excess fluid can cause dehydration leading to a life‐ threatening event (option 2). Instituting enteric isolation is not necessary as there is no risk of infection from the stools (option 4).
| Recognize these assessment findings as expected for a newborn undergoing phototherapy but increasing the risk for dehydration. The correct answer would be the option that contains a nursing action to decrease the risk for dehydration. |
5039 A term newborn weighs 3,405 grams (7 pounds, 8 Correct answer: 2 Most infants, whether breastfed or formula‐fed, average a weight gain of 4–7 ounces per ounces). The parents question how rapidly their baby week during the first six months. An infant's weight triples by 1 year (option 1). A pound a should grow. Which response by the nurse is correct? month for six months is an insufficient weight gain (option 3). One pound per week for the first six months represents an excessive weight gain (option 4).
| Knowledge of the normal weight gain for the infant will aid in choosing the correct answer. |
4.‐ Most babies gain a pound a week for the first six months. | |
5040 Five hours after birth, an infant is awake and alert. Correct answer: 1 The respirations are within normal limits and periodic breathing with short periods of apnea The respiratory rate is 44 per minute, shallow, with may be expected at this age. The nurse should continue routine assessment. Even though heart periods of apnea lasting up to five seconds, and the rate is at the upper end of the normal range, the infant is pink with no central cyanosis. heart rate is 160 beats per minute. The skin is pink Cyanosis on the soles of the feet is to be expected (option 1). The infant is not displaying signs except for some cyanosis on the soles of the feet. of cold stress (option 2) or the need for oxygen (option 3). The clinician need not be called at Based upon this assessment data, the nurse should: this time (option 4).
| The key focus of the question is normal assessment findings for the newborn at this time. The correct answer would be the option that continues the current plan of care. |
5041 The nurse who is estimating a newborn's gestational Correct answer: 2 Maternal conditions such as pregnancy‐induced hypertension (PIH), diabetes mellitus, and age should utilize the concept that assessment criteria: medications the mother received during labor may affect certain gestational age components. Assessment criteria do not have to correlate with the composite score (option 1), nor do they always correlate with the weeks of pregnancy (option 3). Assessment criteria are equally useful in assessing postmaturity and prematurity (option 4).
| Knowledge of how to estimate gestational age of the newborn will aid in determining the correct answer. Eliminate options 1 and 3 because assessment criteria do not have to correlate with the composite score, nor do they always correlate with the weeks of pregnancy. Eliminate option 4 because assessment criteria are equally useful in assessing postmaturity and prematurity. |
5042 A newborn's temperature drops when placed on the Correct answer: 1 Conduction is the transfer of body heat to a cooler surface, the infant seat. Convection is the cool plastic surface of an infant seat. The nurse heat loss to a cooler air current (option 2). Evaporation is the heat loss through conversion of a explains to a nursing student that this is an example of liquid to a vapor (option 3). Radiation is heat loss to a cooler solid object not in contact with heat loss via: the infant (option 4).
| Knowledge of the avenues of heat loss from the body surface to the environment will aid in determining the correct answer. |
5043 A new breastfeeding mother tells the nurse that she Correct answer: 2 After lactation is well established between 3 and 4 weeks after the birth, the father can give a wants her husband to give the baby at least one bottle relief bottle of pumped milk. Giving supplemental bottles of formula daily can prevent the of formula a day. The nurse should give which of the letdown reflex from being established and may result in engorgement. Husbands can following information? participate in other ways the first few weeks through diapering, burping, bathing, and infant massage.
| Knowledge of how to successfully initiate and maintain breastfeeding will help to identify the correct answer. |
5044 The nurse would suggest which breastfeeding Correct answer: 3 The football, or clutch, position provides the mother with more control of the newborn's position to allow a new mother to have the best head and full view of face. The lying‐down position is usually done in bed (option 1). The cradle control of her newborn's head and give the mother a position often causes the newborn's head to wobble around on the mother's arm (option 2). full view of the infant's cheeks and jaw? Options 1, 2, and 4 do not allow full view of the infant's face.
| The critical words in the question are "full view of the infant's face." Eliminate options 1, 2, and 4 because they do not allow full view of the infant's face. |
4.‐ The across‐the‐lap position | |
5045 When a newborn is 2 days of age, the nurse hears a Correct answer: 2 The foramen ovale is an opening between the right and left atria that should close shortly murmur over the right and left auricles of the after birth so the newborn will not have a murmur or mixed blood traveling through the newborn's heart. The nurse concludes that this may vascular system. Options 1, 3, and 4 are incorrect, as they do not connect the right and left represent a patent: atria.
| The critical concept in question are right and left auricles. The correct answer is the option that references a structure located between the right and left atria of the heart. |
5046 The maternal–newborn nurse formulates which of Correct answer: 3 One of the nursing goals of newborn care during the first few hours after birth is to identify the following as a nursing goal for a newborn in actual and potential problems that might require immediate attention. Options 1, 2, and 4 are transition within the first few hours after birth? all considered to be continuing care goals. All of these should be carried out after the initial goals are met.
| This question is time‐related. The transition period occurs in the first four hours after birth, when the newborn transition to extrauterine life is most critical. The correct answer would be the option that contains an action to ensure assessment and safety during this critical period of adjustment. |
5047 The nurse conducts a neurological assessment of the Correct answer: 1, 4 The usual position of the infant is partially flexed, and all movements should be symmetrical. newborn. Which of the following findings indicate the Any weak, absent, asymmetrical, or fine jumping movements suggest nervous system disorders need for further evaluation? Select all that apply. and indicate the need for further evaluation. Common reflexes found in the normal newborn include Babinski's or plantar, fanning, and hyperextension of the toes when the sole is stroked upward from the heel toward the ball of the foot; the grasping, stimulating the newborn to grasp on an object by touching the palm of the hand; and the stepping, placing one foot in front of the other as though walking in response to one foot touching a flat surface.
| This question is worded as a negative statement. The correct answer would be the options that contain abnormal assessment findings that warrant further investigation. |
5048 Most newborns void in the first 24 hours after birth. Correct answer: 1 Uric acid crystals in the urine may produce the reddish "brick dust" stain on the diaper. Mucus The nurse interprets that which of the following has and urate do not produce a stain. Bilirubin and iron are from hepatic adaptation. caused a reddish stain, sometimes called "red brick dust," after noting this on the newborn's diaper?
| The focus of the question is a colored stain in the diaper. The correct answer would be the option that contains a true statement. Options 2, 3, and 4 can be eliminated because these substances do not leave a red stain in the diaper. |
5049 A nurse providing care to a newborn would use which Correct answer: 3 The newborn cannot limit the invading organism at the port of entry. Options 1, 2, and 4 are of the following concepts underlying adaptation of the true adaptations in other body systems. newborn's immune system when planning nursing care?
| Because the question is worded in a positive manner, the correct answer would be the option that contains a true statement about adaptation in the immune system of the newborn. Eliminate options 1, 2, and 4, as they do not contain information related to immune function. |
5050 The nurse trying to prevent heat loss in the newborn Correct answer: 1 The flexed position of the term infant decreases the surface area exposed to the interprets that which of the following physical environment, thereby reducing heat loss (option 1). Blood vessels are closer to the skin than in characteristics serves to decrease a newborn's loss of an adult and constrict when exposed to cooler temperatures (option 2). Limited subcutaneous heat? fat will increase a newborn's heat loss (option 3). Larger body surface than an adult increases the newborn's heat loss (option 4).
| The focus of the question is conservation of heat in the newborn. Eliminate options 2, 3, and 4 because they would promote heat loss. |
5051 A postpartal client is bottle‐feeding her newborn. The Correct answer: 2, 5 Small amounts of regurgitation of formula are common, often caused by "overfeeding" or an nurse should teach her that when her baby immature cardiac sphincter (option 2). Regurgitation of formula is not necessarily a sign of regurgitates small amounts of formula, she should: infection, or a reason to take a temperature (option 1), or discontinue a feeding (option 3). (Select all that apply.) Vomiting or forceful or persistent expulsion of formula should be further investigated (option 4).
| Because the wording in the stem of the question is positive, the correct option(s) will all be true statements. Knowledge of normal newborn care related to bottle‐feeding will aid in answering this question correctly. |
5052 A mother recently gave birth to her second child. She Correct answer: 4 Mothers are encouraged to offer both breasts to the infant in the beginning for simultaneous began breastfeeding in the birthing room. An stimulation, but it is not imperative or harmful if the infant doesn't feed off of one breast at a appropriate nursing intervention would be to suggest session. Giving supplemental feedings can upset the natural supply and demand and can that the mother, for now: shorten the breastfeeding experience (option 1). Prolonged exposure to plastic liners or wet nursing pads may result in skin breakdown (option 2). Time limits should not be imposed on breastfeeding infants, as they each have different styles of suckling (option 3).
| The question is worded in a positive manner, so the correct option is a true statement. Knowledge of breastfeeding will aid in answering this question correctly. |
5053 A postpartal client has decided to bottlefeed her Correct answer: 4 Opened cans of formula must be used within a 24‐hour period (option 4). There are no infant. The nurse would teach the client that which of nutrients in whole milk that can enhance formula, and the Academy of Pediatrics strongly the following is an acceptable guideline for the use and recommends that infants only take mother's milk or formula for the first 12 months of life to storage of canned formula? decrease the chance of allergies (option 1). Tap water is not always safe (option 2). Any formula not taken by the infant should be disposed of as bacteria from the infant's mouth can enter the bottle and contaminate the remaining formula (option 3).
| The correct answer would be the option that contains a true statement about a point of client education. Knowledge of contraindications for storage of infant formulas will aid in answering the question correctly. |
5054 The nurse is assisting a new mother in breastfeeding. Correct answer: 3 Audible swallowing during a feeding produces sounds heard as a soft "ka" or "ah." Burping is The mother asks how she will know if her infant is related to how much air the infant swallows during feedings (option 1). Newborns usually getting anything from her breasts. The nurse's spend 15–20 minutes at the breast in the first few weeks. Some older infants may be able to response is that the best indicator that the infant is finish a feeding in 3–5 minutes (option 2). Because breast milk is more digestible than formula, getting breast milk is: and a newborn's stomach is small, feeding is usually needed more frequently than every four hours. Frequent feedings are important in the early days to establish lactation (option 4).
| Because the question is worded in a positive manner, the correct option is a true statement. Knowledge of breastfeeding will aid in answering the question correctly. |
5055 A newborn's head circumference is 34 cm and chest Correct answer: 4 This finding is normal. No further action is required. circumference is 32 cm. Which nursing action would be appropriate?
| The key focus in the question is normal assessment findings. The correct answer would be the option that contains the accurate documentation of the information with no additional action. |
5056 The nurse tests the newborn's Babinski's reflex by Correct answer: 4 Babinski's reflex is elicited by stroking the lateral aspect of the sole of the heel upward and doing which of the following? across the ball of the foot. A positive test (in newborns) of fanning the toes and dorsiflexing the big toe is an indicator of fetal well‐being. Touching the corner of the mouth or cheeks (option #1) elicits the rooting reflex. Changing the newborn's equilibrium (option #2) elicits the Moro reflex. Placing a finger in the palm of the newborn's hand (option #3) elicits the palmar grasp reflex.
| Recall that Babinski's reflex involves a response of the newborn's foot. Eliminate the options that do not include assessment of the foot |
5057 A new mother questions the nurse about the "lump" Correct answer: 3 Cephalhematoma is a collection of blood between the skull bone and its covering on her baby's head and says the physician told her it (periosteum). Caput succedaneum is swelling of the tissue over the presenting part of the fetal was a "collection of blood between the skull bone and head caused by pressure during labor. Molding refers to the overlapping of cranial bones or its covering (periosteum)." The nurse explains that this shaping of the fetal head to accommodate and conform to the bony and soft parts of the is called: mother's birth canal during labor. Subdural hematoma refers to bleeding between the dural and arachnoid membranes of the brain.
| Knowledge of the definition of cephalhematoma will aid in answering this question. |
5058 Risk management, a standard for nursing care, Correct answer: 3 The normal range is 120–160 beats/min. The rate varies with activity, increasing to 160 while requires the nurse to evaluate all assessment findings. crying and decreasing to 120 while in deep sleep. Bradycardia, rates below 120 (included in To uphold that standard, the nurse assesses a newborn options #1 and #2), and tachycardia, rates above 160 (included in options #2 and #4), are not and should find that the heart rate is within which of normal and require further evaluation and intervention. the following ranges within 3 minutes of birth?
| The focus of the question is normal assessment findings. Options #1, 2, and 4 can be eliminated because they contain abnormal findings. |
5059 The nurse notes the results of assessment for which Correct answer: 3 After 12 hours, the edema of tissues present in most newborns begins to resolve and creases of the following criteria of gestational age, which must appear; these creases do not have the same predictive value as those assessed before be determined within 12 hours of birth for valid resolution of newborn edema (option #3). All of the criteria in options #1, 2, and 4 remain results? predictive beyond the first 12 hours after birth.
| This question is time‐related. The correct answer would be the option that contains a true statement for this period of time after birth. Knowledge of normal newborn care is essential to answer the question correctly. |
5060 A newborn is admitted to the nursery 15 minutes Correct answer: 2 These symptoms reflect cold stress and require the temperature to be taken immediately after birth. He is moderately cyanotic, has a mottled (option #2). These symptoms are not associated with bleeding from the umbilical stump trunk, active movement of the extremities, and is (option #1), congenital abnormalities (option #3), or respiratory distress (option #4). wrapped in a cotton blanket. The primary assessment by the nurse would be to check:
| The key focus of the question is abnormal findings related to cold stress. The critical word in the stem is cyanotic. The correct answer would be the option that contains a true assessment for cold stress: the temperature of the newborn. |
5061 The nurse observes that a client, who is one day Correct answer: 4 Periodic breathing with no color or heart rate changes is normal in the newborn adapting to postpartum and breastfeeding her first child, appears extrauterine life. Option #4 provides verbal reassurance and also physical reassurance by the frightened. The client says, "The baby has been presence of the nurse. Option #2 doesn't reassure the mother and option #3 confirms the breathing funny, fast and slow, off and on." To mother's fears. Option #1 provides information but doesn't address the mother's subjective reassure the client, a nursing response would be: sense of fear.
| Use of therapeutic communication techniques is the key to answering communication questions. The correct answer is the one that provides factual information and also addresses the client's concern or worry. |
5062 Which behavior observed by the nurse indicates good Correct answer: 1, 5 Keeping the infant close with head elevated is an optimal position for bottle‐feeding. Keeping bottle‐feeding technique? The mother: (Select all that the nipple full of formula prevents the infant from sucking air. Options #2 and #4 can cause apply.) aspiration of formula and option #3 could cause the infant to gag and vomit.
| The question is worded positively, indicating that the correct options are also correct actions. Use principles related to prevention of aspiration to help make your selections. |
5063 A mother is beginning to experience nipple Correct answer: 2 Discomfort while breastfeeding is almost always caused by improper latch‐on. Removing the discomfort while breastfeeding. The nurse's first infant from the breast and repositioning with proper position can reduce the discomfort. priority in the plan of care would be to: Having the mother pump and give the breast milk from a bottle can interfere with the breastfeeding process and may cause nipple confusion. Giving the mother a nipple shield to wear and having the mother breastfeed from the uninjured nipple will not solve the poor latch‐ on, and feeding from one breast will cause engorgement in the other breast.
| The focus of the question is nipple discomfort, commonly caused by poor positioning of the newborn while feeding. The correct answer would be the option that contains a true statement aimed at correct positioning of the infant. |
5064 A mother asks, "Is it true that breast milk will prevent Correct answer: 1 Breast milk will not protect the baby from all illnesses. Lactoferrin (a whey protein in human my baby from catching colds and other infections?" milk) inhibits the growth of iron‐dependent bacteria in the GI tract together with secretory IgA The nurse should make which of the following replies (another whey protein in human milk), which protects against respiratory and GI bacteria, viral based on current research findings? organisms, and allergies. Breast milk does have other enzymes and proteins that protect the infant from illness.
| The wording of the question indicates the correct option is also a true statement of fact. Knowledge of breastfeeding will aid in answering the question correctly. |
5065 A goal on the nursing care plan is “to facilitate Correct answer: 1 Bonding occurs best when parents have direct and prolonged contact with their newborn in a parent–infant bonding.” To which of the following supportive environment. Although the other answers may be appropriate, they would not be interventions should the nurse give priority in attaining the priority in facilitating bonding. this goal?
| The word priority in the stem of the question indicates that more than one or all options may be partially or totally correct. Identify the key issue as parent–infant bonding. Compare each option in terms of its ability to stimulate attachment, and then use the process of elimination to make a final selection. |
5066 The nurse identifies that teaching has been effective Correct answer: 2 Regression to previous behaviors is normal in young children when a new sibling is brought when a postpartum client states, “When we bring the into the family. An example for a 2‐year‐old is drinking from a bottle again, which is baby home, my 2‐year‐old:" characteristic of an earlier stage of growth and development. The other options represent items that are expected to happen in future growth and development, but would not be characteristic of the expected regression.
| Use knowledge of concepts related to growth and development to answer this question. Focus on the issue of the question, regressive behavior, to make the appropriate selection. |
5067 A postpartum client who delivered 3 hours ago states, Correct answer: 4 It is possible that a significant amount of lochia could pool beneath the client after delivery. “I feel all wet underneath.” Which of the following The highest priority at this time is risk for hemorrhage, and this should be the initial should be the initial action of the nurse? assessment. Options 1 and 3 could then follow. Option 2 is irrelevant to the question as stated.
| The key word initial in the stem of the question tells you that more than one or all actions are potentially correct, but one is better than the others. Focus on the ABCs (airway, breathing, and circulation) and on risk of hemorrhage to make your selection. |
5068 After delivering a 9‐pound, 10‐ounce baby, a client Correct answer: 1 Uterine atony is the most common cause of early postpartum hemorrhage. This client is at who is a gravida 5, para 5 is admitted to the greater risk for hemorrhage because she had an overdistended uterus with a large baby, and postpartum unit. Priority nursing care for this client she is a grand multipara. Parity does not influence dehydration. The client may be at risk for should be to: thromboembolism, but there is no indication passive range of motion should be implemented rather than early ambulation. Nutritional assessment is important, but there is no indication the client is anemic and this action is not the priority for the client.
| The key word priority in the stem of the question tells you that more than one or all actions are potentially correct, but one is better than the others. Consider that the core issue of the question is uterine atony and associated risk of hemorrhage. Then focus on the ABCs (airway, breathing, and circulation) and on the risk of hemorrhage to make your selection. |
5069 Although a client initially wanted to breastfeed, she Correct answer: 4 Mothers who are bottle‐feeding should be encouraged to suppress milk production by has now decided to bottle‐feed her baby. The nurse wearing a snug bra or breast binder, applying cold compresses, and avoiding breast stimulation concludes that teaching regarding breast care for this until primary engorgement subsides. Pumping the breasts and applying lotion to them (options client has been effective when the client makes which 1 and 2) are forms of breast stimulation that should be avoided; option 2 is not helpful anyway. of the following statements? Applying heat via a warm bath (option 3) will also stimulate the breasts and should not be done.
| The core issue of the question is measures that will reduce breast stimulation and milk production. With this in mind, eliminate options 1 and 2 as mechanical stimulants, and then option 3 as a thermal stimulant. |
5070 When teaching a new mother how to breastfeed, the Correct answer: 3 It is important for a breastfeeding mother to break the infant s suction on the nipple before nurse should include which of the following removing the baby from the breast. This will help prevent the nipples from becoming sore and interventions? the skin from cracking. The nipples should be cleansed with water after each feeding, but soaps can be harsh or irritating. The client should alternate between the right and left breasts for first use at each feeding. Milk production and supply is enhanced when no supplementation is used.
| The wording of the question indicates that there is one clearly correct answer. Use nursing knowledge to systematically eliminate each incorrect option based on appropriate breastfeeding techniques. |
5071 The nurse is caring for a client who delivered vaginally Correct answer: 1 Application of heat to the perineum 2 hours after delivery will cause vasodilation, and 2 hour ago. The client’s fundus is firm at 1 centimeter increase the client s risk of edema and hematoma formation. Ice should be applied for the first below the umbilicus and vital signs are stable. She 24 hours. Other interventions presented are appropriate. received meperidine (Demerol) IV 4 hours ago for labor pain. The nurse should question which of the following new orders from the physician?
| The core issue of the question is knowledge of the effects of heat and cold on a client who is newly postpartum. Note the key word question, which tells you that the correct answer is an incorrect item. Eliminate each item that is an acceptable part of care and choose the option that increases the client’s risk through application of heat instead of cold. |
5072 The nurse should notify the physician immediately of Correct answer: 4 A steady trickle of blood in the presence of a firm uterus could indicate the presence of a which of the assessment findings? vaginal or cervical laceration. The physician should be notified immediately so further evaluation can be initiated. The other findings are normal.
| The key words notify . . . immediately indicate that the correct answer is an abnormal finding. From this point, use nursing knowledge and the process of elimination to make a selection. The words steady trickle of blood are also a strong clue that this is the correct answer. |
5073 A client had a cesarean delivery 12 hours ago. Pain Correct answer: 3 This client is at risk for respiratory depression related to the administration of Morphine. For management includes a patient‐controlled pump for this reason, ineffective breathing pattern is of greatest concern. Remember airway, breathing, the administration of Morphine (morphine sulfate). and circulation as priorities for patient safety and promoting maintenance of health. Which nursing diagnosis, if formulated for the client, is Constipation could also occur but is not as high a priority. Morphine should help to alleviate the highest priority? the pain and could have the next highest priority after making certain that respirations are not affected. There is no basis in the question as stated for ineffective family processes.
| The core issue of this question is knowledge of key adverse effects of opioid analgesics. Use this knowledge and the ABCs (airway, breathing, and circulation) to choose this over the other competing nursing diagoses. |
4.‐ Pain | |
5074 Three hours after a vaginal delivery, the client Correct answer: 1 The first step of the nursing process is assessment. Increased perineal pain in a client with a complains of increased perineal pain. What should the vaginal delivery could be a normal process as delivery anesthetics administered locally wear nurse do first? off. It could also indicate abnormal processes, such as the development of a hematoma. Assessment of this client is needed prior to intervention.
| Analyze the question to determine that there is not enough information to guide nursing intervention. When more information is needed, an option that provides for further assessment is a good choice. |
5075 The nurse notes that the postpartum client is Rh‐ Correct answer: 3 An indirect Coombs' test assesses for the presence of Rh antibodies in the maternal blood. negative and her baby is Rh‐positive. Which maternal Direct Coombs' test and bilirubin tests are conducted on the newborn. Hemoglobin is not a laboratory result should the nurse review next in determinant for the administration of RhoGAM. determining if the client is a candidate for RhoGAM?
| The core issue of the question is the effect of an Rh‐positive newborn on an Rh‐negative mother. Use nursing knowledge to select the laboratory test that will directly evaluate the mother rather than the newborn. |
5076 A postpartum client’s hemoglobin is 9.2 mg/dL after Correct answer: 2 Iron absorption is enhanced when taken with vitamin C, and orange juice is a good source of delivery, and she has been instructed to take an iron vitamin C. Darker‐colored stools and constipation (not diarrhea) are common side effects of supplement at home. The nurse should include which iron administration. Iron should not cause impaired judgment or dizziness that would impair of the following instructions when teaching the client safety while driving. about this medication?
| The core issue of the question is knowledge of administration and effects of iron as a supplement. Use the process of elimination to make the selection. Eliminate option 3 first because it is the least plausible, then eliminate options 1 and 4 based on knowledge of pharmacology. |
5077 While assessing a postpartum client, the nurse Correct answer: 2 Homans' sign is tested for by extending the leg and dorsiflexing the foot. This assessment is extends the client’s leg and dorsiflexes her foot. The indicated in the postpartum because of the increased risk for thromboembolism. Sharp pain in client asks why the nurse is doing this. The nurses best the calf is a positive sign. Uterine infection would be indicated by fever, pain, and foul‐smelling response is that this maneuver: lochia. Joint mobility is best maintained by early ambulation. This sign has no effect on afterpains during breastfeeding.
| The core issue of this question is proper identification of the purpose of testing for Homans' sign. Use this factual information to systematically eliminate each incorrect option. The wording of the question tells you that only one option contains a true statement. |
5078 The nurse is teaching a new mother how to Correct answer: 4 The baby should be positioned with the head midline and with the abdomen toward the breastfeed her infant. Which of the following mother’s abdomen. Positive reinforcement will facilitate the development of maternal interventions should the nurse plan to include in the competence and confidence in infant care. teaching plan?
| The core issue of this question is proper breastfeeding techniques. Use factual information to systematically eliminate each incorrect option. The wording of the question tells you that only one option contains a true statement. |
5079 A new mother calls the clinic 4 days after delivery. Correct answer: 1 Once the mother s milk comes in, typically after the third postpartum day, breastfed babies She is breastfeeding and is concerned that her baby is should have 6–8 wet diapers each day. This would indicate the baby is getting enough milk. The not getting enough milk. What is the most important other options address the mother, not the intake of the newborn. Red, tender areas or sore, question for the nurse to ask this mother? bleeding nipples contribute to infection such as mastitis. Tingling is often used to describe the feeling mothers experience with the letdown reflex.
| Analyze the question and determine that the core issue is how to evaluate whether an infant is getting sufficient milk intake while breastfeeding. Then systematically eliminate any option that focuses on the mother instead of the infant. |
5080 A nurse is teaching a new mother how to care for Correct answer: 4 Diaphragms need to be refitted after each delivery and a change in body weight of greater herself after delivery. Which of the following than 10–15 pounds. Night sweats are common and need not be reported. Sexual intercourse statements should the nurse make during this can be safely resumed once the episiotomy is healed and the lochia stops in about 3 weeks. discussion? Perineal pads should be changed after each elimination.
| The core issue of this question is self‐care and self‐management following delivery. The wording of the question tells you that the correct answer is a true statement and only one option contains a true statement. Use nursing knowledge to systematically eliminate each incorrect option. |
5081 A client’s hemoglobin is 10.5 mg/dL. The nurse should Correct answer: 2 A hemoglobin level of 10.5 is low and indicates anemia. Because of this, the client should eat encourage the client to include which of the following foods high in iron, such as red meat. The other foods are important to a well‐balanced diet but in her diet? are not high in iron.
| The core issues of the question are recognition of laboratory indicators of anemia and dietary treatment. Knowledge of both of these concepts are needed to answer the question. As a strategy, however, recall that hemoglobin contains iron; use this knowledge to make a dietary selection from the options presented. |
5082 A postpartum client asks the nurse how to strengthen Correct answer: 1 Kegel exercises are designed to strengthen the muscles of the perineum. By alternately her perineal muscles. The nurse teaches the client to tensing and releasing the muscles of the perineum, as if to start and stop the flow of urine, do which of the following? muscle tone and strength are enhanced. Bearing down is the opposite type of exercise for this set of muscles. Options 3 and 4 are incorrect statements of technique.
| The core issue of the question is specific knowledge of Kegel exercises. As a strategy, however, choose the option that helps to tighten the perineal floor, which is weakened by pregnancy and childbirth. |
5083 The nurse notes the following maternal attachment Correct answer: 3 Establishing an emotional bond with the newborn includes responding to behavioral cues, behaviors. Which behavior indicates the need for attempting to provide comfort, and meeting the infant s needs. Holding the newborn and further observation? consoling the baby when he cries meets the infant s need for comfort and helps to establish trust. The other observed maternal behaviors are positive signs of attachment.
| The wording of the question indicates that the correct answer is an option that is a questionable or abnormal behavior by the mother. Focus on the key word attachment. Use nursing knowledge to systematically eliminate incorrect options. |
5084 In planning care for a postpartum client who Correct answer: 1 By the second or third postpartum day, mothers are moving into the taking‐hold phase of delivered 2 days ago, the nurse should expect the adjustment and are eager to care for the baby and self independently. The other behaviors are client to do which of the following? characteristic of the taking‐in phase, which occurs earlier and reflects greater dependence on the part of the mother.
| The core issue of this question is the progression of maternal behaviors in the days following delivery. The wording of the question leads you to understand that the correct option is a behavior that is customary or normal for that time period. Use nursing knowledge to make a selection. |
5085 The nurse notes that a client's postpartum hematocrit Correct answer: 4 All of the answers could occur in an anemic client and should be included in the teaching plan. is 27% and hemoglobin is 9 grams/dL. Which of the However, the one most likely to risk the client's safety is that she may feel lightheaded or following is the most important to include in this dizzy. Because this could cause the client potential injury, it is the most important information client's teaching? The client may: to include.
| When all options seem plausible, remember to consider client safety in determining the priority. The correct answer would be the option that contains a true statement about a point of client education most likely to risk the client's safety and, therefore, most important to include in teaching. |
5086 The nurse is caring for a client who is one day Correct answer: 3 3 proteinuria is significant and could indicate the presence of pre‐eclampsia within the first postpartum. The nurse should notify the physician 48–72 hours postpartum. The other laboratory values are within normal limits for a client in about which of the following laboratory results? the first postpartum day, and reflect expected physiologic changes related to labor and delivery.
| The key focus of the question is abnormal assessment findings. Eliminate options 1, 2, and 4 because they contain laboratory values within normal limits for a client in the first postpartum day, and reflect expected physiologic changes related to labor and delivery. |
5087 A client is discharged 12 hours after a vaginal delivery. Correct answer: 3 Postpartum clients are at risk for urinary tract infections related to urinary retention after Which of the following findings should the nurse teach delivery. The risk is increased if the client has been catheterized during labor, delivery, or the client to notify the physician immediately if it postpartum. Signs of a urinary tract infection include urgency, burning, and frequency of occurs? urination. The other answers are normal and do not require immediate attention.
| The key focus of the question is time‐related postpartal risk; the greatest risk at this time is urinary retention and subsequent infection. Eliminate option 1 because it is too early for breastfeeding problems. Eliminate option 2 because this could be related to dehydration at this time. Eliminate option 4 because this describes the normal psychological adaptation that commonly occurs at days 2–3 postpartum for the majority of women. |
5088 The nurse determines the father of a newborn is not Correct answer: 2 New fathers may feel overwhelmed with caring for a newborn, especially if they have not had displaying positive bonding behaviors. Which of the many opportunities to interact with babies. By encouraging him to discuss his feelings, the following actions by the nurse may facilitate parental nurse may be able to help him explore his new role as a father and feel more comfortable bonding? asking questions related to infant care. The nurse may also be able to identify cultural expectations of the father's role and avoid misinterpreting the father's behavior.
| The key focus of the question is psychological adaptation. The correct answer would be the option that facilitates communication and expression of feelings. |
5089 After delivery, a Chinese client states that she needs Correct answer: 2 Chinese clients may perceive an imbalance in the hot and cold forces in the body after to restore the balance between hot and cold forces in delivery. They will avoid sources of cold, such as wind, cold beverages, and water (even if her body, and refuses to bathe. The most appropriate warmed) to regain a sense of balance between these extremes. A client's culture plays a very nursing intervention is to: important part in who they are, and nurses should respect their wishes as long as it will not result in harm to the client or others. Showing a videotape will not change the client's cultural beliefs and is not appropriate. The other answers do not show evidence of acceptance of another's culture.
| The key focus of the question is providing culturally competent care for the client. The correct answer would be the option that contains acceptance of the client's cultural beliefs and practices. |
5090 The follow‐up clinic nurse is assessing a single Correct answer: 3 Because this mother is single and this is her first baby, it is important to assess her support primigravida, who delivered 3 days ago. The client system. The other answers are incorrect, there is no indication that the client is in pain or is beings to cry and tells the nurse, "I just can't do all uncomfortable with her parenting skills. Reporting the behavior to the physician isn't this." The nurse should: necessary.
| The critical words in the question are single primigravida. The correct answer would be the option that contains a true statement about the needs of this client for psychosocial support. |
5091 The nurse is caring for a 15‐year‐old primipara who Correct answer: 3 Although all of the options may be appropriate, demonstrating newborn care will allow the delivered yesterday. The nurse identifies the following client to ask questions and gain confidence as she cares for her baby. Having her return the nursing diagnosis for this client: Risk for Impaired demonstration will allow the nurse to evaluate the teaching. Parenting related to knowledge deficit in newborn care. Which is the most appropriate intervention when planning this client's discharge teaching?
| When all options seem plausible, remember the principles of teaching and learning to determine the priority. The correct answer would be the option that best promotes active learning, gaining confidence or self‐esteem, and asking questions. |
5092 The client experienced an 18‐hour labor with a Correct answer: 3 Although this client is not demonstrating positive signs of bonding at this time, it is important second stage that lasted 2 hours. When the nurse to look at her history before concluding that she is not bonding well with her infant. This client brings the infant into the room an hour after delivery, just experienced a long labor and the influence of fatigue on the attachment process should be the client tells the nurse to leave the infant in the crib considered. It is important to continue to assess infant bonding with this client throughout her and shows no interest in holding the newborn. The hospitalization to reach a nursing judgment based on evidence over time. nurse should record which of the following nursing diagnoses in the chart?
| Knowledge of the influence of fatigue on the new mother will aid in choosing the correct answer. |
5093 The registered nurse is assigned to the postpartum Correct answer: 1 The RN is responsible for delegating tasks appropriately, and for the actions of unlicensed unit. Which task could the RN safely delegate to a employees. Ambulating a postoperative client and obtaining supplies for a urine specimen are nursing assistant? the only tasks that the RN could delegate from those listed. The other tasks require higher‐ level assessment and critical thinking skills and should be performed by the RN.
| Tasks that require higher‐level assessment and critical thinking skills should be performed by the RN and should not be delegated. Eliminate options 2, 3, and 4 because they require assessment or critical thinking based on the advanced knowledge of the RN. |
| |
5094 A new mother spends increasingly more time with Correct answer: 3 The en face position, which facilitates parent–infant attachment, is assumed when the her infant positioned to have direct face‐to‐face and mother arranges the newborn in order to have direct face‐to‐face and eye‐to‐eye contact in eye‐to‐eye contact. The nurse interprets this finding as the same plane. There is intense interest in having the infant's eyes open and when they are, the: the mother typically talks to the newborn in a soft, high‐pitched tone of voice.
| Recognize the assessment data presented in the question as the en face position. Eliminate options 1, 2, and 4 as incorrect descriptions of this position. |
5095 This is the first postoperative day for a client who Correct answer: 1 Clients who have had a cesarean delivery are at risk for complications of surgery, including delivered by cesarean. The client asks the nurse why thrombophlebitis. Early ambulation can significantly decrease the risk of blood clots and other she has to get up and walk when it hurts her incision so postoperative complications. much. The nurse responds that:
| The positive wording of the question indicates that the correct answer is also a true statement. Use knowledge of the factors associated with increased risk of thromboembolic disease such as cesarean section and immobility to answer the question. |
5096 A postpartum client delivered by cesarean 2 days ago. Correct answer: 2 This client has signs of an incisional infection. The physician needs to be notified first so that While assessing the client's incision, the nurse notes treatment can be started as soon as possible. Betadine has not yet been ordered. that the skin edges around the incision are red, Documentation should follow reporting. Continued observation would be an ongoing edematous, and tender to the touch. A scant amount intervention. of purulent drainage is noted. What is the most appropriate initial action by the nurse?
| The focus of this question is the collection of assessment data indicating a change in the client's condition: development of infection. The correct answer would be the option that best provides for the safety of the client, reporting the abnormal findings so treatment can be instituted. |
5097 Which of the following interventions should be Correct answer: 2, 5 A third‐ or fourth‐degree perineal laceration involves the rectal sphincter, therefore omitted when caring for a client with a midline suppositories, enemas, and rectal exams are contraindicated until the rectum heals. Increased episiotomy with a third‐degree laceration? Select all fiber and fluids or use of stool softeners is appropriate to promote bowel elimination in all that apply. postpartum clients.
| The stem of the question has negative wording. The correct answer would be the option that would contain inaccurate nursing actions or jeopardize client safety and restoration of health. Use knowledge of the contraindications for a third‐ or fourth‐degree laceration to make your selection(s). |
5098 You are caring for a client whose baby was sent to the Correct answer: 2 Breast milk production is based on supply and demand. The more the breasts are stimulated neonatal intensive care unit because of respiratory to produce milk, by nursing the baby or pumping the breasts, the more milk will be produced. distress. The client plans to breastfeed her baby. You understand teaching has been effective when the client states, "I know I need to continue pumping my breasts to:" | The critical word in the stem of the question is "effective," which tells you the correct option is also a true statement. Use knowledge of breastfeeding and how to stimulate milk production to aid your selection. |
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5099 The nurse palpates the uterus of a client immediately Correct answer: Immediately after expulsion of the placenta, the uterus is firmly contracted, about the size of after delivery. Where does the nurse expect to feel the a grapefruit. The fundus is located in the midline of the abdomen and halfway between the fundus? Select the correct area on the image shown. symphysis pubis and umbilicus. Within 6–12 hours after delivery, the fundus rises to a level of the umbilicus. The top of the fundus then descends the width of a fingerbreadth each day until it descends into the pelvis by about 2 weeks, when it is no longer palpable. | Recall the physiologic process of uterine involution and the changes in fundal position after delivery. |
5100 You are assessing a client's fundus and find it firm, 2 Correct answer: 2 This client's fundus is already firm, so it is not appropriate to massage the fundus. It is also centimeters above the umbilicus and displaced to the higher in the abdomen than expected, and it is displaced to the right, which is probably caused right. What is the most appropriate intervention? by a distended bladder. Having the client void may return the uterus to the expected position; palpating the fundus after voiding will confirm this finding. A pad count would be appropriate if bleeding is increasing; no information given implies that this action is indicated.
| The critical words in the question are "firm" but "displaced" uterine fundus, common findings with a full bladder. Eliminate options that do not focus on this condition. |
5101 A client's prenatal laboratory findings reveal that she Correct answer: 4 The rubella vaccine is a live virus. If a client becomes pregnant within the first 3 months after is not immune to rubella. The physician orders rubella administration, her fetus is at risk for congenital anomalies related to the virus. Women who vaccine prior to discharge. The nurse concludes that are not rubella‐immune should be vaccinated postpartum, prior to discharge. Teaching should teaching about this medication is effective when the include an effective method of birth control and the importance of avoiding pregnancy for the client states: next 3 months.
| The wording of the question indicates that the correct answer is also a true statement. Use knowledge of rubella immunizations in the postpartum period to aid in answering the question. |
5102 A client's vital signs following delivery are: (Day 1) BP Correct answer: 2 The vital signs are not normal. An elevation in body temperature greater than 100.4°F after 116/72, T 98.6, P 68; (Day 2) BP 114/80, T 100.6, P 76; the first 24 hours postpartum could indicate maternal infection. An elevated temperature (Day 3) BP 114/80, T 101.6, P 80. The nurse should within the first 24 hours is usually related to dehydration, although the possibility of infection suspect that the client: still exists. Rising pulse and falling blood pressure rather than rising temperature are an indicator of hypovolemic shock.
| The assessment data include an abnormal and increasing temperature, a sign of infection. Eliminate options that suggest other complications. |
5103 The nurse is reviewing infection‐control policies with Correct answer: 3 Even when perfect sterile technique is used when doing a vaginal exam, organisms present on a nursing student. The nurse knows that the teaching the perineum are transported into the vagina and close to the cervix. By limiting the number of has been effective when the student states, "The best vaginal exams, the risk is decreased. Option #1 is incorrect because clean technique, not sterile way to prevent postpartum infection starts:" technique, is used when palpating the fundus. Options #2 and #4 are correct answers, but not the earliest interventions a nurse could perform.
| Critical words are "best way to prevent postpartum infection." Knowledge of medical and surgical asepsis and preventing postpartum complications will aid in choosing the correct answer. |
4.‐ "When the client goes home by avoiding tub baths until the lochia stops." | |
5104 Which of the following assessments should alert the Correct answer: 1 A potential side effect of Methergine is hypertension. If a client's blood pressure is elevated, nurse to withhold the scheduled dose of the nurse should hold the scheduled dose and notify the physician. An apical heart rate of 56 is methylergonovine maleate (Methergine) for a within normal limits postpartum. Blood type, Rh factor, and chosen feeding method are not postpartum client and call the physician? related to the use of Methergine.
| The focus of the question is an adverse effect of Methergine, an oxytocic drug. The correct answer would be the option that contains a true statement about a side effect. Eliminate options #2, 3, and 4 because they include normal findings or data not related to Methergine use. |
5105 The nurse is assessing a client 24 hours after delivery Correct answer: 3 The fundus should remain firm after delivery to decrease the risk of postpartum hemorrhage, and finds the fundus to be slightly boggy and 2 and should drop 1 centimeter below the umbilicus each day. All nursing interventions centimeters above the umbilicus. What should the presented are appropriate, but massaging the fundus until firm is the most important to priority nursing intervention be? prevent hemorrhage.
| The focus of the question is the priority action to promote maternal safety and prevent hemorrhage related to a boggy uterus. The correct answer would be the option that contains a nursing action to prevent hemorrhage. |
5106 A new mother complains of "afterpains." The nurse's Correct answer: 1 Afterpains are anticipated in the postpartum client and are effectively treated with first action should be to: analgesics.
| The focus of the question is afterpains, a common occurrence that can increase pain. The correct answer would be the option that contains a nursing action to effectively manage pain. |
5107 The nurse is caring for a woman who gave birth to a Correct answer: 4 This client should be encouraged to verbalize her disappointment as the first step in resolving daughter yesterday, but greatly desired a son. Today her negative feelings. The other responses are incorrect. This is not a normal response or one she seems withdrawn, staying in bed and staring at the that requires a psychiatric referral. wall. What is the most appropriate intervention?
| Recognize that the data given in the question may be related to disappointment with the sex of the infant. The best response would be the option that facilitates therapeutic communication to encourage the client to express her feelings. |
5108 The nurse is preparing to instruct a new mother on Correct answer: 3, 5 Having sexual intercourse before the episiotomy is healed or the lochia has stopped increases resuming sexual intercourse postpartum. The nurse the risk of infection. Water‐soluble lubricants can be used, if necessary. An IUD is should include which of the following in the teaching contraindicated during the early postpartum period. plan? Select all that apply.
| Use the process of elimination and look for a statement that is true. Knowledge of client teaching for resumption of sexual activity after delivery will help to answer the question correctly. |
5109 The nurse is caring for a client who has decided not to Correct answer: 3, 5 Binding the breasts, either with a snug bra or binder, and applying cold to the breasts will help breastfeed. Client teaching to promote lactation suppress lactation. Milk supply is stimulated by expressing milk and applying heat to the suppression should include which of the following? breasts. Medications to suppress lactation are not recommended. Select all that apply.
| Knowledge of the ways to suppress lactation in the non‐breastfeeding mother will help to answer the question correctly. The correct answer would be the option that includes a true statement about a point of client education. |
5110 A client has a temperature of 100.2°F 4 hours after Correct answer: 1 Temperature elevation immediately after delivery is often caused by dehydration during delivery. What is the appropriate action for the nurse labor. Increasing the client's fluid intake will usually decrease the temperature to within to take? normal limits. There is no indication for analgesia or antibiotics at this time. If the fever persists beyond 24 hours or the client has clinical signs of infection, then further investigation and perhaps treatment is warranted.
| Recognize that the focus of the question is dehydration fever after delivery. The correct answer would be the option that contains a nursing action to correct this minor and typically temporary finding. |
5111 A client delivered 90 minutes ago. She is alert and Correct answer: 1 Clients are at risk for orthostatic hypotension, especially right after delivery. The nurse should physically active in bed. She states that she needs to go stay with the client the first time she ambulates after delivery to promote safety. Early to the bathroom. The nurse's most appropriate ambulation prevents circulatory stasis in the lower extremities and should be encouraged. The response is: perineum should be patted (not wiped) dry from front to back to avoid trauma, discomfort, and contamination with bacteria from the anal region.
| The most therapeutic response would be the option that promotes client safety in the immediate postpartal period. Eliminate options #3 and #4 as they contain false statements as points of client education. Eliminate option #2 as early ambulation is encouraged, not bedrest, to prevent circulatory stasis. |
5112 Which laboratory finding should the nurse assess Correct answer: 1 A client with a hemoglobin of 7.2 grams/dL would most likely have significant signs and further on a client 24 hours after delivery? symptoms of anemia, and this could be life‐threatening. It would be important to determine if the client had a large estimated blood loss during delivery or if she is currently bleeding excessively. The hematocrit is within normal limits, and mild proteinuria or leukocytosis up to 30,000/mm<sup>3</sup> is common in early postpartum.
| The focus of the question is an abnormal laboratory finding warranting further investigation. Eliminate option 4 as it presents normal data. Eliminate options 2 and 3 because they contain data commonly found in the postpartum. Option 1 is the correct answer because it contains abnormal findings. |
5113 A client is to be discharged 12 hours after delivery. Correct answer: 4 An adult client should have a minimum urinary output of 30 cc/hr and this client is below that The nurse should delay the discharge and notify the minimum. In a postpartum client, this is most likely related to urinary retention secondary to physician if which of the following is observed? perineal edema and trauma from delivery. It is important that postpartal clients are able to empty their bladders without assistance prior to discharge.
| The critical words "delay discharge" and "notify the physician" indicate that you want to choose an abnormal sign/symptom. The only abnormal finding is option #4. |
5114 A client had an episiotomy and complains of perineal Correct answer: 3 If a postpartum client is experiencing pain, she will be less likely to ambulate, less receptive to discomfort. She is also afraid to have a bowel teaching, and more likely to experience constipation because of the fear of pain with a bowel movement. Which of the following nursing diagnoses is movement. By treating her pain first, interventions for the other nursing diagnoses will be the highest priority for this client at this time? more successful.
