Mary Ann Hogan NCLEX PN

44.The nurse concludes that further explanation about standard precautions is needed when a family member of a client with acquired immunodeficiency syndrome (AIDS) states:</question> <question_image/> <choice_1>"I need to wear a mask when I visit."</choice_1> <choice_2>"We can still hug one another."</choice_2> <choice_3>"I don't need to use special dishes."</choice_3> <choice_4>"My children cannot catch AIDS if they play a board game together."</choice_4>

1</correct> <rationale>Standard precautions are used with all clients, regardless of the medical diagnosis. Clients with AIDS are not contagious, and family members are not required to wear protective equipment in a casual interaction.</rationale>

36. A Code Red (fire) has been announced on the hospital unit. What is the nurse's first response?</question> <question_image/> <choice_1>Remove clients in danger from the fire.</choice_1> <choice_2>Contain the fire.</choice_2> <choice_3>Report the fire to other staff.</choice_3> <choice_4>Extinguish the fire.</choice_4>

1</correct> <rationale>The primary responsibility of the nurse is client safety. Removing a client from danger should be the priority. Others can come to help contain or extinguish the fire.

17. A nurse is working for an HMO and caring for one of the members. The member asks if he can see any doctor of his choice in the community. The nurse explains: <choice_1>"You may see any doctor of your choice but there will be additional costs if the doctor is outside the HMO."</choice_1> <choice_2>"No, you must see a doctor within the HMO."</choice_2> <choice_3>"No, you must see a doctor within the HMO or you will cancel your current health insurance policy."</choice_3> <choice_4>"Yes, you may see anyone you want."</choice_4>

1</correct> <rationale>Client/member freedom of choice cannot be taken away. However, HMOs require members to stay with doctors within the network unless they wish to pay all or a larger part of the cost of going outside the system. Options 2 and 3 would remove the client/member's freedom of choice and option 4 would be incorrect.</rationale>

3. A new graduate nurse orientee plans to show an adolescent client a video about self-injection technique. A staff nurse remarks, "I gave the client written literature yesterday, so the video probably isn't necessary." The nurse orientee proceeds with showing the video and discussing the skill with the adolescent after engaging in decision making related to which of the following? 1. Autonomy 2. Informed consent 3. Paternalism 4. Noncompliance

1</correct> <rationale>The nurse is exercising autonomy, the right to make one's own decision. Nurses who follow this principle recognize that each client is unique. In this situation, perhaps because of the developmental level, the nurse assessed that a video would be a better teaching-learning method than written literature. Paternalism restricts the freedom of the individual because another determines choices. Noncompliance occurs when an individual is fully aware of the consequences yet chooses the action anyway. Informed consent is providing agreement to undergo treatment following a description of a procedure with the risks, benefits, and alternatives explained.

40.A major portion of a construction project has collapsed. The emergency department (ED) has been notified that numerous victims are being transported to the ED. The first action of the ED nurses should be which of the following?</question> <question_image/> <choice_1>Assess the department for resources—staff, beds, equipment.</choice_1> <choice_2>Implement the personnel recall system.</choice_2> <choice_3>Discharge stable clients.</choice_3> <choice_4>Set up a temporary morgue.</choice_4>

1</correct> <rationale>The nurses must first assess current emergency department resources. No decisions can be made without a comprehensive assessment, such as outlined in option 1. The other options are not as encompassing, and a comprehensive assessment is needed with a possible impending disaster.</rationale>

21. The nurse is starting the first round of data collection at the beginning of the shift. The first room the nurse enters belongs to a client with a diagnosis of unstable diabetes. The nurse finds the client confused, cold and clammy, and having difficulty breathing. The first priority of care would be to:</question> <question_image/> <choice_1>Deliver oxygen.</choice_1> <choice_2>Test the client's blood sugar.</choice_2> <choice_3>Call the doctor.</choice_3> <choice_4>Run down the hall trying to find help.</choice_4>

1</correct> <rationale>Remembering the ABCs, the first priority is always breathing. Once oxygen has been applied, testing blood sugar, summoning help, and having someone call the physician would all be appropriate care measures.</rationale>

5.An individual has a seizure while walking down the street. During the seizure, a nurse from a physician's office is noticed driving past without stopping to assist. The individual sues the nurse for negligence but fails to win a judgment for which of the following reasons <choice_1>The nurse had no duty to the individual.</choice_1> <choice_2>The nurse did what most nurses would do in the same circumstance.</choice_2> <choice_3>The nurse did not cause the client's injuries.</choice_3> <choice_4>The nurse was off-duty at that time.</choice_4>

1</correct> <rationale>The nurse must have a relationship with the client that involves providing care. The relationship is usually a component of employment. Options 2 and 4 are false. Option 3 is a true statement, but is not the one that applies to this case.</rationale>

33.Which of the following medication orders should the nurse question?</question> <question_image/> <choice_1>Morphine sulfate (Morphine) 4mg IV every 3 to 4 hours as needed for pain</choice_1> <choice_2>Ceftriaxone (Rocephin) IVPB every 8 hours</choice_2> <choice_3>Furosemide (Lasix) 40 mg po daily</choice_3> <choice_4>Metoprolol (Lopressor) 50 mg po twice a day</choice_4>

2</correct> <rationale>Option 2 does not have a medication dosage listed. All other options have required information for dispensing medications.</rationale>

19.The nurse is working in a very busy long-term care facility and recognizes the importance of good time management skills to the delivery of safe nursing care. The nurse recognizes the goal of time management is to:</question> <question_image/> <choice_1>Find more time to accomplish care delivery.</choice_1> <choice_2>Use time wisely by setting a reasonable amount of time to spend on tasks.</choice_2> <choice_3>Manage time perfectly from the first day of the new job.</choice_3> <choice_4>Do the best job possible without worrying about priorities.

2</correct> <rationale>The goal of time management is not finding more time, but using time more wisely by setting a reasonable amount of time to spend on individual tasks. It takes practice and doesn't occur on the first day of the new job. One aspect of time management is setting priorities.</rationale>

7. A female client being treated in an outpatient setting for blood clots in the leg is taking anticoagulant medication. The client reports to her neighbor, a 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? <choice_1>Breech of duty</choice_1> <choice_2>Duty owed</choice_2> <choice_3>Injury</choice_3> <choice_4>Causation between nurse's action and injury</choice_4>

2</correct> <rationale>In this situation, there was no nurse-client relationship. Although the neighbor offering the aspirin was a nurse, this action did not occur as a component of the nurse's employment. All of the other requirements were present.

9. The physician orders a medication in a dose that is considered toxic. The nurse gives the medication to the client, who later suffers a cardiac arrest and dies. Which of the following consequences can the nurse expect? <choice_1>The doctor, not the nurse, can be charged with negligence because the doctor ordered the dose.</choice_1> <choice_2>The nurse and the doctor can dually be charged with negligence.</choice_2> <choice_3>Because the nurse actually gave the medication, only the nurse can be charged with negligence.</choice_3> <choice_4>Negligence will not be charged, as this event could happen to any reasonable person.</choice_4>

2</correct> <rationale>Nurses, along with physicians, can be charged with negligence for failing to recognize the incorrectly prescribed dosage of a commonly known drug. The other responses are incorrect interpretations of possible consequences

12. Which of the following tasks would not be appropriate for the LPN/LVN to accept when delegated by the registered nurse (RN)? <choice_1>Instructing the LPN/LVN to reinforce teaching of the RN's assigned clients prior to discharge</choice_1> <choice_2>Administering IV push morphine sulfate to the client with post-operative pain</choice_2> <choice_3>Removing a dressing from a postoperative client's abdomen</choice_3> <choice_4>Collecting and documenting vital signs and reporting changes to the RN</choice_4>

2</correct> <rationale>The decision to delegate should be consistent with the nursing process (appropriate assessment, planning, implementation, and evaluation). The person responsible for client assessment, diagnosis, care planning, and evaluation is the registered nurse. LPN/LVN functions include reinforcing teaching and removal of dressings. However, LPN/LVNs are not allowed to administer IV push medications and should refuse this assignment as it falls outside of their scope of practice.