| Key words are "episiotomy and complains of perineal discomfort" and "highest priority." Knowledge of nursing diagnosis will aid in choosing the correct one for perineal discomfort. |
5115 After walking for 30 minutes, the laboring client now Correct answer: 4 Bloody mucus is often called bloody show and becomes more profuse during the late active has blood‐tinged mucus on her underpad. Which of the phase and into the transition phase of the first stage of labor and during the second stage of following is the most appropriate interpretation by the labor. Fetal bowel movements are not blood‐tinged. Rupture of the amniotic sac would nurse? produce a clear, watery fluid. There is no correlation of blood‐tinged mucus during labor with injury sustained through walking.
| Note the key term blood‐tinged and associate this with progression in labor. Recall that exercise such as walking hastens labor. Both of these concepts should guide you to select option 4 as the answer. |
5116 After administration of an epidural block for labor Correct answer: 4 Vasodilation occurs with epidural analgesia and anesthesia, which can result in hypotension. analgesia, the client’s blood pressure decreases from The client who is hypotensive after epidural administration should be turned to a left lateral 130/75 to 90/50. The nurse should assist the woman to position and have the IV fluid rate increased. These actions will increase the circulation to the do which of the following? fetus and increase circulating volume, respectively.
| The issue of the question is the appropriate action that counteracts a side effect of epidural analgesia. Recall that opioid analgesics often cause vasodilation, which can be counteracted by proper positioning. Eliminate options 2 and 3 first because they are not helpful; then choose option 4 over option 1 because option 4 assists both the mother and the fetus. |
5117 The client is in active labor and the nurse is taking an Correct answer: 3 Narcotics given for pain relief in labor are most often given intravenously so that the order from the health care provider for an opioid medication will have a rapid onset and a relatively short half‐life. This desired drug profile will analgesic. The nurse verifies that the order is for which provide maternal benefit while preventing neonatal respiratory depression. of the following priority routes for administration?
| Use the process of elimination, choosing the route that will work rapidly but that hastens metabolism and excretion for the benefit of the fetus. With this in mind, eliminate options 1 and 4 first. Then choose option 3 over option 2 because the opioid analgesic is absorbed much more quickly intravenously. |
5118 The nurse would question which of the following Correct answer: 1 Paracervical block is given during the active and transitional phases of labor to block the pain methods of pain relief during repair of an episiotomy? sensations of the dilating cervix. It has no effect on the perineum and would offer no analgesic effect during episiotomy repair. The other options affect the perineum and would offer analgesia during suturing of the episiotomy.
| Specific knowledge of methods of pain relief during episiotomy care is needed to answer this question. Visualize each option, and make the selection that best fits with nursing knowledge. |
5119 The nurse would use which of the following as the Correct answer: 3 Abdominal palpation will give limited information about uterine contractions, especially if the most accurate method to assess the frequency, client is either very thin or obese. The client’s description of the contractions will be influenced duration, and strength of contractions of a woman in by her culturally based expression of pain as well as by her previous pain experiences and pain active labor? threshold. The tocodynamometer, or external uterine transducer, will detect the onset and end of contractions in most women but does not assess intensity of the contractions. Additionally, if the client is either very thin or obese, the fetal monitor tracing will either exaggerate the contractions or minimize them. Internal contraction monitoring through the use of an intrauterine pressure catheter will objectively measure the contractions in mm of Hg and is the most accurate method of contraction monitoring.
| Note the key words most accurate method in the question, which tell you that more than one option may be partially or totally correct but that one option is best. Evaluate each option and make your choice based on the method (IUPC) that is closest to the source (fetus and uterus). |
5120 A laboring client has recently had an intrathecal Correct answer: 2 Women receiving intrathecal narcotics for labor analgesia often experience adverse effects narcotic administered for relief of labor pain. The such as urinary retention, nausea, vomiting, and pruritus (itching). A Foley catheter is routinely nurse determines that teaching has been effective used to allow for urinary elimination. Fetal movement is not affected by intrathecal narcotics. when the client makes which statement?
| Note the issue of the question, which is knowledge of adverse effects of intrathecal narcotics during labor. The word effective in the question tells you the correct answer is a true statement. Eliminate options 1 and 3 first as false statements. Choose option 2 over 4 because it reflects an accurate statement of side effects. |
5121 The nurse concludes that the use of Correct answer: 3 Objective signs of pain relief include decreased muscle tension as evidenced by unclenched nonpharmacologic pain management techniques have fists; relaxed facial muscles and decreased grimacing, frowning, or creasing of the brow; and been helpful to the client after observing which of the slightly lowered blood pressure, pulse rate, and respiratory rate. Frequency of uterine following? contractions would not be affected by relieving pain through nonpharmacological methods.
| The issue of the question is a satisfactory outcome of nonpharmacological methods of pain relief. With this in mind, use knowledge of general signs of pain relief to make your selection. Eliminate options 1 and 4 first because they are not evidence of pain relief, then eliminate option 2 because maternal blood pressure and pulse would decrease rather than increase with pain relief. |
5122 The nurse’s plan of care for the pain of a laboring Correct answer: 4 The pain of labor and childbirth has both physiologic and psychologic components. A support client would incorporate which of the following person’s presence has been shown to decrease the perceived pain of childbearing. However, concepts? the expression of pain through nonverbal cues or verbalizations is highly culturally based (not universal), having been learned in early childhood.
| Note that options 1 and 4 are essentially the opposite of each other. When two options are opposites, often one of them is correct. Choose option 4 over option 1 because it is more comprehensive. |
5123 The nursing care plan for a client with a prolonged Correct answer: 1 Prolonged latent phase of labor is defined as greater than 20 hours in primigravida women latent phase of labor includes which of the following as and greater than 14 hours in multigravida women. Encouraging rest and relaxation during this a priority measure? phase will help the client have enough energy to push effectively during the second stage of labor. Music is often used effectively to induce relaxation. Encouraging a well‐rested client to ambulate will also facilitate the latent phase. Intravenous hydration is given to women who are unable to take oral fluids. Internal monitoring is indicated if labor is being augmented or induced, the amniotic fluid is meconium‐stained, or there is evidence of fetal distress by external monitoring. During the first stage of labor, maternal vital signs are obtained every hour.
| Note the key word priority in the stem of the question. This tells you some or all options may be partially or totally correct, but one is most important. Eliminate option 4 first as unnecessary. Then eliminate option 3 because external monitoring may be equally effective. Choose option 1 over 2 because there is no indication that the client cannot tolerate fluids and also because of the key words prolonged latent phase in the stem of the question. |
5124 The nursing plan of care for the client in early labor Correct answer: 1 Cultural beliefs and practices are inseparable from the labor and birthing experience. The RN would include assessment of which of the following as must include a cultural assessment as part of the admission of all laboring clients. Maternal a high priority at this time? hydration status would be indicated, but nutritional status is not indicated during the birthing admission. Choosing a nurse‐midwife or physician is based on many factors, and the nurse’s role is to follow the protocols of the appropriate care provider, not to be judgmental or question a client’s decision. Asking about names can be a cultural taboo.
| Note the time frame of early labor. With this in mind, eliminate options 2 and 3, which are no longer timely during labor. Choose option 1 over option 4 because it focuses on data that can assist the nurse to provide an individualized plan of care during labor. |
5125 The client’s fetal heart rate is 150 before the Correct answer: 4 Late decelerations are caused by uteroplacental insufficiency and are always ominous. To contraction begins. During the contraction, the heart optimize uteroplacental blood flow and therefore fetal oxygenation, the client should be rate falls to 110 and returns to baseline 30 seconds positioned on her left side. Oxygen is appropriate but would be administered via mask at 7–10 after the contraction ends. Which of the following is liters per minute. A Foley catheter is unrelated to the fetus s needs at this time. the priority nursing action in response to this finding?
| Determine what the question is testing, which is uteroplacental insufficiency. With this mind, eliminate option 3 as unrelated and option 1 as potentially harmful. Choose option 4 over option 2 because it is more effective in increasing delivery of oxygen and blood flow to the fetus. |
5126 The fetal heart rate baseline is 145 beats per minute Correct answer: 4 Normal fetal heart rate baseline is 120–160 beats per minute. Normal short‐term variability is with short‐term variability of 12 beats per minute. The 6–25 beats per minute. This is a normal fetal heart rate tracing and requires continued support nurse should take which of the following actions? and assessment by the nurse. There is no indication to contact the health care provider, provide intravenous fluids, or position the client on her hands and knees.
| The issue of the question is the ability to recognize a normal fetal heart rate and variability on fetal monitoring. Recall that a normal fetal heart rate is 120–160 to determine that at least the fetal heart rate is normal. You can then eliminate options 1 and 2. Choose option 4 over 3, understanding that the variability of 12 beats is acceptable. |
5127 In planning care for the adolescent in labor, the nurse Correct answer: 1 The role of the nurse is to be informative, supportive, but never judgmental. Thus, the should address which of the following concerns? reliability of the boyfriend and the appropriateness of names chosen are not assessments that the labor and delivery nurse should perform. Because the client is in labor, it is too late to address nutritional needs of pregnancy. This might also be perceived by the client as judgmental behavior of the nurse. Adolescents commonly misunderstand the functions of their body parts and additional teaching may be needed so the adolescent client in labor understands how birthing will take place.
| The issue of the question is age‐appropriate care of the adolescent during labor. Choose the option that addresses lack of knowledge. Eliminate option 2 because it is not timely. Option 4 does not address the client’s current needs, and option 3 could create distance between the client and nurse, depending on the conversation. |
5128 The fetal heart rate shows variable decelerations. Correct answer: 4 Variable decelerations are caused by compression of the umbilical cord. The treatment for Which of the following nursing actions could be variable decelerations focuses on relieving the cord compression, which can be accomplished implemented to decrease or eliminate this pattern? by either infusing saline into the uterus via an intrauterine pressure catheter or by repositioning the client to get the weight of the fetus off the portion of cord that is being compressed. Pregnant women are never placed in a supine position because the fetus will compress the vena cava, thus decreasing uterine blood flow. Taking a warm shower would be unlikely to affect fetal heart rate directly.
| Specific knowledge of the meaning of variable decelerations is needed to answer this question. Eliminate options 1 and 3 because option 3 could adversely affect fetal circulation by position and option 1 is ineffective in addressing variability. Choose option 4 over option 2 because it is an intervention rather than a means of obtaining an assessment. |
5129 The laboring client is 8 centimeters dilated, 100 Correct answer: 3 Gradual decelerations that begin and end with contractions are early decelerations and are percent effaced, with vertex presenting at +2 station. caused by fetal head compression. Variable decelerations result from umbilical cord The fetal heart rate gradually slows during each compression and are characterized by a sudden drop from baseline during contractions with a contraction, returning to baseline by the end of the sudden return to baseline as the contraction ends. Late decelerations are caused by contraction. The nurse concludes that which of the uteroplacental insufficiency and are characterized by gradual decrease in the fetal heart rate following is occurring? after the contraction begins, and gradual return to baseline after the contraction has ended. Fetal movement usually results in fetal heart rate accelerations.
| Specific knowledge of the relationship between fetal monitoring results and the effect on the fetus is needed to answer this question. Rely on nursing knowledge and choose option 3 because the data indicate the changes occur during contractions, when the head would be compressed against the lower pelvic structures. |
5130 A woman is admitted to the birth unit. She is bearing Correct answer: 2 Delivery appears imminent and priority should be given to the safety of the woman and her down uncontrollably with contractions and says, “The newborn through a controlled and attended birth. Another person can be summoned to baby is coming!” Which of the following is the priority contact the health care provider and perform assessments. The history provides helpful action of the nurse? information but can be obtained at a later time.
| The situation in the question is urgent and requires immediate action by the nurse. Eliminate options 3 and 4 because they are assessments, and choose option 2 over 1 because it addresses the immediate physiological and safety needs of the mother and fetus. |
5131 The laboring client has begun to make guttural, Correct answer: 1 The second stage of labor begins when the cervix is completely dilated and pushing begins. grunting sounds during contractions. The nursing plan Most women make a low‐pitched, guttural, grunting sound when they push spontaneously. of care should now include which of the following? When the client begins to make these sounds, she is pushing. The nurse should immediately inspect the perineum for bulging and the appearance of the presenting part. If neither of these is occurring, the nurse should perform a vaginal examination to assess for complete dilatation of the cervix. | The issue of this question is accurate interpretation of onset of the second stage of labor. Knowing that pushing is characteristic of this stage, eliminate option 2 first because it is important for the husband to be present at this time. Eliminate option 3 next because it is not timely. Choose option 1 over 2 because it addresses the status of the fetus during the pushing stage. |
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5132 A primigravida client is in the second stage of labor. Correct answer: 3 The average duration of the second stage of labor for primigravidas is 2 hours. Many women The nurse determines that teaching has been effective feel rectal pressure, as if they were having a bowel movement, as the baby descends deeper when the client makes which of the following into the pelvis. The use of vacuum extraction or forceps to assist delivery is not routine. statements?
| The wording of the question indicates that the correct answer is a statement that is true. Use knowledge of the second stage of labor to systematically eliminate each of the incorrect options. |
5133 The newly delivered infant has been placed on the Correct answer: 4 Although all of the nursing actions presented are important after delivery, clearing the airway mother’s abdomen. The priority nursing intervention is the highest physiologic need and ensures safe adaptation to the extrauterine environment. for the newborn is to do which of the following?
| The key word in the question is priority, which indicates that one intervention is more important than the others to be completed first. Eliminate options 2 and 3 first because physiological needs take priority, and choose option 4 over option 1 because it addresses the airway. |
5134 A laboring client’s membranes spontaneously Correct answer: 1 The nurse should immediately assess the fetal heart rate to detect changes, which may be rupture. The first action of the nurse should be to do associated with prolapse of the umbilical cord. Ambulation is appropriate if the fetal heart is which of the following? determined to be within normal parameters and the presenting part is engaged. Documentation is important but is not the priority intervention. The membranes may rupture at any time during labor; preparing for delivery may not be indicated at this time.
| The key word in the question is first, which indicates that one intervention is more important than the others to be completed at this time. Choose the option that protects the fetus after membrane rupture, which allows you to eliminate options 2 and 3. Eliminate option 4 because delivery is not necessarily imminent. |
5135 The multiparous client is 9 centimeters, 100 percent Correct answer: 4 Multiparous women in the transition phase of the first stage of labor with strong regular effaced, at a 2 station, with strong contractions every contractions will progress to the second stage of delivery very quickly. The health care provider 2–3 minutes lasting 70 seconds. The nurse should: should be notified prior to this time to ensure her presence for delivery. Analgesia is inappropriate this late in labor because it may cause fetal sedation and respiratory depression. Most women prefer to lie down during transition.
| The question gives assessment findings indicating imminent delivery. Eliminate option 1 because the health care provider should be notified prior to this time to ensure her presence for delivery. Eliminate option 2 because analgesia is inappropriate this late in labor as it may cause fetal sedation and respiratory depression. Eliminate option 4 because safety of the fetus during precipitous delivery cannot be promoted in this position. |
5136 The primiparous client with intact membranes is 4 Correct answer: 1 Upright positioning and walking facilitate the progress of labor. Staying in bed continuously centimeters, 90 percent effaced, ‐1 station, vertex, and may slow labor progress. Blood pressure is usually taken every 4 hours during the first stage of having contractions every 5 minutes that are of labor. The nurse should encourage the partner's involvement as the couple desires. moderate intensity and last 45 seconds. An appropriate nursing plan of care would include:
| The focus of the question is a plan of care to promote a safe and satisfying birth. Eliminate option 2 because staying in bed continuously may slow labor progress. Eliminate option 3 because blood pressure is usually taken every 4 hours during the first stage of labor. Eliminate option 4 because the nurse should encourage the partner's involvement as the couple desires. |
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5137 During the second stage of labor, the nurse should Correct answer: 2 The second stage extends from complete cervical dilatation to delivery of the newborn. Any implement which of the following actions for an position of comfort may be selected by the woman. Ice chips and clear fluids prevent assigned client? dehydration and are normally allowed. Analgesics are administered in the first stage of labor, usually during the active phase, to prevent fetal sedation and respiratory depression at birth. An Apgar assessment would be conducted after delivery of the newborn during the third stage of labor.
| The core issue of the question is the promotion of a safe and satisfying second stage of labor. Eliminate option 1 because ice chips and clear fluids prevent dehydration and are normally allowed. Eliminate option 3 because analgesics are administered in the first stage of labor, usually during the active phase, to prevent fetal sedation and respiratory depression at birth. Eliminate option 4 because an Apgar assessment would be conducted after delivery of the newborn during the third stage of labor. |
5138 The nurse should include which of the following in a Correct answer: 1, 5 Knowing what culture the client comes from, and how traditional she is with her cultural psychosocial assessment of the laboring client? Select beliefs and practices, is important to understand, as it may dictate labor and birthing practices all that apply. that the client will want to follow, as well as the client's response to pain. The expectations of the experience are important in order to try to integrate realistic ones into the labor plan or help to establish realistic ones that can be explored. FHR assessment is not part of the psychosocial assessment. Plans to name the child are not relevant at this time.
| Eliminate option 2 as it can be included in option 1. Eliminate option 3 because it does not focus on psychosocial assessment of the woman. Eliminate option 4 because financial resources do not provide insight into beliefs, practices, or coping strategies at the time of birth. |
5139 Your nursing interventions for a client in the second Correct answer: 1 During the second stage of labor, fetal heart tones are assessed every 5 minutes or after each stage of labor would include: contraction when continuous fetal monitoring is not in use. Blood pressure is assessed every 5–15 minutes, not after every contraction. Maternal position can change according to the woman's comfort and desire and the health care provider's preference. Urine testing is not undertaken during the second stage because of the likelihood of contamination of the sample by amniotic fluid, blood, or feces.
| The core issue of the question is the second stage of labor. The correct answer would contain a true statement of the nurse's action during this time period. |
5140 A client in the clinic is questioning why some women Correct answer: 3 Most women have a gynecoid pelvis, which is rounded and most conducive to vaginal can deliver vaginally. The nurse responds that women delivery. Android pelvic shapes are more common in men. Anthropoid and platypelloid shapes who deliver vaginally are most likely to have what‐ tend to slow the labor‐and‐birthing process, and are not favorable for a vaginal birth. shaped pelvis?
| The core issue of the question is the shape of the woman's pelvis that facilitates vaginal delivery. Eliminate option 1 because android pelvic shapes are more common in men. Eliminate options 2 and 4 because anthropoid and platypelloid shapes tend to slow the labor‐and‐birthing process, and are not favorable for a vaginal birth. |
5141 The nurse determines teaching has been effective Correct answer: 1 The largest diameter of the fetal presenting part must reach or pass the pelvic inlet in order when the client describes engagement of the fetal for engagement to occur. This can be detected with a vaginal examination with the fetal head presenting part as the: being deep enough into the pelvis so that gentle upward pressure on the presenting part does not cause it to float away from the fingers.
| Knowledge of the definition of engagement is necessary to choose the correct answer. |
5142 The nurse determines that teaching has been Correct answer: 3 Contraction frequency is determined from the onset of one contraction, through the length of effective when the client reports her contractions are that contraction including the rest period between contractions, and up to the start of the next 3 minutes apart when timed from the: contraction.
| Knowledge of how to correctly time contractions is necessary to choose the correct answer. |
5143 The nurse expects a client to feel the pain of labor Correct answer: 2 The pain felt during advanced labor is primarily caused by the stretching of the lower uterine during the active and transition phases of the first segment and dilatation of the cervix. It is normally felt posteriorly in the lower back or stage of labor: anteriorly at the symphysis pubis. The other answers are incorrect descriptions of pain during this stage.
| The core issue of the question is the cause of pain in active labor and transition. The correct answer would be the option that contains a true statement about the physiologic progress during this time period, dilatation of the cervix. |
5144 The nurse externally palpates small parts of the fetus Correct answer: 4 Fetal position is described by first giving the presenting part, then relating the presenting part on the right side of the woman's abdomen. Vaginal to the maternal pelvis. In this example, the occiput, or back of the fetal head, is closest to the examination reveals the occiput presenting and toward posterior aspect of the maternal pelvis. This position, LOP, is represented in option 4. the mother's left side. The fetal back is located posteriorly toward the woman's back. The anterior fontanelle can be palpated on the mother's right and toward the symphysis pubis. The nurse concludes that the fetal position is which of the following?
| Knowledge of the fetal positions will aid in determining the correct answer. |
5145 The nurse is planning to teach a class of expectant Correct answer: 3, 4, 5, The cardinal movements (position changes) of the fetus occur in the order of engagement, parents about the cardinal movements, or changes in 2, 1 descent, flexion, internal rotation, extension, restitution, external rotation, and expulsion. position, that occur as the fetus passes through the These movements represent the normal adaptation of the fetus in a cephalic presentation to birth canal. The nurse plans to teach the positional the maternal pelvis and facilitate vaginal birth. changes in the sequence in which they occur when the fetus is in a cephalic presentation. Order the cardinal movements into this sequence by clicking and dragging the options below to move them up or down.
| Recall the memory aid Every darn fool in Rotterdam eats rotten egg rolls everyday. The first letters of each word in the memory aid represent the first letter of each of the cardinal movements of the fetus in a cephalic position. |
| |
5146 Which statement would indicate that the laboring Correct answer: 1 Analgesia and anesthesia methods are used for pain relief during labor as indicated by the client needs further education? client's response to pain, what phase and stage of labor the woman is in, how fast labor is progressing, and the fetal response to contractions. Parity alone does not determine what analgesia or anesthesia is indicated. The other responses are all accurate.
| Knowledge of the labor process and its effect on the client is necessary to choose the correct answer. Options #2, 3, and 4 can be eliminated because they are correct responses. The incorrect response is option #1, which indicates the need for further teaching. |
5147 The nurse anticipates that assessment of a normal Correct answer: 2 Moderate ecchymosis and edema are normal responses to the trauma of childbirth, as well as episiotomy immediately post‐delivery is most likely to to the presence of sutures. Sutures should be closely aligned without gaps and there should be reveal which of the following? no pus‐like drainage, indicating infection. Edema severe enough to cause the tissue to look shiny or taut is abnormal.
| Key words are "normal" and "immediately postdelivery." Knowledge of episiotomy management and care will help to answer the question correctly. |
5148 Fourth‐stage nursing care for a client with an Correct answer: 3, 5 Frequent inspection for redness, swelling, tenderness, and hematoma is essential to fourth‐ episiotomy includes which of the following? Select all stage nursing care. Pain relief begins with immediate application of ice. Ice packs should be that apply. applied for 20–30 minutes and removed for at least 20 minutes. If ice is applied for more than 30 minutes, vasodilation and edema may occur. Clients are usually advised to wait until bleeding stops and stitches heal (about 3 weeks) before resuming sexual activity, but this teaching would be part of the client's discharge instructions, and is not appropriate during the fourth stage of labor.
| The critical issue in this question is time‐related. The fourth stage of labor is a time of critical physiologic adaptation and requires frequent assessment. The correct answer is the option that includes a true statement about nursing action at this time. |
5149 The nurse would formulate which of the following as Correct answer: 3 The goal of childbirth education classes is to teach pregnant women and their support a general goal when developing childbirth education person(s) the birth process, strategies to cope with the pain of labor and to facilitate an easier classes for pregnant women in the community? labor, what to expect during childbirth, an understanding of operative delivery (use of forceps, vacuum extraction, and cesarean birth), and common procedures that may be performed throughout the birthing process. Many pregnant families get the information they need about the childbearing process by reading or from friends and extended family members. Childbirth preparation cannot prevent complications and thus cannot ensure vaginal deliveries for all clients.
| Knowledge of the goals of childbirth education will help to choose the correct answer. Eliminate options #1, 2, and 4, which are unrealistic and unattainable. |
5150 The nurse concludes that client teaching has been Correct answer: 3 Crowning is the point in time when the perineum is thin and stretching around the fetal head effective when the laboring client's partner shouts, both between and during contractions. Delivery is imminent when crowning occurs. "She's crowning!" as:
| The question is worded in a positive way. The correct answer will be the option that is a true statement about a point of client education. |
5151 The nurse notes on the antepartal history that the Correct answer: 1 An android pelvic structure is narrow in both the anterior–posterior diameter and the lateral pregnant client has an android pelvis. The nurse diameter, and can cause prolonged labor with a large fetus or a malpositioned fetus. concludes that this client is at an increased risk for:
| Recall the 4 Ps of labor; pelvic size and shape influence labor outcome. The correct answer is the option that delays or slows the birth process. |
5152 The nurse determines teaching has been effective Correct answer: 3 Frank breech position is when the sacrum of the baby is presenting, the hips are flexed, and when a client with a fetus in a frank breech position the feet are extended upward toward the fetal head. Option #1 describes a complete breech, says, "My baby's hips are:" option #2 is characteristic of a kneeling breech, and option #4 represents a double footling breech.
| The correct answer would be the option that contains a true statement about a point of client education. Knowledge of the types of breech presentations is necessary to choose the correct answer. |
5153 The fetal head is determined to be presenting in a Correct answer: 2 The normal attitude of the fetal head is one of moderate flexion. Changes in fetal attitude, position of complete extension. The labor and delivery particularly the position of the head, present larger diameters to the maternal pelvis, which nurse should anticipate a: contributes to a prolonged and difficult labor and increases the likelihood of cesarean delivery.
| The critical words in this question are "complete extension." Recall that flexion is the preferred fetal attitude for birth. The correct answer would be the option that contains a statement about a delayed or impossible vaginal birth. |
5154 The pregnant client is 7 cm dilated, 100% effaced, and Correct answer: 1 Presentation refers to the part of the fetus that is coming through the cervix and birth canal at a +1 station. The fetus is in a face presentation. The first. Thus a face presentation occurs when the face is coming through first. nurse concludes that client teaching has been effective when the client's husband states:
| The wording of the question tells you the correct option is a true statement that matches the information in the stem of the question. Use knowledge of the fetal presentation and presenting part to make a selection. |
5155 The nurse performs a vaginal examination and Correct answer: 1 The presenting part is given first when describing fetal position. The second half of the fetal determines that the fetus is in a sacrum anterior position description refers to the maternal pelvis. In this example, it is the sacrum presenting, position. The nurse draws which conclusion from this and the fetal sacrum is toward the maternal anterior pelvis. assessment data?
| The critical words in this question are "sacrum anterior." Eliminate options #3 and #4 that do not refer to the sacrum. Recall that the first locator, sacrum, refers to the fetus and the second locator, anterior, refers to the mother. The correct answer would be the option that refers to the fetal sacrum closest to the anterior maternal reference point, the symphysis. |
| |
5156 The client has been having contractions every 5 Correct answer: 1 A change in the cervix is the only indicator of true labor. The other factors do not correlate as minutes for 7 hours. Which factor would the nurse use closely as the cervical changes. to determine if this is true or false labor?
| The critical words in this question are "true labor." Recalling that true labor is defined only by cervical change, eliminate options that do not include change in the cervix. |
5157 Which of the following would be the highest priority Correct answer: 4 The fetal heart rate response to contractions is a physiologic assessment that indicates the of the nurse who is caring for the laboring client? presence or absence of fetal well‐being. The other options are appropriate for the laboring client, but safety of the fetus is the first priority of the options presented.
| Recall that the goal for every birth is a safe outcome for mother and baby. The correct answer will be the option that includes a true statement about maintaining safe passage. |
5158 As labor progresses, the nurse expects to assess that Correct answer: 2 As labor progresses, contractions will become more intense, occur more frequently (shorter a client's contractions are becoming: resting phase between contractions), and have an increasing duration. Less‐frequent or shorter contractions can impede labor progress.
| The focus of this question is the relationship of contractions to birth. Recall that contractions are the powers to facilitate birth; the work gets harder over time. The correct answer would be the option that makes a true statement about increasing intensity, frequency, and duration of contractions. |
5159 The neonate is crying, pink except for blue Correct answer: 9 Apgar scores are based on 0, 1, or 2 points in each of the five categories: respiratory effort, extremities, has flexed arms with clenched hands, a color, muscle tone, heart rate, and reflexes. This neonate would score 2 points in each heart rate of 154, and gags when the bulb suction is category except color, where the presence of acrocyanosis would warrant a score of 1 point. used. The Apgar score would be . | Recall that the Apgar score includes 0–2 points on five criteria. The data given in the question include one exception statement, making a perfect score of 10 unlikely and leading you to subtract one point. |
5160 Which of the following nursing observations would Correct answer: 3 As the uterus contracts and the placenta begins to shear off the uterine wall and be expelled, indicate a sign of impending placental separation and you will see a small gush of blood resulting from the uterine contractions emptying the uterus. expulsion? In addition, the cord will lengthen as the placenta is released from the uterine wall and moves toward the cervix prior to expulsion.
| The critical words in this question are "separation" and "expulsion." As the placenta and cord are expelled, more of the umbilical cord becomes visible. Eliminate options #1 and #4 because they do not include a true statement about cord change. Option #2 contains a red‐ flag word, "no" bleeding; eliminate this incorrect option. |
5161 The nurse who determines a laboring client is anxious Correct answer: 2 Anxiety commonly increases the perception of pain, and childbearing is no exception to this. anticipates that this may result in: Decreasing anxiety through education and support will facilitate the birthing process.
| Recall the 4 Ps of labor; the psyche influences the experience and progress of birth. Recall the fear–tension–pain cycle; anxiety and pain are directly related. This should help you to eliminate incorrect options and select the correct answer. |
3.‐ No reliance on support person. 4.‐ Need for episiotomy. | |
5162 Earlier in the day, the fetal heart rate baseline was Correct answer: 1, 5 An increase in fetal heart rate baseline can be an indication of fetal distress, as well as 140. It is now 170. An explanation for this could be: maternal fever. Narcotics may decrease the short‐term variability but do not affect the (Select all that apply.) baseline. Fetal movement will create an acceleration of the fetal heart rate. Utero‐placental insufficiency causes late decelerations.
| Eliminate options that are obviously incorrect; narcotics are CNS depressants, movement temporarily increases heart rate, and utero‐placental insufficiency causes periodic late decelerations. |
5163 The nurse determines teaching has been effective Correct answer: 2 Effacement is the thinning of the cervix from 0 to 100%. The opening of the cervix from 0 to when a laboring client makes which of the following 10 centimeters is called dilatation. In primigravidas, effacement usually precedes dilatation, statements? while in multigravidas, these processes usually occur concurrently.
| The positive wording of the question indicates that the correct option is also a true statement of fact. Knowledge of the definitions of effacement and dilatation, and of when they occur for the primipara and multipara, will aid in answering the question correctly. |
5164 The client's vaginal examination reveals: 3 Correct answer: 1 The first stage of labor is from the onset of labor to complete dilatation, and is divided into centimeters dilated, 80% effaced, vertex at a 21 latent (0–3 centimeters), active (4–7 centimeters), and transition (8–10 centimeters) phases. station. The woman is talkative and appears excited. The second stage of labor has no phases and is from complete dilatation until delivery of the The nurse determines the client to be in which stage newborn. The third stage has no phases and extends from delivery of the newborn to delivery and phase of labor? of the placenta.
| Recall that the first stage of labor is from 0 to 10 cm dilatation and is divided into phases. Eliminate options #3 and #4 to increase the likelihood of identifying the correct answer. |
5165 The client has come to the clinic for her first prenatal Correct answer: 4 Beginning around the fourth week of pregnancy, vasocongestion in the pelvic area results in a visit. During the pelvic examination, the examiner bluish color to the vulva, vagina, and cervix, known as Chadwick’s sign. Hegar’s sign is a indicates that the vaginal mucosa has a bluish color. softening of the lower uterine segment, Goodell’s sign is a softening of the cervix, and The nurse documents this as a positive: McDonald’s sign is an ease in flexing the body of the uterus against the cervix; none of these other signs involve color changes.
| The key words in the question are first prenatal visit and bluish color. Use the process of elimination and knowledge of the changes in cervical mucosa in early pregnancy to make your selection. |
5166 With regard to normal changes in the reproductive Correct answer: 1 During pregnancy, increased estrogen production results in an increased amount and system during pregnancy, the nurse should teach the thickening of vaginal secretions. The uterus grows by cell hypertrophy, not by adding more pregnant client about which of the following? cells. Red and hard breasts or a cervix dilating during the second trimester are not normal findings.
| Note the key words normal changes during pregnancy. Eliminate options 3 and 4 first because they are abnormal. Use concepts of physiology to choose option 1 over option 2. |
5167 With regard to normal changes in the cardiovascular Correct answer: 2 Pressure on the vena cava from the gravid uterus may cause a decrease in blood flow to the system during pregnancy, the nurse should teach the right atrium and result in a decrease in blood pressure. Dizziness is a symptom of hypotension. pregnant client that: The pulse rate could stay the same or increase as the workload of the heart increases during the course of pregnancy. There is an increase in the number of red blood cells to meet physiological demand. Option 4 is not a cardiovascular change during pregnancy, although abdominal fullness occurs as the pregnancy progresses.
| Note the key words “normal changes,” “cardiovascular,” and “pregnancy.” With these in mind, eliminate options 1 and 3 as incorrect. Choose option 2 over 4 by keeping in mind concepts of maternal and fetal circulation. |
5168 During a prenatal visit in the second trimester, which Correct answer: 1 Urinary frequency usually disappears in the second trimester. Thirst and urinary frequency of the following, if reported by the client, would be a may be signs of developing gestational diabetes and warrant further investigation. Deep cause for concern? tendon reflexes are assessed during a physical examination and are not reported to a health care provider by the client.
2.‐ +1 deep tendon reflexes 3.‐ Constipation 4.‐ Backache in the lower sacral area | Note the key words cause for concern, which indicate that the correct answer will be an option that is an abnormal finding. Eliminate options 3 and 4 first, since they are typical complaints that may be associated with pregnancy. Choose option 1 over 2 by noting that the symptoms in option 1 are clearly abnormal and are also subjective data that are reported by the client. |
5169 The nurse is examining a client who is at 12 weeks Correct answer: 3 By the 12th week of gestation, the uterus should have increased in size to be palpable at the gestation. The examiner would expect to find the symphysis pubis. Factors affecting this finding include abnormal fetal growth or the presence fundus at which of the following locations? of a multiple gestation.
| To answer this question correctly, you must be familiar with expected physiological changes during pregnancy. Use nursing knowledge and the process of elimination to make your selection. |
5170 When considering maternal serum alpha‐fetoprotein Correct answer: 1 This test, which measures the level of maternal serum alpha‐fetoprotein, is most sensitive testing for a client, the nurse would conclude that between 16 and 18 weeks gestation. However, it can be performed at up to 22 weeks there is a contraindication for the test if the client: gestation.
| Note the key word contraindication. This means the correct answer is an option that is a false statement. Use knowledge of the purpose of the test to eliminate each of the incorrect options. |
5171 The nurse would formulate which of the following as Correct answer: 2 Quickening usually begins around 16 weeks and results in enhanced attachment as the fetus a wellness‐oriented nursing diagnosis for a client in the becomes more real. Anxiety about early‐pregnancy changes would be more appropriate for second trimester of pregnancy? the client in the first trimester. Knowledge Deficit related to labor and delivery is an appropriate diagnosis in the third trimester. Promoting client safety is a nursing action, not a nursing diagnosis.
| Note the key words wellness‐oriented nursing diagnosis and second trimester. Eliminate options 1 and 4 because they are not wellness‐oriented, then eliminate option 3 because it is a nursing goal rather than a nursing diagnosis. |
5172 At the first prenatal visit, the client reveals that her Correct answer: 4 According to Naegele s rule, the estimated date of birth can be calculated by subtracting 3 last menstrual period began March 18. The nurse months from the beginning date of the last menstrual period and then adding 7 days to that calculates her estimated date of delivery to be which date. of the following?
| Specific knowledge of Naegele s rule is needed to answer the question. Use knowledge of this rule and mathematical/calculating ability to determine the appropriate due date. |
5173 The nurse concludes by which of the following client Correct answer: 3 Maternal folic acid deficiency has been linked to infant neural tube defects. Folic acid may be statements that the pregnant client understands obtained from prenatal vitamin supplements as well as foods. The other responses contain prenatal nutrition education? incorrect statements and do not indicate understanding of prenatal nutrition.
| Note the key word understands, which indicates that the correct answer is also a correct statement. Eliminate option 4 first because water‐soluble vitamins do not accumulate in the liver. Eliminate option 1 next because of the words “will have.” This implies a level of certainty that is unrealistic. Choose option 3 over option 2 because it is a true statement and because oranges are not an especially good source of folic acid. |
5174 A pregnant client, who is a vegetarian, is concerned Correct answer: 1 Both peanuts and hamburger are good sources of folic acid, but since the client is a about her folic acid intake and asks the nurse to vegetarian, peanuts are a better recommendation. The other options do not contain significant recommend some foods that she should include in her amounts of folic acid. diet. Which of the following should the nurse recommend?
| Use the process of elimination and knowledge of nutrition to answer this question. Eliminate option 2 first because the client is a vegetarian, and eliminate options 3 and 4 because they are fruit or fruit products. Nuts are better sources of folic acid. |
5175 The pregnant client has been started on an iron Correct answer: 2 Iron supplementation can cause gastric distress, constipation, and diarrhea. It does not cause supplement. The nurse determines that the client a red, raised rash (option 1), blood in the stool (option 3), or headache (option 4). understands possible side effects of therapy when the client states that the supplement may cause which of the following?
| Note that the wording of the question indicates that the correct answer is a true statement. Recalling that iron is associated with GI side effects will help you eliminate options 1 and 4. Recall that iron causes tarry, not bloody, stools to eliminate option 3. |
5176 The pregnant client has been started on an iron Correct answer: 2 Iron is absorbed best on an empty stomach (not after a full meal) and in the presence of supplement. Which of the following information vitamin C. It may or may not be taken at the same time as other vitamin supplementation. It should be included by the nurse as a priority in her does not replace the need for other vitamins. prenatal teaching about the iron supplement?
| First eliminate option 3 because iron intake does not eliminate the need for other vitamins. Next eliminate option 1 because a full meal may decrease iron absorption. Choose option 2 over 4 by recalling the beneficial effect of vitamin C on iron absorption. |
5177 The pregnant client tells the nurse that she is lactose‐ Correct answer: 1 Increased calcium intake can lead to formation of kidney stones. A calcium supplement is not intolerant. When considering the recommendation of expected to affect leg cramps, color of mucous membranes and conjunctiva, or resting heart a calcium supplement, which of the following should rate. be assessed?
| Recall that calcium is a salt, and use this information to recall that salts can form crystals, which can in turn lead to kidney stones. |
5178 During the first prenatal assessment, the nurse Correct answer: 3 The measles, mumps, and rubella vaccine contains live, attenuated virus and could cause discovers that the client has not had a second disease and harm to the fetus during pregnancy. It should be given after delivery, and the vaccination for measles, mumps, and rubella. The best woman should avoid conceiving for 3 months. plan for this client is to:
| Determine that the issue in this question is immunization safety during pregnancy. Eliminate option 4 first because it is totally incorrect. Next eliminate option 2 because it would not make sense to wait until late in the pregnancy to administer a vaccine. Note also that options 1 and 3 are opposites; choose option 3 over option 1, recalling the live attenuated viral nature of the vaccine. |
5179 The pregnant client, who is at 34 weeks gestation, Correct answer: 2 Braxton‐Hicks contractions are probably caused by stretching of the myometrium. They are calls the prenatal clinic complaining of cramping pain usually relieved by position changes, frequent emptying of the bladder, resting in a lateral in her abdomen. After the diagnosis of Braxton‐Hicks recumbent position, and walking or light exercise. contractions is made, the nurse should give the client which of the following recommendations?
| The question addresses the issue of client teaching about Braxton‐Hicks contractions. The wording of the question indicates the correct answer is a true statement. Eliminate option 3 because it is factually incorrect; breathing may decrease discomfort during contractions. Next eliminate option 1 as unnecessary. Choose option 2 because it is a correct statement, and it does not patronize the client as does option 4. |
5180 The client, who is at 37 weeks gestation, is Correct answer: 4 Heat may relieve pain caused by increased joint mobility resulting from hormonal changes. complaining of joint pain, especially in the lower back Aspirin (option 3) should be avoided in the last trimester because it increases bleeding time. and pelvic area. The best response by the nurse is: Option 1 is not a therapeutic communication. Option 2 may not be helpful for maternal–fetal circulation because the gravid uterus may cause pressure on the great vessels in the abdomen. The client should lie on one side; often the left is advised.
| Use general knowledge of care during pregnancy to eliminate options 2 and 3. Next eliminate option 1 because it violates principles of therapeutic communication. |
5181 The pregnant client tells the nurse that she keeps Correct answer: 4 The doula is a trained professional who provides physical and emotional support during labor. hearing about someone called a “doula” but she isn t A doula does not replace either the father or the labor‐and‐delivery nurse in the delivery sure what a doula does. The nurse s best response is, room. The doula is not responsible for clinical tasks and will not deliver the baby. “A doula:"
| Recall that the doula is an ancillary caregiver to eliminate options 2 and 3. Choose option 4 over option 1 because the father’s presence in the delivery room should not be affected by a doula. |
5182 The pregnant client is trying to decide where she Correct answer: 4 The LDRP room provides for all phases of the delivery process in one room with the added would like to give birth. She states she wants to be safety of full hospital services for both mother and infant that home delivery and a delivered by a nurse‐midwife, doesn’t want to move to freestanding birthing center cannot provide. several different rooms, and wants to be near pediatric services in case the baby has a problem. The nurse should advise her to consider which of the following birthing sites?
| Match the client statement in the question to the option that has the best match. This will easily allow you to eliminate the incorrect options. |
5183 In reviewing the chart of a prenatal client, which of Correct answer: 3 Probable signs of pregnancy are those that are detected by the examiner and are usually the following would be considered by the nurse to be a related to the physical signs of pregnancy. Amenorrhea and chloasma are reported by the probable sign of pregnancy? client (presumptive signs) and can be caused by conditions other than pregnancy. Fetal heartbeat on ultrasound is a positive sign of pregnancy.
| Specific knowledge of the different classifications of signs of pregnancy is needed to answer this question. If you recall that “probable” is the middle category, it may help you to eliminate option 1 (positive sign) and options 2 and 4 (possible signs). |
5184 The client is planning to breastfeed and asks the Correct answer: 1 Trauma and the use of substances other than water can cause nipples to crack during nurse what she should do to prepare. The nurse should lactation. The pinch test is to determine if nipples are inverted and need only be done one advise the client to do which of the following? time.
| Use nursing knowledge to answer the question. It may also be helpful to recall general principles of skin care and avoidance of skin trauma, which helps eliminate each of the incorrect options. |
5185 The client has come to the clinic for her first prenatal Correct answer: 1 The client who is not eating meat may have a problem with decreased iron intake, which visit and tells the nurse that she eats only vegetables. could impact her hemoglobin level. Polymorphonuclear cells, lymphocytes, and platelets are To assess for a problem related to this information, unrelated to iron intake. the nurse should assess what part of the complete blood count (CBC)?
| Recall that meat is rich in iron, which is needed for RBC production. Then recall that the hemoglobin level is affected by iron intake and iron stores. As an alternate strategy, eliminate each of the other options because they do not identify RBCs. |
5186 The nurse interprets that which of the following Correct answer: 4 Rubella titer higher than 1:16 is indicative of immunity to rubella. Rubella is a mild illness, and indicates a need for instruction to the pregnant client the client may or may not be aware of past infection (option 1). A rubella titer of 1:8 or less about avoiding infection with the rubella virus? does not demonstrate immunity, and avoidance of those with rubella infection is indicated. A level of 1:12 is midway between susceptibility and immunity, so a client with this level is not at greatest risk.
| Use the process of elimination to omit option 1 first because it does not address a laboratory value and relies on patient history for accuracy. Use specific knowledge of the direction of titer values to choose the correct answer. In this case, the higher the number, the better the immunity. |
5187 Which of the following, if revealed to the nurse in a Correct answer: 2 Day care workers are frequently exposed to the virus. Exposure to cat litter can result in prenatal interview, would indicate an increased risk for toxoplasmosis exposure. IV drug use increases the risk for HIV or hepatitis. Giving blood does exposure to cytomegalovirus? not increase the client’s risk.
| Use the process of elimination and knowledge of transmission of viral infections to answer this question. Eliminate option 4 first as unrelated to acquiring infection. Eliminate option 1 next because the organism in toxoplasmosis is not a virus. Choose option 2 over 3 because option 3 is transmitted by blood or body fluids. |
5188 Which of the following, if found by the nurse during Correct answer: 2 Indications for cesarean section are presence of a herpes lesion or prodromal symptoms. If prenatal care, would indicate a need for delivery by there are no herpes symptoms or lesions, a vaginal delivery is recommended. cesarean section?
| Specific knowledge related to risk of delivery with herpes infection is needed to answer the question. Use concepts of time and direct contact with lesions to eliminate the incorrect options. |
5189 Follow‐up for the pregnant client who is diagnosed Correct answer: 1 All partners have been exposed and should be made aware, tested, and treated as indicated. with a sexually transmitted disease includes: Cesarean section would be appropriate only if there were symptoms of a herpes lesion or prodromal symptoms. Genetic assessment and more‐than‐routine assessment of hematocrit and hemoglobin are not indicated.
| Use knowledge of principles of communicable disease transmission to answer the question. The client in the question is actually the sexual partner(s), not the fetus. |
5190 The nurse should plan for Group B streptococcus Correct answer: 2 Carrier status of Group B streptococcus is variable, so identification several weeks before screening if the pregnant client meets which of the delivery may not identify a woman who is positive at the time of delivery. The current following criteria? recommendation is screening during the 36–37th week of gestation. Rash and history of STI do not alter this recommendation.