16. An LPN/LVN is about to make first rounds after receiving an intershift report at 3 p.m. In what order should the LPN/LVN see the following clients? Fill in the order below <choice_1>A 54-year-old client 4 hours post-cardiac catheterization who has mild discomfort at the access site</choice_1> <choice_2>A client newly diagnosed with diabetes mellitus who needs reinforcement of sick day management guidelines</choice_2> <choice_3>A client who arrived 30 minutes ago from the postanesthesia care unit</choice_3> <choice_4>A client who is ready for discharge but will not have transportation to home available until 5 p.m.</choice_4> <choice_5>A client with pneumonia who has received two doses of IV antibiotics and has an oxygen saturation of 93%</choice_5>

3, 5, 1, 4, 2</correct> <rationale>Priority setting can be implemented using a variety of models. The client who is postoperative should be seen first because the client is newly arrived on the unit and is at most risk of becoming unstable or experiencing a change in clinical condition. The client with pneumonia 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 examination 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.</rationale> <cognitive_ll>Analysis</cognitive_level> <client_need>Safe Effective Care Environment: Coordinated Care</client_need> <integrated_process>Nursing Process: Planning</integrated_process> <content_area>Leadership/Management</content_area> <strategy>Determine which client is at most risk of becoming unstable to pick client 3, followed by monitoring 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 fourth 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.</strategy> <special_handling>0</special_handling> </record>

15. A staff nurse decides to attend a continuing education class on the use of advanced technology in health care delivery. The nurse manager should interpret this participation in staff development and continuing education as which of the following? <choice_1>A waste of time because CEU credits are not a mandate for promotion or relicensure</choice_1> <choice_2>Not important because advanced technology is too expensive and only drives up the cost of health care without increasing direct client care</choice_2> <choice_3>Essential to nursing care because advanced technology impacts several facets of health care delivery</choice_3> <choice_4>Only important for nurse managers because they allocate the unit's resources for the use of advanced technology in client care

3</correct> <rationale>Staff education is essential to maintaining clinical competence and client safety; therefore, options 1 and 2 are incorrect. Information technology is important to all nurses not just to nurse managers to organize and manage nursing and health care delivery. Option 4 is incorrect as well.</rationale> <cognitive_level>Application</cognitive_level> <client_need>Safe Effective Care Environment: Coordinated Care</client_need> <integrated_process>Nursing Process: Evaluation</integrated_process> <content_area>Leadership/Management</content_area> <strategy>The core of the question is understanding the impact of advanced technology on client care and its underlying costs. Use general nursing knowledge and the process of elimination to make a selection.</strategy>

8.The client has decided to discontinue further treatment for cancer. Although the nurse would like the client to continue treatment, the nurse recognizes the client is competent and supports the client's decision using which of the following ethical principles?<choice_1>Justice</choice_1> <choice_2>Fidelity</choice_2> <choice_3>Autonomy</choice_3> <choice_4>Confidentiality</choice_4>

3</correct> <rationale>Autonomy refers to the right to make one's own decisions. Justice refers to fairness; fidelity refers to trust and loyalty; confidentiality refers to the right to privacy of personal health information.

34.The nurse is aware that a confused elderly client is at risk for falls. Which of the following interventions would the nurse avoid using with this client?</question> <question_image/> <choice_1>Orient the client to the call light system.</choice_1> <choice_2>Keep the hospital bed in low position.</choice_2> <choice_3>Keep the full bed rails up at all times.</choice_3> <choice_4>Assist with appropriate toileting every 2 hours.</choice_4>

3</correct> <rationale>Full bed rails are a type of physical restraint. A confused client may attempt to climb over the rails, increasing the risk for fall and injury. The other options are positive interventions for reducing risk for falls.</rationale>

11. An LPN/LVN who has been in practice for 6 months is due for the first performance evaluation. In preparing for the evaluation, the nurse should look to which standard against which to evaluate personal performance during the first 6 months of employment? <choice_1>ANA standards of care</choice_1> <choice_2>The state nurse practice act</choice_2> <choice_3>The written job description</choice_3> <choice_4>The organization's standard of clinical care</choice_4>

3</correct> <rationale>The best way that the nurse can effectively self-evaluate performance of his or her job is to compare individual performance against the written job description. Job descriptions help identify activities that each staff member may perform. The ANA standards of care help set the parameters for minimal standards and should be used as guidelines. Individual state boards of nursing identify the legal boundaries of nursing practice to safeguard the public. The state 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.</rationale>

28.The home health nurse is visiting an elderly client with diabetes mellitus. The nurse becomes concerned and implements safety education when which of the following occurs?</question> <question_image/> <choice_1>The neighbors bring a warm lunch to the elderly client.</choice_1> <choice_2>The children install new air-conditioning units in the kitchen and bedroom.</choice_2> <choice_3>The grandchildren fold laundry and place the baskets by the door to the bedroom.</choice_3> <choice_4>The client stores the diabetic testing supplies on the kitchen table.</choice_4>

3</correct> <rationale>Laundry baskets that are set on the floor will pose a risk for falling for the elderly client. All hallways, floors, stairways, and furniture should be free of clutter. Neighbors bringing lunch and family controlling climate for the elderly client are good safety interventions. Keeping diabetic supplies on a kitchen table with easy access will facilitate diabetic testing.</rationale>

20. The nurse working in a sub-acute nursing home is assigned four clients. Place these clients in order of first to last priority of care.</question> <question_image/> <choice_1>Client A is complaining of feeling sad and lonely.</choice_1> <choice_2>Client B has just recently returned from the doctor's office after undergoing a stress test.</choice_2> <choice_3>Client C needs to be repositioned and has several pressure ulcers.</choice_3> <choice_4>Client D is complaining of feeling short of breath.</choice_4>

4, 2, 3, 1</correct> <rationale>Shortness of breath is always first priority. The client who had a stress test requires careful monitoring for potential complications. Client C needs to be repositioned to prevent further skin breakdown. While Client A's emotional concerns are important, they are of lower priority than the other three clients.</rationale>

35.The nurse has applied elbow splints on a confused client to prevent the client from removing the intravenous (IV) line. Which of the following interventions is required?</question> <question_image/> <choice_1>Document the appearance of the client's IV site every hour.</choice_1> <choice_2>Remove the restraints every 8 hours.</choice_2> <choice_3>Ask for a renewal of the physician's restraint order every 72 hours.</choice_3> <choice_4>Assess and document client condition at least every hour.</choice_4>

4</correct> <rationale>The client should be checked at least hourly, and the nurse is required to document status. The IV site should be checked every hour, but documentation may be done only once per shift unless a problem occurs. Physical restraints impede a client's freedom, and thus their use 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 to 2 hours rather than every 8 hours.</rationale>

23. The result of a toddler's lead screening is 12mg/dL. The nurse should say which of the following to the mother at this time?</question> <question_image/> <choice_1>"His lab values are just fine."</choice_1> <choice_2>"Have you noticed any blood in his stools?"</choice_2> <choice_3>"When were his last immunizations?"</choice_3> <choice_4>"Tell me about where you live."</choice_4>

4</correct> <rationale>The lead value of 12mg/dL is high. Lead levels below 10mg/dL are acceptable. Levels of 10-19mg/dL require an environmental history. Levels above 20mg/dL require a full medical 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 options 2 and 3 are unrelated to lead poisoning.</rationale>

4.A client asks why a diagnostic test has been ordered and the nurse replies, "I'm unsure but will find out for you." When the nurse later returns and provides an explanation, the nurse is acting under which principle? 1. Nonmaleficence 2. Veracity 3. Beneficence 4. Fidelity

4</correct> <rationale>Fidelity means to be faithful to agreements and promises. This nurse is acting on the client's behalf to obtain needed information and report it back to the client. Nonmaleficence is duty to do no harm. Veracity refers to telling the truth—for example, not lying to a client about a serious prognosis. Beneficence means doing good, such as by implementing actions (keeping a salt shaker out of sight) that benefit a client (heart condition requiring sodium-restricted diet).

18. The nurse is working in a nursing home that uses the team nursing approach to client care. The nurse is orienting a new CNA who asks if she will be assigned her own clients to care for. The nurse would respond: <choice_1>"Yes, every day you come in you'll have a client list that will be your sole responsibility once you've completed orientation."</choice_1> <choice_2>"Yes."</choice_2> <choice_3>"No, you'll just complete the tasks you are told to complete on whatever client you are asked to care for."</choice_3> <choice_4>"No. In team nursing you will be assigned to a team that will share responsibilities for a specific group of clients."</choice_4>

4</correct> <rationale>In team nursing, RNs, LPNs/LVNs, and CNAs work together to care for a group of clients, with each care provider working to his or her scope of practice. Working as a team means no client is any nurse's sole reponsibility. Option 2 doesn't provide any helpful information, and option 3 doesn't explain that each team member is expected to work within their scope of practice.

42.The nurse would do which of the following when washing the hands as part of medical asepsis before caring for an assigned client in an outpatient clinic?</question> <question_image/> <choice_1>Wash the hands with the hands held higher than the elbows.</choice_1> <choice_2>Adjust the temperature of the water to the hottest possible.</choice_2> <choice_3>Scrub the hands and nails with a scrub brush for 5 minutes.</choice_3> <choice_4>Use a clean paper towel to turn the water off.</choice_4>

4</correct> <rationale>Option 4 is correct because the faucet is considered contaminated. The hands are considered to be more contaminated than the elbows. Therefore, water should flow from least 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.</rationale>

43.The nurse's forearm is splattered with blood while inserting an intravenous catheter. What action should the nurse take?</question> <question_image/> <choice_1>Wipe the blood away with an alcohol swab.</choice_1> <choice_2>Wipe the blood away with a tissue.</choice_2> <choice_3>Flush the forearm with hot water, letting the water flow from the elbow toward the fingers.</choice_3> <choice_4>Wash the forearm with soap and water.</choice_4>

4</correct> <rationale>Washing the skin with the combination of soap and water will remove the blood through mechanical friction. While alcohol can kill bacteria, it cannot kill viruses and fungi (option 1). 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).</rationale>

61.The nurse is caring for a client with hepatitis A. Which of the following client statements indicates that teaching conducted by the nurse about disease transmission was effective? Select all that apply.</question> <question_image/> <choice_1>"We must avoid kissing."</choice_1> <choice_2>"We can use the same bath towels."</choice_2> <choice_3>"We must avoid eating with the same utensils."</choice_3> <choice_4>"We must wear masks."</choice_4> <choice_5>"No special precautions are needed."</choice_5>

<correct>1, 3</correct> <rationale>Hepatitis A is an infectious disease transmitted by the fecal-oral route. Standard precautions are mandatory. Contact precautions are instituted if the client is incontinent of stool. Family members should avoid close contact with the client. They should not kiss the client or use the same eating utensils and bath towels. Masks are not necessary because the disease is not transmitted by the respiratory tract.</rationale>

72.Which of the following statements by the client could indicate a potential problem for the couple planning to use coitus interruptus?</question> <question_image/> <choice_1>"I really don't want to get pregnant right now, so we need a very effective method."</choice_1> <choice_2>"I think I can always pull out before I ejaculate."</choice_2> <choice_3>"We don't have any other sex partners."</choice_3> <choice_4>"We want a contraceptive method that is inexpensive and completely natural."</choice_4>

<correct>1</correct> <rationale>Because some semen is released before ejaculation, coitus interruptus has an 18% failure rate and would not be considered a very effective method for a couple wanting to avoid pregnancy.</rationale>

66.What information does the nurse need to gather before scheduling a client's endometrial biopsy?</question> <question_image/> <choice_1>Usual length of menstrual cycle</choice_1> <choice_2>Blood type and Rh factor</choice_2> <choice_3>Presence of any metal implants</choice_3> <choice_4>Last type of birth control used</choice_4>

<correct>1</correct> <rationale>The nurse needs to know the first day of the last normal menstrual period and the length of the menstrual cycle. Endometrial biopsy is performed on day 21 to 27 of the menstrual cycle to assess the endometrial response to progesterone and the degree of development of the luteal phase endometrium.</rationale> <cognitive_level>Application</cognitive_level>

98.The pregnant client tells the nurse that she is lactose intolerant. When considering the recommendation of a calcium supplement, which of the following data should be collected?</question> <question_image/> <choice_1>History of kidney stones</choice_1> <choice_2>Presence of leg cramps</choice_2> <choice_3>Color of mucous membranes and conjunctiva</choice_3> <choice_4>Resting heart rate</choice_4>

<correct>1</correct> <rationale>Increased calcium intake can lead to formation of kidney stones. A calcium supplement is not expected to affect leg cramps, color of mucous membranes and conjunctiva, or resting heart rate.</rationale>

62.Which of the following statements indicates to the nurse that a couple is coping with the stress of infertility treatment?</question> <question_image/> <choice_1>"We are really trying to maintain a little romance in our relationship." </choice_1> <choice_2>"My wife was so upset that she threw the syringe at me yesterday."</choice_2> <choice_3>"My husband couldn't even have an erection when he was supposed to."</choice_3> <choice_4>"We have two or three glasses of wine each night to help us relax."</choice_4>

<correct>1</correct> <rationale>Maintaining a healthy relationship is important during infertility treatments, which can be very stressful. Options 2, 3, and 4 may indicate ineffective coping strategies and warrant further investigation.</rationale>

50.A client with suspected severe acute respiratory syndrome (SARS) arrives at the emergency department. Which of the following physician orders should the nurse implement first?</question> <question_image/> <choice_1>Airborne and contact isolation</choice_1> <choice_2>IV D₅NS at 100 mL/hr</choice_2> <choice_3>Nasopharyngeal culture for reverse-transcription polymerase chain reaction</choice_3> <choice_4>Sputum for enzyme immunoassay testing</choice_4> <choice_5/>

<correct>1</correct> <rationale>SARS is a highly contagious viral respiratory illness that is spread by close person-to-person contact. SARS is transmitted by airborne respiratory droplets and by touching surfaces and objects contaminated with infectious droplets. Instituting infection control measures would be 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.</rationale>

29. The nurse supervisor observes the new LPN/LVN administering medications on the unit. The nursing supervisor concludes there is a risk for medication error when the nurse does which of the following?</question> <question_image/> <choice_1>Answers a physician's page while passing medications</choice_1> <choice_2>Uses military time for documentation</choice_2> <choice_3>Asks for help with a dosage calculation</choice_3> <choice_4>Does not give a medication that the client questions</choice_4>

<correct>1</correct> <rationale>The nurse should never interrupt the process for administering medications. Errors are typically made when the nurse is interrupted. Military time is frequently used by institutions for documentation. The nurse should always ask for assistance with dosage calculations when 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.</rationale>

60.The nurse assigned to the respiratory care unit is working with four clients who have pneumonia. The nurse should assign the only remaining private room on the nursing unit to the client infected with which of the following organisms?</question> <question_image/> <choice_1>Penicillin-resistant <i>Streptococcus pneumoniae</i> pneumonia</choice_1> <choice_2><i>Pseudomonas aeruginosa</i> pneumonia</choice_2> <choice_3><i>Pneumocystis carinii</i> pneumonia</choice_3> <choice_4><i>Legionella pneumophila</i> pneumonia</choice_4>

<correct>1</correct> <rationale>While each option contains "pneumonia," the causative agent is different for each. Option 1 includes a pathogenic microorganism that is difficult to treat and requires droplet precautions.</rationale>

95.A pregnant client, who is a vegetarian, is concerned about her folic acid intake and asks the nurse to recommend some foods that she should include in her diet. Which of the following should the nurse recommend?</question> <question_image/> <choice_1>Peanuts</choice_1> <choice_2>Hamburger</choice_2> <choice_3>Bananas</choice_3> <choice_4>Apple juice</choice_4>

<correct>1</correct> <rationale>Both peanuts and hamburger are good sources of folic acid, but since the client is a vegetarian, peanuts is a better recommendation. The other options do not contain significant amounts of folic acid.</rationale>

58.The nurse is assisting the client who has methicillin-resistant <i>Staphylococcus aureus</i> in collecting a clean-catch urine specimen. Which of the following protective equipment is unnecessary?</question> <question_image/> <choice_1>N95 particulate respirator</choice_1> <choice_2>Gown</choice_2> <choice_3>Eye protection</choice_3> <choice_4>Sterile gloves</choice_4>

<correct>1</correct> <rationale>Methicillin-resistant <i>Staphylococcus aureus</i> requires transmission-based contact precautions. Eye protection would be worn to protect the mucous membranes of the eyes when splatters of body fluids or excretions are possible. A gown would be worn when the nurse is in direct 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.</rationale>

90.During a prenatal visit in the second trimester, which of the following, if reported by the client, would be a cause for concern?</question> <question_image/> <choice_1>Thirst and urinary frequency</choice_1> <choice_2>+1 deep tendon reflexes</choice_2> <choice_3>Constipation</choice_3> <choice_4>Backache in the lower sacral area</choice_4>

<correct>1</correct> <rationale>Urinary frequency usually disappears in the second trimester. Thirst and urinary frequency may be a sign of developing gestational diabetes and warrants further investigation. Deep tendon reflexes are assessed during a physical examination and are not reported to a health care provider by the client.</rationale>

80.In teaching the client about factors that can decrease the effectiveness of oral contraceptives, which of the following should be included by the nurse?</question> <question_image/> <choice_1>Antibiotic use</choice_1> <choice_2>Weight gain</choice_2> <choice_3>Amenorrhea</choice_3> <choice_4>Iron-deficiency anemia</choice_4>