| Specific knowledge of the timing of prenatal assessments is needed to answer this question. Eliminate option 1 because of the word history, which does not necessarily imply a risk for an active problem. Eliminate option 4 as unrelated, and choose option 2 over 3 by considering the risk for exposure at the time of delivery. |
5191 Which of the following, if reported to the nurse by a Correct answer: 4 Menstrual blood can affect the results of a gonorrheal culture. Douching within 24 hours can pregnant client prior to collection of a gonorrhea affect results, but diagnosis/treatment of herpes and persistent vaginal discharge would not culture, would result in postponing specimen affect the results, and therefore do not interfere with specimen collection. collection?
| Use general knowledge of specimen collection procedures to answer the question. Visualize each option and choose the one that could physically alter the test results. |
5192 The client has come to the prenatal clinic complaining Correct answer: 3 Urine‐specific gravity is a measure of the concentration of particles in the urine. Urine‐specific of repeated nausea and vomiting. The nurse would gravity rises when the client is dehydrated. Hematocrit would also rise when the client is look to which of the following as providing the best dehydrated, but is an indirect measure. Hemoglobin measurements are not as greatly affected. information about client hydration status? Platelet count and IgG levels are not affected.
| Note the key word best in the question, which means that more than one value could be affected. Use knowledge of laboratory indicators of dehydration to eliminate options 2 and 4. Then choose option 3 over option 1 because it is a more direct measurement of fluid balance. |
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5193 In taking a history from a pregnant client, which of Correct answer: 1 Because it frequently involves tissue trauma that facilitates invasion of pathogens, anal the following would the nurse recognize as a risk factor intercourse is considered a high‐risk sexual behavior. As such, it could lead to contraction of an for contracting a sexually transmitted infection? STI. The other factors listed here do not increase the client’s risk for contraction of an STI.
| Use knowledge of principles related to spread of infection to answer the question. Only option 1 directly relates to a link in the chain of infection. |
5194 In interviewing a pregnant client concerning sexually Correct answer: 3 Closed‐ended questions are a barrier to communication in many nurse–client interactions. transmitted infections, the nurse should recognize They are best used when trying to elicit very specific pieces of assessment data. Use of open‐ which of the following as a barrier to client disclosure? ended questions, framed in a culturally sensitive and nonjudgmental approach, tends to establish a trusting and open relationship with the client and enhance client disclosure. Conducting the interview with the client dressed may also increase overall client comfort and aid in client disclosure.
| Use general principles related to communication and history taking to answer this question. Application of these principles will help to eliminate each incorrect option. |
5195 A pregnant client is concerned about changes in Correct answer: 1 The woman has linea nigra, a line of darker pigmentation from the umbilicus to the pubis. It is pigmentation of her skin on her andomen. The best normal, caused by hormonal changes in pregnancy, and will fade after delivery. Cloasma response by the nurse is: affects the face, and striae gravidarum are reddish stretch marks on the abdomen, breasts, thighs, or buttocks.
| Knowledge of linea nigra as a common change in pregnancy will help to answer the question. |
5196 When asked by the nurse "How do you think your life Correct answer: 3 The addition of a new baby causes many changes in family roles, emotions, and money will be different after the baby comes?" which of the management. If these changes are not anticipated, family dysfunction can result. following replies would indicate to the nurse a need for further discussion?
| Knowledge of the changes that will occur with the addition of a baby will help to choose the answer that indicates that the family is not aware of the need to discuss these changes |
5197 The nurse is reviewing the chart of a client who has Correct answer: 2 A rapid increase in fundal height could indicate a problem such as multiple gestation, come in for her prenatal visit at 34 weeks. In hydatidiform mole, or polyhydramnios. The other answers are all normal findings and not comparing the findings from this visit to those of her causes for concern. visit at 30 weeks, which of the following would be a cause for concern?
| The core issue of the question is an abnormal assessment finding. Eliminate options 1, 3, and 4 because they contain normal assessment findings that would not be of concern. |
5198 The client who is 34 weeks pregnant is complaining of Correct answer: 3 Lower back pain results from increased hormone levels that cause the joints to relax and lower back pain. Which of the following would be the curvature of the lumbosacral vertebrae as the uterus enlarges. Pelvic tilt exercises help restore best response of the nurse? proper body alignment and can decrease discomfort. The other answers are not therapeutic but blame the client rather than helping to intervene to decrease the discomfort.
| This is a positive statement. The correct answer would be the option that contains a true statement about a point of client education. |
5199 During the initial prenatal assessment at 9 weeks, the Correct answer: 2 Flat nipples are caused by adhesions around the nipple that prevent it from becoming erect. nurse notes that the client's nipples are flat. Which of Hoffman's exercises break the adhesions. Nipple shields are effective in breaking the the following would be the best statement by the adhesions, but they should be worn in the last 3–4 months of pregnancy and only a few hours nurse? at a time. Flat nipples do not preclude breastfeeding.
| Knowledge of breast care for the prenatal client will aid in determining the correct answer. |
5200 Which of the following statements by the pregnant Correct answer: 2 Although the fetal risk from alcohol appears to be proportionate to the amount of intake, no client in her first trimester indicates that she safe level of drinking has been established. Therefore, it is recommended that pregnant understood prenatal education? women not consume alcohol. The risks related to tobacco use are present throughout pregnancy. No teratogenic effects of marijuana use during pregnancy have been documented, but caffeine has been found to interfere with absorption of iron.
| Knowledge of teratogenic substances and the effect on the fetus will aid in determining the correct answer. |
5201 Which of the following statements by the pregnant Correct answer: 1, 5 Protein and iron intake in pregnancy must increase to meet the needs of the growing fetus. client indicates to the nurse an understanding of the Calcium requirements increase at the same rate as phosphorus. Caloric needs increase, but client's nutritional needs during the second and third only about 300 calories per day. Iodine requirements increase during pregnancy. trimester? Select all that apply.
| Knowledge of nutrition during pregnancy will help to answer the question correctly. |
5202 In planning nutritional intake for a pregnant woman Correct answer: 1 Anemia in pregnancy is often caused by inadequate iron intake. Lean meat and enriched who is anemic, which of the following foods would be bread are good sources of iron. the best food choice to increase the intake of iron?
| Knowledge of foods high in iron will help to answer the question correctly. Take time to review these if needed. |
5203 Which of the following would be an appropriate Correct answer: 1 Conveniently located prenatal services that are open at convenient hours ease access for strategy for nurses interested in decreasing barriers to poor and working women. Support for prenatal care from the public and legislature increases early prenatal care? access for poor women.
| Key words are "decreasing barriers to prenatal care," which indicates that it should be a direct global point that would enable access for all women. |
5204 A client at 20 week's gestation is concerned about Correct answer: 3 The child should be included in planning for the new baby. Children may feel threatened by a how to tell her 3‐year‐old son about her pregnancy. new sibling and so may need extra time and attention. Parents should avoid putting too much Which of the following would be the best advice for responsibility on the child. Option 1 is not therapeutic but places shame on the child. Staying the woman? with the grandparents may be felt as further rejection from the parents.
| Knowledge of therapeutic communication and support for the child will aid in choosing the correct answer. |
5205 The nurse has given the client information on Correct answer: 3 If the maternal level of alpha‐fetoprotein is elevated, it could indicate that fetal alpha‐ maternal serum alpha‐fetoprotein screening. Which of fetoprotein from a fetal neural tube defect has leaked into the maternal serum. The test is the following statements by the mother would indicate most sensitive between 16 and 18 weeks' gestation. It is not definitive enough to make a that she understood the information? diagnosis and is best used as a screening tool.
| Knowledge of the test and its indications would help to answer the question correctly. |
5206 Which of the following would be the best indicator of Correct answer: 2 In singleton births with fetal growth within normal limits, fundal height in centimeters normal fetal growth? multiplied by 8 and divided by 7 should correlate with gestational age in weeks. Eliminate options that do not address this assessment.
| Remember that from about 22–34 weeks' gestation, fundal height correlates well with weeks of gestation, plus or minus 2 cm. |
5207 The nurse is planning an educational program for a Correct answer: 4, 5 Childbirth education should be geared to the time in pregnancy. In the third trimester, the client who is in her third trimester of pregnancy. pregnant woman begins to focus on labor, delivery, and newborn care. Which of the following childbirth education topics would be most appropriate? Select all that apply.
| Key words are "third trimester" and "childbirth education topics ... most appropriate." Knowledge of childbirth education and the related information that corresponds to the trimester aids in answering this question. This question is time‐sensitive. |
5208 Following confirmation of pregnancy, the client has Correct answer: 1 The first number, gravida, represents the total number of pregnancies including the current come into the clinic for her first prenatal visit. She one. In this case that equals 4. Para is represented by using the TPAL system. T represents the reports having a 5‐year‐old child who was born at 40 number of term births, 1; P represents the number of preterm births, 1; A represents the weeks' gestation, a set of 3‐year‐old triplets who were number of therapeutic or spontaneous abortions, 1; and L represents the number of living born at 34 weeks' gestation, and a first‐trimester children, 4. Multiple births do not affect the parity in the T, P, or A categories; they are abortion when she was in college. On her medical counted in the L category. record, the nurse would make which of the following entries?
| Specific knowledge of the TPAL system to document pregnancies, preterm births, abortions, and living children is needed to choose the correct answer. |
5209 The client has come to the clinic because she suspects Correct answer: 4 Palpation of fetal movement is considered to be a completely objective sign of pregnancy that she is pregnant. Which of the following would be that cannot have any other cause. The other signs listed here could have another etiology. the most definitive way to confirm the diagnosis?
| A critical word in the stem of the question is "confirm." Eliminate the answers that could have another etiology. Fetal movement by a trained examiner after about 20 weeks' gestation is a diagnostic (positive) sign of pregnancy. |
5210 The client, who is at 34 weeks' gestation, says to the Correct answer: 3 The husband can take on a variety of roles during labor and delivery, including coach, nurse, "I had hoped to use the Lamaze method when teammate, and observer. Exploring both partners' expectations may help to clarify reasons for my baby is born, but my husband doesn't want to . . . the husband's hesitancy in participating in the birth. This could result in improved so I guess I'll just have an epidural." The best response communication and family coping. by the nurse would be:
| The core issue of this question is expectations and communication. The correct answer includes the most therapeutic response to facilitate couple communication. Option #3 is the only therapeutic response that could open the communication between the husband and wife about the upcoming delivery expectations. |
5211 The client, who is a primigravida, has come to the Correct answer: 2 Increased pigmentation during pregnancy is a response to increased estrogen levels. It can be clinic for a scheduled prenatal visit. She is concerned worsened by the sun, is harmless, and generally fades after the pregnancy ends. about facial chloasma that has developed since her last prenatal visit. The best response by the nurse is:
| Knowledge of the normal changes during pregnancy and the educational needs of the mother is essential to choose the correct answer. |
5212 The client, who is at 32 weeks' gestation, complains Correct answer: 1 Heartburn is usually caused by gastric reflux. Remaining in an upright position, not overeating, of severe heartburn, especially at night. Following and use of low‐sodium antacids all help to relieve the problem. instruction by the nurse, which of the following statements by the client indicates that she understands the best course of management?
| Knowledge of the changes in the GI system as a result of pregnancy and the educational needs of the mother will aid in answering this question. Since the question is worded positively, the correct option will also be a true statement. |
4.‐ "Heartburn is a common discomfort in pregnancy, there is really nothing to do about it." | |
5213 The client, who is at 8 weeks' gestation, is Correct answer: 3 Nausea and vomiting, probably related to hormonal changes, usually disappear by the 12th experiencing frequent nausea and vomiting. Following week of pregnancy. Small, frequent meals, carbonated beverages, and crackers or toast instruction by the nurse, which of the following sometimes relieve the symptoms. statements by the client demonstrates that she understands the best course of management?
| Knowledge of the self‐care measures for common discomforts of pregnancy will help to choose the correct answer. |
5214 Which of the following statements would indicate to Correct answer: 3 While some ambivalence is common during pregnancy, the client should also have some the nurse that a client demonstrates acceptance of feelings of happiness, tolerance of physical discomforts, and a feeling that she can deal with pregnancy? the changes and problems related to the pregnancy.
| Knowledge of the emotional responses to pregnancy and the common responses toward the pregnancy will help to choose the answer that identifies the acceptance of the pregnancy. |
5215 During the client's initial prenatal visit, which of the Correct answer: 1 Maternal diabetes places both the mother and infant at risk during pregnancy and would following would indicate a need for further require further follow‐up. The other answers present no further untoward risk. assessment?
| Key words are "initial prenatal visit" and "indicate a need for further assessment," thereby indicating you need to look for a potential problem. Only option #1 indicates a problem. |
5216 The low‐risk client, who is 16 weeks pregnant, should Correct answer: 4 The risk for the mother and fetus increases as the pregnancy progresses. Therefore, clients be told to return to the prenatal clinic in: are seen more frequently as pregnancy nears term. Visits every 4 weeks for low‐risk clients are appropriate until 28 weeks of gestation.
| Correlate low risk in early pregnancy in the question with the most infrequent visit schedule in the options to identify the correct answer. Knowledge of the regular plan for prenatal visits helps to answer this question. |
5217 The client has completed an at‐home pregnancy test Correct answer: 3 A positive at‐home pregnancy test indicates the presence of growing trophoblastic tissue and with positive results. Which of the following indicates not necessarily a uterine pregnancy. It could even indicate a potential ectopic pregnancy. that the client understands the meaning of the test results?
| Critical words are "understands the results." Knowledge of over‐the‐counter pregnancy tests and the interpretation of the results will help to choose the correct answer. |
5218 A client comes to the clinic for her first prenatal visit Correct answer: 04‐17 Using Naegele's rule, the estimated date of birth is calculated by subtracting 3 months from and reports that July 10 was the first day of her last the first day of the last menstrual period and then adding 7 days to that date. menstrual period. Using Naegele's rule, the nurse calculates the estimated date of birth for the client to be? Write in a numerical answer using format month‐ day; i.e., July 10 = 07‐10. | Recall Naegele's rule to calculate the answer to this question. |
5219 The pregnant client reports that she has a 3‐year‐old Correct answer: 3 Counting the current pregnancy, the client has been pregnant a total of four times for gravida child at home who was born at term, had a miscarriage 4. Para is the number of pregnancies that have reached viability, in this case two. at 10 weeks' gestation, and delivered a set of twins at 28 weeks' gestation who died within 24 hours. In the prenatal record, the nurse should record:
| Knowledge of gravida and para definitions aid in answering the question. |
5220 The client, who is at 36 weeks' gestation, calls her Correct answer: 3, 5 The fluid leaking from her breasts is colostrum. It normally leaks from the breasts during the prenatal care provider because she is concerned about last trimester. The client should wear a supportive bra. a thin, bluish‐white fluid leaking from her breasts. The nurse's best response is: (Select all that apply.)
| Knowledge of the normal changes to the breast during pregnancy and the teaching needs will help to answer this question. |
5221 The client's prenatal education includes danger signs Correct answer: 1 Dizziness and blurred vision can be symptoms of pregnancy‐induced hypertension, a to report. Which of the following, if reported, would complication that requires further assessment and medical management. The other answers indicate that the client understood the teaching? are not danger signs of pregnancy.
| Option #1 is the only answer that indicates a high risk; the other options are not danger signs of pregnancy. |
5222 The client, a pregnant 20‐year‐old single woman, tells Correct answer: 3 The client has expressed a realistic concern. The nurse needs to help her explore what the nurse that she wants to keep her baby, but she support systems are available for her and her child. isn't sure she can manage by herself. The best response by the nurse is:
| Eliminate options #1 and #4 because they are not what the client indicated. Option #2 is not empathetic and supportive. Option #3 is the only one that indicates the nurse's support and opens the opportunity to explore the client's concerns. |
5223 The nurse is planning a childbirth education class for Correct answer: 2 Topics should be timed to present information that the woman needs at that specific stage of women in their first trimester of pregnancy. Which of pregnancy. The items identified in the other options can be covered later in the pregnancy. the following topics will be most appropriate?
| Critical words are "childbirth ... class ... in ... first trimester" and "most appropriate." Use the process of elimination and knowledge about the progression of pregnancy to make a selection. |
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5224 The client, who was an appropriate weight for height Correct answer: 2 For women of normal pre‐pregnant weight, the recommended pattern of weight gain during at the time she became pregnant, is 20 weeks pregnancy is 3–5 pounds during the first trimester and 1 pound per week thereafter. pregnant and has gained a total of 12 pounds. She is Nutritional counseling is an appropriate action for the nurse, or the nurse should make a concerned about weight gain. The best response by referral for the client to meet with the nutritionist. Salt intake during normal pregnancy should the nurse is: be moderate but not restricted.
| Specific knowledge of the recommended weight gain during pregnancy will aid in answering this question. The correct answer provides a true statement about a point of client education and explores the client's concerns. |
5225 Which of the following statements indicates to the Correct answer: 1 Maintaining a healthy relationship is important during infertility treatments, which can be nurse that a couple is coping with the stress of very stressful. Options 2, 3, and 4 may indicate ineffective coping strategies and warrant infertility treatment? further investigation.
| Note a key word in the question is coping. Look for the option that indicates effective functioning or therapeutic communication with questions such as these. |
5226 The client has been diagnosed with Trichomonas Correct answer: 3 Vaginal fluid pH is slightly alkaline, as is semen. Spermatozoa cannot survive in an acidic vaginitis. The nurse explains during client teaching that environment. Trichomonas vaginitis increases the acidity of the vaginal and cervical secretions, this infection can affect fertility by: thus reducing the number of viable sperm.
| Look for the option that is a true statement and use knowledge of pathophysiology to eliminate incorrect distractors. |
5227 The nurse is concerned that which of the following Correct answer: 4 Mumps in adult males can cause permanent blockage of the vas deferens, contributing to or viral infections, if experienced by an adult male, may resulting in infertility. The other responses are incorrect. cause infertility?
| Look for the option that exerts this effect and use knowledge of pathophysiology to eliminate incorrect distracters. |
5228 Which of the following client statements indicates the Correct answer: 3 The sperm penetration test, which tests for the ability of sperm to penetrate an egg, should need for additional teaching? be performed after 2–7 days of abstinence.
| The wording of this question guides you to look for an incorrect statement as the correct answer to the question. Evaluate each option as to whether it is true or false. The false statement is then the correct answer. |
5229 What information does the nurse need to gather Correct answer: 1 The nurse needs to know the first day of the last normal menstrual period and the length of before scheduling a client’s endometrial biopsy? the menstrual cycle. Endometrial biopsy is performed on day 21–27 of the menstrual cycle to assess the endometrial response to progesterone and the degree of development of the luteal phase endometrium. | Eliminate option 3 first as irrelevant and then option 2 because excessive bleeding requiring transfusion is not expected. Use knowledge of the relationship between the menstrual cycle and the biopsy procedure to choose option 1 over 4. |
| |
5230 The nurse is teaching a class in the community on Correct answer: 4 Hot tubs, saunas, and tight underwear can raise the temperature of the testes too high for common myths regarding fertility and infertility. Which efficient spermatogenesis and lead to decreased sperm numbers and motility. of the following statements made by class participants indicates teaching has been successful?
| The wording of this question guides you to look for a correct statement as the answer to the question. Evaluate each option as to whether it is true or false. The true statement is then the correct answer. |
5231 The client couple is planning intracytoplasmic sperm Correct answer: 3 In vitro fertilization usually creates multiple embryos, of which up to four are implanted. injection, followed by intrauterine embryo transfer. Cryopreservation of excess embryos is common, and they can be implanted at a later date. Which of the following statements indicates that the nurse’s teaching was effective?
| The wording of this question guides you to look for a correct statement as the answer to the question. Evaluate each option as to whether it is true or false. The true statement is then the correct answer. |
5232 The clinic nurse is interviewing a client couple for an Correct answer: 2 The psychological, cultural, and social ramifications of infertility can be extensive. You need to initial infertility workup. Which of the following topics assess this area to ascertain if the couple needs assistance in coping with their infertility and should the nurse plan to address? treatment.
| Note the key word infertility and note also that this is a nursing assessment. With this in mind, eliminate option 1 as a non‐nursing function and options 3 and 4 as not directly related to the topic. |
5233 The client is experiencing an inability to become Correct answer: 2 Secondary infertility is the term for couples that have had one pregnancy but are unable to pregnant after she has had one full‐term pregnancy. conceive again. Primary infertility describes the inability to conceive even once. Options 3 and The nurse should develop a plan of care for which 4 are not terms that are used when discussing fertility. health problem?
| Eliminate options 3 and 4 first as terms that are not used, then choose option 2 over 1 because the couple has had one successful pregnancy. |
5234 The client has an obstruction between the uterus and Correct answer: 2 Infectious processes of the reproductive tract such as PID may result in tubal scarring and the fallopian tubes. In obtaining a health history, the therefore tubal blockage. Rubella infection in childhood usually results in the development of nurse collects information about which of the active immunity to the disease. Smoking and alcohol present health risks to the woman but following that may have caused this problem? not related to tubal patency.
| The wording of the question guides you to look for an association between blockage in the reproductive system and a condition that is causally related to this. Recall that inflammation and infection can lead to scarring and obstruction in the body (which eliminates options 3 and 4). Choose option 2 over 1 because of the age in option 1 and the association of inflammation with option 2. |
5235 Which of the following statements by the client could Correct answer: 1 Because some semen is released before ejaculation, coitus interruptus has an 18% failure rate indicate a potential problem for the couple planning to and would not be considered a very effective method for a couple wanting to avoid pregnancy. use coitus interruptus?
| The key words in the question are potential problem; they lead you to look for a statement that corresponds to a negative aspect of coitus interruptus. With this in mind, each incorrect option can be systematically eliminated. |
5236 Which of the following, if stated by the client, would Correct answer: 4 Cervical mucus that is thin and clear indicates a rising level of estrogen and impending indicate that teaching about cervical mucus changes as ovulation. Stretchability of the cervical mucus, or spinnbarkeit, is indicative of the fertile period an indicator of ovulation has been understood? and promotes motility of the sperm. Options 1 and 3 represent cervical mucus during the infertile period when sexual intercourse is unlikely to result in pregnancy.
| The key word understood indicates that the correct option is also a correct statement. Use knowledge of physical changes during ovulation to make a selection, or use logic to reason that sperm are more motile through thinner liquids than thicker liquids. |
5237 The client who is married and has three children has Correct answer: 3 The symptothermal method combines cervical mucus and BBT measurements and results in a come to the family planning clinic asking about a birth lower failure rate than single assessments of the fertile period. This method is completely control method that is sanctioned by the Roman natural and acceptable to the beliefs of this religious group. Ovulation testing kits do not give Catholic Church. She wants the most effective method enough warning of ovulation to prevent pregnancy. possible. The nurse’s best recommendation is which of the following?
| Note the key word best, which indicates more than one option could be true. In this question, eliminate option 2 first as least timely, and choose option 3 over options 1 and 4 because option 3 is comprehensive and includes these other options. |
5238 The client is interested in using female condoms and Correct answer: 2 Made of polyurethane, the female condom does not require a prescription but can be difficult wants to know if there are any disadvantages. The to insert, and can cause discomfort. It is effective against both sexually transmitted infections nurse’s best response would be: and pregnancy.
| Eliminate option 3 first because only advanced practice nurses have prescriptive privileges and this is not relevant to the question. Use the key word disadvantages to focus your selection. Eliminate option 1 next because it is an effective barrier, and eliminate option 4 as a false statement. |
5239 Which of the following clients would be the best Correct answer: 3 Intrauterine devices are usually recommended for women who have been pregnant and are candidate for insertion of an intrauterine device? in a monogamous relationship so that they are at a low risk for sexually transmitted disease.
| Use knowledge of advantages and disadvantages of this birth control method to evaluate the options. Eliminate options 2 and 4 because of the risk for infection, and choose option 3 over 1 because the method is for long‐term use, not short‐term use. |
5240 The client, a 16‐year‐old female, has come to the Correct answer: 4 Spermicides must be used within 30 minutes of intercourse, have a failure rate of 21%, and clinic to discuss contraception because she has do offer some protection against sexually transmitted infections. Other key information recently become sexually active. The client states that needed is the sexual history of the client and her partner(s) to more accurately assess risk for many of her friends are using spermicides and asks the STIs. Option 1 provides advice, which the nurse should not give. Options 2 and 3 are false nurse about their advantages and disadvantages. The statements. nurse’s best response would be:
| Note the key word best, which indicates more than one response may be partially or totally correct in terms of its content. Eliminate options 2 and 4 first as false statements, then choose option 4 over option 1 because it is true and it is a more therapeutic communication. |
5241 In teaching a client about the risk of toxic shock Correct answer: 4 When using the device, the woman should wash her hands with soap and water, remove the syndrome associated with diaphragm use, the nurse device within 24 hours of intercourse, clean the device with soap and water, and seek should tell the client to do which of the following to treatment for vaginal infections before reusing the device. decrease her risk?
| The wording of the question indicates that the correct answer is an option that contains a true statement. Use nursing knowledge and the process of elimination to reject the incorrect options, which are false statements. |
5242 The client has come to the clinic to discuss use of a Correct answer: 3 Long‐term exposure to secretions, spermicides, and bacteria trapped inside the cap can result cervical cap for contraception. If determined by the in abnormal Pap smear results. This client has a history of an abnormal Pap smear; cervical cap nurse’s assessment, which of the following would be a use could negatively impact this finding, and another method should be explored for this contraindication to use of the cervical cap? client. The other options have no relationship to use of the cervical cap.
| Note the key word contraindication, and use the process of elimination and nursing knowledge to select the option that would pose a risk to this client with regard to use of a cervical cap. |
5243 In teaching the client about factors that can decrease Correct answer: 1 Antibiotic use can decrease the effectiveness of oral contraceptives. Oral contraceptives can the effectiveness of oral contraceptives, which of the help prevent iron‐deficient anemia by decreasing menstrual blood flow. Weight gain and following should be included by the nurse? anemia are not related to the effectiveness of birth control pills.
| Note the key phrase decrease the effectiveness, and use the process of elimination and nursing knowledge to select your answer. Recall as a general principle that medications can adversely interact, which is the basis for this question. |
5244 In addition to prevention of pregnancy, oral Correct answer: 2 Oral contraceptives can reduce acne; result in signs and symptoms of early pregnancy, contraceptives would provide benefits for a client with including chloasma; and accelerate the progress of gallbladder disease. Birth control pills do which of the following problems? not provide protection against STIs that can result in PID.
| This question is actually asking about secondary uses of oral contraceptives. Eliminate option 1 first because it is the least plausible. Eliminate options 3 and 4 next because they are aggravated by the use of oral contraceptives. |
5245 The client, who delivered her first child 2 days ago, is Correct answer: 1 Oral contraceptives with a combination of estrogen and progestin are not recommended in being discharged from the hospital. She is interested in the first 6 weeks of lactation. In addition, the long‐term effects on the infant are not known. a contraceptive method that is not associated with The use of female condoms and a diaphragm are associated with sexual intercourse. Progestin‐ intercourse and will not interfere with lactation. The only pills are safe for lactating women. nurse concludes that which of the following probably would be the best method for this client?
| Note the key phrase not associated with intercourse, which would lead you to first eliminate options 2 and 3. Choose option 1 over 4 because progestin‐only contraceptives are estrogen‐free and thus contain fewer hormones to which a breastfeeding infant would be exposed. |
5246 Which of the following statements would indicate to Correct answer: 2 Norplant is a subdermal contraceptive implant that has about the same failure rate as surgical the nurse that teaching was effective for the client sterilization, is effective for 5 years, and must be surgically removed. who is to receive a Norplant subdermal implant?
| The wording of the question indicates that the correct answer is an option that contains a true statement. Use the process of elimination and knowledge of contraceptive subdermal implants to eliminate the incorrect options. |
5247 The nurse is preparing to administer an injection of Correct answer: 3 The medication is administered intramuscularly every 80–90 days. Anemia, while important Depo‐Provera. Which of the following would result in to the client s health, is not related to Depo‐Provera use. The drug does not provide protection safe and effective administration of this drug? against sexually transmitted infections; counseling regarding the consistent use of condoms would be an effective intervention to prevent the reoccurrence of pelvic inflammatory disease.
| The key words in the question are safe and effective administration. Eliminate options 2 and 4 first because they are unrelated to the question, and choose option 3 over 1 because it is true regarding administration of this drug. |
5248 In giving instruction to the client who is to receive Correct answer: 2 The most common side effect of Depo‐Provera is amenorrhea or irregular bleeding. With a Depo‐Provera, the nurse should tell the client which of failure rate similar to oral contraceptives, Depo‐Provera does not interfere with lactation. the following? Typically, the estrogen component of hormonal contraceptives is associated with thromboembolic disease; Depo‐Provera contains only progestin.
| The wording of the question indicates that the correct answer is an option that is a true statement. Use medication knowledge and the process of elimination to make your selection. |
5249 A client has been admitted as an outpatient for a Correct answer: 3 Some clients report mild pain after the procedure, which is usually relieved with analgesics. tubal ligation. Following the procedure, the client Changes in menstruation, sexual function, or other hormonal symptoms are not typical. should be told to expect which of the following?
| The wording of the question indicates that the correct answer is an option that is a true statement. Use knowledge that this is a minor surgical procedure and the process of elimination to make your selection. |
5250 The nurse would include which of the following in a Correct answer: 1 Infertility is often a very stressful situation, and the nurse's assessment of the couple's coping nursing care plan for a couple who have secondary mechanisms is important. The other options would not be appropriate for the clients at this infertility? time.
| Eliminate options that are not appropriate at this time. Option 2 would have been determined prior to the visit. Option 3 may be appropriate for the female client but is unlikely for the client as a couple. Option 4 is premature at this time since pregnancy has not been achieved. |
5251 A client is receiving treatment with clomiphene Correct answer: 3 These are common side effects of clomiphene citrate (Clomid) that usually disappear in a few citrate (Clomid) for primary infertility. After 2 days the days or weeks. Intervention is directed toward relief of the symptoms. They do not represent woman reports hot flashes and blurred vision. The an allergic response or pregnancy, or require immediate assessment by a physician. nurse should instruct the client to do which of the following?
| Critical words are "Clomid" and "hot flashes and blurred vision," which are side effects of the drug. Use knowledge of the nursing considerations for working with clients who are prescribed this infertility drug. |
5252 In a high school health class, the nurse is discussing Correct answer: 3 Motility is the swimming ability of sperm. Morphology is the shape, and sperm count is the how sperm motility is important for achieving number of sperm. Ejaculation is not dependent on the age of sperm. pregnancy. Which related statement does the nurse include in this discussion?
| Critical words are "sperm motility" and "achieving pregnancy." Understanding of the need for sperm to swim is necessary to answer this question. |
5253 The nurse determines that the client needs additional Correct answer: 1 During ovulation, cervical mucus is more abundant and thinner, and becomes stretchy. These teaching when the client states: changes facilitate sperm transport toward the ovum.
| Critical words are "needs additional teaching" so an incorrect answer is one that is needed. Option 1 is correct because it is a false statement; the other answers are all accurate responses which do not require further teaching. |
5254 The nurse anticipates that the health care provider Correct answer: 3 Anovulatory menstrual cycles are those in which ovulation does not take place. Medications will prescribe which of the following to a woman with such as clomiphene citrate (Clomid) or Pergonal, a menotrophin, are given to stimulate the anovulatory menstrual cycles? ovaries to mature and release an ovum. Multifetal pregnancies are sometimes a side effect of these medications, not a desired outcome.
| Critical words are "anovulatory menstrual cycle" and "prescribed," indicating a medication. Knowledge of anovulation and what is needed to correct this problem will help to answer the question. |
5255 The infertility clinic nurse determines that which of Correct answer: 1 Delegated assignments must be according to the legal practices of each state and the abilities the following nursing interventions can be delegated of those being delegated to. Only registered nurses perform complex interventions requiring to the certified medical assistant? nursing judgment such as assessment or teaching. A client's first ovum retrieval procedure will involve assessment, teaching, administration of intravenous medications for sedation and comfort, and monitoring of vital signs, which require the additional knowledge and skill of the registered nurse. | Critical words are "delegate" and "certified medical assistant". Recognize that assessment and client education should not be delegated. Eliminate options 2, 3, and 4 because they contain these essential functions of the professional nurse. |
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5256 The nurse determines that a male client needs Correct answer: 1 Varicoceles raise the scrotal temperature, thus decreasing the number of sperm and the additional teaching about an upcoming varicocele number with normal morphology. Repairing the varicocele does not affect the ability to have repair surgery when he states: or maintain an erection.
| Critical words are "needs additional teaching" and "varicoceles." Knowledge of varicoceles and the affect on fertility is needed to answer this question. The need for further teaching requires an incorrect response from the client. |
5257 The nurse should teach the client that in vitro Correct answer: 1 In vitro fertilization occurs in a laboratory, thus bypassing the fallopian tubes. fertilization can overcome which of the following conditions?
| Critical words are "teach," "in vitro fertilization," and "overcome." The wording of the question is positive. The correct answer would be the option that contains a true statement about a point of client education. |
5258 In planning care for the infertile client, the nurse Correct answer: 3, 5 Self‐esteem can be threatened by the inability to conceive a child. Care must be taken to should do which of the following? Select all that apply. avoid placing blame on the person whose body is not functioning as expected. The amount of formal education does not affect fertility or treatments for infertility. Information should be given when appropriate and never withheld. Relaxing vacations to conceive are a myth that can become very expensive. Fertility testing takes a long time and therefore results are not instantaneous.
| The core issue of the question is the care of a client experiencing infertility. Eliminate option 1 as education does not affect fertility. Eliminate option 2 because information should be given when appropriate and never withheld. Eliminate option 4 because relaxing vacations to conceive are a myth that can become very expensive. |
5259 A man has decided to take total responsibility for Correct answer: 4 The scrotal portion of the vas deferens is surgically incised or cauterized. Sperm are still birth control and elects to have a vasectomy. The produced, but they can no longer be squeezed from the storage site (epididymis) into the nurse teaches the client that the: urethra for ejaculation. The epididymis and prostate gland are not excised during this procedure. Severing the urethra would prevent passage of urine from the bladder as well as semen and would not be considered.
| The critical words are "vasectomy" and "teach the client." Use knowledge of the male reproductive system and vasectomy to choose the correct answer. |
5260 Which of the following should the nurse include when Correct answer: 1 Either partner may experience feelings of guilt when faced with infertility. If the problem is developing the plan of care for an infertile client? with one partner, that partner's feelings of guilt are often more intense. Option #2 relates to client history, not the plan of care. Option #3 is nontherapeutic. Option #4 is not the role of the nurse.
| Critical words are "infertile client" and "plan of care." Option #1 deals with the feelings of loss. Remember Maslow's hierarchy of needs and address the emotional needs of the client. |
5261 The client is scheduled for a hysterosalpingogram. Correct answer: 2 Iodine‐based dye is instilled into the uterus and watched on X‐ray to detect uterine anomalies Which of the following should the nurse include in the or lack of tubal patency. An allergy to iodine or to shellfish, which is high in iodine content, preoperative assessment? should alert the nurse to a potential allergic response to the iodine‐based dye.
| A critical word in the stem is "hysterosalpingogram," which is a diagnostic test. Recall the use of a dye with this procedure; the greatest risk to be assessed preoperatively would be allergy to a component of the dye. |
5262 A female client is considering in vitro fertilization and Correct answer: 3 Ova retrieval and GIFT are outpatient procedures. The client will not be hospitalized gamete intrafallopian transfer (GIFT). Which of the overnight. The other statements are correct and do not require any follow‐up by the nurse. following statements indicates that she needs additional information?
| The wording of the question has a negative stem, which leads you to look for an option that contains a false statement about a point of client teaching. Specific knowledge of this procedure is necessary to answer this question, so review it carefully if you chose incorrectly. |
5263 The client is seeking to become pregnant through Correct answer: 3 The identity of sperm donors is confidential information. Donors are assigned random artificial insemination using donor sperm. In teaching numbers to identify their sperm, and the listing of donors and numbers is kept locked. the client about this procedure, which information should the nurse plan to include?
| Critical words in the stem are "artificial insemination" and "donor sperm." Use knowledge of donor sperm process and confidentiality of donor to answer the question. |
5264 Which of the following statements made by the client Correct answer: 4 To maximize the chances of conception through achieving the greatest number of motile indicates that she and her husband are having difficulty sperm, couples must abstain for 2–3 days prior to expected ovulation and then have coping with their infertility regimen? intercourse on the day of ovulation or the date of artificial insemination or in vitro fertilization. Because of this, the client's husband must be a willing participant in the infertility regime.
| Critical words in the stem are "difficulty coping" with "infertility regimen." Option #4 is the only one that is a response about finding the process difficult; the other three options are typical responses to the cost and procedures involved. |
5265 The nurse interprets that a client who has a complete Correct answer: 2, 5 A complete bicornate uterus is two complete and separate unicornate uteri. Because the bicornate uterus with two vaginas will: (Select all that uteri are long and narrow (instead of pear‐shaped), the maximum uterine volume is often less apply.) than that of a normally shaped uterus. Risks of bicornate uterus include multiple pregnancy losses, preterm labor, and breech presentation. Becoming pregnant is not an issue; carrying the pregnancy to term is the problem.
| The critical words are "bicornate uterus." Use knowledge of the anatomy of the uterus and bicornate uterus to answer the question, keeping in mind that the risks involve carrying a pregnancy due to the altered anatomy. |
5266 The nurse determines that which of the following Correct answer: 3 Severe abdominal pain during a cycle of induced ovulation may indicate hyperstimulation of clients in the infertility clinic needs to be seen first? the ovaries. The ovaries could potentially rupture, leading to death. The risk of this complication takes precedence over the routine care required by the other clients in the question.
| The critical word in the question is "first." This indicates that the correct option is the one where the client is at greatest risk. Use knowledge of "pergonal" and "HCG" side effects to determine that this client might be at the greatest risk. Using Maslow's hierarchy of needs would also allow you to choose correctly, because this client has the greatest physiological need over those with needs for routine care. |
5267 The nurse has explained to the client that the results Correct answer: 3 Bilateral tubal blockage requires surgical intervention. The client will not become pregnant of her hysterosalpingogram revealed bilateral tubal until the tubes are cleared surgically; a pregnancy cannot occur and "unblock" the tube. This blockage. The nurse realizes that further education is statement indicates that the client does not understand her situation and requires further needed when the client asks which of the following education. The other options contain statements that indicate understanding of the condition questions? or its treatment.
| Critical words are "bilateral tubal blockage" and "further education." The correct option is the one that indicates a faulty understanding on the part of the client. Use nursing knowledge of this condition and the process of elimination to select correctly. |
5268 The client is a long‐distance runner, with 9.0% body Correct answer: 4 Fourteen percent body fat is considered adequate to have regular menses and regular fat. Which of the following would the nurse expect to ovulation. A client with less than 10% body fat will ovulate and menstruate very irregularly if at assess in this client? all.
| Critical words are "long‐distance runner" and "9.0% body fat." Use knowledge of physiology of menstrual cycle and ovulation to answer the question. |
5269 The client is a 43‐year‐old nullipara who is in for her Correct answer: 1 Pregnancy is characterized by a 0.5–1.0°F persistent increase in BBT. The incorrect responses first intrauterine insemination of her partner's washed do not follow this trend. semen. The nurse determines that client teaching has been effective when the client states:
| Critical words are "intrauterine insemination" and "effective" teaching. These tell you that the correct option is also a correct statement. Use knowledge of pregnancy and its effect on body temperature to answer the question. |
5270 The client brings her basal body temperature (BBT) Correct answer: An ovulatory cycle is biphasic. The basal body temperature drops slightly, then rises 0.5–1.0°F chart to the clinic. In evaluating the chart, the nurse 24–48 hours after ovulation. Progesterone is thermogenic (heat‐producing), thereby suspects that ovulation has occurred. Indicate the area maintaining the temperature increase during the second half of the menstrual cycle. on the chart shown that supports the nurse's judgment. | Recall the timing of ovulation at about the midpoint of the menstrual cycle to help choose correctly. |
5271 A client who has had pelvic inflammatory disease Correct answer: 2 Chlamydial PID causes scarring of the fallopian tubes, thus increasing the incidence of ectopic (PID) caused by Chlamydia trachomatis is at risk for pregnancy. All other options do not reflect the true possible consequence of chlamydial PID. which of the following?
| Critical words are "PID" and "Chlamydia trachomatis." Use knowledge of residual effects of STD to determine correct answer. Recognize the option with the greatest risk to client safety: ectopic pregnancy with tubal rupture and hemorrhage. |
4.‐ Cervical dysplasia | |
5272 The nurse explains to a male client with a vas Correct answer: 2 A vas deferens blockage will prevent the sperm from being ejaculated, resulting in a deferens blockage to expect which of the following deficiency of sperm in the seminal fluid (oligospermia). The other options do not correctly problems? explain the effects of the blockage.
| Key words are "vas deferens" and "blockage." Use knowledge of normal anatomy and physiology to determine correct answer. This is a positively worded question, so the correct answer would be a true statement about the client with this condition. |
5273 Which of the following statements tells you that a Correct answer: 4 Options #1, 2, and 3 all increase the likelihood of conception by timing intercourse around the client needs further teaching? "To become pregnant, expected time of ovulation. Option #4 decreases the likelihood of becoming pregnant and we should:" indicates a need for further teaching.
| Key words are "needs further teaching," indicating an incorrect response from the client. Use knowledge of the normal menstrual cycle to eliminate options #1, 2, and 3. |
5274 The nurse working in an infertility clinic explains to an Correct answer: 1, 5 Inadequate number or motility of sperm and tubal anomaly or blockage are the most infertile couple that they will likely have which of the common causes of infertility. Semen analysis will provide information on number of and following tests ordered? Select all that apply. motility of sperm, and hysterosalpingogram will detect uterine or tubal anomalies or blockage. The other tests do not diagnose infertility problems.
| Key words are "infertile" and "tests," which eliminate those tests not pertinent to infertility diagnosis. The focus of the question is testing for the couple, so the correct responses will include tests for both the male and the female. |
5275 The nurse would include which of the following Correct answer: 1 Infertile couples must deal with guilt, shame, and other psychosocial issues. The nurse's role nursing interventions when planning care for an is to be supportive, facilitate sharing of feelings between the couple, and provide guidance infertile couple? through the infertility assessment and treatment process. There is no indication that the couple needs family therapy or that there should be anyone to blame for the infertility problem.
| Key words are "nursing care" and "infertile couple." Use knowledge of good psychosocial support and response to loss of childbearing capability to choose correct answer and eliminate other answers. |
5276 The nurse reinforces the physician's explanation that Correct answer: 2 Tubal blockage will prohibit sperm from traveling through the fallopian tubes to reach an a client with fallopian tube blockage would be a ovum and fertilize it. In vitro fertilization involves harvesting ova and placing them with sperm candidate for which of the following methods of in a petri dish. The resultant embryos are then returned to the uterus. The other options would achieving pregnancy? not result in pregnancy.
| Critical words in the stem of the question are "fallopian tube blockage" and "achieve pregnancy." Use knowledge of anatomy and physiology and methods of artificial insemination to choose correctly. |
5277 The client has been scheduled to have a Correct answer: 3 Hysterosalpingograms are performed in the follicular phase of the cycle to avoid interrupting hysterosalpingogram. Which of the following questions an early pregnancy, so the nurse needs to establish the client's phase of the menstrual cycle. does the nurse need to ask? The other options do not address this point.
| The core issue of the question is an assessment that could reduce the risk associated with hysterosalpingogram. Recalling that interruption of pregnancy is a risk, use knowledge of the test and timing of the menstrual cycle to choose correctly. |
5278 Which of the following statements made by the client Correct answer: 4 Three to four embryos are implanted in the uterus or fallopian tube following in vitro scheduled for in vitro fertilization would indicate the fertilization to maximize the chance of achieving pregnancy while minimizing the risk of need for additional teaching? multifetal pregnancy. The information contained in the other client statements are correct and therefore do not require any follow‐up on the part of the nurse.
| Key words are "in vitro fertilization" and "need for additional teaching," indicating the correct answer is one that is a wrong statement from the client, namely the one addressing the number of eggs implanted. |
5279 The nurse interprets that partner sperm intrauterine Correct answer: 3 Anti‐sperm antibodies can develop in the vaginal and cervical secretions. Inserting the sperm insemination is likely to be indicated for a couple when directly into the uterus via intrauterine insemination bypasses the secretions so that the sperm which of the following has occurred? are not destroyed.
| The critical phrase is "intrauterine insemination," which indicates the process of bypassing the vagina and cervical secretions. Compare each option to this phrase to determine which option has the closest association with this process. |
5280 A client's basal body temperature graph presents the Correct answer: 2 The basal body temperature usually drops just before ovulation occurs, then rises and following data: days 5–12: 97.6–97.8°F, days 13–14: remains elevated for several days. This client likely ovulated on day 14, with the fertile period 97.3°F, days 15–16: 98.0–98.2°F, day 17: 98.6°F, and occurring days 14–17. days 18–23: 98.0‐98.2°F. The nurse determines that the client's most likely days to have been fertile were:
| The core focus of the question is the fertile period, or time of ovulation. The correct answer would be the option that contains a true statement about the time of ovulation for this woman. |
5281 The client has decided to use the calendar method of Correct answer: 2 The woman's shortest and longest cycles must be determined to calculate the number of days family planning. Which of the following statements per month to abstain from sex. The woman is unlikely to ovulate during menses. The woman would indicate that the client understands when to must abstain from sex for the 5 days that the sperm are viable as well as the time the ovum is abstain from sexual activity? viable.