<correct>1</correct> <rationale>Antibiotic use can decrease the effectiveness of oral contraceptives. Oral contraceptives can help prevent iron-deficient anemia by decreasing menstrual blood flow. Weight gain and anemia are not related to the effectiveness of birth control pills.</rationale>

54.The nurse would formulate which of the following as the most appropriate goal for the client with droplet precautions?</question> <question_image/> <choice_1>The client will identify three ways to reduce the spread of infection.</choice_1> <choice_2>The client will limit the risk of exposure to the causative agent.</choice_2> <choice_3>The client will be taught how to take antimicrobial medication.</choice_3> <choice_4>The client will understand how to protect other family members.</choice_4>

<correct>1</correct> <rationale>Option 1 is the only goal that is client-focused, specific, and measurable. Options 2 and 4 are client-focused but vague. Option 3 focuses on the nursing action of teaching.</rationale>

The client, who delivered her first child 2 days ago, is being discharged from the hospital. She is interested in a contraceptive method that is not associated with intercourse and will not interfere with lactation. The nurse concludes that which of the following probably would be the best method for this client?</question> <question_image/> <choice_1>Progestin-only oral contraceptives (mini-pills)</choice_1> <choice_2>Female condoms</choice_2> <choice_3>Diaphragm</choice_3> <choice_4>Triphasic pills</choice_4>

<correct>1</correct> <rationale>Oral contraceptives with a combination of estrogen and progestin are not recommended in the first 6 weeks of lactation. In addition, the long-term effects on the infant are not known. The use of female condoms and a diaphragm are associated with sexual intercourse. Progestin-only pills are safe for lactating women.</rationale>

92.When considering maternal serum alpha-fetoprotein testing for a client, the nurse would conclude that there is a contraindication for the test if the client:</question> <question_image/> <choice_1>Is at 25 weeks' gestation.</choice_1> <choice_2>Would not consider termination of the pregnancy.</choice_2> <choice_3>Does not have a family history of neural tube defects.</choice_3> <choice_4>Had an ultrasound at 8 weeks' gestation.</choice_4>

<correct>1</correct> <rationale>This test, which measures the level of maternal serum alpha-fetoprotein, is most sensitive between 16 to 18 weeks' gestation. However, it can be performed up to 22 weeks' gestation.</rationale>

48.A client with tuberculosis asks the nurse if visitors will need to wear masks. What response by the nurse is most accurate?</question> <question_image/> <choice_1>"Everyone who enters your room must wear a mask to protect themselves from tuberculosis."</choice_1> <choice_2>"Masks would not be necessary for visitors who have had tuberculosis before."</choice_2> <choice_3>"It is less important for your family to wear masks, since they live in close contact with you."</choice_3> <choice_4>"Only visitors who are at risk for tuberculosis need to wear a mask."</choice_4>

<correct>1</correct> <rationale>Tuberculosis is highly contagious and spread by inhalation of airborne droplets. Airborne precautions would be initiated, requiring everyone to wear a special particulate respirator fit-tested mask. Individuals who have had tuberculosis in the past can be re-exposed and develop the active form of the disease again.</rationale>

27. A school nurse is planning a health class on accidents and injuries for a high school class. Which topic is most important to include?</question> <question_image/> <choice_1>Occupational-related injuries at work</choice_1> <choice_2>Motor vehicle-related injuries</choice_2> <choice_3>Fall-related injuries</choice_3> <choice_4>Injury due to residential fires</choice_4>

<correct>2</correct> <rationale>Driving a car and having the independence to ride with friends is an important milestone for high school-aged adolescents. Some adolescents experiment with alcohol and drugs, putting 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.</rationale>

45.The nurse would do which of the following to protect the client from infection at the portal of entry?</question> <question_image/> <choice_1>Place a sputum specimen in a biohazard bag for transport to the lab.</choice_1> <choice_2>Empty a Jackson-Pratt drain, using sterile technique.</choice_2> <choice_3>Dispose of soiled gloves in a waste container.</choice_3> <choice_4>Wash hands after providing client care.</choice_4>

<correct>2</correct> <rationale>Option 2 is an action aimed at interrupting the portal of entry link in the chain of infection. By 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.</rationale

89.With regard to normal changes in the cardiovascular system during pregnancy, the nurse should reinforce teaching to the pregnant client about which of the following?</question> <question_image/> <choice_1>Her pulse rate will decrease.</choice_1> <choice_2>She may experience dizziness if she lays on her back.</choice_2> <choice_3>She will have a decrease in red blood cells.</choice_3> <choice_4>She may experience a feeling of fullness in her chest.</choice_4>

<correct>2</correct> <rationale>Pressure on the vena cava from the gravid uterus may cause a decrease in blood flow to the right atrium and result in a decrease in blood pressure. Dizziness is a symptom of hypotension. 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.</rationale>

69.The clinic nurse is interviewing a client couple for an initial infertility workup. Which of the following topics should the nurse plan to address?</question> <question_image/> <choice_1>Whether the couple has medical insurance</choice_1> <choice_2>How infertility is affecting their lives</choice_2> <choice_3>Whether the man has seafood allergies</choice_3> <choice_4>Whether the woman works outside the home</choice_4>

<correct>2</correct> <rationale>The psychological, cultural, and social ramifications of infertility can be extensive. You need to ascertain if the couple needs assistance in coping with their infertility and treatment.</rationale>

52.The nurse is changing an abdominal dressing on a client who has an infection spread by droplets. Which of the following pieces of personal protective equipment would the nurse use?</question> <question_image/> <choice_1>Clean gloves</choice_1> <choice_2>Mask</choice_2> <choice_3>Gown</choice_3> <choice_4>Eye protection</choice_4>

<correct>2</correct> <rationale>A mask is necessary for anyone within 3 feet of a client with an infection spread by particle droplets. There is not enough information in the question to support the use of any other equipment.</rationale>

100.The pregnant client, who is 34 weeks' gestation, calls the prenatal clinic complaining of cramping pain in her abdomen. After the diagnosis of Braxton-Hicks contractions is made, the nurse should give the client which of the following recommendations?</question> <question_image/> 4. Go to bed and wait for your real labor to begin." <choice_2>"Empty your bladder frequently and change positions if these contractions are bothering you."</choice_2> <choice_3>"Avoid using your Lamaze breathing with these contractions because it might precipitate preterm labor."</choice_3> <choice_4>"Just ignore these contractions; we will let you know if there is a problem."</choice_4>

<correct>2</correct> <rationale>Braxton-Hicks contractions are probably caused by stretching of the myometrium. They are usually relieved by position changes, frequent emptying of the bladder, resting in a lateral recumbent position, and walking or light exercise.</rationale>

71.The client has an obstruction between the uterus and the fallopian tubes. In obtaining a health history, the nurse collects information about which of the following that may have caused this problem?</question> <question_image/> <choice_1>Rubella infection prior to adolescence</choice_1> <choice_2>Pelvic inflammatory disease caused by gonorrhea</choice_2> <choice_3>Smoking two packs of cigarettes per day</choice_3> <choice_4>Ingestion of 2 ounces of alcohol daily</choice_4>

<correct>2</correct> <rationale>Infectious processes of the reproductive tract such as PID may result in tubal scarring and therefore tubal blockage. Rubella infection in childhood usually results in the development of active immunity to the disease. Smoking and alcohol present health risks to the woman but not related to tubal patency.</rationale> <cognitive_level>Analysis</cognitive_level>

96.The pregnant client has been started on an iron supplement. The nurse determines that the client understands possible side effects of therapy when the client states that the supplement may cause which of the following?</question> <question_image/> <choice_1>Red, raised rash</choice_1> <choice_2>Gastric upset</choice_2> <choice_3>Blood in the stool</choice_3> <choice_4>Headache</choice_4>

<correct>2</correct> <rationale>Iron supplementation can cause gastric distress, constipation, and diarrhea. It does not cause a red, raised rash (option 1), blood in the stool (option 3), or headache (option 4).</rationale>

75.The client is interested in using female condoms and wants to know if there are any disadvantages. The nurse's best response would be:</question> <question_image/> <choice_1>"The female condom provides good protection against pregnancy but does not protect against sexually transmitted infections."</choice_1> <choice_2>"The female condom may be difficult to insert and may be uncomfortable to both partners."</choice_2> <choice_3>"The female condom is very effective; let me write you a prescription for some."</choice_3> <choice_4>"The female condom is made of latex and should not be used when allergy is present."</choice_4>

<correct>2</correct> <rationale>Made of polyurethane, the female condom does not require a prescription but can be difficult to insert and can cause discomfort. It is effective against both sexually transmitted infections and pregnancy.</rationale>

51.In addition to standard precautions, which other type(s) of isolation precautions should the nurse use when caring for the client with severe acute respiratory syndrome (SARS)?</question> <question_image/> <choice_1>Droplet precautions</choice_1> <choice_2>Airborne precautions and contact precautions</choice_2> <choice_3>Contact precautions and droplet precautions</choice_3> <choice_4>Airborne precautions</choice_4>

<correct>2</correct> <rationale>SARS is a highly contagious viral respiratory illness that is spread by close person-to-person contact. SARS is transmitted by airborne respiratory droplets and by touching surfaces and objects contaminated with infectious droplets. Personal protective equipment would include 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.</rationale>

The client is experiencing an inability to become pregnant after she has had one full-term pregnancy. The nurse would know this client is suffering from which health problem?</question> <question_image/> <choice_1>Primary infertility</choice_1> <choice_2>Secondary infertility</choice_2> <choice_3>Unexplained infertility</choice_3> <choice_4>Combined factor infertility</choice_4>

<correct>2</correct> <rationale>Secondary infertility is the term for couples that have had one pregnancy but are unable to conceive again. Primary infertility describes the inability to conceive even once. Options 3 and 4 are not terms that are used when discussing fertility.</rationale>

97.The pregnant client has been started on an iron supplement. Which of the following information should the nurse include as a priority when reinforcing prenatal teaching about the iron supplement?</question> <question_image/> <choice_1>It should be taken 30 minutes after eating a full meal.</choice_1> <choice_2>It is better absorbed if taken with a liquid containing Vitamin C.</choice_2> <choice_3>It will eliminate the need for prenatal vitamins.</choice_3> <choice_4>It should be taken at the same time as the prenatal vitamin.</choice_4>

<correct>2</correct> <rationale>Iron is absorbed best on an empty stomach (not after a full meal) and in the presence of Vitamin C. It may or may not be taken at the same time as other vitamin supplementation. It does not replace the need for other vitamins.</rationale>

83.Which of the following statements would indicate to the nurse that teaching was effective for the client who is to receive a Norplant subdermal implant?</question> <question_image/> <choice_1>"By the end of 5 years, the capsules will be absorbed by my body."</choice_1> <choice_2>"If I get the Norplant implant, for 5 years I will have about the same risk of pregnancy as if I had surgical sterilization."</choice_2> <choice_3>"I will need to wait until I am 18 to receive a Norplant implant."</choice_3> <choice_4>"I will need to come to the clinic to have the implant reinserted every 3 months."</choice_4>

<correct>2</correct> <rationale>Norplant is a subdermal contraceptive implant that has about the same failure rate as surgical sterilization, is effective for 5 years, and must be surgically removed.</rationale>

81.In addition to prevention of pregnancy, oral contraceptives would provide benefits for a client with which of the following problems?</question> <question_image/> <choice_1>Pelvic inflammatory disease</choice_1> <choice_2>Severe facial acne</choice_2> <choice_3>Chloasma</choice_3> <choice_4>Gallbladder disease</choice_4

<correct>2</correct> <rationale>Oral contraceptives can reduce acne, result in signs and symptoms of early pregnancy including chloasma, and accelerate the progress of gallbladder disease. Birth control pills do not provide protection against STIs that can result in PID.</rationale>

85.In reinforcing instructions for the client who is to receive Depo-Provera, the nurse should tell the client which of the following?</question> <question_image/> <choice_1>Like oral contraceptives, Depo-Provera increases the risk of venous thrombosis.</choice_1> <choice_2>The most common side effects of Depo-Provera are amenorrhea and irregular uterine bleeding.</choice_2> <choice_3>Depo-Provera has a higher failure rate than oral contraceptives.</choice_3> <choice_4>Depo-Provera will interfere with lactation.</choice_4>

<correct>2</correct> <rationale>The most common side effects of Depo-Provera are amenorrhea and irregular bleeding. With a failure rate similar to oral contraceptives, Depo-Provera does not interfere with lactation. Typically, the estrogen component of hormonal contraceptives is associated with thromboembolic disease; Depo-Provera contains only progestin.</rationale>

39. Public health nurses have been activated to open a shelter due to an approaching hurricane. What most important items should families be encouraged to take to the emergency shelter?</question> <question_image/> <choice_1>Food and extra clothing</choice_1> <choice_2>Cats and small dogs</choice_2> <choice_3>Medication and vital records</choice_3> <choice_4>Radios, televisions, and small personal electronics</choice_4>

<correct>3</correct> <rationale>Client medications and vital records are needed for a short or extended stay at an emergency shelter. Space is very limited in a shelter. There is no provision for storing food, and animals are not allowed. Loud electronic devices such as radios or televisions may cause disturbance between families or individuals. Electricity may or may not be available.</rationale

13. The charge nurse on the night shift reports that the narcotic count is incorrect. The nurse has already spoken to the staff nurse believed responsible for the incorrect count and has reason to believe that substance abuse by the nurse is the cause. If substance abuse by the staff nurse proves to be the cause of the incorrect count, what is the most appropriate next step? <choice_1>Recount the narcotics with the staff nurse and take disciplinary action.</choice_1> <choice_2>Ask the staff nurse to leave the unit immediately and report the incident to the American Nurses Association.</choice_2> <choice_3>Complete an incident report, report findings to the pharmacy, and notify the nursing administration for the facility.</choice_3> <choice_4>Submit the findings to the Council on Nursing Practice

<correct>3</correct> <rationale>An incident report must be completed because of the inaccurate narcotic count. Narcotics are controlled substances and fall under federal law and regulation. Both the pharmacy and nursing administration must be notified. If the staff nurse is found to be using a controlled substance, this finding must be reported to the state board of nursing. Individual state boards of nursing identify the legal boundaries of nursing practice, including disciplinary action, through nurse practice acts (which differ among the states). The American Nurses Association, through the Code of Ethics for Nurses, provides guidance to nurses and protection for clients and their families but does not have the authority to discipline nurses.</rationale> <cognitive_level>Application</cognitive_level> <client_need>Safe Effective Care Environment: Coordinated Care</client_need> <integrated_process>Nursing Process: Planning</integrated_process> <content_area>Leadership/Management</content_area> <strategy>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 which strive to develop standards of practice for professional nurses.</strategy>

79.The client has come to the clinic to discuss use of a cervical cap for contraception. Which of the following would the nurse view as a contraindication to use of the cervical cap?</question> <question_image/> <choice_1>History of blood clots</choice_1> <choice_2>Age greater than 35 years</choice_2> <choice_3>Abnormal Pap smear 6 months ago</choice_3> <choice_4>Elevated liver enzymes</choice_4>

<correct>3</correct> <rationale>Long-term exposure to secretions, spermicides, and bacteria trapped inside the cap can result in abnormal Pap smear results. This client has a history of an abnormal Pap smear; cervical cap use could negatively impact this finding, and another method should be explored for this client. The other options have no relationship to use of the cervical cap.</rationale>

86 A client has been admitted as an outpatient for a tubal ligation. Following the procedure, the client should be told to expect which of the following?</question> <question_image/> <choice_1>Hot flashes and other hormonally associated symptoms</choice_1> <choice_2>Heavier bleeding with menstruation</choice_2> <choice_3>Possible pain for several days</choice_3> <choice_4>Change in sexual function</choice_4>

<correct>3</correct> <rationale>Some clients report mild pain after the procedure, which is usually relieved with analgesics. Changes in menstruation, sexual function, or other hormonal symptoms are not typical.</rationale>

99.During the first prenatal exam, the nurse discovers that the client has not had a second vaccination for measles, mumps, and rubella. The nurse would expect the provider to do which of the following?</question> <question_image/> <choice_1>Administer the vaccine during this visit.</choice_1> <choice_2>Wait until the third trimester to administer the vaccine.</choice_2> <choice_3>Administer the vaccine following delivery.</choice_3> <choice_4>Omit the vaccine because these are childhood diseases not acquired by adults.</choice_4>

<correct>3</correct> <rationale>The measles, mumps, and rubella vaccine contains live, attenuated virus and could cause disease and harm to the fetus during pregnancy. It should be given after delivery, and the woman should avoid conceiving for 3 months.</rationale>