| Key words are "calendar method" and "when to abstain from sexual activity." Knowledge of the calendar method of birth control is needed to answer this question correctly and you are looking for a correct response from the client. |
5282 When counseling a client about contraception, the Correct answer: 1 Since the condom must be correctly applied to the penis at the time of sex, use can affect nurse should include information about the spontaneity and sensation. The cost of male condoms remains relatively low. advantages of male condoms including: | Key words are "male condoms" and "advantages." Knowledge of male condoms is essential to answer this correctly. |
| |
5283 The nurse would formulate which of the following as Correct answer: 1 This client has not yet decided on a method of fertility; she is in the decision phase. Fear, an appropriate nursing diagnosis for the client who has pain, and grieving are not even mentioned in the question. come to the reproductive health clinic to discuss contraceptive options?
| The critical words in the question are "discuss contraceptive options." Eliminate option 2 because it assumes a decision has been made. Eliminate options 3 and 4 because they assume problems not yet determined. |
5284 The nurse determines that which of the following Correct answer: 3 Abnormal spotting or bleeding may be experienced with the use of an intrauterine device. signs and symptoms would indicate a problem caused Weakness or numbness, headache, and chest pain are typically signs of complications by an intrauterine device? associated with oral contraceptives.
| The focus of the question is an intrauterine contraceptive. Eliminate options 2, 3, and 4 because they focus on complications associated with oral contraceptives. |
5285 The client who has received adequate teaching Correct answer: 1 A spermicide must be used with the diaphragm to achieve a high level of effectiveness. No regarding the use of a diaphragm will do which of the more than 4 hours should elapse between insertion of the diaphragm and intercourse. The following? diaphragm should not be removed for 6 hours after intercourse. The diaphragm is a good contraceptive choice for nursing mothers.
| Key words are "received adequate teaching" and "diaphragm." Knowledge of diaphragms and the necessary teaching of how to use it are needed to answer the question. |
5286 The client, who has used progestin‐only oral Correct answer: 2 If the pill is forgotten for more than 12 hours, the pill should be taken and a back‐up method contraceptives for several months, calls the office to of contraception used for the rest of the cycle for extra protection. Extra pills are not typically report that she has missed one of the pills. The nurse prescribed. There is no evidence that the client is pregnant; counseling regarding pregnancy should instruct the client to: options at this time is unwarranted. If the menses is missed, this may be appropriate.
| Key words are "progestin‐only pill" and "missed one of the pills." Knowledge of oral contraceptives and appropriate teaching is needed to answer the question correctly. |
5287 Which medical condition should alert the nurse to a Correct answer: 4 Hypertension is an absolute contraindication to oral contraceptives. While epilepsy is not an contraindication for a woman's use of oral absolute contraindication, clients affected by it require extra monitoring. History of toxic shock contraceptives? syndrome and pelvic inflammatory disease are not factors in oral contraceptive use.
| Recognize that cardiovascular disease is a contraindication of oral contraceptives. Eliminate option 1 because epilepsy is not an absolute contraindication, although clients affected by it require extra monitoring. Eliminate options 2 and 3 because toxic shock syndrome and pelvic inflammatory disease are not factors in oral contraceptive use. |
5288 Which of the following clients would be an Correct answer: 4, 5 Emergency contraception must be initiated within 72 hours of unprotected intercourse, rape, appropriate candidate for use of emergency postcoital or method failure. Oral contraceptives may be taken up to 12 hours late and cervical caps may contraception? A client who: (Select all that apply.) be left in up to 48 hours without compromising safety. Depo‐Provera is given every 80–90 days; this client is not within this time period and emergency contraceptive protection is indicated.
| Critical words are "candidate" and "emergency postcoital contraception." Knowledge of emergency postcoital indications is necessary to answer the question correctly. |
5289 The client tells the nurse that her last two Correct answer: 2 The cervical cap and diaphragm both require use associated with intercourse. The client does pregnancies were unplanned, one because she forgot not give any indication that she is willing to abstain from intercourse. Depo‐Provera injections to take her oral contraceptive pills and the other meet all of the client's requirements. because she and her partner failed to use condoms. The woman states she wants a contraceptive that doesn't require daily or intercourse‐associated use. The nurse concludes that which of the following contraceptive choices may be best for this client?
| The core focus of the question is a contraceptive not dependent on daily dosing or association with sexual intercourse. Eliminate options 1, 3, and 4 because they do not meet the client's criteria for a method. |
5290 Which intervention would be most effective in Correct answer: 3 Option #1 is part of assessing the client's knowledge and should be performed before the teaching a client with low literacy skills how to insert a teaching session. Printed materials may not be appropriate to the client's reading ability. Visual diaphragm? cues are provided by demonstration of the procedure. Practice sessions provide the nurse with an opportunity to give positive and corrective feedback integrating visual, auditory, and tactile senses.
| The critical words in this question are "low literacy." The correct answer is the teaching strategy that relies the least on the use of words that the client may not be able to read or understand. |
5291 Which statements best demonstrates a male client Correct answer: 3, 5 Leaving space at the end of the condom to collect the semen can prevent breakage or spillage understands how to correctly apply a condom? Select after ejaculation. The male condom is placed when the penis is erect, then rolled down. Water‐ all that apply. based lubricants can be used to provide additional comfort, if needed. Oil‐based lubricants are contraindicated.
| The wording of the question is positive, indicating that the correct options are true statements about points of client education. Use nursing knowledge to select these options. |
5292 A client with a history of toxic shock syndrome comes Correct answer: 1 The cervical cap increases the risk of toxic shock syndrome because it may be left in place for to the reproductive clinic seeking contraception. Based up to 48 hours. The other methods identified pose no additional risk to this client based on her on this information, which method should the nurse history and could be considered for contraception. avoid recommending for this client?
| Critical words are "toxic shock syndrome" and "avoid." The focus of this question is a method that increases the client's risk of a reproductive tract infection. The incorrect options can be eliminated because they do not pose this risk for the client. |
4.‐ Norplant | |
5293 The rationale for the nurse to ensure that a client Correct answer: 4 Ethical and legal considerations dictate that clients are knowledgeable of the benefits and gives informed consent for contraception prior to use risks of the contraceptive method. This empowers the client in making an informed decision. is based on knowledge that contraceptive methods: Not all contraceptive methods are invasive or require a surgical procedure. Informed consent is not related to the effectiveness of a method.
| Key words are "informed consent" and "ensure." Use knowledge of informed consent to determine that the client should be told the potential risks and benefits of contraceptives. The correct answer would be the option that includes information needed by the client to make a decision. |
5294 The nurse should instruct the client who has had an Correct answer: 2 Specific information about the type of IUD inserted is not provided; Progestasert needs to be IUD inserted to do which of the following as part of replaced annually and the Copper T380A can be left in place for 10 years. The string should be follow‐up self‐care? checked once a week for the first month, then after menses thereafter. Contraceptive effectiveness begins when the IUD is inserted. Although douching is sometimes used to treat vaginal infections, it is not a recommended practice to prevent infection.
| Key words are "instruct" and "IUD." Because the question is worded in a positive way, the correct option is also a true statement about a point of client education. |
5295 Following a teaching session on how to use the Correct answer: 1 A spermicidal cream or jelly is applied to the rim and dome of the diaphragm before inserting diaphragm as a contraceptive method, the nurse the device to increase the contraceptive effectiveness of the device. Options #2, 3, and 4 are evaluates the client's understanding. Which statement statements reflecting correct client behavior for effective diaphragm use. made by the client demonstrates the need for additional teaching?
| Critical words are "diaphragm" and "need for additional teaching." Use knowledge of diaphragms to answer the question. |
5296 A client taking oral contraceptive pills calls the clinic Correct answer: 1 Shortness of breath and chest pain can indicate a serious complication associated with the and reports the presence of chest pain and shortness use of oral contraceptives and require immediate evaluation. Waiting for a return telephone of breath. The nurse should instruct the client to do call could delay evaluation and treatment, jeopardizing the client's health. Changing the which of the following? contraceptive method or food intake pattern does not reduce the immediate health risk to the client.
| Key words are "chest pain" and "shortness of breath," which indicate the need for immediate help from health care providers. The other answers indicate delayed responses on the part of the client rather than emergency care for potential emergency needs. |
5297 A client has decided to use a cervical cap for Correct answer: 2 Spermicide should be applied to the inside of the cervical cap. The device may be left in place contraception. In providing instruction to the client on up to 48 hours after sexual activity. Reapplication of spermicide with repeated acts of the correct use of this method, the nurse should tell intercourse is not needed. the client to:
| Key words are "correct use of this method" and "cervical cap." The correct answer should be a true statement about a point of client education. Use knowledge of the cervical cap as a contraceptive device to determine the correct answer. |
5298 The nurse is teaching a client how to correctly use Correct answer: 1 Every pill contains a low dose of hormone and should be taken daily; consistency in taking the progestin‐only oral contraceptives. The nurse should pills ensures a constant serum level of the hormone to maximize effectiveness. The pills are include which information in the teaching plan? absorbed with or without the presence of calcium. If a pill is missed, it should be taken immediately and an additional method of contraception utilized through the remainder of that cycle.
| Key words are "correctly use" and "progestin‐only oral contraceptive." The correct answer would include a true statement about a point of client education. Use knowledge of oral contraceptives to answer the question correctly. |
5299 A client comes to the family planning clinic for Correct answer: 3 This client has a need for information about the various contraceptive methods available to contraceptive advice. She states she has never used her and their risks and benefits. No information is provided to determine if the client fears contraception before and does not know what options pregnancy or is engaging in unprotected sexual intercourse. If the client does not know what are available to her. The nurse determines the priority contraceptive methods are available, it is unlikely she knows or fears potential complications nursing diagnosis for this client to be: from using a method of contraception.
| The critical focus in this question is the client's need for information. The correct answer includes knowledge as a focus. Use knowledge of contraceptives and nursing diagnosis to answer the question. |
5300 The client is making her first visit to the contraceptive Correct answer: 1, 3, 5 Family planning can help the client make decisions about avoidance of pregnancy, clinic to discuss family planning. The nurse should determining the number of children to conceive and the spacing of those children, and instruct the client that which of the following are goals voluntary termination of pregnancy. of family planning? Select all that apply.
| Focus on the critical words "contraceptive clinic" and "goals of family planning" to focus on the option that deals with family planning. Eliminate options that relate to screening and increasing fertility, because these do not relate to contraception. |
5301 The client has come to the family planning clinic to Correct answer: 3 Contraceptive counseling is best done in private, assessing the client's needs, desires, and risk discuss the use of contraceptives. The nurse should do factors. This will result in a contraceptive method that best suits the needs and health of the which of the following to facilitate a productive client. discussion?
| Avoid options that give advice (option 2) or use extreme words such as "only" (option 1). From there, use knowledge of counseling, effective communication, and family planning to choose the correct answer. |
5302 The client, who has been married for 3 years and Correct answer: 2 Condoms, used with or without a spermicide, are mechanical methods of contraception. sexually active but not yet ready to begin having While abstinence is a natural method, since the woman is sexually active it will increase children, has expressed a desire to use a natural compliance if she only needs to be abstinent during fertile periods. Therefore, using the basal method of family planning. Based on this information, body temperature method permits her to be sexually active at certain times. which of the following would be the best choice for this client?
| Critical words are "married 3 years" and "natural method of family planning." Use knowledge of contraceptive methods to identify the correct answer. |
5303 Which of the following statements by a male client Correct answer: 3 Oil‐based lubricants can break down latex condoms. The condom should be unrolled onto the would indicate that he understands the instructions for penis, starting at the tip of the penis. Holding the rim keeps the condom from slipping off and use of a condom? leaking semen into the vagina. Small amounts of semen are released before ejaculation and can result in pregnancy.
| Note the critical words "understands" and "use of a condom." Note that the question is worded to elicit a positive statement as the correct answer. The correct answer is a true statement about a point of client education. |
5304 After the nurse counsels a client about several Correct answer: 3 Female condoms can be applied up to 8 hours before intercourse, are not made of latex, and contraception options, the client tells the nurse that do not require that the client be measured for proper fit Both partners are protected for STD she has decided to use female condoms. The nurse during intercourse. evaluates that the client understood the information if she says:
| The critical words are "female condoms" and "understood." Since the question is worded in a positive manner, you are looking for a correct statement about the use of female condoms. |
5305 In planning education for a client who has decided to Correct answer: 2, 3, 5 Cleaning agents other than soap and water and oil‐based lubricants can damage the rubber of use a diaphragm for contraception, the nurse should the diaphragm. The chemical barrier (spermicidal cream or jelly) supplements the mechanical include which of the following information in the barrier (diaphragm) to increase the effectiveness of this contraceptive method. It takes at least teaching plan? Select all that apply. 6 hours for the spermicidal cream or jelly at the rim to destroy sperm deposited in the vagina. Use during menses increases the risk of toxic shock syndrome and should be avoided.
| This question is worded in a positive manner. Therefore, the correct options are also true statements about points of client education. |
5306 When reviewing the assessment data of the client, Correct answer: 2 Oral contraceptives place the client at decreased risk for iron‐deficiency anemia, ovarian which of the following would lead the nurse to cancer, and fibrocystic breast disease. Oral contraceptives can decrease the effectiveness of recommend a method of contraception other than insulin. oral contraceptives?
| Note the critical words "assessment data" and "method other than oral contraceptives." The focus of this question is to identify a disadvantage or reason not to use oral contraceptives. The incorrect options are all benefits of oral contraceptive use. |
5307 The client is interested in having a subdermal implant Correct answer: 1 Because of alteration of hormone levels, irregular bleeding and thickened cervical mucus can (Norplant) inserted. As part of maintaining a standard result. Norplant does not cause incomplete emptying of the bladder, increased production of of quality care, the nurse would ensure that the client this cervical or vaginal mucus, or increase the risk for pelvic inflammatory disease. is aware of which of the following side effects of this therapy?
| Key words are "subdermal implant" and "side effects." Specific knowledge of the side effects of subdermal implants is needed to choose the correct option of irregular bleeding. Eliminate options that are not related to the use of a long‐acting progestin‐only contraceptive. |
5308 A male client has come to the clinic to discuss having Correct answer: 4 The procedure, usually performed in a clinic under local anesthesia, is not effective for 4–6 a vasectomy. Which of the following indicates the weeks. The client should rest with minimal activity for 48 hours following the procedure. client understands about the procedure?
| Critical words are "vasectomy" and "understands," which indicate the correct option is also a correctly worded response from the client after the teaching. |
5309 A pregnant client, who is considering a tubal ligation Correct answer: 3 The pregnancy rate following tubal ligation is 1–4 per 1,000 women. Reversal of the following her delivery, asks the nurse about the procedure, not effectiveness, is affected by the method used for the procedure. The effectiveness of the method. Which of the following is effectiveness of the method is not related to client behavior. the best response by the nurse?
| The critical words in the question are "tubal ligation" and "effectiveness of the method." Use specific knowledge of tubal ligation and its effectiveness to select the correct option. |
5310 The nurse would do which of the following when Correct answer: 4 Option 4 is correct because the faucet is considered contaminated. The hands are considered washing the hands as part of medical asepsis before to be more contaminated than the elbows. Therefore, water should flow from least caring for an assigned client in an outpatient clinic? contaminated to most contaminated, eliminating option 1. Option 2 can result in burns to the nurse. Warm water removes less of the protective oils in the skin. Option 3 describes a surgical scrub.
| The core issue of the question is utilization of medical asepsis. Recall basic principles of care and use the process of elimination to make a selection. |
5311 The nurse’s forearm is splattered with blood while Correct answer: 4 Washing the skin with the combination of soap and water will remove the blood through inserting an intravenous catheter. What action should mechanical friction. While alcohol can kill bacteria, it cannot kill viruses and fungi (option 1). the nurse take? Tissues would not adequately remove the blood (option 2). Hot water can burn the nurse, and water alone is inadequate in removing the blood (option 3).
| The core issue of the question is the most effective means of reducing the risk of bloodborne disease transmission after contact with the skin. Recall principles of medical asepsis and use the process of elimination to make a selection. |
5312 The nurse concludes that further teaching about Correct answer: 1 Standard precautions are used with all clients, regardless of the medical diagnosis. Clients standard precautions is needed when a family member with AIDS are not contagious, and family members are not required to wear protective of a client with acquired immunodeficiency syndrome equipment in a casual interaction. (AIDS) states:
| The word further in the stem indicates the question is asking which statement indicates the family member does not understand standard precautions. Options 2, 3, and 4 are somewhat similar in that no special precautions are needed. Select option 1 by process of elimination. |
5313 The nurse would do which of the following to protect Correct answer: 2 Option 2 is an action aimed at interrupting the portal‐of‐entry link in the chain of infection. By the client from infection at the portal of entry? using sterile technique, the nurse reduces the risk of introducing pathogens into the client s wound via the drain. Option 1 is an action that breaks the chain of infection at the reservoir link. Options 3 and 4 control the mode of transmission. | Knowledge of the chain of infection is required. The portal of entry has to be a route whereby microorganisms can enter the client. Option 2 is the only choice in which that is possible. |
| |
5314 Which of the following actions by the nurse comply Correct answer: 2, 4 Options 2 and 4 are core principles of surgical asepsis. Options 1 and 3 are core principles of with core principles of surgical asepsis? Select all that medical asepsis. Option 5 is an incorrect principle of surgical asepsis. The outer 1 inch of a apply. sterile field is considered contaminated.
| The core issue of the question is the ability to discriminate between medical and surgical asepsis and to choose correct interventions that support surgical asepsis. Use these principles and the process of elimination to make a selection. |
5315 Which of the following precautions would the nurse Correct answer: 2 Herpes zoster is caused by the herpes virus varicella zoster. It can be transmitted by direct implement when admitting to the nursing unit a client contact with the client. It is not transmitted via droplets or air currents. Neutropenic with herpes zoster? precautions are not indicated, because the client is not at risk for contracting an infection from the nurse or other individuals.
| Herpes zoster is a viral skin infection. Specific knowledge of the types of transmission‐ based precautions is needed to select the correct answer. Eliminate options 1 and 3 because herpes zoster is not transmitted on air currents. Choose option 2 over 4 because neutropenic precautions are used with immunocompromised clients. |
5316 A client with tuberculosis asks the nurse if visitors will Correct answer: 1 Tuberculosis is highly contagious and spread by inhalation of airborne droplets. Airborne need to wear masks. What response by the nurse is precautions would be initiated, requiring everyone to wear a special particulate respirator fit‐ most accurate? tested mask. Individuals who have had tuberculosis in the past can be re‐exposed and develop the active form of the disease again.
| Look for similarities among the options in order to eliminate choices. Options 2, 3, and 4 are similar in that they suggest certain individuals would not be required to wear masks. Since they are similar and the opposite of option 1, they should be eliminated. |
5317 The nurse is leaving the room of a client who has Correct answer: 2, 3, 4, Gloves are removed first because they would be most contaminated. The mask would be methicillin‐resistant Staphylococcus aureus (MRSA) 1 removed next, followed by the gown. Eye protection is removed last, followed by washing the microorganisms in a wound and the urine. Place the hands. following personal protective equipment in order of removal. Click and drag the options below to move them up or down.
| Remember that removal of PPE should occur in order of most contaminated to least contaminated items. |
5318 A client with suspected severe acute respiratory Correct answer: 1 SARS is a highly contagious viral respiratory illness that is spread by close person‐to‐person syndrome (SARS) arrives at the Emergency contact. SARS is transmitted by airborne respiratory droplets and by touching surfaces and Department. Which of the following physician orders objects contaminated with infectious droplets. Instituting infection‐control measures would be should the nurse implement first? the first priority of the nurse. This action would protect both health care workers and other clients in the Emergency Department. Then all other interventions can be safely implemented.
| The key words implement first indicate all of the answers are correct and the nurse needs to set priorities. The first priority is to implement measures that protect the client and/or nurse—option 1. |
| |
5319 In addition to standard precautions, which other Correct answer: 2 SARS is a highly contagious viral respiratory illness that is spread by close person‐to‐person type(s) of isolation precautions should the nurse use contact. SARS is transmitted by airborne respiratory droplets and by touching surfaces and when caring for the client with severe acute objects contaminated with infectious droplets. Personal protective equipment would include respiratory syndrome (SARS)? protective gowns, gloves, N95 respirators, and eye protection. Airborne precautions would also include placing the client in a private room with negative air pressure flow. The correct answer is option 2. Airborne and contact precautions would provide the necessary protection outlined above. Options 1 and 3 are incorrect. Droplet precautions would not protect the nurse who touches contaminated items. Droplet precautions do not provide a negative air pressure room. Option 4 is incorrect. Contact precautions alone would not provide adequate protection from airborne particles.
| Knowledge about SARS and its transmission is essential. Think about the signs and symptoms the client with SARS exhibits. |
5320 The nurse is changing an abdominal dressing on a Correct answer: 2 A mask is necessary for anyone within 3 feet of the client with an infection spread by particle client who has an infection spread by droplets. Which droplets. There is not enough information in the question to support the use of any other of the following pieces of personal protective equipment. equipment would the nurse use?
| Look for PPE that provides adequate protection from an infection spread by droplet particles. Option 2 is the only choice that would protect the nurse from respiratory droplets. |
5321 A client with vancomycin‐intermediate‐resistant Correct answer: 4 Clients with antibiotic‐resistant microorganisms must be isolated with transmission‐based Staphylococcus aureus (VISA) is admitted to the precautions. The organism is transmitted via close person‐to‐person direct contact and by nursing unit. What type of precautions should the touching contaminated surfaces and objects. Standard precautions are used with all clients, nurse institute? regardless of medical diagnosis. Reverse isolation is instituted for immunocompromised clients. This organism is not transmitted via droplet nuclei.
| The key words vancomycin‐intermediate‐resistant suggest the microorganism is difficult to eradicate, indicating it is highly contagious. Eliminate options 1 and 2. Select option 4 over 3, using nursing knowledge that Staphylococcus aureus is a microorganism that is commonly found on skin. |
5322 The nurse would formulate which of the following as Correct answer: 1 Option 1 is the only goal that is client‐focused, specific, and measurable. Options 2 and 4 are the most appropriate goal for the client with droplet client‐focused but vague. Option 3 focuses on the nursing action of teaching. precautions?
| Recall that criteria for writing an appropriate client goal include that the goal is client‐ focused, specific, and measurable. Each of the incorrect options can be eliminated using the rationale provided above. |
5323 The nurse would implement which of the following as Correct answer: 4 The client with tuberculosis can spread the infection by breathing, and requires a private a requirement of care specific to the client who has room and airborne precautions. Options 1, 2, and 3 are aspects of standard precautions that tuberculosis? would be implemented with any client, regardless of medical diagnosis.
| The key words specific care requirement suggest that more than one answer may be correct or partially correct. Only option 4 is specific for the client with a diagnosis of tuberculosis. |
| |
5324 The nurse would expect to institute transmission‐ Correct answer: 4 Transmission‐based precautions are required for all antibiotic‐resistant microorganisms based precautions for a client with which of the regardless of their mode of transmission. The other options indicate the need for medical and following? surgical asepsis in the care of the client but not the use of transmission‐based precautions.
| The key words methicillin‐resistant in option 4 indicate a microorganism that is difficult to eradicate. Eliminate each of the incorrect options after visualizing each situation because they can be managed by use of standard precautions. |
5325 A client asks, “How did I get scarlet fever?” Which of Correct answer: 4 Scarlet fever is transmitted by particle droplets larger than 5 microns. Scarlet fever is not the following would be the best response by the transmitted through sexual intercourse or the blood, or by consuming contaminated food. nurse?
| Begin by recalling that scarlet fever is transmitted by droplets. With this in mind, use the process of elimination to select the client situation that is compatible with the mode of transmission. |
5326 The nurse is assisting the client who has methicillin‐ Correct answer: 1 Methicillin‐resistant Staphylococcus aureus requires transmission‐based contact precautions. resistant Staphylococcus aureus in collecting a clean‐ Eye protection would be worn to protect the mucous membranes of the eyes when splatters catch urine specimen. Which of the following of body fluids or excretions are possible. A gown would be worn when the nurse is in direct protective equipment is unnecessary? contact with the client. Contact precautions require gloves. N95 respirators are needed when caring for the client with tuberculosis, so it is inappropriate for this scenario.
| The critical word unnecessary suggests that all but one of the answers are correct. Using the process of elimination, look for the choice that identifies personal protective equipment that is not needed for contact precautions. |
5327 The nurse is preparing to irrigate a wound infected Correct answer: 4 An infection with vancomycin‐resistant enterococci requires transmission‐based contact with vancomycin‐resistant enterococci. Which of the precautions. Since the nurse will be irrigating the wound and splatters of body fluids or following should the nurse wear? exudates are possible, eye protection and surgical mask should be worn to protect the mucous membranes of the eyes, nose, and mouth. A gown would be worn when the nurse is in direct contact with the client. Contact precautions require gloves.
| Wound infections require contact precautions. Look for the option that identifies the correct PPE to be used with contact precautions. Options 1 and 3 are eliminated, since a particulate respirator is used with clients with tuberculosis, not those on contact precautions. Choose option 4 over 2 because the risk for splatters exists. |
5328 The nurse assigned to the respiratory care unit is Correct answer: 1 While each option contains “pneumonia,” the causative agent is different for each. Option 1 working with four clients who have pneumonia. The includes a pathogenic microorganism that is difficult to treat and requires droplet precautions. nurse should assign the only remaining private room on the nursing unit to the client infected with which of the following organisms?
| Note the critical word resistant in option 1. This provides a clue that the infection is difficult to treat and requires specific additional infection control practices, in this instance droplet precautions. The pneumonias in options 2, 3, and 4 do not require droplet precautions. |
5329 The nurse is caring for a client with hepatitis A. Which Correct answer: 1, 3 Hepatitis A is an infectious disease transmitted by the fecal–oral route. Standard precautions of the following client statements indicate that are mandatory. Contact precautions are instituted if the client is incontinent of stool. Family teaching conducted by the nurse about disease members should avoid close contact with the client. They should not kiss the client or use the transmission was effective? Select all that apply. same eating utensils and bath towels. Masks are not necessary because the disease is not transmitted by the respiratory tract.
| The critical word effective indicates options that are correct are the ones that should be selected. Knowledge of how hepatitis A is transmitted is necessary. The fecal–oral route of transmission eliminates options 2 and 4. Options 1 and 3 are similar in that they limit close contact with the client, so they are both correct. |
5330 Which of the following is the most important action Correct answer: 1 Hand hygiene is a core principle of standard precautions. Using gloves (option 2) is the nurse would take when trying to reduce the spread appropriate when there is a risk of exposure to blood, body fluids, secretions, and excretions, of microorganisms on the clinical nursing unit? but gloves may not be needed for every care activity. If gloves are used, however, handwashing should be done after removal of the gloves. Not all clients require transmission‐ based precautions (option 3) or a private room (option 4).
| Use the process of elimination based on nursing knowledge of standard precautions. Recall that elements of transmission‐based precautions are not initiated with all clients. |
5331 The nurse would plan to use medical aseptic Correct answer: 3 Medical asepsis requires clean, not sterile, technique. Of the options listed, only collecting a technique when collecting which of the following stool specimen for ova and parasites (option 3) requires medical aseptic technique. Collecting specimens? a wound culture (option 1), suctioning a tracheostomy (option 2), and catheterizing the client (option 4) all require the nurse to use sterile asepsis.
| Knowledge of medical versus surgical asepsis is essential. Look for similarities in the choices. Options 1, 2, and 4 require sterile technique. Option 3 is the only choice that requires medical aseptic technique. |
5332 A client with acquired immunodeficiency syndrome Correct answer: 1 Standard precautions are used with all clients, regardless of the medical diagnosis. Clients (AIDS) and Pneumocystis carinii pneumonia is being with neither AIDS nor Pneumocystis carinii pneumonia are not contagious and thus do not admitted to the nursing unit. The nurse should require transmission‐based precautions. institute which of the following precautions for infection control?
| Use the process of elimination based on nursing knowledge about the route of transmission for AIDS. |
5333 The school nurse explains to a parent who is also a Correct answer: 3 Immunizations interrupt the chain of infection by generating immunity in a susceptible host student nurse that administering childhood by introducing a weakened or killed antigen into the body. Immunizations do not affect the immunizations is an example of a nursing action that portal of entry, portal of exit, or the mode of transmission of a pathogenic organism. interrupts the chain of infection at what link?
| Knowledge of the chain of infection is required. Immunizations change the immunity status of the person receiving them. Option 3 is the only choice where that is possible. |
5334 The nurse would take which of the following actions Correct answer: 1, 2 Options 1 and 2 are core principles of medical asepsis. Option 3 violates principles of medical to comply with principles of medical asepsis? Select all asepsis, and option 4 violates principles of surgical asepsis. Option 5 violates principles of that apply. transmission‐based precautions for a client with tuberculosis. The nurse should wear an N95 (fit‐tested) mask instead of a simple surgical mask.
| Knowledge of medical versus surgical asepsis is essential to answer this question. Note that options 1 and 2 require medical aseptic technique, while options 3 and 4 do not represent these principles. Also discard option 5 because it addresses transmission‐based precautions and is an incorrect statement. |
5335 Which of the following actions is specific to caring for Correct answer: 1 Tuberculosis is a respiratory infection, transmitted via airborne droplet nuclei less than 5 a client with tuberculosis? microns in size. Wearing a surgical mask (option 1) will not protect the nurse from infection. The client will wear a surgical mask (not a particulate respirator mask as in option 2) when being transported within the hospital. Clean gloves rather than sterile ones (option 3) are needed to obtain a sputum specimen. The door to the client’s room should be kept closed (option 4) as part of transmission‐based precautions for tuberculosis.
| Specific knowledge of the mode of transmission of Mycobacterium tuberculosis and the types of transmission‐based precautions is needed to select the correct answer. Eliminate options 2 and 3, as tuberculosis is transmitted via air currents. Choose option 1 over option 4, because tuberculosis is transmitted via airborne droplet nuclei less than 5 microns in size. |
5336 A nurse is teaching volunteers about the chain of Correct answer: 4 Sneezing and coughing are examples of modes of transmission, whereby droplet nuclei can infection. Which of the following items would the transmit infection directly to a susceptible host. The items in options 1, 2, and 3 are examples nurse include as an example of how an infection would of fomites, inanimate objects that could carry microorganisms if medical asepsis is not utilized. spread through droplets?
| To eliminate choices, look for commonalities among the options. Options 1, 2, and 3 are inanimate objects that serve as vehicles for transmitting infectious microorganisms. Choose option 4, as direct transmission of microorganisms occurs. |
5337 The nurse should implement contact precautions with Correct answer: 3 A wound infection would be an indication for a nurse to utilize contact precautions, since the client with which of the following health contamination could occur when caring for the wound. Scarlet fever, pertussis, and rubella problems? (options 1, 2, and 4, respectively) involve the spread of infection by respiratory particle droplets larger than 5 microns.
| To eliminate choices, look for commonalities among the options. Options 1, 2, and 4 are contagious infections characterized by coughing. Choose option 3, as direct transmission of microorganisms occurs by direct contact with the client. |
5338 The nurse is preparing to enter the room of a client Correct answer: 4, 3, 1, The gown is applied first, as it takes the most time to don. The mask is donned next, followed with pneumonia caused by penicillin‐resistant 2 by eye protection. These items can be more securely applied with ungloved hands. Gloves are Streptococcus pneumoniae (PRSP). The client has a donned last, so the gloves can be pulled up to cover the cuffs of the gown. tracheostomy and requires suctioning. Put the following personal protective equipment in order of donning. Click and drag the options below to move them up or down.
| Rationalize the ordering based on nursing knowledge of standard precautions and surgical asepsis. Visualize the procedure to aid in choosing correctly. |
5339 The nurse observes an unlicensed assistive person Correct answer: 4 The employee should limit the amount of time in the client’s room to minimize exposure. In (UAP) in the room of a client with sudden acute option 1, the employee is wearing the correct combination of personal protective equipment. respiratory syndrome (SARS). Which of the following In option 3, the employee has followed the correct procedure for exiting the client’s room. actions by the UAP indicates that further teaching by Equipment required for the care of the isolation client should remain in the client’s room the nurse is needed? (option 2) to limit exposure to other clients on the nursing unit.
| The wording of the question indicates that something was done incorrectly. Options 1, 2, and 3 are correct actions. Only option 4 describes an incorrect action. |
5340 The nurse concludes that client teaching about Correct answer: 1 If transportation to another hospital department is unavoidable, a client with tuberculosis infection‐control measures has been effective when a must wear a particulate respirator mask. This is an element of airborne precautions necessary client with tuberculosis states: to limit the transmission of the microorganism. Tuberculosis is not transmitted by eating utensils (option 3) or urine (option 4). Removal and disposal of respiratory secretions (option 2) is important but does not require the client to wear gloves.
| Knowledge of how tuberculosis is transmitted is essential. Eliminate options 3 and 4 because they do not address transmission via the respiratory tract. Select option 1 over option 2, as clients would not wear gloves to protect themselves from their own infection. |
5341 The nurse must assess the temperature and blood Correct answer: 1 Equipment for client care is dedicated to the client on contact precautions and kept in the pressure of a client on contact precautions every shift. client’s room. It should not be stored in the utility room (option 2), because this could transmit Which is the appropriate nursing action to minimize infection. It is not realistic to be able to adequately cleanse the equipment after each use the spread of microorganisms? (option 3). Special action is needed with this equipment (option 4).
| The key word “appropriate” suggests there is only one correct answer. Look for the nursing action that would limit the spread of pathogenic microorganisms. |
5342 Which of the following actions taken by the nurse is Correct answer: 3 Methicillin‐resistant Staphylococcus aureus is transmitted by direct contact. Options 1, 2, and specific to caring for a client with methicillin‐resistant 4 are not appropriate because the microorganism is not transmitted by airborne or particulate Staphylococcus aureus (MRSA)? droplets. Gloves (option 3) are necessary when providing nursing care.
| Look for commonalities among choices. Options 1, 2, and 4 address a client who requires respiratory precautions. Select option 3, as it is different. |
5343 The nurse would implement transmission‐based Correct answer: 2 Transmission‐based precautions are required for all these organisms; however, only penicillin‐ droplet precautions after learning that a client is resistant Streptococcus pneumoniae is transmitted via respiratory droplets. The organisms infected with which of the following antibiotic‐ specified in options 1, 3, and 4 are transmitted by direct contact. resistant microorganisms?
| Knowledge of droplet precautions is necessary to answer the question. Penicillin‐resistant Streptococcus pneumoniae suggests a microorganism that causes a type of pneumonia. Clients with pneumonia have increased respiratory secretions and coughing. Using the process of elimination, choose the microorganism that sounds as if it would cause a respiratory infection (option 2). |
5344 The nurse has taught family members how to prevent Correct answer: 2 Transmission‐based airborne precautions require everyone entering the client’s room to wear re‐exposure of the client to tuberculosis. Which finding a mask at all times. It is not acceptable to remove a mask to kiss the client goodbye. The would indicate that further teaching is needed? actions in options 1, 3, and 4 are correct.
| The wording of the question indicates that something was done incorrectly. Options 1, 3, and 4 are correct actions. Only option 2 identifies an incorrect action. |
5345 Which nursing diagnosis requires the nurse to Correct answer: 3 The ability of the client to manage effectively the therapeutic regimen requires the nurse to function most collaboratively to achieve the best collaborate with the physician, Social Services, and community health agencies to achieve the outcome for the client with tuberculosis? best outcome for the client. Medications to treat the infection require a physician order. The nurse assesses the client s response to medications and provides feedback to the physician, alerts Social Services regarding client concerns about the cost of medications, and makes referrals to home health agencies. Social services can assist the client in obtaining financial aid to cover the cost of medications, if necessary. The public health department must be notified of the client s infection and will follow the client once discharged. Home health agencies and directly observed therapy (DOT) programs can assist with medication compliance. Options 1 and 4 are managed with independent nursing interventions, such as pacing nursing care to promote rest and minimize client fatigue; providing small, frequent meals; and teaching the client about the rationale for, dosing schedule of, side effects of, and importance of taking prescribed medications. Option 2 (nutrition) may involve the physician and dietitian, but not the entire health care team.
| Look for the nursing diagnosis that requires a collaborative approach to resolve. Note the critical word “most,” which indicates that one option will require the greatest number of collaborative resources. The nurse can independently or relatively independently treat the nursing diagnoses in options 1, 2, and 4, leaving option 3 as the correct answer. |
5346 In addition to standard precautions, the nurse caring Correct answer: 2 Varicella is a contagious viral infection spread through airborne droplets smaller than 5 for a client with varicella would implement which of microns in size. Airborne precautions (option 2) should be instituted to limit the transmission the following transmission‐based precautions? of this infection. Varicella would not be adequately controlled using contact or droplet precautions, or with reverse isolation (options 1, 3, and 4, respectively).
| Knowledge about the transmission of scarlet fever and the elements of each type of transmission‐based precaution is required. Select an option based on nursing knowledge. |
5347 The nurse is preparing to leave the room of a client Correct answer: 2, 3, 1, Gloves are removed first, as they would be the most contaminated. The mask would be on transmission‐based precautions. Place in the 4, 5 removed next, followed by the gown. Eye protection is removed last, followed by hand‐ correct order the steps the nurse would follow to washing. remove personal protective equipment and perform hand hygiene. Click and drag the options below to move them up or down.
| Washing the hands is last. Removal of gloves is first, as the gloves would be the most contaminated. |
5348 A nursing student is explaining to the client how Correct answer: 3 Clients with rubella are placed in droplet precautions, as the causative agent is transmitted by rubella is transmitted. The nursing instructor particle droplets larger than 5 microns. Rubella is not transmitted by the airborne route determines the student comprehends correctly if the (option 1), contaminated food (option 2), or direct contact (option 4). student states that rubella is transmitted by:
| Knowledge about the transmission of rubella and the elements of each type of transmission‐based precaution is required. Select an option based on nursing knowledge. |
5349 A client who is being treated for tuberculosis is being Correct answer: 2 Signs of tuberculosis include low‐grade fever, increased sputum production, purulent or blood‐ seen by the home health nurse for directly observed streaked sputum, increased shortness of breath or difficulty breathing, decreased activity therapy. A client outcome on the care plan includes tolerance, decreased appetite, weight loss, and night sweats. Option 2 indicates the client is preventing re‐exposure to infection. Which finding getting better, while options 1, 3, and 4 indicate the client is having a relapse. would indicate that this outcome is being met?
| Note the phrase “outcome is met.” Use the process of elimination to find a sign or symptom that confirms that the client is getting better. |
5350 The nurse determines a new mother is in greatest Correct answer: 2 Infants should always be put to sleep on the back. Options 1, 3, and 4 are correct statements need of more education about infant care and safety related to infant care and therefore pose no risk to the infant and no concern to the nurse. when the mother states:
| The wording of the question guides you to look for a false statement as the correct response. Use the process of elimination and nursing knowledge. |
5351 The result of a toddler s lead screening is 12 mg/dL. Correct answer: 4 The lead value of 12 mg/dL is high. Lead levels below 10 mg/dL are acceptable. Levels of The nurse should say which of the following to the 10–19 mg/dL require an environmental history. Levels above 20 mg/dL require a full medical mother at this time? evaluation. Asking a question regarding the child s address is the first step in evaluating the environment. Older homes may have lead paint and lead in the plumbing. Option 1 is inaccurate because the level is high (not normal), and option 2 and 3 are unrelated to lead poisoning.
| To answer the question it is required to know acceptable lead values. Option 4 is related to environmental assessment. |
5352 When planning for discharge from the birthing center Correct answer: 2, 3 An infant child restraint system should always be in the back seat and rear‐facing. After a on the following day, the nurse learns that the father child is 1 year of age and weighs 20 pounds, the seat may be in the rear and front‐facing. will drive the new mother and infant home. When Although bright colors are stimulating to an infant, the color of the system does not matter. teaching the new parents about infant restraint systems, the nurse should include that the restraint system be (select all that apply):
| Option 3 and 4 cannot both be correct. Use the process of elimination and nursing knowledge of infant safety measures to make a selection. |
5353 Which of the following snacks should the nurse offer Correct answer: 1 Crackers are of a soft consistency when chewed and swallowed. Toddlers can easily choke on the hospitalized toddler? small foods such as peanuts, popcorn, and grapes, and on firm‐consistency foods such as cereal bars.
| Option 1 is correct because it is unlike the other three options. Options 2, 3, and 4 are hard foods that do not dissolve in the mouth with the action of saliva. |
5354 What is the best method for the nurse to use to Correct answer: 2 Parent role models of behavior are the best method to develop good habits in children. The encourage the use of bicycle helmets by school‐aged other options, although possibly valid (except option 3), are not the best answer. children?
| The key word is best. All answers could be correct. Option 1 is a good idea but may not change behaviors. Option 3 is a negative behavior. Option 4 may be effective but is not realistic for all families. |
5355 A school nurse is planning a health class on accidents Correct answer: 2 Driving a car and having the independence to ride with friends are an important milestone for and injuries for a high school class. Which topic is most high school–aged adolescents. Some adolescents experiment with alcohol and drugs, putting important to include? them at increased risk for motor vehicle accidents. Option 1 is a risk for working adults, and options 3 and 4 are risk factors for the elderly.
| Use knowledge of the principles of growth and development to aid in answering this question. |
5356 The home health nurse is visiting an elderly client Correct answer: 3 Laundry baskets that are set on the floor will pose a risk for falling for the elderly client. All with diabetes mellitus. The nurse becomes concerned hallways, floors, stairways, and furniture should be free of clutter. Neighbors bringing lunch and implements safety education when which of the and family controlling climate for the elderly client are good safety interventions. Keeping following occurs? diabetic supplies on a kitchen table with easy access will facilitate diabetic testing.
| Focus on the critical word safety and choose the option that poses a risk to the client. Recall that older adults are at increased risk for falls, so this should guide your thought process as you make a selection. |
5357 The nurse supervisor observes the new RN Correct answer: 1 The nurse should never interrupt the process for administering medications. Errors are administering medications on the unit. The nursing typically made when the nurse is interrupted. Military time is frequently used by institutions supervisor concludes there is a risk for medication for documentation. The nurse should always ask for assistance with dosage calculations when error when the nurse does which of the following? in doubt. The nurse should never give a medication that a client questions. Always double‐ check the order, dosage, and medication, and give the client an explanation.
| Review the process for medication administration to make the correct selection. |
5358 The nurse would ask a client scheduled for thyroid Correct answer: 2 Iodine is used in many radiological procedures. Shellfish allergies may be an indicator of scanning about allergy to which of the following before iodine allergy. The other options do not address this concern. the procedure?
| Knowledge of radiological procedures must be applied. In addition, recall that allergy to iodine or shellfish commonly applies to radiological procedures. |
4.‐ Meat tenderizer | |
5359 The nurse prepares a dose of a medication ordered Correct answer: 1 If there is confusion related to a medication order, refer to and verify the original written by the subcutaneous route and calculates the dose to order. Be careful to read abbreviations and dosage correctly. Asking another nurse or the be 4.5 mL. What is the first nursing action that the pharmacist, or calling the physician, are correct interventions, but not the first intervention, nurse should take? because the first step in the medication process is the writing of the order. Once that is verified, the nurse could choose any of the other options, which are correct.
| Think about the process involved in delivering a medication to a client. Recall that the order is first written, then filled by and delivered from the pharmacy, then drawn up by the nurse, and then administered to the client. Begin with the first step checking the order. |
5360 The nurse is restarting an IV line on a client known to Correct answer: 1, 2 Handwashing and gloves are the only precautions needed for starting an IV. Masks, face have hepatitis B. Which precautions should the nurse shields, and gowns are appropriate for procedures that may result in body fluids splashing. use to protect against exposure? Select all that apply.
| Recall standard precautions and infectious disease precautions. Handwashing and use of gloves are appropriate for any procedure. |
5361 Which of the following medication orders should the Correct answer: 2 Option 2 does not have a medication dosage listed. All other options have required nurse question? information for dispensing medications.
| Read all options carefully. Apply the five rights of medication administration. |
5362 The nurse is aware that a confused elderly client is at Correct answer: 3 Full bed rails are a type of physical restraint. A confused client may attempt to climb over the risk for falls. Which of the following interventions rails, increasing the risk for fall and injury. The other options are positive interventions for would the nurse avoid using with this client? reducing risk for falls.
| Use the process of elimination and visualize the client in the question to select the option that could lead to client harm for a confused client. |
5363 The nurse has applied elbow splints on a confused Correct answer: 4 The client should be checked at least hourly, and the nurse is required to document status. client to prevent the client from removing the The IV site should be checked every hour, but documentation may be done only once per shift intravenous (IV) line. Which of the following unless a problem occurs. Physical restraints impede a client s freedom, and thus their use interventions is required? needs to be ordered every 24 hours. Because restraints may also impede circulation, they should be removed according to agency policy, which is generally every 1–2 hours rather than every 8 hours.
| Utilize knowledge of common policy and procedures for use of physical restraints. Always consider an answer that contains assessment as an option. |
5364 A Code Red (fire) has been announced on the hospital Correct answer: 1 The primary responsibility of the nurse is client safety. Removing a client from danger should unit. What is the nurse’s first response? be the priority. Others can come to help contain or extinguish the fire.
| Option one is client‐focused. The other options are fire‐focused. Remember the mneumonic RACE (remove, alarm, contain, extinguish). |
5365 A client on the hospital unit has fallen. Place the Correct answer: 3, 4, 2, The primary actions of the nurse are emergency assessment and first aid. If the nurse nursing interventions in order of priority by clicking 1, 5 contacts the nursing supervisor, there will be nursing help to contact the physician and speak and dragging the options below to move them up or with witnesses. After caring for the client and assessing the situation, the nurse is prepared to down. fill out the incident report.
| Focus on the client first. Then obtain additional help, collect data, and do the paperwork last. |
5366 Which of the following items would the nurse avoid Correct answer: 4 The medical record belongs to the client and should contain all of the facts related to the documenting when a reportable incident has client and the incident. The incident report belongs to the hospital and should contain all of occurred? the facts and supportive data related to the client and the incident. The medical record should not refer to the incident report.