63.The client has been diagnosed with <i>Trichomoniasis vaginitis</i>. The nurse explains while reinforcing client teaching that this infection can affect fertility by:</question> <question_image/> <choice_1>Utilizing the glycogen in vaginal secretions, leaving no nutrition for the spermatozoa.</choice_1> <choice_2>Creating a blockage of the fallopian tubes that prohibits spermatozoa from reaching an ovum.</choice_2> <choice_3>Decreasing the pH of the vaginal secretions, thereby destroying most spermatozoa.</choice_3> <choice_4>Increasing the temperature inside the vagina, which decreases the motility of spermatozoa.</choice_4>

<correct>3</correct> <rationale>Vaginal fluid pH is slightly alkaline, as is semen. Spermatozoa cannot survive in an acidic environment. Trichomoniasis vaginitis increases the acidity of the vaginal and cervical secretions, thus reducing the number of viable sperm.</rationale>

68.The client couple is planning intracytoplasmic sperm injection, followed by intrauterine embryo transfer. Which of the following statements indicates that the nurse's teaching was effective?</question> <question_image/> <choice_1>"His sperm swim too fast for me to become pregnant."</choice_1> <choice_2>"My eggs have thick walls and don't let his sperm in."</choice_2> <choice_3>"Any extra embryos can be frozen for implantation later."</choice_3> <choice_4>"We will have to wait several weeks to see if any eggs get fertilized."</choice_4>

<correct>3</correct> <rationale>In vitro fertilization usually creates multiple embryos, of which up to four are implanted. Cryopreservation of excess embryos is common, and they can be implanted at a later date.</rationale>

65.Which of the following client statements indicates the need for additional teaching?</question> <question_image/> <choice_1>"I should come back for a postcoital test 1 to 2 days before I expect to ovulate."</choice_1> <choice_2>"I should schedule my hysterosalpingogram for the week after ovulation."</choice_2> <choice_3>"We should abstain for 14 days prior to coming back for the sperm penetration test."</choice_3> <choice_4>"I should schedule my endometrial biopsy for the last week of my menstrual cycle."</choice_4>

<correct>3</correct> <rationale>Sperm penetration test, which tests for the ability of sperm to penetrate an egg, should be performed after 2 to 7 days of abstinence.</rationale>

74. The client who is married and has three children has come to the family planning clinic asking about a birth control method that is sanctioned by the Roman Catholic Church. She wants the most effective method possible. The nurse's best recommendation is which of the following?</question> <question_image/> <choice_1>Billings or cervical assessment method</choice_1> <choice_2>Ovulation testing kit</choice_2> <choice_3>Symptothermal method</choice_3> <choice_4>Basal body temperature method</choice_4>

<correct>3</correct> <rationale>The symptothermal method combines cervical mucus and BBT measurements and results in a lower failure rate than single assessments of the fertile period. This method is completely natural and acceptable to the beliefs of this religious group. Ovulation testing kits do not give enough warning of ovulation to prevent pregnancy.</rationale>

94.The nurse determines the client understands her prenatal nutritional education when she states:</question> <question_image/> <choice_1>"I understand that if I don't eat foods with folic acid, my baby will have birth defects."</choice_1> <choice_2>"I understand that eating citrus fruits, especially oranges, will help me meet my need for folic acid."</choice_2> <choice_3>"I understand that if my level of folic acid is low, it could cause my baby to have a neural tube defect."</choice_3> <choice_4>"I understand that I should limit my intake of folic acid because it can build up in the liver and cause birth defects."</choice_4>

<correct>3</correct> <rationale>Maternal folic acid deficiency has been linked to infant neural tube defects. Folic acid may be obtained from prenatal vitamin supplements as well as foods. The other responses contain incorrect statements and do not indicate understanding of prenatal nutrition.</rationale> <cognitive_level>Analysis</cognitive_level>

84.The nurse is preparing to administer an injection of Depo-Provera. Which of the following would result in safe and effective administration of this drug?</question> <question_image/> <choice_1>Check to see that it has been at least 8 weeks since the client's last injection.</choice_1> <choice_2>Determine that the client's hemoglobin level is within normal range.</choice_2> <choice_3>Using a 23-gauge needle, inject the medication into the deltoid muscle.</choice_3> <choice_4>Check the client's medical record for a history of pelvic inflammatory disease.</choice_4>

<correct>3</correct> <rationale>The medication is administered intramuscularly every 80 to 90 days. Anemia, while important to the client's health, is not related to Depo-Provera use. The drug does not provide protection against sexually transmitted infections; counseling regarding the consistent use of condoms would be an effective intervention to prevent the reoccurrence of pelvic inflammatory disease.</rationale>

76.Which of the following clients would be the best candidate for insertion of an intrauterine device?</question> <question_image/> <choice_1>A client who is married, has one child, and wants to get pregnant in about 6 months</choice_1> <choice_2>A client who is unmarried, has no children, and has numerous sexual partners</choice_2> <choice_3>A client who is married, has two children, and does not want more children for at least 3 years</choice_3> <choice_4>A client who is unmarried, has one child, and has a history of pelvic inflammatory disease</choice_4>

<correct>3</correct> <rationale>Intrauterine devices are usually recommended for women who have been pregnant and are in a monogamous relationship so that they are at a low risk for sexually transmitted disease.</rationale>

73.Which of the following, if stated by the client, would indicate that teaching about cervical mucus changes as an indicator of ovulation has been understood?</question> <question_image/> <choice_1>"If my cervical mucus is yellowish and thick, I am probably fertile."</choice_1> <choice_2>"The thin, clear mucus will block sperm from getting to my cervix."</choice_2> <choice_3>"If my cervical mucus is thick and white, I will need to avoid intercourse or use a back-up method of contraception."</choice_3> <choice_4>"If my cervical mucus is thin and stretchable, I am probably fertile."</choice_4>

<correct>4</correct> <rationale>Cervical mucus that is thin and clear indicates a rising level of estrogen and impending ovulation. Stretchability of the cervical mucus, or spinnbarkeit, is indicative of the fertile period 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.</rationale>

57.A client asks, "How did I get scarlet fever?" Which of the following would be the best response by the nurse?</question> <question_image/> <choice_1>"Scarlet fever is transmitted through sexual intercourse."</choice_1> <choice_2>"You can get scarlet fever if you share contaminated needles or get a blood transfusion."</choice_2> <choice_3>"Most people get it by eating contaminated food."</choice_3> <choice_4>"You inhaled infected droplets in the air."</choice_4>

<correct>4</correct> <rationale>Scarlet fever is transmitted by particle droplets larger than 5 microns. Scarlet fever is not transmitted through sexual intercourse or the blood or by consuming contaminated food.</rationale>

56.The nurse would expect to institute transmission-based precautions for a client with which of the following?</question> <question_image/> <choice_1>Pneumonia caused by <i>Pseudomonas aeruginosa</i></choice_1> <choice_2><i>Pneumocystis carinii</i> pneumonia</choice_2> <choice_3>A sacral wound contaminated by <i>Escherichia coli</i></choice_3> <choice_4>A draining leg wound with methicillin-resistant <i>Staphylococcus aureus</i></choice_4>

<correct>4</correct> <rationale>Transmission-based precautions are required for all antibiotic-resistant microorganisms regardless of their mode of transmission. The other options indicate the need for medical and surgical asepsis in the care of the client but not the use of transmission-based precautions.</rationale>

59.The nurse is preparing to irrigate a wound infected with vancomycin-resistant <i>enterococci</i>. Which of the following should the nurse wear?</question> <question_image/> < choice_1>Gloves, gown, and particulate respirator</choice_1> <choice_2>Gloves and surgical mask</choice_2> <choice_3>Gloves, eye protection, and particulate respirator</choice_3> <choice_4>Gloves, gown, eye protection, and surgical mask</choice_4>

<correct>4</correct> <rationale>An infection with vancomycin-resistant <i>enterococci</i> requires transmission-based contact precautions. Since the nurse will be irrigating the wound and splatters of body fluids or 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.</rationale>

87.The client has come to the clinic for her first prenatal visit. During the pelvic examination, the examiner indicates that the vaginal mucosa has a bluish color. The nurse documents this as a positive:</question> <question_image/> <choice_1>Hegar's sign.</choice_1> <choice_2>Goodell's sign.</choice_2> <choice_3>McDonald's sign.</choice_3> <choice_4>Chadwick's sign.</choice_4>

<correct>4</correct> <rationale>Beginning around the fourth week of pregnancy, vasocongestion in the pelvic area results in a bluish color to the vulva, vagina, and cervix, known as Chadwick's sign. Hegar's sign is a softening of the lower uterine segment, Goodell's sign is a softening of the cervix, and McDonald's sign is an ease in flexing the body of the uterus against the cervix; none of these other signs involve color changes.</rationale>