| Use knowledge of policy and procedure regarding incident reports to analyze this situation. |
5367 Public health nurses have been activated to open a Correct answer: 3 Client medications and vital records are needed for a short or extended stay at an emergency shelter due to an approaching hurricane. What most shelter. Space is very limited in a shelter. There is no provision for storing food, and animals important items should families be encouraged to take are not allowed. Loud electronic devices such as radios or televisions may cause disturbance to the emergency shelter? between families or individuals. Electricity may or may not be available.
| Focus on the required items for a stay in the emergency shelter. A client’s medications are the only provisions listed that emergency personnel may not be able to provide. |
5368 A major portion of a construction project has Correct answer: 1 The nurses must first assess current Emergency Department resources. No decisions can be collapsed. The Emergency Department (ED) has been made without a comprehensive assessment, such as outlined in option 1. The other options notified that numerous victims are being transported are not as encompassing, and a comprehensive assessment is needed with a possible to the ED. The first action of the ED nurses should be impending disaster. which of the following?
| Choose the option that is the most comprehensive or global of the option choices. |
5369 A young man is brought to the Emergency Correct answer: 2 The client is awake and alert. He does not have overt signs of cardiac or respiratory distress. Department as one of the first victims of a motor This client can wait for treatment for 1–2 hours. Check on his status every 30–60 minutes. vehicle accident that caused multiple casualties. The Depending on the status of the other incoming casualties, this client may move up in priority. man is awake and alert. He has a fracture of his right tibia and several small lacerations on his face. How will the triage nurse categorize this client?
| Know the principles and protocols of triage. Eliminate priority 1, which is always life‐ threatening, and option 4, which indicates death. Choose option 2 over 3 because fractures need attention within a few hours to reduce risk of complications. |
5370 The nurse should explain to the mother of an 12‐ Correct answer: 20 The infant must weigh at least 20 pounds in order to be safe in a forward‐facing infant seat month‐old infant that a forward‐facing infant seat is and must be 1 year or older. safest once the infant weighs at least pounds. | Because this item is a standard, it is necessary to commit this information to memory. A quick way to remember this requirement is at that the number 20 is also the number of fingers and toes on an infant. |
5371 The nurse is treating a client who continues to return Correct answer: 1 Option 1 is correct. The client is feeling powerless, and the nurse should empower her to a violent relationship saying, “There is nothing I can through mutual goal setting. Feeling powerless is common in victims of ongoing violence, as do.” What is the best response by the nurse? the emotional component of the violence instills terror and helplessness. The client is ashamed and demoralized, criticized and controlled by the perpetrator, who makes numerous dire threats and convinces the victim that there is no hope of escaping. Option 2 is incorrect, as teaching about further risk of violence is an appropriate intervention, but it will not be effective if the client feels powerless to act. Options 3 and 4 are incorrect; providing resources and/or mobilizing are appropriate interventions, but they will not be effective if the client feels powerless to act.
| Recognize the powerlessness of the client and choose an option that will allow the client to take action to combat this feeling and achieve a feeling of competence and power. |
5372 The nurse is teaching a community class on elder Correct answer: 3 Option 3 is correct. Elder abuse is not easily identifiable, because of the reluctance of the abuse. What comment by class attendees would elders to report and lack of definitive physical findings. Additionally, many elderly persons have indicate a need for further teaching? health problems that may result in significant changes in physical appearance or psychological functioning. Options 1, 2, and 4 are incorrect because no further teaching is needed, as these statements are true. Many elders have a strong fear of abandonment in general and see admission to a nursing home as the ultimate form of abandonment (option 1); while there are many motivators leading to child to parent violence, sometimes the abuser is retaliating for past actions/problems with the parent (option 2); and 60% of elder violence is carried out by spouses or partners.
| Look for an option that suggests continuation of a myth or factually inaccurate statement. |
5373 The nurse is assessing a 6‐year‐old boy who has Correct answer: 3 Option 3 is correct. A 6‐year‐old who has begun exhibiting behaviors of a younger child is recently begun thumb sucking, asking for a bottle, and demonstrating regressed behavior, which can be an indicator of the child s having been abused soiling his underwear. What meaning should the nurse or violated. Option 1 is incorrect, as oppositional defiant disorder is a medical diagnosis ascribe to this behavior? The client may be exhibiting: associated with negative, defiant, and hostile behavior such as defying rules, rather than a return to infantile behaviors. Option 2 is incorrect because attention‐deficit hyperactivity disorder is a medical diagnosis associated with lack of ability to concentrate on and attend to the environment, rather than a return to infantile behaviors. Option 4 is incorrect, as developmental delay is a medical diagnosis indicating that the child is delayed in the normal achievement of developmental milestones.
| Look for a human response that is within the range of areas that can be diagnosed and treated by a nurse. |
5374 The nurse is assessing a school‐age child. Which of Correct answer: 3 Option 3 is correct. Children who are physically neglected will often steal and hoard food the following may indicate physical neglect? because of inadequate nutrition. Options 1 and 2 are incorrect as the child’s level of physical activity and response to discipline may be indicators of emotional or physical abuse. Option 4 is incorrect because a sudden onset of enuresis is one possible indication of sexual abuse.
| Look carefully at the options. Identify the one that has to do with meeting basic needs. This child has been neglected and is trying to cope with that, and provide for own basic needs. |
5375 The nurse is assessing the parents of a child who has Correct answer: 1 Option 1 is correct. Parents who have high expectations of their children and/or are extreme been admitted for suspected physical abuse. Which disciplinarians and believe in physical punishment are at risk for abuse. The nurse should statement made by the father would indicate risk for recognize that being “tough” can have either physical or emotional components, or both. abuse? Option 2 is incorrect, as the question is asking for risk factors for child abuse. Not having been beaten is not a risk factor, but a family history of violence is. Option 3 is incorrect because most abusive parents have high, not low, expectations of a child s abilities and do not accept things about the child that are below the parental standard. Option 4 is incorrect as children who are wanted are less likely to be abused than children who were unplanned and/or unwanted.
| Look for a statement by the parent that suggests harshness or unreasonably high expectations of the child. |
5376 The nurse is assessing a family in which violence is Correct answer: 2 Option 2 is correct. Intergenerational transmission violence, where children learn violence in occurring. The violent parent says, “You can t say that I their own homes by observing family members, is an example of social learning theory. In such m violent. Just like my father before me, I m very situations, the child lacks positive role models who can assist with learning interaction and gentle with applying the belt.” The nurse who problem‐solving skills. Option 1 is incorrect, as while it is certainly true that personality issues understands social learning theory concludes that this would motivate this parent to be abusive, the question is asking about social learning theory, represents which of the following? not psychodynamic issues.<BR />
| Pay attention to what the client is saying. This parent has learned abusive behaviors from others, principally the father, and considers the behaviors to be average and non‐abusive. |
5377 The nurse is caring for a parent suspected of Correct answer: 4 physically abusing a child. In the first nurse–client interaction, what should the nurse first attempt to accomplish?
| Option 4 is correct. The nurse should approach the client in a nonjudgmental manner to build a working relationship. The client will not be open to teaching or information sharing if the nurse is judgmental. The nurse should self‐assess to determine if strong negative feelings are present. When they are, they can interfere with the objectivity of the nurse, and professional or peer supervision is recommended.<BR /> | Recognize that the suspected perpetrator’s basic human needs will be the same as those of any other person. |
5378 When teaching clients in the community about Correct answer: 2 relevant theories of family violence, the nurse should emphasize that an area of commonality between children and adult victims is that they are: | Option 2 is correct. Experts on interfamilial violence agree that three common conditions for violence exist in almost every situation involving family violence: (1) a violence‐prone individual, whose propensity for violence is related to childhood experiences and to personality issues related to low self‐esteem and general dissatisfaction with self and life; (2) a vulnerable person, who is someone in the family who lacks psychologic and/or physical power. Such persons include infants, children, pregnant women, and the elderly, especially if financially, physically, or psychologically dependent on family members; (3) a crisis situation that puts stress on the family and taxes the coping skills of the abuse‐prone individual. Option 1 is incorrect, as the very young, as well as the old, can learn to modify their expressions of emotion. It is not emotion of the victim that precipitates the violence. The causes arise from within the psyche of the perpetrator. Option 3 is incorrect because very young children and some elders may be engaged in ill–thought out or careless behaviors. However, it is not the behavior of the recipient of the violence that precipitates the violence. Rather, the violence arises from unmet and unhealthy needs in the perpetrator. Perpetrators will say that the victim “asked for it,” but this is a rationalization of the perpetrator. Option 4 is incorrect, as children and elders are vital parts of a family unit. If at times their behaviors are annoying, this is not a sufficient reason for violence against them. Perpetrators may try to justify their actions with an explanation of this sort, but the nurse should remember that causes of the violence arise from within the psyche of the perpetrator, not the recipient of the abuse. | Review the basic conditions that predispose to interfamily abuse and violence, regardless of the age of the victims. |
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5379 An adolescent client is admitted to an inpatient unit Correct answer: 2 following an arrest for shoplifting. The client s parents report that until three months ago, the client was “totally normal, a great student and a pleasure to be around.” They also state that the client has begun to have failing grades in school and to “act like a tramp with anyone and everyone.” Based on this data, the nurse makes it a priority to assess the client for indications of: | Option 2 is correct. This client s history was one of normalcy until very recently. The nurse should recall that adolescent victims of sexual violence are likely to have behavioral symptoms such as failing grades, seductive or promiscuous behaviors, running away from home, being arrested, and violent acting‐out behaviors. This is in contrast to child victims who tend to have obviously lowered self‐esteem, a variety of somatic complaints, and depressive symptoms. Option 1 is incorrect; since the client has done well in school until recently, the academic difficulties of this student could be symptomatic of significant difficulty in another aspect of the client s life. Option 3 is incorrect because if this client had a diagnosed medical problem such as antisocial personality disorder, the behaviors that resulted in arrest would not have had a sudden onset. Antisocial and problematic behaviors would have been present very early in the client s life. Option 4 is incorrect, as this is an “it doesn t compute” answer. Look carefully back at the stem of the item (the part that indicates what information is expected). Would indications of usual coping be something negative that would require further nursing assessment? Eliminate this option without giving it serious consideration. | Look at the particular constellation of behaviors described by the parents. Notice that there has been a significant recent change in the client’s behavior. |
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5380 | The nurse is assessing a female client in the Emergency Department who arrives with a black eye and reports of headache, chronic pain, GI problems, menstrual irregularities, and anxiety. A previous physical workup was negative. The nurse should next assess the client for which of the following? Select all that apply. | Correct answer: 2, 4 | Options 2 and 4 are correct. The client is showing several possible signs of having been the victim of violence. Anxiety, a black eye, and various somatic complaints, when combined together, are suggestive of unacknowledged violence against the client. The client s safety should be a priority. In situations where violence might have or actually has occurred, many people feel so trapped and desperate that suicide (or homicide) may seem the only way out of a horrible and detrimental relationship and situation. Providing for the safety of the client includes assessing for suicidal and/or homicidal potential. Options 1, 3, and 5 are incorrect, as after assessing for abuse and the risk of destructiveness toward self or others, the nurse can assess for other physical causes, such as premenstrual syndrome, migraine headache, and irritable bowel syndrome. | Look beyond the physical and think what might, in the absence of physical explanations, be causing the client’s symptoms. Remember that violence occurs in all strata of society. |
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5381 An elderly client has been admitted to the hospital for Correct answer: 1 dehydration. The client is poorly dressed, has body odor, appears unkempt, and has numerous unexplained bruises. The nurse’s priority initial action should be to:
| Initial observations of dehydration, unexplained bruises, and poor hygiene indicate possible abuse or neglect, the possibility of which should be assessed immediately. It is premature for the nurse to report the suspected abuse before more data are gathered (option 2). Some of the necessary data will come from the history of the present illness and rehydration methods attempted at home (option 3), and medications the client has been taking at home (option 4). | Don’t jump to conclusions. Gather data before making a decision. | ||
5382 | The nurse is caring for a client who is being treated for migraine headaches. Upon physical exam, the nurse assesses old scars on the client s arms and legs. The client confides childhood memories of sexual abuse by the father. The nurse s immediate response should be: | Correct answer: 4 | The migraines may be the presenting problem (option 1), but the client is indicating a need to discuss the abuse (option 4). A nonjudgmental approach considering the client’s comfort level would be best to prevent the client from feeling guilt and shame. The nurse should acknowledge the client’s comment and explore what the client would like to share at this time. Obtaining the information in options 2 and 3 is secondary at this point. The client is indicating a readiness to express feelings, not provide data. | Note that the client has introduced the topic of having been abused as a child. This indicates a readiness and need for further discussion and active support from the nurse. |
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5383 | A mother brings her 2‐ and 7‐year‐old sons in for | Correct answer: 4 | Sibling abuse is often unrecognized and can lead to serious injury if not addressed. The | Notice the mother’s lack of responsiveness to the situation. Could this be unconscious enabling? |
immunizations. The nurse observes the mother | physical abuse described goes beyond sibling rivalry (option 1). The younger boy would not be | |||
ignoring the 7‐year‐old, who is pushing and slapping | able to stand up to someone older and larger than himself (option 2). The younger boy would | |||
the 2‐year‐old. What would be the most appropriate | not be mature enough or have the language skills needed to work things out with his sibling | |||
nursing intervention? | (option 3). | |||
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2.‐ Encourage the younger son to stand up for himself. | ||||
3.‐ Tell the mother it is best if they work this out themselves. | ||||
4.‐ Teach the mother this behavior may indicate sibling abuse. | ||||
5384 A mother brings in an 8‐month‐old infant who is Correct answer: 2 having difficulty breathing. The nurse assesses bleeding in the baby’s retinas. The mother states that the child was being cared for by the father while the mother was out of the house. What is the most appropriate initial response of the nurse?
| The respiratory distress and retinal bleeding are symptoms of shaken baby syndrome and represent a medical emergency. The child will continue to be at grave risk at least until cerebral and ocular bleeding subsides. The events leading up to the distress are relevant but secondary at this time (option 1). Informing the mother that the greatest danger period has passed is inaccurate (option 3), as the child will continue to be at grave risk at least until cerebral and ocular bleeding subsides. Reporting the incident to the children s protective agency is important (option 4), but at this time is secondary to providing emergency care to the child. | Recognize this child’s symptoms as a grave consequence of child abuse and a medical emergency of the highest order. |
5385 The nurse is conducting a home visit. The nurse Correct answer: 2 observes a 5‐year‐old child wearing a diaper while sucking his thumb, rocking, and banging his head. The child made adequate verbal response to the nurse s verbal greeting. The nurse reports this behavior as: | The age‐inappropriate behaviors combined with capacity to communicate verbally would indicate probable abuse or neglect. If mental retardation (option 1), autism (option 2), or pervasive developmental delay (option 3) were present, the child’s language skills would be affected. | Notice the incongruity between the physical appearance and the language development of the child. |
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5386 An adult survivor of child abuse states: “Why couldn t Correct answer: 3 I make him stop the abuse? If I were a stronger person, I would have been able to make him stop. Maybe it was my fault he abused me.” Based on this data, which would be the most appropriate nursing diagnosis?
| Inappropriate self‐blame and feelings that a child could have stopped an adult s abuse indicate low self‐esteem. Options 1, 2, and 3 are possible diagnoses for adult survivors of abuse, but there is no evidence in the situation to support these diagnoses. More data would be needed. | Note that chronic low self‐esteem is just one of many possible consequences of childhood sexual abuse. Recognize that this client s statements are very typical of survivors of childhood sexual abuse. |
5387 The mother of a 6‐year‐old client in the Emergency Correct answer: 3 Department (ED) tells the nurse that the child vomits after every meal. The child has a normal appearance and is in no acute distress. This is the sixth time within 3 months that the child has been taken to the ED by the mother. The mother states: “This time I won t go away until my child is admitted for a complete and thorough gastrointestinal workup. The doctors say there s nothing wrong, but I know my child is very ill.” The nurse should suspect that it is likely that the mother is experiencing: | Munchausen syndrome by proxy is characterized by a caregiver, usually a parent, fabricating or causing illness in another person in order to gain sympathy or attention for herself. The mother s statement and the past history of repeated attempts to have the child hospitalized in the absence of diagnosed problems suggest that this rare somatoform disorder might be present. Somatoform disorders are considered anxiety‐related disorders. While the mother is anxious, she is not in panic level anxiety (option 1), since she is able to organize and verbalize her thoughts very clearly. There is no indication of more than one personality or alter ego being present in the mother, which would be the case if a dissociative identity disorder were present (option 2). There is no indication of Cluster A personality traits (option 4), which present as odd, eccentric, and suspicious behaviors. | Recognize that these four options are all medical diagnoses. It is useful for the nurse to understand behaviors associated with the diagnoses, but the physician will actually determine these diagnoses. |
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5388 The nurse is counseling an extremely distressed Correct answer: 1 female victim immediately after a rape. What is the nurse’s most important initial intervention?
| Victims of rape and other sexual assaults often feel guilty and responsible for the assault. It is essential for the nurse to reassure the client that the rape was not her fault. Teaching and testing (options 3 and 4) are secondary interventions after the client is calmer. Gathering evidence (option 2) would proceed only after reassuring the client and obtaining permission to gather evidence. | Unless the client is suffering grave physical consequences of the assault, attend to the psychologic needs of the client first. This is the reverse of the usual priority in caregiving situations. |
5389 The nurse is evaluating a family in which an 18‐month‐ Correct answer: 4 old child has been abused by both parents. At the initial interview with the nurse, the parents stated that they spank the child because the child “cries and cries and never tells us what is wrong.” The parents are teenagers who are still in high school. The nurse determines that what outcome would indicate progress for the parents? The parents report: | The parents need to learn that 18‐month‐old children cry as a means of communication. The word less in option 1 makes it incorrect, since the child should not be spanked for crying. Attendance at parenting classes alone (option 2) does not indicate behavior change. Having unreasonably high expectations for children is a continued risk factor for abuse (option 3). Understanding normal growth and development will help the parents have more reasonable expectations of the child. | Note that age of the parents does not point in the direction of any particular option. Older parents could engage in exactly the same kind of behavior as these young parents. |
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5390 A 16‐year‐old female is brought to the Emergency Correct answer: 3 Department following a suicide attempt. During the interview the client reports to the nurse that she is doing poorly in school, is engaging in high‐risk sexual activity, and has a history of running away from home. What should the nurse assess for first?
| The sexual behavior, suicide attempt, and running away indicate possible sexual abuse. Assessing for pregnancy (option 1), physical abuse (option 2), and sexually transmitted diseases (option 4) would be secondary assessments. | Look at the presenting behaviors of the client as a unit, not as separate occurrences. |
5391 An 18‐month‐old client is scheduled for a minor Correct answer: 1 surgical procedure. The client has numerous large bruises of different stages over the back and buttocks. The mother states that the child must have fallen down while playing alone outside but cannot provide specific information about these incidents. The nurse evaluates this as: | The number, extent, and location of the bruises, and the mother s vague explanations of the injuries, indicate possible child abuse, as does the mother s statement that the child was unsupervised while playing. Children of this age should be supervised during play. No information is given about the level of maturity of the mother (option 2), but it appears that the parenting is inadequate. While it is true that an 18‐month‐old is unsteady and will fall often (option 3), the nurse would not expect to see numerous large bruises of different stages confined to the back and hips. If tissue fragility were present in this child (option 4), it would not be limited to the back and buttocks. | Notice the extent of bruising and the mother’s explanation. Do they seem to “fit” together? |
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5392 An 85‐year‐old client is brought to the Emergency Correct answer: 4 Department after a fall at home. The client appears confused and malnourished and is severely dehydrated. The client can speak but appears reluctant to explain how the fall happened. The client’s 62‐year‐ old daughter frequently interrupts the client and does not allow the client to answer questions. Which of the following nursing interventions is a priority? | The symptoms, client’s behavior, and daughter’s behavior would indicate possible abuse or neglect. The daughter may be the abuser, and it is necessary to first interview the client apart from the daughter to assess for abuse. Most abusers of elders are family caretakers. If the daughter is an abuser, she will not give an accurate account of the client’s fall (option 1). Nutritional assessment and teaching (option 2) may be appropriate later, but at this time the client’s safety is more important. Requesting a psychiatric evaluation (option 3) is premature at this time. Confusion alone is not a symptom of mental illness. Malnourishment and dehydration, both of which are treatable and reversible, may be responsible for the client’s confusion. | Note the client’s reluctance and the daughter’s controlling behavior. Use this as a guide in evaluating the various options. |
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5393 A 5‐year‐old girl is brought to the clinic for symptoms Correct answer: 3 of a urinary tract infection (UTI). The nurse’s assessment reveals bruises in the child’s genital and rectal areas. The mother reports that she had left the little girl with her boyfriend the night before. The nurse’s first priority with this client is to take which action?
| The child’s examination shows probable signs of sexual abuse, which must be reported. Nurses are mandated reporters of suspected child abuse. Further data gathering (options 1 and 4) and teaching (option 2) would be secondary priorities. | Apply the “vulnerable person” theory to this situation. Recognize that meeting the child’s safety needs is the first priority for the nurse, who is also legally mandated to report suspected child abuse. |
5394 A client comes to the Emergency Department with a Correct answer: 3 broken wrist and severe bruises inflicted by a beating by the intimate partner. The client states an intention to remain in the relationship at this time. What is the most appropriate response by the nurse?
| The client s safety is of utmost importance. If the client is returning to the violent environment, it is urgent for her to have a safety plan. Instructing the client to leave the relationship (option 1) will not help if the client is not ready to do so. Additionally, the nurse should assist the client to make her own decision, rather than trying to impose his personal views on the client. Providing information about legal assistance (option 2) and a list of services that are available (option 4) are appropriate, but are secondary to assisting the client to plan for personal safety. | Recall that, for varied and complex reasons, the decision to terminate an abusive relationship is very difficult for most victims to reach. Keep the client’s needs for safety at the forefront of your thinking. |
5395 A nurse is teaching a class on domestic violence to Correct answer: 3 high school students. Which statement by a student would indicate to the nurse that further teaching is needed? | Education and money do not make persons immune from violence. It crosses all socioeconomic lines. Violence often begins in dating relationships (option 1). It is estimated that 30–40% of college students and 10–20% of high school students are in abusive relationships. As part of a predictable cycle of violence, abusers typically apologize and promise to stop (option 2). However, the reality is that the level of abuse generally intensifies with the passage of time. Abusers are often excessively jealous and possessive (option 3). They control the victim s life and isolate the victim from outside family or social contacts. | Look for an inaccurate statement. The question is asking you to identify a need for continued teaching. |
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5396 The nurse is interviewing a client who has Correct answer: 1 experienced both physical and psychological abuse in an intimate relationship. Which statement by the client indicates a need for more teaching about abuse? | The most dangerous time in an abusive relationship is when the victim leaves; having left, the victim is in greater danger. It often takes several times before victims are able to leave (option 2). For various complex reasons, emotional, social, and financial, many victims feel bound to the relationship. Victims often feel that the abuse is their fault (option 3). This area can be addressed once safety has been addressed. Abusers will make threats of removing children from the victim to intimidate and control the victim (option 4), which can also be addressed once safety has been addressed. | Look for an indicator of absence of change in the client. Teaching, if effective, will bring about a change in attitude or behavior, or both. |
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5397 A 5‐year‐old child has been removed from the home Correct answer: 3 The child will be at risk for depression, both now and in the future. Among other frequent because of sexual abuse by the stepfather. When consequences are self‐esteem disturbances, feelings of guilt, sexual acting‐out behaviors, teaching the child’s mother about possible posttraumatic stress disorders (PTSD), and self‐mutilation behaviors. There are many long‐ consequences the child might experience, which of the term consequences of child abuse (option 1). Abuse is more devastating if the abuser is a following should the nurse include? person the child knew and trusted (option 2). It is true that many victims of child abuse do themselves become abusers in the future but one cannot predict that this will happen in all cases (option 4). Many victims of child abuse are able to have normal, healthy, nonabusive parent–child relationships.
| Consider the fact that sexual abuse is an assault of the entire person: psychological, physical, and spiritual. | |
5398 A 15‐year‐old female student visits the school nurse’s Correct answer: 4 office asking about date rape and pregnancy. She confides to the nurse that her boyfriend forced her to have sex against her will. The most appropriate initial intervention of the nurse would be to do which of the following? | The client has been raped, and the nurse needs to respond to the client’s immediate concerns. Since the student describes occurrences that often lead to a situational crisis response, it is most important for the nurse to allow the student to ventilate feelings at the beginning of the interview. The nurse should listen patiently and supportively, understanding that compulsive retelling helps the victim gradually become desensitized to the rape. Pregnancy testing (option 1) and teaching (options 2 and 3) are secondary interventions that can be begun after the client has ventilated feelings about the rape. | Recall that one of the ways of coping with rape is to avoid talking about it. Notice that the client has initiated the topic with the nurse. This indicates readiness and a need to discuss the event and express feelings. |
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5399 A pregnant female comes to the Emergency Correct answer: 1 Department with bruises on her arms and abdomen after a fight with her boyfriend. What is most important for the nurse to address when teaching this client?
| It is vital that the client understand that the pregnancy may be in danger from the abuse. Among possible consequences of abdominal beating of a pregnant woman are miscarriage, placenta abruption, fetal loss, premature labor, and fetal or maternal fracture. The client will need resources (option 4), childbirth classes (option 3), and assertiveness training (option 2) in the future, but she must first understand the risk to the baby in order to provide safety for herself and the baby. | Note that this client has sustained trauma to the abdomen. If you were this pregnant client, what would your concerns be? The nurse should have the same concerns and recognize a need to try to provide information that could lead to safety for the victim and her unborn child. |
5400 A pediatric client has severe injuries to the abdomen. Correct answer: 1 The nurse should suspect child abuse if the parents:
| A delay in seeking treatment for serious injuries is an indication of abuse. Vague descriptions of the injuries with little detail are more likely to indicate abuse than is a detailed description (option 2). Anxiety and concern on the parents part would be expected (option 3). Preventing the child from explaining the injuries, not encouraging explanation (option 4), would be an indication of abuse. | Look for what appears to be atypical parental behavior. This is the option that is the correct answer. |
5401 Which of the following is the most appropriate safety Correct answer: 1 Adolescents are at risk for sunburn and skin damage, and this skin damage may not surface measure for the nurse to teach a group of high school until later in life. Adolescents may minimize this risk. Options 2, 3, and 4 are safety measures students? more appropriate for adults and the elderly.
| Be familiar with growth and development milestones. | |
5402 Which of the following would be the most Correct answer: 2 appropriate safety measure for the nurse to include when teaching the parents of 2‐year‐olds?
| Toddlers are at risk for poisoning due to curiosity and the ability to climb. Childproofing the home by locking up toxic substances and medications can prevent poisoning. Options 1 and 3 are incorrect, as toddlers are not developmentally ready to learn rules of fire and traffic safety. Option 4 is also incorrect, as scissors are not a safe toy for toddlers. | Be familiar with growth and development milestones. |
5403 While performing an environmental assessment of a Correct answer: 1 72‐year‐old client, what hazards should the nurse document and correct?
| Older adults are at risk for falls. Navigating in the bathroom and the presence of throw rugs pose a threat for falls. Options 2–4 are good means of preventing falls. | Option 1 is a negative response, while options 2–4 are positive measures. |
5404 The occupational health nurse is planning an Correct answer: 3 educational offering for a group of factory workers. What is the most appropriate content for this course?
| Adults are at risk for injury in the workplace. Muscle pulls and strains are a common workplace injury. Option 1 is more appropriate for children and adolescents. Option 2 is more appropriate for the elderly. Option 4 is appropriate for everyone, from adolescents through the elderly. | Use principles of adult growth and development to determine the risks to this age group. The word “factory” also helps point to the correct option, since factory workers may engage in manual labor that involves lifting or pulling. |
5405 A client is found on the bathroom floor having a Correct answer: 3 grand mal seizure. What is the nurse’s priority intervention?
| The priority intervention is to protect the client and prevent injury. Do not leave the client. The application of oxygen with a mask may be appropriate as an additional measure once the head is protected, and the nurse should observe and document the seizure activity after the client has been stabilized. | The nurse’s first priority is to protect clients and provide a safe environment. |
4.‐ Observe and document the client’s respiratory status. | |
5406 Which type of physical restraint is most appropriate Correct answer: 1 A mitt restraint is appropriate for a client who is confused and picking at dressings and tubes. for the nurse to apply with an order to a client who is It allows the client to continue to move around freely. A belt, limb, or wrist restraint would not confused and pulling at an incisional dressing? necessarily prevent picking at the dressing; instead, it would prevent movement of the client and may agitate a confused client.
| Assess the need for the restraint. Do not restrain more than necessary. |
5407 When evaluating the effectiveness of a restraint, it is Correct answer: 4 It is imperative for the nurse to assess and document the client’s behavior while the client is most important for the nurse to document the: in restraints. The restraints must be removed as soon as the nurse feels there is no longer a safety risk to the client, staff, or family members. Options 1–3 can be documented, but they are not as critical as option 4. There must be documentation as to why the client has a continued need for restraints.
| Option 4 is the only response that is totally client‐focused. Client safety is always the nurse’s primary focus. |
5408 A 78‐year‐old client has been admitted to the medical Correct answer: 4 When a client is confused, a restraint may cause agitation. A restraint is only a last resort. A unit with a fever of 103ºF. The client is lethargic and creative alternative such as moving the client to a room that nurses can easily observe is a disoriented to time and place. What is the best nursing better choice. Option 1 is incorrect because there is no PRN order for restraints. Options 2 and intervention at this time? 3 (vest restraint and private duty nurse or companion) should not be the primary interventions.
| As a primary option, always consider reasonable alternatives to physical or chemical restraint. |
5409 Which of the following interventions should be a Correct answer: 3 The priority action is to restrict the spill so there is no danger to clients or staff. Each chemical priority for the nurse who is cleaning a chemical spill? spill is unique and will require a unique method to clean. Option 1 (MSDS form) must be done, but not until after the spill is cleaned. Options 2 and 4 are not the correct actions for every spill.
| The priority action is always client safety. Restricting the spill will protect clients and staff from further contamination. |
5410 A 68‐year‐old woman is going home to live with her Correct answer: 4 A heating pad is a dangerous intervention when used with a confused or elderly client. The daughter after being hospitalized and diagnosed with client is at risk for burns resulting from improper use. Options 1, 2, and 3 are statements that Alzheimer’s disease. Which statement by the daughter reflect good safety measures for a confused elderly client. as caretaker demonstrates the need for further safety education?
| The critical words are “68‐year‐old woman” and “Alzheimer’s disease.” Assess the cognitive and physical abilities of the client when discharge planning or teaching about safety. |
5411 The son of an 80‐year‐old confused client has asked Correct answer: 3 A hospital bed in low position with a mattress on the floor is a good safety measure for the nurse to use a restraint to keep his mother in bed. preventing injuries that could result if the client falls from bed. Option 1 for restraint should He fears that she will fall while in the hospital. The not be the priority intervention. Bedside rails (option 2) may only agitate the client and nurse’s best response would be: increase the risk of injury if the client tries to climb over the rails. It is inappropriate to expect the family to stay with the client (option 4). Family members may assist with, but are not responsible for, client care and safety in the hospital.
| Restraint is rarely a first priority. Always seek creative interventions to keep clients safe. |
5412 The nurse is passing medications in the day room of a Correct answer: 1 To prevent medication errors, always ensure that you are administering medicine to the right long‐term care facility. Which of the following is the client by checking an ID band. Option 2 is incorrect. In a long‐term care facility, clients are not best technique for the nurse to use to prevent in beds and may be confused. Do not ask, “Are you Mrs. Smith?” Options 3 and 4 are not medication error when passing medications? correct. Follow the procedure of the medical facility for passing medication.
| When passing medications, review the “right” person, medication, dose, route, and time. |
5413 The nurse is taking a health history of a client being Correct answer: 2 A major cause of adverse reactions during hospitalization is allergic response. Always inquire admitted for surgery. Which of the following questions and document any history of allergic response to medications, foods, tape, or latex. Options 1, would best prevent an adverse reaction during hospital 3, and 4 should also be part of a health history interview, but they are not priorities for the admission? prevention of adverse reactions.
| The critical word in the question is “best.” This indicates that more than one option may be appropriate but that one has higher priority than the others. Evaluate the relative risk to clients, and choose the option that ensures client safety to the greatest degree. |
5414 A group of parents at the local preschool are Correct answer: 4 Toddlers are at risk for poisoning due to their developmentally appropriate inquisitive attending a health class. The nurse explains that the behavior. Toddlers must be supervised at all times. Option 3 is a good answer, as toxic major cause for childhood poisoning is: substances and medications should be stored in a locked cabinet; however, there are substances in the home, such as plants, that can be a hazard and yet are not locked. Options 1 and 2 are risks for poisoning for adolescents and adults.
| Review growth and development milestones to choose the option that addresses the safety risks for the toddler. |
5415 A new registered nurse (RN) shares with the nursing Correct answer: 4 Never re‐cap a used needle. If no sharps container is available, carefully use a one‐handed supervisor fears of being infected by a contaminated scoop method to re‐cap. Options 1, 2, and 3 are good safety tips for preventing a needle or needle or suffering a sharp injury. The supervisor sharps injury. explains that which of the following actions should be avoided to decrease the risk of a needle or sharp injury?
| Read the question carefully. “Should be avoided” is a critical phrase and indicates that the correct answer is an incorrect nursing action. |
5416 The infection‐control nurse is teaching a group of new Correct answer: 4 In case of a puncture wound from a needle or a sharp, the nurse should encourage bleeding registered nurses (RNs) the hospital policy on needle and wash the area with soap and water. Options 1 and 2 are correct actions to take the injury injuries. In the case of a needle or sharps injury, the needs to be reported, and the client could be questioned about the incident but these are not first action of the nurse should be to: the priority actions. Option 3 (washing the area with saline for 5–10 minutes) is the action for exposure to membranes.
| Emergency assessment and care are always priorities. Notification and documentation are essential but not a priority. |
5417 The home health nurse is making a visit to a 58‐year‐ Correct answer: 3 Toddlers need to be supervised at all times. Options 1 and 2 are good safety tips, but they are old client who is living with her daughter. The nurse not the priority or the most effective means to prevent drowning. Option 4 is incorrect and is a notes that the daughter is playing with her 2‐year‐old personal decision for any parent. and 3‐year‐old children in the backyard wading pool. What is the most important water safety tip that the nurse could share with this mother?
| Recall that toddlers need to be supervised at all times in any situation. |
5418 The nurse who is teaching a babysitting class to a Correct answer: 2 Infants explore and learn by putting things in their mouths. Choking is a major risk in infants. group of high school students understands that it is Options 1, 3, and 4 are incorrect development milestones for an infant. important for a sitter to know how to select a toy for an infant. Which of the following statements best describes the growth and development concepts that apply to safe toys for an infant?
| Be familiar with growth and development milestones. Note that the question mentions infants. |
5419 After heavy spring rains, a local river has risen and Correct answer: 1 After a flood, insects may spread disease through contaminated or stagnant water. Options 2, forced many families from their homes. The public 3, and 4 are psychological effects that may be caused by a disaster. health nurse is preparing families in the shelter to return to their homes. The biophysical effects of a flood that the nurse should be prepared to treat are:
| Read the answers carefully. The critical word is “biophysical.” Option 1 is the only physical effect. Options 2 through 4 are psychological effects. |
5420 The Emergency Department nurse is assigned to the Correct answer: 4 The purpose of triage is to sort accident victims for the purpose of treatment. The focus of trauma room upon the arrival of several victims of a the primary survey is to identify victims with life‐threatening injuries and send these victims for motor vehicle crash. The nurse would first conduct a priority treatment. Options 1 and 3 are incorrect and unrelated. Option 2 is the focus of the primary survey in triaging the accident victims in order secondary survey. to identify which of the following?
| The first action is usually assessment/identification. In any emergency, always treat life‐ threatening conditions first. Remember “ABCD” assess airway, breathing, circulation, and disability. |
| |
5421 After being notified of an airline disaster, the local Correct answer: 1 All of the clients listed are ill. When assessing clients for discharge in a disaster, determine hospital has activated the emergency response plan to who is the most stable, and then consider the home situation. Option 1 is a stable recovering prepare for many victims. There are limited beds client who will return to a health care environment. Option 2 is a stable recovering client who available at the hospital, and nursing staff has been is a single mother and may need help in the home. Options 3 and 4 are undiagnosed clients. instructed to assess and determine which current clients could be discharged. Which of the following would be the first client discharged?
| Whenever discharging clients ahead of schedule because of a disaster, analyze the client condition in each option and select the client who is the most stable and/or at the least risk of experiencing complications. |
5422 Several victims of a motor vehicle accident arrive at Correct answer: 4 Option 4 is a victim with a possible head injury. This is the least stable victim and the victim in the Emergency Department. Which of the following need of urgent treatment. Options 1, 2, and 3 have injures that do not appear life‐threatening. clients would the triage nurse label Priority I?
| When doing a primary survey, identify the victims who are in need of immediate treatment. Use airway, breathing, circulation, and disability (ABCD) as a reminder. |
5423 The triage nurse is assessing a victim injured in an Correct answer: 2 Ensuring an open or patent airway is the first step in a primary assessment. Options 1, 3, and earthquake. What should the nurse assess for first? 4 are valid assessments, but they are not primary.
| As part of emergency assessment, use airway, breathing, circulation, and disability (ABCD) as a reminder of the elements of the primary survey. |
5424 A client on the unit has fallen trying to get from the Correct answer: 3 The primary intervention in an accident is to assess for injury and provide urgent care. Client bed to the chair. What is the primary intervention by safety is always first. Notify the doctor after the assessment; gather data and fill out an the nurse? incident report after the client is stable.
| In case of an accident, always assess the client and give the client urgent care. Note that options 1, 2, and 4 are valid interventions in response to a fall, but not the priority. |
5425 The nurse is admitting a client with a history of grand Correct answer: 2 The purpose of seizure precautions is to protect the client. Always pad the bed rails and have mal seizures. As a precaution in case a seizure occurs, suction available. Options 1 and 3 are incorrect. Do not use a nasal cannula for oxygen; have a what equipment should the nurse ensure is placed in mask available instead. Option 4 is also incorrect. Medications are not usually kept at the the room? bedside, and a padded tongue blade is a matter of hospital policy. Many institutions will have an airway at the bedside.
| Evaluate each of the options in sequence, and eliminate the ones that could pose a risk to the client (padded tongue blade and nasal cannula). Use the process of elimination. |
5426 A client has been admitted with a drug overdose. The Correct answer: 1 There can be no PRN order for a restraint. A restraint order must include the reason for the client has become combative. Which of the following restraint, type of restraint, and a time to use the restraint. Options 2, 3, and 4 are correct written doctor’s orders should the nurse question? orders for a restraint.
| Use the process of elimination, and recall that there can never be a PRN order for a restraint. Use principles of client rights and client safety to make a selection. |
5427 A 97‐year‐old man has been admitted to the unit. Correct answer: 4 The first step in determining an appropriate intervention is always assessment. The nurse What is the nurse’s priority intervention in the must assess the client’s ability to ambulate before determining the appropriate fall management of the fall‐prevention program? precautions. Options 1, 2, and 3 are good interventions for reducing the risk of falls.
| The critical word in the question is “priority.” This indicates that more than one option may be a correct action, but that one is most appropriate or timely. Recall that assessment is very often an appropriate first step. |
5428 The school nurse is speaking to parents at a parent Correct answer: 2 A third‐grade student is approximately 9 years old. Any child under the age of 12 and shorter teacher organization (PTO) meeting on car safety. than 4 feet, 9 inches should be in the rear of a car. A booster seat is needed if the lap/shoulder What car restraint system would the nurse harness in the car does not properly fit the child. Options 1, 3, and 4 are incorrect according to recommend for use with a child in third grade? car‐restraint‐system guidelines.
| Remember that children under 12 and shorter than 5 feet should always be in the rear seat. |
5429 Which of the following are the most age‐appropriate Correct answer: 3 The school‐age child is capable of participating in a family fire‐escape plan. School‐age safety tips to teach parents and school‐aged children? children are at risk for fire injuries due to an interest in matches, lighters, and fireworks. Option 1 is a good safety tip for toddlers. Option 2 is a good safety tip for families with firearms. Keep in mind that, if there are children in the home, firearms should be locked and ammunition kept in a separate locked location. Option 4 is a good safety tip for adolescents and adults.
| Be familiar with growth and developmental milestones. Note that the client in the question is school‐age, indicating that the child is able to use reason but also may have high levels of curiosity about dangerous objects. |
5430 The nurse who is the nursing unit representative to Correct answer: 4 In case of emergency, the primary action is to assess victims and give urgent care. In case of the hospital’s safety committee is conducting an in‐ disaster, there will be a protocol for treatment. Options 1, 2, and 3 are actions that need to be service with the unit to review the unit’s disaster plan. taken in a disaster; however, the disaster plan should designate the person responsible. Not The nurse includes in the discussion that all staff every staff nurse will have responsibilities in these areas. nurses must be prepared to do which of the following actions in case of a disaster?
| Keep in mind that nurses should be prepared as a priority to assess and give urgent care in emergency situations. |
5431 The nurse manager notes that several key Correct answer: 1 The nurse leader must be willing to instill a deep‐seated sense of ownership in the organizational changes are about to begin, but staff organization’s work to address the challenges and opportunities presented within the health morale is low on the nursing unit. How can the nurse care organization. Options 2, 3, and 4 are incorrect. A command‐and‐control leadership style leader best prepare the staff for the upcoming changes will not gain the support of the frontline nursing staff, nor will sharing information and creating while maintaining the support of the frontline nursing a culture of “know how to act right.” Frontline staff must believe that they have staff? entrepreneurial opportunities and a stake in the organization’s success.
| Use the process of elimination. The core issue of the question is determining the most effective way to prepare staff for needed organizational changes. |
5432 A nurse is working in an organization that has a Correct answer: 2 In a shared governance model, there are decentralized power sharing and decision making. shared governance model. The nurse would assign Options 1, 3, and 4 are incorrect. The assigned priorities of the organization are accomplished priorities of the organization via which of the following through a series of councils. An example of a council might be a joint practice committee or a mechanisms? leadership council, but these councils would not be assigned the sole responsibility of assigning the organizational priorities.
| The core issue of the question is methods for assigning priorities within a health care system using a shared governance model. Use the process of elimination and knowledge of the characteristics of this model in making a selection. |
5433 The nurse manager learns that the unit expenses have Correct answer: 2 The management process includes planning, organizing, coordination, and control. Option 1 is exceeded the budget allowance by $600,000 for the incorrect because management is the process of coordinating actions and allocating resources first half of the fiscal year. The nurse manager would to achieve organizational goals. Option 3 and 4 are also incorrect. Time management is a set of use which of the following processes to most skills that helps nurses to use their time in the most effective and productive way possible. effectively prioritize client care activities and control Total quality management process is a systematic process to improve outcomes based on the cost of care? client or customer needs.
| The core issue of the question is the appropriate process that will assist with determining appropriate, cost‐effective priorities of care. Use the process of elimination and nursing knowledge in making a selection. |
5434 A nurse is getting restless in his current position and Correct answer: 2 A middle‐level manager is called a director. Option 1 is incorrect because a lower‐level is ready to apply for a middle‐level manager position. A managerial job is a first‐line management position. Options 3 and 4 are incorrect because a job is posted for a manager who would be responsible nurse in an executive role is called a chief nurse executive or vice president of Client Care for directing and supervising several nursing personnel Services. assigned to the surgical division of an acute care hospital. The nurse concludes that this position is at which level in the organization?
| The core issue of the question is knowledge of the various levels of nursing positions within a health care organization. Use this knowledge and the process of elimination in making a selection. |
5435 A female staff nurse on the unit asks the charge nurse Correct answer: 1 Reverse delegation occurs when a person with a lower rank delegates to someone with to complete the wound care and dressing change on authority. In this instance, the nurse with a limited client assignment is delegating upward to a an assigned client because she finds wound care nurse who has responsibility for the entire nursing unit for that shift. Option 2 is incorrect distasteful. The nurse manager would counsel the because overdelegation occurs when the delegator loses control over a situation by providing nurse about which of the following subjects? the delegate with too much authority or responsibility. Option 3 is incorrect, since underdelegation occurs when full authority and responsibility are not transferred. Option 4 is incorrect because incomplete delegation occurs when the delegator delegates a task and then, due to fear or inexperience, removes the task either while it is being accomplished or before it is fully accomplished, leaving the delegate feeling frustrated.
| The core issue of the question is knowledge of the various types of delegation. Use knowledge of delegation and the process of elimination to make a selection. |
5436 The Emergency<BR /> Correct answer: 2 Democratic leadership is participatory, and authority is delegated to others. Option 1 is incorrect. Autocratic leadership involves centralized decision making with the leader making decisions and using power to command and control others. Option 3 is incorrect. Laissez‐faire leadership is passive and permissive, and the leader defers decision making. Option 4 is incorrect. Employee‐centered leadership focuses on the human needs of subordinates.
| Note the critical words most effectively in the stem of the question. This tells you that more than one option could be chosen but that one is better than the others for one or more reasons. Use knowledge of leadership styles to make a selection. |
5437 A staff nurse on the clinical excellence committee Correct answer: 2 The main purpose of delegation is to get the job done in the most efficient way using must prepare an in‐service on delegation for nursing appropriate resources. The job must be delegated to team members who can understand and staff. In preparing the presentation, the nurse includes accept the responsibility of what the goal is and how it is to be achieved. Options 1, 3 and 4 are which explanation of how delegation impacts the incorrect. Delegation can promote interest and prevent team members from becoming bored, safety and quality of client care? nonproductive, and ineffective. By finding the duties or tasks that best fit team members, the nurse leader can help them feel valuable to the team regardless of their position. Each team member wants to feel that she is making a difference in the well‐being of the client.