64.The nurse is concerned that which of the following viral infections, if experienced by an adult male, may cause infertility?</question> <question_image/> <choice_1>Varicella zoster</choice_1> <choice_2>Rubella</choice_2> <choice_3>Influenza</choice_3> <choice_4>Mumps</choice_4>

<correct>4</correct> <rationale>Mumps in adult males can cause permanent blockage of the vas deferens, contributing to or resulting in infertility. The other responses are incorrect.</rationale>

In teaching a client about the risk of toxic shock syndrome associated with diaphragm use, the nurse should tell the client to do which of the following to decrease her risk?</question> <question_image/> <choice_1>Leave the diaphragm in place for 36 to 48 hours after intercourse.</choice_1> <choice_2>Avoid using soap when cleaning the device.</choice_2> <choice_3>Wear latex or rubber gloves when handling the device.</choice_3> <choice_4>Seek treatment of any vaginal infection before reusing the device.</choice_4>

<correct>4</correct> <rationale>When using the device, the woman should wash her hands with soap and water, remove the device within 24 hours of intercourse, clean the device with soap and water, and seek treatment for vaginal infections before reusing the device.</rationale>

67.The nurse is teaching a class in the community on common myths regarding fertility and infertility. Which of the following statements made by class participants indicates teaching has been successful?</question> <question_image/> <choice_1>"If my husband works out every day, he won't be able to make a baby."</choice_1> <choice_2>"If we have intercourse standing up, we won't be able to conceive."</choice_2> <choice_3>"If we have intercourse on the even days after ovulation, we will conceive a girl."</choice_3> <choice_4>"If my husband sits in the hot tub every night, his sperm count will decrease."</choice_4>

<correct>4</correct> <rationale>Hot tubs, saunas, and tight underwear can raise the temperature of the testes too high for efficient spermatogenesis and lead to decreased sperm numbers and motility.</rationale>

55.The nurse would implement which of the following as a requirement of care specific to the client who has tuberculosis?</question> <question_image/> <choice_1>Disposal of needles and syringes in a rigid, puncture-proof container</choice_1> <choice_2>Handwashing after removing contaminated gloves</choice_2> <choice_3>Wearing a gown if splashing is possible</choice_3> <choice_4>A private room with negative air flow</choice_4>

<correct>4</correct> <rationale>The client with tuberculosis can spread the infection by breathing and requires a private room and airborne precautions. Options 1, 2, and 3 are aspects of standard precautions that would be implemented with any client, regardless of medical diagnosis.</rationale>

38. Which of the following items would the nurse avoid documenting when a reportable incident has occurred?</question> <question_image/> <choice_1>Names of witnesses in the incident report</choice_1> <choice_2>Nursing interventions in the medical record</choice_2> <choice_3>Time the physician was called in the incident report</choice_3> <choice_4>That an incident report was submitted in the medical record</choice_4>

<correct>4</correct> <rationale>The medical record belongs to the client and should contain all of the facts related to the client and the incident. The incident report belongs to the hospital and should contain all of the facts and supportive data related to the client and the incident. The medical record should not refer to the incident report.</rationale>

53.A client with vancomycin-intermediate-resistant <i>Staphylococcus aureus</i> (VISA) is admitted to the nursing unit. What type of precautions would be appropriate for this client?</question> <question_image/> <choice_1>Standard precautions</choice_1> <choice_2>Neutropenic precautions</choice_2> <choice_3>Droplet precautions</choice_3> <choice_4>Contact precautions</choice_4>

<correct>4</correct> <rationale>Clients with antibiotic-resistant microorganisms must be isolated with transmission-based precautions. The organism is transmitted via close person-to-person direct contact and by touching contaminated surfaces and objects. Standard precautions are used with all clients, regardless of medical diagnosis. Reverse isolation is instituted for immunocompromised clients. This organism is not transmitted via droplet nuclei.</rationale>

14.As a member of the long-term care facility quality improvement team, the nurse has been asked to evaluate the quality of nursing care on the unit. The nurse has decided to ask the nursing staff for assistance in this endeavor. Which of the following would be appropriate to ask the nursing staff to do? <choice_1>Track the number of supplies used by clients on the unit.</choice_1> <choice_2>Document the time spent on direct client care.</choice_2> <choice_3>Administer a client and family satisfaction survey.</choice_3> <choice_4>Assess clients and report acuity daily.</choice_4>

Answer: 3 <rationale>Client satisfaction surveys are an important tool to monitor and evaluate patient and family needs. This information helps health care organizations meet those needs. Options 1, 2, and 4 are extremely helpful but do not improve client satisfaction and outcomes. Tracking supplies, documenting nursing time, and reporting on client acuity provides information that can be used in preparing a budget or unit staffing requirements.</rationale> <cognitive_level>Application</cognitive_level> <client_need>Safe Effective Care Environment: Coordinated Care</client_need> <integrated_process>Nursing Process: Planning</integrated_process> <content_area>Leadership/Management</content_area> <strategy>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.</strategy>

32.The nurse is administering an IM medication to a client known to have hepatitis B. Which precautions should the nurse use to protect against exposure? Select all that apply.</question> <question_image/> <choice_1>Hand washing</choice_1> <choice_2>Gloves</choice_2> <choice_3>Mask</choice_3> <choice_4>Face shield</choice_4> <choice_5>Gown</choice_5>

1, 2</correct> <rationale>Hand washing and gloves are the only precautions needed for administering an IM medication IV. Masks, face shields, and gowns are appropriate for procedures that may result in body fluids splashing.

31.The nurse prepares a dose of a medication ordered by the subcutaneous route and calculates the dose to be 4.5 mL. What is the first nursing action that the nurse should take?</question> <question_image/> <choice_1>Verify the written order.</choice_1> <choice_2>Call the physician.</choice_2> <choice_3>Call the pharmacist.</choice_3> <choice_4>Ask another nurse to check the dosage calculation.</choice_4>

1</correct> <rationale>If there is confusion related to a medication order, refer to and verify the original written order. Be careful to read abbreviations and dosage correctly. Asking another nurse or the pharmacist, or calling the physician are correct interventions, but not the first intervention, 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.</rationale>

25. Which of the following snacks should the nurse offer the hospitalized toddler?</question> <question_image/> <choice_1>Crackers</choice_1> <choice_2>Peanuts</choice_2> <choice_3>Grapes</choice_3> <choice_4>Cereal bar</choice_4>

1</correct> <rationale>Crackers are a soft consistency when chewed and swallowed. Toddlers can easily choke on small foods such as peanuts, popcorn, and grapes, and on firm consistency foods such as cereal bars.</rationale>

6.>The nurse is participating in a seminar about legal and ethical practice of nursing for continuing education credit. Which statement by a nurse best describes the relationship between law and ethics for the practice of nursing? <choice_1>"The ethics of a discipline attempt to formulate and justify responses to moral dilemmas and may or may not be regulated by law."</choice_1> <choice_2>"Laws dictate the ethics of nursing as they reflect societal choices about the ordering of relationships in society."</choice_2> <choice_3>"Ethics represent the moral customs of an individual nurse; therefore, they cannot be regulated by the law."</choice_3> <choice_4>"Ethical practice decreases the threat of a lawsuit, which is the primary source of legal influence on nursing practice."</choice_4>

1</correct> <rationale>Law is not the sole source of the ethical practice of nursing; numerous legal sources influence nursing practice. An individual should understand the ethics of a profession before becoming a member of that profession because those ethics may differ from personal ones.</rationale>

49.The nurse is leaving the room of a client who has methicillin-resistant <i>Staphylococcus aureus</i> (MRSA) microorganisms in a wound and the urine. Place the following personal protective equipment in order of removal.</question> <question_image/> <choice_1>Eye protection</choice_1> <choice_2>Gloves</choice_2> <choice_3>Mask</choice_3> <choice_4>Gown</choice_4>

2, 3, 4, 1</correct> <rationale>Gloves are removed first because they would be most contaminated. The mask would be removed next, followed by the gown. Eye protection is removed last, followed by washing the hands.</rationale>

24. When planning for discharge from the birthing center on the following day, the nurse learns that the father will drive the new mother and infant home. When teaching the new parents about infant restraint systems, the nurse should include that the restraint system be (select all that apply):</question> <question_image/> <choice_1>Forward facing</choice_1> <choice_2>Rear facing</choice_2> <choice_3>In the back seat</choice_3> <choice_4>In the front seat</choice_4> <choice_5>Of a bland or neutral color</choice_5>

2, 3</correct> <rationale>A child restraint system should always be in the back seat and rear facing. After a child is 1 year of age and 20 pounds, the seat may be in the rear and front facing. Although bright colors are stimulating to an infant, the color of the system does not matter.</rationale>

46.Which of the following actions by the nurse comply with core principles of surgical asepsis? Select all that apply.</question> <question_image/> <choice_1>Wash hands before and after client care.</choice_1> <choice_2>Keep the sterile field in view at all times.</choice_2> <choice_3>Wear personal protective equipment.</choice_3> <choice_4>Add contents to the sterile field holding the package 6 inches above the field.</choice_4> <choice_5>Consider the outer 1.5 inches of the sterile field as contaminated.</choice_5>

2, 4</correct> <rationale>Options 2 and 4 are core principles of surgical asepsis. Options 1 and 3 are core principles of medical asepsis. Option 5 is an incorrect principle of surgical asepsis. The outer 1 inch of a sterile field is considered contaminated.</rationale>

41.The nurse should explain to the mother of a 12-month-old infant that a forward-facing infant seat is safest once the infant weighs at least how many pounds? Fill in the number.