| The core issue of the question is basic knowledge related to the activity of delegation. Use this knowledge and the process of elimination to make a selection. |
5438 A client on the medical–surgical unit begins to code. Correct answer: 3 The nurse leader derives his source of authority within the workplace directly from a formally The assigned registered nurse and the charge nurse appointed position or rank. Options 2, 3 and 4 are incorrect. Although the followers or are at lunch. The newly hired nurse manager begins to subordinates must accept the nurse leader s orders, they do so because of official authority. A direct the resuscitation efforts until the code team nurse leader s personality traits, such as intelligence, are helpful for gaining compliance for arrives, using which of the following as the basis of delegated tasks but are not a source of authority. A nurse leader s expertise and experience power in this situation? are essential for delegation, but true authority and accountability for delegated tasks come directly from the organizational authority of the assigned position.
| The core issue of the question is what type of power is best utilized in an urgent or emergent situation. Use knowledge of different sources of power and the process of elimination to make a selection. |
5439 A registered nurse who has been in practice for 6 Correct answer: 3 The best way that the nurse can effectively self‐evaluate performance of her job is to months is due for the first performance evaluation. In compare individual performance against the written job description. Job descriptions help preparing for the evaluation, the nurse should look to identify activities that each staff member may perform. The ANA standards of care help set the which standard against which to evaluate personal parameters for minimal standards and should be used as guidelines. Individual state boards of performance during the first 6 months of nursing identify the legal boundaries of nursing practice to safeguard the public. The state employment? nurse practice act assists nurse leaders in knowing what tasks are within the scope of their state s nurse practice act and the scope of practice for their staff members. The job descriptions are designed to support the organization s work and aid in standards of performance.
| The core issue of the question is knowledge of appropriate reference points when preparing for employee evaluations. Use the process of elimination and knowledge that the job description provides specific direction for practice in an institution to make a selection. |
5440 The registered nurse must delegate care of an Correct answer: 4 Factors to consider when delegating care include complexity of task, problem‐solving assigned client to an unlicensed assistive person (UAP) innovation required, unpredictability, and level of client interaction. The client in option 4 is for the shift. Which of the following clients would be best because this client is likely to be stable with a low level of unpredictability. The client in best to delegate to the UAP? option 1 requires a high level of client interaction. The client in option 2 represents a more complex client. The client in option 3 represents a client who would benefit from problem‐ solving innovation.
| The core issue of the question is basic concepts that are useful when considering delegation to a UAP. Use this knowledge and the process of elimination to make a selection. |
5441 Which of the following tasks would not be Correct answer: 3 The decision to delegate should be consistent with the nursing process (appropriate appropriate for the registered nurse to delegate to assessment, planning, implementation, and evaluation). The person responsible for client licensed practical nurses (LPNs) or unlicensed assistive assessment, diagnosis, care planning, and evaluation is the registered nurse. LPN functions personnel (UAPs)? include reinforcing teaching and removal of dressings. Assistive personnel may perform simple nursing interventions, but the registered nurse remains responsible for analyzing the data and the client outcome.
| The core issue of the question is the knowledge related to delegation of nursing tasks. Options 1, 3, and 4 are all within the scope of responsibilities of the assigned nursing personnel. UAPs cannot practice nursing. They cannot be delegated to assess or evaluate responses to treatment. |
5442 Nurse leaders have an obligation to find new ways to Correct answer: 4 The purpose for using UAPs in acute care settings is to control cost and free registered nurses deliver needed nursing care services within new from duties, primarily non‐nursing duties. This allows time for registered nurses to complete payment structures and cost‐cutting strategies. What assessments of clients and evaluate their potential response to treatments. measures can the nurse leader take in an acute care setting to reduce the cost of health care?
| Choose option 4 because personnel costs are the highest burden placed on health care institutions. By using UAPs, many institutions decreased their personnel budget and reduced significant costs. Eliminate option 2 because most health institutions have implemented quality improvement programs to improve client satisfaction and reduce risk first and then to save costs as a secondary factor. Then eliminate option 3 because it is incorrect. Acute care hospitals have increased the nurse–client ratios. |
5443 The charge nurse on the night shift reports that the Correct answer: 3 An incident report must be completed because of the inaccurate narcotic count. Narcotics are narcotic count is incorrect. The nurse has already controlled substances and fall under federal law and regulation. Both the pharmacy and spoken to the staff nurse believed responsible for the nursing administration must be notified. If the staff nurse is found to be using a controlled incorrect count and has reason to believe that substance, this finding must be reported to the state board of nursing. Individual state boards substance abuse by the nurse is the cause. If substance of nursing identify the legal boundaries of nursing practice, including disciplinary action, abuse by the staff nurse proves to be the cause of the through nurse practice acts (which differ among the states). The American Nurses Association, incorrect count, what is the most appropriate next through the Code of Ethics for Nurses, provides guidance to nurses and protection for clients step? and their families but does not have the authority to discipline nurses.
| The core issue of the question is an understanding of the nature and purpose of professional nursing organizations and institutions. Each state board is responsible for the regulation of nursing and articulates the principles for delegation and disciplinary action. Options 1 and 2 represent actions that a nurse manager would have to take to protect the public good. The functions of professional nursing organizations do not include statutory laws but rather ethical codes of conduct for both nursing students and professional nurses. Option 4 refers to professional organizations like ANA who may have a Council on Nursing Practice that strives to develop standards of practice for professional nurses. |
5444 The nurse manager has the responsibility to transfer Correct answer: 1 A key behavior in delegating tasks is to provide the delegatee with a reason for the task. or delegate to competent staff the authority to Option 2 is incorrect because the nurse manager should delegate a task for the right reason perform a selected task in a selected situation. Which and not because the task is time‐consuming or undesirable. Option 3 is incorrect: Delegating of the following statements would be important for performance evaluations is inappropriate because they contain private and confidential the nurse manager to make when delegating a information. This task is solely the responsibility of the nurse manager and cannot be responsibility? delegated. Option 4 is incorrect because the delegatee should be assigned a task that meets her abilities.
| The core of the question deals with the delegation process. Delegation is transferring to a competent individual the authority to perform the task. |
5445 A quarterly audit is now due to assess the Correct answer: 1 When people accept change, they integrate it into their routines and the change is implementation of an electronic medical record maintained. Verbalizing, mentally rehearsing the change before agreeing to a pilot or trial, or system for client documentation on your unit. As the even trying out the change are not indications that an individual has accepted the change. nursing unit representative who supervised the adaptation of this documentation system, how can the nurse determine if nursing staff members have accepted this change of the electronic medical record?
| Resistance to change is expected. The best way to know whether change has occurred is to witness it. Through observing how staff members adapt to the change by integrating into daily nursing assignments, the nurse manager knows for sure that the change has been accepted. Options 2, 3, and 4 do not illustrate that true change has occurred; actions speak louder than words. |
5446 As a member of the hospital quality improvement Correct answer: 3 Patient satisfaction surveys are an important tool to monitor and evaluate patient and family team, the nurse has been asked to evaluate the quality needs. This information helps health care organizations meet those needs. Options 1, 2, and 4 of nursing care on the unit. The nurse has decided to are extremely helpful but do not improve patient satisfaction and outcomes. Tracking supplies, ask the nursing staff for assistance in this endeavor. documenting nursing time, and reporting on patient acuity provide information that can be Which of the following would be appropriate to ask used in preparing a budget or unit staffing requirements. the nursing staff to do?
| The core issue of the question is quality management. The purpose of quality management is to improve performance and meet client needs. The best way to assess client satisfaction is to ask the client directly. Established standards of practice, policies, and procedures safeguard clients and protect them from potential injury and harm. Quality management programs seek to ensure quality care and improve client satisfaction. |
5447 As the registered nurse (RN) accountable for the Correct answer: 2 Assignment making requires that the nurse assess the education, skill, knowledge, and delegation of nursing care activities for the shift, what judgment levels of the staff being assigned to the task. This means that the nurse must know must the nurse consider in determining the the functions of all personnel in delegating tasks, including the appropriate use of a UAP and appropriate use of an unlicensed UAP? LPN. Option 2 requires that the nurse understand the complexity of the nursing task before delegating it. Option 1 is incorrect because it is not the support but the amount of supervision the RN can provide that must be considered. Option 3 and 4 are incorrect because the UAP cannot provide total nursing care or perform a client care assessment.
| The core issue of the question is the delegation process. The nurse must always assess the client situation first. Know the skills and comfort level of the person to whom you are delegating. |
5448 A staff nurse decides to attend a continuing education Correct answer: 3 Staff education is essential to maintaining clinical competence and patient safety; therefore, class on the use of advanced technology in health care options 1 and 2 are incorrect. Information technology is important to all nurses, not just to delivery. The nurse manager should interpret this nurse managers, to organize and manage nursing and health care delivery. Option 4 is participation in staff development and continuing incorrect as well. education as which of the following?
| The core of the question is understanding the impact of advanced technology on patient care and its underlying costs. Use general nursing knowledge and the process of elimination to make a selection. |
5449 Authority occurs when a person has been given the Correct answer: 2 The manager must feel worthy of the authority granted, and self‐doubt can undermine this right to delegate, based on the state nurse practice authority. Self‐doubt is shown by being unsure. Options 1, 3, and 4 are all positive act, and also has official power to delegate from the characteristics and attributes of a good manager. health care organization. Which characteristic of a nurse manager could undermine this authority in the workplace?
| The core of the question is knowledge about having and using authority. Nurse managers are given formal authority upon appointment to the position by the organization. It is critical that nurse managers accept this authority and learn how to apply the power that comes from the appointed position. |
5450 As a newly appointed charge nurse, the nurse has Correct answer: 2 A preceptor is an experienced nurse who assists someone new in learning his job. Asking decided to assess the skills and competencies of all others to keep an eye on the new nurse does not ensure learning. Pointing out weaknesses new nursing personnel assigned to your unit. What can after a staff meeting does not help the orientee become aware of learning needs. Learning the nurse do to help these new personnel learn their without interference does not ensure correctly learning the unit s expectations. job duties and responsibilities?
| The core issue of the question is knowledge about the skills and competencies of the nurse manager. A nurse manager at any level, including charge nurse, is responsible for meeting the organizational needs. In order to meet this objective, the nurse must ensure all personnel are fully competent to carry out their job duties and functions. |
5451 An RN is about to make first rounds after receiving an Correct answer: 3, 5, 1, Priority setting can be implemented using a variety of models. The client who is postoperative intershift report at 3 p.m. In what order should the RN 4, 2 should be seen first because the client is newly arrived on the unit and is at greatest risk of see the following clients? Click and drag the options becoming unstable or experiencing a change in clinical condition. The client with pneumonia below to move them up or down. should be seen next because the infection involves the airway, although oxygen saturation levels are higher than the critical value of 90% or less. The client who is 4 hours post–cardiac catheterization should be seen next to evaluate the site and conduct general assessment of the affected extremity. The client who will be discharged should be seen next to determine that there are no last‐minute needs or issues. The client who needs teaching should be seen last because this is not a physiological need.
| Determine which client is at greatest risk of becoming unstable to pick client 3, followed by assessing the client whose airway is potentially at risk (client 5). The client with the cardiac catheter could become unstable but has been on the unit for 4 hours, so this client can be seen third. The client scheduled for discharge should be checked fourth, because of time it will not take long to address any remaining issues or concerns. The client needing teaching will need the most time and can be planned for last. |
5452 A client is experiencing respiratory distress. Correct answer: 2 This client’s condition is deteriorating. The nurse has to work quickly to prepare this client for Respirations are 32 bpm and shallow. The client is stat medication orders. When a client’s condition is deteriorating, the nurse needs a lot of positioned in an orthopneic position, with a heart rate support, especially from experienced nurses. The assigned nurse should complete a head‐to‐ of 118 and a blood pressure of 90/40. The client is pale toe assessment. The nurse assigned to the client knows more about the client than other and confused. Which task should the nurse delegate to nurses on the floor do, and can determine a change in the client’s status. The application of the charge nurse? oxygen is a task for the nurse assigned to the client. Given the information provided in the scenario, the nurse should apply the oxygen immediately to rectify low oxygen levels. The unit secretary could page RT to the room stat for assistance. The charge nurse should be used to complete a task within the RN’s scope of practice, such as starting an intravenous line.
| Use knowledge of scope of practice and delegation to select the correct answer. |
5453 A registered nurse (RN) delegates complicated wound Correct answer: 2 In this scenario, the LPN clearly has authority to change the dressing. The RN has care to an LPN. The LPN has only changed this type of communicated the task to the LPN; however, the RN does not relinquish the responsibility of dressing once. What component of delegation has the the delegated task to the LPN. The RN did not consider the LPN’s skills and knowledge with registered nurse neglected? regard to complicated dressing changes.
| Use knowledge of scope of practice and delegation to select the correct answer. |
5454 A nurse is beginning the shift overwhelmed by many Correct answer: 1 The scenario does not imply the nurse is disorganized or that the work environment is hostile. tasks. The staff has been working short for months, The nurse is not incompetent. Due to the lack of health care workers, the nurse is handicapped and the nurse has been unable to delegate tasks to in the ability to delegate. The nurse cannot delegate tasks to staff, because people are not other qualified individuals. Which type of barrier available. prevents the nurse from delegating?
| Use knowledge of delegation barriers and the process of elimination to select the correct answer. |
5455 A nurse is assisting a client in room 1 with lunch. The Correct answer: 2 The nurse should stop feeding the client in room 1, and medicate the client in room 3. While charge nurse calls the nurse and reports the client in eating is a priority, it does not take precedence over an individual with pain. The client in pain room 3 is complaining of pain and requesting pain is experiencing discomfort that should be addressed immediately. The task of feeding the medication. What is the nurse’s best and first action? client in room 1 can be delegated, but it should be delegated to an appropriate person, such as the nursing assistant. The charge nurse is busy overseeing the functions on the unit.
| Use knowledge of prioritization and delegation to select the correct answer. |
5456 A nurse is preparing for a long day on a medical floor. Correct answer: 3, 5 The RN should irrigate the nasogastric tube and flush the clogged urinary catheter; these The registered nurse (RN) has many tasks to complete. tasks are not in the unlicensed assistant’s scope of practice and job description. A BP of 100/60 Of the following tasks, which may be delegated to an is normal, and does not warrant further follow‐up at this time. A client with an infected wound unlicensed assistant? Select all that apply. should have the dressing changed by the registered nurse for assessment of effectiveness of wound therapy and complications. The unlicensed assistant can measure and record the urine output, although the RN would need to make further assessments about the client’s status. In general, the RN should perform any task that might require assessment skills and critical thinking for solving problems.
| Use knowledge of delegation and the process of elimination to select the correct answer. Recall that the RN makes client assessments, engages in problem solving, and does client teaching as key roles. |
5457 A nurse is preparing for a long day on a medical floor. Correct answer: 2, 4 The scope of practice for LPNs allows them to flush Foley catheters and change dressings on The nurse has many tasks to complete. Which tasks diabetic ulcers. Blood administration should not be delegated to an LPN due to the may be delegated to an LPN? Select all that apply. complications that could arise during the transfusion. While LPNs are allowed to irrigate nasogastric tubes, in this case the client has had a colectomy, and could have complications; the RN should perform this task. The client with a BP of 100/60 does not need to have vital signs rechecked at this time.
| Use knowledge of delegation and scope of practice to select the correct answer. |
5458 The delivery of care system on a medical floor is team Correct answer: 2 In this case, the delivery care system is team nursing. Due to scope of practice and the nursing. On wing A, there is an RN/LPN team to care registered nurse’s ability to problem‐solve and think critically, the registered nurse should for eight clients. Which tasks should be delegated to check vitals and assess the postoperative client, and assess both stable clients. However, the the LPN? nursing assistant should check vitals and complete bed baths on the clients. The LPN may check vitals and give bed baths, but the skill set of the LPN is better utilized in providing wound care and medications for the clients.
| Use knowledge of delegation and scope of practice to make the correct answer. |
5459 A nurse is delegating care of clients to the certified Correct answer: 1 The scope of practice and most job descriptions for certified nursing assistants include vital nursing assistant (CNA) and licensed practical nurse signs. It is within the scope of practice for the LPN to administer oral medications. The best (LPN). Which tasks should the nurse give the CNA and answer option is 1. In some facilities, certified nursing assistants are allowed to change LPN? dressings; however, changing a client s dressing gives the registered nurse the opportunity to assess the incision, and it is the registered nurse s responsibility to assess the client. Nursing assistants are allowed to ambulate clients; however, LPNs should not assess clients or complete admission paperwork on new clients.
| Use knowledge of delegation and scope of practice to select the correct answer. |
5460 A nurse is preparing for the day, and makes a list of Correct answer: 4 Due to the risk for aspiration, the nurse should feed the client with dysphagia. The nurse delegated tasks for the unlicensed assistant (UA). should monitor drainage from a chest tube for characteristics of exudate being removed from Which task should the nurse delegate to the UA? the client’s thoracic cavity. When a client has an elevated or low blood pressure, the nurse should recheck and assess the client for validity of information and changes in status. Of the four answer options, option 4 is the best choice. The UA is qualified to turn a client with multiple sclerosis and severe weakness.
| Use knowledge of delegation and the process of elimination to select the correct answer. |
5461 A nurse assesses a client and finds the client is using Correct answer: 4 In this scenario, the client is in distress, so the nurse should stay with this client and call for accessory muscles to breathe; respirations are 27 bpm. help from other members of the team. The charge nurse has expertise in handling Two hours previously, this client was eupneic. What emergencies, and the CNA can obtain the equipment necessary for assessment. Nurses caring should the nurse do next? for a client in distress should reassess the client s vitals. In emergencies, the nurse should handle tasks such as taking vitals and obtaining oxygen saturation levels. In this case, the nurse wants to check not only the oxygen level but also the vital signs. The nurse should never leave the room of a client in distress.
| Use the ABCs of prioritization and delegation principles to select the correct response. |
5462 An LPN is assigned six clients. One client is receiving Correct answer: 3 The administration of IVP morphine for the client with pain is within the scope of practice for IV push morphine for left shoulder pain rated as 7 on a the registered nurse, but not in the scope of practice for the LPN. While the administration of scale of 0–10; the second client has an oral order of oral medications for the client with CHF is in the scope of an LPN, this client might need digoxin (Lanoxin) and furosemide (Lasix) for congestive comprehensive assessments due to the pathophysiology of CHF. The administration of heart failure (CHF); the third client is stable, and has vitamins for the client with wounds is in the scope of practice for the LPN; the client is stable, vitamins ordered to improve wound healing. What task and does not require immediate assessment. should the LPN request be completed by the registered nurse?
| Use knowledge of delegation and the process of elimination to select the correct answer. |
5463 A registered nurse (RN) who is the charge nurse for Correct answer: 2 A client with sickle‐cell anemia who requires pain medications every three hours needs the shift is making assignments for the day. Which of frequent observations and assessments. Due to the RN’s ability to problem‐solve and think the following should be assigned to the licensed critically, this client should be assigned to a registered nurse. A 76‐year‐old client with a practical nurse (LPN)? chronic condition, type II diabetes, exacerbated by an acute condition, pneumonia, might have many changes in status and require more care. A sickle‐cell client with a hemoglobin of 6.4 grams/dL might need a blood transfusion, and has unpredictable outcomes. The RN should care for clients with unpredictable outcomes. The RN should have this client. The four‐day postoperative client who will be discharged today is stable. The client’s outcomes have been met. The LPN could provide the care of this client.
| Use knowledge of delegation and the process of elimination to select the correct answer. |
5464 A nurse manager finds a licensed practical nurse (LPN) Correct answer: 1 In this scenario, various members of the nursing team are performing different elements of performing wound care and venipunctures; another client care on the unit, a characteristic of task nursing. When primary nursing is utilized, the LPN is administering oral and IV piggyback nurse assigned to the client performs most of the duties for the nurse’s assigned clients. In medications. Registered nurses (RNs) are completing team nursing, a team of an RN and an LPN or CNA provides care to a group of assigned clients. assessments. The charge nurse is administering IV push Operational nursing is a distracter. medications. What care‐delivery model is being utilized in this nursing unit?
| Use knowledge of delivery of care systems and assessment to select the correct answer. |
5465 The nursing supervisor calls the charge nurse of a Correct answer: 2 Of the answer options, the best option is 2; the skilled RN should get the postoperative client medical–surgical unit and informs the charge nurse with the hip replacement and the abdominal hysterectomy. Postoperative clients are critical that clients from the Emergency Department (ED) and clients due to the risk for hypervolemia and shock. The experienced nurse should receive the operating room (OR) will be admitted to the surgical clients. The RN on orientation should care for the clients with medical conditions such medical–surgical unit. The ED is sending two clients to as CHF, hypertension, and diabetes. In this case, the LPNs should assume duties such as vital the medical unit: a client with hypertension and an signs and assisting with ADLs. exacerbation of heart failure, and a client with pneumonia who has a history of diabetes. The OR is transferring a client who had a total abdominal hysterectomy and a client with a hip replacement. How should the charge nurse assign these clients to a staff of two RNs (one on orientation) and two LPNs?
| Use nursing knowledge and knowledge of client assignments to select the correct response. |
5466 A client has an old cerebrovascular accident (CVA) Correct answer: 2 The charge nurse does not need to assume total care for these clients. In this case, the charge and requires assistance with ADLs. The client is being nurse needs to assist in the care of these clients. The charge nurse should administer the IVP treated for a urinary tract infection (UTI) with pain medications. The LPN can administer the IVPB medications and provide wound care. The intravenous antibiotics and IV push pain medication. CNA should not perform wound care, because CNAs are not trained to assess wounds. The client has wound care twice a day. Which tasks should the LPN delegate to the CNA and charge nurse?
| Use knowledge of delegation and the process of elimination to select the correct answer. |
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5467 The nurse manager reports to the charge nurse that Correct answer: 4 In team nursing, a small group of nursing staff provides care to a small group of clients. In task the new method of delivery on the unit is team nursing, each member of the nursing team has to perform specific tasks for clients on the unit. nursing. On the unit, a nurse observes the following: Operational nursing is a distracter. In primary nursing, the nurse assigned to the clients On each wing, there is an RN/LPN or RN/CNA pair that assumes the majority of care for most of the clients. provides care for a group of eight clients. The nurse should label the delivery system as:
| Use knowledge of delivery care systems and delegation to make the selection. |
5468 A nurse is caring for a client with an unsteady gait. Correct answer: 2 The nurse should complete an incident report, and document the fall in the client s chart. The The client was found by the unlicensed assistant (UA) nurse should never place an incident report in the client s chart. The incident report is an on the floor. The client is complaining of hip pain. How internal tool to monitor incidents within the facility. A copy of the incident report does not should the nurse document this incident? enter the nurse s record, and the client s caregiver does not receive a copy.
| Use knowledge of delegation and the process of elimination to select the correct answer. |
5469 An obstetric nurse is floated to a medical unit to care Correct answer: 1 The float nurse should receive clients who are not compromised by chronic conditions for a group of acutely ill clients. The charge nurse exacerbated by acute conditions. The float nurse should not receive postoperative clients, due should assign which group of clients to the float nurse? to their high acuity. Generally, geriatric clients can have fluctuations in status, placing them at higher risk for complications, which is not an ideal situation for the float nurse. The float nurse’s expertise is in obstetrics; the care of medical–surgical clients will be new to the nurse. The charge nurse should not overwhelm the float nurse. The best selection is option 1.
| Use knowledge of delegation and the process of elimination to select the correct answer. |
5470 A nurse receives a call from a client s son, who is Correct answer: 3 Health Insurance Portability and Accountability Act (HIPAA) regulations do not permit health requesting specific information about the client s care workers to disclose information about a client unless the client has signed a release‐of‐ diagnosis for “insurance purposes.” How should the information form. The nurse does not have a method to verify the person s identity over the nurse respond to the client s son? phone. The nurse should respond truthfully in an effort to make the son aware of confidentiality policies, but the nurse should respond using a mild tone.
| Use knowledge of communication and the process of elimination to select the correct response. |
4.‐ “I can describe for you your mother’s surgical procedure, but that is all.” | |
5471 A nurse plans to delegate some responsibilities of Correct answer: 3 The best choice is to assign the LPN to change the client’s dressing. The nursing assistant may client care to a licensed practical nurse (LPN). Which ambulate the client and provide AM care. However, the registered nurse should perform all task should the nurse delegate to the LPN? assessments. The registered nurse is skilled in assessment and in providing care to those with unpredictable outcomes.
| Use knowledge of delegation and the process of elimination to select the correct answer. |
5472 A registered nurse must complete an admission Correct answer: 2 The nurse has delegated a task that is not in the nursing assistant’s scope of practice and job assessment on a postoperative client. The nurse description. Moreover, this client is a fresh, postoperative client; the incision should be delegates to the unlicensed assistant the incision care assessed by the registered nurse to detect wound complications. Supervision and on a clean wound. Which element of delegation has communication are not breached. the nurse neglected?
| Use knowledge of elements of delegation and the process of elimination to make the correct selection. |
5473 A nurse has delegated a venipuncture to an Correct answer: 1, 4, 5 The nurse has delegated a venipuncture to a nursing assistant who is not comfortable unlicensed assistant (UA) who has been off orientation providing the skill. Though the task is permissible, venipuncture is not the right task for this for five days. The UA reports to the nurse, “This client nursing assistant. Supervision also was neglected. The nurse assigned a task at which the has a large, raised red area where the needle was nursing assistant was weak, and did not provide supervision. And last, skill was breached. The inserted.” The nurse assesses the area and finds the nursing assistant is not skilled in providing venipunctures. Communication and circumstances client has a hematoma. What elements of delegation are adequate. have been breached? Select all that apply.
| Use knowledge of delegation and the process of elimination to select the correct answer. |
5474 A nurse is late in performing care to some assigned Correct answer: 3 A misconception of many nurses is thinking they do not need help. Nurses are often hesitant clients. The charge nurse recommends delegating to ask for help because they are seen as heroes who do everything for everyone. However, in some tasks to another nurse or CNA. The nurse this case, the nurse is not receiving support from Administration. The nurse does not have responds, “I ll catch up; I can handle it.” The charge enough staff available to delegate tasks. The scenario does not support an answer of nurse then counsels the nurse about which delegation disorganization or inexperience. barrier?
| Use knowledge of delegation and the process of elimination to select the correct answer. |
5475 A charge nurse is attempting to complete the work Correct answer: 1 The charge nurse should delegate the administration of IV pain medications to another RN. schedule; however, the charge nurse also is tasked The staff nurses in this scenario all are busy. The administration of blood and chemotherapy with two clients. Each nurse on the floor has six clients, will pull the other nurses away from their clients for a lengthy period. The work schedule also and they are busy with client care. Which tasks should is time‐intensive, and requires familiarity with the staff and scheduling. The IV push the charge nurse delegate to another registered nurse medications will require less time from the other nurses, and therefore are the best option. (RN)? | Use knowledge of delegation and the process of elimination to select the correct answer. |
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5476 A nurse manager is changing the medication Correct answer: 3 The nurse manager should communicate the instructions for the development of the new administration system on the floor. The nurse manager policy clearly. The task is clear, and the person to perform the task is appropriate, but the delegates the development of the new medication intricate details surrounding the policy should be explicated. The right circumstances are administration policy to the charge nurse. The nurse demonstrated in this scenario. manager must provide which pertinent element of delegation to ensure the charge nurse understands the task?
| Use knowledge of delegation and the process of elimination to select the correct answer. |
5477 A nurse manager has many tasks to complete in a few Correct answer: 1 A function of the nurse manager is to develop and present the unit’s budget to the CFO; the days. Which task should the nurse manager delegate nurse manager should handle this task. Another role of the nurse manager is to hire and to the charge nurse? terminate employees. The nurse manager should interview prospective nurses either in isolation or in concert with the charge nurse, but it should not be delegated. Attending the management meeting is a function of the nurse manager. The task that should be delegated is the completion of the work schedule. This task is within the scope of the charge nurse.
| Use knowledge of delegation and the process of elimination to select the correct answer. |
5478 A nurse manager has to compile some nursing unit Correct answer: 3 The nurse manager must consider the charge nurse s competence level in completing the quality improvement data during the next few days. work that may be assigned. The task of compiling data would clearly be within the scope of When considering whether to delegate some of this practice for the charge nurse, so this is not a priority consideration. The nurse manager is work to the shift charge nurse, what component of giving the charge nurse authority to complete the work schedule, so that is not an issue. delegation must the nurse manager consider as the Clinical skills are not required to complete compilation of quality improvement data. priority?
| Use knowledge of delegation and the process of elimination to select the correct answer. |
5479 A nurse delegates to an unlicensed assistant (UA) the Correct answer: 1 The nurse must provide feedback and evaluate performance to ensure the BG checks are task of blood glucose (BG) monitoring, which must be completed every two hours. The nurse does not need to watch the UA to see that the BG done every two hours. What critical component of checks are done; this defeats the purpose of delegation. The purposes of delegation are to delegation by the nurse is necessary to ensure the allow the person who is assigned the delegated task to operate at his fullest level and to allow measurements are completed every two hours? the individual delegating the task time to perform other critical tasks. The nurse gives the UA authority to complete the task; authority is not limited. Rotating BG checks limit the UA s authority to complete the job.
| Use knowledge of delegation and the process of elimination to select the correct answer. |
5480 A charge nurse is supervising the work of a new Correct answer: 1 The charge nurse should tell the nurse to delegate tasks based on the task and the skill of the registered nurse (RN). The new nurse is asking for help LPN. When delegating, the nurse should provide feedback, but constant feedback sends a with delegating tasks to licensed practical nurses negative message to the person to whom the task has been delegated. In option three, the (LPNs). How should the charge nurse respond? term only is used, which is a good indicator this option is not the right choice. Nurses may delegate care provided by the nurse. In fact, the nurse may perform most of the tasks delegated, but the nurse does not have time to provide these tasks. The responsibility of the tasks rests with the nurse; however, the LPN is given authority to complete the task.
| Use knowledge of delegation and the process of elimination to select the correct answer. |
5481 A nurse assesses a client and finds an irregular heart Correct answer: 3, 4, 5 The nurse should delegate venipuncture to the phlebotomist. The electrocardiogram may be rhythm. The nurse completes the assessment and finds delegated to the Respiratory Therapy department, and the vital signs may be delegated to the client diaphoretic with pyrosis. The nurse calls the someone on the nursing staff. The nurse caring for the client should administer the health care provider and receives orders for an medications and continue to assess the client. The nurse assigned to the client has a baseline electrocardiogram, cardiac panel, morphine 2 mg IV of the client s condition, and can attest the changes in status. push, nitroglycerin 0.1 mg sublingual, and aspirin 325 mg chew and swallow. Which tasks should the nurse delegate? Select all that apply.
| Use knowledge of delegation and the process of elimination to select the correct answer. |
5482 A nurse assesses a client and finds an irregular heart Correct answer: 4 This client is in distress. The nurse needs immediate assistance. In this case, the best person rhythm. The nurse completes the assessment and finds to whom to delegate these tasks is the charge nurse. The nurse needs support and someone the client diaphoretic with pyrosis. The nurse calls the with skilled expertise to help provide the rapid care this client needs to prevent cardiac arrest. health care provider and receives orders for an The charge nurse is well versed on the policies, procedures, and emergency actions of the unit. electrocardiogram, cardiac panel, morphine 2 mg IVP, An unlicensed assistive personnel and the licensed practical nurse are both capable of nitroglycerin 0.1 mg sublingual, and aspirin 325 mg. providing these duties; however, client assessment falls outside their scopes of practice. A The best person to whom to delegate venipuncture, registered nurse is also capable of providing these skills, but the registered nurse needs to electrocardiogram, and vital signs is a: cover the floor and care for the other clients on the unit.
| Use nursing knowledge, knowledge of delegation, and the process of elimination to make the correct selection. |
5483 A nurse is assessing a client who has a serum glucose Correct answer: 1 The client is asymptomatic; there is a possibility this lab value is erroneous. The first action is of 35 mg/dL. On assessment, the client is alert and to redraw the serum glucose. The health care provider should be notified after the serum oriented; skin is warm to the touch and dry, and no glucose is confirmed. The nurse should not administer an amp of D50 without an order from distress is noted. What is the nurse’s next action? the health care provider. The nurse should review the client’s medication record, but this is not a priority at this time.
| Use assessment skills and nursing knowledge to select the correct response. |
5484 A nurse is assessing a client who has a serum glucose Correct answer: 1 This client needs a venipuncture for serum glucose. The nursing assistant may perform this of 65 mg/dL. On assessment, the client is alert and task. The client is not in distress, so it is appropriate to allow the nursing assistant to draw the oriented x 4; skin is warm to touch and dry, and no blood. The nursing assistant should not notify the health care provider of the serum glucose or distress is noted. What task should the nurse delegate review the medication record. The nurse should perform these duties. The nursing assistant to the nursing assistant? may give orange juice, but the client’s serum glucose must be verified prior to such an intervention.
| Use nursing knowledge and knowledge of delegation to select the correct answer. |
5485 A charge nurse observes a staff nurse accessing a Correct answer: 3 The staff nurse has clearly breached HIPAA (Health Insurance Portability and Accountability client s financial record. The staff nurse is not assigned Act) regulations regarding client confidentiality. This infraction should be addressed with the to the client. What action or actions by the charge staff nurse immediately. The nurse’s best and first option is to approach the nurse and review nurse are priorities? the HIPAA regulations. Once this is accomplished, the charge nurse then should discuss this with the nurse manager, who will make the decision to discipline the staff nurse. An incident report is not necessary; however, an anecdotal note should be written. The charge nurse should not take any disciplinary actions such as issuing warnings and termination; the nurse manager should carry out disciplinary actions.
| Use nursing knowledge and the process of elimination to make the correct selection. |
5486 A nurse is assigned four clients, all of whom have Correct answer: 2 This nurse clearly is not managing time very well. Typically, a nurse listens to report first, multiple chronic illnesses exacerbated by acute takes a quick peek at the assigned clients, reviews AM lab results, checks the MAR, and conditions. On arrival to the floor, the nurse spends proceeds from there. This nurse is meandering around wasting invaluable time. The concepts time drinking coffee, talking with co‐workers, and of communication, priority setting, and delegation are not applicable in this scenario. The stem reading e‐mail messages. What work‐related concept of the question is focused on the nurse’s time‐wasting behavior. has this nurse breached?
| Use knowledge of time management and the process of elimination to make the correct selection. |
5487 A registered nurse (RN) working on the medical unit Correct answer: 1, 3, 4, The nurse should start the day by listening to report. This allows the nurse to receive arrives at work 15 minutes late. The nurse is assigned 2 information about the status of each client. The next action is to check the clients. The nurse five clients, and an admission is on the way. Place in should check on each assigned client to determine the current status of each client. The goal of order of priority how the nurse should complete the checking each client at the beginning of the shift is to make sure distress is not present. Once following activities at the beginning of the work shift. the nurse has checked each client, the nurse should review AM labs. This information gives the Click and drag the options below to move them up or nurse pertinent information that helps plan the day and detect subtle changes in the client’s down. status, which allows earlier treatment and preventative interventions. Lastly, the nurse should review the MAR to detect priority medications. The laboratory results can impact the medications given, which is why they need to be checked before the MAR.
| Use knowledge of time management and the process of elimination to make the correct selection. |
5488 A client with chronic obstructive pulmonary disease Correct answer: 3 The ABCs of care apply in this case. Emergency inhalers and emergency procedures take (COPD) requires education on the detrimental effects precedence over dietary implications and oral medications. Typically, people with COPD do not of the disorder. Which topic is a priority for this client? have atrophied respiratory muscles. The pathophysiology is at the level of the alveoli, bronchioles, and bronchi.
| Use the ABCs (airway, breathing, and circulation) of care and the process of elimination to make the correct selection. |
5489 A nurse’s client is deteriorating. The client’s vitals are Correct answer: 1 The first action by the nurse is to elevate the HOB to allow the lungs to expand. The nurse BP of 96/58, heart rate 116, and respirations irregular then should check the client’s oxygen saturation level. Option 2 indicates lowering the HOB will at 28 breaths/minute. What action should the nurse increase the blood pressure; this supposition is false. Lowering the HOB theoretically should take first? elevate the blood pressure or prevent the blood pressure from dropping. Option 3 implies the application of oxygen will decrease respirations, but this is not true. The best answer in this case is option 1.
| Use the ABCs of prioritization (airway, breathing, and circulation) and the process of elimination to make the correct selection. |
5490 A client’s respirations are 32 and shallow. The nurse Correct answer: 3 The nurse needs an order from the health care provider to obtain an arterial blood gas or to auscultates breath sounds, and finds crackles in the stop the intravenous fluid. This client is receiving intravenous fluid at a “keep vein open” rate, lower right base. The client is receiving normal saline which should not contribute to fluid volume overload. The nurse first should check the client’s at 30 ml/hr. What is the next action by the nurse? oxygen saturation level and then call the health care provider with more comprehensive assessment data.
| Use nursing knowledge and strategies for prioritization to make the correct selection. |
5491 The nurse is preparing for a busy day on the unit. Correct answer: 1 Due to the safety risk of physical restraints, the nurse should assess the client in physical Which task should the nurse complete first? restraints first. The nurse then should check the dialysis schedule, which will provide the nurse with dialysis times for clients. The nurse then could change the surgical dressing. However, the nurse should not inform the client’s friend of the client’s condition, as this is a breach in confidentiality.
| Use nursing knowledge and strategies for prioritization to make the correct selection. |
5492 The nurse is preparing for a busy day on the nursing Correct answer: 3 The role of the charge nurse is to supervise and ensure proper functioning of the unit. An unit. Which task should the nurse ask the charge nurse appropriate task for the charge nurse is to check the dialysis schedule for all clients on the unit. to do? The nurse assigned to the client with physical restraints and the client with the surgical incision should assess these clients. The nurse should make every attempt to secure the client’s health information, which should not be disclosed to the client’s friend without permission.
| Use nursing knowledge and strategies for delegation to make the correct selection. |
5493 A nurse is caring for a client whose caregiver is Correct answer: 4 The nurse should make every attempt to actively listen to the caregiver’s concerns and unsatisfied with the client’s care. The caregiver is attempt to resolve them. The city police should not get involved with this case; the client is not yelling and screaming, “No one here cares about my threatening anyone. The client’s health care provider should be informed, but this is not a mom. I’m going to sue every one of you.” What action priority. Should the client refuse to allow the nurse to address the concerns, and continue the should the nurse take next? irate behavior, the nurse then should call Security. Overall, the nurse should resolve the issue.
| Use nursing knowledge and strategies for prioritization to make the correct selection. |
5494 A nurse is caring for a group of clients. One client is Correct answer: 4 The nurse should consider pressing issues such as surgeries first. The client who is scheduled scheduled to go to the operating room (OR) in one for surgery needs special preparation prior to the surgery. This is a priority that takes hour. The second client needs information on nursing precedence over the urine specimen, documentation, and client education. homes, and the third client needs to provide a urine specimen. The nurse has not documented on any clients. What should the nurse do first?
| Use nursing knowledge and strategies for prioritization to make the correct selection. |
5495 A nurse is caring for a group of clients. One client is Correct answer: 4 The nurse should delegate the retrieval of the urine specimen to the LPN. This task is in the scheduled for the operating room (OR) in one hour. LPN’s scope of practice, and constitutes appropriate use of staff. The nurse should prepare the The second client needs information on nursing client for the operating room and document care that has been provided. The charge nurse homes, and the third client needs to provide a urine could provide the client in need of information on nursing homes with this information. A specimen. The nurse has not documented on any registered nurse should provide client teaching. clients. What task should the nurse delegate to an LPN?
| Use nursing knowledge and strategies for delegation to make the correct selection. |
5496 A nurse is caring for a group of clients. One client is Correct answer: 3 The charge nurse could provide a client with nursing home information. The nurse providing scheduled for the operating room (OR) in one hour. care to these clients should complete client preparation for the operating room and The second client needs information on nursing documentation of care. The nurse or an LPN could collect the urine specimen. Providing a homes, and the third client needs to provide a urine client with information on nursing homes should be tasked to someone with some degree of specimen. The nurse has not documented on any teaching ability. This task is within the scope of the charge nurse and discharge planner, and clients. What task should the nurse delegate to the constitutes appropriate use of staff. charge nurse?
| Use delegation strategies to make the correct selection. |
5497 A client sustains a fall after admission to a medical Correct answer: 4 The nurse always should start with assessment; a head‐to‐toe approach is the easiest way to nursing unit. The client is reporting left hip pain. What remember what to assess first. The nurse should start the assessment with inspection of the action by the nurse takes priority? head for injuries and neurologic damage. Assessment of range of motion does not precede a head assessment. Vital signs and oxygen saturation levels may be taken after the assessment. The client might need an x‐ray based on the findings from the assessment, but it would be ordered after the assessment. | Use the nursing process and strategies for prioritization to make the correct selection. |
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5498 It is 0715, and a registered nurse (RN) receives report Correct answer: 4 The charge nurse should make a point to approach the staff nurse from the team perspective on a group of six clients. At 0730, the charge nurse and communicate the charge nurse’s role. A terse attitude could escalate the nurse’s notion to announces a new assignment because another nurse refuse more clients. The nurse has not taken report on the two additional clients, and is not has called out ill. The new assignment will increase the responsible for them. The charge nurse must be able to motivate the staff to accomplish the client load to eight clients per nurse. The nurse refuses unit’s goals, and the goal for each shift is safe, effective client care. A calm voice, supportive to accept report on two additional clients. The first and attitude, and advocacy on the part of the charge nurse will help accomplish the unit’s goal. best response by the charge nurse is:
it.” | Use therapeutic communication and the process of elimination to make the correct selection. |
5499 A nurse is preparing for a busy morning. The client in Correct answer: 2 The nurse should use the ABCs of care to help guide this decision. The client in bed 3 needs bed 1 has hemodialysis this morning. The client in bed furosemide (Lasix) to treat CHF, which is a respiratory and cardiac illness. All the other clients 2 has discharge orders. The client in bed 3 has can wait until the client in bed 3 is medicated. The client who is going to dialysis could be congestive heart failure (CHF), and needs furosemide assessed next, but does not take precedence over the client in CHF. The diabetic client with a (Lasix) IV push. The client in bed 4 is a 36‐year‐old with blood glucose of 156 should be seen next to administer the two units of insulin to prevent the type 2 diabetes mellitus and a blood glucose of 156 glucose level from rising. Lastly, the nurse should discharge the client who is ready to go home. mg/dL. What should the nurse do first?
| Use the ABCs (airway, breathing, and circulation) of care and the process of elimination to make the correct selection. |
5500 A nurse is prepared to administer 0900 medications. Correct answer: 2 The client with a potassium level of 2.8 mEq/L could go into a detrimental cardiac arrhythmia. Which medication should the nurse administer first? The client’s potassium level is critically low. This client should receive the potassium rider immediately. The montelukast (Singulair) is a maintenance medication, and can wait until after the potassium rider is administered. The client with an oxygen saturation of 95% does not need two liters of oxygen. This client’s oxygen saturation level is within the therapeutic range. The client with a BP of 108/66 might not need 50 mg metoprolol (Toprol). This medication could decrease the blood pressure below 100/50, so this is not urgent to give in relation to other actions.
| Use nursing knowledge and strategies for prioritization to make the correct selection. |
5501 The registered nurse (RN) who is in charge on the unit Correct answer: 4, 2, 1, The nurse in charge should start by assessing the client whose status is deteriorating to for the day is inundated with tasks. The supervisor 3 provide the client with the necessary care to improve status. The charge nurse then should needs four beds for Emergency Department (ED) assign beds for the supervisor so that order is maintained in other departments as well as the admissions, and two beds for postoperative clients. A charge nurse’s unit. The charge nurse then should perform rounds with the orthopedist, and client on the floor is deteriorating quickly. The lastly attend the 0800 meeting, if time permits. orthopedist is demanding the charge nurse assist with AM rounds, and an 8:00 A.M. meeting is scheduled. Rank the following duties in the order that they should be performed. Click and drag the options below to move them up or down.
| Use time management and the process of elimination to make the correct selection. |
5502 A nurse is preparing for a busy day on a medical Correct answer: 5, 1, 2, The first task to be completed by the nurse is the administration of blood products to the nursing unit. Prioritize the tasks by clicking and 4, 3 anemic client. This client is at risk for decreased tissue perfusion. The nurse then should check dragging the options below to move them up or down. the postoperative client with the nasogastric tube and irrigate the tube to ensure it is functioning properly. The urinary catheter should be flushed next; while it is not an urgent matter, it otherwise could cause some discomfort. The nurse then should proceed to the client with the diabetic foot ulcer. Dressing changes often are ordered a few times per day. This is not a medical emergency, but is a scheduled treatment. And lastly, the 30‐year‐old client could have vitals checked by the nursing assistant; the nurse does not have to perform this task.
| Use nursing knowledge and strategies for prioritization to make the correct selection. |
5503 After receiving intershift report, the registered nurse Correct answer: 4 The client with a magnesium level of 0.8 mEq/L is in danger of having seizures and tetany if it (RN) is aware that it will be a busy shift. Which task is a falls further, so this client is a priority. It is important to keep this client safe and prevent priority nursing action? seizure activity. A potassium level of 3.7 mEq/L is within the therapeutic range. The administration of potassium is not necessary. The client in option 2 is stable; the ABG results are normal. No intervention is warranted. Assessment of the diabetic foot ulcer can wait until after the nurse has administered the magnesium. The assessment of the foot ulcer is not a priority.
| Use nursing knowledge and strategies for prioritization to make the correct selection. |
5504 A nurse is caring for a group of clients. Which client Correct answer: 4 The geriatric client with dehydration and a low BP could go into multiple‐organ failure due to takes priority? fluid loss. The major organs might not receive adequate perfusion. This client is a priority over the other clients. The client in option 1 has a history of CHF; the stem does not indicate the client is actively in CHF. Most sickle‐cell clients have low hemoglobin levels. The stem does not specify lab values. The middle‐aged client with pneumonia is not in distress; the client with the low blood pressure is in physiologic distress, and needs immediate intervention.
| Use the ABCs (airway, breathing, and circulation) of priority of care and the process of elimination to make the correct selection. |
5505 A nurse reads this order: furosemide (Lasix) 40 mg IV Correct answer: 4 The question specifically asks for actions to prevent medication errors on the unit. Writing an push now. The nurse accidentally administers 80 mg. incident report does not prevent medication errors. Reviewing incidents and verifying the What action should the nurse manager take to prevent percent of medication errors on the unit provide statistical data to serve as the foundation for medication errors on the unit? the intervention. In option 3, there is a wrong answer followed by the right answer, making this option wrong. Calling the vice president of quality does not prevent medication errors. However, providing medication administration in‐services may decrease errors. Analyzing the causes of medication errors on the unit and developing in‐services for the nurses on the unit is the best response.
| Use nursing knowledge and strategies for prioritization to make the correct selection. |
5506 A nurse comes into work late the first two days of Correct answer: 4 The nurse manager needs to deal with the tardiness of the employee, and to focus on the one workweek. The nurses on the offgoing shift are behavior and expectations of employment. A work contract is a good method to measure the upset with this nurse. On the third workday of the nurse s behavior. The manager also should include repercussions of a breached contract. week, the nurse comes in late, again citing no child Options 1 and 3 are too extreme and are not consistent with generally accepted termination care as an excuse. Which of the following is the best procedures. Option 4 is better than option 2 because it is more complete in content. response by the nurse manager to this nurse?
| Note the critical word best in the question. This indicates that more than one option may be partially correct and that you must consider which is the most appropriate response. Use communication skills and strategies for prioritization to make the correct selection. |
5507 A nurse is planning for the work shift by assessing Correct answer: 3 The 3‐month‐old infant with bronchitis should be assessed first because infants go into assigned clients. Which client should the nurse assess respiratory distress quicker than older individuals due to their smaller airways. Infants cannot first? communicate distress, and distress often creeps up insidiously. A compromised respiratory status puts this client at the top of the assessment list. The 80‐year‐old client with pneumonia and weakness should be seen next due to a compromised respiratory status and weakness. This client’s condition could change rapidly. The postoperative client and the client with multiple sclerosis both have functional deficits that can wait until the 3‐month‐old infant can be assessed.
| Use the ABCs of priority of care and the process of elimination to make the correct response. |
5508 A client is receiving care for a diabetic foot ulcer. This Correct answer: 2 This is a diabetic client who has become diaphoretic, disoriented, and unsafe. These are client has type 2 diabetes mellitus and poor circulation classic symptoms of hypoglycemia. The nurse should check the client’s finger stick blood sugar to the lower extremities. The client becomes first. Assessment of vital signs every hour is not warranted in this case. The nurse needs to disoriented x 4, diaphoretic, and unsafe. The charge check the client’s finger stick blood sugar prior to implementing any interventions, including nurse recommends the use of chemical restraints. the application of wrist restraints. Chemical and wrist restraints should be a last option in any What is the nurse s priority action? case, but neither is warranted in this case.
| Use nursing knowledge and strategies for prioritization to make the correct selection. |
5509 A nurse is caring for a client with a total knee Correct answer: 1 The nurse may assess the client prior to blood administration and send the nursing assistant replacement (TKR) who needs a blood transfusion. The to the blood bank to obtain the blood. The vital signs should be checked before the blood is blood bank called, and the blood is ready. What action administered, and the UA may check the client’s vitals. Retrieving the blood from the blood should the nurse take first? bank is not a task the nurse must complete; this task may be delegated to the UA. Option 4 does not address the blood.
| Use nursing knowledge and strategies for prioritization to make the correct selection. |
5510 A staff nurse is receiving report on assigned clients. Correct answer: 1 The nurse is using the ABCs of priority to plan care for the day. The client with a pleural The client in bed 1 has congestive heart failure (CHF); effusion is not able to expand pulmonary fields 100%. A chest tube is inserted to drain the fluid the client in bed 2 has multiple pressure ulcers; the from the effusion. This client has a compromised respiratory system, making this client a client in bed 3 has a chest tube to treat a pleural priority. Priorities in medication therapy and client and family preferences are not being set in effusion; and the client in bed 4 has pneumonia. The this scenario. Time management is not being used, as the nurse is organizing the priorities by nurse decides to assess the client in bed 3 with a using the ABCs of care. pleural effusion and chest tube. What framework for determining priorities of care is this nurse using?
| Use the ABCs (airway, breathing, and circulation) of prioritization and nursing knowledge to make the correct choice. |
5511 A staff nurse is receiving report on assigned clients. Correct answer: 1 This nurse is basing the day on the ABCs of care. Oxygen saturation levels greater than 95% The client in bed 1 has CHF; the client in bed 2 has will prevent these clients from going into respiratory distress. Injury is also a priority, but multiple pressure ulcers; the client in bed 3 has a respiratory issues take precedence over injury. Pain and skin integrity fall behind safety on the pleural effusion with a chest tube; and the client in bed priority list. 4 has pneumonia. The nurse decides to assess the client in bed 3 with a pleural effusion and chest tube. The priority outcome for the day is:
| Use knowledge of the nursing process and the process of elimination to make the correct choice. |
5512 A nurse is caring for a client with an acute Correct answer: 4 In this scenario, the nurse is using priorities based on medication therapy. This client is in exacerbation of congestive heart failure (CHF). The respiratory distress, and requires medication immediately to prevent full heart failure and client’s respiratory rate is 28, pulmonary congestion. Administering this medication is a priority at this time due to the O<sub>2</sub> saturation level is 88% on client’s condition. Policies and procedures are not applicable to this scenario. Time is essential, room air, and the nurse auscultates crackles in the but the question specifically is asking for a framework for determining priorities. lower bases. The client has an order for furosemide (Lasix) 80 mg IV push now. Which framework for determining priorities of care should the nurse use as a guide?
| Use nursing knowledge and strategies for prioritization to make the correct selection. |
5513 A charge nurse is overseeing nursing care provided by Correct answer: 3 The nurse should start assessment with the 1‐month‐old infant. Infants are unable to a staff nurse. Which nursing action should the charge communicate problems, and their status can change rapidly. Frequent assessments and nurse question? observations are critical in detecting subtle changes in infants. Interventions must be implemented early and quickly to prevent detrimental effects of various disease processes. The nurse should delegate AM and vital signs to the nursing assistant. The continuous passive motion devices can be applied to a client with a knee replacement as a part of physical therapy. A very common intervention to relieve pressure over boney prominences is to turn clients every two hours.
| Use nursing knowledge and strategies for prioritization to make the correct selection. |
5514 A staff nurse is orienting a new nurse to the unit. The Correct answer: 1 The staff nurse should respond by instructing the orientee to make a to‐do list and prioritize orientee is overwhelmed by the many tasks required. to stay on track. Many experts in leadership and management recommend to‐do lists to help How should the staff nurse respond? organize tasks that must be accomplished throughout the day. Prioritizing the to‐do list is a method to allow the nurse to focus on tasks that require immediate attention first, then finish up with tasks that do not require immediate attention. The other options are examples of poor time management and barriers to time management.
| Use nursing knowledge and strategies for prioritization to make the correct selection. |
5515 A charge nurse from the rehabilitation unit is floating Correct answer: 3 The float nurse should get a quick orientation of the floor operation prior to receiving report. on the medical unit to fill in as charge nurse. This is the A quick orientation could alleviate tensions and fears the float nurse might have, and certainly nurse’s first time on the medical unit. What should the could save time. Once report starts, the shift officially begins, and the float nurse might not get charge nurse do first? an opportunity to get an orientation. After report is given, the float nurse should make client assignments for the staff. The charge nurse could review orders written by health care providers as the orders are written. This is not an immediate task.
| Use nursing knowledge and strategies for prioritization to make the correct selection. |
5516 A charge nurse from the rehabilitation unit is floating Correct answer: 1 The charge nurse’s responsibility is to make assignments for the nursing staff; this task should to the medical unit to fill in as charge nurse. This is the not be delegated. The charge nurse also should assess critically ill clients on the floor and make nurse’s first time on the medical unit. Which duty bed assignments for admissions. However, the charge nurse should delegate client care to staff should the charge nurse delegate? nurses. The charge nurse cannot care for all the clients on the floor. The role of the charge nurse is to supervise and assist the functions on the unit.
| Use nursing knowledge and strategies for delegation to make the correct selection. |
5517 A nurse is assessing a client, and auscultates an Correct answer: 2 The nurse is in the process of assessing the client; the next action is to complete the irregular, abnormal heart rhythm. What is the nurse’s assessment to detect other aberrant findings. The health care provider should be called after next action? the assessment has been completed, so the nurse can convey all aberrant findings. The health care provider might order an electrocardiogram after the nurse has communicated assessment findings. The health care provider could direct an order for a phosphate level when the nurse calls with assessment findings.
| Use nursing knowledge and strategies for prioritization to make the correct selection. |
5518 A nurse is making rounds after receiving report. The Correct answer: 2 The nurse should replace the fluid with the correct fluid immediately, to prevent the nurse observes the client is receiving the wrong detrimental effects of receiving the wrong intravenous fluid. Once the bag of fluid has been intravenous fluid. What is the nurse’s next action? replaced, the nurse should write an incident report and notify the physician of the error. The charge nurse and nurse manager should be alerted to the incident, but the first action is to replace the bag of intravenous fluid.
| Use nursing knowledge and strategies for prioritization to make the correct selection. |
5519 A nurse assesses a client who has an elevated blood Correct answer: 1 This client has classic heart failure symptoms. The client has an order for furosemide (Lasix) pressure, crackles in the lower bases, respiratory rate IVP; the nurse should administer the medication first to remove the extra fluid from the of 26, and an oxygen saturation of 89%. What is the client’s circulating blood volume. The physician does not need to be informed at this time. The nurse’s next action? nurse needs to administer the medication and monitor the client’s response to the medication. Should the client’s symptoms persist, the nurse should call the health care provider. The charge nurse does not need to verify the assessment findings in this case.
| Use knowledge of pathophysiology and medication administration to make the correct choice. |
5520 A registered nurse (RN) is assigned several clients. Correct answer: 3 The nurse should administer morphine IVP to the client in pain. This client is in an One client has IV push morphine for left shoulder pain uncomfortable state of pain, 7 of 10. This should be addressed immediately. The rated 7 on a scale of 0–10; the second has an oral administration of cardiac medications to the client with CHF should be addressed next, to order of digoxin (Lanoxin) and furosemide (Lasix) prevent symptoms of CHF. The administration of bolus enteral feedings should be addressed ordered for congestive heart failure (CHF); the third next to meet the basic physiologic need of this client. The administration of enteral feedings has vitamins ordered to improve wound healing; and a comes after the nurse administers cardiac medications, which are important in preserving fourth client needs a bolus of enteral feeding. What cardiac function. Vitamins typically are ordered daily. This is not an immediate priority. task takes priority?
| Use nursing knowledge and strategies for prioritization to make the correct selection. |
5521 A charge nurse has several requests from the nurse Correct answer: 2 The charge nurse does not have time to work on both the work schedule and in‐services manager. The nurse manager is requesting the charge simultaneously. The nurse should complete the schedule first, since it is due first, then nurse to develop in‐services for the staff on shared complete the in‐services second, but stop working overtime to get both jobs done governance. The charge nurse has been working satisfactorily. overtime weekly due to poor staffing. The charge nurse must complete the work schedule in two days, and the in‐services are due in four days. How should the nurse organize these tasks?
| Use knowledge of time management and the process of elimination to make the correct choice. |
5522 A charge nurse has several requests from the nurse Correct answer: 4 The charge nurse should not delegate either task, because these tasks were delegated to the manager. The nurse manager is requesting the charge charge nurse. One of the charge nurse’s duties is to complete the work schedule, a task not to nurse to develop in‐services for the staff on shared be delegated. governance. The charge nurse has been working overtime weekly due to poor staffing. The charge nurse must complete the work schedule in two days, and the in‐services are due in four days. What task should the charge nurse delegate?
| Use nursing knowledge and strategies for delegation to make the correct selection. |
5523 A nurse is caring for four clients on the unit. The Correct answer: 1 In this case, the nurse must consider the physiologic needs of the clients. The client in bed 4 client in bed 1 has a gastrointestinal (GI) bleed; the needs to have her physiologic needs met. Physiologic needs are addressed on the first level of client in bed 2 had a stroke a year ago; the client in bed Maslow’s hierarchy of needs. Moreover, the nurse must consider the ABCs of care; the client 3 has a blood glucose of 356 mg/dL; and the client in in bed 1 with the GI bleed could develop shock and renal failure, which speaks to the bed 4 is calling to get assistance to go to the ABCs—circulation. Option 1 offers a solution that addresses the client who needs to go to the bathroom. What is the nurse’s first action? bathroom and the client with the GI bleed. Option 2 is appropriate, but it does not address the client who needs to go to the bathroom. Option 3 is not an immediate priority. The nurse first should assess the client with a GI bleed due to the potential for severe blood loss. Option 4 does not address any of the pressing assessment issues. ADLs can wait until physiologic needs have been addressed.
| Use knowledge of Maslow s hierarchy of needs and the ABCs to select the correct answer. |
5524 A nurse is caring for four clients on the unit. The Correct answer: 1, 2, 4 The nurse should use Maslow’s hierarchy of needs to address physiologic needs and safety client in bed 1 has a GI bleed; the client in bed 2 had a issues. The ABCs (airway, breathing, and circulation) should be used to prioritize care for stroke a year ago; the client in bed 3 has a blood clients with physiologic problems. Time should be used to so that care can be duly provided to glucose level of 356 mg/dL; and the client in bed 4 is the clients. The stem of the question does not address the administration of medications or calling to get assistance to go to the bathroom. What client preferences. framework(s) for determining priorities of care should the nurse use? Select all that apply.
| Use knowledge of the ABCs and Maslow s hierarchy of needs to make the correct choice. |
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5525 A client has a platelet count of Correct answer: 4 A client with a platelet count of 45,000/mm<sup>3</sup> has bleeding tendencies 45,000/mm<sup>3</sup>. Which nursing and abnormal bleeding, and when injured, the client will bleed for longer periods of time. The diagnosis takes priority? normal platelet range is 150,000–400,000/mm<sup>3</sup>. The goal for this client is to remain free of injuries, to prevent massive bleeding and hemorrhage. The scenario does not imply nutritional or cardiac problems. Tissue perfusion is not the pressing issue at this time.
| Use knowledge of the nursing process and Maslow’s hierarchy of needs to make the correct selection. |
5526 A client presents to the Emergency Department (ED) Correct answer: 2 This client has acute pain secondary to the fall and fracture. The client’s pain level is 8 out of with a left hip fracture secondary to a fall, and a 10, and should be treated immediately to increase the client’s comfort. Impaired comfort will history of osteoarthritis. The client complains of pain be addressed when the pain is treated. The client came to the ED for acute pain related to a rated as 8 out of 10. Which nursing diagnosis takes fall, not chronic pain related to osteoarthritis. Mobility is not a pressing issue at this time. Pain priority? should be addressed first.
| Use the ABCs (airway, breathing, and circulation) of prioritization and nursing knowledge to make the correct selection. |
5527 A registered nurse (RN) working on an acute care Correct answer: 3 Option 3 is correct because it considers the scope of practice for the LPN. LPNs are prepared hospital unit plans to delegate some responsibilities of academically to change dressings. Option 1 is incorrect because the RN is educationally client care to a licensed practical nurse (LPN). Which prepared to assess new admissions holistically; moreover, LPNs are not prepared academically task should the RN delegate to the LPN? to assess clients. The RN should always be the one to assess a postoperative client, due to potential complications and abrupt changes in status secondary to the surgical procedure. Assisting a client to ambulate and AM care are aligned with the scope of practice, job description, and duties for a nursing assistant.
| Use nursing knowledge and strategies for delegation to make the correct selection. |
5528 A client is receiving a unit of packed red blood cells. Correct answer: 2 There has been a change in the client s vital signs. The BP now is low, with tachycardia and an The client s initial vital signs were stable. The client s elevated temperature. A temperature change of 1° Fahrenheit is an indicator of a transfusion new vital signs are blood pressure (BP) 94/58 mm Hg; reaction. The temperature coupled with the low blood pressure is conclusive for a transfusion heart rate (HR) 116 bpm; respirations 28 bpm; and reaction. The nurse s first action is to stop the transfusion and infuse normal saline. After this, temperature 100.8°F. What should the nurse do next? the nurse may call the health care provider for additional orders. A diuretic is not indicated, because this client is experiencing a transfusion reaction, not hypervolemia. A diuretic could cause this client s BP to drop to detrimental levels, placing this client in shock. These findings should be documented, but they are not stable.
| Use nursing knowledge and prioritization strategies to select the correct response. Recall that it is prudent to stop a transfusion whenever there is evidence of a severe or adverse reaction. |
5529 A client has a blood pressure (BP) of 100/54 mm Hg. Correct answer: 1 This client s BP is within the normal range. However, adding a calcium channel blocker, beta The 0900 medications include amlodipine (Norvasc) 10 blocker, and diuretic could lower the client s BP to extremely low levels, placing the client at mg, metoprolol (Toprol) 25 mg, and furosemide (Lasix) risk for falls and possibly shock. The nurse should wait until hearing from the health care 40 mg. What should the nurse do next? provider before administering these medications to the client. The nurse should document the findings and continue to monitor the client s status.
| Use knowledge of medication of administration and prioritization strategies to select the correct response. |
5530 A nurse finds the following order: phenytoin (Dilantin) Correct answer: 2 This client’s phenytoin level is elevated. The normal is 10–20 mg/dL. The health care provider 200 mg orally at night. The client’s phenytoin (Dilantin) might not be aware of this lab result. The nurse should inform the health care provider of the level is 23.4 mg/L. What is the nurse’s next action? client’s elevated phenytoin level. The health care provider might change the dose and or frequency of the medication. The phenytoin level does not need to be redrawn; it is not critically elevated. The medication should not be administered until the nurse receives new orders from the health care provider. The nurse cannot make the decision to administer half the dose of phenytoin; a new order must come from the health care provider.
| Use knowledge of laboratory date and prioritization strategies to select the correct response. |
5531 A client is being treated for a wound infection; the Correct answer: 4 This client is allergic to a broad category of medications. The nurse should start with health care provider ordered cephalexin (Keflex) 500 identifying specific drug allergies. This information can be gathered from the client and mg t.i.d. The client is allergic to cephalosporins. What caregiver. Not all clients are allergic to all drugs in a general category of medications, and this is the nurse’s next action? client might not have a reaction to cephalexin. However, because this client has allergies to other cephalosporins, it is reasonable to anticipate that this client could have a reaction to this medication. Once the allergy data have been gathered, the nurse should inform the health care provider of the client’s current allergy status. This medication should not be administered until medication allergies are verified.
| Use knowledge of medication administration and prioritization strategies to select the correct response. |
5532 A client has type 2 diabetes mellitus, hypertension, Correct answer: 2 This client has an elevated glucose level that leads to damage to the client’s vasculature. The and coronary artery disease. The client’s 0730 finger insulin is rapid‐acting, and will decrease the client’s glucose level more quickly than the oral stick glucose is 214 mg/dL, and the blood pressure is medications. Actos is ordered once daily, and is not a priority, although it should be 134/69 mm Hg. What medication should the nurse administered around the same time each day. Actos may be given in conjunction with administer first? Humalog, but the client must be able to produce insulin for Actos to work effectively. Starlix is ordered three times daily, and may be given in conjunction with insulin. However, it takes longer for this medication to work; the half‐life is 1.5 hours. Starlix requires functioning pancreatic beta cells. Furthermore, Starlix should be administered on schedule, since it is ordered three times per day. Lipitor is given once daily, and is not a priority. In fact, Lipitor can be administered at night.
| Use medication prioritization strategies to select the correct response. |
5533 A client is admitted to the medical floor with Correct answer: 1 Excessive vomiting and diarrhea cause this client’s dehydrated status. The client’s blood gastroenteritis secondary to food poisoning. The client pressure is low because the client has lost fluid; the heart is pumping harder and faster to has had many episodes of vomiting and diarrhea. The pump the remaining circulating volume to all parts of the body. A priority for this client is to client’s blood pressure (BP) is 86/40 mm Hg, heart rate replace fluid; once fluid is replaced, the client’s heart rate and blood pressure will return to the is 108, and the client appears weak. What nursing therapeutic range. The problem is not a pump malfunction; it is a fluid deficit. Nutrition will be diagnosis is a priority for this client? addressed, but later. Moreover, this is not a pressing priority. The client may receive nutritional augmentation intravenously. The diagnosis in option four is not properly formatted, making it the wrong option.
| Use the nursing process and prioritization strategies to select the correct response. |
5534 What nursing diagnosis is a priority for a client with a Correct answer: 3 This client’s sodium level is low (normal is 135–145 mEq/L), causing water to shift from the sodium level of 122 mEq/L? vascular space to the cellular space, causing cerebral edema. Eventually, these cells will burst. This client is at risk for seizure activity and muscle spasms. The safety issue takes priority over the other options. The client might experience altered comfort and pain, but pain and comfort do not take precedence over safety. The water shift does contribute to dehydration of the extracellular space, but the priority is safety. The health care provider may order a hypertonic solution to pull water out of the cells back into the vascular space. This problem should be addressed; however, the nurse must keep the client safe.
| Use knowledge of the nursing process and prioritization strategies to select the correct response. |
5535 What priority intervention should the nurse include in Correct answer: 1 The nurse must initiate seizure precautions, because this client is at risk for seizure activity. the client’s plan of care when the client’s sodium level The administration of one‐half normal saline (option 2) is contraindicated, as this will pull more is 123 mEq/L? fluid from the vascular space into the cell, worsening cerebral edema. Repositioning the client is a comfort measure, not a priority. Antispasmodics may be administered, but this action is not a priority at this time. The nurse should make every effort to minimize harm should a seizure occur.
| Use knowledge of electrolytes and prioritization strategies to select the correct response. |
5536 The nurse has initiated seizure precautions for a client Correct answer: 2 The nurse has initiated seizure precautions, and should now hang a bag of hypertonic IV with a critically low sodium level. Which action should solution as ordered to shift fluid back into the vascular space. The nurse then may administer the nurse take next? antispasmodics as ordered and reposition the client in bed. After these measures have been instituted, the nurse should reassess the client to determine the effectiveness of treatment and interventions.
| Use nursing knowledge and prioritization strategies to select the correct response. |
5537 Of the following tasks, which one should the Correct answer: 4 The most appropriate task for the LPN of the listed options is checking vital signs. The client in registered nurse (RN) delegate to a licensed practical option 1 is more critical, and requires frequent monitoring by the nurse for seizure activity. nurse (LPN)? Intravenous lines may be started by LPNs who are trained in this area, but this is not identified as a skill possessed by the LPN in the question. The nurse must consider the LPN’s scope of practice and competence when delegating tasks. The nurse should conduct assessment of a 4‐ year‐old child. Assessments require skilled knowledge that the RN possesses.
| Use knowledge of delegations principles and the process of elimination to make the correct selection. |
5538 What is a priority intervention of the nurse for a Correct answer: 4 A client with a platelet count of 58,000/mm<sup>3</sup> could bleed client who has a platelet count of spontaneously, and should be kept safe. This client requires activity restrictions due to the lack 58,000/mm<sup>3</sup>? of clotting ability. A low platelet count does not yield an elevated WBC. Aspirin is contraindicated, as it could decrease clotting time. The prothrombin time should be monitored, as it indicates the amount of time it takes for a platelet plug to form, but it is not an immediate priority.
| Use nursing knowledge and prioritization strategies to select the correct response. |
5539 A nurse is discharging a client with a platelet count of Correct answer: 3 This client is more likely to have an increase in clotting time due to the low platelet count, but 100,000/mm<sup>3</sup>. What discharge spontaneous bleeding is unlikely at this level. However, the client should refrain from instruction is a priority for this client? strenuous activity that might cause injuries. Blood in the urine and stool is an indication the client is actively bleeding and that her platelet count has decreased. In this case, the client should be seen immediately. This client’s platelet level should be monitored within 7–10 days.
| Use nursing knowledge and prioritization strategies to select the correct response. |
5540 A registered nurse (RN) is caring for a preoperative Correct answer: 3 This client’s blood glucose is elevated, and should be treated prior to surgery for better client who has diabetes mellitus. The client’s fasting surgical outcomes. The nurse should administer the 6 units of Humalog insulin immediately, to finger stick glucose is 256 mg/dL. What task should the gain a tighter control on the client’s blood glucose. All other tasks may be handled after the RN complete first? nurse has administered the insulin. The nurse does not need to call the surgeon about the elevated glucose. The nurse should recheck the finger stick glucose 30 minutes to an hour after the insulin has been administered.
| Use nursing knowledge and prioritization strategies to select the correct response. |
5541 A nurse is caring for a client who had a colectomy Correct answer: 3 The client has lost considerable circulating volume. The client’s output is inadequate (less four hours ago. The estimated total blood loss from than 30 mL/hr), indicating the client does not have enough fluid in the circulating blood the surgery is 400 ml. The client has an IV infusing at volume. The client’s pain is rated 4 out of 10, which is tolerable in most cases; this pain score 100 ml/hr, an indwelling catheter that has drained 100 does not require immediate attention by the nurse. While the client’s comfort is impaired ml since surgery, and the client’s pain is “4 out of 10.” related to the pain and surgical experience, this diagnosis does not take precedence over Which diagnosis is a priority for this client? deficient fluid volume. Option 4 implies the client is at risk for fluid imbalance; in this case, the client has a fluid imbalance. The best choice is deficient fluid volume. | Use knowledge of the nursing process and prioritization strategies to select the correct response. |
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5542 A nurse is caring for a client who had a hysterectomy. Correct answer: 2 The client in this case is bleeding; the likely source is the incision. The first action by the nurse The client’s blood pressure (BP) is dropping from a is to check the incision for drainage. Calling the health care provider is immature without first prior level of 132/84 to a current reading of 126/78. assessing the client. Elevating the head of the bed on a client with a low blood pressure could What action should the nurse take next? decrease the blood pressure; the head of the bed should be lowered to prevent the blood pressure from dropping. A nurse needs an order from the health care provider to increase the rate of intravenous fluids.
| Use knowledge of the surgical experience and the process of elimination to select the correct response. |
5543 A nurse is assessing a surgical client. An unlicensed Correct answer: 3 There is an urgent situation in the next room, and the nurse should go assess the client to assistant enters the room and informs the nurse that a determine the extent of the client’s change in status. After assessing the client in the next client in the next room is cold, clammy, and room, the nurse should then call the charge nurse if extra help is necessary. The surgical client, diaphoretic. What should the nurse do first? while not technically stable, does not have any aberrant findings at this time, and therefore the nurse should check on the client who is presently having problems. The health care provider should be called after the assessment of the clammy client, with a detailed update of the client’s change in condition.
| Use nursing knowledge and the process of elimination to select the correct response. |
5544 The nurse is about to assess the status of a client who Correct answer: 3 The nurse could instruct the CNA to obtain a set of vital signs on the postoperative client. This returned from surgery four hours ago when a certified action allows the nurse to have ongoing data about the postoperative client, which could nursing assistant (CNA) reports that another client’s determine a change in the postoperative client’s status and need for medical attention. skin is cool and diaphoretic. The nurse should instruct Checking on the postoperative client does not yield as much data as checking vital signs does. the CNA to take which action at this time? Checking on the client will yield information that can be gathered only by inspection. However, vital signs provide a better picture of the client’s physiologic status. The CNA should not stay with the clammy client; the nurse should assess this client, take the client’s vitals, and check the client’s finger stick glucose.
| Use knowledge of delegation principles and the process of elimination to select the correct response. |
5545 The nurse is about to perform a routine assessment Correct answer: 1 Given these options, the best response is obtaining a set of vital signs and finger stick glucose on a client who is four hours postoperative. A licensed on the client who is clammy. The LPN can collect data and report the data to the registered practical nurse (LPN) reports that another client’s skin nurse for interpretation. While the nurse is completing the assessment on the surgical client, is cool and diaphoretic. The nurse should instruct the the LPN can obtain a set of vitals and finger stick glucose for the registered nurse’s use. This LPN to take which action at this time? data are vital for the nurse to have while assessing the clammy client; the nurse will have pertinent real‐time data to draw conclusions.
| Use knowledge of delegation principles and the process of elimination to select the correct response. |
4.‐ Stay with the diaphoretic client until the nurse completes the current assessment. | |
5546 A charge nurse is making assignments. Which nurse Correct answer: 1 The nurse should assign the postoperative client with coronary artery disease and diabetes to should the charge nurse assign to care for a one‐day the registered nurse with experience in medical–surgical nursing. This nurse is trained in caring postoperative client with coronary artery disease and for clients with surgical interventions complicated by chronic illnesses. A registered nurse two diabetes? days off orientation may care for this client, but the nurse with the experience is better qualified to do so. Licensed practical nurses should not care for clients with unpredictable outcomes.
| Use knowledge of management and prioritization strategies to select the correct response. |
5547 A client is experiencing intractable vomiting, and Correct answer: 4 The registered nurse should administer IV ondansetron, assess the client’s gastrointestinal demonstrates weakness. Which task should the nurse system, and inform the health care provider of the client’s status. All of these duties require delegate to the licensed practical nurse (LPN)? the critical thinking skills of the registered nurse. Assessment and the administration of IVP medication are not part of the LPN’s scope of practice. The LPN in this case may provide comfort measures such as oral care and providing ice chips.
| Use knowledge of delegation principles and the process of elimination to select the correct response. |
5548 A client has left hemiparesis, and consistently tries to Correct answer: 3 The client is high risk for falls and subsequent injuries. This client also is higher‐risk for the get out of bed. What nursing diagnosis is a priority for development of tissue impairment due to impaired blood flow in the periphery. Injury is a this client? priority. Safety must be considered after airway, breathing, and circulation. Decreased mobility and risk for impaired skin integrity are not priority issues at this time. The first priority is to keep the client safe. The stem of the question does not indicate this client’s comfort is altered.
| Use knowledge of the nursing process and prioritization strategies to select the correct response. |
5549 A nurse is assigned a group of five clients. The nurse is Correct answer: 2 The nurse must assess the client who has fallen; this client could have a head injury, assessing a client with pneumonia. The unlicensed hemorrhage, or some other grave complication from the fall. This client is a priority; the client assistant enters the room and informs the nurse the could die if not given the proper and timely care that is needed to prevent complications from client in the next room has fallen. What should the a fall. The assessment on the client with pneumonia can wait. The nurse may ask the nursing nurse do next? assistant to check vital signs on the client who fell, but the nurse must still assess the client first. The nursing assistant does not need to stay with the client who has pneumonia.
| Use nursing knowledge and prioritization strategies to select the correct response. |
5550 The nurse has assessed a client who has fallen while Correct answer: 3 The bed alarm system could alert the staff of the client’s large motor movements while in getting out of bed, and has determined that the client bed, which is an indicator that the client might attempt to get out of bed. The bed alarm is stable and has no injuries. What action should the system is a good device to notify the staff that a fall is likely. Monitoring the client every ten nurse take next? minutes might be plausible, but if a bed alarm system is available, it should be used. Monitoring the client every ten minutes, in many cases, is not enough to prevent the client from falling. While assessing the etiology of the fall is warranted and needed, this is not an immediate priority. The immediate priority is to prevent the client from falling, and this can be done through the bed alarm system. The caregiver may sit with the client in an effort to prevent falls; however, the caregiver is not currently with the client. Something must be done now to alert the staff of major body movement.
| Use nursing knowledge and the process of elimination to select the correct response. |
5551 A nurse has just received intershift report on a Correct answer: 1 Any client with a BNP of 800 pg/ml is in congestive heart failure, and should be assessed first medical nursing unit. Which client should the nurse for respiratory and cardiac complications. This client also might need dialysis to remove assess first? additional fluid from circulation. A 90‐year‐old client with weakness and pneumonia does not take priority over the client with a BNP of 800 pg/ml. The hematocrit of this young individual is a little low but not life‐threatening. While the 72‐year‐old postoperative client is at risk for postoperative complications, this client can wait until the client in option 1 is assessed. Respiratory and cardiac are first in assessment.
| Use knowledge of the laboratory test results and of the nursing process, and the process of elimination, to make a selection. |
5552 What intervention is a priority for a client with a B‐ Correct answer: 2 A client with a BNP of 800 pg/ml has too much fluid in the circulating volume. The heart is type natriuretic peptide (BNP) of 800 pg/ml? unable to pump the additional volume effectively; thus it secretes the B‐type natriuretic peptide to alert the body of this problem. This individual will have difficulty breathing; fluid backs up in the lungs, decreasing gas exchange and impairing respirations. The nurse first should administer this client s diuretic to remove the additional fluid from the circulating volume. Oxygen is needed in most cases, and the actual order should be based on the client s need for it. Most of these individuals need oxygen in excess of two liters per minute. Providing the client with oxygen does not improve heart failure. Ambulation is not a priority at this time, and could increase the oxygen demand of the heart, increasing the workload of the heart. Coughing, turning, and deep‐breathing could help the client cough up pulmonary secretions, but do not address the heart failure.
| Use knowledge of laboratory data and prioritization strategies to select the correct response. |
5553 How should the nurse delegate the following tasks? Correct answer: 3 The licensed practical nurse (LPN) should perform tasks that are in the scope of practice for Assist a client to the bathroom; wound care; the LPN, such as administering oral medications and wound care. These tasks are not, administer oral medications to two clients; and assist however, in the scope of practice for the nursing assistant. clients with lunch.
| Use knowledge of delegation principles and the process of elimination to select the correct response. |
5554 The registered nurse (RN) is making assignments. Correct answer: 3 The LPN should care for a client with predictable outcomes. The 29‐year‐old client with Which client should the RN assign to the licensed pneumonia does not have a history of any comorbid conditions that could exacerbate the practical nurse (LPN)? client’s condition. The other clients, with the exception of the surgical client, all have chronic conditions that could impact the course of treatment for these clients. The surgical client should be assigned to a registered nurse for frequent assessment and observations.
| Use nursing knowledge and prioritization strategies to select the correct response. |
5555 A registered nurse (RN) is making a list of tasks that Correct answer: 1, 2, 4, The tasks of the unlicensed assistant that correspond with the scope of practice are the need to be completed for clients within the nurse’s 5 application of a heating pad, measurement of dietary intake percentages, assisting with ADLs, assignment. What tasks should the RN delegate to the and emptying urinary catheter bags. The task that is not in the scope of the nursing assistant is unlicensed assistant? Select all that apply. changing a soiled dressing. When delegating, the nurse must use the elements of delegation, including scope of practice.
| Use knowledge of delegation principles and the process of elimination to select the correct response. |
5556 A registered nurse (RN) is in charge of the nursing unit Correct answer: 4 The task of checking bed alarms on assigned clients may be delegated to a staff nurse. In fact, for the shift because the regular charge nurse is sick, all the nurses with client assignments could check bed alarms for their assigned clients. This and did not report to work. The RN will not take a task does not require any undue strain, may be handled relatively easily, and takes very little client assignment, and is making a list of tasks that time. Staff nurses do not have extra time to worry about mundane tasks such as checking the must be completed today. Which task should the nurse crash cart, checking the temperature in the refrigerator, and making follow‐up phone calls to delegate to another RN? discharged clients. The charge nurse can complete these tasks, since the charge nurse has no‐ to‐few assigned clients. These tasks are important, but the staff nurse does not have time to complete them.
| Use knowledge of delegation principles and the process of elimination to select the correct response. |
5557 A registered nurse (RN) has been appointed to be in Correct answer: 1 The crash cart is used in case a “code blue” or “rapid response” is called, to supply the staff charge of the nursing unit today because the usual with the equipment and medications that are needed to resuscitate a client. The charge nurse charge nurse is ill. Which task is a priority for the should make sure that the crash cart is fully stocked and that the defibrillator is working nurse? properly. This task should be completed at the beginning of the shift. The other tasks may be performed throughout the shift as time permits.
| Use nursing knowledge and prioritization strategies to select the correct response. |
5558 A charge nurse is determining to which nurse to Correct answer: 4 The charge nurse should review the experience of the nurse who will assume care of the delegate the care of a postoperative client who had a client with the TURP. The care of this client requires knowledge of bladder irrigation, and some transurethral resection of the prostate (TURP). What nurses have not had the opportunity to care for clients needing this procedure. Time element of delegation should the charge nurse management is a component of organizational skills, and does not apply to the stem of this consider when making this assignment? question. Feedback and comprehension are components of delegation, but are not applicable in this case, because the nurse must demonstrate competence in the task before it can be delegated.
| Use knowledge of delegation principles and the process of elimination to select the correct response. |
5559 A nurse is caring for four clients. Each of the four Correct answer: 3 The client with fluid overload is a priority in this case. Clients with airway impairments are the clients has a priority nursing diagnosis. Based on each highest priority in most cases. With impaired gas exchange, the client is not able to exchange client’s nursing diagnosis, which client should the carbon dioxide for oxygen, leaving the client in air hunger. Depending on the situation, the nurse assess first? nurse must decide whether to address pain or risk of injury. If the client’s pain level is high, the nurse should address this first if the client with the risk of injury is safe. If the client with the risk for injury is unsafe, the nurse must address that client first. Airway, breathing, circulation, safety, and pain are the order in which most cases should be prioritized; however, every nursing scenario is different. The client with impaired communication does not take precedence over the client with hypervolemia.
| Use nursing knowledge and prioritization strategies to select the correct response. |
5560 Which nursing intervention should the Correct answer: 3 The nursing intervention that should be addressed first for the priority nursing diagnosis nurse—utilizing orders that have already been Impaired Gas Exchange is the administration of a diuretic. The cause of the impaired gas written—complete first for a client who has fluid exchange is fluid in the pulmonary fields. Lasix is effective in removing additional fluid, thereby overload? correcting the overload. While elevating the HOB is a good option, it is not a priority in this case; the client needs treatment that will remove the additional fluid. Lanoxin also is necessary, but the nurse should treat the cause of the impaired gas exchange first. Morphine sulfate is used to regulate respirations, but it does not correct the overload.
| Use knowledge of medication administration and the process of elimination to select the correct response. |
5561 A registered nurse (RN) has delegated a task to a Correct answer: 3 The RN neglected to communicate the details of the task, and did not verify the LPN’s licensed practical nurse (LPN). The LPN still has many understanding of the task. The question does not imply the task, person, or competence questions about the task, and does not seem to affected the LPN’s ability to perform the task. The LPN does not understand the details of the understand some of the details of the task. The RN task, and therefore cannot perform the task properly. considers that which element of delegation has been neglected?
| Use knowledge of delegation principles and the process of elimination to select the correct response. |
5562 The charge nurse is planning to delegate the task of Correct answer: 2, 4 The charge nurse has not considered the staff nurse’s capability of completing the schedule. completing the work schedule for the nursing The staff nurse has never completed a schedule before, and is unsure of the outcome. The task assistants. The nurse selected for the job is a new is right, but the person is wrong. A registered nurse may complete the task; however, the nurse who has been off orientation three months. The registered nurse in this scenario has never completed the task, which also neglects the nurse does not have any experience in scheduling, and competence of the staff nurse. Communication is clear. The staff nurse understands what must does not feel confident about completing the job. be done, but has never completed such a task. Organizational skills are not an issue. Which elements of delegation has the charge nurse neglected? Select all that apply.
| Use knowledge of delegation principles and the process of elimination to select the correct response. |
5563 A nurse has instructed the nursing assistant to record Correct answer: 1 The nurse is providing the nursing assistant with communication and feedback in relation to assigned clients’ urine output on their graphic sheets. the task. Organizational skills do not apply to this situation. The question does not imply the The nurse checks every client’s record to make sure nursing assistant is incapable of performing the task, and the task is within the scope of the the client’s urine output is documented accurately, nursing assistant. and is providing feedback to the nursing assistant. The nurse is using which element of delegation?
| Use knowledge of delegation principles and the process of elimination to select the correct response. |
5564 A registered nurse (RN) has delegated uncomplicated Correct answer: 1, 2, 3 The nurse has assigned the wrong task—incision care—to the wrong person, a nursing incision care to an unlicensed assistant. Which assistant. It is not within the scope of the nursing assistant to provide incision care. In this case, elements of delegation has the RN breached? Select all the wrong task was delegated to the wrong person. The nursing assistant is not competent to that apply. provide this task, because this is not a part of the assistant’s job description and scope of practice. This task should have been delegated to a practical nurse or another registered nurse. Time and organizational skills are not an issue.
| Use knowledge of delegation principles and the process of elimination to select the correct response. |
5565 A charge nurse is delegating care of a surgical client Correct answer: 1 The charge nurse should consider the staff nurse’s experience with surgical clients. to a staff registered nurse (RN). What critical element Postoperative orders are important; they explain the type of care clients need following of delegation should the charge nurse consider? surgery. However, surgical experience verifies the nurse is able to care for surgical clients. The time the client returns to the unit does not impact the nurse’s experience with surgical clients. The type of nursing degree does not verify a nurse’s surgical experience.
| Use knowledge of delegation principles and the process of elimination to select the correct response. |
5566 A registered nurse (RN) prepares to delegate finger Correct answer: 3 The nurse should instruct the unlicensed assistant to check the client’s finger stick glucose stick glucose measurements to an unlicensed assistant. level before breakfast and lunch. This direction gives the nursing assistant a time frame to get What should the nurse include in the instructions? the task done. A high‐protein snack does not contribute to the task of the finger stick glucose check. Checking the client’s arm for bleeding might be a plausible request by the nurse; however, it does not relate to the task of checking the client’s glucose level. The results should be reported to the nurse who is delegating the task to the unlicensed assistant.
| Use knowledge of delegation principles and the process of elimination to select the correct response. |
5567 A charge nurse is delegating the transfusion of blood Correct answer: 1 The charge nurse should communicate detailed orders surrounding the task that is being to another registered nurse (RN). What should the delegated. This gives the nurse specific details about the transfusion, and makes the task charge nurse include in the instructions? comprehensible and clear. Option 2 provides a history of the administration of blood products; it does not clarify the task that is delegated to the nurse. The nurse should not call the family unless the client has signed a release of information form; further, even if the family has a right to the information, this option still does not involve the task of administering the blood product. Option 4 does not clarify the task.
| Use knowledge of delegation principles and the process of elimination to select the correct response. |
5568 There are several client assignments to be made: a Correct answer: 4 Standards of care affect the assignment of the staff; the nurse’s request, while it might be client who has difficulty with communication, a client important to her, is not an indicator of proper assignments. Likewise, the nurse’s ability to talk with multiple procedures to be done, and a client with to difficult clients and time management are not considered in making assignments. teaching needs. How should the charge nurse determine who is assigned the particular clients?
| Recall the rules and regulations used by all nurses in the care of the client to select the correct answer. |
5569 A nurse on the floor is in charge of a new group of Correct answer: 4 Monitoring for bleeding, need for pain meds, and obtaining vital signs on an unstable client certified nursing assistants (CNAs) for the day. When are outside the scope of practice for the CNA. Recording intake and output is within the scope delegating care to a CNA, which of the following is an of practice. appropriate assignment?
| Recall types of clients for whom the nursing assistant can care, and which client is the most stable. |
5570 The nurse is making assignments on the floor, and has Correct answer: 4 The LPN should be assigned to the most stable client, which in this situation is the client the following staff members: two RNs and one LPN. awaiting placement in a long‐term care facility. The client on a ventilator is unstable, as is the Based on proper delegation, the LPN should be client who was transferred from the ED. The client who requires teaching is outside the scope assigned to the care of the client who: of practice for an LPN.
| Recall that LPNs must care for those individuals who are deemed stable and do not require teaching. |
4.‐ Is waiting for long‐term care placement. | |
5571 Which of the following clients would be appropriate Correct answer: 1, 2 The clients in options 1 and 2 are stable clients who do not have any acute needs to be for the nurse to assign to the LPN? Select all that addressed by the RN. Options 3, 4, and 5 list clients who will require interventions that are to apply. be completed by the RN only.
| Recall that LPNs should work with clients considered stable who should have expected outcomes. |
5572 A certified nursing assistant (CNA) is assigned to a Correct answer: 3 Ambulating a confused client will not have any unexpected outcomes. Changing a postop medical–surgical unit. Which of the following dressing and assisting a client who has had a recent stroke with meals require assessment assignments is appropriate for the RN to delegate to skills. The client with a new tracheostomy has the potential to be unstable. the CNA?
| LPNs should be assigned to clients who are the most stable, and who will have expected outcomes. Remember not to choose clients whose outcomes might be adverse. |
5573 A new nurse graduate is orienting to the psychiatric Correct answer: 2 This client is the most stable, as this behavior is expected in the manic client. All other clients unit. Which of the following clients would be the best are not stable in their current state, being at risk for possible violence (option 3) or suicide assignment for the new nurse? (options 1 and 4).
| New graduate nurses should be assigned those clients who are considered stable and who are displaying the expected outcomes for their illness. |
5574 A registered nurse (RN) has an assignment that Correct answer: 1 This client is stable, and requires help with activities of daily living (ADLs) and designated includes four clients. Which of the following can the nursing procedures. The other clients are in need of a higher level of care, including RN delegate to the nursing assistant? assessment and teaching, which can be provided only by the RN.