20</correct> <rationale>The infant must weigh at least 20 pounds in order to be safe in a forward-facing infant seat and must be 1 year or older.</rationale>

47.Which of the following precautions would the nurse implement when admitting a client to the nursing unit with herpes zoster?</question> <question_image/> <choice_1>Airborne precautions</choice_1> <choice_2>Contact precautions</choice_2> <choice_3>Droplet precautions</choice_3> <choice_4>Neutropenic precautions</choice_4>

2</correct> <rationale>Herpes zoster is caused by the herpes virus varicella zoster. It can be transmitted by direct contact with the client. It is not transmitted via droplets or air currents. Neutropenic precautions are not indicated because the client is not at risk for contracting an infection from the nurse or other individuals.</rationale> <cognitive_level>Application</cognitive_level>

22. The nurse determines a new mother is in greatest need of more education about infant care and safety when the mother states:</question> <question_image/> <choice_1>"I am pretty sure that I am going to breastfeed my baby."</choice_1> <choice_2>"After feeding, the baby should be put on her tummy to prevent choking."</choice_2> <choice_3>"Solid foods are not necessary during the baby's first 4 to 6 months."</choice_3> <choice_4>"My baby will sleep frequently and should be awakened every 3 to 4 hours for feeding."</choice_4>

2</correct> <rationale>Infants should always be put to sleep on the back. Options 1, 3, and 4 are correct statements related to infant care and therefore pose no risk to the infant and no concern to the nurse.

30. The nurse would ask a client scheduled for thyroid scanning about allergy to which of the following before the procedure?</question> <question_image/> <choice_1>Peanuts</choice_1> <choice_2>Shellfish</choice_2> <choice_3>Eggs</choice_3> <choice_4>Meat tenderizer</choice_4>

2</correct> <rationale>Iodine is used in many radiological procedures. Shellfish allergies may be an indicator of iodine allergy. The other options do not address this concern.</rationale>

26. What is the best method for the nurse to use to encourage the use of bicycle helmets by school-aged children?</question> <question_image/> <choice_1>Advocate for legislation on helmet laws.</choice_1> <choice_2>Teach parents to role-model helmet use while riding bicycles.</choice_2> ' <choice_3>Verbally reprimand children who report not wearing helmets while riding.</choice_3> <choice_4>Recommend the parents purchase stylish helmets to increase compliance.</choice_4>

2</correct> <rationale>Parent role models of behavior are the best method to develop good habits in children. The other options, although possibly valid (except option 3), are not the <i>best</i> answer.</rationale>

37. A client on the hospital unit has fallen. Place the following nursing interventions in order of priority.</question> <question_image/> <choice_1>Identify all witnesses.</choice_1> <choice_2>Call the physician.</choice_2> <choice_3>Monitor and provide urgent care.</choice_3> <choice_4>Notify the house supervisor.</choice_4> <choice_5>Fill out the incident report.</choice_5>

3, 4, 2, 1, 5</correct> <rationale>The primary action of the nurse is emergency assessment and first aid. If the nurse contacts the nursing supervisor, there will be nursing help to contact the physician and speak with witnesses. After caring for the client and assessing the situation, the nurse is prepared to fill out the incident report.</rationale>

10. A nurse and teacher are discussing legal issues related to the practice of their professions. The teacher asks what is the primary purpose of the Nurse Practice Act in that state. The nurse replies that the Nurse Practice Act is intended to do which of the following? <choice_1>Accredit schools of nursing</choice_1> <choice_2>Enforce ethical standards of behavior</choice_2> <choice_3>Protect the public</choice_3> <choice_4>Define the scope of nursing practice</choice_4>

3</correct> <rationale>A Nurse Practice Act serves to protect the public by setting minimum qualifications for nursing in relation to skills and competencies. One way it fulfills the responsibility to protect the public is by defining the scope of nursing practice in that state. The state's board of nursing approves schools to operate but does not accredit them. It does not enforce ethical standards.

91.The nurse is collecting data on a client who is 12 weeks' gestation. The examiner would expect to find the fundus at which of the following locations?</question> <question_image/> <choice_1>3 cm below the sternum</choice_1> <choice_2>The level of the umbilicus</choice_2> <choice_3>The level of the symphysis pubis</choice_3> <choice_4>3 cm below the umbilicus</choice_4>

<correct>3</correct> <rationale>By the twelfth week of gestation, the uterus should have increased in size to be palpable at the symphysis pubis. Factors affecting this finding include abnormal fetal growth or the presence of a multiple gestation.</rationale>

93.At the first prenatal visit, the client reveals that her last menstrual period began March 18. The nurse calculates her estimated date of delivery to be which of the following?</question> <question_image/> <choice_1>June 25</choice_1> <choice_2>November 18</choice_2> <choice_3>January 11</choice_3> <choice_4>December 25</choice_4>

<correct>4</correct> <rationale>According to Nägele's rule, the estimated date of birth can be calculated by subtracting 3 months from the beginning date of the last menstrual period and then adding 7 days to that date.</rationale>

2. A nurse forgets to administer a client's diuretic and the client experiences an episode of pulmonary edema. This medication error would be considered negligence if it constituted which of the following? 1. The purposeful failure to perform a health care procedure 2. The unintentional failure to perform a health care procedure 3. The act of substituting a different medication for the one ordered</choice_3> 4. Failure to follow a direct order by a physician

Answer 2: Negligence is the unintentional failure of an individual to perform or not perform an act that a reasonable person would or would not do in the same or similar circumstances. Options 3 and 4 do not fit the description of the event, and option 1 is the opposite of option 2.

1. A client is referred to a surgeon by the general practitioner. After meeting the surgeon, the client decides to find a different surgeon to continue treatment. The nurse supports the client's action, utilizing which ethical principle 1. Beneficence 2.Veracity 3. Autonomy 4. Privacy

Answer 3: Autonomy is the right of individuals to take action for themselves. Beneficence is duty to help others by doing what is best for them, whereas negligence is a legal term. Veracity is truthfulness. Privacy is the nondisclosure of information by the health care team.

88.With regard to normal changes in the reproductive system during pregnancy, the nurse should reinforce client teaching about which of the following?</question> <question_image/> <choice_1>Vaginal secretions will increase and thicken.</choice_1> <choice_2>Uterus will grow by adding many new cells.</choice_2> <choice_3>Breasts will become red and hard.</choice_3> <choice_4>Cervix will begin to dilate during the second trimester.</choice_4>

Answer: 1 <rationale>During pregnancy, increased estrogen production results in an increased amount and thickening of vaginal secretions. The uterus grows by cell hypertrophy, not by adding more cells. Red and hard breasts or a cervix dilating during the second trimester are not normal findings.</rationale>

77.The client, a 16-year-old female, has come to the clinic to discuss contraception because she has recently become sexually active. The client states that many of her friends are using spermicides and asks the nurse about their advantages and disadvantages. The nurse's best response would be:</question> <question_image/> <choice_1>"If you want an effective method, you should choose something else."</choice_1> <choice_2>"It is a very convenient method and you will be able to insert the spermicide up to 4 hours before intercourse."</choice_2> <choice_3>"Spermicides cause very few problems, and they are almost 100 percent effective."</choice_3> <choice_4>"Spermicides may or may not be a good choice for you. They have a failure rate of about 21 percent and offer some protection against sexually transmitted infections."</choice_4>

<correct>4</correct> <rationale>Spermicides must be used within 30 minutes of intercourse, have a failure rate of 21%, and do offer some protection against sexually transmitted infections. Other key information needed is the sexual history of the client and her partner(s) to more accurately assess risk for STIs. Option 1 provides advice, which the nurse should not give. Options 2 and 3 are false statements.</rationale>