| Nursing assistants work under the supervision of the LPN or RN. Therefore, their tasks should be minor, with no risk of adverse outcomes. |
5575 A nurse is working in the Emergency Department Correct answer: 1 The clients in options 2–4 are unstable, and their care is within the scope of the RN only. A when the victims of a multi‐casualty accident arrive. client with a wrist deformity and pain can be cared for in an emergency by the LPN. Which of the following clients can be delegated to the LPN initially?
| An LPN should be assigned clients who are relevantly stable and do not require in‐depth, frequent assessments. |
5576 A registered nurse (RN) is floated from a Correct answer: 4 Older children deal better with continuity of care, and the newborn would not be affected by medical–surgical adult unit to the pediatric unit. Which a different caregiver. For this reason, the nurse should be assigned to the care of the newborn. of the following assignments would be the most Additionally, the 13‐year‐old would have increased teaching needs that should be addressed appropriate for the float RN? taking into account the stage of growth and development. The 12‐year‐old and 16‐year‐old could also need care according to their level of growth and development, and this would be best provided by an RN with pediatric experience.
| Recall the developmental needs of children, and how they are affected by hospitalizations, to select the correct answer. |
5577 Which of the following is an appropriate assignment Correct answer: 3 The client in option 3 requires routine care that is within the scope of practice of the LPN. The for the registered nurse (RN) to delegate to the clients in options 1 and 2 require teaching, and this is within the scope of practice of the RN. licensed practical nurse (LPN)? The client in option 4 is unstable, and also requires the care of the RN.
| Recall that an LPN cannot teach a client, and should not be assigned clients considered unstable. |
5578 A client is diagnosed with full‐thickness burns to the Correct answer: 1 Collecting supplies (option 1) is the only choice within the scope of practice for the nursing lower legs. Which of the following tasks would be most assistant. The actions in options 2–4 all require skills of the RN. The RN is responsible for appropriate for the registered nurse (RN) to delegate assessment (options 2 and 4). The RN also is able to engage in therapeutic communication with to the unlicensed assistant (UA) in this situation? the client (option 3), and depending on the reason the physician needs to be called, the client might need continued monitoring by the RN.
| An unlicensed assistant can assist the nurse in procedures of limited role. Therefore, think of which option helps the nurse but is limited in actual care. |
5579 A child is admitted with suspected abuse. Which of Correct answer: 4 Option 4 is within the scope of the CNA (basic care and comfort). The other options involve the following actions is most appropriate for the RN to assessment, and therefore are in the scope of the RN. request of the nursing assistant?
| Recall that a certified nursing assistant can not assess clients. Which option is within the scope of practice for the nursing assistant? |
5580 Which of the following tasks is appropriate for the Correct answer: 3 Option 3 (ambulating a client) is within the scope of practice of the LPN. The other options registered nurse (RN) to delegate to the licensed are in the scope of practice for the RN, because they require teaching (option 1), assessment practical nurse (LPN)? (option 2), or high‐level assessment and care (option 4).
| Which of the situations is relevant to the scope of practice for the LPN? Remember that LPNs can care for stable clients with expected outcomes. |
5581 Which of the following clients should the registered Correct answer: 3 The client in option 3 is stable and within the scope of practice for the LPN. The other clients nurse (RN) on the postpartum unit assign to the are unstable, and the client in option 2 requires teaching, which is not within the LPN’s scope licensed practical nurse (LPN)? of practice.
| Which of the options is best suited for the LPN? Which of the options will have an expected outcome, and does not require teaching? |
| |
5582 Which of the following is an appropriate assignment Correct answer: 2 The client in option 2 (cleft palate) is considered most stable, and the remaining clients are for the registered nurse (RN) to delegate to the less stable and so must be cared for by the RN. licensed practical nurse (LPN)??
| An LPN must care for the stable client, so which of the options could be considered stable? |
5583 Which of the following is an appropriate task for the Correct answer: 1 Intake and output are tasks that fall within the scope of practice for the nursing assistant. The registered nurse (RN) to delegate to the nursing other options all are in the scope of practice for an RN. assistant?
| Nursing assistants are limited in their tasks. Which option falls in the scope of the nursing assistant and does not require the skills of the LPN or RN? |
5584 A registered nurse (RN) is reassigned from a Correct answer: 4 Option 4 is the most stable of the clients, and therefore is most appropriate for the RN who medical–surgical unit to the pediatric unit. Which of has floated to the pediatric unit. The clients in the other options are not considered stable, and the following clients is the best assignment for this RN should be cared for by a regular pediatric RN. to be given for the shift?
| Which of the clients is the most stable? Nurses unfamiliar with the policies and procedures of a new unit should be given the most stable of clients. |
5585 Which of the following clients is most appropriate for Correct answer: 1 The client in option 1 is the most stable, and can be cared for by the nursing assistant. The the registered nurse (RN) to delegate to the nursing clients in the other options are unstable, and need the care of the RN. assistant?
| Which of the clients is within the scope of practice for the nursing assistant? A nursing assistant should be able to care for the client who is stable and in need of minimal care. |
5586 A nurse is making assignments on the unit. Which of Correct answer: 4 Option 4 places two “clean” clients together, while the other options are cohorting clients the following assignment groups is best? who could contaminate each other.
| Which clients can be placed in a room together? Think of infection control and the priority of care for those clients who are immunocompromised. |
5587 The staffing on the unit consists of one registered Correct answer: 3 Option 3 is a stable client, and dressing changes on a stable client are within the scope of nurse (RN), two licensed practical nurses (LPNs), and a practice of the LPN. Options 1 and 2 are unstable clients, and option 4 is a task to be nursing assistant. Which task is the most appropriate performed by the nursing assistant. to be completed by the LPN?
| The LPN should care for the client who is most stable and does not require teaching or assessment for instability, but an LPN should not do tasks that the assistant can do. |
| |
5588 A new nurse graduate is reassigned to a Correct answer: 4 Option 4 is an expected state for a client with dementia, and the client therefore is stable. medical–surgical unit. Which of the following Option 1 requires teaching, while options 2 and 3 are unstable, and should be cared for by the assignments is the most appropriate? RN, who has more experience.
| New graduates should care for the most stable of clients. Which of the group can be considered most stable? |
5589 The registered nurse is working with an unlicensed Correct answer: 2 Option 2 is within the scope of the RN only. RNs are responsible for any teaching that might assistant (UA) for the shift. Which activity is best be needed for the client. retained by the RN rather than delegated to the UA?
| Which of the activities is within the scope of the RN only? Which things can be done by an assistant? |
5590 What is the most important point for the registered Correct answer: 3 Assignments should be made with the responsibilities of the person in mind. It is possible that nurse (RN) to consider when assigning tasks to the each facility has somewhat different expectations for nursing assistants. nursing assistant?
| What are the rules regarding making assignment? Remember the importance of following protocol at a particular facility. |
5591 Which of the following client assignments would be Correct answer: 4 The client listed in option 4 is stable. The clients in options 1 and 3 require assessment by the appropriate for registered nurse (RN) to make for the RN, and the client in option 2 requires discharge teaching, which like assessment can be done licensed practical nurse (LPN)? only by the RN.
| Which of the options falls with the scope of practice for the LPN? Which is more detailed, and in need of the attention of the RN? |
5592 The registered nurse (RN) is making assignments for Correct answer: 4 Of the clients presented, the client who underwent breast biopsy is the most stable, and is the 7–3 shift. The clients consist of a78‐year‐old male also one who might not require teaching at this time. The LPN’s scope of practice does not with pneumonia, a 22‐year‐old female with abdominal include teaching, or care of the unstable client. pain, a 34‐year‐old client who just underwent breast biopsy, and a 19‐year‐old new mother. The staff consists of one RN and one licensed practical nurse (LPN). Which client is most appropriate for the RN to assign to the LPN?
| Remember the LPN’s scope of practice. Delegating clients to others requires that we be aware of the limitations of each staff member. LPNs are not able to take care of individuals with needs that must be addressed by the RN. |
5593 A registered nurse (RN) and a licensed practical nurse Correct answer: 1 In delegation, “dumping off” a client who is annoying or complex is a violation of delegation (LPN) are working together on the unit. The RN rules. Because this client is the most complex of the clients listed, the RN should retain this mentions being unhappy with the client in room 306, client in his own assignment for the shift. and states that the client has many procedures today. The other clients are a man with minimal medications, a woman with a small dressing, and a young adult male with a urinary catheter. Which client should be cared for by the RN?
| Remember the rules of delegation. Effective delegation requires that the RN refrain from assigning clients that he does not want on his team to others. |
5594 A registered nurse (RN) delegates to the unlicensed Correct answer: 3 The unlicensed assistant is not allowed to teach the client. This is only within the scope of assistant (UA) the task of teaching a preoperative practice of the RN. The current issue has nothing to do with time for feedback (option 1), the client how to cough and deep‐breathe. The charge UA’s weaknesses (option 2), or educational advancement (option 4). nurse speaks to the RN about the violation of which rule of delegation?
| Remember the roles of the unlicensed assistive personnel, and the expectations of such. Teaching falls within the role of only one group of nursing professionals. |
5595 Which of the following tasks is best delegated by the Correct answer: 3 The nursing assistant can complete and be assigned tasks that do not require teaching or registered nurse (RN) to the nursing assistant? assessment. In this case, the tasks that can best be assigned are feeding and bathing.
| The nursing assistant has a certain set of roles and expectations. Remember to consider the roles and expectations of the nursing assistant. |
5596 A registered nurse (RN) is floated to the Correct answer: 2 The psychiatric nurse needs to have a client who is stable, and the expected outcomes should medical–surgical floor from the psychiatric unit. To be favorable. In this case, the client who had surgery two days ago and has a simple dressing which of the following clients should the change is the most stable. The clients in options 3 and 4 are actively unstable, and the client in medical–surgical RN assign the float RN? option 1 is at greater risk of becoming unstable than the client in option 2 is.
| Nurses who are not familiar with the routine client population of a particular floor should be given clients with expected outcomes. |
5597 A registered nurse (RN) is assigning tasks to the Correct answer: 1 Unlicensed assistive personnel can be assigned routine tasks, such as I & O unlicensed assistive personnel (UAP). Which of the measurements. The activities in options 2, 3, and 4 involve skills that are outside the scope of following tasks would be appropriate to delegate to practice for unlicensed assistive personnel. the UAP?
| Remember what the unlicensed person is able to do: simple tasks that have routine outcomes and are not likely to result in an adverse situation. |
5598 The registered nurse (RN) engages in which role when Correct answer: 3 The role of delegation encompasses making assignments based on the skills and competence making assignments such as stable patient care, of the person to whom work is being delegated. Leadership is not making assignments based routine dressing changes, and oral medications for the on tasks; responsibility is a quality, not a role; and policies and standards provide guidelines for licensed practical nurse (LPN)? accomplishing work; however, they are not actual roles in and of themselves.
| Remember the roles of a registered nurse. Consider how the roles are used, and to what extent. |
5599 The charge nurse is delegating the transfer of clients Correct answer: 1 Pediatric nurses take care of clients with appendicitis on the pediatric unit. Clients who have from the medical–surgical unit to the pediatric unit to chest pain, are post‐mastectomy, or are undergoing cataract removal are best cared for on the make room for an influx of clients from an external adult medical–surgical floor. disaster. Which of the following clients would be best to transfer to the pediatric floor?
| Remember the roles of the nurse, and how the care of the client can best be maximized. |
5600 A nurse who works in the newborn nursery is pulled Correct answer: 1 A nurse from the newborn nursery will be familiar with babies who have reflux and are to the Emergency Department (ED). Which of the spitting up. Babies with RSV, full fontanels, and fever all are potentially infectious, and should following clients would be the best assignment for the not be placed in the care of a nurse returning to the nursery. ED nurse to make to the newborn nursery nurse?
| Remember what would be best for the client, which is a nurse who is experienced in the disorder/illness that the client has at present. An additional concern in this question is infection control. |
5601 A charge nurse is delegating assignments on the Correct answer: 1 When people are a part of the delegation process, they tend to take more pride in doing a medical–surgical unit. Which of the following aspects good job. In addition, the health care team might find something that is not clear to the nurse of delegation would be appropriately done by the RN? who is delegating. Options 2, 3, and 4 are not solutions that will have positive outcomes.
| Remember team‐building and role‐enhancing tips. |
5602 A charge nurse is making assignments for the unit. Correct answer: 4 The client in option 4 is the most stable of clients. The clients in options 1, 2, and 3 all have Which of the following assignments is best for the the potential to become more ill quickly, and are less stable. LPNs should take clients who are licensed practical nurse (LPN)? more likely to achieve expected outcomes without complications.
| Remember the roles of the LPN. Stability of the client and likelihood of achieving expected outcomes are factors in making the best assignments. |
5603 A registered nurse (RN) from the rehabilitation unit is Correct answer: 4 The client in option 4 is the most stable, and is closest to the type of client with whom a floated to a medical–surgical unit. To which of the rehabilitation nurse might work in the rehabilitation unit. The clients in options 1, 2, and 3 all following clients should the medical–surgical RN assign are unstable clients who are likely to go to the rehabilitation unit at some point, but not at this the float RN? time.
| Look for the client who is most stable, and is likely to achieve expected outcomes. |
5604 A registered nurse (RN) who is in charge for the shift Correct answer: 3 When delegating, it is important to get the staff’s thoughts on assignments. The staff is making assignments, and another RN is upset about members are the frontline personnel, and may have valuable insights and information that the assignment. Which of the following is the best would ultimately influence the assignment made. Even if the staff’s wishes cannot be response by the charge RN to the staff RN? accommodated at all times, this provides for opportunity for dialogue and the staff may be less upset if they have input.
| Delegation requires that managers make fair assignments. Which response will ensure that the nurse is more comfortable with her assignment? |
5605 A nurse is pulled from the Emergency Department Correct answer: 1 An unstable client is better suited for the ED nurse, who deals with that on a daily basis. The (ED) to the medical–surgical unit. Which client clients in options 2, 3, and 4 are more stable, and are more likely to have expected outcomes. assignment would be best for the medical–surgical unit RN to give to the ED RN?
| Remember the scope of practice for nurses. Also remember the expertise of certain specialties. |
5606 A registered nurse (RN) with six months’ experience Correct answer: 2 The client in option 2 is less stable, and should be assessed by the RN. The clients in options 1, who is orienting to the charge nurse role on the night 3, and 4 are stable, and their care is within the scope of practice of a nursing assistant. shift assigns four clients to the nursing assistant. An experienced registered nurse (RN), who is also working the night shift, should question which client assignment made to the nursing assistant?
| Remember that the nursing assistant will be able to take care of a person who is stable. |
5607 The registered nurse (RN) is assigning staff to a group Correct answer: 3 Option 3 is within the scope of the nursing assistant, and this client is not unstable at present. of clients. Which of the following is an appropriate The clients in options 1, 2, and 4 are unstable, or have greater potential to become so, and assignment for the nursing assistant? require the level of education of an RN.
| Remember the scope of the nursing assistant, and what the assistant should not be responsible for in the hospital. |
5608 Which of the following is an appropriate assignment Correct answer: 4 The client in option 4 is early in the pregnancy, and is having an expected symptom during for the licensed practical nurse (LPN) who is floated early pregnancy. The clients in options 1, 2, and 3 are less stable, and require greater from the prenatal clinic to the maternity unit? assessment and care by the RN. | Consider the LPN’s specialty, and reasons that assignments should be made based on that person’s expertise. |
| |
5609 The registered nurse (RN) in a medical–surgical unit is Correct answer: 1 The client in option 1 is the most stable of clients. The clients in options 2, 3, and 4 are less making staff assignments. The staff consists of an RN, stable, and might require the care of a more experienced nurse. an LPN, and a new graduate. Which of the following assignments is most appropriate for the new graduate?
| The new graduate should be able to care for a stable client. This is within the realm of practice for a new graduate. |
5610 During the beginning‐of‐shift assessments, which Correct answer: 4 Option 4 deals with the airway, which is a priority in care. The other options are not as high client would the nurse see first? priorities as the airway. The client in pain would require attention second, the client with diarrhea and need for skin care third (however, this also could be delegated to another caregiver for faster attention), and the dressing change would be last.
| Think ABCs and the basis for life. Which one of the options could be potentially life‐ threatening if not addressed first? |
5611 Which client should the nurse observe at the start of Correct answer: 4 Chest pressure or pain is potentially life‐threatening, making option 4 the priority. The other the work shift? options are not as critical as option 4. The nurse next would assess the recent transfer from the ICU, the second day–postop client, and finally the client with mild dementia.
| Think priority assessment, and which client may have the most life‐threatening condition. |
5612 If four call bells are alarming at the same time, which Correct answer: 2 The client in option 2 could be experiencing a severe reaction to the transfusion. The other of the clients listed would require immediate options are not as likely to be having an immediate crisis, and should be seen after client 2. intervention by the nurse? The client who is receiving IV fluids likely would be second because of the risk of infiltration or a completed infusion, followed by the client who is blind (and therefore less able to function in a new environment) and finally the client who is immobile.
| Which client would experience a severe event if not assessed or addressed first? Which client has the potential to become sick quickly? |
5613 There has been a flood. Which of the following clients Correct answer: 1 The pregnant client who has experienced a disaster could develop preterm labor, and in the emergency shelter would the nurse need to see requires immediate assessment. The other clients might be ill, but will not suffer immediate first? consequences from a natural disaster.
| Which client could experience a major complication from the stress of a natural disaster if not seen first? |
5614 A client has been involved in an automobile accident. Correct answer: 2 Clear fluid from the nose is a priority, indicating head injury. Option 1 is serious, but can be The nurse is assessing the client. Which assessment managed after the client with the head injury. Options 3 and 4 are relatively minor, as head requires priority intervention? wounds bleed profusely.
| Which problem is most serious, and would have the most adverse outcome if not attended to immediately? |
5615 A client has sustained a fractured femur. Which of the Correct answer: 2 Femur fractures can precipitate a fat embolism, and so require immediate assessment, such following assessments should be completed first? as a neurological assessment. The pain level is important, but not as important as neurological assessment. Nutritional status and a medical history can be assessed at a later time.
| Consider which client is the least stable and might have a condition that could precipitate another illness. |
5616 A client has sustained full‐thickness burns to the Correct answer: 4 This is indicative of compartment syndrome, which is a condition that will cause ischemic lower legs. Upon assessment, the client reports injury and loss of limb within a few hours if a fasciotomy is not done to treat this, and is a tingling and numbness of the toes. What should be the priority in the care of clients. The nurse should assess the distal extremity for adverse nurse s priority or priorities? circulatory changes, and then notify the physician. Elevating the head of the bed and administering pain medication will not address this potential loss of limb. Elevating the foot of the bed actually could worsen the situation by further reducing blood flow to the distal extremity.
| Consider what the illness in question (compartment syndrome) is, and what the priority is in this situation. If the treatment is a surgery option, only a physician can do this and save the limb. |
5617 A male client is extremely agitated. He has made Correct answer: 2 This client is in danger of harming either himself or others, depending on what the thoughts reference to disturbing thoughts, and is pacing the are, and needs supervision. The nurse needs to protect the client and all others in the room. What is the nurse’s priority intervention? environment. The other options will not address this priority.
| This client is a risk for hurting himself or others. Think about what should be done to prevent this from occurring. |
5618 Which of the following clients should the nurse plan Correct answer: 4 The client in option 4 is exhibiting danger signs. Depressed clients who suddenly begin to feel to see first after receiving intershift report? better are at risk for suicide. The other clients are exhibiting common signs of their illnesses.
| What are the danger signs of a depressed person? When is the depressed person likely to carry out acts of violence? |
5619 Which of the following client situations requires Correct answer: 3 Option 3 is a danger sign, and requires immediate intervention. Frequent swallowing is an immediate action by the nurse? indicator of bleeding. The other options include common signs of those health problems.
| Which client is at greatest risk for an adverse outcome? Which client is most likely to be unstable? |
| |
5620 A client is receiving a blood transfusion, and develops Correct answer: 3 The client is experiencing a transfusion reaction, and must be addressed immediately. The a rash and fever in the first five minutes. What is the other options are not indicated for the client experiencing a transfusion reaction. nurse’s priority?
| What is of concern in a blood transfusion? What are the key steps during a reaction? |
5621 A client is having a grand mal seizure. The family Correct answer: 3 Option 3 is a physiologic need, and must be addressed first. Option 1 is important, but does reports that this seizure has lasted much longer than not address the vital body systems that might be affected. Option 2 is not a priority at this any previous event. What is the nursing priority at this time, and option 4 is beyond the scope of practice of the nurse. time?
| Which of the options is the best choice based on Maslow’s hierarchy of needs? Remember the ABCs and highest priority. |
5622 An infant is admitted with Failure to Thrive, and the Correct answer: 2 Safety is the first priority for any client. The situation of an infant being left in the care of a parents are being interviewed by the nurse. Which school‐age child must be investigated. The other options are important, but do not come comment made by the family requires immediate before safety. Option 3 suggests an acute illness that needs treatment, while options 1 and 4 clarification? imply that the client already is being treated for the failure to thrive, and as such are not emergencies.
| Which of the options is the best choice to address the needs of all parties? In option 2, not only is the infant at risk, but so is the school‐aged child who has been appointed as caretaker at certain times. Use knowledge of infant and child safety to make this selection. |
5623 Which of the following clients should the nurse assess Correct answer: 4 A child with head lag at 10 months of age requires immediate intervention, as neurological first? aspects must be addressed. The clients in the other options represent normal developmental levels.
| Recall development, and the priorities associated with this concept, to select the correct answer. |
5624 Which of the following clients requires immediate Correct answer: 4 Option 4 is a life‐threatening condition. Option 1 is strep throat, option 2 is chickenpox, and nursing intervention? option 3 is scabies, all of which require intervention but are not as emergent.
| Which of the options is the most serious, with the highest likelihood of an adverse outcome? |
5625 A child presents to the Emergency Department (ED) Correct answer: 2 This child is at risk for developing worsening respiratory distress. Remaining calm and with drooling, high fever, and difficulty breathing. A administering cool mist might decrease the risk of respiratory distress, but preparing for diagnosis of epiglottitis is made. Which of the intubation is priority. Options 3 and 4 are important, but not the priority. following would be a priority nursing intervention?
| Which of the interventions is most likely to prevent an adverse outcome? |
5626 A 40‐year‐old man presents to the Emergency Correct answer: 1 Assessment is the first step in any situation, and the other options are all interventions that Department (ED) with complaints of fever, diarrhea, cannot be completed without first making an assessment. and decreased urine output. Which of the following is/are the first nursing intervention(s)?
| What is the nurse’s first priority in care of the client? What is needed to make a proper diagnosis of the client’s condition? |
5627 Which of the following clients is a nurse’s priority Correct answer: 3 Option 3 is indicative of impending delivery. The clients in the other options present with when administering care? situations that are expected or typical.
| Which of the clients is most likely to become ill quickly? Which of the clients might experience an adverse outcome if not addressed first? |
5628 Which of the following clients would the nurse assess Correct answer: 4 The client in option 4 could be experiencing compartment syndrome, which is a medical first at the beginning of the day shift after receiving emergency. The other options are not emergent or life‐threatening, although all clients require intershift report? attention once the client with the potential emergency is addressed.
| Which of the clients would be considered the sickest, and most likely to suffer an adverse outcome without adequate intervention? |
5629 A 48‐year‐old client has just been diagnosed with a Correct answer: 1 The nursing diagnosis in option 1, Risk for Ineffective Coping, is the priority, as this person is cancerous tumor in the abdomen. Which of the experiencing a life‐altering event. The nursing diagnoses listed in the other options might apply following nursing diagnoses is a priority? at some point, but option 1 is most detrimental, and is more likely to occur first.
| Which of the options deals directly with the client’s feelings about the situation? |
5630 A client has been diagnosed with a terminal illness, Correct answer: 4 Option 4 is priority for this dying client. Grief is normal after this type of diagnosis, and must advanced testicular cancer. At the seventh day postop, be prepared for. The client is exhibiting grief through the withdrawn behavior and drawn the client is withdrawn, and is sleeping all day with the window shades. The client s statement also indicates some remorse for past inadequate health window shades closed. The wife tells the nurse that screening, and is also consistent with grieving. The client may be at risk for ineffective coping she is concerned because her husband had said, “I (option 2), but option 4 would take precedence. There is not enough data to support the should have been doing my self‐exams but I was too nursing diagnoses of Risk for Falls or Anxiety. busy!” What is the priority nursing diagnosis for this client that the nurse should discuss with other members of the health care team?
| Note that the client is withdrawn and keeps the window shades closed. Note also the client’s regretful statement. Visualize this client and choose the option that is the best match. |
5631 A nurse is preparing to administer pain medications Correct answer: 1 The priority when caring for a client is handwashing. Opening the container of pills, raising the to a client. What should the nurse do first when head of the bed, and getting the client a drink can be done after the handwashing. entering the client’s room?
| Which of the options would prevent the spread of microorganisms? |
5632 The nurse is giving a medication to a client at 8:00 Correct answer: 3 Option 3 is critical for client safety. Options 1 and 2 are important, but not safety‐related, and A.M. What is the first thing the nurse should do before option 4 is inappropriate. administering the medication?
| Recall the six rights of drug administration: right patient, right drug, right dose, right route, right time, and right documentation. |
5633 An adult male is scheduled for a coronary artery Correct answer: 3 Option 3 is important so that potentially fatal reactions do not occur. Option 1 is important bypass graft. The nurse has received the preoperative postop. Option 2 is important after checking the history, and option 4 is not appropriate. medications from the pharmacy. Which of the following is a priority in administering these drugs?
| Which of the options would be critical when administering a medication? |
5634 A client diagnosed with phobia who has a fear of Correct answer: 2 Option 2 must be done in order for the client to progress through the stages of phobic water is admitted to outpatient counseling. What disorders. Option 1 is not appropriate, and options 3 and 4 might cause more anxiety. priority goal of care would the nurse formulate for this client?
| In regard to the client with phobias, what is most important in preparing to address those fears? |
5635 A woman calls the hospital Emergency Department Correct answer: 4 Option 4 is important in this situation, as showering will obscure the evidence. This client also (ED) stating that she has been raped. Which of the needs to be seen to address the both the physiological and psychological trauma from the following is a nursing priority? rape. The other options all are important but can be addressed afterward.
| In a rape situation, evidence is a key factor. Which of the following is a key aspect related to evidence? |
5636 A client has been diagnosed with bipolar disorder. Correct answer: 1 Manic individuals do not take time to stop and eat, so nutrition is priority. Stopping the She is in the manic phase, and is walking about the unit walking or medicating her will not address the situation, and seclusion is inappropriate. rapidly, with no signs of slowing down. What is a nursing priority at this time that the nurse should share with other members of the health care team?
| A client who is manic does not take the time for basic activities, and might not be able to slow down long enough to care for herself. |
5637 The nurse enters the room of a client diagnosed with Correct answer: 1 Assessment is the first step in any situation. Options 2 and 3 are important, but assessment depression. The nurse finds the client non‐responsive, comes first. Option 4 is inappropriate. with a bottle of pills lying on the floor. What is the nursing priority at this time?
| Which option addresses what the nurse would do first in any situation? Also, what is needed to address the severity of the situation? |
5638 A newborn has been admitted to the nursery. Which Correct answer: 1 A high‐pitched cry in a newborn is indicative of a neurologic problem. The findings in the assessment finding is of the highest priority for this other options all are normal. newborn, which the nurse would ensure is addressed?
| Which assessment finding leads the nurse to believe that there is a serious problem in this newborn? Which is abnormal? |
5639 A client has had an aortic valve replacement. He is Correct answer: 1 Options 1 and 4 are the priorities for safety, and must be addressed first. Of these two, option started on sodium warfarin (Coumadin), and is soon to 1 is most likely to be unknown to the client and requires the greatest teaching, and therefore is be discharged. The nurse instructs the float RN that the priority. The other options all are important, but can be addressed after the issue of which of the following is the priority teaching at this food–drug interactions has been addressed. time?
| Which options can cause a serious reaction with clients on Coumadin? |
5640 A client is scheduled for a cardiac catheterization in Correct answer: 1 Safety is a priority here, and allergies to iodine or shellfish could be dangerous to the client the morning. Which of the following would be a who is undergoing a cardiac catheter with iodine‐containing dye. The nurse would need to priority assessment by the nurse who is working the document the allergy appropriately, and to ensure the cardiologist and cardiac cath team are evening shift of the day prior to the scheduled notified to use a hypoallergenic dye. All of the other options are important, but not as diagnostic test? important as allergies are.
| Which of the options will have the greatest adverse effect in a person who is undergoing a cardiac catheter with dye? |
5641 A child has been diagnosed with strep throat. What Correct answer: 1 Option 1 is immediate priority in teaching, as this is needed to ensure that the child will would be the priority teaching point that the nurse become well. All of the other options are important, but not priorities. would address before discharge?
| Which of the actions will ensure a positive outcome for the client, and is a major teaching point with persons on antibiotics? |
5642 A client has had a liver biopsy for possible Correct answer: 3 A priority for a client post–liver biopsy is bleeding, because the liver is a highly vascular organ. hepatocarcinoma. Which intervention is of highest Positioning the client with the right side down can help to decrease the bleeding, because priority for the nurse to delegate to the licensed pressure is exerted both by the weight of the chest above and the mattress below. Increased practical nurse (LPN)? fluids will not decrease bleeding; aspirin will increase bleeding; and a supine position will not decrease the bleeding.
| What is a postoperative complication for a person undergoing a liver biopsy for liver cancer? Remember how vascular the liver can be. |
5643 An adult male is diagnosed with lung cancer. He is Correct answer: 2 Safety is a priority. Oxygen is flammable, so turning off the oxygen and removing the lighter admitted to a semi‐private room, and is placed on are immediate interventions for the safety of everyone. Yelling for help and removing the oxygen at two liters/minute. When entering the room, clients will not stop the client from setting the room on fire. Pulling the alarm might be the nurse finds the client attempting to light a necessary if a fire starts, but not at this juncture. Removing the roommate does not address cigarette. What is the first action the nurse should the client with the lighter. take?
| Which of the options will ensure the health and wellness of all persons in the area? |
5644 A client has a spinal cord injury at the level of C6, and Correct answer: 1 Assessment is the first priority for all situations. In this case, the client could be experiencing is in the day room experiencing flushing of the skin, autonomic hyperreflexia, which is triggered by a noxious stimulus below the level of the spinal diaphoresis, and a throbbing headache. What is the lesion and leads to sudden and severe hypertension. The most common cause is a distended nurse’s priority action at this time? bladder, so the nurse should check that first. Next, the blood pressure should be measured, and the client might need to be removed from the day room if the source cannot be detected and corrected immediately. The client does not require pain medication for an episode of autonomic hyperreflexia, although an antihypertensive agent may be ordered.
| Remember that autonomic hyperreflexia can occur with clients who have spinal cord injury. Recall also the signs and symptoms of hypertension. Use this knowledge and information about the cause to make a selection. |
5645 A client has been placed in skeletal traction for leg Correct answer: 1 A priority in the care of the client with skeletal traction is skin integrity, as skeletal traction fractures sustained in a motor vehicle accident. What requires the use of pins. Because the skin is broken by the traction pins, there is a risk of is the priority nursing assessment for this client? infection to the bone. Bowel sounds and nutritional status are important, but the risk of infection takes priority, and the knowledge level is not as important at this time.
| Which of the options can have the greatest impact on the client? |
5646 A client who was involved in a motor vehicle accident Correct answer: 1 A priority for the teaching that will occur in rehabilitation is the client’s willingness to learn. is being admitted to the rehabilitation center for All of the other options can be important, but if the client is not willing, those answer options ongoing care. Which of the following items is the most are not relevant. important for the admission nurse to assess as a predictor of the client’s success in rehabilitation therapy?
| First consider that a major focus of rehabilitation is learning to regain function or adapt to disability. Next, ask what the key components of teaching and learning are. |
5647 A woman in preterm labor complains of fatigue, Correct answer: 1 Turning the client to the left side is a priority in prenatal care to facilitate blood flow to the headache, and dizziness. What would be a priority fetus. The other options are not necessary when option 1 is performed. nursing intervention by the nurse at this time?
| Which of the options will maximize blood flow and nutrients to the fetus? |
5648 A client is diagnosed with type 1 diabetes mellitus. Correct answer: 1 The priority for this client is visual acuity, as this client will be self‐administering insulin. The What would be of priority when the nurse is teaching other options are important, but safety is a priority. the client how to manage this health problem?
| Focus on the critical issue, which is learning to manage diabetes. Reason that this includes diet, exercise, and insulin administration (because it is type 1). From there, consider which sensory aspect could be affected, and how this could affect self‐care. |
5649 A new mother has brought her 3‐month‐old infant to Correct answer: 1 Developmentally, this child is getting ready to start progressing to other stages. This is a the pediatrician’s office for a well‐baby checkup. The safety issue for parents. The other options are not as high‐priority at this age. nurse would consider which of the following to be the priority type of information needed by this parent?
| What is a critical element in the care of a child and teaching for the parent as that child grows older? |
5650 A physician has ordered a nasogastric (NG) tube to be Correct answer: 1 The priority in this situation is safety (to avoid risk of aspiration of tube feedings), and the inserted for a client with full‐thickness burns to the critical issue is which method is most reliable in determining NG tube placement. Visualization legs. Which of the following actions by the nurse to of placement using x‐ray is most reliable, followed by checking pH. Air should not be used as confirm NG tube placement would be a priority before the sole method of checking placement, because it is not as reliable. Instilling water is not a starting a continuous enteral feeding? method used to check placement, although it would verify tube patency.
| Correct placement is critical when an NGT is used for feedings. What is the priority in an NGT insertion prior to instilling feedings? |
5651 A child is diagnosed with pneumonia. Upon Correct answer: 1 Low levels of oxygen can be harmful, and immediate application of oxygen is needed. The assessment, the oxygen saturation is 88%. What would nurse should prepare to administer oxygen with a physician’s order. Checking other vital signs be the nurse’s next priority action? can be done after the oxygen issue is addressed, while options 3 and 4 are unnecessary.
| Think about the ABCs and what is a priority action with a client whose saturation is low. How can the client’s health be maximized? |
5652 Which client should be seen first by the pediatric Correct answer: 3 Two degrees in one hour is a quick escalation of temperature, and this client needs nurse after receiving intershift report? assessment by the nurse. The clients in the other options have important needs, but these can be addressed later. The client in pain should be assessed second, the child requiring a feeding third, and the child who is crying with boredom last. As an alternative, the nurse might delegate the feeding (which is a task) to another caregiver.
| Which of the children is at risk for a serious adverse condition? |
5653 A client is referred to a surgeon by the general Correct answer: 3 Autonomy is the right of individuals to take action for themselves. Beneficence is duty to help practitioner. After meeting the surgeon, the client others by doing what is best for them, whereas negligence is a legal term. Veracity is decides to find a different surgeon to continue truthfulness. Privacy is the nondisclosure of information by the health care team. treatment. The nurse supports the client’s action, utilizing which ethical principle?
| Select the response that protects the client s information, but allows for the delivery of necessary care. |
5654 A nurse forgets to administer a client’s diuretic and Correct answer: 2 Negligence is the unintentional failure of an individual to perform or not perform an act that the client experiences an episode of pulmonary a reasonable person would or would not do in the same or similar circumstances. Options 3 edema. This medication error would be considered and 4 do not fit the description of the event, and option 1 is the opposite of option 2. negligence if it constituted which of the following?
| Options 1 and 2 are opposites, which is a clue that one of them may be correct. Choose option 2 over option 1 because it matches the description given in the stem of the question. |
5655 A new graduate nurse orientee plans to show an Correct answer: 1 The nurse is exercising autonomy, the right to make one’s own decision. Nurses who follow adolescent client a video about self‐injection this principle recognize that each client is unique. In this situation, perhaps because of the technique. A staff nurse remarks, “I gave the client developmental level, the nurse assessed that a video would be a better teaching‐learning written literature yesterday, so the video probably method than written literature. Paternalism restricts the freedom of the individual because isn’t necessary.” The nurse orientee proceeds with another determines choices. Noncompliance occurs when an individual is fully aware of the showing the video and discussing the skill with the consequences yet chooses the action anyway. Informed consent is providing agreement to adolescent after engaging in decision making related undergo treatment following a description of a procedure with the risks, benefits, and to which of the following? alternatives explained.
| Use the process of elimination. The correct answer is the one that supports the nurse s right to make decisions about his own practice. |
5656 A client asks why a diagnostic test has been ordered Correct answer: 4 Fidelity means being faithful to agreements and promises. This nurse is acting on the client s and the nurse replies, “I’m unsure but will find out for behalf to obtain needed information and report it back to the client. Nonmaleficence is duty to you.” When the nurse later returns and provides an do no harm. Veracity refers to telling the truth for example, not lying to a client about a explanation, the nurse is acting under which principle? serious prognosis. Beneficence means doing good, such as by implementing actions (e.g., keeping a salt shaker out of sight) that benefit a client (heart condition requiring sodium‐ restricted diet).
| Use the process of elimination. The correct answer is the one that matches the description in the stem; that is, the nurse made a promise to a client and kept it, which constitutes fidelity. |
5657 An individual has a seizure while walking down the Correct answer: 1 The nurse must have a relationship with the client that involves providing care. The street. During the seizure, a nurse from a physician’s relationship is usually a component of employment. Options 2 and 4 are false. Option 3 is a office is noticed driving past without stopping to assist. true statement, but is not the one that applies to this case. The individual sues the nurse for negligence but fails to win a judgment for which of the following reasons?
| Use the process of elimination and nursing knowledge. The correct answer is the one that recognizes that the nurse was not in the role of employee at the time of the incident, removing the requirement of acting on the client’s behalf. |
5658 The nurse is participating in a seminar about legal and Correct answer: 1 Law is not the sole source of the ethical practice of nursing; numerous legal sources influence ethical practice of nursing for continuing education nursing practice. An individual should understand the ethics of a profession before becoming a credit. Which statement by a nurse best describes the member of that profession because those ethics may differ from personal ones. relationship between law and ethics for the practice of nursing?
| Use the process of elimination and nursing knowledge to answer the question. The wording of the question tells you that only one answer can be correct. |
5659 A female client being treated in an outpatient setting Correct answer: 2 In this situation, there was no nurse–client relationship. Although the neighbor offering the for blood clots in the leg is taking anticoagulant aspirin was a nurse, this action did not occur as a component of the nurse’s employment. All of medication. The client reports to her neighbor, a the other requirements were present. nurse, that she has a headache. The nurse offers the individual aspirin for the headache, which she takes. The client suffers a bleeding episode secondary to interaction between the aspirin and the anticoagulant. The legal nurse consultant interprets that which of the following elements of malpractice is missing from this case?
| Use the process of elimination. The wording of the question tells you that all of the options are requirements that must be met. Choose the one that focuses on the personal, not professional, relationship between the client and the nurse. |
5660 The client has decided to discontinue further Correct answer: 3 Autonomy refers to the right to make one’s own decisions. Justice refers to fairness; fidelity treatment for cancer. Although the nurse would like refers to trust and loyalty; confidentiality refers to the right to privacy of personal health the client to continue treatment, the nurse recognizes information. the client is competent and supports the client’s decision using which of the following ethical principles?
| Use the process of elimination. The wording of the question indicates that only one option is correct and that you need to select the principle that is consistent with the circumstances in the question. |
5661 The physician orders a medication in a dose that is Correct answer: 2 Nurses, along with physicians, can be charged with negligence for failing to recognize the considered toxic. The nurse gives the medication to incorrectly prescribed dosage of a commonly known drug. The other responses are incorrect the client, who later suffers a cardiac arrest and dies. interpretations of possible consequences. Which of the following consequences can the nurse expect?
| The wording of the question tells you that only one option is correct. Choose the response that holds both individuals accountable, since the nurse failed to question an incorrect dose. |
5662 A nurse and teacher are discussing legal issues related Correct answer: 3 A Nurse Practice Act serves to protect the public by setting minimum qualifications for to the practice of their professions. The teacher asks nursing in relation to skills and competencies. One way it fulfills responsibility to protect the what is the primary purpose of the Nurse Practice Act public is by defining the scope of nursing practice in that state. The state’s board of nursing in that state. The nurse replies that Nurse Practice Act approves schools to operate but does not accredit them. It does not enforce ethical standards. is intended to do which of the following?
| Use the process of elimination and basic nursing knowledge to answer the question. The wording of the question tells you that only one option is a true statement. |
5663 A nurse is concerned about maintaining the standards Correct answer: 4 The client has a right to confidentiality. Unless a nurse is assigned presently to care for an for client confidentiality. The nurse can perform the individual, the nurse should not seek or share known details about a client s status. Family duties of the position and still maintain client members would need approval from the client and the physician prior to reviewing a medical confidentiality by: record.
| Select the response that protects the client s information, but allows for the delivery of necessary care. |
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5664 The nurse caring for a client fails to monitor the client Correct answer: 1 Negligence is defined as the failure to act as a reasonable person guided by ordinary in the postoperative period, as is the standard of care. consideration and situations, or doing something that a reasonable person would not do. The The nurse would be guilty of: other answers are unrelated to the action.
| Recall the definition of negligence: failure to do what a reasonable person would in similar circumstances. The other responses do not apply to the situation. |
5665 A nurse accidentally administers a drug to the wrong Correct answer: 2 Malpractice occurs when any form of negligence causes injury to the client. It is the failure to client, leading to a drug reaction. This action could lead act as a reasonable person with the same knowledge and experience would do. A tort is a to charges of: wrong or injury that a person has suffered from another's actions. Fraud is deliberate deception, and assault is the threat of harm or unwanted contact with a client that causes the client fear.
| Select the response that best describes the situation. Recognize that malpractice best describes this situation. |
5666 While working in an acute care environment, the Correct answer: 3 The nurse can decrease the risk of malpractice claims and litigation by maintaining expertise nurse can reduce the risk of malpractice litigation by: in practice by keeping up to date in knowledge and skills, understanding the effects and correct dosage of medication, and practicing within the statutory scope of practice. The nurse should not offer value judgments at any time or discuss errors with the family. Incident reports should be kept on file but do not decrease the risk of malpractice litigation.
| Recall the definition of malpractice. Maintaining expertise is the best way to reduce risk. |
5667 The nursing class at the local university is discussing Correct answer: 1 Law is not the sole source of the ethical practice of nursing, as there are numerous legal legal and ethical practice of nursing. Which statement sources influencing nursing practice. An individual should understand the ethics of a profession by a student nurse best describes the relationship when entering it, as those ethics may differ from personal ones. between law and ethics for the practice of nursing?
| Recall that the ethics of a practice assist in solving moral dilemmas and do not necessarily prevent legal action. |
5668 An individual is being treated in an outpatient setting Correct answer: 2 In this situation, there was no nurse–client relationship. Although the neighbor offering the for blood clots in the leg and is on an anticoagulant aspirin was a nurse, this action did not occur as a component of the nurse s employment. All of medicine. The client complains to the next‐door the other requirements were present. neighbor, a nurse, about a headache. The nurse offers the individual aspirin for the headache, which the individual takes. The individual suffers a bleeding episode secondary to the aspirin and anticoagulant combination. The element of malpractice missing is: | Recall the elements of malpractice. The nurse did not owe a duty to the neighbor. The other elements are present. |
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5669 A hospital discharge planning nurse is making Correct answer: 3 According to JCAHO Pain Standards, if a facility cannot treat a client for pain, the individual arrangements for a client (who has an epidural must be referred to a facility that can provide the skill. The physician may not be able to catheter for continuous infusion of opioids) to be extend hospitalization because of insurance limitations (option 1). It is the long‐term care placed in a long‐term care facility in the client's facility's decision and responsibility to become prepared to provide a new service (option 2). neighborhood to encourage family visiting. The facility Private‐duty nurses may be cost prohibitive for the family and the long‐term care facility may has never cared for a client with this type of need. not have the resources needed to provide safe care for this client (option 4). What would be the discharge planning nurse's best action?
| Recall accreditation agencies standards on pain control to allow you to plan acceptable care measures. |
5670 A client was assessed to have a Stage I pressure ulcer Correct answer: 2 Impaired skin integrity is a result of constant shearing force and pressure (option 2). The on his hip despite every two‐hour turning and client was turned and positioned frequently enough, making option 1 incorrect; in addition, positioning. The nurse formulates which of the this type of statement is incorrectly written as it implies that the staff are to blame for the following as the appropriate nursing diagnosis for this client’s condition. Options 3 and 4 are incorrect because the client has an actual diagnosis, not client? a risk diagnosis.
| The critical phrase is appropriate nursing diagnosis. Discriminate between actual and risk diagnoses to eliminate options 3 and 4, and then use information in the question to choose option 2 over option 1. |
5671 A nurse stops to assist a man on the street who is Correct answer: 1 The Good Samaritan Act provides freedom from liability for professional people providing having a seizure. Despite the nurse’s assistance, the first aid. man dies. Protection from liability is provided the nurse by the:
| Note that the situation is an emergency and the Good Samaritan Act is the only option that addresses protection from liability. |
5672 When the client resists taking a liquid medication that Correct answer: 2 Diluting the medication in a beverage may make the medication more palatable. Using critical is essential to treatment, the nurse demonstrates thinking skills, the nurse should try to problem‐solve in a situation such as this before asking critical thinking by doing which of the following first? for the assistance of the nurse manager. Suggesting an alternative method of taking the medication (provided that there are no contraindications to diluting the medication) should improve the likelihood of the client taking the medication.
| The critical word is first. Options 3 or 4 may ultimately be necessary, but not until option 2 has been tried without success. |